Every finding on record at Estates of Spanish Lake, The

Based on interview and record review, the facility failed to administer medications as ordered for two of three sampled residents (Resident #1 and #2). The census was 144.Review of the Administering Medication Policy, reviewed date 1/24/24, showed the following:Policy: Medications will be administered in a safe and timely manner, and as prescribed.Procedure included:-Medications must be administered in accordance with the orders, including any required timeframe;-Medications are to be administered within one hour of their prescribed time, unless otherwise specified;-If a medication is withheld, refused or given at a time other than the scheduled time, the individual administering the medication will document the rationale;-While residents have the right to refuse medications, it is vital to notify the appropriate physician of the resident's refusal after three days to allow for a medication review;-If a medication is unavailable, the Certified Medication Technician (CMT)/Nurse will look in the First Dose Cabinet and/or Central Supply for over the counter medications, and administer the medication. If the medication is still unavailable, the CMT/Nurse will re-order the medication by either faxing or calling the request into the pharmacy;-If a medication is missing, and the pharmacy has not sent the requested medication the following day, the Director of Nursing (DON) or designee is to be notified to assist in removing barriers and obtaining the medication in a timely manner, whether the issue lies within the pharmacy or a new prescription needs to be updated. 1. Review of Resident #1's medical record, showed the following:-Severely impaired cognition;-No behaviors;-Diagnoses included: Schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), anxiety, insomnia, hallucinations, bipolar (mood disorder that can cause intense mood swings). Review of the resident's care plan in use at the time of the investigation, showed the following:-Problem: The resident has impaired cognitive function or impaired thought process related to schizophrenia;--Approaches included: Administer medications as ordered;-Problem: The resident uses psychotropic medications related to schizophrenia;--Approaches included: Administer psychotropic medications as ordered by the physician;-Problem: The resident has a severe mental illness;-Approaches included: Medication administration by staff and monitor compliance with prescription medication. Review of the resident's current physician's orders sheet (POS), showed the following:-Quetiapine fumarate (Seroquel) 400 milligrams (mg) at bedtime for schizophrenia;-Seroquel 200 mg at bedtime, give with 400 mg to equal 600 mg for bipolar. Review of the resident's July 2025 Medication Administration Record (MAR), showed the following:-Seroquel 400 mg at bedtime, entries marked as a 9 on 7/8, 7/9, 7/10 and 7/11/25;-Seroquel 200 mg at bedtime, entries marked as a 9 on 7/8, 7/9, 7/10 and 7/11/25;-Chart Code of 9 defined as Other/see progress note. Review of the resident's progress notes, showed the following:-7/8/25 at 9:27 P.M., Seroquel 200 mg, not available;-7/10/25 at 6:31 P.M., 400 mg and 200 mg, order;-No documentation between 7/8 to 7/10/25 regarding attempts to obtain the resident's ordered Seroquel; -7/11/25 at 6:18 P.M., pharmacy contacted about medications being sent out tonight for delivery;-7/11/25 at 10:39 P.M., Seroquel 200 mg, on order. During an Interview on 7/16/25 at 10:45 A.M., the resident said he/she was currently receiving all of his/her medications, but there was a time recently where he/she did not receive his/her medications for about five days. Not receiving all of his/her medications occurs on a monthly basis. During an Interview on 7/16/25 at 2:35 P.M., CMT A said when he/she was working on the medication cart (as a CMT), there were never problems with the resident's medications not being available. There was a day where he/she worked on the floor (as a nursing assistant) when the resident told CMT A he/she was missing his/her Seroquel. CMT A informed a Nurse, whom CMT A had never seen before. During an interview on 7/16/25 at 2:10 P.M., Nurse B said the resident had concerns last week about his/her medications. Earlier in the month, the resident went on a leave of absence (LOA) at the same time as the medication change over occurred for the next month, so they pulled some of the medications the resident needed for his/her LOA from the next month's supply. The resident's medications ran out sooner than expected. Staff contacted the pharmacy, but the insurance would not allow a refill so soon. Staff can pull from the emergency kit for some medications, but the resident takes a high dose of Seroquel that was not available in the emergency supply. 2. Review of Resident #2's medical record, showed the following:-Cognitively intact;-Experienced delusions;-Diagnoses included: Schizophrenia, major depressive disorder, anxiety, sleep terrors, insomnia, diarrhea, irritable bowel syndrome with diarrhea. Review of the resident's care plan in use at the time of the investigation, showed the following:-Problem: The resident has a behavior problem related to serious mental illness;--Approaches included: Administer medications as ordered;-Problem: The resident has impaired cognitive function or impaired thought process related to schizophrenia;--Approaches included: Administer medications as ordered;-Problem: The resident has an alteration in gastrointestinal status ;--Approaches included: Saccharomyces boulardi (type of probiotic), give one capsule by mouth two times per day related to irritable bowel syndrome with diarrhea;-Problem: The resident uses psychotropic medications for mood/behavior management/disease process/nightmares;-Approaches included: Latuda (medication to treat schizophrenia), give one tablet in the evening for mood with dinner. Review of the resident's July 2025 POS, showed the following:-Latuda 60 mg, give one tablet in the evening for mood with dinner;:-Saccharomyces boulardi 250 mg, give one capsule two times per day for supplement related to irritable bowel syndrome with diarrhea. Review of the resident's July 2025 MAR, showed the following:-Latuda 60 mg, entries marked as 9 on 7/12, 7/13 and 7/14;- Saccharomyces boulardi 250 mg, the following entries marked as 9:--7/2, evening dose--7/4, morning and evening dose;--7/8, evening dose;--7/9, morning dose;--7/10, morning dose;--7/11, evening dose;--7/12, evening dose;--7/13, evening dose;--7/15, morning dose. Review of the resident's progress notes, showed the following:-7/2/25 at 7:19 P.M., Saccharomyces boulardi 250 mg, medication not on medication cart or in medication room;-7/4/25 at 9:17 A.M., Saccharomyces boulardi 250 mg, on order;-7/4/25 at 4:45 P.M., Saccharomyces boulardi 250 mg, medication not on medication cart or in medication room;-7/8/25 at 5:55 P.M., Saccharomyces boulardi 250 mg, medication not on medication cart nor in medication room;-7/8/25 at 5:59 P.M., Latuda 60 mg, medication on order because none is in or on cart;-7/9/25 at 9:14 A.M., Saccharomyces boulardi 250 mg, on order;-7/10/25 at 10:00 A.M., Saccharomyces boulardi 250 mg, on order;-7/11/25 at 5:16 P.M., Saccharomyces boulardi 250 mg, medication not on medication cart nor in medication room;-7/12/25 at 6:24 P.M., Saccharomyces boulardi 250 mg, medication not on cart;-7/13/25 at 5:59 P.M., Latuda 60 mg, medication not on cart nor in medication room;-7/13/25 at 8:15 P.M., Saccharomyces boulardi 250 mg, medication not on cart;-7/14/25 at 10:52 P.M., Latuda 60 mg, awaiting on medication;-7/15/25 at 9:58 A.M., Saccharomyces boulardi 250 mg, on order. During an interview on 7/16/25 at 1:45 P.M., the resident said his/her medications run out at times, and he/she recently went without his/her Latuda for a couple of days. 3. During interviews on 7/16/25 at 3:30 P.M. and 4:00 P.M., the second floor Assistant Director of Nursing (ADON) said Resident #1's Seroquel was delivered on 7/11/25, and the problem with it not being delivered earlier was an insurance issue. The resident's dosage of Seroquel was not available in their emergency kit. Resident #2's Latuda is delivered from the pharmacy on its own, they do not have to order it, and sometimes, it is a day or two late. Latuda is not available in the emergency kit. The Saccharomyces boulardi is a probiotic, and it is in the house stock. It should not be unavailable. The ADON spoke to the CMTs when the probiotic was marked as a 9 on the MAR, and they said they were unaware the facility had the probiotic in stock. The ADON would plan a staff education regarding medication administration. 1469537

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This had the potential to affect all residents at the facility. The census was 140. Review of the facility's Nursing Staffing Policy, reviewed 12/22/21, showed: -Policy: This facility will maintain nursing staffing ratios to ensure appropriate care is provided; -Procedure: -A copy of the Nursing Staffing Information form will be posted daily; -The facility's charge nurse and/or designee will update the number of Certified Nurse Assistants (CNAs), Nurse Assistants (NAs), Certified Medication Technicians (CMTs), Environmental Aides (EAs), Licensed Practical Nurses (LPNs), and RNs that are in the facility at the beginning of each shift throughout each 24-hour period; -The completed copies of the Nursing Staffing Information forms will be maintained in a binder by the Staffing Coordinator; -We will have an RN 8 hours a day 7 days a week. Review of the facility's daily assignment sheets, dated 3/20/25 through 4/25/25, showed no RNs were scheduled. During an interview on 04/22/25 at 12:50 P.M., the Director of Nursing said the facility did not have an RN at least eight hours a day, seven days a week. She was the only RN in the facility and was on-call as needed. During an interview on 04/25/25 at 4:14 P.M., the Administrator said she expected to have an RN in the facility at lest eight hours a day, seven days a week.

Based on interview and record review, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. In addition, the facility failed to maintain evidence of the submission of sent notices, including Resident #140. The census was 140. Review of Resident #140's medical record, showed: -admitted to the facility on [DATE]; -re-admitted to the facility on [DATE]. -discharged from the facility to home on 2/20/25 Review of the facility's admissions and discharge report, dated 1/1/25 to 4/11/25, showed the resident was discharged home on 2/20/25. Additionally, the discharge report showed 71 residents had been transferred or discharged during this time period. Review of the facility records, showed a fax cover sheet: -To: The Ombudsman; -Date: 4/14/25; -Phone: a local phone number; -Re: SSD and a local phone number and extension number; -Notes: January through April transfers and discharges. Further review of the facility record, showed no confirmation or verification of the submission of the January through April transfers and discharges to the Ombudsman. During an interview on 4/17/25 at 10:20 A.M., the Ombudsman said they had not received any transfer notifications since December, 2024. During an interview on 4/24/25 at 9:15 A.M., the Social Service Director (SSD) said he/she had been at the facility for one week and could not produce a tracking mechanism to verify when discharge summaries and transfer notices are sent to the Ombudsman.

45083 Based on observation, interview and record review, the facility failed to immediately intervene when one resident (Resident #43), who was recently hospitalized for suicidal ideation, indicated he/she wanted to commit suicide. In addition, the facility failed to address one resident's behavior when he/she became agitated and left the secured unit he/she resided on (Resident #105). The sample size was 29. The census was 140. Review of the facility's Suicidal Ideations policy, updated 1/24/25, showed: -Definition: Suicidal ideation refers to wanting to take one's own life or thinking about suicide. Should a resident have a history of or begin to show signs of suicidal ideation, the following steps must be implemented: -When a resident is observed by a team member to exhibit verbally and/or physically suicidal tendencies, the following measures should be taken in an effort to prevent an attempt or further attempt by the resident from harming him/herself; -The resident is not to be left unattended until the resident's intent is evaluated. The team member observing the resident that exhibits verbal and/or physical suicidal tendencies should notify another team member. Review of the facility's Supervision and Management of Residents with Behaviors, updated 1/24/25, showed: -Policy: To provide support to team members to maintain safety and security when providing care to our residents who may exhibit behaviors, while treating our residents with dignity, respect and compassion; -Protocol: -De-escalation education will be provided to team members; -The best way to manage resident behaviors is to provide care in a dignified, respectful and compassionate manner; -When a resident is exhibiting anxiety, paranoia, defensive or risky behaviors, staff will respond by using de-escalation techniques: -Use a clear voice tone; -Be active in helping; -Build hope-resolution if possible; -Present yourself as a calming influence; -Remove distractions, disruptive or upsetting influences; -Validate their feelings and accept them; -Recognize that a mentally ill person may be overwhelmed by sensations, thoughts, frightening beliefs, sounds, environment-provide careful explanations and instructions; -Determine need for basic needs; -Use active listening skills. 1. Review of the resident #43's care plan, revised 1/21/24, in use during the time of the investigation, showed: -Problem: Suicide: The resident reports he/she was sad at the time and attempted to overdose while living at home with his/her parent. This attempt was more than four years ago; -Goal: Resident will remain safe and will not harm self through next review date; -Approaches/Tasks: If resident poses a potential threat to injure self or others, notify physician for behaviors and keep power of attorney informed. If wandering or pacing, initiate visual supervision during acute episodes. Monitor for cognitive, emotional or environmental factors that may contribute to violent behaviors. Monitor resident for signs/symptoms of agitation. Redirect to activities, socials, groups. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/14/5, showed: -Cognitively intact; -Little interest or pleasure in doing things occurred nearly every day; -Feeling down, depressed and hopeless occurred nearly every day; -Exhibited physical behaviors directed toward others four to six days out of the week; -Exhibited verbal behaviors directed toward others daily; -Exhibited other behaviors not directed towards others such as hitting, scratching and disruptive sounds four to six days out of the week; -Diagnoses included anxiety and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). Review of the resident's progress note, showed: -On 3/16/24 at 2:30 P.M., the nurse heard a loud yelling from the hall. The resident was crying and stated that he/she wants to harm himself/herself as this nurse walked toward the unit could see resident with a belt that he/she began to wrap around his/her neck. Staff intervened immediately and remained with resident. This nurse placed a call to 911 for assistance and transport to the emergency room for evaluation. Staff continued to remain with resident until emergency medical technicians (EMT) arrived. Physician notified, agreed to send resident out for an evaluation; -On 3/21/25 at 10:01 A.M., resident returned to the facility from the hospital; -On 3/21/25 at 10:30 A.M., resident was one to one to discuss behaviors and his/her needs. Resident was educated on the positive ways of communicating and expressing self and allow staff to assist when feeling upset. followed up with resident on 15-minute checks. Review of the resident's progress notes, showed no further Social Services or psychosocial notes until 4/4/25. Review of the resident's progress notes, showed: -On 4/4/25 at 5:00 P.M., resident on unit screaming and yelling because he/she was escorted back to his/her unit after yelling at another resident in activities; -On 4/5/25 at 9:44 P.M., resident pushed his/her way off the locked down unit and refused to go back. Resident was yelling profanities and walking up on staff and other residents threatening to hit them. Call was placed to his/her guardian and explained to him/her what resident was doing and agreed with this nurse to send resident to the hospital for evaluation and treatment. Call was placed to 911 to have resident transported to the hospital for treatment. Call will be placed to the Nurse Practitioner; -On 4/14/25 at 3:43 P.M., the resident returned to the facility from the hospital. Review of the resident's Hospital After Visit Summary, dated 4/14/24, showed: -Reason for Admission: Suicide attempt by drinking hand sanitizer times one and wrapping a belt around his/her neck times two; -Presenting Problem: Recent suicide attempt; -Duration of Problem: Past one month; -Reason for Admission: Danger to self. Three recent suicide attempts; -Key Factors: Stressors of getting along with peers. He/She feels the peers at the nursing home pick on him/her. Review of the resident's psychosocial note, dated 4/15/25 at 9:54 A.M., showed Therapy Talk: Resident states he/she wants to go to a group home. Resident was educated on the positive ways of communicating and expressing self and allow staff to assist when feeling upset. Social Services for support. Review of the progress notes, showed no further behavioral, psychosocial or Social Services notes as of 4/22/24 at 12:08 P.M. Observation on 4/23/25 at 12:05 P.M., showed Environmental Aide (EA) C sat on the secured unit with another resident, conducting a 15-minute check of the resident. A Housekeeper was also present on the unit. At 12:06 P.M., the resident was observed laying in bed on his/her back in his/her room. The resident said he/she was not doing well and began to cry loudly. He/She said he/she had not seen his/her psychiatrist, and when he/she did see them, they cut the visits short. He/She denied receiving group or individual counseling but wanted to receive both. He/She said he/she had been in bed all day. The resident began to cry and yelled, I want to kill myself. This surveyor and another surveyor were present. The other surveyor remained with the resident as this surveyor told EA C the resident said he/she wanted to kill himself/herself. EA C said he/she would inform the nurse and left the secured unit. The resident receiving the 15-minute checks paced up and down the hallway. At 12:13 P.M., EA C returned to the unit and said he/she informed the nurse. The nurse was on a phone call and would assess the resident when he/she was done. EA C sat down and continued monitoring the resident receiving the 15-minute checks. The resident remained in his/her room, in the bed, crying. He/She mentioned drinking hand sanitizer and wrapping a housecoat belt and shoestrings around his/her neck, while crying. At 12:16 P.M., no staff had come to check on the resident. At 12:22 P.M., this surveyor went to the hallway and observed Social Services Designee (SSD) E walking down the hallway. This surveyor informed SSD E of the resident's statements and said no one has checked on the resident as of yet. SSD E said he/she did not know and was training at the time. The surveyor asked if someone would check the resident. SSD E said he/she would get the nurse and left the unit without checking the resident. The surveyor asked EA C to get the nurse he/she spoke with earlier. At 12:24 P.M., Licensed Practical Nurse (LPN) D arrived in the resident's room and asked what was wrong. LPN D then told the resident to get up. The resident began to cry and said, I want to kill myself. At 12:27 P.M., LPN D said he/she would get someone to help and left the resident's room. The resident continued to cry loudly. At 12:29 P.M., EA C entered the room and said he/she would be doing one on one monitoring with the resident. EA C said when the surveyor informed him/her about the resident, he/she told LPN D immediately. At the time, LPN D was on the phone and said he/she would check on the resident after he/she was done with the phone call. At 12:33 P.M., LPN D returned and said he/she would send the resident to the hospital. During an interview on 4/23/25 at 12:34 P.M., LPN D said the resident always exhibited behaviors. However, the threats of suicide was a new behavior. LPN D was not sure how often the resident received visits from the psychiatrist or Nurse Practitioner. He/She did not know if the resident received one on one counseling or behavioral health services. Observation on 4/23/25 at 12:59 P.M., showed the resident leaving the facility with Emergency Medical Services (EMS). During an interview on 4/24/25 at 2:41 P.M., SSD E said he/she does group and one on one therapy with residents. Therapy consisted of how to cope with anxiety, depression, coping skills and going over medications. When a resident was suicidal, staff were to let the team know immediately and the resident would be placed on one-on-one monitoring. The resident was always in his/her feelings and wanted to be liked. The resident yelled, screamed and cried on a regular basis. When this happened, SSD E provided therapy to the resident. Yesterday was the first time she heard the resident say he/she was suicidal. If the resident said it in the past, he/she could not recall. When told the resident had episodes on 3/16/25 and 4/5/25, SSD E said he/she did one on one therapy with the resident upon his/her return from the hospital. He/She did not document the notes in the medical record. The resident was not receiving any additional services. When asked about SSD E's qualifications, he/she said he/she had the SSD certification and was a Certified Nursing Assistant (CNA). During an interview on 4/25/25 at 12:12 P.M., CNA I said he/she was familiar with the resident and the resident always displayed suicidal ideations and behaviors. If a resident would express suicide, you immediately checked the resident to ensure their safety. If no one was available on the hallway, you took the resident with you and informed the nurse. The resident should not be left alone. The resident would be brought to the nurse's station if no one else was available. During an interview on 4/25/25 at 12:37 P.M., CNA J said if a resident said they wanted to commit suicide, the resident should not be left alone. At times, there was one person on the locked unit, and they could not leave the resident alone. During those times, they would take the resident with them to the nurse's station. If the resident was not able to get to the nurse's station, staff would yell out until someone came to check the resident. The resident should not be left alone. During an interview on 4/24/25 at 5:49 P.M., the Social Services Director (SSD) said he had worked at the facility since 4/14/25. His duties included overseeing the psychosocial needs of the resident population. When a resident displayed behaviors, staff would try to deescalate the behaviors and find out what triggers the emotions and work backwards from there. If a resident said they were suicidal, staff should intervene immediately and make the resident safe. The resident was placed on one to one monitoring until they were deemed safe to be taken off one on one. Facility staff could determine whether the resident was considered safe, based of observation and judgement. If the threat is credible, staff would send the resident to the hospital for an evaluation. Resident #43 was reaching out for some kind of connection. The behavior was not new. When asked if appropriate interventions were put into place for the resident, SSD said there were interventions put into place for the resident. The interventions depended on the outcome. There was no specific box for the resident. He/She was provided the opportunity to express himself/herself. The resident could manipulate the situation. When you all (surveyors) comes in, you save the day (residents get their way) and they know it. When a resident was in an immediate crisis, there should be an immediate response. When asked if staff responded immediately and or appropriately to the resident's crises, the SSD said he was not familiar with the policy. Going forward, staff would be expected to respond immediately. He was not sure what services were in place for the resident and could not say if SSD E was able to provide therapy or determine if a resident was safe to take off of one-on-one monitoring. The resident could use additional services if he/she had a history of suicidal ideations, but he was not sure what was in place and said, there was no structure to determine the needs of the resident. During an interview on 4/25/25 at 2:50 P.M., the Administrator and Director of Nursing (DON) said when the resident expressed he/she wanted to kill himself/herself, staff should have immediately intervened and laid eyes on the resident. EA C should have stayed with the resident and/or took the resident with him/her until the nurse arrived. The nurse should have arrived immediately after EA C informed him/her the resident was suicidal. They would expect qualified professionals to provide services to the resident. 2. Review of Resident #105's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Behavioral Symptoms, Presence and Frequency: verbal and others, occurred 1-3 days; -Wandering Presence and Frequency: occurred 1-3 days; -No impairment to both upper and lower extremities; -No mobility device used; -Required supervision and verbal cues with self-care and mobility. -Diagnoses included dementia, anxiety disorder, and manic depression; -Current tobacco use. Review of the resident's care plan in use at time of survey, showed: -Problem: Resident is a smoker. He/She fixates on cigarette times. He/She used to bum cigarettes from strangers on a regular basis; -Goal: Resident will not smoke without supervision; -Approaches/Tasks: Instruct the resident about the facility policy on smoking; locations, times, safety concerns. Requires supervision while smoking; -Problem: Resident is an elopement risk, wanderer/wanders aimlessly, significantly intrudes on the privacy or activities, decreased cognition, repeats his/her questions consecutively, and unable to retain education, and redirection; -Goal: Resident will not leave the facility unattended; -Approaches/Tasks: Distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Prefers smoking to activity room. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is the resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Remind resident of structured or scheduled activity or smoke times. Observation on 4/22/25 at approximately 9:45 A.M., showed the resident paced back and forth to the locked door of second floor D-Hall. The resident repeatedly said he/she wanted to go out smoking. The resident ran towards the locked doors leading out into the nurse's station in the hallway and pushed his/her way out of the door. Certified Medication Technician (CMT) F yelled out the resident's name when he/she managed to go out the door. EA C chased the resident and redirected him/her back to the locked unit. EA C then took five residents out to smoke and left the resident on the unit. No other activities were offered or explanations provided by the staff. The resident continued to pace and said he/she wanted to go outside to smoke. During an interview on 4/25/25 at 2:50 P.M., the Administrator and DON said when the resident became agitated, staff should have allowed him/her to go outside for a supervised smoking session with staff. They should not have taken other residents and left residents on the unit while he/she displayed agitation from not being able to go outside to smoke. MO00252342 MO00252437

Based on observation, interview and record review, the facility failed to ensure a resident received appropriate person-centered care to meet his/her highest practical psychosocial well-being when the facility failed to provide medically related social services for one resident with a known history of suicidal ideation (Resident #43). The sample size was 29. The census was 140. The Administrator was notified on 4/25/25 of the past non-compliance. The facility has hired a Social Services Director on 4/14/25. The deficiency was corrected on 4/14/25. Review of the facility's Supervision and Management of Residents with Behaviors policy, updated 1/24/25, showed: -Policy: To provide support to team members to maintain safety and security when providing care to our residents who may exhibit behaviors, while treating our residents with dignity, respect and compassion; -Protocol: -De-escalation education will be provided to team members; -The best way to manage resident behaviors is to provide care in a dignified, respectful and compassionate manner; -When a resident is exhibiting anxiety, paranoia, defensive or risky behaviors, staff will respond by using de-escalation techniques: -Use a clear voice tone; -Be active in helping; -Build hope-resolution is possible; -Present yourself as a calming influence; -Remove distractions, disruptive or upsetting influences; -Validate their feelings and accept them; -Recognize that a mentally ill person may be overwhelmed by sensations, thoughts, frightening beliefs, sounds, environment-provide careful explanations and instructions; -Determine need for basic needs; -Use active listening skills. Review of Resident #43's care plan, revised 1/21/24, in use during the time of the investigation, showed: -Problem: Suicide: The resident reports he/she was sad at the time and attempted to overdose while living at home with his/her parent. This attempt was more than four years ago; -Goal: Resident will remain safe and will not harm self through next review date; -Approaches/Tasks: If resident poses a potential threat to injure self or others, notify physician for behaviors and keep power of attorney informed. If wandering or pacing, initiate visual supervision during acute episodes. Monitor for cognitive, emotional or environmental factors that may contribute to violent behaviors. Monitor resident for signs/symptoms of agitation. Redirect to activities, socials, groups. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/14/5, showed: -Cognitively intact; -Little interest or pleasure in doing things occurred nearly every day; -Feeling down, depressed and hopeless occurred nearly every day; -Exhibited physical behaviors directed toward others four to six days out of the week; -Exhibited verbal behaviors directed toward others daily; -Exhibited other behaviors not directed towards others such as hitting, scratching and disruptive sounds four to six days out of the week; -Diagnoses included anxiety and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). Review of the resident's progress note, showed: -On 3/16/24 at 2:30 P.M., the nurse heard a loud yelling from the hall. The resident was crying and stated that he/she wants to harm himself/herself as this nurse walked toward the unit could see resident with a belt that he/she began to wrap around his/her neck. Staff intervened immediately and remained with resident. This nurse placed a call to 911 for assistance and transport to the emergency room for evaluation. Staff continued to remain with resident until emergency medical technicians (EMT) arrived. Physician notified, agreed to send resident out for an evaluation; -On 3/21/25 at 10:01 A.M., resident returned to the facility from the hospital; -On 3/21/25 at 10:30 A.M., resident was one to one to discuss behaviors and his/her needs. Resident was educated on the positive ways of communicating and expressing self and allow staff to assist when feeling upset. followed up with resident on 15-minute checks. Review of the resident's progress notes, showed no further Social Services or psychosocial notes until 4/4/25. Review of the resident's progress notes, showed: -On 4/4/25 at 5:00 P.M., resident on unit screaming and yelling because he/she was escorted back to his/her unit after yelling at another resident in activities; -On 4/5/25 at 9:44 P.M., resident pushed his/her way off the locked down unit and refused to go back. Resident was yelling profanities and walking up on staff and other residents threatening to hit them. Call was placed to his/her guardian and explained to him/her what resident was doing and agreed with this nurse to send resident to the hospital for evaluation and treatment. Call was placed to 911 to have resident transported to the hospital for treatment. Call will be placed to the Nurse Practitioner; -On 4/14/25 at 3:43 P.M., the resident returned to the facility from the hospital. Review of the resident's Hospital After Visit Summary, dated 4/14/24, showed: -Reason for Admission: Suicide attempt by drinking hand sanitizer times one and wrapping a belt around his/her neck times two; -Presenting Problem: Recent suicide attempt; -Duration of Problem: Past one month; -Reason for Admission: Danger to self. Three recent suicide attempts; -Key Factors: Stressors of getting along with peers. He/She feels the peers at the nursing home pick on him/her. Review of the resident's psychosocial note, dated 4/15/25 at 9:54 A.M., showed Therapy Talk: Resident states he/she wants to go to a group home. Resident was educated on the positive ways of communicating and expressing self and allow staff to assist when feeling upset. Social Services for support. Review of the progress notes, showed no further behavioral, psychosocial or Social Services notes as of 4/22/24 at 12:08 P.M. Observation on 4/23/25 at 12:06 P.M., showed the resident laying in bed on his/her back in his/her room. The resident said he/she was not doing well and began to cry loudly. He/She said he/she had not seen his/her psychiatrist, and when he/she did see them, they cut the visits short. He/She denied receiving group or individual counseling but wanted to receive both. He/She said he/she had been in bed all day. The resident began to cry and yelled, I want to kill myself. This surveyor informed Social Services Designee (SSD) E of the resident's statements and said no one has checked on the resident as of yet. SSD E said he/she did not know and was training at the time. The surveyor asked if someone would check the resident. SSD E said he/she would get the nurse and left the unit without checking the resident. At 12:24 P.M., Licensed Practical Nurse (LPN) D arrived in the resident's room and asked what was wrong. LPN D then told the resident to get up. The resident began to cry and said, I want to kill myself. At 12:27 P.M., LPN D said he/she would get someone to help and left the resident's room. The resident continued to cry loudly. At 12:29 P.M., Environmental Aide (EA) C entered the room and said he/she would be doing one on one monitoring with the resident. At 12:33 P.M., LPN D returned and said he/she would send the resident to the hospital. During an interview on 4/23/25 at 12:34 P.M., LPN D said the resident always exhibited behaviors. However, the threats of suicide was a new behavior. LPN D was not sure how often the resident received visits from the psychiatrist or Nurse Practitioner. He/She did not know if the resident received one on one counseling or behavioral health services. During an interview on 4/24/25 at 2:41 P.M., SSD E said he/she does group and one on one therapy with residents. Therapy consisted of how to cope with anxiety, depression, coping skills and going over medications. When a resident was suicidal, staff were to let the team know immediately and the resident would be placed on one-on-one monitoring. The resident was always in his/her feelings and wanted to be liked. The resident yelled, screamed and cried on a regular basis. When this happened, SSD E provided therapy to the resident. Yesterday was the first time she heard the resident say he/she was suicidal. If the resident said it in the past, he/she could not recall. When told the resident had episodes on 3/16/25 and 4/5/25, SSD E said he/she did one on one therapy with the resident upon his/her return from the hospital. He/She did not document the notes in the medical record. The resident was not receiving any additional services. When asked about SSD E's qualifications, he/she said he/she had the SSD certification and was a Certified Nursing Assistant (CNA). During an interview on 4/24/25 at 4:12 P.M., SSD L said he/she has been a Social Services Designee since August 28, 2024 and will be taking the SSD class next month. As a Designee, he/she was not a Social Worker or Therapist, but conducted groups, wrote Social Services progress notes and completed various other duties. The facility had a Social Worker in August 2024, but they left the following September. They had another Social Worker in December 2024, who left in January 2025. The facility had been without a Social Worker since January 2025. SSD L said they had not received any formal training on how to deal with residents expressing suicidal ideations. They have received paperwork and review it regularly. The facility also used to offer an outside mental health therapist, but they no longer have those services. Outside behavioral services would be beneficial for residents exhibiting behaviors. They had not had any outside services since August 2024. During an interview on 4/24/25 at 5:49 P.M., the Social Services Director said he has worked at the facility since 4/14/25. He was not sure how long the facility had been without a social worker. Duties included overseeing the psychosocial needs of the resident population. When a resident displays behaviors, staff will try to deescalate the behaviors and find out what triggers the emotions and work backwards from there. If a resident says they are suicidal, staff should intervene immediately and make the resident safe. The resident is placed on one-to-one monitoring until they are deemed safe to be taken off one on one. Facility staff can determine whether the resident is considered safe. Based off observation and judgment. If the threat is credible, staff would send the resident to the hospital for an evaluation. The resident was reaching out for some kind of connection. The behavior was not new. When asked if appropriate interventions were put into place for the resident, SSD said there were interventions put into place for the resident. The interventions depended on the outcome. There was no specific box for the resident. He/She was provided the opportunity to express himself/herself. When a resident is in an immediate crisis, there should be an immediate response. When asked if staff responded immediately and or appropriately to the resident's crises, SSD said he was not familiar with the facility's policy. Going forward, staff would be expected to respond immediately. He was not sure what services were in place for the resident and could not say if Social Services Designee's were able to provide therapy or determine if a resident was safe to take off of one-on-one monitoring. The resident could use additional services if he/she has a history of suicidal ideations, but he was not sure what was in place and said, there was no structure to determine the needs of the resident. During an interview on 4/25/25 at 2:50 P.M., the Administrator and Director of Nursing (DON) said they expected qualified professionals to provide services to the resident. Social Service Designees were not qualified to provide medically related social services to residents. The facility has since hired a Social Services Director.

45083 Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice. The facility identified six medication carts and two medication rooms. Three of the six carts and both medication rooms were checked for medication storage. Issues were found in both medication rooms, and all three medication carts. In addition, a non-licensed staff had access to one medication room using a key located at the nurses' station. The census was 140. Review of the facility's Storage and Labeling of Medications policy, dated [DATE], showed: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts and medication supplies are locked when not attended by persons with authorized access; -Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart; -Temperature: Medications and biologicals are stored at their appropriate temperatures and humidity according to the USP guidelines for temperature ranges; -Medications requiring storage at room temperature are kept at temperatures ranging from 59 Fahrenheit (F) to 77 F; -Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 F and 46 F with a thermometer to allow temperature monitoring; -A temperature log is kept in the storage area to record temperatures at least once a day; -Certain medications or package types, such as, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency; -When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated; -The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. Review of the manufacturer's insert for Tuberculin Purified Protein Derivative (PPD, (Mantoux) is a skin test to aid in diagnosis of tuberculosis infection (TB) in persons at increased risk of developing active disease); -Store at 35 to 46 F. A vial of PPD (tubersol) which has been entered and in use for 30 days should be discarded. Do not use after expiration date. 1. Observation and interview on [DATE] at 10:00 A.M., showed inside the top drawer of the first floor nurse cart, one opened, undated and unlabeled vial of Levemir (long-acting medication used to treat diabetes) insulin. Licensed Practical Nurse (LPN) A said he/she did not know who the insulin belonged to, and the insulin was expired. LPN A removed the insulin from the cart. Observation and interview on [DATE] at 11:14 A.M., showed in the top drawer of the second floor Certified Medication Technician's (CMT) cart, one opened and undated Lantus (long-acting medication used to treat diabetes) insulin pen, and one opened, and undated Lispro (short-acting medication used to treat diabetes) insulin pen. The Assistant Director of Nursing (ADON) said the labels may have fallen off the pens. He/She expected the insulin pens to be dated once opened. The insulins were good for 28 days. 2. Observation and interview on [DATE] at approximately 10:05 A.M., showed the first floor medication room had one opened and undated vial of PPD. The date on the bag, in which the vial of medication was located, had a dispense date of [DATE]. LPN A said he/she did not know when the medication was opened. Whomever opened the medication was responsible for dating it. The medication was good for 30 days after it was opened. Observation and interview on [DATE] at 11:10 A.M., showed in the top drawer of the second floor nurse cart, one opened and undated vial of PPD. LPN M said he/she did not know when the medication was opened. Whomever opened the medication should date it. The medication was good for 30 days after it was opened. PPD should be stored in the refrigerator. 3. Observation and interview on [DATE] at 10:55 A.M., showed: -Inside the second floor medication room, on a shelf above the sink, was a plastic bag with a Lispro insulin pen inside it. The ADON said insulin should be stored in the refrigerator until it was opened. After insulin was opened, it could be stored on the medication cart. The ADON said the insulin was probably put on the shelf because it looked like the other injectable medications that were stored on the shelf. There was one bottle of fungi care (an over the counter liquid antifungal) that was open and unlabeled. The expiration date of the medication was ,d+[DATE]. The ADON said the medication probably came from a new admission, but she could not recall who the resident was; -The medication refrigerator's temperature log sheet showed multiple dates with no documentation of temperature readings and staff signatures: -[DATE], [DATE], [DATE], [DATE] to [DATE], [DATE] to [DATE]; -[DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE]; -[DATE] to [DATE], [DATE], [DATE] to [DATE], [DATE] and [DATE]; -The ADON said the housekeepers were responsible for monitoring the temperatures of the medication refrigerator. He/She said they may not have a pen with them when they checked the temperatures on those days mentioned above. The ADON said only nurses and CMTs had access to the medication rooms. 4. Observation on [DATE] at 9:49 A.M., showed Environmental Aide (EA) C obtained a set of keys from one of the drawers in the second floor nurses' station and opened the medication room. There were no nurses or CMTs in the station or accompanying EA C. He/She came out of the room after a few seconds with a box which contained the residents' cigarettes. He/She then returned the keys to the drawer where he/she removed them from. During an interview on [DATE] at 12:36 P.M., EA C said the residents' cigarettes were stored in the locked medication room. He/She would enter the medication room when assigned to monitor and provide cigarettes to the residents who smoked. He/She said the medication room keys had always been in the nurses' station. He/She used them without supervision since his/her employment in [DATE]. The nurses told him/her to obtain and use the keys when needed. During an interview on [DATE] at 1:15 P.M., LPN A said the cigarettes for residents in the locked units were kept in the medication rooms. Nurses, CMTs, CNAs and EAs could supervise the residents who smoked, but only nurses and CMTs had access to the medication rooms. CNAs and EAs had to ask the nurses or CMTs to obtain the cigarettes for them. 8. During an interview on [DATE] at 2:50 P.M., the Director of Nursing (DON) said she expected medication to be stored per manufacturer's recommendations. She said the nurses and CMTs were responsible for monitoring and documenting the medication refrigerator temperature. Non-licensed staff should not have access to the medication rooms. She expected staff to follow the facility's policies and procedures.

Based on interview and record review, the facility failed to ensure one resident (Resident #342) had a code status (a legal document or instructions that outlines a patient's wishes regarding medical care, particularly if they experience cardiac or respiratory arrest) and another resident's code status was accurate (Resident #32). The sample was 29. The census was 140. Review of the facility's Advanced Directive Policy & Procedure, dated [DATE], showed: -Purpose: The facility aims to support a resident's self-determination and respects each individual's right to have their choices related to healthcare planning, advanced directives, and end-of-life care preferences throughout their stay; -At the time a resident is admitted into the facility, it must be determined if a resident has existing advanced directives or wishes to establish advanced directives. The following steps are taken as part of the admission process: -The facility admissions coordinator and/or a Social Service Worker (SW) will supply the resident and/or their representative with a copy of the facility's advanced directive policy, as well as, educational materials and explanation of the resident's rights regarding formulating an advanced directive. If the resident has existing advance directives, the admissions coordinator and/or SW will document in the medical record what documentation was provided by the resident and/or their representative; -The staff is to offer and assist the resident and/or representative in the completion of the paperwork, related to: -Identifying the primary decision-maker(resident and/or legal representative); -Identifying situations where healthcare decision-making is needed, including life sustaining treatments, such as: Cardiopulmonary Resuscitation, also known as: CPR (full code, all life saving measures wanted); Do Not Resuscitate, also known as: DNR, No Code, or No CPR Artificial Ventilation, also known as: breathing machine, respirator or ventilator; -Communication of the resident's and/or resident representative choices to the interdisciplinary team, through: -Emergency code status and if a resident has a legal representative will be reflected on the resident's face sheet in the medical record; completion of code status form; Physician's order to be obtained to reflect the resident and/or representatives advance directive wishes; comprehensive care plan established to reflect advance directive decisions; -If you choose to not establish an advance directive, no preference for end of-life decisions, and/or if a resident unexpectedly goes into cardiac and/or respiratory arrest CPR will be initiated and attempted, resident will be considered to have an emergency code status of: full code; -The facility SW and/or designee will review the currently established advanced directive wishes and goals of care with the resident and/or their representative during quarterly and annual care plan conferences, which will be documented in the medical record. If a resident's advance directive wishes change: face sheet will be modified, the care plan will be modified; the code status form will be modified; the physician order will be modified. 1. Review of Resident #342's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -admitted [DATE]; -Cognitively intact; -Diagnoses included high blood pressure, hemiplegia or hemiparesis (weakness or paralysis on one side of the body), traumatic brain injury, malnutrition, anxiety disorder, manic depression, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and post-traumatic stress disorder. Review of the resident's electronic medical records (EMR) showed no code status indicated, and no physician's order for code status under order summary. During an interview on [DATE] at 10:07 A.M., the Director of Nursing (DON) said the SW was responsible for completing the initial code status sheet. The facility did not have a SW during the resident's admission and the resident's code status was not completed. Code status order should be obtained from the physician and the form should be signed and completed upon admission. The DON said the staff were expected to apply full code until the resident's code status was completed. 2. Review of Resident #34's annual MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart failure, high blood pressure, renal insufficiency or renal failure, diabetes, stroke, seizure disorder, anxiety, depression, asthma or chronic lung disease. Review of the medical record, showed: -On the ribbon in the computer the resident was a full code; -The order summary report dated [DATE], the resident was a full code, start date was [DATE]; -The care plan in use at the time of survey, showed, the resident chooses to be full code. Review of the Code Status Decision Form, dated [DATE], showed: In the event of cardiac or respiratory arrest, I do request the following: DNR-Do not perform measures that will keep me alive, was checked. During an interview on [DATE] at 9:20 A.M. Licensed Practical Nurse (LPN) A said the code status could be found in the computer on the ribbon and on the face sheet. The SW was responsible for completing the code status form. Then, the SW will tell the nurse and the nurse will enter the code status in the computer. LPN A checked the chart and said the ribbon in the computer showed the resident was full code and the code status form showed the resident was DNR. If the resident was not breathing, he/she would treat the resident as a DNR. LPN A said he/she would clarify the code status order. 3. During an interview on [DATE] at 2:50 P.M., the DON said she expected for the code status to be completed and for the code status to be accurate. 45083

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for three of three sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #39, #36 and #6). The sample size was 29. The census was 140. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled using either the SNFABN (form CMS-10055) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have; and -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. 1. Review of Resident #39's medical record, showed: -Medicare Part A skilled services start date of 1/17/25 and end date of 2/25/25; -No SNFABN form issued. 2. Review of Resident #36's medical record, showed: -Medicare Part A skilled services start date of 12/25/24 and end date of 1/7/25; -No SNFABN form issued. 3. Review of Resident #6's medical record, showed: -Medicare Part A skilled services start date of 3/20/25 and end date of 4/18/25; -No SNFABN form issued. 4. During an interview on 4/23/25 at 7:31 A.M., the Minimum Data Set (MDS) Nurse said Social Services used to be responsible for issuing SNFABN's upon a resident's discharge. She is currently responsible for issuing notification. She was not aware the SNFABN's were not done for all of the residents. 5. During an interview on 4/25/25 at 2:50 P.M., the Administrator and Director of Nursing (DON), said they expected for the beneficiary SNFABN to be completed after a resident discharged from Medicare Part A.

Based on observation, interview and record review, the facility failed to maintain a homelike environment for residents at the facility, by not ensuring ceilings and water spots in resident bathrooms were repaired during three of five days of the survey (Residents #27 and #129). In addition, the facility failed to ensure the bedroom door in one resident's room was in proper working condition and functional (Resident #69). The sample was 29. The census was 140. Review of the facility's Maintain a Safe, Clean, Comfortable, and Homelike Environment policy, reviewed 1/24/24 showed: -Policy: This facility will accommodate, to the extent possible, a personalized, homelike environment that recognizes the individuality and autonomy of each resident, while maintaining the safety of all residents and staff; -Policy Explanation and Compliance Guidelines: - Report any furniture in disrepair to maintenance promptly; -Maintain a clean, comfortable and homelike environment (I.e., ceiling tiles, wallpaper, floor tiles); -Report any unresolved environmental concerns to the Administrator. 1. Review of Resident #27's medical record, showed: -Moderate impaired cognition; -Diagnoses of hypertension (high blood pressure), diabetes, hyperlipidemia (high cholesterol) and stroke. Review of Resident #129's medical record, showed: -Cognitively intact; -Diagnoses of hypertension, heart failure, anxiety disorder, depression, and schizophrenia. Observations of Residents #27's and #129's bathroom on 4/22/25 at 9:26 A.M., 4/23/25 at 12:23 P.M., and 4/24/25 at 4:17 P.M., showed: -A damaged spot on the left side of the ceiling over the commode which measured approximately 6 inches wide and approximately 8 inches in length. The ceiling plaster/paint was observed torn away and hanging down from the ceiling; -A water stain, approximately a little larger than a basket ball was on the wall in the top left hand corner adjacent to the peeled ceiling, that had the old paint hanging down. During an interview on 4/22/25 at 9:26 A.M. with Residents #27 and #129, Resident #27 said he/she had been at the facility for approximately four or five months. The ceiling had been like that. Staff told the resident they were going to fix the ceiling in the bathroom but they had not. Resident #129 said sometimes the ceiling in the bathroom leaked, and sometimes it didn't. The maintenance people checked it and said were they going to fix it but they had not. 2. Review of Resident #69's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/11/25, showed; -Cognitive impairment; -No behaviors; -Ambulates with a walker; -Diagnoses included anxiety and depression. Observations of the resident's room, showed: -On 4/21/25 at 11:14 A.M., the resident's door was closed upon approach. When the surveyor opened the door, the door slammed shut extremely loud. The door would not remain open; -On 4/23/25 at 5:35 A.M., the resident's door was closed upon entry. The surveyor opened the door and it closed loudly afterwards. The door would not remain open; -On 4/23/25 at 11:44 A.M., the resident sat in bed. The resident said the door bothered him/her. The resident's roommate opened the door and left the room. Upon the roommate leaving, the door slammed shut. During an interview on 4/22/25 at 8:30 A.M., the resident sat in his/her bed. The door had been like this for awhile. He/She said it was extremely loud and sometimes woke him/her out of his/her sleep. Staff were aware of the door, but had not addressed it. During an interview on 4/25/25 at 8:47 A.M., Certified Nursing Assistant I said the resident's door would not remain open and had slammed when shut for a long time. The loud noise was annoying. Staff were aware the door did not function properly. During an interview on 4/25/25 at 1:58 P.M., the Maintenance Director and Corporate Maintenance Director said they just heard about the door the day before and removed the door closure. The door was currently working. The door started malfunctioning recently, because they walked the units weekly. When told the door was not functioning properly since at least 4/21/25, the Maintenance Director said he was not aware. Staff would usually make him aware of any maintenance issues in the facility. 3. During an interview on 4/25/25 at 2:50 P.M., the Administrator and Director of Nursing said the facility should be homelike and in good repair. Doors slamming and stains were not considered homelike. 40291

Based on interview and record review, the facility failed to notify the State Survey Agency (Department of Health and Senior Services-DHSS) no later than two hours after one resident made an allegation of sexual abuse (Resident #191). The sample size was 29. The census was 140. Review of the facility's Abuse, Neglect and Exploitation policy, dated 4/8/24, showed: -Policy explanation and compliance guidelines: the abuse coordinator in the facility is the Administrator or facility appointed designee. -Report allegations or suspected abuse, neglect, or exploitation immediately to: Administrator; -State Survey and Certification agency through established procedures; -Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, sexually inappropriate interactions, or sexual assault; -Response and Reporting of abuse, neglect and exploitation: anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: -Respond to the needs of the resident and protect them from further incident (document); -Notify the Administrator and Director of Nursing (document); -Contact the State Agency to report the alleged abuse; -The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies. Review of Resident #191's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/14/25, showed: -Cognitively intact; -Clear speech-distinct intelligible words; -Ability to express ideas and wants with verbal or non-verbal expression-understood; -Understanding verbal consent, however able understands-clear comprehension; -Diagnoses included high blood pressure, seizure disorder, anxiety, depression, bipolar disease (mood disorder that can cause intense mood swings), psychotic disorder (severe mental illness characterized by loss of contact with reality, marked by abnormal thinking and perceptions), schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of Resident #131's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Clear speech-distinct intelligible words; -Ability to express ideas and wants with verbal or non-verbal expression-understood; -Understanding verbal consent, however able understands-clear comprehension; -Required supervision or touching assistance for eating and oral hygiene and for sit to stand transfers and for walking at least 150 feet; -Diagnoses included dementia, anxiety, depression, psychotic disorder and schizophrenia. During an interview on 4/22/25 at 10:30 A.M., Resident #191 said the Saturday before last (4/12/25), he/she was sleeping in his/her bed, between 10:30 P.M. and 12:00 A.M. Resident #131 came into his/her room and grabbed his/her package (genitalia). When he/she opened their eyes, Resident #131 had one hand on his/her package and was making a shhh motion by placing a finger over his/her mouth with his/her other hand. Once Resident #191's eyes were open, Resident #131 left the room. Resident #191 went out into the hall and reported the incident to the worker, and they reported it to the nurse. During an interview on 4/24/25 at 8:35 A.M., Certified Nurse Aide (CNA) G said Resident #191 came to him/her and reported Resident #131 came into his/her room and tried to give him/her oral sex and CNA G reported it to the nurse. Review of the facility's investigation showed: -Date and time of alleged incident: 4/13/25, no time was listed; -Summary of alleged incident: staff reported Resident #191 woke up and stated he/she had a dream that peer was in his/her room holding his/her genitalia, and it was similar to a situation that occurred at another facility; -A handwritten statement, written by Licensed Practical Nurse (LPN) H, on 4/12/25 around 11:40 P.M., Resident #191 was walking in the hallway, approached the CNA and had a conversation. Following the conversation both the CNA and the resident approached the nurse. Resident began describing an event he/she believed to have just happened but was unsure because beforehand he/she was sleeping (per resident). Resident stated that he/she was in a deep sleep, and he/she was awakened by movement on his/her blanket. Resident stated that it felt like someone was touching his/her blanket. He/She opened his/her eyes to see another resident touching his/her blanket. The resident stated shhh. The other resident believed to be Resident #131, went to pull back his/her covers and said shhh again and then abruptly stopped and ran out of the room. Since the event was so strange resident was not sure if it had occurred. Resident went into the hall, and no one was there but Resident #131's room was across the hall, so it had to be Resident #131. Resident stated that he/she was unsure if he/she was mixing this event with the event at previous home and it was causing his/her distress because if this had occurred then it would be the second time this happened to him/her in an establishment owned by the same people, and they must be in on it and it was causing him/her great distress. Also, after resident initially told the nurse his/her original version, the nurse asked if the person was successful in getting to his/her privates. He/She said no. Then, he/she changed it and said the person had it in their hands. By the time 911 arrived, it had changed again. Before 911 arrived he/she was unsure. By the time 911 arrived he/she switched again. He/She left (went to the hospital). Review of the self-report filed by the facility showed the incident was reported on 4/13/25 at 9:56 A.M. During an interview on 4/25/25 at 2:50 P.M., the Director of Nursing (DON) said allegations of abuse should be reported to the state within two hours. The DON was responsible for reporting allegations to the State. The DON was made aware of the allegation on 4/13/25 at approximately 8:30 A.M. and 9:00 A.M. She reported within two hours after she was made aware of the incident. MO00252707 MO00252889 MO00252909 MO00252695 MO00252688

Based on interview and record review, the facility failed to ensure a resident with a mental disorder had a DA-124 Level II evaluation (Pre-Admission Screening and Resident Review (PASRR), a comprehensive assessment conducted on individuals identified by a Level I PASARR screening as potentially having a mental impairment or developmental disability) as required, for one resident investigated for PASRR requirement (Resident #106). The census was 140. Review of the facility's Pre-Admission Screening and Resident Review Process, reviewed on 1/24/24, showed: -Purpose: Our facility will follow the Missouri Department of Health and Senior Services in obtaining the PASARR to determine the psychological needs they require based on their past history, allowing the facility to provide individualized care; -Process: -Prior to admission the DA 124 is completed while in the hospital; -The code is verified on the Central Office Medical Review Unit (COMRU) website to ensure it has been filled out completely; -COMRU website will alert the facility if a Level Il was triggered and when the assessment will be completed; -Once the Level Il has been completed and reviewed, the facility determines if they are able to meet the needs of the potential new resident; -Once accepted and admitted , the Level II/PASRR are placed in the resident's medical record; -An individualized care plan will be developed based on the resident's Level II/PASARR, care plan meetings, interview with resident/family/guardian and staff observations. Review of Resident #106's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/21/25, showed: -Re-admission on 6/18/24; -Cognitively intact; -Diagnoses included depression and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly); -Received antidepressant and antipsychotic medications routinely. Review of the resident's DA-124 Level I (PASARR, used to evaluate for the presence of psychiatric conditions to determine if a PASRR Level II screen is required), dated 9/1/21, showed a Level II was indicated for serious mental illness. During an interview on 4/24/25 at 11:05 A.M., the Administrator said she was new to the facility and had to request the DA-124 Level II from their corporate office. The Administrator provided a copy of the Level I and said it was all they had for the resident. During an interview on 4/25/25 at 2:50 P.M., the Administrator and Director of Nursing said they expected the resident's DA-124 Level II to be completed as required.

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, whose care plans did not address recent self-harming behaviors, dialysis and discharge planning (Residents #43, #121 and #120). The sample size was 29. The census was 140. Review of the facility's Care Plan and Care Plan Conference Policy, dated 8/24/24, showed: -Policy: A care plan shall be used in developing the resident's daily care routine and will be available to the team for review to ensure the best person-centered care is provided to our residents. Every quarter, an attempt will be made to schedule a care plan conference with the resident, family and/or responsible party to allow the staff to provide the best person-centered care; -Procedure; -An interim care plan will be completed by the Nursing Deportment within 24 hours of admission and provided to the responsible party within 48 hours of admission; -The Minimum Data Set (MDS) Coordinator will review resident medical records and complete appropriate assessments needed to obtain information to complete the admission MDS; -A comprehensive care plan will be generated through collaboration with the interdisciplinary team, resident and responsible party, to be completed by the 21st day of admission; -The care plan will reflect a problem, goal and interventions to guide the interdisciplinary team to assist the resident in achieving the desired outcome for a specific problem; -The care plan will be accessible to team members for review at any time; -The care plan will be reviewed quarterly and updated as needed; -Care plan meetings will be held quarterly with the interdisciplinary team, resident and responsible party or guardian. 1. Review of Resident #43's care plan, revised 1/21/24, in use during the time of the investigation, showed: -Problem: Suicide: The resident reports he/she was sad at the time and attempted to overdose while living at home with his/her parent. This attempt was more than four years ago; -Goal: Resident will remain safe and will not harm self through next review date; -Approaches/Tasks: If resident poses a potential threat to injure self or others, notify physician for behaviors and keep power of attorney informed. If wandering or pacing, initiate visual supervision during acute episodes. Monitor for cognitive, emotional or environmental factors that may contribute to violent behaviors. Monitor resident for signs/symptoms of agitation. Redirect to activities, socials, groups. Review of the resident's progress note, showed: -On 3/16/24 at 2:30 P.M., the nurse heard a loud yelling from the hall. The resident was crying and stated that he/she wants to harm him/herself as this nurse walked toward the unit could see resident with a belt that he/she began to wrap around his/her neck. Staff intervened immediately and remained with resident. This nurse placed a call to 911 for assistance and transport to the emergency room for evaluation. Staff continued to remain with resident until Emergency Medical Technicians (EMT) arrived. Physician notified, agreed to send resident out for an evaluation; -On 3/21/25 at 10:01 A.M., resident returned to the facility from the hospital. Review of the resident's care plan, viewed 4/22/25 at 12:10 P.M., showed no information regarding the resident's hospitalization for suicide ideation on 3/16/25. Review of the resident's progress notes, showed: -On 4/4/25 at 5:00 P.M., resident on unit screaming and yelling because he/she was escorted back to his/her unit after yelling at another resident in activities; -On 4/5/25 at 9:44 P.M., resident pushed his/her way off the locked down unit and refused to go back. Resident was yelling profanities and walking up on staff and other residents threatening to hit them. Call was placed to his/her guardian and explained to him/her what resident was doing and agreed with this nurse to send resident to the hospital for evaluation and treatment. Call was placed to 911 to have resident transported to the hospital for treatment. Call will be placed to the nurse practitioner; -On 4/14/25 at 3:43 P.M., the resident returned to the facility from the hospital. Review of the resident's Hospital After Visit Summary, dated 4/14/24, showed: -Reason for Admission; -Suicide attempt by drinking hand sanitizer times one and wrapping a belt around his/her neck times two. Review of the resident's care plan, viewed 4/22/25 at 12:10 P.M., showed no information regarding the resident's hospitalization for suicide ideation on 4/5/25. During an interview on 4/24/25 at 2:41 P.M., Social Services Designee (SSD) E said the resident's recent suicide attempts should have been on the care plan. 2. Review of Resident #121's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/31/24, showed: -Cognitively intact; -Diagnoses included stroke and end stage renal disease (ESRD, chronic irreversible kidney failure); -Received dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys are not working properly), while a resident. Review of the order summary report, dated 4/21/25, showed a physician order, may attend dialysis on Monday, Wednesday and Friday. Review of the care plan, in use at the time of survey, showed there was no focus area for monitoring dialysis such as the access site or what to do in case of an emergency. During an interview on 4/25/25 at 9:20 A.M., Licensed Practical Nurse (LPN) A said dialysis should be on the care plan. During an interview on 4/25/25 at 2:15 P.M., LPN B said he/she was responsible for completing the MDS and updating the care plans. Dialysis should be a focus area on the care plan. LPN B was aware the resident was on dialysis. LPN B said dialysis was not on the resident's care plan, he/she was must have been moving too fast. 3. Review of Resident #120's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included high blood pressure, anxiety disorder, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and chronic obstruction pulmonary disease (COPD, lung disease). Review of the resident's progress notes, showed no information regarding the resident's plan to discharge. Review of the care plan, in use at the time of survey, showed there was no focus area for discharge planning. 4. During an interview on 4/25/25 at 2:17 P.M., the MDS Nurse said care plans were updated quarterly, and with a significant change. Information regarding care plans and resident behaviors were discussed with the interdisciplinary team, and the team decides the interventions. The care plan should be complete and accurate and reflect each resident individually. Information regarding dialysis, discharge planning and suicide ideations should be listed on the care plans. She was not aware the information was not on the care plans for Residents #43, #121 and #120. 5. During an interview on 4/25/25 at 2:50 P.M., the Administrator and DON said care plans should be accurate and reflect the resident's current needs. Dialysis, discharges and suicide ideation should have been included in the care plans. 40291 42247

Based on observation, interview and record review, the facility failed to ensure services provided met acceptable professional standards of care when staff failed to transcribe one resident's new order into the computer, resulting in the resident's urine analysis (UA, urine to check for signs of disease or infection) and culture and sensitivity (C/S, a lab test to attempt to grow bacteria, viruses, or fungi. and then test which medications will effectively work to stop the infection) not being obtained (Resident #68). Staff also failed to obtain a physician order for one resident's oxygen (Resident#31). The sample was 29. The census was 140. Review of the facility's Physician Orders policy, dated 8/24/24, showed: -Purpose: The purpose of this policy is to ensure our residents receive the care prescribed by their physician; -The Registered Nurse (RN)/Licensed Practical Nurses (LPN) and Certified Medication Technicians (CMT) are to follow the orders as written. 1. Review of Resident #68's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 3/20/25, showed: -Moderately impaired cognition; -Required partial/moderate assistance (helper does less than half the effort) for toileting and personal hygiene; -Always incontinent of bowel and bladder; -Diagnoses included anemia (low red blood cell count), high blood pressure, dementia, anxiety, depression and bipolar disorder (a mental health condition that causes extreme mood swings). Review of the care plan in use at the time of survey, showed: -Problem: Is on antibiotic therapy (Macrobid) related to infection (urinary tract infection, UTI). He/She was prone to UTls. On 3/1/24 Macrobid x 10 days; -Goal: Will be free of any discomfort or adverse side effects of antibiotic therapy through next review date; -Interventions: Administer antibiotic medication as ordered by physician. Monitor/document side effects and effectiveness every shift. Review of the resident's physician routine visit note, dated 4/15/25, showed: -Reason for visit: Physician visit for medical management I have pelvic pain, and it burns; -Chief complaint: Resident today complained of dysuria (painful or difficult urination) and suprapubic (above the pubic bone) pain; -Assessment overview: Get UA and C/S to evaluate for possible UTI. Further recommendations to follow once these results are known. Review of the resident's order summary report, dated 4/21/25, showed no physician order for the UA and C/S. Review of the progress notes, dated 4/14/25 through 4/21/25, showed no documentation the urine had been collected or the physician was notified of the results. During an interview on 4/25/25 at 11:05 A.M., the Director of Nursing (DON) said the facility had four to five different lab companies in the past year. Sometimes the facility received the test results and sometimes they did not. The facility got access to the current lab's portal on 1/7/25. The resident had a history of UTIs, but they were far and few in between. When the physician visited the facility, he/she wrote new orders on a physician order sheet and nursing transcribed the order into the computer. The DON said the facility did not have the UA and C/S results from 4/15/25 and she would have to investigate who transcribed the order to see what happened. The DON expected new orders to be transcribed into the computer and the urine obtained. 2. Review of Resident #31's significant change MDS, dated [DATE], showed: -Cognitively intact; -Required supervision for eating, dressing and personal hygiene; -Diagnoses included thyroid disorder, anxiety, depression, asthma or chronic lung disease; -Oxygen therapy while a resident. Review of the resident's order summary report, dated 4/21/25, showed no physician order for oxygen. Observation on 4/22/25 at 9:25 A.M., showed the resident lay on top of the bed with oxygen on via nasal cannula (NC, a medical device consisting of lightweight, flexible tube with two prongs designed to be inserted into the nose) at three liters (L)/minute (m). Observation on 4/24/25 at 11:35 A.M. and at 2:20 P.M., showed the resident in bed with oxygen on at 4L/m. Review of the progress notes, from 3/18/25 through 4/21/25, showed: -On 3/21/25 at 1:00 P.M., at 11:41 A.M., Emergency Medical Technician (EMT) arrived in the unit stating resident had called 911, wanting to be transferred to the hospital. Upon assessment, resident complained of chest pain (elephant sitting on his/her chest and unable to breath). Oxygen saturation (amount of oxygen in the blood) was 94% (normal 95 through 100%) on 1 L/m. Concentrator was adjusted to 3L/m; -On 3/27/25 at 7:07 P.M., resident in bed resting quietly with oxygen going continuously via NC; -On 4/10/25 at 11:30 A.M., EMT arrived on the unit, resident called 911 stating he/she can't breathe, had just came in from smoking outside, staff put oxygen on resident per NC; -On 4/21/25 at 9:00 A.M., resident came from outside and went directly into the resident's phone room. Resident called 911 stating he/she was having difficulty breathing. EMT arrived at facility to perform assessment. The nurse attempted to obtain resident's vitals and provide oxygen prior to EMT arrival and resident refused; -On 4/21/25 at 3:08 P.M., resident returned from hospital. No new orders. Refused oxygen upon arrival. During an interview on 4/25/25 at 9:20 A.M., Licensed Practical Nurse (LPN) A said the resident used oxygen all the time except for when he/she was smoking. There should be a physician order for oxygen. LPN A checked the chart and said the resident did not have an order for oxygen. During an interview on 4/25/25 at 2:50 P.M., the DON said residents should have a physician order for oxygen. MO00251490 MO00250134

Based on interview and record review, the facility failed to ensure staff followed their policy for dialysis (a procedure that cleanses the blood of its impurities) when staff failed to assess/document the dialysis catheter (a catheter used for exchanging blood to and from a hemodialysis machine and a patient) or arteriovenous fistula, (AV, a surgical connection between an artery and a vein, usually in the arm, that's used for dialysis) site every shift and failed to fully complete the dialysis communication forms for two out of two residents who were receiving dialysis services (Residents #121 and #104). In addition, the facility failed to have a physician order for dialysis for one resident (Resident #104) and failed to have a contract with the dialysis companies. The sample was 29. The census was 140. Review of the facility's Management of a Resident Receiving Dialysis policy, dated 2/22/25, showed: -General guidelines: monitor the resident for the following problems associated with renal failure and/or dialysis: fluid and electrolyte imbalance; cardiovascular/hemodynamic instability; pain; infection; altered nutrition and immobility; -Assess dialysis catheter or AV fistula every shift and document; -The nursing staff should work in conjunction with the resident's dialysis center to schedule transportation, have open communication, and provide adequate/appropriate care for the resident; -A care plan should be initiated to determine the needs of the resident and to monitor effective/ineffective interventions for the resident. 1. Review of Resident #121's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 10/31/25, showed: -Cognitively intact; -Diagnosis included end stage renal disease (ESRD, chronic irreversible kidney failure); -Received dialysis while a resident. Review of the order sheet report, dated 4/21/25, showed a physician order: may go to dialysis on Monday (M), Wednesday (W) and Friday (F). Review of the Medication/Treatment Administration Record (MAR/TAR) dated 4/1/25 through 4/21/25, showed there were no documentation the dialysis catheter or AV fistula was assessed every shift. Review of the dialysis communication sheets, dated 4/2/25 through 4/23/25, showed pre-dialysis: the weight and site were blank 8 out of 8 opportunities; post dialysis: weight was blank seven out of eight opportunities and site was blank eight out of eight opportunities. Review of the progress notes, dated 3/21/25 through 4/21/25 showed: -On 3/25/25 at 2:30 P.M., resident returned from his/her outpatient procedure. A new port was placed into his/her left upper arm, dressing clean dry and intact. Old port in place until new port heals; -On 4/16/25 at 2:13 P.M., hemodialysis on M-W-F at dialysis center; -There were no post dialysis vital signs documented and no documentation showing the dialysis catheter or AV fistula was assessed every shift and there was no documentation showing the resident refused to be assesses. 2. Review of Resident #104's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnosis included ESRD; -Received dialysis while a resident. Review of the resident's care plan, in use at the time of survey showed: -Problem: resident needs hemodialysis related to ESRD. He/She has had multiple complications from ESRD, in example, blindness, left lower leg amputation, impaired circulation, impairment skin integrity, kidney transplant recipient. He/She was at risk for alterations in psychosocial wellbeing related to progress, quality of life; -Goal: will have no signs and symptoms of complications from dialysis through the review date; -Interventions: monitor for dry skin and apply lotion as needed; monitor labs and report to doctor as needed. No blood pressure in left arm. Left lower leg prosthesis. Blind. Dialysis on Tuesday, Thursday and Saturday at the dialysis center at 10:45 A.M., No orange juice, bananas, no potatoes/tomatoes. Limit milk to eight ounces daily. Review of the order sheet report, dated 4/21/25, showed: -A physician order to check the bruit (swishing sound that is heard with a stethoscope indicates patency) and thrill (vibration that indicates arterial and venous blood flow and patency) every shift and as needed for hemodialysis; -There was no physician order for dialysis. Review of the MAR/TAR, dated 4/1/25 through 4/21/25, showed no documentation of the bruit and thrill was assessed. Review of the dialysis communication form, dated 4/1/25 through 4/17/25, showed pre-dialysis: weight and site were blank for six out of six opportunities and post-dialysis: weight was blank four out of six opportunities, site was blank three out of six opportunities. Review of the progress notes, dated 3/21/25 through 4/21/25, showed there were no post dialysis vital signs documented and no documentation the bruit and thrill was assessed There was no documentation the resident refused to be assessed. 3. During an interview on 4/25/25 at 9:20 A.M., Licensed Practical Nurse (LPN) A said residents who receive dialysis services should have a physician order and dialysis should be on their care plan. He/She checked the residents' vital signs pre-dialysis and documented it on the dialysis communication form. The weight was checked if he/she had time to get it completed before the resident left. If the weight was obtained, it would be documented on the communication form. The post dialysis section on the dialysis communication form was completed by the dialysis center. Once the resident returned from dialysis, LPN A said he/she checked the resident's vital signs and the access site. This information was not documented anywhere. It would be documented in the progress notes if something was abnormal, and the physician would be called. Neither resident needed to have a bruit and thrill checked because their access sites were in their chest. Resident #121 also had a port in his/her upper arm. The dialysis center has not accessed that port yet, so he/she did not need to do anything with it yet. He/She asked the resident every day if dialysis used that port because once they do, he/she will need to check the bruit and thrill. The dressing on the access sites is checked daily to be sure they are intact. 4. During an interview on 4/25/25 at 2:50 P.M., the Director of Nursing (DON) said residents who receive dialysis services should have physician orders for dialysis. Dialysis should be addressed on the care plan and staff should monitor the resident's bruit and thrill, the dressing covering the access site and document it on the TAR. The days the resident went for dialysis, they should have vital signs and weight checked before going out and documented on the dialysis communication form. The post dialysis section on the communication form was documented by the dialysis center. When the resident returned from dialysis, the nurse should check the residents' vital signs, bruit and thrill and observe for any changes. This should be documented in the progress notes. If the residents' access site was in their chest, staff should monitor their dressing. The facility should have dialysis contracts. The DON expected staff to follow the facility's policy and procedures.

42247 Based on interview and record review, the facility failed to ensure staff accurately administered/documented medications, weekly skin assessments, pain and behavior monitoring, as well as blood pressure, per physician orders for two residents (Resident #31 and #62). The sample was 29. The census was 140. Review of the facility's Administering Medication policy, dated 1/24/24, showed: -Policy: Medications will be administered in a safe and timely manner, and as prescribed; -Only persons licensed or permitted by the state of Missouri to prepare, administer and document the administration of medications and/or have related functions can administer medications; -The Director of Nursing (DON) or designee will supervise and direct all nursing personnel who administer medications and/or have related functions; -Medications must be administered in accordance with the orders, including any required time frame; -If a medication is withheld, refused or given at a time other than the scheduled time the individual administering the medication will document the rationale; -While residents have the right to refuse medications, it's vital to notify the appropriate physician of the resident's refusal after three days to allow for a medication review; -It is best practice to document medication administration in the moment, prior to moving on to the next resident; -If a medication is unavailable, the Certified Medication Technician (CMT)/Nurse will look in the first dose cabinet and/or central supply for over-the-counter medications and administer the medication. If the medication is still unavailable, the CMT/Nurse will reorder the medication by either faxing or calling the request into the pharmacy; -If a medication is missing, and the pharmacy has not sent the requested medication the following day, the DON or designee is to be notified to assist in removing barriers and obtaining the medication in a timely manner, whether the issue lies within the pharmacy, or a new prescription needs to be updated. Review of the facility's Charting and Documentation policy, undated, showed: -Policy: All services provided to the resident, or any changes in the resident's medical or mental condition will be documented in the resident's medical record; -Procedure: -All observations, medications administered, services performed, etc., will be documented in the resident's medical record; -All incidents, accidents, or changes in the resident's condition must be recorded; -To ensure consistency in charting and documentation of the resident's medical record, only facility approved abbreviations and symbols may be used when recording entries in the resident's medical record; -Documentation of procedures and treatments will include care specific details and at a minimum, will include: -Date and time procedure/treatment was provided; -Name and title of the individual(s) who provided the care; -Assessment data and/or any unusual findings obtained during the procedure/treatment; -How the resident tolerated the procedure/treatment; -Whether the resident refused the procedure/treatment; -The signature and title of the individual documenting. 1. Review of Resident #31's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/20/25, showed: -Cognitively intact; -Diagnoses included anxiety, depression, asthma or chronic lung disease and thyroid disorder. Review of the order summary report, dated 4/21/25, showed a physician order for alprazolam (Xanax, antianxiety) disintergrating 0.5 milligrams (mg), give one tablet three times a day for anxiety. During an interview on 4/22/25 at 1:55 P.M., the resident said he/she did not always receive his/her medications. When he/she went to the hospital in March, he/she was not receiving his/her Xanax like he/she was supposed to. The facility was trying to blame it on the pharmacy. Review of the alprazolam (Xanax) tab 0.5 mg, one tablet three times daily, controlled drug (a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) receipt record/disposition form (control log) dated received on 3/10/25, showed: -On 3/11/25 the medication was signed as administered three out of three opportunities; -On 3/14/25, the medication was signed as administered two out of three opportunities; -On 3/15/25, the medication was signed as administered one out of three opportunities; -On 3/16/25, the medication was signed as administered zero out of three opportunities; -On 3/17/25, the medication was signed as administered two out of three opportunities; -On 3/18/28, the medication was signed as administered zero out of three opportunities; -On 3/20/25, the medication was signed as administered one out of three opportunities; -On 3/21/25, the medication was signed as administered three out of three opportunities; -On 3/25/25, the medication was signed as administered one out of three opportunities. Review of the Medication Administration Record (MAR), dated 3/11/25 through 3/26/25, showed: -A physician order for alprazolam disintegrating 0.5 mg give one tablet three times a day for anxiety; -On 3/11/25, the medication was documented administered two out of three opportunities; -On 3/14/25, the medication was documented administered three out of three opportunities. -On 3/15/25, two out of three opportunities were documented as refused and one opportunity was documented with a nine (other, see progress notes); -On 3/16/25, two out of three opportunities were documented as refused and one opportunity was documented with a five (hold, see progress notes); -On 3/17/25, the medication was documented as administered one out of three opportunities; -On 3/18/25, the medication was documented as administered three out of three opportunities; -On 3/20/25, the medication was documented as administered three out of three opportunities; -On 3/21/25, the medication was documented as administered two out of three opportunities; -On 3/25/25, the medication was documented as administered zero out of three opportunities. Review of the progress notes, dated 3/11/25 through 3/25/25, showed: -On 3/21/25 at 1:00 P.M., at 11:41 A.M., resident was transferred to the hospital; -On 3/26/25 at 6:34 P.M., resident returned from hospital; -There was no documentation showing the resident refused his/her medication or the medication was on hold or showing why the medication was not administered as ordered. 2. Review of Resident #62's quarterly MDS, dated [DATE], showed the following: -admitted on [DATE] and readmitted on [DATE]; -Severe cognitive impairment; -Substantial/maximal assistance required eating; -Dependent on staff for bathing, transfer, dressing, toileting, personal hygiene, and transfers; -Diagnoses include hypertension (high blood pressure) hyperlipidemia (high cholesterol), stroke, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), dementia, and depression (other than bipolar). Review of the resident's physician order sheet (POS), dated 4/22/25 showed: -An order dated 4/26/24 for Artificial tears ophthalmic solution 1%, instill 1 drop in both eyes two times a day for dry eyes; -An order dated 5/22/23, Senna-Docusate Sodium oral tablet, give 1 tablet by mouth two times a day for constipation; -An order dated 11/12/20, to assess and monitor resident for pain, four times daily with med pass; -An order dated 7/24/23, for weekly skin checks on Monday 7:00 P.M. to 7:00 A.M., document under skin only assessment every Monday for skin assessment; -An order dated 12/4/23, to monitor Behaviors: Has the resident demonstrated any behaviors during that shift? Made any inappropriate comments and pushed boundaries with female staff, refusals of medications, and any other behaviors, every shift; -An order dated 10/5/24, to monitor blood pressure every shift for hypertension; Review of the MAR, dated 3/1/25 through 3/31/25, showed: -An order dated 4/26/24, for Artificial tears ophthalmic solution 1%, instill 1 drop in both eyes two times a day for dry eyes; -Documentation showed five out of 31 opportunities left bank; -An order dated 5/22/23, Senna-Docusate Sodium oral tablet, give 1 tablet by mouth two times a day for constipation; -Documentation showed five out of 31 opportunities left bank. -An order dated 11/12/20, to assess and monitor resident for pain, four times daily with med pass; -Documentation showed twelve out of 124 opportunities left bank; Review of the Treatment Administration Record (TAR), dated 3/1/25 to 3/31/25, showed: -An order dated 7/24/23, for weekly skin checks on Monday 7:00 P.M. to 7:00 A.M., document under skin only assessment every Monday for skin assessment; -Documentation showed one out of 5 opportunities left blank. -An order dated 12/4/23, to monitor Behaviors: Has the resident demonstrated any behaviors during that shift? Made any inappropriate comments and pushed boundaries with female staff, refusals of medications, and any other behaviors, every shift; -Documentation showed two out of 93 opportunities left blank. -An order dated 10/5/24, to monitor blood pressure every shift for hypertension; -Documentation showed two out of 93 opportunities left blank; Review of the MAR, dated 4/1/25 through 4/30/25, showed: -An order dated 11/18/20, Atorvastatin 20 mg tablet, give 1 tablet orally at bedtime related to hyperlipidemia; -Documentation showed two out of 24 opportunities left bank; -An order dated 4/26/24, for Artificial tears ophthalmic solution 1%, instill 1 drop in both eyes two times a day for dry eyes; -Documentation showed one out of 24 opportunities left bank; -An order dated 5/22/23, Senna-Docusate Sodium oral tablet, give 1 tablet by mouth two times a day for constipation; -Documentation showed one out of 24 opportunities left bank. -An order dated 11/12/20, to assess and monitor resident for pain, four times daily with med pass; -Documentation showed four out of 72 opportunities left bank; Review of the TAR, dated 4/1/25 to 4/30/25, showed: -An order dated 7/24/23, for weekly skin checks on Monday 7:00 P.M. to 7:00 A.M., document under skin only assessment every Monday for skin assessment; -Documentation showed one out of 3 opportunities left blank. -An order dated 12/4/23, to monitor Behaviors: Has the resident demonstrated any behaviors during that shift? Made any inappropriate comments and pushed boundaries with female staff, refusals of medications, and any other behaviors, every shift; -Documentation showed two out of 72 opportunities left blank. -An order dated 10/5/24, to monitor blood pressure every shift for hypertension; -Documentation showed two out of 72 opportunities left blank; 3. During an interview on 4/25/25 at 9:20 A.M., Licensed Practical Nurse (LPN) A said all medications should be documented on the MAR/TAR when given. If the medication was a controlled substance, the medication would also be signed out on the control log. A blank on the MAR would indicate the medication was not signed out or the medication was not given. There should be no blanks on the MAR/TAR. If a resident refused a medication or a medication was not given, staff should document a code in the box. If a resident was in the hospital, it should be documented. The control log would be more accurate as compared to the MAR. 4. During an interview on 4/25/25 at 2:50 P.M., the Director of Nursing (DON) said medications should be documented when they are administered. If the medication was a controlled substance, it should also be documented on the control log. The MAR and the control log should match. If a resident refused a medication or if the medication was not administered staff should document a code showing the reason the medication was not administered. If the code showed see progress note she would expect there to be a corresponding progress note. The DON expected staff to follow the facility's policy and procedures and to follow physician orders. MO00251490

Based on interview and record review, the facility failed to follow their policy and ensure staff reported an allegation of sexual abuse, resulting in a delayed abuse investigation regarding two residents (Resident #1 and Resident #2). The sample was six. The census was 132. Review of the facility's Abuse, Neglect, and Exploitation policy, undated, showed the following: -Policy: Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. -Resident must not be subject to abuse by anyone, including, but not limited to: Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals; -When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, it must be communicated to the facility's Administrator, department head, or supervisor and the Administrator and/or designee must initiate an investigation. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/23/24, showed: -Cognitively intact; -Diagnoses included bipolar disorder (characterized by extreme mood swings from depressive lows to manic highs), anxiety, major depressive disorder, and paranoid schizophrenia (mental disorder characterized by hallucinations, delusions, disorganized thinking and behavior). Review of the resident's care plan, dated 10/6/24, showed: -Problem: Behaviors: Resident became upset about concerns about his/her brother and punched a wall. He/She fixates on his/her brother, and can be overprotective, even if there is no sustained reason for concern. He/She accuses others of being rude/or mistreating his/her brother, even if the brother never voices any concern himself. Co- dependent on brother; -Goal: Resident will verbalize thoughts and feelings through the next review date; -Interventions: Allow resident to talk to his/her brother for support. Re-direct resident to an activity that he/she can enjoy with his/her brother. Call resident's guardian for support. Allow time outside if feasible. Put resident in a quiet room and allow resident to verbalize his/her concerns freely. Refer to counselor for support. When resident is feeling upset, encourage resident to take a walk to release his/her frustrations. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Diagnoses included mild intellectual disabilities, bipolar disorder, and schizophrenia; -No behavior concerns. During an interview on 10/10/24 at 10:30 A.M., the Social Service Designee said on 10/9/24 at an unknown time, she was informed by Certified Nursing Assistant (CNA) D that in the morning, he/she had walked into the bathroom and witnessed Resident #1 and Resident #2 performing sexual intercourse with each other. The Social Service Designee spoke with the resident's counselor but did not inform her supervisor or the Administrator. She said she should have reported the abuse allegation immediately. Review on 10/10/24 at 9:45 A.M., of Resident #1's progress notes, showed: - No notes about the alleged abuse allegation made on 10/9/24. Review on 10/10/24 at 10:00 A.M., of Resident #2's progress notes, showed: - No notes about the alleged abuse allegation made on 10/9/24. During an interview on 10/10/24 at 10:13 A.M., the Director of Social Services said he heard a rumor of the alleged sexual abuse between Resident #1 and Resident #2 from the Social Service Designee this morning. He said he thought the abuse allegation had already been reported to the Administrator and to the Department of Health and Senior Services. He expected any abuse or neglect of a resident to be reported immediately. During an interview on 10/10/24 at 11:13 A.M., CNA D said the residents are siblings so they are close. He/She said he/she did not walk in on the residents in the shower and did not witness the alleged abuse. During an interview on 10/10/24 at 10:42 A.M., the Administrator said she was not aware of the alleged sexual abuse that occurred between Resident #1 and Resident #2. No investigation had been started. She said the Social Service Designee should have reported this abuse allegation to her supervisor or her, immediately upon being informed by CNA D. MO00243311

Based on observation, interview and record review, the facility failed to ensure call lights were accessible to residents while in their rooms for five out of five sampled residents (Resident #5, #11, #12, #13 and #15). This had a potential to affect all residents. The census was 127. 1. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/14/24, showed: -Cognitively intact; -Had impaired vision; -Impairment on one side of upper and lower body; -Always incontinent of bladder; -Frequently incontinent of bowel; -Dependent on staff for toileting and transfers from the bed/chair; -Required moderate assistance for rolling left and right in the bed; -Required maximal assistance to transfer from a lying to sitting position and from a sitting to lying position; -Used a wheelchair for mobility; -Diagnoses included heart failure, stroke, diabetes, respiratory failure, muscle weakness, cognitive communication deficit and seizure disorder. Observation on 8/23/24 at 9:46 A.M., showed the resident lay in his/her bed. A short call light string hung off the wall, out of reach of the resident. During an interview on 8/23/24 at 10:14 A.M., the resident said he/she could never use the call light because it was not in reach. The resident would scream for help from his/her bed if he/she needed something from staff, in hopes they would hear him/her. It did not make him/her feel safe. 2. Review of Resident #11's quarterly MDS, dated [DATE], showed: -Moderately impaired cognitive skills; -Occasionally incontinent of bladder; -Required moderate assistance with hygiene; -Used a cane/crutch for mobility; -Wore corrective lenses for impaired vision; -Had incidents of hallucinations and delusions; -Diagnoses included stroke, end stage renal disease (where the kidneys permanently stop functioning and require dialysis or a kidney transplant to stay alive) and schizophrenia (breakdown in relation between thought, emotion and behavior leading to faulty perception, inappropriate actions and feelings). During an observation and interview on 8/23/24 at 10:11 A.M., the resident lay supine in bed. His/Her call light was a single piece of string hanging down at the wall and out of reach of the resident. He/She would have to lean out over the side of the bed and reach for the call light if needed. He/She said he/she could not reach the call light. Staff rarely made sure the call light was in reach. He/She would get up and take himself/herself to the bathroom during the day and at night. He/She has had falls going to the bathroom. During an interview on 8/23/24 at 4:30 P.M., Certified Nurse Assistant (CNA) E said that call lights should be in reach of all residents, at all times. It is dangerous for the resident; anything can happen, if they do not have a call light in reach. The resident cannot get to the call light in the dark at night and has an increased risk of falling. 3. Review of Resident #12's admission MDS, dated [DATE], showed: -Rarely/never understood others; -Long term memory problem; -Severely impaired eyesight; -No corrective lenses; -Could not recall current season, location of own room, or staff names and faces; -Moderately impaired cognitive skills for daily decision making; -Required moderate assistance for rolling left and right in the bed, to transfer from a lying to sitting position and from a sitting to lying position; -Required maximal assistance for toileting, from sit to stand position and chair/bed-to-chair transfers; -Dependent on staff to pick up objects; -Used a wheelchair for mobility; -Frequently incontinent of bowel; -Diagnoses included diabetes, schizophrenia and dementia. Observation on 8/23/24 at 4:07 P.M., showed the resident sat in a wheelchair, in the middle of his/her private room, watching television. The call light string was on the resident's bed, out of reach of the resident. The Director of Nursing (DON) walked into the room, picked up the call light string off of the resident's bed and tried to secure it to the resident's wheelchair. The call light string did not extend far enough to reach the resident. During an interview on 8/23/24 at 4:08 P.M., the DON said the resident could not reach the call light from where he/she was sitting in the room. The resident could not walk. The resident could call out for help if needed. During an interview on 8/23/24 at 4:30 P.M., CNA E said the resident could not propel him/herself in the wheelchair to get to the call light. 4. Review of Resident #13's annual MDS, dated [DATE], showed: -Cognitively intact; -Required maximal assistance with dressing, personal hygiene, rolling to left or right in bed, going from a sitting to lying position, going from a lying to sitting position, going from sitting to standing position, bed to chair and chair to chair transfers, transfers on and off the toilet and in/out of the shower; -Used a manual wheelchair for mobility; -Had occasional bladder incontinence; -Had frequent bowel incontinence; -Diagnoses included debility (physical weakness), gastroesophageal reflux disease (GERD, a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach), arthritis, schizophrenia and anxiety. During an observation and interview on 8/23/24 at 11:18 A.M., the resident sat in his/her wheelchair in front of the television in his/her room. His/Her call light was a single piece of string hanging down at the wall and out of reach of the resident. He/She said he/she could not reach the call light. Staff do not make sure the call light is in reach most of the time. He/She has had to yell out for help on several occasions. 5. Review of Resident #15's quarterly MDS, dated [DATE], showed the following: -Diagnoses of schizophrenia, major depressive disorder and seizures; -Cognitively intact. Observation on 9/17/24 at 8:07 A.M., showed the call light box in the resident's room had only one pull cord. The pull cord was positioned towards the resident's roommate. During an interview on 9/17/24 at 2:14 P.M., the resident said if he/she needed staff assistance in his/her room, he/she had to ask his/her roommate to pull the cord for him/her. During an interview on 9/17/24 at 2:11 P.M., Licensed Practical Nurse (LPN) A said he/she was aware the resident's room does not have two pull cords for the call light. The resident does not need a call light, so staff kept the one pull cord positioned for the resident's roommate. 6. Review of an email, sent on 9/10/24 at 12:54 P.M., showed the Administrator said the facility did not have a call light policy. 7. During an interview on 8/23/24 at 10:02 A.M., CNA B said: -Residents would use call lights when they needed help from staff; -Nursing staff were alerted when call lights were activated by an audible bell sound and a light would come on over the resident's room. During an interview on 8/23/24 at 4:30 P.M., CNA E said: -Each resident should have a call light available at all times; -The call light should be in reach of all residents at all times; -Each time staff enters a room, they should verify that the call light was in reach of the resident; -The call lights in the facility were a single string; -Not all strings had a clip on them to clip it to the resident or bedding; -It was dangerous, anything can happen, for the resident if they did not have a call light in reach; -The resident could fall trying to get to the call light; -If the resident was in a wheelchair and could not propel themselves to the call light, they could yell out, but that was dependent on people hearing them yell. During an interview on 8/23/24 at 4:16 P.M., the DON said: -She expected staff to ensure call lights were in reach of residents before they left the room; -She expected nursing staff to round on residents at least every two hours to ensure residents had their needs met and call lights were in reach; -She was not sure why the call lights were made out of a thin string; there was risk of the call light string breaking when pulled for use; -Residents were at risk of serious injury and/or danger if they could not access their call lights to use when they needed help; -Some residents were not able to yell loud enough for staff to hear them if they were in need of assistance; -Residents were at a higher risk of falling if they tried to get up out of their chair/wheelchair to get to a call light; -Residents were at higher risk of falling out of bed if they tried to lean over to retrieve a call light that was out of reach or stuck behind them. During an interview on 9/17/24 at 2:47 P.M., the Maintenance Associate said he was not employed at this facility, but he worked at a sister facility and was at the facility helping out. He expected for a room with two residents to have a call light box with two pull cords. He expected staff to let him know if a resident's room was missing a call light pull cord. During interviews on 9/11/24 at 2:02 P.M. and on 9/17/24 at 2:49 P.M., the Administrator said: -Nursing staff were expected to make sure call lights were in reach and working properly. -She expected nursing staff to notify maintenance if call lights were too short or not working. -There was a risk to residents if call lights were not in reach, as they couldn't notify staff of an emergency and would not get their basic needs met. -She expected each room to have a call light box with two pull cords. -She expected each resident to have their own pull cord. MO00241652

Based on interview and record review, the facility failed to ensure pain medications were given as ordered for one of three sampled residents (Resident #14). The census was 127. Review of the facility's Administering Medication Policy, reviewed on 1/24/24, showed: -Policy: Medications will be administered in a safe and timely manner, and as prescribed; -Medications must be administered in accordance with the orders, including any required time frame; -If a medication is unavailable, the Certified Medication Technician (CMT)/Nurse will look in the First Dose Cabinet and/or central supply for over-the-counter medications, and administer the medication. If the medication is still unavailable, the CMT/Nurse will reorder the medication by either faxing or calling the request into the pharmacy; -If a medication is missing, and the pharmacy has not sent the requested medication the following day, the Director of Nursing or designee is to be notified to assist in removing barriers and obtaining the medication in a timely manner, whether the issue lies within the pharmacy or a new prescription needs to be updated. Review of Resident #14's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/26/24, showed: -Cognitively intact; -Continually in an altered level of consciousness; -Scheduled pain medication regime present; -Pain was present occasionally; -Pain interfered with day-to-day activities occasionally; -Diagnoses included anxiety, depression, schizophrenia (breakdown in relation between thought, emotion and behavior leading to faulty perception, inappropriate actions, and feelings), post-traumatic stress disorder (PTSD), Parkinson's disease (disorder of central nervous system that affects movement) and chronic pain due to trauma. Review of the resident's care plan, undated, showed: -Problem: The resident fixates on pain medications/narcotics (used to treat severe pain); -Interventions included give medications as ordered. Review of the resident's Medication Administration Record (MAR), dated August 2024, showed: -An order, dated 7/2/24, for Lidocaine patch, no strength noted, (prevents pain by blocking the signals at the nerve endings in the skin), apply to neck and back topically, give one time a day for pain; -Documentation showed the Lidocaine patch was not given on the following days due to not available: 8/3, 8/6, 8/8, 8/12, 8/18, 8/20 and 8/22/24. Review of the resident's progress notes, showed no documentation the facility ordered the Lidocaine patches or informed the Primary Care Physician (PCP) of the missing medication. Review of the facility's emergency (e) kit medication list, undated, showed: -Lidocaine 4% patch, five per box, were kept in stock. During an interview on 8/24/24 at 7:56 P.M., the resident said he/she was told by nursing staff that his/her medications were misplaced when the resident went to get them. The resident did not know what happened to his/her medications. During an interview on 8/23/24 at 1:13 P.M., Licensed Practical Nurse (LPN) G said: -The CMTs were responsible for re-ordering medications; -He/She expected CMTs to inform their nurse immediately if a medication was missing; -He/She would look in the medication room for a missing medication or see if the facility had the missing medication in the e-kit; -Nurses had access to the e-kit; -He/She expected CMTs to tell their nurse if they were not able to get a medication for the resident, so the nurse could call the pharmacy to determine the hold-up and/or call the PCP to see if they wanted an alternative medication ordered; -Nurses were expected to document in the progress notes when a resident was missing a medication, what they did to try to resolve the issue, who they notified and how they followed up to resolve the issue. During an interview on 9/11/24 at 2:02 P.M., the Administrator said: -She expected staff to have knowledge of and follow policies; -She expected nurses to follow physician orders; -When a resident was missing a medication, she expected staff to see if there was medication in the medication room, call pharmacy in regards to re-ordering medication, call the PCP to see if the medication was correct, if needed a script to re-order to pharmacy, or if the medication needed changed, then document all they did in the resident's progress notes and update the resident on the status of their medication; -Lidocaine patches were in the facility's e-kit; -She expected CMTs to notify the nurse when they found the resident was missing Lidocaine patches; -She expected the nurses to get the Lidocaine patches out of the e-kit to use for the resident; -Nursing staff not following physician orders was adverse to quality of care; -The resident was at risk of increased pain due to missing medication. MO00241056 MO00240725

Based on observation, interview and record review, the facility failed to ensure nurses completed weekly skin assessments, weekly wound assessments and to ensure treatments were applied as ordered to pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), for one resident (Resident #5) out of three sampled residents. The facility also failed to ensure facility wound reports were accurate. This had the potential to affect all residents at risk for skin breakdown. The census was 127. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: Quick Reference Guide, Washington DC: National Pressure Ulcer Advisory Panel 2014 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observe the pressure ulcer for signs that indicate a change in treatments as required (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, showed the definitions of different stages of pressure ulcers as follows: -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (necrotic (dead)/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy). May also present as an intact or open/ruptured blister; -Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Review of the NPUAP, Prevention and Treatment of Pressure Ulcers; Quick Reference Guide, Washington DC: National Pressure Ulcer Advisory Panel: 2009, showed ongoing assessment of the skin is necessary to detect early signs of pressure. Review of the facility's Pressure Ulcer Prevention and Management policy, reviewed date of 1/24/24, showed: -Policy: This facility is committed to the prevention of avoidable pressure ulcers and the promotion of healing of existing pressure ulcer(s); -Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach for pressure ulcer prevention and management, starting with prompt assessment and treatment, including efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate; -Licensed nurses will conduct a full body skin assessment on all residents upon admission, readmission and weekly; -Assessments of pressure ulcers will be performed by a licensed nurse or physician and documented daily with treatments and weekly wound report; -Evidence-based treatments, in accordance with current standards of practice will be provided for all residents who have a pressure ulcer present; -The Director of Nursing (DON), the Assistant Director of Nursing (ADON), Wound Nurse or designee will review all relevant documentation regarding skin assessment, pressure ulcer risks progression towards healing and compliance at least weekly and discussed at the weekly Interdisciplinary Team (IDT) meeting; -The attending physician will be notified of the presence, progressions toward healing or lack of healing of any pressure ulcers upon identification of the ulcers. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/14/24, showed: -admitted on [DATE]; -Cognitively intact; -Impairment on one side of upper and lower body; -Always incontinent of bladder; -Frequently incontinent of bowel; -Dependent on staff for toileting and transfers from the bed/chair; -Required moderate assistance for rolling left and right in the bed; -Required maximal assistance to transfer from a lying to sitting position and from a sitting to lying position; -At risk for pressure ulcers; -No unhealed pressure ulcers; -Diagnoses included heart failure, stroke, diabetes, respiratory failure, kidney disease, muscle weakness and seizure disorder. Review of the facility's wound report, dated 6/2/24 through 6/29/24, showed no documentation found for the resident. Review of the resident's progress notes, showed: -On 7/5/24 at 4:52 P.M., the resident was evaluated to be at high risk for pressure ulcers; -On 7/12/24 at 1:23 P.M., the resident refused to allow the primary care physician (PCP) to assess his/her wound. Review of the facility's wound reports, showed: -On the 7/7/24 through 7/13/24 wound report, the resident was admitted on [DATE] with a pressure ulcer (stage not noted) on his/her buttock, no stage noted, no measurement noted, no wound assessment noted. The resident refused the physician visit; -On the 7/21/24 through 7/27/24 wound report, the resident was noted as admitted on [DATE] with a Stage II pressure ulcer on his/her buttock, measured on 7/24/24, with slough tissue present. There was no documentation found of the resident's wound measurement. Review of the facility's wound report, dated 7/28/24 through 8/3/24, showed the resident had a pressure ulcer to his/her buttock, stage not noted, no measurement noted, resident refused to be seen by PCP. Review of the resident's progress notes, showed: -On 7/31/24 at 3:57 P.M., the resident was sent out to the hospital due to chest pains; -On 8/6/24 at 3:15 P.M., the resident returned from the hospital. Review of the resident's care plan, undated, showed: -Problem: The resident had actual impairment to his/her skin integrity related to a Stage II pressure ulcer (PU) to his/her buttocks and unstageable PU to his/her left heel noted on 8/6/24; Interventions included: On 8/6/24, apply barrier cream to buttocks as ordered and apply skin prep to left heel as ordered. Review of the resident's assessments found in the electronic medical record (EMR), showed: -No documentation found of a skin evaluation completed upon admission on 8/6/24; -No documentation found showing any wound assessments. Review of a dietary note in the resident's progress notes, dated 8/8/24 at 1:06 P.M., showed the resident had no skin concerns. Review of the facility's wound reports, showed: -On the 8/4/24 through 8/10/24 wound report, the resident had a Stage II pressure ulcer on his/her left buttock, measuring 0.5 centimeters (cm) by 0.5 cm on 8/8/24, with granulation tissue (healthy, red tissue) present, treat with barrier cream twice a day and as needed; the resident had a Stage II pressure ulcer on his/her left heel, measuring 4.0 cm by 3.5 cm on 8/8/24, with granulation tissue present, treat with skin prep daily; -On the 8/12/24 wound report, the resident had a Stage II pressure ulcer on his/her left buttock measuring 0.5 cm by 0.5 cm, the tissue type was scab, treat with barrier cream twice a day and as needed. The resident had a pressure ulcer, not staged, measuring 4.0 cm by 3.5 cm, the tissue type was scab, treat with skin prep daily. Review of the resident's skin evaluations, showed: -A skin evaluation, dated 8/15/24, showed the resident did not have any current skin issues; -There were no other skin evaluations found. Review of the resident's Treatment Administration Record (TAR), dated August 2024, showed: -An order, dated 7/25/24, for a weekly skin assessment every Thursday day shift. Documentation showed left blank on 8/8 and 8/22; -An order, dated 8/21/24, to cleanse left buttock with soap and water, apply barrier cream twice a day and as needed until healed. Documentation showed on 8/21/24 during day shift, the entry was left blank; -An order, dated 8/22/24, to cleanse the resident's left heel with soap and water, then apply skin prep daily until healed. Documentation showed the order was followed; -There was no documentation found for treatment to the resident's buttock prior to 8/21/24; -There was no documentation found for treatment to the resident's left heel prior to 8/22/24. Review of the facility's wound reports, dated 8/18/24 through 8/23/24, showed no documentation found for the resident. Review of the resident's progress notes, showed: -On 8/23/24, at 1:21 P.M., a dietary note : The resident's care plan showed the resident had a Stage II Pressure Ulcer on his/her buttocks and an unstageable pressure ulcer on his/her left heel. -No documentation found showing when the wounds were found on the resident's buttocks or left heel, who was notified, if new orders were obtained and how the facility was following up on the resident's care. Observation on 8/23/24 at 9:47 A.M., showed the resident received perineal care (peri-care, washing the front and back of the hips, genitals, anal area and buttocks) from a Certified Nurse Assistant (CNA). The resident's brief and paper chuck were soaked with urine and fecal matter. The CNA cleaned the resident. The CNA did not apply barrier cream to the resident's left buttock. There was no pressure ulcer observed. During an interview on 8/23/24 at 10:19 A.M., the resident said: -The nursing staff did not put any type of cream on his/her buttocks; -He/She was in pain related to his/her buttocks; -The nursing staff did not apply anything to his/her left heel. During an interview on 8/23/24 at 1:13 P.M., Licensed Practical Nurse (LPN) G said: -He/She was the nurse assigned to the resident; -The resident did not have any treatments ordered for wounds; -Nurses were responsible for completing treatments listed on the TAR during their shift; -Nurses were responsible for completing skin assessments listed on the TAR during their shift; -If there were any skin issues, nurses were expected to document the location of the wound, what was done, when they contacted the PCP and what orders were put in place. Review of the PCP's wound report, dated 8/26/24, showed: -The resident had a Stage II pressure ulcer on his/her left buttock, measuring 0.8 cm by 0.5 cm, tissue present scab, stable, treat with barrier cream twice a day and as needed; -The resident had a pressure ulcer (unstaged) on his/her left heel, measuring 1.0 cm by 1.0 cm, tissue present scab, improving, treat with skin prep daily. During an interview on 8/23/24 at 3:13 P.M., the DON said: -She expected nurses to complete weekly skin assessments; -She expected nurses to assess any new skin issues, describe the wound, plus the location, contact the PCP, get new orders and document all in a progress note; -She was responsible for completing weekly wound assessments for each resident and entering the information into their individual EMR; -She was responsible for completing the facility wound reports. She used the information from her own wound assessment and from the wound assessments she received from the PCP, who did rounds on each resident, completing weekly wound assessments; -The wound assessments from the PCP did not have complete assessments of the wounds, did not show drainage, peri-wound (skin around wound) status, tissue type in wound bed or the percentage of different tissue types; -The facility wound reports were not accurate; -She expected accurate wound assessments both in the residents' EMR and on the facility wound report, so the IDT could adequately monitor if residents' wounds were healing or declining; -Inaccurate or lack of assessment increased the risk of residents' wounds not healing and could affect the plan of care. During interviews on on 8/23/24 at 2:26 P.M. and on 9/11/24 at 2:02 P.M., the Administrator said: -She expected staff to have knowledge of and follow policies; -The DON was responsible for completing the facility wound report; -The DON was responsible for completing residents' weekly wound assessments with the PCP or by herself; -She expected the DON to update residents' weekly wound assessment in their EMR, documented in either a wound assessment or in the progress notes; -Nurses were responsible for completing physician orders; -The DON was responsible for checking TARs for completeness on a daily basis; -Wound reports were not accurate if the information was repeated from week to week, using the same measurements from the week before; -Inaccurate wound reports increased the risk of delayed wound healing, of infection, and prohibited the facility from determining if a wound was healing or declining and ultimately affected residents' plans of care; -Lack of weekly wound assessments in a resident's EMR would affect their plan of care since clinicians could not see the progression of the wound, would not be able to determine if the treatment was appropriate or if changes were needed. It would also make the EMR incomplete; -The DON was responsible for putting orders in as soon as she got them from the PCP; -Wounds were at increased risk of deterioration and increased risk of infection if orders were not put in when given by the PCP; -She expected nurses to report any new skin issues to the DON and the PCP, get a treatment order and document a full assessment on the wound in the skin evaluation and progress note; -Nurses were expected to complete skin assessments on admission, readmission, weekly and at discharge and were documented on skin evaluation forms; -She expected the DON and the ADON to audit residents' charts for skin assessment completions on a weekly basis. If they were not done, she expected the DON and ADON to tell the nurse who would then complete the skin assessment; -Residents were at risk of having undetected skin issues with increased risk of infection and wound healing delayed if skin assessments were not completed. MO00238790

Based on observation, interview and record review, the facility failed to ensure residents who required colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall) services received such care consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for one resident (Resident #7) out of three sampled residents. The census was 127. Review of the facility's Administering Medication Policy, reviewed on 1/24/24, showed: -Policy: Medications will be administered in a safe and timely manner, and as prescribed; -Only persons licensed or permitted by the state of Missouri to prepare, administer and document the administration of medications and/or have related functions can administer medications; -Medications must be administered in accordance with the orders, including any required time frame; -Topical medications used in treatments will be documented on the Treatment Administration Record (TAR); -Residents may self-administer their own medications only if the attending physician and nursing personnel has determined they have the decision-making capacity to do so safely. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/19/24, showed: -admitted on [DATE]; -readmitted on [DATE] from an inpatient psychiatric facility; -Cognitively intact; -No behaviors noted; -Moderately impaired eyesight; -No corrective lenses; -Supervision or touching assistance needed for all activities of daily living (ADLs); -Colostomy present; -Diagnoses included anxiety, depression, bipolar disease (psychiatric illness characterized by both manic and depressive episodes, or manic ones only), psychotic disorder (mental disorder characterized by a disconnection from reality) and post-traumatic stress disorder (PTSD). Review of care plan, undated, showed: -Problem: The resident had impaired cognitive function/dementia or impaired thought process. Interventions included administer medications as ordered. Monitor/document for side effects and effectiveness; -No documentation found for a plan of care for colostomy status. Review of the resident's skin evaluation, dated 7/30/24 at 5:41 P.M., showed no current skin issues. Review of the resident's progress notes, showed: -On 8/6/24 at 3:23 P.M., a skin evaluation note showed irritation and redness was noted to the colostomy peri-skin (skin surrounding the stoma); -There was no documentation found showing when the resident went out to the emergency department (ED); -On 8/6/24 at 8:45 P.M., the resident returned from the ED for colostomy site irritation. Review of the resident's hospital discharge documents, dated 8/6/24, showed: -Diagnosis: Colostomy complication, unspecified; -There were no medications prescribed. Review of the resident's progress notes, showed: -On 8/11/24 at 4:51 P.M., the resident called 911 to escort him/her to the ED for colostomy complications; -On 8/11/24 at 11:59 P.M., the resident returned from the ED with a discharge diagnosis of ostomy care. The Primary Care Provider (PCP) was notified and there were no new orders. Review of the resident's hospital discharge documents, dated 8/11/24, showed: -Chief complaint: the resident has a colostomy, complains the facility was out of bags and he/she was in severe pain at the site; site was red and inflamed; -Skin surrounding ostomy has mild erythema (redness), no drainage noted, mild tenderness, nontoxic appearance -Wound care was provided by the Registered Nurse (RN) and ostomy bag was replaced. Resident sent back with ostomy supplies. Review of the resident's PCP progress note, dated 8/13/24, showed: -The resident complained of irritation around the colostomy stoma (an opening in the body). The resident had previously been to the ED and was provided some zinc (barrier cream) protection; -The resident was not wearing a colostomy bag when examined; -The resident complained the colostomy bags fell off because they were not the right size; -The Director of Nursing (DON) and staff said the resident was exhibiting a behavior and intentionally removing the colostomy bags. The bags should last three days but the resident's bag did not last one day; -Assessment plan for colostomy complication showed the resident was stable, colostomy supplies were ordered, hopefully the resident was not removing them. Continue barrier cream. Review of the resident's skin evaluation, dated 8/12/24 at 7:20 P.M., showed the resident had redness and irritation around the colostomy area. Review of the resident's Treatment Administration Record (TAR), dated August 2024, showed: -An order dated 8/14/24, to apply a barrier ring (used to fill uneven skin contours near stoma) to affected area, one time a day every other day, for colostomy care. Documentation showed the nursing staff left 8/14, 8/16 and 8/20 blank. -An order dated 8/14/24, to apply stoma adhesive (protective skin barrier) paste to affected area one time a day, every other day related to colostomy status. Documentation showed the nursing staff left 8/14, 8/16 and 8/20 blank; -An order dated 8/14/24, to apply skin prep barrier wipes, once a day every other day, related to colostomy status. Documentation showed the nursing staff left 8/14, 8/16 and 8/20 blank; -An order dated 8/14/24, to change the [NAME]-plus 2 border barrier opening (stoma site flange, adhesive plate to secure an ostomy pouch to the body) every other day, one time a day for colostomy status. Documentation showed the nursing staff left 8/14, 8/16 and 8/20 blank; -An order, dated 8/14/24, for a two-piece drainable pouch to get changed every other day, one time a day, for colostomy status. Documentation showed the nursing staff left 8/14, 8/16 and 8/20 blank. Review of the resident's progress notes, showed: -On 8/19/24 at 11:31 A.M., a skin evaluation note showed irritation was noted to ostomy site. Review of the resident's Physician Order Sheet, active as of 8/23/24, showed: -There was no order found for the resident to complete his/her own colostomy care. Observation on 8/23/24 at 11:41 A.M., showed the resident in his/her room, laying on his/her bed fully clothed. The resident lifted his/her shirt to show his/her colostomy bag. The colostomy bag was intact. The skin under the colostomy flange was not visible. During an interview on 8/23/24 at 11:42 A.M., the resident said: -He/She had to ask nursing staff for colostomy supplies to change his/her flange and bag; -He/She changed his/her entire colostomy apparatus, including the flange and bag when needed; -He/She was told by the Director of Nursing (DON) the nurses were expected to change and care for his/her ostomy site; -The nurses did not change or care for his/her ostomy site; -Nursing staff did not put any ointments on the skin surrounding his/her stoma; -The skin surrounding his/her stoma was red and painful. During an interview on 8/23/24 at 1:35 P.M., Licensed Practical Nurse (LPN) A said: -The resident changed his/her own colostomy apparatus and bag; -Nurses were expected to apply the stoma adhesive, skin prep and flange to the resident's colostomy site as ordered; -He/She was not sure if he/she had ever followed the orders; -The resident had to get the colostomy supplies to change the stoma site flange and bag from nursing staff as they were stored in the nurses' treatment cart; -Nurses were expected to document when they followed physician orders on the MAR/TAR. During an interview on 9/11/24 at 2:02 P.M., the Administrator said: -She expected staff to have knowledge of and follow policies; -The facility did not have a policy on ostomy care; -Nurses were responsible for ostomy care to residents, include changing ostomy apparatus and topical treatments; -She expected nurses to assess the site during treatments to note any changes, irritation, make sure skin was still intact; -She expected nurses to document any skin changes to ostomy site, inform DON, call PCP and get any new orders; -The nurses were responsible for providing ostomy care to the resident, including changing ostomy apparatus, due to the resident changing his/her ostomy apparatus too often and causing irritation to the ostomy site. Prior to 8/13/24, the resident was allowed to do it on his/her own; -Nurses were responsible for completing all orders on the TAR; -Blanks in a TAR/MAR meant the nurses failed to document or the resident was out of the building; -She could not confirm if an order was followed if there was a blank in the MAR/TAR; -She expected the resident's care plan and order to reflect if the resident was able to change his/her own ostomy site; -The MDS care plan team was responsible for updating care plans; -Nurses were responsible for putting in orders; -She expected nurses to chart honestly and accurately to maintain accurate medical records; -The resident was at risk of delayed healing of the ostomy site and increased risk of skin irritation if the resident was changing his/her own ostomy site and the nurses were not applying the topical cream per the physician order. MO00239083 MO00240867

Based on observation, interview, and record review, the facility failed to ensure a safe environment for one resident (Resident (R) 203), who resided on a secured unit, out of a total of 14 residents reviewed for accidents. The facility failed to ensure R203, who had a known history of drinking hand sanitizer and making statements indicating he/she wanted to kill himself/herself, did not have access to hand sanitizer and antimicrobial wipes. R203 reported he/she obtained and drank hand sanitizer on the night of 01/17/24 and that he/she obtained the hand sanitizer from the unit. Direct care staff were unaware of R203's previous behaviors or how to interact with R203 related to his/her behaviors. R203 had the potential for significant physical harm up to, and potentially including, death related to staff's failure to monitor the resident and provide basic psychosocial/behavioral interventions related to his/her behaviors. The census was 118. On 01/18/24 at 7:20 PM, the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were notified of immediate jeopardy (IJ). On 01/20/24, the Administrator, was notified that the IJ was removed. The deficient practice remained at a D scope and severity following the removal of the immediate jeopardy. The findings include: The facility's ''Chemical Storage Policy'' dated 01/30/22 read, in pertinent part, ''Policy: To ensure chemicals are kept in a secure location and residents do not have access to chemicals;'' and ''3. Chemicals are kept in a secured area and out of reach of residents;'' and ''5. Staff are educated to report resident who has ingested or has been in close contact with chemicals to the charge nurse immediately.'' The facility's ''15-Minute Rounds Protocol'' dated 02/05/23 read, in pertinent part, ''The facility recognizes that residents require individualized care and may require more oversight based on their behaviors and thought processes;'' and ''1. Residents that require more supervision will be placed on 15-minute rounds;'' and ''3. The CNA [Certified Nursing Assistant] and/or designees must visually monitor the location and status of any and all residents assigned to the team member's 15-minute round list;'' and ''4. These rounds must be documented on the 15-minute round sheets.'' Review of the Poison Control website showed: Hand sanitizers usually contain alcohols that have been FDA approved for topical use. These can be hazardous in larger quantities. Some people abuse hand sanitizer to try to become intoxicated or drunk. If someone you know is abusing hand sanitizer, get help. While it is never safe to intentionally drink hand sanitizer, if a person is abusing a contaminated hand sanitizer, this behavior could be deadly. Review of R203's ''Face Sheet'' indicates R203 was admitted to the facility on [DATE] with diagnoses including history paranoid schizophrenia, history of traumatic brain injury (TBI), major depression, history of alcohol abuse, psychoactive, abuse, post traumatic stress disorder (PTSD), mild intellectual disabilities, epilepsy, and violent behavior. R203's quarterly Minimum Data Set (MDS)'' assessment with an Assessment Reference Date (ARD) of 11/18/23 indicated a ''Brief Interview for Mental Status (BIMS)'' of 8 out of 15 (moderately cognitively impaired). R203's ''Behavior Care Plan,'' found in the EMR under the Care Planning tab and initiated on 10/02/23 and then most recently updated on 11/23/23, read, ''BEHAVIORS/ PSYCHOSOCIAL WELLBEING: [R203] shows aggressive behaviors by punching items, walls, and mailbox. He/She has dx [diagnosis] of Intellectual Disabilities, Malingering, PTSD, Factitious D/o [disorder], Suicidal Ideations. He/She has drunk hand sanitizer because he/she is 'just tired of it all.' He/She has made statements that he/she hurts himself/herself because it gets him/her out of the facility. Poor interpersonal skills. Insomnia. H/o [history of] suicidal ideations secondary to schizoaffective d/o & MDD [major depressive disorder]. Recently lost his/her adoptive mother. At risk of Mood Disturbances. He/She has been observed attempting to concoct fermented drinks with his/her leftover foods and states he/she will not stop. Destructive to furniture, has broken the window to his/her room. H/o self-inflicted intentional injury to wrist to harm self.'' R203's ''Incident/Accident Note,'' dated 12/03/21 at 12:03 PM and found in the EMR under the ''Notes'' tab, read, ''Note Text: nurse called to floor because pt [patient] had swallowed 2 quarters. Breathing normal. Pt stated 'I thought it was my medicine' redirected and educated patient on difference between medication and money. Verbalized understanding. Denies chest pain or abdominal pain, no sig [significant] bleeding on initial assessment. 97.9 [temperature in Fahrenheit], 87 [pulse], 138/74 [blood pressure], 97RA [oxygen saturations on room air] 16R [respirations]. Palpated and inspected throat. With normal limits, normal mucosa, no redness or bleeding. No drainage or difficulty swallowing present on shift. Attending physician called with orders to send pt to hospital . R203's ''Alert Note,'' dated 02/06/22 and found in the EMR under the ''Notes'' tab, read, ''Text: CNA nurse aware resident noted to be cutting wrists. Found him/her with butter knife cutting on himself/herself redirected with no success pt becoming more aggravated standing up out of chair charging at nurse, nurse again tried to redirect pt and reroute behavior. Pt told this nurse his/her exact plan on how he/she would kill himself/herself and this was through cutting wrist until he/she would bleed out. 911 contacted and updated pt transported to [hospital] via stretcher.'' R203's ''Incident/Accident Note,'' dated 09/15/22 and found in the EMR under the ''Notes'' tab, read, ''Text: Resident observed having suicidal ideations. Object observed in use with trying to self-harm. Resident states he/she is going to harm himself/herself and further states he/she will do the same every time he/she returns to the facility. Call placed to 911. EMS [emergency medical services] arrived and transported the resident per stretcher as appropriate. Nursing supervisor made aware.'' R203's ''Behavior Note,'' dated 04/19/23 at 8:49 PM and found in the EMR under the ''Notes'' tab, read, ''Note Text: Res. [resident] was witnessed by staff member drinking hand sanitizer from dispenser, when asked by this nurse res. admitted that he/she had drank from dispenser several times, call was placed to physician gave info of res.'s behavior gave order to send to [hospital] for eval. [evaluation] and treat, call also placed to guardian [name redacted] gave all info of res.'s behavior and doctor's order to send to hosp. for eval. said he/she would be available for consent to treat at hospital. A call was placed to [ambulance] for transport to hospital. eta-30 minutes, res. is on 15-minute checks until EMS arrives.'' R203's ''Behavior Note,'' dated 05/04/23 at 9:55 PM and found in the EMR under the ''Notes'' tab, read, ''Text: res. has been having loud outburst during day, being very argumentative with staff and other residents, reported to this nurse by resident that he/she was hearing voices in his/her head telling him/her to harm himself/herself and others around him/her, was asked by this nurse if he/she had a plan to harm himself/herself he/she replied with a cable cord, call was placed to physician gave order to send to [hospital] for eval. and treat, call was also placed to [ambulance] eta-20 minutes, call was also placed to POA [power of attorney] left message with answering service.'' R203, Behavior Note,'' dated 06/21/23 at 6:27 PM and found in the EMR under the ''Notes'' tab, read, ''Note Text: staff brought resident to nurses station where this nurse observed superficial scratches to right inner wrist, resident had a tobacco can with the lid split in half, resident stated he/she used the lid to cut his/her wrist when this nurse asked why resident stated that he/she didn't like himself/herself and wants to harm him/her self, resident kept and nurse station with staff . received orders to send resident to [emergency room ], call then paced to guardian after hours number and made aware .'' R203's ''Incident/Accident Note,'' dated 07/16/23 at 11:15 AM and found in the EMR under the ''Notes'' tab, read, ''Text: One of the residents on D-Hall came to the door and summoned this nurse and then advised that res was on the floor. This nurse entered res's room and saw res laying on the floor on his back with his eyes open. Res was lying in a pool of brown fluid and there was a jug with brown fluid in it beside the res. VS [vital signs] taken and WNL [within normal limits]. Res got up from the floor by himself with standby assist. Res replied that he hit his head on the floor and displayed signs of pain with touch to the back of his head. Skin was intact and appeared normal at that time. Neuro checks were initiated. VM [voicemail] left for PCP [primary care physician] and guardian. DON [Director of Nursing] advised via telephone.'' R203's ''Alert Note,'' dated 08/18/23 at 12:15 PM and found in the EMR under the ''Notes'' Tab, read, ''Note Text: Resident tried to wrap a sheet around his/her neck attempting to hang himself/herself, attempt not successful. Resident was sent to [Adult behavior unit.]'' R203's ''Behavior Note,'' dated 09/08/23 at 2:57 PM and found in the EMR under the ''Notes'' tab, read, ''Note Text: resident had c/o [complaints of] feeling suicidal stated that he/she had a plan, call placed to [physician] and received orders to send to [emergency room ] for eval, call placed to [transport service] to request transport, resident remained under supervision of staff until emt came to transport to ER .'' R203's ''Health Status Note,'' dated 01/18/24 at 9:53 AM and found in the EMR under the ''Notes'' tab, read, ''Text: Staff informed this writer that resident stated he/she drank hand sanitizer last night. Upon assessing resident while in bed resident stated, 'I am angry, so I drank a half of a bottle of hand sanitizer.' Resident was asked where this occurred, he/she replied in his/her room, unwitnessed alone. Resident also stated he/she just wanted to get high, because this is just a feeling 'I get.' Resident states he/she rather smoke some marijuana. Resident educated on the risk of drinking hand sanitizer, and the importance of letting staff know when he/she begins to feel this way.'' R203's ''Health Status Note,'' dated 01/18/24 at 10:57 AM and found in the EMR under the ''Notes'' tab, read, ''Text: 1010 [10:10 AM]- Call placed to 911 for transport to hospital per physician order.'' R203's ''15 Minute Check'' Documentation,'' dated 01/18/24 and provided directly to the surveyor on the unit, was reviewed and indicated 15-minute checks for R203 beginning at 7:00 AM on 01/18/24. The documentation for entries from 01/18/24 at midnight through 01/18/24 at 6:45 AM were blank. Staff were not observed to check on R203 or note the location of the resident for 9:30 AM check until after 9:45 (the 9:30 AM check was observed to be missed). The 9:30 AM and 9:45 AM checks were documented by the staff member on the form at 9:46 AM. The location of the resident was documented on the form, however no additional information was documented on the 15-minute check documents. Additional 15-minute check documentation for R203 was requested for 12/24/23 through 01/18/24. No documentation was provided to indicate R203 was checked every 15 minutes on 01/01/24, 01/06/24, 01/13/24, or 01/14/24 through 01/17/24. Documentation of 15-minute checks for 01/02/24 through 01/05/24, 01/07/24 through 01/12/24, and 01/15/23 through 01/16/24 revealed incomplete documentation of 15 minute checks. Observations were made of R203 on the secured unit or seated in the activities room on 01/15/24 between 9:45 AM and 1:00 PM and between 2:30 PM and 3:00 PM, on 01/16/24 between 8:30 AM and 9:00 AM, 11:00 AM and 11:30 AM, and 1:00 PM and 2:45 PM, on 01/17/24 between 8:15 AM and 8:45 AM, 11:00 and 11:30 AM, and 1:15 and 1:45 PM, and on 1/18/24 at between 9:15 AM and 10:20 AM. Staff was continuously present in the activities room when R203 was seated at the large common table in the facility's activities room (not on the secured unit), however 1:1 supervision was not provided in the activities room. Observations of R203 in the secured unit revealed the resident was wandering throughout the unit or in his/her room with his/her door closed about half of the time and in the smoking area or seated in the dining room at the table with intermittent staff supervision the rest of the time. Staff was not observed to be supervising the resident 1:1 at any time during the observations. During the continuous observations conducted of R203 on 01/18/24 between 9:15 AM and 9:48 AM, the resident was not observed to be checked by any staff (the 9:30 AM check was not observed to be conducted). During an interview on 01/18/24 at 9:21 AM, R203 stated to the surveyor, ''I wasn't ok last night. I drank hand sanitizer, and it made me sick.'' The surveyor asked R203 why he/she drank the hand sanitizer and he/she stated, ''I don't know. I just do. I drink hand sanitizer sometimes.'' When R203 was asked where he/she got the hand sanitizer, he/she stated, ''I just took it from out here, pointing to the overbed table in the hallway.'' R203 then pointed at two packages of ''CleanCide Wipes'' sitting on the overbed table in the hallway and stated, ''I drink that, too.'' When R203 was asked how he/she was able to drink the sanitizing wipes, he/she stated, ''I put those wipes in a cup and add water and drink it. I don't know why.'' No staff was observed to be in the hallway monitoring residents during the interview. One staff member (CNA 3) was observed monitoring smokers in the outdoor smoking area on the unit and the other staff member on the unit (CNA27) was observed in the unit dining room playing cards with two residents while R203 and other residents were observed walking about throughout the unit hallway and in and out of their rooms. After the interview, R203 was observed returning to his/her room and closing the door behind him/her, where he/she stayed with no observed 15-minute checks of him/her until 9:46 AM after the surveyor notified CNA3 R203 reported he/she drank hand sanitizer the night before. The label on the ''CleanCide Wipes'' read, ''Active Ingredients: Citric Acid,'' and ''Keep Out Of Reach Of Children; and'' Precautionary Statements: Hazard to humans and domestic animals.'' The label on the ''Purell Advanced Hand Sanitizer'' read, in pertinent part, ''Active Ingredient: Ethyl Alcohol 70% . Antimicrobial;'' and ''Warnings: For external use only;'' and ''Keep out of reach of children. If swallowed, get medical help, or call Poison Control Center right away.'' During an interview on 01/18/24 at 9:34 AM, CNA3 was informed of R203's report of drinking hand sanitizer. CNA3 stated he/she was familiar with residents on hall and worked regularly on the unit. CNA3 confirmed he/she was supposed to monitor R203 every 15 minutes and provided the current 1:1 monitoring form to the surveyor. CNA3 stated he/she usually had to start a new 1:1 monitoring form in the morning when he/she started his/her shift because he/she was not able to find a 1:1 monitoring sheet from the night shift when he/she arrived. When asked what R203 was monitored for, he/she stated he/she did not know. CNA3 stated, ''I don't know if [R203] had a behavior or not, I was just told to monitor [R203]. The aides from last night just told me I only had to monitor [R203 and two other residents]. I'm just making sure they are not doing anything they are not supposed to, like trying to fight or smoking in their rooms. The night shift is supposed to monitor too, but when I come in, I don't see the [monitoring] sheets from them, so I just make new ones. There is nothing I am aware of that we are supposed to be monitoring [R203] for. I get him/her up and get him/her dressed and he/she is normal throughout the day. No-one reported anything to me about him/her drinking hand sanitizer last night.'' CNA3 stated R203 was normally forthcoming and would tell staff when he/she had a behavior. When asked how R203 was able to access hand sanitizer, CNA 3 stated, ''That is a good question. Normally there is one in the bathroom up here in the dining room. Unless someone left a container out.'' When asked if CNA3 had ever received training on how to provide behavioral interventions for residents on the unit, he/she stated he/she used to work at another behavioral health unit and had been trained there but had never received any sort of training related to behavioral interventions at this facility. CNA3 stated, ''We just have to wing it here.'' CNA3 stated, ''The [CleanCide] cleaning wipes are left there [on the overbed table in the hallway] are left there all the time and they get used for residents. I like to clean up [with the wipes] after smoking [times]. I didn't know [R203] might drink the wipes with water. No one has said anything about that. CNA3 stated if R203 had consumed hand sanitizer on the night shift he should have been told about that in report so he could monitor the resident for it. During an interview on 01/18/24 at 9:46 AM, CNA27 stated this was his/her second shift on the unit, he/she was a new CNA in the building, and was not familiar with the residents on the unit. CNA27 stated, ''No one told me [R203] drank hand sanitizer. I didn't hear about that.'' CNA27 stated he/she had not received any training on how to provide behavioral health services or how to interact with residents having behaviors in the facility. CNA27 stated R203 was supposed to be monitored every 15 minutes and CNA3 was doing that on this shift. When asked what behaviors R203 should be monitored for, he/she stated he/she did not know. CNA27 stated, ''Behaviors, but nothing specific. I don't know what we are specifically checking for.'' During an interview on 01/18/24 at 10:02 AM, Licensed Practical Nurse (LPN) 7 stated he/she was in charge of the D100 Secured unit and two additional units on the first floor. LPN7 stated he/she rounded on the D100 secured unit about once every two hours and was not always back on that unit since she had two additional units to take care of. LPN7 stated no one had reported anything to him/her about R203 drinking hand sanitizer prior to the surveyor reporting the incident to staff. LPN7 said, ''If he/she said he/she [R203] did it, he/she probably did. LPN7 stated the resident's physician was being contacted and the resident was going to be sent to the Emergency Department at the hospital for evaluation. When asked how R203 was able to access hand sanitizer, he/she stated, ''Hand sanitizer . I have no idea. I don't know if they have the [hand sanitizer] dispensers on the wall back there? Or maybe he/she got it out of the bathroom sanitizer in the dining room.'' When asked if any training had been provided to him/her regarding behavioral interventions for residents or de-escalation techniques when residents were exhibiting behaviors, he/she stated he/she had not. LPN7 stated he/she was unaware of R203's behaviors and stated, ''[Hand Sanitizer and sanitizer wipes] is not supposed to be out and available [on the D100 Secured Unit].'' During an interview on 01/18/24 at 10:12 AM, Social Services Designee (SS) 2 stated she had not finished her training related to being a social services provider on the unit but had been an Environmental Aide (EA) in the facility prior to becoming the SS2 on the D100 Secured Unit. She stated she started her position as a social services designee on the unit on 06/01/23, was responsible for three units total and floated between the units and did a walk-through of the unit about four times per day while she was at work (between 9:00 AM and 5:30 PM.) SS2 stated her responsibilities included ''Being the heart of the building'' and getting everyone's concerns collected and redirecting residents if there were concerns. She stated if an incident occurred with a resident, someone would normally get on the phone and call the front desk or send someone out of the unit to ask for a nurse and/or 911 to come. She stated she had not received any training related to de-escalation techniques or behavioral health. She stated she was not aware of R203 being monitored for any specific behaviors and was not aware of the resident having a history of drinking hand sanitizer but stated ''R3 ''tries to make hooch (a mixture of bread and other foods and liquids mixed together)'' and had a history of drug and alcohol abuse and could be drug seeking. During an interview on 01/18/24 at 4:19 PM, CNA18 confirmed he/she was the staff member working on the D100 Secured Unit on the night of 01/17/24 through 01/18/24 and stated he/she had been told R203 drank hand sanitizer when he/she arrived for his/her shift at approximately 11:00 PM on 01/17/24. CNA18 stated he/she was told to keep a close eye on R24 but was given no details about what to look for regarding R203's behavior or physical signs or symptoms of potential poisoning. CNA18 stated he/she was not able to keep a close eye on R203 continuously because, though two CNAs had been scheduled on the unit, the other CNA was pulled from the unit due to staffing issues and so he/she had been on the unit by himself/herself through the night shift with nursing staff check-ins from other nursing staff about every two hours throughout the night. CNA18 stated he/she did not report the incident to oncoming staff at shift change on the morning of 01/18/24. CNA18 stated he/she had never been told of R203's prior history of drinking hand sanitizer or potential suicide attempts prior to the incident on 01/17/24. During an interview on 01/18/24 at 1:44 PM, the Administrator stated she had been told about R203 drinking the hand sanitizer after the survey team identified the concern. The Administrator stated, ''The hand sanitizer and CleanCide Wipes should not be available to residents on that unit. I was not aware the wipes were even on the hall. Sanitizer should be secured, and the wipes shouldn't be back there at all. The last time [R203] did something like that was last year . maybe in April . and that is why the hand sanitizer and hand wipes shouldn't be back there. Its care planned for him/her.'' The Administrator stated all residents on the D100 Secured unit were expected to be monitored at least every 15 minutes and any resident exhibiting harmful and or/suicidal behaviors was expected to either be placed on 1:1 monitoring or every 5-minute checks. The documentation should include the location of the resident and what the resident was engaged in and whether any behaviors were being exhibited or not.

40902 Based on record review, staff interview, and facility policy review, the facility failed to ensure residents were free from abuse, for seven of nine sampled residents (Resident (R) 4, R77, R84, R30, R62, R350, and R83) reviewed. Examples include: R4 struck R77 in the mouth, resulting in a cut to the inner right lip where the resident's tooth hit it, a contusion to the upper lip and a transfer to the hospital for assessment. In a second incident, R4 pulled up the shirt of one resident with impaired decision making and cognition related to intellectual disability (R84), reaching underneath R84's shirt and touching his/her chest. In a third incident, staff entered the hallway and observed R4 being punched in the face by R30 after R4 spit on R30 and threw a cup of juice on him/her. R30 hit R4 in the face several times, resulting in a laceration under the right eye and a transfer to the hospital for a medical evaluation. A fourth incident showed R4 in the hallway sitting in his/her wheelchair, when R62 ran towards the resident. R4 ducked, however, R62 hit R4 in the back of the head, and falling out of his/her wheelchair. R4 and R350 had at least two altercations that included F350 grabbing R4 by the hair and hitting him/her in the face and then the next day getting into another fight. Last, R30 hit R83 in the leg while R30 was exhibiting sexually aggressive and verbal behaviors. The facility failed to make any changes to the residents' plans of care following the incidents. The census was 118. Findings include: Review of the facility's undated policy titled, ''Abuse, Neglect and Exploitation'' revealed, ''. each resident has the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, and involuntary seclusion. The resident has the right to be free from mistreatment, neglect, and misappropriation of property. Residents must not be subject to abuse by anyone, including but not limited to; facility staff, other residents' consultants or volunteers, staff or other agencies serving the resident .'' 1. Review of R4's ''Admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed he/she was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cognitive communication deficit, schizophrenia, bipolar disorder, major depressive disorder, generalized anxiety disorder, altered mental status, high risk bisexual behavior, traumatic brain injury, and schizoaffective disorder. Review of R4's annual ''Minimum Data Set (MDS),'' located under the ''MDS'' tab of the EMR, with an Assessment Reference Date (ARD) of 12/08/23, revealed he/she scored 15 out of 15 on the ''Brief Interview for Mental Status (BIMS),'' indicating no cognitive impairment. Review of R4's care plan,' located under the ''Care Plan'' tab of the EMR and dated 02/11/23, revealed, ''The resident has behaviors as evidenced by poor interpersonal skills. R4 is manipulative and has had verbal and physical altercations with other residents.'' Review of R77's ''Admission Record,'' located in the ''Profile'' tab of the EMR, revealed he/she was initially admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, cognitive communication deficit, altered mental status, bipolar disorder, anxiety disorder, and difficulty in walking. Review of R77's quarterly ''MDS,'' located under the ''MDS'' tab of the EMR, with an ARD of 06/01/23, revealed he/she scored 15 out of 15 on the ''BIMS,'' indicating no cognitive impairment. Review of R77's care plan, located under the ''Care Plan'' tab of the EMR and dated 11/16/23, revealed, ''The resident has impaired cognitive function due to a diagnosis of schizophrenia.'' Review of a ''Nurse's Note,'' located under the ''Notes'' tab of the EMR written by the Director of Nursing (DON) and dated 07/20/23 at 1:02 PM, indicated, ''[R4] was in the dining area with peers when he/she struck [R77] in the mouth. [R4] stated he/she was upset because his/her sodas were being stolen, and the person he/she struck did not know how to shut up, so he/she hit [R77] in the mouth. [R4] also stated, 'I was going to punch another resident for stealing too.'. [R4] was transported to hospital due to aggressive behaviors. Physician and guardian were notified.'' Review of a ''Health Status Note,'' located under the ''Notes'' tab of the EMR dated 07/20/23 at 8:46 PM indicated that R77 returned from the hospital and was diagnosed with a facial contusion. Review of a ''Physician encounter,'' located under the ''Notes'' tab of the EMR and dated 07/20/23 at 12:00 AM, indicated, ''physician followed up with [R77] post emergency room [ER] visit and observed that [R77] had a cut to the inner right lip where the resident's tooth hit it and a contusion to the upper lip. [R77] reported it was still painful but was getting better. During an interview on 01/17/24 at 11:52 AM, the DON stated she did not remember the specifics of the incident but what was documented in the nurses' notes was what occurred. She said both residents were separated, and she thought R4 may have been given a ''PRN (as needed)'' and sent out to the hospital. The DON stated there were no updates made to the resident's care plan or plan of care after the incident. During an interview on 01/18/24 at 6:22 PM, R77 said R4 accused him/her of calling R4 a punk and the R4 ''sucker punched'' R77. R77 said he/she was not afraid of R4 but was leery of him/her because R4 could hit him/her again. 2. Review of R84's ''Admission Record,'' located in the ''Profile'' tab of the EMR, revealed he/she was initially admitted to the facility on [DATE] with diagnoses including major depressive disorder, intellectual disabilities, drug induced subacute dyskinesia, and unspecified mood disorder. Review of R84's quarterly ''MDS,'' located under the ''MDS'' tab of the EMR, with an ARD of 10/05/23, revealed he/she scored 99 out of 15 on the ''BIMS,'' indicating he/she was unable to complete the assessment. Review of R84's care plan, located under the ''Care Plan'' tab of the EMR and dated 07/12/23, revealed, ''The resident has impaired decision making and cognition due to the resident having intellectual disabilities.'' Review of a ''Nurse's Note,'' located under the ''Notes'' tab of the EMR written by Licensed Practical Nurse (LPN) 7 and dated 07/31/23 at 2:23 PM, indicated, ''[R4] was observed by staff to have [R84]'s shirt pulled up and touching the other resident's nipple. The two were separated and are on 15-minute checks. Staff educated [R4] on consent and inappropriate behaviors. Physician and Responsible party were made aware.'' During an interview on 01/16/24 at 11:16 AM, Certified Nurse Aide (CNA) 44 said he/she was in the C unit dining room putting trays away when he/she observed R4 reaching back to R84 and pulling up R84's shirt and R4 reached underneath R84 shirt touching his/her chest and he/she told R4 to stop. He/She said R84 finished eating and then he/she walked R84 down to his/her room to wash the resident's hands and face. He/She said R4 denied the incident and remained in the dining room at that time. He/She said he/she reported the incident to LPN7. He/she said he/she was not instructed to do anything different about supervising either resident after the incident occurred. During an interview on 01/16/23 at 11:58 AM, LPN7 said staff reported to him/her that R4 was in the dining room when he/she raised R84's shirt up and touched R84's nipple and staff separated both residents. LPN7 said when he/she spoke with R4, he/she stated he/she was playing with the other resident. He/She said he/she attempted to talk to R84, but he/she did not say anything. LPN7 said he/she was not aware of any changes made to R4's care other than 15-minute checks but that was standard for all the residents on C unit. LPN7 said he/she reported this incident to the MDS coordinator. 3. Review of R30's ''Admission Record,'' located in the ''Profile'' tab of the EMR, revealed he/she was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of auditory hallucinations, antisocial personality, paranoid schizophrenia, bipolar disorder, and personality disorder. Review of R30's quarterly ''MDS,'' located under the ''MDS'' tab of the EMR, with an ARD of 10/24/23, revealed he/she scored 03 out of 15 on the ''BIMS,'' indicating severe cognitive impairment. Review of R30's care plan, located under the ''Care Plan'' tab of the EMR and dated 10/11/23, revealed, ''The resident has behaviors as evidenced by aggression towards family, argues with himself/herself loudly, resident to resident altercation and requires a secured unit.'' Review of a ''Nurse's Note,'' located under the ''Notes'' tab of the EMR written by agency nurse dated 10/11/23 at 2:45 AM, indicated, ''Staff was made aware that [R4] and [R30] were in the hallway fighting. Staff entered the hallway and observed [R4] being punched in the face by [R30]. [R4] said he/she spit on [R30] resident and threw a cup of juice on him/her and then [R30] hit him/her in the face several times. Both residents were immediately separated. [R4] was taken into the activity room on the unit. 911 was called and requested EMTs [Emergency Medical Technician] with police assistance. [R4] was transferred to the hospital for a medical evaluation. All parties were notified via telephone.'' It was noted that R4 had a laceration under the right eye. During an interview on 01/18/24 at 10:44 AM, the Assistant Director of Nursing (ADON) revealed she was in the office when she heard a loud commotion and looked up and saw R30 and R4 in the hall. R30 was cursing and accused R4 of throwing juice on him/her. The ADON said R30 was difficult to redirect and suddenly jumped out his/her wheelchair and punched R4 in the face. The ADON stated she immediately grabbed R4 and pushed him/her into the dining room and closed the door. The ADON stated she went outside the door and that was when the police arrived and spoke with R30 who was still cussing. The ADON stated she left after that. 4. Review of R62's ''Admission Record,'' located in the ''Profile'' tab of the EMR, revealed he/she was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder, and intellectual disabilities. Review of R62's annual ''MDS,'' located under the ''MDS'' tab of the EMR, with an ARD of 12/08/23, revealed he/she scored 15 out of 15 on the ''BIMS,'' indicating no cognitive impairment. Review of R62's care plan, located under the ''Care Plan'' tab of the EMR and dated 05/16/23, revealed, ''The resident has behaviors as evidenced by resistive to care, susceptible to being manipulated, and makes false allegations.'' Review of an ''Incident/Accident note,'' located under the ''Notes'' tab of the EMR dated 12/25/23 at 4:30 PM, revealed R4 was approached by R62. R4 was struck by R62 and fell to the floor. R4 said he/she was okay, and he/she wasn't struck that hard. R4 was assisted up by staff and separated from R62. There were no injuries noted. The residents' guardian and physician were notified. During an interview on 01/16/24 at 11:27 AM, CNA24 said R62 was upset after coming back from a visit with family. He/She said R4 was in the hallway sitting in his/her wheelchair when R62 ran towards him/her and R4 ducked, but R62 hit R4 in the back of the head. Staff ran over and grabbed R62 while he/she and another staff helped R4 up off the floor and back into his/her wheelchair. R62 was still aggressive after he/she hit R4, and staff called police. He/She said that R62 has had these types of behaviors before, and staff only gave him/her a PRN or would send him/her out to the hospital. He/She said staff would just move the more aggressive residents to another locked unit and that staff kept an eye on them, but there was really nothing done to address the aggressive behaviors. During an interview on 01/17/204 at 5:48 AM, LPN6 said R62 was upset on 12/25/23 about a recent visit with his/her family and was threatening staff and yelling. LPN6 said he/she walked off the unit briefly to call 911 and while he/she was on the phone, he/she could see R62 running down the hall. LPN6 stated he/she hung up the phone and went back onto unit and saw staff helping R4 up and back into his/her wheelchair. He/She said staff told him/her that R62 ran at R4 and hit him/her. R62 was changed to another unit but there was no change in either of the residents' care. 5. Review of R350's ''Admission Record,'' located in the ''Profile'' tab of the EMR, revealed he/she was initially admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, moderate intellectual disabilities, bipolar disorder, major depressive disorder, disruptive mood disorder, anxiety disorder, and disorder of adult personality and behavior. Review of R350's annual ''MDS,'' located under the ''MDS'' tab of the EMR, with an ARD of 12/08/23, revealed he/she scored 15 out of 15 on the ''BIMS,'' indicating no cognitive impairment. Review of R350's care plan, located under the ''Care Plan'' tab of the EMR and dated 12/08/23, revealed ''The resident has behaviors as evidenced by making false allegations, and has been involved in a resident-to-resident altercation.'' Review of a ''Behavior Note,'' located under the ''Notes'' tab of the EMR dated 01/10/24 at 10:30 AM, revealed, ''at about 9:30 AM [R4] said [R350] grabbed [R4] by the hair and hit him/her in the face and then [R4] hit [R350] back in the face. This writer informed [R4] that if he/she has a problem with another resident to report it to staff and not to be fighting. [R4] said that he/she was only defending himself/herself.'' During an interview on 01/15/24 at 11:13 AM, R350 said that R4 and himself/herself were roommates and R4 had stolen some of his/her personal belongings. He/She said that R4 got smart and that he/she beat him up. R350 did not explain what ''beat him up'' meant. During an interview on 01/15/24 at 11:51 AM, R4 said R350 was his/her roommate but he/she kept accusing R4 of stealing his/her stuff. He/She said there was several altercations between the two of them. R4 said on one occasion R350 was blocking the doorway to room, so he/she kicked the wheel on R350's wheelchair to get his/her attention. R350 started kicking R4 in the leg and they both ended up in the hallway and staff intervened and broke up the fight. About a week later R350 was sitting in his/her wheelchair in the middle of the hallway, blocking R4 from getting past. He tapped R350 on the shoulder, but he/she ignored him/her so R4 kicked R350's wheelchair. R4 said R350 told him/her if he/she did it again, R350 would kick his/her ass, but staff separated them again and they stayed away from one another the rest of the day. The next day R4 wheeled past R350 in the hallway and R350 grabbed him/her by the hair and hit him/her in the face and bit his/her arm so R4 said he/she slapped R350 in the face and staff came and broke it up. R350 was moved downstairs, and there had not been any more issues. During an interview on 01/16/24 at 11:27 AM, R4 told staff that he/she and R350 had got into a fight and R350 was moved to another floor. He/She said R4 told him/her that R350 bit and scratched R4's arm. He/She said they were roommates but that R350 was moved off the unit after the fight occurred. He/She said there was no change in their plan of care or any increase in supervision for either resident after the incident occurred. During an interview on 01/17/24 at 11:30 AM, the ADON said that on 01/10/24, staff came and got her and told her there was an incident between R4 and R350. The ADON stated she spoke with both residents who stated R350 pulled R4's hair and hit him/her and that R350 admitted to doing this because R4 was taunting him/her about his/her sexual orientation. The ADON stated both residents were separated and R350 was transferred downstairs. The ADON stated there were no injuries and that R4 reported that R350 ''hit like a girl,'' but there were no changes to either residents' plan of care. During an interview on 01/17/24 at 11:52 AM, the DON stated due to the resident population and all the behaviors, they had started an outside therapy group. The DON stated she was unsure of the specifics but stated it would be run by the Social Services (SS) department. The DON confirmed that services in the facility were not being integrated together, and that the nursing department was not aware of what services SS was doing to address residents' behaviors. The DON said R4 had become increasingly difficult to manage behaviorally, but he/she did get along with some peers and some staff. The DON stated that R4 was medication seeking and had a substance abuse issue, but the facility had no drug and alcohol services to provide. The DON confirmed there was a need for services related to drug and alcohol abuse. The DON stated they have spoken about the need for therapy services for residents during IDT (interdisciplinary team) meetings and stated the facility should be doing more for residents with behaviors. During an interview on 01/17/24 at 10:40 AM, the Social Services Director (SSD) said there are two behavior techs that assist residents with activities, provide encouragement, support, talking to them, and de-escalation, but they do not have specialized training to do their job and they were not hired for a particular unit. The SSD said they also have aides that help monitor on the halls and report concerns but they are not trained to intervene or prevent incidents from occurring. She said the facility had just gotten one counselor that started in December 2023, but the facility did not have any providers prior to December 2023 to provide any mental health services to any of the residents to address their behaviors. 6. R30's ''Admission Record,'' dated 01/20/24 and found in the EMR under the ''Admissions'' tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including antisocial personality disorder, bipolar disorder, and paranoid schizophrenia. R30's quarterly ''MDS,'' with an ARD of 10/24/23 and found in the EMR under the ''MDS'' tab, indicated a ''BIMS'' score of 3 out of 15 (severely cognitively impaired). The assessment indicated R30 experienced hallucinations and delusions during the assessment reference period and exhibited verbal behavioral symptoms toward others on 4 to 6 of the days during the assessment reference period. R30's ''Oder Summary Report,'' dated 01/11/24 and found in the EMR under the ''Orders'' Tab, indicated an order for medroxyprogesterone (a hormone) 10 MG (milligrams) one time daily for hypersexuality. R30's ''Behavior Progress Note,'' dated 01/07/24 and found in the EMR under the ''Notes'' Tab, read ''Resident [R30] up in w/c [wheelchair] on D-hall unit. Agitation with aggressive behavior. A/H & V/H [auditory hallucinations and visual hallucinations]. Delusion [s]. Yelling and cussing at other residents. Staff attempted to redirect. No success. Resident propelled self toward staff making threats. Resident took off clothes in hallway, started masturbating stating, 'I'm going to rape one of these [expletive].' Resident [R83] walked passed [sic] this resident [R30] who proceeded to punch the other resident [R83] in his leg. Staff separated residents. This resident's [R30's] behaviors continued to escalate. MD [Medical Doctor] aware. New order received. 911 notified. Police and EMT's [Emergency Medical Technicians] arrived to [sic] facility. Resident [R30] transported to [Local Emergency Department] for eval/tx [evaluation and treatment]. Call placed to [R30's Legal Guardian], left a message [sic] to contact facility ASAP [As Soon As Possible] for an update. Call placed to [R30's Family Member], left a message to contact facility. On call nurse [ADON] notified. ADM [Administrator] made aware of situation.'' R30's care plan was reviewed and indicated no care plan related to the resident exhibiting any type of abusive behavior toward others. No documentation was found to show the resident's plan of care had been updated related to the 01/07/24 incident of potential sexual and physical abuse. R30 was not able to be interviewed by the survey team due to his cognitive/mental health status (BIMS of 3). Review of R30's record indicated R30 was sent to the local emergency department on 01/07/24 (the afternoon of the above incident) and remained hospitalized for one night (through 01/08/24). R30's ''24 Hour-15 Minute Checks'' documentation was requested on 01/17/24; however, the facility was unable to provide any documentation of 15-minute checks for the resident as the resident had not been receiving the monitoring at any time during the month of January 2024. Comprehensive review of the facility's ''Reportable Occurrences and Incident Log'' on 01/16/24 and 01/17/24 revealed an incident of potential physical/sexual abuse occurred involving R30 on 01/07/24. Review of the facility's investigation of the 01/07/24 incident involving R30 indicated a summary of the above referenced progress note dated 01/07/234. Nothing could be found in the record to indicate that either R30 or R83 were ever assessed by a licensed nurse related to the incident. The investigation documentation indicated the investigation was complete on 01/10/24 and indicated that neither sexual nor physical abuse had been substantiated for either resident related to this incident. During an interview on 01/16/24 at 2:17 PM, LPN8 confirmed he/she was present at the time of the 01/07/24 incident, confirmed he/she was the author of the above referenced progress note, and stated, ''About two weeks ago [R30] was having psychotic events [audio and visual hallucinations]. He/She was yelling and cussing out other residents. He/She stripped his/her clothes off in the hallway and was masturbating and saying he/she was going to rape everyone back there [on the secured D Unit]. I was present and did witness most of it. We [staff] tried to get [R30] to go in his/her room but there was no redirecting him/her. We tried. It actually made [the situation] worse. At first there were other residents in the hall, but we had them go in their rooms or in the dining room. I was there and two aides [CNA6 and CNA7] were there [during the incident]. I did call our psych doctor at the beginning [of the incident] and he either gave me an order or [R30] had an order for a Haldol [an anti-psychotic medication] injection. I drew it up but was unable to give it. We don't have an in-house response team so have to call the police [when an incident occurs]. It took them [the police] 5 to 7 minutes to get here. At the beginning of [the incident] a resident [R83] walked past [R30] and [R30] hit [R83] in the leg and then [R83] turned around and hit [R30] twice in the face.'' LPN8 indicated R30 was placed back in his original room (in close proximity to R30) upon his/her return from the hospital on 01/08/24. He/She stated no changes had been made to R30's plan of care since the incident occurred to ensure his/her safety or the safety of any of the other residents residing on the unit (including R83). During an interview on 01/16/24 at 3:02 PM, CNA6 confirmed he/she was present at the time of the incident on 01/07/24 and stated R30 could get kind of aggressive and angry. He/She stated, ''That day [the day of the incident] I think he/she [R30] was a little off and he/she acted out and it was a bad day for him/her. I came into hall and he/she exploded and he/she was yelling and cursing and smacked [R83] on his/her butt and [R83] did turn around and hit [R30] back and I had to go get the other staff working with me [CNA7] because when they [residents on the unit] get started [with behaviors] it can be a chain reaction and then we got [LPN8] and we had to get him/her [R30] sent out [to the ED].'' CNA6 stated, ''[R30] stood up and was playing with himself/herself [masturbating] and other residents were in the hallway.'' CNA6 stated R30 was still residing on the same secured unit, and he/she was not aware of any changes to his/her plan of care after the incident occurred. During an interview on 01/17/24 at 12:14 PM, the Administrator stated she had not been able to substantiate any abuse related to the incident; however, she confirmed she was unaware of the physical altercation that occurred between R30 and R83 and stated had she known the physical altercation occurred, she would have substantiated physical abuse related to the incident, and one or both of the residents involved would have been moved to a different location in the building to ensure both residents' safety. MO000230064

Based on observation, interview and record review, the facility failed to maintain temperatures in resident accessible areas at or below 81 degrees and/or meet the comfort needs of residents for one of two resident floors. On [DATE], temperatures in the facility on the second floor exceeded 81 degrees Fahrenheit (F) up to 92.3 degrees F in resident use areas and resident rooms. Resident #1, whose diagnosis includes seizure disorder, sat by the air conditioning unit and reported he/she was hot and uncomfortable. His/Her room temperature registered 91.2 degrees F. Resident #2, whose diagnoses included asthma/chronic obstructive pulmonary disease (COPD)/chronic lung disease and seizure disorder, was in his/her room where the air blew out and the code flashed E8. He/She said the air conditioning unit was replaced yesterday. The temperature registered 89.3 degrees F. Staff reset the unit to turn on the cold air. Two residents were in the C hall dining room, where the temperature registered 91.8 degrees F. Temperatures on the D hall, showed temperatures exceeding 81 degrees F and temperatures on the B hall exceeded 85 degrees F (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #12 and #14). The census was 116. The administrator was informed on [DATE] at 5:56 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 Maintaining Temperatures Comfortable for Residents Policy, revised ,d+[DATE], showed: -Policy: -This facility will be monitoring temperatures to ensure residents are kept comfortable and safe; -Policy explanation and compliance guidelines: -1. Maintenance or designee will keep records of environmental temperatures; -2. Facility temperatures will range between 71 degrees F and 81 degrees F; -3. Residents' packaged terminal air conditioner (PTAC, commercial grade heating, ventilation, and air conditioning (HVAC) units installed through a wall) in their rooms will be cleaned and maintained monthly; -4. When temperatures exceed 81 degrees F residents will stay in their rooms on a short term bases; -5. The area affected will be shut off from residents for their safety; -6. Staff will conduct hydration rounds to ensure residents are receiving adequate fluids; -7. Meals may have to be served in residents' rooms; -8. In the event temperatures cannot be kept within range residents may be moved to another location to ensure they are safe; -9. Outside vendor will be contacted to correct problem and bring facility to a comfortable level. Review of the facility's Emergency Preparedness Excessive Heat Event Policy, undated, showed: -Preparedness before an excessive heat event (remember the following guidelines if an excessive heat event is likely to occur in the area of the facility): -Insulate around personal HVAC units and that there is minimal gapping; -Install weather stripping around the windows; -Keep storm windows up, if available; -Replace PTACs after initial repair if unable to fix; -What to do during an Excessive Heat Event: -Monitor local radio or television reports and other media source for information about current status and changes in weather/temperatures; -Maintenance or Designee will keep records of environmental temperatures; -Stay indoors as much as possible and limit exposure to the sun. If a heat index/heat warning has been issued for the facility's local area, residents should remain indoors, until the warning has been cleared by the National Weather Service; -Residents' PTAC in their rooms will be cleaned and maintained monthly if residents identify PTAC E8 Code, staff will follow procedures to reset (power off, unplug for 15 seconds, plug back up and turn on to 67 F); -Use exhaust fans when needed; -When temperatures exceed 81 F, residents will be encouraged to stay in their rooms on a short term basis or removed from the affected area; -Drink plenty of water. Individuals with epilepsy or heart, kidney or liver disease, are on fluid restricted diets or who have problems with fluid retention should consult with a physician before increasing fluid intake; -Dress in light weight, loose fitting, and light colored clothing that cover the skin as much as possible; -Use sunscreen, when going outdoors; -Keep curtains, shades, and/or blinds closed on all windows; -Conduct routine ambient temperature checks to ensure that it remains in a safe, comfortable zone for the residents; -Portable A/C units will be utilized to cool affected areas; -If air conditioning becomes disabled during the severe heat event: -Open all windows in the early morning hours; -Closed windows and curtains/blinds after early morning hours and until dusk; -Use floor fans to circulate air; -The area affected will be shut off for residents and their safety; -Limit use of appliances that give off heat, as much as possible; -Routinely monitor temperatures and document; -Monitor residents and staff for signs of excessive heat exposure or hyperthermia; -Staff will conduct hydration rounds to ensure residents are receiving adequate fluids; -Outside vendors will be conducted to correct problem and bring facility to a comfortable level; -Implement evacuation plan if needed to ensure safety of all residents affected. Review of local weather from [DATE] through [DATE], as found on https://world.weather.info, showed the following: -On [DATE], the average temperature during the day was 97 degrees F, humidity (the amount of water vapor in the air) of 60%, and a heat index (a measure indicating the level of discomfort the average person is thought to experience as a result of the combined effects of the temperature and humidity of the air) of 118 degrees F. The average temperature during the evening was 95 degrees F, humidity of 71%, and a heat index of 124 degrees F. The average temperature during the night was 82 degrees F, humidity of 91%, and a heat index of 93 degrees F; -On [DATE], the average temperature during the day was 97 degrees F, humidity of 57%, and a heat index of 117 degrees F. The average temperature during the evening was 93 degrees F, humidity of 67%, and a heat index of 115 degrees F. The average temperature during the night was 84 degrees F, humidity of 91%, and a heat index of 102 degrees F; -On [DATE], the average temperature during the day was 97 degrees F, humidity of 51%, and a heat index of 113 degrees F. The average temperature during the evening was 99 degrees F, humidity of 57%, and a heat index of 122 degrees F. The average temperature during the night was 82 degrees F, humidity of 85%, and a heat index of 90 degrees F. 1. Review of the facility maintenance temperature log, dated [DATE], showed: -B hall upstairs 82.1 degrees F; -C hall upstairs 83.6 degrees F; -The time temperatures were taken was not documented; -Specific area on halls not noted where temperatures were taken; -No other maintenance temperature logs were provided for the dates of [DATE] through [DATE] (prior to the start of survey on [DATE] at 1:45 P.M.). During an interview on [DATE] at 1:45 P.M., the Administrator said the facility currently had no issues with temperatures in resident rooms. Fans were placed on some of the hallways, but each resident had their own air conditioner (A/C) unit in their room. 2. Observation of the secured D Wing on the second floor on [DATE] at 2:20 P.M., showed the following: -The recorded temperature with a digital electronic thermometer, showed a temperature of 81.5 degrees F after entering the hallway; -A large fan sat in the hallway; -Several residents sat in chairs at the end of the hallway. 3. Review of Resident #14's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Moderate cognitive impairment; -Limited assistance of one person with bed mobility, transfers, walking in room, dressing, toilet use, and personal hygiene; -Used a wheelchair for mobility; -Shortness of breath (SOB) or trouble breathing when lying flat; -Diagnoses of chronic obstructive pulmonary disease (COPD, inflammation of the lung or lung disease), high blood pressure and anxiety disorder. Review of the resident's care plan, in use at the time of survey, showed the following: -Problem: The resident has COPD. The resident keeps his/her head of bed (HOB) elevated to prevent SOB while lying flat; -Goal: The resident will display optimal breathing patterns daily through review date; -Approaches: -Give aerosol or bronchodilators as ordered; -Monitor/document any side effects and effectiveness; -Intermittent difficulty breathing lying flat. Elevate HOB to comfort to facilitate ventilation; -Monitor for difficulty breathing on exertion. Remind resident not to push beyond endurance; -Monitor for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, SOB at rest, cyanosis (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.), and somnolence (state of drowsiness or strong desire to fall asleep); -Monitor/document for anxiety. Offer support, encourage resident to vent frustrations, fears and reassure. Give as needed (PRN) medications for anxiety as ordered; -Monitor, document and report PRN any signs or symptoms of respiratory infection: Fever, chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing, increased coughing and wheezing. Observation and interview on [DATE] at 2:24 P.M., showed the resident had a small window A/C in his/her room. There was no fan in the room and the A/C was not turned on. The illuminated digital display on the front of the A/C unit was not illuminated. The recorded temperature on a digital electronic thermometer, showed a temperature of 81.6 degrees F. The resident was lying flat in bed with a sheet covering him/her. The resident said the temperature in his/her room was too hot. There was no water in the room. The resident said the temperature in his/her room has been hot for days. The resident said staff know about the temperature being hot. 4. Review of Resident #12's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Supervision with transfers and walking; -Limited assistance of one staff needed for bed mobility, dressing, toilet use and personal hygiene; -Diagnoses of seizure disorder, depression and schizophrenia. Observation and interview on [DATE] at 2:26 P.M., showed the resident had a small window A/C in his/her room. The resident lay flat in bed with a blanket covering him/her. The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 83.1 degrees F. There was no fan or water in the room. The illuminated digital display of 75 degrees F, showed on the front of the A/C. The air coming out of the A/C did not feel cool. The resident said it was too hot in his/her room and it had been hot for a while. Certified Nurse Aide (CNA) A entered the room and adjusted the A/C unit temperature. The A/C then showed an illuminated digital display of 61 degrees F, on the front of the A/C and cool air was felt coming out of the A/C. 5. Review of Resident #11's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Supervision with bed mobility, transfers, walking, dressing, bathing, toilet use and personal hygiene; -Diagnosis of high blood pressure, diabetes mellitus (DM, metabolic disease) and depression. Observation and interview on [DATE] at 2:26 P.M., showed the resident had a small window A/C in his/her room. The resident was lying flat on the bed on top of the covers. The illuminated digital display of 61 degrees F, showed on the front of the A/C. The recorded temperature on a digital electronic thermometer, showed a temperature of 81.3 degrees F. The resident said the temperature in his/her room was a little warm. There was no fan or water in the room. During an interview on [DATE] at 2:28 P.M., CNA A said it has been hotter than normal for a few days on the second floor. Management is aware of it. Staff are trying to keep the residents hydrated by offering drinks frequently. Staff are also trying to encourage residents to limit time spent outside while smoking. 6. Observations of the secured D Wing on the second floor, on [DATE], showed: -At 2:47 P.M., the recorded temperature on a digital electronic thermometer, showed a temperature of 81.3 degrees F in the hallway outside room [ROOM NUMBER]. 7. Observation of the secured C Wing on the second floor on [DATE] at 2:57 P.M., showed the recorded temperature on a digital electronic thermometer, showed a temperature of 83.7 degrees F after entering the hallway. Two large fans where in located in the hallway, one placed near the entrance and one placed at the end of the hallway; 8. Review of Resident #8's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Required limited assistance of one staff for bed mobility, transfers, walking, dressing toileting and personal hygiene; -Diagnoses of high blood pressure, Alzheimer's disease and depression. Observation on [DATE] at 2:58 P.M., showed the resident had a small window A/C in his/her room. The illuminated digital display of 73 degrees F, showed on the front of the A/C. The recorded temperature on a digital electronic thermometer, showed a temperature of 84.4 degrees F. The resident lay flat in bed eyes closed with a blanket covering him/her. There was no fan or water in the room. 9. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required extensive assist of one staff for bed mobility, transfers, dressing, toileting and personal hygiene; -Diagnoses of COPD, seizure disorder and atrial fibrillation (irregular heart beat). Review of the resident's care plan, in use at the time of survey, showed the following: -Problem: The resident has COPD. The resident is a smoker and at risk for impaired gas exchange. Resident keeps his/her head of bed (HOB) elevated to prevent SOB while lying flat; -Goal: The resident will remain free from compilations of asthma through the review date; -Approaches: -Resident educated regarding role of stress in precipitating asthma attacks; -Keep HOB elevated to prevent SOB while lying flat; -Teach resident relaxation techniques. Observation and interview on [DATE] at 3:02 P.M., showed the resident had a small window A/C in his/her room. The illuminated digital display of E8, showed on the front of the A/C. The recorded temperature on a digital electronic thermometer, showed a temperature of 89.3 degrees F. The resident sat in wheelchair, propelling self in room. The resident said a new A/C unit was placed in his/her room yesterday and the A/C unit keeps displaying E8 and blowing out air that was not cool. The resident said he/she woke up at 4:00 A.M. this morning sweating due to the heat. The resident said he/she told the night shift workers that he/she could not sleep due to the heat. One of the night shift workers came down to look at the A/C unit and told the resident it was a new unit and should be working. The resident said it is hot in his/her room and asked to please make them do something about it. The resident said the code E8 continued to show on the display of the A/C unit. Environmental Aide (EA) B entered the room and said the A/C unit needed to be reset. EA B walked over to the A/C unit, unplugged the unit from the wall, plugged the unit back into the wall, and pressed the power button. The A/C then showed an illuminated digital display of 61 degrees F, on the front of the A/C and cool air was felt coming out of the A/C. EA B said if he/she has problems with an A/C unit, he/she will let Maintenance know and take the resident off the unit for a couple of hours for hydration. EA B said the temperature was alright earlier in the day, but then it got hotter outside and the room is hotter now. EA B said Maintenance is aware of the rooms being warmer than they were earlier. During an interview on [DATE] at 3:11 P.M., CNA D said it has been hot on the second floor for a few days and everyone was aware of it. Staff are encouraging residents to hydrate often and limit time spent outside for residents that smoke. 10. Review of Resident #1's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required limited assistance of one staff for bed mobility, transfers, dressing, toilet use and personal hygiene; -Diagnoses of seizure disorder, resorption atelectasis (oxygen and carbon dioxide in the alveoli (tiny air sacs of the lungs which allow for rapid gas exchange) move into the bloodstream and no new air moves in) without respiratory distress syndrome, and chronic (persisting for a long time or constantly recurring) embolism (clot that moves through your bloodstream) and thrombosis (clot in a blood vessel) of other specified veins. Observation and interview on [DATE] at 3:12 P.M., showed the resident had a small window A/C in his/her room. The illuminated digital display of E8, showed on the front of the A/C. The recorded temperature on a digital electronic thermometer, showed a temperature of 91.2 degrees F. The resident sat on the side of his/her bed in front of the A/C unit. The resident said the temperature in the room was too hot and he/she was uncomfortable. He/She said the air coming out of the A/C unit is not cool. The resident reported the problem with the A/C to the nurse's station this morning and the Maintenance Director (MD) came in to the room a couple of times, but it stays the same after the MD comes. There was no fan or water in the resident's room. CNA D said he/she was unsure how to reset the A/C unit and then went to where the A/C unit was plugged into the wall and pressed a button on the outside part of the A/C plug. CNA D then went and adjusted the temperature on the A/C unit. The A/C showed an illuminated digital display of 62 degrees F, on the front of the A/C and cool air was felt coming out of the A/C. 11. Review of Resident #9's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required limited assistance of one staff member for dressing; -Required supervision with bed mobility, transfers, walking, bathing, toilet use and personal hygiene; -Diagnosis of COPD, high blood pressure and atrial fibrillation. Review of the resident's care plan, in use at the time of survey, showed the following: -Problem: The resident has COPD. The resident is at risk for impaired gas exchange. Resident keeps his/her head of bed (HOB) elevated to prevent SOB while lying flat; -Goal: The resident will display optimal breathing patterns daily through review date; -Approaches: -Avoid extremes of hot and cold; -Experiences difficulty breathing when lying flat. Elevate HOB to comfort; -Give aerosol or bronchodilators as ordered. Monitor /document any side effects and effectiveness; -Monitor for difficulty breathing on exertion. Remind resident not to push beyond endurance; -Monitor for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, SOB at rest, cyanosis, and somnolence; -Monitor, document, report PRN any signs and symptoms of respiratory infection: fever, chills, increased difficulty breathing, increased coughing and wheezing; Observation and interview on [DATE] at 3:12 P.M., showed the resident had a small window A/C in his/her room. The illuminated digital display of E8, showed on the front of the A/C. The recorded temperature on a digital electronic thermometer, showed a temperature of 91.2 degrees F. The resident lay on his/her bed without a shirt on. He/She said the temperature in the room was way too hot and he/she was not comfortable. There was no fan or water in the resident's room. CNA D said he/she was unsure how to reset the A/C unit and then went to where the A/C unit was plugged into the wall and pressed a button on the outside part of the A/C plug. CNA D then went and adjusted the temperature on the A/C unit. The A/C then showed an illuminated digital display of 62 degrees F, on the front of the A/C and cool air was felt coming out of the A/C. During an interview on [DATE] at 3:18 P.M., CNA C fanned him/herself and said he/she is hot. CNA C said it was hot like this yesterday too. CNA C said the hot temperatures were reported to the MD yesterday. 12. Observations of the secured C Wing on the second floor, on [DATE], showed: -At 3:20 P.M., the recorded temperature on a digital electronic thermometer, showed a temperature of 92.3 degrees F in the hallway outside room [ROOM NUMBER]; -At 3:21 P.M., the recorded temperature on a digital electronic thermometer, showed a temperature of 91.8 degrees F in the dining room where two residents sat. 13. Observation of the secured B Wing on the second floor on [DATE] at 3:24 P.M., showed the recorded temperature on a digital electronic thermometer, showed a temperature of 88.3 degrees F after entering the hallway. No fans were located in the hallway. 14. Review of Resident #6's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required supervision with bed mobility, transfers, walking, dressing, bathing, toilet use and personal hygiene; -Diagnoses of COPD, high blood pressure and diabetes mellitus. Review of the resident's care plan, in use at the time of survey, showed the following: -Problem: The resident has COPD. The resident is a smoker. Resident keeps his/her head of bed (HOB) elevated to prevent SOB while lying flat; -Goal: The resident will remain free from signs and symptoms of respiratory infections through review date; -Approaches: -Monitor for difficulty breathing on exertion. Remind resident not to push beyond endurance; -Monitor for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, SOB at rest, cyanosis, and somnolence; -Monitor, document, report PRN any signs and symptoms of respiratory infection: fever, chills, increased difficulty breathing, increased coughing and wheezing; -Resident teaching on smoking and lung disease. Respect wishes. Observation and interview on [DATE] at 3:27 P.M., showed the resident had a small window A/C in his/her room. There was no fan in the room and the A/C was not turned on. The digital display on the front of the A/C unit was not illuminated. The recorded temperature on a digital electronic thermometer, showed a temperature of 87.8 degrees F. The resident lay flat in bed with a blanket covering him/her. The resident said the temperature in his/her room is hot. There was no water in the room. CNA C entered the room and adjusted the A/C unit temperature. The A/C then showed an illuminated digital display of 71 degrees F, on the front of the A/C and cool air was felt coming out of the A/C. 15. Review of Resident #7's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required limited assistance of one staff member for bed mobility, transfers, toilet use and personal hygiene; -Required extensive assistance of one staff member for dressing; -Diagnoses of narcolepsy (sleep disorder that causes overwhelming daytime drowsiness), post-traumatic stress disorder (PTSD, difficulty recovering after experiencing or witnessing a terrifying event) and depression. Observation and interview on [DATE] at 3:31 P.M., showed the resident had a small window A/C in his/her room. The illuminated digital display of 61 degrees F, showed on the front of the A/C. The recorded temperature on a digital electronic thermometer, showed a temperature of 85.5 degrees. The resident sat in his/her wheelchair directly in front of the A/C. The resident said the A/C unit only stays on for approximately five to nine minutes and then it stops and the resident has to turn the A/C unit back on. The resident said it has been reported to staff and the MD has looked at the A/C unit and nothing changes. It has been hot for the last several days and it is so hot, he/she cannot even think straight, and he/she is miserable. There was no water or fan in the room. During an interview on [DATE] at 3:11 P.M., CNA E said it is a little hot, while he/she fanned himself/herself. CNA E said he/she has spoken to other CNAs about how hot it was on the second floor. CNA E said everyone has been talking about how hot it is on the second floor since Monday, [DATE]. CNA E had not reported the elevated temperatures to management. 16. Observations of the secured B Wing on the second floor, on [DATE], showed: -At 3:25 P.M., the recorded temperature on a digital electronic thermometer, showed a temperature of 87.9 degrees F in the C hall dining room, where one resident sat. The illuminated digital display of E8, showed on the front of the A/C; -At 3:40 P.M., the recorded temperature on a digital electronic thermometer, showed a temperature of 88.0 degrees F in the hallway outside room [ROOM NUMBER]. 17. Observation of the unsecured A Wing on the second floor on [DATE] at 3:42 P.M., showed the recorded temperature on a digital electronic thermometer, showed a temperature of 83.3 degrees F after entering the hallway. No fans were located in the hallway. 18. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment: -Required limited assistance of one staff member for walking and toilet use; -Required supervision with bed mobility, transfers, dressing, and personal hygiene; -Shortness of breath or trouble breathing with exertion; -Shortness of breath or trouble breathing when lying flat; -Diagnoses of malignant (cancerous cells that have the ability to spread to other sites in the body) neoplasm (abnormal growth of tissue) of unspecified part of unspecified bronchus (two large tubes that carry air from your windpipe to your lungs) or lung, high blood pressure and depression. Review of the resident's care plan, in use at the time of survey, showed the following: -Problem: The resident has altered respiratory status, difficulty breathing related to lung cancer. Resident is on long term antibiotic for prophylaxis (medication or a treatment designed and used to prevent a disease from occurring). The resident has a behavior of refusing appointments at times; -Goal: The resident will have no signs or symptoms of poor oxygen absorption through the review date; -Approaches: -Administer medications inhalers as ordered. Monitor effectiveness and side effects; -Assist resident, family, caregiver in learning signs of respiratory compromise; -Long term antibiotic, give as ordered and monitor; -Monitor, document changes in orientation, increased restlessness, anxiety, and air hunger (sensation of not being able to breathe in sufficient air). Observation and interview on [DATE] at 3:44 P.M., showed the resident had a small window A/C in his/her room. The illuminated digital display of E8, showed on the front of the A/C. The recorded temperature on a digital electronic thermometer, showed a temperature of 86.6 degrees F. The resident lay flat in bed with a blanket covering him/her. The resident had a small fan sitting on the nightstand next to the bed, blowing directly on him/her. There was no water in the room. The resident showed no signs of respiratory distress during the observation. The resident said the temperature in his/her room is hot and it has been hot for a few days. The resident said he/she told management down in the office about it being hot and nothing has changed. 19. Review of Resident #4's electronic medical record at time of survey, showed: -Cognitively intact; -Independent with walking, dressing, bathing, toilet use and personal hygiene, staff provide supervision while at facility; -Diagnoses of SOB, high blood pressure and depression. Review of the resident's care plan, in use at the time of survey, showed the following: -Problem: Resident has SOB and is a smoker. Resident is at risk for injury, complications related to smoking; -Goal: Resident will have no complications related to SOB through the review date; -Approaches: -Assist resident, family, caregiver in learning signs of respiratory compromise. Refer significant other, caregiver to participate in basic life support class for cardiopulmonary resuscitation (CPR), as appropriate; -Monitor, document changes in orientation, increased restlessness, anxiety, and air hunger. During an interview on [DATE] at 3:47 P.M., while on the elevator, the resident said he/she was moved to the second floor the previous day, [DATE]. The resident said the A/C unit is not working in his/her room and it is hotter than you can imagine. Resident stated the code E8 is showing on the A/C unit. Observation and interview on [DATE] at 5:03 P.M., showed the resident had a small window A/C in his/her room. The illuminated digital display of E8, showed on the front of the A/C. The recorded temperature on a digital electronic thermometer, showed a temperature of 84.7 degrees. The resident sat in a recliner next to his/her bed. He/She has to keep the door open to his/her room because if the door is shut, it feels like a sauna in the room. The resident would prefer to have his/her door shut, but cannot because of the heat. The resident said he/she was sweating all night long the previous night and could not hardly sleep because it was so hot and said he/she was miserable due to the heat. He/She said while in the room downstairs, it felt good down there, but it is miserable on the second floor. The resident said he/she spoke to the MD yesterday about it as soon as he/she was moved to the room. The resident said he/she felt like the MD blew it off, because the MD told him/her there are other people somewhere else that needed the A/C. When he/she was moved into the room, the A/C unit displayed E8. If the A/C unit is reset, it goes right back to the E8 code. 20. Review of Resident #3's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required supervision with bed mobility, transfers, walking, dressing, bathing, toilet use and personal hygiene; -Diagnoses of high blood pressure, diabetes mellitus and depression. Observation and interview on [DATE] at 5:12 P.M., showed the resident had a small window A/C in his/her room. The illuminated digital display of E8, showed on the front of the A/C. The recorded temperature on a digital electronic thermometer, showed a temperature of 85.1 degrees. The resident lay on the bed with no covers. The resident said it is hot in his/her room and he/she wishes the A/C unit would turn down lower. The resident said it is very uncomfortable in his/her room because it is so hot. The resident said he/she is having trouble sleeping because it is so hot. It has been hot like this for several days and he/she is used to 70 degree temperatures. The resident said he/she has not told anyone because they can all feel how hot it is. 21. Observation of the unsecured A Wing on the second floor on [DATE], showed: -At 5:12 P.M., the recorded temperature on a digital electronic thermometer, showed a temperature of 83.5 degrees F in the hallway outside room [ROOM NUMBER]; -At 5:16 P.M., the recorded temperature on a digital electronic thermometer, showed a temperature of 82.9 degrees F in the A hall dining room, where a few residents sat. Review of the Liberty Heating and Cooling invoice, dated [DATE], showed the company found one of the rooftops for that area of building not working because it had blown fuses. Found a damper that had broke and caused it to shut off the air flow to one hallway. Found several of the individual room PTAC units had air codes because of the extreme heat that was shutting off the outside temperature sensor so those had to be reset and those are now functioning fine. 22. During an interview on [DATE] at 5:22 P.M., the Administrator said because of the excessive heat warning that started ear

Based on observation, interview and record review, the facility failed to identify a resident's heel pressure ulcer and failed to provide daily treatments to the wound as ordered. Weekly skin assessments were not routinely completed in accordance with the facility's policy. The facility failed to develop an individualized care plan to address the resident's pressure ulcer. Additionally, upon wound deterioration, the facility failed to notify the resident's physician. Four residents were sampled and problems were identified with one (Resident #1). The census was 105. Review of the facility Pressure Ulcer Prevention and Management policy, revised 10/16/22, showed: -The facility is committed to the prevention of avoidable pressure ulcers and the promotion of healing of existing pressure ulcer(s); -The facility shall utilize a systematic approach for pressure ulcer prevention and management, starting with prompt assessment and treatment, including efforts to identify risk, stabilize, reduce, or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate; -Licensed nurses will conduct a Braden Scale (an assessment tool used to determine a resident's risk for developing pressure ulcers) on all residents upon admission/re-admission weekly for four weeks; -Licensed nurses will conduct a full body skin assessment on all residents upon admission, readmission, and weekly; -Assessments of pressure ulcers will be performed by a licensed nurse or physician and documented on daily with treatments and weekly wound report; -The Certified Nurse Assistants (CNA) will follow the Skin Care Protocol and report any concerns to the resident's nurse immediately; -Training in the completion of the pressure ulcer risk assessment, full body skin assessment, and pressure ulcer assessment will be provided as needed; -Interventions will be based on specific factors identified on the skin assessment and any pressure ulcer assessments; -Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure ulcer present; -Evidence-based treatments will be provided for all residents who have a pressure ulcer present; -Pressure ulcers will be differentiated from non-pressure ulcers; -Monitoring will be done by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Wound Nurse or designee who will review all relevant documentation regarding skin assessment, pressure ulcer risks, progression towards healing, and compliance at least weekly and discussed at the weekly interdisciplinary team (IDT) meeting; -The physician will be notified of the presence, progressions toward healing or lack of healing, of any pressure ulcers upon identification of the ulcers; -An incident review will be performed on each pressure ulcer that develops in the facility and findings will be reported at the weekly IDT meeting. Review of the facility Skin Care Protocol policy, revised 1/12/21, showed: -CNA will perform a visual assessment of a resident's skin when giving the resident a shower and immediately report any abnormal looking skin to the Charge Nurse; -CNA will document findings on the Shower Sheet and turn form into Charge Nurse; -Charge Nurse will place their signature on the Shower Sheet after assessing the resident's skin issues; -Charge Nurse will notify Primary Care Physician (PCP) with changes and document any new orders and interventions; -Charge Nurse will forward any problems to the DON/designee for review and will notify DON/designee immediately if he/she on duty when skin issues found; -Areas of concern will be added to the care plan; -Charge Nurse will perform weekly skin assessments and document in point click care (PCC-electronic medical record); -Wounds will be measured on a weekly basis and documented; -All wounds will be discusses at weekly IDT meetings; -The facility will work in collaboration with the residents PCP for wound care management. Review of Resident #1's physician orders, dated 4/26/23, showed: -8/17/22-Weekly skin assessments and document assessment under Skin Only, every Wednesday for skin health. Start date 8/17/22 and no stop date; -10/12/22-Cleanse left lateral foot with wound cleanser, apply skin prep, leave open to air, every day. Start date 10/12/22 and no stop date. (No further documentation on what was treated.); -12/9/22-Apply skin prep to left heel and top of first left toe every day for two weeks or longer, as needed, until healed. Start date 12/9/22 and no stop date. (No further documentation on what was treated.); -12/9/22-Apply ammonium lactate 12% lotion (cream used to treat dry scaly skin conditions, and can help relieve itching from these conditions) to both lower extremities daily for dry skin. Start date 12/9/22 and no stop date. Review of the resident's licensed nurse weekly Skin Only Evaluations, showed: -1/4/23-No current skin issues; -1/11/23-No current skin issues; -1/18/23-No skin evaluation; -1/25/23- No current skin issues, treatment in place for skin prep on right/left foot and ammonium lactate to both lower legs; -2/1/23- No current skin issues. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 2/1/23, showed no skin issues identified, CNA signature, no Charge Nurse signature. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 2/2/23, showed no current skin issues, coccyx (tailbone area) is scarred over, dry skin on feet. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed: -2/3/23-No skin issues identified, CNA signature, Charge Nurse initials; -2/8/23-No skin issues identified, CNA signature, Charge Nurse initials. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 2/8/23, showed no skin evaluation. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed: -2/10/23-No skin issues identified, CNA initials, Charge Nurse initials; -2/15/23-No skin issues identified, CNA signature, Charge Nurse initials. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 2/15/23, showed no current skin issues. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed: -2/17/23-No skin issues identified, CNA signature, Charge Nurse signature; -2/22/23-No skin issues identified, CNA signature, Charge Nurse initials. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 2/22/23, showed no skin evaluation. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 2/24/23, showed no skin issues identified, CNA signature, Charge Nurse initials. Review of the resident's progress notes, dated 2/27/23 at 8:19 P.M., showed the primary care physician's (PCP's) skin assessment: no new rashes. Review of the resident's progress notes, dated 3/1/23 at 11:06 A.M., showed a nursing skin evaluation: No current skin issues noted at this time. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 3/1/23 at 11:06 A.M., showed no current skin issues. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed: -3/1/23-Right heel circled and middle of anterior (situated in the front) right arm circled, no information given for purpose of circles, CNA signature, Charge Nurse initials; -3/5/23-No skin issues identified, CNA signature, Charge Nurse signature; -3/7/23-Complete bed bath written, anterior upper left arm circled with bandages written, both heels circled with Dry heels, but okay written in, CNA signature, Charge Nurse signature. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 3/8/23, showed no skin evaluation. Review of the resident's progress notes, dated 3/12/23 at 4:10 P.M., showed the resident reported shortness of breath (SOB), missed dialysis 3/10/23 due to diarrhea, Nurse Practitioner agreed to send resident to hospital. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed: -3/10/23-No skin issues identified, no CNA signature, Charge Nurse initials; -3/15/23-Hospital written, CNA signature, Charge Nurse initials. Review of the resident's progress notes, dated 3/16/23 at 1:05 A.M., showed the resident returned from hospital with discharge diagnosis of fluid overload and no pain, discomfort, distress, SOB, or new orders received. No note regarding skin condition or assessment completed. Review of the resident's re-admit skin integrity screen, dated 3/16/23 at 1:58 A.M., showed skin color normal, warm and dry, turgor normal. No wounds identified. Review of the resident's Braden Scale assessment, dated 3/16/23, showed a re-admission showed a score of 15. A score of 15-18 is considered at risk. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed the following: -3/17/23-No skin issues identified, CNA signature, Charge Nurse signature; -3/21/23-Both heels circled with no explanation, inner side of left foot circled with old scab written in, arrow to outer side of left foot with old scab written in, forwarded to DON: boxes for yes or no left blank, CNA signature, Charge Nurse signature. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 3/22/23, showed no skin evaluation. Review of the resident's five day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/23/23, showed: -Diagnoses of stroke, hemiplegia, high blood pressure, end stage renal disease (on hemodialysis), diabetes, depression, and schizophrenia (chronic mental disorder with symptoms of emotional instability, detachment from reality, and withdrawal into the self); -No cognitive impairment; -Unable to walk; -Required extensive assistance of one person for transfers, bed mobility, dressing, toileting and personal hygiene; -Range of motion impairment on one side of both upper and lower extremity; -Incontinent of bowel and bladder; -Required one person physical assistance of wheelchair for locomotion; -At risk for pressure ulcers: Yes; -Unhealed pressure ulcers: No; -Diabetic foot ulcer with medication and dressing to foot. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed the following: -3/24/23-Refused written, no skin issues identified, CNA signature, Charge Nurse initials; -3/28/23-Arrow to right heel identified as a blister, arrow to middle part of bottom of right foot identified as abnormal color, forwarded to DON: boxes for yes or no left blank, CNA signature, no Charge Nurse signature. Review of the resident's Treatment Administration Record (TAR), dated 3/1/23 through 3/28/23, showed no treatment order for a diabetic foot ulcer or a right heel pressure ulcer. Review of the resident's hospital Wound Center Note, dated 3/28/23 at 11:07 A.M., showed the following:-The resident presented for evaluation of his/her right heel pressure ulcer, Stage II (Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater). The resident said the wound was present for a couple of weeks and he/she was referred to the wound clinic after pointing the ulcer out to the nurse during his/her fistulagram (an x-ray of an individual's dialysis fistula to check blood flow and look for blood clots/other blockages) a week ago; -The wound measured 2.5 centimeters (cm) in length by 1.5 cm in diameter, with a depth of 0.1 cm. The wound base was clean appearing with a small area of central necrosis (necrotic tissue is a condition where living skin dies as a result of blood and oxygen deprivation to its cells) surrounding erythema (redness of the skin), no drainage, and no odor; -The Stage II pressure ulcer on the resident's right heel was stable and the wound was expected to heal with proper treatment; -The Wound Physician placed SilvaSorb (a micro-lattice synthetic hydrogel matrix that contains silver chloride used to protect and hydrate dry wounds utilizing microscopic particles of controlled-release ionic silver and claims to maintain a moist environment and hold a significant amount of exudate due to its hydrogel matrix; used to treat pressure ulcers, burns, incisions, and abrasions) on the wound base and covered with a dry dressing; -The resident will need off-loading boots (special medical boots to prevent of mitigate pressure on the heels) on both heels to prevent further pressure injury and to return in one month; -The Wound Clinic Nurse noted the Wound Physician ordered SilvaSorb and silicone dressing to the right heel and float heels with heel boots. The resident's caregiver (transportation employee) was given the SilvaSorb and instructions for the facility to follow. The facility would need to provide the heel boots. Review of the resident's physician orders, dated 4/26/23, showed the following: -3/28/23-Float right heel with boot and follow up with Wound Clinic on 4/25/23. Start date 3/28/23 and no stop date. (The order did not say to float both heels as recommended by the wound clinic); -3/28/23- Apply SilvaSorb Gel to right heel topically at bedtime, after cleansing with soap and water, and cover with a dry dressing daily. Start date 3/29/23 and discontinued 4/2/23. Review of the facility's Weekly Wound Tracking report, dated 3/27/23 to 3/31/23, showed: -Date of measurement: 3/28/23; -Wound type: Pressure ulcer (PU); -PU present on admitted : Box left blank; -PU acquired at facility date: Box left blank; -Location: Right heel; -PU stage: Stage II; -Size (length x width x depth): 2.5 cm x 1.5 cm x 1.0 cm; -Worst tissue type present: Box left blank; -Treatment (include date initiated or changed): SilvaSorb, border gauze, off-loading boots; -Completed by and date: Lines left blank/no signature and no date. Review of the resident's progress notes, showed: -3/28/23 at 1:12 P.M.-Nurse's note, resident had a wound visit today with new orders and follow-up visit; -3/29/23 at 2:34 P.M.-Nurse's skin/wound note: Wound to resident's right heel has a treatment; -The progress notes did not show wound location, type, description, or measurements and did not show documentation of physician and family notification. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 3/29/23, showed no skin evaluation. Review of the resident's TAR, dated 3/29/23 to 3/30/23, for SilvaSorb to right heel, after cleaning with soap and water, cover with a dry dressing daily at bedtime, showed: -3/29/23-No nurse initials in box (indicating not done). -3/30/23-No nurse initials in box. Review of the resident's TAR, dated 3/28 through 3/31/23, showed no order to float both heels with pressure relief boots. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 3/31/23, showed Refused written, no skin issues identified, no CNA signature, Charge Nurse initials. Review of the resident's physician orders, showed: -4/2/23-Order for SilvaSorb Gel to right heel, after cleansing with soap and water and covering with a dry dressing daily, changed to every morning (was every evening). Start date 4/3/23 and no stop date. Review of the resident's TAR, dated 4/5/23, for SilvaSorb to right heel, after cleaning with soap and water, cover with a dry dressing daily at bedtime, showed: -4/5/23-Nurse initials in box with number 9 (9: other, see progress note-not done). Review of the resident's progress notes, showed no notes dated 4/5/23. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 4/5/23, showed Refused written, no skin issues identified, no CNA signature, Charge Nurse initials. Review of the resident's licensed nurse weekly Skin Only Evaluations, dated 4/5/23, showed no skin evaluation. Review of the whole facility's Weekly Wound Tracking reports, showed no wound report for the week of 4/3/23 to 4/7/23. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated, 4/7/23, showed the right heel circled and middle of anterior right arm circled, no information given for purpose of circles, forwarded to DON: boxes for yes or no left blank, CNA signature, Charge Nurse signature; Review of the resident's PCP skin assessment in the progress notes, dated 4/10/23 at 12:00 A.M., showed a pressure ulcer of the right heel; no stage, appearance, or measurements. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 4/12/23, showed the right heel circled and middle of anterior right arm circled, no information given for purpose of circles, forwarded to DON: boxes for yes or no left blank, no CNA signature, Charge Nurse initials. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 4/12/23, showed no skin evaluation. Review of the Hospital Wound Center's telephone conversation/call log, showed the following: -4/12/23 at 11:01 A.M., resident called stating his/her heel wound was turning black and would like to see the wound doctor sooner than his/her scheduled follow-up appointment. The resident was told to have a facility nurse call to arrange the appointment and if no call from them, then the wound nurse will call the facility; -4/12/23 at 4:09 P.M.,.the Wound Nurse called the facility and was told there are only agency nurses available, please call back tomorrow. Review of the resident's Nurse Practitioner (NP) skin assessment in the progress notes, dated 4/13/23 at 12:00 A.M., showed right foot pain. Review of the facility's Weekly Wound Tracking reports, for the week of 4/10/23 to 4/14/23, showed no wound information for the resident. Review of the resident's Braden Scale assessment, dated 4/14/23, showed a score of 15. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed: -4/14/23-Both heels circled and middle of anterior right arm circled, no information given for purpose of circles, forwarded to DON: boxes for yes or no left blank, no CNA signature, Charge Nurse initials; -4/18/23-Both heels circled with Rashes healing on left and upper anterior right arm circles with rash on arm a little red but healing, forwarded to DON: boxes for yes or no left blank, no CNA signature, Charge Nurse initials. Review of the Hospital Wound Center's telephone conversation/call log, showed the following: -4/18/23 at 11:42 A.M., the wound nurse contacted Nurse A; -4/18/23 at 12:17 P.M., Nurse A called back and said he/she and the DON assessed the resident's wound and there was no black discoloration. Nurse A was informed the resident has a follow up appointment on 4/25/23. During an interview on 5/2/23 at 1:00 P.M., the DON said she started work at the facility on 3/22/23. She recalled Nurse A saying something to her about the resident having an appointment with the wound clinic but she did not look at the resident's wound and could not recall when this conversation had occurred. She recalled an agency aide telling her, one day, the resident had a heel wound. She told ADON C, who also functioned as their Wound Nurse, to look at it. ADON C arranged for their Medical Director, who was also a Wound Physician, to see the resident on a day when he/she would not be out of the building for dialysis. However, she recalled Nurse A saying the resident already had an appointment with the Hospital Wound Clinic. Their Medical Director did come to see the resident, on a Thursday, but the resident went out with his/her family that day, or went somewhere. It was 4/24/23, because Social Services made a note about it. She did not know why ADON C did not document seeing the wound and scheduling an appointment with their Medical Director/Wound Doctor. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 4/19/23, showed no skin evaluation. Review of the facility's Weekly Wound Tracking reports, dated 4/16/23 through 4/22/23, showed the following: -Date of measurement: 4/19/23; -Wound type: PU and diabetic ulcer; -PU present on admitted : 7-15-22; -PU acquired at facility date: Box lined through; -Location: Right heel; -PU stage: unstageable; -Size (length x width x depth): 2 cm x 4.7 cm x 4 cm; -Worst tissue type present: Necrotic tissue; -Treatment (include date initiated or changed): SilvaSorb, gauze, Kerlix, change daily. -Completed by and date: Lines left blank/no signature & no date. Review of the resident's progress notes, showed no note, dated 4/19/23, documenting the decline of the right heel wound and notification of the resident's physician. During an interview on 5/5/23 at 12:03 P.M., Social Service (SS) F said the wound physician made a special arrangement to see the resident's wound on Thursday, 4/20/23. The resident had agreed to the visit, knew the date and time of the visit, yet he/she still left the building that day. SS F was not in that day and did not hear about it until the ADON, who was very upset about it, told him/her on Monday, 4/24/23, which is when he/she wrote the progress note. The resident was young, alert, and oriented times four (cognitively alert and aware of person, place, time and situation), had a history of making his/her own appointments, arranging his/her own transportation, and not sharing the information with the staff. When he/she asked the resident what happened, why he/she left without letting anyone know prior to, the resident said he/she was aware of the appointment, but had business at the social security office. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 4/21/23, showed bruising, dryness, and scratches circled, upper anterior right arm circled, both heels circled, back of right thigh and right fifth finger circled. No identifying information given for purpose of circles. Forwarded to DON: boxes for yes or no left blank, CNA signature, Charge Nurse signature. Review of the resident's TAR, dated 4/21/23 through 4/24/23, for SilvaSorb to right heel, after cleaning with soap and water, cover with a dry dressing daily every morning, showed: -4/21/23-Treatment initialed by Agency Nurse B; -4/22/23-Treatment initialed by Nurse A; -4/23/23-Treatment initialed by Nurse A; -4/24/23-Treatment initialed by ADON C. Review of the resident's Social Service progress note, dated 4/24/23 at 5:17 P.M., showed the resident was to see the facility's Medical Director/Wound Physician, however the resident chose to go out. The resident was aware of the Wound Doctor's appointment, prior to the resident making plans to leave, but the resident still went out. The resident was educated on the importance of compliance with wound care and the risks involved in not allowing the doctor to see/treat the wound. Review of the resident's hospital Wound Center Note, dated 4/25/23 at 10:44 A.M., showed the following: -The resident said the wound is much worse, there is a foul smell from the wound, and the nursing home was not doing the dressing changes as instructed; -Unstageable right heel pressure ulcer with thick, adherent eschar (a collection of leathery black or brown dead tissue within the wound, reflecting deep damage to tissues, and is flush with the skin surface) coverage and a foul smell. The skin surrounding the eschar was beginning to slough off; -Overall the wound is much worse since last seen; -Measurements were 4.5 cm by 6.0 cm by 0.1, unstageable right heel pressure ulcer with moderate slough (white or yellow dead tissue), moderate foul odor, moderate purulent exudate (fluid or semisolid that has exuded out of a tissue or its capillaries, more specifically because of injury or inflammation), with boggy, red, and edematous peri-wound area (skin surrounding the wound); -The resident requires the operating room for surgical debridement; -The Wound Clinic Nurse's note showed the facility dressing on the wound was soiled, with a foul smell, and moderate drainage; -The resident said the nursing home had not changed his/her wound dressing since 4/21/23 and he/she was concerned the wound was unable to heal due to the lack of care by the nursing home staff; -The Wound Physician was unable to do a bedside debridement due to the amount of eschar coverage of the wound; -The nursing home's Assistant Administrator was called and notified of the wound findings and was sent new wound care instructions and the surgery date. During an interview on 4/28/23 at 2:23 P.M., the hospital Wound Clinic Nurse said surgical debridement in the operating room was necessary because the wound, on 4/25/23, had a foul smell and the eschar was not stable. When the eschar was pressed on, it moved and felt boggy because it was soft underneath, and fluid came out around it. The resident was crying about needing the surgery and about the poor nursing home care he/she received. During an interview on 4/27/23 at 4:08 P.M., the Assistant Administrator D said the hospital Wound Clinic nurse called her on 4/25/23 and wanted to speak with the DON. The DON could not be reached. The hospital Wound Nurse told her the resident's dressing had a date of 4/21/23, he/she was going to need wound surgery, and they would be faxing something over about it. Review of the resident's progress notes, dated 4/25/23 at 1:54 P.M.,, showed the resident returned from an endocrinology (the study of hormones and endocrine glands and organs) appointment, has a surgical appointment on 4/27/23 at the hospital and transportation has been made aware. Review of the resident's physician orders, showed: -4/25/23-Cleanse right heel with wound cleanser, pat dry, apply a nickel size layer of Santyl ointment (an enzymatic ointment that removes dead tissue from wounds at the microscopic level) to the base of the wound and cover with a silicone border dressing (a self-adhering silicone dressing, with an additional bordered edge, a self-adherent silicone contact layer, and a high capacity fluid lock-away core for use on moderate to medium-high levels of wound exudate) daily in the evening. Review of the facility's Weekly Wound Tracking reports for the week of 4/24/23 through 4/28/23, showed: -Date of measurement: 4/25/23; -Wound type: PU; -PU present on admitted : Box left blank; -PU acquired at facility date: Box left blank; -Location: Right heel; -PU stage: unstageable; -Size (length x width x depth): 4.5 cm x 6.0 cm x 0.1 cm; -Worst tissue type present: Unstageable; -Treatment (include date initiated or changed): Santyl, border gauze, change daily; -Completed by and date: Lines left blank/no signature & no date. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 4/26/23, showed no skin evaluation. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 4/26/23, showed Refused written, no skin issues identified, no CNA signature, Charge Nurse initials. Review of the resident's undated care plan, received from the facility on 4/27/23, showed no plan of care for any type of skin issues or pressure ulcer prevention, assessment, interventions, and monitoring of the right heel pressure ulcer. During an interview on 4/26/23 at 4:00 P.M., the resident said Agency Nurse B always did his/her right heel wound treatments when he/she worked. Agency Nurse B also took a picture of it for him/her. It was turning black so the resident called the hospital wound clinic twice. The first time he/she called, they called the facility nurse because the facility nurses have to arrange the appointments. He/She called again and the wound clinic said the same thing. The resident thought the first floor ADON (ADON C) made the appointment. The resident said Nurse B was the only one who did his/her wound treatments, until now. When the Wound Physician saw him/her on 4/25/23, the date on the dressing was 4/21/23. The Wound Doctor said he could not debride the wound chair side because it was too far gone. He/She now needed surgery, with anesthesia involved, because the wound was so bad. He/She assumed the missing 3 days of treatments, could have made a difference. The resident started crying when the Wound Doctor told him/her he/she needed surgery on the wound. Observation on 4/27/23 at 9:30 A.M., showed a large area of intact black eschar, approximately 5 cm by 6 cm, on the resident's right heel. The peri-wound area appeared moist, red to pink in color, with whitish/yellowish streaks. The resident wore blue pressure relief boots prior to the wound treatment. There was no low air loss mattress on the bed. During an interview on 5/5/23 at 11:19 A.M., Agency Nurse B said he/she did not recall finding instances of no dressing to the resident's right heel and did not recall finding old dressings on his/her heel, but the resident did tell him/her the other nurses were not doing the treatment. It was possible he/she may not have paid that much attention to the dates on the dressings, but there was always a dressing in place and they did not look old. He/She also took a picture of the resident's heel every week, to show to the resident, because the resident could not see his/her heel wound. The last time he/she took a picture of the heel, which could have been one and a half weeks ago, the wound had turned black. Agency Nurse B showed the resident and told him/her that was not good. The resident said he/she was going to call the wound clinic. Agency Nurse B also showed the wound picture to ADON C and told him/her it did not look good. ADON C said he/she would call their facility wound physician. Agency Nurse B said he/she did not document the findings or call the resident's primary care physician because he/she told ADON C, who follows up on the wounds. ADON C set up a visit with the facility wound physician and the resident agreed to it the day before and the day of the appointment, but when the Wound Doctor came to find him/her, he/she was gone from the building. Agency Nurse B asked the resident why he/she left the building and the resident said it was none of his/her business. During an interview on 5/5/23 at 10:40 A.M., ADON C said he/she started at the facility on 2/2/23 as a floor nurse and was promoted to the ADON/Wound Nurse position the beginning of March, 2023. He/ She is the wound nurse for the whole building, which is okay because they only have around seven wounds in the whole building. He/She had no prior experience, education, or training as a wound nurse, and the facility was aware of that. The facility did not give him/her a wound nurse job description. He/She recalled the DON asking him/her to check on the wound. It was a Wednesday, because the resident had returned from dialysis and had just returned from the shower room and there was no dressing on the wound. He/She talked with the resident and he/she looked at the wound. ADON C thought this was the facility's first encounter with the wound and did not know the resident had already been to the wound clinic and had a treatment order for the wound. The resident did not give him/her that information either. ADON C put a wet to dry dressing on it and knew their Medical Director/Wound MD was going to be at the Quality Assurance (QA) meeting the next day, Thursday, and he/she would have him look at it after the meeting. This was discussed with the resident and he/she agreed. The next day, after the QA meeting, they went to look for the resident and were told he/she had left the building with family or someone. ADON C said he/she is new to the Wound Nurse role and did not know the PCP should have been called immediately. When asked why he/she did not do the resident's treatment on 4/24/23, but did initial the TAR, signifying it was completed, he/she said there were two residents on the same hall with right heel wounds and he/she must have accidentally signed off on the wrong resident. However, he/ [TRUNCATED]

Based on interview and record review, the facility failed to ensure the resident's right to be free from physical and verbal abuse, when two residents had a physical altercation (Residents #3 and #4). In addition, the Behavior Health Manager (BHM) punched a resident (Resident #4) in his/her right shoulder, resulting in the resident crying out in pain, followed by the BHM's verbal threat of additional physical harm. The sample size was 10. The census was 112. Review of the facility's Abuse Prevention policy, undated, showed: -Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Resident must not be subject to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals; -Policy Explanation and Compliance Guidelines: -The Abuse Coordinator in the facility is the Administrator or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: -Administrator; -Other Officials in accordance with State Law; -State Survey and Certification agency through established procedures; -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain, physical, mental and psychosocial well-being; -Verbal Abuse means the use of oral, written or gestured language that willfully includes derogatory and disparaging terms towards residents or their families, or within their hearing regardless of their age, ability to understand, or disability; -Physical Abuse includes, but not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment; -Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment, or deprivation; -Neglect means failure to provide goods and services necessary to avoid physical harm mental anguish, or mental illness; -Facility Abuse Prevention Plan: -Employee Screening: Background, reference and credentials' checks should be conducted on employees prior to or at the time of employment, by facility administration/business office managers, in accordance with applicable state and federal regulations. Any person having knowledge that an employee's license or certification is in question should report such information to the Administrator and Leadership Team; -Employee Training: New employees should be educated on abuse, neglect and exploitation during initial orientation. Annual education and training is provided to all existing employees. Front line supervisors or other department heads should provide education as situation arise; -Prevention of Abuse, Neglect, and Exploitation; -The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: -Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents; -Observe resident behavior and their reaction to other residents, roommates, and/or tablemates. Place residents in accommodations and environments that keep them calm; -Provide education on what constitutes abuse, neglect and misappropriation of property; -React to all allegations or questions of abuse by residents, family members, employees or visitors; -Take appropriate actions when abuse, neglect or exploitation is suspected; -Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring resident while providing care, directing residents that require toileting assistance to relieve their bowels or bladder in their beds; -Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect. Utilize facility's abuse/neglect risk assessment and develop care needs according to findings; -Identification of Abuse, Neglect, and Exploitation: The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following factors: -Resident, staff or family report of abuse; -Verbal abuse of a resident overheard; -Physical abuse of a resident witnessed; -Psychological abuse of a resident observed; -Investigation of Alleged Abuse, Neglect, and Exploitation: When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, it must be communicated to the facility's Administrator, Department Head, or Supervisor and the Administrator and/or designee must initiate an investigation. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of the investigation may include: -Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses; -Resident Protection after Alleged Abuse, Neglect and Exploitation: The facility will make efforts to protect any and all residents after alleged abuse, neglect and/or exploitation; -Response and Reporting of Abuse, Neglect and Exploitation: Anyone in the facility can report suspected abuse to the abuse agency hotline; When abuse, neglect or exploitation is suspected, the Licensed Nurse should: -Respond to the needs of the resident and protect them from further incident (document); -Notify the Administrator and Director of Nursing (DON), document; -Initiate an investigation immediately; -Notify the attending physician, resident's family/legal representative and Medical Director; -Obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately; -Contact the State Agency to report the alleged abuse; -Monitor and document the resident's condition, including the response to medical treatment or nursing interventions; -Document actions taken in steps above in the medical record; -The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies. Facility administration should report to the state nurse aide registry or nursing board, any knowledge it has of any actions by a court of law which should indicate an employee is unfit for service. Review of the facility Incidents and Occurrences log, dated January 8, 2023, 7:00-3:00 P.M., showed a Resident to Resident altercation between Resident #1 and Resident #4. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/4/22, showed: -admitted [DATE]; -Diagnoses included anxiety and bipolar syndrome (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)). Review of Resident #1's undated care plan, showed: -Problem: Has a potential for self-care decline related to intellectual disability (ID, a neurodevelopmental disorder, is characterized by deficits in intellectual and adaptive functioning), Asperger's Syndrome (repetitive patterns of behavior, preoccupation with restricted interests, and difficulties with social interaction), borderline personality disorder (a mental illness that severely impacts a person's ability to regulate their emotions) and Adult Attention-Deficit/Hyperactivity Disorder, (ADHD, a neurodevelopmental disorder, may have trouble paying attention, and controlling impulsive behaviors); -Interventions: Monitor/document/report as needed, any changes, any potential for improvement, reasons for self-care deficit, expected course and declines in function; -Problem: Has a behavior problem due to wandering into other's rooms and taking things; -Interventions: Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Review of Resident #1's nurse's progress notes, dated 1/7/2023 at 3:19 P.M., showed: the Infection Note, Note Text: Notified the nurse, LPN that this resident was involved in a verbal altercation with Resident #4 that resulted in this resident being punched in his/her left eye. During the assessment the nurse noted his/her eye to be slightly red and tender to touch. Review of Resident #4's undated care plan, showed: -Problem: Has the potential for mood problems due to diagnoses of schizophrenia (a serious mental disorder in which people interpret reality abnormally), depression and anxiety; -Interventions: Monitor/record/report to physician as needed, risk for harming others: increased anger, [NAME] (rapid, often exaggerated changes in mood, where strong emotions or feelings, uncontrollable laughing or crying, or heightened irritability or temper occur) mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons; -Problem: Has potential to be physically/verbally aggressive due to ineffective coping and poor impulse control. He/She has an extensive and recent history of yelling, cursing, and fighting others when she becomes angry. He/She is also disruptive at times as evidenced by banging on doors and throwing items. He/She also has a history of high-risk heterosexual behavior when he/she lived in the community; -Interventions: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later; -Problem: Has a communication problem due to soft mumbling speech and cognitive impairment. At times, he/she has difficulty finding words to articulate him/herself. He/She is usually able to make his/her needs known and usually able to follow commands; -Interventions: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed. Review of Resident #4's nurse's progress notes, showed: -On 1/7/23 at 3:05 P.M., Behavior Note, Note Text: Notified Nurse A that the resident was being combative towards staff and other residents. Staff reported that this resident punched resident (Resident #1) during a verbal altercation. Staff immediately isolated all residents involved in their rooms. Later staff notified the nurse again due to this resident punching the certified medication technician (CMT) B; -On 1/7/23 at 5:28 P.M., Behavior Note, Note Text: Physician updated on resident's behavior. New order received to send the resident to the hospital to evaluate and treat. Director of Nursing (DON) updated. Spoke with ambulance service, estimated time of arrival (ETA) 30-45 minutes. During an interview on 1/24/23 at 9:49 A.M., Resident #1 said Resident #4 hit him/her and he/she hit him/her back. Resident #1 said the area under his/her eye turned red. He/She said the BHM came to the unit, but he/she didn't know if the BHM hit Resident #4. He/she said he/she didn't see it happen. During an interview on 1/25/23 at 11:48 A.M., Resident #4 said the BHM hit him/her in his/her shoulder. The BHM hit him/her with his/her fist. The BHM works security. The resident said after the BHM hit him/her, he/she started crying, because it hurt his/her feelings. The BHM told him/her he/she was sorry, but the resident is afraid of him/her. During an interview on 1/24/23 at 9:29 A.M., on the secured D hall unit, Resident #3 said he/she witnessed Resident #4 hit Resident #1. Resident #3 said he/she saw the BHM hit Resident #4 on his/her arm, and he/she felt uncomfortable seeing that happen. He/She said this happened about three to four weeks ago, the BHM hit him/her with a closed fist. Resident #3 said the BHM said to Resident #4 after he/she hit him/her, How does that feel when someone hits you? After it happened, Resident #4 didn't say anything, but it made him/her stop hitting. During an interview on 1/24/22 at 11:37 A.M., the BHM said his/her position is a supervisory position over all the certified nursing assistants (CNAs). He/She ensures they have no problems with the residents and everything goes smoothly. He/she is called if staff need help to diffuse situations. He/She worked in the mental health field for over [AGE] years and is trained in Crisis Prevention Intervention (CPI, management of disruptive and assaultive behavior) and he/she knows how to restrain people without hurting anyone. He/She was familiar with Resident #4. The resident gets bored and starts hurting other residents. The last time he/she thought that happened was on a Saturday, date unknown. He/She thought the staff present were agency and could not recall their names. Resident #4 was hitting people and he/she believed he/she blocked the resident with his/her hand. He/She never hit Resident #4. He/She does not hit people. During an interview on 1/24/23 at 2:04 P.M., Nurse A said he/she recalled an altercation regarding Resident #4. He/She struck Resident #1 under the eye. Nurse A assessed the area under Resident #1's eye and there was no redness. He/She didn't remember the names of the staff present and never heard a resident complain about the BHM being rough or hitting them. Nurse A said he/she went onto the secured D unit, and the BHM and Resident #4 were seated across from each other in the hallway. CMT B was walking on the hall ahead of him/her, and when CMT B passed Resident #4, Resident #4 hit CMT B on the leg. The BHM got up from his/her chair, walked across the hall and hit Resident #4 on the right shoulder. Resident #4 said, Ow, that hurts! The BHM then said to Resident #4, If you keep hitting residents, the next hit will be harder! This was the first and only time he/she saw the BHM do something like that. The BHM has been on the schedule since the incident. Nurse A said when he/she saw the BHM hit Resident #4, he/she left the secured D unit and went to the medication room to call the Administrator. The Administrator told the BHM to clock out and leave. He/She said he/she assessed Resident #4 for injury and there was no redness or swelling on his/her arm. About 15-20 minutes later, he/she saw the BHM again and told him/her, weren't you supposed to be leaving? The BHM said he/she was collecting statements, and asked Nurse A, Why did he/she report him/her? Now he/she is going to get fired. About an hour later, the BHM was still in the building. The DON arrived to send a report to state, because of the two hour window for reporting. The BHM was still there and they were standing by the DON's office talking. Nurse A left a witness statement underneath the Administrator's door. Nurse A said the BHM worked this weekend, and he/she saw him/her numerous times since the incident. When Resident #4 returned from the hospital, he/she said he/she didn't want to be here because he/she didn't want the BHM hitting him/her. During an interview on 1/25/23 at 3:53 P.M., CMT B said he/she was on the secured D hall passing medication on the date of the incident. When he/she walked past Resident #4, he/she thought Resident #4 had bumped him/her. When he/she turned around, he/she saw Resident #4 with his/her fist balled up, and the BHM walked over to Resident #4 and punched the resident in his/her right upper arm/shoulder area. CMT B said Resident #4 and the BHM were sitting across from each other in the hallway. CMT B said the BHM said to Resident #4, something like, It would be harder next time. CMT B said both he/she and Nurse A exited the D unit at the same time. CMT B didn't think the BHM knew the charge nurse was on the hall when it happened. The BHM stayed with the resident for a little while. CMT B said he/she believed the charge nurse contacted the Administrator about the incident. CMT B said no one had talked to him/her regarding the incident or collected a statement. During an interview on 1/26/23 at 12:24 P.M., CNA C said he/she was the only CNA on the secured D Hall on the date of the incident. He/She said Resident #4 was hitting Resident #1 and he/she hit CMT B. Resident #4 was sitting in a chair across from the BHM, and the BHM punched Resident #4 in the arm after Resident #4 hit CMT B. The BHM told Resident #4, The next time it will be harder. The DON came on the D hall and he/she informed the DON the BHM hit the resident. The DON said you'll have to talk to the Administrator about that. The DON only asked him/her what happened on the hall regarding the resident to resident altercation. The BHM was trying to get him/her to lie. The BHM told CNA C to write a statement which needed to say Resident #4 was aggressive to him/her, however the resident was not aggressive to him/her. Neither the DON or the Administrator have asked him/her about this incident or asked for a statement. CNA C said when it happened, Resident #4 said, Ow, and held his/her right arm. He/She asked him/her later, where did the BHM hit him/her, and Resident #4 pointed at his/her right arm. CNA C said he/she walked out of the D Hall, right behind Nurse A. Nurse A went into the medication room and the BHM got on his/her phone and called the Administrator, then handed Nurse A his/her phone. CNA C said the BHM came back on his/her hall twice, trying to pressure CNA C into writing a statement and lie about what happened. During an interview on 1/27/23 at 9:15 A.M., the Administrator said when the BHM called her on the date of the incident, he/she did not mention there was an allegation against him/her. She said she had the BHM write a statement about the altercation between the two residents. The BHM had been trying to deescalate the behaviors. The BHM told her Resident #4 hit Resident #1 in his/her eye and also hit a CMT. The DON and she contacted the nurses, and reported the resident-to-resident altercation to DHSS. She said Nurse A was downstairs and was not aware of an allegation the BHM hitting Resident #4. (Nurse A said she told her and placed his/her statement under the administrators door, the administrator denied knowledge or a statement by Nurse A) No one was aware, the DON was not aware, the only information they received was regarding Resident #4. She said they were only aware of a resident-to-resident altercation. She said they did not talk to CMT C, they asked the BHM to collect statements regarding the resident to resident altercation, and nothing in the statements mentioned the BHM hitting anyone. No staff person called and told her the BHM hit the resident. The administrator said she told the BHM and Nurse A she needed statements regarding Resident #4's behaviors. She said she was never told anything else had happened. If she was made aware, she would have told the BHM to leave, and would have started an investigation. Not a resident or staff person told her about the incident. She did ask the charge nurse for a statement, but never received anything. Review of the facility investigation, dated 1/24/23, and signed by the Administrator on 1/31/23, showed the Administrator was unaware of the allegation of the BHM striking Resident #4 and was only made aware when the surveyor brought this to her attention on 1/24/23. An investigation was started on 1/24/23, and the BHM suspended. A witness statement obtained from Resident #3, stated he/she witnessed the BHM hit Resident #4 on the left arm. No witness statement was obtained from Resident #4, as he/she was out of the facility at the time of interview. Resident #4 is now back in the facility and is currently residing on the secured B hall unit. The witness statements included the following: -The BHM's handwritten witness statement, signed and dated, 1/7/23 at 3:45 P.M., On this day he/she was called to the second floor to redirect Resident #4 because of his/her aggressive behaviors towards other residents and staff members. When the nurse on duty attempted to administer an as needed (PRN) medication, Resident #4 became aggressive and struck the nurse, causing the BHM to administer CPI to the resident in order to get the situation under control; -Resident #3's witness statement, signed and dated 1/26/23, showed the resident witnessed Resident #4 hit CMT C. Resident #3 saw the BHM hit Resident #4 and asked if that hurt or something like that. Resident #3 said Resident #4 was hit in the lower arm; -No witness statements were provided by Nurse A, CMT B, CNA C or Resident #4. During an interview on 2/2/23 at 4:45 P.M., the DON said she was not aware of an incident involving the BHM and a resident. She said she had arrived to the facility to submit a report to DHSS regarding the resident-to-resident altercation. She was made aware Resident #4 was hitting other residents, but nothing regarding the BHM hitting a resident. He/she said was made aware by the state surveyor on 1/24/23, and the administrator was investigating the allegation. MO00212957

Based on observation, interview and record review, the facility failed to meet the requirement of staff vaccination for 100% of their 82 facility-employed staff to either have one dose of a COVID-19 vaccine, or a pending exemption or approved exemption within 30 days of CMS' vaccination rule being in effect. As of the first date onsite at the facility, on [DATE], 23 of 82 facility-employed staff had not received their first dose of the COVID-19 vaccination and/or requested an exemption or temporary medical delay. This equals 28.048% of facility-employed staff who have not met the requirement for staff COVID-19 vaccinations. The facility failed to provide evidence to show attempts made to ensure staff met the requirements by the [DATE] deadline as the facility administration said they thought they had until [DATE]. An unvaccinated staff member failed to wear an N95 mask and failed to wear a mask properly to ensure both the nose and mouth were covered while in the facility and staff were observed to not follow proper infection control prevention standards in the COVID-19 unit and in the kitchen. Five residents acquired the COVID-19 infection at the facility within the past four weeks (Residents #63, #64, #65, #66, and #67). In addition, the facility failed to develop all required components of their policies and procedures for COVID-19 staff vaccinations. This failure resulted in the facility's implementation of their emergency staffing policy to allow unvaccinated staff to provide direct resident care. The census was 106. The administrator was notified on [DATE] at 1:08 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the Guidance for the Interim Final Rule for Medicare and Medicaid Programs Omnibus COVID-19 for Health Care Staff Vaccination dated [DATE] Within 30 days after the issuance of the memorandum, if a facility demonstrates: · Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or resident contact are vaccinated for COVID-19, including all required components of the policies and procedures specified below (e.g., related to tracking staff vaccinations, documenting medical and religious exemptions, etc.); and · 100% of staff have received at least one dose of COVID-19 vaccine or have a pending request for, or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the CDC, the facility is compliant under the rule. 1. Review of the facility's undated COVID-19 Vaccine Policy and Procedure, provided on [DATE], showed: -Purpose: To establish the process to comply with the federal mandate that all staff are vaccinated against COVID-19, unless they have a medical or religious exemption, to help reduce the risk of residents and staff contracting and spreading COVID-19; -Definitions: Fully vaccinated is defined as being 2 weeks or more since completion of a primary vaccination serious for COVID-19. A primary vaccination series is defined as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine; -Nursing home leadership is responsible for developing, implementing and maintaining these policies and procedures; -Staff vaccine requirements: -All facility staff are required to be fully vaccinated by [DATE]; -New hires will be subject to the same requirements as current staff and must have received, at a minimum, the first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine by the regulatory deadline or prior to providing any care, treatment, or other services for the facility and/or its patients; -Under federal law, staff may be eligible for a medical or religious exemption, but must meet the criteria for the exemption to qualify; -Religious exemptions: Fill out the COVID-19 exemption request form; -The policy failed to address the process for staff to request a medical exemption or temporary delay; -Additional precautions and contingency plans for unvaccinated staff: -Staff who receive an exemption to the COVID-19 vaccine will be subject to additional precautions to mitigate the transmission and spread of COVID-19, which includes: -The policy failed to identify any additional precautions; -In event of an emergency or low staffing, the facility will utilize agency staffing that can provide vaccinated staff to meet the resident needs. When vaccinated staff are not sufficient to meet resident needs, the temporary utilization of unvaccinated staff may be facilitated until sufficient vaccinated staff are identified to meet resident needs. However, these staff will be required to meet the additional precautions identified above; -Documenting COVID-19 vaccine for staff and residents: -The facility will maintain documentation for all residents and staff on COVID-19 vaccination, including the primary serious, boosters and additional doses; -For staff, requesting a medical exemption, the information is provided by the physician and includes the following information: -The policy failed to identify what information must be provided by the physician for a medical exemption; -The policy failed to address temporary delays. Review of the facility's Infection Control COVID Positive policy, dated February 2022, showed: -The facility will strive to control the spread of the coronavirus and subsequent variants; -COVID testing of all unvaccinated staff is mandatory every Monday and Thursday; -In an outbreak, COVID testing of all staff, regardless of vaccination status, is mandatory every Monday and Friday; -Masks will be worn at all times while in the building as follows: -N95 masks must be worn at all times during an outbreak; -Surgical masks must be worn at all other times until further notice; -All personal protective equipment (PPE) must be donned and doffed according to protocol to enter COVID positive rooms. During an interview on [DATE] at 9:30 A.M., the administrator said the facility currently has five residents positive for COVID-19 and no current positive staff. No residents have been hospitalized or expired in the past four weeks related to COVID-19. On [DATE] at 9:35 A.M., the administrator said corporate told her that the deadline was not until [DATE], and that no staff can work if they do not have an exemption on file or have had one vaccine dose by the [DATE] date. 2. Review of the facility's COVID-19 vaccine staff roster, corrected by facility staff and provided on [DATE], showed as of [DATE]: -82 facility-employed staff; -23 facility-employed staff with no COVID-19 vaccination and no documentation of a requested or pending exemption; -28.048% of facility-employed staff who have not met the requirement for staff COVID-19 vaccinations; -Unvaccinated staff without a requested or approved exemption included cooks, dietary aides (DAs), certified nursing assistants (CNAs), licensed nurses, housekeepers, certified medication technicians, and the dietary manager. During an interview on [DATE] at 9:30 A.M., the administrator said it is the administrator and assistant director of nursing (ADON) who are responsible for the staff vaccination efforts. 3. Review of the facility's Emergency Staffing policy, dated [DATE], showed: -The facility will ensure that during an emergency situation, staffing ratio will meet regulatory standards to ensure safe and effective care is provided to our regions. The following procedure will be implemented and part of the Emergency Preparedness Plan; -Any managers with licenses able to provide care will be used to work shifts as needed; -Vaccinated staff will be utilized first before unvaccinated staff. Review of time cards, showed 15 out of 23 unvaccinated staff without a requested or approved exemption, worked at the facility between the dates on [DATE] and [DATE]; -Cook QQ - worked 40.95 hours; -DA SS - worked 31.21 hours; -Housekeeper TT - worked 31.57 hours; -Certified Nursing Assistant (CNA) UU - worked 7.07 hours; -Housekeeper H- worked 27.48 hours; -Nurse K - worked 11.10 hours; -CNA XX - worked 20.58 hours; -Licensed Practical Nurse (LPN) YY - worked 24.95 hours; -CNA J - worked 31.49 hours; -Housekeeper ZZ - worked 22.31 hours; -Certified Medication Technician (CMT) AAA - worked 36.78 hours; -LPN CCC - worked 6.70 hours; -CNA DDD - worked 31.81 hours; -Housekeeper EEE - worked 9.32 hours; -CMT FFF - worked 22.80 hours. 4. Review of the facility's Donning and Doffing Personal Protective Equipment (PPE), revised [DATE], showed: -To provide guidelines for infection control while caring for residents; -The facility shall ensure all nursing personnel have proper training and instruction using PPE; -Recommended PPE components: A long, rear-fastening, fluid resistant long sleeved surgical gown. A respirator, a disposable full-face [NAME] or goggles and gloves; -Donning the respirator: With both hands mold the nose piece from the bridge of the nose firmly pressing down both sides of the nose with your fingers until you have a good facial fit. Position the upper straps on the crown of your head, above the ears and the lowers trap at the nape of the neck. Ensure that the respirator is flat against your cheeks; -When donning PPE has been completed, proceed to enter the patient's room. 5. Further review of the facility's COVID-19 vaccine staff roster, showed DA SS not vaccinated for COVID-19. An exemption requested on [DATE] and approved. Observation on [DATE] at 11:30 A.M., showed DA SS clocked in at the time clock. He/she held an N95 mask in his/her hand and had a surgical mask on, pulled down past his/her mouth area and exposed his/her nose and part of his/her mouth. He/she started to walk into the dining room and said he/she had been working at the facility for almost one year. He/she is not vaccinated for COVID-19 and is not getting the vaccination. He/she was not aware of any exemption form. After further thought, he/she said he/she does have some paperwork to bring in for an exemption and he/she planned to bring it tomorrow. He/she did not recall if he/she was provided education on the vaccine. At 11:42 A.M., the dietary manger walked up and told DA SS that he/she is supposed to have his/her mask pulled all the way up. The Dietary manager then pulled DA SS buy his/her arm over to the front desk area and told the front desk staff that employees should have their mask on before they make it past that entry way. The front desk staff replied to the dietary manager that DA SS was provided a mask. The dietary manager said yes, but he/she was just holding it in his/her hand. 6. Observation in the kitchen and dining area, at the food bar on [DATE] at approximately 12:20 P.M., showed staff made plates of food and set them on the food bar: -At 12:22 P.M., a cook wore his/her mask under his/her nose, and coughed as he/she grabbed a plate and placed food on the food bar. At 12:25 P.M., he/she pulled up the mask to cover his/her nose and left the area. At 12:26 P.M., he/she returned to the kitchen door. The mask again positioned under his/her nose. At 12:29 P.M., his/her mask remained under his/her nose. He/she opened the kitchen door and grabbed empty trays from the top of the food cart and then returned into the kitchen; -At 12:22 P.M., 12:28 P.M. and 12:34 P.M., a different cook wore his/her mask under his/her nose. The mask barely covered his/her mouth. When he/she talked, the inside of his/her mouth became visible. At 12:37 P.M., he/she made trays of food with his/her mouth exposed; -At 12:26 P.M., a staff person stood at the juice cart in the dining room. His/her N95 mask positioned under his/her nose. The bottom strap of the mask hung down below his/her chin. -At 12:27 P.M., a different staff person entered the dining area and told the staff person at the juice cart to cover his/her mouth. He/she pulled the mask back up over his/her mouth and then placed food on the food cart. 7. Further review of the facility's COVID-19 vaccine staff roster, showed DA MM not vaccinated for COVID-19. An exemption requested on [DATE] and approved. During an observation and interview on [DATE] at approximately 2:00 P.M., showed DA MM wore an N95 mask and said he/she started at the facility on Tuesday ([DATE]). The Dietary Manager hired him/her. He/she is not vaccinated for COVID-19 and has not requested an exemption. The facility did not provide him/her information or a deadline as to when he/she was required to be either vaccinated or request an exemption. 8. Review of the sign posed outside the COVID-19 unit, showed: Please apply before entering: Gown, mask, goggles/face shield, and glove. Review of a sign posted outside COVID-19 positive resident rooms, showed prior to entering room: Clean hands, mask, eye protection and gloves. Observation on [DATE], on the COVID-19 B Wing, showed: -At 8:01 A.M., a staff person entered the COVID-19 unit and wore an N95 mask. No other personal protective equipment (PPE) was worn. His/her mask was positioned under his/her chin an exposed his/her nose and mouth; -At 8:03 A.M., a different staff person approached and whispered something into the ear of the staff person who had his/her mask positioned his/her chin, who then walked off the COVID-19 unit; -At approximately 8:10 A.M., the staff person returned to unit and wore an N95 mask and was actively donning a gown and gloves, as he/she walked inside a COVID-19 positive resident room. No face shield or goggles were worn. During an interview on [DATE] at 9:58 A.M., the DON said the required PPE per the signs entering the COVID-19 unit, should be applied prior to entering the COVID-19 unit. 9. Observation on [DATE] at 8:22 A.M., a staff person entered the building and had no mask on. He/she held an N95 mask in his/her hand. He/she did not place the mask on until he/she reached room A-10. 10. Review of Resident #63's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -admitted on [DATE]; -Cognitively intact; -Independent with bed mobility; -Limited assistance required for transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene; -Primary medical condition category: Medically complex conditions; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's electronic medical record (EMR), showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -A care plan, dated [DATE], showed the resident has shortness of breath. Goal to have no complications related to shortness of breath. Interventions included assist in learning signs or respiratory compromise. Refer significant other/caregiver to participate in basic life support classes as appropriate. Monitor/document changes in orientation, increased restlessness, anxiety and air hunger. Monitor/document breathing patterns, report abnormalities to the physician. Use universal precautions as appropriate; -An order dated [DATE], may obtain COVID and/or respiratory panel via nurse practitioner on admission, readmission, quarterly and/or when symptoms arise as needed; -A progress note, dated [DATE] at 2:01 P.M., the resident tested positive for COVID-19. Physician made aware, resident made aware, call placed to guardian and message left. The resident placed on isolation. Review of the resident's COVID-19 laboratory specimen report, showed: -Collected [DATE] at 7:00 A.M.; -Test: [CONDITION(S)]-CoV-2; -Results: Positive; -Positive results indicates that severe acute respiratory syndrome coronavirus 2 is present and suggest the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 11. Review of Resident #64's EMR, showed: -admitted [DATE]; -The resident not COVID-19 vaccination and refused a vaccination on [DATE]; -A progress note dated [DATE] at 4:06 P.M., resident tested positive for COVID-19. Physician made aware, new order isolation x10 days. Resident made aware. Review of the resident's COVID-19 laboratory specimen report, showed: -Collected [DATE] at 7:00 A.M.; -Test: [CONDITION(S)]-CoV-2; -Results: Positive; -Positive results indicates that severe acute respiratory syndrome coronavirus 2 is present and suggest the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 12. Review of Resident #65's entry MDS, dated [DATE], showed: -admitted [DATE]; -Re-entry [DATE]; -The resident not COVID-19 vaccination and refused a vaccination on [DATE]. Review of the resident's EMR, showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -A care plan, undated and reviewed on [DATE], showed the resident tested positive for COVID-19. Goal to be free from symptoms of infection. Approaches included monitor/document/report to physician as needed for signs and symptoms of dehydration; -A progress note dated [DATE] at 1:55 P.M., resident tested for COVID-19. Physician made aware, resident made aware, placed on isolation for 10 days. Review of the resident's COVID-19 laboratory specimen report, showed: -Collected [DATE] at 7:00 A.M.; -Test: [CONDITION(S)]-CoV-2; -Results: Positive; -Positive results indicates that severe acute respiratory syndrome coronavirus 2 is present and suggest the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 13. Review of Resident #66's entry MDS, dated [DATE], showed the resident admitted on [DATE]. Review of the resident's EMR, showed: -admitted [DATE] and readmitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -A care plan, undated and reviewed on [DATE], showed the resident tested positive for COVID-19. Goal to be free from symptoms of infection. Approaches included monitor/document/report to physician as needed for signs and symptoms of dehydration; -A progress note dated [DATE] at 2:11 P.M., resident tested for COVID-19. Physician made aware, placed on isolation for 10 days. Resident made aware. Review of the resident's COVID-19 laboratory specimen report, showed: -Collected [DATE] at 7:00 A.M.; -Test: [CONDITION(S)]-CoV-2; -Results: Positive; -Positive results indicates that severe acute respiratory syndrome coronavirus 2 is present and suggest the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 14. Review of Resident #67's EMR, showed: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -A care plan, undated and reviewed on [DATE], showed the resident tested positive for COVID-19. Goal to be free from signs and symptoms of infection. Approaches included emphasize good hand washing techniques to all direct care staff. Isolation per physician order; -A progress note dated [DATE] at 7:32 P.M., pharmacy called the facility to report positive test result, resident aware. Physician and administrator aware. Call placed to guardian. COVID-19 restrictions in place at this time. Will continue to monitor for change in condition. Review of the resident's COVID-19 laboratory specimen report, showed: -Collected [DATE] at 8:00 A.M.; -Test: [CONDITION(S)]-CoV-2; -Results: Positive; -Positive results indicates that severe acute respiratory syndrome coronavirus 2 is present and suggest the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 15. During an interview on [DATE] at 10:22 A.M., the administrator and corporate executive assistant said in order to encourage staff to become vaccinated, vaccinations are discussed at all staff meetings. These occur two times a month on paydays. Many staff have requested exemptions. The facility has collaborated with a pharmacy to provide vaccinations to residents and staff. The facility talked with staff about the importance of vaccinations. Unvaccinated staff will be required to test weekly for COIVD-19 regardless of the community rate or outbreak status. If in outbreak status or the community rate goes up, they will have to test more often if indicated. The facility utilizes two staffing agencies to supplement staffing needs and try to only book vaccinated agency staff. The goal is to limit the amount of interaction between the residents and unvaccinated staff. They would expect all the required elements specified under the requirements to be included in the policy. Non-vaccinated are required to wear an N95 at all times while in the facility. Having high numbers of unvaccinated staff could increase the risk of transmitting COVID-19 from staff to the residents. Staff should wear masks that completely cover their mouth and nose. 16. During a telephone interview on [DATE] at 11:20 A.M., the Medical Director said he expected the facility to know the Centers for Medicare and Medicaid Services (CMS) regulations and Centers for Disease Control and Prevention (CDC) guidelines. The facility policy should reflect those regulations and guidelines and they should be followed. He could not say if unvaccinated staff posed a greater risk of transmitting COVID-19 to residents, but deferred to what CMS and the CDC data is in regards to transmission rates. He expects staff to wear PPE per the policy, CDC guidelines and CMS regulations. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level L. 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 E level.

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse, when the facility failed to follow their policy, state and federal regulations by failing to develop an appropriate care plan upon admission to closely monitor Resident #23's behaviors that included a history of violent outbursts, being physically aggressive, threatening staff and residents over cigarettes, using racial slurs, and punching holes in the walls. On 1/2/22, the facility failed to ensure staff were present on the behavioral unit when a verbal and physical confrontation occurred involving Resident #23, Resident #26 and Resident #1, failed to immediately intervene once they were aware of the physical altercation, and failed to ensure staff knew how to use the intercom system to alert other facility staff of the physical altercation. Resident #26 sustained an injured rib and black right eye. On 1/3/22, the facility failed to ensure staff were present on the COVID-19 unit when verbal and physical altercations occurred involving Resident #23, Resident #28 and Resident #4. Resident #23 sustained a bloody nose. On 1/9/22, the facility failed to ensure staff were instructed to monitor Resident #23 one on one when a physical altercation occurred between Resident #23 and Resident #33. In addition, the facility failed to ensure they had a behavioral tracking system in place and failed to ensure agency staff were inserviced to the facility abuse and neglect policy. The census was 99. The administrator was notified on 1/11/22 at 12:55 P.M., of an immediate jeopardy (IJ) which began on 1/2/22. The IJ was removed on 1/14/22 as confirmed by surveyor onsite verification. Review of the facility Abuse, Neglect and Exploitation policy, last updated on 11/30/17, included the following: Policy: Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals; Policy Explanation and Compliance Guidelines: The Abuse Coordinator in the facility is the Administrator or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: -Administrator; -Other officials in accordance with State Law; -State Survey and Certification agency through established procedures. -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the depravation by an individual, including caretaker of goods or services that are necessary to attain or maintain, physical, mental and psychosocial well-being. -Verbal abuse means the use of oral, written or gestured language that willfully includes derogatory and disparaging terms towards residents or their families, or within their hearing regardless of their age, ability to understand, or disability. -Physical abuse includes, but not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. -Mental abuse includes, but not limited to, humiliation, harassment, threats of punishment, or deprivation. Facility Abuse Prevention Plan: -Prevention of Abuse, Neglect, and Exploitation: -The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents. -Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents; -Observe resident behavior and their reaction to other residents, roommates, and/or tablemate's. Place residents in accommodations and environments that keep them calm; -Provide education on what constitutes abuse, neglect and misappropriation of property; -React to all allegations or questions of abuse by residents, family members, employees or visitors; -Take appropriate actions when abuse, neglect or exploitation is suspected; Provide residents, staff and family members information on how and to whom they should report concerns, suspicious, incidents, and grievances without the fear of repercussions; -Provide instructions to staff on care needs of residents; -Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect. Utilize facility's abuse/neglect risk assessment and develop care needs according to findings. Investigation of Alleged Abuse, Neglect, and Exploitation: -When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, it must be communicated to the facility's Administrator, Department Head, or Supervisor and the Administrator and/or designee must initiate an investigation. -Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of the investigation may include: -Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses; -Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and ay noted visitors in the area. Obtain witness statements according to appropriate policies. All statements should be signed and dated by the person making the statement. -Document the entire investigation chronologically. Resident Protection after Alleged Abuse, Neglect and Exploitation: -The facility will make efforts to protect any and all residents after alleged abuse, neglect and/or exploitation. Examples of ways to protect any and all residents after alleged abuse, neglect and/or exploitation may include, but are not limited to: -Temporary (less than 24 hours) separation from other residents if a resident's behavior poses a threat of abuse or violence; -Temporary or permanent room or roommate change, where incompatibility creates the potential for abuse; -Involve family members to sit with resident; -Temporary one on one supervision of a resident; -Engage a resident in diversionary activities; -Involve clergy, social services, and/or counselors as appropriate; Response and Reporting of Abuse, Neglect and Exploitation; -Anyone in the facility can report suspected abuse to the abuse agency hotline; -When abuse, neglect or exploitation is suspected, the Licensed Nurse should: -Respond to the needs of the resident and protect them from further incident; -Notify the Administrator and Director of Nursing; -Initiate an investigation immediately; -Notify the attending physician, resident's family/legal representative and Medical Director; -Obtain witness statements, following appropriate policies; -Contact the State Agency to report the alleged abuse; -Monitor and document the resident's condition, including the response to medical treatment or nursing interventions; -Document actions taken in steps above in the medical record; The facility Administrator and/or designee must ensure that all alleged violations, involving abuse or have a result of significant injury are reported immediately, but not later that 2 hours after the allegation is made. If an allegation did not involve abuse ad did not result in significant injury it must be reported within 24 hours of when the allegation is made. Reports must be made to the appropriate officials, including to the State Survey Agency, in accordance with State law through established procedures. Review of the facility behavioral unit admission criteria, undated, showed: Policy: Admission criteria for the secured C (dementia) and D (behavioral) unit; Purpose: To ensure the safety of the residents with the least restrictive measures used; Procedure: All residents will be screened by Admissions coordinator/Licensed nurse/Social Services during the admissions process to ensure that their room selection meets the safety needs and comfort of the resident and other residents that live in the facility. Residents will be evaluated quarterly by the interdisciplinary team to see if they qualify for a less restricted environment; Criteria: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Confused or disoriented; -Elopement risk/exit seeking behaviors; -Significant behavioral problems; -Combative with staff and/or others; -[CONDITION(S)]/suicide attempts; -Requires a less stimulating environment to decrease anxiety; -Requires closer supervision regarding safety or behaviors. Review of the facility Residents Rights, undated, but provided to residents upon admission, showed: -As a resident of The Estates and residing in the state of Missouri, you have the right to be treated with dignity and respect while living in our facility. In addition, the resident rights listed below will provide explanation related to being protected from abuse, open communication with orders, being provided with privacy and confidentiality; -The resident's rights included: - Be free from abuse and restraint. You should not be subjected to physical, sexual or emotional abuse. Review of the facility Resident Admission Agreement, undated, but provided to residents upon admission, showed: Prevention Information: Abuse and neglect does not happen in every nursing home. Many nursing homes provide quality care. However, even one case of abuse is too many. We need your help to spot abuse and report it. Sometimes abuse may not be obvious, it can take on many forms, Abuse may be physical, mental or sexual and also take action to stop it. If you think you see signs of abuse or neglect, take action to help stop it. Signs may include, but not limited to: - Skin tears; - Scratches; - Fearful; - Swelling; - Cuts; - Broken bones; - Withdrawal; - Unusual bruises; Report it as soon as possible to the facility Administrator or other department heads and then these steps will be taken: - The Long-Term Care Ombudsman called. - State Licensing Agency (DHSS) called. - Adult Protective Service Agency called. This will start the investigation process. Working together, we can help assure quality care in this facility. The Centers for Medicare ad Medicaid Services (CMS), a part of the federal government and your state will not tolerate abuse in nursing homes. 1. Review of Resident #23's, electronic medical record (EMR), showed: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's Aggression Assessment, dated 12/22/21 at 4:28 P.M., showed: -Have you ever had episodes of violence?: Yes; -What specifically happened?: It was reported that the resident became angry at the assisted living (prior residence) and punched a hole in the wall. The hospital referral reports he/she used racial slurs and can be verbally aggressive; -Who were the targets of the violent behavior? Resident denies any violent or aggressive behaviors stating he/she never gets angry; -Were the victim(s) significantly injured?: No; -Did you intend on injuring the individuals?: No; -What psychiatric symptoms, if any, were associated with the violent behavior?: Resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . His/her sister is afraid of him/her and will not allow him/her to live with her. There is a report that he/she was physical with one of his/her elderly parents. He/she denies this; -Do you have a history of impulsive or dangerous behaviors such as suicidal behavior, alcohol abuse, destruction of property, reckless spending or criminal behavior?: Yes. Review of Resident #23's interim care plan, dated 12/22/21 at 3:29 P.M., showed: Safety/Risk: -Does the resident smoke?: Yes, with supervision; Functioning: -Is the resident cognitively impaired?: Yes; -Does the resident have any visual impairment?: No; -Is the resident hearing impaired?: No; -Can the resident communicate easily with staff?: Yes; -Does the resident understand staff?: Yes; Activity of Daily Living Function: -Bed mobility: Independent; -Transferring: Independent; -Ambulation: Independent; -The interim care plan did not address the resident's history of physical and verbal aggression, violent outbursts or how staff should monitor the resident, track his/her behaviors and/or report his/her behaviors. Review of Resident #23's progress notes in the EMR, showed the following psychosocial note, dated 12/22/21 at 5:23 P.M.: Resident is alert and oriented times three (person, place, time) and able to make his/her needs known, but there is some short term memory impairment noted. Resident admits he/she has trouble remembering things sometimes. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she is a smoker and can become fixated on when he/she can smoke. He/she currently does not have his/her own cigarettes. He/she ambulates (walks) independently with a slight limp and is independent with his/her transfers. He/she denies any aggressive behavior, but hospital records reported he/she was physically aggressive and threatening with staff and residents over cigarettes. He/she frequently used racial slurs and was discharged for punching holes in the walls. When he/she was home with his/her parents, he/she was physically aggressive with his/her father and his/her sister is afraid of him/her. Review of Resident #23's undated care plan on 1/3/22, located in the resident's EMR, showed: Problem: Resident has the potential to be physically aggressive related to anger, history of harm to others, and poor impulse control; Goals: Resident will not harm self or others; Approaches: -Resident triggers for physical aggression are related to smoking. His/her behaviors are de-escalated by allowing him/her to smoke at the designated times; -Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; -When resident becomes agitated, intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later; Problem: Resident has impaired cognitive function or impaired thought processes related to TBI; Problem: Resident has mood problem related to disease process. Review of Resident #26's EMR, showed: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's EMR, showed: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/5/22 at 7:00 A.M., Certified Nursing Assistant (CNA) J said he/she had worked the day shift on the behavior unit on Saturday 1/1/22 and Sunday 1/2/22. Residents fight each other, kick walls, throw trash cans and set off alarms on the behavioral unit. There was only one CNA on the behavioral unit on Saturday and Sunday, but they need two staff at all times on the behavior unit. If two residents get into a fight with only one staff how do you get help without leaving the residents? On 1/1/22 he/she arrived about 6:45 A.M. Resident #23 was escalating calling residents names. Resident #26 was looking after the female residents because Resident #23 was getting in their faces and calling them names. This was going on when he/she arrived. On Sunday 1/2/22, he/she arrived to work about the same time. Resident #23 was exhibiting the same behaviors with the same residents. He/she did not report the behaviors because the residents had not been physical with each other. Since he/she started at the facility he/she has not been inserviced on abuse/neglect or resident behaviors. He/she had worked at the facility for about three months. He/she had not received an abuse and neglect inservice he/she is aware of and had not received any inservice on resident behaviors. It would be a good idea for behavioral inservices since so many of the residents have behavioral problems. During an interview, on 1/3/22 at 10:35 A.M. Resident #1 said he/she, Resident #23 and Resident #26 got into a fight the night before (1/2/22). Resident #23 had been calling him/her names for a long time yesterday. Resident #26 did not like Resident #23 calling him/her names and told Resident #23 to stop. Resident #23 started hitting Resident #26. He/she started hitting Resident #23 in the head. There were no staff on the behavioral unit for several hours that day including when the fight between the three of them broke out. It is not uncommon for there not to be staff on the behavioral unit. Review of Residents #23, #26 and #1's, progress notes, located in their EMRs, showed: Resident #23: -1/2/22 at 6:56 P.M., and completed by Nurse K: Resident became increasingly agitated this shift. Staff is unable to redirect behavior at this time. Resident became physically and verbally aggressive with another resident (Resident #26). Residents separated at this time. Call placed to physician. New order to send resident out for evaluation and treatment. Emergency Medical Services (EMS) arrived to the facility to transport resident. Resident is safely transferred onto gurney and transported to hospital; -1/2/22 at 9:06 P.M., and completed by Nurse G: Resident returned to facility via ambulance and accompanied by 2 Emergency Medical Technicians (EMTs) via stretcher from hospital where he/she was seen for disruptive mood disorder. No complaints of pain or discomfort. No signs/symptoms of distress noted at this time; Resident #26: -1/2/22 at 6:52 P.M., and completed by Nurse K: Resident became increasingly agitated this shift, staff is unable to redirect behavior at this time. Resident became physically and verbally aggressive with another resident (Resident #23). Residents are separated at this time. No apparent injuries noted. Call placed to physician and guardian is aware. New order to send resident out for evaluation and treatment. EMS arrived to the facility to transport resident. Resident is safely transferred onto gurney; -1/3/22 at 5:35 A.M., and completed by Nurse G: Resident arrived back to the facility via ambulance and accompanied by 2 EMTs from hospital. Resident has a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . No complaints of distress or shortness of breath; -1/3/22 at 12:19 P.M., and completed by Assistant Director of Nursing (ADON) A: Noted bruising, purple in color under left eye. No swelling noted. Bruise is 3.0 centimeters (cm) by 0.5 cm, purple in color to lower abdomen. Resident denies pain and feels safe at facility. Call placed to guardian and Nurse Practitioner (NP) to make aware; -1/3/22 at 1:19 P.M., and completed by ADON A: NP made aware of bruising to left eye and abdomen, also of injury to rib; Resident #1: -1/2/22 at 5:36 P.M., and completed by Nurse K: Resident became increasingly agitated this shift. Staff is unable to redirect behavior at this time. Resident became physically and verbally aggressive with another resident (Resident #23). Residents are separated at this time. Call placed to physician. New order to send resident out for evaluation and treatment. EMS arrived to the facility at approximately 5:30 P.M Resident is safely transferred onto gurney and transported to hospital; -1/3/22 at 12:25 P.M., and completed by ADON A: Abrasion 0.4 cm by 0.4 cm to right hand. No bruising noted, denies pain. Call placed to guardian. Call placed to NP, awaiting call back. Review of the facility investigation, undated and completed and signed by the administrator, showed: -On 1/2/22 at 5:49 P.M.: Reported to me three residents had an altercation, all without injury and were all sent out to the emergency room ; -Witnesses: CNA E, CNA X and CMT Y; -1/3/22 A.M. meeting at 10:10 A.M.: Reported to me all residents returned to the facility. Resident #26 had a bruised eye and injured rib. Resident #1 had a 0.5 cm by 0.5 cm on top of right hand; 1/4/22: -CNA E: He/she was on the unit dealing with two other residents who were also having behavioral issues, around 2:45 P.M. He/she heard Resident #23 and Resident #26 yelling. He/she was right there. No one got physical and they were all asked to wait in their own rooms. He/she left a little after 3:00 P.M. because his/her shift was over. -CNA X statement: He/she clocked in at 3:06 P.M. and clocked out at 6:20 P.M. 1/2/22. We sat on the behavioral unit after the altercation occurred. He/she did not see any of the incident, he/she was just there to monitor. By the time he/she arrived on the unit, the residents had been separated and were in their doorways; -CMT Y: He/she heard residents yelling sometime after dinner about 5:45 P.M.- 6:00 P.M., and by the time he/she got up from the nurse's station and in there, Resident #1 had hit Resident #23 and Resident #23 and Resident #26 were already on the floor tussling. They broke things up and all walked away without further issue until the ambulance arrived; - Administrator: Throughout this investigations, the statements do not match up. The verbal altercation (CNA E's statement) appears to have occurred somewhere between 2:45 P.M. and 3:00 P.M. on 1/2/22. It does appear something more occurred with the residents. Increased staffing and separation of the residents in an attempt to decrease such occurrences was put into place. During an interview on 1/3/22 at 1:35 P.M., Resident #26 sat in a wheelchair in his/her room. Observation at that time showed the resident had a black right eye. The resident said Resident #23 was calling Resident #1 names and he/she told Resident #23 to stop. Resident #23 became angry and began to hit him/her. He/she did not hit Resident #23 back until Resident #23 began to choke him/her. He/she had not seen staff on the unit for about an hour prior to the fight and there were no staff present when Resident #23 began hitting him/her. Staff did not come onto the unit until after the fight began. He/she had not had problems with any resident other than Resident #23. During a telephone interview on 1/10/22 at 10:09 A.M., CNA E (an agency CNA) said he/she worked the day shift on 1/2/22. Around 2:30 P.M., Resident #23 was upset, yelling, kicking the walls, and getting in the face of Resident #26. No one was in a physical fight at that time. There was no way he/she could have done a one on one with Resident #23 because he/she was the only staff member on the unit and there was another situation going on he/she had to deal with. He/she did not tell anyone about Resident #23's behavior at the time it occurred because to him/her it was more like a temper tantrum. They were calm by the time he/she left at 3:00 P.M. His/her replacement was going to be late so the Staffing Coordinator came to the unit so he/she could leave. He/she told the Staffing Coordinator about Resident #23's behavior before leaving. The Staffing Coordinator was on the behavioral unit when he/she left. During a telephone interview on 1/4/22 at 8:45 A.M., the facility Staffing Coordinator who is also a CNA and CMT, said right at the change of shift on 1/2/22 around 2:45 P.M. or 3:00 P.M., he/she relieved CNA E who worked the day shift. The CNA that was supposed to relieve CNA E was late. CNA E told him/her Resident #23 had been yelling down the hall at Resident #1 during the day shift. Resident #23 was calling Resident #1 a bastard. Resident #26 was defending Resident #1 then all three residents began yelling at each other. CNA E told him/her he/she had separated the residents and there were no other problems. He/she left the behavior unit shortly after speaking to CNA E. CNA E's replacement had not arrived yet. During a telephone interview on 1/10/22 at 10:21 A.M., CMT Y said he/she has worked at the facility part-time for the past couple of years. He/she works a 12 hour shift (7:00 A.M. - 7:00 P.M.). To his/her knowledge he/she had not received an inservice on behaviors or abuse/neglect. Other than passing medications or dinner trays, he/she never watches the halls or relieves the CNAs for their breaks and management knows that. On the eveninf shift of 1/2/22 CNA X was covering the behavioral unit and another unit on the second floor until another CNA who was running late got there. Around 5:45 P.M. or 6:00 P.M. he/she was at the nurse's station (the nurses station is located outside the behavioral unit) when he/she heard Resident #23 yelling, calling other residents bastards and using racial slurs. He/she got up and looked through the unit door windows and saw Resident #1 punch Resident #23 in the head three times. Resident #23 and Resident #26 were on the floor fighting. There was no staff on the behavioral unit at that time. He/she ran back to the nurse's station and tried to call a code gray on the intercom, but he/she did not know how to use the intercom system. He/she was trying to call for the nurse on the first floor, but no one was answering. CNA X was coming down the hall at that time and he/she told the CNA to go and get the nurse from the first floor. He/she did not go onto the unit while CNA X went to the first floor because he/she did not want to get hit. The residents were fighting with no intervention until the nurse got there. During an interview on 1/10/22 at 11:58 A.M., the administrator said she was not aware CMT Y was under the impression he/she did not have to relieve the CNAs when they are on break. That is part of his/her job description and duties. She will be discussing that with CMT Y. During a telephone interview on 1/4/22 at 12:00 P.M., CNA X said he/she worked the evening shift on 1/2/22. His/her shift began at 3:00 P.M He/she was not assigned to the behavioral unit. Around 3:30 P.M., CMT Y told him/her there were no staff on the behavioral unit and asked him/her to keep an eye on the behavioral unit in addition to the unit he/she had been scheduled to work. Since there had been no staff on the behavioral unit, he/she went to that unit to make sure everything was ok. He/she stayed on the behavioral unit about 10 minutes before leaving. There were no staff on the behavioral unit when he/she left. After leaving the behavioral unit, he/she needed linens for the other unit so he/she went down stairs to get the linens. When he/she came back, CMT Y was at the nurses station trying to call the nurse downstairs. The CMT told him/her to go and get help because there were residents fighting on the behavioral unit. This was around 4:30 P.M. He/she went back downstairs, told Nurse K what was happening and Nurse K came back upstairs right away. When they got onto the behavioral unit, Resident #23 said Resident #1 was agitating him/her. Resident #1 said he/she was not going to allow Resident #23 to hit him/her. Resident #26 said he/she did not like how Resident #26 was talking to Resident #1. Staff stayed on the floor with the residents after that until the residents had left for the hospital. CNA X said he/she had worked on the behavioral unit prior to 1/2/22. During an interview on 1/3/22 at 3:30 P.M., Nurse K said earlier in the day yesterday, there was a verbal confrontation between Resident #23 and Resident #26, he/she could not recall the time. He/she de-escalated it. There was no threatening remarks at that time. Resident #26 appeared to be more upset than Resident #23 saying Resident #23 was being disrespectful. He/she did not give any directives to staff to monitor the residents as the confrontation did not appear threatening. Later around 5:30 P.M., he/she was working on the first floor when CNA X came downstairs and told him/her they needed him/her on the behavioral unit because of a fight. By the time he/she arrived on the unit, staff had separated the residents. Resident #1 said Resident #23 was saying disrespectful things to him/her and he/she hit Resident #23 over the head. All three residents were sent to the hospital for fighting. CNA X was working both the behavioral unit and the locked dementia unit upstairs and CMT Y was working as a CMT and CNA. No one told him/her there were no staff on the behavioral unit prior to or at the time of the fight. There should always be at least one staff member on the behavioral unit. Typically, the CMT on duty will replace the CNA when the CNA goes to break or lunch. Review of Resident #23's hospital notes, dated 1/2/22 at 7:44 P.M., showed: History: -Resident came in and states he/she does not know why he/she is here. Per EMS (Emergency Medical Services), resident was involved in a verbal altercation with another resident, then began to hit the walls and door. Resident denies injuries. Medical Decision Making: -Behavioral outburst. History of TBI. Currently no signs of aggression. Give dose of [MEDICATION(S)] (antipsychotic medication). Plan for discharge back to facility. During an interview on 1/3/22 at 4:15 P.M., ADON B said after Resident #23 returned to the facility last night he/she told staff to watch the resident closely, and to keep their eyes on the resident. The DON said they really did not have the staff last night to monitor the resident one on one after he/she returned from the hospital. Staff were basically doing every 15 minutes checks, but no one was documenting the 15 minute checks. The administrator and DON said there should always be at least one person on the behavioral unit. The administrator said she would have expected someone to monitor Resident #23 closely after returning. During an interview with the administrator and DON on 1/5/22 at 8:00 A.M., the administrator said the DON texted her about the incident that occurred between Resident #23 and Resident #26, but did not mention that a physical altercation occurred. The DON said she was under the impression it was a verbal altercation only. She did not read the residents progress notes in the EMR. Had she read them and saw where the altercation was physical, she would have asked more questions. She was not aware there had been on-going verbal confrontations between the three residents prior to the physical altercation occurring. That should have been reported to her and staff should have monitored them. Both the administrator and DON said there should always be at least one staff member on the behavioral units at all times. The DON was aware Resident #23 had aggressive behaviors prior to admission, but she was not aware the resident used racial slurs, and punched holes in the walls. When there is a physical altercation taking place, staff should call a code gray on the intercom. She did not know CMT Y had not been trained to use the intercom system. The resident's care plan should have been updated to reflect interventions and staff monitoring. On 1/10/22 at 7:30 A.M., residents were observed peering through the windows in the doors of the behavioral unit. A surveyor entered the behavioral unit to conduct an interview with Resident #30. One unknown resident wandered the hall repetitively asking the surveyor Who are you? Are you the nurse? At 7:40 A.M., Resident #25 was observe

Based on observation, interview and record review, the facility failed to notify the physician of a resident's change in condition. The resident vomited at least three times, one of which was coffee ground emesis. The nurse failed to adequately access the resident's condition, obtain vital signs, document in the medical record and notify the physician. The resident later expired at the facility. (Resident #79) The census was 80. Review of the facility's undated Change in a Resident's Condition or Status policy, showed: -Policy: The facility shall promptly notify the resident, his/her attending physician and representative of changes in the resident's medical/mental condition and or status; -Procedure: 1. The Nurse Supervisor/Charge Nurse will notify the resident's attending physician or on-call physician when there has been: d. A significant change in the resident's physical/emotional/mental condition. 2. A significant change of condition is a decline or improvement in the resident's status that: Will not normally resolve itself with intervention by staff or by implementing standard disease related clinical interventions (is not self limiting). B. Impacts more than one area of the resident's health status. C. Requires interdisciplinary review and or revision to the care plan D. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to to changes in the resident's medical/mental condition or status. 7. If a significant change in the resident's medical status occurs, a comprehensive assessment of the resident's condition will be conducted as required. Review of Resident #79's care plan, updated [DATE], showed: -Problem: History of [MEDICAL CONDITION]; -Approach: Monitor for signs of [MEDICAL CONDITION]: fatigue, skin pallor, shortness of breath, lightheadedness, dizziness and fast heartbeat. Encourage resident to consume iron rich foods at meal times when available. Complete lab work as ordered. Notify the physician of any abnormal lab values and or change in physical condition. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -[DIAGNOSES REDACTED]. -Short/long term memory loss; -Required extensive staff assistance for bed mobility and dressing; -Required total staff assistance for transfers, toileting, personal hygiene and bathing; -Incontinent of bowel and bladder; -No prognosis of life expectancy of 6 months or less. Review of the resident's nurse's notes, dated [DATE], showed: -No time: Resident has blood noted in stool. Call placed to the physician's office; -4:00 P.M.: Received new order to send to the emergency room for evaluation to rule out gastrointestinal (GI) bleed. Call placed to ambulance-estimated time of arrival 30 minutes; -5:30 P.M.: Ambulance arrived to transport resident. Call placed to responsible party. Review of the resident's Hospital Discharge Summary, completed by the physician, dated [DATE], showed: -Admission Diagnosis: [REDACTED].>-Discharge Diagnosis: [REDACTED]. -Hospital Course: The patient was transferred to the hospital due to GI bleed. He/she was admitted to the hospital. His/her hemoglobin remained stable. There was no evidence of active bleeding. [MEDICATION NAME] was consulted. Discussion with family. Plan was to continue with conservative therapy and observation. The resident will be discharged back to the nursing home. He/she has been taken off [MEDICATION NAME] (anti-[MEDICAL CONDITION] drug used to treat arthritis pain) and aspirin due to the GI bleed. Recheck labs in one week. The patient will follow up with his/her primary physician; -Code status at discharge: Full code. Review of the resident's hospital Transfer Orders For Receiving Facility, dated [DATE], showed: -Discharge Diagnosis: [REDACTED].>-Code status: Full Code; -General instructions: Basic Metabolic Panel (BMP, blood test that measures sugar (glucose) level, electrolyte and fluid balance, and kidney function) and Complete Blood Count (CBC, blood test used to evaluate overall health and detect a wide range of disorders, including [MEDICAL CONDITION], infection and [MEDICAL CONDITION]) in one week; -Follow-up with primary physician in one to two weeks. Review of the resident's physician's orders [REDACTED]. Review of the resident's nurse's notes, showed: -[DATE] at 4:00 P.M.: readmitted to the facility via stretcher. Alert and oriented to self. Able to make needs known at times. Call placed to the physician to verify medicines. Copy of medicines faxed to physician's office to verify. Resident lay in bed resting. No signs and symptoms of distress or discomfort noted at this time. No complaint of pain. Will continue to monitor; -No documentation regarding BMP and CBC; -[DATE] at 2:30 P.M.: (Completed by the unit manager) Recent readmit from the hospital with a [DIAGNOSES REDACTED]. Able to make some needs known. Required assist of one to two staff for activities of daily living and transfers. No acute distress noted. Respirations are even and unlabored. -[DATE], no time: Physician in to see the resident. New order to obtain BMP, magnesium (blood test used to measure the amount of magnesium in the blood) and CBC in two weeks. Review of the resident's POS, dated [DATE], showed an order dated [DATE], for a BMP, MG (magnesium) and CBC in two weeks. Review of the resident's nurse's note, showed: -[DATE] through [DATE], no documentation regarding lab work. No further documentation until [DATE]; -[DATE] at 7:10 P.M.: Hemoglobin (H) 7.1 (normal 14.0 - 18.0) and hematocrit (H) 22.6 (normal 42.0 - 54.0%). Call placed to the resident's physician. New order for stool guaiac (test used to check for blood in stool) and CBC; on Monday [DATE]; -No further documentation until [DATE]. Review of the resident's POS, dated ,[DATE], showed an order dated [DATE] at 3:00 P.M., for CBC and stool guaiac on Monday [DATE]. During an interview on [DATE] at 10:40 A.M., Laboratory Technician W said they had no results or request for a CBC or stool guaiac for [DATE]. Review of the resident's nurse's notes, showed: -No documentation whether staff obtained stool for guaiac or whether the CBC was obtained; -No nurse's notes for the day shift or evening shift on [DATE]; -[DATE] at 10:30 P.M. (first note documented since [DATE]): Changed the resident's dressing to left hip and left heel. Resident tolerated procedure well. Noted coffee ground emesis. Certified nurse aide (CNA) cleaned the resident. No further incident; -[DATE] at 12:00 A.M.: Resident sleeping in bed at this time. (next note) 5:00 A.M.: CNA called the nurse to the room. Resident was having more emesis at this time. CNA was afraid to get resident up. 5:25 A.M.: 911 called to take the resident to the hospital. 5:50 A.M. Paramedic arrive. Resident became unresponsive. Initiated cardiopulmonary resuscitation (CPR) with the paramedic staff. 6:15 A.M. Paramedic work on resident for twenty five minutes until 6:15 A.M. 6:25 A.M. Family notified. 6:30 A.M. During an interview on [DATE] at 10:27 A.M., day CNA A said he/she has been employed at the facility for a year and a half. He/she took care of the resident on ,[DATE], ,[DATE] and [DATE] and he/she worked the day and evening shift on [DATE]. On [DATE], during the day, the resident was his/her usual self, confused and talking. He/she provided care and assistance with standing. The resident was able to feed himself/herself. No complaints on the day or evening shift. [DATE], he/she was irritable at times and got out of his/her gerichair which was unusual for him/her. He/she was unaware the resident was able to stand and walk. He/she was unaware the resident could get up and walk because he/she hadn't done so recently. The resident said repeatedly he/she was going home. He/she and Nurse B assisted the resident into his/her gerichair. On [DATE], day shift, the resident was quiet and sat in his/her gerichair with a cover over his head, which was normal. He/she didn't say anything which was unusual. The look on his/her face was like he/she was tired. The resident consumed very little breakfast and refused to eat more when he/she offered. He/she usually eats 100% of his/her meal. He/she drank very little water. He/she usually drinks 4 cups. Right after lunch, the resident asked him/her to put him/her back to bed because he/she was ready to lay down. A tear came down his/her face and he/she shook his/her head. The CNA asked him/her what was wrong but he/she didn't say anything else. The resident laid down at approximately 1:45 P.M. He/she could hear the resident talking to God, saying, I got to go. He/she repeated that phrase several times. At 4:45 P.M., he/she asked the resident if he/she wanted to get up for dinner. The resident did not answer and was staring into space. The CNA brought him/her a hall tray and tried to feed him/her some mashed potatoes. The resident refused but sipped a small amount of water. He/she reported the resident's poor intake to Nurse B. Nurse B did go in to check the resident but didn't say anything about the resident's condition. At approximately 8:45 P.M., he/she checked the resident for wetness. He/she had a large amount of clear emesis. The odor of the emesis was worse than anything he/she had ever smelled. It smelled like stool. It covered his/her gown and sheets. He/she washed the resident and changed his/her entire bed. He/she reported the emesis and odor to Nurse C. Nurse C went in and checked the resident's eyes with a light. He/she told him/her the resident had an upset stomach and to give him/her water. During his/her last rounds at approximately 10:15 P.M., he/she asked the resident to drink some water, but he/she refused. He/she threw up at least twice on her shift, both times the odor was very strong. It was clear with a strong stinky smell. He/she reported both emesis to Nurse C. During report he/she asked CNA D, the night CNA, to keep an eye on the resident because he/she had emesis on his/her shift. He/she asked Nurse C to send the resident to the hospital because something was just not right with him/her. Nurse C told him/her he/she had done all he/she could for him/her, gave him/her a towel and bucket and that the resident will be alright. He/she was very upset and had a hard time sleeping that night. The resident didn't look right, he/she couldn't explain the odor from the vomit. It wasn't the normal smell. It was nothing he/she had ever smelled before. During an interview on [DATE] at 3:03 P.M., Nurse B said he/she worked 12 hours as the day/evening charge nurse on [DATE]. He/she didn't recall staff reporting any changes in the resident's condition. When he/she reported to work between 6:30 A.M. and 7:00 A.M., on [DATE], staff at the desk said the resident had passed away. CNA D said the resident had vomited during the night. During an interview on [DATE] at 11:07 A.M., CNA D said he/she worked the night shift starting on [DATE] into the morning of [DATE]. During report CNA A asked him/her to keep an eye on the resident during the night because he/she had been vomiting all day. He/she saw the resident at approximately 11:30 - 12:00 midnight. The resident lay in bed but didn't say anything. At around 2:00 A.M., the resident vomited a large amount of brown emesis. He/she didn't say anything. His/her eyes were closed. The CNA called his/her name several times while cleaning him/her. After about 10 minutes he/she opened his/her eyes. CNA D reported the emesis to Nurse C. Nurse C went in to see the resident, checked his/her vital signs, said the resident looked comfortable and left the room. At 2:30 A.M., the resident was resting quietly in bed. When he/she went in at 4:30 A.M., the resident was gurgling and having a hard time breathing. He/she asked CNA H, the other CNA on the floor, to come in to check the resident. CNA H said he/she needed to get Nurse C immediately. Nurse C came right away and said the resident needed to go to the hospital. Nurse C left the room to call the 911 ambulance. The nurse instructed him/her to get some vital signs. He/she left the room to get the equipment. When he/she returned Nurse C was in the room and said the resident was gone and no longer responding. CNA D became very upset and started crying. CNA H came to comfort him/her. No code blue was called. Nurse C went to the nurse's desk to get some paper work and wait for the ambulance. No crash cart was brought to the room. Nurse C didn't instruct him/her to apply oxygen to the resident. One Emergency Medical Technician (EMT) arrived to the resident's room with Nurse C. The EMT applied a mask and started CPR. He/she also asked Nurse C to assist him/her with CPR. Several minutes later two more EMTs arrived and they began to assist. He/she left the room after that. During an interview on [DATE] at 11:10 A.M., CNA H said he/she worked the night shift, on [DATE] into [DATE], on the first floor. He/she saw the resident at the beginning of the shift with CNA D. He/she was resting quietly and was alive. The next time he/she saw the resident was when CNA D asked him/her to come to the room early that morning. He/she didn't look right. He/she was breathing funny, like he/she was getting ready to pass away. He/she asked CNA D what the brown stuff that was on the resident's pillow. He/she told CNA D to get Nurse C immediately. CNA D ran to get Nurse D. Nurse D came to the resident's room quickly. He/she looked at the resident to see if he/she was still breathing and left the room and went to the desk to call 911. No Code Blue was called and he/she didn't give them any instructions on what to do. He/she left the room at that time. CNA D became very upset and started crying. He/she went to comfort him/her. No CPR was done before the EMTs arrived. During an interview on [DATE] at 11:26 A.M., CNA I said he/she worked the night shift on the second floor on [DATE] through [DATE]. He/she didn't see the resident until after he/she had passed away. No code was called. When a Code Blue is called you can hear it all over the building. During an interview on [DATE] at 11:30 A.M., CNA J said he/she worked the night shift, on [DATE] into [DATE], on the second floor. At the beginning of the shift before he/she went upstairs he/she overheard CNA A tell CNA D the resident wasn't looking good and to keep an eye on him/her. He/she came down to smoke early that morning. CNA D said the resident had passed away. He/she went to the nurse's desk and asked Nurse C why wasn't a code called. Nurse C said he/she was waiting for the ambulance to come. He/she was getting paperwork together. No code was called for the resident and he/she didn't see a crash cart at the room. During an interview on [DATE] at 1:00 P.M., Nurse C said he/she worked a 12 hour shift, from 7:00 P.M. on [DATE] through 7:00 A.M., on [DATE]. He/she couldn't recall whether staff made him/her aware of the resident's emesis during the evening. He/she remembered changing the resident's dressing early that night. He/she does recall the CNA reporting the resident had vomited after 5:00 A.M. After assessing the resident he/she left the room and called 911. It took the ambulance 20 - 25 minutes before they arrived. He/she instructed the CNA to keep an eye on the resident while he/she gathered the resident's information. He/she accompanied the EMTs to the room and that was when he/she noted the resident had passed away. The EMT began CPR and he/she assisted with compressions. There was no need to call a Code Blue because the resident was still alive. He/she took the resident's vital signs but doesn't know why he/she failed to document them in the medical record. He/she did not instruct the CNA to apply oxygen, but did instruct him/her to keep an eye on the resident while he/she called 911. No one reported the resident had vomited on the earlier shift. During an interview on [DATE] at 8:32 A.M., the Director of Nurses (DON) and administrator said Nurse C was terminated on [DATE]. He/she failed to respond in a urgent manner to the resident's change of condition. Staff reported the resident vomited at least twice with one being coffee ground emesis. The resident's status continued to deteriorate. Nurse C failed to do an adequate nursing assessment and did not notify the physician. He/she failed to document the resident's change in condition in the medical record. The DON said she would have expected Nurse C to follow the facility's policy. When staff report a change in condition he/she would expect the nurse to assess the resident's condition, notify the physician and document in the medical record. During an interview on [DATE] at 11:32 A.M., the resident's physician said if the resident was throwing up blood then he would expect the staff to notify him. During an interview on [DATE] at 9:55 A.M., the facility's medical director said he would have expected the staff to notify the primary physician for any acute changes in condition. He would have expected staff to follow physician orders [REDACTED]. the physician of the change in condition and give him/her the opportunity to decide whether to send the resident to the hospital.

Based on observation, interview and record review, the facility failed to follow physician's orders for weekly weights and follow the Registered Dietician's (RD) recommendation for nutritional supplements once weight loss was identified for one resident. The facility also failed to implement interventions to address the weight loss once it became severe. The resident experienced an 11.31% loss over a three month period. (Resident #43) The census was 80. Review of the facility's policy for Unplanned Weight Loss, dated 10/12/17, showed: -Assessment and Recognition: -The nursing staff will monitor and document the weight of residents in a format which permits readily available comparison over time; -The resident will have their current nutritional status reviewed by their physician and Registered Dietician in order to define the resident's current nutritional status; -The threshold for significant unplanned/undesired weight loss will be based on the following criteria: -One month - 5% weight loss is significant; greater than 5% is severe; -Six months - 10% weight loss is significant; greater than 10% is severe; -Cause Identification: The physician (or staff based on a discussion with the physician) will document relevant medical observations and conclusions regarding the nature, severity, cause and consequences of impaired nutritional status, especially in complex situations or where multiple active causes may coexist. Review of Resident #43's monthly weights, showed; -On 3/8/19 at 12:39 P.M., a weight of 159.20 pounds (lbs); -On 4/10/19 at 12:36 P.M., a weight of 142.20 lbs; -On 5/10/19 at 11:11 A.M., a weight of 141.20 lbs; Review of the resident's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/10/19, showed: -Brief interview of mental status (BIMS) score: 12 of 15 (Mild cognitive impairment); -Exhibited no behaviors; -Required supervision and set up for eating; -Required extensive assistance of one staff for personal hygiene; -[DIAGNOSES REDACTED]. -Weight of 142 lbs; -No weight loss within the past six months; Review of the resident's (MONTH) 2019 physician's order sheet (POS), showed an order dated 5/10/19, for weekly weights for five weeks due to weight loss. Review of the resident's medical record, showed no weekly weights documented. Review of the resident's care plan, updated on 5/13/19, showed: -Problem: At risk for weight loss due to refusal of care at times. Current diet of regular with nectar thick liquids and double portion meats. Also receiving a house supplement three times per day; -Goal: Will be free from any unplanned significant weight loss through the next review; -Approach: Provide with reminders about approaching meal times, assist in getting to the main dining room for meals, provide with education about benefits associated with maintaining good nutrition. Review of the resident's dietary note, dated 5/17/19, showed the resident experienced a significant weight loss of 7.8% in three months. Recommendation of Med Pass (a nutritional supplement), 120 milliliters (ml) twice a day to deter further weight loss. Further review of the resident's (MONTH) 2019 POS, showed no order for Med Pass. Review of the resident's quarterly dietary review, dated 5/21/19, showed: -Regular diet with nectar thickened liquids; -Med Pass three times per day; -Double portions with each meal; -Feed self at table side with assistance. Review of the resident's Dietary Likes/Dislikes/Preferences Admission Interview, dated 5/21/19, showed the resident liked eggs, oatmeal and grilled cheese sandwiches. Review of the resident's (MONTH) 2019 POS, showed an order for [REDACTED]. Further review of the resident's medical record, showed no weekly weights or an order for [REDACTED].>During an interview on 6/13/19 at 1:54 P.M., the administrator, corporate nurse and Director of Operations said they could not locate the (MONTH) 2019 medication administration review for the resident. During an interview on 6/13/19 at 8:42 A.M., Certified Medication Technician (CMT) G said he/she would have been responsible for administering Med Pass if there was an order for [REDACTED]. During an interview on 6/14/19 at 7:45 A.M., the director of operations said they could not locate weekly weights for the resident. If there was a physician's order for weekly weights, they should have been done. Observation on 6/12/19 at 7:36 A.M., showed the resident was wheeled to the main dining room for breakfast. He/she received his/her food at approximately 7:45 A.M. The resident's meal card said he/she was to receive double portions. The resident received one serving of scrambled eggs, one serving of oatmeal, one piece of toast cut in half, one cup of juice and one cup of water. The resident did not receive double portions. As the dietary staff gave the resident his/her plate, the resident reached for the toast and dropped one half of the toast. Certified Nurse Aide (CNA) [NAME] said, You dropped your toast. CNA [NAME] did not pick up the toast or ask the dietary staff to replace the dropped toast. CNA [NAME] sat directly across from the resident and assisted another resident with his/her meal. The resident picked up the spoon and attempted to eat the oatmeal. His/her hand shook as he/she tried to get the food into his/her mouth. The oatmeal dropped onto his/her lap. The resident then picked up the fork and ate his/her eggs. The eggs fell off the fork onto the table and into his/her lap. The resident placed the fork down on the table and began using his/her hands to eat the eggs off the table and his/her lap. He/she then tried to pick up the juice but was unsuccessful. He/she used his/her hand and scooted the juice toward him/her and reached for the juice with his/her head to try to take a drink using the provided straw. CNA [NAME] sat across from the resident and did not ask the resident if he/she needed assistance. At 7:54 A.M., the resident looked at the floor in the direction of the toast underneath the table. The resident then looked in the direction of CNA E. He/she then backed the wheelchair from the table, used his/her foot and scooted the toast from the floor toward him/her. The resident picked the toast up from the floor, and ate it. After eating the toast from the floor, he/she used his/her hands to eat the eggs from his/her lap and off the table. After eating 100% of the eggs, the resident attempted to scoop up the oatmeal with a spoon. His/her hand shook and the oatmeal spilled into his/her lap. At 7:57 A.M., CNA [NAME] asked the resident if he/she wanted his/her oatmeal. The resident replied, Yes. CNA [NAME] called Nurse F and said, Come get him/her and took off the resident's clothing protector. As the CNA removed the resident's clothing protector, the resident became angry and threw what appeared to be a balled up napkin. CNA [NAME] said, There he/she goes over here getting mad and throwing stuff. Nurse F cleaned the resident's mouth with the clothing protector and rolled him/her away from the table. The resident ate all of the eggs, one piece of toast, including the half piece he/she picked up from the floor, two attempted scoops of oatmeal and one attempted sip of juice from a straw. Approximately 80% of the oatmeal was left in the bowl. The cups of juice and water were full. The resident wheeled himself/herself out of the dining room. During an interview on 6/12/19 at 3:27 P.M., the resident said staff don't usually assist him/her with meals. However, he/she did not mind if they helped with meals. Observation on 6/12/19 at 3:28 P.M., showed a staff member gave the resident a snack of cookies in a tied up plastic bag. When the resident asked if the surveyor would open the cookies, the staff member took the cookies and opened them. Observation on 6/13/19 at 8:10 A.M., showed the resident sat in the main dining room and received breakfast which included one serving of eggs, one piece of toast, a bowl of oatmeal and glasses of juice and water. CNA D fed the resident the meal. The resident ate 100% of the food. During an interview on 6/13/19 at approximately 8:15 A.M., CNA D said they try to allow the resident to eat on his/her own, but will assist as needed. The resident refused care at times but never had a problem with staff feeding him/her. During an interview on 6/13/19 at 8:31 A.M., Nurse B said if a resident experienced a significant weight loss, they would regularly weigh the resident. The dietician would make the recommendation. The nurse was expected to read the dietary notes, then contact the physician and obtain orders. He/she could not recall reading any dietary recommendations for the resident. Observation on 6/14/19 at 8:57 A.M., showed the resident weighed 141.3 lbs. During an interview on 6/12/19 at 3:55 P.M., the Registered Dietician (RD) said she recommended Med Pass after the resident experienced a significant weight loss. After she made the recommendation, she communicated it with the nurses, including the Director of Nursing (DON). The nurses were expected to write the order on the POS and get the order from the physician. There was no order from the physician. The resident should have received Med Pass and double portions for each meal. During an interview on 6/13/19 at 1:54 P.M., the administrator, corporate nurse and director of operations said the resident experienced a significant weight loss over a six month period. The expectation was to meet weekly to discuss interventions for the resident. They would notify the physician. The physician was notified and an order was given for weekly weights. The expectation was to also communicate with the RD. The RD recommended Med Pass and double portions. The weekly weights order was on the POS but not done. The Med Pass was recommended by the RD and not on the POS. The expectation was the Med Pass was to be placed on the POS and administered as ordered. The resident was also supposed to receive double portions. If the resident was observed struggling with feeding him/herself, staff was expected to assist. It was not appropriate to allow the resident to eat food off the floor. During an interview on 6/20/19 at 11:43 A.M., the physician said the resident experienced a significant weight loss so she ordered weekly weights. The expectation was for the resident to be weighed weekly if there was an order. The nurse was expected to communicate with the dietician if she made a recommendation for the resident to receive Med Pass and double portions. The recommendation should have been communicated with the physician and she would have placed it on the POS. She was not aware of the order for Med Pass and the nurse did not communicate it with her. The resident had neurological problems and experienced tremors and needed assistance with activities of daily living. Staff was expected to assist the resident if he/she had a difficult time with eating meals. It was not appropriate for the staff to have allowed the resident to eat off the floor. The weight loss may have been prevented if the resident received Med Pass, double portions and assistance with meals.

Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors. Staff failed to administer [MEDICATION NAME] (diuretic, medication used to remove excess fluid) as ordered for one resident with a [DIAGNOSES REDACTED].#52). The sample was 18. The census was 80. Review of Resident #52's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/16/19, showed: -No documented diagnoses; -Short/long term memory loss; -Supervision of staff for eating; -Limited staff assistance for bed mobility and dressing; -Extensive staff assistance for transfers, toileting, personal hygiene and bathing; -Incontinent of bowel and bladder; -Received diuretic for last seven days; -Hospice care: Yes. Review of the resident's physician's orders [REDACTED]. -3/15/19: Call the physician for a weight gain of more than 5 pounds (lbs); -[MEDICATION NAME] ([MEDICATION NAME], medication used to treat high blood pressure and [MEDICAL CONDITION]) 40 milligrams (mg) by mouth twice a day; -Losartan potassium ([MEDICATION NAME], medication used to treat high blood pressure and [MEDICAL CONDITION]) 25 mg once daily. Review of the facility's weekly weight sheet, dated 3/25/19, showed: -Last weeks weight: 185.3 lbs; -This week's weight: 191.0 lbs; -Gain of 5.7 lbs; -Reason: [MEDICAL CONDITION]. Review of the resident's nurse's notes, showed: -3/27/19, no time: Nurse made aware of resident wheezing. Oxygen saturation (O2 SAT, amount of oxygen in the blood) 94% (normal 95 to 100%). Weight gain of 3.3 lbs for the week of 3/18/19 and 5.7 lbs for the week of 3/25/19. Resident has a history of [MEDICAL CONDITION] and is currently on [MEDICATION NAME]. Call placed to hospice. New order received for [MEDICATION NAME] 40 mg intramuscularly (IM) twice a day for one week then [MEDICATION NAME] 60 mg by mouth twice a day and discontinue Losartan. Orders verified with physician. Review of the resident's POS, dated 3/1/19 through 3/31/19, showed: -Order dated 3/27/19: [MEDICATION NAME] 40 mg IM twice a day for one week; -When complete start [MEDICATION NAME] 60 mg by mouth twice a day; -Discontinue Losartan. Review of the resident's nurse's notes, showed: -3/28/19 at 5:15 P.M.: [MEDICATION NAME] has not arrived from pharmacy. Pharmacy called to check estimated time of arrival (ETA). Pharmacy said they did not receive the new order. New order faxed to the pharmacy; -3/29/19 at 9:00 A.M.: Call placed to the pharmacy, ETA of [MEDICATION NAME] IM injection. It will be delivered on 3/29/19. 1:30 P.M.: Medication has not arrived from the pharmacy. Call placed to hospice company awaiting return call; -No further documentation whether the hospice company returned call; -No documentation whether the resident received the [MEDICATION NAME]; -No further documentation until 4/8/19. Review of the resident's Medication Administration Record [REDACTED] -[MEDICATION NAME] 40 mg IM twice a day for one week. When complete start [MEDICATION NAME] 60 mg by mouth twice a day; -Front of MAR: -9:00 A.M.: 3/28 circled as not given, 3/29 blank, 3/30 circled, 3/31/19, initialed as given; -5:00 P.M.: 3/28 circled as not given, 3/29 blank, 3/30 circled, 3/31/19, initialed as given; -Back of MAR: -3/28 at 9:00 A.M. [MEDICATION NAME] 40 mg IM has not arrived from pharmacy. 5:00 P.M.: [MEDICATION NAME] 40 mg IM has not arrived from pharmacy; -3/29/19, no time, [MEDICATION NAME] 40 mg IM has not arrived from pharmacy. Call placed to pharmacy at 12:05 P.M.: to be delivered today 3/29/19; -3/30/19 at 9:00 A.M.: [MEDICATION NAME] 40 mg IM not in facility; -[MEDICATION NAME] 40 mg tablet discontinued 3/27/19; -Losartan 25 mg tablet discontinued 3/27/19. Review of the resident's MAR, no date, showed: -Front of MAR: order dated 3/27/19, [MEDICATION NAME] 40 mg IM twice a day. - 9:00 A.M.; 4/1 and 4/2 initialed as given, 4/5 blank, 4/3, 4/4 and 4/6/19 initials circled (indicating not given); -5:00 P.M.: 4/1 and 4/2 initialed as given, 4/5 blank, 4/3, 4/4 and 4/6/19 initials circled; -Back of MAR: -No documentation regarding 4/1, 4/3 and 4/5/19; -4/4/19 at 5:00 P.M.: [MEDICATION NAME] 40 mg IM on order; -4/6/19 at 8:00 A.M. and at 5:00 P.M.: [MEDICATION NAME] 40 mg IM not available. Review of the facility's weekly weight sheet, dated 4/1/19, showed: -Last weeks weight: 191.0 lbs; -This week's weight: 196.2 lbs; -Gain of 5.2 lbs; -Reason: [MEDICAL CONDITION]. Review of the resident's POS, dated 4/1/19 through 4/30/19, showed: -an order written [REDACTED]. -Discontinue [MEDICATION NAME] 40 mg twice a day; -[MEDICATION NAME] 40 mg IM twice a day for one week; -Start [MEDICATION NAME] 60 mg by mouth after one week of IM [MEDICATION NAME]. Review of the resident's nurse's note, dated 4/8/19 at 1:00 P.M., showed: -First nurse's note since 3/29/19; -Resident has a new order for to discontinue [MEDICATION NAME] 40 mg twice a day by mouth, start [MEDICATION NAME] 40 mg IM twice a day for one week, then start [MEDICATION NAME] 60 mg by mouth; -Responsible party made aware. Review of the resident's Hospice Comprehensive Assessment, dated 4/9/19, completed by the hospice nurse, showed: -[DIAGNOSES REDACTED]. -Changes in medication: 3/27/19: [MEDICATION NAME] 40 mg twice a day for one week, then change to 60 mg by mouth twice a day due to fluid retention. 4/8/19: [MEDICATION NAME] 40 mg IM twice a day for one week then [MEDICATION NAME] 60 mg by mouth twice a day after the IM doses are completed; -4/1/19: Decreased cardiac function as evidenced by clients heart rate today (4/8/19), was 49 (normal 60 to 100), O2 SAT 91%. 3/25/19: eight lb weight gain in two weeks due to fluid retention. 4/8/19: 22 lb weight gain from fluid retention in the last two months. Review of the resident's MAR, dated 4/1/19 through 4/30/19, showed: -Front of MAR: [MEDICATION NAME] ([MEDICATION NAME]) 40 mg IM twice a day for one week; -8:00 A.M.: 4/8 and 4/15 blank, 4/9, 4/10, 4/11, 4/12, 4/13, 4/14/19 were initialed as given; -5:00 P.M.: 4/8 blank, 4/9, 4/10, 4/11, 4/12, 4/13, 4/14 and 4/15/19 were initialed as given; -Back of MAR: blank. Review of the resident's physician's progress note, dated 4/19/19, showed: -Chief complaint: Fluid overload; -Weight 188 lbs; -Review of symptoms: Respiratory: Short of breath off/on, not increased; -Physical exam: Respiratory clear. Musculoskeletal: 2+ pedal (foot) [MEDICAL CONDITION] (depth and duration of the indentation in the swollen area); -Assessment: Pedal [MEDICAL CONDITION] improved; -Plan: Received [MEDICATION NAME] IM for one week, now on 60 mg twice a day by mouth. Weight improved from 196 lbs (fluid overload). Hospice continue to follow. Review of the resident's nurse's notes, from 4/8/19 through 4/19/19, showed no documentation regarding missed [MEDICATION NAME] doses. Observation on 6/12/19 at 12:14 P.M., showed the resident sat in his/her Broda chair with oxygen on at 2 liters per nasal cannula and staff assisting him/her with lunch. Observation on 6/14/19 at 7:10 A.M., showed the facility emergency drug kit located in the medication room on the first floor showed it contained (4) 20 mg vials of IM [MEDICATION NAME]. Nurse M confirmed the emergency drug kit showed (4) doses of 20 mg of IM [MEDICATION NAME]. During an interview on 6/17/19 at 6:48 A.M., Nurse V said he/she was unaware the IM [MEDICATION NAME] was located in the IM Box, in the medication room on the first floor. The resident has been treated several times before with IM [MEDICATION NAME]. The resident becomes more agitated and restless when there is a fluid buildup. He/she has notified the hospice nurse of this in the past. The IM Box has equipment used to start and IV and various IM medications. He/she was the nurse who called the pharmacy on 3/28/19. He/she was unaware the resident had not received the full doses of IM [MEDICATION NAME]. During an interview on 6/17/19 at 9:25 A.M., the hospice nurse said he/she was not aware the resident had not received the IM [MEDICATION NAME] as ordered. When he/she came in on 4/8/19, the resident was [MEDICAL CONDITION] and his/her weight had increased. He/she called the physician for an order. On 4/13/19, the second floor charge notified him/her the facility was having problems getting the medication from the pharmacy. During an interview on 6/21/19 at 2:13 P.M., the facility's pharmacy said the IM [MEDICATION NAME] was sent to the facility by the pharmacy and signed by a staff member that they received it. He/she was not aware the resident hadn't received the medication. During an interview on 6/14/19 at 7:47 A.M., the Director of Corporate Operations said she would expect the nurse to pull medication from the Emergency kit and administer the medication. During an interview on 6/14/19 at 2:14 P.M. the Director of Nurses (DON) said there is no reason a resident should go without a medication, because it is available in the emergency medication kit. Staff had not made her aware they were having trouble getting the medication from the pharmacy. She would expect staff to make her aware anytime they have problems obtaining medications. During an interview on 6/20/19 at 12:11 P.M., the resident's physician said he/she would expect staff to follow the physician's orders [REDACTED]. He/she would have expected staff to notify him/her if the resident hadn't received the medication.

Based on interview and record review, the facility failed to ensure two residents with mental disorders received treatment and services to meet their needs (Residents #8 and #9). Both residents had a history of [REDACTED]. Residents #8 and #9 were involved in an altercation that led to Resident #8's death. The facility failed to adequately assess both residents, put necessary care measures in place and monitor both residents' behavior. The facility also failed to assess for ongoing, appropriate interventions, including adequate social service intervention provided by a qualified social worker, psychiatric services for both residents and completion of the necessary pre-admission screening and resident review (PASARR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings. The resident's Level II PASARR identifies the specialized services required by the resident.) The census was 85. Review of the facility policy titled Abuse, Neglect and Exploitation updated [DATE], showed a resident must not be subject be abuse from anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse included, but was not limited to hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment. Review of the facility policy titled Change in a Resident's Condition or Status, last reviewed [DATE], showed direction for facility staff to promptly notify the resident, his/her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). Among the things a nurse supervisor/charge nurse was to notify the resident's attending physician or on-call physician about was a significant change in a resident's physical/emotional/mental condition, a need to alter the resident's medical treatment significantly and a need to transfer a resident to a hospital/treatment center. A significant change of condition was a decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self limiting), impacted more than one area of the resident's health status, required interdisciplinary review and/or revision to the care plan and is ultimately based on the judgement of the clinical staff and the guidelines outlined in the resident assessment instrument and 42 CFR 483.20 (b)(ii). Unless otherwise instructed by the resident, the nurse supervisor/charge nurse was to notify the resident's family or representative (sponsor) when there was a significant change in the resident's physical, mental, or psychosocial status. 1. Review of Resident #8's undated face sheet, showed an admission date of [DATE], with the latest return on [DATE] and the presence of a cardiac pacemaker. Review of Resident #8's criteria for second floor B (secured) unit placement, dated [DATE], showed [DIAGNOSES REDACTED]. Further review of his/her identified criteria for placement on the unit, was his/her age of [AGE] years or older, history of aggressive behaviors, danger to self or others and required closer supervision for safety or behaviors. The assessment criteria showed the resident should reside on the secured B unit. Any new resident who was an elopement risk, engaged in exit seeking behaviors, or was a danger to self or others was to be placed on the secured B or C unit, depending upon his/her cognitive status, and undergo a seven day initial trial period, with reassessments to coincide with Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) scheduled assessments at day 14, 30, 60, 90, and every quarter thereafter or upon their request. Each resident was to be assessed, monitored and care planned for their safety and comfort. Review of Resident #8's criteria for B unit placement, dated [DATE], showed the resident had a [DIAGNOSES REDACTED]. The criteria was the resident's age of [AGE] years or older. The assessment criteria determined the resident should be moved to an unrestricted environment. During interviews on [DATE] at 10:45 A.M. and [DATE] at 12:12 P.M., the Administrator said the resident was content on the B unit, but his/her family member wanted him/her to be in a less restrictive environment. Constant walking was his/her only behavior. Resident #8 was having problems with peers getting in his/her way as he/she walked. Staff conducted several trials with him/her coming off of unit B for activities and meals. It took quite a while for staff to feel comfortable with him/her coming off of the unit. They were attempting to determine if his/her constant walking was purposeful behavior and whether or not it posed a danger to him/her. Based on staff observations during activities and meals, the interdisciplinary team (IDT) determined Resident #8 was not a danger to him/herself. The IDT selected Resident #9 as his/her roommate based upon the vacancy of a bed in his/her room on the unsecured second floor unit A, as well as them being close in age and having similar functional abilities. Based on staff observations, the IDT also evaluated whether or not Resident #8 and Resident #9 were getting along. The two of them appeared to be pretty well matched. They were both pretty quiet. Staff was expected to perform annual and quarterly reviews, to evaluate the appropriateness of the move and placement. Review of the resident's social service progress notes, showed the following: -[DATE], the resident was present for a care plan meeting and had no significant status change; -[DATE], the social worker introduced herself. The resident was able to complete an assessment, answering questions to the best of his/her abilities; -[DATE], a care plan meeting was conducted. A family member expressed concerns about missing clothes and an eye exam. Social worker will follow-up on the eye-appointment. Activities director will search for missing clothes and follow up. The family member was not ready for the resident to come home. Social worker will continue to follow up as needed; -[DATE], social worker informed the power of attorney (POA) the resident would have an eye exam in-house on [DATE]. The social worker gave the resident and POA the resident's circuit breaker check. The social worker will continue to be a support for the family. Further review of the resident's social service notes, showed no further documented social service visits/support. During an interview on [DATE] at 11:20 A.M., the psycho-social assistant (PSA) said she greeted Resident #8 every morning, Good morning, how are you doing today? The resident would speak, but was very reserved. There were no one-on-one sit down discussions. Resident #8 came to her one time, concerned about what time the facility banking took place. She answered the resident's question and that was that. Their only other interactions occurred when she had to redirect him/her, due to incontinence issues. She would tell the resident to go up to his/her room and she would call a staff person on the second floor to change the resident. Review of the resident's care plan, dated [DATE] and reviewed on [DATE], showed the facility identified the resident's dementia with poor safety awareness. The resident's score of eight on the abuse/neglect risk assessment, indicated he/she was at risk for potential abuse from others. He/she had a [DIAGNOSES REDACTED]. The resident said he/she frequently got upset when he/she felt others were getting in his/her face, in order to provoke him/her. The resident had cognitive loss, forgetfulness and impaired decision making. After moving from the secured unit, he/she could become lost and required verbal cues at times. He/she had a prior history of elopement and need for a locked unit. The facility put a wanderguard (electronic monitoring device) in place, to manage his/her elopement risk. Review of the resident's elopement risk assessment, dated [DATE], showed a total score of 11 (a score from eight to 14 indicated moderate risk for elopement: care planning, increased elopement monitoring and/or eyesight precautions were recommended). Review of the resident's neurology consult, dated [DATE], showed the resident had abnormal CT angiogram (computed tomography; procedure combining many x-ray images via computer for cross-sectional views and three-dimensional images of blood or lymph vessels) results showing possible posterior (near the rear) cerebral artery aneurysms (abnormal focal dilation of an artery in the brain which results from a weakening of the inner muscular layer of a blood vessel wall). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Signs and symptoms of [MEDICAL CONDITION] (an abrupt change in the brain that causes mental confusion and emotional disruption): continuous inattention and fluctuating disorganized thinking; -[DIAGNOSES REDACTED].>-Independent ambulation. Review of the resident's physician's order sheet (POS), dated (MONTH) 2019, showed the following: -[DIAGNOSES REDACTED]. -Elopement risk; -[DATE], check wanderguard every shift for placement; -[DATE], [MEDICATION NAME] (treats dementia) extended release 28 milligrams (mg) once daily for dementia. 2. Review of Resident #9's Missouri Department of Health and Senior Services (DHSS) initial social and medical assessment, dated [DATE], showed he/she required monitoring for safety and routine procedures. The resident benefited from supervision/guidance from staff. He/she required constant supervision by professional staff for medication compliance. Review of the resident's DHSS level II PASARR evaluation, dated [DATE], showed the resident experienced an onset of [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), agitation, poor impulse control and behavior problems at age 11. He/she was convicted and jailed age 18 and served [AGE] years in prison for murder. Due to the major mental illness of [MEDICAL CONDITION] (a disorder that affects a person's ability to think, feel and behave clearly), difficulty interacting appropriately/communicating effectively with others. He/she manifested agitation, exacerbated signs and symptoms associated with the illness. The resident's individual weakness included poor impulse control, poor insight and judgment. He/she required intervention by mental health or judicial systems, as well as a secure environment for monitoring of mental status, administration of medications and assistance with care. The resident continued to need services of a lesser intensity including medication therapy/monitoring to change inappropriate behavior or alter manifestations of psychiatric illness, implementation of systemic plans to change inappropriate behavior, case management/social work services and a structured environment. Review of the resident's DHSS level II screening findings letter, dated [DATE], for admission into a long-term care facility, showed, after review, the Department of Mental Health determined that the resident's diagnosed condition met the federal definition of serious mental illness, but he/she did not require specialized services. The lesser intensity services were to be incorporated into the care plan. Review of the resident's undated face sheet, showed an admission date of [DATE], and [DIAGNOSES REDACTED]., [MEDICAL CONDITION] and chronic pain. Review of the Administrator's undated written statement, showed the resident was admitted directly onto the B secured unit due to his/her expressed interest in returning to Chicago and concerns about possible elopement attempts. Review of the resident's psychiatrist encounter note, dated [DATE], showed the resident was polite, respectful and stayed in his/her room except for meal times. He/she had poor recent memory, insight and judgment. He/she had [DIAGNOSES REDACTED]. The resident denied symptoms of depression or anxiety. The resident was receiving [MEDICATION NAME] extended release (anti-depressant) 75 mg, [MEDICATION NAME] (treats [MEDICAL CONDITION]) 100 micrograms (mcg), and [MEDICATION NAME] (cognition enhancer) 10 mg daily. The resident's [MEDICATION NAME] (anti-psychotic) 50 mg was stopped, due to a low absolute [DIAGNOSES REDACTED] count (real number of white blood cells which are [DIAGNOSES REDACTED]s; key components in the body's defense against infection). The resident was doing well, even though the [MEDICATION NAME] was stopped. His/her psychiatrist decided to hold off on restarting the antipsychotics, as the resident was doing well and not experiencing symptoms of [MEDICAL CONDITION]. The psychiatrist planned to monitor any symptoms and make recommendations or changes as needed. Review of the resident's elopement risk assessment, dated [DATE], showed a total score of 9 (scores from eight to fourteen indicated moderate risk for elopement: care planning, increased elopement monitoring and/or eyesight precautions were recommended). Review of the resident's undated POS, showed an order dated [DATE], for his/her [MEDICATION NAME] ([MEDICATION NAME]) order to be discontinued. Review of the resident's care plan, updated [DATE], showed the resident had a [DIAGNOSES REDACTED]. He/she had a wanderguard in place to manage elopement risk, due to a history of [MEDICAL CONDITION] and history of wandering. Further review of the resident's care plan, showed no interventions or specified monitoring and reporting of aggressive or psychotic behavior. The care plan also did not include any interventions related to his/her history of violence or address the necessary supportive services of lesser intensity specified on his/her level II PASARR. During interviews on [DATE] at 10:45 A.M. and [DATE] at 12:12 P.M., the Administrator said the PASARR was generally obtained by the admissions coordinator and reviewed by the IDT, in order to ensure that information was part of the comprehensive care plan. The facility only had a copy of Resident #9's level I PASARR, not his/her level II PASARR. Review of the resident's social service progress notes, showed the following: -[DATE] (no time documented), social worker introduced him/herself to the resident, who was pleasant. The social worker will continue to be a support; -[DATE] (no time documented), social worker attempted to complete the quarterly assessment with resident. He/she answered the first question, then said he/she no longer wanted to complete it; -[DATE] (no time documented), social worker completed the assessment with the resident. He/she answered questions to the best of his/her abilities; -[DATE] (no time documented), the resident was aware of the care plan (meeting), but would not attend. He/she was able to make his/her needs and wants known. Review of the resident's medical records, showed no further documented social service visits/support. Review of Resident #9's nurse's notes, dated [DATE] 7:00 P.M. to 7:00 A.M., showed the resident was having tactile hallucinations and said that he/she could feel someone spitting on him/her through the wall. The charge nurse checked the resident's bed and clothing, in order to see if water could be coming from somewhere. His/her clothes and bed were dry. On [DATE] 7:00 P.M. to 7:00 A.M., the charge nurse determined the resident was having auditory hallucinations, contacted the resident's primary care physician, and received an order for [REDACTED]. Review of the resident's urinalysis and urine culture results, dated [DATE], showed findings within the normal range except for a few [MEDICATION NAME] cells (a type of cell that lines the surfaces of your body. They are found on your skin, blood vessels, urinary tract, and organs. Normal range: none). Further review of the resident's nurse's notes, showed no further monitoring of the resident's hallucinations or notification and follow-up with the resident's primary care physician regarding laboratory results. There was no documentation of any notification about the resident's hallucinations provided to his/her psychiatrist. Review of the resident's POS, dated (MONTH) 2019, showed an order dated [DATE], for donepezil [MEDICATION NAME] (treats mild to moderate dementia) 10 mg, every night at bedtime. Further review of the resident's POS, showed no prescribed antipsychotic or antidepressant medications. 3. Review of Resident #8's emergency medical services (EMS) patient care report, dated [DATE], showed hospital EMS received a call at 7:11 A.M. and dispatched an ambulance for a patient in cardiac/respiratory arrest. Paramedics arrived on the scene at 7:14 A.M. and found the resident lying supine (face upward) in his/her bed with a backboard underneath him/her (placed by staff). Staff was performing cardiopulmonary resuscitation (CPR, life sustaining measures in the event the heart stops beating). Staff said the resident was last seen sitting up on the side of his/her bed at 6:00 A.M., awake. They had just found him/her lying in bed, not breathing or responding, and then noticed the resident did not have a pulse. Staff started CPR at 7:00 A.M. Paramedics took over compressions. They ventilated the resident with a bag valve mask resuscitator (a hand-held self-inflating bag, attached to a face mask, used to provide positive pressure ventilation to individuals not breathing or not breathing adequately). The resident was bleeding and showed signs of what appeared to be trauma to the right eye and nose. When asked if they had any idea or saw what happened to the resident, staff denied having any knowledge. The resident's right eye was swollen shut, with blood around the eye and nose. Paramedics continued CPR throughout the arrest, only stopping for rhythm checks. The resident had multiple rhythm changes, but was pulseless and apneic (absence or cessation of breathing) the entire time. The paramedics received orders from a physician to discontinue CPR at 7:35 A.M. All efforts were stopped at that time. The resident was pronounced dead at the scene. Review of the undated facility investigation, showed on [DATE] at approximately 7:00 A.M., staff found Resident #8 unresponsive in his/her room, made a STAT (at once) announcement for assistance and started an emergency code. Staff called 911 and started CPR on the resident. EMS arrived, took over CPR, and provided medical treatment to Resident #8. Resident #9 was in the dining room for breakfast at the time of the 911 call and intervention. Staff interviewed Resident #9, who had a small, deep scratch on his/her right cheek, a cut between his/her left pinky and ring finger, as well as what appeared to be dried blood on his/her left hand. Resident #9 said, yes when asked if he/she had a fight before breakfast that morning. Resident #9 said he/she was trying to get his/her clothes out of his/her closet, when Resident #8 stood up and grabbed Resident #9's arm. Resident #9 said he/she turned towards Resident #8, they fell on to Resident #8's bed, and wrestled around on it. Resident #9 said he/she hit Resident #8 in the face repeatedly, until Resident #8 stopped fighting back. During an interview on [DATE] at 12:39 P.M., Charge Nurse A said his/her shift started at 7:00 P.M. on [DATE]. He/she was assigned to the first floor. However, the charge nurse assigned to the second floor was out sick. Charge Nurse A had to work both floors with a certified medication technician (CMT). One certified nurse aide (CNA) normally worked the second floor, unit A. The night shift was quiet on [DATE]. Charge Nurse A conducted three to four rounds on the second floor. He/she and the CMT relieved the secured unit staff for breaks. At 5:00 A.M., Charge Nurse A went up to relieve one of them and then returned to the first floor at 5:15 A.M. At 6:00 A.M., Charge Nurse A walked past the room of Resident #8 and Resident #9. Resident #8 was sitting up on the end of his/her bed. Charge Nurse A said, hey. Resident #8 turned towards him/her and said, hey then responded affirmatively when Charge Nurse A noted aloud that Resident #8 was up. Charge Nurse A went down to the first floor. At 7:00 A.M., Charge Nurse A heard a STAT announcement and rushed back upstairs. He/she noticed a chair was flipped over, but did not really think about it at the time. Resident #8 was lying across the bed, up against the headboard, bleeding from the nose and mouth. There was blood on the bed sheets, as though Resident #8 had fallen backwards. His/her right eye was swollen shut. Staff checked and found out Resident #8's status was full code, so they began CPR and called 911. Additional blood squirted out of Resident #8 during CPR. Paramedics arrived ten minutes later, took over CPR, and called Resident #8's time of death. Charge Nurse A and Charge Nurse E went back down to the nurses' station. Someone told them Resident #9 was in the dining room with bloody hands. Resident #8 and Resident #9 normally got along with one another. However, some said Resident #9 had a mean streak. Charge Nurse A never saw it, because he/she normally worked on the first floor. During an interview on [DATE] at 7:02 P.M., CMT B said he/she knew both residents. Resident #8 was compliant. Resident #9 was aggressive, closed-in, shut-off and antisocial. However, they seemed to get along with one another. At 6:30 A.M. on [DATE], CMT B entered their room, in order to administer medications to Resident #9. He/she sat up and and took them. CMT B said good morning to Resident #8, who got out of bed, went to the bathroom, came out, and sat on his/her bed. CMT B went directly across the hall to administer medications in another resident's room. CMT B did not hear anything that occurred in the room of Resident #8 and Resident #9, because other residents had turned on their televisions and radios. When staff discovered Resident #8's body, CMT B made the STAT announcement. Resident #9 calmly walked out of the room, past staff running to the room in response to the STAT announcement. Resident #8 was lying supine up against the headboard. Blood had dripped from his/her nose and the side of his/her mouth. There was a baseball-sized bloodstain on the bed and a spray/mist of blood on the wall beside the bed. CMT B did not see any blood on the headboard. When staff placed a backboard underneath Resident #8 and began performing CPR, CMT B went downstairs in order to escort the paramedics up to Resident #8's room. During an interview on [DATE] at 3:12 P.M., CNA C said on [DATE], he/she worked the 11:00 P.M. to 7:00 A.M. shift on the second floor and conducted rounds every two hours. It was quiet all night. The last round CNA C conducted, prior to leaving at 5:30 A.M., was at 4:00 A.M., Resident #8 was sitting at the foot of his/her bed with his/her back to the door. CNA C did not go all the way into the room, but could see that he/she was fine. The lights were off, but the television was on. Resident #8 did not say anything. CNA C returned to the facility around 6:40 A.M. and went up to the floor, past their room without looking in, to get another resident up. After staff discovered Resident #8 was unresponsive, CNA C entered the room and saw him/her on the bed with his/her back up against the headboard. His/her legs were hanging over the side of the bed. The resident's entire face was covered with blood. On the bed was a baseball-sized amount of blood. They called STAT and nursing staff responded. Resident #8 and Resident #9 were both normally quiet and got along with one another. CNA C believed the altercation was over a discrepancy regarding their clothing. Their closets were side-by-side. Being the only CNA on the second floor was sometimes overwhelming, because it got busy attempting to get everyone up for dinner, downstairs to the dining room and then back up to their rooms afterwards. Then at 5:00 A.M., staff had to get them up for breakfast. During an interview on [DATE] at 12:41 P.M., CNA D said he/she worked at the facility for four years and knew Resident #8 well. Resident #8 was pretty quiet and kept to him/herself. However he/she got into moods in which he/she became agitated, aggressive and would walk up on others, call them names, and threaten them. Resident #9 mostly stayed to him/herself and only came out of his/her room to smoke cigarettes and eat. They got along with one another. CNA D was not aware of any previous altercations between them. On [DATE], CNA D arrived at the facility at around 6:45 A.M. It was quiet and there was no nurse or CNA up on the second floor. He/she clocked in at 6:53 A.M. He/she was assigned to the second floor. CNA D went up and arrived at the door of the room occupied by Resident #8 and Resident #9 around 7:00 A.M. CNA D told them to get up and go to breakfast. Resident #9 got up, but Resident #8 did not move. CNA D turned on the light and walked over to the bed. Resident #8 was lying in bed with his/her back up against the headboard, with his/her face covered in blood. One eye was open. There was blood on the bed underneath Resident #8, from his/her shoulders down to the middle of his/her back. He/she was not breathing or moving. CNA D screamed and CNA C came to the room. During an interview on [DATE] at 1:06 P.M., Charge Nurse E said on [DATE], he/she arrived at the facility at 6:55 A.M. A STAT announcement went out at 7:00 A.M. Charge Nurse E and Charge Nurse A rushed up to the room of Resident #8 and Resident #9. No other licensed staff was in the room when they arrived. Resident #8 was on the bed with his/her back against the headboard and his/her legs hanging over the left side of the bed. While waiting for staff to check his/her code status, Charge Nurse E and Charge Nurse A positioned Resident #8 supine on the bed. Once they found out he/she was full code, they put a backboard underneath him/her and performed CPR. Blood had run out of his/her nose and was smeared on his/her cheeks. The blood was still dripping. Resident #8's right eye was swollen shut and his/her left eye was partially open, with a fixed pupil. There was a bloodstain on the bed, which was the size of a baseball. Spatters of blood were on the right side of the headboard. Resident #8's body did not respond to the CPR. Staff had called 911. They performed CPR until the paramedics arrived and took over. Resident #9 later told Charge Nurse E that Resident #9 was standing at his/her closet trying to get clothes out, when Resident #8 grabbed his/her arm. They wrestled, falling onto the bed and Resident #9 began punching Resident #8 in the face. Resident #9 had a couple of scratches on the right side of his/her face. That was all Charge Nurse E saw on him/her. The altercation had begun over belongings. Residents did not have much and were very protective of what they did have. During an interview on [DATE] at 10:24 A.M., the Forensic Investigator with the medical examiner's office said when she entered Resident #8's room, he/she was lying flat in bed. A lot of blood had run down from his/her nose over the bottom half of his/her face, some was smeared on the bridge of the nose as well. The resident had hemorrhaging in both eyes, which was indicative of head trauma. There were bloodstains on the bed, towards his/her right shoulder, on the wall and floor. The blood on the wall and headboard appeared to be cast off bloodstains (a pattern/trail created when blood is flung or projected from a blood-bearing object in motion). The police seized the sheets and headboard as evidence. The resident's injuries appeared to be consistent with the timeframe reported by staff last seeing him/her alive at 6:30 A.M. and finding him/her unresponsive at 6:55 A.M. During an interview on [DATE] at 11:02 A.M., Resident #10 said Resident #9 had a tendency to threaten other residents. He/she would run right over people with his/her walker, if they did not get out of the way. He/she would ignore staff redirection and keep going. Resident #8 was very soft-spoken and a sweet person. During the night shift, residents on the second floor hardly ever saw a CNA, until the next morning. During the night prior to the altercation on [DATE], the second floor was quiet. Resident #10 heard Resident #9's walker making noise as he/she walked past Resident #10's door, on the way to take the elevator down to the first floor for a smoke break at 12:00 A.M. Resident #10 did not hear anything else and did not see any staff making rounds. There was no charge nurse up on the floor that night. Staff were unaware of the altercation between Resident #8 and Resident #9, because they never checked on Resident #8, in order to see why he/she was not at his/her usual spot in the doorway the next morning. During breakfast, staff noticed Resident #9 had blood on him/her. He/she told them that he/she fought with Resident #8. Staff went to check on Resident #8 and discovered his/her body. During interviews on [DATE] at 12:12 P.M., [DATE] at 1:32 P.M., [DATE] at 11:50 A.M. and [DATE] at 8:53 A.M., the Administrator said on [DATE], the charge nurse and one of the CNAs scheduled to work on the second floor unit A during the night shift did not report to work. When there was only one CNA on the second floor unit A, the CMT and charge nurse were to provide assistance as second spotters for Hoyer lift transfers. When Resident #9 started having hallucinations last October, staff thought it was an isolated occurrence. A physician from Resident #9's attending physician's medical group discontinued his/her [MEDICATION NAME]. Generally, [MEDICAL CONDITION] medications were handled by a resident's psychiatrist. Nursing was expected to communicate changes to and/or discontinuation of [MEDICAL CONDITION] medications to the resident's psychiatrist. Prior to the altercation on [DATE], social services was responsible for tracking psychiatrists' visit dat

Based on observation, interview and record review, the facility failed to follow physician's orders, adequately monitor, and assess the condition of 3 of 8 sampled residents (Resident #54, #5, and #57). Two of the three residents required continuous oxygen which was not provided. One of those residents experienced [MEDICAL CONDITION], and one resident exhibited a low oxygen saturation level. The third resident experienced changes in condition which were not reported to the physician. The census was 103. 1. Review of Resident #54's hospital record, dated [DATE], showed he/she was admitted to the hospital from another long term care facility with a [DIAGNOSES REDACTED]. Review of the resident's face sheet, not dated, showed the resident had a legal guardian and no advance directive listed. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admitted [DATE]; -Alert and oriented; -Physical and verbal behavioral symptoms; -[DIAGNOSES REDACTED]. -Required extensive assistance of staff for transfers, locomotion off the unit, eating and personal hygiene; -Required limited assistance of staff for bed mobility, locomotion on the unit, dressing, and toilet use; -Always continent of bowel and bladder; -Shortness of breath or trouble breathing with exertion (walking, bathing and transferring), with sitting at rest and when lying flat; -No swallowing disorder and a therapeutic diet; -Oxygen therapy. Review of the resident's physician's order sheet (POS), dated ,[DATE] through [DATE], showed an additional [DIAGNOSES REDACTED]. On [DATE], his/her diet was changed from a regular diet to mechanical soft. Review of the resident's medical record, dated [DATE] though [DATE], showed no documented oxygen saturation levels. Review of the resident's treatment administration record (TAR), dated ,[DATE] through [DATE], showed staff documented they provided oxygen, except for the following shifts: -[DATE], ,[DATE] and ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]. The [MEDICAL CONDITION] machine was documented as provided on [DATE], which the resident refused, and also on [DATE]. Oxygen tubing was unable to be changed on ,[DATE] and ,[DATE], due to no oxygen tubing available. Oxygen tubing was changed on ,[DATE] and ,[DATE]. Review of the resident's nurse's notes, dated ,[DATE] through [DATE], showed staff did not document the resident's physician was notified of his/her refusal of the [MEDICAL CONDITION] machine on [DATE], or any other date during the month of [DATE]. Staff documented the resident had behaviors, hallucinated and was agitated on [DATE] at 5:30 A.M. On [DATE] at 10:30 A.M., the resident was seen by his/her primary care nurse practitioner (NP) with no new orders received. Staff documented the resident had further behaviors, hallucinated and was agitated on [DATE] at 12:15 P.M., [DATE] at 9:00 P.M., and [DATE] at 1:30 A.M. On [DATE] at 6:30 P.M., he/she was found sitting on the floor in his/her room. Staff assessed the resident, found no injury, performed neurochecks, and notified his/her physician and responsible party. Review of the resident's social service progress notes, showed: -[DATE], the resident was admitted to the facility on [DATE], was a full code, alert and oriented with periods of delusions, and had no discharge plans; -[DATE], his/her code status was mailed to the resident's guardian for an update; -No further social service notes to show the facility staff reviewed the resident's code status directives with the resident's guardian. During an interview on [DATE] at 3:35 P.M., the social worker said she had not received anything back from the resident's family regarding his/her code status and had not spoken to the resident's family. The resident remained a full code. The advance directive sheet was mailed to the family on [DATE]. Review of the resident's care plan, dated [DATE], showed the following: -Problem: Potential for difficulty breathing related to chronic condition: [MEDICAL CONDITION]; -Goal: Resident will be maintained at their respiratory baseline with a patent airway and unlabored respirations through next review date: [DATE]; -Approaches: -Monitor for changes in/development of signs and symptoms of breathing difficulty and report to nurse if noted: shortness of breath, cough (productive or nonproductive), fever, chills, difficulty speaking, bluish skin color, changes in cognition; -Report changes in respiratory status to physician; -Administer/monitor effectiveness of treatments (see current physician's orders): oxygen continuously; -Monitor lab/diagnostics as ordered and report results to physician; -Remind resident to breathe slowly and deeply when short of breath; -Administer/monitor effectiveness of drugs affecting respiratory status (see current physician's orders and Medication Administration Record [REDACTED] -Provide resident/responsible party education to include: coughing/deep breathing, pursed-lip breathing, and need for rest. Review of the resident's POS, dated ,[DATE] through [DATE], showed no change in orders. Review of the resident's TAR, dated ,[DATE] through [DATE], provided by the facility on [DATE], showed staff documented they provided the oxygen, except for [DATE] from ,[DATE], and [DATE] from ,[DATE]. The [MEDICAL CONDITION] machine was not documented as being used. Review of the resident's MAR, dated ,[DATE] through [DATE], showed [MEDICATION NAME] 0.25 mg, one tablet by mouth twice daily, documented as not administered from ,[DATE] through [DATE], due to medication not available. Review of the resident's nurse's notes, dated [DATE] through [DATE], showed no entries documented. Review of the resident's nurse's notes, dated [DATE], showed the following: -12:45 P.M., the resident was sitting in dining room eating lunch and became unresponsive, Nurse I observed mechanical soft food drooling out of right side of the resident's mouth, removed remaining food from side to mouth and at the same time transferred the resident in the wheelchair with the assist of two more staff members to the closest room, slid the resident out of wheelchair to floor and applied a sternal rub. The resident made a sound and went unresponsive. Nurse I called out for stat and cardiopulmonary resuscitation (CPR) began. The resident had a low oxygen saturation level at 79% (normal range, ,[DATE]%). Nurse I was unable to get the resident's blood pressure, CPR continued and 911 was called; -1:00 P.M., CPR was still in process, his/her heart rate was 51 (normal resting heart rate, 60 to 100 beats per minute). Emergency medical services (EMS) arrived; -1:03 P.M., paramedics took over with CPR, the resident was not responsive; -1:15 P.M., paramedics continued CPR as they transferred the resident to the hospital; -2:35 P.M., Nurse I called the resident's physician. During an interview on [DATE] at 2:45 P.M., Nurse I said he/she did not know why the resident did not have oxygen on in the dining room on [DATE] at 12:45 P.M. Nurse I walked into the main dining room as the resident was rolled out in his/her wheelchair by staff. The resident did not have oxygen on. The resident had a history of [REDACTED]. Staff performed CPR when the resident was unconscious. Whatever Nurse I charted was what happened, everything moved so fast. He/she could not recall any additional information. During an interview on [DATE] at 2:55 P.M., certified nurse aide (CNA) AA said he/she was at the opposite end of the assisted dining table during lunch on [DATE], when the resident made a noise. CNA AA got up and assisted CNA BB and CNA CC. The CNAs wheeled the resident out of the dining room toward Nurse I, who directed staff to a room three doors down the hall where CPR was done. CNA AA obtained the resident's chart for the nursing staff during the incident and then continued care for other residents on his/her assignment. During an interview on [DATE] at 3:00 P.M., CNA BB said he/she was to the left of the resident at the assisted dining table during lunch on [DATE] at 12:45 P.M. The resident was talking during the meal and said, I don't know why people keep feeding me food. The resident took two more bites, threw his/her head back and gurgled in a low tone. CNA BB, CNA CC, and the speech therapist assumed the resident was choking. CNA BB ran to get Nurse I. Nurse I responded and asked CNA BB to get oxygen. A stat was called. CNA BB looked for oxygen. CNA BB could not recall if the resident had oxygen on in the main dining room prior to the incident. CNA BB borrowed oxygen from another resident and brought it to Nurse I. During an interview on [DATE] at 10:24 A.M., CNA CC said he/she was regularly assigned to care for the resident since his/her admission. The resident frequently cursed and had behaviors. He/She would hallucinate and talk out loud to people not present. At times, the resident made guttural sounds. CNA CC never saw a care card for the resident, or any resident on his/her assignment. He/she received report, provided care according to that report, assisted with ADLs, fed and walked residents and reported resident meal consumption and bowel movements. The resident had an oxygen concentrator in his/her room. CNA CC had no idea the resident needed oxygen on when he/she left the room. CNA CC thought oxygen was just in use in the resident's room. Nurse I saw CNA CC with the resident out of the room often, spoke with the resident and never told CNA CC to put oxygen on the resident. CNA CC encouraged the resident to go to the main dining room for meals. The resident frequently agreed to go to the main dining room with CNA CC. When the resident was in his/her room, he/she did not have oxygen on at all times. CNA CC did not know if the resident took his/her oxygen off on his/her own. However, the resident would ask CNA CC for his/her oxygen when he/she sat in his/her room. CNA CC would turn on the oxygen concentrator and hand the resident his/her oxygen tubing with nasal cannula attached when in the room. CNA CC did not know what level it was set at. He/she just turned it on. CNA CC had no idea it was continuous oxygen. The charge nurse never told CNA CC it was continuous oxygen. The resident had no respiratory distress and was not short of breath during his/her assigned shifts. On [DATE] at 12:05 P.M., CNA CC propelled the resident to the main dining room and passed the nurse's station where Nurse I spoke with the resident. Nurse I did not tell CNA CC to put oxygen on the resident. CNA CC sat on the resident's right side at the assisted dining table during lunch. The resident spoke during lunch, questioned why he/she needed to eat and then threw his/her head back and made a guttural noise. This caught the attention of staff at the table, who quickly responded as food went down the side of the resident's mouth. Staff went to get Nurse I. CNA CC asked the resident if he/she was choking, the resident moved his/her head and continued with the noise. The resident's tongue became purple. CNA CC and CNA AA pushed the resident's chair out of the dining room and met Nurse I in the hall. Nurse I directed the CNAs to a resident room three doors down the hall and began CPR. Multiple nursing staff responded when a stat was called. CNA CC did not know where the oxygen came from that was administered to the resident during CPR. EMS responded and continued CPR during the resident's transfer to the hospital. CNA CC later learned the resident had expired at the hospital. During an interview on [DATE] at 2:00 P.M., the facility speech therapist (ST) said he/she was sitting at the assisted dining table directly across from the resident during lunch on [DATE]. The ST asked the resident if he/she was enjoying his/her meal and the resident responded yes. The ST had recommended a dietary change from regular to mechanical soft the previous week due to tardive dyskinesia (delayed abnormal movement) of the tongue noted during an ST evaluation. The resident had mild to moderate dysphasia (difficulty swallowing) and his/her diet was downgraded for safety. The ST noted the resident's tolerance for the new diet while he/she evaluated another resident at the table. The resident had a behavior where he/she threw his/her head back. The resident appeared normal, rolled his/her head back, babbled, and went into respiratory distress. The CNAs appeared to lift the resident up as if to give him/her the [MEDICATION NAME] maneuver, the ST immediately ran to get Nurse I, and then CNA BB, CNA CC, and CNA AA quickly exited the main dining room with the resident in his/her wheelchair. The resident had labored breathing as he/she exited the main dining room. The resident went quickly from exhibiting a behavior to respiratory distress. The resident did not have oxygen on at the time. During interviews on [DATE] at 7:40 A.M. and 4:10 P.M., the Assistant Director of Nursing (ADON) said staff responded and all nurses in the building assisted when the resident became unresponsive. Staff did exactly what the ADON expected them to do. Oxygen on the crash cart was connected to an Ambu-bag (a hand-held device used to provide positive pressure ventilation to patients who are not breathing) and was used during CPR for the resident. The ADON ordered the oxygen for the facility and maintained documentation of oxygen supply orders. The facility had recently changed oxygen providers and was awaiting the former provider's pick up of more than 40 tanks utilized by the facility. The oxygen tanks were stored in the storage rooms on both floors of the facility, along with the current supply from the new provider. Only one resident in the facility utilized oxygen tanks. All others had oxygen concentrators. Four current residents in the facility had orders for continuous oxygen. One oxygen tank, each, was on the crash carts on the two floors of the facility. The ADON ordered 40 tanks every two weeks, when the supply was down to five tanks in reserve. The facility was not out of oxygen supply since the ADON was hired on [DATE]. During an interview on [DATE] at 8:15 A.M., the central supply staff said he/she checked the facility oxygen tank supply and crash carts once weekly, documented it and informed the ADON of the status. Residents with continuous oxygen orders also took oxygen cylinders with them to offsite medical appointments as needed. During an interview on [DATE] at 11:30 A.M., the operations manager said the facility did not use a care card system for CNAs. The CNAs were to reference the care plan book kept at the nurse's station. During an interview on [DATE] at 9:33 A.M., the Director of Nursing (DON) said the facility staff followed physician's orders and used nursing judgment. There was no measurement of oxygen saturation through pulse oximetry, unless the resident's physician ordered it measured. If a resident had a change in respiratory status or was ill, staff performed a spot check pulse oximetry. If there was no change in status, no distress and no order for pulse oximetry, staff would not measure a resident's oxygen saturation level through pulse oximetry. Although the resident had an order for [REDACTED]. During an interview on [DATE] at 1:30 P.M., the resident's primary care physician said he expected nursing staff to keep a resident who had an order for [REDACTED]. He expected staff to assess a resident in respiratory distress and if breaths and pulse cease, staff was to perform CPR then and there. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Moderate cognitive impairment, rarely or never understood; -[DIAGNOSES REDACTED]. -Total dependence on staff for activities of daily living (ADLs); -Oxygen therapy. Review of the resident's POS, dated [DATE] through [DATE], showed the following: -Additional [DIAGNOSES REDACTED]. -Do not resuscitate status; -Oxygen at ,[DATE] liters per minute via nasal cannula continuously, originally dated [DATE]; -Check and record oxygen saturation level every shift and keep saturation above 90%; -Change oxygen tubing weekly on Tuesdays on the ,[DATE] shift. The facility did not provide the resident's TAR or the nurse's administration flow sheet, dated ,[DATE] through [DATE]. Review of the resident's nurse's notes, dated ,[DATE] through [DATE], showed the following: -[DATE] at 3:10 P.M., alert and confused. Started Z-pack (antibiotic medication) this morning. Oxygen saturation 98%; -[DATE] at 9:00 A.M., spoke with the resident's primary care physician, who instructed staff to administer the resident's [MEDICATION NAME] (inhaler that relaxes muscles in the airways and increases air flow to the lungs) treatment, not given since [DATE], due to the MAR indicated [REDACTED] -[DATE] on the ,[DATE] shift, oxygen saturation 96% on 2 L of oxygen via nasal cannula; -[DATE] on the ,[DATE] shift, oxygen saturation 98% on 2 L of oxygen via nasal cannula; -No documentation from ,[DATE]-,[DATE]. Review of the resident's TAR, dated ,[DATE] through [DATE], showed staff documented they provided the oxygen at ,[DATE] L per minute, except for the following shifts: -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]. Oxygen tubing was documented as changed on ,[DATE] and ,[DATE]. Review of the resident's nurse's administration flow sheet, dated ,[DATE] through [DATE], showed staff documented the resident's oxygen saturation levels at 90% and above, except for the following shifts: -,[DATE] through [DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]. Staff documented 78%; -,[DATE] through [DATE], ,[DATE]; -,[DATE] through [DATE], ,[DATE]; -,[DATE]-,[DATE], ,[DATE]. Staff also documented they provided oxygen at ,[DATE] L per minute, except for the following shifts: -,[DATE] through [DATE], ,[DATE]; -[DATE], ,[DATE]; -,[DATE] through [DATE], ,[DATE]; -,[DATE] through [DATE], ,[DATE]; -,[DATE] through [DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE] and ,[DATE]; -[DATE], ,[DATE]. Review of the resident's nurse's notes, dated ,[DATE] through [DATE], showed the resident was seen by his/her primary care physician on ,[DATE] and ,[DATE], with no new orders given. Review of the resident's POS, dated ,[DATE] through [DATE] at 1:29 P.M., showed no change in orders. Review of the resident's nurse's notes, dated [DATE], no time noted, showed a call was placed to the resident's RP to confirm a care plan meeting on [DATE]. The RP was unable to attend and was given an update on the resident's status. There was no mention of any change in respiratory status. Review of the resident's care plan, updated [DATE], showed the following: -Problem: Resident has potential for difficulty breathing related to chronic condition: [MEDICAL CONDITION] and other; -Goal: Resident will be maintained at his/her respiratory baseline with a patent (open and clear) airway and unlabored respirations through next review date: [DATE]; -Approach: -Monitor for changes in/development of signs & symptoms of breathing difficulty and report to nurse if noted: SOB, cough (productive or nonproductive), fever, chills, difficulty speaking, bluish skin color, changes in cognition; -Report changes in respiratory status to physician; -Administer/monitor effectiveness of treatments (see current physician's orders): oxygen, nebulizer treatments, elevate the head of the bed at least 45 degrees, encourage cough and deep breathing; -Turn and reposition to optimize breathing; -Monitor lab/diagnostics as ordered and report results to physician; -Remind resident to breathe slowly and deeply when short of breath; -Administer/monitor effectiveness of drugs affecting respiratory status (see current physician's orders and MAR); -Provide resident/responsible party education to include: coughing/deep breathing, fluid needs, pursed-lip breathing, need for rest and compensatory strategies; -Change all oxygen/respiratory tubing/supplies weekly; -Ensure that respiratory tubings/devices are properly stored when not in use to prevent cross-contamination; -Check and record oxygen saturation each shift and keep sats above 90%; -Oxygen at ,[DATE] L, per nasal cannula, continuously. Review of the resident's TAR, dated ,[DATE] through [DATE], provided by the facility on [DATE], showed staff documented they provided the oxygen at ,[DATE] L per minute, except for the following shifts: -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]; -[DATE], ,[DATE]. Staff also documented oxygen at 2 L per minute continuously administered on the ,[DATE] shift on ,[DATE] through [DATE], and ,[DATE] through [DATE]. Review of the resident's nurse's administration flow sheet, dated ,[DATE] through [DATE], showed staff documented the resident's oxygen saturation levels at 90% and above each shift. Review of the resident's nurse's notes, dated ,[DATE] through [DATE], showed no documentation. Observation and interviews on [DATE], showed the following: -At 9:00 A.M. and 12:10 P.M., an oxygen concentrator was on in the resident's room and an oxygen tank sat on the floor in the corner and was not secured or tethered. The resident was not in the room; -At 12:20 P.M., the resident was in the main dining room, up in his/her broda chair (tilt and reclining chair), and awaited lunch. An empty oxygen cylinder bag was attached to the back of the chair. The resident had no oxygen in use and was alert with confusion. The resident said he/she was not feeling well today. No respiratory distress was noted. He/She sat on the side of the table two feet opposite an electrical plug; -At 12:30 P.M., CNA EE brought the resident's oxygen concentrator to the main dining room. Nurse I directed the residents be rearranged and Resident #5 was moved next to the electrical outlet. Nurse I measured the resident's oxygen saturation level at 84%. Nurse I said he/she was not assigned to care for the resident on that shift. He/She turned the resident's oxygen concentrator on and placed the nasal cannula on the resident. Nurse I said the resident's oxygen was set at 2 L per minute. He/She knew the proper flow rate because the resident was usually in the main dining room with an oxygen tank set at 2 L per minute. Review of the resident's POS, dated [DATE] at 1:30 P.M., showed an order to discontinue oxygen at ,[DATE] L. Administer oxygen at 2 L per nasal cannula continuously. Review of the resident's nurse's notes, dated [DATE], no time noted, showed resident's oxygen order changed to 2 L per nasal cannula. During an interview on [DATE] at 2:05 P.M., Nurse DD said the resident was on continuous oxygen. CNA EE was the resident's assigned CNA that shift. The resident had a sleeve which held oxygen on the back of his/her broda chair and should have gone to the main dining room for lunch with an oxygen tank in that sleeve and continuously as ordered. During an interview on [DATE] at 2:26 P.M., CNA EE said he/she was assigned to care for the resident on [DATE]. He/She arrived for work at 8:30 A.M., and saw the resident sat at the nurse's station with the oxygen concentrator in use. The resident used the oxygen concentrator all day on [DATE], and did not use an oxygen tank. Usually, CNA EE obtained an oxygen tank from the charge nurse during report and placed it in the resident's room, on the back of the resident's broda chair in the mounted oxygen sleeve. The charge nurse checked the tank to see it was full before he/she gave it to CNA EE. When the resident was out of his/her room, he/she would use an oxygen tank. The resident did not use an oxygen tank on [DATE]. CNA EE did not take the resident to breakfast or lunch on [DATE]. When CNA EE returned from his/her lunch break, someone else had brought the resident to the main dining room, without his/her oxygen. A nurse asked CNA EE to get the resident's oxygen and he/she brought an oxygen concentrator to the main dining room for the resident. Nurse I placed the resident's oxygen on after his/her oxygen saturation reading was completed. CNA EE had no idea why the resident's oxygen concentrator was observed in his/her room running unattended at 9:00 A.M. and 12:10 P.M. on [DATE]. The resident did not get a shower that morning. Review of the facility's policy on oxygen administration, undated and not signed, showed the following: -Purpose: to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; -Equipment: oxygen cylinder on stand, wall oxygen outlet or concentrator; -Procedure: -Check physician's order for liter flow and method of administration; -A reserve oxygen tank should be available to provide continuity of care; -When using oxygen cylinders, secure oxygen cylinder at bedside by using heavy metal floor flange and placing tank in center of flange. Secure by tightening bolts around base of the cylinder, or place cylinder carrier vertically, being sure cylinder is strapped or chained to carrier and wheels on carrier are folded flat against cylinder; -At regular intervals, check and clean oxygen equipment, masks, tubing and cannulas; -At regular intervals, check liter flow contents of oxygen cylinder and assess resident's respiration to determine the need for further oxygen therapy. 3. Review of Resident #57's physician's orders, dated ,[DATE] through [DATE], showed the following: -admission date of [DATE]; -Full code; -[DIAGNOSES REDACTED]. Review of the resident's social service notes, dated [DATE], showed he/she refused to go to [MEDICAL TREATMENT], stating the chairs were too uncomfortable and he/she was in quite a bit of pain. Social services will speak with resident and family regarding the option of hospice and resident being a DNR (do not resuscitate). Review of the resident's MDS admission assessment, dated [DATE], showed the following: -Brief Interview Mental Status (BIMS) score of ,[DATE], (moderate impairment); -Totally dependent on staff for all ADLs. Review of the resident's care plan, dated [DATE], showed the resident had behavior problems which included verbal abuse. Approaches included report changes in behavioral status to physician. Review of the physician's orders, dated [DATE], showed admit to hospice: [DIAGNOSES REDACTED]. Review of the resident's care plan, updated [DATE], showed the resident required hospice services. The facility would continue to provide services as given to the resident prior to election of hospice care or palliative care services. Resident or representative, continued to have the right to refuse services offered. If the resident refused or rejected interventions to manage symptoms or other aspects of the plan of care, the charge nurse would notify the hospice provider, the DON, the resident's physician, and RP. The resident/RP would be provided alternatives to assist in addressing the needs of the resident. During an interview on [DATE] at 5:00 P.M., CMT FF said on [DATE] he/she started working the shift at 3:00 P.M. He/she gave the resident medication and he/she threw it back up. The resident's family member said the resident hadn't been keeping anything down and wasn't feeling good. CMT FF reported to Nurse GG, but wasn't aware of what was done for the resident. The resident was alert and talking. Review of the resident's nurse's notes, showed no documentation regarding vomiting or refusal to attend [MEDICAL TREATMENT] treatment. On [DATE] at 2:00 A.M., the resident's oxygen saturation level was 90% on room air, he/she was lethargic, and slowly responded when his/her name was called. The resident was able to siphon water from a straw. Continue to monitor for change. On [DATE] at 12:00 P.M., the resident's family member was notified the resident's follow-up general surgery appointment would be canceled due to the resident's hospice status. Review of the resident's nurse's notes, dated [DATE], showed the following: -9:25 P.M., No pulse, no respirations. Call placed to hospice and told of death. Physician called and informed of death. Cause of death complications of [MEDICAL CONDITION] of liver. Call placed to ADON and Administrator. Messages left and awaiting return calls to the facility. Call placed to resident's family member and informed of death; -9:25 P.M., Resident checked on at 9:00 P.M. Remained lethargic and breathing. Checked again at 9:25 P.M., no pulse, no respirations, and body cold to touch. Arms in full rigor. Hospice nurse here. Spoke with family members; -(no time), Coroner call by hospice nurse. Hospice stated resident had been deceased over 30 minutes, and body in rigor and cold. Cardiopulmonary resuscitation (CPR) not needed. During an interview on [DATE] at 3:50 P.M., CMT HH said he/she found the resident expired during the evening shift on [DATE]. The resident's chest was not moving and his/her body felt cold. CMT HH notified Nurse GG. The resident had been lethargic earlier. During an interview on [DATE] at 11:17 A.M., Nurse GG said she didn't remember the resident vomiting. If the resident vomited, staff didn't report it to him/her. The resident was very ill, in bad shape, and was receiving hospice services. The resident had no change in condition, but was very sick. The resident was still talking and communicating on [DATE]. The resident was lethargic the day he/she passed away, on [DATE]. Nurse GG thought the resident didn't talk at all on [DATE], and his/her eyes were not open. Nurse GG didn't notify hospice. The resident never had respiratory distress. After the resident died , Nurse GG found out the resident was a full code. If a full code resident had respiratory distress, Nurse GG would have applied oxygen. During an interview on [DATE] at 11:50 A.M., the resident's physician said he was not told the resident had refused [MEDICAL TREATMENT] on three occasions until after the resident passed away. The physician was not called and informed of the resident's refusals when they occurred, and staff pr

This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies cited on 6/2/15. Based on observation, interview and record review the facility failed to provide services and interventions for residents with injuries for two of 22 residents who had a fractured femur and bruises (Residents #58 and #2). The census 111. 1. Review of Resident #58's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/1/15, showed the following: -Rarely/never understood -No speech - absence of spoken words; -Sometimes understands; -Cognitive skills for daily decision making: Severely impaired - never/rarely made decisions; -Inattention: Behavior present, fluctuates (comes and goes, changes in severity); -Disorganized thinking: Behavior continuously present, does not fluctuate; -Rejection of care: Behavior not exhibited; -Extensive assistance of one person required for bed mobility and personal hygiene; -Total dependence of one person required for transfers, locomotion on/off the unit, dressing and toilet use; -Walking in room/corridor did not occur; -No limitations of the upper or lower extremities; -Mobility device: Wheelchair; -Always incontinent of bladder and bowel; -[DIAGNOSES REDACTED]. -No indications of pain observed or documented; -No falls since admission or prior assessment; -No skin issues. Review of the facility Fall Log (where facility staff document incidents and accidents), showed the resident had no falls/bruises or injuries from 7/31/15 through 8/20/15. Review of the resident's physician's orders [REDACTED]. -Aspirin 81 milligrams (mg) daily for preventative (normally administered routinely to prevent heart disease); -Ibuprofen (an anti-inflammatory and pain medication) 400 mg, one tablet three times a day; -Acetaminophen (Tylenol) 500 mg, one tablet every four hours as needed; -Up in wheelchair with the assistance of one staff; -Weight bearing as tolerated. During an interview on 8/20/15 at 3:50 P.M., the Director of Nurses (DON) and the Regional Operational Manager (ROM) said they found out today (8/20/15) the resident had a right femur fracture. Neither the DON or ROM knew how the fracture occurred. The nursing staff noted the resident had a bruise on his/her right leg on 8/17/15 or 8/18/15, but failed to document it, begin an investigation or notify them. The doctor was notified on 8/19/15, the leg was bruised and had swelling and a doppler (ultrasound) was done on the leg to determine if the resident had a blood clot. The doppler was done on 8/19/15 and the resident did not have a blood clot. Staff got an order for [REDACTED]. They did not know much more than that, because no one completed an incident report or initiated an investigation when the bruise was first noted. Staff are suppose to complete an incident report for any resident injury and send a copy to her, the DON said. That did not happen and she did not know why. Had she received an incident report, she would have initiated an investigation immediately. She was not even aware of any of this until today (8/20/15). She thinks the resident transfers with a hoyer lift (mechanical device used to transfer residents unable to bear weight), but she is not sure. Review of the resident's nurse's notes, showed no documentation on 8/18/15. Review of the resident's nurse's notes, dated 8/19/15 at 9:45 A.M., showed staff notified the resident's physician regarding the resident having facial grimaces of pain when right leg was touched. Right leg also swollen and warm. New order to obtain a doppler of the right leg. Review of the resident's nurse's notes, dated 8/19/15 at 4:00 P.M., showed the resident's physician was in the facility and staff informed him the doppler was negative for a blood clot. The physician ordered lab work and an x-ray of both of the resident's hips. Review of the resident's nurse's notes, dated 8/19/15 at 4:20 P.M., showed staff notified the x-ray company regarding the physician's orders [REDACTED]. X-ray company would be out in the morning. Review of the resident's nurse's notes, dated 8/19/15 at 9:45 P.M., showed the resident remained in bed at that time. Right thigh swollen and painful to touch. Medicated for pain as ordered. Review of the resident's POS and nurse's notes, showed no new orders for pain medication. Review of the resident's nurse's notes, dated 8/20/15 at 10:15 A.M., showed the x-ray company obtained the x-rays of the resident's thighs. At 11:15 A.M., the x-ray company contacted the facility. The resident had a right femur fracture. At 11:50 A.M., the resident's physician gave orders for the resident to be sent to the hospital. At 12:30 P.M., the resident was transferred to the hospital via an ambulance. During a telephone interview on 8/21/15 at 2:00 P.M., the Administrator said their investigation had revealed a Certified Nursing Assistant (CNA) who worked 11:00 P.M. to 7:00 A.M. on the night of 8/17/15 (Monday), was the first person to notice the bruising on the resident's right leg. The CNA told the night nurse about the bruising on that shift. The night nurse wrote the CNA's concerns down on a note, but took those notes home. The night nurse did not document anything about the leg in the resident's medical record, complete an incident report, begin an investigation or notify anyone, including the oncoming shift, about the resident's leg. During a telephone interview on 8/21/15 at 2:30 P.M., the DON reviewed the resident's nurse's notes with the surveyor and said the nurse who phoned the x-ray company should have made them aware the x-ray needed to be done stat (immediately) because the resident was in pain and his/her leg was swollen. If the x-ray company could not complete the x-ray stat, the nurse should have contacted the resident's physician to send the resident to the hospital and have the x-ray completed. 2. Review of Resident #2's quarterly MDS, dated [DATE], (most recent MDS available), showed the following: -[DIAGNOSES REDACTED]. -Short/Long term memory loss; -Cognitive impairment; -Required extensive assistance of staff for bed mobility, transfers, dressing and personal hygiene; -Required total care of staff for toilet use and bathing; -No range of motion impairment; -Incontinent of bowel and bladder; -No falls. Review of the resident's care plan, updated 4/28/15, showed the following: -Problem: Activities of daily living (ADL) self deficit. Needs total assistance with bed mobility, transfer, dressing, toilet use, personal hygiene and bathing; Approach: Report changes in ADL self performance to the nurse. Provide only the amount of assistance/supervision that is needed: Weight bearing; -Problem: At risk for falls. (Last documented fall on 6/3/15); -Approach: Report falls to physician and responsible party. Provide low bed, call light with in reach, glare free lighting and area free from clutter. Provide/monitor use of wheelchair, remind resident of and reinforce safety awareness. (No documentation on the residents transfer status) Review of the resident's POS, dated 8/1/15 through 8/31/15, showed the following: -[DIAGNOSES REDACTED]. -Mobility: Up with assistance of one to wheelchair. Review of the resident's nurse's notes dated 8/10/15 at 6:30 P.M., showed the following: -Certified Medication Technician (CMT) reported a bruise to the resident's left lateral interior foot. Measured 6.5 centimeter (cm) by 5 cm, purple/bluish on outer circle. Unable to voice how he/she got the bruise. No indication of broken bone, no complaint of pain or discomfort. 10:30 P.M.: Physician notified, no new orders. Review of the resident's Incident Report, dated 8/10/15, no time, showed the following: -Date of Incident: 8/10/15; -Exact location of incident: Blank; -Resident's condition before the incident/accident: The word confused checked; -Describe exactly what happened, why it happened, what the cause were, if injury, state the part of body injured: CMT reported bruise on left lateral foot: 6.5 cm by 5 cm bluish/purplish in color, reported to the physician; -Type of Injury: The word bruise written in; -Signed by the nurse. Observation on 8/20/15 at 7:00 A.M., showed the resident lay in bed sleeping. During an interview on 8/20/15 at 7:10 A.M., CNA JJ said the resident has not had any recent falls or bruises. He/she uses a wheelchair to get around the facility. During an interview on 8/20/15 at 3:40 P.M., the DON said she did not have an investigation regarding the resident's left foot bruise identified by staff on 8/10/15. The DON said staff completed an incident report but staff did not follow-up with an investigation. 3. Review of the facilities policy and procedure for Accident/Incident Reporting, submitted to the Department of Health and Senior Services (DHSS) as part of the facilities plan of correction for a revisit completed on 5/12/15, showed the following: -Policy: It is the policy of this facility to ensure that all accidents/incidents are thoroughly investigated for etiology; and that all accident/incident reports receive thorough follow through; -Types of incidents: Falls, skin tears, bruises - unknown origin/unknown origin, allegations of abuse, medication errors, elopement, resident to resident altercations and visitor to resident abuse/mistreatment; -What to do: Nursing assessment and documentation; -Examine the entire skin surface for injuries; -Interview the resident to determine cause of any conditions identified; -Interview any witnesses to determine cause of any conditions identified; -Measure vital signs and temperature and assess for pain; -Identify any skin discoloration, redness, swelling, edema, tenderness, breaks or change in skin temperature; -Measure the size/depth/color and location of any skin condition identified; -Palpate peripheral pulses (pulses in the wrists, behind the knee and in the feet); -Assess any change in mental and cognitive status through observation and interview of the resident; -Observe and assess all neurological signs for obvious signs of head trauma; -Attempt to determine the cause of any condition identified; -Document investigation process and use and use of any assistive devices used or implemented; -Notify the resident's primary physician/resident representative/medical director and DON of any falls or change in condition concerns that may have been identified; -Implement preventative measures as appropriate; -Complete Accident and Incident form; -If resident abuse is suspected, proceed with Abuse Protocol Investigation; -Fill out incident report completely - do not leave blank spaces - include preventative measures in the space provided; -The DON/ADON will immediately notify the Administrator of above occurrences; -Where a fracture has occurred, the DON will complete the Physician Resident Injury Notification form immediately upon receipt of x-ray reports and submit to the primary physician. 4. Review of a facility staff handout, as part of the facility's plan of correction to a revisit of 6/2/15, showed the following: -Identification and reporting of acute changes in resident conditions; -An acute change in condition is a sudden important deviation from the residents normal condition; -Changes in condition can occur suddenly or over several hours to several days; -Changes in a resident's condition may present as physical, functional, mood, cognition or behavior; -Residents at risk for having acute change in conditions: newly admitted to readmitted to the facility, respiratory conditions, prolonged bed rest, impaired memory and incidence of confusion, fall events or a history of multiple falls, pressure ulcers and multiple medications; -Basically every resident in a long term care facility is predisposed to experiencing acute changes in condition. 5. Review of the facility Neuro Checks/Incident and Accident Report form, dated 5/2015, showed the following: -all incident/accident reports must be filled out completely; -Every line must be filled if it applies; -All incident/accident reports must be reported to the ADON/DON. MO 813

Based on interview and record review, the facility failed to provide the necessary care to maintain the highest practicable physical well-being for three of four sampled residents (Residents #5, #6 and #7). Staff failed to adequately monitor a resident's condition and intake and failed to inform the resident's responsible party when he/she experienced cold symptoms (Resident #5). When the resident arrived at the hospital, eight days after staff noted the initial cough, the resident had [DIAGNOSES REDACTED]. Staff also failed to track a resident's pacemaker checks, inform the resident's physician of a rapid weight gain and initiate cardio-pulmonary resuscitation (CPR), as ordered by the physician, when staff found the resident without vital signs (Resident #6). Staff also failed to obtain a physician ordered speech therapy evaluation, and failed to contact the physician when a resident experienced respiratory changes (Resident #7). Staff failed to provide an on-going assessment for the resident during the subsequent eighteen hours after the initial respiratory changes. The census was 98. 1. Review of Resident #5's admission face sheet with an original admission date of [DATE], showed the following Diagnoses: [REDACTED]. Review of the resident's care plan, dated [DATE], showed the following information: -The resident had some difficulty with chewing food. The staff approaches included the following: -Staff to encourage/assist the resident with meals as needed; -Mechanical soft diet, double portions, mighty shakes; -Allow extra time to eat; -Determine food preferences and incorporate into diet as order allows; -Provide resident with a mechanical soft diet; -Monitor tolerance of diet; -Weigh resident; -Offer alternatives if not eating what was served; -Stay with resident during meals; -Schedule the dietician to see the resident; -In the dehydration category, the resident was prone to urinary tract infections (UTIs). The staff approaches included the following: -Observe for [MEDICAL CONDITION] in extremities and inform charge nurse; -Observe for diarrhea, vomiting, fever and diabetes; -Test skin turgor; -Observe for signs/symptoms of UTIs; -Offer extra fluids on a routine basis; -The resident had incontinent episodes due to a decline in cognitive status. The staff approaches included the following: -Encourage liquids at meals and between meals; -Observe for signs and symptoms of UTIs. Review of the resident's basic metabolic panel (BMP, a group of blood tests), dated [DATE], showed the following: - Blood Urea Nitrogen (BUN, indicator of kidney function) 27 milligrams (mg)/deciliter (dL), (normal ,[DATE]); -Sodium 138 milliequivalents (mEq)/liter (L), (normal ,[DATE]); -Potassium 3.8 mEq/L, (normal 3XXX,[DATE].5); -Chloride 100 mEq/L, (normal ,[DATE]); -Creatinine 0.8 mg/dL (indicator of kidney function), (normal 0XXX,[DATE].5). Review of the dietary manager's progress note, dated [DATE], showed the resident's weight was up seven pounds in the last three months. The resident received a mechanical soft diet with double portions and health shakes with all meals. The resident fed his/her self with set-up help. Per the consumption chart, the resident usually ate 100% at breakfast and 75% at lunch and dinner. Staff will continue the diet order and monitor weight and intake. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Score of 2 of 15 on the brief interview for mental status (indicated severe cognitive impairment); -Required extensive one-person assistance with eating; -Mechanically altered diet; -No weight loss; -No swallowing problems; -[DIAGNOSES REDACTED]. During an interview on [DATE] at 2:00 P.M., the dietary manager said the resident usually had a good appetite but needed cueing/supervision with meals. Nursing staff documented the residents' intake. During an interview on [DATE] at 2:50 P.M., certified nurse's aide (CNA) D said the resident normally ate fairly well and received double portions. Review of the resident's [DATE] physician's orders sheets, showed the following: -[DIAGNOSES REDACTED]. -Diet orders included: mechanical soft diet, double portions and mighty shakes at all meals; -Orders included the following: -[MEDICATION NAME] (a diuretic medication used to treat hypertension) 12.5 mg once daily; -Health shake three times daily with medications; -Oxygen 2 liters per minute (min) per nasal cannula, may titrate for comfort; -Suction as needed. Review of the CNA tracking form for eating, dated [DATE], showed on [DATE], blank entries for breakfast, lunch, dinner and blank entries for amount of fluids offered. Review of the nurse's notes, showed the following: -[DATE] at 7:00 P.M., staff noted the resident up in his/her wheelchair for the evening meal. The resident's appetite was poor and ate approximately 25% of the evening meal. The resident had a moist cough. Staff took the resident's vital signs: temperature 98.8 degrees Fahrenheit (F) (normal 97XXX,[DATE].1 degrees F), pulse 92 (normal ,[DATE] beats/minute), respirations 20 (normal ,[DATE] breaths/minute) and blood pressure of ,[DATE] (normal ,[DATE]-,[DATE]); -[DATE] at 3:20 A.M., staff noted the resident had no pain, discomfort or emesis. The resident's vital signs were temperature of 98.8 degrees F, pulse 78, respirations 18, and blood pressure ,[DATE]. Review of the CNA tracking form for eating, dated [DATE], showed the following: -[DATE], blank entries for breakfast, lunch, dinner and blank entries for amount of fluids offered; -[DATE], blank entries for breakfast and lunch, 40% consumed for dinner and 580 milliliters(ml) of fluids consumed for the day; -[DATE], blank entries for breakfast, lunch, dinner and blank entries for amount of fluids offered. During an interview on [DATE] at 10:20 A.M., the administrator said she was unable to find documentation of the resident's as needed oxygen use for [DATE]. Review of nurse practitioner (NP) X's progress note, dated [DATE], showed staff asked her to see the resident for complaints of cough and congestion. The NP noted the resident's cough and ordered a chest x-ray, oxygen 2 L/min per nasal cannula as needed and [MEDICATION NAME] (cough syrup) 10 ml every four hours as needed. During an interview on [DATE] at 11:45 A.M., NP X said the resident was generally frail. Staff asked NP X to see the resident because he/she had a cough. NP X told staff to give the resident the cough syrup and call if his/her condition changed. Although not given as an order, NP X assumed staff would continue to monitor the resident. Review of the nurse's notes, showed the following: -[DATE] at 10:00 A.M., staff noted NP X saw the resident and ordered a chest x-ray and [MEDICATION NAME] related to his/her cough. Staff contacted the x-ray company; -[DATE] at 2:00 P.M., Nurse C reported the negative x-ray results to NP Y who gave no new orders. Review of the chest x-ray, report date [DATE], showed, "Fairly prominent [MEDICAL CONDITION] but no consolidative pneumonitis yet." Staff wrote and circled a negative sign and noted they reported the findings to NP Y who gave no new orders. During an interview on [DATE] at 2:35 P.M., Nurse C said the resident was quiet and his/her appetite was up and down. The resident sometimes required cueing and coaching with eating. The resident did not normally use oxygen. Prior to his/her hospitalization , the resident had a cold with a runny nose and wheezy lung sounds. The nurse practitioner ordered a chest x-ray. When Nurse C read the x-ray results to the nurse practitioner, he/she read the results "word for word." There was already an order for [REDACTED]. The nurse did not remember anything unusual happening with the resident during the days prior to his/her hospitalization . Generally, the nurse documented normal or abnormal vital signs in the nurse's notes. If a resident had an upper respiratory infection or received antibiotics, staff monitored and documented the resident's condition every shift. During an interview on [DATE] at 11:00 A.M., NP Y said many residents had cough and cold symptoms around the same time of the year as the resident. The purpose of the chest x-ray was to make sure the cough and cold had not progressed further. If a resident had cough and cold symptoms, NP Y expected staff to assess lung sounds once per shift and assess vital signs a couple times throughout the course of the illness. NP Y said it was always important to stay hydrated and monitor intake when someone was ill. If staff had reported the resident did not eat or drink much, he/she would have ordered additional lab tests. Review of the February 2013 intake tracking form, showed the following: -[DATE]: 60% for breakfast, blank for lunch, 60% for dinner; -[DATE]: "zero" for breakfast, "zero" for lunch, blank for dinner, "zero" for fluids; -[DATE]: "zero" for breakfast, "zero" for lunch, 45% for dinner, 350 mls fluids; -[DATE]: 75% for breakfast. Review of the February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the February 2013 treatment administration record (TAR), showed no documentation the resident received any "as needed" oxygen. Per faxed documentation from the administrator, dated [DATE], there was no documentation to show the resident received any [MEDICATION NAME]. During an interview on [DATE] at 4:45 P.M., CNA D said generally, staff fed and encouraged the resident to eat. The resident was always thirsty. The CNA did not remember the resident with cough or cold symptoms, but he/she "kind of gave up" the last couple weeks prior to his/her hospitalization . During an interview on [DATE] at 4:30 P.M., Nurse B said the resident normally had good and bad days with how much he/she ate. Prior to his/her hospitalization , the resident had a cough but no fever. The resident still ate during this time, and the nurse did not remember anything unusual happening with the resident the night before he/she went to the hospital. The nurse remembered the resident had a chest x-ray but could not remember if he/she received any antibiotics. Around the same time as this resident's cough and cold symptoms, there were many other residents with cough and flu-like symptoms. The nurse did not know if he/she assessed and documented all these residents' conditions. Review of the nurse's notes, showed the following: -[DATE] at 11:30 A.M., (next entry after the nurses note on [DATE] at 2:00 P.M.) the CNA summoned the nurse to the resident's room. The resident was shaking in his/her wheelchair and had blue nail beds. The resident's oxygen saturation was 75% (normal ,[DATE]%). The resident's blood pressure was ,[DATE], pulse was 63 and respirations were 26. Staff placed the resident on 2 L/min oxygen via a simple mask, and the resident's oxygen saturation was 65%. Staff increased the oxygen to 3 L/min and then 5 L/min via a non-rebreather mask (allows delivery of higher concentrations of oxygen). The resident's oxygen saturation stabilized at 91%. Staff noted the resident had a Do Not Resuscitate (DNR) code status. Staff contacted the physician and family member, who wanted the resident sent to the hospital even though the resident had a DNR code status; -[DATE] at 12:00 P.M., the resident left the facility via ambulance with oxygen saturation of 88% on 10 L via a non-rebreather mask. During an interview on [DATE] at 4:40 P.M., CNA E said the resident was confused and received double portions. Sometimes the resident ate well and sometimes did not. About two weeks prior to his/her hospitalization , the resident had a runny nose with a cough and congestion. The CNA did not hear the resident have any wheezing with breathing. The resident had a very runny nose. The resident did not use any oxygen. When the CNA assisted the resident up in the wheelchair on [DATE], the resident had a runny nose, but the CNA knew the nurse was already aware of the resident's cold symptoms. During interviews on [DATE] at 2:25 P.M. and [DATE] at 2:20 P.M., Nurse F said the resident normally ate well with staff cueing, but he/she did not remember how much the resident ate during breakfast on [DATE]. During the previous days, the nurse remembered the resident had a runny nose but did not remember the resident coughing. Generally, if a resident had a cough, the nurse described the cough and documented it in the nurse's notes. Generally, the nurse documented abnormal vital signs in the nurse's notes. The nurse did not remember the resident having much of a change of condition. The nurse did not remember taking vital signs, listening to the resident's lung sounds or any additional monitoring in the days prior to his/her hospitalization . The resident did not routinely use oxygen. The night shift staff ([DATE]) did not report anything unusual with the resident. The resident was his/her usual self earlier in the day on [DATE]. Sometime after breakfast, staff reported the resident was shivering like he/she was cold. The nurse assessed the resident and his/her nail beds were blue. They administered oxygen and sent the resident to the hospital. Review of the transfer sheet, dated [DATE], showed the resident's temperature was 93.0 degrees F. The resident's lower extremity nail beds were blue and lung sounds were clear. The resident's oxygen saturation was 86% with 5 L/min oxygen. Review of the ambulance trip sheet, dated [DATE], showed the resident's vital signs at 12:10 P.M. as the following: blood pressure of ,[DATE], pulse of 114, respirations of 32 and oxygen saturation at 80% on 15 L/min oxygen. The resident had diminished lung sounds and received a nebulizer treatment. The resident's extremities were cyanotic (bluish discoloration of the skin due to decreased oxygen). The resident had premature ventricular contractions (PVCs, extra abnormal heart beats), about ten per minute. Review of the hospital emergency department record, dated [DATE], showed the following: -The examination showed the following: -Acute on chronically ill; -Thin, bordering on cachexia ([MEDICAL CONDITION]/physical wasting); -Gross, diffuse tremor; -Poor air bilaterally. -The comprehensive metabolic panel (CMP, blood tests) included the following: -BUN 135 mg/dL; -Sodium 164 millimoles (mmol)/L (normal ,[DATE]); -Potassium 2.9 mmol/L (normal 3XXX,[DATE].1); -Chloride 121 mmol/L (normal 98XXX,[DATE].0); -Creatinine 5.18 mg/dL; -[MEDICATION NAME] 2.4 grams (g)/dL (a type of protein) (normal 3XXX,[DATE].0); -The blood lactic acid level 6.4 mmol/L (acid formed during times of low oxygen levels) (normal 0XXX,[DATE].1). -The emergency department final [DIAGNOSES REDACTED]. During interviews on [DATE] at 2:20 P.M. and [DATE] at 2:45 P.M., the Director of Nurses (DON) said when a resident had a change of condition, staff should notify the physician and follow the orders. Staff would not necessarily have done any additional monitoring with the resident because there were no further symptoms. If something abnormal continued to occur with the resident, staff would have assessed the resident and documented the abnormalities. If staff documented "zero" on the intake record, it meant the resident did not eat anything or ate just a few bites of the meal. During interviews on [DATE] at 9:30 A.M. and [DATE] at 9:45 A.M., the administrator said staff should notify a resident's responsible party when the resident experienced a change of condition. If staff obtained an x-ray order, staff "ought to" notify the responsible party, but there was no documentation to show staff contacted the resident's responsible party. During an interview on [DATE] at 8:30 A.M., Family Member (FM) W said the resident was thin, frail and had [MEDICAL CONDITION]. Staff called a family member on [DATE] to ask if they should administer oxygen to the resident since he/she had a DNR order. Staff said the resident needed to go to the hospital. FM W said neither he/she nor the other designated responsible party were aware the resident was previously sick. When the resident arrived at the hospital, he/she shook badly. The resident had a urinary tract infection, pneumonia,[MEDICAL CONDITION] and severe dehydration. During an interview on [DATE] at 10:15 A.M., Physician Z said he saw the resident in the hospital. Considering the resident's condition upon arrival at the hospital, the physician said the resident's condition change had to have started at least a day or two previously. Because of the resident's dementia, monitoring the resident was even more important because the resident could not adequately express how he/she felt. The resident was "pretty dehydrated" upon admission to the hospital. If staff had told him the resident was not eating or drinking well, he would have ordered additional lab tests, and intravenous fluids or a repeat chest x-ray, if warranted. If staff assessed the resident and contacted the physician, it could have changed the resident's outcome. The resident's acidosis was likely due to a combination of the dehydration [MEDICAL CONDITION]. 2. Review of Resident #6's admission face sheet, showed the following: -Original admission date of [DATE]; -[DIAGNOSES REDACTED]. Review of faxed correspondence from the administrator showed the last documented pacemaker check, of which the facility had record, occurred on [DATE]. Review of the resident's care plan, dated [DATE], showed the following: -The resident was at risk for dehydration due to daily [MEDICATION NAME] (a diuretic medication) use. Staff approaches included the following: -Observe for [MEDICAL CONDITION] to all my extremities, notify charge nurse; -Offer fluids frequently and make available at bedside; -Monitor intake at all meals; -Monitor for dry mouth, increased thirst and decrease in voiding; -Frequently remind the resident about the importance of adequate fluid intake; -The resident was at risk for altered nutrition due to a [DIAGNOSES REDACTED]. -Monitor and record food consumption at all meals, if less than 50% eaten, report to the nurse; -Monitor for signs/symptoms of dehydration, poor skin turgor, mental status changes, dry mucous membranes and [MEDICAL CONDITION] (low blood pressure); -The care plan did not address the resident's pacemaker care. Review of the resident's quarterly MDS, dated [DATE] (most recent available assessment), showed the following: -Score of 10 of 15 on the brief interview for mental status (indicated moderately impaired cognition); -[MEDICAL CONDITION]; -Required supervision/set-up help with eating; -[DIAGNOSES REDACTED]. -Shortness of breath with exertion; -Therapeutic diet; -No known weight loss or gain. Review of the resident's 2012 weight record, showed the following: -[DATE] (readmission weight) 124 pounds; -[DATE], 123.1 pounds; -[DATE], 144.8 pounds. Review of the nurse's notes, dated [DATE] at 8:00 A.M., showed the resident complained of shortness of breath. The resident's oxygen saturation was 94% on room air. Staff administered a nebulizer treatment and oxygen 2 L/min per nasal cannula. The resident's lungs were clear to auscultation (listening to internal sounds) and diminished at the bases. The resident's blood pressure was ,[DATE], pulse 96, respirations 24 and temperature was 98.6 degrees F. The resident's oxygen saturation was 98% after the nebulizer and oxygen administration. Review of the resident's weight record showed on [DATE], the resident weighed 160.4 pounds. Review of the [DATE] physician's orders sheet, showed the following: -[DIAGNOSES REDACTED]. -Orders included: -[MEDICATION NAME] ([MEDICATION NAME]) 40 mg once daily, dated [DATE]; -Klor-con M20 (potassium supplement) once daily, dated [DATE]; -[MEDICATION NAME] ([MEDICATION NAME]) (appetite stimulant) 10 mls twice daily, dated [DATE]; -[MEDICATION NAME] (treatment for [REDACTED]. -[MEDICATION NAME] 0.2% (Atrovent, increases air flow to the lungs) one vial per nebulizer every four hours as needed for shortness of breath/wheezing, dated [DATE]; -Change nebulizer tubing weekly on Tuesdays on night shift when used; -Oxygen ,[DATE] L/min as needed to keep oxygen saturation above 92%; -Orders dated [DATE] included the following: -Discontinue Potassium; -Discontinue [MEDICATION NAME] 40 mg daily; -[MEDICATION NAME] 20 mg daily; -Urinalysis with culture and sensitivity; -Renal function panel in one week; -Daily weights for one week and notify physician if greater than two pounds in a day. Review of the facility's weight documentation, showed the following daily weights for the resident: -[DATE], 166.4 pounds; -[DATE], 166.2 pounds; -[DATE], 166.2 pounds; -[DATE], 166.2 pounds; -[DATE], 166.6 pounds; -[DATE], 166.8 pounds; -[DATE], 166.9 pounds. Review of the dietary manager's progress note, dated [DATE], showed the resident's weight of 160.9 pounds; a weight gain of 36 pounds in the past three months. The resident consumed meals independently. The resident had a regular diet and liked sweets. Staff would continue the resident's diet and monitor the resident's weight and intake. During an interview on [DATE] at 2:00 P.M., the dietary manager said the resident was a selective eater in the past, but prior to his/her death, his/her appetite increased. The dietary manager, one of the nursing supervisors, the care plan nurse and the DON received copies of the residents' weights. When the dietician visited the facility, the dietary manager gave the dietician a copy of the weights, the wound reports and the dietary manager's nutritional screens. The 36-pound weight gain seemed like a lot for a short amount of time. The dietary manager did not know if the dietician saw the resident after his/her weight gain. Review of the social service notes, dated [DATE], showed the resident ambulated independently, voiced his/her needs, was alert and oriented times two (person, place), and was a "full code" status. Review of the nurse's notes, dated [DATE] at 7:40 P.M., showed a male nurse said when he went into the resident's room to administer a breathing treatment, the resident touched him inappropriately. The resident denied the incident. Staff informed the unit manager, DON and administrator of the incident. (Staff did not document the resident's lung sounds or vital signs). Review of the [DATE] MAR, showed staff administered the resident's Atrovent and [MEDICATION NAME] nebulizers on [DATE] and they were both effective. Review of the [DATE] physician's orders sheet, showed the resident had orders for "full code." Review of the resident's appetite record, dated [DATE], showed the following: -"Zero" breakfast and 240 mls fluid; -"Zero" lunch and "zero" fluids; -Blank entries for supper. Review of the [DATE] TAR, showed no documentation the resident received any "as needed" oxygen. Review of the nurse's notes (no date noted), showed the following: -At 5:20 A.M., staff found the resident deceased in bed. The resident was cool to the touch and had an oxygen nasal cannula in his/her hand. Staff observed no rising or falling of the resident's chest. Staff last saw the resident at 3:15 A.M. with chest rising and falling and oxygen on at 2 L/min per nasal cannula. At 5:30 A.M., staff notified the administrator and the on-call physician. Staff notified the family member at 5:23 A.M. (Staff did not document they initiated CPR or called 911); -At 6:00 A.M., staff notified the medical examiner's office of the resident's death. The family member arrived at 6:18 A.M., who contacted the funeral home; -At 7:10 A.M., the funeral home picked up the resident's body. Review of the death reporting form to the medical examiner, showed the resident's date of death was [DATE]. Nurse A last saw the resident at 3:20 A.M. on [DATE] and found the resident dead at 5:20 A.M. on [DATE]. The pronouncement of death entries were blank. Nurse A noted the resident's body was released to a funeral home. The resident's most recent hospitalization was on [DATE] for [MEDICAL CONDITION]. During an interview on [DATE] at 9:15 A.M., CNA G said he/she checked the resident at approximately 2:00 A.M. (on [DATE]), and the resident slept with oxygen on. This was the first night the CNA saw the resident with oxygen. The CNA worked two halls that night and could not say if staff initiated a code or if paramedics arrived at the scene. The nurse asked the CNA to clean up the resident's body after he/she died . The resident's body was cold but not rigid. During an interview on [DATE] at 9:50 A.M., CNA H said he/she did not have the resident on his/her assignment the night the resident died . The CNA heard the "commotion" when the resident died , but did not hear staff call a code. During an interview on [DATE] at 1:20 P.M., Nurse A said the resident used oxygen for a little while, but the nurse did not remember exactly why. On the night shift of the resident's death ([DATE]), the nurse entered the resident's room to change the oxygen tubing. The resident looked different. The resident looked blue and his/her skin was cool to the touch. The nurse checked for vital signs and found no pulse or blood pressure. The nurse thought maybe another nurse started CPR and another staff member called 911. Then, Nurse A said he/she did not remember if staff called 911 or started CPR. He/she just didn't remember. Generally, the information about the residents' code status was available in the chart and easy to find. During interviews on [DATE] at 2:20 P.M., [DATE] at 3:38 P.M. and [DATE] at 2:45 P.M., the DON said she started at the facility in [DATE], and they realized there were problems with the October and [DATE] weights. They re-calibrated the scale and assigned a different staff member to obtain residents' weights. Generally, an outside company came in to conduct the residents' monthly pacemaker checks. The DON checked with the company, and they did not check the resident's pacemaker in [DATE]. Residents' pacemakers were usually noted on the [DIAGNOSES REDACTED]. When the resident died in the early morning, the administrator contacted the DON, and the DON assumed staff followed the resident's code status orders. Staff did not tell the DON they did not initiate CPR. The DON only knew what staff documented, and there was no documentation to show staff performed CPR or called 911. Review of faxed correspondence from the administrator, dated [DATE], showed the facility had no orders for follow-up cardiologist appointments. The resident expired before the dietician saw the resident's weight gain. Review of faxed correspondence from the administrator, dated [DATE], showed the facility did not have a specific code status policy; they had a form for the resident to elect either "full code" or "DNR." During interviews on [DATE] at 2:15 P.M., [DATE] at 9:30 A.M. and [DATE] at 9:45 A.M., the administrator said staff called her about 5:00 A.M. on the morning the resident died , but the administrator did not think she asked staff about the resident's code status. The administrator said it was her understanding staff should initiate CPR even if rigor began. The administrator did not know why the nurse did not initiate CPR when he/she found the resident without vital signs. Staff should have announced the code overhead, initiated CPR, called 911 and continued CPR until the paramedics arrived. The administrator did not know if staff reported the resident's weight gain to the physician. Generally, the residents' weights during the fall of 2012 were not reliable. Because of that concern, they had a new restorative aide obtain the residents' weights. There were no physician's orders for pacemaker checks for the resident. Generally, pacemakers should be checked every six to twelve months. The last documented pacemaker check, of which the administrator was aware, occurred in [DATE]. During an interview on [DATE] at 10:15 A.M., Physician Z said the resident had [DIAGNOSES REDACTED]. In the past, the resident did not always have good intake, so increased intake and weight was positive for this resident. However, a rapid weight gain could indicate fluid overload. The physician would have wanted staff to contact him about the resident's weight gain. Pacemaker checks were routinely required at least yearly. Although the resident's pacemaker could have been checked during a hospitalization , the physician expected the facility to have a system for tracking the resident's pacemaker checks. Although the resident's outcome might not have changed, when the resident had no vital signs, staff should have called 911 and performed CPR since the resident had full code orders. 3. Review of Resident #7's care plan, dated [DATE], showed the following: - The resident was at risk for alteration in nutritional status/dehydration related to a [DIAGNOSES REDACTED]. The staff approaches included the following: -Provide resident with a mechanical soft, low caffeine diet with large portions at all meals; -Observe daily for signs/symptoms of altered nutrition or hydration status, such as but not limited to, decreased or absent urine output, decreased tears, dry eyes, dryness of oral mucous membranes, dry chapped lips, sunken eyes, constipation, abdominal distension. Assess and report to physician promptly; -The resident received hospice services for a [DIAGNOSES REDACTED]. -The facility will continue to provide services as given prior to election of hospice services. The resident or representative continued to have the right to refuse services offered; -Nursing and hospice staff coordinated services to address the resident's needs. The resident and family would be involved in planning care on an on-going basis; Review of the resident's weight record, showed the following: -[DATE].6 pounds; -[DATE].2 pounds; -[DATE].9 pounds; -[DATE].2 pounds; -[DATE] pounds. Review of the [DATE] physician's orders sheets, showed the following: -Full Code; -Hospice level of care; -[DIAGNOSES REDACTED]. -Snacks three times per day, dated [DATE]; -Large portions; -[MEDICATION NAME] ([MEDICATION NAME], anti-anxiety medication) injection, 0.4 mls every six hours as needed for agitation, dated [DATE]. Review of the nurse's notes, showed the following: -[DATE] at 6:30 P.M., the resident pocketed food and choked on fluids. Staff notified the physician who gave orders for a pureed diet with thickened liquids, speech therapy evaluation, oxygen as needed, and suction orally as needed for excess secretions; -[DATE] at 7:00 P.M., staff contacted a hospice triage nurse and informed him/her of the new orders. The hospice nurse said they would arrange delivery of an oxygen concentrator and suction equipment that night. Review of the [DATE] physician's orders sheets, showed the following orders, dated [DATE]: -Discontinue mechanical soft diet with low caffeine; -Pureed d

Based on observation, interview and record review, the facility failed to provide the necessary care and services for one of 17 sampled residents (Resident #11) to attain or maintain the highest practicable mental and physical well-being while being treated for [REDACTED]. Scabies is contagious). The census was 100. Review of Resident #11's medical record, showed the following: -A February 2012 face sheet, showed an admission date of [DATE] and [DIAGNOSES REDACTED]. -Review of nurse's notes, showed the following: -12/13/11, complaint of severe itching on bilateral lower extremities with scratches and red open areas; -2/13/12, resident seen by physician for itchy rash. Dermatology referral ordered; -2/14/12, scratched leg open; -2/16/12, complaint of itching, [MEDICATION NAME] (medication used to treat itching), administered; -2/24/12, resident rammed wheel chair into medication cart and requested itch pill; -3/24/12, complaint of itching, [MEDICATION NAME] administered; -3/25/12, complaint of itching, scabbing to bilateral arms and legs; -4/2/12, resident went to dermatology appointment, returned with new orders, first dose of antibiotic pulled from emergency kit. Review of the April 2012 physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -An order dated 4/2/12, for Premethrin (medication used to treat scabies) 5% cream, apply to entire body, leave on overnight, wash off in the morning and repeat in one week (4/9/12); -An order dated 4/2/12, for [MEDICATION NAME] (a corticosteroid used for itching) 0.1% ointment, apply sparingly to affected areas twice a day; -An order dated 4/2/12, for [MEDICATION NAME] (an antibiotic) 100 milligrams (mg) capsule twice a day for two weeks. Further review of a nurse's note dated 4/3/12, showed treatment done for scabies, resident's room deep cleaned and bed frame and mattress replaced. Review of a skin monitoring/shower sheet dated 4/5/12, showed three scratched areas to the left arm between the wrist and the shoulder and three scratched areas to the left leg between the knee and the ankle. Review of the resident's care plan on 4/9/12, showed it was last reviewed on 2/8/12, and included no problem, goals or interventions concerning the resident's scabies. Review of the resident's care card (used by certified nurse aides to know the resident care needs) on 4/9/12, showed no skin problems, interventions or precautions concerning the resident's scabies. During an interview on 4/10/12 at 8:30 A.M., the resident said staff did not apply the medication to his/her entire body the previous night. He/she did receive a shower that morning. Observation at that time, showed the resident sat in his/her wheel chair scratching his/her bilateral arms. His/her forearms and elbow areas contained several bleeding scratches. His/her unmade bed, showed several small circles of dried blood on the linen. Review of the treatment administration record (TAR) on 4/10/12, showed the 4/9/12 space to document the application of Premethrin 5% cream to the resident's entire body highlighted (indication of treatment due date) but, blank. The 4/10/12 space to document the shower to remove the Premethrin 5% cream highlighted but, blank. During an interview on 4/10/12 at 1:05 P.M., the Director of Nursing said the Premethrin treatment scheduled for 4/9/12 did not happen. The 4/9/12 evening staff did not think there was enough Premethrin cream left after the initial treatment dose to complete a second treatment. Additional Premethrin had to be ordered today.

This deficiency is uncorrected. For previous examples, see the statement of deficiencies dated 4/10/12. Based on interview and record review, the facility failed to continuously assess and monitor the resident for change in condition, following a medication error in which the resident received [MEDICATION NAME] at 20 times the ordered dose. The facility also failed to ensure the physician was aware of the extent of the medication error and failed to keep the physician informed of the resident's condition. An ambulance was called and the resident received medical treatment 15 hours after the medication was administered. (Resident #30) The census was 96. 1. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/7/12, showed the following: -Occasionally in pain; -Always incontinent of bowel and bladder; -Total assistance required for toileting, bathing and transfers; -Extensive assistance required for personal hygiene and range of motion; -Limited assistance required for eating; -Non-ambulatory. Review of the resident's care plan last updated 3/7/12, showed the following: -Pain: Problem: I will receive pain management with [MEDICATION NAME] (narcotic pain medication to treat moderate to severe pain) related to pain in my stump. Goal: I want to be comfortable. Approaches: administer medications as ordered, assess effectiveness of pain medication, assess pain characteristics, duration and quality, assess present pain coping strategies, monitor for side effect of pain medication like constipation, nausea and vomiting, observe for sedation like [MEDICAL CONDITION] (low heart beat) respiration depression (decreased breathing rate), dizziness, physical dependence, if noted, report to the resident's physician. Ongoing assessment of pain status. Review of the physician's orders [REDACTED]. -Diagnoses: [REDACTED]. -[MEDICATION NAME] 100 milligrams (mg)/5 milliliters (ml), administer 0.25 ml by mouth every four hours as need (PRN) for pain (0.25 ml = 5 mg.) Review of the nurse's notes, dated 5/20/12, showed the following: -2:00 A.M., resident complained of pain. This nurse was asked to give pain medication. Read instruction as 5 ml, which was wrong, it read 0.25 ml. Placed call to hospice, asked to monitor the resident. Phone call to the resident's physician, no response at this time. Review of the controlled substances proof of use sheet, dated 5/20/12, showed Nurse M documented he/she administered 5 ml of [MEDICATION NAME] (100 mg) to the resident at 2:00 A.M. Further review of the nurses notes showed: -4:15 A.M., Vital signs: temperature 96.7 degrees Fahrenheit (F) (normal 98.6 degrees F) , heart rate 76 (normal 60-80), respirations 18 (normal 12-18), blood pressure 108/64 (normal range 110/60 to 120/80) and oxygen saturation level 98% (a device placed on a finger to monitor the oxygen level in the blood. Normal range 95% to 100%). Resting peacefully, no signs or symptoms of distress noted, no return call from the resident's physician at that time, would continue to monitor; -7:30 A.M., placed call to the resident's physician, new order for 2 to 4 liters of oxygen PRN and continue to monitor; -10:00 A.M., assessed resident's respirations even and unlabored oxygen saturation level 88% on 3 liters of oxygen. Increased ? liter more of oxygen. Resident continued to be lethargic, would continue to monitor; -2:00 P.M., contacted hospice to update them of the resident's current state, also spoke with supervisor; -No time documented, vital signs temperature 98.0 F, heart rate 68, respirations 17, blood pressure 110/60. No oxygen saturation level documented; -3:00 P.M., temperature 98.1 F., heart rate 75, respirations 18, blood pressure 120/59, 98% oxygen saturation level. Remained lethargic, responsive to touch and sound, skin warm and dry; -4:45 P.M., the Interim Director of Nursing (DON), wrote she arrived at the facility after receiving a call from a staff member requesting her presence; -4:50 P.M., received a call from hospice Nurse N asking for an assessment of the resident. Upon arrival at the resident's bedside, resident appeared lethargic and difficult to arose. Head of bed elevated at a 45 degree angle, eyes closed, oxygen on at 3.5 liters per nasal cannula. Temperature 98.1 F, heart rate 78, respirations 17, blood pressure 88/60 and 98% oxygen saturation level. Respirations even, unlabored and shallow. Sternal rub (rubbing on the breast bone) done and resident opened his/her eyes. Spoke to the resident, received no verbal response and he/she blinked his/her eyes several times. Returned to phone and reported assessment to hospice Nurse N; -5:00 P.M., attempted to call the resident's power of attorney (POA) and received answering machine. Placed a call to other family members and no one answered the phone. Another family member said he/she would contact the POA and have him/her contact the facility; -5:15 P.M., received a call from the resident's POA and updated him/her on the medication error. He/she expressed concern over not being notified earlier and requested that someone stay with the resident to monitor his/her condition overnight. The POA was assured that would happen and that the hospice nurse would contact him/her; -5:25 P.M., notified hospice Nurse N of POA's request for the resident to be monitored. Hospice Nurse N said he/she would contact the POA; -5:35 P.M., received a call from the resident's POA requesting the resident be sent to the hospital; -5:38 P.M., call placed to 911; -5:48 P.M., Emergency Medical Services (EMS) and resident's family arrived at the facility; -6:15 P.M., the resident left the facility via stretcher accompanied by family and EMS; -10:00 P.M., the resident returned from the emergency room via stretcher, family returned with resident. Temperature 97.6 F, heart rate 69, respirations 20, blood pressure 97/52, no oxygen saturation level documented. The resident was alert and very talkative upon arrival. He/she was assisted to bed with the head of the bed elevated. Interim DON was notified of the resident's return to the facility, no new orders noted; -10:46 P.M., oxygen saturation level 99%, 3 liters of oxygen per nasal cannula. During an interview on 6/4/12 at 11:30 A.M., Nurse M said he/she worked 11:00 P.M. through 7:00 A.M., on 5/19 into 5/20/12; it was his/her second shift on orientation. Nurse M said Nurse S was his/her orientating nurse and had delegated him/her to administer the pain medication to Resident #30. He/she administered [MEDICATION NAME], by mouth, to the resident at approximately 2:00 A.M. Nurse M read the [MEDICATION NAME] order as: administer 5 ml. He/she realized he/she made a medication error when he/she went read the physician's orders [REDACTED].= 5 mg. He/she reported the medication error immediately to Nurse S. Nurse M said he/she used the 1 ml syringe (provided with the liquid medication, filled the syringe five times with [MEDICATION NAME], placed the 5 ml of medication in a medication cup and administered the medication to the resident. Nurse M said he/she was a hospice nurse in the past and had administered that amount of [MEDICATION NAME] many times before. Nurse S notified Nursing Supervisor A who came to the floor to assist with the medication error. Nurse M attempted to notify the resident's physician, but did not receive a return phone call. He/she had left a voicemail. He/she notified hospice of the [MEDICATION NAME] medication error around 2:30 A.M. He/she told the on call hospice nurse that 5 ml had been administered to the resident instead of the ordered 0.25 ml. The hospice nurse instructed Nurse M to monitor the resident and to notify the resident's physician of the medication error. Nurse M was unable to explain why the on call hospice nurse said it was reported "double the dose" of [MEDICATION NAME] was administered to the resident. Nurse M said he/she documented that 5 ml was administered on the narcotic sheet and in the nurse's notes. After the medication error, Nurse M assessed the resident's vital signs around 2:45 A.M. The resident was alert and responded to his/her name being called. He/she assessed the resident only two times after the medication error occurred because he/she said a certified nurse's aide (CNA) was delegated to assess the resident's vital signs and respiratory status because [MEDICATION NAME] has a side effect of decreasing respirations. Before he/she administered the PRN pain medication, the resident was screaming out in pain and 15 to 20 minutes later, the resident was resting peacefully. Nurse M did not notify the resident's family of the medication error because it happened at 2:00 A.M. and Nurse S said he/she would notify the resident's family later because he/she was working a double shift. Nurse M said he/she should have documented all the assessments that he/she did on the resident. He/she did not think to send the resident to the hospital because the on call hospice nurse said to monitor the resident and notify the resident's physician. Nurse M left the facility at approximately 7:30 A.M. on 5/20/12, he/she was contacted by the facility on 5/21/12 related to the medication error and he/she resigned his/her position on 5/21/12. During an interview on 6/4/12 at 11:00 A.M., Nurse S said he/she worked 10:30 P.M. through 9:40 A.M. on 5/19 into 5/20/12. He/she used to work evening shift, 3:00 P.M. through 11:00 P.M., but that was the first night shift he/she had worked. Nurse S was instructed to orient Nurse M and that it was Nurse M's second night of orientation. At approximately 2:00 A.M., CNA R reported the resident was complaining of pain. He/she was caring for other residents at that time and Nurse M informed Nurse S, he/she was a nurse for over [AGE] years. He/she delegated Nurse M to administer [MEDICATION NAME] to Resident #30. Shortly after Nurse M administered the pain medication, he/she reported to Nurse S that a medication error had occurred. Nurse M said he/she read the order wrong and administered 5 ml instead of the ordered 0.25 ml of [MEDICATION NAME]. Nurse S clarified that Nurse M gave 5 ml instead of 0.5 ml and Nurse M said that was correct. Nurse S immediately contacted Nurse Supervisor A and told him/her to come downstairs right away. Nurse S said after the medication error occurred; Nurse Supervisor A and Nurse M called the resident's physician and notified hospice of the medication error. Nurse S said he/she thought Nurse Supervisor A and Nurse M could handle the situation and he/she continued with his/her nursing tasks. Nurse Supervisor A said hospice had been notified and they were to monitor the resident and the physician had been paged. Nurse S said he/she did go in and out of the resident's room throughout the shift, assessing the resident's vital signs. He/she had to shake the resident to wake him/her up a few times, but he/she woke up and would say a few words and go right back to sleep. Nurse S said he/she did not document his/her assessments in the resident's chart because he/she thought Nurse M was documenting the assessments. At 4:15 A.M., Nurse S documented the resident's vital signs in the nurses notes. He/she informed the oncoming nurse, Nurse T, about the [MEDICATION NAME] medication error and that 5 ml had been administered instead of 0.25 ml. Shortly after giving report to Nurse T, the resident's oxygen saturation level dropped into the 80's and 3 liters of oxygen was administered and the head of the bed raised. Nurse S could not recall if the resident's physician had called back. He/she was unaware if the resident's family was notified because he/she thought Nurse Supervisor A and Nurse M were taking care of that. During an interview on 6/4/12 at 10:20 A.M., Nurse Supervisor A said he/she worked 11:00 P.M. through 7:00 A.M. on 5/19 into 5/20/12. He/she received a phone call from Nurse S that night around 2:15 A.M. Nurse S said there was a situation and he/she did not know how to handle it. Nurse Supervisor A went to assist the nurses. When Nurse Supervisor A arrived on the first floor, he/she was notified that Nurse M had administered 5 ml of [MEDICATION NAME] to the resident instead of 0.25 ml. Nurse S told him/her, he/she was multi tasking and delegated to Nurse M to give the PRN pain medication. Nurse Supervisor A told Nurse M to notify hospice and the resident's physician of the medication error immediately. Nurse M told him/her the hospice nurse said to monitor the resident and that a voicemail was left with the resident's physician. Nurse Supervisor A told Nurse M to monitor the resident's vital signs. He/she did not assess the resident because he/she thought there were two nurses assigned to the first floor and they would know to assess the resident. Nurse Supervisor A did not send the resident to the emergency room due to the hospice nurse saying to monitor the resident. He/she notified the oncoming nurse supervisor of the [MEDICATION NAME] medication error. During an interview on 6/5/12 at 10:40 A.M., CNA R said he/she worked 11:00 P.M. through 7:00 A.M. on 5/19 into 5/20/12. CNA R was assigned to the resident. During rounds, at approximately 2:00 A.M., he/she observed the resident moaning with facial grimacing and asked the resident if he/she was in pain, the resident replied yes. CNA R reported the resident's pain to the nurse. Shortly after, Nurse M administered pain medication. CNA R heard a medication error had occurred and was instructed by Nurse S to keep an eye on the resident's respirations. CNA R did not recall taking the resident's vital signs or seeing the nurse take the resident's vital signs after the medication error occurred. He/she was not instructed to conduct 15 minute checks on the resident. After the medication was administered, CNA R said the resident slept the rest of the shift. During an interview on 6/4/12 at 10:00 A.M., Nurse T said he/she worked 7:00 A.M. through 3:00 P.M. on 5/20/12. He/she was informed by the night shift nurses that a medication error had occurred and the resident was administered 5 ml of [MEDICATION NAME] instead of the ordered 0.25 ml. He/she assessed the resident at the beginning of the shift and the resident was sleepy, but woke up after he/she shook the resident. He/she took the resident's vital signs at that time. Nurse T then notified the resident's physician, around 7:30 A.M., and reported the medication error. The resident's physician ordered oxygen at 2 to 4 liters per nasal cannula and to monitor the resident. He/she was in and out of the resident's room all day assessing the resident's vital signs and mental status. At one point, in the afternoon, the resident was not looking like him/herself, the resident started to decline and became harder and harder to wake up. At that time, the resident was receiving 3.5 liters of oxygen per nasal cannula, the Interim Director of Nurses (DON) was also in the room and assisted to assess the resident. Nurse T said he/she did not document all of his/her assessments because the CNA assigned to the resident was completing 15 minute checks on the resident. He/she took the resident's vital signs three times during his/her shift. Nurse Supervisor P had come down at the start of the shift and delegated him/her to do vital signs hourly and 15 minute checks on the resident. He/she delegated those tasks to the CNA assigned to the resident. After the Interim DON came in, he/she said they no longer needed to conduct the hourly vital signs and monitor vital signs every two to three hours. He/she asked Nurse Supervisor P and he/she said the family did not get notified when the medication error occurred. He/she contacted hospice to give an update on the resident's status. When Nurse T told hospice Nurse N about the medication error, hospice Nurse N said he/she thought the resident was administered 0.5 ml not 5 ml of [MEDICATION NAME]. Nurse T clarified that the resident was administered 5 ml of [MEDICATION NAME]. He/she received a phone call from hospice saying to send the resident to the hospital per the hospice medical director. He/she said that phone call was received during shift change and there was a lot of confusion related to why the resident was not sent to the hospital when the medication error had occurred. He/she would have sent the resident to the hospital that morning, but the resident's physician instructed them to monitor the resident and administer oxygen. During an interview on 6/4/12 at 9:30 A.M., Nurse Supervisor P said he/she worked 6:30 A.M. through 3:00 P.M. on 5/20/12. He/she was notified in nurse report of the [MEDICATION NAME] error that occurred at 2:00 A.M. He/she was told the resident was administered 5 ml instead of the ordered 0.25 ml, the resident's physician and hospice had been notified and there were no new orders other than to monitor the resident. He/she went to assess the resident as soon as he/she arrived at the facility. Nurse Supervisor P assessed the resident's lungs, mental status and vital signs. Nurse T was assigned to the resident for the day shift on 5/20/12 and was in the resident's room during the assessment. During the assessment, the resident's oxygen saturation level was in the 80's and he/she administered oxygen per nasal cannula at that time. The resident was very sleepy during the assessment, but when he/she called the resident's name, the resident opened his/her eyes. He/she told Nurse T to monitor vital signs hourly and conduct 15 minute checks to assess for mental status changes and respiratory depression, which is a negative side effect of [MEDICATION NAME]. He/she did not document the assessments because he/she thought Nurse T was documenting the assessments. Nurse Supervisor P said he/she was not sure when the Interim DON came into the facility, but that he/she was informed the Interim DON said there was no need to continue the hourly vital signs. He/she assessed the resident multiple times throughout the shift and at one point the resident's blood pressure started to plummet. The resident's blood pressure was really low and the resident was very lethargic. He/she had to shake the resident a little bit and speak loudly in the resident's ear to get him/her to respond. The resident would open his/her eyes and go right back to sleep. It was getting more difficult to arouse the resident. He/she delegated to Nurse T to notify the resident's family. He/she was unaware the resident's family had not been notified of the medication error. He/she spoke to hospice Nurse N and transferred the phone call to the Interim DON who was with the resident at the time. He/she did not send the resident to the emergency room because the resident received hospice services and had a do not resituate (DNR) order. He/she should have documented all his/her assessments on the resident that day. Review of the 15 minute resident observation sheet dated 5/20/12, showed the following: -2:00 A.M. through 6:45 A.M., no documentation of 15 minute checks; -7:00 A.M. through 9:15 A.M., either asleep or alert; -9:30 A.M. through 10:45 A.M., nonresponsive; -11:00 A.M. through 11:30 A.M., alert; -11:45 A.M. through 2:45 P.M., unresponsive; -3:00 P.M. through 6:00 P.M., responsive; -6:15 P.M., sent to the emergency room ; -No documentation of vital signs, oxygen saturation levels or further assessment of the resident's condition. During an interview on 6/5/12 at 8:22 A.M., the administrator said the vital signs that were taken after the medication error were documented in the nurses notes. The one hour vital sign sheet was not available. During an interview on 6/1/12 at 12:55 P.M., Nurse O said he/she worked on 5/20/12, in the morning, and he/she passed Nurse A in the parking lot as he/she entered the building. Nurse A informed him/her of the [MEDICATION NAME] medication error and that 5 ml was administered to the resident at approximately 2:00 A.M. Nurse A said the resident's physician had been notified, orders obtained to monitor the resident and apply oxygen and hospice had been notified and gave the same order to monitor the resident. Nurse O said he/she heard 5 ml, but assumed it was 0.5 ml administered. He/she left for the day, but returned at approximately 4:30 P.M., because he/she was the Interim DON at that time. So when Nurse T called him/her concerned about the resident's status and that 5 ml of [MEDICATION NAME] had been administered to the resident that morning, he/she returned to the facility. After returning to the facility, Nurse O spoke with the hospice nurse. Nurse O did a complete assessment on the resident, including vital signs. The resident was difficult to arouse, but did flutter his/her eyes after stimulating the resident with a sternal rub. He/she notified the resident's family at approximately 5:15 P.M. He/she was not sure why the resident's family was not notified prior to that time. When a medication error occurred the expectation was to notify the physician and POA immediately. Nurse O did not understand why facility staff did not follow the hospice medical director's orders to send the resident to the emergency room . During an interview on 6/5/12 at 11:30 A.M., hospice Nurse Q said he/she was on-call on 5/20/12. He/she received a phone call at 2:30 A.M., from the facility stating a small [MEDICATION NAME] medication error had occurred and the facility nurse wanted to notify hospice. Nurse M said he/she accidently gave the resident too much [MEDICATION NAME]. Hospice Nurse Q asked how much [MEDICATION NAME] was administered to the resident; the nurse replied "double the dose". Hospice Nurse Q clarified double the dose would be 0.5 ml because the dose on the POS was 0.25 ml. The facility nurse agreed it was 0.5 ml administered. Hospice Nurse Q asked how the resident was doing and the nurse said the resident was resting peacefully. Hospice Nurse Q told them to monitor the resident and contact the resident's physician. Hospice Nurse Q gave report to oncoming Hospice Nurse N at 7:00 A.M. Hospice Nurse Q told hospice Nurse N the resident received double the dose of [MEDICATION NAME], the resident's physician was notified and the facility was monitoring the resident. Hospice Nurse Q said during the phone call he/she specifically recalled the facility nurse saying double the dose was administered and he/she did not find out 5 ml of [MEDICATION NAME] was administered until the next day. If Nurse M would have notified him/her the resident was administered 5 ml of [MEDICATION NAME], he/she would have told the facility nurse to contact the resident's physician and would have gone to the facility immediately to assess the resident. During an interview on 6/1/12 at 12:00 P.M., hospice Nurse N said he/she worked day shift on 5/20/12. He/she received report from hospice Nurse Q that the resident received double the dose of [MEDICATION NAME] which would have been 0.5 ml. At approximately 3:40 P.M. on 5/20/12, a facility nurse called to update him/her on the resident's status. The facility nurse told him/her there was a [MEDICATION NAME] medication error and he/she wanted to make sure hospice knew about the error. Hospice Nurse N said he/she was aware the resident was administered double the dose of [MEDICATION NAME] at approximately 2:00 A.M. The facility nurse said no, not double the dose, the ordered dose was 0.25 ml and the resident received 5 ml. Hospice Nurse N asked how the resident was doing and the facility nurse said the resident was sleepy, but woke up with light sternal stimulus. The facility nurse told him/her the resident's physician had been notified, oxygen was ordered and the CNAs were conducting 15 minute checks on the resident. Hospice Nurse N hung up the phone and called his/her supervisor, who notified the hospice medical director. He/she called the facility back and said he/she had told multiple facility nurses to send the resident to the emergency room immediately. Hospice Nurse N was told by Nurse Supervisor P that he/she could not send the resident to the emergency room and transferred him/her to the first floor nurse where he/she was put on hold for over 20 minutes. Then the Interim DON picked up the phone and put him/her back on hold to go assess the resident. When the Interim DON came back to the phone, hospice Nurse N asked him/her if the resident's family had been notified. He/she said no and he/she would notify them. Review of the emergency medical service (EMS) report, dated 5/20/12, showed EMS arrived at the facility at 6:00 P.M. It was reported a resident was administered the wrong dose of [MEDICATION NAME]. The resident lay in bed when EMS arrived and unresponsive to a vigorous sternal rub; the resident was pale in color. [MEDICATION NAME] (drug that reverses the effects of other narcotic medicines) was administered 1 mg in each nares (nostril). The resident became more alert, opened his/her eyes and recognized family at the bedside. During an interview on 6/1/12 at 10:40 A.M., the resident's physician said he/she was notified of the [MEDICATION NAME] medication error on 5/20/12 at approximately 7:00 A.M. The nurse informed him/her 2.5 ml of [MEDICATION NAME] was administered to the resident instead of the ordered 0.25 ml. Since the resident received hospice services, he/she ordered facility staff to administer oxygen, push fluids and continue to monitor the resident for unresponsiveness and lethargy, because those were side effects of [MEDICATION NAME]. He/She received a voicemail in the morning on 5/20/12 from the facility, but did not understand why facility staff did not call his/her cell phone, they have the number. He/She was not aware the resident received 5 ml of [MEDICATION NAME] which was 4.75 ml more than ordered (95 mg more than ordered). He/she would have expected facility staff to notify the resident's family within one to two hours of the medication error due to the resident's change in condition. He/She was unaware the resident's hospice medical director ordered the resident sent to the emergency room and did not understand why the resident was not sent to the emergency room in a timely fashion. He/She would expect the facility to follow the hospice medical director's orders and send the resident to the emergency room immediately. He/She said this was a very significant medication error and could have been a lethal dose. During further interview on 6/1/12 at 11:15 A.M., the resident's physician said he/she would have expected facility staff to monitor the resident's vital signs every one to two hours, including his/her oxygen saturation level and assess the resident's mental status for two to three days after the medication error occurred. During an interview on 6/4/12 at 11:20 A.M., the administer said she was notified of the [MEDICATION NAME] medication error by the Interim DON on 5/20/12 sometime in the afternoon. She was told facility staff were investigating the error to determine how much [MEDICATION NAME] the resident received and were monitoring the resident. She found out, the family had not been notified. She did not go into the facility on [DATE] because she did not realize the substantial amount of medication given. She investigated the medication error on 5/21/12. She was unsure why Nurse M administered medication by him/herself on the night shift of 5/19/12 since he/she was on the second day of orientation and should have been following another nurse. Review of the facility's investigation dated 5/21/12, showed the following: -The Administrator wrote he/she was notified on 5/20/12 at approximately 3:30 P.M., that Nurse M administered an incorrect dose of [MEDICATION NAME] to the resident at 2:00 A.M. Per the nurses notes; a call was placed to the physician at the time of the medication error, as well to the on-call hospice nurse. At 4:15 A.M., the resident's physician had not returned the call and staff continued to monitor the resident. At 7:30 A.M., a new order was received for 2 to 4 liters of oxygen PRN. The resident was monitored throughout the night and day with periods of lethargy noted. Vital signs remained stable and no respiratory distress noted. Hospice was updated on the resident's condition at 2:00 P.M. and the Interim DON was also updated. The resident's family was notified by the Interim DON at approximately 5:15 P.M. on 5/20/12. Per family request, the resident was sent to the emergency room for evaluation at 6:15 P.M. and returned at 10:09 P.M., the same evening. Per review of the emergency room notes, the [DIAGNOSES REDACTED]. Per review of the narcotic count sheet for the medication, it was verified that 5 ml of medication was signed out by Nurse M. He/she was asked to report to the facility on [DATE] to write a statement regarding the event. Nurse M said he/she misread the order, the narcotic count sheet, medication bottle and labels were shown to Nurse M who looked at each and again said she made a mistake and misread the order. Nurse M was then informed he/she had been removed from the nursing schedule until further notice. The facility then accepted Nurse M's resignation. The resident had remained stable throughout the day with periods of lethargy, but otherwise no distress noted, respirations were even and unlabored. The administrator spoke with the resident's POA at great length. An apology on behalf of the facility was extended to him/her, and it was explained that the facility was conducting a thorough investigation. -The Interim DON wrote he/she arrived to the facility on [DATE] at approximately 8:30 A.M., and was notified of the medication error from Nurse Supervisor A. Nurse Supervisor A told him/her the resident's physician and hospice had been notified and to monitor the resident. He/she went to his/her office and to assess the resident. The resident was lethargic but his/her eyes opened after patting his/her shoulder. He/she instructed the nurses to closely monitor the resident. He/she checked on the resident several times throughout the morning and afternoon prior to leaving the facility at 1:30 P.M. He/she received a phone call from the facility later that afternoon informing him/her another staff member had called the resident's doctor about sliding scale insulin and that there was a nursing judgment dispute. He/she spoke with a clinical coordinator prior to returning to the facility to talk about the medication error. Upon returning to the facility, he/she received a call from hospice requesting clarification of the situation. He/she assessed the resident at that time; the resident was lethargic and difficult to arouse. Vital signs were taken and the resident responded to tactile stimulation by opening his/her eyes, but received no verbal response. He/she reported the findings to the hospice nurse and discussed various options of coping with the situation. The resident's POA was informed of the medication error and the hospice nurse would call him/her to also discuss the situation. The resident's POA called the facility approximately 10 minutes later and requested the resident be sent to the hospital. A call was then placed to 911. The family arrived just prior to the ambulance. The resident was transferred to the hospital. Later that evening he/she received a call from a facility nurse informing him/her, the resident would be returning to the facility. During an interview on 6/1/12 at 3:10 P.M., the clinical coordinator said she would have expected the facility nurse to communicate the correct dose of medication that was administered to the resident on 5/20/12 at 2:00 A.M., to ensure continuity of care. During an interview on 6/1/12 at 3:10 P.M., the corporate nurse said the resident's physician was also the facility's medical director. She would have expected facility staff to contact the resident's physician, hospice and family as soon as possible. She would have expected facility staff to contact with the resident's physician within 30 minutes of the medication error because she considered this to be a significant error. If the resident's physician was unable to be notified, she would have expected the nurse to send the resident to the emergency room immediately. There was no need for an order to send a resident to the hospital, it would have been good nursing judgment. After the medication error occurred she would have expected the nurse to monitor t

Based on observation, interview and record review, the facility failed to identify, assess and provide appropriate care for residents with and at risk for pressure ulcers. The facility identified eight residents with pressure ulcers. Five of those eight residents were included in the sample of 17 and the facility failed to provide pressure ulcer treatment and care for those resident and one of those residents had an unstageable pressure ulcer. (Residents #1, #2, # 4, #5 and #6) The census was 100. 1. Review of Resident #1's physician's orders [REDACTED]. -Diagnosis: [REDACTED]. -Hospice services related to end stage [MEDICAL CONDITION]; -Up ad lib (ambulatory as desired); -No skin treatment orders; -admitted on [DATE]. Review of the nurse's notes for January 2012, showed the following: -1/21/12 at 1:00 P.M., no open areas present. The resident said he/she has incontinent episodes with bowel and bladder throughout the day and night. Incontinence brief worn throughout the day and night; -1/22/12, 3:00 P.M. to 11:00 P.M. shift, the resident's skin was warm, dry and intact; -1/23/12 at 2:00 P.M., the resident had a routine body assessment completed, no open areas noted; -1/23/12 at 2:00 P.M., alert and oriented to person, place and time and able to make his/her needs known; -1/24/12 at 2:00 A.M., skin is warm and dry; -1/24/12 at 1:30 P.M., able to make his/her needs known. Review of the admission skin assessment, dated 1/21/12, showed no open areas. Review of the Braden scale (pressure ulcer risk assessment) dated 1/21/12, showed a score of 29 (a score of 12 or less is considered high risk for pressure ulcers.) Review of the weekly skin assessment dated [DATE], showed no open areas, no issues. Review of the care plan, showed the following: -1/21/12, problem: at risk for altered skin integrity related to [DIAGNOSES REDACTED]. -Goal: staff to recognize and treat any complications; -Interventions: adequate fluid and food intake, keep linens dry, monitor for incontinence and keep the area clean and dry, body/skin audit at least weekly, Braden scale quarterly and PRN, evaluate nutritional and circulatory status, keep skin clean and dry, wash with soap, rinse and dry, maintain good body alignment with weight distributed evenly as much as possible. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 2/3/12, showed the following: -Usually understands; -Understood; -No behaviors exhibited; -Always continent of bowel and bladder; -Ambulated independently; -At risk for development of pressure ulcers; -Pressure reducing device for bed; -No unhealed pressure ulcers on admission. Review of the weekly skin assessments, showed the following: -2/6/12: Skin had no open areas. Feet dry, A&D ointment ([MEDICATION NAME] based ointment); -2/13/12: Excoriation noted to bilateral buttocks, [MEDICATION NAME] (moisture barrier cream) used. Review of the resident's care card (located in a book at the nurse's station for certified nurse's aides (CNA's) to use as a guide for caring for the residents), last updated 2/7/12, showed the following: -One or two staff to supervise during bathing; -Independent with dressing, transfers, ambulation and toilet use; -Independent with eating; -Ambulated with a cane; -Occasionally incontinent of bladder; -Preventive skin care program; -Hospice; -Nutrition risk; -Pain frequency/intensity; -Monitor for further decline; -Fall risk; -Sometimes confused. Review of the resident's record, showed no documentation that staff notified the resident's physician of the resident's buttocks excoriated on 2/13/12. No documentation was found to show how often staff had or should apply [MEDICATION NAME] to the resident's buttocks. Review of the nurse's notes, showed the following: -2/17/12 at 12:15 P.M., charge nurse made the writer aware of an open area on the resident's coccyx that measured 3.5 centimeters (cm) by 4.2 cm by 0.1 cm, new orders obtained; -2/17/12 at 7:00 P.M., skin warm and dry, no documentation of the open area; -2/18/12 at 10:20 A.M., the resident was incontinent of bowel and bladder, peri-care provided per staff. Further Review of the POS [REDACTED] -2/17/12: Cleanse the coccyx (tailbone) with wound cleanser, pat dry with a 4 x 4 gauze, apply Hydrogel (a gel that maintains a moist wound healing environment), cover with 4 x 4 gauze and secure with tape daily and as needed (PRN). Review of the weekly skin assessment dated [DATE], showed the following: -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 without slough (yellow or white tissue that adheres to the ulcer in strings or thick clumps, or is mucinous) to the coccyx measured 7.0 cm by 6.0 cm by 0.1 cm, wound bed light red, edges flush with wound bed with a small amount of serosanguinous drainage (drainage composed of serum and blood). Review of the weekly wound tracking worksheet, showed on 2/20/12, the resident had a facility acquired Stage II pressure ulcer on coccyx which measured 7.0 cm by 6.0 cm by 0.1 cm, slough present, treatment was Hydrogel. Review of the care plan, showed an update on 2/20/12, that the resident had a Stage II pressure ulcer on the coccyx. Review of the resident's record, showed no treatment administration record (TAR) dated 1/21/12 through 2/21/12. Review of the POS [REDACTED] -2/24/12: discontinue Hydrogel. change treatment order to cleanse open area on coccyx with wound cleanser or normal saline. Apply a [MEDICATION NAME] dressing (dressing that provides a moist wound environment while protecting the wound from contamination) and change every three days and PRN. Discontinue when healed. Review of the nurse's notes, showed the following: -2/24/12, no time documented, hospice visited that day, new order for coccyx wound; -2/25/12 at 3:00 P.M. through 11:00 P.M., the resident was incontinent of bowel. He/she entered the clean utility room with a chair, put feces in a bag behind the door and used wash cloths in an attempt to clean the floor. Review of the TAR, dated 2/22/12 through 3/21/12, showed the following: -No documentation of treatment completed for the pressure ulcer on the resident's coccyx on 2/25/12 (Saturday) or 2/26/12 (Sunday). Review of the resident's record, showed no shower sheets from 1/21/12 through 2/26/12. Review of the weekly skin assessment dated [DATE], showed the following: - Stage II pressure ulcer to the coccyx measured 8.0 cm by 7.0 cm by 0.1 cm. The area continued to grow larger, the wound bed red with light pink center. Edges flush with a small amount serosanguinous drainage. Review of the shower sheet dated 2/27/12, showed nothing to report. Review of the weekly skin assessment dated [DATE], showed a coccyx Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) pressure ulcer measured 11.0 cm by 5.5 cm by 0.2 cm, area not healing, poor nutrition and disease process. Area has necrosis (dead tissue) in center. Edges are higher than the wound base. Moderate amount of serosanguinous drainage with odor present. Review of the nurse's note dated 3/9/12 at 1:00 P.M., showed the nurse observed the area to the resident's coccyx had progressively worsened. The area had changed from Stage II to a Stage III pressure ulcer and measured 11.0 cm by 5.5 cm by 0.2 cm. Light yellow slough in wound bed, peri-wound (area surrounding the wound) normal. The edges flush with wound bed. Moderate serosanguinous drainage. Orders changed from [MEDICATION NAME] ([MEDICATION NAME] dressing). The resident ambulates freely throughout the facility, had poor intake and a terminal illness. It is the nurse's assessment that this wound progress is unavoidable due to poor nutrition and disease process. New treatment orders were obtained. Hospice notified and family notified. Hospice notified of the need for a low air loss mattress for comfort. During an interview on 4/9/12 at 4:30 P.M., the wound nurse said he/she did not work on 2/24/12 and the resident's hospice case manager obtained an order from the resident's physician to apply [MEDICATION NAME] and to change the dressing every three days. The wound nurse disagreed with the treatment change and finally called the resident's physician on 3/9/12 to get the order changed. The wound nurse said that [MEDICATION NAME] was not the correct dressing for a wound that has drainage. Further Review of the POS [REDACTED] -3/9/12: discontinue [MEDICATION NAME]. Change treatment order to cleanse open area to coccyx, pat dry with 4 x 4 gauze, apply Hydrogel, cover with 4 x 4 gauze and ABD (extra thick dressing) and secure with tape daily and PRN. Review of the care plan, showed the following updates: -3/2/12: Hydrogel for the treatment of [REDACTED]. -3/9/12: Stage III pressure ulcer with slough. Treatment with [MEDICATION NAME] and a low air loss mattress. Review of the shower sheets, which included a body diagram for March 2012, showed the following: -3/3/12: Nothing to report; -3/6/12: No documentation of open area; -3/9/12: The resident's feet were circled and the notation feet dry, A&D ointment used; -3/12/12: No documentation of open area; -3/13/12: Coccyx area circled and an open area noted. Treatment in place for indicated area; -3/16/12: Coccyx area circled and an open area noted. Treatment in place for indicated area; -3/19/12: Coccyx area circled and the word old noted. Treatment in place for indicated area. Review of a receipt dated 3/9/12, showed a low air loss mattress was at the facility on 3/9/12. Review of the weekly skin assessment dated [DATE], showed the resident's coccyx Stage III pressure ulcer measured 12.0 cm by 5.6 cm by 0.6 cm, wound bed red with dark area in the center, foul smelling and large amount of serosanguinous drainage. Area not healing and appears to be a terminal end stage ulcer. Review of the weekly skin assessment dated [DATE], showed the coccyx Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer with scant slough. Necrotic in center and edges higher than base. Very foul smelling with a large amount of drainage. Not healing. Measured 13.0 cm by 5.5 cm by 0.4 cm. Review of the care plan updates, showed the following: -3/16/12: Stage III with slough, treatment of [REDACTED]. -3/23/12: Stage IV and Hydrogel and a low air low mattress. Review of the POS [REDACTED] -3/21/12: [MEDICATION NAME] 0.2% with [MEDICATION NAME] 2% spray gel (opioid [MEDICATION NAME] spray for severe pain), to be applied once daily and PRN for dressing change (maximum changes four times a day.) -3/23/12: discontinue Hydrogel to coccyx. Change treatment to cleanse coccyx with wound cleanser, pat dry with a 4 x 4 gauze, apply Santyl ([MEDICATION NAME] agent) to wound bed, cover with a 4 x 4 gauze and ABD, secure with tape. Change daily and PRN.; -3/27/12: [MEDICATION NAME] powder (antifungal) to wound base with each dressing change; -3/28/12: Okay for wound care specialist to follow for wound care; -3/28/12: Pre [MEDICATION NAME] (blood test to detect [MEDICAL CONDITION]); Review of the TAR, dated 2/22/12 through 3/21/12, showed the following: -[MEDICATION NAME] spray gel ordered 3/21/12 was not transcribed on the TAR and not documented as applied. Review of the nurse's note, showed the following: -3/23/12 at 3:30 P.M., treatment orders changed due to yellow slough present in the wound. The area appears to be an end stage wound and now a Stage IV that measured 12.5 cm by 6.0 cm by 2.0 cm. This area was unavoidable due to poor intake and disease process; -3/29/12 at 3:30 P.M., the resident's [MEDICATION NAME] lab result measured 5.0 (normal range 15-35) and reported to the resident's physician; -3/29/12 at 7:00 P.M., incontinent of bowel and bladder. Review of the TAR, dated 3/21/12 through 4/10/12 showed the following: -Santyl not initialed by staff as administered on 3/24/12 (Saturday), 3/25/12 (Sunday) and 4/1/12 (Sunday). No documentation on the back of the TAR of the reason the treatment was not performed. -[MEDICATION NAME] spray gel not initialed by staff as applied on 3/24/12, 3/25/12 and 4/1/12. No documentation on the back of the TAR of the reason the treatment not performed. Review of the weekly skin assessment dated [DATE], showed coccyx Stage IV, bed edges pink, center dark brown slough, edges higher than base, visible muscle and measured 12.0 cm by 6.0 by unable to determine depth. During an interview on 4/9/12 at 4:20 P.M., the wound nurse said he/she works Monday through Friday and he/she assigns the wound treatments to the charge nurses on the weekends. He/she said they did have some issues getting the treatments done on the weekends but it is getting better and it was a work in progress. Review of the care plan updates, showed the following: -3/30/12: Unable to determine the stage of the pressure ulcer, necrotic (dead tissue) [MEDICATION NAME] spray, Santyl; -4/6/12: Unable to determine the stage of the pressure ulcer, necrotic, [MEDICATION NAME] spray, Santyl and [MEDICATION NAME] powder. Further review of the shower sheets, showed the following: -3/30/12: Nothing to report. -4/3/12: No documentation of open area; -4/9/12: Coccyx area circled and the word treatment noted. Treatment in place for indicated area. Observation and interview on 4/5/12 at 11:00 A.M., showed the wound nurse provided care to Resident #1's coccyx pressure ulcer. The wound nurse said the open area to the coccyx was a Stage IV and said it was an end stage terminal Kennedy ulcer (ulcer developed when someone is actively dying). The area measured 13.0 cm by 6.5 cm, yellow slough covered 80% of the wound bed. The wound nurse cleansed the area with wound cleanser, sprayed [MEDICATION NAME] spray on the wound bed, applied Santyl and [MEDICATION NAME] powder, covered with a gauze pad and an ABD dressing and tape. The wound nurse said the pressure ulcer started as excoriation then progressed extremely fast into a Stage II pressure ulcer in February 2012. Observation on 4/6/12, showed the following: -9:45 A.M., the resident walked around his/her room with a saturated incontinence brief on. The resident wore two incontinence briefs that were so saturated with urine, it sagged down. The dressing on the resident's coccyx was saturated with urine and half off from the top of the wound. The resident took the soiled incontinence briefs off and put pants on, without putting on a clean incontinence brief or cleansing the urine from his/her skin; -10:10 A.M., the hospice aide in the resident's room. He/she was straightening up the resident's room and changing the bed linens; -10:45 A.M., the resident walked around the facility being social with staff and other residents; -11:00 A.M., Certified Medication Technician (CMT) E gave the resident a cup of juice and a snack . The resident sat in a chair by the nurse's station and ate his/her snack; -11:15 A.M., the wound nurse dressed the resident's coccyx area. During an interview on 4/6/12 at 2:30 P.M., CNA H said he/she was assigned to the resident often. CNA H said to find how to care for a resident there was a care card book at the nurse's station. It shows staff what the resident care needs are including activities of daily living (ADL's) care. Resident #1 needs assistance with grooming, dressing and peri-care, as often as needed. The resident refuses assistance with care sometimes and he/she reports that to the nurse when it occurs. He/she assists the resident to the toilet and if the dressing on the resident's back is saturated or coming off, he/she notifies the charge nurse to get the dressing replaced. Observation on 4/9/12 at 10:15 A.M., showed the resident in his/her room. The resident had one incontinence brief on. No dressing covered the resident's coccyx pressure ulcer. During an interview on 4/9/12 at 10:55 A.M., the hospice aide said he/she has been assigned to the resident since prior to his/her admission on 1/21/12. He/she said the resident had no open areas when he/she was admitted to this facility. He/she comes to the facility five days a week and assists the resident with personal care, including a shower or bed bath, makes the bed, changes bed linen when needed, straightens the resident's room, nail care, takes the resident outside to smoke and chats with the resident. The resident received one bed bath because the resident was very sleepy that day, but all the other visits he/she showered the resident. The hospice aide said the check mark on the hospice aide progress note, shows the resident was showered. The hospice aide could not recall the resident's coccyx area being open prior to 2/21/12. He/she said the facility already knew about the open area so he/she did not document it on the progress note. There was usually a dressing on the coccyx area but it was often not intact when he/she arrived to the facility to care for the resident. The resident was always incontinent of bowel and bladder. When preparing the resident for a shower, the resident often had on two incontinence briefs, both of them saturated with urine and feces. The dressing on the resident's coccyx was often saturated with urine and feces. When he/she showers the resident, the dressing always comes off and he/she informs the resident's nurse the dressing is off. He/she has observed the resident go into the bathroom, pull down his/her pants, rip off the saturated urine and feces filled incontinence brief and throw it in the corner. Then the resident pulls his/her pants back up and ambulates around the facility without a incontinence brief on. The hospice aide said the resident has never been uncooperative or refused care from him/her. The hospice aide showered the resident that day at approximately 9:15 A.M. The dressing was removed during the shower. He/she notified the resident's nurse the dressing was off. Observation on 4/9/12 at 12:10 P.M., showed the back of the resident's pants were wet. The resident went into his/her bathroom pulled down his/her pants, ripped off the incontinence brief that was saturated with urine, threw it in the corner of the bathroom and pulled up his/her pants. The resident said "oh I guess I do not need to go to the bathroom now because I already went." There was no dressing on the resident's coccyx pressure ulcer at that time. Observation on 4/9/12 at 12:40 P.M., CNA C entered the resident's room. He/she donned gloves and threw away the soiled incontinence brief that was on the resident's bathroom floor. Without providing peri-care, the CNA assisted the resident to put on a clean incontinence brief. The resident requested to put two incontinence briefs on. CNA C said only one incontinence brief should be worn at a time. The incontinence brief was marked by the surveyor at that time. Observation on 4/9/12 at 12:50 P.M., showed the wound nurse and the wound specialist doctor entered the room to assess and provide treatment to the resident's coccyx pressure ulcer. No dressing covered the pressure ulcer. The wound specialist doctor measured the area on the resident's coccyx, 10.5 cm by 7.5 cm by 3.0 cm. He/she debrided the wound, removing the necrotic tissue. Observation on 4/9/12 at 2:00 P.M., showed the resident walked around the facility socializing with staff and other residents. Observation on 4/9/12 at 5:35 P.M., showed the resident walking around the facility. The resident's pants were wet in the back. CNA D walked the resident to his/her room to assist the resident with peri-care. The resident pulled his/her pants down. The resident had on two urine saturated incontinence briefs. The resident ripped off both incontinence briefs and threw them on the floor. The dressing over the coccyx pressure ulcer was not intact, it was saturated with urine and feces and drainage from the wound was coming out of the bottom of the dressing. The resident requested to put two incontinence briefs on, CNA D said only one incontinence brief should be worn at a time. Observation showed the incontinence brief remained marked from the 12:40 P.M. observation. During an interview on 4/9/12 at 5:40 P.M., CNA D said the resident always requested to wear two incontinence briefs at a time. The Director of Nurses (DON) has told staff they should encourage him/her to only wear one incontinence brief at a time. CNA D said he/she had not changed the resident since getting to work at 3:00 P.M. She said the resident puts two incontinence briefs on and sometimes he/she wears three incontinence briefs. During an interview on 4/10/12 at 9:17 A.M., the wound nurse said for the most part the resident is continent of bowel and bladder. The resident does have bad days, meaning he/she is incontinent of bowel and bladder. The resident's dressing gets saturated with urine and feces. The wound nurse said the CNA's should be checking the resident every two hours for incontinence because urine and feces can break the skin down quickly. The dressing should not be off for any period of time, if someone told him/her the dressing was off or not intact, he/she would change it right away because it could cause infection and would slow down the healing process. The resident does put multiple incontinence briefs on at a time. Hospice supplies them and leaves them in the resident's drawer. He/she said the wound is an unavoidable pressure ulcer because the resident is up and ambulatory. His/her labs show the resident is nutritionally compromised, he/she is terminally ill with poor nutritional intake. The area on the resident's coccyx started out as excoriation and got worse really fast. The resident's hospice aide showers the resident five days a week and should be completing the shower sheets, but he/she does not always document his/her findings on the shower sheet. The wound nurse said he/she documents the resident's weekly skin assessments and measures the wounds weekly also. During an interview on 4/10/12 at 9:45 A.M., the DON said the resident was admitted on [DATE] with no open areas. The interventions in place when the resident was admitted were to shower the resident twice a week, monitor his/her nutrition, complete the Braden scale and skin assessments weekly. The DON said the resident was nutritionally compromised at the time of admission and he/she had lost a lot of weight, has no body fat, poor fluid and food intake, incontinent at times of bowel and bladder and refuses care from staff at times. She said the resident rarely lies in bed because he/she is afraid he/she will die. The resident has a history of loose feces. The CNA's have care cards that are kept in a book at the nurse's station. The care cards show how to care for the resident and should include how the resident gets around the facility, in a wheelchair or ambulatory, transfers, continence status and diet. The care cards should be updated and she would have expected to see on the 2/7/12 care card that the resident should have a dressing on the coccyx area and if it's not on, to notify the wound nurse. Basically, the care card is a continued communication for the facility staff to use. The DON said the area on the resident's coccyx is not a pressure ulcer; it is a Kennedy terminal ulcer due to poor nutritional status. She would expect staff to check the resident for incontinence care every one to two hours to ensure the dressing on the resident's coccyx is intact and the resident is clean and dry. She said if the resident was incontinent and the dressing was saturated with urine and/or feces or not intact she would expect the CNA to let the charge nurse know immediately so the wound could be cared for properly and to keep the area clean and dry. She would expect a dressing to cover the wound at all times. The DON was unaware the dressing on the resident's coccyx was not dressed for hours. She would expect the hospice aide to communicate with the wound nurse and the wound should dress the pressure ulcer immediately after the resident is out of the shower. When staff find the resident is incontinent and the dressing is soiled with urine and/or feces, staff should notify the charge nurse because anyone can change the resident's dressing not just the wound nurse. She was unaware of the treatments not initialed on the TAR. She said if the treatment was not signed off by staff she has to assume it was not done. If it was not done for a reason she expects staff to write the reason on the back of the TAR. She would expect staff to order a low air loss mattress with any open area regardless of the stage of the wound. She did not know why the facility failed to order a low air loss mattress until 3/9/12. When the resident's buttocks were assessed and found excoriated, she expected staff to notify the resident's physician, get treatment orders and transcribe the treatment orders onto the TAR. She said the resident's family puts two incontinent briefs on him/her when they go out on outings; it is probably for convenience for them. The resident does request to wear two incontinence briefs at a time, but she informed staff only one incontinence brief is to be worn at a time. During an interview on 4/10/12 at 2:55 P.M., the corporate nurse said a Braden scale should be completed when a resident is a new admit, readmitted to the facility, once a week for the first four weeks and quarterly thereafter. That's the standard practice for the facility. Further review of the resident's record, showed no other Braden Scales completed other than the admission one dated 1/21/12. During an interview on 4/12/12 at 11:48 P.M., the wound specialist physician said he saw the resident for the first time on 4/9/12. He assessed the pressure ulcer and said it would be classified as an Unstageable (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) pressure ulcer. He said you cannot see the depth of the wound due to the necrotic tissue and that's why it is considered a Stage IV. The wound specialist debrided the necrotic area during the visit and said he would treat it more aggressively but the resident is on hospice. He said he is familiar with Kennedy Ulcers and the wound was not the classic look of a Kennedy ulcer. A Kennedy ulcer occurs in the groin and perineal area. The skin looks red and the area gets infected and spreads to the fascia (connective tissue that surrounds muscles.) A resident that has a Kennedy ulcer dies within a few days. The wound is on the resident's coccyx area and wounds in that area are almost always due to pressure. He said a Stage I pressure ulcer is reddened skin and that is when he would put additional interventions in place, like a specialty mattress to prevent further skin breakdown. 2. Review of Resident #2's care plan, last updated 10/14/11, showed the following: -Problem: at risk for altered skin integrity due to dependence on staff for all tasks/ADL completion and incontinent of bowel and bladder; -Goal: Staff to recognize and treat any complications; -Interventions: adequate fluid and food intake, administer medications as ordered, apply heel and elbow guards as necessary, assist to turn and reposition every two hours and PRN while in bed, assist to change wet clothing immediately, body/skin audit at least weekly, Braden scale quarterly and PRN, evaluate nutritional and circulatory status, keep linens dry and wrinkle free, keep skin clean and dry, wash with soap, rinse and dry, maintain good body alignment with weight distributed evenly, monitor for increase in urinary incontinence, if noted report to the nurse, monitor for skin redness, irritation, rashes, open areas, non blanching areas, and discoloration and notify the charge nurse, observe for any repeat signs and symptoms of infection, peri care given per each incontinent episode with barrier ointment applied PRN and skin audits with showers and PRN. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Usually understands; -Usually understood; -Always incontinent of bowel and bladder; -Total assistance for toileting, bathing and transfers; -Extensive assistance for personal hygiene and range of motion; -Nonambulatory; -Stage III pressure ulcer. Review of the resident's care card, last updated 2/3/12, showed the following: -Dependent on one to two staff for all ADL's; -Frequently incontinent of bladder; -Incontinent of bowel; -Tilt wheelchair all or most of the time; -Range of motion (ROM)/positioning, turn and reposition every two hours; -Monitor skin daily; -Staff to monitor skin and reposition frequently as need. Review of the re-admission nurse's note dated 2/22/12, showed a laceration to the left foot. The hospital was treating the area with [MEDICATION NAME] (gauze packing) and a dry dressing. The resident's second toe and a blister to the resident's left foot. The right foot had an old black area. The resident's heels were soft and the coccyx noted with white to yellow area. Review of the re-admission skin assessment, dated 2/22/12, showed a treatment to a Stage II pressure ulcer on the resident's coccyx. Treatment to the left outer foot, an intact blister on the left posterior lower extremity (the back side of the left leg). Review of the Braden Scale dated 2/22/12, showed a score of 12. Review of the weekly skin assessment, showed the following: -2/27/12: Left lateral foot Stage III pressure ulcer that measured 1.3 cm by 1.5 cm by 1.0 cm. Tunneling at 3:00 o'clock through 6:00 o'clock at 1 cm. Pink wound bed with dark red and serosanguinous drainage; -3/5/12: Left lateral foot Stage III pressure ulcer that measured 3.0 cm by 1.8 cm by 0.2 cm. The wound bed had slough in the center with heavy amount of serosanguinous drainage; -3/12/12: Left lateral foot Stage III pressure ulcer that measured 2.3 cm by 1.5 cm by 0.2 cm. The wound bed light pink, with white edges with a moderate amount of serosanguinous drainage; -3/19/12: Left lateral foot Stage III pressure ulcer that measured 2.0 cm by 2.0 cm by 0.2 cm. The wound bed light pink, with white edges, with a moderate amount of serosanguinous drainage; Review of the POS [REDACTED] -Diagnoses: [REDACTED]. -4/3/12: Cleanse left lateral foot with wound cleanser, pat dry with a 4 by 4 gauze, cover with Calcium Alginate (dressing used to manage full thickness wounds, proving a moist wound environment and absorption of drainage), cut to size, cover with 4 by 4 gauze, an ABD, wrap in a gauze wrap and secure with tape daily and PRN. Review of the weekly skin assessment dated [DATE], showed left later foot Stage III pressure ulcer measured 2.2 cm by 1.5 cm by 0.1 cm. The wound bed 25% dark red and 75% light pink, with white edges. Observation on 4/4/12, showed the following: -During the initial tour of the facility at 9:00 A.M., the resident sat in his/her tilt wheelchair at the nurse's station. A dressing was observed on the resident left foot. The resident had bunny boots (pressure reducing devices) on his/her feet. The resident's legs were contracted with his/her feet placed directly against the pedals of the wheelchair. The resident was tearful and grimacing; -10:25 A.M., the resident sat up in his/her wheelchair at the nurse's station. The resident's right bunny boot lay on the floor next to his/her wheelchair. His/her right foot pressed directly against the pedals of the wheelchair; -2:15 P.M., the resident lay in bed. His/her right foot pressed directly on his/her left foot, while wearing bunny boots; -3:40