Every finding on record at Ellisville Rehabilitation and Nursing

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse when one staff member, Certified Nursing Assistant (CNA) A struck two residents. On 06/28/26 at approximately 2:50 A.M., CNA A was observed by Licensed Practical Nurse (LPN) B and CNA D using excessive force for one resident (Resident #2) while boosting him/her up in bed which caused Resident #2 to hit his/her head on the backboard. CNA A was also observed striking the resident on the lower back with a closed fist. Between 4:00 A.M. to 4:30 A.M., LPN B assessed CNA A and instructed him/her to leave the facility, due to concerns of intoxication. CNA A did not leave the facility as instructed. CNA A pleaded with LPN B to stay and was allowed to continue with his/her assignment. At approximately 6:00 A.M., LPN C entered Resident #1's room after hearing loud yelling coming from the resident's room. CNA A was observed slapping the resident on the face with an open hand, causing his/her nose to bleed. Emergency Medical Services (EMS) was dispatched to the facility and upon assessment, Resident #1 was found to be in mild distress with multiple abrasions to the bilateral upper extremities, an abrasion to the forehead, redness to the right cheek and dried blood around the nose. A secondary assessment revealed additional abrasions to the neck, chest, and back. The resident was transferred to the hospital where he/she remained. The sample size was four. The census was 129. The administrator was notified on 07/08/26 of the immediate jeopardy (IJ) past non-compliance which occurred on 06/28/26. When the facility identified the issue, they terminated the employee and in-serviced staff regarding abuse and neglect, with a focus on what to do if staff witnessed abuse, notifying management/Director of Nursing (DON), resident rights, focus to be free from abuse, and mandated reporters. The IJ was corrected on 06/28/26. Review of the facility's Abuse policy, date revised 12/25, showed:-Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse;-Definitions:--Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including facilitated or enabled through the use of technology;--Alleged Violation: a situation or occurrence that is observed or reported by staff, resident, relative, or visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property;--Covered individual: anyone who is an owner, operator, employee, manager, agent or contractor of the facility;--Crime: defined by law of the applicable political subdivision where the facility is located. A political subdivision would be a city, county, township or village, or any local unit of government created by or pursuant to State law;--Mistreatment: inappropriate treatment or exploitation of a resident;--Physical Abuse: includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment;--Serious Bodily Injury: an injury involving extreme physical pain; requiring medical intervention such as hospitalization;--Staff: includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program, and students from affiliated academic institutions, including therapy, social and activity programs;--Verbal Abuse: the use of oral, written or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability;-Policy Explanation and Compliance Guidelines:-The facility will provide ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written;-Possible indicators of abuse include, but are not limited to:--Resident, staff or family report of abuse;--Physical marks such as bruises or patterned appearances such as handprint, belt or ring mark on a resident's body;--Verbal abuse of a resident overheard;--Physical abuse of a resident observed;--Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame;-Investigation of Alleged Abuse:-An immediate investigation is warranted when suspicion of abuse or reports of abuse occur. Review of the facility's Compliance with Reporting Allegations of Abuse, date revised 12/25, showed:-Policy: It is the policy of this facility to report all allegations of abuse or mistreatment immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes;-Procedure for Response and Reporting Allegations of Abuse:--When suspicion of abuse or reports of abuse occur, the following procedure will be initiated:---The LPN will:----Respond to the needs of the resident and protect him/her from further incident;----Remove the accused employee from resident care areas;----Notify the administration or designee;----Notify the attending physician, resident's family/legal representative, and Medical Director (MD);----Monitor and document the resident's condition, including response to medical treatment or nursing interventions;----Document actions taken in the medical record. Review of the facility's Resident Rights policy, date implemented 09/24, showed:-Respect and dignity: The resident has a right to be treated with respect and dignity;-Safe environment: The resident has a right to a safe environment. Review of CNA A's employee file, showed:-06/12/26 signed acknowledgement of receipt of policy and procedure regarding freedom from abuse, neglect, and exploitation and the Elder Justice Act, Resident Rights, Code of Conduct, Substance Abuse, and Drug Testing in the Workplace;-06/21/26 resident verbiage descriptions related to CNA A's verbal tone, including but not limited to:-snippy, nasty, rude, and persnickety, and said she hears me;-Removed from unit to another floor;-Told to clock out;-Received 1:1 sensitivity training, focus on tone and remarks. During an interview of 07/06/26 at 9:56 AM., the DON said some residents said CNA A had a smart mouth. CNA A was made to clock out. The aide was in-serviced and later put on a different floor. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/03/26, showed the resident assessed with:-Severely impaired cognition;-Dressing: Dependent;-Toileting hygiene: Dependent;-Used wheelchair for mobility. Review of Resident #2's incident note, dated 06/28/26 at 5:56 P.M., showed staff observed to be physically aggressive toward the resident. The employee (CNA A) was separated from the facility. Resident assessed, no injuries. Medical Doctor, family, and Department of Health and Senior Services (DHSS) notified at this time. Neurological checks started. Will continue to monitor. Review of Resident #1's annual MDS, dated [DATE], showed:-Mental Status Assessment: Memory problems, severely impaired, inattention continuously present, doesn't fluctuate;-Behavioral Symptoms:-Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) -Behavior not exhibited;-Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) - Behavior not exhibited;-Upper/Lower extremities: Impairment on one side, Dressing: Dependent, Toileting hygiene: Dependent;-Mood:-Should a mood interview be conducted: No resident rarely/never understood;-Diagnoses included but not limited to, hemiplegia (paralysis on one side of the body) or hemiparesis (partial weakness or the inability to move one side of the body), stroke, seizure disorder (recurrent, unprovoked seizures caused by sudden electrical disturbances in the brain), anxiety disorder (persistent, excessive worry and fear that interfere with daily life), and depression (persistent sadness). Review of Resident #1's incident note, dated 06/28/26 at 10:54 A.M., showed at approximately 6:30 A.M. to 7:00 A.M., the resident had been involved in a physical altercation with an employee. The resident was moved to safety and employee removed from immediate area via another staff member. Resident assessed via the nurse and injuries were noted. In addition, the resident had a light nose bleed as a result of the altercation. The resident is alert and oriented to self (A&O x1). Neurological checks were completed and no abnormalities indicated. Resident was sent to the hospital via 911. Medical Doctor and family were notified of incident. Review of the facility's investigation, dated 06/28/26, showed:-Review of staffing assignment dated 06/27/26, showed:-200-Cardinal Court, 11:00 P.M. -7:00 A. M., LPN B and CNA D;-400-Turtle Cove, 11:00 P.M. - 7:00 A.M., CNA A;-Disciplinary Action Form:-Type of offense: Critical;-CNA A termination. Employee was observed becoming physically aggressive with resident. Employee escorted out, police called, and arrested. Review of employee statements, showed: -During an interview on 06/28/26 at 4 P.M., CNA D said at approximately 2:50 A.M., he/she and CNA A were in the room changing Resident #2. LPN B entered the room and assisted in changing the resident. While repositioning the resident and pulling him/her up, CNA A used so much force that the resident bumped his/her head on the headboard. Afterwards, CNA A balled up his/her fist and punched Resident #2 in his/her lower back. CNA D said he/she didn't request any help from CNA A. He/She was standing at the nurse station talking to LPN B when he/she requested help from LPN B. CNA A insisted on assisting and LPN B said, this my girl, referencing CNA A as his/her (LPN B) friend. When the incident occurred LPN B, CNA A, and CNA B were all in the room. CNA D said he/she later reminded LPN B about CNA A hitting Resident #2 in the lower back. He/She told LPN B that CNA A acted like something was wrong with him/her. He/She told LPN B that he/she didn't want CNA A's help ever. CNA D told LPN B that he/she didn't need help from anyone that mistreated residents. At the end of the shift, he/she saw the police and CNA A was in handcuffs. The police took his/her statement about CNA A's behavior regarding Resident #2;-On 06/28/26 at 1:36 P.M., LPN B said he/she did not witness any staff member strike Resident #2. The resident displayed no behavior consistent with being struck. No allegations of a punch were made to him/her by CNA D during, or immediately following, the event. Any subsequent allegations of physical abuse did not occur under LPN B's observation and were not reported to him/her during discussions regarding the head bump;-A written statement on 07/02/26 showed LPN B reported CNA A pleaded not to be asked to leave work. When CNA A approached LPN B in the pantry stating the resident had urinated on CNA A's leg. LPN B said he/she knew by CNA A's mannerism that he/she needed to go home. When LPN B spoke with LPN C, he/she told LPN C that he/she was sending CNA A home if it was LPN B's decision. LPN B informed LPN C that it was his/her unit, his/her decision. LPN B took a ten-minute break. He/She saw CNA A was still at work;-On 06/28/26 a written statement showed LPN I said he/she had been the nurse for Resident #1 on 06/27/26. Resident #1 did not have any skin issues, bruising, open areas, scratches or skin tears on his/her body;-In a written statement, LPN C said at approximately 5:45 A.M., he/she was concerned that CNA A was possibly intoxicated and stated to CNA A that he/she need to go home due to suspicion of intoxication. CNA A reassured and pleaded, refusing to leave. CNA A continued to get Resident #1 up. He/She heard CNA A talking loud and aggressively to the resident. That's when LPN C ran into the hall, noting CNA A slap the resident really hard in the face causing a nosebleed. LPN C immediately ran up on to CNA A, telling him/her to get away from resident and leave the building now. CNA A continued to try and plead his/her case stating he/she did nothing wrong. LPN C told CNA A to leave or else. LPN C assessed the resident, noting bruising to both arms that appeared new. Also an abrasion to the forehead and a skin tear to the right elbow. LPN C placed a call to 911 services to report the assault, after speaking with the nurse manager and then notified the family. CNA A was arrested by the police. All made aware. Resident taken to the hospital for assessment;-A follow-up interview on 07/02/26 at 3:00 P.M., showed LPN C said, after pleading not to be sent home, CNA A stated that he/she was tired and had been picking up a lot of shifts elsewhere. He/She got himself/herself together. CNA A seemed fine and didn't appear to be a threat. He/She continued on to his/her job, but LPN C said he/she continued to monitor to be certain no other issues arouse until that very moment at approximately 6:15 A.M. - 6:30 A.M.;-During an interview on 06/28/26, CNA H said he/she was leaving out of his/her rooms when an unnamed nurse, stopped him/her to let him/her know CNA A was leaving for putting his/her hands on a resident. They called unnamed persons to report the incident. He/She looked over Resident #1 for bruises and found plenty. Throughout the whole night, CNA A slurred his/her words, stumbling, etc. But it just got worse over time, so they honestly were prepared to just do CNA As work so he/she could leave, however CNA A wouldn't leave, even after asking him/her to go multiple times;-A follow-up interview on 07/02/2026 at 3:15 PM. showed CNA H said he/she saw CNA A sitting in front, grabbing sheets to place in the laundry room. CNA A said he/she was going to get two people up and then he/she was out of there for the night;-During an interview on 06/28/2026 at 7:10 A.M., the DON said he/she was notified there was an incident in the facility concerning a staff and a resident. Per information that had been received, the staff member became physically aggressive towards the resident. The employee had already been removed, the resident was safe, and the authorities had been called. Upon this nurse arriving at the facility, approximately 7:55 A.M., the employee had been booked and arrested. The resident had been sent to the hospital for an evaluation, families and MD had been notified. Investigation started immediately. DHSS was notified at 7:59 A.M. via hotline. Review of EMS report, dated 06/28/26, showed:-Resident #1;-Primary Impression: Laceration/Abrasion/Hematoma (minor surface trauma);-Chief complaint: Multiple bruising to arms and forehead;-Signs and Symptoms: Multiple injuries (Primary);-Injury: Assault - Assault - Facility 06/28/26;-Mechanism of Injury: Blunt;-Medical/Trauma: Trauma;-Assessment Time: 06/28/26 at 7:09 A.M.;-Mental Status: Oriented - Person;-Head, Eyes, Ears, Nose, and Throat (HEENT):-Comments:-Bruising to forehead, dried blood to nose, redness to cheek;-Abrasion in the middle of his/her back;-Bruising to right arm;-Narrative:-Dispatch notes indicated that a staff member had allegedly assaulted a resident. The patient (Resident #1) appeared to be in mild distress. Initial assessment revealed multiple abrasions to the bilateral upper extremities, and abrasion to the forehead, redness to the right cheek, and dried blood around the nose. The patient was alert and oriented to person only (A&Ox1), which staff reported was his/her normal baseline mental status. Due to his/her cognitive impairment, the patient was only able to answer (yes) when asked if experiencing pain and was unable to provide any additional history or answer further questions. A secondary assessment revealed additional abrasions to the neck, chest, and back. Review of Police Department Investigative Report 26-467 - Original, showed:-Resident #2;-Red marks on his/her checks and bruising on his/her right forearm;-CNA A;-Charges: Assault - 3rd Degree - Special Victim;-Physical State: Suspected Alcohol Use;-Emotions: Angry, apologetic, crying, hysterical, calm, irrational, threatening;-Emotions Comments: I'll beat your [expletive];-Additional information: This charge is being charged two times two separate victims, same incident;-Narrative: -On 06/28/26 at approximately 6:55 A.M., police were dispatched to the facility for an assault complaint. CNA A was asked if he/she knew what was going on. CNA A said he/she didn't know. Police reported the following:A female (LPN C) walked out of the building and pointed to the first lady stating he/she hit one of the patients. Officer then spoke further with the first staff (LPN C), who was working at the time this incident occurred. LPN C informed the officer he/she observed CNA A strike victim (Resident #1) in the face causing his/her nose to bleed. LPN C stated this occurred at approximately 6:20 A.M. After speaking with LPN C, the officer was stopped by CNA D. CNA D stated at approximately 2:50 A.M., the same day, while CNA A was treating the victim (Resident #2), CNA D observed CNA A pull Resident #2 up from his/her bed causing him/her to hit his/her head on the headboard of his/her bed. CNA A then hit Resident #2 in the lower back with his/her fist. Officer went to room where Resident #1 was assaulted and observed the room in disarray. The bed and the area around the bed looked like a struggle had taken place. Officer was not able to speak with either of the two victims (Resident #1 and #2). Resident #1 was not able to speak either due to an unknown medical condition and seemed to be lethargic. With this information, CNA was arrested on two charges of assault special victim. During a telephone interview on 07/07/26 at 3:51 P.M., CNA D said LPN B went to check out CNA A. CNA D said he/she smelled alcohol on CNA A when helping the aide and LPN B with Resident #2. CNA D wasn't sure if he/she should report it, but after CNA A hit Resident #2, CNA D asked LPN B if the nurse was going to say something after seeing CNA A hit Resident #2 on the back. CNA D didn't know either LPN B or CNA A, but when LPN B said, that's my boy/girl, he/she knew LPN B and CNA A were friends. CNA A was assessed upstairs after he/she hit Resident #2. CNA A hit Resident #2 in the back and rammed his/her head into the headboard around 2:50 A.M. LPN B came back around 4:30 A.M. and said he/she was drunk. CNA D asked who? LPN B kind of laughed and said CNA A. LPN B and LPN C agreed CNA A was drunk, so he/she wasn't sure why CNA A wasn't sent home. LPN B told CNA A he/she needed to just go home, but was talking to him/her like a friend, not a supervisor. CNA D was headed downstairs to tell the DON. The DON wasn't there yet. CNA D didn't report it to LPN B, because the nurse was in the room too and saw the same thing. LPN B and CNA D were on one side of the bed and CNA A on the other side of the bed. During a telephone interview on 07/08/26 at 12:35 P.M., LPN C said he/she was concerned CNA A was intoxicated. CNA A generally had a bubbly personality, but this was strange, more than normal. He/She didn't know CNA A very well. CNA A was working when he/she was asked about drinking. CNA A said he/she wasn't drinking. LPN C said he/she attributed the behavior to his/her bubbly personality. CNA A was heard loud talking. LPN C said he/she asked who was talking to residents like that? He/She heard yelling, so he/she (LPN C) ran to see who was talking like that. LPN C said he/she heard CNA A say, I know you hear me, then observed CNA A slap Resident #1 across the face with an open hand. The slap was loud and made noise. Resident #1's nose started bleeding instantly, like a line of blood. The resident didn't do anything. Resident #1 made a face but didn't cry. He/She made a sad face. He/She was a quiet person. LPN C told CNA A to get out and not touch another resident. The resident was moved to the nurses station for assessment. Resident #1 held his/her face at the nurse station while being assessed. That's when LPN C said he/she saw the bruises. Another staff member walked CNA A out of area. LPN C said LPN B told him/her that he/she saw CNA A hit someone else, but CNA A said he/she didn't. LPN B said he/she told LPN C that CNA A was tired, and he/she had told CNA A to go home. The facility had an alcohol policy and no drinking on the job. During a telephone interview on 07/06/26 at 8:01 P.M., CNA A said he/she was employed at the facility, and had not been involved in any altercation(s) with any residents. He/She didn't hit Resident #2 in the back. He/She went over resident rights and abuse in orientation. He/She wasn't assessed by LPN B or any other nurse while on shift. He/she never hit Resident #2. CNA A said he/she didn't hit Resident #1 in the face. Resident #1 was being sent out as he/she was being arrested. Resident #1 was non-verbal. He/She never had anything like this happen before. He/She never slapped Resident #1. CNA A said he/she was placed under arrest, booked, and released on 06/28/26. He/She had been arrested and charged for an incident with a resident. He/She said the shift had ended. He/She wouldn't hurt a resident. CNA A didn't think he/she would go back to work at the facility. This was his/her livelihood, so he/she wouldn't risk that. He/She did not drink or do drugs on the job. He/She worked overtime evenings/nights at the facility and agency hours at other facilities. During the investigation, unsuccessful attempts were made to interview LPN B. During an interview on 07/09/26 at 9:48 A.M., a family member said Resident #1 had been discharged to another facility. The doctors wouldn't let him/her go back to the facility and that sounded like the best thing for the resident. After reading the police report, he/she (family member) wouldn't send the resident back. The report found the same staff assaulted another resident (Resident #2) three (3) hours earlier. Apparently, it was witnessed by another nurse, but that nurse didn't call 911 for the first incident. Resident #1 had some bruising. He/She expected the resident to look worse, but his/her The resident's left arm (the only arm the resident can use) was bruised and there was bruising to the face and cheeks. The resident couldn't talk. He/She had a few strokes, was paralyzed and couldn't speak. The answers to questions would be hit and miss. The family member said he/she thought Resident #1 looked scared because he/she didn't know what happened and there were so many different people. Another family member visited Resident #1 in the hospital. He/She said Resident #1 cried the first half hour because he/she didn't know where he/she was or what was going on. Resident #1 was still confused, seeing people he/she hadn't seen before. It was frustrating for Resident #1, and it could be read on his/her face, wanting to say something but couldn't. During an interview on 07/06/26 at 1:25 P.M., the DON said she found out about Resident #2 around 10:00 A.M., 06/28/26. CNA D said LPN B was in the room during the incident. CNA A pleaded not to go home. CNA D said he/she thought CNA A made Resident #2 hit his/her head on the headboard on purpose. Once Resident #2 was turned onto his/her side, CNA A hit him/her in the back. CNA D thought LPN B had reported the incident. The DON said she didn't find out about Resident #2 until 10 A.M. when LPN C told her. LPN C told the DON that he/she overheard CNA D telling the story to the police when they were investigating. CNA D said he/she had reminded LPN B about reporting the incident, so CNA D thought it was reported. The DON said he/she couldn't substantiate Resident #2 because it was one staff word against another. Because CNA D was there along with LPN B, CNA D said his/her reporting part was done. DON said he/she expected LPN B to say something if Resident #2 had been hit in the back. She expected LPN B and any other staff to report what they saw. When questioned, LPN B denied the incident occurred. LPN B was placed on Do not return (DNR) status pending an investigation. LPN B should have told the DON or a manager the alleged incident occurred. The DON said if he/she had known, CNA A would have been suspended, pending investigation and the 2nd incident with Resident #1 would not have happened. The DON said investigation showed that LPN B left the 2nd floor and went to the 4th floor, at the request of LPN C, to assess CNA A because it seemed like something was wrong with him/her. LPN C said he/she was concerned and recommended that CNA A be sent home. At that time, CNA A pulled himself/herself together and said he/she wouldn't do anything to residents. LPN B told the DON he/she would have sent CNA A home, but it wasn't his/her floor. The decision not to follow the recommendation was LPN C's. The DON said LPN C said CNA A pulled himself/herself together and was fine. The situation with Resident #1 happened an hour later. The DON said LPN C said he/she had no other concerns and had monitored CNA A as much as any other staff. During an interview on 07/07/26 at 4:28 P.M., the DON said CNA D's reporting was done because LPN B and CNA D were in the room at the same time the alleged incident occurred with Resident #2. She expected them to call him/her about Resident #2 at the time it happened, because the second incident with Resident #1 could have been prevented. She expected residents to be free from all forms of abuse and staff to notify her of allegations of abuse at the time they happen or as soon as it's possible to do so. 30628603062873

Based on observation, interview, and record review, the facility failed to ensure residents received adequate assistance to prevent accidents for one resident (Resident #3) when Certified Nurse Aide (CNA) A performed an improper transfer resulting in a deep laceration (cut in the skin and soft tissue caused by a sharp object or blunt impact) to the resident's left lower leg. The facility identified the resident as requiring a Hoyer lift (full body mechanical lift) for transfers. CNA A performed a pivot transfer on the resident without the use of a mechanical lift or the assistance of a second person despite knowing the resident required a mechanical lift with two people for transfers. Following the transfer, a deep laceration was noted to the resident's left lower leg. CNA A denied knowledge of how the laceration occurred. The resident was sent out to the hospital, where he/she was found to have a left lower extremity laceration, per the hospital record, the laceration was approximately 9 inches (approximately 23 centimeters (cm)), and down to the bone, requiring dressing changes for treatment. After the incident, CNA A was not sent home and continued to care for residents until the end of his/her shift, including other residents that required the use of a mechanical lift. The census was 133.Review of the facility's Safe Transfers and Handling Policy, revised 7/2026, showed:-It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the residents while keeping the employees safe in accordance with current standards and guidelines.-Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used.-Compliance Guidelines:--The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status.-The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations.-Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies.-Mechanical lifts may include equipment such as full body lifts, sit to stand lifts, or ceiling track mounted lifts.-Handling aids may include gait belts, transfer boards, and other devices.-Two staff members must be utilized when transferring residents with a mechanical lift.-Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment.-Resident lifting and transferring will be performed according to the resident's individual plan of care. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/12/26, showed:-Severe cognitive impairment;-Mobility Devices: Wheelchair;-Upper body dressing: Substantial/maximal assistance;-Lower body dressing: Dependent;-Putting on/taking off footwear: Dependent;-Mobility: Roll left and right, sit to lying, lying to sitting on bed side, sit to stand, chair/bed-to-chair transfer: Dependent;-Walking 10 feet- Not attempted due to medical condition or safety concerns;-Diagnoses include non-Alzheimer's dementia, end stage renal disease (ESRD, kidney disease), malnutrition, anxiety, and heart failure. Review of the resident's care plan, revised 7/31/26, showed:-Focus: Resident requires maximal/dependent assistance with his/her Activities Daily Living (ADL) functions including but not limited to dressing, bathing, hygiene, toileting, mobility, transfers, and locomotion:--Goal: Resident will maintain current level of ADL functions through next review;--Interventions/Tasks: Mobility: --Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. Resident is a dependent on staff; --Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Hoyer lift; --Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). Resident is dependent on staff, 2 staff assist Hoyer lift; --Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. Resident is a dependent on staff; --Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. Resident is a dependent on staff; --Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Resident is a dependent on staff.-Focus: Resident is at risk for falls related to unsteady balance, poor safety awareness, and use of psychotropic medication:--Goal: Resident will remain free of serious injury related to falls now through next review; --Interventions/Tasks: Anticipate and meet the resident's needs, the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, bed in the lowest position at all times. Review of the resident's medical record showed a skin assessment, dated 7/31/26, showed:-Skin Intact: Yes;-New skin concern: No;-Excessive dry or flaky skin: No;-Rashes: No;-Reddened areas that remain after 30 minutes of pressure reduction: New Finding. Order in place: Blank;-Physician or Nurse Practitioner Notified of New Findings: Yes;-Open lesions, cutes, lacerations, or skin tears: No;-Blister(s): No;-Bruise(s): No;-Open area(s) such as pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction), venous ulcers (ulcers caused by decrease in blood circulation), arterial ulcers (ulcer caused by decreased blood circulation): No;-Moisture Associated Skin Damage (MASD): No;-Any Edema (swelling): No;-Body Diagram (Skin Observation): Blank;-Comments and Orders (New or Old) to address skin abnormalities: reddened area on bone at base of great toe. Review of the resident's progress notes, showed:-On 8/2/26 at 11:35 A.M., called to the resident room by an aide stating that the resident had a skin tear and it was bleeding, upon assessment this nurse noted resident left lower extremity had a deep laceration. Physician, Director of Nursing (DON), responsible party, and hospice all made aware. Orders to send the resident to the emergency room for evaluation and treatment, ambulance called to transport resident to hospital waiting for arrival;-On 8/2/26 at 12:05 P.M., ambulance and two Emergency Medical Technicians (EMTs) here to transport resident to the hospital. Review of the emergency department (ED) hospital records showed: -An emergency room physician note, dated 8/2/26 at 1:04 P.M, which included:History of Present Illness: The patient presents for evaluation of a laceration. He/She is accompanied by a hospice nurse.-The patient sustained a significant laceration during an independent transfer conducted by a staff member at their facility. The circumstances surrounding the incident are unclear, as the staff member involved was unable to provide an explanation.-The accompanying hospice nurse reports that Emergency Medical Services (EMS) have expressed concerns about the facility's handling of such situations.-Medical Decision Making: Resident on hospice in a facility coming in with left lower extremity laceration, about 9 inches, down to the bone, skin is torn, underlying flesh is macerated (the softening, whitening, and breakdown of skin caused by prolonged exposure to moisture), he/she was apparently being moved by somebody at the facility alone when he/she is supposed to use a Hoyer lift. That caregiver apparently does not know how he/she got the laceration. Patient unable to provide any additional information, does wince during evaluation of the extremity laceration. See imaging in chart. Vital signs notable for hypertension (high blood pressure), x-ray without evidence of acute underlying fracture. Discussed with trauma service given how extensive the wound is. They do not think the tissue would be viable if they attempted repair, recommend wet-to-dry dressing with Xeroform (non-adherent dressing) , outpatient follow-up in their clinic in the next 1 to 2 weeks.-A ED course note dated 8/2/26 at 3:47 P.M., General surgery consulted. They recommend Xeroform and wrapping the wound, damaged tissue not viable. Will discharge back to facility. Review of the resident's, electronic Physician Order Sheet (ePOS), showed:-An order dated 8/3/26 and discontinued 8/5/26, gently clean around the wound with saline or mild soap and water. Place Xeroform directly on the wound. Wrap site with gauze/kerlix (gauze wrap). Day shift every Monday, Wednesday, Friday for left lower extremity.-An order dated 8/4/26 and discontinued 8/5/26, for Mupirocin (antibiotic) Topical Ointment 2%. Apply transdermal (topical) one time a day to left lower leg.-An order dated 8/7/26, gently clean with wound cleanser. Apply mupirocin. Place Xeroform directly on the wound. Cover with ABD (thick, highly absorbent dressing), cover with rolled gauze and ACE wrap. Day shift every Monday, Wednesday, Friday for left lower extremity.-An order dated 8/7/26, for Mupirocin Topical Ointment 2%. Apply transdermal one time a day every Monday, Wednesday, Friday to lower left leg.-An order dated 9/2/26, for Mupirocin Topical Ointment 2 %. Apply transdermal one time a day every Monday, Wednesday, Friday to lower left leg. New order noted for triple antibiotic ointment (TAO) to be used until it becomes available. Review of the resident's medical record, showed:-A progress note, dated 8/5/26 at 12:04 P.M., Hospice here and changed wound dressing to left leg. Received new orders to discontinue carvedilol (medication to treat high blood pressure) and torsemide (medication used to treat fluid retention) due to low blood pressure;-A progress note, dated 8/8/26 at 9:24 A.M., removed old dressing, no odor no drainage, slight bleeding, cleansed with normal saline, applied Mupirocin ointment, covered with Xeroform, cover with ABD, wrapped with Kerlix secured with paper tape.-A progress note, dated 8/9/26 at 9:00 A.M., removed old dressing, no odor no drainage, slight bleeding, cleansed with normal saline, applied Mupirocin ointment, covered with Xeroform, covered with ABD, wrapped with Kerlix, secured with paper tape, wrapped loosely with ACE wrap secured with paper tape.-A progress note, dated 8/16/26 at 9:39 P.M., cleansed with normal saline and covered with Xeroform gauze and Bactroban (topical antibiotic medication) ointment wrapped with Kerlix loosely and ACE wrap. Tolerated well.-A progress note, dated 8/17/26 at 11:26 A.M., wound assessment noted for skin tear to left lower leg, measuring 16.0 cm x 4.5 cm x 0.4 cm, pink to red, edges open, moderate sanguineous (bright, red blood) drainage noted, improvement noted, treatment continues as ordered. Morphine (opioid pain medication) given for verbal complaints of pain.-A progress note, dated 8/24/26 at 1:18 P.M., hospice here and changed dressing to left leg.-A progress note, dated 9/2/26 at 11:19 A.M., resident noted to not have Mupirocin ointment available for treatment to be changed to left lower leg. New order noted, may use TAO. Observation and interview on 9/2/26 at 9:36 A.M., showed Resident #3 in his/her room. The resident sat in his/her Broda chair with the chair reclined and his/her eyes closed. The resident had an ace wrap to the left lower leg. The ADON gathered supplies for the dressing change and entered the resident's room. The ADON removed the dressing dated 8/31. The open wound measured 13 cm long by 2.1 cm wide at top where it is the widest. It extends down along the shin bone in an uneven line. The ADON said she was told the area was open when it happened and measured approximately 16 cm by 5 or 6 cm. The physician at the hospital thought the resident would need surgery but then they did not do it. The ADON pushed around on the open area and says it is soft but not boggy (soft, spongy, or mushy). The resident appeared to be asleep for most of the dressing change except when the ADON touched the open area. When touched, the resident opened his/her eyes, looked at the ADON, and then closed them again. The hospital was going to do sutures, but they would have had to go underneath and do surgery to do that. They decided not to do that as it was deep. The resident did not have blood blisters or other wounds to the leg prior to the transfer. The ADON finished the dressing change per the order and left the room. During an interview on 9/1/26 at 12:10 P.M., the Assistant Director of Nursing (ADON) said she is the wound nurse and the nurse manager for Resident #3's floor. The resident got hurt when an agency CNA did a transfer without a Hoyer. The leg got caught or slipped down and EMS was called. The aide was put on do not return status within five minutes. The incident happened over a weekend on day shift. We have a list of resident transfer statuses on the floor. She would expect agency staff to get their assignment and then check the list. We also try not to have the entire floor agency. The ADON is not sure if that was the agency CNA's first time here. During an interview on 9/1/226 at 12:30 P.M., CNA E said he/she is one of the restorative aides. The aides know the resident's transfer status because there is a list and then CNAs also are informed when they do start of shift rounds. If a resident is a Hoyer transfer, staff cannot get them up or transfer them without a Hoyer lift and a Hoyer pad. The resident can get hurt. During an interview on 9/1/26 at 12:37 P.M., CNA G said there is a book by the nurse's station to list the resident transfer status. If a resident is a Hoyer lift, there is no reason to not use a Hoyer lift for transfer with 2 people. If there is no Hoyer lift available or another person is not available, staff are not to get the residents up. During an interview on 9/1/26 at 1:10 P.M., the DON said after getting statements from staff, she found the agency aide was informed of the resident's transfer status and given instructions to use the Hoyer lift, but he/she never used the Hoyer lift. The aide had the Hoyer pad in the chair in the room but did a pivot transfer by themselves instead. The resident had a blood blister on his/her shin, and it must have busted open. Initially CNA A lied. He/She put pants on the resident to cover the blood and did not report the injury. She believes the nurse or one of aides went by the room and saw blood on floor. CNA C and LPN B told CNA A the resident had to be up for lunch, and CNA A was told how to transfer the resident. CNA A was also told to just grab someone when he/she was ready to use the Hoyer lift. CNA A first told the nurse he/she used Hoyer lift. That did not make sense because that takes two people and how would the resident have that type of injury if the aide had used the Hoyer lift. LPN B called the DON when CNA A revealed the truth. She does not remember if the aide was sent home. The aide may have gotten angry and left. The DON got statements and the aide has not been back since. During an interview on 9/1/26 at 1:54 P.M., Human Resources looked at the timecards for 8/2/26 which showed CNA A worked from 8:27 A.M. until 3:31 P.M. The aide was not on the staffing sheet provided for 8/2/26, but there may have been a call-in that CNA A was filling in for and CNA A was not updated on the sheet. She confirmed that CNA A was put on do not return list that day. During an interview on 9/1/26 at 3:39 P.M., the DON said LPN B was the assigned nurse for the resident with CNA C assisting. CNA C no longer works at the facility. Review of CNA A's signed statement showed: Around 11:20 A.M., I was informed by another staff member that Resident #3 had to be up for lunch. Upon getting him/her dressed I noticed a skin tear to the left leg while getting him/her dressed. It was a very dark purple skin ear. While rolling him/her back and forth to put his/her pants on he/she stated his/her leg and pointed to it. I transferred the resident by myself from the bed to the wheelchair. When I leaned the wheelchair back to position the resident right in his/her chair I noticed blood coming through his/her paints. The skin tear appeared to be bleeding heavily. I then went and got my nurse, LPN B, he/she pulled the resident's pant leg up and we observed a deep gash. Looks like it opened up. LPN B cleaned it to the best of his/her ability, called responsible parties, and ambulance. During an interview on 9/3/26 at 9:02 A.M, CNA A confirmed he/she worked on 8/2/26 as a CNA and was assigned to Resident #3. When he/she got there he/she was told who he/she was supposed to get up and was told to not get up Resident #3. Then, a different staff person told CNA A to get the resident up. It was around lunchtime. The resident was a Hoyer lift. CNA A went to prepare to get the resident up. CNA A said the facility staff were rude from the minute he/she got there and did not help. CNA A got the resident dressed. He/She then moved the resident from the bed to the chair. When CNA A was putting the resident in the chair he/she noticed left leg had a skin tear/old bruise. It must have reopened and came out to the surface during the transfer. CNA A went and got the nurse, LPN B, who came in to assess the resident. The nurse said that the resident is a Hoyer lift, so he/she hoped CNA A did not use the Hoyer lift by themselves. CNA A responded and said no, he/she knew not to use the Hoyer lift by him/herself, he/she just transferred the resident him/herself from the bed to the Broda chair, and that the resident was an easy transfer, really tiny. When CNA A first went to sit the resident up, the resident was wheezing so CNA A let the resident sit on the side of the bed for a minute and then transferred him/her to the chair. Before CNA A got the resident up, the resident was a little wet. The resident also had a purple gash that was covered. CNA A said he/she does not know what to call it, but it was covered with a patch and it looked like they had been treating it. The resident did not bump his/her leg when he/she transferred the resident, so he/she was not sure what happened. The Broda chair would not recline to allow CNA A to raise the resident's leg, so he/she had to just let the blood run down. The staff said they would help him/her when needed, but then he/she could not find anyone when he/she went to get the resident up, so he/she just moved the resident by him/herself. The resident was sent to the hospital after the transfer. CNA A said he/she left at 3:00 P.M. He/She had to transfer residents by himself/herself the whole shift and pivot them on his/her own. CNA A said he/she only had one other Hoyer lift on his/her assignment. The nurse finally helped him/her with that Hoyer. During an interview on 9/2/26 at 10:25 A.M., LPN B confirmed he/she worked on 8/2/26 and was at the nurse's station when the agency aide came up to him/her. CNA A told LPN B he/she did not know if the resident needed treatment, but he/she needed some kind of dressing because his/her leg was bleeding like a skin tear. LPN B immediately went into the resident's room to assess the resident. LPN B said the resident was sitting in his/her Broda chair with a pool of blood under the chair. LPN B asked CNA A what happened and if CNA A transferred the resident by themselves with a Hoyer lift because the Hoyer pad was on the chair and the Hoyer was also in the room. CNA A replied no, he/she lifted the resident by him/herself and put the resident in the chair. LPN B had the CNA write a statement and called his/her boss because it was extreme gash/laceration. The resident was sent to hospital. The rest of day the aide kept saying, they set me up and that the leg was like that. LPN B said there is no way it was like that. CNA A stayed the rest of the shift. The DON/Manager did not tell him/her to send the CNA home, just told him/her to send resident to hospital and get statements. The resident went immediately to the hospital. LPN B called family and left a message and believed the DON eventually talked to them. CNA A said at first he/she was going to keep the resident in bed but then was told the resident needed to get up. This happened before lunch. There were enough staff to ask for help if that aide needed help. LPN B said he/she has never seen anything open like that and has been a nurse for 20 years. When he/she saw the open area, he/she was like whoa and like how? He/She looked at the Hoyer lift to see if there was any blood on it because of the pool of blood under the resident and did not see any. LPN B just does not know how the resident got a gash that deep. There were 2 aides on each side so plenty of staff to assist. During an interview on 9/2/26 at 11:05 A.M., CNA C said he/she worked on 8/2/26. There was an agency CNA, CNA A, that did an improper transfer because the CNA did not use the Hoyer lift. CNA C was at lunch and when he/she came back that is when he/she saw the resident. CNA C said he/she told CNA A the resident was a 2-person Hoyer assist and to let him/her know when he/she needed assistance. Instead, CNA A went and did it by themself. When CNA C came back from lunch, the resident's leg was messed up. CNA A had put pants on to cover it up. CNA A never asked for help. The resident must sit up to eat. CNA A was already told at the beginning of the shift, the resident needed to get up at lunch and to let CNA C know when ready. There was blood all over, the nurse cleaned it up. The resident was sent to the hospital. CNA A did not leave, he/she completed the shift. During an interview on 9/2/26 at approximately 11:00 A.M., CNA D said he/she was up on the resident's floor on 8/2/26 but did not have the resident on his/her assignment. CNA A did talk to him/her and told him/her that the resident's leg was like that and the staff over there acted like CNA A did that to the resident. CNA A said he/she knew the resident was a Hoyer lift. The side Resident #3 was on, is the other side of the hall from his/her assignment, so CNA C was CNA A's partner. He/She was never asked to write a statement and just told CNA A to talk to the Administrator. If the resident is a Hoyer lift for transfer, then staff are supposed to use the Hoyer lift with two people. During an interview on 9/2/26 at 11:14 A.M., CNA E said he/she worked as a CNA on 8/2/26 but was not the assigned aide for the resident. LPN F was working with him/her passing medications when CNA A came up to them to ask about the resident. CNA A asked if they were regular staff and if the resident had a bruise on his/her leg. CNA E told CNA A that he/she does not know. He/She then went to the resident's room to look at the resident. The open area looked like it had just happened. CNA A had called someone, and CNA E could hear the conversation. He/She said it sounded like they were telling CNA A what to put on a statement. CNA A also had the phone in his/her hand like he/she was talking to someone when he/she first came over to them. When he/she got down to the resident, the nurse had already cleaned the resident up to get him/her to the hospital. Both the paramedics and nurse were there. The area was fresh. The resident was sent out. There was a lot of blood. The resident is not alert. CNA A was working with CNA C who would help other staff if asked. CNA A just did not get help. During an interview on 9/4/26 at 1:30 P.M. LPN F said he/she worked on 8/2/26 but was on the opposite side of the resident. He/She was passing medications on her hall when a CNA who he/she believes was agency came over to talk to him/her and the other CNA on that hall. The aide said he/she had Resident #3 and asked if he/she was familiar with him/her because he/she believes something happened on a previous shift. LPN F said he/she told the aide, no, because and the other CNA did not know either. The agency aide walked off mumbling. LPN F said he/she did not go over there and look. There was another nurse over there. Further along in the shift, he/she asked the nurse on that side, LPN B, if something happened and the nurse said the resident had skin tears and had to be sent out to the hospital. During an interview on 9/2/26 at 11:40 A.M., the DON said the incident with the resident happened on 8/2/26 after 11:00 A.M. After the nurse, LPN B got resident situated he/she called the DON. It was within the hour. The DON said this was improper transfer, maybe CNA A was rushed. CNA A made a bad decision and did an improper transfer. She would not have expected nurse to send CNA A home because she does not think it was intentional. It was a bad decision. The resident had a skin tear, a big one, no bruise. There are no other written statements besides CNA A. She just talked to staff on phone and did not have them write a statement. During an interview on 9/2/26 at 9:26 A.M., the resident's Nurse Partitioner (NP) said he/she started to come to the facility in July but started officially seeing everyone is August. He/She is familiar with the resident now. The NP would expect staff to use 2 people if they are a 2-person assist and to use 2-person assist with the Hoyer lift if they are ordered to be a Hoyer transfer. Therapy orders the Hoyer lift to be used for transfers for safety reasons. During an interview on 9/2/26 at 12:53 P.M., the Administrator said she would expect staff to follow the facility's policy and physician orders. She would consider the incident a poor decision considering staff did tell CNA A the resident was a Hoyer transfer. The help was there. She does not know if she would have expected the nurse to send CNA A home. If it was facility staff, then staff would have disciplined and in-serviced for not following policy. 3131091

Based on interview and record review, the facility failed to ensure physician-ordered treatment was provided for one resident (Resident #3) by failing to obtain and administer the ordered Gentamicin (antibiotic) catheter (a thin, flexible tube inserted into the body to drain fluids, deliver medications, or perform diagnostic tests) irrigation solution in a timely manner. Facility staff failed to provide the ordered treatment for four out of fifteen days in [DATE]. On [DATE], the resident requested removal and replacement of the urinary catheter because the ordered antibiotic irrigation had not been administered. During catheter replacement, there was no urine return, and bleeding occurred that staff was unable to control. The resident required transfer to the hospital for evaluation and catheter replacement. In addition, the facility failed to maintain documentation identifying the pharmacy used to obtain the resident's Gentamicin irrigation solution. The census was 128.Review of the facility's Medication Reordering policy, date reviewed/revised 06/26, showed:-Policy: It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident;-Definition:-Biologicals are products made from a variety of natural sources that are used to treat, prevent or diagnose diseases and medical conditions (such as vaccines, blood or blood components, allergenics, gene therapy, and recombinant therapeutic proteins);-Pharmaceutical services refers to the process of receiving and interpreting prescriber's orders (e.g., acquiring, receiving, storing, controlling, re-ordering medications, etc.);-Acquiring medication is the process by which the facility requests and obtains a medication;-Policy Explanation and Compliance Guidelines:-The facility will use a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident;-Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner;-Each time a nurse is administering medication and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permitting;-The nurse that is assigned to each medication cart will perform a medication cross match every Thursday night;-In the event of new orders, the facility is allowed (24) hours to begin a medication unless otherwise specified by the physician. Review of the facility's Catheter Care policy, dated/revised 06/26, showed:-Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use;-Policy Explanation:-Catheter care will be performed every shift and as needed by nursing personnel;-Compliance Guidelines:-Gather supplies needed;-Document care and report any concerns noted to the nurse on duty. Review of Resident #3's Physician Order Sheet (POS), in use at the time of the investigation, showed:-Ordered: [DATE];-End: Indefinite;-Gentamicin solution Foley (a sterile flexible tube inserted into the bladder to continuously drain urine) flush. Use a 60-cubic centimeter (cc) catheter tip syringe draw up 50 milliliters (ml) of Gentamicin into syringe. Gently push out the air. Disconnect catheter from bag. Allow all the urine to drain from the bladder. Once bladder is empty, attach syringe to end of catheter and slowly push into bladder. Once syringe is empty, leave it attached to the catheter for 60 minutes. You may need to clamp catheter at the end of the dwell time. Unclamp catheter. Let the fluid drain out on its own into drainage bag. Review of the resident's medical record, showed:-Pharmacy used was the facility's preferred pharmacy;-The resident's preferred pharmacy was not listed. During an interview on [DATE] at 3:15 P.M., a technician at the facility's preferred pharmacy said the Gentamicin had never been filled with this pharmacy. The order was not in the resident's profile. He/She didn't see it. Review of the resident's progress notes, showed:-[DATE] at 10:58 P.M., resident continues antibiotic therapy (ABT) Gentamicin 480 milligram (mg)/Liter (L) catheter flush every evening shift related to history of urinary tract infection (UTI). Upon entering to attempt treatment, nurse noted the bottle was empty; pending reordering from resident choice of pharmacy. Nurse attempted to call in the reorder to the pharmacy, but it closed. A.M. nurse to follow up with orders. Resident now resting in bed. No signs/symptoms (S/S) of distress noted, catheter intact with amber urine return in bag;--[DATE] - no documentation related to Gentamicin at pharmacy of choice follow-up;-[DATE] at 11:20 P.M., Medication Coordination: noted the Gentamicin 480 ml solution script is currently unavailable at the facility. A refill request was called in to the resident's preferred pharmacy. A voicemail message was left for the pharmacist to contact the facility regarding the status of the refill;Catheter care: Due to the temporary absence of the Gentamicin solution, the resident's suprapubic catheter was irrigated utilizing normal saline; Plan: Track the return call from the pharmacy to secure the Gentamicin refill and continue to monitor catheter patency and urinary output;-[DATE] at 12 A.M., encounter;-Visit type: Acute/ Follow-up;-Catheter and ostomy care every shift;-The resident's suprapubic catheter has an order from Urology to be irrigated utilizing Gentamicin. Solution was not available today and normal saline was utilized; --No normal saline order for catheter irrigation noted;-[DATE] at 3:28 P.M., Gentamicin solution catheter flush. Use a 60-cc catheter tip syringe. Draw up 50 ml of Gentamicin into syringe. Gently push out the air. Disconnect catheter from bag. Allow all the urine to drain from the bladder. Once bladder is empty, attach syringe to end of catheter and slowly push into bladder. Once syringe is empty, leave it attached to the catheter for 60 minutes. You may need to clamp catheter. At end of the dwell time, unclamp catheter. Let the fluid drain out on its own into drainage bag every evening shift for antibiotic flush. Flush before going to bed. On order from pharmacy. Review of the resident's Medication Administration Record (MAR), dated 06/2026, showed:-The resident had an 18 French catheter and 30 cc balloon (found on Foley catheters and used for post-operative drainage, urological interventions or to apply pressure to stop bleeding);-Gentamicin Solution Foley flush. Use a 60-cc catheter tip syringe. Draw up 50 ml of Gentamicin into syringe. Gently push out the air. Disconnect catheter from bag. Allow all the urine to drain from the bladder. Once bladder is empty, attach syringe to end of catheter and slowly push into bladder. Once syringe is empty, leave it attached to the catheter for 60 minutes. You may need to clamp catheter at the end of the dwell time. Unclamp catheter. Let the fluid drain out on its own into drainage bag, every evening shift for antibiotic flush. Flush before going to bed. Start [DATE];--[DATE] - Code 13 (Medication not available);--[DATE] - Code 13 (Medication not available);--[DATE] - Code 13 (Medication not available);--[DATE] - hole in MAR; (no documented initials and/or numerical code reflecting medication administered or not) Review of the resident's nursing notes, showed: -On [DATE] at 7:30 A.M., called to room/room/other nurse. He/She was unable to flush resident's catheter. Old catheter removed, 16 French (F) with 10 milliliter ml balloon inserted, did not obtain immediate return of urine. Nurse Manager (NM) in room to assess;-A note, dated [DATE] at 9:32 A.M., showed around 8:30 A.M., the charge nurse informed this nurse he/she changed the residents' catheter per the resident's request stating it hasn't been flushed. Charge nurse stated there were no issues when changing it out. The aide came to the charge nurse saying there wasn't any urine entering into the bag. This nurse went to see what was going on. This nurse flushed the catheter with no return. The resident said put in another one. This nurse released the fluid from the bulb of the catheter and slowly pulled it out with no difficulty. As the catheter was coming out there was some bright red blood. After fully removed (catheter), the resident continued to bleed. The aide and this nurse attempted to stop the bleeding. Pressure applied, cold wash cloth applied to aid with slowing the blood flow. Blood continued with no signs of slowing down. Had the charge nurse call for ambulance. All parties notified. During an interview on [DATE] at 10:15 A.M., LPN G said he/she went in to flush the catheter. It wouldn't flush, plunger sprayed back. He/She got another nurse. Inserted a new catheter, no urine after ten minutes. Bleeding started when the catheter was pulled out. 911 was called. Applied pressure but bleeding didn't stop. LPN G needed a coude (curved catheter) tip catheter to go around the prostate. It wasn't put in the resident's notes that they needed a coude, but it was now. LPN G said the resident told the DON they needed a coude when the resident came back from the hospital, but it wasn't in the notes. Review of the resident's hospital discharge paperwork, showed:-No admission or discharge date provided on the hospital discharge documentation provided by the DON on [DATE] at 4 P.M.-Additional Instructions: You were seen in the emergency room (ER) today for evaluation of catheter replacement and some blood at the meatus (the external opening at the tip of the penis). Bleeding resolved with placement of catheter and evacuation of clots. It is important that your catheter is flushed appropriately at your care facility to prevent re-accumulation of clot. Your urinalysis today shows potential infection. We will start you on antibiotics. Review of the resident's nursing note, dated [DATE] at 9 P.M., showed the resident readmitted to the facility. Draining clear yellow urine. The resident will be on Bactrim DS (a combination antibiotic (sulfamethoxazole and trimethoprim) used to treat bacterial infections such as UTIs). Double Strength (DS)) twice a day (BID) times four days. Review of the resident's Medication Administration Record (MAR), dated 06/2026, showed on [DATE] - Code 2 indicating the resident refused the Gentamicin Solution Foley flush. During an interview on [DATE] at10:15 A.M., Licensed Practical Nurse (LPN) G said the resident would never refuse this medication (Gentamicin), because the resident knew what would happen if the catheter wasn't flushed. Review of the resident's History and Physical Code status document, dated [DATE], showed:-Chief Complaint/Nature of Presenting Problem: On [DATE] the charged nurse changed the patient's Foley per the resident's request stating it hadn't been flushed. Later, the aide informed charged nurse there hadn't been any urine enter into the Foley bag. Upon request of the patient to put in another one, as the Foley was coming out there was some bright red blood. Patient was sent to the hospital. Returned on [DATE];-History of Present Illness: Resident resides in this facility due to the ongoing need of nursing care, mediation management, and safety;-Catheter working well;-Chronic, stable but severe functional impairment; Requires total assist with activity of daily living (ADLs), including catheter; -Neurogenic bladder;-Presence of urogenital implants;-Catheter required due to urinary retention secondary to spinal cord injury. Continue catheter care per facility protocol. Monitor UTI, sediment, obstruction. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:-readmitted from acute hospital on [DATE];-Cognitively intact;-Neurogenic bladder (occurs when nerve damage disrupts brain-to-bladder communication);-Paraplegia (the partial or complete paralysis of the lower half of the body, which typically affects both legs and the lower trunk);-Quadriplegia (the partial or total loss of movement and sensation in all four limbs (both arms and both legs) and the torso);-Other additional diagnosis, presence of urogenital implants (medical devices surgically placed to support, repair, or replace the function of the urinary or reproductive systems), calculus of kidney (a hard mineral deposit that forms inside the kidneys)' During an interview on [DATE] at 3:20 P.M., a technician with the resident's preferred pharmacy stated he/she delivered Gentamicin to the resident's home address. When the medication went to the facility, they couldn't find it. The facility didn't order the medication in a timely fashion, not ordered before the medication was empty. On [DATE], the resident's family member picked up the medication. The medication was a compounding chemical/custom medication. It wasn't kept on the shelf. Only made when it was requested. The representative said something was worked out with the resident's family for delivery. The medication was sent to the facility on [DATE], but the facility took a long time to find it. The medication was filled on 06/12 and 7/2. The medication was delivered to the resident's family member and a family member picked up the medication, respectively. During an interview on [DATE] at 10:15 A.M., LPN G said the resident's preferred pharmacy should be included in the resident's medical record. During an interview on [DATE] at 12:15 P.M., the Director of Nursing (DON) said she didn't know the resident was using a different pharmacy or ordering their own medication. She thought the Gentamicin had come from the facility's pharmacy. Resident #3 could order their own medication, but the nurse(s) on the floor was responsible for reordering the medication. She thought Gentamicin reorder timeframe request should be about ten days of dosage left, because she didn't know how long it would take to get or the process for making the Gentamicin. She would reach out to the facility's pharmacy to see if the Gentamicin could come from there. During an interview on [DATE] at 12:15 P.M., the DON said patients don't know they needed a coude tip until they had an issue. She mentioned positioning and said the nurse probably ran into the penis. The manager then tried, but no urine returned. Probably didn't get past the prostate. Removing caused trauma and bleeding. Coude tip is a stiffer type of catheter and should be documented in the resident's records. She expected it to be documented in the record. The DON would have gotten a temporary order for another kind of flush. Saline was acceptable to keep flow open and was a nursing judgement. The nurses should have asked for an order to continue the saline flush until the Gentamicin flush was available. She expected nursing to do have done that. During an interview on [DATE] at 9:36 A.M., Resident #3 said on [DATE] around 10:30 P.M., an agency nurse said he/she couldn't do the flush, because there were no orders for it. The resident did get the flush, but it wasn't until early A.M. on [DATE]. The flush medications came from the resident's preferred pharmacy because it was a special solution that had to be made. It only came from this pharmacy. The resident had to call the pharmacy to order it. The order came from their Urologist. The facility was supposed to take over and have the medication re-filled, was their understanding. The last order was sent to the resident's home on [DATE]. The resident ordered the medication because they wanted it to come. The medication was supposed to go through the facility, but they were not reordering it in time, so the resident ran out. The facility was not ordering it. They resident wanted the medication and said had almost died because the catheter hadn't been flushed. He/She had blood clots. No flushes were done at all. They could have used saline. The catheter was pulled out. The wrong catheter was put in and it got infected. Blood was coming out of his penis. The resident was transferred to the emergency room and was in the hospital for five days. During the interview, observation of the Gentamicin bottle, located in the resident's room, on his/her dresser, showed instill 50 ml into bladder as directed. 480 mg/L NACL Irrigation, 2.0 (the use of a sterile isotonic sodium chloride (salt) solution (0.9%) delivery method) refill before [DATE], expires 08/26. During an interview on [DATE] at 10:15 A.M., LPN G said he/she thought all the residents got all medications from the facility pharmacy. He/She didn't know Resident #3 had a preferred pharmacy. When the Gentamicin first came, they didn't know what to do with the flush. The flushes started a month or two ago. Nothing was sent to the facility by the Urologist office, so they didn't know what to do. This was not a normal flush. [DATE] is when the first bottle showed up. No instructions were sent. The medication was delivered in a bag with no instructions. Staff called for instructions on [DATE]. The resident was supposed to start the flushes on [DATE] but didn't start until [DATE] because there were no instructions. LPN G said he/she didn't know the resident was ordering and/or had been ordering this medication himself/herself. If there were an order and instructions, the facility was responsible for ordering the flush medication. The person responsible for reordering medications was the nurses. The order came from a Urologist outside of the facility. The flush should be done once a day, scheduled for evening shift. Nurses were supposed to re-fill when the amount of liquid in the bottle reached a certain level or dose. LPN G was not sure about the reorder parameter for the Gentamicin but said five days. He/She then held up the thumb and index finger in such a way, indicating two to three inches. He/She said two to three inches represented where the liquid would be from the bottom of the bottle to show it was time to reorder. He/She later said the bottle had rungs (graduations or step-like measuring lines on the side of a liquid medicine container) on it. After going to the resident's room and picking the bottle up from his/her dresser, LPN G said reorder at 300 ml. The resident would have three days. LPN G said the Gentamicin had two refills but didn't know that before looking at the medication bottle. He/She didn't know the medication didn't come from the facility's pharmacy and said he/she would call the number listed on the medication. He/She didn't know why the medication wasn't available, but it should have been. He/She would have called the pharmacy. At first the Gentamicin was kept on the treatment cart, but somehow it ended up in the resident's room. The medication was probably not supposed to be in the resident's room. There was not an order for that. If it were a different resident, it would not be left in the room. The resident could have asked someone to leave it in their room but that should've been documented so everyone would know where the Gentamicin was. During an interview on [DATE] at 12:15 P.M., the DON said orders from the physician should have been followed for the Gentamicin solution Foley flush. She said this didn't happen on any day when the Gentamicin wasn't available. The possible outcomes were clogging, back up of urine not flowing, and infection. She expected staff to get an order for an alternate flush of the catheter and to make sure the Gentamicin was reordered timely and available. She expected the resident's preferred pharmacy and coude tip catheter to be documented. She expected the Gentamicin to be on the medication cart unless the resident had been assessed to have it in his/her room. It may have been on the cart, but Resident #3 may have told staff to leave it in their room. She expected staff to provide care as ordered by the physician. During a telephone interview on [DATE] at 5:10 P.M., the Nurse Practitioner (NP) said she would think the resident's preferred pharmacy would be on their profile because more than one could be on it. When asked who was responsible for ordering medication (Gentamicin), the NP said the initial order should be placed by the physician, after that, the nurse caring for the resident was responsible for reordering the medication. The resident should come back from an appointment with paperwork, the nurse files that paperwork in the resident's chart. That's where the physician looks. The resident should not run out of medication (Gentamicin) and she expected nursing to reorder in a timely manner. When asked what indefinite meant as it related to end date of a physician's order, she said it meant no end to the order until the Urologist reassessed and determined the order needed to end. She said if the physician order and/or MAR said to use 18 French catheter, the nurse needed a physician order to use anything other than that. She expected the nurse to follow the physician order and/or notify the physician if something else was needed. If the medication (Gentamicin) wasn't available, staff should make the provider aware. If a resident misses one dose, that can usually be okay, but if the resident misses more than one dose, that would be a problem, and it was. She expected the facility to reach out to her if the medication was unable so that she could reach out to the Urologist to see if there was another antibiotic that could be used. The medication (Gentamicin) should not be left in the resident's room because the nurses needed it to flush the catheter. She expected that medication to be on the nurse's cart. The physician's order would have been another way to communicate the coude. If it was determined the resident needed a coude tip catheter, the information should have been added to his/her medical records and passed along. When asked what the DON meant by the catheter probably into the penis? NP said it meant the catheter went through the urethra to the prostate, poking and caused bruising and trauma. The regular catheter was not flexible whereas the coude was more flexible and curved in comparison. The coude would have allowed the nurse to get around the prostate without causing trauma. When asked about the possible outcomes of not flushing the catheter as ordered, NP said the resident could have clot formations and increased risk of infection, which looks like the resident did. It could lead to sepsis which can lead to death, which was concerning and not optimal. Seems like some of those things happened. NP expected nursing to contact the physician if the medication was not available, to use the physician order sized catheter, keep medication on the nurse cart, unless there was an order stating otherwise, flush the catheter as ordered, and for the resident's record to be complete and accurate. Review of email correspondence dated [DATE] at 1:33 P.M., the DON provided a doctor's note that showed:-To whom it may concern;-Re: Resident #3;-This letter is to document an incident that occurred in [DATE] involving Resident #3. During routine catheter care, normal saline flush was used three times instead of gentamicin solution to flush the catheter. The resident experienced no adverse effects or harm as a result of this incident. The resident remained clinically stable, and no complications were identified related to the error;-Medical Director (MD), dated [DATE]. During a telephone interview on [DATE] at 11:28 A.M., the MD said the DON had made him aware of the catheter incident on this past Saturday ([DATE]). He was not aware prior to Saturday and would not have been notified because he only started [DATE]st. He was made aware of the resident paying for and ordering the medication (Gentamicin). The nurse failed to order the medication timely. He didn't think not getting the Gentamicin flush would lead to the blood clots. The catheter is not anchored to anything so the movement and pulling of the catheter could have caused the blood clots. That was somewhat common. The resident was pretty knowledgeable about the catheter and was doing the best they could. The nurse using normal saline without gentamicin was not optimal, but the saline itself was not harmful. He expected nursing to order the medication as soon as possible and notify a physician with concerns. 3039676

Based on observation, interview and record review, the facility failed to ensure staff immediately reported an incident of abuse involving Certified Nursing Assistant (CNA) A and one resident (Resident #2) to the Administrator, in accordance with the facility policy. This resulted in the facility's failure to report the allegation of abuse to the State Survey Agency within the required timeframe of two hours, and CNA A remained in the facility and physically abused a different resident (Resident #1) during the same shift. This deficient practice had the potential to affect all residents receiving care from CNA A. The census was 129. The administrator was notified on 07/08/26 of the past non-compliance which occurred on 06/28/26. When the facility identified the issue, they terminated the employee and in-serviced staff regarding abuse and neglect, with a focus on what to do if staff witnessed abuse, notifying management/Director of Nursing (DON), resident rights, focus to be free from abuse, and mandated reporters. Thedeficiency was corrected on 06/28/26. Review of the facility's Abuse policy, date revised 12/25, showed:-Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse;-Definitions:--Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including facilitated or enabled through the use of technology;--Alleged Violation: a situation or occurrence that is observed or reported by staff, resident, relative, or visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property;--Covered individual: anyone who is an owner, operator, employee, manager, agent or contractor of the facility;--Crime: defined by law of the applicable political subdivision where the facility is located. A political subdivision would be a city, county, township or village, or any local unit of government created by or pursuant to State law;--Mistreatment: inappropriate treatment or exploitation of a resident;--Physical Abuse: includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment;--Serious Bodily Injury: an injury involving extreme physical pain; requiring medical intervention such as hospitalization;--Staff: includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program, and students from affiliated academic institutions, including therapy, social and activity programs;--Verbal Abuse: the use of oral, written or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability;-Policy Explanation and Compliance Guidelines:-The facility will provide ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written;-Possible indicators of abuse include, but are not limited to:--Resident, staff or family report of abuse;--Physical marks such as bruises or patterned appearances such as handprint, belt or ring mark on a resident's body;--Verbal abuse of a resident overheard;--Physical abuse of a resident observed;--Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame;-Investigation of Alleged Abuse:-An immediate investigation is warranted when suspicion of abuse or reports of abuse occur. Review of the facility's Compliance with Reporting Allegations of Abuse, date revised 12/25, showed:-Policy: It is the policy of this facility to report all allegations of abuse or mistreatment immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes;-Procedure for Response and Reporting Allegations of Abuse:--When suspicion of abuse or reports of abuse occur, the following procedure will be initiated:---The LPN will:----Respond to the needs of the resident and protect him/her from further incident;----Remove the accused employee from resident care areas;----Notify the administration or designee;----Notify the attending physician, resident's family/legal representative, and Medical Director (MD);----Monitor and document the resident's condition, including response to medical treatment or nursing interventions;----Document actions taken in the medical record. Review of the facility's Resident Rights policy, date implemented 09/24, showed:-Respect and dignity: The resident has a right to be treated with respect and dignity;-Safe environment: The resident has a right to a safe environment. Review Of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/03/26, showed:-Severely impaired cognition;-Dressing: Dependent;-Toileting hygiene: Dependent;-Wheelchair. Review Of Resident #1's annual MDS, dated [DATE], showed:-Mental Status Assessment: Memory problems, severely impaired, inattention continuously present, doesn't fluctuate;-Behavioral Symptoms:-Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) - Behavior not exhibited;-Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) - Behavior not exhibited;-Upper/Lower extremities: Impairment on one side, Dressing: Dependent, Toileting hygiene: Dependent;-Diagnoses included but not limited to, hemiplegia (paralysis on one side of the body) or hemiparesis (partial weakness or the inability to move one side of the body), stroke, seizure disorder (recurrent, unprovoked seizures caused by sudden electrical disturbances in the brain), anxiety disorder (persistent, excessive worry and fear that interfere with daily life), and depression (persistent sadness). Review of the facility's investigation, dated 06/28/26, showed:-Review of staffing assignment dated 06/27/26, showed:-200-Cardinal Court, 11 P.M. -7 A. M., LPN B and CNA D;-400-Turtle Cove, 11 P.M. - 7 A.M., CNA A;-Disciplinary Action Form:-Type of offense: Critical;-CNA A termination. Employee was observed becoming physically aggressive with resident. Employee escorted out, police called, and arrested. Review of employee statements, showed:-During an interview on 06/28/26 at 4 P.M., CNA D said at approximately 2:50 A.M. he/she and CNA A were in the room changing the Resident #2. LPN B entered the room and assisted in changing the resident. While repositioning the resident and pulling him/her up, CNA A used so much force that the resident bumped his/her head on the headboard. Afterwards, CNA A balled up his/her fist and punched Resident #2 in his/her lower back. CNA D said he/she didn't request any help from CNA A. He/She was standing at the nurse station talking to LPN B when he/she requested help from LPN B. CNA A insisted on assisting and LPN B said, this my girl, referencing CNA A as his/her (LPN B) friend. When the incident occurred LPN B, CNA A, and CNA B were all in the room. CNA D said he/she later reminded LPN B about CNA A hitting Resident #2 in the lower back. He/She told LPN B that CNA A acted like something was wrong with him/her. He/She told LPN B that he/she didn't want CNA A's help ever. CNA D told LPN B that he/she didn't need help from anyone that mistreated residents.;-On 06/28/26 at 1:36 P.M., LPN B said he/she did not witness any staff member strike Resident #2. The resident displayed no behavior consistent with being struck. No allegations of a punch were made to him/her by CNA D during, or immediately following, the event. Any subsequent allegations of physical abuse did not occur under LPN B's observation and were not reported to him/her during discussions regarding the head bump;-A written statement on 07/02/26 showed LPN B it reported that CNA A pleaded not to be asked to leave work. When CNA A approached LPN B in the pantry stating the resident had urinated on CNA A's leg. LPN B said he/she knew by CNA A's mannerism he/she needed to go home. When he/she spoke with LPN C, he/she told him/her that he/she was sending CNA A home if it was LPN B decision. LPN B informed LPN C that it was his/her unit, his/her decision. LPN B took a ten-minute break. He/She saw CNA A was still at work; -In a written statement, LPN C said at approximately 5:45 A.M., he/she was concerned that CNA A was possibly intoxicated and stated to CNA A that he/she need to go home due to suspicion of intoxication. CNA A reassured and pleaded, refusing to leave.-A follow-up interview on 07/02/26 at 3:00 P.M., showed LPN C said, after pleading not to be sent home, CNA A stated that he/she was tired and had been picking up a lot of shifts elsewhere. He/She got himself/herself together. CNA A seemed fine and didn't appear to be a threat. He/She continued on to his/her job, but LPN C said he/she continued to monitor to be certain no other issues arouse until that very moment at approximately 6:15 A.M. - 6:30 A.M.; -In a written statement, LPN C said at approximately 5:45 A.M. CNA A continued to get Resident #1 up. He/She heard CNA A talking loud and aggressively to the resident. That's when LPN C ran into the hall, noting CNA A slap resident really hard in the face causing a nosebleed. LPN C immediately ran up on to CNA A, telling him/her to get away from resident and leave the building now. CNA A continued to try and plead his/her case stating he/she did nothing wrong. LPN C told CNA A to leave or else. LPN C assessed the resident, noting bruising to both arms that appeared new. Also an abrasion to the forehead and a skin tear to the right elbow. LPN C placed a call to 911 services to report the assault, after speaking with the nurse manager and then notified the family. CNA A was arrested by the police. All made aware. Resident taken to the hospital for assessment;-During an interview on 06/28/26, CNA H said he/she was leaving out of his/her rooms when an unnamed nurse, stopped him/her to let him/her know CNA A was leaving for putting his/her hands on a resident. They called unnamed persons to report the incident. He/She looked over Resident #1 for bruises and found plenty. Throughout the whole night, CNA A slurred his/her words, stumbling, etc. But it just got worse over time, so they honestly were prepared to just do CNA As work so he/she could leave, however CNA A wouldn't leave, even after asking him/her to go multiple times;-During an interview on 06/28/2026 at 7:10 A.M., the DON said he/she was notified that there was an incident in the facility concerning a staff and a resident. Per information that had been received, the staff member became physically aggressive towards the resident. The employee had already been removed, the resident was safe, and the authorities had been called. Upon this nurse arriving at the facility, approximately 7:55 A.M., the employee had been booked and arrested. The resident had been sent to the hospital for an evaluation, families and MD had been notified. Investigation started immediately. DHSS was notified at 7:59 A.M. via hotline. Review of the Emergency Medical Services (EMS) report, dated 06/28/26, showed:-Resident #1;-Primary Impression: Laceration/Abrasion/Hematoma (minor surface trauma);-Chief complaint: Multiple bruising to arms and forehead;-Signs and Symptoms: Multiple injuries (Primary);-Injury: Assault - Assault - Facility 06/28/26;-Mechanism of Injury: Blunt;-Medical/Trauma: Trauma;-Assessment Time: 06/28/26 at 7:09 A.M.;-Mental Status: Oriented - Person;-Head, Eyes, Ears, Nose, and Throat (HEENT):-Comments:-Bruising to forehead, dried blood to nose, redness to cheek;-Abrasion in the middle of his/her back;-Bruising to right arm;-Narrative:-Dispatch notes indicated that a staff member had allegedly assaulted a resident. The patient (Resident #1) appeared to be in mild distress. Initial assessment revealed multiple abrasions to the bilateral upper extremities, and abrasion to the forehead, redness to the right cheek, and dried blood around the nose. The patient was alert and oriented to person only (A&Ox1), which staff reported was his/her normal baseline mental status. Due to his/her cognitive impairment, the patient was only able to answer (yes) when asked if experiencing pain and was unable to provide any additional history or answer further questions. A secondary assessment revealed additional abrasions to the neck, chest, and back. Review of the Police Department Investigative Report 26-467 - Original, showed:-Resident #2;-Red marks on his/her checks and bruising on his/her right forearm;-CNA A;-Charges: Assault - 3rd Degree - Special Victim;-Physical State: Suspected Alcohol Use;-Emotions: Angry, apologetic, crying, hysterical, calm, irrational, threatening;-Emotions Comments: I'll beat your [expletive];-Additional information: This charge is being charged two times two separate victims, same incident;-Narrative: --On 06/28/26 at approximately 6:55 A.M., police were dispatched to the facility for an assault complaint. CNA A was asked if he/she knew what was going on. CNA A said he/she didn't know. -Police reported the following:--A female (LPN C) walked out of the building and pointed to the first lady stating he/she hit one of the patients. Officer then spoke further with the first staff (LPN C), who was working at the time this incident occurred. LPN C informed the officer he/she observed CNA A strike victim (Resident #1) in the face causing his/her nose to bleed. LPN C stated this occurred at approximately 6:20 A.M. After speaking with LPN C, the officer was stopped by CNA D. CNA D state at approximately 2:50 A.M., the same day, while CNA A was treating the victim (Resident #2), CNA D observed CNA A pull Resident #2 up from his/her bed causing him/her to hit his/her head on the headboard of his/her bed. CNA A then hit Resident #2 in the lower back with his/her fist. Officer went to room where Resident #1 was assaulted and observed the room in disarray. The bed and the area around the bed looked like a struggle had taken place. Officer was not able to speak with either of the two victims (Resident #1 and #2) in this case as Resident #2 spoke another language and could not give a statement. Resident #2 was not able to speak either due to an unknown medical condition and seemed to be lethargic. With this information, CNA was arrested on two charges of assault special victim. Officer placed CNA A's hands behind his/her back and handcuffed CNA A. During a telephone interview on 07/07/26 at 3:51 P.M., CNA D said LPN B went to check out CNA A. CNA D wasn't sure if he/she should report it but after CNA A hit Resident #2, he/she asked LPN B if he/she was going to say something after seeing CNA A hit Resident #2 on the back. CNA A was assessed upstairs after he/she hit Resident #2. CNA A hit Resident #2 in the back and rammed his/her head into the headboard around 2:50 A.M. CNA D was headed downstairs to tell the DON. He/She didn't report it to LPN B because he/she was in the room too and saw the same thing he/she saw. LPN B and CNA D were on one side of the bed and CNA A was on the other side of the bed. He/She told the police what he/she saw. The DON wasn't there yet. He/She didn't know anything about the incident with Resident #1. During the investigation, unsuccessful attempts were made to interview LPN B. During a telephone interview on 07/06/26 at 8:01 P.M., CNA A said he/she was employed at the facility, and he/she was not/had not been involved in any altercation(s) with any residents. He/She didn't hit Resident #2 in the back. He/She went over Resident Rights and Abuse in orientation. He/She wasn't assessed by LPN B or any other nurse while on shift. He/she never hit Resident #2. This was his/her livelihood, so wouldn't risk that. He/She did not drink or do drugs on the job. He/She worked overtime evenings/nights at the facility and agency hours at other facilities. Review of Resident #1's incident note, dated 06/28/26 at 10:54 A.M., showed approximately 6:30 A.M. to 7:00 A.M., this resident had been involved in a physical altercation with an employee. The resident was moved to safety and employee was removed from immediate area via another staff member. The resident was assessed via the nurse and injuries were noted. In addition, the resident had a light nosed bleed as a result of the altercation. The resident is alert and oriented to self (A&O x1). Neurological checks were completed and no abnormalities indicated. Resident was sent to the hospital via 911. MD and family were notified of said incident. During a telephone interview on 07/08/26 at 12:35 P.M., LPN C said he/she heard loud talking. LPN C said he/she asked, who was talking to his/her residents like that? He/She heard yelling, so he/she (LPN C) ran see who was talking like that. LPN C said he/she heard CNA A say, I know you hear me, then observed CNA A slap Resident #1 across the face with an open hand. The slap was loud and made noise. Resident #1's nose started bleeding instantly, like a line of blood. The resident didn't do anything. He/She (Resident #1) made a face but didn't cry. He/She made a sad face. He/She was a quiet person. LPN C told CNA A to get out and not touch another resident. The resident was moved to the nurses station for assessment. Resident #1 held his/her face at the nurse station while being assessed. That's when LPN C said he/she saw the bruises. Another staff member walked CNA A out of area. LPN C said LPN B told him/her that he/she saw CNA A hit someone else but CNA A said he/she didn't. LPN B said he/she told LPN C that CNA A was tired, and he/she had told CNA A to go home. During an interview on 07/09/26 at 9:48 A.M., a family member said after reading the police report, he/she (family member) wouldn't send the resident back. The report found that the same staff assaulted another resident (Resident #2) three (3) hours earlier. Apparently, it was witnessed by another nurse, but that nurse didn't call 911 for the first incident. Resident #1 had some bruising. He/She had a few strokes and was paralyzed and couldn't speak. The answers to questions would be hit and miss. The family member said he/she thought Resident #1 looked scared because he/she didn't know what happened and there were so many different people. Another family member visited Resident #1 in the hospital. He/She said Resident #1 cried the first half hour because he/she didn't know where he/she was or what was going on. There were so many nurses at the facility Resident #1 knew and liked, that is why it was such a shock when the family got the call about what happened. Resident #1 was still confused, seeing people he/she hadn't seen before. It was frustrating for Resident #1, and it could be read on his/her face, wanting to say something but couldn't. During an interview on 07/06/26 at 1:25 P.M., the DON said she found out about Resident #2 around 10 A.M., 06/28/26. CNA D said LPN B was in the room during the incident. CNA A pleaded not to go home. CNA D said he/she thought CNA A made Resident #2 hit his/her head on the headboard on purpose. Once Resident #2 was turned onto his/her side, CNA A hit him/her in the back. CNA D thought LPN B had reported the incident. The DON said she didn't find out about Resident #2 until 10 A.M., when LPN C told her. LPN C told the DON that he/she overheard CNA D telling the story to the police when they were investigating. CNA D said he/she had reminded LPN B about reporting the incident, so CNA D thought it was reported. Because CNA D was there along with LPN B, CNA D said his/her reporting part was done. DON said he/she expected LPN B to say something if Resident #2 had been hit in the back. She expected LPN B and any other staff to report what they saw. When questioned, LPN B denied the incident occurred. LPN B should have told the DON or a manager that the alleged incident occurred. The DON said if he/she had known, CNA A would have been suspended, pending investigation and the 2nd incident with Resident #1 would not have happened. The DON said investigation showed that LPN B left the 2nd floor and went to the 4th floor, at the request of LPN C, to assess CNA A because it seemed like something was wrong with him/her. LPN C said he/she was concerned and recommended that CNA A be sent home. At that time, CNA A pulled himself/herself together and said he/she wouldn't do anything to residents. LPN B told the DON he/she would have sent CNA A home, but it wasn't his/her floor. The decision not to follow the recommendation was LPN C. DON said LPN C said CNA A pulled himself/herself together and was fine. The situation with Resident #1 happened an hour later. The DON said LPN C said he/she had no other concerns and had monitored CNA A as much as any other staff. During an interview on 07/07/26 at 4:28 P.M., the DON said CNA D's reporting was done because LPN B and CNA D were in the room at the same time the alleged incident occurred with Resident #2. She expected them to call him/her about Resident #2 at the time it happened, because the second incident with Resident #1 could have been prevented. She expected residents to be free from all forms of abuse and staff to notify her of allegations of abuse at the time they happen or as soon as it's possible to do so. 30628603062873

Based on interview and record review, the facility failed to appropriately respond to one resident's (Resident #35) change of condition and/or conduct and document a thorough assessment and contact the resident's physician. The resident began vomiting on 02/25/26, continued to vomit through 03/01/26 when staff called 911 to send him/her to the hospital. Staff documented the nurse practitioner (NP) assessed the resident on 2/26/26. The order for ondansetron (Zofran, anti-nausea medication) was sent on 2/27/26. Staff administered the medication on 2/27/26 at 1:53 P.M. The resident continued to vomit after the administration of the medication. On 2/28/26, staff said the vomit started to darken in color. Staff did not document notification to the physician when the vomiting continued or darkened in color until 3/1/26. On 3/1/26, the nurse notified the physician's office after the resident vomited three times during the day with the last time being a copious amount of black emesis (vomit). Staff called 911 to send the resident out, and he/she expired upon arrival at the hospital. The sample was 15. The census was 130. The Administrator was notified on 04/24/26 at 4:00 P.M., of an Immediate Jeopardy (IJ) which began on 2/28/26. The IJ was removed on 04/24/26, as confirmed by surveyor onsite verification. Review of the facility's Notification of Changes policy, dated 9/24, showed:-Policy: The purpose of the policy is to ensure the facility promptly informs the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification;-Definitions: --Life-threatening conditions: Examples-heart attack or stroke; --Clinical complications: Examples - development of a stage 2 pressure ulcer, recurrent episodes of delirium, recurrent urinary tract infections or onset of depression;-Circumstances requiring notification include: --Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: -Life-threatening conditions or; -Clinical complications; -Circumstances that require a need to alter treatment. This may include: --New treatment; --Discontinuation of current treatment due to: --Adverse consequences; --Acute condition; --Exacerbation of a chronic condition. Review of Resident #35's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/11/25 showed:-Resident admitted on [DATE];-Diagnoses included: Cerebral palsy (a group of conditions that affect movement and posture), muscle weakness, dysphagia (difficulty swallowing), chronic heart failure, epilepsy (chronic neurological disorder characterized by recurrent, unprovoked seizures), and unspecified convulsions (rapid, involuntary and rhythmic muscle contractions). Review of the resident's care plan dated 4/16/25, showed:-Focus: Resident has impaired cognitive function or impaired thought processes related to developmentally delayed;-Interventions: Administer medications as ordered. Review of the resident's progress notes, showed:-On 02/26/26 at 11:47 A.M., the resident warm, clammy, and refused breakfast. He/She was COVID negative. Staff placed a call to the nurse practitioner and were awaiting his/her arrival to the floor;-A late entry dated 04/22/26 at 4:38 P.M., by the NP, showed on 02/26/26, no time noted, the resident experienced nausea and vomiting. The nausea was improving with recent concern for infectious gastroenteritis (stomach flu) exposure in the facility and household contacts. Continue ondansetron 4 milligrams (mg) as needed. Nursing would monitor for ongoing symptoms of nausea, vomiting, and diarrhea and the NP would follow up if symptoms persisted. The resident advised to report any worsening of symptoms or new symptoms to nursing staff immediately. Review of the resident's electronic Physician's Order Sheet (ePOS) for February 2026, showed no order dated 02/26/26 for ondansetron. Review of the resident's progress notes on 02/27/26 at 1:49 P.M., showed the resident complained of nausea, emesis times four. Staff called the resident's physician exchange and received an order for Zofran (name brand for ondansetron), 4 mg every four hours as needed. Staff called the resident's family member who told them another family member had a stomach bug and visited the resident last week. Review of the resident's ePOS for February 2026, showed:-An order dated 02/27/26 for ondansetron HCL, 4 mg. Give one tablet by mouth every four hours as needed for nausea and vomiting;-Aspirin (used to prevent blood clots) 81 mg, give one a day;-Digoxin (used to treat heart failure) 250 micrograms (mcg), give one time a day. Hold if heart rate less than 60. If held for more than two days, notify the physician;-Linaclotide (used to treat constipation) 145 mcg. Give one capsule by mouth one time a day;-Melatonin (used to treat insomnia) 3 mg. Give by mouth at bedtime;-Pravastatin sodium (used to treat high level of lipids) 40 mg, give one tablet by mouth at bedtime;-Eliquis (used to treat blood clots) 2.5 mg. Give one tablet by mouth, two times a day;-Oxcarbazepine (used to treat seizures) 600 mg, give 600 mg by mouth two times a day;-Topiramate (used to treat seizures), 200 mg, give one tablet by mouth, two times a day. Review of the resident's electronic Medication Administration Record (eMAR) dated February 1, 2026, through February 28, 2026, showed:-On 02/27/26:-Ondansetron administered at 1:53 P.M.;-Heart rate documented at 60; --A 9 (Chart code: 9 = Other/See progress notes) documented for: --Melatonin administered at night, --Pravastatin sodium administered at bedtime; --Eliquis administered in the evening; -- Oxcarbazepine administered at 4:00 P.M.; -- Topiramate administered at 4:00 P.M.; Review of the resident's progress notes dated 02/27/26, showed no documentation of why staff did not administer medications in the evening and/or night. Review of the resident's February 2026 eMAR, showed:-On 02/28/26: --Heart rate not documented; --A 5 (Chart code: 5 = Hold/See progress notes) documented for: --Aspirin at 7:30 A.M.; --Digoxin at 7:00 A.M.; --Linaclotide at 7:00 A.M.; --Eliquis at 7:00 A.M.; --Oxcarbazepine at 8:00 A.M.; --Topiramate at 8:00 A.M.; Review of the resident's February 2026 eMAR, showed:-On 02/28/26: --A 2 (Chart code: 2 = Drug refused) documented for: --Melatonin at night; --Pravastatin at night; --Eliquis in the evening; --Oxcarbazepine at 4:00 P.M.; --Topiramate at 4:00 P.M.;-Ondansetron not administered. Review of the resident's progress notes dated 02/28/26 at 1:49 P.M., showed the certified nurse aide (CNA) attempted to feed the resident at lunch. Emesis noted. When assessed, the resident's emesis was dark in color on his/her face and noted with food on clothing. Staff assisted the resident back to bed;-No documentation of an assessment completed or vital signs obtained;-No documentation of physician notification regarding resident's continued vomiting and change of color of vomit;-No documentation of why medication not administered on 02/28/26. Review of the resident's medical record, showed:-Vitals: --Blood pressure: No documentation of blood pressures recorded in February 2026; --Respirations: No documentation of respirations recorded in February 2026; --Oxygen saturation (O2 sat): No documentation of oxygen levels recorded in February 2026. Review of the resident's eMar dated March 1, 2026, through March 31, 2026, showed: -Ondansetron administered on 3/1/26 at 2:42 AM.; --Heart rate not documented; --A 5 (Chart code: 5 = Hold/See progress notes) documented for: --Aspirin at 7:30 A.M.; --Digoxin at 7:00 A.M.; --Linaclotide at 7:00 A.M.; --Eliquis at 7:00 A.M.; --Oxcarbazepine at 8:00 A.M.; --Topiramate at 8:00 A.M. Review of the resident's progress notes dated 03/01/26 at 10:05 P.M., showed the resident experienced three episodes of emesis. The last episode being a copious amount of black emesis. The resident was pale and clammy. The resident's abdomen was distended with the left side bouncy and the right side hard. Staff were unable to obtain blood pressure on the upper extremities (arms) via an automatic or manual cuff and were unable to obtain an oxygen saturation due to all the resident's digits (fingers) cold and unable to warm up. The resident's blood pressure was taken with a wrist cuff and recorded at 68 over 40 (normal is 120 over 80). The resident's temperature was 98.5 (normal) and heart rate was 80 (normal). Staff notified the Assistant Director of Nursing (ADON) who directed the nurse to call the on-call physician's office. The NP told staff to call the residents power of attorney (POA) and if in agreement, to send the resident to the emergency room (ER). The resident's family member agreed, and emergency medical services (EMS) came to transport the resident to the hospital. Review of the resident's EMS record, dated 03/1/26, showed:-Dispatch notified on 03/1/26 at 9:34 P.M.;-Arrived on-scene at 9:40 P.M.;-Last known well: 02/26/26 at 8:00 A.M., (estimated);-Signs and symptoms: Cardiac arrest, projectile vomiting;-Vital signs: --At 9:53 P.M, no blood pressure documented, Pulse 120, respirations 20; --At 9:57 P.M., no blood pressure documented, oxygen saturation 49 (normal is 95-100) --At 10:00 P.M., no vitals documented, resident unresponsive;-Treatment: --At 10:00 P.M., Cardio-pulmonary respirations (CPR), CPR initiated once the patient was found to be pulseless and apneic (temporary, involuntary cessation of breathing). Patient response: Unchanged; --Oxygen: Device: Bag valve mask. Flow rate 25 lpm (liters per minute). Patient response: Improved; --Suction: Contents: Vomit 100; --Video laryngoscopy (a procedure used to examine throat tissue to determine causes of breathing issues): Airway complications: Cardiac arrest, patient vomiting/aspiration (occurs when food, liquid or foreign material enters the airway and lungs). Patient response: Unchanged, unsuccessful;-EMS was dispatched for a sick case and crew responded emergently to the scene. EMS crew entered the facility and met with staff who told them the resident had been throwing up since Thursday but today it was noted the patient was having dark emesis. The patient was alert to him/herself but not answering any questions the crew asked. The EMS crew removed the patient from the bed to a stretcher, was placed in a semi-Fowler (semi-sitting position where head is raised) position and secured to the stretcher. The patient was moved to the ambulance where the EMS crew attempted to obtain a full set of vitals but were unable to obtain a pulse oximeter (measures blood oxygen saturation) reading due to the patient's fingers being cold. EMS crews noted the patient to be tachycardic (resting heart rate that is faster than normal) but were unable to obtain a blood pressure. While in-route to the hospital, the resident started vomiting dark emesis (black in color and approximately 250 milliliters). The EMS crew went emergent to the station for additional manpower. While in route to the station, the patient stopped breathing and became pulseless. EMS crew immediately initiated CPR. The crew continued manual CPR while the patient was ventilated (assisted breathing) via BVM (bag-valve-mask, used for rescuing breathing during CPR). The crew also suctioned the patient's airway due to a large amount of secretions in the patient's airway. The patient was placed on a cardiac monitor at this time and was asystole (a severe form of cardiac arrest where all electrical and mechanical activity in the heart ceases). The crew continued CPR and attempted to intubate (medical procedure where a tube is inserted into the windpipe to maintain an open airway) but were unsuccessful. After two minutes of CPR, an additional rhythm check was done, and the patient was noted to be pulseless and in asystole. EMS crew continued CPR while preparing the LUCAS (a battery-operated mechanical device that delivers automatic, consistent chest compressions to cardiac arrest patients) device. After two more minutes of CPR, a rhythm check was completed (pulseless and asystole) and the LUCAS device was placed on the patient. EMS crew continued to ventilate the patient every five to six seconds and continued CPR for an additional two minutes. The patient was still pulseless and in asystole at this time. EMS crew also gave the patient 1 mg of epinephrine (used during cardiac arrest to increase blood flow) every three to five minutes throughout the transport. The patient was continuously monitored and given advanced life support given throughout the duration of transport. EMS then arrived at the hospital-Specialty patient: Illness involving airway. Potential for future airway complications. Difficult patient airway anatomy. Unable to position or access patient. Blood, vomitus or secretions in airway. Review of the resident's death certificate dated 03/09/26, showed:-date of death : 03/01/26;-Cause of death: Probably acute abdomen. Possible bowel ischemic (reduction of blood flow to the intestines that results in tissue death). During an interview on 04/22/26 at 11:15 A.M., Licensed Practical Nurse (LPN) A said staff reported the resident started vomiting earlier in the week. The LPN notified the NP to get an order for anti-nausea medication. He/She did not contact the NP or on-call provider later in the week, because he/she thought the medication was working. The staff did not tell him/her the resident continued to vomit and he/she looked fine when he/she saw him/her. During an interview on 04/23/26 at 1:05 P.M., LPN Q said he/she assessed the resident on 02/27/26 after he/she vomited. The LPN did not see an order for an anti-nausea medication, so he/she called the on-call exchange and got an order for Zofran. He/She notified the family who reported a family member was sick with a stomach virus and visited the resident earlier in the week. During an interview on 04/23/26 at 2:10 P.M., LPN G said on 02/28/26, at shift change, staff reported the resident was not eating and had been vomiting the last few days. The LPN did not work with the resident a lot so did not know if he/she was getting worse. The resident vomited a couple of times, and LPN G called the on-call physician's office to report it. They were already aware of the vomiting and did not give any new orders. The LPN did not know why he/she did not document this notification. He/She did not remember administering any anti-nausea medication to the resident. During an interview on 04/24/26 at 1:15 P.M., CNA I said the resident vomited a lot that week. He/She thought it started around 02/23/26. The CNA was concerned, because the resident was not receiving any medication for the nausea and he/she was not eating much. CNA I gave the resident some soda to try and keep him/her hydrated. CNA I asked the nurse earlier in the week if they could administer something for it and was told they could not administer any medication without a physician's order. During an interview on 4/24/26 at 1:20 P.M., CNA J said the resident was throwing up all week. On 02/28/26, the resident's vomit was a dark brown color like cola. CNA J notified the nurse. During an interview on 4/24/26 at 1:15 P.M., CNA K said on 02/28/26, the resident threw up a dark colored vomit. He/She threw up all week and it was now projectile. The resident was not eating very much, especially toward the time he/she went out to the hospital. Normally he/she would eat everything on his/her plate. The resident did not communicate well and could not tell you if he/she was in pain. During an interview on 04/27/26 at 10:15 A.M., LPN O (night shift from 02/28/26 to 03/01/26) said on 02/28/26, the evening shift nurse told him/her at shift change the resident vomited throughout the day. On 03/01/26, an aide reported the resident was nauseous and vomited on him/herself. It was not a lot of vomit, and he/she did not notice the color of it. He/She administered a dose of Zofran, and the resident did not complain of any more nausea for the rest of his/her shift. During an interview on 04/27/26 at 11:00 A.M., Certified Medication Technician (CMT) N said the resident had been throwing up all week. On 03/01/26, the resident had thrown up a few times, so he/she got permission from the nurse to administer his/her anti-nausea medication. He/She did not know why this was not documented. He/She was scheduled to work on both sides of the floor that day and may have forgotten to document it. During an interview on 4/24/26 at 1:00 P.M., CNA P said the resident had been throwing up all week. He/She was not eating very much food, and the staff were trying to keep him/her hydrated. On 03/01/26, the resident sat in the dining room after lunch with therapy staff and made a belching noise. There was a liquid sound to it, so CNA P ran to get some towels, but the resident vomited before he/she could get back to him/her. It was projectile vomiting and it exploded out of his/her mouth. He/She took the resident to his/her room and cleaned him/her up. He/She notified the nurse who came in and checked on the resident, but did not administer any anti-nausea medication. The CNA asked the nurse earlier in the week if they could administer something for the nausea and was told they could not give the resident anything without a physician's order. They finally got an order later in the week. The resident threw up again later, but he/she did not notify the nurse, because the nurse already saw him/her a little while earlier. During an interview on 4/27/26 at 11:00 A.M., CMT M said the resident vomited a lot for several days. He/She asked the nurse about giving an anti-nausea medication to the resident earlier in the week and was told they could not give him/her anything unless they had an order. They finally got an order on 02/27/26 for Zofran. The resident was administered a dose on 02/27/26, and the CMT did not observe staff administering it after that date. He/She did not administer it on 02/28/26 or 03/01/26, because it was not effective when they administered it the first time. The resident was not eating and continued to throw up. The CMT asked the nurse on 02/28/26, if the resident should be sent to the hospital because he/she continued to vomit and was not eating, but was told no. He/She was instructed to keep trying to administer his/her medications. The staff kept trying to feed the resident and he/she kept throwing it up. He/She noticed the vomit was getting darker in color on 02/28/26. On 03/01/26, he/she could not administer the resident's medications, because he/she was vomiting so much and could not keep them down. He/She notified the nurse of this. The resident did not look good and stopped communicating with the staff. The CMT did not assess the resident, because this was the nurse's responsibility. During interviews on 04/22/26 at 12:30 P.M. and on 04/27/26 at 10:15 A.M., Registered Nurse (RN) E said he/she worked the day and evening shift on 03/01/26. At shift change, the night nurse told him/her the resident vomited earlier. They thought the resident caught a bug from his/her family when they visited him/her the prior weekend. The night nurse administered him/her a dose of anti-nausea medication earlier that morning. An aide came and got him/her after lunch to report the resident vomited in the dining room. RN E assessed the resident and helped clean him/her up. The vomit was brown in color. RN E did not call the physician at that time, because it was not a lot of throw up. RN E was unaware of how much the resident had been throwing up all week, and he/she looked okay. RN E told the CMT to administer the resident's anti-nausea medication and thought this was done. An aide came and got him/her sometime after dinner and reported the resident had vomited again all over him/herself. This time the vomit was black in color. The aide reported the resident threw up a second time after lunch, but they just cleaned him/her up and did not tell RN E. They should have told him/her the resident continued to vomit. RN E assessed the resident, but could not get a blood pressure reading with the vitals machine. His/Her fingers were very cold. They finally got a blood pressure using a wrist cuff, and it was like 60 over 40. The resident did not communicate well, but he/she would usually be loud and cursing. Now he/she was not saying anything at all. RN E contacted the ADON to ask her if they could send the resident to the hospital and the ADON told him/her to call the on-call physician's office for an order. RN E called the office and spoke to the NP who told him/her to call the family for permission and call them back if there was a problem. The family agreed to send the resident to the hospital for evaluation. RN E was not aware of how sick the resident had been all week until he/she went in to document this information and read his/her progress notes. If the resident was continually throwing up and the medication was not working, staff should have contacted the on-call physician to send him/her to the hospital earlier. During an interview on 04/24/26 at 11:25 A.M., the Director of Nursing (DON) said the staff should have notified the DON and on-call provider if the resident continued to vomit and the medication ordered was not working. Medication should be administered as ordered. All this information should have been documented. Staff should have assessed the resident including taking blood pressure, temperature and respiration rates and documented this information. During an interview on 04/24/26 at 3:00 P.M., the interim Administrator said staff should administer medication as ordered. The resident's physician should be notified if there is a change in condition. All this information should be documented in the resident's medical record. During an interview on 04/22/26 at 1:45 P.M., NP H said he/she assessed the resident that week after the nurse notified him/her the resident experienced nausea and vomiting. He/She ordered Zofran. Staff told him/her, one of the resident's family members reported having some type of gastrointestinal upset and visited the resident earlier in the week, so they thought the resident caught something from the family member. The NP's documentation of the assessment somehow got deleted from the resident's medical record after his/her discharge. The NP would find the documentation and enter into the resident's medical record. When he/she assessed the resident, his/her bowel sounds were normal. The NP saw the resident later in the week while on the floor, and he/she looked fine. No one notified him/her, the resident continued to vomit after being administered the medication. If he/she knew this, he/she would have immediately sent the resident to the hospital for evaluation. Staff did not notify him/her on 02/28/26, when the resident's vomit was noted to be darker in color. This could have indicated gastrointestinal or internal bleeding. He/She would have expected staff to notify him/her or the on-call physician when this occurred. During an interview on 04/23/26 at 10:00 A.M., the resident's physician said he was notified when the resident needed an order for the anti-nausea medication and did not remember being notified again until the resident was sent to the hospital on [DATE]. Dark brown emesis could indicate a bowel obstruction and black emesis could indicate bleeding somewhere. He would have expected the staff to administer the medication as ordered and notify him if it was not working. If the medication was not working and the resident continued to vomit, this could lead to dehydration. The physician would probably have sent the resident to the hospital to be evaluated and run labs and tests. The hospital could have offered more options for determining what was wrong and how to treat it. There was someone at the medical exchange 24 hours who could notify him or the nurse practitioner if there was a problem. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I 2971599

Based on observation, interview and record review, the facility failed to provide residents with alternate food choices and preferences listed on the Always Available menu (Residents #4 and #25). In addition, the facility failed to serve foods listed on meal tickets for three of 11 sampled residents (Resident #22, #19, and #24). The census was 126. Review of the dietary Always Available menu on 03/02/16, showed items included hamburger/cheeseburger, grilled cheese, cold cut sandwiches, chef or garden salad, cold cereal, hot dogs, and peanut butter and jelly sandwiches. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/30/25, showed: -admitted on [DATE];-Cognitively intact. During an interview on 03/04/26 at 9:00 A.M., the resident said the facility had an Always Available menu, but when residents ask a staff member for an alternative, they are always told the kitchen is too busy to send it up, they are out of the alternative, or the staff member just does not return. It does no good to try and call to the kitchen early, because the kitchen staff will not answer the phone or return their messages. 2. Review of Resident #25's quarterly MDS, dated [DATE], showed: -admitted on [DATE];-Cognitively intact. During an interview on 03/04/26 at 9:10 A.M., the resident said he/she did not like the food. He/She calls to the kitchen to request something else and they will still send up the same food. He/She has requested hot dogs for over a month and they keep telling him/her they are out of them. All they will send is a cold meat or peanut butter and jelly sandwich. He/She stopped asking staff for an alternative, because they are always busy and the kitchen does not have what he/she is requesting. 3. Review of Resident #22's MDS, dated [DATE], showed:-Cognitively intact;-Supervision or touching assistance needed with eating. Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity;-Diagnoses included iron deficiency anemia (a common blood condition occurring when you have an insufficient number of healthy red blood cells or low hemoglobin (an iron rich oxygen-transporting protein located within red blood cells), reducing the blood's capacity to carry oxygen to tissues), unspecified severe protein-calorie malnutrition, muscle weakness, need for assistance with personal care, unsteadiness on feet, hemiplegia (the severe or complete paralysis of one side of the body caused by brain damage on the opposite side) and hemiparesis (a neurological condition characterized by weakness or reduced motor control on one side of the body) following stroke and dysphagia (difficulty swallowing, indicating a disruption in moving food or liquid from the mouth to the stomach). Review of the resident's care plan dated 01/29/26, showed:-Focus: The resident is on hospice care. Has severe anemia;-Interventions/Tasks: Hospice to consult for changes to resident care plan/medications. Provide resident and family with education and support during end-of-life care;-No documentation of eating issues and/or preferences for food. Review of the resident's electronic Physicians Order Sheet (ePOS) dated 03/01/26 through 03/31/26, showed an order dated 06/20/25 for a regular diet. Regular texture. Serve meat with breakfast. No eggs. Review of the resident's meal ticket dated 03/03/26, showed serve meat with breakfast. No eggs. Coke soda for lunch and dinner. Observation on 03/03/26 at 8:45 A.M., showed the resident was served scrambled eggs, toast, and cereal for breakfast. The resident scooped his/her eggs onto his/her tablemate's plate. There was no meat on the tray. Observation on 03/04/26 at 8:35 A.M., showed the resident was served scrambled eggs, hashbrowns, a muffin, and cereal for breakfast. There was no meat on the tray. During an interview on 03/03/26 at 8:45 A.M., the resident said staff served him/her eggs for breakfast every day. He/She did not like eggs and will not eat them, because they make him/her sick. He/She asked for meat at meals, but rarely gets it at breakfast. The kitchen ran out of soda a couple of weeks ago, so he/she had to buy his/her own for meals if he/she could get a staff member to go to the vending machine and get it for him/her. 4. Review of Resident #19's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Dependent on staff for eating;-Diagnoses include include paraplegia (loose of function in the lower extremities), quadriplegia (paralysis that affects all a person's limbs), cachexia (a severe, involuntary wasting syndrome marked by significant loss of weight, skeletal muscle and fat), chronic pain syndrome and mild protein-calorie malnutrition. Review of the resident's care plan dated, 02/25/26, showed:-Focus: The resident has nutritional problem or potential nutritional problem;-Interventions/Tasks: Double portions at lunch and dinner. Prefers two bowls of oatmeal and a yogurt for breakfast. Review of the resident's meal ticket dated 03/03/26, showed he/she preferred three fried eggs for breakfast. He/She did not want white bread. Observation of the resident's breakfast on 03/03/26 at, showed a regular portion of scrambled eggs, hashbrowns, and one muffin. Observation of the resident's lunch tray on 03/03/26 at 12:50 P.M., showed he/she was served a regular portion of baked chicken thighs, one baked potato, green beans, and one slice of white bread. During an interview on 03/03/26 at 7:20 A.M., the resident said the food was terrible and the kitchen will not send what he/she prefers. He/She goes out every day around 9:00 A.M. to 9:30 A.M. and if breakfast runs late, then he/she did not get to eat until dinner. They do not send a lunch with him/her and the place he/she goes does not provide a lunch. He/She must buy his/her own snacks to take on leave or when they send food he/she does not like, because they never get an alternative for him/her. He/She complained to the Dietary Manager and he/she added what he/she wanted or did not want for meals, but the dietary staff still sent the wrong things. When he/she asked for something, the staff were too busy or the kitchen is out of whatever he/she wants. 5. Review of Resident #24's quarterly MDS, dated [DATE], showed:-admission date of 10/01/24;-Diagnoses included hemiplegia, diabetes, anemia, dysphagia, and muscle weakness. Review of the resident's care plan dated 10/22/25, showed the following:-Focus: The resident has potential nutritional problem related to risk for malnutrition;-Interventions/Tasks: Provide and serve diet as ordered. Review of the resident's ePOS dated 03/01/26 through 03/31/26, showed an order dated 04/05/25 for a no salt added diet, regular texture, double portions, four pieces of bacon for breakfast, no sausage. Review of the resident's breakfast meal ticket, dated 03/03/26, showed the resident preferred two bowls of oatmeal, double portions, four slices of bacon, and four fried eggs. No sausage. Observation on 03/03/26 at approximately 9:10 A.M., showed the resident's breakfast plate contained one serving of scrambled eggs, a sausage patty, and a bowl of cream of wheat. Observation on 03/04/26 at 8:45 A.M., showed the resident's breakfast plate contained one serving of scrambled eggs, a muffin, hash browns, and a bowl of cream of wheat. During an interview on 03/04/26 at approximately 8:55 A.M., the resident said staff told him/her to call to the kitchen if he/she wanted a substitution, but when he/she calls to remind them he/she does not want scrambled eggs or sausage, it continues to come up on his/her tray. The dietary staff will brush him/her off or not answer the phone at all. He/She does not like cream of wheat so he/she will not eat it. They have an alternate menu for lunch or dinner, but they usually will only offer peanut butter and jelly sandwiches. The nursing staff were very busy and if you ask them for a substitute, they will say the kitchen ran out of food or they just will not come back at all. 6. During an interview on 03/02/26 at 8:40 A.M., Certified Nurse's Aide (CNA) I said staff try to order substitutes if the resident wants them, but often the kitchen is out of what they are asking for or does not answer the phone. During an interview on 03/04/26 at 12:15 P.M., the Dietary Manager said she started working at the facility a couple of weeks prior. The resident's preferences for meals were sent to her on their dietary tickets and the dietary staff were supposed to read the tickets before they prepared the trays. The residents should receive what was noted on the meal ticket. They had been ordering more food since she started and the alternatives were available if a resident asked for it. The staff should be calling down if the resident did not like what they received. She did not know the staff were not following the meal tickets and the phone was not being answered when residents were calling. During interviews on 03/04/26 at 12:00 P.M. and at 4:20 P.M., the Administrator said they did not have a specific policy for food preferences. On admission, the staff went over what the residents liked to eat and recorded it on a food preferences form. This information was then entered into the resident's medical record and would generate a meal ticket listing those preferences. The kitchen staff should be reviewing the meal tickets and honoring the resident's preferences. There was an Always Available menu posted on each floor the resident could order from if they did not like what was being served. All the resident needed to do was ask a staff member and he/she would call the kitchen to have the alternative sent up. There was no time frame on when the resident could call to ask for the alternative. He did not know the residents were complaining the kitchen staff would not answer the phone or the nursing staff would tell them the food was not available. They just hired a new Dietary Manager a month ago and were working on improving the meal service. 2725202

Based on observation, interview, and record review, the facility failed to maintain food at a palatable, safe, and appetizing temperature during meal service. This deficiency affected five of 11 sampled residents (Residents #19, #24, #25, #28, and #21). The census was 126. Review of the facility's On Tray Dietary Policies and Procedures, not dated, showed:-Food temperatures are maintained during serving times;-Food and beverage temperatures should be taken and logged upon being cooked and again prior to meal service;-Food temperatures should be within the required temperatures per state and federal guidelines when cooked and served. If foods are not in the correct temperature zone, corrections should be made or food is discarded;-Poultry is cooked to a minimum of 165 degrees Fahrenheit (F);-Eggs should be cooked to 145 degrees F,-Hot foods are served at 135 degrees F or higher and cold foods/beverages are served at 41degrees F or lower;-Log cook and service (holding) temperatures;-Logs should be on file for one year. 1.Review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff), dated 02/18/26, showed: -Cognitively intact;-Diagnoses included paraplegia (impairment or loss of motor and sensory function in the lower half of the body), quadriplegia (paralysis that affects all a person's limbs), calculus of kidney, cachexia (a severe, involuntary wasting syndrome marked by significant loss of weight, skeletal muscle and fat), chronic pain syndrome and mild protein-calorie malnutrition. During an interview on 03/03/26 at 7:15 A.M., the resident said the food was always cold by the time the staff served it. It tasted very nasty and he/she could often not eat it. 2. Review of Resident #24's quarterly MDS dated [DATE], showed: -Cognitively intact;-Diagnoses included hemiplegia (total or partial paralysis of one side of the body), diabetes, anemia (lack of healthy red blood cells), dysphagia (swallowing difficulty) and muscle weakness. During an interview on 3/4/26 at 8:55 A.M., the resident said the food is terrible. The residents sit and wait up to an hour for the food to get to them, and then it is cold. 3. Review of Resident 25's quarterly MDS dated [DATE], showed: -admitted on [DATE];-Cognitively intact. During an interview on 03/04/26 at 9:55 A.M., the resident said the quality of the food had really gone downhill. Residents wait a long time for meals and when they get there, the food was always cold. They have complained about this to administration several times. The facility had a heating station on the floor for a while, and the food was hot when it was used, but they stopped using it recently, and now the food was always cold. 4. Review of Resident #28's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included chronic kidney disease, depression, anxiety, and heart failure. During an interview on 03/02/26 at 9:14 A.M., the resident said he/she ate in his/her room and the food was cold. 5. Review of Resident #21's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included high blood pressure, liver disease, heart disease, anxiety disorder, and major depressive disorder. During an interview on 03/02/26 at 9:32 A.M., the resident said he/she ate in his/her room. The food was always cold. 6. Observation on 03/02/26 at 11:58 A.M. of lunch service on the 300 hall, showed:-A dietary aide arrived on the hall at 12:16 P.M., with a large, metal meal tray delivery cart, with two doors on each side, and resident meal trays/drinks inside. Staff opened all four doors and passed trays to residents in the dining room and residents in their rooms;-The last tray was given to the surveyor at 12:40 P.M.;The biscuit measured 102 degrees F;The green beans measured 106 degrees F;The beef stew measured 100 degrees F. Observation on 03/03/26 at 8:09 A.M., of breakfast service on the 300 hall, showed:-A dietary aide arrived on the hall at 8:12 A.M., with a large, metal meal tray delivery cart, with two doors on each side and resident meal trays/drinks inside. Staff opened all four doors and passed trays to residents in the dining room and residents in their rooms;-The last tray was given to the surveyor at 8:32 A.M.;The eggs measured 115 degrees F;The milk measured 50 degrees F. Observation on 03/03/26 at 1:00 P.M. of lunch service on the 400 hall, showed:-A dietary aide arrived on the hall at 12:30 P.M., with a large, metal meal tray delivery cart, with two doors on each side, and resident meal trays/drinks inside. Staff opened all four doors and passed trays to residents in the dining room and residents in their rooms;-The last tray was given to the surveyor at 1:00 P.M.;The milk measured 54 degrees F. 7. During an interview on 03/04/26 at 8:29 A.M., Nurse Manager A said he/she was not sure why dietary staff stopped using the warming station in the dining room during meal services. The facility recently changed kitchen staff. During an interview on 03/04/26 at 12:10 P.M., the Dietary Manager said she just started working at the facility a couple of months ago. She stopped the steam table at that time, because she was working on getting the kitchen in order first. The staff were supposed to be taking temperatures of the food while preparing it and right before it was put on the trays. The milk and juice were served with the trays and this could lead to higher temperatures of the milk and juice when served. During an interview on 03/04/26 at 3:23 P.M., the Administrator said food temperatures should be taken with every meal. The cold drinks should have been in an ice bucket. 2740631

Based on interview and record review, the facility failed to ensure services provided met acceptable professional standards of care when staff failed to administer and document morning and afternoon medications as order by the physician for seven residents (Resident #8, Resident #7, Resident #11, Resident #9, Resident #12, Resident #2 and Resident #6 and Resident #10). Additionally, the facility failed to refill Hydrocodone (prescription opioid used for moderate to severe pain) 5-325 milligrams (mg) for one resident (Resident #4) who had severe pain in a timely manner. The resident did not receive his/her hydrocodone for two days. The sample was 18. The census was 109.Review of the facility's Medication Administration policy, dated October 2024, showed:-Medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection;-Ensure the six rights of medication administration were followed:a. Right resident;b. Right drug;c. Right dosage;d. Right route;e. Right time;f. Right documentation;-Administered within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Review of the facility's Medication and Treatment Orders policy, undated, showed:-Orders for medications and treatments would be consistent with principles of safe and effective order writing;-Only authorized personnel may call in orders for prescribed medications to the pharmacy;-Drugs and biologicals (treat diseases by targeting specific parts of the immune system) required to be refilled will be reordered from the issuing pharmacy in a timely manner prior to the last dosage being administered to ensure refills are readily available. 1. Review of Resident #8's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 10/14/25, showed:-Cognitively intact;-Wheelchair for mobility;-Partial/moderate assistance with activities of daily living (ADLs) and mobility;-Received scheduled pain medication;-Diagnoses included: Stroke, dysphagia (difficulty swallowing), insomnia, anemia, high blood pressure, chronic kidney disease, diabetes, high cholesterol, acid reflux, major depressive disorder and psychotic disorder. Review of the resident's care plan, in use during survey, showed:-Focus: The resident had diabetes;-Intervention: Staff administered medications as ordered by physician;-Focus: The resident had acid reflux;-Intervention: Staff administered medications as ordered by physician;-Focus: The resident was on diuretic therapy due to edema (swelling);-Intervention: Staff administered diuretic (removal of excess water and sodium) medications as ordered by physician;-Focus: The resident was on antiplatelet therapy (medications used to prevent blood from clumping) due to history of stroke;-Intervention: Staff administered antiplatelet medications as ordered by physician;-Focus: The resident used psychotropic medications due to depression;-Intervention: Staff administered psychotropic medications as ordered by physician;-Focus: The resident had weakness due to stroke;-Intervention: Staff administered medications as ordered by physician;-Focus: The resident had potential for pressure injury development due to history of ulcers, incontinence and immobility;-Intervention: Staff administered medications as ordered by physician. Review of the resident's Order Summary Report, dated January 2026, showed:-Airborne oral tablet, chewable (multi-vitamins with minerals). Give one tablet by mouth once a day to support immune system for six months;-Allopurinol tablet (used to lower uric acid levels) 100 mg. Give half tablet by mouth once a day for gout (painful form of inflammatory arthritis caused by high levels of uric acid in the blood);-Clopidogrel bisulfate tablet (used to prevent blood clots) 75 mg. Give one tablet by mouth once a day for blood clot prevention;-Ferrous sulfate oral tablet (iron) 325 mg. Give one tablet by mouth once a day for supplement;-Folic acid oral tablet (vitamin B-9) 1 mg. Give one tablet by mouth once a day for supplement;-Furosemide tablet (diuretic) 20 mg. Give one tablet by mouth once a day;-Pepcid oral tablet. Give 10 mg by mouth in the morning for indigestion;-Carvedilol oral tablet (used to manage high blood pressure) 6.25 mg. Give one tablet by mouth twice a day for high blood pressure;-Gabapentin capsule (used to treat neuropathic pain (nerve pain)) 100 mg. Give one capsule by mouth twice a day for neuropathy pain;-Venlafaxine oral tablet (anti-depressant used to treat major depressive disorder) 37.5 mg. Give one tablet by mouth twice a day for major depressive disorder. Review of the resident's Medication Administration Record (MAR), dated January 2026, showed:-Airborne not administered on 01/03/26. No documentation as to why;-Allopurinol not administered on 01/03/26. No documentation as to why;-Clopidogrel bisulfate not administered on 01/03/26. No documentation as to why;-Ferrous sulfate not administered on 01/03/26. No documentation as to why;-Folic acid not administered on 01/03/26. No documentation as to why;-Furosemide not administered on 01/03/26. No documentation as to why;-Pepcid not administered on 01/03/26. No documentation as to why;-Carvedilol not administered on 01/03/26 midday. No documentation as to why;-Gabapentin not administered on 01/03/26 at 8:00 A.M. No documentation as to why;-Venlafaxine not administered on 01/03/26 at 7:00 A.M. No documentation as to why. 2. Review of Resident #7's comprehensive MDS, dated [DATE], showed:-Cognitively intact;-Wheelchair for mobility;-Substantial assistance with ADLs;-Partial to moderate assistance with transfers;-Diagnoses included: Congestive heart failure (CHF), diabetes, acid reflux, high blood pressure, high cholesterol, arthritis, depression and stroke. Review of the resident's care plan, in use during the survey, showed:-Focus: The resident had diabetes;-Intervention: Staff administered diabetes medication as ordered by physician;-Focus: The resident was on anticoagulant therapy (used medications, often called blood thinners, to prevent blood from clotting easily) due to atrial fibrillation (AFib) (irregular heart beat) and history of stroke;-Intervention: Staff administered anticoagulant medications as ordered by physician;-Focus: The resident used psychotropic medications due to insomnia and depression;-Intervention: Staff administered psychotropic medications as ordered by physician;-Focus: The resident was on diuretic therapy due to CHF;-Intervention: Staff administered diuretic medications as ordered by physician;-Focus: The resident had a stroke which resulted in dysphagia, severe weakness of lower limb and cognitive deficit;-Intervention: Staff administered medications as ordered by physician;-Focus: The resident had potential for pressure injury development due to history of ulcers, incontinence and immobility;-Intervention: Staff administered medications as ordered by physician. Review of the resident's Order Summary Report, dated January 2026, showed:-Cyanocobalamin (prevents vitamin B12 deficiency) tablet 1000 micrograms (mcg). Give one tablet by mouth once a day for supplement;-Fenofibrate micronized oral capsule (used to lower high triglycerides and bad cholesterol) 200 mg. Give 200 mg by mouth once a day for cholesterol;-Glycolax powder (used to treat constipation). Give 17 grams by mouth once a day for constipation;-Lisinopril tablet (treats high blood pressure) 10 mg. Give one tablet by mouth once a day for high blood pressure;-Metoprolol succinate ER tablet (treats high blood pressure) 50 mg. Give one tablet by mouth once a day for high blood pressure;-Spironolactone oral tablet (used to treat high blood pressure and fluid retention) 25 mg. Give half tablet by mouth once a day for high blood pressure;-Venlafaxine oral tablet 37.5 mg. Give one tablet by mouth once a day for depression;-Apixaban oral tablet (blood thinner) 5 mg. Give 5 mg by mouth twice a day for AFib. Review of the resident's MAR, dated January 2026, showed:-Cyanocobalamin not administered on 01/03/26. No documentation as to why;-Fenofibrate not administered on 01/03/26. No documentation as to why;-Glycolax not administered on 01/03/26. No documentation as to why;-Lisinopril not administered on 01/03/26. No documentation as to why;-Metoprolol succinate not administered on 01/03/26. No documentation as to why;-Spironolactone not administered on 01/03/26. No documentation as to why;-Venlafaxine not administered on 01/03/26. No documentation as to why;-Apixaban not administered on 01/03/26 at 7:00 A.M. No documentation as to why. Review of the resident's progress notes showed no documentation of why medications were not administered. During an interview on 01/15/26 at 12:00 P.M., the resident said sometimes his/her medication was administered late. He/She could not remember if he/she missed any doses on 01/03/26. 3. Review of Resident #11's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Wheelchair for mobility;-Substantial assistance with ADLs and mobility;-Diagnoses included: Dementia, fractured left femur, Chronic Obstructive Pulmonary Disease (COPD), anemia, hypothyroidism (underactive thyroid), heart disease, Obsessive Compulsive Disorder (OCD) (uncontrollable, reoccurring thoughts and repetitive behaviors) and brittle bones. Review of the resident's care plan in use during survey, showed:-Focus: The resident used antidepressant medications due to depression;-Intervention: Staff administered antidepressant medications as ordered by physician;-Focus: The resident was on pain medication therapy due to brittle bones and left femur fracture;-Intervention: Staff administered pain medications as ordered by physician;-Focus: The resident was on antiplatelet therapy due to rheumatic mitral stenosis (narrowing of the mitral valve);-Intervention: Staff administered antiplatelet medications as ordered by physician;-Focus: The resident was at risk for malnutrition due to chronic/progressive diseases;-Intervention: Registered Dietician evaluated and made diet changes as needed. Review of the resident's Order Summary Report, dated January 2026, showed:-Aspirin Tablet 81 mg. Give one tablet by mouth once a day for deep vein thrombosis (a serious condition where a blood clot forms in a deep vein) prevention;-Cetirizine oral tablet (over-the-counter antihistamine) 10 mg. Give one tablet by mouth once a day for allergies;-Cholecalciferol oral capsule (used to treat and prevent vitamin D deficiency) 50 mg. Give one capsule by mouth once a day for vitamin D deficiency;-Folic acid tablet 1 mg. Give one tablet by mouth once a day for supplement;-Losartan potassium oral tablet to (used treat high blood pressure) 50 mg. Give 50 mg by mouth one time a day for high blood pressure;-Sertraline oral tablet (treats OCD) 25 mg. Give one tablet by mouth once a day for depression;-Super B-Complex Oral Tablet (dietary supplement). Give one tablet by mouth once a day for supplement;-Trelegy ellipta inhalation aerosol powder breath activated (used for the long-term, maintenance treatment of COPD) 100-62.5-25 mcg. One puff inhaled orally once a day for COPD;-Eliquis oral tablet (blood thinner) 5 mg. Give one tablet by mouth twice a day for AFib;-Polysaccharide iron complex oral capsule (used to treat anemia). Give 150 mg by mouth twice a day for vitamin;-House shake (a high-protein, nutrient-dense meal replacement supplement) three times a day for supplement;-Oyster calcium (treats calcium deficiencies) oral tablet 500 mg. Give 500 mg by mouth three times a day for left hip fracture. Review of the resident's MAR, dated January 2026, showed:-Aspirin not administered on 01/03/26. No documentation as to why;-Cetirizine not administered on 01/03/26. No documentation as to why;-Cholecalciferol not administered on 01/03/26. No documentation as to why;-Folic acid not administered on 01/03/26. No documentation as to why;-Losartan not administered on 01/03/26. No documentation as to why;-Sertraline not administered on 01/03/26. No documentation as to why;-Super B-Complex not administered on 01/03/26. No documentation as to why;-Trelegy Ellipta inhalation aerosol powder breath activated not administered on 01/03/26. No documentation as to why;-Eliquis not administered on 01/03/26 at 7:00 A.M. No documentation as to why;-Polysaccharide iron complex not administered on 01/03/26 at 7:00 A.M. No documentation as to why;-House shake not administered on 01/03/26 at 7:00 A.M and midday. No documentation as to why;-Oyster calcium not administered on 01/03/26 at 8:00 A.M and 12:00 P.M. No documentation as to why. Review of the resident's progress notes showed no documentation of why medications were not administered. 4. Review of Resident #9's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Wheelchair and walker for mobility;-Set up or clean up assistance with ADLs and mobility;-Received scheduled pain medication;-Diagnoses included: Dementia, anxiety disorder, major depressive disorder, hypothyroidism, heart failure and overactive bladder. Review of the resident's care plan, in use during survey, showed:-Focus: The resident had hypothyroidism;-Intervention: Staff administered thyroid replacement therapy as ordered;-Focus: The resident used psychotropic medications due to depression and anxiety;-Intervention: Staff administered psychotropic medications as ordered by physician;-Focus: The resident was on anticoagulant therapy due to AFib;-Intervention: Staff administered anticoagulant medications as ordered by physician;-Focus: The resident was on diuretic therapy due to CHF;-Intervention: Staff administered diuretic medications as ordered by physician. Review of the resident's order summary report, dated January 2026, showed:-Buspirone oral tablet (used to treat anxiety) 5 mg. Give half tablet by mouth once a day for anxiety related to dementia;-Cyanocobalamin tablet 1000 mcg. Give one tablet by mouth once a day for supplement;-Famotidine oral tablet (used to treat heartburn, gastroesophageal reflux disease (GERD), and ulcers) 10 mg. Give 10 mg by mouth once a day for indigestion;-Furosemide tablet 40 mg. Give one tablet by mouth once a day for edema;-Pataday ophthalmic solution (used to relieve itchy, red eyes) 0.2 %. Instill one drop in both eyes once a day for allergies;-Polyethylene glycol 3350 powder (laxative used to relieve occasional constipation). Give 17 grams by mouth once a day for constipation;-Potassium chloride Extended Release (ER) oral capsule (used to treat potassium deficiency) 10 milliequivalent. Give two capsules by mouth once a day for low potassium;-Duloxetine oral capsule delayed release sprinkle (used to treat major depressive disorder) 20 mg. Give 20 mg by mouth twice a day for depression;-Eliquis oral tablet 2.5 mg. Give one tablet by mouth twice a day for AFib;-Memantine tablet (used to treat Alzheimer's disease) 5 mg. Give one tablet by mouth twice a day for memory loss;-Metoprolol tartrate tablet 25 mg. Give one tablet by mouth every 12 hours for high blood pressure;-Oyster shell calcium tablet 500 mg. Give one tablet by mouth twice a day for supplement;-Pyridium oral tablet (used to temporarily relieve pain) 100 mg. Give one tablet by mouth twice a day for pain. Review of the resident's MAR, dated January 2026, showed:-Buspirone not administered on 01/03/26. No documentation as to why;-Cyanocobalamin not administered on 01/03/26. No documentation as to why;-Famotidine not administered on 01/03/26. No documentation as to why;-Furosemide not administered on 01/03/26. No documentation as to why;-Pataday ophthalmic solution not administered on 01/03/26. No documentation as to why;-Potassium chloride not administered on 01/03/26. No documentation as to why;-Duloxetine not administered on 01/03/26. No documentation as to why;-Eliquis not administered on 01/03/26 at 7:00 A.M. No documentation as to why;-Memantine not administered on 01/03/26 at 7:00 A.M. No documentation as to why;-Metoprolol tartrate not administered on 01/03/26 at 8:00 A.M. No documentation as to why;-Oyster shell calcium not administered on 01/03/26 at 7:00 A.M. No documentation as to why. Review of the resident's progress notes showed no documentation of why medications were not administered. During an interview on 01/16/26 at 1:49 P.M., the resident said he/she did not get his/her medication on time. Sometimes he/she did not get his/her thyroid and anxiety medication in the morning. He/She had trouble with anxiety and depression. He/She needed his/her medication in the morning. He/She was anxious when he/she did not get his/her medication. 5. Review of Resident #12's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Wheelchair for mobility;-Substantial assistance with ADLs and mobility;-Diagnoses included: Parkinson's disease (a progressive, neurological disorder affecting the central nervous system), stroke, high blood pressure and respiratory failure. Review of the resident's care plan, in use during the survey, showed:-Focus: The resident was on anticoagulant therapy due to AFib;-Intervention: Staff administered anticoagulant medications as ordered by physician;-Focus: The resident used anti-anxiety medications due to depression;-Intervention: Staff administered anti-anxiety medications as ordered by physician;-Focus: The resident had Parkinson's Disease;-Intervention: Staff administered medications as ordered by the physician;-Focus: The resident had acute/chronic pain due to comorbities (two or more distinct medical conditions present in the same person at the same time);-Intervention: Staff administered pain medication as ordered by physician Review of the resident's Order Summary Report, dated January 2026, showed:-Acetaminophen oral tablet 325 mg. Give two tablets by mouth twice [NAME] for pain;-Aspirin oral capsule 81 mg. Give one capsule by mouth once a day for stroke;-Amantadine oral capsule (used to treat Parkinson's disease) 100 mg. Give one capsule by mouth twice a day for Parkinson's;-Diltiazem ER 12-hour oral capsule (used to treat high blood pressure) 60 mg. Give one capsule by mouth every 12 hours for high blood pressure;-Eliquis oral tablet 5 mg. Give one tablet by mouth twice a day for AFib;-House supplement 120 milliliters (ml) once a day for nutrition;-Lidocaine (numbs tissue ) external patch 4 %. Apply to left shoulder topically inthe morning for arthritis pain;-Losartan potassium tablet 50 mg. Give one tablet by mouth once a day for high blood pressure;-Polyethylene glycol 3350 powder. Give 17 grams by mouth once a day for constipation. Review of the resident's MAR, dated January 2026, showed:-Aspirin not administered on 01/03/26. No documentation as to why;-Acetaminophen not administered on 01/03/26 at 7:00 A.M. No documentation as to why; -Amantadine not administered on 01/03/26 at 7:00 A.M. No documentation as to why;-Diltiazem not administered on 01/03/26 at 8:00 A.M. No documentation as to why;-Eliquis not administered on 01/03/26 at 7:00 A.M. No documentation as to why;-House supplement not administered on 01/03/26. No documentation as to why;-Lidocaine external patch not administered on 01/03/26. No documentation as to why;-Losartan potassium not administered on 01/03/26. No documentation as to why;-Polyethylene glycol 3350 powder not administered on 01/03/26. No documentation as to why. Review of the resident's progress notes showed no documentation of why medications were not administered. 6. Review of Resident #2's quarterly MDS, showed:-Severe cognitive impairment;-Totally dependent on staff for ADLs;-Diagnoses included: Dementia, high blood pressure, seizure disorder, anxiety disorder and depression. Review of the resident's care plan, in use during the survey, showed:-Focus: The resident had a mood problem due to major depressive disorder;-Intervention: Staff administered medications as ordered;-Focus: The resident had a seizure disorder;-Intervention: Staff gave medications as ordered. Monitored/documented for effectiveness and side effects; Review of the resident's order summary report, dated January 2026, showed:-Ascorbic acid oral tablet (a dietary supplement to prevent deficiency and support overall health) 500 mg. Give one tablet by mouth once a day;-Calcium carbonate tablet chewable (used to treat heartburn ) 500 mg. Give two tablets by mouth once a day; -Cholecalciferol oral tablet 25 mcg. Give two tablets by mouth once a day for supplement;-Cyanocobalamin oral tablet 1000 mcg. Give one tablet by mouth once a day;-Escitalopram oxalate tablet (used to treat major depressive disorder) 10 mg. Give one tablet by mouth once a day for depression;-Lacosamide oral tablet (used to control epilepsy) 50 mg. Give one tablet by mouth twice a day for seizures;-Lasix oral tablet (diuretic) 20 mg. Give one tablet by mouth in the morning for edema;-Levetiracetam tablet (anticonvulsant) 250 mg. Give one tablet by mouth twice a day for seizures;-Metoprolol succinate ER tablet 25 mg. Give one tablet by mouth once a day for high blood pressure;-Oxybutynin chloride oral tablet (relaxes the bladder) 2.5 mg. Give one tablet by mouth twice a day for overactive bladder;-Pantoprazole sodium tablet delayed release (used to decrease stomach acid) 40 mg. Give one tablet by mouth twice a day for acid reflux. Review of the resident's MAR, dated January 2026, showed:-Calcium carbonate not administered on 01/03/26. No documentation as to why;-Cholecalciferol not administered on 01/03/26. No documentation as to why;-Cyanocobalamin not administered on 01/03/26. No documentation as to why;-Escitalopram oxalate not administered on 01/03/26. No documentation as to why;-Lasix not administered on 01/03/26. No documentation as to why;-Lacosamide not administered on 01/03/26 at 7:00 A.M. No documentation as to why;-Levetiracetam not administered on 01/03/26 at 7:00 A.M. No documentation as to why;-Metoprolol succinate ER not administered on 01/03/26 at 7:00 A.M. No documentation as to why;-Oxybutynin chloride not administered on 01/03/26 at 7:00 A.M. No documentation as to why;-Pantoprazole sodium not administered on 01/03/26 at 7:00 A.M. No documentation as to why. Review of the resident's progress notes showed no documentation of why medications were not administered. 7. Review of Resident #6's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Dependent on staff for ADLs and mobility;-Received scheduled pain medication;-Diagnoses included: Dementia, high blood pressure, high cholesterol, diabetes, vitamin deficiency, constipation, osteoarthritis (degenerative joint disease where protective cartilage breaks down over time, causing bones to rub together, leading to pain, stiffness, swelling, and reduced movement), and edema. Review of the resident's care plan in use during the survey, showed:-Focus: The resident had diabetes;-Intervention: Staff gave diabetes medication as ordered by doctor. Staff monitored/documented side effects and effectiveness;-Focus: The resident had an alteration in musculoskeletal status due to plantar flexion contracture (the ankle and foot become stuck pointing downwards);-Intervention: Staff gave pain medication as ordered by the physician. Staff monitored/documented side effects and effectiveness. Review of the resident's order summary report, dated January 2026, showed:-Amlodipine besylate tablet (a prescription calcium channel blocker) 10 mg. Give one tablet by mouth once a day for high blood pressure;-Glipizide tablet (used to lower blood sugar) 10 mg. Give one tablet by mouth in the morning for diabetes;-Multiple vitamin tablet. Give one tablet by mouth once a day for supplement;-Vitamin B-12 oral tablet 1000 mcg. Give one tablet by mouth once a day for vitamin supplement;-Lisinopril tablet 20 mg. Give one tablet by mouth twice a day for hypertension;-Metformin tablet (lowers blood sugar) 1000 mg. Give one tablet by mouth twice a day for diabetes;-Metoprolol tartrate oral tablet 50 mg. Give 50 mg by mouth twice a day for high blood pressure;-Acetaminophen extra strength tablet 500 mg. Give one tablet by mouth three times a day for pain;-Ibuprofen oral tablet 200 mg. Give 400 mg by mouth before meals and at bedtime for back pain. Review of the resident's MAR, dated January 2026, showed:-Amlodipine besylate not administered on 01/03/26. No documentation as to why;-Glipizide not administered on 01/03/26. No documentation as to why;-Multiple vitamin not administered on 01/03/26. No documentation as to why;-Vitamin B-12 not administered on 01/03/26. No documentation as to why;-Lisinopril not administered on 01/03/26 at 7:00 A.M. No documentation as to why;-Metformin not administered on 01/03/26 at 7:00 A.M. No documentation as to why;-Acetaminophen not administered on 01/03/26 at 7:00 A.M. and midday. No documentation as to why;-Ibuprofen not administered on 01/03/26 at 7:30 A.M. and 11:30 A.M. No documentation as to why. Review of the resident's progress notes showed no documentation of why medications were not administered. 8. Review of Resident #10's comprehensive MDS, dated [DATE], showed: -Cognitively intact;-Wheelchair for mobility;-Supervision or touch assistance with ADLs;-Totally dependent with mobility;-Diagnoses included: Seizures, OCD, vitamin deficiency and cognitive communication deficit. Review of the resident's care plan, in use during survey, showed:-Focus: The resident used psychotropic medications due to OCD and appetite stimulant;-Intervention: Staff administered psychotropic medications as ordered by physician. Review of the resident's order summary report, dated January 2026, showed:-Cholecalciferol oral tablet 25 mcg. Give three tablets by mouth once a day for supplement;-Cyanocobalamin tablet 1000 mcg. Give one tablet by mouth once a day for supplement;-Magnesium oxide tablet (treats low magnesium levels) 400 mg. Give one tablet by mouth once a day for supplement;-Sertraline tablet 100 mg. Give one and a half tablets by mouth once a day for OCD;-Doxycycline hyclate oral tablet (used to treat bacterial infections) 100 mg. Give 100 mg by mouth twice a day for prophylaxis (a preventative healthcare measure, to guard against, stop, or reduce the risk of diseases and infections before they start). Review of the resident's MAR, dated January 2026, showed:-Cholecalciferol not administered on 01/03/26. No documentation as to why;-Cyanocobalamin not administered on 01/03/26. No documentation as to why;-Magnesium oxide not administered on 01/03/26. No documentation as to why;-Sertraline not administered on 01/03/26. No documentation as to why;-Doxycycline hyclate not administered on 01/03/26. No documentation as to why. Review of the resident's progress notes showed no documentation of why medications were not administered. During an interview on 01/15/26 at 10:23 A.M., the resident said he/she often did not get his/her medicine on time. Sometimes his/her medicine was not given in the morning. Staff did not come in his/her room to give it to him/her. 9. Review of the facility staffing sheet, dated 01/03/26, showed Licensed Practical Nurse (LPN) E, LPN G, and Certified Medication Technician (CMT) F assigned to the 300 hall. During an interview on 01/15/26 at 11:05 A.M., Scheduler H said there was a CMT scheduled for 300 east and 300 west. The CMT scheduled on 300 west called off. The CMT on 300 east refused to pass medication on 300 west. Scheduler H could not remember the CMT's name. If a CMT calls off, the nurse assigned to the hall passed the medication. Scheduler H is a CMT. Scheduler H arrived at the facility at 12:41 P.M. The nurse assigned to 300 west passed the medication and Scheduler H helped. He/She was not sure why the MAR was blank. During an interview on 01/15/26 at 12:46 P.M., CMT C said the medication pass started at 7:00 A.M. Medication could be passed one hour before or one hour after it was scheduled. There was a CMT for each floor. If the CMT called off, the scheduled nurse passed the medications. Sometimes a CMT was pulled from another floor. If a medication was not given, it was documented in the MAR and progress notes. If the MAR was blank, the medication was not given. During an interview on 01/16/26 at 10:38 A.M., Nurse Manager D said there was a CMT scheduled on each floor. If the CMT did not show up, the nurse or nurse manager passed medications. If a medication was not passed, it should be documented in the MAR and progress notes. If the MAR is blank, the medication was not given. During an interview on 01/27/26 at 8:21 A.M., LPN E said he/she could not recall 01/03/26. The facility was always short staffed. He/She does not know the policy for medication pass when the CMT called off. They usually called in another CMT. Scheduler H was a CMT and worked on the weekend. Sometimes he/she passed the medication. There were two nurses scheduled on 300 hall. The nurse assignments on the 300 hall were heavy. He/She did not pass medications on the cart. During an interview on 01/27/26 at 9:36 A.M., CMT F said he/she was not scheduled on 01/03/26. He/She was called in to work. He/She worked from 6:55 A.M. to 9:00 P.M. He/She was assigned to hall 300 east. The CMT scheduled on 300 west called off. The facility tried to pull a CMT from the second floor. The CMT refused to help pass medication on the third floor. The nurse scheduled on 300 west said he/she would pass medication. The nurse had the keys for the medication cart. He/She could not remember the nurse's name. Scheduler H came in. CMT F did not see Scheduler H pass medication. If a medication is not given, it was documented in the MAR and progress notes. If the MAR was blank, the medication was not given. During an interview on 01/28/26 at 11:39 A.M., LPN G said he/she was assigned to 300 east and LPN E was assigned to 300 west. Sometimes there were two nurses and two CMTs scheduled on 300 hall. There was not a CMT on 300 west. Scheduler H asked CMT F to pass meds on 300 hall. CMT F refused to pass meds on 300 west. CMT F said they should have asked him/her in advance. LPN E passed medication to some of the residents. Several residents did not receive their medications. When CMT F refused to pass medications, LPN E should have passed them. During an interview on 01/16/26 at 12:01 P.M., the Director of Nursing (DON) said Scheduler H was responsible for scheduling staff. There was a CMT assigned to each floor. Sometimes there were two CMTs assigned to the 300 hall. If a CMT did not show up for his/her shift, they would replace him/her. If a replacement was not found, the nurse passed medications for their assignment. The CMT assigned to 300 west was late on 01/03/26. She was told the nurse passed medication. Scheduler H came in and helped the nurse pass medications. If a medication was not given, it was documented in the MAR and progress notes. She was not aware the MAR was blank. If the MAR was blank, the medication was not given. She would have expected staff to notify her if the medications were not given. She should have checked the MAR. 10. Review of Resident #4's pain assessment, dated 08/07/25, showed:-Pain presence: Yes;-Pain frequency: Almost constantly;-Pain intensity: Severe;-Indicators: Verbal complaints daily. Review of the resident's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Set up/supervision with ADLs;-Independent with mobility;-Received scheduled pain medication;-Diagnoses included: Legal blindness, CHF, depression, anxiety and osteoarthritis (the degeneration of cartilage in joints, leading to pain). Review of the resident's care plan, in use during the survey, showed:-Focus: The resident had pain due to chest pain, muscle spasms and chronic pancreatitis (inflammation of the pancreas);-Intervention: Staff administered pain medication as ordered. Review of the resident's Order Summary Report, dated January 2026, showed hydrocodone-acetaminophen tablet 5-325 mg. Give one tablet by mouth every six hours for pain. Review of the resident's MAR, dated January 2026, showed:-Hydrocodone-acetaminophen tablet:-01/02/26 administered at 12:00 A.M. Not administered at 6:00 A.M. No documentation as to why. Staff documented 13 (means not available) at 12:00 P.M. and 6:00 P.M.;-01/03/26 not available at 12:00 A.M., 6:00 A.M. and 12:00 P.M. Given at 6:00 P.M.;-01/04/26 staff documented nine (means see progress notes) at 12:00 A.M. Not available at 6:00 A.M. and 12:00 P.M. Given at 6:00 P.M. Review of the resident's outbound (sent by facility) electronic order transmissi

Based on observation, interview, and record review, the facility staff failed to ensure one resident with an indwelling urinary catheter (a sterile tube inserted into the bladder through the urinary tract to drain urine) was provided catheter care and antibiotic flushes as ordered for one of three residents sampled for catheter care (Resident #19). The resident suffered from several urinary infections in the prior months leading to hospitalizations and this failure increased the risk of another infection. The census was 126. Review of the facility's Catheter Care policy revised 5/25, showed:-Policy: It is the policy of the facility to ensure residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use:-Policy Explanation: --Catheter care will be performed every shift and as needed by nursing personnel; --Leg bags will be attached to the resident's thigh or calf making sure to have slack on the tubing to minimize pressure and tension; --Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. Review of Resident #19's medical record, showed:-admitted on [DATE].-Diagnoses include paraplegia (impairment or loss of motor and sensory function in the lower half of the body), quadriplegia (paralysis that affects all a person's limbs), calculus of kidney (hard mineral deposits which form inside the kidneys when urine contains more crystal-forming substances), neuromuscular dysfunction of bladder (a loss of bladder control caused by nerve damage, resulting in dysfunction of the muscles that store or empty urine retention of urine, weakness), cachexia (a severe, involuntary wasting syndrome marked by significant loss of weight, skeletal muscle and fat), chronic pain syndrome, and mild protein-calorie malnutrition. Review of the resident's care plan, showed:-Initiated on 08/28/25: --Focus: The resident has an in-dwelling catheter; --Interventions/Tasks: The resident has 18 French (F) Foley with 30 cubic centimeter (cc) balloon. Position catheter bag and tubing below the level of the bladder. Change catheter per physician order. Maintain catheter drainage bag below bladder level. Review of the electronic physician order sheet (ePOS) dated 12/01/25 through 12/31/25, showed:-An order, dated 06/09/25, Foley care every shift;-An order, dated 08/27/25, to cleanse peri area and provide catheter care two times a day and as needed. Cleanse with soap and water two times a day for fungal infection;-An order dated 08/28/25, resident has a urinary catheter, 18 French 30 cc balloon. Change every 30 days plus/minus four days;-An order, dated 11/18/25, Gentamicin solution (a highly effective treatment for chronic or recurrent urinary tract infections (UTIs) where antibiotic solution is instilled directly into the bladder via a catheter) flush, use a 60-cc catheter tip syringe to draw up 50 milliliters (ml) of gentamicin into syringe, gently push out the air. Disconnect catheter from the bag. Allow all urine to drain from the bladder. Once the bladder s empty, attach the syringe of the catheter and slowly push into bladder. Once the syringe is empty leave it attached to the catheter for 60 minutes. May have to clamp the catheter. At the end of the dwell time, clamp the catheter, let the fluid drain; at bedtime for antibiotic flush. Review of the December 2026 medication administration record (MAR) showed an order, dated 11/18/25, Gentamicin solution flush, use a 60-cc catheter tip syringe to draw up 50 ml of gentamicin into syringe, gently push out the air. Disconnect catheter from the bag. Allow all urine to drain from the bladder. Once the bladder is empty, attach the syringe of the catheter and slowly push into bladder. Once the syringe is empty, leave it attached to the catheter for 60 minutes. May have to clamp the catheter. At the end of the dwell time, clamp the catheter, let the fluid drain; at bedtime for antibiotic flush. -Noted as blank and undocumented on night of 12/01/25;-A 9 documented on nights 12/02/25 and 12/04/25;-A 13 documented on nights 12/05/25, 12/06/25 and 12/07/25;-Chart code, showed 9 = Other/See progress notes; 13 = Medicine not available. Review of the electronic treatment administration record (TAR) for 12/01/25 through 12/31/25, showed an order, dated 06/09/25, Foley care every shift. Noted as blank and undocumented day shift on 12/23/25. Review of the resident's progress notes, showed: -On 12/02/25 at 9:07 P.M., staff were unable to flush the resident's catheter. The old Foley was removed after a balloon deflation. Staff inserted a 16 F with 30 ml bulb. This was met with some resistance, but staff were finally able to clear the catheter with the return of blood tinged urine;-On 12/03/25 at 2:57 P.M., the nurse placed a call to the resident's urologist to request to fax over flush orders by the end of the day. Staff also called the pharmacy to inquire about why the flush solution had not been sent, and the pharmacy staff told them they never received an order. The nurse sent the order two times before but informed the pharmacy staff he/she would send it over now;-On 12/04/25 at 7:51 A.M., the gentamicin flush still not available and the nurse would notify the urologist. At 6:54 P.M., the gentamicin still not available. The staff flushed the Foley with saline;-On 12/05/25 at 1:18 P.M., the nurse again attempted to reach the nurse practitioner from the resident's urologist, regarding an update about the gentamicin flush, with no success;-On 12/05/25 at 10:59 P.M., prior to catheter insertion, the resident voided spontaneously. A 16 F Foley catheter was removed with a 7-cc balloon. The resident had some tenderness with the removal. Upon assessment, the peri area was noted to be reddened with the presence of a bump and minimal bleeding observed on the penis and scrotum. A new 16 F catheter inserted with a 15-cc balloon inflated. Blood-tinged urine returned initially, with minimal pain reported during insertion. Catheter secured and draining appropriately;-On 12/06/25 at 6:01 A.M., the catheter was draining blood-tinged urine. Output approximately 500 cc of urine. At 3:51 P.M., the nurse received a report the resident had blood noted in urine and from penis. A call was placed to the resident's urologist who instructed to bladder scan the resident and call back if the volume exceeded 150 ml and ordered a repeat urinalysis (a set of tests that looks at the appearance of urine and checks for blood cells, proteins and other substances in it) for the following Monday. Staff notified the Director of Nursing (DON). The resident wanted to go to the hospital. Based on the resident's condition and request, the decision was made to send the resident out for further evaluation. At 6:08 P.M., the resident returned from the hospital with no new orders. Review of the resident's urology physician's progress note dated 12/06/25, showed:-The resident underwent a Foley change last night following a previous change on Tuesday (12/02/25). On Wednesday (12/03/25) morning, he stated he had been in pain since the previous Foley change. Removal of 10 cc from the balloon at that time reportedly alleviated some of his discomfort. On Thursday (12/4/25), he noticed minimal urinary leakage (dripping) around the catheter and on Friday (12/5/25) he reports urinating completely around the Foley with no urine flowing into the device. The catheter was changed again but only tolerated 15 cc in the balloon. Since then, he has experienced blood-tinged urine and bleeding from the penile meatus (opening). Staff noted he produced around 500 cc of brownish drainage overnight. He currently receives gentamicin flushes through the Foley. Review of the resident's hospital discharge paperwork dated 12/07/25, showed:-Diagnosis: Foley catheter problem, discharge;-Follow up: Return to the emergency department for catheter not draining or any new or concerning symptoms. Review of the resident's progress notes, showed:-On 12/08/25 at 9:14 A.M., the resident was not acting himself. The nurse had the physician come and assess the resident who ordered intravenous (IV-existing or taking place within, or administered into, a vein or veins) fluids. At 2:05 P.M., the resident not doing well, began to decline. The nurse called the resident's physician who sent orders for the resident to be sent to the hospital;-On 12/15/25 at 2:37 P.M., the resident returned from the hospital;-On 12/16/25 at 2:52 P.M., staff called the nurse to the resident's room for an assessment of the resident's penis and right hip. The right hip appeared fluid filled and the penis appeared extremely swollen in multiple places and draining a small amount of blood. A Foley catheter was inserted and draining yellow colored urine. The resident recalled no trauma or injury noted for cause of the bleeding. The nurse practitioner assessed the resident as well and wanted to send the resident out to the emergency room. The nurse attempted to call the resident's urologist office around 12:00 P.M., due to the resident's follow up appointment in one week to see if he could be seen sooner due to this issue. Awaited call back for several hours. Multiple call attempts made to speak with someone again but unsuccessful. The resident was okay with being sent out to the hospital. At 3:38 P.M., the resident was sent to the hospital;-On 12/17/25 at 3:08 A.M., the resident returned from the hospital. Review of the ePOS, dated 01/01/26 through 01/31/26, showed:-An order, dated 08/27/25, to cleanse peri area and provide catheter care two times a day and as needed. Cleanse with soap and water two times a day for fungal infection;-An order dated 08/28/25, resident has a urinary catheter, 18 F 30 cc balloon. Change every 30 days plus/minus four days;-An order, dated 06/09/25, Foley care every shift. Review of the electronic TAR for 01/01/26 through 01/31/26, showed:-An order, dated 08/27/25, to cleanse peri area and provide catheter care two times a day and as needed. Cleanse with soap and water two times a day for fungal infection; --Noted as blank and undocumented on evenings 01/12/26, 01/25/26 and 01/19/26; --Noted with code 1 on days 01/26/26 and 01/27/26; ---Chart code, showed 1 = Leave of absence without meds;-An order, dated 06/09/25, foley care every shift. Notes as blank and undocumented: --Evenings 01/12/26, 01/15/26 and 01/19/26; --Nights 01/10/26 and 01/18/26. Review of the resident's progress notes, showed:-On 01/20/26 at 10:40 P.M., the nurse was unable to do treatment or flush the Foley as the resident did not want to go to bed yet;-On 01/21/26 at 12:30 P.M, critical labs reported for E. Coli (bacteria), enterococcus faecalis (a species of bacteria that is naturally found in the intestines) and Pseudomonas Aeruginosa (bacteria that can cause infections in the blood, lungs, or other parts of the body after surgery);-On 01/22/26 at 10:08 P.M., the nurse unable to flush the Foley, old Foley removed. 16 F Foley placed, obtained immediate return of dark amber colored urine. Review of the ePOS, dated 02/01/26 through 02/28/26, showed:-An order, dated 06/09/25, Foley care every shift;-An order, dated 08/27/25, to cleanse peri area and provide catheter care two times a day and as needed. Cleanse with soap and water two times a day for fungal infection;-An order dated 08/28/25, resident has a urinary catheter, 18 F 30 cc balloon. Change every 30 days plus/minus four days;-An order dated 01/20/26, flush Foley A.M. (morning) and P.M. (evening) with 30 ccs every evening and night shift. This must be completed twice a day, not passed on to the next shift. Review of the eTAR for 02/01/26 through 02/28/26, showed:-An order, dated 06/09/25, Foley care every shift: --Noted as blank and undocumented on day shift 02/03/26, 02/05/26, 02/19/26, 02/21/26 and 02/24/26; --Noted as blank and undocumented on evenings 02/12/26, 02/21/26 and 02/22/26; --Noted as blank and undocumented on night shift 02/03/26.-An order, dated 08/27/25, to cleanse peri area and provide catheter care two times a day and as needed. Cleanse with soap and water two times a day for fungal infection; --Noted as blank and undocumented on days 02/03/26, 02/05/26, 02/19/26, 02/21/26 and 02/24/26; --Noted as blank and undocumented on nights 02/12/26 and 02/20/26 through 02/23/26; --Noted with code 1 on days 02/09/26, 02/10/26 and 02/12/26;-An order dated 01/20/26, flush Foley A.M. and P.M. with 30 ccs every evening and night shift --Noted as blank and undocumented on evenings 02/12/26, 02/15/26, 02/21/26,0 2/22/26 and 02/27/26; --Noted as blank and undocumented on nights 02/01/26, 02/03/26 and 02/05/26. Review of the resident's progress notes, showed:-On 02/03/26 at 2:47 P.M., the resident was reporting pain and concerns with skin and is upset about skin and catheter care;-On 02/05/26 at 11:00 P.M., an encounter note, this morning the resident reported not feeling well, with cough, chills and feeling cold. He was swabbed for COVID and flu both of which were negative. He has yellow, cloudy urine in his Foley catheter, which is scheduled for a change today;-On 02/19/26 at 11:30 P.M., the nurse was unable to flush the resident's Foley. Old Foley removed. 16F with 30 ml bulb placed without difficulty, obtained immediate return of cloudy, dark amber, blood tinged urine. Review of the ePOS dated 03/01/26 through 03/31/26, showed:-An order, dated 08/28/25, resident has a urinary catheter, 18 F 30 cc balloon. Change every 30 days plus/minus four days;-An order, dated 06/09/25, Foley care every shift;-An order dated 01/20/26, flush Foley A.M. and P.M. with 30 ccs every evening and night shift. This must be completed twice a day, not passed on to the next shift. Review of the March 2026 eMAR showed: -An order, dated 06/09/25, Foley care every shift. Documented as performed on night shift by Licensed Practical Nurse (LPN) E on 03/03/26; -An order, dated 08/27/25, cleanse peri area and provide catheter care two times a day and as needed, cleanse with soap and water. Noted as blank and undocumented in the evening on 3/3/26;-An order dated 01/20/26, flush foley am and pm with 30 ccs every evening. Documented as performed on night shift by LPN E on 03/03/26. Review of the resident's progress notes, showed:-On 03/03/26, no documentation the resident, the resident was at the hospital for a urological procedure which involved inserting a tube into the resident's penis. No documentation of the time the resident returned from the hospital or any instructions regarding care needed after the procedure;-On 03/04/26, no documentation the resident's catheter care was not provided. Observation on 03/04/26 at 7:15 A.M., showed the resident lay in bed moaning. His catheter bag was hooked to the side of the bed, level with the mattress. The tubing from the catheter lay flat approximately 8-10 inches along the mattress, curved to the left at the bed frame and into the bag. The urine in the tubing had red blood and a whitish, cloudy gritty sediment in it. The urine stopped flowing approximately 1/2 way down the tubing on the bed, blocked with the sediment. During an interview on 03/04/26 at 7:15 A.M., the resident said he was sent out for a procedure yesterday and was not feeling good today. He continued to moan out in pain and could not get comfortable. He gestured to his catheter tubing and said he thought something was wrong because he was in so much pain. He said no one provided catheter care to him since he came back from the hospital the evening before. During interviews on 03/40/26 at 7:20 A.M., 9:10 A.M., and 12:10 P.M, Nurse Manager B said the resident's catheter was not clipped in the right position on the bed. It should be lower. He/She acknowledged the sediment in the tubing and shook it so the sediment would run through it. The resident had gone to the hospital the day before for a procedure and the blood and sediment in the tubing could be a result of it. Evening catheter care was usually done between 9:00 P.M. and 11:00 P.M. It depended on when the resident was ready for bed. The staff member who provided the care would document this on the resident's MAR or TAR. If the staff member did not provide the catheter care, he/she should document why it was not done in the medical record. Staff should not document in the MAR/TAR it was done if it was not done. If the catheter care was not done as ordered, bacteria could build up and cause an infection. During an interview on 03/04/26 at 1:15 PM., LPN F said he/she worked the evening prior. The catheter care would be done by the nurse when the resident went to bed. He/She did not flush the resident's catheter because the resident was not ready for bed when he/she left the facility at 11:00 P.M. During an interview on 03/04/26 at 8:35 A.M. and 11:55 A.M., LPN E said he/she worked the night before, 11:00 P.M. until 7:00 A.M. He/She did not provide catheter care to the resident the night before. He/She thought the resident might have already been in bed when he/she started the shift. No one told him/her the resident returned from the hospital earlier or to monitor him after his procedure. LPN E did not know why it was documented on the MAR/TAR with his/her initials, it must have been a mistake. During an interview on 03/04/26 at 2:20 P.M., the DON said she was not aware the resident's catheter care was not documented as provided several times in the past couple of months. She did not know the staff did not provide catheter care for the resident the prior evening and documented it was done. The staff should provide catheter care per the physician's order. If they did not provide the care, the reason should be in the resident's medical record. Staff should not document the care was done on the TAR if it was not done. She did not know the resident went out for a procedure the day before and staff should have documented this and made observations of him through the night. If the staff did not provide Foley care or flush the catheter, this could lead to infections. It was possible if Foley care and flushes were not provided in 12/25, this could have led to the infections resulting in the hospitalizations. During an interview on 03/04/26 at 3:45 P.M., the Administrator said he just started working at the facility last month. He did not know documentation showed the resident was not provided catheter care several times in the past few months. He did not know the resident went out for a procedure yesterday and there was no documentation of it, the resident's return or any observations made during the night. Staff should document when care was provided in the medical record or a reason why it was not provided. If care was not provided, staff should not document it was provided. Care should be provided per the physician's order. If catheter care was not provided, then infections could occur. 2725202

Based on interview and record review, the facility failed to provide pharmaceutical services when a nurse dispensed and signed out narcotics and allowed Certified Medication Technician (CMT) J to administer them to two residents (Resident #19 and #22). Additionally, a resident (Resident #17) refused his/her medication, and the nurse disposed of the medications in the resident's trash can. The sample was 11. The census was 126. Review of the facility's Controlled Substance Administration and Accountability policy, dated 9/24, showed:-Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion or accidental exposure.-Policy Explanation and Compliance Guidelines: --Controlled substances are stored in a separate compartment of an automated dispensing system or other locked storage unit with access limited to approved personnel; --Specifically compounded or non-stock-controlled substances are dispensed from the pharmacy according to physician orders for a specific patient; --All controlled substances are accounted for in one of the following ways; --All specially compounded or non-stock Schedule II controlled substances dispensed from the pharmacy for a specific patient are recorded on the controlled Drug Record supplied with the medication or other designated form per facility policy; --The Controlled Drug Record is a permanent medical record document and in conjunction with the medication administration record (MAR) is the source for documenting any patient-specific narcotic dispensed from the pharmacy. Review of the Medication Administration policy, dated 10/24, showed:-Policy: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection;--Ensure that the six rights of medication to be administered: --Right resident; --Right drug; --Right dosage; --Right route; --Right time; --Right documentation; --Review MAR to identify medication to be administered;--Compare medication source with MAR to verify resident name, medication name, form, dose route and time; -Remove medication from source;--Observe resident consumption of medication; --Sign MAR after administered; --If medication is a controlled substance, sign narcotic book.-Report and document any refusals;-Correct any discrepancies and report to nurse manager. Review of the facility's Destruction of Unused Drugs policy, revised December 2025, showed:-Drugs will be destroyed in a manner which renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements;-Unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed;-The actual destruction of drugs conducted by the facility must be witnessed by the consultant pharmacist and one of the following individuals:-An agent of the State Board of Pharmacy;-The facility Administrator; or-The Director of Nursing (DON) services;-A non-controlled medication destruction record must be maintained for all non-controlled drugs destroyed and such record must be verified by the consultant pharmacist. 1. Review of Resident #19's medical record, showed:-Cognitively intact;-Diagnoses included paraplegia (impairment or loss of motor and sensory function in the lower half of the body), quadriplegia (paralysis that affects all a person's limbs), calculus of kidney (hard mineral deposits which form inside the kidneys when urine contains more crystal-forming substances), neuromuscular dysfunction of bladder (a loss of bladder control caused by nerve damage, resulting in dysfunction of the muscles that store or empty urine retention of urine, weakness), cachexia (a severe, involuntary wasting syndrome marked by significant loss of weight, skeletal muscle and fat), chronic pain syndrome, and mild protein-calorie malnutrition. Review of the resident's 02/01/26 through 02/28/26, electronic Physician's Order (ePOS), showed:-An order dated 12/02/25, for hydrocodone-acetaminophen (narcotic used for pain) 10-325 milligrams (mg), take one tablet by mouth as needed every 12 hours for pain;-No order to self-administer or take medication on leave. Review of the resident's progress notes, showed on 02/10/26 at 11:00 A.M., it was the agency nurse's (LPN K) first time on the floor, and he/she was told it is regular procedure the resident takes his/her oxy (oxycodone, a narcotic pain medication) to go. The nurse said that does not sound legal and is not a good idea. CMT J said that is what we do and he/she needs it. The nurse said no, and the CMT grabbed and placed the medication in the resident's bag and said he/she knows what to do with it. Review of the resident's, electronic Medication Administration Record (eMAR), showed on 02/10/26 at 8:00 A.M., Licensed Practical Nurse (LPN) K administered the resident's hydrocodone-Acetaminophen. 2. Review Resident #22's medical record, showed:-Cognitively intact;-Diagnoses included iron deficiency anemia (a common blood condition occurring when you have an insufficient number of healthy red blood cells or low hemoglobin (an iron rich oxygen-transporting protein located within red blood cells), reducing the blood's capacity to carry oxygen to tissues), unspecified severe protein-calorie malnutrition, muscle weakness, need for assistance with personal care, unsteadiness on feet, hemiplegia (the severe or complete paralysis of one side of the body caused by brain damage on the opposite side) and hemiparesis (a neurological condition characterized by weakness or reduced motor control on one side of the body) following stroke, and dysphagia (difficulty swallowing, indicating a disruption in moving food or liquid from the mouth to the stomach). Review of the resident's February 2026 ePOS, showed MS Contin oral tablet extended release 15 mg (Morphine Sulfate), give one tablet by mouth every 12 hours for pain. Review of the resident's 02/01/26 through 02/28/26 eMAR, showed on 02/10/26 at 8:00 A.M., LPN K administered the resident's MS Contin. 3. During an interview on 03/02/26 at 2:15 P.M., CMT J said he/she was allowed to administer narcotics and would sign off on the documentation if he/she administered the medication. He/She worked on 02/10/26 with an agency nurse (LPN K). LPN K did not want to give the pain medication to the residents. He/She was new to the floor and did not know the residents the way the CMT did. The LPN thought it was too soon to give Resident #22 his/her medication, but the CMT knew the resident was in pain and he/she needed it, so he/she gave the resident his/her medication that LPN K had signed out. Resident #19 went out all day and would need his/her medication, so they would send it with him/her. The LPN did not tell the CMT he/she had an issue with this, and the CMT did not think there was a problem with it. During an interview on 03/04/26 at 11:30 A.M., Nurse Manager B said he/she was not working the day the nurse gave the narcotics to the CMT to administer and was not aware it happened. Up until a few weeks prior, the CMTs were allowed to prepare and administer narcotics and sign off on this. The nurse should not have documented he/she administered the medication if the CMT did it. The CMT should not have accepted the medication from the nurse if he/she did not prepare it. During an interview on 03/04/26 at 2:20 P.M., the DON said the person who prepares the medication should be the person who administers the medication. The staff member who administers the medication is the person who documents the medication was administered. The nurse should not have allowed the CMT to take the medication and administer it. If the nurse had concerns about the dosage or effects of the medication, he/she should have talked to the nurse manager or DON. 4. Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/22/25, showed:-Severe cognitive impairment;-Diagnoses included unspecified dementia with agitation and depression. Review of the resident's February MAR, showed on 02/24/26, LPN C documented all night medications were given. Review of the resident's progress notes, showed on 02/24/26 at 6:02 A.M. (late entry), LPN C documented the resident refused his/her medication. He/She said he/she would take it later. LPN C said he/she had to watch the resident take the medication. The resident did not want LPN C to watch him/her take the medication. The resident again refused the medication. LPN C took the medication from the resident and tossed them in the trashcan, in the resident's room. LPN C charted on the nurse-to-nurse report and notified the night shift nurse. During an interview on 03/02/26 at 8:22 A.M., the resident said he/she thinks he/she got his/her medications. He/She did not recall staff leaving medication in his/her room. During an interview on 03/04/26 at 10:16 A.M., LPN C said he/she was the night shift agency nurse on the memory care unit on 02/23/26. He/She had worked at the facility before. He/She asked the resident if he/she wanted his/her medications. The resident said no. LPN C told the resident he/she had to watch him/her take the meds. The resident refused to take the medications. LPN C tossed them in the trashcan, by the resident's bed. He/She did not return the medications to the medication cart, because the resident refused them. He/She reported the refusal to the night shift charge nurse. LPN C said when he/she started his/her shift he/she got report. Staff did not tell him/her about policies. LPN C said he/she always tossed refused medications in the trash. During an interview on 03/04/26 at 10:43 A.M., CMT H said the resident refused medications. He/She notified the nurse when it happened. The unused medications were placed in a plastic container. The container contained a dissolving liquid. Staff should never dispose of medication in a resident's room. During an interview on 03/04/26 at 2:55 P.M., the DON said she was told the pills were left at the resident's bedside. She was not aware LPN C threw the pills in the resident's trashcan. The pills should have been placed in the drug buster bottle. It was not okay to throw the pills in the trashcan. When agency staff started a shift, they went straight to the floor. There was no training on facility policies. During an interview on 03/04/26 at 3:23 P.M., the Administrator said he started working at the facility a couple of weeks prior and was not aware the CMT passed the narcotics for the LPN. Nurses were responsible for administering narcotics. The nurse should not have allowed the CMT to administer pills. The nurse should not have signed off on the pills. He/She should have contacted the nurse manager or DON. Staff are supposed to document medication refusals and follow protocol for disposal. It was not okay to dispose of medication in the resident's room. 279071227252022740288

Based on observation, interview, and record review, the facility failed to administer and ensure the resident consumed nutritional supplements for one resident who was identified with significant weight loss and wounds (Resident #19). This failure could result in continued weight loss and/or deterioration of wounds. The sample was 11. The census was 126. Review of the facility's Nutrition/Hydration Management policy, revised 12/25, showed:-Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;-Compliance guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (Gradual intended loss over a period of time) may indicate a nutritional problem; --The facility will utilize a systematic approach to optimize a resident's nutritional status. This process includes: -Identifying and assessing each resident's nutritional status and risk factors; -Evaluating/analyzing the assessment information; -Developing and consistently implementing pertinent approaches; -Monitoring the effectiveness of interventions and revising them as necessary; --A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status; --Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences; --Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status; --A weight monitoring schedule will be developed upon admission for all residents; --Weight analysis: The newly recorded weight should be compared to the previous recorded weight. A significant change in weight is defined as: --5 % change in 1 month (30 days); --7.5 % change in 3 months (90 days); --10 % change in 6 months (180 days); -Though a significant weight change may not occur, the resident may be identified as below ideal body weight by the Registered Dietician or designee;-Documentation: The physician should be informed of a significant change in weight and may order nutritional interventions. Review of Resident #19's medical record, showed:-admitted on [DATE].-Diagnoses include paraplegia (impairment or loss of motor and sensory function in the lower half of the body), quadriplegia (paralysis that affects all a person's limbs), cachexia (a severe, involuntary wasting syndrome marked by significant loss of weight, skeletal muscle and fat), chronic pain syndrome, and mild protein-calorie malnutrition. Review of the resident's electronic physician order sheet (ePOS), showed:-An order dated 01/20/26 for protein oral liquid (protein that is consumed as a drink,), give 30 milliliters (ml) by mouth two times a day for wound;-An order dated 01/21/26, for Boost (supplement) with resident to his/her day program (Paraquad), every day shift for supplement. Review of the resident's progress notes, showed:-On 01/21/26 at 11:00 P.M., an encounter note, the resident's weight 151.4 pounds (lb). Warning: -5% change over 30 days. The resident has ongoing weight loss and is followed by a registered dietician with Boost supplements ordered. He/She requires assistance with eating and is fed by staff. Comparison Weight 12/02/25, 170 Lbs, -11.2% , -19 Lbs;--Monitored for protein-calorie malnutrition by dietary team;-On 02/03/26 at 6:09 A.M., a nutritional/dietary note, noted weight loss. Resident is a very selective eater and can become irritated. Recommend adding 30 ml supplement two times a day, A.M. and P.M. to accommodate ongoing leave of absence during the day, to further promote wound healing. Review of the resident's February electronic medical administration record (eMAR) showed an order for Boost supplement with resident to Paraquad. No documentation completed with areas left blank on 02/03/26 and 02/05/26. Review of the resident's progress notes, showed:-On 02/08/26 at 11:00 A.M., a nutritional/dietary note, ongoing weight loss, importance of sending supplements and snacks to Paraquad emphasized. Followed by registered dietician. Weight documented as 150.4 lbs;-On 02/13/26 at 11:01 A.M., medication administration note, protein oral liquid. Resident had to leave so did not get it;-On 02/17/26 at 7:30 A.M., a nutritional/dietary note, based on registered dietician's review, recommend adding diagnosis of mild protein calorie malnutrition at this time. Review of the resident's care plan in use at the time of the survey, showed:-Focus: Resident has nutritional problem or potential nutritional problem;-Interventions/Tasks: Administer medications as ordered.-Focus: Resident is at risk for impaired skin integrity;-Interventions/Tasks: Provide adequate nutrition/hydration. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/18/26, showed:-Cognitively intact;-No rejection of care;-Dependent on staff for eating;-Weight loss: Yes, on physician-prescribed weight loss regimen. Review of the resident's progress notes on 03/03/26 at 7:42 A.M., showed a nutrition/dietary note, noted weight fluctuations - recent weight gain. Weight 160 lbs. Observation on 03/04/26 at 7:15 A.M., showed a medication cup of an amber liquid on the resident's dresser. During interviews on 03/03/26 at 7:25 A.M., and on 03/04/26 at 7:15 A.M., the resident said the medication in the cup helped with weight loss. Staff usually administered it in the evening or night. The staff did not always send his/her Boost or a lunch with him/her to Paraquad, and they did not provide food there. He/She always felt hungry. The resident purchased snacks of his/her own to take because if breakfast was running late and he/she had to leave, he/she would not get anything to eat until dinner. During an interview on 03/04/26 at 7:20 P.M., Nurse Manager B acknowledged the liquid filled medication cup and said he/she did not know what was in the cup. He/She took the medication cup up to the nurse's station to ask if any of the staff knew what it was or when it was passed. He/She said staff should not have left it on the resident's dresser. During an interview on 03/04/26 at 7:30 A.M., Certified Medication Technician (CMT) J said the medication was the resident's protein supplement, but he/she did not leave it in his/her room, as he/she just started his/her shift and had not passed any medication yet. Review of the resident's February eMAR, showed the protein supplement was documented as administered on 03/03/26 by CMT G. During an interview on 03/04/26 at 10:25 A.M., CMT G said he/she passed medications and supplements the prior evening. The resident was in the dining room when he/she tried to administer his/her protein supplement, and the resident told the CMT, he/she was on the way back to his/her room and would take it there. The CMT went in the resident's room and left it on his/her dresser. The CMT knew he/she was supposed to watch the resident take all his/her medications, but since it was protein, he/she did not consider it medication. The resident assured the CMT, he/she would take the protein as soon as he/she got to the room. He/She documented the protein supplement was administered because he/she thought the resident took it. During an interview on 03/04/26 at 2:20 P.M., the Director of Nursing said the liquid protein should not have been left in the resident's room. The resident does have a weight loss issue, and the supplements should be administered as ordered. The documentation should reflect whether they were administered or not. Staff should not document it was administered if they did not see the resident take it. If the resident did not get these supplements, the resident could have more weight loss or wounds might take longer to heal. During an interview on 3/4/26 at 4:20 P.M., the Administrator said if the resident refuses to take the supplement at the time it is offered, then the staff member should take it back to the medication cart, dispose of it and document the resident refused. If the resident just wanted to go back to his/her room, the staff member should have waited until he/she got to the room and then administered it. The medication should be administered as ordered by the physician. 2725202

Based on observation, interview and record review, the facility failed to ensure resident care plans were updated and accurate to reflect resident needs. This failure affected three residents (Residents #22, #23, and #24) whose care plans did not address increased need for eating assistance, increased depression, safety concerns, increased confusion, wandering behavior, and recent fall interventions. The sample size was 11. The census was 126. Review of the facility's Comprehensive Care Plans policy dated 9/24, showed:-Policy: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment;-Policy Explanation and Compliance Guidelines: --The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided and arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed; --The comprehensive care plan will describe, at a minimum, the following: --The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; --Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment; --The comprehensive care plan will be prepared by an interdisciplinary team; --The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment; --The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed; --Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 1. Review of Resident #22's medical record, showed:-admission date of 06/20/25;-Diagnoses included iron deficiency anemia (a common blood condition occurring when you have an insufficient number of healthy red blood cells or low hemoglobin (an iron rich oxygen-transporting protein located within red blood cells), reducing the blood's capacity to carry oxygen to tissues), unspecified severe protein-calorie malnutrition, muscle weakness, need for assistance with personal care, unsteadiness on feet, hemiplegia (the severe or complete paralysis of one side of the body caused by brain damage on the opposite side) and hemiparesis (a neurological condition characterized by weakness or reduced motor control on one side of the body) following stroke, and dysphagia (difficulty swallowing, indicating a disruption in moving food or liquid from the mouth to the stomach). Review of the resident's progress notes, showed:-On 12/06/25 at 3:21 P.M., staff observed the resident experiencing an acute anxiety episode. Staff remained with the resident, provided verbal reassurance and emotional support. During conversation, the resident stated, I wish someone would just shoot me in the head three different times. At 11:59 A.M., staff notified the Director of Nursing (DON) immediately of the resident's statement and mental status. The DON recommended the resident be sent out for further psychiatric evaluation. At 12:16 P.M., emergency medical services (EMS) arrived and transported the resident for further evaluation. Review of the resident's hospital records, dated 12/06/25, showed:-Date of admission: [DATE] at 12:48 P.M.;-Arrival complaint: Facility changed Xanax (used for anxiety) dose two days ago. Had anxiety attack this morning. Had argument with nurse and stated he/she wished someone would shoot him/her. States he/she regrets saying it now;-Comment: Suicidal. Patient states he/she got into an argument with one of the nurse's aides and stated he/she was going to put a gun to his/her mouth. Patient denies suicidal ideations currently. Patient states he/she regrets making the statement and never feels suicidal ideations. History of panic attacks. Recently adjusted Xanax prescription;-The patient was seen in the emergency room by an intake clinician. Per the consulting provider, it has been determined the patient is safe for discharge to follow-up with outpatient providers and resources. Review of the resident's progress notes, showed:-On 12/06/25 at 5:54 P.M., the resident returned to the facility with no new orders. No documentation of a follow up with outside services in the resident's record;-On 12/22/25 at 11:52 A.M., a nutrition/dietary note, weight 117.4 pounds (lbs). Feeds self in the dining room. Enjoys house supplement three times a day (TID) between meals. Indicating some weekly weight loss. Note continued weight loss despite nutritional interventions in place. Recommend alternative appetite supplement;-On 01/06/26 at 1:50 P.M., a nutrition/dietary note, weight 114.2 lbs. Recently admitted to palliative care. Note continued weight loss despite nutritional interventions in place. Recommend trial alternate appetite stimulant. Active diagnosis of severe protein calorie malnutrition at this time;-On 01/10/26 at 8:55 P.M., the resident had a tear to his/her left wrist. The resident stated he/she scraped his/her arm against the wheel of his/her wheelchair while trying to apply the brake;-On 01/13/26 at 9:00 A.M., a nutrition/dietary note, weight 112.5 lbs. Resident aware of weight loss and desires gain. Megace (an appetite stimulant) added 01/13/26, which may help increase appetite and weight;-On 01/19/26 at 11:50 A.M., a nutritional/dietary note, weight 115.2 lbs. Body Mass Index (BMI-a screening tool calculating a person's weight to height ratio) indicates resident underweight for age. Recommend continue with above outlined interventions at this time;-On 01/22/26 at 11:00 P.M., an encounter note, a patient health questionnaire-9 (PHQ-9 mental health screening) dated 01/15/26 for depression. The resident scored a 22. A score of 20-27 indicates severe depression. Treat using antidepressants with or without psychotherapy. Treatment plan required: Mental health care management. The resident reported being referred to hospice and is considering this option, but is unsure whether he/she wants to pursue it at this time. The reasons he/she is wanting hospice is because he/she is lonely and scared. He/She is seeking additional resources and people to talk to;-On 01/26/26 at 1:49 P.M., a nutrition/dietary note, weight 118 lbs. Order for hospice evaluation. Recommend continue current interventions at this time;-On 01/27/26 at 1:18 P.M., staff noted the resident with a skin tear to his/her left wrist sustained by self-propelling self in his/her wheelchair;-On 02/01/26 at 5:00 A.M., staff noticed a tear to the back of the resident's left hand. When asked what happened, the resident stated he/she must have hit his/her hand on the wheelchair;-On 02/03/26 at 6:33 A.M., a nutrition/dietary note, weight 116.8 lbs. Resident receiving hospice care. Can be selective eater however makes needs known. Recommend increasing house supplement to two cartons three times a day between meals;-On 02/06/26 at 5:30 A.M., the resident is more confused and states he/she is having vivid dreams. He/She is also not making it to the bathroom when he/she needs and is very upset. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/18/26, showed:-Cognitively intact;-No behaviors or resistance to care;-Wandering presence or frequency: not exhibited;-Functional abilities: --Eating: Supervision or total assistance. Helper provides verbal cues and/pr touching/steadying contact as resident completes activity. Review of the resident's progress notes, showed:-On 02/22/26 at 10:33 A.M., the resident is becoming more and more anxious and confused. Forgetting how to do simple tasks, he/she was able to do a few days ago. Unable to find room or how to use the restroom. Afraid to be alone, not knowing the time of day, calling family and hospice during the night hours. Will discuss with hospice the possibility of too much medication versus possible low hemoglobin (iron-rich protein in red blood cells);-On 02/23/26 at 10:30 P.M., the resident appeared to be on the floor in prone position with staff surrounding him/her. According to the Certified Nurse's Aide (CNA), the resident was observed throwing him/herself out of the chair and onto the floor;-On 02/24/26 at 9:22 A.M., the resident was very confused this shift. Pushing a dining room chair across the room and not realizing it. The receptionist reported he/she went to the lobby and began yelling for help, for the DON and random people;-On 2/26/26 at 9:29 A.M., the resident was tearful this shift. When attempting to explain why, the resident gave nonsensical responses. The resident left the floor without staff knowledge to go to the receptionist to ask for something to drink. Very confused. Can't find room, not following directions, entering other resident's rooms. At 10:16 A.M., staff placed a Wanderguard (electronic monitoring bracelet) on the resident's left ankle and explained its purpose to the resident. Review of the resident's care plan dated 02/26/26, showed:-Focus: The resident is prescribed a psychotropic medication for alteration in mood/behavior related to anxiety;-Interventions/Tasks: Monitor/document/report as needed any adverse reactions of medications: Unsteady gait, frequent falls, refusal to eat, depression, suicidal ideations, social isolation, loss of appetite, weight loss and behavior symptoms not usual to the person;-The resident has chronic pain;-Interventions/Tasks: Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in range of motion or resistance to care;-Focus: Resident is on hospice;-Interventions/Tasks: Hospice to consult for changes to resident care plan/medications;-Focus: Resident is at risk for impaired skin integrity;-Interventions/Tasks: Apply moisturizer as needed to skin. Apply protective/preventative skin care. Encourage resident to use arm support for wheelchair. --No further interventions on preventing the resident from cutting his/her arm on the wheelchair.-No documentation the resident had increased confusion, wore a Wanderguard, had a noted weight loss, expressed suicidal ideations or needed increased assistance with eating. Observation on 03/02/26 at 9:25 A.M., showed the resident being wheeled out of the shower room, by a staff member. The resident's left hand had blood running down it. The staff member was unaware the resident had cut him/herself. He/She wore a Wanderguard on his/her ankle. During an interview on 03/02/26 at 9:45 A.M., the resident said he/she cut his/her hand on the wheel of the wheelchair. The wheelchair was not working right and the wheel turned inward, and he/she would catch his/her hand on the wheel. He/She kept asking if this was a hospice visit. He/She wanted to speak to someone from hospice. He/She was very depressed because he/she could not remember things or do the things he/she used to do, and the staff told him/her hospice would help him/her do those things like assisting him/her to the bathroom. He/She had fallen several times and was afraid to go to the bathroom by him/herself anymore. The resident started crying during the interview asking, what was he/she going to do? Observation on 03/03/26 at 8:30 A.M., showed the resident was wheeling around the dining room in his/her wheelchair. The staff would move his/her wheelchair to the table, and he/she would immediately move away from the table. The resident kept trying to take another resident's walker and the resident would move the walker out of his/her reach. At 8:45 A.M., a staff member delivered the resident's tray. The staff member opened the resident's milk and cereal but not his/her butter or jelly packets. The resident was served scrambled eggs, cereal, and two pieces of toast. The resident poured his/her milk into his/her cereal and ate a couple of bites of it. The resident then offered his/her eggs to another resident at the table. The other resident scooped the eggs off the resident's plate and offered him/her an orange juice. The other resident opened the orange juice for Resident #22 and put a straw in it and gave it to him/her. Resident #22 tried to open his/her jelly and butter packets but could not get them open with his/her fingers. He/She used his/her spoon to jab at the packets with no success. The resident pleaded with the surveyor to open the packets. The resident got frustrated and left the table leaving most of his/her meal. During an interview on 03/03/26 at 8:55 A.M., the resident said he/she gave the eggs away because he/she does not like them, and they make him/he sick. The staff serve him/her eggs almost every morning. His/Her hands did not work as well as they use to, and it was harder to open things or feed him/herself some foods. Observation on 03/03/36 at 12:30 P.M., the resident wheeled in and out of the dining room continually. The staff would push his/her wheelchair to the table, and he/she would immediately wheel away again. Another resident at the table opened a butter packet for the resident and gave it to him/her. A staff member served him/her a tray with chicken thighs, corn, ice cream and a baked potato. The resident attempted to cut the chicken thighs with his/her spoon but could not. He/She used the spoon to scoop up some corn but spilled most of it trying to get it to his/her mouth. An aide noticed him/her struggling and offered to cut up the chicken thigh for him/her. The resident wheeled away from the table again, and the aide brought him/her back to finish eating. He/She ate another bite of corn and attempted to leave the table again. The aide brought the resident back to the table again. The resident ate some more corn but none of the chicken or potato. During an observation on 03/03/26 at 11:30 A.M., the resident was in the dining room moving from table to table. The staff would place him/her back at his/her table, remind him/her it was time for lunch, and he/she would immediately move away again. The resident finally told staff he/she wanted to go lay down. The staff member took the resident to his/her room and put him/her to bed. Staff brought the resident a tray which and placed it on his/her bedside table, but the resident slept through the meal. During an interview on 03/13/26 at 1:00 P.M., the Registered Dietician said she knew the resident was having increased confusion and depression. The last time she met with him/her, the resident was inconsolable. The resident should not be served eggs if he/she did not like them. If the resident did not like the food this could contribute to weight loss. He/She knew the staff were helping set up the meals but did not know the resident needed more supervision to finish his/her meal. The confusion, depression, and weight loss should have been addressed in the resident's care plan. During an interview on 03/13/26 at 2:15 P.M., Nurse Manager B said he/she was out of the facility when the resident got off the floor in February. He/She updated the care plan on 03/04/26 after he/she returned. It should have been added when the behavior occurred. The resident was more confused now because when they placed him/her on hospice, they no longer check his/her blood levels and fluctuating blood levels cause confusion. He/She added the confusion on 03/04/26 when he/she updated the care plan. He/She did not know the resident was sent to the hospital in December 2025 for suicidal ideations. He/She thought the resident saw a psychiatrist recently and was going to send the records. During an interview on 03/04/26 at 2:10 P.M., the DON said the care plan should include the resident's increased need for assistance with eating and activities of daily living (ADLs). If the resident had a noted weight loss this should have been addressed in the care plan with the interventions put in place. During interviews on 03/04/26 at 4:20 P.M. and on 03/13/26 at 1:18 P.M., the Administrator said he just started working at the facility a couple weeks ago and was not aware the resident had a change in condition with needing more assistance with eating. Staff should have documented this and added it to the care plan with interventions. He did not know the resident got off the floor in 02/26 and staff placed a Wanderguard on him. The staff member who placed the Wanderguard should have documented it in his/her care plan. If the resident was sent to the hospital for suicidal ideations this should have been documented in his/her care plan with interventions.2. Review of Resident #23's progress notes, showed:-On 12/02/25 at approximately 8:15 P.M., the resident was found on the floor near his/her bedside by a CNA. The nurse was notified and arrived to assess the resident. The resident was alert and oriented. The resident said he/she attempted to transfer him/herself from the chair to the bed without assistance. He/She said his/her shoe slipped, and he/she lowered him/herself to the floor. The resident denied hitting his/her head or losing consciousness. No visible injuries noted. His/Her skin was intact. No redness, bruising, or abrasions observed. Range of motion was at baseline with no pain on movement. Vital signs were within normal limits (wnl). The resident was assisted back to bed and reminded to call for assistance before transfers. Call light placed within reach and safety measures reinforced. Voicemail left for family member. Note left in electronic medical records;-On 12/11/25 at 11:30 A.M., the resident was heard yelling out for help. The nurse entered the room and found him/her seated on the floor. No injuries and he/she denied hitting his/her head. He/She denied pain. Full range of motion (ROM) in all extremities and no changes in mental status. Vital signs were temperature 98.1 (normal 98.6), pulse 98 (normal 60-100), respirations 18 (normal 12-18), blood pressure 138/89 (normal 120/80), oxygen (O2) saturation 96% room air (normal 95-100%);-On 01/11/26 at 3:05 A.M., the resident was found on the floor at 2:30 A.M. He/She was seated upright on the floor next to his/her bed. There was blood on the floor and bed linen. Resident helped off floor with gait belt. Resident was able to bear weight and moved self to head of bed. Skin tear on left thumb. Skin tear cleaned and dressed. The resident denied pain or discomfort. Bed was in lowest position and call light was within reach. At 2:49 P.M., resident on fall follow up. Vital signs were stable. No complaint of pain or discomfort. Resident in bed with eyes closed. Call light within reach. Bed was in lowest position;-On 01/19/26 at 10:03 P.M., the resident was found on the floor by his/her bed at 6:45 P.M. He/She faced the nightstand, and his/her wheelchair faced the TV. The resident said he/she tried to transfer him/herself from wheelchair to bed. Resident educated on using call light for assistance. Two staff assisted resident off the floor with gait belt. No injuries noted. The resident's family and the DON were notified. The bed was in the lowest position;-On 01/31/26 at 6:43 A.M., the resident was found on the floor in his/her bedroom. The resident said he/she rolled out of bed. The resident denied hitting his/her head. Two staff assisted resident off floor with gait belt. Resident had a skin tear on his/her left elbow. Treatment applied to skin tear. The resident's bed was in the lowest position. His/her call light was within reach. Review of the resident's quarterly MDS, dated [DATE], showed;-Moderate impairment;-Wheelchair for mobility;-Partial/moderate assistance with activities of daily living (ADLs) and transfers/mobility;-Diagnoses included cancer, stroke, heart failure, high blood pressure, urinary tract infection (UTI), and left side weakness;-Falls since admission. One fall with injury. Review of the resident's progress notes, showed on 03/01/26 at 10:09 P.M., the resident was found seated on the fall mat. No injuries were noted. The bed was in the lowest position. Review of the resident's care plan in use during the survey, showed:-Focus: The resident was at risk for falls due to impaired cognition, incontinence, use of medications that could alter balance (initiated: 08/04/2025, revised on: 02/22/2026). The resident had falls on 10/14/25 (without injury), 10/24/25 (without injury), 12/02/25 (without injury), 12/11/25 (without injury), -1/11/26 (without injury), 01/19/26 (without injury), 01/31/26: (without injury);-Interventions: Staff anticipated and met the resident's needs. Staff ensured the resident's call light was within reach and encouraged the resident to use it for assistance. The resident needed prompt response to all requests for assistance. Bed was always in the lowest position. Staff encouraged the resident to engage in activities of interest outside his/her room. Physical and occupational therapy evaluation;-No documentation of fall mats. Observation and interview on 03/04/26 at 8:00 A.M., showed the resident seated in his/her wheelchair in his/her room. There were two fall mats in the resident's room. A blue mat on the right side of the resident's bed and one folded between the dressers. The resident said he/she needed to do a better job asking for assistance to eliminate falls. The fall mat is a pain in the butt. During an interview on 03/04/26 at 2:21 P.M., the DON said she was not sure what fall interventions were in place. The fall mat should have been added to the care plan. 3. Review of Resident #20's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Lower extremity impairment on one side;-Required substantial/maximum assistance with mobility and transfers;-Diagnoses included stroke, difficulty walking, muscle weakness and heart disease. Review of the resident's progress notes, showed on 01/30/26 at 6:58 P.M., the resident reported to family he/she fell two nights ago. The nurse spoke with resident's power of attorney and assessed the resident. He/She noted bruising on neck folds and under left eye. The resident said it happened overnight and could not remember what happened. He/She woke up on the floor. Review of the resident's care plan in use during the survey, showed:-Focus: The resident was a risk for falls due to incontinence, multi-medication use and history of stroke. On 04/26/25 the resident had a fall without injury (Initiated: 09/24/24);-Interventions: Staff anticipated and met the resident's needs. Assist bar on right side of bed (Initiated: 5/14/25). Staff made sure the resident's call light was within reach. Staff encouraged the resident to use his/her call light for assistance. Staff responded promptly to all requests for assistance. Staff educated the resident/family/caregivers about safety reminders and what to do if a fall occurred. Staff educated resident to ask for help when transferring or standing on wet surfaces. Staff ensured the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair;-No new interventions after recent fall (reported 01/30/26). Observation and interview on 03/04/26 at 10:56 A.M., showed the resident seated in his/her wheelchair. There were no fall mats in the resident's room and no assist bars on the resident's bed. The resident said he/she thought he/she fell out of bed and hit his/her eye. He/She woke up on the floor. Some nice people put him/her back in bed. He/She had never fallen before. He/She probably turned and rolled out of bed. During an interview on 03/04/26 at 2:10 P.M., the DON said she was not sure what interventions were put in place after the fall. During an interview on 03/04/26 at 3:23 P.M., the Administrator said fall mats should be an intervention for any resident with falls. The fall mat should have been on the care plan. 4. During an interview on 03/04/26 at 2:21 P.M., the DON said herself, the nurse managers, and Assistant Director of Nursing (ADON) are responsible for updating care plans. The care plans should have been updated. 2732324

Based on interview and record review, the facility failed to conduct a thorough and immediate investigation of an injury of unknown source after a facility Certified Nurse Assistant (CNA) discovered a resident (Resident #20), with a bruise on his/her neck fold and under his/her left eye. The resident said he/she remembered staff helping him/her off the floor. He/She did not remember falling. The sample was 11. The census was 126. Review of the facility's Abuse Policy, not dated, showed the following:-It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures which prohibit and prevent abuse and neglect;-Alleged violation is defined as a situation or occurrence observed or reported by staff, resident, relative, visitor or others, but has not yet been investigated. If verified, could be indication of noncompliance with the federal requirements related to neglect, or abuse, including injuries of unknown source;- Possible indicators of abuse include, but are not limited to:-Resident, staff or family report of abuse;-Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body;-Physical injury of a resident, of unknown source;-An immediate investigation is warranted when suspicion of abuse or neglect occur;-Written procedures for investigations include:-Identify staff responsible for the investigation;-Exercising caution in handling evidence for possible could be use in a criminal investigation;-Investigating different types of alleged violations;-Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;-Focusing the investigation on determining if abuse or neglect, and/or mistreatment occurred, the extent, and cause; -Providing complete and thorough documentation of the investigation;-Abuse non-witness statement form attached to policy included: -Location, incident date, date of report, resident's name; -Signature and date if no knowledge of incident. Review of Resident #20's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/11/25, showed:-Cognitively intact;-Lower extremity impairment on one side;-Required substantial/maximum assistance with mobility and transfers;-Diagnoses included stroke, difficulty walking, muscle weakness, and heart disease. Review of the resident's progress notes, showed:-On 01/29/26 at 8:45 A.M., (late entry) Nurse Manager A documented a CNA notified him/her of bruises on the resident's eye and neck. Nurse Manager A assessed the resident and notified the Assistant Director of Nursing (ADON). Nurse Manager A and the ADON interviewed the resident. The resident said he/she believed he/she was on the floor. The aide told the resident he/she was on the floor. He/She was transferred back to bed, but he/she did not know how. The resident denied pain. Nurse Manager A asked the resident if he/she wanted an x-ray. The resident said no. Staff continued to follow the plan of care;-On 01/30/26 at 6:58 P.M., the resident reported to family he/she fell two nights ago. The nurse spoke with resident's power of attorney (POA) and assessed the resident. He/She noted bruising on neck folds and under left eye. The resident said it happened overnight and could not remember what happened. He/She woke up on the floor. The nurse checked the communication book. A nurse documented the resident had bruising on 01/25/26. The nurse did not document his/her name or how long the resident had bruises. The nurse manager was notified. At 7:59 P.M., the Director of Nursing (DON) contacted the POA and notified him/her of investigation. At 10:42 P.M., the family requested the resident be sent to the hospital for bruising and a scalp laceration;-On 01/31/26 at 3:23 A.M., the resident returned from the hospital. He/She was diagnosed with a facial contusion (a bruise on the face, caused by blunt trauma, such as a fall, blow, or impact). CT scan (a non-invasive, painless imaging procedure) on head and spine was negative. Vitals were temperature 98.3 (normal 98.6), pulse 66 (normal 60 to 100), respirations 20 (normal 12-18), and blood pressure 131/68 (normal 120/80). The resident denied pain or discomfort;-On 02/02/26 at 11:12 A.M., the DON noted she explained to the resident's POA the resident fell out of bed, and someone picked him/her up off the floor. At 11:16 A.M., the DON noted she asked staff if they saw the resident on the floor and if they helped him/her up. Staff denied knowledge of the incident. Review of the facility's investigation received on 03/03/26, not dated, showed:-A white sheet of paper with employee names, if they knew about the fall/bruises, and if they answered the phone or if a message was left;-Staffing sheets for 01/19/26-01/29/26;-No summary, skin assessment, written/signed staff interviews/statements and no conclusion;-No in-services on abuse/neglect and documenting incidents. During an interview on 03/04/26 at 10:56 A.M., the resident said he/she thought he/she fell out of bed and hit his/her eye. He/She woke up on the floor. Some nice people put him/her back in bed. He/She had never fallen before. He/She probably turned and rolled out of bed. He/She went to the hospital. He/She does not remember when he/she went to the hospital. During an interview on 03/04/26 at 8:33 A.M., Nurse Manager A said he/she did not know what happened. The CNA noticed the bruises, but he/she did not know what happened. The resident said he/she thought he/she fell two or three days prior. The bruises were not consistent with the resident's story. The resident had bruises on his/her neck and eye. He/She said someone put him/her back in bed. The bruises looked like it occurred a week prior. The resident refused an x-ray. The resident had a POA. The resident is alert and oriented. The POA was notified later in the evening. Nurse Manager A was waiting on the instructions from the ADON. The resident's POA came to the facility and saw the bruises. Staff tried to figure out what happened. The night nurse checked the communication book and saw something. Someone documented the resident had bruises in the physician communication book. Nurse Manager A was not notified of the bruises and there was not documentation in the electronic medical record (prior to 01/29/26). He/She looked at the resident's skin and did not notice anything else. She did not complete a skin assessment. The resident was sent to the hospital on [DATE]. During an interview on 03/04/26 at 2:10 P.M., the DON said the resident's injury was reported to her during an interdisciplinary team meeting. She found out when the POA complained. The resident's POA notified staff of the bruises. She would have expected Nurse Manager A to notify her when he/she found out about the bruises. An investigation was completed when there was an injury of unknown origin. She completed the investigation. She asked staff from the last 72 hours if they saw the bruise or knew how it happened. A skin assessment should have been completed. Staff interviews were conducted via phone or in person. She wrote responses on a sheet of paper. She did not ask for statements. She should have done more. During an interview on 03/04/26 at 3:23 P.M., the Administrator said a thorough investigation should have been completed. He would expect staff to contact the physician, family and interview staff on duty, get statements in writing, with date/signature. 2732324

Based on observation, interview and record review, the facility failed to promptly document and investigate a physical relationship between two cognitively impaired residents (Resident #33 and #39) after it was reported staff observed them together in one of their rooms, with one of the residents partially unclothed. The facility also failed to follow their policy, notify the residents' physician and immediately update the care plan with interventions to protect the residents and their rights. The sample was 15. The census was 130. Review of the facility's Abuse, Neglect, and Exploitation policy, dated 2022, showed:-Policy: It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; --Sexual abuse is non-consensual sexual contact of any type with a resident;-Policy explanation and compliance guidelines: --The facility will develop and implement written policies and procedures that: ---Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property; ---Establish policies and procedures to investigate any such allegations; ---Establish coordination with the Quality Assurance and Performance Improvement (QAPI) program;-Prevention of abuse, neglect and exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation: ---Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing polices and protocols for preventing sexual abuse. This may include identifying when, how and by whom determinations of capacity to consent to sexual contact will be made and where this documentation will be recorded, and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship; ---Identifying, correcting and intervening in situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual resident's care needs and behavioral symptoms;-The facility will have written procedures to assist staff in identifying the different types of abuse, mental/verbal abuse, sexual abuse, physical abuse and the deprivation by an individual of goods and services. Review of the facility's Sexual Expression of Resident's policy dated 09/24, showed:-Policy: It is the policy of this facility to respect the right of residents to express themselves sexually, if it does not violate the rights of other residents. This policy applies to individuals who exhibit intact cognitive decision-making capacity;-Policy explanation and compliance guidelines: --The staff will document observations of residents engaging in intimacy and/or sexual activity and notify social services and the Director of Nursing (DON); --The social services staff will notify the interdisciplinary team; --The social services staff will educate the resident about any disease processes and the residents' rights; ---Residents with decisional capacity have the right to seek out and engage in consensual intimacy and/or sexual expression; ---Residents with decisional capacity have a right to privacy, including private space for sexual expression; ---Residents with decisional capacity have a right to confidentiality; --The physician will be notified regarding all residents participating in sex for a clinical and cognitive evaluation to determine intact cognitive decision-making capacity and capacity to give consent; --The decision to conduct cognitive re-assessment will be made by the interdisciplinary team and based upon noticing a change in a resident's behavior or demeanor; --Care plan meetings with the interdisciplinary team shall be scheduled as soon as possible from initial notification of the social services staff; ---The interdisciplinary team shall conduct a review of situations and accounts of sexual expression among or between residents or with visitors to determine a solution that best meets the needs of and protects those involved; ---Outcomes of the interdisciplinary team review will be shared with the residents involved and documented in plan of care; --Based on the plan of care, intimacy and sexual expression shall be permitted if both parties consent, and the risks do not exceed the benefits; --The facility will ensure the resident's right to privacy, including providing a private place for intimacy and/or sexual expression; --The staff will re-direct residents engaging in intimacy and/or sexual expression in public areas; --Residents who express the desire to be sexually active will receive education on the definition of abuse, sexual assault and who contact to report any issues; --If at any time, either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and will place the resident in another location until an investigation can be completed, to include notifications of the appropriate person(s). 1. Review of Resident #33's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/01/26, showed:-Severely cognitively impaired;-Unclear speech, sometimes understood, usually understands;-Needs partial/moderate assistance from staff for upper body dressing and undressing;-Needs substantial/maximal assistance from staff for lower body dressing and undressing;-Diagnoses included aphasia (a language disorder that impairs speaking, writing and understanding), hemiplegia (severe weakness or total paralysis of one side of the body) and hemiparesis (neurological condition characterized by mild to moderate weakness on one side of the body). Review of the resident's care plan, in effect at the time of the survey, showed:-Initiated on 04/01/26 and updated on 04/22/26: - Focus: The resident expresses desire to engage in romantic/intimate relationship with another resident;-Interventions: Continue to monitor the appropriateness of relationship. Ensure resident is wanting to pursue relationship. Inform family (responsible party) of resident's wishes. Provide privacy for the resident. Support resident's rights to engage in romantic relationship. Review of the resident's progress notes, showed on 04/03/26 at 4:29 P.M., the Social Worker spoke with the resident's guardian. The guardian was made aware of the resident's physical relationship with another resident. The guardian expressed his/her consent for the resident to have a physical relationship. During an interview on 04/21/26 at 12:45 P.M., Resident #33 said he/she did not have a boy/girlfriend at the facility and was not in a relationship with Resident #39. He/She had never been in Resident #39's room and there was no physical relationship. 2. Review of Resident #39's quarterly MDS dated [DATE], showed:-Brief Interview for Mental Status - 3. (BIMS-an assessment to determine cognition. A score of 0-7 means severe cognitive impairment);-Diagnoses included stroke, dysphagia (difficulty swallowing), other speech and language disorders, aphasia and cognitive communication deficit. Review of the resident's nurse practitioner note dated 04/01/26, showed:-The resident continues to require assistance with personal care and activities of daily living. Nursing oversight remains medically necessary to support treatments, prevent complications and maintain quality of life related to ongoing functional limitations, comorbidities and safety risk;-No documentation of assessment of resident's cognitive ability to consent to a sexual relationship. Review of the resident's care plan, in effect at the time of the survey, showed:-Initiated on 04/01/26 and updated on 4/22/26:-Focus: The resident expresses interest in pursuing romantic/intimate relationship with another resident;-Interventions: Support resident's decision in consensual relationship by providing safe boundaries. Ensure optimal safety of resident while pursuing relationship. Ensure resident is consenting to relationship and intimacy. Identify resident is own responsible party (RP). Maintain resident's dignity. Provide ongoing support to resident's wishes. Provide privacy to resident. Review of the resident's progress notes, showed:- On 04/03/26 at 4:44 P.M., the nurse spoke with the resident's RP. The RP made aware of the resident's physical relationship with another resident. The RP expressed he/she gave consent for resident to have a physical relationship;-No documentation of observations of resident's physical relationship with the other resident. During an interview on 04/22/26 at 12:35 P.M., Resident #39 said he/she was not in a relationship with Resident #33. He/She denied being in or having Resident #33 in his/her room. The resident responded to questions by shaking his/her head yes or no. 3. Observation on 04/21/26 at 12:25 P.M., of Resident #33's and #39's rooms, showed they were directly across the hall from one another. 4. During an interview on 04/22/26 at 11:05 A.M., Certified Nurse Aide (CNA) Q said he/she heard rumors Resident #33 was found in Resident #39's room partially unclothed. The residents like each other. They go into each other's rooms. Resident #33 calls the other resident his/her husband/wife. The CNA did not know if the behavior was addressed in the residents' care plans and thought they were supposed to redirect them out of the rooms and back to their own rooms if they saw this behavior. He/She did not report it, because all the nurses have seen the residents' behavior. During an interview on 04/22/26 at 3:45 P.M., Licensed Practical Nurse (LPN) R said he/she saw the residents holding hands. He/She did not document this, because it was only holding hands, and he/she did not think it was a problem. He/She reported it to the social worker. LPN R knew the care plan was updated to give them privacy, so they would redirect them to their rooms and/or pull the privacy curtain if they wanted privacy. During an interview on 04/22/26 at 11:10 A.M., Certified Medication Technician (CMT) C said he/she had not seen the residents in each other's rooms, but if he/she did, he/she would redirect them back to their own rooms. He/She had not been told to provide the residents with privacy. During interviews on 04/22/26 at 10:45 A.M. and on 04/27/26 at 10:45 A.M., Social Worker (SW) L said he/she was told by a floor nurse, Resident #33 was found in Resident #39's room with his/her pants down and Resident #39's hands on him/her. The SW did not remember which staff told him/her this. The staff should have documented when the incident occurred and who witnessed it so they could investigate it immediately. He/She brought it up at the morning meeting, because he/she had questions about it. The regional corporate nurse directed him/her to call Resident #33's guardian to get permission for the resident to have a physical relationship. He/She did not talk to the resident about the relationship, because he/she was not given this task. He/She had not experienced a situation like this before and did not know what to do, so only did what administration told him/her to do. The resident was assessed for cognitive status using the BIMS and scored a 4 (severely impaired cognition). The SW did not assess Resident #39 or educate him/her, because he/she could not talk. The SW did not call resident #39's representative, because he/she did not feel comfortable asking him/her if the resident could be in a physical relationship with someone else. The SW did not notify the resident's physician or update the care plan, because he/she was not directed to do so by administration. 5. Review of a statement typed by the Assistant Director of Nursing (ADON) dated 04/27/26, showed on 04/03/26 between 2:45 P.M. and 3:30 P.M., the charge nurse reported two residents were becoming increasingly close with each other, displaying close interactions in hallways and attempting to hold hands. The DON and regional nurse were made aware. The social services director was asked to call Resident #33's RP and the ADON called Resident #39's emergency contact to discuss the resident showing interest in another resident. The RP was asked if he/she consented to Resident #33's intended physical relationship. The RP gave consent, and the ADON documented this in the resident's chart. Once both parties consented, the ADON emailed the MDS Coordinator to ask her to update the care plan of the two residents involved. During interviews on 04/24/26 at 2:15 P.M. and on 04/27/26 at 4:30 P.M., the ADON said she first became aware there was an incident between the two residents after a morning meeting. She did not attend the meeting, but was told the residents were getting close and staff observed them holding hands. She was instructed to talk to Resident #39's friend and get permission for the two residents to have a physical relationship. The resident was his/her own RP, but had cognitive issues, so they just wanted to make sure there was no problem with the consent. The resident's friend did not have a problem with the two residents having a physical relationship, and the ADON documented this in the resident's medical record. The ADON told the MDS coordinator to update the resident's care plans to include this physical relationship. The ADON did not find out until recently there was an allegation Resident #33 had been observed by staff in Resident #39's room partially unclothed. The ADON did not address these allegations with the resident or educate him/her on having sex, because the ADON was not told to do so by administration and it was her understanding it was the SW's responsibility to do this. Speech therapy assessed the Resident #39 for cognition, and the ADON believed they raised the resident's score to a 9 (moderately impaired cognition). 6. During an interview on 04/24/26 at 2:20 P.M., the MDS Coordinator said she was responsible for updating the residents' care plans. She was made aware in a morning meeting that Resident #33 was observed by staff in Resident #39's room partially unclothed. She was instructed by administration to update the residents' care plan to include the potential romantic/physical relationship on 04/01/26. The MDS Coordinator did not add interventions at this point, because they were still investigating the situation to determine if the residents were really in a relationship and/or if there was anything else going on. On 04/22/26, the MDS Coordinator was told by administration to add the additional interventions. During an interview on 04/24/26 at 11:25 A.M., the DON said she had started working at the facility the prior week and was not aware of the residents' relationship. Staff should have documented if they observed the residents spending time with and/or touching each other. They should have moved the residents' rooms away from each other until they investigated the incident to ensure both residents consented to the relationship. Staff should have assessed residents to ensure they were capable of consenting, and then staff should have notified the guardians to get permission if they were not their own responsible parties. Staff should have been notified once the care plan was updated to include physical contact between the residents to protect their rights. During an interview on 04/22/26 at 3:50 P.M., the Administrator said he was only aware the residents were spending time together and held hands. He did not know there was an allegation of one of the residents being partially unclothed in the other resident's room. To get ahead of the situation, he instructed staff to assess the residents for ability to consent, call the guardians to get approval for the relationship and add the information to the care plan. Staff did what they were supposed to do once the relationship was brought to their attention. 29713192971599

Based on observation, interview and record review, the facility failed to ensure residents right to personal privacy and confidentiality when Certified Nursing Assistant (CNA) A provided peri-care (incontinence care) to a resident (Resident #1) during a video call with CNA B and Scheduler H. CNA B was at home and two children were on camera with him/her. The resident's genitals and buttocks were exposed. Additionally, CNA B took pictures of a resident (Resident #2) while he/she slept and shared it to a group chat with staff and non-staff members. The sample was 18. The census was 109.Review of the facility's Resident Rights policy, dated September 2024, showed:-The resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility;-The resident had a right to be treated with respect and dignity-The resident had a right to a safe, clean, comfortable and homelike; environment, including but not limited to receiving treatment and supports for daily living safely. Review of the facility's Personal Cell Phone policy, revised September 2025, showed:-It was the policy of the facility to provide quality care to residents without interruption;-The facility prohibited employees from using personal cell phones for any reason, on the nursing units or in working areas of the facility;-This included calls, texts, social media, or any other use of cell phones;-Under no circumstance should employees take pictures, videos, or any other personal representations of any resident for the purpose of personal use, social media or any other reason;-Employees who violated this policy were subject to disciplinary action up to and including termination. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/15/25, showed:-Severe cognitive impairment;-Difficulty focusing and disorganized thinking;-Rarely/never understood;-No behaviors;-Wheelchair for mobility;-Dependent on staff for all Activities of Daily Living (ADLs) and mobility;-Always incontinent of bowel and bladder;-Diagnoses included: Aphasia (a language disorder from brain damage (like stroke or injury) which impairs speaking) and hemiparesis (partial weakness on one side). Review of the resident's care plan in, use during survey, showed:-Focus: The resident had a behavior problem due to dementia (a severe decline in mental abilities);-Interventions: Staff provided an opportunity for positive interaction/attention, stopped and talked to him/her in passing. Staff explained all procedures to the resident before starting and allowed him/her to adjust to changes;-Focus: The resident had impaired cognitive function or impaired thought processes due to a stroke;-Intervention: Staff asked yes/no questions to determine the resident's needs. Review of a video call showed Scheduler H in the top frame of the video and CNA A in the middle frame. The sound was muted. CNA A was in Resident #1's room. The resident lay on his/her back in bed. The resident had on a black shirt, no pants, a brief and grey socks. CNA A said something to the resident, then removed his/her brief. The resident's genitals were exposed. CNA A and the resident exchanged words. CNA A rolled the resident onto his/her left side. The resident's buttocks were exposed. CNA B joined the video call after 36 seconds. Two young children were on camera with CNA B. One of the children waved at the camera. Both children watched CNA A clean the resident's buttocks. The children left the video call after one minute and 21 seconds. CNA A, CNA B and Scheduler H remained on the call. CNA A and the resident exchanged words again. CNA A rolled the resident on his/her right side. The resident was on the edge of the bed. He/She held onto CNA A's buttock with both hands. CNA A moved his/her buttocks in a circle, looked back at the camera and smiled. CNA B laughed. The video ended. Observation on 01/14/26 at 9:14 A.M., showed the resident in the dining room, seated in his/her Broda chair (a specialized, high-quality medical wheelchair). The resident did not respond to questions. During an interview on 01/15/26 at 11:05 A.M., Scheduler H said he/she was in a group chat with co-workers and friends. He/She did not remember who initiated the call. He/She thinks the call was in September 2025. He/She did not think it was inappropriate to be on a video call while providing care. He/She did not know the call was recorded. He/She did not share any videos or photos. He/She was not oriented on resident rights and personal cell phone policies. The facility in-serviced staff after something happened. He/She was suspended on 01/09/26 and terminated on 01/15/26. During an interview on 01/15/2026 at 11:31 A.M., CNA A said he/she did not remember when the call occurred. He/She was a part of a cousins group chat. The group chat included staff and non-staff. He/She knew it was wrong to answer the call while providing care. He/She did not know why he/she did it. He/She was not oriented on resident rights and personal cell phone policies. He/She was suspended on 01/09/26 and terminated 01/15/2026. Review of CNA A, CNA B and Scheduler H employee files, showed they acknowledged receipt of the resident's rights policy. 2. Review of Resident #2's quarterly MDS, showed:-Severe cognitive impairment;-Difficulty focusing and disorganized thinking;-Rarely/never understood;-No behaviors;-Wheelchair for mobility;-Diagnoses included: Dementia, high blood pressure, seizure disorder, anxiety disorder (a mental health condition marked by persistent, excessive fear and worry about everyday situations) and depression. Review of a photo received by Department of Health & Senior Services (DHSS), showed Resident #2 sleeping in a recliner. The photo was sent to a group chat by CNA B. The group chat included other staff and non-staff members. During an interview on 01/16/26 at 12:01 P.M., the Director of Nursing identified the resident in the photo as Resident #2. During an interview on 01/15/26 at 11:05 A.M., Scheduler H said he/she muted the group chat. He/She did not see the photo of the resident. During an interview on 01/15/26 at 11:31 A.M., CNA A said he/she muted the group chat. He/She did not see the photo of the resident. He/She would have reported it. During an interview on 01/15/26 at 02:39 P.M., the Regional Director of Clinical Services said she was notified via email, of the video and photos on the evening of 01/08/26. Staff were suspended after review of the video. She would have expected staff in the group chat to report the videos when they occurred. 27123342712840

Based on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when another resident hit the resident in the face, resulting in the resident's face being scratched (Residents #4 and #5). The sample was five. The census was 113. Review of the facility's Abuse, Neglect and Exploitation Policy, dated 4/28/25, showed the following: -Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Definition: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/3/25, showed the following: -Moderate cognitive impairment; -Verbal behaviors; -No impairment to extremities; -Partial to Moderate assistance with activities of daily living (ADLs, self care); -Diagnoses of stroke, high blood pressure, diabetes and depression. Review of the resident's care plan, dated 6/9/25, showed the following: -Focus: The resident has a behavior problem of physical aggression, and verbal aggression in regards to cognitive communication deficit and depression; -Intervention: Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and potential causes. Review of the resident's nurse's notes, dated 6/25/25 at 5:02 P.M., showed, the nurse heard yelling coming from 400 west hallway. The nurse went down the hall to see why resident was yelling. Another resident stated he/she was hit by Resident #4 in the face. Certified Nurse Aides (CNAs) had already separated residents from each other and confirm this resident was aggressive and hit the other resident in the face, causing an injury. Another nurse removed Resident #4 from the west hallway and down to his/her room to provide a quiet space. The resident was placed in line of sight monitoring. skin assessment was attempted and resident refused. The resident's family was notified. The nurse practitioner (NP) and nurse manager was notified and 911 called. The resident was interviewed by police and resident sent to hospital for further evaluation. Review of Resident #5's quarterly MDS, dated [DATE], showed the following: -Cognitive status not documented; -No behaviors; -No impairment of extremities; -Wheelchair mobility; -Partial to Moderate assistance with ADLs; -Diagnoses of stroke, high blood pressure and seizure disorder. Review of the resident's nurse's note dated 6/25/25 at 4:43 P.M., showed the nurse heard yelling coming from 400 west hallway. The nurse went down the hall to see why the resident was yelling. The resident said he/she was hit by another resident in the face. CNAs had already separated the residents from each other. The nurse assessed the resident and he/she has two scratches to his/her face. One above his/her top lip and one on the side of his/her left eye. The nurse cleaned blood off the resident with wound cleaner, no bandages were needed. The resident's glasses were bent during altercation, which were able to be bent back into shape. The resident did complain of pain and as needed pain medication was given. The resident's power of attorney was notified. The NP and nurse manager were notified. During an interview on 6/26/25 at 9:15 A.M. the resident said he/she did not want to be hit in the face by Resident #4. The resident said he/she has had a problem with Resident #4 but had not been hit before. The resident said he/she felt safe at the facility. Observation at that time, showed the resident had no visual bruising to his/her face. During an interview on 6/26/25 at 9:27 A.M., Certified Medicine Technician (CMT) B said Resident #4 came rolling in his/her wheelchair down the west wing hall. Resident #5 was sitting outside his/her room. When Resident #4 wheeled almost past Resident #5, Resident #4 swung a with an open fist and hit Resident #5 in the face. CMT B yelled for Resident #4 to stop. Resident #4 looked at Resident #5 and hit him/her fast three or four more times in the face. CMT B said he/she grabbed Resident #4's hands, and he/she shook loose. Resident #4 reached again and tried to grab for Resident #5's face. CMT B turned Resident #4's wheelchair around to get him/her away. CMT B said he/she had heard the two residents did not get along but he/she had never seen anything. CMT B said Resident #4 could be aggressive with care and when getting medications. CMT B said he/she was recently inserviced on the facility abuse and neglect policy. During an interview on 6/26/25 at 9:23 A.M., Licensed Practical Nurse (LPN) A said the two residents had sat together and talked and socialized and also argued. LPN A said Resident #4 had never gotten physical until now. Resident #4 was sent to the hospital for evaluation. LPN A said he/she was recently inserviced on the facility abuse and neglect policy. During an interview on 6/26/25 at 12:13 P.M., the Administrator and Director of Nursing said they would expect the facility's abuse and neglect policy to be followed as written. The Administrator said Resident #4 had a history of being verbally aggressive with residents and staff. The staff would just try to redirect the resident. This was the first time Resident #4 had gotten physical with anyone. The resident was given an immediate discharge and not be allowed back due to safety issues. MO00256468

Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary physical restraints when staff held one resident's wrist down while providing personal care (Resident #503). The staff did not follow facility policy or the resident's care plan when the resident was resistive to care. After the resident refused care, the staff continued to provide care while holding the resident down, instead of allowing the resident to calm down and self-soothe, as the care plan instructed. During the forced care, the resident's behaviors remained escalated when he/she swung, kicked, and bit the staff. A skin assessment on the day of the incident showed a skin tear to the resident's chin and bruising on both hands. The sample was 23. The census was 111. The Administrator was notified on 5/16/25 at 3:30 P.M., of the past non-compliance, which began on 5/12/25. The facility immediately removed the Registered Nurse (RN) from the floor. The Assistant Director of Nursing (ADON) assumed responsibility of the nurse's assignment. The Certified Nurse Aide (CNA) remained in the lower conference room with the Director of Nursing (DON). The police were called, and two officers responded. Nursing Administration was sent to the floor to conduct interviews on all able residents, collect statements from all staff on the floor, and perform head to toe skin assessments on all residents who were unable to be interviewed. The Administrator and police interviewed the resident and his/her roommate. A skin assessment was completed on Resident #503. The nurse was terminated. The CNA was re-educated on expectations when dealing with alleged violations and specifically, reporting parameters. The CNA was suspended pending the investigation. An all-staff education was immediately started on abuse, neglect, and exploitation with emphasis on identifying and reporting, along with care approaches when caring for combative residents, resident safety, and restraints. The noncompliance was corrected on 5/14/25. Review of the facility's Restraint Free Environment policy, date implemented 4/22/25, showed: -Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of such restraints; -Definitions: Physical restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to holding down a resident in response to a behavioral symptom, or during the provision of care if the resident is resistive or refusing the care; -Compliance guidelines: The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the resident's medical symptoms. Review of the facility's Managing Resident Behaviors -Assessment, Intervention and Monitoring policy, undated, showed: -Definitions: Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes. Behavior is regulated by the brain and is influenced by past experiences, personality traits, environment, and interactions with other people. Behavior can be a way for an individual to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated; -Behavioral or Psychological Symptoms of Dementia (BPSD) describes behavioral symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause. Appropriate assessment and treatment of behavioral symptoms requires differentiating between behavioral symptoms that can be managed by treating underlying factors and those that cannot; -Policy: The facility will provide appropriate and compassionate care specific to individuals who demonstrate behaviors in an effort to minimize resident distress and promote a sense of safety and well-being; -General guidelines: -Behavioral symptoms will be identified using comprehensive assessments; -Assessment: As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: the resident's usual patterns of cognition, mood, and behavior; the resident's usual method of communicating things like pain, hunger, thirst, and other physical discomforts; the resident's typical or past responses to stress, fatigue, fear, anxiety, frustration, and other triggers; and the resident's previous patterns of coping with stress, anxiety, and depression; -Management: The care plan will incorporate findings from the comprehensive assessment; -Monitoring: If any devices (restraints) are prescribed, the Interdisciplinary Team (IDT) will monitor the situation to ensure that they are beneficial to the individual (for example, enhancing function and improving symptoms) and are not causing complications or disabling the individual. Review of Resident #503's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/6/25, showed: -Severe cognitive impairment; -Physical symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing, and abusing other sexually): behavior of this type occurred one to three days; -Verbal behavioral symptoms directed towards others (e.g. threatening others, screaming at others, cursing at others) behavior of this type occurred one to three days; -Other behavioral symptoms not directed towards others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste or verbal/vocal symptoms like screaming, disruptive sounds) behavior of this type occurred one to three days; -Did any of the identified symptoms put the residents at significant risk for: -Physical illness or injury? Yes; -Significantly interfere with resident care? Yes; -Significantly interfere with resident participation in activities or social interaction? Yes; -Significantly disrupt care of living environment? Yes -Did the resident reject evaluations or care (e.g. bloodwork, taking medications, Activities of Daily Living (ADLs, grooming, dressing, personal hygiene) assistance) that is necessary to achieve the resident goals for health and well-being? Behavior of this type occurred one to three days; -How does resident current behavior status, care rejection or wandering compare to last assessment? Worse; -Required partial/moderate assistance. (Helper does less than half the effort) for toilet hygiene, lower body dressing and rolling left to right; -Required substantial/maximal assistance (helper does more than half the effort) for personal hygiene; -Diagnoses included: High blood pressure, diabetes, arthritis, dementia, anxiety and depression and multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue). Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Resident is/has potential to be physically and verbally aggressive related to anger. History of harm to others, poor impulse control. On 7/2(no year), aggression noted, on 3/15(no year), aggression and on 4/25(no year), altercation; -Goal: Resident will demonstrate effective coping skills through review date. Resident will not harm self or others through review date; -Interventions included: -Assess and anticipate resident needs: Food, thirst, toileting needs, comfort level, body positioning, pain, etc. -Behavior monitoring every shift; -Give the resident as many choices as possible about care and activities; If resident noted to be agitated, ensure he/she is safe and allow him/her to calm down and self-soothe; -Resident's potential triggers for physical aggression are overstimulation, boredom and pain. Resident's behaviors are de-escalated by giving space and reducing stimulation, monitoring for pain, and provide meaningful activities; -Medication review; -Monitor/document/report as needed any signs and symptoms of resident posing danger to self and others; -Upon reapproach after self-soothe, approach at eye level, palms open and explain what you are going to do; -When the resident becomes agitated: Intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later; -Focus: Resident required assistance with selfcare, and mobility related to multiple sclerosis, senile degeneration of the brain, dementia with agitation, resident will refuse care at times, hospice services; -Goal: Resident will maintain current selfcare/mobility status throughout the review date; -Interventions included: Personal hygiene: Substantial/maximal assistance; toileting hygiene: partial/moderate assistance. Review of the facility's five-day summary of investigation, undated, showed: -Summary of Event: On 5/12/25 at approximately 2:30 P.M., Resident #503's assigned CNA reported to the Administrator that when providing peri care (the process of cleaning a patient's genital and anal area) to the resident, the CNA felt the nurse was too aggressive and restrained the resident by his/her wrist when he/she became combative. The CNA reported the resident bit the nurse's arm, and the nurse grabbed the resident's lower jaw to try to get the resident to release his/her arm. During this event that allegedly occurred somewhere around 9:00 A.M., the CNA felt he/she had to remain in the room to deescalate the situation and ensure the residents' safety. Review of the facility's statement of an interview completed on 5/12/25, showed the Administrator and the police officer interviewed the resident immediately following the incident. While the resident is not a good historian and has a Brief Interview for Mental Status (BIMS) score of 00, (a score of 0-7, showed the resident had severe cognitive impairment) he/she was able to communicate bad nurse while making a motion with his/her wrist that appeared like someone holding them together in front of his/her face. When asked additional probing questions, the resident was unable to provide any response. Review of the progress notes dated 5/11/25 through 5/12/25, showed no progress note written for 5/12/25. Review of the resident's skin observation tool, showed: -On 5/9/25: Is skin intact? Yes; -Notes: Blank; -On 5/12/25: Is the skin intact? No; -Observation: -Site: Number 4, face, type: Skin tear; -Site: Number 27 back of left hand, type: Bruising; -Site: Number 30 back of right hand, type: Bruising; -Site Number 16 left antecubital (bend of elbow), type: Scratch; -Site: Number 15 right antecubital, type: Scratch; -Notes: 4. [NAME] pin dot opening; 4. Right side of face chin fingernail opening; 27. Back of hand has three dime size bruises; 30. Back of hand four dime size bruises near thumb; -On 5/13/25: is the skin intact? Blank; -Observation: Blank; -Notes: Bruises to both arms and small scab on right cheek. During an interview on 5/16/25 at 8:22 A.M., CNA A said the incident happened on 5/12/25, he/she must have written the wrong date in his/her statement. The resident can be combative if he/she feels like you're not listening to him/her, or if your nagging at him/her, or if you are trying to wake him/her up. CNA A was assigned to care for the resident on 5/12/25. After breakfast he/she went to change the resident's brief, and the resident said no and refused. The next time the CNA went into the room the resident said No, let me sleep. The CNA said the same thing has happened in the past, and when he/she reported it to the nurse the nurse said okay. The CNA reported the resident refused to the nurse, RN B. The nurse said come on, and he/she would help him/her. While walking to the room, the nurse stated in a whisper tone, these people know who to play with and who not to play with. CNA A said he/she thought the resident and nurse were familiar with each other. The nurse stood by the wall as the CNA adjusted the height of the bed. The resident was awake and calm. The CNA explained the procedure and pulled down the resident's pants. The resident began kicking and yelling stop, I don't want my brief changed, and at that point the nurse approached the resident and grabbed his/her wrists and held them down while the CNA unfastened the brief and started to clean the resident. The CNA tucked the fasteners under the resident, to get ready to turn the resident on to his/her side. The CNA told the nurse he/she was ready to turn the resident, while the nurse was holding the resident's wrist, the nurse scooped up the resident's legs and flipped him/her onto their left side. The nurse and the CNA changed places; now the nurse was cleaning the resident, and the CNA was holding the resident's wrist loosely. The resident got his/her hands loose twice and pulled the CNA's hair. They changed places again. The CNA finished cleaning the resident, and the nurse held the resident's wrist. After they finished cleaning the resident, the resident was turned onto his/her back, then the resident was turned slightly to get the brief adjusted under the resident. The resident was kicking. The CNA said he/she was trying not to hurt the resident. The resident bit the nurse's arm. The nurse had his/her hands on the resident's face, trying to unclench the resident's teeth. The nurse said in a whisper voice, This [expletive] won't unclench his/her teeth in my arm. The CNA told the nurse to chill, and he/she put his/her hand between the nurse's arm and the resident's teeth. They fastened the resident's brief, and the CNA pulled the resident's pants up and lowered the bed down. The resident had some bleeding on the right side of his/her chin, but he/she did not see any bruising on the resident. The CNA asked the nurse if he/she was going to fill out an incident report because he/she knew he/she would need to write a statement. The nurse said What incident report? he/she has gotten bitten plenty of times. The CNA said typically when a resident says stop, he/she would stop. After the incident the CNA kept it to him/herself because he/she was conflicted because he/she looked at the nurse as a leader and thought the nurse might retaliate against him/her. At lunch time the CNA went to the Administrator's office to report the incident. The Administrator called the police. The CNA talked with the police and the higher ups (nurse managers), wrote a statement, and was educated on reporting allegations of abuse and neglect immediately and about not restraining residents. The CNA was suspended. Review of RN B handwritten statement, dated 5/12/25, showed he/she was called into a resident's room to assist CNA (no name provided) to change the resident because he/she was resisting care. We went to assist with care, informed resident of what we were about to do. Resident became verbally aggressive. We continued to reposition and change resident due to being soiled to the sheet. We lowered the bed and left the resident clean and call light in place. Resident stated he/she would tell his/her sister. We informed him/her we want him/her to be clean and comfortable while he/she's here. During an interview on 5/16/25 at 9:21 A.M., Police Officer D said he/she responded to a call to the facility on 5/12/25. The nurse was attempting to change the resident's brief, and they had a problem; one nurse held the resident, and one nurse was changing the resident. The resident bit one nurse. The resident had some bruises, but Police Officer D did not know if the bruises were new or old. Police Officer D did not feel there was an intent to harm the resident. The nurse who got bit said he/she was just trying to do his/her job. Observation and interview on 5/16/25 at 11:05 A.M., showed the Nurse Practitioner (NP) entered the resident's room. The resident was asleep in bed. The NP called the resident's name and pulled the resident's blanket part way down. The resident began yelling Go away, drop dead and began swinging. The NP covered the resident up and left the resident's room. The NP said, the resident was at his/her baseline, what she could see, the skin on the resident's arms looked the same as it did last month. The resident has very fragile skin. Review of CNA A's written statement dated 5/12/25, showed, on May 5 at 10:30 A.M., he/she asked the resident if it was okay to change his/her brief and the resident did not answer. The CNA attempted to change the resident, and the resident yelled and kicked and said no. So, the CNA went to RN B (nurse) and told the nurse the resident refused. The nurse followed the CNA to the resident's room. While walking to the room, the nurse was gloving up and saying, These people know who to play this shit on, They know who to pull this shit on. So, CNA A thought the nurse and the resident were familiar with each other. When entering the room, the nurse stood against the wall, and the CNA started to raise the bed up to the desired height. The nurse told the CNA that he/she could start pulling the resident's pants down, while the CNA was raising the bed up. The CNA told the nurse Yea, I'm aware, I'm just raising the bed up. So, CNA A pulled the resident's pants down, and the nurse immediately grabbed the resident's wrist and started holding the resident down. The CNA proceeded to clean the resident and the whole time he/she was cleaning and wiping the resident, the resident was still being held down, while sometimes finding his/her way free from the nurse. When the resident could free his/her hands, the resident pulled the CNA's hair and swung on him/her. The nurse then grabbed the resident's hands again, flipped the resident onto his/her left side so the nurse could put the brief under the resident. While the nurse put the brief under the resident, the CNA had to hold the resident. While the CNA was holding the resident, the resident got free and managed to pull the CNA's hair again. So, the CNA grabbed the resident's wrist, and as soon as the CNA grabbed it, the nurse stopped with the brief and grabbed the resident's wrist. After the CNA got the brief fully under the resident, they put the resident on his/her back. The brief needed to be pulled up between his/her legs and as the CNA was doing that the nurse was still trying to hold the resident down and in the midst of that, the resident bit the nurse's arm. The CNA didn't notice it until the nurse started gripping the resident's face/cheeks so the resident would unclench his/her teeth from the nurse's arm. The resident wasn't unclenching, so the nurse proceeded to smush the resident's face, as the nurse was still holding both arms with one hand. When the CNA saw what was happening, the CNA stopped fooling with the brief and told the nurse to chill out. The CNA went back to fastening the brief and the resident was kicking. So, the nurse picked up the resident's legs up and tossed them back on the bed and proceeded to hold the resident's legs down too. The CNA finally got to pull up the resident's pants and the nurse was still holding the resident. They covered the resident up, lowered the bed down, and left the room. During an interview on 5/16/25 at 2:51 P.M., the NP said if staff were trying to provide care, and the resident was resistive and became combative, staff should make the resident safe and give them some time. They could try to find a staff member who was familiar with the resident and take them with them when they check back in 10-15 minutes. Staff should explain what needs to be done and provide reassurance. If a resident was swinging at staff, staff should deflect, and they could try to give the resident a hand to hold on to. Staff should not hold residents down to provide care. Review of the facility's five-day summary of investigation showed: -Disposition: The Facility cannot substantiate abuse, neglect, or the restraint of Resident #503 due to the lack of corroborating witnesses, a lack of prior reported concerns, and the resident being unable to provide a meaningful account of the event. The facility substantiated a professional conduct violation and failure to follow facility protocols when caring for combative residents and the RN was terminated at the time of discovery and had no further access to any resident. All staff were reeducated on abuse, neglect, and exploitation with an emphasis on identifying and reporting. Staff were also educated on care approaches when caring for combative residents, resident safety, and restraints. Education is being completed on an ongoing basis for agency staff and prior to the next shift worked for any facility staff. The reporting CNA was allowed to return to work. Monitoring of Resident #503 showed no deviation to baseline mood or behavior, and no latent bruising or other injury from the alleged violation. During an interview on 5/16/25 at 2:30 P.M. and on 5/17/25 at 3:30 P.M., the Administrator said sometimes the resident refused care or can become combative with care. The facility has been working on trying to figure out if anything triggers the resident. Sometimes there are no triggers, the resident will start out okay then become combative, then stop, all within a few minutes. The staff felt the resident may become overstimulated on a regular floor, so they decided to trial him/her on the memory care hall. The memory care hall is smaller, and the staff are more consistent. Currently the facility has assigned one staff member to the resident so they can keep the resident in their direct sight. If a resident was resisting care or was combative, the Administrator would expect staff to make sure the resident was in a safe position and step away, to allow the resident to self soothe. Staff should attempt three times to provide care. If the resident continues to resist care, the CNA should report this to the nurse, which the CNA did. The Administrator would expect for the nurse to assess the resident and try to provide care. If the resident continued to resist care, the nurse should stop and report it to the DON and Administrator. They may need to call the family to see if they could encourage the resident or they may need to call the physician. It is never appropriate for the staff to restrain a resident to provide care. If the resident said no, staff should have stopped, even if the resident was incontinent. Staff should not force care. The Administrator expects staff to follow the facility's policy and procedures. MO00254142

Based on observation, interview and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to follow its policy to have an Administrator who planned, directed and monitored compliance with State and Federal government regulatory agencies by not having an active Administrator on-site on a full time basis. The facility census was 123. Review of the facility's (undated) job description for the Administrator, showed: -Job Title: Administrator; -Reports To: Chief Operating Officer; -Status: Exempt; -Positions Summary: -Provides leadership, oversight and administration to all long-term care operations. Responsible for ensuring maximum operating efficiency, overall cost-effectiveness, and strict compliance with all applicable State and Federal rules and regulations; -Develops, monitors and improves facility quality standards; -Essential Duties and Responsibilities: -Develops and ensures the implementation of the facility's short and long-term goals and objectives; -Establishes, supports and continually assesses the facility structure for maximum realization of objectives; -Assures that facility maintains standards at the highest possible level and is responsible for results of survey by the Department of Health; -Develops, implements and assesses facility policies and procedures to ensure compliance with applicable State and Federal rules, regulations, and accreditation standards; -Oversees and directs the department heads in direct line of responsibility. Conducts regular department head meetings to promote a constant flow of information, open discussions, knowledge sharing and to keep department heads well-informed; -Oversees, evaluates and ensures the ongoing delivery of care and services. Provides routine analysis of the quality of care based on observation, customer service surveys and feedback; -Plans, directs and monitors compliance with State and Federal government regulatory agencies; -Ensures the implementation and continued maintenance of facility standards in compliance with the organization's values, goals and objectives; -Participates actively in census development and public relations process to provide input and management; -Maintains contacts with peers and professional colleagues among other local health care facilities, vendors, service providers, and other potential referral sources; -Serves as a mentor, leader, and role model, representing the corporation in a manner that conveys professionalism, confidentiality, courtesy, honesty and fairness; -Promotes excellent community relations; -Performs all tasks and duties in an efficient and safe manner; -Performs other related duties as assigned or as necessary; -Remains flexible and adaptable in work schedules and work assignments as defined by departmental and facility needs; -Represents the corporation in a manner that conveys professionalism, confidentiality, courtesy, fairness, personal integrity, and respect for the fundamental rights, dignity, personal comfort and privacy of others; -In the event that the corporation has an opening for an Administrator in any of its Missouri facilities, the current Administrator will be responsible for assigning a licensed Administrator to assume duties at [NAME] Bluffs. The Administrator will serve as the interim Administrator for the vacant facility until a permanent hire is made, or until the current administrator notifies the corporation that he/she is no longer able to accommodate the interim assignment; -Signed by: Administrator M and Dated 1/20/2025; -The job description did not include if the position was a full time position and/or a remote position. Review of an email sent to the facility's Residents and Family members on 1/21/25 at 5:40 P.M. showed; Dear facility Residents and Family Members, I hope this message finds you well. At this facility, we value transparency and want to share some important updates regarding our leadership and medical services. As of today, Former Administrator L is no longer the Administrator of the facility. We are pleased to announce that Administrator M will be stepping in as Interim Administrator while we conduct a search for a permanent replacement. Many of you may remember, Administrator M's name, from her time as Interim Administrator last summer. In addition to her experience here, Administrator M , serves as the Executive Director of [NAME] Bluffs and [NAME] Bluffs [NAME] in [NAME] City. She is deeply committed to ensuring the care and well-being of your loved ones remains our top priority. If you have any questions or concerns Administrator M can be reached directly and her personal cell phone and/or her work email address. 1. During interviews on 3/28/25 at 6:53 A.M., 8:55 A.M., 10:30 A.M., and 3:00 P.M., the Director of Nursing (DON) said she was aware the facility had had multiple citations one right after the other, including three Immediate Jeopardies (IJ). It seemed like there had been a different surveyor in the facility every week with multiple complaints. The facility couldn't get one thing fixed before there was something else. She had never seen anything like it. The facility had an interim Administrator. Administrator M would not be at the facility today because she had a survey team in her other building in [NAME] City, MO. Administrator M was an interim Administrator at the facility and split her time between the facility in St. Louis, MO and two other facilities in [NAME] City, MO. Administrator M usually worked two to three days in St. Louis and the remaining time at the other two facilities. It would benefit the facility to have a full time Administrator. Administrator M was available by phone or text but it was not the same as having that support in the facility. The corporation does not have a local Regional Nurse Manager to assist with the day to day operations of the facility. She was only one person and could only handle so much. It had been overwhelming the past couple of months since former Administrator L left. 2. During an interview on 3/28/25, at 6:57 A.M., the Assistant Director of Nursing (ADON) said Administrator M was physically in the facility two to three times a week. Administrator M was over two additional facilities in [NAME] City, MO. 3. During interviews on 3/28/25 at 8:11 A.M., and 3/28/25 at 11:00 A.M., the Human Resource (HR) representative said Administrator M was an interim Administrator. Administrator M was onsite at the facility two to three days per week. She splits her time between the facility in St. Louis and two additional facilities in [NAME] City. 4. During an interview on 3/28/25, at 8:40 A.M., Administrator M said she was in the facility five days per week. She worked a 40 hour week. She would not be in the facility today because she was in [NAME] City. There is no way to track the time she actually spent working in the facility. 5. During an interview on 3/28/25, at 8:55 A.M., Staffing Coordinator (SC) A said he/she had worked at the facility for a little over a month. Administrator M was not physically in the facility five days a week. Administrator M was there maybe two to three days a week. She splits her time between St. Louis and [NAME] City. 6. During an interview on 3/28/25, at 9:13 A.M., Social Worker (SW) C said Administrator M did not typically work a five day week at the facility. Administrator M was there at the most three days a week. Administrator M was also the Administrator of two additional facilities in [NAME] City. Administrator M was there last week for five days, but that was the first time he/she could recall the Administrator M was in the facility for five consecutive days. 7. During an interview on 3/28/25, at 9:15 A.M., Registered Nurse (RN) D said Administrator M was there Monday through Friday last week. Other than that, Administrator M was usually there two to three days a week. She splits her time between one home in St. Louis and two homes in [NAME] City. 8. During an interview on 3/28/25, at 9:22 A.M., Admissions Coordinator (AC) E said Administrator M was onsite in the facility approximately three days a week. She had two additional facilities in [NAME] City she was responsible to oversee. Administrator M was the interim Administrator. AC E believed the facility had hired a new full time Administrator, but he/she didn't know when that person was supposed to start. 9. During an interview on 3/28/25, at 9:28 A.M., Medical Records (MR) F said the Administrator M was in the facility on a flexible schedule. Administrator M was usually in the building two to three days per week, but had worked up to five days in the past. Administrator M was also the Administrator at two facilities in [NAME] City. Administrator M was an interim Administrator and was only working until a full time Administrator could be hired for the facility. 10. During an interview on 3/28/25, at 9:30 A.M., Licensed Practical Nurse (LPN) G said Administrator M was physically in the facility about three days per week. Administrator M was not in the facility today because there was an ongoing survey at her other facility. 11. During an interview on 3/28/25, at 9:32 A.M., Business Manager (BOM) F said Administrator M averaged maybe two or three days physically in the facility. Administrator M was also the Administrator of two facilities in [NAME] City. Administrator M was available by phone if BOM F needed anything. 12. During an interview on 3/28/25, at 9:37 A.M., the Director of Rehabilitation (DOR) I said Administrator M was did not work five days a week in the facility. She worked remotely. Administrator M averaged about three days a week in the facility. Administrator M was also the Administrator of two additional facilities in [NAME] City. 13. During an interview on 3/28/25, Activity Director (AD) J said Administrator M was not physically in the facility five days a week. Administrator M was the interim Administrator. Administrator M split her time between the facility and two other facilities in [NAME] City. 14. During an interview on 3/28/25, at 10:15 A.M. Housekeeping and Laundry Supervisor (HLS) K said Administrator M did not work a 40 hour week in the facility. Administrator M worked two to three days a week because she was also the Administrator at two facilities in [NAME] City. When Administrator M was in the facility things seemed to be much calmer. 15. During an interview on 3/28/25, at 2:00 P.M. the Ombudsman for the facility said the facility had not had a full time Administrator since Administrator L left in January. Administrator M was splitting her time between St. Louis and [NAME] City, MO. The Ombudsman had heard complaints and concerns voiced by residents and residents' family members about the lack of a full time Administrator in the facility. He/She has been in contact with the Administrator M by email. He/She felt there should be a full time Administrator on site at least five days a week.

Based on interview and record review, the facility failed to provide basic life support including cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing and/or heartbeat has stopped) after Resident #1 had a rapid change in condition and coded. Registered Nurse (RN) F began CPR when he/she was unable to locate the resident's code status (initiate CPR or do not initiate CPR). RN F did not call for additional staff assistance over the facility intercom system, did not provide rescue breaths during CPR, and did not use the automated external defibrillator (AED, a portable device that can be used to treat a person whose heart has suddenly stopped working) located at the nurse's station. RN F did not continue CPR until emergency medical services (EMS) arrived at the resident's bedside. This had the potential to affect 19 of 24 residents residing on the 200 hall with an order to initiate CPR. The sample size was 3. The census was 135. The Administrator was notified on [DATE] at 2:15 P.M., of an immediate jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility's CPR policy, dated [DATE], showed: -Basic Life Support (BLS): is a level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital, and may include recognition of sudden cardiac arrest, activation of the emergency response system, early CPR, and rapid defibrillation with an AED; -CPR: refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased; -Code Status: refers to the level of medical interventions a person wishes to have started if their heart or breathing stops; -Policy: The facility will provide emergency BLS immediately when needed, including CPR to any resident requiring such care, prior to the arrival of emergency medical personnel, in accordance with physician orders, and resident advance directives; -The facility will ensure that there are an adequate number of staff available immediately 24 hours a day, who are trained and certified in CPR for Healthcare Providers; -Training will include recognizing the obvious signs of irreversible death rigor mortis (stiffening of muscles that occurs after death), dependent lividity (blueish-purple discoloration of skin after death due to blood pooling at the lowest point), decapitation, decomposition. Review of the American Heart Association (AHA) AED Fact Sheet, dated 11/2023, and located on the AHA web site, showed: -Inside the AED box are pads and a diagram that shows where to place the pads on bare skin. Once the device is turned on, a voice tells the person using it exactly what to do; -The first thing the AED will do is determine whether an electric shock is needed by analyzing the person's heart rhythm. You should only stop CPR while the machine is doing this analysis. If no shock is advised, it will tell you to resume CPR. If there is a shockable rhythm, it will tell you to press the Shock button and then to resume CPR; -Your chance of survival while waiting for EMS during a cardiac emergency decreases by 10% every minute without CPR; -Of the people with cardiac arrest who receive a shock from an AED in the first minute, 9 out of 10 survived. Review of Resident #1's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff dated [DATE], showed: -admission date of [DATE]; -Makes Self Understood: Understood; -Ability To Understand Others: Understands; -Cognitively intact; -Diagnoses of atrial fibrillations (A-fib, irregular heart rate and rhythm), coronary heart disease (a condition where the coronary arteries that supply blood to the heart become narrowed or blocked), and congestive heart disease (the heart can't pump efficiently). Review of the resident physician's order sheet, located in the electronic medical record (EMR), showed an order for full code (in the event of no pulse/respirations, CPR should be initiated and 911 should be called), dated [DATE]. Review of the resident's care plan, showed: -[DATE]: Focus: Potential/actual rehabilitation candidate. Goal: Will increase and maintain level of functioning. Intervention/Tasks: Refer to physical, occupational, and speech therapy to improve resident mobility, transfer, strengthening as recommended post evaluation; -[DATE]: Focus: Requires assistance with self-care and mobility. Goal: will improve current self-care /mobility level. Intervention/Task: none listed; -[DATE]: Focus: Resident plans to discharge. Goal: To return to prior level of function. Interventions/Tasks: Coordinate education and training for discharge needs as needed. Encourage resident/family to participate in discharge planning. Review of the resident's Consent for CPR form, signed by the resident's family on [DATE], and the resident's physician on [DATE], showed: I want to have CPR initiated. I understand that the procedure for CPR is initiated when there is absence of a heartbeat or an absence of breathing. The procedure includes manually compressing the chest to promote circulation and using an airway to introduce air into the lungs. Immediately upon initiating this procedure, 911 is called and EMS services will transport me to the nearest hospital. The procedure cannot be stopped until a physician gives an order to stop CPR. Review of the resident's progress notes, showed: -[DATE] at 10:31 A.M., Vital Signs: Temperature (T) 96.9 (normal range 97 F (Fahrenheit) to 99.6), Pulse (P) 107 (normal range 60-100 beats per minute), Respirations (R) 16 (normal range 12-20 breaths per minute, Blood Pressure (BP) 149/67 (normal 120/80). Resident is alert. Oriented to person, place, time and situation. No changes in mood or behavior; -[DATE] at 5:55 A.M., documented by Registered Nurse (RN) F: Called to resident's room at approximately 5:55 A.M. Upon entering room noted resident foaming at mouth, and color was bluish/gray and warm to touch. Resident was not responding to commands or sternal (chest bone) rub. Oxygen saturation (O2 Sats, the amount of oxygen in the blood. A normal oxygen level is 92%-100%, anything below 90% is considered critical) 64%-25%. Applied oxygen per nasal cannula at 15 liters per minute. O2 Sat at this point was 0 and unable to obtain vitals. Resident was placed on the floor and CPR initiated with no response from resident. 911 called at 6:10 A.M., and upon their arrival resident had expired. Time of death 6:24 A.M. Supervisor, Nurse Manager and Director of Nursing (DON) notified. Review of RN F's employee file on [DATE], showed he/she successfully completed the AHA Basic Life Support course on [DATE], with an expiration date of 6/2026. The curriculum included: calling for help from other staff, calling 911, chest compressions, rescue breaths using a barrier device, and using the AED. Review of the EMS report dated [DATE], showed: call received at 6:17 A.M. on scene at 6:23 A.M., at patient 6:27 A.M. EMS crew makes way to nurse's station. Met by RN who reports the resident is dead. Crew makes way to resident's room where they find resident in bed supine (on back) with blanket over him/her. Crew notes patient to be pulseless apneic (no respirations), with white frothy mucous out of his/her mouth. Staff reports that after 18 minutes of CPR there was no change in condition and made the decision the patient is dead. Staff then moved the patient back to bed and covered him/her with a blanket. Crew sees no additional evidence on scene of life saving efforts by staff. Crew connects patient to the cardiac monitor electrocardiogram (electrocardiogram (EKG or ECG), a machine that measures electrical impulses of the heart) and notes patient to be asystole (no heart rate/rhythm detected). Crew notes time of death to be 6:28 A.M. Observation on [DATE] at 6:22 A.M., showed an AED hanging on the wall behind the nurse's station. Observation of the facility crash cart (a cart prepared with supplies to use in an emergency), showed it contained an AMBU bag and suction machine. Review of a written statement by Certified Nurse Aide (CNA) E (an agency staff member), dated [DATE], showed: On [DATE], he/she called RN F to the resident's room around 5:45 A.M. to 6:00 A.M., after the resident was found with foam coming from the mouth and nose, and was not breathing right. The CNA was unable to get an oxygen level at first, but then obtained a level of 52%, but dropped below 25%. The CNA could not get any vitals and the resident did not have a pulse. The resident was placed on the floor to perform CPR which the resident did not respond to and then the resident was placed back in bed. By the time the ambulance arrived the resident had expired. During a telephone interview on [DATE] at 1:32 P.M., CNA E said he/she was CPR certified. He/She confirmed his/her written statement dated [DATE], and added the following: Prior to the resident coding, neither CNA E nor RN F could find the resident's code status. This was his/her second time working at the facility and no one had showed him/her where to find a code status. When the resident coded, they still did not know the code status but decided to initiate CPR. The intercom system was not used to call for assistance from other staff in the building. Only CNA E and RN F participated with CPR. He/She pulled the tag on the air mattress bed to deflate it so they could initiate CPR on a flat surface. However, the bed did not deflate all the way, so they placed the resident on the floor. RN F started chest compressions but did not provide rescue breaths by using a barrier device (placed of the mouth of the resident so mouth to mouth breaths can be given) or an artificial manual breathing unit bag (AMBU bag, a handheld medical tool used to push air into the lungs of someone that is not breathing), and suction machine (used to suction secretions from the mouth). RN F did not use the AED that was at the nurse's station. He/She could not recall how long RN F provided the chest compressions, but about 5 to 10 minutes before EMS arrived RN F said the resident was dead. They put the resident back into bed. He/She did not think CPR should have been stopped until EMS arrived, but he/she followed the RN's orders. During an interview on [DATE] at 6:22 A.M., Licensed Practical Nurse (LPN) A said he/she was working on another floor when the resident passed away. He/She did not hear RN F call a stat to the resident's room or he/she would have responded to offer assistance. He/She was CPR certified. If a resident coded, he/she would check the code status book at the nurse's station or the EMR, page for assistance, call 911 then take the crash cart and AED to the code site. Once CPR was imitated you did not stop CPR until EMS arrived. During an interview on [DATE] at 6:30 A.M., LPN B said he/she was not working when the resident passed away. He/She was CPR certified. If a resident coded, he/she would check the code status book at the nurse's station or in the EMR, page for assistance, call 911 then take the crash cart and AED to the code site. Once CPR was initiated you did not stop CPR until EMS arrived. During an interview on [DATE] at 6:43 A.M., LPN D said he/she was not working when the resident passed away. He/She was CPR certified. If a resident coded, he/she would check the code status book at the nurse's station or in the EMR, page for assistance, call 911 then take the crash cart and AED to the code site. Once CPR was initiated you did not stop CPR until EMS arrived. During an interview on [DATE] at 9:22 A.M., the Administrator said the facility began an investigation regarding the resident on [DATE]. They had spoken to CNA E, but RN F, a facility employee, left the building before they could interview him/her. They have not been able to contact RN F despite leaving voice messages to call the facility on [DATE] and [DATE]. She reviewed the resident's medical record and the resident's code status was in the resident's EMR. She was not sure why RN F could not find the code status. The CNAs had access to the EMRs as well. During an interview on [DATE] at the DON said she read CNA E's [DATE] statement that day. Human Resources did get into contact with RN F yesterday and said he/she needed to come to the facility and provide a written statement. RN F had not come in yet to do that. RN F had not worked since [DATE]. When a resident coded, she expected staff to check the resident's code status, and if a full code, staff should call 911, then announce the emergency followed by the room number on the intercom so other staff in the building could respond. She expected staff to take the crash cart and AED to the room. The DON would have expected RN F to have used the AMBU bag to provide rescue breaths between the chest compressions and to have applied the AED and follow the prompts. RN F should have continued CPR until EMS arrived. Review of RN F's written statement to the facility, completed on [DATE] around 5:00 P.M., showed: [DATE] at 5:55 A.M., called to resident room by CNA stating resident not looking so good. Resident foaming at mouth and nose (white foam). Turned head to side, resident was unresponsive. Color was purple, gray, and abnormally warm to touch. 6:00 A.M., Vitals: T 95, 0 (unknown what this meant), BP 64/35 and O2 Sat of 38%. Ran to desk to find CPR status. Unable to locate. 6:05 A.M., Unable to obtain vitals. Applied O2 at 15 liters/minute. Not breathing. Chest compressions initiated with no response. CPR stopped with arrival of EMS. 6:12 A.M., EMS arrived. Death was confirmed with EKG. During a telephone interview on [DATE] at 8:51 A.M., RN F said he/she had been employed by the facility for about three years. He/She worked weekends from 3:00 P.M. until 7:00 A.M. He/She was at the facility yesterday around 4:45 P.M. and gave the DON his/her written statement. He/She was currently CPR certified and had been trained on using the AED, and AMBU bag. He/She knew there was an AED at the nurse's station and an AMBU bag on the crash cart. On [DATE], CNA E called him/her into the resident's room. The resident was not doing good. The resident had a moderate amount of white froth coming from his/her mouth and nose. He/She laid the resident down flat, turned the resident's head to the side and used a tissue to clean the resident's mouth out. They took the resident's vitals. He/She confirmed the vitals on his/her written statement but said he/she did not know what the 4 meant and the 0 was respirations. He/She went to the nurse's station and looked in the resident's hard chart but could not find the resident's code status. He/She did not look in the EMR for the code status. He/She should have called an emergency on the facility intercom but did not. He/She called 911, grabbed the oxygen and returned to the resident's room and started the oxygen at 15 liters/minute. He/She should have taken the AED and crash cart but he/she just got overwhelmed and wanted to get back to the resident. The resident coded when he/she returned to the room, but the bed did not deflate all the way, so RN F and CNA E placed the resident on the floor. RN F started CPR which included chest compressions and mouth to mouth rescue breaths. He/She did not know why CNA E said he/she did not give mouth to mouth rescue breaths. After a few minutes the resident was dead. RN F and CNA E put the resident back to bed. Two or three minutes later EMS arrived. He/She could not recall if he/she was in the hall or at the nurse's station when they arrived. Looking back, he/she should have continued CPR until EMS arrived and assumed care of the resident. During an interview on [DATE] at 10:32 A.M., the DON said she asked RN F why he/she stopped CPR when he/she came in to write his/her statement. The RN said he/she only stopped CPR a couple of minutes before EMS arrived but did not say why. During a telephone interview on [DATE] at 11:21 A.M., the facility's Medical Director, and the resident's physician said he expected staff to follow the facility's policy. When the resident coded, he would have expected staff to know where to quickly find the resident's code status. Since the resident was a full code, he would have expected staff to immediately call 911, and call a code over the intercom for assistance. He would have expected staff to provide rescue breaths with chest compressions. He would have expected staff to have taken the crash cart with the suction machine and AMBU bag to the room. He would have expected staff to have used the AED. When an AED was used there was a proven chance of increased survival. The facility notified him about the resident's passing on [DATE], but he was not informed RN F failed to do all these things during the code. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the D level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00250888

Based on observation, interview and record review, the facility failed to follow their Abuse Prevention and Prohibition Program policy by failing to thoroughly investigate Resident #4's allegation that Certified Nurse Assistant (CNA) BB provided rough care while cleaning him/her up causing a hematoma (a localized collection of blood outside of blood vessels that forms due to injury or trauma) on his/her left inner calf. The resident resided on the fourth floor. The CNA's normal assignment was on the third floor. Review of the facility investigation showed three residents who resided on the fourth floor were interviewed, including Resident #4. No residents from the third floor were interviewed and no staff from either floor were interviewed including staff that worked when the alleged incident occurred. In addition, the facility failed to notify the resident's physician regarding Resident #4's allegation. The sample size was 14. The census was 135. Review of the facility Abuse policy dated 11/22/23, showed: -Definitions: -Abuse is defined as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -Mistreatment is defined as inappropriate treatment or exploitation of a resident. -Policy: This organization recognizes and respects that each resident has the right to be free from abuse and neglect as defined in the federal regulations. -The facility is committed to developing and operationalizing policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of allegations of abuse, neglect, and mistreatment. The facility will encourage reporting of reasonable suspicions of a crime and will develop and implement policies and procedures that promote a culture of safety and open communication in the work environment. -Prevention: -The organization will maintain protocols and procedures to identify, correct and intervene in situations in which abuse and neglect is more likely to occur. This may include an analysis of: -The supervision of staff to identify inappropriate behaviors, such as derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in the briefs. -Identification: -Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking; -Example of injuries that could indicate abuse include, but are not limited to: Injuries that are non-accidental or unexplained. -Mental and verbal abuse: Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. -Injuries of Unknown Source: Injuries of unknown source that meet the criteria for reporting may include but are not limited to: -Unobserved/Unexplained swelling that is not linked to a medical condition. -Note: Any injury that is explained and appears to be a result of abuse must be reported. -Reporting: -The facility will inform the resident's physician when the resident has alleged or been involved in an incident of abuse or mistreatment. -Protection: -In the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician, and protect the resident and other residents from further harm or incident. -Investigation: -Designated staff will immediately review and investigate all allegations or observations of abuse. -The results of the investigations are to be communicated to the administrator or his or her designated representative and to other official in accordance with State law, including the State Survey Agency, within 5 working days of the incident. Review of Resident #4's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 2/24/25, showed: -Adequate hearing/vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Moderately impaired cognition; -No behaviors identified; -Toileting Hygiene: Partial/moderate assistance. Helper does less than half the effort; -Roll Left and Right: Supervision or touching assistance; -Always incontinent of bowel and bladder; -Diagnoses of atrial fibrillations (irregular heart rate and rhythm), coronary heart disease (a condition where the coronary arteries that supply blood to the heart become narrowed or blocked), and congestive heart disease (the heart can't pump efficiently), high blood pressure, anxiety and Alzheimer's Disease. Review of the resident's care plan, located in the electronic medical records (EMR), showed: -2/20/25: Focus: Bladder incontinence. Goal: Will remain free from sin breakdown due to incontinence and brief use. Interventions/Tasks: Clean peri-area (genitalia/buttocks) with each incontinence episode; -3/7/25: Focus: Anticoagulant Therapy (blood thinner): Goal: Will be free from discomfort or adverse reactions to anticoagulant use. Interventions/Tasks: Daily skin inspection, report abnormalities to the nurse. Monitor for side effects every shift; -3/9/25: Focus: Impaired cognition or impaired though processes related to impaired decision making. Goal: Will be able to communicate basic needs on a daily basis. Interventions/Tasks: Communicate with the resident/family/caregivers regarding capabilities and needs. Use resident's preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Resident understands consistent, simple, directive sentences. Stop and return if agitated; -3/9/25: Focus: Requires assistance with self-care and mobility. Goal: Will maintain current care/mobility status. Interventions/Tasks: Lower body dressing - substantial/maximal assistance. Personal hygiene and showering/bathing - substantial/maximal assistance. Review of the resident's medication administration record (MAR), located in the EMR and dated 3/1/25 through 3/31/25, showed the resident received an Oxycodone (narcotic pain medication) 10 milligram at 1:20 A.M. on 3/6/25. Review of the resident's progress notes, located in the EMR, showed: -3/6/25 at 9:23 A.M. and documented by NM Z: Left inner calf there is a discolored area midway up the calf oval shaped and slightly raised; -3/7/25 at 9:17 A.M. and documented by NM Z: Area to left inner calf remains unchanged. Resident states it does not hurt; -3/7/25 at 6:53 P.M.: Family member to desk. Very upset regarding hematoma to left inner calf. Reports that resident is very upset and scared when he/she sees the CNA BB walk by. Spoke with Nurse Manager x2 with decision made to send the CNA home pending investigation. Family member updated and ok with plan; -3/7/25 at 7:15 P.M. and documented by NM Z: Resident's family member called this NM today with questions about resident's hematoma and with concerns he/she had heard different stories. This NM informed family member that an investigation was done, and the resident even stated he/she did not believe anyone caused this area to his/her calf. Resident even stated, look there isn't even anywhere he/she could have hit it on. NM said to resident remember when we talked yesterday about this area and mentioned resident leaning forward with his/her right arm on his/her left leg as he/she was picking skin off his/her left foot? Resident said he/she remembered. NM also looked at resident's medication and he/she is on two different kinds of blood thinners which can cause someone to bruise very easily and if you had any kind of pressure on your inner left leg it's highly possible that's what caused this hematoma. Resident voiced that this could possibly be what happened. When this NM explained this to family member, family member said thank you, he/she felt better now. We also discussed that family knows the resident doesn't always get all the facts correct when telling things to the family; -3/8/25 at 9:25 A.M.- Resident was complaining of pain on his/her left lower extremity. Nurse observed an area that was red and purple in color and slightly swollen. Nurse Practitioner was called and order to get a doppler (used to measure blood flow through the blood vessels) of the left lower extremity; -3/8/25 at 11:20 A.M.- Resident is alert and oriented to person, place, time and situation; -3/10/25 at 12:00 A.M. and documented by the resident's physician- Chief Complaint/Nature of Presenting Problem: 3/8 Reason for call. Has a raised bruise on his/her left leg. Concerns for blood clot. Requesting order for doppler. Family member was present last night voicing concerns about the area. New orders for venous doppler to rule out blood clot. Extremities: pulses are present, no edema (swelling). Left thigh (calf) has subcutaneous (the lower most layer of the integumentary system (skin)) hematoma about 3 inches by 3 inches. No redness to suggest infection. Plan: Patient (hematoma) is likely traumatic in nature. Currently there is no evidence of inflammation of cellulitis (a bacterial infection of the skin). Discussed with nursing to put ice packs three times a day to decrease the edema. Continue monitoring for possible developing infection. Resident is at increased risk for bleeding and bruising due to anticoagulation therapy. Doppler results pending. During an interview on 3/12/25 at 11:33 A.M., the Administrator provided the facilities completed investigation regarding Resident #4, and CNA BB. She said Resident #4 resides on the fourth floor. CNA BB normally works the third floor but worked the fourth floor that night. The investigation was completed on 3/6/25. The facility could not substantiate Resident #4's allegation CNA BB was rough while providing care and potentially causing the hematoma. CNA BB was allowed to return to work on 3/7/25, on the third floor. Review of the investigation showed three resident interviews: Resident #4, his/her roommate Resident #2, and Resident #11 who resides across the hall from Resident #4. The investigation did not include staff interviews that worked with CNA BB that night, residents residing on the third floor where CNA BB frequently worked, or staff from the third floor that worked with CNA BB. Review of the facility investigation dated 3/6/25, and completed by Nurse Manager (NM) Z, showed: -3/6/25 (no time documented): The 4th floor charge nurse came to this NM saying Resident #4 has a large hematoma to his/her left leg and said night CNA BB caused it. As we were walking to his/her room the nurse said the resident said the CNA would not change him/her. Whenever he/she put the light on, the CNA would stand in the doorway and tell him/her to never put the light on again. The resident then proceeded to say the CNA caused the hematoma. As we entered the room the resident was lying on his/her back with legs bent and feet on the bed. The resident said this morning after he/she got a pain pill he/she put the call light on to be changed and the CNA said he/she would have to wait a minute because he/she was busy, but then the CNA never came back. The resident said he/she put his/her call light on again and this time he/she had a bowel movement, and the CNA was very mad he/she had to clean him/her up. NM Z asked the resident what did the CNA do that made the resident know the CNA was mad. NM Z asked was the CNA rough when cleaning him/her up and rolling him/her back and forth did the CNA hit your inner calf on something? The resident said he/she can't even blame the CNA for that because there is nothing here that he/she could have hit it on. And no, the CNA was not rough while cleaning him/her up. NM Z told the resident he/she would continue to investigate what happened. The resident said ok and asked for pain medication. Upon assessing the area to the left inner calf noted some light green discoloration at the top of the bruise; -NM Z went to resident's roommate (Resident #2) and asked if he/she heard anything when CNA BB was taking care of Resident #4. The Resident #2 said no, he/she did not hear the CNA yell and when the CNA came in the room he/she did not seem upset. NM Z asked the Resident #2 if he/she heard Resident #4 yell ouch or stop and Resident #2 said he/she never heard anything. Resident #2 said CNA BB did not take care of him/her, but when the CNA came in, he/she did ask the roommate if he/she was wet or needed to be changed; -NM Z then went across the hall and asked Resident #11 how his/her night went and he/she said ok. NM Z asked the resident how CNA BB treated him/her. The resident said CNA BB asked him/her why he/she did not use the urinal and was not happy that he/she was wet, but he/she changed him/her. CNA BB was fine when he/she changed him/her; -NM Z went to the Director of Nursing (DON) and informed her what was being said. They called CNA BB together. The CNA denied yelling at Resident #4 about the call light. He/She then said when he/she went into the resident's room, the resident had his/her leg up and was picking at something. He/She did not see anything on the resident's left leg but noticed a scab on the right leg. They went over reporting things to the nurse and told CNA BB about a form that will be on the floor so staff can fill them out and give to the nurse when staff notice anything different with residents; -After talking with Resident #4 and CNA BB, the resident's medications were reviewed, and the resident takes two blood thinners (Eliquis and Plavix) and when the resident had his/her leg up and picking at it his/her arm would have pressed against his/her inner calf and with that dose of blood thinners a hematoma could very likely happen. Review of the facility investigation dated 3/6/25, and completed by the DON, showed: -3/6/25 (no time documented): Received call from resident's family regarding the resident. Family said he/she had received a text from the resident that CNA BB was rough with him/her the prior night. Alerted 4th floor NM Z who was already aware and investigating. The NM said Resident #4 said the CNA BB was irritated that the resident had a bowel movement, but the CNA was not rough. The NM questioned the roommate who said he/she did not hear anything going on between the resident and the CNA. The NM questioned the resident across the hall who did not have any issues to report. The NM and I called the CNA who denied being rough or yelling at the resident. He/She said when he/she went into the resident's room, the resident had his/her leg in the air and appeared to pick at something. Called family member and discussed the text and told him/her the NM was investigating and had spoken to the resident's roommate and residents in nearby rooms. Discussed the results of the NM interviews and interview with the CNA. Family member said he/she was not sure about his/her mother's complaint because he/she knows how the resident is. The resident lived with him/her for 5 years, and he/she did not want someone's job to be affected. He/She did not want to dismiss the resident's text but also knew firsthand about the resident's behavior. Family member was satisfied with the interviews and the information we had assembled. Observation on 3/12/25 at 11:53 A.M., showed Resident #4 lay in bed with a large purple/yellow hematoma on his/her inner left calf. He/She said a CNA (CNA BB) threw him/her around in his/her bed a few days ago. He/She was not sure if that is what caused the hematoma but he/she did grab him/her by the leg and he/she was not gentle. The CNA was not cursing at him/her, he/she was just loud and rough while providing care. The CNA took care of him/her on the evening shift and the night shift. He/She did not have any problem with the CNA until the night shift. He/She had turned on his/her call light a couple of times and the CNA would turn it off and said he/she would be back. The third time he/she turned on his/her call light, he/she had a bowel movement. When the CNA came in, he/she was upset because of him/her having the bowel movement and that is when he/she was rough with him/her. He/She told the nurse on the day shift and two nurses came back to talk to him/her. The CNA had not taken care of him/her since, although he/she did see the CNA walk by his/her room again. He/She told the nurse he/she did not want that CNA to take care of him/her. He/She is afraid of that CNA. During an interview on 3/12/25 at 11:53 A.M., Resident #4's roommate, Resident #2 said he/she did not see anything because the privacy curtain was closed. He/She did not hear CNA BB cursing at Resident #4, but the CNA's voice did seem aggravated and raised. He/She had not had any problems with the CNA. During an interview on 3/12/25 at 12:10 P.M., Resident #3 said he/she had not had any problems with staff. During an interview on 3/12/25 at 12:25 P.M., agency Licensed Practical Nurse (LPN) H said he/she had worked at the facility on-off for over a month. He/She had not witnessed any staff being abusive or rough with residents and had not had any residents complain about staff. During an interview on 3/12/25 at 12:30 P.M., agency CNA I said he/she had not witnessed any staff being abusive or rough with residents. He/She had not had any residents complain to him/her about staff being abusive or rough. During an interview on 3/12/25 at 12:40 P.M., a family member of Resident #5 said he/she had never had any problems with staff taking care of the resident. The resident had never had any unexplained injuries or bruises. Review of doppler study results dated 3/13/25, showed: Impression: No evidence of an acute (sudden) deep vein thrombosis (clot) left lower extremity. Suspected hematoma of the left ankle measuring 2.0 centimeters (cm) by 0.5 cm by 0.8 cm. During an interview on 3/13/25 at 7:00 A.M., Resident #11 said CNA BB does not give him/her the assistance he/she needs, doesn't honor his/her wishes. The CNA acts as if he/she is annoyed that he/she has to help him/her with incontinence care. The CNA will answer his/her call light, turn it off and say he/she will be right back but never return. The CNA has not been rough or abusive to him/her though. During an interview on 3/13/25 at 7:30 A.M., Resident #10 said CNA BB is rough with him/her. About a week ago, the CNA came in to his/her room to provide incontinent care and acted annoyed he/she had to help him/her. The CNA then pulled his/her sheet off and ripped his/her clothes off in a fast-sweeping motion. The CNA tossed him/her around like a rag doll. He/She does not want that CNA to take care of him/her anymore. That was the only incident he/she had. He/She said he/she had told NM Z about the incident. During an interview on 3/13/25 at 8:30 A.M., NM Z denied the resident told him/her about the incident involving CNA BB. He/She conducted the investigation. He/She interviewed Resident #4, Resident #2 and Resident #11. He/She was going to interview more residents, but it was lunchtime and he/she never went back to get more interviews. He/She should have gone back and interviewed more residents. CNA BB typically works the third floor, not the fourth floor where Resident #4 resides. He/She did not think to interview residents on the third floor. He/She did not think to interview staff that worked with CNA BB the night Resident #4 said the incident happened and he/she did not think to go to the fourth floor and interview staff that frequently work with the CNA. He/She is going to start his/her investigation again. Review of NM Z's resumed investigation dated 3/13/25, and sent to the Department of Health and Senior Services via e-mail on 3/14/25 at 2:51 P.M., showed: -12 residents residing on the third floor were interviewed and no problems were found; -CNA JJ said Resident #14 told him/her he/she does not want CNA BB taking care of him/her any longer because the CNA won't put him/her on the bed pan and tells him/her to just go in his/her brief; -CMT KK said Resident #13 told him/her CNA BB tells him/her to stop putting on his/her call light. Sometimes the CNA can be rough. NM Z discussed with CMT KK the importance of reporting this to the charge nurse right away. He/She tried to interview Resident #13 who told him/her to go away; -Both CNA JJ and CMT KK were in-serviced to the importance of reporting any allegations immediately to the nurse or NM. During an interview on 3/13/25 at 1:34 P.M., the Administrator said the facility should have interviewed more residents including residents from the third floor. They should have interviewed staff that worked when alleged the incident occurred and staff from the third floor that frequently work with CNA BB. She has added new guidelines to include in the facility investigations going forward. Due to Resident #4, Resident #10, and Resident #13 having similar stories of the CNA being rough during care she is she is terminating the CNA's employment. Review of the Administrator's new guidelines, showed: -Send staff member home pending investigation as soon as report/complaint is received; -Get statement from resident/family with complaint. Dates, times, staff/residents involved; -Interview any witnesses and get written and signed statement During an interview on 3/14/25 at 11:21 A.M., the Medical Director, and also the resident's physician said he expects staff to follow their abuse/neglect policy including investigating and reporting. He expects staff to conduct a thorough investigation. He was at the facility and assessed the hematoma. No one told him about the allegation. He should have been told. During an interview on 3/19/25 at 8:23 A.M., NM Z said this was the first time he/she had done an abuse investigation. On 3/13/25, after speaking to the surveyor he/she expanded his/her initial investigation by questioning more residents and also began to question staff. He/She attempted to talk to Resident #13, but he/she is rather confused and he/she was unable to get any information from the resident. He/She also spoke to Resident #14 who said he/she did not have any problems with CNA BB being abusive or rough.

Based on interview and record review, the facility staff failed to appropriately respond to a resident's (Resident #1's) change of condition, failed to conduct a thorough, documented assessment, and failed to contact the resident's physician, regarding the resident's change of condition, which began on 2/20/25. Staff failed to assess the resident who was not eating, stared blankly and could not keep his/her head up. The resident became unresponsive and was sent to the hospital with diagnoses of pneumonia (a lung infection, often caused by bacteria, viruses, or fungi, that inflames the air sacs (alveoli) and can lead to fluid or pus buildup, causing symptoms like cough, fever, and difficulty breathing), respiratory failure, and sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage). The sample was four. The facility census was 140. The Administrator was notified on 2/27/25 at 3:30 P.M., of an immediate jeopardy (IJ) which began on 2/20/25. The IJ was removed on 2/28/25 as confirmed by surveyor on-site verification. Review of the facility's undated Change of Condition Notification policy, showed: -Definitions: Significant change in the resident's condition is any physical mental or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). -Policy: The facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident's medical/mental condition and/or status; -Specific procedures/requirements: --The nurse will notify the resident's attending physician/ practitioner or physician on call when there has been a(an): -- Significant change in the resident's physical, mental or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); --Prior to notifying the physician/practitioner, the nurse will make detailed observations and gather relevant and pertinent information for the provider; --The nurse/designee will record in the resident's medical record, information relative to changes in the resident's medical/mental condition or status, including documentation of who was notified. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/18/24, showed: -Severely cognitively impaired; -No behaviors or rejection of care noted; -Mobility device: Cane/crutch; -Functional abilities: -Eating: Independent-completes the activity by self with no assistance from helper; -Toileting hygiene: Supervision or touching assistance -helper provides verbal cues or touching assistance as the resident completes activity; -Lower body dressing: Independent; -Upper body dressing: Independent; -Mobility: -Able to roll left to right: Independent; -Sit to lying: Independent; -Lying to sitting on side of bed: Supervision or touching assistance; -Sit to stand: Supervision or touching assistance; -Resident is continent of bowel and bladder; -Diagnoses included cognitive communication deficit, dysphagia (a condition which makes it difficult to swallow), chronic obstructive pulmonary disease (lung disease), Alzheimer's Disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, often resulting in dementia), high blood pressure, dementia (a general term for a decline in mental ability severe enough to interfere with daily life), malignant neoplasm (cancer) of lung, heart failure and sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). Review of the resident's February 2025 physician's orders, showed an order dated 2/11/25, for treatment of the sacrum (large, triangle-shaped bone in the lower spine that forms part of the pelvis): Clean wound with wound cleanser and apply zinc oxide (barrier cream) two times a day. Review of the resident's electronic Treatment Administration Record (eTAR) for February 2025, showed: -Sacrum: Clean wound with wound cleanser and apply zinc oxide two times a day starting 2/11/25; -No documentation regarding the sacrum wound treatment for the following shifts: -On 2/13/25 evening shift; -2/14/25 day and evening shifts; -2/15/25 evening shift; -2/18/25 evening shift; -2/19/25 day and evening shifts; -2/20/25 day and evening shifts. Review of the resident's care plan dated 2/5/25, showed: -Focus: Resident requires assistance with self-care and mobility; -Interventions/Tasks: Upper body dressing, lying siting to sitting on side of bed, chair/bed to chair transfer, lower body dressing, toileting hygiene, sit to lying, sit to stand, roll left and right, personal hygiene, walk ten feet, walk 150 feet required supervision or touching assistance; -Focus: Resident has impaired cognitive function or impaired thought processes; -Interventions/Tasks: Administer medications as ordered. Monitor/document/report PRN (as needed) any changes in cognitive function, specifically changes in: Decision making ability, memory, recall and general awareness, level of consciousness, and mental status; -Focus: Resident has dehydration or potential fluid deficit; -Interventions/Tasks: Administer medications as ordered. Monitor/document/report PRN any signs and symptoms of dehydration: Decreased or no urine output, concentrated urine, strong odor, tenting skin (when pinched skin stays lifted instead of returning to its normal position), cracked lips, new onset confusion, dizziness on sitting /standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss or dry/sunken eyes; -Focus: Resident has potential for pressure injury development related to impaired mobility and incontinence; -Interventions/Tasks: Administer medications as ordered. Monitor nutritional status. Serve diet as ordered, monitor intake and record; -Focus: The resident has pressure injury inside bilateral buttocks and potential for pressure injury; -Interventions/Tasks: Administer treatments as ordered and monitor for effectiveness. The resident requires supplemental protein, amino acids (building block of proteins), vitamins, minerals as ordered to promote wound healing. Review of the resident's progress notes, showed: -On 2/18/25 at 10:26 A.M., a nutritional/dietary note showed staff reported decreased appetite related to pneumonia and assistance needed with feeding, however often refuses to be fed. Sleeps often in morning and has better intake at lunch meal. Tolerating pureed diet; -On 2/20/25 at 7:32 P.M., staff sent the resident to the hospital for being non-responsive and not able to respond to outside stimuli. Staff administered a sternum rub (a medical procedure where a healthcare professional firmly rubs the middle of the chest bone sternum with their knuckles to elicit a painful response, used to assess a person's level of consciousness when they are unresponsive to verbal commands) with no response. Review of the Emergency Medical Service (EMS) records, dated 2/20/25, showed: -At 6:51 P.M., the station received the 911 call from the facility for an unresponsive resident; -At 6:57 P.M., EMS arrived at the facility and were directed to the fourth floor; -Upon exiting the elevator, the EMS staff could hear laughing at the nurse's station and had to ask the resident's whereabouts; -Staff at the desk pointed to the resident seated in his/her wheelchair in the dining room unresponsive; -The resident's head was tilted back and emesis (vomit) visible in the resident's airway, possible aspiration (a condition in which food, liquids, saliva or vomit is breathed into the airways) observed; -A staff member from another floor gave report and said he/she had not been aware of the resident's condition; -The fourth floor staff said they believed the resident had been in this unresponsive state since 3:00 P.M.; -EMS staff asked the facility staff why the notification to 911 was delayed and no response was given to indicate reasoning for the delay; -The resident had an open airway with emesis observed in it. He/She was breathing fast and had a strong radial pulse. He/She not alert to person, place, time or event. EMS staff applied a sternal rub with an audible groan observed, with no other response; -Resident's oxygen saturation level (refers to how well the body is delivering oxygen to tissues and organs) was 85% (normal range is 95-100) and oxygen was supplied bringing it up to 98%; -EMS attempted to suction the resident's airway with no success as the emesis was dried and stuck to the resident's mouth and throat; -The resident's mental status remained in an unresponsive state with no motor or verbal response; -EMS transported the resident to the hospital. Review of the resident's hospital records, dated 2/20/25, showed: -At 7:29 P.M., the resident arrived at the hospital; -Chief complaint: Altered mental status due to being unresponsive since 3:00 P.M. at facility; -Vital diagnoses: Pneumonia of both lungs due to infectious organism, acute hypoxemic respiratory failure (a condition where the body does not have enough oxygen in the blood), severe sepsis without septic shock (the body is severely reacting to an infection without causing a drop in blood pressure); -History of present illness: --Resident presented to the emergency department with complaints of altered mental status; --Today's last known well check showed the resident was seated in the dining room of his/her nursing home at 3:00 P.M., he/she was found in the same spot unresponsive prompting nursing home staff to call EMS; --Concern for aspiration. He/She was suctioned with minimal improvement; -Physical Exam: --Blood pressure 90/50 (low blood pressure is generally considered to be below 90/60); --Pulse 110 (a normal resting heart rate is between 60 and 100 beats per minute); --Oxygen saturation 65%; -Medical Decision Making: Here the resident is hypoxic. CT (computerized tomography scan - a diagnostic imaging procedure) shows pneumonia. He/She meets sepsis criteria; -Laboratory results showed elevated white blood count, abnormal metabolic panel, elevated troponin (indicates a myocardial injury which can be a sign of a heart attack or other heart conditions) and signs of infection in the urinalysis; -Imaging indicated acute pneumonia, new small pleural effusion (a buildup of fluid in the space between the lungs and the chest) and splenic infarcts (areas of dead tissue in the spleen that occur when blood flow to the organ is blocked). During an interview on 2/21/25 at 7:00 A.M., Certified Medical Technician (CMT) P said the resident looked real bad for both shifts (2/20/25). Around 9:00 A.M., certified nurse aide (CNA) Y came and got him/her and said the resident did not look right. The resident was restless, so CMT P took the resident's vitals, and they got him/her out of bed, dressed and in a wheelchair. The CNA pushed the resident to the dining room. The resident's vitals were normal. CMT P did not know if he/she documented the vitals. Throughout the day, the resident did not look like him/herself. He/She appeared to be very tired and his/her head kept falling back. There was no nurse working on the fourth floor that day or evening shift and he/she did not call anyone from another floor to assess the resident because his/her vitals were normal. After dinner, the CNA on the evening shift told him/her something was wrong with the resident, and when CMT P checked on the resident, he/she did not respond. CMT P called Licensed Practical Nurse (LPN) J up to assess the resident and sent him/her to the hospital. Review of the resident's medical record on 2/27/25, showed no documentation of vitals taken since 1/30/25. During an interview on 2/26/25 at 12:00 P.M., CNA D said he/she worked with the resident on 2/20/25. The resident was in bed when he/she got to his/her room that morning. He/She usually stays in bed until after breakfast, and then they heat up his/her food for him/her. CNA D went to the resident's room around 9:00 A.M., and the resident had his/her legs up like he/she was trying to climb out of bed. The CNA got the resident out of bed, dressed him/her and took him/her to the dining room. The resident has not looked well since he/she had a fall last month. The resident did not eat breakfast or lunch, but he/she did drink some juice and water. CNA D changed the resident a couple of unspecified times and put him/her back in the dining room. They kept the residents who were fall risks in the dining room so they could be observed by staff. CNA D might have told the CMT the resident did not look good because the resident stared into space, like in a daze. The CMT took the resident's vitals after breakfast, and they were fine. The resident looked very sleepy through the day. CNA D did not work on the resident's floor that evening, but he/she might have told the CNA to check on him/her since the resident had not been him/herself since the fall. A nurse came up to assess the resident after dinner. CNA D did not see a nurse assess the resident or treat his/her wounds prior to the nurse coming to the floor after dinner. During an interview on 2/25/25 at 1:15 P.M., CNA X said he/she worked with the resident on 2/20/25 but did not get him/her up. The resident did not look like him/herself that morning. His/Her head looked like it was too heavy for his/her body. He/She looked extremely tired. The CNA did not see the resident eat breakfast or lunch. CNA X was worried about the resident and asked other staff members about him/her, and they said the resident was breathing, so he/she was alright. The resident's head kept falling back between breakfast and lunch. The resident used to be more alert. He/She would walk around and try and help staff with trays. Lately he/she had been less active. He/She sleeps a lot and does not interact with the staff or other residents. When the CNA got ready to leave at 3:00 P.M., he/she told the oncoming staff the resident did not look like he/she was breathing, almost like he/she was leaving or dying. During an interview on 2/25/25 at 2:30 P.M., CNA S said he/she worked with the resident on 2/20/25 on the evening shift. At shift change, CNA D told him/her to keep an eye on the resident because he/she did not look good. The resident was in the dining room at shift change, and the CNA thought he/she looked dead. He/She told the other staff the resident did not look good, and they checked on him/her, and he/she was breathing. The resident would look at you if you called his/her name loudly several times. The resident remained in the dining room until he/she went to the hospital. He/She did not eat his/her dinner. After dinner, the CNA noticed the resident's eyes were rolling back in his/her head and he/she told the CMT. The CMT called a nurse from another floor, and he/she came to assess the resident. The resident would not respond, and they sent him/her to the hospital. During an interview on 2/26/25 at 12:30 P.M., CMT Z said he/she worked that morning passing medication and administered the resident's medication. The resident took his/her medication with no problem with a few sips of water. The resident looked tired and slept a lot. He/She did not know there was a problem so did not call anyone. During interviews on 2/21/25 at 6:15 A.M. and on 2/26/25 at 1:50 P.M., LPN J said he/she worked on the second floor on 2/20/25. After dinner, the CMT called down from the fourth floor and asked him/her to come up and assess a resident who did not look good. When LPN J got up to the fourth floor, the resident was seated in his/her wheelchair with his/her head tilted back. The resident did not respond when he/she tried to speak with him/her. The LPN lifted his/her head but still received no response. He/She performed a sternum rub, but the resident did not respond. The LPN told the CMT to take vitals and left the floor to get his/her glasses and the paperwork to send the resident to the hospital. When he/she returned to the floor, EMS were there and asked the staff how long the resident had been in this condition. One of the staff said, since shift change. The EMS staff were unable to get the resident to respond and transported him/her to the hospital. The LPN did not know the resident was having problems prior to being called up to the floor after dinner. He/She had been at work since 3:00 P.M., and no one called down to his/her floor to report a problem prior to the call to come up and assess the resident after dinner. During an interview on 2/25/25 at 12:15 P.M., Registered Nurse (RN) AA said he/she worked day shift on 2/20/25, and no one called from the fourth floor to assess a resident. During an interview on 2/25/25 at 2:15 P.M., LPN T said he/she worked the morning of 2/20/25, and no one called him/her from the fourth floor to assess a resident. He/She did not know there was anything wrong with the resident until LPN T heard the resident was sent to the hospital the next day. During an interview on 2/25/25 at 2:40 P.M., LPN Q said he/she worked the day shift on 2/20/25, and no one from the fourth floor called down to ask him/her to come up and assess the resident. During an interview on 2/25/25 at 3:00 P.M., LPN BB said he/she worked the morning of 2/20/25, and no one called from the fourth floor to assess a resident. During an interview on 2/27/25 at 9:45 A.M., the Director of Nursing said if the resident did not eat breakfast, lunch and dinner, a nurse should have assessed him/her to ensure he/she was not dehydrated. If the resident was not responding to staff and could not keep his/her head up, staff should have notified the nurse because the resident could have been having a heart attack or a stroke. If there is not a nurse scheduled for a floor, the staff on that floor are supposed to call down to another floor to ask a nurse to come up and assess residents if there are problems. One of those nurses would be responsible to come up and treat any wounds. Staff should have called a nurse to assess the resident when he/she did not look good that morning. They should have taken the resident's vitals and documented them. They should have documented the resident's condition and notified the physician. During an interview on 2/27/25 at 10:00 A.M., the Administrator said she expected staff to call a nurse from another floor to assess a resident if there was a change in condition. She expected staff to document the change in condition and to notify the resident's physician if necessary. During an interview on 2/26/25 at 2:50 P.M., the resident's physician said no one from the facility called her or the office on 2/20/25. No one called to notify them the resident was in the hospital. No one told her the resident was declining or had wounds. The physician's office has a 24 hour on-call line where the facility could reach someone any time. If the resident did not look good, was not responding as usual and could not keep his/her head up, someone should have called the office. The resident had been diagnosed with pneumonia last month and was still recovering from it. If the resident did not eat breakfast, lunch or dinner, the nurse should have assessed him/her because this could lead to dehydration. If the resident had dried material in his/her throat, this would indicate dehydration. If the resident had wounds which required treatment, this should have been done or an infection like sepsis could happen. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the D level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00250009

Based on interview and record review, the facility staff failed to appropriately respond to a resident's (Resident #351) change of condition, failed to conduct a thorough, documented assessment, and failed to contact the resident's physician, regarding the resident's change of condition, which began on [DATE]. The resident expired in the facility on [DATE]. The sample was 23. The facility census was 134. The Administrator was notified on [DATE] at 11:45 A.M., of an immediate jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility's, undated Change of Condition Notification Policy and Procedure, showed: -Definitions: Significant change in the resident's condition: Is any physical, mental or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); -Policy: The facility will promptly notify the resident, his or her physician/practitioner and representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, resident rights, etc); -Specific procedures/requirements: -The nurse will notify the resident's attending physician/practitioner or physician on call when there has been a: --Significant change in the resident's physical, mental, or psychosocial status; --Need to transfer the resident to a hospital/treatment center; -Prior to notifying the physician/practitioner of changes in the resident's condition, the nurse will make detailed observations and gather relevant and pertinent information for the provider; -Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: --The resident is involved in any accident or incident that results in an injury of unknown source: --There is a significant change in the resident's physical, mental or psychosocial status; -The nurse/designee will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status, including documentation of who was notified. Review of Resident #351's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Cognitively intact; -No behaviors or rejection of care; -Functional abilities and goals: --Functional limitations in range of motion -Lower extremity: Impairment on one side; --Mobility devices: Wheelchair, walker; -Mobility: Roll left to right: Supervision or touching assistance; -Sit to lying: Supervision or touching assistance; -Lying to sitting on side of bed: Supervision or touching assistance; -Sit to stand: Supervision or touching assistance; -Chair/bed to chair transfer: Supervision or touching assistance; -Toilet transfer: Supervision or touching assistance; -Pain management: -At any time has resident been on a scheduled pain medication regiment: No; -At any time has resident received as needed pain medications: No; -Should pain assessment interview be conducted: Yes; -Pain presence: Yes; -Pain frequency: Almost constantly; -Pain effect on sleep: Almost constantly; -Pain intensity: Numeric rating scale (00-10): 8; -Diagnoses included gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), peripheral vascular disease (PVD - a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), acute embolism and thrombosis of right calf muscular vein (any clot involving the deep veins of the calf) and polyneuropathy (a condition in which multiple peripheral nerves throughout the body are damaged). Review of the resident's care plan dated [DATE], showed: -Focus: Resident requires assistance with self care and mobility related to polyneuropathy, PVD, gangrene and post-op surgery; -Interventions: Bilateral half rails as needed for mobility; -Focus: The resident is at risk for falls; -Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; -Focus: The resident has pain; -Interventions: Administer analgesia (medications that relieve pain) (specify medication) as per orders. Monitor/document for side effects of pain medication. Observe for new onset or increased agitation, restlessness, confusion, nausea and falls. Report occurrences to the physician. Monitor/record pain characteristics (specify frequency) and as needed. Review of the resident's electronic Medication Administration Record for [DATE], showed: -Norco Oral Tablet 10-325. Give one tablet by mouth every four hours as needed for pain; -On [DATE] at 1:45 A.M., Norco administered, pain level a 5. At 6:29 A.M., Norco administered, pain level a 7. At 12:06 P.M., Norco administered, pain level an 8. At 5:24 P.M., Norco administered, pain level a 4; -On [DATE] at 3:17 P.M., Norco administered, pain level a 6; -No documentation Norco administration after this time. Review of the resident's progress notes, showed: -On [DATE] at 3:17 P.M., staff administered Norco oral tab; -On [DATE] at 2:08 A.M., a note regarding the effectiveness of the pain medication administered at 3:17 P.M., was unknown. -On [DATE] at 9:05 A.M., a note the nurse was informed by the tech at 8:30 A.M., the resident was Not how he/she was before. The nurse entered the room with the tech at 8:31 A.M. The tech said the resident was fine before and was talking to him/her while he/she was taking him/her to the bathroom. The resident was found next to bed in the wheelchair facing the television. The resident was drooling and leaning to one side. His/Her pupils were fixed (pupils that are unresponsive to light, remaining dilated or constricted). The resident was still breathing, airway was open and he/she had a thready pulse (a pulse that is so weak that it is not always palpable). Neurochecks (neurological checks) were performed and the resident was unable to do them. The nurse informed the Director of Nursing (DON) at 8:33 A.M. of the situation. While the DON called emergency medical services (EMS) at 8:34 A.M., the nurse obtained the vital signs machine at 8:35 A.M. The nurse took the blood pressure, pulse and oxygen. The resident's oxygen was at 80 (normal range is 95-100) and his/her blood pressure and pulse could not be obtained. His/Her manual pulse was thready. Neurochecks were performed again at 8:40 A.M., and the resident was guided to the floor from his/her wheelchair. Cardiopulmonary resuscitation (CPR, life sustaining measure) was started at 8:42 A.M. Help was called at 8:42 A.M., and at 8:45 A.M., an Automated External Defibrillator (AED, a medical device that can help save lives during sudden cardiac arrest) was applied. No shock was advised. EMS arrived at 8:44 A.M. Time of death was 9:17 A.M. Review of the EMS records, dated [DATE], showed: -Called for a patient in cardiac arrest; -Staff on scene were performing CPR and had an AED attached to patient; -EMS crew took over manual CPR at this time; -Staff stated to EMS the patient woke this morning and was acting normally. Staff stated the patient had no complaints. They said he/she never stated to them he/she had chest pain and never told them he/she had difficulty breathing; -Ten minutes prior to call, the patient became lethargic and lost consciousness; -The staff thought the resident was having a stroke; -After over 20 minutes of continuous resuscitation efforts the decision was made to call medical control and request terminating effort; -Complete report given to doctor and permission was given to stop resuscitation. Review of Resident #352's annual MDS dated [DATE], showed: -Adequate hearing and vision; -Able to understand others; -Able to make self understood. During an interview on [DATE] at 6:30 A.M., Resident #352, Resident #351's roommate, said the resident was in pretty bad shape when he/she was placed in their room, and he/she just got worse. On the morning of [DATE] around 2:00 A.M., he/she was watching television and heard his/her roommate choking. He/She asked his/her roommate, if he/she was okay, but the other resident did not respond. Resident #352 looked around the curtain and saw the Resident #351 gasping for breath. Resident #352 put on his/her shoes and rushed to the nurse's station and told the person there, his/her roommate was very sick and needed to see a nurse immediately. The person at the desk said the nurse was in another room helping another resident and he/she could not leave the desk to go get him/her, but would let the nurse know as soon as he/she returned. The resident went back to his/her room and waited, but no one came. He/She put on his/her call light and no one responded. After about 15 minutes he/she pushed Resident #351's call light, but no one responded. He/She finally fell asleep, and when he/she woke up Resident #351 was asleep in his/her bed. Then at breakfast ([DATE]), he/she heard Resident #351 had died. During interviews on [DATE] at 12:48 P.M. and on [DATE] at 2:00 P.M., Certified Nurse's Aide (CNA) Y said he/she worked with the resident from 3:00 P.M. to 11:00 P.M. on [DATE]. The resident was on his/her light all evening long. He/She was feeling sick and irritated. The resident told him/her, his/her head and chest were hurting. The CNA said he/she told the nurse several times. He/She thought the nurse went in to see the resident, but then he/she would hit the light again. The CNA saw the resident for the last time around 10:30 P.M. and he/she said he/she was fine. He/She passed the information along to the oncoming CNA that the resident was not feeling well. Between 11:00 P.M. and 11:15 P.M., as he/she was getting ready to leave, the resident's roommate came to the desk and told him/her, the resident was throwing up. He/She told the roommate the night CNA was aware the resident was not feeling good and would be in to see him/her soon. The CNA did not tell anyone the resident's roommate said he/she was throwing up. During an interview on [DATE] a 11:10 A.M., Registered Nurse (RN) W said he/she worked from 4:00 P.M. to 11:00 P.M. on [DATE]. He/She did not know the resident because this was his/her first time working on the floor. He/She did not remember anyone telling him/her there was a problem with the resident, and he/she thought there was another nurse working with him/her who would have passed medication to the resident. He/She did not call the physician or document anything, because he/she did not know there was a problem. During an interview on [DATE] at 10:40 A.M., Certified Medication Technician (CMT) S said he/she relieved the 3:00 P.M. to 11:00 P.M. nurse, who did not tell him/her the resident was having any problems on [DATE]. The 3:00 P.M. to 11:00 P.M. CNA told him/her the resident had an upset stomach shortly after shift change, and he/she gave the resident some Tums (antacid for upset stomach). The resident's roommate complained about the resident's television being too loud and asked if he/she could turn it off, but the CMT told the resident he/she could not do that because the other resident had the right to watch television. He/She did not see the resident again until around 6:30 A.M., and he/she was sleeping. They did not have a nurse on duty on the fourth floor that night. He/She would have called a nurse up from the other floor if there had been any problems. He/She did not administer any pain medication for the resident that night and the roommate did not say anything else to him/her about the resident being ill. During an interview on [DATE] at 11:45 A.M., CNA X said he/she worked overnight on [DATE] (into [DATE]). When he/she came in, the CNA who was leaving told him/her Resident #351 complained of not feeling well. He/She did not get to the resident's room until around 11:30 P.M., because they were trying to figure out where everyone would be assigned. The resident was in bed and said he/she needed something for his/her stomach, because he/she was nauseous. He/She told the CMT who took the resident some Tums, and the CNA got him/her a Coke. The resident's roommate told him/her, Resident #351 was not feeling good. The next time the CNA saw the resident was around 3:00 A.M. The resident was in the bathroom. He/She checked to see if he/she needed help, because he/she was not supposed to be getting up by him/herself. The resident did not look good. He/She was all clammy (sweaty). The CNA helped the resident back to his/her chair beside the bed and said he/she did not look well. The resident said he/she was alright so the CNA did not report this to the CMT or a nurse. Around 4:30 A.M. to 5:00 A.M., he/she checked on the resident again and he/she was asleep in bed. The CNA checked on the resident again around 7:00 A.M., and he/she was still sleeping. Between 8:00 A.M. and 8:30 A.M., the CNA took the resident his/her breakfast and he/she was in the bathroom again. The CNA went to wheel the resident out to his/her room for breakfast and the resident told him/her, he/she did not feel good. By the time they got to the bedside table, the resident slumped over in his/her wheelchair and stopped talking. He/She thought the resident was having a stroke. He/She immediately went and got the nurse. The nurse came into the room and said they needed to take vitals. The CNA thought they should send the resident to the hospital because it looked like a stroke. When they took the vitals, they could not be read. The nurse went and got oxygen and put it on 2 liters. Another nurse came in the room and put the oxygen on 10 liters. Another CNA came and told him/her other residents had their call lights on, so the nurse told him/her to go take care of the other residents. The CNA told the nurse he/she thought they should call 911, and the nurse told him/her it was done. When he/she was in the room with another resident, he/she heard the nurse calling for everyone to help, and when he/she got back in the room, the nurse was performing CPR. During an interview on [DATE] at 1:20 P.M., RN B said when he/she came in the morning of [DATE], no one told him/her anything about Resident #351. There was not a nurse working on the resident's floor the night before, so he/she did not get a verbal shift change. He/She only had the 24 hour shift report and there was nothing noted about the resident on it. He/She was passing medications when CNA X came and got him/her and said Resident #351 did not look like he/she had before. When the nurse got to the room, the resident was seated in his/her wheelchair by the bed. He/She was not responding, only grunting and had a pulse. The nurse told the CNA they needed to get vitals, and he/she ran down the hall to get the vitals machine. As he/she was getting the machine, he/she saw the DON on the other hall and told her to call 911. The nurse went back to the room and took the resident's vitals but could not get a reading for the resident's blood pressure or pulse. The resident's oxygen saturation level was 80, so he/she believed the resident needed oxygen. He/She left the CNA in the room with the resident and went to find oxygen. He/She found the oxygen tank but could not locate the tubing to apply the oxygen, so he/she went down to the second floor to get supplies. He/She told the nurse down on the second floor there was a resident in distress and ran back up to the fourth floor. RN B applied the oxygen but could not get the oxygen saturation level to go higher than 80. Licensed Practical Nurse (LPN) R came into the room and the resident was starting to get weaker, so they got him/her out of the wheelchair and onto the ground and started doing CPR. The DON came in then and helped them perform CPR. The EMS personnel arrived shortly after and took over CPR. CNA X told RN B the resident was responding to him/her prior to him/her coming to get the nurse. During an interview on [DATE] at 9:50 A.M., LPN R said he/she was working on the second floor on [DATE] when RN B came down looking for oxygen supplies. He/She took the oxygen back up to the fourth floor and LPN R printed up the paperwork to send the resident to the hospital. When he/she got up to the fourth floor, the DON and another nurse were standing at the nurse's station. LPN R asked them if they needed to paperwork to give EMS and the DON told him/her they had not called 911. The DON thought RN B had called 911. LPN R went down to the resident's room to ask the nurse if he/she called 911. When he/she got to the room, the resident was up in his/her wheelchair and was breathing shallowly. RN B told LPN R, he/she had not called 911 because he/she told the DON to call. LPN R ran back to the nurse's station to tell the DON and nurse to call 911 and then went back to the resident's room to help. When he/she got back to the resident's room, the resident was unconscious. He/She told RN B they needed to get the resident out of the wheelchair, onto the floor and start CPR. They moved the resident onto the floor and then he/she ran to get the crash cart on the second floor. It took a few minutes to get back up to the fourth floor because the elevator stopped on each floor. When he/she got back to the room, the DON and RN B were performing CPR. EMS arrived shortly after to take over. He/She worked the night on [DATE] from 11:00 P.M. to 7:00 A.M. ([DATE]) and no one called down to report there were any problems with the resident. During interviews on [DATE] at 3:00 P.M. and on [DATE] at 11:30 A.M., the DON said she was passing medications on the other side of the 400 hall on [DATE] when RN B came over and said the resident was having trouble breathing and needed oxygen supplies. The RN did not tell him/her to call 911. The RN went down to the second floor to get the supplies. They usually keep oxygen supplies in the oxygen room or supply cabinet on each floor, so he/she did not know if they were out of supplies or the RN did not know where to locate them. The DON would have stayed with the resident and sent the CNA out to get the supplies. Staff should have called 911 immediately. She thought the RN had already called 911. When she got to the resident's room, RN B was performing CPR and they worked together to continue CPR until the EMS arrived. She did not know the resident complained of head and chest pain to the staff the night before. No one told her the resident did not look good during the night. This should have been documented. Staff should have notified the resident's physician and/or sent the resident to the hospital with these symptoms. He/She did not know the roommate alleged he/she tried to get help for the resident the night before and no one came to assess him/her. During an interview on [DATE] at 11:50 A.M., the Administrator said if the staff observed the resident not looking good and he/she complained of head and chest pain, the staff should have notified the nurse on duty to assess him/her. If the resident's roommate notified staff the resident needed help, they should have responded immediately. The staff should have notified the physician about these observations and complaints. All of this should have been documented. During an interview on [DATE] at 1:50 P.M., the nurse practitioner said he did not receive any calls at the office on [DATE] from the facility, and they have a 24 hour line that is always available. The facility staff told him the resident was found unresponsive and they performed CPR. No one told him the resident complained of head pain, chest pain or nausea the night before. If they would have told him, he would have told the staff to send the resident to the hospital because he was an extremely high risk for a Myocardial Infarction (MI, medical term for a heart attack) or a stroke. During an interview on [DATE] at 3:15 P.M., the resident's physician said no one called her office about the resident on [DATE]. If the resident was having head and chest pain, nauseous and sweaty, they definitely should have called, as these could be signs of a heart attack. The resident was at a higher risk for this with his/her diagnoses. Someone should have called when he/she first started having these symptoms. She would have had him/her immediately sent to the hospital. The hospital could have provided a higher level of care. She signed the death certificate, and stated the cause of death was acute coronary syndrome because she did not know all of this happened. She was just told the resident was found unresponsive and the facility performed CPR, and he/she died. It is possible if the resident went to the hospital and provided interventions, the outcome might have been different. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the D level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00247802 MO00247822

35394 40865 JW Based on observation, interview and record review, the facility failed to provide pain management, for one resident (Resident #524) with a fractured hip who complained of pain when staff provided care upon waking, when assessed by therapy at breakfast and when put to bed after dinner. The resident was administered no pain medication for 19 hours until he/she was transferred to the hospital. The facility staff also failed to provide as needed (PRN) pain medication to one resident (Resident #516) who suffered from chronic pain for four hours. The facility also failed to ensure one resident's (Resident #507's) Lidocaine patch (a topical pain reliever) was ordered timely and administered as ordered. In addition, the facility failed to ensure timely referral to pain management and failed to implement alternative interventions after discontinuing the resident's Norco (an opioid pain reliever), placing the resident at higher risk for unnecessary pain and discomfort. The sample size was 30. The facility census was 114. The Administrator was notified on 4/17/25 at 4:45 P.M., of an immediate jeopardy (IJ) which began on 3/14/25. The IJ was removed on 4/18/25 as confirmed by surveyor on-site verification. Review of the facility's undated Pain Management policy, showed: -Definitions: Pain is an unpleasant sensory and emotional experience that can be acute, recurrent or persistent; -Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals; -Policy: The organization will ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. Pain management will be a collaborative effort between the resident, physician and representatives of the interdisciplinary team, including but not limited to pharmacy, nursing, mental health professionals, rehab therapy, social services, activities, etc; -Specific procedures/requirements: -Pain management is a multi-disciplinary care process that includes the following: -Assessing the potential for pain; -Effectively recognizing the presence of pain; -Identifying the characteristics of pain; -Addressing the underlying causes of pain; -Developing and implementing approaches to pain management; -Identifying and using specific strategies for different levels and sources of pain; -Monitoring for the effectiveness of interventions; -Modifying approaches as necessary; -It is important to recognize cognitive, cultural, familial, or gender specific influences on the resident's ability or willingness to verbalize pain; -Licensed nursing staff will conduct a comprehensive pain evaluation upon admission/readmission to the facility, at the quarterly review, whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain; -Licensed nursing staff will evaluate the resident's pain and consequences of pain at least each shift for the presence and/or absence of acute or breakthrough pain or significant changes in levels of chronic pain. Findings will be documented in the medical record; -If pain has not been adequately controlled, the multidisciplinary team, including the physician may reconsider approaches and make adjustments as indicated; -If pain symptoms have resolved or there is no longer an indication for pain medication, the multidisciplinary team and physician may try to discontinue or taper analgesic medications to the extent possible; -The physician and staff in collaboration with the resident/resident's representative will establish a treatment regimen based on consideration of the following: --The resident's medical condition; --Current medication regimen; --Nature, severity and cause of the pain; --Course of the illness; --Treatment goals; -The resident's care plan will address pain based on the pain assessment and resident/resident representative choice. 1. Review of the Resident #524's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/23/25, showed: -Severely cognitively impaired; -Adequate hearing and vision; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Behaviors (physical and verbal) frequency: One to three days; -Rejection of care frequency: One to three days; -Diagnoses included weakness, cognitive communication deficit, unspecified dementia, age related osteoporosis (a condition where bones become weakened and brittle, increasing the risk of fractures, particularly in the hip, spine, and wrist), muscle weakness and heart failure; -Should a pain assessment be completed? Yes; -Pain management: -On scheduled pain regime? No; -Received as needed pain medications? No; -Pain Presence? No. Review of the resident's electronic Medication Administration Record (eMAR) dated March 2025, showed: -An order with a start date of 2/17/25 to obtain pain level via numeric pain scale every shift (pain is rated on a scale of 1-10, with 10 being the highest); -On 3/14/25, day shift, a 4 documented, on evening shift, a 4 documented and on night shift, a 6 recorded; -No order for pain medication. Review of the resident's speech therapy notes, dated 3/14/25 at 10:06 A.M., showed the resident verbalized pain in right hip area. The medication technician was notified. Review of the resident's physical therapy notes, dated 3/14/25 at 10:23 A.M., showed the resident seated in wheelchair at the dining table. The Certified Nurse's Aide (CNA) reported the resident complained of pain in the right hip. The resident stated My leg hurts and has pain with light touch at greater trochanter (the bony bump over the side of the hip) of right hip and has edema (swelling) in right lower extremity (RLE). Stop and watch form (staff communication form) filled out and given to the nurse. Per nurse practioner, X-ray ordered. Further treatment withheld until result of X-ray. Review of the resident's progress notes, showed: -On 3/14/25 at 11:53 A.M., the nurse practioner (NP) saw the resident seated in his/her wheelchair down in the dining room and in no acute distress. Therapy asked the NP to see the resident. Resident was noted to be screaming out and would not let anyone move his/her RLE. When the NP saw the resident, he/she was much more calm and allowed him/her to palpate (examine a part of the body by touch) his/her RLE. It was significantly swollen and tender to palpation during the exam. The NP reviewed with nursing, an X-ray was ordered and pending arrival. Assessment plan: RLE pain, unable to ambulate, pending X-ray, continue to keep resident hydrated and continue with pain management. Allow resident to rest until X-ray is completed and continue to monitor; -At 7:15 P.M., the nurse reported the CNA informed him/her the resident was having increased right leg pain. Upon assessment, the resident was noted to have right hip pain radiating to his/her right knee. When staff assisted the resident to bed, the resident was noted to have right foot external rotation (the hip joint can have a limited range of internal rotation, leading to the foot turning out as a compensation) and was unable to tolerate bending his/her right knee. When attempted, the resident grabbed his/her right hip and yelled, Ouch! No discoloration noted to his/her right hip or knee. Bi-lateral lower extremity (BLE) edema noted. Staff stated the resident had increased swelling to his/her BLE. When assessing his/her right hip, the resident once again responded to any movement with Ouch! It was previously noted that morning on the nurse's station by the unit manager that a Stop and Watch was presented by the physical therapist. An order was noted in the electronic medical record by nurse practioner on this date for an X-ray of the right hip related to complaints of pain. The nurse called the unit manager to inform him/her of the resident's complaint of pain. The unit manager said he/she was aware and informed this nurse an X-ray order was to be placed per previous conversations in the day prior to his/her leaving for the day. The order was noted and the nurse would follow through with the X-ray company. The nurse placed the order with the X-ray company at that time. The X-ray company would be out as soon as possible; -At 9:40 P.M., the X-ray company was on-site at the facility to obtain rays of the right hip. Staff called the resident's family member to inform them of the resident's complaints of pain. The Director of Nursing (DON) called the facility to check on everyone due to the weather, and the nurse informed her of the X-ray obtained due to the resident's pain in right hip. Review of the resident's eMAR dated March 2025, showed: -No order for pain medication; -No medication for pain administered. Review of the resident's progress notes, showed: -On 3/15/25 at 2:35 A.M., the X-ray company informed the nurse of critical X-ray results. Findings: Acute intertrochanteric fracture (a broken hip that occurs between the greater and lesser trochanters of the femur- the thighbone.) noted. At 2:42 A.M., the nurse called the physician's office and left a message. At 2:59 A.M., the nurse called the physician's office and informed the NP of the X-ray results. The NP gave an order to send the resident to the emergency room (ER) for evaluation and treatment. At 3:30 A.M., staff placed a call to 911 for a non-emergent transfer to the hospital. At 4:00 A.M., emergency medical services (EMS) at facility to transport the resident to the hospital. At 11:03 A.M., the resident was admitted to the hospital with a closed fracture of the right femur; -At 4:46 P.M., the unit manager noted therapy brought the nurse a form he/she filled out for a change in condition from yesterday's therapy saying the resident's leg was warm, red and swollen. The nurse was actually walking out of his/her office for an appointment and passed this information on to the DON. X-ray orders were received by the 3-11 shift. They had not arrived so the nurse called and made the order STAT (immediate). Review of the resident's hospital admission records, dated 3/15/25, showed: -Resident presented to the emergency department with chief complaint of right hip pain after a fall. His/Her facility states he/she fell and hurt his/her right hip; -Primary pain intensity: 5 = moderate pain. Observation and interview on 4/15/25 at 5:30 A.M., showed the resident lay in bed yelling out Help me, Help me! The resident pointed to his/her right side and said it hurt. He/She did not remember how he/she hurt his/her hip. During interviews on 4/16/25 at 12:45 P.M. and on 4/17/25 at 9:15 A.M., CNA D said the resident was yelling out that morning (3/14/25), and he/she went into the room to check on him/her and get him/her up for the day. This was not unusual because the resident yelled out all of the time. The resident could stand on his/her own and would transfer to his/her wheelchair with assistance. When the CNA went to help the resident out of bed, he/she yelled out in pain. He/She could not stand on his/her own and the CNA put him/her back into the bed and changed him/her. The resident's leg looked swollen so he/she went to certified medication technician (CMT) E and told him/her the resident was complaining of pain and needed some pain medication. The CNA thought the CMT gave the resident the pain medication but did not know for sure because he/she waited for about an hour to go back so the medicine could kick in. The CNA got another staff member to assist him/her with getting the resident out of bed because the resident could not stand on his/her own or assist with the transfer. The CNA got the resident dressed and took him/her to the dining room. The resident received therapy in the morning, so CNA D asked the physical therapist (PT) to assess the resident to make sure he/she was able to do therapy. The PT assessed the resident and decided he/she could not do therapy and left. The PT did not say anything else to the CNA about the resident. The NP came down later and assessed the resident but did not say anything to him/her about what to do with the resident. The CNA thought a nurse came down but could not remember the nurse's name. No one told him/her to do anything differently with the resident. He/She did not know the resident's hip was broken because the resident always yelled out throughout the day, and he/she thought this was just his/her usual behavior. The resident ate his/her breakfast, lunch and dinner, so the CNA did not think the resident was in pain. CNA D changed the resident after lunch by having him/her hold onto the grab bar in the bathroom. The resident did not act any differently at that time. After dinner, the CNA decided to put the resident to bed first, before the other residents. CNA D got another aide to help him/her since the resident could not help with transferring that morning. When they went to transfer the resident into bed, he/she yelled out again in pain and needed more pain medication. The nurse immediately came and assessed the resident and ordered an x-ray. During an interview on 4/16/25 at 2:15 P.M., speech therapist (ST) EE said he/she was sitting with the resident that morning, and he/she was rubbing his/her leg and said it hurt. The ST told CMT E the resident was complaining of pain, left and did not see him/her again that day. During an interview on 4/16/25 at 9:30 A.M., PT DD said he/she thought the nurse manager had already looked at the resident when he/she got down there. He/She assessed the resident, wrote out a stop and watch note and told the nurse manager the leg was swollen. The resident was fine the day before and in fact walked further than ever before. During an interview on 4/16/25 at 1:15 P.M., LPN/Nurse Manager FF said he/she came in early that day and left early around 9:00 A.M. due to a medical appointment. Just as he/she was leaving, a PT person brought up a stop and watch note and handed it to the DON. A stop and watch note is anything out of the ordinary with a resident. He/She did not know there was anything wrong with the resident prior to this because the CNA did not say anything about the resident being in pain. He/She thought the DON was going to follow up on the resident. During an interview on 4/16/25 at 2:25 P.M., CMT E said he/she remembered the resident did not want to get up that day because he/she complained of pain. He/She could not remember who he/she notified, but someone came down to assess the resident. There was a concern about his/her pain but there was nothing for pain in the order book after the nurse and NP assessed him/her, so he/she did not request an order for anything or remember if he/she administered anything. During an interview on 4/17/24 at 9:45 A.M., CMT HH said they were short staffed that evening (3/14/25), and he/she had to go down to the resident's floor to administer medications. He/She remembered LPN GG going down with him/her to assess the resident. He/She did not administer any pain medication to the resident because the nurse assessed him/her and would have been responsible to get an order for the pain medication. During an interview on 4/16/25 at 2:00 P.M., LPN GG said he/she ended up coming down to assess the resident because the nurse scheduled left early that day. No one told him/her prior to coming down to assess the resident, that he/she complained of pain earlier that day or that he/she needed an X-ray. He/She did not realize it until later that evening after he/she assessed the resident when he/she was reviewing his/her electronic records and saw the NP notes for an order. He/She then notified the nurse manager and sent the order out for an X-ray. He/She did not remember giving the resident any pain medication that night. During interviews on 4/16/25 at 9:30 A.M. and on 3/17/25 at 3:30 P.M., the DON said she did not remember anyone telling her the resident was in pain that day. The information about the resident should have been passed to the oncoming nurse. If the resident complained about pain and did not have an order, the nurse should have called the physician to get an order. It would depend on if the resident was complaining about pain. It also depended on whether he/she complained of pain if he/she should have been left in his/her wheelchair all day. She did not remember seeing the stop and watch note on the resident or if the nurse told her about the X-ray. If someone did tell her a resident needed an X-ray, she would have a nurse order it and followed up with it. During interviews on 4/17/24 at 8:45 A.M. and at 12:45 P.M., the NP said he/she did not order an x-ray because he/she was told by staff the nurse had already called the physician to order an X-ray before he/she came down to assess the resident. He/She did not know the staff who gave him/her this information. If he/she had known the X-ray was not ordered, he/she would have ordered it immediately. He/She thought the staff called a private X-ray company and it just took awhile for them to get to the facility. He/She did not order pain medication for the resident because he/she thought the resident had an order for Tylenol and did not look like he/she was in pain when he/she assessed him/her. No one told him/her the resident continued to complain of pain. He/She did not find out about the delayed X-ray until the next day when staff called him/her to let him/her know the results of the X-ray. During an interview on 4/21/25 at 1:55 P.M., the resident's physician said he was not notified the day the resident fractured his/her hip and needed an X-ray. If an x-ray was ordered, staff should have followed up to ensure it was done in a timely manner. If the resident did not have pain medication on his/her orders, someone should have contacted him after he/she complained of pain the first time, so he could have ordered it. Staff should not have left the resident in his/her wheelchair all day because this could increase his/her pain. 2. Review of Resident #516's admission MDS dated [DATE], showed: -Adequate hearing; Vision: Adequate - sees fine detail, including regular print in newspaper/books; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Moderate cognitive impairment; -Diagnoses of anemia (the blood has a reduced ability to carry oxygen), coronary artery disease (heart disease due to plaque build-up in the arteries), high blood pressure, renal (kidney) insufficiency, respiratory failure and anxiety; -Pain Management: At any time in the past five days has the resident been on a scheduled pain medication regiment?: Yes. Received as necessary pain medication? No; -Pain Presence: Yes; -Pain Frequency: Frequently; -Pain Effect on Sleep: Almost constantly; -Pain Interference with Therapy Activities: Almost constantly; -Pain Interference with Day-to-Day Activities: Almost constantly; -Verbal Description Scale: Very severe, horrible. Review of the resident's care plan, located in the electronic health care record (EHR), showed: -Revised on 4/14/25: Focus: Impaired cognitive function and impaired thought processes related to impaired decision making. Goal: Will be able to communicate basic needs on a daily basis. Interventions/Tasks: Administer medications as ordered. Resident understands consistent, simple, directive sentences; -Revised on 4/14/25: Focus: Pain related to right hip fracture surgery. Goal: Resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Interventions/Tasks: Administer pain medications per physician orders. Monitor/Document for side effects of pain medication. Review of the resident's physician's orders sheet (POS), located in the EHR, showed: -3/21/25: Acetaminophen (Tylenol) 325 mg every six hours PRN; -3/21/25: Oxycodone HCI (a narcotic pain medication) 10 milligrams (mg), 1 tablet every six hours PRN; -3/22/25: Gabapentin (used to treat neuropathic/nerve pain) 300 mg 3 times a day. During an interview on 4/15/25 at 5:38 A.M., the resident lay in bed and said he/she had constant pain on his/her right side. He/She turned on his/her call light around 4:00 A.M., because he/she needed an Oxycodone for the pain. CNA J answered his/her call light and told him/her there was no nurse on their floor (the fourth floor) to administer the pain medication. The resident rated the pain at a 6 at the time he/she asked. He/She has still not received the Oxycodone, and his/her pain is a 10 now. A clock was hanging on the wall across from the resident's bed. The resident was able to state the correct time. At 8:22 A.M., the resident lay in bed. He/She said he/she received his/her Oxycodone a few minutes ago. During an interview on 4/15/25 at 6:00 A.M., LPN LL said he/she was the only nurse for the third floor with 50 people and could not be responsible for another floor. No one called him/her to report anyone needed pain medication on the fourth floor. During an interview on 4/15/25 at 6:07 A.M., CNA J said the resident did ask for a pain pill a couple of hours ago, but there was no nurse scheduled to work this floor last night. He/She was waiting on a nurse from one of the other floors to make rounds on this floor so he/she could tell that nurse the resident needed a pain pill, but he/she had not seen another nurse making rounds. He/She should have called one of the other floors and told one of those nurses, but he/she did not. During an interview on 4/15/25 at 6:30 A.M., CMT II said CNA J told him/her a resident requested pain medication this morning, but he/she was not able to administer narcotics. He/She usually works on a floor where a nurse is assigned, and this was his/her first time working on this floor. The nurses always administered the pain medications when he/she was on the other floors. He/She did not know the protocol of who to call if a resident needed narcotics. During an interview on 4/15/25 at 6:45 A.M., LPN KK said he/she was responsible for the second floor and the medications on the first floor overnight. No one called him/her to let him/her know a resident needed pain medication on the fourth floor. During an interview on 4/16/25 at 7:07 A.M., LPN O said he/she would not go to another floor to give a medication if he/she is not the nurse scheduled for that floor. During an interview on 4/16/25 at 7:12 A.M., CMT Q said if a resident needed a narcotic and there was no CMT or nurse on the floor, the CNA should call the floor where a nurse or CMT was so they could come to the floor and administer the narcotic. During an interview on 4/16/25 at 7:15 A.M., CNA R said if he/she was working a floor with no nurse and a resident needed a pain medication he/she would call the floor where there was a nurse and tell them the resident needed a pain pill. During an interview on 4/16/25 at 7:46 A.M., CNA N said if a resident needed a pain medication and there was no nurse scheduled on that floor, he/she would call a nurse from one of the other floors and tell them what the resident needed. Review of the resident's MAR located in the EHR, dated 4/1/25 through 4/15/25, showed: -Acetaminophen 325 mg was administered on 4/1/25 for a pain level (pain is rated on a scale of 1-10, with 10 being the highest) of 5, 4/4/25 for a pain level of 6, and 4/5/25 for a pain level of 5; -Oxycodone HCl 10 mg was administered 26 times, on 14 of the 16 days. The last dose initialed as administered was on 5/14/25 was at 4:00 P.M. Only one dose was recorded administered on 4/15/25 and that was at 5:17 P.M. The MAR did not show the resident received an Oxycodone administered at approximately 8:00 A.M.; -Review of the resident's pain scale, showed out of a possible 45 times (three recordings a day for 15 days) a pain level of 0 recorded 36 times, a pain level of 2 recorded two times, a pain level of 5 recorded three times, a pain level of 7 recorded two times, and a pain level of 10 recorded one time. Review of the resident's Oxycodone Individual Narcotic Record (where staff initial a medication was administered and how many doses are left in the medication card) showed the resident received one dose of Oxycodone 10 mg on 4/14/25 AT 4:00 P.M. The resident did not receive another dose of Oxycodone until 4/15/25 at 8:00 A.M. (four hours after the resident said he/she had requested the medication at 4:00 A.M.). During a telephone interview on 4/21/25 at 3:10 P.M., Administrator NN said it should not take longer than 30 minutes for a resident to receive a medication after it's requested. Waiting four hours for medication is unacceptable. Administrator MM said the facility has a protocol identifying what floor a staff member should contact if a nurse is needed. Staff on the fourth floor where Resident #516 resided should have contacted a nurse on another floor as soon as the resident requested the pain medication. 3. Review of Resident #507's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Has frequent pain; -Occasional pain during sleep; -Occasional pain interference with therapy activities; -Occasional pain with day to day activities; -Pain scale 7 out of 10; -Diagnoses included coronary artery disease, high blood pressure, anxiety, depression, and asthma. Review of the resident's care plan, in use during survey, showed: -Focus: Resident has pain related to neck/back discomfort; -Goal: Resident will verbalize adequate relief of pain or ability to cope with incompletely relived pain; -Interventions: Administrator analgesia as per orders; -Resident prefers to wear back brace at times for comfort. He/She is able to apply and remove at will; -Monitor/Document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria (general distress), nausea, vomiting, dizziness, and falls. Report occurrences to the physician; -Monitor/Record/report to nurse any signs and symptoms of non-verbal pain. Changes in breathing, vocalizations, mood/behavior, eyes, face, and body; -Refer to pain clinic on 4/8/25. Review of the resident's POS, dated April 2025, showed: -An order, dated 7/15/24, Celebrex (to treat pain) oral capsule 200 mg. Give one capsule by mouth one time a day for pain; -An order, dated 7/15/24, Hydrocodone-Acetaminophen (Norco) oral tablet 10-325 mg. Give one tablet by mouth every six hours as needed for 4-10 out of 10, for moderate to severe pain; -An order, dated 7/20/24, screen and rate pain using pain scale 0-10 every shift; -An order, dated 7/15/24, Tylenol oral tablet 325 mg. Give two tablets by mouth every four hours as needed for fever; -An order, dated 7/15/24, Tylenol oral tablet 325 mg. Give two tablets by mouth every six hours as needed for mild pain, 1-3 out of 10; -An order, dated 7/23/24, Lidocaine external patch, apply to left shoulder topically one time a day for pain and remove per schedule; -An order, dated 4/5/25, call pain clinic to schedule appointment. Update this order with appointment date and time. Advise resident appointment day for pain; -An order, dated 4/8/25, patient needs a referral for pain management. May contact pain clinic, one time only for pain management; -An order 4/15/25, Hydrocodone-Acetaminophen oral tablet 5-325 mg. Give one tablet by mouth every four as needed for pain scale 1-5. -An order, dated 4/8/25 to discontinue the Norco on 4/8/25. During an interview on 4/16/25 at 9:15 A.M., the resident said the physician discontinued his/her Norco, prior to 4/8/25. He/She has it written down. He/She was told by a nurse that he/she had to go to pain management and he/she could not receive anymore Norco. They did not wean him/her off the Norco, so he/she experienced nausea and diarrhea. During an interview on 4/16/25 at 12:20 P.M., the DON said the resident needed to go to pain management. He/She did not want to go, but ended up making an appointment with the physician of his/her choosing. The Medical Director discontinued the order. The DON did not know if there was anything documented about the medication being discontinued. The physicians put their order in the record at the time, and nursing confirms the order. The DON said she confirmed the order to discontinue the resident's Norco. The Medical Director would not re-fill the Norco. The resident was aware he/she cannot get a refill until he/she goes to pain management. The DON was not aware of any adverse effects or withdrawal symptoms from discontinuing the resident's Norco. Review of the resident's MAR, dated March 2025, showed: -An order, dated 7/15/24, Hydrocodone-Acetaminophen oral tablet 10-325 mg. Give one tablet by mouth every six hours as needed for 4-10 out of 10 for moderate to severe pain was administered on the following dates and times: -On 3/22/25, no documentation of Norco administered; -On 3/23/25, Norco was administered: -At 8:11 A.M., with a pain score of 5; -At 4:14 P.M., with a pain score of 8; -At 10:47 P.M., with a pain score of 8; -On 3/24/25, Norco was administered: -At 8:22 A.M., with a pain score of 5; -At 4:10 P.M., with a pain score of 8; -On 3/25/25, Norco was administered: -At 10:19 A.M., with a pain score of 8; -At 6:06 P.M., with a pain score of 9; -On 3/26/25, Norco was administered: -At 3:44 A.M., with a pain score of 5; -At 11:37 A.M., with a pain score of 5; -On 3/27/25, Norco was administered: -At 8:57 A.M., with a pain score of 0; -At 4:03 P.M., with a pain score of 0; -An order, dated 7/15/24, Tylenol oral tablet 325 mg. Give two tablets by mouth every six hours as needed for mild pain 1-3 out of 10, was administered on the following dates and times: -On 3/28/25 at 8:45 P.M., with a pain score of 9; -On 3/29/25 at 1:57 P.M., with a pain score of 9. Review of the resident's MAR, dated April 2025, showed: -An order, dated 7/15/24, Hydrocodone-Acetaminophen oral tablet 10-325 mg. Give one tablet by mouth every six hours as needed for 4-10 out of 10, for moderate to severe pain, was not administered on 4/1 through 4/8/25; -Discontinued on 4/8/25; -An order, dated 7/23/24, Lidocaine external patch, apply to left shoulder topically one time a day for pain and remove per schedule, showed: -On 4/15/25 at 8:00 A.M., staff documented the administration of the Lidocaine patch; -At 8:00 P.M., staff documented medication not available for removal of Lidocaine patch; -On 4/16/25 at 8:00 A.M, staff documented medication not available; -At 8:00 A.M., staff documented other. During an interview on 4/16/25 at 2:30 P.M. and 3:42 P.M., the resident read off his/her personal notes. He/She said on 3/22/25 at 10:00 A.M., he/she was told by the nurse that the Hydrocodone has been canceled and you need to see pain management. He/She never received any information on where to go or who to see. They said the Medical Director discontinued the pain medicine. The resident did not meet the Medical Director until two days ago. The resident stated having diarrhea and pain by that Friday after the medication was discontinued (3/28/25). He/She notified staff of his/her symptoms. They told him/her that he/she could have two Tylenol every six hours. There were no assessments; the nurse did not give anything for his/her diarrhea. He/She had diarrhea as recent as two days ago. The last time he/she received Norco was on 3/22/25. The Tylenol helps a little at night, but he/she has pain and neuropathy (nerve damage that causes pain). He/She did not receive th [TRUNCATED]

Based on observation, interview and record review, the facility failed to provide pain management for Resident #524, who complained of pain when staff provided care upon waking, again when assessed by therapy at breakfast and also when put to bed after dinner. The resident was administered no pain medication for 19 hours until he/she was transferred to the hospital after an x-ray showed the resident had a fractured hip. The facility staff also failed to provide as needed (PRN) pain medication to Resident #516 who suffered from chronic pain for four hours. The facility also failed to ensure Resident #507's Lidocaine patch (a topical pain reliever) was ordered timely and administered as ordered. In addition, the facility failed to ensure timely referral to pain management and failed to implement alternative interventions after discontinuing the resident's Norco (an opioid pain reliever), placing the resident at higher risk for unnecessary pain and discomfort. The sample size was 30. The facility census was 114. The Administrator was notified on 4/17/25 at 4:45 P.M., of an immediate jeopardy (IJ) which began on 3/14/25. The IJ was removed on 4/18/25 as confirmed by surveyor on-site verification. Review of the facility's undated Pain Management policy, showed: -Definitions: Pain is an unpleasant sensory and emotional experience that can be acute, recurrent or persistent; -Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals; -Policy: The organization will ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. Pain management will be a collaborative effort between the resident, physician and representatives of the interdisciplinary team, including but not limited to pharmacy, nursing, mental health professionals, rehab therapy, social services, activities, etc; -Specific procedures/requirements: -Pain management is a multi-disciplinary care process that includes the following: -Assessing the potential for pain; -Effectively recognizing the presence of pain; -Identifying the characteristics of pain; -Addressing the underlying causes of pain; -Developing and implementing approaches to pain management; -Identifying and using specific strategies for different levels and sources of pain; -Monitoring for the effectiveness of interventions; -Modifying approaches as necessary; -It is important to recognize cognitive, cultural, familial, or gender specific influences on the resident's ability or willingness to verbalize pain; -Licensed nursing staff will conduct a comprehensive pain evaluation upon admission/readmission to the facility, at the quarterly review, whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain; -Licensed nursing staff will evaluate the resident's pain and consequences of pain at least each shift for the presence and/or absence of acute or breakthrough pain or significant changes in levels of chronic pain. Findings will be documented in the medical record; -If pain has not been adequately controlled, the multidisciplinary team, including the physician may reconsider approaches and make adjustments as indicated; -If pain symptoms have resolved or there is no longer an indication for pain medication, the multidisciplinary team and physician may try to discontinue or taper analgesic medications to the extent possible; -The physician and staff in collaboration with the resident/resident's representative will establish a treatment regimen based on consideration of the following: --The resident's medical condition; --Current medication regimen; --Nature, severity and cause of the pain; --Course of the illness; --Treatment goals; -The resident's care plan will address pain based on the pain assessment and resident/resident representative choice. 1. Review of the Resident #524's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/23/25, showed: -Severely cognitively impaired; -Adequate hearing and vision; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Behaviors (physical and verbal) frequency: One to three days; -Rejection of care frequency: One to three days; -Diagnoses included weakness, cognitive communication deficit, unspecified dementia, age related osteoporosis (a condition where bones become weakened and brittle, increasing the risk of fractures, particularly in the hip, spine, and wrist), muscle weakness and heart failure; -Should a pain assessment be completed? Yes; -Pain management: -On scheduled pain regimen? No; -Received as needed pain medications? No; -Pain Presence? No. Review of the resident's electronic Medication Administration Record (eMAR) dated March 2025, showed: -An order with a start date of 2/17/25 to obtain pain level via numeric pain scale every shift (pain is rated on a scale of 1-10, with 10 being the highest); -On 3/14/25, day shift a 4 documented, on evening shift a 4 documented, and on night shift a 6 recorded; -No order for pain medication. Review of the resident's speech therapy notes, dated 3/14/25 at 10:06 A.M., showed the resident verbalized pain in right hip area. The medication technician was notified. Review of the resident's physical therapy notes, dated 3/14/25 at 10:23 A.M., showed the resident seated in wheelchair at the dining table. The Certified Nurse's Aide (CNA) reported the resident complained of pain in the right hip. The resident stated My leg hurts and has pain with light touch at greater trochanter (the bony bump over the side of the hip) of right hip and has edema (swelling) in right lower extremity (RLE). Stop and watch form (staff communication form) filled out and given to the nurse. Per nurse practitioner (NP), X-ray ordered. Further treatment withheld until result of X-ray. Review of the resident's progress notes, showed: -On 3/14/25 at 11:53 A.M., the nurse NP saw the resident seated in his/her wheelchair down in the dining room and in no acute distress. Therapy asked the NP to see the resident. Resident was noted to be screaming out and would not let anyone move his/her RLE. When the NP saw the resident, he/she was much more calm and allowed him/her to palpate (examine a part of the body by touch) his/her RLE. It was significantly swollen and tender to palpation during the exam. The NP reviewed with nursing, an X-ray was ordered and pending arrival. Assessment plan: RLE pain, unable to ambulate, pending X-ray, continue to keep resident hydrated and continue with pain management. Allow resident to rest until X-ray is completed and continue to monitor; -At 7:15 P.M., the nurse reported the CNA informed him/her the resident was having increased right leg pain. Upon assessment, the resident was noted to have right hip pain radiating to his/her right knee. When staff assisted the resident to bed, the resident was noted to have right foot external rotation (the hip joint can have a limited range of internal rotation, leading to the foot turning out as a compensation) and was unable to tolerate bending his/her right knee. When attempted, the resident grabbed his/her right hip and yelled, Ouch! No discoloration noted to his/her right hip or knee. Bi-lateral lower extremity (BLE) edema noted. Staff stated the resident had increased swelling to his/her BLE. When assessing his/her right hip, the resident once again responded to any movement with Ouch! It was previously noted that morning on the nurse's station by the unit manager that a Stop and Watch was presented by the physical therapist. An order was noted in the electronic medical record by nurse practioner on this date for an X-ray of the right hip related to complaints of pain. The nurse called the unit manager to inform him/her of the resident's complaint of pain. The unit manager said he/she was aware and informed this nurse an X-ray order was to be placed per previous conversations in the day prior to his/her leaving for the day. The order was noted and the nurse would follow through with the X-ray company. The nurse placed the order with the X-ray company at that time. The X-ray company would be out as soon as possible; -At 9:40 P.M., the X-ray company was on-site at the facility to obtain rays of the right hip. Staff called the resident's family member to inform them of the resident's complaints of pain. The Director of Nursing (DON) called the facility to check on everyone due to the weather, and the nurse informed her of the X-ray obtained due to the resident's pain in right hip. Review of the resident's eMAR dated March 2025, showed: -No order for pain medication; -No medication for pain administered. Review of the resident's progress notes, showed: -On 3/15/25 at 2:35 A.M., the X-ray company informed the nurse of critical X-ray results. Findings: Acute intertrochanteric fracture (a broken hip that occurs between the greater and lesser trochanters of the femur- the thighbone.) noted. At 2:42 A.M., the nurse called the physician's office and left a message. At 2:59 A.M., the nurse called the physician's office and informed the NP of the X-ray results. The NP gave an order to send the resident to the emergency room (ER) for evaluation and treatment. At 3:30 A.M., staff placed a call to 911 for a non-emergent transfer to the hospital. At 4:00 A.M., emergency medical services (EMS) at facility to transport the resident to the hospital. At 11:03 A.M., the resident was admitted to the hospital with a closed fracture of the right femur; -At 4:46 P.M., the unit manager noted therapy brought the nurse a form he/she filled out for a change in condition from yesterday's therapy saying the resident's leg was warm, red and swollen. The nurse was actually walking out of his/her office for an appointment and passed this information on to the DON. X-ray orders were received by the 3-11 shift. They had not arrived so the nurse called and made the order STAT (immediate). Review of the resident's hospital admission records, dated 3/15/25, showed: -Resident presented to the emergency department with chief complaint of right hip pain after a fall. His/Her facility states he/she fell and hurt his/her right hip; -Primary pain intensity: 5 = moderate pain. Observation and interview on 4/15/25 at 5:30 A.M., showed the resident lay in bed yelling out Help me, Help me! The resident pointed to his/her right side and said it hurt. He/She did not remember how he/she hurt his/her hip. During interviews on 4/16/25 at 12:45 P.M. and on 4/17/25 at 9:15 A.M., CNA D said the resident was yelling out that morning (3/14/25), and he/she went into the room to check on him/her and get him/her up for the day. This was not unusual because the resident yelled out all of the time. The resident could stand on his/her own and would transfer to his/her wheelchair with assistance. When the CNA went to help the resident out of bed, he/she yelled out in pain. He/She could not stand on his/her own and the CNA put him/her back into the bed and changed him/her. The resident's leg looked swollen so he/she went to certified medication technician (CMT) E and told him/her the resident was complaining of pain and needed some pain medication. The CNA thought the CMT gave the resident the pain medication but did not know for sure because he/she waited for about an hour to go back so the medicine could kick in. The CNA got another staff member to assist him/her with getting the resident out of bed because the resident could not stand on his/her own or assist with the transfer. The CNA got the resident dressed and took him/her to the dining room. The resident received therapy in the morning, so CNA D asked the physical therapist (PT) to assess the resident to make sure he/she was able to do therapy. The PT assessed the resident and decided he/she could not do therapy and left. The PT did not say anything else to the CNA about the resident. The NP came down later and assessed the resident but did not say anything to him/her about what to do with the resident. The CNA thought a nurse came down but could not remember the nurse's name. No one told him/her to do anything differently with the resident. He/She did not know the resident's hip was broken because the resident always yelled out throughout the day, and he/she thought this was just his/her usual behavior. The resident ate his/her breakfast, lunch and dinner, so the CNA did not think the resident was in pain. CNA D changed the resident after lunch by having him/her hold onto the grab bar in the bathroom. The resident did not act any differently at that time. After dinner, the CNA decided to put the resident to bed first, before the other residents. CNA D got another aide to help him/her since the resident could not help with transferring that morning. When they went to transfer the resident into bed, he/she yelled out again in pain and needed more pain medication. The nurse immediately came and assessed the resident and ordered an x-ray. During an interview on 4/16/25 at 2:15 P.M., speech therapist (ST) EE said he/she was sitting with the resident that morning, and he/she was rubbing his/her leg and said it hurt. The ST told CMT E the resident was complaining of pain, left and did not see him/her again that day. During an interview on 4/16/25 at 9:30 A.M., PT DD said he/she thought the nurse manager had already looked at the resident when he/she got down there. He/She assessed the resident, wrote out a stop and watch note and told the nurse manager the leg was swollen. The resident was fine the day before and in fact walked further than ever before. During an interview on 4/16/25 at 1:15 P.M., LPN/Nurse Manager FF said he/she came in early that day and left early around 9:00 A.M. Just as he/she was leaving, a PT person brought up a stop and watch note and handed it to the DON. A stop and watch note is anything out of the ordinary with a resident. He/She did not know there was anything wrong with the resident prior to this because the CNA did not say anything about the resident being in pain. He/She thought the DON was going to follow up on the resident. During an interview on 4/16/25 at 2:25 P.M., CMT E said he/she remembered the resident did not want to get up that day because he/she complained of pain. He/She could not remember who he/she notified, but someone came down to assess the resident. There was a concern about his/her pain but there was nothing for pain in the order book after the nurse and NP assessed him/her, so he/she did not request an order for anything or remember if he/she administered anything. During an interview on 4/17/24 at 9:45 A.M., CMT HH said they were short staffed that evening (3/14/25), and he/she had to go down to the resident's floor to administer medications. He/She remembered LPN GG going down with him/her to assess the resident. He/She did not administer any pain medication to the resident because the nurse assessed him/her and would have been responsible to get an order for the pain medication. During an interview on 4/16/25 at 2:00 P.M., LPN GG said he/she ended up coming down to assess the resident because the nurse scheduled left early that day. No one told him/her prior to coming down to assess the resident, that he/she complained of pain earlier that day or that he/she needed an X-ray. He/She did not realize it until later that evening after he/she assessed the resident when he/she was reviewing his/her electronic records and saw the NP notes for an order. He/She then notified the nurse manager and sent the order out for an X-ray. He/She did not remember giving the resident any pain medication that night. During interviews on 4/16/25 at 9:30 A.M. and on 3/17/25 at 3:30 P.M., the DON said she did not remember anyone telling her the resident was in pain that day. The information about the resident should have been passed to the oncoming nurse. If the resident complained about pain and did not have an order, the nurse should have called the physician to get an order. It would depend on if the resident was complaining about pain. It also depended on whether he/she complained of pain if he/she should have been left in his/her wheelchair all day. She did not remember seeing the stop and watch note on the resident or if the nurse told her about the X-ray. If someone did tell her a resident needed an X-ray, she would have a nurse order it and followed up with it. During interviews on 4/17/24 at 8:45 A.M. and at 12:45 P.M., the NP said he/she did not order an x-ray because he/she was told by staff the nurse had already called the physician to order an X-ray before he/she came down to assess the resident. He/She did not know the staff who gave him/her this information. If he/she had known the X-ray was not ordered, he/she would have ordered it immediately. He/She thought the staff called a private X-ray company and it just took awhile for them to get to the facility. He/She did not order pain medication for the resident because he/she thought the resident had an order for Tylenol and did not look like he/she was in pain when he/she assessed him/her. No one told him/her the resident continued to complain of pain. He/She did not find out about the delayed X-ray until the next day when staff called him/her to let him/her know the results of the X-ray. During an interview on 4/21/25 at 1:55 P.M., the resident's physician said he was not notified the day the resident fractured his/her hip and needed an X-ray. If an x-ray was ordered, staff should have followed up to ensure it was done in a timely manner. If the resident did not have pain medication on his/her orders, someone should have contacted him after he/she complained of pain the first time, so he could have ordered it. Staff should not have left the resident in his/her wheelchair all day because this could increase his/her pain. 2. Review of Resident #516's admission MDS dated [DATE], showed: -Adequate hearing; Vision: Adequate - sees fine detail, including regular print in newspaper/books; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Moderate cognitive impairment; -Diagnoses of anemia (the blood has a reduced ability to carry oxygen), coronary artery disease (heart disease due to plaque build-up in the arteries), high blood pressure, renal (kidney) insufficiency, respiratory failure and anxiety; -Pain Management: At any time in the past five days has the resident been on a scheduled pain medication regimen?: Yes. Received as necessary pain medication? No; -Pain Presence: Yes; -Pain Frequency: Frequently; -Pain Effect on Sleep: Almost constantly; -Pain Interference with Therapy Activities: Almost constantly; -Pain Interference with Day-to-Day Activities: Almost constantly; -Verbal Description Scale: Very severe, horrible. Review of the resident's care plan, located in the electronic health care record (EHR), showed: -Revised on 4/14/25: Focus: Impaired cognitive function and impaired thought processes related to impaired decision making. Goal: Will be able to communicate basic needs on a daily basis. Interventions/Tasks: Administer medications as ordered. Resident understands consistent, simple, directive sentences; -Revised on 4/14/25: Focus: Pain related to right hip fracture surgery. Goal: Resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Interventions/Tasks: Administer pain medications per physician orders. Monitor/Document for side effects of pain medication. Review of the resident's physician's orders sheet (POS), located in the EHR, showed: -3/21/25: Acetaminophen (Tylenol) 325 mg every six hours PRN; -3/21/25: Oxycodone HCI (a narcotic pain medication) 10 milligrams (mg), 1 tablet every six hours PRN; -3/22/25: Gabapentin (used to treat neuropathic/nerve pain) 300 mg 3 times a day. During an interview on 4/15/25 at 5:38 A.M., the resident lay in bed and said he/she had constant pain on his/her right side. He/She turned on his/her call light around 4:00 A.M., because he/she needed an Oxycodone for the pain. CNA J answered his/her call light and told him/her there was no nurse on their floor (the fourth floor) to administer the pain medication. The resident rated the pain at a 6 at the time he/she asked. He/She had still not received the Oxycodone, and his/her pain is a 10 now. A clock was hanging on the wall across from the resident's bed. The resident was able to state the correct time. At 8:22 A.M., the resident lay in bed. He/She said he/she received his/her Oxycodone a few minutes ago. During an interview on 4/15/25 at 6:00 A.M., LPN LL said he/she was the only nurse for the third floor with 50 people and could not be responsible for another floor. No one called him/her to report anyone needed pain medication on the fourth floor. During an interview on 4/15/25 at 6:07 A.M., CNA J said the resident did ask for a pain pill a couple of hours ago, but there was no nurse scheduled to work this floor last night. He/She was waiting on a nurse from one of the other floors to make rounds on this floor so he/she could tell that nurse the resident needed a pain pill, but he/she had not seen another nurse making rounds. He/She should have called one of the other floors and told one of those nurses, but he/she did not. During an interview on 4/15/25 at 6:30 A.M., CMT II said CNA J told him/her a resident requested pain medication this morning, but he/she was not able to administer narcotics. He/She usually works on a floor where a nurse is assigned, and this was his/her first time working on this floor. The nurses always administered the pain medications when he/she was on the other floors. He/She did not know the protocol of who to call if a resident needed narcotics. During an interview on 4/15/25 at 6:45 A.M., LPN KK said he/she was responsible for the second floor and the medications on the first floor overnight. No one called him/her to let him/her know a resident needed pain medication on the fourth floor. During an interview on 4/16/25 at 7:07 A.M., LPN O said he/she would not go to another floor to give a medication if he/she is not the nurse scheduled for that floor. During an interview on 4/16/25 at 7:12 A.M., CMT Q said if a resident needed a narcotic and there was no CMT or nurse on the floor, the CNA should call the floor where a nurse or CMT was so they could come to the floor and administer the narcotic. During an interview on 4/16/25 at 7:15 A.M., CNA R said if he/she was working a floor with no nurse and a resident needed a pain medication he/she would call the floor where there was a nurse and tell them the resident needed a pain pill. During an interview on 4/16/25 at 7:46 A.M., CNA N said if a resident needed a pain medication and there was no nurse scheduled on that floor, he/she would call a nurse from one of the other floors and tell them what the resident needed. Review of the resident's MAR located in the EHR, dated 4/1/25 through 4/15/25, showed: -Acetaminophen 325 mg was administered on 4/1/25 for a pain level (pain is rated on a scale of 1-10, with 10 being the highest) of 5, 4/4/25 for a pain level of 6, and 4/5/25 for a pain level of 5; -Oxycodone HCl 10 mg was administered 26 times, on 14 of the 16 days. The last dose initialed as administered was on 4/14/25 was at 4:00 P.M. Only one dose was recorded administered on 4/15/25 and that was at 5:17 P.M. The MAR did not show the resident received an Oxycodone administered at approximately 8:00 A.M.; -Review of the resident's pain scale, showed out of a possible 45 times (three recordings a day for 15 days) a pain level of 0 recorded 36 times, a pain level of 2 recorded two times, a pain level of 5 recorded three times, a pain level of 7 recorded two times, and a pain level of 10 recorded one time. Review of the resident's Oxycodone Individual Narcotic Record (where staff initial a medication was administered and how many doses are left in the medication card) showed the resident received one dose of Oxycodone 10 mg on 4/14/25 at 4:00 P.M. The resident did not receive another dose of Oxycodone until 4/15/25 at 8:00 A.M. (four hours after the resident said he/she had requested the medication at 4:00 A.M.). During a telephone interview on 4/21/25 at 3:10 P.M., Administrator NN said it should not take longer than 30 minutes for a resident to receive a medication after it's requested. Waiting four hours for medication is unacceptable. Administrator MM said the facility has a protocol identifying what floor a staff member should contact if a nurse is needed. Staff on the fourth floor where Resident #516 resided should have contacted a nurse on another floor as soon as the resident requested the pain medication. 3. Review of Resident #507's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Has frequent pain; -Occasional pain during sleep; -Occasional pain interference with therapy activities; -Occasional pain with day to day activities; -Pain scale 7 out of 10; -Diagnoses included coronary artery disease, high blood pressure, anxiety, depression, and asthma. Review of the resident's care plan, in use during survey, showed: -Focus: Resident has pain related to neck/back discomfort; -Goal: Resident will verbalize adequate relief of pain or ability to cope with incompletely relived pain; -Interventions: Administrator analgesia as per orders; -Resident prefers to wear back brace at times for comfort. He/She is able to apply and remove at will; -Monitor/Document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria (general distress), nausea, vomiting, dizziness, and falls. Report occurrences to the physician; -Monitor/Record/report to nurse any signs and symptoms of non-verbal pain. Changes in breathing, vocalizations, mood/behavior, eyes, face, and body; -Refer to pain clinic on 4/8/25. Review of the resident's POS, dated April 2025, showed: -An order, dated 7/15/24, Celebrex (to treat pain) oral capsule 200 mg. Give one capsule by mouth one time a day for pain; -An order, dated 7/15/24, Hydrocodone-Acetaminophen (Norco) oral tablet 10-325 mg. Give one tablet by mouth every six hours as needed for 4-10 out of 10, for moderate to severe pain; -An order, dated 7/20/24, screen and rate pain using pain scale 0-10 every shift; -An order, dated 7/15/24, Tylenol oral tablet 325 mg. Give two tablets by mouth every four hours as needed for fever; -An order, dated 7/15/24, Tylenol oral tablet 325 mg. Give two tablets by mouth every six hours as needed for mild pain, 1-3 out of 10; -An order, dated 7/23/24, Lidocaine external patch, apply to left shoulder topically one time a day for pain and remove per schedule; -An order, dated 4/5/25, call pain clinic to schedule appointment. Update this order with appointment date and time. Advise resident appointment day for pain; -An order, dated 4/8/25, patient needs a referral for pain management. May contact pain clinic, one time only for pain management; -An order 4/15/25, Hydrocodone-Acetaminophen oral tablet 5-325 mg. Give one tablet by mouth every four as needed for pain scale 1-5. -An order, dated 4/8/25 to discontinue the Norco on 4/8/25. During an interview on 4/16/25 at 9:15 A.M., the resident said the physician discontinued his/her Norco, prior to 4/8/25. He/She had it written down. He/She was told by a nurse that he/she had to go to pain management and he/she could not receive anymore Norco. They did not wean him/her off the Norco, so he/she experienced nausea and diarrhea. During an interview on 4/16/25 at 12:20 P.M., the DON said the resident needed to go to pain management. He/She did not want to go, but ended up making an appointment with the physician of his/her choosing. The Medical Director discontinued the order. The DON did not know if there was anything documented about the medication being discontinued. The physicians put their order in the record at the time, and nursing confirms the order. The DON said she confirmed the order to discontinue the resident's Norco. The Medical Director would not re-fill the Norco. The resident was aware he/she cannot get a refill until he/she goes to pain management. The DON was not aware of any adverse effects or withdrawal symptoms from discontinuing the resident's Norco. Review of the resident's MAR, dated March 2025, showed: -An order, dated 7/15/24, Hydrocodone-Acetaminophen oral tablet 10-325 mg. Give one tablet by mouth every six hours as needed for 4-10 out of 10 for moderate to severe pain was administered on the following dates and times: -On 3/22/25, no documentation of Norco administered; -On 3/23/25, Norco was administered: -At 8:11 A.M., with a pain score of 5; -At 4:14 P.M., with a pain score of 8; -At 10:47 P.M., with a pain score of 8; -On 3/24/25, Norco was administered: -At 8:22 A.M., with a pain score of 5; -At 4:10 P.M., with a pain score of 8; -On 3/25/25, Norco was administered: -At 10:19 A.M., with a pain score of 8; -At 6:06 P.M., with a pain score of 9; -On 3/26/25, Norco was administered: -At 3:44 A.M., with a pain score of 5; -At 11:37 A.M., with a pain score of 5; -On 3/27/25, Norco was administered: -At 8:57 A.M., with a pain score of 0; -At 4:03 P.M., with a pain score of 0; -An order, dated 7/15/24, Tylenol oral tablet 325 mg. Give two tablets by mouth every six hours as needed for mild pain 1-3 out of 10, was administered on the following dates and times: -On 3/28/25 at 8:45 P.M., with a pain score of 9; -On 3/29/25 at 1:57 P.M., with a pain score of 9. Review of the resident's MAR, dated April 2025, showed: -An order, dated 7/15/24, Hydrocodone-Acetaminophen oral tablet 10-325 mg. Give one tablet by mouth every six hours as needed for 4-10 out of 10, for moderate to severe pain, was not administered on 4/1 through 4/8/25; &nbs

Based on interview and record review, the facility staff failed to appropriately respond to a resident's (Resident #351) change of condition, failed to conduct a thorough, documented assessment, and failed to contact the resident's physician, regarding the resident's change of condition, which began on [DATE]. The resident expired in the facility on [DATE]. The sample was 23. The facility census was 134. The Administrator was notified on [DATE] at 11:45 A.M., of an immediate jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility's, undated Change of Condition Notification Policy and Procedure, showed: -Definitions: Significant change in the resident's condition: Is any physical, mental or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); -Policy: The facility will promptly notify the resident, his or her physician/practitioner and representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, resident rights, etc); -Specific procedures/requirements: -The nurse will notify the resident's attending physician/practitioner or physician on call when there has been a: --Significant change in the resident's physical, mental, or psychosocial status; --Need to transfer the resident to a hospital/treatment center; -Prior to notifying the physician/practitioner of changes in the resident's condition, the nurse will make detailed observations and gather relevant and pertinent information for the provider; -Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: --The resident is involved in any accident or incident that results in an injury of unknown source: --There is a significant change in the resident's physical, mental or psychosocial status; -The nurse/designee will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status, including documentation of who was notified. Review of Resident #351's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Cognitively intact; -No behaviors or rejection of care; -Functional abilities and goals: --Functional limitations in range of motion -Lower extremity: Impairment on one side; --Mobility devices: Wheelchair, walker; -Mobility: Roll left to right: Supervision or touching assistance; -Sit to lying: Supervision or touching assistance; -Lying to sitting on side of bed: Supervision or touching assistance; -Sit to stand: Supervision or touching assistance; -Chair/bed to chair transfer: Supervision or touching assistance; -Toilet transfer: Supervision or touching assistance; -Pain management: -At any time has resident been on a scheduled pain medication regiment: No; -At any time has resident received as needed pain medications: No; -Should pain assessment interview be conducted: Yes; -Pain presence: Yes; -Pain frequency: Almost constantly; -Pain effect on sleep: Almost constantly; -Pain intensity: Numeric rating scale (,d+[DATE]): 8; -Diagnoses included gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), peripheral vascular disease (PVD - a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), acute embolism and thrombosis of right calf muscular vein (any clot involving the deep veins of the calf) and polyneuropathy (a condition in which multiple peripheral nerves throughout the body are damaged). Review of the resident's care plan dated [DATE], showed: -Focus: Resident requires assistance with self care and mobility related to polyneuropathy, PVD, gangrene and post-op surgery; -Interventions: Bilateral half rails as needed for mobility; -Focus: The resident is at risk for falls; -Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; -Focus: The resident has pain; -Interventions: Administer analgesia (medications that relieve pain) (specify medication) as per orders. Monitor/document for side effects of pain medication. Observe for new onset or increased agitation, restlessness, confusion, nausea and falls. Report occurrences to the physician. Monitor/record pain characteristics (specify frequency) and as needed. Review of the resident's electronic Medication Administration Record for [DATE], showed: -Norco Oral Tablet ,d+[DATE]. Give one tablet by mouth every four hours as needed for pain; -On [DATE] at 1:45 A.M., Norco administered, pain level a 5. At 6:29 A.M., Norco administered, pain level a 7. At 12:06 P.M., Norco administered, pain level an 8. At 5:24 P.M., Norco administered, pain level a 4; -On [DATE] at 3:17 P.M., Norco administered, pain level a 6; -No documentation Norco administration after this time. Review of the resident's progress notes, showed: -On [DATE] at 3:17 P.M., staff administered Norco oral tab; -On [DATE] at 2:08 A.M., a note regarding the effectiveness of the pain medication administered at 3:17 P.M., was unknown. -On [DATE] at 9:05 A.M., a note the nurse was informed by the tech at 8:30 A.M., the resident was Not how he/she was before. The nurse entered the room with the tech at 8:31 A.M. The tech said the resident was fine before and was talking to him/her while he/she was taking him/her to the bathroom. The resident was found next to bed in the wheelchair facing the television. The resident was drooling and leaning to one side. His/Her pupils were fixed (pupils that are unresponsive to light, remaining dilated or constricted). The resident was still breathing, airway was open and he/she had a thready pulse (a pulse that is so weak that it is not always palpable). Neurochecks (neurological checks) were performed and the resident was unable to do them. The nurse informed the Director of Nursing (DON) at 8:33 A.M. of the situation. While the DON called emergency medical services (EMS) at 8:34 A.M., the nurse obtained the vital signs machine at 8:35 A.M. The nurse took the blood pressure, pulse and oxygen. The resident's oxygen was at 80 (normal range is ,d+[DATE]) and his/her blood pressure and pulse could not be obtained. His/Her manual pulse was thready. Neurochecks were performed again at 8:40 A.M., and the resident was guided to the floor from his/her wheelchair. Cardiopulmonary resuscitation (CPR, life sustaining measure) was started at 8:42 A.M. Help was called at 8:42 A.M., and at 8:45 A.M., an Automated External Defibrillator (AED, a medical device that can help save lives during sudden cardiac arrest) was applied. No shock was advised. EMS arrived at 8:44 A.M. Time of death was 9:17 A.M. Review of the EMS records, dated [DATE], showed: -Called for a patient in cardiac arrest; -Staff on scene were performing CPR and had an AED attached to patient; -EMS crew took over manual CPR at this time; -Staff stated to EMS the patient woke this morning and was acting normally. Staff stated the patient had no complaints. They said he/she never stated to them he/she had chest pain and never told them he/she had difficulty breathing; -Ten minutes prior to call, the patient became lethargic and lost consciousness; -The staff thought the resident was having a stroke; -After over 20 minutes of continuous resuscitation efforts the decision was made to call medical control and request terminating effort; -Complete report given to doctor and permission was given to stop resuscitation. Review of Resident #352's annual MDS dated [DATE], showed: -Adequate hearing and vision; -Able to understand others; -Able to make self understood. During an interview on [DATE] at 6:30 A.M., Resident #352, Resident #351's roommate, said the resident was in pretty bad shape when he/she was placed in their room, and he/she just got worse. On the morning of [DATE] around 2:00 A.M., he/she was watching television and heard his/her roommate choking. He/She asked his/her roommate, if he/she was okay, but the other resident did not respond. Resident #352 looked around the curtain and saw the Resident #351 gasping for breath. Resident #352 put on his/her shoes and rushed to the nurse's station and told the person there, his/her roommate was very sick and needed to see a nurse immediately. The person at the desk said the nurse was in another room helping another resident and he/she could not leave the desk to go get him/her, but would let the nurse know as soon as he/she returned. The resident went back to his/her room and waited, but no one came. He/She put on his/her call light and no one responded. After about 15 minutes he/she pushed Resident #351's call light, but no one responded. He/She finally fell asleep, and when he/she woke up Resident #351 was asleep in his/her bed. Then at breakfast ([DATE]), he/she heard Resident #351 had died . During interviews on [DATE] at 12:48 P.M. and on [DATE] at 2:00 P.M., Certified Nurse's Aide (CNA) Y said he/she worked with the resident from 3:00 P.M. to 11:00 P.M. on [DATE]. The resident was on his/her light all evening long. He/She was feeling sick and irritated. The resident told him/her, his/her head and chest were hurting. The CNA said he/she told the nurse several times. He/She thought the nurse went in to see the resident, but then he/she would hit the light again. The CNA saw the resident for the last time around 10:30 P.M. and he/she said he/she was fine. He/She passed the information along to the oncoming CNA that the resident was not feeling well. Between 11:00 P.M. and 11:15 P.M., as he/she was getting ready to leave, the resident's roommate came to the desk and told him/her, the resident was throwing up. He/She told the roommate the night CNA was aware the resident was not feeling good and would be in to see him/her soon. The CNA did not tell anyone the resident's roommate said he/she was throwing up. During an interview on [DATE] a 11:10 A.M., Registered Nurse (RN) W said he/she worked from 4:00 P.M. to 11:00 P.M. on [DATE]. He/She did not know the resident because this was his/her first time working on the floor. He/She did not remember anyone telling him/her there was a problem with the resident, and he/she thought there was another nurse working with him/her who would have passed medication to the resident. He/She did not call the physician or document anything, because he/she did not know there was a problem. During an interview on [DATE] at 10:40 A.M., Certified Medication Technician (CMT) S said he/she relieved the 3:00 P.M. to 11:00 P.M. nurse, who did not tell him/her the resident was having any problems on [DATE]. The 3:00 P.M. to 11:00 P.M. CNA told him/her the resident had an upset stomach shortly after shift change, and he/she gave the resident some Tums (antacid for upset stomach). The resident's roommate complained about the resident's television being too loud and asked if he/she could turn it off, but the CMT told the resident he/she could not do that because the other resident had the right to watch television. He/She did not see the resident again until around 6:30 A.M., and he/she was sleeping. They did not have a nurse on duty on the fourth floor that night. He/She would have called a nurse up from the other floor if there had been any problems. He/She did not administer any pain medication for the resident that night and the roommate did not say anything else to him/her about the resident being ill. During an interview on [DATE] at 11:45 A.M., CNA X said he/she worked overnight on [DATE] (into [DATE]). When he/she came in, the CNA who was leaving told him/her Resident #351 complained of not feeling well. He/She did not get to the resident's room until around 11:30 P.M., because they were trying to figure out where everyone would be assigned. The resident was in bed and said he/she needed something for his/her stomach, because he/she was nauseous. He/She told the CMT who took the resident some Tums, and the CNA got him/her a Coke. The resident's roommate told him/her, Resident #351 was not feeling good. The next time the CNA saw the resident was around 3:00 A.M. The resident was in the bathroom. He/She checked to see if he/she needed help, because he/she was not supposed to be getting up by him/herself. The resident did not look good. He/She was all clammy (sweaty). The CNA helped the resident back to his/her chair beside the bed and said he/she did not look well. The resident said he/she was alright so the CNA did not report this to the CMT or a nurse. Around 4:30 A.M. to 5:00 A.M., he/she checked on the resident again and he/she was asleep in bed. The CNA checked on the resident again around 7:00 A.M., and he/she was still sleeping. Between 8:00 A.M. and 8:30 A.M., the CNA took the resident his/her breakfast and he/she was in the bathroom again. The CNA went to wheel the resident out to his/her room for breakfast and the resident told him/her, he/she did not feel good. By the time they got to the bedside table, the resident slumped over in his/her wheelchair and stopped talking. He/She thought the resident was having a stroke. He/She immediately went and got the nurse. The nurse came into the room and said they needed to take vitals. The CNA thought they should send the resident to the hospital because it looked like a stroke. When they took the vitals, they could not be read. The nurse went and got oxygen and put it on 2 liters. Another nurse came in the room and put the oxygen on 10 liters. Another CNA came and told him/her other residents had their call lights on, so the nurse told him/her to go take care of the other residents. The CNA told the nurse he/she thought they should call 911, and the nurse told him/her it was done. When he/she was in the room with another resident, he/she heard the nurse calling for everyone to help, and when he/she got back in the room, the nurse was performing CPR. During an interview on [DATE] at 1:20 P.M., RN B said when he/she came in the morning of [DATE], no one told him/her anything about Resident #351. There was not a nurse working on the resident's floor the night before, so he/she did not get a verbal shift change. He/She only had the 24 hour shift report and there was nothing noted about the resident on it. He/She was passing medications when CNA X came and got him/her and said Resident #351 did not look like he/she had before. When the nurse got to the room, the resident was seated in his/her wheelchair by the bed. He/She was not responding, only grunting and had a pulse. The nurse told the CNA they needed to get vitals, and he/she ran down the hall to get the vitals machine. As he/she was getting the machine, he/she saw the DON on the other hall and told her to call 911. The nurse went back to the room and took the resident's vitals but could not get a reading for the resident's blood pressure or pulse. The resident's oxygen saturation level was 80, so he/she believed the resident needed oxygen. He/She left the CNA in the room with the resident and went to find oxygen. He/She found the oxygen tank but could not locate the tubing to apply the oxygen, so he/she went down to the second floor to get supplies. He/She told the nurse down on the second floor there was a resident in distress and ran back up to the fourth floor. RN B applied the oxygen but could not get the oxygen saturation level to go higher than 80. Licensed Practical Nurse (LPN) R came into the room and the resident was starting to get weaker, so they got him/her out of the wheelchair and onto the ground and started doing CPR. The DON came in then and helped them perform CPR. The EMS personnel arrived shortly after and took over CPR. CNA X told RN B the resident was responding to him/her prior to him/her coming to get the nurse. During an interview on [DATE] at 9:50 A.M., LPN R said he/she was working on the second floor on [DATE] when RN B came down looking for oxygen supplies. He/She took the oxygen back up to the fourth floor and LPN R printed up the paperwork to send the resident to the hospital. When he/she got up to the fourth floor, the DON and another nurse were standing at the nurse's station. LPN R asked them if they needed to paperwork to give EMS and the DON told him/her they had not called 911. The DON thought RN B had called 911. LPN R went down to the resident's room to ask the nurse if he/she called 911. When he/she got to the room, the resident was up in his/her wheelchair and was breathing shallowly. RN B told LPN R, he/she had not called 911 because he/she told the DON to call. LPN R ran back to the nurse's station to tell the DON and nurse to call 911 and then went back to the resident's room to help. When he/she got back to the resident's room, the resident was unconscious. He/She told RN B they needed to get the resident out of the wheelchair, onto the floor and start CPR. They moved the resident onto the floor and then he/she ran to get the crash cart on the second floor. It took a few minutes to get back up to the fourth floor because the elevator stopped on each floor. When he/she got back to the room, the DON and RN B were performing CPR. EMS arrived shortly after to take over. He/She worked the night on [DATE] from 11:00 P.M. to 7:00 A.M. ([DATE]) and no one called down to report there were any problems with the resident. During interviews on [DATE] at 3:00 P.M. and on [DATE] at 11:30 A.M., the DON said she was passing medications on the other side of the 400 hall on [DATE] when RN B came over and said the resident was having trouble breathing and needed oxygen supplies. The RN did not tell him/her to call 911. The RN went down to the second floor to get the supplies. They usually keep oxygen supplies in the oxygen room or supply cabinet on each floor, so he/she did not know if they were out of supplies or the RN did not know where to locate them. The DON would have stayed with the resident and sent the CNA out to get the supplies. Staff should have called 911 immediately. She thought the RN had already called 911. When she got to the resident's room, RN B was performing CPR and they worked together to continue CPR until the EMS arrived. She did not know the resident complained of head and chest pain to the staff the night before. No one told her the resident did not look good during the night. This should have been documented. Staff should have notified the resident's physician and/or sent the resident to the hospital with these symptoms. He/She did not know the roommate alleged he/she tried to get help for the resident the night before and no one came to assess him/her. During an interview on [DATE] at 11:50 A.M., the Administrator said if the staff observed the resident not looking good and he/she complained of head and chest pain, the staff should have notified the nurse on duty to assess him/her. If the resident's roommate notified staff the resident needed help, they should have responded immediately. The staff should have notified the physician about these observations and complaints. All of this should have been documented. During an interview on [DATE] at 1:50 P.M., the nurse practitioner said he did not receive any calls at the office on [DATE] from the facility, and they have a 24 hour line that is always available. The facility staff told him the resident was found unresponsive and they performed CPR. No one told him the resident complained of head pain, chest pain or nausea the night before. If they would have told him, he would have told the staff to send the resident to the hospital because he was an extremely high risk for a Myocardial Infarction (MI, medical term for a heart attack) or a stroke. During an interview on [DATE] at 3:15 P.M., the resident's physician said no one called her office about the resident on [DATE]. If the resident was having head and chest pain, nauseous and sweaty, they definitely should have called, as these could be signs of a heart attack. The resident was at a higher risk for this with his/her diagnoses. Someone should have called when he/she first started having these symptoms. She would have had him/her immediately sent to the hospital. The hospital could have provided a higher level of care. She signed the death certificate, and stated the cause of death was acute coronary syndrome because she did not know all of this happened. She was just told the resident was found unresponsive and the facility performed CPR, and he/she died . It is possible if the resident went to the hospital and provided interventions, the outcome might have been different. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the D level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00247802 MO00247822

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when staff failed to assess one resident in a timely manner, prior to moving the resident, after he/she fell and sustained a fractured hip (Resident #4). The facility also failed to immediately provide care to one resident after spilling a cup of hot coffee in his/her lap and to contact the resident's physician and/or nurse practitioner after the resident was burned (Resident #2). The sample was six. The census was 128. Review of the facility's Condition Changes, Incidents, Injuries-Reporting of Policy dated 3/2019, showed the following: -Purpose: To provide an orderly process for reporting changes in condition, incident or injuries involving residents; -It will be the responsibility of the licensed nurses to know and follow this policy; -It is the facility's policy to report condition changes, incidents or injuries involving residents; -Practice: -When reporting changes in condition or incidents, the following procedure should be followed: 1. Evaluate symptoms and/or injury. Complete overall head to toe assessment including taking vital signs, temperature and neurochecks as indicated; 2. All change of condition must be reported to the doctor, supervisor and family; 3. Serious incidents are reported to the physician at the time of occurrence. Per individual physician's order, any non-emergent issues may be reported to the physician at a later time, such as the next business day, if so specified within their order; 4. The Director of Nursing is to be promptly notified of any fractures, including fractures of unknown origin or other serious injury; -Documentation: * If an incident occurred, chart the incident in the resident's medical record; * Document objective details of incident and nursing interventions/corrective measures taken; * All charting should include notification of doctor and resident representative/appropriate family member. 1. Review of Resident #4's change in condition Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/5/22, showed: -admitted on [DATE]; -Adequate vision and hearing; -Resident understood by others and understands others; -Moderately cognitively impaired; -No mood issues; -No behavior exhibited; -No rejection of care exhibited; -Diagnoses included Parkinson's disease (central nervous system disorder), Lewy body dementia (a brain disorder that can lead to problems with thinking, movement, behavior and mood), history of right side stroke and age-related osteoporosis (condition that leads to loss of bone mass) with current pathological fracture of vertebra (series of small bones forming the backbone). Review of the resident's progress notes, dated 9/16/22 at 11:25 P.M., showed the resident noted to have a fall with right hip injury with fracture per x-ray results. Staff notified nurse practitioner with resident's physician's office who sent orders to send the resident to the hospital for further evaluation. The resident's family member was at his/her bedside. EMS arrived at the facility at 9:30 P.M. to transport the resident to the emergency room . The evening supervisor was notified at the time of the fall. During an interview on 10/7/22 at 3:00 P.M., Certified Nurse's Aide (CNA) L said he/she found the resident on the floor on 9/16/22. He/she knew the resident was in pain because he/she was moaning. It happened at 4:23 P.M., because he/she remembered looking at his/her watch. He/she told the resident he/she would be right back and went and told Nurse M the resident had fallen and was in pain. The nurse said he/she would be there to assess him/her soon. The CNA went back to the room to tell the resident the nurse would be coming to assess him/her. He/she waited for a while and then CNA K came in the room and told him/her the nurse told him/her to get the resident up off the floor. CNA L did not think this was right because staff were supposed to assess a resident after a fall before getting them up. They picked the resident up and put him/her in the wheelchair. He/she moaned out loud in pain when they lifted him/her up. CNA L covered him/her up with a sheet and they left the room. When he/she walked by the room a few minutes later, he/she noticed the resident's family member in the room. The family member asked what happened to the resident and he/she told him/her, the resident had just fallen out of his/her wheelchair and they were waiting for the nurse to come assess him/her. This was around 4:35 P.M. CNA L went out and looked for Nurse M and saw him/her passing medication on the hall. The family member was getting frustrated about the resident not being assessed and went to the desk to ask another nurse to come assess him/her. Nurse E came to the room and assessed the resident and said he/she was going to call the physician for an x-ray. During an interview on 10/7/22 at 8:00 P.M., Nurse M said on 9/16/22, he/she immediately went in and assessed the resident, and he/she said the resident was not in pain. (Note: This statement is not consistent with statements made by other staff on-duty.) The nurse, CNA L and CNA K assisted the resident off the floor and put him/her in his/her wheelchair. Nurse M was busy passing medications and forgot to document the fall. Since the resident was not complaining of pain, he/she did not think the resident was hurt until he/she heard the staff talking about it later. Nurse M did tell Nurse E the resident had fallen. He/she heard Nurse E call the physician and obtain an order for the x-ray. They were very busy that evening. They were short staffed. Nurse M was having to pass medications. During an interview on 10/10/22 at 3:00 P.M., CNA K said on 9/16/22, he/she assisted CNA L and Nurse M get the resident off the floor and into the wheelchair. Nurse M assessed the resident and he/she did not complain of pain at that time. During an interview on 10/11/22 at 1:00 P.M., Nurse N said on 9/16/22, he/she was working another hall on the same floor and CNA L told him/her a nurse directed him/her and CNA H to get the resident off the floor and put him/her in his/her wheelchair without being assessed. During an interview on 10/6/22 at 3:30 P.M., the resident's family member said he/she arrived at the facility a little after 4:30 P.M. on 9/16/22. When he/she arrived to the resident's room, the resident was in the wheelchair covered by a sheet and only wearing his/her shirt and shoes. The family member asked the resident if he/she was in pain, and he/she said Yes. CNA L walked in and told him/her the resident had fallen, and the nurse was supposed to be coming to assess him/her. The family member waited about 15-20 minutes and no one came. The family member was concerned because the resident said he/she was in pain; so he/she went out to the desk to find someone to come in and assess the resident. He/she found Nurse E at the desk and told him/her about the resident, and he/she came in to assess him/her. During an interview on 10/6/22 at 3:15 P.M., Nurse E said no one told him/her the resident fell prior to the resident's family member coming out of the resident's room around 4:50 P.M. on 9/16/22. He/she was assigned to work the desk that day because he/she was leaving at 7:00 P.M. The family member came to the desk and asked him/her to assess the resident because he/she was in pain. When he/she walked in the room, the resident was already in the wheelchair. He/she did not know who put him/her in the chair or if he/she had been assessed prior to being put in the chair. The resident kept saying his/her leg hurt, but he/she did not rate the pain. The nurse said he/she was going to call the physician to get an x-ray, but they would put him/her in bed first to make him/her more comfortable. The nurse, CNA L, CNA K and another staff member lifted the resident out of the wheelchair and put him/her in his/her bed. Then the nurse went out to call the physician. Review of the post fall evaluation completed on 10/6/22 (the date of the investigation), showed the following: -The unwitnessed fall occurred on 9/16/22 at 5:00 P.M.; -The resident fell from his/her wheelchair; -Pain present: Yes, actual or suspected pain; -Self Report Pain: Numeric rating scale: No documentation of rating of pain; -Post Fall Injury: Injury type: Suspected fracture; -Post Fall Notification: Attending notified 9/16/22 at 5:00 P.M.; -Name of Attending Notified: Resident's physician's name; -Team Meeting Notes: This nurse assessed resident at this time. Resident complained of pain to hip area. When asked what happened, resident stated in the presence of family member, he/she was trying to transfer self out of wheelchair into bed. Physician notified of possible fracture. New orders given for x-ray to area; -The report was completed by Nurse E. During an interview on 10/11/22 at 1:30 P.M., the Director of Nursing said she believed Nurse M did not immediately go down and assess the resident. Nurse M did not complete any assessment documentation or the post fall evaluation. 2. Review of Mayo Clinic's basic first aid for treating minor burns showed the following guidelines: -Cool the burn. Hold the area under cool (not cold) running water for about 10 minutes. -Remove rings or other tight items from the burned area. Try to do this quickly and gently, before the area swells. -Don't break blisters. Blisters help protect against infection. If a blister does break, gently clean the area with water and apply an antibiotic ointment. -Apply lotion. After the burn is cooled, apply a lotion, such as one with aloe vera or cocoa butter. This helps prevent drying and provides relief. -Bandage the burn. Cover the burn with a clean bandage. Wrap it loosely to avoid putting pressure on burned skin. Bandaging keeps air off the area, reduces pain and protects blistered skin. -If needed, take a nonprescription pain reliever, such as ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) or acetaminophen (Tylenol, others). Review of Resident #2's MDS, a federally mandated assessment instrument completed by facility staff, dated 9/9/22, showed the following: -Diagnoses included macular degeneration (an eye disease that can blur your central vision), history of stroke and other symptoms and signs involving cognitive functions and awareness. Review of the resident's care plan dated 9/9/22, showed the following: -Activities of daily living: Requires assist of one for all; -At risk for falling due to poor vision; -Likes to be out of bed and in dining room for all meals and needs food cut up for him/her and in separate bowls; -Family prefers he/she come out to dining room for all meals. He/she is never to eat alone in room; -Needs assistance with set up and cutting up foods; -Resident has severely diminished eyesight; -No documentation of history or risk of burning self with hot coffee at meals or interventions in place to prevent in future. During an interview on 10/6/22 at 10:30 A.M., the resident's family member said he/she was concerned for the resident because on 9/14/22 around 11:30 A.M., he/she spilled a cup of hot coffee in his/her lap and the staff were very slow to respond. The resident cannot see very well and the cup of coffee was very hot. When the family member arrived at the facility shortly after the incident, the staff were not even standing near the resident. Certified medication technician (CMT) O told the family member the resident had spilled some coffee on him/herself, but the CMT had used a towel to clean it up. He/she kind of laughed about it and said, You should have heard (him/her) yell. This concerned the family member and he/she wanted the resident assessed. He/she asked the CMT to come to the bathroom with them and look at the resident's legs. The liquid was cool by then. A nurse heard them talking about the incident and also came to the room. When they removed the pants, there was a red mark on the resident's legs. The family member thought they should at least put a cool cloth on the burn when it happened but they acted like it was not even burned. A few days later, the burn blistered up and the resident had to be referred to the wound nurse. During an interview on 10/6/22 at 10:40 A.M., the resident said it really hurt when he/she spilled the coffee on him/herself. His/her vision is not so good and he/she did not realize the cup was so close to the end of the table. Review of the resident's medical record, showed: -The 9/2022 electronic medication record (eMAR), showed no medication administered for the burn on 9/14/22; -The facility provided no documentation of a treatment administered on the electronic treatment administration record (eTAR). Review of the resident's progress notes, showed the following: -No documentation on 9/14/22, of the incident or of notification to the resident's physician about the incident; -On 9/19/22 at 6:39 A.M., the staff reported a new skin issue and the nurse examined the resident. He/she had redness and a blister on the inner aspect of the right thigh. He/she said he/she spilled coffee on him/herself yesterday; -On 9/20/22 at 12:38 P.M., the resident's family member made the nurse aware he/she had spilled coffee on him/herself during lunch and what he/she believed to be a burn on his/her thigh. Upon assessment, the nurse observed a red mark on the resident's inner thigh. The resident stated he/she had pain in the reddened area. There was no bruising or blistering to the area on assessment, area was covered and monitored; -On 10/4/22 at 10:41 A.M., the resident's burn to the right inner thigh healing well, no drainage, no warmth, wound bed is pink in color. Treatment completed. Wound doctor was there that day. Review of the resident's wound reports provided by the facility on 10/13/22, showed the following: -On 9/22 - 9/28: Location of wound: Right thigh. Type of wound: Burn. Origin date: 9/21/22. Initial measurement: 2 x 5 x 1. Comments: Coffee spill. -On 9/29/22 -10/5/22: Current measurements: 1.1 x 1.8. Review of an undated written statement by CMT O, provided by the facility on 10/13/22, showed he/she heard the resident yell loud. He/she went over to assist him/her. That is when he/she realized the resident had spilled his/her coffee. CMT O then proceeded to get a towel and wipe the resident off. He/she continued to eat his/her banana. Right after that the resident's family member walked in and he/she explained to him her that the resident had not been incontinent; he/she had just spilled his/her coffee. The family member said okay, and he/she was going to take the resident to the bathroom and asked the nurse to come with him/her. The nurse had just walked up while CMT O was explaining what happened, and they went to the room. During an interview on 10/11/22 at 11:05 A.M., CMT O said he/she was working the day the resident was burned. He/she heard the resident yell out he/she had spilled his/her coffee and CMT O saw it dripping. He/she immediately went over and got a towel and patted the resident dry. Then he/she went over to assist another resident. The coffee was usually not scorching hot. The resident needs set up assistance with meals. His/her family member arrived immediately after it happened and wanted to take him/her back to his/her room, and then the nurse went in to assess him/her and the CMT left the area. Review of an undated written statement from Nurse H, provided by the facility on 10/13/22, showed on the date in question, he/she walked to the desk and heard the CMT explaining to the family member that the resident had spilled coffee on him/herself. The family member said he/she was taking the resident to the restroom and asked if the nurse could assess the resident. The nurse followed the resident to his/her room. The resident's thigh was a light pink/red color. He/she was not complaining of pain upon assessment. He/she shared his/her findings with the family member and explained it was possible the heat from his/her pants was the cause of the redness and that he/she would monitor and reassess it at the end of his/her shift. The family member said he/she would apply Vaseline to the area. The nurse added the issue to the 24 hour report so the next shift could monitor. Review of the 24 hour report dated 9/14/22, provided by the facility on 10/13/22, showed the resident spilled coffee on his/her right thigh. There was a thin red line of redness. Applied aquaphor (skin protestant ointment). No blistering. During an interview on 10/13/22 at 1:10 P.M., Nurse H said as he/she was coming back to the desk that day, he/she heard the resident's family member and CMT O talking about the resident having spilled coffee on him/herself. They were taking him/her to the resident's room and asked if he/she could come assess him/her. When they removed the resident's pants, there was a small area inside the thigh which was a light reddish pink color which could have been from the heat. He/she did not notify the physician or document it in the resident's progress notes because he/she was so slammed. He/she did put it in the 24 hour report sheet. He/she did not get back to assess the resident because he/she got so busy. When someone spills hot liquid on their clothing, staff should remove it immediately because the clothing can continue to burn them. They should put a cool compress on the burn. He/she should have notified the physician. Usually the coffee is not that hot. He/she did not realize the resident was actually burned. The resident did not complain of pain. He/she complained of pain a few days later and then Nurse H saw the blisters. During an interview on 10/13/22 at 1:15 P.M., Nurse P said he/she worked the night shift on 9/19/22 and the staff notified him/her about the blisters on the resident's legs when they were changing him/her. When he/she assessed the resident, he/she had redness and blisters on the inside of his/her right thigh. The resident told him/her, he/she had spilled coffee on him/herself the prior day. Nurse P did not know the injury occurred five days prior. He/she did not call the resident's physician because it was at the end of his/her shift, and he/she let the morning nurse know. That was his/her mistake. If a resident spills a hot liquid on themselves, staff should immediately remove the clothing because the heat from the clothing could still burn them. Then you would put something cool on the burn. You would immediately notify the resident's physician and emergency contact. During an interview with the resident's physician on 10/6/22 at 12:30 P.M., she said she was not aware the resident burned him/herself until he/she saw him/her on 9/21/22. No one from the facility called to let him/her know he/she had spilled hot coffee on him/herself. If someone spills a hot liquid on themselves, staff should remove the clothing immediately. Someone should have notified her about the burn. During an interview on 10/11/22 at 1:30 P.M., the Director of Nursing said she would have expected staff to have immediately removed the pants to prevent further burning. She would have expected staff to contact the physician and to document this. It was documented in the 24 hour report but also needed to be in resident's medical record. During an interview with the administrator on 10/17/22 at 11:00 A.M., he said he would have expected staff to change the resident out of the clothing if he/she had spilled hot coffee on them. He would have expected staff to have contacted the resident's physician if he/she sustained a burn or if they noticed an injury and would have expected them to immediately document this in the resident's medical record. MO00207384

Based on interview and record review, the facility failed to ensure one resident (Resident #4) received adequate pain management (pharmacological and/or non-pharmacological) after he/she fell and fractured his/her hip. Staff failed to complete a thorough, documented pain assessment after the resident's fall. Staff failed to administer pain medication or inform the physician of the resident's continued pain during the four and a half to five hours between the fall and emergency medical services (EMS) arrival. The sample was six. The census was 128. Review of the facility's Pain Management Policy and Procedure dated 11/2013, showed: -Purpose: To provide patients receiving care, treatment and/or services from Agency with effective pain assessment and management process thereby promoting positive patient outcomes; -To Provide that a comprehensive pain management assessment is conducted as appropriate to the patient's condition and the scope of care, treatment and/or services provided by Agency; -To uphold the patient's right to appropriate assessment and optimal management of pain; -To uphold the patient's right to receive information about and, when appropriate, to be involved in the decision-making process about his/her care, treatment and/or services; -Responsibility: It is the responsibility of the Director of Home Health to understand and enforce this policy. It is the responsibility of all employees of the Agency to abide by this policy; -Policy: 1. Agency plans, supports and coordinates activities and resources to assure that the patient's pain is recognized and addressed appropriately; 2. The single most reliable indicator of the existence and intensity of pain is the patient's self-report; 3. All patients served by Agency have the right to an effective pain management plan based on clinical status, needs, cultural, religious and ethnic preferences, age and physical and cognitive abilities; 4. Agency believes that effective pain management is a physical, psychological and social process that should be managed collaboratively and proactively by the patient, family, professional staff, physician, social worker and spiritual coordinator; 5. Pain management may be achieved through the use of drug and/or complementary modalities; 6. Agency staff including contracted personnel are instructed in pain and pain management strategies during orientation, at least annually and more often if necessary; -Procedure: The Registered Nurse or Licensed Therapist performs a comprehensive pain assessment and reassessment; -The assessment and measure of pain intensity and quality, i.e., pain character, frequency, location and duration, should be appropriate to the patient's age; -Elements addressed in a comprehensive pain assessment include, but are not limited to: *Description, nature, duration, variations and intensity of pain using an Agency-approved pain intensity rating scale appropriate to the patient's age, cognitive and learning abilities; *Location of pain and radiation, if any; *Circumstances of the onset of pain; *Aggravating/alleviating factors; -Patient's and family's pain management goals: *The registered nurse/therapist: Formulates, implements and updates the pain management plan of care based on the assessment findings; *Assesses the patient's pain and evaluates his/her response to pain management interventions using a standard pain management tool based on the patient's self-report during each visit; -Pain control mechanisms include, but are not limited to: *Medications administered for the control of pain and symptom control; *Medications administered for the control or relief of anxiety; -Document pain assessment, interventions and evaluation activities in the medical record. Review of Resident #4's change in condition Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/5/22, showed: -admitted on [DATE]; -Adequate vision and hearing; -Resident understood by others and understands others; -Moderately cognitively impaired; -No mood issues; -No behavior exhibited; -No rejection of care exhibited; -Diagnoses included Parkinson's disease (central nervous system disorder), Lewy body dementia (a brain disorder that can lead to problems with thinking, movement, behavior and mood), history of right side stroke and age-related osteoporosis (condition that leads to loss of bone mass) with current pathological fracture of vertebra (series of small bones forming the backbone). Review of the resident's SBAR (Situation-Background-Assessment-Recommendation Communication Tool) dated 9/16/22 at 5:56 P.M., showed the following: -Appearance and evaluation findings: Resident was trying to put self to bed when fell out of wheelchair. Resident complained of right hip pain. Physician on call notified. New orders to obtain x-ray of right hip. X-ray company notified of new order; -Date/Time attending notified: 9/16/22 at 5:56 P.M.; -Physician response to findings: X-ray orders Review of the resident's progress notes, dated 9/16/22 at 11:25 P.M., showed the resident noted to have a fall with right hip injury with fracture per x-ray results. Staff notified nurse practitioner with resident's physician's office who sent orders to send the resident to the hospital for further evaluation. The resident's family member was at his/her bedside. EMS arrived at the facility at 9:30 P.M. to transport the resident to the emergency room . The evening supervisor was notified at the time of the fall. During an interview on 10/7/22 at 1:45 P.M., the resident said he/she tripped and fell and hurt his/her hip. It was very scary. It hurt a lot. It was dark by the time he/she got to the hospital. He/she did not remember getting any medication for the pain at the facility. His/her hip still hurt. During an interview on 10/7/22 at 3:00 P.M., Certified Nurse's Aide (CNA) L said he/she found the resident on the floor on 9/16/22. He/she knew the resident was in pain because he/she was moaning. It happened at 4:23 P.M., because he/she remembered looking at his/her watch. He/she told the resident he/she would be right back and went and told Nurse M the resident had fallen and was in pain. The nurse said he/she would be there to assess him/her soon. The CNA went back to the room to tell the resident the nurse would be coming to assess him/her. He/she waited for a while and then CNA K came in the room and told him/her the nurse told him/her to get the resident up off the floor. CNA L did not think this was right because staff were supposed to assess a resident after a fall before getting them up. They picked the resident up and put him/her in the wheelchair. He/she moaned out loud in pain when they lifted him/her up. CNA L covered him/her up with a sheet and they left the room. When he/she walked by the room a few minutes later, he/she noticed the resident's family member in the room. The family member asked what happened to the resident and he/she told him/her, the resident had just fallen out of his/her wheelchair and they were waiting for the nurse to come assess him/her. This was around 4:35 P.M. CNA L went out and looked for Nurse M and saw him/her passing medication on the hall. The family member was getting frustrated about the resident not being assessed and went to the desk to ask another nurse to come assess him/her. Nurse E came to the room and assessed the resident and said he/she was going to call the physician for an x-ray. After the nurse assessed the resident, CNA L, CNA K, Nurse E and another staff member assisted the resident out of the wheelchair and put him/her into his/her bed. The resident cried out in pain when they moved him/her. CNA L did not think they gave the resident anything but Tylenol (pain reliever) all evening and he/she kept moaning out in pain. The family member was getting upset because it was taking so long. It took five hours for an ambulance to come. During an interview on 10/7/22 at 8:00 P.M., Nurse M said on 9/16/22, he/she immediately went in and assessed the resident, and he/she said the resident was not in pain. The nurse, CNA L and CNA K assisted the resident off the floor and put him/her in his/her wheelchair. Nurse M was busy passing medications and forgot to document the fall. Since the resident was not complaining of pain, he/she did not think the resident was hurt until he/she heard the staff talking about it later. Nurse M did tell Nurse E the resident had fallen. He/she heard Nurse E call the physician and obtain an order for the x-ray. They were very busy that evening. They were short staffed. Nurse M was having to pass medications. He/she did not give the resident any pain medication because he/she did not complain of pain. Once the x-ray came back and he/she realized the hip was broken, he/she called the physician back to get an order to send the resident to the hospital but did not request any medication for pain. Nurse M did not know the resident was in pain and he/she thought the resident would be going to the hospital soon. Then he/she called the ambulance company. With all of this going on, there was no time to call the physician back to ask for a stronger pain medication. (Note: This statement is not consistent with statements made by other staff on-duty and facility documentation.) During an interview on 10/10/22 at 3:00 P.M., CNA K said on 9/16/22, he/she assisted CNA L and Nurse M get the resident off the floor and into the wheelchair. Nurse M assessed the resident and he/she did not complain of pain at that time. He/she did not complain of pain when he/she helped the other staff move him/her from the wheelchair to the bed. During an interview on 10/11/22 at 1:00 P.M., Nurse N said on 9/16/22, he/she was working another hall on the same floor and CNA L told him/her a nurse directed him/her and CNA H to get the resident off the floor and put him/her in his/her wheelchair without being assessed. No one asked Nurse N to administer any pain medication to the resident. When he/she saw the x-ray and knew the resident's hip was fractured, he/she talked to the nurse who told him/her, he/she had called 911. They teach you to call 911 in an emergency. During an interview on 10/6/22 at 3:30 P.M., the resident's family member said he/she arrived at the facility a little after 4:30 P.M. on 9/16/22. When he/she arrived to the resident's room, the resident was in the wheelchair covered by a sheet and only wearing his/her shirt and shoes. The family member asked the resident if he/she was in pain, and he/she said Yes. CNA L walked in and told him/her the resident had fallen, and the nurse was supposed to be coming to assess him/her. The family member waited about 15-20 minutes and no one came. The family member was concerned because the resident said he/she was in pain; so he/she went out to the desk to find someone to come in and assess the resident. He/she found Nurse E at the desk and told him/her about the resident, and he/she came in to assess him/her. The nurse told the family member he/she was going to call the physician and order an x-ray, and they put the resident into his/her bed. It took a long time for the x-ray company to come out and take the x-ray and then to get the resident to the hospital. The resident was in pain the whole time. The family member stayed at the facility with the resident until he/she left for the hospital. The resident was in the hospital for 12 days and had to have surgery for the hip, which was broken in three places. During an interview on 10/6/22 at 3:15 P.M., Nurse E said no one told him/her the resident fell prior to the resident's family member coming out of the resident's room around 4:50 P.M. on 9/16/22. He/she was assigned to work the desk that day because he/she was leaving at 7:00 P.M. The family member came to the desk and asked him/her to assess the resident because he/she was in pain. When he/she walked in the room, the resident was already in the wheelchair. He/she did not know who put him/her in the chair or if he/she had been assessed prior to being put in the chair. The resident kept saying his/her leg hurt, but he/she did not rate the pain. The nurse said he/she was going to call the physician to get an x-ray, but they would put him/her in bed first to make him/her more comfortable. The nurse, CNA L, CNA K and another staff member lifted the resident out of the wheelchair and put him/her in his/her bed. Then the nurse went out to call the physician. The resident's physician was not on duty; so he/she talked to someone whose name he/she could not remember who ordered an x-ray. This was around 5:00 P.M. He/she did not go back in the resident's room. He/she did not administer any pain medication. The x-ray company arrived about an hour later but the results were not back by the time he/she left at 7:00 P.M. Review of the post fall evaluation completed on 10/6/22, showed the following: -The unwitnessed fall occurred on 9/16/22 at 5:00 P.M.; -The resident fell from his/her wheelchair; -Pain present: Yes, actual or suspected pain; -Self Report Pain: Numeric rating scale: No documentation of rating of pain; -Post Fall Injury: Injury type: Suspected fracture; -Post Fall Notification: Attending notified 9/16/22 at 5:00 P.M.; -Name of Attending Notified: Resident's physician's name; -Team Meeting Notes: This nurse assessed resident at this time. Resident complained of pain to hip area. When asked what happened, resident stated in the presence of family member, he/she was trying to transfer self out of wheelchair into bed. Physician notified of possible fracture. New orders given for x-ray to area. Review of the resident's 9/2022, electronic medication administration record, showed the following: -On 9/16/22 at 8:00 A.M., staff administered aspirin (blood thinner, pain reliever) 81 milligrams; -No documentation of anything administered for pain after the fall. Review of the EMS report dated 9/16/22, showed the following: -The company was called at 7:55 P.M.; -They arrived at the facility at 9:30 P.M.; -Staff reported the resident fell out of his/her wheelchair at approximately 4:00 P.M.; -At 10:01 P.M., the resident's blood pressure was 206/100 (normal is 120/80) and his/her pain level was 5 out of 10; -At 10:16 P.M., the resident arrived at the hospital. Review of the resident's hospital records dated 9/16/22, showed the following: -The resident arrived via EMS for a diagnosis of hip fracture; -He/she reported a 7 out of 10 pain level; -He/she fell out of his/her wheelchair around 4:20 P.M.; -Right hip x-ray showed fracture; -Acute leg pain, right; -Closed fracture of right hip. During an interview on 10/11/22 at 1:30 P.M., the Director of Nursing said she believed Nurse M did not immediately go down and assess the resident. She thought the resident might have gotten some Tylenol or Tramadol (pain reliever) for pain but could not find any documentation to support this. If the staff suspected the resident had a fracture, staff could have called 911 and sent the resident out immediately. During an interview on 10/11/22 at 12:30 P.M., the resident's physician said she was out of town the day the staff called her office. Her notes said the nurse called because the resident fell and had pain and they wanted an x-ray. The nurse practitioner gave an order for an x-ray. The next call was about the x-ray showing a hip fracture and wanting an order to send the resident to the hospital. There were no notes about the resident having continued pain. If the resident continued to have pain, staff should have notified them and they could have ordered medication for it. During an interview on 10/17/22 at 11:00 A.M., the administrator said if the resident was in pain then staff should have administered pain medication or notified the physician if stronger pain medication was needed. MO00207384 .

See deficiency cited in Event ID IU0113. Based on interview and record review, the facility failed to keep one resident (Resident #18) free from physical abuse, when one agency staff member, Certified Nursing Assistant (CNA) E, slapped the resident on the mouth with the back of his/her hand. The resident informed his/her family member, that was outside the room, when the incident occurred. The resident had a swollen lip that later became bruised. The census was 119. The administrator was notified on 5/27/22 at 2:00 P.M. of an immediate jeopardy (IJ) which began on 5/1/22. The IJ was removed on 5/27/22, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect Policy, revised 8/2019, showed: -Every resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Resident's must not be subject to abuse by anyone, including, but not limited to residence, staff, other residents, consultants or volunteers, other agencies serving the individual, family members or legal guardians, friends or other individuals; -Any employee who receives an allegation or suspects that there is a situation of abuse, neglect, or exploitation of a resident including a potential or actual criminal action shall immediately disrupt all perceived or observed abusive situations and immediately report such to the Administrator; -Upon receiving any allegation of abuse, the alleged perpetrator will be suspended/removed immediately from the residence, pending the investigation; -The Administrator will direct staff to complete an incident report and initiate investigation process. Review of Resident #18's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/22, showed: -Moderate cognitive impairment; -Total dependence with transfers, extensive assistance with bed mobility, dressing, toileting and personal hygiene; -Diagnoses included: Diabetes, high blood pressure and depression. Review of the resident's care plan, in use at the time of the investigation, showed: -Goal: Mood to be stable; -Problem: Risk of altered mood due to diagnoses of depression and some memory loss; -Approach: Take medications as prescribed, monitor for any noted episodes of tearfulness, anger, or becoming more reclusive. Notify the nurse and social worker if resident's mood changes or if resident's willingness to interact changes. Review of the resident's progress notes, showed: -On 5/1/22 at 3:00 P.M., the charge nurse came to Nurse Manager H and said the resident's family member wanted to talk to the manager. The family member was approached and was visibly upset. The family member said he/she went to the resident's room to visit and the door was closed. He/she opened the door and saw CNA E was in the room. The family member told the CNA he/she would step out while he/she was providing care to the resident. The family member went in the room right after CNA E exited the resident's room. The family member said the resident told him/her that racial slur slapped me with the back of his/her hand. Nurse Manager H went to question the resident and the resident said CNA E slapped him/her with the back of his/her hand. The resident said it may have happened because of his/her smart mouth. The resident had swelling noted to the right side of his/her lip; -On 5/1/22 at 9:00 P.M., the resident's right lower lip has a dark red area that is swollen and sore. There is no other injury noted. Nurse Manager H and physician notified. The staff will monitor the resident; -On 5/2/22 at 2:39 A.M., the resident is alert and greeted the nurse. The resident said he/she is comfortable. The resident has a notable bruise to right side of his/her upper lip. The resident denies pain; -On 5/2/22 at 3:41 P.M., the resident remains on follow up for resident to staff altercation. The resident has some swelling to right side of his/her lip with some bruising. The resident denies pain; -On 5/3/22 at 11:20 A.M., the resident remains on follow up for bruising and swelling to right lip and cheek. The resident denies pain. Review of the facility's self-report, dated 5/1/22, showed the following: -At approximately 3:00 P.M., the resident's family member came to Nurse Manager H to inform that the resident told his/her family member that CNA E came into the resident's room and slapped the resident across the face. Nurse Manager H went to investigate and found the resident had swelling on the right side of his/her lip. The family member said the resident may have been smarting off to the aide. CNA E said he/she did not slap the resident. The facility sent CNA E home and told him/her to not come back until the investigation is complete. The resident is fine expect for the lip which is a little swollen; -On 5/1/22 CNA E's written statement showed, he/she went to do his/her last rounds on Resident #18. As he/she was finishing up with the resident's care, a family member knocked on the resident's door. The family member asked if care was being performed and said he/she would wait outside the door. CNA E finished with care and handed the resident his/her soda and left the room. The family member asked what was wrong with the resident. The family member then said the resident's mouth was busted. CNA E went back to room to look at the resident and said he/she saw nothing on the resident's mouth that looked busted; -On 5/1/22, Nurse B's written statement, showed the resident's family member came up to the nurses station and asked who was the nurse for the resident. Nurse B said he/she was the nurse and the family member requested to talk in private. The family member said a CNA went in to change the resident while he/she was in the hallway, waiting. The staff member came out of the room. When the family member went into the room, the resident stated the staff member hit him/her on the lip. Nurse B told the family member he/she needed to talk to the supervisor, Nurse Manager H. As the family member told Nurse Manager H what happened, the nurse manager told Nurse B to tell CNA E to go to the lobby. Nurse B asked CNA E to go to the lobby and Nurse Manager H would be there to talk to him/her. Nurse B and Nurse Manager H went to the resident's room and talked to the resident and did a body check on the resident. The resident's right upper lip was swollen; -On 5/2/22 at 8:30 A.M., the administrator said CNA E was an agency staff member. Once the family member notified the nurse of the incident, the nurse removed the CNA from the floor, and had the CNA write a statement. The CNA was sent home pending investigation. CNA E denied he/she hit the resident. The resident was assessed after the incident and had a red mark on the right side of his/her face. This morning the resident has some bruising to the right upper lip. The resident is alert and consistent with his/her story. CNA E was placed on do not return list for all company homes; -On 5/2/22, the Director of Nursing (DON) said Nurse Supervisor H was contacted at 2:30 P.M. on Sunday May 1, 2022 that Resident #18 had reported to his/her family member, who was visiting, that CNA E had slapped him/her making contact with his/her lip. The family member sought out the charge nurse to report the alleged incident. Nurse Supervisor H instructed the nurse to have CNA E leave the unit immediately. He/she then went to investigate the incident and afterwards the CNA went home pending further investigation. The administrator and DON went together to assess and speak to the resident regarding the reported incident. The resident had a bruise to his/her right upper lip. The resident was able to say the CNA had made contact with the back of his/her hand to the resident's lip on Sunday. The resident was alert and cognitively intact at the time of the interview. The resident's statement and clinical assessment, along with nursing documentation led to the conclusion that the complaint of conduct is justified. Family was present at the time of the incident. The physician was notified and came in on Monday to assess the resident. The police department was notified by the administrator of the incident. During a phone interview on 5/26/22 at 4:10 P.M., CNA E said at the time of the incident, he/she was doing the last shift rounds and checking everyone. He/she performed care on the resident's roommate then started care on Resident #18. CNA E said the resident is normally mean and yells at him/her. He/she said on this day, the resident was actually really nice and didn't say one mean thing to the CNA. While he/she was performing care, the family member knocked on the door. After care, he/she grabbed the trash and walked out of the room. The family member came up to him/her and asked, What happened? The family member said the resident told him/her that CNA E put their hands on the resident. CNA E said no and that he/she had been doing this for [AGE] years. CNA E then got a call from the nurse to write a statement. CNA E said he/she did not hit the resident. During an interview on 5/26/22 at 4:22 P.M., Nurse B said the resident's family member came out of his/her room and said he/she needed to speak in private. Once in private, the family member said the resident told him/her that CNA E hit the resident in the lip. Nurse B called the supervisor, Nurse Manager H. Nurse B said he/she then went to assess the resident. He/she said the resident's top lip was swollen on the right side. The resident said he/she was backhanded by CNA E, because he/she probably said something mean. Nurse B told the resident that staff still should not hit residents. During an interview on 5/26/22 at 5:10 P.M., the family member said the resident's door was closed so he/she knocked and the CNA said he/she was providing care to the resident. The family member waited in the hall and said after a few minutes the CNA came out of the room with the resident's roommate. The family member said he/she then went into the room. The family member asked how the resident was doing. The resident replied, The CNA hit me. (He/she) just smacked me across the face with (his/her) hand. The resident had a red mark to his/her neck, lips, and his/her face was red. The family member said he/she went and got the CNA and told CNA E what the resident had told him/her. CNA E went in the room and assessed the resident. The CNA then walked out of the room shaking his/her head and said, I did not hit that (man/woman). The family member said he/she reported the incident to the nurse. The lip kept getting more swollen as time passed. The family member returned on 5/5/22 and the police came up and the resident gave the same story. The family member also said the resident said this was the first time CNA E took care of him/her. The family member said he/she had never heard the resident say something like this before which is why he/she reported the incident to the nurse. During an interview on 5/31/22 at 12:30 P.M., Nurse Manager H said he/she was on another unit and a nurse came to him/her. He/she was told that CNA E smacked the resident across the face and the resident's lip was swollen. Nurse Manager H said he/she went and removed the CNA from the floor and then assessed the resident. The resident's lip and right side of his/her face were swollen. The CNA said it did not happen and denied the resident had swelling. The resident had a red mark to the side of his/her neck and cheek. The corner of the resident's lip was swollen. During an interview on 5/25/22 at 4:00 P.M., the administrator and DON said the resident is known to be rude with staff and to make racial comments. The administrator said he would expect staff to be nice and respectful with the residents. He/she would expect staff to not abuse the residents. During an interview on 5/31/22 at 10:30 A.M., the medical director said he was not the resident's physician, but was disappointed the incident occurred. He would expect staff to not be abusive or hit residents. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00200589

Based on interview and record review, the facility failed to keep one resident (Resident #18) free from physical abuse, when one agency staff member, Certified Nursing Assistant (CNA) E, slapped the resident on the mouth with the back of his/her hand. The resident informed his/her family member, that was outside the room, when the incident occurred. The resident had a swollen lip that later became bruised. The census was 119. The administrator was notified on 5/27/22 at 2:00 P.M. of an immediate jeopardy (IJ) which began on 5/1/22. The IJ was removed on 5/27/22, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect Policy, revised 8/2019, showed: -Every resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Resident's must not be subject to abuse by anyone, including, but not limited to residence, staff, other residents, consultants or volunteers, other agencies serving the individual, family members or legal guardians, friends or other individuals; -Any employee who receives an allegation or suspects that there is a situation of abuse, neglect, or exploitation of a resident including a potential or actual criminal action shall immediately disrupt all perceived or observed abusive situations and immediately report such to the Administrator; -Upon receiving any allegation of abuse, the alleged perpetrator will be suspended/removed immediately from the residence, pending the investigation; -The Administrator will direct staff to complete an incident report and initiate investigation process. Review of Resident #18's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/22, showed: -Moderate cognitive impairment; -Total dependence with transfers, extensive assistance with bed mobility, dressing, toileting and personal hygiene; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, in use at the time of the investigation, showed: -Goal: Mood to be stable; -Problem: Risk of altered mood due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Approach: Take medications as prescribed, monitor for any noted episodes of tearfulness, anger, or becoming more reclusive. Notify the nurse and social worker if resident's mood changes or if resident's willingness to interact changes. Review of the resident's progress notes, showed: -On 5/1/22 at 3:00 P.M., the charge nurse came to Nurse Manager H and said the resident's family member wanted to talk to the manager. The family member was approached and was visibly upset. The family member said he/she went to the resident's room to visit and the door was closed. He/she opened the door and saw CNA E was in the room. The family member told the CNA he/she would step out while he/she was providing care to the resident. The family member went in the room right after CNA E exited the resident's room. The family member said the resident told him/her that racial slur slapped me with the back of his/her hand. Nurse Manager H went to question the resident and the resident said CNA E slapped him/her with the back of his/her hand. The resident said it may have happened because of his/her smart mouth. The resident had swelling noted to the right side of his/her lip; -On 5/1/22 at 9:00 P.M., the resident's right lower lip has a dark red area that is swollen and sore. There is no other injury noted. Nurse Manager H and physician notified. The staff will monitor the resident; -On 5/2/22 at 2:39 A.M., the resident is alert and greeted the nurse. The resident said he/she is comfortable. The resident has a notable bruise to right side of his/her upper lip. The resident denies pain; -On 5/2/22 at 3:41 P.M., the resident remains on follow up for resident to staff altercation. The resident has some swelling to right side of his/her lip with some bruising. The resident denies pain; -On 5/3/22 at 11:20 A.M., the resident remains on follow up for bruising and swelling to right lip and cheek. The resident denies pain. Review of the facility's self-report, dated 5/1/22, showed the following: -At approximately 3:00 P.M., the resident's family member came to Nurse Manager H to inform that the resident told his/her family member that CNA E came into the resident's room and slapped the resident across the face. Nurse Manager H went to investigate and found the resident had swelling on the right side of his/her lip. The family member said the resident may have been smarting off to the aide. CNA E said he/she did not slap the resident. The facility sent CNA E home and told him/her to not come back until the investigation is complete. The resident is fine expect for the lip which is a little swollen; -On 5/1/22 CNA E's written statement showed, he/she went to do his/her last rounds on Resident #18. As he/she was finishing up with the resident's care, a family member knocked on the resident's door. The family member asked if care was being performed and said he/she would wait outside the door. CNA E finished with care and handed the resident his/her soda and left the room. The family member asked what was wrong with the resident. The family member then said the resident's mouth was busted. CNA E went back to room to look at the resident and said he/she saw nothing on the resident's mouth that looked busted; -On 5/1/22, Nurse B's written statement, showed the resident's family member came up to the nurses station and asked who was the nurse for the resident. Nurse B said he/she was the nurse and the family member requested to talk in private. The family member said a CNA went in to change the resident while he/she was in the hallway, waiting. The staff member came out of the room. When the family member went into the room, the resident stated the staff member hit him/her on the lip. Nurse B told the family member he/she needed to talk to the supervisor, Nurse Manager H. As the family member told Nurse Manager H what happened, the nurse manager told Nurse B to tell CNA E to go to the lobby. Nurse B asked CNA E to go to the lobby and Nurse Manager H would be there to talk to him/her. Nurse B and Nurse Manager H went to the resident's room and talked to the resident and did a body check on the resident. The resident's right upper lip was swollen; -On 5/2/22 at 8:30 A.M., the administrator said CNA E was an agency staff member. Once the family member notified the nurse of the incident, the nurse removed the CNA from the floor, and had the CNA write a statement. The CNA was sent home pending investigation. CNA E denied he/she hit the resident. The resident was assessed after the incident and had a red mark on the right side of his/her face. This morning the resident has some bruising to the right upper lip. The resident is alert and consistent with his/her story. CNA E was placed on do not return list for all company homes; -On 5/2/22, the Director of Nursing (DON) said Nurse Supervisor H was contacted at 2:30 P.M. on Sunday May 1, 2022 that Resident #18 had reported to his/her family member, who was visiting, that CNA E had slapped him/her making contact with his/her lip. The family member sought out the charge nurse to report the alleged incident. Nurse Supervisor H instructed the nurse to have CNA E leave the unit immediately. He/she then went to investigate the incident and afterwards the CNA went home pending further investigation. The administrator and DON went together to assess and speak to the resident regarding the reported incident. The resident had a bruise to his/her right upper lip. The resident was able to say the CNA had made contact with the back of his/her hand to the resident's lip on Sunday. The resident was alert and cognitively intact at the time of the interview. The resident's statement and clinical assessment, along with nursing documentation led to the conclusion that the complaint of conduct is justified. Family was present at the time of the incident. The physician was notified and came in on Monday to assess the resident. The police department was notified by the administrator of the incident. During a phone interview on 5/26/22 at 4:10 P.M., CNA E said at the time of the incident, he/she was doing the last shift rounds and checking everyone. He/she performed care on the resident's roommate then started care on Resident #18. CNA E said the resident is normally mean and yells at him/her. He/she said on this day, the resident was actually really nice and didn't say one mean thing to the CNA. While he/she was performing care, the family member knocked on the door. After care, he/she grabbed the trash and walked out of the room. The family member came up to him/her and asked, What happened? The family member said the resident told him/her that CNA E put their hands on the resident. CNA E said no and that he/she had been doing this for [AGE] years. CNA E then got a call from the nurse to write a statement. CNA E said he/she did not hit the resident. During an interview on 5/26/22 at 4:22 P.M., Nurse B said the resident's family member came out of his/her room and said he/she needed to speak in private. Once in private, the family member said the resident told him/her that CNA E hit the resident in the lip. Nurse B called the supervisor, Nurse Manager H. Nurse B said he/she then went to assess the resident. He/she said the resident's top lip was swollen on the right side. The resident said he/she was backhanded by CNA E, because he/she probably said something mean. Nurse B told the resident that staff still should not hit residents. During an interview on 5/26/22 at 5:10 P.M., the family member said the resident's door was closed so he/she knocked and the CNA said he/she was providing care to the resident. The family member waited in the hall and said after a few minutes the CNA came out of the room with the resident's roommate. The family member said he/she then went into the room. The family member asked how the resident was doing. The resident replied, The CNA hit me. (He/she) just smacked me across the face with (his/her) hand. The resident had a red mark to his/her neck, lips, and his/her face was red. The family member said he/she went and got the CNA and told CNA E what the resident had told him/her. CNA E went in the room and assessed the resident. The CNA then walked out of the room shaking his/her head and said, I did not hit that (man/woman). The family member said he/she reported the incident to the nurse. The lip kept getting more swollen as time passed. The family member returned on 5/5/22 and the police came up and the resident gave the same story. The family member also said the resident said this was the first time CNA E took care of him/her. The family member said he/she had never heard the resident say something like this before which is why he/she reported the incident to the nurse. During an interview on 5/31/22 at 12:30 P.M., Nurse Manager H said he/she was on another unit and a nurse came to him/her. He/she was told that CNA E smacked the resident across the face and the resident's lip was swollen. Nurse Manager H said he/she went and removed the CNA from the floor and then assessed the resident. The resident's lip and right side of his/her face were swollen. The CNA said it did not happen and denied the resident had swelling. The resident had a red mark to the side of his/her neck and cheek. The corner of the resident's lip was swollen. During an interview on 5/25/22 at 4:00 P.M., the administrator and DON said the resident is known to be rude with staff and to make racial comments. The administrator said he would expect staff to be nice and respectful with the residents. He/she would expect staff to not abuse the residents. During an interview on 5/31/22 at 10:30 A.M., the medical director said he was not the resident's physician, but was disappointed the incident occurred. He would expect staff to not be abusive or hit residents. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 589

Based on observation, interview, and record review, facility staff failed to ensure the resident environment remained free of accident hazards. Staff failed to ensure fall interventions were in place for one resident (Resident #62) with a history of multiple falls and propelled seven residents (Residents #6, #23, #26, #33, #49 and #61 and #93) in wheelchairs without foot rests. The facility census was 114. 1. Review of the facility's Fall Prevention/Reduction Program policy and procedure, dated (MONTH) (YEAR), showed the following: -When a resident is found on the floor, the facility is obligated to investigate and try to determine how he or she got there, and to put into place an intervention to prevent this from happening again. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred; -The distance to the next lower surface is not a factor in determining whether a fall occurred. If a resident rolled off a bed or mattress that was closest to the floor, this is a fall; -The fall prevention/reduction program requires the following: -The resident will be identified with a visual identifier selected by the community (a falling leaf/star); -The identifier will be placed outside the resident room door on the name plate and on the resident's wheelchair or assistive device; -A yellow fall risk indicator will be added to the ID bracelet; -Other safety interventions specific to the individual resident will be implemented as deemed appropriate by the nurse or supervisor and added to the care plan. Post fall assessment for care plan interventions. -Once a fall occurs, an immediate assessment and investigation occur to determine possible cause of the fall utilizing the post fall huddle assessment worksheet. From the assessment, meaningful, individualized intervention to prevent subsequent falls will be implemented. 2. Review of Resident #62's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/12/18, showed staff assessed the resident as follows: -Severely impaired cognition; -No behaviors; -Dependent on two staff for bed mobility, transfers, personal hygiene, and bathing; -Dependent on one staff for eating, dressing, and toilet use; -Limited ROM to one side of the upper and lower extremity; -Always incontinent of bowel and bladder; -Indicators of possible pain 1-2 days/week; and -Two or more falls without injury. Review of the resident's care plan, undated, showed staff assessed the resident requires the following: -Extensive assistance with most activities of daily living (ADLs), mechanical lift transfers, bathing, dressing, and bed mobility; -On aspiration precautions; -Unable to express himself/herself due to [MEDICAL CONDITION] (inability to understand and/or express oneself); -Dependent upon staff to anticipate needs; -1/8/18 found sitting on the mat against the bed with a soiled brief. Check and change the resident as needed to ensure that he/she is dry when in bed; -2/8/18 found on the floor, please check on the resident more frequently when laying down; -2/9/18 found sitting on the mat next to the bed. Check frequently though the night to ensure the resident is in the middle of the bed; -2/11/18 slid out of bed to mat, continue to monitor; -3/5/18 slid from the low bed. Ensure the resident is in the center of the bed and it is in its lowest position. Round on him/her frequently, ensure clean and dry. The resident is a fall risk due to limited mobility; -4/19/18 rolled his/her legs off the side of the bed and bruised the left knee on the tube feeing pole, put a pillow on the left side to keep the resident from rolling and to promote comfort; -4/24/18 rolled out of bed and hit the recliner and feeding pole. He/she has bruising to the right orbital, clavicle, and wrist. X-ray showed a fractured wrist; -4/26/18 he/she has an abrasion to the left lateral knee from previous fall; -Assist the resident with repositioning and skin hygiene; -Assess and turn the resident every two hours and as needed; -Has a reactive air mattress with bolsters for prevention. Review of the resident's physician order [REDACTED]. -Monitor left knee and shoulder every shift for 72 hours, ordered on [DATE]; -Check ace wrap to right wrist every shift for signs and symptoms of swelling; -Keep ace wrap on right wrist continuously except when showering; remove at that time and re-wrap; -X-ray to right orbital area, right shoulder, right arm, and right wrist, ordered on [DATE]; -Follow-up x-ray to right radial distal fracture on 5/10/18; -Cleanse left lateral knee with normal saline and apply [MEDICATION NAME] lite (adhesive foam dressing) every seven days and as needed, ordered on [DATE]. Review of the resident's post fall evaluation, dated 4/24/18, showed staff documented as follows: -The resident rolled out of bed onto the mat; -Showed signs and symptoms of pain; -Nurse went in to answer roommate's call light and noticed resident on the mat, face down, head near base of food pump, upon assessment noticed bruise forming at corner of right eye, abrasion on right wrist and left knee. The resident was returned to bed, vital signs and neuro checks were completed and within normal limits. The nurse applied ice to the right eye and abrasions were cleaned and covered; -Interventions in place to prevent falls include adequate lighting, consult with family, frequent observations, low bed with mat, and mat placed on the floor next to the bed. Review of the resident's post fall evaluation, dated 3/5/18, showed staff documented the resident sliding out of bed onto the floor mat and the nurse was unable to stop the slide. The resident ended in a sitting position on the floor mat. The feeding tube was connected and continued to flow. Interventions in place to prevent falls included adequate lighting, consult with family, frequent observations, low bed with mat, and mat placed on the floor next to the bed. Review of the resident's post fall evaluation, dated 2/11/18, showed staff documented the resident's roommate called the nurses station to inform staff the resident was on the floor. Resident was found sitting on the floor mat with back resting on bed frame. Interventions in place to prevent falls included adequate lighting, consult with family, frequent observations, low bed with mat, and mat placed on the floor next to the bed. Review of the resident's post fall evaluation, dated 2/9/18, showed staff documented the resident was found on the fall mat on his/her bottom and back against the bed. Frequent safety checks are in place and will continue to monitor. Interventions in place to prevent falls included adequate lighting, consult with family, frequent observations, low bed with mat, and mat placed on the floor next to the bed. Review of the resident's post fall evaluation, dated 2/8/18, showed staff documented the resident was found on the floor. Fall mats were at both bedsides. The resident was in an upright sitting position with his/her back leaning against the bed. Resident transferred to bed then to wheelchair. Resident at nurses station for close observation. Interventions in place to prevent falls included adequate lighting, consult with family, frequent observations, low bed with mat, and mat placed on the floor next to the bed. Review of the resident's post fall evaluation, dated 1/8/18, showed staff documented the resident was found laying on the floor next to bed sitting on buttock with back and head up against the bed. The feeding tube pole fell on to the bed. The resident was transferred back to the bed and incontinence care was provided. Review of the resident's nurses notes, dated 2/8/18, showed staff documented the resident was found on the floor at 4:10 P.M. on his/her right side of the bed sitting in an upright position with back against the bed and feeding tube remained in place. Review of the resident's nurses notes, dated 2/9/18, showed staff documented the resident was found on the mat next to his/her bed without signs or symptoms of injury. Review of the resident's nurse's notes, dated 3/5/18, showed staff documented they continue to monitor resident after resident rolled onto mat next to bed. Staff are to make frequent rounds to ensure resident safety, keep the bed in low position, and mats next to bed. Review of the resident's nurse's notes, dated 4/20/18, showed staff documented they continue to monitor two bruises, one on the left knee and one of the left shoulder. Review of the resident's nurse's notes, dated 4/24/18, showed staff documented a call placed to Biotech to schedule an x-ray of the right orbital area, right shoulder, right arm, and right wrist. Biotech will be out later today to obtain an x-ray. Review of the resident's nurse's notes, dated 4/24/18, showed staff documented x-ray results received and called the physician. Staff obtained a new order for a brace to the right wrist and an orthopedic consult. An ace wrap was applied to the wrist. Review of the resident's x-ray results, dated 4/26/18, showed findings are suspicious for distal radial fracture ventrally. Consider dedicated imaging of the wrist. Further review showed the resident's physician documented the following: -To do as discussed; -See orthopedist; -Place wrist brace; and -Discussed with nurse yesterday. Observation on 4/23/18 at 5:43 P.M., showed the resident's door closed. Observation showed the resident lying diagonally in bed with his/her legs hanging off the edge of the bed. The resident had a large bluish bruise on the left knee. Further observation showed fall mats on both sides of the bed that did not extend the full length of the bed and the resident's feeding pole at the head of the bed on the right side. Observation on 4/24/18 at 9:11 A.M., showed the resident's door closed. Observation on 4/24/18 at 10:39 A.M., showed the resident lying flat in bed with audible snoring respirations. Observation showed a large purple bruising on the right side of the resident's face. The resident had a large amount of swelling and purple bruising to the right outer wrist. Further observation showed the feeding pole on the right side at the head of the bed with fall mat below the feeding pole wheels. Observation on 4/24/18 at 2:14 P.M., showed the resident lying flat in bed with pillows tucked under the resident's sheet on both sides. Observation showed the resident's feeding pole at the head of the bed on the right side with a recliner next to the pole. Further observation showed the resident's fall mats did not extend to the head of the bed. Observation on 4/25/18 at 1:22 P.M., showed the resident lying in bed with fall mats next to both sides of the bed. Observation showed the resident's feeding tube pole and recliner on the right side at the head of the bed, and a fall mat below the feeding pole and recliner. Further observation showed the resident with a large bruise on the right occipital area and on the right wrist. Observation on 4/25/18 at 2:34 P.M., showed the resident lying in bed with fall mats next to both sides of the bed. Observation showed the fall mats unable to position at the head of bed due to the recliner and tube feeding pole. Further observation showed the resident crossing his/her legs out of the bed toward the left side of the bed. Observation on 4/25/18 at 3:14 P.M., showed the resident lying in bed with fall mats next to both sides of the bed. Observation showed the fall mats unable to position at the head of bed due to the recliner and tube feeding pole. Further observation showed the resident crossing his/her legs out of the bed toward the left side of the bed. Observation on 4/26/18 4:22 A.M., showed the resident lying in bed. The resident's floor mats were not all the way to the head of the bed. Observation showed the tube feeding pole next to the left head of the bed and recliner at the head of the bed on the right side. Observation on 4/26/18 at 5:01 A.M., showed the resident lying flat in bed with snoring respirations. Observation showed the feeding pole on the left head of the bed, with a pillow on the legs of the pole. Observation on 4/26/19 at 10:26 A.M., showed the resident lying flat in bed. Observation showed a pillow over the feet of the feeding pole on the left head of bed with a fall mat below the feeding pole. During an interview on 4/27/18 at 4:19 P.M., Licensed Practical Nurse (LPN) E said if a resident is a fall risk staff should try to keep them in view to ensure their safety. When a resident is in his/her room unsupervised staff should ensure the call light is in reach. During an interview on 4/27/18 at 04:20 P.M., Registered Nurse (RN) F said when a resident falls the nurse completes an assessment of the resident with vital signs and pain assessment. If a fall is unwitnessed neuro checks are completed. The RN said staff lift the resident with a hoyer lift and ask the resident questions about the fall, if the resident is able to communicate. During an interview on 4/27/18 at 4:30 P.M., LPN G said the resident has floor mats as a fall intervention. His/Her roommate is alert and oriented and lets us know if the resident falls. The resident has a tendency to stick his/her feet out of the bed. The roommate will notify staff when the resident falls, staff are to frequently check on the resident, and get the resident up when they can. The LPN said staff could push the resident's bed over further to ensure the fall mats are at the head of the bed. The resident tends to roll out on the right side of the bed and the fall mat should be at the head of the bed, especially on the right side. During an interview on 4/27/18 at 4:40 P.M., RN Nurse Manager H said the resident gets restless while up in the chair. Staff are expected to frequently round on the resident, fall mats are supposed to be on the floor next to the bed, and the resident is supposed to have pressure relief on both sides by using pillows tucked under both sides of the sheet. The nurse manager said he/she expects staff to have the bed pushed up against the wall with mat in place to where nothing is obstructing the fall mat. Fall mats should go all the way to the head of the bed with the feeding tube pole pushed away to where the resident would not hit it if he/she rolled out of bed. 3. Observation on 4/24/18 at 9:25 A.M., showed the Administrator Intern propelled Resident #23 from the dining room to his/her room with his/her feet dragging on the floor. Observation at 2:30 P.M., showed the Administrator Intern propelled the resident down the hall with the resident's feet dragging on the ground and no foot pedals. 4. Observation on 4/24/18 at 9:28 A.M., showed Certified Medication Technician (CMT) O pushed Resident #93 down the hall from the spa room. Observation showed the resident's feet dragging off and on while staff propelled him/her down the hall. 5. Observation on 4/25/18 at 10:23 A.M. showed an unidentified CNA wheeled Resident #61 in his/her wheelchair from the dining room toward the hallway. The CNA tried to wake the resident, saying he/she was sleepy. The CNA began to wheel the resident from the dining room by tilting the front of the wheelchair up and wheeling the wheelchair on the two back wheels, to keep the resident's feet from dragging on the floor. Observation showed an unidentified staff member stopped the CNA at the nurses station, had the CNA place the wheelchair's four wheels back onto the floor, then lifted the resident's feet while the CNA wheeled the resident toward the hallway for a short distance. The staff member then put the resident's feet back down on the floor and the CNA began to wheel the resident in the normal fashion. Observation showed the resident's feet dragged and the top of his/her feet started to drag beneath chair, causing a potential for accident. 7. Observation on 4/25/18 at 1:19 P.M., showed CNA I propelled Resident #49 into his/her room from the dining room. The resident's wheelchair did not have foot pedals, and the resident's feet dragged on the floor. 8. Observation on 4/25/18 at 1:34 P.M., showed CNA I propelled Resident #6 in his/her wheelchair from the dining room to his/her room. The resident's wheelchair did not have foot rests and the resident's feet dragged on the floor. 9. Observation on 4/25/18 at 1:43 P.M., showed CNA B propelled Resident #33 from the dining to his/her room then to the shower room in his/her wheelchair without footrests. 10. Observation on 4/25/18 at 2:24 P.M., showed CNA B propelled Resident #26 in his/her wheelchair without footrests. Further observation showed the resident's feet dragging on the floor with his/her toes touching the floor and his/her feet under the chair. 11. During an interview on 4/27/18 at 4:15 P.M., the Director of Nursing (DON) said when a resident falls, staff should first assess the resident. Staff are expected to conduct a post fall huddle and come up with any contributing factors. Staff should complete a post fall evaluation and followup for 72 hours after the fall. Staff should complete vital signs and neuro checks if indicated for 72 hours. Staff should update the resident's care plan with new interventions after a fall. The nurses or nurse managers can review and update the care plan. The DON said if a resident is unable to hold up their feet staff are expected to encourage a resident to hold them up. It is never ok to propel a resident with their feet on the ground. 12. During an interview on 4/27/19 at 4:19 P.M., LPN E said when propelling a resident in a wheelchair staff should ensure the foot pedals are on the chair and the resident's hands are inside the arms of the chair or in their lap. 13. During an interview on 4/27/18 at 4:20 P.M., RN F said when staff are propelling residents in wheelchairs they should always have their feet positioned on foot pedals. 14. During an interview on 4/27/18 at 4:30 P.M., CNA C and D said foot rests are not needed on residents' wheelchairs if their feet do not touch the floor. Staff assist residents by propelling their wheelchairs and some residents use their feet to propel wheelchairs, but staff still push their wheelchairs to assist them. 15. During an interview on 4/27/18 at 4:40 P.M., RN Nurse Manager H said residents have foot rests on their wheelchairs depending on their ability to self propel. If staff are pushing a resident in a wheelchair then they should put foot pedals on to ensure the residents feet do not land on the floor.

Based on observation, interview, and record review, the facility failed to thoroughly and accurately assess, document and notify the resident's physician of a change in condition sustained by one sampled resident selected for a closed record review. (Resident #1) Staff witnessed the resident fall and hit his/her head. Staff failed to notify the resident's physician that the resident hit his/her head, communicate to other staff the resident hit his/her head and consistently document neurological checks per facility policy. After the fall, staff allowed the resident to sleep for over 24 hours before staff identified a change in condition and transferred the resident to the emergency room . The resident was diagnosed with [REDACTED]. The facility also failed to consistently document neurological checks for another resident that fell , went to the hospital and returned the same day. (Resident #2) The census was 120. 1. Review of the facility's policy for Neuro Checks, dated 5/2002 and revised 9/2009, showed the following: -Neuro Checks will be completed on all falls; -All unwitnessed falls will have neuro checks completed at the following intervals; -Initial assessment; -Every 15 minutes X 4, then; -Every 30 minutes X 2, then; -Every hour X 2, then; -Once every shift for 72 hours; -All witnessed falls when head not struck; -Initial assessment; -Once every shift for 72 hours; -If a neuro check assessment is done for a change in condition rather than a post fall; -Notify the physician and obtain orders for frequency of the neuro checks; -Use the neurological checklist form, dated 11/2011. -Report findings to the physician as ordered and as needed: -Change in mental status; -Nausea and vomiting; -Change in pupil size and/or reaction to light; -Elevated blood pressure or headache; -Note that neuro checks are only one element of assessment: -Monitor and observe the resident for at least 72 hours; -Results of monitoring and assessment should be the guide to determine further interventions and notification of the physician if abnormalities develop; -Document all observations and interventions; -At the end of the neuro check assessment period: -Place the form in the resident's chart under the nurse's notes tab; -For residents using electronic medical records, neuro checks will be part of the resident's progress notes. Review of the facility's policy for reporting incidents, injuries and changes of condition, dated 5/1999 and revised on 11/2011, showed the following: -Purpose of policy is to provide an orderly process for reporting changes in condition, incident or injuries involving residents; -All licensed nurses and Certified Medication Technicians (CMTs) are to know and follow the policy; -When reporting changes in condition or incidents the following procedure should be followed: -Evaluate symptoms and/or injury; -Complete overall head to toe assessment including taking vital signs, temperature and neuro checks as indicated (see neuro check policy); -All falls, head injuries and change of condition must be reported to the physician, supervisor and family; -Serious incidents are reported to the physician at the time of the occurrence, i.e., possible fractures, head injuries, uncontrolled bleeding; -Be prepared to report results of the assessment, including pertinent information relative to items such as medications, lab results; -The Director of Nursing (DON) is to be promptly notified of any fractures, including fractures of unknown origin or other serious injury; -A post fall assessment is to be completed on each fall; -When completing an incident report, be specific and fill in all areas as directed. For electronic medical record, complete all areas and print out the accident and injury report; -If an incident occurred, chart the incident. Do NOT refer to the incident report in the chart; -Document details of the incident and nursing interventions/corrective measures taken; -Chart for seventy-two (72) hours following an incident, include vital signs and neuro checks as indicated. See neuro check policy in the nursing policy and procedure manual for details; -All charting should include notification of doctor and resident representative/appropriate family member. Review of the facility's Fall Prevention/Reduction Program, dated 5/1999 and revised on 3/2016, showed the following: -All staff are responsible to know and follow the policy; -NOTE: when a resident falls or is found on the floor, the resident must be assessed by a nurse before the resident is moved; -An incident report is to be completed after any resident fall; -Additionally, neuro checks per neuro check policy and a narrative note in the resident's medical record will also be completed; -Nurses will document in the medical record every shift for seventy-two (72) hours after the fall to describe the post fall condition, injury and interventions. 2. Review of Resident #1's hospital record, showed the following: -admitted on [DATE], related to a fall at home; -Alert and oriented to name; -[DIAGNOSES REDACTED]. -Wakes easily to voice when sleeping; -Magnetic resonance imaging (MRI, noninvasive medical test used to diagnose and treat medical conditions) of the brain, dated 9/15/16, showed no mass, hemorrhage (bleeding) or midline shift (the brain moves past its center line); -discharged on [DATE]. Review of the resident's Admission Nursing Assessment, dated 9/16/16, showed staff documented the following: -admitted on [DATE] at 9:35 A.M.; -Required assistance of one staff for mobility; -Full weight bearing; -Wheelchair; -Alert, oriented to person and place; -Mood: Questioning, wandering; -Slow comprehension; -Continent of bowel and bladder; -Needed staff assistance with dressing, bathing, grooming, and toileting; -No pain; -Sleep/rest pattern: Eight hours a night average, no naps, no sleep apnea (a sleep disorder in which breathing repeated stops and starts), no medications needed to sleep; -Unsteady gait; -Balance problem; -Skin: Bruise, skin tear. Review of the resident's Profile History Report, dated 9/18/16, showed staff documented the following: -Activities of daily living (ADLs): Extensive assistance with bathing, dressing, toileting, transfers, and grooming; -Independent with eating, will use call light to make needs known; -Fall risk, needs 1:1 staff attention when up in wheelchair; -Continent of bowel and bladder with incontinent episodes at times; -Wanders; -Moderate cognitive impairment, alert to self only; -Fall with skin tears; keep resident in sight of nursing for closer observation. Review of the resident's physician's orders [REDACTED]. -Oxygen (O2) 2 - 5 liters (L) via nasal cannula (NC); -Fall precautions every shift; -Physical (PT), occupational (OT) and speech (ST) therapy evaluation and treatment; -[MEDICATION NAME] (blood thinner) 5,000 unit/ milliliter (ml) injection, 1 ml twice a day (BID); -[MEDICATION NAME] and [MEDICATION NAME] (medications used to open airways and increase air low to the lungs) via nebulizer (a device used to convert liquid medication into a fine mist, so it can be inhaled) 3 ml four times a day; -Aspirin 325 milligrams (mg) every day; -Carvedilol (antihypertensive) 3.125 mg BID; -[MEDICATION NAME] (water pill) 40 mg BID; -[MEDICATION NAME] (antihypertensive) 5 mg BID; -[MEDICATION NAME] (laxative) 17 grams every day; -[MEDICATION NAME] (pain medication) as needed (PRN) 50 mg every six hours; -Tylenol 325 mg PRN every four hours for pain/fever; -[MEDICATION NAME] (antibiotic) 875 mg/125 mg BID with meals, for [DIAGNOSES REDACTED].>-Skilled PT six times a week for 60 days; -All orders verified by the resident's physician. Review of the resident's interdisciplinary notes, dated 9/16/16 at 11:59 P.M., showed staff documented the following: -[DIAGNOSES REDACTED].>-Alert and oriented to self and place. Pupils assessed equal and reactive to light (PEARL); -Noncompliant with oxygen; -Required constant redirection from staff; -Not able to follow simple commands; -Multiple bruises and skin tears assessed; -Frequently used the bathroom during admission. Review of the resident's FRAT (fall risk assessment tool), dated 9/16/16 at 12:44 P.M., showed staff documented a score of 31 (high risk: 16-20). Review of the resident's PT plan of care, dated 9/16/16, showed the following: -Resident oriented to person and time; -Cognition severely impaired; -Ambulated with a two wheel walker and assistance of staff for 50 feet during the therapy evaluation. During an interview on 9/28/16 at 11:00 A.M., the physical therapist said the following: -Completed the resident's PT evaluation before lunch on 9/16/16; -Resident alert and cooperative during the evaluation; -Resident participated in sit to stand transfers and ambulated 50 feet with a wheeled walker and assist of staff; -Resident not safe to transfer himself/herself or ambulate alone. Review of the resident's interdisciplinary notes, dated 9/16/16 at 2:09 P.M., showed staff documented the following: -Agitated and anxious; -Refused to eat lunch; -Refused to keep oxygen on, self propelled wheelchair and pushed the oxygen concentrator; -Redirected by staff; -On 1:1 with staff for safety; -Repeatedly stood up saying he/she needed to get of there and he/she had no money or insurance to pay for his/her stay; -Reassurance provided without effectiveness; -Asked to go to the bathroom every 30 minutes; -Family in to visit. Review of the resident's Vitals Detail Report, dated 9/16/16 at 2:59 P.M., showed staff documented the following: -Blood pressure (B/P): 140/80 (normal 120/80); -Pulse (P): 64 (normal 60 to 100); -Respirations (R): 18 (normal 12-20); -Temperature (T): 97.2 (normal 98.6); -Oxygen saturation (O2 sat, oxygenation of the blood): 98% (normal 95-100%); -No complaint of pain. During an interview on 9/28/16 at 8:30 A.M., Nurse A said the following: -He/she worked the day shift, on 9/16/16, was assigned to the resident and did the admission paperwork; -The resident was alert and oriented to name and date, could understand the nurse, did not understand why he/she was at the facility and wanted to go home; -Self propelled wheelchair up and down the halls the entire shift and ambulated with assist of one staff; -Restless and anxious, would not keep the oxygen NC on and refused to eat lunch. During an interview on 9/27/16 at 2:00 P.M., Certified Nurse Aide (CNA) G said the following; -He/she worked the day shift, on 9/16/16, and was assigned to the resident; -The resident was calm when admitted to the facility. During the course of the day his/her behaviors escalated; -Nurse A sat in the resident's room, with resident, to complete the admission nursing assessment and attempted to redirect the resident at that time, but was unsuccessful; -He/she was alert, talkative and very busy. He/she propelled himself/herself in a wheelchair up and down the hall all day and displayed repetitive motions of sitting and standing; -Showed no safety awareness; -Insisted on going to the bathroom frequently and was continent; -CNA G could not recall if the resident ate breakfast or lunch that day; -Family came to the facility for a visit and the resident recognized them. Review of the resident's interdisciplinary notes, dated 9/16/16 at 5:50 P.M., showed staff documented the following: -Resident up in wheelchair throughout the division; -Alert and oriented to name only. Confused kept repeating, he/she wanted to go home and wanted his/her car; -Reported he/she was tired and hungry, but refused to eat or drink; -Staff attempted to lay resident down, but he/she refused and refused to sit in a recliner; -Staff observed the resident stand up from his/her wheelchair without assistance multiple times; -Balance unsteady; -Staff educated resident not to stand without assistance; -Staff provided 1:1 supervision. During an interview on 9/30/16 at 12:45 P.M., the Assistant Director of Nurses (ADON) said he/she worked the evening shift on 9/16/16. The resident was alert to name only, exit seeking, very agitated at times, confused and looking for his/her car. He/she sat with the resident to keep him/her safe. Review of the resident's Vitals Detail Report, dated 9/16/16 at 8:01 P.M., showed staff documented the resident had no complaint of pain. No vital signs were documented. During an interview on 9/28/16 at 8:40 A.M., Nurse K said the following: -He/she worked the evening shift, on 9/16/16, and was assigned to the resident; -The resident appeared confused that shift, but took his/her medications; -Resident alert, talking and able to make his/her needs known; -Family came to visit, the resident recognized and interacted with them; -Resident also spoke to family on the phone; -Resident wandered throughout the halls, self propelling wheelchair. Kept trying to get out of the wheelchair without assistance; -Staff continued to educate and remind the resident to ask for help before getting up, because his/her balance was off; -Resident did not eat or drink anything during the shift. During an interview on 9/29/16 at 1:10 P.M., Nurse J said the following: -He/she worked the night shift, starting on 9/16/16 and ending on 9/17/16; -The resident self propelled his/her wheelchair all night long; -Staff told Nurse J the resident was a 1:1 for the evening shift, so he/she continued that for the night shift; -Resident pleasantly confused during the shift; -Staff used a gait belt around the resident's waist to walk with him/her up and down the hall; -Resident alert and able to make his/her needs known; -At approximately 3:00 A.M., the resident complained of shoulder pain. Nurse J administered pain medication at that time; -Resident ate 1/2 cup of yogurt that shift. Review of the resident's interdisciplinary notes, dated 9/17/16 at 2:42 A.M., showed staff documented the following: -Continued to wander up and down the halls in wheelchair; -Staff tried to keep him/her in the dining room, but he/she was agitated. Staff tried to put the resident in a recliner, but he/she would not stay more than a few minutes; -Complained of left shoulder pain; -Pain medication administered at 1:50 A.M. Review of the resident's interdisciplinary notes, dated 9/17/16 at 7:16 A.M., showed staff documented the following: -Awake all night, continuously moving; -Staff used a gait belt to ambulate the resident; -No safety awareness; -Staff observed the resident standing up, holding onto chairs and bedside tables; -Did not know to lock the wheels on the wheelchair prior to standing up. He/she got agitated when staff tried to assist him/her; -Would not keep the oxygen on or follow directions. During an interview on 9/29/16 at 1:30 P.M., Housekeeper L said the following: -He/she worked the day shift on 9/17/16; -He/she witnessed the resident ambulating behind his/her wheelchair. The resident lost his/her balance, fell backwards hitting his/her head on the floor; -The wheelchair fell on top of the resident; -He/she immediately notified the nurses; -Three nurses assessed the resident on the floor; -After the nurses were back at the nurse's station, he/she said to them again, You know he/she hit his/her head right? Both nurses nodded their heads and seemed busy at that time. Review of the resident's Neuro Check (neurological check, an assessment completed to monitor for changes in the neurological (nervous system) status and level of consciousness) form, dated 9/17/16 at 8:00 A.M., showed staff documented the following: -Level of consciousness: Alert; -Orientated to: Name; -Is this a change from usual functioning: Yes; -Pupil response: Reacts to light, immediate; -Pupil shape: Round; -Ask resident to smile: No response; -Ask resident to stick his/her tongue out and move side to side: No response; -Ask resident to squeeze two of your fingers from both hands: Squeeze is firm and tight in both hands; -Ask resident to lift their knee against the pressure of your hands on their knee: No response; -Quality of speech: Disoriented and converses; -Is this a change from usual functioning? No. Review of the resident's Post Fall Huddle Assessment, dated 9/17/16 at 8:00 A.M., showed staff documented the following: -Date of fall: 9/17/16; -Time of fall: 8:00 A.M.; -Injuries: Yes; -Witnessed fall: Yes; -Number of staff on unit at the time of the fall: Three;-Description of occurrence: Resident observed ambulating behind wheelchair and fell back to the floor in the hallway. The resident had been awake since admission on 9/16/16; -Vital signs: B/P: Unable to obtain, R: 20, Pulse: blank, O2 sat: 87% on room air. Will not keep oxygen on; -Neuro checks initiated: Yes; -Factors related to the fall: Ambulating in the hallway, last time toileted by staff 7:00 A.M., hearing impaired, hearing aids off; -Additional comments: Had been agitated since admission, up all night, extremely exhausted. Review of the resident's interdisciplinary notes, dated 9/17/16 at 9:29 A.M., showed staff documented the following, but then put a line through the entire note: -Resident fell in the hallway; he/she ambulated without staff assistance and sustained three skin tears; -Prior to the fall, the resident was agitated, confused and self propelled his/her wheelchair; -Alert and oriented to self only; -Staff will keep the resident within sight as best as possible; -Family and physician were notified. Fall huddle findings were the resident had unsafe behavior and he/she was overly tired due to lack of sleep. Review of the facility's 24 Hour Nursing Report Sheet, dated 9/17/16, showed staff documented the resident fell at 8:00 A.M., and sustained new skin tears. No other information provided on report sheet. During an interview on 9/28/16 at 8:30 A.M., Nurse A said the following: -He/she worked the day shift, on 9/17/16, and was assigned to the resident; -The night shift nurse reported the resident was awake all night and did not sleep at all; -The resident continued to self propel up and down the halls and stood up multiple times without staff assistance. Staff attempted to redirect the resident multiple times; -At approximately 8:00 A.M., Housekeeper L reported the resident was on the floor; -Nurse A and Nurse B assessed the resident immediately. Nursing Supervisor C saw the resident on the floor and went to get dressings for the skin tears he/she sustained; -A housekeeper reported seeing the resident ambulate behind the wheelchair. The resident fell backward and the wheelchair fell on top of him/her; -The housekeeper came to the nurse's station a few minutes after the resident fell and reported the resident hit his/her head; -Nurse A assessed the resident's neurological status right away and per facility policy during the shift. He/she notified the resident's physician and family of the fall; -After staff treated the resident's skin tears, the resident was assisted to his/her wheelchair. He/she continued to self propel up and down the hall, refused to eat lunch and refused all medications except the antibiotic; -Staff assisted the resident to the bathroom and then to sit in a recliner across from the nurse's station at approximately 11:00 A.M. The resident was restless and fidgety, but calmed down and fell asleep between 1:30 P.M. and 2:00 P.M.; -When Nurse A left the facility at approximately 3:30 P.M., the resident was still asleep in the recliner across from the nurse's station; -No staff provided care to the resident after staff assisted him/her into the recliner at approximately 11:00 A.M.; -Nurse A reported to Nurse D, the resident fell , did not sleep the night before and needed to rest; -Nurse A did not recall telling Nurse D the resident hit his/her head when he/she fell . Nurse A notified the resident's physician of the fall, but did not recall if he/she reported the resident hit his/her head. He/she should have reported the fall was witnessed by staff and the resident hit his/her head, because there could have been a severe head injury. He/she did not recall talking to the resident's physical therapy assistant (PTA) on 9/17/16. He/she did not tell therapy staff the resident fell that morning. During an interview on 9/27/16 at 12:15 P.M., Nurse B said the following: -He/she worked the day shift, on 9/17/16. He/she was not assigned to the resident, but did assist Nurse A after the resident fell ; -Before the resident fell he/she was alert to name, restless and self propelled his/her wheelchair up and down the hall. Staff redirected the resident to the dining room while the nurses administered medications to other residents; -At approximately 8:00 A.M., Nurse B overheard Housekeeper L say the resident was on the floor. -Nurse B and Nurse A responded and assessed the resident on the floor. His/her legs were straight out and he/she sat on his/her buttocks. Nursing Supervisor C also assisted with the fall assessment. The resident sustained [REDACTED]. Staff assisted the resident into his/her wheelchair after dressing the skin tears; -The resident continued to self propel up and down the halls. He/she took a few bites of breakfast and drank a little and then was off again propelling down the halls; -Between 11:00 A.M. and 11:30 A.M., staff transferred the resident into a recliner across from the nurse's station. Nurse B went to lunch from 11:45 A.M. through 12:15 P.M. The resident was restless in the recliner, but calmed down between 1:00 P.M. and 2:00 P.M. He/she appeared to be asleep, but was still moving his/her arms; -Nurse B did not know if staff provided care to the resident after he/she was transferred into the recliner. When Nurse B left the facility at 3:15 P.M., the resident appeared to be asleep; -Nurse B did not recall if the housekeeper said the resident hit his/her head when they assessed him/her on the floor, but the housekeeper came to the nurse's station and told Nurse A and Nurse B he/she witnessed the resident hit his/her head when he/she fell . Nurse A and Nurse B gave shift report to Nurse D. Nurse B did not recall if Nurse A told Nurse D the resident hit his/her head when he/she fell . During an interview on 9/27/16 at 2:00 P.M., CNA G said the following: -He/she worked the day shift, on 9/17/16, and was assigned to the resident; -The night shift nurse told him/her the resident was up all night propelling his/her wheelchair up and down the halls; -Staff tried to keep the resident in the dining room during breakfast, but he/she kept leaving the dining room, self propelling down the hall. He/she refused to eat breakfast, was alert to his/her name and able to make his/her needs known; -At approximately 8:00 A.M., CNA G overheard a housekeeper report the resident was on the floor. Nurse A, Nurse B and Nursing Supervisor C assessed the resident; -After staff assisted the resident back into his/her wheelchair the resident continued to self propel up and down the halls and refused to eat lunch; -Staff transferred the resident into a recliner across from the nurse's station at approximately 11:00 A.M. His/her eyes were open and he/she continued to talk. At approximately 1:00 P.M. the resident fell asleep; -He/she did not provide care for the resident after staff transferred him/her into the recliner at 11:00 A.M. -When CNA G left the facility at 3:15 P.M., the resident was asleep in the recliner. He/she knew staff witnessed the resident fall, he/she was unaware the resident hit his/her head. During an interview on 9/28/16 at 10:03 A.M., Nursing Supervisor C said the following: -He/she worked the day and evening shift, on 9/17/16; -While doing rounds in the morning the resident was alert and awake. He/she self propelled up and down the hall and was all over the place; -Nursing Supervisor C left the unit and came back at approximately 8:00 A.M. and observed the resident on the floor. Nurse A and Nurse B were assessing the resident at that time. He/she went to get dressing supplies for the skin tears; -Nurse A told him/her the resident fell while walking behind a wheelchair. No additional information was provided to him/her at the time. No staff told him/her, staff witnessed the fall or that the resident hit his/her head. Review of the resident's PT treatment note, dated 9/17/16 from 9:31 A.M. through 9:51 A.M., showed he/she did not actively participate in physical therapy, but only did passive range of motion in the seated position. During an interview on 9/28/16 at 12:50 P.M., the PTA said the following: -He/she was not aware the resident fell or that he/she hit his/her head during the fall, prior to working with him/her in therapy on the morning of 9/17/16; -The resident self propelled in the dining room when the PTA approached him/her for therapy; -The resident cooperated with heel lift and march in place exercises while sitting in his/her wheelchair; -The resident kept pushing the wheelchair backwards and refused to ambulate with the therapist; -Therapist tried to assist the resident to stand, but the resident refused to bend his/her knees to stand; -After therapy the PTA spoke to Nurse A and Nurse B at the nurse's station. They told him/her the resident had fallen earlier that morning and he/she had not slept. Review of the resident's Vitals Detail Report, dated 9/17/16 at 9:33 A.M., showed staff documented the resident had no complaint of pain. No vital signs were documented. Review of the resident's interdisciplinary notes, dated 9/17/16 at 9:43 A.M., showed staff documented the following: -Alert and oriented to self, required assist with dressing, toileting, personal hygiene and transfers due to weakness related to falls; -Continues to work with therapy to help increase strength with no complaints with care; -Constantly attempts to transfer himself/herself. Self propelled his/her wheelchair; -Appeared tired, closed his/her eyes for a minute and then resumed self propelling; -Would not sit in a recliner, refused to wear oxygen and refused all morning medications except the antibiotic; -Staff continuously redirected the resident. He/she pulled the dressings off his/her right knee. Review of the resident's Daily Skilled Nurse's Notes, dated 9/17/16 at 9:50 A.M., showed staff documented the following: -Alert; -Oriented to: Person and uncooperative; -Symptoms of [MEDICAL CONDITION]: Disorganized thinking, -Mood problems: Moving/speaking, slowly/fidgety; -Behavior problems: Resists care and wanders; -Pain management: No nonverbal signs of current pain; -[MEDICAL CONDITION]: Frequent urgency, no documentation if resident was continent; -Gastrointestinal: Poor appetite and continent; -Safety: Resident attempted to leave: yes; -Skin: Bruise, skin tear. Review of the resident's interdisciplinary notes, dated 9/17/16, showed staff documented the following: -12:31 P.M., recently admitted to the facility, moderate cognitive impairment and alert to self only; -12:33 P.M., fidgety and moving about the division. Not able to tell staff the place or time due to fatigue. Noncompliant with staff and needs constant monitoring. Would not keep oxygen on. Staff not able to assess vital signs, because the resident was too restless. Continues to pull at dressings to skin tears. At 11:00 A.M., staff assisted the resident into the recliner near the nurse's station and applied oxygen. Fighting sleep and keeps trying to lean forward. Massage given and soothing music available. Fluids offered. Resident took a few sips of water. Continued to pull at oxygen tubing, moaned and talked in his/her sleep. Will continue to monitor. Review of the resident's Vitals Detail Report, dated 9/17/16 at 12:55 P.M., showed staff documented R: 18, and the resident declined B/P, P, T and O2 sat. No complaint of pain. Review of the resident's interdisciplinary notes, dated 9/17/16, showed staff documented the following: -Correction/addendum to the 9:29 A.M. nurse's note. Staff documented at 2:16 P.M., fall huddle findings noted the resident hit his/her head, but no trauma or hematoma was assessed; -4:43 P.M., asleep in a recliner. Physician was at the facility to see him/her; -9:45 P.M., physician in to visit, new orders received and noted, see POS. Review of the resident's POS, dated 9/17/16 at 11:00 P.M. through 9/18/16 at 7:00 A.M., showed the following: -Discontinue [MEDICATION NAME] and [MEDICATION NAME]; -Added [MEDICATION NAME] (nutritional supplement) 100 mg every day, multivitamin every day; -Lab work: Complete Blood Count (CBC, test used to evaluate the cells that circulate in the blood), Comprehensive Metabolic Panel (CMP, test used to evaluate organ function), TSH (blood test to monitor the treatment of [REDACTED]. During an interview on 9/30/16 at 12:45 P.M., the ADON said she was the house supervisor, on 9/17/16 from 9:00 A.M. through 4:00 P.M. Nursing Supervisor C reported the resident fell that morning, but did not say the resident hit his/her head. No other staff spoke to her about the resident. Review of the resident's Vitals Detail Report, dated 9/17/16, showed staff documented the following: -7:07 P.M., no complaint of pain. No vital signs were documented; -9:33 P.M., declined B/P, T, P, R and O2 sat. No complaint of pain. During an interview on 9/28/16 at 8:30 A.M., Nurse D said the following: -On 9/17/16, he/she worked the day shift on another floor and then the evening shift on the resident's floor; -The resident was sleeping in a recliner at the nurse's station when he/she got to the floor; -Nurse D received report from Nurse A and Nurse B at approximately 1:00 P.M.; -Between 1:00 P.M. and 1:30 P.M., the resident's physician assessed the resident while he/she slept in a recliner at the nurse's station; -Nurse D had not met the resident before and did not know his/her baseline; -Both Nurse A and Nurse B told Nurse D the resident fell that morning. He/she was walking behind a wheelchair and fell on his/her buttocks. No staff reported the resident hit his/her head when he/she fell ; -Nursing Supervisor C reported the resident had not slept in over a week and before falling asleep, had been on the wild side, with behaviors including taking off his/her oxygen and attempting to walk by himself/herself; -Nursing Supervisor C told Nurse D, if it was safe to let the resident sleep in the recliner, to do so. Staff did not want to wake the resident up by transferring him/her to bed. The resident did not wake up to eat dinner or take medications that evening, because staff wanted him/her to rest; -Nurse D said he/she would have been more concerned if he/she had known the resident hit his/her head when he/she fell , because the resident could have had a [MEDICAL CONDITION]. All staff assumed the resident was exhausted from being up for over a week and needed to rest; -Sometime after dinner, Nurse D assessed the resident's T, O2 sat and did neuro checks, but did not document the assessments because he/she got busy with other tasks; -The resident did not move that shift, he/she slept in the recliner across from the nurse's station the entire shift and kept the oxygen on; -During report, Nurse D reported to Nurse I, staff provided no care to the resident during the entire evening shift, because he/she had fallen and staff did not want to wake him/her because of the behaviors he/she had prior to falling; -Nurse I told Nurse D he/she would take care of the resident; -When Nurse D left the facility at approxi

Based on observation, interview, and record review, the facility staff failed to assess and prevent a fecal impaction for one resident (Resident #2) with a history of fecal impaction, of 21 sampled residents. The fecal impaction resulted in hospitalization with a three overnight stay. The certified census was 105 residents. Review of the facility's policy and procedure on Bowel Management, dated 9/98 and revised 11/11 showed "It is the policy of Bethesda to monitor, assess, document, and to follow the physician's treatment plan to promote adequate bowel function." And "It is the responsibility of all nursing personnel involved with direct resident care to monitor and document bowel function. " Further review of the facility's policy and procedure on Bowel Management, dated 9/98 and revised 11/11 showed under the heading of practice the policy included: -Assess bowel function; consult the daily records, bi-weekly summary and admission assessment record. -CNAs (certified nurse aides) will document daily bowel routines on the ADL (activity of daily living) record or equivalent CNA documentation area in the EMR (electronic medical record). -Nurse aides on all three shifts are responsible for monitoring the bowel function of assigned residents. Documentation of bowel activity or lack thereof must appear on the Daily Bowel Record and the ADL sheet (or equivalent). It is the responsibility of the nurse to check the bowel record daily on each shift to be sure the nurse aides are properly documenting. It is only with accurate and consistent documentation that the resident's need for intervention can be evaluated. -Nurses will evaluate the resident's bowel pattern. Laxatives, suppositories or enemas will be given on an individual basis as prescribed by the physician. -Bowel function is an essential component of the nursing assessment. Many residents are admitted with bowel problems. One of the most important ways to assist residents to higher quality of life is to try to establish a regular pattern of elimination. The facility's policy and procedure on Bowel Management, dated 9/98 and revised 11/11 further gave the following definitions: -Constipation: Infrequent passage of dry, hard stool. Most constipation will pass without manual extraction through the use of laxatives, enemas, high fiber diets, hydration and other remedies. In constipated residents, many times doing a digital exam, if not contraindicated, will stimulate the bowels to move. -Impaction: A firm, immobile mass of stool most often in the rectum, but may also occur in the sigmoid or descending colon. May be diagnosed per digital exam, x-ray, CT scan or other methods. 1. Review of Resident #2's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool used in the care planning process, dated 8/22/11, showed staff assessed the resident as follows: -Always incontinent of bowel; -Constipation not present; and -No additional [DIAGNOSES REDACTED]. Review of the resident's hospital Admission History and Physical, dated 8/4/11, showed the resident was admitted to the hospital from the skilled nursing facility with shortness of breath and mental status changes. Further review of the resident's past hospital records (page 12 of 34) showed under laboratory results, a CT Abdomen Pelvis with Contrast conducted on 8/4/11 showed a large fecal impaction. The impression also showed fecal impaction. During an interview on 1/14/14 at 12:00 P.M. the resident's family member (FM A) said the resident had a hospitalization in August 2011 related to a fecal impaction. He/She said following the August 2011 hospitalization the resident was moved to a different floor in the facility because the family felt staff should have been able to assess for and prevent the fecal impaction. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment tool used in the care planning process, dated 11/1/13, showed staff assessed the resident as follows: -Rarely or never understands or makes self understood; -Severely impaired for daily decision making; -Did not walk; -Occasionally incontinent of bowel; and -[DIAGNOSES REDACTED]. Review of the resident's November 2013 physician order [REDACTED]. -Polyethylene [MEDICATION NAME] (laxative) 17 gram dose daily for constipation; -[MEDICATION NAME] (stimulant laxative) 10 mg suppository for constipation once daily as needed; -Milk of Magnesia 30 mls daily as needed for constipation; and -Disposable enema 133 mls, daily as needed for constipation. Review of the resident's November 2013 medication administration records (MARs) showed staff did not document administration of any as needed medications for constipation. Review of the resident's plan of care, dated 11/1/13 showed staff assessed the resident was unable to make his/her needs known and was incontinent of bowel and bladder. The plan of care directed staff to encourage good hydration, but did not specifically address constipation for the resident. Review of the resident's December 2013 physician order [REDACTED]. -Polyethylene [MEDICATION NAME] (laxative) 17 gram dose daily for constipation; -[MEDICATION NAME] (stimulant laxative) 10 mg suppository for constipation once daily as needed; -Milk of Magnesia 30 mls daily as needed for constipation; and -Disposable enema 133 mls, daily as needed for constipation. Review of the resident's December 2013 medication administration records (MARs) showed staff did not document administration of any as needed medication for constipation during the period of 12/1/13 through 12/23/13 . Review of the resident's physician order [REDACTED]. ("[MEDICAL CONDITION], often called [DIAGNOSES REDACTED]icile or [DIAGNOSES REDACTED], is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon." http://www.mayoclinic.org/diseases-conditions/[MEDICAL CONDITION]/basics/definition/con- 664). During an interview on 1/16/14 at 2:05 P.M. LPN H said a loose stool, similar to the liquid stool that presents with [MEDICAL CONDITION] may go around an impaction and present as diarrhea. He/She said the soft ware used for the certified nurse aide (CNA) charting would show the loose stool as no bowel movement. (No bowel movement for 72 hours would prompt an assessment.) Review of the resident's CORP - Bowel and Bladder Detail Report showed the CNAs documented the following time frames with no bowel movement for the resident: -12/1/13 at 1:49 P.M. through 12/5/13 at 12:37 P.M.; -12/5/13 at 12:37 P.M. through 12/10/13 at 2:10 P.M.; -12/12/13 at 5:17 P.M. through 12/15/13 at 4:18 P.M.; and -12/17/13 at 6:33 P.M. through 12/21/13 at 9:49 A.M. Review of the resident's Interdisciplinary Notes, dated 12/10/13 through 12/23/13 showed staff did not document assessment or treatment regarding the resident's bowel management. Review of the resident's Interdisciplinary Notes, dated 12/24/13, showed at 2:51 P.M. LPN H documented the resident's abdomen was "distended and tender to palpation - obstructive series ordered." Review of the resident's Interdisciplinary Notes, dated 12/24/13, 11:13 P.M. showed RN D documented at 7:00 P.M. the resident's physician was contacted regarding the obstructive series showed the resident with a distal obstruction. The resident continued to have pain with palpation and his/her abdomen continued to be distended. ... RN D further documented the resident was sent to the emergency room via ambulance. Further review of the resident's December 2012 POS showed on 12/24/13 at 9:30 P.M. the resident's physician directed staff to send the resident to the emergency room for an evaluation and treatment. Review of the resident's hospital History and Physical, dated 12/25/13 showed the resident was admitted to the hospital on [DATE] with a history of dementia and impacted colon (per the spouse). He/She presented the Emergency Department from the nursing home with a two day history of abdominal distention. The family said they noted the distention"yesterday" and the resident was given [MEDICATION NAME] (laxative) last night with a small bowel movement this morning. In the Emergency Department the resident was found to have a fecal impaction/colonic obstruction on computed tomography (CT). She was manually disimpacted and passed [MEDICATION NAME] and stool. Review of the resident's hospital records (page 10 of 12) showed the results of a CT Abdomen Pelvis with contrast on 12/25/13 at 12:27 A.M. showed the CT images demonstrated significant colonic distention. "A very large and significant impaction of the rectum is demonstrated with the rectum measuring over 14 cm in diameter." Review of the resident's hospital Discharge Summary and Inpatient Acute therapy orders at transition of care, dated 12/27/13 showed the resident was admitted through the Emergency Department with abdominal distension and findings of "massive fecal impaction and resulting colonic obstruction on CT." Review of the resident's Interdisciplinary Notes, dated 12/28/13 at 1:58 A.M. showed staff documented the resident returned to the facility at 5:30 P.M. via ambulance. The resident's admitting [DIAGNOSES REDACTED]. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: -Rarely or never understands or makes self understood; -Severely impaired for daily decision making; -Did not walk; -Always incontinent of bowel; -Constipation not present; and -[DIAGNOSES REDACTED]. Review of the resident's Care Area Assessment (CAA), a federally mandated portion of the care planning process, dated 1/3/14, showed the areas of dehydration/fluid maintenance did not trigger and staff did not discuss the issue of a fecal impaction in the care area assessment to indicate it should be carried over to the care planning process. Review of the resident's January 2014 physician order [REDACTED]. Review of the resident's January 2014 POS showed on 12/27/13 the resident's physician directed staff to provide the resident with the following: -Polyethylene [MEDICATION NAME] (laxative) 17 gram dose daily for constipation; and -[MEDICATION NAME] (stimulant laxative) 10 mg suppository for constipation once daily as needed. Review of the resident's plan of care, dated 1/3/14, showed staff assessed the resident as at risk for dehydration and constipation. The care plan further showed the resident: -Recent history of constipation; -Was incontinent of bowel and bladder; and -Required staff to provide incontinence care. Further review showed the plan of care directed staff to monitor/assess the resident for constipation and active bowel sounds with a start date of 1/9/14. During an interview on 1/13/14 at 10:30 A.M. Nurse Manager B said the resident was mostly unresponsive, totally dependant for activities of daily living, had a recent hospital stay, and recently became a hospice patient. During an interview on 1/14/14 at 12:00 P.M. the resident's family member (FM A) said he/she came to visit the resident on 12/23/13 and the resident's abdomen was visibly distended and "hard as a drum." FM A said he/she informed the nurses and after a obstruction series was completed at the facility the resident was sent to the emergency room . The emergency room physician told FM A that this was very serious. FM A said the resident's entire large intestine was full of stool. He/She said the test showed in some areas the intestine measured 13 cm in diameter. He/She said "They should have been able to assess a bowel problem and prevent this hospitalization ." FM A said the resident spent Christmas Eve and Christmas day in the hospital "getting enemas and being cleaned out." FM A said we just want him/her to be "safe, clean, and comfortable." During an interview on 1/15/14 at 9:05 A.M. CNA H said staff are to chart the resident's bowel movements every time he/she has one and the hospice staff also know to report bowel movements so that it can be recorded. During an interview on 1/15/14 at 11:00 A.M. LPN H said the resident was having bowel movements prior to the hospitalization . He/She had not been assessing the resident's bowel sounds prior to the recent hospitalization . He/She said the resident's family member first noticed the resident's distended abdomen. LPN H said when he/she assessed the resident after the family member noted the distended abdomen the resident's abdomen was very distended and firm. He/She gave the resident [MEDICATION NAME] (laxative) and when it didn't work in 24 hours, he/she asked the physician to order an obstruction series. LPN H said the evening or night shift is supposed to pull the report to show anyone who had not had a bowel movement in 72 hours and that as far as he/she knew the resident had not been on that report. During an interview on 1/15/14 at 3:50 P.M. the evening shift LPN I said he/she had been off just prior to the resident's hospitalization . LPN I said he/she pulls the computer report that shows any resident who has not had a bowel movement in three days. LPN I said the resident was never on the list of residents who required a laxative based on no bowel movement for the past three days. He/She said prior to the resident's hospitalization for bowel obstruction, he/she did not routinely check for bowel sounds. He/She said it would not be routine to check for bowel sounds unless a resident had a history or a complaint of constipation. LPN I said he/she was not aware the resident had a prior history of bowel obstruction. During an interview on 1/16/14 at 2:05 P.M. LPN H said the computer treats a loose bowel movement as no bowel movement, so if a loose bowel movement is going around an impaction, it would flag on the list of residents with no bowel movement in the last 72 hours. He/She said day shift does not routinely pull the list of residents with no bowel movement in the last 72 hours. LPN H said he/she did not know the resident had a prior history of a fecal impaction until after this happened and the resident's spouse told him/her it had happened before in 2006 or 2007. Observation of the resident throughout the survey dates of 1/13/14 through 1/17/14 showed the resident was occasionally alert, but unable to make his/her needs known, and required total staff assistance for all of his/her care.

Based on observation, interview, current and closed record review, the facility staff failed to provide care to prevent the development of pressure sores and promote healing of existing pressure sores for four of 21 sampled residents (Residents #19, #1, #14, and #5). Staff did not provide ongoing skin assessments, follow Physician orders, and follow their own policy for repositioning to prevent decline in residents' skin condition and promote healing of existing pressure sores. The certified census was 105 residents. 1. Closed record review of Resident #19's history and physical report dated 12/17/13, showed "resident admitted to hospital for urinary tract infection and had a prior hospitalization [DATE] through 12/4/13, for [MEDICAL CONDITION] of his/her left ankle which was treated with antibiotic". Review showed the resident's [DIAGNOSES REDACTED]. Review of the resident's nurses' notes showed staff readmitted the resident to the facility on [DATE]. Review showed staff documented the following skin assessment information; open area to both gluteal folds; right gluteal 0.5 centimeters (cm) by 0.5 cm, left gluteal 0.1 cm by 0.1 cm, excoriation noted at the rectal area. Resident lethargic, slow to arouse left leg slightly swollen, crack no redness, [MEDICAL CONDITION]. Further review showed staff did not record any other open areas or skin impairments at the time of the resident's readmission. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment tool used for planning care, dated 12/23/13 showed staff assessed the resident as follows: - Required extensive assistance of staff for bed mobility and transfers; -Incontinent of bowel and bladder; -Did not walk; -At risk for pressure sore development, and had two stage II pressure sores (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) upon admittance; - Brief Interview for Mental Status (BIMS) score was three (severely impaired). Review of the plan of care dated 12/23/13, showed staff documented the resident returned from hospital with two Stage II pressure sores on his/her coccyx, at risk for breakdown due to decreased mobility, incontinence, and general weakness. Review showed staff planned the following care: - Provide the resident a shower two times a week; -Contact family and physician if any problems noted, provide treatment as ordered, notify physician of abnormal findings or if treatment is not effective; -Reposition resident while in bed or wheel/gerichair and provide pressure relief; -Break tasks into subtasks for completion; -Provide peri care and barrier protection after each incontinent episode as needed. Wears briefs for dryness. - Provide weekly skin assessment, document findings and notify physician of any problems. Review of the resident's Braden Scale (assessment to predict risk of pressure sore development) dated 12/25/13, showed a score of 12 (a score of 12 or below = high risk). Review of nurses notes dated 12/27/13 showed staff documented the resident developed two new pressure sores. Review showed staff assessed the resident; "has blisters to bilateral heels, noted to be rubbing heels into bed. Right heel measures 4.5 cm by 7.0 cm, left heel 4.5 cm by 3.5, fluid filled no drainage noted. Fax out to physician for skin prep and heel protectors." Review of the resident's skin assessment dated [DATE], showed staff assessed the areas on the resident's heels as follows: -"Right outer heel, wound black tissue to right heel clear drainage, no odor, wound base white, and periwound macerated. Wound measured 6.0 cm by 3.6 cm, no depth or pain. Eschar (thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue) and slough present, no granulation, drainage scant and clear. Physician ordered treatment of [REDACTED]. -Left Heel large fluid filled blister measuring 4.5 cm by 3.5 cm, wound edge pink and intact. Physician ordered treatment skin prep to both heel every shift; -Review showed staff documented "Not Applicable" in the section titled 'Cause'. Review of the resident's most recent plan of care dated 12/23/13 showed staff did not update the care plan with additional interventions, after staff identified the resident's new pressure sores on his/her heels on 12/27/13, to promote healing or prevent further decline. Review of the resident's interdisciplinary notes dated 1/1/14, showed staff assessed; bilateral heels with dried blisters, skin remains intact, "[MEDICATION NAME]" applied to bilateral heels and heel protectors on. Review of the resident's interdisciplinary notes dated 1/4/14, showed staff documented; "resident's family member stated he/she had severe sores on both heels, demands to see Director of Nurses (DON), family made aware DON not here and supervisor made aware. This nurse observed resident's heels, blisters opened, black eschar tissue noted to right heel, the left heel opened pink tissue noted, will follow up with measurements, notify physician and follow wound protocol." Review of the resident's skin assessment dated [DATE], showed staff documented; left heel blister opened, Stage II surrounding old calloused tissue from blister, surrounding [DIAGNOSES REDACTED]. The resident's left heel wound measured 4.7 cm by 5.3 cm with no depth and pain rated as a 5 on a scale of 1 to 10. Physician ordered treatment of [REDACTED]. Review of the resident's interdisciplinary notes dated 1/6/14, showed staff documented; "staff spoke with family members regarding bilateral heel wounds and family discussed a different type of chair for resident. Family talked about taking resident to an outside wound clinic regarding heel wounds. Staff reported the facility had a wound consultant that could see resident's wounds. Staff reported in speaking with Wound Consultant that it may be a day or two before he/she could come assess resident's wounds due to weather. Occupational therapy assessed resident's wheelchair and recommended a broda chair. Reported to DON and placed an order for [REDACTED]. Review of the resident's skin assessment form dated 1/6/14, showed staff assessed the resident's right heel pressure sore as Stage II and documented "has center that is brown (eschar) and skin intact, smaller area of 2.5 cm by 2.0 cm is open in the center. The residents right heel wound measured 5.0 cm by 4.5 cm with .12 cm of depth tissue necrotic/eschar and was unstageable". Pain level rated a 1 on a scale of 1 to 10. The physician treatment order changed to [MEDICATION NAME] cream with 4 by 4 (gauze dressing)then cover with and and wrap with Kling (gauze dressing wrap) once daily until healed. Review of the resident's skin assessment dated [DATE], showed staff documented the resident's left heel pressure sore as a Stage II which measured 4.0 cm by 5.0 cm by .12 depth. Staff assessed the area with slough, light serous drainage with mild odor and unstageable. Staff documented a treatment of [REDACTED]. During an interview on 1/15/14 at 2:00 P.M., the resident's family said the resident had pressure sores on both heels. Family member said the resident would rub his/her heels on the footrest of the gerichair. The family member said the staff did not identify the resident's heel pressure sores until one of them was black. During an interview on 1/15/14 at approximately 4:30 P.M., the DON and Administrator said the resident developed heel pressure sores after his/her most recent hospitalization . She said the areas started out as blisters and the resident would rub his/her feet on the footrest of his/her gerichair and on the sheets while in bed. During an interview on 1/17/14 at 8:00 A.M., Nurse Manager B said she could not locate a skin assessment when the resident was re-admitted to the facility on [DATE]. Nurse Manager B said she did not know why staff did not identify the resident's heel pressure sores before they were necrotic (black). 2. Review of Resident #5's Significant Change MDS, dated [DATE] showed staff assessed the resident as follows: -Rarely or never makes self understood; -Sometimes understands others; -Severely impaired for daily decision making skills; -Required extensive assistance of two or more persons for bed mobility; -Required total assistance of two or more persons for transfers; -Required extensive physical assistance of one staff for eating; -Always incontinent of bowel and bladder; -Pressure relieving device for chair; -Pressure relieving device for bed; -Nutrition or hydration intervention to manage skin problems; -Applications of ointments/medications other than to feet; -At risk for developing pressure ulcers; and -No pressure ulcers. Review of the resident's CAA (Care Area Assessment - a portion of the federally mandated Resident Assessment Instrument used in planning care), dated 8/9/13 showed staff documented the resident as at risk for developing pressure ulcers and should be developed to direct staff to assist with frequent repositioning and skin hygiene. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Rarely or never makes self understood; -Rarely or never understands others; -Severely impaired for daily decision making skills; -Required extensive assistance of two or more persons for bed mobility; -Required total assistance of two or more persons for transfers; -Required extensive physical assistance of one staff for eating; -Always incontinent of bowel and bladder; -Pressure relieving device for chair; -Pressure relieving device for bed; -Nutrition or hydration intervention to manage skin problems; -Applications of ointments/medications other than to feet; -At risk for developing pressure ulcers; -One stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) ; -Pressure ulcer care; and -Application of nonsurgical dressings other than to feet. Review of the resident's plan of care, dated 11/8/13, showed staff assessment of the resident included the following: -Incontinent of bowel and bladder; -Required staff to assist with repositioning, etc.; and -Stage II pressure ulcer on right buttock. Further review of the resident's plan of care, dated 11/8/13, showed the plan of care directed staff to provide care that included the following for the resident: -Observe skin and document with each care provided; -Report problem areas with skin to family and physician; -Weekly skin assessments documented and notify physician of any abnormalities; -Pressure relieving devices in bed and wheelchair; -Assist to bed after meals; -Use barrier cream after brief changes; -Notify my nurse of any red/open areas; -Turn and reposition frequently while up in wheelchair or in bed; and -Nurses- preform treatments as ordered for Stage II on buttock. Review of the resident's CORP - Resident Profile Report, dated 1/16/14 showed it did not direct staff to provide frequent repositioning or monitoring for skin breakdown. Review of the resident's Interdisciplinary Notes, dated 12/12/13 showed staff documented the resident had open areas to his/her buttocks and perineum. Further review of the resident's Interdisciplinary Notes, printed on 1/14/14 showed staff did not document, in the Interdisciplinary Notes, any new skin break from 12/12/13 to current. Review of the resident's Skin Assessment Forms, dated 12/6/13, 12/12/13, 12/26/13, and 1/2/14 showed staff documented the resident did not have any open areas on his/her body. Review of the resident's physician order [REDACTED]. -Apply [MEDICATION NAME] cream to perirenal if red or irritated; -Skin assessment, body assessment check and record weekly with shower or bath; and -Barrier cream to buttock every shift and as needed. The January 2014 POS, did not contain new orders related to a Stage II pressure ulcer on the resident's right gluteal fold (lower buttock area) During an interview on 1/13/14 at 11:15 A.M. Nurse Manager B said the resident had dementia, was incontinent of bowel and bladder, had an excoriated perirenal "on and off," and did not have any pressure ulcers. Observation on 1/13/14 at 4:35 P.M. showed CNA I and CNA J provided incontinence care for the resident. A brief that was wet with urine a smear of fecal material was removed, resident cleaned and clean brief applied. Observation of the resident's skin showed an open area approximately 2 cm by 0.5 cm on his/her right gluteal fold. Both CNA's said they did not have prior knowledge of the open area on the resident's gluteal fold. CNA I said he/she had been off for a week (only works as needed) and CNA J said he/she was agency staff. CNA I said he/she would report the open area to the charge nurse. CNA I and CNA I transferred the resident to a specialized wheeled chair. The chair did not contain a pressure relieving device. At 5:00 P.M. the CNAs wheeled the resident to the dining room for the evening meal. At 6:30 P.M. the resident remained in the chair with no pressure relieving device in place. Observation and interview on 1/14/14 at 6:24 A.M. showed CNA K removed a brief that was wet with urine and provided pericare for the resident. CNA K did not apply barrier cream prior to applying a clean brief. CNA K said the resident gets pressure areas on the backs of his/her right leg. CNA K said CNA's are to report any skin issues to the nurses. He/She said the resident used to get up on the night shift, but had some skin issues and was changed to day shift. CNA K said the resident currently had some reddened areas. He/She said the resident's hips are bony. During an interview Nurse Manager B said he/she looks at any wounds weekly. Observation on 1/14/14 at 8:00 A.M. showed the resident sat up in his/her wheeled chair without a pressure relieving device, in the dining room. The resident remained in the dining room with a pressure relieving device in his/her chair until at least 8:46 A.M. Observation on 1/14/14 at 11:35 A.M. showed the resident again in his/her chair without a pressure relieving device. Observation on 1/14/14 at 1:30 P.M. showed the resident sat in his/her room in his/her wheeled chair without a pressure relieving device. Observation on 1/15/14 at 8:45 A.M. showed the resident sat in his/her wheeled chair in the dinning room without a pressure relieving device in the chair. At 9:20 A.M. the resident remained in the chair without a pressure relieving device in the seat of the chair, in his/her room. Observation and interview on 1/15/14 at 9:50 A.M. Nurse Manager B said staff did not report an open area on the resident to him/her. He/She said the day shift staff get the resident up instead of night shift because he/she had an open area a couple of months ago, but he/she does not have any open areas now. Observation with Nurse Manager B and CNA showed the small open area on the resident's right gluteal fold remained open. During an interview on 1/15/14 at 10:45 A.M. Nurse Manager B said he/she obtained a Roho (specialized pressure relieving) cushion for the resident's chair. During an interview on 1/15/14 at 12:00 P.M. LPN A, charge nurse on resident's wing, said he/she was on vacation last week and he/she was unaware of an open area on the resident's gluteal fold. He/She said no staff had reported to him/her about the open area. During an interview on 1/17/14 at 8:00 A.M. the Director of Nursing said CNAs and licensed staff should always be watching for any skin issues. The CNAs should report immediately to the charge nurse and the charge nurse should report to the floor manager or supervisor. It should be documented by the CNA and the licensed staff. Licensed staff should use the algorithm to guide the treatment plan, and notify the doctor and the family. 3. Review of Resident #1's most recent quarterly MDS dated [DATE] showed the staff assessed the resident as follows: - Brief Interview for Mental Status (BIMS) score was a 3 (severe cognitive impairment); - Does not walk; - Always incontinent of bowel and bladder; - Was at risk for pressure ulcers with none at that time; - Weight 126#. Review of the resident's care plan dated 10/08/13 showed: - Potential for skin breakdown; - No current skin breakdown; - Requires skin barrier cream to be provided after incontinent episodes; - May require bilateral heel protectors as indicated; - Will need weekly skin assessments done and documented; - Check skin daily when giving care and notify charge nurse of any red/open areas. Review of the resident's current Physician order [REDACTED]. - [DIAGNOSES REDACTED]. - Heel protectors in bed with initiation date of 09/05/13; - May follow Bethesda LTC skin care prevention protocol. Review of the resident's interdisciplinary notes showed: - Braden scale dated 01/14/14 as 14 (moderate risk for skin breakdown); - The nutritional assessment documentation dated 07/09/13 showed the resident had a pressure ulcer; - Last General Skin Check completed 01/07/14 showed no skin breakdown; - No documentation regarding skin since 01/07/14. Review of the Resident's Profile Report located on the inside closet door of the resident's room showed: - Heel protectors on when in bed; - Full incontinence - purple briefs; - Shower on Wednesday and Saturday evenings- Get nurse for weekly skin assessment. Observation of the resident's incontinence care and skin while lying on the bed on 01/15/14 at 10:00 A.M. showed: - The resident currently resided on the fourth floor; - Bilateral heel protectors were not on; - Right heel was red. CNA E applied pressure with her finger to the red area on the right heel per surveyor request to see if blanchable (indicator to show if blood flow returned quickly when pressure was applied). The area was blanchable; - Left outer heel was pink; - An approximate 5 inch reddened area on left hip near the area when the incontinence brief was taped; - CNA E changed the brief and cleansed the resident. CNA E did not apply skin barrier cream to the skin; - CNA E commented about the reddened area on the hip stating that this is why he/she used the larger briefs on this resident rather than the smaller one he/she had just removed. - CNA E did not apply heel protectors before leaving the room; - CNA E did not say if she would notify the nurse of the reddened areas. During an interview on 01/17/14 at 8:50 A.M. RN D and LPN F said: - Skin assessments are done weekly on every resident; - Documented skin assessments are located in the Electronic Health Record under the assessment tab; - Residents should be turned and repositioned every 2 hours. During an interview on 01/17/14 at 8:50 A.M. RN D said: - He/she was responsible for the resident's care that day; - He/she did not receive information in report regarding the resident's skin; - He/she was not aware of any reddened areas on the resident's skin. 4. Review of Resident #14's Electronic Health Record showed: - Original admission to the facility on [DATE] and most recent current readmission to facility on 03/31/11. - The resident currently resided on the fourth floor. Review of the resident's most recent quarterly MDS dated [DATE] showed the staff assessed the resident as follows: - Severely impaired in cognition and decision making; - Does not walk; - Always incontinent of bowel and bladder; - Was at risk for developing pressure sores; - No current pressure ulcers but did have Moisture Associated Skin Damage (skin damage caused by urine/feces, perspiration and/or drainage); - Was not currently on a turning/repositioning program. Review of the resident's care plan dated 11/01/13 showed: - Potential for pressure ulcers due to decreased bed mobility, incontinence and history of pressure ulcers; - Skin is currently excoriated; - Monitor skin with care provided for problem areas; - Provide treatments as doctor orders; - Assess skin at least weekly and document findings; - Help to reposition in bed or wheelchair routinely off buttocks; - Encourage to lie down after meals; - Extensive assist with all ADLs including incontinence care, bed mobility and transfers secondary to dementia [MEDICAL CONDITION](stroke) with left side weakness. - Transfer with Hoyer lift and two person total assist. Review of the resident's last annual comprehensive MDS dated [DATE] showed the staff assessed the resident as follows: - Brief Interview for Mental Status (BIMS) score was a 4 (severe cognitive impairment) - Does not walk; - Always incontinent of bowel and bladder; - No current pressure ulcers but had a healed Stage II since the prior assessment; - Was currently on a turning/repositioning program. Review of the resident's current physician orders [REDACTED]. - [DIAGNOSES REDACTED]. - May follow Bethesda LTC skin prevention protocol; - Resident to lie on sides at all times when in bed to prevent pressure areas; - Cleanse wounds to bilateral ischial folds(bottom of buttocks), apply mixture of barrier cream and [MEDICATION NAME] powder twice a day; - Sensi cream applied to reddened areas on buttocks, after every incontinent change and check. Review of the resident's interdisciplinary notes showed: - The most recent skin assessment form was dated 12/17/13; - On 12/17/13 the left lower buttock had "excoriated skin with a bloody area" and measured 8 cm length by 8.5 cm width and 0.2 cm depth; - On 12/17/13 the right lower buttock had "excoriated skin with a bloody area" and measured 5.0 cm length by 5.0 cm width and 0.1 cm depth. During observation and family interview on 01/04/14 at 12:30 P.M. showed: - The resident resided on the fourth floor; - Resident sitting up in reclining wheelchair in room; - Daughter was feeding the resident lunch and commented that she was worried because the resident's bottom was constantly sore. During an interview on 01/15/14 at 9:00 A.M. CNA E said: - The CNAs get verbal report from the nurse at the beginning of every shift; - The CNAs get written instructions for care by looking at the Resident Profile Report located on the inside closet door of the residents' room and also by looking at the kiosk located in each hallway. Review/observation of the Resident Profile Report on 01/15/14 at 10:00 A.M. (which is normally located on the inside closet door of the resident's room) showed: - The resident did not have a profile report in his/her name. Noted that his/her roommate had two (one on his/her side of the closet and one on the resident's side of the closet). Review of the Resident Profile Report located on the Electronic Health Record/kiosk showed: - Transfer - 2/Hoyer provide a bath blanket between myself and Hoyer pad; - Lie down after lunch; - Preferred daily routine; Up at 0600 (6:00 A.M.). bedtime between 2200-2300 (10:00 P.M. and 11:00 P.M.; - The Resident Profile Report does not say how frequently the resident should be repositioned/turned. Observation on 01/15/14 at 10:00 A.M. showed: - The resident sitting up in reclining wheelchair in room. Observation on 01/15/14 at 12:00 P. M. showed: - The resident remained sitting up in reclining wheelchair in the dining area awaiting lunch. During an interview on 01/16/14 at 8:45 A.M. the Director of Nursing (DON) said: - The Resident Profile Reports are specific written instructions on how to care for each individual resident. They are located on the inside door of each resident's closet and also on the kiosk in each hallway. The staff is trained and told to look at the profile when providing care. Observation on 01/16/14 at 10:00 A.M. showed; - The resident sitting in reclining wheelchair in the dining area. During an interview on 01/16/14 at 10:30 A.M. LPN F said: - The resident has some skin breakdown in the ischial fold (lower buttock) on both sides. Nurses are to cleanse and apply cream. Observation on 01/16/14 at 10:35 A.M. showed: -The resident sitting up in reclining wheelchair in his/her room. During an interview on 01/16/14 at 10:35 A.M. CNA F said: - The resident was transferred from the bed to his/her reclining wheelchair at about 8:00 A.M. - The resident was repositioned and "changed" at approximately 9:30 A.M. - Written instructions for the resident's care is located on the inside of the closet door and also on the kiosk. Interview and observation on 01/16/14 at 1:45 P.M. showed: - The resident being transferred with a Hoyer lift from the reclining wheelchair with assist of CNA F and CNA G (the resident had not been repositioned for 4 hours and 25 minutes); - The CNAs removed the urine soiled brief and provided incontinence care; however they did not cleanse all the prior applied cream from the buttocks (approximately 5 inches of white substance was still clearly visible over the lower buttocks); - Skin assessment showed a Stage II pressure ulcer on the left buttock measuring approximately one inch in diameter and a Stage II pressure ulcer on the right buttock measuring approximately 2 inches in diameter. The area surrounding both ulcers was red and inflamed measuring approximately 5 inches around each ulcer. - Both CNAs commented that the ulcer areas "looked better" and that the areas go away and then come back. At one time the buttocks "looked like ground beef".; - CNA F said that the resident had been sitting up in the reclining wheelchair since 9:20 A.M. He/she had checked the resident for wetness at 11:30 and the resident was dry so he/she did not change nor reposition at that time. - CNA G said the resident goes long periods without urinating so he/she doesn't need changed very often; - LPN B then entered the room to apply new cream to the buttocks as ordered. LPN B did not cleanse the old cream off (as ordered) prior to applying the new cream; - LPN B also commented that the ulcers "looked better". He/she had been employed at the facility for over 2 years and the resident "has always had it"; - LPN B said that the ulcers were caused from pressure, friction and shear; - The staff left the room with resident lying on his/ her back in bed (the physician's orders [REDACTED]. During an interview on 01/17/14 at 8:50 A.M. RN D and LPN F said: - Skin assessments are done weekly on every resident; - Documented skin assessments are located in the Electronic Health Record under the assessment tab; - Residents should be turned and repositioned every 2 hours. 5. Observation throughout all days of the survey showed that the fourth floor did not have a Nurse Manager present. Also noted throughout the survey were concerned family members requesting to speak to the survey team regarding care, especially on the fourth floor. Further observation throughout the survey showed an inconsistency in instructions for care between physician orders, resident profile reports, care plans and what was observed. During an interview on 01/15/14 at approximately 10:45 A.M. the Assistant Director of Nursing (ADON) said: - The current fourth floor nurse manager was absent that week; - Nurse Managers attend care plan meetings; - He/she was was trying to do nurse manager responsibilities that week; - Nurse Managers are the contact person for the families. During an interview on 01/16/14 at 8:45 A.M. the Director of Nursing (DON) said: - He/she started employment with the facility in September, 2014. He/she had discharged the fourth floor Nurse Manager in November; - The current fourth floor Nurse Manager was absent the prior two weeks and was also absent this week of survey; - He/she had not replaced the fourth floor Nurse Manager with an interim but did say he/she directed the ADON to try to be on that floor as much as possible.(The ADON had also been on a three month leave of absence until the week prior to survey); - Nurse Mangers attend care plan meetings; - The families know that the Nurse Manager is the contact person for that floor; - Families had been contacting him/her with concerns in the Nurse Manager's absence; Review of the facility's policy and procedure for Skin Integrity, Assessment and Prevention of Wounds/Other Skin Conditions last revised 11/11 showed in part: - It is the policy of the Nurse Manager to oversee this policy; - On admission, the Bethesda Skin Prevention Protocol will be implemented if ordered by the physician; - The admitting nurse will complete a head to toe skin assessment to determine the absence or presence of any existing skin impairment and document accordingly; - An admission evaluation helps identify the residents at risk of developing a pressure ulcer or areas of skin that are at risk for breakdown. Because residents at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, at-risk residents need to be identified and interventions implemented promptly to attempt to prevent pressure ulcers; - Residents as risk should have a visual skin inspection daily. CNAs will report any abnormal finding to a nurse. Some examples of reportable observations are reddened skin, blanching, black or red heel, rashes, denuded or raw skin, skin tears. - Abnormal findings will be assessed by a licensed nurse and appropriate interventions and documentation completed by that nurse; - Change of position on a routine schedule will reduce pressure and aid in providing comfort. An individualized turning/positioning schedule is advised and must be communicated to the CNA; - Minimize skin exposure to moisture, including urine and feces; - Apply moisture barrier product to exposed skin surfaces to provide protection from future incontinent episodes; - For bed bound residents, individualized turning schedule with a minimum of turn every 2 hours; - For chair bound residents, individualized repositioning schedule. Develop plan of care for scheduled rest periods in bed; - Heels should be elevated off the bed surface; - Prevention Protocol: Change position of both bedbound and chairbound residents at least every 2 hours. Have chairbound residents shift weight every 15 minutes as able.

Based on observation, interview and record review, the facility staff failed to provide appropriate dining assistance to two dependent residents (Residents #9 and #5) of 21 sampled residents, to prevent significant and/or on-going weight loss. The certified census was 105 residents. 1. Review of Resident #9's Significant Change MDS, dated [DATE], showed staff assessed the resident as follows: -Able to make self understood; -Usually understands other; -Brief Interview for Mental Status score =4 (0-7 = severe impairment); -Required extensive physical assistance of one person to eat; -Height = 64 inches (5 feet 4 inches); -Weight = 109 lbs; -Unintended weight loss; and -Mechanically altered diet. Review of the resident's Care Area Assessment (CAA), a portion of the federally mandated Resident Assessment Instrument that is used in the care planning process, dated 12/12/13, showed staff assessed the resident with significant decline and weight loss. Weight loss of 14% in one month, 16% in three months, and 12% in six months. The resident has to be fed by staff at this time. Review of the resident's plan of care, dated 12/10/13, showed staff assessed the resident as follows: -With a significant change and beginning hospice care; -Body Mass Index is low; and -Has a significant weight loss. Further review of the resident's plan of care, dated 12/10/13, showed the plan of care directed staff to provide the following: -Assist and feed at meals; -Give verbal cueing and encouragement at meals. During an interview on 1/13/14 at 11:30 A.M., Nurse Manager B said the resident did not have weight loss. Observation on 1/13/14 at 5:30 P.M. showed the resident sat in the dining room with a glass of juice and a glass of water in front of him/her on the table. At 5:35 P.M., staff served him/her a grilled cheese sandwich, green beans and tomato juice. Staff did not sit down to assist the resident with his/her meal. At 6:00 P.M., the resident attempted to feed him/herself the sandwich. He/She had tremors and moved extremely slowly as he/she raised the sandwich to his/her mouth. Staff did not assist, cue, or encourage the resident with his/her meal. Observation on 1/14/14 at 8:25 A.M. showed the resident sat in the dining room attempting to feed him/herself. The resident moved extremely slowly and with tremors. No staff assisted, cued or encouraged the resident with his/her meal. Observation on 1/15/14 at 11:50 A.M. showed staff wheeled the resident to the dining room and up to the table. At 12:26 P.M. staff delivered a plate with ground hamburger, cooked carrots, a brownie, mashed potatoes, and bread and butter. The resident also had water and an empty glass beside her plate. The resident very slowly and with tremors attempted to feed him/herself. At 12:31 dietary staff brought the resident a glass of juice. The resident reached for the glass very slowly and with tremors to drink from it. Staff did not assist the resident. At 12:43 P.M. the resident continued to attempt to feed him/herself very slowly and with tremors. Staff did not assist or provide cueing or encouragement. At 12:45 the resident dropped his/her fork and CNA L assisted the resident by placing a spoon in his/her hand, but did not offer any other assistance or encouragement with the meal. At 12:58 P.M. the resident spilled the food from his/her spoon while attempting to get the food to his/her mouth onto his/her napkin on his/her chest. CNA L assisted with cleaning the food from the resident's chest, but did not assist with feeding or encouraging the resident. At 1:10 P.M. the resident had consumed approximately 25% of his/her meal. He/She continued to try to feed him/herself extremely slowly with tremors. At 1:21 P.M. the resident continued to try to feed him/herself. At 1:24 the resident said he/she was tired and "about done" eating. No staff assisted or encouraged him/her. Observation on 1/16/14 at 7:23 A.M. showed the resident reclined back in a geri-chair in the 3rd floor dining room. The resident's eyes were closed. At 8:07 A.M. a CNA placed the geri-chair into an upright position. The resident opened his/her eyes and took a drink from one of three sippy cups located on a bedside table place in front of the resident. At 8:20 A.M. the resident continued to be seated upright in a geri-chair in the 3rd floor dining room. The resident was able to take a few drinks from sippy cups placed in front of the resident. The resident was offered no food. At 8:23 A.M. the 3rd floor nurse manager placed the resident's breakfast plate on the bedside table in front of the resident. The resident was able to use his/her fingers to pick up and eat one piece of bacon. At 8:33 A.M. the resident had made no more attempts to eat any more food and no staff assisted or encouraged the resident to eat. Observation on 1/16/14 at 1:28 P.M. showed the resident sat at the table with approximately 95% of his/her meal untouched. Observation on 1/17/14 at 8:30 A.M. showed the resident sat at the table, eyes closed, holding a piece of toast to his/her mouth, but not eating. No staff offered assistance or encouragement. At 8:53 A.M. the resident continued to sit at the table. His/Her plate of food and bowl of cereal appeared untouched. An empty glass sat on the table next to his/her plate. The resident's eyes were closed and his/her mouth open. Staff did not provide assistance, cueing, or encouragement. During an interview on 1/17/14 at 9:00 A.M., Nurse Manager B said residents who need assistance with their meals should not go for long periods of time without getting assistance. The residents who can feed themselves get their plates first, then those who require assistance get their plates one at a time so they can be fed at time of service. 2. Review of Resident #5's quarterly Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Rarely or never makes self understood; -Rarely or never understands others; -Severely impaired for daily decision making skills; -Required extensive physical assistance of one staff for eating; -Nutrition or hydration intervention to manage skin problems; -Height was 73 inches (6 feet and 1 inch); -Weight was 135; -At risk for developing pressure ulcers; and -One stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) Review of the resident's plan of care, dated 11/7/13, staff assessed the resident has lost weight, sometimes need help and encouragement with meals and has skin breakdown. Further review of the resident's plan of care, dated 11/7/13, showed the plan of care included the following interventions: -Mechanical soft diet with finger foods; -Whole milk at all meals; -Two shakes with all meals; -Double portions of protein; -Super cereal and cheesy eggs to help improve weight and intake; -Two Cal supplement with med pass related to weight loss; -Put all liquids in sippy cups; -Offer choices; and -Monitor intake, weight, labs and skin integrity. Review of the resident's Interdisciplinary Notes, dated 12/16/13 showed the Dietary Technician Reviewer (DTR) documented the resident has had a 3 pound. weight loss over one month, a 5 pound. weight loss over three months, and a 7 pound. weight loss over six months and the resident has a low BMI (Body mass Index) 17.41. Review of the resident's Interdisciplinary Notes, dated 12/17/13, showed staff documented notification of physician and spouse regarding the dietary recommendations and new orders were received. Review of the resident's Interdisciplinary Notes, dated 12/18/13, showed DTR documented the new order for the 2 Cal supplement and wrote "will monitor tolerance." Review of the resident's CORP - Resident Profile Report, dated 1/16/2014, showed the report directed staff the resident should receive a mechanical soft diet and finger foods. The Resident Profile Report did not show the resident was at risk for weight loss or needed help/assistance with meals. During an interview on 1/13/14 at 11:15 A.M., Nurse Manager B said the resident had dementia. He/She said staff feed the resident and the resident did not have weight loss or pressure ulcers. Observation on 1/13/14 at 5:00 P.M. showed CNA I and CNA J assisted the resident into a wheeled gerichair and wheeled the resident to the dining room. At 5:55 P.M., the resident had a plate with a tuna sandwich, a bowl with green beans and a can of tomato juice on the table in front of him/her. There were no staff at the resident's table. At 6:00 P.M., there continued to be no staff at the table and the resident picked up the tomato juice with his/her right hand, and with moderate tremors, and spilled some of it into the bowl of green beans. He/She then laid the can on top of the green beans. At 6:10 P.M., the tomato juice can remained on top of the green beans and no staff assisted the resident. At 6:12 P.M., CNA J brought a plate to a resident sitting beside Resident #5 and began to feed the other resident, but did not offer to assist or encourage Resident #5. At 6:15 P.M., CNA I took over feeding Resident #5's table mate. CNA I moved Resident #5's bowl of green beans with the tomato juice can on top of them out of the resident's reach, but did not offer the resident any assistance with eating his/her meal. At 6:19 P.M., the resident still had not received any staff assistance to eat his/her meal. At 6:30 P.M., CNA I continued to feed the resident's table mate, but did not feed Resident #5. Observation on 1/14/14 at 8:00 A.M. showed the resident sat in the dining room in his/her gerichair with an over bed table. A divided plate held an omelet, white toast, and ground sausage. A bowl of hot cereal sat beside the plate. Three sippy cups also sat on the over bed table with water and milk in them. The resident sat and looked, but did not try to feed him/herself. No staff assisted the resident with his/her meal. At 8:15 A.M., the resident picked up a piece of toast and pulled the plate into his/her lap. Staff fed another resident nearby, but did not assist the resident with the plate in his/her lap. At 8:32 A.M., the resident's plate remained in his/her lap. At 8:35 A.M., a dietary aide picked the plate up out of the resident's lap and placed it back on the over bed table in front of him/her. The dietary aide did not offer the resident any assistance. The resident picked up the omelet in his/her hand and began to try to feed him/herself. At 8:46 A.M., no staff have offered the resident any assistance or encouragement. Observation on 1/15/14 at 1:10 P.M. showed a carton of 2% lowfat milk sat on the resident's over bed table, in the dining room. At 1:20 P.M., LPN A wheeled the resident out of the dining room saying, he/she "didn't eat good." LPN A said the resident needed to be taken down to see the eye doctor. During an interview on 1/17/14 at 9:00 A.M., Nurse Manager B said residents who need assistance with their meals should not go for long periods of time without getting assistance. The residents who can feed themselves get their plates first, then those who require assistance get their plates one at a time so they can be fed at time of service. He/She said the resident should be receiving supplemental shakes.

Based on observation, interview and record review the facility failed to prevent a fall that resulted in a fracture during a sit to stand lift transfer for one resident (Resident #21), failed to provide adequate assistance during one resident's (Resident #12) mechanical lift transfer, failed to use a gait belt for two resident's (Residents #3 and #5) transfers, resulting in a fall with injury for one resident (Resident #3), and failed to prevent one resident's (Resident #5) skin tears caused by his/her wheelchair. Staff also failed to use a gait belt with transfers, did not keep the call light within reach of the resident, did not place non skid shoes on the resident, and returned the resident to a previous room without making the room safe for the resident (Resident #1). Staff also left one resident (Resident #2), who had a recent fall with injury from his/her wheelchair, in his/her wheelchair for long periods allowing the resident to lean to the right side and forward, and placed the resident back in the wheelchair after the Nurse Manager (NM) said it was not safe and the resident needed another chair. Staff left three residents (Residents #18, #14 and #19) unattended with the bed raised. Staff failed to place a bed alarm for one resident (Resident #14) and failed to use the Velcro leg belt during sit to stand lift transfers for four residents (Residents #2, #4, #19 and #31). The facility census was 135 with 114 residents in certified beds. 1. Review of the facility's Use of Mechanical Lifts policy, dated 08/2011, showed staff are directed to: - Apply waist belt snugly to the resident's waist; - Resident should be capable of standing and grasping lift bar; - Open the legs of stand with leg spreader bar and position stand in front of the resident; - Have the resident place their feet on foot support plate, assist as needed, place shins against shin support, use Velcro belt behind legs if available; - Throughout transfer, observe resident's feet, knees and hands for proper placement; - With the lifting arm device in the lowest position, attach adjustment loops to the hook on the stand; - Position the resident's arms outside of the harness and place hands on the padded handles; - When lifting from a wheelchair always lock the stand and wheelchair; - One staff will use the hand controller while the other guides the resident's body during the transfer. 2. Review of Resident #21's Minimum Data Set (MDS), a federally mandated assessment instrument used to plan care, dated 2/28/13, showed staff assessed the resident as: - Two person physical assist for bed mobility and toileting; - Extensive assistance for dressing and personal hygiene; - Surface to surface transfer only able to stabilize with human assistance; - Wheelchair; - Always incontinent of urine; - One fall with major injury; - Hospice care. Review of the resident's plan of care, updated 2/11/13, showed staff are directed to: - Use standing lift (sit to stand lift) with two CNAs (Certified Nurse Aides) for all transfers: - Staff will be very careful when they use the lift for transferring not to hit legs; - Please notify my physician, family and Hospice team of any falls immediately; - Requires extensive staff assistance of one to two for transfers and toileting. Review of the resident's Fall Risk Assessment, dated 11/7/12, showed staff assessed the resident as: - One to two falls in past three months; - Checked no for being at high risk for falls. Review of the resident's Physician Order Sheet (POS), dated 2/1/2013, showed staff are directed to: - Transfer with assist of two with sit to stand lift (Ordered 1/29/13); - Tubigrips (skin protectors) to bilateral lower extremities; Review of the resident's POS showed on 02/20/13 staff were directed: - X-ray left knee, Right hip, left hip and fax results to physician; - Brace to left shoulder and elbow; - Left knee and leg rigid brace due to femur (upper leg) fracture; - Norco 5/325 (pain medication) one tablet every six hours as needed for pain; - Treat symptomatically; - Bed rest. Review of the resident's x-ray report, dated 2/20/13, showed the resident had an impacted fracture of the distal femur (upper leg). Review of the resident's POS showed on 2/21/13 staff were directed: - Roxanal 20 mg/ml (pain medication) give 0.25 ml sublingual (under tongue) every two hours as needed for pain; - Lorazepam 2 mg/ml give 0.25 ml sublingual every four hours as needed for anxiety and restlessness; - Acetaminophen 650 mg suppository every four hours as necessary for pain or elevated temperature. Review of the resident's Interdisciplinary (IDT) Notes, dated 2/20/13, showed Registered Nurse (RN) A documented a Nurse Assistant (NA) reported to the RN at 8:00 A.M. the resident had a skin tear. The NA told RN A that the resident was in the stand up lift, let go, slipped and had skin tears that needed to be looked at. The RN entered the resident's room and the resident was sitting in a wheelchair with a large skin tear to his/her left arm. The RN cleaned and dressed the skin tear with Teflon and Kerlix (dressing supplies). Review of the resident's IDT notes, dated 2/20/13 at 8:20 A.M. showed, RN A called hospice to notify of resident's fall. Hospice nurse was to notify resident's family and physician. Resident complained of his/her knee hurting when being transferred to bed. Tylenol 650 mg given for pain. Review of the resident's IDT notes, dated 2/20/13 at 9:30 A.M., showed staff documented skin tears to right shin cleansed, steri strips applied on lower skin tear with Teflon applied to upper skin tear with Kerlix. During an interview on 3/7/13 at 10:45 A.M., CNA C said lift transfers require two staff assistance. CNA C said Resident #21 used the sit to stand lift and he/she assisted the resident on 2/20/13 when the resident was injured. CNA C said the resident's legs gave out and the resident's right arm came out of the sling and the sling then slid up on one side of the resident around the resident's neck. CNA C said he/she was in back of the resident holding the wheelchair. CNA C said CNA B operated the lift in front of the resident and unhooked the lift belt when the belt slipped up around the resident's neck. The resident then sat hard into wheelchair. CNA C said the resident may have hit the wheelchair hard. The resident received a skin tear to his/her arm and a bruise on his/her head by the temple. CNA C said RN A examined the resident after the fall. The resident was then taken to breakfast in his/her wheelchair and after breakfast transferred to a recliner. CNA C said the belt used may have slipped during the transfer and said he/she did inform RN A. During an interview and observation on 3/7/13 at 2:20 P.M., CNA C showed the DHSS surveyor the lift belt in the third floor west side tub room that sat on a sit to stand lift. CNA C showed that the lift belt slips when used. Further, CNA C showed that the leg strap does not hold in place. CNA C said most of the staff would know not to use the lift. Observation showed there was not a sign directing staff to not use the lift belt. CNA C said that the Nurse Manager was aware of the lift belt needing repair. During an interview on 3/7/13 at 11:30 A.M., Nurse Manager (NM) D said two staff are required for all mechanical lift transfers. NM D said Physical Therapy decides how a resident is transferred if having problems with a transfer. NM D was not in the building on 2/20/13 when resident #21 was injured. NM D said the resident had previously been transferred with a gait belt by two staff and then resident's family requested the resident be transferred with the lift due to skin tears. NM D did not know if the resident had been evaluated by Physical Therapy. NM D said he/she was told the resident let go of the lift as the resident was being transferred. NM D said the staff present were RN A, CNA B and CNA C. NM D said he/she talked to RN A and does not remember what RN A said about the resident's fall. Further, NM D said he/she was told the resident did not go to the hospital and x-rays were done in the facility. NM D said the resident had a right distal femur fracture and some bruising. The resident had a splint on his/her leg. NM D said he/she did not have any concerns about the lift equipment needing repairs. NM D said staff had not told him/her of any concerns about needed repairs. During a telephone interview on 3/7/13 at 3:30 P.M., RN A said that on 2/20/13 CNA C told him/her the resident had a skin tear from slipping in the sit to stand lift. When RN A entered the resident's room the resident was in his/her wheelchair. RN A said the resident had a skin tear on his/her left upper arm, left leg, lower left leg and right arm by elbow. The resident complained of pain when moved. RN A notified the Hospice nurse and the Hospice nurse notified the resident's family and physician. The resident's physician then ordered x-rays. RN A did not know of any problems or malfunctions with the lift. RN A said CNA C said the lift belt came up on the resident. When RN A entered the resident's room the lift belt was not on the resident. During an interview on 3/7/13 at 4:45 P.M., the Director of Nursing (DON) said mechanical lifts may be used for a resident without a physical therapy recommendation due to decline in a resident's ability to transfer with a gait belt. The DON said there should be two staff present for all mechanical lift transfers. The DON said on 2/20/13 at 11:00 A.M. she was informed of the accident with resident #21 by the resident's family member. The DON then did examine the resident and interviewed the staff present when the resident was injured. The DON said CNA B and CNA C told her that they were getting the resident up with the lift to transfer the resident to his/her wheelchair. The resident was holding on to the lift and approximately 3/4 of the way up the resident let go. The belt came up around the resident's neck and CNA B then released the belt and the resident landed in the wheelchair. The resident landed mostly on the front of the wheelchair. CNA C said the skin tears may have been caused by him/her grabbing the resident as the resident went into the wheelchair. The CNAs then had RN A come to the resident's room. RN A then assessed the resident and left the resident in the wheelchair or recliner. The DON observed the resident in his/her bed. X-rays had been ordered due to the resident's complaint of pain. The DON said she called the hospice nurse to report the resident's injury. The DON said the lift belt should be securely fastened and under the resident's breast when used. Further, the DON said during the initial investigation CNA B and CNA C did not tell her the belt had slipped up on the resident and told her that after she investigated the transfer. CNA C then attempted to use it on another resident after Resident #21's fall and then realized the belt needed repair. During the interview the DON showed the DHSS surveyor the lift belt now in the DON's office as of 3/7/13. The DON said staff should have removed the lift belt from the floor to prevent it being used by staff. During an interview on 3/8/13 at 8:55 A.M., the Hospice Nurse said the resident fell during a transfer with the sit to stand lift. He/She said CNA C had been the spotter and CNA B operated the lift during the transfer. CNA B and CNA C told him/her that the resident's legs buckled and the lift belt went up around the resident's neck. Staff then transferred the resident to his/her recliner. The Hospice nurse notified the resident's physician of the fall and the physician ordered x-rays. The resident had a skin tear on his/her right elbow and a knot on right side of forehead close to temple. The resident's x-rays showed a distal femur fracture. During an interview on 3/8/13 at 9:00 A.M., CNA B said a fall happened with Resident #21 on the sit to stand lift about two weeks ago. CNA C had been in back of the resident's wheelchair and CNA B operated the lift. CNA B said the lift belt had been put on the resident under his/her breast and pulled tight. CNA B did not remember the belt coming loose on the resident. The lift had been all the way up to standing position and the resident let go of the lift and the belt slid up to the resident's neck. CNA B said it happened fast and when the belt was around the resident's neck he/she released the belt and the resident landed on front edge of the wheelchair. The resident had skin tears on his/her arms, his/her knees had skin tears and a swollen, bump on his/her forehead from the lift he/she thought. CNA B said the resident's care plan directed staff to use the sit to stand lift for the resident and family requested the lift. CNA B said he/she had told a nurse the resident needed a different form of transfer due to inability to hold tightly. CNA B did not know if the belt came loose during the transfer. After the fall CNA C went to get the charge nurse to come to the resident's room. Review of CNA B's written statement, dated 2/20/13, showed CNA B documented he/she went in to get Resident #21 up in the morning. CNA B was trying to get the resident's shirt on and the resident kept leaning back in the bed. CNA B and CNA C then hooked the resident up to the lift and when they started to raise the resident up his/her knees and legs gave way and the resident let go of the lift. The belt that was around the resident then was unsnapped as it was choking the resident. CNA C grabbed the resident and was trying to hold him/her and in the process the resident received skin tears and complained about his/her leg hurting. Review of CNA C's written statement, dated 2/20/13, showed CNA C documented he/she assisted CNA B to transfer Resident #21 with the stand up lift. As they lifted the resident his/her legs gave out and the resident let go of the lift and fell to his/her wheelchair right on the front edge. CNA C held the resident until CNA B could unhook the belt from around the resident's neck. CNA B and CNA C then pulled the resident back into the wheelchair. CNA C asked CNA B to get the nurse due to the bleeding on the resident's arms. CNA C documented it happened so fast he/she did not where the resident hit his/her head or leg. Review of the DON's written statement, dated 2/20/13, showed the DON documented on 2/20/13 at 11:00 A.M., Resident #21's family member informed the DON of the resident's fall. The DON went to the resident's room and examined the resident. The resident was lying flat in bed with a pillow under his/her left knee and ice bag to his/her right temple. Further, the resident's left upper arm had a bandage wrapped around it. When the resident's knee was touched the resident groaned in pain. The resident's left distal shin had a bandage on two skin tears. The resident had a skin tear on his/her right swollen deep purple elbow. The resident groaned in pain when elbow moved. Resident's family member said the resident had bruising to his/her chest and the DON did not observe the resident's chest due to the resident's pain. The DON met with RN A and he/she said he/she had been called to the resident's room about 8:00 A.M. by a CNA as the resident had slid through the stand up lift. When RN A saw the resident he/she was seated back in the wheelchair. The resident then was assisted to bed and RN A made her assessment and treated the wounds. RN A then called the Hospice nurse and received orders for x-rays of the resident's hips and knees. The DON met with CNA B and CNA C who said the resident had been weak and unable to remain upright when upper body dressing had been attempted. The sit to stand belt was placed around resident and latched. Next the resident had been positioned in the lift with his/her feet on the platform and his/her knees against the rest. As the CNAs raised the resident in the lift his/her knees buckled, resident's arms extended into the air and the sling slid up around resident's neck. CNA B then released the belt clip so the resident did not choke and caused resident to "plop" onto edge of wheelchair. Both CNAs said things happened so quickly they are unable to determine whether any of the resident's body made contact with the lift or at all. The resident was then placed in wheelchair and CNA C went to get charge nurse. CNA C said he/she may have caused the skin tear to the resident's right elbow when he/she grabbed the resident. CNA B and CNA C said the bruise to the resident's head may have been from the lift. Neither CNA could account for the left upper arm injury. Skin tears to the resident's left lower leg may have been from contact with the lift base. X-rays were done at 1:45 P.M. The x-ray reports showed a left impacted femoral fracture. Family member had been present when x-ray report received. The resident's physician did not recommend any type of hospitalization as resident was not a surgical candidate. During an interview on 03/07/13 at 2:30 P.M., CNA G said he/she was aware a resident was injured when staff used one of the sit to stand lifts and the lift had been stored in the west side shower room after the injury. During an interview on 3/7/13 at 2:40 P.M., CNA E said he/she had heard a resident was injured during the use of one of the sit to stand lifts. The CNA said he/she did not think that particular resident was very comfortable using the lift, but the resident's family member was okay with staff using it. The CNA said he/she had not received any instruction not to use a particular lift or sling on the third floor. During an interview on 03/07/13 at 2:45 P.M., CNA S said the sit to stand lift and hoyer lifts were stored in the shower rooms and he/she was not aware there had been a problem with any equipment on the floor. The CNA said any equipment that was on the floor and did not have a sign saying it was out of order he/she would believe was in working order. During an interview on 03/07/13 at 2:55 P.M., CNA T said he/she was not aware of any problems with any equipment on the floor and would expect all equipment was in working order if it did not have a sign on it. During an interview on 3/7/13 at 3:15 P.M., Licensed practical Nurse (LPN) U said he/she was an agency staff nurse. The LPN said as an agency staff person, he/she receives information on anything he/she needs to know about, during report. If there were problems with any equipment on the unit, he/she would receive that information in report, or the equipment would have some type of lock-out tag on it. During an interview on 3/7/13 at 4:30 P.M., CNA V said if there is equipment on the floor the staff are not to use, staff would be told about it. The CNA was not aware of any problems with any of the lifts or slings on the unit. The CNA said he/she was aware of an accident where one of the residents slipped out of the lift. The CNA said he/she heard the sling was not placed tight enough. The CNA said that resident had been getting weaker and weaker and would not grip the lift bars. 3. Review of Resident #12's MDS, dated [DATE], showed staff assessed the resident as: - Long and Short term memory problems; - Extensive assistance for bed mobility, transfer, dressing, eating, toileting, and personal hygiene; - [DIAGNOSES REDACTED]. Review of the resident's CNA care card (Directs CNA care and hung inside resident's closet), dated 2/4/13, showed staff are directed to: - At risk for falls; - Stand up lift with two assist for all transfers. Review of the resident's care plan, dated 2/4/13, showed staff are directed to transfer with a standing lift and two staff assist. Observation on 3/6/13 at 9:35 A.M., showed CNA J entered the resident's room to provide incontinent care. The resident sat in his/her wheelchair. CNA J put the sit to stand lift belt on the resident and hooked it to the lift. CNA J then lifted the resident up and provided incontinent care. No other staff were present in the resident's room during use of the lift. 4. During an interview on 3/7/13 at 9:00 A.M., CNA K said there should always be two staff present when using a lift for a resident. There are care plans inside each resident's closet that tell what care and assistance a resident needs. 5. During an interview on 3/7/13 at 10:10 A.M., LPN L said anytime a mechanical lift used with a resident that two staff need to be present. The resident's care plans tell number of staff needed for transfers. 6. During an interview on 3/7/13 at 11:30 A.M., NM D said all lift transfers require two staff. 7. During the initial tour of the facility on 3/4/13 at 1:40 P.M., Nurse Manager D said Resident #3 was alert and oriented x 3, had COPD (chronic obstructive pulmonary disease), and used BiPAP (bi-level positive airway pressure, helps keep the airways of the lungs open by providing a flow of air delivered through a face mask). The nurse manager said the resident fell recently and sustained bruises and a skin tear on his/her right elbow. He/she said the resident used to transfer him/herself, but no longer does due to his/her advanced COPD. The nurse manager said due to the resident's condition, he/she falls asleep a lot. Review of the resident's most recent comprehensive MDS, dated [DATE], showed the following staff assessment of the resident:-Moderately impaired cognitive skills for daily decision making; -Required extensive assistance from at least two staff for transfers; -Required extensive assistance from at least two staff for toilet use, including transfers on/off the toilet; -Not steady and only able to stabilize with staff assistance while moving from a seated to standing position; -Not steady and only able to stabilize with staff assistance while moving on and off the toilet; -[DIAGNOSES REDACTED]. -Had one fall with injury since admission or the prior assessment; -Was on hospice care; -Used oxygen therapy and BiPAP/CPAP. Review of the resident's plan of care showed the following: -Staff planned care, dated 2/13/13, to address the resident having periods of lethargy due to a [DIAGNOSES REDACTED]. -Staff planned care, dated 12/14/12, related to the resident requiring extensive assistance with his/her ADL needs due to decreased mobility related to arthritis pain and general decline. The plan directed staff to assist the resident with his/her toileting needs upon request, and directed staff to the resident's need for extensive assistance from two staff for bed mobility and transfers. -Staff planned care, dated 12/14/12, related to the resident's risk for falls. Staff documented the resident had a recent fall and complained of back pain a couple days after the fall. The plan directed staff to assist the resident with all transfers, and to remind the resident of safety when assisting him/her with care. Review on 3/7/13 of the resident's CNA care card posted in the closet of the resident's room, dated 5/19/12, showed the care card directed staff that the resident only needed one staff member assist to transfer. The care card did not address the need for staff to use a gait belt for the resident's transfers. Observation on 3/4/13 at 4:20 P.M. showed the resident had fading bruising evident to the right side of his/her face. During an interview at that time, the resident said his/her bruising was related to a fall he/she had recently in the bathroom. The resident's said his/her legs don't hold him/her up very good anymore. The resident said when he/she was standing up from the toilet, his/her legs gave out. The resident said there was an aide in the bathroom with him/her, and if the aide would have held onto him/her during his/her transfer, the staff member could have kept him/her from falling. The resident said he/she hit the clothes hamper and hurt his/her face and legs. When asked if staff used a belt around his/her waist during transfers, the resident said staff did not. Review of the resident's interdisciplinary notes showed the following: -On 12/1/12, staff documented the resident was found sitting on the floor up against his/her wheelchair. Staff documented the resident said he/she fell asleep and slid out of his/her wheelchair. -On 12/14/12, staff documented the resident was very lethargic throughout the shift. Staff noted the resident had an episode in his/her bathroom where he/she fell asleep while two aides were standing the resident to be toileted and the aides had to lower the resident to the ground and call for assistance. Staff documented the resident had no apparent injuries. -On 2/19/13, staff documented the resident was assisted to the floor when trying to transfer the resident to the toilet at 9:20 P.M. that evening. Staff noted as the resident was lowered to the floor, he/she struck his/her right temple on his/her plastic hamper that was beside the toilet and received a three centimeter hematoma approximately 1.5 centimeters in height. -On 2/20/13, staff documented the resident had bruising evident that evening to his/her bilateral knees that was darkening, his/her left and right wrist, and the side of his/her right eye. The hematoma had resolved and dissipated. The resident complained of minor pain in his/her knees. Staff documented the resident stated his/her fall was not assisted as the aide had reported the previous evening, but may have been prevented if the aide would have reached out to assist him/her during the transfer. Staff noted the resident had been asking for assistance with each transfer prior to his/her fall, but is now requesting a strong aide with hands-on during the transfer or two aides to assist to prevent further falls due to his/her knees feeling weaker than usual and trepidation during transfers. During an interview on 3/8/13 at 10:50 A.M., LPN P said he/she was working at the time of the resident's fall. The LPN said CNA Q, who usually works on the first floor, was the aide who was assisting the resident when he/she was lowered to the floor on 2/19/13. The LPN said when he/she entered the resident's room to assess the resident, the resident was on his/her knees. The LPN said he/she did not observe a gait belt on the resident. The LPN said staff should use a gait belt for the resident's transfers due to his/her varied mental status and lethargy. The LPN said the resident did not tell him/her about the aide not holding on to him/her during the transfer until the next evening, when he/she documented that note and reported it to the evening supervisor. The LPN said the resident is oriented most of the time and can make his/her needs known. During an interview on 3/8/13 at 1:20 P.M., CNA Q said he/she normally works on the first floor, but can be pulled to a different floor one or two times per week. When asked to describe the incident when the resident was lowered to the floor, the CNA said the resident had used the toilet and when he/she was standing up, he/she started to slide. The CNA said he/she saw the resident sliding down, so he/she grabbed onto the resident and lowered him/her down to the floor. The CNA said the resident "sometimes loses her balance", and he/she "is awfully wobbly". The CNA said the resident's was standing "pretty well" and all of a sudden lost his/her balance. When asked if he/she used a gait belt for the resident's transfer, the CNA said he/she had it with him/her, but did not use it. Observation on 3/4/13 at 4:32 P.M. showed CNA O assisted the resident to transfer from his/her wheelchair to the toilet. The CNA did not obtain assistance from another staff member for the transfer, and did not apply a gait belt for support during the transfer. CNA O pulled up on the back of the resident's waistband as he/she assisted the resident to transfer to and from the toilet. During an interview on 3/8/13 at 1:40 P.M., Nurse Manager D said the resident is alert and oriented x 3, but fluctuates at times depending on his/her CO2 (carbon dioxide) levels. The nurse manager said the resident's transfer needs fluctuate depending on the day. The nurse manager said staff should use a gait belt for the resident's transfers. 8. Review of Resident #5's most recent MDS, dated [DATE], showed the following staff assessment of the resident: -BIMS score of 15 (score of 13-15 shows cognitively intact); -Required extensive assistance from at least two staff for transfers; -Used a wheelchair as his/her mobility device; -At risk for pressure ulcers. Review of the resident's plan of care showed the following: -Staff planned care, dated 2/13/13, related to the resident requiring assistance with his/her activities of daily living related to generalized weakness and back pain. The plan directed staff that the resident required assistance from one or two staff for transfers, depending on his/her cognition, with a gait belt. The plan showed the resident used a wheelchair to get around. -The plan directed staff to encourage the resident to participate with all care (intervention dated 2/13/13). -The plan directed staff to monitor the resident's skin daily and report any red/open areas to the resident's charge nurse, physician, and hospice team (intervention dated 2/13/13). During an interview on 3/5/13 at 1:30 P.M., the resident showed the surveyor a skin tear on his/her left wrist, which was covered with a bandaid. The resident showed the surveyor a metal piece exposed from the vinyl on the left side of the seat of his/her wheelchair, which had a jagged, rough edge. The resident said he/she got the skin tear from the metal piece on his/her wheelchair on Sunday (3/3/13). When asked if staff were aware of the skin tear, the resident said staff were aware, because one of them had put the bandaid on the area. The resident said he/she also told staff he/she got the skin tear from the wheelchair. The resident said he/she had a cut on his/her right hand previously, that was also caused by his/her wheelchair, and showed the surveyor a scar on his/her right hand. Observation of the right arm rest of the resident's wheelchair showed a piece of guaze taped over the front edge of the right arm rest, covering an area where a plastic piece was missing from the chair. The resident said his/her family member taped the gauze on that side of the chair after the resident got his/her previous skin tear. Observation on 3/5/13 at 1:45 P.M. showed LPN I changed a dressing beneath the resident's left armpit. The resident told the LPN at that time that the bandaid on his/her left wrist was peeling up. The LPN then cleansed the skin tear beneath the bandaid and applied a new bandaid. The resident told the LPN at that time that he/she cut his/her skin on the area on his/her wheelchair. Observation on 3/6/13 at 8:50 A.M. showed the metal piece on the left side of the seat of the resident's wheelchair still exposed and the right arm rest with the gauze taped to the outside edge. Observation on 3/6/13 at 9:03 A.M. showed CNA E assisted the resident to the toilet. The CNA did not use a gait belt for the resident's transfer on or off the toilet. During an interview on 3/8/13 at 10:45 A.M., LPN H said staff should use a gait belt for safety during the resident's transfers. Observation on 3/7/13 at 9:05 A.M. showed the metal piece on the left side of the seat of the resident's wheelchair still exposed and the right arm rest with the gauze taped to the outside edge. Observation on 3/8/13 at 8:35 A.M. showed the metal piece on the left side of the seat of the resident's wheelchair still exposed and the right arm rest with the gauze taped to the outside edge. Record review showed a physician's order, dated 3/5/13, which directed staff to cleanse the skin tear on the resident's left wrist and apply a bandaid daily and as needed. Review showed no physician's order to treat the skin tear prior to 3/5/13. Additionally, review of the treatment administration record showed staff first recorded treatment of [REDACTED]. Record review on 3/8/13 showed no interdisciplinary notes regarding the resident's left wrist skin tear, including no notes regarding staff's first notification and treatment of [REDACTED]. During an interview on 3/8/13 at 1:40 P.

Based on interview and record review, facility staff failed to ensure one resident (Resident #22) was medicated for pain in a timely manner and failed to obtain the resident's physician ordered ankle splint in a timely manner. The facility census was 151, with 130 in certified beds. 1. Review of Resident #22's admission Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 03/20/12, showed the following: -The resident was admitted to the facility on [DATE]; -Staff assessed the resident as cognitively intact; -Staff assessed the resident fell within the month prior to admission, and sustained a fracture related to a fall; -The resident reported he/she had frequently experienced pain in the last five days. Review of the resident's Integrated Plan of Care Related to Pain, dated 03/13/12, showed the plan directed staff to: -Administer the resident's medications as prescribed to reduce the resident's pain; -Schedule the administration of the resident's pain medications to reduce pain and promote the resident's maximum independence towards his/her highest level of functioning. Review of the resident's Integrated Plan of Care for Alteration in Mobility, dated 03/13/12, showed the plan directed staff to: -Refer the resident to therapy; -Monitor the resident for complicating factors that may impede the resident's progress towards his/her level of independence; -Provide the resident with appropriate supplies/adaptive equipment as needed. Review of the resident's history and physical completed while a patient at the hospital, dated 03/09/12, showed the resident fell , landing on his/her right knee and twisting the left ankle. Review of the resident's history and physical, dated 03/18/12, showed the resident: -Sustained a right femur fracture from a fall, and had ORIF (open reduction, internal fixation) with a rod placed to repair his/her femur fracture. -Had bruising and minimal swelling to his/her left ankle. Review of the resident's nurse's admission assessment form, dated 03/13/12 at 11:30 A.M., showed staff documented the following: -The resident complained of pain to his/her right knee; -Staff did not fill out the portion of the form entitled "pain assessment", which staff use to document how much pain and the location of the pain the resident was having at the time of the assessment, how much pain and the location of the pain the resident had last week, and what triggered the resident's pain. Review of the resident's admission nurse's note dated 03/13/12 at 11:30 A.M. showed staff documented the following: -The resident arrived via ambulance from the hospital; -The resident was alert and oriented x three (oriented to person, place, and time); -The resident had 18 staples to the right knee, five staples to the side of the right knee, two staples to the right upper thigh, and two areas to the thigh covered with bandaids; -The resident's right knee was swollen; -The resident had polar ice (ice packs encased in a soft material, used to reduce pain and control [MEDICAL CONDITION]) intact; -The resident complained of pain to his/her knee; -The resident had [MEDICATION NAME] (a narcotic pain medication containing a combination of [MEDICATION NAME] and [MEDICATION NAME], used to relieve moderate to severe pain) that morning at the hospital; -A call was placed to the resident's physician, awaiting call back. Review of the resident's nurse's notes showed no further notes until 03/13/12 at 8:00 P.M., when the nurse documented he/she received an order for [REDACTED]. Further review of the resident's nurse's notes showed the following: -A late entry dated 03/13/12, timed 5:30 P.M., showed the nurse called the pharmacy about the resident's request to have pain medicine pulled from the Pyxis (a medication dispensing machine within the facility) and questioned the estimated time of arrival of the resident's medications; -A late entry dated 03/13/12, timed 7:00 P.M., showed the nurse again called the pharmacy to find out where the patient's medications were and to page the resident's physician again for access to pull medication from the Pyxis. The nurse documented the resident complained of 10/10 pain (pain which the resident rated 10 on a scale from 0-10, with 10 being the worst pain) upon movement of his/her right leg. The nurse documented the pharmacy said they had called once and would page the physician again; -A late entry dated 03/13/12, timed 7:45 P.M., showed the nurse called the pharmacy again to check on the progression of the resident's medications. The pharmacy put the nurse on hold and paged the resident's physician, and was now on the phone with the physician. The nurse noted a verbal order to pull [MEDICATION NAME] 5/325, two tablets from the Pyxis. The form to authorize pulling the medication from the Pyxis came through the fax and the nurse pulled the medication. Review of the resident's physician's orders [REDACTED]. -Licensed Practical Nurse (LPN) D noted he/she verified the resident's admission orders [REDACTED]. The time the nurse received the telephone order to verify the resident's orders with the physician was not noted. -Medication orders which included [MEDICATION NAME] 10/325, one tablet by mouth every six hours for severe pain; -A physician's orders [REDACTED]. During an interview on 04/25/12 at 2:35 P.M., the resident said he/she received pain medication at 9:30 A.M. before being released from the hospital to the nursing home on 03/13/12. The resident said he/she arrived at the nursing home at 11:00 A.M. The resident said when he/she first got to the facility, no one seemed to know he/she had arrived. The resident said around 12:30 P.M. to 1:00 P.M., some aides were walking by the resident's door, saw him/her, asked if he/she was new there, and asked if they could bring him/her something to eat. The resident said the aides brought the resident a peanut butter and jelly sandwich and some milk. The resident said the nurse did not come to assess him/her until sometime after that. The resident said he/she was in pain, and started asking for pain medication at 2:00 P.M., but facility staff said the resident's physician had not returned their call about continuing the resident's medications from the hospital. The resident said he/she finally received pain medication around 7:30 P.M. The resident said at 2:00 A.M. the next morning, he/she again asked for pain medication. The resident said the aides just kept saying, "we're working on it". The resident said at 3:00 A.M., his/her pain was again a "10" on the pain scale. The resident said, "I was scared" and "I didn't know what would happen to me". The resident said at 4:30 A.M., the nurse came in with the resident's pain medication and said the resident's medications had just arrived at the facility. During an interview on 04/23/12 at 2:35 P.M., LPN E said after a resident is admitted , the general process staff take is to introduce themselves, allow the resident to eat if it is mealtime, and then complete a body assessment before calling the physician for verification of orders, so that if staff need any further orders for a resident's skin condition, they can obtain those at the time they contact the physician. After verification of orders, staff fax the medication orders to the pharmacy. The LPN said the pharmacy then calls the physician if the medication orders contain controlled substances. The LPN said sometimes getting the orders verified with the physician can take a while, and if necessary, staff can call the medical director to get verification of orders. The LPN said for a resident who was admitted after repair of a fractured femur, it would be important to get the resident's medications verified with the physician as soon as possible, in anticipation of the resident having pain. The LPN said the resident was admitted on [DATE] at 11:30 A.M. The LPN said staff went in to introduce themselves, and then it was time for lunch. The LPN said staff completed a body assessment after lunch, before staff called the physician to get verification of admission orders [REDACTED]. The LPN said he/she probably went in to assess the resident around 1:00 P.M., so he/she placed the call to the physician after that. The LPN said he/she does not know when the physician called back for verification of orders, but it would have had to have been before 3:15 P.M. since that's when the shift ends for the nurse who took the physician's orders [REDACTED].M. according to fax records at the facility (almost four hours after staff documented the resident was admitted ). The LPN said the admission note shows he/she recorded the resident complained of pain at that time, but the LPN did not document the amount of pain the resident was having. The LPN said he/she could not find the admission assessment staff completed which would include an assessment of the resident's pain. The LPN said hospital staff told her during report that they had given the resident two [MEDICATION NAME] at the hospital, but the LPN did not know the time the medication was administered. During an interview on 04/24/12 at 2:45 P.M., LPN D said for a newly admitted resident who was admitted after repair of a fractured femur and anticipated pain issues, it is important to get the resident's orders verified with the resident's physician as soon as possible in order to get pain medications ordered from the pharmacy as soon as possible. The nurse said he/she did receive the physician's telephone order for verification of the resident's medications on 03/13/12, but did not document the time of the verification of orders. The LPN said he/she did not write a nurse's note after he/she talked with the physician. The nurse said he/she had to have talked with the physician sometime before his/her shift was over at 3:15 P.M., and he/she would have faxed the orders over to the pharmacy right after talking with the physician. During an interview on 04/23/12 at 3:20 P.M., LPN F said his/her shift starts at 2:45 P.M. The LPN said during report on 03/13/12, he/she was told of the new admission of the resident, that the resident had some work done to his/her hip or knee, the resident had some staples, and staff had just sent the resident's medications over to the pharmacy and were waiting for a call back from the resident's physician. The LPN said the resident's medications were already verified with the physician, and staff were waiting on a response from the physician for something else, but he/she could not remember what. The LPN said the resident requested pain medication the first time, shortly after the LPN's shift began. The LPN said it was 3:30 P.M. to 4:00 P.M. the first time he/she knew staff needed to get pain medications for the resident. The LPN said the resident had pain that was "pretty severe" with movement. The LPN said after the resident's first request for pain medication, the LPN went to see if the resident's medications were at the facility yet, and checked with the house supervisor. The LPN said he/she called the pharmacy to ask about the medications, and then started the process to get authorization to pull [MEDICATION NAME] from the Pyxis for the resident, which involved faxing a form to pharmacy. The LPN said the fax machine on his/her floor was not working, so he/she had to go to a different floor to fax the form. The LPN said he/she tried three times on the different floor to fax the form, and it took up to five minutes to get verification of whether the fax went through each time, so he/she had to go back and forth between the floors several times while trying to fax the form. The LPN said he/she had a lot of other patients and a lot to do. The LPN said the fax would not go through so he/she finally called the pharmacy, and by then the pharmacy had the physician approval and they sent the form to the LPN with the physician's okay to pull the medication from the Pyxis. The LPN said once he/she got the okay to pull the medication, he/she went to the Pyxis and realized the medication was not available in the Pyxis, so he/she had to call the physician and get an order for [REDACTED]. The LPN said her documentation shows the first time she tried to call the pharmacy was at 5:30 P.M. (at least two hours after the resident asked for pain medication). The LPN said he/she recorded the resident's pain as 10 out of 10 on movement of the right leg at 7:00 P.M. The LPN said his/her documentation shows, he/she received the order from the resident's physician for the pain medication at 8:00 P.M. The LPN said there was delay in the time it took the pharmacy to contact the physician for authorization to allow facility staff to pull the medication from the Pyxis. The LPN said during the time the pharmacy was attempting to call the physician for authorization, he/she could have attempted to call the physician him/herself and ask the physician to call the pharmacy, but he/she did not do so. During an interview on 04/26/12 at 2:50 P.M., RN J (who worked the night shift on 03/13/12) said he/she remembered having issues with the pharmacy getting the resident's medications to the facility after the resident's admission. The RN said he/she thought there was about an hour delay between the time the resident started asking for pain medication overnight, and when the medications arrived to the facility. The RN said he/she did not attempt to call the resident's physician, but did call pharmacy staff, who said the medications were on their way to the facility. The RN said he/she did not document his/her telephone call to the pharmacy. The RN said he/she gave the resident his/her [MEDICATION NAME] after it arrived to the facility, on 03/14/12 at 4:30 A.M. During an interview on 04/19/12 at 2:20 P.M., the Director of Nurses (DON) said once a resident is admitted , staff confirm the admission orders [REDACTED]. The DON said when calling the physician, the directions from the physician's exchange is to call back every half hour until staff hear from the physician. There are three scheduled deliveries from the pharmacy. The facility also has a Pyxis machine onsite. If a medication is due prior to the next delivery, staff can pull from the Pyxis. If the medication is a narcotic, staff can't pull from the Pyxis until the pharmacy notifies the facility they've gotten the okay from the physician. The DON said facility staff made numerous calls to the pharmacy, but the pharmacy had difficulty making contact with the physician. The DON said per documentation in the resident's record, facility staff received an order at 8:00 P.M. to pull the [MEDICATION NAME] from the Pyxis. The DON said at the time of admission staff documented they called the physician (note timed 11:30 A.M.), but the next documentation found is at 5:30 P.M. when the nurse called the pharmacy, and then at 7:45 P.M., and 8:00 P.M., when staff documented they got the one time order for the [MEDICATION NAME]. The DON said based on her review of the chart, the admission orders [REDACTED]. The DON said the amount of time the resident had to wait on a pain medication was inappropriate. The DON reviewed the resident's record and said staff did not document a rating of the resident's pain upon admission. The DON looked for a pain assessment form in the chart, but could not find the form. During an interview on 04/19/12 at 1:00 P.M., and on 04/24/12 at 2:17 P.M., Registered Nurse (RN) Nurse Manager G said when a resident is admitted , staff verify orders with the resident's physician. Once the medications are verified, staff fax the orders to the pharmacy. Staff ask that the medications be sent within four hours, but they aren't always. The medications could be sent in 12 hours, or even the next day. The RN said staff can pull medications from the Pyxis, and they also ask the hospital to medicate the resident if necessary before the resident is sent from the hospital. Facility staff ask for a script for controlled substances, but the hospital does not always send them. After facility staff verify admission orders [REDACTED]. The RN said he/she remembered there being a problem getting the resident's medications on the day of his/her admission. The RN said if a newly admitted resident is complaining of pain, he/she would expect staff to get the resident's admission orders [REDACTED]. The RN said if staff knows someone may have skin issues, staff like to go ahead and look at those things before calling the physician, but in certain situations, such as when a resident is complaining of pain upon admission, staff should call the physician back later on those things. The RN said the resident was admitted at lunch time, and it took several hours to get anything started. The RN said the resident started complaining of pain and asked for pain medication right after the day shift left and when the evening nurse came on. The RN said staff should have started the process of getting the resident's medication then. The RN said LPN F pulled pain medication from the Pyxis at 7:38 P.M. (at least four hours after the resident first asked for pain medication), but the resident's other medications were not delivered to the facility until approximately 4:30 A.M. The RN said it was not acceptable for a resident to have to wait as long as he/she did for pain medication. The RN said facility staff were working on problem solving related to this incident, and said there were things facility staff could have done in this situation to quicken the process. The RN said the admitting nurse who obtains the order for verification of a resident's medications should write a nurse's note and should include the time the orders were verified. The RN said facility fax records show they faxed the resident's admission orders [REDACTED].M. The RN said the evening nurse's documentation shows his/her first telephone call to the pharmacy was at 5:30 P.M. The RN said LPN F had a problem getting the fax sent to pharmacy for authorization to pull [MEDICATION NAME] from the Pyxis, and that he/she was going up and down to and from the third floor trying to get the fax to go through. The RN said if the resident requested pain medication as early as 2:00 P.M., it was definitely not an acceptable amount of time for the nurse to have waited to call the pharmacy to check on the medications and to attempt to get authorization to pull medication from the Pyxis until 5:30 P.M. During an interview on 04/20/12 at 1:50 P.M. and on 04/24/12 at 9:00 A.M., Pharmacist H said pharmacy staff received the order for the resident's medications on 03/13/12 at 4:14 P.M. per the pharmacy's fax records., although the pharmacist said he/she was aware facility staff's records showed they faxed the orders on 03/13/12 at 3:19 P.M. The pharmacist said the facility does have a Pyxis, from which they can pull medications needed before the delivery of medications from the pharmacy. The pharmacist said pharmacy staff have to speak with the resident's physician before sending controlled substances to the facility, and before pharmacy staff can authorize facility staff to pull a controlled substance from the Pyxis. The pharmacist said per pharmacy records, pharmacy staff paged the physician for authorization for facility staff to pull the [MEDICATION NAME] from the Pyxis and for the authorization to send out the emergency supply of [MEDICATION NAME] 10/325, at 5:29 P.M. The pharmacist said pharmacy's records show the physician called pharmacy staff back at 7:18 P.M. The pharmacist said pharmacy staff left a message for facility staff at 7:21 P.M. for the nurse to call back, and fax records show pharmacy staff faxed authorization for the facility staff to pull the [MEDICATION NAME] from the Pyxis at 7:32 P.M. The pharmacist said the facility's Pyxis does not contain the [MEDICATION NAME] 10/325 ordered by the resident's physician, and so facility staff obtained a "now" order for [MEDICATION NAME] 5/325 that is contained in the facility's Pyxis. The pharmacist said the Pyxis records show facility staff pulled two [MEDICATION NAME] 5/325 from the Pyxis at 7:38 P.M. The pharmacist said the delays in the pharmacy had to do with a volume issue. The pharmacist said the pharmacy is very busy in the evening, as there are many evening admissions for which the pharmacy has to fill prescriptions. The pharmacist said if the resident's physician's orders [REDACTED]. The pharmacist said the resident's medications were delivered to the facility on [DATE] at 4:23 A.M. Review of the resident's physical therapy evaluation form, completed on 03/14/12, showed therapy staff documented the resident was very anxious this morning due to a delay in getting his/her pain pills. Review of the resident's physical therapy evaluation form, dated 03/14/12, showed therapy staff noted the resident required treatment for [REDACTED]. Therapy staff noted the resident had a left ankle sprain, as well as bruising and [MEDICAL CONDITION] to the left ankle. Therapy staff documented the resident's weight bearing status was weight bearing as tolerated on the left leg and non-weight bearing on the right leg. Review of the resident's physician's orders [REDACTED]. Review of a physical therapy treatment note, dated 03/16/12, showed Physical Therapist (PT) I documented the resident's physician gave an order for [REDACTED]. on that date. The PT documented he/she gave a picture of an air splint to the nurse, who gave it to the evening nursing supervisor, who contacted the DON. PT I documented the DON would not deal with the issue until Monday, nor would she allow anyone to get it from (the local chain pharmacy located approximately one-half mile from the facility), saying she has no authority to authorize that. The PT documented he/she informed the nursing supervisor that the resident's ankle was more swollen and bruised after following the surgeon's orders of weight bearing as tolerated. The PT documented he/she cautioned the evening nursing supervisor that there was a safety and liability issue with waiting until Monday. Review of a physical therapy treatment note, dated 03/19/12 (Monday), showed PT I documented he/she worked with the resident on pivot transfers on his/her left foot. The PT documented a nurse was going out to get the ankle brace for the resident's left ankle, and staff would wait until P.M. to stand the patient with the brace on. The PT documented the resident was full weight bearing on his/her sprained left ankle and had variable [MEDICAL CONDITION] and much bruising. The PT documented he/she instructed the patient that it would be critical to protect his/her left ankle to avoid further injury before he/she is full weight bearing with the right lower extremity. Review of a Therapy Weekly Progress Record, covering the period from 03/14/12 through 03/20/12, showed therapy staff documented they recommended the air splint to stabilize the left ankle in weight bearing, and nursing had obtained the splint. Therapy staff documented the left ankle stability brace enabled the resident to hop on his/her left foot with a wheeled walker. During an interview on 04/25/12 at 2:35 P.M., the resident said on Wednesday (03/14/12), the therapist told him/her that facility staff were going to go to (the local chain pharmacy) to get the resident a splint for his/her left ankle. On Friday (03/16/12) the resident asked the therapist where the splint was, and the therapist then told him/her that they were going to wait on that until Monday. The resident said he/she needed the splint to support his/her sprained ankle, which was very sore. The resident said he/she lost time having to wait on staff to get the brace, and this contributed to setting his/her rehabilitation time back. During an interview on 04/19/12 at 1:45 P.M., PT I said when a resident has a new order for a splint, the splint is ordered through the DON or ADON, unless it is a specialized type of splint. The PT said therapy staff often assist by showing nursing staff a picture of the splint needed in a catalog. The PT said for this resident, the physician called the order for the splint late on a Friday afternoon. The PT said this was the type of splint that would have to go through nursing, and nursing would obtain. The PT said from what he/she understood, the DON was already gone for the day and there was no one who could go to (the local chain pharmacy) and get the splint. The PT said he/she had recommended they get the splint sooner rather than later. The PT said the resident was non-weight bearing on one leg and had a sprained ankle on the other. The PT said he/she thought nursing staff eventually got the splint from (the local chain pharmacy). The PT said once the resident got the air splint on his/her left ankle, he/she wasn't feeling a lot of pain in the ankle. During an interview on 04/19/12 at 2:20 P.M., the DON said when a resident has a new order for a splint, if it is something generic, nursing staff can get the splint at (the local chain pharmacy). If an order is received on a Friday evening, and the splint could be obtained from (the local chain pharmacy), then staff could go and get the splint from (the local chain pharmacy). The DON said she would not have said she couldn't authorize the purchase. The DON said she thought that when she was contacted that Friday evening, she told the nursing supervisor if someone had the money to go to (the local chain pharmacy), they were more than welcome to go and get the splint. The DON said there is no access to funds for that type of purchase after normal business hours. MO 800