Every finding on record at Country View Nursing

Based on observation, interview, and record review, the facility failed to ensure a safe environment free of fall hazards for three residents (Residents #2, #1 and #3), in a review of six sampled residents, when the facility failed to repair a broken toilet seat and secure the toilet armrest frame for over two weeks in their shared bathroom. Residents #2 and #1 fell as a result of the broken toilet seat. The facility census was 37.Review of the facility policy, Falls-Clinical Protocol, dated September 2012, showed the following:-As a part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors of subsequent falling;-The staff will document risk factors for falling in the resident's record and discuss the resident's falls risk;-Risk factors for subsequent falls include lightheadedness, or dizziness, multiple medications, musculoskeletal abnormalities, gait an balance disorders, cognitive impairment, weakness, environmental hazards, confusion, and visual impairment-In addition, the nurse shall assess and document/report precipitating factors, details on how the fall occurred;-For anyone who has fallen, staff will attempt to define possible causes within 24 hours of the fall;-Causes refer to factors that are associated with or that directly result in a fall; for example, a balance problem caused by an old or recent stroke;-Often, multiple factors in varying degrees contribute to falling problem. 1. Review of a plumbing quote, dated 4/15/26, showed 10 toilet seat bolts needed replaced. During an interview on 5/21/26 at 11:30 A.M., the Administrator said between 4/03/26 and 4/15/26, the facility had an issue with toilet seat bolts breaking and continued to have a problem. The bolts were plastic and were constantly breaking. 2. Review of Resident #2's face sheet showed the resident's diagnoses included legal blindness, muscle weakness, dizziness and giddiness, and repeated falls. Review of the resident's care plan, dated 05/06/26, showed the following:-The resident had impaired visual function related to blindness and glaucoma;-The resident was at risk of falls related to history of falls and other disease processes;-The resident had limited physical mobility and required assistance of one staff for ambulation due to blindness;-The resident required one staff to assist with toileting. Review of the facility's maintenance log, dated 5/12/26, showed the following:-The toilet seat in the resident's room was missing a bolt; -The section for the date it was repaired was left blank. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 5/15/26, showed the following:-The resident's vision was severely impaired. The resident had no vision or only saw light colors or shapes; his/her eyes did not appear to follow objects;-Cognitively intact;-The resident walked with a walker;-Required partial to moderate assistance with toilet transfers;-Once standing, the resident required supervision or touch assistance when walking 10 feet. Review of the resident's event report, dated 5/20/26 at 4:20 A.M., showed the following:-The resident was on his/her knees in his/her bathroom. He/She had an abrasion to his/her right knee. The resident said he/she was trying to get off the toilet when he/she fell;-Predisposing environmental factors: other;-Predisposing physiological factors: visual impairment;-The resident said the toilet seat needed to be replaced due to it being too high. During an interview on 5/21/26 at 9:30 A.M., the resident said the following:-The toilet seat in his/her room was broken, and the armrests on each side of the toilet were loose and moved when he/she tried to sit down or get up off of the toilet; -The toilet had been broken for a couple weeks;-He/She fell yesterday morning because the toilet seat was loose and broken. He/She tried to get up and the toilet seat moved. He/She fell to the floor. His/Her right knee was sore;-He/She was blind and the issues with the toilet made him/her afraid to use the bathroom in his/her room;-The staff were aware of the issues with the toilet, but he/she was not sure why they had not repaired the toilet. Observation on 5/21/26 at 9:35 A.M., in resident's bathroom showed the toilet seat was missing a bolt and was not secured to the toilet. The toilet armrest frame was loose and not secured in place. There was no portable commode available in the bathroom or in the resident's room. During an interview on 5/21/26 at 12:25 P.M., Licensed Practical Nurse (LPN) E said the following:-On 5/20/26, the previous nurse told him/her during shift-to-shift report the resident fell off the toilet; -The direct care staff said it was because the resident's toilet seat was loose and broken;-He/She did not assess the resident's toilet or talk to the resident about the fall;-The residents were to use portable commodes when their toilets were broken;-He/She did not check to see if staff placed a portable commode in the resident's room; -On 5/20/26, he/she told the Administrator about the resident's broken toilet; -He/She also told Maintenance Staff D the resident's toilet seat was broken. 3. Review of Resident #1's undated face sheet showed the resident's diagnoses included hemiplegia (complete paralysis of one side of the body), hemiparesis (partial weakness or reduced strength) following cerebral infarction (stroke), dementia, and muscle weakness. Review of the resident's care plan, dated 3/11/26, showed the following:-The resident had hemiplegia/hemiparesis related to a stroke;-Encourage the resident to notify staff if he/she needed assistance with activities of daily living (ADLs) as needed;-Assess clothing for proper fit, be sure call light was within reach and encourage the resident to use the call light for assistance. Review of the resident's unwitnessed fall report, dated 4/20/26 at 11:00 A.M., showed the following:-The resident lay on the bathroom floor on his/her left side in front of the toilet. The resident said he/she slipped while trying to get in his/her wheelchair from the toilet;-The resident was oriented to person, place, time and situation;-Predisposing physiological factors was gait imbalance;-Predisposing situation factors was ambulating without assistance, improper footwear and using wheelchair. Review of the resident's care plan showed no documentation the resident fell on 4/20/26 or evidence to show staff reviewed or revised the resident's care plan to prevent future falls. Review of the facility's maintenance log, dated 5/12/26, showed the following:-The toilet seat in the resident's room was missing a bolt; -The section for the date it was repaired was left blank. Review of the resident's quarterly assessment, dated 5/15/26, showed the following:-Cognitively intact;-Upper and lower extremity impairment on one side;-Used a wheelchair for mobility;-Required supervision or touching assistance with toilet transfers;-The resident had two more falls with no injury since the last assessment. During an interview on 5/21/26 at 8:05 A.M., the resident said the following:-His/Her toilet seat and the armrest support for the toilet were very loose and moved side to side when he/she tried to sit down or get off the toilet;-He/She fell about a month ago in his/her bathroom because the toilet seat and armrest support were loose;-He/She was afraid he/she would fall again because the toilet seat was not secured and had not been repaired;-Maintenance staff was aware the toilet seat was broken. Observation on 5/21/26 at 9:35 A.M., in resident's bathroom showed the toilet seat was missing a bolt and was not secured to the toilet. The toilet armrest frame was loose and not secured in place. There was no portable commode available in the bathroom or in the resident's room. 4. Review of Resident #3 comprehensive MDS, dated [DATE], showed the following:-The resident was cognitively intact;-Used a walker and wheelchair for mobility;-Required supervision or touch assistance with toilet transfers;-The resident had one fall without injury since the last assessment. Review of the resident's care plan, dated 3/18/26, showed the following:-The resident required assistance from one staff to transfer and to walk with a wheeled walker; -The resident was at risk of falls and had a history of falls. Review of the facility's maintenance log, dated 5/12/26, showed the following:-The toilet seat in the resident's room was missing a bolt; -The section for the date it was repaired was left blank. Observation on 5/21/26 at 9:35 A.M., in resident's bathroom showed the toilet seat was missing a bolt and was not secured to the toilet. The toilet armrest frame was loose and not secured in place. There was no portable commode available in the bathroom or in the resident's room. During interviews on 5/21/26 at 8:21 A.M. and 12:30 P.M., the resident said the following:-His/Her toilet seat had been broken for a few weeks. The toilet seat moved around, and the armrest support was loose;-It made him/her very nervous when he/she used the bathroom, and he/she was worried he/she would fall;-Today, he/she had to sit on the toilet for over 15 minutes because he/she was afraid to get up, as he/she may fall. He/She usually could get off the toilet on his/her own. He/She had to wait on staff to answer his/her call light and assist him/her off the toilet. 5. During an interview on 5/21/26 at 10:45 A.M., Maintenance Staff D said on 5/20/26, he/she was doing rounds with the plumber and got busy. The plumber was replacing and repairing broken toilets. He/She did not follow-up with the plumber to ensure the plumber repaired the toilet seat in Residents #1, #2, and #3's shared bathroom. During an interview on 5/21/26 at 10:45 A.M., the Maintenance Supervisor said the following:-He/She was aware the toilet seat in the residents' room was not secured because the toilet seat was broken. It had been broken for a few weeks. He/She thought the residents used a portable commode until the toilet was repaired;-The toilet armrest frame was not secured to the back of the toilet because he/she was waiting for the plumber to replace the bolts so it could be secured in place; -The plumber came last week to look at the toilet seat, but did not repair it. The plumber came back yesterday, so he/she assumed the plumber repaired the toilet. He/She did not do rounds with the plumber yesterday; -The residents should not use the toilet until it was repaired. The toilet seat was unstable and spun around which was a fall risk. During an interview on 5/21/26 at 1:05 P.M., the Director of Nursing (DON) said the following:-Resident #2 fell yesterday morning. She was not aware the resident's toilet seat was broken or not secured. She thought the resident was having difficulty getting off the toilet because the toilet seat was too high, and the resident had balance problems; -LPN E mentioned there was an issue with the toilet, but he/she was not sure what was wrong with it. She did not talk to the resident after the resident fell and did not assess the resident's toilet;-She expected staff to determine the root cause of a resident's fall and to put interventions in place and to review and update the care plan. -She expected maintenance staff to repair the toilet. During interviews on 5/21/26 at 10:50 A.M. and 1:50 P.M., the Administrator said the following: -He was aware the toilet seat in the residents' bathroom was broken. He thought the residents used a portable commode and/or the toilet in the shower room until the toilet was repaired. The broken toilet was a fall risk for the residents in the room;-He was not aware Resident #2 fell yesterday morning in his/her bathroom. He was not in the morning meeting when staff discussed the resident's fall;-Staff should discuss all falls in the morning meetings including all the details of what happened so staff could put appropriate interventions in place to prevent future falls. Complaint 2994388

Based on observation, interview and record review, the facility failed to timely repair toilets in residents' bathrooms and failed to adequately repair the door to one resident's room. The facility census was 37.Review of the undated policy, Homelike Environment, showed the following:-The facility was responsible for providing the residents with a safe, clean, comfortable and homelike environment;-Part of this responsibility is maintaining the physical structure in good repair as well as maintaining the resident areas in a clean manner. Scratched doors, missing tiles, structural damage or environmental safety issues must be corrected;-In the event a staff member identifies an environmental issue their responsibility is to notify the Maintenance Director. Any identified issue should be logged in the maintenance binder at the nurse's station. A brief description of the issue as well as location should be entered into the log. If the issue is a safety hazard for the resident, the Maintenance Director should be contacted immediately as well as logging the issue into the maintenance binder. 1. During an interview on 5/21/26 at 11:30 A.M., the Administrator said around 04/03/26 to 04/15/26, the facility had an issue with toilet seat bolts breaking and this continued to be a current problem. The bolts were plastic and were constantly breaking. Review of a plumbing quote from the facility's plumber, dated 04/15/26, showed ten toilet seat bolts needed replaced. Review of the facility's maintenance log, dated 05/12/26, showed the following: -The toilet seat in Resident #1, #2 and #3's shared bathroom was missing a bolt; -The section for the date it was fixed was left blank. Observation on 5/21/26 at 9:35 A.M., in Resident #1, #2, and #3's shared bathroom showed the toilet seat was loose, missing a bolt, and was not secured in place. The armrest frame was loose and not secured in place. During an interview on 5/21/26 at 8:05 A.M., Resident #1 said the following:-His/Her toilet seat and the armrest support for the toilet were very loose and side to side when he/she tried to sit down or get off the toilet;-He/She fell about a month ago in his/her bathroom because the toilet seat and armrest support were loose;-He/She was afraid he/she would fall again because the toilet seat was not secured and had not been repaired;-Maintenance staff was aware the toilet seat was broken. During an interview on 5/21/26 at 9:30 A.M., Resident #2 said the following:-The toilet seat in his/her room was broken and had been broken for a couple weeks;-He/She fell on [DATE] because of the loose and broken toilet seat. He/She tried to get up and the toilet seat moved;-The staff were aware of the issues with the toilet. During interviews on 5/21/26 at 8:21 A.M. and 12:30 P.M., Resident #3 said the following:-His/Her toilet seat had been broken for a few weeks. The toilet seat moved around, and the armrest support was loose;-It made him/her very nervous when he/she used the bathroom, and he/she was worried he/she would fall. During an interview on 5/21/26 at 10:45 A.M., Maintenance Staff D said on 5/20/26, he/she was doing rounds with the plumber and got busy. The plumber was replacing toilets and repairing broken toilets. He/She did not follow up with the plumber to ensure the toilet seat in Residents #1, #2, and #3's shared bathroom was repaired. During an interview on 5/21/26 at 10:45 A.M., the Maintenance Supervisor said the following:-He/She was aware Resident #1, #2 and #3's toilet seat was not secured because the toilet seat was broken. It had been broken for a few weeks. He/She thought the residents used a portable commode until the toilet was repaired;-The toilet armrest frame was not secured to the back of the toilet because he/she was waiting for the plumber to replace the bolts, so it could be secured in place;-The plumber came last week to look at the toilet seat but did not repair it. The plumber came back yesterday, so he/she assumed the plumber repaired the toilet. He/She did not do rounds with the plumber on 5/20/26;-The residents should not use the toilet until it was repaired. The toilet seat was unstable and spun around which was a fall risk. During interviews on 5/21/26 at 9:45 A.M., 10:50 A.M. and 1:50 P.M., the Administrator said he was aware the toilet seat in Resident #1, #2 and #3's bathroom was broken. He thought the residents used a portable commode and/or the toilet in the shower room until the toilet was repaired. He thought the plumber repaired the toilet on 5/20/26. The broken toilet was a fall risk for the residents in the room. 2. Review of the maintenance log showed the following:-On 3/30/26, the toilet in Resident #4 and #5's shared bathroom was noted to completely swivel;-On 04/03/26, the toilet was fixed;-There was no documentation on the log regarding continued issues regarding the toilet. Review of the maintenance log showed no documentation staff completed any further repairs on Resident #4 and #5's shared toilet. During interview on 5/21/26 at 9:10 A.M., Resident #4 said the following:-He/She was without a functioning toilet in his/her shared bathroom for two to three months. He/She used a commode in the middle of his/her room. Staff did not clean the commode well and it had odors;-The plumber just fixed the toilet. Review of the maintenance log showed the following:-On 05/05/26, Resident #5's door would not latch closed;-On 05/06/26, the door was adjusted;-There was no documentation on the maintenance log regarding the door making noises when it was closed or opened. Observation on 5/21/26 at 12:49 A.M. showed a hand towel hung over the top of Resident #5's door. The door squeaked loudly when the door opened or closed. During an interview on 5/21/16 at 12:50 P.M., Resident #5 said the following:-His/Her door made a horrible noise when it was opened or closed. His/Her door only closed if a towel was placed along the top of the door;-He/She was without a functioning toilet in his/her shared bathroom for over two months. He/She used a portable commode in the middle of his/her room. The commode in the middle of his/her room was undignified. The plumber just replaced the toilet the day before (5/20/26). During interviews on 5/21/26 at 10:45 A.M. and 1:02 P.M., the Maintenance Supervisor said the following:-The plumber replaced the toilet in Resident #4 and #5's shared bathroom on 5/20/26;-Resident #4 and #5 were without a functioning toilet for a couple of months;-He/She was unaware Resident #5's door squeaked when opened or closed. He/She thought Resident #5's door was fixed. During interviews on 5/21/26 at 9:45 A.M., 1:00 P.M. and 1:50 P.M., the Administrator said the following: -The facility tried to repair things in house if possible;-Corporate staff had to approve the toilet replacement in Resident #4 and Resident #5's shared bathroom before it could be replaced;-There were two issues with the toilet. On 2/24/26 a plumbing company replaced the toilet, and it was not fixed correctly. Approximately two weeks later, it was wobbly and unsafe to use. The facility maintenance staff tried to fix the toilet, but it was still unsafe to use. The facility hired a second plumbing company to repair the toilet;-It was approximately two months before residents were able to use the toilet again. The toilet was finally repaired on 5/20/26;-It was not homelike for a resident to use a portable commode in the middle of the room for over two months. 2994388

Based on observation, interview and record review, the facility failed to follow their policy to address weight loss for two residents, (Resident #5 and #6), in a review of 17 sampled residents. The facility failed to notify the physician of weight loss, assess for root cause, evaluate the care plan, or initiate interventions based on the evaluation to address weight loss. Review of Resident #6's weight records showed the resident lost 7.4 pounds (lbs.) between 10/01/25 and 11/01/25, a 6.32 percent (%) weight loss in one month. Review of Resident #5's record showed the resident lost 6.6.lbs. since 10/18/25 a 5.79 % weight loss in approximately 45 days and a 7 lbs. or 6% weight loss in 30 days (since 10/31/25. The resident weighed 106.0 lbs. on 11/07/25, and lost 9.2 lbs. in one week, a 7.96% weight loss. The facility census was 40. Review of the facility policy, Weight Assessment and Intervention, reviewed 02/2021, showed the following: -Weight Assessment1. The nursing staff will measure resident weights on admission, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly;2. Weights will be recorded in the individual's medical record;3. The threshold for significant, unplanned and undesired, weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe; b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe; c. 6 months - 10% weight loss is significant; greater than 10% is severe. Review of the facility policy, Nutrition (Impaired)/Unplanned Weight Loss-Clinical protocol, reviewed 02/2021, showed the following:-Assessment and Recognition:1.The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time;2. As part of the initial assessment, the staff and physician will review the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with recent weight loss and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever and infection, or those taking medications that may be causing or increasing the risk of anorexia or weight loss;3. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe; b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe; c. 6 months - I0% weight loss is significant; greater than 10% is severe.4. The Physician will consider whether any assessment, including additional diagnostic testing, is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition. No lab tests are sensitive or specific enough for defining nutritional status that they should be ordered for everyone. Lab tests may be ordered if they are likely to substantially help establish status or prognosis, causes of anorexia or weight loss, or choice of interventions; otherwise, routine ordering to assess or follow nutritional status is not indicated.-Cause Identification:1. The Physician will review possible causes of anorexia or weight loss with the nursing staff and/or Dietitian before ordering interventions; a. The Dietitian will estimate calorie, nutrient and fluid needs and, with the Physician, will identify whether the resident's current intake is adequate to meet his or her nutritional needs; b. For individuals with recent or rapid weight loss (for example, more than a pound a day), the staff and physician should consider possible fluid and electrolyte imbalance as a cause. Fluid deficits can result in rapid weight loss (1 kg/2.2 pounds lost for each liter of fluid deficit);2. The Physician, with the help of the multi-disciplinary team, will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: a. Cognitive or functional decline; b. Chewing or swallowing abnormalities; c. Pain; d. Medication-related adverse consequences; e. Environmental factors (such as noise or distractions related to dining); f. Increased need for calories and/or protein; g. Poor digestion or absorption; h. Fluid and nutrient loss; and/or i. Inadequate availability of food or fluids;3. The Physician will consider whether any additional diagnostic testing is indicated to help clarify the causes of impaired nutrition. An extensive workup may not be appropriate in some individuals, and knowing the cause may not change the interventions. However, a systematic review for causes based on an individual's history, co-morbidities, risk factors, etc., may be appropriate even if an extensive workup is not;4. The interdisciplinary team (IDT) will document relevant medical observations and conclusions regarding the nature, severity, causes, and consequences of impaired nutritional status, especially in complex situations or where multiple active causes may coexist;-Treatment/Management:1. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes. Treatment decisions should consider all pertinent confirmation or evidence (e.g., food intake, overall condition and prognosis, etc.), and should not be based solely on lab test results (albumin, cholesterol, etc.);2. The Physician will authorize, and the staff will implement, appropriate, general or cause-specific interventions, as indicated, b. Nutritional needs: The Dietitian and Physician consult to determine the appropriate diet for the resident based on the resident's degree of nutritional impairment, expressed wishes, and underlying causes and conditions. Order for appropriate diet will be obtained from the physician; c. Supplementation: Strategies to increase a resident's intake of nutrients and calories may include fortification of foods, increasing portion sizes at mealtimes, and providing between-meal snacks and/or nutritional supplementation. 1. Review of Resident #6's face sheet showed diagnoses included anemia (low iron level), dementia, depression, and multiple traumatic fractures that included a pelvic fracture. Review of the resident's Physician's Orders, dated 03/30/25, showed med pass supplement (concentrated, liquid nutritional supplement to drink) 60 milliliters (ml) two times a day. Review of the resident's Physician's Orders, dated 07/29/25, showed orders for regular, mechanical soft texture, soft and bite sized, diet. Review of the resident's Care Plan, last updated 08/06/25, showed the following:-Resident has nutritional problem or potential nutritional problem;-Goal: Resident will maintain adequate nutritional status through review date (goal date listed is 10/27/24 which is past);-Provide and serve diet as ordered;-Provide and serve supplements as ordered;-Registered Dietitian to evaluate and make diet change recommendations as needed. Review of the resident's Dietary Notes, dated 09/07/25 at 7:33 A.M., showed the Registered Dietitian documented the following:-Nutrition Progress Note:-Resident's weight is 115 lbs., height is 62 inches;-Diet is Regular;-Resident has supplements ordered: 60 ml med pass two times daily;-The resident's weight remains stable, weight within normal limits; stability and adequate by mouth consumption desired;-Will continue to monitor. Review of the resident's Weight Record, dated 10/01/25 at 3:28 P.M., showed staff documented the resident's weight as 117 lbs. Review of the resident's Dietary Notes, dated 10/12/25 at 9:03 P.M., showed the Registered Dietitian documented the following:-Nutrition Progress Note:-Resident's weight is 117 lbs., height is 62 inches;-Diet is Regular;-Resident has supplements ordered: 60 ml med pass two times daily;-The resident's weight remains stable for 6 months;-Current diet exceeds needs, would continue to monitor;-Weight stability and adequate by mouth consumption is desired, will continue to monitor. Review of the resident's Physician's Orders, dated 10/24/25, showed Depakote (seizure medication) 125 milligrams (mg) two times a day for behavioral disturbance. Review of drugs.com showed Depakote has a warnings that includes: Call your physician at once if the person taking this medicine has signs of liver or pancreas problems, such as: loss of appetite, upper stomach pain (that may spread to your back), ongoing nausea or vomiting, dark urine. Common side effects include loss of appetite, mental depression, nausea, trouble thinking and planning, unusual tiredness or weakness, unusual weight gain or loss. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 10/31/25, showed the following:-Severe cognitive impairment; -Independent with eating;-Weight 117 lbs. (would be last weight so weight from 10/01/25). Review of the resident's facility Weight Record, dated 11/01/25 at 2:04 P.M., showed staff documented the resident's weight as 109.6 lbs. On 10/01/2025, the resident weighed 117 lbs.; a 6.32% loss. Review of the resident's medical record, including nurse's notes and physician's notes, showed staff did not document any communication to the physician or the dietitian about the resident's significant weight loss of greater than 5% in 30 days. There was no evidence of updates, reviews, or new interventions in the resident's care plan or the resident's physician orders after the documentation of the 6.32 % weight loss. Review of the resident's Dietary Notes, dated 11/17/25, at 4:53 P.M., showed the Registered Dietitian documented the following:-Resident's weight is 109 lbs., height is 62 inches;-Diet regular;-Resident has supplements ordered: 60 ml med pass two times daily;-Estimated Nutrition Needs 1700 kilocalories (kcal) 80 grams (g) protein and 1700 ml fluid;-Resident's weight indicates slight loss;-Current diet exceeds needs, would continue;-Weight stability and adequate by mouth consumption desired;-Will monitor. Review of the resident's record showed there was no evidence of updates, reviews, or new interventions in the resident's care plan or the resident's physician orders after the resident's weight loss. The Registered Dietitian did not identify the weight loss as significant. Review of the resident's facility Weight Record, dated 12/01/25 at 6:14 P.M., showed staff documented the resident's weight was 110.2 lbs. Review of the resident's Nurses Notes, dated 12/16/25 at 1:55 P.M., showed the IDT team reviewed the resident's weights. The resident had a significant weight loss of 5 % in November, the IDT did not make recommendations at this time. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-110 lbs. 5.9% weight loss in one month (unplanned weight loss was not checked on the resident's MDS);-New Mechanically altered diet. Review of the resident's care plan showed no updates to the resident's nutrition risk since 08/06/25 and there was evidence the care plan was reviewed or revised after the resident's 5.9% weight loss. Observation on 01/06/26 at 1:02 P.M., showed the resident at the dining room table with his/her family member. The family member cued the resident during the meal, and he/she consumed 100 percent (%) of his/her meal. Observation on 01/07/26 from 5:35 P.M. to 6:20 P.M., showed the following:-5:35 P.M the resident in his/her wheelchair at the dining room table;-5:40 P.M., staff served the resident pot roast with carrots and onions in a bowl, salad, roll and mixed fruit;-5:55 P.M., the resident moved his/her food around with his/her fork/spoon, not consuming any food;-No staff cued or encouraged the resident to eat or offered an alternative;-6:20 P.M., the resident left the table in his/her wheelchair; the resident consumed less than 10 % of his/her meal. During an interview on 01/08/26 at 12:15 P.M. and 01/09/26 at 7:35 P.M., Certified Nurse Assistant (CNA) E said the following:-He/She was a full time CNA at the facility;- He/She was not sure which residents at the facility had weight loss;-The resident sometimes just played with his/her food. 2. Review of Resident#5's face sheet showed he/she has a resident representative. Review of the resident's Physician Orders, dated 10/17/25, showed the resident was ordered a regular diet. Review of the resident's Care Plan, dated 10/22/25, showed the following:-Diagnosis of Alzheimer's disease;-Impaired cognitive function/dementia or impaired thought processes;-Review of the care plan did not identify nutritional risk. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 10/30/25, showed the following:-Moderate cognitive impairment;-Diagnosis: Alzheimer's, anemia, thyroid disorder and depression;-Set up or clean up assistance from staff for eating;-Weight 115 lbs.;-No weight loss or therapeutic/mechanical diet. Review of the resident's facility Weight Record showed staff documented the following: -On 10/31/25 at 1:55 P.M., the resident weighed 115.2 lbs.; -On 11/07/25 at 4:57 P.M., the resident weighed 106.0 lbs. (a 9.2 lbs. weight loss in one week, which is a 7.96% weight loss in one week Review of the resident's care plan showed no documentation the resident's care plan was updated with interventions regarding nutrition or weight loss. Review of the resident's medical record, including his/her nurses' notes, dietitian notes, physician orders and physician progress notes, showed no identification of the weight loss, notification to the physician, dietitian or resident representative, evaluation, interventions, or updates about the resident's nutrition or weight loss. Review of the resident's facility Weight Record showed staff documented the following:-11/14/25 at 6:30 P.M., the resident weighed 107.8 lbs.;-12/01/25 at 10:19 A.M., the resident weighed 108.2 lbs. (the resident lost 6.6.lbs. since 10/18/25 which is a 5.79 % weight loss in approximately 45 days and a 7 lbs. or 6% weight loss in 30 days (since 10/31/25)). Review of the resident's medical record including Nurses Notes, Physician's Orders, and Dietary notes showed no identification of the resident's weight loss. There were no notifications to the physician or dietitian, and no new orders to address the resident's weight loss on 12/01/25. Review of the resident's Dietary Note, dated 12/18/25 at 8:52 P.M., showed the Registered Dietitian documented:-Resident weighs 108 lbs. and is 64 inches tall;-Regular diet; -Weight stable after slight loss;-Add 60 ml med pass twice a day;-Will continue to monitor. Review of the resident's Dietary Note, dated 12/23/25 at 11:57 A.M., showed staff received a dietary recommendation from the Registered Dietitian, recommending adding Med Pass 60 ml two times daily due to weight loss. Physician notified and new order received. (The first significant weight loss was identified on 11/07/25, the first intervention with the addition of this supplement was 12/23/25). Review of the resident's Physician Orders, dated 12/23/25, showed a new order for Med Pass 60 ml two times a day for weight loss. Review of the resident's care plan showed no documentation staff updated the plan with interventions to address nutrition or weight loss. Review of the resident's medical record, including his/her nurses' notes, dietitian notes, physician orders, and physician progress notes showed no identification, notifications of the physician, resident representative, no evaluation, interventions, or updates about the resident's nutrition or weight loss. Observation on 01/06/26 at 1:20 P.M through 1:40 P.M., showed the resident at 1:20 P.M. in his/her room with a meal tray. At 1:40 P.M., the resident had moved his/her meal away from him/her and had consumed 25%. During an interview on 01/07/26 11:51 A.M., the resident's representative said no one had made him/her aware the resident had lost weight. He/She would expect facility staff to try to find out why the resident lost weight so they could try to stop the weight loss if possible. During an interview on 01/09/26 at 6:20 P.M., Licensed Practical Nurse (LPN B) said the following:-Resident weights are obtained weekly times four weeks after admission and then monthly; -Significant weight loss was reviewed by the IDT team and the charge nurse carried through order requests when received. -He/She was not sure who updated the care plan and speaks to the dietitian;-The charge nurses call the physician and resident representative about weight loss if the IDT team communicate to them. The charge nurse would then document those notifications in the nurses notes;-She knew both Resident #5 and #6 have had weight loss and they were both on Med Pass. He/She was not sure if they have had further weight loss. During an interview on 01/09/26 at 8:53 P.M., the Director of Nursing said the following: -If a resident has a significant weight change, she will ask staff to re-weigh the resident to ensure it was accurate; -Staff are expected to assess the resident; if it's a gain, determine if it was from edema or illness and document in the nurses notes;-If there was weight loss, the facility should try to determine why the resident lost weight (through assessment and investigation) and put an intervention in place to stabilize the resident's weight or assist with gaining the weight back; -The MDS coordinator was in charge of monitoring the weights. The facility did not currently have a MDS coordinator in house and used a Corporate offsite MDS coordinator; -She expected Interventions for weight loss would include supervision while eating, prompting, cueing, snacks, supplements, check for mouth pain, and medications that could cause issues; -The facility used to have an assist table where residents who required more help and cueing would eat; The facility will chart consumptions of meals when staff notice the resident is not eating; she was not sure if this was done for Resident #5 or Resident #6;-When there was weight loss identified, the physician, family and dietician should be notified and the care plan updated;-She was responsible for the IDT meetings. She was not aware of the residents 'weight loss (Resident #5 and #6). During an interview on 01/26/26, at 12:26 P.M., the MDS/Care plan coordinator said she was offsite doing MDS's until the facility can hire and train a new MDS coordinator. She was not in charge of monitoring weights for all residents. During an interview on 01/09/26 at 8:53 P.M., the Corporate Nursing Manager said when there is weight loss identified, staff are expected to notify the physician, family and dietician, and the care plan should be updated with the weight loss and interventions attempted. During an interview on 01/27/26, at 3:06 P.M., the Registered Dietitian said the following:-Unplanned weight loss is considered significant weight loss if the resident loses 5 % one month, 7.5 % in 90 days, or 10 % in six months;-Unplanned significant weight loss can put a resident at risk for malnutrition, wounds, and lean muscle loss;-If a resident has unplanned significant weight loss staff are expected to get a verbal order for a supplement from the physician or something if she was not going to be at the facility within 48 hours-She expected nursing to obtain the resident's weights and if there was an unplanned significant weight loss she would expect nursing staff to contact her of the physician for orders;-She is not sure what the facility policy is for monitoring consumptions, but someone should be paying attention to the resident's eating and consumptions;-She would expect nursing staff and the physician to look at possible causes of weight loss or things that could interfere with weight stability like mouth pain, medication side effects, lack of appetite, or possible swallowing issues to get appropriate referrals if needed; -When unplanned weight loss is found, she would expect the nursing staff to start an intervention like a Med Pass supplement within 48 hours;-She was not involved in the IDT meetings to discuss possible reasons for weight loss. That information would come to her after the IDT meeting to discuss the resident;-She did not know about Resident #5's unplanned significant weight loss until his/her visit at the facility on 12/23/26, and she recommended Med Pass be started. Staff did not contact her before that date about the resident's unplanned significant weight loss;-She would expect them to try a supplement or something prior to three weeks for Resident #5;-Resident #6 has been up and down over the years, he/she was stable for a while. She would expect staff to try monitor the resident at meals to see if the resident needed assistance or cues and assess for other issues that could be causing him/her to lose weight again;-She would want staff to try different things and see if anything would help to stabilize the resident's weight, and document those attempts. During an interview on 01/15/26, at 4:10 P.M. the Medical Director (also Resident #6's primary physician) said the following:-He considered weight loss significant if a resident had a loss of 5% of their body weight in one month, or 10 % in six months;-Significant weight loss can increase the risk of decline in physical abilities, skin issues, weakness, falls, and other systemic issues; When significant weight loss was identified, he expected staff to call/contact the physician, then he would give an order to check the resident's weight more often, like weekly and would order something to help with the weigh' loss, like supplements or medications such as appetite supplements;-He expected staff to check for possible issues including ill-fitting dentures, possible swallowing issues, or if the resident needed assistance or cues with eating;-When on weekly weights, he expected staff to check the weekly weight and if the resident's weight goes down, staff should consult the dietitian and/or him;-When there is a weight loss, medication side effects should be reviewed, dental and swallowing issues considered, level of needed assistance assessed and attempts to find a reason for the weight loss;-If there was a resident with weight loss or a concern, he would expect staff to monitor and document consumptions of meals and supplements;-Finding the root cause of the weight loss like mouth pain, medication side effects, lack of appetite help to address the issue and prevent further weight loss;-Possible interventions for weight loss include weekly weights, snacks, supplements, monitoring consumption, physician review, dietitian review, pharmacist review, possible speech therapy or dental referral;-Resident #6 lost weight, gained some back, and then started losing weight again;-He expects staff to notify him every time a resident loses weight as he may try something new;-He doesn't remember when/if staff told him about weight loss;-If he was told about the weight loss, he would have immediately ordered something to try;-When alerted about the weight loss, he would have looked at the residents' medications, possibly tried Remeron (an antidepressant that stimulates appetite), asked staff to try assisting the resident to eat, added or increased supplements, and possibly other interventions after discussion with staff to see what could be attempted.

Based on interview and record review, the facility failed to provide appropriate treatment and services consistent with acceptable standards of practice to prevent and treat urinary tract infections (UTIs) when the facility failed to ensure one resident (Resident #6), went to his/her follow up urology appointments as scheduled and failed to ensure his/her urinary catheter (a sterile tube inserted into the bladder to drain urine) was changed as ordered either at the urology clinic or by facility staff. The resident missed three scheduled appointments. The resident was diagnosed with a UTI which the medical director said could be a result of lack urinary catheter changes. Facility staff identified the resident's catheter was split and unable to be connected to the drainage system and used tape to hold the two pieces together rather than consulting with the urologist or the resident's physician. Further review showed when the two pieces would not connect to ensure a closed drainage system, the facility left the urinary catheter open, unconnected to a collection bag, draining into an incontinent brief which led to risk of infection. The facility identified two residents with an indwelling catheter. The facility census was 39. Review of the facility policy, Urinary Catheter Care, reviewed 02/2021, showed the following: -The purpose of this procedure is to prevent catheter-associated UTIs; -Infection control: -Use standard precautions when handling or manipulating the drainage system;-Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag;-Change catheters and drainage bags based on clinical indications such as infection, obstructions, or when the closed system was compromised. Catheters will be changed per medical practitioner order. Review of the Centers for Disease Control (CDC) Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated March 25, 2024, showed the following: -Proper techniques for urinary catheter maintenance: -Following aseptic insertion of the urinary catheter, maintain a closed drainage system;-If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment;-Change catheters and drainage bags based on clinical indications such as infections, obstruction, or when the closed system is compromised. 1. Review of Resident #6's updated face sheet showed his/her diagnoses included neuromuscular dysfunction of bladder (a loss of bladder control caused by nerve damage, resulting in dysfunction of the muscles that store or empty urine). Review of the resident's October 2025 Physician Order Sheet (POS) showed the following: -Change urinary catheter monthly and as needed, one time a day starting on the last day of the month and ending on the last day of month every month; -Indwelling catheter, ensure catheter is patent and draining, document any changes to baseline. Note color and consistency in progress note, every shift for catheter use;-Change urinary catheter monthly and as needed for urinary catheter maintenance. Review of the resident's October 2025 treatment administration record (TAR) showed staff changed the resident's urinary catheter on 10/31/25. Review of the resident's November 2025 POS showed the following: -Change urinary catheter monthly and as needed, one time a day starting on the last day of the month and ending on the last day of month every month;-Indwelling catheter: ensure catheter is patent and draining, document any changes to baseline. Note color and consistency in progress note, every shift for catheter use;-Change urinary catheter monthly and as needed for urinary catheter maintenance. Review of the resident's progress notes, dated 11/03/25 at 3:40 P.M., showed staff documented the wound care nurse had tugged on the resident's catheter when he/she moved the resident's walker. The resident complained of brief pain and a burning sensation; catheter inspected with no issues noted. After the nurse left the room, the resident ambulated independently to the bathroom, the resident alerted nursing staff for assistance and staff noted the resident's catheter had been removed and sat on the bathroom floor. Nursing staff attempted to replace the urinary catheter and was unsuccessful. Staff received an order from the physician to leave the catheter out and try a void trial (see if the resident could pass urine on his/her own). The resident urinated within 30 minutes. Review of the resident's November 2025 POS showed indwelling urinary catheter, ensure catheter is patent and draining, document any changes to baseline. Note color and consistency in progress note, every shift for catheter use (discontinued 11/06/25). Review of the resident's progress notes dated 11/09/25 at 3:35 P.M, showed staff documented the resident was not feeling well, transferred to the local hospital for evaluation, and admitted to the hospital for influenza. Review of the resident's discharge documents from the hospital, dated 11/12/25, showed the following:-Diagnosis for hospitalization was influenza and urinary retention;-While hospitalized , the resident was treated for a urethral stricture (a narrowing of the urethra - the opening that urine passes through - which obstructs urine flow from the bladder) that required dilation (opening) and had a urinary catheter placed;-He/She was to return to the urology clinic in about one month for catheter change (unless the changes would be done by facility staff);-The follow-up urology appointment was scheduled for 12/11/25 at 9:15 A.M. Review of the resident's November 2025 POS showed an order for an indwelling catheter, 20 French 30 milliliter balloon (size of catheter) with an order start date of 11/12/25. (The order did not specify the frequency of catheter changes or additional information related to urinary catheter care). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 11/13/25, showed the following:-Cognitively intact;-Supervision or touch assistance for toileting hygiene;-Indwelling catheter present;-Diagnoses included renal insufficiency/renal failure/or end-stage renal disease and neurogenic bladder. Review of the resident's electronic health record (HER), History and Physical, dated 11/21/25, showed the resident was seen as a re-admit, had urinary retention and apparently still needed the urinary catheter and the catheter was replaced at the hospital. Review of the resident's December 2025 POS showed an order for indwelling catheter (The order did not specify the frequency of changes, or any additional information related to urinary catheter care). Review of the resident's care plan, revised on 12/26/25, showed the following:-He/She has a catheter secondary to neuromuscular dysfunction of the bladder and will show no signs or symptoms of urinary infection through review date of 01/30/26;-Catheter care every shift and as needed;-Monitor for signs and symptoms of discomfort on urination and frequency;-Monitor/record/report to physician for any signs or symptoms of UTI. Review of the resident's December 2025 treatment administration record (TAR) showed no documentation staff changed the resident's catheter or completed any type of monitoring of the catheter. Review of the resident's EHR, including progress notes, showed no documentation staff changed the catheter, the resident attended his/her urology appointment scheduled for 12/11/25 at 9:15 A.M. or the reason why the resident missed the urology appointment. Further review showed no documentation staff rescheduled the appointment. Review of the resident's January 2026 POS showed an order for indwelling catheter. (The order did not specify the frequency of changes or additional information related to urinary catheter care). Review of the resident's nursing progress notes, dated 01/12/26 at 3:32 P.M., showed staff documented the resident's urology appointment was cancelled due to the resident having coronavirus disease (Covid- a virus that can be very contagious and spreads quickly). There was no documentation to show staff rescheduled the appointment, changed the resident's catheter or there had been a consultation with the urologist or the resident's physician about changing his/her catheter. Review of the resident's EHR, results section, showed a urine culture with specimen collection date of 01/26/25 and final culture results 01/29/26, that showed a positive UTI, greater than 100,000 CFU/milliliter of Proteus Mirabilis (a rod-shaped bacteria that causes UTIs) (Proteus Mirabilis should not be present in urine). There was no documentation in the record why this urine sample was obtained for testing. Review of the resident's nursing progress notes, dated 01/30/26 at 4:20 P.M., showed staff documented the urine culture final was sent to his/her physician with a new order to add Augmentin (an antibiotic) 875mg every 12 hours for seven days for a diagnosis of UTI. Review of the resident's January 2026 POS showed an order on 01/30/26 for Augmentin 875-125 milligrams, give one tablet by mouth every 12 hours for UTI for seven days. Review of the resident's January 2026 TAR showed no documentation staff changed the resident's catheter or completed any type of monitoring of the catheter. Review of the resident's February 2026 POS showed the following:-An order for indwelling catheter; -An order for Augmentin 875-125 milligrams, give 1 tablet by mouth every 12 hours for UTI for seven days with start date of 1/30/26.(The order did not specify the frequency of changes or additional information related to urinary catheter care). Review of resident's nursing progress notes showed staff documented the following: -On 02/14/26 at 1:50 P.M., the resident's urinary catheter was patent and draining yellow urine at this time, there were no new concerns related to the catheter or his/her output, will continue to monitor;-On 02/14/26 at 2:59 P. M., urinary catheter was split at the attachment to the drainage site. End of catheter was split, and resident said it has been like that for several days. The two ends had been taped together. There was about 600 cubic centimeters (cc's) of yellow urine in the drainage bag, but urine also leaked from the end of the catheter. There was old tape on the end of the connection tubing to the bag. Both ends of the catheter tubing were cleaned, old tape removed, and the drainage bag reconnected to catheter with tape. The resident said he/she was going to the physician on Monday (two days after this date), and they would replace his/her catheter. Urine was now draining in the drainage bag (no documentation staff notified the urologist's office or the resident's physician of the condition of the catheter. Review of the resident's February 2026 TAR showed no documentation staff changed the resident's catheter or completed any type of monitoring of the catheter. Review of the resident's Urology Clinic Note, dated 02/17/26, showed the following:-Resident presented to clinic for first time since previously seen as inpatient and had urethral dilation on 11/11/25;-The resident reported that he/she was unable to follow-up previously due to lack of transportation at the facility, still has the same catheter;-Urethral catheter in place draining clear urine (although no bag is connected to the catheter). Catheter removed; a new catheter placed without difficulty;-The resident's facility was apparently unable to do catheter changes for the resident so the clinic will be doing it for now;-Follow-up in about one month for another change;-Resident agrees with this plan. Review of the resident's March 2026 POS, reviewed on 03/03/26, showed the continued order for indwelling catheter 20 French 30ml balloon. Review of the resident's March 2026 TAR showed no documentation staff changed the resident's catheter or completed any type of monitoring of the catheter. During an interview on 03/03/26 at 4:15 P.M., the resident said the following: -He/She was supposed to have his/her catheter changed every month;-The appointments that he/she had scheduled in November and December did not occur because the arranged transportation service got cancelled;-He/She missed one appointment in December because he/she was counting on family to take him/her, and it did not work out; -He/She missed the next appointment in January due to having Covid; -Before going to urology in February, his/her catheter had not been changed since he/she was in the hospital in November; -Prior to the urology appointment in February, the catheter hose tip that goes to the bag was split in two and the bag was just being taped to the catheter, he/she is not sure how long it had been split but it had been that way for a little while;-He/She wasn't sure if the nurses at the facility could change the catheter or not;-When he/she went to his/her urology appointment in February the bag would not stay connected because of the split, so staff put on an adult brief and he/she went to the appointment with the incontinent brief on and the catheter tubing was left open and was put in the brief to drain the urine into the brief;-His/Her last UTI was about a month ago and he/she has history of UTI's. During an interview on 03/04/26 at 11:39 A.M., medical records staff member said the following:-The resident missed one appointment in November or December because there was a disagreement between the resident and the family member that was going to take him/her to the appointment;-She immediately rescheduled the appointment for the next available date which was January;-In January the resident was in isolation for Covid, and the urology clinic would not see him/her, so that appointment had to be cancelled;-The next available appointment was in February and the resident was able to go to that appointment;-The facility does not have their own transportation but must rely on family or Medicare/Medicaid arranged transportation to transport the residents. During an interview on 03/04/26, at 11:54 A.M., Licensed Practical Nurse (LPN) A said the following:-He/She was not aware the resident had missed urology appointments or procedures related to no transportation;-The resident had a catheter, but the facility was not able to change it, and the resident must go to the urology clinic to have it changed;-Orders should always be completed and include the frequency of administration or treatment time to be completed; for example, urinary catheters should have direction including when to change; -He/She was unaware that he/she did not complete hospital discharge orders from 11/12/25 related to the resident's catheter changes; -Catheters changes are typically monthly and as needed. During an interview on 03/04/26 at 12:41 P.M., the Infection Preventionist (IP) said the following:-She was working as a charge nurse on Saturday, 02/14/26;-The resident had some issues with the connection part of his/her catheter and a urine collection bag would not stay connected due to the end of the urinary tubing being split;-She could see where the catheter had been taped with surgical tape;-She cleaned the end of the urinary tubing and the end of the existing urine collection bag with alcohol and put the urine collection bag connector back in the urinary tubing and the taped the two together with the surgical tape;-She did not change the catheter because the resident was going to the urology clinic on the Monday following her shift; -The resident told her staff at the facility could not change the catheter, so she did not investigate any further as the urine was draining in the bag after taped;-She did not notify the on-call physician, urology clinic or DON about the catheter splitting for further instructions. During an interview on 03/04/26, at 12:21 P.M., the DON said the following: -No residents had missed any appointments that she was aware of;-Any resident with a catheter should have a physician order to address changes and care;-Urinary catheters are changed as ordered by the physician and are individualized, typically orders are to change a urinary catheter monthly;-The resident was supposed to have orders for his/her urinary catheter changes and care and she was waiting on a clarification from the medical director to complete his/her orders;-An order for a 20 Fr 30cc balloon was not a complete order and should have been completed when written or clarified with the physician if clarification was needed;-It was not a professional standard to tape a splitting urinary catheter, the physician should have been notified for further instructions/orders;-If a urinary catheter was taped due to an issue, there could be an increased risk of infection;-She would expect discharge orders from a hospital to be followed;-The resident did not go to his/her appointment in December because it was cancelled by family and did not go to his/her appointment in January due to illness, but did go to his/her appointment in February and had his/her catheter changed at that time;-The resident had not had his/her catheter changed since hospitalization in November;-In January, the facility contacted the urology clinic and the physician and there were no concerns noted as the resident did not have any problems, so the facility was supposed to monitor the resident and keep his/her appointment in February; (There was no documentation in the EHR of this contact with the urology clinic or the resident's physician); -The resident was treated for a UTI at the end of January into February. During an interview on 03/05/26 at 3:22 P.M., a Urology Clinic LPN said the following:-On 02/17/26 the resident came to an appointment at the clinic for a follow-up appointment after a surgical procedure in November; -The resident missed appointments on 12/11/25, 12/29/25, and 01/12/26 due to no transportation or illness; -The resident had orders after hospitalization in November 2025 to return to the clinic in one month to have his/her catheter changed, or it needed to be changed at the facility monthly;-When the resident arrived at the clinic in February for his/her appointment, the urinary catheter was not attached to a drainage bag, it was open to air in an adult brief/incontinent product;-The hub/connecting end of the urinary tubing was also found to have tape wrapped around the end due to it splitting;-The resident should have had his/her catheter changed by either the facility or the clinic monthly as ordered;-Records showed the catheter had not been changed since the November 2025 hospitalization. During an interview on 03/04/26 at 12:53 P.M., the Medical Director said the following:-Residents with a urinary catheter should have an order to change their catheter on a regular basis; he usually orders it to be changed once a month and as needed;-He was aware the resident recently had his/her catheter changed and assumed there was an order for it to be changed;-If a resident missed multiple urology appointments in a row, urology should have been consulted for orders;-If a resident had a catheter split at the end where it connects to the urinary drainage bag, he, or urology, should have been contacted for orders;-The urinary collection bag and the urinary tubing should not have been urinary taped together; this would be a potential risk for increased infection;-The lack of changing a urinary catheter could have increased the resident's risk of obtaining an infection or UTI;-If a resident has specific orders from a specialist, such as urology, to change a catheter in one month or return to the clinic, the catheter should have been changed by either the facility staff or by urology. #2788565

Based on observation, interview and record review, the facility failed to follow facility policy for the documentation, notification, review and monitoring of falls and implementation of interventions for two residents (Resident #6 and #5), in a review of 17 sampled residents, who experienced multiple falls. Resident #5 sustained rib fractures due to falls. The facility census was 40. Review of the facility's Fall-Clinical Protocol policy, dated September 2012, showed the following:-As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling;a. Staff will ask the resident and the caregiver or family about a history of falling;b. The staff and physician should document in the medical record a history of one or more recent falls;-In addition, the nurse shall assess and document/report the following: Vital signs; recent injury especially fracture or head injury; musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; change in condition or level of consciousness; neurological status; frequency and number of falls since last physician visit; precipitating factors, details on how fall occurred; all current medications, especially those associated with dizziness or lethargy; and all active diagnoses;-The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk;-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.;-Details about where and how the resident fell along with circumstances of the fall will be documented;- Falls should also be identified as witnessed or unwitnessed events;-For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall;-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 (ADR), 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;-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;-The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling;-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 #5's face sheet showed the resident admitted to the facility on [DATE] and had a resident representative. The resident has diagnosis of Alzheimer's disease, radiculopathy (pinched nerve) cervical (neck) region and chronic pain. Review of the resident's Care Plan, dated 10/17/25, showed the following:-Resident had actual/potential for falls;-Resident will not sustain serious injury through the next review;-Be sure call light is within reach and encourage the resident to use it for assistance;-Do not leave the resident in the bathroom unattended;-Ensure personal items are within reach. Review of the resident's Nurses Notes, dated 10/18/25 at 6:42 A.M., showed staff documented notifying the resident's representative of a fall. There was no documentation the resident's physician or administration was notified of a fall and no documentation regarding the details of the fall per facility policy. Review of the resident's Fall risk assessment, dated 10/18/25, showed the resident scored a 28 and was considered a high risk for falls. Review of the resident's Nurses Notes, dated 10/18/25, showed follow up assessment for a fall with no abnormal findings documented at 9:30 P.M., 9:45 P.M., 10:30 P.M., 11:00 P.M., 11:33 P.M. Review of the resident's medical record showed no evidence of an IDT review following the fall on 10/18/25, where the resident's frequency and number of falls since last physician visit would be evaluated, precipitating factors considered, medications reviewed or attempt to define possible causes of the fall would have been conducted. Further reviewed showed no documentation the resident's care plan was reviewed or updated with new interventions to prevent falls. Review of the resident's Nurses Notes, dated 10/22/25 at 5:40 A.M., showed the resident had an unwitnessed fall. The resident was found on the floor in front of his/her bathroom door. The resident complained of pain in both arms and his/her head. The resident had a large skin tear to his/her left arm right above his/her elbow. Emergency medical services called. Notified the Director of Nursing (DON), resident representative and the nurse practitioner. Review of the resident's Nurses Notes, dated 10/22/25 at 9:34 A.M., showed the resident returned from the emergency room via the resident representative's vehicle. The resident had diagnosis of hematoma (localized collection of clotted or pooled blood outside blood vessels, typically caused by trauma or injury) of the scalp and chest wall contusion (bruise to the chest wall). No new orders. Review of the resident's Care Plan, updated 10/22/25, showed the resident had one unwitnessed fall in the bathroom, no injury (no specific date), and a witnessed fall in the resident's room when he/she took a step and fell to his/her knees then onto his/her shoulder (no specified date). Review showed staff added no new interventions to the care plan to prevent falls. Review of the resident's Nurses Notes, dated 10/25/25, at 5:05 A.M., showed the resident yelled from his/her room. Staff arrived to find him/her in a kneeling position with one knee and one foot on the ground, holding onto his/her walker and leaning over his/her wheelchair. Resident explained he/she was trying to get to the bathroom. Staff reported the resident was having severe pain in left side ribs. Assessed the resident and found bruising to left side abdomen and severe pain on light palpation. The resident screamed when left arm was raised to assess abdominal bruising, then said his/her arm didn't hurt but the arm movement hurt his/her ribs. Physician advised the resident to go to the hospital for chest x-ray. The resident's representative and Director of Nursing notified.Review of the resident's Nurses Notes, dated 10/25/25, at 5:20 A.M., showed staff administered morphine sulfate concentrate (concentrated liquid morphine, medication for pain) 100 milligram (mg)/1 milliliter (ml) 0.25 ml administered for resident complaints of severe pain to left abdomen. Review of the resident's Medication Administration Record dated 10/25/25, at 5:20 A.M., showed the staff administered Morphine Sulfate concentrate 100 mg/ml, 0.25 ml, for pain rated a nine on a one to ten scale (ten being the worst pain). Review of the resident's Nurses Notes, dated 10/25/25 at 1:08 P.M., showed upon further research with the hospital, the resident fractured his/her seventh, eighth and ninth ribs. Review of the resident's emergency room record, dated 10/25/25, showed the resident was treated in the emergency room and three rib fractures were found on x-ray. The medical record showed no evidence of any new intervention or re-evaluation of the resident's care plan following identification of the rib fractures. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 10/30/25, showed the following: -Limited range of motion in one upper and one lower extremity;-Utilizes a wheelchair;-Requires partial/moderate assistance from staff for upper body dressing, personal hygiene, chair/bed-to-chair transfer, and toilet transfer;-Requires substantial/maximal assistance from staff for lower body dressing, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, tub/shower transfer, wheel 50 feet with two turns or wheelchair 150 feet;-Occasionally incontinent of urine;-Scheduled and as needed pain medication, and non-medication intervention for pain;-Pain present, effects sleep occasionally, limits day-to-day occasionally, highest rated, 7 (on a 1-10 scale, 10 being worst pain) in the last five days, -Two non-injury falls, and one injury fall since admission;-Receives antipsychotic, antianxiety, antidepressant and opioid medications (medications that increase the risk of falling);-Receives Hospice care;-No therapy or restorative nursing services. Review of the resident's Care Plan, updated 11/05/25, showed IDT reviewed the fall from 10/22/25, and implemented purposeful rounding. (14 days after the fall and there were no definitions or indications as to what purposeful rounding included). Review of the resident's Nurses Notes, dated 11/10/25 at 3:01 A.M., showed staff found the resident on the floor. The resident said he/she was going to the bathroom. Resident able to move all extremities without pain or discomfort. Resident vitals normal. Notified the resident representative, and neurological checks initiated. There was no documentation to show that the resident's physician or administration was notified as facility policy directed. Review of the resident's Fall risk assessment, dated 11/12/25, showed the resident scored a 31 and was high risk for falls. Review of the resident's medical record showed no evidence of an IDT review for the fall of 11/10/25. Review of the resident's Care Plan, updated 11/17/25, showed motion sensor in place in his/her room; ensure sensor was positioned to correctly pick up the resident's movements. Review of the resident's Nurses Notes, dated 11/28/25 at 2:30 P.M., showed the nurse entered the resident's room to answer his/her call light. The resident was in the fetal position in front of his/her bed with his/her cover on and pillow under his/her head. This nurse asked resident if he/she put him/herself on the floor and the resident said he/she did not remember. Resident said, I don't know how I got here, I just remember grabbing my pillow, so I didn't have to lay my head on the ground. Full head to toe assessment performed, vital signs obtained, neurological checks initiated. Hospice arrived during the assessment and was notified on site, DON notified, physician notified, resident's representative was notified. The resident said he/she turned his/her call light on to alert staff he/she was on the floor. Resident has a small skin tear to the outer left forearm. The resident had a motion detector alarm, but it was facing the door and not the resident, adjusted the monitor. Review of the resident's medical record showed no evidence of an IDT review for the fall of 11/28/25 or that education was provided to staff regarding the proper placement of the motion detector. Further review showed no evidence the resident's care plan was reviewed or updated with new interventions to prevent falls. Review of the resident's Nurses Notes, dated 12/13/25 at 7:11P.M., showed staff assisted the resident to walk from the dining room to the resident's room with a gait belt and a walker. When staff got the resident to the bathroom and turned away from resident, the resident tried to finish taking himself/herself to the toilet and fell between the toilet and the wall. No injuries noted, vital signs and neurological checks were initiated. Notified the resident representative, the on-call physician, the DON and hospice. Review of the resident's Fall risk assessment, dated 12/13/25, showed the resident scored a 27 and was high risk for falls. Review of the resident's Nurses Notes, dated 12/15/25 at 10:30 A.M., showed the nurse and an aide were walking down the resident's hall and noticed the resident trying to reach for his/her wheelchair. The resident reached too far and went down on to his/her knees from his/her bed in front of the wheelchair. The resident said, I was just trying to go to the bathroom. Staff assessed the resident and helped the resident back to his/her chair via a gait belt. DON, hospice and physician notified. No documentation to show staff notified the resident's representative after the fall on 12/15/25. Review of the resident's Fall risk assessment, dated 12/15/25, showed the resident scored a 25 and was high risk for falls. Review of the resident's Nurses Notes, dated 12/17/25 at 4:23 P.M., showed IDT reviewed the unwitnessed fall of 12/13/25. The resident was ambulating from dining hall to bathroom with walker and one staff assist using gait belt. Staff turned around and resident tried to sit down on his/her own and fell. Educated staff on proper gait belt usage. No documentation that the resident's care plan had been reviewed or updated with new interventions after this fall. Review of the resident's Nurses Notes, dated 12/17/25 at 4:28 P.M., showed IDT reviewed the witnessed fall of 12/15/25. It showed the resident attempted to get up on his/her own. The resident's wheelchair was not within reach of resident, the resident then fell onto his/her knees on the fall mat. Educated staff on placing walker and wheelchair at bedside to aide in resident transfers. No documentation that the resident's care plan had been reviewed or updated with new interventions after this fall. Review of the resident's Nurses Notes, dated 12/17/25 at 2:20 A.M. and 6:52 A.M., showed the resident came walking out of his/her room with his/her walker and attempted to run towards the nurse's station; the walker wheels got caught and the resident fell on the floor. The resident grazed his/her head in the doorway near the door frame and landed on his/her right side. The resident said he/she did not know how the fall occurred. The resident complained of 6/10 pain in the right side of his/her body near his/her hip. The resident repeatedly refused any pain medication. Hand grips equal and strong, vital signs normal. Hospice notified and advised not to send the resident to the hospital. The resident's representative was notified of the fall. There was no documentation to show staff notified the resident's physician or administration after the fall on 12/17/25. Review of the resident's Fall risk assessment, dated 12/17/25, showed the resident scored a 31 and was high risk for falls. Review of the resident's medical record showed no evidence of an IDT review following the fall on 12/17/25 or that the resident's care plan was reviewed or updated with new interventions to prevent falls. Review of the resident's Nurses Notes, dated 01/05/26 at 5:15 A.M., showed staff observed the resident on the floor in his/her bathroom. Range of motion normal. Resident assessed with no obvious injuries noted. Staff assisted the resident back to bed with assist of one staff member. Neurological checks initiated per house protocol. No documentation to show staff notified the resident's physician, resident's representative or administration after the fall on 01/05/25. Review of the resident's Fall risk assessment, dated 01/05/25, showed the resident scored a 30 and was high risk for falls. Review of the resident's medical record showed no evidence of an IDT review following the fall on 01/05/26 or that the resident's care plan was reviewed or updated with new interventions to prevent falls. Observation on 01/06/26 at 4:41 P.M., showed the surveyor heard a resident yell and then staff yell for help. Observation showed the resident's door; the resident was on the floor on his/her right side beside the floor matt. The resident said he/she fell to the floor and don't know what happened. The charge nurse and the DON went into the resident's room. During an interview on 01/06/26 at 5:15 P.M., Licensed Practical Nurse (LPN) B said the resident's motion detector did not go off prior to hearing the resident yell for help. Review of the resident's Care Plan showed the IDT reviewed the resident's fall of 01/06/26 and a new intervention of physical therapy and occupation therapy evaluation and treatment as soon as ordered or as needed. Review of the resident's Care Plan, updated 01/07/25, showed the following:-Witnessed falling of resident in the doorway of his/her room [ROOM NUMBER]/17/25;-Assist the resident to the bathroom at least every two hours and as needed, initiated for 12/17/25 fall;-Mat on floor beside the resident's bed when resident is in bed, initiated for 12/17/25 fall.(The interventions were added to the care plan 21 days after the resident's fall). During an interview on 01/07/26 at 11:51 A.M., the resident's representative said the following:-After the surveyor reviewed the list of resident falls with the resident representative, the resident's representative said the facility had not called him/her with notification of each of the resident's falls, he/she said the facility staff had called with a few of the falls but not all of them; -Staff did not call him/her to report the resident's fall on 01/05/26; -He/She expected staff to try to prevent falls; -The facility had not asked him/her about the resident's history of falls and possible interventions to put in place; -The resident was not cognitively able to pull the call light for help;-There was a motion detector above the sink to alert staff when the resident was up and moving;-He/She has been in the resident's room, and it was unplugged and therefore not working. 2. Review of Resident #6's face sheet showed the following:-Diagnoses included anemia (low iron level), dementia, depression and multiple traumatic fractures that included a pelvic fracture;-The resident has a resident representative. Review of the resident's Care Plan, last updated 04/28/25, showed the following:-Resident was high risk for multiple disease processes and recent history of fall with fractures;-Call light within reach and encourage the resident to call for assistance;- Call don't fall sign;-Gripper socks;-Remote motion sensor placed in the resident's room to alert staff when resident was attempting to transfer from bed without assistance (alarmed at the nurses station);-Gripper strips on the resident's floor beside the bed;-Limit the amount of disposable bed pads on the bed to decrease slipping;-Bed in low position when not providing care;-Place one side of the bed against the resident's wall, and a fall matt on the open side of the bed; resident forgets he/she is unable to ambulate without assistance;-Always keep items in reach;-Turn on night light at night;-Purposeful rounding added 04/28/25. The facility has no policy for purposeful rounding. Review of the resident's Nurses Notes, dated 7/23/25 at 4:53 P.M., showed the following:-Certified Nurse Assistants (CNA)s reported at approximately 4:00 P.M., the resident was found in another resident's room on the floor;-The resident was found on the floor on his/her left side and his/her head was on the bottom of the bedside table;-The resident had his/her wheelchair turned the opposite way and was wearing shoes during the fall;-Redness present on left side of the resident's face;-Assessment completed;-Due to the resident's cognitive level, the resident was unable to say how the fall occurred;-The resident said he/she hit his/her head during the fall, the resident said pain was present on the lower back and forehead;-Attempted to turn resident to his/her back and the resident winced and groaned in pain;-Called emergency medical services and the resident was picked up at 4:35 P.M. to be transported to the emergency room;-Notified the resident's power of attorney, physician and Director of Nursing (DON). Review of the resident's Nurses Notes, dated 07/23/25 at 9:45 P.M., showed the nurse took report at 9:45 P.M. from the resident's nurse at the hospital. The hospital nurse reported the resident had a displaced fracture of the right and left iliac crest (portion of the pelvic bone), and his/her sacrum (an additional part of the pelvic bone). The hospital nurse reported their care team had a phone conference with orthopedic surgeons and ultimately decided to transfer him/her to another hospital. Review of the resident's medical record showed no evidence of an IDT review following the resident's fall with fractures on 07/23/25. Review of the resident's care plan, updated 07/30/25, showed recent fall with fractures. There were no new interventions added to the care plan to prevent further falls. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 07/31/25, showed the following:-Moderate cognitive impairment; -Wandering behavior present one to three days;-Limited range of motion in both upper extremities;-Wheelchair use;-Independent with wheeling 50 feet with two turns;-Requires supervision/touching assistance from staff members to roll left and right, wheel 150 feet; -Requires partial/moderate assistance from staff for to go from sitting to lying flat, sitting on the bed, chair/bed-to-chair transfer-Requires substantial/maximal assistance from staff to shower/bathe, sit to stand, toilet transfer, tub/shower transfer,-Dependent on staff for toileting hygiene, lower body dressing, and putting on/taking off footwear;-Frequently incontinent of bladder and always incontinent of bowel;-Diagnosis of fractures from trauma, osteoporosis (bone disease making bones weak, thin, and brittle by decreasing bone density and mass), dementia, depression and pelvic fractures; -One major injury fall since last assessment; -Receives antidepressant medication. Review of the resident's Nurses Notes, dated 08/01/25 at 5:08 P.M., showed the resident was found on the ground by a neighboring resident who notified nursing staff that he/she had fallen. Resident denies hitting his/her head or having pain. No bruising/ injury noted at this time, vital signs within normal limits, neurological checks initiated. Family was present at time of fall. The DON and physician were notified. Review of the resident's Nurses Notes showed no evidence of an IDT review following the resident's fall on 08/01/25. Review of the resident's Care Plan, last updated 08/06/25, showed a new intervention to provide activities as needed to engage the resident. There was no documentation regarding the fall of 08/01/25 or new interventions specific to fall prevention. Review of the resident's Nurses Notes, dated 08/14/25 at 6:20 P.M., showed staff found the resident on his/her buttocks on the floor in front of bathroom toilet in another resident's room. Resident was alert and showing no sign of distress. Neurological checks were initiated at 6:20 P.M. and vital signs within normal limits. Resident reports no pain currently. All appropriate parties notified. Review of the resident's record showed no evidence of an IDT review following the fall on 08/14/25. Review of the resident's Care Plan showed no reevaluation of the resident's care plan, no revision of current interventions or new interventions added after the fall on 08/14/25. Review of the resident's annual MDS, dated [DATE], showed the following:-Severe cognitive impairment; -No acute mental status change;-Independent with going from lying to sitting on the bed, and wheels 50 feet with two turns;-Requires supervision/touching assistance from staff members to wheel 150 feet; -Requires substantial/maximal assistance from staff to shower/bathe, roll left and right, sit to lying, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer;-Two non-injury falls since last assessment. Review of the resident's Nurses Notes, dated 12/09/25 at 6:59 A.M., showed the following:-At approximately 6:35 A.M., the CNA alerted this nurse that resident was on the floor;-Upon entering the resident's room, the resident was lying on his/her left side towards the bed on the fall mat;-Resident said he/she did not hit his/her head and ended up rolling off bed while sleeping;-Resident noted to have pain in left shoulder rated 5/10, as needed (PRN) Tylenol administered;-Assessment completed;-Notified DON at 6:56 A.M, notified resident representative at 7:00 A.M., and on call physician at 6:45 A.M.-Neurological checks initiated. Review of the resident's fall assessment, dated 12/09/25, showed the resident scored a 30 on his/her fall risk assessment, indicating the resident was high risk according to the assessment. (no fall assessment had been completed with any of the previous falls). Review of the resident's record showed no evidence of an IDT review of the resident's fall on 12/09/25. Review of the resident's Care Plan showed no reevaluation of the resident's care plan, no revision of current interventions or new interventions added after the fall on 12/09/25. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-As needed pain medications and non-medication intervention for pain;-One non-injury fall since last assessment;-New opioid medication. Observation on 01/06/26 at 10:48 A.M., of the resident's room showed remnants of gripper strips (glue residue in strip shape) in the middle of the resident's room and no gripper strips by the resident's bed as directed in the resident's care plan. Observation showed no motion sensor or call don't fall signage in the resident's room as the care plan directed.3. During an interview on 01/09/26 at 7:35 P.M., Certified Nurse Assistant (CNA) E said staff know who has been falling from report and the resident's falls and interventions should be on their care plans. During an interview on 01/09/26, at 6:20 P.M., Licensed Practical Nurse (LPN) B said the following:-He/She worked as a charge nurse;-Interventions in place to prevent falls are expected to be on the care plan;-Staff attempt to determine what caused the fall; that documentation should be documented in the IDT notes; IDT reviews the documentation and updates the care plans; -Resident #5 and Resident #6 have had a lot of falls;-Resident #5 was confused and wandered a lot. The resident was found many times in other residents' rooms on the floor near the bathroom or trying to get into be. The resident was not on a toileting or nap schedule; -Resident #6 was newer to the facility and was confused and forgets he/she needs help; - The motion detector had not been alarming like it should. During an interview on 01/09/26, at 8:53 P.M., the DON said the following:-After a resident falls staff respond to the fall, and the charge nurse will assess and treat the resident for injuries;-The charge nurse should document the fall, and find an intervention to prevent further falls and add it to the care plan;-The charge nurse should notify the DON, resident representative and the resident's physician when a fall happened. If the fall happened in the middle of the night and the resident had no injury, notification could be made the next morning or as soon as possible. During an interview on 01/15/26, at 4:10 P.M., the Medical Director (and Resident #6's physician) said the following:-Staff are expected report to the resident's physician if a resident has a fall;-The physician would review medications, and see if any with side effects could be discontinued; He had not done this for Resident #6 recently;-Nursing should try to identify the root cause of a fall and implement interventions to prevent falls;-Staff are expected to follow policies for fall prevention.

Based on observation, interview and record review, the facility failed to provide restorative nursing services to assist one resident (Resident #9), in a review of 17 sampled residents, to attain or maintain his/her highest level of functioning. Resident #9, who had contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and a physician order for participation in a Restorative Nursing program six days a week, had not been provided with this service since the order start date of 04/04/25. Resident #9 had a decrease in his/her range of motion abilities and required additional muscle relaxant medication to control his/her contracture pain. The facility census was 40. Review of the facility's policy, Restorative Nursing Services, revised July 2017, showed the following:-Residents will receive restorative nursing care as needed to help promote optimal safety and independence;-Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies);-Residents may be started on a restorative nursing program upon admission, during the stay, or when discharged from rehabilitative care;-Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care;-The resident or representative will be included in determining goals and the plan of care;-Restorative goals may include, but are not limited to, supporting and assisting the resident in: -Adjusting or adapting to changing abilities;-Developing. Maintaining or strengthening his/her physiological and psychological resources; -Maintaining his/her dignity, independence and self-esteem; and -Participating in the development and implementation of his/her plan of care. 1. Review of Resident #9's face sheet showed the following:-The resident had a family member as his/her responsible party;-Diagnoses included stroke, hemiplegia and hemiparesis (hemiplegia is the complete paralysis of one side of the body, while hemiparesis is a partial weakness affecting one side) affecting left non-dominant side; contracture of muscle, and monoplegia (weakness or paralysis affecting only one limb, typically an arm or leg, resulting from damage to the part of the brain or nervous system controlling that limb) of lower limb affecting right dominant side. Review of the resident's Physician Order Recap Report showed orders for the following:-May participate in Restorative Nursing program six days a week with an order start date of 04/04/25;-Tizanidine HCL (short-acting muscle relaxant) tablet 2 milligrams (MG), give one tablet by mouth two times a day for muscle relaxant, start date 03/26/25. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/30/25, showed the following:-Diagnoses included stroke and hemiplegia and hemiparesis;-Dependent on staff for oral hygiene, toilet hygiene, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, chair/bed to chair transfer, and tub/shower transfer, upper and lower body dressing;-Dependent on staff for locomotion in wheelchair;-Upper extremity impairment on one side in functional limitations in range of motion (ROM) (the full extent and direction a joint can move, measured in degrees, assessing flexibility and function, crucial for diagnosing issues like stiffness or injury, and improved through exercises (active/passive) to maintain mobility for daily activities);-Lower extremity impairment on both sides in functional limitations in ROM;-Restorative nursing program had been completed for passive range of motion (the extent a joint can move when an external force, like a physical therapist or machine, moves the limb or body part, without the patient using their own muscles to create the motion) (PROM) and training and skill practice with eating and/or swallowing for at least 15 minutes for one day;-Had restorative ROM passive training and skill practice with eating and/or swallowing. Review of the resident's care plan, revised 04/30/25, showed the following:-Focus: The resident had contractures of his/her bilateral upper extremities and bilateral lower extremities;-Goal: The resident will not have any negative effects from his/her contractures through the review date, date initiated 10/30/24;-Interventions: He/She was on restorative nursing program six days a week for PROM and eating, date initiated 04/04/25;-He/She was on the restorative program, date initiated 04/24/25;-Range of motion as outlined by therapy, date initiated 10/30/24; -Focus: The resident has pain related to multiple disease processes, revision date 04/30/25;-Goal: The resident will voice a level of comfort through the review date, revised on 04/30/25;-Interventions: Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care, date initiated 11/18/24;-Focus: The resident has an activities of daily living (ADL) self-care performance deficit related to multiple disease processes; date revised on 10/30/24;-Interventions: Restorative program - PROM to left hand and right and left leg; active (the extent to which a person can voluntarily move a joint using their own muscles, without any external help, demonstrating functional movement, muscle strength, coordination, and willingness to move) ROM;-Focus: The resident has limited physical mobility, date revised 04/30/25;-Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date, date revised 04/30/25. Review of the resident's medical record from 04/04/25 through 08/05/25, showed no documentation staff completed PROM six days a week for the resident as ordered or as the care plan directed. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Diagnoses included stroke and hemiplegia and hemiparesis;-Dependent on staff for oral hygiene, toilet hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, chair/bed to chair transfer, and tub/shower transfer;-Upper extremity impairment on one side in functional limitations in ROM;-Lower extremity impairment on both sides in functional limitations in ROM;-No restorative nursing program documented. Review of the resident's medical record from 08/06/25 through 12/19/25, showed no documentation staff completed PROM six days a week for the resident as ordered or as the care plan directed. Review of the resident's physician progress notes, dated 12/19/25, showed the following:-Chief complaint: The resident wanted a stronger muscle relaxer;-Primary history: Stroke; the resident has muscle spasms and contractures and would like muscle relaxer;-Exam: There is muscle weakness and gait abnormality and limited ROM; neurologically the resident is weak and contracted;-Diagnoses: Flexion contractions (a joint stuck in a bent (flexed) position, unable to straighten fully, caused by structural changes (shortened muscles, tendons, ligaments) from issues like injury, prolonged immobility, or disease, leading to chronic loss of motion, stiffness, and impaired movement, commonly affecting knees, hips, or fingers) and hemiplegia and hemiparesis following a stroke affecting left non-dominant side;-Plan: Flexion contractures: Increase Zanaflex (brand name for tizanidine) (short-acting muscle relaxant) from 2 MG twice daily to 4 mg three times daily as requested by the resident. Review of the resident's progress notes, dated 12/19/25 at 5:46 P.M., showed provider in house today to round on this resident and increased tizanidine 2mg from one tab two times a day (BID) to two tabs three times a day (TID). Review of the resident's Physician Order Recap Report showed the resident had orders for the following:-May participate in Restorative Nursing program six days a week with an order start date of 04/04/25;-Tizanidine hcl tablet 2 mg, give one tablet by mouth two times a day for muscle relaxant, start date 03/26/25, end date 12/19/25;-Tizanidine hcl tablet 2 mg, give two tablets by mouth three times a day for muscle relaxant, start date 12/19/25. Review of the resident's medical record from 12/19/25 through 12/30/25, showed no documentation staff completed PROM six days a week for the resident as ordered or as the care plan directed. Review of the resident's progress notes dated 12/30/25 at 11:15 P.M., showed the following:-Behavior note: Overuse of the call light system, pressing call light three times per hour during bedtime cares, for repositioning and bed comfortability;-Non-pharmacological interventions: Repositioning by nursing staff. Review of the resident's medical record from 12/31/25 through 01/07/25, showed no documentation staff completed PROM six days a week for the resident as ordered or as the care plan directed. Observation on 01/07/26 at 6:20 A.M., 6:50 A.M. and 4:09 P.M., showed the following:-The resident lay on his/her right side in bed;-His/Her left arm was drawn up and his/her left hand was contracted and closed;-The resident's legs were drawn up in the fetal position;-The resident had contractures at the knee, left arm and left hand;-Certified Nurse Aide (CNA) F came into the resident's room and assisted him/her to move; the resident was unable to straighten his/her legs, left arm or hand;-CNA F did not perform any stretches (ROM) exercises for the resident during cares. Observation on 01/07/26 at 4:09 P.M., showed the following:-The resident was in his/her bed;-His/Her left arm was drawn up and his/her left hand was contracted and closed;-The resident's legs were drawn up in the fetal position;-The resident had contractures at the knee, left arm and left hand;-CNA K entered the resident's room to assist the resident up out of bed;-During cares, CNA K did not perform any stretches (ROM) exercises for the resident. During an interview on 01/07/26 at 7:16 A.M. and 7:48 A.M., the resident said the following:-There had been no restorative nursing program for the past two months;-He/She felt he/she could benefit from a restorative program;-He/She felt a lot stiffer in his/her left arm and legs and has had discomfort in his/her left arm since stopping restorative nursing program; -He/She had to be repositioned by staff because he/she was uncomfortable and due to his/her contractures and could not do it him/herself; -He/She felt his/her contractures had gotten worse;-He/She had increased stiffness and soreness and could not roll over without help from staff;-His/Her sleep had been affected, and he/she was unable to stay asleep due to discomfort;-He/She had an increase in agitation and frustration because he/she felt his/her contractures were getting worse due to no restorative nursing program. During an interview on 01/08/26 at 2:42 P.M., the resident's responsible party said the following:-The resident should be getting restorative therapy;-Some of the staff had helped the resident with range of motion exercises in the past and it had helped the resident feel better and he/she was not as stiff and sore. During an interview on 01/09/26 at 6:20 P.M., CNA E said the following:-Currently, there was no restorative nursing program at the facility;-He/She would stretch the resident during his/her shift; -The resident had gotten more tense;-The resident had gotten stiffer and had been more uncomfortable since restorative therapy had stopped. During an interview on 01/09/26 at 3:34 P.M., Licensed Practical Nurse (LPN) B said the following:-The facility used to have a restorative nursing program;-Staff who used to do restorative with the resident said after a few days of working with him/her he/she seemed looser;-The resident has used his/her call light more frequently to be repositioned. During an interview on 01/09/26 at 8:53 P.M., the Director of Nursing (DON) said the following:-There was no restorative nursing program; -Therapy had completed training with the CNAs to train them on range of motion. During an interview on 01/07/26 at 11:29 A.M., the administrator said there was no restorative nursing program at this time. The facility had not had a program in place for the past two months and he was working on getting a restorative nursing program started again, but did not have a start date yet. During an interview on 01/15/26 at 4:10 P.M., the Medical Director said the following:-He is the resident's physician;-He expected staff to follow physician orders;-Staff had not notified him the resident was not getting range of motion;-He would expect the facility to provide restorative nursing services; -Not getting range of motion can cause pain, stiffness or worsening of contractures;-The facility did not make him aware the resident was having more pain, stiffness, or worsening of contractures.

Based on interview and record review, the facility failed to ensure one resident (Resident #34), in a review of 17 sampled residents, was free from abuse by staff. Certified Nursing Assistant (CNA) J slapped the resident in the face with a dirty incontinent product, was physically rough with the resident causing the resident pain and discomfort, spoke to the resident in a harsh tone and told the resident he/she could complete tasks that the resident requested help for. CNA J's actions were witnessed by Resident #34's roommate. The interaction made Resident #34 feel unsafe and angry. The facility census was 40. The administrator was notified of the past noncompliance on 01/09/26, which occurred on 01/04/26. On 01/05/26, the facility placed the agency charge nurse and aide on a Do Not Return list (meaning they could not return to the facility for a work assignment) for the allegation of staff to resident abuse. In-servicing of staff on abuse was conducted and the facility began their investigation into the allegation. In-servicing was completed on 01/06/26. This deficiency was corrected on 01/06/26 Review of the facility policy, Abuse, Prevention and Prohibition Policy, revised 2021, showed the following: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion;-Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals;-This facility prohibits mistreatment, neglect or abuse of residents;-This presumes that all instances of abuse can cause physical harm, pain or mental anguish;-Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish;-Mental abuse includes but is not limited to, humiliations, harassment and threats of punishment or deprivation;-Neglect means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress. 1. Review of Resident #34's face sheet showed the following: -He/She was responsible for self;-Diagnoses include unspecified dementia (a clinical term for cognitive decline such as memory loss or thinking problems that could affect daily life), unspecified low back pain, neuralgia and neuritis (sharp, shocking nerve pain and inflammation of the nerve, causing pain, tingling and weakness) and osteoarthritis (a degenerative joint disease causing pain, stiffness, swelling and reduced mobility). Review of the resident's care plan, revised 01/06/25, showed the following: -The resident was at risk for falls, encourage him/her to prepare for bedtime, assist with dressing and toileting prior to going to bed;-The resident had an activities of daily living (ADL) self-care performance deficit and required one assist with undergarment change and peri-care, and one assist with dressing, transfers and toileting. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/02/25, showed the following:-Cognitively intact;-Adequate hearing and clear speech;-No delirium, hallucinations, behaviors or rejection of cares;-Set up or clean up assistance required for toileting hygiene, upper and lower body dressing;-Supervision or touch assistance from staff for sitting to standing transfers and toilet transfers;-Occasional pain that interfered with day-to-day activities. Review of the resident's electronic health record, nursing progress notes, from 01/04/26 through 01/05/26, showed the following:-On 01/05/26, at 6:39 P.M., charge nurse was directed to do a full skin assessment of the resident. The resident made allegation of abuse toward an agency staff member;-No progress note indicated for the date of the allegation. During an interview on 01/06/26 at 4:04 P.M., the resident said the following: -Last Sunday night at bedtime, he/she asked a staff member to help him/her get ready for bed;-The staff member, someone from an agency that did not work at the facility full time, told him/her do it yourself;-He/She explained he/she needed help with his/her brief change (incontinent product) and the agency staff member said, no, you don't need help;-The resident took his/her brief off, the agency staff member took it and slapped the resident in the face with it;-He/She asked for help and the agency staff member said, for what, you can do it yourself;-He/She did not know the agency staff member's name; agency staff do not wear name tags; when he/she asked the agency staff his/her name, the agency staff member said, for what?;-The agency staff gave a name of a staff member that was working (Nurse Aide NA G), but the resident knew that staff member and he/she was not in the room;-The agency staff member jerked him/her around and it made the resident's shoulder hurt. The agency staff member pulled his/her brief up and pinched the resident;-He/She told the agency staff, don't pinch me and the agency staff said, I'm not; the aide was rude and short in the way he/she spoke to him/her; -The way the agency staff member treated him/her made him/her angry and he/she felt unsafe because of the way he/she was treated;-He/She reported the incident to NA G. During an interview on 01/09/26 at 1:43 P.M., NA G said the following:-He/She was working over his/her regular scheduled shift until 9:00 P.M. on 01/04/26;-Agency staff, Certified Nurse Aide (CNA) J, was assigned to Resident #34's hall and an agency nurse was the charge nurse;-He/She was checking to make sure everyone was ready for bed before he/she left for the night;-Resident #34 said he/she was not feeling very well after the way he/she was treated by the other aide;-Resident #34 said, the other aide was aggressive, and the aide slapped him/her in the face with the resident's brief;-The resident said the other aide was very rough when taking his/her clothes off and jerked him/her around;-NA G reported to the charge nurse what occurred;-When he/she asked the resident who the other aide was, the resident described the staff member as having a big tattoo on his/her arm;-The only staff member working meeting the description was Certified Nurse Aide (CNA) J, the staff assigned to the resident's hall. 2. Review of the facility staffing assignment sheet for the night shift on 01/04/26 showed CNA J was assigned to the resident's hall from 7:00 P.M. thru 7:00 A.M.; review of the facility provided agency staff list, listed CNA J as working for the agency the facility used for staffing. 3. Review of Resident #37's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Adequate hearing and vision;-No delusions or hallucinations. During an interview on 01/06/26 at 12:26 P.M., the resident said the following:-There was one person that did not treat his/her roommate, Resident #34, very nice the other night; that person worked for an agency; -The agency aide came in the room and took Resident #34 to the bathroom, and then he/she heard Resident #34 say, stop pinching me, you are pinching me;-The agency staff member said, I'm not pinching you; I'm just trying to care for you;-He/She did not see that part because they were in the bathroom, but the door was open, and he/she could hear the conversation;-The agency aide was really pushing Resident #34's buttons and told the resident he/she wasn't going to help the resident get ready for bed; he/she could do it himself/herself;-Resident #34 asked the agency aide what his/her name was; he/she was not wearing a name tag, and the agency staff said, [NAME] - my name is [NAME];-The resident knew [NAME] and the agency aide was not [NAME];-He/She saw the agency aide smack Resident #34 back and forth in the face with gloves, back and forth a few times, in the resident's room;-The privacy curtain was not pulled because Resident #34 does not like it pulled;-The agency aide was very rude and disrespectful in the way he/she talked to Resident #34 and the tone he/she was using was harsh; the aide was very mean to the resident;-This happened about 8:30 P.M. the other night;-Resident #34 did not deserve to be treated that way;-The whole interaction made him/her feel uncomfortable;-He/She did not report this to anyone because Resident #34 reported it to staff; he/she was asked about it the next day. 4. Review of the facility investigation, Initial Reporting Form, completed by the administrator, dated 01/05/26, showed the following: -Allegation type: abuse, physical;-NA G reported that Resident #34 came to him/her at 9:00 P.M. (on 01/04/26) and said he/she was not feeling very well after an aide left his/her room;-The resident said an aide had slapped his/her face with his/her dirty incontinent product;-The staff member told the resident to take of his/her shirt himself/herself and would not listen to the resident when he/she asked the staff member for help;-The resident said he/she also hit his/her hand on the door when he/she came out of the bathroom;-The resident reported to NA G the staff member was very rough and that his/her body now hurt because of the way he/she was handled;-The resident voiced he/she was pinched, with no bruise noted;-Do Not Return (DNR) of agency CNA J and reached out to the agency used for staffing;During an interview on 01/06/26 at 10:00 A.M and 01/09/26 at 8:53 P.M., the administrator said the following: -CNA J and LPN M, who were working at the time of the allegation, have been placed on the Do Not Return list and will not be back at the facility due to the allegation of abuse and not reporting it to Director of Nursing or himself; -Abuse and neglect training took place 01/05/26 and 01/06/26 for all staff;-The local law enforcement organization (LEO) was contacted and a statement from CNA J was collected by the LEO pertaining to the allegation;-NA G has been educated on the process to report allegations of abuse or neglect. 2707975

Based on observation, interview, and record review, the facility failed to develop complete policies and procedures to monitor the facility's water system and implement the facility policy to monitor for Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease that included specific control parameters based on the Center for Disease Control and Prevention (CDC) and the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)) standards. The facility failed to follow infection control practices when staff failed to utilize proper Transmission Based Precautions (TBP) when caring for one resident (Resident #34), who was positive for COVID (coronavirus disease 2019 - a contagious respiratory disease) infection and in isolation. The facility failed to ensure a barrier was utilized during use of a blood glucose monitor (device used to evaluate a drop of blood to determine the amount of sugar in the blood) for two residents (Resident #3 and #29) and one additional sampled resident (Resident #15). The facility failed to ensure the multi-use blood glucose monitor was properly cleaned after each resident use for two residents (Resident #3 and #29). The facility failed to ensure Tuberculin Skin Tests (TST) were completed and documented in accordance with the requirements for Tuberculosis (TB) (infectious bacterial disease that affects the lungs) testing for long-term care employees when the facility failed to ensure the first-step TST was administered and read in the appropriate time frame for two employees (Licensed Practical Nurse (LPN) B and Housekeeper O) in a review of 10 newly hired employees and failed to ensure the second-step TST was administered and/or read in the appropriate time frame for one employee (Certified Occupational Therapy Assistant (COTA) O). The facility census was 40. 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:-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 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. Review of the undated, Centers for Disease Control and Prevention Legionella Environmental Assessment Form, showed Legionella generally grew 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. Review of the Centers for Disease Control Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings Toolkit, dated 06/24/21, showed the following: -Clinicians should test patients with healthcare-associated pneumonia (pneumonia with onset 48 hours after admission) for Legionnaires' disease. This is especially important among patients at increased risk for developing Legionnaires' disease (see Appendix B), among patients with severe pneumonia (particularly those requiring intensive care), or if any of the following are identified in your facility: -Other patients with healthcare-associated Legionnaires' disease diagnosed in the past 12 months;-Positive environmental tests for Legionella in the past 2 months; -Current changes in water quality that may lead to Legionella growth (e.g., low residual disinfectant levels, temperatures permissive to Legionella growth, nearby construction, areas of stagnation); -Other patients, besides those with healthcare-associated pneumonia, should also be tested for Legionnaires' disease (see Appendix B). The preferred diagnostic tests for Legionnaires' disease are culture of lower respiratory secretions on selective media and the Legionella urinary antigen test.-Symptoms of Legionella include headache, confusion, cough, shortness of breath, nausea, vomiting, diarrhea, fever, chills, tiredness, muscle or body aches;-Symptoms usually begin two to ten days after being exposed to Legionella. Review of the undated, facility Legionella Water Management Program, showed the following:-Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella;-As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team;-The water management team will consist of at least the following personnel: Infection preventionist, administrator, medical director (or designee), director of maintenance, and director of environmental services;-The purpose of the water management program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease;-The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing a Legionella water management program;-The water management program includes the following elements: 1. An interdisciplinary water management team; 2. A detailed description and diagram of the water system in the facility, including receiving, cold water distribution, heating, hot water distribution; and waste; -The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers, humidifiers, hot tubs, fountains, and medical devices such as CPAP machines, hydrotherapy equipment; etc.;-The identification of situations that can lead to Legionella growth, such as construction, water main breaks, changes in municipal water quality, the presence of biofilm, scale or sediment, water temperature fluctuations, water pressure changes, water stagnation and inadequate disinfection;-Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants);1. The control limits or parameters that are acceptable and that are monitored;2. Diagram of where control measures are applied;3. System to monitor control limits and the effectiveness of control measures;4. Plan for when control limits are not met and/or control measures are not effective; and;5. Documentation of the program;-The Water Management Program will be reviewed at least once a year, or sooner if any of the following occur:a. The control limits are consistently not met;b. There is a major maintenance or water service change;c. There are any disease cases associated with the water system; or;d. There are changes in laws, regulations, standards or guidelines.Review of the facility's Legionella policy, dated 01/14/23, showed the previous administration had developed a water flow map and had parts of the CDC Legionella tool kit in the binder. The binder included the members of the water management team by staff name and their responsibilities. All the staff listed were former employees that were no longer employed by the facility. Review of the facility Water Safety Management Assessment and Plan, dated 01/14/23, showed the following:The building is a healthcare facility where residents stay overnight, and house/treat people who have chronic and acute medical problems or weakened immune systems;-The building primarily house people older than sixty-five years old;-The facility must have a water management program for hot and cold-water distribution system;-The facility water flow map was last updated 01/14/23 (the plan had not been reviewed yearly as the Legionella Water Management Program policy directed). Upon request, the facility was not able to provide a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system as CMS directed. 1. Review of the facility Antibiotic Stewardship Log, dated 09/01/25-12/31/25, showed the following:-Resident #116 was diagnosed with pneumonia on 09/25/25; no documentation to show the resident was tested for Legionnaires' disease;-Resident #45 was diagnosed with pneumonia on 10/6/25; no documentation to show the resident was tested for Legionnaires' disease;-Resident #31 was diagnosed with pneumonia on 11/6/25; no documentation to show the resident was tested for Legionnaires' disease. During an interview on 01/08/26 at 5:46 P.M., the facility Infection Preventionist (IP) said the following:-Legionella is a water borne disease;-Maintenance staff would be the water management team, so she is not on the water management team;-She does not know how to test for Legionella; -They do not do any screening or testing for residents with new cases of pneumonia for possible Legionella. During an interview on 01/09/26 at 9:05 A.M., the Maintenance Director said the following:-He just started this week;-He does not know what Legionella is, or the ASHRAE guidelines; -He knows to check to make sure the water was hot but not scalding;-He did not know if there was a water management policy or if there was a water flow map for the facility;-He was not sure what the water temperatures should be; -He has not seen the facility water temperature documentation. During an interview on 01/09/26 at 9:10 A.M., the Director of Nursing (DON) said the following:-She did not know if the facility had a water management team; -She did not know what the signs and symptoms of Legionella infection were; nursing was not monitoring for Legionella. During an interview on 01/09/26 at 9:15 A.M., the Administrator said the following:-The facility did not have an active water management team;-The facility was expected to check water temperatures and do test sticks, but he was not sure what the test sticks measured;-He did not know if the facility implemented the CDC Legionella toolkit;-He was not familiar with ASHRAE guidelines;-The facility did not have a water management program at this time;-He had not seen the facility water temperature documentation and did not think they had any water temperatures documented. 3. Observation of water temperatures on 01/09/26 at 10:00 A.M. to 10:36 A.M., showed the following water temperatures fell between 77 and 113 degrees, temperatures at which legionella generally grows well:-At 10:00 A.M., occupied resident room [ROOM NUMBER] sink, hot water temperature measured with a digital thermometer read 105 degrees Fahrenheit (F); -At 10:05 A.M., occupied resident room [ROOM NUMBER] sink, hot water temperature measured with a digital thermometer read 104.3 degrees F; -At 10:13 A.M., occupied resident room [ROOM NUMBER] sink, hot water temperature measured with a digital thermometer read 107.2 degrees F; -At 10:15 A.M., 200 hall women's shower room, shower head read with a digital thermometer showed the hot water read 104.5 degrees F, the shower head had very low water pressure and scaling;-At 10:27 A.M., 200 hall men's shower room, shower head read with a digital thermometer showed the hot water read 104.5 degrees F, the shower head had very low water pressure and scaling. 4. Review of the facility's COVID-19 Action Plan, updated 05/22/23, showed the following: -Policy statement: The practices are based on infection prevention and control recommendations form the CDC, Centers for Medicare and Medicaid Services (CMS), World Health Organization (WHO);-Source Control: refers to use of respirators, well-fitting face masks, or well-fitting cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing;-PPE for healthcare personnel (HCP) who enter the room of a resident with suspect or confirmed COVID-19 should adhere to standard precautions and use a NIOSH approved respirator with N95 filters or higher, gown, gloves, and eye protection (goggles or face shield). 5. Review of Resident #34's electronic health record showed the resident had a positive diagnosis of COVID on 01/05/26. Observation on 01/07/26 at 6:38 A.M. showed the following: -Resident #34 had his/her call light activated;-The resident was in an isolation room due to a diagnosis of Covid; the door was closed with a droplet precautions sign on the outside of the resident's door and a PPE cart directly outside the resident's room that included N95 masks, goggles, gloves and gowns; the signage instructed staff to utilize gowns, gloves and mask (not specifically N95);-Certified Nurse Assistant (CNA) I was wearing a black surgical mask;-CNA I entered the resident's room at 6:38 A.M. and provided care with no PPE applied or N95 mask applied per facility policy;-CNA I exited the resident's room at 6:45 A.M., performed hand hygiene with alcohol based hand sanitizer, continued to wear the same black surgical mask, answered another resident's call light (this resident was not in an isolation room) and assisted the resident with a transfer and to use the bathroom. During an interview on 01/07/26 at 6:58 A.M., CNA I said the following:-Resident #34 was on isolation due to a diagnosis of Covid;-When caring for a Covid resident, staff should wear a gown, gloves and an N95 mask;-He/She did not apply a gown or N95 to care for the resident because the resident was on the commode, and he/she was unsure how long the resident's call light had been going off;-He/She would normally put on all the PPE, gown, gloves, N95 mask or goggles, when going into a Covid positive resident room, but did not with Resident #34 because he/she was in a hurry;-Without using proper PPE, the infection could be spread to another resident or staff member. During an interview on 01/08/26 at 1:30 P.M. and 01/09/26 at 8:53 P.M., the DON said the following:-The facility followed CDC guidelines on PPE use for residents on isolation due to COVID positive status;-She expected staff to apply a gown, gloves, N95 face mask and eye protection when entering a COVID positive room to provide any resident care. 6. Upon request, the facility did not provide a policy related to blood glucose testing. 7. Review of the undated American Health Care Association, Tips for Meeting the Cleaning and Disinfection of Blood Glucose Meters Requirements in Skilled Nursing Facilities, showed the following: -Place barrier under blood glucose meter when in resident's room or placed on top of medication cart to avoid spread of microorganisms and contamination of surfaces and other equipment or supplies;-Tip: Place clean and dry paper towel(s) under blood glucose meter before placing on resident table or on top of medication cart. 8. Review of the undated Sani-Cloth Germicidal Disposable Wipes online manufacturer's instructions for use showed the following:-Sani-Cloth wipes are used for fast-acting, broad-spectrum disinfection of hard, non-porous surfaces in healthcare settings;-To use: remove visible soil, wipe the surface thoroughly with a fresh cloth to ensure it remains visibly wet for the required contact time (2 minutes for Super Sani-Cloth);-Key Procedures for Use:-Disinfecting: Using a new wipe, thoroughly wipe the surface, ensuring all areas and crevices are covered.Contact Time: The surface must remain visibly wet for the full, EPA-registered contact time specified on the canister (typically 2 minutes depending on the product);-Drying & Disposal: Allow the surface to air dry completely. 9. Review of Resident #15's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/12/25, showed the resident had a diagnosis of diabetes mellitus (a chronic disease process where there is too much sugar in the blood stream). Observation on 01/08/26 at 5:50 P.M., showed the following: -The IP removed supplies and a multi resident used glucometer from the medication cart drawer and laid them on the top of cart without a barrier; -The IP took the supplies into the resident's room, and without preparing a barrier, placed the supplies, including the single test strip, on the resident's bedside table; -Items on the resident's bedside table included two empty food packets, a urinal half full of yellow urine, an empty urinal and food crumbs in the same location of the blood glucose testing supplies;-The IP completed the Accu check procedure, rolled the supplies up (including the lancet and blood filled test strip) into her gloves, removed the gloves and threw them into the resident's trash can and performed hand hygiene with an alcohol based hand sanitizer;-The IP took the glucometer and placed it on top of the medication cart;-The IP cleaned the glucometer with a purple top Sani-wipe for approximately 2-3 minutes, threw the wipe away and placed the glucometer on top of the medication cart; the top of the medication cart had not been cleaned and no barrier under the glucometer. During an interview on 1/8/25, at 6:03 P.M., the IP said the following: -She should have placed a barrier on the resident's bedside table prior to placing the blood glucose testing supplies on the table;-The glucometer should not have been placed on the medication cart without a barrier, after the glucometer had been cleaned;-A barrier should have been placed on the medication cart to place the glucometer on to allow it to air dry. 9. Review of Resident #3's quarterly MDS, dated [DATE], showed the resident had a diagnosis of diabetes mellitus. Observation on 01/07/26 at 5:42 P.M., showed the following: -LPN B had just used the multi resident use glucometer on a resident and sat it on top of the medication cart without a barrier; -LPN B took two Sani-wipes out of a purple top container and placed the glucometer between the two wipes and left it sitting for two minutes;-LPB B picked up the glucometer and threw the wipes away;-LPN B did not rub the glucometer off with the wipes;-LPN B placed the glucometer back on top of the medication cart;-The top of the medication cart had not been cleaned and no barrier placed for the glucometer. Observation on 01/07/26 at 5:46 P.M. and 5:49 P.M., showed the following:-LPN B placed the glucometer directly on top of Resident #3's left leg while he/she cleaned the resident's finger with an alcohol pad;-LPN B performed the Accu check procedure and sat the glucometer directly on top of the medication cart without a barrier;-LPN B took two Sani-wipes out of a purple top container and placed the glucometer between the two wipes and left it sitting for two minutes;;-At 5:49 P.M. LPB B picked up the glucometer and threw the wipes away;-LPN B did not rub the glucometer off with the wipes;-LPN B placed the glucometer directly on top of the medication cart without a barrier. 10. Review of Resident #29's quarterly MDS, dated [DATE], showed the resident had a diagnosis of diabetes mellitus. Observation on 01/07/26 at 5:53 P.M., showed the following:-LPN B gather supplies from the cart to check the resident's blood sugar;-LPN B picked the glucometer up off the medication cart, took the supplies into the resident's room and sat the glucometer directly on top of a desk without a barrier;-LPN B completed the Accu check procedure and sat the glucometer directly on top of the medication cart without a barrier;-LPN B took two Sani-wipes out of a purple top container and placed the glucometer between the two wipes and left it sitting for two minutes;-At 5:54 P.M. LPN B picked up the glucometer and threw the wipes away;-LPN B did not rub the blood glucometer off with the wipes. During an interview on 01/09/26 at 11:55 A.M., LPN B said the following:-He/She did not put the glucometer on a barrier;-He/She did not rub the glucometer with Sani-wipes; he/she thought the glucometer was clean after sitting in between two Sani-wipes for two minutes;-He/She did not know the glucometer needed to be on a barrier in a residents' room or on the medication cart;-He/She did not feel the glucometer needed to be on a barrier after it was cleaned;-He/She had never been instructed to use a barrier; -He/She did not know the glucometer should not have been set directly on the residents' leg before she used the blood glucometer to conduct an Accu check for a resident. During an interview on 01/09/26, at 8:53 P.M., the DON said the multi resident use glucometers should not be placed on a resident's bedside table or a resident's leg but should always have a barrier between the surface and the glucometer. 11. Review of the facility policy, Tuberculosis Screening - Employees, dated March 2019, showed the following: -It is the policy of this facility to assess risks for TB based on regional/community data and screen staff according to state law;-All healthcare workers are to be tested for TB upon hire and yearly thereafter unless contraindicated or in accordance with state requirements;-Initial testing will be a two-step procedure with the first does given before beginning work and the second given seven to 21 days after the first if the first dose is negative;-TST: employees who will be receiving the two-step TST may begin work after the first step results are negative. 12. Review of the Department of Health and Senior Services Tuberculosis Screening for Long-Term Care Facility Employees Flowchart (based on the requirements identified in the state regulation for administering TB testing), updated 03/11/14, showed the following:-Administer TST first step prior to employment. (Can coincide reading the results with the employee start date by administering TST two to three days prior to the employee start date);-Read results of first step TST within 48-72 hours of administration (results must be read and documented in millimeters (mm) induration prior to or on the employee start date);-If first TST is negative, administer second step within 1-3 weeks;-Read results within 48-72 hours of administration;-The employee cannot start work for compensation until the first step TST is administered and read. 13. Review of LPN B's employee file showed the following:-First date of paid compensation was 02/19/25;-First-step TST administered on 02/19/25 (the same day as paid compensation);-First-step TST read on 02/21/25 (two days after first date of paid compensation), results were 0 millimeters (mm);(The employee received compensation before the first step TST was administered and read). Review of Housekeeper O's employee file showed the following:-First date of paid compensation was on 03/13/24;-First-step TST administered on 04/11/24 (29 days after first date paid compensation);-First-step TST read on 04/13/24 (30 days after first date of paid compensation), results were 0 mm;(The employee received compensation before the first step TST was administered and read). Review of COTA O's employee file showed the following: -First date of paid compensation was on 10/31/25;-An immunization record provided by the employee showed a first-step TST performed on 05/09/25, read on 05/12/25, results were 0 mm;-No documentation of a second step TST completed within 1-3 weeks after the first TST was read;-No record of a prior 2-step TST;-No documentation of a first-step TST administered by the facility;-No documentation of a second-step TST administered by the facility. 14. During an interview on 01/08/26 at 1:30 P.M. and 01/09/26 at 8:53 P.M., the DON said the following:-New employee TB tests were done by any nurse;-The first-step TST should be administered before starting and read either before starting work or on the first day of work;-She was responsible for tracking the new employee TB tests to ensure they were administered and read on or by the first day of compensation and resident contact. During an interview on 01/09/26, at 8:53 P.M., the administrator said the DON was responsible for ensuring the new hire TB tests are completed as required.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not practice proper hand and glove hygiene or hair restraint usage. Staff did not maintain surfaces and equipment to be free from a buildup of grease and debris. Staff failed to ensure an air gap was present at the ice machine drains to prevent possible backflow from the drain back into the ice machine. The facility census was 40. 1. Review of the facility policy, Sanitation, revised January 2016, showed employees shall wash their hands: after touching bare human body parts (face, nose, etc.); after using the restroom; after coughing, sneezing, using a handkerchief or tissue; after eating or drinking; after handling soiled equipment; as much as possible during food preparation to remove soil and contamination and to prevent cross contamination; when changing tasks; when changing from handling raw to ready-to-eat food; before donning gloves; and after engaging in any activity or task which contaminates hands. Review of the facility policy, Food Handling and Use of Gloves, revised January 2016, showed the following: -Staff shall use gloves when making direct contact with food and when handling the area of utensils or supplies that will come in direct contact with foods;-Glove use will be observed during the following procedures: during food preparation which requires direct hand contact; when handling of utensils may cause direct contact with the part of the utensil that may come in direct contact with food; when handling soiled dinnerware; when bussing tables and washing dinnerware and utensils; and when deemed appropriate by the Dietary Manager or Consulting Dietitian. -When donning gloves, hands must be washed. Once gloves are donned, one job should be completed. When changing jobs or major tasks, gloves should be removed and discarded. New gloves should be put on after hands are washed. Observation on 01/06/26 from 10:24 A.M. to 10:33 A.M., in the kitchen, showed the following: -Nurse Aide H used an ice scoop to scoop ice from a cooler into cups with lids for residents; -He/She dropped a lid to one of the cups onto the floor, picked up the lid, and placed the lid on the beverage preparation counter; -He/She picked up the dropped lid from the counter and carried it to the dishwashing area and placed it into a dishwashing rack; -Without washing his/her hands, he/she returned to the counter where he/she continued to scoop ice into residents' cups. Observation on 01/06/26 from 12:18 P.M. to 12:59 P.M., in the kitchen, showed the following: -Head Dietary [NAME] A used his/her gloved hands to sort residents' meal cards at the steam table counter; -He/She dropped a meal card onto the floor, picked up the card, and placed the card on the steam table counter with the rest of the cards; -Without washing his/her hands or changing his/her gloves, he/she served food from the steam table onto residents' plates for the lunch meal service. He/She touched the serving utensil handles and grasped bread with his/her gloved hands. He/She touched his/her glasses and then touched the eating surface of plates, serving utensil handles, and resident meal cards;-While wearing the same gloves, he/she reached into a bag of chips, grasped chips with his/her hand, and placed the chips onto a resident's plate; -He/She removed his/her gloves, did not wash his/her hands, and made a grilled cheese sandwich at the stove. He/She touched the surface of the sandwich in the pan with his/her bare hands as he/she flipped the sandwich. Observation on 01/06/26, from 12:15 P.M. to 12:35 P.M., showed the following:-Nurse Assistant H served meal trays to residents in the dining room;-He/She served Resident #6 his/her tray. He/She touched each of the resident's beverage cups (filled with beverages) by the drinking surface as he/she took the cups off the tray and placed them on the table;-He/She did not perform hand hygiene and served Resident #11 his/her tray. He/She touched each of the resident's beverage cups by the drinking surface as he/she took them off the tray and placed them on the table; -He/She did not perform hand hygiene and served Resident #3 his/her tray. He/She touched each of the resident's beverage cups by the drinking surface as he/she took them off the tray and placed them on the table;-He/She continued serving trays and drinks to other residents in the dining room and touched the drinking surfaces of each glass. During an interview on 01/09/26 at 3:15 P.M., Head Dietary [NAME] A said staff were to change their gloves when soiled and to wash their hands after they touched dirty surfaces. Staff should not touch ready-to-eat food items with bare hands and should not pick up dropped items and place them on the counter. Staff should not touch the eating and drinking surfaces of cups, plates, and utensils. 2. Review of the facility policy, Personal Hygiene and Appearance, revised January 2016, showed staff shall wear hair nets or hair coverings while in the kitchen or storage areas. Observation on 01/06/26 from 10:20 A.M. to 10:24 A.M., in the kitchen, showed the following: -Nurse Aide H walked into the kitchen and walked by Head Dietary [NAME] A who was cutting up tomatoes at the food preparation table; -Nurse Aide H did not wear a hair restraint and had an approximately 8-inch long ponytail that was not contained in a hair restraint; -Nurse Aide H scooped ice from the ice machine into a cooler on a cart. Observation on 01/06/26 from 12:20 P.M. to 12:59 P.M., in the kitchen during the lunch meal service, showed the following:-Dietary Aide Q wore a hair restraint but several six-inch long sections of his/her hair, located along the front and sides of his/her head, were not contained within the hair restraint;-He/She opened the reach-in refrigerator and removed a tray of uncovered bowls of pudding;-He/She placed the bowls of pudding, cups filled with beverages, and silverware onto residents' meal trays. During an interview on 01/09/26 at 3:15 P.M., Head Dietary [NAME] A said staff were to wear hair restraints in the kitchen that fully covered their hair. 3. Review of the facility policy, Department Sanitation, revised 01/2016, showed the following: -Department sanitation shall be maintained in a manner to support procedures for Food Safety. Staff shall be responsible for daily and weekly cleaning assignments as determined by the Dietary Manager and/or his/her designee. -Cleaning assignments shall include all equipment, cabinets, storage areas, walls, floors and refrigeration units. Cleaning of equipment condensers, lights, vents, etc. shall be completed by the Maintenance Department as determined by the Administrator. Observation on 01/06/26 at 9:58 A.M., during the initial tour of the kitchen, showed the following: -In the walk-in cooler, trash, food debris, and a dried black residue was visible on the middle of the metal floor and under the shelves. The floor had several areas of rust with pitted sections and was not a smooth, cleanable surface; -The rangehood contained four baffle filters that protected a six-burner stove, ovens, griddle, and fryer. The filters above the six-burner stove and oven had a moderate accumulation of yellow grease and fuzzy debris. The filters above the griddle, oven, and fryer had a heavy accumulation of yellow grease and fuzzy debris. Dark yellow and brown grease drips were visible along the edges above and below the filters;-One of two light bulbs under the rangehood did not contain a cover;-The backsplash above the stove and griddle had food splatters and grease across the surface; -Two of six stove burners had a heavy accumulation of black encrusted debris; -The surfaces of the fryer and the surfaces between the fryer and griddle had a heavy accumulation of grease splatters and food debris; -The inside of the ice machine had black moist specks on the underside of the lid and along the edge of the lid; -A large metal ice scoop, located inside a wall-mounted ice scoop holder, had various white drips scattered across the scoop's surface. There was a moderate accumulation of moist, brown residue at the bottom interior of the scoop holder where the tip of the scoop rested; -The metal wire bread storage rack, located next to the ice machine, was heavily corroded with areas of rust across 50% of the rack's surface; -There were ten light fixtures located in the food preparation and serving areas. A heavy accumulation of dust and cobwebs was visible on four of the ten fixtures. Two of the ten fixtures did not have a cover. Six of the ten fixtures were broken and had pieces missing from the covers; One of the ten light fixtures was not illuminated; -The light fixture by the exit did not contain light bulbs or a cover and was not illuminated; -Two of two light fixtures in the clean dish storage area had a heavy accumulation of dust and debris. One of the two light fixtures did not have a cover or light bulbs in the fixture; -Two of the five fixtures in the dishwashing area were not illuminated. Three of the five fixtures did not have a cover, and one fixture was cracked with missing pieces; During an interview on 01/06/26 at 10:24 A.M., Head Dietary [NAME] A said he/she started work at the facility four months ago and the lights (that were not working) had not worked since she started. He/She told the prior maintenance staff who said the reason the lights didn't work was due to the fixtures needing new ballasts. During an interview on 01/09/26 at 3:15 P.M., Head Dietary [NAME] A said he/she expected food and non-food surfaces in the kitchen to be clean. Staff should store, prepare, and serve food in a safe and sanitary manner. Staff deep cleaned the kitchen weekly but there was not a cleaning schedule. There was no dietary manager at the facility. 4. Observation on 01/06/26 at 10:19 A.M., of the ice machine in the kitchen, showed there was no air gap at the drain. The ice machine drain at the back of the unit was connected to an approximately 3-foot gray flexible hose that was inserted directly into an approximately 2-inch PVC floor drainpipe. During interviews on 01/06/26 at 10:19 A.M. and on 01/09/26 at 3:15 P.M., Head Dietary [NAME] A said he/she was unsure if the ice machine drain in the kitchen had an air gap. He/She thought maintenance staff was responsible for ensuring there was an air gap at the ice machine drain. During an interview on 01/028/26 at 10:02 A.M., the Maintenance Director said he was unaware the kitchen ice machine drain did not contain an air gap to prevent possible backflow from the drain back into the ice machine. During an interview on 01/09/26 at 3:05 P.M., the Administrator said maintenance staff was responsible for ensuring the ice machine drain had an air gap.

Based on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature and taste. The facility census was 40. Review of the facility policy, Meal Service Temperatures, revised January 2016, showed the following: -Hot food shall be cooked or heated to a temperature above 165 degrees. Cold food shall be chilled to a temperature below 40 degrees;-The [NAME] shall take temperatures of food (as appropriate) during meal preparation to ensure food is cooked or chilled to the appropriate temperature. Staff shall also take the temperatures once the food is on the steamtable prior to the start of meal service.-Food which registers temperatures outside acceptable range shall be removed and reheated or rechilled to meet acceptable temperatures. 1. During an interview on 01/06/26 at 11:05 A.M., Resident #7 said the following:-He/She preferred to eat in his/her room. Sometimes the food staff served was warm but was not hot;-The food did not have much flavor;-Sometimes the food wasn't completely cooked; the vegetables were hard. -The textures of the food were not good. During an interview on 01/06/26 at 12:04 P.M., Resident #14 said the following:-He/She always ate in his/her room;-The food staff served at meals was not always warm; -The oatmeal was always cold; it tasted like it came straight out of the refrigerator. During an interview on 01/06/26 at 12:26 P.M., Resident #37 said the following:-The food did not taste good;-The bread was always hard and dry and did not have a good flavor. During an interview on 01/06/26 at 1:16 P.M., Resident #34 said the food was terrible. During an interview on 01/07/26 at 9:46 A.M., Resident #2 said the following:-The food was not good and usually was not well seasoned;-Sometimes the food looked good, but the flavor was bland;-The food was not always served hot;-Sometimes the food tasted like it came straight out of the can, and staff did not heat it. During an interview on 01/07/26, at 12:29 P.M., Resident #8 said sometimes the food at the facility was not good. 2. Review of the Diet Orders, printed 01/06/26, showed the following: -37 residents had a physician-ordered regular diet; -Three residents had a physician-ordered mechanical soft diet. 3. Observation on 01/06/26, in the kitchen, showed the following:-From 12:21 P.M. to 12:37 P.M., Head Dietary [NAME] A served food from the steam table to residents in the dining room;-From 12:37 P.M. to 12:59 P.M., Head Dietary [NAME] A plated hall trays, added a plate cover to each plate of food, and staff placed the trays of food on a cart;-At 12:59 P.M., Head Dietary [NAME] A plated a test tray of food items. Dietary Aide Q placed the test tray on the cart with the resident hall meal trays and transported the cart to each of the resident halls;-Staff did not check the temperature of the food during the meal service. Observation on 01/06/26 from 1:02 P.M. to 1:22 P.M., showed staff served trays from the meal tray cart to residents' rooms on the 100-300 halls. Observation on 01/06/26 at 1:23 P.M., of the test tray, after staff served all residents, showed the following:-The temperature of the Italian vegetable blend was 104.9 degrees Fahrenheit (F). The vegetables tasted bland, and the green beans were very firm;-The temperature of the garlic bread was 98.8 degrees F. The crust of the bread was tough and the bread inside the crust was very chewy;-The lasagna tasted bland;-The chips (an alternate food item) tasted stale. 3. Observation on 01/07/26, in the kitchen, showed the following:-From 12:15 P.M. to 12:35 P.M., Head Dietary [NAME] A served food from the steam table to residents in the dining room;-From 12:35 P.M. to 12:48 P.M., Head Dietary [NAME] A plated hall meal trays, added a plate cover to each plate of food, and staff placed the trays of food on a cart;-At 12:48 P.M., Head Dietary [NAME] A plated a test tray of food items. Dietary Aide Q placed the test tray on the cart with the resident hall meal trays and wheeled the cart to each of the resident halls;-Staff did not check the temperature of the food during the meal service. Observation on 01/07/26 from 12:50 P.M. to 1:14 P.M., showed staff served trays from the meal tray cart to residents' rooms on the 100-300 halls. Observation on 01/07/26 at 1:15 P.M., of the test tray, after staff served all the residents, showed the following:-The temperature of the corn was 111 degrees F. The corn tasted cool, oily, and bland;-The temperature of the peach cobbler was 66.9 degrees F. The cobbler consisted primarily of 1-inch by 2-inch slices of peach that were very firm with a small amount of yellow cake mix powder on top of the peaches;-The tuna noodle casserole had a strong tuna flavor and was dry and pasty in texture;-The temperature of the tomato soup (an alternate food item) was 117.7 degrees F and tasted cool;-The temperature of the grilled cheese sandwich (an alternate food item) was 102.9 degrees F. The sandwich was very firm to bite, difficult to chew, dry, and sponge-like in texture. 4. During an interview on 01/06/26 at 11:58 A.M., Head Dietary [NAME] A said staff should heat the food to 150-160 degrees Fahrenheit (F) and place it into the steam table. He/She was not sure what temperature food should be when served to the residents. During an interview on 01/09/26 at 3:05 P.M., the Administrator said the facility had been without a dietary manager since June 2025. The food staff served to residents should taste good. Hot foods should be hot, and cold foods should be cold.

Based on interview and record review, the facility failed to employ a qualified dietary manager with appropriate competencies and skills set to carry out the function of the food and nutrition services program. This practice affected all residents at the facility. The facility census was 40.Review of the facility's Facility Assessment, dated 02/11/25, showed the following:-Average daily census 45;-Services and care offered are based on our resident needs: Nutrition - individualized dietary requirements, liberal diets, specialized diets, IV nutrition, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions, hypodermoclysis;-Facility resources needed to provide competent support and care for our resident population every day and during emergencies: Food and Nutrition Services (Director, support staff, registered dietitian);-Staffing plan for food and nutrition service staff: three full time staff on days, three part time staff on evenings, one dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. Review of the facility's current employee list showed Head Dietary [NAME] A started employment with the facility on 9/22/25. During an interview on 01/09/26 at 3:15 P.M., Head Dietary [NAME] A said he/she started at the facility four months ago. The facility did not have a dietary manager, and he/she was unsure how long the facility had been without a dietary manager. He/She was working to become a certified dietary manager but had not started any training. During an interview on 01/09/26 at 3:05 P.M., the Administrator said the facility had been without a dietary manager since June 2025. Head Dietary [NAME] A was currently going through training to become a certified dietary manager.

Based on observation, interview and record review, the facility failed to provide a clean, comfortable, safe, and homelike environment by failing to maintain ceilings, walls, railings, floors, doors and toilets, in resident rooms and bathrooms, in good repair. The facility failed to maintain outside gutters and trim in good repair. The facility census was 40. Upon request, the facility did not provide a policy related to maintaining the environment. 1. Observation on 01/06/26 through 01/09/26, during the survey process, showed the following in occupied resident room [ROOM NUMBER]: -Build-up of dirt around the bottom trim, where the wall met the floor, around the room;-Three strips of duct tape, each approximately 6 - 8 inches long, on the bathroom floor, covering cracks or broken tile;-A golf ball size portion of the bathroom floor tile missing;-The bathroom floor tiles had a buildup of dirt;-Anti-skid tape in front of the toilet was worn off in places and curling on the edges;-The door frame going into the bathroom had scrapes in multiple places, exposing the metal underneath;-A gold tack strip covering where the bathroom floor and bedroom floor met. The strip was not flush with the floor and was slightly raised, approximately 1/4 inch; the state agency (SA) could not smoothly rub a shoe covered foot across the strip without catching on the strip. During an interview on 01/06/26 at 12:04 P.M., the resident who resided in room [ROOM NUMBER] said the following: -His/Her room needed a deep cleaning, especially around the baseboards; staff sweep daily and mop almost daily, but they never do a deep clean and never clean the baseboards;-The duct tape on the bathroom floor had been there for a long time;-He/She had reported the broken bathroom floor tiles and the raised tack strip going from the bedroom to the bathroom a few times and did not know if a maintenance request was completed.-The metal strip going into his/her bathroom is raised and he/she has stumbled on it about three times;-He/She has not fallen but is afraid he/she will. 2. Observations on 01/07/26 at 9:32 A.M. and 01/09/26 at 10:15 A.M., in the women's shower room on 200 hall, showed the following:-The door to the room did not close fully and remained open approximately 1 inch (the door did not latch in the frame or have a privacy latch);-The door frame was chipped and missing paint across 25% of the lower 3-foot section of the frame. The plastic material that covered the left side of the frame was torn in a 4-inch section;-The toilet was marred with gray scratches across the front surface and the caulk around the base of the toilet was discolored brown with sections of missing caulk;-Approximately ten tiles on the wall next to the toilet were duct taped to the wall; the wall had one missing tile and several bulging tiles. Where wall tile was missing the wall surface underneath was brown and crumbling. Wall tiles near the toilet were cracked and damaged;-The grip strips on the floor in front of the toilet, were worn and disintegrating with adhesive showing;-The shower head had scaling, and the water pressure was low when turned on with water leaking between the head and the hose; -Drywall tape was coming loose from the wall, with cracks in the tape and mud, where the wall and the ceiling met near the room divider;-The linen cart cover was folded over the top of the cart with two clean, unused incontinent briefs, nine pairs of gripper socks and a hanger, the top shelf had clean linens and a bath basin with scissors and a resident's personal shampoo sitting on top of the clean gowns, the second shelf had another bath basin sitting on top of clean linens with a used shampoo and condition bottle in it, the third shelf had the ties of a gown hanging down touching the floor; -The tile on the floor by the tub was soiled with dark brown debris. During an interview on 01/07/26 at 2:42 P.M., Resident #20 said the shower rooms needed to be repaired. The rooms were dirty and smelled bad. 3. Observation on 01/06/26 at 10:48 A.M., showed the following: -The flooring of occupied resident room [ROOM NUMBER] had residue left from old gripper strips in the middle of the floor and chips in the paint on the door frame exposing metal underneath;-The brass door plate of occupied resident room [ROOM NUMBER] had several black marred areas at the base of the brass door plate;-The wall from room [ROOM NUMBER] to 105 had a long, black marred area below the handrail;-The wall from room [ROOM NUMBER] to room [ROOM NUMBER] had a long, black marred area above the handrail;-The 100 hall wooden handrail had mars and nicks down the entire handrail with exposed wood;-The door frame of occupied resident room101 had nicks in the paint, exposing the metal underneath;-The door frame of occupied resident room103 had nicks in the paint, exposing the metal underneath;-The door frame of occupied resident room105 had nicks in the paint, exposing the metal underneath;-The door frame of occupied resident room110 had nicks in the paint, exposing the metal underneath. 4. Observation on 01/06/26 at 12:30 P.M., showed the ceiling in the dining room with dry wall tape hanging, and a large amount of mud from repairing the ceiling that was not sanded or painted. 5. Observations on 01/07/26 at 9:40 A.M. and 01/09/26 at 10:25 A.M., in the men's shower room on the 200 hall showed the following:-The paint was missing on 25% of the door frame and the plastic material that covered the hinge side of the frame was missing in a two-inch by eight-inch area;-The room smelled like sewer gas;-The toilet bowl lid had an opening exposing the bowl of the toilet; the bowl of the toilet had silver streaks and gouges in the toilet bowl; -The floor in front of the toilet had grip strips that were worn with irregular shapes and holes in the black strips;-An approximate six foot section of trim was missing between the wall and the ceiling with some paint peeled back and the area between the wall and the ceiling had varying shades of a brown substance. 6. Observations on 01/07/26 from 8:34 A.M. to 4:42 P.M., during the Life Safety Code tour of the facility, showed the following: -In room [ROOM NUMBER], a board that was previously attached to the wall (to protect the wall from damage from the bed frame) was no longer attached, sat along the base of the bed between the wall and the bed, and had exposed screws sticking out of the board; -In the bathroom to room [ROOM NUMBER], the floor around the toilet was discolored brown and was missing caulk around the toilet base; -In room [ROOM NUMBER], a 3-inch by 18-inch section of cove base trim was no longer attached to the wall. There was a 1-inch hole in the wooden door to the bathroom; -In room [ROOM NUMBER], approximately 25% of the paint on the door frame to the bathroom was missing. The wooden door was badly chipped on the hinge side of the door; -In room [ROOM NUMBER], the metal threshold strip between the room and bathroom was not securely attached to the floor and was coming up approximately 0.5-inches on both sides of the strip; -In the bathroom between rooms [ROOM NUMBERS], there were pieces of duct tape on the floor. The threshold from room [ROOM NUMBER] to the bathroom was raised at the edges and corners and did not provide a smooth transition between the two areas. The mounting hardware on the grab bars was not mounted flush to the wall and created a 0.5-inch gap between the wall and upper portion of the grab bar; -In room [ROOM NUMBER], an approximate 1-foot by 2-foot brown stained area was on the ceiling. There was excessive wear on the bathroom door frame with approximately 50% of the paint missing from the lower left (latch side) portion of the frame; -In room [ROOM NUMBER], there was a 3-inch by 3-inch missing section of floor tile and two 1-inch by 2-inch missing sections of floor tile. The floor under the wardrobe had an excess accumulation of dirt and debris buildup; -In room [ROOM NUMBER], a 3-inch by 12-inch broken section of unpainted wall by the heating/air conditioning unit was pushed in 0.5-inches and was not flush with the rest of the wall. There were worn, scraped areas on the wall by the door to the bathroom that were missing paint in a 3-inch by 2-foot area. The cove base trim was loose from the wall, with an approximate 1-inch gap between the trim and the wall, and had exposed nails; -In room [ROOM NUMBER], an approximate 2-foot by 2-foot patched area of ceiling was loose and coming away from the ceiling surface. The metal kickplate on door to the bathroom was loose and missing a screw on the top left corner of the kickplate; -In the bathroom between rooms [ROOM NUMBERS], there were two 1-inch holes in the wall above the grab wall that were not filled or painted; -In room [ROOM NUMBER], there was a 1-inch hole and six pencil-sized holes in the wall above the television; -In room [ROOM NUMBER], a board that was once attached to the wall was coming off the wall and created a 3-inch gap between the board and the wall. Behind the loose board, there was a large, unpainted indented area on the wall; -In room [ROOM NUMBER], the wall near the bathroom was heavily marred across its surface with gray marks and peeling paint. The door frame to the bathroom was missing paint across 75% of the lower 2-foot portion of both sides of the frame. The door to the bathroom was badly worn and had several chipped and scraped areas across its surface; -In the bathroom of room [ROOM NUMBER], the floor around the toilet was discolored gray and black and was missing caulk around the toilet base; -In room [ROOM NUMBER], there was a 0.5-inch by 3-inch areas of painted wall that was coming loose above the cove base trim. The veneer on the base of the wardrobe was badly chipped, the exposed particle board was swollen, and the drawers would not open freely; -In the bathroom between room [ROOM NUMBER] and 308, the base of the toilet had a 6-inch long crack in it and the floor around the toilet was discolored brown in a 4-inch by 6-inch area; -In room [ROOM NUMBER], there was a heavy accumulation of dirt buildup under both wardrobes; -In room [ROOM NUMBER], there was a moderate accumulation of dirt and debris under the wardrobe. A board that was once attached to the wall behind a bed was on the floor. Where the board had been attached, there were deep gouges in the unpainted wall; -In room [ROOM NUMBER], a board approximately 1-foot by 5-foot in size that was once attached to the wall lay on the nearby bed. The unpainted wall where the board was attached had several small holes. The floor around the base of the toilet was discolored brown and was missing caulk around the toilet which created a 0.25-inch gap between the floor and the toilet; -In room [ROOM NUMBER], 90% of the paint on the bathroom door was missing from the lower 1-foot section of door frame (hinge side) and there was a 1-inch by 3-inch tear in the plastic material that covered the latch side of the door frame; -In the soiled utility room, a 6-inch by 2-foot section of tile flooring and a 3-inch by 3-inch area tile flooring was missing and the concrete under the missing tiled areas was exposed; -The sitting area by the nurses' station had a 2-foot by 2-foot section of ceiling that was discolored brown; -The drinking water fountain by the janitor's closet (across from the nurses' station) had dried drips and stains across the surface of the unit. There was dried black and brown debris on the drain area and white crusty debris around the nozzle. 7. Observations on 01/07/26 from 4:43 P.M. to 5:08 P.M., during the outside Life Safety Code tour, showed the following: -Several triangular sections of wood, measuring approximately 2-foot by 8-inches and located at the corners of the building, had heavy rot damage and approximately 75% of the paint was missing from the wood. The trim boards near these triangular sections and under the roof line and gutters were also missing paint across their surface; -The gutter outside room [ROOM NUMBER] was not securely connected and the downspout was disconnected; -A section of gutter on the 300 hall was cracked and an excess accumulation of dried leaves was visible in the cracked area. 8. During an interview on 01/09/26 at 9:05 A.M., the Maintenance Director said he started at the facility a couple days prior to the survey. He was just trying to get acquainted with the facility. He had not done a full environment assessment and did not know where the maintenance documentation was other that what the Administration had in his office. During an interview on 01/06/25 at 8:53 P.M. and 01/09/26, at 8:53 P.M., the Administrator said the following:-The metal plate between the room and bathroom should be flush and not create a potential fall hazard.; -Environment issues are taken care of through housekeeping and maintenance staff when they are working or cleaning;-He was trying to get quotes on fixing the broken tiles in the women's shower room, but the work had not been scheduled yet;-The dining room ceiling keeps coming down; he has personally tried to fix it without success;-If staff identify an area that needs to be fixed, they are to put the identified need in the maintenance book.

Based on interview and record review, the facility failed to ensure ten additional residents (Resident #108, #109, #110, #112, #106, #107, #111, #113, #114 and #115), who were discharged from the facility and held money in the Resident Trust Fund account, had their funds reimbursed to the appropriate entity within the required timeframe of their discharge. The facility census was 40. Review of the facility policy, Facility Resident Trust Fund, revised [DATE], showed the following:-Policy: It will be the policy of the management company that the Resident Trust Fund is managed and accounted for in accordance with state and federal regulations. Each facility should follow the State Guidelines of the payment programs using the greatest level of specificity if requirements vary in State and Federal programs;-Refund check requests for discharged or expired residents should have copies of the resident's ledger card balance and A/R system balance before a check can be signed. This must be completed within five business days of the resident discharge. Per state regulations, a completed discharge/trust fund accounting form reflecting discharge date and monies disbursed must be sent to the caseworker within five business days;-The facility shall refund the balance of the resident's personal funds when a resident is discharged . The amount shall be refunded by the end of the month following the month of discharge or by State/Federal specific guidelines if such policies are more stringent. The date, check number, and to close account should be noted on the Resident's ledger sheet. A copy of the check in the resident file shall serve as sufficient documentation that funds were released;-If the facility does not receive notification of appropriate claim for deceased /discharged resident's funds, the unclaimed funds will be sent to the Unclaimed Property Section, Secretary of Revenue for the State with detailed information about the resident, next of kin if known, and amount of funds and such disbursement will be handled per the guidelines. 1. Review of the facility provided list of residents who held money in the resident fund account showed the facility held funds for thirty-one residents, including Resident #106, #107, #108, #109, #110, #111, #112, #113, #114 and #115. 2. Review of Resident #108's face sheet showed the following:-He/She was his/her own responsible party;-He/She discharged on [DATE]. Review of the resident's monthly Resident Trust Fund account statement dated [DATE], showed the resident maintained a balance of $2,162.73 in the Resident Trust Fund account. Review of the accounting records and Resident Trust Fund account showed no documentation the facility refunded money in the Resident Trust Fund account to the resident within five days of discharge. The facility held the resident's money 1,007 days past the date the money should have been returned/refunded. 3. Review of Resident #114's face sheet showed he/she discharged on [DATE]. Review of the resident's death in facility tracking Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following:-The resident had expired;-The resident had been on Medicaid. Review of the resident's monthly Resident Trust Fund account statement dated [DATE] through [DATE], showed the resident maintained a balance of $45.36 in the Resident Trust Fund account. Review of the accounting records and Resident Trust Fund account showed no documentation the facility sent a notice of death to the state or refunded money in the Resident Trust Fund account to the State of Missouri by the end of the month that the resident expired, following the resident's death. The facility held the resident's money 342 days past the date the money should have been returned/refunded. 4. Review of Resident #109's face sheet showed the following:-He/She had a responsible party;-He/She discharged on [DATE]. Review of the resident's monthly Resident Trust Fund account statement dated [DATE], showed the resident maintained a balance of $105.11 in the Resident Trust Fund account. Review of the accounting records and Resident Trust Fund account showed no documentation the facility refunded money in the Resident Trust Fund account to the resident's responsible party within five days of discharge and as the facility policy directed. The facility held the resident's money 302 days past the date the money should have been returned/refunded. 5. Review of Resident #113's face sheet showed he/she was discharged on [DATE]. Review of the resident's death in facility tracking MDS, dated [DATE], showed the following:-The resident had expired;-The resident had been on Medicaid. Review of the resident's monthly Resident Trust Fund account statement dated [DATE] through [DATE], showed the resident maintained a balance of $462.80 in the Resident Trust Fund account. Review of the accounting records and Resident Trust Fund account showed no documentation the facility sent a notice of death to the state or refunded money in the Resident Trust Fund account to the State of Missouri by the end of the month that the resident expired, following the resident's death. The facility held the resident's money 283 days past the date the money should have been returned/refunded. 6. Review of Resident #115's face sheet showed he/she was discharged on [DATE]. Review of the resident's death in facility tracking MDS, dated [DATE], showed the following:-The resident had expired;-The resident had been on Medicaid. Review of the resident's monthly Resident Trust Fund account statement dated [DATE] through [DATE], showed the resident maintained a balance of $846.14 in the Resident Trust Fund account. Review of the accounting records and Resident Trust Fund account showed no documentation the facility sent a notice of death to the state or refunded money in the Resident Trust Fund account to the State of Missouri by the end of the month that the resident expired, following the resident's death. The facility held the resident's money 283 days past the date the money should have been returned/refunded. 7. Review of Resident #110's face sheet showed the following:-He/She was his/her own responsible party;-He/She discharged on [DATE]. Review of the resident's monthly, Resident Trust Fund account statement dated [DATE], showed the resident maintained a balance of $2.19 in the Resident Trust Fund account. Review of the accounting records and Resident Trust Fund account showed no documentation the facility refunded money in the Resident Trust Fund account to the resident within five days of discharge. The facility held the resident's money 219 days past the date the money should have been returned/refunded. 8. Review of Resident #112's face sheet showed the following:-He/She was his/her own responsible party;-He/She discharged on [DATE]. Review of the resident's monthly Resident Trust Fund account statement dated [DATE] through [DATE], showed the resident maintained a balance of $40.02 in the Resident Trust Fund account. Review of the accounting records and Resident Trust Fund account showed no documentation the facility refunded money in the Resident Trust Fund account to the resident within five days of discharge and as the facility policy directed. The facility had been holding the resident's money 210 days past the date the money should have been returned/refunded. 9. Review of Resident #106's face sheet showed the following:-He/She had a responsible party;-He/She was discharged on [DATE]. Review of the resident's monthly, Resident Trust Fund account statement, dated [DATE], showed the resident maintained a balance of $14.00 in the Resident Trust Fund account. Review of the accounting records and Resident Trust Fund account showed no documentation the facility refunded money in the Resident Trust Fund account tothe resident's responsible party within five days of discharge and as the facility policy directed. The facility had been holding the resident's money 200 days past the date the money should have been returned/refunded. 10. Review of Resident #107's face sheet showed the following:-He/She was his/her responsible party;-He/She was discharged on [DATE]. Review of the resident's monthly, Resident Trust Fund account statement, dated [DATE], showed the resident maintained a balance of $139.81 in the Resident Trust Fund account. Review of the accounting records and Resident Trust Fund account showed no documentation the facility refunded money in the Resident Trust Fund account to the resident's responsible party within five days of discharge. The facility held the resident's money 52 days past the date the money should have been returned/refunded. 11. Review of Resident #111's face sheet showed the following:-He/She had a responsible party;-He/She discharged on [DATE]. Review of the resident's monthly Resident Trust Fund account statement dated [DATE], showed the resident maintained a balance of $280.51 in the Resident Trust Fund account. Review of the accounting records and Resident Trust Fund account showed no documentation the facility refunded money in the Resident Trust Fund account to the resident's responsible party within five days of discharge. The facility held the resident's money 40 days past the date the money should have been returned/refunded. 12. During an interview on [DATE] at 12:55 P.M., the Social Service Director (SSD) said the following:-She had been in the SSD position since around the end of [DATE];-Prior to her assuming the role, it was the Regional Business Office Manager (BOM) who was responsible to track residents who had discharged or expired and if they had money in the Resident Trust Fund account; -If a resident was discharged or expired, money should be reimbursed back to the resident or their next of kin or responsible party; -If the resident was discharged after the end of October or [DATE], she would have been responsible for ensuring the resident got their money; -If the resident was receiving Medicaid when he/she expired, their money in the Resident Trust Fund should go back to the State of Missouri; -If a resident expired, she would reach out to the next of kin/responsible party to clarify were the Resident Trust Fund money should be sent;-If a resident was their own person and discharging from the facility, the facility would refund them their Resident Trust Fund account balance immediately. She would let the administrator know the resident was discharging and he would write out a check for the resident;-If she did not refund the money at the time of discharge, she would reach out to the resident by phone to get an address to send a check to. The check would come from their Resident Trust Fund and the facility would send the check;-All checks must be signed by the administrator; -She could see a resident's Resident Trust Fund account balance in the facility electronic record, but she did not have physical access to the resident's monies; only the administrator had access to the Resident Trust Fund account. Durning an interview on [DATE] at 8:18 A.M. and [DATE] at 12:21 P.M., the Regional BOM said the following:-A resident who had been discharged or had expired should not have money in the Resident Trust Fund account;-When a resident discharges, she emails the SSD letting them know if the resident had money in the Resident Trust Fund account and it was the SSD's responsibility to contact the resident and/or resident representative to find out where to send the refund check; -If a resident expired and had money in the resident trust account, it was the SSD's responsibility to notify the next of kin or representative there was money to be refunded and get the information on where to send a check, except if the resident was on Medicaid, then the money would be sent back to the State of Missouri;-It would be the SSD's responsibility to know if an expired resident was on Medicaid or was private pay to ensure the money was sent to the correct entity;-If an expired resident was on Medicaid, she would send a notice of death to the state and a letter would be sent back to let their corporate office know where the money needed to be sent; -The previous SSD had been doing these things, but with the new SSD, she had begun assisting her with her responsibilities beginning in [DATE];-She did not have a tracking system in place to know what residents had money in the resident trust fund account and had discharged or expired or to ensure the monies were reimbursed to the proper entity;-None of the monies had been refunded to the residents who had discharged or expired that were listed on the [DATE] Resident Trust Fund current account balance sheet, including Resident #106, 107, 108. 109, 110, 111, 112, 113, 114 and 115;-She was aware there were discharged and/or expired residents who still held funds in the resident fund trust account. During an interview on [DATE] at 4:44 P.M., [DATE] at 12:00 P.M. and [DATE] at 1:24 P.M., the Administrator said the following:-The BOM could find reports in the computer of the residents who were discharged or had expired;-He had not written any check out of the Resident Trust Fund after a resident had discharged . There were certain steps to take and documentation to be sent to the corporate office;-The BOM was to notify corporate when a resident had been discharged or expired and held money in the resident trust fund account;-The BOM and corporate should refund a discharged or expired resident's Resident Trust Fund account balance to the resident or the resident's representative;-A resident who had been discharged or expired should not have money in the Resident Trust Fund account;-Residents #106, #107, #108, #109, #110, #111 and #112, #113, #114 and #115 were discharged resident or residents who had expired and still held money in the Resident Trust Fund account. No refunds had been made for these residents that he was aware of;-He did not know the timeframe for money to be refunded to a resident or next of kin/responsible party;-He did not know any further information on why resident's who were discharged had not been reimbursed their money from the Resident Trust Fund account.

Based on observation, interview and record review, the facility failed to ensure residents received sufficient nourishing bedtime snacks. The facility census was 40. Upon request, the facility did not provide a policy for bedtime snacks. 1. Review of the facility provided, mealtime service schedule, showed the following:-Supper to be served at 5:30 P.M.;-Breakfast to be served at 7:45 A.M.;(14.25 hours between meals). 2. During the group interview on 01/07/26 at 2:42 P.M., residents said the following:-Resident #17 said staff used to pass snacks every night, but now the residents must ask for snacks; snacks most generally are cookies and snack cakes, sometimes graham crackers; there are not enough snacks available for everyone in the building to have one if they want it;-Resident #25 said snacks used to be put on a cart at the nursing station, but one resident would go up and take multiple snacks, so now they are not available for residents to go up and get one; he/she asks for snacks in the evening, and they frequently run out of snacks, so he/she does not get one;-Resident #20 said staff tell the residents they must get their work done before they can get a snack if the resident requests it; sometimes they don't get him/her a snack until after 9:00 P.M. and that snack is a high sugar snack. He/She is diabetic and should not have a sugary snack because it affects his/her morning blood sugar; it would be nice to have a snack that was not sweet but rather something with some protein. 3. Observation on 01/07/26 and 01/08/26 at 6:30 P.M. and 01/09/26, from 6:30 P.M. through 8:50 P.M., showed the following:-No snacks at the nursing station;-No staff passing or offering snacks to the residents; -No cooler was observed at the nursing station. 4. During an interview on 01/09/26 at 3:15 P.M., Head [NAME] A, said the following: -He/She directs staff to prepare the evening snack in a cooler and deliver it to the nursing staff to take care of the snack pass; -Bedtime snacks included graham crackers, oatmeal cream pies and cookies; no protein type snack was offered;-There are only 12-15 snacks prepared for the bedtime snack because not everyone takes one or wants one. During an interview on 01/09/26 at 3:05 P.M. and 8:53 P.M., the administrator said the following:-Bedtime snacks include vanilla wafers, cookies, graham crackers, pudding, applesauce and occasionally oatmeal cream pies;-Staff are to pass bedtime snack at 8:00 P.M.;-He feels like there are enough snacks put out every night for each resident to have one if they want it;-He would expect there to be enough snacks provided for each resident to have one;-There are no specific snacks for diabetic residents;-There are no specific protein-based snacks given nightly. During an interview on 01/15/26 at 4:10 P.M., the Medical Director said he would expect a protein-based snack to be available at bedtime for diabetic residents. He expects the facility to offer all residents a bedtime snack.

Based on interview and record review, the facility failed to implement policies and procedures to ensure resident trust accounts were not allowed to go into a negative balance for four residents (Resident #29, #9, #44 and #10) and one additional resident (Resident #103) in a review of 17 sampled residents. Further review showed the facility failed to obtain a signature from the resident when funds were removed from the Resident Trust Fund account, failed to send quarterly statements to the residents or the resident representatives for those with transactions in the Resident Trust Fund Account, and failed to reimburse the Resident Trust Fund account after charges for check printing fees were taken out of the Resident Trust Fund account. The facility held funds in the Resident Trust Fund account for 31 residents. The facility census was 40. Review of the facility policy, Facility Resident Trust Fund, revised May 2012, showed the following:-Purpose: To establish policy and procedures for the Facility Resident Trust Fund.-Policy: It will be the policy of the management company that the Resident Trust Fund is managed and accounted for in accordance with state and federal regulations. Each facility should follow the State Guidelines of the payment programs using the greatest level of specificity if requirements vary in State and Federal programs;-Procedure: All Resident Trust withdrawals must have the resident signature on a receipt & ledger page;-The manual Resident Trust Ledger cards, the Accounts Receivable Trust Balances per Resident, and the Bank Statement/Checkbook register should always all balance to each other. Any discrepancies should be reported to Administrator, Regional and Field Analyst immediately;-The above balancing should be done as close to month end as possible, any discrepancies or variances should be resolved immediately;-Any bank charge or fees for this account are the responsibility of the facility and shall be reimbursed to the Resident Trust bank account. 1. Review of the facility provided list of residents who held money in the Resident Trust Fund account, showed the facility held funds for 31 residents, including Resident #9, 10, 29, 44 and 103. 2. Review of Resident #29's face sheet showed he/she was his/her own responsible party. Upon request, the facility did not provide ledgers or receipts with the resident signature for transactions regarding the Resident Trust Fund account. Review of the resident's monthly, Resident Trust Fund account statement, dated 08/31/25, showed the following:-The statement was addressed to the resident in an apartment in another city; -Opening balance $0.00;-Effective date 08/20/25;-Description: Beauty Shop;-Debit amount $12.00;-Balance (-$12.00). Review of the resident's monthly, Resident Trust Fund account statement, dated 10/31/25, showed the following:-The statement was addressed to the resident in an apartment in another city; -Opening balance (-$12.00);-Closing balance (-$12.00). Review of the resident's monthly, Resident Trust Fund account statement, dated 11/30/25, showed the following:-The statement was addressed to the resident in an apartment in another city; -Opening balance (-$12.00);-Closing balance (-$12.00). During an interview on 01/08/26 at 11:37 A.M., the resident was able to respond to interview questions using a written communication board as well shaking his/her head yes or no:-He/She had no money in a resident trust account;-He/She had not been told by anyone he/she owed any money;-He/She had not received any statements showing he/she owed any money. 2. Review of Resident #9's face sheet showed he/she had a power of attorney. Upon request, the facility did not provide ledgers or receipts with the resident signature for transactions regarding the Resident Trust Fund account. Review of the resident's monthly, Resident Trust Fund account statement, dated 10/31/24, showed the following:-Opening balance $0.00;-Effective date 12/06/24;-Description: Beauty Shop; -Debit amount $12.00;-Balance (-$12.00). Review of the resident's monthly, Resident Trust Fund account statement, dated 03/31/25, showed the following:-Opening balance (-$12.00);-03/13/25 deposit $12.00;-Closing balance $0.00. Review of the resident's monthly, Resident Trust Fund account statement, dated 06/30/25, showed the following:-Opening balance $0.00;-Effective date 04/24/25;-Description: Beauty Shop:-Closing balance (-$12.00). Review of the resident's monthly, Resident Trust Fund account statement, dated 08/31/25, showed the following:-Opening balance (-$12.00);-Closing balance (-$12.00). Review of the resident's monthly, Resident Trust Fund account statement, dated 10/31/25, showed the following:-Opening balance (-$12.00);-09/25 deposit $100.00;-Balance $88.00. During an interview on 01/08/25 at 2:42 P.M., the resident's power of attorney said the following:-He/She had given the facility $100.00 for haircuts for the resident; -He/She had never been notified there was no money in the account;-He/She had never been notified the account had a negative balance;-He/She had never received a resident trust fund account statement from the facility. 3. Review of Resident #44's face sheet showed he/she had a legal guardian. Upon request, the facility did not provide ledgers or receipts with the resident signature for transactions regarding the Resident Trust Fund account. Review of the resident's monthly, Resident Trust Fund account statement, dated 08/31/25, showed the following:-Opening balance $0.00;-Effective date 08/20/25;-Description: Beauty Shop; -Debit amount $12.00;-Balance (-$12.00). Review of the resident's monthly, Resident Trust Fund account statement, dated 10/31/25, showed the following:-Opening balance (-$12.00);-Closing balance (-$12.00). Review of the resident's monthly, Resident Trust Fund account statement, dated 11/30/25, showed the following:-Opening balance (-$12.00);-Effective date 11/24/25 deposit $50.00;-Balance $38.00;-Closing balance $38.00. During an interview on 01/09/26 at 2:08 P.M., the resident's legal guardian said the following:-He/She had not received a resident trust statement from the facility;-He/She believed the resident was caught up and no longer in debt. 3. Review of Resident #10's face sheet showed he/she was his/her own responsible party. Upon request, the facility did not provide ledgers or receipts with the resident signature for transactions regarding the Resident Trust Fund account. Review of the resident's monthly, Resident Trust Fund account statement, dated 12/31/24, showed the following:-Addressed to the resident at an old address;-Opening balance $0.00;-Effective date 12/06/24;-Description: Beauty Shop; -Debit amount $12.00;-Balance (-$12.00);-Effective date 12/06/24; -Description: Beauty Shop;-Debit amount $12.00;-Closing balance: (-$24.00)(The statement showed two withdrawals for the same date of service for the same amount that no current employee could explain). Review of the resident's monthly, Resident Trust Fund account statement, dated 03/31/25, showed the following:-Addressed to the resident at an old address;-Opening balance (-$24.00);-Effective date 03/13/25 deposit $24.00;-Closing balance $0.00. During an interview on 01/09/26 at 10:15 A.M. the resident said the following:-He/She did not know if he/she had any money in the Resident Trust Fund account;-His/Her family took care of his/her money and any money that was in the Resident Trust Fund account would have to be sent by his/her family member;-He/She had never received a statement from the facility. During an interview on 01/09/26 at 7:23 P.M., the resident's family member said the following:-He/She did not know anything about a Resident Trust Fund;-He/She had never received a statement;-He/She had never been told his/her family member had a negative balance in the resident trust account. 4. Review of Resident #103's face sheet showed he/she had a guardian. Upon request, the facility did not provide ledgers or receipts with the resident signature for transactions regarding the Resident Trust Fund account. Review of the resident's monthly, Resident Trust Fund account statement, dated 08/31/25, showed the following:-Opening balance $0.00;-Effective date 08/20/25;-Description: Beauty Shop; -Debit amount $10.00; -Balance (-$10.00). Review of the resident's monthly, Resident Trust Fund account statement, dated 10/31/25, showed the following:-Opening balance (-$10.00);-Closing balance (-$10.00). Review of the resident's face sheet showed he/she discharged from the facility on 11/07/25. Review of the resident's monthly, Resident Trust Fund account statement, dated 11/30/25, showed the following:-Opening balance (-$10.00);-Closing balance (-$10.00). Review of the accounting records and Resident Trust Fund account showed no documentation the former resident, his/her guardian, or the facility, refunded the Resident Trust Fund account for the discharged resident's negative balance which began on 08/20/25. During an interview on 01/21/25 at 1:47 P.M., the resident's guardian said the following:-He/She did t know the resident owed any money to the Resident Trust Fund account for a haircut;-He/She had never received a statement for the Residents' Trust Fund account. 5. Review of the facility Resident Trust Fund Account bank statement, dated 12/31/24, showed a debit on 12/10/24 for deluxe checks for $22.50. Review of the facility, Resident Trust Fund Monthly Reconciliation, prepared by the BOM, showed the following:-December 2024; Variance of $22.50 for check order;-January 2025; no documentation of a variance of $22.50 for check order;-February 2025; no documentation of a variance of $22.50 for check order;-March 2025; no documentation of a variance of $22.50 for check order;-April 2025; -9. Variance of $22.50 for check order;-May 2025; -9. Variance of $22.50 for check order;-June 2025; -9. Variance of $22.50 for check order;-July 2025; -9. Variance of $22.50 for check order. Review of the accounting records and bank statements for the Resident Trust Fund account, showed no documentation in the months of December 2024, January 2025, February 2025, March 2025, April 2025, May 2025, June 2025 or July 2025, that the facility had refunded the Resident Trust Fund account for the 12/10/24 check order. Review of the facility Resident Trust Account bank statement, dated 08/31/25, showed a debit on 08/19/25 for deluxe checks for $22.50. Review of the facility, Resident Trust Fund Monthly Reconciliation, prepared by the BOM, showed the following:-August 2025; Variance of $45.00 for check order;-September 2025; Variance of $45.00 for check order;-October 2025; Variance of $45.00 for check order;-November 2025; Variance of $45.00 for check order. Review of the accounting records and bank statements for the Resident Trust Fund account, showed no documentation in the months of August 2025, September 2025, October 2025 or November 2025, that the facility had refunded the Resident Trust Fund account for the 12/10/24 or the 08/19/25 check orders. 6. During an interview on 01/16/26 at 12:55 P.M., the Social Service Director (SSD) said the following:-All checks must be signed by the administrator; -She could see a resident's Resident Trust Fund account balance in the facility electronic record, but she did not have physical access to the resident's monies; only the administrator had access to the Resident Trust Fund account. During an interview on 01/09/25 at 8:18 A.M. and 01/16/26 at 12:21 P.M., the Regional BOM said the following:-It was not okay for a resident to have a negative balance in the resident trust fund account;-Before October 2025, she would tell the previous SSD if a resident had a negative balance, the resident trust fund would be reimbursed with the facility petty cash; she did not know how residents got a negative balance in the first place;-The previous SSD should have been getting signatures from residents for withdrawals from the Resident Trust Fund account;-She was responsible for sending the Resident Trust Fund statements to residents and or their representatives;-Check fees should be reimbursed to the Resident Trust Fund account by the facility within 30 days; there were two check printing fees that still had not been refunded to the Resident Trust Fund account. She was responsible for ensuring any fees accrued were reimbursed back into the Resident Trust Fund account; she had not sent the paperwork to corporate for the reimbursement process yet. During an interview on 01/08/25 at 4:44 P.M., 01/16/26 at 12:00 P.M. and 01/21/25 at 1:24 P.M., the Administrator said the following:-Basic haircuts were billed by adding up the total haircuts given to residents and writing a check out of the Resident Trust Fund account to the beautician; -The Resident Trust Fund account should not be used to pay for haircuts for those residents who do not have an account or any funds available;-He was unsure if residents were aware a Resident Trust Fund account was opened for them to pay for a haircut;-He did not know if residents were signing any document allowing money to be taken out of the Resident Trust Fund account for their haircut;-He checked each individual resident's balance in the Resident Trust Fund account before he authorized money to be taken out of a residents' Resident Trust Fund account;-If a resident went into a negative balance, it was okay because they would have a check/deposit for $50.00 put in the account the next month; -It would not be okay for another resident to be using another residents' money;-The SSD should have a resident sign a paper with a receipt for each withdrawal that was made from the resident's Resident Trust Fund Account for record keeping purposes;-If a resident discharged and had a negative balance in the Resident Trust Fund account, it would be corporate's responsibility to put money back into the resident trust account to cover the negative balance;-The Regional BOM was responsible for sending monthly Resident Trust Fund statements to the resident or responsible party for those who had a Resident Trust Fund account;-The Resident Trust Fund account was not supposed to be charged any kind of fees, i.e. check printing.

Based on interview and record review, the facility failed to provide a written notice of transfer to two residents (Residents #1 and #37), or their representatives, in a review of 17 sampled residents and to one resident (Resident #42), in a closed record review, when the residents were transferred to the hospital. The facility failed to provide a recapitulation of the resident's stay that included a summary of the resident's stay, a summary of the resident's status at the time of discharge and a reconciliation of all pre-discharge medications with the resident's post-discharge medications for Resident #42. The facility census was 40. Review of the facility policy, Transfer or Discharge Notice, revised December 2018, showed the following: -Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: -The health of individuals in the facility would otherwise be endangered; -An immediate transfer or discharge is required by the resident's urgent medical needs;-The resident and/or representative will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. A statement of the resident's rights to appeal the transfer or discharge, including: (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; e. The facility bed-hold policy; f. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; g. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); h. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies); and i. The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. 1. Review of Resident #1's face sheet showed he/she had a durable power of attorney (DPOA). Review of the resident's nursing progress notes showed the following:-On 08/19/25 at 9:36 P.M., the resident went to the local hospital emergency room (ER) via ambulance with a temperature of 104.9 degrees Fahrenheit (normal is 98.6 degrees Fahrenheit) and vomiting;-On 08/28/25 at 2:00 P.M., the resident returned to the facility via ambulance.(Review of the resident's medical record showed no documentation the facility provided a transfer/discharge notice or copy of the bed hold policy to the resident or the resident's representative when the resident transferred to the hospital on [DATE]). Review of the resident's nursing progress notes showed the following:-On 09/18/25 at 9:35 P.M., the resident had complaints of nausea and shakiness. Staff notified the on-call physician at 9:14 P.M. and received orders to transfer the resident to the local hospital ER via ambulance. The ambulance transported the resident to the local hospital ER at 9:20 P.M. -On 09/19/25 at 6:24 A.M., the local hospital reported the resident was being admitted with acute respiratory distress (difficulty breathing), sepsis (a serious condition because of a complication with an infection) and urinary tract infection;-On 09/23/25, at 4:19 P.M., the resident was re-admitted to the facility. (Review of the resident's medical record showed no documentation the facility provided a transfer/discharge notice or copy of the bed hold policy to the resident or the resident's representative when the resident transferred to the hospital on [DATE]). During an interview on 01/09/26 at 4:36 P.M., the resident's DPOA said he/she did not receive any paperwork related to a transfer/discharge or the bed hold policy with any of the resident's hospitalizations. 2. Review of Resident #37's face sheet showed he/she had a DPOA/responsible party. Review of the resident's nursing progress notes showed the following:-On 07/29/25 at 2:06 A.M., the resident had aggressive projectile vomiting and a fever of 102.1 degrees F. The resident transferred to the local hospital ER via ambulance at 1:55 A.M.;-On 07/29/25 at 11:35 A.M., the resident admitted to the hospital for treatment of a urinary tract infection with sepsis;-On 08/02/25 at 12:39 A.M., the resident returned to the facility with a discharge diagnosis of bacteremia (bacteria in the blood). (Review of the resident's medical record showed no documentation the facility provided a transfer/discharge notice or copy of the bed hold policy to the resident or the resident's representative when the resident transferred to the hospital on [DATE]). During an email communication on 01/21/26 at 1:47 P.M., the resident's DPOA said he/she did not receive any paperwork related to a transfer/discharge or the bed hold policy with any of the resident's hospitalizations. 3. Review of Resident #42 closed record showed he/she had a DPOA. Review of the resident's progress notes showed staff documented the following: -On 12/03/25, at 12:13 P.M., the resident continued to hit, kick and yell at staff. The resident was sent for evaluation via ambulance at 12:00 P.M.; -On 12/03/25, at 9:20 P.M., the resident returned to the facility via ambulance after receiving as needed medication with no new orders and no specific diagnosis documented. (Review of the resident's medical record showed no documentation the facility provided a transfer/discharge notice or copy of the bed hold policy to the resident or the resident's representative when the resident transferred to the hospital on [DATE]). Review of the resident's progress notes showed the following: -On 12/06/25, at 11:23 P.M., the resident continued to have behaviors. The resident was transferred to the hospital via ambulance at 9:21 P.M.; -On 12/07/25, at 7:30 A.M., the resident returned to the facility via ambulance after receiving as needed medication with no new diagnosis. (Review of the resident's medical record showed no documentation the facility provided a transfer/discharge notice or copy of the bed hold policy to the resident or the resident's representative when the resident transferred to the hospital on [DATE]). Review of the resident's electronic health record census list showed he/she discharged from the facility on 12/09/25. Review of the resident's progress notes showed no documentation the resident was discharged from the facility on 12/09/25. Review of the resident's medical record showed no documentation the facility completed a recapitulation of the resident's stay which included a summary of the resident's stay, a summary of the resident's status at the time of discharge or a reconciliation of all pre-discharge medications with the resident's post-discharge medications. During an interview on 01/08/26 at 3:37 P.M., the resident's DPOA said the following:-He/She did not receive any paperwork related to a transfer/discharge or a bed hold policy with any of the resident's hospitalizations;-It was decided during a care plan meeting the resident would be discharged home;-The facility did not provide any paperwork at the time of discharge. The facility did not provide a summary of the resident's stay and did not provide a list of the resident's medications. 4. During an interview on 01/09/26 at 6:20 P.M., Licensed Practical Nurse (LPN) B said the following:-The charge nurse was responsible to provide the resident or their representative with a bed hold policy when the resident transferred to the hospital;-Staff did not give a written discharge notice upon transfer to the hospital. During interviews on 01/09/26 at 10:28 A.M. and 9:25 A.M., and 8:53 P.M., the Director of Nursing (DON) said the following:-The charge nurse completed a bed hold agreement with the resident prior to or at the time the resident was sent to the hospital or as soon as possible;-The facility did not have a written transfer/discharge notice to give to the resident or their representative when a resident transferred to the hospital. -Staff should complete a discharge summary/recapitulation and give it to the resident or representative prior to discharge;-Resident #42 discharged from the facility after his/her care plan meeting, and there was not enough time for staff to give him/her or his/her DPOA a recapitulation of his/her stay.

Based on interview and record review the facility failed to ensure one resident's (Resident #2) of 17 sampled resident's, comprehensive care plan included direction to the staff for the resident with a diagnosis of Post Traumatic Stress Disorder (PTSD, (a treatable mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events like violence, accidents, or disasters.) to ensure trauma-informed care was provided. The facility did not communicate triggers or interventions to eliminate or mitigate the resident's triggers that may cause re-traumatization. The facility census was 40. Review of the facility's policy Comprehensive Assessment and the Care Delivery Process, revised December 2016, showed the following:-Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions;-Complete the Minimum Data Set (MDS) within 14 days after admission, within 14 days after it is determined that the resident has had a significant change in physical or mental condition, and annually.-Define issues, including problems, risk factors, and other concerns (to which all disciplines can relate).-Define conditions and problems that are causing, or could cause, other problems.-Identify potential causes or contributing factors of problems and symptoms, including:a. Medical;b. Psychosocial;c. Environmental; andd. Functional;-Try to determine the interrelationship between existing problems. -Determine the most plausible relationships between conditions and their causes. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed the following:-The RAI and Care Planning as required at the comprehensive care plan is an interdisciplinary communication tool;-It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;-The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care.-Following the decision to address a triggered condition on the care plan, key staff or the IDT should subsequently: Review and revise the current care plan, as needed; and communicate with the resident or their family or representative regarding the resident, care plans, and their wishes. Review the facility's policy Trauma Informed Care Policy, dated February 2021, showed the following:-It is the policy of this facility to consider residents' past traumatic experiences in developing person- centered care plans designed to avoid re-traumatization through the application of the principles of trauma-informed care;-Definitions:Trauma: Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well- being. The individual's experience of the event(s) determines whether it is a traumatic event. An event may be traumatic for one individual & not for another. The individual's interpretation will determine whether it is experienced as traumatic.Trigger: Something that causes the survivor to remember the traumatic event and induces a reaction similar to when they were originally traumatized. Triggers can re-traumatize survivors.Re-traumatization: Occurs when any situation, interaction, or environmental factor replicates events or dynamics of prior traumas and evokes feelings and reactions associated with the original traumatic experiences.-Care Planning for Trauma Survivors-Interdisciplinary staff work together with the resident/resident's representatives to assess the resident's needs and to identify triggers that may cause the survivor to remember the traumatic event and induce a reaction like when the resident was originally traumatized;-Strategies (interventions) to cope with triggers are included in the resident's plan of care;-Care plans are reviewed and revised as needed on at least a quarterly basis. 1. Review of Resident #2's face sheet showed a diagnosis of PTSD and anxiety disorder. Review of resident's Trauma Informed Care Assessment, dated 11/27/19, showed the following:-The resident was interviewed about traumatic life events;-The resident has combat or exposure to a war zone;-The resident has PTSD, he said it bothers him/her when there is a crowd of people that are loud, seeing someone in an argument, or if it's quiet and a loud noise startles him/her. Review of resident's Trauma Informed Care Assessment, dated 11/11/22, showed the following:-The resident was interviewed about traumatic life events;-The resident experienced a very stressful event that makes him/her feel fearful, he/she prefers not to share information about it;-Triggers that prompt him/her to recall the previous traumatic events are loud noises and a sudden change in environment. Review of the resident's Care Plan, last updated 08/24/23, showed the following:-Psychotropic drug use related to PTSD, nightmares and insomnia;-Resident will be on lowest possible therapeutic dose through the next review;-Document any reports of insomnia or nightmares;-Follow up with psychiatric services for medication management;-Physician and consulting pharmacist to review medications and attempt a gradual dose reduction (GDR) as appropriate. The care plan did not identify what the resident's triggers were or what triggers had the potential to retraumatize the resident or increase the resident's anxiety. The care plan did not provide direction to staff for what interventions were specific relative to the resident's PTSD. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 07/23/25, showed the following:-The resident was a veteran;-No PASSR checked;-Cognitively intact;-No signs and symptoms of depression;-Diagnosis includes stroke, PTSD, anxiety, and insomnia; -Receives antipsychotic medication GDR attempted last attempt 06/05/25, physician documented clinical contraindication on 06/05/25. Review of the resident's quarterly MDS, dated [DATE], showed the resident has no symptoms of depression, no depression diagnosis, and was started on a new antidepressant medication. Review of the resident's care plan did not include the new antidepressant medication, why the resident required new antidepressant medication, or the resident's PTSD triggers with interventions on how to minimize possible triggers that could cause re-traumatization of the resident. During an interview on 01/06/26 at 9:43 A.M., the resident said the following:-He/She was a war veteran;-He/She had PTSD and loud crowds of people, people arguing and loud sudden noises, sometimes gave him/her flashbacks;-He/She can have nightmares at times;-He/She has told staff about it and thought it was on his/her care plan; this was important because the facility used a lot of agency staff, and he/she would want them to know what was going on if he/she could not tell someone. During an interview on 01/09/26, at 7:35 P.M., Certified Nurse Assistant (CNA) E said he/she had heard the resident had a diagnosis of PTSD. To his/her knowledge it had not affected the resident. He/She did not know what the resident's triggers were; these should be on the care plan. He/She was not sure if the resident had his/her PTSD triggers listed on the care plan. During an interview on 01/09/26, at 6:20 P.M., Licensed Practical Nurse (LPN) B said the following:-He/She worked as a charge nurse;-All information needed to take care of a resident was expected to be on the resident's care plan;-The resident has PTSD. During an interview on 01/09/25, at 8:43 P.M., showed the Director of Nursing said the following:-Trauma and diagnosis of PTSD were expected to be on the resident's care plan with triggers, and interventions to minimize triggers that could potentially retraumatize residents;-The facility does not have an in house MDS coordinator/care plan coordinator at this time, (offsite corporate staff assisting) but that role would normally ensure that PTSD and triggers were on the resident's care plan.

Based on interview and record review, the facility failed to notify the state mental health authority promptly after a significant change in the mental condition of a resident who has mental illness for one resident (Resident #4) in a review of 17 sampled residents. The facility census was 40. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed the following:-Guidelines for Determining When a Significant Change Should Result in Referral for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation:-If a Significant Change in Status Assessment (SCSA) occurs for an individual known or suspected to have a mental illness, intellectual disability, or related condition (as defined by 42 CFR 483.102), a referral to the State Mental Health or Intellectual Disability/Developmental Disabilities Administration authority (SMH/ID/DDA) for a possible Level II PASRR evaluation must promptly occur as required by Section 1919(e)(7)(B)(iii) of the Social Security Act.5;-Referral should be made as soon as the criteria indicating such are evident. The facility should not wait until the SCSA is complete;-Referral for Level II Resident Review Evaluations is also required for individuals who may not have previously been identified by PASRR to have mental Illness, intellectual disability/developmental disability, or a related condition in the following circumstances:A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a diagnosis of mental illness as defined under 42 CFR 483.100 (where dementia is not the primary diagnosis). 1. Review of Resident #4's Level One Nursing Facility Pre-admission Screening for Mental Illness/Mental Retardation or related condition, dated 01/27/11, showed the following:-Section B: Level one screening criteria for serious mental illness;-Document was checked No;-Section C: Level on screening criteria for mental retardation or related condition;-Document was checked No;-Section D: Special admission categories;-Document was checked No. Review of the resident's Face Sheet showed the following:-Original admission date of 1/28/11;-admission diagnoses included no mental illness or mood disorders;-re-admission date of 12/23/15;-Diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms;-New diagnosis of paranoid schizophrenia with an onset date of 09/26/22. Review of the resident's re-entry MDS, a federally mandated assessment instrument completed by facility staff, dated 12/05/22, showed the resident's acute hospital diagnosis included schizophrenia. Review of email communication from the surveyor with Central Office Medical Review Unit (COMRU), on 01/08/26 at 10:05 A.M., showed a Change in Status PASRR should have been submitted to COMRU when the new mental illness of schizophrenia was diagnosed. During an interview on 01/09/26 at 2:00 P.M., the Social Services Director (SSD), said the following -Residents usually had a DA124 (a state form used for applicants for nursing facility placement, including medical necessity) and Level I PASARR screening for mental illness or intellectual disability upon admission;-If a resident triggered for a Level II PASARR in the computer, she would follow up to ensure it was completed;-She would print the Level II PASARR out and put the document in the resident's chart;-The resident would need a level II PASARR if there was a change in condition, a new diagnosis or coming from a psychiatric hospital;-She had started as the SSD in October and was not responsible for obtaining a PASARR II for Resident #4;-Resident #4 had not been recently diagnosed with schizophrenia, so it would not have popped up on her list to conduct a follow up. During an interview on 01/09/26 at 8:53 P.M. the Director of Nursing (DON), said the following:- If someone had a new diagnosis of schizophrenia or a major change to their psychology, it would be between social services and MDS staff to determine if there needed to be a new PASSAR. During an email correspondence on 01/27/26 at 6:46 P.M., the MDS Coordinator said the following:-Social Services was responsible for the Level II PASARR to be done and scanned into the medical record;-If a new diagnosis of schizophrenia was determined in the hospital, the hospital staff should complete the PASARR prior to discharge;-The Social Service designee was responsible for ensuring a resident has a Level II PASARR with a new diagnosis of schizophrenia;-If a resident reentered the facility 12/05/22 with a new diagnosis of schizophrenia a Level II PASARR should have been completed by the hospital prior to discharge.

Based on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for two residents ( Residents #6 and #2), in a review of 17 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the residents' health status and required interdisciplinary review and/or revision of the care plan. The facility census was 40.Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that:-Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and is not self-limiting;-Impacts more than one area of the resident's health status;-Requires interdisciplinary review and/or revision to the care plan.-The manual also showed a SCSA was appropriate if there was a consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of activities of daily living (ADL) decline or improvement);-Decline in two or more of the following: -Resident's decision-making ability has changed; -Presence of a resident mood item not previously reported by the resident or staff and/or an increase in the symptom frequency (PHQ-2 to 9(C)), e.g., increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for items in Section E (Behavior); -Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment; -Any decline in an ADL physical functioning area (e.g., self-care or mobility) (at least 1) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning; -Resident's incontinence pattern changes or there was placement of an indwelling catheter; -Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days); -Emergence of a condition/disease in which a resident is judged to be unstable.- Improvement in two or more of the following: -Any improvement in an ADL physical functioning area (at least 1) where a resident is newly coded as Independent, setup or clean-up assistance, or supervision or touching assistance since last assessment and does not reflect normal fluctuations in that individual's functioning.Review of the facility's policy Significant Change in Status Assessment (SCSA) Completion-To ensure accurate, timely, and compliant completion of Significant Change in Status Assessments (SCSAs) in accordance with the Resident Assessment Instrument (RAI) Manual and all applicable federal and state regulations;-The MDS Department will follow the most current version of the CMS RAI Manual as the authoritative guidance for determining when a Significant Change in Status Assessment is required and for ensuring its completion within required timeframes;-All Significant Change in Status Assessments will be completed accurately, thoroughly, and within the timeframes outlined in the RAI Manual to reflect the resident's current condition, -support appropriate care planning, and maintain regulatory compliance;-A Significant Change in Status is defined by the RAI Manual as a major decline or improvement in a resident's physical, mental, or psychosocial status that:Is not self-limiting;Impacts more than one area of the resident's health or function;Requires interdisciplinary review or revision of the care plan;-The MDS nurse is responsible for using the RAI Manual criteria to determine whether a change meets the definition of significant. 1. Review of Resident #6's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 10/31/25, showed the following:-Severe cognitive impairment, BIMS (Brief Interview for Mental Status) score five (0-15 scale, 0-7 scale severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact;-No pain, or interventions for pain;-Weighs 117 pounds (lbs.);-AD, Antiplatelet, anticonvulsant-Oxygen therapy, -Influenza 10/14/24-Pneumococcal up to date, COVID not up to dateSection V: Cognitive loss/dementia, ADL, Urinary incontinence, falls, nutrition, pressure ulcer, psychotropic drugs Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment, BIMS 10 (improvement);-New as needed (PRN) pain medications administered, and non-medication intervention for pain (decline with new pain and new interventions);-Weighs 110 lbs. 5.9% in one month weight loss (change);-New mechanically altered diet (new intervention related to new weight loss);-New opioid (new medication in response to pain but can have side effects that could change other parts of the resident's care). The facility did not complete a SCSA when the resident had new weight loss, new pain, a new diet, new medications, and new interventions. 2. Review of Resident #2's annual MDS, dated [DATE], showed the following:- Cognitively intact;-Independent with eating;-Requires partial/moderate assistance from staff for toileting hygiene, lower body dressing, personal hygiene; - Indwelling urinary catheter;-Continent of bowel;-Diagnoses include stroke, heart failure, high blood pressure, benign prostatic hyperplasia (non-cancerous, age-related enlargement of the prostate gland), obstructive uropathy (blockage of urinary tract), diabetes mellites (inability to regulate blood sugar) hemiplegia (weakening or paralysis of one side of the body), anxiety, respiratory failure, insomnia, irregular heartbeat, tremor, and post-traumatic stress disorder;-PRN pain medications;-Occasional pain, rarely effects sleep, rates a seven (on 1-10 scale, 10 being worst pain);-Risk of pressure ulcers, no current skin issues;-No antidepressant medication;-Radiation therapy while a resident. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Set up or clean up assistance from staff for eating (a decline); -Dependent on staff for toileting hygiene (decline), lower body dressing (decline), and personal hygiene (decline), -Indwelling urinary catheter removed (change);-Occasionally incontinent of bowel and bladder (decline);-New scheduled pain medication, and new non medication intervention for pain (new interventions);-New skin tear and dressing, nutrition and hydration intervention (change and new interventions)-Antidepressant medication added (change);-The resident no longer received radiation (improvement/change). During an interview on 1/8/26, at 2:58 P.M. and 01/26/26, at 12:26 P.M., the MDS/Care plan coordinator said the following:-She did all the MDS and care plan updates offsite;-She had been covering that position since the MDS coordinator left (a couple of months ago);-She does not get a lot of communication from the facility about who needs a significant change; if it triggered when she completed a MDS she will change the assessment to a significant change;-A significant change was required to be completed within 14 days of a change to the resident that would involve changes in two or more areas of the Activities of Daily Living (ADL)s or two changes other sections that are not expected to resolve within two weeks;-A SCSA is expected to be completed if there are two or more changes compared to the last comprehensive assessment (annual, admission, or SCSA);-She would complete the SCSA after communicating with the Director of Nurses (DON) and other department heads via emails or phone calls. During an interview on 01/09/26, at 8:53 P.M., the DON said she did not know much about SCSA requirements. She would ask the MDS coordinator for assistance with MDS questions. During an interview on 01/09/26, at 8:53 P.M., the Corporate Operations Manager said a SCSA was required when there were two or more changes compared to the last MDS, quarterly assessment or otherwise.

Based on record review and interview, the facility failed to maintain documentation to show the staff notified the resident's physician and the resident's representative following a significant weight loss and falls for one resident (Resident #5), in a sample of 17 residents. The facility census was 40. Review of the facility's policy Change in a Resident's Condition or status, revised December 2016, showed the following:-Our facility shall promptly notify the resident, his/her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status;-The nurse will notify the resident's attending physician or physician on-call when there has been an accident or incident involving the resident, significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment significantly;-Unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident is involved in any accident or incident, and when there is a significant change in the resident's physical, mental, or psychosocial status;-Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status;-Notifications will be documented in the resident's medical record. 1. Review of Resident #5's face sheet showed the resident admitted to the facility on [DATE] and had a representative. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 10/30/25, showed the following:-Moderate cognitive impairment;-Required partial/moderate assistance from staff for chair/bed-to-chair transfer and toilet transfer;-Required substantial/maximal assistance from staff to stand, wheel 50 feet with two turns or wheelchair 150 feet; -Two non-injury falls, and one injury fall since admission;-Weight 115 pounds;-No weight loss or therapeutic/mechanical diet. Review of the resident's Weight Record showed the following: -On 10/31/25 at 1:55 P.M., the resident weighed 115.2 pounds; -On 11/07/25 at 4:57 P.M., the resident weighed 106.0 pounds (a 9.2 pounds, or 7.96%, weight loss in one week). Review of the resident's medical record showed no documentation staff notified the resident's physician, dietician or the resident's representative of the resident's significant weight loss. Review of the resident's Nurses Notes, dated 11/10/25, at 3:01 A.M., showed staff found the resident on the floor. The resident was able to move all his/her extremities without pain or discomfort. Staff notified the resident's representative. (Review showed no documentation staff notified the resident's physician of the resident's fall on 11/10/25.) Review of the resident's Nurses Notes, dated 12/15/25, at 10:30 A.M., showed the nurse and an aide noticed the resident tried to reach for his/her wheelchair. The resident reached too far and went down onto his/her knees from the bed in front of the wheelchair. Staff notified the Director of Nursing (DON), hospice and physician. (Review showed no documentation staff notified the resident's representative of the resident's fall on 12/15/25.) Review of the resident's Nurses Notes, dated 12/17/25, at 2:20 A.M. and 6:52 A.M., showed the resident walked out of his/her room with his/her walker and attempted to run towards the nurse's station. The walker wheels got caught and the resident fell on the floor. The resident grazed his/her head in the doorway near the door frame and landed on his/her right side. The resident complained of pain in the right side of his/her body near his/her hip. The resident refused pain medication. Staff notified hospice who advised not to send the resident to the hospital. Staff notified the resident's representative of the fall. (Review showed no documentation staff notified the resident's physician of the resident's fall on 12/17/25.) Review of the resident's Nurses Notes, dated 1/5/26, at 5:15 A.M., showed staff observed the resident on the floor in his/her bathroom. Staff assessed the resident assessed, and he/she had no obvious injuries. (Review showed no documentation staff notified the resident's physician or the resident's representative of the resident's fall on 01/05/25.)During an interview on 01/07/26, at 11:51 A.M., the resident's representative said the following:-Staff did not call him/her every time the resident fell. Staff did not call him/her when the resident fell on [DATE]; -Staff did not make him/her aware the resident had lost weight;-He/She wanted to know everything regarding the resident, including falls, weight loss, or anything else significant. During an interview on 01/09/26 at 6:20 P.M., Licensed Practical Nurse (LPN B) said the charge nurses were responsible to call the physician and resident representatives when a resident fell or lost weight. During an interview on 01/09/26 at 8:53 P.M., the Director of Nursing said the charge nurse was responsible to update the physician and resident representative when a resident fell or had weight loss. During an interview on 01/09/26 at 8:53 P.M., the Corporate Nursing Manager said when staff identified a resident lost weight, staff should notify the resident's physician, representative, and the dietician. During an interview on 01/15/26, at 4:10 P.M., the Medical Director said the following:-A weight loss of 5% in one month was a significant weight loss; -He expected staff to contact the resident's physician when a resident had a significant weight loss;-Staff were to notify the resident's physician every time the resident fell, so the physician could investigate possible causes to prevent future falls.

Based on interview and record review, the facility failed to ensure one resident (Resident #1), who utilized a wheelchair for mobility and required assistance of one staff member during a facility van transport, was appropriately secured in the facility van when two of the four straps in the van were not functional. At the time of the transport on 5/23/25 at about 8:00 A.M., Transport Staff A said he/she could only attach two of the four straps in the van to the resident's wheelchair (front left and back right), because the other two straps were stuck. During the return transport to the facility, Transport Staff A attached the same two straps to secure the wheelchair in the van and a seat belt to secure the resident. During the return transport one strap came loose while driving through a round-a-bout, the resident's wheelchair tipped backwards, the resident hit his/her head on the van lift platform and slid from the wheelchair to the floor of the van. The Activity Director met the facility van at the round-a-bout and assisted Transport Staff A to transfer the resident back to his/her wheelchair. Neither the Transport nor Activity staff were licensed nurses. Staff returned the resident to the facility using the same two van straps to secure the resident's wheelchair. The resident was assessed upon arrival to the facility and was found to have a bump on his/her head. Transport Staff A continued to transport another resident (Resident #3) who utilized an electric wheelchair, after the accident occurred with Resident #1, when returning the resident from a medical appointment. Staff only secured the resident with the front right and back left straps and a seat belt. The facility census was 42. The Administrator was notified on 6/2/25 at 4:35 P.M. of the Immediate Jeopardy (IJ), which began on 5/23/25. The IJ was removed on 6/2/25, as confirmed by surveyor onsite verification. The facility did not provide a policy regarding the facility transport van or training for staff that transport residents upon request. 1. Review of the Resident Council Minutes, dated 3/7/25, showed the residents voiced concerns that the van seatbelts needed to be fixed. Review of the facility Department Response to Issues form, dated 3/7/25 showed the following: -Department: Maintenance -The date of the meeting referred to was 3/7/25; -Issue(s) identified by resident council, family council, or resident was not indicated; -Complaint/Issue was blank (not identified); -Plan of action: therapy said seat belts were fine; -Resolved, left blank (no response); -Communicated to resident was blank; -Maintenance department supervisor signed the form on 3/11/25; -Administrator signature line was blank. Review of the Resident Council Minutes, dated 4/4/25, showed the residents voiced concern about the van seatbelt. Review of the facility Department Response to Issues form, dated 4/4/25 showed the following: -Department: Maintenance; -The date of the meeting referred to was 4/4/25; -Issue(s) identified by resident council; -Complaint/Issues: seatbelt in the van was broken; -Plan of Action: look at seatbelt; -Resolved was blank (no response); -Communicated to resident was left black; -Maintenance Department supervisor signed the form on 4/9/25; -Administrator 2 signed the form on 4/9/25. Review of the Resident Council Minutes, date 5/2/25, showed the following issues for transportation: -Not tying/strapping residents down; -One resident's chair went into another resident because of not being strapped down; -Residents said they must hold on so they did not fly out of their wheelchairs. A Department Response Form from the 5/2/25 meeting was not available from the facility upon request. 2. Review of Resident #1's undated Face Sheet showed the resident had diagnoses that included end stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer adequately filter waste and fluid from the blood), dependence on renal dialysis (a machine used that filters the blood, removing waste and excess fluid when kidneys are unable to do so) hemiplegia (the loss of voluntary movement of one side of the body) and hemiparesis (weakness of one entire side of the body) following a stroke affecting his/her right dominant side. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/4/25, showed the following: -The resident was cognitively intact; -The resident did not have any behaviors or rejection of cares; -The resident required partial to moderate assistance of a staff member for chair to bed transfers; -The resident did not have the ability to walk 10 feet due to his/her medical condition. Review of the resident's Care Plan dated, 4/30/25, showed the following: -The resident had limited physical mobility; -Provide supportive care and assistance with mobility as needed; -The resident used a wheelchair for locomotion; -The resident had an activities of daily living self-care performance deficit related to multiple disease processes; -The resident required assistance of one staff member with transfers; -The resident needed dialysis related to end stage renal disease; -The resident had impaired visual function. Review of the resident's Progress Notes, dated 5/23/25, showed the following: -At 8:00 A.M., the resident left the facility via facility van transportation to go to dialysis; -At 12:07 P.M., the resident was picked up by facility transportation from dialysis. The transportation driver went around a round-a-bout and the resident started to go backwards in his/her wheelchair. The seat belt and floor straps were in place and the floor straps came loose. The resident fell back in his/her wheelchair and hit the back of his/her head on the facility van lift bar. Transportation called and notified the facility of the accident, and that transportation needed help to get the resident back in his/her wheelchair to transport the resident back to the facility. The physician was at the facility and gave an order to send the resident to the emergency room (ER). The resident refused to go to the ER. The resident returned to the facility and was assessed by the physician. Acting Director of Nursing (DON) called the corporate DON to notify them of the accident and was awaiting further instructions; -At 12:26 P.M., the resident was assessed by the physician and he/she gave an order for an antibiotic ointment to the scratch/dime size bump to the back or right side of the resident's head for seven days; -At 12:37 P.M., the resident returned from dialysis and a full assessment was completed. The resident was alert and oriented times four (person, place, time, and event), speech was clear, the resident denied a headache, and pupils are equal, round, and reactive to light and accommodation. A small 0.5 inch in length scratch to back side of the head at the top with dime size knot with orders to apply antibiotic ointment daily for seven days; -No open areas to head, face, or neck. No evidence of bruising to upper and lower extremities, no deformities, no dislocations. The resident denied pain to upper and lower extremities. Review of the resident's weekly skin assessment, dated 5/24/25, showed the following: -Staff documented the resident had a new left lower extremity skin discoloration; -Staff documented the resident had a 0.5 inch scratch on the back right side of his/her head due to an accident in the facility van; -Staff obtained a treatment order. Review of the resident's Progress Note, dated 5/27/25, showed at approximately 1:15 P.M. the physician gave an order to send the resident to the hospital. During an interview on 5/29/25 at 9:31 A.M., Licensed Practical Nurse (LPN) H said he/she sent the resident to the emergency room due to a sudden loss of vision. During an interview on 5/29/25 at 9:45 A.M., Administrator L said Resident #1 went to the hospital on 5/27/25 for complaints of a headache and trouble with his/her vision. 3. Review of Resident #3's undated Face Sheet showed the resident had diagnoses that included diabetes, chronic kidney disease (CKD) stage four (severe), morbid obesity and bilateral below the knee amputations. Review of the resident's Care Plan, dated 5/2/25, showed the following: -The resident needed dialysis related to CKD; -The resident had limited physical mobility related to bilateral amputation and morbid obesity; -The resident used an electric wheelchair; -The resident had actual and potential for fall and gait/balance problems related to bilateral lower amputation; -The resident had an activities of daily living self-care performance deficit; -The resident required assistance from two staff for transfers with a Hoyer lift (a mechanical machine used to transfer residents from one place to another). Review of the resident's progress notes showed no documentation staff transported the resident by the facility van to and from dialysis on 5/23/25. During an interview on 6/2/25 at 9:59 A.M. the resident said the following; -On 5/23/25, his/her wheelchair was not secured with straps in the van on the way to dialysis; -On 5/23/25, his/her wheelchair was secured with only two straps, the front right, and the back left and no seatbelt on his/her return to the facility from dialysis; -He/She was not sure why only two straps were used; -When the van went around curves his/her chair would sway without the straps in place; -He/She had to use different transportation now because the sister facility's van could not accommodate his/her wheelchair; -He/She did have to use the sister facility van once, but he/she had to squeeze into a smaller wheelchair to get into the van. 4. During an interview on 5/29/24 at 8:14 A.M., 3:48 P.M. and 6/2/25 at 3:30 P.M., the Maintenance Director said the following: -He transported residents a few times, but did not like how the straps worked; -If a person knew how to operate the straps they worked fine; -If a person could not get the straps tight it would cause a problem; -In February or March 2025, he spoke with the Regional Director of Clinical Operations about the function of the straps and the need for new straps; -Staff (unsure who) said they could work the straps properly and got them tight; -The Regional Director of Clinical Operations said if there were any more issues with the straps to let him/her know and new ones would be ordered; -The Maintenance Director did not have any work orders on the maintenance log for the facility van; -During a morning meeting after the 3/7/25 resident council meeting the van seatbelt was discussed. The Therapy Director spoke up and said the seatbelt in the van was fine so the Maintenance Director did not make any repairs at that time; -He did not make routine checks of the straps or the seatbelts in the transportation van; -He was not aware if the facility had a manufacturer's manual for the straps or seatbelts for the van at the facility. Review of the facility Maintenance Work Log showed there were no requests for repairs to the transportation van, seatbelts, or straps from 10/15/24 through 5/29/25. During an interview on 5/29/25 at 5 9:14 A.M., Resident #4 said the following: -He/She did not always feel safe when he/she rode in the transportation van; -The straps in the transportation van were loose when he/she was transported; -His/Her wheelchair moved about one quarter of a turn when the driver turned or went around a curve. He/She had to hold on to the seat in front of him/her to keep from moving around; -Transport Driver/CNA/CMT G was the driver for Resident #4 most of the time and asked if the resident was all right when the resident's chair moved around. During an interview on 5/29/25 at 1:17 P.M., Resident #6 said the following: -He/She had an electric wheelchair; -Transport Driver/CNA/CMT G never strapped him/her in the transportation van; -He/She held onto a bar in the transportation van, because he/she was afraid of falling when his/her electric wheelchair would move around during transports; -He/She called the transportation van the death trap. During an interview on 5/29/25 at 1:25 P.M. and 6/2/25 at 1:35 P.M., Transport Driver A said the following: -About two months ago Transport Driver A and Administrator L were told the straps in the van were broken. The two of them looked at the straps and they were not frayed or torn. They could pull the straps tight and thought they were all right; -He/She did not know the straps would come loose until he/she began as a transport driver in May; -He/She did not have training on how to secure the residents' wheelchairs in the transportation van; -The Maintenance Director told him/her the straps could be pulled tight, but they could possibly come loose; -He/She fastened the seatbelt, the front left and back right strap to Resident #1's wheelchair to transport the resident to the facility after dialysis. He/She did not use the other two straps because they were stuck and would not reach the wheelchair; -The front left strap came loose from Resident #1's wheelchair and that is when the resident fell backwards and out of the wheelchair; -He/She called the facility and reported the accident and the Activity Director came and helped him/her get Resident #1 back in his/her wheelchair in the van for the return to the facility; -He/She used the same two straps (front left and back right) to secure Resident #1 in the van for the return to the facility; -The MDS Coordinator's spouse (not a facility employee) came to the facility and looked at the straps, sprayed some lubricant on them and said they would be all right to transport Resident #3 from dialysis back to the facility; -He/She picked up Resident #3 from dialysis and used the seatbelt to secure the resident and the front right and back left straps to secure the resident's wheelchair in the van for the return ride to the facility; -Resident #3's straps came loose during transportation and the resident could undo the straps on his/her own after the van stopped; -He/She always only used two straps to secure the residents; -He/She never put a work order on the maintenance work log because everyone already knew there were problems with the straps. During an interview on 5/29/25 at 2:28 P.M., the Regional Director of Clinical Operations said the following: -A few months ago, someone said the straps in the van were not working. Transport Driver A and Administrator L assessed the straps and said there was no need to order new straps; -If there were any more issues with the straps or the van, he/she expected staff to enter it on the maintenance work log. During an interview on 5/29/25 at 3:00 P.M. and 6/2/25 at 12:15 P.M., the Activity Director said the following: -If a grievance was brought up in the Resident Council Meeting, he/she wrote them on a Department Response to Issues form and gave it to the appropriate department head; -The department head returned the form to him/her within 48 hours with a resolution and their signature; -He/She then took the form to the administrator to get a signature; -The 5/2/25 Department Response to Issues form he/she filled out with a grievance from residents that reported staff not strapping resident's wheelchairs down was missing. Transport Driver/CNA/CMT G did sign the form, and he/she took it to Administrator L who also signed it; -On 5/23/25, he/she went to assist Transport Driver A when Resident #1 fell backwards and out of the wheelchair in the van; -He/She rode in the van and stood in the back by Resident #1 on the return to the facility. During an interview on 5/29/25 at 3:29 P.M., Transport Driver/CNA/CMT G said the following: -He/She did not remember getting a Department Response to Issues form in May from the Activity Director; -He/She was able to get one side of the straps tighter than the other side. He/She thought it had to do with the wheelchair brakes; -Resident #6 said his/her electric wheelchair did not have to be strapped in the van so Transport Driver/CNA/CMT G did not secure the resident with the straps; -He/She should have secured Resident #6's electric wheelchair with the straps; -Transport Driver/CNA/CMT G assisted Resident #6 and Resident #1 into the van for a transportation (date unknown). Resident #6 was not secured with straps and ran his/her wheelchair into Resident #1 while he/she was adjusting his/her wheelchair. Resident #6 hit Resident #1's chair so hard it took the rubber off of one of Resident #1's wheelchair wheels. Transport Driver/CNA/CMT G had to use a crowbar to get the rubber piece back on the wheelchair. During an interview on 6/2/25 at 10:16 A.M., the MDS Coordinator's spouse said the following: -He/She went to the facility on 5/23/25 after Resident #1 fell in the facility van to check the straps; -He/She had to clean out one of the tracks that held the straps in place before he/she could get the strap locked in the track; -The front two straps' levers would not spring back in a locked position and hold the strap tight. He/She sprayed a lubricant on the levers of the front two straps before they locked correctly; -He/She felt the straps were safe to use and transport residents at that point. During an interview on 6/2/25 at 11:18 A.M., Registered Nurse (RN) J said the following: -On 5/23/25, Transport Driver A called the facility and told him/her Resident #1 fell backwards in the van and hit his/her head; -The Activity Director and the Social Services Director went to meet the van and help the transport driver get the resident back into his/her wheelchair; -When Resident #1 returned to the facility RN J and the Physician assessed the resident; -The resident had a knot on the upper right back of his/her head about the size of a nickel with a small scratch. The physician ordered an antibiotic ointment to the scratch for five days; -He/She was never aware the straps in the van did not work. During an interview on 5/29/25 at 3:24 P.M., the Certified Occupational Therapy Assistant (COTA) I said the therapy department did not assess any part of the facility transportation van. During an interview on 6/2/25 at 11:33 A.M., the Director of Rehabilitation said the following: -He/She had never assessed the seatbelts in the van; -The function of the seatbelts in the van was not something he/she assessed; -The therapy department only assessed resident's ability to sit and tolerate transport in the van. During an interview on 5/29/25 at 2:21 P.M., Administrator L said the following: -In March 2025 there was discussion about the straps in the transportation van because someone said they were broken; -She and Transport Driver A went to the van and looked at the straps; -The straps were not frayed or broken; -She thought they were fine to continue to use to secure residents during transports; -After Resident #1 fell in the van, the MDS Coordinator's spouse checked out the straps to see if they were defective. The MDS Coordinator's spouse cleaned out the tracks that hold the straps and said he/she could tighten all the straps; -Administrator L called the Regional Director of Clinical Operations and told him/her the straps needed to be replaced; -She did not know the transportation drivers were not trained on how to secure residents in the transportation van with the straps; -She did not think there was anything in place to train transportation drivers on securing residents with the straps in the van; -There was no manufacturer's manual for the straps or seatbelts in the van. During an interview on 6/2/25 at 12:28 P.M., Resident #1's Physician said the following: -Resident #1 fell in the facility van and hit his/her head; -The resident refused to go to the hospital for evaluation; -Upon return to the facility the physician assessed the resident's cranial nerves and completed a physical assessment, and the resident was fine. The resident had a small bump and scratch on the back of his/her head; -The Physician was at the facility on 5/27/25 and the resident presented with a change in condition; -The Physician sent Resident #1 to the hospital for evaluation due to her change in condition that could have been from the fall in the van; -The resident's change on 5/27/25 was a big change from 5/23/25. The resident had vision changes that required an evaluation at the hospital; -He/She expected the facility to have a safe and reliable form of transportation for the residents to get to and from appointments. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO254722

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of fourteen sampled residents, was free from abuse when resident (Resident #2) hit Resident #1 on the head with his/her walker, causing an injury to Resident #1's head. Resident #1 was tearful and expressed fear of Resident #2 after the incident. The facility census was 38. Review of the facility policy, Abuse, Prevention and Prohibition Policy, reviewed 2021, showed the following: - Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals; Abuse - means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain or mental anguish. It includes physical abuse and mental abuse. Willful, as used in this definition of abuse, means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 1. Review of Resident #1's face sheet showed the following: -Diagnoses included: encephalopathy (a general disturbance in brain function), stroke, mood disorder (a mental health condition that impacts a person's emotional state, causing extreme sadness, happiness, or both), flaccid hemiplegia (paralysis of one side of the body that occurs when muscles are weak and cannot be voluntarily moved) affecting left non-dominant side contracture (muscles, tendons, or other tissues become abnormally shortened and stiff, restricting movement) right hand, muscle weakness, depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and anxiety disorder (a mental health condition that involves excessive fear and worry that interferes with daily life); -The resident has a power of attorney (POA); -The resident was on hospice. Review of the resident's care plan, dated 11/28/2023, showed the following: -He/She has impaired thought processes; -The resident has a behavior problem: attention seeking behaviors of yelling, throwing things, hitting and kicking staff; -Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/11/24, showed the following: -He/She had minimal depression; -The resident's behavioral symptoms not directed toward others, physical symptoms such as verbal/vocal symptoms like screaming, and disruptive sounds, occurred daily; -The resident's behaviors had an impact which significantly interfered with the resident's participation or social interactions; -The resident's behavior had an impact on others which significantly disrupt care or the living environment; -Functional limitation in range of motion of upper and lower extremities; -Dependent on staff for all mobility functions; -Dependent on staff for wheelchair mobility. Review of the resident's progress notes, dated 02/23/25 at 8:45 A.M., showed the resident was sitting at the nurses station and the aides attempted to lay him/her down after breakfast and the resident began yelling, I wanna stay up, I wanna stay up!. Review of the resident's progress notes, dated 02/23/25 at 9:50 A.M., showed the following: -The nurse was down the hallway for another resident when he/she heard Resident #1 yelling; -The nurse witnessed Resident #2 yelling at the housekeeping staff, I'm going to kill him!; -Resident #2 began crying and said he/she hit Resident #1 in the head; -The nurse moved Resident #1 behind the nurses station and assessed his/her head; -A quarter sized, red raised area was noted to the top of Resident #1's forehead; -At 9:52 A.M. the police department was contacted; -At 9:54 A.M., the on call physician was notified; -An ice pack was applied to Resident #1's forehead. During an interview on 02/26/25 at 1:15 P.M., the resident said the following: -Two days ago, Resident #2 hit him/her on his/her forehead and on the left side of the head with his/her walker; -When Resident #2 hit him/her on the head it hurt; -Resident #2 said he/she was going to kill him/her; -He/She did not know why Resident #2 hit him/her on his/her head with a walker; -He/She had been minding his/her own business and nothing had been going on that morning; -While crying, he/she said he/she did not know if Resident #2 was still in the facility, but he/she did not want Resident #2 to be in the facility any longer; -He/She had been afraid Resident #2 was going to hit him/her again; -His/Her left shoulder had been hurting and had started hurting after he/she was hit on the head with Resident #2's walker; -He/She felt he/she had to move if Resident #2 came back to the facility because he/she (Resident #1) would not feel safe at the facility if Resident #2 came back; -He/She did not know why Resident #2 had been so angry and hit him/her. 2. Review of Resident #2's face sheet showed the following: -The resident's diagnoses included major depressive disorder (a mental health condition that involves persistent feelings of sadness and loss of interest in activities), psychosis not due to a substance or physiological condition (state of psychosis (a loss of contact with reality) that cannot be directly attributed to substance use, medication effects, or any underlying medical or neurological condition), and anxiety disorder. Review of the resident's care plan, dated 10/31/24, showed the following: -The resident had a behavioral problem; -Monitor his/her behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes; -Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed; -The resident was independent with activities of daily living (ADLs); -The resident was up ad lib (indicates that a resident can take or do something as much or as often as they want, without restrictions) in the facility. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had moderate cognitive impairment; -He/She had no physical or verbal behavioral symptoms directed toward others; -He/She was taking antipsychotic and antidepressant medications; -He/She had no functional limitations in either upper or lower extremities; -He/She used a walker for mobility. Review of the resident's progress notes, dated 02/23/25 at 9:50 A.M., showed the following: -The resident was last seen in his/her room at 9:30 A.M. watching television; -The nurse was down a hallway for another resident when he/she heard yelling coming from the nursing desk area; -The nurse witnessed Resident #2 yelling. I'm going to kill him, I don't care if I go to prison, I'm gonna kill him!; -At 9:52 A.M. the police department was contacted and informed Resident #2 struck Resident #1 with his/her walker; -Two police officers arrived at 10:05 A.M.; -The nurse went into the resident's room with the police while they got his/her statement; -When asked what happened, Resident #2 said,I did hit him/her and I don't care. I'll go to prison for it; -The nurse was told by other staff members, Resident #2 struck Resident #1 two times in the forehead with his/her walker and Resident #2 began yelling, I am going to kill him; -The resident said he/she was sorry that he/she had gotten angry; -The resident said he/she never meant to hit anyone. During an telephone interview on 03/13/25 at 9:10 A.M., the resident said the following: -The day he/she struck Resident #1 with his/her walker, he/she had a really bad headache from the flu and Resident #1 was yelling. He/She had asked Resident #1 to be quiet three to four times and Resident #1 would not stop yelling; -He/She was so enraged with Resident #1's yelling, he/she went out of his/her room and hit Resident #1 in his/her head with his/her walker. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -He/She was cognitively intact; -He/She had adequate hearing; -He/She had the ability to clearly understand and make him/herself understood. During an interview on 02/28/25 at 12:40 P.M., the resident said the following: -Resident #1 sat next to him/her by the big couch in the common area on the 300 hallway right down from the nurses station after breakfast on 02/23/25. Resident #1 was in his/her broda chair (a special tilt in space chair); -Resident #1 started yelling and he/she tried to calm Resident #1 down but he/she continued to yell; -Resident #2 came out of his/her room into the common area; -He/She heard Resident #2 say to Resident #1, Shut up or I will kill you!; -As soon as Resident #2 swung his/her walker, he/she yelled for staff; -He/She saw the housekeeping supervisor and Certified Nurse Aide (CNA) B coming down the hall. 3. During a telephone interview on 02/26/25 at 3:08 P.M., Certified Nurse Assistant (CNA) C said the following: -He/She had not witnessed Resident #2 hit Resident #1 on his/her head with his/her walker but had been working the day of the incident; -He/She had been providing cares on another hallway; -When he/she came around the corner, he/she heard Resident #1 say, Ow that hurt and Resident #2 said, I did it twice and I am going to kill him/her; -Resident #1 was crying and holding his/her head; -Resident #1 was afraid and kept asking if Resident #2 was gone, was Resident #2 out there?, Resident #1 had not wanted to come out of his/her room because he/she was scared. Staff could not bring up Resident #2's name without Resident #1 becoming upset. During an interview on 02/26/25 at 3:30 P.M., CNA G said after Resident #1 had been hit on the head, he/she was terrified to come out of his/her room During a phone interview on 02/26/25 at 2:26 P.M., the Housekeeping supervisor said the following: -She had been working on the 100 hallway checking linen barrels and was walking back to the nurses station right before she heard the commotion between Resident #1 and Resident #2; -She started walking faster and heard the first hit with the walker, but did not see who was involved; -She came around the corner and saw Resident #2 hit Resident #1 with his/her walker in the head; -Resident #2 said, I want to kill that (expletive) and I don't care if I go to prison. During an interview on 02/26/25 at 1:58 P.M., the MDS Coordinator said the following: -She had worked the weekend and was the nurse working on Sunday, 02/23/25; -Breakfast was finished and Resident #1 sat in the common area near the nurses station; -She had left the nurses station to help with a resident on the 100 hallway; -She heard Resident #1 start yelling and heard a commotion while she was still helping the resident on the 100 hallway; -She came back to the nurses station and was told by the housekeeping supervisor, that Resident #2 hit Resident #1 with his/her walker; -Resident #1 and Resident #2 were separated and placed one on one with a staff member; -She took Resident #1 behind the nurses station and assessed him/her; -When she assessed Resident #1, he/she had a quarter sized bump on his/her forehead; -She contacted the police, the Director of Nursing (DON), the physician and Resident #1's Power of Attorney (POA); -When the police arrived, Resident #2 said he/she could not take the yelling and he/she wanted to kill Resident #1. During an interview on 02/26/25 at 11:06 A.M., Licensed Practical Nurse (LPN) A said the following: -Resident #1 had told him/her about the incident and pointed to his/her head when he/she came back to work on Monday 02/24/25; -Resident #1 cried and voiced he/she was really scared after being hit by Resident #2; -Resident #1 was tearful when he/she recounted the incident of being hit in the head with Resident #2's walker. During an interview on 02/28/25 at 11:36 A.M., the social services director said the following: -Resident #3 had witnessed Resident #2 hit Resident #1 in the head with his/her walker; -Resident #1 and Resident #3 had been sitting in front of a couch on the 300 hallway in the common area and it was about 20 feet from Resident #2's room; -The DON called her on Sunday, 02/23/25, and instructed her to go to the facility to help with the investigation process; -When she arrived at the facility, Resident #1 was sitting in the dining room with CNA B; -She asked Resident #1 what had happened and he/she was crying and pointing to his/her head; -Resident #3 was alert and oriented and had witnessed the incident; -From what she understood, Resident #2 had hit Resident #1 with his/her walker because Resident #1 was yelling. During an interview on 02/26/25 at 4:29 P.M. and 02/28/25 at 2:50 P.M., the DON said the following: -She was not in the building when Resident #2 hit Resident #1 in the head with his/her walker; -She received a phone call from the MDS Coordinator who reported the incident to her; -She called the administrator and told her about the incident and the administrator told her she would go to the facility; During an interview on 02/28/25 at 12:58 P.M., the administrator said the following: -The DON had called her on her phone around 10:00 A.M. on Sunday 02/23/25 and said there had been an incident at the facility; -The DON had given her a brief description that Resident #1 had been hit on the head with Resident #2's walker; -She arrived at the facility around 11:00 A.M. and went to the nurses station; -Resident #2 was in his/her room and Resident #1 was in the dining room with three staff members around him/her; -She spoke to Resident #1 and he/she had tears running down his/her face and he/she was pointing to his/her head; -Resident #1 had a knot on the left side of his/her head and the start of a bruise on his/her right forehead area near his/her hair line; -Her investigation showed the abuse had been founded. MO 250032

See event ID IU2912 Based on interview and record review the facility failed to provide adequate supervision and assistance for one resident (Resident #1) in a review of eleven residents. Resident #1 utilized a Broda chair (a type of wheelchair that tilted and reclined) and required extensive assistance from staff for bed mobility, required mechanical lift transfers and had impaired range of motion on one side of the upper body. On 5/16/23, during a transport in the facility van to a medical appointment approximately 54 miles away from the facility, staff transferred Resident #1 into a regular wheelchair prior to transport as the resident's Broda chair would not fit in the facility van. Transport staff A did not secure the resident with a seatbelt in the van. During transport the resident slid from the wheelchair onto the floor of the van. Transport staff A arrived at a local hospital and obtained assistance for the resident who was evaluated in the emergency room . Transport staff A continued to transport another resident (Resident #18) in a wheelchair in the van, three times weekly to medical appointments without securing the resident with a seat belt following the incident with Resident #1 on 5/16/23. The facility census was 39. The administrator was notified of the Immediate Jeopardy (IJ) on 6/2/23 at 1:00 P.M. which began on 5/16/23. The IJ was removed on 6/7/23 as confirmed by surveyor onsite verification. Review of the facility policy, Resident Transportation, dated April 2020 showed the following: -Resident transportation needs would be met and transportation would be provided as available; -Before transporting, post notices of scheduled transportation in a clear, easy to read format and explain schedules to visually or other disabled residents. Ensure special arrangements were made for residents with special needs; -For resident safety residents were to have the cognitive and physical ability to be transported without assistance. The facility did not provide a policy regarding seat belt and safety mechanism use while transporting residents in the facility van. 1. Review of Resident #1's care plan dated 5/8/23 showed the following: -admitted [DATE]; -Diagnosis of cancer of the lymph symptom (the disease fighting system in the body), pain, urinary tract infection and below elbow amputation of the right arm; -The resident was at risk for falls. -The resident had difficulty performing Activities of Daily Living (ADLs) and had limited physical mobility. Staff should assist with bed mobility. He/She was totally dependent on staff for ambulation and locomotion and required two staff member's assistance with lifting, and a mechanical lift for all transfers. The resident utilized a wheelchair for mobility. Review of the resident's Fall Risk Assessment (a tool used to determine a resident's risk of falls) dated 5/8/23, showed staff documented the following: -History of falls in the previous 90 days; -Took blood pressure and narcotic pain medication that increased the risk of falls; -Incontinent; -The resident was unable to independently come to a standing position, exhibited loss of balance while standing, required hands-on assistance to move from place to place, and used an assistive device; -Fall risk score of 31 indicating a high fall risk. Review of the resident's physical therapy plan of care dated 5/10/23 showed the following: -Presented to therapy with a decline in functional ability of bed mobility, transfers and ambulation due to sudden increase in lethargy and weakness. Staff had noticed a decrease in mobility since admission resulting in decreased safety and an increased need for assistance. Required therapy to improve safety and function; -Fall risk; -Oriented to his/her name, struggled to remain awake and needed several redirection cues, had some reflexive withdrawals with stretching of lower legs; -Required total assistance with bed mobility of rolling over and repositioning, was unable to maintain balance without moderate/maximum staff support; -Treatment diagnosis of generalized muscle weakness. Review of the resident's nurses' notes showed staff documented the following: -On 5/10/23 at 9:48 A.M. the resident was alert and oriented to self, required extensive assistance of two staff members with ADLs and required a mechanical lift for transfers; -On 5/16/23 at 11:22 A.M. staff received notification from an outside hospital the resident was being evaluated at the emergency room due to a fall. The resident slid out of the wheelchair and was assisted to the emergency department by EMS (Emergency Medical Services). Review of the Emergency Department physician note dated 5/16/23 showed the following: -Chief complaint was a fall; -The resident presented to the hospital emergency department following a fall prior to emergency department arrival. The resident was coming to the hospital for a medical treatment and was in a wheelchair in the van. Apparently the wheelchair fell over. The resident complained of headache and neck pain, denied any other injuries. During an interview on 6/1/23 at 4:00 P.M. Transporter A said the following: -On 5/16/23 at about 7:20 A.M. he/she transported the resident to a hospital about 45 miles from the facility in the facility van. He/She helped transfer the resident from the Broda chair to a regular straight back wheelchair before loading the resident in the facility van with the van's wheelchair lift. The resident's Broda chair did not fit in the facility van. During the transport the resident sat in the wheelchair just behind the bench seat. No other residents or staff rode in the van during the transport; -He/She hooked the resident's wheelchair frame to the van with four S hooks (metal S shaped hooks attached to the wheelchair frame connected to heavy straps secured directly to the van floor for safety) and locked the resident's wheelchair brakes. He/She did not place the van seatbelt on the resident and the resident did not wear a seatbelt during the transport. Transporter A asked the resident if he/she wanted to wear the seatbelt and the resident said no; -During the transport he/she told the resident they were almost at the hospital and the resident said okay. When he/she looked in the review mirror again the resident was gone, the resident had slid out of the wheelchair on to the van floor; -The van had seat belts to secure residents in wheelchairs, but the seat belts fit loosely and did not pull tight when fastened; -The facility had no rules requiring seat belt use. It was the resident's choice if they wanted to wear a seatbelt or not. During an interview on 6/2/23 at 10:10 A.M. The Assistant Director of Nurses (ADON) said the resident required a mechanical lift for transfers and extensive assistance with ADLs. The resident is very tall, had gotten weaker and had trouble sitting up in a regular wheelchair for any length of time. On 5/15/23 staff changed the resident from a regular wheelchair to a Broda chair when out of bed for his/her safety and comfort. The Broda chair sat up too high and would not fit in the facility van. Staff transferred the resident into the regular wheelchair prior to transport in the facility van on 5/16/23. Staff should have ensured all residents wore seat belts during transport. 2. Review of Resident #18's care plan updated 3/27/23 showed the following: -Diagnosis of right leg below the knee amputation, end stage renal disease (ESRD) (kidney failure resulting in need for dialysis), dependence on renal dialysis (medical procedure filtering toxins from the blood in the absence of proper kidney function), muscle weakness, and obesity; -The resident required dialysis treatments. Staff should ensure the resident attended dialysis appointments at the local dialysis clinic three times weekly on Mondays, Wednesdays and Fridays; -The resident had difficulty performing ADLs and was dependent on staff for assistance with bed mobility, dressing, personal hygiene and transfers. Staff should provide assistance with ADLs and provide mechanical lift transfers. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 5/28/23 showed the following: -Cognitively intact; -Required extensive assistance of two staff members with bed mobility; -Required total assistance of two staff members with transfers; -Required extensive assistance of one staff member with locomotion on and off the unit; -Required a wheelchair for mobility. Review of the facility transport schedule provided 6/1/23 showed staff documented facility staff transported Resident #18 in the facility van on 5/22/23, 5/24/23, 5/26/23, 5/29/23, and 5/31/23 to and from a medical appointment. During an interview on 6/2/23 at 9:25 A.M. Transporter A said the following: -He/She transported Resident #18 to a medical appointment three times weekly in the facility van and the resident never wore a seatbelt. The resident refused to wear a seat belt; -He/She transported Resident #18 on 6/2/23 in the facility van without a seatbelt to dialysis; -After Resident #1 slid out of the wheelchair during transport, the administrator informed Transporter A verbally all residents were required to wear seatbelts during transport. Transporter A said he/she thought it was a resident's right to choose not to wear a seatbelt. Resident #18 had never worn a seatbelt when he/she drove the resident to and from dialysis. Observation on 6/2/23 at 2:10 P.M. showed Resident #18 sat outside in a wheelchair smoking. He/She sat at an angle with a pillow tucked behind his/her right side/back area and sat on a mechanical lift transfer sling. His/Her legs and hips touched the sides of the wheelchair with legs stretched out straight in front of the wheelchair. Staff attempted to push the resident in the wheelchair into the facility, the resident was unable to bend his/her knees or elevate his/her legs and feet off the floor. Staff pulled the resident backwards in the wheelchair into the facility and continued two doors down the hall after entering the facility to the resident's room. During an interview on 6/2/23 at 2:12 P.M., the resident said he/she went to a medical appointment (dialysis) three times weekly and just got back to the facility. His/Her usual wheelchair was wider and more comfortable, but did not fit in the facility van. Staff transferred him/her into the smaller wheelchair for transports to go in the facility van. The smaller wheelchair was not comfortable, did not fit him/her, and he/she was unable to bend his/her knee today. He/She did not wear a seatbelt during transports in the facility van, he/she refused the seatbelt three times a week during transport. He/She did not wear a seatbelt during transport in the facility van on 6/2/23. He/She was aware as of 6/2/23 a seat belt was required and would wear a seat belt. 3. Observation on 6/7/23 at 11:55 A.M. showed the facility van contained a bench seat behind the driver's seat and space for two wheelchairs behind the bench seat with four S hook harness belts available to secure each wheelchair, one behind the other. The driver's side of the van directly behind the bench seat, contained a folding seat, folded and secured to the side of the van near the side window, with wire wrapped around the folded seat frame and around the seat belt strap intended for the front wheelchair. The wire secured the folding seat to prevent the seat from falling open onto a resident in a wheelchair during transport. Transporter A attempted to pull the seatbelt and said the wire needed to be removed to use the seatbelt. Transporter A removed the wire and pulled the seatbelt loose, extended the seatbelt and fastened the seatbelt over the area for the wheelchair position directly behind the bench seat. During an interview on 6/2/23 at 9:45 A.M. the Maintenance Supervisor said during resident transports in the facility van, staff should attach the S hooks four point harness to secure the wheelchair and fasten the seat belt on all residents. Staff were taught to use the facility van including the S hook harness and the seatbelts. Transports should ensure all residents were secured in the facility van including the use of seatbelts prior to transport. During an interview on 6/2/23 at 10:30 A.M. the Administrator said the following: -All residents and staff should wear a seatbelt during transport in the facility van. Seatbelts were required at all times. She became aware Resident #1 did not have seatbelt on during the 5/16/23 transport two days after the resident fell out of the wheelchair in the facility van. She informed the maintenance supervisor and Transporter A verbally on 5/18/23 seatbelts were required during all transports; -She was unaware staff did not ensure Resident #18 wore a seatbelt during the facility van transports three times weekly for medical appointments. If a resident refused the seatbelt staff should not transport the resident; -The facility did not have a current policy regarding the use of seatbelts in the facility van or regarding safety during facility van transports. MO00218547 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. 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 violations(s).

See event ID IU2912 Based on observation, interview and record review, the facility failed to ensure one resident (Resident #7) in a review of eleven residents, received treatment and care in accordance with professional standards of practice. The resident, a known fall risk, fell and fractured both bones of the left arm just above the wrist at approximately 3:30 A.M. on 5/12/23. Staff failed to provide emergent care after pain, swelling, bruising and deformity of the left lower arm above the wrist was identified with no immobilization of the arm for twelve hours following the fall. Staff administered one Tylenol for pain, gave the resident a shower without immobilization of the fractured arm, and did not transfer the resident to the emergency room when pain and swelling was identified. The facility census was 39. Review of the facility undated policy Fall Assessment showed the following: -The charge nurse will assess the resident's level of consciousness, pain, change in mobility or obvious injury, obtain vital signs, and provide a head to toe body assessment and every shift for 72 hours. Report any new findings after initial assessment to the physician, resident and/or representative and Director of Nursing (DON) and document in the nurses' notes. Address any injuries as necessary. The facility provided no specific policy regarding standard of practice and treatment following a fall with injury. Review of mayoclinc.org showed the following: -A fracture is a broken bone. It requires medical attention. If the broken bone is the result of major trauma or injury, call 911 or your local emergency number. Also call for emergency help if even gentle pressure or movement causes pain, the limb or joint appeared deformed; -Don't move the person except if necessary to avoid further injury; -Take these actions immediately while waiting for medical help: -Immobilize the injured area. Don't try to realign the bone or push a bone that's sticking out back in. If you've been trained in how to splint and professional help isn't readily available, apply a splint to the area above and below the fracture sites. Padding the splints can help reduce discomfort; -Apply ice packs to limit swelling and help relieve pain. Don't apply ice directly to the skin. Wrap the ice in a towel, piece of cloth or some other material. 1. Review of Resident #7's care plan dated 4/11/23 showed the following: -admitted [DATE]; -Diagnosis of dementia and history of falling; -The resident had impaired cognition due to dementia; -The resident required assistance with Activities of Daily Living (ADLs). Staff should assist with bathing, dressing, and transfers; -The resident was at risk for falls related to decreased mobility and history of falls. Review of the resident's Physician Order Sheet (POS) dated 4/11/23 showed Tylenol 500 milligrams (mg) one tablet every six hours as needed for pain. Review of the physical therapy plan of care dated 4/12/23 showed the following: -Treatment diagnosis of muscle weakness and unsteadiness on feet; -Referred to therapy following recent hospitalization for mental status change, failure to thrive at home with frequent falls at home. Now having difficulty with transfers and ambulation. Review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 4/17/23 showed the following: -Cognitively intact; -Required limited assistance of one staff member with transfers, walking in room and corridor, locomotion on the unit (moving between locations in his/her room and corridor) and personal hygiene; -Required extensive assistance of one staff member with dressing and toileting; -History of falls in the previous two to six months without fractures. Review of the resident's nurses' notes dated 5/12/23 showed the following: -At 3:30 A.M. Licensed Practical Nurse (LPN) C documented he/she walked past the resident's room and noted the resident up ambulating with the walker to the bathroom. The resident lost his/her balance and fell backwards hitting his/her left wrist on the roommate's bed. The resident denied any pain at the time, noted to have small bruise to the left outer wrist as well as a skin tear measuring 1.5 centimeters by 1.5 centimeters. LPN C cleaned the area and applied a bandage, he/she assessed the resident's range of motion. The resident could move all extremities without difficulty and denied pain at the time. Staff assisted the resident off the floor and transferred the resident to the recliner chair. A voicemail was left for the physician's office notifying of the fall, family was notified; -At 3:48 A.M. the resident sat in his/her recliner with eyes closed, no appearance of pain or discomfort. Review of the resident's record showed no additional documentation staff assessed the resident on 5/12/23 from 3:48 A.M. through 8:55 A.M. following the resident's fall. Review of the resident's nurses' notes dated 5/12/23 showed staff documented the following: -At 8:55 A.M. Licensed Practical Nurse (LPN) B documented the resident had 10/10 (pain scale used to assess level of pain with zero as no pain and 10 as worse pain ever felt) pain to the left wrist with no range of motion. The wrist was swollen with dark blue bruising. The physician was notified with orders received for x-ray of the wrist per portable x-ray (x-ray provided by outside company who came to the facility); -At 9:00 A.M. the resident's family made aware of the resident's left wrist pain, swelling and bruising with new physician orders for x-ray. Review of the POS dated 5/12/23 showed order received at 9:00 A.M. for x-ray of the resident's left wrist due to pain and swelling. Review of the resident's Medication Administration Record (MAR) dated 5/12/23 showed staff documented at 9:00 A.M. Tylenol 500 mg administered for complaints of left wrist pain with no staff documentation indicating the effectiveness of the pain medication administered. Review of the resident's nurses' notes dated 5/12/23 showed staff documented the following: -At 11:48 A.M. portable x-ray company completed the left wrist x-ray; -At 1:16 P.M. x-ray results of acute oblique fracture (a complete fracture of the bone at an angle all the way through the bone) of the left distal radius and ulna (both bones in the forearm above the wrist). Staff notified the physician with orders for transfer to the emergency room . Review of the resident's left wrist x-ray report dated 5/12/23 showed findings of acute oblique fracture (a complete fracture of the bone at an angle all the way through the bone) of the distal radius and ulna (both bones in the forearm above the wrist). Review of the shower sheets showed staff documented the resident received a shower the morning of 5/12/23. Review of the resident's nurses' notes dated 5/12/23 showed staff documented at 2:00 P.M. family transported the resident in personal vehicle to the emergency room . Observation on 6/1/23 at 10:40 A.M., showed the resident's left arm casted from above the elbow to the hand. The left fingers were swollen. During an interview on 6/1/23 at 10:45 A.M. the resident's family member said the following: -On 5/12/23 at 3:45 A.M. staff called and said the resident fell and was okay. Staff had offered to send the resident to the emergency room , but the resident refused and said he/she was fine; -The family arrived at the facility about 8:00 A.M. on 5/12/23 and found the resident's left wrist was swollen and had an indentation with appearance of a broken bone at the wrist; -The resident remained in his/her chair, left wrist was swollen with bruising and malformed with a dent in the wrist area. No ice or splinting of the wrist was in place. The portable x-ray was completed about 12:00 P.M. and the entire time the resident had no ice or splinting of the wrist. Staff gave the resident a shower that morning without immobilizing the wrist. Staff said they wanted to wait for the x-ray results before sending the resident to the emergency room ; -At 2:30 P.M. family transported the resident to the emergency room instead of waiting for an ambulance and learned two bones were fractured in the resident's left wrist. The resident had surgery on 5/15/23 to repair the fractured bones. During an interview on 6/1/23 at 10:46 A.M. the resident said he/she was going to the bathroom when he/she fell . He/She remembered hanging on to the bathroom door knob, fell backward and hit his/her arm. His/Her arm hurt after the fall and he/she knew something was wrong. His/Her arm swelled and bruised after the fall. During an interview on 6/2/23 at 3:08 P.M. Certified Nurse Assistant (CNA) D said he/she worked night shift on 5/12/23. Resident #7 fell at about 3:30 A.M. that night. The resident said his/her wrist hurt when he/she and another staff member were getting the resident up off the floor. LPN C assisted with the transfer off the floor and was aware the resident's left wrist hurt at that time. The resident's wrist started bruising as the night went on after the fall between 4:00 A.M. and 6:30 A.M. The resident sat in the recliner chair for a few hours and then was transferred to bed and said his/her wrist hurt. CNA D saw LPN C check the resident over after the fall, LPN C was aware the resident's wrist hurt following the fall. When LPN C checked on the resident again sometime before the end of the shift (7:00 A.M.), the resident said he/she was okay but his/her wrist hurt. During an interview on 6/2/23 at 3:30 P.M. CNA E said he/she worked the night shift on 5/12/23. At about 3:30 A.M. LPN C saw Resident #7 fall. LPN C called CNA E and another staff member (CNA D) for help getting the resident up off the floor. CNA E and CNA D lifted the resident off the floor while LPN C was in the resident's room. The resident complained of pain in the left arm and said his/her left arm hurt. LPN C was in the resident's room during the transfer and was aware the resident said his/her arm hurt. Staff sat the resident in the recliner chair for a while and later transferred the resident to bed. CNA E noticed swelling of the resident's left wrist. LPN C assessed the resident during the night (unknown time) after the initial fall assessment and did not send the resident to the emergency room during the shift. No ice or treatment was applied to the resident's left wrist during the night shift after the fall. During an interview on 6/1/23 at 8:45 P.M. LPN C said he/she was the charge nurse when the resident fell on [DATE]. The fall happened about 3:30 A.M. as LPN C was walking past the resident's room and saw the resident going into the bathroom. The resident fell backward and hit his/her left wrist on the bed frame as he/she fell . LPN C checked the resident over and found a skin tear on the left wrist, the resident said his/her left wrist hurt. LPN C cleaned and applied a dressing to the skin tear. The resident had no complaints of pain and there was no swelling of the left wrist at the time of the fall. A voice mail was left for the on-call physician notifying him of the resident's fall with no pain or apparent injury. The resident slept in his/her chair the rest of the night. LPN C woke the resident early that morning (around 6:00 A.M. on 5/12/23) and noted bruising to the left wrist at that time. The resident could move his/her fingers and make a fist. LPN C told LPN B in report at the change of shift of the fall. He/She did not apply ice or immobilize the resident's left wrist during the night shift after the fall. During an interview on 6/1/23 at 3:20 P.M., LPN B said he/she came to work at 7:00 A.M. on 5/12/23. The resident's left wrist was swollen and the resident was unable to move the wrist. He/She called the physician and obtained orders for an x-ray. The resident had a lot of pain. LPN B put some ice on the wrist. The resident was grimacing and in pain at 7:00 A.M. The left wrist was not immobilized following the fall. Night shift had not applied any ice or splinting following the fall. The portable x-ray was completed about noon and the physician notified of the results with orders to send the resident to the emergency room . Family transported the resident to the emergency room in the afternoon instead of waiting for an ambulance. The resident returned from the emergency room with a soft cast and scheduled for surgical repair a few days later. During an interview on 6/2/23 at 2:00 P.M. the resident's physician said if Resident #7 had no obvious injury and no pain at the time of the fall, he would not order an x-ray at that time. When pain was present, he would order an x-ray following a fall. If the resident had pain and apparent injury, staff should immobilize the area, obtain an x-ray and start treatment including sending the resident to the emergency room . If a resident required an x-ray in the night, staff should send the resident out to the emergency room at the time of the injury. During an interview on 6/7/23 at 1:15 P.M. the Director of Nursing said the resident fell on [DATE] at about 3:30 A.M. Staff should assess the resident's condition at the time of the fall, provide treatment and notify the physician of the resident's condition. Staff checked on the resident a couple of times during the night and reported the fall to the day shift nurse at 7:00 A.M. At 8:30 A.M. on 5/12/23, staff said the resident had bruising and swelling of the left wrist, a portable x-ray was obtained. At about 10:00 A.M. she saw the resident's wrist, it was swollen with swollen fingers and an indentation at the wrist. Staff should have immobilized the left wrist after the fall, applied ice and sent the resident out to the emergency room as soon as an injury was noted. Staff should not have given the resident a shower with a fractured wrist. Undressing and showering without an immobilizer, moving the resident and the fractured wrist would have caused the resident more pain. During an interview on 6/7/23 at 2:00 P.M. the Administrator said following a fall staff should send the resident to the emergency room if injured. Following the fall staff should continue to assess the resident's condition, monitor for injuries and call the physician. If the resident worsened send the resident to the emergency room immediately. Resident #7 had two fractured bones in the left arm, staff did not immobilize the left arm or apply ice and did not send the resident to the emergency room for treatment when injury was noted. Staff gave the resident a shower with the fractured bones causing more pain. Staff should have immobilized the resident's left arm, applied ice and transferred the resident to the emergency room as soon as symptoms of injury was evident. MO00218496

Based on interview and record review the facility failed to provide adequate supervision and assistance for one resident (Resident #1) in a review of eleven residents. Resident #1 utilized a Broda chair (a type of wheelchair that tilted and reclined) and required extensive assistance from staff for bed mobility, required mechanical lift transfers and had impaired range of motion on one side of the upper body. On 5/16/23, during a transport in the facility van to a medical appointment approximately 54 miles away from the facility, staff transferred Resident #1 into a regular wheelchair prior to transport as the resident's Broda chair would not fit in the facility van. Transport staff A did not secure the resident with a seatbelt in the van. During transport the resident slid from the wheelchair onto the floor of the van. Transport staff A arrived at a local hospital and obtained assistance for the resident who was evaluated in the emergency room. Transport staff A continued to transport another resident (Resident #18) in a wheelchair in the van, three times weekly to medical appointments without securing the resident with a seat belt following the incident with Resident #1 on 5/16/23. The facility census was 39. The administrator was notified of the Immediate Jeopardy (IJ) on 6/2/23 at 1:00 P.M. which began on 5/16/23. The IJ was removed on 6/7/23 as confirmed by surveyor onsite verification. Review of the facility policy, Resident Transportation, dated April 2020 showed the following: -Resident transportation needs would be met and transportation would be provided as available; -Before transporting, post notices of scheduled transportation in a clear, easy to read format and explain schedules to visually or other disabled residents. Ensure special arrangements were made for residents with special needs; -For resident safety residents were to have the cognitive and physical ability to be transported without assistance. The facility did not provide a policy regarding seat belt and safety mechanism use while transporting residents in the facility van. 1. Review of Resident #1's care plan dated 5/8/23 showed the following: -admission date 5/8/23; -Diagnosis of cancer of the lymph symptom (the disease fighting system in the body), pain, urinary tract infection and below elbow amputation of the right arm; -The resident was at risk for falls. -The resident had difficulty performing Activities of Daily Living (ADLs) and had limited physical mobility. Staff should assist with bed mobility. He/She was totally dependent on staff for ambulation and locomotion and required two staff member's assistance with lifting, and a mechanical lift for all transfers. The resident utilized a wheelchair for mobility. Review of the resident's Fall Risk Assessment (a tool used to determine a resident's risk of falls) dated 5/8/23, showed staff documented the following: -History of falls in the previous 90 days; -Took blood pressure and narcotic pain medication that increased the risk of falls; -Incontinent; -The resident was unable to independently come to a standing position, exhibited loss of balance while standing, required hands-on assistance to move from place to place, and used an assistive device; -Fall risk score of 31 indicating a high fall risk. Review of the resident's physical therapy plan of care dated 5/10/23 showed the following: -Presented to therapy with a decline in functional ability of bed mobility, transfers and ambulation due to sudden increase in lethargy and weakness. Staff had noticed a decrease in mobility since admission resulting in decreased safety and an increased need for assistance. Required therapy to improve safety and function; -Fall risk; -Oriented to his/her name, struggled to remain awake and needed several redirection cues, had some reflexive withdrawals with stretching of lower legs; -Required total assistance with bed mobility of rolling over and repositioning, was unable to maintain balance without moderate/maximum staff support; -Treatment diagnosis of generalized muscle weakness. Review of the resident's nurses' notes showed staff documented the following: -On 5/10/23 at 9:48 A.M. the resident was alert and oriented to self, required extensive assistance of two staff members with ADLs and required a mechanical lift for transfers; -On 5/16/23 at 11:22 A.M. staff received notification from an outside hospital the resident was being evaluated at the emergency room due to a fall. The resident slid out of the wheelchair and was assisted to the emergency department by EMS (Emergency Medical Services). Review of the Emergency Department physician note dated 5/16/23 showed the following: -Chief complaint was a fall; -The resident presented to the hospital emergency department following a fall prior to emergency department arrival. The resident was coming to the hospital for a medical treatment and was in a wheelchair in the van. Apparently the wheelchair fell over. The resident complained of headache and neck pain, denied any other injuries. During an interview on 6/1/23 at 4:00 P.M. Transporter A said the following: -On 5/16/23 at about 7:20 A.M. he/she transported the resident to a hospital about 45 miles from the facility in the facility van. He/She helped transfer the resident from the Broda chair to a regular straight back wheelchair before loading the resident in the facility van with the van's wheelchair lift. The resident's Broda chair did not fit in the facility van. During the transport the resident sat in the wheelchair just behind the bench seat. No other residents or staff rode in the van during the transport; -He/She hooked the resident's wheelchair frame to the van with four S hooks (metal S shaped hooks attached to the wheelchair frame connected to heavy straps secured directly to the van floor for safety) and locked the resident's wheelchair brakes. He/She did not place the van seatbelt on the resident and the resident did not wear a seatbelt during the transport. Transporter A asked the resident if he/she wanted to wear the seatbelt and the resident said no; -During the transport he/she told the resident they were almost at the hospital and the resident said okay. When he/she looked in the review mirror again the resident was gone, the resident had slid out of the wheelchair on to the van floor; -The van had seat belts to secure residents in wheelchairs, but the seat belts fit loosely and did not pull tight when fastened; -The facility had no rules requiring seat belt use. It was the resident's choice if they wanted to wear a seatbelt or not. During an interview on 6/2/23 at 10:10 A.M. The Assistant Director of Nurses (ADON) said the resident required a mechanical lift for transfers and extensive assistance with ADLs. The resident is very tall, had gotten weaker and had trouble sitting up in a regular wheelchair for any length of time. On 5/15/23 staff changed the resident from a regular wheelchair to a Broda chair when out of bed for his/her safety and comfort. The Broda chair sat up too high and would not fit in the facility van. Staff transferred the resident into the regular wheelchair prior to transport in the facility van on 5/16/23. Staff should have ensured all residents wore seat belts during transport. 2. Review of Resident #18's care plan updated 3/27/23 showed the following: -Diagnosis of right leg below the knee amputation, end stage renal disease (ESRD) (kidney failure resulting in need for dialysis), dependence on renal dialysis (medical procedure filtering toxins from the blood in the absence of proper kidney function), muscle weakness, and obesity; -The resident required dialysis treatments. Staff should ensure the resident attended dialysis appointments at the local dialysis clinic three times weekly on Mondays, Wednesdays and Fridays; -The resident had difficulty performing ADLs and was dependent on staff for assistance with bed mobility, dressing, personal hygiene and transfers. Staff should provide assistance with ADLs and provide mechanical lift transfers. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 5/28/23 showed the following: -Cognitively intact; -Required extensive assistance of two staff members with bed mobility; -Required total assistance of two staff members with transfers; -Required extensive assistance of one staff member with locomotion on and off the unit; -Required a wheelchair for mobility. Review of the facility transport schedule provided 6/1/23 showed staff documented facility staff transported Resident #18 in the facility van on 5/22/23, 5/24/23, 5/26/23, 5/29/23, and 5/31/23 to and from a medical appointment. During an interview on 6/2/23 at 9:25 A.M. Transporter A said the following: -He/She transported Resident #18 to a medical appointment three times weekly in the facility van and the resident never wore a seatbelt. The resident refused to wear a seat belt; -He/She transported Resident #18 on 6/2/23 in the facility van without a seatbelt to dialysis; -After Resident #1 slid out of the wheelchair during transport, the administrator informed Transporter A verbally all residents were required to wear seatbelts during transport. Transporter A said he/she thought it was a resident's right to choose not to wear a seatbelt. Resident #18 had never worn a seatbelt when he/she drove the resident to and from dialysis. Observation on 6/2/23 at 2:10 P.M. showed Resident #18 sat outside in a wheelchair smoking. He/She sat at an angle with a pillow tucked behind his/her right side/back area and sat on a mechanical lift transfer sling. His/Her legs and hips touched the sides of the wheelchair with legs stretched out straight in front of the wheelchair. Staff attempted to push the resident in the wheelchair into the facility, the resident was unable to bend his/her knees or elevate his/her legs and feet off the floor. Staff pulled the resident backwards in the wheelchair into the facility and continued two doors down the hall after entering the facility to the resident's room. During an interview on 6/2/23 at 2:12 P.M., the resident said he/she went to a medical appointment (dialysis) three times weekly and just got back to the facility. His/Her usual wheelchair was wider and more comfortable, but did not fit in the facility van. Staff transferred him/her into the smaller wheelchair for transports to go in the facility van. The smaller wheelchair was not comfortable, did not fit him/her, and he/she was unable to bend his/her knee today. He/She did not wear a seatbelt during transports in the facility van, he/she refused the seatbelt three times a week during transport. He/She did not wear a seatbelt during transport in the facility van on 6/2/23. He/She was aware as of 6/2/23 a seat belt was required and would wear a seat belt. 3. Observation on 6/7/23 at 11:55 A.M. showed the facility van contained a bench seat behind the driver's seat and space for two wheelchairs behind the bench seat with four S hook harness belts available to secure each wheelchair, one behind the other. The driver's side of the van directly behind the bench seat, contained a folding seat, folded and secured to the side of the van near the side window, with wire wrapped around the folded seat frame and around the seat belt strap intended for the front wheelchair. The wire secured the folding seat to prevent the seat from falling open onto a resident in a wheelchair during transport. Transporter A attempted to pull the seatbelt and said the wire needed to be removed to use the seatbelt. Transporter A removed the wire and pulled the seatbelt loose, extended the seatbelt and fastened the seatbelt over the area for the wheelchair position directly behind the bench seat. During an interview on 6/2/23 at 9:45 A.M. the Maintenance Supervisor said during resident transports in the facility van, staff should attach the S hooks four point harness to secure the wheelchair and fasten the seat belt on all residents. Staff were taught to use the facility van including the S hook harness and the seatbelts. Transports should ensure all residents were secured in the facility van including the use of seatbelts prior to transport. During an interview on 6/2/23 at 10:30 A.M. the Administrator said the following: -All residents and staff should wear a seatbelt during transport in the facility van. Seatbelts were required at all times. She became aware Resident #1 did not have seatbelt on during the 5/16/23 transport two days after the resident fell out of the wheelchair in the facility van. She informed the maintenance supervisor and Transporter A verbally on 5/18/23 seatbelts were required during all transports; -She was unaware staff did not ensure Resident #18 wore a seatbelt during the facility van transports three times weekly for medical appointments. If a resident refused the seatbelt staff should not transport the resident; -The facility did not have a current policy regarding the use of seatbelts in the facility van or regarding safety during facility van transports. MO00218547 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. 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 violations(s).

Based on interview and record review the facility failed to provide adequate supervision and assistance for one resident (Resident #1) in a review of eleven residents. Resident #1 utilized a Broda chair (a type of wheelchair that tilted and reclined) and required extensive assistance from staff for bed mobility, required mechanical lift transfers and had impaired range of motion on one side of the upper body. On 5/16/23, during a transport in the facility van to a medical appointment approximately 54 miles away from the facility, staff transferred Resident #1 into a regular wheelchair prior to transport as the resident's Broda chair would not fit in the facility van. Transport staff A did not secure the resident with a seatbelt in the van. During transport the resident slid from the wheelchair onto the floor of the van. Transport staff A arrived at a local hospital and obtained assistance for the resident who was evaluated in the emergency room . Transport staff A continued to transport another resident (Resident #18) in a wheelchair in the van, three times weekly to medical appointments without securing the resident with a seat belt following the incident with Resident #1 on 5/16/23. The facility census was 39. The administrator was notified of the Immediate Jeopardy (IJ) on 6/2/23 at 1:00 P.M. which began on 5/16/23. The IJ was removed on 6/7/23 as confirmed by surveyor onsite verification. Review of the facility policy, Resident Transportation, dated April 2020 showed the following: -Resident transportation needs would be met and transportation would be provided as available; -Before transporting, post notices of scheduled transportation in a clear, easy to read format and explain schedules to visually or other disabled residents. Ensure special arrangements were made for residents with special needs; -For resident safety residents were to have the cognitive and physical ability to be transported without assistance. The facility did not provide a policy regarding seat belt and safety mechanism use while transporting residents in the facility van. 1. Review of Resident #1's care plan dated 5/8/23 showed the following: -admitted [DATE]; -Diagnosis of cancer of the lymph symptom (the disease fighting system in the body), pain, urinary tract infection and below elbow amputation of the right arm; -The resident was at risk for falls. -The resident had difficulty performing Activities of Daily Living (ADLs) and had limited physical mobility. Staff should assist with bed mobility. He/She was totally dependent on staff for ambulation and locomotion and required two staff member's assistance with lifting, and a mechanical lift for all transfers. The resident utilized a wheelchair for mobility. Review of the resident's Fall Risk Assessment (a tool used to determine a resident's risk of falls) dated 5/8/23, showed staff documented the following: -History of falls in the previous 90 days; -Took blood pressure and narcotic pain medication that increased the risk of falls; -Incontinent; -The resident was unable to independently come to a standing position, exhibited loss of balance while standing, required hands-on assistance to move from place to place, and used an assistive device; -Fall risk score of 31 indicating a high fall risk. Review of the resident's physical therapy plan of care dated 5/10/23 showed the following: -Presented to therapy with a decline in functional ability of bed mobility, transfers and ambulation due to sudden increase in lethargy and weakness. Staff had noticed a decrease in mobility since admission resulting in decreased safety and an increased need for assistance. Required therapy to improve safety and function; -Fall risk; -Oriented to his/her name, struggled to remain awake and needed several redirection cues, had some reflexive withdrawals with stretching of lower legs; -Required total assistance with bed mobility of rolling over and repositioning, was unable to maintain balance without moderate/maximum staff support; -Treatment diagnosis of generalized muscle weakness. Review of the resident's nurses' notes showed staff documented the following: -On 5/10/23 at 9:48 A.M. the resident was alert and oriented to self, required extensive assistance of two staff members with ADLs and required a mechanical lift for transfers; -On 5/16/23 at 11:22 A.M. staff received notification from an outside hospital the resident was being evaluated at the emergency room due to a fall. The resident slid out of the wheelchair and was assisted to the emergency department by EMS (Emergency Medical Services). Review of the Emergency Department physician note dated 5/16/23 showed the following: -Chief complaint was a fall; -The resident presented to the hospital emergency department following a fall prior to emergency department arrival. The resident was coming to the hospital for a medical treatment and was in a wheelchair in the van. Apparently the wheelchair fell over. The resident complained of headache and neck pain, denied any other injuries. During an interview on 6/1/23 at 4:00 P.M. Transporter A said the following: -On 5/16/23 at about 7:20 A.M. he/she transported the resident to a hospital about 45 miles from the facility in the facility van. He/She helped transfer the resident from the Broda chair to a regular straight back wheelchair before loading the resident in the facility van with the van's wheelchair lift. The resident's Broda chair did not fit in the facility van. During the transport the resident sat in the wheelchair just behind the bench seat. No other residents or staff rode in the van during the transport; -He/She hooked the resident's wheelchair frame to the van with four S hooks (metal S shaped hooks attached to the wheelchair frame connected to heavy straps secured directly to the van floor for safety) and locked the resident's wheelchair brakes. He/She did not place the van seatbelt on the resident and the resident did not wear a seatbelt during the transport. Transporter A asked the resident if he/she wanted to wear the seatbelt and the resident said no; -During the transport he/she told the resident they were almost at the hospital and the resident said okay. When he/she looked in the review mirror again the resident was gone, the resident had slid out of the wheelchair on to the van floor; -The van had seat belts to secure residents in wheelchairs, but the seat belts fit loosely and did not pull tight when fastened; -The facility had no rules requiring seat belt use. It was the resident's choice if they wanted to wear a seatbelt or not. During an interview on 6/2/23 at 10:10 A.M. The Assistant Director of Nurses (ADON) said the resident required a mechanical lift for transfers and extensive assistance with ADLs. The resident is very tall, had gotten weaker and had trouble sitting up in a regular wheelchair for any length of time. On 5/15/23 staff changed the resident from a regular wheelchair to a Broda chair when out of bed for his/her safety and comfort. The Broda chair sat up too high and would not fit in the facility van. Staff transferred the resident into the regular wheelchair prior to transport in the facility van on 5/16/23. Staff should have ensured all residents wore seat belts during transport. 2. Review of Resident #18's care plan updated 3/27/23 showed the following: -Diagnosis of right leg below the knee amputation, end stage renal disease (ESRD) (kidney failure resulting in need for dialysis), dependence on renal dialysis (medical procedure filtering toxins from the blood in the absence of proper kidney function), muscle weakness, and obesity; -The resident required dialysis treatments. Staff should ensure the resident attended dialysis appointments at the local dialysis clinic three times weekly on Mondays, Wednesdays and Fridays; -The resident had difficulty performing ADLs and was dependent on staff for assistance with bed mobility, dressing, personal hygiene and transfers. Staff should provide assistance with ADLs and provide mechanical lift transfers. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 5/28/23 showed the following: -Cognitively intact; -Required extensive assistance of two staff members with bed mobility; -Required total assistance of two staff members with transfers; -Required extensive assistance of one staff member with locomotion on and off the unit; -Required a wheelchair for mobility. Review of the facility transport schedule provided 6/1/23 showed staff documented facility staff transported Resident #18 in the facility van on 5/22/23, 5/24/23, 5/26/23, 5/29/23, and 5/31/23 to and from a medical appointment. During an interview on 6/2/23 at 9:25 A.M. Transporter A said the following: -He/She transported Resident #18 to a medical appointment three times weekly in the facility van and the resident never wore a seatbelt. The resident refused to wear a seat belt; -He/She transported Resident #18 on 6/2/23 in the facility van without a seatbelt to dialysis; -After Resident #1 slid out of the wheelchair during transport, the administrator informed Transporter A verbally all residents were required to wear seatbelts during transport. Transporter A said he/she thought it was a resident's right to choose not to wear a seatbelt. Resident #18 had never worn a seatbelt when he/she drove the resident to and from dialysis. Observation on 6/2/23 at 2:10 P.M. showed Resident #18 sat outside in a wheelchair smoking. He/She sat at an angle with a pillow tucked behind his/her right side/back area and sat on a mechanical lift transfer sling. His/Her legs and hips touched the sides of the wheelchair with legs stretched out straight in front of the wheelchair. Staff attempted to push the resident in the wheelchair into the facility, the resident was unable to bend his/her knees or elevate his/her legs and feet off the floor. Staff pulled the resident backwards in the wheelchair into the facility and continued two doors down the hall after entering the facility to the resident's room. During an interview on 6/2/23 at 2:12 P.M., the resident said he/she went to a medical appointment (dialysis) three times weekly and just got back to the facility. His/Her usual wheelchair was wider and more comfortable, but did not fit in the facility van. Staff transferred him/her into the smaller wheelchair for transports to go in the facility van. The smaller wheelchair was not comfortable, did not fit him/her, and he/she was unable to bend his/her knee today. He/She did not wear a seatbelt during transports in the facility van, he/she refused the seatbelt three times a week during transport. He/She did not wear a seatbelt during transport in the facility van on 6/2/23. He/She was aware as of 6/2/23 a seat belt was required and would wear a seat belt. 3. Observation on 6/7/23 at 11:55 A.M. showed the facility van contained a bench seat behind the driver's seat and space for two wheelchairs behind the bench seat with four S hook harness belts available to secure each wheelchair, one behind the other. The driver's side of the van directly behind the bench seat, contained a folding seat, folded and secured to the side of the van near the side window, with wire wrapped around the folded seat frame and around the seat belt strap intended for the front wheelchair. The wire secured the folding seat to prevent the seat from falling open onto a resident in a wheelchair during transport. Transporter A attempted to pull the seatbelt and said the wire needed to be removed to use the seatbelt. Transporter A removed the wire and pulled the seatbelt loose, extended the seatbelt and fastened the seatbelt over the area for the wheelchair position directly behind the bench seat. During an interview on 6/2/23 at 9:45 A.M. the Maintenance Supervisor said during resident transports in the facility van, staff should attach the S hooks four point harness to secure the wheelchair and fasten the seat belt on all residents. Staff were taught to use the facility van including the S hook harness and the seatbelts. Transports should ensure all residents were secured in the facility van including the use of seatbelts prior to transport. During an interview on 6/2/23 at 10:30 A.M. the Administrator said the following: -All residents and staff should wear a seatbelt during transport in the facility van. Seatbelts were required at all times. She became aware Resident #1 did not have seatbelt on during the 5/16/23 transport two days after the resident fell out of the wheelchair in the facility van. She informed the maintenance supervisor and Transporter A verbally on 5/18/23 seatbelts were required during all transports; -She was unaware staff did not ensure Resident #18 wore a seatbelt during the facility van transports three times weekly for medical appointments. If a resident refused the seatbelt staff should not transport the resident; -The facility did not have a current policy regarding the use of seatbelts in the facility van or regarding safety during facility van transports. MO00218547 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. 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 violations(s).

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #7) in a review of eleven residents, received treatment and care in accordance with professional standards of practice. The resident, a known fall risk, fell and fractured both bones of the left arm just above the wrist at approximately 3:30 A.M. on 5/12/23. Staff failed to provide emergent care after pain, swelling, bruising and deformity of the left lower arm above the wrist was identified with no immobilization of the arm for twelve hours following the fall. Staff administered one Tylenol for pain, gave the resident a shower without immobilization of the fractured arm, and did not transfer the resident to the emergency room when pain and swelling was identified. The facility census was 39. Review of the facility undated policy Fall Assessment showed the following: -The charge nurse will assess the resident's level of consciousness, pain, change in mobility or obvious injury, obtain vital signs, and provide a head to toe body assessment and every shift for 72 hours. Report any new findings after initial assessment to the physician, resident and/or representative and Director of Nursing (DON) and document in the nurses' notes. Address any injuries as necessary. The facility provided no specific policy regarding standard of practice and treatment following a fall with injury. Review of mayoclinc.org showed the following: -A fracture is a broken bone. It requires medical attention. If the broken bone is the result of major trauma or injury, call 911 or your local emergency number. Also call for emergency help if even gentle pressure or movement causes pain, the limb or joint appeared deformed; -Don't move the person except if necessary to avoid further injury; -Take these actions immediately while waiting for medical help: -Immobilize the injured area. Don't try to realign the bone or push a bone that's sticking out back in. If you've been trained in how to splint and professional help isn't readily available, apply a splint to the area above and below the fracture sites. Padding the splints can help reduce discomfort; -Apply ice packs to limit swelling and help relieve pain. Don't apply ice directly to the skin. Wrap the ice in a towel, piece of cloth or some other material. 1. Review of Resident #7's care plan dated 4/11/23 showed the following: -admission date 4/11/23; -Diagnosis of dementia and history of falling; -The resident had impaired cognition due to dementia; -The resident required assistance with Activities of Daily Living (ADLs). Staff should assist with bathing, dressing, and transfers; -The resident was at risk for falls related to decreased mobility and history of falls. Review of the resident's Physician Order Sheet (POS) dated 4/11/23 showed Tylenol 500 milligrams (mg) one tablet every six hours as needed for pain. Review of the physical therapy plan of care dated 4/12/23 showed the following: -Treatment diagnosis of muscle weakness and unsteadiness on feet; -Referred to therapy following recent hospitalization for mental status change, failure to thrive at home with frequent falls at home. Now having difficulty with transfers and ambulation. Review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 4/17/23 showed the following: -Cognitively intact; -Required limited assistance of one staff member with transfers, walking in room and corridor, locomotion on the unit (moving between locations in his/her room and corridor) and personal hygiene; -Required extensive assistance of one staff member with dressing and toileting; -History of falls in the previous two to six months without fractures. Review of the resident's nurses' notes dated 5/12/23 showed the following: -At 3:30 A.M. Licensed Practical Nurse (LPN) C documented he/she walked past the resident's room and noted the resident up ambulating with the walker to the bathroom. The resident lost his/her balance and fell backwards hitting his/her left wrist on the roommate's bed. The resident denied any pain at the time, noted to have small bruise to the left outer wrist as well as a skin tear measuring 1.5 centimeters by 1.5 centimeters. LPN C cleaned the area and applied a bandage, he/she assessed the resident's range of motion. The resident could move all extremities without difficulty and denied pain at the time. Staff assisted the resident off the floor and transferred the resident to the recliner chair. A voicemail was left for the physician's office notifying of the fall, family was notified; -At 3:48 A.M. the resident sat in his/her recliner with eyes closed, no appearance of pain or discomfort. Review of the resident's record showed no additional documentation staff assessed the resident on 5/12/23 from 3:48 A.M. through 8:55 A.M. following the resident's fall. Review of the resident's nurses' notes dated 5/12/23 showed staff documented the following: -At 8:55 A.M. Licensed Practical Nurse (LPN) B documented the resident had 10/10 (pain scale used to assess level of pain with zero as no pain and 10 as worse pain ever felt) pain to the left wrist with no range of motion. The wrist was swollen with dark blue bruising. The physician was notified with orders received for x-ray of the wrist per portable x-ray (x-ray provided by outside company who came to the facility); -At 9:00 A.M. the resident's family made aware of the resident's left wrist pain, swelling and bruising with new physician orders for x-ray. Review of the POS dated 5/12/23 showed order received at 9:00 A.M. for x-ray of the resident's left wrist due to pain and swelling. Review of the resident's Medication Administration Record (MAR) dated 5/12/23 showed staff documented at 9:00 A.M. Tylenol 500 mg administered for complaints of left wrist pain with no staff documentation indicating the effectiveness of the pain medication administered. Review of the resident's nurses' notes dated 5/12/23 showed staff documented the following: -At 11:48 A.M. portable x-ray company completed the left wrist x-ray; -At 1:16 P.M. x-ray results of acute oblique fracture (a complete fracture of the bone at an angle all the way through the bone) of the left distal radius and ulna (both bones in the forearm above the wrist). Staff notified the physician with orders for transfer to the emergency room. Review of the resident's left wrist x-ray report dated 5/12/23 showed findings of acute oblique fracture (a complete fracture of the bone at an angle all the way through the bone) of the distal radius and ulna (both bones in the forearm above the wrist). Review of the shower sheets showed staff documented the resident received a shower the morning of 5/12/23. Review of the resident's nurses' notes dated 5/12/23 showed staff documented at 2:00 P.M. family transported the resident in personal vehicle to the emergency room. Observation on 6/1/23 at 10:40 A.M., showed the resident's left arm casted from above the elbow to the hand. The left fingers were swollen. During an interview on 6/1/23 at 10:45 A.M. the resident's family member said the following: -On 5/12/23 at 3:45 A.M. staff called and said the resident fell and was okay. Staff had offered to send the resident to the emergency room, but the resident refused and said he/she was fine; -The family arrived at the facility about 8:00 A.M. on 5/12/23 and found the resident's left wrist was swollen and had an indentation with appearance of a broken bone at the wrist; -The resident remained in his/her chair, left wrist was swollen with bruising and malformed with a dent in the wrist area. No ice or splinting of the wrist was in place. The portable x-ray was completed about 12:00 P.M. and the entire time the resident had no ice or splinting of the wrist. Staff gave the resident a shower that morning without immobilizing the wrist. Staff said they wanted to wait for the x-ray results before sending the resident to the emergency room; -At 2:30 P.M. family transported the resident to the emergency room instead of waiting for an ambulance and learned two bones were fractured in the resident's left wrist. The resident had surgery on 5/15/23 to repair the fractured bones. During an interview on 6/1/23 at 10:46 A.M. the resident said he/she was going to the bathroom when he/she fell. He/She remembered hanging on to the bathroom door knob, fell backward and hit his/her arm. His/Her arm hurt after the fall and he/she knew something was wrong. His/Her arm swelled and bruised after the fall. During an interview on 6/2/23 at 3:08 P.M. Certified Nurse Assistant (CNA) D said he/she worked night shift on 5/12/23. Resident #7 fell at about 3:30 A.M. that night. The resident said his/her wrist hurt when he/she and another staff member were getting the resident up off the floor. LPN C assisted with the transfer off the floor and was aware the resident's left wrist hurt at that time. The resident's wrist started bruising as the night went on after the fall between 4:00 A.M. and 6:30 A.M. The resident sat in the recliner chair for a few hours and then was transferred to bed and said his/her wrist hurt. CNA D saw LPN C check the resident over after the fall, LPN C was aware the resident's wrist hurt following the fall. When LPN C checked on the resident again sometime before the end of the shift (7:00 A.M.), the resident said he/she was okay but his/her wrist hurt. During an interview on 6/2/23 at 3:30 P.M. CNA E said he/she worked the night shift on 5/12/23. At about 3:30 A.M. LPN C saw Resident #7 fall. LPN C called CNA E and another staff member (CNA D) for help getting the resident up off the floor. CNA E and CNA D lifted the resident off the floor while LPN C was in the resident's room. The resident complained of pain in the left arm and said his/her left arm hurt. LPN C was in the resident's room during the transfer and was aware the resident said his/her arm hurt. Staff sat the resident in the recliner chair for a while and later transferred the resident to bed. CNA E noticed swelling of the resident's left wrist. LPN C assessed the resident during the night (unknown time) after the initial fall assessment and did not send the resident to the emergency room during the shift. No ice or treatment was applied to the resident's left wrist during the night shift after the fall. During an interview on 6/1/23 at 8:45 P.M. LPN C said he/she was the charge nurse when the resident fell on 5/12/23. The fall happened about 3:30 A.M. as LPN C was walking past the resident's room and saw the resident going into the bathroom. The resident fell backward and hit his/her left wrist on the bed frame as he/she fell. LPN C checked the resident over and found a skin tear on the left wrist, the resident said his/her left wrist hurt. LPN C cleaned and applied a dressing to the skin tear. The resident had no complaints of pain and there was no swelling of the left wrist at the time of the fall. A voice mail was left for the on-call physician notifying him of the resident's fall with no pain or apparent injury. The resident slept in his/her chair the rest of the night. LPN C woke the resident early that morning (around 6:00 A.M. on 5/12/23) and noted bruising to the left wrist at that time. The resident could move his/her fingers and make a fist. LPN C told LPN B in report at the change of shift of the fall. He/She did not apply ice or immobilize the resident's left wrist during the night shift after the fall. During an interview on 6/1/23 at 3:20 P.M., LPN B said he/she came to work at 7:00 A.M. on 5/12/23. The resident's left wrist was swollen and the resident was unable to move the wrist. He/She called the physician and obtained orders for an x-ray. The resident had a lot of pain. LPN B put some ice on the wrist. The resident was grimacing and in pain at 7:00 A.M. The left wrist was not immobilized following the fall. Night shift had not applied any ice or splinting following the fall. The portable x-ray was completed about noon and the physician notified of the results with orders to send the resident to the emergency room. Family transported the resident to the emergency room in the afternoon instead of waiting for an ambulance. The resident returned from the emergency room with a soft cast and scheduled for surgical repair a few days later. During an interview on 6/2/23 at 2:00 P.M. the resident's physician said if Resident #7 had no obvious injury and no pain at the time of the fall, he would not order an x-ray at that time. When pain was present, he would order an x-ray following a fall. If the resident had pain and apparent injury, staff should immobilize the area, obtain an x-ray and start treatment including sending the resident to the emergency room. If a resident required an x-ray in the night, staff should send the resident out to the emergency room at the time of the injury. During an interview on 6/7/23 at 1:15 P.M. the Director of Nursing said the resident fell on 5/12/23 at about 3:30 A.M. Staff should assess the resident's condition at the time of the fall, provide treatment and notify the physician of the resident's condition. Staff checked on the resident a couple of times during the night and reported the fall to the day shift nurse at 7:00 A.M. At 8:30 A.M. on 5/12/23, staff said the resident had bruising and swelling of the left wrist, a portable x-ray was obtained. At about 10:00 A.M. she saw the resident's wrist, it was swollen with swollen fingers and an indentation at the wrist. Staff should have immobilized the left wrist after the fall, applied ice and sent the resident out to the emergency room as soon as an injury was noted. Staff should not have given the resident a shower with a fractured wrist. Undressing and showering without an immobilizer, moving the resident and the fractured wrist would have caused the resident more pain. During an interview on 6/7/23 at 2:00 P.M. the Administrator said following a fall staff should send the resident to the emergency room if injured. Following the fall staff should continue to assess the resident's condition, monitor for injuries and call the physician. If the resident worsened send the resident to the emergency room immediately. Resident #7 had two fractured bones in the left arm, staff did not immobilize the left arm or apply ice and did not send the resident to the emergency room for treatment when injury was noted. Staff gave the resident a shower with the fractured bones causing more pain. Staff should have immobilized the resident's left arm, applied ice and transferred the resident to the emergency room as soon as symptoms of injury was evident. MO00218496

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #7) in a review of eleven residents, received treatment and care in accordance with professional standards of practice. The resident, a known fall risk, fell and fractured both bones of the left arm just above the wrist at approximately 3:30 A.M. on 5/12/23. Staff failed to provide emergent care after pain, swelling, bruising and deformity of the left lower arm above the wrist was identified with no immobilization of the arm for twelve hours following the fall. Staff administered one Tylenol for pain, gave the resident a shower without immobilization of the fractured arm, and did not transfer the resident to the emergency room when pain and swelling was identified. The facility census was 39. Review of the facility undated policy Fall Assessment showed the following: -The charge nurse will assess the resident's level of consciousness, pain, change in mobility or obvious injury, obtain vital signs, and provide a head to toe body assessment and every shift for 72 hours. Report any new findings after initial assessment to the physician, resident and/or representative and Director of Nursing (DON) and document in the nurses' notes. Address any injuries as necessary. The facility provided no specific policy regarding standard of practice and treatment following a fall with injury. Review of mayoclinc.org showed the following: -A fracture is a broken bone. It requires medical attention. If the broken bone is the result of major trauma or injury, call 911 or your local emergency number. Also call for emergency help if even gentle pressure or movement causes pain, the limb or joint appeared deformed; -Don't move the person except if necessary to avoid further injury; -Take these actions immediately while waiting for medical help: -Immobilize the injured area. Don't try to realign the bone or push a bone that's sticking out back in. If you've been trained in how to splint and professional help isn't readily available, apply a splint to the area above and below the fracture sites. Padding the splints can help reduce discomfort; -Apply ice packs to limit swelling and help relieve pain. Don't apply ice directly to the skin. Wrap the ice in a towel, piece of cloth or some other material. 1. Review of Resident #7's care plan dated 4/11/23 showed the following: -admitted [DATE]; -Diagnosis of dementia and history of falling; -The resident had impaired cognition due to dementia; -The resident required assistance with Activities of Daily Living (ADLs). Staff should assist with bathing, dressing, and transfers; -The resident was at risk for falls related to decreased mobility and history of falls. Review of the resident's Physician Order Sheet (POS) dated 4/11/23 showed Tylenol 500 milligrams (mg) one tablet every six hours as needed for pain. Review of the physical therapy plan of care dated 4/12/23 showed the following: -Treatment diagnosis of muscle weakness and unsteadiness on feet; -Referred to therapy following recent hospitalization for mental status change, failure to thrive at home with frequent falls at home. Now having difficulty with transfers and ambulation. Review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 4/17/23 showed the following: -Cognitively intact; -Required limited assistance of one staff member with transfers, walking in room and corridor, locomotion on the unit (moving between locations in his/her room and corridor) and personal hygiene; -Required extensive assistance of one staff member with dressing and toileting; -History of falls in the previous two to six months without fractures. Review of the resident's nurses' notes dated 5/12/23 showed the following: -At 3:30 A.M. Licensed Practical Nurse (LPN) C documented he/she walked past the resident's room and noted the resident up ambulating with the walker to the bathroom. The resident lost his/her balance and fell backwards hitting his/her left wrist on the roommate's bed. The resident denied any pain at the time, noted to have small bruise to the left outer wrist as well as a skin tear measuring 1.5 centimeters by 1.5 centimeters. LPN C cleaned the area and applied a bandage, he/she assessed the resident's range of motion. The resident could move all extremities without difficulty and denied pain at the time. Staff assisted the resident off the floor and transferred the resident to the recliner chair. A voicemail was left for the physician's office notifying of the fall, family was notified; -At 3:48 A.M. the resident sat in his/her recliner with eyes closed, no appearance of pain or discomfort. Review of the resident's record showed no additional documentation staff assessed the resident on 5/12/23 from 3:48 A.M. through 8:55 A.M. following the resident's fall. Review of the resident's nurses' notes dated 5/12/23 showed staff documented the following: -At 8:55 A.M. Licensed Practical Nurse (LPN) B documented the resident had 10/10 (pain scale used to assess level of pain with zero as no pain and 10 as worse pain ever felt) pain to the left wrist with no range of motion. The wrist was swollen with dark blue bruising. The physician was notified with orders received for x-ray of the wrist per portable x-ray (x-ray provided by outside company who came to the facility); -At 9:00 A.M. the resident's family made aware of the resident's left wrist pain, swelling and bruising with new physician orders for x-ray. Review of the POS dated 5/12/23 showed order received at 9:00 A.M. for x-ray of the resident's left wrist due to pain and swelling. Review of the resident's Medication Administration Record (MAR) dated 5/12/23 showed staff documented at 9:00 A.M. Tylenol 500 mg administered for complaints of left wrist pain with no staff documentation indicating the effectiveness of the pain medication administered. Review of the resident's nurses' notes dated 5/12/23 showed staff documented the following: -At 11:48 A.M. portable x-ray company completed the left wrist x-ray; -At 1:16 P.M. x-ray results of acute oblique fracture (a complete fracture of the bone at an angle all the way through the bone) of the left distal radius and ulna (both bones in the forearm above the wrist). Staff notified the physician with orders for transfer to the emergency room . Review of the resident's left wrist x-ray report dated 5/12/23 showed findings of acute oblique fracture (a complete fracture of the bone at an angle all the way through the bone) of the distal radius and ulna (both bones in the forearm above the wrist). Review of the shower sheets showed staff documented the resident received a shower the morning of 5/12/23. Review of the resident's nurses' notes dated 5/12/23 showed staff documented at 2:00 P.M. family transported the resident in personal vehicle to the emergency room . Observation on 6/1/23 at 10:40 A.M., showed the resident's left arm casted from above the elbow to the hand. The left fingers were swollen. During an interview on 6/1/23 at 10:45 A.M. the resident's family member said the following: -On 5/12/23 at 3:45 A.M. staff called and said the resident fell and was okay. Staff had offered to send the resident to the emergency room , but the resident refused and said he/she was fine; -The family arrived at the facility about 8:00 A.M. on 5/12/23 and found the resident's left wrist was swollen and had an indentation with appearance of a broken bone at the wrist; -The resident remained in his/her chair, left wrist was swollen with bruising and malformed with a dent in the wrist area. No ice or splinting of the wrist was in place. The portable x-ray was completed about 12:00 P.M. and the entire time the resident had no ice or splinting of the wrist. Staff gave the resident a shower that morning without immobilizing the wrist. Staff said they wanted to wait for the x-ray results before sending the resident to the emergency room ; -At 2:30 P.M. family transported the resident to the emergency room instead of waiting for an ambulance and learned two bones were fractured in the resident's left wrist. The resident had surgery on 5/15/23 to repair the fractured bones. During an interview on 6/1/23 at 10:46 A.M. the resident said he/she was going to the bathroom when he/she fell . He/She remembered hanging on to the bathroom door knob, fell backward and hit his/her arm. His/Her arm hurt after the fall and he/she knew something was wrong. His/Her arm swelled and bruised after the fall. During an interview on 6/2/23 at 3:08 P.M. Certified Nurse Assistant (CNA) D said he/she worked night shift on 5/12/23. Resident #7 fell at about 3:30 A.M. that night. The resident said his/her wrist hurt when he/she and another staff member were getting the resident up off the floor. LPN C assisted with the transfer off the floor and was aware the resident's left wrist hurt at that time. The resident's wrist started bruising as the night went on after the fall between 4:00 A.M. and 6:30 A.M. The resident sat in the recliner chair for a few hours and then was transferred to bed and said his/her wrist hurt. CNA D saw LPN C check the resident over after the fall, LPN C was aware the resident's wrist hurt following the fall. When LPN C checked on the resident again sometime before the end of the shift (7:00 A.M.), the resident said he/she was okay but his/her wrist hurt. During an interview on 6/2/23 at 3:30 P.M. CNA E said he/she worked the night shift on 5/12/23. At about 3:30 A.M. LPN C saw Resident #7 fall. LPN C called CNA E and another staff member (CNA D) for help getting the resident up off the floor. CNA E and CNA D lifted the resident off the floor while LPN C was in the resident's room. The resident complained of pain in the left arm and said his/her left arm hurt. LPN C was in the resident's room during the transfer and was aware the resident said his/her arm hurt. Staff sat the resident in the recliner chair for a while and later transferred the resident to bed. CNA E noticed swelling of the resident's left wrist. LPN C assessed the resident during the night (unknown time) after the initial fall assessment and did not send the resident to the emergency room during the shift. No ice or treatment was applied to the resident's left wrist during the night shift after the fall. During an interview on 6/1/23 at 8:45 P.M. LPN C said he/she was the charge nurse when the resident fell on [DATE]. The fall happened about 3:30 A.M. as LPN C was walking past the resident's room and saw the resident going into the bathroom. The resident fell backward and hit his/her left wrist on the bed frame as he/she fell . LPN C checked the resident over and found a skin tear on the left wrist, the resident said his/her left wrist hurt. LPN C cleaned and applied a dressing to the skin tear. The resident had no complaints of pain and there was no swelling of the left wrist at the time of the fall. A voice mail was left for the on-call physician notifying him of the resident's fall with no pain or apparent injury. The resident slept in his/her chair the rest of the night. LPN C woke the resident early that morning (around 6:00 A.M. on 5/12/23) and noted bruising to the left wrist at that time. The resident could move his/her fingers and make a fist. LPN C told LPN B in report at the change of shift of the fall. He/She did not apply ice or immobilize the resident's left wrist during the night shift after the fall. During an interview on 6/1/23 at 3:20 P.M., LPN B said he/she came to work at 7:00 A.M. on 5/12/23. The resident's left wrist was swollen and the resident was unable to move the wrist. He/She called the physician and obtained orders for an x-ray. The resident had a lot of pain. LPN B put some ice on the wrist. The resident was grimacing and in pain at 7:00 A.M. The left wrist was not immobilized following the fall. Night shift had not applied any ice or splinting following the fall. The portable x-ray was completed about noon and the physician notified of the results with orders to send the resident to the emergency room . Family transported the resident to the emergency room in the afternoon instead of waiting for an ambulance. The resident returned from the emergency room with a soft cast and scheduled for surgical repair a few days later. During an interview on 6/2/23 at 2:00 P.M. the resident's physician said if Resident #7 had no obvious injury and no pain at the time of the fall, he would not order an x-ray at that time. When pain was present, he would order an x-ray following a fall. If the resident had pain and apparent injury, staff should immobilize the area, obtain an x-ray and start treatment including sending the resident to the emergency room . If a resident required an x-ray in the night, staff should send the resident out to the emergency room at the time of the injury. During an interview on 6/7/23 at 1:15 P.M. the Director of Nursing said the resident fell on [DATE] at about 3:30 A.M. Staff should assess the resident's condition at the time of the fall, provide treatment and notify the physician of the resident's condition. Staff checked on the resident a couple of times during the night and reported the fall to the day shift nurse at 7:00 A.M. At 8:30 A.M. on 5/12/23, staff said the resident had bruising and swelling of the left wrist, a portable x-ray was obtained. At about 10:00 A.M. she saw the resident's wrist, it was swollen with swollen fingers and an indentation at the wrist. Staff should have immobilized the left wrist after the fall, applied ice and sent the resident out to the emergency room as soon as an injury was noted. Staff should not have given the resident a shower with a fractured wrist. Undressing and showering without an immobilizer, moving the resident and the fractured wrist would have caused the resident more pain. During an interview on 6/7/23 at 2:00 P.M. the Administrator said following a fall staff should send the resident to the emergency room if injured. Following the fall staff should continue to assess the resident's condition, monitor for injuries and call the physician. If the resident worsened send the resident to the emergency room immediately. Resident #7 had two fractured bones in the left arm, staff did not immobilize the left arm or apply ice and did not send the resident to the emergency room for treatment when injury was noted. Staff gave the resident a shower with the fractured bones causing more pain. Staff should have immobilized the resident's left arm, applied ice and transferred the resident to the emergency room as soon as symptoms of injury was evident. MO00218496

Based on interview and record review, the facility failed to provide care and treatment for one resident (Resident #20), in accordance with professional standards of practice, in a review of seven sampled residents. Staff failed to notify the physician of the resident's abnormal urinalysis results that indicated the resident had a urinary tract infection and failed to arrange transportation to the emergency room when the resident requested. The resident's white blood cell count was elevated indicating a systemic infection upon hospital admission and urine culture report showed the presence of Escherichia Coli (bacteria normally present in the intestines and feces, frequent cause of urinary tract infections) microorganism. The resident's left hip incision subsequently opened and drained and the wound drainage culture report also showed the presence of E. Coli requiring intravenous antibiotics and hospitalization to treat. The facility census was 49. Review of the facility undated policy Significant Condition Change and Notification showed the following in part: -The purpose was to ensure the resident's medical practitioner was notified of resident changes; -A significant change in the resident's physical, mental, or psychosocial status including change in/or unstable vital signs, symptoms of infections process, abnormal laboratory values, abnormal assessment findings, a need to significantly alter treatment, transfer of the resident from the facility; -The licensed nurse would contact the resident's medical practitioner immediately for any emergencies regardless of the time of day. 1. Review of Resident #20's face sheet showed the following: -admitted [DATE]; -Diagnosis of fractured left femur (bone in the upper leg) with surgical repair, fractured humerus (bone in the upper arm), blood clots, and unsteadiness on feet. Review of the resident's nursing Admission Data Collection tool dated 12/2/22 showed the following in part: -Required extensive staff assistance with Activities of Daily Living (ADLs); -Left arm in a sling and left hip with staples intact covered with dressings; -Alert and oriented; -Continent of bladder and used a bed pan for urination; -No current infections. Review of the resident's Physician Order Sheet dated 12/2/22 showed an order to remove left hip incision staples on 12/5/22 and apply steri strips (adhesive strips used to secure an incision or opening in the skin). Review of the resident's nurses' notes showed the following: -On 12/5/22 at 12:34 A.M. staff documented the resident frequently used the bedpan to urinate; -On 12/5/22 at 4:24 A.M. staff documented the resident was continent of bowel and bladder and used the bedpan. He/She had the call light on many times during the night for the bedpan. Surgical incision to left hip intact with no redness or signs and symptoms of infection at the site. Review of the nurses' notes dated 12/5/22 showed no documentation staff removed the resident's left hip incision staples and applied steri strips as ordered by the physician. Review of the resident's nurses' notes showed the following: -On 12/6/22 at 1:25 A.M., staff documented the resident was alert and oriented, was very tired and required three staff members to assist with transfer to bed from the wheelchair. The left hip incision had no drainage or redness with steri-strips intact. The resident was continent of bowel and bladder and used the bedpan when in bed. The resident wore briefs when up in the chair and had a pad on the bed; -On 12/7/22 at 3:18 A.M., staff documented the resident was incontinent at times. Left hip incision was dry with steri strips in place; -On 12/7/22 at 3:46 P.M., staff documented the resident's family member called and reported the resident had not urinated since after breakfast. The family member requested a straight catheter (sterile tube inserted into the bladder draining the bladder of urine and then removed to determine retention of urine). Staff encouraged family member and resident not to use a straight catheter and placed the resident on the bedpan; -On 12/7/22 at 4:03 P.M.,. staff documented the physician was notified the resident had difficulty urinating and received an order for straight catheter; -On 12/7/22 at 4:39 P.M., staff documented the resident's family member said hospital staff used a wick device (external urinary collection device to help prevent incontinence) while the resident was hospitalized to prevent incontinence. Family was concerned the wick device had caused a urinary tract infection. Staff attempted to straight cath the resident, was unsuccessful, and would have night shift try to insert the catheter and obtain a urine specimen for urinalysis (a diagnostic lab procedure used to determine urinary changes and infection) and culture (diagnostic lab procedure used to identify the type of bacteria causing an infection) if indicated; -On 12/7/22 at 11:41 P.M. staff documented the resident complained of difficulty urinating. Staff inserted the straight catheter and received 20 milliliters (ml) of dark yellow urine. The urine specimen was collected to be sent to the laboratory. The resident complained of persistent urge to urinate but very little came out, had episodes of urinary incontinence and discomfort. Staff encouraged the resident to drink more fluids. Review of the nurses' notes showed no documentation staff notified the physician of resident's complaints of persistent urge to urinate, only urinating small amounts, episodes of urinary incontinence and discomfort or straight cath results of 20 ml of dark yellow urine. Review of the resident's nurses' notes showed the following: -On 12/8/22 at 3:49 A.M. staff documented the resident had urinated in the bedpan several times and had episodes of incontinence. Large amounts of medium yellow urine each time; -On 12/8/22 at 3:54 P.M. staff documented the resident requested his/her temperature be checked. The resident's temperature was 100.9 degrees orally (normal 98.6 degrees orally). Staff had taken the urine specimen to the laboratory that morning. No urinalysis results currently. The resident reported he/she had not urinated, however staff brought the incontinence pad to the nurses' desk and the pad was soiled with urine. Review of the resident's urinalysis report dated 12/8/22 at 7:02 P.M. showed the following: -Specimen collected on 12/7/22 at 11:00 P.M.; -Urine source was straight cath (specimen obtained by catheter insertion); -Color brown (normal: yellow); -Appearance cloudy (normal: clear); -Blood moderate (normal: negative); -Culture was indicated (normal: not indicated) (presence of infection and need to determine type of bacteria in urine); -White Blood Cell 16-30 cells visible (normal: none) (indicates presence of infection); -Bacteria few seen (normal: none seen) (indicates presence of infection). Review of the resident's nurses' notes dated 12/8/22 showed no documentation the physician was notified of the resident's urinalysis report indicating a urinary tract infection. Review of the resident's nurses' notes dated 12/8/22 at 11:32 P.M. showed staff documented the resident said he/she wanted to go to the hospital and said he/she was vomiting white phlegm that day and had a fever. Staff assured the resident her temperature was 98.8 degrees orally currently, the facility received the urinalysis results and the physician would see the results and the resident the following day. The resident said his/her pain was 10 out of 10 (scale of 0-10 with 10 indicating the most pain experienced) in the left arm and leg. The left incision had steri strips in place, no drainage or redness, no signs or symptoms of infection. The resident was calm, alert and oriented. Staff explained to the resident she was stable and there was no medical emergency to send the resident to the hospital, the resident became teary-eyed and wanted to be sent to the hospital. The resident's family member called and informed staff the resident wanted to go to the hospital and requested the resident be sent or they would call the ambulance themselves. The physician was not notified as there was no condition change to report and no valid reason to send the resident to the emergency room for evaluation and treatment. Call placed to the ambulance and report given including there was no reason for the transfer and if the resident was not kept in the hospital there was no staff to pick the resident up from the hospital until the following morning. The ambulance dispatcher said the resident had already called the ambulance for transfer and they were on their way. Staff faxed the urinalysis result to the hospital emergency room . Review of the resident's hospital records showed the following: -On 12/8/22 resident presented to the emergency room for evaluation of pain and chills. Laboratory tests showed evidence of acute urinary tract infection, acute signs of infection, fever and not feeling well. The resident felt like he/she had very little urine output. White Blood Cell (WBC) count of 20.9 (normal: 4-10) indicating infectious process. Started intravenous antibiotics and admitted to the hospital; -On 12/9/22 urine culture report showed urinary tract infection with E. Coli microorganism. Treatment of continued intravenous antibiotics; -On 12/11/22 left hip incision opened and drained large amount of purulent (pus like drainage) drainage with more drainage expressed when pressure applied to the wound. Culture of the wound obtained; -On 12/13/22 left hip drainage culture results showed E. Coli microorganism. During interview on 1/4/23 at 11:05 A.M. Certified Nurse Assistance (CNA) A said the resident used the bedpan and thought he/she had to urinate every 10 minutes. The resident thought he/she was not urinating enough. Staff put the resident on and off the bedpan frequently. During interview on 1/4/23 at 11:30 A.M. Licensed Practical Nurse (LPN) B said he/she removed the surgical staples from the left hip incision a few days after admission. The incision was intact. The resident requested to go to the hospital, called the ambulance his/herself and never returned to the facility. The resident was always in pain even with pain medications administered and required two staff to get on and off the bedpan. During interview on 1/4/23 at 12:05 P.M. Physical Therapist C said he/she evaluated the resident on admission. The resident required maximum assistance of staff for transfers out of bed. The resident complained of a lot of pain with repositioning and took pain medication. He/She demanded to go the emergency room and the nurse told the resident no, an ambulance would not be called. During interview on 1/4/23 at 3:20 P.M. the Director of Nursing said staff should call the physician directly with the abnormal urinalysis report and obtain treatment orders immediately if a UTI was indicated on the urinalysis report. Staff should not fax the physician and wait until the following day for treatment without consulting the physician. Staff should complete a thorough assessment when the resident asked to go to the hospital, call the physician and arrange an ambulance for transport when the resident requested transfer to the hospital. If the resident wanted to be seen in the emergency room staff should allow transfer and not delay the transfer. During interview on 1/17/23 at 12:45 P.M. the Administrator said staff were hesitant to send the resident to the hospital. Staff received the urinalysis results and were waiting for the culture and sensitivity report. The resident had a urinary tract infection, staff did not obtain treatment and delayed the resident's request to be seen in the emergency room . Staff should not prolong the resident's illness by waiting to notify the physician the following day. Staff should call abnormal laboratory results to the physician when the test results were received and not delay the resident receiving treatment. During interview on 1/30/23 at 11:50 A.M. the resident's physician said if the resident was in distress with symptoms of urinary tract infection and the urinalysis indicated infection, he would start treatment prior to receiving the culture and sensitivity report. He received the resident's urinalysis report on 12/9/22 after the resident was admitted to the hospital. He could not say for sure if starting antibiotics earlier based on the resident's clinical picture and the initial urinalysis report would have altered the outcome for the resident. He would prefer a clear clinical picture in order to treat the resident and avoid hospitalization , staff had not provided a clear clinical picture that he was aware of. There should not be a delay in seeking treatment for a resident. MO# 00211460

Based on interview and record review, the facility failed to ensure the facility transporter, who transported three sampled residents (Residents #1, #12 and #29) and one closed record resident (Resident #5) in the facility van, all of which had elected a full code status, was trained and certified to provide cardiopulmonary resuscitation (CPR-process of providing rescue ventilation and chest compressions to maintain circulation of blood). Additionally, the facility to obtain physicians' orders for three residents' (Resident #1, #12 and #29) requested code status and failed to maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes hands-on practice and in-person skills assessment and to monitor to ensure CPR certified staff were scheduled. This failure affected 17 residents who were identified as full code status (CPR required in the event of cardiac or respiratory arrest). The facility census was 32. The administrator was notified on [DATE], of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by the surveyor onsite verification. Review of the facility policy Emergency Procedure-Cardiopulmonary Resuscitation reviewed ,d+[DATE] showed the following: Policy statement: Personnel have completed training on the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest; Policy interpretation and implementation: 1. Cardiac arrest is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness); 2. Sudden cardiac arrest (SCA) is a leading cause of death in adults; 3. Victims of cardiac arrest may initially have gasping respirations or may even appear to be having a [CONDITION(S)]. Training in BLS includes recognizing the atypical presentations of SCA; 4. The likelihood of recovering from SCA due to an acute event (such as an arrhythmia) differs substantially from the likelihood of recovering from cardiac arrest that is the end result of multi-system failure and advanced irreversible or terminal conditions; 5. Depending on the underlying cause, the changes of surviving SCA may be increased if CPR is initiated immediately upon collapse; 6. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness; 7. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS); 8. If a resident is found unresponsive and not breathing normally, a licensed staff member will verify code status using the medical record; 9. If the resident is full code, per the medical record, a staff member that is certified in CPR will initiate CPR; 10. If the resident is Do Not Resuscitate (DNR), per the medical record, notify the attending provider; Preparation for CPR: 1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for clinical staff members who will direct resuscitative efforts, including non-licensed personnel; 2. Facility staff certified for CPR is available for each shift in the case of an actual cardiac arrest. Staff will call 911 when CPR is initiated; 3. The certified staff in this facility have received training and received certification in CPR/BLS. 1. Review of the facility assessment updated [DATE] showed staff training and competencies: CPR certification for all nursing staff and drivers. 2. Review of the Transportation Driver's employee file showed no CPR certification. Review of the facility transportation log for [DATE] showed the following: -The Transportation Driver transported Resident #12 (full code status) to an eye appointment on [DATE]; -The Transportation Driver transported Resident #1 (full code status) to an out of town physician clinic on [DATE] (31 miles from the facility one way); -The Transportation Driver transported Resident #5 (full code status) to an out of town appointment on [DATE] (86 miles from the facility one way); -The Transporter Driver transported Resident #29 (full code status) to an out of town appointment on [DATE] (12 miles from the facility one way). During interview on [DATE] at 2:10 P.M. the Transportation Driver said the following: -He/She was not CPR certified; -He/She transported full code residents to and from appointments; -He/She does not know how to perform CPR but he/she was in the process of taking an online only CPR class; -If a full code resident became unresponsive he/she would pull over and call 911. 3. Review of agency staff Licensed Practical Nurse (LPN) C's National CPR Foundation's certification card showed the following: -He/She was now certified in the above mentioned course by demonstrating proficiency in the subject by passing the examination in accordance with the terms and conditions of National CPR Foundation. Valid for two years; -Dated [DATE]. During an interview on [DATE] at 6:00 A.M. LPN C said he/she had taken an on-line CPR class; there was no hands on portion for this class. He/She was not aware he/she needed to have CPR certification with a hands on skills portion. 4. Review of agency staff Certified Nurse Assistant (CNA) M's National CPR Foundation's certification card showed the following: -He/She was now certified in the above mentioned course by demonstrating proficiency in the subject by passing the examination in accordance with the terms and conditions of National CPR Foundation. Valid for two years; -Dated [DATE]. (Same course with no hands-on skills training) 5. Review of agency staff LPN N's American Health Care Academy CPR certification card showed the following: -He/She successfully completed the requirements in accordance with American Health Care Academy's curriculum; -Issue date [DATE]. Renewal date [DATE]. Review of www.cpraedcourse.com showed American Health Care Academy was nationally accepted and easy-to-understand Adult, Child and Infant Online CPR certification and Online First Aid certification courses for the community, school, workplace and Healthcare Providers. 6. Review of Resident #29's Consent for: Do Not Resuscitate dated [DATE] showed the following: -I do wish Cardiopulmonary Resuscitation efforts. I understand that the Emergency Medical System (EMS) will automatically be activated (ambulance transfer to the hospital); -Signed by the resident and facility staff. Review of the resident's physician's orders dated [DATE] showed no physician's order for code status. 7. Review of Resident #12's Consent for: Do Not Resuscitate dated [DATE] showed the following: -I do wish Cardiopulmonary Resuscitation efforts. I understand that the EMS will automatically be activated (ambulance transfer to the hospital); -Signed by the resident and facility staff. Review of the resident's physician's orders dated [DATE] showed no physician's order for code status. 8. Review of Resident #1's Consent for: Do Not Resuscitate dated [DATE] showed the following: -I do wish Cardiopulmonary Resuscitation efforts. I understand that the EMS will automatically be activated (ambulance transfer to the hospital); -Signed by the resident's representative and facility staff. Review of the resident's physician's orders dated [DATE] showed no physician's order for code status. During interview on [DATE] at 5:00 P.M. Registered Nurse (RN) A said resident code status should be on each resident's physician order sheet. During interview on [DATE] at 11:45 A.M. and [DATE] at 1:27 P.M. the Assistant Director of Nursing (ADON) said the following: -She just recently started doing the nursing schedule; -The previous administrator did the nursing schedule until he left in October; -There was a list of CPR certified staff that the former Director of Nurses (DON) had but she could not find that list; -Several staff were recertified not too long ago; -She does not make out of the nursing schedule based on ensuring coverage by CPR certified staff ,d+[DATE]; -She hasn't been shown how to know if staff was CPR certified or not; -The facility used agency staff; -All the agency staff were CPR certified; -She had access to the agency staff's CPR cards; -She did not know the online only CPR course was not acceptable; -She did not know the National CPR Foundation certification was an online only course; -CNA M, LPN C and LPN N routinely worked shifts in the facility. During interview on [DATE] at 2:34 P.M. and [DATE] at 5:30 P.M. the administrator said the following: -There should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -She and the ADON were responsible for the nursing schedule; -She was not aware the online only CPR classes were not acceptable; -She and the ADON scheduled to ensure CPR coverage on all shifts; -All agency staff were CPR certified. They have to be CPR certified to be in the facility. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. 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. 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 E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations(s).

Based on observation, interview, and record review, facility staff failed to thoroughly investigate falls, including two falls which resulted in a fracture, to determine the root cause, and failed to consistently implement and modify interventions as necessary, in accordance with current standards of practice, to reduce the risk of falls for one resident (Resident #10), who was identified as at risk for falls. The facility also failed to review and add interventions to protect one resident (Resident #18) from self-inflicted harm after he/she verbalized intent to self harm. A sample of 12 residents was selected for review. The facility census was 40. 1. Review of the facility's Fall Prevention Policy (S.[NAME]F.E.), revised (MONTH) 2014, showed the following: -The S.[NAME]F.E. program promotes safety, assessment, fall prevention, and education of both staff and residents; -At the time of admission/readmission the fall risk data collection and fall risk questionnaire will be completed; -Residents found to be at high risk for falls are placed on the S.[NAME]F.E. program and specific interventions are implemented to meet individual need; -Resident representatives will be notified of placement on the S.[NAME]F.E. program and interventions the facility is implementing, related to the resident's high risk for falls; -As updates occur the representative will continue to be notified; -Following any falls, the facility completes an Occurrence Report. Details of the fall will be reported and potential causal factors identified and investigated; -Interventions will be immediately implemented following each fall and added to the resident's plan of care; -Staff will review the resident's fall risk data collection; -Occurrences will also be reviewed weekly at the facility care management meeting to ensure the occurrence report is completely finished and closed, that interventions were implemented timely, and to evaluate the outcome of interventions; -Revision to the plan of care will be done if indicated; -Patterns and trends will also be reviewed at that time to enhance the success of the program. 2. Review of Resident #10's care plan, revised 3/29/19, showed the following: -The resident was at risk for falls due to a history of falls: -Assess or safety in ambulation with wheeled walker and encourage frequent rest period for fatigue; -Determine causative factors for the fall; -Make sure equipment is in good working order; -Physical therapy consult as needed for strength and mobility. Review of the resident's fall risk score, dated 4/17/19, showed the resident was at moderate risk for falls. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/29/19, showed the following: -[DIAGNOSES REDACTED]. -Independent with bed mobility, transfers, walking, and toileting; -Balance was steady; -No impairments in range of motion; -No falls since the previous assessment. Review of the resident's nurse's notes showed on 5/25/19 at 3:20 P.M., staff yelled for help and the nurse responded to find the resident on the floor outside of his/her bathroom. The resident's pants and underwear were pulled down and the walker was close by. The resident mumbled and said he/she needed help to get to the bathroom. The resident was not acting normal. The resident's right arm was flaccid and skin was pale. The resident did not respond to painful stimuli. Another staff member called the paramedics who arrived at 3:35 P.M. and the resident was transferred to the emergency room . Review of the resident's fall investigation form, dated 5/25/19, showed the following: -The resident fell at 3:20 P.M.; -The resident was walking at the time of the fall with a walker; -The resident was unable to answer questions regarding the fall; -The new intervention added was to assess for acute illness. Review of the resident's nurses notes showed the following: -On 5/26/19 at 2:30 P.M., the resident's family called and updated facility staff the resident was found to have had a stroke and sustained a broken nose; -On 5/30/19 at 11:00 P.M., the resident was back in the facility in his/her room with family. The resident required assistance of two staff for transfers until evaluation by physical and occupational therapy. Bed and chair alarm in place per the family's request. Review of the resident's care plan showed an update on 5/31/19 (for the fall on 5/25/19). The resident fell in his/her room and was sent to the emergency room for evaluation. A fall mat, chair alarm, and bed alarm were used at that time for fall prevention. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition was severely impaired; -Required limited assistance of one staff for transfers, walking, and toileting; -Balance was not steady, only able to stabilize with human assistance; -No falls since the previous assessment; -Impaired range of motion of the upper extremity on one side. Review of the resident's therapy documentation showed the last day he/she received therapy services was on 8/29/19. Review of the resident's physician order [REDACTED]. Review of the resident's fall risk assessment, dated 9/29/19, showed the resident was at low risk for falls. Review of the resident's nurse's note, dated 9/29/19 at 12:29 P.M., showed staff found the resident on the floor beside his/her bed between the bed and the recliner with a sheet wrapped around his/her legs. The resident hit his/her nose on the floor and it was bleeding from the left nostril. Staff noted bruising to the bridge and left side of the nose. No other injuries were found. Staff took the resident to the nurse's station in his/her recliner so staff could monitor him/her. Review of the resident's care plan showed no update following the fall on 9/29/19. Review of the resident's medical record showed no evidence staff completed an investigation to determine the root cause of the fall on 9/29/19. Review of the resident's nurse's notes showed the following: -On 10/3/19 at 2:00 [NAME]M., the resident had a fall on 9/29/19. Multiple bruises were still noted to the left lower extremity, under both eyes, and to the nose. A bed and chair alarm were in place; -On 10/6/19 at 11:00 P.M., staff heard the resident's bed alarm sound and responded. Staff found the resident sitting on the side of the bed with his/her hand near his/her nose. The resident had blood all over his/her face, arms, shirt, and under the bed and pillow. On closer inspection, the resident was having a nose bleed. The nurse applied pressure for 20 minutes but was not able to stop the bleeding. The resident yelled out in pain and pushed staff member's hand away. The nurse noted the resident's nose was slightly crooked. It was reported the resident had fallen earlier in the week. The nurse contacted the physician who gave orders to send the resident to the emergency room for evaluation and treatment. The resident left the facility with paramedics at 11:55 P.M.; -On 10/7/19 at 1:39 [NAME]M., facility staff received report from the hospital the resident had a left sided nasal fracture that may have resulted from a previous fall. The resident was treated and returned to the facility at 2:20 [NAME]M. Review of the resident's care plan showed no update regarding the resident's nasal fracture or any updated fall interventions. Review of the resident's nurse's notes, dated 10/30/19 at 2:04 P.M., showed staff found the resident lying on the floor in the dining room. The resident's wheelchair was still at his/her table. The resident was wearing shoes. No injury was noted. Review of the fall investigation form, signed by the charge nurse on 10/30/19, showed the following: -The resident was walking at the time the fall occurred; -The resident was confused and could not recall the cause of the fall; -The resident had been asleep. Staff changed the resident and took him/her to the dining room in a wheelchair for lunch; -This fall followed a pattern similar to previous falls; -Comments: Anytime the resident was in the dining room, staff was to monitor and employee to remain in the dining room at all times. Review of the resident's nurses notes, dated 10/31/19 at 8:42 [NAME]M., showed the facility received the results of the resident's left hip and pelvic X-ray (a photographic image of the internal composition of parts of the body) which showed a left femur fracture. The physician was notified and orders received for the resident to be on bed rest and for pain medication. Review of the resident's fall risk assessment, dated 11/1/19, showed the resident was at low high risk for falls. Review of the resident's care plan showed an update on 11/6/19. The resident was on bed rest due to a [MEDICAL CONDITION]. There were no additional fall interventions added to the care plan. Review of the resident's report care card (kept at the nurse's desk for staff access), dated 11/6/19, showed the resident was at high risk for falls. There were no interventions to prevent falls listed on the care card. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Long-term and short-term memory problems; -Dependent on staff for bed mobility and toileting; -Walking and transfers did not occur; -Balance was not steady, only able to stabilize with human assistance; -Impaired range of motion on one side of the lower extremity; -One fall with major injury since the previous assessment. Review of the resident's nurse's note, dated 11/17/19 at 7:00 P.M., showed staff heard the resident yell for help. Staff entered the room and did not see the resident in bed. Staff found the resident on the floor between the bed and the air conditioner. The resident's legs were at the head of the bed and the resident's head was at the foot of the bed. The resident said he/she had to go to the bathroom and just fell down. Staff assessed the resident. The resident denied pain and staff assisted the resident to the commode. Staff assisted the resident to bed and put the bed in the lowest position with fall mats in place and the alarm attached and functioning. Review of the resident's medical record showed no evidence staff completed an investigation to determine the root cause of the fall on 11/17/19. Review of the resident's care plan showed staff did not update the care plan to include the resident's fall on 11/17/19 and no interventions were added or revised. Review of the resident's nurse's notes showed the following: -On 12/9/19 at 3:09 [NAME]M., the resident rested in bed. Pain was controlled from the left lower extremity fracture. The resident continued on bed rest per physician orders. The bed alarm was turned on; -On 12/19/19 at 4:48 [NAME]M., the resident rested in bed with the bed alarm turned on. Observation on 1/6/20 at 4:10 P.M. showed the resident lay in bed on a sensor pad alarm (electronic alarm that sounds when weight is removed). The resident's bed was in the low position. During an interview on 1/6/20 at 4:25 P.M., Certified Nurse Assistant (CNA) B said the resident used an alarm in the bed and in his/her wheelchair. The resident fell a while ago in the dining room and broke his/her hip. The resident had been on bed rest following a [MEDICAL CONDITION] after a fall in the dining room. The resident used a low bed and a fall mat along with the alarms to prevent falls. CNA B was not aware of the resident falling after he/she broke his/her hip. The resident did not have to remain in bed but did stay in bed that day due to not feeling well. CNA B found out about falls and interventions to prevent falls in shift report and the residents' care cards and care plans. During an interview on 1/7/20 at 9:14 [NAME]M., the Care Plan Coordinator (CPC) said devices such as bed and chair alarms should be on a resident's care plan if they were used. The CPC was not aware any alarms were currently being used in the facility. The CPC found out information about residents and the care required from discussions with nursing staff. During an interview on 1/7/20 at 12:50 P.M., Physical Therapy Assistant G said he/she had worked the resident in the past for left hand movement following a stroke. The resident did not receive any therapy services after he/she started receiving hospice services sometime in September. During an interview on 1/07/20 at 12:01 P.M., the administrator said staff did not complete investigations for the resident's falls on 9/29/19 and 11/17/19. During an interview on 1/7/20 at 1:33 P.M., the administrator said the resident had a fall mat in place but it was discontinued in (MONTH) 2019 due to being more of a hazard to the resident. The resident utilized a bed and chair alarm prior to the fall on 9/29/19. After the resident fell on [DATE], the fall mat and low bed were put back into place. The resident sustained [REDACTED]. On 10/30/19, the resident fell in the dining room. The resident complained of hip pain and a mobile X-ray was obtained in the facility which showed a [MEDICAL CONDITION]. The physician and family opted not to have the fracture repaired surgically. A staff member was in the dining at the time the resident fell and heard him/her fall but did not see it happen as the staff member was assisting another resident to eat and had his/her back turned to Resident #10. The administrator did not recall if the resident had a chair alarm in place at the time of the fall on 10/30/19 or not. The resident fell out of bed on 11/17/19. She was not certain if there was an alarm in place at the time of this fall or whether or not it sounded. The bed and chair alarms have been discontinued since that time as they can scare residents and usually just alert staff the resident had already fallen. She would expect staff to document all the circumstances of a fall when it occurred including any interventions that had been put into place. Fall interventions should be on the resident's care plan. Resident falls were discussed in a weekly meeting. Staff reviewed previous falls and circumstances regarding the fall to determine the root cause. 3. Review of Resident #18's admission MDS, dated [DATE], showed the following: -admitted [DATE]; -Cognition intact; -Verbal behaviors toward others; -Independent with activities of daily living (ADL)s; -[DIAGNOSES REDACTED]. -Required supplemental oxygen. Review of the resident's care plan, last revised on 11/24/19, showed the following: -His/Her [DIAGNOSES REDACTED]. -He/She had a potential psychosocial well-being problem due to ineffective coping; -He/She was tearful and argumentative, and physically aggressive with staff when he/she did not get his/her way; -He/She had issues with getting along with his/her roommates; -Staff were directed to assist, encourage, and support him/her to set realistic goals; -He/She required assistance, encouragement, and support to identify problems that could not be controlled; -He/She required assistance, supervision, and support to identify precipitating factor(s)/stressors; -When conflict arose, staff was to remove him/her to a calm and safe environment to allow him/her to vent/share his/her feelings. Review of the resident's physician's orders [REDACTED]. -His/Her [DIAGNOSES REDACTED]. -[MEDICATION NAME] (antidepressant) 20 milligrams (mg), one tablet every day; -[MEDICATION NAME] 5 mg, one tablet every day; -[MEDICATION NAME] (antianxiety medication) 1 mg tablet, administer one tablet three times a day; -On 12/4/19 orders were obtained to discontinue Escitralopram 5 mg and continue Escitralopram 20 mg. Review of the resident's behavioral nursing notes, dated 12/22/19 at 6:40 P.M., showed the following: -The resident told nursing staff he/she wanted them to wrap his/her oxygen tubing around his/her neck; -The resident said if he/she really wanted it done, he/she would do it himself/herself; -Non-pharmacological interventions placed at that time included visiting with the resident at which time he/she told staff he/she was just joking, and sometimes he/she said things he/she did not mean. Review of the resident's care plan showed no interventions or revisions were made after the resident made comments to staff about placing the oxygen tubing around his/her neck. Review of the resident's behavioral nurse's note, dated 12/25/19 at 2:30 P.M., showed the following: -The resident told nursing staff he/she used nail clippers to try to cut the vein in his/her wrist because he/she could not breathe and was tired of it all; -Non-pharmacological interventions included removal of clippers and other harmful objects from his/her room, his/her call light was removed, and he/she was provided a bell; -His/Her physician was notified and orders were obtained to transfer the resident to the hospital. Review of the resident's hospital discharge summary, dated 12/27/19, showed the following: -The resident was originally sent to the hospital for evaluation after he/she attempted to cut him/herself with nail clippers because he/she said he/she was not getting his/her nebulizer treatments; -He/She was psychiatrically cleared and was sent to second hospital for medical management of [MEDICAL CONDITION] ([MEDICAL CONDITION]; a chronic [MEDICAL CONDITION] lung disease that causes obstructed airflow from the lungs) exacerbation; -There were no new psychiatric medication changes documented. Review of the resident's care plan showed no documentation of the resident's attempt of self-harm and/or interventions to protect the resident from further attempts after the incident on 12/25/19. Review of the resident's MDS Kardex (document certified nursing assistants (CNAs) use to provide care for the residents) report, dated 12/31/19, showed no documentation of the resident's comments and/or attempt at self-harm. The Kardex was not updated to include interventions to protect the resident from further incidents. During an interview on 1/6/20 at 10:44 [NAME]M., CNA F said the following: -The resident had been depressed because it was Christmas and his/her family member would not come see him/her; -He/She was present the day the resident attempted self-harm with the nail clippers. The nurse entered the room and the resident told him/her he/she had attempted to harm himself/herself with nail clippers; -The resident had never had these behaviors in the past; -The resident was sent out to the hospital and returned with increased monitoring; -Staff were to check on the resident at meal times and frequently throughout the day to assess the resident's mood. During an interview on 1/7/20 at 6:30 [NAME]M., CNA I said the following: -He/She monitored the resident every two hours during bed checks; -He/She had never been told to increase monitoring of the resident; -He/She was aware of the resident's attempt at self-harm, but was not told to increase monitoring of him/her. During an interview on 1/7/20 6:45 [NAME]M., Licensed Practical Nurse (LPN) D said the following: -He/She was aware of previous comment that involved the oxygen tubing on 12/22/19, but the resident told nursing staff, including LPN D, he/she was just joking; -The resident told nursing staff the reason he/she attempted to cut his/her wrists was because staff did not respond quickly enough for him/her; -The resident was sent out for evaluation after the incident of self-harm, he/she was cleared by psych and sent to another hospital for treatment of [REDACTED]. -The hospital determined the resident was attention seeking and was sent back from the hospital with no changes with his/her psychiatric medication. -The resident told staff he/she would never do it again, and the resident did not have clippers or scissors in his/her room; -Staff checked rooms periodically for hazardous materials; -The resident told him/her he/she felt sad due having family issues on the holiday. During an interview 1/7/20 at 8:35 [NAME]M., the Social Service Designee (SSD) said the following: -The resident's family member did not come visit the resident because of the resident's behaviors; -He/She was unaware of the resident's comments of wanting the oxygen tubing around his/her neck on 12/22/19 until recently; -He/She did not think if he/she would have known, it would have prevented the incident on 12/25/19 because the resident told staff he/she was just kidding; -The resident was sent out after an incident of self-harm and it was determined he/she was attention seeking; -The hospital cleared the resident and sent him/her back with on no specific observation instructions. During an interview on 1/6/20 at 11:30 [NAME]M., the MDS/Care Plan Coordinator said the following: -Nursing staff notify him/her of any changes in a resident's status; -He/She was unaware of the incident when the resident asked staff to put the oxygen tubing around his/her neck on 12/22/19; -The resident was sent to the hospital on [DATE] for behaviors of self-harm; -He/She added an intervention to the resident's care plan after the incident on 12/25/19 to use two staff when caring for the resident because he/she had delusions of staff spitting in his/her water or turning off his/her oxygen. He/She was so focused on the resident's delusions involving staff and other people, he/she failed to address the event of self-harm and add interventions to prevent further incidents; -Staff should have notified him/her of the incident on 12/22/19 because it could have prevented the incident on 12/25/19 if protective interventions were put into place. During an interview on 1/7/20 at 3:20 P.M., the resident's physician said the following: -He/She was not aware of the resident's statement involving the oxygen tubing on 12/22/19; -He/She would have expected staff to increase monitoring of the resident when he/she returned to the facility after he/she attempted to harm himself/herself; -The resident has had a lot of family problems and life changing events including the death of an adult child and a falling out with his/her child which was very upsetting to the resident around Christmas; -He/She was not surprised the resident had these behaviors on the holiday, but that did not mean staff did not need to monitor the resident. During an interview on 1/7/20 at 4:10 P.M., the Director of Nursing (DON) said the following: -He/She expected care plan to be updated with interventions to protect the resident after a psychiatric event; -He/She expected staff to increase monitoring of the resident.

Based on interview and record review the facility failed to implement, evaluate, and modify interventions as necessary to address prevention of falls for one resident, (Resident #2) in a sample of five residents. Resident #2 fell from his/her wheelchair sustaining a fractured skull , a brain bleed and facial lacerations that required sutures. The facility census was 41. 1. Record review of the facility's fall prevention and risk reduction policy (no date), showed the following: - The facility will protect residents from injury by falls through risk assessment and identification; -Every resident is considered at high risk for falls until the admission fall assessment is completed; - Fall risk assessment includes evaluation of balance, strength, gait, transfer, and safety; -Fall risk assessment will be completed the first day of admission on every resident, quarterly, and with every significant change; -Risk for falls includes; history of falls, impaired mobility, unsteady gait, weakness, dizziness, postural [MEDICAL CONDITION] (a drop in blood pressure due to a change in body position), impaired vision, impaired safety awareness, risky behaviors, polypharmacy (simultaneous use of multiple medications) or use of [MEDICAL CONDITION] medications; -The admitting nurse will initiate fall risk protocols as soon as the resident is assessed at risk; - Fall risk to be indicated in chart and on nursing care form; -The nursing assistant care form will indicate method of transfer, transfer aids, and how many staff members are required for transfer and ambulation; -The MDS (minimum data set) coordinator will complete a comprehensive care plan of all residents who identifies at risk for falls, communicate the falls care plan to the health care team, update nursing assistant care forms, charge nurses and MDS coordinator will update interventions on fall care plan with any new occurrence of falls; -Staff will continually assess for and reduce risk for falls. 2. Review of Resident #2's fall risk assessment, (no date) showed the following: -The resident was disoriented at all times; -The resident was chair bound, had poor vision, and was unable to ambulate; -The resident received four or more medications which would cause lethargy (lack of energy or enthusiasm); -Had three or more [DIAGNOSES REDACTED]. -The resident was at high risk for falls. Record review of the resident's care plan (no date) showed the following: -The resident was at risk for falls; -The resident's [DIAGNOSES REDACTED]. -The staff should modify the resident's environment for safety, check the resident frequently for safety and intervene as needed; -The staff should use personal alarms for safety. Record review showed no documentation as to when the personal alarms should be utilized. Review of the resident's nurse's note dated 1/16/19, (no time) showed the resident was leaning over in his/her wheelchair and was assisted to lay down. Record review of the resident's care plan showed the care plan was not updated or interventions put in place regarding the resident leaning over in the wheelchair. Record review of the resident's nurse's note dated 1/23/19 at 4:00 P.M. showed staff found the resident had halfway slid off his/her low bed. Record review showed no documentation the resident's care plan was updated when the resident slid part way off the bed or interventions put in place. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff dated 2/20/19, showed the following: -The resident's cognition was severely impaired; -The resident required the extensive assistance of two staff for transfers and bathing; -The resident required minimal assistance of one staff for locomotion in a wheel chair; -The resident's balance was not steady and required assistance of staff to stabilize; -The resident's [DIAGNOSES REDACTED]. -The resident had no falls since admission. Review of the resident's incident report dated 3/19/19 at 7:30 A.M. showed the following: -The resident was sitting in his/her wheelchair in the hallway; -The Certified Nurse Aide (CNA) pulled the resident up in the wheelchair; -When the CNA went down the hall into another resident's room, the nurse said he/she found the resident on the floor. Record review of the facility's investigation of the resident's incident, dated 3/21/19, showed the following: -The resident fell out of his/her wheelchair at 7:00 A.M.; -The resident had a laceration on his/her forehead and cheek and had multiple stitches; -The resident was transferred to the hospital emergency room and was admitted to the hospital; -The resident sustained [REDACTED]. Record review of the resident's hospital history and physical dated 3/21/19 showed the following: -The resident had an unwitnessed fall; -The resident had two left sided facial lacerations; -CT (computerized tomography) scan showed a small subarachnoid bleed; -The resident was admitted to the hospital. During an interview on 3/26/19 at 7:29 P.M., the resident's family member said the following: -The resident was in a regular wheelchair and the back of the chair could be leaned back; -The resident would lean forward a lot; -The family member was worried the resident would fall out of the wheelchair. During an interview on 3/22/19 at 12:30 P.M., CNA [NAME] said the following: -Staff go the resident up at 6:00 A.M.; -The resident was in his/her wheelchair and it was reclined because the resident goes to sleep; -That day the resident was awake and at the nurse's station; -The resident would roll out of bed and try to climb out of bed; -The resident had an alarm on his/her bed; -The staff would monitor the resident while in his/her wheelchair at the nurse's station; -The back of his/her wheelchair would be reclined; -The resident would always lean forward and sideways; -CNA [NAME] thinks the resident bent over and fell out of the wheelchair. During an interview on 3/22/19 at 10:25 A.M., CNA B said the following: -The day the resident fell , he/she was up in his/her wheelchair at 6:30 A.M.; -The nurse told the resident to sit back in the wheelchair; -CNA B repositioned the resident and leaned (tilted) the wheelchair back; -If the residents are at risk for falls they are the last residents to get out of bed for meals; -The staff try to keep a close eye on the resident; -The resident should have been the last resident out of bed; -CNA B was not sure if the resident was at risk for falls; -The resident would lean forward and to the side when in his/her wheelchair. During an interview on 3/22/19 at 11:59 A.M., CNA C said the following: -He/she arrived to work on 3/19/19 at 7:00 A.M.; -The night shift got the resident out of bed to go to the dining room; -The resident was sitting in the wheelchair sometime between 7:00 A.M. and 7:30 A.M.; -CNA C did not notice if the resident was asleep; - The resident had a history of [REDACTED].>-CNA C and CNA F saw the resident on the floor; -CNA C does not know if the resident was at risk for falls, this may be in his/her care plan; -The staff would try to watch how the resident was sitting, if the resident was talkative and moving a lot they would keep him/her near the nurse's station where someone would see the resident; -Early in the morning, the resident would lean out of the chair and sleep, the resident should have been in bed. During an interview on 4/4/19 at 9:45 A.M., CNA I said the following: -The resident was at risk for falls; there was an alarm on his/her bed; -The resident would sit on the side of his/her bed; -The resident would lean forward and sideways when in the wheelchair. During interview on 3/22/19 at 2:30 P.M. Restorative Certified Nurse Assistant (RCNA) F said the following: -The RCNA was working day shift on 3/19/19; -The resident was in the wheelchair in the hallway sleeping; -The RCNA was helping another CNA and saw the resident face first on the floor; -The other CNA had just reclined the resident back in the wheel chair but the resident does try to reposition himself/herself; -The resident does lean forward; -The resident was at risk for falls because he/she is restless some days. During an interview on 3/22/19 at 12:05 P.M., Licensed Practical Nurse (LPN) D said the following: -The LPN works on the night shift; -The night shift would typically get the resident out of bed; -The resident would be wide awake for a couple of days and nights and then the resident would sleep for a couple of days; -The staff would still get the resident out of bed for one meal a day, usually breakfast; -The resident was sleeping that day; -The nurse does not know why the resident fell ; -The resident was leaning forward (in his/her wheelchair), and the CNA leaned the resident back in the wheelchair; -Then the resident was asleep; -The LPN was called to come because the resident fell ; -The LPN does not know how the resident fell without tipping the wheelchair over; -The resident was laying on his/her left side on his/her shoulder, cheek and forehead; -The resident may have been reaching for something; - The LPN was not aware the resident had fallen previously, but the resident would be considered at risk for falls; -The resident does lean forward in the wheelchair, he/she would sit back if you told him/her to. During an interview on 3/22/19 at 7:45 P.M., LPN H said the following: -The resident would sit in the chair at the nurse's station; -Normally the resident would sleep in the chair; -The resident would try to slide down; -Staff would pull the resident up and he/she would slide down again; -The resident was at high risk for falls; -The resident was kept at the nurse's station in the wheelchair where he/she could be seen by staff. During an interview on 3/22/19 at 3:15 P.M., Registered Nurse (RN) A said the following: -The resident was at risk for falls; -The CNAs should monitor the resident's position whether the resident is in bed or the chair; -The resident was high risk for falls, this is determined by the fall assessment; -The CNA's and nurses would monitor the resident at the nurse's station when he/she was in the wheelchair. During an interview on 3/22/19 at 10:50 A.M., the Occupational Therapist (OT) said the resident had a problem with balance. During an interview on 3/22/19 at 2:10 P.M., the Physical Therapist (PT) said the following: -The resident was treated by therapy for positioning and transfers; -The resident was unable to follow commands; -The resident would sleep all day and be awake all night; -Therapy put the resident in a standard wheelchair but the resident's family didn't like the standard wheelchair because family thought the resident was comfortable; -Before the resident fell , PT and the hospice nurse requested the resident be laid down or have a different chair; -When the resident was tired he/she would lean forward and to the side; -When that happened the resident needed to go back to bed. During an interview on 3/28/19 at 1:45 P.M., the nurse practitioner said: -The/she last saw the resident on 2/22/19: -The resident was sleeping in the wheelchair near the nurse's station; -That is where the resident was nine times out of ten when the nurse practitioner would see the resident. During an interview on 3/22/18 at 2:30 P.M., the physician said the following: -The resident slumps (when seated) and has no postural (posture/position of the body) control. -The staff should not leave the resident in a compromised position; -The resident was returning to the facility (from the hospital) on hospice care. During an interview on 3/22/19 at 7:00 P.M. and 3/28/19 at 2:00 P.M., the director of nursing (DON) said the following: -The resident had dementia and poor cognition; -Staff kept the resident at the nurse's station; -The DON does not know the routine in the morning; -The CNA's can check the kardex (a brief over view of the resident) and care card on the closet door to know who was at risk for falls; -This system was not set up well, the CNA's may not have known which residents were at risk for falls; -The care plans should be updated after a resident falls; -A fall is when a resident's buttocks touch the floor; -The resident was high risk for falls; -The resident should have an alarm on his/her wheelchair and the staff should keep the resident in close proximity when he/she was out of bed. During an interview on 3/29/19 at 9:00 A.M., the administrator said the following: -The staff should take measures to prevent falls; -The residents should be positioned well to prevent sliding and receive close observation; -The resident's care plan should reviewed and updated when a resident falls. MO 3

Based on observation, interview and record review showed the facility failed to provide necessary treatment and services consistent with standards of practice to promote the healing of existing pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) for one resident (Resident #1) in a sample of five residents, who developed an unstageable (full thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because the wound bed it obscured by slough (soft stringy tissue) or eschar (dead tissue) pressure ulcer. The facility census was 41. 1. Record review of the facility policy, (no date) for prevention and care of pressure ulcers showed the following: -Observe skin, any reddened area that remains red longer than 15 minutes after pressure is relieved, is a high risk area for a pressure sore to begin; -Pay particular attention to bony prominences; -Change bed linen whenever wet or soiled; -Keep foundation sheet dry and free of wrinkles and food particles; -Pressure reducing mattresses may be used to relieve pressure; -Use a pressure reducing pad when resident is in the wheelchair; -Turn the resident and position with pads or pillows to protect bony prominences; -Active and passive range of motion may be ordered by the physician to improve circulation; -Whenever possible, teach the resident to change his position at regular intervals and shift his weight in wheelchair; - Use elbow and heel protectors if needed; -Assess resident for adequate nutrition intake and develop a plan that meets the needs; -Offer fluids frequently for adequate hydration; -The dietitian should assess the resident and make recommendations for adequate nutrition; -treatment of [REDACTED]. - The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent decubiti; -Preventive measures used; -Condition of the resident's skin; -Physician notification, if appropriate; -Preventive equipment used; -If a decubitus is present, the licensed nurse is responsible to record condition of the skin, including stage, size, depth, color, drainage and odor as well as the treatment provided; - Notification of the physician is required when a new decubitus is identified as well as when treatment is not effective; -The resident's care plan should identify the underlying problem causing the formation of decubitus (pressure ulcer), and establish a measurable goal for resolution of the condition and maintenance of skin integrity; -The staff should develop a plan to treat the condition, observe and monitor resident's response to treatment, preventive measures, safety measures and resident education, observation and reporting of complications, and nutritional support for healing. 2. Record review of the Prevention and treatment of [REDACTED]. -Ongoing assessment of the skin is necessary to detect early signs of pressure damage; -Repositioning should be considered in all at-risk individuals, repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body; -In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure he/she is exposed to; -When an individual is seated in a chair, the weight of the body causes the greatest exposure to pressure to occur over the ischial tuberosity (sit bone). As the loaded area in such cases is relatively small, the pressure will be high, therefore, without pressure relief, a pressure ulcer will occur very quickly; -Avoid positioning the individual on an area of [DIAGNOSES REDACTED] (redness) whenever possible; -[DIAGNOSES REDACTED] indicates that the body has not recovered from the previous loading and requires further respite from repeated loading; -Keep the skin clean and dry. 3. Record review of Resident #1's care plan dated 10/17/18 showed the following: -The resident had an alteration in his/her activities of daily living and required two staff (assistance) due to decreased mobility; -The resident's impaired cognition may impair his/her ability to make his/her needs and wants known. Record review of the resident's kardex (brief overview of the resident's needs) report dated 10/17/18 (located on the resident's closet door) showed the following: -The resident required extensive assistance of one staff for bed mobility; -The resident was always incontinent of bowel and bladder; -The resident requires pressure relieving device for his/her bed and chair; -The resident requires a turning and repositioning program. Record review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/19/19, showed the following: -The resident's cognition was severely impaired; -The resident required extensive assistance of one staff for repositioning; -The resident was always incontinent of bowel and bladder; -The resident was at moderate risk for pressure ulcers. Record review of the resident's Braden (scale for predicting pressure ulcer risk) assessment dated [DATE] showed the following: -The resident was slightly limited in his/her ability to communicate discomfort or the need to be turned; -The resident's skin is often very moist, but not always; -The resident's ability to walk is non-existent; the resident must be assisted into a chair; -The resident's ability to change position was very limited; -The resident can make occasional slight changes in position but was unable to make frequent or significant changes independently; -The resident's meal intake pattern is adequate, and the resident eats over half of most meals; -Friction and shear is a problem, the resident requires moderate to maximum assistance in moving, complete lifting without sliding against the sheets is impossible; -The resident is at moderate risk for pressure ulcers. Record review of the resident's physician order sheet dated 2/1/19 through 2/28/19 showed the following: -The resident's [DIAGNOSES REDACTED]. -The resident should have a weekly skin assessment. Record review showed no documentation the resident's care plan was updated to include the resident's risk for pressure ulcers or interventions to prevent skin breakdown. Record review of the resident's weekly skin assessment dated [DATE] showed the resident had no red areas, no blisters and no open ulcers. Record review of the resident's physician order sheet showed: -an order for [REDACTED].>-Cleanse with wound cleanser, and apply calcium alginate (highly absorbent wound dressing) dressing and ABD (absorbent pad) pad daily and as needed. Record review of the resident's nurse's note dated 2/13/19 showed the following: -The resident was noted to have a Stage II (partial thickness skin loss with exposed dermis, presenting as a shallow open ulcer) pressure ulcer on the bottom of the left buttock; -The wound was treated with wound cleanser, calcium alginate and an ABD. -There was no documentation showing the wound size, depth, color, drainage or odor. Record review of the resident's treatment administration record (TAR) showed: -2/13/19, cleanse left lower buttock with wound cleanser, apply calcium alginate and ABD; -Change daily and as needed scheduled for 7:00 A.M. to 7:00 P.M.; -On 2/15/19, there was no documentation showing staff had completed the treatment/dressing change. Record review showed no documentation the resident's care plan addressed the resident had a pressure ulcer, or treatments and interventions to address the ulcer. Record review of the resident's weekly skin assessment dated [DATE] showed: -The resident had a Stage II area to the right lower buttock; -There was no documentation showing the wound size, depth, color, drainage or odor. Record review of the resident's TAR showed on 2/16/19 and 2/17/19, staff initialed/circled the documentation spaces for these dates showing the resident's treatment/dressing change was not completed. Record review of the resident's physician's order sheet showed an order dated 2/22/19 directing staff to lay the resident down between meals and reposition the resident to the right side or back to decrease pressure to the left buttock pressure ulcer. Record review of the resident's weekly skin assessment dated [DATE] showed: -The resident had a Stage II area to the right lower buttock with a foul odor; -The dressing was not changed in two days -There was no documentation showing the wound size, depth, color, or drainage. Record review showed no documentation the resident's care plan addressed the resident had a pressure ulcer or included a new physician's order to lay the resident between meals and reposition the resident to the rights side or back to decrease pressure to the buttock area. Record review of the resident's physician's order sheet showed: -An order dated 2/28/19 to discontinue the previous treatment order to the left lower buttock; -New order to cleanse the wound with wound cleanser, and apply Santyl ([MEDICATION NAME] ointment) and a dressing twice daily. Record review of the resident's physician order sheet dated 3/1/19 through 3/31/19 showed the following: -3/1/19 Refer the resident to the wound clinic for the unstageable right ischium (lower back part of the hip bone) wound; -Discontinue the previous treatment orders to the left buttock, the wound is on the right buttock (clarified there was no wound on the left buttock, it was documented incorrectly); -Cleanse the right buttock wound with wound cleanser and pat dry; -Apply Santyl and cover with a dry dressing twice a day until healed; -Culture the wound on the right buttock; -Turn and reposition the resident to his/her back and left side every two hours and PRN. Record review of the resident's nurse note dated 3/1/19 showed: -The nurse practitioner was here and new orders were received to discontinue the treatment to the left buttock wound, the wound is on the right buttock; -Refer the resident to the wound clinic for treatment of [REDACTED]. Record review of the resident's weekly skin assessment dated [DATE] showed the resident had an unstageable (the base of the wound was covered with eschar) area on the coccyx (tailbone). Record review of the resident's wound/skin healing record dated 3/6/19 showed the following: -The wound site was the right buttock; -The area was unstageable; -The size in cm length and width was 3.0 cm black, 0.25 cm white and 3.0 cm. red; -No depth indicated; -No exudate (a mass of cells and fluid which has seeped out of blood vessels onto an area of inflammation) type indicated; -The odor was moderate and foul; -There was a large amount of exudate; -The wound bed was black/brown eschar (dead tissue); -The surrounding skin color was bright red, white/gray pallor; -The surrounding tissue edges are rolled. Record review showed no documentation the resident's care plan addressed the resident had a pressure ulcer, treatments of the ulcer or interventions to address pressure relief and wound healing. Record review of the resident's physician order sheet dated 3/1/19 through 3/31/19 showed the following: -An order dated 3/7/19 to cleanse the wound on the right buttock with normal saline; -Apply Santyl to the wound bed and barrier cream (cream used to form barrier between the skin and contaminants) to the surrounding skin; -Apply a dressing to the wound; -Cover with border foam (highly absorbent, waterproof dressing with adhesive backing) daily; -May change the outer dressing twice daily as needed; -Cover the dressing with op-site (transparent adhesive film). Record review of the resident's TAR showed the following: -On 3/7/19, cleanse the wound on the right buttock with normal saline and apply Santyl ointment to the wound bed; -Apply barrier ointment to the surrounding skin; -Apply the dressing to the wound; - Cover and secure the dressing; -Change daily scheduled for 7:00 A.M. to 7:00 P.M.; -No documentation staff completed the dressing change on 3/7/19. Record review of the resident's significant change MDS dated [DATE] showed the following: -The resident's cognition was severely impaired; -The resident required extensive assistance of one staff for repositioning; -The resident was always incontinent of bowel and bladder; -The resident was at risk for pressure ulcers and had one unstageable pressure ulcer. Record review of the resident's nurse's note dated 3/9/19 at 7:00 A.M. to 7:00 P.M showed the following: -The wound on the resident's right buttock measured 8 centimeters (cm) by 10 cm (includes the surrounding redness).; -The actual open wound measures 6 cm by 4 cm with slough and eschar covering the entire wound base. Record review of the resident's TAR showed no documentation the resident's treatment/dressing change was completed on 3/10/19 or 3/11/19. During interview on 3/22/19 at 9:30 A.M. and 4/2/19 at 1:15 P.M., Registered Nurse (RN) A said the resident's wound treatment supply did not come. Record review of the resident's daily wound log dated 3/12/19 showed: -The resident had a dressing present on his/her right lower buttock; -The dressing had a large amount of purulent (thick fluid which includes blood cells and debris) exudate (fluid that filters from the circulatory system) with an odor; -The wound bed had granulation (new vascular tissue) and slough, and the surrounding skin was bright red; -New treatment orders were obtained. Record review of the resident's weekly skin assessment record dated 3/13/19 showed the resident had an unstageable area on the coccyx. Record review of the resident's daily wound log dated 3/13/19 showed -The resident had a dressing on his/her right lower buttock; -The dressing had a large amount of purulent exudate with an odor; -The wound bed had granulation and slough, and the surrounding skin was bright red. Record review of the resident's daily wound log dated 3/15/19 showed; -The dressing on the resident's right lower buttock had a large amount of purulent exudate with an odor; -The wound bed had granulation and slough, and the surrounding skin was bright red; -A new treatment was started. Record review of the resident's weekly skin assessment dated [DATE] showed the resident had an unstageable area on the right lower buttock. Record review of the resident's daily wound log dated 3/18/19 showed: -The dressing on the resident's right lower buttock had a large amount of purulent exudate with an odor; -The wound bed had granulation and slough, and the surrounding skin was bright red. Record review of the resident's physician order sheets showed: -An order dated 3/20/19 to discontinue the previous wound treatment to the right lower buttock; -Cleanse the wound with normal saline and pat dry; -Apply a quarter sized amount of Santyl to the wound bed only; -Cover the wound with Polymem (non-adhesive foam dressing which absorbs) with silver (anti-[MEDICAL CONDITION]) cut to fit the wound bed; -Apply skin protectant to the peri (surrounding area) wound; -Cover the wound with opsite and change daily and PRN; -Check every shift. Record review of the resident's daily wound log dated 3/20/19 showed: -The dressing on the resident's right lower buttock had a large amount of purulent exudate with odor; -The wound bed had granulation and slough, and the surrounding skin was bright red. Observation on 3/22/19 at 3:00 P.M. showed the following: -The resident's pressure ulcer over the right ischial tuberosity measured 5 cm by 6.5 cm; -There was a narrow rim of yellow slough surrounding the open area; -The peri-wound (outer perimeter of the wound) measured 13 cm by 11 cm and the skin was red; -The center of the wound was filled with dark stringy necrotic tissue, and bands of thick white tissue. Review showed the resident's care plan was not updated to show the resident had skin breakdown, including a pressure ulcer on the buttock, treatments to address the ulcer or interventions for staff to follow to provide appropriate care for healing and prevention of further breakdown. During an interview on 3/22/19 at 10:25 A.M., Certified Nurse Aide (CNA) B said the following: -The resident is totally dependent (on staff); -The resident has a pressure ulcer; -The resident sits in his/her recliner; -Staff would reposition the resident in the recliner by shifting his/her weight with the pad under the resident, or reclining the recliner to make him/her comfortable; -The resident did not want to lay down. During an interview on 3/22/19 at 11:59 A.M. and 4/2/19 at 1:24 P.M., CNA C said the following: -The resident's pressure ulcer went from a small area to a big area about three weeks ago; -The resident sat too much; -The resident would sit in the recliner, then in the wheelchair, then in the recliner; -The resident's position was changed when the resident went from one chair to the other chair; -The staff would look at the resident's care plan to know what the resident needed. During an interview on 3/22/19 at 2:30 P.M., Restorative Nurse Assistant (RCNA) F said the following; -He/she saw the resident's pressure ulcer in mid February; -The area was quarter sized and red with no broken skin; -The nurse was notified, but the CNA does not remember which nurse; -Before the resident had the pressure ulcer he/she would get up in the recliner and sit until lunch, that was the routine; -The RCNA would shift the resident's weight when the resident was seated in the chair by pulling on one side of the pad under the resident; -The area was caused by sitting in the chair and not being cleaned; the resident was incontinent. During an interview on 3/22/19 at 12:15 P.M., Licensed Practical Nurse (LPN) D said the following: -The resident would get up for breakfast and then would sit in his/her recliner; -The resident would eat lunch in his/her wheelchair then sit in his/her recliner; -The resident doesn't lay down; -The staff could not reposition the resident when he/she was in the chair; -LPN D doesn't know why the resident got the pressure ulcer or why it got so bad so fast. During an interview on 3/22/19 at 9:30 A.M. and 4/2/19 at 1:15 P.M., RN A said the following: -The resident had a blister then the wound had a black center; -The resident's wound treatment supply did not come; -When the area was noted on 2/13/19 it was already open and the color was beefy pink; -The staff would toilet the resident per the resident's request, this is how the resident's position was changed. During an interview on 3/28/19 at 1:45 P.M., the nurse practitioner said: -When he/she saw the resident is December, the resident had no skin issues; -When she saw the resident on 2/22/19, he/she was sitting in a chair and the wound could not be checked; -He/she was asked to look at the pressure ulcer on 3/1/19; -The area was unstageable, the wound was on the right buttock, not the left buttock; -The pressure ulcer measured 4.00 cm. by 3.0 cm, the depth could not be measured, there was some black and yellow slough; -The surrounding skin was [DIAGNOSES REDACTED]tous (red); -The wound was foul smelling with green-brown drainage; -When the nurse practitioner saw the wound on 3/15/19 the wound was still necrotic and foul smelling and measured 7.0 cm by 4.0 cm. During an interview on 3/22/19 at 4:10 P.M. and 3/28/19 at 2:39 P.M., the physician said: -The resident needs to be repositioned more often; -When the physician was notified of the pressure area it was already large; -If the facility had notified the physician of the wound earlier and treated the wound earlier, it could possibly have made a difference in the outcome; -The wound got worse rapidly; -The wound is down to the muscle, it will take a long time to heal; -The staff need to do a weekly wound report; -The documentation (regarding pressure ulcer) should start when the area is a Stage I (An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may aappear with persistent red, blue or purple hues). During an interview on 3/22/18 at 8:45 P.M., the Director of Nurses (DON) said the following: -RN A found the pressure ulcer on 2/13/19; it was a Stage II area; -The area was about the size of a dime; -On 3/6/19 the area had a 3.0 cm necrotic center; -The surrounding area was moist and had a foul odor. During an interview on 3/29/19 at 9:00 A.M., the administrator said the following: -He/she expected the staff to reposition residents every two hours; -The CNA's should report skin problems to the nurse; -The nurses should monitor the resident's skin; -If a resident has a pressure ulcer the nurse should complete the treatments as ordered; -The treatment should be documented on the TAR; -If the TAR has a blank this means the treatment was not completed; -The care plan should be updated when a pressure ulcer is identified; -Staff should measure the pressure ulcer weekly; -The nurse should talk to the physician as needed. MO# 3

Based on interview and record review, the facility failed to ensure Cardiopulmonary Resuscitation (CPR-process of providing rescue ventilation and chest compressions to maintain circulation of blood) certified staff were scheduled and present in the facility 24 hours a day, seven days a week and failed to develop and implement a policy addressing CPR requirements for staff. This failure affected 25 residents who were identified as full code status (CPR required in the event of cardiac or respiratory arrest). The facility failed to ensure the medical record accurately and consistently indicated residents' code status for one resident (Resident #28) in a review of 13 sampled residents, for one additional resident (Resident #1) and for three closed records (Resident #152, #42 and #157) and failed to ensure staff were trained and available to provide CPR when transporting residents who requested to be full code, in the facility van. Ten additional residents (Resident #26, #33, #153, #25, #30, #150, #155, #154, #151 and #5) who were a full code, were transported multiple times by the facility transporter who was not certified to perform CPR. The facility census was 47. 1. During an interview on [DATE] at 1:00 P.M. the Director of Nursing (DON) said the facility had no policy regarding staff CPR certification requirements, no policy regarding scheduling CPR certified staff on every shift 24 hours per day, seven days per week and no policy regarding CPR certified staff transporting residents who were full code. Review of the facility undated Cardiopulmonary Resuscitation policy showed the following: -Responsibility: Licensed nurse and any person in the facility with CPR experience; -Purpose: To ventilate and establish circulation on a resident with absence of respirations and pulse; -Procedure: 3. Delegate a specific individual to check resident's CPR status; have individual to call paramedics, attending physician and administrative personnel when appropriate. Review of the facility policy Advanced Directives, dated (MONTH) (YEAR), showed the following: Policy: -Residents will be informed upon admission by the Social Service Director (SSD) of the right to have and maintain Advanced Directives, including Do Not Resuscitate (DNR) and refusal of treatment, care and services. This will be explained in detail and written documentation of this policy and procedure will be given to each resident and/or resident representative upon admission; -Residents will be involved in the initial plan of care and quarterly review of care outlining their care wishes and informing the physician, charge nurses, Certified Nurse Aides (CNA) and other providers of services what the specific wishes are regarding the resident's Advanced Directives, Do Not Resuscitate, and the right to refuse treatment, care and services; -The plan of care will be reviewed and revised at least quarterly and as needed to reflect the resident's cognitive decision making abilities as well as their refusal of treatments, care and services by the Interdisciplinary Team and resident and/or resident representative; Procedures: The following procedures will be adhered to in maintaining the Resident's Rights regarding Advanced Directives: 1. It will be determined on admission whether the resident has an Advanced Directive and, if not, determine whether the resident wishes to formulate an Advanced Directive. This will be done by the Social Service Director and documented in the Social Service progress notes upon admission; -Resident's medical record will be identified with a red dot (no CPR) or a green dot (full code) on the binder of the medical record. The resident's room shall have a red or green dot, or other similar designation, beside their name on the outside of the door to their room to designate the resident's code status; -Staff will be trained upon hire and at least annually regarding the Code Status Identification and Resident Advanced Directives Policies. This will be completed by the Social Service Director or Director of Nursing ongoing. During an interview on [DATE] at 9:00 A.M., the Administrator said the following: -All licensed nurses should maintain current CPR certification; -She did not know the CPR certification status of the licensed nurses or the certified nurse aide (CNA) staff; -The nurses' work schedule should reflect a CPR certified licensed nurse on every shift 24 hours per day. Review of licensed nurses' employee files on [DATE], showed the following: -Licensed Practical Nurse's (LPN) O CPR certification expired ,[DATE]; -LPN P's CPR certification expired ,[DATE]. Review of the facility Licensed Nurse Staffing Schedule, dated (MONTH) 2019, showed the following: -Day shift staff worked eight hours from 6:30 A.M. to 3:00 P.M. or 12 hours from 7:00 A.M. to 7:00 P.M.; -Evening shift staff worked eight hours from 2:30 P.M. to 11:00 P.M.; -Night shift staff worked 12 hours from 7:00 P.M. to 7:00 A.M. Review of the facility Licensed Nurse Staffing Schedule, dated [DATE] through [DATE], showed the following: -On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 7:00 P.M. to 7:00 A.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 P.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. and LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 A.M.; -On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 11:00 P.M. to 7:00 A.M.; -On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 11:00 P.M. to 7:00 A.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 P.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 P.M.; -On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 11:00 P.M. to 7:00 A.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. and LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 A.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 P.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 P.M.; -On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 11:00 P.M. to 7:00 A.M.; - On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. and LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 A.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 P.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 P.M.; -On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 11:00 P.M. to 7:00 A.M.; -On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 11:00 P.M. to 7:00 A.M.; -On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 11:00 P.M. to 7:00 A.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. and LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 A.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 P.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 P.M.; -On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 11:00 P.M. to 7:00 A.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. and LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 A.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 P.M.; -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff were scheduled to work from 2:30 P.M. to 7:00 P.M. Review of the facility Licensed Nurse Staffing Schedule, dated (MONTH) 2019, showed the following: -Day shift staff worked eight hours from 6:30 A.M. to 3:00 P.M. or 12 hours from 7:00 A.M. to 7:00 P.M.; -Evening shift staff worked eight hours from 2:30 P.M. to 11:00 P.M.; -Night shift staff worked 12 hours from 7:00 P.M. to 7:00 A.M. Review of the facility Licensed Nurse Staffing Schedule, dated [DATE] through [DATE], showed the following: -On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff worked from 2:30 P.M. to 7:00 P.M.; -On [DATE], LPN O was scheduled to work evening shift from 2:30 P.M. to 11:00 P.M. and LPN P was scheduled to work from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled from 2:30 P.M. through 7:00 A.M.; -On [DATE], LPN O was scheduled to work evening shift from 2:30 P.M. to 11:00 P.M. and LPN P was scheduled to work from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled from 2:30 P.M. through 7:00 A.M. During an interview on [DATE] at 8:50 A.M., the DON said the following: -She was responsible for completing the nursing staff work schedule; -She did not know which staff were CPR certified; -She did not schedule CPR certified staff on every shift, 24 hours per day; -She did not ensure CPR certified staff were in the facility at all times; -She did not track staff CPR certification status. No one was currently responsible to ensure staff was CPR certified. 2. Review of the Social Service Designee (SSD)/Transporter's employee file on [DATE], showed his/her CPR certification expired ,[DATE]. Review of the SSD/Transporter's (MONTH) (YEAR) through (MONTH) 2019 schedule showed the following: -On [DATE], he/she transported Resident #26 (a full code resident) to a physician's appointment; -On [DATE], he/she transported Resident #33 (a full code resident) to a physician's appointment; -On [DATE], he/she transported Resident #153 (a full code resident) to a clinic appointment; -On [DATE], he/she transported Resident #25 (a full code resident) to the hospital clinic; -On [DATE], he/she transported Resident #30 (a full code resident) to a physician's appointment; -On [DATE], he/she transported Resident #153 and Resident #150 (a full code resident) to the hospital clinic; -On [DATE], he/she transported Resident #150 and #155 (a full code resident) to the hospital clinic; -On [DATE], he/she transported Resident #154 (a full code resident) and Resident #5 (a full code resident) to a physician's appointment; -On [DATE], he/she transported Resident #151 (a full code resident) to the hospital clinic. During interview on [DATE] at 8:30 A.M., the SSD said the following: -He/She provided transport of residents to physician visits and other appointments; -He/She transported residents in the facility van; -No other facility staff usually go with him/her on transports; -He/She was not CPR certified. His/Her CPR certification expired in (MONTH) (YEAR). During interview on [DATE] at 9:00 A.M., the Administrator said the facility transporter should maintain current CPR certification status. The SSD was the only facility transporter. He/She transported residents in the facility van to appointments. The administrator was responsible for ensuring transporter staff was CPR certified. 3. Review of Resident #28's Consent for DNR, dated [DATE], showed the following: -He/She wished CPR to be started in the event of [MEDICAL CONDITION]; -He/She understood that emergency medical system would be automatically activated and he/she would be transferred to the hospital; -The consent was signed by the resident in front of two witnesses; -The consent was not signed by a physician. Review of the resident's Physicians Order Sheet (POS), dated [DATE] to [DATE], showed there was no code status documented. Review of the resident's care plan, last revised on [DATE], showed the following: -On [DATE], the resident was admitted to Hospice; -There was no documentation to identify the resident's code status. Review of the resident's Hospice comprehensive assessment and plan of care update report, dated [DATE], showed documentation the resident wished to be a DNR on the advanced directive portion of the assessment. Review of the resident's Hospice comprehensive assessment and plan of care update report, dated [DATE], showed there was no documented code status on the assessment. Review of the resident's POS, dated [DATE] to [DATE], showed no code status documented. Review of the resident's POS, dated [DATE] to [DATE], showed no code status documented. 4. Review of the Resident #152's closed record showed the following: -Consent for DNR dated [DATE]; -He/She did not wish to have CPR efforts in the event of [MEDICAL CONDITION]; -The consent was signed by the resident's legal representative in front of two witnesses; -The consent was not signed by a physician. Review of the resident's POS, dated [DATE] to [DATE], showed no code status order documented. 5. Review of Resident #42's closed record showed the following: -Consent for DNR dated [DATE]; -He/She did not wish CPR efforts in the event of [MEDICAL CONDITION]; -The consent was signed by the resident's legal representative in front of two witnesses; -The consent was not signed by a physician. Review of the resident's POS, dated [DATE], showed the following: -Hospice level of care; -Code Status was left blank. No DNR physician's order documented. 5. Review of Resident #157's closed record showed the following: -Consent for Do Not Resuscitate (DNR) dated [DATE]; -He/She did not wish CPR efforts in the event of [MEDICAL CONDITION]; -The consent was signed by the resident's legal representative in front of two witnesses; -The consent was not signed by a physician. Review of the resident's POS, dated [DATE] through [DATE], showed the following: -Hospice level of care; -Full code status. 6. Review of Resident #1's consent for DNR, dated [DATE], showed the following: -He/She wished CPR to be started in the event of [MEDICAL CONDITION]; -He/She understood that emergency medical system would be automatically activated and he/she would be transferred to the hospital; -The consent was signed by the resident's legal representative in front of two witnesses. Review of the resident 's medical chart showed a green sticker on the binder indicating Full Code Status. Review of the resident's POS, dated [DATE] through [DATE], showed a physician's order for DNR. 7. During an interview on [DATE] at 4:10 P.M., LPN C said the following: -If a resident was in cardiac or respiratory arrest, he/she would check the resident's door or closet door for a red or green sticker to determine the resident's code status. If no red or green stickers were on the resident's room door or closet door, he/she would check the resident's face sheet; -He/she could also look at the resident's Consent for DNR form in the chart. The Consent for DNR form should match the physician's order for DNR. The Consent for DNR form was not a physician's order. -He/she did not know why the residents' code status did not match. During an interview on [DATE] at 4:16 P.M., the Assistant Director of Nursing (ADON) said the following: -Staff should go by the DNR consent form in the resident's chart to determine whether a resident was a full code or DNR; -There should be a physician's order if the resident's code status was DNR. During an interview on [DATE] at 4:20 P.M., the SSD said the following: -He/she obtained the resident's code status consent when the resident was admitted to the facility; -He/she reviewed the Consent for DNR form with the resident and/or the resident's family. The consent form was completed indicating the resident's wishes and signed by either the resident or the resident's legal representative and two witnesses. The completed Consent for DNR was placed in the resident's chart; -The Consent for DNR forms were not signed by the physicians. The form did not include the physician's signature; -He/she kept four binders containing all resident's Consent for DNR forms. The four binders were located at the nurses' desk, the dining room, the activity room and in the transport van. The four books were not currently up to date and did not currently reflect the resident's current code status; -He/she put red or green stickers on the resident's room door and on the binder of the resident's medical chart. The red sticker indicated DNR and the green sticker indicated Full Code; -The current POS should reflect the resident's code status. During an interview on [DATE] at 3:45 P.M., the DON said the following: -On admission the SSD or the charge nurse completed the Consent for DNR form with the resident and family. If the resident was unable to express their code status wishes, the family was consulted; -The consent for DNR form was placed in the chart and a red or green sticker should be placed on the outside binder edge of the chart. The red sticker indicated DNR and the green sticker indicated Full Code status; -There was no facility policy that required a physician's order for DNR status; -If a resident requested DNR status the resident's POS should contain a signed DNR physician's order; -If the resident's chart did not include a signed DNR physician's order, staff should perform CPR; -He/she did not know why the residents' code status did not match; -There was nobody responsible to ensure that code status matched. During an interview on [DATE] at 5:57 P.M., the DON said the following: -He/she expected all resident's Consent for DNR and Physician Orders to match indicating the resident's current code status. The resident's medical chart should include a corresponding red or green sticker on the binder; -The resident's POS should include either Full Code or DNR and should include the physician's signature; -If a resident requested DNR status, a physician's signed DNR order was required otherwise the staff should perform CPR in the event of cardiac or respiratory arrest. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility implemented a new policy regarding scheduling CPR certified staff on every shift 24 hours per day, seven days per week, began inservicing of staff to ensure CPR certified staff were on duty at all times, began review of staffing schedules, and an audit of staff to determine CPR certification status. The facility scheduled to ensure CPR certified staff were on duty on all shifts. 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 E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations(s).

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #12), of 13 sampled residents was free from physical abuse. The facility census was 47. Review of the facility policy Abuse Prohibition, dated 8/2017, showed the following: Purpose: To ensure residents are free from abuse, corporal punishment, and involuntary seclusion; Policy: -It is the policy of this facility that each resident has the right to be free from abuse, corporal punishment, exploitation, and involuntary seclusion; -Residents must not be subjected to abuse by anyone, including but not limited to staff, other residents, consultants, volunteers, staff of other agencies servicing the residents, family or legal guardians, friends, or other individuals; -ABUSE means the willful infliction of injury, unreasonable confinement, intimidation, punishment, or the taking or using photographs or recordings resulting in physical harm, pain, mental anguish, demean or humiliate the resident; -Physical abuse: includes hitting, slapping, pinching and kicking; -If resident to resident abuse occurs staff should separate the residents then report to the charge nurse. The charge nurse should then notify the Administrator and/or Director of Nursing (DON). 1. Review of Resident #12's care plan dated 5/21/18 showed the following: -Focus: Activities of Daily Living (ADL's) care performance deficit; -No behaviors. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility staff, dated 11/17/18, showed the following: -Cognitively intact; -Made self understood and understood others; -No mood or behavior indicators; -Supervision only with mobility in wheelchair on and off unit. Review of the resident's Physician Order Sheet (POS), dated (MONTH) 2019, showed the following: -[DIAGNOSES REDACTED]. -Up in wheelchair to transport self. Observation on 2/5/19 at 4:10 P.M., showed a half dollar sized, yellowish-green bruise on the resident's right, top forearm. During an interview on 2/5/19 at 4:10 P.M., the resident said the following: -He/she was returning from lunch one day and a resident, he/she did not know the resident's name, but could identify the resident, grabbed and pinched his/her arm; -The aggressive resident never said anything, but grabbed his/her arm and then slapped his/her face four times; -The aggressive resident sat at the first table when entering the dining room and wore a red jacket; -If he/she saw the resident headed down the hall, he/she would wait until the resident passed by to avoid him/her; -He/she denied a history of conflicts with any other residents; -The bruise on his/her right forearm was where this resident grabbed and pinched his/her arm. Observation and interview on 2/5/19 at 4:45 P.M., showed the resident pointed to Resident #24 as the resident who struck him/her and caused the bruising to his/her arm. During an interview on 2/13/19 at 11:50 A.M., the resident said Resident #24 tried to hit him/her many times before, but he/she had always been able to grab the resident's arm to stop him/her. The day Resident #24 grabbed his/her arm, he/she had just exited the dining room and Resident #24 was entering the dining room. 2. Review of Resident #24's Admission MDS, dated [DATE], showed the following: -Severe cognitive impairment;-Delusions; -Physical behavioral symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) one to three days; -Verbal behaviors directed towards others (e.g. threatening others, screaming at others, cursing at others) one to three days; -Behaviors put resident at significant risk for physical illness or injury, interfered with the resident's care and with the resident's participation in activities or social interactions; -Behaviors significantly disrupted care or living environment. Review of the resident's care plan, dated 6/6/18, showed the following: -Focus: Impaired cognitive function/dementia. Goal: Will develop skills to cope with cognitive decline and maintain safety, Interventions: None. -Focus: Behavior Problem. Goal: will have fewer/no episodes of behavior by next review date of 9/4/18, Interventions: None. -Focus: Potential for physical behaviors. Goal: Will not harm self or others through the review date of 9/4/18, Interventions: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document, Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. Review of the resident's nurses' note, dated 11/10/18 at 12:00 P.M., showed the resident in room xxx (staff did not document a room number, but rather xxx), claimed to have been slapped by this resident. This resident said he/she did not slap the resident in room xxx. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Verbal behaviors occurred daily; -Independent with locomotion on/off unit in wheelchair. Review of the resident's nurse's note, dated 1/26/19 and untimed, showed resident provoking another resident, hit him/her three times then laughed. Staff intervened and separated the residents. While pushing the resident he/she said, Won't do nothing about it. The resident then turned his/her head towards the resident he/she hit and laughed. Review of a faxed document from the facility to the resident's physician, dated 1/29/19 (three days after the incident on 1/26/19), showed the following handwritten note authored by Registered Nurse (RN) H: -On 11/10/18 the resident slapped another resident; -On 1/26/19 slapped another resident three times. During an interview on 2/8/19 at 8:45 A.M. and 2/13/19 at 2:30 P.M., Certified Nurse Aide (CNA) F said the following: -He/she was standing at the nurse's desk on 1/26/19 when he/she heard Resident #12 yelling and cursing; -As he/she arrived to the area just outside of the dining room, he/she took hold of Resident #24's wheelchair and began to push him/her back to his/her room; -Registered Nurse (RN) H arrived and began to assess Resident #12; -He/she was unsure if Resident #12 had any injuries; -RN H attempted to speak with Resident #24 when the resident struck him/her in the stomach. During an interview on 2/6/19 at 8:10 A.M., 2/8/19 at 9:15 A.M. and 2/13/19 at 10:15 A.M., RN H said the following: -He/she did not witness the altercation between Resident #12 and Resident #24. He/She was at the desk when he/she heard Resident #12 yell, You can't hit me like that! He/She responded to the hall between the dining room and the nurse's desk where CNA F had already arrived. Resident #12 said Resident #24 had smacked him/her on the back of the head three times. Staff separated the residents; -After the altercation with Resident #12 and Resident #24, he/she had attempted to speak with Resident #24 about the incident and the resident yelled at him/her and struck him/her in the arm with his/her hand. During an interview on 2/8/19 at 1:12 P.M. and 5:12 P.M., the Director of Nurses (DON) said the following: - The resident's behaviors would be considered abuse; -He/she was not aware of an allegation of a resident being slapped by Resident #24 prior to this incident. During interview on 2/13/19 at 3:15 P.M., the Administrator said the following: -He/she had only been at the facility since (MONTH) 2, 2019; -He/she believed Resident 24's behaviors toward Resident #12 constituted abuse. MO # 152

Based on observation, interview, and record review, the facility failed to comprehensively assess pain, intervene when the resident exhibited crying out, facial grimacing and tearfulness and failed to notify the physician of the pain and ineffectiveness of the current pain medication regimen for one resident (Resident #11) in a review of 12 sampled residents. The facility census was 28. 1. Review of the facility's undated pain policy, showed the following: -Purpose: to provide prompt and ongoing assessments of the acute and chronic pain needs of each resident. These assessments will assist in the development of an effective program of [MEDICATION NAME] and/or other treatment modalities to address those needs. We believe that a resident should maintain their highest level of potential using the least amount of medication; -Equipment: pain assessment on computer; -Procedure: nursing will complete the pain assessment form upon admission/readmission. These forms will be reassessed at each MDS assessment, worsening of pain condition and in a timely manner by the interdisciplinary team. A pain management plan of care will be developed a and followed for appropriate residents based on this assessment process. The effectiveness of interventions will be evaluated utilizing a numerical pain scale and/or monitoring nonverbal behaviors. Any as needed (PRN) doses of pain medication administered will be logged on the resident's electronic Medication Administration Record [REDACTED]. 2. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/3/18 showed the following: -[DIAGNOSES REDACTED]. -Unclear speech; -Short and long term memory problem; -Cognition severely impaired for daily decision making; -Sometimes makes self-understood; -Usually understands others; -Dependent on one staff for bed mobility, dressing, eating, toileting, bathing, and personal hygiene; -Dependent on two or more staff for transfers; -Functional limitation in range of motion upper and lower extremities on both sides; -Always incontinent of urine and stool; -Received scheduled pain medication within the past five days; -Did not receive any PRN pain medications; -A verbal pain assessment was to be completed; -The resident did not have pain at the time of the assessment; -Non-medication interventions: Left blank; -Pain indicators (expression and body): Left blank; -Pain frequency: Left blank; -Pain intensity: Left blank. Review of the resident's care plan last revised 1/11/18 showed the following: -Focus: The resident was at risk of not having daily physical needs met related to inability to communicate (unclear speech) due to stroke side effects. Intervention: Staff to monitor for nonverbal and verbal signs of pain or discomfort and report/address if occur; -Focus: (Pain) Potential for alteration in comfort related to presence of pain, likely caused by dysarthria (a motor speech disorder affecting muscles in the mouth, face, and respiratory system)and joint/muscle stiffness/contractures, as evidenced by history either verbalization or non verbal signs of pain. Intervention: Administer routine pain medication and monitor for absence of signs as evidence pain is being effectively controlled. Handle the resident carefully and with mechanical lift with two staff to minimize physical discomfort associated with transfers. If the resident begins to display or verbalize presence of pain, consult with the physician and review and possible amending of orders. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. Speech is characteristically slurred, slow and difficult to understand) and stroke; -[MEDICATION NAME] (used for pain and fever) 325 milligrams (mg) give two tablets orally every six hours as needed elevated temperature and pain. Do not exceed 4,000 mg of [MEDICATION NAME] in 24 hours; -[MEDICATION NAME]/[MEDICATION NAME] (narcotic medication used to treat moderate to severe pain) 10/325 mg give one tablet by mouth three times a day (8:00 A.M., 2:00 P.M., and 8:00 P.M.); -No order for pain assessment. Review of the resident's pain assessment for (MONTH) (YEAR) showed staff documented the resident's pain level was zero or no pain for all shifts 3/1/18 to 3/6/18. Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's MAR indicated [REDACTED].M. on 3/5/18. Observation on 3/6/18 at 5:40 A.M. in the resident's room showed the following: -The resident lay in bed on his/her back with his/her eyes open, the resident's right wrist was bent down and his/her hand in a fist with a wash cloth in the fist. The resident's left hand was in a fist with a wash cloth in his/her fist; -Certified Nurse Assistant (CNA) K entered the resident's room and pulled the resident's covers back; -The resident was visibility soiled with urine; -CNA K grasped hold of the resident's right forearm and lifted the resident's arm, the resident yelled out and exhibited facial grimacing, CNA K removed the resident's gown from the resident's right arm; -CNA K lifted the resident's left arm, the resident yelled out and made facial grimacing, CNA K removed the resident's gown from the resident's left arm and body; -CNA L entered the resident's room; -The resident lay on his/her back in bed with his/her right knee bent and legs together; -CNA L tried to pull the resident's left leg from the resident's right leg to allow CNA K to clean the resident, the resident yelled out, Oh, oh, oh! and made facial grimacing when CNA L tried to pull the resident's legs apart; -CNA K cleaned the front of the resident's perineal area; -The resident's perineal area was bright red with small red open areas; -The resident yelled out, Oh, oh! and exhibited facial grimacing when CNA K wiped the resident's perineal area; -CNA K and CNA L rolled the resident over on his/her left side pushing the resident on his/her right side and back, the resident yelled out and made facial grimacing when CNA K and CNA L rolled the resident; -CNA K cleansed the resident's buttocks, rectum and legs; -CNA K and CNA L rolled the resident back onto his/her back; -CNA L removed the rolled wash cloth from the resident's right hand by sliding the wash cloth from the resident's fist, then put a clean rolled cloth in the resident's right hand. The resident cried out, exhibited facial grimacing and a tear fell from the resident's right eye when CNA L touched the resident's hand; -CNA K and CNA L put a clean gown on the resident and covered the resident. Review of the resident's nurse's note on 3/6/18 showed no documentation staff noted the resident's pain or assessed the resident' pain. During an interview on 3/6/18 at 5:56 A.M. CNA K said the following: -The resident always yelled out in pain every morning; -The resident had a lot of pain in his/her arms; -The resident was hard to understand and understood some staff questions; -The resident was dependent on staff for all cares; -The resident was incontinent of urine and feces; -The resident yelled out and had facial grimacing. During an interview on 3/6/18 at 6:00 A.M. CNA L said the following: -The resident hurt when he/she was moved; -The resident had a tear coming out of his/her eye and appeared to be in pain; -The resident understood some staff directions; -The resident was dependent on staff for all ADLs. During an interview on 3/6/18 at 6:14 A.M., Licensed Practical Nurse (LPN) M said the following: -The resident was in pain; -Staff were to check the resident for incontinency and turn the resident every two hours; -The resident was so contracted he/she yelled out with every little movement while staff assisted him/her; -The resident was on scheduled [MEDICATION NAME] and received his/her last dose at 8:00 P.M. on 3/5/18; -The pain medication the resident took at 8:00 P.M. was probably already out of his/her system as it normally only lasted for four to six hours; -The resident was totally dependent on staff for all cares; -The resident had PRN [MEDICATION NAME] for pain if needed but he/she never administered the resident any pain medication prior to cares or during the night when the resident cried out with cares; -The resident normally slept all night and did not yell out in pain during the night, only when the staff turned or repositioned him/her; -The resident was not easy to assess for pain; -The resident was not able to verbally make his/her needs known; -He/she would normally call a physician if the resident was having pain and didn't have anything else for pain; -He/she did not give the resident [MEDICATION NAME] or call the physician regarding the resident's pain because the resident only yelled out when being moved or touched. During an interview on 3/7/18 at 3:17 P.M. the Director of Nursing (DON) said the following: -She would expect staff to do a pain assessment on the resident shiftly; -She would expect staff to document the resident's pain and pain level on the pain assessment; -She thought the staff were assessing the resident's pain at zero at first of shift but she would expect them to go back and change if the resident had pain; -She would expect staff to first try PRN [MEDICATION NAME] prior to cares if the resident was yelling out in pain; -If the [MEDICATION NAME] did not help then she would expect staff to contact the physician and try and get an order for [REDACTED].>-She would expect staff to watch for facial grimacing and yelling out with cares as indicators of pain.

Based on observation, interview, and record review, the facility staff failed to reposition one resident (Resident #6) in a review of nine sampled residents who had a history of [REDACTED]. Pressure ulcers usually occur over a bony prominence), and whose comprehensive assessment identified him/her as being at risk for developing pressure ulcers and requiring extensive assistance of two staff members for bed mobility and transfer. The resident developed five Stage II pressure ulcers. The facility census was 35 . 1. Review of the Nurse Assistant in Long Term Care Manual, 2001 Revision, Lesson Plan 11, Preventing and Caring for Pressure Ulcers, showed the following: -Elderly residents and residents who are incontinent are prone to forming pressure ulcers, due to sluggish circulation, poor hydration, poor nutrition, lack of exercise/mobility, and constant wetness irritates the skin; -A pressure ulcer is an inflammation , sore, or lesion that develops over areas where the skin and tissue underneath are injured due to a lack of blood flow and oxygen supply to an area of the body; -This lack of circulation usually happens because of continuous pressure on the skin over a bony prominence resulting from the way or length of time a resident is positioned; -Pressure is the main cause. Other things such as moisture, stool, and urine can hasten the development of sores; -Change the resident's position at least every two hours. Encourage resident sitting in a wheel to raise themselves every 10 to 15 minutes; -Turning should be scheduled for residents who are helpless; -A pressure ulcer can be as stressful to the human body as major surgery; it is worth every effort to prevent one; for every minute it takes to cause a pressure ulcer, it takes weeks to heal. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of [REDACTED]. -Repositioning should be considered in all at-risk individuals, repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body; -In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure he/she is exposed to; -When an individual is seated in a chair, the weight of the body causes the greatest exposure to pressure to occur over the ischial tuberosities. As the loaded area in such cases is relatively small, the pressure will be high, therefore, without pressure relief, a pressure ulcer will occur very quickly. 2. Review of the undated facility policy, Decubitus Ulcer Care and Prevention, provided by the Administrator, showed the following: -Turn the resident and position with pads or pillows to protect bony prominences; -Whenever possible, teach the resident to change his position at regular intervals and shift his weight in the wheelchair. 3. Review of Resident #6's Significant Change in Status (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/6/13,showed the following staff assessment -Brief Interview for Mental Status (BIMS) score was 9, indicating moderate cognitive impairment; -Required extensive assistance of two or more staff members for bed mobility, transfer, dressing, toilet use, and bathing; -Required extensive assistance of one staff member for personal hygiene; -Frequently incontinent of bladder and occasionally incontinent of bowel; -Five Stage II pressure ulcers. (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.); -At risk for pressure ulcers; -Skin and ulcer treatments included, pressure reducing device for chair and bed, turning/repositioning program, nutrition or hydration intervention and ulcer care. Review of the resident's CAAS (Care Area Assessment) (provides a framework for guiding the review of triggered areas and a basis for additional assessment of potential issues including related risk factors identified in the MDS), dated [DATE] showed the resident triggered for pressure ulcers. Staff documented he/she had impaired skin integrity and risk for further breakdown related to impaired mobility and self care deficit. The resident had a history of [REDACTED]. Review of the resident's Weekly Wound/Skin Healing Record, dated 12/12/13 showed the following: -The resident had a Stage II pressure ulcer on his/her coccyx which measured 1.4 (no units of measure indicated) by 0.5 with a depth of less than 0.2; -Staff documented the pressure ulcer was healed on 1/25/14. Review of the resident's Braden scale (Scale to assess pressure ulcer risk), dated 12/13/13 showed a score of 11, indicating the resident was at high risk for developing pressure ulcers. Review of the facility Wound/Skin Healing Record, dated 12/23/13, showed the following: -The resident was readmitted from the hospital with a Stage II pressure on his/her right buttocks (#1); -The pressure ulcer measured 13 centimeters (cm) by 4 cm with a depth of less than 0.2 cm; -Staff documented the pressure ulcer was healed on 1/19/14. Review of the facility Wound/Skin Healing Record, dated 12/23/13, showed the following: -Stage II pressure ulcer on his/her right buttocks (#2); -The pressure ulcer measured 1.3 (no units indicated) by 1.3, with a depth of 0.2; -Staff documented the pressure ulcer was healed on 1/19/14. Review of the Wound/Skin Healing Record, dated 12/23/13, showed the following: -Stage II pressure on his/her left buttocks (#4); -The pressure ulcer measured 5 cm by 1.8 cm, with a depth on less than 0.2 cm -Staff documented the pressure ulcer was healed on 1/19/14. Review of the resident's care plan, dated 6/16/12, and review on 12/26/13, showed the following: -Potential alteration in skin integrity, at risk for pressure ulcers secondary to decreased mobility, occasional urinary incontinence, and self-care deficit. Resident requires staff assist of one with toileting and transfer; (MDS showed extensive assist of two) -History of pressure ulcers; -12/26/13 Multiple Stage II and III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) ulcers with infection, see specific plan of care; -Antipressure devices to bed and chair at all times; -Monitor skin during routine care and showers for signs of potential skin breakdown; -Assist with repositioning at least every two hours; -Weekly skin assessment by licensed staff, report any breakdown to physician for follow up care; -Toilet before and after meals, at bedtime and as needed, give pericare after each episode of incontinence; -Offer bedpan or toilet during the night at least every 2-3 hours if awake, check frequently for incontinence. Review of the resident's 30 day MDS, dated [DATE], showed the following staff assessment: -Long and short term memory problems; -Cognitive skills for daily decision making, severely impaired; -Required extensive assistance of two plus staff members for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Totally dependent on two staff members for bathing; -Did not walk in the room or in the corridor; -Indwelling catheter (a sterile tube inserted through the urethra into the bladder to drain urine); -Always incontinent of bowel; -Three unstageable pressure ulcers (known but not stageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). -At risk for pressure ulcers; -MASD (Moisture associated skin damage); -Skin and ulcer treatments included, pressure reducing device for chair and bed, turning/repositioning program, nutrition or hydration interventions, and ulcer care. Review of the resident's weekly skin assessment showed the following: -1/21/14 Treatment continues to buttocks, coccyx, inner thighs, outer thigh, right lateral foot, left lower leg, left heel and left lateral foot; -1/28/14, Treatment continues to left heel, left foot, and left lower extremity. All other areas healed. During the initial tour of the facility on 2/3/14 at 10:20 A.M., Licensed Practical Nurse (LPN) H identified venous stasis ulcers on the resident's left lower leg and no pressure ulcers. Observation on 2/3/14 at 2:54 P.M. showed the following: -Staff positioned the resident in the bed on his/he left side with a wedge placed behind his/her back: -Continued observation from 2:54 P.M. to 4:33 P.M. showed the resident remained on his/her left side: -At 5:36 P.M. the resident remained on his/her left side: -At 6:02 P.M. staff transferred the resident from the bed to the chair with the Hoyer lift (mechanical patient lift); -The staff did not reposition the resident for a period of approximately three hours. Observation on 2/4/14 showed the following: -At 5:50 A.M. the resident was seated in the wheelchair in his/her room; -At 6:10 A.M., staff wheeled the resident into the hallway by the nurse's station; -The resident remained seated in the wheelchair in the hallway from 6:10 A.M. until 8:00 A.M.; -At 8:00 A.M. staff wheeled the resident to the facility dining room and he/she remained in the dining room until 9:00 A.M.; -At 9:00 A.M. staff pushed the resident to his/her room; -At 9:20 A.M. the resident remained seated in the wheelchair in his/her room; -At 9:35 A.M. staff transferred the resident from the wheelchair to the bed; -Staff did not reposition the resident for a period of three hours and 45 minutes. During interview on 2/5/14, at 10:55 A.M., Licensed Practical Nurse (LPN) G said the Certified Nurse Assistants (CNA) reported the resident had open areas on his/her buttocks. Observation on 2/5/14 at 11:00 A.M. showed the following: -LPN G assessed the resident's skin; -He/she identified five Stage II pressure ulcers; -A: Right buttocks, measuring 0.9 centimeters (cm) X 1.6 cm X less than 0.2 cm depth; -B: Right buttocks measuring 1 cm X 2 cm X less than 0.2 cm depth; -C: Coccyx/sacrum measuring 0.9 cm X 1.3 cm X less that 0.2 cm depth; -D: Right buttocks measuring 0.6 cm X 0.4 cm X less that 0.2 cm depth; -E: Right buttocks 0.4 cm X 0.4 cm X less that 0.2 cm depth; Review of the facility's fax to the physician dated 2/5/14, showed staff documented the resident had five new Stage II open areas, right buttocks with four and coccyx/sacrum with one. Review of the nurse's notes dated 2/5/14 at 10:35 A.M. showed staff documented they noted five Stage II ulcers on the resident's right buttocks and coccyx. The physician was notified. During interview on 2/5/14 at 12:25 P.M., CNA F said staff get the resident up for meals and then put him/her back to bed. He/she also said the resident is not able to reposition him/herself in bed. During interview on 2/5/14 at 11:15 A.M., LPN G (charge/wound nurse) said he/she expected staff to reposition the resident at least every two hours when in bed and every hour when up in the wheelchair. During interview on 2/5/14 at 1:45 P.M., the Director of Nursing (DON) said she expected staff to reposition the resident every two hours whether in the bed or in the wheelchair.

Based on observation, interview and record review, the facility failed to provide necessary services for one resident (Resident #1) of 10 sampled residents to maintain or improve their highest practicable physical and mental well-being, by failure of staff to routinely assess and provide interventions for pain, and by failure of staff to routinely assess changes in resident's condition. The facility census was 39. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 05/12/10, showed the following: -He/she had short-term and long-term memory problems; -Resisted care; -He/she had pain less than daily and the intensity was mild; -[DIAGNOSES REDACTED]. Review of Resident #1's resident assessment protocol (RAP) documentation record dated 05/12/10 showed the following: Behavioral symptoms: -[DIAGNOSES REDACTED]. -Refused to take his/her scheduled showers; -Has an altered sleep pattern related to [MEDICAL CONDITION]; -Received routine [MEDICATION NAME]-N-100 (an opioid [MEDICATION NAME] combined with 650 mg of [MEDICATION NAME] (Tylenol) and 100 mg of [MEDICATION NAME]) and [MEDICATION NAME] (an [MEDICATION NAME]) 325 milligrams (mg) two tablets every A.M. for relief of his/her chronic pain. Staff documented they would proceed with care plan; Cognitive loss/dementia: -The resident complained of mild pain less than daily and had pain medication for relief. Staff documented they would proceed with care plan. Review of Resident #1's MDS dated [DATE], showed the following: Repetition of three words: -He/she was able to recall the three word repetition of "sock", "blue" and "bed" with no cueing required; Temporal orientation: -He/she was able to report the correct year; -Was able to report the correct month within five days; -Was able to report the correct day of the week; Recall: -He/she was able to recall the three word repetition of "sock", " blue" and "bed" with no cueing required; Pain management: -Had been on a scheduled pain medication regimen; -Had received PRN (as needed) pain medications; -Had not received non-medication intervention; (Even though the resident's was alert and oriented, staff failed to conduct the pain assessment interview section of the MDS with the resident when staff scored the resident a 15. A score of 13-15 means the resident was cognitively intact. Review of Resident #1's care plan dated 11/12/08 and reviewed 05/12/10, showed staff did not include a plan for the resident's pain management. Review of Resident #1's physician's orders [REDACTED]. He/she had orders for Tylenol 325 mg two tablets by mouth every 6:00 A.M. and 12:00 A.M. for pain and [MEDICATION NAME]-N-100 at HS (bedtime) 8:00 P.M. daily. There were PRN orders for Tylenol 325 mg two tablets every four hours for pain/temperature and [MEDICATION NAME]-N 100 one tablet every four hours for pain and not to exceed 4 grams in 24 hours. Review of the resident's daily pain assessment sheets for 10/01-10/31/10, showed the staff recorded the resident had no pain on the 11:00 P.M. to 7:00 A.M. shift, no pain on the 7:00 A.M. to 3:00 P.M. shift and no pain on the 3:00 P.M. to 11:00 P.M. shift. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. and 12:00 A.M.(midnight) and the [MEDICATION NAME]-N-100 at 8:00 P.M. daily. Review of the MAR indicated [REDACTED]. Review of the resident's physician's orders [REDACTED]. Review of the resident's daily pain assessment sheets for 11/01 -11/30/10, showed staff recorded the resident had no pain on the 11:00 P.M. to 7:00 A.M. shift, no pain on the 7:00 A.M. to 3:00 P.M. shift and no pain on the 3:00 P.M. to 11:00 P.M. shifts. Review of the resident's physician's orders [REDACTED].M. and no replacement pain medication was ordered). Review of the resident's MAR for 11/01-11/30/10, showed the following: -On 11/24/10 at 7:30 P.M., staff administered the PRN Tylenol 325 mg by mouth to the resident due to generalized pain; -On 11/25/10 at 9:20 P.M., staff administered the PRN Tylenol 325 mg two tablets to the resident due to generalized pain, resting and no complaints at 10:20 P.M.; -On 11/27/10 at 8:00 P.M., staff administered the PRN Tylenol to 325 mg two tablets to the resident due to general discomfort, at 9:00 P.M., resting; -On 11/28/10 at 8:00 P.M., staff administered the PRN Tylenol to 325 mg two tablets to the resident due to general discomfort, at 9:00 P.M., resting. Review of the resident's weekly summary sheet showed the following: -On 11/29/10, the frequency of pain was rarely; -Indicators of pain, the resident had vocal complaints of pain with the numeric 0 = no pain and the number 10 = the worst pain. Staff recorded the resident's pain was five (five is considered moderate pain). Review of the resident's weekly summary sheets for December, 2010, showed the following: -On 12/05/10, the frequency of pain was rarely and the resident had vocal complaints of pain; -On 12/13/10, the frequency of pain was rarely and the resident had vocal complaints of pain; -On 12/19/10, the frequency of pain was rarely and the resident had vocal complaints of pain; -On 12/16/10, the resident was independent with bed mobility, transfers, dressing, eating, toileting. It was noted under health conditions it listed pain, with the frequency almost constantly mild to moderate. Indicators of pain staff had checked vocal complaints of pain. Review of the resident's daily pain assessment sheet for 12/01-12/31/10, showed the following: -On the 11:00 P.M. to 7:00 A.M. shift staff recorded the resident's daily pain scale was zero; -On the 7:00 A.M. to 3:00 P.M. shift staff recorded the resident's daily pain scale was zero; -On the 3:00 P.M. to 11:00 P.M. shift staff recorded the resident's pain scale was zero except for on 12/11/10, staff wrote general aching, and on 12/19/10 at 8:45 P.M., the resident scored his/her pain on a scale of 1-10 a score of 6 (six) with PRN Tylenol given. During interview on 01/05/11 at 11:05 A.M., Resident #1 said when he/she coughed or bends over his/her side and back hurt and he/she hurt all around his/her stomach. The resident said he/she asked but only gets Tylenol and it's "no good", he/she "needs something stronger". The resident said he/she has told staff the Tylenol doesn't do any good. The resident turned his/her call light on to ask staff for something for pain. He/she rated his/her pain on a scale of 1-10 and said it was a 10. Review of the resident's daily pain assessment sheet for 01/01-01/07/11, showed the following: -On the 11:00 P.M. to 7:00 A.M. shift staff recorded on 01/07/10, the resident's pain scale was a six out of 10; -On the 7:00 A.M. to 3:00 P.M. shift staff recorded the resident had a zero pain scale from 01/01 thru 01/05/10. On 01/06/10, staff recorded the resident's pain scale was five out of 10; -On the 3:00 P.M. to 11:00 P.M. shift staff recorded the resident had a zero pain scale from 01/01 thru 01/04/10. On 01/05/10, staff recorded the resident had a pain scale of 10. Review of the resident's MAR for 01/01-01/07/10, showed the following: -On 01/05/11 at 6:50 P.M., staff administered the resident his/her PRN Tylenol due to generalized pain; -On 01/06/11 at 11:00 A.M., staff administered the resident his/her PRN Tylenol due to complaints of general pain. Staff recorded a pain scale of six out of 10. During interview on 01/05/10 at 5:30 P.M., the resident said his/her back was hurting and does every time he/she bends over or coughs. The resident said he/she needed something stronger than Tylenol. The resident rated his/her pain scale on a 1-10 scale a 10 and said his/her pain was as bad as it can get and staff won't give him/her nothing but Tylenol. He/she said it hurt to bend over or move in bed. He/she said the pain just started this week. The resident denied any falls. The resident said he/she doesn ' t ask for any pain medication or turn the call light on. The resident said it would feel good if he/she could get 2-3 Tylenol before supper. The resident turned his/her call light on at 5:40 P.M., and staff answered the call light at 5:44 P.M. Staff asked the resident and the resident told staff that he/she hurt when he/she coughed or bends. He/she said it hurts all the way around his/her waist. Staff asked if general pain. The staff left to report the resident's pain to another staff. Observation on 01/05/11 at 5:55 P.M., showed the resident had not received his/her pain medication; -At 6:05 P.M., the resident walked out of his/her room with his/her roller walker to the dining room without getting any pain medication; -At 6:10 P.M., staff had not given the resident any pain medication at this time; -At 6:15 P.M., the resident remained in the dining room table and said he/she was still hurting; -At 6:20 P.M., the resident was served his/her food tray (no pain medication at this time); -At 6:35 P.M., the resident left the dining room and went back to his/her room (no pain medication given at this time); -At 6:40 P.M., the resident turned his/her call light on and Certified Nurse Aide (CNA) D went to the resident's room and the resident asked for his/her Tylenol. CNA D went to the nurses desk and told staff. CNA D returned to the resident's room and told the resident that staff would be there as soon as they could. Observation showed Licensed Practical Nurse (LPN) E and LPN F were sitting at the nurses desk preparing a transfer sheet for a resident; -At 6:45 P.M., staff had not given the resident any pain medication; -At 6:48 P.M., LPN E went into the clean utility room and came out with the medication cart and went down the 200 Hall and did not go to the resident's room first, but stopped and prepared another resident's medications and administered them; -At 6:50 P.M., LPN E went to the resident's room prepared the resident's PRN Tylenol 325 mg two tablets, and administered (over one hour after the resident reported to CNA D). Staff then asked the resident where he/she hurt and the resident said all over, and when he/she lies down or coughs. Staff asked the resident what his/her pain scale was on a scale of 1-10 and the resident said it was a 10. LPN E did not complete any physical assessment of the resident's condition at the time. During interview on 01/05/10 at 6:55 P.M., LPN E said the resident had asked about his/her pain medication about an hour ago. LPN E said he/she had another resident that was sick and he/she was preparing to transfer the resident. LPN E said he/she was in charge of the 100 and 200 Halls and he/she wasn't comfortable to ask the other charge nurse to get the resident's pain medication because he/she was busy charting. LPN E said it was important to give pain medication and he/she had to prioritize and get the other resident ready to transfer out. During interview on 01/06/10 at 8:05 A.M., Registered Nurse (RN) G said the resident does not complain a lot on days. He/she said in the last 24 hours the resident has complained of pain and in report the resident had complained of pain yesterday evening and this A.M. and this was something new. He/she said would call the physician and try to get something stronger, evidently the Tylenol was not taking care of the pain. During interview on 01/06/10 at 8:45 A.M., the resident's physician said he/she was going to up the resident's Tylenol to QID (four times a day) and monitor to see if it helps before he/she ordered medication such as [MEDICATION NAME] or [MEDICATION NAME] (opioid [MEDICATION NAME]). During interview on 01/06/10 at 11:00 A.M., the resident said he/she hurt around his/her abdomen all away around to his/her back (the resident took both hands and moved them from his/her front abdomen area around both sides to his/her back). The resident said it stays this way lately last 1-2 weeks and won't go away. When the resident was asked to rate his/her pain scale from 1-10, he/she said it is as high as it will go and then said he/she can't move in bed, it's just pain. Review of the resident's physician orders [REDACTED].M., 12:00 P.M., 6:00 P.M. and 12:00 A.M. During interview on 01/07/10 at 5:50 A.M., LPN H said the resident had no pain during the night and had his/her Tylenol. He/she said the resident said his/her ribs were sore from coughing, but he/she never heard the resident coughing. Review of the Guidance for Long-Term Care Surveyors at F 309, dated 03/31/09, showed that the facility's evaluation of the resident at admission and during ongoing assessments helps identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment. It is important that a resident be monitored for the presence of pain and be evaluated when there is a change in condition or whenever new pain or an exacerbation of pain is suspected. Expressions of pain may be verbal or nonverbal. A resident may avoid the use of the term "pain". Other words used to report or describe pain may differ by culture, language and/or region of the country. Examples of descriptions may included heaviness or pressure, stabbing, throbbing, hurting, aching, gnawing, cramping, burning, numbness, tingling, shooting or radiating, spasms, soreness, tenderness, discomfort, pins and needles, feeling "rough", tearing or ripping. Nonverbal indicators which may represent pain need to be viewed with consideration given to pain as well as other clinically pertinent explanations. Examples of possible indicators of pain include, but are not limited to the following: -Negative verbalizations and vocalizations (e.g., groaning, crying/whimpering, or screaming); -Facial expression (e.g., grimacing, frowning, fright, or clenching of the jaw); -Changes in gait (e.g., limping), skin color, vital signs (e.g., increased heart rate, respirations and/or blood pressure, perspiration; -Behavior such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities; -Loss of function or inability to perform Activities of Daily Living (ADLs), rubbing a specific location of the body, or guarding a limb or other body parts; -Difficulty eating or loss of appetite; and -Difficulty sleeping ([MEDICAL CONDITION]). The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain, such as during a treatment. The regimen considers factors such as the causes, location, and severity of the pain, the potential benefits, risks and adverse consequences of medications; and the resident's desired level of relief and tolerance for adverse consequences.