Every finding on record at Country Villa Wellness & Rehabilitation

Based on interview and record review, the facility failed to ensure one resident (Resident #9), assessed to have swallowing problems per the speech therapist after choking on medication on the day shift, was provided supervision during the evening meal. The day staff failed to notify the evening staff the resident had been assessed with swallowing difficulties, and no interventions were put in place to protect the resident during the evening, while further tests were pending. The resident, who was not supervised by staff during dinner, choked on a cheeseburger, requiring staff to attempt to perform the Heimlich maneuver (emergency action to reverse choking), initiate cardiopulmonary resuscitation (CPR), call 911 and send the resident to the hospital. The resident was subsequently diagnosed with aspiration pneumonia at the hospital. The sample size was 18. The census was 89. The Administrator was notified on 08/26/26 at 4:00 P.M., of an immediate jeopardy (IJ) which began on 08/20/26. The IJ was removed on 08/26/26 as confirmed by surveyor on-site verification. Review of the facility's Activities of Daily Living (ADLs) policy, dated 01/26, showed:-Purpose: To promote dignity, independence and quality of life by providing individualized support with activities of daily living and ensuring compliance with federal, state and local regulations;-Policy-This policy establishes guidelines for assessing, planning, documenting and assisting residents with activities of daily living. The facility will ensure all residents receive the necessary services and support to maintain or improve their ability to perform ADLs, unless the residents clinical condition makes it nonviable; --Procedure: Definition: Activities of daily living include eating; --A comprehensive assessment of each resident's ability to perform ADLs will be completed upon admission and at regular intervals, including quarterly or upon significant change of condition; --Staff will provide assistance, cueing or supervision with ADLs as identified in the care plan; --ADL performance and staff assistance levels will be documented in the resident's medical record, including changes in the resident's ability or refusal to participate in the ADL task. Review of the facility's Restorative Dining Program, revised on 06/20, showed:-Purpose: To provide the opportunity for residents to attain their highest level in independence in feeding, improve appropriate mealtime behavior, self-image and socialization skills;-Policy: Based upon the admission assessment or upon recognition of a resident need, residents may be referred to and assessed by an occupational or speech therapist for possible assignment to the restorative dining program; --A resident may be included in the restorative dining program if the resident is unable to feed themselves due to physical limitations which include, but are not limited to: ---Decreased range of motion due to arthritis, head trauma, multiple fractures, bursitis (causes painful or stiff joints), shoulder dislocations or other neuromuscular skeletal problems, ---Poor hand-eye coordination due to tremor, limb apraxia (a neurological disorder that impairs a person's ability to perform skilled, purposeful movements), spasticity (a condition where muscles become stiff, tight and involuntarily contract because of damage to the central nervous system) and/or other neuromuscular skeletal problems;-Objectives: --Facilitate maximal potential in feeding: --Determine the least amount of assistance required; --Improve the resident's safety and awareness during mealtimes. Review of the facility's Eating and Swallowing policy, revised on 06/20, showed:-Purpose: To improve or maintain the resident's self-performance in feeding oneself food and fluids, or activities used to improve or maintain the resident's ability to ingest nutrition and hydration by mouth;-Policy: Eating activities are individualized to the resident's needs, planned, monitored, evaluated and documented in the resident's medical record;-Restorative Nursing Aide (RNA) training: --RNA will understand the sequence of food progression and its implications for safe swallowing; --RNA will have knowledge of aspiration and its warning signs; ---Body positioning is a critical component in addressing self-feeding and swallowing skills. Posture affects the resident's ability to use the upper extremities during self-feeding and plays a significant role in safe swallowing. To help the resident achieve the highest independent level possible during the eating process, the following positioning guidelines should be followed: ----The resident's hips should be positioned in the wheelchair as far back on the seat as possible; ----The resident's weight should be evenly distributed on the buttocks and thighs to prevent weight shift and leaning to one side; ----The resident's trunk, neck and head should be supported in midline; ----Food should be placed within a 12-inch reach; ----The table height should allow the wheelchair to be positioned so the resident can see the food and comfortably reach their plate. 1. Review of Resident #9's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/11/26 showed:-Moderately cognitively impaired;-No behaviors noted;-Rejection of care -The resident rejected evaluation or care necessary to achieve the resident's goals for health and well-being four to six days a week;-Functional limitation in range of motion: --Upper extremity-Impairment on one side; --Lower extremity-Impairment on both sides;-Self-care: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident: --Eating: No information: Supervision or touching assistance;-Nutritional: Malnutrition (a health condition that happens when a body does not get the right amount of vitamins, minerals and energy to stay healthy) or at risk for malnutrition: Yes;-Functional abilities: Eating - Requires staff supervision or touching assistance;-Diagnoses included epilepsy (a common chronic brain disorder defined by two or more recurring, unprovoked seizures caused by abnormal electrical activity in nerve cells), dysphagia (difficulty or discomfort when swallowing) and unspecified convulsions (a medical event where your body's muscles contract and relax rapidly, causing uncontrolled shaking). Review of the resident's care plan, dated 06/09/26, showed:-Focus: Resident has ADL self-care performance deficit related to epilepsy and contractures;-Interventions: Assist table. Substantial/Maximal assistance by staff. Review of the resident's undated Kardex (a quick reference summary system used by nursing staff to manage daily resident care and coordinate shift handoffs), in use at the time of the survey, showed:-Eating/meals: Eating-Assisted dining table. Substantial/Maximal assistance by staff. Review of the resident's progress notes on 08/20/26 at 3:00 P.M., showed the resident noted to be coughing and turning red in the face when administering medications this A.M. The nurse attempted to give the resident water to aid in swallowing, and he/she again began coughing with sips of water. The nurse notified speech to assess resident for difficulty swallowing. Speech did trials with resident and said a barium swallow (an imaging test of throat, esophagus and stomach to look for abnormalities) would follow. Review of the resident's speech therapy note, dated 08/20/26, showed:-Lingual (tongue) sensation/Function: Impaired;-Laryngeal/pharyngeal (throat) performance: Impaired;-Current referral: Resident is currently consuming a regular/thin diet, however nursing reports resident has been demonstrating severe coughing with thin liquids;-Resident required supervision prior to onset: Yes;-Resident needs assistance feeding self? Yes;-What modified liquid is recommended for the patient to swallow safely?= Thin liquid (No modifications) (pending instrumental swallow study) -What modified diet is recommended for the patient to swallow solids safely? = Regular (No modifications) (pending instrumental swallow study) Review of the progress notes dated 08/20/26 at 6:34 P.M., showed staff alerted the nurse the resident was choking in the dining room. When the nurse approached the resident, he/she was observed to be cyanotic (blue or purple) in color, fading in consciousness, with a weak and thready pulse. Staff called 911. The nurse and an aide moved the resident to the floor and performed chest thrust and mouth sweeps while other staff retrieved the crash cart. Chunks of food were visible and able to be removed. The crash cart arrived and suctioning performed, more food was removed from this resident's mouth. This resident began coughing, and staff then rolled him/her onto his/her side where he/she was able to cough up remaining food. 911 arrived. Resident transferred to the hospital. Review of the resident's hospital records, showed:-Arrival date and time: 08/20/26 at 6:45 P.M.;-Condition: Serious:-Resident presented to the emergency room with shortness of breath, choked on a cheeseburger which occurred at dinner that evening. Per the emergency medical services (EMS) personnel, the resident was eating a cheeseburger, and staff noticed he/she began to choke. Staff had to suction him/her. At that point, he/she was having difficulty breathing and EMS was called;-Resident was brought in on a nonbreather (an emergency face mask used to deliver high concentrations of oxygen to patients breathing on their own);-Pulmonary: Tachpneic (abnormally rapid and shallow breathing). Course breath sounds all lung fields;-Diagnoses included aspiration pneumonitis (lung injury caused by the chemical irritation of stomach acid entering the airway), sepsis (life-threatening medical emergency which happens when the body has an extreme, harmful response to an infection) secondary to aspiration event, wheezing active airway disease secondary to aspiration event;-Assessment: --Acute hypoxic respiratory failure (critical condition where the lungs cannot transfer enough oxygen into the bloodstream); --Dysphagia: Difficulty swallowing pills starting in last one to two days before aspiration event; --Aspiration pneumonia of both lungs due to regurgitated food; --Severe sepsis without septic shock;-History: Presents from facility after aspiration event. Reported having difficulty swallowing starting earlier this week with pills; -X-rays performed on 08/23/26, showed bilateral pneumonia. During an interview on 08/26/26 at 9:00 A.M., Licensed Practical Nurse (LPN) J said he/she updated the resident's care plan in June 2026. The resident had issues with eating because he/she had trouble using his/her upper extremities due to contractions (conditions where one or more fingers bend toward the palm of the hand) in his/her hands. The resident needed assistance setting up his/her food and it needed to be cut into smaller sections. LPN J was concerned the resident was not able not get enough food into his/her mouth. The resident did not necessarily need to be at the assist table but needed to be where staff could monitor his/her eating to ensure he/she was getting enough to eat. During an interview on 08/26/26 at 8:50 A.M., LPN F said he/she worked with the resident the morning of 08/20/26, but did not administer his/her medication. He/She heard the resident coughing when the other staff member administered the medication and went in to check on him/her. The resident continued to cough when given a drink of water. The nurse called the resident's physician and the speech therapy department to evaluate the resident. The speech therapist had not finished evaluating the resident when the LPN left for the day, so he/she told the oncoming nurse, LPN G, the resident had a choking incident and would need to be monitored until speech therapy cleared him/her. During an interview on 08/26/26 at 6:15 A.M., LPN G said he/she worked with the resident the evening of 08/20/26. The outgoing nurse told him/her the resident had a problem with choking during morning medication administration, and they had notified the physician and had speech therapy attempt to assess him/her. It was LPN G's understanding the resident refused to participate in the assessment and so there were no new orders to change anything. The resident did not have a problem with choking prior to this and refused assistance/supervision from staff with eating prior, so they did not provide added supervision that evening. If he/she had known the resident had problems noted with his/her speech evaluation earlier, he/she would have told staff to provide supervision during dinner. No one told him/her the resident had a problem with choking prior to this incident. During dinner on 08/20/26, a dietary staff member alerted him/her the resident was choking in the dining room. LPN G assisted the staff with getting the resident on the floor so they could start CPR. The resident had a lot of food in his/her mouth, and they had to use the suction machine to remove it. 911 arrived shortly after and was able to take over for the staff. Review of Resident #8's admission MDS, dated [DATE], showed:-Able to understand and make self-understood;-Cognitively intact. During an interview on 08/26/26 at 7:50 A.M., Resident #8 said he/she was seated at the table next to Resident #9 on 08/20/26 talking to him/her, when the resident suddenly stopped talking and started having trouble breathing. Resident #8 asked if Resident #9 if he/she was alright, and the resident shook his/her head no. Resident #8 then asked Resident #9 if he/she was choking, and he/she shook his/her head yes. Resident #8 said there were no staff near the table, and he/she had to yell across the room to get a staff member's attention. Review of Resident #7's annual MDS, dated [DATE], showed the following:-Able to understand and make self-understood;-Cognitively intact. During an interview on 08/25/26 at 5:15 A.M., Resident #7 said he/she was seated at the table next to Resident #9 on 08/20/26. The staff placed the resident at his/her table and walked away and left him/her there unsupervised. There was only one staff member in the dining room that evening and he/she was clear across the room. Resident #9 had a choking incident earlier in the day and staff should have been watching him/her. Resident #9 had problems eating and often choked on his/her food. Resident #7 reported these issues to staff several times, but nothing changed. During an interview on 08/26/26 at 6:15 A.M., Certified Nurse's Aide (CNA) H said he/she was working in the dining room on the evening of 08/20/26 when a resident yelled Resident #9 was choking. The CNA was standing on the other side of the dining room when he/she heard the resident yell. He/She ran to the resident and noticed him/her turning blue. The resident's mouth was full of food, and the CNA was not sure what to do. Another resident told him/her they had to get the food out of the resident's mouth. CNA H yelled for help, and LPN J came into the dining room and attempted the Heimlich maneuver, but was unsuccessful because the resident was seated in a soft backed wheelchair. The CNA yelled for a dietary staff to go to the resident's floor and get the nurse. They were able to get the resident on the floor and perform CPR and get his/her mouth cleared out. The CNA worked on the resident's floor that evening, but no one told him/her the resident had a choking issue earlier that morning, or he/she would have been supervising the resident at dinner. He/she knew staff were supposed to set the resident's meal up and cut up his/her food, but he/she did not do it that evening. CNA H thought maybe the cook might have cut his/her food up. The CNA believed the resident was in the assisted dining room off the 300 hall for awhile but got moved to the main dining room when they closed the assisted dining room for renovations. The resident did not want to sit at the assisted table in the main dining room, so staff let him/her sit where he/she wanted to sit. During an interview on 08/26/26 at 6:20 A.M., Certified Medication Technician (CMT) L said he/she was working on the hall when he/she heard staff yelling that a resident was choking. By the time he/she got to the dining room, the resident was on the floor and the staff were performing CPR. He/She ran back and called 911. He/She heard the resident had a problem with choking prior to this incident. During an interview on 08/26/26 at 10:10 A.M. speech therapist (ST) K said he/she assessed the resident on 08/20/26, and the resident did not refuse. The resident had delayed and immediate swallowing difficulties during the assessment, and they scheduled him/her for a barium test the next day. The ST said he/she told the nurse to monitor the resident for potential swallowing problems during the evening until they could get the test done the next day. Monitoring meant watching the resident and providing assistance when needed. Staff should have been present (within the area) to continuously watch the resident during the whole meal. During an interview on 08/26/26 at 1:00 P.M., the Director of Nursing said if the resident's care plan indicated he/she should be at the assist table and needed maximal assistance, he/she should have been there and staff should have been providing on-going supervision. If he/she was refusing to sit at the table, this should have been documented in the resident's medical record, and they still should have been supervising him/her while eating. Staff did not notify her when the resident choked on the morning of 08/20/26, so she did not know there was a problem with the resident. Staff also did not notify her the resident choked in the dining room until the next morning. She would have expected staff to notify her immediately both times so she could have ensured interventions were put in place after speech therapy assessed him/her. She would have expected staff to contact the physician after being assessed by the ST team if there were issues identified, to get instructions on what interventions to put in place until the barium test could be done. She would have expected staff to supervise and monitor the resident when eating that evening whether in his/her room or in the dining room. During an interview on 08/28/26 at 3:15 P.M., the Administrator said staff should have put interventions into place after speech therapy noted the resident had swallowing difficulties. The morning staff should have passed the information onto the evening staff, and they should have provided supervision to the residents when he/she was eating. Staff should have notified the resident's physician to let him know there were problems with the assessment and if he wanted to change his/her diet order. All of this should have been documented. During an interview on 08/26/26 at 5:45 P.M., the resident's physician said his office was notified when the resident choked the first time and after he/she was sent to the hospital. He was not notified speech therapy saw the resident and noted irregularities with his/her swallowing. Staff should have notified his office and/or put interventions into place until the resident could be cleared. The staff should have provided assistance and supervision to the resident during dinner that evening to prevent him/her from choking. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the D' level. This statement does not denote 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). 3097586

Based on interview and record review, the facility failed to maintain a system of full and complete accounting of funds and to ensure residents were refunded upon transfer to another facility for four residents (Residents #10, #11, #12, and #13). The sample size 18. The census was 79. Review of the facility's Resident Funds - Handling and Recording policy, revised August 2020 showed:-Objective of policy is to provide a means to protect resident funds managed by the facility. Provide for an individual and confidential accounting of funds received and disbursed on the resident's behalf;-Procedure: Residents may elect to have the facility act as a fiduciary of their funds and hold, safeguard, and manage his or her personal funds;-Depositing resident funds with the facility:--If the resident permits the facility to act as a fiduciary and hold, safeguard, and manage his or her personal funds, the facility will:---Residents whose care is funded by Medicaid: The facility will deposit the resident's personal funds in a demand trust account. The facility will maintain personal funds in an interest-bearing account;----All banking records related to these funds, including but not limited to deposit slips, checks, cancelled checks, statements and check registers, should be maintained in the facility for three years from the date of transaction;---Provide the resident with a confidential quarterly statement of funds on deposit with the facility, including activity since the previous statement;--The facility may maintain a petty cash fund to allow withdrawals under fifty dollars;--Upon discharge or eviction of the resident, all resident funds that are entrusted to the facility and kept within the facility are surrendered to the resident or authorized representative within state specific guidelines;--Upon change of ownership of the facility or cease of operation all funds and property held in a trust shall be transferred to the new operator in accordance with sound accounting principles, and a closeout report must be signed by both the outgoing operator, and the successor operator shall be prepared. The close-out report shall include all items required by state law. 1. Review of Resident #10's medical record, showed:-admission date 05/07/25; -discharged from the facility on 02/10/26. Review of the resident's Department of Social Services (DSS), Missouri Healthnet Vendor Notice, dated 12/30/25, showed monthly benefit of $2,678.54, start date 01/01/26. Review of the facility's agreement between the previous owner and the current owner's Chief Financial Officer (CFO), dated 01/31/26, showed the resident's trust fund ending balance of $394.27. Review of the resident's trust fund statements showed:-Quarterly statement, dated 07/01/25 through 09/30/25, showed available fund balance of $331.13;-Quarterly statement, dated 10/1/25 through 12/31/25, showed available fund balance of $392.27;-No quarterly statement for January 2026;-No quarterly statement for February 2026;-Quarterly statement, dated 03/23/26 through 03/31/26, showed available fund balance of $0.00. Review of the resident's financial statement landscape, closed 03/24/26 showed:-Open account, dated 03/23/26, total of $394.27;-Deduction of $394.27 for February 2026 care cost, dated 03/24/26;-Account closed, dated 03/24/26, balance of $0.00. Review of the resident's financial records, showed no resident trust withdrawal for $394.27. 2. Review of Resident #11's medical record, showed:-admission date 07/02/24;-discharged from the facility on 02/09/26. Review of the resident's DSS Missouri Healthnet Vendor Notice, dated 12/30/25, showed monthly benefit of $1,291.00, start date 01/01/26. Review of the facility's agreement between the previous owner and the current owner's CFO, dated 01/31/26, showed the resident's trust fund ending balance of $2,774.66. Review of the resident's trust fund statements showed:-Quarterly statement, dated 07/01/25 through 09/30/25, showed available fund balance of $2,954.86;-Quarterly statement, dated 10/01/25 through 12/31/25, showed available fund balance of $2,707.66;-No quarterly statement for January 2026;-No quarterly statement for February 2026;-Quarterly statement, dated 03/23/26 through 03/31/26, showed available fund balance of $0.00. Review of the resident's financial statement landscape, closed 05/15/26, showed:-Open account, dated 03/23/26, total of $2,774.66;-Deduction of $50.00 for cash advanced February 2026, dated 03/24/26;-Deduction of $1,291.00 for February 2026 care cost, dated 03/24/26;-Deduction of $1,433.66 for close account, dated 03/24/26;-Account closed, dated 03/24/26, zero balance;-Addition of $1,1310.00 for February 2026 SS check transferred from previous owner, dated 05/08/26;-Deduction of $1,291.00 for February 2026 care cost, dated 05/11/26;-Deduction of $19.00 to close account, dated 05/15/26;-Account balance as of 05/15/26, $0.00. Review of the facility's financial records, showed:-Check #1118, dated 06/17/26, showed SS funds received for multiple residents to be transferred to the new facility of each resident, including the resident's SS funds for March, April, and May 2026, in the amount of $1,342.00 for all three months. The amounts were not reflected on the resident's trust fund ledger;-Canceled checks associated with the resident's account as follows:--Check #1433, dated 03/24/26, in the amount of $1,433.66, paid to the resident and deposited by the resident's current facility;--Check #1029, dated 05/19/26, in the amount of $19.00, paid to the resident and deposited by the resident's current facility;--Check #1158, dated 07/21/26, in the amount of $1,291.00, paid to the resident and deposited by the resident's current facility. Check not recorded on resident trust fund account. 3. Review of Resident #12's medical record, showed:-admission date 01/01/19;-discharged from facility on 02/09/26. Review of the resident's DSS Missouri Healthnet Vendor Notice showed monthly benefit of $1125.00, start date 01/01/26. Review of the facility's agreement between the previous owner and current owner's CFO, dated 01/31/26, showed the resident's trust fund ending balance of $933.52. Review of the resident's trust fund statements, showed:-Quarterly statement, dated 07/01/25 through 09/30/25, showed available fund balance of $1,404.69;-Quarterly statement, dated 10/01/25 through 12/31/25, showed available fund balance of $1,089.07-No quarterly statement for January 2026;-No quarterly statement for February 2026;-Quarterly statements, dated 03/23/26 through 03/31/26 and 04/01/26 through 06/30/26, showed available fund balance of $0.00. Review of the resident's statement landscape, closed 07/22/26, showed:-Open account, dated 03/23/26, total of $933.52;-Deduction of $50.00 for cash advance for February 2026, dated 03/24/26;-Deduction of $50.00 for cash advance for February 2026, dated 03/24/26;-Deduction of $833.52 for February 2026 care cost, dated 03/24/26;-Account closed, dated 03/24/26, balance of $0.00;-Addition of $1,342.00 for February 2026 SS check transferred from previous owner, dated 05/08/26;-Deduction of $1,125.00 for February 2026 care cost, dated 05/11/26;-Deduction of $217.00 to close account, dated 05/15/26;-Addition of $1,345.00 for June 2026 SS check, dated 07/21/26;-Deduction of $1,345.00 to close account, dated 07/22/26;-Account balance as of 07/22/26, $0.00. Review of the facility's financial records, showed:-Check #1118, dated 06/17/26, showed SS funds received for multiple residents to be transferred to the new facility of each resident, including the resident's SS funds for March, April, and May 2026, in the amount of $1,345.00 for all three months. The amounts were not reflected on the resident's trust fund ledger;-Canceled checks associated with the resident's account as follows:-Check #1028, dated 05/19/26, for $217.00 made out to the resident and deposited by the resident's current facility;-Check #1157, dated 07/21/26, for $833.52 made out to the resident's responsible party and resident's current facility, deposited by the resident's current facility. Not recorded in resident trust fund records. 4. Review of the Resident #13's medical record, showed:-admission date 07/02/24;-Resident discharged from facility on 02/09/26. Review of the resident's DSS Missouri Healthnet Vendor Notice, dated 12/30/25, showed monthly benefit of $1,029.00, start date 01/01/26. Review of the facility's agreement between the previous owner and current owner's CFO, dated 01/31/26 showed the resident's trust fund ending balance of $568.48. Review of the resident's trust fund statements showed:-Quarterly statement, dated 07/01/25 through 09/30/25, showed available fund balance of $754.47;-Quarterly statement, dated 10/01/25 through 12/31/25, showed available fund balance of $543.48;-No quarterly statement for January 2026;-No quarterly statement for February 2026;-Quarterly statements, dated 03/23/26 through 03/31/26 and 04/01/26 through 06/30/26, showed available fund balance of $0.00. Review of the resident's statement landscape, closed 05/18/26 showed:-Open account, dated 03/23/26, total of $568.48;-Deduction of $50.00 for February 2026 cash advance, dated 03/24/26;-Deduction of $518.48 for February 2026 care cost, dated 03/24/26;-Account closed, dated 03/24/26, balance of $0.00;-Addition of $1,079.00 for February 2026 SS check transferred from previous owner, dated 05/08/26;-Deduction of $1,029.00 for February 2026 care cost, dated 05/11/26;-Deduction of $50.00 to close account, dated 05/18/26;-Account balance as of 05/18/26, $0.00. Review of the facility's financial records, showed:-Check #1118, dated 06/17/26, showed SS funds received for multiple residents to be transferred to the new facility of each resident, including the resident's SS funds for March, April, and May 2026, in the amount of $1,079.00 for all three months. The amounts were not reflected on the resident's trust fund ledger;-Canceled check #1033, associated with the resident's account, 05/29/26, for $50.00 made out to resident and deposited by facility resident transferred to;-No documentation of a resident authorized withdrawal of $518.48 on 03/23/26. 5. During an interview on 08/26/26 at 12:10 P.M., the Regional Business Office Consultant said the facility was purchased by new owners on 02/01/26. The new company received resident funds from the previous owners in March 2026. Several residents transferred to a different facility in February 2026. The new ownership did not have resident trust fund account ledgers for the months of January 2026 and February 2026. The facility was responsible for maintaining 12 months of resident trust fund account records in the facility at all times. The closing balances from the old ownership ending balance report, dated 01/31/26, were balances from the resident's personal trust fund and those funds should only be used for resident personal expenses. The facility must obtain and maintain a signed authorization from the resident to deduct funds from the trust account, including $50.00 monthly cash advances. The facility owed $394.27 to Resident #10, $1,291.00 to Resident #11, $833.52 to Resident #12, and $518.48 to Resident #13. These residents should not have been double-billed for February 2026 care cost. During an interview on 08/26/26, at around 3:30 P.M., the Regional Business Office Consultant some of the residents were reimbursed out of another account. Two checks were produced, neither of which were recorded on the resident trust fund accounts. During an interview on 08/28/26 at 3:24 P.M., the Administrator and Regional Nurse said they were not aware that several residents were not refunded for money owed to them. They expect resident funds to be refunded in accordance with state guidelines. 3065846305664230566993055426

Based on observation, interview, and record review, the facility failed to ensure medications were stored safely, physician orders and care plans were updated, and medication administration was documented appropriately, in accordance with facility policy, for one resident of five residents reviewed for self-administration of medication (Resident #1). The census was 85. Review of the facility's Ordering Self Administration of Medications policy, dated 12/15, showed:-Facility responsibility: Individual residents may self-administer medication if the following criteria are met: --Must have physician order to self-administer each particular medication; --Charge nurse must complete the self-administration of medication assessment form; --The interdisciplinary team must determine that it is safe for the resident to self-administer drugs before the resident may exercise that right; --The interdisciplinary team must also determine who will be responsible (resident or staff) for storage and documentation of the drugs, as well as the location of the drug administration (e.g. resident room, nurse's station); --Appropriate notation of these determinations will be placed in the resident's care plan; --Ability to self-administer medication is accessed every six months in skilled facilities and every year in assisted living facilities and upon change in resident's status. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/21/26, showed:-admitted on [DATE];-Cognitively intact;-No behaviors or refusal of care;-Diagnoses included chronic congestive heart failure. Review of the resident's care plan, dated 05/23/26, showed:-Focus: Self administration of medications. The resident has orders to self-administer medication;-Interventions/Tasks: Certified Medication Technician (CMT) or nurse will prepare medications for resident to self-administer;-No documentation of where the resident's medications would be stored, how staff would ensure it was administered, or who would be responsible for documenting the medication was administered. Review of the resident's June 2026 electronic physician order sheet (ePOS), reviewed on 06/02/26, showed:-Trelegy Ellipta inhalation aerosol powder (used to treat breathing disorders) 200-62.5-25 microgram (mcg), one puff orally one time a day;-Adempas (used to treat cardiovascular disease) oral tablet 2 milligrams (mg), give one tablet by mouth, three times a day;-Macitentan oral tablet (used to treat cardiovascular disease), 10 mg, give one tablet by mouth, three times a day;-An order, dated 04/21/26, for resident may go out on leave of absence with meds;-An order, dated 04/21/26, for resident may not go out on leave of absence with meds;-No order for acetaminophen (used to treat pain)-No order for eyedrops;-No order for resident to self-administer any medications. Review of the resident's progress notes, showed:-On 05/06/26 at 1:11 A.M., staff documented the resident upset about medication times. Feels that it is being given at the wrong time every day. Has been reported meds are being hoarded and not taken as they should. Resident feels that he/she should be able to take meds on his/her own;-On 05/24/26 at 11:29 A.M., staff documented when the nurse went in to give the resident medication, he/she asked the nurse what he/she was supposed to do with them. The nurse stated they were the resident's morning meds to be taken at that time, and the resident poured the medication in his/her hand. The resident said he/she already took his/her meds from his/her backup stash, and the nurse would have to call the police to get them from him/her. The resident said he/she called State to report he/she did not receive medication that day. The nurse told the resident those were the medications he/she just gave him/her. The nurse walked out of the room and the resident placed the medication in an unknown place. Nursing management was made aware of the incident. Review of the resident's self-administration evaluation completed by the Director of Nursing (DON), dated 05/27/26, showed:-Able to correctly document self-administration of medications including as needed (PRN) medication: Able;-Able to demonstrate secure storage for medication kept in room: Able;-Able to correctly state situations warranting administration of PRN medication: Able;-Able to correctly document the documentation of PRN medications: Able;-Additional comments: Resident states it is his/her right to safely self-administer medications for the following reason: No reason documented. Review of the resident's progress note, dated 05/27/26 at 7:45 AM., showed the resident stated he/she was ready to self-administer medications. Assessment completed. Resident capable of self-administration of medications. Review of physician's phone order, dated 06/02/26, showed it was okay to leave medications at bedside. The resident could self-administer medications independently. Observation on 06/02/26 at 12:00 P.M., the resident lay in bed with his/her bedside table next to him/her. There was an inhaler, one unopened box of brand-name acetaminophen 650 mg capsules, two unopened boxes of brand-name acetaminophen 500 mg capsules, and several individual packets of eyedrops on the table. During an interview, the resident said he/she wanted to decide when his/her own medication was administered because the staff were giving it to him/her outside the required timeframes. He/She was prescribed orphan drugs (pharmaceutical treatments developed specifically to treat rare medical conditions, known as orphan diseases), Adempas, and macitentan for treating his/her high blood pressure. The government paid for these prescriptions so they could not be billed to the facility. The resident sent them to another address, and someone brought them to the facility once they were received. The last time they were brought to the facility, the staff misplaced them, and he/she did not receive the medication for a few days. He/She was required to work with an agency paying for the medications and provided information about when he/she took it and how many pills were left in the bottles. The staff would refuse to tell him/her how many pills were left in the bottle and he/she felt like they were going to jeopardize the assistance paying for the medications. There were strict guidelines for when the medication had to be administered, and the staff would bring the medication outside those timeframes. He/She did not want to lose the assistance because the medication was very expensive, and they might stop prescribing it if these guidelines were not met. The staff gave him/her a hard time if he/she asked for acetaminophen. He/She did not like generic acetaminophen, and the facility would not provide the name brand, so he/she ordered it on-line. He/She sometimes needed his/her inhaler, and the staff would not get it for him/her immediately and this caused problems with his/her breathing. He/She did not tell the staff when he/she ordered medications because he/she did not want the medications coming up missing again. The staff had not offered him/her a safe place to lock up his/her medications so he/she just kept them where he/she could reach them in an emergency. He/She would be willing to lock them up if there was an area to do so. During an interview on 06/02/26 at 12:10 P.M., Licensed Practical Nurse (LPN) A said he/she stopped administering the resident's medication or going in his/her room because he/she did not feel comfortable with it because the resident hid his/her medication and the LPN A did not know if or when the resident was taking the medication. The resident often refused to take the medication when staff administered it and was known to hide it between his/her legs. The resident became threatening when he/she addressed about this behavior or if staff tried to remove the medications. The resident threatened to call the police and State on staff. LPN A had no idea what medications were in the resident's room because the resident ordered them and hid them. He/She knew the resident had an order to self-administer his/her medication, but the staff were supposed to store the medications and prepare them for him/her. It was his/her understanding that the resident's physician said it was okay for the resident to self-administer if the facility said there was a policy, and they were following their policy. LPN A did not know if the resident was documenting the medication administration or if the staff were just supposed to leave the medication with resident and take his/her word. LPN A was concerned the resident would take too much of his/her medication. The resident did not lock up the medication and had it out where other residents might be able to get hold of it. Staff were not told what to do with the medications in the resident's room or how they could be safely stored outside the nurse's stations and carts. During an interview on 06/02/26 at 12:25 P.M., CMT E said he/she did not know the resident had an order to self-medicate. He/She did not see an order when he/she administered the resident's medication earlier. He/She was new at the facility and did not know the resident well. No one told him/her the resident might hide the medication or refuse to accept it. He/She saw the resident's inhaler in his/her room, but the resident told CMT E that he/she was allowed to keep it in there. CMT E had not been given any instruction regarding leaving the resident's medication in his/her room or what to do with medications found in the room. During an interview on 06/02/26 at 12:45 P.M., the Assistant Director of Nursing (ADON) said she knew the resident had an order to self-administer his/her medication, but staff were not supposed to leave the medication bottles in the resident's room. The staff were supposed to prepare the medication. The resident refused to take the medication sometimes when it was brought to him/her, and staff would leave it for him/her to take when he/she was ready. The ADON expected nursing staff to go back later and check with the resident to ensure he/she took the medication and documented they were administered. The staff had to trust the resident to take the medication as ordered. The resident ordered over-the-counter medications online. The ADON removed several bottles of acetaminophen from the resident's room. The resident just went online and ordered more. Staff did not know what medications the resident had in his/her room because the resident would not let them know what he/she ordered. They only had one delivery of the orphan drugs, and they had been delivered to the facility. The ADON did not know anything about a friend delivering the medication or that it had been misplaced for several days. The resident had been assessed to self-administer the medication, but there were questions about whether he/she was responsible enough to do this. During interviews on 06/02/26 at 1:00 P.M. and on 06/03/26 at 10:00 A.M., the DON said he could not give good answers about the resident's self-administration. The resident continually gave staff a hard time about his/her medications and yelled them if they did not do as he/she demanded. The resident did not like certain staff and refused to take medication from them. He/She wanted the medication prepared in front of him/her and sometimes refused it, even if he/she saw it poured from the bottles. The staff would hand him/her medication and he/she refused to take it, and then refused to give it back to the staff to be administered later. He/She yelled at staff and threatened to call the police or the State on them, stating it was his/her right to take the medication when he/she wanted it. The resident continually called the DON at all hours of the day and night to complain about staff and demand his/her medication immediately. He/She hid the medication in his/her room or on his/her person and refused to return it to the staff. The resident ordered over-the-counter medication online and did not tell staff it was delivered and refused to give the medication to nursing staff for storage. The staff have removed medication from the resident's room several times, but he/she kept getting more. The DON assessed the resident for the capability of being able to administer his/her own medications because he/she kept demanding it. The resident was cognitively able to answer the questions, but the DON had concerns about the resident's ability to be responsible for the medication. Staff were supposed to keep the medications stored at the nurse's station, prepare them for administration, and leave the medication with the resident to self-administer when he/she was ready to take it. Staff did not go back and check with the resident to see if he/she took the medication. They documented it as administered as soon as it was given to the resident. Staff took the resident's word it was being taken as ordered. Since the medication was supposed to be stored at the nurse's station, he did not think the resident needed to be provided with a locked area to keep the medication safe. The acetaminophen and eye drops should have been on the resident's physician's orders, but they did not know the resident ordered them him/herself. The DON assessed the resident the prior week and got an order from the physician to self-administer but missed updating it in his/her medical record. He did not know the information about documentation and storage needed to be included in his/her care plan. They had not run into an issue like this before and thought the assessment showing the resident was knowledgeable about the medication and documentation was enough to meet the guidelines to self-medicate. During an interview on 06/03/26 at 10:00 A.M., the Administrator said he expected staff to follow the facility's policy on self-administration of medication. Staff should be following up with the resident to ensure he/she took his/her medication and there should be documentation it was taken properly. The resident should take the medication safely in his/her room. 3016857

Based on interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice when staff failed to administer an antibiotic as ordered by the physician for one resident (Resident #8), and when staff administered blood pressure medication outside the parameters noted in the physician orders for two residents (Residents #7 and #17). The sample was 18. The census was 89. Review of the facility's Medication Administration policy, revised January 2026, showed:-Purpose: To provide practice standards for safe administration of medications for residents in the facility;-Policy: Medication will be administered by a licensed nurse via the order of an attending physician or licensed independent practitioner or as consistent with state law;-Medications may be administered one hour before or after the scheduled medication administration time;-Tests and taking of vital signs, upon which administration of medications or treatments are conditioned may be performed as required by state law, and the results recorded;-When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record (i.e. blood pressure, pulse, finger stick blood glucose monitoring, etc.);-Procedure: --Follow the seven rights of medication administration: ---Right medication; ---Right dose; ---Right resident; ---Right time; ---Right route; ---Right indication; ---Right outcome;-Use the rule of three: Compare the physician's order, pharmacy label, and medication administration record (MAR) before administration;-Documentation:--Record the time, dose, and initials of the nurse administering medication;--Ensure legible documentation with full signature on each MAR page;--Monitor for adverse drug reactions and document in the resident's medical record. Review of the facility's Physician's Orders policy, revised June 2020, showed:-Purpose: This will ensure that all physician orders are complete and accurate;-Policy: The medical records department will verify that physician's orders are complete, accurate and clarified as necessary;-Procedure: -Orders will include a description complete enough to ensure clarity of the physician's plan of care;-Whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order;-Medication/treatment orders will be transcribed onto the appropriate resident administration record;-Documentation pertaining to physician's orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the MAR/treatment administration record (TAR). 1. Review of Resident 8's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/06/26, showed diagnoses included end stage renal disease (ESRD, kidney failure), congestive heart failure, atrial fibrillation (irregular heart rhythm), acute respiratory failure, and high blood pressure. Review of the resident's care plan, dated 08/08/26, showed:-Focus: Risk for infection;-Interventions: Administer antibiotic therapy as prescribed. Review of the resident's electronic physician order sheet (ePOS) and MAR for August 2026, showed:-An order, dated 08/07/26, for levofloxacin (antibiotic) 500 milligrams (mg), give one tablet by mouth, one time a day for three days;-No documentation the medication was administered on 08/08/26 or 08/10/26. Observation of the medication room on 08/28/26 at 2:45 P.M., showed the resident's medication card for levofloxacin contained two tablets. During an interview on 08/28/26 at 2:45 P.M., Certified Medication Technician (CMT) Y said he/she did not know why there were two of the levofloxacin tablets left on the medication card. Staff should have administered the medication as ordered. During an interview on 08/28/26 at 5:15 A.M., CMT L said he/she had experienced medications not being available due to being ordered and/or reordered late, including prescription and over the counter medications. There were several reasons attributing to this: some needed a signed script such as narcotics, some needed preapproval by insurance, but a lot of the time, it was regular medications and over the counter medications that ran out due to nursing staff not being educated on the facility and medical record process. Some staff were never educated on reordering medication in the medical record system. During an interview with the Regional Nurse and Administrator on 08/18/26 at 3:04 P.M., the Regional Nurse said the nurse who transcribed the original order entered it wrong in the system and it did not record correctly on the MAR. The Administrator said the medication should have been administered as ordered. The Regional Nurse and Administrator said they expected nursing staff to know where to find back up medications in the medication room or in the E-kit. They expected staff to know the process of when to reorder medications. If a medication was not administered for any reason, the CMT should alert the charge nurse and the charge nurse should follow up with pharmacy and reorder the medication, if needed. The charge nurse should also look in the E-kit and if not available, the physician should be notified and the progress note should show steps taken. CMTs, including agency staff, could reorder routine medications through the medical record system. Nurses were responsible for reordering controlled medications and insulin. The nursing staff should know the blister pack card had a blue area that started when medications needed to be reordered. When the first medication in the blue area was administered, it was time for the nurse to reorder the medication through the medical record system. The CMTs were responsible for refilling the medication carts with over-the-counter medications. 2. Review of Resident 7's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Diagnoses include congestive heart failure, atrial fibrillation, high blood pressure, and chronic pain syndrome. Review of the resident's care plan, dated 07/26/26, showed:-Focus: The resident has hypotension (low blood pressure);-Interventions: Administer meds as ordered. Resident receives midodrine (used to treat low blood pressure) as ordered. Check blood pressure prior to giving and hold per parameters. Monitor and record blood pressure as ordered/needed Review of the resident's MAR for August 2026, showed:-An order, dated 05/06/26 for midodrine 5 mg, give one tablet by mouth three times a day. Hold if blood pressure is more than 130;-On 08/01/26 at 8:00 A.M., blood pressure measured 140/92. Medication documented as administered;-On 08/02/26 at 4:00 P.M., blood pressure measured 146/84. Medication documented as administered;-On 08/04/26 at 4:00 P.M., blood pressure measured 137/84. Medication documented as administered;-On 08/05/26 at 4:00 P.M., blood pressure measured 137/89. Medication documented as administered;-On 08/10/26 at 4:00 P.M., blood pressure measured 164/89. Medication documented as administered;-On 08/12/26 at 8:00 A.M., blood pressure measured 158/87. Medication documented as administered. At 4:00 P.M., blood pressure measured 139/95. Medication documented as administered;-On 08/14/26 at 4:00 P.M., blood pressure measured 134/82. Medication documented as administered;-On 08/16/26 at 4:00 P.M., blood pressure measured 136/84. Medication documented as administered;-On 08/17/26 at 8:00 A.M., blood pressure measured 136/84. Medication documented as administered. At 12:00 P.M., blood pressure documented as 137/84. Medication documented as administered. At 4:00 P.M., blood pressure measured 142/71. Medication documented as administered;-On 08/19/26 at 4:00 P.M., blood pressure measured 154/86. Medication documented as administered. During an interview on 08/25/26 at 6:15 A.M., the resident said staff regularly messed up his/her medications. They did not take his/her blood pressure and then attempted to give him/her the medication without knowing if his/her blood pressure was below 130. They wanted to take his/her blood pressure at one time and give him/her the medication hours later, and the parameters of the blood pressure could have changed by then. 3. Review of Resident #17's quarterly MDS, dated [DATE], showed diagnoses included anemia, heart failure, high blood pressure, coronary artery disease (CAD), ESRD, diabetes, and malnutrition. Review of the resident's care plan, revised 05/18/26, showed:-Focus: The resident has congestive heart failure;-Interventions: Administered cardiac medications as ordered. Review of the resident's MAR for August 2026, showed:-An order, dated 02/21/26 through 08/17/26, for carvedilol (used to treat high blood pressure) 12.5 mg tablet, administer one tablet by mouth two times a day for high blood pressure. Hold if blood pressure is less than 110 and/or heart rate is less than 60. Medication scheduled for morning (A.M.) and evening (P.M.);--On 08/04/26 at P.M. dose, heart rate measured 56. Medication documented as administered;--On 08/05/26 at P.M. dose, heart rate measured 57. Medication documented as administered;--On 08/08/26 at P.M. dose, heart rate measured 57. Medication documented as administered;--On 08/09/26 at P.M. dose, heart rate measured 57. Medication documented as administered;--On 08/09/26 at P.M. dose, heart rate measured 57. Medication documented as administered;--On 08/10/26 at A.M. dose, heart rate measured 57. Medication documented as administered;--On 08/11/26 at A.M. dose, blood pressure measured 106/62. Medication documented as administered;--On 08/14/26 at P.M. dose, heart rate measured 55. Medication documented as administered;--On 08/15/26 at A.M. dose, heart rate measured 55. Medication documented as administered;--On 08/17/26 at A.M. dose, blood pressure measured 107/52 and heart rate measured 52. Medication documented as administered;-An order, dated 08/17/26, for carvedilol 12.5 mg tablet, administer one 12.5 mg tablet by mouth two times a day every Tuesday, Thursday, Saturday for high blood pressure, hold if blood pressure is less than 110 and/or heart rate less than 60. Scheduled for A.M. and P.M.;--On 08/18/26 at A.M. dose, heart rate measured 55. Medication documented as administered;--On 08/18/26 at P.M. dose, heart rate measured 57. Medication documented as administered;--On 08/25/26 at A.M. dose, heart rate measured 56. Medication documented as administered;-An order dated 02/21/26 through 8/17/26, for clonidine (used to lower high blood pressure) oral tablet 0.1 mg, administer one tablet by mouth two times a day for high blood pressure, hold if blood pressure is less than 110. Scheduled for A.M. and P.M.;--On 08/11/26 at A.M. dose, blood pressure measured 106/62. Medication documented as administered;--On 08/11/26 at P.M. dose, blood pressure measured 108/52. Medication documented as administered;--On 08/17/26 at P.M. dose, blood pressure measured 107/50. Medication documented as administered; -An order, dated 02/21/26 through 08/17/26 for hydralazine (used to treat high blood pressure) oral tablet 50 mg, administer one tablet by mouth three times a day for high blood pressure. Hold if blood pressure is less than 110. Scheduled for A.M., afternoon, and P.M.;--On 08/11/26 at A.M. dose, blood pressure measured 107/62. Medication documented as administered;--On 08/11/26 at afternoon dose, blood pressure measured 106/62. Medication documented as administered;--On 08/11/26 at P.M. dose, blood pressure measured 108/52. Medication documented as administered;--On 08/17/26 at P.M. dose, blood pressure measured 107/50. Medication documented as administered. 4. During an interview on 08/26/26 at 1:00 P.M., the Director of Nursing (DON) said staff should not have administered blood pressure medications if a resident's blood pressure was outside the parameters noted on his/her physician orders. Staff should obtain a resident's blood pressure prior to administering their blood pressure medication and hold the medication if the resident's blood pressure was outside of the physician-ordered parameters. During an interview on 08/28/26 at 3:15 P.M., the Administrator said staff should administer medication in accordance with the parameters noted by the physician orders. 3097586

Based on observation, interview, and record review, the facility failed to consistently assess pain or provide medication as ordered for one resident (Resident #7) resulting in the resident experiencing unresolved pain when being provided care. The sample was 18. The facility census was 89. Review of the facility's Pain Management policy, revised 01/26, showed:-Purpose: To ensure accurate assessment and management of the resident's pain;-Policy: A licensed nurse will assess residents for pain upon admission, quarterly and with significant changes in condition and as needed. Nursing staff is responsible for helping residents attain or maintain their highest level of well-being while managing pain through pharmacological and non-pharmacological interventions;-Ongoing reassessment: Pain will be reassessed at least quarterly, post fall, post-surgical procedures and with changes in condition as needed;-The interdisciplinary team will review pain assessments quarterly and following significant events;-The care plan will be upgraded based on reassessment findings:-Pain management: --Medication administration: ---The licensed nurse will administer pain medication as ordered; ---Documentation of administration will be recorded on the Medication Administration Record (MAR). Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/27/26, showed the following:-Cognitively intact; -Pain presence: Yes;-Pain frequency: Occasionally;-Has pain made it hard to sleep in last five days? Occasionally;-How often have day-to-day activities been limited in last five days due to pain: Occasionally;-Rate worst pain over last five days on scale of one to ten: Six;-Diagnoses included congestive heart failure, atrial fibrillation (irregular heartbeat), high blood pressure and chronic pain syndrome. Review of the resident's care plan, dated 07/26/26, showed:-Focus: I have complaints of pain that occasionally interfere with my rest and day-to-day activities;-Interventions: Administer medications as ordered. Evaluate effectiveness of analgesics (pain relievers). Review of the resident's August 2026 electronic physician's order sheet (ePOS), showed an order dated 08/08/26 for Lidocaine (used to treat pain) topical patch (on skin) 4%, apply to lower back, one time a day for pain. Review of the resident's electronic Medication Administration Record (MAR), dated 08/01/26 through 08/31/26, showed: -An order dated 04/08/26 for pain assessment before and after as needed medications: Utilize 0-10 pain scale. Document pain scale results, vitals, interventions, outcomes in progress notes. As needed for pain, document interventions both non-medication and medications in progress notes;-Area for treatment: Nothing documented for the month of August;-Area for pain level: Nothing documented for the month of August;-Area for as needed medications: Nothing documented for the month of August;-An order for pain assessment every shift for pain. All 0's recorded for the month of August;-An order to remove the lidocaine patch in the evening. Staff documented this was completed 08/8/26 through 08/25/26;-An order for lidocaine topical patch 4%, apply to left shoulder one time a day for pain, removed after 12 hours.-Codes for documentation on the MAR:2=Resident refused; 7=Not administered-See progress notes.-MAR documentation:On 08/08/26, a 7 recorded.On 08/09/26, a 7 recorded;On 08/10/26 and 08/11/26, a 2 recorded;On 08/18/26, a 7 recorded;On 08/19/26, a 7 recorded;On 08/20/26 and 08/21/26, a 2 recorded;On 08/22/26, a 7 recorded;On 08/23/26, a 7 recorded;On 08/24/26, a 7 recorded. Review of the resident's progress notes showed no documentation of why the medication was not administered on 08/08/26, 08/09/26, 08/18/26, 08/19/26, 08/22/26, 08/23/26 and 08/24/26. During an interview on 08/26/26 at 11:30 A.M., the resident said he/she had not been administered a lidocaine patch all week. He/She did not refuse the medication. Staff were not even offering it. If he/she asked about it, the staff told him/her they did not have it in supply, or they were waiting for him/her to get a shower. The medication was supposed to help with the pain in his/her left shoulder, and the pain was getting worse. The pain was bad when staff provided care or used the Hoyer lift to transfer him/her out of bed. Observation and interview on 08/26/26 at 11:45 A.M., showed Certified Medication Technician (CMT) X said he/she did not administer the resident's Lidocaine because he/she did not have an order for it. He/She checked the resident's record and found the resident did have an order. CMT X then checked the medication cart for the patches, but could not find any with the resident's name on them. CMT X did find a box of stock patches with no name on them, but did not know he/she could administer them to the resident because he/she did not know the order was active. CMT X did not regularly work at the facility and believed the regular staff did not order the resident's pain patches. During an interview on 08/26/26 at 1:00 P.M., the Director of Nursing said staff should have reviewed the resident's order when they were administering his/her medication and administered the lidocaine patch. If the resident did not have any patches, they should have checked stock patches, checked the emergency kit or called the physician to order more. All of this should have been documented in the resident's medical record. During an interview on 08/28/26 at 3:15 P.M., the Administrator said staff should have administered the pain medication as ordered. If the resident did not have any of the medication, staff should have notified the nurse or DON and ordered it. All of this should have been documented. 3097586

Based on observation, interview and record review, the facility failed to obtain a current physician's order, provide thorough assessments, monitoring and ongoing communication with the dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) center or provide a lunch meal for one of two residents (Resident #8) who receive dialysis treatments. The sample size was 18. The census was 89. Review of the facility's Dialysis Care policy, revised on 06/20, showed:-Purpose: To provide care for residents diagnosed with renal disease requiring ongoing dialysis treatments:-Policy: --The facility will be responsible for the overall care delivered to the resident, monitoring the resident prior to and after the completion of each dialysis treatment, and providing for all non-dialysis needs of the resident including the time period when the resident is receiving dialysis; --The facility maintains a contract with a dialysis service provider which addresses communication between the facility and the provider; --The facility will arrange dialysis care for residents as ordered by the attending physician;-Procedure: ---Dialysis arrangements: The facility will arrange for dialysis care for such residents as ordered by the attending physician; ---The facility will arrange transportation to and from the dialysis provider, as well as for meals (if necessary), medication administration and a method of communication between the dialysis provider and the facility;-Dialysis care: --Diet: The attending physician orders all diets served to the residents on dialysis; --On the day of the dialysis treatment, the resident may be NPO (nothing by mouth) only when ordered by the physician. Otherwise, the diet will be served according to the facility policy and procedure. A sack lunch to be provided, if indicated;-Dialysis catheter: --The licensed nurse will monitor the integrity of the catheter dressing every shift and reinforce the dressing with tape as needed; --The licensed nurse will inspect the catheter every shift for cracks, breaking, or leakage and notify the physician immediately if signs are present: In case of accidental separation or dislodging of the cannula, transfer resident to the hospital immediately; --Catheter dressing will be maintained by the dialysis center; --Catheters will not be opened, flushed, or used by facility staff;-Communication and collaboration: --The nursing staff, dialysis provider staff and attending physician will collaborate on a regular basis concerning the resident's care as follows: ---Nursing staff will communicate pertinent information in writing to the dialysis staff which may include: ---Any medication changes; ---Any recent changes in condition; ---The resident's tolerance of dialysis procedures;---The dialysis provider will communicate in writing to the staff: ---The resident's current vital signs; ---Pre and post dialysis weight; ---Any problems encountered while the resident was at the dialysis provider; --The nursing staff will keep the attending physician, the resident and the resident's family informed of any change in condition; --The nephrologist/dialysis provider and the residents' attending practitioner must be notified of a canceled or postponed dialysis treatment and responses to change in treatment must be documented in the resident's medical record. If dialysis is cancelled or postponed, the nursing staff and dialysis provider should provide or obtain ongoing monitoring and medical management for changes such as fluid gain, respiratory issues, review of relevant lab results and any other complications that occur until dialysis can be rescheduled based on resident assessment, stability and need; --Nursing staff use nurse's dialysis communication form or comparable form in Point Click Care to convey information to the dialysis provider;-Care Plan: --The interdisciplinary team will ensure the resident's care plan includes documentation of the resident's renal condition and necessary precautions; --The resident's care plan will be updated as needed;-Documentation: All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. Review of Resident #8's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/06/26, showed the following:-admitted on [DATE];-Cognitively intact;-No moods or behaviors;-Required extensive assistance with bed mobility and transfers, -Required total dependence with toilet use and dressing;-Special treatments: Dialysis;-Diagnoses of end stage renal disease (ESRD-happens when the kidneys no longer work well enough to meet the body's needs), congestive heart failure, atrial fibrillation (irregular and often rapid heart rhythm), acute respiratory failure (lungs cannot get enough oxygen into blood or remove enough carbon dioxide from it) and high blood pressure. Review of the resident's care plan, dated 07/09/26, showed:-Focus: Resident needs dialysis;-Interventions: --Check and change dressings daily at access site; --Encourage resident to go for the scheduled dialysis (Tuesday, Thursday and Saturday 11 A.M. -12 P.M.); --Monitor labs and report to doctor as needed; --Monitor/document for peripheral edema (swelling in lower legs, ankles, feet, hands or arms caused by fluid buildup in body's tissues); --Monitor/document/report to physician any signs or symptoms of infection to access site; --Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and blood pressure immediately; --Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss; --Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, withdrawal or resistance to care. Review of the resident's progress notes, showed:-On 07/18/26 at 3:34 P.M., the resident refused dialysis. No documentation of physician notification;-On 07/19/26 at 11:00 A.M., emergency medical transportation (EMT) arrived at facility. The resident called 911. EMT staff told the resident called for chest pains. The resident made no complaints to staff regarding chest pains prior to call;-On 07/28/26 at 9:53 P.M., the resident readmitted to the facility. Received dialysis prior to discharge from the hospital;-On 07/29/26 at 11:27 A.M., a dialysis progress note, the resident continues to go to hemodialysis on Tuesday, Thursday and Saturdays with no concerns;-No documentation of dialysis on 08/01/26;-On 08/03/26 at 1:30 A.M., the resident let the nurse know he/she was feeling short of breath, pulse oxygen saturation (sat) was 63% (normal is 65-100 percent). Nurse grabbed an oxygen tank and placed it on 4 liters and applied nasal cannula (hose placed in nose). Resident called 911 and oxygen sat came up to 80 percent while awaiting emergency medical services (EMS). Resident transferred to hospital. Message left for physician with no answer;-On 08/07/26 at 9:42 P.M., the resident returned from the hospital. Admitting diagnosis was acute hypoxemic respiratory failure. New med changes;-No documentation of dialysis on 08/08/26, 08/11/26, 08/13/26, 08/15/26, 08/20/26, 08/22/26 or 08/25/26. Review of the resident's medical records showed:-Hemodialysis flowsheets for the resident dated 07/07/26, 07/09/26 and 07/11/26;-No other documentation of communication between the facility and the dialysis center. Review of the resident's August 2026 electronic Physician's Orders (ePOS), showed:-An order dated 07/08/26 for dialysis, three times a week on Tuesday, Thursday and Saturday. The order status was discontinued;-An order dated 07/29/26 to assess dialysis: Location left chest double lumen subclavian (an artery and a vein located immediately beneath the collarbone) catheter (a type of central venous line (a long, flexible tube inserted into a large vein in the neck, chest, arm or groin that reaches a large vein near the heart) inserted under the collarbone into the subclavian vein to allow for high-flow vascular access), assess every shift for hemodialysis. The order status was discontinued;-An order dated 07/08/26 for dialysis. Days on Tuesday, Thursday and Saturday with pick-up time between 11 A.M. and 12:00 P.M. The order status was discontinued;-An order dated 07/29/26 for dialysis transportation three times a week Tuesday, Thursday and Saturday. The order status was discontinued;-An order dated 07/29/26 for staff to send a bagged lunch with the resident. The order status discontinued. Review of the resident's electronic Medication Administration Record for August 1, 2026, through August 31, 2026, showed:-No order documented for dialysis in August 2026;-An order dated 07/29/26 to assess dialysis: Location left chest double lumen every shift for hemodialysis. The order was discontinued on 08/03/26. No documentation of site assessed in the month of August 2026;-An order dated 07/29/26 for dialysis transportation. The order was discontinued on 08/03/26. No documentation of any transportation completed in the month of August 2026-An order dated 07/29/26 to send a bagged lunch with the resident. The order was discontinued on 08/03/26. No documentation of lunch sent on any day of the month of August 2026. Review of the resident's ePOS, dated August 2026, showed the following:-Special instructions at the top of the page: Dialysis; please fill out dialysis communication sheet before and after each dialysis visit;-No current order for dialysis. Review of the resident's August 2026 electronic treatment administration record (eTAR), showed:-An order dated 07/29/26 to address dialysis: Location of chest double lumen subclavian every shift for hemodialysis. The order was discontinued on 08/03/26;-An order dated 07/29/26 for dialysis transportation to be picked up at 11 A.M. The order was discontinued on 08/03/26;-An order dated 07/29/26 to send a bagged lunch with the resident. The order was discontinued on 08/03/26;-No new orders for dialysis documented. Review of the resident's medical record for vitals on 08/26/26, showed:-No blood pressure vitals documented from 07/07/26 through 07/28/26;-No blood pressure vitals documented on 08/03/26 through 08/06/26, 08/08/26, 08/12/26, 08/13/26, 08/15/26, -Weights documented on 07/07/26, 07/28/26, 08/07/26 and 08/11/26. Observation on 08/25/26 at 11:00 A.M., showed the resident was picked up by a transportation service for dialysis. The resident was not provided with a sack lunch. During an interview on 08/26/26 at 6:25 A.M., the resident said he/she goes to dialysis on Tuesday, Thursday and Saturdays. Sometimes they check his/her vitals and bandages when he/she returns from dialysis, but it depends on the nurse on duty. The dialysis center usually changes the bandage. He/She is often in pain at the treatment center because he/she cannot always find a nurse to administer his/her pain pill before he/she leaves for the treatment. He/She knows it is every four hours as needed but he/she always has to find the nurse to get the medication and they are sometimes hard to track down or too busy to administer it when he/she asks for it. It can be several hours past the four-hour time frame once he/she gets his/her pain medication. He/She does not get lunch sent with him/her and he/she usually does not get anything to eat until dinner. This is frustrating because he/she gets hungry during the day. He/She did not know he/she was supposed to get a bagged lunch. No one ever offers him/her one. During an interview on 08/26/26 at 11:00 A.M., the dialysis center nursing manager said they have been having problems with the resident since he/she started dialysis with them. The resident has continuous behavioral issues while at the center. He/She has loud verbal outbursts with the staff and other patients and they have had to cut his/her time in the chair short several times due to his/her outbursts. The resident complains of being in pain all the time and gets extremely angry with the staff whenever they try to do anything with him/her. The facility does not send over any communication sheets, so they do not know when he/she was last administered pain medication or if there have been any issues with him/her prior to transportation. The facility staff will not answer the phone when their staff try to report what has happened or are trying to get the residents back to the facility early. There have been problems with getting the resident transported for his/her treatments due to his/her behaviors with the transport staff. They have had to cancel several treatments due to the issues with transportation. During an interview on 08/26/26 at 5:20 P.M., Certified Medication Technician (CMT) M said the resident went to dialysis on Tuesday, Thursday and Saturdays. He/She did not take the resident's vitals or weights, because the nurse was supposed to do this when they evaluated him/her. Sometimes the resident would cooperate with this, and sometimes he wouldn't. CMT M did not know about any communication form and had not sent one with the resident or filled one out when he/she returned from dialysis. During an interview on 08/26/26 at 5:30 P.M., Licensed Practical Nurse (LPN) N said he/she believed there was a dialysis communication form, but did not know where they kept them after they were filled out. He/She had not been given one from the resident when he/she returned from the center to fill out. He/She did not always take the resident's vitals or weights after dialysis because the resident would not always be cooperative. During an interview on 08/26/26 at 1:00 P.M., the Director of Nursing (DON) said the resident goes out for dialysis three days a week. They have forms at the nurse's station for staff to fill out and send to dialysis with the resident. The facility would fill out any information on their part and send it back to the facility when the resident returned. She thought staff were filling the form out and sending it with the resident. The form would then be uploaded into the resident's medical record. There had been a problem with the dialysis center sharing information with the facility. The resident should have an updated order in his medical record for the dialysis. There had been a change recently when they had to change his/her treatment days. There was a problem with the transportation company, and the family was now having to transport the resident on Saturdays. She did not know the resident was having behavior issues at the center because no one told her. The staff should have been checking the resident's vitals and access site when he/she returned from the facility and documented this information. If the physician ordered a lunch to be provided for the resident when he/she went to dialysis, then staff should have been ensuring a lunch was sent. During an interview on 08/26/26 at 1:30 P.M., the Regional Nurse said they could not find any communication forms for the resident and there was limited information about dialysis appointments in his/her medical record. Staff should have filled out a form to send with the resident and check the resident's vitals on return. This should have been documented in the resident's medical record. During an interview on 8/28/26 at 3:15 P.M., the administrator said if a resident was going to dialysis there should be a current physician's order in the medical record. The staff should be sending a communication form to the dialysis center with the resident's information and then recording vitals and weight on it when the resident returned. All of this should be documented in the resident's medical record. During an interview on 08/26/26 at 5:45 P.M., the resident's physician said he did not know the resident's order for dialysis was discontinued. If the resident was going to dialysis, he/she should have an active order. The physician knew the resident was sent to the hospital at the beginning of the month, and the facility recently changed the days of treatment due to transportation issues and the order might have gotten changed. Staff should have notified him if there was a problem with the order and it was not current. There should be ongoing communication between the facility staff and the dialysis center to identify any problems. Staff should be recording the resident's weights and vitals before and after dialysis and letting him know if there are any issues. If the resident was supposed to be sent with a meal, staff should have ensured a meal was sent with him/her.

Based on interview and record review, the facility failed to follow their policy for documenting medication administration records for two of 13 sampled residents (Resident #7 and #5) who received intravenous (IV-injected directly into a person's vein) medications. The census was 79. Review of the facility's Medication Administration policy dated 01/26, showed:-Purpose: To provide standards for safe administration of medications for residents in the facility;-Policy: --Medication will be administered by a licensed nurse via the order of an attending physician or licensed independent practitioner, or as consistent with state law; --Medications must be given to the resident by the licensed nurse preparing the medication or as consistent with state law;-Documentation: Record the time, dose and initials of the nurse administering medication. Review of the facility's Intermittent Infusion (the process of delivering medication, fluids or nutrients directly into the bloodstream through a vein or under the skin) policy revised 12/14, showed:-Purpose: To provide guidance and procedures for intermittent infusion administration;-Documentation: Documentation in the medical record includes, but is not limited to: --Date and time; --Medication/solution; --Rate and method of infusion ; --Prescribed flushing agent(s); --Site assessment; --Complications and interventions; --Resident response to procedure and/or medication. Review of the facility's Documentation-Nursing policy, dated 06/20, showed: -Purpose: To provide documentation of resident status and care given by nursing staff; -Policy: Nursing documentation will be concise, clear, pertinent, accurate and evidence-based. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatment or procedures. Documentation for subsequent and/or routine care and procedures may be completed by exception; -Procedure: --Nursing documentation: ---Nurse's notes are dated, timed and signed when written; ---Medication administration records and treatment administration records are completed with each medication or treatment completed; ---Documentation will be completed by the end of the assigned shift. 1. Review of Licensed Practical Nurse's (LPN) B's nurse license verification on 07/20/26, showed he/she is not certified in the state of Missouri to administer IV medications. 2. Review of Resident #7's face sheet located in the electronic medical record, showed:-admitted on [DATE];-Diagnoses included cellulitis (bacterial infection of the deeper layers of the skin and underlying tissues) of left lower leg and right lower limb, heart disease with heart failure and high blood pressure. Review of the resident's June 2026, electronic Medication Orders, showed Meropenem intravenous solution (an antibiotic used to treat severe bacterial infections), one gram intravenously, three times a day for cellulitis. Review of the resident's electronic Medication Administration Record dated June 1, 2026, through June 30, 2026, showed:-On 06/06/26 at 9:00 A.M., LPN B documented he/she administered Meropenem intravenously;-On 06/07/26 at 9:00 A.M., LPN B documented he/she administered Meropenem intravenously. Review of the resident's progress notes showed:-On 06/06/26, no documentation of medication administered including who administered it, the rate and method of infusion, site assessment or resident response to procedure and/or medication;-On 06/07/26, no documentation of medication administered including who administered it, the rate and method of infusion, site assessment or resident response to procedure and/or medication. 3. Review of Resident #5's face sheet located in the electronic medical record, showed:-admitted on [DATE];-Diagnoses included acute cystitis with hematuria (irritation of the bladder with blood in urine), adverse effects of other drugs, chronic obstructive pulmonary disease (lung disease) and heart disease. Review of the resident's progress notes on 07/11/26 at 4:58 P.M., showed an order change note for ceftazidime (antibiotic used to treat bacterial infections) intravenous solution, use 1 gram every eight hours related to acute cystitis. At 6:33 P.M., IV placed in left forearm. Review of the resident's July 2026, electronic Medication Orders, showed an order for ceftazidime intravenous solution, use 1 gram intravenously every 8 hours. Review of the resident's electronic Medication Administration Record dated June 1, 2026, through June 30, 2026, showed:-On 07/13/26 at 7:00 A.M., LPN B documented he/she administered ceftazidime intravenously;-On 07/14/26 at 7:00 A.M., LPN B documented he/she administered ceftazidime intravenously. Review of the resident's progress notes, showed on 07/13/26 at 1:28 P.M., resident sent to emergency room for a PICC line (a long , thin flexible tube inserted into a vein in the upper arm and threated to a large vein near the heart. It provides long-term intravenous access) replacement. No documentation of 7:00 A.M. medication administration, any complications noted or who administered the medication. 4. During an interview on 07/17/26 at 2:45 P.M., Licensed Practical Nurse B said he/she did not administer IV medications on the halls he/she worked because he/she was not IV certified in the state. He/She would ask another nurse who was IV certified to come administer the IV medications and then he/she would document the other nurse administered them. He/She thought since he/she was in the room during the administration and observed the other nurse administer the medication, it was okay to document the medication was administered. 5. During an interview on 07/21/26 at 1:35 P.M., Licensed Practical Nurse E said he/she would help LPN B by hooking up and administering IV medications for residents who were on his/her hall because LPN B was not IV certified in the state so could not administer them. LPN E said he/she knew he/she was supposed to document he/she administered the medication but did not do so because when he/she went in to document it, LPN B already documented it was done. 6. During interviews on 07/17/26 at 9:10 A.M., 11:55 A.M. and 4:05 P.M., the Administrator said he knew LPNs needed to be certified in the state to administer IV medications. He did not know LPN E was administering the IV medications for LPN B and not documenting this administration. If LPN E administered the medications, he/she should follow the policy and documented the medication administration. 3035864

Based on interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to administer physician-ordered medications to 10 residents (Resident #8, #6, #4, #7, #17, #5, #9, #10, #2, and #3). The sample was 17. The census was 80.Review of the facility's Physician Orders policy, revised 6/2020, showed: -Purpose: This will ensure that all physician orders are complete and accurate;-Policy: The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary;-Procedure:--Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline;--Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the Medication Administration Record (MAR)/Treatment Administration Record (TAR). Review of the facility's General Guidelines for Medication Administration policy, revised 8/2020, showed:-Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions;-Administration: Medications are administered in accordance with written orders of the prescriber;-Documentation (including electronic):--The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure that necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications;--The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are cross-referenced to a full signature in the space provided;-- If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at a scheduled time or a starter dose of an antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If three consecutive doses, or in accordance with facility policy, of a vital medication are withheld, refused, or not available, the physician is notified. Nursing documents the notification and physician response;--If an electronic MAR system is used, specific procedures required for resident identification, identification of medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual. These procedures should be followed and may differ slightly from the procedures for using paper MARs. Electronic systems also describe procedures for secure access, maintaining privacy of resident information, and for electronic signatures. Maintenance and support procedures for these systems are described in the system user manuals. Procedures will vary between the various electronic systems available. 1. Review of the facility's Resident Council Meeting Minutes, dated 2/19/26, showed resident concerns that they are not receiving medication timely and doses are being missed. 2 Review of Resident #8's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/6/25, showed:-Cognitively intact;-Diagnoses included heart failure, morbid obesity, anxiety, chronic pain syndrome, high blood pressure, muscle weakness, and right knee pain. Review of the resident's care plan, dated 12/9/25, showed:-Problem: Anticoagulant (blood thinning medication) use;-Goal: Resident will have not noted bleeding through the next review;-Approach: Administer medication as ordered. Review of the resident's February 2026 MARs, dated 2/1/26 through 2/24/26 showed:-An order, dated 4/20/25, for Eliquis (blood thinning medication) 5 milligrams (mg), twice daily;--MAR blank with no documentation that Eliquis was administered on morning of 2/10/26, 2/11/26, and 2/19/26, or at night on 2/2/26, 2/3/26, and 2/9/26;-An order, dated 12/28/25, for Lasix (used to treat excess fluid retention (swelling)) 20 mg, administer two tablets once in the morning, give 40 mg daily;--MAR blank with no documentation that Lasix was administered on 2/11/26, 2/17/26, 2/18/26, and 2/19/26;-An order, dated 11/21/25, for Vitamin B-12 500 micrograms (mcg), two tablets equaling 1,000 mcg once a day;--MAR blank with no documentation that Vitamin B-12 was administered on 2/5/26, 2/10/26, 2/11/26, 2/15/26, and 2/18/26;-An order, dated 3/10/26, for Vitamin D3 125 mcg, administer one tablet daily;--MAR blank with no documentation that Vitamin D3 was administered on 2/5/26, 2/10/26, 2/11/26, 2/15/26, and 2/18/26;-An order, dated 12/1/25, for potassium chloride extended release (ER) 10 milliequivalent (mEq), administer once daily for congestive heart failure;--MAR blank with no documentation that potassium chloride was administered on 2/5/26, 2/10/26, 2/11/26, 2/15/26, and 2/18/26;-An order, dated 1/8/26, for Aspercreme (lidocaine, pain reliever) adhesive patch, medicated; 4 percent (%), administer one patch twice a day, apply to left shoulder in the morning (AM) and off at hour of sleep (HS);--MAR blank with no documentation that Aspercreme adhesive patch was applied in AM on 2/10/26, 2/11/26, 2/17/26, 2/19/25, and 2/22/26, or removed HS on 2/2/26, 2/6/26, 2/8/26, 2/11/26, 2/15/26, and 2/22/26;-An order, dated 12/26/25, for famotidine (used to treat heartburn) tablet 20 mg, twice daily at AM and evening (PM);--MAR blank with no documentation that famotidine was administered in AM on 2/10/26 and 2/11/26, or at PM on 2/2/26 and 2/9/26;-An order, dated 11/20/25, for ondansetron (used to prevent nausea) hydrochloride (HCI) tablet 4 mg, administer twice daily, take one tab in AM and HS;--MAR blank with no documentation that ondansetron was administered in AM on 2/10/26 and 2/11/26, or at HS on 2/2/26, 2/9/26, 2/17/26, and 2/24/26;-An order, dated 3/10/25, for Senna Plus (sennosides-docusate sodium, laxative and stool softener) tablet; 8.6-50 mg, administer twice daily at AM and PM;--MAR blank with no documentation that Senna Plus was administered in AM on 2/10/26 and 2/11/26, or at PM on 2/2/26, 2/3/25, and 2/9/26;-An order, dated 4/5/25, for gabapentin (treats nerve pain) 200 mg, administer three times daily at 8:00 A.M., 2:00 P.M., and 10:00 P.M., order date 4/5/25;--MAR blank with no documentation that gabapentin was administered on:---8:00 A.M. on 2/10/26 and 2/11/26;---2:00 P.M. on 2/10/26, 2/11/26, 2/12/26, 2/15/26, and 2/17/26;---10:00 P.M. on 2/2/26, 2/3/26, and 2/9/26;-An order, dated 5/28/25, for artificial tears two drops (gtts), each eye four times daily at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M., order date 5/28/25;--MAR blank with no documentation that artificial tears were administered on:---8:00 A.M. on 2/10/26 and 2/11/26;---12:00 P.M. on 2/10/26, 2/11/26, 2/15/26, 2/17/26, and 2/19/26;---4:00 P.M. on 2/2/26, 2/9/26, 2/10/26, and 2/17/26;---8:00 P.M. on 2/2/26 and 2/9/26;-An order, dated 5/28/26 Miralax (medication used to treat constipation) 17 gram (gm) once an evening;--MAR blank with no documentation that Miralax was administered on 2/2/26, 2/9/26, 2/10/26, 2/17/26, and 2/22/26;-An order, dated 11/20/25, for Tylenol 1000 mg at HS for chronic pain;--MAR blank with no documentation that Tylenol was administered on 2/2/26, 2/9/26, and 2/15/26. During an interview on 2/20/26 at 1:35 P.M., the resident said that he/she had not been receiving his/her medication as ordered. He/She has missed doses of his/her gabapentin and this caused him/her to have more pain in his/her feet. 3. Review of Resident #6's comprehensive MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included diabetes, stroke, hemiparesis (weakness or reduced motor function on one side of the body), hypertension (high blood pressure), and depression. Review of the resident's electronic physician order summary (ePOS) and paper MAR from 2/3/26 to 2/24/26, showed:-An order, dated 4/22/25, before meal blood sugars, scheduled for 7:30 A.M., 11:30 A.M. and 4:30 P.M., along with Novolog insulin (a rapid-acting insulin) to be given per sliding scale (a medication regimen where the dose of rapid-acting insulin is given, based on pre-meal blood glucose readings), was not documented as completed or given on:-2/5/26 at 4:30 P.M.;-2/6/26 at 11:30 A.M.;-2/13/26 at 4:30 P.M.;-2/15/26 at 7:30 A.M.;-2/15/26 at 11:30 A.M.;-2/17/26 at 11:30 A.M.;-2/24/26 at 4:30 P.M.;-An order, dated 11/5/25, for Tresiba FlexTouch U-100 insulin pen (a prefilled injectable pen, with degludec, a long-acting insulin), with 100 units/milliliter (ml), give 24 units subcutaneously (SQ, under the skin) every day between 7:00 A.M. and 11:00 A.M., not documented as given on:-2/4/26;-2/7/26;-2/15/26;-2/24/26;-An order, dated 1/18/26, for metformin 500 mg tablet, administer one tablet, twice daily, was not documented as given on:-2/12/26 at 7:15 P.M. to 11:00 P.M.;-2/14/26 at 7:15 A.M. to 11:15 A.M.;-2/15/26 at 7:15 A.M. to 11:15 A.M.;-2/18/26 at 7:15 P.M. to 11:00 P.M.;-2/19/26 at 7:15 A.M. to 11:15 A.M.;-2/21/26 at 7:15 P.M. to 11:00 P.M.;-2/22/26 at 7:15 P.M. to 11:00 P.M.; During an interview on 2/19/26 at 12:52 P.M., the resident said he/she had not received insulin for four days last week, never saw a nurse, and his/her blood sugar was high. When his/her blood sugar was eventually taken, it was over 200. This week, the nurse came in and took his/her blood sugar but gave no insulin. 4. Review of Resident #4's medical record, showed diagnoses included diabetes with diabetic neuropathy (a potentially serious complication of diabetes where high blood sugar damages nerve fibers, primarily in the legs and feet), chronic kidney failure, dementia, major depressive disorder with psychotic symptoms, and adult failure to thrive. Review of the resident's care plan, in use at the time of survey, showed:-Problem: Diabetes, at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar);-Goal: Resident will remain free of signs and symptoms of hypoglycemia and hyperglycemia through the next review;-Approaches included:--Administer medications as ordered;--Administer insulin as ordered;--Accuchecks (blood glucose monitoring with a machine that reads a small sample of blood that is obtained via a small skin prick) as ordered. Review of the resident's February 2026 MARs, dated 2/1/26 through 2/24/26 showed:-An order, dated 1/15/26, before meal blood sugars, at 8:00 A.M., 12:00 P.M. and 4:00 P.M., along with Novolog insulin, to be given per sliding scale;--The MAR blank with no documentation the accuchecks were completed and no documentation the insulin was administered on:--2/5/26 at 4:00 P.M.;--2/7/26 at 8:00 A.M.;--2/8/26 at 12:00 P.M.;--2/14/26 at 8:00 A.M.;--2/15/26 at 8:00 A.M.;--2/15/26 at 12:00 P.M.;--2/18/26 at 12:00 P.M.-An order, dated 1/15/26, for insulin glargine-yfgn (a long-acting) insulin 3 ml pen, with 100 units/ml, administer 18 units SQ at bedtime (7:15 P.M. to 11:00 P.M.);--MAR blank with no documentation the insulin administered on 2/13/26;-An order, dated 1/27/26, for metformin 500 mg tablet, administer one tablet, twice daily (7:15 A.M. to 11:15 A.M. and 3:15 P.M. to 6:45 P.M.);--MAR blank with no documentation the metformin was administered on:--2/12/26 at 3:15 P.M. to 6:45 P.M.;--2/18/26 at 3:15 P.M. to 6:45 P.M.;-An order, dated 1/15/26, for lidocaine adhesive medicated patch, apply one patch every morning, between 7:15 A.M. to 11:15 A.M.;--MAR blank with no documentation the lidocaine adhesive medicated patch was applied on 2/15/26;-An order, dated 1/27/26, for buspirone (anti-anxiety) 10 mg tab, administer one tablet, three times daily, between 7:15 A.M. to 11:15 A.M, 3:15 P.M. to 6:45 P.M., and at bedtime between 7:15 P.M. to 11:00 P.M.;--MAR blank with no documentation buspirone was administered in the morning on 2/15/26;--MAR blank with no documentation buspirone was administered in the afternoon on 2/12/26;--MAR blank with no documentation buspirone was administered at bedtime on 2/12/26 and 2/22/26;-An order, dated 1/22/26, for hydroxyzine HCL (antihistamine), 25 mg tablet, administer one tablet, three times daily, at 8:00 A.M, 12:00 P.M., and 4:00 P.M., for generalized anxiety disorder:--MAR blank with no documentation hydroxyzine was administered in the morning on 2/10/26, 2/15/26, and 2/18/26;--MAR blank with no documentation hydroxyzine was administered at noon on 2/5/12, 2/10/26, 2/14/26, 2/15/26, 2/16/26, 2/17/26, and 2/18/26;--MAR blank with no documentation hydroxyzine was administered at 4:00 P.M. on 2/12/26;-An order, dated 1/15/26, for melatonin 3 mg tablet at bedtime;--MAR blank with no documentation melatonin was administered on 2/12/26;-An order, dated 1/18/26, for mirtazapine 15 mg tablet at bedtime;--MAR blank with no documentation melatonin was administered on 2/12/26;-An order, dated 1/15/26, for quetiapine (antipsychotic medication) 25 mg tablet, administer one tablet at bedtime:--MAR blank with no documentation melatonin was administered on 2/12/26, 2/14/26, and 2/22/26. 5. Review of Resident #7's admission MDS, dated [DATE], showed: -Moderate cognitive impairment;-Diagnoses included dementia, sepsis (blood infection), vitamin D deficiency, insomnia, multiple fractures of ribs, kidney disease, vitamin B12 deficiency anemia (body lacks enough healthy red blood cells due to insufficient B12), and gastroesophageal reflux disease (GERD). Review of the resident's February 2026 MARs, dated 2/1/26 through 2/24/26 showed:-An order, dated 1/29/26, for Aspirin 81 mg once daily for atrial fibrillation (increased heart rate);--MAR blank with no documentation that aspirin was administered on 2/1/26 and 2/17/26;-An order, dated 1/9/26, for Vitamin D3 25 mcg, administer two tablets daily;--MAR blank with no documentation that vitamin D3 was administered on 2/17/26;-An order, dated 1/9/26, for Vitamin B12 1,000 mcg daily;--MAR blank with no documentation that vitamin B12 was administered on 2/17/26;-An order, dated 1/9/26, for finasteride (shrinks the prostate gland) 5mg once daily;--MAR blank with no documentation that finasteride was administered on 2/17/26;-An order, dated 1/23/26 through 2/2/26, for ciprofloxacin HCI (antibiotic) 250 mg twice daily at AM and HS for urinary tract infection (UTI);--MAR blank with no documentation that ciprofloxacin HCI was administered 2/2/26 at HS;-An order, dated 1/9/26, for docusate sodium (stool softener) 100 mg twice daily at AM and HS;--MAR blank with no documentation that docusate sodium was administered on:---AM on 2/16/26 and 2/17/26;---HS on 2/2/26, 2/3/26, 2/4/26, and 2/16/26;-An order, dated 1/24/26, for metoprolol tartrate (used to treat high blood pressure) 25 mg twice daily at AM and HS-MAR blank with no documentation that metoprolol tartrate was administered on: ---AM on 2/16/26 and 2/17/26;---HS on 2/2/26, 2/3/26, 2/4/26, and 2/16/26;-An order, dated 1/9/26, for Senna Plus 8.6-50 mg twice daily at AM and HS;--MAR blank with no documentation that Senna Plus was administered on:---AM on 2/16/26 and 2/17/26;---HS on 2/2/26, 2/3/26, 2/4/26, 2/16/26, and 2/17/26;-An order, dated 1/14/26, for mirtazapine (antidepressant) 15 mg daily at HS;--MAR was blank with no documentation that mirtazapine was administered on 2/2/26, 2/3/26, 2/4/26, 2/16/26 and 2/18/26;-An order, dated 1/9/26, for trazodone (antidepressant) 50 mg daily at HS;-MAR blank with no documentation that trazodone was administered on 2/2/26, 2/3/26, 2/4/26, 2/9/26, 2/15/26, 2/16/26, 2/18/26, 2/21/26, 2/22/26, and 2/23/26. 6. Review of Resident #17's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Diagnoses included anemia, insomnia, chronic pain, high blood pressure, GERD, kidney disease, and rheumatoid arthritis (autoimmune disease). Review of the resident's February 2026 MARs, dated 2/1/26 through 2/16/26, showed:-An order, dated 9/29/25, for gabapentin 100 mg at 7:00 A.M., 2:00 P.M., and 10:00 P.M.;--MAR blank with no documentation that gabapentin was administered on 2/14/26 at 2:00 P.M.;-An order, dated 12/24/25, for Lasix 20 mg daily; --MAR blank with no documentation that Lasix was administered on 2/14/26 and 2/15/26;-An order, dated 9/29/25, for Vitamin B12 500 mcg once daily;--MAR blank with no documentation that vitamin B12 was administered on 2/14/26;-An order, dated 9/29/25, for iron 325 mg once daily;--MAR blank with no documentation that iron was administered on 2/14/26;-An order, dated 9/29/25, for folic acid (supplement) 400 mcg daily;--MAR blank with no documentation that folic acid was administered on 2/14/26;-An order, dated 9/29/25, for leflunomide (used to treat rheumatoid arthritis) 10 mg daily;--MAR blank with no documentation that leflunomide was administered on 2/14/26;-An order, dated 2/14/26, for lisinopril (used to treat high blood pressure) 20 mg daily;--MAR blank with no documentation that lisinopril was administered on 2/14/26;-An order, dated 9/29/25, for carvedilol (used to treat high blood pressure) 25 mg twice daily at 9:00 A.M. and 9:00 P.M;--MAR blank with no documentation that carvedilol was administered on 2/14/26 at 9:00 A.M. and on 2/15/26 at 9:00 P.M.;-An order, dated 9/29/25, for cholestyramine (used to lower high cholesterol) powder in packet 4 gram (g) once a day at noon;--MAR blank with no documentation that cholestyramine was administered on 2/14/26;-An order, dated 9/29/25, for mirtazapine 7.5 mg once daily at HS;--MAR blank with no documentation that mirtazapine was administered on 2/14/26. 7. Review of Resident #5's quarterly MDS, dated [DATE], showed:-Memory problem;-Diagnoses included stroke, diabetes, seizure disorder, aphasia (a language disorder), bipolar disorder (a chronic mental health condition characterized by intense, extreme shifts in mood, energy, and activity levels, ranging from manic highs to depressive lows), peripheral vascular disease (a blood circulation disorder caused by narrowing, blockage, or spasms in blood vessels outside the heart and brain), and hypertension. Review of the resident's February 2026 MARs, dated 2/1/26 through 2/24/26 showed:-An order, dated 10/23/25, for carbamazepine (a mood-stabilizing medication used to treat seizures, nerve pain, and bipolar disorder) 100 mg tablets, administer 250 mg every 6 hours (12:00 A.M., 7:00 A.M., 12:00 P.M, and 7:00 P.M.), for unspecified convulsions (seizures);--MAR blank with no documentation the carbamazepine was administered at:---12:00 A.M on 2/14/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, and 2/21/26;---7:00 A.M. on 2/14/26;---12:00 P.M. on 2/14/26;---7:00 P.M. on 2/16/26, 2/17/26, and 2/20/26;-An order, dated 12/24/25, for Lasix 20 mg, administer one tablet once in the morning;--MAR blank with no documentation that Lasix was administered on 2/11/26, 2/17/26, 2/18/26, and 2/19/26;-An order, dated 11/1/25, for Eliquis 5 mg tablet, administer one tablet twice daily, in the morning and at bedtime;--MAR blank with no documentation the Eliquis was administered at bedtime on 2/7/26;-An order, dated 10/23/25, for Keppra (an anticonvulsant/seizure medication used to control seizures) 500 mg tablet, administer 500 mg twice daily, in the morning and at bedtime, for unspecified convulsions;--MAR blank with no documentation the Keppra was administered at bedtime on 2/7/26 and 2/21/26;-An order, dated 10/23/25, atorvastatin (medication used to lower cholesterol) 40 mg at bedtime;--MAR blank with no documentation the atorvastatin was administered at bedtime on 2/12/26;-An order, dated 2/18/26, for metformin 1000 mg by mouth, twice daily, with a start date of 2/18/26;--MAR blank with no documentation the metformin was administered in the morning on 2/19/26, 2/20/26, and 2/21/26;--MAR blank with no documentation the metformin was administered at bedtime on 2/19/26, 2/20/26, and 2/21/26. 8. Review of Resident #9's quarterly MDS, dated [DATE], showed:-Cognition intact;-Diagnoses included diabetes, heart failure, embolism of pulmonary artery (major blood vessel that carries deoxygenated blood from the right ventricle of the heart to the lungs for oxygenation), depression, high cholesterol, and hypertension. Review of the resident's February 2026 MARs, dated 2/1/26 through 2//24/26, showed:-An order, dated 10/9/25, for pantoprazole (used to treat GERD) 40 mg once every morning at 6:00 A.M.:--MAR blank with no documentation the pantoprazole was administered in the morning on 2/18/26;-An order, dated 10/9/25, for gabapentin 600 mg, administer three times daily at 7:00 A.M., 2:00 P.M., and 10:00 P.M.;--MAR blank with no documentation that gabapentin was administered at:---7:00 A.M. on 2/8/26;---2:00 P.M. on 214/26 and 2/15/26;---10:00 P.M. on 2/7/26, 2/16/26, and 2/21/26;-An order, dated 10/9/25, for allopurinol (drug that inhibits uric acid formation in the body) 100 mg tablet, give 200 mg (two tablets) once daily in the morning;--MAR blank with no documentation that allopurinol was administered on 2/14/26;-An order, dated 10/9/25, for Jardiance (drug used to lower blood sugar) 10 mg by mouth, once daily every morning:--MAR blank with no documentation that gabapentin was administered on 2/14/26;-An order, dated 10/9/25, for Miralax 17 gm once every morning between 7:15 A.M. to 11:15 A.M.;--MAR blank with no documentation that Miralax was administered on 2/14/26;-An order, dated 10/9/25, for multivitamin tablet, take one tablet every morning between 7:15 A.M. to 11:15 A.M.;--MAR blank with no documentation that multivitamin was administered on 2/14/26;-An order, dated 10/9/25, for oxybutynin chloride, extended release (ER) 5 mg tablet, once daily between 7:15 A.M. to 11:15 A.M.;---MAR blank with no documentation that oxybutynin was administered on 2/14/26;-An order, dated 10/21/25, for Eliquis 5 mg tablet, administer one tablet twice daily, in the morning and at bedtime, for chronic embolism and thrombosis of both lower extremities;--MAR blank with no documentation the Eliquis was administered in the morning on 2/14/26;--MAR blank with no documentation the Eliquis was administered at bedtime on 2/7/26, 2/16/26, 2/17/26, and 2/21/26;-An order, dated 12/8/25, for ferrous sulfate 325 mg tablet in the morning between 7:15 A.M. to 11:15 A.M and in the late afternoon/early evening between 3:15 P.M. to 6:45 P.M.;--MAR blank with no documentation ferrous sulfate was administered in the morning on 2/14/26;--MAR blank with no documentation ferrous sulfate was administered late afternoon/early evening on 2/21/26;-An order, dated 10/9/25, for PreserVision (supplement for the eyes) capsule twice daily in the morning between 7:15 A.M. to 11:15 A.M and in the late afternoon/early evening between 3:15 P.M. to 6:45 P.M.;--MAR blank with no documentation PreserVision was administered in the morning on 2/10/26, 2/14/26, and 2/15/26;--MAR blank with no documentation PreserVision was administered late afternoon/early evening on 2/7/26 and 2/21/26;-An order, dated 10/9/25, for atorvastatin 10 mg at bedtime;--MAR blank with no documentation the atorvastatin was administered at bedtime on 2/7/26, 2/14/26, 2/17/26, and 2/21/26;-An order, dated 10/9/25, for duloxetine (antidepressant) 20 mg once daily at bedtime;--MAR blank with no documentation the medication was administered at bedtime on 2/7/26, 2/14/26, 2/17/26, and 2/21/26. 9. Review of Resident #10's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Diagnoses included seizure disorder, repeated falls, dementia, Parkinson's disease (a progressive neurodegenerative brain disorder that affects the whole-body due to dopamine loss-movement disorders, loss of smell, constipation, mood disorders, fatigue, memory fog, and dementia in later stages), chronic obstructive pulmonary disease (COPD, lung disease) and stroke. Review of the resident's February 2026 MARs, dated 2/1/26 through 2/22/26, showed:-An order, dated 12/21/25, for metoclopramide (medication used to treat severe heartburn and diabetic gastroparesis or slow stomach emptying) 10 mg tablet once daily, at 6:00 A.M. before breakfast;--MAR blank with no documentation the metoclopramide was administered at 6:00 A.M. on 2/10/26;-An order, dated 8/26/25, amlodipine (a calcium channel blocker) 10 mg once daily between 7:15 A.M. to 11:15 A.M.;--MAR blank with no documentation amlodipine was administered on 2/15/26, 2/16/26, and 2/19/26;-An order, dated 8/26/25, for aspirin 81 mg once daily between 7:15 A.M. to 11:15 A.M.;--MAR blank with no documentation aspirin was administered on 2/15/26, 2/16/26, and 2/19/26;-An order, dated 8/2/25, hydrochlorothiazide (a diuretic/water pill used to treat high blood pressure and edema fluid retention) 12.5 mg once daily between 7:15 A.M. to 11:15 A.M.;--MAR blank with no documentation aspirin was administered on 2/15/26, 2/16/26, 2/17/26, and 2/22/26;-An order, dated 9/1/25, for Klor-Con (potassium chloride) ER, 20 mEq once daily between 7:15 A.M. to 11:15 A.M.;--MAR blank with no documentation medication was administered on 2/16/26;-An order, dated 12/16/25, for amantadine (medication used to treat Parkinson's disease) 100 mg capsule, one capsule twice daily between 7:15 A.M. to 11:15 A.M and in the evening between 7:15 P.M. to 11:00 P.M.;--MAR blank with no documentation amantadine was administered in the morning on 2/10/26 and 2/16/26;--MAR blank with no documentation amantadine was administered in the evening on 2/4/26, 2/5/26, 2/9/26, 2/10/26, 2/16/26, and 2/20/26;-An order, dated 3/21/25 for Budesonide-glycopyr-formoterol HFA aerosol inhaler (a prescription, fixed-dose combination medication used for the long-term maintenance treatment of COPD), administer 2 inhalation puffs twice daily between 7:15 A.M. to 11:15 A.M and in the late afternoon/early evening between 3:15 P.M. to 6:45 P.M.;--MAR blank with no documentation amantadine was administered in the morning on 2/15/26 and 2/16/26;--MAR blank with no documentation amantadine was administered in the late afternoon/early evening on 2/5/26, 2/9/26, 2/10/26, and 2/16/26;-An order, dated 3/21/25, for memantine (medication used to treat moderate to severe Alzheimer's disease and dementia) 5 mg, twice daily twice daily between 7:15 A.M. to 11:15 A.M and in the evening between 7:15 P.M. to 11:00 P.M.;--MAR blank with no documentation memantine was administered in the morning on 2/16/26;--MAR blank with no documentation memantine was administered in the evening on 2/9/26 and 2/16/26;-An order, dated 7/7/25, for carbidopa-levodopa (medication used to treat Parkinson's disease) 25-100 mg, administer 3.5 tabs, three times daily, between 7:15 A.M. to 11:15 A.M, 11:30 A.M. to 2:45 P.M., and in the evening between 7:15 P.M. to 11:00 P.M.;--MAR blank with no documentation carbidopa-levodopa was administered in the morning on 2/10/26 and 2/16/26;--MAR blank with no documentation carbidopa-levodopa was administered late morning to early afternoon on 2/10/26, 2/15/26, 2/16/26, 2/17/26, and 2/19/26;--MAR blank with no documentation carbidopa-levodopa was administered in the evening on 2/3/26, 2/9/26, 2/16/26, and 2/18/26;-An order, dated 3/21/25, for bisacodyl (a stimulant laxative), 5 mg tablets, take 2 tablets once daily at bedtime;--MAR blank with no documentation bisacodyl was administered on 2/4/26, 2/7/26, 2/9/26, 2/13/26, 2/16/26, and 2/18/26;-An order, dated 12/5/25, for melatonin 3 mg tablet at bedtime;--MAR blank with no documentation melatonin was administered on 2/3/26, 2/4/26, 2/9/26, 2/10/26, 2/13/26, 2/16/26, and 2/18/26. 10. Review of Resident #2's medical record, showed diagnoses included Parkinson's disease, diabetes, major depressive disorder, hypertension, hyperlipidemia, allergic rhinitis (environmental allergies), cerebrovascular disease (a group of conditions that impair blood flow to the brain, leading to oxygen deprivation, brain cell damage, and often stroke), and calculus (a solid, crystal-like mineral deposit) of the ureter (the narrow tube that carries urine from the kidney to the bladder). Review of the resident's February 2026 MARs, dated 2/1/26 through the morning on 2/18/26, showed:-An order, dated 11/25/24, for polyethylene glycol (laxative), 17 gm, once daily between 7:00 A.M. and 3:00 P.M.;--MAR blank with no documentation polyethylene glycol was administered on 2/8/26, 2/13/26, 2/14/26, 2/15/26, and 2/17/26;-An order, dated 7/2/25, for fluticasone propionate (nasal spray used to reduce inflammation and treat allergies, asthma, and COPD) spray, 50 mcg, administer one nasal spray, in each nostril, once daily in the morning;--MAR blank with no documentation fluticasone propionate was administered in the morning on 2/8/26, 2/16/26, 2/17/26, and 2/18/26;-An order, dated 8/8/23 for hydrochlorothiazide 12.5 mg once daily between 7:15 A.M. to 11:15 A.M.;--MAR blank with no documentation hydrochlorothiazide was administered on 02/15/26, 2/16/26, 2/17/26, and 2/18/26;-An order, dated 10/9/23 for metoprolol succinate ER) 25 mg once daily in the morning, for hypertension;--MAR was blank with no documentation that Metoprolol was administered on 02/15/26, 2/17/26, and 2/18/26;-An order, dated 1/22/25, for multivitamin tablet, take one tablet every morning between 7:15 A.M. to 11:15 A.M.:--MAR blank with no documentation that multivitamin was administered on 02/17/26 and 2/18/26;-An order, dated 8/8/23, for sertraline (antidepressant) 50 mg tablet, administer once daily in the morning;--MAR blank with no documentation sertraline was administered on 02/17/26 and 2/18/26;-An order, dated 8/8/23, for amantadine 100 mg capsule, one capsule twice daily between 7:15 A.M. to 11:15 A.M and between 3:15 P.M. to 6:45 P.M.;--MAR blank with no documentation amantadine was administered in the morning on 2/15/26, 2/17/26 and 2/18/26;--MAR blank with no documentation amantadine was administered between 3:15 P.M. to 6:45 P.M on 2/12/26 and 2/14/26;-An order, dated 5/20/25, for loteprednol etabonate eye drops (an ophthalmic corticosteroid used to treat eye inflammation, pain, and swelling), suspension 0.5 %, administer one drop, ophthalmic (eye), twice daily;--MAR blank with no documentation loteprednol etabonate eye drops was administered in the morning on 2/15/26, 2/16/26, 2/17/26 and 2/18/26;--MAR blank with no documentation loteprednol etabonate eye drops was administered in the afternoon on 2/14/26;-An order, dated 8/15/23, for metformin 1000 mg by mouth, twice daily;--MAR blank with no documentation the metformin was administered in the morning on 2/17/26 and 2/18/26;--MAR blank with no documentation the metformin was administered at bedtime on 2/14/26;-An order, dated 8/8/23, for carbidopa-levodopa 25-100 mg, administer three tabs, three times daily, at 8:00 A.M., 2:00 P.M., and 8:00 P.M.;--MAR blank with no documentation carbidopa-levodopa was administered in the morning on 2/17/26 and 2/18/26;--MAR blank with no documentation carbidopa-levodopa was administered at 2:00 P.M. on 2/6/26, 2/7/26, 2/14/26, and 2/15/26;-An order, dated 1/30/25, for ocean nasal spray (a non-medicated, 0.65% sodium chloride solution) 0.65%, administer two sprays into each nostril, twice daily;--MAR blank with no documentation ocean nasal spray was administered in the morning on 2/15/26 and 2/17/26;--MAR blank with no documentation ocean nasal spray was administered in the afternoon on 2/5/26 and 2/8/26. 11. Review of Resident #3's medical record, showed diagnoses included heart failure, COPD, moderate protein-calorie malnutrition, anxiety disorder, hypertension, spinal stenosis (a chronic, degenerative condition where the spinal canal narrows, putting pressure on the spinal cord and nerve), alcohol abuse, depression, hyperlipidemia, anxiety disorder, peripheral vascular disease, and GERD. Review of the residen[

Based on interview and record review, the facility failed to ensure residents received treatment in accordance with acceptable standards of practice when facility staff failed to complete and document neurological assessments (neuro checks) following unwitnessed falls for three residents (Residents #3, #10 and #15). The sample was 17. The census was 80.Review of the facility's Fall Evaluation and Prevention policy, dated 8/2020, showed:-Purpose: To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents;-Policy: The facility will evaluate residents for their fall risk and develop interventions for prevention. Upon admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls. The staff should not utilize a restraint to prevent falls unless they receive written documentation to support the use of the restraint. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed;-Procedure:-Definition: A fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions;--An un-witnessed fall occurs when a resident is found on the floor and neither the resident nor anyone else knows how he or she got there;-Following a fall the following steps should be undertaken:--Evaluate the resident promptly in order to identify and treat injuries. The resident should not be moved until the licensed nurse has evaluated their condition, unless absolutely necessary. The evaluation should include vital signs and neurological (neuro) evaluation - pulse (P), respiration (R), and blood pressure (BP) measurements, assessment of pupil size and reactivity, and equality of hand grip strength) status;--If there was a loss of conscious or the fall was unwitnessed, neuro signs should be initiated and checked for at least 72 hours. 1. Review of Resident # 3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/8/25, showed:-Cognitively intact:-Falls since admission/entry or reentry or the prior assessment: No;-Diagnoses included high blood pressure, anxiety, restless leg syndrome (occurrence of uncomfortable sensations in the legs and the urge to move them to relieve the sensations), and pain in spine. Review of the resident's incident report, dated 2/6/26 at 3:40 A.M., showed:-Nursing description: Notified by aide that resident had an unwitnessed fall out of bed upon assessment resident was lying on her back flat on the floor, noted resident with skin tear to left elbow and bruising on left scapula (shoulder blade);-Resident description: Resident stated he/she was in a deep sleep and he/she just fell;-Was this incident witnessed: No;-Description: Full assessment of skin and vitals taken, vitals within normal limits (WNL) assessed bruising, cleaned and bandaged left elbow. As needed (PRN) pain medication given for pain. Notified Director of Nursing (DON) and left message with physician on file;-Injury Type: No Injuries observed at time of incident;-Level of pain: Seven out of 10;-People Notified: DON and physician;-Resident family/emergency contact not notified of fall. Review of resident's medical record, showed no documentation of neuro checks completed for the unwitnessed fall. 2. Review of Resident #10's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Falls since admission/entry or reentry or the prior assessment: No;-Diagnoses included dementia, Parkinson's disease (a progressive, chronic brain disorder that primarily affects movement), stroke, seizure, and repeated falls. Review of the resident's incident report, dated 2/16/26 at 12:30 P.M., showed:-Nursing description: Resident slid out of wheelchair onto floor in hallway;-Resident description: Resident unable to give description;-Was this incident witnessed: No;-Description: Vital signs obtained, hospice contacted, resident assisted to bed;-Injury type: Abrasion;-Injury location: Face;-People Notified: DON and physician;-Resident family/responsible party not notified of fall. Review of the resident's medical record showed, no neuro checks completed for the unwitnessed fall. 3. Review of Resident #15's annual MDS, dated [DATE], showed:-Severe cognitive impairment;-Falls since admission/entry or reentry or the prior assessment: Yes;-Number of falls: One;-Falls with no injury: One;-Falls with injury (except major): One;-Diagnoses included seizure, dementia, high blood pressure, sleep disorder, and osteoarthritis (joint disease, causing the protective cartilage on bone ends to break down, resulting in pain, swelling, and stiffness). Review of the resident's incident report dated 2/8/26 at 9:43 P.M., showed:-Nursing Description: Resident was trying to get in the bed and fell, resident did not hit his/her head. Family and physician aware no new orders. Denies any pain or discomfort at this time;-Resident Description: Resident Unable to give description;-Was this incident witnessed: No;-Injury type: No injuries observed at time of incident;-People Notified: None listed. Review of the resident's medical record, showed no neuro checks completed for the unwitnessed fall. 4. During an interview on 2/20/26 at 11:06 A.M., the Interim Director of Nursing (DON) and the Previous Administrator (PA) said they expected staff to be knowledgeable of and to follow facility policies and procedures. If a resident had a fall, they expected the nurse to complete a head to toe assessment, including obtaining vital signs and starting neuro checks if the fall was unwitnessed or if the resident hit their head. They expected notifications to be made to the physician, family/Resident Representative (RR) and the DON. They expected the notifications to be documented in the incident report and/or progress note. They expected post-fall monitoring to be completed for 72 hours after the fall. They expected documentation of the post fall monitoring to be completed in the resident's progress notes once per shift for 72 hours. They expected vital signs to be completed each shift if neuro checks were not being completed and for them to be documented in the progress note or placed in the resident's medical record under vital signs.

Based on observation, interview and record review, the facility failed to identify interventions to reduce the likelihood of another fall for four residents who had unwitnessed falls (Residents #3, #10, #1, and #15), and facility staff failed to notify the resident's family/resident representative (RR) of falls for two residents (Residents #3 and #10). In addition, the facility failed to ensure three staff performed an assisted transfer for one resident (Resident #8) as instructed by the resident's physician orders and care plan, and staff failed to document an incident report and to notify the resident's physician and RR when the resident was injured during a staff-assisted transfer. The sample was 17. The census was 80.Review of the facility's Fall Management Program Policy, undated, showed:-Purpose: To prevent resident falls and minimize complications associated with falls through the development of a fall management program;-Policy: The facility will provide the highest quality care in the safest environment for the residents residing in the facility. The facility has developed a fall management program that strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation;-Procedure:-Post Fall:--A. Following a resident's fall, the licensed nurse will complete an incident report and a Post Fall Assessment & Investigation within 24 hours or as soon as practicable;--B. The licensed nurse will review the circumstances of the fall, review the plan of care, implement new interventions as appropriate, and revise the plan as indicated;--C. The interdisciplinary team (IDT) committee will meet within 72 hours of a fall. The IDT committee will review and document:---i. Summary of event following a fall;---ii. Root cause analysis;---iii. Referrals, as necessary and;---iv. Interventions to prevent future falls; -Documentation:--A. Fall Risk Assessments will be maintained in the resident's medical record; --B. The IDT committee will document findings and recommendations in the resident's medical record. The IDT committee may use the IDT Minutes - Sub Committee form for documentation purposes; --C. Nursing staff will document the resident's response to interventions being utilized in the resident's medical record;--D. The resident's care plan will be updated as necessary;-Resident/responsible party:--i. Education provided to the resident and/or responsible party will be documentedin the medical record;--ii. Both resident and family should be informed and understand fall risk factors andagree on strategies to prevent the resident from falling. Review of the facility's Fall Evaluation and Prevention Policy, dated 8/2020, showed:-Purpose: To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents;-Policy: The facility will evaluate residents for their fall risk and develop interventions for prevention. Upon admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls. The staff should not utilize a restraint to prevent falls unless they receive written documentation to support the use of the restraint. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed;-Procedure:-Definition: A fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions; -An un-witnessed fall occurs when a resident is found on the floor and neither the resident nor anyone else knows how he or she got there;-Root Cause Analysis;--Complete the Accident/Incident report and notify the physician and responsible party. Document the physician orders and/or response from the physician and responsible party;-If the fall was un-witnessed, initiate the investigation including witness statements from staff and residents. Try to determine who was the last person to see the resident prior to the fall and the resident's condition at that time;-The IDT team will review the plan of care and update the interventions as appropriate. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/8/25, showed:-Cognitively intact:-Falls since admission/entry or reentry or the prior assessment: No;-Diagnoses included high blood pressure, anxiety, restless leg syndrome (occurrence of uncomfortable sensations in the legs and the urge to move them to relieve the sensations), and pain in spine. Review of the resident's incident report dated 2/6/26 at 3:40 A.M., showed:-Nursing description: Notified by aide that resident had an unwitnessed fall out of bed upon assessment resident was lying on her back flat on the floor, noted resident with skin tear to left elbow and bruising on left scapula (shoulder blade);-Resident description: Resident stated he/she was in a deep sleep and he/she just fell;-Was this incident witnessed: No;-Description: Full assessment of skin and vitals taken, vitals within normal limits (WNL) assessed bruising, cleaned and bandaged left elbow. As needed (PRN) pain medication given for pain. Notified Director of Nursing (DON) and left message with physician on file;-Injury Type: No Injuries observed at time of incident;-Level of pain: Seven out of 10;-People Notified: DON and physician;-Resident family/emergency contact not notified of fall. Review of resident's progress notes 2/6/26 through 2/8/26, showed no IDT committee meeting notes or interventions implemented following the resident's fall on 2/6/26. Review of the resident's care plan, in use at the time of survey, showed:-Problem: Resident is at risk for falls related to impaired mobility, anti-depression drug use, previous falls, and alcohol abuse;-Goal: Minimize the risk for falls and related injury through the next review;-Approaches, dated 8/27/24, included:--Despite decreased safety and recommended assist with mobility, resident chooses to remain as independent as possible and continues to self transfer. Staff to provide frequent checks and offer to assist with toileting and transfers;--Determine ability to understand use of call light and ability to utilize. Provide appropriate call light system;--Keep personal items and frequently used items within reach;--Occupational therapy (OT) to screen. Evaluation and treatment as indicated/ordered;--Physical therapy (PT) to screen. Evaluation and treatment as indicated/ordered;-No interventions identified following the resident's fall on 2/6/26. 2. Review of Resident #10's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Falls since admission/entry or reentry or the prior assessment: No;-Diagnoses included dementia, Parkinson's disease (a progressive, chronic brain disorder that primarily affects movement), stroke, seizure, and repeated falls. Review of the resident's incident report, dated 2/16/26 at 12:30 P.M., showed:-Nursing description: Resident slid out of wheelchair onto floor in hallway;-Resident description: Resident unable to give description;-Was this incident witnessed: No;-Description: Vital signs obtained, hospice contacted, resident assisted to bed;-Injury type: Abrasion;-Injury location: Face;-People Notified: DON and physician;-Resident family/responsible party not notified of fall. Review of resident's progress notes 2/16/26 through 2/18/26, showed no IDT committee meeting notes or interventions implemented following the resident's fall on 2/16/26. Review of the resident's care plan, in use at the time of survey, showed:-Problem: Resident has recent history of falls related to seizures and mobility;-Goal: No further incident of falls with/without injury through next review;-Approaches, dated 6/11/25, included: -Evaluate history/cause of past falls. Incorporate findings into care needs;-Keep call light within reach. Assess for ability to understand use of call light and ability to use;--Keep personal items and frequently used items within reach;--OT to screen. Evaluation and treat as indicated;--PT to screen. Evaluation and treat as indicated;--Transfer status independent;-No interventions identified following the resident's fall on 2/16/26. 3. Review of Resident #1's admission MDS, dated [DATE], showed:-Severe cognitive impairment;-Falls since admission/entry or reentry or the prior assessment: No;-Diagnoses included dementia, high blood pressure, stroke, diabetes, and anxiety. Review of the resident's incident report, dated 2/6/26 at 8:35 P.M., showed:-Type of incident: Fall with injury;-Description of incident: Nurse heard resident screaming. Upon entering resident room observed resident on his/her left side. Resident left wrist was swollen and he/she complained of hip pain. Emergency medical services (EMS) called and resident was transferred to the hospital. Message left for resident family member. Physician and DON notified. Review of resident's progress notes 2/6/26 through 2/8/26, showed no IDT committee meeting notes or interventions implemented following the resident's fall on 2/6/26. Review of the resident's care plan, in use at the time of survey, showed:-Problem: Resident is at risk for falls related to impaired mobility, incontinent of bladder and anti-psychotic drug use;-Goal: Minimize the risk for falls and related injury through next review;-Approach, dated 12/11/25, for monitoring within monitoring, antithrust cushion (cushion that prevents forward sliding in chair);-Approaches, dated 12/3/25, included: --Despite decreased safety and recommended assist with mobility, the resident chooses to remain as independent as possible and continues to self transfer. Staff to provide frequent checks and offer to assist with toileting and transfers;--Determine ability to understand use of call light and ability to utilize. Provide appropriate call light system;--Keep personal items and frequently used items within reach;--OT to screen. Evaluation and treatment as indicated/ordered;--PT to screen. Evaluation and treatment as indicated/ordered,--No intervention identified following the resident's fall on 2/6/26. Review of the resident's medical record, showed no post fall risk evaluation completed for fall on 2/6/26. 4. Review of Resident #15's annual MDS, dated [DATE], showed:-Severe cognitive impairment;-Falls since admission/entry or reentry or the prior assessment: Yes;--Number of falls: One;--Falls with no injury: One;--Falls with injury (except major) skin tears, abrasions, lacerations, superficial bruises, hematomas (bruise that happens when an injury causes blood to collect and pool under the skin) and sprains: One;--Falls with major injury: None;-Diagnoses included seizure, dementia, high blood pressure, sleep disorder, and osteoarthritis (joint disease, causing the protective cartilage on bone ends to break down, resulting in pain, swelling, and stiffness). Review of the resident's incident report, dated 2/8/26 at 9:43 P.M., showed:-Nursing description: Resident was trying to get in the bed and fell, resident did not hit his/her head. Family and physician aware no new orders. Denies any pain or discomfort at this time;-Resident description: Resident unable to give description;-Was this incident witnessed: No;-Injury type: No injuries observed at time of incident;-People notified: None listed. Review of resident's progress notes, dated 2/8/26 through 2/10/26, showed no IDT committee meeting notes or interventions implemented following the resident's fall on 2/8/26. Review of the resident's care plan, dated 1/8/26, showed:-Problem: Resident has a recent history of falls related to poor safety awareness, impulsive, anti-depressant drug use, impaired mobility, and has a sleep disorder;-Minimize the risk for falls and related injury through next review;-Approach, dated 1/13/26, for resident has very poor safety awareness and is very forgetful. Will have staff assist him/her to bed after dinner;-Approaches, dated 1/6/26, included:--Despite decreased safety and recommended assist with mobility, the resident chooses to remain as independent as possible and continues to self transfer. Staff to provide frequent checks and offer to assist with toileting and transfers;--Despite frequent reminders, the resident does not remember to use call light to ask for assist. Staff to attempt to anticipate needs;--Ensure call light is in reach and educate on the use of the call light, if indicated;--Evaluate history/cause of past falls. Incorporate findings into care needs;--PT to screen. Evaluation and treatment as indicated/ordered;-No interventions identified following the resident's fall on 2/8/26. 5. During an interview on 2/20/26 at 11:06 A.M., the Interim DON and the Physician Assistant (PA) said they expect staff to be knowledgeable of and to follow facility policies and procedures. If a resident had a fall, they expected notifications to be made to the physician, family/RR and the DON. They expected the notifications to be documented in the incident report and/or progress note. They expected the IDT, which consisted of the DON, ADON, Administrator, Social Services, Director of Rehab (DOR), and MDS Coordinator, to meet within 24 hours after a fall, unless the fall occurred Friday through Sunday and then they would meet on Monday morning. They expected the DON to enter the IDT note in the resident's medical record within 72 hours post-fall. The IDT note would include a summary of the incident and the intervention and the MDS Coordinator would enter the intervention onto the resident's care plan with the date of the fall. 6. Review of the facility's Incident log policy, dated 6/2020, showed:-Purpose: To provide a standardized system for the Facility to track incidents and analyze trends to identify root cause and improve the quality of care provided to residents;-Policy: The Facility will log incident reports as they occur. Each log will capture a month's worth of incident data;-Procedure: In the event of an incident, a licensed nurse or the individual who first encounters or witnesses an incident will complete an Incident/Accident Report Form and ensure the following information is included in the Incident Log:--A. Resident name;--B. Day and shift during which the incident occurred;--C. Type code;--D. Injury code;--E. Location code;--F. Severity code and;--G. Medication/Treatment error code. Review of the Resident #8's medical record, showed:-Diagnoses included heart failure, morbid obesity, anxiety, chronic pain syndrome (condition defined by pain lasting over three to six months), high blood pressure, muscle weakness, and right knee pain;-An order, dated 3/10/25, for transfer status: Full body lift with three people. Review of the resident's annual MDS, dated [DATE], showed cognitively intact. Review of the resident's care plan, dated 12/9/25, showed:-Problem: Resident required cares in pairs with activities of daily living (ADL, bathing, dressing, eating, toileting, and transferring) assistance due to history of embellished stories and transferred full body lift with three people;-Goal: Needs will be met and cares provided safely through next review. Review of the resident's progress notes dated 2/17/26 through 2/19/26, showed:-No progress note of an incident on 2/17/26;-On 2/18/26 at 4:34 P.M., staff documented the resident stated that on 2/17/25 at 4:00 P.M. two agency Certified Nurse Aides (CNAs) were putting him/her into the Hoyer lift and were turning him/her without informing him/her first. Once resident was in the Hoyer and was being lowered into his/her chair, the crossbar on the Hoyer scraped his/her hand and wrist. The resident yelled stop, but the staff was trying to get him/her out of the air and into his/her seat. Resident had a skin tear on his/her hand with a dressing on it and he/she had a bruise on his/her wrist. Resident admitted that he/she refused to cross his/her arms while in the Hoyer because he/she was afraid of falling again;-No progress notes for post-incident monitoring. Further review of the resident's medical record, showed:-No incident report completed on 2/17/26;-No skin assessment completed on 2/17/26;-No notifications to physician and RR. Observation on 2/19/26 at 1:33 P.M., showed the resident had bruising on top of his/her left forearm and left hand with a small, half-circular scab on top of his/her left hand. During an interview, the resident said that two CNAs were getting him/her up with the Hoyer lift and while the CNAs were lowering him/her into the wheelchair, the bar of the Hoyer starting touching his/her left hand. His/Her hands were on his/her sides and while staff placed his/her buttocks into the wheelchair, the bar pushed against his/her left hand, then pushed up onto his/her forearm causing bruising and a skin tear. Observation on 2/25/26 at 10:55 A.M., showed CNA A and CNA B used a Hoyer lift to transfer the resident from his/her bed into his/her wheelchair. There was not a third staff member involved in the transfer. During an interview after the transfer, CNA A and CNA B said only two people were needed for the Hoyer transfer. CNA A and CNA B said they were not aware that the resident's care plan showed three people were needed during the resident's transfers. During an interview on 02/26/26 at 3:09 P.M., the Interim DON and Current Administrator (CA) said if a resident obtained an injury during a staff-assisted transfer, they expected a nurse to do a head to toe assessment to evaluate the resident's skin. They expected an incident report and progress note to be completed with a description of the injury. They expected the physician, family/RR and DON to be notified and the notifications to be documented in the incident report/progress note. Any new orders should be entered onto the resident's physician order summary and the nurse should enter an order on the resident's treatment administration record (TAR) to monitor the site until healed if no treatment is needed. They expected staff to complete a progress note each shift for 72 hours after the incident. They expected the post-incident progress note to include observations of the resident and if there were any changes to the injury. They expected staff to follow the interventions listed in the resident's care plan. They expected physician orders to be followed. 273784727378382786977

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when staff failed to administer seizure medication as ordered for one resident who experienced increased seizures (Resident #10). The sample was 17. The census was 80. Review of the facility's Physician Orders policy, revised June 2020, showed:-Purpose: This will ensure that all physician orders are complete and accurate;-Policy: The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary;-Procedure: --Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline;--Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the Medication Administration Record (MAR)/Treatment Administration Record (TAR). Review of the facility's General Guidelines for Medication Administration policy, dated August 2020, showed:-Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions;-Preparation:-At a minimum, the Five Rights (right resident, right drug, right dose, right route, and right time) should be applied to all medication administration and reviewed at three steps in the process of preparation: --When medication is selected;--When the dose is removed from the container; --After the dose is prepared and the medication is put away;-Always employ the MAR during medication administration;--Prior to the administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. If the label and the MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule;-If the medication cannot be located, after further investigation, the pharmacy is contacted or medication removed from the emergency kit;-Administration:-Medications are administered in accordance with written orders of the prescriber;-The person who prepares the dose for administration is the person who administers the dose;-A schedule of routine dose administration times is established by the facility and utilized on the administration records;-For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR is flagged. After completing the medication pass. the nurse returns to the missed resident to administer the medication;-Refusals of Medication:--Residents may actively refuse medications;--Medication refusal must be reported to the prescriber after three doses are refused, or in accordance with facility policy, and prescriber notification must be documented;-Documentation (including electronic):-The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given;-At the end of each medication pass, the person administering the medications reviews the MAR to ensure that necessary doses were administered and documented;-In no case should the individual who administered the medication report off-duty without first recording the administration of any medications;--The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration.-When PRN medications are administered, the following documentation is provided:--a. Date and time of administration;--b. Dose;--c. Route of administration (if other than oral);--d. Injection site, if applicable;--e. Complaints or symptoms for which the medication was given;--f. Results achieved from giving the dose and the time the results were noted;--g. Signature or initials of the person recording the effects, if different from the person administering the medication;-If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at a scheduled time or a starter dose of an antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled;--An explanatory note is entered on the reverse side of the record;--If three consecutive doses, or in accordance with facility policy, of a vital medication are withheld, refused, or not available, the physician is notified;---Nursing documents the notification and physician response;-If an electronic MAR system is used, specific procedures required for resident identification, identification of medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual;--These procedures should be followed, and may differ slightly from the procedures for using paper MARs. Review of the facility's Seizure Precautions policy, dated June 2020, showed:-Purpose: To ensure the safety of residents during seizure activity;-Policy: The facility will provide preventative measures prior to and during seizure activity to prevent resident injury to the extent possible;-Procedure:-Residents considered at risk for seizures are those with a history of seizures and those withconditions that predispose them to seizures;-Determine the appropriate seizure precautions based on, included:--The kind of seizure has the resident had before;--Missed doses of anticonvulsants;--Whether the previous seizure was an acute episode or if it resulted from a chronic condition. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/29/26, showed:-Moderate cognitive impairment;-Diagnoses included seizure disorder, repeated falls, dementia, Parkinson's disease (a progressive neurodegenerative brain disorder that affects the whole-body), and stroke. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident is at risk for seizures, due to diagnosis of seizure disorder;-Goal: Resident will decrease the number of seizures he/she has through the next review;-Approaches included administer medications as ordered. Review of the resident's physician order sheet, dated 1/1/26 to 1/31/26, showed:-An order, dated 8/11/25, to admit to hospice;-An order, dated 5/7/25, for Depakote (divalproex, anti-seizure medication) extended release (ER) 24-hour, 500 milligram (mg) tablet. Give two tablets, 1000 mg, oral once a day at morning medication pass (7:25 A.M. to 11:15 A.M.) for epilepsy (seizure disorder);-An order, dated 5/13/25, for divalproex tablet ER, 250 mg tablet. Give five tablets, 1,250 mg oral, once daily at bedtime (7:15 P.M. to 11:00 P.M.) for epilepsy;-An order, dated 9/1/25, for levetiracetam (anti-seizure medication) 1,000 mg tablet. Give one, 1,000 mg oral tablet, twice daily (at 07:15 AM to 11:15 AM and at 03:15 PM to 06:45 PM) for epilepsy;-An order, dated 9/30/25, for lacosamide (anti-seizure medication), 100 mg tablet. Give one tablet, 100 mg oral, twice daily (at 07:15 AM to 11:15 AM and at 03:15 PM to 06:45 PM) for localization-related (focal/partial) epilepsy;-An order, dated 12/5/25, for lorazepam (medication used to treat anxiety and active seizures) concentrate 2 mg per milliliter (mg/ml). Give 0.5 ml (1mg) oral, every 12 hours, at 9:00 A.M. and 9:00 P.M. Review of the resident's paper MAR, dated February 2026, showed:-Depakote ER 1,250 mg, scheduled for 7:15 P.M. to 11:00 P.M., not documented as given on 2/2/26, 2/4/26, 2/8/26, and 2/9/26;-Lacosamide 100 mg, scheduled for 3:15 P.M. to 6:45 P.M., not documented as given on 2/9/26;-Levetiracetam 1000 mg, scheduled for 3:15 P.M. to 6:45 P.M., not documented as given on 2/9/26. Review of the resident's paper Licensed Nurse MAR, dated February 2026, showed:-Lorazepam concentrate 2mg/ml, administer 0.5 ml (1 mg), scheduled for every 12 hours, not documented as given at 9:00 P.M. on 2/2/26, 2/3/26, 2/4/26, 2/5/26, 2/6/26, and 2/9/26;Lorazepam concentrate 2mg/ml, administer 0.5 ml (1 mg), scheduled for every 12 hours, not documented as given at 9:00 A.M. on 2/3/26, 2/4/26, 2/5/26, 2/6/26, 2/7/26, 2/9/26, and 2/10/26. Review of the resident's electronic progress note, dated 2/10/26 at 2:10 P.M., showed Licensed Practical Nurse (LPN) F documented the 200-hall nurse reported the resident had a brief seizure, while visiting a resident on the 200 hall, and there was no injury. During an interview on 3/6/26 at 11:01 A.M., LPN F said in a progress note he/she wrote on 2/10/26, he/she documented the lorazepam was given because he/she must have looked at the resident's paper MAR at that time. When told the paper MAR had no documentation for 9:00 A.M. on 2/10/26, LPN F said he/she must have looked at the lorazepam-controlled count sheet, as some days the nurses were not signing off on the paper MARs because it was too much. The new facility owners were taking away the CMTs and the nurse could not pass the nursing medications (medications assigned to the licensed nurse only), do all the wound and skin treatments, and pass the hundreds of medications normally passed by the CMT. There were days when the resident's morning medications did not get passed until after lunch, because of this. He/She was aware the resident received three other anti-seizure medications, twice daily, but did not check to see if they were being given as ordered, because he/she could not keep up and there was too much going on and too much to do. The resident had not had a seizure for a couple of months, prior to 2/10/26. Further review of the resident's paper MAR, dated February 2026, showed:-Lacosamide 100 mg, scheduled for 7:15 A.M. to 11:15 A.M., not documented as given on 2/15/26 and 2/16/26;-Levetiracetam 1000 mg, scheduled for 7:15 A.M. to 11:15 A.M., not documented as given on 2/16/26;-Depakote/divalproex ER 1,000 mg, scheduled for 7:15 A.M. to 11:15 A.M., not documented (box blank/no staff initials) as given on 2/16/26;-2/16/26.-Lacosamide 100 mg, scheduled for 3:15 P.M. to 6:45 P.M., not documented as given on 2/10/25, 2/15/25, and 2/16/26;-Levetiracetam 1000 mg, scheduled for 3:15 P.M. to 6:45 P.M., not documented as given on 2/10/26 and 2/16/26;-Depakote/divalproex ER 1,250 mg, scheduled for 7:15 P.M. to 11:00 P.M., not documented as given on 2/13/26, 2/14/26, 2/15/26, and 2/16/26. Further review of the resident's paper Licensed Nurse MAR, dated February 2026, showed:-Lorazepam concentrate 2mg/ml, administer 0.5 ml (1 mg), scheduled for every 12 hours, at 9:00 A.M. and 9:00 P.M., not documented as given at 9:00 A.M. on 2/11/26, 2/12/26, and 2/13/26;-Lorazepam concentrate 2mg/ml, administer 0.5 ml (1 mg), scheduled for every 12 hours, at 9:00 A.M. and 9:00 P.M., not documented as given at 9:00 P.M. on 2/10/26, 2/11/26, 2/12/26, and 2/16/26;-A handwritten order, undated, for lorazepam concentrate 2mg/ml, administer 0.5 ml (1 mg), every 4 hours PRN (as needed). Time row listed PRN 1, PRN 2, PRN 3, and PRN 4;--In column for PRN 1, for 2/16/26, the time 10:00 A.M., was written in (no nurse initials);--In column for PRN 2, for 2/16/26, the time 10:05 A.M. was written in (no nurse initials);-A handwritten order, undated, for lorazepam concentrate 2 mg/ml, administer 1 ml (1 mg) now;--The time row had 10:15 A.M. written in;--LPN C's initials inside MAR box for 2/16/26;-A handwritten order, undated, for lorazepam concentrate 2 mg/ml, administer 1 ml every 5 minutes, times 3 doses, as needed for uncontrolled seizures;--Time row listed PRN 1, PRN 2, PRN 3, with blank MAR boxes. Review of the hospice company's Patient Care Order (Verbal Order) sheet, dated 2/16/26 at 10:16 A.M., showed:-Lorazepam 2mg/ml oral concentrate, administer 1 ml (1 mg) sublingually (under the tongue) every 5 minutes as needed for uncontrolled seizures, times 3 doses;-Lorazepam 2mg/ml oral concentrate, administer 1 ml (1 mg) sublingually stat (immediately) for anxiety. Review of the resident's electronic progress notes, dated 2/16/26, showed:-No progress note regarding the resident's seizure activity at approximately 10:00 A.M. that morning; -At 2:54 P.M., LPN E documented the resident was found lying on the left side, on the floor, in front of the wheelchair. A pea-size abrasion was noted to the left forehead above the eyebrow and resident was alert and oriented times 4 (oriented to person, place, time, and situation). During an interview on 3/5/26 at 3:05 P.M., Certified Medication Technician (CMT) D said he/she worked at the facility on 2/16/26 as a CMT. He/She did not recall anyone having any seizures at the facility. He/She recalled going into the resident's room and passing medications to the resident's roommate, but did not recall seeing the resident who lived on the right side of the room. CMT D signed out the medications on the paper MAR for the people to whom he/she passed medications. When asked why none of the resident's medications were signed out on the 2/16/26 day shift, he/she said maybe the resident's MARs were not in the binder. Some residents did not have MARs, but he/she did not know who they were, how many there were, or to whom he/she reported the issue. He/She went from room to room, passing the medications, and if a resident was not in their room at the time, he/she went back later to see if they were there. During an interview on 2/26/26 at 11:56 A.M., LPN E said an aide came to him/her on the morning of 2/16/26 to report the resident had a seizure in the dining room. LPN E went to the dining room and saw the resident have three seizures, each lasting about one minute, with maybe 30 seconds in between each one. He/She did not write a progress note because the resident often had seizures but LPN E could not say how often because he/she worked the other units. During an interview on 3/4/26 at 11:00 A.M., the resident's Hospice Registered Nurse (RN) said she was on her way to the facility on 2/16/26 when the Nurse Practitioner (NP) texted her, a little before 10:00 A.M., notifying her the resident had two seizures in less than 10 minutes. At 10:00 A.M., the NP called to notify her the resident had two more seizures, they had exhausted their lorazepam orders, and they needed immediate orders for more lorazepam. The Hospice RN called the Hospice Physician, who gave additional lorazepam orders at 10:09 A.M., including one stat (given immediately) dose of 1 mg and another order to give lorazepam 1 mg every 5 minutes, for three doses total, if needed, for recurrent seizures. Review of the resident's progress note, dated 2/20/26 at 9:00 A.M., showed LPN E documented the resident had a seizure in the dining room, was taken to his/her room, placed into the bed, and given his/her seizure medications and a pain pill. No further seizure activity noted. During an interview on 02/20/26 at 11:06 A.M., with the Interim Director of Nursing (DON) and the Previous Administrator (PA), they said they expected staff to be knowledgeable of and to follow facility policies. They expected when medication was administered by a nurse or a CMT, they should document that it was administered by initialing on the resident's MAR. If there was no documentation, then it was not done/administered. During an interview on 2/26/26 at 3:09 P.M., with the Interim DON and the Current Administrator (CA), they said they expected medication to be administered as ordered. The Interim DON said the risk of not receiving seizure medication as ordered would increase the possibility of the resident having a seizure. During an interview on 2/26/26 at 11:44 A.M., the resident's physician, Physician I, said the resident admitted to the facility over two years ago because he/she was having multiple uncontrolled seizures at home. He/She had been stable, until this month, which Physician I thought was due to missed seizure medications, because things were so messed up with the medication issue at the facility. The resident told Physician I that he/she had five seizures back-to-back. The DON notified Physician I about the resident's seizure activity on 2/20/26, but Physician I was not notified about the seizure activity on 2/16/26. There have been times when residents were not getting their medications until 1:00 P.M. The resident had missed one dose of a seizure medication about six or eight months ago and had an immediate seizure episode. This is how Physician I knew the resident could not miss any seizure medications. 2743991

Based on observation, interview and record review, the facility failed to maintain an environment free of hazards by not maintaining water temperatures in resident bathrooms on the 100 hall between 105 degrees Fahrenheit (F) and 120 F. This affected 10 resident bathrooms, including Residents #10 and #25. The temperatures at the bathroom sinks measured as high as 148 F. The sample size was 22. The census was 94. Review of the facility's Monitoring Water Temperatures policy, revised 11/2022, showed: -Policy: The water temperature will be maintained between 110 degrees F and 120 degrees F; -Procedure: Environmental staff will check random water temperatures weekly, including three resident room sinks on each wing, common area sinks and bathing rooms; -Water temperatures will be documented on the Water Temperature Monitoring Log; -Procedure for checking water temperatures from water faucets: Let hot water run from faucet for three to five minutes. Review of the facility's June 2025 Weekly Water Temperature Log, showed: -On 6/3/25, room [ROOM NUMBER] measured at 120.0 F, room [ROOM NUMBER] measured at 117.0 F and room [ROOM NUMBER] measured at 114.0 F; -On 6/10/25, room [ROOM NUMBER] measured at 115.0 F, room [ROOM NUMBER] measured at 118.0 F and room [ROOM NUMBER] measured at 114.0 F. 1. Review of the Resident #10's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 4/9/25, showed: -Cognitively intact; -Uses walker or cane; -Diagnoses included anxiety and manic depression. Review of the resident's electronic records, showed diagnoses included idiopathic peripheral autonomic neuropathy, which is a condition where there is damage to the nerves that control automatic bodily functions. This could cause lack sensitivity to heat, which when water gets too hot will cause burns. Observations on 6/12/25 of Resident #10's bathroom sink, showed: -At 11:51 A.M., the water measured 138.0 F; -At 12:49 P.M., Maintenance Assistant (MA) A and the Administrator checked the water temperature at the bathroom sink. The water measured 134.5 F. During an interview on 6/12/25 at 11:49 A.M., the resident said the water from the bathroom faucet got very hot, like boiling water. It was hot enough for staff to fix instant coffee in the bathroom. 2. Review of Resident #25's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -No behaviors; -Used manual wheelchair independently; -Diagnoses included Alzheimer's disease, brain dysfunction and anxiety. Observations on 6/12/25, of the resident's room bathroom sink, showed: -At 12:06 P.M., the water measured 125.0 F. Observation on 6/12/25 at approximately 12:00 P.M., showed the resident propelled in his/her wheelchair down the hallway with a doll in his/her lap. The resident did not respond when attempts were made to talk with him/her. During an interview on 6/12/25 at 2:00 P.M., Certified Nursing Assistant (CNA) B said the resident wandered throughout the facility constantly, but did not think the resident would wander into the bathroom to turn on the water faucet. During an interview on 6/12/25 at 2:05 P.M., Licensed Practical Nurse (LPN) C said the resident wandered throughout the day and could not make his/her needs known, but the resident would not wander into his/her bathroom. 3. Observations on 6/12/25 of resident room [ROOM NUMBER]'s bathroom sink, showed: -At 11:46 A.M., the water measured 140.2 F; -At 12:48 P.M., MA A and the Administrator checked the water temperature at the bathroom sink. The water measured 135.5 F. 4. Observations on 6/12/25, of resident room [ROOM NUMBER]'s bathroom sink, showed: -At 10:17 A.M., the water measured 131.0 F; -At 1:00 P.M., MA A and the Administrator checked the water temperature at the bathroom sink. The water measured 141.0 F. 5. Observations on 6/12/25, of resident room [ROOM NUMBER]'s and 108's shared bathroom sink, showed: -At 11:57 A.M., the water measured 138.0 F.; -At 12:56 P.M., MA A and the Administrator checked the water temperature at the bathroom sink. The water measured 136.0 F. 6. Observations on 6/12/25, of resident room [ROOM NUMBER]'s bathroom sink, showed: -At 11:46 A.M., the water measured 140.2 F; -At 12:48 P.M., MA A and the Administrator checked the water temperature at the bathroom sink. The water measured 135.5 F. 7. Observations on 6/12/25, of resident room [ROOM NUMBER]'s bathroom sink, showed: -At 10:13 A.M., the water measured 140.0 F; -At 1:04 P.M., MA A and the Administrator checked the water temperature at the bathroom sink. The water measured 148.0 F. 8. Observations on 6/12/25, of resident room [ROOM NUMBER]'s bathroom sink, showed: -At 12:01 P.M., the water measured 144.0 F; -At 1:02 P.M., MA A and the Administrator checked the water temperature at the bathroom sink. The water measured 147.0 F. 9. Observations on 6/12/25, of resident room [ROOM NUMBER]'s bathroom sink, showed: -At 12:04 P.M., the water measured 144.0 F; -At 12:48 P.M., MA A and the Administrator checked the water temperature at the bathroom sink. The water measured 148.0 F. 10. Observation on 6/12/25 at 1:07 P.M., of the 100 hall boiler, showed the hot water tank's dials showed low, medium, hot, hot A, hot B, hot C, hot D and very hot. The temperature was set on Hot A. During an interview on 6/12/25 at 1:08 P.M., MA A said water temperatures should measure between 105.0 F through 120.0 F. Anything over 120.0 F was too hot. He/She took water temperatures weekly and said he/she did not always let the water run for three to five minutes when checking temperatures. The water tank should have been set to hot, not hot A. MA A turned the temperature down to low. 11. During an interview on 6/12/25 at 2:08 P.M., the Administrator said the plumber was in the building and drained the water from the 100 hall water tank. The temperature should have been set to hot, not hot A. The water temperature had been adjusted.

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with wounds requiring treatments for two residents (Resident #40 and Resident #14) and while administering medications through one resident's (Resident #58) gastrostomy tube (g-tube, a surgically inserted tube into the abdomen that is used for liquid nutrition and medications). The facility failed to ensure staff used good infection control practices for one resident (Resident #40) when providing perineum care (peri-care, cleansing of the genitals and anal area) and in three resident bathrooms (Resident #56, Resident #31 and Resident #64) that had soiled trash cans, urinals and catheter tubing (a flexible tube inserted into the body to drain fluids or administer medication) not properly stored. The sample was 22. The census was 94. Review of the facility's Enhanced Barrier Precautions (EBP) policy, revised on 3/2024, showed: -Purpose: To reduce the spread of multi-drug resistant organisms (MDRO); - EBP are indicated for residents with any of the following: -Infection or colonization with a CDC-targeted (refers to the Centers for Disease Control and Prevention's efforts to focus on specific health threats or populations to improve public health) MDRO when Contact Precautions do not otherwise apply; -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; - Procedure: -Residents with colonization of MDRO and/or with indwelling medical devices (central lines, G-tubes, Foley catheters) will be placed on EBP; -Signage will be placed outside of their rooms to alert staff that PPE (Personal protective equipment) is needed; -PPE including gowns and gloves, will be available immediately outside of the resident room; -PPE should be worn during high-contact resident care activities, such as: -Dressing; -Bathing/showering; -Transferring (not needed when transferring in common areas); -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use included: urinary catheter and feeding tube (G-tube); -Wound care: chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing; - Trash can will be placed inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room; -Private room is not required; - Resident may participate in communal activities and dining. Review of the facility's Hand Washing policy, revised 1/2021, showed: -When to wash hands (at a minimum): - When reporting to work and before going home; -Before eating and drinking; -Before and after using the toilet; -After sneezing, coughing, or blowing your nose; -After touching your hair, face, etc.; -After smoking cigarettes; -Before and after each resident contact; -After touching a resident or handling his or her belongings; -Whenever hands are obviously soiled; -After contact with any body fluids; -After handling any contaminated items (linens, soiled diapers, garbage, etc).; -When to use alcohol hand sanitizer: - Only when visible soil is absent; -After contact with residents' intact skin; -After contact with inanimate objects (including medical equipment); -Before donning sterile gloves; -Before entering the resident's room; -Before exiting the resident's room. 1. Review of Resident #40's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/6/25, showed: -Cognitively intact; -Diagnoses included heart failure, diabetes, anxiety, and depression. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is at risk for contraction of MDRO due to wound to right lower leg that requires the use of PPE; -Approach: The resident is on EBP; Staff is to wear gloves and gowns when providing high contact activities; -Problem: The resident is incontinent of bowel and bladder; -Approach: Provide incontinence care after each incontinent episode; Toilet as need per facility protocol. Review of the residents physician order sheets (POS) dated 6/17/25, showed: -An order dated 6/9/25, cleanse right lower extremity with normal saline, apply Santyl (a specialized ointment used to remove dead skin), apply moistened gauze and cover with ABD pad (a thick and large dressing), wrap with Kerlix (a specialized dressing), daily and as needed; -No orders for EBP. Observation on 6/16/24 at 9:47 A.M., showed an EBP magnet on the door frame of the resident's room. The resident lay in bed. Licensed Practical Nurse (LPN) N entered the resident's room and applied gloves and an isolation gown. LPN N prepared the resident's treatment to be completed. At 9:52 A.M., the Director of Education came into the resident's room and offered to assist LPN N with the resident's treatment. The Director of Education applied gloves and did not apply an isolation gown and removed the resident's soiled dressing to his/her right leg. After LPN N completed the treatment, the Director of Education held the resident's right leg while LPN N wrapped the resident's leg with the Kerlix dressing. The Director of Education did not wear an isolation gown during the resident's treatment. At 10:00 A.M., the Director of Education left the resident's room and Certified Nursing Assistant (CNA) P entered the resident's room. CNA P applied gloves and an isolation gown. CNA P rolled the resident's brief between the resident's legs. The resident was turned to his/her left side with the assistance of CNA P and LPN N. The resident's brief was saturated with urine and loose stool. CNA P cleaned the stool off the resident's buttocks and anal area. CNA P and LPN N assisted the resident roll to his/her right side. The resident's soiled brief was then removed. The resident was then positioned on his/her back. CNA P did not perform hand hygiene or change his/her gloves. CNA P then cleaned the resident's genitals with the same gloves on. A clean brief was applied by turning the resident side to side. The resident was positioned on his/her back and with the same gloved hands, CNA P adjusted the residents clothing and covered the resident with a sheet. During an interview on 6/17/25 at 10:06 A.M., LPN N said staff should change their gloves and wash their hands after cleaning the resident of bowel movement and prior to going to another body part. Staff should not touch the resident or anything in the room with soiled gloves. During an interview on 6/17/25 at 10:20 A.M., CNA M said staff should wash their hands and change gloves after cleaning a resident of bowel movement and prior to going to another body part. Staff should never touch the resident or other surfaces in the resident's room with soiled gloves. That included the bedding and the resident's clothing. 2. Review of Resident #58's quarterly MDS, dated [DATE], showed: -The resident is rarely understood; -The resident has a feeding tube; -Diagnoses included stroke, heart disease, and aphasia (inability to speak). Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is at risk for contraction of a MDRO due to G-tube that requires the use of PPE; -Approach: The resident is on EBP; Staff is to wear gloves and gowns when providing high contact activities. Review of the resident's physician order sheets (POS), dated 6/17/25, showed an order dated 1/21/25, Gowns and gloves are to be worn for all high contact activities. Observation on 6/13/25 at 8:22 A.M., showed the door frame to the resident's room had an EBP sign posted. LPN N prepared the resident's medications at the medication cart outside the resident's room. LPN N entered the resident's room and performed hand hygiene and applied gloves. LPN N then administered the resident's medications through his/her G-tube. LPN N did not wear an isolation gown. During an interview on 6/17/25 at 10:06 A.M., LPN N said the resident was on EBP precautions. He/She wasn't sure exactly the specifics on why certain residents required EBP. EBP required staff to wear an isolation gown and gloves when providing care. 3. Review of Resident #14's annual MDS, dated [DATE], showed: -Severely impaired cognitive skills for daily decision-making; -Had indwelling catheter; -Diagnoses included heart failure, high blood pressure, diabetes, and stroke; -Had one or more unhealed pressure ulcers at Stage I (intact skin with redness to a localized area that develops due to pressure) or higher. --------------------------------------------------------------------------------------------- Review of the resident's active POS, showed: -Catheter care per shift; -Gloves and gowns for all high contact task, wear eye protection if splash anticipated. Discontinue order when wound is healed, or medical device has been removed; -Santyl ointment 250 unit/gram, cleanse with wound cleanser, pat dry, right buttock, apply Santyl, calcium alginate (wound dressing derived from seaweed), apply foam dressing. Observation on 6/16/25 at 12:14 P.M., showed the door frame to the resident's room had a magnet EBP sign. PPE supplies hung behind the resident's door. LPN E entered the resident's room to provide wound care. He/She put on gloves. He/She did not put on a gown. He/She turned the resident to the side to expose the right buttock, then cleaned a small stool on the resident's bottom with wet wipes. He/She changed gloves then removed the old dressing to the right buttock. He/She wiped the wound area with gauze wet with wound cleanser. He/She then changed gloves prior to applying the ointment, then covered the wound with foam dressing. LPN E did not wash or sanitize his/her hands in between changing gloves. He/She did not wear a gown during the entire wound treatment process. During an interview on 6/18/25 at 9:39 A.M., LPN D said residents with catheters and wounds were in EBP rooms. EBP signs were on doors to remind staff gloves and gowns were to be worn. PPEs were to be worn anytime staff entered the room, even when providing care to the roommate who was not on EBP. LPN D said gloves needed to be changed in between steps and in between contact with dirty to clean. LPN D would wash his/her hands with soap and water then use hand sanitizer prior to putting on clean gloves. 4. During an interview on 6/18/25 at 11:42 A.M., the Director of Nursing (DON) said she expected staff to wear gloves and a gown when providing care to residents in EBP rooms. She expected staff to perform hand hygiene in between changing gloves. Staff were expected to change gloves after cleaning the resident's anal area and prior to cleaning the resident's genitals. Staff were expected not to touch the resident or the resident's belongings with soiled gloves. 5. Review of Resident #56's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Diagnoses included a stroke. Observations on 6/12/25 at 10:17 A.M., 6/13/25 at 8:08 A.M., 6/16/25 at 8:18 A.M. and 6/17/25 at 7:13 A.M., showed the resident shared a bathroom with two other residents. Two uncovered urinals hung on the bathroom rails. One urinal had the name of a resident who did not share the bathroom with the current residents of the room. A dentures case sat in the bathroom during the observations. The bathroom trash can had brown spots on the inner wall of the can. During an interview on 6/12/25 at 10:17 A.M., the resident said he/she shared a bathroom with two other residents. The urinals did not belong to him/her. One belonged to someone who was no longer in the room. He/She was not sure how long the urinals had been in the bathroom. He/She was not sure who the dentures case belonged to. Housekeeping cleaned out the trashcans. He/She was not sure how long the brown spots were on the trash can. 6. Review of Resident #31's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Exhibited delusions; -Rejection of care occurred four to six days of the week; -Wandering occurred one to three days of the week; -Diagnoses included dementia and depression. Observations on 6/12/25 at 10:30 A.M., 6/13/25 at 8:13 A.M. and 12:37 P.M., 6/16/25 at 8:21 A.M. and 6/17/25 at 7:21 A.M., showed the resident shared a bathroom with three other residents. Upon entering the resident's room, the smell of bowel was present. An uncovered and unlabeled wash basin lay on the bathroom floor. The bathroom trashcan had an empty trashcan liner. [NAME] spots were visible on the inside of the wall of the trash can. During an interview on 6/12/25 at 10:37 A.M., the resident did not respond when asked if he/she used the shared bathroom. The resident's roommate said the resident used the bathroom regularly. The roommate did not use the bathroom because he/she did not get out of bed. The roommate was not sure if the other two residents used the bathroom. 7. During an interview on 6/17/25 at 10:12 A.M., CNA F said urinals and wash basins should be covered and labeled. One of the urinals in Resident #56's shared bathroom belonged to a resident who was no longer in the room. CNA F was not sure who the wash basin belonged to in Resident #31's shared bathroom. The stains on the bathroom trashcan were bowel and should be cleaned. The urinals and wash basin should be covered and trashcans should be cleaned for infection control. During an interview on 6/17/25 at 10:19 A.M., LPN D said urinals and wash basins should be covered and labeled due to infection control. The trashcans had bowel on them and should be cleaned by Housekeeping. Nursing was responsible for ensuring urinals and wash basins were covered and labeled. During an interview on 6/17/25 at 10:22 A.M., the Housekeeping Supervisor said aides were not supposed to throw soiled briefs in resident trashcans due to odors and infection control. Housekeeping staff were responsible for cleaning resident bathrooms, but nursing was responsible for ensuring wash basins and urinals were covered. During an interview on 6/18/25 at 11:41 A.M., the Administrator and DON said wash basins and urinals should be covered and labeled. Staff should not throw soiled briefs in resident bathroom trashcans. 8. Review of Resident #64's quarterly MDS, dated [DATE], showed: -Cognition not assessed; -Rarely/never understood; -Rarely/never understands; -Speech Clarity: Unclear words, slurred or mumbled words; -Substantial/Maximal assistance from staff with toileting; -Dependent on staff for personal hygiene and bathing; -Section H: Bladder and Bowel: -H0100: Appliances: None marked; -Diagnoses included cerebral palsy (a group of neurological disorders that affect movement, posture, and muscle coordination) and depression. Review of the resident's electronic care plan dated 6/10/25, and in use during the survey, showed the resident needed assistance with self-care. Observations of the resident's bathroom, showed: -The resident shared the room with another resident; -On 6/12/25 at 11:27 A.M., an empty catheter bag lay on the left side of the commode in the corner, on the floor; -On 6/13/25 at 12:03 P.M. and 12:50 P.M., an empty catheter bag lay on the left side of the commode in the corner, on the floor. There was a plastic bag that contained a used catheter bag inside it, hanging on a rail on the wall. During an interview on 6/18/25 at 12:48 P.M., the Administrator said he would have expected for the plastic bag that contained the catheter bag to have been discarded. The catheter bag, the tubing and/or the blue cap on the end should not have touched the floor.

Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and respect when a staff member took a video of a resident from a personal phone and posted in social media (Resident #39). In addition, staff used their personal phones while monitoring residents during mealtime. The census was 94. The sample was 22. Review of the facility's undated Resident Rights, showed: -Your right to be treated with dignity and respect is the foundation of which all other resident rights and responsibility are based; -Your right to privacy and confidentiality is as important to you as it is to any other person. Review of the facility's Social Media and Electronic Devices Policy, dated 11/2019, showed: -To ensure residents receive the highest quality of care and to minimize risks associated with the use of social media and electronic devices in healthcare, the facility expects its employees to adhere to the guidelines and rules outlined in this policy; -Employees are strictly prohibited from posting, uploading, sending, or otherwise sharing or disclosing photos, videos or personal information of any resident without prior written permission of the resident or the resident's authorized agent; -Employees must use the facility's authorization form to obtain such prior written permission. This prohibition includes photos, videos, or other postings where the resident is not easily identifiable (e.g., a photo of the resident's hand, a close up photo of any part of a resident's body, or a photo of the back of a resident in the far background of the photo). -Employees are prohibited from having personal cell phones, smartphones, or digital cameras while working with or near residents, resident charts or other medical documents, white boards containing resident information, or resident medications. Additionally, employees are prohibited from using an electronic device with camera, video, and audio capabilities to record conversations or actions of anyone in the facility, including other employees. 1. Review of Resident #39's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -admitted on [DATE]; -Severely impaired cognitive skills for daily decision-making; -Diagnoses included heart disease, diabetes, dementia and anxiety; -On hospice care. Review of the resident's care plan, in use at time of survey, showed: -Problem: Behavioral symptoms. Resident at risk for harm related to the behavior, has inattention and disorganized thinking, elopement risk, looking for his/her care, talks out loudly and yells 'help' a lot; -Goal: Resident will be safe and free from harm to self and others and decreased in behavior through next review; -Approach: Assess and document behaviors as they occur, treat him/her with respect; -Problem: Cognitive loss/dementia; -Goal: Resident will have positive experiences in daily routine without overly demanding tasks and without becoming overly stressed through next review; -Approach: Encourage to verbalize feelings, concerns and fears, clarify misconceptions. Respect the resident's rights to make decisions. Support and reassure the resident in new situations. Review of a video clip posted on TikTok (a social media platform for creating, sharing and discovering short videos), by Licensed Practical Nurse (LPN) D, showed a resident sat in a wheelchair propelled by another staff. The eight second video showed the staff pointed the camera mostly to the floor. He/She walked towards the resident who was moved away from a door by the other staff. The side of the resident's face and body was shown very quickly, while the rest of his/her body showed most of the duration of the video. The resident was not easily identifiable, though the facility's floor indicated the facility's unique carpet design. During an interview on [DATE] at approximately 8:15 A.M., the Administrator said he did not recall a report where a staff posted a video on social media involving a resident but would find out if there was anything on file. At 9:20 A.M., the Administrator said the Director of Nursing (DON) had investigated the incident, but it was not proven where and when it occurred, and there was no resident identified. During an interview on [DATE] at 9:30 A.M., LPN D said he/she took the video around [DATE]. The resident in the video was Resident #39, who expired about a week ago. LPN D said he/she had no reason for taking the video, he/she was just tired. The video was taken down when he/she realized it was not appropriate. He/She said per the facility's policy, staff were not allowed to take or post video because of HIPAA (Health Insurance Portability and Accountability Act, is a US federal law that protects sensitive patient health information from being disclosed without the patient's consent or knowledge). The DON educated him/her on it. LPN D said the incident was sent to the Corporate office but was determined to not be concerning due to the resident's name was not disclosed. During an interview on [DATE] at 9:54 A.M., the DON said the TikTok video involving LPN D and Resident #39 was brought to her attention by another staff. The DON was unable to recall the staff member's name. The DON could not find a documented investigation, education or in-services following the incident. She discussed the issue with LPN D and instructed him/her to take down the video, which was already done prior to their conversation. She reminded LPN D he/she could not do it without the resident's permission. The DON said LPN D continued to work and stayed on his/her schedule after their discussion. The DON said staff were not allowed to use their cell phones while at work. The staff signed the cellphone usage policy during onboarding orientation. 2. Observations on [DATE] of the breakfast meal service in the main dining room showed: -At 8:17 A.M., Certified Nurse Aide (CNA) G at a table with three residents. He/She leaned back in his/her chair and took out his/her phone and began to scroll through his/her phone; -At 8:18 A.M., LPN D sat at a table alone, pulled his/her phone out and scrolled through his/her phone while eating grapes; -At 8:20 A.M., LPN D appeared to type something on his/her phone; -At 8:21 A.M., the Assistant Administrator said something to LPN D and he/she stopped scrolling through his/her phone; -At 8:22 A.M., another staff said something to LPN D. He/She then stood up from the table and placed the phone in his/her pocket; -At 8:23 A.M., CNA G continued to scroll through his/her phone; -At 8:24 A.M., CNA G got up and assisted a resident. During an observation and interview on [DATE] at 11:16 A.M., CNA G was sitting at the Hall 100 nurses' station. Two residents sat in wheelchairs and were parked facing the station. CNA G said he/she was currently on break so he/she could use his/her cellphone. He/She had not observed other staff on cellphones while providing residents' care. During an interview on [DATE] at 11:19 A.M., Housekeeper H said he/she never used his/her cellphone while working and while at the residents' areas. Housekeeper H kept his/her cellphone in his/her pocket at all times. 3. During an interview on [DATE] at 11:21 A.M., LPN I said staff were not allowed to use their cellphone while in the residents' areas. If he/she observed staff using their cellphones in the hallway or while working, he/she would address it immediately. LPN I had heard about a staff posted a video in social media but was not aware of the details. He/She would report to the supervisor or management immediately if he/she observed staff taking videos or photos of the residents. No recent in-services had been provided by the facility regarding social media and personal phone usage. 4. During an interview on [DATE] at 11:42 A.M., and 12:48 P.M. the Administrator and DON said they expected the staff to treat the residents with dignity and respect. The staff should not be using their phones while working in resident areas. Staff should not be recording or taking photos of residents and posting in social media because it violates their rights. The Administrator said he would have expected for staff to not have had their phones out in the dining room. They needed to have been standing up and attentive to the residents. MO00241876

Based on observation, interview and record review, the facility failed to ensure residents who required activities of daily living (ADLs, bathing, dressing and toileting) received necessary services to maintain adequate personal hygiene when staff left two residents soiled for an extended period (Resident #61 and Resident #40). The sample size was 22. The census was 94. Review of the facility's Perineal Care (cleansing of the genitals and anal area) policy, revised March 2021, showed: Purpose: To establish routine practices for providing perineal care, which will cleanse, prevent skin breakdown, prevent infection, and prevent odors. All residents will receive perineal care, as needed, in the morning before breakfast every evening with evening care at bedtime, as needed after bowel movement or urination, and each time the resident is incontinent. 1. Review of Resident #61's quarterly minimum data set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/15/25, showed: -Moderate cognitive impairment; -Requires maximum assistance from staff for toileting and personal hygiene; -Occasionally incontinent of urine; -Always continent of bowel; -Requires moderate assistance from staff for toilet transfers; -Diagnoses include diabetes and dementia. Review of the resident's care plan, in use at the time of survey, showed: -Problem: The resident is incontinent of urine; -Approach: Assist with incontinent care as needed or requested by the resident. Cleanse the perinium area with each incontinent episode. Observations on 6/12/25 at 9:23 A.M. and 12:38 P.M., and on 6/16/25 at 7:55 A.M., showed the resident lay in bed on his/her left side, partially covered with a bedspread. A strong odor of urine was noted and the resident's brief was saturated with urine. During observation and interview on 6/13/25 at 10:52 A.M., Certified Nursing Assistant (CNA) J removed the resident's breakfast tray out of the room. There was a strong odor of urine and one fly positioned on the resident's comforter. CNA J said the resident's room tended to be a little smelly and that staff tried to keep residents clean and dry to the best of their abilities. Observation and interview on 6/16/25 at 12:28 P.M., showed the resident sat up on the side of the bed eating lunch. A strong odor of urine was present. The resident said he/she was wet and needed to be changed. Licensed Practical Nurse (LPN) N and CNA O entered the resident's room and assisted the resident to a standing position. The resident's brief was saturated with urine and the resident's flat sheet, folded in half on his/her bed, was also saturated with urine. During an interview on 6/18/25 at 8:40 A.M., LPN N said he/she did not think the resident was changed in a long time because of how saturated with urine the resident was. 2. Review of Resident #40's annual MDS, dated [DATE], showed: -Cognitively intact; -Dependent on staff for toilet and personal hygiene; -Always incontinent of bladder and occasional incontinent of bowel; -Diagnoses include, heart failure, diabetes, anxiety, and depression. Review of the resident's care plan in use at the time of survey, showed: -Problem: The resident is incontinent of bowel and bladder; -Approach: Provide incontinence care after each incontinent episode; Toilet as need per facility protocol. Observation on 6/16/25 at 10:00 A.M., showed the resident lay in bed. Staff prepared to do a skin assessment with the resident. CNA P rolled the resident's brief between the resident's legs. The resident was turned to his/her left side with the assistance of CNA P and LPN N. The resident's brief was saturated with urine and loose stool. During an interview on 6/16/25 at 10:05 A.M., the resident said he/she was changed at 5:00 A.M. The resident said that he/she was frequently left soiled for extended periods. 3. During an interview on 6/16/25 at 10:06 A.M., LPN N said it was expected that staff check on residents who were incontinent at least every two hours and as needed. Residents should never be left soiled for extended periods. During an interview on 6/17/25 at 10:20 A.M., CNA M said residents who were incontinent should be checked on at least every one and a half hours and as needed on every shift. 4. During an interview on 6/18/25 at 11:41 A.M., the Director of Nursing (DON) said she would expect staff to check on a resident and change them if a foul odor was detected. She expected staff to clean incontinent residents in a timely manner. She expected all residents to be clean, dry and odor free.

Based on observation, interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of one resident (Resident #61). The sample was 22. The census was 94. Review of the facility's Urine Specimen Collection Guidelines, reviewed, June 2021, showed: -Purpose: The reported prevalence of asymptomatic bacteriuria (the presence of bacteria in the urine) is higher than that of the symptomatic urinary tract infections (UTI). Therefore, the quality of urine specimens sent for culture and sensitivity testing must be assured. The quality and accuracy of the results relies directly on the manner in which the specimens are obtained, stored, and processed. -Procedure guidelines: A straight catheter (a tube inserted into the bladder to drain urine) technique for urine collection is one method for urine cultures however this may be difficult to obtain from some residents due to behaviors or cognitive deficits; Clean catch urine (a urine specimen that is collected in a specimen container) sampling may be used if the resident is alert and able to follow directions. Review of the facility's Following Physician Orders policy, dated 6/29/21, showed all physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record. Review of Resident #61's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by the facility staff, dated 5/15/25, showed: -Moderate cognitive impairment; -The resident required maximum assistance from staff for toileting and personal hygiene; -Occasionally incontinent of urine; -Diagnoses included diabetes and dementia. Review of the resident's care plan in use at the time of survey, showed: -Problem: The resident is incontinent of urine; -Approach: Report signs or symptoms of UTI, acute confusion, urgency, frequency, bladder spasms, nocturia (frequent nighttime urination), burning, pain, difficulty urinating, low back pain, malaise (tiredness), nausea or vomiting, chills, fever, foul odor, concentrated urine, or blood in urine. Observation on 6/12/25 at 9:23 A.M. and 12:38 P.M., and 6/16/25 at 7:55 A.M., showed the resident lay in bed on his/her left side, partially covered with a bedspread, a strong odor of urine in the room, and the resident's brief was saturated with urine. Observation and interview on 6/13/25 at 10:52 A.M. showed Certified Nursing Assistant (CNA) J removed the resident's breakfast tray out of the room. There was a strong odor of urine and one fly positioned on the resident's bedspread. CNA J said the resident's room tends to be a little smelly at times, and staff try to keep residents clean and dry to the best of their abilities. Observation on 6/16/25 at 9:15 A.M., showed Linen Technician K and CNA L stocked linen in a linen closet in the hallway across from the resident's room. Linen Technician K said to CNA L It stinks out here. Review of the resident's progress notes, showed: -On 6/16/25 at 5:14 P.M., the Nurse Practitioner (NP) was on call for the physician and a urinalysis (UA, a urine test to detect infection) order was obtained related to odor; -On 6/18/25 at 9:20 A.M., this nurse attempted to obtain a urine specimen from the resident. The resident refused to get out of bed and go to the bathroom. The resident said he/she would like to eat first and then try to urinate. The nurse explained to the resident that a urine sample is needed today and if the resident could not urinate on his/her own, then a urine sample would be obtained by using a straight catheter. The straight catheter procedure was explained to the resident, and the resident said, Oh no. I'm going to go in the bathroom; -On 6/18/25 at 9:52 A.M., the resident's physician was updated on the resident's current condition, and an order was received that staff may straight catheterize the resident to obtain a urine sample; -No further documentation related to obtaining the resident's urine sample was noted. Review of the resident's Medication Administration Record (MAR), dated 6/1 through 6/18/25, showed: -An order, start date 6/16/25, every shift, urinalysis with culture and sensitivity (a urine test that determines appropriate antibiotics are used), discontinue order when obtained; -On 6/16/25, 3:00 P.M. through 11:00 P.M. shift, the urine collection documented, not obtained; -On 6/16/25, 11:00 P.M. through 7:00 A.M. shift, the urine collection documented, unable to obtain; -On 6/17/25, 7:00 A.M. through 3:00 P.M. shift, the urine collection documented, specimen not obtained; -On 6/17/25, 3:00 P.M. through 11:00 P.M. shift, the urine collection documented as obtained; -On 6/17/25, 11:00 P.M. through 7:00 A.M. shift, the urine collection documented as obtained. During an interview on 6/18/25 at 8:40 A.M., Licensed Practical Nurse (LPN) N said the urine specimen had not been obtained. LPN N said any shift can get the urine specimen, and it should be documented by the staff member why the urine specimen was not obtained in the progress notes, and the physician should be notified. The normal lab pick up days for specimens are Monday through Friday in the morning. LPN N did not know why the urine specimen was not yet collected, but thought it should have been before today because the resident is symptomatic. During an interview on 6/18/25 at 10:20 A.M., CNA M said if the resident has any signs or symptoms of a UTI such as strong odor, the nurse should be notified immediately. Urine specimens can be collected in a specimen container that can be placed in the resident's toilet any time by any shift. During an interview on 6/18/25 at 11:41 A.M., the Director of Nursing (DON) said she would expect staff to check on the resident and change them if a foul odor is detected. She would expect staff to obtain the urine specimen as soon as possible and document in the resident's medical record with a reason as to why it was not obtained. If the staff member is not able to obtain the specimen in a timely manner, she would expect staff to reach out to her for direction.

Based on interview and record review, facility staff failed to keep residents free from accidents when staff failed to use safe, professional standards of care when transferring two residents (Residents #1 and #2) using a Hoyer lift (a mechanical device that helps people with limited mobility move from one place to another, such as from bed to a wheelchair). This failure caused an injury requiring hospitalization and surgery for one resident (Resident #1). The facility also failed to investigate two improper Hoyer transfers involving one resident (Resident #2) and did not put corrective measures in place to prevent further injuries to both residents. The sample was three. The census was 88. Review of the facility's Incident/Accident Policy, dated December 9,2016, showed: -Purpose: to record any unusual situation or injury to a resident, staff member or visitor; -Examine the person for possible injury; -Administer emergency treatment as indicated; -Notify the physician and responsible party of all incidents of falls and possible head injuries of resident; -Complete Incident/Accident Report Form; -Forward report to appropriate persons per center policy. Review of the facility's Mechanical Full Body Lift policy, dated January 2017, showed: -Purpose: To ensure that all nursing staff are using proper transfer techniques to minimize the risk of injury to resident and staff, while using full body lift; -Secure the assistance of another Certified Nursing Assistant (CNA) or other qualified employee; -Positioning of transferring surfaces should be in close proximity to minimize transport area allowing enough room to move base from bed to chair or chair to bed; -Position lift sling (supports resident's weight during transfer) under the resident; -Attach the lift sling to the lift (attach to metal cradle, a frame with four attachment points for the sling); -Widen the base/legs of the lift prior to moving the lift. The lift is more stable when the legs are widened; -Begin lifting the resident, using the control panel on the lift; -The second staff member monitors the resident's body position, making sure the resident's extremities or head does not bump or swing into any object including the mast (vertical support component of the lift) of the lift; -As the first staff member moves the lift toward the chair/bed with the resident in the sling, the second staff member is guiding the resident's legs to prevent injury; -Bring the lift into position so that the resident is over the seat of the chair or centered over the bed. Do not close the support legs, while transporting residents; -While the resident is facing the person operating the lift, the second staff member will pull the sling back so that the resident will be seated properly in the chair or centered on the bed once lowered; -Lower the sling so the resident is seated in the chair or on the bed; -Remove the sling from the hooks on the lift; -Protect the resident from injury from the bar that may swing during this process; -Carefully move the lift away from the resident; watching to make sure the resident is not bumped with the lift; -There must be two staff members present when transferring a resident using a mechanical lift; -Complete competency checks with staff with orientation, semi-annually and as needed; -Failure to follow the above policy may result in immediate termination. Review of the facility's Injury Unknown Source - Investigative Protocol, dated May 2021, showed: -The following indicators of abuse/neglect are provided to help determine if abuse/neglect should be suspected. Staff are mandated to report suspected abuse. The list is not all inclusive; -Indicators of physical abuse may include, but are not limited to the following: Bruises and/or hematomas (collection of blood beneath the skin); Injures of unknown source without abuse/neglect suspected; -If a logical/reasonable explanation of the source of injury cannot be determined, notify the local state agency within two hours of discovery; -If there is reason to suspect injury was caused by abuse/neglect, staff must immediately notify the Administrator/Designee. The Administrator/Designee is responsible to report to other officials in accordance with State law, including to the State survey and Certification agency; -Staff must provide a statement as to their knowledge or lack of knowledge of the injury; -The resident's Physician must be notified; -The Resident's Representative must be notified; -A complete body assessment must be completed on the resident. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/4/24, showed: -Cognitively intact; -No behaviors noted; -Dependent on staff members assistance for toileting, showers, lower body dressing and transfers; -Height of 68 inches and weight of 379 pounds (lbs); -Diagnoses included heart failure, diabetes mellitus, anxiety, morbid obesity and polyneuropathy (damage to nerves causing pain, discomfort and mobility difficulties). Review of the resident's care plan, dated 1/23/25, showed: -Problem: The resident required assistance with activities of daily living (ADLs); Interventions included: Assume unhurried manner, allow ample time for tasks; Provide A.M. and P.M. care per facility policies and procedures; Mechanical lift used for transfers; -Problem: The resident had complaints of pain; Interventions included: observe for nonverbal indicators of pain; Accept the resident's description of pain. Review of the resident's skin integrity event report, dated 1/23/25, at 11:52 A.M., showed: -The resident complained of pain to his/her right lower leg to Licensed Practical Nurse (LPN) C, an agency nurse; -The nurse assessed the resident and saw a bruise to resident's right shin (lower leg) measuring 9 centimeters (cm) by 10.5 cm; -The Nurse Practitioner (NP) was called to the room; -The NP arrived and gave new orders to sent the resident to the hospital immediately; -The resident was transferred to the stretcher via Hoyer lift; -The resident's emergency contact was notified; -The resident was transferred to the hospital; -Evaluation note included the resident obtained a bruise which became a rapidly growing hematoma. The resident said he/she believed he/she bumped his/her right shin while in the mechanical lift. The staff did not recall any bumps and the resident did not complain of pain to the area during or after transfer until late in the morning. The hematoma was growing rapidly so the resident was discharged to the hospital for evaluation. Review of the investigation, dated 1/23/25, no time noted, completed by the Director of Nursing (DON), showed: -On the morning of 1/23/25, at approximately 10:00 A.M., the DON was called to the resident's room by the NP, to assess the resident's hematoma located at his/her right shin; -The resident had a dollar coin sized hematoma on his/her right shin that was dark blue, purple and swollen; -The resident reported he/she hit it at some point during his/her transfer that morning but was unsure where on the lift he/she was bumped, yet he/she felt a slight bump; -The resident was sent out to the hospital for evaluation; -Both CNAs who got the resident out of the bed that morning were interviewed over the phone and gave written statements to the DON; -Both CNAs said nothing occurred during the transfer. The resident did not say ouch or complain of pain prior to, during or after the procedure; -CNA A's statement, undated, showed on 1/22/25, when getting the resident up out of bed, CNA A spotted CNA B during the transfer; CNA A was in the back, pulling and guiding the resident into his/her wheelchair; Never did the resident say Ouch, that hurt or anything to make or alert the CNAs that the resident was being injured; Before leaving the room both CNAs were laughing and joking with the resident -CNA B's statement, undated, showed on January (day left blank) 2025, at 5:05 A.M., he/she went to the resident's room to get the resident dressed and ready to get out of bed. CNA B got assistance from another aide (unnamed). The two CNAs transferred the resident into his/her bed with no inconvenience. CNA B finished dressing the resident and then gave report to the on-coming shift; -There was no documentation showing the conclusion of the investigation; -There was no documentation showing what corrective measures were taken. Review of the training sign in sheet, dated 1/30/25, showed: -Material Covered included: Mechanical Lift Policy; -There was no documentation CNA A, CNA B or LPN C received the training. Review of the resident's Medication Administration Record, dated January 2025, showed: -An order, dated 7/15/24, for Eliquis (anti-coagulant) 5 milligrams (mg) give twice a day; -The facility administered the medication as ordered from 1/1/25 through 1/23/25. Review of the resident's hospital Discharge summary, dated [DATE], showed: -Resident admitted on [DATE] due to leg pain related to swelling and bruising on the resident's right shin; -Diagnoses included: Hematoma of the right lower extremity (leg); -History of Present Illness, undated, no time noted, showed on 1/23/25, the resident came to the Emergency Department (ED) from the facility after he/she sustained an injury while being lifted in a Hoyer lift. The resident denied falling but somehow his/her leg was pushed with the transfer. A computed tomography (CT scan, combines a series of x-ray images taken from different angles around the body) of the lower right extremity showed a large superficial hematoma. On the morning of 1/24/25, the resident complained of high amount of pain to his/her right extremity. There was significant swelling and increased blistering to the injury site compared to the images taken in the ED. The resident said he/she had a decreased sensation to his/her right foot compared to his/her left which was new; -Problems addressed: Large right lower leg hematoma/abscess (pocket of pus) status post (s/p) debridement (removal of dead tissue) surgery on 1/25/25; -The resident had a wound vacuum (medical device that uses negative pressure to promote wound healing) applied to his/her right lower extremity surgical wound; -The resident required a skin graft (the removal and transplantation of healthy skin from one area of the body to another area) later to his/her right lower extremity. Review of the resident's nursing note, dated 1/29/25 at 1:30 P.M., showed the resident was readmitted to the facility from the hospital. The resident had a wound vacuum on his/her right lower extremity with new orders for wound care and antibiotic therapy. During an interview on 2/4/25 at 10:16 A.M., CNA D said: -Nursing staff were expected to always have two people present when transferring a resident with the Hoyer lift. One staff member worked the controls of the Hoyer while the second staff member guided the resident from one surface to another for safety, ensuring the resident was not bumped into any surfaces; -He/She came in to work on 1/23/25 at 6:45 A.M. and was assigned to care for the resident; -The resident was dressed and in his/her wheelchair when CNA D first saw the resident during rounds; -The resident went to his/her meeting after breakfast; -The resident first complained of pain at his/her right lower extremity when he/she returned from his/her meeting around 11:00 A.M.; -The resident said he/she was hit by the Hoyer that morning during a transfer; -CNA D told the agency nurse, LPN C, who came and assessed the resident; -The resident was sent out the hospital. Observation on 1/31/25 at 12:41 P.M., showed the resident lay in his/her bed, with pillows placed under his/her right lower extremity. There was a wound vacuum attached to the resident's right lower extremity wound, actively running. The resident was visiting with a guest and was grimacing in pain. Observation on 1/31/25 at 1:17 P.M., showed the facility's bariatric Hoyer lift in the hall. The remote control to the Hoyer was approximately 10 inches long and two inches wide. During an interview on 1/31/25 at 1:29 P.M., the resident said: -He/She was hurt when staff moved him/her from the bed to his/her wheelchair while using the Hoyer lift; -While the resident was up in the air, one of the two CNAs was pushing on his/her right leg, trying to open the resident's legs up wider; -The CNA had the Hoyer remote control in his/her hand while the CNA was pushing on the resident's right leg; -The resident told them to stop, they were hurting him/her, and to be careful with his/her legs; -The resident told the CNA who was pushing on his/her right leg with the remote control in his/her hand, to stop because the CNA was hurting him/her. The CNA ignored the resident and kept pushing the remote control into the resident's right lower leg; -After the resident was placed in his/her wheelchair, the resident went to the sink to clean him/herself up before going out to the meeting; -During the meeting, the resident's right lower leg started to hurt more and more; -The resident did not want to interrupt the meeting by complaining of pain so he/she was quiet and tried to ignore the pain, which kept increasing; -The resident was in his/her room right after the meeting and decided to look at his/her right lower leg to try to find out why it hurt so badly; -The resident raised his/her pant leg and saw a black and blue, swollen area on his/her right lower leg; -The resident described the pain as throbbing really hard; -The resident put the call light on and the nurse came to look at his/her leg; -Then the DON and NP came to look at his/her leg and told the resident he/she needed to go out to the hospital; -The resident had surgery on his/her right lower leg to clean the dead tissue out; -He/She was in constant pain, he/she could barely stand to look at his/her right leg as it made him/her sick to see it; -The resident had not transferred out of his/her bed since he/she was readmitted to the facility due to the horrible pain in his/her right leg; -The resident always had to tell the CNAs to be careful of his/her legs, told them to stop when they were hurting him/her and the staff never listened, even before the incident on 1/23/25. During an interview on 2/4/25 at 10:52 A.M., the DON said: -On 1/23/25, she was notified by the NP to come to the resident's room to assess the resident's right lower leg; -The resident was complaining of severe pain to his/her right lower leg after he/she left a meeting; -When she got to the room, she saw a black and blue bruise that was swollen and growing at a fast rate; -The resident said he/she had bumped his/her right leg on the Hoyer lift, maybe on the mast, when the CNAs had gotten him/her up that morning; -The resident was sent out to the hospital for evaluation, as the bruise on his/her right lower leg kept spreading; -When the resident returned from the hospital, he/she said the injury on his/her right lower leg was because one of the CNAs bumped his/her right lower leg with the Hoyer lift remote control. The resident could not describe the event; -It was not appropriate to push on a resident while there was an object in the staff's hand as it increased the risk of injury to the resident; -She interviewed both CNAs who denied anything happened during the transfer, saying the resident never voiced he/she was in pain or was hurt; -The CNAs did not perform an improper transfer because there were two staff members present, one to control the machine and the other to guide the resident to prevent injury, and they had the Hoyer lift legs open for stability; -She did not write up, counsel or provide in-services to the CNAs involved in the event because they said nothing occurred that could have caused injury to the resident; -Injury of unknown origin was when the facility had no explanation of how the injury occurred; -The injury was called an injury with a mechanical lift because the resident said it happened during the transfer, although the resident could not say how it occurred exactly and the CNAs denied any action occurred to cause injury; -She did not feel any corrective measures or interventions were necessary since the CNAs were unaware of how the injury could have occurred and it was unintentional; -She did not update the resident's plan of care to prevent further accidents. 2. Review of Resident #2's nurse note, dated 11/20/24 at 6:26 P.M., showed LPN G wrote the resident was pushed into room in wheelchair and left medial (middle) foot was bumped against the transfer pole, assessment showed no tenderness, no bruising or swelling was present and the resident was not complaining of pain. The primary care physician (PCP) and family were made aware. Review of the resident's Miscellaneous Event report, dated 11/20/24 at 6:46 P.M., showed: -Description: Left foot bumped on transfer pole; -No injury noted; -Evaluation note: the resident was being transferred in the lift when his/her leg was bumped on the wall., No injury noted. Monitored for 72 hours with no concerns. Review of the resident's care plan, dated 1/2/25, showed: -Problem: The resident was at risk for discomfort related to diagnosis of chronic pain syndrome; Interventions included: The resident was in a mechanical lift when it tilted his/her body when lowering him/her to the bed and the resident said it caused pain to his/her shoulder. No injuries were noted and the next day the resident said his/her shoulder was fine. The resident was non-compliant with care and moves unsafely in the mechanical lift. Multiple staff members go into the room when transferring the resident to keep him/her safe; Assess level of pain and provide comfort measures; -Problem: The resident was at risk for falls related to impaired mobility and weakness. Interventions included: The resident was lowered to the floor after the mechanical lift being used started to tilt. Employees lowered the lift down to the floor and reconnected to another lift to place the resident into his/her chair. The resident had a small bruise to his/her right cheek. Two employees were present during transfer; -Problem: The resident requires care in pairs with ADL assistance due to history of embellished stories; Interventions included: Direct care staff may pair two staff members together when providing care; -There was no documentation the resident required a Hoyer lift for transfers. Review of the resident's annual MDS, dated [DATE], showed: -Cognitively intact; -No behaviors noted; -Dependent on staff members' assistance for toileting, showers, lower body dressing and transfers; -Height of 66 inches and weight of 287 lbs; -Diagnoses included atrial fibrillation (irregular heart rate), heart failure, anxiety, morbid obesity and polyneuropathy. Review of the resident's nurse progress note, dated 1/29/25 at 9:53 P.M., showed LPN G wrote an aide informed him/her that during a transfer with a Hoyer lift with two aides, the resident was hit with the hook on the Hoyer lift. The resident said the Hoyer hook hit his/her right temple; on assessment no bruising or swelling was noted. Neuro checks were within normal limits and the resident denied pain. The PCP and resident's responsible party (RRP) was notified. Review of the resident's Miscellaneous Event report, dated 1/29/25 at 10:05 P.M., showed: -Description: The resident was hit with Hoyer hooks to the right temple with no injury; -Neurological check (neuro-checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status) were started; -Evaluation notes: Event still open. During an interview on 2/4/25 at 10:39 A.M., LPN G said: -He/She did not remember an incident, on 11/20/24, involving the resident getting his/her foot bumped during a Hoyer transfer; -On 1/29/25, he/she was the nurse assigned to the resident when the resident was struck in the face by the lift bar during a Hoyer transfer; -He/She was alerted by a CNA (unknown) that the resident was struck by the lift bar during a Hoyer transfer; -He/She went and assessed the resident, who confirmed he/she was hit in the right side of his/her temple by the metal lift bar; -The resident did not have any bruising, swelling, and did not complain of pain to his/her right temple; -The nurse competed a neuro-check and found the resident was within his/her normal limits, called the PCP and RRP; -The nurse then completed an event report in the resident's EMR with the PCP's new orders to monitor the resident's neurological status for 72 hours; -The nurse started the neurological checks and passed on in report to the next nurse; -The DON asked the nurse the next day about what happened; -The DON did not instruct the nurse to make any changes to the resident's plan of care; -He/She had not received any in-services on Mechanical Lift Policy in the last year; -He/She expected CNAs to transfer resident's safely while using a Hoyer lift by always having two staff present, one to work the machine and the other to guide the resident in the sling to prevent injury. During an interview on 2/4/25, at 12:51 P.M., the resident said: -Last week, he/she was hit in the head with the lift arm during a Hoyer transfer. The CNAs jerked the strap of the sling off of the lift arm so hard, it smacked the resident in his/her right temple; -The resident had neuropathy in his/her legs which made them very sensitive and painful; -He/She did not feel safe when CNAs transferred him/her with the Hoyer lift; -CNAs did not listen to the resident during transfers, ignoring the resident's pleas to be careful when moving his/her legs, to make sure he/she does not bump into objects while up in the sling; -When the resident was up in the Hoyer lift, he/she would swing without any support and hit his/her legs and feet against the wall; -The CNAs would say they were doing the best they could when the resident said they were hurting him/her and would continue with their task; -The resident would remind the CNAs to be careful with his/her left shoulder, as it was always in pain, when removing the sling from the lift bar; -The CNAs would jerk the sling off of the lift bar causing the resident to fall back into his/her wheelchair or bed, causing him/her pain; -There have been several near misses with the lift bar because the CNAs would not hold it still when they attached or removed the sling from it, causing the lift bar to swing back and forth in front of the resident's face; -There were some CNAs who were very kind and listened to the resident but most of them acted so angry and worked hastily; -The resident feared retribution from staff if he/she complained about the treatment and the fear he/she has when up in the Hoyer lift during transfers; -He/She did not feel that his/her concerns or complaints were taken seriously; -During the interview the resident was often tearful and whispered because he/she was afraid others might hear him/her. During an interview on 2/4/25 at 10:52 A.M., the DON said: -She did not recall an event on 11/20/24 involving the resident and a Hoyer lift transfer; -The facility did not investigate the event on 11/20/24; -She was not aware of the event that occurred on 1/29/25 and had not started investigation on the event; -She expected staff to report any accidents to her so she could conduct an investigation; -Nurses were not expected to report all events to the DON as nursing staff were able to take care of them independently; -She was responsible for reviewing events daily or at least every couple of days; -Staff conducted an improper Hoyer transfer if a resident was struck in the face by the metal arms of the cradle when staff removed the sling from the hook; -Staff conducted an improper Hoyer transfer if the resident's foot bumped into an object, causing them pain, due to staff not guiding the resident to prevent injury; -She did not update the resident's plan of care to prevent further accidents. 3. During an interview on 1/31/25 at 11:36 A.M., LPN E said: -When a resident had a fall, an accident or injury of unknown origin, nurses were responsible for assessing the resident for injury or any change of condition, notify the PCP for any new orders, notify the RRP, list what interventions were tried or put in place, and the plan of care going forward. All of that information was then documented on an event note found in the resident's electronic medical record (EMR); -Nurses would try to find out what caused the fall, accident or injury of unknown injury by talking to their staff; -Neglect was defined as any time a staff member did not care for a residents' needs, by ignoring them or acting carelessly, causing the residents harm; -Nurses were expected to report any suspicion of abuse or neglect to their supervisor. Supervisors were expected to then investigate the incident by interviewing all residents and/or staff involved and making report to the appropriate agencies. During an interview on 2/4/25 at 10:27 A.M., LPN F said: -Nursing staff were expected to always use two people during a Hoyer Lift, one to operate the machine and the other to guide the resident to make sure the resident was safe and did not bump into any surfaces; -He/She would report to a Supervisor if a resident had an injury due to an unsafe transfer so they could investigate the incident. During an interview on 2/4/25 at 10:52 A.M., the DON said: -She expected nursing staff to have knowledge of and to follow facility policies; -An incident or accident was defined as a fall, an injury to the skin, anything that changed the condition of the resident unexpectedly; -An incident or accident also included events where staff caused harm or injury to the resident due to not following facility policies or professional standards of care; -She expected nurses to complete an event report in residents' EMR for any incident that changed the condition of the resident; -The facility would investigate events by interviewing staff and residents to see what occurred and based on what was found would provide in-services to staff to address the issue; -If staff conducted a transfer incorrectly, she would write-up the staff involved and provide education and counseling; -If staff conducted a transfer incorrectly that caused injury to a resident, she would suspend the staff involved pending investigation; -In-services to staff were started right after the event occurred, provided by the DON or the Assistant Director of Nursing (ADON); -Staff were expected to retain the education they received during in-services; -In-services were based on professional standards of care and facility policies; -If there was a pattern of the same type of accidents occurring again and again, she would do more in-services to staff and try to find out why the issue was still occurring; -She was not aware of any improper Hoyer transfers in her facility; -A proper Hoyer transfer consisted of two staff members, one to control machine, the other to spot the resident for safety and to keep the Hoyer legs open for stability; -She recently gave nursing staff education on Hoyer lift transfers as part of a mock survey and had not completed it as of time of interview; -She did not recognize a pattern of improper mechanical lifts in the facility. MO00248154 MO00243707

Based on observation, interview and record review, the facility failed to maintain all areas of the facility in a safe, functional, sanitary and comfortable environment for visitors, staff and residents. The census was 95. Review of the facility's Preventative Maintenance and Inspections policy, reviewed 2022, showed: -Policy: To provide a safe environment for residents, employees, and visitors, a preventative maintenance program has been implemented to promote the maintenance of equipment in a state of good repair and condition; -A schedule is developed to delineate all inspections that are to be completed on a regular basis. inspections verify that ail equipment and furnishings are in working order and free from safety hazards. During an interview on 9/26/24 at 11:28 A.M., Employee E said: -He/She heard there was mold found in the building from a fellow employee; -He/She said the fellow employee was very frustrated because nothing was done about the reported mold. During an interview on 9/26/24 at 11:31 A.M., the Housekeeping Supervisor said: -He reported a suspicion of mold found in a resident's room above the wall air conditioner unit to the Administrator about a month ago; -He found what he thought was mold located on the walls outside of the bathroom across from the nurses' station on the 100 hall. He reported his discovery to the Administrator about a week ago; -The resident was moved out of the room but the black matter that was suspicious of mold was not cleaned off the wall or air conditioning unit; -The facility did not do anything to clean or contain the wall with the suspicion of mold at the 100 hall nurses' station. During an interview on 9/26/24 at 11:53 A.M., Employee F said: -There was mold all over the building, especially on the walls outside of the bathroom located at the 100 hall nurses' station. There was black substances all over the lower wall outside of the bathroom. The facility did not remove it, just put wallpaper over the black substances; -The ceiling leaks in 100 hall, especially around the nurses' station. The ceiling panels were brown and a week or so ago, the air vent was so wet with water from the roof, it fell out of the ceiling; -The facility does not remove the mold, instead, they just paint over it; -He/She told the Administrator about the mold in the 100 hall a few weeks ago. Observation on 9/26/24 at 12:04 P.M., on 100 hall nurses' station, showed: -A brown ceiling tile, wet with water, over the left side of the nurses' station; -Wallpaper located on the left side of the bathroom door was peeling away from the wall with an unidentifiable brown and black substances on the back of the wallpaper and on the wall; -The lower wall, located on the left side of the bathroom door, had wallpaper and baseboards peeling back from the wall, extending from the door jamb to the end of the wall, with unidentifiable brown and black substances on the back of the wall paper and on the wall; -The nurses' station and surrounding area had a strong, musty smell. During an interview on 9/26/24 at 12:12 P.M., the Administrator and Assistant Administrator said: -They were made aware of mold located at the bathroom in the 100 hall nurses' station; -Staff made the Administrator aware of the mold two or three weeks ago and he notified the Director of Clinical Operations (DCO) and the Senior Project Manager; -A painting company came out last week to test the mold and the Administrator was waiting on results to see if it was black mold; -The plan was to remove the affected drywall and wallpaper, repaint or re-wallpaper to match the rest of the building; -The DCO and the Senior Project Manager toured the building with the painting company to identify areas in the building that needed repair and to develop a plan for both mold eradication and to make aesthetic improvements last week; -The Administrator created a building map showing where suspected mold was identified while on the tour with the painting company and the two Corporate staff members; -The map showed the suspected mold was found at nurses' station 100, on the walls outside of the bathroom and the walls directly across the bathroom, at resident rooms 127, 120, 135, 136, 202, 204, 206, 201, 203, 205, 209, 211, nurses' station 200 hall, residents room at 303, 305 and at the Beauty Shop and Nursing Office; -The water mark in the ceiling of the 100 hall nurses' station was caused by the roof leaking during hard rain. The drains on top of the roof sometimes were clogged with debris and caused the standing water to leak into the ceiling below; -The facility regularly checked the drains on the roof to prevent leaking; -If the damage to the ceiling was small, Maintenance was directed to paint over the brown marks with paint and if the area was large, they were to replace the entire ceiling panel. During an interview on 9/26/24 at 12:40 P.M., Maintenance Tech A and Maintenance Tech B said: -The roof leaked during hard rain due to the roof drains getting clogged with debris; -They went up to the roof to check the drains about once or twice a month; -They used buckets to collect the water from the roof leaks to protect the carpet; -They were aware there was mold or mildew in the building located on a wall in a residents' room [ROOM NUMBER]; -They notified the Administrator and the residents were moved to a new room; -The mold was still there on the residents' wall; -They were told by their supervisor a company was coming in to assess the damage and give bids for repair; -They were not aware of any other suspicion of mold in the building; -They expected staff to inform them of any suspicion of mold so they could address the problem and make the Administrator aware. During an interview on 9/26/24 at 12:50 P.M., the Administrator said: -He was alerted by staff of the possible mold found in the residents' room [ROOM NUMBER] and had the residents moved to a new room a week or so ago; -He toured the building with the Assistant Administrator to identify any other areas of suspected mold and then informed Corporate for their direction about two weeks ago; -They did not remove any other residents out of their room as the suspected mold they found was located on the walls outside of their room; -He told staff not to disturb or touch the suspected mold; -Staff voiced their concerns about the suspected mold, asking when it would get removed, what it was exactly, and were worried it was detrimental to the residents' health and their own health; -He did not instruct any staff to clean or to seal off the areas with suspected mold; -The suspected mold was ok if it was undisturbed, not touched; -If the suspected mold was disturbed, the spores could get in the air and cause issues with lungs, cause staff or residents to get sick, have an allergic reaction and aggravate asthma (chronic inflammatory disease of the lungs) making it difficult to breathe; -If staff, visitors or residents were allergic to the suspected mold, they could have a severe reaction, possible anaphylaxis shock (severe and potentially life-threatening allergic reaction that can occur within minutes of exposure to an allergen) During an interview on 9/26/24 at 1:06 P.M., the Director of Nursing (DON) said: -Mold could cause respiratory issues, make staff/visitors/residents sick, could cause confusion, increase in behaviors and possible anaphylactic shock; -She suspected there was mold located in the wall air conditioner in a staff office, either room [ROOM NUMBER] or room [ROOM NUMBER], and told the Administrator months ago; -The Administrator said the suspected mold was removed from the air conditioning unit; -She knew there was suspected mold found in a resident's room and the resident was moved to a new room. She could not recall the room number; -She was not aware of any other areas suspected mold in the building; -She expected to be informed if there were any areas of suspected mold so she could take measures to ensure resident safety; -If suspected mold was found outside of resident rooms or in high traffic areas, she expected the Administrator to fix the issue immediately or move residents who were residing in rooms around the suspected mold to reduce the risk of an allergic reaction or respiratory issues; -She expected nursing staff to document in resident progress notes if there was any suspected mold found in or around residents' rooms, to notify the Primary Care Physician (PCP), and residents' responsible party as the suspected mold could affect plan of care if there was a change of condition as the change might be related to the suspected mold. During an interview on 9/26/24 at 2:27 P.M., the DCO said: -About two weeks ago, she was made aware of scuffs on the wall and minor cosmetic repairs needed on the building; -She contacted the Senior Project Manager of the the painting company; -She did not know of any suspected mold or mildew in the facility. Observation on 9/26/24 at 2:51 P.M., of resident room [ROOM NUMBER], showed: -A large area of black and dark brown splotches on the wall, underneath peeling wallpaper, located behind the door entering the room; -A section of wallpaper, peeling off halfway up the wall, above the wall air conditioning unit, with a large amount of black and brown substances on the back of the wall paper and on the wall; -The room had a strong musty odor; -There were no residents in the room. Observation on 9/26/24 at 2:56 P.M., of resident room [ROOM NUMBER], showed: -Large, black spots located on the vents of the wall air conditioning unit and inside to the air conditioning unit; -The room was inhabited by a resident. During an interview on 9/26/24 at 2:59 P.M., the DCO said: -She confirmed there was black discoloration on the walls, under the wallpaper, at the base boards in the 100 hall nurses' station next to the bathroom and on the wall directly across the bathroom; -She confirmed there was black discoloration on the wall, under the wallpaper, in room [ROOM NUMBER] behind the door and on the wall above the air conditioning unit; -She confirmed there was black spots on the air conditioning unit found in resident's room [ROOM NUMBER]; -She was not an expert on mold or mildew and required an expert to come out and identify the substances for resident safety. During an interview on 9/27/24 at 9:30 A.M., Employee G said: -He/She has had an allergic reaction every time he/she worked in the facility, particularly when he/she worked in 100 Hall; -He/She experienced an itchy nose, constant sneezing during his/her shift which dissipates after he/she exits the facility; -He/She saw the Housekeeping Supervisor peel back the wallpaper from the wall next to the bathroom at the 100 hall nurses' station about 10 - 12 days ago. There was a large amount of black matter on the wall and on the back of the wallpaper; -He/She reported the suspected mold to the Administrator at the same time; -The Administrator said he told Corporate and it would be addressed; -He/She expected the facility to put up a barrier to contain the suspected mold after the Administrator was made of it; -He/She was concerned about the residents' health; the exposure to possible mold put the staff and residents at risk for respiratory issues; -Residents were often sitting in their wheelchairs against the wall that had the suspected mold at the 100 hall nurses' station; -He/She felt the facility did not do enough to clean up the suspected mold or contain it; -The facility constantly had wet carpets due to the ceiling leaking. The facility cleaned the carpets but they were never completely dry and smelled musty; -There was a leak in the ceiling at the 200 hall nurses' station which caused a huge hole in the ceiling. It took over two weeks for the facility to fix the hole; -The carpet was very wet due to the water damage and the facility failed to put out fans to dry the carpet. Observation on 9/27/24 at 10:12 A.M., and at 10:27 A.M., of the 100 hall nurses' station, showed: -The carpet in front of the nurses' station was wet to the touch with a fan directed on it; -The tile which housed a ceiling vent to the right of the nurses' station had brown water marks around the vent; -The tile which housed a ceiling vent to the left of the nurses' station was stained dark brown, with a large area that appeared water logged, was buckling away from the ceiling grid with water dripping down to the carpet beneath. Review of the Environmental inspection report, dated 9/27/24, showed: -On 9/26/24, at 3:50 P.M., the inspector came into the facility to inspect the areas of concern as discussed during the DHSS inspection of the facility; -Air samples were taken at a nursing station and in two resident rooms to provide scientific data concerning the air quality. Review of the Environmental inspection report, dated 10/1/24, showed: -The visual inspection identified mold along the base of the wall and behind wallpaper in the 100 nurses' station; -Various rooms had slight amount of mold and dirt on the air diffusers of the wall air conditioner units; -Two rooms had mold located underneath wallpaper as well as on the wall air conditioner units; -Rooms 301, 307 and the 100 hall nurses' station will go undergo remediation action to safely remove wallpaper and damaged drywall; -Recommend continue cleaning and disinfecting the wall air-conditioner units in rooms 301, 302, 307, 316, 318, and 321; -Recommend removing damaged wallpaper, disinfecting surfaces, and removing drywall as needed for 100 hall nurses station, room [ROOM NUMBER] and room [ROOM NUMBER]; -All work should be performed while the rooms remain vacant. The rooms will be isolated during the work and a high efficiency particulate air filter (HEPA (pleated mechanical air filter) equipped fan will operate inside the work area to create negative pressure and scrub the air; -The area at 100 hall nurses' station will be isolated with pop-up poles and plastic. All damaged wallpaper and drywall will be removed and immediately packaged while inside the enclosed work area. HEPA vacuums are to be used to clean the surfaces after exposure and when finished. A disinfectant will be used to wipe down all surfaces in each work area. Rooms are to be completely restored prior to moving residents back in; -Recommend cleaning the carpeting in room [ROOM NUMBER] and the tile floor in room [ROOM NUMBER]. MO00242499

Based on observation, interview and record review, the facility failed to provide care that met professional standards of quality by failing to follow physician orders for wound care and failed to accurately document in the Medication Administration Record (MAR) for two residents (Resident #2 and #5). The facility also failed to notify the Primary Care Physician when a resident was struck in the head, document an incident fully and failed to follow their policy to initiate and document complete neurological assessments (exam to identify signs of disorders affecting the brain, spinal cord and nerves) for one resident (Resident #2) after the resident was hit in the head. The sample was three. The census was 95. Review of the facility's Following Physician Orders policy, dated 6/29/21, showed: -Policy: To ensure all Licensed Professional Nurses and other Healthcare Professionals to follow Physician Orders in accordance with State, Federal regulations and their respective practice acts; -Procedure: All physicians orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record. Review of the facility's Neurological Checklist Policy, reviewed on 7/2021, showed: -Purpose: To establish a base line neurological assessment. To recognize neurological trends and changes in the resident's condition. To provide an evaluation tool for reference when evaluating the resident's neurological status; -Procedure included: -Equipment: Flashlight and Neurological Record (tool for evaluating and recording resident's level of consciousness, pupil response and motor/verbal response); -Assess vital signs; -Establish awareness by calling out the resident's name, touching the resident, shaking the resident for a response, and /or applying a painful stimulus; -Assess the resident's level of consciousness; -Assess the resident's verbal response; -Complete neurological assessment for potential head injuries. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/12/24, showed: -Cognitively intact; -No behaviors noted; -Required supervision or touching assistance for personal hygiene and upper body dressing; -Required moderate assistance for chair/bed-to-chair transfers, -Wheelchair for mobility; -No skin issues noted; -Received anticoagulant (used to treat and prevent blood clots) and antiplatelet (prevent blood clots from forming) medications; -Diagnoses included heart failure, high blood pressure, peripheral vascular disease (poor circulation) and chronic obstructive pulmonary disease (COPD, a group of lung disease that block airflow and make it difficult to breathe). Review of the resident's progress notes, showed: -On 9/17/24, at 3:06 P.M., the resident was sitting in his/her wheelchair, watching T.V. when his/her roommate became agitated thinking the resident had taken his/her shoes. The roommate tried to grab the shoes off of the resident's feet, the resident refused and the roommate grabbed the resident's left arm, causing a skin tear (layers of skin separate). Review of the facility's initial reporting form, sent into the Department of Health and Senior Services, dated 9/17/24 at 3:18 P.M., showed: -On 9/17/24, the nurse was made aware the resident's roommate was arguing about a pair of shoes. The roommate went behind the resident, hit the resident on the left side of his/her head and grabbed the resident's left arm causing four skin tears. The roommate also struck the resident in his/her left eye; -Vital signs were obtained and were within normal limits. Review of the resident's Physician Order Sheet (POS), showed: -There were no orders for neurological checks for the incident that occurred on 9/17/24. Review of resident's care plan, dated 9/19/24, showed: -Problem: The resident was at risk for bleeding or bruising; -Interventions included: Notify nurse if nosebleed, excessive bruising/bleeding, flu-like symptoms, upset stomach, weakness or fatigue. Review of the resident's MAR, dated 9/27/28, showed: -An order, dated 7/2/24, for Eliquis (anti-coagulant) 5 milligrams (mg), give every 12 hours. Documentation showed the facility staff administered the medication as ordered; -An order, dated 9/23/24, to monitor left arm and hand skin tears for signs and symptoms of infection, change dressings as needed, clean with normal saline, apply Vaseline gauze and apply dry dressing to left back of hand, forearm, elbow and left inside forearm every three days until healed on Mondays and Thursdays. Documentation showed facility staff completed the order as written on 9/23/24 and 9/26/24. Observation on 9/27/24 at 8:56 A.M., showed: -The resident sat in his/her wheelchair in his/her room; -The resident had a skin tear on his/her left inside forearm, covered with a dark brown dried substance, without a dry dressing covering it; -The resident had a dark brown scab on his/her left elbow, covered with an undated band aid, which was lifting up at the edges; -The resident had white bandage on his/her lower forearm, dated 9/24. The bandage was dirty with dried, dark, brown substance. The bandage's borders were not secured and was lifting off of the resident's skin showing a skin tear and multiple hematomas (blood filled blister) directly under the bandage; -The resident's left hand had multiple hematomas located on the back of his/her left hand and on the outside of his/her hand below the smallest finger. The wounds did not have a dressing covering them. During an interview on 9/27/24 at 9:00 A.M., the resident said: -His/Her roommate thought he/she was wearing the roommate's shoes; -The roommate did not believe the resident when he/she told the roommate the shoes were his/hers; -The roommate attacked the resident from behind, hitting the back of his/her head; -The resident tried to get the roommate to get out from behind him/her and the roommate grabbed at the resident's left arm, tearing at it causing his/her skin to break open and bruise; -He/She needed the bandage on his/her left forearm changed as it was dirty and coming off; -He/She did not feel the staff took the incident seriously and he/she was not getting care for his/her wounds. During an interview on 10/4/24 at 3:56 P.M., the Director of Nursing (DON) said: -She expected the nursing staff to initiate 72 hour neurological checks after he/she was struck in the head by his/her roommate to ensure there were no neurological changes due to the hit; -She expected nurses to write a progress note showing the resident was on incident follow up (IFU) for 72 hours for continuity of care; -She expected the nurse to write a complete progress note which described the exactly what occurred, including the resident was struck in the head, to notify the Primary Care Physician that he/she was struck in the head and to tell nursing management staff so all would know what happened to keep the resident safe and for continuity of care. 2. Review of Resident #5's care plan, dated 7/1/24, showed: -Problem: The resident was at risk for skin tears and bruises related to impaired balance and mobility; -Interventions included: Observe skin with activities of daily living, dressing changers, showers as needed for bruises, skin tears and open areas. Review of the resident's annual MDS, dated [DATE], showed: -Cognitively intact; -No behaviors noted; -Independent for upper body dressing and transfers; -Wheelchair for mobility; -No skin tears noted; -Diagnoses included pulmonary embolus (one or more arteries in the lungs blocked by a blood clot) and lymphedema (swelling, most often in arm or leg). Review of the resident's progress notes, showed: -On 9/2/24 at 10:22 P.M., the resident was rolling in his/her room and scraped his/her arm on the wheelchair at the door. The area was well approximated with wound edges together, no signs of infection, with scant amount of blood at the site and measured 2 centimeters (cm) by 1.5 cm. Observation on 9/26/24 at 11:36 A.M., showed the resident lying in his/her bed. The resident had a white bandage, dated 9/24/24, on his/her left wrist. During an interview on 9/26/24 at 11:37 A.M., the resident said: -He/She scraped his/her left wrist on the wall when he/she was coming out of the shower room; -The nurse just left after applying compression wraps to his/her legs. Observation on 9/27/24 at 9:13 A.M., showed the resident sat in his/her wheelchair in the hall. The resident's left wrist had a white bandage on it, dated 9/24/24. Review of the resident's MAR, dated 9/27/24, showed: -An order dated 9/3/24 to cleanse area to left lower arm with normal saline, apply steri strips (thin bandage used to secure wound edges closed for healing) and kling wrap (rolled gauze), once a day, until healed. Documentation showed the facility completed the treatment as ordered. 3. During an interview on 9/26/24 at 11:53 A.M., Licensed Practical Nurse (LPN) C said: -The nurses were responsible for completing wound treatments if they come up on the MAR during their shift; -Nurses were expected to follow the orders as prescribed by the physician and document completion in the MAR; -Nurses were expected to report to their on-coming nurse if they were not able to complete all treatments during their shift so the new nurse could finish the task. During an interview on 9/26/24 at 1:06 P.M., the DON said: -She expected nurses to complete wound treatments during their shift as ordered; -She expected nurses to document accurately in resident MARS after completing an order. During an interview on 10/4/24 at 3:20 P.M., the Administrator said: -He expected nursing staff to have knowledge of and follow facility policies; -He expected nursing staff to follow physician orders; -He expected nursing staff to document in residents' MAR what they actually did for complete and accurate records; -If an observation of a wound treatment did not match what was documented in the MAR, it was falsification of records and could affect plan of care; -Residents were at a higher risk of delayed wound healing and/or infection if nursing staff did not complete wound treatments as ordered. MO00242223

Based on observations, interviews, and facility document and policy review, the facility failed to ensure housekeeping services were provided to maintain clean floors in resident rooms on 2 (Unit 200 and Unit 300) of 3 units. Specifically, the facility failed to ensure resident rooms were vacuumed and/or mopped daily to prevent food and debris from remaining on the floor. Findings included: A review of the facility's policy titled, Housekeeping Resident Room Cleaning, effective March 2020, revealed, Purpose: To clean and disinfect each resident room in a safe and efficient manner and in such a way as to support the needs and preferences of each resident we serve. The policy further indicated staff should wet mop the bathroom and bedroom floor with [floor cleaner] (if bedroom hard surface) and Vacuum the bedroom floor if carpeted. In an interview on 09/11/2023 at 9:44 AM, Resident #20, who resided on Unit 200, stated that the floor was sticky, and staff did not clean the floor consistently. According to Resident #20's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/13/2023, Resident #20 had resided in the facility since 10/07/2022 and had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. In an interview on 09/11/2023 at 10:07 AM, Resident #91, who resided on Unit 200, stated the floor was sticky and had some kind of buildup. Resident #91 indicated staff would mop the floor, but it needed to be scrubbed. At this time, the surveyor observed the edges of the floor near the walls in the resident's room appeared dirty. According to Resident #91's quarterly MDS, with an ARD of 07/11/2023, Resident #91 had resided in the facility since 01/20/2022 and had a BIMS score of 15, indicating the resident was cognitively intact. Observation of Resident #69's room, located on Unit 300, on 09/11/2023 at 1:13 PM revealed crumbs on the carpeted floor. A quarter and an unknown reddish-brown ball-shaped substance were on the carpeted floor near the closet door. Observation of Resident #69's room on 09/12/2023 at 9:45 AM revealed a ball of paper on the floor. The unknown reddish-brown ball-shaped substance remained on the carpeted floor near the closet door. Observation of Resident #69's room on 09/13/2023 at 12:00 PM revealed the resident was sitting up in a chair in their room. A goldfish cracker was on the floor. A brown substance was observed ground into the carpet near the resident's bed. The unknown substance remained on the floor near the closet door. Observation of Resident #45's room, located on Unit 300, on 09/11/2023 at 10:59 AM revealed papers on the floor. In an interview at this time, Resident #45 stated staff did not clean the floors. According to Resident #45's quarterly MDS, with an ARD of 07/15/2023, Resident #45 had resided in the facility since 09/06/2022 and had a BIMS score of 15, indicating the resident was cognitively intact. Observation of Resident #45's room on 09/13/2023 at 2:00 PM revealed small pieces of paper and a cough drop on the floor. In an interview at this time, Resident #45 stated housekeeping had mopped the floor the previous day but that they needed to do a better job mopping. Resident #45 stated they were supposed to mop every day, but it was usually about every two to three days. In an interview on 09/13/2023 at 11:28 AM, the Housekeeping Supervisor (HS) stated housekeeping was supposed to clean the resident rooms daily. The HS stated the daily cleaning included mopping, vacuuming, cleaning the bathrooms, and restocking paper goods. The HS stated if a resident spilled something on the floor, housekeeping would clean the floor again. The HS stated they replaced the carpet in resident rooms as needed. In a follow-up interview on 09/13/2023 at 3:14 PM, the HS stated there was a deep-cleaning schedule posted on each unit and that housekeeping would complete deep cleaning on two rooms per unit per day and initial when it was complete. The HS said the schedule included a furniture pull list, which was when they moved the furniture and cleaned under furniture and beds. The HS stated they did not have deep cleaning schedules for previous months because they had been short staffed so had just restarted the schedule in September (2023). The HS was shown Resident #69's room, and he stated he did not think the room had been cleaned yet. The HS stated that the item in the corner should not have remained on the floor for three days. The HS could not identify the substance on the floor. The HS confirmed that the carpet in Resident #69's room needed to be replaced because of faded areas but that they could only do so many at a time. A review of the Furniture Pull List for September 2023 for Unit 200 and Unit 300 revealed Resident #45's room was not signed off as having been completed, and Resident #69's room was not included on the list. On 09/13/2023 at 4:18 PM, the HS confirmed he had no records from August 2023. In an interview on 09/14/2023 at 9:25 AM, the Director of Nursing (DON) stated her expectation was that rooms should be clean and there should not be anything on the floors. The DON stated they had floor technicians that cleaned the floors during the day, and CNAs could clean if there was a need after hours. In an interview on 09/14/2023 at 10:07 AM, the Administrator stated that a lot of the carpets needed to be replaced. The Administrator stated they were trying to address concerns with the floors by hiring a floor technician to clean the floors.

Based on interview and record review, the facility failed to follow their policy for observing, recording, and reporting one resident's condition change that included a change in level of consciousness, change in respirations, and a change in oxygen saturation levels. Staff observed the resident's changes in condition, but failed to adequately assess, monitor, and document the changes in condition, and failed to promptly notify facility management and the resident's physician until the resident was found unresponsive on [DATE]. Six residents were sampled and problems were found with one (Resident #1). The census was 103. Review of the facility Condition Change, of the Resident (Observing, Recording, and Reporting) policy, dated [DATE], showed: Purpose: -To observe, record and report any condition change to the attending physician so proper treatment will be implemented; Procedure: 1. Equipment: -Blood pressure cuff; -Stethoscope; -Thermometer; -Flashlight; 2. After all falls, injuries or changes in physical or mental function, monitor the following (included): -Observe for alternations in consciousness; -Observe for sensory weakness; -Observe for generalized weakness; -Observe for speech disorder; -Observe for stiff neck; -Observe for proper reflexes (response to painful stimuli); -Take vital signs and include temperature (T); -Observe for dyspnea (breathlessness or shortness of breath; labored or difficult breathing); -Observe for flushing or cyanosis (a bluish discoloration of the skin); -Observe for pain; -Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility Medical Director; -Complete an incident report per facility policy; -Notify resident's responsible party; -Monitor resident's condition frequently until stable. Review of the facility Condition Report (24 Hour Nursing Report) policy, undated, showed: Purpose: -The Condition Report is used to communicate changes in the resident status over a 24-hour period and to document actions taken or needed. It is the responsibility of the charge nurse to complete the Condition Report at the end of their shift; Procedure: Guidelines for providing complete information; -Resident with significant change in condition note any change. Physician and family (if indicated) notified or not. Review of Resident #1's pre-admission hospital records (received by the facility from the hospital), showed: Hospital Course: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident reports being scared of dying and does not want to be left in his/her room alone; -Resident presented to hospital after a fall (on [DATE]) sustaining multiple injuries including: right femoral neck fracture ((hip fracture, femur - the thigh bone) the femoral neck connects the femoral shaft with the femoral head), right humerus fracture (the long bone in the arm that runs from the shoulder to the elbow), and right distal fracture (situated farthest from the middle and front of); -Resident reports pain in the right shoulder; Physical Exam: -Musculoskeletal: Right shoulder with anterior (before or in front) displacement, signs of old bruising, tender to light palpation. Right forearm with cast in place. Right thigh with bruising, clean surgical site; -Psychiatric: Anxious; Assessment/Plan: -Resident's pain is not controlled and present in the leg, arm and ribcage. Today resident is alert and oriented x 2 (orientation is often referred to as person, place, time and situation) and demonstrating increased anxiety; Medical Problems Managed During Hospital Stay: -Fracture right humerus; -Fracture right radius (radius is one of the two forearm bones and located on the thumb side); -Closed fracture (an uncomplicated fracture in which the broken bones do not pierce the skin) of the right hip; -Fall; -Post-traumatic stress syndrome (a mental health condition that's triggered by a terrifying event); -Fracture of the glenoid cavity (the shallow cavity of the upper part of the scapula (either of a pair of large, flat, triangular bones forming the back part of the shoulder)), and neck of the right scapula; -Closed fracture of styloid process (a style in shape: slender and pointed) of right ulna (the bone extending from the elbow to the wrist on the side opposite of the thumb); -Closed fracture of multiple pubic rami right (four bones at the front of the pubic area that protect internal organs like the bladder, each of these bones when referred to individually, is known as a pubic ramus); -Thoracic (situated in or near the thorax (between the neck and diaphragm, partially encased by the ribs and containing the heart, lungs and the chest)) compression fracture (a fracture in which the bone collapses); -Chronic obstructive pulmonary disease ([CONDITION(S)], an [CONDITION(S)] lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, [MEDICATION(S)] production and wheezing); -Closed displaced intertrochanteric (between the two trochanters which are bony protrusions on the femur fracture); -Decreased activities of daily living; -Acute blood loss [CONDITION(S)]. Review of the resident's facility admission face sheet, showed; -admitted [DATE]; -Full code (cardiac pulmonary resuscitation should be initiated in the event the resident is found without signs of life); -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Code status: Administer CPR; -Vital signs daily 7:00 A.M. - 3:00 P.M.; -Monitor Temperature (T) and oxygen saturation level (O2 sat, blood oxygen level, measured with a pulse oximeter (a hand held machine) by clipping a sensor on the fingertip) daily. Immediately report results over 99.6 degrees or O2 sats below 90% to the charge nurse; -No order for oxygen. Review of the resident's EMR progress notes, showed: -[DATE] at 8:45 P.M.: Resident arrived at 6:45 P.M. from hospital via ambulance. Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Appears alert to self only. Hard cast to right forearm. Medical history includes [CONDITION(S)] and dementia. Somewhat able to make needs and wants known. Incontinent of bowel and bladder. Total assist with perineal care (washing/bathing), assist of one with turning and repositioning. Education given related to call light, verbalized understanding. Denies pain upon admission. Bruising observed right shoulder, right hand, right hip, left buttock and pubic area. All bruising dark purple in color. Resident on continuous oxygen (O2) at 3 liters via nasal cannula. Family notified of resident's arrival to facility; Review of the resident's admission care plan, dated [DATE], showed: -Problem: Anticoagulant (blood thinner) use; -Problem: [CONDITION(S)] drug use; -No problems or interventions had been identified regarding the resident's [CONDITION(S)], history of [CONDITION(S)], oxygen use, or when staff should contact the resident's physician regarding changes in the resident's O2 level or respirations (R); -No problems or interventions regarding orders for oxygen use. Review of the facility's treatment administration record (TAR) for the resident, showed: Order: -Monitor T and O2 sat daily. Immediately report results over 99.6 degrees or O2 sats below 90% to the charge nurse; Time 11:00 P.M. - 7:00 A.M.: -,d+[DATE] (no time entered): T 97.6 (normal range 98.6), O2 sat 97% (normal range ,d+[DATE]%); -,d+[DATE] (no time entered): T 97.9, O2 sat 99%; -,d+[DATE] (no time entered): T 97.0, O2 sat 96%; -,d+[DATE] (no time entered): T 97.2, O2 sat 99%; -No other T or O2 sats on the TAR after ,d+[DATE]; -,d+[DATE]: No T or O2 sat documented on the TAR; -No order for oxygen. Review of the resident's electronic medical record (EMR), vital signs page, showed: -,d+[DATE] 9:06 A.M.: T 97.4, pulse (P) 77 (normal range ,d+[DATE]), R 20 (normal range ,d+[DATE]), blood pressure (B/P) ,d+[DATE] (normal range ,d+[DATE]), O2 sat 96%; -,d+[DATE] 4:10 P.M.: T 96.4, P 62, R 16, B/P ,d+[DATE], O2 sat 94%; -,d+[DATE] 12:36 A.M.: T 97.0, (no P, R, or B/P documented), O2 sat 96%; -,d+[DATE] 12:37 P.M.: T 98.3, P 91, R 17, B/P ,d+[DATE], O2 sat 99%; -,d+[DATE] 5:39 P.M.: T 97.2, P 97, R 18, B/P ,d+[DATE], O2 sat 99%; -,d+[DATE] (night shift, beginning ,d+[DATE] at 11:00 P.M. and ending on ,d+[DATE] at 7:00 A.M.): No vitals or O2 sats documented by Nurse K; -,d+[DATE] 9:19 P.M.: T 97.9, P 110 (alert symbol), R 50 (alert symbol), B/P ,d+[DATE], O2 sat 79% (alert symbol). During an interview on [DATE] at 11:00 A.M., CNA B said he/she had the resident on day shift on Saturday [DATE]. He/she and another CNA got the resident out of bed in the morning using a full body lift (a machine used to transfer a resident unable to bear weight), gave the resident a shower, then used the full body lift to put the resident back to bed. The resident was not having any respiratory problems During an interview on [DATE] at 10:00 A.M., Physical Therapist (PT) A said he/she worked with the resident for the first time on Friday ,d+[DATE], and again on Saturday [DATE]. On Saturday [DATE], he/she and the Certified Occupational Therapist worked with the resident for about 45 minutes. They got the resident up. They did not lay the resident back down as family was present and asked that the resident remain up. The resident complained of pain in the right arm again and they fitted him/her with a sling for the arm. PT A did not put the resident back to bed that day. The resident had no other problems other than the pain in the right arm. During an interview on [DATE] at 7:10 A.M., Nurse F said he/she worked the evening shift (3:00 P.M. - 11:00 P.M.) on Saturday [DATE]. When he/she arrived, the resident's family was visiting. The resident was up in his/her wheelchair. Around 5:00 P.M., the family left and the resident was crying because he/she did not want the family to leave. He/she denied pain at that time. Between 8:00 P.M. and 10:00 P.M., CNA C reported the resident's IV had dislodged. The resident was back in bed at that time with his/her head tilted back. The resident was not saying anything, his/her breathing was different than earlier in the shift when Nurse F saw him/her. The resident was mouth breathing, kind of like panting. He/she thought it was due to exertion from having been turned and repositioned, but he/she was not sure when the resident was last turned and repositioned. Nurse F did not obtain vitals and an O2 sat or instruct anyone to get the resident's vitals or O2 sat, and he/she did not document any of his/her observations regarding the resident's breathing. During a telephone interview on [DATE] at 12:50 P.M., Nurse F said he/she wanted to clarify his/her original statement from [DATE] at 7:10 A.M. The surveyor reviewed the nurse's original statement with him/her. The nurse added he/she recalled the resident becoming anxious and breathing different as he/she was reinserting the IV needle into the resident's abdomen. He/she said if he/she felt the resident was having breathing problems for another reason, he/she would have completed a full assessment on the resident. He/she did not go back to the resident at a later time to ensure the resident's breathing was in fact related to anxiety due to the insertion of the IV needle. Review of the resident's EMR progress notes, showed: -[DATE] at 6:25 P.M., and completed by Nurse F: Resident yelling out at this time. When asked what is needed resident is unable to make self clear to understanding needs or wants. Resident asking questions as to where writer is from, then states he/she does not know where he/she is from. Call light is attached and in reach. No documentation between 8:00 P.M. and 10:00 P.M. by Nurse F regarding the resident's respirations, vitals or O2 sat. During an interview on [DATE] at 6:37 A.M., CNA E said he/she had been employed at the facility for about [AGE] years. He/she was assigned to care for the resident from 11:00 P.M. on Saturday [DATE] through Sunday [DATE] at 7:00 A.M. Around 12:00 A.M. to 12:30 A.M., CNA E was making his/her first rounds. The resident was in bed with oxygen infusing per nasal cannula. He/she did not know what the oxygen setting was on. CNA E did not think the resident looked good. The resident's skin appeared normal, but he/she was taking slow, deep breaths, and looked like he/she was going to die. He/she took the resident's O2 sat and it was extremely low, in the 50s. CNA E took the resident's O2 sat a second time using a different finger and it was still in the 50s. Nurse K came in the room to do something with the resident's IV at that time. He/she discussed the resident's condition with the nurse. The nurse took the resident's O2 sat and said it was in the 60s. CNA E asked the nurse if they should send the resident to the hospital, and the nurse said he/she did not think the resident looked bad, because his/her vitals were ok. The nurse increased the resident's oxygen to 10 liters. The nurse did not give him/her any directives to monitor the resident, obtain vitals or O2 sats. The last time CNA E saw the resident was around 5:00 A.M. on his/her last rounds. The resident's skin was normal in color, but he/she still appeared to be having problems breathing. He/she asked the nurse about the resident's oxygen around 6:00 A.M., and CNA E thinks the nurse went in and turned the oxygen rate back down. He/she also worked the evening shift on [DATE], and although CNA E was not assigned to care for the resident, he/she did assist with getting the resident ready for transport to the hospital. The resident seemed to be having similar respirations as he/she did when CNA E spoke to Nurse K the night before. Review of the resident's EMR progress notes, showed: -[DATE] (night shift, beginning on ,d+[DATE] at 11:00 P.M. and ending on ,d+[DATE] at 7:00 A.M.): No assessments, vitals or O2 sats documented by Nurse K. During an interview on [DATE] at 3:40 P.M., Nurse K said he/she was an agency nurse and had worked at the facility a couple of times. He/she worked on the night shift of [DATE] and left the morning of [DATE] around 7:00 A.M. He/she had been told in report by the evening shift nurse (Nurse F) the resident was having a little bit of respiratory distress. He/she checked on the resident three or four times during his/her shift. Around 12:30 A.M., CNA E told him/her the resident was upset so Nurse K went to the resident's room to comfort the resident. He/she personally obtained a set of vitals at that time which were within normal limits, and documented the vitals in the resident's EMR. When asked why the vitals could not be found in the resident's EMR or TAR, Nurse K said he/she must have forgotten to record the vitals. The resident seemed fine throughout the shift, although he/she seemed a little bit upset, but he/she did have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Around 4:00 A.M. or 5:00 A.M., the CNA asked him/her to take a look at the resident. The CNA mentioned something about the resident's O2 sats being in the 50's, and that's when he/she went out to his/her car to get his/her own pulse ox. Nurse K re-checked the resident's O2 sat with his/her pulse ox and the resident's O2 sats were in the 90's. Had he/she gotten an O2 sat in the 60's he/she would have sent the resident to the hospital. He/she did not test the pulse ox the CNA used to determine if it was defective. Nurse K did not recall the CNA telling him/her any other resident's O2 sats were critically low, only Resident #1. Nurse K increased the resident's oxygen to 10 liters and sat with resident for about 15 minutes before lowering the oxygen back to about 2 or 3 liters. The resident was alert and asked to be changed at that time. The resident was feisty and talking, but confused. The resident was fine when he/she left that morning. Nurse K did not document an assessment, vitals or increasing the oxygen for 15 minutes in the resident's progress notes or on the 24 hour daily report because the resident was fine. During an interview on [DATE] at 10:35 A.M., CNA E said the resident was talking on/off during his/her shift and did ask to be changed. He/she said the resident's O2 sats were low. In all his/her years of working he/she had never gotten O2 sats in the 50s or 60s. He/she used the pulse oximetry machine (pulse ox, clipped to the finger tip and used to determine a resident's O2 saturation), on other residents as well that shift and none of those were showing a low reading. During an interview on [DATE] at 11:00 A.M., CNA B said he/she worked on the day shift on Sunday [DATE], but was not assigned to care for the resident. He/she took the resident's breakfast tray around 8:00 A.M. to 8:30 A.M. The resident did not look good. He/she did not open his/her eyes. His/her breathing was different than on [DATE]. His/her breathing was not steady and he/she was taking short breaths. CNA B tried to speak to the resident, but the resident kept his/her eyes closed and did not respond. He/she mentioned the resident did not look good at the nurse's station. There was a nurse present at the time, but CNA B did not recall what nurse. The nurse did not ask him/her any questions or give him/her any directives. He/she is not sure if the nurse discussed anything about the resident with the CNA assigned to the resident. Review of the resident's EMR progress notes, showed: -[DATE] at 10:54 A.M., Resident in bed. Head of bed up 30 degrees. No signs or symptoms of acute distress noted. Skin warm and dry to touch. Respirations even and non-labored. O2 on at 3 liters, eyes closed. Refused medications this morning. Light sternum rub, resident opened his/her eyes, but continues to refuse food. Family brought in [CONDITION(S)] (a machine that forces air into the lungs during sleep) with instructions for use. Remains incontinent of bowel and bladder, total assistance with peri-care. Bed in low position and call light in reach. No further assessments documented on the day shift after 10:54 A.M.; -[DATE] at 7:09 P.M.: Resident laying quietly in bed, is difficult to arouse. Respirations even and unlabored. Wearing O2 at 3 liters. Second bag of IV fluids infusing in right lower abdomen as ordered. No signs or symptoms of infection observed. During an interview on [DATE] at 12:20 P.M., CMT J said he/she worked the resident's unit on the day shifts on Friday ,d+[DATE], Saturday ,d+[DATE], and the day shift and evening shift of [DATE]. On day shift, there are two med pass times (7:15 A.M. - 11:15 A.M. and 11:15 A.M. - 2:45 P.M.). On Friday ,d+[DATE], during the first med pass, the resident seemed fine. He/she was talking and swallowed his/her medications whole with no problems. The resident did not have orders for medications on the second med pass, only the first med pass. On Saturday ,d+[DATE] day shift during the first med pass, the resident was alert, but refused his/her medications. On the day shift of Sunday ,d+[DATE], during the first med pass, the resident was not opening his/her eyes, just calling out names and mumbling. CMT J tried to give the resident water, but it just ran out the side of his/her mouth. He/she did not recall what the resident's respirations were like. CMT J did not feel comfortable giving the resident his/her medications so he/she withheld them. On evening shifts, there are two med passes (3:15 P.M. - 6:15 P.M. and 7:15 P.M. - 9:15 P.M.). On the evening shift of Sunday ,d+[DATE], during the first med pass, the resident was not opening his/her eyes or responding, He/she could not recall what the resident's respirations were like. CMT J told the evening charge nurse about not being comfortable giving the resident his/her meds on the day shift or the evening shift either and withheld them. He/she did not receive any directives from the charge nurse. Review of the resident's EMR progress notes, showed: -[DATE] at 8:40 P.M., This writer entered resident's room and found resident unresponsive with rapid and shallow respirations. Vitals: T 97.9, P 110, R 50, BP ,d+[DATE] and O2 sat 79%. This writer contacted resident's physician and received orders to 911 resident to the hospital; -[DATE] at 8:50 P.M.: Ambulance here to transport resident to hospital. Resident's family notified. Review of the facility Nursing Home to Hospital Transfer Form, dated [DATE] at 9:15 P.M., and completed by Nurse M, showed the resident was unresponsive with shallow and rapid respirations and O2 sat of 79%. On 3 liters of oxygen. Received orders to 911 resident to hospital. Review of the resident's hospital medical records, dated [DATE] through [DATE], showed: History of Present Illness and Subjective Assessment: -Recent hospital admission for fall resulting in multiple fractures ([DATE] - [DATE]). admitted to the ICU on [DATE] for acute (sudden) on chronic (long-term) [CONDITION(S)]. Presented to the emergency department on [DATE] after chronic [CONDITION(S)]. At nursing home, emergency medical staff (EMS) found resident agonally breathing (abnormal pattern of breathing characterized by gasping, labored breathing, accompanied by strange vocalizations and [CONDITION(S)] (sudden, brief involuntary twitching or jerking of a muscle or muscle group)) with O2 sats in the 60s. He/she was placed on non-rebreather masks (a special type of mask that helps provide oxygen in emergencies for people who can breath on their own but require a lot of extra oxygen) with improvement to 90% O2 sat. Resident was intubated (a tube is inserted through the mouth or nose into the windpipe/airway keeping the windpipe open so air can get through) once code status was verified; Assessment/Plan: -Resident has Alzheimer's dementia, [CONDITION(S)] and a recent fall with multiple fractures, and was admitted on [DATE] with [CONDITION(S)]; Problems Being Addressed and Management Recommendations: -Acute (sudden) hypoxic [CONDITION(S)] (not enough oxygen in the blood, symptoms may cause dyspnea, restlessness, anxiety, confusion, alteration of consciousness, tachypnea (rapid respirations, and [CONDITION(S)] (rapid heart rate), acute metabolic [CONDITION(S)] (a condition in which brain function is disturbed whether temporarily or permanently due to different diseases or toxins in the body) secondary to respiratory compromise; -Acute rib fractures: Right #5-#9, #8-#9 displaced (the bone is broken in two or more places and is no longer correctly aligned, symptoms can include pain and difficulty taking deep breaths). During an interview on [DATE] at 11:15 A.M., the Director of Nurses (DON) said CNA E is a good employee and she would have no reason to doubt the CNA's observations in the past. If a CNA notes a change in condition, they are expected to report it to the charge nurse. Nurse K is an agency nurse and he/she never reported or documented the resident having O2 sats in the 50s or 60s, labored respirations or increasing the resident's oxygen to 10 liters. Nurse K never documented anything in the resident's EMR that night or on the 24 hour daily report. If there was a change in condition, it should be documented in the progress notes in the EMR, and the 24 hour daily report sheet. She collects the 24 hour daily report sheets every morning, and replaces them with the next days 24 hour report sheets. If the resident was having respiratory problems and low O2 sats, she expected Nurse K to have called the physician, document the O2 sats and complete a physical assessment of the resident in the EMR. If unable to reach the resident's physician, then the Medical Director should have been notified. Nurse K never reported any of this to anyone. The facility did not have a policy for low O2 parameters showing when a nurse should contact the resident's physician, but generally if a resident's O2 sat go below 90, the nurse should assess the resident and follow up. Nurses document the vitals in the EMR, and if there are abnormals, they will show up in red, prompting the nurse to further assess the resident. The DON said she checked other residents' O2 sats and none of them were below normal ranges. During a telephone interview on [DATE] at 2:37 P.M., the Medical Director (MD) said if Nurse F felt there was a change in the resident's condition with the resident's breathing, then he expected the nurse to assess the resident, notify the physician, and document it. If CNA E obtained the O2 sats in the 50s or 60s, that would be critical for anyone, even a resident with a chronic respiratory diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An assessment should have been completed, the physician notified and it should have been documented. Anytime the CNAs or CMTs notice changes, he expected it to be reported to the nurses and the nurses should assess the resident and notifying the physician if needed. Fractured ribs could cause a change in condition due to pain. It could also affect respirations and O2 sats, but not into the 50s or 60s, so something else may have been going on with the resident. He expected the facility to follow their policies for change in condition. During an interview on [DATE] at 12:35 P.M., the MD said he was at the facility with the administrator present, had reviewed the resident's medical record and wished to discuss the resident a bit more; -Nurse F: He said if the nurse did not perceive the resident to be in any distress, he/she may have thought it was only temporary. He cannot comment on what the nurse should have done in regards to the residents respirations. Is it a temporary problem and is the resident alright later? It would have been a good thing to follow up though and document. He is not saying what the nurse did or did not do is right or wrong; -Nurse K: If the resident's O2 sats were in the 50s or 60s, it would indicate a severe problem. He reviewed the resident's pre-admission hospital notes and it showed the resident was very frail with chronic pain and [CONDITION(S)]. The resident also had lab work completed at the facility and it indicated he/she had chronic lung problems. If that were the case regarding the O2 sats, then he expected the physician and family to be notified. He expected it to be documented in the resident's record and discussed in the shift change report; -As far as the other staff that were interviewed, if they were not documenting or reporting their observations, then he would have no way of knowing what occurred. During an interview on [DATE] at 1:20 P.M., the resident's physician said she was in her office and had access to the resident's EMR from the facility. She completed the resident's history and physical on [DATE]. Her notes showed no acute distress and the resident's lungs were clear to auscultation. She said if CNA E was obtaining O2 sats in the 50s and the nurse obtained an O2 sat in the 60s, she should have been notified immediately and she would have ordered the resident be sent the hospital. Since the resident had a recent surgery, she would be concerned the resident may have a pulmonary embolism (a clot in the lung). Any time O2 sats are in the 80s or below, she would send a resident to the hospital. She expected the nurse to have assessed the resident, including vitals, and documented it in the EMR. When CMT J said the resident was mumbling, and couldn't drink water on the day and evening shift of [DATE], she should have been notified, as this would be a mental status change. She expected a nurse to have assessed and documented the CMT's observations. Again, had she been made aware of that kind of a mental status change, she would have sent the resident to the hospital. She read the progress note dated [DATE] at 7:09 P.M., where the nurse documented the resident was difficult to arouse and said she should have been notified of that change. MO 010