Every finding on record at Eldon Nursing & Rehab

Based on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 53.1.Review of the facility's policy titled, Antibiotic Stewardship Program (ASP), undated, showed it directed staff as follows: -Infection Preventionist (IP): This person will be the hub of the ASP. They will have the knowledge and expertise to effectively develop, implement, and monitor the ASP; -The IP/designee will be responsible to audit the clinical assessment documentation at the time of the antibiotic prescription; -The IP/designee will be responsible for auditing of the completeness of antibiotic prescribing documentation to include dose, route, state date, end date, days of therapy, and indication; -The IP/designee will track C. difficile (a bacterium that causes severe, often painful, watery diarrhea and intestinal inflammation, usually following antibiotic treatment that disrupts healthy gut flora) and antibiotic-resistant infections. The facility will work with the consultant laboratory personnel to develop a quarterly report of any instances of C. difficile or antibiotic-resistant infections, such as methicillin-resistant Staphylococcus aureus ((MRSA) is a type of staph bacteria that causes infections resistant to many common antibiotics) or E. coli (a bacterium commonly found in the intestines of humans and other animals, some strains of which can cause severe food poisoning). This report will be discussed with the Medical Director, Pharmacist Consultant, and Lab Consultant during the quarterly Quality Assurance meeting. Review of the facility's antibiotic stewardship program showed the program did not contain documentation of an infection/antibiotic control log for January 2025 through June of 2025. Review of the facility's Infection/Antibiotic control log, dated July 2025, showed 20 antibiotics used, 12 of the antibiotics did not have documentation of signs and symptoms, four did not have documentation of the site of infection, six did not have documentation of onset of symptoms, four did not have documentation if a culture was done, 17 did not have documentation if the pathogen identified, and 20 antibiotics did not have documentation if the infection was resolved. Review of the facility's Infection/Antibiotic control log, dated August 2025, showed nine antibiotics used, six of the antibiotics did not have documentation of signs and symptoms, one did not have documentation of the site of infection, three did not have documentation if a culture was done, nine did not have documentation if the pathogen identified or documentation if the infection was resolved. Review of the facility's Infection/Antibiotic control log, dated September 2025, showed 18 antibiotics used, 15 of the antibiotics did not have documentation of signs and symptoms, four did not have documentation if a culture was done, 18 did not have if the pathogen was identified or documentation the infection was resolved. Review of the facility's Infection/Antibiotic control log, dated October 2025, showed 11 antibiotics used, two of the antibiotics did not have documentation of signs and symptoms, two did not have documentation of the site of infection, one did not have documentation if a culture was done, 11 did not have if the pathogen was identified or documentation the infection was resolved. Review of the facility's Infection/Antibiotic control log, dated November 2025, showed 17 antibiotics used, 12 of the antibiotics did not have documentation of signs and symptoms, six did not have documentation if a culture was done, 17 did not have if the pathogen was identified or documentation the infection was resolved. Review of the facility's Infection/Antibiotic control log, dated December 2025, showed nine antibiotics used, nine did not have if the pathogen was identified or documentation the infection was resolved. Review of the facility's Infection/Antibiotic control log, dated January 2026, showed 21 antibiotics used, 18 of the antibiotics did not have documentation of signs and symptoms, 17 did not have documentation if the pathogen identified, and 21 antibiotics did not have documentation if the infection was resolved. During an interview on 02/26/25 at 1:03 P.M., the IP said he/she has completed the IP training and is certified to be the infection preventionist. The IP said he/she helps gather and document in the facility's Infection/Antibiotic control log the antibiotic usage in the facility. The IP said he/she does not do anything else with that information it is given to the Director of Nursing (DON) or Assistant Director of Nursing (ADON) and they implement whatever is needed. He/She said the log isn't fully completed because he/she did not know what information is required. The IP said he/she has been in this role for a year. During an interview on 02/26/26 at 1:15 P.M., the DON said the IP is responsible for maintaining the information in infection/antibiotic log and for tracking and trending infections and use of antibiotics in the facility. During an interview on 02/26/26 at 1:16 P.M., the ADON said the IP is responsible for the antibiotic stewardship program. During an interview on 02/26/26 at 4:53 P.M., the administrator said she was not aware the antibiotic stewardship was not being completed. She said she is aware of the importance and the risks are for not having the antibiotic stewardship program in place.

Based on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants during perineal and/or wound care, when staff failed to perform appropriate hand hygiene, and glove changes for three residents (Resident #1, #6, and #34 ), of five sampled residents, Facility staff failed to ensure sanitary conditions for catheter tubing when they failed to keep the tubing off the floor for three residents (Resident #2, #48, and #54) out of three sampled residents. Facility staff failed to post Enhanced Barrier Precautions (EBP) signs for five residents (Resident #2, #23, #31, #48, and #54) out of five sampled residents. The facility census was 53.1. Review of the facility's policy titled, Perineal Care, undated, showed the policy did not direct staff on appropriate hand hygiene and glove changes during care. Review of the facility's policy titled, Handwashing, undated, showed the policy did not direct staff on when to wash hands. Review of the facility's policy titled, Gloves, undated, showed dirty gloves are worse than dirty hands because microorganisms adhere to the surface of the glove easier than to the skin on your hands and directed staff to change gloves between contacts with different residents or with different body sites of the same resident. 2. Review of Resident #1's Quarterly Minimum Data Set Assessment (MDS), a federally mandated assessment tool, dated 02/06/26, showed staff assessed the resident as: -Always incontinent of bowel and bladder; -Dependent on staff for toileting, and shower/bathe; -Diagnosis of traumatic brain injury, Paraplegia (impairment or loss of motor and sensory function in the lower half of the body). Observation on 02/24/26 at 9:20 A.M., showed Certified Nursing Assistant (CNA) B and CNA M entered the resident's room to provide perineal care, both CNA's applied gloves. CNA B cleaned the residents front side, rolled the resident to his/her side and CNA M cleaned the residents back side. CNA B and CNA M did not change their gloves, and with the same soiled gloves placed a clean pad under the resident and covered the resident up with a blanket. During an interview on 02/24/26 at 9:35 A.M., CNA B said he/she should have changed his/her gloves when going from front to back, and a clean to dirty task. During an interview on 02/24/26 at 9:36 A.M., CNA M said he/she did not think about changing gloves throughout the task but should have. 3. Review of the facility's policy titled, Wound care and Treatment, undated, showed staff were directed as follows: -Hand washing must be done as outlined in the guidelines; -Put on gloves; -Remove the soiled dressing and place in the trash bag; -Remove gloves and discard in the bag; -Wash your hands and put on clean gloves; -Clean the wound according to order; -Remove gloves, place in the trash bag, and put on clean pair of gloves; -Apply clean dressing as ordered; -Wash your hands. 4. Observation on 02/25/26 at 8:50 A.M., showed Licensed Practical Nurse (LPN) A placed gauze in a cup with his/her bare hands and sprayed the gauze with wound cleanser. The LPN did not perform hand hygiene, applied gloves, gown and a mask, and entered Resident #6's room to provide wound care. The LPN touched the resident's pillow and right foot with the same gloves on and then placed wound supplies, and scissors on the resident's dresser without a clean barrier. The LPN touched a trash can and urinal in the room, removed his/her gloves, applied clean gloves, and did not perform hand hygiene with gloves changes. He/She removed the soiled bandage from the resident's right foot, removed his/her gloves, did not perform hand hygiene, put on clean gloves, and applied the gauze from the cup to the resident's wound. The LPN removed his/her gloves, performed hand hygiene, applied new gloves, and used the scissors from the resident's dresser to cut foam and xeroform (Vaseline) gauze, placed the scissors on the bed without a barrier and applied the foam and gauze to the resident's wound. 5. Review of Resident #34's comprehensive MDS, dated [DATE], showed staff assessed the resident as cognitively intact and at risk for developing pressure ulcers/injuries. Review of the resident's care plan, dated 02/24/26, showed the resident receives wound care services for a wound on his/her right lower abdominal fold and right posterior knee. Observation on 02/24/2026 at 9:00 A.M., showed LPN A entered Resident #34's room to provide wound care applied a gown, mask, gloves and washed his/her hands. The LPN pulled the covers back to expose the residents leg bandage, pushed the resident's door closed, removed the leg bandage. He/She did not change his/her gloves before he/she removed the clean gauze sponges, applied wound cleaner to the sponges, and placed the wet sponges on the wound. He/She removed his/her gloves, left the resident's room with gown and mask on, removed supplies from the treatment cart, returned to the resident's room and did not perform hand hygiene before he/she applied gloves. He/She cleaned the residents wound, applied a petroleum dressing, covered with a bandage and wrapped the resident's lower leg with gauze. With the same gloves he/she cleaned the resident's foot with wound cleaner. LPN A replaced his/her gloves and touched the bathroom door, water faucet, the basin, turned off the faucet, turned on the call light, moved the bipap machine mask, removed the bandages from the resident's right toe, and cleaned the right toe wound with gauze sponges. He/She did not perform hand hygiene before he/she applied new gloves and bandaged the right toe. He/She removed the gloves, gown and mask and did not perform hand hygiene before he/she left the resident's room. The LPN returned to the resident's room to perform perineal care. He/She used the same area of the washcloth multiple times to clean the resident's groin area. With the same soiled gloves, the LPN opened the wipes container and removed a wipe. He/She used the same are of the wipe to clean the resident's groin three times, folded the wipe over, and wiped three more times with the same area of the wipe. He/she removed another wipe and wiped the resident's groin four times, folded it, wiped five times with the same area, folded it and wiped five more times with the same area. Observation on 02/24/26 9:44 A.M., showed the resident's room did not contain posted EBP signs. Observation on 02/25/26 at 12:19 P.M., showed resident's room did not contain posted EBP signs. Observation on 02/26/2026 12:37 P.M., showed resident's room did not contain posted EBP signs. During an interview on 2/26/26 at 4:04 P.M., Registered Nurse (RN) I said staff are expected to perform hand hygiene between dirty and clean tasks and when gloves are changed. 6. Review of the facility's policy titled, Catheter Care, undated, showed the policy did not direct staff on the appropriate placement of catheter tubing or the level of the catheter bag. Review of the facility's policy titled, EBP to Infection Control Guidance, revised 3/2024, showed EBP included residents with an indwelling medical device including urinary catheters and residents with a wound. The policy showed it did not direct staff on the use of EBP signs. Review of the Centers for Disease Control (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), Updated 04/02/24 showed: -EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: --Wounds or indwelling medical devices, regardless of MDRO colonization status; --Infection or colonization with an MDRO; -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 (e.g., gown and gloves); --For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. 7. Review of Resident #2's comprehensive MDS, dated [DATE], showed staff assessed the resident as: -Has indwelling catheter; -Has a pressure injury. Review of the Physician Order Sheet (POS), dated 2/24/26, showed a treatment for a right heel stage three pressure ulcer and a treatment for an unstageable sacral wound. Observation on 2/23/26 at 10:32 A.M., showed the resident in bed, urinary catheter bag hung on side of bed. The resident's room did not contain posted EBP signs. Observation on 2/24/26 at 12:14 P.M., showed the resident wheeled from the dining room past two staff members to the social services office with his/her catheter tube dragging the floor. Observation on 2/24/26 1:40 P.M., showed resident's room did not contain posted EBP signs. Observation on 2/25/26 3:04 P.M., showed resident's room did not contain posted EBP signs. Observation on 2/26/26 at 10:39 A.M., showed resident's room did not contain posted EBP signs. 8. Review of Resident #23's comprehensive MDS, dated [DATE], showed staff assessed the resident as at risk for pressure ulcer/injury. Review of the Resident's care plan, dated 1/06/26, showed the resident sees wound care for a wound located on calf. Review of the POS, dated 2/10/26, showed and order for lower right lateral leg wound care. Observation on 2/23/26 at 11:09 A.M., showed the resident in his/her wheelchair with bandages on his/her legs. The resident's room did not contain posted EBP signs. Observation on 2/24/26 at 11:15 A.M., showed resident's room did not contain posted EBP signs. Observation on 2/26/26 at 925 A.M., showed resident's room did not contain posted EBP signs. 9. Review of Resident #31's comprehensive MDS, dated [DATE], showed staff assessed the resident with two unhealed pressure ulcers. Review of the resident's care plan, dated 10/22/25, showed the resident sees wound care for a wound on the resident's left and right buttock. Review of the resident's POS, date 2/24/26, showed an order to cleans left and right buttock daily and as needed. Observation on 02/23/2026 at 10:39 A.M., showed resident's room did not contain posted EBP signs. Observation on 02/24/2026 at 1:49 P.M., showed resident's room did not contain posted EBP signs. Observation on 2/26/26 at 9:25 A.M., showed resident's room did not contain posted EBP signs. 10. Review of Resident #48's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Has indwelling catheter; -Uses a wheelchair for mobility. Review of the resident's POS, dated 02/2026, showed an order for catheter care every shift, change catheter monthly, and to change catheter as needed. Observation on 02/23/26 at 1:45 P.M., showed the resident in the common area with his/her catheter tubing on the floor, with staff present. Observation on 02/24/26 at 9:20 A.M., showed the resident wheeled his/herself around the common area and his/her catheter tubing dragged the floor, with staff present. Observation on 02/24/26 at 9:25 A.M., showed resident's room did not contain posted EBP sign. Observation on 02/25/26 at 3:50 P.M., showed the resident in the common area with his/her catheter tubing on the floor, with staff present. Observation on 2/25/26 at 3:55 P.M., showed resident's room did not contain posted EBP sign. Observation on 2/26/26 at 1:00 P.M., showed resident's room did not contain posted EBP sign. 11. Review of Resident #54's Quarterly MDS, dated [DATE], showed staff assessed the resident has indwelling catheter and a pressure ulcer/injury, one stage two, and two stage three pressure ulcers. Review of the Resident's care plan, dated 12/20/25, showed the resident has a foley catheter. Review of the resident's POS, dated 02/2026, showed an order for catheter care every shift, cleanse sacrum wound once a day, cleanse left foot heel once a day, and cleanse right foot heel once a day. Observation on 02/23/26 at 2:00 P.M., showed resident's room did not contain posted EBP sign. Observation on 02/24/26 at 9:30 A.M., showed the resident in bed with their catheter bag hooked to the bed frame with the bed lowered to the floor and the catheter bag on the floor. The resident's room did not contain posted EBP sign. Observation on 02/25/26 3:55 P.M., showed the resident's room did not contain posted EBP sign. Observation on 02/26/26 at 1:00 P.M., showed the resident's room did not contain posted EBP sign. Observation on 02/24/26 at 9:30 A.M., showed the resident in bed with their catheter bag hooked to the bed frame Observation on 2/25/26 at 3:16 P.M., showed CNA D entered the resident room to perform catheter care. Observation showed CNA D lifted the catheter bag above his/her waistline and the resident's bladder. Observation showed the urine back flowed from the catheter tube into the resident's bladder. CNA D lowered the resident's bed and the catheter bag on the floor. During an interview on 2/25/26 at 3:38 P.M., CNA D said the bag and tubing should not be on the floor. He/She said it is so it doesn't get a hole in the bag or tubing. He/She said the bag should be kept below the bed/below the resident so urine doesn't back flow. He/She said he/she doesn't know why he/she lifted the catheter bag above waist level and does not know why he/she lowered the bed placing the bag and tubing on the floor. 12. During an interview on 2/25/26 at 3:38 P.M., CNA D said catheter bags and tubing should not be on the floor. He/She said it is important that the tubing doesn't drag because it can cause a hole. During an interview on 02/26/26 at 2:15 P.M., CNA B said he/she don't know for sure if a sign needs to be posted for EBP. CNA B said they must wear PPE when doing care for a resident who has a catheter, so thinks there probably should be a sign so everyone knows why they have to wear PPE with certain residents. During an interview on 02/26/26 at 3:55 P.M., with Certified Medication Technician (CMT L) said he/she does not know what an EBP sign looks like. During an interview on 2/26/26 at 4:04 P.M., RN I said catheters should not drag the floor and it is his/her expectation that staff adjust the catheter tubing if they see the tubing dragging the floor. He/She said this is an infection control concern. During an interview on 2/26/26 at 4:36 P.M., the administrator said he/she expects catheters to be up off the floor and not dragging. He/She said it is an infection control concern, and he/she expects staff to step in if they see tubing dragging. he/she believes signs should be placed on the doors to alert staff a resident is on EBP. He/She said anyone with a catheter, or wounds should be on EBP. He/She said he/she is new to the facility and is unsure why staff are not using EBP signs. During an interview on 2/26/26 at 4:28 P.M., the Director of nursing (DON) said catheter tubing should not drag the floor to prevent the spread of infections. He/She said he/she expects staff to keep an eye on catheter tubing as residents ambulate and correct it if they see the tubing dragging. Staff are made aware of who is on EBP residents during shift-to-shift report. He/She said anyone on catheters or have wounds should be on EBP. He/She said he/she was not aware signs needed to be posted.

Based on observation, interview, and record review, facility staff failed to provide appropriate care to meet basic hygiene needs for three dependent residents (Resident #8, #34 and #35), to include appropriate incontinent care, out of sampled residents. The facility census was 53.1.Review of the facility's policies showed staff did not provide a policy that addressed toileting/ incontinent care of dependent residents. 2. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 12/12/25, showed staff assessed the resident as follows: -Moderately impaired cognition; -Required mobility device - wheelchair; -Required substantial/maximal assistance with toilet transfer. toilet hygiene, both upper and lower body dressing and with putting on/taking off footwear; -Frequently incontinent of urine. -Diagnosed with Chronic Obstructive Pulmonary Disease, Constipation, Type II Diabetes Mellitus with hyperglycemia, Emphysema, Diabetes Mellitus due to underlying condition with diabetic chronic kidney disease, Essential (primary) hypertension, Presence of artificial eye-prosthetic right eye, Schizophrenia. Review of the resident's plan of care, dated 12/10/25, showed staff assessed the resident required the assistance of one staff with toileting. Did not contain an intervention for frequency of checking and/or changing incontinent resident or intervention for agitated behaviors or refusals of care. Review of the resident's Treatment Administration Records (TAR), dated 09/01/25 – 02/26/26, showed the record did not contain documentation of behaviors or interventions for the resident. Observation on 02/24/26 at 11:54 A.M., showed the resident in a wheelchair at the dining room table with a strong urine odor, a large wet area on the front of his/her pants and down each pant leg, and with puddling on the floor. Observation showed three staff members in the dining room preparing residents for lunch. Observation showed the resident ate lunch while he/she sat in wet pants. Observation on 02/25/26 at 12:02 P.M., showed the resident in a wheelchair at the dining room table with a strong urine odor. Observation on 02/25/26 at 2:45 P.M., showed the resident in a wheelchair at the dining room table with a strong urine odor. Observation on 02/25/26 at 3:34 P.M., showed the resident left the dining room via self-propelled wheelchair with a large wet area on the front of his/her pants. Observation on 02/25/26 at 3:41 P.M., showed the resident in a wheelchair at the entrance to his/her room. The resident yelled out, Can someone bring me a brief. Observation on 02/25/26 at 3:45 P.M., showed the Director of Nursing (DON) brought the resident a brief as requested. Observation showed no toileting assistance was provided. Observation on 02/25/26 at 4:04 P.M., showed the resident self-propelled to the dining room. A strong urine odor still present. During an interview on 02/25/26 at 4:05 P.M., the resident said, I had to change clothing and I'm wore out. The resident said no body helped with going to the bathroom or changing clothing. Observation on 02/26/26 at 12:49 P.M., showed the resident in a wheelchair at the dining room table with strong urine odor. During an interview on 02/26/26 at 12:51 P.M., Certified Nurse Assistant (CNA) H said he/she checks incontinent residents at least every two hours. The CNA said the resident will get agitated if the CNA's ask if he/she needs to go the bathroom and because of that some CNA's don't check on the resident often enough. During an interview on 02/26/26 at 1:15 P.M., the resident said staff only ask some of the time if he/she needs to go to the bathroom. The resident said, It makes me feel pretty bad when I'm left wet for too long. During an interview on 02/26/26 at 3:51 P.M., Registered Nurse (RN) I said staff should check on incontinent residents at least every two hours, and they should follow the care plan. The RN said the care plan should include interventions for checking incontinent residents, and staff should follow the care plan for ADL's of toileting. For residents needing behavior monitoring, the staff should document in the TAR any behaviors that were seen, what intervention was done and the result of the intervention. During an interview on 02/26/26 at 4:37 P.M., the DON said staff should check on incontinent residents every two hours. The DON said care plans should include interventions for checking incontinent residents every two hours, and staff should follow the care plan for ADL's of toileting. Staff should always document in the TAR any resident behaviors that were seen, what intervention was performed and the result of the intervention. During an interview on 02/26/26 at 5:10 P.M., the Administrator said that all incontinent residents should be checked at least every two hours. The administrator said the care plans should have an intervention for two-hour checks, and staff should be following the care plan for ADL's of toileting. Staff should document in the TAR any behaviors that are observed, what intervention they did, and the result of the intervention. 3.Review of Resident #34's Quarterly MDS, dated [DATE] , showed staff assessed the resident as: -admitted to facility on 01/25/24; -Frequently incontinent; -The resident did not reject care; -Dependent with toilet assist and transfer. Review of the resident's care plan, dated 02/12/25, showed staff are directed to assist the resident with peri-care and transfer to/from the toilet every two hours. The staff will check for incontinent episodes, change every two hours and as needed. Review of the resident's functional assessment ability, dated 02/04/26, showed, the resident is dependent with all toilet transfers as a two person assist. Observation on 02/24/26 at 1:47 P.M., showed the resident sat in the dining room with small puddle of wet substance under the resident's wheelchair, strong smell of urine and the resident's pants were wet. Observation on 02/24/26 at 2:04 P.M., showed the Activity Director (AD) pushed the resident to activity table. The resident's pants were wet, and a wet substance dripped from the resident's wheelchair. Observation on 02/25/26 at 11:01 A.M., showed the resident sat in his/her wheelchair in the dining room, with a wet substance on the floor under his/her wheelchair. The wet substance dripped from the resident's wheelchair as Certified Medication Technician L (CMT) administered his/her medications. Observation on 2/25/26 at 11:31 A.M., showed the resident spoke with Nurse Aide E (NA) while he/she sat in his/her wheelchair in the dining room with a large puddle under his/her chair. Observation on 02/25/26 at 11:50 A.M., showed staff served the resident lunch. Observation showed a large wet puddle under the resident's chair and strong smell of urine. During an interview on 02/25/26 at 12:32 P.M., the resident said he/she has been sitting in the dining room since about 8:00 A.M. The resident said he/she is unable to tell when he/she urinates. The resident said he/she feels bad and embarrassed because he/she is not able to help it. The resident said the staff usually change him/her when he/she wakes up, after lunch and at bedtime. The resident said staff are aware he/she is not able to control his/her bladder because the staff will let the resident know when he/she has urine under the dining room table. The resident said he/she is not able to transfer by themselves. He/She said the staff assist him/her to the toilet and change him/her. The resident said the staff usually do not ask him/her throughout the day if he/she needs changed. Observation on 02/26/26 11:59 A.M., showed the resident in the dining room with a large wet puddle under his/her wheelchair. During an interview on 02/26/26 at 12:19 P.M., CNA D said he/she does not know how often the resident is changed. He/She assumed the resident would tell him/her if he/she needed to use the bathroom. CNA D said he/she is unaware of the specifics related to the resident's assistive needs. CNA D said they usually change the resident after lunch. He/She does not check the resident every couple hours. During an interview on 02/26/26 at 3:55 P.M., CMT L said the staff try and change the resident every couple of hours at least, because CMT said he/she is aware, but he/she will not tell you. CMT said if he/she sees a resident's pants wet then he/she will take and change them if they are a one person assist. The CMT said the CNAs are responsible to ensure the residents are clean and dry. The CMT said the DON would monitor a residents' change in conditions. The staff tell the charge nurse of a resident's change in condition. The CMT said he/she is aware of the residents' incontinent issues as the resident is often wet. The CMT said he/she did not realize the resident was wet when he/she administered his/her medications. The CMT said he/she was aware the resident, at times, has puddles of urine under his/her wheelchair in the dining room. The CMT said the staff is not consistent with cares. The CMT said he/she expects the CNA's to check/monitor the resident every couple of hours. During an interview on 02/26/2026 4:24 P.M., RN I, said he/she expects CNA's to check on the resident's incontinence. RN said he/she notices the resident 34's urine on the floor in the dining room and he/she expects his/her staff to change him/her. Staff is expected to check on the residents every two hours or in between activities. RN said the CNA's should help the resident change his/her clothes. He/She said if the resident sat in his/her urine for several hours, the resident has potential to develop sores and skin breakdown on his/her bottom. RN said the charge nurses have oversight to ensure the resident's Activities of Daily Living ADL's are carried out and followed properly. During an interview on 02/26/26 at 5:11 P.M., the DON said he/she expects staff to follow resident's care plans/ADL's for toilet cares. The DON said he/she expects staff to check the resident every two hours. The DON said the resident is not aware when he/she is incontinent of bladder. The DON expects his/her staff to check or offer to take the resident to the restroom every two hours. The DON said staff remind the resident to shower. The DON said the CNA's check the residents to ensure they are clean, dry and smell good every two hours. The DON said he/she is responsible to ensure the ADL's are followed. 4.Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -The resident admitted on [DATE]; -The resident required substantial/maximum assistance from staff to maintain perineal hygiene, toileting and bathe; -The resident did not reject care.Review of the resident's care plan, dated 02/17/26, showed: - Diagnosis of incontinence without sensory awareness; -The resident to remain clean and dry after each incontinent episode; -The staff to reminds the resident to use the restroom regularly; -The staff assists the resident with dressing; -The staff assists the resident during incontinent episodes and toileting; -The staff assists the resident with showers once a week. Observation on 02/23/26 at 11:27 A.M., the resident sat in the dining room with wet pants and a large puddle under his/her [NAME] Observation on 02/24/26 at 10:01 A.M., the resident sat in a common chair near the exit door corridor of the courtyard. The resident wore the same pants, shirt, and jacket from yesterday. There was a strong odor present. During an interview on 02/24/26 10:02 AM., the resident said the staff help him/her shower. The resident said he/she feels embarrassed after he/she has an accident and is not aware when he/she is incontinent. The resident said he/she needs help with his/her pants, shoes and socks. The resident said he/she needs help with showers and is unsure how often he/she showers. The resident said he/she depends on the staff to help him change and shower. The resident said he/she did not refuse cares. Observation on 02/25/26 at 11:50 A.M., the resident sat in the dining room, with the grey t-shirt, blue sweatpants that exposed his/her bottom and smell of urine odor. The resident had small puddles under his/her chair. During an interview on 02/26/26 at 3:55 P.M., CMT L said he/she is unaware of any incontinent issues with the resident. CMT said he/she never provided hygiene or perineal cares for the resident. CMT said he/she reviews care plans at least every morning. CMT said he/she was unaware of the resident's overactive bladder diagnosis. During an interview on 02/26/2026 4:24 PM Registered Nurse (RN) I said he/she is not familiar with the resident and is not aware if staff check on him/her for incontinent cares. He/She said if the resident sat in his/her urine for several hours, the resident has potential to develop sores and skin breakdown on his/her bottom. 5.During an interview on 02/26/26 at 4:59 P.M., the Administrator said he/she expects his/her staff to follow all resident's ADL's. The administrator said he/she does not expect residents to set in his/her wet clothes for long periods. The administrator said if there is urine on the floor, he/she expects his/her staff to place a wet floor sign and change the resident. The Administrator said the resident's care plans match the ADL's and toileting/hygiene interventions. The Administrator said the DON is responsible to ensure the ADL's are followed

Based on observation, interview and record review, facility staff failed to ensure a medication error rate of less than five percent (%). Out of 34 opportunities observed, three errors occurred, resulting in a 9.68% error rate, which affected one resident (Resident #24) of eleven sampled residents. The facility census was 53. 1.Review of the facility's Medication Errors and Drug Reactions policy, undated, showed staff are directed to report all medication errors immediately to the physician, Director of Nursing (DON) and administrator. The policy did not contain a definition of a medication error. Review of the facility's Medication Administration Guidelines policy, undated, showed the physician's order must be verified before the medication is administered. The policy did not contain a definition of a medication error. Review of the facility's Medication Administration policy, undated, showed the policy did not contain a definition of a medication error. 2. Review of Resident #24's physician order sheet (POS), dated 2/26/26, showed the order sheet did not contain an order to crush medications. Observation on 2/26/26 at 8:05 A.M., showed certified medication technician (CMT) J administered nine of twelve pills to the resident, walked back to the medication cart and then crushed the remaining three pills before administering them to the resident. During an interview on 2/26/26 at 8:16 A.M., CMT J said the resident was having trouble getting all his/her pills down, so he/she crushed his/her medications to help. He/She said the resident sometimes has problems swallowing, so he/she crushes his/her medications before giving them. He/She said he/she thought the resident had an order for crushing medication as needed. He/She said he/she should not have crushed the medications. He/She said he/she is not supposed to crush medications without an order. During an interview on 2/26/26 at 4:28 P.M., the Director of Nursing (DON) said it is his/her expectation CMT and nurses have orders before administering medications. He/She said staff should not crush medications without an order. He/She said he/she would consider it a medication error because it is not administered according to the physician order. He/She said he/she would expect staff to notify the charge nurse and contact the physician and/or pharmacy if a medication error was made. He/She said he/she was not made aware of any medication errors during survey. During an interview on 2/26/26 at 4:36 P.M., the administrator said it is his/her expectation staff follow physician orders when administering medications. He/She said staff need an order to crush medications and should not crush them without an order. He/She said if an error is made, he/she would expect his/her staff to notify the charge nurse and DON right away so they could assess the resident and call the physician/pharmacy. He/She said he/she was not made aware of any medication errors during survey.

Based on interview and record review, facility staff failed to meet professional standards when staff failed to obtain proper Against Medical Advice (AMA) documentation for one resident (Resident #60) of one sampled discharge close record. The facility census was 53.1.Review of the facility's Leaving the Facility against Medical Advice policy (AMA) Release, undated, showed staff are directed when a resident or resident's legal representative expresses the desire to leave the facility before the attending physician has discharged the resident staff will: --Notify the physician; --Notify the administrator; --Notify the Director of Nursing (DON); -Document completion of leaving Facility Against Medical Advice release form; -Present form to resident or legal representative regardless of whether it is believed it is the resident or legal representative will sign it. The release should be offered for signature in the presence of witnesses: --If the resident refuses to sign: i.In the space provided for the resident's signature, write the words, Resident refused to sign. Beneath this line, sign your name and exact time, date, and give a brief notation concerning the circumstances of the refusal. ii.Place a summary of facts leading up to the incident and what occurred in the resident's medical record. 2. Review of Resident #60's Comprehensive Minimum Data Set Assessment (MDS), a federally mandated assessment tool, dated 12/10/25, showed staff assessed the resident as: -admission date of 12/10/25; -Cognitively intact; -Did not exhibit behaviors towards others physical, verbal, or other; -Did not refuse care. Review of the resident's nurse's notes, dated 12/11/25, showed: -At 12:33 P.M., the resident is upset about being at the facility and has clothes packed on his/her bed; -At 3:48 P.M., resident was upset about being at the facility and left against medical advice with his/her family member; -At 3:54 P.M., the physician and administrator were notified. Review of the resident's electronic medical record (EMAR) showed the record did not contain documentation an AMA release form was completed. During an interview on 2/25/26 at 2:42 P.M., the Social Services Director (SSD) said he/she was not working the day the resident left AMA. He/She does not have any documentation an AMA form was filled out. He/She said any time a resident wants to leave AMA a form should be filled out and signed by the resident. He/She said if the resident refuses to sign the form, staff should indicate that on the form. He/she does not know why the form was not signed. He/She was not notified the form was not signed. During an interview on 2/26/26 at 4:28 P.M., the DON said the resident didn't want to stay at the facility and left AMA. He/She said an AMA form should have been fileld out, he/she is not sure why it was not done. He/She said he/she is not sure what their policy says about resident refusals to sign. He/She said he/she would expect there to be notes in the system regarding why the form was not signed/filled out. During an interview on 2/26/26 at 4:36 P.M., the administrator said it is his/her expectation when a resident wants to sign out AMA that the physician and family are notified right away, and that the AMA form is followed and filled out. He/She said the AMA is important documentation because it contains all the steps of what staff should do in the event a resident wants to sign out AMA and documents important information. He/She was made aware of the situation during survey and was not aware before.

Based on observation, interview, and record review, facility staff failed to review and revise the plan of care for three residents (Resident #1, #2, and #23) out of 14 sampled residents. The facility census was 53.1. Review of the facility's Care Plan Comprehensive, undated, showed the assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition. The interdisciplinary care plan team is responsible for the periodic review and updating the care plans as follows: -When a significant change in the resident's condition has occurred; -At least quarterly; -When changes occur that impact the residents' care (i.e., change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment). 2. Review of Resident #1's Quarterly Minimum Data Set Assessment (MDS), a federally mandated assessment tool, dated 02/06/26, showed staff assessed the resident as: -Cognition not assessed; -Impairment on one side of upper extremity, impairment on both sides of lower extremity; -Dependent on staff for toileting, and shower/bathe; -Diagnosis of Paraplegia (impairment or loss of motor and sensory function in the lower half of the body), Monoplegia of upper limb affecting right dominant side (a form of paralysis affecting only on arm or leg). Review of the resident's care plan, dated 02/10/26, showed the plan did not contain documentation or interventions of the resident's contracture. Observation on 02/24/26 at 9:20 A.M., showed the resident in bed with his/her right hand contracted. Observation on 02/25/26 at 11:30 A.M., showed the resident in the dining room with his/her right hand contracted. Observation on 02/26/26 at 12:50 P.M., showed the resident in the common area with his/her right hand contracted. During an interview on 02/26/26 at 1:09 P.M., the Care plan coordinator said specific interventions for contractures should be on the care plan, and he/she was not aware the resident's contractures were not acknowledged on the care plan. During an interview on 2/26/26 at 4:07 P.M., Licensed Nurse Practitioner (LPN) C said the resident does have a right-hand contraction. He/She said he/she would expect to see the resident have an order for an intervention as well as see it documented on the care plan with interventions. During an interview on 2/26/26 at 4:36 P.M., the administrator said he/she would expect the resident's contractures to be addressed on the resident's care plan. 3. Review of Resident #2's comprehensive MDS, dated [DATE], showed staff assessed the resident as: -Moderate Cognitive impairment; -Had a pressure injury. Review of the resident's wound care note, dated 02/02/26, showed wound care for a wound to his/her right-side sacrum, left lateral foot, left lateral foot near 5th digit, and right heel. Review of the resident's care plan, dated 12/09/26, showed the plan did not contain interventions for the wounds or wound prevention. During an interview on 02/26/26 at 1:01 P.M., the Care plan coordinator said the resident's wounds should be addressed on the care plan with interventions. He/She said sometimes the information or changes are not communicated. He/She there were no orders or documentation of interventions that he/she is aware of and he/she believes that is why interventions were not addressed for the residents wound. During an interview on 02/26/26 at 4:04 P.M., Registered Nurse (RN) I said the resident has multiple wounds. He/She said he/she would expect the care plan to have interventions for the current wounds and for prevention of any further wounds. During an interview on 02/26/26 at 4:28 P.M., the Director of Nursing (DON) said the resident does have wounds. He/She said he/she would expect the wounds and interventions to be addressed on the care plan. He/She was not aware interventions were not addressed. During an interview on 2/26/26 at 4:36 P.M., the Administrator said he/she would expect the resident's wounds to be addressed on the care plan with interventions. He/She said interventions are important for the prevention of wounds. 4. Review of Resident #23's comprehensive MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -At risk for pressure ulcer/injury; -Diagnosis of peripheral vascular disease, chronic venous insufficiency (occurs when leg vein valves are damaged or weak, preventing efficient blood return to the heart, causing blood to pool in legs). Review of the resident's care plan, dated 01/09/26, showed the plan did not contain direction on how to care for the resident's lower leg edema and did not have interventions in place. Review of the Physician Order Sheet (POS), dated 02/18/26, showed an order to cleanse lower left calf wound with soap and water, pat dry, apply Gentamicin ointment to wound base, cover with an abdominal pad, and apply tubi-grip (a brand of elasticated, tubular, multi-purpose bandage used to provide, comfortable, and lasting, compression support for strains, sprains, and soft tissue injuries) size G to hold in place, three times daily and to place a gel foam cushion in his/her wheelchair. Observation on 02/23/26 at 11:09 A.M., showed the resident in his/her wheelchair with bilateral swollen and red legs. Observation on 02/24/26 at 11:19 A.M., showed the resident in his/her wheelchair with bilateral tubi-grips on his/her swollen lower legs. Observation on 02/25/2026 at 12:30 P.M., showed the resident in his/her wheelchair with bilateral swollen and red legs. Observation on 02/26/26 at 9:25 A.M., showed the resident in his/her wheelchair with bilateral swollen and red legs. During an interview on 02/26/26 at 1:01 P.M., the Care plan coordinator said edema should be addressed on the care plan. He/She said there should be interventions to keep legs elevated. He/She is not sure why it is not addressed on the care plan. He/She said sometimes resident changes get overlooked due to documentation or lack of communication. During an interview on 02/26/26 at 4:04 P.M., RN I said he/she would expect the care plans to include a continuous issue of edema. He/She said the resident does have issues with edema and he/she believes it should be addressed with interventions on the care plan. He/She said if there are frequent refusals of care or interventions those should also be addressed on the care plan. During an interview on 02/26/26 at 4:28 P.M., the DON said he/she would expect the resident's edema concerns to be addressed on the care plan with relevant interventions. He/She wasn't aware the care plan did not address the edema. During an interview on 02/26/26 at 4:36 P.M., the Administrator said he/she would expect the resident's edema to be addressed on the care plan. He/She said he/she would expect the care plan coordinator to have interventions in place for edema prevention and for it to address any refusals/behaviors associated.

Based on interview and record review, facility staff failed to update the Facility Assessment at least annually, failure to review the assessment within 12 months may result in the facility failing to identify a factor that would require a change to the assessment. The facility census was 53.1. Review of the Facility's Assessment, dated 12/04/24, showed the assessment did not contain documentation the assessment was reviewed for 2025 During an interview on 02/26/26 at 1:37 P.M., the administrator said she does not know why the facility assessment has not been reviewed and updated since 2024. The administrator said she is aware the assessment needs to be completed at least annually. During an interview on 03/04/26 at 9:50 A.M., the Director of Nursing (DON) said he/she was not aware the facility assessment had not been updated since 2024. The DON said the administrator would be responsible and he/she is not familiar with the facility assessment process.

Based on observation, interview, and record review, facility staff failed to provide care to meet the basic hygiene needs for six residents (Resident #1, #2, #3, #4, #5, and #6) out of six sampled residents who required assistance with showers. The facility census was 62. 1. Review of policies provided by facility staff showed the policies did not contain a shower policy. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/14/25, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required substantial to maximal assistance from staff for personal hygiene;-Dependent on staff for showers. Review of the resident's care plan, dated 10/08/25, showed staff documented the resident prefers one shower per week and as needed, and required assistance from two staff with a gait belt or mechanical lift if ordered to assist with transfer to shower chair. Review of the resident's electronic shower record, dated 08/01/25 through 08/31/25, showed staff documented the resident received a shower on 08/05/25 and 08/08/25.Review of the resident's electronic shower record, dated 09/01/25 through 09/30/25, showed staff documented the resident received a shower on 09/27/25, and refused a shower on 09/06/25.Review of the resident's electronic shower record, dated 10/01/25 through 10/19/25, showed staff documented the resident received a shower on 10/04/25, 10/11/25, and 10/18/25.Observation on 10/20/25 at 10:30 A.M., showed the resident in bed with greasy unkempt hair.During an interview on 10/20/25 at 10:30 A.M., the resident said staff are supposed to assist him/her with a shower two times per week, but he/she had not had a shower in two and a half weeks, and he/she feels yucky when he/she does not get a shower because he/she is often incontinent of bowel and bladder. He/She said he/she uses a washcloth to try and rub his/her hair, but it only does so much. He/She said it takes two people to transfer him/her for a shower, and he/she feels like staff don't want to be bothered to assist him/her.3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact;-Required partial to moderate assistance from staff for personal hygiene;-Required substantial to maximal assistance from staff for shower/bathe. Review of the resident's care plan, dated 11/19/24, showed the resident required assistance from one staff with bathing. Review of the resident's electronic shower record, dated 08/01/25 through 08/31/25, showed staff documented the resident received a shower on 08/06/25.Review of the resident's electronic shower record, dated 09/01/25 through 09/30/25, showed the record did not contain documentation the resident received a shower, or the resident refused any baths/showers. Review of the resident's electronic shower record, dated 10/01/25 through 10/19/25, showed staff did not document the resident received a shower, and did not document the resident refused any baths/showers. Observation on 10/20/25 at 9:04 A.M., showed the resident sat at the side of his/her bed with short greasy unkempt hair.During an interview on 10/20/25 at 9:04 A.M., the resident said staff are supposed to assist him/her with a shower two times per week, but he/she had not had a shower in two weeks. He/She said it makes him/her feel dirty and stinky when he/she must wait that long for a shower, so sometimes he/she uses a washcloth at the sink to freshen up, but he/she would feel better with an actual shower.4. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact;-Required substantial to maximal assistance from staff for personal hygiene;-Required substantial to maximal assistance from staff for shower/bathe. Review of the resident's care plan, dated 02/13/25, showed staff documented the resident prefers one shower per week and as needed, and requires assistance from two staff for bathing (includes transfer, not include wash back and hair). Review of the resident's electronic shower record, dated 08/01/25 through 08/31/25, showed staff documented the resident received a shower on 08/06/25.Review of the resident's electronic shower record, dated 09/01/25 through 09/30/25, showed the record did not contain documentation the resident received a shower, or the resident refused any baths/showers. Review of the resident's electronic shower record, dated 10/01/25 through 10/19/25, showed the record did not contain documentation the resident received a shower, or the resident refused any baths/showers. During an interview on 10/20/25 at 9:09 A.M., the resident said staff are supposed to assist him/her with a shower two times per week, which has not been happening because they skip us all the time. He/She said the last time staff assisted him/her with a shower was two weeks ago, and before that, he/she went about four to five weeks without a shower. He/She said he/she does not refuse a shower because he/she wants to receive showers but needs help, and his/her hair feels rough when dirty, and is looking lousy now. 5. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment;-Required substantial to maximal assistance from staff for personal hygiene;-Required substantial to maximal assistance from staff for shower/bathe. Review of the resident's care plan, dated 11/27/24, showed staff documented the resident would like one shower per week and as needed, and required assistance from one to two staff for bathing. Review of the resident's electronic shower record, dated 08/01/25 through 08/31/25, showed the record did not contain documentation the resident received a shower, or the resident refused any baths/showers. Review of the resident's electronic shower record, dated 09/01/25 through 09/30/25, showed staff documented the resident received a shower on 09/22/25 and 09/29/25. Review of the resident's electronic shower record, dated 10/01/25 through 10/19/25, showed staff documented the resident received a shower on 10/03/25. Observation on 10/20/25 at 9:16 A.M., showed the resident laid in bed with greasy unkempt hair and unkempt facial hair. During an interview on 10/20/25 at 9:16 A.M., the resident said he/she liked his/her facial hair, but he/she needed a shower to make him/her feel clean and fresh. He/She said staff are supposed to assist him/her with a shower two times per week, but he/she had not had a shower for about three weeks. 6. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, and dependent on staff for personal hygiene and shower/bathe.Review of the resident's care plan, dated 08/21/25, showed staff documented the resident would like one shower per week and as needed, requires total assist from one staff for bathing (includes transfer, not include wash back and hair), and staff to assist the resident with going into the shower room, gathering items and adjusting water.Review of the resident's electronic shower record, dated 08/01/25 through 08/31/25, showed staff documented the resident received a shower on 08/21/25. Review of the resident's electronic shower record, dated 09/01/25 through 09/30/25, showed the record did not contain documentation the resident received a shower, or the resident refused any baths/showers. Review of the resident's electronic shower record, dated 10/01/25 through 10/19/25, showed the record did not contain documentation the resident received a shower, or the resident refused any baths/showers. Observation on 10/20/25 at 9:28 A.M., showed the resident with greasy unkempt hair in a reclined wheelchair in front of the hallway television. 7. Review of Resident 6's Significant Change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment;-Required partial to moderate assistance from staff for personal hygiene;-Required substantial to maximal assistance from staff for shower/bathe. Review of the resident's care plan, revised 07/02/25, showed staff documented the resident prefers one shower per week and as needed, required assistance from one staff with gait belt to transfer to shower chair and to assist the resident with bathing (includes transfer, not include wash back and hair). Review of the resident's electronic shower record, dated 08/01/25 through 08/31/25, showed staff documented the resident received a shower on 08/20/25.Review of the resident's electronic shower record, dated 09/01/25 through 09/30/25, showed staff documented the resident received a shower on 09/04/25, 09/22/25, and 09/29/25.Review of the resident's electronic shower record, dated 10/01/25 through 10/19/25, showed staff documented the resident received a shower on 10/03/25.Observation on 10/20/25 at 8:46 A.M., showed the resident went up and down the hallways in his/her wheelchair with greasy, unkempt hair, food debris on his/her shirt, and dark brown stains on his/her pants. Observation on 10/20/25 at 9:38 A.M., showed the resident went up and down the hallways in his/her wheelchair with greasy, unkempt hair, food debris on his/her shirt, and dark brown stains on his/her pants. 8. During an interview on 10/20/25 at 4:04 P.M., Certified Nurse Aide (CNA) C said he/she is the shower aide and works 12-hour shifts. CNA C said he/she assists residents with showers from 7:00 A.M. to 3:00 P.M., and works the floor from 3:00 P.M. to 7:00 P.M. CNA C said he/she tries to do as many showers as he/she can during the day but sometimes he/she can't get all the showers completed. CNA C said staff should document showers in the Electronic Medical Record (EMR) but if it gets too busy, he/she doesn't do it. He/She said if a resident refuses a shower, he/she should tell the charge nurse or Director of Nursing (DON) and that should also be documented in the EMR. He/She said the residents who require two staff to assist are hard to get done, because they take more time and there aren't always two staff available to assist. During an interview 10/20/25 on at 4:28 P.M., Registered Nurse (RN) A said staff are expected to offer residents two showers per week, the CNAs are expected to tell the nurse if a resident refuses a shower, and the nurse would try to get the resident to shower. During an interview on 10/20/25 at 1:50 P.M., the DON said staff are expected to offer residents a shower two times per week, and he/she expects each resident to be assisted with at least one shower per week. The DON said if a resident refuses his/her shower, staff should first try to re-approach, have the resident sign refusal on paper, tell the nurse, document the refusal in the computer, and the nurse should complete a progress note. He/She said if staff did not document the resident refused his/her shower, it is likely staff did not offer or assist the resident with a shower/bath. During an interview on 10/20/25 at 4:45 P.M., the Administrator said the residents get showers at least once a week, but the expectation is two times a week, and staff are expected to document showers in the residents' medical record. The administrator said he/she has not reviewed the shower documentation in the EMR recently, but he/she visually monitors residents and directs staff to assist residents with hygiene needs. Complaint # 2620436, 2645723

Based on observation, interview and record review, facility staff failed to meet professional standards of care when staff failed to document an assessment of new wounds and obtain treatment orders from the physician for one resident (Resident #7) out of two sampled residents with pre-existing wounds. The facility census was 62.1. Review of the facility's Pressure Ulcer Care and Prevention policy, undated, showed the purpose is to prevent and treat further breakdown of pressure ulcers, and the nurse is responsible to provide the treatment as ordered by the attending physician and to implement measures for pressure ulcer prevention. Review of the facility's Wound Care and Treatment policy, undated, showed the purpose is to prevent and treat all wounds, and there must be a specific order for the treatment. 2. Review of Resident #7's Significant Change Minimum Data Set (MDS), a federally mandated assessment, dated 10/16/25, showed staff assessed the resident as follows: -Severe cognitive impairment;-At risk for developing pressure ulcers;-Had one or more unhealed pressure ulcers;-Received hospice care. Review of the resident's care plan, revised 10/14/25, showed staff assessed the resident with wounds to his/her sacrum, left buttock, right hip, and left back. Review of the resident's weekly skin assessment note, dated 10/07/25, showed staff documented the resident was evaluated by the mobile wound physician. Orders to continue treatments to coccyx, left mid back, bilateral hips., and recommendation to add antimicrobial dressing (provides wound protection, absorbs moisture, and treats bacteria in wounds) to right hip. Notified administration of recommendation for antimicrobial dressing and resident's family notified of new orders. Review of the resident's weekly skin assessment note, dated 10/15/25, showed staff documented the resident reported pain in both knees, crying out, administered pain medication, dressings changed to both hips, left flank (between the ribs and hip), coccyx and right buttock per order. Observed new deep tissue injury to left medial knee measuring five-centimeter (cm) x three cm, applied skin prep (a dressing to protect skin from moisture, adhesive, and friction). Observed a scabbed area to right lower leg measuring 2.2 cm x 1.2 cm, applied skin prep. Per DON, hospice will be in to see resident the next day. Review of the resident's Physician's Order Sheet (POS), dated 10/15/25 through 10/19/25, showed the POS did not contain documentation of a physician's ordered wound treatment for the resident's right inner knee and left heel. Review of the resident's Treatment Administration Record (TAR), dated 10/15/25 through 10/19/25, showed the TAR did not contain documentation staff provided wound treatments to the resident's right inner knee and left heel. Review of the resident's progress notes, dated 10/17/25 through 10/19/25, showed the record did not contain documentation staff assessed, or initiated interventions to treat new wounds to the resident's right inner knee and left heel. Observation on 10/20/25 at 11:15 A.M., showed resident in bed on his/her left side with knees contracted together, heels directly on the air mattress, a dressing to the right outer leg and left inner knee dated 10/19/25, and an undated dressing to his/her right hip. Observation on 10/20/25 during wound care from 12:14 P.M. to 1:30 P.M., showed hospice Registered Nurse (RN) G completed treatments to wounds on the resident's right hip, right buttock, coccyx, right outer leg, left inner knee, right inner knee, left lower back, left hip, and reinforced an undated foam dressing to the resident's left heel which was soft and spongy. During an interview on 10/20/25 at 12:48 P.M., hospice RN G said RN A reported to him/her the wound to the resident's right inner knee must have appeared over the weekend, and there wasn't a treatment order for the left heel. Hospice RN G said he/she received orders from RN A to treat the resident's right and left inner knees. During an interview on 10/20/25 at 1:18 P.M., the Director of Nursing (DON) said he/she assessed the resident's wounds on 10/17/25, and there was redness to the resident's right inner knee. The DON said he/she applied skin prep, placed a blanket between the resident's knees and directed the aides to float the resident's heels. He/She said he/she passed on the information in report to the oncoming nurse, but did not document an assessment of the resident's skin other than on the TAR. During an interview on 10/20/25 at 4:21 P.M., RN A said a facility nurse in collaboration with the hospice nurse completes the treatments to the resident's wounds daily and documents on the TAR. RN A said if the nurse identifies a new wound/skin concern, the nurse is expected to document an assessment (measurement, color, drainage, odor), notify the DON, and obtain orders from the physician. RN A said he/she did not personally assess the resident's wounds earlier in the day, but he/she took the recommendations from hospice RN G and contacted the physician for orders. During an interview on 10/20/25 at 3:55 P.M., the DON said he/she would expect the nurses to complete a skin assessment on the resident daily with scheduled wound care and document any new skin concerns. The DON said he/she would expect to see a progress note dated 10/18 or 10/19 regarding any new skin concerns and what staff did about it. During an interview on 10/22/25 at 12:32 P.M., the resident's physician said he/she considered the resident's wounds highly unavoidable but would expect if staff identified new skin concerns/wounds, staff would assess the resident and obtain a treatment. The physician said he/she had deferred the resident's wound management to a mobile wound care provider, but if the wound care provider was not available to give an order for treatment, staff could have contacted him/her for an order.Complaint# 2634421

Based on observation, interview and record review, facility staff failed to ensure one resident (Resident #1) out of three sampled residents received timely assistance to schedule an appointment with a dentist, after the resident reported he/she had broken teeth and an intermittent toothache. The facility's census was 62.1. Review of the facilities policies showed facility staff did not provide a policy for dental care and services.2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 10/14/25, showed staff assessed the resident as moderate cognitive impairment, with mouth or facial pain, and discomfort or difficulty with chewing.Review of the resident's care plan, revised 10/08/25, showed staff assessed the resident has his/her own teeth, with missing or broken teeth, and required staff assistance for oral care as needed.Review of the resident's Physician's Order Sheet (POS), dated 09/01/25 through 10/20/25, showed may see dentist (to treat issues with the mouth/teeth) as needed.Review of the resident's progress note, dated 09/03/25, showed staff documented the resident requested PRN (as needed) pain medication for tooth pain this evening. PRN acetaminophen (pain medication) was brought into his/her room.Review of the resident's progress note, dated 09/05/25, showed staff documented resident upset and yelling related to his/her tooth, stating he/she needed something for the pain, the nurse offered the resident Tylenol.Review of the resident's progress note, dated 09/18/25, showed staff documented resident upset at beginning of shift, stating he/she has tooth pain which was not relieved by the acetaminophen that was given earlier in day, he/she had over-the-counter pain gel that was confiscated two weeks, and his/her pain is a chronic issue. Slight swelling observed to right side of face, physician notified and gave order for Hydrocodone (a narcotic pain medication), resident reports he/she has multiple dental complaints and needs his/her teeth extracted.Review of the resident's progress notes, dated 09/03/25 through 10/19/25, showed the notes did not contain documentation staff attempted to schedule a dental appointment for the resident.Observation on 10/20/25 at 10:30 A.M., showed the resident's mouth with three to four broken upper front teeth. During an interview on 10/20/25 at 10:30 A.M., the resident said he/she had issues with tooth decay, broke a tooth a few months ago, and reported to staff several weeks ago he/she was having frequent toothaches. He/She said staff took his/her over the counter pain gel and have been giving him/her acetaminophen for the pain. He/She said he/she did not know if staff had tried to schedule an appointment for him/her to see a dentist yet.During an interview on 10/20/25 at 2:33 P.M., the Social Worker (SW) said he/she is responsible to schedule dental appointments for residents either at the facility or outside the facility based on the resident's specific oral concerns and insurance. The SW said he/she was notified about a month ago during a morning meeting that the resident had complained of dental issues, but he/she had not met with the resident yet to see what his/her specific dental concerns are and have not attempted to schedule a dental appointment for the resident. The SW said he/she did not have a specific reason for not attempting to schedule an appointment before but knew he/she would have to find a dentist that could accommodate the resident. During an interview on 10/20/25 at 3:55 P.M., the DON said the SW is responsible to schedule dental appointments for residents either at the facility or outside the facility based on specific oral concerns and insurance. The DON said he/she would have expected the SW to attempt to make a dental appointment for the resident by now.During an interview on 10/20/25 at 4:45 P.M., the administrator said the SW is responsible to schedule dental appointments for the residents. The administrator said he/she and other staff have addressed multiple concerns for the resident and was not aware of any specific dental concern for the resident that had not been addressed by staff, but he/she would expect staff to attempt to schedule a dental appointment for the resident if needed.During an interview on 10/22/25 at 12:32 P.M., the resident's physician said he/she was notified a few weeks ago the resident complained of a toothache, and he/she ordered pain medication to relieve the resident's pain. The physician said he/she would expect staff to attempt to schedule the resident to see a dentist to address his/her dental concerns.Complaint #2620436

Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #1) remained free from physical abuse when Resident #2 with a history of physical aggression punched Resident #1 in the face which resulted in bruising to his/her eye. The facility census was 65.Review of the facility's abuse and neglect policy, undated, showed staff are directed that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. Residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection.1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 04/04/25, showed staff assessed the resident with severe cognitive impairment.Review of the resident's nurse's notes, 04/17/25 at 04:16 A.M., showed staff documented Resident #1 reported he/she was shoved by Resident #2.Review of the resident's nurse's notes, 05/03/25 at 1:28 P.M., showed staff documented a yelling altercation occurred between Resident #1 and Resident #2 over a chair in the day room.Review of the resident's plan of care, dated 5/12/25, showed staff assessed the resident with behavior disturbances due to intellectual disabilities. Review showed staff did not document the altercations with Resident #2 or interventions to direct staff on how to handle them and did not contain information to direct staff related to abuse.Review of the resident's nurse's notes, 05/27/25 at 12:27 A.M., showed staff documented Resident #2 entered Resident #1's room and Resident #1 started screaming he/she choked me, he/she hit me. Nurse assessment of Resident #1's skin showed red mark on side of neck. Resident #1 cried throughout assessment. Review of the resident's nurse's notes, 06/26/25 at 6:07 A.M., showed staff documented Resident #1 with a black eye and bruising to his/her shoulders. Physician and DON notified. Staff documented Resident #1 said Resident #2 hit him/her. Observation on 6/30/25 at 2:00 P.M., showed the resident in his/her room, his/her left eye had black discoloration around the eye and the white of the eye was red. 2. Review of Resident #2's MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment.Review of the resident's plan of care, dated 1/20/25, showed staff did not document the altercations with Resident #1 and did not contain anything to direct staff on abuse.Review of the resident's nurse's notes, dated 04/17/25, showed staff documented Resident #2 shoved Resident #1. Review of the resident's nurse's notes, dated 05/15/25, showed staff documented Resident #2 told Resident #1, Don't yell at me I'll drag your ass outside, you loud son of a bitch.Review of the resident's nurse's notes, dated 05/27/25, showed staff documented Resident #2 was physically aggressive with Resident #1, because he/she stated he/she was trying to get Resident #1 out of his/her room.Review of the resident's nurse's notes, dated 05/27/25, showed staff documented at 12:20 A.M. Resident #2 entered Resident #1's room and nurse heard Resident #1 scream out he/she is choking me and hitting me.Review of the resident's nurse's notes, dated 06/29/25, showed staff documented Resident #1 was at the nurse's desk tearful and calling out wanting copies. Resident #2 comes up toward the desk and said, I'm going to beat the fuck out of him/her.During an interview on 06/30/25 at 2:07 P.M., Resident #2 said he/she had an altercation with Resident #1, due to Resident #1's mouth. Resident #2 said it was two or three in the morning. Resident #2 said he/she knocked on Resident #1's door and told Resident #1 to knock it off. Resident #2 said then Resident #1 threw a fit and Resident #2 said he/she hit Resident #1. 3. During an interview on 06/30/25 at 3:30 P.M, the Nurse Practitioner (NP) said on 06/27/25 he/she voiced concern Resident #1 was potentially hit by Resident #2The NP said what Resident #2 has done to Resident #1, he/she would consider abuse. During an interview on 06/30/25 at 5:22 P.M., Registered Nurse (RN) B said when he/she came in on 6/27/25 at 7:00 A.M. Resident #1 had a black eye, the resident reported yes to someone hitting him/her the night prior. The RN said knowing the previous altercations between the two residents, he/she would say it is not safe for the two resident's rooms to be next to each other. The RN said he/she would consider hitting abuse. During an interview on 07/02/25 at 8:32 A.M., the administrator said when Resident #2 said he/she hit Resident #1 he did not necessarily believe it. During an interview on 07/02/25 at 9:17 A.M. the DON said he/she does not remember anything being reported to him/her, about Resident #2 hitting Resident# 1. The DON said that would have been a big deal. The DON said staff did call him/her when he she pulled into the facility on [DATE] about Resident #1's black eye and he/she immediately went back on the unit and Resident #1 was sitting on his/her bed. The DON said there had been with multiple incidents between the two residents A resident saying another resident hit them, is an allegation of abuse. complaint #1579387

Based on observation, interview, and record review, facility staff failed to update the plan of care with changes in the resident's behaviors and measurable interventions for one resident (Resident #2) out of four sampled residents. The facility census was 65.1. Review of the facility's Comprehensive Care Plan policy, dated March 2015, showed an individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment tool. Assessment of each resident is an ongoing process, and the care plan will be revised as changes occur in the resident's condition. The interdisciplinary care plan team is responsible for the periodic review and updating of care plans when changes occur that impact the resident's care. 2. Review of Resident #2's MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment. Review of the resident's care plan, dated 01/20/25, showed staff did not assess the resident with behaviors and did not document interventions to direct staff on how to handle them. Review of the resident's nurse's notes, showed staff documented the following: -04/17/25: The resident shoved another resident;-05/15/25: The resident told another resident, Don't yell at me I'll drag your ass outside, you loud son of a bitch.;-05/27/25: The resident had been physically aggressive with another resident; had been physically aggressive with another resident.-05/27/25: The resident entered another resident's room, and the nurse heard the other resident scream out he/she is choking me and hitting me. -06/29/25: The resident told another resident I ' m going to beat the fuck out of him/her. During an interview on 06/30/25 at 2:07 P.M., the resident said he/she had an altercation with another resident, and he/she hit the other resident. During an interview on 07/09/25 at 10:40 A.M., Certified Nurse Aide (CNA) K said if a resident has verbal or physical behaviors directed at others it should be in the resident's care plans. During an interview on 07/09/25 at 10:45 A.M., Registered Nurse (RN) D said if a resident has physical or verbal behaviors directed towards others it should be care planned. During an interview on 07/09/25 at 10:51 A.M., The MDS Coordinator said if a resident has behaviors, the behaviors should be coded on the MDS, so all the staff know. The MDS Coordinator said besides nurses' notes, he/she is not sure where staff documents the behaviors. The MDS Coordinator said if he is told about the behaviors, he/she will ensure it is on the care plan. Care plans should highlight the type of behavior, so staff know what they are monitoring for. The care plan should have interventions for the behaviors and be updated with new behaviors and new interventions for staff. The MDS Coordinator said he/she does not know why the resident's care plan did not have behaviors listed with interventions, it should have. The MDS Coordinator said he/she is responsible for updating the care plans. During an interview on 07/10/25 at 10:57 A.M., the Director of Nursing (DON) said a resident's physical and verbal behaviors should be on the care plan. The DON said behavioral interventions should be on the resident's care plan. The DON said he/she doesn't know why the resident's behaviors and interventions had not been care planned, unless the MDS Coordinator was not notified. The DON said the behaviors and interventions should have been care planned for the resident's behaviors. During an interview on 07/09/25 at 11:08 A.M., the administrator said resident behaviors should be care planned and there should be interventions for the behaviors. The administrator said he/she did not specifically know why the resident's behaviors and interventions had not been care planned, but assumed it was because it had not been reported. Complaint #1579387

Based on interview, and record review, the facility staff failed to report an allegation of abuse for one resident (Resident #1) out of four sampled residents within in two hours to the administrator and the Department of Health and Senior Services (DHSS). The facility census was 65.1. Review of the facility's Abuse and Neglect policy, undated, showed all allegations of abuse will be reported no later than two hours to the State Survey Agency and if applicable law enforcement.2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 04/04/25, showed staff assessed the resident with severe cognitive impairment.Review of the resident's nurse's notes, 06/26/25 at 6:07 A.M., showed staff documented Resident #1 with a black eye and bruising to his/her shoulders. Review showed staff documented the resident said someone hit him/her. Physician and DON notified.Review of the resident's nurse's notes, dated 6/26/25 to 07/09/25, did not contain documentation staff notified DHSS of the allegation of abuse within the required two hours.During an interview on 07/02/25 at 10:44 A.M., Licensed Practical Nurse (LPN) E said he/she called the Director of Nursing (DON) and told the DON about the resident's black eye and told the DON he/she could not make out what happened to the resident. The LPN said told DON the resident said someone hit him/her. The LPN said he/she even asked the DON if this is reportable to the state and the DON said No, he/she will come in and talk to the resident.During an interview on 07/09/25 at 10:45 A.M., Registered Nurse (RN) D said if staff hear an allegation of abuse, or see it, staff will investigate and report it if the investigation comes back there is actual abuse. The RN said the facility has two hours to report abuse to state health agency. During an interview on 07/10/25 at 10:57 A.M., the Director of Nursing (DON) said he/she has two hours to report abuse, or allegations of abuse to state health agency. The DON said he/she was not told about the allegations of abuses in the nurse's notes, so he/she did not report the allegation to the state agency. During an interview on 07/09/25 at 11:08 A.M., the administrator said the facility has two hours to report abuse, or allegations of abuse to state health agency. The administrator said staff should report allegations of abuse or abuse to their immediate supervisor and then it is forwarded up the chain to him/her. The administrator said the allegation of abuse were not reported to state, because the allegations had not been reported to the DON or himself/herself. The administrator said if he/she had been made aware, he/she would have reported to state.Complaint #1579387

Based on interviews and record reviews, facility staff failed to initiate and complete a thorough investigation of alleged resident to resident abuse for one resident (Resident #1). The facility census was 65.1. Review of the facility's Abuse and Neglect policy, undated, showed when an incident of abuse is reported the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: Who was involved; Resident's statements; Resident roommates' statements; Interviews obtained from 3-4 three to four residents; Involved staff and witness statements of events; A description of the resident's behavior and environment at the time of the incident; Injuries present including a resident assessment; Observation of resident and staff behaviors during the investigation and environmental considerations. The designated personnel will begin the investigation immediately.2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 04/04/25, showed staff assessed the resident with severe cognitive impairment.Review of the resident's nurse's notes, 06/26/25 at 6:07 A.M., showed staff documented the resident had a black eye and bruising to his/her shoulders. Review showed staff documented the resident said someone hit him/her. The nurse's note did not contain documentation staff investigate the black eye and bruising. Review of the resident's nurse's notes, dated 6/26/25 to 07/09/25, did not contain documentation the facility completed an investigation. During an interview on 07/02/25 at 10:44 A.M., Licensed Practical Nurse (LPN) E said he/she called the Director of Nursing (DON) to inform of the resident's black eye and told the DON he/she could not make out what happened to the resident. The LPN said he/she did tell the DON the resident said someone hit him/her. LPN E said he/she does not do investigations the DON is responsible to start them once they report to his/her. During an interview on 07/02/25 at 9:17 A.M. the DON said staff did call him/her when he/she pulled into the facility about the resident's black eye and he/she immediately went back on the unit. He/She said the resident was sitting on his/her bed. The DON said he/she asked what happened, and he/said he/she did it. The DON said he/she did not do a formal investigation with all the paperwork, because the resident hits himself/herself all the time, he/she would be filling out paperwork all day. During an interview on 07/09/25 at 11:08 A.M., the administrator said if a resident says another resident hit them, it's an allegation. The administrator said staff should report allegations of abuse or abuse to their immediate supervisor and then it is forwarded up the chain to him/her. The administrator said abuse investigations should be taken care of as soon as the abuse is reported but depends on if you're talking about abuse or an allegation of abuse. The administrator said the allegations of abuse were not investigated or reported to state, because the allegations had not been reported to the DON or himself/herself. incident #1579387

Based on observation, interview, and record review, facility staff failed to provide protective oversight for one cognitively impaired resident (Resident #1) with a history of elopement, when facility staff left the transport van keys in the vehicle and the resident with a history of exit seeking, wandering and elopement attempts eloped from the facility, got into the facility van, and drove nine miles. Facility staff were not aware the resident was missing. The facility census was 63. The administrator was notified on 1/22/25 at 3:17 P.M., of an Immediate Jeopardy (IJ) which began on 1/18/25. The IJ was removed on 1/22/25, as confirmed by surveyor onsite verification. Review of the Facility's Elopement Policy, undated, showed staff are directed as follows: -Determine when resident was last seen and by whom, description of their clothing, and where last seen; -Notify all departments and begin a thorough search of the facility and grounds, including bathroom storage areas, and crawl spaces; -Search streets and neighborhoods adjacent to facility; -Notify Director of Nursing and Administrator; -Notify attending physician; -Notify responsible party, and request notification if resident makes contact with them; -If absence exceeds 30 minutes, notify law enforcement agency and give dispatch all the residents identifying information. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/08/24, showed staff assessed the resident as follows: -Cognitively impaired; -Suffers from delirium (a temporary state of mental confusion and disorientation that can cause significant changes in behavior, thinking, and perception); -Wanders daily; -Inattention and disorganized thinking that comes and goes. Review of the resident's elopement/wandering assessment form, dated 06/26/24, showed staff documented the resident as a one, a low elopement risk. Review of the resident's nurses notes, dated 8/8/24, showed staff documented the resident activated the fire alarm system and exited the dining room door, resident brought back into the facility without incident. Review of the resident's nurses notes, dated 9/30/24, showed staff documented the resident tried to get out the hall door and did exit the 400 hall door and was returned to the center. Review of the resident's care plan, dated 12/18/24, showed no interventions were put into place for the resident's elopement and exit seeking behavior after the 8/8/24 and 9/30/24 incidents. Review of the resident's elopement/wandering assessment form, dated 10/04/24, showed staff did not complete the assessment form. Review of the resident's elopement/wandering assessment form, dated 01/07/25, showed staff did not complete the assessment form. Review of resident's nurses notes, dated 1/8/25 at 2:12 P.M., showed staff documented the resident wanders about the facility and at times trying to get out the doors. Review of resident's nurses notes, dated 1/13/25 at 9:44 A.M., showed staff documented the resident up wandering around facility today. Review of resident's nurses notes, dated 1/14/25 at 12:26 P.M., showed staff documented the resident wandered around door to door and looking out windows. Review of resident's nurses notes, dated 1/16/25 at 4:02 A.M., showed staff documented the resident does wander the hallways, going to the exit doors, and looks out and at times will push on the doors. Review of the resident's care plan, dated 12/18/24, showed no documented interventions for elopements or the resident's exit seeking behaviors. Review of the resident's nurses notes, dated 1/18/25, showed staff documented Certified Nursing Assistant (CNA) B reported the local Sheriff on the phone, the officer reported being at a residential house on Highway 52 and evaluating the safety of Resident #1. Will return call and discuss safety. Spoke with resident's family on the phone about coming to facility for the resident's return. Officer returned call to come get the resident. Sent CNA B and van driver to return resident to facility. He/She arrived safely without injury. Physical and mental assessment within normal limits. Review of the facility's investigation, dated 1/18/25, showed Resident #1 exited the facility and drove the facility van to a residential area where a homeowner contacted the local Sheriffs office. The resident was picked up by facility staff. Did not have injuries. During an interview on 1/22/25 at 9:39 A.M., the administrator said the resident was exit seeking and did go to doors often. Staff know to redirect the resident. The resident had eloped once, but did not make it off the property. The resident often talks about going home to be with his/her brother and dog. The administrator said on 1/18/25 he/she did not know how the resident got out of the building, if an alarm was set off, or if the resident was let out by a guest. The administrator said he/she did not know how the resident drove the company van, because he/she had delusions and was not of sound mind. He/She said the keys were left in the van the previous day by the transport driver. During an interview on 1/22/25 at 10:07 A.M., the transport driver said he/she takes full responsibility for leaving the keys in the van. He/She was in a hurry and did not realize they were left in there. He/She does not know how the resident drove the van because he/she is not cognitive to do so. He/she does not know how the staff at the facility did not catch the resident leaving, because everyone knows to watch him/her, because he/she was constantly exit seeking and wanting to go home. During an interview on 1/22/25 at 10:43 A.M., CNA B said he/she gave the resident a shower and took him/her to the dining room for lunch, unsure of the exact time. He/She then left for his/her own lunch break, and was not sure what time it was. He/She came back from his/her lunch break after 25-30 minutes on 1/18/25 through the employee entrance and heard a faint door alarm. CNA B said he/she started to check doors for residents and found the door alarm at the end of the 100 hall was tripped. He/She said Resident #2 was by the door, but he/she checked outside and did not see any other residents. CNA B said CNA C told him/her to check for the resident because he/she is always exit seeking, CNA B said he/she turned off the alarm and went to the nurses station to look for the resident and that is when the sheriff's office called that they had the resident. He/She said the resident was known for trying to leave the building. During an interview on 1/22/25 at 10:25 A.M., Registered Nurse (RN) A said he/she was on the unit when CNA B came to him/her and said the sheriff's department was on the phone and the resident was missing. RN A said he/she could not say how long the resident was gone or if the alarm went off when he/she left. He/She said the resident was not cognitively intact to operate a vehicle and often had delusions. He/She said the resident had eloped before and had exit seeking behaviors and was very fixated about what was outside. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote the facility has complied with State law (Section 198.026.1 RSMo.) requiring prompt remedial action to be taken to address Class I violation(s). MO00248228 / MO00248234

Based on interview and record review, facility staff failed to accurately complete elopement assessments for one resident (Resident #1), who staff identified as a resident who wanders daily. The facility census was 63. Review showed the Facility's Elopement Policy, undated, did not direct staff on how to complete an elopement assessment. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool used to assess resident, dated 10/08/24, showed staff assessed the resident as follows: -Cognitively impaired; -Suffers from delirium (a temporary state of mental confusion and disorientation that can cause significant changes in behavior, thinking, and perception); -Wanders daily; -Inattention and disorganized thinking that comes and goes. Review of the resident's elopement/wandering assessment form, dated 06/26/24, showed staff documented the resident as a one, a low elopement risk. Review of the resident's elopement/wandering assessment form, dated 10/04/24, showed staff did not complete the assessment form. Review of the resident's elopement/wandering assessment form, dated 01/07/25, showed staff did not complete the assessment form. Review of resident's nurses notes, dated 1/8/25 at 2:12 P.M., showed staff documented the resident wanders about the facility and at times trying to get out the doors. Review of resident's nurses notes, dated 1/13/25 at 9:44 A.M., showed staff documented the resident up wandering around facility today. Review of resident's nurses notes, dated 1/14/25 at 12:26 P.M., showed staff documented the resident wandered around door to door and looking out windows. Review of resident's nurses notes, dated 1/16/25 at 4:02 A.M., showed staff documented the resident wanders the hallways, going to the exit doors, and looks out, and at times will push on the doors. During an interview on 1/22/25 at 11:30 A.M., the Director of Nursing (DON) said the resident has had three incomplete or incorrect elopement assessments since he/she has been here. The first elopement assessment, dated 6/24/24, showed the resident scored a one, a low elopement risk, which is inaccurate. The DON said he/she expected for an assessment to be redone if it was inaccurate, because from day one the resident showed signs of elopement and exit seeking behavior. The resident has had two more elopement assessments, dated 10/4/24 and 01/07/25, and both were not completed. He/She said the MDS/Assessment coordinator is responsible for all elopement assessments and does not know why they were not completed as required. During an interview on 1/29/25 at 9:34 A.M., the MDS/Assessment coordinator said he/she has only been at the facility for five months and was instructed to open the assessments. He/She said the nurses fill out the elopement assessments and then he/she or the DON goes in and completes them. He/She said the resident's elopement assessments must have fallen through the cracks. During an interview on 2/3/25 at 10:53 A.M., the DON said the nurses are only responsible for filling out and completing the resident's first admission elopement assessment, the MDS/Assessment coordinator is responsible for quarterly and annual assessments. He/She said the admission assessment is filled out with the knowledge the facility received upon admission and fourteen days later when the care plan is completed. The admission assessment should be redone if not accurate when there is a clearer picture of the resident's behavior. The DON said he/she does not know why the MDS/ assessment coordinator believed the nurses were in charge of all the elopement assessments. He/She said corporate runs reports and alerts the facility if they are behind on assessments and he/she does not know why they were not alerted for the resident's elopement assessments that were not completed. MO00248228 / MO00248234

Based on observation, interview and record review the facility failed to implement the enhanced barrier precautions (EBP) policy developed and educated on at the facility when facility staff failed to post signage or other system to alert staff of resident's who required EBP and place appropriate personal protective equipment (PPE) in close proximity for two (Resident #13 and #52) of two sampled residents with wounds and one (Resident #60) of one sampled resident with an indwelling gastrostomy tube ((g-tube) surgically placed tube that inters the stomach to deliver fluids and nutrition, that required EBP). The facility census was 63. 1.Review of the facility's EBP to infection Control Guidance policy dated March 2024 showed: -To prevent broader transmission or multidrug-resistance organisms (MDRO), bacteria resistant to antibiotics and/or antifungals, and to help protect residents with chronic wounds and indwelling devices. EBP should be implemented for the period of the stay or until wounds have been resolved or indwelling medical devices have been removed; -Residents that require EBP are those with an indwelling medical device including a feeding tube (g-tube) regardless of their MDRO status and residents with a wound, regardless of their MDRO status; -Staff should use EBP when providing high contact resident care activities such as: bathing/showering, transferring residents from one position to another, providing hygiene, changing briefs or toileting, caring for or using an indwelling medical device, and performing wound care; -EBP includes the use of gloves and a gown; -Residents that are placed on EBP should have personal protective equipment (PPE) in close proximity outside the door and a trash can in the resident's room for disposal prior to leaving the room; -The policy did not contain direction on who is responsible to implement and/or monitor the policy, nor did the policy contain direction on how to notify staff of residents who needed to have EBP in place. Review of the Centers for Disease Control (CDC) website https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html article, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated June 2021, showed: -Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE required and defining high risk resident care activities; -Gowns and gloves should be available outside of each resident room, and alcohol-based hand rub should be available for every resident room (ideally both inside and outside of the room). 2. Review of Resident #13's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/17/24, showed staff assessed the resident as: -Cognitively intact; -One unhealed stage III (injury extends to the tissue under the skin) and one unhealed stage IV pressure (loss of skin and tissue exposing bone, cartilage, and/or tendon) wound present on admission; -Received pressure ulcer care that included ointment or medications other than to feet; -Diagnosis of diabetes. Observation on 07/21/24 at 12:35 P.M., showed the resident room did not contain a EBP sign or PPE located outside the resident room. Observation on 07/22/24 at 8:54 A.M., showed the resident room did not contain a EBP sign or PPE located outside the resident room. Observation on 07/22/24 at 3:36 P.M., showed the resident room did not contain a EBP sign or PPE located outside the resident room. Observation on 07/23/24 at 8:08 A.M., showed the resident room did not contain a EBP sign or PPE located outside the resident room. Registered Nurse (RN) B entered the room, applied a medicated soaked gauze to a wound and did not wear a gown. Observation on 07/23/24 at 8:45 A.M., showed RN B provided wound care to the resident. RN B did not wear a gown. The door to the room did not contain a EBP sign or PPE located outside the resident room. During an interview on 07/23/24 at 1:20 P.M., RN B said staff only have to wear the gown when residents have wounds infected with multidrug-resistant staphylococcus aureas (a bacteria that does not get better with use of an antibiotic that usually will cure it). He/She said the facility has no residents at this time that required use of EBP. 3. Review of Resident #52's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Diabetic ulcer to the foot with or without topical medication; -Diagnosis of diabetes and vascular disease. Observation on 07/22/24 at 3:42 P.M., showed the resident room did not contain a EBP sign or PPE located outside the resident room. Observation on 07/23/24 at 8:29 A.M., showed RN B provided wound care to the resident amd did not wear a gown. The door to the room did not contain a EBP sign or PPE located outside the resident room. 4. Review of Resident #60's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Use of a feeding tube. Observation on 07/22/24 at 3:44 P.M., showed the resident room did not contain a EBP sign or PPE located outside the resident room. Observation on 07/23/24 at 3:25 P.M., showed Certified Nurse Aide (CNA) C provide toileting assistance to the resident. He/She did not wear a gown and the room did not contain an EBP sign or PPE located outside the room. Observation on 07/24/24 at 8:57 A.M., showed RN B administer medication and fluids to the resident via g-tube. RN attached the resident g-tube to a feeding pump after administration of medication. RN B did not wear a gown and the resident room did not contain an EBP sign or PPE located outside the resident room. During an interview on 07/23/24 at 3:42 P.M., CNA C said he/she has been educated on when to use a gown and would wear one for things like c-diff. He/She was not aware to wear a gown or EBP for resident's that had a feeding tube but are supposed to wear EBP if the resident has a wound, like cellulitis. He/She said off-going staff report on who is on EBP, if they forget, then there should be isolation gear outside of the resident room. The CNA said the facility does not use signs for isolation to notify staff of any needed PPE and does not believe there are any residents right now that use EBP. During an interview on 07/24/24 at 9:08 A.M., RN B said he/she does not wear a gown to provide care or work with a resident with a g-tube. He/She said he/she did not think the EBP rules were in place yet. 5. During an interview on 07/24/24 at 10:52 A.M., the DON said staff had the training for EBP, but it is still new to the facility. He/She said he/she was told to hold off on implementing the policy due to concerns for dignity issues. The DON said EBP should be used for open gaping wounds with drainage and not a chronic wounds and should be used for residents with a g-tube. CNA's do not do anything with the g-tubes or wounds, so CNA's should not have to wear EBP for care of those residents. A sign is not placed to maintain a resident dignity but staff are informed by the nurse of any changes with a resident. The decision to place a resident on precautions is done by the charge nurse during the admission process or with any changes that would require EBP. He/She is not sure who is ultimately responsible for oversight that EBP are followed for residents who require EBP. During an interview on 07/24/24 at 12:19 A.M., the administrator said the last directive he/her received was discretionary if the resident wanted the precautions due to dignity concerns. He/She said the nursing staff are responsible to ensure the direct care staff are informed of residents who require EBP but do not utilize signage to maintain the resident's dignity. 43327

Based on observation, interviews, and record review, facility staff failed to safely store and label medication in one out of two medication storage rooms, and two out of three medication storage carts. The facility census was 63. 1. Review of the facility's Medication, Storage of policy, dated March, 2015, showed no discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with established guidelines. Drugs must be stored in an orderly manner in cabinets, drawers, or carts. 2. Observation on 07/23/24 at 2:22 P.M., showed the 300/400 hall medication storage room contained: -Four intravenous caps with an expiration date of 06/26/24; -One 30 Oz. bottle of Liquid Protein with an expiration date of 01/19/24. Observation on 07/23/24 at 2:45 P.M., showed the 300/400 hall medication cart contained one loose white oval tablet. 3. Observation on 07/23/24 at 2:58 P.M., showed the 100 hall medication cart contained: -Three loose white oval tablets; -One loose brown and tan capsule; -Five loose white tablets; -Three loose brown round tablets; -One loose oval shaped orange tablet. 4. During an interview on 07/23/24 at 3:00 P.M., Certified Medication Technician (CMT) A said any out of date or loose medications should be destroyed or returned to the Pharmacy. He/She said they normally check the carts daily but just returned from vacation so it was not done. During and interview on 07/24/24 at 8:49 A.M., Registered Nurse (RN) B said the medication rooms and medication carts should be checked for damaged or out of date medications at least monthly. It is the CMT's responsible for the carts, and if they find any out of date or loose medications they should destroy them or return them to the Pharmacy. During an interview on 07/24/24 at 10:53 A.M., the Director of Nursing said staff should throw away loose or out of date medications. He/She said CMT's are directly responsible for out of date or loose medication daily but ultimately he/she said they are responsible to make sure this is finished. During an interview on 07/24/24 at 12:19 P.M., the administrator said all out of date or loose medications should be destroyed in the correct manner. The medication carts and storage rooms are done as a part of a daily routine. Nursing staff are responsible for making sure this is done but ultimately he/she said they were responsible.

Based on interview, and record review, facility staff failed to monitor weights, notify the physician of the Registered Dietician's (RD) recommendations and of the resident's significant weight loss of 8.97% in three months and 12.68 % in six months for one resident (Resident #21) out of three sampled residents. The facility failed to monitor weights and notify the physician of the RD's recommendations for one resident (Resident #61) out of three sampled residents. The facility census was 63. 1. Review of the facility's Diet Orders policy, undated, showed the policy did not address recommendations of the RD nor monitoring of residents' weight loss. Review of the facility's policies showed staff did not provide a policy for weight loss, or RD recommendations. 2. Review of Resident #21's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 05/25/24, showed staff assessed the resident as: -Severely cognitively impaired; -Staff provide partial to moderate assistance with meals; -Weight: 159 pounds (lbs); -Loss or gain of 5 percent (%) to 10 % in the last six months: no or unknown; -No special diet; -Diagnoses of anemia, and diabetes. Review of the resident's care plan, reviewed/revised on 05/31/24, showed staff assessed the resident required assist of one with eating. The resident will be able to eat meals without difficulty and will maintain his/her weight within 5% by next review. The resident on a regular diet, regular liquids, nursing staff to encourage fluid/food intake as needed. Review of the resident's weight record, dated January 2024 - July 2024, showed staff documented the resident weight as follows: -01/01/24, weighed 178.2 lbs; -02/01/24, weighed 169.8 lbs; -03/01/24, weighed 172.4 lbs; -04/01/24, weighed 162.2 lbs (a 8.97% weight loss in three month); -05/01/24, weighed 159.2 lbs; -06/01/24, weighed 157.6 lbs; -07/01/24, weighed 155.6 lbs (a 12.68% loss over in six months). Review of the resident's RD notes, dated April 2024 - July 2024, showed the RD documented: -On 04/02/24, Weekly weights for four weeks to monitor weight. Add super cereal with breakfast. Add house supplement two times a day; -On 05/02/24, 19 lbs. 10.7% weight loss in 121 days. Recommend add house supplement three times a day to maintain weight; -On 07/02/24, 22 lbs. 12.7% weight loss over the last six months. Recommend add Vitamin D supplement. Review of the resident's weight monitoring form did not contain documentation of the residents weekly weights as recommended by the RD on 04/02/24. Review of the resident's physician orders sheets (POS), dated April 2024 through July 2024, did not contain an order for super cereal, house supplements, or vitamin D. Review of the resident's medical record did not contain documentation staff notified the resident's physician of the residents weight loss or the RD recommendations. Review of the resident's dietary card showed the dietary card did not contain the RD recommendations. During an interview on 07/24/24 at 8:56 A.M., Certified Nursing Assistant (CNA) E said the resident is served larger portions. He/She was not aware of any supplements needed and the intake of meals was not monitored. During an interview on 07/24/24 at 9:40 A.M., Registered Nurse (RN B) said the resident looked like he/she had lost weight. RN B said he/she did not think the resident received any supplements. RN B said the Director of Nursing (DON) would normally enter orders for the physician if the RD recommended any supplements for the resident. During an interview on 07/24/24 at 10:04 A.M., the physician said he/she was not aware of RD recommendations for the resident. 3. Review of Resident #61's Admission MDS, dated [DATE] showed staff assessed the resident as: -admitted [DATE]; -Severely cognitively impaired; -Staff provide setup or clean up for meals; -Weight: 136 pounds; -Loss or gain of 5% to 10% in the last six months: no or unknown; -No special diet; -Diagnoses of cancer, Alzheimer's Disease, stroke, and depression. Review of the resident's Care Plan, reviewed/revised on 07/22/24, showed the resident will be able to eat meals without difficulty and will maintain weight within 5% by next review. The resident is on a regular diet, regular liquids, nursing staff to encourage fluid/food intake as needed. The resident requires set up but able to feed self. Review of the resident's weight record, dated June 2024 - July 2024, showed staff documented the resident weight as follows: -06/10/24, weighed 136.2 lbs; -06/17/24, weighed 136 lbs; -06/24/24,weighed 132.6 lbs; -07/01/24, weighed 126 lbs; -07/04/24, weighed 126 lbs; -07/16/24, weighed 131.6 lbs; -07/20/24, weighed 131.6 lbs. Review of the RD progress note, dated 07/01/24, showed: -Current weight 132.6 lbs; -Inadequate food intake related to decreased appetite with dementia as evidenced by weight loss; -New admit, diagnosis dementia. Weight trending down since prior admit. Receives regular diet, eats independently with good appetite. Now resides on the unit; -Recommended to add house supplement two times a day. Review of the resident's POS, dated July 2024, showed the POS did not contain an order for a house supplement two times a day or dietary supplement. Review of the resident's medical record did not contain documentation staff notified the resident's physician of the residents weight loss or the RD recommendations. During an interview on 07/24/24 at 08:56 A.M., CNA E said the resident does not eat very much and required staff assist by feeding the resident to increase the volume he/she will consume. Staff place food on the fork and assist with feeding, and the resident will then eat what he/she initially refuses. CNA E said he/she was not aware of any supplements used to increase intake. CNA E said intake of meals was not monitored. During an interview on 07/24/24 at 9:40 A.M., RN B said the resident ate finger foods and required encouragement to eat. He/She was not aware of any issues with weight loss and did not think the resident received any supplements. RN B said the DON would normally enter orders for the physician if the RD recommended any supplements for the resident. During an interview on 07/24/24 at 10:04 A.M., the physician said he/she was not aware of RD recommendations for the resident. 4. During an interview on 07/24/24 at 9:29 A.M., the MDS Coordinator said he/she was new to the position and did not know Resident #21 had a significant weight loss during the first admission. With any significant weight loss during the prior admission, the MDS should have indicated the loss, and the weight loss would also be included in the updated care plan, and he/she would assume that dietary supplements would be a part of the care plan and the CNA's would be aware of the weight loss strategies. During an interview on 07/24/24 at 10:04 A.M., the physician said he/she is made aware of any recommendations by the nursing staff who call and request the order. The physician said if staff report recommendations by the RD, he/she usually approves and orders a supplement or dietary change as recommended. He/She said staff are to report significant weight losses, so action is taken, and supplements or protein shakes are ordered. During an interview on 07/24/24 at 10:53 A.M., the DON said residents' weights are monitored with monthly weights, and staff reports if the resident is not eating well. If a significant amount of weight is lost, the RD or the physician may order supplements. The nursing staff does not calculate weight percentages lost or gained. If the RD recommends a supplement, the RD sends an email or reports it by mouth to the nursing staff. The DON did not know why the RD recommendations were not implemented by the physician, as the physician will follow the recommendations unless there is a specific reason not to make the change. The DON did not know why the RD recommendations were not followed through by the physician, or how the breakdown in communication occurred. During an interview on 07/24/24 at 11:37 A.M., the RD said he/she makes recommendations and emails or talks to the DON about the recommendations. The RD did not know why the recommendations were not followed through by the physician. During an interview on 07/24/24 at 11:51 A.M., the Dietician Manager said the RD will discuss strategies to use if a resident is losing weight. The Dietician Manager is not aware of individual weight losses of residents, and only is made aware if new orders are put in by the physician. During an interview on 07/24/24 at 12:20 P.M., the administrator said any resident with significant weight loss is brought to the attention of the physician. The RD makes recommendations which are routed by nursing to contact the physician and enter orders. The administrator said the recommendations were missed probably due to human error.

Based on observation, interview and record review, facility staff failed to obtain and maintain an agreement and ongoing communication with the dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) facility for one of one resident who received dialysis services at a dialysis facility and provide staff training on dialysis and/or renal disease. The census was 63. 1. Review of the facility's dialysis policy, dated March 2015, showed communication between the facility and dialysis unit as follows: -The Dialysis Communication record will be sent with the resident on each dialysis visit; -All care concerns in the last 24 hours will be addressed, including the last medications given and facility contact person; -The dialysis unit will complete the lower portion of the report to include weight prior to and after dialysis, any labs completed, and medications given, follow up information and any new physician orders; -The lower portion will be signed by the dialysis nurse and returned to the facility; -These records will be maintained in the medical record. Review of the Facility Assessment, dated December 2023, showed the facility is able to accept residents with end stage renal disease (ESRD) that require dialysis. Staff to identify a resident change in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life and specialized care to include dialysis. Review of the facility agreements showed staff did not provide a dialysis agreement. Review of a handwritten list of dialysis responsibilities provided by the Director of Nursing (DON), on 07/21/24 at 3:23 P.M., showed Resident #55 goes to an outside provider for dialysis treatments and no agreement listed at the bottom. 2. Review of Resident #55's admission Minimum Data Set (MDS), a federally mandated assessment tool, showed staff assessed the resident as: -admitted on [DATE]; -Cognitively intact; -Received dialysis; -Diagnosis of ESRD. Review of the resident's physician order sheet (POS), dated July 2024, showed an order for dialysis three times a week on Tuesday, Thursday and Saturday at an outside facility. Review of the resident's care plan, dated 06/25/24 showed the plan did not contain guidance on when to communicate with the dialysis facility. Review of the resident's medical record showed the record did not contain a communication record used on dialysis days. During an interview on 07/22/24 at 01:38 P.M., the resident said the facility does not send any paperwork with him/her when he/she goes or returns from the dialysis facility. During an interview on 07/22/24 at 03:50 P.M., the administrator said the facility did not have an agreement with the dialysis facility. During an interview on 07/23/24 at 10:56 A.M., the dialysis center Nurse Manager said there was not an agreement with the facility and would fax one over for them to review and sign. The center said facilities normally send a communication report when the resident comes on dialysis days but could not remember if they were doing that process. He/She said that communication helps the dialysis center and the physician better care for the residents. During an interview on 07/23/24 at 01:20 P.M., Registered Nurse (RN) B said the staff do not send any communication paperwork along with the resident on dialysis days. He/She said the facility has not provided any training specific to dialysis or renal disease. During an interview on 07/24/25 at 10:52 A.M., the DON said the facility has not provided any training on dialysis but would expect staff to report any changes of any kind with residents to the charge nurse. He/She said that he/she is not aware of who is responsible to obtain an agreement with the dialysis facility. The facility does not use a communication tool with the dialysis facility but utilizes the phone if there are communication needs with the dialysis facility. During an interview on 07/24/24 at 12:19 P.M., the administrator said he was not aware an agreement was required. He/She said it is his/her responsibility to ensure agreements are in place for the facility.

Based on interview and record review, facility staff failed to implement interventions for one resident (Resident #2), with a history of similar behaviors, which failed to ensure one resident (Resident #1) remained free from sexual abuse, when Resident #2 put his/her hand down Resident #1's pants without Resident #1's consent. The facility census was 65. 1. Review of the facility's abuse and neglect policy, undated, showed it is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 5/5/24, showed staff assessed as: -Severely cognitively impaired; -Diagnoses of Dementia, Multiple Sclerosis (disease of the central nervous system); -Impairment on both sides of body; -Used wheelchair; -Total dependence on staff for eating, toileting, transferring, bed mobility and hygiene. Review of the resident's plan of care, dated 5/29/2020, showed staff are directed to keep resident free from harm. Review of the residents nurse's notes, dated 5/19/24 at 4:47 P.M., showed staff documented Resident #2's family member reported around 2:00 P.M. when they came in to visit with Resident #2 they witnessed him/her in the main dining room in a chair by Resident #1 in his/her wheelchair. Resident #2's family observed Resident #2's hand down Resident #1's pants. The incident was immediately reported to the Director of Nursing (DON) and Administrator at 2:10 P.M. The physician was notifed of the incident at 2:12 P.M. Resident #1's Durable Power of Attorney (DPOA) was notified of the incident. Incident paperwork was filled out. Safety plan in place. Resident said he/she did not know Resident #2's hands were down his/her pants. When asked if he/she was hurt,the resident said no. Staff documented the resident did not have an injury upon assessment. During an interview on 5/20/24 at 12:05 P.M., the resident's spouse said he/she was notified of the incident and was told the other resident would be moved to a different unit. He/She said if his/her spouse was in his/her right mind he/she would not have liked anyone putting their hands down his/her pants in a public place. During an interview on 5/20/24 at 12:47 P.M., the resident said he/she does not remember an incident with another resident but he/she would not like it if someone put their hands down his/her pants. 3. Review of Resident #2's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Moderately cognitively intact; -Diagnoses of Dementia, Alzheimer's Disease and Depression; -Required minimal or no supervision for eating, toileting, transferring, bed mobility and hygiene. Review of the residents plan of care, dated 5/8/24, showed staff assessed the residents at risk for behavioral episodes due to cognitive changes related to diagnoses. Review showed plan of care, updated 5/20/24, to address the resident's sexual behavior toward another resident and intervention to redirect resident if behaviors occurs, rearrange seating to avoid provocation, attempt to engage resident in activities as often as possible. Review of the residents nurses notes, dated 5/19/24 at 4:21 P.M., showed the DON documented It was reported by the resident's family that around 2:00 P.M., when they came into visit with the resident, they witnessed him/her in the main dining room sitting in a chair by Resident #1 in his/her wheelchair. The family observed the resident with his/her hand down Resident #1's pants. Family quickly pulled his/her hand out of Resident #1's pants. The incident was immediately reported to the DON and Administration at 2:10 P.M., the physician was notified of the incident at 2:12 P.M., and new orders were given to place the resident on 15 minute checks for the next 24 hours. Incident paperwork was filled out. Safety plan in place. The resident remained on 15 minute checks at this time. During an interview on 5/20/24 at 11:44 A.M., the resident's DPOA said he/she stopped by to see the resident in the main dining room. He/She said when he/she approached the resident, he/she saw the residents hands were down Resident #1's pants. He/She said Resident #1 was turned away from Resident #2 in his/her wheelchair and it was hard to see if he/she was awake. He/She said a nurse was at the nurses station but the incident was out of his/her line of sight. He/She said he/she let the nurse know what happened because he/she wanted to make sure the other resident was okay. During an interview on 5/20/24 at 11:57 A.M., Registered Nurse (RN) A said on 5/19/24 around 2:00 P.M., the residents family member let him/her know the resident's hand was down Resident #1's pants. He/She said the family immediately stopped the resident. He/She said the Resident #2 did not remembered the incident and he/she has never seen Resident #2 show sexual behaviors previously. 4. Review of the facilities investigation, dated 5/19/24, showed Resident #2's DPOA reported to RN A he/she witnessed the resident's hands down Resident #1's pants. The DPOA had already removed Resident #2 from the dining room away from Resident #1. Review showed staff documented neither resident could recall the incident. 5. During an interview on 5/20/24 at 12:50 P.M., the DON said he/she was not aware Resident #2 had sexual behaviors prior to admittance and has not shown signs of sexual behaviors. Resident #2 was placed here because of wandering and needed a locked unit. He/She said the resident was not on the locked unit now because he/she has had no issues. During an interview on 5/20/24 at 1:01 P.M., the administrator said his/her staff handled the incident per his/her expectation, they contacted him/her and the DON. The physician and the family were notified and a safety watch was put into effect to make sure Resident #1 was not around Resident #2. He/She said he/she was aware that a similar allegation had been made at his/her previous skilled nursing facility but he/she does not know the outcome. MO00236354

Based on interview and record review, facility staff failed to notify one resident's (Resident #1's) out of three sampled residents physician of the resident's blood glucose (the main sugar found in your blood) results over 400 milligrams (mg) per deciliter (dL) results in a timely manner which resulted in the resident being admitted to the local hospital for diabetic ketoacidosis (a complication of diabetes in which acids build up in the blood to levels that can be life-threatening). The census was 57. 1. Review of the facility's policies showed the facility did not have a policy to direct staff on when to notify the physician for changes in resident conditions. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/01/24, showed staff assessed the resident as follows: -Severely cognitively impaired; -Complete dependence on staff for eating, personal hygiene, toileting, locomotion and mobility; -Diagnoses of Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels); -Insulin injections given seven of seven days in the lookback period. Review of the resident's Physician Order Sheet (POS), dated 2/1/24 to 2/29/24, showed a physician order directing staff to administer Novolog Flexpen U-100 (insulin) four times per day per sliding scale of one unit for every twenty (20) untis over a glucose result of 150. Review of the resident's electronic health record under the results tab, showed blood glucose test results, dated 2/29/24 to 3/29/24 as follows: -3/4/24 at 11:31 A.M., 430 milligrams (mg) per deciliter (dL); -3/6/24 at 11:02 A.M., 470 mg/dL; -3/12/24 at 11:10 A.M., 441 mg/dL; -3/14/24 at 4:21 P.M., 407 mg/dL; -3/22/24 at 5:38 A.M., 478 mg/dL, -3/22/24 at 10:49 A.M., 556 mg/dL, -3/22/24 at 3:44 P.M., 422 mg/dL; -3/23/24 at 5:27 A.M., too high for glucometer to provide results. Review of the resident's progress notes, dated 3/1/24-3/23/24, showed staff did not document they notified the residents physician of the resident high blood glucose results. Review of the resident's progress notes, dated 3/23/24, showed staff documented around 5:30 A.M., resident blood glucose test results HI over 600 hundred on the facilities gluocmeter, two types if insulin adminstered with results still HI. Resident phyicians notified, resident to be sent to hospital. Review of the resident's hospital records, dated 3/23/24, showed the resident was admitted for decreased level of consciousness and, reportedly exhibiting decreased levels of consciousness on 3/22/24 and found essentially unresponsive on the morning of 3/23/24. Resident admitted to the intensive care unit with insulin infusion for profound diabetic ketoacidosis. During an interview on 3/29/24 at 11:12 A.M., the physician said he/she expects to be contacted if the resident's blood sugar is over 400 mg/dL or is under 60 mg/dL, he/she said he/she was contacted about sending the resident out due to high blood sugar but was not notified before that. During an interview on 3/29/24 at 11:53 A.M., the Director of Nursing (DON) said the expectation is any blood sugar reading over 400 mg/dL would be reported to the physician. During an interview on 3/29/24 at 1:39 P.M., Certified Medication Techniican (CMT) A said he/she would contact the physician or have the charge nurse contact the physician for any blood sugar reading over 400 mg/dL. He/She does not know why this was not done for the resident. During an interview on 3/29/24 at 1:40 P.M., Licensed Practical Nurse (LPN) B said he/she would contact the physician for high blood sugar between 300 and 400 mg/dL, he/she said it depends on the resident. He/She said it is the responsibility of the nurse or the CMT on duty and to chart the physician's response. LPN B said he/she assumed the physician was getting notified. During an interview on 3/29/24 at 1:47 P.M., the DON said the charge nurse is responsible for reporting high blood sugars to the physician, but the CMT is responsible for telling the charge nurse if the resident's glucose reading is high. He/She said if staff speak to the physician regarding resident care, it is to be documented in the progress notes. He/She does not know why the physician was not contacted, especially on 3/22/24 when the resident had multiple high readings in one day. During an interview on 3/29/24 at 1:59 P.M., the administrator said his/her expectation is facility staff notify the resident's physician with any significant change. He/She does not know why the resident's physician was not notified. During a phone interview on 4/11/24 at 3:09 P.M., CMT C said he/she alerts the charge nurse if a resident's blood glucose test results are under 60 or over 400 mg/dL because it is the professional standard. He/She said he/she does not know why the nurses on duty the days of 3/4/24, 3/6/24, 3/12/24, and 3/14/24, when the resident had over 400 results, did not contact the physician. MO00233892

Based on observation, interview, and record review facility staff failed to provide medications in accordance with professional standards leading to a significant medication error and hospitalization for one resident, Resident #1. Certified Medication Technician (CMT) A prepared medications for Resident #2 and administered the medications to Resident #1. The CMT failed to ensure the medications prepared were provided to the correct resident. Resident #1 was hospitalized for [REDACTED].), [MEDICAL CONDITION] (slow heart rate), and low blood pressure. The facility census was 81. 1. Review of the facility Medication Administration Policy, dated March 2012, showed staff are directed as follows: Purpose: Medications are given to benefit a resident's health as ordered by the physician. Guidelines: 1. Bring cart to resident room. 2. Knock on door before entering. 3. Introduce yourself, call resident by name, and check picture ID in medication book. 4. Explain to resident what you are going to do. 5. Wash hands. 6. Read the label three times before administering medication; when comparing the label to with medication sheet; when setting up medication; and when when preparing to administer medication to the resident. Review of Resident #1's Physician order [REDACTED]. Review of the facility's Investigative Report, dated 7/1/15, showed staff documented the following: - Certified Medication Technician (CMT) A provided the following medications to Resident #1 on 7/1/15 at around 8:30 A.M. in error: -[MEDICATION NAME] 10 milligram (mg); -[MEDICATION NAME] 25 mg; -Diliazem 240 mg; -[MEDICATION NAME] 20 mg; -[MEDICATION NAME] 100 mg; -[MEDICATION NAME] 20 meq(milliequivalent); -Oyster Shell Calcium; -Multivitamin with minerals. - CMT A realized the error and reported it to the Registered Nurse (RN) B. - RN B notified the physician who gave new orders (see POS). Staff monitored the resident's vital signs and transferred the resident to the hospital ER (emergency room ) for evaluation. -Staff did not report any other medication errors. Staff provided education to CMT A regarding the five rights of medication administration. Review of the resident's nurses note dated 7/1/15 at 2:12 A.M. showed staff documented the resident rested quietly in bed with vital signs including temperature 96.9, pulse 78, respirations 22, blood pressure 146/85 mmHg (a measure unit of pressure), oxygen saturation level at 95% with oxygen provided. Review of the resident's nurses note dated 7/2/15 at 7:44 A.M. showed staff documented staff administered the wrong medication to the resident on the morning of 7/1/15. Staff documented they held the resident's medications to monitor for a reaction. Staff documented the resident's vital signs as temperature 98.7, pulse 69, respirations 18, blood pressure 131/70, and oxygen saturation level 99% on 8 liters/minute of oxygen. Staff documented the resident's blood pressure dropped to 92/48, and they notified the resident's physician. The physician directed staff to insert an IV, administer [MEDICATION NAME] Ringer's (common IV solution for fluid replacement), and observe for signs/symptoms of infection. The physician directed staff they may transfer the resident to the hospital to evaluate and treat if needed. Staff notified the resident and his/her responsible party of the new orders. Staff documented the resident's blood pressure dropped again to 60/31 and they decided to send the resident to hospital. When the Emergency Medical Technicians (EMT) arrived the resident's blood pressure was 50/25. Staff gave the resident cool wash cloths for comfort as he/she was hot and perspired. The resident stated he/she did not feel good and was dizzy. Staff provided one on one care as the resident stated he/she may pass out. EMTs transferred the resident to the hospital by ambulance accompanied by his/her responsible party. Review of the Nursing Home to Hospital Transfer Form' dated 7/1/15, showed staff listed the reason for resident's transfer was due to medication error and low blood pressure. Staff documented the resident's blood pressure was 60/31 at 10:30 A.M Review of hospital ER records showed they admitted the resident to theER on [DATE] at 12:54 P.M. with a chief complaint of being provided the wrong medications. The resident complained of feeling terrible all over and was short of breath. ER staff documented the resident was hypotensive (low blood pressure). The resident's blood pressure was 80/43, pulse 50, and oxygen level of 96%. Review of the resident's hospital record showed the following: -Treatment showed the resident was started with an IV saline bolus and received calcium [MEDICATION NAME] (used to treat low blood pressure) 1 [MEDICATION NAME] IV. The resident's cardiologist recommend a second [MEDICATION NAME] of calcium [MEDICATION NAME] be given followed by [MEDICATION NAME] (used to treat low blood pressure) drip if blood pressure was not improved. The physician recommended Intensive Care Unit (ICU) admission. -Emergency Department staff documented the resident showed [MEDICAL CONDITION] related to medications. The ER staff documented the resident received medication that was not his/hers that morning and the resident was symptomatically hypotensive (low blood pressure) and they provided treatment for [REDACTED]. Review of the resident's hospital History and Physical, dated 7/1/15 at 2:05 P.M., showed the hospital physician documented the facility staff transferred the resident to the ER after administering the wrong medications at approximately 8:30 A.M Prior to the medication error, the resident's blood pressure was 131/70, and subsequently dropped to 50/25 at which time staff called emergency medical services (EMS). While in route to the ER, EMS reported the resident's blood pressure dropped to 35/25. The resident was reportedly dizzy and diaphoretic (sweating), however never lost consciousness. The resident's heart rate was also noted in the 50s, which the resident reported was abnormal, and stated it typically ran in the 70s. The physician documented the resident had mild cardiogenic shock with profound [MEDICAL CONDITION] and [MEDICAL CONDITION] on admission secondary to wrong medications given at the nursing home. Observation on 7/2/15 at 11:40 A.M. showed CMT C administered medications to residents. Review of residents' medication administration records (MAR) showed no resident photos available to assist in identifying residents. CMT C said he/she was familiar with the residents and did not have issues with identifying the residents. During an interview on 7/2/15 at 1:00 P.M., Licensed Practical Nurse (LPN) D said the MARs used to have pictures to assist in identifying residents, and was not sure when they were discontinued. The LPN said he/she had worked at the facility for a long time and was familiar with all the residents. During an interview on 7/2/15 at 12:21 P.M. CMT A said he/she administered Resident #2's medication to resident #1 during the morning medication pass on 7/1/15. The CMT said he/she immediately recognized the error when returning to the medication cart and notified the charge nurse (RN B) of the medication error. The CMT said he/she was unsure why he/she made the error, he/she denied being rushed during the medication pass, reported he/she knew both residents well, and could only explain the error as possibly caused by resident names starting with the same letter and vaguely similar. I think I just got the names mixed up. During an interview on 7/2/15 at 1:30 P.M., the DON said she expected all licensed personnel to ensure proper medication administration and perform the five rights of medication administration: right person, right drug, right time, right dose, right route. The DON said that she counseled the CMT on the 5 rights of medication administration. The DON said the only possible explanation found for the medication error is that the CMT possibly got the residents' names mixed up due to them beginning with the same letter and the resident MARs being in close proximity to one another in medication administration book, as their rooms are next to each other. During an interview on 7/22/15 at 2:50 P.M. the DON said the facility was not currently utilizing picture identification in the MARs for all residents. The DON said they were in the process of changing over to a computerized system possibly at the end of the month or possibly next month and picture identification would be on all MARs at that time. MO 129

Based on interview and record review, facility staff failed to notify the physician of one resident (Resident # 5) out of 15 sampled residents of the resident's continued vomiting and diarrhea and failed to implement interventions to prevent dehydration. The resident was subsequently admitted to the Intensive Care Unit (ICU) for acute renal (kidney) failure, [MEDICAL CONDITION] (low blood pressure), dehydration, septic shock (a medical condition resulting from a severe infection which can cause multiple organ failure and death), and [MEDICAL CONDITIONS] (a bacteria that can cause symptoms ranging from diarrhea to life threatening inflammation of the colon). The facility census was 73. 1. Review of Resident #5's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 1/2/13, showed staff assessed the resident as follows: - Cognitively intact; - Independent with no assistance required for bed mobility, transfers, ambulation, dressing, eating, toilet use, and personal hygiene; - diagnosed with [REDACTED]. - Did not have vomiting within the last seven days; - Did not have potential signs of dehydration within the last seven days; - Received a diuretic (medication that increases the excretion of water from the body through urination) seven out of the last seven days. Review of the resident's nurses' notes showed the following: - 1/1/13 at 2:00 P.M.- One episode of vomiting. Order received to give [MEDICATION NAME] (antinausea medication); - 1/1/13 at 10:36 P.M. - The resident complained of nausea. Ate broth in room tonight due to nausea; - 1/2/13 at 1:31 P.M. - The resident had diarrhea at lunch time and staff gave the resident antidiarrheal medication; - 1/3/13 at 1:25 P.M. - The resident had diarrhea and staff gave the resident antidiarrheal medication; - 1/5/13 at 10:27 P.M. - The resident had diarrhea and staff gave the resident antidiarrheal medication. Review of the resident's Monthly Meal Intake, dated January 2013, showed on 1/6/13 the resident ate 25 % of breakfast, refused lunch, and ate 50 % of supper. Further, review showed the resident drank 600 ml of fluid during the three meals. Review of the resident's Nurses' Note, dated 1/6/13, showed nursing staff documented the following: - At 2:17 P.M. - The "resident went to the main dining room for breakfast and lunch, otherwise visiting with other residents". Review showed nursing staff did not document the residents poor oral intake for breakfast or that the resident refused lunch on 01/06/13; - At 10:18 P.M. - The resident complained of diarrhea and staff gave the resident antidiarrheal medication. During an interview on 2/1/13 at 12:45 P.M., the MDS/Care Plan Coordinator said the resident did not have diarrhea in January prior to him/her going to the hospital but did have vomiting. Review of the resident's Monthly Meal Intake, dated January 2013, showed on 1/7/13 the resident ate 25 % of breakfast, 5 % of lunch, and refused supper. Further, review showed the resident drank only 600 ml of fluid during all three meals. Review of the resident's Nurses' Notes, dated 1/7/13, showed nursing staff documented the following: - At 1:00 P.M. - The resident's "appetite is good and feeds self in dining room"; - At 8:57 P.M. - The resident fed him/herself in the dining room. Review showed the nurses did not document the residents poor oral intake for breakfast and lunch or that the resident refused supper as recorded on the meal intake sheet for 1/7/13. Review of the resident's Monthly Meal Intake, dated January 2013, showed on 1/8/13 the resident ate 75 % of breakfast, 10 % of lunch, and refused supper. Further, review showed the resident drank 360 ml of fluid during all three meals. Review of the resident's Nurses' Notes, dated 1/8/13 at 8:29 P.M., showed nursing staff documented the resident had two episodes of vomiting before mealtime. Review of a late entry nurses' note, dated 02/01/13 showed staff recorded, order received for labs to be drawn on 01/09/13. During an interview on 2/15/13 at 8:15 A.M., the resident's physician said staff notified him/her on 1/8/13 that the resident had a change in his/her mental status, the resident was confused. Review of the resident's Monthly Meal Intake, dated January 2013, showed on 1/9/13 the resident refused breakfast and ate only 5 % of lunch. Further, review showed the resident drank 240 ml of fluid during all three meals. Review of the resident's Nurses' Notes, dated 1/9/13, showed nursing staff documented the following: - 1/9/13 at 11:41 A.M. - At 5:30 A.M. "This nurse was notified that the resident was pale and weak upon standing and vomited. Upon assessment the resident was sitting in bed and was pale." "The resident's blood pressure was 83/44" (desired range is 90 - 119 systolic (top number) and 60 - 79 diastolic (bottom number); a low blood pressure is a systolic less than 90 or diastolic less than 60). "This nurse assisted the resident to the laying position and elevated the residents feet". "At 6:45 A.M., the resident's blood pressure was 128/43. The resident to have labs drawn today"; Further review did not show staff recorded the resident's physician was informed of the resident's change is condition. - 1/9/13 at 5:13 P.M. - "The resident's blood pressure was running low, resident was weak and dizzy. Labs were drawn this morning, waiting for results"; - 1/9/13 at 10:48 P.M. - "Resident continues to be confused labs came in critical. Physician notified and gave order at 1630 to send the resident to the Emergency Department (ED). The resident left the facility at 5:17 P.M. This nurse called the ED and was notified that the resident is positive for [MEDICAL CONDITION] and possibly septic". Review of the resident's physician's orders [REDACTED].[REDACTED] - [MEDICATION NAME] 2.5 mg by mouth once daily for high blood pressure; - [MEDICATION NAME] (diuretic) (has a known warning that profound water and electrolyte depletion can occur and careful medical supervision is required) 40 mg by mouth once daily at 8:00 A.M. for [MEDICAL CONDITION]; - [MEDICATION NAME]/[MEDICATION NAME] 10 mg/ 12.5 mg by mouth once daily at 8:00 A.M. for high blood pressure; - [MEDICATION NAME] 50 mg by mouth twice daily at 8:00 A.M. and 4:00 P.M. for high blood pressure; - [MEDICATION NAME] 25 mg by mouth or rectally every eight hours as needed for nausea and/or vomiting; - Antidiarrheal (2 caps) by mouth after first diarrhea stool, then one cap after each loose stool as needed (not to exceed four in 24 hours). Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [MEDICATION NAME] (anti-nausea medication) administered once on 1/1/13, twice on 1/6/13, and once on 1/9/13; - Antidiarrheal medication administered once on 1/2/13, once on 1/5/13, and twice on 1/6/13. - [MEDICATION NAME] 40 mg by mouth once daily 1/1/13 through 1/9/13 at 8:00 A.M.; - [MEDICATION NAME]/[MEDICATION NAME] 10 mg/ 12.5 mg by mouth once daily at 8:00 A.M. on 1/1/13 through 1/8/13; - [MEDICATION NAME] 50 mg by mouth twice daily at 8:00 A.M. and 4:00 P.M. 1/1/13 through 1/8/13 as well as on 1/9/13 at 4:00 P.M.. Review of the resident's labs drawn in the ED on the evening of 1/9/13 showed the following: - A urinalysis showed the resident's urine was red and cloudy (an indication of kidney failure); - The resident's white blood cell (WBC) count was 22.07 (a normal WBC is 4.5 to 10.0; an elevated count is an indication of an infection; - The resident's Blood Urea Nitrogen (BUN) level (measures kidney function) was 149 (normal BUN range is 7-20; an elevated BUN can indicate kidney damage or kidney disease) - A creatinine level (measures kidney function) of 6.0 (normal creatinine range is 0.6-1.2; an elevated creatinine can indicate kidney damage or kidney disease); - A stool analysis was positive for [MEDICAL CONDITION]. Review of one of the resident's hospital physician's Consultation Report, dated 1/9/13 at 10:29 P.M. showed the physician documented the following: - The resident was admitted to the intensive care unit (ICU) out of the ED after presenting to the ED with a report of increasing weakness; - "Apparently nursing home personnel reported that the resident had reflected a decreasing level of function over approximately a week or so. There apparently was not other significant change in his/her vital signs by nursing home personnel. He/she has previously had a stroke and has multiple other medical issues, none of which appear to have been recently exacerbated."; - The resident's BUN was 149 and creatinine was 6.0. "There is no pre-existing history of [MEDICAL CONDITION]" "the resident does indeed have a creatinine that was perfectly normal within the last six months at this institution"; - "As an incidental finding, the resident also had a [MEDICAL CONDITION] analysis of a loose stool he/she had in the ED that was positive."; - "[MEDICAL CONDITION] although the source of the infection is not immediately clear. The resident does have a positive [MEDICAL CONDITION] analysis of his/her stool but there was no diarrhea reported from the nursing facility although perhaps that was simply omitted."; - "dehydration seems to have been a very significant component to the resident's illness". Review of the resident's nephrology physician's Consult Note from the hospital, dated 1/10/13, showed the physician documented the following: - "I was asked by the ED physician to see the resident for acute [MEDICAL CONDITION]." The resident "was admitted yesterday with septic shock and a blood pressure of 70/50." The resident "had multiple bowel movements since admission, positive for [MEDICAL CONDITION]." The resident "has no history of kidney disease, creatinine was 1.0 in November 2012 and is now 6.0. Urinary output was only 50 ml today with 6 bowel movements"; - Impression - Acute [MEDICAL CONDITION] from [MEDICAL CONDITION] and dehydration, septic shock, and [MEDICAL CONDITION]; - Plan - Intravenous fluids, [MEDICAL CONDITION] waiting for recovery of renal function, [MEDICATION NAME] (an antibiotic) for [MEDICAL CONDITION] and other antibiotics, stop all blood pressure lowering medications. Review of the resident's Vital sign and Weight Flow Record, undated, showed the following weights for the resident: - 11/3/12 - 141 pounds (lbs); - 12/4/12 - 141 lbs; - 1/1/13 - 128 lbs. Review of the residents Medical Record showed the resident was readmitted to the facility from the hospital on [DATE] with a weight of 140.8 lbs. During an interview on 2/4/13 at 3:45 P.M., the Director of Nurses (DON) said the resident did have a 13 lb weight loss in one month, but that would be an expected outcome of the [MEDICATION NAME] the resident was started on in December, so the staff did not notify the resident's phsyician. During an interview on 2/1/13 at 1:35 P.M., Graduate Practical Nurse (GPN) M said the following: - A nurse should notify a resident's physician if nausea, vomiting, and diarrhea has not resolved after three days; - He/she was not aware that the resident's nausea, vomiting, and/or diarrhea lasted over a period of nine days. During an interview on 2/1/13 at 1:45 P.M., Licensed Practical Nurse (LPN) N said the following: - Several other residents had gastrointestinal symptoms (nausea, vomiting, and/or diarrhea) during the time that the resident had those symptoms; - Most of the other residents gastrointestinal symptoms only lasted a few days; - A nurse should have notified a physician of the resident's continued gastrointestinal symptoms when they did not resolve after a "couple of days". During an interview on 2/1/13 at 2:55 P.M., the MDS/Care Plan Coordinator said the following: - The resident normally took care of him/herself and did his/her own toileting and personal hygiene; - She saw the resident in his/her room on 1/9/13 before he/she went to the hospital and the resident was "very sick" and almost unresponsive. During an interview on 2/1/13 at 3:45 P.M., the Director of Nurses (DON) said the following: - Any time staff call a physician to notify them of a change or issue with a resident or to request an order for [REDACTED]. - The resident "had fluids at his/her bedside" to prevent dehydration. During an interview on 2/15/13 at 8:15 A.M., the resident's physician said the following: - Typically, the stomach flu lasts four to five days; - He/she did not recall if staff notified him/her of the resident's continued gastrointestinal symptoms that lasted over a week; - He/she wouldn't expect a resident's gastrointestinal symptoms caused by the stomach flu to continue for seven days or more, but if they did, he/she expects staff to notify him/her of that.

Based on observation, interview, and record review the facility staff failed to provide appropriate foot support during wheelchair transportation to prevent avoidable accidents for three (Residents #1, #2 and #3) of three residents sampled for review. Facility staff failed to apply wheelchair foot rests to one resident's (Resident #1) wheelchair prior to wheeling the resident from his/her room to the dining room, which resulted in the resident suffering a fracture of his/her right tibia (inner and larger leg bone between the ankle and knee). The facility census was 77. 1. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/22/12 showed staff assessed the resident as follows: - Alert and oriented; - Dependent on assistance of two staff for bed mobility, transfers, toilet use, dressing and personal hygiene; - Did not walk; - Independent for locomotion on unit; - Required limited assistance of one staff for locomotion off unit; - Limited range of motion in all extremities; - Utilized a wheelchair for mobility; - History of a stroke; - Weight of 286 pounds; - Height of 63 inches. Review of the resident's plan of care updated 11/06/12 showed staff planned the following interventions/information regarding the resident's abilities for the resident: - Provide assistance with transfers as needed (two staff with a Hoyer lift-mechanical device used to transfer residents); - Required wheelchair for mobility - did not walk. Would at times propel self by holding handrail; - The resident liked to propel self at times with lower extremities. The resident did not make it all the way down hall. Required assistance at times. While in his/her room able to move from the television to bed with lower extremities. Review of the resident's physician's orders [REDACTED]. Record review of the resident's medical record showed the following Diagnoses: [REDACTED]. - Insulin Dependent Diabetes Mellitus; - Neuropathy (damage to the peripheral nerves of the nervous system which usually affects the hands and feet, causing weakness, numbness, tingling and pain); - Hand joint contractures; - Muscle weakness. Review of the resident's nurses notes dated 11/06/12 at 11:15 A.M., showed facility staff recorded the Certified Nurse Assistant (CNA) staff transferred the resident from his/her bed to a wheelchair using a mechanical lift for the noon meal. Staff recorded upon entering the 100 hallway, the resident dropped his/her right leg and before staff could stop or prevent the incident, the resident's right lower extremity got caught beneath his/her wheelchair. Staff recorded the charge nurse assessed the resident's right lower extremity and noted the resident's right shin swollen, and the resident complained of the area being tender to touch. Staff recorded the resident stated "they pushed him/her too fast and his/her leg got caught." Staff notified the resident's physician and staff obtained an order to transfer the resident for evaluation. Review of the resident's radiology report dated 11/06/12, showed a fracture to the resident's right tibia. Review of the resident's medication record dated 11/06/12 at 12:00 P.M., showed staff administered Hydrocodone/Acetaminophen 5/325 mg to the resident for complaints of leg pain. Further review showed staff recorded the medication as ineffective. Staff did not record they notified the resident's physician to obtain additional pain medication. Review of the resident's narcotic record dated 11/06/12 at 12:00 P.M., showed staff administered Hydrocodone/Acetaminophen 5/325 mg, one tablet, to the resident. Review of the resident's hospital progress notes dated 11/08/12 showed hospital staff documented a fracture to the resident's right tibia due to trauma and as a result, applied a long leg cast. Observation on 11/09/12 at 9:00 A.M., showed the resident lay in his/her hospital bed with a cast on his/her right leg. During an interview at this time, the resident said a CNA pushed him/her "too fast" and caught his/her leg under the wheelchair. The resident said CNA A told him/her that the CNA got the resident up "late" for lunch and was afraid he/she would get in "trouble" over it. The resident said his/her wheelchair did not have leg rests at that time. The resident said he/she could not remember telling the staff he/she did not want leg rests on his/her wheelchair or that he/she wanted to push him/herself in his/her wheelchair. The resident said he/she typically grabbed onto the handrails on the wall and pulled himself/herself along with his/her hands. The resident said he/she could propel himself/herself in the wheelchair but did so slowly. The resident said he/she could only wheel himself/herself short distances, and then the staff would help the rest of the way. During an interview on 11/20/12 at 12:20 P.M., CNA B said the resident propelled himself/herself "at times", and would ask staff for assistance if needed. CNA B said the resident grabbed onto the handrails and pulled himself/herself up and down the hallway. CNA B said they did not apply leg rests on wheelchairs of residents who self-propelled. CNA B said staff trained the CNAs to always ask the resident to hold his/her feet up, push the wheelchair slowly and place one hand on the resident's shoulder. During an interview on 11/20/12 CNA C said the resident pushed himself/herself in his/her room, but the majority of the time, staff wheeled him/her in a wheelchair in the hallway. CNA C said the resident pushed himself/herself slowly in his/her wheelchair. CNA C said due to the resident's weight and his/her inability to stand, they utilized a Hoyer lift to transfer the resident. CNA C said it was difficult for the resident to push himself/herself about in his/her wheelchair. CNA C said staff are taught to always ask the resident to hold his/her feet up, push the wheelchair slowly, place one hand on the resident's shoulder, and if the resident can not hold his/her feet up and gets tired, to tell the staff. During an interview on 11/20/12 at 12:30 CNA D said he/she did restorative nursing. CNA D said he/she practiced passive range of motion to the resident's left hand. CNA D said the resident also wears a brace at night on his/her left hand for contractures. CNA D said the resident self-propelled in his/her wheelchair in the hallway by pulling on the handrails. CNA D said staff use a Hoyer lift for the resident because the resident could no longer transfer himself/herself safely. During an interview on 11/20/12 at 12:35 P.M., CNA E said when he/she pushed the resident in his/her wheelchair, he/she instructed him/her to hold his/her feet up. CNA E said "some days" the resident had strength enough to hold his/her feet up and "other days, not". During an interview on 11/20/12 at 12:40 P.M., Certified Medication Technician (CMT) F said the resident self-propelled, but did so very slowly. CMT F said at times, staff assisted the resident while in his/her wheelchair. CMT F said he/she believed the resident's family member requested the leg rests not be placed on the resident's wheelchair so he/she could be more independent in his/her wheelchair. During an interview on 11/20/12 at 12:50 P.M., CNA A said the day of the accident, he/she and CNA G assisted the resident up for lunch. CNA A said he/she told the resident to hold his/her feet up, and if he/she got tired, to let the CNA know. CNA A said he/she placed his/her hand on the resident's right shoulder and started "easing" the resident's wheelchair down the hallway to the dining room. CNA A said he/she did not realize the resident's right foot dropped and got caught under the resident's wheelchair until the resident started complaining of pain and felt the wheelchair stop suddenly. CNA A said the resident did not lean forward in his/her wheelchair enough for him/her to notice any problem occurred. CNA A said he/she did not tell the resident he/she was in a hurry or he/she would get in trouble for getting the resident up late. CNA A said the resident did not use leg rests because he/she wants to be more independent with his/her mobility. CNA A said staff use a Hoyer lift for the resident because the resident could not walk and felt like "dead weight." During an interview on 11/20/12 at 1:45 P.M., CNA G said he/she and CNA A got the resident up for lunch. CNA G said he/she walked up the hallway in front of CNA A, who pushed the resident in his/her wheelchair. He/She heard the resident say "ow, ow, ow." CNA G said he/she looked back and saw the resident's right leg bent backwards underneath his/her wheelchair. CNA G said the resident pushed himself/herself at times, but also required staff assistance. CNA G said staff use a Hoyer lift because the resident is non-weight bearing and like "dead weight." During an interview on 11/20/12 at 2:00 P.M., LPN H said he/she worked as the charge nurse 11/06/12, the day of the resident's right leg fracture. LPN H said CNA A pushed the resident in his/her wheelchair to the dining room and got past a couple of residents' rooms when the incident occurred. LPN H said at that time, the resident complained of a lot of pain in his/her right leg and he/she instructed CMT F to give the resident pain medication. LPN H said the resident tried to propel himself/herself in the wheelchair, but staff assisted the resident as well. LPN H said the resident is a "large" person and non weight bearing. The LPN said staff use a Hoyer lift to assist the resident. LPN H said the resident pushed himself/herself around in his/her wheelchair while in his/her room. During an interview on 11/26/12 at 12:15 P.M., the resident's Physician I said to the best of his/her recall, he/she saw staff push the resident in his/her wheelchair in the hallway. Physician I said the only time he/she saw the resident push him/herself in his/her wheelchair was in the resident's room. Physician I said the resident was a "good size" person, with weakness in his/her extremities. Staff use a Hoyer lift because the resident is non weight bearing and could not "get around" on his/her own very far without staff assistance. Physician I said he/she could not imagine it is easy on staff to push the resident in his/her wheelchair without leg rests. Physician I said he/she did not recall if the resident requested his/her leg rests be discontinued so he/she could be more independent. Physician I said the resident is very alert and oriented. Physician I said the best person to ask if he/she requested the leg rests be removed from his/her wheelchair for more independence, would be the resident himself/herself. During an interview on 11/27/12 at 1:00 P.M., Physician I said due to the resident's overall poor health, he/she felt it would benefit the resident to have leg rests on his/her wheelchair. Physician I said it would be difficult for the resident to push him/herself in his/her wheelchair long distances. Physician I said it would be difficult for the resident to hold his/her feet up for very long while being wheeled in his/her wheelchair by the staff. During an interview on 11/28/12 at 10:05 A.M., LPN J said the facility contains a closet where leg rests are stored. LPN J said all staff have to do is ask restorative or therapy for leg rests, and they will find them for the staff. LPN J said it is just a matter of finding the right leg rests to fit that particular wheelchair. During an interview on 11/28/12 at 12:30 P.M., CMT F said after the resident's right leg injury on 11/06/12, he/she administered him/her Hydrocodone/Acetaminophen 5/325 milligrams for pain. CMT F said he/she reassessed the resident maybe 30-45 minutes for any relief, and the resident continued to complain of right leg pain. CMT F said he/she notified LPN H the resident continued to complain of right leg pain. During an interview on 11/28/12 at 12:35 P.M., LPN H said CMT F did not notify him/her the resident continued to complain of right leg pain or he/she would have notified the physician for additional pain medication. During an interview on 11/28/12 at 12:45 P.M., the DON said she expects staff to notify the resident's physician of the resident's continued complaints of right leg pain, and obtain additional pain medication. The DON said the resident and his/her family want the resident to be more independent in his/her wheelchair and requested the leg rests be removed. The DON said the resident could self-propel in his/her wheelchair, but did require staff assistance at times. During an interview on 11/29/12 at 10:15 A.M., the resident's Family Member (FM) K said he/she did not tell the facility to discontinue the resident's leg rests. FM K said when the facility notified him/her on 11/06/12 of the resident's right leg injury, he/she asked if the resident's leg rests were in place on the resident's wheelchair. FM K said the facility staff informed him/her the resident did not need leg rests. FM K said the resident held onto the handrails to pull him/herself up and down the hallway, and could only do so until he/she got to a doorway where there were no handrails for the resident to hold on to. 2. Record review of Resident #2's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument, dated 09/11/12 showed staff assessed the resident as follows: - Alert and oriented; - Vision severely impaired; - Extensive assistance of two facility staff for bed mobility, transfers, walking, dressing and toilet use; - Limited assistance of one facility staff for locomotion and personal hygiene - Wheelchair for mobility. Review of the resident's medical record showed the following Diagnoses: [REDACTED]. - Blindness; - Muscle weakness. Review of the resident's plan of care updated 11/08/12 showed staff assessed the resident required extensive assistance with his/her Activities of Daily Living (ADLs) due to the resident's blindness and generalized weakness. Further reviewed showed the care plan directed staff to provide the following interventions for the resident: - Majority of mobility in the resident's wheelchair; - Ambulate with staff only. Observation on 11/20/12 at 7:45 A.M., showed staff wheeled the resident in his/her wheelchair to the dining room. Further observation showed the resident did not have leg rests on his/her wheelchair. The resident held his/her legs up to be wheeled in the wheelchair. During an interview, at this time, CNA L said the resident is blind and is pushed in his/her wheelchair. CNA L said the resident's wheelchair did not have leg rests. CNA L said staff are taught to always ask the resident to hold his/her feet up, push the wheelchair slowly, place one hand on the resident's shoulder, and if the resident cannot hold his/her feet up and gets tired, to tell the staff. During an interview on 11/20/12 at 9:20 A.M., the resident said he/she can not push him/herself in his/her wheelchair because he/she can not see. The resident said he/she tried to push him/herself in his/her wheelchair, but did not do a very good job of it. The resident said staff did not use leg rests on his/her wheelchair. 3. Record review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/20/12 showed staff assessed the resident as follows: - Confused; - Required limited assistance of one staff for bed mobility, transfers, walking, locomotion on the unit; - Severely impaired vision; - Wheelchair for mobility. Review of the resident's plan of care updated 11/21/12 showed staff assessed the resident required assistance with his/her ADLs due to the resident's blindness related to his/her Macular Degeneration (condition which causes vision loss) and Glaucoma (condition which causes vision loss). Further reviewed showed the care plan directed staff to provide the following interventions for the resident: - Walk with staff assistance only; - Wheelchair as needed and may use walker as needed. Observation on 11/28/12 at 10:45 A.M., showed Nurse Assistant (NA) M wheeled the resident to his/her room. Further observation showed the resident's wheelchair did not have leg rests. The resident held his/her legs up to be wheeled in the wheelchair. During an interview, at this time, NA M said the resident pushed himself/herself in his/her wheelchair. NA M said the resident's wheelchair did not require leg rests because of his/her ability to self-propel while in his/her wheelchair. NA M said staff are to ask the resident to hold his/her feet up, push the wheelchair slowly, place one hand on the resident's shoulder, and if the resident can not hold his/her feet up and gets tired, to tell the staff. 4. During an interview on 12/28/12 at 12:45 P.M., the DON said only residents who can not self-propel in their wheelchairs require leg rests. The DON said the facility has a closet where leg rests are stored. MO 379 MO 391