Every finding on record at Delhaven Manor

Based on observation, interview, and record review, the facility failed to obtain physician orders for monitoring and care of a gastrostomy tube (g-tube, a medical device placed through the belly directly into the stomach to deliver food, liquids, and medication) for one resident (Resident #3). The sample was 5. The census was 58. Review of the facility's Enteral Nutrition policy, dated November 2018, showed the following:-Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered;-Policy Interpretation and Implementation:-If the resident has a feeding tube placed prior to admission or returning to the facility, the provider and the interdisciplinary team will review the rationale for the placement of the feeding tube, the resident's current clinical and nutritional status, and the treatment goals and wishes of the resident;-The decision to continue or discontinue the use of the feeding tube is made through collaboration between the interdisciplinary team, the provider and the resident. Review of the facility's Physician Services policy, dated February 2021, showed the following:-Policy Statement: The medical care of each resident is supervised by a licensed physician.-Policy Interpretation and Implementation: -Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS);-Supervising the medical care of residents includes (but is not limited to):--Monitoring changes in resident's medical status;--Prescribing medications and therapy. Review of Resident #3's medical record, showed the following:-admission date: 07/14/26;-Diagnoses included stroke. Review of the resident's After Visit Hospital Summary, dated 07/14/26, showed the resident's medication to be administered orally or by g-tube. Review of the resident's nurse's note, date 07/14/26 at 12:29 P.M., showed the resident is alert and oriented time four. The resident transported via facility transportation accompanied by his/her spouse from the hospital to his/her room. The resident is a maximum assist of two. The resident's skin was intact with no open areas or bruising noted. Plan of care initiated. No documentation related to the resident's g-tube. Review of the resident's admission skin assessment, dated 07/14/26, showed no skin issues and no documentation of a g-tube. Review of the resident's care plan, in use at the time of the survey, showed no documentation regarding a g-tube. Review of the resident's physician orders and administration records, showed no physician orders related to g-tube from 07/14/26 through 07/27/26 and no documentation of g-tube care provided from 07/14/26 through 07/27/26. Observation on 07/28/26 at 11:10 A.M., showed the resident with a g-tube inserted on the left side of his/her stomach. During an interview on 07/28/26 at 10:55 A.M, the Assistant Director of Nursing (ADON) said the admission charge nurse should have assessed the resident's skin and should have seen the resident's g-tube, then called the resident's physician to obtain g-tube care orders and any necessary orders. During an interview on 07/28/26 at 12:57 P.M., the Director of Nursing (DON) said he expected the facility's policies to be followed as written. The charge nurse should have documented the resident's g-tube in his/her medical record and should have notified the resident's physician for any necessary orders. The DON did not know why this was not done. During an interview on 07/28/26 at 12:50 P.M., the Administrator said he expected the facility's policy to be followed as written. The charge nurse should have called the resident's physician immediately to get any necessary orders for the g-tube. 3117249

Based on observation, interview, and record review, the facility failed to ensure residents requiring dialysis received services consistent with professional standards of practice when staff failed to conduct an ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments for two residents (Residents #1 and #3). The facility identified two residents receiving dialysis and problems were found with both. The sample was 3. The census was 35. 1. Review of Resident #1's medical record, showed:-admission date 2/5/26;-Diagnoses included end stage renal disease (ESRD, permanent kidney failure that requires a regular course of dialysis or a kidney transplant). Review of the resident nurse's note, dated 2/5/2026 at 1:42 P.M., showed the resident arrived via transportation from the dialysis center. They were unable to dialyze him/her due to inability to lift the resident. The resident requires Hoyer pad, not sent with him/her from the previous facility. The resident is an assist times two with a Hoyer lift. He/She refused to allow the nurse to assess skin wounds that are noted on his/her lower extremity. The dialysis shunt (surgically created connection between artery and vein that acts as an access point for dialysis) is in the resident's right upper extremity with thrill and bruit noted. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/10/26, showed the resident cognitively intact. Review of the resident's care plan, in use at the time of survey, showed the following:-Focus: The resident is at risk for ineffective tissue perfusion (process in which blood carries oxygen and nutrients to body tissues and organs) and excessive fluid volume related to a diagnoses of ESRD. The resident is dependent on dialysis;-Tasks: Ensure to attend dialysis appointments as scheduled. Monitor the resident's fistula (surgically created connection between the artery and a vein), monitor the bruit (whooshing sound heard with a stethoscope over a functioning fistula) and thrill (vibration felt when touching a fistula) as ordered. Review of the resident's active physician order summary (POS), showed no physician orders for the resident to receive dialysis, and no physician orders for staff to monitor the resident's dialysis site or to check the resident's bruit or thrill before and after dialysis. Observation on 3/16/26 at 10:35 A.M., showed the resident had a dialysis shunt to his/her right upper arm. During an interview, the resident said he/she goes to dialysis three times a week, on Tuesdays, Thursdays, and Saturdays. The staff at the facility do not check his/her dialysis shunt before or after dialysis treatment. 2. Review of Resident #3's medical record, showed the following:-admission date 3/4/26;-Diagnoses included ESRD. Review of the resident's care plan, in use at the time of survey, showed the following:-Focus: Resident at risk for imbalanced fluids and ineffective tissue perfusion related to diagnoses of ESRD;-Tasks: Ensure the resident attends dialysis at scheduled times and nursing to assess the resident as ordered. Review of the resident's active POS, showed:-An order, dated 3/5/26, for dialysis on Tuesdays, Thursdays, and Saturdays, with chair time at 10:45 A.M.;-No physician orders for staff to monitor the resident's dialysis access site or to check his/her bruit and thrill. Observation on 3/16/26 at 11:45 A.M., showed the resident with a dialysis shunt in his/her upper left arm. During an interview, the resident said he/she goes to dialysis on Tuesdays, Thursdays, and Saturdays. The staff do not always check his/her vital signs or check his/her bruit and thrill before or after dialysis. 3. During an interview on 3/16/26 at 11:37 A.M., Licensed Practical Nurse (LPN) A said before a resident goes to dialysis, the nurse should get a set of vital signs, make sure the resident is administered his/her medications, and check the resident's bruit and thrill, then document it in the resident's medical record. The resident should have a physician order for dialysis and an order for staff to monitor the resident's bruit and thrill. The resident's bruit and thrill should be monitored to ensure they are functioning properly. He/She was not aware the residents did not have proper physician orders for dialysis. 4. During an interview on 3/16/26 at 12:55 P.M, with the Director of Nursing (DON) and Administrator, the DON said the facility did not have a dialysis policy. The Assistant Director of Nursing (ADON) is responsible for ensuring the residents have orders for dialysis and orders for staff to monitor the resident's bruit and thrill. The DON was not aware the residents did not have physician orders for dialysis or orders to monitor the bruit and thrill and she did not have an explanation as to why the residents did not have the proper orders. It is important to have physician orders for dialysis for staff to monitor the resident for any infection. The Administrator agreed with the DON and did not know why the facility did not have a policy related to dialysis. 2742660

Based on observation and interview, the facility failed to label, date, and cover food in the kitchen. In addition, the facility failed to ensure that kitchen equipment was clean and was in proper working order. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 60. 1. Observations of the kitchen dry storage room, showed: -On 11/6/24 at 11:14 A.M., 11/7/24 at 4:14 P.M., and 11/8/24 at 2:46 P.M.,: -A package of opened mostaccioli noodles wrapped in plastic without a date; -A package of opened cheese flakes wrapped in plastic without a date; -On 11/6/24 at 11:14 A.M. and 11/7/24 at 4:14 P.M., a package of opened stuffing mix wrapped in plastic without a date. 2. Observation on 11/6/24 at 11:14 A.M. and 11/7/24 at 4:14 P.M., showed: -Walk in cooler: -Tortilla shells opened, wrapped in plastic, and without a date; -A salad mix opened, wrapped in plastic, and without a date; -Walk in freezer: -A box of cookies opened, undated, and exposed to the air; -Catch all freezer: -French toast in a plastic bag with a knot tied at end, without a date; -Biscuits in a plastic bag with a knot tied at end, with a hole in the bag, opened, and exposed to air; -A package of hot dogs opened, wrapped in plastic, and without a date; -An unidentified food item in an aluminum container, wrapped in plastic, and without a date. 3. Observations on 11/6/24 at 11:14 A.M., 11/7/24 at 4:14 P.M., and 11/8/24 at 2:46 P.M. in the kitchen, showed: -The deep fryer: -Old grease sat in the fryer; -Caked on grease and batter along the inside of the fryer; -Two straining baskets with caked on grease; -The stove: -Heavy caked on stains on the stove burners; -Old food particles inside the stove burners. 4. Observations of the walk-in cooler on 11/6/24 at 11:14 A.M., 11/7/24 at 4:14 P.M., and 11/8/24 at 2:46 P.M., showed a fan in the ceiling leaked water into a metal pan that sat on the top shelf in the cooler. 5. During interviews on 11/13/24 at 2:23 P.M., the Director of Dietary Services said it is her expectation that all food items should be properly labeled, dated, and stored. Everyone is responsible for labeling and dating food. She does not have a designated sanitation staff person. Staff clean every day in the kitchen, but deep cleaning is done on Sundays because their stock comes in on Mondays. She does not fry a lot in the deep fryer. She changes the grease one time a week. She had not used the deep fryer since last week on Thursday. She is responsible for cleaning the stove. The stove should be getting cleaned every two weeks. Regarding the fan in the cooler, they have someone coming out to look at it on Monday. She expects for the fan as well as all the equipment in the kitchen to be in proper working order. Maintenance is aware of the issue and have called someone out to fix it. 6. During interviews 11/13/24 2:35 P.M. and 11/18/24 at 11:45 A.M., the Administrator said he would have expected for all food to be properly labeled, dated, and stored. He also expected for all equipment in the kitchen to be clean and in proper working order.

Based on interview and record review, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. This deficiency had the potential to affect all residents who have money in the resident trust fund. The census was 60. Review of the facility's Surety Bond Invoice, dated 12/28/23, showed a bond amount of $75000. Review of the facility's average resident trust fund balance for the previous twelve months, showed: -A monthly average of $52,000.00; -For this amount, the bond amount should have been $78,000. During an interview on 11/12/24 at 2:00 P.M., the Business Office Manager said she was not aware the amount was not sufficient and would request an increase immediately. The bond amount should have been sufficient. During an interview on 11/13/24 at 2:40 P.M., the Administrator said he was unaware the bond amount was not sufficient. The bond should be sufficient and he had the bond amount increased immediately.

42247 45083 Based on observation, interview and record review, the facility failed to place signage and follow indications for enhanced barrier precautions (EBP, an infection control intervention that utilizes personal protective equipment (PPE) to reduce the spread of multidrug-resistant organisms (MDROs)) for two residents who had pressure ulcers (open wounds that occur when skin and tissue are damaged by prolonged pressure), and an indwelling urinary catheter (a flexible tube that drains urine from the bladder into a collection bag) (Residents #42 and #38). In addition, the facility failed to ensure the indwelling urinary catheter bag was off the floor for one resident (Resident #38). Furthermore, the facility failed to ensure the nebulizer mask was stored in bag or clean container when not in use for one resident (Resident #45). The sample was 18. The census was 60. Review of the Centers for Disease Control and Prevention's (CDCs) Implementation of PPE Use in Nursing Homes to Prevent Spread of MDRO guidelines, dated 4/2/2024, showed: -Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization; -Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: -Dressing; -Bathing/showering; -Transferring; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use: central line, urinary catheter, feeding tube, tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe (trachea) to help a person breathe)/ventilator (type of breathing aparatus); -Wound care: any skin opening requiring a dressing; -In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to Standard Precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions (Steps taken to prevent the spread of germs), they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk; -When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: -Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (such as, gown and gloves); -Signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves; -Make PPE, including gowns and gloves, available immediately outside of the resident room; -Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room); -Position a trash can 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; -Incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education; -Provide education to residents and visitors. Review of the facility's Enhanced Barrier Precautions Policy, revised on 10/12/24, showed: -Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms; -Prompt recognition of need: -All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions; -All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions; -The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities; -Initiation of Enhanced Barrier Precautions: -The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC; -Enhanced barrier precautions will be initiated for residents with any of the following: -Wounds (such as, chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling/implanted medical devices (such as, central lines, ports, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO; -Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. The facility did not have policies to address process and procedure for infection control related to oxygen tubing and nebulizer mask storage. 1. Review of Resident #42's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 10/21/24, showed: -Both short term and long-term memory loss; -Resident had an indwelling catheter; -Two Stage III pressure ulcers (full thickness tissue loss, subcutaneous fat may be visible, but the bone, tendon or muscle is not exposed) Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling); -Two Stage IV pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling); -One Unstageable (slough and/or eschar known but not stageable due to coverage of wound bed by slough and/or eschar); -One unstageable (deep tissue suspected deep tissue injury in evolution); -Diagnoses included: cancer, heart failure, benign prostatic hyperplasia (BPH, enlarged prostate), stroke and aphasia (a language disorder that makes it difficult to communicate due to damage to the brain's language center). Observation on 11/8/24 at 7:40 A.M., showed no sign on the door to indicate the resident was on EBP. The resident sat in his/her chair with the covered catheter drainage tube draining to gravity. Certified Nurse Aide (CNA) C and Certified Medication Technician (CMT) D entered the resident's room, performed hand hygiene and put on gloves. CNA C and CMT D transferred the resident from the chair to the bed using a mechanical lift. After the resident was in bed, CNA C and CMT D rolled the resident side to side to remove his/her pants and brief. The resident had a dressing on his/her left buttocks dated 11/5/24. The CMT provided personal hygiene to the resident while CNA C held the resident over on his/her side. There were two superficial open areas on the sacrococcygeal area (pertaining to both the sacrum and coccyx (the tailbone)) which were not covered. After the CMT finished cleaning the resident, he/she applied a barrier cream to the buttocks and removed his/her gloves and left the room. A few minutes later, CMT D and the Assistant Director of Nursing (ADON) entered the room, performed hand hygiene and put gloves on. The ADON observed the open areas on the sacrococcygeal area, removed her gloves and left the room to go get supplies to clean the wounds. CMT D emptied 600 milliliters (mL) from the resident's catheter. The ADON returned to the room, performed hand hygiene, put gloves on, then provided wound care to the resident. Staff failed to wear a gown while providing high-contact resident care. 2. Review of Resident #38's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included traumatic spinal cord dysfunction (a condition where the spinal cord is damaged due to trauma), hypotension (low blood pressure), and quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down); -Resident had indwelling catheter; -One Stage II pressure ulcer; -One Stage III pressure ulcer; -One Stage IV pressure ulcer. Observation on 11/8/24 at 10:28 A.M., showed no EBP sign on the door. The resident's indwelling catheter bag did not have a barrier cover on it and hung on the side of the lowered bed. Part of the bag lay on the floor. CNA C entered the room, performed hand hygiene and applied gloves. CNA C did not adjust or pick up the catheter bag. At approximately 10:35 A.M., the ADON entered the room, performed hand hygiene and applied gloves. The ADON provided wound care while CNA C assisted in turning the resident from side to side. Both staff failed to wear a gown while providing high-contact resident care. During an interview on 11/8/24 at 11:39 A.M., the Director of Nursing (DON) and ADON said they had not heard of EBP, and they did not recall hearing about it. 3. During an interview on 11/13/24 at 2:40 P.M., the Administrator said he would expect for staff to use EBP. He would expect the staff to keep the indwelling urinary catheter bag off the floor. 4. Review of Resident #45's quarterly MDS, dated [DATE], showed: -admitted to the facility: 10/20/23; -Understood/understand; -Severely impaired vision; -Special treatments and programs; Oxygen therapy: while a resident; -Diagnoses included COPD (Chronic obstructive pulmonary disease, is a common lung disease that makes it difficult to breathe), diabetes mellitus, and hyperlipidemia (high cholesterol). Review of the resident's care plan, used during the survey showed: -Focus: The resident requires oxygen therapy related to diagnosis of persistent asthma and is frequently short of breath (SOB); -Goal: The resident will remain free of SOB and complications related to diagnosis of persistent asthma; -Interventions: Keep head of bed (HOB) elevated for optimal breathing. Medication provided as prescribed. Monitor oxygen saturation (SPO2, percentage of oxygen in blood) as ordered. Provide supplemental oxygen as prescribed. Review of the resident's physician's order sheet dated 11/8/24 showed: -An order dated: 10/18/24, for albuterol sulfate inhale aero 108 micrograms (mcg)/ACT (90 MCG base equivalent) two puff inhale orally every six hours as needed for SOB/wheezing. Unsupervised. Self-administration may keep at bedside; -An order dated: 9/9/24, albuterol sulfate nebulization solution (2.5 mg/3 ML) 0.083% three milliliter (ml) inhale orally via nebulizer every six hours as needed for SOB; -An order dated: 5/27/24, start date: 6/3/24, for fluticasone-salmeterol aerosol powder breath activated 250-50 mcg/Dose 1 puff inhale orally two times a day for lung disease. Observations of the resident, showed: -On 11/07/24 at 10:33 A.M., a nebulizer machine (turns liquid medicine into a mist that can be inhaled to treat lung conditions) and the mask lay uncovered on the windowsill; -On 11/08/24 at 11:15 A.M., a nebulizer mask lay on the windowsill. No bag to cover the mask was noted; -On 11/08/24 at 2:36 P.M., the resident was out of his/her room. The nebulizer mask lay on the windowsill and was uncovered; -On 11/12/24 at 12:03 P.M., the resident sat in his/her room. The nebulizer mask lay on the windowsill, uncovered. During an interview on 11/13/24 at 2:35 P.M., the administrator said he would have expected for the resident's mask to have been covered due to infection control issues.

42247 Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected three of three sampled residents who expired and had money in their accounts longer than 30 days (Residents #314, #315 and #316). The census was 60. 1. Review of Resident #314's financial records, showed: -Expired on [DATE]; -Ending balance of $390.49; -TPL form sent on [DATE]. 2. Review of Resident #315's financial records, showed: -Expired on [DATE]; -Ending balance of $29.04; -TPL form sent on [DATE]. 3. Review of Resident #316's financial records, showed: -Expired on [DATE]; -Ending balance of $20.04; -TPL form sent on [DATE]. 4. During an interview on [DATE] at 3:42 P.M., the Business Office Manager (BOM) said the facility was supposed to send the TPL form within 30 days. The BOM started working at the facility in June of last year and realized TPLs were not sent. It was not acceptable to send the funds later than 30 days.

Based on interview and record review, the facility failed to assure the residents' Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) accurately reflect the residents' status for two of 26 sampled residents (Resident #57 and #60). The census was 60. 1. Review of Resident #57's significant change MDS, dated [DATE], showed: -admitted to the facility: [DATE]; -Diagnoses included high blood pressure, aphasia (language disorder that affects a person's ability to understand, speak, read and write), and depression; -Special services received while a resident: Hospice Care; -Does the resident have a condition or chronic disease that may result in life expectancy less than six months: No; -Staff failed to accurately document the resident's condition resulted in a life expectancy of less than six months necessitating hospice services. Review of the resident's physician order sheet, dated [DATE], showed an order dated [DATE], for Hospice care. Review of the resident's care plan in use during the survey, showed: -Problem: Resident has been admitted to Hospice related to diagnosis of senile degeneration of the brain; -Goal: Resident will have his/her needs met thru the next review date; -Interventions included: Facility and Hospice to coordinate for continuity of care. Follow up with Physician and Hospice as needed. Medication provided as prescribed. Monitor for a decline in functions. Provide spiritual and emotional support as needed. 2. Review of Resident #60's admission MDS, dated [DATE], showed: -admitted to the facility: [DATE]. -Diagnoses included cancer, asthma, malnutrition, and Parkinson's Disease; -Special services received while a resident: Hospice Care; -Does the resident have a condition or chronic disease that may result in life expectancy less than six months: No; -Staff failed to accurately document the resident's condition resulted in a life expectancy of less than six months necessitating hospice services. Review of the resident's physician order sheet, dated [DATE], showed an order dated [DATE], for Hospice care. Review of the resident's medical record showed he/she expired at the facility on [DATE]. Review of the resident's care plan, showed: -Problem: Resident has been admitted to Hospice related to diagnosis of metastatic lung cancer; -Goal: Resident will have his/her needs met thru the next review date; -Interventions included: Follow up with Hospice as needed. Follow up with Physician as needed. Medication provided as prescribed. Monitor for a decline in functions. Provide medication as prescribed. 3. During an interview on [DATE] at approximately 2:00 P.M., the MDS Coordinator said she updates the MDS. She is responsible for the MDS. Under Section J, and answer of yes would be noted under if the person is actively dying, and there has to be a physician documentation that they are dying. If the resident is on hospice, it should be noted on the MDS under section O. 4. During an interview on [DATE] at 11:45 A.M., the Administrator said he would expect for the residents' MDS to be accurately coded. The MDS should be accurate and should reflect the residents' current condition.

Based on interview and record review, the facility failed to ensure residents who received dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) had documented assessments and monitoring related to dialysis and ongoing documented communication with the dialysis center. The facility identified two residents who received dialysis, and one resident was sampled (Resident #53). In addition, the facility failed to have a copy of the dialysis contract. The sample was 18. The census was 60. Review of the facility's Care of a Resident with End-Stage Renal Disease Policy, dated reviewed 10/12/24, showed: -Policy statement: residents with end stage renal disease (ESRD, chronic irreversible kidney failure) will be cared for according to currently recognized standards of care; -Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents; -Education and training of staff includes, specially: -The nature and clinical management of ESRD (including infection prevention and nutritional needs); -The type of assessments data that is to be gathered about the resident's condition on a daily or per shift basis; -Signs and symptoms of worsening condition and/or complications of ESRD; -How to recognize and intervene in medical emergencies such as hemorrhage (bleeding) and septic infections (serious condition in which the body responds improperly to an infection); -Care of the grafts (arteriovenous graft (AVG), is a surgical procedure that connects an artery and vein using a synthetic tube to create a vascular access point for hemodialysis (a medical treatment that removes waste and excess water from the blood when the kidneys can no longer do so)), and fistulas (access made by joining an artery and vein in the arm); -Agreements between the facility and the contracted ESRD facility include all aspects of how the residents care will be managed, including: -How the care plan will be developed and implemented; -How information will be exchanged between the facilities. Review of Resident #53's medical record, showed: -Cognitively intact; -Diagnoses included: ESRD and dependence on renal dialysis. Review of the care plan, in use at the time of survey, showed: -Focus: is at risk for fluid imbalance and decreased physical mobility related to diagnosis of ESRD. Dependent on dialysis Monday (M), Wednesday (W) and Friday (F); -Goal: will remain free of complications related to diagnoses of ESRD now through next review; -Interventions: ensure to attend dialysis appointments as scheduled, monitor for infections and monitor shunt site (a surgically created connection between an artery and vein) for bruit and thrill (sound and sensation that indicate a good blood flow in a dialysis fistula or graft). Review of the order summary, dated active orders as of 11/6/24, showed an order to check every shift for monitoring dialysis access. Report absence or weak thrill or bruit to dialysis provider and primary medical doctor, start date 8/29/24. Review of the Medication Administration Record (MAR)/Treatment Administration Record (TAR) dated 10/1/24 through 10/31/24. showed no documentation to show staff checked every shift for monitoring dialysis access or report the absence or weak thrill or bruit to the dialysis provider and primary medical doctor. Review of the progress notes dated 10/1/24 through 10/31/24, showed: -On 10/9/24 at 1:14 P.M., 10/18/24 at 7:55 A.M., 10/21/24 at 1:35 P.M., and on 10/30/24 at 6:42 P.M., staff documented dialysis assessments; -Staff did not document any other dialysis assessments. Review of the Dialysis Communication Records, provided by the facility, dated 10/1/24 through 10/31/24, showed four out of 13 assessments were completed. Review of the MAR/TAR, dated 11/1/24 through 11/6/24, showed no documentation to show staff checked every shift for monitoring dialysis access or report the absence or weak thrill or bruit to the dialysis provider and primary medical doctor. Review of the progress notes, dated 11/1/24 through 11/6/24, showed staff did not document any dialysis assessments. Review of the dialysis communication records, provided by the facility, showed no assessments were completed from 11/1/24 through 11/6/24. During an interview on 11/12/24 at 11:40 A.M., Licensed Practical Nurse (LPN) A said residents who received dialysis services had their vital signs and weights completed before going to dialysis. This information was documented on the dialysis communication form along with the medications given to the resident. The form was sent with the resident to dialysis. He/She also called dialysis to give them a report and he/she would document that the resident went out to dialysis in the electronic medical record. When the resident returned home, the nurse should reassess the resident by taking their resident's vital signs and checking the access site. The only place the weight and vital signs are documented was on the dialysis communication form. During an interview on 11/12/24 at 12:43 P.M., LPN E said residents who received dialysis services had a communication form that was completed when they went to dialysis which included the resident's vital signs, the location of the dialysis access site and the medications the resident received. The form was sent to dialysis with the resident. Dialysis was pretty good at sending the forms back to the facility. During an interview on 11/13/24 at 8:15 A.M. and 11:35 A.M., the Director of Nursing (DON) said the facility did not have a copy of the dialysis contract. The facility reached out to the dialysis company to try to obtain a copy but was told the contract was at a different location. She would expect the facility to have a copy of the dialysis contract. Staff should check the resident's vital signs and weight before going to dialysis and document them on the communication form. The form is sent to dialysis with the residents. Sometimes the facility got the form back and sometimes dialysis did not send the form back. If the resident returned home and there was no weight or vitals completed by dialysis, the nurse should complete it. The nurse should monitor the access site for bleeding, bruit and thrill every shift and document it on the TAR. The DON would expect for dialysis monitoring to be documented. During an interview on 11/13/24 at 2:40 P.M., the Administrator said he would expect for dialysis monitoring to be documented. During an interview on 11/13/24 at 8:15 A.M. and 11:35 A.M., the DON said the facility did not have a copy of the dialysis contract. The facility reached out to the dialysis company to try to obtain a copy but was told the contract was at a different location. She would expect the facility to have a copy of the dialysis contract During an interview on 11/13/24 at 2:40 P.M., the Administrator said he would expect for the facility to have a copy of the dialysis contract on premises

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 37 opportunities observed, three errors occurred resulting in an 8.11% error rate (Resident #50). The census was 60. Review of the facility's Medication Administration Policy, undated, showed: -Only licensed personnel or certified medical technicians (CMT) are assigned responsibility of preparing, administering, and recording medication or permitted access to drug storage areas; -Medication may be administered to a resident only if ordered by a practitioner licensed to prescribe medication in that location. Review of the facility's Administering Medications through a Metered Dose Inhaler Policy, dated reviewed 10/1/24, showed: -Purpose: The purpose of this procedure is to provide guidelines for the safe administration of inhaled medications; -Allow at least one minute between inhalations of the same medication and at least two minutes between inhalations of different medications. 1. Review of Resident #50's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 7/2/24, showed: -Cognitively intact; -Diagnoses included: high blood pressure and chronic obstructive pulmonary disease (COPD, chronic lung disease). Review of the resident's Order Summary Report, active orders as of 11/8/24, showed: -An order for: Spironolactone (used to treat fluid retention) 25 milligram (mg), give one tablet once time daily for diuretic (water pill); -An order for: Spiriva Respimat (used to treat COPD) Inhalation (Inhaler) 1.25 microgram (mcg), give two puff inhale one time daily for COPD; -An order for: Combivent Respimat (Ipratropium-Albuterol, medication used to treat lung disease) inhalation 20-100 mcg, give two puff inhale one time daily for COPD. Observation on 11/8/24 at 9:10 A.M., showed CMT D administered one tablet of Spironolactone- Hydrochlorothiazide (a combination of two different diuretic medications) 25-25, then administered Combivent Respimat inhaler one puff and Spiriva Respimat inhaler one puff, without waiting at least 2 minutes between the different types of inhalers. At 9:40 A.M., CMT D administered Spiriva Respimat inhaler one puff and Combivent inhaler one puff without waiting at least 2 minutes between the different types of inhalers. During an interview on 11/8/24 at 11:20 A.M., the pharmacist said Spironolactone and Spironolactone HCTZ were not the same medication, and the medications are not interchangeable. During an interview on 11/8/24 at 11:39 A.M., the Director of Nursing (DON) said when staff administer medication, she would expect for staff to follow the five rights of medication administration (right resident, right medication, right dose, right time, and right route). Spironolactone and Spironolactone HCTZ were not the same medication. If the card of medication did not match the Medication Administration Record (MAR) she would expect for CMTs to notify the nurse and the nurse to verify the order. She would expect for staff to administered one inhaler, both two puffs, then wait a few minutes and administer the second inhaler, two puffs. During an interview on 11/13/24 at 2:40 P.M., the Administrator said he would expect staff to follow physician orders and to follow the facility's policies and procedures.

Based on observation and interview, the facility failed to provide accessible information on the location of the State Survey Agency hotline number that was readily available to residents in the facility without assistance. The census was 60. Observations throughout the survey on 11/ 7/24, 11/8/24 and 11/12/24 showed, the State Survey Agency number not posted in the facility. During a group interview on 11/8/24 at 9:55 A.M., seven residents, whom the facility identified as alert and oriented, attended the group meeting and said they did not know where the State Survey Agency hotline number was posted. During an interview on 11/12/24 at 3:17 P.M., the Director of Nursing said the State contact information was not posted. The facility has ordered a new poster and frame. During an interview on 11/13/24 at 2:40 P.M., the Administrator said he would expect for the State Survey Agency hotline number to be posted.

Based on interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behaviors, which included alcohol use and verbal/physical aggression, for one resident (Resident #2). The facility failed to address the behaviors and inform staff how to handle the resident's escalating behaviors. The sample was eight. The census was 62. The Administrator was informed on [DATE] of an Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility's Substance Use Disorder policy dated [DATE], showed: -Residents admitted to the facility with substance use disorder (SUD) will receive the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being, provided by the facility and in accordance with the comprehensive assessment and care plan; -SUD is defined as recurrent use of alcohol and/or drugs which causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home; -The behavioral health care needs of those with SUD or other serious mental health disorders are evaluated as part of the facility assessment. During the facility assessment, the facility determines whether the capacity, services and staff skills are available to meet the needs of those with SUD or other serious mental health disorders; -All residents are screened for serious mental health disorders, intellectual disabilities, and related conditions prior to admission to determine if specialized services under the Preadmission Screening and Resident Review (PASARR) requirements are necessary; -If the resident does not qualify for specialized services under PASARR, but requires more intensive behavioral health services, the facility will provide for and/or arrange for these services; -The specific services needed by the resident are identified during the comprehensive assessment; -The care plan will address the individualized needs the resident may have related to the mental disorder or the SUD. For example: -Activity needs that are different from other residents; -Access to group counseling; -Access to medication assisted treatment, if applicable; -The resident's history of substance use disorder and risk for using substances which could lead to an overdose while in the facility are identified to the extent possible and documented in the medical record; -In addition, safety, and health concerns specific to the resident and his/her history are identified. Health and safety considerations related to substance use disorder may include: -Risk of respiratory depression and fatal overdose; -Increased risk of falls and other accidents; -Potential for wandering and elopement; -Potential for resident-to-resident altercations and other disruptive behaviors; -Constipation and fecal impaction; -Skin infections; -Weight loss and malnutrition; -Potential for cognitive decline and mood disorders; -Care plan interventions are directed at maintaining the safety of the resident, staff, and other residents and not necessarily on addressing the underlying addictive behaviors. Examples of appropriate care interventions for a resident with SUD include: -Monitoring the resident for signs and symptoms of substance use (changes in behavior, unexplained lethargy, odors, new needle marks, slurred speech, lack of coordination, etc.) and overdose, especially after returning from a leave of absence or during/after visitation; -Increasing supervision of the resident and, if needed, the resident's visitors; -Supporting the resident's efforts to prevent substance use such as coordinating behavioral health services, medication assisted treatment, and 12-step meetings; -Facility staff are trained on the signs and symptoms of opioid overdose and emergency interventions (the administration of opioid reversal agents (i.e., naloxone and cardiopulmonary resuscitation (CPR)) when drug overdose is suspected; -Behavioral contracts may be initiated to address behaviors which could endanger the resident, other residents, and staff and to encourage residents to follow their plan of care; -Behavioral contracts are only used with residents who have the capacity to understand them; -Examples of appropriate uses of behavioral contracts include: -A behavioral contract that communicates the resident's right to have a leave of absence and explains the health and safety risks of leaving without facility knowledge or leaving against medical advice (AMA). The contract does not restrict a resident's right to leave the facility, but can distinguish between a leave of absence, elopement, and leaving AMA; -A behavioral contract which clarifies the facility response to suspected illegal substance abuse. If substance abuse is suspected, a behavioral contract may stipulate: -Monitoring and supervision in the facility may be increased to maintain the health and safety of the resident suspected of substance abuse, as well as the other residents; -Visitation may be restricted or supervised if the resident's visitors are deemed to be a danger to the resident, other residents, or staff; -Voluntary drug testing may be conducted if there are concerns that suspected drug use could adversely affect the resident's condition; -Voluntary inspections may be conducted if there is reasonable suspicion of possession of illegal drugs, weapons, or other unauthorized items which could endanger the resident or others; - Local law enforcement will be notified if there is suspicion of a crime in accordance with state laws, such as possession of illegal substances, paraphernalia, or weapons; -Refusal to accept or non-adherence to the terms of a behavioral contract will not be the sole basis for a denial of admission, a transfer or discharge; -Non-adherence to the contract will be treated as a care plan intervention that needs attention or needs to be altered to meet the needs of the resident. The interdisciplinary team (IDT) will work with the resident and resident representative to revise the care plan and contract. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -admitted [DATE]; -Cognitively intact; -No behaviors exhibited; -Diagnoses included high blood pressure, high cholesterol, and depression. Review of the resident's progress notes, dated [DATE] at 6:00 A.M., showed the resident arrived back to the facility at 5:10 A.M. after checking him/herself out the facility at 2:50 P.M. on [DATE]. The resident's speech was slurred, and he/she was loud. His/Her gait was unsteady, and he/she was belligerent due to inebriation (drunk or intoxicated). The resident's physician was notified. He/She gave order to hold all medications and give fluids. Review of the resident's hospital discharge paperwork, dated [DATE], showed: -Diagnosis: Alcohol intoxication delirium; -Drugs of abuse screen completed; -Zofran (used to treat nausea or vomiting) four milligrams given. Review of the resident's care plan, in use during the survey, showed: -Problem Onset [DATE]: The resident placed him/herself in unsafe situations when away from the facility. He/She was a danger to him/herself due to polysubstance abuse. He/She had poor decision-making skills. He/She was educated and agreed to leave of absence (LOA) with supervision; -Approaches: Place resident in area with frequent observation. Alert staff of unsafe behavior. Provide diversion activities. Approach in calm and accepting manner. Monitor and document behaviors. -The care plan did not list who is designated to monitor the resident's behaviors, the frequency of monitoring, which behaviors would be monitored, and specific diversional activities. Review of the resident's progress notes, showed: -On [DATE], time unknown, the resident went into another resident's room and cursed at him/her. Staff deescalated the situation; -On [DATE] at 11:00 P.M., the resident told the nurse he/she was going to sign out of the facility. He/She was encouraged to stay inside. He/She refused, put on his/her coat, and exited the front door. The Administrator and Director of Nursing (DON) were notified; -On [DATE] at 12:15 A.M., the resident returned to the facility; -On [DATE] at 6:15 P.M., the nurse reported the resident had a falling out spell (passed out). The resident was wheeled back to his/her room. Staff notified the physician; -On [DATE] at 1:00 A.M., the resident tried to leave the facility. Staff redirected him/her. His/Her speech was slurred, and his/her eyes rolled up/down and side to side rapidly. Nurse practitioner notified. No new orders given. Review of the resident's physician progress note, dated [DATE] and [DATE], showed: -History of polysubstance abuse; -The resident reported depression and anxiety; -Alcohol and cocaine abuse in early remission; -No documentation of resident's aggressive behaviors or intoxication. Review of the resident's progress note, dated [DATE] at 5:37 P.M., showed the resident was physically aggressive with another resident. Review of the resident's medical record on [DATE], showed no documented Social Services notes. During an interview on [DATE] at 8:38 A.M., LPN E said he/she has worked at the facility since [DATE]. The resident would get drunk and bully staff and other residents. On [DATE], the resident asked to speak to LPN E. He/She refused to talk to the resident. The resident was drunk and made irrational statements. The resident grabbed him/her by the neck and pushed him/her in the corner. He/She filed a grievance against the resident immediately. He/She did not document the incident in the nurse's notes. He/She did not notify the resident's physician. Staff were aware the resident was getting drunk. He/She did not know what staff are supposed to do when residents return to the facility intoxicated. The resident got physical when he/she did not get his/her way. The DON said she would have a meeting with the resident and LPN E. They did not have a meeting. Review of the facility's complaint/grievance report, dated [DATE], showed: -Resident #2 was under the influence of alcohol; -He/She cursed at Licensed Practical Nurse (LPN) E and grabbed him/her by the collar; -Plan to resolve investigation: Social Worker will have a discussion with Resident #2; -Results of actions taken: The Administration team set up a meeting with Resident #2. Review of the resident's physician progress note, dated [DATE], showed: -History of cocaine and alcohol abuse. Improved, in early remission; -No complaints and anxiety was better; -No documentation of resident's verbal and physical aggression towards staff and other residents; -No documentation of resident's recent alcohol abuse. Review of the resident's progress note, dated [DATE] at 12:18 A.M., showed the receptionist asked the nurse to come to the lobby for a fight. The resident was in the lobby with blood on his/her hands and shirt. His/Her speech was slurred, and he/she smelled of alcohol. The resident told the nurse he/she tried to talk to Resident #1, and he/she disrespected him/her. Staff called the police. During an interview on [DATE] at 12:18 P.M., Certified Medication Technician (CMT) A said Resident #2 would come back to the facility drunk. He/She was combative and verbally aggressive. He/She usually drank between 2:00 P.M. and 8:00 P.M. CMT A notified the nurse. The nurse did not find alcohol in Resident #2's room. Resident #2 has had altercations with other residents. When residents are under the influence of alcohol or drugs, staff just tells the nurse. During an interview on [DATE] at 12:40 P.M., CNA C said the resident returned to the facility intoxicated at least two or three times per week. He/She reported it once to a nurse eight months ago. He/She is not sure if the Administrator is aware. If a resident comes back to the facility intoxicated, he/she would report it to a nurse. During an interview on [DATE] at 12:46 P.M., CMT B said the resident was very aggressive. He/She would often return to the facility drunk. He/She has reported the instances to the nurse. They could not find any alcohol on him/her. He/She did not document the incidents. If a resident returns to the facility under the influence, staff are supposed to notify the Charge Nurse. During an interview on [DATE] at 1:05 P.M., LPN D said the resident has returned to the facility intoxicated. He/She would stumble around and had slurred speech. The facility did not have a policy for intoxicated residents. He/She would go to his/her room and go to sleep. During an interview on [DATE] at 2:08 P.M., the Social Worker said the resident was having substance use issues. She was made aware in April. She offered him/her Alcohol Anonymous and counseling services. He/She refused the services. The resident would get drunk on the weekends. He/She attacked LPN E on [DATE]. She met with the resident on [DATE], time unknown. after he/she attacked LPN E. She is not sure if the resident was on a behavior contract. He/She should have been put on a behavior contract after the first incident. The nursing staff was supposed to initiate the behavior contract. During interviews on [DATE] at 11:14 A.M., [DATE] at 1:21 P.M. and [DATE] at 1:45 P.M., the DON said she has been at the facility since [DATE]. The resident had a history of being verbally and physically aggressive. He/She returned to the facility intoxicated. He/She denied drinking alcohol. He/She had an altercation with another resident in April and he/she attacked LPN E in May. She thought the Administrator talked to the resident about the incident with LPN E. LPN E said the resident smelled like alcohol. She was not aware of the problem in his/her care plan. The resident did what he/she wanted to do. The resident's physician was aware of his/her substance use and behaviors. The physician did not address the issues with the DON. The facility does not have a substance abuse assessment. Substance abuse is covered under the facility assessment. She thinks 80% of the residents drink alcohol or have a history of substance abuse. She tried to initiate an Alcohol Anonymous group at the facility. The residents came in, got snacks, and left. She is not sure if Resident #2 was on the attendance list. The facility is not allowed to search residents' rooms or person. Resident #2 should have been on a behavior contract. She was not sure who initiated behavior contracts. During an interview on [DATE] at 8:10 A.M., the Administrator said staff would meet with the resident when possible. He does not have control over what residents do when they sign out. Staff will address the situation when residents return. He never saw the resident intoxicated. The resident did not trigger a PASARR. When residents are intoxicated, staff should contact the physician and send them out. The facility puts residents on behavior contracts when deemed necessary. Resident #2 should have been on a behavior contract. He thought the DON or Social Services was responsible for initiating behavior contracts. He did not know why the resident was not on a behavior contract. During an interview on [DATE] at 10:01 A.M., Resident #2's physician said staff notified him/her of the resident being intoxicated on [DATE]. He/She told staff to hold the resident's medications. He/She was not aware the resident assaulted another resident. If the resident was getting drunk and being aggressive, the facility should have contacted his/her office. The resident should have been on a behavior contract and discharged from the facility sooner. MO00238048 MO00238149 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of 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).

Based on observation, interview and record review, the facility failed to ensure staff transporting residents in the company vehicle held the proper driver license in accordance with Missouri state regulations, for one of one days of observation. This had the ability to affect all residents who were transported in the facility vehicles. The census was 61. Review of the Missouri State Driver's Guide, revised August 2023, showed the following: -A Class F license is Missouri's basic driver license and is needed to operate any motor vehicle other than one requiring the driver to have a Class A, B, C or E license. -Anyone who transports 14 or fewer passengers for pay or as part of his/her job must have a class E license; -Anyone who regularly operates a motor vehicle for his or her employment, that belongs to another person and is designed to carry freight and merchandise, must also have a Class E license. Review of the facility's transportation escort job description, showed the following: -Duties: Escort patients to medical appointments and other areas of the facility; -Requirements: Class E certification (license). Review of Driver G's employee file, showed the following: -Hire date 1/26/24; -Job classification: Transportation; -A copy of his/her class F driver's license; -No documentation of a Class E driver's license. Observation on 8/12/24 at 11:30 A.M., showed Driver G propelled a resident in his/her wheelchair from the lobby, out of the back door and into the facility van. He/She then transported the resident to his/her dialysis appointment. During an interview on 8/13/24 at 9:58 A.M., Driver G said he/she was hired in January 2024. He/She was hired specifically for transportation. He/She was the only driver working. The nursing staff gives him/her a list of residents' appointments and their face sheets. He/She transports the residents to their appointments. The facility van seats four passengers and has a wheelchair lift. He/She has a regular license. He/She was not aware he/she needed a Class E license. During an interview on 8/13/24 at 2:40 P.M., the Administrator said he did not know if Driver G had a Class E driver's license. He was not aware staff had to have a class E driver's license to operate the van. MO00240229

Based on observation, interview and record review, the facility failed to ensure staff transporting residents in the company vehicle held the proper driver license in accordance with Missouri state regulations, for one of one days of observation. This had the ability to affect all residents who were transported in the facility vehicles. The census was 61. Review of the Missouri State Driver's Guide, revised August 2023, showed the following: -A Class F license is Missouri's basic driver license and is needed to operate any motor vehicle other than one requiring the driver to have a Class A, B, C or E license. -Anyone who transports 14 or fewer passengers for pay or as part of his/her job must have a class E license; -Anyone who regularly operates a motor vehicle for his or her employment, that belongs to another person and is designed to carry freight and merchandise, must also have a Class E license. Review of the facility's transportation escort job description, showed the following: -Duties: Escort patients to medical appointments and other areas of the facility; -Requirements: Class E certification (license). Review of Driver G's employee file, showed the following: -Hire date 1/26/24; -Job classification: Transportation; -A copy of his/her class F driver's license; -No documentation of a Class E driver's license. Observation on 8/12/24 at 11:30 A.M., showed Driver G propelled a resident in his/her wheelchair from the lobby, out of the back door and into the facility van. He/She then transported the resident to his/her dialysis appointment. During an interview on 8/13/24 at 9:58 A.M., Driver G said he/she was hired in January 2024. He/She was hired specifically for transportation. He/She was the only driver working. The nursing staff gives him/her a list of residents' appointments and their face sheets. He/She transports the residents to their appointments. The facility van seats four passengers and has a wheelchair lift. He/She has a regular license. He/She was not aware he/she needed a Class E license. During an interview on 8/13/24 at 2:40 P.M., the Administrator said he did not know if Driver G had a Class E driver's license. He was not aware staff had to have a class E driver's license to operate the van. MO00240229

Based on interview and record review, the facility failed to employ a qualified social worker on a full-time basis. The facility was licensed and certified for 156 residents. The current census was 61. Review of the facility's license and certification records, showed the facility licensed for 156 beds, of which 156 beds were certified for Medicaid and Medicare. Review of the facility's Social Worker's job description, showed the following: -The primary purpose of this position is to assist in planning, organizing, implementing, evaluating, and directing the overall operation of the facility's Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Director of Social Services and/or Administrator, to assure the medically related emotional and social needs of the resident are met/maintained on an individual basis; -Experience: Must have, as a minimum, a bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, and psychology. Must have, as a minimum, one year supervised social work experience in a health care setting working directly with individuals. Review of the Social Worker's employee file, showed: -Hire date: 3/4/24; -Department: Social Worker Assistant; -Education history included accounting, cosmetology and massage therapy; -No documentation of a bachelor's degree in a human services field or a minimum of one year of social services experience. During an interview on 8/12/24 at 9:58 A.M., the Social Worker said she started in her position on 3/4/24. She is the Social Services Designee (SSD). She assists the residents with all social service needs. She has some college history but does not have a bachelor's degree. She has not taken the SSD test because it is expensive. During an interview on 8/13/24 at 2:40 P.M., the Administrator said he was not aware of all the qualifications of a Social Worker. The SSD was working at the facility when he was hired. She does not have a bachelor's degree. He thought the need for a qualified social worker was based on the census, not the number of licensed beds. MO00240229

Based on interview and record review, the facility failed to employ a qualified social worker on a full-time basis. The facility was licensed and certified for 156 residents. The current census was 61. Review of the facility's license and certification records, showed the facility licensed for 156 beds, of which 156 beds were certified for Medicaid and Medicare. Review of the facility's Social Worker's job description, showed the following: -The primary purpose of this position is to assist in planning, organizing, implementing, evaluating, and directing the overall operation of the facility's Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Director of Social Services and/or Administrator, to assure the medically related emotional and social needs of the resident are met/maintained on an individual basis; -Experience: Must have, as a minimum, a bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, and psychology. Must have, as a minimum, one year supervised social work experience in a health care setting working directly with individuals. Review of the Social Worker's employee file, showed: -Hire date: 3/4/24; -Department: Social Worker Assistant; -Education history included accounting, cosmetology and massage therapy; -No documentation of a bachelor's degree in a human services field or a minimum of one year of social services experience. During an interview on 8/12/24 at 9:58 A.M., the Social Worker said she started in her position on 3/4/24. She is the Social Services Designee (SSD). She assists the residents with all social service needs. She has some college history but does not have a bachelor's degree. She has not taken the SSD test because it is expensive. During an interview on 8/13/24 at 2:40 P.M., the Administrator said he was not aware of all the qualifications of a Social Worker. The SSD was working at the facility when he was hired. She does not have a bachelor's degree. He thought the need for a qualified social worker was based on the census, not the number of licensed beds. MO00240229

Based on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for four out of four narcotic count books reviewed. This had the potential to affect all residents with controlled substance orders. The census was 64. Review of the facility's Controlled Substances policy, revised November 2022, showed: -Dispensing and Reconciling Controlled Substances: -Controlled substance inventory if monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up; -Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count; -The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. 1. Review of the controlled drug count sheets for the 1st Certified Medication Technician (CMT) cart, dated 5/1/24 through 5/31/24, showed: -No outgoing staff signature for 12 of 84 opportunities; -No incoming staff signature for eight of 84 opportunities; -No documentation under, Count ok, for 35 of 84 opportunities. Review of the controlled drug count sheets for the 1st CMT cart, dated 6/1/24 through 6/11/24, showed: -No outgoing staff signature for four of 31 opportunities; -No incoming staff signature for one of 31 opportunities; -No documentation under, Count ok, for 10 of 31 opportunities. 2. Review of the controlled drug count sheets for the 2nd floor nurse cart, dated 5/1/24 through 5/31/24, showed: -No outgoing staff signature for 13 of 72 opportunities; -No incoming staff signature for 12 of 72 opportunities; -No documentation under, Count ok, for 59 of 72 opportunities. -Review of the controlled drug count sheets for the 2nd floor nurse cart, dated 6/1/24 through 6/16/24, showed: -No outgoing staff signature for four of 43 opportunities; -No incoming staff signature for five of 43 opportunities; -No documentation under, Count ok, for 29 of 43 opportunities. 3. Review of the controlled drug count sheets for the 2nd floor 2nd cart, dated 5/1/24 through 5/31/24, showed: -No outgoing staff signature for 10 of 82 opportunities; -No incoming staff signature for five of 82 opportunities; -No documentation under, Count ok, for 22 of 82 opportunities. Review of the controlled drug count sheets for the 2nd floor 2nd cart, dated 6/1/24 through 6/16/24, showed: -No outgoing staff signature for two of 41 opportunities; -No incoming staff signature for three of 41 opportunities; -No documentation under Count ok, for seven of 41 opportunities. 4. Review of the controlled drug count sheets for the 4th floor cart, dated 5/1/24 through 5/31/24, showed: -No outgoing staff signature for five of 86 opportunities; -No incoming staff signature for five of 86 opportunities; -No documentation under, Count ok, for five of 86 opportunities. Review of the controlled drug count sheets for the 4th floor cart, dated 6/1/24 through 6/17/24, showed: -No outgoing staff signature for one of 46 opportunities; -No incoming staff signature for two of 46 opportunities; -No documentation under, Count ok, for one of 46 opportunities. 5. During an interview on 6/17/24 at 2:03 P.M., Registered Nurse (RN) said narcotic medications should be counted at the beginning and end of each shift by the oncoming and outgoing nurse or CMT. Both staff who complete the count should document their signatures and the total count on the count sheets. 6. During an interview on 6/17/24 at 2:51 P.M., the Staffing Coordinator said she is also a CMT. She administered narcotic medications on the 4th floor. There is no nurse assigned to the 4th floor. Staff who pass medications were required to count the narcotics on their cart at the beginning and end of each shift. The count should be completed by the oncoming staff and the staff going out. Both staff were required to count the total number of narcotics and both staff were supposed to sign off on the count sheet and document the count. 7. During an interview on 6/17/24 at 4:01 P.M., the Director of Nurses (DON) said narcotics should be counted by the oncoming and outgoing nurse or CMT. Both staff were expected to sign the count sheet and document the count. On 6/12/24, she reviewed the narcotic count books and saw the counts were not consistently being signed by two staff. An in-service was completed with the nurses employed by the facility, but not the CMTs. The CMTs should have been in-serviced as well. Going forward, narcotic medications will only be administered by nurses. Review of the facility's list of active employees and in-service training, dated 6/12/24, showed: -In-service topic: Narcotics must be counted by two nurses each shift; -Seven nurses documented as in attendance; -Five nurses employed by the facility not in attendance; -No CMTS in attendance. 8. During an interview on 6/17/24 at 5:46 P.M., the Administrator said he expected licensed nurses to be the only staff to administer narcotic medications. Narcotics should be counted by the oncoming and outgoing nurse at the end of each shift. Both nurses should sign off on the narcotic count at the same time. If CMTs have been administering narcotic medications, they should have been included in the facility's in-service training on narcotic counts.

Based on interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated (Resident #4) when a resident (Resident #5) hit the other resident in the face. The sample was 5. The census was 62. Review of the facility's Residents Rights policy, revised 2/2021, showed: -Be free from abuse, neglect, misappropriation of property, and exploitation; -Includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Review of the facility's abuse and investigation and reporting policy, revised 7/2017, showed: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported; -Policy interpretation and implementation: -The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented; -The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Review of Residents #4's admission assessment Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/22/23, showed moderate cognitive impairment. Review of the resident's face sheet, showed diagnoses included schizophrenia disorder (serious mental condition of the mind), hypertension (high blood pressure), obesity, intellectual disabilities, hypothyroidism (low thyroid hormone level) and bipolar type (extreme emotional highs and lows). Review of the resident's care plan, in use at the time of the survey, showed: -Category: Behaviors- resident is at risk for socially inappropriate/disruptive behavior; -Interventions: Administer behavior medications as ordered by physician; -Interventions: Remove from public area when behavior is disruptive and unacceptable; -Goal: episodes of inappropriate and disruptive behaviors will decrease by 50% within specified time frame. Review of Resident #4's progress note, dated 4/16/24 at 5:46 P.M., showed Licensed Practical Nurse (LPN) C observed Resident #4 being struck by another resident and fell to the floor. LPN C assisted resident from the floor, care was denied. Staff was able to separate the residents, however Resident #4 was verbally aggressive with the other resident. He/She called Resident #5 a nigger and he/she punched a laptop, knocking it to the floor and breaking it. He/She was also observed punching a wall. He/She was also verbally aggressive with staff. Emergency Medical Services (EMS) was called to transport resident to the hospital for further evaluation. He/She was transported to the hospital. Review of Resident #5's annual MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high blood pressure, anxiety disorder and depression. Review of the resident's baseline care plan, dated 3/11/24, showed: -Care plan description, resident is at risk for socially inappropriate/disruptive behavior; -Category Behaviors-on going; -Care plan Goal-Episodes of inappropriate and/or disruptive behaviors will decrease by 50% within specified time frame; -Interventions: -Talk in calm voice when behavior is disruptive; -Refer to Social Services for evaluation; -Remove from public area when behavior is disruptive and unacceptable; -Praise for demonstrating desired behavior; -Monitor and document target behaviors; -Do not argue with resident; -Discuss options for appropriate channeling of anger. Review of the facility's investigation report, showed on 4/16/24 at approximately at 4:20 P.M. on the 200-unit, Resident #4 and Resident #5 were involved in an altercation on the 200 unit: -Summary of alleged incident: While on unit 200, it was reported that Resident #4 and Resident #5 were having words in front of the nursing station. They may have bumped into each other on the elevator. Resident #4 called Resident #5 a racial slur. Resident #5 hit Resident #4. Resident #4 fell while they were fighting. He/She did not hit their head. The staff separated them both and immediately called 911. Resident #4 started hitting the walls and destroying equipment. No police report was done. Resident #4 was taken to the hospital by EMS. During an interview on 4/17/24 at 10:05 A.M., Resident #5 said several months ago, Resident #4 snapped out and was calling the other residents niggas. The resident reported him/her to the Director of Nurses (DON), and he/she thought it was better. But yesterday when Resident #4 saw him/her, he/she started calling Resident #5 the N word again. He/She then made a move like he/she was going to swing on Resident #5. So, he/she defended him/herself. Resident #5 hit him/her once and he/she went down. He/She fell to the ground. The staff came running and told Resident #5 to go to his/her room and he/she did. In the past, they have had about 4 altercations but it wasn't physical until now. He/She stayed in his/her room all night. Resident #4 cursed at Resident #5 today as well, but he/she just ignored him/her. During an interview on 4/18/24 at 8:26 A.M., Certified Nurse Assistant (CNA) G said he/she was in the dining room on the second floor, and he/she heard them arguing and heard another employee say stop. He/She ran over and got between both residents. Resident #5 reached over CNA G's head and hit Resident #4. It was a one/two punch. Resident #4 fell to the floor. Certified Medication Technician (CMT) D called a stat page to the floor. Four or five staff members came. They both were separated and Resident #5 was sent to his/her room. Resident #4 didn't appear to be injured. LPN C called EMS and Resident #4 was sent to the hospital. When EMS came, Resident #4 was still agitated. He/She is usually agitated every day. He/She says things like he/she is going to hit CNA G. He/She is very verbally abusive. It is reported to the nursing. He threatens people saying I'll kick your ass or black bitch. He/She called Resident #5 the N word numerous times. During an interview on 4/18/24 at 8:40 A.M., CNA F said he/she was coming from around the corner out of the linen closet when he/she heard the noise and commotion. He/She and CMT G ran around to find out what was going on. Resident #5 and Resident #4 were having words. Then Resident #4 called Resident #5 the N word. CNA F thought he/she bumped him/her on the elevator. It triggered something in Resident #5. He/She reached over CNA G and punched him/her while they were trying to break them up. Every time Resident #4 said something, Resident #5 tried to hit him/her. They finally broke them up. Resident #4 hit the wall and broke one of the computers until one of the Administrators stopped him/her. The police and ambulance were called. During an interview on 4/19/24 at 9:28 A.M., the Administrator and DON said they expected residents to be free from abuse. It is their right. They expected staff to provide good services to residents that are necessary to avoid physical harm, pain, mental anguish, or emotional stress. MO00234782

Based on interview and record review, the facility failed to ensure services provided met professional standards of practice by not following the physician orders for two residents (Resident #1 and #4). The facility failed to administer all medication as ordered and did not document the reasons for the omissions. The sample was 5. The census was 62. Review of the facility's Medication orders policy revised November 2014, showed; Policy: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. -Each resident must be under the care of a Licensed physician authorized to practice medicine in this state and must be seen by the physician at least every sixty (60) days; -A current list of orders must be maintained in the clinical record of each resident; -Orders must be written and maintained in chronological order. Review of the facility's administering medications policy, revised 2019, showed: Policy: Medications are administered in a safe and safe and timely manner, and as prescribed. -Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. -Medications are administered in accordance with prescriber orders, including any required time frame. -Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan. -Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). -If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR) space provided for that drug and dose. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 1/24/24 showed: -Cognitively intact. -Diagnoses included congestive heart failure (fluid surrounding the heart), high blood pressure, Type 2 diabetes mellitus and edema (swelling). Review of the resident's face sheet, dated 4/16/24, showed diagnoses included transient ischemic attack (TIA, mild stroke), and cerebral infarction (blockage of blood to the brain) without residual deficits. Review of the resident's care plan, dated 3/13/24, showed: -Problem: The resident is at risk for edema related to refusal to elevate legs and lay down after meals; -Intervention: Administer diuretics as ordered; -The care plan did not address the resident's heart or high blood pressure. Review of the resident's MAR, dated 4/1/24 through 4/30/24, showed: -An order dated 1/19/24, for Amiodarone (regulates heart rhythm) 100 milligrams (mg) tablet/dose oral. One tablet once daily was not given on 4/10/24 and 4/14/24; -An order dated 1/19/24, for Loratidine (regulates allergies)10 mg/dose oral. One tablet once daily was not given on 4/10/24 and 4/14/24; -An order dated 1/19/24, for Klor-Con M20 Milliequivalent tablet, extended release (helps heart rhythm) dose oral. One tablet once daily was not given 4/10/24 and 4/14/24; -An order dated 1/19/24, for lisinopril (reduces blood pressure) 20 mg tablet/dose oral. One tablet once a day was not given 4/10/24 and 4/14/24; -An order dated 3/22/24, for Furosemide (reduces swelling) 20 mg/dose oral. One tablet once daily was not given on 4/4/24, 4/8/24, 4/10/24 and 4/14/24. Review of the the resident's progress notes, did not show documentation of the reason the medications were not given or communication with the physician, Administration or with the pharmacy. During an interview on 4/16/24 at 7:17 A.M., the resident said he/she did not get his/her medications and he/she did not refuse them. During an interview on 4/18/24 at 9:13 A.M., Registered Nurse (RN) H said he/she was not sure why resident didn't get the medications. The computer was not user friendly. He/She was not sure why medication was not signed off. 2. Review of Resident #4's admission MDS, dated [DATE], showed: -Moderate cognitive impairment. -Diagnoses of schizophrenia (serious mental condition of the mind) and neurological conditions (chemical imbalance of the brain and spinal cord). Review of the resident's face sheet, showed diagnoses included schizophrenia disorder, high blood pressure, obesity, intellectual disabilities, hypothyroidism (low thyroid hormone level) and bipolar type (extreme emotional highs and lows). Review of the resident's progress notes, did not show documentation of the reason the medications were not given or communication with the physician, management or with the pharmacy. Review of the resident's MAR, dated 2/1/24 through 2/29/24, 3/1/24 through 3/31/24 and 4/1/24 through 4/17/24, showed staff did not document administration of the resident's following physician ordered medications: -Miralax (relieves constipation) 17 grams by mouth once daily; February (1 out of 7 opportunities), March (9 out of 31); -Senna (relieves constipation) 8.6 mg by mouth once daily. February (1 of 7 opportunities), March (8 out of 31); -Multivitamin 1 tablet by mouth once daily. March (7 out of 31 opportunities). During an interview on 4/19/24 at 8:30 A.M., the resident's physician said he did not know the resident was missing medications and it could result in a negative outcome if medications were not given in a timely fashion. 3. During an observation and interview on 4/18/24 at 9:23 A.M., Certified Medication Technician (CMT) D said he/she was not sure why medications were not given or not documented as not given. It may be a computer problem that day or someone may have not clicked out. Even if they were given, the system did not let staff go back and click given with the way it was set up. Sometimes, residents refused medications, but they don't know how to get back to put it in. 4. During an interview on 4/18/24 at 1:10 P.M., the Assistant Director of Nursing (ADON) said the medication administration dates were missing, and it appeared the residents did not get their medication. 5. During an interview on 4/19/24 at 9:28 A.M., the Administrator and Director of Nurses said they expected all residents receive their medications per orders. If medication is not given, they expected documentation to reflect the reason why it was not given. They expected a resident who does not get their medication per order may be non-therapeutic and can affect their mental and physical health. MO00234444

Based on interview and record review, the facility failed to ensure services provided met professional standards of practice by not following the physician orders for Resident #4. The facility failed to administer his/her medication and did not document the reasons and notification to the physician. The sample was 5. The census was 62. Review of the facility's Medication orders policy, revised November 2014, showed; -Policy: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders; -Each resident must be under the care of a Licensed physician authorized to practice medicine in this state and must be seen by the physician at least every sixty (60) days; -A current list of orders must be maintained in the clinical record of each resident; -Orders must be written and maintained in chronological order. Review of the facility's administering medications policy, revised 2019, showed: -Policy: Medications are administered in a safe and safe and timely manner, and as prescribed; -Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions; -Medications are administered in accordance with prescriber orders, including any required time frame; -Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: -a. Enhancing optimal therapeutic effect of the medication; -b. Preventing potential medication or food interactions; and -c. Honoring resident choices and preferences, consistent with his or her care plan; -Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). -If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR) space provided for that drug and dose. Review of Resident #4's admission assessment Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/22/23, showed: -Moderate cognitive impairment; -Diagnoses of schizophrenia (serious mental condition of the mind) and neurological conditions (chemical imbalance of the brain and spinal cord). Review of the resident's face sheet, showed diagnoses included schizophrenia disorder, high blood pressure, obesity, intellectual disabilities, hypothyroidism (low thyroid hormone level) and bipolar type (extreme emotional highs and lows). Review of the resident's care plan, in use at the time of the survey, showed: -Category: Behaviors-resident is at risk for socially inappropriate/disruptive behavior; -Interventions: Administer behavior medications as ordered by physician; -Goal: episodes of inappropriate and disruptive behaviors will decrease by 50% within specified time frame. Review of the resident's MAR, dated 2/1/24 through 2/29/24, 3/1/24 through 3/31/24 and 4/1/24 through 4/17/24, showed staff did not document administration of the resident's following physician ordered medications: -Chloropromazine (antipsychotic medication) 100 mg tablet 1 tablet by mouth four times daily. February (5 out of 14 opportunities), March (50 out of 124), April (18 out of 68). -Haloperidol (treats mental conditions) 10 mg tablet 0.5 tablet by mouth three times daily. February (3 out of 10 opportunities), March (33 out of 93), April (12 out of 51); -Lithium carbonate (treats manic episodes of bipolar disorder) 300 mg capsule 1 capsule by mouth twice daily. March (23 out of 62 opportunities), April (6 out of 34); -Quitiapine (typical antipsychotic used to treat schizophrenia, bipolar disorder and depression) 200 mg tablet by mouth at bedtime daily. February (1 out of 7 opportunities); -Lorazepam (treats anxiety) 1 mg tablet 1 tablet by mouth three times daily. February (1 out of 10 opportunities), March (31 out of 93), April (5 out of 51); -Divalproex ER (treats seizure disorders and certain psychiatric conditions) 500 mg by mouth two times daily. February (2 out of 14 opportunities); -Metoprolol Tartrate (lowers blood pressure) 25 mg tablet 1 tablet by mouth two times daily. February (7 out of 20 opportunities), (March 33 out of 62), April (10 out of 19); -Abilify (antidepressant) 10 mg tablet 1 tablet by mouth once daily. February (1 out of 7 opportunities); -Atorvastatin (treats high blood pressure) 10 mg tablet 1 tablet by mouth 1 times daily. February (1 out of 7 opportunities), March (7 out of 31); -Benztropine (reduce movement disorders) 1 mg tablet 1 tablet by mouth once daily. February (1 out of 7 opportunities); -Lasix (diuretic) 20 mg tablet 1 tablet by mouth once daily. February (1 out of 7 opportunities), March (7 out of 31); -Medroxyprogesterone (hormonal therapy) 10 mg tablets 1 tablet by mouth once daily. February (1 out of 7 opportunities), March (8 out of 31). Review of the resident's progress notes, did not show documentation of the reason the medications were not given or communication with the physician, administration or with the pharmacy. Review of the resident's progress notes, showed: -On 2/2/24 at 8:54 A.M., the resident was sent to the hospital emergency department for psych evaluation due to aggressive behavior. Family and Doctor notified of resident's behavior. Call placed to Emergency Medical Services (EMS), awaiting arrival; -On 2/4/24 at 11:22 A.M., resident was coming off the elevator yelling at another resident calling resident a bitch and yelling at staff and being redirected to his/her room; -On 2/7/24 at 6:23 P.M., Director of Nursing called to main dining room (MDR), noted resident being verbally aggressive to other residents using racial slurs; calling residents nigger and nigger bitch and advancing towards two residents and stating I'll take you both, and I'll beat the fuck out of you, MDR was cleared of all residents; resident is in close supervision 1:1 at this time; 911 called; -On 3/7/24 at 6:36 P.M., late entry: resident loud yelling down the hall calling staff out of their name and saying that he/she can leave if we don't want him/her there. Resident continues yelling for laundry to be put back in his/her room and for staff not to steal it. Resident taken by the nurse to laundry to show him/her that clothes were in the washer, and it would take an hour to wash and an hour to dry. Resident continues to be increasingly agitated and verbally aggressive with staff. At this time resident placed in lobby and supervised until ambulance arrived. Doctor and Director of Nursing aware; -On 3/7/24 (no time documented), aggressive behavior intervention and protocol plan was put in place due to resident following behavior: Resident swings but does not hit, calls name, yell; -On 3/7/24 at 9:56 A.M., resident was asked to pull shirt down because he/she had exposed his/her entire stomach, he/she told this writer to Kiss (his/her) Ass! He/She did comply as he/she was going to his/her room; -3/11/24 at 2:37 P.M., staff responded to resident yelling in the hallway by Social Service office. Resident accusing anyone that was attempting to find out what he/she was upset about stealing from him/her. Resident refusing to give details and says you done stealing from me. Resident was educated that he/she can come to Social Services, Administrator to report what is missing so that we can follow up and investigate. Resident still refusing. Staff backed away and continued to observe to make sure behavior did not escalate. Staff stayed near by for 10-15 minutes, no further outburst at this time; -On 4/16/24 at 4:20 P.M., resident was being verbally aggressive with another resident. Resident was struck by another resident. Resident was sent to the hospital. -On 4/17/24 at 7:29 A.M., resident was returned to the facility; -On 4/17/24 at 10:56 A.M., resident continued to have verbally aggressive outbursts. Walked toward staff and other residents making threatening gestures and yelling and cursing. Resident verbalized desire to harm self. Resident continues 1:1 observation until EMS arrives. Resident to be sent to hospital for evaluation and treatment. Review of the resident's hospital emergency room record, dated 4/17/24 at 1:03 P.M., showed the resident's Lithium level measured 0.2 millimoles per liter (2mmol/L) (Normal range is 0.6-1.2mmol/L). During an interview on 4/18/24 at 9:23 A.M., Certified Medication Technician (CMT) D said he/she was not sure why medications were not given or not documented as not given. It may be a computer problem that day or someone may have not clicked out. Even if they were given, the system does not let staff go back and click given with the way it was set up. Sometimes residents refused medications, but they don't know how to get back to put it in. During an interview on 4/18/24 at 9:13 A.M., Registered Nurse (RN) H said he/she is not sure why resident didn't get his/her medications. The computer is not user friendly. He/She was not sure why medication was not signed off. During an interview on 4/18/24 at 9:34 A.M., Hospital Staff A said lab results showed his/her lithium level was undetectable. The medical team surmised that failure by the facility to consistently administer his/her medications could be contributing to his/her increased aggression. During an interview on 4/18/24 at 12:20 P.M., the Administrator said he spoke to the resident's family. The hospital was admitting the resident for medication adjustment. During an interview on 4/18/24 at 1:10 P.M., the Assistant Director of Nursing (ADON) said the medication administration dates were missing, and it appeared the resident did not get their medication. During an interview on 4/19/24 at 9:28 A.M., the Administrator and DON said they expected all residents receive their medications per orders. They expect staff to administer medications per physician's orders. If medication is not given, they expect documentation to reflect the reason why it was not given. They expect a resident who does not get their medication per order may be non-therapeutic and can affect their mental and physical health. During an interview on 4/19/24 at 8:30 A.M., the resident's physician said he did not know the resident was missing medications and it could result in a negative outcome if medications are not given in a timely fashion. MO00234870

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of needs and preferences for one resident when staff failed to assist him/her out of bed when he/she requested (Resident #1). The sample size was 3.The census was 60. Review of the facility's Activities of Daily Living (ADLs) Supporting policy, last reviewed by the facility 2/6/24, showed: -Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living; -Policy Interpretation and Implementation: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: -Mobility (transfer and ambulation, including walking); -Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression; -Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice; -The resident's response to interventions will be monitored, evaluated and revised as appropriate. Review of the facility's Resident's Rights Policy Statement, revised February 2021 and reviewed 2/21/24, showed: -Policy Statement: Employees shall treat all residents with kindness, respect, and dignity; -Policy Interpretation and Implementations: -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -A dignified existence; -Be treated with respect, kindness, and dignity; -Self-determination; -Exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; -Be supported by the facility in exercising his or her rights; -Exercise his or her rights without interference, coercion, discrimination or reprisal from the facility. Review of Resident #1's admission nursing evaluation, dated 7/4/23, showed: -Bed mobility - dependent, assistance required, one person; -Transfer - Assistance required, two person. Review of the resident's activity evaluation, dated 7/5/23, showed: Psychosocial well-being: very interested in life/activities. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/23/24, showed: -Cognitively intact; -Functional limitation in range of motion, impairment on both upper and lower extremity; -Chair/bed-to-chair transfer was blank, not addressed; -Diagnosis included traumatic spinal cord dysfunction (damage to any part of the spinal cord or nerves at the end of the spinal canal), quadriplegia (affected by or relating to paralysis of all four limbs). Review of the resident's progress note, showed: -On 2/6/24 at 10:14 A.M., Resident was found on the floor. The resident stated that the bed remote was behind his/her right shoulder and head of bed began to elevate. The resident stated that he/she slid out of bed. The resident is alert and oriented times three, complains of neck pain and headache. There was a one centimeter (cm) laceration observed to the right lateral side of his/her head. A pressure dressing was applied. This writer and two Certified Nurse Assistants (CNA) assisted with transferring the resident back to bed via mechanical lift. A call was placed to Emergency Medical Service (EMS). Awaited arrival of EMS; -On 2/6/24 at 11:02 A.M., staff received report from hospital emergency department that the resident has a fracture C-2, and he/she was coming back to the facility. The resident to always remain in his/her cervical collar (C-collar, a medical device used to support and immobilize a person's neck) and has a follow-up medical appointment in two weeks; -On 2/7/24 at 12:50 A.M., Addendum, diagnoses closed nondisplaced fracture (the bone cracks or breaks but retains its proper alignment) of second cervical vertebra unspecified fracture morphology; -On 2/10/24 at 3:03 P.M., caregiver responded to the resident's call light and alerted this writer that the resident was on the floor at bedside. This writer asked the resident if he/she could explain what happened, resident stated that he/she had a muscle spasm in bilateral lower extremities and slid out of the bed. Bed was in the safest position and mat was in place. Resident denied pain. Call was placed to 911; -On 2/20/24, this writer was informed by the CNA the resident was found on the floor laying on mat in bedroom. This writer asked the resident what happened, he/she stated, I rolled out of the bed, rolled over twice on the mat. This writer observed the resident laying on mat facing the wall. The CNA stated that the resident was also laying in the bed facing the wall when he/she checked on him/her earlier. This writer and two caregivers and therapy assisted the resident back to bed. Resident denied being in pain. Resident back in bed. Bed in safest position with call light within reach. Skin assessed underneath C-collar. Skin dry and intact; -On 2/20/24 at 7:13 P.M., the resident was found on the floor this morning unable to tell how it happened. Resident denied any pain or discomfort. Review of the resident's care plan, dated 2/22/24, showed staff did not address the resident's need for staff assistance with transfers. Review of the resident's medical record, showed no new physicain orders the resident could not get out of bed. Observation and an interview on 2/21/24 at 2:50 P.M., showed the resident was in bed. The resident said staff told him/her it would take four people to get him/her out of bed. He/She believed that was an excuse not to get him/her up. The resident said staff told him/her every day if he/she did not get up that day, he/she would get up on the next day. However, staff never got him/her up out of bed. The resident said he/she felt isolated, sad, and like he/she was in jail. He/She had not participated in activities such as dominoes, bingo or going outside since his/her fall. Before the fall, he/she participated in activities but couldn't now. During an interview on 2/21/24 at 3:32 P.M., Certified Medication Technician (CMT) C said he/she knew the resident, but didn't work with him/her regularly. The resident was total care, quadriplegic and used a mechanical lift for transfers. He/She saw the resident outside smoking before, but not lately. Observation and interview on 2/22/24 at 3:11 P.M., showed the resident was in bed. He/She wanted to get up today, but no one got him/her up. He/She thought staff didn't want to get him/her up. The resident said staff told him/her therapy had to check on him/her before he/she could get into his/her motorized wheelchair. The resident thought staff were just telling him/her that. He/She didn't think he/she would get up tomorrow either. The resident said he/she felt like a hostage. During an interview on 2/23/24 at 9:37 A.M., Social Worker G said the resident had been up all the time and attended activities before his/her fall. He/She thought the resident had been a little depressed because the resident wanted to get up but staff had not gotten him/her up out of bed. Social Worker G said he/she understood. The resident required total care, had two falls, and was wearing a neck collar. The resident had not gotten up because of a pressure sore (areas of damage to the skin and the underlying tissue caused by constant pressure or friction) on his/her bottom. The resident wouldn't get back into bed when the staff would ask him/her to. Social Worker G said staff would get him/her up provided the resident would agree to go back to bed. Social Worker G expected staff to get the resident up to his/her chair, if he/she had a pressure relieving cushion in it. Social Worker G said the resident had a pressure relieving cushion for his/her chair. During an interview on 2/23/24 at 10:36 A.M., Therapist D said he/she thought the resident had not been out of bed because he/she was waiting on a follow-up appointment with a physician. He/She didn't know for sure why the resident hadn't gotten out of bed. During an interview on 2/23/24 at 11:28 A.M., CNA E said the resident used to get up every day before his/her fall. The resident could not get out of bed until he/she saw the doctor. Staff would then know if they could get the resident up out of bed. During an interview on 2/23/24 at 2 P.M., Activity Assistant H said before the resident's fall, he/she would come down for activities but after the fall, the resident didn't come down because staff didn't get him/her up. During an interview on 2/23/24 at 2:57 P.M., CMT F said the resident got out of bed every day and participated in activities before he/she fell on [DATE]. He/She said the resident still wanted to participate and was ready to get back rolling like he/she had been. During an interview on 2/23/24 at 2:55 P.M., the Director of Nursing expected staff to get the resident up out of bed if there were not any documented reasons for him/her not to get up. MO00231477 MO00232048

Based on interview and record review, facility staff failed to monitor one resident (Resident #1), in accordance with facility stated standards of practice to ensure the health and safety of residents, when facility staff failed to check on the resident at shift change and every two hours. Facility staff reported administering medications to and speaking to the resident on [DATE] at 9:00 P.M. On [DATE] at 9:00 A.M., the resident was found on the floor, with a coat on. The resident did not have signs of life, and he/she had rigor mortis (stiffening of the joints and muscles of a body a few hours after death). The night shift nurse left the facility at approximately 6:00 A.M. without checking on residents with the day shift nurse. A certified medication technician (CMT) documented medication administration and a blood pressure reading at 8:00 A.M. without administering/observing the resident. Facility staff noted the resident was not at breakfast, which was uncharacteristic, however did not check on the resident. The sample was 4. The census was 50. The administrator was notified on [DATE] at 3:00 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's documentation of medication administration policy, dated 2001 and revised [DATE], showed the following: -The facility shall maintain a medication administration record to document all medications administered; -A nurse or certified medication aide shall document all medications administered to each resident on the resident's MAR; -Administration of medication must be documented immediately after (never before) it is given. During an interview on [DATE] at 3:00 P.M., the Administrator said the following: -She expects nursing staff to make rounds when they came on and off shift and every two hours for resident safety; -She expects nursing staff to stay at their assignment until their relief came and they were able to give report. During an interview on [DATE] at 3:00 P.M., the Regional Nurse said the following: -Nursing staff were expected to make rounds on their residents when coming on and off shift and at every two hours during their shift to ensure resident safety; -Making frequent rounds on residents was considered a professional standard of care. During an interview on [DATE] at 4:14 P.M., the Primary Care Physician (PCP) said he expects nursing staff to round on residents at least two times a shift, but ideally every couple of hours. Review of Resident #1's care plan, undated, showed the following: -Problem: The resident was at risk for falls and fall related injury due to abnormalities of gait and mobility; Interventions included: Remind the resident to keep his/her area free of clutter, including the path to the bathroom. Assist as needed; -Problem: At risk for respiratory infection/illness due to choosing to smoke cigarettes; Interventions included: Monitor for any changes in mental status and report changes to the physician; -Full code (provide resuscitation procedures). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Cognitively intact; -Independent with activities of daily living (ADLs); -Walked without devices; -Diagnoses included heart failure, high blood pressure, diabetes mellitus, chronic obstructive pulmonary disease (COPD, lung disease) and schizophrenia. Review of the resident's physician order sheets, dated [DATE] through [DATE], showed the resident was full code. (Full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive.) Review of the facility's investigation, received on [DATE] at 5:20 P.M., showed the Director of Nursing (DON) wrote a document titled Nursing progress note, dated [DATE], no time noted, detailing the time line of events of that morning: -At 9:04 A.M., the DON received a call from the Certified Medication Technician (CMT) on the third floor reporting a resident was found on the floor and appeared dead. -Upon arriving to the floor, the psychiatric (psych) Nurse Practitioner (NP) and CMT were kneeled next to the resident. The resident was on the floor at the foot of the bed, fully clothed to include coat and gloves. -Further noted, resident's extremities (arms and legs) were in rigor mortis with swelling to his/her face, legs and arms. The resident was unresponsive. -Calls were placed to the Primary Care Physician (PCP) for further instruction. The Regional Registered Nurse was notified. -The resident's temporal (artery that runs across the forehead) temperature was 35.6 C (equal to 96.0 Fahrenheit) (The average body temperature is 98.6 F (37 C)- but can range between 97 F (36.1 C) and 99 F (37.2 C)Celsius, equal to 96.0 degrees Fahrenheit); -A statement, undated, from the psych NP. On the morning of [DATE], he/she was doing rounds at the facility. When he/she arrived to the resident's room, he/she noticed a person lying face down on the floor. He/she immediately notified the nursing staff who was standing just outside the resident's room near his/her medication cart. They entered the room together and checked for the resident's pulse. The resident had no pulse. The resident was very stiff, but they managed to turn the resident over and immediately noticed rigor mortis in the resident's face muscles. The resident's skin was very cold to the touch. The nursing staff immediately called for assistance and the nursing facility staff responded promptly; -An investigation statement, dated [DATE], no time noted, signed by CMT A. He/she was on his/her way to give the resident his/her morning medications when the psych NP found the resident face down on the floor. They entered the room and the psych NP checked the resident arm for a pulse, which was absent. They turned the resident around to see if he/she was alright. The CMT saw the resident was unresponsive and called the DON to inform her what was happening; -A statement, dated [DATE], signed by Nurse D. He/she worked on the third floor on [DATE] on the 11:00 P.M. to 7:00 A.M. shift. The resident was in bed under the covers during his/her rounds; -A statement, undated, signed by CMT E. On [DATE], the CMT entered the resident's room around 8:50 P.M. The resident was asleep. CMT E woke the resident to give him/her medications. The resident woke up, took his/her medications, said thank you and went back to sleep; -There were no other statements found. -There was no final summary or conclusion of the investigation provided by the facility. During an interview on [DATE] at 11:41 A.M., CMT E said the following: -He/she worked on the third floor as a CMT on [DATE] during the evening shift from 3:00 P.M. to 11:00 P.M.; -He/she last saw the resident around 9:20 P.M. when he/she administered medications to him/her; -The resident was in bed when the CMT went in the bedroom. The resident was easily roused, sat up in the bed, took the medications from the CMT, said thank you and went back to sleep; -He/she did not notice anything different with the resident; -The resident went to bed a little earlier than usual that evening; -He/she left at approximately 11:00 P.M. when Nurse D came to relieve him/her; -He/she remembered Nurse D coming on shift. He/she gave the nurse report. They did not do rounds together. During an interview on [DATE] at 3:53 P.M., Nurse D said the following: -He/she worked the night shift on [DATE] from 11:00 P.M. to 7:00 A.M. on [DATE]; -He/she was assigned to the third floor; -There were no other staff working with him/her that shift; -He/she would do rounds on his/her residents to check to make sure they were all stable, make sure all the beds were in the low position, take report from the off-going nurse and count the narcotics on the medication cart when he/she started his/her shift; -He/she could not recall if he/she did rounds at the start of the shift; -The resident was already in bed when he/she started his/her shift; -He/she thought the last time he/she saw the resident was maybe around 4:00 A.M. The resident was in bed asleep under the covers; -He/she left between 6:00 A.M. and 7:00 A.M. that morning; -He/she gave report to Registered Nurse XX (RN-XX); -He/she did not do rounds before he/she left his/her assignment; -He/she did not do rounds with RN-XX or see RN-XX do rounds before leaving the third floor; -There were no other staff on the third floor when he/she left his/her assignment; -He/she often worked on the third floor without any other staff; -He/she often worked on the second floor during night shift and was responsible for both the second and third floor assessments and medication pass; -The third floor was often staffed with just a CNA during the night shift; -He/she found it challenging to cover both floors by him/herself to ensure the residents safety. During an interview on [DATE] at 1:03 P.M., RN-XX said the following: -She worked on [DATE]; -She did not see the resident down on the first floor for breakfast that morning, which was unusual; -RN-XX did not follow up on this unusual behavior by checking on the resident; -She was alerted by CMT A the resident was deceased at approximately 9:16 A.M.; -She went upstairs to the third floor and entered the resident's room and saw the psych NP kneeling next to the body. He/she told RN-XX he/she could not find a pulse; -The body had rigor mortis and appeared a little swollen; -She called the PCP and the family to alert them of the resident's death; During an interview on [DATE] at 11:36 A.M., the psych NP said the following: -He/she was on the third floor at approximately 9:00 A.M. on [DATE] to visit residents; -He/she normally walked around the floor, popping into rooms to say hello to his/her residents before he/she started his/her assessments; -At approximately 9:20 A.M., he/she went to the resident's room and saw him/her lying on the floor next to his/her bed, face down; -He/she went to the door and saw CMT A outside in the hall with the medication cart. He/she asked the CMT to come into the room; -He/she knelt down beside the resident and felt for a pulse. Finding none, he/she had the CMT assist him/her in rolling the resident over to his/her back; -The resident was cold to the touch, the body was stiff with rigor mortis and his/her face was distorted; -The CMT left the room to alert other staff and he/she stayed with the body; -He/she attempted a few rounds of chest compressions. The body was cold, lifeless and stiff and did not respond to the compressions; -RN-XX and another nurse came in and said the resident was dead, it was apparent from the presence of rigor mortis. During an interview on [DATE] at 11:49 A.M., CMT A said the following: -He/she worked on the third floor as a CMT on [DATE]; -He/she was running late that day and didn't arrive on the floor until approximately 7:40 A.M.; -There were no other staff on the third floor when he/she arrived. He/she retrieved the keys to the medication cart from Nurse C, the night nurse on the second floor; -He/she did not receive report from anyone; -The third floor usually was not staffed with certified nurse assistants (CNAs); -Nurse D worked the night shift, but was not there when he/she started his/her shift; -The facility usually staffed a CMT for the evening shift (3:00 P.M. to 11:00 P.M.); -CMT E worked the evening shift and had left the previous night at 11:00 P.M.; -He/she did not do rounds on the residents at the beginning of his/her shift; -He/she began passing out medication at approximately 8:00 A.M. to residents on the hall on the other side of the floor from the resident's room; -The psychiatric NP came on the floor around 9:18 A.M.; -The psych NP was checking on his/her patients when he/she entered the resident's room at approximately 9:20 A.M.; -The psych NP exited the resident's room and called out to the CMT, who was on the resident's hall, to come and check on the resident as there was something wrong; -The CMT entered the room with the psych NP and saw the resident was on the floor, near his/her bed, face down. The psych NP knelt down beside the resident, checked for a pulse, and found none; -Both the CMT and the psych NP rolled the resident over onto his/her back. The resident was cold to the touch, there was a knot on his/her forehead, and the left side of the resident's face looked smooshed in. The resident's arms were stiff, bent at the elbow, to his/her chest and there was dried spit around the resident's mouth; -The resident's body was stiff and unbending when they rolled the resident onto his/her back; -The resident was wearing street clothes, a coat and socks with no shoes; -The CMT left the room to call RN-XX; -RN-XX came up to the resident's room with Nurse B to assess the resident; During an interview on [DATE] at 12:33 P.M., Nurse B said the following: -Nurses were expected to round when they first got on shift and then every two hours with the CNAs; -Breakfast was served between 7:00 and 7:30 A.M.; -He/she was present the day the resident passed away. He/she was told a CMT found the resident on the floor and he/she was not breathing; -RN-XX asked him/her to go up with her to assess the resident; -The resident was lying on his/her back, arms were contracted up and bent at the elbow. The resident's face was puffy; -Rigor mortis had set in as the resident was not normally contracted. During an interview on [DATE] at 11:30 A.M., Nurse B said the following: -He/she would do rounds on the residents with the off-going nurse or by him/herself, before starting his/her assignment to ensure the safety of the residents; -If there was not a nurse scheduled on the third floor, the DON or Assistant Director of Nursing (ADON) were responsible for the third floor; -RN-XX was assigned to the third floor on [DATE] during the day shift; -Nurse B worked as the nurse on the second floor during the day shift on [DATE]; -He/she did not make rounds on the third floor, as it was not part of his/her assignment. During an interview on [DATE] at 12:00 P.M. CNA G said the following: -He/she was assigned to work the second floor on [DATE] during the day shift; -CMT A was the only staff member working on the third floor when CNA G came on shift at 7:00 A.M.; -CNA G normally made rounds on residents every two hours and when coming on and off shift to ensure safety. Review of the resident's MAR, dated [DATE] through [DATE], showed the following: -On [DATE], CMT A initialed he/she administered one medication at 8:00 A.M.; -On [DATE], CMT A initialed he/she administered eight medications at 9:00 A.M.; -On [DATE], CMT A initialed he/she administered metoprolol tartrate (used to lower blood pressure) 25 mg at 9:00 A.M. with a blood pressure listed. There was a dark mark drawn over the blood pressure reading making the numbers difficult to read. During an interview on [DATE] at 10:45 A.M., CMT A said the following: -The facility was always very prompt at giving breakfast between 7:00 A.M. and 7:30 A.M.; -He/she did not see the resident go downstairs to breakfast. The resident also usually goes outside to smoke after breakfast; -He/she was not sure why he/she did not round on the residents at the beginning of his/her shift. He/she was focused on passing out the medications; -He/she did not give the resident any medication on [DATE]; -He/she was preparing to give the resident his/her medication by putting medication in a pill cup; -He/she signed his/her initials on the MAR after he/she prepared the resident's medication before administration; -He/she did not see the resident before the psych NP alerted him/her to the resident's death; -He/she was not sure why there was a blood pressure listed on [DATE] on the MAR; -If a resident did not consume the medication, he/she would circle his/her initials on the MAR and write a note on the back, explaining the medication was not consumed. During an interview on [DATE] at 3:51 P.M., NA F said the following: -He/she was assigned to work on the third floor on [DATE] during the day shift; -He/she came on shift at approximately 8:30 A.M., and got to the floor approximately 10 minutes later; -Only CMT A was working on the third floor when he/she came on shift; -He/she did not get report from anyone when he/she started his/her assignment; -He/she started to do rounds on all residents on the floor when he/she started his/her assignment; -He/she did not round on the resident as he/she did not get to the resident's side of the building before CMT A alerted him/her the resident was found dead. Review of the worksheet for nursing home deaths for the Office of the Medical Examiner, undated, showed the following: -The resident was listed as deceased at the facility; -Date/time last seen on [DATE] by a CMT; -Condition/circumstances when last seen alive: sleeping at 9:00 P.M.; -Date/time found on [DATE] at 9:20 A.M. by a CMT and psych NP. No unusual conditions noted; -No medical problems including recent illness, injury trauma or fall; -The body was found in a room, on the floor, at the foot of the bed; -Date/time pronounced: [DATE] at 9:20 A.M. During an interview on [DATE] at 9:13 A.M., the coroner said the following: -The county coroner released the body to him to perform an autopsy of the body due to the state of the body when it was found and questionable ligature (something that binds or ties) marks found on the resident's wrists; -The ligature marks found on the resident's wrists may have been caused by a coat and/or gloves the resident was reported to wear often; -The resident had a bruise on his/her right forehead and a subgaleal hemorrhage (an accumulation of blood formed between the skin and skull) at the right front of his/her scalp, showing the resident had a very recent fall, within a few hours of death. It may or may not have been significant to the resident's death; -He was not able to determine a conclusive cause of death. During an interview on [DATE] at 10:22 A.M., an anonymous resident who resided on the third floor, said the following: -The staff do not come around and check on the residents to make sure they were ok; -The facility consistently did not staff a nurse to the third floor. During an interview on [DATE] at 3:00 P.M., the Administrator said the following: -Breakfast was served between 7:15 A.M. and 7:20 A.M. It was a combination of both dining room service and hall tray service; -If residents did not eat in the dining room, the dietary aides would take breakfast trays up to the rooms for the residents who missed breakfast; -CNAs were responsible for passing out meal trays; -She expected staff to pass all room trays; -She expected staff to alert the nurse if a resident did not receive a meal so the nurse could assess the resident to see if there was a change of condition, attempt to get the resident to eat, offer an alternative and then document in progress notes if the resident refused to eat; -The third floor was generally staffed with a nurse and a CNA or a CMT and a CNA with the second floor nurse responsible for oversight; -She expected the second floor nurse to round on the third floor as appropriate or every two hours, deal with acute issues, changes of conditions, contact the PCP as needed and document in progress notes; -She expected the CMT on the third floor to pass medications to the residents and help the CNA as needed; -She expected staff to document on the resident's MAR after administering a medication for accuracy of records; -She expected the DON to investigate any death to see what occurred, what was the possible cause of death, if a change of condition was missed, if the resident could have been sent out sooner to avoid death and to provide education to staff if needed. During an interview on [DATE] at 10:03 A.M., the Administrator said the following: -RN-XX was the charge nurse responsible for the third floor on [DATE] during the day shift; -She expected RN-XX to make rounds with Nurse D before Nurse D left the building to ensure all residents were safe; -CMT A and CNA G were assigned to work on the third floor on [DATE] during the day shift; -She expected CMT A and CNA G to make rounds when they first came on shift; -She expected CMT A and CNA G to make sure all residents either went down to the dining hall on the first floor or received a breakfast tray in their room; -She expected the DON to begin an investigation on the resident's death on the day he/she had passed; -She expected the investigation to include interviews with all nursing staff who were assigned to the third floor on [DATE] night shift and on [DATE] during the day shift in order to determine a timeline of when the resident was last seen by staff and his/her last known condition to give a broader picture of what might have occurred leading up to and after the resident's death; -The DON was responsible for starting the investigation within 24 hours of the incident and to complete it with a summary of findings within 72 hours; -The Administrator was responsible to follow up on the investigation to check it for completeness; -The facility did not provide any education to staff regarding monitoring of residents during their shift. During an interview on [DATE] at 9:37 A.M., the Administrator said the facility did not have a list for residents who received hall trays; if a resident did not go to the dining room for a meal, the dietary staff would prepare a meal tray and send it to the resident's floor. There was no documentation the resident received a breakfast tray on the morning of [DATE]. During an interview on [DATE] at 9:53 A.M., the resident's family member, said the following: -He/she was notified of the resident's death on [DATE] between 11:00 and 11:45 A.M.; -The DON met the family member at the lobby and brought the family member up to the third floor; -The DON said they had given the resident his/her medications the night before and then put the resident to bed. The DON did not say what time, just specified last night; -The DON said the last time the resident was seen by staff was at 9:00 P.M. when nursing staff gave him/her medication; -The DON said when she arrived to the facility that morning, she noticed the resident was not in the dining room or in the lobby. She said the resident was always downstairs and always so friendly .(he/she) didn't come to breakfast .we just thought (he/she) was sleeping in. -The DON said the psych NP found the resident when he/she was doing rounds and the resident was already dead. During an interview on [DATE] at 3:00 P.M., the Regional Nurse said the following: -The facility did not have a policy on rounding; -Nursing staff were expected to make rounds on their residents when coming on and off shift and at every two hours during their shift to ensure resident safety; -Making frequent rounds on residents was considered a professional standard of care. During an interview on [DATE] at 4:14 P.M., the PCP said the following: -He expected nursing staff to round on residents at least two times a shift, but ideally every couple of hours; -The facility told him the resident was found dead on the floor, next to his/her bed, lying face down with significant amount of rigor mortis found in his/her limbs and face; -Rigor mortis sets into a body within six to seven hours after death; -If the resident had fallen trying to get out of bed, the nursing staff could have intervened if they had performed frequent rounding and found the resident on the floor; -He expected the facility to check on a resident's status if they miss a meal; -He expected the facility to find the deceased resident's body much sooner, during rounds, on-coming/off-going rounds or, at the very least, after the resident missed breakfast; -There was an autopsy performed on the resident due to some questions by the county coroner and the family of the resident; -He listed CHF as the cause of death based on the resident's diagnoses although he was not sure if that was the reason yet; -He expected facility staff to document after they administered medications to a resident for accuracy of records. It was obvious the resident could not have consumed medication at 8:00 A.M. or at 9:00 A.M. given the facility found him/her dead with rigor mortis between 9:00 and 9:20 A.M. MO00208478 Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. Note: At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview and record review, the facility failed to ensure staff provided necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for pressure ulcers. The facility failed to ensure staff assessed, consistently completed treatments as ordered and notified the physicians of the deterioration of residents' pressure ulcers. The facility identified seven residents with pressure ulcers. Four residents were sampled, three current and one from a closed record review, and problems were found with three (Residents #3, #2 and #1). The census was 59. Review of the facility's Wound and Skin Care Protocols and Procedures, updated 1/2012, showed: -Purpose: 1. To promote a systematic approach and monitoring process for the care of residents/patients with existing wounds and for those who are at risk for skin breakdown. This protocol serves as a tool for treatment options for the staff member to utilize. 2. To prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and to develop appropriate interventions. 3. To promote healing of pressure ulcers in a cost efficient and timely manner; -General Policy: The Director of Nursing at each facility is responsible for informing and educating the attending physicians and the facility's Medical Director regarding Wound Care Protocols. It will also be the responsibility of the facility Director of Nursing to ensure that the wound care protocols are instituted and followed for all residents/patients needing wound treatment and have orders for protocol. The Director of Nursing will be responsible for reviewing weekly wound report and monitoring progress/decline of any wound and assuring compliance with current standards of wound care practice. All residents will be assessed by the charge nurse for risk of skin breakdown using the Braden Scale (reference tool used for predicting pressure ulcer risk) on admission, re-admission and with any major change in condition. RAI (Resident Assessment Instrument) process to be used for ongoing risk assessment. The interdisciplinary plan of care will address problems, goals and interventions directed toward the prevention and or treatment of [REDACTED]. 1. Review of Resident #3's discharge tracking Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed a discharge date of [DATE]. Review of the resident's entry tracking MDS, showed a re-admission date of [DATE]. Review of the resident's medical record, showed: -No admission nursing note for 8/10/20; -No admission nursing assessment for 8/10/20; -No documentation of a skin/pressure ulcer assessment for 8/10/20. Review of the resident's physician's orders [REDACTED]. -Order dated 8/11/20: Cleanse coccyx with wound cleanser, apply Santyl (topical ointment used to remove dead tissue) ointment and cover with Allevyn (foam dressing), change every three days; -Order dated 8/19/20: Cleanse left heel with wound cleaner, apply Santyl, cover with dry dressing daily and as needed. Review of the resident's treatment administration record (TAR), dated 8/11/20 through 9/6/20, showed: -Front of First TAR: Order dated 8/11/20: Cleanse coccyx with wound cleanser, apply Santyl, cover with Allevyn, change every three days. Staff documented as complete: 8/11, 8/14, 8/17, discontinued 8/20/20; -Back of First TAR: Written in by staff: 8/11/20: Treatment in place, no new open areas; -No documentation regarding the measurement or description of the pressure ulcers. Review of the resident's skilled nursing note, showed the following: -8/11/20: Front of note: Pressure ulcer checked. Back of note: No documentation regarding pressure ulcer; -8/12/20: Front of note: Skin within normal limits checked. Back of note: No documentation regarding pressure ulcer; -No note for 8/13/20; -8/14/20: Front of note: Skin within normal limits checked. Back of note: No documentation regarding pressure ulcer; -8/15/20: Front of note: Skin within normal limits checked. Back of note: No documentation regarding pressure ulcer; -8/16/20: Front of note: Skin within normal limits checked. Back of note: No documentation regarding pressure ulcer. Review of the facility's Wound Report, dated 8/16/20, showed no documentation regarding the resident's pressure ulcers. Review of the resident's five day admission MDS, dated [DATE], showed: -[DIAGNOSES REDACTED]. -Required extensive staff assistance for bed mobility, dressing, personal hygiene and bathing; -Required total staff assistance for transfers and toilet use; -Incontinent of bowel and bladder; -Two Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue). May also present as an intact or open blister). Present upon admission. Review of the resident's skilled nursing note, showed the following: -8/17/20: Front of note: Skin within normal limits checked. Back of note: No documentation regarding pressure ulcer; -No note for 8/18/20; -8/19/20: Front of note: Skin within normal limits and pressure ulcer checked. Back of note: No documentation regarding pressure ulcer; -8/20/20: Front of note: Skin within normal limits checked. Back of note: Blank. Review of the resident's initial outside wound care company Wound Assessment, dated 8/20/20, showed: -Left gluteus (buttocks): dated acquired 6/12/20, Etiology: MASD (moisture associated skin damage), measurement: 0.5 centimeter (cm) by 0.5 cm by 0.1 cm, Classification: Partial thickness, drainage: small amount red, brown, no necrotic tissue, wound improvement: initial assessment, Wound cleaning and dressing: Cleanse with soap and water, apply zinc oxide (topical ointment used to treat minor skin irritation such as diaper rash) daily and as needed; -Left heel: date acquired 8/20/20, Etiology: diabetic wound, measurement: 3.7 cm by 3.5 cm by 0.1 cm, Classification: Grade I, drainage small amount of red/brown, no necrotic tissue, Wound cleaning and dressing: Cleanse with wound cleaner, cover with gauze, wrap with Kling (stretch wrap), change daily and as needed. Review of the resident's POS, 8/20/20, showed: -Discontinue previous wound care orders; -Left buttocks pressure ulcer: apply zinc oxide daily and as needed; -Left heel: Cleanse with wound cleaner, cover with dry dressing. Clean and access daily. Review of TAR, dated 8/11/20 through 9/6/20, showed: -Front of TAR: Order dated 8/20/20: Cleanse left gluteal pressure ulcer with wound cleaner, apply zinc oxide daily and as needed after incontinent episode. Staff documented as completed: 8/20 through 9/5/20; -Order dated 8/20/20: Cleanse left heel with wound cleaner and cover with a dry dressing daily. Staff documented as completed: 8/24, 8/25 and 8/26/20. Blank 8/21, 8/22 and 8/23/20. Discontinued on 8/27/20; -Back of TAR: 8/18/20: Treatment to left heel, and coccyx done without difficulty. Turn and repositioned every 2 hours. Low air loss mattress. 8/25/20: Treatment in place. 9/1/20: No new open areas noted. Treatments in place. Zinc oxide to buttock. Review of the facility's Wound Report, dated 8/20/20, showed: -Wound location: Left buttock, Date acquired: 8/20/20, Measurement: 0.5 cm by 0.5 cm by 0.5 cm, Etiology: P (pressure), Stage II, Treatment: Zinc Oxide daily until healed; -Wound location: Left Heel, Date acquired: 8/20/20, Measurement: 3.7 cm by 3.5 cm by 0.1 cm, Etiology: P (pressure), Stage II, Treatment: Dry dressing. Review of the resident's care plan, updated 8/20/20, showed the following: -Problem: Left heel diabetic ulcer; -Approach: Reposition every two hours, pressure reducing device on chair/bed, wound care as ordered by physician, weekly evaluation of wound healing, needs daily observation of skin with routine care, full skin evaluation weekly with bath/shower, monitor the resident's skin status for worsening of pressure ulcer and notify the physician, will be seen by wound care team at least once a week. Review of the resident's skilled nurse's notes, showed: -8/21/20: Front of note: Pressure ulcer: written in by staff: Left heel and left buttock. Back of note: No documentation regarding pressure ulcer; -8/22/20 through 8/26/20, showed no documentation regarding the resident's left buttocks and left heel. Review of the resident's care plan, updated 8/24/20, showed: -Problem: Right elbow abscess, 8/24/20; -Approach: Reposition every two hours, pressure reducing device on chair/bed, wound care as ordered by physician, weekly evaluation of wound healing, needs daily observation of skin with routine care, full skin evaluation weekly with bath/shower, monitor the resident's skin status for worsening of pressure ulcer and notify the physician, will be seen by wound care team at least once a week; -No further documentation regarding pressure ulcers. Review of the facility's Wound Report, dated 8/26/20, showed: -Wound location: Left gluteus (buttock), Date acquired: admitted with 6/12/20, Measurement: blank, Etiology (cause) MASD (moisture associated skin damage), current treatment: healed; -Wound location: Left heel, acquired (no date documented), measurements: blank, etiology: diabetic ulcer, treatment: paint with [MEDICATION NAME] (antiseptic used to clean skin) daily. Review of the resident's POS, showed: -Order dated 8/26/20; -Discontinue previous wound care to right elbow and left heel; -Cleanse both pressure ulcers with wound cleanser, paint with [MEDICATION NAME], cover with dry dressing and Kling daily and as needed if soiled. Review of the resident's TAR, showed: -Front of TAR: 8/27/20: Discontinue treatment to left heel and right elbow; -Back of TAR: No documentation regarding treatment to left heel and right elbow. Review of the resident's POS, dated 9/7/20 through 10/6/20, showed: -Weekly Skin assessment on Wednesday; -Order dated 7/10/20: Cleanse pressure ulcer on left buttock with wound cleaner, pat dry, apply skin prep (a liquid film forming dressing used to provide a protective film to help reduce friction during the removal of tape and tubes), apply Santyl to the wound bed and cover with dry dressing; -9/17/20: Discontinue previous wound orders. Right elbow: Cleanse with normal saline, apply Santyl ointment to the wound bed, cover with 4 x 4 dry dressing and wrap with Kerlix, change daily and as needed. Left heel: paint with [MEDICATION NAME] daily. Review of the resident's medical record, showed no weekly skin assessments or bath sheets prior to the POS dated 9/7/20 through 10/6/20. Review of the resident's TAR, dated 9/7/20 through 10/6/20, showed: -Weekly Skin Assessment on Wednesday 7:00 A.M. to 3:00 P.M. Staff documented as complete: Blank: 9/9, 9/16, 9/23 and 9/30; -Undated 11:00 P.M. to 7:00 A.M.: Right elbow: Cleanse with wound cleanser, paint with [MEDICATION NAME], cover with dry dressing, wrap with Kerlix, change daily and as needed. Staff documented as complete: 9/7, 9/8, 9/14 and 9/15/20. Blank 9/9 through 9/13 and 9/16/20. Discontinued 9/17/20; -Undated: 11:00 P.M. to 7:00 A.M.: Left heel: Cleanse with wound cleaner, paint with [MEDICATION NAME], cover with dry dressing, wrap with Kerlix, change daily and as needed. Staff documented as complete: 9/7, 9/8, 9/14, and 9/15/20. Blank: 9/9 through 9/13, and 9/16/20. Discontinued 9/17/20; -Dated 8/20/20: 11:00 P.M. to 7:00 A.M.: Zinc Oxide apply to left buttock daily and as needed. Staff documented as completed 9/7, 9/8, 9/14 and 9/15/20. Blank: 9/9 through 9/13 and 9/16/20. Discontinued 9/17/20; -Order dated 9/17/20: Right elbow: Cleanse with normal saline, apply Santyl to wound bed, cover with dry dressing, wrap with Kerlix daily and as needed. Staff documented as complete: 9/19, 9/25, 10/1/20. Blank: 9/18, 9/20 through 9/24, 9/25 through 9/30, 10/2/20; -Order dated 9/17/20: Left heel: Paint with [MEDICATION NAME] daily. Staff documented as completed: 9/19, 9/25, 10/1/20. Blank: 9/18, 9/20 through 9/24, 9/25 through 9/30, 10/2/20; -No treatment order documented for left buttock. Observation on 10/3/20 at 2:10 P.M., showed the resident lay on his/her back on a low air loss mattress. After washing their hands and applying gloves, Certified Medication Technician (CMT) A and the facility's Administrator turned the resident to his/her left side revealing dressings dated 10/1 on the resident's (right) elbow and left heel. The resident's incontinence pad was soiled with a large amount stool with blood oozing from multiple open areas on the buttocks. There was no dressing to any of the areas on the buttocks. The Administrator said the pressure ulcer to the right upper buttock was Unstageable (wound bed covered with slough (dead tissue) or eschar (hardened dead tissue), measured 1.3 cm by 1.4 cm by 0.1 cm with 75% slough covering the pressure ulcer, with scant serous (clear thin watery) drainage, no odor. Right lower buttock was a Stage II, measuring 0.3 cm by 0.4 cm by 0.1. Left upper buttock was a Stage II, measuring 1.2 cm by 1.2 cm by 0.1 cm. Left medial buttock was a Stage II measuring 0.4 cm by 0.3 cm by 0.1 cm. Left buttock near coccyx was a Stage II measuring 0.2 cm by 0.3 cm by 0.1 cm. The Administrator said no one made her aware of the pressure ulcers. CMT A said he/she was not aware of the pressure ulcers to the resident's buttocks. During an interview on 10/3/20 at 3:14 P.M., the Administrator said she would have expected the staff to notify the charge nurse of changes in the resident's skin. The charge nurse should assess the resident's skin, follow the facility's wound protocols, notify the physician, document the orders on the POS and in the nurse's notes. They should also notify the family. The resident's dressings should have been changed on 10/2/20. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Diagnosis: [REDACTED].>-Short/long term memory loss; -Total staff assistance for all activities of daily living; -Incontinent of urine; -Skin: MASD; -No pressure ulcer. Review of the resident's care plan, updated 8/16/20, showed: -Problem: At risk for skin breakdown. Stage III (Full thickness loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed, slough may be present include but does not obscure the depth of the tissue loss. May include undermining (wound edges becomes eroded forming a pocket beneath the skin at the wound's edge) and tunneling (wound has formed passageways under the skin), pressure ulcer to left buttock; -Approach: Turn and position every two hours. provide daily skin assessments, apply skin barrier to periarea after each incontinent episode, see TAR for current wound orders, seen by the outside wound company. Review of the facility's Wound Report, dated 8/16/20 and 8/20/20, showed no documentation regarding the resident's pressure ulcer to the left buttock. Review of the resident's POS, dated 8/20/20 through 9/6/20, showed: -8/20/20: Discontinue previous wound care orders. Left buttock: clean with normal saline, apply Santyl to wound bed, cover with large gauze pad, change daily and as needed; -8/21/20: Send to the hospital for evaluation of [DEVICE] (a tube surgically inserted through the abdomen into the stomach). Review of the resident's readmission Nursing Assessment, dated 8/25/20 at 4:05 P.M., showed: -[DIAGNOSES REDACTED]. -Skin condition: Pressure ulcer to left buttock: 8.5 cm by 6.1 cm by 0.1 cm. Review of the resident's nurse's note, dated 8/25/20 at 6:00 P.M., showed: -Received via a stretcher to facility; -[DEVICE] replaced; -Pressure ulcer to the left buttock: 8.5 cm by 6.1 cm by 0.1 cm, wound bed pink; -Admit orders verified. Review of the resident's POS, dated 8/25/20, showed: -Skin assessments daily; -Miconazode 2% powder (a topical powder used to treat fungal/yeast infections of the skin): Apply to sacral area three times per day; -Apply zinc oxide to buttock daily and as needed after incontinence. Review of the resident's medical record, showed no TAR for the 8/25/20, treatment orders. Review of the facility's Wound report, dated 8/26/20, showed: -Wound location: left gluteus; -Date acquired: admission; -Measurements: 6.0 cm by 6.0 cm by 0.1 cm; -Etiology: pressure; -Stage: Unstageable (slough soft dead tissue) and or eschar (dry hard dead tissue) known but not stageable due to coverage of wound bed by slough and or eschar. Review of the resident's POS, dated 8/25/20 through 9/6/20, showed; -Order dated 8/26/20; -Discontinue previous wound care orders; -Apply zinc oxide to gluteus daily and as needed after incontinence. Review of the resident's nurse's note, dated 8/27/20 at 3:00 P.M., showed he/she was seen by the wound nurse on 8/26/20. New order see POS. Review of the facility's Wound Report, dated 9/3/20, showed: -Wound location: Left gluteus; -Date acquired: 8/16/20; -Measurements: 7.0 cm by 5.0 cm by 0.1 cm; -Etiology: Pressure; -Stage: Unstageable; -Current treatment: Barrier cream daily and after each incontinent episode. Review of the resident's POS, dated 9/7/20 through 10/6/20, showed: -Dated 8/25/20: Weekly skin assessment on Monday 11:00 P.M. to 7:00 A.M.; -Dated 8/21/20: Zinc oxide, apply to gluteus daily and as needed after incontinent episodes; -Dated 8/25/20: [MEDICATION NAME] powder 2%, apply to left ischial (lower and back part of hip bone) area three times per day. Review of the resident's TAR, dated 9/7/20 through 10/6/20, showed: -Weekly skin assessment on 11:00 P.M. to 7:00 A.M. Staff documented as completed: 9/14/20. Blank: 9/21 and 9/28/20; -11:00 P.M. to 7:00 A.M.: Zinc Oxide to gluteus daily and as needed after incontinent episode. Staff documented as completed: 9/7, 9/8 and 9/9/20. Blank 9/10 through 10/1/20. Review of the facility's Wound Report, dated 9/10/20, showed: -Wound location: Left gluteus; -Date acquired: 8/16/20; -Measurements: Blank; -Etiology: Pressure; -Stage: Unstageable; -Current treatment: Barrier cream daily and as needed after incontinent episode. Review of the resident's outside wound care company Wound Assessment, dated 9/17/20, showed: -Wound location: Left gluteus, date acquired 8/16/20, measurement: 6.4 cm by 4.2 cm by 0.1 cm, Stage III, no necrotic tissue, exudate: medium amount of red/brown drainage; -Wound treatment: Cleanse with soap and water. Apply barrier cream daily and after incontinent episodes. Review of the facility's Wound Report, dated 9/17/20, showed: -Wound location: Left gluteus; -Date acquired: 8/16/20; -Measurements: 6.4 cm by 4.2 cm by 0.1 cm; -Etiology: Pressure; -Stage: Unstageable; -Current treatment: Skin Prep, Santyl, cover with large gauze dressing daily and as needed. Review of the facility's Wound Report, dated 9/23/20, showed: -Wound location: Left gluteus; -Date acquired: 8/16/20; -Measurements: 6.4 cm by 4.2 cm by 0.1 cm; -Etiology: Pressure; -Stage: Unstageable; -Current treatment: Skin Prep, Santyl, cover with large gauze dressing daily and as needed. Review of the resident's outside wound company Wound Assessment, dated 10/1/20, showed: -Wound location: Left gluteus, date acquired 8/16/20, measurement: 5.4 cm by 3 cm by 0.1 cm, Stage III, no necrotic tissue, exudate (drainage): medium amount of red/brown drainage; -Wound treatment: Cleanse with soap and water. Apply barrier cream daily and after incontinent episodes. Observation on 10/3/20 at 1:42 P.M., showed the resident lay in bed on a low air loss mattress. The incontinence pad was soiled with urine and a large amount of tube feeding. The Administrator and Certified Nurse Aide (CNA) B turned the resident to the right side, revealing a large, undated gauze dressing. The administrator removed the dressing, revealing a large dark pink pressure ulcer on the left buttock. The pressure ulcer measured: 4.7 cm by 4.1 cm. The administrator said the zinc oxide was the wrong treatment for [REDACTED]. Zinc Oxide is used for redness and or excoriation. 3. Review of Resident #1's Admission Nursing Assessment, dated 9/10/20 at 7:00 P.M., showed: -Coccyx: 7 cm by 5 cm by 1.5 cm; -Left heel: 6 cm by 7 cm by 0 cm; -Right heel: 6 cm by 8 cm by 1 cm; -Right lower leg: 10 cm by 3 cm by 0.2 cm; -No documentation of any Stages or description of pressure ulcers. Review of the resident's nurse's note, dated 9/10/20, no time, showed: -admitted from the hospital; -[DIAGNOSES REDACTED]. -Non-verbal; -[DEVICE] in place; -No documentation regarding the resident's pressure ulcers. Review of the resident's POS, dated 9/10/20, showed: -Wound care to evaluate and treat; -Low air loss mattress; -Pressure ulcer: Coccyx: Clean daily and cover with [MEDICATION NAME] (zinc based [MEDICATION NAME] paste that absorbs moderate levels of wound exudate) daily; -Left heel: Clean daily and cover with [MEDICATION NAME] daily; -Right heel: clean and apply wound gel; -No documentation regarding pressure ulcer to right lateral ankle; -No documentation regarding what staff are to use to clean pressure ulcers. Review of the resident's TAR, undated, showed: -7:00 A.M.: Coccyx pressure ulcer: Clean daily, apply with [MEDICATION NAME] daily. Staff documented as completed: Blank: 9/10 through 9/16/20, discontinued 9/17/20; -7:00 A.M.: Left heel: clean daily and leave open to area. Staff documented as completed: Blank 9/10 through 9/16/20, discontinued 9/17/20; -7:00 A.M.: Right heel: clean daily and apply wound gel. Staff documented as completed: Blank 9/10 through 9/16/20, discontinued 9/17/20; -No documentation regarding pressure ulcer to right lateral ankle; -No documentation regarding what staff are to use to clean pressure ulcers. Review of the facility's Wound Report, dated 9/10/20, showed no documentation regarding the resident's pressure ulcers. Review of the resident's initial care plan, dated 9/11/20, showed: -Mobility: needs to be pushed; -Pressure relief: pressure reduction mattress, floating heels; -Bowel: total incontinence; -Bladder: total incontinence; -Toileting: brief; -Personal hygiene: total assist. Review of the resident's skilled nurse's notes, showed: -9/12/20: Front of the note: Pressure ulcer: coccyx, right and left heel written in by staff. Back of note: No documentation regarding pressure ulcers; -No 9/13 or 9/14/20 note; -9/15/20: Front of note: Pressure ulcer: coccyx, right and left heel written in by staff. Back of note: No documentation regarding pressure ulcers; -9/16/20: Front of note: Pressure ulcer: coccyx, right and left heel written in by staff. Back of note: No documentation regarding pressure ulcers. Review of the resident's admission MDS, dated [DATE], showed: -[DIAGNOSES REDACTED]. -Short/long term memory loss; -Required total staff assistance for all activities of daily living; -admitted with five, Stage IV (Full thickness loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcers; -Three unstageable pressure ulcers. Review of the resident's initial outside wound care company Wound Assessment, dated 9/17/20, showed: -Wound location: Left heel, date acquired: 9/10/20, measurement: 7.7 cm by 7 cm, wound description: Unstageable, wound bed: eschar, treatment: cleanse wound with cleaner, paint with [MEDICATION NAME] daily; -Wound location: Right heel, dated acquired: 9/10/20, measurement: 4 cm by 7 cm by 0.7 cm, description: Unstageable, wound bed: slough, treatment: cleanse wound with saline, apply Skin prep to periwound, apply Santyl to wound bed, cover with large gauze dressing and secure with Kling, change daily; -Wound location: Right ankle, dated acquired: 9/10/20, measurement: 5.3 cm by 1 cm by 0.4 cm, description: Unstageable, wound bed: slough, treatment: cleanse wound with saline, apply Skin prep to periwound, apply Santyl to wound bed, cover with large gauze dressing and secure with Kling, change daily; -Wound location: sacrum, dated acquired 9/10/20, measurement: 17 cm by 15 cm by 3 cm, description: Unstageable, wound bed: eschar, treatment: cleanse wound with saline, apply zinc oxide to periwound, apply Santyl to wound bed, apply zinc oxide to bilateral buttock wounds, cover with large gauze dressing, change daily and as needed for soiling or saturation. Review of the resident's POS, undated, showed an order dated 9/17/20: -Discontinue previous wound care orders; -Sacrum: Clean with normal saline, apply Santyl to the wound bed at coccyx, apply zinc oxide to bilateral buttock wounds, lightly pack with dry gauze, cover with a large gauze dressing, change daily and as needed; -Right heel and right lateral ankle: clean with normal saline, apply Santyl to the wound bed, cover with large gauze dressing and wrap with Kling; -Left heel: paint the heel with [MEDICATION NAME] daily. Review of the resident's undated TAR, showed: - 9/17/20: Discontinue treatment to coccyx; -9/17/20: Discontinue treatment to left heel; -9/17/20: Discontinue treatment to right heel; -No treatment documentation for right ankle; -No new treatment orders documented for coccyx, left heel, right heel and right ankle. Review of the facility's Wound Report, dated 9/17/20, showed: -Wound location: Left heel, date acquired: blank, measurement: 7.6 cm by 7.0 cm by eschar, etiology: blank, Stage: blank, treatment: Santyl daily, dry packing with large gauze dressing daily and as needed; -Wound location: Right heel, date acquired: blank, measurement: 7.6 cm by 7.0 cm by eschar, etiology: blank, Stage: blank, treatment: Santyl daily, dry packing with large gauze dressing daily and as needed; -Wound location: Right lateral ankle, date acquired: blank, measurement: 4.0 cm by 7.0 cm by 0.7 cm, etiology: blank, Stage: blank, treatment: Santyl daily, dry packing with large gauze dressing daily and as needed; -Wound location: Sacrum, date acquired: admission, measurement: 17.0 cm by 15.0 cm by 3.0, etiology: blank, Stage: blank, treatment: Zinc Oxide. Review of the resident's skilled nurse's notes, showed: -No nurse's note for 9/17, 9/18 and 9/19/20; -9/20/20: Front of the note: Pressure ulcer: coccyx, right and left heel written in by staff. Back of note: No documentation regarding pressure ulcers; -9/21/20: Front of the note: Pressure ulcer: coccyx, right and left heel written in by staff. Back of note: No documentation regarding pressure ulcers; -9/22/20: Front of the note: Pressure ulcer: coccyx, right and left heel written in by staff. Back of note: No documentation regarding pressure ulcers; -No 9/23/20 note. Review of the facility's Wound Report, dated 9/23/20, showed: -Wound location: Left heel, date acquired: admission 9/10/20, measurement: 6.4 cm by 5.7 cm by eschar, etiology: pressure, Stage: Unstageable, treatment: Santyl daily, dry packing with large gauze dressing daily and as needed; -Wound location: Right heel, date acquired : admission 9/10/20, measurement: 4.5 cm by 5.0 cm, etiology: pressure, Stage: Unstageable, treatment: Santyl daily, dry packing with large gauze dressing daily and as needed; -Wound location: Right lateral ankle, date acquired: admission 9/10/20, measurement: 5.3 cm by 1.0 cm by 0.3 cm, etiology: pressure, Stage: Unstageable, treatment: Santyl daily, dry packing with large gauze dressing daily and as needed; -Wound location: Right lateral foot, dated acquired 9/23/20, measurement: 1.0 cm by 1.0 cm by eschar, etiology: blank, stage: blank, treatment: [MEDICATION NAME] daily; -Wound location: Sacrum, date acquired: admission 9/10/20, measurement: 12.0 cm by 12.0 cm by 1.5 cm with tunneling 4.0 cm, etiology: pressure, Stage: Unstageable, treatment: Zinc Oxide. Review of the resident's nurse's notes, showed: -9/24/20: Front of note: Pressure ulcer: coccyx, right and left heel written in by staff. Back of note: No documentation regarding pressure ulcers; -No further nurse's notes until 10/1/20. Review of the resident's outside wound care company Wound Assessment, dated 10/1/20, showed: -Wound location: Left heel, date acquired: 9/10/20, measurement: 6.6 cm by 6 cm, wound description: Unstageable, wound bed: eschar, wound progress: worsening, treatment: cleanse wound with cleaner, paint with [MEDICATION NAME] daily; -Wound location: Right heel, dated acquired: 9/10/20, measurement: 6 cm by 7.3 cm by 0 cm, description: Unstageable, wound bed: eschar/slough, wound progress: worsening, treatment: cleanse wound with saline, apply Skin prep to periwound, apply Santyl to wound bed, cover with large gauze dressing and secure with Kling, change daily; -Wound location: Right ankle, dated acquired: 9/10/20, measurement: 5.0 cm by 0.8 cm by 0 cm, description: Unstageable, wound bed: eschar, Wound progress: worsening, treatment: cleanse wound with saline, apply Skin prep to periwound, apply Santyl to wound bed, cover with large gauze dressing and secure with Kling, change daily; -Wound location: sacrum, dated acquired 9/10/20, measurement: 12.5 cm by 13 cm by 0.5 cm, description: Unstageable, wound bed: eschar/slough, wound progress: worsening, treatment: cleanse wound with saline, apply zinc oxide to periwound, apply Santyl to wound bed, apply zinc oxide to bilateral buttock wounds, cover with large gauze dressing, change daily and as needed for soiling or saturation; -Wound location: right foot, date acquired 9/23/20, measurement: 1 cm by 2 cm by 0 cm, description: Unstageable, wound bed: eschar, wound progress: worsening, periwound dry with deep tissue bruising, treatment: Cleanse with wound cleaner, paint with [MEDICATION NAME] daily. Review of the resident's POS, dated 9/29/20, showed: -Multivitamin once a day per [DEVICE]; -Protein supplement 30 cubic centimeter (cc) per [DEVICE] once a day; -Vitamin C 1000 mg per [DEVICE] once a day for 30 days; -Zinc 220 mg per [DEVICE] once a day for 30 days. Review of the resident's nurses' notes, showed: -No nurse's note for 9/29/20; -10/1/20: Seen by Nurse Practitioner. New order for [MEDICATION NAME] (antibiotic) (no reason listed for order) 100 mg per [DEVICE] twice a day for five days, Vitamin D 50,000 units per [DEVICE] once a month, CBC (Complete Blood Count, laboratory test), CRP (C-Reactive Protein, blood test used to determine the amount of c-reactive protein in the blood, a sign of inflammation); -No further documentation in the resident's medical record. Review of the resident's hospital record, dated 10/2/20, showed he/she presented to the hospital emergency room for suspected blood infection. Upon arrival, resident had Stage IV pressure ulcers on his/her coccyx and necrotic ulcers on both heels. Resident was admitted to the hospital. During an interview on 10/3/20 at 8:52 A.M., the hospital charge nurse said the resident was a patient at the hospital on [DATE]. The resident was readmitted to the hospital on [DATE], from the facility for [MEDICAL CONDITION] (blood infection). The resident's pressure ulcers were worse in comparison to his/her hospitalization on [DATE]. The bilateral heel pressure ulcers were unstageable, deep and black in color. The sacral ulcer was a Stage IV, with tunneling and was debrided on 10/2/20 at 1:00 A.M. 4. During an interview on 10/3/20 at 3:08 P.M., the Administrator said the Director of Nurses was in charge of the facility's wound care. They discussed t

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents when a staff person failed to followed their transfer policy for one resident (Resident #1). Certified Nursing Assistant (CNA) A transferred the resident in a Hoyer lift (full body mechanical lift) without a second staff person to assist. The Hoyer lift malfunctioned and CNA A was not able to maintain control of the resident and the Hoyer lift, causing the resident to fall to the floor. This resulted in a laceration (cut) and a small hematoma (collection of blood under the skin) to the resident's forehead and mental status changes. Staff called 911 and the resident was sent to the hospital. The sample was 4. The census was 63. Review of the facility's resident handling and transfer policy, dated June 2010, showed: -Purpose: To ensure a safe working environment for residents and caregivers when transferring and/or handling residents; -Procedure: An initial screen will be performed on all residents to assess transfer and ambulation status by the Rehab Department within 48 hours of admission; -If admissions occur over the weekend the Charge Nurse for the unit which the resident is admitted will complete a nursing assessment and obtain temporary orders for mobility status from the physician; -Rehab will perform a screen quarterly and when necessary after the initial admission screen; -All resident's transfer status will be placed on the profile, care plan, and within the nurse's resource book; -All transfers will be designated into the following categories; -Independent; -One staff assist; -Two staff assist; -Mechanical lift; -All manual lifts shall be performed by lifting machine policy. Review of the facility's lifting machine policy, dated July 2017, showed: -Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions; -General guidelines: At least two nursing assistants are needed to safely move a resident with a mechanical lift; -Mechanical lifts may be used for tasks that require: -Lifting a resident from the floor; -Transferring a resident from bed to chair; -Lateral transfers; -Lifting limbs; -Toileting or bathing; -Repositioning; -Types of lifts that may be available in the facility are: -Floor-based full body sling lifts; -Overhead full body sling lifts; -Sit to stand lifts; -Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/25/20, showed the following: -A Brief Interview for Mental Status (BIMS, a screening tool used to determine cognitive impairment), score 15 out of 15, showed the resident as cognitively intact; -[DIAGNOSES REDACTED]. -Two person assist with transfers; -Extensive assistance with bed mobility; -Total dependence with transfers, dressing and toileting; -Range of motion (ROM) impairment on both sides of the lower and upper extremity; -Used a wheelchair. Review of the resident's care plan, dated 6/23/16, and updated 7/28/20, showed: -Problem: Resident is non-weight bearing and uses a wheelchair for locomotion. He/she depends on staff to assist with transfers and he/she is also at risk for falls; -Goal: He/she will remain free from serious injury; -Approaches: -Instruct him/her to call when he/she needs to transfer, use the bedpan, toilet, etc.; -Assist him/her to the extent required to perform Activities of Daily Living (ADLs); -Notify nurse practitioner/physician of significant changes in status; -Transfer with Hoyer lift with two assist; -Problem updated 7/28/20: Resident incident involving hydraulic lift and inappropriate transfer technique by staff member. Resident received skin tear approximately one inch and hematoma; -Goal: Resident will remain free from injury through next review period; -Approach: -Therapy positioning screen to be completed; -Education on hydraulic lift to be provided to staff; -Encourage resident to assist with transfer by holding on in hydraulic lift. Review of the resident's progress notes, dated 7/28/20, showed: -At 7:45 A.M., called to room via CNA. Resident laying on the floor with head against the night stand. One inch laceration to the right side of the forehead with hematoma. Neurological checks done. Right pupil reactive to light (normal reaction), left eye sluggish to respond (abnormal reaction). ROM to all extremities without complaints of pain. Oriented to name, place, and could not recall the date, month, or President. Cold compress applied to laceration. Applied steri-strip (adhesive tape used to close opened wounds) times one to the forehead. Vital signs: Temperature 97.6 degrees Fahrenheit (normal 97.8 through 99.1), blood pressure 156/89 (normal 90/60 through 120/80), heart rate 74 (normal 60 through 100), respirations 22 (normal 12 through 20), oxygen saturation (sats, percentage of oxygen in the blood) 96% (normal 95% through 100%) on room air. Call placed to 911. Waiting for arrival; -At 8:00 A.M., resident remained alert. Responded briskly to verbal stimuli; -At 8:15 A.M., resident left unit per stretcher transferred to hospital for evaluation and treatment; -At 8:16 A.M., called placed to physician. Waiting on return call; -At 8:17 A.M., call placed to next of kin. Made aware of resident change of status and transfer to hospital; -At 8:30 A.M., Nurse Practitioner returned call. Made aware of resident's change in status; -At 2:40 P.M., resident returned to unit from the hospital. Review of the facility's investigation summary, provided on 8/3/20 and completed by the corporate administrator, showed the incident occurred on 7/28/20 at 7:45 A.M. CNA A transferred the resident improperly with use of the hydraulic lift. The resident had a one inch laceration to the right side of the forehead and a small hematoma was observed upon assessment. Resident's pupil was reactive to light and lift pupil assessed and observed to be sluggish to respond. Charge nurse on duty, Licensed Practical Nurse (LPN) B, documented that the incident occurred. Appropriate notification was completed to the family and the physician, and was documented. The resident was sent to the local emergency room for evaluation and treatment. The resident returned to the facility at approximately at 2:40 P.M. Resident interviews were completed on 7/29/20 and 7/30/20. During the interviews, residents stated that he/she felt safe, residents stated that he/she did not have an issue with CNA A. The question was directly asked if they had ever been mistreated and the residents interviewed denied mistreatment. CNA A was interviewed and statement obtained on 7/28/20 by the Director of Nursing (DON) and union steward. CNA A was suspended pending an investigation on 7/28/20. CNA A was terminated on 7/31/20. Review of CNA A's written statement, dated 7/28/20, showed CNA A got the resident up with a Hoyer lift. The resident was almost in the chair, he/she started talking, and moved around in the Hoyer lift. The Hoyer lift gave out and the resident slid backwards. CNA A held and lay him/her to the floor. The Hoyer lift fell on CNA A and CNA A's nose started bleeding and the resident had a small cut on the forehead. CNA A should have went for help. Staff have no other staff to help out. He/she was the only CNA on the floor. Observation and interview on 7/29/20 at 2:50 P.M., showed the resident in his/her wheelchair. Dark bruising visible above the resident's right eyebrow, approximately 1 inch in size. The resident said he/she went to the hospital on [DATE] because the Hoyer lift went out on him/her. It happened in the morning when staff transferred him/her from the bed to the wheelchair. There was only one staff in the room during the transfer. It is normally two people. The last time staff used the Hoyer lift alone was a month ago. CNA A operated the lift alone on 7/28/20. The Hoyer lift went out, which happens all the time because the battery needed to be charged. The resident said he/she was midair when the Hoyer lift went out and he/she fell to the floor. He/she hit his/her head and there was blood everywhere. The resident said he/she had an injury above his/her right eyebrow. He/she remembered the incident, but did confirm he/she forgot who the President was. He/she thought it was President(NAME) but later remembered who the current President was. He/she was taken to the hospital and was told that he/she was fine. There were no fractures and he/she returned to the facility on the same day. During an interview on 7/29/20 at 3:00 P.M., the corporate administrator said he was aware of the incident and the investigation had started. CNA A was removed from the situation. The DON spoke to CNA A and the corporate administrator spoke to the resident. He completed a questionnaire for the resident and began in-servicing. The transfer/lift competency will be done in the next 30-45 days. The resident was not scared and did not believe that it was done on purpose. It was a policy violation. Re-education is a constant thing. Review of CNA A's training record, received 8/4/20, showed no documented education on the use of the mechanical lift. During an interview on 7/29/30 at 3:37 P.M., Rehab Manager C said the resident transferred with the use of the Hoyer lift. He/she has a [DIAGNOSES REDACTED]. Rehab Manager C was aware that the resident had a bad transfer with only one staff operating it. All employees are educated and in-serviced at the time of hire that the Hoyer lift is operated by two people. There is a form given to employees called Handling and Transfer policy that is signed at orientation. Rehab manager personally goes over it with new hires. Staff are educated on what to do if the lift malfunctions or if the battery dies. If the lift malfunctions, the Hoyer lift will rise to the highest point. When that happens, staff are expected to move the resident above their bed and raise the bed, so the resident does not drop. Once the clip is removed, the resident is dropped, not lowered slowly. During an interview on 7/30/20 at 10:37 A.M., CNA A said he/she entered the Resident's room at 6:45 A.M. He/she had to get the resident's up and there was no one else on the floor to assist. He/she knew he/she was supposed to have two staff assist with a Hoyer lift transfer. The nurses were busy getting report. CNA A connected the lift pad to the lift and raised the resident up using the Hoyer handheld controller. He/she attempted to position the resident above the wheelchair. The wheelchair was locked and CNA A lowered the resident to the wheelchair. The resident started laughing and wiggling around while still suspended in the air. CNA A told the resident to stop laughing at the television. The resident was approximately one inch from the wheelchair when the top part of the lift hit him/her (CNA A) in the face. He/she tried to protect the resident, so he/she lowered the resident on the floor instead of the wheelchair. The Hoyer lift also hit the resident in the head. The resident started to bleed; however, most of the blood was from his/herself. He/she tried to get LPN B and the other nurse's attention, but they just looked at him/her and did not come into the room. A housekeeper came in and asked if CNA A needed help. The housekeeper notified the nurses and they entered the resident's room. CNA A was asked to assist with vitals. The resident was fine and did not lose consciousness. He/she did not know how the lift malfunctioned. There are a lot of staff who use the Hoyer lift by themselves. He/she seen therapy operate it alone. Everyone was focused on the resident and no one asked about CNA A's injuries as he/she had a bloody nose and became dizzy. He/she gave his/her statement to the DON at 10:45 A.M., and was suspended pending the investigation. During an interview on 7/30/20 at 12:10 P.M., LPN B said it was 7:45 A.M. when he/she was notified by the housekeeper that a resident had fallen. LPN B went into the room and observed the resident on the floor next to the bed. He/she was face up. LPN B assessed the resident, and saw he/she had a laceration to the right side of the forehead. There was a moderate amount of blood and a small hematoma that was raised in the same area. At first, the resident could not recall the date, month, or President; however, he/she was able to recall it later. He/she was alert and did not lose consciousness. The resident said he/she slipped from the lift. It was CNA A that operated the lift. He/she called 911 because the resident was on the floor and they were unsure about his/her injuries. The ambulance arrived at 8:15 A.M., and at that time, the resident could name all the people in the room, time, place, date, and month. The first responders assisted the resident from the floor onto the stretcher and transported him/her to the hospital. During an interview on 7/30/20 at 9:50 A.M., the physician's social worker said the physician was unavailable; however, he/she was able to speak on their behalf. The facility reported the incident to the physician on 7/28/20 at 8:21 A.M. The social worker said the physician would expect the staff to follow the facility's policy in regards to using the mechanical lift. During an interview on 8/4/20 at 10:35 A.M., the DON said she was notified by LPN B on 7/28/20 at approximately 8:00 A.M. that there was an incident and the resident was injured during the transfer on the lift. She was told that CNA A operated the lift alone. CNA A said he/she performed the resident's ADL care and put him/her on the lift and that the resident fell because the lift tilted. CNA A said he/she was aware that the Hoyer lift is operated by two people. CNA A did not ask anyone to assist him/her. CNA A said, I just did it. She would expect staff to follow the facility's policy when using the mechanical lift. CNA A was expected to find another person to assist him/her with operating the mechanical lift. He/she should not operate it alone. During an interview on 8/4/20 at 2:30 P.M., the corporate administrator said he would expect staff to be educated in the use of the mechanical lift. The expectation would be to reach out to the therapy director for training. He could not say definitively if CNA A received education upon hire. MO 275

Based on observation, interview and record review, the facility failed to follow two of two sampled residents' physician's orders for Cardiopulmonary Resuscitation (CPR) when staff discovered the residents without signs of life (Residents #65 and #66). Both residents expired. The census was 71. 1. Review of Resident #65's hospital record, showed the following: -[DATE], [DIAGNOSES REDACTED]., sinus [MEDICAL CONDITION] (a regular but unusually slow heart beat); -[DATE], Discharge to Extended Care Facility (ECF) form: -code status: full; -patient is stable for admission and transfer to ECF, and has no emergency medical conditions. Review of the resident's facility face sheet, showed the following: -admitted to the facility on [DATE]; -Advanced directives: yes; -Code status: full. Review of the resident's admission physician orders, included the following: -Code status: full code. Review of the resident's nurses notes, included the following: -[DATE] at 2:15 P.M., admitted to the facility. Vital signs stable. Resident was comatose and unresponsive. Staff spoke with the physician. All medications reviewed. -Evening shift: Resident is comatose. Respirations noted at this time are shallow. Resident currently on oxygen at 2 liters. Blood glucose checked at this time was 78. At 10:30 P.M., blood glucose was 61. Resident has order for 50 units of [MEDICATION NAME]. [MEDICATION NAME] held as a result of decreased blood glucose. Further review of the resident's nurses notes, included the following: -Night shift: While making rounds, staff found resident to be unresponsive when (nurse) arrived to patient's room, (nurse) attempted to arouse patient with a sternal rub times two. Immediately after patient was assessed for vitals at that time. Blood pressure or pulse weren't palpable (felt). Patient wasn't responsive to tactile or painful stimuli. Doctor notified of findings at that time. No cause of death was given. Nurse was instructed by doctor to notify family of change in condition with patient. Nurse explained to him (physician) at that time, (nurse) needed to call the coroner. Stated to call them and then the family. Call placed to family. Resident's body released to funeral home. Review of the resident's death certificate, included the following as the underlying cause: -Hypoxic/ischemic [MEDICAL CONDITION]; -[MEDICAL CONDITION]. During an interview on [DATE] at 2:00 P.M., Certified Nurse Aide (CNA) K said: -He/she found the resident unresponsive during rounds, and called for Licensed Practical Nurse (LPN) Y. LPN Y entered the resident's room. CNA K left the room. He/she did not see staff take a "crash" cart to the resident's room or anywhere else. CNA K did not see an ambulance or coroner. LPN Y called the resident's time of death. During an interview on [DATE] at 10:00 A.M., LPN Y said: -He/she was the charge nurse for the resident's floor. An unknown staff called him/her to the resident's room. Nurse Y did not know the resident's code status, and staff should do CPR if staff do not know the code. LPN Y tried to resuscitate the resident by placing an ambu-bag (a bag valve mask, a hand held device used to provide ventilation) over the resident's mouth and nose to seal. LPN G came in the resident's room, and he/she helped with the ambu-bag. LPN Y started compressions, and performed a sternal rub. He/she called the physician to inform him the resident expired. He/she did not know if he/she had current CPR certification in April, 2011. He/she had no CPR certification card for April, 2011. During an interview on [DATE] at 12:20 P.M., LPN G said a CNA reported the resident was not breathing. LPN G was at the nurses' station, and he/she pulled the resident's chart. LPN G asked LPN Y if he/she needed the chart. Nurse Y said, "It's good. I got it." LPN Y went to the resident's room, and he/she had a stethoscope and a blood pressure cuff. LPN G did not go into the resident's room. He/she saw the "crash" cart at the nurses' station, and did not see staff take it from the nurses' station. If LPN Y performed CPR, he/she would have taken the crash cart. He/she did not call 911, and he/she did not hear staff call 911. LPN Y had full responsibility for the hall, already made rounds, and had the keys. LPN Y went upstairs to talk to a nursing supervisor. The nursing supervisor called the Director of Nurses (DON). During an interview on [DATE] at 12:27 P.M., former DON P said: -She was the DON from February, 2011 until [DATE]. She was the DON when the resident was at the facility. Staff did not provide CPR to the resident. LPN Y reported he/she performed a sternal rub. A sternal rub is not CPR. Staff did not call 911. She expected staff to perform CPR for the resident because he/she was a full code. The resident's face sheet and the physician orders showed the resident's code status. The resident's hospital documentation showed full code. She knew it was an error after staff did not perform CPR. The resident's nurses note was the correct picture of what the nurse did. The resident's nurses note showed no CPR was performed on the resident. The nurses' note is not the original nurses note in the chart. LPN Y re-wrote the nurses note because former DON P told him/her to paint a picture of what happened. He/she did not know the location of the original nurses note. Former DON P reported to the physician's nurse practitioner the same day that staff did not perform CPR for the resident. She also notified the physician within several days. She did not talk with the resident's family. During an interview on [DATE] at 10:40 A.M., the administrator said: -On [DATE], LPN G reported to her that on [DATE] after the resident expired, former DON P told him/her to re-write the resident's nurses notes. LPN G re-wrote the nurses notes. That was why the facility inserviced staff on CPR on [DATE]. The administrator did not ask LPN G for other information; -If a nurse performed CPR, he/she must be CPR certified. The "Good Samaritan rule" did not apply in a facility; -LPN Y's employee file did not have a CPR certification card for April, 2011. If he/she had CPR certification for April, 2011, the certification card would be in his/her employee file; -He/she did not know LPN Y had no CPR certification for April, 2011. Review of LPN Y's employee file on [DATE] at 12:20 P.M., showed no CPR certification for April, 2011. During a subsequent interview on [DATE] at 3:05 P.M., LPN Y said: -He/she did not perform CPR for the resident; -He/she did not use an ambu-bag for the resident; -He/she did not remember why he/she did not perform CPR for the resident; -He/she was not certified in April, 2011 for CPR; -He/she was recently inserviced on resident's code status. If a resident did not have a "red sticker" on his/her chart, he/she was a full code. During an interview on [DATE] at 9:30 A.M., the administrator said: -Resident #65 was his/her own responsible party; -The resident's hospital discharge papers, and the physician's orders showed he/she was a full code; -The resident's code status was full code; -A sternal rub is not CPR; -The residents' nurses notes showed staff did not perform CPR for the resident; -The administrator expected staff to perform CPR for the resident. During an interview on [DATE] at 11:00 A.M., the physician said: -He expected staff to follow a resident's physician's orders for code status; -Staff need to be educated if a resident is full code, staff had to abide by the full code; -He expected staff to follow Resident #65's code status; -He expected staff to perform CPR for the resident. 2. Review of Resident #66's face sheet, showed the following: -Readmitted to the facility on [DATE]; -Daughter-in-law was power of attorney; -Advance Directives: blank; -Code status: blank. Review of the hospice patient/family informed consent form, dated [DATE], showed the following: -Signed by the resident's durable power of attorney; -Initialed the following: If I should experience a cardiopulmonary arrest, i.e. a cessation of heart and lung functioning, I specifically request that I be kept alive by any available measures, such as artificial respiration or cardiopulmonary resuscitation. I understand that I may change this election at any time by notifying the Hospice program, either orally or in writing. I understand that activation of EMS, Advanced Cardiac Life Support and/or Artificial Ventilation is not a covered benefit. Review of the hospice care plan, dated [DATE], showed the following: -No advance directives; -Daughter-in-law was power of attorney; -Primary [DIAGNOSES REDACTED]. -Full code. During an interview on [DATE] at 3:00 P.M., hospice nurse W said: -The resident had a full code status when admitted to hospice; -The resident had a power of attorney, and the power of attorney wanted him/her to remain a full code; -The power of attorney was "adamant" the resident remain a full code; -The resident remained a full code; -It not mandatory for a resident to be on hospice and be a Do Not Resuscitate (DNR) code. Review of the resident's physician orders, included the following: -[DATE], admit to hospice with [DIAGNOSES REDACTED]. Review of the nurses notes, showed the following: -[DATE] at 11:45 P.M., patient with no distress at this time. Respiratory even and non-labored with lung sound diminished. No cough noted at the time. Patient is responsive to tactile stimuli only. Vital signs, (body temperature) 98.2 (degrees Fahrenheit), (respirations) 20, blood pressure ,[DATE]. -[DATE] at 6:20 A.M., this writer called to patient's room. Patient pale, no respiration, no vital signs. (This entry was crossed through.) -[DATE] at 12:30 (A.M. or P.M. not specified), patient resting in bed. No distress noted, respiration remains even. Small amount of emesis noted. Siderails up times two with call light within reach. -[DATE] at 2:00 A.M., no distress noted. Foley catheter draining without difficulty. [DEVICE] patent and flushing without difficulty. Resting with siderails up times two and call light is within reach. -[DATE] at 4:00 A.M., [MEDICATION NAME] (tube feeding) infusing without difficulties. Tissue integrity warm and dry. Respiration, 94% room air. No distress noted at this time. -[DATE] at 6:00 A.M., new bag of [MEDICATION NAME] hung. Placement verified. No distress noted. Siderails up times two with call light within reach. -[DATE] at 6:20 A.M., this writer called to resident's room by CNA. Resident with no noted vital signs, no audible blood pressure, no palpable pulse, no visible signs of respiration. Tissue integrity still warm. -[DATE] at 6:25 A.M., hospice informed of resident's expiration, and on call nurse to call back. Resident remains properly dressed/cleaned. -[DATE] at 7:00 A.M., hospice returned call, informed of expiration. -[DATE] at 7:10 A.M., power of attorney called, received answering machine. This writer requested a call back, patient's expiration was not advised. -[DATE] at 7:20 A.M., resident's second contact was called with no answer. -[DATE], late entry for 6:30 A.M., physician exchange called. -[DATE] at 8:30 A.M., call place to medical examiner. (Signed by former DON) -[DATE] (late entry for 8:15 A.M.) call placed to physician (Signed by former DON). During an interview on [DATE] at 9:00 A.M., CNA J said: -He/she cleaned the resident at approximately 5:30 A.M. The resident did not respond to his/her voice, but he/she felt the resident's chest go up and down. He/she left the room, and reported it to LPN Z; -At approximately 6:30 A.M., he/she saw the resident was not breathing, and not responsive. The resident's skin temperature felt "normal", which was "rather cool and clammy". The resident's skin was rather cool to the touch when CNA J provided care in the past. The resident was not cold or stiff. He/she immediately summoned LPN Z, and LPN Z saw the resident; -He/she brought the vital sign machine to the resident's room, per LPN Z's instructions. LPN Z said he/she did not know the resident's code status. LPN Z went to the resident's chart. LPN Z said he/she did not need help; -CNA J left the resident's room. He/she did not hear staff call 911. He/she did not see an ambulance. During an interview on [DATE] at 11:00 A.M., LPN Z said: -CNA J reported the resident was not breathing; -He/she assessed the resident who had no pulse or no respirations; -He/she told CNA J to reposition the resident; -The resident's face sheet showed no code; -He/she did not attempt to resuscitate the resident because the resident was hospice; -He/she did not call 911 or the physician; -He/she called hospice; -He/she talked with the DON the same day, and found out the resident was full code; -The resident had already expired. During an interview on [DATE] at 3:00 P.M., hospice nurse W said he/she expected staff to provide CPR to a resident who had full code status. During an interview on [DATE] at 12:27 P.M., former DON P said: -The resident had a power of attorney; -Staff did not perform CPR for the resident; -Staff did not perform CPR because the resident was hospice; -She expected staff to perform CPR for the resident because he/she was a full code; -Prior to and during hospice, he/she was a full code; -She and the administrator checked the resident's chart after he/she expired; -She and the administrator determined the resident had a full code; -She did not remember if she notified the physician; -She did not talk with the resident's family. During an interview on [DATE] at 3:00 P.M., the administrator said: -The resident's hospice note, dated [DATE], showed the resident had full code status, and the facility honored this; -The resident's chart showed no indicators of a no code status; -After the resident expired, she was aware of the resident's code status but she was not told whether staff performed CPR or not; -In June, 2011, the DON, ADON, and medical records staff worked together to audit all charts. During an interview on [DATE] at 11:00 A.M., the physician said: -Resident #66 should never been a full code from a medical standpoint; -It was possibly an oversight for Resident #66 to have a full code; -He assumed Resident #66 was no code; -He expected staff to follow a resident's physician's orders for code status; -In Missouri, a resident can be on hospice and be a full code; -Staff need to be educated if a resident is full code, staff had to abide by the full code; -He expected staff to follow Resident #66's code status. -He expected staff to perform CPR for Resident #66. 3. Observation on [DATE] at 3:25 P.M., showed the second floor crash cart at the nurses' station had a code status sheet, dated [DATE]. Observation on [DATE] at 3:40 P.M., showed the third floor crash cart at the nurses' station had no code status sheet. During an interview on [DATE] at 3:40 P.M., LPN Y said the third floor crash cart had no code status sheet. Any resident who did not have a "red dot" on his/her chart was a full code. If the chart was not available, he/she considered the resident a full code. During an interview on [DATE] at 3:30 P.M., the DON said he expected staff to refer to the code status sheet on the crash cart. If the code status sheet on the crash cart was incorrect, staff should return to the nurses' station to refer to the code status sheet in the nurse reference book. During an interview on [DATE] at 3:50 P.M., the administrator said she expected staff to use the code status sheets to determine code status. Updated code status sheets should have been on both crash carts at the nurses' stations. She expected nursing staff to update code status sheets on the crash carts for admitted and readmitted residents. 4. Review of the facility's undated policy, entitled, "Cardiopulmonary Resuscitation", showed the following: -Policy Statement: Cardiopulmonary Resuscitation will be provided to residents who suddenly cease to have spontaneous pulse and respirations unless there is a physician's order for no CPR, Do Not Attempt Resuscitation, or a do not resuscitate order, or allow natural death. -Procedure: -Palpate for victim's carotid or femoral pulse; -Observe victim for signs of breathing; -Note condition of pupils (dilated or constricted (constricted is normal)) and whether they are equal and reactive to light; -If above is negative, pull call light in victim's room and sound alarm by calling for assistance STAT to resident's room; -Activate 911, or community emergency response services. *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, on [DATE], it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, on [DATE], the facility implemented a plan of correction which included the following: The facility staff will be inserviced on CPR and advanced directive policies, which include when CPR should be initiated and what actions to take when CPR is initiated, including announcing "code blue and/or stat" beginning [DATE]. All resident charts have been audited for advanced directives. The list of residents' code status were updated on crash carts and residents' face sheets. The facility scheduled CPR class for all nursing personnel that was not CPR certified for [DATE]. The facility scheduled a mock code to assess staff performance on [DATE]. Anyone requiring one on one education will receive to ensure understanding policies. The facility will routinely check CPR certification to ensure CPR certification is current. Nurse Y's employment was terminated. Nurse Z was inserviced [DATE] regarding code status. The facility will staff licensed nurses so there is at least one licensed nurse on each shift that is CPR certified and at minimum two other nursing personnel on each shift that is CPR certified. When code blue and/or stat is called, all licensed staff will respond to ensure polices are followed. On [DATE], the DON was not employed at the facility. The facility will need to determine how to maintain these new procedures on a long-term basis. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. On [DATE], the severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 786

Based on interview and record review, the facility failed to identify, assess, monitor, and document significant changes in the resident's condition and failed to notify the physician of these changes for one of four sampled residents (Resident #4) resulting in the hospitalization of the resident. The facility census was 74. 1. Review of Resident #4's transfer orders, dated 11/11/10, showed the following: -Diagnosis: [REDACTED]. -Diet: nothing by mouth (NPO), [MEDICATION NAME] 1.2 (nutritional supplement that contains 1.2 calories per cubic centimeter (cc) of solution) tube feeding at 60 cc's per hour per feeding tube; -Respiratory: #8 [MEDICAL CONDITION] with 21% at 6 liters, suction every four hours and as needed and pulse oximetry reading as needed. Review of the resident's face sheet, showed the following: -Readmitted on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's admission physician order [REDACTED]. -[MEDICATION NAME] AC (diabetic supplement) to run continuously at 55 cc per hour rate. -[MEDICATION NAME] (used to prevent [MEDICATION NAME] in people with [MEDICAL CONDITION]) inhaler six puffs every four hours. Review of the resident's initial care plan, dated 11/19/10, showed the following: -Eating: total. The resident's care plan did not address any interventions related to the administration of nutritional support through the feeding tube. -Other: The resident's care plan did not address any interventions related to the care of the resident's [MEDICAL CONDITION] or the administration of oxygen. -Bed mobility: turn with the assistance of one. -Dressing: total assistance from the facility staff. Review of the resident's nurses' notes, showed the following: -12/4/10 at 3:00 P.M., decision making poor; needs cues with a non-productive cough present. No documentation of respiratory status, but the resident oxygen saturation was documented as 96% (normal range, 95% to 100%). Pulse 91 (normal range, 60 to 100 beats per minute) and blood pressure 156/96 (normal range, 90 to 140 over 60 to 90). -12/5/10 at 12:30 A.M., cough present with a blood pressure of 159/106. The oxygen saturation was 99%. -2/5/10 at 7:10 P.M., the resident had rales (wet crackly lung sounds heard on inspiration and indicative of pneumonia) and rhonchi (coarse rattles in the [MEDICATION NAME] airways) with thick mucus. No oxygen saturation documented. -12/6/10 at 6:00 A.M., the resident had decreased breath sound in both lower lobes. -12/11/10 at 7:30 P.M., the resident was restless with rales, rhonchi and wheezing present. The oxygen saturation was 84%. The resident had his/[MEDICAL CONDITION] place with mist. Licensed Practical Nurse (LPN) A suctioned the resident and the oxygen saturation was 80%. During an interview on 12/27/10 at 9:36 A.M., LPN A said he/she did not call the physician on the resident's change of condition of restlessness, the new development of rales and rhonchi, and the oxygen saturation of 80% and 84 % on 12/11/10. During an interview on 12/27/10 at 9:40 A.M., Certified Nurses Assistant (CNA) C said when he/she walked past the resident's room on 12/10/10, the resident usually smiled and tried to say something. The resident did not smile. CNA C knew the resident could not talk, but he/she tried to talk to the resident. On 12/11/10, the resident did not smile. CNA C said the resident looked very sleepy and run-down looking. CNA C did not report to LPN A how the resident looked on 12/11/10. During an interview on 12/27/10 at 9:20 A.M., the Director of Nurses (DON) said the resident's change in condition on 12/11/10 should have been reported to the physician on 12/11/10. She expected her staff to assess the resident first and call the physician on any change of condition with the resident. Further review of the resident's nurses' notes, showed the following: -12/12/10 on the day shift, no documentation regarding the resident's condition. -12/12/10, staff documented the resident's feeding tube working properlypatent, [MEDICAL CONDITION], and administered pain medication. Staff did not document the resident's vital signs. -12/12/10 on the night shift, no documentation regarding the resident's condition. -12/13/10, no documentation regarding the resident's condition for all three shifts 7:00 A.M. through 3:00 P.M., 3:00 P.M. through 11:00 P.M., and 11:00 P.M. through 7:00 A.M. -12/14/10 at 9:30 A.M., the resident's temperature registered 102.6 degrees Fahrenheit (normal range, 97.8- 99.1 degrees Fahrenheit), blood pressure of 180/105 with an oxygen saturation of 90%. LPN B was called to the resident's room by the resident's family to find these vital signs. The family was at the bedside and said the resident had a change in his/her mental status. LPN B suctioned a small amount of secretion. LPN B called the resident's physician and obtained orders to send the resident to the emergency room . During an interview on 12/16/10 at 9:17 A.M., Family Member (FM) A said she visited the resident on 12/14/10, and she noticed a huge change in the resident's cognitive functioning. FM A tried to get assistance from the staff, but there was no staff on the floor. All of the staff were in the dining room on another floor. Finally, she found the DON and the charge nurse. During an interview on 12/27/10 at 9:03 A.M., LPN B said he/she was called to the resident's room by the family on 12/14/10. LPN B said it was the first time he/she saw the resident because he/she was passing medications. The resident's family said something was wrong with the resident. LPN B suctioned the resident and took his/her vital signs. LPN B said the resident did not look like anything was wrong, only his/her skin felt hot. There was no order for an oxygen saturation to be obtained. During an interview on 12/27/10 at 9:16 A.M., the DON said one of the family members came to her office and asked her to go to the resident's room. The DON arrived to the room and the nurse had suctioned the resident. The DON said LPN B did not notice anything different with the resident. The DON told the family the resident had "good days and bad days" and left the resident's room. Review of the resident's emergency room record, dated 12/14/10, showed the following: -Family and nursing home records reports reduced level of consciousness over the past 24 hours and a fever to 102 F. This is a new problem and the problem gradually worsened. -Physical examination: patient is nonverbal and appears distressed. The CT (computed tomography) showed possible infarct or possible bleeding. The chest x-ray showed a new questionable left lower lobe infiltrate. Review of the resident's hospital history and physical, dated 12/14/10, showed the following: -The resident was found by his/her family to be very agitated, confused and a high fever. The head CT was done which showed possible left cerebella stroke. The resident seemed not to move his/her eye ball on the right side. Review of the resident's physician discharge summary, dated 12/28/10, showed the following: -Discharge Diagnoses: [REDACTED]. -Disposition: Long term acute care ventilator facility. Review of the facility's policy on resident's change or condition, dated 2001 and revised March 2004, showed the following: -Our facility shall promptly notify his or her attending physician of changes in the resident's medical/mental condition and /or status. -The nurse supervisor/charge nurse will notify the resident physician of changes in the resident's medical/mental condition and /or status. During an interview on 1/5/11 at 10:08 A.M., the resident's physician, (who is also the Medical Director of the facility), said the following: -The facility should call the physician on any change in the resident's condition. - The facility did not call the resident's physician regarding this change in condition. -The facility should have called him on 12/11/10 when the resident's oxygen level was down to 84%. -If the facility would have called, he would have given the order to send the resident to the emergency roiagnom on [DATE]. -Placing a call to him on 12/11/10 would have prevented further deterioration of the resident's conditions such as the stroke and the pneumonia, and the treatment of [REDACTED]. M 7333