Every finding on record at Copper Rock Healthcare

Based on observation, interview, and record review, the facility failed to provide residents with a complete and fully functional call light system when the facility failed to have process in place to notify staff of sounding call lights when call lights notifications could not be heard on the hall and the facility staff did not use the cell phone pagers for notification of call lights. The facility census was 77. Review of the facility policy titled, Call System, Residents, dated November 2025, showed the following:-Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station;-Each resident is provided with a means to call staff directly from his/her bed, from toileting/bathing facilities and from the floor;-Call system communication may be audible or visible;-The resident call system remains functional at all times;-If audible communication is used, the volume is maintained at an audible level that can be easily heard;-If visible communication is used, the lights remain functional at all times;-Calls for assistance are answered as soon as possible, but no later than 5 minutes, with urgent requests addressed immediately. 1. Observation on 03/08/26, at 11:48 A.M., showed Resident #1 sat in a wheelchair in his/her room. The wheelchair was approximately five feet away from the bed. During the observation, the resident complained of pain to the back of his/her leg. When the surveyor asked if he/she had notified the staff, the resident said he/she couldn't reach the call light, which was on the other side of the bed. The resident asked the surveyor if they could retrieve the call light for him/her, but then said it probably wouldn't matter anyway because they never come when I call them. Observation and interview on 03/8/26, at 1:40 P.M., showed Resident #33 was dressed, and lay on the bed. The resident could not talk and picked up his/her phone on the bed to converse. He/she used his/her own phone to text staff were slow to come to answer call light when surveyor asked him/her. During interview on 03/10/26, at 9:20 A.M., Resident #58 said staff answering their call lights depended on the day and how many people worked. It ranged from 10 to 15 minutes, or 45 minutes or one hour waiting for them to answer the call light.Observation on 03/09/26, at 10:22 A.M., showed no call light panel at the nurses' station. There was a slight buzzing noise at the nurses' station. During interview on 03/09/26, at 10:22 A.M., Licensed Practical Nurse (LPN) E said the nurse aides had phones for the call lights. Observation and interview on 03/09/26 showed the following:-At 1:18 P.M. CNA B went to a resident's room and made his/her bed as he/she sat in the wheelchair. CNA B said she needed to answer a resident's call light. There was a whistling noise every four to five seconds while CNA B put a gait belt on the resident in his/her wheelchair and he/she transferred the resident to the bed. -At 1:27 P.M., there was a whistling noise every four to five seconds throughout the observation in another resident's room. CNA B said the phone was making this noise because it kept trying to reconnect to the facility wi-fi; -At 1:45 P.M., CNA B turned off the phone which was whistling every four to five seconds while in his/her pocket. CNA B said he/she had tried three other facility phones and they didn't work. The staff can see the lights at the end of the hall from the exit door, but not at the front of the hall looking down the hall. The call lights were white lights above on the ceiling. NA B left the phone by the other phones at the nurses' station. Observation on 03/09/26, at 2:30 P.M., showed the following:-Call box at the nursing station showed five call lights alarming;-Four cell phones on the charger at the nursing station;-At the end of the 100 and 200 hall the alarms at the nursing station could not be heard;-Call lights on the ceiling outside of the resident room were not visible at the entrance of the hall until at the room door due to wooden beams on the ceiling. Observation on 03/09/26, at 3:35 P.M., showed call lights not visible from 100 hallway entry way due to wooden beam in front of each call light on the ceiling. Observation on 03/12/26, at 11:45 A.M., showed a resident's call light was on the ceiling a few feet from his/her door. The resident's room was the last room on the hall near the exit door. There was no audible sound with the call light. There was a whistling sound every four to five seconds when staff were at the nurses' desk when one phone kept making the sound. There was one phone lying face down on the nurses' desk. Three other phones were nearby in a plastic divider. There was no visible call light monitoring system at the 400/500 hall nurses' station. Observation on 03/12/26, at 12:00 PM, showed call light for room [ROOM NUMBER] alarming at nurse station. No staff were at the nurses' desk. No alarm was audible when in the hall near the room. Call light was only visible when standing outside the resident room. Observation on 03/12/26, at 12:15 PM, four cell phones located in the nursing station on the charging stand. During an interview on 03/10/26, at 9:55 A.M., Certified Nurse Assistant (CNA) X said the staff can see the call lights above the room doors. Every aide should carry one of the phones that ties to the call light system, but he/she forgot to pick one up that morning, so he/she just watches for the lights. CNA X said staff could hear the call light chimes if they were up close to the nurses' station. During an interview on 03/09/26, at 10:31 A.M., Certified Medication Tech (CMT) T said that the call lights alarm at a dashboard at the nursing station. He/she said they do not carry pagers but he/she wished he/she did. He/she walked up and down the halls checking on residents. During an interview on 03/09/26, at 2:30 P.M., NA U said there were call lights on the ceiling outside of resident room doors. There was not any noise with the alarms. He/she walked down the hall and looked for the call lights above resident doors. He/she did not know which call light was pressed, just had to go in the room and ask both residents what he/she could help with. He/she was not aware of any pagers. During an interview on 03/12/26, at 12:05 PM, CNA R said there was an alarm system at the nursing station for call light. A call light illuminated at the entry to hall. Then he/she would go up and down the hall and find the call light. He/she said there were call light phones, but he/she did not carry a phone as he/she was up and down the halls. During an interview on 03/12/26, at 12:20 PM, LPN S said there was a call light box in the nursing station that lit up with room number and a beeping noise. There were call light phones for staff to carry. The phone will vibrate and tell show the resident room number that had activated the call light. All staff should carry the phones. There are lights on the ceiling outside of the resident rooms that would light up when activated. During an interview on 03/13/26, at 10:30 AM, the Director of Nursing (DON) said there was a main call light panel at the 100/200/300 nursing station that showed all call lights in the building. It produced a sound and another panel at the 400/500 hall for those call lights. There were call light phones that the aides on shift should be carrying. The phone tells the staff which call light was alarming. Some staff choose not to carry a phone but all aides should be carrying a phone. During an interview on 03/13/26, at 2:30 PM, Administrator said aides should carry the call light phones every shift. Staff should generally answer call lights as soon as possible.

Based on observation, interview, and record review, the facility failed to ensure nurse aides (NA) were not used for more than four months without completing required training and evaluations when the facility did not have an effective process in place to ensure certified nurse aide (CNA) training programs were completed timely for NAs resulting in one NA (NA K) working longer than four months in the facility without completing the CNA training course. The facility census was 77.Review showed the facility did not provide a policy regarding NA training. 1. Review of NA K's personnel file showed the following:-Date of hire of 08/25/25 (six months and sixteen days prior);-NA K enrolled in the nurse aide training program on 01/06/26;-Staff did not have documentation NA K completed the nurse aide training program. Review of the facility's Daily Rosters showed the following:-On 03/08/26, NA K scheduled to work on the floor as an aide;-On 03/09/26, NA K scheduled to work on the floor as an aide;-On 03/11/26, NA K scheduled to work on the floor as an aide;-On 03/13/26, NA K scheduled to work on the floor as an aide.Observation on 03/11/26, at 2:00 P.M., showed NA K assisted residents with personal cares. Observation on 03/13/26 showed the following:-At 12:45 PM, NA K assisted residents with meals;-At 1:30 PM, NA K assisted a resident to the shower and assisted with showering and personal hygiene.During an interview on 03/12/26, at 2:30 P.M., NA K said he/she was hired in August 2025 as a NA. He/she took the initial testing in December 2025, but did not pass. He/she restarted classes in January 2026 and continued to work on the floor as a nurse aide.During an interview on 03/13/26, at 10:30 A.M., the Director of Nursing (DON) said that nurse aide staff should be certified within 120 days of date of hire. She was not aware that the staff could not restart class and continue working as NA past that time. Once a nurse aide started classes, they were able to complete the work that had been taught in classes and signed off by the supervising nurse.During an interview on 03/13/26, at 2:30 P.M., the Administrator said the following: -Aides should be certified as CNAs within 120 days;-After 120 days, the NA would put back in class and should not be working as an NA at that time.

Based on observation, interview, and record review, the facility failed to ensure food served was appetizing when staff served food that was not an appetizing temperature, failed to season food, and failed to cook food appropriately for 10 residents (Residents #17, #34, #15, #60, #28, #61, #66, #58, #5, and #38) of 25 sampled residents. The facility census was 77.Based on observation, interview, and record review, the facility failed to ensure food served was appetizing when staff served food that was not an appetizing temperature, failed to season food, and failed to cook food appropriately for 10 residents (Residents #17, #34, #15, #60, #28, #61, #66, #58, #5, and #38) of 25 sampled residents. The facility census was 77. Review of the facility policy The Dining Experience: Staff Roles, Guideline and Procedure Manual, dated 2020, showed the dining services manager or designee will be present in the dining room at all meals to ensure that the meals served follow a planned menu, are plated in an attractive manner. are palatable, served at the appropriate temperatures, served according to safe food handling practices, and meets the residents' individualized plan of care. 1. Review of the resident council minutes, dated 12/09/25, showed the following:-Ombudsman attended and addressed residents' concern from the last meeting that included food was served cold. All residents agreed that food was still served cold, stating food temperatures and presentations were worse on weekends;-Side items still not being served in separate bowls (vegetables); Review of the Department Response to Issues form, referring to the 12/09/25 meeting, showed the following: -Still needed concerns from November addressed;-Side items not served separately;-Not serving menus/ticket items-what is stated;-Salad drenched in dressing/prefer on the side;-Food temperatures, taste and presentation;-Dietary Manager's (DM's) response noted as educated dietary staff to put side-items in bowls. Record review of the resident council minutes, dated 01/13/26, showed the following:-Side items still not being served in separate bowls (vegetables);-Cold food. Review of the Department Response to Issues form, referring to the 01/13/26 meeting, showed the following:-Side items not served separately;-Cold food;-The DM's response noted he/she needed to know what vegetables residents wanted in a side bowl. Review of the resident council minutes, dated 02/10/26, showed the following:-The DM attended the meeting with questions on side bowl specifics. The residents stated only the runny veggies were preferred in a side bowl;-The DM educated residents that the plate warmer was unusable at that time to keep plates warm;-The DM educated residents on seasonal fresh fruit, the Bistro being closed, and encouraged families to provide specific/special requests that are not in budget. Review of the Department Response to Issues form, referring to the 02/10/26 meeting, showed no DM response regarding food temperatures. Review of the facility's Grievance Log, showed the following:-On 02/23/26, grievance filed by Resident #17 regarding concern of meals/budget. Concerned following last resident council meeting, regarding choices and quality of food and the budget concerns. Resolution taken: Resident will provide all likes/dislikes to the Bistro and will receive fresh toast;-On 02/27/26, grievance filed by Resident #34 concerning meals/nutrition. Resident said he/she was served food that the resident was unable to consume. The resident was on a mechanical soft diet and was served un-chopped lettuce. The resident was dependent on staff and was unable to hold a cup for him/herself but was served a cup of poor-quality soup. Resolution taken: The DM will correct the meal tickets and educate dietary staff on following tickets;-On 03/05/26, grievance filed by Resident #15 regarding meal ticket preferences not being followed. Resolution taken: The DM will educate dietary staff on following tickets;-On 03/06/26, grievance filed by Resident #60 regarding did not receive meal requested on his/her ticket. Resolution taken: The DM spoke with the resident and provided them a copy of a menu for the current month. During the resident council meeting held on 03/09/26, at 1:00 P.M., residents stated the following: -Resident #28 said if residents ask for a turkey-club sandwich, it is made with only one thin slice of turkey with a paper-thin tomato slice and nothing else. It is very dry, and he/she has asked for mayonnaise, and no one comes back with it;-Resident #61 said the facility had a lot of problems that do not ever get resolved. He/she said he/she had just purchased a little over $60.00 in food him/herself so he/she could have a few items they enjoyed eating. If you ask for something else or make a request, it goes unanswered. Observation of the lunch meal serve-out on 03/11/26, at approximately 12:30 P.M., showed the following:-Serve-out to residents each meal was plated and put on a tray. Staff took the tray to the resident, set the food on the table, and returned for the next tray;-After all residents in the dining room were served, the cook began making hall trays for residents who chose to eat in their rooms;-At approximately 12:40 P.M., the cook placed the first plate of food onto a tray, which was placed onto a large, metal, rolling cart;-At approximately 12:55 P.M., the last plate of food was placed onto the rolling cart and taken down the hall, ready to deliver to residents. Observation on 03/11/26, at approximately 12:55 P.M., the last hall tray, requested as a test-tray sample, showed the following: -The sweet and sour chicken was 128.2 degrees Fahrenheit (F). The chicken was dry and tough to chew;-The rice was 112.4 F. The rice was dry with hard pieces that were undercooked;-The broccoli was 24.1 F. The broccoli was mushy and almost all stems and stalks, with only one floret. Observation on 03/12/26, at approximately 12:45 P.M., of the last hall tray, requested as a test-tray sample, showed the following:-Chicken-bacon penne pasta was 123.4 F. The pasta was dry, not a creamy texture and had a pasty taste (such as when corn starch or thickener added);-The green beans measured 113.0 F and were unseasoned. During an observation and interview on 03/12/26, at approximately 12:28 P.M., Resident #3 said the meals were usually bad. During an interview on 03/08/26, at 12:07 P.M., Resident #66 said the food was awful and tasted terrible. One evening, he/she was served a hot dog, which was not cooked, in a bun. There were no mustard or ketchup packets, and no napkin. During an interview on 03/08/26, at 1:50 P.M., the Resident #58 said the food was mediocre. The food was never hot. During an interview on 03/09/26, at 10:00 AM, Resident #5 said the food was cold and nasty. He/she ate in his/her room and did not receive hot food. During an interview on 03/09/26, at 3:28 PM, Resident #38 said he/she often would eat cereal in room his/her for supper because the meal was cold and did not taste good. During an interview on 03/12/26, at approximately 1:00 P.M., [NAME] M, said the following:-The aides are not serving the food fast enough;-The trays are sitting for some time before going down the halls;-Food was going to get cold because of the way hall trays were being passed. During an interview on 03/12/26, at approximately 2:30 P.M., Nurse Aide (NA) K, said the following:-He/she had heard complaints from residents that the food was cold;-If the food was sitting on a cart for over 30 minutes, it was going to get cold. During an interview on 03/13/26, at 9:30 A.M., the Social Services Director (SSD), said the following:-He/she sat in on all resident council meetings involving the residents;-He/she takes the minutes and helps the president run the meeting;-There were often food concerns;-Food is served cold;-He/she believed the problem was the food was not getting served out fast enough. During an interview on 03/13/26, at approximately 10:40 A.M., Dietary Aide (DA) N said the following:-Residents often complain of not being happy with the food that is served, usually regarding not much seasoning or being too cold;-The biggest problem was there was not enough staff to serve the trays quick enough;-The residents' likes and dislikes are marked on the meal tickets, and the plates were served based on the tickets. During an interview on 03/13/26, at approximately 11:10 A.M., DA O said he/she did hear complaints from residents about the food, usually the lack of variety, not enough seasoning or being too cold. During an interview on 03/13/26, at approximately 11:30 A.M., [NAME] P said the following:-He/she takes the food temperatures in the kitchen and then from the serve-out table, from whichever side he/she is working from;-He/she knows the trays that are taken to the rooms are cold because they sit on the cart for the entire time trays are being served, instead of being taken to the residents as they are made;-When the last tray gets ready, the first tray has completely cooled down, but is still served to the resident. During an interview on 03/13/26, at approximately 11:45 A.M., [NAME] Q, said the following:-The cook they had up until this past week never seasoned anything;-He/she was taught to taste-test everything, and if it was not good the residents would not want it either;-Choices/preferences are on the residents' menu cards, and they followed these to make the plates. These were important, especially if a resident was allergic to something;-He/she had heard complaints of preferences not being considered, usually regarding vegetables;-Most complaints were regarding the taste or cold food;-There were also complaints about a lack of variety or no fresh fruit;-He/she had been told the food in the dining room was fine, but if someone eats in his/her room, the food was cold. During an interview on 03/13/26, at approximately 12:20 P.M., the Dietary Manager (DM), said the following:-Food had probably been colder on the hall trays lately, because the food warming cart was not working;-He/she was hoping it would be replaced but was unsure at that time;-He/she had been speaking with the Administrator and discussing different ideas to come up with a solution;-He/she had heard of concerns about the food being cold;-He/she expected the cooks to be taking food temps prior to being served;-The aides on the floor should be getting the trays to the residents faster;-He/she denied the taste of food was not good and said he/she thought residents usually enjoyed the food;-The residents' menu cards showed preferences and those were honored;-Vegetables were now being served in bowls, for those who want that. During an interview on 03/13/26, at approximately 2:00 P.M., the Director of Nursing (DON), said temperatures should always be to the resident's preference; want to eat. During an interview on 03/13/26, at approximately 2:40 P.M., the Administrator said the following:-He/she always does taste testing;-He/she was now aware of the temperatures being an issue and was concerned.

Based on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure an oxygen tank was turned on while in the dining room for one resident (Resident #18), failed to ensure the oxygen tank contained sufficient oxygen for one resident (Resident #75) while in the dining room, and failed to ensure the humidifying bottles were filled with water for three residents (Resident #75, #9, and #2) with oxygen concentrators in their room. The facility census was 77.Review of the facility policy titled, Oxygen Administration, dated November 2025, showed the following:-Purpose to provide guidelines for safe oxygen administration;-Verify that there is a physician's order for this procedure;-Review the physician's orders of facility protocol for oxygen administration;-Review the resident's care plan to assess for any special needs of the resident;-Oxygen therapy is administered by way of an oxygen mask (device that fits over mouth and nose), nasal cannula (tube that place into nose about one-half inch), or nasal catheter (tubing inserted into nostrils into back of mouth);-The following equipment and supplies will be necessary when performing this procedure: portable oxygen cylinder (lightweight, high-pressure tank designed to provide supplemental oxygen to patients with breathing difficulties); nasal cannula, nasal catheter, or mask (as ordered); humidifier bottle (add moisture to dry oxygen, reducing nasal dryness and throat irritation); and regulator (medical device that reduces high-pressure oxygen from a cylinder to a safe, breathable, and adjustable low-pressure flow (typically 0-15 liters per minute (LPM)) for patient use ;-Check the mask, tank, and humidifying bottle, to be sure they are in good working order and are securely fastened;-Be sure there is water in the humidifying bottle and that the water level is high enough that the water bubbles as oxygen flows through;-Periodically re-check the water level in the humidifying bottle.1. Review of Resident #75's face sheet (brief information sheet about the resident) showed the following information: -admission date of 01/24/23;-Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), shortness of breath, asthma (chronic, long-term lung disease that inflames and narrows the airways, making breathing difficult), and congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 02/04/26, showed the following:-Severe cognitive impairment;-Use of oxygen.Review of the resident's care plan, last reviewed 02/06/26, showed the following:-Resident uses oxygen therapy related to COPD;-Staff should monitor for resident distress and report to the physician;-Staff should set oxygen via nasal cannula or mask at 2 to 3 liters (L) continuously;-Oxygen should be humidified as needed.Review of the resident's Physician's Order Sheet (POS), current as of 03/12/26, showed the following:-An order, dated 02/27/23, to check humidifier bottle every shift;-An order, dated 07/23/25, for oxygen at 2 to 3 liters continuously for diagnosis of COPD every shift.Observations on 03/08/26 showed the following:-At 12:30 PM, the resident sat in a wheelchair in the dining room for lunch. The resident's oxygen tank was set at 2 L and showed the tank in the red low to empty zone;-At 12:55 PM, another resident's family member requested staff check the oxygen tank. Staff noted the red low to empty zone and changed the tank.Observation on 03/09/26, at 10:15 AM, showed the resident in bed with eyes closed with his/her oxygen set at 3 L. The humidifier bottle was empty. Observation on 03/11/26, at 11:35 AM, showed the resident in bed with eyes closed with oxygen set at 3 L. The humidifier bottle was empty.During an interview on 03/12/26, at 11:30 AM, the resident's family member said there had been a time or two that hospice staff had contacted him/her and said that the resident's oxygen level was low and the oxygen was not turned on. 2. Review of Resident #9's face sheet showed the following information: -admission date of 04/01/25;-Diagnoses included chronic respiratory failure (long-term condition where the lungs cannot properly exchange oxygen and carbon dioxide) with hypoxia (condition where the body's tissues and organs do not receive enough oxygen to function properly), COPD, CHF, and shortness of breath.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-On oxygen therapy.Review of the resident's care plan, updated on 12/30/25, showed the following:-Resident had CHF;-Staff should administer oxygen via nasal cannula at 2 to 6 L continuously to maintain oxygen saturation at greater than 90%;-Resident had shortness of breath related to CHF and COPD.Review of the resident's POS, current as of 03/13/26, showed an order, dated 07/23/25, to administer oxygen at 2 to 6 liters via nasal cannula continuously, may titrate to maintain oxygen saturation greater than 90% (measures the percentage of oxygen in the blood ), if diagnosis of COPD, no more than 3 liters continuously every shift for oxygenation related to COPD.Observation on 03/08/26, at 11:15 AM, showed resident seated in chair in room, reading a book. The oxygen concentrator was set at 3 L with no water in humidifier bottle. Observation on 03/09/26, at 1:30 PM, showed the resident seated in chair working on crafts. The oxygen concentrator was set at 3L with no water in humidifier bottle.Observation on 03/10/26, at 11:20 AM, showed resident seated in a chair. The oxygen concentrator was set at 3 L and there was no water in humidifier bottle.During observation and interview on 03/11/26, at 11:15 AM, resident was working on sewing project. The oxygen concentrator was set at 3 L with was no water in the humidifier bottle. The resident said there should be water in it. The staff were to do that for him/her. 3. Review of Resident #18's face sheet showed the following:-admission date of 01/17/25;-Diagnoses included CHF and atrial fibrillation (an irregular, often rapid heart rate caused by faulty electrical signals in the heart's upper chambers).Review of the resident's care plan, updated on 01/13/26, showed the following:-Resident had CHF;-Staff should administer oxygen at 2 L via nasal cannula continuously to maintain oxygen saturation greater than 90%.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Use of oxygen.Review of the resident's POS, current as of 03/13/26, showed an order, dated 07/23/25, to apply oxygen via nasal cannula at 2 L to maintain oxygen saturation greater than 90 % every shift for dyspnea (shortness of breath or uncomfortable, labored breathing) related to CHF.Observation on 03/08/26 showed the following: -At 12:30 P.M., the resident sat in a wheelchair at the dining room table. The oxygen tank regulator showed the oxygen setting at zero with tank showing partially full;-At 12:50 PM, the resident's family member entered dining room and sat with the resident. He/she then went to a certified medication tech (CMT) and asked if he/she could check the resident's oxygen saturation as the resident appeared sleepy. The CMT checked and found O2 saturation to low. The CMT checked the tank regulator and noted that the regulator was not turned on.4. Review of Resident #2's face sheet showed the following:-admission date of 12/05/24;-Diagnoses included chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood), chronic respiratory failure with hypoxia, COPD, and shortness of breath.Review of the resident's care plan, updated on 09/25/25, showed the following:-Resident had COPD and chronic respiratory failure with shortness of breath and required supplemental oxygen;-Staff should administer oxygen via nasal cannula per order for shortness of breath or to maintain oxygen saturation at greater than 90%.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-On oxygen therapy.Review of the resident's POS, current as of 03/13/26, showed the following:-An order, dated 09/13/25, to administer oxygen at 3 liters via nasal cannula continuous, every shift related to chronic respiratory failure with hypercapnia, chronic respiratory failure with hypoxia, and COPD;-An order, dated 09/13/25, for oxygen tubing and humidifier change every 7 days.During an observation on 03/10/26, at 10:40 AM, Licensed Practical Nurse (LPN) H was in the resident's room completing wound care. The oxygen concentrator was set at 3 L with no water in the humidifier bottle. 5. During an interview on 03/12/26, at 12:05 PM, Certified Nurse Aide (CNA) R said the following:-Residents with humidifier bottles should have the bottles filled and there was distilled water in the resident room to use for this;-He/she said when a resident is brought out of their room on a portable oxygen tank the staff should ensure the tank is turned on.During an interview on 03/12/26, at 12:20 PM, LPN S said the following: -Nurses are responsible for the resident oxygen tanks and settings;-Staff should add distilled water to the humidifier bottle and it should be enough to last an entire shift;-Any staff can notify the nurse if the water level is low or empty;-The portable oxygen tanks should be checked before leaving a resident room to ensure turned on and enough oxygen to get through a meal or activity the resident was attending.During an interview on 03/12/26, at 1:20 PM, LPN H said the following: -Nursing staff are responsible for oxygen and humidifier bottles on oxygen tanks;-The nursing staff will have a notification on their Treatment Administration Record (TAR) for the nurse to complete the task;-The water in the humidifier bottle should last all shift;-If a CNA noted that a humidifier bottle was empty, they should refill the humidifier bottle;-There should be distilled water in the resident rooms;-Staff should ensure the portable tanks are turned on when going to a meal or activity and ensure the tank has enough oxygen;-If the regulator is in the red zone the tank should be changed as soon as possible.During an interview on 03/13/26, at 10:30 A.M., the Director of Nursing (DON) said the following: -Nursing staff were responsible for setting the liter setting on the tank regulators;-The nurses receive a task on their TAR to add water to humidifier bottles;-If the aides see an empty humidifier they should tell the nurse;-The bottle should have enough water to last the entire shift;-The water is for resident comfort;-Some residents do not want the water;-If there is a physician order the nursing staff should follow the order;-The aides should turn the regulator on the portable tank when transferred from concentrator and leaving the resident room for meals or activities;-The staff should ensure there is enough oxygen on the regulator and that it is turned on. If the regulator is in the red low to empty zone, it varies how long it will last for each resident depending on the flow rate and individual resident oxygen needs. During an interview on 03/13/26, at 2:30 PM, Administrator said the following: -Staff should ensure the portable oxygen tanks are full and should change when empty or right before empty;-If the regulator is in the red zone, staff should be closely monitoring;-Oxygen should be turned on when in their room and when out of their room;-Staff should follow physician orders;-The staff should fill humidifier bottles per physician orders and resident care plan;-If the resident has a humidifier, it should be filled or checked every shift.

Based on observation, record review, and interview, the facility failed to maintain effective and complete an infection prevention and control program when staff failed to follow appropriate Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) for one resident (Resident #5) with an indwelling catheters (tubing placed to drain the bladder to outside the body). Staff failed to follow acceptable standards of care for performing hand hygiene and glove use during personal care for four residents (Residents #49, #3,#21, and #23). The facility census was 77. 1. Review of the facility's policy titled Enhanced Barrier Precautions, reviewed December 2025, showed the following:-EBP are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents;-EBP employs targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply;-Gloves and gowns are applied prior to performing the high contact resident care activity;-Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs included dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.), and wound care (any skin opening requiring a dressing);-EBP are indicated, when contact precautions do not otherwise apply, for residents with wounds and/or indwelling medical devices regardless of MDRO colonization;-EBP remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk;-Staff are trained prior to caring for residents on EBP;-Personal protective equipment (PPE) is available outside the resident rooms;-Residents, families and visitors are notified of the implementation of EBP throughout the facility. Review of Resident #5's face sheet showed the following:-admission date of 08/05/24;-Diagnoses included neuromuscular dysfunction of bladder (condition where nerve damage or disease interrupts signals between the brain and bladder, causing loss of bladder control) and cystostomy status (an artificial, surgically created opening (stoma) in the urinary bladder that allows urine to drain directly through the abdominal wall into a collection bag). Review of the resident's quarterly Minimum Data Set (MDS – a comprehensive assessment tool completed by facility staff), dated 02/20/26, showed the following:-Cognitively intact;-Indwelling catheter. Review of the resident's care plan, reviewed on 12/02/25, showed the following:-Resident required EBP due to central line, suprapubic catheter, and open wound;-Staff should post signage on the door or wall outside of the room indicating precautions for PPE;-Staff should utilize PPE as indicated during cares. Review of the resident's Physician's Order Sheet (POS), current as of 03/13/26, showed the following:-An order, dated 08/12/25, for suprapubic catheter (flexible tube inserted through a small, surgical incision in the lower abdomen directly into the bladder to drain urine) care every shift;-An order, dated 11/12/25, for urinary catheter drainage bag, change every night shift on the 12th of every month;-An order, dated 03/10/26, to change suprapubic catheter every day shift on the fourth of every month related to retention of urine;-An order, dated 03/10/26, to change suprapubic catheter a need. Observation on 03/10/26, at 12:55 PM, showed the following:-Licensed Practical Nurse (LPN) H entered the resident's room;-An EBP sign on door stated use of gown and gloves required for personal cares;-A hospice nurse was present in the room;-The nurse and hospice nurse applied gloves;-The nurses did not put on gowns;-LPN H prepared supplies on bedside table to change supra pubic catheter, removed resident sheet from abdominal area, and opened incontinent brief and inspected at catheter bag and tubing;-LPN H touched the tubing and drainage bag and noted that the bag contained clear yellow urine and noted the catheter appeared to be functioning properly; -The hospice nurse and LPN H decided not to change catheter since it was changed on 03/04/26 and was working at this time;-Staff removed gloves and used hand sanitizer and applied new gloves and lifted the resident's right leg to view bandage on outer side of calf;-LPN H removed the bandage and noted skin to be darker in appearance and healing well;-Staff removed gloves and washed hands;-The staff did not apply gowns during resident contact. During an interview on 03/12/26, at 12:20 PM, LPN S said the following: -Residents with wounds, catheters, tube feeding, or IV's require staff to use EBP;-There were signs on the resident door and PPE in the closet of the room;-The staff should be wearing gown and gloves with any personal cares to protect the resident. During an interview on 03/13/26, at 11:00 A.M., Certified Medication Tech (CMT) A said the EBP should be following when doing cares for a resident that has wounds, a catheter or other indwelling device. During an interview on 03/13/26, at 11:25 A.M., LPN H said EBP included wearing a gown and gloves and a mask if necessary for bodily fluid precaution. During an interview on 03/13/26, at 1:57 P.M., the Director of Nursing (DON) said EBP should be worn when doing close contact care for a resident who has a wound, catheter or other indwelling device. During an interview on 03/13/26, at 2:27 P.M., the Administrator said EBP should be worn while caring for a resident with an open sore, catheter, or other indwelling device. 2. Review of the facility's policy entitled Handwashing/Hand Hygiene, reviewed October 2025, showed the following:-Hand hygiene was the primary means to prevent the spread of healthcare associated infections;-All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections;-All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors;-Hand hygiene products and supplies are readily accessible and convenient for staff to use to encourage compliance with hand hygiene policies. Alcohol-based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility;-Hand hygiene is indicated immediately before touching a resident; before performing an aseptic task; after contact with blood body fluids, or contaminated surfaces; after touching a resident; after touching the resident's environment; before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal;-Wash hands with soap and water when hands are visibly soiled;-Single-use disposable gloves should be used before aseptic procedures, when anticipating contact with blood or body fluids, and when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions;-The use of gloves does not replace hand washing/hand hygiene;-Perform hand hygiene before applying non-sterile gloves;-Perform hand hygiene after removing gloves. 3. Review of Resident #49's face sheet showed the following:-admission date of 04/25/25;-Diagnoses included multiple sclerosis (chronic autoimmune disease - can cause problems with vision, numbness/tingling, fatigue, balance/coordination, and muscle stiffness/tremors/weakness) and neuromuscular dysfunction of the bladder. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Mild impairment to cognition;-Dependent on others for bathing/showers, dressing, personal hygiene, bed mobility, transfers, and mobility using a manual wheelchair;-Presence of indwelling catheter (tubing placed to drain the bladder to outside the body into a collection bag);-Presence of feeding tube - intake greater than 51% via use. Review of the resident's Physician Order Sheet (POS), current as of 03/12/26, showed the following:-An order, dated 10/15/25, to change the urostomy (indwelling catheter with tubing placed through the abdomen) wafer and bag every three days. Change as needed for leaking or dislodgement;-An order, dated 12/01/25, for urinary catheter care every shift;-An order, dated 01/28/26, to drain urostomy bag every shift;-An order, dated 03/12/26, for tube feeding four times a day, give 300 milliliters (ml) Jevity (nutritional supplement) 1.5 mixed with 100 ml water and flush with 100 ml water.(Staff did not document orders related to EBP.) Review of the resident's care plan, updated 03/04/26, showed the following:-Resident required EBP due to urostomy and feeding tube;-Post EBP signage on the door or wall to outside of room indicating precautions for PPE;-Utilize PPE as indicated during cares. Observation on 03/12/26, at 12:32 A.M., showed the following:-Nurse Aide (NA) K washed his/her hands and donned a surgical gown and gloves. CMT J washed his/her hands and donned gloves. The CMT then donned a surgical gown without securing the sleeves using the thumb holes; -CMT J used pre-moistened wipes to clean the resident's front peri area;-NA K turned the resident onto his/her left side, toward the NA;-Without changing gloves or performing hand hygiene, CMT J used wipes to clean the resident's coccyx and buttocks of feces;-The CMT removed his/her gloves, did not perform hand hygiene, and placed a clean disposable brief under the resident's left side;-The CMT and NA turned the resident to his/her right side;-NA K finished placement of the brief and secured the sides;-Without performing hand hygiene, CMT J rolled a blanket and placed it under the resident's right arm and NA K covered the resident. 4. Review of Resident #3's face sheet showed the following:-admission date of 12/7/24;-Diagnoses included spinal chord disease, paraplegia (partial or complete paralysis of the lower half of the body, including both legs), an obstructive and reflux uropathy (conditions where urine flow is blocked or flows backward, causing urine backup, kidney swelling and potential kidney damage). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognition was intact;-Impairment on both lower extremities;-Substantial/maximal assistance for toileting hygiene, shower/bath, roll left and right, move from sitting to lying and lying to sitting on side of bed, and toilet transfer;-Indwelling urinary catheter;-Always incontinent of bowel;-Application of ointments/medications other than to feet. Review of the resident's care plan, revised 09/19/25, showed the following:-The resident had actual impairment to skin integrity of the buttocks present upon admission related to immobility and incontinence;-Keep skin clean and dry and assist with repositioning and cleansing after incontinent episodes. Observation on 03/10/26, at 9:53 A.M., showed the following:-LPN D took Triad (used to treat wounds) and gauze and laid it on the resident's bedside table where the resident's food tray was and put on a gown and gloves. There were several tubes of cream on the bedside dresser;-He/she assisted the resident over to his/her side in bed with the indwelling urinary foley catheter;-There was hard bowel movement between his/her legs between buttocks;-The LPN cleansed with wet wipes between the buttocks with several wipes by wiping front to back and turning the wet wipe with each wipe;-After cleansing between the buttocks, LPN D did not remove his/her gloves and wash hands. With the same gloves, he/she turned the resident;-LPN D removed the gown and gloves, did not wash hands, opened the closet door to look for an incontinence brief, and then went out of the room to the outside treatment cart, got an incontinence brief, and then went to the closet, touched all the closet doors and drawers to look for a brief;-He/she used hand sanitizer from on the wall, put on a new gown and gloves, and put a clean brief underneath him/her, got the Triad and applied to the resident's reddened peri-area;-LPN D removed his/her gloves, and picked up a pair of gloves placed on the bedside table where the food tray was;-He/she helped the resident turn over and applied the Triad on his/her left lower buttock;-He/she removed gloves, did not wash hands, put on a new pair of gloves, got the wet wipes and cleaned the inner right thigh, and then the left inner thigh and the perineal area which was red near the opening for the catheter tubing;-LPN D put Triad cream on the front perineal area, removed gloves, did not wash hands. He/she put on another pair of gloves to wipe off some of the Triad cream before he/she pulled up his/her pants with the gloves after he/she wiped some of the Triad cream off with a wet wipe, and then pulled up his/her blanket;-He/she gathered the trash bags in both garbage cans on both sides of bed;-LPN D wiped off the milk beneath the glass on the bedside table, then removed the gloves, put on a new pair of gloves, without washing and/or sanitizing hands, and removed the gown and gloves, didn't wash hands, put on one glove and picked up plate and trash to take out of room, shut off the light;-LPN D took the trash to the soiled utility room behind the nurses' desk and then washed his/her hands. 5. Review of Resident #21's face sheet showed the following:-admission date of 06/30/25;-Diagnoses that included vascular dementia without behaviors, peripheral vascular disease (reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), and high blood sugar. Review of the resident's admission MDS, dated [DATE], showed the following:-Cognition was severely impaired and did not make decisions;-Had impairment on lower extremity on one side;-Dependent on staff for oral hygiene, toileting, shower/bath, upper and lower body dressing, personal hygiene, mobility to roll, turn, and reposition and transfers;-Always incontinent of bowel and bladder. Review of the resident's care plan, revised 11/18/25, showed the following:-Risk for self-care deficit of bathing, dressing, and feeding due to dementia with confusion and incontinence of bowel and bladder;-Required substantial to maximum assistance and dependent with dressing, transfers, shower, and mobility;-Frequently incontinent and needed assistance with perineal care from staff. Observation on 03/9/26, at 12:55 P.M., showed the following:-Nurse Aide (NA) C and Certified Nurse Aide (CNA) B used hand sanitizer, put on gloves, and CNA B put the gait belt around the resident's waist;-They transferred the resident from the wheelchair to the bed;-They removed the resident's house slippers, raised his/her bed;-They laid a clean incontinence brief and cleansing wipes at the foot of the bed;-They removed his/her pants and CNA B pulled bed pad down as they rolled the resident to his/her side and removed his/her incontinence brief which was wet with urine;-NA C took wet cleansing wipes and wiped front to back with the wipe. The resident had a small bowel movement;-NA C talked to the resident and used more wet wipes to cleanse the resident between the legs;-NA C put a clean incontinence brief on the resident;-NA C removed gloves, did not wash hands, touched the dresser drawer and then held the resident's hand. CNA B kept the same gloves on, and pulled up the resident's blanket, after taking her pants and putting them on the back of the wheelchair to put on later;-NA C took out trash bag from trash can and put a new bag into it;-CNA B took the trash bag out without washing and/or sanitizing hands before he/she left the room. 6. Review of Resident #23's face sheet showed the following:-admission date of 10/30/24;-Diagnoses included stroke, left hemiplegia (one sided paralysis), mini strokes, and gastrostomy tube (opening into the skin to the stomach). Review of the resident's annual MDS, dated [DATE], showed the following:-Cognition was moderately impaired;-Impairment on one side of upper extremity;-Impairment on both sides of lower extremities;-Dependent for toileting and personal hygiene, upper and lower body dressing;-Frequently incontinent of bowel and bladder;-Application of ointments/medications other than to feet. Review of the resident's care plan dated 12/08/25, showed the following:-Dependent on staff for all cares, transfers, and mobility;-Incontinent of bowel and bladder and required staff assistance with hygiene;-Keep skin clean and dry, assist with toileting, cleansing, and repositioning as needed. Observation on 03/09/26, at 1:27 P.M., showed the following:-CNA B and NA C took the resident to his/her room. CNA B used the hand sanitizer at the door. NA C went to the resident's bathroom and grabbed a pair of gloves and put them on without washing or sanitizing hands;-CNA B brought the mechanical lift into the room and he/she and NA C transferred the resident to the bed;-They removed his/her soft boots from both feet, drew the privacy curtain and then CNA B put a pair of gloves on and then got the urinal to assist the resident lying in bed;-The resident voided into the urinal and then CNA B used wet wipes around the area, and then pulled the brief up since it was not wet;-CNA B removed his/her gloves, did not wash or sanitize hands, covered the resident with the blanket, and raised the bed, opened the privacy curtain;-Both CNA B and NA C sanitized hands at the door before leaving the room. 7. During an interview on 03/12/26, at 2:20 P.M., CNA I said the following:-Staff were to wash their hands before and after changing their gloves;-They were to sanitize their hands in the resident's room;-They were to sanitize and/or wash hands if they carry trash and go up at the nurses' station to place in the soiled utility room. During an interview on 03/13/26, at 11:00 A.M., CMT A said staff should wash their hands prior to donning a gown and gloves, and sanitize or wash their hands every time gloves are removed. During an interview on 03/12/26, at 2:45 P.M., LPN E said the following:-Staff were to wash their hands when soiled and before and after they do personal cares on a resident;-Staff should wash their hands or use hand sanitizer when entering a resident's room and when they leave a resident's room;-They were to wash hands before applying gloves, and after removing their gloves. During an interview on 03/13/26, at 11:25 A.M., LPN H staff should wash their hands prior to performing personal care, perform the care, and change gloves after a soiled area. Hands should be sanitized with every glove change. Staff should wash or sanitize their hands before touching other items or doing other care and utilize the hand sanitizer gel before exiting a resident's room. During an interview on 03/12/26, at 2:55 P.M., the Associate Director of Nursing (ADON) said the following:-Staff were wash and/or sanitize hands before they enter and leave the resident's room;-They were to wash hands before applying gloves and after taking off their gloves;-They should wash hands when they touch residents' belongings or like someone's cup or dishes. During interview on 03/13/26, at 1:58 P.M., the Director of Nursing (DON) said the following:-Staff were to wash their hands and/or sanitize hands and put on gloves before they enter a resident's room, and wash or sanitize hands when they leave a resident's room;-They were to wash hands before putting on gloves and after removing gloves, during perineal care, transfers, and when hands were soiled. During an interview on 03/13/26, at 2:27 P.M., the Administrator said gloves should be worn to do any bodily care for a resident, and staff should wash/sanitize their hands with any glove change.

Based on observation, interview, and record review, the facility failed ensure all residents had interventions in place and followed to ensure acceptable parameters of nutritional status were maintained when staff failed to assist two residents (Resident #18 and #75) during meals. A sample of 25 residents was reviewed for dietary concerns. The facility census was 77. 1. Review of Resident #18's face sheet (a quick-glance referral of the resident's information) showed the following:-admission date of 01/17/25;-Diagnoses included dementia, chronic systolic (heart failure), chronic kidney disease, stage 3 (kidneys losing the ability to filter blood, leading to waste build-up), and paroxysmal atrial fibrillation (irregular heart rhythm). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 01/22/26, showed severe cognitive deficit. Review of the resident's current care plan showed the following:-An ADL (activities of daily living) self-care performance deficit due to dementia;-Resident dependent on staff for all ADL's;-Monitor intake and record at meals;-Resident to receive adaptive cup with lid to assist with fluid intake and independence. Observation of the breakfast meal on 03/09/26, beginning at 8:35 A.M., showed the following:-The resident sat in a wheelchair at a dining table with eyes closed. Resident occasionally opened his/her eyes, look to either side, and closed them again;-He/she had an untouched plate of food in front of him/her on the table;-The resident did not try to eat the food on his/her own;-Staff did not approach the resident to encourage the resident to eat, or to assist the resident with eating;-At 8:45 A.M., the resident's plate remained untouched;-At 8:52 A.M., the resident's plate remained untouched;-At approximately 9:05 A.M., staff took the resident to his/her room without offering to assist the resident with the meal; -At 9:17 A.M., Dietary Aide (DA) L removed the resident's plate of food and threw it away. During an interview on 03/13/26, at 9:30 A.M., the Social Services Director (SSD), said the following:-He/she will assist residents with eating whenever he/she was available to do so;-He/she assisted the resident many times in the past;-The resident can feed him/herself, but does need someone to assist a lot of the time or the resident just will not do it on his/her own;-Even if the resident does not feel like eating, it should still be offered to him/her;-The resident should never be taken back to his/her room without being offered food. During an interview on 03/13/26, at 2:40 P.M., the Administrator said the following:-He/she would expect staff to offer help to all residents who may require it;-The resident's family member usually came in during most meals and helped the resident eat. 2. Review of Resident #75's face sheet showed the following information: -admission date of 01/24/23;-Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), shortness of breath, asthma (chronic, long-term lung disease that inflames and narrows the airways, making breathing difficult), dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), anorexia (serious, often chronic eating disorder characterized by extreme food restriction, intense fear of weight gain, and a distorted body image, leading to dangerous weight loss), chronic pain, and dysphagia (difficulty swallowing). Review of the resident's care plan, last reviewed on 02/02/26, showed the following:-Resident at risk for impaired nutrition related to poor appetite and low body weight;-Staff should assist with meals, feeding and set-up, as needed;-Educate resident to avoid fluid intake with meals, and instead encourage fluids between meals;-Ensure resident in proper position for eating;-Serve diet as ordered and adaptive equipment as ordered. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 02/04/26, showed the following:-Severe cognitive impairment;-Dependent on staff for eating, oral hygiene, showering, personal hygiene, dressing, and toileting hygiene;-Required mechanically altered diet – change in texture of foods. Review of the resident's Physician's Order Sheet (POS), current as of 03/12/26, showed the following:-An order, dated 11/19/25, for fortified diet with pureed texture, regular/thin consistency and super cereal at breakfast. Super pudding at lunch and supper. Thin fluids to resident's preference;-An order, dated 02/06/26, for staff to offer assist with meals. Observation on 03/08/26, beginning at 12:40 PM, showed the following: -The resident seated in wheelchair in dining room;-Meal included pureed (cooked, blended, or strained food processed into a thick, smooth, and creamy liquid or paste, often resembling baby food or thick pudding) meat and vegetables and pudding in a cup with plastic wrap covering top;-Resident ate meal with a fork by dipping the fork into the food and getting food on just the tip of the fork;-The resident poked the fork through the plastic wrap to get some pudding;-Staff did not assist the resident. Observation on 03/10/26, beginning at 1:20 PM, showed the following: -Resident sat in a wheelchair in the dining room;-No staff seated with the resident;-The resident ate pudding with a butter knife;-The resident then put the butter knife in pureed pork;-Resident was getting small bites of food on the knife;-Staff did not assist the resident. Observation on 03/12/26 showed the following:-At 12:35 P.M., staff put a puree meal that included chicken penne pasta, green beans, and cake, in front of the resident at the dining table and removed the warming cover. The resident was seated in a wheelchair with eyes closed. The staff did not attempt to rouse the resident;-At 12:48 P.M., resident sat with eyes closed at dining room table. Staff did not assist the resident. The puree food on plate remained uncovered and untouched;-At 1:05 P.M., CNA G encouraged resident to wake up and asked if resident was done with food. The resident said no and kept eyes closed. The staff walked away and did not offer assistance or provide encouragement;-At 1:18 PM, the resident remained at table with eyes closed. The resident did not attempt to eat any food. Staff were not seated with or near the resident;-At 1:38 PM, the resident's eyes remained closed and resident had not attempted to eat any food. Staff were not seated with or near the resident. One kitchen staff asked resident if he/she was done eating, the resident said no. The kitchen staff left the untouched meal plate at the table. The resident's eyes remained closed; -At 1:45 PM, Licensed Practical Nurse (LPN) H came out of the nursing station and took another resident to his/her room. The resident remained in dining room with meal untouched in front of him/her;-At 1:52 PM, the resident remained in dining room with no food intake. Staff were not near the resident;-At 1:58 PM, the Activities Assistant asked resident if he/she was done eating. The resident said yes. The resident's plate was untouched. The Activities Assistant pushed the resident's wheelchair to the common area. During an interview on 03/12/26, at 11:30 AM, resident's family member said that the staff should help the resident with his/her meals. The resident could not feed him/herself. The hospice staff told him/her that the resident's intake was dwindling and the resident needed assistance with meals. 3. During an interview on 03/12/26, at 12:00 PM, Certified Nurse Aide (CNA) R said there would be information in the resident chart if they required meal assistance and would be passed along in report. During the meals the aides try to leave one aide on the floor to watch call lights and other staff to keep an eye on the dining room. The staff in the dining room should sit with residents that require meal assistance. During an interview on 03/12/26, at 12:20 PM, LPN S said residents that need meal assistance generally sat at the middle table in the dining room. The staff should help and cue residents for meals. If a resident had orders to assist with meals the staff should be seated with the resident for the meal. The staff should follow physician orders. During an interview on 03/12/26, at 1:20 PM., LPN H said residents that require meal assistance generally sat at the middle table in the dining room. However, they could sit where they choose. The staff should be helping residents with meals and providing assistance as needed. The staff should encourage and monitor residents in the dining rooms. If there is an order to assist with meals, the staff should sit with the resident for the whole meal. The staff should ensure residents have the appropriate utensils for meals. During an interview on 03/12/26, at 2:10 PM, the Director of Nursing (DON) said residents should be seated at the middle table for assistance with meals but there were not assigned seats. If a resident had an order that said assist with meals the staff should observe, monitor, and assist the resident. Residents should not be eating puree food with fork. During an interview on 03/12/26, at 2:25 PM, the Administrator said residents that need assistance were generally seated at the middle table in the dining room. The staff should be circulating the dining room offering assistance and encouragement to all the residents. A resident with an order for assistance with meals should have more supervision and staff should check frequently.

Based on observation, interview, and record review, the facility failed to ensure an effective pain management program was in place for each resident when staff failed to address one resident's (Resident #23) complaint of pain. The facility census was 77.Review of the facility policy Pain Assessment and Management, revised April 2025, showed the following:-Purpose to help staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying causes of pain;-Pain management included identifying signs and symptoms of and assessing existing pain; -recognizing situations and conditions with the potential for pain; -addressing the underlying causes of the pain; developing and implementing approaches to pain management based on accepted standards of practice; monitoring for the effectiveness of interventions, and modifying approaches as necessary;-Comprehensive pain assessments are conducted upon admission, quarterly, whenever there is a significant change in condition, and when there is an onset of new pain or worsening of existing pain;-Recognize signs of pain such as facial expressions such as grimacing, frowning, clenching of the jaw, behavior such as resisting care, irritability, depressed mood, decreased participation in usual physical and /or social activities, guarding, rubbing or favoring a part of the body;-Ask the resident if they are experiencing pain and be aware the resident may avoid the term pain and use other descriptors such as throbbing, aching, hurting, cramping, numbness, or tingling;-Characteristics of pain including location, intensity, description, patter, frequency, timing, and duration;-Identify underlying causes of pain such as common procedures such as moving the resident can cause pain;-Monitor the resident's pain and consequences of pain at least each shift for acute or sub-acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain;-Monitor to determine if the resident's pain is being adequately controlled;-Document the following in the resident's medical record: the resident's reported pain using a standardized pain scale, characteristics of the pain such as location, intensity, description, pattern, and frequency; and underlying cause of the pain, factors that worsen or improve pain, interventions, and outcomes after interventions.1.Review of Resident #23's face sheet showed the following:-admission date of 10/30/24;-Diagnoses included stroke, left hemiplegia (one sided paralysis), pain in left shoulder and in left hand, and arthritis. Review of the resident's care plan, dated 12/8/25, showed the following:-Had occasional complaint of pain:-Monitor/record/report to nurse if any signs and symptoms of non-verbal pain such as changes in breathing, vocalizations such as grunting, moans, yelling out, silence, mood or behavior such as more irritable, restless, aggressive, constant motion, squirmy, eyes wide open/shut, tearing, face is sad, crying, clenched teeth, grimacing, body is tense, rigid, and thrashing;-Monitor/record/report to nurse if resident complains of pain or requests pain treatment and notify physician if interventions are unsuccessful or current complaint is a significant change from resident's past experience of pain;-Observe and report changes in usual routine, sleep patterns, decrease range of motion (ROM), and withdrawal or resistance to care;-Report to nurse any change in usual activity or refusal to attend activities related to pain or discomfort.Review of the resident's annual MDS, dated [DATE] ,showed the following:-Moderately impaired cognition-No behaviors;-Impairment on one side of upper extremity;-Impairment on both sides of lower extremities;-Had occasional pain which occasionally affected sleep and occasionally interfered with day-to-day activities;-Had mild pain.Review of the resident's February 2026 and March 2026 Medication Administration Record (MAR) showed the following:-An order, dated 02/28/26, for Tylenol Extra Strength oral tablet 500 milligrams (mg) to give 1000 mg by mouth every 8 hours for pain control. Administration scheduled at 12:00 midnight, 8:00 A.M., and 4:00 P.M.;-An order, dated 09/08/25, for ibuprofen oral tablet to give 800 mg by mouth every 12 hours as needed (PRN) for pain. Staff to document pain level.Review of the resident's progress note dated 02/22/26, at 6:14 A.M., showed the following: -The past two mornings when getting the resident up for the day, the resident had started swinging his/her arms at staff and state, I am going to hurt you;-Staff familiar with resident doing the same activities of daily living (ADLs) and cares and getting the resident in his/her chair with Hoyer (mechanical) lift and resident stated, If you are going to hurt me, I am going to hurt you!-Staff was being gentle with resident doing the regular morning routine. (Staff did not document addressing the resident's comments of being in pain.) Review of the resident's MAR, dated 02/22/26, showed staff did not document administration or offering PRN ibuprofen for as needed for pain to the resident.Observation on 03/09/26, at 1:27 P.M., showed the following:-Certified Nurse Aide (CNA) B and Nurse Aide (NA) C took the resident to his/her room;-CNA B brought the mechanical lift into the room;-CNA B said the resident had been in pain this day. He/she noticed this around 12:30 P.M. at lunchtime and since the resident had been yelling out with pain in his/her left arm which doesn't move. He/she had not told anyone about the resident's pain;-CNA B and NA C attached the mechanical lift pad to the Hoyer lift and as CNA B operated the lift to raise the resident, the resident said, Ow. His/her eyes remained closed and the resident grimaced the aides raised and then lowered him/her on to the bed;-The aides rolled him/her to his/her good side on the right so CNA B could check his/her incontinence brief and it was dry;-The resident said, Ow several times with eyes closed and grimaced, when they moved the resident to his/her side;-The aides rolled covered the resident with the blanket and raised the bed;-CNA B asked the resident if he/she was comfortable and the resident said, No;-CNA B asked what he/she could do to make him/her comfortable and the resident did not answer.Review of the resident's March 2026 MAR showed on 03/09/26 staff did not document the resident's pain for the resident and did not administer ibuprofen as needed for pain. During an interview on 03/12/26, at 2:20 P.M., CNA I said the following:-The resident had pain in his/her left arm and it always hurts;-The resident was in a lot of pain;-Staff do go in and ask his/her level of pain and he/she randomly blurts out, Ow;;-If the resident complained of pain, he/she will see if the resident needed a pain medication, and will let the nurse know.During an interview on 03/12/26, at 2:26 P.M., CNA B said the following:-The resident yelled out a lot with the pain in his/her left arm;-He/she would let the medication technician know when the resident had pain to see if there was a pain medication he/she could have.During interviews on 03/11/26, at 11:00 A.M., and on 03/12/26, at 2:30 P.M., Licensed Practical Nurse (LPN) E said the following:-He/she will look at the resident's face and what they say in regards to having pain;-Pain was subjective and he/she expected staff to report pain with a resident;-Staff were to pre-medicate some residents before treatments, and before a shower;-The resident yelled out with pain a lot and repeatedly in his/her left arm and they try to pop it up on a pillow;-He/she would expect staff to let him/her know if the resident had more pain when they transferred him/her.During an interview on 03/12/26, at 2:55 P.M., the Associate Director of Nursing (ADON) said the following:-For pain, they were to look for signs if the resident could not tell them they were in pain;-Signs included grimacing, touch, not sleeping well, or not doing normal activities like not wanting to get out of bed or go for a shower;-The resident experienced a lot of pain and typically ibuprofen worked for his/her pain;-The nurses and medication technicians do assess pain and do re-assess pain in the computer;-They were to follow up with the physician with any changes and new orders.During an interview on 03/13/26, at 11:21 A.M., the Director of Nursing (DON) said when staff know a resident was in pain, they should talk to the nurse and report this. The nurse should look into this.During an interview on 03/13/26, at 2:27 P.M., the Administrator said if staff noted a resident in pain, they were to notify the nurse, and the nurse should address the pain.

Based on interview and record review, the facility failed to ensure the administrator of the facility had an active and valid administrator's license when the facility failed to confirm renewal of his/her license, and the administrator continued his/her normal job duties for a period of 20 days without a valid license. The facility census was 77.On 07/21/25, the facility's corporation became aware of the Administrator's license expiration. The facility removed the Administrator from his/her role and provided counseling. The facility's corporation appointed the [NAME] President (VP) of Operations, who had a current valid administrator's license, to the administrator role on 07/21/25. The corporation implemented audits of the licenses of all administrators with the corporation. The noncompliance was corrected on 07/21/25. Review of the facility's Administrator Job Description Policy, dated 01/01/19, showed the following:-Must possess a current Nursing Home Administrator's license from the State of Missouri;-Employee must be able to maintain the facility's current licensure to operate the facility;-Administers fiscal operations such as budget planning, accounting and establishing rates for services;-Plans, develops, organizes implements, evaluates and directs the facility's programs and activities;-Develops, maintains, and implements written policies and procedures to residents, family members, visitors, government agencies and employees as necessary;-Reviews and develops a plan of correction for deficiencies noted during survey inspections and provide a written copy of such plan to the governing board and ombudsman representative as required;-Directs and coordinates activities of medical, nursing, social services, food service, maintenance and administrative staffs and services.1. Review of the Missouri Board of Nursing Home Administrators'' records showed the Administrator's license expired on 06/30/25. The Administrator failed to complete the necessary paperwork and education for timely renewal. Review of the [NAME] Health Care record of council, dated 07/21/25, showed disciplinary action against the Administrator, immediately, for not maintaining a current, active licensure necessary for performance of his/her job. Review of the Change of Administrator/Manager in Long Term Care Facility form showed Copper Rock Healthcare removed the Administrator and appointed the VP of Operations to the administrator role 07/21/25.During an interview on 09/30/25, at 11:05 A.M., the VP of Operations said he/she has been the administrator of Copper Rock Health Care since the beginning of July. During an interview on 10/01/25, at 10:35 A.M., the VP of Clinical Operations said the Administrator completed his/her administrative license renewal online on 06/30/25. He/she received an email the application was submitted but was also required to mail his/her check. The fee for the renewal was not postmarked on or before 06/30/25. According to the board, the Administrator's license expired on 06/30/25. On 07/18/25, an email was sent, but that was a Friday, so they didn't get it until 07/21/25. The email was from the review board, saying they the Administrator's renewal paperwork, did not have sufficient CEUs (continuing education units). Copper Rock found on 07/21/25, the Administrator's license had expired. The Administrator had served without a license from 06/30/25 to until they removed him/her on 07/21/25. They assigned the VP of Operations to the administrator position. He/she completed disciplinary action with the Administrator.2614906

Based on interviews and record review, the facility staff failed to implement their abuse/neglect policy to protect all residents during an abuse allegation investigation when staff allowed one staff member (Certified Medication Tech (CMT) A) continue to work independently after one resident (Resident #1) made an allegation of abuse involving the CMT. The facility census is 80. Review of the facility policy titled Abuse Prevention, Reporting, and Investigation, revised 02/2017, showed the following:-It is the policy of the facility that reports of suspicions of abuse will be reported and thoroughly investigated;-Physical abuse is defined as hitting, slapping, pinching, kicking, etc;-Should an allegation be made of an incident, or suspected incident of resident abuse, mistreatment, neglect, exploitation, or mistreatment, or events that cause the allegation to occur involve abuse or result in serious bodily; the incident will be immediately, but no later than two hours after the allegation is made, reported to the Administrator, or his/her designee, and other officials including the state survey agency. If not done by the administrator themselves, the administrator will appoint a member of management to investigate the alleged incident and make an immediate report to Department of Health and Senior Services (DHSS);-Should the investigation determine that a facility employee has been implicated in the potential abusive incident, the employee will be placed on suspension until it has been determined that he/she was not involved in abuse. This determination will be the result of the investigation process. 1. Review of Resident #1's face sheet (admission data) showed the following:-admission date of 03/27/25;-Diagnoses included malignant neoplasm of pancreas (cancerous tumor), parkinson's disease (a progressive neurodegenerative disorder that mostly affects movement), type II diabetes, (body doesn't produce enough insulin which leads to high blood-sugar), chronic obstructive pulmonary disease (lung disease that causes breathing problems), paraplegia (partial paralysis), chronic pain, heart disease, and fracture of lower end of left humerus (upper arm bone). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/03/25, showed the following information:-No cognitive impairment;-No behaviors;-Required substantial assistance with toileting hygiene and showers. Review of the resident's care plan, revised 08/04/25, showed the following:-At risk for fatigue;-Has limited physical mobility. Provide supportive care/assistance with mobility as needed;-Resident has chronic pain. Anticipate the resident's need for pain relief and respond immediately to any complain of pain. Review of the resident's progress note dated 08/03/25, at 11:56 P.M., showed the Registered Nurse (RN) C documented the following:-The resident was up in wheelchair most of the afternoon and into the evening so previous RN was unable to get a full skin assessment upon return from hospital. He/she attempted around 7:00 P.M., but resident refused;-Resident continued to exhibit agitated behaviors thereafter. Voicing frustration with inability to transfer self and that he/she had forgotten his/her cell phone in family member's vehicle; -Yelling out in bed for help but not using call light. Assisted to toilet by nursing staff. Behaviors further escalated around 8:30 P.M., with resident screaming at staff; -Redirection and reassurance attempted by multiple staff members. Speech slurred at times. Resident appeared very tired. Often speaking with eyes closed-Resident began saying he/she had been hit in the stomach by Certified Medication Tech (CMT) A;-CMT A stated he/she had dropped jelly on resident's shirt and wiped it off during their interaction while resident was on the toilet. There was a purple sticky substance to note on right breast/abdominal area of shirt. Food had otherwise been spilled on shirt as well. Resident refused to allow he/she or other nursing staff to help the resident to change clothing and was unable to do so independently. While he/she was attempting to deescalate the situation, the resident did acknowledge he/she was very familiar and knows the staff on shift and that they usually provide good care; -Resident did get into bed with assistance at approximately 8:50 P.M. and allowed him/her to verify there was no bruising, swelling, or other sign of injury on right or left lower quadrants of abdomen. Refusing all other care to include full skin assessment and now vital signs; -Administrator and Director of Nursing (DON) made aware of events. DON called family member. Family members bedside at approximately 10:00 P.M. -Investigation process explained. Resident and family agreeable to plan of care for duration of investigation of CMT A not to reenter room, care to be provided in pairs, and resident not to be left alone on the toilet. Reviewed current pain medication orders with daughter. Resident had requested pain medication at this time. Family exited facility for the night at approximately 11:00 P.M.Review of CMT A's timesheet, dated 08/03/25, showed he/she worked from 6:30 A.M., to 10:30 P.M.During an interview on 08/06/25, at 10:51 A.M., Certified Medication Technician (CMT) A said the following:-When a resident alleges abuse, he/she would ask the resident what happened, and report it to the nurse;-He/she would consider hitting a resident to be physical abuse and yelling at a resident would be verbal abuse. He/she did not feel he/she had been abusive or disrespectful towards the resident;-On 08/03/25, about 8:30 P.M., he/she was eating a sandwich, counting medications, and rounding up charting. The resident began screaming for an aide. Nurse Aide (NA) B came through about that time and attempted to calm down the resident, but the resident continued to scream. He/she walked to the resident's room and with a louder voice so the resident could hear, he/she told the resident he/she shouldn't behave like that, NA B was trying to help another resident and would be with him/her shortly. He/she was standing close to the resident, and jelly dropped on the resident's blouse. When he/she attempted to wipe the jelly off, the resident said CMT A hit him/her;-He/she didn't remember if NA B and the other aide were in the room at the time, as they were in/out and had been helping the roommate;-He/she never hit the resident, he/she only tried to remove the jelly on the resident's blouse;-RN C had heard the commotion and went to the resident's room;-CMT A was told to stay out of the resident's room;-He/she administered medications the remainder of the night and did administer the resident's roommate's pills around 9:00 P.M., but did not administer any medications to the resident;-He/she knew the facility does an investigation when there are allegations of abuse, but he/she doesn't know if the accused staff is suspended. He/she was not suspended on 08/03/25. He/she came to work on 08/05/25 and was told he/she was suspended during the investigation. A nurse was supposed to have called him/her to let him/her know but they did not. During an interview on 08/06/25, at 11:50 A.M., NA B said the following:-On 08/03/25, between 8:00 and 8:30 P.M., he/she and the hall partner put the resident on the toilet. They did not leave the room but went to help the roommate. CMT A came into the room and said to the resident to stop yelling as they're going to help you when they get done helping the other resident. CMT was in the hall, The resident said you're not going to hit me. When NA B and his/her hall mate were done, they went to assist the resident. CMT A said the Resident said CMT A hit him/her, but CMT A only dropped jelly on the resident. He/she didn't hear CMT A yell at the resident, but CMT A did raise his/her voice as the resident was yelling. He/she couldn't see CMT A, but could hear what was going on in the bathroom and were in the room the entire time;-He/she went to speak to the resident and the resident said CMT A came in and cussed at him/her;-RN C in the area and heard the commotion, and came in when he/she and the other hall mate were going to assist the resident from the toilet;-CMT A worked the rest of his/her shift, until 10:00 P.M., or 10:30 P.M., passing medications but he/she did not have any further interaction with the resident. RN C told CMT A not to go back into the resident's room and we were told to go in pairs to provide care. During an interview on 08/06/25, at 12:05 P.M., RN C said the following:-On 08/03/25, around 8:30 P.M., he/she heard screaming from the room. The resident had been screaming all evening about various things and couldn't get him/her content. He/she had just gotten back from the hospital earlier in the day. He/she had been observing the resident and trying to de-escalate, as any little thing would set the resident off;-He/she went down the 400 hall, the hall next to the resident's room. He/she believed NA B told him/her the resident was saying CMT A hit the resident. He/she put his/her stuff down and went to the resident's room. CMT A had already left the room. He/she spoke to the resident and the resident said CMT A had hit him/her in the stomach. The resident did allow him/her to minimally observe both the right and left quadrants. There was no injury. The resident said he/she would not stand for this type of treatment. The resident did not say he/she was afraid. The resident was visibly and audibly upset;-He/she spoke to the aides in the room, and they verified they heard the conversation between the resident and CMT A, and they did not hear anything foul or physical contact;-He/she interviewed CMT A and he/she said she only dropped jelly on the resident's shirt and did not hit the resident;-He/she called the DON, and the family came into the facility;-CMT A was told not to go back into the resident's room. To the best of his/her knowledge, the CMT A did not go back into the resident's room;-He/she didn't know if CMT A had more medications to pass. He/she knew CMT A was squaring up his/her cart and putting things away;-He/she knew alleged abuse was to be reported to the state within two hours, but was wondering about staff being suspended. He/she didn't know if they're suspended when a resident makes allegations of abuse. During an interview on 08/06/25, at 12:34 P.M., the DON said the following:-He/she would expect any staff to report abuse to the Social Service Director (SSD), DON, or the Administrator;-He/she received a text from RN C on 08/03/25, at 9:21 P.M. This text was sent to the DON and the Administrator;-The text said RN C didn't think the allegation was legitimate, but the resident was adamant that CMT A hit him/her;-The resident had been screaming and agitated, and the aides were in the room a lot;-When the resident was on the toilet CMT A came in to see if the resident was okay and he/she was holding a peanut butter and jelly sandwich. Part of the jelly fell onto the resident. CMT A began to wipe it off and the resident started screaming you hit me and was going to call his/her daughter and the police. He/she asked RN C when the incident happened, and he/she was told within the last 30 minutes. A report was made to the state;-He/she had to learn the policy on suspension of staff when there are allegations of abuse. The CMT was at the end of his/her shift, so he/she left between 9:00 P.M., and 10:00 P.M. He/she assumed CMT A was already gone so he/she didn't ask if CMT A was still working. He/she didn't know if CMT A was around other residents or if he/she continued to pass medications after the allegation of abuse. He/she knew CMT A was not to go back into the resident's room and the aides were to do cares in pairs. If the CMT passed medications after the incident, he/she would have passed them on his/her on and did not have other staff with him/her;-He/she knows they have abuse training upon hire, as he/she went through the training.During an interview on 08/06/25, at 12:49 P.M., Licensed Practical Nurse (LPN) D said abuse was reported immediately to the nurse and he/she would tell the DON. He/she was not involved in the investigation process, but knew the facility does investigate and they're required to call the state within two hours. The accused staff are sent home immediately. During an interview on 08/06/25, at 12:57 P.M., CMT E said he/she would let the nurse know if a resident reports abuse. He/she would imagine the facility does an investigation and he/she doesn't know if the accused staff would be sent home. During an interview on 08/06/25, at 12:57 P.M., CMT F said he/she would report abuse immediately to the nurse, DON, or Administrator. They are to report the abuse to the state within four to six hours. The accused staff would be removed from the hall, but he/she didn't know if they're sent home. It would probably depend on the situation. If someone witnessed the abuse, they would be sent home. If not, they may be moved to another hall. During an interview on 08/06/25, at 1:10 P.M., the Assistant Administrator and Corporate Administrative Nurse said the following:-They would expect staff to intervene if a resident was being abused and remove them from the situation, so the staff is not around the resident;-The aide should notify the nurse, and the nurse would speak with the resident and report to the Administrator, DON, and/or the on call;-He/she received a text from RN C on 08/03/25, at 9:03 P.M., and was told the incident happened about 30 minutes prior. It said the resident was in the restroom and began screaming. CMT A entered to see what was going on and while speaking to the resident, the CMT had been eating a peanut butter and jelly sandwich, and some jelly fell onto the resident. CMT A attempted to wipe it off, and the resident said he/she was going to call his/her family and the police. RN C attempted to do a skin assessment, but didn't get one right away. RN C began to ask questions of the aides and CMT A. The resident's story has changed with various people. A report was made to the state. CMT A left soon after he/she gave report, a little after 10:00 P.M. He/she didn't believe CMT A passed anymore medications after the incident. He/she believed CMT A was at his/her cart counting meds when the incident happened. No one was assigned to be with CMT A the remainder of his/her shift;-When a resident makes allegations of abuse, they would suspend the accused staff at that time. CMT A was close to time to leave and needed to count the narcotics with the nurse. The resident said he/she wasn't afraid, and CMT A had always given good care. There were no changes in the resident's behavior after the incident. Complaint #25796190

Based on observation, interview, and record review, the facility failed to ensure all residents dependent on staff to for grooming and personal hygiene received baths/showers in a timely fashion for two dependent resident's (Resident #1 and #2). The facility census was 79. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed the following: -Purpose to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Document date and time the shower/tub bath was performed; -Document the name and title of the individual(s) who assisted the resident with the shower/tub bath, all assessment data obtained during the shower/tub bath, how the resident tolerated the shower/tub bath, if the resident refused the shower/tub bath, the reason(s) why and the intervention taken, and the signature and title of the person recording the data; -Notify the supervisor if the resident refuses the shower/tub bath; -Notify the physician of any skin areas that may need to be treated; -Report other information in accordance with facility policy and professional standards of practice. Review of the facility's Weekly Shower List Sheet showed anyone who refuses shower, staff to come back and try again. Staff to have the nurse try if the resident still refuses. Have the resident sign the shower sheet, or if they can't sign have the nurse sign the shower sheet and make a nurse's note. 1. Review of Resident #1's face sheet (admission data) showed the following information: -readmission date of 08/02/24; -Diagnoses included cerebral infarction (a condition where blood flow to the brain is blocked, leading to brain tissue damage), osteoarthritis (a condition where the cartilage (tissue that protects and supports joints and other structures in the body) in joints gradually wears away, leading to pain, stiffness, and reduced movement) and unspecified pain. Review of the resident's significant change assessment Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 01/28/25, showed the following information: -Cognitively intact; -No assessment of shower/bathing noted; -Resident frequently incontinent of bowel and bladder. Review of the resident's care plan, initiated 08/14/24, showed the following information: -Resident had activities of daily living (ADL) self-care performance deficit related to diagnosis of stroke with right sided weakness; -Dependent on staff for all ADL's except eating; -Incontinent with bowel and bladder and staff to assist with hygiene; -The resident had potential for impairment to skin integrity related to immobility and incontinence; -Keep skin clean and dry. (Staff did not care plan related to preferred shower frequency or any shower/bath preferences. The staff did not care plan regarding any pattern of resident refusal to bathe.) Review of the facility's Weekly Shower List sheet showed the resident was scheduled for a shower/tub bath on Mondays and Thursdays. Review of the resident's March 2025 Shower Sheets showed the following: -On 03/02/25, the resident received a shower; -On 03/09/25, the resident refused a shower; -On 03/10/25, the resident refused a shower; -On 03/19/25, the resident received a shower (17 days after prior shower and 9 days after last offered shower); -On 03/24/25, the resident received a shower. Review of the resident's March 2025 progress notes showed the following: -Staff did not document showers offered or completed any other days in March; -Staff did not document regarding the resident missing and/or going 17 days without a shower. 2. Review of Resident #2's face sheet showed the following information: -admission date of 12/12/24; -Diagnoses included cerebral infarction, irregular heartbeat, and paralysis of the left non-dominant side. Review of the resident's admission assessment MDS, dated [DATE], showed the following information: - Cognitively intact; -Dependent with showering/bathing; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, initiated 12/18/24, showed the following information: -Keep skin clean and dry; -Dependent on staff for all ADL's and mobility; - The care plan does not indicate that the resident frequently refuses showers and/or resident specific requests regarding shower days and/or times. (Staff did not care plan related to preferred shower frequency or any shower/bath preferences. The staff did not care plan regarding any pattern of resident refusal to bathe.) Review of the facility's current Weekly Shower List Sheet showed the resident was scheduled for a shower/tub bath on Mondays and Thursdays. Review of the resident's March 2025 Shower Sheets showed the following: -The resident received a shower on 03/05/25; -The resident received a shower on 03/10/25 (seven days after the prior shower); -The resident received a shower on 03/23/25 (13 days after the prior shower); -The resident received a shower on 03/27/25. Review of the resident's March 2025 progress notes showed the following: -Staff did not document showers offered or completed any other days in March; -Staff did not document regarding the resident missing shower days and/or going 13 days without a shower. During an interview on 04/02/25, at 12:38 P.M., the resident and his/her spouse said the resident's last shower was Thursday, 03/26/25 and that residents were having to fight for showers. The resident's spouse said the resident had gone as long as 12 days without a shower. When the spouse had requested that the resident be given a shower, the staff ask him/her to do it his/herself. 3. During an interview on 04/03/25, at 11:58 A.M.,Certified Nursing Assistant (CNA) D said the following: -There were designated shower aides every day; -If a resident refused a shower that should be documented on the resident's shower sheet. During an interview on 04/03/25, at 12:24 P.M., CNA E said the following: -He/she was not aware of any recent shower refusals; -He/she would assume that it would be appropriate to notify the charge nurse for any frequent refusals and/or write it in on the resident's shower sheets; -It would not be appropriate for a resident to go several days without a shower. During an interview on 04/03/25, at 12:05 P.M., Licensed Practical Nurse (LPN) A said the following: - Resident showers were scheduled weekly and the facility did have a shower aide, but shower aide coverage was slim; -Sometimes, residents do not get one shower per week. -The Administrator makes the shower schedule. -The nurses receive a copy of showers given from the showers aide and the form includes new wounds. -If a resident continually refuses to take a shower, the family should be notified. - Nurses are not told if a resident refuses a shower or even who receives a shower. During an interview on 04/03/25, at 3:00 P.M., Registered Nurse (RN) B said the following: -He/she had not looked at the shower schedule. -The facility had one shower aide for 100, 200, and 300 halls and one for 400 and 500 halls. -Hospice provides showers/bathing for some residents. -Residents should receive a shower two times per week. -Residents have a right to refuse showers. Residents are encouraged to take at least one shower per week. -He/she had not received any shower sheets showing residents are refusing showers. During an interview on 04/04/25, at 10:15 A.M., the Director of Nursing (DON) said the following: -The facility had shower aides Monday through Friday and if there was extra staff on the weekend, they did showers on the weekend. -There was one shower aide for the 100, 200, and 300 halls and one shower aide for the 400 and 500 halls. -Some residents are care planned to have showers one time per week per the resident's preference. -Residents were provided two showers per week unless they refuse. If a resident refused a shower, staff have a form to document the refusal on. -He/she would expect staff to complete the refusal form and notify the charge nurse to encourage showers. -It was not appropriate for residents to go greater than 10 days without receiving a shower, unless the resident refuses. In that case staff would document the refusal During an interview on 04/04/25, at 10:38 A.M., the Administrator said the following: -She would expect staff to offer residents showers two times per week. -Some residents only want a shower one time per week and some residents refuse showers. -She stated that there were only two weeks since December of 2024 that he/she was aware of that staff was not available to give showers to residents two times per week. That has not been the case recently. -If residents refused a shower, staff was expected to fill out the refusal sheet. -The Administrator was not aware of any residents going over 10 days without a shower. -If a resident refused a shower for the third time, he/she would expect staff to offer at least a sink bath. He/she said no resident was missing a shower because it was not offered. Staff should document refusals on the shower sheet. - In the past, staff offered residents to tell what one day of the week works best for them if they want a shower a specific day of the week. MO00251182, MO00251915, MO00251921

Based on observation, interview, and record review, the facility failed to provide care per professional standards related to pressure ulcers (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) when the facility staff failed to obtain physician's orders for treatment and interventions of wounds and failed to update the care plan regarding skin breakdown intervention changes for one resident (Resident #3) out of seven sampled residents. The facility census was 79. Review of the facility's policy titled, Pressure Injury Risk Assessment, revised March 2020, showed the following: -Identify all risk factors and then determine which can be modified and which cannot, or which can be immediately addressed, and which will take time to modify; -The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed; -Once the assessment is conducted a risk factor are identified and characterized, a resident centered care plan can be created to address the risks for pressure injuries; -If a skin alteration is noted, initiate a pressure or non pressure form related to the type of alteration; -Establish interventions for the skin alteration; -Document the type of skin alteration, time and date of discovery, treatment, initiation of pressure reduction devices, and notifications to the physician and family. -Notify the supervisor, physician, and family. Review of the facility's policy titled, Wound Care, revised October 2010, showed staff to document the type of care given, the date and time, name and title of person performing care, change in status, and assessment data such as wound bed color, size, and drainage. 1. Review of the Resident #3's face sheet (brief look at resident information) showed the following information: -admission date of 03/31/25; -Diagnoses included osteonecrosis (a condition where bone tissue dies due to lack of blood supply), hypertension (a condition where blood pressure in the artery wall is too high), chronic obstructive pulmonary disease (COPD - a lung disease causing restricted airflow and breathing problems), and rheumatoid arthritis with rheumatoid factor (a disease that causes inflammation in the joints, leading to pain, swelling, and stiffness). Review of the resident's baseline care plan, dated 03/31/25, showed the following information: -Current skin integrity issues identified as left buttock 2 x 2 centimeter (cm) open lesion; right buttock approximate 4 x 4 cm open lesion; 3 x 2 cm open lesion to sacrum (a bone located in the lower back and upper part of the pelvic bone). -The resident had right hip arthroplasty (joint replacement surgery) for necrotic (death of living tissue) hip. Wound vac (a medical device that uses negative pressure to help wounds heal) intact at -125. Weight bearing as tolerated right lower extremity. -On Lovenox (a medication that helps prevent blood clots) for deep vein thrombosis (DVT - a condition where a blood clot forms in a deep vein) non-occlusive (does not completely block blood flow). -admitted for physical therapy, occupational therapy, and resolution of DVT. (Staff did not care plan related to care of or treatment for the denitrified wounds.) Review of the resident's Facility to Facility Discharge Information, document from the discharging hospital, dated 03/31/25, showed the following information: -To contact the physician for increased pain; -To follow wound/incision care instructions as recommended by the physician. (The form did not include any specific care or treatment instructions for the identified wounds.) Review of the resident's admission skin assessment, dated 03/31/25, showed the following: -Present on admission, a stage 2 (partial-thickness skin loss with exposed dermis) pressure ulcer/injury on left medial gluteus (buttocks), 2 cm in length, 2 cm width, and zero depth; -Present on admission, a stage 2 pressure ulcer/injury on right gluteus, 4 cm in length, 4 cm width, and zero depth. Light exudate (drainage) amount, with peri wound (skin around the wound) edges flush with wound bed or as a sloping edge; -Present on admission, a stage 2 pressure ulcer/injury on lateral coccyx (bone at the bottom of the spine), 3 cm in length, 2 cm width, zero depth, epithelial (a type of tissue in the body that forms a protective barrier on the outside of organs and lines internal cavities and passageways) 10%, granulation (a type of tissue that forms during the healing process of wounds, appearing as a pink or red, moist, and bumpy tissue) 20%. Peri wound edge appears flush with wound bed or as a sloping edge. (Staff did not document regarding wound treatments/orders, or regarding the resident's surgical incision.) Review of the resident's March 2025 Progress Notes showed the following: -On 03/31/25, at 9:47 P.M., resident was chair-fast and very limited. Resident made occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently. Potential problem with friction and shear. -On 03/31/25, at 9:48 P.M., a new stage 2 pressure ulcer/injury on the resident's left gluteal fold, laterally and medial. Measurements showed 2 cm in length, 2 cm in width, and zero depth. A second stage 2 pressure ulcer/injury was noted on the right gluteus, medial, with a length of 4 cm, width 4 cm, zero depth, and light exudate. A stage 2 pressure ulcer/injury was also noted on the lateral coccyx. It was 3 cm in length, 2 cm width, zero depth, 10% epithelial, and 20% granulation. All three wounds were present on admission, but staff was unsure how long the wounds were present. Additional documentation showed skin issue education provided to the resident, which included changing or shifting positions frequently and turning every two hours. Notification of skin issue included the dietitian, family, and provider. The RN also documented the resident had a right hip surgical incision with a wound vac. Review of the resident's March 2025 Physician Order Sheet (POS) showed the following: -No wound vac orders; -No wound treatment ordered for the buttock wounds. Review showed the facility did not provide a March 2025 Treatment Administration Record (TAR) for the resident. Review of the resident's April 2025 POS showed the following: -An order, dated 04/01/25, for house barrier cream as needed; -No wound vac orders; -No wound treatment orders for buttock wounds on 04/01/25 or 04/02/25. Review of the resident's April 2025 Progress Notes showed the following: -On 04/01/25, at 11:24 A.M., an RN noted a skin issue on the left gluteal fold had been evaluated. Described as a lateral, medial, stage 2 pressure ulcer/injury with partial thickness skin loss with exposed dermis. The wound was present on admission. It was unknown how long the wound had been present. Skin issue number two was described as a stage 2 pressure ulcer/injury, with partial thickness skin loss with exposed dermis. The wound was present on admission. It was unknown how long the wound was present. Wound number three was evaluated and documented as a stage 2 pressure ulcer/injury on the lateral coccyx with partial thickness skin loss and exposed dermis. The wound was present on admission, and it was unknown how long the wound had been present. No measurements were documented as part of the assessment. All wounds were staged in-house by nursing and no measurements were documented as part of the skin assessment; -On 04/01/25, at 4:39 P.M., a RN noted wound vac to surgical site. (Staff did not document any care and/or treatment of the wounds.) Review of the resident's April 2025 TAR showed staff did not document wound care treatments completed or ordered on 4/01/25 or 4/02/25. Review of the resident's April 2025 progress notes showed staff did not document any care and/or treatment for the wounds for 04/01/25 and 04/02/25. Observation on 04/03/25, at 9:57 A.M., showed the resident was behind closed doors using the restroom. The resident reported to the staff member present that he/she had wounds to his/her bottom. The staff member questioned the resident about how long the wounds had been there, and that he/she would report it. During an interview on 04/03/25, at 9:57 A.M., the resident said the following: -He/she had wounds to his/her buttocks since admission to the facility. He/she had told multiple staff members, and no one had done anything about it; -A nurse did assess the wounds on admission, but did not initiate treatment; -The staff were aware that he/she also had a surgical incision to the right hip with a wound vacuum in place. -The wounds hurt. During an interview on 04/03/25, at 10:01 A.M., Licensed Practical Nurse (LPN) C said the following: -He/she was aware the resident had a wound vac in place to his/her right hip; -He/she had not been made aware of any wounds to the residents buttocks; -He/she looked in the resident's electronic medical record (EMR) and said he/she could not find any documentation or treatment orders related to the residents reported buttocks wounds and/or the wound vac. Observation on 04/03/25, at 10:10 A.M., showed LPN enter the resident's room and asked to assess the residents' wounds. The resident agreed. The resident told the LPN that he/she believed he/she was going to an orthopedic appointment on the following Monday for removal of the wound vac. The resident reported to the LPN that the wounds to his/her buttocks had been there when he/she admitted to the facility and that they were painful. Two wounds were seen, one on each buttock. Both wounds had partial thickness skin loss, and no dressings and/or cream in place. Both wounds were approximately dime sized and the wound on the right buttock was seen to have 50% slough tissue (dead tissue that presents as yellow or white, stringy, moist and often adherent tissue found in wound beds). The wound on the left buttock appeared to be 100% granulation tissue. Both wounds had purple peri-wounds. Review of the resident's April 2025 POS showed an order, dated 04/03/25, for zinc oxide (cream) 10%, apply to two inner buttock areas topically every day and evening shift until healed. During an interview on 04/03/25, at 11:58 A.M., Certified Nursing Assistant (CNA) D said the following: -Any new skin concern should be reported to the charge nurse immediately; -The aides have a documenting task in the resident's EMR and it asks about skin integrity; -The resident came in with blisters on his/her bottom; -The nurses were supposed to do a full body assessment when a resident admitted , but he/she personally documented it as well; -He/she had never seen a treatment on the resident's wounds. During an interview on 04/03/25, at 12:24 P.M., CNA E said the following: -He/she was aware that the resident has a wound vac to the right hip; -He/she was aware that the resident has wounds to his/her buttocks; -He/she had not seen any treatment on the buttocks wounds. During an interview on 04/03/25, at 12:05 P.M., LPN A said the following: -Skin assessments were completed by the nursing staff at least weekly; -The skin assessment due dates pop up on the Medication Administration Record (MAR) to alert the nursing staff; -The facility had a wound care doctor that was employed outside of the facility, and he/she completed rounds with the nursing staff; -He/she has been instructed by the Director of Nursing (DON) to do a dressing change on new wounds and relay the information to other staff until the wound doctor is available to evaluate the wound. During an interview on 04/03/25, at 3:00 P.M., Registered Nurse (RN) B said the following: -Contracted wound care staff came to the facility one time per week; -Skin assessments were completed weekly by the charge nurse and documented in the assessment section within the resident's electronic health record; -Wound orders should be on the resident's Treatment Administration Record (TAR); -If a resident did not have wound care orders, but needed them, staff would contact the primary care physician to obtain orders; -If a new wound was observed, he/she would place a dressing over it and notify the physician; -The facility had two physicians that see and treat residents at least one time per week; -The facility had limited physician standing orders for wounds; -The skin assessment was one of the first assessments that should completed with the head-to-toe assessment; -He/she would cleanse and cover new wounds, until the physician is notified and provides guidance. During an interview on 04/04/25, at 10:14 A.M., the DON said the following: -She was not aware of the resident's wounds until 04/03/25, when wound care orders were placed; -Newly admitted residents were expected to have a head-to-toe assessment within 30 minutes after admission; -If wounds were found on the head-to-toe assessment, he/she would expect staff to contact the physician for wound care orders; -The facility did have some standing orders for wound care, but the orders are not very specific. During an interview on 04/04/25, at 10:38 A.M., the Administrator said the following: -He/she would expect the admitting nurse to document wounds and wound vac information; -Treatment should be initiated for wounds; -All necessary notifications should be made. During an interview on 04/04/25, at 10:38 A.M., the Regional Nurse Consultant said the following: -If a resident is admitted with a wound vac, there should be an order from the physician that gives direction on the wound vac; -All wounds should be assessed and have treatment initiated; -All necessary notifications should be made. MO00251919, MO00252115

Based on observation, interview, and record review, the facility failed to ensure an effective and accurate pain management program was in place when staff failed to ensure pain patches were on-hand for administration, when staff documented administration of pain patches that were not administered, and when staff failed to accurately document monitoring of the pain patch placement for one resident (Resident #1) out of 7 sampled residents. The facility census was 79. Review of the facility's policy titled, Documentation of Medication Administration Policy, revised April 2007, showed the following: -Administration of medication must be documented immediately after (never before) it is given; -Documentation must include at a minimum: name, strength of drug, dose, method of administration, date and time of administration, reason(s) why a medication was withheld, not administered, or refused, signature and title of person administering the medication, and resident response to the medication, if applicable. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, showed drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available. Review of the facility's policy titled, Administering Medications, revised April 2019, showed the following: -The Director of Nursing (DON) supervise and directed all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescriber orders, including any required time frame; -If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR) space for that drug and dose; -As required or indicated for a medication, the individual administering the medication records in the residents medical record the following; date and time the medication was administered, dosage, route of administration, injection site if applicable, complaints or symptoms associated, results achieved and when those results were observed, and the signature and title of the person administering the drug. 4. Review of the Resident #1's face sheet (brief resident profile sheet) showed the following information: -readmission date of 08/02/24; -Diagnoses included cerebral infarction (a condition where blood flow to the brain is blocked, leading to brain tissue damage), osteoarthritis (a condition where the cartilage (tissue that protects and supports joints and other structures in the body) in joints gradually wears away, leading to pain, stiffness, and reduced movement) and unspecified pain. Review of the resident's significant change assessment Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 01/28/25, showed the resident was cognitively intact and had been on a scheduled pain medication regimen. Review of the resident's care plan, initiated 08/14/24, showed the following: -The resident had pain related to a diagnosis of osteoarthritis (a degenerative joint disease where cartilage breaks down, causing pain, stiffness, and reduced movement); -Staff was to anticipate the resident's need for pain relief and respond immediately to any complaint of pain; -Staff was to monitor, record, report to nurse any signs and symptoms of non-verbal pain, changes in breathing, vocalizations such as moaning or yelling out, mood or behavior changes, and changes to eyes, face, and body related to pain; -Staff was to monitor, record, report to nurse resident complaints of pain or requests for pain treatment; -Staff was to notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Review of the resident's Physician Order Sheet (POS) showed an order, dated 12/21/24, for fentanyl (a potent synthetic opioid drug approved by the Food and Drug Administration (FDA) for use as an analgesic (pain relief) and anesthetic) transdermal patch 72-hour 25 micrograms per hour (mcg/hr), apply one patch transdermally (route of administration where medication is delivered via a patch through the skin) every 72 hours for pain. The order was discontinued on 03/07/25. Review of the resident's February 2025 Controlled Drug Receipt Record/Disposition Form showed the following: -On 02/22/25, one Fentanyl 25 mcg/hr patch was removed at 7:01 P.M., and four patches remained available; -On 02/25/25, one Fentanyl 25 mcg/hr patch was removed at 5:00 P.M., and three patches remained available; - On 02/28/25, one Fentanyl 25 mcg/hr patch was removed at 6:00 P.M., and two patches remained available. Review of the resident's March 2025 Medication Administration Record (MAR) and March 2025 Progress notes, dated 03/01/25, showed the day, evening, and night shift staff documented the fentanyl 25 mcg/hr patch was observed on the resident's left upper back. Review of the resident's March 2025 Controlled Drug Receipt Record/Disposition Form showed on 03/02/25, at 5:08 P.M., staff applied a fentanyl patch 25 mcg/hr to the resident's left chest. Review of the resident's March 2025 MAR and March 2025 progress notes showed on 03/02/25, the day, evening, and night shift documented the fentanyl patch was observed on the residents left upper back. (Staff did not document related the the patch noted to be on the resident's chest.) Review of the resident's March 2025 Controlled Drug Receipt Record/Disposition Form showed on 03/03/25, one Fentanyl 25 mcg/hr patch was removed from the count, and a new patch was applied to the resident at 5:30 P.M., and one patch remained available. Review of the resident's March 2025 MAR and progress notes showed on 03/03/25, the day, evening and night shift staff documented the Fentanyl patch was observed on the resident's left upper back. (Staff did not document related the the patch noted to be on the resident's chest.) Review of the resident's March 2025 Drug Destruction Log showed on 03/03/25 the newly applied fentanyl 25 mcg patch was destroyed and verified by two staff signatures. Review of the resident's March 2025 MAR and March 2025 Progress Notes showed the following: -On 3/04/25, the day, evening and night shift staff documented the fentanyl patch was observed on the resident's left chest; -On 3/05/25, the day, evening and night shift staff documented the fentanyl patch was observed on the resident's left chest; -On 3/06/25, the day, evening and night shift staff documented the fentanyl patch was observed on the resident's left chest; -On 3/06/25, at 5:38 P.M., staff applied a new fentanyl patch 25 mcg/hr to the resident's left chest. Review of the resident's POS showed the previous fentanyl order was discontinued on 03/07/25, and a new order, dated 3/07/25, showed the same instructions of fentanyl transdermal patch 72-hour 25 mcg/hr, apply one patch transdermally every 72 hours for pain. Review of the resident's March 2025 Progress Notes showed an order note dated 03/07/25, at 10:30 P.M., for a drug protocol alert/warning for fentanyl transdermal patch 72-hour 25 mcg/hr, controlled drug, apply one patch transdermally every 72 hours for pain with drug-to-drug interaction triggered for Zofran (a medication that prevents nausea and vomiting) oral tablet 4 mg, hydrocodone-acetaminophen (a opioid mediation used to treat pain) oral tablet 5-325 mg, and sertraline (an antidepressant) HCL oral tablet 25 mg. Review of the resident's medical record showed staff did not document follow-up related to alert/warning. Review of the resident's March 2025 MAR and March 2025 Progress Notes showed on 03/07/25, the day, evening and night shift staff documented the fentanyl patch was observed on the resident's left chest. Review of the resident's March 2025 Controlled Drug Receipt Record/Disposition Form showed on 03/08/25, one fentanyl 25 mcg/hr patch was removed from the count and applied to the resident at 8:50 A.M., and zero patches remained available. Review of the resident's March 2025 MAR and March 2025 Progress Notes showed the following: -On 03/08/25, at 9:02 A.M., staff applied fentanyl patch 25 mcg/hr to right chest; -On 03/08/25, the day, evening, and night shift staff documented the fentanyl patch was observed on the resident's right upper chest. Review of the facility's Emergency Kit Usage Report showed one fentanyl 25 mcg/hr patch removed for the resident on 03/09/25, at 4:31 P. M. Review of the resident's March 2025 Progress Notes showed the following: -Administration note on 03/09/25, at 4:41 P.M., showed Registered Nurse (RN) F applied new patch on 03/09/25 related to previous patch applied on 3/08/25, falling off and due to the plastic not being removed. Physician notified. Old patch was wasted in sharps container with Certified Medication Tech (CMT) H; -Administration note on 03/09/25, at 6:22 P. M., showed RN F reapplied new patch to left upper chest. Review of the resident's March 2025 MAR and March 2025 Progress Notes showed the following: -On 03/09/25, the day, evening, and night shift staff documented the fentanyl patch was observed on the resident's right upper chest; -On 03/10/25, the day, evening, and night shift staff documented the fentanyl patch was observed on the resident's right upper chest; -On 03/11/25, at 4:41 P.M., staff applied a fentanyl patch 25 mcg/hr to the resident's right chest. (The resident was not due for administration until 03/12/25.) Review of the resident's Controlled Drug Receipt Record/Disposition form showed the resident did not have a current supply of fentanyl patches to remove for administration. Review of the facility's Emergency E-kit use log, dated 03/11/25, showed staff did not withdraw a fentanyl patch for the resident. Review of the resident's medical record showed no order of fentanyl patches had been received for the resident since the the patch applied on 03/08/25. Review of the resident's March 2025 MAR and March 2025 Progress Notes showed the following: -On 03/11/25, the day, evening, and night shift staff documented the fentanyl patch was observed on the resident's right upper chest; -On 03/12/25, the day, evening and night shift staff documented the fentanyl patch was observed on the resident's right upper chest; -On 03/13/25, the day, evening and night shift staff documented the fentanyl patch was observed on the resident's right upper chest; -On 03/14/25, at 7:43 A.M., RN B documented administration of 25 mcg/hr fentanyl patch to resident's right chest. Review of the resident's Controlled Drug Receipt Record/Disposition form showed the resident did not have a current supply of Fentanyl patches to remove for administration on 03/14/25. Review of the Emergency E-kit use log, dated 03/14/25, did not indicate staff removed a fentanyl patch for the resident. Review of the resident's medical record showed no order of fentanyl patches had been received for the resident since the the patch applied on 03/08/25. Review of the resident's progress note, showed a late entry entered on 04/02/25 or 03/14/25, that stated the fentanyl 25 mcg/hr medication was not administered as previously documented, as the resident had no patches for administration. Review of the resident's March 2025 MAR and March 2025 progress notes showed the following: -On 03/14/25, the day, evening, and night shift staff documented the fentanyl patch was observed on the resident's right upper chest; -On 03/15/25, the day, evening and night shift staff documented the fentanyl patch was observed on the resident's right upper chest; -On 03/16/25, the day, evening and night shift staff documented the fentanyl patch was observed on the resident's right upper chest; - On 03/17/25, at 8:00 A.M., staff applied fentanyl patch 25 mcg/hr to left chest. Review of the resident's Controlled Drug Receipt Record/Disposition form showed the resident did not have a current supply of fentanyl patches to remove for administration on 03/17/25. Review of the Emergency E-kit use log, dated 03/17/25, showed staff did not indicate a fentanyl patch withdrawal for the resident. Review of the resident's medical record showed no order of fentanyl patches had been received for the resident since the the patch applied on 03/08/25. Review of the resident's progress note, showed a late entry entered on 04/02/25 for 03/17/25, noting the fentanyl 25 mcg/hr medication was not administered as previously documented, as the resident had no patches for administration. Review of the resident's March 2025 MAR and progress notes showed the following: -On 03/17/25, the day, evening, and night shift staff documented the fentanyl patch was observed on the resident's left upper chest; -On 03/18/25, the day and evening shift staff documented the fentanyl patch was observed on the resident's left upper chest; - On 03/18/25, the night shift staff documented the fentanyl patch was observed on the resident's right upper chest; - On 03/19/25, the day, evening, and night shift staff documented the fentanyl patch was observed on the resident's right upper chest. Review of the resident's March 2025 Progress Notes showed an administration note on 03/19/25, at 2:13 P.M., entered by Licensed Practical Nurse (LPN) A, noted LPN observed the fentanyl patch from 03/09/25 remained on the resident's chest. No new patches on hand and waiting for further direction on removal. Review of the resident's Controlled Drug Receipt Record/ Disposition form showed the resident received 5 fentanyl patches from the pharmacy on 03/19/25. During an interview on 04/03/25, at 12:05 P.M., LPN A said the following: -On 03/19/25, he/she observed a fentanyl patch on the resident that was dated 03/09/25. He/she informed the house supervisor nurse and was instructed to leave the patch in place until the Director of Nursing (DON) was aware of it; -There were no fentanyl patches available for the resident at the time. He/she left the fentanyl patch on until a new order was received, and more patches arrived at the facility; -He/she notified the DON of the outdated patch several times and was repeatedly told that he/she was aware of the situation, but no direction was provided by the DON; -The new fentanyl order was the exact same order as the discontinued order. The new order was placed to restart the fentanyl patches, as there had been a gap in administration; -Fentanyl patches should be removed and destroyed with another nurse or medication technician in the locked medication room; -Narcotic counts are to be completed every shift. During an interview on 04/03/25, at 3:00 P.M., RN B said the following: -He/she was familiar with the resident and recalled resident not having fentanyl patches available for the resident, but he/she did not know why they were not available; -Protocol was to pull the unavailable medications from the facilities E-Kit, but at the time, he/she was new to the facility and did not have access to the E-kit in order to obtain the fentanyl patch; -He/she did not ask another staff member to pull the fentanyl patch for the resident from the emergency kit; -He/she charted incorrectly two times that fentanyl patches were applied to the resident, but no fentanyl patches were available or applied to the resident; -The resident had an old fentanyl patch in place for more days than it should have been. He/she does not remember speaking to the doctor about it. -He/she did notify the DON that the resident was out of fentanyl patches, but he/she did not notify the DON regarding the old patch being in place beyond its removal date. -Certified medication technicians (CMT) are not aloud to assist in the destruction and/or administration of fentanyl patches; -Medications are re-ordered through the residents EMR, and/or by phone to the pharmacy. The pharmacy delivers medications Monday through Friday. -He/she believed there was an issue with the physician not signing the script timely enough for delivery, but did not notify the physician of the concerns. During an interview on 04/04/25, at 10:14 A.M., the DON said the following: -She would expect staff to pull the fentanyl patch from the emergency kit if no patches were available in the resident's medication supply; -She would expect staff to correctly document medication administration on the resident; -When the staff seen the medication error had occurred, the physician should have been notified for direction. During an interview on 04/04/25, at 10:38 A.M., the Administrator said the following: -She would expect staff to follow facility policies and procedures for applying, documenting, and destroying fentanyl patches. -It is her assumption that Fentanyl patches would go into a medication destroyer bucket in the locked medication room. During an interview on 04/04/25, at 10:50 A.M., the Regional Nurse Consultant said staff should follow facility policy and procedures for applying, documenting, and destroying fentanyl patches. MO00251182, MO00251919

Based on record review and interview, the facility failed to ensure all residents were free from significant medication errors when staff administered another resident's medication to one resident (Resident #1) resulting in an unsafe drop in blood pressure and hospitalization of the resident. Staff also failed to administer insulin as ordered and contact the physician regarding insulin not available for one resident (Resident #3) resulting in elevated blood sugar levels and hospitalization of the resident. A sampled of ten residents were reviewed in a facility with a census of 67. 1. Review of the facility policy titled Administering Medications, April 2019, showed the following: -Medications are administered in a safe and timely manner, and as prescribed; -The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescribed orders, including any required time frame; -Medication errors are documented, reported, and reviewed by the QAPI (quality assurance and performance improvement) Committee to inform process changes of the need for additional staff training; -Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders); -The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking identification band; checking photograph attached to medical record; and if necessary, verifying the resident with other facility personnel; -The individual administering the medications checks the label three times to verify the right resident, right medication, right time, and right method (route) of administration before giving the medication; -Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services. During an interview on 08/16/24, at 10:25 A.M., Certified Medication Tech (CMT) A said the following: -He/she had been trained on seven rights of medication administration, which included the right resident, right medication, right dose, right time, right route, right documentation, and right reason; -Staff should verify resident and medication by the resident picture in the computer and the resident name on the medication; -He/she worked on the morning of 08/12/24 and had the medication cart in front of Resident #2's room and was preparing medications for Resident #2; -Resident #1 walked down the hall with physical therapy staff; -Resident #1 stopped at the medication cart and he/she handed the resident a cup of medication and a cup of water; -Almost immediately the he/she realized he/she had given the wrong medication to the resident and had the resident spit out as much medication as he/she could; -He/she notified the charge nurse and the resident was seated near the nurses' station; -The CMT believed that all of Resident #2's morning medications were in the cup given to Resident #1. -The nurse contacted the physician and when the resident's blood pressure was too low, the resident was was sent to the emergency room ; -This occurred at approximately 11:00 A.M. as the CMT was behind with the morning medications; -The CMT did not administer any additional medications to Resident #1. Review showed the facility did not provide an investigation related to the medication error. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included cerebral infarction (stroke), encephalopathy (a disease that affects the function or structure of your brain), dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), hypertension (high blood pressure), and paroxysmal atrial fibrillation (type of irregular heartbeat that causes the heart to beat quickly and erratically for a few hours or days); -A picture of the resident on the face sheet. Review of Resident #1's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 08/06/24, showed severe cognitive impairment and use of oxygen. Review of the Resident #1's care plan, last updated 08/09/24, showed staff should administer medications as ordered. Review of Resident #2's face sheet showed the following: -Original admitted [DATE]; -Re-admitted [DATE]; -Diagnoses included osteomyelitis (bone infection that causes inflammation and swelling in the bone) of vertebra lumbar region (lower back), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), and sepsis (an infection that has spread throughout the body); -No picture of the resident. Review of Resident #2's admission MDS, dated [DATE], showed severe cognitive impairment and use of oxygen. Review of Resident #2's care plan, last updated 08/13/24, showed the following: -Resident currently receiving medications that has black box warnings (required warning the U.S. Food and Drug Administration (FDA) for certain medications that carry serious safety risks); -Medications with black box warning are flagged on the Medication Administration Record (MAR); -Staff should administer medications as ordered. Review Resident #2's physician's orders, current as of 08/16/24, showed the following: -An order, dated 07/23/24, carvedilol (treats high blood pressure and helps prevent heart disease) 37.5 milligrams (mg), give 37.5 mg two times day related to hypertension. Administer at 8:00 A.M.; -An order, dated 07/23/24, for Xarelto (can treat and prevent blood clots) 2.5 mg, give 2.5 mg two times day related to hypertension. Administer at 8:00 A.M.; -An order, dated 07/24/24, ascorbic acid (vitamin C) 500 mg, give two tablets one time day related to osteomyelitis of vertebra. Administer medication between 7:00 A.M. and 10:00 A.M.; -An order, dated 07/24/24, for losartan potassium (can treat high blood pressure) 50 mg, give one tablet one time day related to hypertension. Administer medication between 7:00 A.M. and 10:00 A.M.; -An order, dated 07/24/24, for Amitizia (used to treat certain types of constipation) 24 micrograms (mcg), give one capsule two times day related to constipation. Administer medication between 7:00 A.M. and 10:00 A.M. and between 4:00 P.M. and 7:00 P.M.; -An order, dated 07/26/24, for spironolactone (used to treat certain types of edema and high blood pressure) 12.5 mg, give 12.5 mg one time day related to hypertension. Administer medication between 7:00 A.M. and 10:00 A.M.; -An order, dated 08/06/24, for hydralazine HCL (used to treat high blood pressure) 25 mg, give three tablets three times day related to hypertension. Administer at 9:00 A.M.; -An order, dated 08/06/24, for amlodipine besylate (lowers blood pressure) 10 mg, give 10 mg one time day related to high blood pressure. Administer medication between 7:00 A.M. and 10:00 A.M.; -An order, dated 08/06/24, aspirin 81 mg, give 81 mg one time day related to high blood pressure. Administer medication between 7:00 A.M. and 10:00 A.M.; -An order, dated 08/06/24, CoQ10 100 mg (antioxidant that the body produces naturally), give one capsule one time for supplement. Administer medication between 7:00 A.M. and 10:00 A.M.; -An order, dated 08/06/24, for fenofibrate (can lower high cholesterol and triglyceride levels) 54 mg, give 54 mg one time day related to hypercholesterolemia (high cholesterol). Administer medication between 7:00 A.M. and 10:00 A.M.; -An order, dated 08/06/24, for pantoprazole sodium (used for heartburn) 20 mg, give one tablet one time day for acid reflux. Administer medication between 7:00 A.M. and 10:00 A.M.; -An order, dated 08/06/24, for docusate sodium (helps soften stool) 100 mg, give 200 mg two times per day related to constipation. Administer at 8:00 A.M.; -An order, dated 08/07/24, for aspirin (used to relieve mild or chronic pain and to reduce fever and inflammation) 81 mg, give 81 mg two times day related to hypertension. Administer at 8:00 A.M.; -An order, dated 08/07/24, for Effer-K 10 meq (dietary supplement that raises potassium levels when they are too low), give one tablet two times day for supplement. Administer at 8:00 A.M.; -An order, dated 08/08/24, for Milk [NAME] (supplement can be used for liver disorders and gallbladder problems) 150 mg, give 600 mg one time day for liver disease. Administer medication 8:00 A.M.; -An order, dated 08/08/24, for multiple vitamin, give one tablet one time day for supplement. Administer medication at 8:00 A.M.; -An order, dated 08/09/24, for acidophilus probiotic (used to promote the growth of good bacteria in the body), give one capsule two times day for prophylactic treatment until 08/19/24. Administer medication between 7:00 A.M. and 10:00 A.M.; -An order, dated 08/10/24, for Keflex (used to treat certain infections) 500 mg, give 500 mg three times day for infection until 08/15/24. Administer at 9:00 A.M. Review of the Resident #2's Medication Administration Record, dated 08/01/24 through 08/31/24, showed the following: -A picture of the resident; -Staff documented the resident's morning medications for 08/12/24 as administered. Review Resident #1 physician's orders, current as of 08/12/24, showed the following: -Picture of the resident on the MAR; -An order dated 08/02/24, for docusate sodium 100 mg, give one capsule two times day for constipation, administer between 7:00 A.M. and 10:00 A.M. (half the dose that was administered in error); -An order dated 08/02/24, losartan potassium 25 mg, give one tablet two times day for hypertension, administer between 7:00 A.M. and 10 A.M. (half the dose that was administered in error); -The resident did not have orders for any additional medication administered in error. Review of Resident #1's nurse's progress note dated 08/12/24, at 11:04 A.M., showed it was brought to the nurse's attention that the resident was given another resident's medication. Upon review of the medication given the nurse noticed that several medications could inadvertently affect the resident's blood pressure. The nurse notified the physician and received orders to transfer the resident to the emergency department if his/her systolic blood pressure was less than 90 millimeters of mercury (mm/Hg). Staff took the resident's blood pressure which measured 85/49 mm/Hg. Staff called emergency medical services (EMS) for transport to the emergency department for evaluation and treatment. Review of the Resident #1's MAR, dated 08/01/24 to 08/31/24, showed on 08/12/24 staff documented the resident's morning medications were not given due to resident being hospitalized . During an interview on 08/16/24, at 11:00 A.M., Registered Nurse (RN) E said the following: -Staff should verify resident for medication administration with two identifiers, including a picture in the resident chart, the resident's date of birth, the resident's name; -The nurse was notified Resident #1 receive the incorrect medication at about 11:00 A.M.; -The nurse had the resident sit in front of the nurses' station and not go to the physical therapy office; -The nurse had the CMT write list of all medication possibly administered; -The nurse reviewed the MAR to determine what was given; -The nurse noted the resident received Coreg 37.5 mg (brand name for carvedilol) and called the physician; -The physician advised if the resident's systolic blood pressure dropped below 90 mm/Hg, the resident was to be sent to the emergency department; -The nurse immediately took the resident's blood pressure, and it was 85/40's mm/Hg; -The nurse contacted his/her supervisor and called the ambulance; -The resident's blood pressure had been in the 90 mm/Hg range earlier in the morning. During an interview on 08/16/24, at 8:25 A.M., CMT C said that when preparing medications for administration the staff person should check the resident name, medication name, medication dose, and scheduled time of medication. He/she said that if he/she was aware of a medication error it should be reported to the charge nurse and fill out a medication error report. The DON should also be notified, and the resident should be monitored. During an interview on 08/16/24, at 8:40 A.M., Licensed Practical Nurse (LPN) E said the following: -There is a picture of the resident in the computer for verification; -He/she was familiar with most residents from working with them; -Staff should report medication error to the boss; -Staff should monitor the resident for 24 hours; -Staff should notify the physician and the family. During an interview on 08/16/24, at 8:50 A.M., CMT B said the following: -Medication administration rights included providing medications to the right resident, the right medication, the right form, the right time; -If staff was unsure of resident name, the staff could ask the resident to verify their name; -If a medication error occurred the staff should report the charge nurse; -The family and doctor should be notified; -The resident should be monitored. During an interview on 08/16/24, at 12:18 P.M., LPN D said the following: -Staff should verify the resident name, date of birth, medication name and double check orders in computer before giving a medication; -Sometime the picture in the computer does not reflect the person. Staff should then ask the Director of Nursing (DON); -The nurse MAR tells staff what to do at what time. During an interview on 08/16/24, at 2:25 P.M., VP (Vice President) Clinical Services said the following: -Staff are expected to immediately report a medication error; -Staff should notify the physician after assessing the resident; -Staff should follow the physician orders and the family should be contacted; -The resident should be closely monitored for up to 72 hours if remain in the building; -There were seven rights of medication administration, right resident, right medication, right route, right strength, right time, right documentation, and right reason; -Staff should verify resident by looking at the picture on the computer and checking the resident name on the door. Staff could also ask the resident or other staff to verify the name; -She was aware of the error that occurred with Resident #1. During an interview on 08/13/24, at 3:40 P.M., the DON said staff should be aware of the seven rights of medication administration. During an interview on 08/19/24, at 8:45 A.M., the Administrator said that staff should verify residents by looking at the picture in the computer and the resident names on the door. If there was not a picture in the computer staff should ask the resident name or ask coworkers if necessary. The social services staff had some trouble with the app for the resident pictures in the computer software. She was aware of the medication error but VP was handling the education. 2. Review of the facility policy titled Insulin Administration, dated September 2014, showed the following: -The policy provides the guidelines for the safe administration of insulin to resident with diabetes; -The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order; -The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies, before giving the insulin; -Staff to notify the physician if the resident has signs and symptoms of hypoglycemia (low blood sugar level) that are not resolved by following the facility protocol for hypoglycemia management. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus with hyperglycemia (high blood sugar) and pure hyperglycemia; -No picture of the resident was on the face sheet. Review of the resident's hospital nursing discharge plan, dated 06/17/24, showed the following medication orders: -Insulin aspart (Novolog FlexPen - rapid acting insulin used to help lower blood sugar levels), inject 44 units with breakfast and lunch, and 35 units with supper, plus medium dose sliding scale. The next dose due on 06/17/24 at 6:00 P.M.; -Insulin glargine-lixisenatide (Soliqua 100/33 - long acting insulin used to treat diabetes), inject 46 units subcutaneous (under the skin) daily. The next does due on 06/17/24 at 9:00 P.M. Review of the resident's physician's orders, active as of 06/17/24, showed the following: -An order, dated 06/17/24, for Soliqua Solution Pen-injector 100-33 units-mcg/ml, inject 46 units subcutaneously at bedtime related to type 2 diabetes mellitus with hyperglycemia; -An order, dated 06/17/24, for Novolog FlexPen 100 unit/ml, inject 35 units subcutaneously in the afternoon related to Type 2 diabetes mellitus with hyperglycemia; -An order, dated 06/17/24, for Novolog FlexPen 100 unit/ml, inject 44 units subcutaneously two times day related to Type 2 diabetes mellitus with hyperglycemia; -An order, dated 06/17/24, for Novolog FlexPen 100 unit/ml, inject per sliding scale of if blood glucose level measured 150 mg/deciliter (dL) to 200 mg/dL, administer three units of insulin; if blood glucose level measured 201 mg/dL to 250 mg/dL, administer five units of insulin; if blood glucose level measured 251 mg/dL to 300 mg/dL, administer seven units of insulin; if blood glucose level measured 301 mg/dL to 350 mg/dL, administered nine units of insulin; if blood glucose level measured 351 mg/dL to 400 mg/dL, administered 11 units of insulin subcutaneously (below the skin) before meals and at bedtime related to Type 2 diabetes mellitus with hyperglycemia. Review of the resident's MAR, dated 06/01/24 through 06/30/24, showed the following: -On 06/17/24, at 5:00 P.M., staff documented Novolog Flex pen, 35 units as administered and blood glucose level at 269 mg/dL; -On 06/17/24, at 5:00 P.M., staff documented Novolog Flex pen, 7 units sliding scale administered and blood glucose at 269 mg/dL; -On 06/17/24, at 8:00 P.M., staff documented Novolog Flex pen, 5 units sliding scale administered and blood glucose at 250 mg/dL; -On 06/17/24, at 8:00 P.M., staff documented Soliqua Pen-injector not administered and see nurse notes. Review of the resident's nurse progress note showed staff documented the following: -On 06/17/24, at 3:24 P.M., resident admitted for skilled services and had history of insulin-dependent diabetes mellitus type 2 and was on insulin; -On 06/17/24, at 4:35 P.M., admission orders received from hospital; -On 06/17/24, at 8:30 P.M., insulin was unavailable and awaiting pharmacy delivery. Staff unable to give medication. (Staff did not document any notification to the physician of medication unavailable.) Review of the resident's MAR, dated 06/01/24 through 06/30/24, showed the following: -On 06/18/24, at 7:00 A.M., staff documented resident blood glucose as 468 mg/dL and Novolog sliding scale documented as held and see progress notes; -On 06/18/24, at 7:00 A.M., staff documented Novolog FlexPen 44 units as administered. Review of the resident's nurses' showed the staff did not document why the noted sliding scale insulin was held or notification of the physician at that time. Review of the resident's nurse progress note dated 06/18/24, at 9:41 A.M., showed resident had a shower, and the bath aide stated the resident's speech was not making any sense. Resident's blood sugar was 469 mg/dL. Nurse notified on call provider and received an order to give 13 units of Novolog at this time. Staff keeping the resident at nursing station to monitor. Review of the resident's physician's orders, active as of 06/17/24, showed an order, dated 06/18/24, for Novolog 100 unit/ml, inject 13 unit subcutaneously one time only for hyperglycemia. Review of the resident's MAR, dated 06/01/24 through 06/30/24, showed on 06/18/24, at 10:36 A.M., staff documented Novolog FlexPen 13 units one time only administered. Review of the resident's nurse progress note showed staff documented the following: -On 06/18/24, at 10:38 A.M., resident continued with elevated blood sugar at 448 mg/dL at 10:00 A.M. Vital signs showed blood pressure 76/52 mg/Hg (normal 120/80), pulse 54 (normal 60-100), respiration 17 (normal 12-20), oxygen 93% and (normal 95-100%) on room air. Notable decline in mental status. Nurse notified on call provider and new orders received to transport resident to emergency department for evaluation and treatment. Ambulance arrived and transporting resident at the time; -On 06/18/24, at 10:51 A.M., the resident transferred to the hospital. Review showed the facility did not provide an investigation of the medication error. During an interview on 08/16/24, at 11:00 A.M., RN F said the following: -Staff should contact the pharmacy for missing medications on admission for stat (immediate) fill, especially critical medication such as insulin; -Staff should check the emergency kit to see if the medication is available there; -If unable to get the medication from the pharmacy, the nurse should notify the physician to receive new orders for a different medication or whether okay to hold until available from the pharmacy; -The nurse vaguely remembered the resident and said that the resident was difficult to keep aroused and alert that morning and after contacting the provider the resident was sent to the emergency room ; -The nurse was not aware the resident had not received the bedtime dose of insulin as ordered. During an interview on 08/16/24, at 12:18 P.M., LPN D said the following: -If a medication was not available, staff should mark the medication as not available and notify the DON; -If insulin was not available the nurse would contact the pharmacy to get sent immediately and check the emergency kit; -When insulin was not available the nurse should call the doctor to let him/her know and see if could give anything else; -Usually, the pharmacy delivered by nighttime, but sometimes not until the next morning. During an interview on 08/13/24, at 3:40 P.M., the DON said staff should call the pharmacy if medication was not available. Staff should contact the DON of medication errors. She was aware of the medication error. During an interview on 08/16/24, at 2:25 P.M., VP Clinical Services said the following: -Staff are expected to notify the DON or Assistant Director of Nursing (ADON) if a medication was not available; -Nursing staff should notify the physician if the medication would not be available regardless of the medication type; -The doctor should have the option to change the medication or approve to be held until received from the pharmacy; -After a medication error staff should do a root cause analysis to review why the error occurred. MO00240494 MO00238817

Based on observations, staff interviews, and record review, the facility failed to ensure food stored in the kitchen pantry, refrigerators, freezer and the kitchenette refrigerators for five of five halls were labeled, dated, sealed, and stored at the appropriate temperature. These failures had the potential to increase the prevalence and spread of foodborne illness and infection among all facility residents. Review of the facility's policy titled, Food Storage (Dry, Refrigerated, and Frozen,) dated 2020, showed the general storage dry storage guidelines were as follows: -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded; -Discard food that has passed the expiration date and discard food that has been prepared in the facility after seven days of storing under proper refrigeration; -Keep potentially hazardous foods out of the temperature danger zone (41 degrees Fahrenheit (F) to 135 degrees F); -Leftover contents of cans and prepared food will be stored in covered, labeled, and dated containers in refrigerators and/or freezers; -Follow and adhere to the guidelines regarding proper storage temperatures and maximum length of storage found in storage guidelines in the Sanitation section of the manual. Review of the facility's policy titled, Food Storage (Dry, Refrigerated, and Frozen,) dated 2020, showed the general storage guidelines for refrigerated storage guidelines were as follows: -Set refrigerators to the proper temperature. The setting must ensure the internal temperature of the food is 41 degrees F or lower. Place a thermometer in the warmest part of the refrigerator to monitor the air temperature in the refrigerator; -Conduct random temperature checks of food items; -Store raw animal foods such as eggs, meat, poultry, and fish separately from cooked and ready-to-eat food. If they cannot be stored separately, place raw meat, poultry, and fish items on shelves beneath cooked and ready-to-eat items. If multiple shelves are available, the raw animal food with the highest final cooking temperatures should be stored on the lowest level, i.e. poultry and stuffed foods. Raw animal foods such as eggs, meat, poultry, and fish should be stored in drip proof containers. Wrap food properly. Never leave any food item uncovered and not labeled; -ln the event of a refrigerator malfunction such as the internal thermometer registering above 41 degrees F, a food sample will be taken from the warmest part of the unit. If the food item is 41 degrees F or less, it will be removed from the malfunctioning unit to a functioning cold storage unit. The malfunctioning unit will be locked out, tagged out per facility maintenance policy. Any food item at greater than 41 degrees F for an unknown duration of time, such as during opening of the kitchen, will be discarded immediately. 1. Observations on 01/22/24, from 11:36 A.M. to 12:00 P.M., showed the following items were observed in the refrigerator near the tray line during the initial kitchen tour: -A squeeze bottle with white sauce, unlabeled, with no date when opened; -A jar of beef base, missing its lid and covered with plastic, with no date when opened; -An opened tub of sour cream with no date when opened; -An opened tub of cottage cheese with no date when opened; -A zipped plastic bag of cooked ham with no date. 2. Observations on 01/22/24, from 11:36 A.M. to 12:00 P.M., showed the following items were observed in the refrigerator near the bistro during the initial kitchen tour: -Two opened and used tubs of sour cream with no date when opened; -An uncovered metal pan of cooked bacon and sausage, unlabeled, with no date. 3. Observations on 01/22/24, from 11:36 A.M. to 12:00 P.M., showed the following items were observed in the walk-in refrigerator during the initial kitchen tour: -A raw beef bottom round pot roast in a sealed plastic wrapper and raw hamburger wrapped in plastic wrap on the second shelf from the bottom, with a tray of prepared sandwiches in zipped plastic bags on the bottom shelf underneath the thawed meat. During an interview on 01/23/24, at 2:35 P.M., the Dietary Manager (DM) said nothing should be stored underneath thawed meat, especially ready-to-eat foods, to prevent cross-contamination. 4. During observation on 01/22/24, at 12:54 PM, the following items were observed in the kitchenette refrigerator for the 300 hall: -The temperature of the refrigerator was 50 degrees Fahrenheit (F). The temperature log on the door was not completed from 01/13/24 to 01/22/24; -An opened tub of pimento cheese with no date when opened; -An opened tub of whipped topping with no date when opened; -An opened tub of sour cream with no date when opened; -A zipped plastic bag of lunch meat, unlabeled, with no date when opened. During a follow-up interview the DM confirmed the temperature of the refrigerator was 50 degrees F and had not been recorded on the log since 01/13/24. The DM said the temperature of the refrigerator was too high. Dietary staff were responsible for monitoring the temperatures of the kitchenette refrigerators and dietary and nursing staff were jointly responsible for ensuring foods were labeled and dated when opened. 5. During an interview on 01/25/24, at 1:24 P.M., the Registered Dietician (RD) said she was aware of sanitation concerns with food storage temperatures, dating and labeling food, and not storing meat below ready-to-eat foods.

Based on interview and record review, the facility failed to maintain documentation for clinical indication of use for antibiotics with the potential to effect all residents in the facility. Review of the facility's Facility Antibiotic Stewardship Review and Surveillance of Antibiotic Use and Outcomes Policy Statement, revised December 2016, showed the following: -Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form; -The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship; -The Infection Preventionist (IP), or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics; -Therapy may require further review and possible changes if the organism is susceptible to narrower spectrum antibiotic; therapy was ordered for prolonged surgical prophylaxis; or therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics. 1. Review of the Facility's Surveillance Binder, provided by the facility, showed the following: -An Order Listing Report for medications classes of penicillin, cephalosporins macrolides, tetracyclines, fluoroquinolones, sulfonamides, antimycobacterial agents, antifungals, and antivirals for the month of November 2023; December 2023 and January 2024; -the Order Listing Report for November 2023, December 2023, and January 2024 showed staff did not make entries or surveillance analysis notations. During an interview on 01/25/24, at 10:30 P.M., the IP said she had not completed the antibiotic stewardship analysis documentation for 10/01/23 to 12/31/23. The IP stated that she had been working as a floor nurse and had not had an opportunity to complete the documentation. During an interview on 01/25/24, at 12:49 P.M. the Director of Nurses (DON) said she was unaware that the IP had not documented and completed antibiotic stewardship analysis for the months of 10/01/23 to 12/31/23. The DON said her expectation would be that the IP would communicate that she had not documented the analysis. During an interview on 01/25/24, at 8:04 P.M., the DON said that she received infection control data numbers verbally, but had not kept the information. She said the IP was providing information regarding infection control in Quality Assessment Performance Improvement (QAPI) meetings. The Administrator said at this time that the IP used to give a verbal report in QAPI meetings that included infection control data.

Based on interview and record review, the facility failed to provide documentation in each resident's medical record of the consulting pharmacist's recommendations after the monthly medication review was conducted for each resident in the facility and documentation of the attending physician's response to the consulting pharmacist's recommendations for four of four residents (Residents #38, #55, #31 and #2) reviewed for monthly medication regimen review in a sample of 19 residents. Review of the facility's Facility Medication Regimen Review Policy showed the following: -The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility; -Routine reviews will be done monthly; -Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report; -The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity; -If the Physician does not provide a pertinent response, or the Consultant Pharmacist identifies that no action has been taken, he/she will then contact the Medical Director, or if the Medical Director is the physician, the Administrator; -The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions; -Copies of drug/medication regimen review reports, including physician responses, will be maintained as part of the permanent medical record. 1. Review of Resident #38's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) with an assessment reference date (ARD) of 08/30/23, found under the MDS Tab in the electronic medical record (EMR), showed the resident was admitted to the facility on [DATE]. During an interview on 01/25/24, at 7:42 P.M., the [NAME] President of Clinical Operations (VPCO) said there was a list that indicated the resident's monthly MRR was completed. The list did not indicate the consulting pharmacist's recommendation and the physician's response to the pharmacist recommendation. 2. Review of Resident #55's annual MDS, with an ARD of 05/09/23, found under the MDS tab of the EMR, showed an admitted [DATE]. Review of the resident's MRR, dated 11/07/23, showed the consulting pharmacist's recommendation to reevaluate unused as needed (PRN) medications and an outcome statement of agreed. During an interview on 01/25/24, at 7:42 P.M., the VPCO confirmed that the consultant pharmacist completed the resident's MRRs, but she was unable to find the documentation of the physician's response stating agreement with the consultant pharmacist's recommendation. 3. Review of Resident #31's Profile tab of the EMR showed an admitted [DATE]. Review of the resident's quarterly MDS assessment, with an ARD of 11/28/23 and located in the MDS tab of the EMR, showed the following; -Short- and long-term memory problems; -Severely impaired cognition; -Did not exhibit behavioral symptoms; -Received antipsychotic and antidepressant medications routinely. Review of the resident's Orders tab of the EMR showed the following: -A physician's order, dated 10/18/23, for Seroquel (an antipsychotic medication), 50 milligrams (mg), once daily for dementia with behaviors; -A physician's order, dated 09/12/23, for Remeron (an antidepressant medication), 30 mg daily for insomnia. Review of the resident's Care Plan, dated 10/14/22 and located in the Care Plan tab of the EMR, showed the following: -Resident is currently receiving medication(s) that has Black Box Warnings; -Pharmacy review of medications monthly. Review of the resident's Care Plan, dated 01/22/24, showed the following: -The resident uses psychotropic medications related to behavior management; -Consult with pharmacy, physician to consider dosage reduction when clinically appropriate, at least quarterly. Review of the resident's EMR showed no documentation of the pharmacist's monthly medication regimen review including any recommendations and the physician's response and rationale from September 2023 through January 2024. During an interview 01/24/24, at 1:37 P.M., the VPCO provided a list of monthly consultant pharmacist drug regimen reviews. However, the list did not document the pharmacist's recommendations or the physician's rationale for agreeing or disagreeing with recommendations. The VPCO said he/she was unable to locate any documentation of the pharmacist's recommendations or physician's responses and was unable to obtain them from the pharmacist. Review of the residents' undated list of monthly medication regimen reviews, provided on paper, showed the following: -On 09/14/23, a recommendation was made for documentation/charting issues. The physician agreed. There was no further information documented; -On 10/05/23, no recommendations were made; -On 11/07/23, a recommendation was made for medication reduction request (non-psych). The physician agreed. There was no further information documented; -On 12/12/23, no recommendations were made; -On 01/05/23, a recommendation was made for order clarification request. There was no outcome documented. There was no further information documented. During an interview on 01/25/24, at 7:43 P.M., the VPCO said she was unable to locate the pharmacist's recommendations and/or the physician's responses for the dates listed above. She could confirm the pharmacist conducted the review, but could not tell from the documentation which medications were addressed and what the recommendations were, or how the physician responded and why. 4. Review of Resident #2's Profile tab of the EMR showed the following: -admitted [DATE]; -Diagnoses included dementia, psychotic disorder with delusions, anxiety, and insomnia. Review of the resident's significant change of condition MDS assessment, with an ARD of 11/28/23 and located in the MDS tab of the EMR, showed the following; -Severely impaired cognition; -Had delusions and wandered occasionally; -Suffered two or more falls with no injury in the past three months; -Received antipsychotic, antianxiety, and antidepressant medications. Review of the resident's Orders tab of the EMR showed the following: -An order, dated 01/04/24, for Depakote sprinkles (an anticonvulsant medication with mood stabilizing properties),125 mg twice daily; -An order, dated 11/26/23, for clonazepam (an antianxiety medication), 0.5 mg twice daily; -An order, dated 05/19/23, for Seroquel, 100 mg twice daily for dementia with mood and behavioral disturbance. Review of the resident's Care Plan, dated 10/14/22 and located in the Care Plan tab of the EMR, showed the following: -Resident is currently receiving medication(s) that has Black Box Warnings; -Pharmacy review of medications monthly. Review of resident's Care Plan, dated 01/22/24, showed the following: -The resident uses psychotropic medications related to behavior management; -Consult with pharmacy, MD to consider dosage reduction when clinically appropriate, at least quarterly. Review of the resident's EMR showed no documentation of the pharmacist's monthly medication regimen review including any recommendations and the physician's response and rationale from October 2023 through January 2024. During an interview 01/24/24, at 1:37 P.M., the VPCO provided a list of monthly consultant pharmacist drug regimen reviews. However, the list did not document the pharmacist's recommendations or the physician's rationale for agreeing or disagreeing with recommendations. The VPCO said she was unable to locate any documentation of the pharmacist's recommendations or physician's responses and was unable to obtain them from the pharmacist. Review of the resident's undated list of monthly medication regimen reviews, provided on paper, showed the following: -On 10/05/23, a recommendation was made for order clarification request. The physician agreed. There was no further information documented; -On 11/07/23, no recommendations were made; -On 12/12/23, no recommendations were made; -On 01/05/23, a recommendation was made for additional documentation/records needed. There was no outcome documented. There was no further information documented. During an interview on 01/25/24, at 7:43 P.M., the VPCO said she contacted the consultant pharmacist, physician and DON and was unable to find the consultant pharmacist's recommendations and/or the physician's responses for the dates listed above. She could confirm the consultant pharmacist conducted the review but could not tell from the documentation which medications were addressed and what the recommendations were, or how the physician responded and why. 26006

Based on observations, interviews, and record review, the facility failed to ensure the nutritional needs of all residents were met when staff failed to follow the recipe and failed to provide the correct serving size of pureed foods to four residents on pureed diets. Review of the Standardized Recipes policy, dated 2020, showed the following: -Standardized recipes will be used for all menu items, including pureed and therapeutic diets; -Each standardized recipe will include name of product; number of servings or yield; ingredients; measurement and/or weight of ingredients; procedures for assembling/method of production; size of pan needed; serving sizes; and modifications for therapeutic diets if applicable; -Recipes will be scaled to the number served; -The Registered Dietitian will approve recipe changes or new recipes utilized for a menu item. 1. Review of the lunch menu, dated 01/24/24, showed the cooks were to serve the following pureed foods: beef stew, creamed peas, biscuit, and pear cake. Review of the 2024 Pureed Creamed Peas recipe, showed the ingredients included: 2.5 cups of prepared creamed peas, 2.5 slices of bread, and 2 tablespoons of margarine. The directions indicated, place prepared vegetables, bread, and margarine in a washed and sanitized food processor and blend until smooth. During an observation on 01/24/24, at 10:58 A.M., Cook (C) 1 began making the pureed foods for the lunch meal. For the pureed creamed peas, he/she added seven 3-ounce (oz.) scoops (approximately 2.5 cups) of prepared creamed peas to a blender, blended until smooth, then added thickener until the appropriate consistency was reached. During an interview on 01/24/24, at 11:20 A.M., C 1 said he/she followed the recipes when making the pureed foods, but he/she did not know the recipe called for bread or margarine to be added. He/she did not add bread or extra margarine to the pureed peas; however, he added butter to the peas when cooking. During an interview on 01/24/24, at 11:23 A.M., the Dietary Manager (DM) said the puree recipes usually did not call for bread to be added and he/she did not know bread and margarine were to be added to the peas. 2. Review of the lunch menu for 01/24/24, showed residents on pureed diets should receive two #8 scoops (8 oz. total) of pureed beef stew. During an observation on 01/24/24, at 12:16 P.M., C 1 and C 3 began plating the lunch meal for service. C 1 and C 3 served one #10 scoop (3.75 oz. total) of pureed beef stew to the residents receiving a pureed meal. During an interview on 01/24/24, at 12:45 P.M., C 1 said he/she served only one #10 scoop of pureed beef stew to the residents on a pureed diet and confirmed the menu called for two #8 scoops. C 1 said he/she did look at the menus for portion size, but had missed the information on the pureed beef stew portion size. During an interview on 01/25/24, at 1:24 PM, the Registered Dietician (RD) said it was important for the staff to follow the menu and recipes to ensure each resident received the calories and nutrients planned on the menu.

Based on observations, record review, and interviews, the facility failed to ensure that 10 of the 10 residents (including Resident #20, #11, and #62) with a physician's order for a mechanical soft diet were served foods prepared in a mechanical soft form to meet their needs. Review of the facility's policy titled, Diet Summary, dated 2023, showed the following; -Dental soft (mechanical soft) diet is a consistency modified diet for individuals with limited or difficulty in chewing regular textured foods; -The diet follows the regular diet planned and provides foods that can be easily chewed; -The diet consists of food of nearly regular textures, but eliminates very hard, sticky, crunchy or hard to chew foods; -Foods should be moist and fork tender; -Meat is ground or chopped into bite-size pieces (1/2 inch or smaller) and should be mixed or served with gravy, broth, or another type of moistening agent; -Casseroles should contain bite-size chunks of meat, ground or tender meats that are less than 1/2 inch in size (this will generally fit though the tongs of a fork). 1. Review of Resident #20's Profile tab of the electronic medical record (EMR) showed the following: -admitted [DATE]; -Diagnoses included dysphagia (difficulty swallowing). Review of the residents' quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) assessment, with an assessment reference date (ARD) of 12/19/23 and found in the MDS tab of the EMR, showed the following: -Cognitively intact; -Received a therapeutic diet. Review of the resident's Orders tab of the EMR showed an order for a mechanical soft diet. During an interview on 01/23/24, at 10:03 A.M., the resident said he/she had no teeth and was not a candidate for dentures due to ongoing issues with his/her mouth. He/she was supposed to receive soft foods because he/she could not chew a lot of regular foods; however, he/she typically received foods that were still too hard to chew. He/she said, They're supposed to know how to serve soft foods but they don't do it. Review of the 01/24/24 lunch menu, showed the residents on a mechanical soft texture diet were to receive ground beef stew. During an observation on 01/24/24, at 11:56 A.M., Cook (C) 1 prepared the mechanical soft beef stew by placing scoops of the premade beef stew in a pan, with chunks of beef over 1-inch cubed, and began to coarsely chop it using a spatula. Chunks of beef, many appearing larger than 1/2-inch cubed, remained. Between 12:16 P.M. and 12:50 P.M., staff served to 10 residents with physician orders for a mechanical soft diet texture received the coarsely chopped beef stew. During an interview on 01/24/23, at 12:51 PM, the Dietary Manager (DM) said the chunks of beef in the mechanical soft beef stew were not ground and were too large for a proper mechanical soft texture. The beef should have been ground. 2. During an observation on 01/24/24, at 12:16 P.M., C 2 served Resident #11 and Resident #62, with orders for a mechanical soft texture diet per their tray cards, the regular beef stew rather than the mechanical soft. The stew had large chunks of beef over 1-inch cubed. The beef was not chopped or ground at all before service to the two residents. During an observation on 01/24/24, at 12:53 PM, the DM confirmed residents were on a mechanical soft diet; however, they had received a regular texture meal, and the meat was not ground or chopped. During an interview on 01/24/24 at 1:05 PM, C 2 said he/she missed the two mechanical soft orders. 3. During an interview on 01/25/24, at 1:24 P.M., the Registered Dietician (RD) said the beef in the mechanical soft beef stew should have been ground.

Based on observation, interview, and record review, the facility failed to ensure dignity was provided to all residents when staff failed to keep urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) drainage bags covered for two residents (Resident #128 and #5) and when staff administered nasal medication in the dining room to one resident (Resident #31). A sample of 19 residents was reviewed. Review of the facility's policy titled, Dignity, dated February 2021, showed the following: -Each resident will be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; -Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 08/23/23, located in the electronic medical record (EMR) under MDS tab, showed the following: -admitted [DATE]; -Diagnoses included neurogenic bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problem) and urinary tract infection. Observations on 01/22/24, at 1:47 P.M., showed the resident laid in bed with his/her urinary catheter drainage bag uncovered hanging from the bed frame. The catheter drainage bag had 250 cubic centimeters (cc) of amber colored urine in the bag. During an interview on 01/22/24, at 2:01 P.M., Certified Nurse Aide (CNA) 3 said the resident's catheter bag did not have a covering over it and it should have been covered. Observation on 01/23/24, at 11:55 A.M., showed the resident laid in bed with his/her urinary catheter drainage bag, with approximately 200 cc of amber colored urine in the urinary catheter bag, uncovered and hanging from the bed frame. Observation on 01/23/24, at 2:53 P.M., showed the resident slept in his/her bed with the urinary catheter drainage bag, that had approximately 50 cc of amber colored urine, hanging uncovered from the bed frame. During an interview on 01/23/24, at 2:59 P.M., CNA 4 and CNA 1 said the resident's urinary drainage bag was not covered, and that the urinary drainage bag should have a cover. 2. Review of Resident #5's Profile tab of EMR showed the following: -admitted [DATE]; -Diagnoses included enlarged prostate with lower urinary tract symptoms, neurogenic bladder, and urinary tract infection. Review of the resident's quarterly MDS assessment, with an ARD of 10/30/23, and located in the MDS tab of the EMR, showed the following: -Severely impaired cognition; -Used an indwelling urinary catheter. During an interview on 01/22/24, at 12:33 P.M., the resident laid in bed and had an indwelling urinary catheter bag and tubing hanging on the side of the bed. The urine collection bag was not covered and urine was visible with the room door and privacy curtain both open. During an observation on 01/22/24 at 12:50 P.M., the resident laid in bed with his/her urinary catheter bag visible from the hall outside of the doorway. The catheter bag was not covered and the urine collected was visible. During an observation on 01/22/24, at 1:33 P.M., in the dining room, CNA 3 transported the resident in his/her wheelchair from his room to the dining room table. The urinary catheter bag was hanging underneath the resident's wheelchair with no privacy cover leaving the urine visible to all in the dining room. During an observation on 01/23/24, at 9:55 A.M., the resident laid in bed with his/her urinary catheter bag visible from outside of the doorway. The bag was not covered and urine collected was visible. During an observation on 01/24/24, at 9:04 A.M., the resident was in bed with his/her urinary catheter bag visible from outside of the doorway. The bag was not covered and the urine collected was visible. During an observation on 01/25/24, at 8:29 A.M., in the dining room, the resident sat in his/her wheelchair with the catheter bag hanging underneath the wheelchair with no privacy cover. The urine was visible to all in the dining room. During an interview on 01/25/24, at 8:31 A.M., Licensed Practical Nurse (LPN) 1 said the resident's catheter bag was not covered for privacy. The LPN said the catheter bag should always be covered for dignity and the staff usually used a privacy bag to cover it. 3. During an interview on 01/25/24, at 11:00 A.M., the Director of Nursing (DON) said the catheter bag should always be covered in a privacy cover for dignity whether in the room or out in the dining room. 4. Review of Resident #31's Profile tab of the EMR showed the following; -admitted [DATE]; -Diagnoses included Alzheimer's disease and major depression. Review of the resident's quarterly MDS, with an ARD of 11/28/23 and located in the MDS tab of the EMR, showed the following: -Short- and long-term memory problems; -Severely impaired cognition. Review of the resident's Orders tab of the EMR showed an order, dated 05/09/23, for fluticasone propionate (allergy nasal spray), one spray in both nostrils. During an observation on 01/25/24, at 8:25 A.M., in the dining room, LPN 1 approached the resident as he/she had just begun eating his/her meal and administered his/her nasal spray at the dining table. There were two residents seated with the resident at the table who watched the administration. There were additional residents in the dining room that were able to witness the administration. During an interview on 01/25/24, at 8:26 A.M., LPN 1 said he/she had administered fluticasone propionate to the resident at the dining table during the meal. He/she did not know if she needed to remove a resident from the dining room to administer a medication, such as an inhaler. The LPN said it would be ok to administer a resident's nasal spray in the dining room if the resident preferred to stay in the dining room, but said the resident did not voice his/her preference and was unable to do so consistently because of his/her cognitive status. During an interview on 01/25/24, at 12:52 P.M., the DON said staff should never administer medication, such as an inhaler, at the dining room table or during a meal. This could lead to a breach of confidentiality of health information and lack of privacy during treatment or cause a loss of appetite during the resident's meal. 26006

Based on record review and interviews, the facility failed ensure one (Resident #2), of two residents reviewed for hospitalization , received written notice of transfer to the hospital that included the reason for the transfer, the location of the transfer, a statement of the resident's appeal rights, and the contact information for the office of the Ombudsman. Review of the facility provided a blank form named, Notice of Resident and Discharge, undated showed the form contained spaces to document the following: -Location of the transfer; -Reason for the transfer; -Resident's appeal rights; -Contact information for the State Long-Term Care Appeal Agency, the Missouri Protection and Advocacy Agency, and the Long-Term Care Ombudsman for the region. 1. Review of Resident #2's Profile tab of the electronic medical record (EMR) showed the following: -admitted [DATE]; -Diagnoses included dementia, anxiety, and unsteadiness on feet. Review of the resident's significant change of condition Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an assessment reference date (ARD) of 11/28/23, and located in the MDS tab of the EMR, showed the following: -Severely impaired cognition; -Resident had delusions and wandered occasionally. Review of Resident #2's Communication - with Physician notes, dated 01/13/24, located in the Notes tab of the EMR showed staff found the resident on the floor of his/her room at the entrance by his/her bathroom. The resident was found lying down, conscious, in a pool of blood. The on-call clinician ordered the resident be sent to the emergency room via ambulance. Review of the resident's Communication - with Family/NOK (Next of Kin)/POA (Power of Attorney) note, dated 01/13/24, located in the Notes tab of the EMR, showed staff noted message left for famiy member about fall to floor. During an interview on 01/25/24, at 10:11 A.M., the resident's representative said he/she did not receive any written notice of transfer for the hospitalization for 01/13/24. He/she had only received verbal notice via telephone message. During an interview on 01/24/24, at 1:37 P.M., the [NAME] President of Clinical Operations (VPCO) said he/she was unable to find evidence a written notice of transfer provided to the resident's representative upon his/her transfer to the hospital on 01/13/24. During an interview on 01/25/24, at 12:52 P.M., the Director of Nursing (DON) said during the week, the Social Worker was responsible for printing and sending the written transfer notice to the resident or their representative. However, on weekends, the nursing staff were responsible for printing and sending the notice. The DON said since this transfer occurred on a Saturday, the nurse should have provided the written notice to the representative.

Based on observation, interview, and record review, the facility failed to obtain written consent for side rail use, failed to complete a documented side rail assessment, and failed to complete a risk versus benefits side rail assessment for one resident (Resident #1) who got entangled in the side rail when falling out of bed and suffered fractured bone. The facility failed to obtain written consent for side rail use, failed to complete a documented side rail assessment, and failed to complete a risk versus benefits side rail assessment for three additional residents (Resident #2, #3, and #4). The facility census was 79. Record review of the facility's policy titled Proper Use of Side Rails, revised December 2016, showed the following: -The purpose of these guidelines are 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; -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's bed mobility; ability to change positions, transfer to and from bed or char, and stand and toilet; risk of entrapment from use of side rails; and that the bed's dimensions are appropriate for the resident's size and weight; -The use of side rails as an assistive device will be addressed in the resident care plan; -Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol; -Less restrictive interventions that will be incorporated in care planning include: providing restorative care to enhance abilities to stand safely and to walk; providing a trapeze to increase bed mobility; placing the bed lower to the floor and surrounding the bed with a soft mat; equipping the resident with a device that monitors attempts to arise; providing staff monitoring at night with periodic assisted toileting for residents attempting to arise to use the bathroom; and/or furnishing visual and verbal reminders to use the call bell for residents who can comprehend this information; -Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails; -The risks and benefits of side rails will be considered for each resident; -Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. (Note: Federal regulations do not require written consent for using restraints. Signed consent forms do not relieve the facility from meeting the requirements for restraint use, including proper assessment and care planning. While the resident or family (representative) may request a restraint, the facility is responsible for evaluating the appropriateness of that request.); -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 (the amount of safe space may vary, depending on the type of bed and mattress being used); -Facility staff, in conjunction with the Attending Physician, will assess and document the resident's risk for injury due to neurological disorders or other medical conditions. 1. Record review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -His/her own responsible party; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 09/23/21, showed the following: -Moderate cognitive impairment; -Required total dependence, two or more full staff performance, for bed mobility and transfers; -Bed rail not used. Record review of the resident's care plan, dated 3/31/21, showed the following: -At risk for falls related to weakness, cerebral vascular accident ([CONDITION(S)] - medical term for stroke) and receiving antidepressants; -Required extensive assistance with activity of daily living (ADL- dressing, grooming, bathing, eating, and toileting) and required a Hoyer lift (a mechanical lift used by staff to assist residents with transfers) for transfers; -Preferred the use of positioning bars on both sides of bed for safety and assistance with repositioning and bed mobility. Facility staff educated him/her and his/her family on risks of positioning bars and they communicated understanding; -Positioning bars to both sides of the bed. Facility staff would evaluate him/her for use of positioning bars quarterly and annually. The maintenance department assessed positioning bars for defects, ill-fitting and broken parts. He/she used positioning bars for bed mobility and they were not a restraint. Facility staff would evaluate him/her quarterly and annually for the use of positioning bars; -Totally dependent of the facility staff for ADLs such as toileting, transfers, bed mobility, personal hygiene and dressing. He/she required assist of two staff with Hoyer transfers. Record review of the resident's physician order, dated 4/29/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's [MEDICATION(S)] Rock Healthcare Bed Positioning Device Risk Assessment (an assessment of the seven zones in the hospital bed system where there is a potential for patient entrapment), dated 07/16/21, showed staff documented a score of pass. Record review of the resident's Gap Assessment (an assessment of the measurement of the area between the bed's mattress and side rails), dated 09/13/21, showed staff documented a score of pass. Record review of the resident's record showed the staff did not document a signed consent, a bed rail risk versus benefits, or side rail use assessment. Record review of the resident's clinical notes showed the following: -On 10/28/21, at 3:28 A.M., an aide called the nurse to the resident's room and stated the resident fell out of bed. The nurse entered the room and noted the resident laid between the window and his/her bed on his/her right side with a large bowel movement in his/her brief. His/her right arm was over his/her head and twisted with his/her arm stuck between the bed's mattress and right side hand rail. The resident's arm was twisted and his/her shoulder appeared to be dislocated. His/her right arm was cold to touch and had a bluish mottled tinge (marked with spots or smears of color) and his/her nail beds were blue. To move the resident's bed, the nurse moved the resident's arm enough to get it over the handrail and the nurse laid the resident's arm on the floor above the resident's head. The resident yelled and cried and stated his/her shoulder hurt. The mottling and bluish tinge decreased immediately. The nurse called the Director of Nursing (DON) immediately and the DON instructed the nurse to send the resident to the hospital for evaluation. The nurse called 911 and emergency medical services (EMS) arrived at 2:05 A.M. EMS examined the resident, rolled him/her onto a sheet with his/her arm folded against his/her right chest. The resident cried out and yelled when EMS rolled and repositioned the resident. Facility staff changed the resident's brief and EMS and two certified nursing assistants (CNA) lifted the resident onto the litter (stretcher). The resident left the facility at 3:20 A.M. The nurse contacted the resident's emergency contact at 2:25 A.M. and the nurse practitioner at 2:30 A.M.; -On 10/28/21, at 8:37 A.M., emergency room called the nurse and informed the nurse they were sending the resident back to the facility. The resident had a humeral neck fracture, would need to wear a sling at all times, use ice and Tylenol as needed and to follow up with orthopedic surgeon; -On 10/28/21, at 11:10 A.M., the resident arrived back to the facility at 10:15 A.M. with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Two staff assisted the resident back to bed using a Hoyer lift. Facility staff placed fall mats by bed. Staff notified the family, nurse practitioner and physician notified of the resident's; -On 10/28/21, at 12:15 P.M., the registered nurse (RN) spoke with staff and resident and determined the resident did not need the positioning rails at this time. The RN discontinued the order. The licensed practical nurse (LPN) spoke with the resident's family and informed them that the staff removed the positioning bars and the family agreed with the decision. The nurse notified the physician about the removal of the positioning bars. Record review of the resident's Fall Risk Assessment, dated 10/28/21, showed staff assessed the resident as a high risk for falls. Record review of the resident's care plan, dated 3/31/21, showed the following: -On 10/28/21, resident received a closed fracture of the proximal end (close to the shoulder joint) of right humerus (long bone of the arm); -Resident wore a sling on his/her right arm and staff assisted with applying the sling and checked skin integrity under and around the brace. Record review of the October 2021 POS an order, dated 11/02/21, to don sling to right arm and check skin integrity under and around brace every shift and as needed. During an interview on 11/02/21, at 2:00 P.M., the resident said the following: -He/she used the side rail to turn him/herself, but now was not able to use it; -He/she just fell out of bed and the bed rail caught his/her arm. During an interview on 11/02/21, at 3:25 P.M. and 3:55 P.M., CNA H said the following: -The resident does not have use of one side of his/her body. During an interview on 11/02/21, at 3:30 P.M., CNA I said the following: -The resident does have use of right side of his/her body; -The resident tries to be more cautious as he/she is afraid of getting hurt. During an interview on 11/02/21, at 4:12 P.M., Licensed Practical Nurse (LPN) D said the following: -Staff should consider side rails to be the half, full and small positioning bars at the head of the bed. During an interview on 11/02/21, at 4:53 P.M., the Administrator said he could not find side rail consents, risk versus benefits assessments, or side rail assessments for the resident. During an interview on 11/04/21, at 11:41 A.M., the Medical Director said the following: -Facility staff told him/her that the resident could use the side rail to assist with repositioning him/herself in bed. He/she did not participate in the assessment of the resident for side rail use. The facility staff did not have concerns that the resident would attempt to get out of bed on his/her own. 2. Record review of Resident #2's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident was his/her own responsible party. Record review of the resident's care plan, dated 04/30/21, showed the following: -Required extensive to dependent assistance with bed mobility, transfers, locomotion, dressing, toileting and personal hygiene; -Requested use of positioning bars on both sides of the bed for repositioning purposes; -While in bed assist the resident to turn and reposition him/herself; -Maintenance department assessed positioning bars for defects, ill-fitting and broken parts; -Used positioning bars for bed mobility and are not a restraint; -Facility staff will evaluate the resident for the use of the positioning bars, including the risk versus benefits quarterly and annually. Record review of the resident's Fall Risk Assessment, dated 07/01/21, staff assessed the resident to be a high risk for falls. Record review of the resident's [MEDICATION(S)] Rock Healthcare Bed Positioning Device Risk Assessment, dated 07/16/21, showed staff documented a score of pass. Record review of the resident's Gap Assessment, dated 09/13/21, showed staff documented a score of pass. Record review of the resident's record showed the facility did not document consent, a bed rail risk versus benefit assessment, or side rail use assessment. Record review of the resident's MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assist of two or more people and the resident able to assist in bed mobility; -Did not use a bed rail. Record review of the resident's October 2021 POS showed an order, dated 12/30/20, for position rails for repositioning purposes per resident request. During an interview and observation on 11/02/21, at 9:37 A.M., the resident said he/she used the rails on both sides of his/her bed to help with turning over. The rails help him/her a lot. The bed has small side rails on both sides of the bed, approximately one foot from the top of the bed. During an interview on 11/02/21, at 4:53 P.M., the Administrator said he could not find side rail consents, risk versus benefits assessments, or side rail assessments for the resident. 3. Record review of Resident #3's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident was his/her own responsible party. Record review of the resident October 2021 POS showed the following and order, dated 10/22/20, for positioning bar to one side of the bed per the resident's request 10/22/20. Record review of the resident's [MEDICATION(S)] Rock Healthcare Bed Positioning Device Risk Assessment, dated 07/16/21, showed staff documented a score of pass. Record review of the resident's care plan, dated 7/30/21, showed the following: -At at risk for falls related to his/her history of falls, use of opiate medication and weakness; -He/she had a side rail for positioning, transferring and bed mobility that was not a restraint; -He/she had a chair and bed alarm to alert staff; -He/she was on a low bed in the lowest position; -He/she had a scoop mattress with fall mats in place; -He/she had Dycem (nonslip products) placed in the seat of his/her wheelchair; -He/she preferred use of side rails up on both sides of the bed for safety and assistance with repositioning; -Facility staff educated the resident and his/her family on the risks of side rails and they communicated understanding. (Staff did not care plan maintenance of the bed rails, evaluation of the resident for use of the grab bars, or completion of risk versus benefits assessments.) Record review of the resident's MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Required extensive assistance of one facility staff member for bed mobility and transfers; -Did not use a bed rail. Record review of the resident's Fall Risk Assessment, dated 08/26/21, showed staff assessed the resident as a high risk for falls. Record review of the resident's Gap Assessment, dated 09/13/21, showed staff documented a score of pass. Record review of the resident's record showed the facility did not document consent, a bed rail risk versus benefit assessment, or side rail use assessment. Observation on 11/02/21, at 9:35 A.M., showed the resident laid in bed with eyes closed. He/she had side rails on both sides of his/her bed approximately three feet from the head of the bed. During an interview on 11/02/21, at 4:53 P.M., the Administrator said he could not find side rail consents, risk versus benefits assessments or side rail assessments on the resident. 4. Record review of Resident #4's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -His/her own responsible party. Record review of the resident's care plan, dated 04/10/20, showed the following: -Positioning rail to the left side of resident's bed to assist him/her in transfers and positioning; -Facility staff would evaluate his/her for the use of positioning bar, including risk versus benefits quarterly and annually over the next review period; -The positioning bar was not a restraint, the resident used it for bed mobility and transfers; -The maintenance department would assess the positioning bar for defects and ill-fitting and broken parts. Record review of the resident's October 2021 POS showed an order, dated 04/29/21, for positioning rails for repositioning only. Record review of the resident's [MEDICATION(S)] Rock Healthcare Bed Positioning Device Risk Assessment, dated 07/16/21, showed staff documented a score of pass. Record review of the resident's Gap Assessment, dated 09/13/21, showed staff documented a score of pass. Record review of the resident's Fall Risk Assessment, dated 10/27/21, showed staff assessed the resident as a high risk for falls. Record review of the resident's record showed the facility did not document consent, a bed rail risk versus benefit assessment, or side rail use assessment. During an interview and observation on 11/02/21, at 9:43 A.M., resident said he/she used the small hand rail on his/her bed to roll in bed. He/she did not get caught in it. A small side rail was located towards the head of the left side of his/her bed. During an interview on 11/02/21, at 4:53 P.M., the Administrator said he could not find side rail consents, risk versus benefits assessments or side rail assessments on the resident. 5. During an interview on 11/02/21, at 11:53 A.M., Certified Medication Technician (CMT) A said the following: -The physician ordered side rails for the residents; -Therapy evaluates the residents for the side rails; -Nurses checked the side rails and have maintenance adjust as needed; -He/she did not know how often side rails were assessed because he/she believed that therapy completed them. 6. During an interview on 11/02/21, at 12:28 P.M., CNA E said the following: -Doesn't know if there is an order is needed for side rails; -Most residents use side rails for repositioning; -Maintenance places the rails and is responsible for the upkeep. 7. During an interview on 11/02/21, at 12:42 P.M., LPN G said the following: -The small bed rails are used for repositioning; -He/she was not sure how the bed rails are determined to be needed for a resident. 8. During an interview on 11/02/21, at 1:52 A.M., CNA B said the following: -Facility staff care planned side rails; -Maintenance installed the side rails; -Nursing and the doctor decided if side rails were appropriate for a resident; -Staff inspected side rails either weekly or monthly. 9. During interviews on 11/02/21, at 2:37 P.M. and 3:46 P.M., LPN C said the following: -The MDS Coordinator completed side rail assessment and risk versus benefits for side rails quarterly; -Nursing gets a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Up until September 2021, the facility did not consider positioning rails as side rails and the MDS coordinator was catching the assessments up as the resident's quarterly MDS assessment becomes due; -MDS Coordinator should complete side rail assessment and risk versus benefits assessment quarterly and the restorative nursing aide (RNA) completed the gap assessments quarterly; -MDS Coordinator should get a restraint informed consent for side rails from the resident and/or family member before the side rails are used; -MDS Coordinator should add side rails to the residents care plan after the nurse received the order from the physician. The nurse informed the MDS Coordinator when he/she received an order; -Side rails are either a quarter, half or full length of the bed. The facility staff did not consider positioning rails to be side rails. 10. During an interview on 11/02/21, at 4:12 P.M., LPN D said the following: -Nursing should assess the resident's ability to assist with rolling over in bed prior to suggesting a side rail; -After this assessment, he/she notified the ADON and/or DON and they get a side rail assessment completed; -He/she did not know what other assessments needed to be completed; -Staff should consider side rails to be the half, full and small positioning bars at the head of the bed. 11. During an interview on 11/03/21, at 8:36 A.M., the Administrator said the following: -The facility had small positioning devices and quarter, half and full bed rails. He/she considered some bed rails as restraints, but the small positioning rails he/she considered to be positioning devices; -The interdisciplinary team (IDT) determined if positioning rails were appropriate for a resident; -Positioning rails assisted the residents to maintain their highest level of independence; -Staff should complete gap assessment, restraint assessment and safety assessment and get informed consent prior to putting a bed rail or positioning rail on a resident's bed; -Staff should evaluate bed rails and positioning rails monthly; -Side rail assessments and gap assessments go hand in hand. Staff should complete these monthly; -MDS Coordinator should care plan the side rails or positioning rails; -Nursing should obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 12. During an interview on 11/04/21, at 11:41 A.M., the medical director said the following: -Facility staff should assess side rails on a regular basis at least quarterly; -He/she believed facility staff should check side rails daily by facility staff and any concerns reported immediately to maintenance to repair; -He/she did not know the facility's policy related to side rails or if facility staff should attempt any other interventions such as a trapeze prior to implementing side rails. He/she believed it depended on the individual resident. MO 910