Every finding on record at Cottages of Lake St Louis

Based on interview and record review, the facility failed to follow professional standards of practice for one resident (Resident #6) in a review of six sampled residents. The facility failed to follow physician orders and administer medications (including medications for heart failure, pain, blood pressure, and to prevent blood clots) as ordered, failed to follow their facility policy for obtaining medications and notification of the physician when medications were not available. The facility census was 56. Review of the undated facility policy, Nursing Practices, showed the following:-If a medication is unavailable, the Stat-Safe (emergency kit of medications) will be checked for medication;-If not in the Stat-Safe, pharmacy will be contacted for immediate delivery;-If a dose of medication is missed, physician will be contacted when the error is discovered for further order;-If physician is unavailable, the Medical Director and the Director of Nursing will be contacted;-Documentation will be entered into electronic health record (point click care/PCC). Upon request, the facility did not provide a policy for Medication Administration, Physician and Family notification or Following Physician Orders. 1. Review of the facility Stat-Safe medication list showed the following medications were available for use if needed:-Metoprolol tartrate (medication to treat high blood pressure) 25 milligram (mg) tablet;-Trazodone (medication to treat insomnia) 50 mg tablet. 2. Review of Resident #6's face sheet showed the following:-He/She was admitted on [DATE];-Diagnoses included chronic diastolic (congestive) heart failure (occurs when the stiffened, thickened left ventricle fails to fill properly, causing blood to back up into the lungs and body; treatment focuses on managing symptoms with diuretics and controlling blood pressure) and atrial fibrillation (rapid, irregular, and chaotic heartbeat; treatment includes medications to control heart rate and rhythm and blood thinners). Review of the resident's hospital discharge orders, dated 01/08/26, showed the following:-Acetaminophen (for pain and fever) 500 mg tablet; take two tablets by mouth three times daily for 10 days; maximum allowable acetaminophen amount = 4 grams (4000 mg) in 24 hours;-Metoprolol tartrate 25 mg tablet; Take 0.5 (one-half) tablet by mouth two times daily;-Aspirin 81 mg (blood thinner) chew tablet; take one tablet my mouth two times daily for 42 days; Take twice daily for blood clot prevention for six weeks then okay to resume home dose daily;-Pregabalin (for chronic pain) 50 mg capsule; take one capsule by mouth twice daily;-Duloxetine (for major depressive disorder, generalized anxiety disorder, fibromyalgia, and chronic neuropathic or musculoskeletal pain) 60 mg capsule; take one capsule by mouth two times daily;-Levothyroxine (to treat underactive thyroid) 88 microgram (mcg) tablet; take one tablet my mouth once daily;-Midodrine 10 mg tablet; take one tablet by mouth three times daily before meals; Reasons: Blood pressure drop upon standing; disorder of low blood pressure;-Potassium chloride (a mineral supplement) extended release (ER) 20 milliequivalents (MEQ) tablet; Take 1/2 (one-half) tablet by mouth twice daily;-Pravastatin (to lower bad cholesterol (LDL) and triglycerides) mg tablet; take one tablet by mouth at bedtime;-Trazadone (to treat insomnia) 100 mg tablet; take one tablet my mouth at bedtime. Review of the resident's progress notes, dated 01/08/26 at 7:55 P.M., showed Registered Nurse (RN) D documented the resident arrived via wheelchair, full assessment and vitals done, medication reconciliation done, no questions at this time. Review of the resident's January 2026 electronic Medication Administration Record (eMAR) showed the following:-Pravastatin; start date 01/08/26 at 9:00 P.M., documented as 9 (see progress note) by Licensed Practical Nurse (LPN) A on 01/08/26 for the scheduled 9:00 P.M. dose;-Trazadone; start date 01/08/26 at 9:00 P.M., documented as 9 (see progress note) by LPN A on 01/08/26 for the scheduled 9:00 P.M. dose;-Aspirin; start date 01/08/26 at 9:00 P.M., documented as 9 (see progress note) by LPN A on 01/08/26 for the scheduled 9:00 P.M. dose;-Duloxetine; start date 01/08/26 at 9:00 P.M., documented as 9 (see progress note) by LPN A on 01/08/26 for the scheduled 9:00 P.M. dose;-Metoprolol tartrate; start date 01/08/26 at 9:00 P.M., documented as 9 (see progress note) by LPN A on 01/08/26 for the scheduled 9:00 P.M dose;-Potassium chloride; start date 01/08/26 at 9:00 P.M., documented as 9 (see progress note) by LPN A on 01/08/26 for the scheduled 9:00 P.M. dose;-Acetaminophen; start date 01/08/26 at 9:00 P.M., documented as 9 (see progress note) by LPN A on 01/08/26 for the scheduled 9:00 P.M. dose; -Midodrine; start date 01/08/26 at 9:00 P.M., documented as 9 (see progress note) by LPN A on 01/08/26 for the scheduled 9:00 P.M. dose;-Pregabalin 50 mg; start date 01/08/26 at 9:00 P.M., documented as 9 (see progress note) by LPN A on 01/08/26 for the scheduled 9:00 P.M. dose;-Levothyroxine; start date 01/09/26 at 6:00 A.M., documented as 9 (see progress note) by LPN A on 01/09/26 for the scheduled 6:00 A.M. dose;-Pregabalin 50 mg (two times a day); start date 01/08/26 at 9:00 P.M., documented as 9 (see progress note) by Registered Nurse (RN) B for morning (AM) dose on 01/09/26;-Pregabalin 100 mg; start date 01/09/26 at 9:00 P.M., documented as 9 (see progress note) by LPN A on 01/09/26 for the scheduled 9:00 P.M. dose. Review of the resident's progress notes, for 01/08/26 and 01/09/26, showed no documentation as to why the medications were not administered. Review of the resident's progress note, dated 01/09/26 at 6:30 P.M., showed RN B documented the following:-The resident appeared restless due to lack of sleep; -The resident said he/she needed to get some sleep. During an interview on 02/02/26 at 10:15 A.M. and 4:40 P.M., the resident's representative said the following:-The resident admitted to the facility around 6:00 P.M. on 01/08/26;-He/She asked staff about the resident's medications not being administered yet on the evening of 01/08/26 and was reassured by staff that the resident would receive his/her medications that night;-He/She was never notified by the facility of any missed medications, or he/she could've brought medications in;-The resident missed his/her evening/bedtime medications on 01/08/26 and early morning medications on 01/09/26 and was anxious and unable to sleep because of this. During an interview on 02/19/26 at 3:35 P.M., LPN A said the following:-He/She was the nurse that worked with the resident on the evening/night shift on 01/08/26 and 01/09/26;-RN D was the nurse that was at the facility until 7:00 P.M. on 01/08/26 and helped with the admission by inputting the medication orders;-All medication orders must be put into the system no later than 5:00 P.M. for pharmacy to deliver the medication in time for bedtime med pass;-Since it was after hours, the medications did not arrive that evening and he/she did not have access to the stat safe;-Without access to the stat safe, he/she would have had to call another nurse from another cottage to access the stat safe since there was no one from management there at night;-He/She did not call to ask anyone for access to the stat safe;-He/She did not recall the family asking about the resident's medication on 01/08/26, because if they would have asked, he/she would have called the Director of Nursing (DON) to get permission to administer any home medications;-He/She was aware of the resident's missing medication doses and did not call the pharmacy or physician because he/she was not aware he/she could call the pharmacy to request medications STAT;-He/She passed it along in report to day shift that the medications still had not arrived for the 6:00 A.M. medication pass, and they would need to access the stat safe;-The resident came out of his/her room around 4:00 A.M. on the morning of 01/09/26 saying that he/she was having a hard time sleeping;-He/She noticed a change in the resident on 01/09/26 and thought it was because he/she was just overly tired from not sleeping;-The resident went from being alert and oriented times 3 or 4 to being alert and oriented times 2 or 3, but he/she just thought it was from the resident being overly tired;-He/She did not notify the physician or call the DON when the medications were not available the night of 01/08/26. During an interview on 02/04/26 at 2:50 P.M., 02/19/26 at 4:32 P.M., and /2020/26 at 2:00 P.M., RN B said the following:-Pharmacy delivers medications around 5:00 - 6:00 P.M., and again around midnight, and again in the mornings;-If he/she does not receive needed medications, he/she checked the stat safe (E-Kit);-If he/she did not receive the medication from the pharmacy and it was not available in the stat safe, he/she will call the pharmacy to see why it was not delivered;-If it is an important medication, he/she would call the family to bring in the medication;- If it was an over the counter medication like Tylenol or aspirin, the facility should have that available; -If a medication was not administered, there would be a 9 (see progress note) on the eMAR and a note should be written explaining that the medication was not available, and pharmacy was contacted;-The current pharmacy the facility used was not getting the medications to the facility at suitable times, so the facility was switching to another pharmacy; -The resident said he/she had not slept at all on the night of 01/08/26;-The resident admitted on the evening of 01/08/26; he/she worked the 7:00 A.M. - 7:00 P.M. shift on 01/09/26 and the medications arrived from the pharmacy that morning;-He/She was aware the resident had not received his/her medications, including a sleeping medication;-The resident's family told him/her that the resident was acting goofy and he/she informed them the resident had been like that all day and thought it was because he/she had not slept all night;-He/She did not notify the physician or DON regarding the missed medications;-If he/she charted the medication as a 9 on the eMAR, it was not given;-If he/she forgot to put a note in the progress notes as to why the medication was not given, it probably just slipped his/her mind. During an interview on 02/04/26 at 12:13 P.M., the DON said the following:-She would expect staff to notify the family and physician regarding any missing medications/doses; -Over the counter medications such as Tylenol or aspirin, could easily be picked up from the pharmacy down the street, if needed;-If a 9 (see progress note) is charted on the eMAR, she would expect staff to put a note in the progress notes as to why the medication was not administered. If there was no progress note, the medication was not administered;-She and/or nurse managers are responsible for reviewing the eMARs, but do not do it daily. During an interview on 02/04/26 at 11:55 A.M. and 3:20 P.M., the Administrator said the following:-If a resident admits to the facility in the evening, the nurse inputs the orders, and the pharmacy delivers the medication later that evening;-If the medication was unavailable, she would expect staff to pull medications from the stat safe/emergency kit (E-Kit);-If a medication was not available in the E-Kit or the facility did not receive the medication from the pharmacy quickly, staff could also notify the family representative to bring in the resident's medication;-If the pharmacy is unable to deliver medications in a timely matter, the facility can use another 24 hour pharmacy down the street to get the medications. During an interview on 02/19/26 at 3:04 P.M., the Pharmacist said the following:-The pharmacy received the resident's medication orders after hours on 01/08/26 at 8:03 P.M.;-After hours (after 7:00 P.M.), there was an on-call pharmacist the facility could call and the pharmacist can get them stat iv antibiotics, controls, or in special instances, other medications that were not available in their E-Kit;-The resident's medications were dispensed and left their pharmacy for delivery on 01/09/26 at 9:27 A.M. During an interview on 02/04/26 at 3:25 P.M., the resident's Nurse Practitioner said the following:-She verified medications for the resident before the resident admitted to the facility on [DATE];-It was not uncommon for the facility to not have medications available right away because the facility cannot order the medications until the resident was admitted ;-She would have expected a call from the facility at least the following day (01/09/26) regarding the missing medications and would have asked them to call the pharmacy and check the E-kit;-There should be no reason not to give an over the counter medication such as aspirin. During an interview on 02/04/26 at 3:10 P.M., the resident's Physician said the following:-She was not notified of any missing medications;-The resident should have been able to at least get aspirin - those should be easily available. #2716303

Based on observation, interview, and record review, the facility failed to follow current infection control standards for seven residents (Residents #3, #28, #31, #49, #76, #81, and #84), in a review of 18 sampled residents. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for three residents (Residents #81, #76 and #49) and one additional resident (Resident #84), when staff failed to appropriately sanitize the glucometer (a machine that tests a drop of blood for the amount of sugar it contains) after use and use a barrier to protect against contamination. The facility failed to store oxygen tubing and continuous positive airway pressure (CPAP - equipment used to treat sleep apnea) masks when not in use in a way to prevent potential contamination for two residents (Residents #3 and #31) and one additional resident (Resident #84). Staff failed to perform proper hand hygiene to prevent infection during personal care for Resident #28 and #49 and failed to properly handle soiled linens during personal care for Resident #28. The facility failed to follow the facility policy for Legionella Control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards, failed to monitor cold water temperatures and failed to complete a water flow map. The facility census was 49. Review of the undated facility policy, Glucometer Disinfection, showed the following:-The community will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-elder use;-Glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, hepatitis B and hepatitis C;-Glucometer will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single elder or multiple elder use;-Procedure is to obtain needed equipment and supplies (gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips and disinfecting wipes);-Wash hands, explain procedure to the elder, provide privacy, put on gloves and obtain blood glucose sampling according to community policy;-Remove and discard gloves, perform hand hygiene;-Reapply gloves if there is visible contamination of the device or if the elder is HIV or hepatitis B or C positive;-Retrieve disinfectant wipes from container, using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer;-After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions;-Allow the glucometer to air dry;-Discard wipes and perform hand hygiene. 1. Review of the Centers for Disease Control and Prevention (CDC), Considerations for Blood Glucose Monitoring, showed the following:-Assign blood glucose meters to a person unless the device is designed for use in professional settings and is cleaned and disinfected after every use;-Clean and disinfect blood glucose meters after every use per the manufacturer's instructions, to prevent the spread of blood and infectious agents;-Place barrier under blood glucose monitor when in resident's room or placed on top of medication cart to avoid spread of microorganisms and contamination of surfaces. 2. Review of the Medline EvenCare G2 Blood Glucose Monitoring System User Manual, revised March 2011, showed the following:-To clean the meter, use a moist lint-free cloth dampened with mild detergent and wipe all external areas of the meter;-To disinfect the meter, use a U.S. Environmental Protection Agency (EPA) registered disinfecting wipe;-Wipe all external areas of the meter until visibly clean;-Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use;-Wipe meter dry or allow to air dry. 3. Review of the CaviWipes Disinfecting Towelettes label showed the following:-CaviWipes is a two-step disinfectant product;-One wipe is required to pre-clean then a second wipe is required to disinfect;-Wipe surface completely to preclean surface of all visible debris;-Wipe surface with second wipe to ensure that the surface remains visibly wet for 2 minutes at room temperature;-This product protects against human immunodeficiency virus (HIV) (virus that is transmitted by contact with infected blood), hepatitis B (virus commonly spread by exposure to infected bodily fluids), and hepatitis C (virus that is spread by contact with contaminated blood) when the surface remains visibly wet for 2 minutes at room temperature. 4. Review of Resident #84's undated Face Sheet showed the resident's diagnoses included Type 2 diabetes. Review of the resident's Physician Orders, dated 7/18/25, showed to monitor blood sugar before meals. Observation on 07/22/25 at 5:46 A.M., showed the following:-Licensed Practical Nurse (LPN) G prepared to obtain a blood sample from the resident;-LPN G took the glucometer (used for multiple residents) out of the treatment cart and placed it directly on top of the cart without a barrier;-LPN G entered the resident's room and placed the glucometer on the resident's bed without a barrier; -LPN G obtained the blood sample from the resident's finger, placed a blood-filled test strip in the glucometer, obtained the result, and then removed the blood-filled test strip from the glucometer;-LPN G returned to the treatment cart and placed the glucometer on the treatment cart without a barrier;-LPN G removed his/her gloves, sanitized his/her hands and put on new gloves;-LPN G cleaned the glucometer with one Super Sani-Cloth Germicidal Disposable wipe for 30 seconds and immediately placed the glucometer back into the treatment cart drawer. 5. Review of Resident #81's undated Face Sheet showed the resident's diagnoses included Type 2 diabetes. Review of the resident's Physician Orders, dated 7/20/25, showed to monitor blood sugar daily. Observation on 07/22/25 at 6:50 A.M., showed the following:-LPN G prepared to obtain a blood sugar sample from the resident;-LPN G took the glucometer (the same glucometer he/she used to obtain Resident #84's blood sugar) out of the treatment cart and placed it directly on top of the cart without a barrier; -LPN G entered the resident's room and placed the glucometer on the resident's bed without a barrier; -LPN G obtained the blood sample from the resident's finger, placed the blood-filled test strip into the glucometer, obtained the result, and then removed the blood-filled test strip from the glucometer;-LPN G returned to the treatment cart and placed the glucometer on the treatment cart without a barrier;-LPN G removed his/her gloves, sanitized his/her hands and put on new gloves;-LPN G cleaned the glucometer with one CaviWipes disinfecting towelette for 15 seconds and immediately placed the glucometer back into the treatment cart drawer. During an interview on 7/28/25 at 1:22 P.M., LPN G said the following:-He/She was to place the glucometer on the bedside table or lay it on the bed next to the resident; -He/She was not aware of the policy to use a barrier between the glucometer and the surface it was on;-He/She was to disinfect the glucometer with a wipe for three minutes and then put the glucometer in the treatment cart drawer. During an interview on 07/24/25 at 3:50 P.M., the Director of Nursing (DON) said the following:-Staff should clean glucometers with disinfectant wipes per guidelines on the container;-Staff should place glucometers on a barrier while in the resident's room. 6. Review of Resident #76's face sheet showed he/she had diagnoses of type II diabetes mellitus. Review of the resident's July 2025 Physician Order Sheets (POS) showed an order for Tresiba Flextouch Pen (an injectable medication to treat high blood sugar) 24 units every day with no indication to check blood glucose prior to administration. Review of the resident's July 2025 Medication Administration Record (MAR) showed an area to record blood glucose results every day with the administration of the Tresiba medication. Observation on 07/22/2025, at 7:42 A.M., showed the following: -The resident lay awake in bed;-LPN A performed hand hygiene and donned gloves;-LPN A collected a glucometer, a test strip, alcohol pads and a lancet device and approached the resident's bed;-LPN A placed the glucometer directly on the resident's bed without placing a barrier, completed the blood sugar check procedure, took the glucometer back to the treatment cart, placed the glucometer on top of the treatment cart and then put the glucometer in the drawer;-LPN A did not clean, sanitize or disinfect the glucometer after obtaining the blood glucose sample;-LPN A doffed his/her gloves, performed hand hygiene, and left the resident's room. 7. Review of Resident #49's care plan, dated 06/24/25, showed the resident had a diagnosis of diabetes mellitus. Staff to perform accu-checks (blood glucose monitoring where a finger stick procedure is completed, and a droplet of blood is obtained for sampling) as ordered. Review of the resident's July 2025 POS showed an order for accu-check daily related to a diagnoses of type II diabetes mellitus. Observation on 07/22/25 at 8:35 A.M., showed the following: -The resident lay awake in his/her bed;-LPN A performed hand hygiene and donned gloves;-LPN A collected a glucometer (the same glucometer he/she just used to obtain Resident #76's blood glucose sample), a test strip, alcohol pads and a lancet device and approached the resident's bed;-LPN A wiped food crumbs off the resident's bed and then placed the glucometer directly on the resident's bed without a barrier. LPN A did not sanitize the glucometer, completed the accu-check procedure and took the glucometer back to the treatment cart and placed the glucometer on top of the treatment cart and then in the drawer where the glucometer was stored;-LPN A did not clean, sanitize or disinfect the glucometer before obtaining the blood glucose sample; -LPN A doffed his/her gloves, performed hand hygiene and left the resident's room. During an interview on 07/24/25, at 9:58 A.M., LPN A said the following: -He/She did not clean, sanitize or disinfect the multi-use glucometer after using it on Resident #76, before using it on Resident #49 or after using it on Resident #49; -He/She did not place a barrier between the surface of the bedside table or bed when obtaining blood glucose samples for either resident;-He/She should have placed a barrier between the glucometer and surface, as well as disinfected/cleaned the multi-use glucometer before and after using with approved bleach/sani-wipes;-He/She did not know why he/she did not place the barrier or disinfect/sanitizer the glucometer after use. During an interview on 07/24/25, at 3:50 P.M., the Director of Nursing (DON) said the following: -Staff should clean and disinfect the glucometer with disinfectant wipes per the guidelines on the wipes container;-Staff should put the glucometer on a barrier in while in the resident's room. 8. Review of the undated facility policy, CPAP/BiPAP, showed the following:-Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections;-Clean mask frame daily after use with CPAP cleaning wipe or soap and water, dry well and cover with plastic bag or completely enclosed in machine storage when not in use;-The policy did not address who was to clean the CPAP masks or who was to ensure a plastic bag was available for supply storage. 9. Review of Resident #3's face sheet showed he/she had a diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's admission MDS showed the following: -Moderate cognitive impairment;-Use of non-invasive mechanical ventilator as a resident;-Dependent on staff for wheelchair mobility of 50 and 150 feet;-Dependent on staff for toilet transfer, sit to stand and chair/bed-to-chair transfers;-Substantial/maximum staff assistance with rolling left to right, sit to lying, lying to sitting on the side of the bed. Review of the resident's July 2025 POS did not show any order for use of a continuous positive airway pressure (CPAP; a device that uses mild air pressure to keep breathing airways open while you sleep). Review of the resident's care plan, revised on 07/08/25, showed no area to address COPD or CPAP use. Observation on 07/21/25, 12:55 P.M., showed a CPAP mask sat uncovered on the resident's bedside table. There was no evidence a storage bag/container for the mask was available for use. During an interview on 07/21/25 at 12:58 P.M., the resident said he/she used the CPAP every night. Observation on 07/22/25 at 5:40 A.M., showed the resident lay awake in his/her bed. Staff had just assisted the resident to the toilet. The resident's CPAP mask sat uncovered on the resident's bedside table. There was no evidence a storage bag/container for the mask to was available for use. During an interview on 07/22/25 at 5:41 A.M., the resident said he/she used the CPAP all night, but just took it off to go to the bathroom and would be getting up for the day soon. Observation on 07/23/25 at 11:03 A.M., showed the resident's CPAP mask sat uncovered on the resident's bedside table. There was no evidence a storage bag/container for the mask was available for use. Observation on 07/24/25 at 9:51 A.M., showed the resident's CPAP mask sat uncovered on the resident's bedside table. There was no evidence a storage bag/container for the mask was available for use. During an interview on 08/05/25, at 6:05 A.M., Certified Nurse Aide (CAN) O said the following: -When he/she helped the resident with anything during the night, the resident typically removed his/her CPAP mask independently;-To the best of his/her recollection, if he/she helped the resident, he/she put the CPAP mask on the bedside table;-He/She did not recall if the resident had been educated on how to store the CPAP mask when not in use or who would have provided that education;-He/She believed the CPAP mask always sat on the bedside table uncovered when not in use;-He/She did not have to help the resident put on or take off the CPAP mask; the resident was able to do it independently;-He/She was unaware of how a CPAP mask should be stored when not in use. 10. Review of the undated facility policy, Oxygen Administration, showed the following:-Change oxygen tubing, mask, and cannula (a plastic tube device for delivering oxygen by way of two small prongs that are inserted into the nares) weekly and as needed if it becomes soiled or contaminated;-Keep delivery devices covered in plastic bag when not in use;-The policy did not address who was to monitor the changing of oxygen tubing or who was to ensure a plastic bag was available for use to keep supplies in and did not address dating the tubing. 11. Review of Resident #31's face sheet showed his/her diagnoses included chronic respiratory failure with hypoxia (a condition where lungs cannot adequately oxygenate the blood over an extended period, often due to underlying respiratory issues) and CHF. Review of the resident's care plan, revised 06/27/25, showed the following: -He/She used continuous oxygen;-Change oxygen tubing weekly as ordered. Review of the resident's July 2025 POS showed the following: -Change oxygen tubing every week on Monday; -Continuous oxygen at two liters per nasal cannula (flexible prongs placed in the nares that deliver supplemental oxygen). Review of the resident's admission MDS, dated [DATE], showed the following:-Cognitively intact;-Oxygen therapy used as a resident. Review of the resident's July 2025 Treatment Administration Record (TAR) showed LPN P documented the resident's oxygen tubing was changed on 07/07/25 and 07/14/25. Observation on 07/21/25 at 12:45 P.M., showed the resident's oxygen tubing rolled up and placed in the resident's bedside table with a date of 07/04/25 (the oxygen tubing had not been changed on 07/07/25 or 07/14/25 as documented on the TAR). No storage bag was visible for the tubing to be placed in when not in use. The resident currently used oxygen by portable tank. During an interview on 07/21/25 at 12:55 P.M., the resident said the following:-He/She used his/her oxygen most of the time; -Sometimes there was a bag to store his/her tubing in and sometimes there was not;-Staff usually just put the oxygen tubing across his/her bed when not in use;-He/She was unsure who put the tubing in his/her bedside table, usually it was across the bed. Observation on 07/23/25 at 11:05 A.M., showed the resident's oxygen tubing connected to the concentrator and the tubing (including the nasal prongs) on the floor, and tubing dated 7/21/25. There was no visible storage bag for the tubing. Observation on 07/24/25, at 9:34 A.M., showed the resident's oxygen tubing connected to the concentrator and the tubing (including the nasal prongs) were on the floor, and tubing dated 7/21/25. There was no visible storage bag for the tubing. During an interview on 07/24/25, at 9:45 A.M., CNA L said when oxygen supplies, including tubing and the CPAP mask are not in use, they should be stored in the plastic bag that has a date on it and hung up in the resident's room. During an interview on 07/24/25, at 9:54 A.M., CNA M said when oxygen supplies like tubing and a CPAP mask are not in use they should be stored in a plastic bag and placed on the bedside table. During an interview on 07/24/25, at 9:58 A.M., LPN A said when oxygen supplies like tubing and a CPAP mask are not in use, they should be stored in a plastic bag and hung in the resident's closet. During an interview on 07/24/25, at 3:50 P.M., the Director of Nursing (DON) said the following: -Oxygen tubing, nasal cannulas and CPAP masks should be stored in gallon zip loc bags in the resident rooms when not in use;-Oxygen tubing/masks should not be stored uncovered on the bedside table, on the bed or on the floor when not in use;-Oxygen tubing was ordered to be changed every week on Monday by the night shift. During an interview 08/05/25, at 2:53 P.M., LPN P said the following: -He/She is responsible for changing the residents oxygen tubing on the Monday night going into the Tuesday morning every week;-He/She changed the tubing on 07/07/25 and 07/14/25;-Someone must have changed the dates of the tubing, because he/she knows he/she changed it on 07/14/25;-He/She puts out new Ziplock bags and tapes them to the oxygen concentrator weekly if one is not there;-The Ziplock bags are where the oxygen tubing should be stored when not in use. During an interview on 07/24/2025 3:50 P.M., DON said the following:-She would expect CPAP masks to be stored in a gallon plastic zip top bag in the resident room when not in use;-CPAP tubing and masks should not be stored on the bed or on the floor;-The night nurse changed the oxygen tubing every Monday night. 12. Review of the undated facility policy, Handling Soiled Linen, showed the following:-It is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection. This policy pertains to soiled linen;-Linen can become contaminated with pathogens from contact with intact skin, body substances, or from environmental contaminants. Transmission of pathogens can occur through direct contact with linens or aerosols generated from sorting and handling contaminated linen;-All used linen should be handled using standard precautions (i.e. gloves) and treated as potentially contaminated;-Linen should not be allowed to touch the floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons;-Used or soiled linen shall be collected at the bedside (or point of use, such as dining room) and placed in a linen bag or designated receptable.-Wash hands after contact with soiled linen. 13. Review of the undated facility policy, Hand Hygiene, showed the following:-Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR);-All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, elders, and visitors;-Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice;-Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations;-Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom;-The use of gloves does not replace hand hygiene;-If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.-Hand hygiene should be done when: before and after handling clean or soiled dressings, linens, after handling items potentially contaminated with blood, body fluids, secretions or excretions, when, during elder care, moving from a contaminated body site to a clean body site, after assistance with personal body functions (e.g. elimination) 14. Review of Resident #28's Care Plan, dated 2/4/25, showed the following:-The resident had an activities of daily living (ADL) self-care need related to stroke;-The resident required substantial/maximum assistance for toileting hygiene. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 5/13/25, showed the following:-Dependent on staff for toileting and hygiene;-Incontinent of bowel and bladder. Observation on 7/22/25 at 5:35 A.M. showed the following:-CNA J entered the resident's room, washed his/her hands, put on gloves, and obtained a clean brief, sheet, and wipes;-The resident was incontinent of bladder;-He/She cleaned the resident, pulled out the urine saturated incontinence brief and sheet from under the resident and placed the soiled incontinence brief and sheet on the floor;-Without changing his/her gloves and performing hand hygiene, CNA J put a clean incontinence brief and sheet under the resident and covered the resident;-He/She picked up the dirty linen and the soiled incontinence brief off the floor and took the linen to the soiled utility room. During an interview on 7/22/25 at 5:45 A.M., CNA J said he/she did not change his/her gloves after cleaning the resident, and he/she should not have put the dirty linen on the floor. During an interview on 7/24/25 at 10:00 A.M., the Infection Preventionist/LPN said the following:-Staff should not put dirty linen on the floor;-Staff should wash their hands before putting on gloves and between clean and dirty tasks. During an interview on7/24/25 at 3:50 P.M. the Director of Nursing said the following:-Staff should perform hand hygiene before and after performing incontinence care;-Staff should wash their hands and apply new gloves before touching clean items. -Staff should not put dirty linen and soiled incontinence briefs on the floor;-Staff should place soiled incontinence briefs in a trash bag and the dirty linen in a laundry hamper or take to laundry room. 15. Review of Resident #49's care plan, dated 06/24/25, showed the following: -He/She was totally dependent on two staff for toilet use;-He/She was incontinent of bladder. Staff to clean peri-area with each incontinent episode. Review of the resident's July 2025 Physician Order Sheet (POS) showed an order to apply moisture barrier cream/ointment to coccyx (tailbone) and peri-area after each incontinent episode with an order start date of 07/08/25. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact;-Dependent on staff for toileting hygiene;-Occasionally incontinent of bladder;-Always incontinent of bowel;-Has moisture associated skin damage;-Application of ointment/medication to area other than to feet. Observation on 07/21/2025, at 2:58 P.M., showed the following: -LPN A and CNA B applied hand sanitizer and put on gloves;-LPN A provided front peri-care for the resident using disposable wipes; -CNA B provided posterior peri-care for the resident, who had a moderate size liquid bowel movement;-Without removing his/her gloves, CNA B obtained barrier cream from the resident's bathroom and applied the barrier cream to the resident's skin; -LPN A wiped the resident's skin one more time and finished applying the resident's new incontinent brief. During an interview on 07/30/25 at 3:49 P.M., CNA B said the following: -He/She should wash his/her hands when entering a room, any time he/she changed his/her gloves, when moving from clean to dirty areas when providing care, when the task was completed, and before leaving the resident's room;-He/She should change gloves after touching any bodily fluids, after a clean to dirty task, after performing rear peri-care and after applying any barrier creams before completing the task or touching anything that is clean;-He/She did not change his/her gloves after providing peri-care for the resident and before applying barrier cream;-He/She realized his/her mistake afterward and knew he/she should have taken the dirty gloves off, washed his/her hands, applied clean gloves and then applied the barrier cream. During an interview on 07/24/25, at 3:50 P.M., the Director of Nursing (DON) said the following: -Staff should not touch equipment with soiled gloves and should not apply cream after peri-care with soiled gloves. Staff should take off their gloves, wash their hands and put on clean gloves before doing a treatment;-Staff should perform hand hygiene (hand sanitizer or soap and water) before and after performing incontinence care;-Staff could use hand sanitizer if their hands were not visibly soiled. 16. Review of the facility's undated policy, Legionella Surveillance, showed the following: -It is the policy of this community to establish primary and secondary strategies for the prevention and control of Legionella infections;-Legionella grows best in water temperatures of 77 degrees Fahrenheit to 108 degrees F, particularly in water that is not moving or that does not have enough disinfectant (i.e. pH 6.5-8.5) to kill germs;-Cold water shall be stored and distributed below 68 degrees F;-Hot water shall be stored above 140 degrees F and circulated at a minimum return temperature of 124 degrees F.;-The community shall use the McGeer criteria when diagnosing pneumonia;-The policy did not address who was to be on the water management team or how often the team was to meet;-The policy did not address the need for a waterflow diagram. 17. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following:-The bacterium Legionella can cause a serious type of pneumonia called LD (Legionnaire's disease) in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs and decorative fountains;-Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water;-CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit;-Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;-Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;-Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. 18. Review of the undated, Centers for Disease Control and Prevention Legionella Environmental Assessment Form showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F and Legionella become dormant below 68 degrees F. 19. Review of the facility's most recent water management team meeting, dated 12/26/24, showed the following: -Members present included the Chief Executive Officer (CEO), Administrator, prior maintenance director, prior Infection Preventionist (IP), DON and food/water management;-Section 3: Describe your building water systems using a flow diagram was blank with no water flow map available for review. Review of the facility's weekly water temperature logs for 07/14/25 through 07/21/25 showed no documentation staff monitored the temperature of the cold water. Review of water temperatures, obtained by the state agency on 07/24/25, showed the following water temperatures fell between 77 and 113 degrees F, temperatures at which legionella generally grows well:-At 8:52 A.M., [NAME] Cottage room [ROOM NUMBER], cold-water faucet temperature was 78.9 degrees F (too warm), and hot-water faucet temperature was 111.9 degrees F (too cool);-At 8:59 A.M., [NAME] Cottage community restroom, cold-water faucet temperature was 77.7 degrees F (too warm);-At 9:06 A.M., [NAME] Cottage room [ROOM NUMBER], cold-water faucet temperature was 77.1 degrees F (too warm);-At 9:14 A.M., [NAME] Cottage room [ROOM NUMBER], cold-water faucet temperature was 77.5 degrees F (too warm);-At 9:24 A.M. [NAME] Cottage room [ROOM NUMBER], cold-water faucet temperature was 77.3 degrees F (too warm);-At 9:32 A.M., Grace Cottage room [ROOM NUMBER], cold-water faucet temperature was 77.5 degrees F (too warm). During an interview on 07/24/25, at 2:15 P.M., the IP said she believed she was a part of the water management team but had not attended a meeting and had been the IP since February. During an interview on 07/24/25 at 3:41P.M., the maintenance director said the following:-He was a part of the water management team;-He had been at the facility since February and there had been no water management team meeting since he had been the director;-He did not check cold water temperatures because he was unaware he was supposed to;-He had heard of the CDC tool kit but had not heard of ASHRAE guidelines;-There should be a water flow diagram as part of the water management plan for Legionella but he had not seen one and could not find one. During an interview on 07/24/25, at 4:06 P.M., the Executive Director said the following: -She was a part of the water management team;-The water management team discussed the Legionella program. The facility was a relatively new building (six years old) and there had not been any plumbing issues since the facility was built; -If a resident had a pneumonia diagnosis, the physician was made aware, and he determined if a legionella test needed to be completed;-She wa

Based on observation, interview, and record review, the facility failed to provide incontinent care consistent with acceptable standards of practice to prevent urinary tract infections (UTI) and failed to follow proper infection control procedures for one sampled resident (Resident #48), of 18 sampled residents. The resident has a history of UTI's with a multi drug resistant organism (MDRO) that required the resident be on Enhanced Barrier Precautions (EBP- infection control measures designed to reduce the transmission of multidrug-resistant organisms (MDROs) in healthcare settings, particularly in nursing homes). The facility census was 49. Review of the facility's undated policy for Perineal Care showed the following:-It is the practice of this facility to provide perineal care to all incontinent elders during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown;-Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate;-Assist the elder in bending the knees and slightly opening the legs, wet a washcloth and apply perineal cleanser, or if using prepackaged product, open package and obtain the wet cloth;-Separate the gluteal folds and cleanse with one hand by wiping in the direction from front to back;-Repeat on the opposite side using separate section of washcloth or new disposable wipe;-Turn the elder on their side and clean and dry the anal area, wiping from front to back. Review of the facility's undated facility policy for hand hygiene showed the following:-All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, elders, and visitors;-Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR);-Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice;-The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves;-Hand hygiene should be performed when hands a visibly soiled, visibly soiled with blood or other body fluids; after caring for a person with known or suspected infectious diarrhea; between elder contacts; after handing contaminated objects; before applying and after removing personal protective equipment (PPE), including gloves; before and after handling clean or soiled dressings, or linens; before performing elder care procedures; before and after providing care to elders in isolation; after handling items potentially contaminated with blood, body fluids, secretions or excretions, when, during elder care, moving from a contaminated body site to a clean body site. 1. Review of Resident #48's face sheet showed the resident admitted to the facility on [DATE] with diagnoses including history of UTI, hydronephrosis (the swelling of one or both kidneys due to a buildup of urine) with ureteral calculous obstruction (a condition where a kidney is swollen due to a blockage in the ureter (the tube carrying urine from the kidney to the bladder) caused by a kidney stone). Review of the resident's Physician Orders dated 10/23/24 showed an order for staff to perform hand hygiene, wear a gown and gloves while performing high contact care activities for elders with infection of Multi Drug Resistant Organism (MDRO) Enhanced Barrier Precautions. Review of the resident's urinalysis (UA) with a culture and sensitivity (C&S) dated 4/21/25 showed greater than 100,000 of Escherichia coli (E. coli is a type of bacteria commonly found in the gastrointestinal (GI) tract.) with an antibiotic ordered. Review of the resident's comprehensive Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff dated 5/22/25 showed the following:-Dependent on staff for Activities of Daily Living (ADL's), including toileting;-Incontinent of bowel and bladder;-Diagnosis of renal insufficiency and obstructive uropathy (a condition where urine flow is blocked or reduced, leading to urine backing up into the kidney and potentially causing damage). Review of the resident's care plan for infection with a revision date of 5/30/25 showed the following:-At risk of transmitting an infection related to history of VRE (Vancomycin Resistant Enterococcus - bacteria that have become resistant to the antibiotic vancomycin. These bacteria are typically found in the intestines and genital tract, and can cause infections, especially in healthcare settings. VRE infections are generally spread through contact with contaminated surfaces or equipment, and person-to-person contact);-Interventions: Enhanced Barrier Precautions; monitor for signs and symptoms of an infection. Review of the resident's urinalysis (UA) with a culture and sensitivity (C&S) dated 4/21/25 showed greater than 100,000 of Escherichia coli (E. coli is a type of bacteria commonly found in the gastrointestinal (GI) tract.) with an antibiotic ordered. Review of the resident's UA with C&S dated 6/2/25 showed greater than 100,000 of E-Coli. Review of the nurses note dated 6/2/2025 at 7:38 P.M. showed the nurse practitioner (NP) visited the elder. Has UTI, started him/her on Rocephin (antibiotic used to treat various bacterial infections) 1 gram intramuscular (IM) for three days. Review of the nurses note dated 6/22/2025 at 10:30 P.M. showed:: When doing care with elder, the elder seemed confused. This nurse asked the elder if he/she felt confused, the elder replied, Yes I feel off, can't put my finger on it, oh yea, when do I get out of here?. Wheezing upper respirations, do not hear anything in lungs. Elder is short of breath (SOB). Called the responsible party wants me to ask the elder if he/she wants to go to hospital. When this nurse asked elder, elder replied, Lord give me the strength to be nice, then looked at care partner and said he/she was going to break her arm in same breath said care partner is his/her best friend can you get me some strawberries but could not pronounce the word. Called the responsible party back he/she is heading to the facility. Review of the nurses notes dated 6/30/2025 at 8:54 A.M. showed:: Elder stated he/she did not feel good. Shaky, confused, SOB, talking about dreams he/she had, not sure if they are real or not, sick to his/her stomach. Body feels warm to the touch, pale, shaking. Review of the nurses note dated 7/6/2025 at 7:27 P.M. showed:-Faxed UA with C&S to provider. Organisms enterococcus faecium -70-99 CFU/ml and two different gram negative rods, no work up less than10,000CFU/ml. Review of the UA with C&S dated 7/7/25 showed the following:-70-99,000 of enterococcus faecium (this type of bacteria is mainly transmitted through direct or indirect contact with contaminated people or objects. Enterococci are bacteria normally found in the human intestines, genital tract, and environment (e.g., soil and water);-Sensitive to Linezolid (an antibiotic used to treat various serious bacterial infections) and nitrofurantoin (an antibiotic medication primarily used to treat and prevent urinary tract; brand names include Macrobid and Macrodantin). Review of the Physician Order Sheet (POS) dated July 2025 showed:-Macrobid 100mg one capsule two times a day (BID)for 10 days for UTI;-Start date of 7/8/25 and end date of 7/15/25. Review of the resident's nurses note dated 7/20/2025 at 7:40 P.M. showed the care partner came to this nurse and said elder had strong odor and blood in his/her urine. Assessed the elder who said, I think I am getting another UTI because it burns when urinating. poke with NP, ordered UA with C&S. Review of the resident's UA collected on 7/21/25 showed the resident's urine was orange (yellow), extra turbid (normal clear), three plus blood (significant amount of blood in the urine), one plus protein (indicative of potential kidney damage), three plus leukocytes (signs of a UTI increase white blood cells), too numerous to count (TNTC) bacteria, mucous present with WBC (white blood cells) clumps present. Review of the resident's C&S collected on 7/21/25 dated 7/26/25 showed the following:-70-99,000 pseudomonas aeruginosa, (a type of bacteria, when present in urine typically indicates a urinary tract infection (UTI), especially in individuals with catheters or those who are elderly. This bacterium is an opportunistic pathogen, meaning it can cause infection when the body's defenses are weakened. While UTIs are common, those caused by P. aeruginosa can be more challenging to treat due to the bacteria's high resistance to many antibiotics);-Sensitive antibiotics: Cipro. Review of the resident's nurses noted dated 7/22/25 at 4:43 P.M. showed the nurse practitioner was onsite and ordered Cipro (a broad-spectrum antibiotic used to treat a wide range of bacterial infections) 500 mg BID for seven days. Observation on at 07/22/2025 6:22 A.M. showed the following:-Certified Nurse Aide (CNA) K and CNA J put on gowns and gloves to provide care. Both said the resident was on EBP due to possible MDRO.;-Both used hand sanitizer and applied gloves;-CNA K using disposable wipes cleaned the resident's front perineal folds then rolled the resident to the right, unfastened the urine saturated brief, and tuck the brief, pad and sheet under the resident, then took disposable wipes and began to wipe between the buttocks. There was a slight amount of blood on the wipe and fecal matter;-CNA K used several wipes to remove fecal matter;-CNA K did not wash the resident's buttocks, thighs or lower back that were in contact with urine. Without changing gloves or performing hand hygiene, CNA K rolled the resident to the left side;-CNA J pulled the urine soaked brief, pad, and sheet out from under the and rolled the resident back onto his/her back without cleaning the urine from the resident's buttocks;-There were several areas of bright red blood on the soiled sheet;-CNA K and CNA J adjusted the resident in the bed, touched items on the resident's over the bed table and put away the bag of disposable wipes with soiled gloves. During an interview on 7/29/25 at 2:15 P.M. CNA J said the following:-He/she did not clean the right side of the resident's buttocks as he/she thought CNA K had cleansed that part of the resident's body;-All areas of the body that come into contact with urine or feces should be cleaned;-He/She should have washed his/her hands or used hand sanitizer between glove changes and after touching anything that is dirty in the resident's room or providing resident cares. During an interview on 7/29/25 at 2:40 P.M. CNA K said the following:-He/She should have cleaned every part of the body that had come into contact with urine or feces;-He/She should have changed his/her gloves after providing peri-care and before touching anything that was clean or the resident. During an interview on 7/24/25 at 12:45 PM Licensed Practical Nurse (LPN) I said the following:-The resident has had recurrent UTI's;-He/She noticed blood on the resident's brief on Sunday and the resident had a change in mental status he/she notified the physician and received an order for the UA which was done on Monday and showed a possible UTI;-The lab was contacted regarding the C&S of the urine, and the results are still pending;-Staff should perform hand hygiene before applying gloves and after providing peri-care and before touching clean items;-Staff should cleanse all areas of the body that come into contact with urine or feces. During an interview on 7/24/25 at 10:00 AM the Infection Preventionist (IP) said the following:-Staff should wash their hands or use hand sanitizer before applying gloves, staff should change gloves and either wash their hands or use hand sanitizer then apply glove before touching clean items or the resident after care;-Staff should cleanse all parts of the residents body that come into contact with urine. During an interview on 7/24/25 at 3:50 P.M. the Director of Nursing said the following:-Staff should wash their hands or use hand sanitizer and apply gloves before performing incontinent care and when finished with incontinent care staff should wash their hands and apply new gloves before touching clean items;- Staff should clean all areas of the body in contact with urine or feces.

Based on interview and record review, the facility failed to ensure one resident (Resident #75) of 18 sampled residents and one additional resident (Resident #100), were treated in a manner to maintain dignity and respect. Resident #75 said the way staff treated him/her during cares made him/her feel disrespected and discouraged. The facility census was 49. Review of the facility's undated policy, Resident Rights, showed the following: -The community will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the community;-The community will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the community to properly care for its residents. 1. Review of Resident #75's undated face sheet showed he/she had diagnoses that include congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). Review of the resident's care plan, dated 07/10/25 showed the following: -He/She had an activities of daily living (ADLs) self-care need;-He/She required limited assistance from one staff to turn and reposition in bed, with personal hygiene, for toileting, to move between surfaces and to walk. During an interview on 07/23/25 at 10:42 A.M., the resident said the following: -He/She was abruptly awakened by staff about 2:00 A.M on 07/23/25; -The staff blasted into his/her room, turned on the overhead light and was very loud and announced bed check time;-He/She went ahead and went to the restroom and the (unidentified) Certified Nurse Assistant (CNA) told the resident he/she needed to be using his/her legs more, insinuating the resident was not doing enough to help staff; -It was very disrespectful for this staff to barge into his/her room and treat the resident in this manner, the resident felt discouraged;-He/She had a rough day, was in significant pain due to a physician's appointment where his/her stitches were removed and x-rays taken, and it took him/her some time to fall asleep again. During an interview on 07/24/25 at 10:10 A.M., the resident said the following: -Last night was rough again;-The CNA was just as gruff and did not act like he/she had much patience;-He/She was not sure if it was the same staff as the night before;-It was not very respectful;-The way staff treated him/her the past two nights made him/her feel like a burden and it was very disheartening. 2. Review of Resident #100's face sheet showed he/she had diagnoses that include bilateral primary osteoarthritis of the knee (a type of arthritis that occurs when flexible tissue at the ends of the bones wears down causing pain in the joints). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 05/14/25, showed the following: -Cognitively intact;-Adequate hearing, makes self understood and understands others;-No behaviors or rejection of cares;-Dependent on staff for toileting hygiene;-Needs substantial/maximum staff assistance for rolling left to right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer and toilet transfer;-Occasionally incontinent of bladder. Review of the resident's care plan, dated 06/08/25, showed the following: -Extensive assistance by one staff for personal hygiene and transfers between surfaces;-Extensive assistance from two staff members for toilet use. During an interview on 05/20/25 at 9:15 A.M., the resident said the evening of 05/19/25 a caretaker, came into his/her room and threw the sheet off him/her and touched his/her private area. He/She asked the caretaker what he/she was doing, and the caretaker said, checking to see if you're wet. The resident told the caretaker to ask next time instead of just throwing the sheet off him/her. The resident did not feel like there was anything sexual about the incident and was not scared. The caretaker told the resident he/she did not want to wake the resident. During an interview on 07/24/25, at 3:49 P.M., the Director of Nursing (DON) said the following: -She would expect staff to speak to residents respectfully;-She would expect staff to treat residents with dignity and respect;-Bed check should be completed during the night by knocking lightly on the door, wake the resident up to provide needed care and not to scare or startle the resident; -During the night, the overhead light should not be flipped on, and staff should not announce themselves in a loud manner;-A resident should never be told by staff that they should be doing more than they are doing or be made to feel like they are not doing enough;-Covers should never be pulled back to do a bed check and a hand should never be placed on an incontinent product without telling the resident what was occurring;-Staff should not be gruff or short with a resident while providing care, the residents should always be treated with respect and kindness. During an interview on 07/24/25 at 4:06 P.M., the administrator said the following:-She would expect staff to speak to all residents with respect;-All residents should be treated with dignity and respect;-Bed check should be completed during the night with respect, dignity and with common decency;-The light should not be flipped on, and staff announce themselves in a manner that startled the resident during the middle of the night;-A resident should not be told they could be doing more, or be made to feel like they are not doing enough;-Covers should not be pulled back to do a bed check and a hand be placed on an incontinent product without tell the resident what is occurring;-Staff should never be gruff or short with a resident when providing care or during any interactions. 1779565

Based on observation, interview and record review, the facility failed to follow acceptable standards of practice for two sampled residents (Resident #10 and Resident #72) out of 18 sampled residents, when staff failed to ensure only current ordered medications were available for administration and medications were kept secured in each resident's individual medication storage cabinet. The facility census was 49. 1. Review of Resident #10's face sheet showed the resident was admitted to the facility on [DATE] with diagnoses of amyotrophic lateral sclerosis (ALS - a progressive neurodegenerative disease that affects nerve cells controlling muscle movement) and major depressive disorder. Review of the resident's care plans dated 6/24/25 showed no care plan for the resident to self-medicate. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 6/26/25 showed the following:-Able to understand others, and usually able to make self-understood;-Brief Interview for Mental Status (BIMS - a screening tool used to assess cognitive function) score of 14, able to make decisions appropriately;-Dependent upon staff for activities of daily living. Observation on 7/22/2025 at 9:14 A.M. showed the following:-A locked medication cabinet inside a series of cabinets on the wall upon entering the resident's room.-Inside a separate unlocked cabinet several cards of medications including baclofen (a muscle relaxer), meclizine (an antihistamine that's used to prevent and treat nausea, vomiting, and dizziness, particularly those associated with motion sickness and vertigo), omeprazole (an antacid), fluticasone (treat various inflammatory conditions), albuterol inhaler (used to treat breathing difficulties), potassium chloride (used to treat low potassium levels); Riluzole (a medication used to treat ALS), Vitamin B12, Vitamin C and a bottle of Thera Vitamins;-A bag of fleets enemas.-The cards of medications were dated from March 2025. The box of individual pill pouches was dated 2024. Review of the resident's physician orders dated July 2025 showed the following:-An order for albuterol sulfate inhaler, but no order for the resident to self-medicate;-Omeprazole 2mg one tablet daily - but no order for the resident to self-medicate;-Bacolfen 10 mg as needed - but no order for the resident to self-medicate;-Omeprazole 20 mg as needed - but no order for the resident to self-medicate;-There were no physician orders for meclizine, fluticasone, potassium chloride, Riluzole, Vitamin B12, Vitamin c or the Thera Vitamins. Review of the resident's medical record showed no assessment for the resident to self-medicate nor a physician order to self-medicate. During an interview on 7/22/25 at 9:05 A.M. the Director of Nursing said the following:-The resident did not have physician orders for some of the medications;-The resident came from an assisted living facility and medications must have come from that facility. The resident admitted to the facility in March of 2025. -The medication should be in the locked cabinet. 2. Review of Resident #72's face sheet showed the following:-admitted to the facility on [DATE];-Diagnoses of dementia, anxiety, Parkinsonism (a general term describing a group of neurological conditions that share similar symptoms with Parkinson's disease, such as tremors, stiffness, and slow movement), fracture of T 11 and T13 vertebra, wedge compression fracture (a type of spinal fracture where the front portion of a vertebra collapses, causing it to take on a wedge shape) of fourth lumbar vertebra. Review of the resident's care plans dated 7/16/25 showed no care plan for the resident to self-medicate. Review of the resident's BIMs dated 7/21/25 showed a score of 11 (indicating moderate cognitive impairment) Review of the resident's medical record showed no self-medication assessment or order to self-medicate. Observation on 7/22/25 at 5:27 AM and again on 7/23/25 at 2:00 PM showed the following:-A bottle of Salonpas (pain relief medication) on the resident's over bed with no pharmacy label. The bottle had been opened;- An open bottle of probiotic medication; -Saline nasal spray on the sink in the bathroom. Review of the resident's physician orders dated July 2025 showed no order for the Salonpas, the probiotic or the nasal spray.During an interview on 7/23/25 at 2:00 PM Licensed Practical Nurse (LPN) I said the following:-The resident should not have the medication at the bedside even if it was over the counter, unless there was a physician order for the resident to keep the medication at the bedside;-The resident did not have an order to keep medication at the bedside. During an interview on 7/24/25 at 3:30 P.M. the Director of Nursing said all medications should be in the locked medication cabinets in each resident's room unless there was a physician's order for the medication to be kept at bedside.

Based on observations, interviews, record review, and facility policy review, the facility failed to conduct timely identification, assessment, and treatment of a wound for two of five residents (Residents (R) 47 and 43) reviewed for pressure sores out of a total sample of 21 residents resulting in the progression of the wound to advanced stages (stage IV - a deep wound reaching the muscles, ligaments, or bones which can cause pain, infection, invasive surgeries, or even death; or unstageable - a term that refers to an ulcer that has full thickness tissue loss but is covered by extensive necrotic (dead) tissue). This failure resulted in harm to R43 and R47 for the development and worsening of stage IV pressure ulcers to the heels. Findings include: Review of the facility's policy titled, Wound Treatment Management, with a revised date of December 2015, revealed To promote wound healing of various types of wounds, it is the policy of this community to provide evidence-based treatments in accordance with current standards of practice and physician orders. The policy further revealed a section for Pressure Injury Prevention and Management. The community is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heel the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injury. Review of the facility's policy titled, Pressure Injury Prevention and Management, with a revised date of December 2015, revealed This community is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Assessment of Pressure Injury risk revealed Licensed nurses will conduct a pressure injury risk assessment, using the Cottages Skin and Wound assessment, on all elders upon admission/re-admission, weekly x four weeks, then quarterly or whenever the elder's condition changes significantly. The policy further revealed Licensed nurses will conduct a full body skin assessment on all elders upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse and documented on the Cottages Skin and Wound assessment. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. Record review of the Interventions for Prevention and to Promote Healing section of the policy revealed Evidence-based interventions for prevention will be implemented for all elders who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: . Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); Minimize exposure to moisture and keep skin clean, especially of fecal contamination; Provide appropriate, pressure-redistributing, support surfaces; Provide non-irritating surfaces; and maintain or improve nutrition and hydration status, where feasible . Review of the facility's policy titled, Skin Assessment, with a revised date of December 2015, revealed A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. Review further revealed Documentation of skin assessment should Include date and time of the assessment, your name, and position title .Document observations (e.g., skin conditions, how the elder tolerated the procedure, etc.) . Document type of wound .Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain) .Document if elder refused assessment and why .Document other information as indicated or appropriate. 1. Review of R47's Admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he/she was admitted to the facility on [DATE], with diagnoses including unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, generalize muscle weakness, difficulty walking, unspecified lack of coordination, and pressure ulcer of sacral region, unspecified stage. Review of R47's Braden Scale located in the EMR under Assessments tab, dated 08/21/23, revealed a score of 16, which indicated the resident was at risk for skin breakdown. His/Her ability to walk was severely impaired and he/she was unable to bear his/her own weight. His/Her bed mobility was very limited and could only make occasional body positioning changes. Friction and Shearing required moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequent sliding down in bed or chair, requiring frequent repositioning with maximum assistance. Review of R47's admission Minimum Data Set (MDS) assessment located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/28/23, revealed a Brief Interview for Mental Status (BIMS) assessment with a score of 12 out of 15 which indicated moderately impaired cognition. R47 required extensive assistance from two staff with bed mobility and transfers and was unable to ambulate. R47 used a wheelchair for locomotion in his/her room and on the unit with set up help only. R47 had only one pressure ulcer on admission, and it was on a bony prominence. However, he/she was at risk of developing pressure ulcers. No deep tissue injury, arterial, or venous ulcers were present. He/She had a pressure reducing device for his/her chair and bed. Pressure ulcer triggered as a care area. Review of R47's Care Plan, located in the Care Plan tab of the EMR, dated 08/24/23, revealed Resident has the potential/actual impairment to skin integrity. The resident's goal was, The skin will remain intact with a target date of 10/31/2023. There were no interventions listed until they were added on 09/06/23. Review of R47's EMR under the Assessments tab revealed on 08/30/23 a Skin & Wound Evaluation was completed and there was no indication of any heel wounds. Record review of the EMR under Physician Orders revealed: -On 08/21/23 A hinged knee brace should be locked at 30 degrees at all times. -On 09/05/23 Prevalon boots to the right foot at all times, right heel offloading measures to heel float, and wound care including use of skin prep and foam dressing. Further review of the Care Plan revealed on 09/06/23 heels off the bed and monitor for signs and symptoms of infection were added as approaches. Another focus area was Physical mobility needs, the resident will remain free of complications related to immobility including contractures, thrombus formation, skin breakdown, falling related injury .The resident is NON-WEIGHT bearing (right) . Locomotion: The resident uses a manual wheelchair for locomotion. Another focus area was, I have ADL [activities of daily living] self-care need. The resident's goal was, The resident will improve current level of function in ADL's. One of the approaches was, BED MOBILITY: The resident requires extensive assistance by (2) staff to turn and reposition in bed. An additional focus area was added on 09/06/23, I have pressure ulcer to my bilateral heels. The resident's goal was, My heels will show signs of healing through next review. The approaches included: Prevalon boots for offloading and Administer treatments as ordered by MD. Record review of the EMR under Physician Orders revealed: -On 09/07/23 A Low Air Loss [LAL] mattress. -On 09/15/23 Weight-bearing status to increase to 50%. Review of R47's Skin & Wound Evaluation, dated 09/13/23, revealed a Stage 2 pressure sore with partial thickness skin loss with exposed dermis was on the left heel. The assessment revealed the pressure sore was in-house acquired. The evaluation revealed there was a right heel pressure ulcer that was in-house acquired. The area was 4.5 cm (centimeters) in length and 2.1 cm in width with an area of 8.9 centimeter squared [cm2]. Review of R47's additional Skin & Wound Evaluation, dated 09/13/23, revealed there was an unstageable in house acquired pressure area to the left heel with no measurements obtained. Review of R47's Skin & Wound Evaluation, dated 10/01/23, revealed a Stage 1: nonblanchable erythema of intact skin in-house acquired pressure area to the left heel. Area was 9.3 cm, length was 3.3 cm, width was 3.5 cm, and depth is 0.1 cm. Review of R47's Cottages Skin & Wound Total Body Assessment, dated 10/04/23, located in the EMR, under the Assessment tab, revealed a blister to left heel is minimal and closed with no open area to measure. Right heel is now a stage 2 wound as skin has broken. Covered with Xeroform gauze and bordered foam dressing. The area was 8.9 cm2, length was 4.5 cm, and width was 2.6 cm. Review of a fax from the physician to the facility revealed the physician saw the resident on 10/10/23 and documented there was a pressure injury to bilateral heels with darkened, well-defined border with each measuring 3x4 cm (centimeters). Physician orders for 10/03/23 revealed a consultation with Wound Care Plus was ordered. The treatment for the right heel was to cleanse the wound with wound cleanser, apply Xeroform gauze and cover with a bordered foam dressing. Physician orders for 10/10/23 revealed the treatment for the bilateral heels was to cleanse with the wound cleanser, apply Xeroform and cover with bordered foam dressing. Observation of R47 on 10/09/23 at 10:05 AM revealed he/she was sitting up in a wheelchair in the hall with a boot on the right foot. At 4:00 PM, the resident was sitting up in a wheelchair and asleep with a boot on the right foot. Review of R47's Skin & Wound Evaluation, dated 10/10/23, for the right heel, revealed a Stage 4: full thickness skin and tissue loss. The measurements were 11.5 cm2 for area, length was 5.0 cm, and width was 3.4 cm. Review further revealed the left heel was a stage one in-house acquired pressure sore. The measurements were 20.9 cm in area, 5.3 cm length, and 5.0 cm width. Observation of R47 on 10/10/23 at 10:37 AM revealed he/she was wheeling himself down the hall and stated he/she had a rash on both heels that he/she did not have before he/she arrived at the facility. R47 believed the rash was from the sheets lying against his/her feet. Observation of R47 on 10/10/23 at 4:30 PM revealed he/she was lying in bed on his/her back with the head of the bed up. Resident was lying on a LAL mattress. A Prevalon boot was on his/her right foot and the left foot was floated on a pillow. Interview on 10/11/23 at 10:21 AM with Licensed Practical Nurse (LPN)2 revealed the areas on the heel were discovered in September. He/She revealed he/she took pictures of the bilateral heel wounds yesterday. He/She stated the right heel measured 11.5 cm for the area, 5.0 length, and 3.4 width. He/She stated the left heel was a blood blister and it burst. He/She stated the measurements were area 20.9 cm2, length 5.3 cm, and width 5.0 cm. He/She revealed they did the treatment once a day and weekly skin assessments. Interview on 10/12/2023 at 12:25 PM with LPN2, by phone, revealed on 09/06/23 a Care Partner (CP) informed him/her about the heels. He/She stated he/she assessed the heels and called the physician to get new orders. He/She stated the orders were skin prep and foam dressing. He/She stated his/her skin assessment was due that day. LPN2 stated R47 liked to sit in his/her wheelchair and used his/her feet to help propel the wheelchair. He/She stated he/she needed assistance of one to turn in bed. LPN2 revealed he/she did not think shearing was a factor in the pressure formation because the resident would help when staff pulled him/her up in bed. Interview on 10/12/2023 at 9:51 AM with CP11 revealed he/she had taken care of R47. He/She stated he/she was non-weight bearing when he/she first came in and he/she needed the assistance of two staff for mobility. He/She stated once he/she became 50% weight bearing he/she was able to do a lot more for himself/herself. He/She stated he/she wore a brace to the right knee all the time. CP11 stated R47 did not move much because it hurt him/her to move. He/She stated he/she had to have the assistance of two staff to turn over in bed at first. CP11 revealed he/she did not have any pressure areas to his/her heels on admission. He/She stated he/she went on vacation at the last of August and when he/she returned in September, he/she saw the heels and reported it to the nurse. He/She stated he/she was not sure why his/her heels broke down, but it was probably because he/she was not moving his/her right leg very much, however he/she could move the left leg. He/She revealed shearing was sliding back and forth on surfaces, but he/she did not think shearing was a factor in the formation of the wounds. He/She stated it was probably from the pressure of being in bed. During an interview on 10/12/23 at 12:08 PM the Director of Nursing (DON) reviewed the EMR and stated R47 was admitted to the facility on [DATE] with no skin issues to the heels. She reviewed the 08/30/23 skin assessment and stated there was no documentation of any heel skin issues. The DON revealed on 09/06/23 documentation showed there were wounds to bilateral heels. Prevalon boots were ordered by the physician. She revealed there were no measurements taken on this skin assessment. The DON revealed from the documentation that the areas to the heels were deep tissue injuries, and it was an error in labeling the staging. She stated she reviewed the physician notes for that day, and he went in to see the resident. The DON stated a low air loss mattress was ordered and was received on 09/07/23. The DON continued to review the pressure assessment and revealed there were no measurements on the 09/13/23 skin assessments, only a picture which looked like a deep tissue injury. She reviewed the skin assessments on 09/27/23 and stated there were no measurements done, only pictures. The DON stated she was not sure if the nurses were supposed to put in measurements. She stated she did not see any skin assessments on 09/20/23. The DON revealed her expectations would have been that skin assessments be done weekly, and measurements should have been taken. But there were pictures. The DON revealed it put the resident at risk if skin assessments and measurements were not done because you could not tell if the wound was healing or worsening. The DON further revealed if skin assessments and measurements were not done you could not tell if the care and treatment was working. Interview with the DON on 10/12/23 at 3:13 PM revealed the initial care plan should have included nutrition and dietary interventions, proper hydration, head to toe assessments, turning and repositioning, pain management, and a low air loss mattress. She revealed R47 did not receive the mattress until 09/07/23 and he/she definitely needed it before that because he/she had a locked brace and would need heel intervention. She stated a low air mattress would have been beneficial sooner to not have the pressure points like a regular mattress did. The DON stated, As a nurse I would advocate for the air loss mattress to help prevent pressure on the heels. During an interview, by phone, on 10/12/23 at 1:54 PM the In-House Physician (PHY) revealed R47 had a pressure ulcer on the left heel and the right heel. He stated the right heel was the side he/she had surgery on. He stated R47 utilized a brace that was locked at 30 degrees, which made it extremely difficult to get the pressure off the heel. He stated the resident was also non weight bearing, for a time, and was up in a wheelchair and bed which contributed to his/her pressure ulcer. PHY stated the staff notified him of the worsening of the wounds, and he thought he ordered consult for him/her. PHY stated he ordered a LAL mattress. PHY stated everything was avoidable, but it was highly likely that he/she would develop pressure ulcers. 26446 2. Review of R43's Admission Record found in the Profile tab of the EMR, revealed he/she was initially admitted to the facility on [DATE] and readmitted from the hospital on 07/14/23, with diagnoses of type 2 diabetes mellitus with ketoacidosis without coma, acute kidney failure, pressure ulcer of right heel (unstageable), and abnormalities of mobility. Review of R43's quarterly MDS assessment located in the MDS tab of the EMR, with an ARD of 08/22/23, revealed he/she scored three out of 15 on the BIMS which indicated significant cognition impairment. He/She did not exhibit any behavioral symptoms. R43 was at risk for pressure ulcers and had one unstageable pressure ulcer. He/She received pressure-reducing devices for her chair and bed, nutritional interventions, and pressure ulcer care. R43 required extensive assistance by one staff member with bed mobility, transfers, toileting, and personal hygiene. Review of R43's EMR under Orders tab revealed a 05/15/23 physician order to float heels off bed to avoid pressure three times a day. Review of Nurse Practitioner (NP) Progress Note located under the Progress Note tab, dated 07/03/23, documented that R43 had an Unstageable pressure ulcer of right heel. Review of R43's Progress Note located under the Progress Notes tab, dated 07/06/23, prior to hospital discharge, documented Elder has pressure sore on right heel. There was no additional documentation noted. Review of R43's Readmission Evaluation located under the Progress Notes tab, dated 07/14/23, revealed documentation: Right heel bandaged over black circular area that is opening at edges. Review of R43's Wound Evaluation located under the Assessments tab, dated 08/31/23, documented that the right heel wound dimensions were 2.23 cm x (by) 1.77 cm. Review of R43's Progress Note located under the Progress Notes tab, dated 09/07/23, revealed documentation Right heel has treatment order in place, appears to be healing, heels are off loaded while in bed to help with the healing process. No drainage noticed. No odor at site. Further review of the EMR revealed R43's Progress Note located under the Progress Notes tab, dated 09/14/23, documented that the resident's Pressure wound to right heel is being treated with Santyl and covered with a foam dressing, wound appearance has not changed. Review of R43's Wound Evaluation located under the Assessments tab, dated 09/15/23, documented that the stage four right heel wound dimensions were 2.15 cm x 1.83 cm. Review of R43's Wound Evaluation, dated 09/22/23, documented that the stage four right heel wound dimensions were 2.79 cm x 1.24 cm. Review of R43's Wound Evaluation, dated 09/29/23, documented that the stage four right heel wound dimensions were 3.58 cm x 2.64 cm. Review of R43's Progress Note located under the Progress Notes tab, dated 10/02/23, revealed documentation that Wound has green drainage and odor. Nurse contacting MD's office. Further review of the EMR revealed R43's Progress Note located under the Progress Notes tab, dated 10/02/23, documented that resident has foul smell and slough noted to heel with moderate purulent drainage no redness or warmth noted to R (right) heel. Review of NP Progress Note, dated 10/03/23, documented Wounds have worsened some odor and pink on edges. Keflex 500mg [milligrams] BID [twice daily] x seven days for wound with odor they will need to educate staff on showering residents with dressings on and get the Santyl in and off load heels. (sic) Review of the October 2023 Medication Administration Record (MAR) revealed a physician order on 10/03/23 for Keflex 500mg. Give one capsule by mouth two times a day for wound for seven days. Review of R43's Care Plan, located in the Care Plan tab of the EMR, dated 05/15/23, revealed I have an unstageable ulcer to R heel [was admitted with stage II]. It was last revised 09/06/23. The resident's goals were, My wound will show signs of healing by next review. The wound will remain stable. The interventions included: Elevate heels off the bed. Encourage good nutrition and hydration in order to promote healthier skin. Monitor for s/s [signs and symptoms] of infection. Pressure reducing boots to bilateral heels. Treat as ordered. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R43's Care Plan had not been updated with the appropriate identified stage four pressure ulcer on his/her right heel documented on his Admission Record on 07/14/23, nor was the identified wound infection. Review of R43's Progress Note located under the Progress Notes tab, dated 10/12/23, revealed documentation that Resident's measurements are 3 x 5 approximately, slough improving, faint foul smell seems to have improved since tx (treatment) of abx (antibiotics), moderate drainage noted purulent with some blood-tinged exudate. An observation of R43 on 10/9/23 at 1:30 PM revealed the resident sleeping in bed. The resident's calves were observed resting on a pillow, and the feet were resting directly on the mattress, not floated. An observation of R43 on 10/10/23 at 2:10 PM revealed the resident sleeping in bed. The resident's feet were placed in Podus boots, resting on the mattress. An observation of wound care was completed with LPN1 on 10/12/23 at 10:10 AM. LPN1 stated the nurse from the night shift had changed the resident's dressing, but she had to redo it because it was not wrapped correctly. During the treatment R43 was noted to have his/her right heel wrapped in Kerlix, dated 10/12/23 7:00 AM, which he/she stated was not the treatment order. The wound was measured at 3.0 cm x 5.0 cm. LPN1 stated that R43 required antibiotic medication for the wound, because it had been infected. He/She stated that the wound appeared better, but there was still an odor. He/She said he/she would be communicating with the nurse practitioner who monitored the wounds. During an interview on 10/12/23 at 9:29 AM the CP1 stated the staff tried to float R43's heels when he/she was in bed and also had Podus boots to wear. CP1 said that R43 did not like to have his/her feet raised when in his/her wheelchair. He/She said the staff tried but the resident did not like it. CP1 stated that for the showers that were scheduled early in the day the Care Partners would have the nurse help undress wounds and then the nurse would help rebandage them afterwards. He/She stated nurses changed bandages daily. He/She stated that if a new skin concern was noted during the shower, they would inform the nurse. CP1 said that R43 had a foot wound after coming back from her last readmission from the hospital, and then went on to hospice care. He/She confirmed that some staff had not been removing the bandages from the heel wound on R43, but the staff had been reeducated. An interview on 10/12/23 at 11:25 AM with the Administrator confirmed the Infection Preventionist (IP) handled and tracked resident wounds. She stated the facility had a wound tracking program that took photos, and helped keep everyone on the same page with how a resident wound was doing. She stated that if a resident's wound was really bad they could send them out to a wound care company. An interview on 10/12/23 at 12:28 PM with the Medical Director revealed he had not been managing the right heel wound for R43, but that the Nurse Practitioner that worked with him was monitoring that. He stated that he had R43 on his list to see next week but was not currently familiar with his/her current right heel wound status. During an interview on 10/12/23 at 1:02 PM the IP stated the facility had a new Performance Improvement Plan (PIP) regarding wounds and ensuring residents had the right interventions in place, communicating the wound assessments with the physicians, and monitoring the weekly wound assessments. The IP stated that R43's right heel wound had deteriorated and had been on an antibiotic recently for an infection with it. She stated R43 had a physician order for calcium alginate if the wound was draining, which the IP said it was. The IP stated the wound was a few months old and was identified in September. The IP confirmed the wound was stage four. She stated that the facility staff had figured out that the Care Partners were keeping the wound wrapped during the showers. The IP stated they had discussed with the staff the proper way to do care. The IP confirmed that she believed a big part of the deterioration was at least in part because of the showering. She stated that during the next all staff mandatory training they would be going over those skills with care staff. The IP stated that the Medical Director had given informal oversight for the resident wounds in the facility to the Nurse Practitioner. She confirmed that LPN1 had requested a continuation of the antibiotic treatment for R43 and had reached out to the physician since the wound had not yet healed. During an interview on 10/12/23 at 1:13 PM the MDS Coordinator (MDSC)1 confirmed that R43 had a right heel wound and that they used Santyl with border foam dressing and calcium alginate if the wound had drainage. MDSC1 stated that R43 had recently finished a round of Keflex antibiotic. She stated the Medical Director used to handle the wounds at the facility, but they were now handled by the Nurse Practitioner (NP). MDSC1 stated that the facility was reviewing wound tracking in their Quality Assurance program, but the NP did not attend those meetings. On 10/12/23 at 2:03 PM the DON stated that she had spoken to the nurse that placed Kerlix on R43 in the morning to find out why it had been done. The DON said that the nurse informed her that the dressing on R43's heel had rolled up underneath, so the nurse had placed the Kerlix around the foot to protect the dressing. The DON stated she had reminded the nurse that it was not a part of the treatment orders for R43 and should not have been done. The DON stated that no resident should have received a shower with a dressing kept in place because it could make things worse. During an interview by phone on 10/12/23 at 2:40 PM the NP stated that she had more recently started doing the wound rounds at the facility, instead of the Medical Director. She stated she had been working with R43 since his/her July readmission. She stated she thought R43 had been admitted with the wound to the right heel from his/her last hospital stay. NP confirmed that the Care Partners had been reeducated because they had been showering R43 with her dressings in place. NP stated they did not think the wound looked very different but did confirm that R43 had been recently on a prescribed order of antibiotics for the right heel due to an infection. NP stated that she came out to the facility about once a month, and as requested by the facility.

Based on observations, record review, staff interviews, and policy review, the facility failed to ensure thawed foods were properly labeled and/or dated as required, failed to ensure the high-temperature dishwasher was monitored for effective sanitation, and failed to ensure food temperatures were properly monitored during meal preparation and service for 48 census residents who received meals from the individual kitchens in six of six cottages. These failures had the potential to lead to food-borne illness among all facility residents. Findings include: 1. Observations during the tour of the kitchen in [NAME] cottage on [DATE] at 10:00 AM revealed: -Five chocolate and two vanilla 4-ounce (oz.) Mighty Shakes thawed in the refrigerator. -The cartons documented, Store frozen. Thaw at/or below 40F [Fahrenheit]. Use thawed product within 14 days. Keep refrigerated. There was no thaw date on the cartons. Observations during the tour of the kitchen in [NAME] cottage on [DATE] at 10:10 AM revealed: -Ten chocolate Mighty Shakes thawed in the refrigerator in a plastic bag dated [DATE]. -Nine strawberry and 13 vanilla Mighty Shakes thawed in the refrigerator in a plastic bag dated [DATE]. -The cartons documented, Store frozen. Thaw at/or below 40F. Use thawed product within 14 days. Keep refrigerated. There was no thaw date on the cartons. In an interview on [DATE] at 10:15 AM, Care Partner (CP) 12 stated that the Mighty Shakes were placed into plastic bags for thawing in the refrigerators. He/She stated that the staff often reused these bags, so the dates written on them may not be accurate. He/She said each cottage had their own process for thawing shakes and was not aware of documenting thawed dates or how long the item could be refrigerated. On [DATE] at 9:50 AM the Dietary Manager (DM) stated that she received food shipments twice a week, and then distributed the necessary food items to each residential cottage so the meals could be prepared in each home. She stated that during this process she monitored each kitchen for expired foods, dating and labeling concerns, and would toss out anything that needed to be discarded. The DM said that all Care Partners had received training to provide a safe food service. 2. An observation on [DATE] at 11:35 AM in [NAME] cottage revealed the kitchen used a High-Temp Dishwasher. Per CP8, the facility staff rinsed the dishes off and then placed them into the dishwasher. She stated that they did not log the temperatures, but they just kept the dishes in the machine until they were done. The placard on the dishwasher instructed for hot water sanitizer the wash cycle should reach 150 degrees F (Fahrenheit), and the rinse 180 degrees F. The outer digital temperature display indicated the wash cycle reached 137 degrees F and the rinse 110 degrees F. An interview with the DM on [DATE] at 9:12 AM revealed that she took temperatures of each cottage high-temperature dishwasher a few times a month by placing a TempRite Dishwasher Temperature Test Strip in the machine. DM stated that she believed it was important for the high-temperature dishwashers to get to 170 degrees F for proper sanitizing but had not reviewed the guidance on the dish machine. An observation with the DM on [DATE] at 9:30 AM in [NAME] cottage revealed an identical dishwasher reached 158 degrees F for the wash cycle and 141 degrees F for the rinse. The DM placed the temperature strip into the machine, which indicated the internal temperature reached at least 160 degrees F yet did not match with the digital displays of the machines. She confirmed that there needed to be better temperature monitoring due to the fact the monitoring strips did not align with the digital displays of the dishwashers. A review of the Dish Machine Schedule revealed the TempRite Dishwasher Temperature Test Strips were used on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Actual digital temperatures were not documented. 3. Record review of food temperature monitoring revealed: -From [DATE] through [DATE] there were 41 missed meal temperatures documented out of 81 opportunities for [NAME] cottage. -From [DATE] through [DATE] there were 22 missed meal temperatures documented out of 81 opportunities for [NAME] cottage. -From [DATE] through [DATE] there were 31 missed meal temperatures documented out of 81 opportunities for [NAME] cottage. -From [DATE] through [DATE] there were 42 missed meal temperatures documented out of 81 opportunities for Grace cottage. -From [DATE] through [DATE] there were 25 missed meal temperatures documented out of 81 opportunities for [NAME] cottage. -from [DATE] through [DATE] there were 44 missed meal temperatures documented out of 81 opportunities for [NAME] cottage. -All meal temperature logs were developed to document only the main menu items such as protein, fruit, vegetables, and dessert. The temperature logs did not capture alternate menu items nor altered textures such as mechanical or puree prepared meals. Observations during lunch service in [NAME] cottage on [DATE] beginning at 11:00 AM revealed: -Lunch items on the menu were country fried steak, mashed potatoes, country gravy, and asparagus. -At 11:50 AM, CP8 recorded the temperature of the mashed potatoes, which were still on the stovetop, at 145 degrees F. The asparagus, still on the stovetop, was documented at 196 degrees F. CP8 stated that she took temperatures of the food right after it was done cooking, not before serving the items. -CP8 then mixed butter into the mashed potatoes and prepared to put it onto the resident plates. Upon a second temperature check, the mashed potatoes were noted to be at 128 degrees F. CP8 then added milk and placed the mashed potatoes back on the stovetop. At 12:06 PM, the mashed potatoes were noted at 150 F and placed on the countertop for service. -At 12:07 PM the country fried steak was removed from the oven, and recorded at 205 degrees F. CP8 cut up the steak into smaller pieces and took a second temperature that read 133 degrees F. The meat was then placed into a food processor to create a mechanical texture, which was then recorded at 98 degrees F. -At 12:15 PM the mashed potatoes and asparagus were plated on the counter. The gravy was left on the stovetop. At 12:23 PM the gravy was 115 degrees F. CP9 stated that to know what temperatures the food needed to be served at, they used a poster in the pantry that identified safe food temperatures. CP8, CP9, and CP10 were not aware of the recipe book on the counter recording expected serving temperatures. They confirmed that the food temperatures had dropped when broken down for altered textures and after adding cold items, but they were not documenting that. The recipes listed the mashed potatoes, gravy, and asparagus to Hold for service at 135F or above. The country fried steak had no hold temperatures on the recipe. During a concurrent interview with CP1 and CP10 on [DATE] at 9:15 AM they confirmed that they documented temperatures for each meal. CP1 stated that the staff usually documented the food items as they were finishing the cooking process, and that they did not recheck temperatures after adding items such as milk, nor when the food was broken down to a mechanical or pureed texture. Both CP1 and CP10 confirmed that the food temperature log that was used did not provide a place to properly document all food items. An interview with the DM on [DATE] at 9:23 AM confirmed that all prepared food items should be monitored for appropriate temperatures but was not aware of the need for also monitoring altered textures. She confirmed that additional training was necessary to ensure all items were properly documented for compliance. During an interview on [DATE] at 2:58 PM the Administrator stated that she was informed that not all cottages had stored, prepared, and served meals with the same service process. She said the DM was new to the role. The Administrator said that it was important that each cottage served the resident meals at the correct temperature and was not aware that not all meal textures were being monitored for the appropriate temperatures. The facility's undated Policy for Dietary Department documented The purpose of THE DIETARY DEPARTMENT is to provide nutritious well-balanced and palatable meals meeting each resident's nutritional needs in accordance with the physician's prescribed orders and the resident's personal preferences. Food is served under high standards of sanitation .Meals are prepared and served in accordance with the US DIETARY GUIDELINES AND STANDARDS set by the AMERICAN DIETETIC ASSOCIATION.

Based on interview and record review, the facility failed to initiate cardiopulmonary resuscitation (CPR, a procedure to support and maintain breathing and circulation for a person who has stopped breathing and/or whose heart has stopped) for one resident (Resident #1) identified as having a full code status (CPR required in the event of cardiac or respiratory arrest). Staff found the resident unresponsive and without a pulse or respirations on [DATE] and failed to initiate CPR and call 911. The resident expired at the facility. The facility census was 52. On [DATE] at 1:30 P.M., the administrator was notified of the past non-compliance immediate jeopardy (IJ) which occurred on [DATE]. On [DATE], the facility recognized the staff's failure. Nursing administration educated Licensed Practical Nurse (LPN) E, who failed to provide CPR, on how to determine resident's code status quickly, and to perform CPR on residents if that was their wish. Licensed staff, care partners, management, and support staff were educated on the residents' code status. The IJ was corrected on [DATE]. 1. Review of the facility's undated policy for Emergency Medical Treatment showed that in the event of resident's ceased breathing or pulse, CPR would be initiated unless the resident had a NO CODE status or Do Not Resuscitate (DNR) order, and 911 would be called immediately. Review of Resident #1's face sheet/medical profile showed the following: -He/She admitted to facility on [DATE]; -Code status: CPR (full code). Review of the resident's Emergency Services and Resuscitation plan, signed and dated on [DATE], showed he/she wished to be full code which meant staff were to provide aggressive medical management. This included all treatments and procedures to reduce advancement of disease and/or death, INCLUDING RESUSCITATION/CPR. Review of the resident's Physician Order Sheet (POS), dated February 2022, showed the resident was a full code status. Review of the resident's progress notes, dated [DATE] at 10:17 A.M., showed Licensed Practical Nurse (LPN) E was summoned to the resident by therapy who said the resident was not breathing. LPN E noted the resident sat in a chair with his/her head leaned over to the left and his/her tongue hung out. LPN E called the resident's name with no response, LPN E performed a sternal rub (the application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) with no response; apical pulse and respirations were absent. Staff assisted the resident to his/her room via wheelchair and transferred the resident to bed. A second nurse arrived to assist and noted no pulse or respirations. Call placed to resident's physician and made him/her aware of the resident's condition. Call placed to the resident's family to notify them of the resident's condition. LPN E invited the resident's family to come see the resident and asked what funeral home to contact. (There was no documentation to show staff initiated CPR or called 911 when staff found the resident without a pulse or respirations). Review of an addendum to the previous progress note, dated [DATE] at 10:56 A.M., showed the resident's skin was warm and dry, but his/her fingertips had begun to mottle (red/purplish marbled discoloration of skin due to lack of blood circulation that occurred before death). During interview on [DATE] at 1:00 P.M., LPN E said the following: -He/She was the charge nurse on the unit where resident resided on [DATE]; -He/She last saw the resident around breakfast when the resident refused to eat. The resident had not had any complaints, had been talking, ambulated several times independently via walker, and drank a health shake; -The resident walked to his/her room, returned to the living room, and sat down in a chair to watch television; -A therapy staff summoned him/her to the resident and reported the resident was not breathing; -The resident was slumped to the left. The resident was non-responsive to sternal rub, and pulse and respirations were absent; -He/She did not initiate CPR and did not call 911 because he/she thought the resident was a DNR (do not resuscitate); -He/She did not realize the resident was a full code until he/she went to the resident's chart to contact the physician. He/She should have initiated CPR, but did not. He/She wanted to get the physician's opinion first; -The resident's physician told LPN E he/she (the physician) knew the resident was going to be one that just stopped. The physician instructed him/her to contact family. The resident's physician did not direct him/her to start CPR; -He/She was CPR certified, -There were papers on the residents' doors, but he/she didn't know what they meant and he/she had worked at the facility for three years; -He/She had since been educated that a purple paper meant the resident was a DNR, and white paper meant the resident was a full code. He/She did not recall what color of paper Resident #1 had on his/her door. During an interview on [DATE] at 4:35 P.M., LPN J said the following: -He/She was on break when he/she received a message that LPN E needed another nurse to verify a death. He/She went to the resident's bedside and verified the resident had expired; -He/She assumed the resident was a DNR; -Two hours after he/she verified the resident's death, he/she realized the resident was a full code after he/she received a group chat message from another staff member who said, wasn't the resident a full code? and LPN E responded in the group chat by saying, it was complicated; -It was his/her mistake that he/she didn't look at the resident's door when he/she entered the resident's room (to verify code status based on the paper on the door), and should have. During an interview on [DATE] at 1:25 P.M., the Director of Nursing (DON) said the following: -She expected staff to initiate CPR and call 911 if they found a full code resident without a pulse and not breathing; -Staff could look at the resident's door for a quick [NAME] to check code status. The purple paper with the resident's name showed the resident was a DNR, and the white paper identified the resident was a full code; -After the event, staff were educated on what to do in full code situation and were provided pocket guides. During interview on [DATE] at 1:25 P.M., the facility's medical director said he expected staff to be aware of a resident's code status and initiate CPR if that was the resident's wish. If there was any confusion, staff were instructed to contact the physician, and he/she could order to discontinue CPR efforts if indicated. During interview on [DATE] at 10:15 A.M., Resident #1's physician said he visited with the resident just the day prior to resident's death and the resident told him that he/she wished to be a full code. He would have expected staff to initiate CPR and contact emergency medical services (EMS) in the event that the resident was without pulse or respirations. He could not comment if CPR would've changed the outcome, but certainly should've been attempted if that was the resident's wish. MO198352

Based on observation, record review, and interview, the facility failed to monitor the effectiveness of current fall interventions and failed to modify the interventions as necessary to prevent further falls and injury for one resident (Resident #20), in a review of 20 residents, who had a history of falling and was identified as a high risk for falls. Resident #20 fell and required 54 stitches to his/her left arm. The facility census was 51. Review of the facility Fall - Clinical Protocol policy, revised October 2010, showed the following: -Assessment and Recognition: -The nurse shall assess and document/report the following: a. vital signs; b. recent injury, especially fracture or head injury; c. musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. change in cognition or level of consciousness; e. neurological status; f. pain; g. frequency and number of falls since last physician visit; h. precipitating factors, details on how fall occurred; i. all current medications, especially those associated with dizziness; j. all active diagnoses; -The staff will document risk factors for falling in the resident's record and discuss the resident's fall risks; -The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls; -The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc.; -Falls should be categorized as: a. those that occur while trying to rise from a sitting or lying to an upright position; b. those that occur while upright and attempting to ambulate; c. other circumstances such as sliding out of a chair or rolling from a low bed to the floor; -Falls should be identified as witnessed or unwitnessed events; -Cause Identification: -For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall; a. causes refer to factors that are associated with or that directly result in a fall; b. after a first fall, the staff should watch the individual rise from a chair without using his/her arms, walk several paces, and return to sitting. If the individual has no difficulty or unsteadiness, further evaluation may not be needed. If the individual has difficulty or is unsteady in performing this test, additional evaluation should occur; -If the cause of a fall is unclear, if the fall may have a significant medical cause such as a stroke or an adverse drug reaction, or if the individual continues to fall despite attempted interventions, a physician will review the situation and help identify contributing causes; -After more than one fall, the physician should review the resident's gait, balance and current medications that may be associated with dizziness or falling; -The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk; -Treatment and Management: -Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling; -If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until reason is identified for its continuation; -Monitoring and Follow-up: -The staff, with the physicians guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma (a pool of blood between the brain and its outermost covering) have been ruled out or resolved; -The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling; -If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention; -If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions; -As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful. 1. Review of Resident #20's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), difficulty in walking, muscle weakness, lack of coordination, and repeated falls. Review of the resident's care plan, revised on 4/20/20, showed the following: -The resident was at high risk for falls related to impaired balance and poor safety awareness; -The resident had falls with actual injury; -On 7/22/19, ensure the resident wore appropriate footwear when ambulating or mobilizing in wheelchair. Anticipate and meet the resident's needs. Frequent monitoring. Physical therapy to evaluate and treat as ordered and as needed (PRN); -On 8/1/19, keep the resident's bathroom door closed to deter him/her from attempting to use the bathroom unassisted; -On 8/21/19, the resident had anti-tippers placed on his/her wheelchair to prevent the resident from turning over the wheelchair. Seat the resident in a dining room chair during meals; -On 8/22/19, keep the resident's bed in the lowest position when occupied; -On 8/23/19, the resident needed activities that minimized his/her potential for falls while providing diversion and distraction; -On 10/8/19, check on the resident frequently. If he/she seemed restless, offer to take the resident to the bathroom so he/she doesn't try to transfer himself/herself; -Revised on 11/6/19 (date initiated 7/22/19), be sure my call light is within reach and encourage me to use it for assistance as needed; -On 12/3/19, fall mat beside bed; -On 12/11/19, keep the resident's bedroom door open and check on him/her frequently; -Revised on 4/17/20 (date initiated 8/1/19), bed against wall to prevent resident from rolling out; -On 4/20/20, offer and assist the resident to the toilet upon waking, after meals and before bed. Review of the resident's progress notes, dated 12/8/21 at 10:01 P.M., showed the following: -The resident was found on the floor on his/her knees in the living room; -The fall was unwitnessed; -The resident said he/she hit his/her left jaw, but there was no pain. Review of the resident's Incident Report, dated 12/8/21, showed the following: -The resident had an unwitnessed fall in the dining room; -The resident was unable to give a description of the fall; -The resident was assessed and there were no injuries observed at time of incident; -The resident was oriented to person only; -There were no predisposing environmental factors to cause the fall; -The resident's predisposing physiological factors were confusion, impaired memory, and weakness/fainted; -The predisposing situational factor was a transfer; -The resident began showing new bruising to his/her left jaw on the third shift (2:00 P.M. - 10:00 P.M.) of the 24-hour check. During an interview on 3/29/22 at 11:17 A.M., Registered Nurse (RN) C said the following; -The resident needed assistance with transfers and with help using the bathroom, but would not use his/her call light or ask for help; -On 12/8/21, he/she turned his/her back and the resident tried to transfer himself/herself between the wheelchair and living room chair without calling for assistance and fell . Review of the resident's high risk for falls related to impaired balance and poor safety awareness care plan, revised on 12/09/21, showed to keep the resident in a visualized area. (Even though the resident fell in a highly visualized area, the facility's dining room - the common area of the facility which included the living room/sitting area, dining room, kitchen and nurses station.) Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/20/21, showed the following: -He/She had severe cognitive impairment; -He/She had delusions; -He/She required supervision from one staff for bed mobility and transfers; -He/She required extensive assistance from one staff for toileting; -His/Her balance when moving from a seated to a standing position was not steady and he/she was able to stabilize without human assistance; -His/Her balance when moving on and off the toilet and during making surface-to-surface transfers (transfers between bed and chair or wheelchair) was not steady and he/she was only able to stabilize with human assistance; -He/She had two or more falls without injury since prior MDS assessment (9/29/21); -He/She used a wheelchair; -His/Her diagnoses included orthostatic hypotension (a form of low blood pressure that happens when standing up from a sitting or lying down), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's progress notes, dated 12/28/21 at 6:51 P.M., showed the following: -The nurse heard the resident call for help; -The resident sat on the bathroom floor in his/her room; -The resident had a laceration to his/her right index finger; -Wound cleansed and applied ointment and a dressing; -The resident was placed on post fall follow ups with neurological protocol started. Review of the resident's Incident Report, dated 12/28/21, showed the following: -The resident had an unwitnessed fall in his/her bathroom; -The resident was unable to give a description of the fall; -The resident was alert to person only; -There were no predisposing environmental factors to cause the fall; -The resident's predisposing physiological factors were confusion, gait imbalance, impaired memory and weakness/fainted; -The predisposing situational factor was a transfer. During an interview on 3/29/22 at 11:17 A.M., RN C said the following: -Sometimes the resident propelled in his/her wheelchair to his/her room to use the bathroom on his/her own and did not ask for assistance; -The resident needed assistance with transfers and with help using the bathroom, but would not use his/her call light or ask for help; -On 12/28/21, the resident fell in the bathroom trying to transfer to his/her wheelchair from the toilet and did not call for assistance. He/She did not believe the resident was assisted to the bathroom, his/her guess would be that the resident propelled himself/herself to the bathroom and did not call for assistance. Review of the resident's medical record showed no documentation staff re-evaluated current interventions or implemented new interventions to prevent the resident from falling after he/she fell in his/her bathroom on 12/28/21. Review of the resident's care plan showed no documentation to show the resident fell on [DATE]. Review of the resident's progress notes, dated 1/27/22 at 10:56 P.M., showed the following: -A care partner found the resident on the floor in the bathroom; -The resident tried to get from the toilet to his/her wheelchair by himself/herself; -The resident denied hitting his/her head or pain. Review of the resident's Incident Report, dated 1/27/22, showed the following: -The resident had an unwitnessed fall in his/her bathroom; -No documentation to show if the resident was able to give a description of fall; -The resident had no injuries observed at time of incident; -No documentation to show predisposing environmental factors, predisposing physiological factors, or predisposing situational factors. During an interview on 3/30/22 at 3:35 P.M., the Nurse Educator said the following: -On 1/27/22, a CNA (unknown) called him/her to the resident's room, and he/she found the resident on the bathroom floor; -The resident did not call for help to go to the bathroom, but was able to get himself/herself on the toilet; -The resident fell to the floor when he/she tried to transfer back to his/her wheelchair; -He/She did not know why he/she did not complete the fall incident report (in it's entirety). Review of the resident's medical record showed no documentation staff re-evaluated current interventions or implemented new interventions to prevent the resident from falling after he/she fell in his/her bathroom on 1/27/22. Review of the resident's care plan showed no documentation to show the resident fell on [DATE]. Review of the resident's progress notes, dated 2/10/22 at 10:14 P.M., showed the following: -The resident was found on his/her knees on the floor mat next to his/her bed; -Care partners assisted the resident into bed; -The resident had a skin tear to his/her left shin. Cleansed, applied ointment and covered the wound with non-adherent dressing; -The resident was unable to verbalize what happened. Review of the resident's Incident Report, dated 2/10/22, showed the following: -The resident had an unwitnessed fall in his/her room; -The resident was unable to give a description of fall; -The resident was alert to person only; -There were no predisposing environmental factors to cause the fall; -The resident's predisposing physiological factors were confusion, incontinence and impaired memory; -The predisposing situational factor was a transfer. Review of the resident's medical record showed no documentation staff re-evaluated current interventions or implemented new interventions to prevent the resident from falling after he/she was found on the fall mat next to his/her bed on 2/10/22. Review of the resident's care plan showed no documentation to show the resident fell on [DATE]. Review of the resident's progress notes, dated 2/20/22 at 2:44 A.M., showed the following: -A care partner (certified nurse assistant) called the nurse and reported the resident had an unwitnessed fall in his/her room; -The resident was found sitting on the floor up against his/her bed unclothed; -The resident had a skin tear and knot above his/her left eye; -The resident had a bruise under his/her left eye; -The resident had three skin tears to his/her left shoulder; -The resident had a ten by four inch skin tear to his/her left forearm and a knot on his/her left wrist; -The nurse cleaned the wounds and covered them with a dressing; -The nurse asked the resident what happened, and the resident said he/she called and then said he/she made a mess; -Staff called the physician who gave orders to send the resident to the hospital. Review of the resident's Incident Report, dated 2/20/22, showed the following: -The resident had an unwitnessed fall in his/her room; -The resident said he/she called and then said he/she made a mess; -The resident's injuries were listed as bruise to face, other to left wrist, skin tear to left front shoulder, other to face and skin tear to left forearm; -The resident was alert to person only; -The predisposing environmental factor was poor lighting; -The resident's predisposing physiological factors were confusion, drowsiness, incontinence, gait balance, impaired memory and weakness/fainted; -The predisposing situational factor was ambulating without assistance. During an interview on 3/30/22 at 1:24 P.M., LPN F said the following: -On 2/20/22, he/she was in another cottage (This facility is comprised of separate cottages/buildings) and was called to the resident's room; -Upon his/her arrival, the resident was sitting on the floor next to the bed; -The resident told LPN F that he/she had been calling and calling for someone to help him/her; -He/She asked CNA I, Didn't you hear the resident yelling? The CNA replied he/she did not hear the resident and did not see the resident fall; -At the time of this incident, the resident had a push button call light. LPN F was not sure the resident could remember what the call light was for, but the resident would yell out if he/she needed something; -After this fall, a pool noodle was cut length wise and placed over the bed frame to protect the resident; -He/She thought the resident tried to get out of bed on his/her own. There was blood on the bed frame; -The cut was ten inches by four inches. It was the length of the resident's forearm and it was cut into the muscle; -The resident had three skin tears that looked like scratch marks across the front of his/her left shoulder; -The resident had a skin tear, a knot above his/her left eye and bruising under his/her left eye. During an interview on 3/30/22 at 3:22 P.M., CNA I said the following: -On 2/20/22, the resident did not use his/her call light or yell out for help before he/she found the resident on the floor in his/her room; -The resident did not use his/her call light; -The resident yelled out for help sometimes, but not every time he/she fell or needed assistance. Review of the resident's hospital records, dated 2/20/22, showed the following: -The resident arrived to the emergency room by ambulance for an unwitnessed fall at the nursing home; -The resident had an abrasion on his/her left forehead; -The resident had a complex left forearm laceration with partial degloving (a large piece of skin and the layer of soft tissue under it partially or completely cut/torn) due to thin skin; -The resident received laceration repair of his/her left forearm. The laceration measured 15 centimeters long by 10 millimeters deep; -Six subcutaneous (deepest layer of tissue) sutures were placed and 20 epidermis (top layer of skin) sutures were placed with 20 steri-strips and a sterile non-adherent dressing and bulk dressing to cover the sutures; -The resident had a left front scalp hematoma (bruise); -The resident was diagnosed with an urinary tract infection and prescribed an antibiotic; -The resident was discharged back to the nursing home with instruction to start taking an antibiotic and to schedule an appointment with his/her primary care physician as soon as possible. Review of the resident's Morse Fall Scale (a rapid and simple method of assessing a patient's likelihood of falling), dated 2/20/22, showed the following: -The resident had a history of falls; -The resident had more than one diagnosis; -The resident's gait was impaired (difficulty rising from a chair, using chair arms to get up, bounces to rise; keeps head down when walking, watches the ground; grasps furniture, person or aid when ambulating, cannot walk unassisted); -The resident overestimates or forgets his/her limits; -The resident scored as a high risk for falls. Review of the resident's high risk for falls related to impaired balance and poor safety awareness care plan, revised on 2/21/22, showed the following: -The resident used a soft touch call button to alert staff he/she required assistance; -The resident understood the use of the call light, but didn't always use it and would attempt to transfer himself/herself; -Place the call light on the resident's left side when in bed; (Staff identified the resident did not always use his/her call light. Review showed no documentation staff implemented any further intervention to prevent falls, other than to address the resident's call light, after the resident fell on [DATE].) Review of the resident's progress notes, dated 3/5/22 at 10:49 P.M., showed the following: -The nurse heard the resident yell for help behind his/her closed bedroom door. (Review of the resident's care plan showed an intervention was implemented on 12/11/19 to prevent falls which included keeping the resident's door open.); -The resident was found sitting on the floor, five feet from the door; -The resident's wheelchair was by the resident's bed; -The resident's bed had blood on the bed frame and the sheets; -The resident's right wrist was bleeding; -The nurse cleaned the resident's wrist, applied ointment and steri-strips and covered it with a dressing. Review of the resident's Incident Report, dated 3/5/22, showed the following: -The resident had an unwitnessed fall in his/her room; -The resident could not explain what happened only that he/she was glad the nurse came in; -The resident was placed on 72-hour monitoring (vital signs, blood pressure, pulse, respirations, orientation to person, place, date/time, evaluation of the resident's skin, range of motion/strength of extremities, eye responses and assessments of the resident's pupils to be checked every 15 minutes for one hour, every 30 minutes for one hour, every hour for two hours and then once every shift for 72 hours); -The resident's had a skin tear to his/her right wrist; -The resident was alert to person only; -There were no predisposing environmental factors; -The resident's predisposing physiological factors were confusion, incontinence, recent change in medications/new, impaired memory and recent illness; -The predisposing situational factor was a transfer. During an interview on 3/30/22 at 1:24 P.M., LPN F said the following: -On 3/5/22, he/she was walking out of the cottage toward the exit door when he/she passed the resident's room. The door was shut and he/she heard the resident yell out for help; -He/She went in the resident's room and found the resident sitting on the floor in the middle of the room with his/her right wrist bleeding; -CNA I was sitting in the living room on his/her personal cell phone and said he/she did not hear the resident call out; -The resident had a four inch skin tear to his/her right wrist that LPN F cleaned and applied about seven small steri-strips and covered it with a dry dressing; -There was blood on the pool noodle and bed frame. Review of the resident's medical record showed no documentation staff re-evaluated current interventions or implemented new interventions to prevent the resident from falling after the resident fell on [DATE]. Review of the resident's care plan showed no documentation to show the resident fell on [DATE]. During an interview on 3/30/22 at 1:24 P.M., LPN F said the following: -Staff should check on residents who are at risk for falling at least every 30 minutes; -He/She witnessed aides sitting on their personal phones and not paying attention to the residents; -He/She did not know who was responsible for updating the care plan, he/she thought it might be the DON; -He/She asked the administrator and DON about using a bed alarm or something similar to help prevent falls with the resident, and he/she was told the residents have the right to fall. During an interview on 3/29/22 at 11:17 A.M., RN C said the following; -He/She believed it was the nurse manager's responsibility to update the resident's care plans, he/she had never updated a resident's care plan; -The resident had a paddle call light (a flat pad that is very sensitive to touch). The staff placed it under the resident's bed pad on the left side so it would alarm when the resident attempted to get up on his/her own; -He/She did not feel this call light was effective because the resident often moved it off the bed to the floor or to the chair beside the bed; -He/She didn't think the resident would understand how to use his/her call light; -He/She felt the resident needed more oversight than he/she was currently getting; -He/She did not feel there were any more interventions that would help prevent the resident from having falls. During an interview on 3/30/22 at 3:27 P.M., MDS/Care Plan Coordinator B said the following: -He/She and MDS/Care Plan Coordinator A were responsible for making updates to the residents' care plans; -He/She knew what to update on the care plans by the correlation with the residents' MDS and the information they received from staff at morning meetings in each cottage; -He/She had not been making notes in Resident #20's care plan after each fall. He/She did not know he/she needed to make notes that showed the care plan had been reviewed after any incident with the residents; -He/She felt they had all interventions in place possible for Resident #20 regarding falls; -The resident could use his/her call light, but did not always remember what the call light was for. During an interview on 4/12/22 at 1:25 P.M., the resident's physician said he expected staff to evaluate falls to determine the root cause and review and/or implement new interventions to prevent further incidents. The resident had a diagnosis of dementia, but was physically able to get up on his/her own even though he/she required assistance. The resident felt as if he/she was 30 (years old) and tried to act as such. During an interview on 3/28/22 at 2:08 P.M., the DON said the following: -The facility had an excessive number of falls and she was trying to figure out why this had happened; -She expected staff to put interventions in place on the resident's care plan as needed; -If a resident fell , she expected the nurse to assess the situation to find the root cause of the fall; -As per the resident's care plan to keep the resident in visualized areas, she expected the resident to be in the common area (living room/dining room area), if the resident was not in bed, where staff can easily visualize the resident while they performed their daily tasks; -She expected staff to consciously walk by the resident's room to check on him/her throughout the night while he/she was in bed; -After a fall, the nurses were to look at the resident's care plan and see if they could come up with a plan and add it to the care plan. They should communicate their new interventions to the nurse managers. During an interview on 4/14/22 at 1:05 P.M., the administrator said the following: -She expected nurses to asses for any injury and do a complete assessment as shown on the 72-hour monitoring sheets after a resident fell ; -She expected nurses and/or nurse managers to evaluate the resident's current care plan after each fall for the existing interventions to make sure they were still appropriate. If the interventions were no longer appropriate, they should be removed, and if new interventions were needed, they should add them to the care plan; -Nursing staff should update the care plan after each fall with a note that showed the resident had a fall and interventions were reviewed, and either add new interventions or comment that the current interventions would remain and were appropriate for the resident.

Based on interview and record review, the facility failed to ensure staff followed standards of practice for four residents (Residents #7, #8, #9, and #10), in a review of 20 sampled residents. Staff failed to follow physician's orders for three residents (Residents #8, #9, and #10) by administering narcotic pain medications without a physician order and administering as needed (PRN) narcotic pain medications more frequently than ordered. Staff failed to document administration of PRN narcotic pain medications on the Medication Administration Record (MAR) after staff pulled the medications from the StatSafe (electronic emergency medication kit to be used when resident's medications were not available), and failed to utilize the StatSafe for obtaining medications according to the facility's policy. The facility failed to administer anti-nausea medication timely to one resident (Resident #7) who was on hospice care when the resident complained of nausea/vomiting, and had orders to administer medication when needed. The facility failed to notify the hospice agency or follow up with the hospice agency and/or resident's physician when the resident complained of nausea, symptoms of a urinary tract infection including reports of thick urine, and increased confusion after the physician had instructed staff to monitor and notify him/her of any complaints. The facility census was 52. Review of facility's policy for acute condition changes/clinical protocol, last revised December 2015, showed the following: -Nurses should assess and document/report baseline and pertinent information to the physician; -Direct care or care partners would report changes they noticed in the resident to the nurse; -Before contact with physician of acute care changes, nurse should conduct an assessment and collect pertinent information, including resident's symptoms and status; -Staff would monitor and document the resident's progress and responses to treatment. Review of facility's policy for medication and treatment orders, last revised July 2016 showed the following: -All drug and biological orders should be written, dated, and signed by the person lawfully authorized to give such an order; -Verbal orders must be recorded immediately in the resident's medical record by the person who received the order and must include prescriber's last name, credentials, and the date and time of the order; -Orders for medications must include name and strength of drug, number of dose, start and stop date, and/or specific duration of therapy, dosage and frequency of administration, route of administration, clinical condition or symptoms for which the medication was prescribed, and any interim follow-up requirements; -Only authorized personnel shall call in orders for prescribed medications to the pharmacy. Review of facility's undated nursing practices policy showed the following: -Nurses administer all medications prescribed by the physicians. New orders would be placed with the pharmacy by entering orders in PCC (electronic health records). Medications would be started when delivered. Changes in orders would be immediately entered in PCC and pharmacy would be notified; -If a medication was unavailable, the StatSafe would be checked for medication; -There was no documentation to show staff where to document administration of resident's medication on the MAR. 1. Review of Resident #8's physician orders for October 2021 showed the following: -He/She was admitted on [DATE]; -His/Her diagnoses included osteoarthritis (degeneration of joint cartilage and the underlying bone that causes pain and stiffness), right hip pain, and presence of an artificial right hip joint; -Order received on 10/28/21 at 5:45 P.M. for Norco (brand name for hydrocodone/acetaminophen) (a narcotic pain medication) 5/325 milligram (mg), one tablet every six hours as needed for pain. Review of the resident's Medication Administration Record (MAR), dated October 2021, showed Licensed Practical Nurse (LPN) L administered hydrocodone/acetaminophen (APAP) 5/325 mg on 10/29/21 at 11:56 A.M. Review of facility's StatSafe audit report, dated 10/12/21 to 12/12/21, showed Licensed Practical Nurse (LPN) L removed the following medications for the resident: -On 10/29/21 at 12:28 P.M., hydrocodone/APAP 5/325 mg. (LPN L documented administration of this medication on the MAR on 10/29/21 at 11:56 A.M., 30 minutes prior to pulling the medication from the StatSafe); -On 10/29/21 at 5:16 P.M., hydrocodone/APAP 5/325 mg. (The resident's physician's order was for hydrocodone/APAP 5/325 mg every six hours PRN. LPN L removed the hydrocodone/APAP from the StatSafe just four hours and 48 minutes after the previous dose was removed from the StatSafe at 12:28 P.M.); -On 10/30/21 at 7:44 A.M., hydrocodone/APAP 5/325 mg; -On 10/30/21 at 4:10 P.M., hydrocodone/APAP 5/325 mg; -On 10/31/21 at 2:34 P.M., hydrocodone/APAP 10/325 mg. (The resident did not have a physician's order for this dosage of the medication). Review of the resident's MAR, dated October 2021, showed no documentation the resident received hydrocodone/APAP on these dates and times. Review of facility's StatSafe audit report showed LPN L removed the following medications for the resident from the StatSafe emergency medication supply: -On 11/1/21 at 3:28 P.M., hydrocodone/APAP 10/325 mg. (The resident did not have a physician's order for this dosage of the medication); -On 11/2/21 at 3:43 P.M., hydrocodone/APAP 5/325 mg. Review of the resident's MAR, dated November 2021, showed no documentation the resident received hydrocodone/APAP on these dates and times. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/4/21, showed the following: -He/She rarely had pain, but rated pain level at a three on the zero to 10 pain scale; pain did interfere with his/her sleep, but not daily activities; -He/She had not received opioids (narcotic pain medication including hydrocodone) during the previous seven day look back period. Review of the facility's StatSafe audit report showed LPN L removed hydrocodone/APAP 5/325 mg for the resident on 11/4/21 at 4:42 P.M. Review of the resident's MAR, dated November 2021, showed the following: -No documentation LPN L administered hydrocodone/APAP 5/325 mg on 11/4/21 at 4:42 P.M.; -On 11/4/21 at 9:38 P.M., LPN L documented he/she administered hydrocodone/APAP 5/325 mg. (LPN L documented he/she administered hydrocodone/APAP four hours and 56 minutes after the previous dose was removed from the StatSafe at 4:42 P.M.) Review of facility's StatSafe audit report showed LPN L removed the following medications for the resident from the StatSafe emergency medication supply: -On 11/8/21 at 12:59 P.M., hydrocodone/APAP 5/325 mg; -On 11/8/21 at 6:22 P.M., hydrocodone/APAP 5/325 mg; -On 11/9/21 at 7:39 A.M., hydrocodone/APAP 5/325 mg; -On 11/9/21 at 12:24 P.M., hydrocodone/APAP 5/325 mg; -On 11/10/21 at 3:38 P.M., hydrocodone/APAP 5/325 mg. Review of the resident's MAR, dated November 2021, showed no documentation the resident received hydrocodone-acetaminophen on these dates and times. Review of the resident's physician order report summary showed an order dated 11/11/21 at 8:00 A.M. for hydrocodone/APAP 10/325 mg, one tablet every six hours as needed for post-operative pain. Review of facility's StatSafe audit report showed LPN L removed hydrocodone/APAP 5/325 mg for the resident on 11/11/21 at 5:56 P.M. Review of the resident's MAR, dated November 2021, showed no documentation the resident received hydrocodone/APAP 5/325 mg on 11/11/21 at 5:56 P.M. Review of the resident's narcotic count sheet for hydrocodone/APAP 10/325 mg showed the following: -Norco (hydrocodone/APAP) 10/325 mg, one tablet every six hours PRN for post-operative pain; -The facility received 20 tablets of the medication on 11/7/21, but were to wait to administer the medication until 11/11/21; -On 11/14/21 14 tablets remained. Review of the resident's MAR, dated November 2021, showed LPN L documented he/she administered hydrocodone/APAP 10/325 mg on 11/17/21 at 7:48 A.M. and 1:40 P.M. Review of the resident's narcotic count sheet for hydrocodone/APAP 10/325 mg showed no documentation LPN L obtained the medication administered on 11/17/21 from the resident's medication card. The count remained at 14 tablets. On 11/19/21, another staff removed one tablet from the resident's medication card, leaving 13 remaining tablets. Review of the resident's MAR, dated November 2021, for hydrocodone/APAP 10/325 mg showed LPN L documented he/she administered the medication on 11/22/21 at 7:59 A.M. Review of the StatSafe log showed LPN L removed hydrocodone/APAP 10/325 mg on 11/22/21 at 3:33 P.M. Review of the resident's MAR, dated November 2021, for hydrocodone/APAP 10/325 mg showed the following: -LPN L did not document he/she administered the medication on 11/22/21 at 3:33 P.M. (after he/she removed the medication from the StatSafe); -LPN L documented he/she administered the medication on 11/22/21 at 7:46 P.M. (LPN documented he/she administered hydrocodone/APAP four hours and 13 minutes after the previous dose was removed from the StatSafe at 3:33 P.M.); -LPN L documented he/she administered the medication on 11/23/21 at 7:35 A.M. and 2:56 P.M.; -LPN L documented he/she administered the medication on 11/24/21 at 7:49 A.M. and 3:04 P.M.; -LPN L documented he/she administered the medication on 11/27/21 at 6:19 P.M.; -LPN L documented he/she administered the medication on 11/28/21 at 8:21 A.M. and 4:57 P.M. Review of the resident's narcotic count sheet for hydrocodone/APAP 10/325 mg showed no documentation LPN L obtained the medication administered on 11/22, 11/23, 11/24, 11/27, and 11/28 from the resident's medication card. Thirteen tablets remained In the resident's card. Review of the StatSafe log showed LPN L removed hydrocodone/APAP 10/325 mg from the StatSafe for the resident on 11/22, 11/23, 11/24, 11/27, and 11/28. (The resident had medications available in the facility for staff to administer, however, LPN L pulled the medication from the StatSafe on all these dates.) Review of the resident's physician order report summary, dated December 2021, showed the following: -Norco (hydrocodone/APAP) 5/325 mg, one tablet every six hours as needed for pain. -Hydrocodone/APAP 10/325 mg, one tablet every six hours as needed for post-operative pain. Review of the resident's MAR, dated December 2021, for hydrocodone/APAP 10/325 mg showed the following: -LPN L documented he/she administered the medication on 12/1/21 at 5:45 P.M.; -LPN L documented he/she administered the medication on 12/2/21 at 4:39 P.M.; -LPN L documented he/she administered the medication on 12/3/21 at 2:13 P.M.; -LPN L documented he/she administered the medication on 12/6/21 at 7:51 A.M. Review of the StatSafe log showed LPN L removed hydrocodone/APAP 10/325 mg on 12/6/21 at 3:52 P.M. Review of the resident's MAR, dated December 2021, showed the following: -No documentation LPN L administered hydrocodone/APAP 10/325 mg on 12/6/21 at 3:52 P.M. (LPN removed the medication from the StatSafe at this time.) -On 12/7/21 at 8:02 A.M. and 3:53 P.M., LPN L documented he/she administered hydrocodone/APAP 10/325 mg; -On 12/12/21 at 11:50 A.M., LPN L documented he/she administered hydrocodone/APAP 10/325 mg; -On 12/12/21 at 3:22 P.M., LPN L documented he/she administered hydrocodone/APAP 5/325 mg. Review of the StatSafe log showed LPN L removed hydrocodone/APAP 10/325 mg on 12/21/21 at 3:23 P.M. Review of the resident's narcotic count sheet for hydrocodone/APAP 10/325 mg showed no documentation LPN L obtained the medication administered on 12/1, 12/2, 12/3, 12/6, 12/7, and 12/12 from the resident's medication card. Thirteen tablets remained on the resident's card. Review of the StatSafe log showed LPN L removed hydrocodone/APAP 10/325 mg from the StatSafe for the resident on 12/1, 12/2, 12/3, 12/6, 12/7, and 12/12. (The resident had medications available in the facility for staff to administer, however, LPN L pulled the medication from the StatSafe on all these dates.) 2. Review of Resident #10's physician's orders, dated September 2022, showed the following: -He/She was admitted on [DATE]; -His/Her diagnoses included discitis/lumbar region (inflammation of the vertebral disc space/low back) and bilateral osteoarthritis of knee; -Order received on 9/15/21 at 9:00 P.M. for Oxycodone 5 mg, one tablet every eight hours as needed for moderate to severe pain. Review of the resident's admission MDS, dated [DATE], showed the following: -His/Her cognition was intact; -He/She was on a scheduled pain medication regimen during previous five days; -He/She received as needed pain medications (PRN) during the previous five days; -He/She complained of frequent pain rated a 10 (on 0-10 pain scale) that affected his/her daily activities; -He/She received opioids four of the previous seven days. Review of facility's StatSafe audit report, dated 10/12/21 to 12/12/21, showed LPN L removed the following medications for the resident from the Stat Safe emergency medication supply and did not document the medication was administered on the resident's MAR: -On 10/12/21 at 2:07 P.M., oxycodone 5 mg; -On 10/12/21 at 5:26 P.M., oxycodone/APAP (a narcotic medication which includes both oxycodone and acetaminophen) 5/325 mg. (The resident did not have a physician's order for this medication, and LPN L had just removed oxycodone 5 mg from the StatSafe three hours and 19 minutes prior to removing this medication for the resident); -On 10/13/21 at 12:38 P.M., oxycodone/APAP 5/325 mg. (The resident did not have a physician's order for this medication); -On 10/13/21 at 6:22 P.M., oxycodone 5 mg; Review of the resident's MAR, dated October 2021, showed LPN L administered oxycodone 5 mg on 10/16/21 at 8:08 A.M. Review of facility's StatSafe audit report, dated 10/12/21 to 12/12/21, showed LPN L removed the following medications for the resident from the emergency medication supply: -On 10/16/21 at 12:51 P.M., oxycodone 5 mg. (LPN L removed the oxycodone from the StatSafe three hours and 43 minutes after the previously administered dose at 8:08 A.M.); -On 10/17/21 at 8:08 A.M., oxycodone 5 mg; -On 10/17/21 at 12:36 P.M., oxycodone 5 mg. (The resident's physician's order was for oxycodone every eight hours PRN. LPN L removed the oxycodone from the StatSafe four hours and 28 minutes after the previous pulled dose at 8:08 A.M.); -On 10/17/21 at 3:55 P.M., oxycodone 5 mg. (LPN L removed the oxycodone from the StatSafe three hours and 19 minutes after the previous pulled dose of the medication at 12:36 P.M.); -On 10/20/21 at 7:36 A.M., oxycodone 5 mg; -On 10/20/21 at 12:18 P.M., oxycodone 5 mg. (LPN L removed the oxycodone from the StatSafe four hours and 42 minutes after the previous pulled dose of the medication at 7:36 A.M.); -On 10/20/21 at 4:52 P.M., oxycodone 5 mg. (LPN L removed the oxycodone from the StatSafe four hours and 34 minutes after the previous pulled dose at 12:18 P.M.) -On 10/21/21 at 12:47 P.M., oxycodone 5 mg; -On 10/21/21 at 5:05 P.M., oxycodone 5 mg. (LPN L removed the oxycodone from the StatSafe four hours and 18 minutes after the previous pulled dose of the medication at 12:47 P.M.) Review of the resident's MAR, dated October 2021, showed no documentation the resident received oxycodone on these dates and times. Review of facility's Stat Safe audit report, dated 10/12/21 to 12/12/21 showed LPN L removed oxycodone-APAP 5/325 mg on 11/4/21 at 9:21 P.M. (The resident did not a physician's order for this medication). 3. Review of Resident #9's admission MDS, dated [DATE], showed the following: -He/She was admitted on [DATE]; -His/Her cognition was mildly impaired; -He/She denied pain; -He/She received opioids four of the previous seven days. Review of the resident's physician order report, dated October 2021, showed the following: -His/Her diagnoses included necrosis of left femur (bone condition that was a result from poor blood supply to an area of the bone causing localized bone death); -Order received on 10/20/21 for oxycodone 5 mg, one tablet every six hours as needed for pain. Review of the resident's StatSafe log showed the following: -On 10/21/21 at 12:47 P.M., LPN L removed oxycodone 5 mg for the resident; -On 10/21/21 at 5:05 P.M., LPN L removed oxycodone/APAP 5/325 mg. (The resident did not have a physician's order for this medication. LPN L removed the oxycodone/APAP 5/325 mg four hours and 19 minutes after the previous pulled dose of oxycodone at 12:47 P.M.) -On 10/21/21 at 8:03 P.M., LPN L removed oxycodone/APAP 5/325 mg. (The resident did not have a physician's order for this medication. LPN L removed the oxycodone/APAP 5/325 mg three hours and 58 minutes after the previous pulled dose of the medication at 5:05 P.M.) Review of the resident's MAR, dated October 2021, showed no documentation the resident received these medications on 10/21/21 at these times. 4. Review of facility's undated investigation regarding narcotic discrepancies showed the following; -LPN L signed out several narcotics for a resident and were not documented as administered on the MAR; -It was also noted that a couple of other nurses had this same poor practice. During an interview on 3/22/22 at 10:38 P.M., the administrator said staff were to remove medications from the StatSafe if there was a new admission, a new order, or if a resident ran out of a particular medication for some reason. Staff, not just LPN L, failed to document administration of narcotic medications appropriately. She was unaware of medications being removed without physician's orders. That issue was never brought to her attention. She was aware of medications being pulled from the StatSafe, being administered, and not being documented until after administered, which could've been hours after administration. During interview on 3/23/22 at 9:30 A.M., the nurse educator said the StatSafe was not to be used for everyday use. Residents should have their medications (from pharmacy) the following day after admission, therefore, there would be no need for staff to pull medications from the StatSafe. During interview on 3/23/22 at 10:00 A.M., the DON said staff were to document all medications removed from the StatSafe on the resident's MAR. Medications from the StatSafe should only be removed if a resident was out of a medication or pharmacy had not delivered the medication. During interview on 3/28/22 at 2:47 P.M., LPN L said he/she was expected to remove medications from the narcotic box and/or StatSafe if necessary. The only reason medications would be removed from the StatSafe was if a resident was a new admission and the pharmacy had not delivered the resident's medications, new orders were obtained, or if a resident ran out of a particular medication. There was no reason to remove medications from the StatSafe if a resident had the medications. The only time he/she took medications from the StatSafe was when medications were unavailable due to either new admissions, new orders, or if resident had ran out of medication and it had not been replaced. Narcotic medications were supposed to be signed out on the resident's narcotic sheets as well as on the resident's MAR. He/She had been sloppy with his/her work. He/She believed if staff had access to the StatSafe via pass code, medications could be dispensed from the StatSafe without a physician's order being entered in the system, but didn't know this for sure as he/she never tried. During interview on 4/12/22 at 1:36 P.M., the facility's medical director/the resident's physician said the facility's StatSafe was to be used for temporary purposes while waiting for resident's prescriptions to be completed and delivered. He expected staff to follow orders and/or have an order for the medication being administered, and document administration, including time of administration on the residents' MARs. 5. Review of Resident #7's significant change in condition MDS, dated [DATE], showed his/her cognition was moderately impaired. He/She received hospice services. Review of the resident's care plan, dated 7/9/21, showed the following: -He/She was at the end stage of life and utilized a hospice company; -Goal: maintain contact with hospice concerning his/her care; -Staff were to notify hospice with any change in his/her condition. Review of the resident's Physician Orders Sheet (POS), dated 8/1/21 to 8/31/21, showed the following: -His/Her diagnoses included stroke (poor blood flow to the brain that causes cell death) and end stage renal disease (kidney failure); -An order for Zofran (medication used to treat nausea) 4 milligram (mg), give one tablet every eight hours as needed for nausea (original order dated 9/13/20). Review of the resident's health status note, dated 8/13/21 at 12:42 P.M., showed the resident told the hospice nurse during the visit that he/she thought he/she had a urinary tract infection (UTI; infection of the urinary system). Hospice contacted the resident's physician who did not wish to start antibiotic treatment at this time. The physician ordered to encourage fluids and monitor for signs and symptoms of UTI. Staff were to contact the physician with any changes in condition or symptoms. During interview on 3/24/22 at 9:25 A.M., the hospice representative said (after review of the hospice notes) on 8/13/21, the resident thought he/she had a UTI. An assessment was completed, the physician contacted, and the physician wanted staff to monitor the resident. The facility was to call the physician with any changes in condition. The hospice nurse educated the facility staff to notify them if the resident had any changes. Review of the resident's progress notes showed no documentation on 8/14/21 regarding the resident's condition or monitoring of his/her complaints of a UTI made on 8/13/21. Review of the resident's health status note, dated 8/15/21 at 12:21 P.M., showed the nurse (LPN M), documented the resident reported he/she was nauseated, his/her urine was thick, and he/she wasn't feeling well. The resident refused to get out of bed, had a slightly decreased appetite, and family noted increased confusion. Hospice notified and the facility was awaiting call back with further orders. Review of the resident's medical record showed no documentation the facility administered Zofran or contacted the resident's physician with a change in condition, or followed up with the hospice company regarding orders after the resident complained of nausea, thick urine, and not feeling well on 8/15/21 at 12:21 P.M. Review of the resident's health status note, dated 8/15/21 at 10:10 P.M. (nine and a half hours after the resident's documented complaints of nausea and not feeling well), showed LPN L went to the resident's room to administer bedtime medications and noted there was emesis (vomit) in the resident's basin located at the resident's bedside. The resident spoke to the nurse, but was not understood. The nurse elevated the head of the resident's bed and placed a basin in his/her bed. The care partner (staff member who assisted resident's with activities of daily living) said he/she called the nurse at 9:45 P.M. to report the resident's family was in the room and were angry that the resident had not received any anti-nausea medication. There were no medications on the orders when the nurse checked. The hospice nurse was notified and orders were obtained. Review of the resident's POS showed an order was obtained on 8/15/21 at 10:08 P.M. for prochlorperazine (medication used to treat nausea) 25 mg to be administered every four hours for nausea. Review of the resident's health status note, dated 8/15/21 at 10:10 P.M., showed LPN L would let the night shift nurse give the resident the medication as they were changing shifts. Review of the resident's health status note, dated 8/15/21 at 10:16 P.M., showed LPN L reviewed the resident's physician orders again and discovered an order for Zofran. He/She would administer this medication. Review of the resident's medication administration record (MAR) showed staff administered Zofran on 8/15/21 at 10:18 P.M. Review of the resident's progress notes, dated 8/15/21 at 11:36 P.M., showed upon arrival to the resident's room, LPN K was told the resident had just had some brown appearing emesis. The nurse provided a basin since the resident had been nauseated. LPN K contacted the hospice company to report the resident's condition and was instructed to send the resident to the hospital. During interview on 3/23/22 at 6:05 A.M., LPN K said the following: -He/She contacted the hospice nurse who would contact the resident's physician; -The resident's family reported to him/her that the resident had been nauseated and vomiting that day (8/15/21). He/She noted brown emesis in the resident's basin and the resident appeared to be sick. He/She did not administer anti-nausea medication, and was unsure if the resident had received any. He/She contacted the hospice nurse who instructed him/her to send the resident to the hospital; -If a physician said to monitor a resident's condition, staff should describe how the resident was doing in a progress note; -All orders given by hospice were to be relayed to the resident's physician. During interview on 3/24/22 at 9:25 A.M., the hospice representative said the following: -There was no documentation in the resident's hospice notes to show facility staff notified the hospice agency/hospice nurse of the resident's complaint of nausea (on 8/15/21); -The facility should notify the hospice nurse about complaints of nausea and any changes in the resident's condition; -Typically, the hospice nurse entered a note when a facility contacted them, but there were no notes made between 8/13/21 until 8/16/21 (when the resident was discharged from hospice); -Resident #7's physician covered his/her own patients, but hospice would use their agency's physician as back up if they were unable to contact Resident #7's physician. During interview on 3/22/22 at 3:30 P.M., Registered Nurse (RN) N said the hospice agency had their own physician to obtain orders. He/She was to contact hospice first, but still had to contact the resident's physician for approval of any orders, and to notify the physician of any changes in the resident's condition. Long-term care residents did not require a daily progress note, but anything out of the ordinary or any complaints the resident had made should be documented in his/her progress notes. During interview on 3/28/22 at 3:40 P.M., the director of nursing (DON) said the following: -When a physician ordered staff to monitor a resident's condition, she expected staff to document the resident's condition in resident's electronic health record/progress notes. Staff should make a note about how the resident was doing; -She expected documentation of the staff monitoring the resident to be completed every shift or as directed by the physician; -She expected staff to have administered anti-nausea medication when the resident and/or his/her family reported nausea at 12:21 P.M. (on 8/15/22). The resident should not have waited until 10:18 P.M. for staff to administer the medication; -She expected staff to follow up with hospice and contact the resident's physician with any changes in the resident's condition, including complaints of nausea, increased confusion, and thick urine; -The nurse was expected to contact the resident's physician and the hospice agency as well with any changes in the resident's condition. During interview on 4/12/22 at 1:35 P.M., the resident's physician said staff should not hesitate to administer anti-emetic medication (medication to treat nausea/vomiting) if a resident complained of nausea/vomiting and there was an order for the medication. He followed his residents who were on hospice, but also utilized the hospice agency's medical director when he was unavailable. Both facility and hospice staff should notify him of any changes in a resident's condition or when needed. He would have expected the staff to notify him of the resident's change in condition. MO 189591

Based on interview and record review, the facility failed to report an allegation of misappropriation of medication, involving one resident (Resident #8), in a review of 20 sampled residents, to the state survey agency, after staff made allegations that Licensed Practical Nurse (LPN) L was misappropriating residents' narcotic medications. Facility census was 52. Review of facility's Abuse Investigation and Reporting Policy, last revised December 2016, showed the following: -All alleged violations that involve abuse, neglect, exploitation or mistreatment, and misappropriation of property would be reported by the facility's administrator or his/her designee to the following persons and/or agencies: state licensing/certification agency responsible for surveying/licensing the facility, local/state ombudsman if required, resident's representative of record, law enforcement officials if necessary; resident's attending physician; -Suspected abuse, neglect, or mistreatment including misappropriation of resident property would be reported within two hours if the alleged event resulted in serious bodily injury; -Allegation would be reported within 24 hours if the alleged event did not result in bodily injury. During interview on 3/23/22 at 10:46 A.M., the former director of nursing (DON) said a couple of nurses had brought to his/her attention (unable to recall dates) that LPN L administered more narcotics to residents than normal. LPN L administered pain medications to residents who normally didn't receive pain medication. Alert and oriented residents reported they didn't receive pain medications, but yet LPN L documented on their Medication Administration Records (MAR) they had received the medication. The pharmacy conducted a comparison audit which showed LPN L administered a lot more narcotic medications than the other nurses. Resident #8 said he/she never had pain, but LPN L documented the resident received pain medication every six hours when LPN L worked. He/She voiced his/her concerns to Resident #8's physician who said the allegation needed to be reported and the physician ordered a rapid drug screen for the resident. The resident's rapid drug screen was negative, and the resident's urine was sent to the lab for more sensitive analysis with negative results. He/She suspected medication diversion, but the administrator disagreed. LPN L had multiple entries on the narcotic sheets where he/she had removed medication, but did not document the medications were given on the resident's MAR. There were too many variables that directed LPN L toward diversion of narcotics. He/She did not report the incident (to the state agency) because the administrator told him/her that he/she would take care of it and instructed him/her not to report. Review of facility's undated investigation regarding narcotic discrepancies showed the following: -There were several concerns regarding LPN L. LPN L signed out several narcotics for residents, but never documented the medications were administered on the MAR; -It was noted that LPN L assessed Resident #8 at high pain level and medicated the resident with narcotic pain medication each day he/she worked, however, when other nurses worked with that same resident, it was documented the resident denied having pain at all; -fell ow co-workers reported that LPN L would pick up shifts in other cottages and administer as needed (PRN) pain medications to a resident that had not been given to that resident in months by any other nurse. During interview on 4/21/22 at 1:35 P.M., the facility's medical director said allegations that staff were suspicious of staff misappropriating medications should be reported to state agency and followed up with investigation.

Based on interview and record review, the facility failed to follow physician orders for administration of [MEDICATION NAME] (a medication given to prevent blood clot formation) for one resident (Resident #1), in a review of three sampled residents. The facility census was [AGE]. Review of the facility policy Administering Medications, revised December 2012, showed the following: -Medications shall be administered in a safe and timely manner, and as prescribed; -The director of nursing services (DON) will supervise and direct all nursing personnel who administer medications and/or have related functions; -Medications must be administered in accordance with the orders, including any required time frame. Review of the facility policy Medication and Treatment Orders, revised July 2016, showed the following: -Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; -Orders for anti-coagulants will be prescribed only with appropriate clinical and laboratory monitoring; -The attending physician must periodically record in the progress notes the results of the laboratory monitoring and the review for potential complications. 1. Review of Resident #1's care plan, dated [DATE], showed the following: -He/She is on anticoagulation therapy; -[DIAGNOSES REDACTED]. Review of the resident's hospital discharge orders, dated [DATE], showed an order for [REDACTED]. Review of the resident's medication admission orders [REDACTED] -[MEDICATION NAME], give 3 mg by mouth one time a day every Monday, Tuesday, Thursday, Friday and Saturday (start date of 1/24/20); -[MEDICATION NAME], give 4 mg by mouth one time a day every Wednesday and Sunday (start date of 1/29/20). Review of the resident's physician's history and physical, dated 1/25/20, showed the following: -Labs/Radiology/Tests: labs on [DATE] INR (International Normalized Ratio; blood test used to detect how well blood thinning medication is working to prevent blood clots) 2.0 (normal 2.0 - 3.0); -Plan: will need an INR on Monday. Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's physician progress notes [REDACTED]. -Chief complaint/nature of presenting problem: [DATE] INR 1.1 (low). Increase [MEDICATION NAME] to 4 mg daily, recheck in one week; -Diagnosis: [REDACTED]. -Plan: [MEDICATION NAME] was increased to 4 mg. During interview on 2/26/20 at 10:15 A.M., Registered Nurse (RN) C said the following: -When a resident is admitted from the hospital, the discharge medications are written as orders; -The discharge medications are compared to the orders, entered, and then sent to the pharmacy; -He/She admitted the resident from the hospital on [DATE], and was responsible for putting the resident's orders in the computer and assigning a start date for the medication; -The [MEDICATION NAME] order was an alternating dose with 3 mg on Monday, Tuesday, Thursday, Friday and Saturday and 4 mg on Sunday and Wednesday; -The order for [MEDICATION NAME] 4 mg was entered to start on 1/29/20, the order should have started on 1/24/20; -He/She entered the start date for [MEDICATION NAME] 4 mg in error; -The incorrect date would have resulted in a missed dose of [MEDICATION NAME]. During interview on 2/11/20 at 11:00 A.M., the DON said the following: -She expected staff to give [MEDICATION NAME] as ordered; -The start date for the alternating dose of [MEDICATION NAME] 4 mg given on Wednesday and Sunday was 1/29/20; -The start date for the alternating dose of [MEDICATION NAME] 4 mg should have matched the [MEDICATION NAME] 3 mg alternating dose of 1/24/20; -She did not see any indication staff administered [MEDICATION NAME] 4 mg on 1/26/20. (The facility had not identified the error or cause prior to the investigation). During interview on 2/11/20 at 12:48 P.M., the resident's physician said the following: -He/She expected the facility to follow written physician orders; -He/She expected staff to administer [MEDICATION NAME] as ordered. During interview on 2/18/2020 at 4:16 P.M, the administrator said the following: -She expected staff to follow physician orders; -She expected staff to administer medications as written. MO 7

Based on observation, interview, and record review, the facility failed to ensure food items were discarded when expired and failed to store scoops outside the containers. The facility also failed to ensure the bottoms of the freezers were clean and free of debris. The facility census was 57. 1. Observation on [DATE] at 9:09 [NAME]M. in Grace's Cottage kitchen, showed a gallon container of mayonnaise with a use by date of ,[DATE] (no year); a quart bag with a white powdery substance dated [DATE]; a quart bag of round meat product dated [DATE]; and a 32-ounce carton of plain yogurt with use by date of [DATE] in the refrigerator in the kitchen area. The bottom of the freezer in the kitchen area was covered with dirt and food debris. Observation on [DATE] at 9:21 [NAME]M. in Harper's Cottage kitchen, showed a gallon container of orange juice (,[DATE] full) with a use by date of [DATE] in the refrigerator in the kitchen. A scoop was stored in the sugar container in the pantry. The handle on the scoop was touching the sugar. The bottom of the freezer in the kitchen was covered with dirt and food debris. Observation on [DATE] at 9:32 [NAME]M. in Ella's Cottage kitchen showed the refrigerator in the storage room had a quart container of coffee creamer with a use by date of [DATE]. The refrigerator in the kitchen area had a gallon container (,[DATE] full) of orange juice with a use by date of [DATE]. The bottom of the freezer in the kitchen area was covered with dirt and food debris. Observation on [DATE] at 9:40 [NAME]M. in Ava's Cottage kitchen showed scoops were stored in a container of cereal and a container marked pancake mix. The scoop handles touched the contents in the containers. In the refrigerator in the kitchen area, there was a gallon container of orange juice (,[DATE] full) with a use by date of [DATE]. The bottom of the refrigerator freezer in the kitchen area was covered with dirt and food debris. Observation on [DATE] at 9:47 [NAME]M. in Betty's Cottage kitchen showed a 10 ounce bottle (,[DATE] full) of honey poppy seed dressing with a use by date of [DATE], a 12.1 ounce bottle of stir fry sauce with a use by date of [DATE], a 10.5 ounce bottle of tartar sauce with a use by date of [DATE], a 14 ounce bottle of ketchup with a use by date of [DATE], two 12 ounce bottles of mustard with use by dates of [DATE] and [DATE], a 16 ounce bottle of balsamic dressing with a use by date of [DATE], and a 16 ounce jar of dill pickle chips with a use by date of [DATE] located in the kitchen refrigerator. The bottom of the refrigerator freezer in the kitchen area was covered with dirt and food debris. Observation on [DATE] at 9:59 [NAME]M. in Kris's cottage kitchen showed scoops were stored in a container of flour, a container of cream of wheat, a container of powered sugar, and a container of brown sugar. The scoop handles were in contact with the contents of the containers. In the refrigerator in the kitchen area, there was a 32 ounce carton of liquid egg product (,[DATE] full) with a use by date of ,[DATE]. The bottom of the freezer in the kitchen area was covered with dirt and food debris. Record review on [DATE] at 11:58 [NAME]M. of the cottage daily task list showed no documentation for staff to clean refrigerators or freezers. During interview on [DATE] at 10:58 [NAME]M., the dietary manger said the cottage staff were responsible for cleaning the refrigerators and freezers. She expected staff to clean the refrigerators and freezers once a week or more often. The refrigerators and freezers should be free of spills and food debris. Cottage staff were also responsible for disposing of expired food. Staff are to remove food three days after opening except condiments and they are good for a month after opening. Foods should be discarded after the use by date. She was responsible to ensure the cottage staff cleaned the refrigerators and disposed of the expired food. Staff should not store scoops in the food containers. During interview on [DATE] at 7:55 [NAME]M., the administrator said she expected staff to discard food by the use by date. Night shift staff should clean the refrigerators and freezers at least once a week. Staff should not store scoops in the food containers.

Based on interview and record review, the facility failed to identify and provide needed care and services to one resident (Resident #2), in a review of seven sampled residents, in accordance with the resident's preferences and professional standards of practice to meet the resident's physical and psychosocial needs. Staff did not intervene timely to symptoms of complications related to the resident's catheter. The resident expressed discomfort and exhibited anxiety requiring medication as a result of the catheter and asked for staff to have it removed. The facility census was 52. 1. Review of the Healthcare Infection Control Practices Advisory Committee, Guidelines for Prevention of Catheter-Associated Urinary Tract Infections, last updated 6/6/19, available through the Centers for Disease Control site showed the following: -Maintain unobstructed urine flow; -If obstruction occurs and it is likely the catheter material is contributing to obstruction, change the catheter. 2. Review of Resident #2's care plan, dated 1/28/19, showed the following: -[DIAGNOSES REDACTED]. -The resident received hospice services; -Notify hospice with any change in condition; -Notify nursing with any change in condition; -Receives anti-anxiety medication due to progression of ALS. Administer anti-anxiety medication as ordered; -Requires tube feeding. Review of the resident's Visual/Bedside Report sheet showed an update (undated), the resident had a urinary catheter. Provide care every shift and as needed. Review of the resident's physician order [REDACTED]. -Water flushes 50 milliliters per hour (ml/hr) via pump from 8:00 P.M. to 8:00 [NAME]M.; -Hospice care; -Tube feeding with [MEDICATION NAME] 1.5 (liquid enteral nutrition) at 60 ml/hr from 1:00 P.M. to 4:00 P.M.; -Tube feeding with [MEDICATION NAME] 1.5 at 60 ml/her from 8:00 P.M. to 8:00 [NAME]M.; -Flush tube feeding with 50 ml/hr continuous from 1:00 P.M. to 4:00 P.M.; -Elder is in charge of his/her care. He/She is able to decide what he/she wants and what he/she does not want; -[MEDICATION NAME] (anti anxiety medication) 0.5 mg via tube three times a day for anxiety at 8:00 [NAME]M., 4:00 P.M., and 10:00 P.M.; -[MEDICATION NAME] 0.5 milligrams (mg) via tube as needed every two hours for anxiety/shortness of breath; -An order, dated 6/24/19, for urinary catheter care every shift and as needed; -An order, dated 6/29/19, for [MEDICATION NAME] sulfate (narcotic pain medication), 20 mg/ml, give 10 ml by mouth every hour as needed for pain/shortness of breath. Review of the resident's nurse's notes on 6/29/19 showed the following: -At 6:17 [NAME]M., the resident was alert and oriented. The urinary catheter drained amber color urine with a moderate amount of sediment. The resident turned on his/her call light several times and requested the catheter be removed. The nurse explained the resident needed the catheter but would ask the physician in the morning if it could be removed. [MEDICATION NAME] administered per physician orders; -At 12:05 P.M., the resident reported the urinary catheter was not comfortable and he/she felt the urge to urinate. As needed medication administered after attempts to decrease anxiety, such as talking with him/her were not effective. Review of the resident's Medication Administration Record [REDACTED].M. and documented the medication was effective (no time listed). Review of the resident's nurse's notes on 6/29/19 at 1:48 P.M., showed the nurse observed thick, yellow/white sediment in the urinary catheter tubing and urine collection bag. The resident reported feeling the urge to urinate. The resident's abdomen was distended. Very little thick urine output was noted in the urinary drainage bag. The nurse would inform the oncoming nurse. (Review showed no further documentation in the nurses notes on 6/29/19 regarding the resident's condition and his/her urinary catheter.) During a telephone interview on 7/11/19 at 11:30 [NAME]M., Licensed Practical Nurse (LPN) D said he/she worked from 6:00 [NAME]M. until 2:00 P.M. on 6/29/19 and was the nurse caring for the resident. LPN D remembered an issue with the resident's catheter that day but could not recall if he/she contacted the resident's physician or the hospice provider. LPN D did not recall if any interventions were attempted for the resident and did not recall what he/she had documented. During a telephone interview on 7/11/19 at 12:50 P.M., Registered Nurse (RN) A said he/she assumed care as the nurse for the resident at 2:00 P.M. on 6/29/19. The day shift nurse, LPN D, said there was a large amount of sediment in the resident's catheter. RN A went to the resident's room right away, just after 2:00 P.M., and in his/her opinion found the catheter needed to be flushed. The resident's family member was at the bedside. The resident's abdomen was distended. RN A said he/she attempted to flush the catheter, and was able to flush the catheter, but did not get any urine to flow, only mucous. (Review of the resident's medical record showed no documentation RN A assessed the resident or flushed the resident's catheter on 6/29/19.) RN A was aware the resident was on hospice service and discussed with the family member what they wanted done. The family member said he/she would call the hospice provider. RN A said he/she felt the catheter should have been removed. RN A did not remove the catheter because the resident was on hospice service and hospice wanted to be notified. RN A said he/she did not feel the resident was uncomfortable. RN A said he/she felt he/she responded to the issue with the catheter based on the family member's wishes. The hospice nurse arrived to the facility around 6:00 P.M. RN A thought the hospice nurse changed the resident's catheter at that time. During a telephone interview on 7/11/19 at 1:14 P.M., Hospice RN B said he/she was on call on 6/29/19. He/She received a call from the hospice triage nurse regarding an issue with the resident's catheter and the resident having increased anxiety and shortness of breath throughout the day. Hospice RN B arrived at the facility just after 6:00 P.M. When he/she arrived, the resident was extremely uncomfortable and anxious and his/her abdomen was distended. Hospice RN B touched the resident's abdomen and his/her bladder was hard. The resident's family member was at the bedside when he/she arrived and was very concerned about the resident and wanted someone to help the resident. RN A reported he/she had flushed the resident's catheter but Hospice RN B saw no evidence the catheter had been flushed because the resident's catheter tubing was dry and crusted. There was no liquid observed in the catheter tubing. There was a urinary catheter kit available in the resident's room. Hospice RN B changed the resident's urinary catheter and there was an immediate return of 1000 mls of dark, milky, foul smelling urine. The resident expressed immediate relief after Hospice RN B changed the catheter. Hospice RN B received an order from the physician to start the resident on an antibiotic due to condition of his/her urine which indicated a possible urinary tract infection [MEDICAL CONDITION]. Review of the resident's physician orders [REDACTED]. During an interview on 7/11/19 at 1:45 P.M., the Director of Nursing (DON) said she expected staff to at least reposition the catheter and attempt to flush the catheter if it was not draining urine. Staff should have removed the catheter and replaced it after flushing the catheter was not effective. The DON thought RN A had mentioned the resident's family member wanted him/her to wait for the hospice nurse before changing the catheter. During a telephone interview on 7/12/19 at 1:56 P.M., the resident's family member said he/she arrived at the facility about 3:00 P.M. on 6/29/19. The resident's stomach was swollen. The resident was extremely uncomfortable and repeatedly asked, please take me to the bathroom. The resident's tube feeding and flushes were still running. The family said he/she called the hospice service right after 3:00 P.M. and was told the nurse was with another patient. RN A told the family member there was nothing he/she could do until the hospice nurse showed up to the facility. The family member called the hospice service back about 5:00 P.M. The resident remained very uncomfortable and continued to ask to go to the bathroom and wanted the catheter removed. Hospice RN B arrived at the facility at 6:00 P.M. and changed the resident's catheter. The resident had an immediate output of a large amount of cloudy, dark, bad smelling urine. The resident immediately felt relief when the catheter was changed. The family member said he/she never asked any facility staff to wait for hospice to arrive before changing the catheter. The family member was desperate for someone to help the resident and that is why he/she called the hospice service twice, trying to get some relief for the resident. During a telephone interview on 7/16/19 at 10:05 [NAME]M., the resident's physician said he would have expected the facility nurse to intervene when there was a noted problem with the resident's catheter. The resident was able to make his/her own decisions about his/her care. If the resident wanted the catheter removed, staff should have contacted him and he would have given the order to do so. There would have been no need to wait for the hospice nurse to arrive to remove the catheter. The physician certainly would have expected staff to call him and to change the catheter when they observed there was little to no urine output. The physician would have expected staff to document if the resident or family refused to allow them to remove or change the catheter. Leaving the occluded catheter in place could have caused the resident discomfort. MO 0

Based on observation, interview, and record review the facility failed to provide protective oversight for two residents (Resident #17 and #16) in a sample of 16 residents. The surveyor observed Resident #17 exit the facility in his/her wheelchair out of the southwest door activating a door alarm. No staff responded to the alarm and Resident #17 continued to propel him/herself towards a busy street. As no staff responded, the surveyor redirected Resident #17 away from the street and back into the facility. One staff member was on duty at the time providing cares to another resident, could not hear the door alarm and did not know Resident #17 exited. The facility failed to ensure all door alarms were audible from all areas of the facility and were functioning in all of the cottages comprising the facility. The facility also failed to prevent Resident #16 from wandering into other residents' rooms, invading their personal space/privacy and into the kitchen area while staff prepared food. The facility failed to identify residents at risk for elopement. The facility census 39. 1. During interview on 11/8/18 at 11:25 A.M., the administrator said the facility did not have a wandering policy in place at the time of survey. 2. Record review of the Resident #17's face sheet showed an admission date of [DATE]. Review of the resident's wandering risk scale assessment dated [DATE] showed the resident was at risk to wander. Review of the resident's care plan, reviewed 3/11/18, showed the following: - I have impaired cognitive function. Interventions: staff to anticipate my needs as I do not always say what I am wanting or needing; -Potential for communication impairment. Interventions: monitor, document, report any changes; -The care plan did not address the resident's risk for wandering; -[DIAGNOSES REDACTED]. Symptoms include confusion) and kidney failure. Review of the resident's significant change, Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/6/2018, showed the following: -Brief interview of mental status (BIMS) of eight indicating moderate cognitive impairment; -Adequate hearing and vision; -No wandering exhibited; -Required extensive assistance of one staff for transfers; -Required limited assistance of one staff for locomotion on the unit; -Required stand by assistance of one staff for locomotion off the unit; -Used a wheelchair and walker for mobility devices. Review of the resident's care plan revised 10/10/18 showed the resident wandered at times and staff were to check on the resident's location frequently and redirect the resident as needed. Review of the resident's electronic medical record from 11/27/17 to 10/23/18 showed the facility completed no elopement risk assessment on the resident. Observation on 10/23/18 at 4:30 P.M. showed the following: -The resident propelled him/herself around in his/her wheelchair inside the facility toward the front double doors; -The resident exited through the first door which was open that lead to the front door (closed); -The chief financial officer (CFO) and certified nursing assistant (CNA) N redirected the resident back inside the first open door and toward the dining room table; -The resident told staff , I want to go home, the CFO and CNA N told the resident, I know you do and redirected the resident to the dining room table. Observation on 10/23/18 from 4:55 P.M. to 4:58 P.M. showed the following: -The south side facility door alarm sounded and could be heard down the hall and in the main dining area; -No staff were present in the main dining area, TV area, kitchen or at the nurses station; -Resident #28 sat at the dining room table in the main dining area waiting for supper. He/she yelled for staff to help, because Resident #17 propelled him/herself out of the south exit door. Staff did not respond to Resident #28 yelling or to the alarms going off; -The resident propelled him/herself out the side door on the south back side of the building on the sidewalk toward a high traffic road with a speed limit of 35 miles per hour; -The surveyor jogged out to the resident to redirect the resident back into the building, as no staff responded to the alarm. With redirection the resident turned him/herself around and propelled him/herself back into the building. The resident repeatedly told the surveyor, I want to go home; -After approximately three minutes, CNA N came into the main area of the dining room and asked why the alarm was going off, what had happened; -The resident told CNA N repeatedly, I want to go home; -CNA N was the only staff in the building at the time the resident exited the building. During an interview on 10/23/18 at 4:59 P.M., CNA N said the following: -CNA O who was working in Ella's cottage with him/her and had gone over to the administrator's office (separate building) for an inservice; -He/she was the only staff in the building and was getting another resident up. He/she could not hear the door alarms going off while in the resident's room; -Resident#17 said earlier that he/she wanted to go home, but CNA N didn't think anything about it; -The resident always propelled him/herself in and out of the facility into the courtyard, but didn't normally try to get out the front or side door; -He/she had been in assisting another resident at the time Resident #17 left the cottage. Observation on 10/23/18 at 5:50 P.M. to 7:50 P.M., showed door alarms could not be heard in the residents' rooms with the room doors closed in each of the six cottages and showed the alarm did not work to the exit door on the spa side of Betty's cottage. Review of the resident's electronic medical record dated 10/23/18, showed no documentation of the resident's change in behavior, exit seeking behavior, or elopement along with any interventions to prevent further elopement. Review of the resident's wandering risk assessment dated [DATE] at 6:30 P.M. (after the resident exited the building without staff knowledge) showed the facility assessed the resident at low risk for wandering. Review of a list of residents at risk for wandering/elopement provided by the facility after the resident's elopement dated 10/23/18 showed the resident was not on the list as at risk. During an interview on 10/23/18 at 6:16 P.M., CNA N said the following: -Usually there were two CNAs in the cottage during the day and evening shift to help with cares for the residents; -He/she did not notify the licensed nurse or administrator of the resident's earlier change in behavior and exit seeking, the resident actually exiting the building, or of not being able to hear the alarm in the resident's room; -When CNA P came over to the cottage , he/she told him/her about the resident eloping out of south door in his/her wheelchair towards the road while he/she was in a resident's room and could not hear the alarm and CNA P reported it to the administrator; -The resident tried to get out earlier in the day, but he/she and the other staff redirected the resident; -The resident enjoyed being outside, but it was a change in behavior that the resident was trying to get out the front door and saying he/she wanted to go home. During and interview on 10/23/18 at 6:31 P.M., CNA O said the following: -He/she left Ella's cottage around 4:40 P.M. to go over to the administration office for an inservice; -He/she had worked by him/herself in the evenings at times and night shift always had one CNA working in each cottage; -He/she did not know if he/she could hear the door alarms while providing cares in a resident's room; -He/she was not familiar with the resident that eloped; -He/she was not aware of any residents that were an elopement risk in the cottage. During an interview on 10/23/18 at 6:42 P.M., CNA P said the following: -CNA N reported to him/her that the resident got out of the building; -He/she reported to the administrator about the incident around 5:15 P.M. to 5:30 P.M.; -The resident always wanders and was an elopement risk; -He/she had worked by him/herself during the evening at times and on nights there was always one CNA to care for the residents. During an interview on 10/23/18 at 5:40 P.M., Licensed Practical Nurse (LPN) R said the following: -The resident propelled him/herself in and out of the building to the secured court yard as he/she desired; -He/she was not aware the resident had tried to get out the front doors of the facility or was saying he/she wanted to go home. This was a change in behavior for the resident; -He/she was in Ava's cottage passing medication and did not know there was only one CNA left in the building when the resident eloped. 3. Review of Resident #16's Wandering Risk Scale, dated 8/4/18, showed the resident was at a high risk to wander. Review of the resident's care plan, last revised 9/4/18, showed the following: -[DIAGNOSES REDACTED]. -He/she wanders aimlessly and enters other residents' room at times; -Redirect the resident when he/she was entering a room other than his/her own; -The resident has impaired cognitive function/dementia or impaired thought processes related [MEDICAL CONDITION], dementia; -Use the resident's preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact, reduce any distractions-turn off television, radio close the door etc. The resident understands consistent, simple directive sentences, provide the resident with necessary cues. Stop and return if agitated; -The resident can be redirected easily with snacks; -Engage simple, structured activities that avoid overly demanding tasks; -Keep my routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion; -He/she had a communication problem related to dementia and [MEDICAL CONDITION]; -Anticipate and meet the resident's needs; -He/she had little or no activity involvement . Review of the resident's quarterly MDS, dated [DATE], showed the following: -Short-term and long-term memory problems; -Sometimes makes self-understood and understands others; -Cognitive skills for daily decision making moderately impaired (the resident's ability to make decisions is poor, cues and supervision required); -Inattention continuously present; -Disorganized thinking, behavior present fluctuates, comes and goes, changes in severity; -Wandering or behavior of this type occurred four to six days over the seven-day look back period; -Used a walker to assist with ambulation. Review of the resident council meeting minutes from 9/7/18 showed the residents in attendance complained the resident wandered throughout the day. Review of the resident's nurse's note, dated 10/8/18 at 8:13 P.M., showed it was reported to this nurse, Resident #7 called his/her family member saying a confused resident had gone in his/her room at 1:00 A.M. Resident #7 reported Resident #16 got into bed with him/her and he/she was scared of a recurrence. The residents will both be visualized while in bed every hour or as often as tolerated. During interview on 10/22/18 at 2:57 P.M., Resident #7 said about about two weeks ago at 1:00 A.M., he/she woke up with Resident #16 on top of him/her in his/her bed. He/she tried to get Resident #16 off of him/her, but the resident wouldn't budge. He/she started yelling for help and staff came into his/her room to help remove the resident. During interview on 10/24/18 at 9:56 A.M., CNA I said the following: -On 10/8/18 around 3:30 A.M., he/she was assisting a resident get changed when he/she heard a resident yell out, Get out of here! He/she knew Resident #16 had probably gone into Resident #7's room, which was next door; -He/she finished providing care to the resident he/she was with, which took less than five minutes, and then went to Resident #7's room. Resident #16 stood at the foot of Resident #7's bed. Resident #7 seemed upset and told the CNA to get Resident #16 out of his/her room; -He/she was the only staff member in the cottage at the time of the incident; -The resident wandered and the facility was well aware of the issue. Record review of the resident's nurse's note, dated 10/10/18 at 2:31 P.M., showed the resident is alert and oriented to self at times. The resident has been wandering in and out of other residents' rooms, gravitates to room [ROOM NUMBER]. This is understandable due to the resident had equivalent room in another cottage. The resident will not enter room [ROOM NUMBER], which is the resident's new room. Review of the communication binder (a summary of the resident's behaviors during a shift for communication), completed by the CNAs, showed on 10/11/18 staff documented it was tough redirecting the resident this evening. He/she finally tired out, had a shower, and was in bed. Review of the resident's care plan, last revised 10/12/18, showed staff was to provide the resident with a distraction when he/she was wandering. He/she liked sweets and could be distracted with a snack at times or conversation. Review of the communication binder showed the following: -On the evening shift on 10/20/18, the resident was wandering around constantly; -On the night shift on 10/20/18, the resident was up wandering around 3:00 A.M. He/she was lost and confused, wandering the halls. Review of the resident's nurse's note, dated 10/21/18 at 6:30 A.M., showed the following: -The resident wandered into another resident's room and said he/she was trying to find his/her way home. The resident is alert and oriented to self only at times; -The resident is an elopement risk due to his/her confusion and exit seeking behaviors; -The resident was not aware other residents had concerns about him/her walking into their rooms and touching their possessions and other residents; -The resident is easily compliant with walking with a staff member to another area and follows instructions well, but is not easily redirected from exit seeking. Review of the resident's nurse's notes, dated 10/23/18 at 2:37 A.M., showed the following: -The resident was up wandering in the cottage and was entering another resident's room; -He/she was escorted back to bed. Observation on 10/23/18 at 9:15 A.M., showed the resident paced unattended in the hall and wandered into another resident's room. The resident (who resided in the room) lay in bed resting. The resident paced around briefly and walked back out of the room. There was no staff in the area. During interview on 10/22/18 at 2:44 P.M., Resident #39 said Resident #16 was in and out of other residents' rooms. Resident #39 had to position himself/herself in the doorway of his/her room to block Resident #16 from going into his/her room. During interview on 10/22/18 at 3:15 P.M., Resident #200 said the following: -He/she was discharging from the facility today and not returning, because of Resident #16. Resident #16 was in and out of residents' rooms day and night; -Recently, Resident #16 was in his/her room around 6:30 A.M. Resident #16 turned on his/her light and woke him/her up; -Resident #16 was in the kitchen area all the time and he/she was not supposed to be. During interview on 10/23/18 at 9:36 A.M., Resident #35 said the following: -Resident #16 wandered into his/her room last night throughout the night; -The resident wandered into his/her room day and night; -The resident had wandered into his/her room, even when he/she was going to the bathroom and that made him/her feel very uncomfortable; -It worried him/her a lot that the resident was in and out of his/her room all of the time. Observation on 10/23/18 at 11:32 A.M., showed the resident wandered with his/her wheeled walker through the kitchen area, where food was prepared. No staff was present in the area. Observation on 10/23/18 showed the following: -At 4:03 P.M., the resident walked into the kitchen area where food was cooked and prepared for meals. A staff person directed the resident to sit down and watch television in the dayroom. The resident sat briefly, stood back up, and walked down the hallway; -At 4:11 P.M., the resident paced down the hallway and was in and out of other residents' rooms as the staff prepared the supper meal. The resident was at the end of the hallway out of staff's view; -At 4:18 P.M., the resident wandered towards Resident #39 who sat at the entrance to his/her room visiting with Resident #35. Resident #16 was intrusive and stood directly in front of Resident #39 (approximately 2 feet away). Resident #39 firmly said, get back now. -At 4:19 P.M., CNA C responded to Resident #39 and redirected Resident #16 away from Resident #39 and into the dayroom to watch television. During interview on 10/23/18 at 4:20 P.M., CNA C said the following: -The resident wandered and was in other residents' personal space when the staff was busy; -Staff tried to redirect him/her when he/she wandered. Observation on 10/23/18 at 4:23 P.M. showed the resident immediately stood up from his/her seat in the dayroom and walked back to Resident #39's door and said, Can I go in there? Resident #16 pointed in the direction of Resident #39's room and was in Resident #39's personal space, directly in front of the resident (approximately 2 feet away). Resident #39 said firmly, No, go that way! Resident #16 walked down the hall and into another resident's room. The resident who resided in this room rested in his/her bed. Staff was in the kitchen preparing the supper meal and was not present in this area. During interview on 10/23/18 at 5:35 P.M., CNA C said the resident was able to walk and wandered about the facility. He/she had tried to open the doors to the facility before. The resident moved fast and was very time consuming. The resident had dementia and did not participate in any activities. Observation on 10/24/18 at 10:23 A.M. showed the following: -The resident exited the door of his/her room, walked to the opposite end of the hallway, and paced around inside of another resident's room. The resident, who resided in the room, rested in his/her bed. No staff was present in the area to redirect; -Resident #16 exited the resident's room, shut the door, and walked back up the hall and into the kitchen area where staff prepared food; -A dietary staff member redirected the resident out of the kitchen and gave the resident a drink of water; -The resident immediately walked back into the kitchen area. During interview on 10/24/18 at 11:45 A.M., LPN A said the following: -Resident #16 required more care then what they were able to provide; -The staff could not consistently monitor the resident, therefore, the resident wandered in and out of rooms and into other residents' spaces throughout the day; -The resident was very difficult to redirect. During an interview on 10/23/18 at 6:58 P.M. and on 10/25/18 at 3:05 P.M. the director of nursing (DON) said the following: -The wandering assessment did not show a true picture of Resident #17's elopement risk; -Resident #17's wandering assessment even after the elopement showed low risk for elopement which was inaccurate due to the resident's elopement; -Any resident who had dementia was at risk for elopement; -He/she wasn't sure the number of residents with a [DIAGNOSES REDACTED]. -The list of residents at risk for elopement that was given to the surveyor was not up to date and was missing residents at risk for elopement including Resident #16 and Resident #17; -One staff on night shift would not be enough to have one on one oversight of Resident #17 or any resident; -The alarms should alert the staff of anyone exiting the building; -She was not aware the alarms were not audible in the rooms while staff were providing care; -Resident #16 should not be in other residents' rooms; -The facility had received many complaints regarding Resident #16 due to his/her cognitive function. During an interview on 10/23/18 at 5:35 P.M. and on 11/1/18 at 1:29 P.M. the administrator said the following: -They were doing training with one of the CNAs from the facility and that left one CNA at Ella's Cottage; -She expected CNA N to have reported the incident to her immediately or at least call the licensed nurse from the other building; -CNA N reported he/she could not hear the door alarm going off; -She did not know if the door alarms were audible in resident rooms; -One staff worked the night shift in the cottages; -Resident #17 had declined recently, but propelled him/herself in and out of the facility courtyard on his/her own; -Staff did not report the Resident #17's earlier exit seeking behavior to her; -Resident #17's behavior was a change, she would have expected staff to notify her; -Resident #16 had been assessed and the facility does not feel they are able to provide the care the resident needs. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the owner installed alarms that were louder and could be heard in the resident rooms and bathrooms (as long as the bathroom doors were open), had a staff one on one with Resident #17 during the night while only one staff was working. Corrected the alarm in the cottage that was not working. Changed the elopement form, working on the policy and procedure for elopement, updated the resident elopement sheet and began inservices on residents at risk for elopement and what to do to prevent and in the event of elopement. The inservices on residents at risk for elopement and the procedure of what to do would continue until all staff were inserviced. The DON or delegated personnel would inservice all staff prior to working. The facility was still trying to figure out what alarm system to use and who would sit with the resident and provide one on one supervision for the resident to prevent further elopement. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview, and record review, the facility failed to ensure food items were labeled, dated, covered or discarded when expired; failed to maintain the internal surfaces of three ice machines; failed to maintain three range hoods to be free of an accumulation of grease and debris; failed to ensure staff utilized sanitary measures during food preparation; failed to ensure fan shrouds in the walk-in cooler in the main kitchen were free of an accumulation of debris; and failed to maintain a ceiling vent to be free of an accumulation of debris in the main kitchen. The facility census was 39. 1. Observation on [DATE] at 2:52 P.M. of the walk-in cooler in the main prep kitchen showed the following: -A metal disposable pan dated ,[DATE] and contained pineapple rings with areas of black mold-like debris on the fruit; -A tall clear plastic container half-full of sour cream, not labeled or dated; -A tall clear plastic container full of coleslaw and not labeled or dated; -A large plastic container contained stewed tomatoes and was not labeled or dated. Observation on [DATE] at 3:58 P.M. of the refrigerator in Kris's Cottage showed the following: -A zip-lock bag of sliced ham dated ,[DATE] and labeled use by ,[DATE] and had not been discarded; -A zip-lock bag of sliced salami dated ,[DATE] and labeled use by ,[DATE] and had not been discarded. Observation on [DATE] at 4:03 P.M. of the freezer in Kris's Cottage showed the following: -A zip-lock bag of tenderloin patties was not labeled or dated; -A zip-lock bag containing three frozen hamburger patties was not labeled or dated; -A plastic bag of frozen cookie dough balls was not labeled or dated. Observation on [DATE] at 3:54 P.M. of the kitchen storage room in Kris's Cottage showed a zip-lock bag containing approximately 15 vanilla wafers was not labeled or dated. Observation on [DATE] at 4:14 P.M. of the refrigerator in Ava's Cottage showed five unthawed sausage patties in a zip-lock bag dated ,[DATE]. Observation on [DATE] at 4:18 P.M. of the kitchen storage room in Ava's Cottage showed a clear plastic container labeled Mrs. Dash. The lid was only partially secured with an opening over the seasoning granules. Observation on [DATE] at 4:37 P.M. of the refrigerator in Ella's Cottage showed the following: -A large zip-lock bag of sliced deli turkey labeled with the Cottage name and was not dated; -A large zip-lock bag containing two sausage patties and was not labeled or dated; -Another large zip-lock bag contained approximately 12 sausage patties and was not labeled or dated. Observation on [DATE] at 4:44 P.M. of the kitchen storage room in Ella's Cottage showed the following items in the refrigerator: -A plastic container with a red lid which contained pasta dated ,[DATE] and ,[DATE] and labeled chic; -A plastic sack with a container of pasta in the sack. The container of pasta was not labeled or dated. Observation on [DATE] at 2:08 P.M. of the kitchen storage room in Harper's Cottage showed the following: -Two containers of Cheerios and cornflakes were not labeled or dated; -A large jug of sweet and sour sauce sat on a shelf of the metal storage rack. The label on the jug indicated the sauce should be refrigerated after opening. The jug had been opened and was half full of sauce. Observation on [DATE] at 5:01 P.M. of the kitchen storage room in Harper's Cottage showed the following items in the refrigerator: -A clear container with a blue lid on the Elders Shelf contained meat, potatoes and green beans and was not labeled or dated; -A container with old grapes or possibly prunes was labeled with a resident's first name and was not dated; -A 15.25-ounce individual container of clam chowder had been opened and covered with foil and was labeled HC 1 and was not dated; -Three dried up and shriveled slices of leftover pizza sat in a cardboard box and were not dated. Observation on [DATE] at 12:11 P.M. of the kitchen storage room in Harper's Cottage showed a 4 pound 11 ounce opened jug of sweet and sour sauce sat on the metal rack and was not refrigerated. Observation on [DATE] at 5:14 P.M. of the freezer in Grace's Cottage showed the following: -A large zip-lock bag of chocolate chip cookie dough balls and a second large zip-lock bag of peanut butter cookie dough balls that were not labeled or dated; -A large zip-lock bag contained two individual frozen biscuits that were not labeled or dated. Observation on [DATE] at 5:16 P.M. of the kitchen storage room in Grace's Cottage showed the following: -Two round plastic containers that contained cereal or granola and were not labeled or dated. The lids were not secure and both containers were open to the air. -A container with spices/seasoning was not labeled or dated. The lid was not secure and was open to the air. During an interview on [DATE] at 4:30 P.M., the dietary manager said the following: -Food items were to be labeled, dated, covered and discarded when past the date; -The stickers show the use by date. Leftovers are good for three days and should be discarded after three days. Some staff still used a marker instead of the stickers to label the food items; -If a date was written on an item with a marker, it was probably the date the item was placed into the refrigerator or freezer; -Items in the freezer should be dated as well and are good for 30 days in freezer. Any item that is opened should be closed or placed in a container with a lid and dated when the item was opened; -The instructions on food item containers should be followed, such as if the item said to refrigerate after opening, then the item should be stored in the refrigerator and not on shelf; -Care partners are responsible to ensure appropriate dates, labels and to discard item. 2. Observation on [DATE] at 3:24 P.M. in the kitchen storage room in Betty's Cottage showed black mold-like debris inside the ice machine on the side walls over the ice. Observation on [DATE] 3:55 P.M. in the kitchen storage room in Kris's Cottage showed black mold-like debris inside the ice machine on the side walls over the ice. Observation on [DATE] at 4:49 P.M. in the kitchen storage room in Ella's Cottage showed black mold-like debris inside the ice machine on the side walls over the ice. During an interview on [DATE] 4:30 P.M., the dietary manager said maintenance emptied, cleaned, and sanitized the ice machines quarterly. He thought the ice machines had last been cleaned approximately three months ago. 3. Observation on [DATE] at 3:29 P.M. in Betty's Cottage showed the kitchen range hood had a heavy buildup of thick yellowish-brown grease and chunky debris on the baffle filter. Observation on [DATE] at 4:07 P.M. in Kris's Cottage showed the kitchen range hood had a heavy buildup of yellow grease and fuzzy debris on the baffle filter. Observation on [DATE] 4:32 P.M. in Ella's Cottage showed the kitchen range hood had a heavy buildup of yellowish-brown grease and fuzzy debris on the baffle filter. During an interview on [DATE] at 4:33 P.M., the dietary manager said maintenance staff was responsible for cleaning filters monthly, however, there was currently no full-time maintenance staff person. During an interview on [DATE] 4:30 P.M., the dietary manager said in the absence of maintenance, the dietary manager or a care partner should clean the filters. He was unsure when the filters were last cleaned. He didn't think maintenance staff documented when the hoods were cleaned. 4. Observation on [DATE] at 8:53 A.M. in Betty's Cottage showed Care Partner Q cracked two raw eggs on the edge of the countertop near the stove and placed the raw eggs directly into a skillet to cook. Egg white ran down the countertop and dripped onto the floor. Care Partner Q did not clean the counter or floor and leaned against the counter top with his/her clothes touching the same general area where the eggs had been cracked open. Observation on [DATE] at 8:55 A.M. in Betty's Cottage showed Care Partner Q cracked two more eggs on the edge of the countertop and placed the raw eggs directly into a skillet to cook scrambled eggs. A small amount of egg white ran down the edge of the counter top and dripped on the cabinet below. During an interview on [DATE] at 4:30 P.M., the dietary manager said staff that cook eggs in the cottages should use a bowl to crack eggs into or crack them directly into the skillet by using the skillet surface for cracking. They should not use the edge of the countertop to crack eggs as the surface was not sanitary. 5. Observation on [DATE] at 2:52 P.M. showed inside the walk-in cooler in the main preparation kitchen, there was a moderate accumulation of fuzzy debris on two fan shrouds that blew in the breeze as the fans were running. During an interview on [DATE] at 4:30 P.M., the dietary manager said staff, usually maintenance staff, cleaned the fan shrouds in the walk-in cooler monthly. He was currently cleaning the fan shrouds until the new maintenance supervisor started in November. 6. Observation on [DATE] at 11:07 A.M. of the main preparation kitchen showed there was a moderate to heavy buildup of fuzzy debris on the large ceiling vent near the metal food preparation counter and positioned over metal storage shelves of cooking equipment. A metal bowl of melons and pineapple sat on the preparation counter underneath the ceiling vent. During an interview on [DATE] at 4:30 P.M., the dietary manager said maintenance or dietary staff should clean the ceiling vents monthly.

Based on interview and record review, the facility failed to provide a resolution regarding the residents' grievances filed in resident council. The resident council members filed grievances/complaints regarding missing items, activities, dietary, and sufficient staffing and did not receive a response from the facility regarding resolution of the grievances. The facility census was 39. 1. Review of the undated facility policy Resident Council showed the following: -This community supports residents' rights to organize and participate in the resident council; -The purpose of resident council is to provide a forum for residents, families, and resident representative to have input in the operation of the community; -Discussion of concerns and suggestions for improvement; -Consensus building and communication between residents and community staff; -Disseminating information and gathering feedback from interested residents; -All residents are eligible to participate in the resident council, the community staff encourages residents who are willing to participate; -The council is encouraged to elect a President or Chair to act as a liaison and facilitate communication between the council and a designated staff person who has been approved by the council. Staff, visitors or other guests may attend resident council meetings if invited by the respective resident group; -Council meetings are scheduled monthly or more frequently if requested by residents. The date, time and location of the meeting are noted in the activities calendar; -A resident council response form will be utilized to track issues and their resolution. The community department related to any issues will be responsible for addressing the item(s) of the concern; -The Quality Assurance and Performance Improvement (QAPI) Committee will review information and feedback from the Elder Council as part of their quality review. Issues documented on council response forms maybe referred to the QAPI Committee, if applicable (i.e., the issue is of serious nature or if there is pattern, etc.) Record review of the facility's Resident Council meeting minutes for Betty's Cottage dated 7/12/18, showed the following : -Activities: Poor system, need more help; -Music therapy needs new songs; -Dietary: There is a lot of breaded food; -Would like more veal parmesan; -Need more nutritious meals; -Dietary need directions and directions detailed; -Peas are in everything; -More fruit, fresh fruits that are in season; -Would like salad before dinner; -Would like fresh tomatoes; -Food is cold sometimes; -Some Certified Nurse Aides (CNAs) don't know how to cook; -CNAs: They are overworked; -Not enough CNAs; -CNAs always sitting at the breakfast bar; -Don't pay the residents any attention; -Would like a longer call cord; -No resident council response forms; -No documentation to show staff followed up on the residents' concerns from the meeting. Record review of the facility's Resident Council meeting minutes for Ella's Cottage dated 7/17/18, showed the following -Activities: Would like to play bingo with other Cottages; -CNAs: Think there should be more people helping; -Some CNAs are mean at times; -No resident council response forms; -No documentation to show staff followed up on the residents' concerns from the meeting. Record review of the facility's Resident Council meeting minutes for Betty's Cottage dated 8/4/18, showed the following: -Activities: They don't like the schedules and the CNAs don't follow it; -Food: Chicken sometimes is hard as a rock, couldn't pick it up with a fork (oriental chicken); -Green beans at every meal; -Food is mushy; -Food isn't up to standards; -Out of wheat bread all the time; -Bowls and plates are chipped; -Silverware looks dirty; -No resident council response forms; -No documentation to show staff followed up on the residents' concerns from the meeting. Record review of the facility's Resident Council meeting minutes for Ella's Cottage dated 8/4/18, showed the following: -Bed time is too early; -CNAs expect them to go to bed too early; -No resident council response forms; -No documentation to show staff followed up on the residents' concerns from the meeting. Record review of the facility's Resident Council meeting minutes for Grace's Cottage dated, 9/7/18, showed the following: -Some items disappeared in my room; -Resident messes up all the decorative pillows; -Beautician isn't all that great. Too much hair spray; -Dietary: Not that tasty; -Could be improved, not just the quality but would like more; -Food isn't equal portions; -No resident council response forms; -No documentation to show staff followed up on the residents' concerns from the meeting. Record review of the facility's Resident Council meeting minutes for Betty's Cottage dated 9/12/18, showed the following: -Overall noise level is high in the kitchen; -Activities: Would like a a movie list; -CNAs: Needs to wash hands properly; -They don't wear gloves when handing food; -Dietary: Not enough food to eat; -No resident council response forms; -No documentation to show staff followed up on the residents' concerns from the meeting. Record review of the facility's Resident Council meeting minutes for Ella's Cottage dated 9/25/18, showed the following: -Need more people at night; -Takes about 30 minutes or longer; -Residents aren't being put first when doing tasks; -Dislikes the bed, been sleeping in the recliner; -No resident council response forms; -No documentation to show staff followed up on the residents' concerns from the meeting. Record review of the facility's Resident Council meeting minutes for Betty's Cottage dated 10/19/18, showed the following: -Yesterday dinner was salty, and couldn't eat. Three residents complained. Residents had to find a substitute for dinner; -Kitchen should taste the food before serving; -CNAs need to dress appropriately for work (seeing their underwear); -Breakfast is served around 8:30 A.M. and residents are having to wait to eat; -The meat doesn't have any flavor; -Vegetables are horrible and being cooked down; -Would like one cook for each cottage; -The meal menu needs to be passed out in a timely fashion so they will know what they will be having. Prefer it to be Saturday morning; -Sometimes the activities aren't being done; -The residents would like to have a exercise video for the exercise groups in the morning; -No resident council response forms; -No documentation to show staff followed up on the residents' concerns from the meeting. Record review of the facility's Resident Council meeting minutes for Grace's Cottage dated 10/22/18, showed the following: -Dietary: Food is mediocre; -CNAs: Sometimes there is too much noise in the kitchen area; -Make a lot of noise while doing the dishes; -No resident council response forms; -No documentation to show staff followed up on the residents' concerns from the meeting. During interview on 10/23/18 at 10:02 A.M. residents at the group meeting said the following: -Five of the seven residents said CNAs were not good to follow-up on grievances; -Resident #8 said there was a resident council, but they do not meet routinely when they do meet; -Resident #28 said they do not have regular meetings unless they have a problem, but it would probably be good to meet monthly to go over things; -Resident #7 said they do not meet regularly. During interview on 10/24/18 at 12:00 P.M. Resident #22 said the following: -The resident council did not get any response back after voicing concerns; -There was never any follow-up; -He/she had asked about activities several times and the lack of and he/she was told by the Activity Director there was only one of him/her; -He/she would like some type of follow-up in the meetings and how the facility was going to address their complaints; -Staff never read the minutes from the previous meeting to see what was taken care of, all he/she ever heard was that there was only one of him/her. During interview on 10/23/18 at 12:15 P.M. the Activity Director said the following: -When certain residents repeated concerns he/she didn't report that to anyone, because it was always the same thing; -The residents will complain about there not being enough staff in resident council meetings, but he/she told the residents that two CNAs worked during the day shift and one CNA on night shift and there was nothing that could be done about that, so he/she didn't tell anyone about that; -Activities were always brought up in the council meetings; -Residents had complained about not having enough staff on evenings and nights during group meeting; -He/she told the residents that there was always just one CNA on nights and on some evenings and that was just the way it was; -He/she did not report the residents' concerns to anyone regarding the complaints of call lights not being answered or not enough staff; -He/she was not aware he/she was to follow up on concerns and grievances from the council meeting or to document. During an interview on 10/29/18 at 3:09 P.M., the social service director said the following: -He/she was not aware of any grievances from group/resident council; -He/she did not receive a copy of the resident council/group meeting minutes and had not received any reports from the activity director regarding resident council/group grievances; -She would expect the activity director to report any missing items reported or any other grievance to her so they could start an investigation and try to find a solution to the problem. During interview on 11/1/18 at 1:29 P.M., the administrator said she would expect to receive a copy of the group minutes and all department heads should be notified with concerns. The minutes should be detailed and identified by which resident said what and who was going to follow up with the concerns.

Based on interview and record review, the facility failed to screen three new employees, (Environmental Service Staff F, Housekeeping Service Staff H and Registered Nurse (RN) G), in a review of nine newly hired employees to determine if any had a Federal indicator with the Nurse Aide Registry that would prohibit employment at the facility. The facility census was 39. 1. Review of the facility's undated policy Screening of Potential Hires for History of Criminal Acts or Abuse for a Valid Licensure showed the following: -In accordance with state and federal laws, all new employees will be checked for criminal background or other reasons that disqualify them from working with elders; -Team members are not allowed to work in elder contact positions (those that provided hands on patient care) until the following record checks have been completed are put into their personal files which included CNA Registry checks. (The policy did not indicate all employees needed to be checked only contact positions) 2. Review of Environmental Service Staff F's employee file showed the following: -Hired on 1/22/18; -No evidence the facility completed the Nurse Aide Registry check upon hire. 3. Review of Housekeeping Service Staff H's employee file showed the following: -Hired on 8/29/18; -No evidence the facility completed the Nurse Aide Registry check upon hire. 4. Review of RN G's employee file showed the following: -Hired on 6/4/18; -No evidence the facility completed the Nurse Aide Registry check upon hire. During interview on 10/25/18 at 1:35 P.M., the Business Office Manager said the following: -She had been the Business Office Manager since (MONTH) (YEAR); -He/she was responsible for completing the background checks on all new employees, which included nurse aide registry checks; -Environmental Service staff, F was hired on 1/22/18 and the Nurse Aide Registry check was not completed upon hire; -Housekeeping Services staff H was hired on 8/29/18 and the Nurse Aide Registry check was not completed upon hire; -He/she did not realize the nurse aide registry checks had to be completed on housekeeping staff; -RN G was hired on 6/4/18 and the Nurse Aide Registry check was not completed upon hire; -He/she was not aware nurse aide registry checks had to be completed on all staff. During interview on 10/25/18 at 12:00 P.M. the administrator said she expected the Business Office Manager to complete the Certified Nurse's Aide Registry checks on all employees upon hire.

Based on observation, interview and record review, the facility failed to provide an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being of each resident, based on the comprehensive assessment, for three residents (Residents #14, #19, and #28) in a review of 16 sampled residents and one additional resident (Resident #22). The facility census was 39. 1. Review of the facility's Activities and Social Services policy, undated, showed the following: -Residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the community; -Residents are encouraged to choose the types of recreational, cultural, and religious activities and social events in which they prefer to participate; -The Interdisciplinary Care Team will evaluate the individual's personal history and preferences, and will consider his/her medical condition and prognosis in identifying relevant recreational and cultural activities; -When the Care Planning Team develops the resident's activity and social care plans, the resident will be given an opportunity to chose when, where, and how he or she will participate in activities and social events. As much as possible, the community will provide activities, social events, and schedules that are compatible with the residents' interests, physical and mental assessment, and overall plan of care; -Residents who wish to meet with or participate in the activities of social, religious, and other community groups, at or away from the community, will be encouraged to do so. As much as possible, the community will help the individual arrange to reach these outside activities, but the community may not necessarily provide the transportation; -Should a resident be considered to lack sufficient decision making capacity, mental incompetence, or physical capacity to participate in Activity and Social Service Programs, the Activities or Social Services Staff will document the reason for any limitations in the resident's medical record (chart). The attending physician may also be asked to document the physical or medical basis for such limitations or restrictions; -Residents are encouraged to participate in community events. However, it is not this community's policy to assign staff members to accompany residents attending community events off premises; -Activities will be scheduled periodically during the day, as well as during evenings, weekends, and holidays. 2. Review of the Long-Term Care Facility Resident Assessment Instrument User's Manual, dated (MONTH) 2013, showed the following: -Most residents capable of communicating can answer questions about what they like; -Obtaining information about preferences directly from the resident, sometimes called hearing the resident's voice, is the most reliable and accurate way of identifying preferences; -If a resident cannot communicate, then family or significant other who knows the resident well may be able to provide useful information about preferences; -Quality of life can be greatly enhanced when care respects a resident's choice regarding anything that is important to the resident; -Interviews allow the resident's voice to be reflected in the care plan; -Activities are a way for individuals to establish meaning in their lives, and the need for enjoyable activities and pastimes does not change on admission to a nursing home; -A lack of opportunity to engage in meaningful and enjoyable activities can result in boredom, depression, and behavior disturbances; -Individuals vary in the activities they prefer, reflecting unique personalities, past interests, perceived environmental constraints, religious and cultural background, and changing physical and mental abilities. 3. Record review of the facility's Resident Council meeting minutes for Betty's Cottage dated, 7/12/18, showed Activities: Poor system, need more help. Record review of the facility's Resident Council meeting minutes for Ella's Cottage dated, 7/17/18, showed Activities: Would like to play bingo with other cottages. Record review of the facility's Resident Council meeting minutes for Betty's Cottage dated, 8/4/18, showed Activities: Residents don't like the schedules and the CNAs don't follow the schedule. Record review of the facility's Resident Council meeting minutes for Betty's Cottage dated, 10/19/18, showed the activities are not always being done. 4. Review of Resident #19's significant change MDS dated [DATE], showed the following: -Cognitively intact; -It was very important to read books, newspapers, or magazines, listen to music keeping up with the news and participating in religious activities or practices; -It was somewhat important doing things with groups of people, participating in favorite activities and spending time outdoors. Review of the resident's care plan last revised on 10/8/18, showed the following: -He/she will participate in activities of choice at least one to two times per week; -He/she was able to move around and about throughout the facility independently; -He/she liked to read the newspaper in the morning; -He/she liked to work with other residents on puzzles; -Invite/encourage my family to attend activities with me in order to support participation; -My favorite activities are putting the community puzzle together, interacting with a few peers, playing games on my tablets, having visits from family, attending music therapy sometimes, some art and crafts; -Remind him/her that he/she may leave activities at any time, and he/she was not required to stay for entire activity. Review of the resident's Daily Participation log for activities dated (MONTH) (YEAR), showed the following: -Family visits: Staff documented participation 10/1/18-10/16/18, and 10/22/18; -Bingo: Staff documented participation 10/5/18 and the remainder of the month showed no documentation; -Games: Staff documented participation on 10/6/18 and the reminder of the month showed no documentation; -TV area: Staff documented participation 10/1/18, 10/2/18 and 10/5/18 and 10/6/18; -Puzzles: Staff documented participation on 10/1/18, 10/2/18 and 10/5/18-10/16/18 (a puzzle was left set up in the dayroom on a table); -Outside: Staff documental participation on 10/7/18. During interview on 10/22/18 at 4:27 P.M., the resident said he/she always enjoyed getting together with his/her friends before he/she came to the facility and enjoyed activities. The facility didn't really do any activities and the activities on the calendar don't take place. He/she got bored. 5. Review of Resident #22's admission MDS dated [DATE], showed the following: -Lifetime occupation: Left blank; -Cognition intact; -Trouble concentrating on things, such as reading the newspaper or watching television two to six days out of 14 days; -Very important to have books, newspapers, and magazines to read; -Very important to keep up on the news, do things with groups of people, do favorite activity and go outside to get fresh air when the weather is good. Review of the resident's bedside Kardex report, undated, showed the following: -Activities - Encourage ongoing, family to attend special events, activities, meals; -I need assistance with ADLs as required during activities; -Introduce me to other residents with similar background, interests and encourage/facilitate interaction; -Provide a program of activities that is of interest and empowers me by encouraging/allowing choice, self-expression and responsibility; -Thank me for attendance at activity functions. Review of the resident's care plan, undated, showed the following: -I can be independent of staff for meeting emotional, intellectual, physical, and social needs; -Encourage ongoing family involvement. Invite my family to attend special events, activities, meals; -Establish and record my prior level of activity involvement and interests by talking with me, my caregivers, and my family on admission and as necessary; -I may need assistance/escort to activity functions; -I need assistance with ADLs as required during activities; -Introduce me to other residents with similar background, interests and encourage/facilitate interaction; -Invite me to scheduled activities; -My preferred activities are socials, parties, putting puzzles together, spending time with other residents in my cottage and I may like to visit other cottages; -Provide a program of activities that is of interest and empowers me by encouraging/allowing choice, self-expression and responsibility; -Provide me with an activities calendar. Notify me of any changes to the calendar of activities; -Provide me with materials for individual activities as desired. I like the following independent activities: reading, putting puzzles together, coloring or drawing, and word search puzzles; -Thank me for attendance at activity functions; -When I choose not to participate in organized activities, I prefer to color, and work on word search puzzles, for social and sensory stimulation. Review of the resident's activity log for the month of (MONTH) (YEAR), showed the following: -Family Visits: Showed no documentation of participation; -Bingo: Staff documented participation 10/5/18 the remainder of the month showed no documentation of participation; -Current Events: Showed no documentation of participation; -Reading: Showed no documentation of participation; -Exercise: Staff documented participation 10/6/18, 10/7/18, 10/8/18, 10/9/18, 10/12/18, 10/13/18, 10/14/18, 10/15/18, 10/16/18 and 10/22/18, the remainder of the month showed no documentation of participation; -1:1 activity: Staff documented participation 10/1/18, 10/2/18, 10/5/18, 10/6/18, 10/7/18, 10/8/18, 10/9/18, 10/10/18, 10/11/18, 10/12/18, 10/13/18, 10/14/18, 10/15/18, 10/16/18 and 10/22/18, the remainder of the month showed no documentation of participation; -Puzzles: Staff documented participation 10/1/18, 10/2/18, 10/5/18, 10/6/18, 10/7/18, 10/8/18, 10/9/18, 10/10/18, 10/11/18, 10/12/18, 10/13/18, 10/14/18, 10/15/18, 10/16/18 and 10/22/18, the remainder of the month showed no documentation of participation; -TV Area: Staff documented participation 10/2/18, 10/3/18, 10/4/18, 10/5/18, 10/6/18, 10/7/18, 10/8/18, 10/9/18, 10/10/18, 10/11/18, 10/12/18, 10/13/18, 10/14/18, 10/15/18, 10/16/18 and 10/22/18, the remainder of the month showed no documentation of participation; -Music therapy: Staff documented participation 10/12/18 and the remainder of the month showed no documentation of participation; -Outside: Staff documented participation 10/5/18 and the remainder of the month showed no documentation of participation. During interview on 10/24/18 at 12:00 P.M., the resident said the following: -He/she had brought up concerns with activities not being done in resident council many times, and there had been no follow-up; -He/she was told by the Activity Director that he/she was only one person; -He/she was told that the certified nurse assistants (CNA)s were responsible for the activities; -The CNAs are too busy with cares to do activities; -On Saturday and Sunday nothing was organized, the residents just watch television or turn on the radio; -The residents have to try and create something to do; -I have felt very alone, I can't stand to sit in my room alone, I have to be around people. 6. Review of Resident #28's admission MDS dated [DATE], showed the following: -Cognitively intact; -Understands others and makes self understood -Activities: Very important to read, listen to music, keep up on the news, go outside, be involved in religion, and do things with groups of people; -Very important to participate in activities. Review of the resident's bedside Kardex report, undated, showed the following: -Activities-I prefer to socialize with staff, family, visitors and other residents; -I prefer socials, parties, reminiscing groups, small simple activities, exercise class, looking at magazines, kids, watching TV shows and movies; -Provide a program of activities that is of interest and empowers me by encouraging/allowing choice, self expression, and responsibility. Review of the resident's care plan, dated 10/31/18, showed the following: -I require ADL help as needed; -I require extensive ADL help with bed mobility, transfers, dressing, bathing and toileting; -I can be independent of staff for meeting emotional, intellectual, physical, and social needs; -Encourage ongoing family involvement. Invite my family to attend special events, activities, meals; -Introduce me to residents with similar backgrounds and interest; -Invite me to scheduled activities; -My preferred activities are socials, parties, reminiscing in groups. Review of the resident's activity log for the month of (MONTH) (YEAR), showed the following: -Family Visits: staff documented participation 10/2/18, 10/11/18, 10/19/18, and 10/20/18; -Bingo: Staff documented participation 10/10/18 and 10/19/18 the remainder of the month showed no documentation of participation; -Current Events: staff documented 10/10/18 and 10/20/18 the remainder of the month showed no documentation of participation; -Reading: showed no documentation of participation; -Exercise: showed no documentation of participation; -Bible/mass: showed no documentation of participation; -Current events: showed no documentation of participation; -Food: showed staff documented participation for 10/7/18 the remainder of the month showed no documentation of participation; -1:1 activity: staff documented participation 10/1/18 through 10/23/18; -Parties: showed no documentation of participation; -Puzzles: staff documented participation 10/1/18, 10/2/18, 10/5/18, 10/6/18, 10/7/18, 10/8/18, 10/9/18, 10/10/18, 10/11/18, 10/12/18, 10/13/18, 10/14/18, 10/15/18, 10/16/18 and 10/22/18, the remainder of the month showed no documentation of participation; -TV Area: staff documented participation 10/1/18 through 10/23/18; -Music therapy: staff documented participation 10/12/18 the remainder of the month showed no documentation of participation; -Outside: showed no documentation of participation; -Pet therapy: showed no documentation of participation; -Reminiscing: showed no documentation of participation. Review of the facility activity calendar for Monday 10/22/18, showed activities of morning-chair exercise, afternoon-parachute, evening-book club. Observation on 10/22/18 from 1:30 P.M. to 5:50 P.M., in Ella's Cottage showed the staff did not conduct the parachute activity as scheduled on the activity calendar. During an interview on 10/22/18 at 5:00 P.M., the resident said the following: -The facility doesn't have any activities; -They have a calendar that says they are supposed to have activities but they rarely do them; -He/she was able to get bingo started once a week on Fridays; -He/she enjoys bingo but wished there were more activities; -The calendar shows they are supposed to do a parachute but he/she didn't know what that was; -The staff hadn't offered a parachute activity and supper was getting ready to be served so the activity wouldn't get done; -He/she was moving to a home closer to family that offered more activities; -One of the main reasons he/she was leaving the facility was due to not getting socialization and scheduled activities. 7. Review of Resident # 14's annual MDS, dated [DATE], showed the following: -Cognitively intact; -It was very important to read books, newspapers, or magazines, listen to music, being around animals such as pets, doing things with groups of people and spending time outdoors; -Somewhat important participating in favorite activities. Review of the resident's care plan last revised on 8/15/18, showed the following: -He/she needed assistance in meeting intellectual and social needs; -He/she wished to attend and or participate in my choice of activities 3-5 times per week to help maintain my cognitive stimulation. This will also keep me socially involved; -Please ask him/her if the activities going on were something he/she would like to do, and what options are available for transportation if needed, then set up appropriately; -If he/she is in his/her room with his/her headphones on and there is an activity, especially one outside, please come in and ask if he/she wished to go out with them; -Introduce him/her to new people with similar interests; -Please also provide an activity schedule and remind me before hand to see if I wish to participate as well as whom else is joining in. Review of the resident's Daily Participation Log for activities dated (MONTH) (YEAR), showed the following: -Family visits: Staff documented participation 10/1/18 -10/16/18, 10/21/18 and 10/22/18; -Puzzles: Staff documented participation 10/1/18-10/16/18 and 10/22/18 (a puzzle was set up in the dayroom); -Exercise: Staff documented participation 10/22/18; -Music therapy: Staff documented participation 10/12/18; -Outside: Staff documented participation 10/1/18, 10/2/18, 10/5/18-10/7/18 and 10/22/18. During interview on 10/22/18 at 4:07 P.M., the resident said the following: -The facility had very few activities and the activities on the calendar did not get done; -He/she liked activities but the facility did not offer much to do; -He/she had told the Activity Director that the activities did not get done and he/she said that there was only one of him/her and the Certified Nurse Assistant (CNA)s were responsible for providing the activities; -The CNAs are busy taking care of the residents and the activities don't get done. 8. Observation on 10/22/18 at 2:39 P.M., in Kris' Cottage showed various residents sat in the dayroom, no activity took place. Observation on 10/23/18 at 9:15 A.M., in Kris' Cottage showed residents sat in different areas of the dayroom, no activity took place. Observation on 10/23/18 at 4:03 P.M., in Kris' Cottage showed various residents sat in the dayroom, the television was turned on but no other activity took place. Observation on 10/24/18 at 10:23 A.M., in Kris' Cottage showed the residents sat in the dayroom and no activity took place. Observation on 10/24/18 at 11:11 A.M., in Kris' Cottage showed various residents sat in the dayroom and no activity took place. 9. Interview with residents at the group meeting on 10/23/18 at 10:02 A.M., showed the following: -Six of the seven residents said there were no routine activities; -Resident #28 said he/she asked if he/she could play bingo so the residents meet in his/her cottage and he/she does the bingo. He/she got bingo started. The residents were told the activities would include musical outings, bands and van rides and he/she has been at the facility around a year and that hasn't occurred. A lot of time the activity calendar is not followed. The residents have to find things to do among themselves; -All seven of the residents agree there were no activities on the weekend; -Resident #19 said he/she gets bored with nothing to do; -Resident #8 said nothing was ever really scheduled routinely for activities. 10. During an interview on 10/23/18 at 12:30 P.M., CNA M said the following: -He/she was in charge of all cares for the residents in the building including activities; -He/she was not always able to get activities completed because the residents' personal cares came first; -He/she did not know what a parachute activity was or how to even conduct an activity with a parachute; -He/she worked in all the cottages at one time or another. During an interview on 10/23/18 at 12:30 P.M., CNA N said the following: -He/she was in charge of all cares for the residents in the building including activities; -He/she was not able to get activities completed because he/she had to provide personal care for the residents, clean, and cook; -He/she was not aware of what a parachute was or how to even conduct an activity with a parachute; -He/she worked in all the cottages. During interview on 10/23/18 at 4:00 P.M., CNA E said activities were put on the back burner. The residents voiced concern with the activities not getting done. On Sunday there was to be a Halloween activity and there were no supplies available, as the supplies were locked up in the office. During interview on 10/23/18 at 5:36 P.M., CNA C said he/she was not able to complete routine activities with the residents as he/she was busy providing personal cares, cooking, cleaning and doing laundry. During interview on 10/24/18 at 10:58 A.M., CNA D said the following: -He/she had worked the day shift for the past two months; -Activities were hard to get done as the staff was busy providing personal cares, cooking and cleaning for the residents; -The CNAs were to follow the calendar but for the last two months he/she has worked the activities did not get done. During interview on 10/24/18 at 11:45 A.M., Licensed Practical Nurse (LPN) A said the CNAs were responsible for doing the activities. The CNAs did not get the activities done. There was not have enough staff to even get all of the resident cares completed. There were activities scheduled and there would be no supplies. During interview on 10/23/18 at 12:15 P.M., the Activity Director said the following: -At resident council, activities were always brought up as a concern. The residents said there were not enough activities; -Keeping up with the activities was overwhelming; -The CNAs were responsible for conducting activities in the cottages they were working per the calendar; -She stopped putting times on the activities because the CNAs were supposed to determine a time and inform the elders in their home; -The facility only had one parachute and she wasn't sure which cottage was supposed to do the parachute or if any of them did the parachute activity as scheduled per the calendar; -The facility had difficulty getting the CNAs to conduct the activities even though it was their responsibility; -The residents had voiced concerns about the activities not being offered as scheduled; -The TV activity noted on the calendar meant the TV was turned on in the main commons area. Residents watched TV as they desired. It was an independent activity. During interview on 11/1/18 at 1:29 P.M., the administrator said she would expect activities to be offered and completed as scheduled and per the residents' preferences. She expected the staff to document if an activity was completed or if there was a reason an activity was not completed.

Based on interview and record review, the facility failed to ensure sufficient staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents, based on resident assessments and plans of care when there was insufficient staff to answer call lights in a timely manner for three residents (Resident #36, #28, and #142), in a review of 16 sampled residents. The facility census was 39. 1. Record review of the facility Staffing policy, undated, showed the following: -Our community provides adequate staffing to meet needed care and services for our resident population; -Our community maintains adequate staffing at all times to ensure that our residents' needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. There is a minimum of one Certified Nurse Assistant (CNA) in each cottage at all times. There is a minimum of one licensed nurse for each pair of cottages at all times. During times of day when most residents are up (7 AM - 11 PM) a second CNA is staffed in each cottage; -A Registered Nurse (RN) will be on duty a minimum of eight hours a day (while residents are generally awake (7 AM - 11 PM) per state and federal regulations; -Other support services (e.g., dietary, activities/recreational, social, therapy, environmental, etc.) are adequately staffed to ensure that resident needs are met. 2. Review of the facility undated call light policy showed the following: -For the comfort and safety of the residents it is imperative that call lights be answered promptly; -Call lights are to be answered as soon as possible but no longer than five minutes for bathroom call lights and 15 minutes for room call lights; -Call light logs will be monitored by the Director of Nurses (DON) and others he/she may designate for patterns of non-compliance. 3. Interview with the residents at the group meeting on 10/23/18 at 10:02 A.M., showed the following: -Resident #8 said on Sunday not as many staff were around to get him/her to bed and up for meals as he/she has a amputated leg. At times there was only one CNA. He/she had to wait up to an hour for assistance; -Resident #28 said he/she had to wait up to 30 minutes for the call light to be answered. He/she takes two water pills a day. He/she had to wait and he/she had an accident, like a two year old it made me feel terrible; -Resident #35 said he/she had to wait 20 minutes for the call light to be answered and had an accident; -Resident #9 said he/she had to wait 40 minutes for assistance to go to the bathroom and it makes him/her feel very uncomfortable. 4. Record review of the facility's Resident Council meeting minutes for Betty's Cottage dated 7/12/18, showed the CNAs are overworked, not enough CNAs, and don't pay the residents any attention. Record review of the facility's Resident Council meeting minutes for Ella's Cottage dated 7/17/18, showed there should be more staff helping. Record review of the facility's Resident Council meeting minutes for Ella's Cottage dated, 9/25/18, showed need more staff at night, takes about 30 minutes or longer, and residents aren't being put first when doing tasks. Record review of the facility's Resident Council meeting minutes for Betty's Cottage dated 10/19/18, showed staff disappear and take breaks and the residents have to wait. 5. Review Resident #36's care plan with effective date 10/1/18, showed the following: -Required extensive assistance of staff for bathing, dressing, and personal hygiene/oral care; -Required limited assistance for bed mobility, toileting, and transfers; -Require assistance of one staff to walk; -Use a motorized wheelchair for locomotion when tired or feel weak; -Bowel incontinence; -Observe pattern of incontinence, and initiate toileting schedule if indicated. Review of the resident's Kardex Report, dated 10/1/18, showed the following: -Anticipate and meet my needs; -I need prompt response to all requests for assistance; -I require extensive assistance by one staff with bathing/showering, dressing, and personal hygiene/oral care; -I require limited assistance by one staff for bed mobility, transfers, and toileting; -I am dependent for eating. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/8/18, showed the following: -Brief Interview for Mental Status (BIMs) of 14 which indicated intact cognition; -Able to make self-understood -Understands others; -Required supervision with limited assistance of one staff for bed mobility, and transfers; -Required limited assistance of one staff for dressing, toilet use, and personal hygiene; -Impaired upper and lower extremity on both sides; -Used a wheelchair; -Continent of urine; -Occasionally incontinent of bowel; -[DIAGNOSES REDACTED]. Review of the call light log provided by the facility showed the following: -On 10/3/18 at 8:08 A.M., the resident's call light was on a total of one hour 17 minutes and 56 seconds; -On 10/5/18 at 10:02 P.M., the resident's call light was on a total of one hour five minutes and 28 seconds; -On 10/7/18 at 12:58 P.M., the resident's call light was on a total of 38 minutes and 42 seconds; -On 10/10/18 at 4:57 P.M., the resident's call light was on a total of 53 minutes and 40 seconds; -On 10/15/18 at 5:06 P.M., the resident's call light was on a total of 44 minutes and 40 seconds. During an interview on 10/24/18 at 10:44 A.M., the resident said he/she has waited at least 20 minutes for his/her call light to be answered and there have been times that he/she has waited an hour or more for light to be answered. 6. Review of Resident #28's quarterly MDS dated [DATE], showed the following: -Cognitively intact; -Understands others and makes self understood; -Required extensive assistance of one staff for bed mobility and bathing; -Required limited assistance of one staff for transfers and dressing; -Required supervision of one staff for toileting and personal hygiene. Review of the resident's Kardex report undated showed the following: -Anticipate and meet my needs; -Make sure the call light is within reach and encourage me to use it for assistance as needed; -I require extensive assistance of staff with bed mobility, transfers, dressing, bathing, and toileting. Review of the resident's call light log provided by the facility showed the following: -On 10/5/18 at 12:23 A.M., the resident's call light was on a total of one hour 27 minutes and 57 seconds; -On 10/7/18 at 4:04 A.M., the resident's call light was on a total of six hours, twelve minutes and 11 seconds; -On 10/14/18 at 6:23 P.M., the resident's call light was on a total of 14 minutes and 13 seconds; -On 10/20/18 at 4:12 A.M., the resident's call light was on a total of 42 minutes and 30 seconds; -On 10/22/18 at 4:11 A.M., the resident's call light was on a total of 56 minutes and 53 seconds; -On 10/22/18 at 7:42 P.M., the resident's call light was on a total of 15 minutes and 40 seconds. During an interview on 10/22/18 at 5:00 P.M. the resident said the following: -He/she had to wait over 30 minutes at times to get staff to answer the call light and take him/her to the bathroom; -He/she had urinated in his/her pants before because staff did not get to him/her; -He/she had reported his/her concern to all staff including the administrator about call light not being answered in a timely manner; -He/she felt like a two year old and made him/her feel terrible when he/she urinated in his/her clothes. Review of the resident's care plan, with a date of 10/31/18, showed the following: -I require ADL help as needed; -I require extensive ADL help with bed mobility, transfers, dressing, bathing and toileting. 7. Review of Resident #124's care plan, with a date of 10/17/18, showed the following: -I require ADL assistance; -I require extensive ADL help with bed mobility, transfers, dressing, bathing and toileting. Review of Resident #124's admission MDS dated [DATE], showed the following: -Cognitively intact; -Understands others and makes self understood; -Required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and bathing. Review of the resident's call light log provided by the facility showed the following: -On 10/17/18 at 12:31 P.M., the resident's call light was on a total of one hour seven minutes and 34 seconds; -On 10/17/18 at 12:57 P.M., the resident's call light was on a total of one hour, ten minutes and 57 seconds; -On 10/19/18 at 1:17 A.M., the resident's call light was on a total of one hour, 43 minutes and 20 seconds; -On 10/21/18 at 7:54 P.M., the resident's call light was on a total of 31 minutes and 52 seconds; -On 10/22/18 at 5:55 P.M., the resident's call light was on a total of one hour, 39 minutes and 20 seconds; -On 10/23/18 at 7:49 A.M., the resident's call light was on a total of 16 minutes and 10 seconds. During an interview on 10/23/18 at 11:02 A.M. the resident said the following: -The staff don't answer the call lights in a timely manner; -When he/she puts on his/her call light, it is for a reason such as needing to go to the bathroom; -He/she doesn't just put on his/her call light to be handed an item he/she cannot reach, he/she waits till staff come to take him/her to bathroom and asks for everything at once, because he/she knows they are busy and don't have enough staff; -He/she has had to wait 25 minutes or longer to have his/her call light answered; -He/she had accidents in his/her pants, because staff didn't answer his/her call light promptly; -It made him/her feel like a child to urinate on him/herself; -He/she and his/her family member had reported the issue to the administrator and owners of the home, but did not feel like they were getting any response to fix the issue. During interview on 10/23/18 at 11:02 A.M. the resident's family member said the following: -He/she stays with the resident frequently and has seen staff not answer the call light for over 25 minutes; -He/she would leave the resident's room to find staff and had found staff eating and talking with other staff or on the computer; -He/she felt staff knew the call light had been on, because as soon as he/she would leave the room to check to see if staff were around and before he/she would say anything, staff would stop what they were doing when they saw him/her and go to the room to assist the resident; -Their biggest complaint is staff not answering the call light and not enough staff to care for the resident when needed. 7. During an interview on 10/23/18 at 12:30 P.M. CNA M said the following: -He/she was in charge of all cares for the residents; -He/she was not always able to get to the call lights as quickly as needed due to helping other residents; -He/she had to work by him/herself during the evening shift at times and it made it difficult to respond to call lights when helping other residents or cooking food. During an interview on 10/23/18 at 12:30 P.M. CNA N said the following: -He/she was in charge of all cares for the residents including cooking, cleaning, and laundry; -He/she was not always able to get to the residents call lights in a timely manner, because he/she had to provide personal care for all the residents, clean, do laundry and cook. During an interview on 10/23/18 at 6:31 P.M. CNA O said the following: -He/she worked evenings and nights; -He/she was responsible for resident care, cleaning, cooking, and laundry; -There were times he/she was the only staff member working in the evenings; -There was always just one CNA on night shift; -There were times it would take longer than 15 minutes to get to a resident's call light if he/she was in the middle of toileting or providing care for another resident. During an interview on 10/23/18 at 12:09 P.M. the activities director said the following: -Residents had complained about not having enough staff on evenings and nights during group meeting; -He/she told the residents there was always just one CNA on nights and on some evenings and that was just the way it was; -He/she did not report the residents' concerns to anyone regarding the complaints of call lights night being answered or not enough staff. During an interview on 10/29/18 at 3:09 P.M. the social service director said the following:-He/she received grievances from residents in the past regarding call lights; -He/she was not aware of any grievances from group regarding call lights; -He/she notified the administrator of call light and all grievances and they tried to come up with a solutions immediately. During an interview on 10/23/18 at 6:58 P.M. the Director of Nursing said the following: -She expected call lights to be answered in five to seven minutes; -She was aware residents had voiced concern regarding call lights; -Night shift only had one CNA and if a resident fell or needed toileted then there wasn't enough staff to answer the call lights; -Evening shift only had one CNA at times, if it was meal time there wouldn't be enough staff to answer call lights; -If any building had one staff and required two person assistance then there wasn't enough staff to provide cares; -The facility provided care for residents that required two staff assistance; -One staff per building was not enough staff when residents needed cares provided for them. During an interview on 11/1/18 at 1:29 P.M. the administrator said the following: -She expected staff to answer call lights within ten minutes; -The facility identified call lights being answered in a timely manner as an issue; -The facility was having weekly meetings regarding call lights complaints; -She was not aware there was an overall resident concern regarding call lights; -She felt the facility had enough staff to provide cares for the residents.

Based on interview and record review the facility failed to consistently implement, evaluate, and modify interventions as necessary to address prevention of falls for five (Resident #1, #2, #3, #7, and #9) of nine sampled residents. Resident #2 sustained a fractured zygomatic arch (facial bone fracture) after a fall and required evaluation at the hospital emergency department The facility census was 28. 1. Record review of the facility's recording and reporting procedure (no date), showed: -Record fall risk assessment findings and specific interventions including instructions used to prevent falls in the nurse's notes, electronic health record and care plan; -Report to staff specific risks to the resident's safety and measures taken to minimize risks; -Document what occurred including the description of the falls given by the resident or a witness; -Include baseline assessment injuries, treatments given, follow up care, and additional safety precautions taken after the fall. -Staff should reinforce identified risks with the resident or review needed safety measures with the family; -The resident is found after suffering a fall; -Staff should call for assistance; -Staff should assess the resident for injuries; -Staff should notify the physician; -Staff should follow the reporting policy; -Determine if the fall could have been prevented; -Reinforce the identified risks with the resident and the measures which were recommended to prevent the recurrent falls; -Monitor the resident closely for injury. 2. Record review of Resident #2's Admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 7/7/17 showed: -The resident required extensive assistance of one staff for transfers, personal hygiene, bathing, and toileting; -The resident ambulated with the assistance of one staff only once or twice during the assessment period; -The resident's balance was not steady and he/she required human assistance to stabilize; -The resident fell prior to admission and had two or more falls after admission without injury. Record review of the resident's nurse's note dated 7/5/17 at 6:45 P.M. showed: - The resident was found lying on the floor on his/her stomach; -The staff noted redness on the resident's left knee. Record review showed no further documentation regarding the resident's fall and no documentation a fall assessment had been completed. Further review showed no documentation fall interventions had been put in place. Record review of the resident's nurse's note dated 7/9/17 at 10:30 P.M. showed: -Staff found the resident on the floor; -The resident made staff aware he/she was okay; - An assessment was done by the nurse and the witness; -No areas noted at the time of the fall. Record review showed no further documentation regarding the resident's fall and no documentation a fall assessment had been completed. Further review showed no documentation fall interventions had been put in place. Record review of the resident's nurse's note dated 7/14/17 at 10:00 A.M. showed: - The resident was found on the floor next to his/her bed; -The resident was lying on his/her left side with his/her head was under the bed; -The bed was in low position; -The resident had an abrasion to the right forehead. Record review showed no further documentation regarding the resident's fall. Record review of the resident's care plan dated 7/17/17 showed: -The resident had an actual fall with minor injury, continue the interventions on the at risk plan (care plan); -Vital signs weekly; - The resident was at high risk for falls related to the resident's [DIAGNOSES REDACTED]. - The resident will be free of falls, free of minor injury and will not sustain serious injury through 7/20/17; - Staff should anticipate and meet the resident's needs; - Physical Therapy was to evaluate and treat the resident as ordered or as needed (no documentation a therapy evaluation had been completed). Record review showed no documentation a fall assessment had been completed and documentation of a fall risk plan. Record review of the resident's nurse's note dated 7/25/17 at 2:16 P.M. showed: -The resident was sent to the emergency room for further work-up; -The resident displayed epistaxis (nose bleed), three episodes, after falling; -The resident sustained [REDACTED]. Record review of the resident's nurse's note dated 7/25/17 at 4:06 PM showed: -The resident was at the hospital following a fall earlier today; -The emergency room nurse called to update facility staff regarding the resident's condition; -The nurse reported the resident had an eye socket fracture. Review of the resident's transfer orders from an area hospital dated 7/25/17 showed the resident's discharge [DIAGNOSES REDACTED]. Record review showed no further documentation regarding the resident's fall and no documentation a fall assessment had been completed. Further review showed no documentation additional fall interventions had been put in place. Record review of the resident's physician's orders [REDACTED]. During an interview on 7/28/17 at 1:35 P.M., Certified Nurse Aide (CNA) B said: -The resident uses a wheel chair; -If the resident needs to toilet, he/she will try to get up; -There has been no change to the resident's care since he/she came back from the hospital with a fractured eye socket; -The CNA's get information from the nurse in report regarding the resident's needs. During an interview on 7/14/17 at 10:00 A.M., Licensed Practical Nurse (LPN) C said: -The resident has Parkinson's disease; -The resident needs help but doesn't ask; -The resident is alert but makes poor decisions; -When a resident falls the staff should get the nurse; -The nurse should assess the resident; -The nurse should notify the resident's physician and family; -The resident should be sent to the hospital if the resident had a head injury, and then follow up is done for 72 hours. During an interview on 7/28/17 at 12:10 A.M., Registered Nurse (RN) A said: -The resident tried to stand up in the shower and fell ; -The resident has Parkinson's disease; -The resident may not use the call light; -The resident moves around in bed and falls; -The resident was sent to the emergency room . During an interview on 7/28/17 at 1:45 P.M. and 8/10/17 at 2:15 PM. Director of Nurses (DON) F said: -The resident fell while two staff was in the shower with the resident; -The resident tried to stand up and the floor was wet; -The resident hit his/her head; -The resident was sent to the emergency room . 3. Record review of the Resident #9's care plan dated 6/15/17 showed: -The resident required the assistance of a manual lift and two staff for transfers; -The resident required the assistance of one staff for dressing; -The resident required the assistance of one staff for toileting; -The resident required the assistance of one staff and the wheel chair for locomotion; - Falls were not addressed. Record review of the resident's nurse's note dated 6/17/17 at 7:08 PM showed: -Staff heard yelling from the resident's room; -Staff found the resident lying on the face down on the floor; -The resident's arms and legs were extended and the wheel chair was sitting upright at the resident's feet; -The resident was assessed and noted to have a four centimeter (cm.) hematoma (pooling of blood) to the left side of the head above the left eye. Record review of the resident's nurse's note dated 6/18/17 showed: -The resident remains on follow up for a fall which occurred on 6/17/17; -The dressing to the wound on the resident's head was dry and intact. Record review of the resident's nurse's note dated 6/20/17 showed: -The resident was found on the floor next to the bed on fall mat; -The bed was in low position; -The resident was found lying on his/her left side with his/her feet under the bed; -Multiple areas of discoloration were noted due to previous falls; -The resident was transported to the emergency department. Record review of the resident's 5 day MDS dated [DATE], showed: -The resident was admitted [DATE]; -The resident had long and short term memory impairment; -The resident required extensive assistance of two staff for transfers, dressing, and toileting; -The resident's balance is not steady and the resident requires human intervention to stabilize; -The resident fell prior to admission to the facility and had two or more falls after admission to the facility with out injuries; -The resident's [DIAGNOSES REDACTED]. Record review showed no documentation of a fall assessment and the care plan was not updated to include the falls on 6/17/17 and 6/20/17. During an interview on 7/14/17 at 4:05 P.M., DON E said: -The resident fell the second day he/she was at the facility; -The resident had a hematoma above his/her eye, and bruising under both eyes. 4. Record review of Resident #3's 14 day MDS dated [DATE], showed: -The resident requires extensive assistance of two staff for transfers, personal hygiene, and toileting; -The resident's balance is not steady; the resident requires human assistance to stabilize; -The resident had impaired range of motion on one side of his/her upper and lower extremities; -Mobility devices included a wheelchair and walker; -The resident has had no falls since admission to the facility. Record review of the resident's care plan dated 5/17/17 showed: -The resident had limited physical mobility; -The resident required extensive assistance of one staff for locomotion using a tilt/lift wheelchair. Record review of the resident's nurse's note dated 7/7/17 at 7:11 A.M. showed: -The resident was found on the floor beside his/her bed; -The resident made staff aware that he/she had pain to the top left side of his/her head; -There was no raised area or bleeding noted; -There was no limitation of movement. Record review showed no documentation a fall assessment had been completed. Record review showed no documentation the resident's care plan had been updated regarding the resident's fall on 7/7/17. Further review showed no documentation fall interventions had been put in place. Record review of the resident's quarterly MDS dated [DATE] showed: -The resident was cognitively intact; -The resident requires extensive assistance of two staff for personal hygiene, and toileting; -The resident's balance is not steady; the resident requires human assistance to stabilize; -The resident has had no falls since admission to the facility (the resident fell on [DATE]). Record review of the resident's POS dated 7/28/17 showed the resident's [DIAGNOSES REDACTED]. During an interview on 7/28/17 at 11:00 A.M., LPN D said: -The resident fell out of bed and hit his head; -The resident had no injury; -When a resident falls the staff assist them up after they are assessed; -The physician is contacted; -The resident's vital signs are checked every 15 minutes. 5. Record review of Resident #7's admission MDS dated [DATE] showed: -The resident was cognitively intact. -The resident requires limited assistance of one staff for dressing and toileting. -The resident had no balance problem; -The resident had falls prior to admission. Record review of the resident's care plan dated 7/1/17 showed falls were not addressed. Record review of the resident's nurse's note dated 7/12/17 at 7:13 P.M. showed: -The resident was putting on his/her pajamas beside the bed and lost his/her balance; -The resident said he/she fell on his/her knees, elbows, and buttocks; -The resident was lying on the floor on his/her back by the side of the bed; -The resident said he/she did not hit /his/her head; -There were no apparent injuries. Record review of the resident's nurse's note dated 7/12/17 at 8:20 P.M. showed: -The resident fell today; -The resident had no apparent injuries. Record review of the resident's Move in Record dated 7/14/17 showed the resident's [DIAGNOSES REDACTED]. Record review showed no documentation a fall assessment had been completed or the care plan had been updated with the fall. During interview on 7/14/17 at 10:45 A.M., the resident said he/she had fallen, he/she doesn't know why she/he falls. 6. Record review of Resident #1's admission MDS dated [DATE] showed: -The resident was severely cognitively impaired; -The resident required limited assistance of one staff for transfers, dressing, ambulation, and toileting; -The resident's balance was not steady, but the resident was able to stabilize without assistance; -The resident had falls prior to admission and fell two or more times after admission with out injury. Record review of the resident's care plan dated 5/10/17 showed: -The resident is at high risk for falls. -The resident will be free of falls. -The staff should anticipate the resident's needs. -The staff should be sure the resident's call light is within reach (the resident had severely impaired cognition); -The resident has had an actual fall; -The resident will resume usual activities without further incident; -The staff should continue interventions on the at risk care plan; -The staff should provide activities that promote exercise and strength building where possible. Record review showed no documentation a fall assessment had been completed and no documentation showing interventions on an at risk care plan (care plan). Record review of the resident's nurse's note dated 6/30/17 at 10:41 A.M. showed the resident was on follow up for a fall she had on Tuesday. Record review showed no other documentation regarding the resident's fall and no documentation the resident's care plan was updated with interventions following this fall. Record review of the resident's nurse's note dated 7/20/17 at 2:21 P.M. showed: -The resident was found on the floor just inside the door of his/her room; -The resident was lying on his/her back; -The resident said he/she did not hit his/her head. Record review of the resident's nurse's note dated 7/20/17 at 9:54 PM showed the resident remains on follow up for fall with no apparent injury. Record review showed no other documentation regarding the resident's fall and no documentation the resident's care plan was updated with interventions following this fall. Record review of the resident's physician order [REDACTED]. During an interview on 7/28/17 at 1:45 P.M., DON F said: -The fall assessments are done on Point Click Care (electronic medical record system); -The staff should update the resident's care plan; -The resident's care plan will filter any new tasks, such as visual check every one hour to Point of Care which the staff can view on an I Phone. During an interview on 7/28/17 at 1:45 P.M. and 8/10/17 at 2:15 PM., DON F said: -The facility could not complete fall assessments on the residents as the Point Click Care was not set up for fall assessments; -There were no fall assessments completed on the residents; -There was no root cause analysis done after each resident's fall; -The fall risk care plan for each resident is the regular care plan that states the resident is at high risk for falls; -The interventions for fall prevention that staff were to utilize would be included in resident care plans; -The facility did not update the residents' care plans with interventions after each fall; -There was no fall program. During an interview on 8/7/17 at 2:30 P.M., the administrator said: -The facility did not have a fall prevention program in place; -Staff should update the resident's care plan with an intervention to prevent another fall. -There is no fall program. MO# 9