Every finding on record at Florissant Valley Health & Rehabilitation Center

Based on interview and record review, the facility failed to provide services per acceptable standards of practice for one resident (Resident #1), when the facility failed to follow physician orders for a new medication to treat nerve pain for 10 days after the resident returned from an appointment with the neurologist (physician who treats the nervous system). The sample size was 4. The census was 79.The administrator was notified on 10/29/25, of the past non-compliance. The administrator of the facility investigated immediately 10/12/25, in-serviced all staff on following up on resident outside appointments to ensure paperwork is received and reviewed when a resident returns from an appointment for new and or changed orders. Facility conducted a 100% audit of residents outside appointments for paperwork for new and/or changed orders and the Medical Director (MD) and resident representative notifications were completed on any missed orders. The past non-compliance was corrected on 10/17/25. Review of the facility's Physician Orders Policy, updated 9/28/22, showed:-Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state & federal guidelines.-The Licensed Practical Nurse (LPN), Registered Nurse (RN), nursing administration and the Director of Nursing (DON) are responsible to follow physician orders as written and clarify illegible or unclear orders prior to implementation. Review of Resident #1's electronic medical record (EMR) showed:-Moderately impaired cognition;-Diagnoses included Wernicke's encephalopathy (a severe neurological emergency caused by Vitamin B1 deficiency), muscle wasting and atrophy, diabetes, and vascular diseases;-A Neurology after visit summary, dated 10/2/25, showed start taking this medication: gabapentin (seizure medicine that can be used to treat nerve pain) 100 milligram (mg) capsule daily;-A nurse progress note dated 10/13/25, resident's family member approached nurses' station regarding the medication gabapentin. This nurse Informed him/her that an order for gabapentin was not on the resident medication list. Call placed to physician; new order received for gabapentin 100 mg daily. Call placed to pharmacy and medication ordered;-A physician order dated 10/13/25 for gabapentin 100 mg in the morning for nerve pain. During an interview with the Administrator and Interim DON on 10/28/25 at 2:40 P.M., they said they were aware of the resident not receiving ordered gabapentin until 10/13/25 due to facility not following up on resident outside appointment on 10/2/25 with the neurologist. They would have expected staff to have called the physician's office and request follow up paperwork since the resident did not return to the facility with the paperwork. 2644453

Based on interview and record review, the facility failed to adequately treat pain for one resident (Resident #2) who was actively dying. The sample size was three. The census was 72. Review of the facility's pain management policy, dated 11/15/22, showed:-Policy: The Facility will use a systematic approach to pain management; Recognition, evaluation, treatment, and monitoring of pain. Individuals experiencing pain may receive pharmalogical/non-pharmalogical interventions to assist in pain management. The Facility will provide employees education on pain management & opioid (class of drugs used for pain relief) overdose;-Recognition included recognizing when a resident was experiencing pain and identify circumstances when pain can be anticipated; Evaluate the resident for pain on admission and routinely; Manage/Prevent pain consistent with comprehensive evaluation and plan of care, current professional standards of practice and resident's goal/preferences;-Observe for non-verbal indicators of pain;-Nurses will complete a pain evaluation tool, appropriate for the resident's cognitive status to assist with evaluation of a resident's pain;-Based on the evaluation, Nursing in collaboration with the physician/prescriber, other health care professionals, the resident and/or the resident's representative will develop, implement, monitor and revise, as necessary, interventions to prevent/manage a resident's pain;-Opioids will be prescribed and dosed in accordance with current professional standards of practice and manufacturers' guidelines to optimize their effectiveness and minimize their adverse consequences;-Nursing will notify Practitioner if the resident's pain is not controlled by the current treatment regimen;-Nursing will reassess resident's pain management for effectiveness and/or adverse consequences at established intervals;-If re-evaluation findings indicate pain is not adequately controlled, the Pain Management Regimen and Plan of Care will be revised as indicated.-If pain has resolved or there is no longer an indication for pain medication, the Interdisciplinary Team will work to discontinue or taper analgesics (pain killers) (as needed to prevent withdrawal symptoms). Review of Resident #2's care plan, undated, showed:-Problem: At risk of unmanaged chronic pain related to poly-neuropathy (multiple nerves are damaged in lower body). Interventions included: Administer analgesics as ordered by physician; Document pain on 1-10 scale; Monitor response to analgesics and pain alleviation measures;Observe resident during care for signs of pain; Update physician on effectiveness of analgesics and pain medication;-Problem: The resident was receiving hospice care due to unspecified protein malabsorption. Interventions included: Encourage support system of family and friends; Observe the resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Review of the resident's physician order sheet, showed:-An order, dated 12/29/22, for a pain evaluation, every shift for monitoring of resident's pain level;-An order, dated 8/23/23, for morphine sulfate solution (morphine, opioid pain reliever used to treat moderate to severe pain) 20 milligrams (mg) for every five milliliters (ml), give 0.25 ml every four hours as needed for pain;-An order, dated 1/31/24, may admit to hospice care;-An order, dated 8/22/24, for Hydrocodone-acetaminophen 5 - 325 mg (Norco, opioid pain reliver combined with acetaminophen), take one tablet every eight hours for pain. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 3/1/25, showed:-Severe cognitive deficiency;-Disorganized thinking and inattention present;-Impairment present on both sides of the upper and lower body;-On a scheduled pain medication regimen;-Did not receive pain medication as needed;-Received non-medication intervention for pain;-Resident reported not presence of pain during pain assessment interview;-Received hospice care (provides comfort and support by managing pain and other symptoms at end of life);-Diagnoses included heart failure, aphasia (language disorder that affects ability to communicate) dementia and kidney disease. Review of the resident's Medication Administration Record (MAR), dated March 2025, showed:-On 3/12/25, at 6:00 A.M., the facility administered one Norco to the resident;-On 3/12/25, at 6:30 A.M., the resident had a pain level of 0. Review of hospice focus visit, dated 3/12/25, showed:-The visit was an unscheduled symptom evaluation;-A hospice nurse started the visit at 7:55 A.M. and ended visit at 8:45 A.M.;-Interventions performed: Call for a change in condition and ordered morphine;-The resident started moaning when touched for care;-The resident was nonverbal;-Report was given to the facility nurse who administered morphine 0.25 ml;-Norco 5-325 mg was not given;-The facility nurse administered morphine 0.25 ml to the resident for pain;-Report of visit given to facility nurse, Director of Nursing (DON) and the resident's family member. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/12/25 at 9:30 A.M., the facility administered 0.25 ml to the resident with 7.75 ml remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered morphine to the resident on 3/12/25;-On 3/12/25, at 2:00 P.M., the facility administered one Norco to the resident;-On 3/12/25, at 2:30 P.M., the resident had a pain level of 0;-On 3/12/25, at 10:00 P.M., the facility administered one Norco to the resident;-On 3/12/25, at 10:30 P.M., the resident had a pain level of 0;-On 3/13/25, at 6:00 A.M., the facility administered one Norco to the resident;-On 3/13/25, at 6:30 A.M., the resident had a pain level of 0. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/13/25, at 6:30 A.M., the facility administered 0.25 ml to the resident with 7.50 ml remaining;-On 3/13/25, at 10:30 A.M., the facility administered 0.25 ml to the resident with 7.25 ml remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered morphine to the resident on 3/13/25. Review of the resident's progress notes, showed:-On 3/13/25 at 10:55 A.M., the resident had a change of condition. The resident was nonresponsive. The hospice nurse was here to see the resident and cancelled all prescription medications except for all pain medications. The primary care physician (PCP) was informed of the resident's condition and gave new order for acetaminophen (pain reliver and fever reducer) 650 mg suppository, give every six hours for a temperature of 99 degrees or greater. Review of the resident's MAR, dated March 2025, showed:-An order dated 3/13/25 at 11:50 A.M., for acetaminophen suppository 650 mg, insert 1 suppository rectally every six hours as need for a temperature of 100 degrees or above;-No documentation the medication was administered to the resident;-On 3/14/25, at 6:00 A.M., the facility administered one Norco to the resident;-On 3/14/25, at 6:30 A.M., the resident had a pain level of 1;-On 3/14/25, at 2:00 P.M., the facility administered one Norco to the resident;-On 3/14/25, at 2:30 P.M., the resident had a pain level of 0;-On 3/14/25, at 10:00 P.M., the facility administered one Norco to the resident;-On 3/14/25, at 10:30 P.M., the resident had a pain level of 0. Review of the hospice focus visit, dated 3/14/25, showed:-The hospice nurse visited the resident at 12:05 P.M. and ended the visit at 1:05 P.M.;-The resident was non verbal;-The resident had a decreased response to verbal and visual stimuli;-The resident had an absent radial (artery found on the thumb side of the wrist) pulse;-The resident had decreased urine output;-The resident's blood pressure was 84/36 and a heart rate of 120 bpm;-Interventions performed: assess for signs and symptoms of pain during visit and assess respiratory (breathing) status during visit;-The resident was unresponsive, not following commands. The facility nurse said the resident had just received morphine and had a fever which was treated by acetaminophen. There was no fever noted by the hospice nurse during assessment;-The resident was on 2.5 liters of oxygen and his/her saturation (amount of oxygen in the blood, typically between 95% and 100%) rate was in the 90s. The facility nurse said he/she would give the resident Ativan. Review of the hospice supplemental interdisciplinary note, dated 3/14/25 at an unknown time, showed:-The writer of the note was a hospice nurse;-Visit type: Patient Services (In person contact);-Reviewed the facility medical record and received report from the facility nurse;-The facility nurse stated the resident had not received any Ativan yet because the in-house physician had not signed the order for it;-The hospice nurse gave the order for Ativan to the facility the day prior, from the hospice physician. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/14/25, at an illegible time, the facility administered 0.25 ml to the resident with 7.0 ml remaining;-On 3/14/25, at 2:00 P.M., the facility administered 0.25 ml to the resident with 6.75 ml remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered morphine to the resident on 3/14/25. Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-Medication Name/Strength: Ativan 0.5 mg, give by mouth every three hours for pain and anxiety;-On 3/14/25, at 2:25 P.M., the facility administered one tablet of Ativan to the resident, with a remaining quantity of one tablet. Review of the resident's MAR, dated March 2025, showed:-An order, dated 3/13/25, at 3:53 P.M., to give Ativan 0.5 mg, every two hours as needed for pain;-No documentation the facility administered Ativan 0.5 g on 3/14/25 at 2:25 P.M. Review of the hospice supplemental interdisciplinary note, dated 3/14/25 at an unknown time, showed:-At 4:00 P.M., the hospice nurse made a follow up call to the facility and found the resident had not yet received any Ativan, as per physician orders;-The facility nurse said the nurses' cart was stuck or would not open to get the Ativan out. The facility nurse was waiting on the pharmacy to come and fix it. Review of the resident's MAR, dated March 2025, showed:-Documentation showed the facility administered Ativan 0.5 mg as ordered on 3/14/25 at 4:30 P.M.; Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-No documentation the facility administered Ativan 0.5 mg to the resident on 3/14/25, at 4:30 P.M.-On 3/14/25, at 6:18 P.M., two tablets were added to the controlled substance accountability sheet, showing three tablets available for administration. Review of the resident's MAR, dated March 2025, showed:-On 3/15/25 at 6:00 A.M., the facility attempted to administer one Norco to the resident. The resident refused;-On 3/15/25 at 6:30 A.M., the resident had a pain level of 0. Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-On 3/15/25 at 12:00 P.M., the facility administered Ativan 0.5 mg to the resident. Review of the resident's MAR, dated March 2025, showed:-No documentation the resident received Ativan 0.5 mg on 3/15/25 at 12:00 P.M. Review of the Hospice RN's focus visit sheet, dated 3/15/25, showed:-The visit started at 12:00 P.M.;-The resident had decreased response to verbal and visual stimuli, hyperextension of the neck, grunting of vocal cord, depression of the jaw on inspiration (when breathing in), death rattle (a gurgling sound heard in a dying person's throat), and Cheyne-Stokes breathing (fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all);-Upon arrival to the facility, the resident was found in bed with the resident's family member at bedside. The resident appeared to be actively dying and displayed signs of discomfort;-Staff stated the resident received comfort medications, however, upon further assessment it was evident the resident exhibited increased respiratory effort and signs of pain;-Review of the resident's MAR showed the resident had not received any comfort medications in almost 24 hours;-The facility nurse assigned to the resident was not present and another nurse on the unit assisted;-The Hospice RN contacted his/her supervisor and the hospice on-call physician, who gave new orders to administer morphine every 15 minutes until the resident was comfortable;-The visit ended at 2:00 P.M. Review of the Hospice RN's supplemental Interdisciplinary note, dated 3/15/25, showed:-The visit stated at 12:00 P.M.;-The resident had a pain level of six, out of a 0 - 10 pain scale (0 was no pain and 10 as the highest level of pain)-Current pain and symptom management was not satisfactory;-A total of three doses (morphine) were given before the resident began to show signs of relief;-Hospice RN expressed his/her concerns directly to the facility Administrator regarding the delay in patient care and the resident's family member's concerns the resident was not receiving adequate attention;-It was also noted the facility was low on morphine;-Hospice RN followed up with the on-call hospice physician who gave verbal orders for morphine give every four hours, scheduled and every two hours as needed, along with staff instructions to assess the resident frequently and administer medication as needed;-Hospice RN was at the facility for approximately two hours to ensure the resident's needs and the resident's family member's needs were addressed;-Hospice RN ensured had clear guidance and new scripts to pull morphine for the resident. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/15/25 at 12:00 P.M., LPN C administered 0.5 ml to the resident with 6.25 ml remaining. Review of the resident's MAR, dated March 2025, showed:-There was no documentation found the facility administered morphine 0.5 ml to the resident on 3/15/25 at 12:00 P.M. Review of the resident's physician order sheet, showed:-An order, dated 3/15/25 at 1:03 P.M., for morphine 10 mg/5 ml, give 10 ml every two hours as needed for pain. Review of the resident's controlled substance accountability sheet, undated, for morphine, showed:-On 3/15/25, at 2:00 P.M., LPN C administered 0.5 ml to the resident with 5.75 ml remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered morphine 0.5 ml on 3/15/25 at 2:00 P.M.-On 3/15/25, at 2:30 P.M., the resident had a pain level of 0;-An order on 3/15/25, at 3:18 P.M., discontinued at 11:40 P.M., for morphine 10 mg/5 ml, give 0.5 ml every two hours as needed for pain. There was not documentation found showing the facility administered morphine for this order;-An order on 3/15/25 at 3:18 P.M., discontinued at 3/15/25 at 11:40 P.M., for morphine 10mg/5ml, give 0.5 ml every four hours as needed for pain. Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-On 3/15/25, at 5:00 P.M., one tablet was administered to the resident, with one tablet remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered Ativan 0.5 mg to the resident on 3/15/25 at 5:00 P.M. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/15/25 at 6:00 P.M., LPN C administered 0.5 mls to the resident with 4.75 ml remaining;-No documentation the facility administered any more doses of morphine to the resident. Review of the resident's MAR, dated March 2025, showed:-The facility administered 0.5 ml of morphine to the resident on 3/15/25, at 6:00 P.M. Review of the hospice telecare call record, dated 3/15/25, showed:-At 7:18 P.M., LPN A called the hospice on-call triage to report the resident was actively transitioning and the resident's Power of Attorney (POA) was requesting an order for morphine, give every two hours;- At 7:19 P.M., a hospice nurse spoke to LPN A who reported he/she did not have any morphine 20 mg/ml on hand for the resident and was requesting medication. The hospice orders were reviewed and noted an order for morphine 20 mg/ml, gave 0.5 ml (10 mg) by mouth every two hours as needed for shortness of breath. LPN A reported the resident's family member was requesting morphine every two hours. LPN A was advised the assigned hospice nurse would get sent out to the facility due to the resident actively transitioning. Hospice would call a pharmacy in regards to getting morphine due to the facility running out/not having any on hand. LPN A was advised to continue to monitor the resident and call back if anything changed. LPN A indicated he/she understood and agreed to the plan;-At 7:30 P.M., hospice called a pharmacy in an attempt to order morphine for the resident. The pharmacy did not work with the facility;-At 7:40 P.M., hospice called the facility pharmacy in regards to medication morphine 20 mg/ml take 0.5 ml (10 mg) by mouth every two hours as needed for shortness of breath. There was no answer;-At 7:46 P.M., hospice called LPN A who said he/she called the facility pharmacy and they were working on having the morphine delivered (waiting call back). LPN A agreed to call back if any changes in pt status; No further needs at this time. Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-On 3/15/25 at 8:00 P.M., one tablet was administered to the resident, with zero tablets remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered Ativan 0.5 mg to the resident on 3/15/25 at 8:00 P.M. Review of the Hospice RN's focus visit sheet, dated 3/15/25, showed:-The visit started at 7:50 P.M.;-The resident had decreased response to verbal and visual stimuli, hyperextension of the neck, grunting of vocal cord, depression of the jaw on inspiration, drooping of the nasolabial folds (lines that run from the sides of the nose to the corner of the mouth), death rattle, and Cheyne-Stokes breathing;-The resident's pain level was 6;-The resident's family member called Hospice RN to report the resident had not received any comfort meds in over four hours. Hospice RN called the facility and they said they were not able to pull morphine out of the ADU for the resident;-Hospice RN sent a script for morphine to a local 24 hour pharmacy, he/she arrived at the local pharmacy at approximately 7:50 P.M., received the morphine from the local pharmacy at approximately 8:30 P.M., then drove back to deliver the morphine to the facility;-At approximately 9:15 P.M., Hospice RN delivered the morphine to the facility staff and ensured the resident received a dose before leaving at approximately 9:30 P.M. Review of the resident's medical record, showed:-A progress note, dated 3/15/25 at 10:08 P.M., said the resident had transitioned at 10:00 P.M. The resident's family was present and aware of the resident's declining condition. Comfort measures were provided including pain management and emotional support for family. Vital signs were absent and postmortem care was provided. The Hospice team and physician was notified. Unable to reach the resident's guardian. Review of the resident's MAR, dated March 2025, showed:-The facility administered 0.5 ml of morphine to the resident on 3/15/25, at 10:00 P.M.-On 3/15/25, at 10:30 P.M., the resident had a pain level of 0. During an interview on 7/25/25 at 9:18 A.M., LPN A said:-He/She checked on residents throughout the day, assessing for pain;-He/She would call the Primary Care Physician to obtain new orders if a resident had pain and no pain management medication available as well as checking the ADU to see if the medication was available to pull before pharmacy delivered;-He/She would call hospice to get a script for Ativan and/or morphine if a resident was on hospice, actively dying and did not have those medications available at the facility to administer;-He/She worked on 3/15/25 from 3:00 P.M. until 7:00 A.M. on 3/16/25, and was assigned to the resident's care;-The resident's family member was at bedside and upset about how nursing staff were administering pain medication to the resident. The family member would ask for pain medication for the resident every couple of hours, just to remind us;-He/She gave the resident one dose of morphine when he/she came on shift. It was the last dose available in the bottle and the resident did not have another bottle of morphine available for his/her next administration;-The off-going nurse (unknown name) told LPN A the resident was almost out of morphine and to get the next bottle from the ADU;-He/She was not able to pull morphine out of the ADU;-He/She called the facility pharmacy who confirmed they had a script for the morphine and it should be available to pull from the ADU. He/She was not sure what time the phone call to pharmacy was made;-He/She called the Hospice RN to notify him/her the resident had run out of morphine and there was some sort of glitch in the ADU which prevented LPN A from pulling morphine out;-He/She informed the resident's family member the Hospice RN had to deliver morphine to the facility and the family member got very upset;-The resident's family member never said he/she was upset about morphine not administered to the resident-The Hospice RN had the morphine ordered and dispensed from a local pharmacy, then delivered to the facility;-LPN A administered morphine to the resident at 10:00 P.M.;-He/She was not sure why the resident's controlled substance accountability sheet for the resident's Morphine showed LPN C administered 0.5 ml of morphine on 3/15/25 at 4:00 P.M.;-He/She was not sure why the resident's MAR and the controlled substance accountability sheet for the resident's morphine showed LPN C administered 0.5 ml of morphine on 3/15/25 at 6:00 P.M.;-LPN A should have documented when the resident ran out of morphine, when the facility pharmacy was notified, when the Hospice RN delivered the morphine from the local pharmacy, and what interventions were done to control the resident's pain;-He/She was expected to document administration of controlled substances in both the resident's MAR and controlled substance accountability sheet;-He/She rounded on the resident every hour and the resident did not seem to be in a lot of pain or distress;-He/She spoke to the Administrator that day but could not recall why;-The resident never missed any doses of morphine. During s on 7/25/25 at 11:40 A.M. and at 12:42 P.M., the Hospice RN said:-He/She was the nurse assigned to the resident on 3/15/25;-He/She had visited the resident several times that day due to the resident in a state of actively dying;-The resident's family member called him/her several times throughout the day to report different issues;-The resident's family member called the Hospice RN, around 10:30 A.M., to report the resident was in horrible pain, had not received any morphine in the last 24 hours and he/she could not find the resident's nurse;-The Hospice RN went to the facility to assess the resident around 12:00 P.M., and found the resident in pain, very uncomfortable with high respirations and groaning;-The Hospice RN could not find the nurse assigned to the resident and had to get a nurse from another assignment to help him/her;-The Hospice RN looked at the controlled substance accountability sheets for both morphine and Ativan and saw there was no documentation showing either medication was administered to the resident in the last 24 hours;-He/She called the Hospice DON at 12:30 P.M., to notify him/her of the situation;-He/She then called the Hospice Doctor and received a new order to give morphine every 15 minutes until comfort was achieved;-The Hospice RN gave the order verbally to the nurse assigned to another unit;-The nurse from the other unit drew up doses of morphine, gave the medication to the Hospice RN, who then administered it. The Hospice RN believes he/she gave two or three doses of morphine to the resident during his/her visit;-The nurse from the other unit signed out the morphine doses were administered because the nurse assigned to the resident was not found during the Hospice RN's visit;-The Administrator came into the facility at approximately 11:30 A.M.;-The Hospice RN reported to the Administrator the resident's morphine was running low and the Administrator stated the nurses could pull additional morphine from the ADU;-The Hospice RN never saw the nurse assigned to the resident during his/her visit;-The Hospice RN recalled he/she left around 1:30 P.M. and the resident was semi-comfortable;-He/She expected the facility staff to put the order for morphine, to give every 15 minutes until comfortable, to follow physician orders, and to give morphine and/or Ativan as ordered until the resident was comfortable;-The resident's family member called the Hospice RN around 7:00 P.M. to report the resident had not received any morphine and was in pain;-The Hospice RN called the facility and the resident's nurse reported the resident had run out of morphine and the nurse was not able to get morphine out of the ADU;-The Hospice RN made several calls to the facility to see if they were able to get morphine from the ADU after speaking to their pharmacy or if their pharmacy could send out morphine quickly;-The Hospice RN also called the Hospice DON to notify him/her of the situation and to get direction from the Hospice team;-At approximately 8:00 P.M., the Hospice DON called the Hospice RN to report the facility was not able to get morphine to the resident from their ADU nor from their pharmacy. The Hospice RN was asked to try to get a script filled for the resident's morphine at a local pharmacy;-The Hospice RN was able to get the resident's morphine script filled at a local pharmacy and delivered the morphine to the facility at approximately 9:30 P.M. The local pharmacy did not provide a controlled substance accountability sheet for the bottle of morphine;-The Hospice RN assessed the resident for pain at approximately 9:30 P.M. and found the resident was in pain and uncomfortable, although not as bad as when the resident was assessed earlier that day on the Hospice RN's last visit;-The Hospice RN left the facility after the resident received a dose of morphine;-The Hospice RN received a call at 10:03 P.M., from the facility nurse who stated the resident had passed;-He/She expected the facility nurses to assess the resident every two hours for pain and administer medications as ordered for pain control;-He/She expected the facility to document all that happened that day, including documentation from the Administrator showing her involvement in the event;-The Hospice RN expected the facility to notify him/her when the resident had not received pain control medications for so long and to report the resident's pain cycle;-The Hospice RN was only updated on the resident's condition and lack of pain control medications administered by the resident's family member. The facility staff communicate the resident's condition to the Hospice RN. During an interview on 7/25/25 at 1:31 P.M., LPN B said:-He/She worked on 3/15/25 from 7:00 A.M. through 3:00 P.M.;-He/She was assigned to a different unit from the resident's;-The resident's family member was at bedside and kept coming out saying the resident was in pain and needed medication. The resident's family member was being extra;-He/She assessed the resident before the Hospice RN came to the facility and the resident looked comfortable without any facial grimacing. LPN B thought maybe the resident's family member assumed the resident was in pain;-LPN B knew the resident received his/her morphine and Ativan as scheduled. He/She was not sure how he/she knew that, just that he/she did;-The Hospice RN came into the facility at an unknown time and both the Hospice RN and the resident's family member kept coming to LPN B to ask for help for the resident because they could not find the resident's assigned nurse, LPN C;-LPN B called to inform the Administrator the resident's family member was very loud when stating the resident was in pain and was not receiving pain medication;-LPN B did not know where LPN C was when the Hospice RN was in the facility;-LPN B drew up two doses of morphine, around 10:00 A.M. through 12:00 P.M. and gave the opioid to the Hospice RN to administer for pain control;-LPN B informed the Hospice RN he/she would tell LPN C to document the two doses of morphine were administered;-LPN B had a lot going on with his/her own assignment and just gave the morphine doses to the Hospice RN to administer to the resident. LPN B saw Hospice RN administer the morphine doses to the resident;-LPN B was responsible for administering the morphine doses to the resident and was responsible for documenting in the resident's MAR and controlled substance accountability sheet when the doses were administered in real time;-He/She gave the morphine doses to the Hospice RN to try to help as they could not find the resident's assigned nurse;-LPN B told LPN C to document the morphine doses the Hospice RN administered to the resident and watched LPN C sign out the morphine doses on the controlled substance accountability sheet;-The Administrator came into the facility, at an unknown time, and LPN B went back to his/her assignment. He/She did not know what happened after the Administrator came into the facility;-He/She did not know where the resident's assigned nurse, LPN C, was during the period in which the Hospice RN was in the building. LPN B believed LPN C came back when the Administrator entered the facility;-LPN B put in a new order for the resident's morphine;-LPN B should have documented his/her assessment of the resident, including the time, any new orders he/she put in the system, the interaction with the resident's family member and the Hospice RN, the morphine doses he/she drew up and gave to the Hospice RN to administer, including the times, who signed out the morphine administration, when he/she called the Administrator and why. LPN B was not sure why he/she did not appropriately document the event on 3/15/25;-LPN B was not interviewed or questioned about his/her involvement on 3/15/25 by any of the administrative staff. During an interview on 5/23/25 at 2:22 P.M., Family Member (FM) F said the facility had all of the resident's orders in the system, but the facility was out of the resident's medications. On the day the resident passed, he/she began experiencing breakthrough pain. Desperate, FM F informed the staff that he/she was going to call an ambulance and have the resident rushed to the emergency room. The nursing staff told FM F that he/she couldn't do that. So, FM F called hospice. Hours later, hospice got the Medical Director to call in a prescription for morphine to a local pharmacy, and hospice picked it up and returned with a big bottle of morphine and administered some to the resident. During an interview on 7/25/25 at 3:06 P.M., the Regional Nurse, the Director of Nursing (DON) and the Area Director of Operations, said:-The Area Director of Operations did not know of any issues regarding the end-of-life care for the resident on 3/15/25. She expected the Administrator to inform her of anything that occurred that was out of the ordinary or if there was an investigation;-They expected nurses to document when they put in a new order as it was best practice;-They expected nurses to document if an actively dying resident was missing any pain medications, including morphine and/or Ativan, what they did to try to remedy the situation who was notified and when, when the pain medications were available at the facility, and the resident's condition;-They expected nurses to put in new orders for pain control immediately for an actively dying resident so the resident could get the pain medications as soon as possible as they did not want the resident in pain;-They expected nurses to be available to their assigned residents while clocked in and if they were on a break, other staff should be able to contact them. Nursing staff had two fifteen-minute breaks and a thirty minute lunch break. Other staff should know when the nurses took a break and where so they could contact them if needed;-Controlled substance accou

Based on interview and record review, the facility failed to maintain accurate medical records as per their policies for one resident of three sampled residents (Resident #2). The facility failed to document assessments for the actively dying resident; failed to accurately document analgesics (pain medication) on narcotic accountability sheets and on the medication administration records; failed to document when morphine sulfate solution (opioid for moderate to severe pain) was delivered and then wasted by facility staff; failed to document when the resident ran out of morphine including notification to hospice and pharmacy; failed to document interactions with hospice staff and failed to document when a new bottle of morphine was delivered by hospice staff from a local pharmacy. The census was 72.Review of the facility's Medication ordering and receiving from pharmacy; Receiving controlled substances policy, dated 12/17, showed:-Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and recordkeeping requirements by the facility in accordance with federal and state laws and regulations;-The Director of Nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized, licensed nursing and pharmacy personnel have access to controlled substances;-An individual resident's controlled substance record is provided by the pharmacy or the facility for each controlled substance prescribed for a resident. The following information is completed upon dispensing or upon receipt of the controlled substance:I) Name of resident;2) Prescription number;3) Drug name, strength (if designated), and dosage form of medication;4) Directions for use (Controlled Substance Accountability Sheet);5) Date received;6) Quantity received;7) Name of person receiving the medication supply;-A controlled drug record/log is provided by the pharmacy or facility for each controlled drug in the emergency supply;-Only licensed personnel may receive controlled substances from the pharmacy driver. Procedures for receiving controlled substances include:1) A nurse signs for the medications, including the controlled substances, on the pharmacy delivery ticket and inspects the medications;2) A nurse reconciles controlled substance orders and refill requests against what has been received from the pharmacy;3) A nurse notifies the pharmacist if controlled substance orders or doses are missing or incorrect;4) The receiving nurse transfers medications and accompanying inventory sheets to an authorized nurse on the unit (if different than the nurse who received the medication).5) Controlled substance inventory sheets are completed, if necessary, and filed appropriately per state regulation. Review of the facility's controlled substance prescriptions policy, dated 12/17, showed:-The prescriber is contacted for direction when delivery of a medication will be delayed or the medication is not or will not be available;-Each controlled substance prescription is documented in the resident's medical record with the date, time and signature of the person receiving the prescription;-If the medication is not available in the Automated Dispensing Unit (ADU), electronic medication cabinet (EMC) or emergency kit, the nurse contacts the pharmacy to request a STAT delivery of the needed medication. If necessary, the nurse uses the after-hours emergency number(s). Review of the facility's Medication Administration General Guidelines policy, dated 12/17, showed:-Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions;-Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to prepare and administer medications;-FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away;-The Medication Administration Record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. When a medication order is changed and the current supply can continue to be used, the container should be flagged right away and the order change communicated to the provider pharmacy so that the next supply of the medication is labeled with the current directions;-If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit;-The person who prepares the dose for administration is the person who administers the dose;-The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications;-The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are cross referenced to a full signature in the space provided;-When an as needed (PRN) medications are administered, the following documentation is provided:a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site;b. Complaints or symptoms for which the medication was given;c. Results achieved from giving the dose and the time results were noted;d. Signature or initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication. Review of Resident #2's care plan, undated, showed:-Problem: At risk of unmanaged chronic pain related to poly-neuropathy (multiple nerves are damaged in lower body). Interventions included: Administer analgesics as ordered by physician; Document pain on 1-10 scale; Monitor response to analgesics and pain alleviation measures;Observe resident during care for signs of pain; Update physician on effectiveness of analgesics and pain medication;-Problem: The resident was receiving hospice care due to unspecified protein malabsorption. Interventions included: Encourage support system of family and friends; Observe the resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Review of the resident's physician order sheet, showed:-An order, dated 12/29/22, for a pain evaluation, every shift for monitoring of resident's pain level;-An order, dated 8/23/23, for morphine sulfate solution (morphine, opioid pain reliever used to treat moderate to severe pain) 20 milligrams (mg) for every five milliliters (ml), give 0.25 ml every four hours as needed for pain;-An order, dated 1/31/24, may admit to hospice care;-An order, dated 8/22/24, for Hydrocodone-acetaminophen 5 - 325 mg (Norco, opioid pain reliver combined with acetaminophen), take one tablet every eight hours for pain. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-The resident's name was listed at the top;-Medication name/Strength: Morphine;-No documentation of the strength of the morphine;-No documentation for the directions of administration;-On 7/2/24, at 5:00 P.M., 0.25 mg was administered to the resident with 9.0 ml remaining;-Documentation showed the facility administered 0.25 ml to the resident on 7/6/24 at 10:00 P.M., on 7/7/24 at 6:00 A.M., on 7/10/24 at 2:17 P.M. and on 11/14/25 with 8.0 ml remaining. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/1/25, showed:-Severe cognitive deficiency;-Disorganized thinking and inattention present;-Impairment present on both sides of the upper and lower body;-On a scheduled pain medication regimen;-Did not receive pain medication as needed;-Received non-medication intervention for pain;-Resident reported not presence of pain during pain assessment interview;-Received hospice care (provides comfort and support by managing pain and other symptoms at end of life);-Diagnoses included heart failure, aphasia (language disorder that affects ability to communicate) dementia, kidney disease. Review of the resident's MAR, dated March 2025, showed:-On 3/12/25 at 6:00 A.M., the facility administered one Norco to the resident;-On 3/12/25 at 6:30 A.M., the resident had a pain level of 0. Review of the hospice focus visit, dated 3/12/25, showed:-The visit was an unscheduled symptom evaluation;-A hospice nurse started the visit at 7:55 A.M. and ended visit at 8:45 A.M.;-Interventions performed: Call for a change in condition and ordered morphine;-The resident started moaning when touched for care;-The resident was nonverbal;-Report was given to the facility nurse who administered morphine 0.25 ml;-Norco 5-325 mg was not given;-The facility nurse administered morphine 0.25 ml to the resident for pain;-Report of visit given to facility nurse, Director of Nursing (DON) and the resident's family member. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/12/25 at 9:30 A.M., the facility administered 0.25 ml to the resident with 7.75 ml remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered morphine to the resident on 3/12/25;-On 3/12/25 at 2:00 P.M., the facility administered one Norco to the resident;-On 3/12/25 at 2:30 P.M., the resident had a pain level of 0;-On 3/12/25 at 10:00 P.M., the facility administered one Norco to the resident;-On 3/12/25 at 10:30 P.M., the resident had a pain level of 0;-On 3/13/25 at 6:00 A.M., the facility administered one Norco to the resident;-On 3/13/25 at 6:30 A.M., the resident had a pain level of 0. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/13/25 at 6:30 A.M., the facility administered 0.25 ml to the resident with 7.50 ml remaining;-On 3/13/25 at 10:30 A.M., the facility administered 0.25 ml to the resident with 7.25 ml remaining. Review of the resident's MAR, dated March 2025, showed no documentation the facility administered morphine to the resident on 3/13/25. Review of the resident's progress notes, showed:-On 3/13/25 at 10:55 A.M., the resident had a change of condition. The resident was nonresponsive. The hospice nurse was here to see the resident and cancelled all prescription medications except for all pain medications. The primary care physician (PCP) was informed of the resident's condition and gave new order for acetaminophen (pain reliver and fever reducer) 650 mg suppository, give every six hours for a temperature of 99 degrees or greater. Review of the resident's MAR, dated March 2025, showed:-An order dated 3/13/25 at 11:50 A.M., for acetaminophen suppository 650 mg, insert 1 suppository rectally every six hours as need for a temperature of 100 degrees or above;-No documentation the medication was administered to the resident;-On 3/14/25 at 6:00 A.M., the facility administered one Norco to the resident;-On 3/14/25 at 6:30 A.M., the resident had a pain level of 1;-On 3/14/25 at 2:00 P.M., the facility administered one Norco to the resident;-On 3/14/25 at 2:30 P.M., the resident had a pain level of 0;-On 3/14/25 at 10:00 P.M., the facility administered one Norco to the resident;-On 3/14/25 at 10:30 P.M., the resident had a pain level of 0. Review of the hospice focus visit, dated 3/14/25, showed:-The hospice nurse visited the resident at 12:05 P.M. and ended the visit at 1:05 P.M.;-The resident was non verbal;-The resident had a decreased response to verbal and visual stimuli;-The resident had an absent radial (artery found on the thumb side of the wrist) pulse;-The resident had decreased urine output;-The resident's blood pressure was 84/36 and a heart rate of 120 bpm;-Interventions performed: assess for signs and symptoms of pain during visit and assess respiratory (breathing) status during visit;-The resident was unresponsive, not following commands. The facility nurse said the resident had just received morphine and had a fever which was treated by acetaminophen. There was no fever noted by the hospice nurse during assessment;-The resident was on 2.5 liters of oxygen and his/her saturation (amount of oxygen in the blood, typically between 95% and 100%) rate was in the 90s. The facility nurse said he/she would give the resident Ativan. Review of the hospice supplemental interdisciplinary note, dated 3/14/25 at an unknown time, showed:-The writer of the note was a hospice nurse;-Visit type: Patient Services (In person contact);-Reviewed the facility medical record and received report from the facility nurse;-The facility nurse stated the resident had not received any Ativan yet because the in-house physician had not signed the order for it;-The hospice nurse gave the order for Ativan to the facility the day prior, from the hospice physician. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/14/25 at an illegible time, the facility administered 0.25 ml to the resident with 7.0 ml remaining;-On 3/14/25 at 2:00 P.M., the facility administered 0.25 ml to the resident with 6.75 ml remaining. Review of the resident's MAR, dated March 2025, showed:-There was no documentation showing the facility administered morphine to the resident on 3/14/25. Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-Medication Name/Strength: Ativan 0.5 mg, give by mouth every three hours for pain and anxiety;-On 3/14/25 at 2:25 P.M., the facility administered one tablet of Ativan to the resident, with a remaining quantity of one tablet. Review of the resident's MAR, dated March 2025, showed:-An order, dated 3/13/25 at 3:53 P.M., to give Ativan 0.5 mg, every two hours as needed for pain;-No documentation the facility administered Ativan 0.5 g on 3/14/25 at 2:25 P.M. Review of the hospice supplemental interdisciplinary note, dated 3/14/25 at an unknown time, showed:-At 4:00 P.M., the hospice nurse made a follow up call to the facility and found the resident had not yet received any Ativan, as per physician orders;-The facility nurse said the nurses' cart was stuck or would not open to get the Ativan out. The facility nurse was waiting on the pharmacy to come and fix it. Review of the resident's MAR, dated March 2025, showed:-The facility administered Ativan 0.5 mg as ordered on 3/14/25 at 4:30 P.M.; Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-No documentation the facility administered Ativan 0.5 mg to the resident on 3/14/25 at 4:30 P.M.-On 3/14/25 at 6:18 P.M., two tablets were added to the controlled substance accountability sheet, showing three tablets available for administration. Review of the resident's MAR, dated March 2025, showed:-On 3/15/25 at 6:00 A.M., the facility attempted to administer one Norco to the resident. The resident refused;-On 3/15/25 at 6:30 A.M., the resident had a pain level of 0. Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-On 3/15/25 at 12:00 P.M., the facility administered Ativan 0.5 mg to the resident. Review of the resident's MAR, dated March 2025, showed:-No documentation the resident received Ativan 0.5 mg on 3/15/25 at 12:00 P.M. Review of the Hospice Registered Nurse (RN's) focus visit sheet, dated 3/15/25, showed:-The visit started at 12:00 P.M.;-The resident had decreased response to verbal and visual stimuli, hyperextension of the neck, grunting of vocal cord, depression of the jaw on inspiration (when breathing in), death rattle (a gurgling sound heard in a dying person's throat), and Cheyne-Stokes breathing (fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all);-Upon arrival to the facility, the resident was found in bed with the resident's family member at bedside. The resident appeared to be actively dying and displayed signs of discomfort;-Staff stated the resident had received comfort medications, however, upon further assessment it was evident the resident exhibited increased respiratory effort and signs of pain;-Review of the resident's MAR showed the resident had not received any comfort medications in almost 24 hours;-The facility nurse assigned to the resident was not present and another nurse on the unit assisted;-The Hospice RN contacted his/her supervisor and the hospice on-call physician, who gave new orders to administer morphine every 15 minutes until the resident was comfortable;-The visit ended at 2:00 P.M. Review of the Hospice RN's supplemental Interdisciplinary note, dated 3/15/25, showed:-The visit stated at 12:00 P.M.;-The resident had a pain level of six, out of a 0 - 10 pain scale (0 was no pain and 10 as the highest level of pain)-Current pain and symptom management was not satisfactory;-A total of three doses (morphine) were given before the resident began to show signs of relief;-Hospice RN expressed his/her concerns directly to the facility Administrator regarding the delay in patient care and the resident's family member's concerns the resident was not receiving adequate attention;-It was also noted the facility was low on morphine;-Hospice RN followed up with the on-call hospice physician who gave verbal orders for morphine give every four hours, scheduled and every two hours as needed, along with staff instructions to assess the resident frequently and administer medication as needed;-Hospice RN was at the facility for approximately two hours to ensure the resident's needs and the resident's family member's needs were addressed;-Hospice RN ensured had clear guidance and new scripts to pull morphine for the resident. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/15/25 at 12:00 P.M., Licensed Practical Nurse (LPN) C administered 0.5 ml to the resident with 6.25 ml remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered morphine 0.5 ml to the resident on 3/15/25 at 12:00 P.M. Review of the resident's physician order sheet, showed:-An order, dated 3/15/25 at 1:03 P.M., for morphine 10 mg/5 ml, give 10 ml every two hours as needed for pain. Review of the resident's controlled substance accountability sheet, undated, for morphine, showed:-On 3/15/25 at 2:00 P.M., LPN C administered 0.5 ml to the resident with 5.75 ml remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered morphine 0.5 ml on 3/15/25 at 2:00 P.M.-On 3/15/25 at 2:30 P.M., the resident had a pain level of 0;-An order on 3/15/25 at 3:18 P.M., discontinued at 11:40 P.M., for morphine 10mg/5ml, give 0.5 ml every two hours as needed for pain. No documentation the facility administered morphine for this order;-An order on 3/15/25 at 3:18 P.M., discontinued at 3/15/25, at 11:40 P.M., for morphine 10mg/5ml, give 0.5 ml every four hours as needed for pain. Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-On 3/15/25 at 5:00 P.M., one tablet was administered to the resident, with one tablet remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered Ativan 0.5 mg to the resident on 3/15/25, at 5:00 P.M. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/15/25 at 6:00 P.M., LPN C administered 0.5 ml to the resident with 4.75 ml remaining;-No documentation the facility administered any more doses of morphine to the resident. Review of the resident's MAR, dated March 2025, showed:-The facility administered 0.5 ml of morphine to the resident on 3/15/25, at 6:00 P.M. Review of the hospice telecare call record, dated 3/15/25, showed:-At 7:18 P.M., LPN A called the hospice on-call triage to report the resident was actively transitioning and the resident's Power of Attorney (POA) was requesting an order for morphine, give every two hours;- At 7:19 P.M., a hospice nurse spoke to LPN A who reported he/she did not have any morphine 20 mg/ml on hand for the resident and was requesting medication. The hospice orders were reviewed and noted an order for morphine 20 mg/ml, gave 0.5 ml (10 mg) by mouth every two hours as needed for shortness of breath. LPN A reported the resident's family member was requesting morphine every two hours. LPN A was advised the assigned hospice nurse would get sent out to the facility due to the resident actively transitioning. Hospice would call a pharmacy in regards to getting morphine due to the facility running out/not having any on hand. LPN A was advised to continue to monitor the resident and call back if anything changed. LPN A indicated he/she understood and agreed to the plan;-At 7:30 P.M., hospice called a pharmacy in an attempt to order morphine for the resident. The pharmacy did not work with the facility;-At 7:40 P.M., hospice called the facility pharmacy in regards to medication morphine 20 mg/ml take 0.5 ml (10 mg) by mouth every two hours as needed for shortness of breath. There was no answer;-At 7:46 P.M., hospice called LPN A who said he/she called the facility pharmacy and they were working on having the morphine delivered (waiting call back). LPN A agreed to call back if any changes in pt status; No further needs at this time. Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-On 3/15/25 at 8:00 P.M., one tablet was administered to the resident, with zero tablets remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered Ativan 0.5 mg to the resident on 3/15/25 at 8:00 P.M. Review of the Hospice RN's focus visit sheet, dated 3/15/25, showed:-The visit started at 7:50 P.M.;-The resident had decreased response to verbal and visual stimuli, hyperextension of the neck, grunting of vocal cord, depression of the jaw on inspiration, drooping of the nasolabial folds (lines that run from the sides of the nose to the corner of the mouth), death rattle, and Cheyne-Stokes breathing;-The resident's pain level was 6;-The resident's family member called Hospice RN to report the resident had not received any comfort meds in over four hours. Hospice RN called the facility and they said they were not able to pull morphine out of the ADU for the resident;-Hospice RN sent a script for morphine to a local 24 hour pharmacy, he/she arrived at the local pharmacy at approximately 7:50 P.M., received the morphine from the local pharmacy at approximately 8:30 P.M., then drove back to deliver the morphine to the facility;-At approximately 9:15 P.M., Hospice RN delivered the morphine to the facility staff and ensured the resident received a dose before leaving at approximately 9:30 P.M. Review of the resident's medical record, showed:-A progress note, dated 3/15/25 at 10:08 P.M., said the resident had transitioned at 10:00 P.M. The resident's family was present and aware of the resident's declining condition. Comfort measures were provided including pain management and emotional support for family. Vital signs were absent and postmortem care was provided. The Hospice team and physician was notified. Unable to reach the resident's guardian. Review of the resident's MAR, dated March 2025, showed:-The facility administered 0.5 ml of morphine to the resident on 3/15/25 at 10:00 P.M.;-On 3/15/25 at 10:30 P.M., the resident had a pain level of 0. During an interview on 7/25/25 at 9:18 A.M., LPN A said:-He/She checked on residents throughout the day, assessing for pain;-He/She would call the PCP to obtain new orders if a resident had pain and no pain management medication available as well as checking the ADU to see if the medication was available to pull before pharmacy delivered;-He/She would call hospice to get a script for Ativan and/or morphine if a resident was on hospice, actively dying and did not have those medications available at the facility to administer;-He/She worked on 3/15/25, from 3:00 P.M. until 7:00 A.M. on 3/16/25, and was assigned to the resident's care;-The resident's family member was at bedside and upset about how nursing staff were administering pain medication to the resident. The family member would ask for pain medication for the resident every couple of hours, just to remind us;-He/She gave the resident one dose of morphine when he/she came on shift. It was the last dose available in the bottle and the resident did not have another bottle of morphine available for his/her next administration;-The off-going nurse (unknown name) told LPN A the resident was almost out of morphine and to get the next bottle from the ADU;-He/She was not able to pull morphine out of the ADU;-He/She called the facility pharmacy who confirmed they had a script for the morphine and it should be available to pull from the ADU. He/She was not sure what time the phone call to pharmacy was made;-He/She called the Hospice RN to notify him/her the resident had run out of morphine and there was some sort of glitch in the ADU which prevented LPN A from pulling morphine out;-He/She informed the resident's family member the Hospice RN had to deliver morphine to the facility and the family member got very upset;-The resident's family member never said he/she was upset about morphine not administered to the resident-The Hospice RN had the morphine ordered and dispensed from a local pharmacy, then delivered to the facility;-LPN A administered morphine to the resident at 10:00 P.M.;-He/She was not sure why the resident's controlled substance accountability sheet for the resident's Morphine showed LPN C had administered 0.5 ml of morphine on 3/15/25 at 4:00 P.M.;-He/She was not sure why the resident's MAR and the controlled substance accountability sheet for the resident's morphine showed LPN C had administered 0.5 ml of morphine on 3/15/25 at 6:00 P.M.;-LPN A should have documented when the resident ran out of morphine, when the facility pharmacy was notified, when the Hospice RN delivered the morphine from the local pharmacy, and what interventions were done to control the resident's pain;-He/She was expected to document administration of controlled substances in both the resident's MAR and controlled substance accountability sheet;-He/She rounded on the resident every hour and the resident did not seem to be in a lot of pain or distress;-He/She did speak to the Administrator that day but could not recall why;-The resident never missed any doses of morphine. During an interview on 7/25/25 at 11:40 A.M. and at 12:42 P.M., the Hospice RN said:-He/She was the nurse assigned to the resident on 3/15/25;-He/She had visited the resident several times that day due to the resident in a state of actively dying;-The resident's family member called him/her several times throughout the day to report different issues;-The resident's family member called the Hospice RN, around 10:30 A.M., to report the resident was horrible pain, had not received any morphine in the last 24 hours and he/she could not find the resident's nurse;-The Hospice RN went to the facility to assess the resident around 12:00 P.M., and found the resident in pain, very uncomfortable with high respirations and groaning;-The Hospice RN could not find the nurse assigned to the resident and had to get a nurse from another assignment to help him/her;-The Hospice RN looked at the controlled substance accountability sheets for both morphine and Ativan and saw there was no documentation showing either medication was administered to the resident in the last 24 hours;-He/She called the Hospice DON at 12:30 P.M., to notify him/her of the situation;-He/She then called the Hospice Doctor and received a new order to give morphine every 15 minutes until comfort was achieved;-The Hospice RN gave the order verbally to the nurse assigned to another unit;-The nurse from the other unit drew up doses of morphine, gave the medication to the Hospice RN, who then administered it. The Hospice RN believes he/she gave two or three doses of morphine to the resident during his/her visit;-The nurse from the other unit signed out the morphine doses were administered because the nurse assigned to the resident was not found during the Hospice RN's visit;-The Administrator came into the facility at approximately 11:30 A.M.-The Hospice RN reported to the Administrator the resident's morphine was running low and the Administrator stated the nurses could pull additional morphine from the ADU;-The Hospice RN never saw the nurse assigned to the resident during his/her visit;-The Hospice RN recalled he/she left around 1:30 P.M. and the resident was semi-comfortable;-He/She expected the facility staff to put the order for morphine, to give every 15 minutes until comfortable, to follow physician orders, and to give morphine and/or Ativan as ordered until the resident was comfortable;-The resident's family member called the Hospice RN around 7:00 P.M. to report the resident had not received any morphine and was in pain;-The Hospice RN called the facility and the resident's nurse reported the resident had run out of morphine and the nurse was not able to get morphine out of the ADU;-The Hospice RN made several calls to the facility to see if they were able to get morphine from the ADU after speaking to their pharmacy or if their pharmacy could send out morphine quickly;-The Hospice RN also called the Hospice DON to notify him/her of the situation and to get direction from the Hospice team;-At approximately 8:00 P.M., the Hospice DON called the Hospice RN to report the facility was not able to get morphine to the resident from their ADU nor from their pharmacy. The Hospice RN was asked to try to get a script filled for the resident's morphine at a local pharmacy;-The Hospice RN was able to get the resident's morphine script filled at a local pharmacy and delivered the morphine to the facility at approximately 9:30 P.M. The local pharmacy did not provide a controlled substance accountability sheet for the bottle of morphine;-The Hospice RN assessed the resident for pain at approximately 9:30 P.M. and found the resident was in pain and uncomfortable, although not as bad as when the resident was assessed earlier that day on the Hospice RN's last visit;-The Hospice RN left the facility after the resident received a dose of morphine;-The Hospice RN received a call at 10:03 P.M., from the facility nurse who stated the resident had passed;-He/She expected the facility nurses to assess the resident every two hours for pain and administer medications as ordered for pain control;-He/She expected the facility to document all that happened that day, including documentation from the Administrator showing her involvement in th

Based on interview and record review, the facility failed to ensure a resident was administered alprazolam (Xanax, used for anxiety) as ordered. In addition, the facility failed to ensure the physician was notified timely when the medication was not delivered and the resident missed multiple doses. The resident experienced anxiety and tearfulness as a result (Resident #3). The sample was 4. The census was 78. Review of the controlled substance prescriptions policy, dated 8/2014, showed: -Policy: -Before a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete and signed written prescription from a person lawfully authorized to prescribe. A chart order is not equivalent to a prescription for controlled drugs. Therefore, the prescriber issuing the chart order must also provide the pharmacist with a valid prescription. The written prescription may be faxed to the pharmacy for long term care residents; -Verbal orders for controlled medications are permitted for class II (CII, a class of drugs with a high potential for abuse) controlled drugs only in emergency situations. Verbal orders for controlled medications received by nursing staff should be noted in the resident's medical record and staff must confirm the prescriber has communicated the order to the pharmacy. Verbal orders received by the pharmacist from the prescriber must also be communicated to the facility before authorized staff may access any controlled substances from the emergency supply. This may be done by the prescriber directly or via telephone order from the pharmacist to the facility; -Procedure: -The prescriber is contacted to verify or clarify a prescription when needed; -New Prescriptions: -If prescriptions are written by the prescriber and sent with the resident upon hospital discharge, the prescriber is encouraged to document on separate paperwork the fact that a prescription has been provided to ensure accountability on the receiving end. When written prescriptions received by the facility: -If the prescription is from a prescriber other than the attending physician, the order is verified with the current attending physician. The nurse communicated that verification to the pharmacy prior to dispensing; -The prescription is faxed or sent electronically to the pharmacy by the prescriber or prescriber agent. Review of Resident #3's discharge hospital summary, dated 3/12/25, showed: -Principle problem: closed fracture of right tibial plateau (break of the larger lower leg bone below the knee into the cartilage) fracture; -Medication: Xanax 1 milligram (mg) tablet. Take one tablet three times a day. Used for anxiety treatment, control panic disorders. Documented as administered three times daily at morning, noon and bedtime in the hospital; -Discharge disposition: long term care facility. Review of the resident's facility medical record, showed: -admitted : 3/12/25; -An order, dated 3/12/25: Alprazolam (Xanax) tablet 1 mg. Give one tablet three time a day for anxiety; -Diagnoses included fracture of the upper end of the right tibia, muscle wasting and anxiety. Review of the emergency kit (E-kit) medication list, showed: -Alprazolam tablet 0.25 mg, available: 61; -Alprazolam tablet 0.5 mg, available: 10. Review of the resident's March 2025 Medication Administration Record (MAR), showed: -An order, dated 3/12/25 at 6:35 P.M.; Alprazolam 1 mg, take one tablet three times a days for anxiety. Scheduled at 6:00 A.M., 2:00 P.M. and 10:00 P.M.; -On 3/12/25 at 10:00 P.M., documented as NA-not administered see nurse note; -An additional note added to the MAR order, dated 3/13/25 10:18 A.M., showed: hold from 3/13/25 to 3/15/24 at 1:32 P.M.; -On 3/13/25 at 6:00 A.M., 2:00 P.M., and 10:00 P.M., showed: H or on hold by physician. Review of the progress notes, showed: -On 3/12/25 at 10:14 P.M., and 3/13/25 at 5:27 A.M., a medication administration note: Alprazolam 1 mg. Give one tablet three times a day for anxiety. Waiting for script and pharmacy approval. No documentation noted of physician or pharmacy follow up; -On 3/13/25 at 10:19 A.M., a skilled nurse note: the resident requires cues and has disorganized thinking. Mood is pleasant; -On 3/13/25 at 11:21 A.M., a skill nursing note: patient is anxious and asks questions repeatedly. Informed of inability to obtain Xanax due to need for script. Offered morning meal and the resident refused. He/She ate toast two hours later. No additional documented physician or pharmacy contact regarding Xanax order; Review of the handwritten pharmacy controlled substance accountability form, dated 3/14/25, showed: -Medication: Xanax 1 mg; -Orders: take one tablet three times a day; -Delivered amount: 21; -Administered: 1; -Left available: 20. Review of the physician visit history and physical admission note, dated 3/14/25, showed: -Generalized anxiety disorder: -Assessment and plan: patient to continue with Prozac (used to treat depression), Buspar (used to treat anxiety) and Alprazolam. Patient is not to attempt a gradual dose reduction (GDR) at this particular time as he/she has a significant stressor with his/her knee fracture and being in the facility away from his/her home; -Other orders: Alprazolam 1 mg. Take one tablet three time a day; -History of present illness (HPI): admitted for medical management for right knee pain following right tibial plateau fracture, non-operative management. Medicines were reconciled. He/She is highly anxious and at times intermittently tearful. During an interview on 3/31/25 at 12:40 P.M., the resident's physician said the resident was very anxious on 3/14/25. The resident was admitted from the hospital with orders for Xanax. The resident wanted to return home. The physician was unaware the resident had not received multiple doses of the Xanax. She expected staff to notify her of any medication issues. She did not receive notification of the Xanax medication needing a signed script, and the hospital would have sent the signed script with the resident upon admission. If staff call her, she can call the pharmacy and give an immediate order, and staff can obtain the medication out of the E-kit. The resident received the Xanax three times a day while in the hospital, and that should have continued upon admission to the facility. During an interview on 3/31/25 at 12:50 P.M., a pharmacy representative said the resident's Xanax order was received on 3/13/25 at 12:19 P.M., and delivered to the facility on [DATE] at 7:49 A.M. In addition, the facility's E-kit system also carries Xanax 0.25 mg and 0.5 mg tablets. If the physician would have called and approved the Xanax via phone to the pharmacist, the pharmacist would have provided a code for facility staff to access the E-kit. The representative said there was no documented calls from the facility regarding the Xanax and no requests to access the E-kit Xanax. During an interview on 3/31/25 at 1:28 P.M., the Director of Nursing (DON) said the facility does not keep any carbon copies of when medications are delivered from pharmacy. The facility has had issues getting medications timely from the pharmacy as it is located in Kansas. The DON is not aware if the facility used a local pharmacy as a back up provider. The admitting nurse should verify all medications with the resident's physician. If a signed script is needed, the nurse is responsible to notify the physician and obtain the signed script quickly. Usually the hospital will include the signed script in the discharge paperwork. She could not locate the discharge paperwork for the resident. The resident received routine Xanax while in the hospital and the medication was to continue at the facility on the same schedule. The physician can call the pharmacy and give a verbal order to the pharmacist, the pharmacist can provide a code to the facility nurse for the E-kit and the medication can be obtained. Staff should not document in the MAR an H as it will cause the order to not be active and staff will not know to administer the medication. Staff should document other in the medication note, and document a progress note. MO00251135

42795 Based on observation, interview and record review, the facility failed to provide reasonable accommodation of individual needs and preferences by failing to ensure call lights were in reach for six residents (Residents #12, #23, #174, #20, #175 and #6). The facility also failed to have one resident's communication device within reach (Resident #126). The sample was 19. The census was 83. 1. Review of Resident #12's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/19/24, showed: -Severe cognitive impairment; -Always incontinent of bowel and bladder; -Required substantial assistance from staff for toileting and lower body dressing; -Required moderate assist from staff from lying to sitting at the side of the bed , sitting to standing and chair to bed transfers; -Diagnoses included Parkinson's disease (a chronic, progressive brain disorder that affects the nervous system and causes movement problems), dementia, stroke and seizures. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is as risk of falling and risk of injury due to falls; -Interventions: Educate resident on use of call light; -Focus: The resident needs help with his/her activities of daily living (ADLs) due to the resident has Parkinson's disease, arthritis, and psychosis (a mental disorder); -Intervention: Encourage the resident to use the call light. Observation and interview on 11/18/24 at 4:35 A.M. and 6:02 A.M., showed the resident lay in bed in a low position and the resident's call light was attached to the top of the privacy curtain located near the resident's bed. At 7:34 A.M., the resident attempted to get out of the bed. The resident's call light was clipped to the top of the privacy curtain near the resident's bed. Certified Medication Technician (CMT) G went into the resident's room. The resident said he/she had to go to the bathroom. CMT G instructed the resident to lay back in the bed and CMT G cleaned the resident and changed his/her brief. CMT G left the room. The call light remained clipped on the privacy curtain near the resident's bed and out of the resident's reach. Observation on 11/19/24 at 12:15 P.M., showed the resident stood at his/her closet in his/her room, looking through his/her clothing items. The resident's unlocked wheelchair was positioned behind him/her. The resident's call light was clipped at the top of the privacy curtain, out of the resident's reach near the resident's bed. At 4:25 P.M., the resident sat in his/her wheelchair in his/her room, attempting to stand up. Licensed Practical Nurse (LPN) Y went into the resident's room and instructed the resident to sit down. The resident sat down in his/her wheelchair. LPN Y left the resident's room. The resident's call light was clipped at the top of the privacy curtain near the resident's bed and out of the resident's reach. 2. Review of Resident #23's quarterly MDS, dated [DATE], showed: -Rarely or never understood; -Upper and lower extremity impairment; -Always incontinent of bowel and bladder; -Dependent on staff for toileting hygiene, eating and bathing; -Required substantial assistance from staff from lying to sitting to the side of the bed, sitting to a standing position, and chair to bed transfers; -Diagnoses included heart disease, kidney disease, diabetes, stroke and dementia. Review of the resident's care plan, in used at the time of survey, showed: -Focus: The resident has an ADL self-care performance deficit related to dementia; -Interventions: Encourage the resident to use the call light for assistance. Observation on 11/18/24 at 5:41 A.M., showed the resident lay in bed and the resident's call light was positioned on top of a set of drawers located near to the resident's bed. The call light was not within reach of the resident. At 7:25 A.M., CMT G entered the resident's room, administered the resident's medications and left the room. The resident's call light remained on top of the set of drawers next to the resident's bed out of the resident's reach. 3. Review of the resident #174's medical record, showed his/her diagnoses included stroke, dysphagia (difficulty swallowing), weakness and heart disease. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's ADL needs. Observation and interview on 11/18/24 at 5:41 A.M., showed the resident lay in bed and the resident's call light was positioned under the resident's pillow. The resident said he/she could not reach the call light and would like some water. At 7:25 A.M., CMT G entered the resident's room, administered the resident's roommate's medications and left the room The resident's call light remained under the resident's pillow and out of reach for the resident. Observation and interview on 11/19/24 at 11:17 A.M., showed the resident lay in bed and the call light was located under the resident's bed on the floor. The resident told Certified Nurse Aide (CNA) O his/her bottom hurt and that he/she needed to be cleaned. LPN I assisted CNA O with cleaning the resident and turning him/her from side to side. When LPN I and CNA O completed cleaning the resident, LPN I and CNA O left the room. The resident's call light remained under the bed on the floor, out of the resident's reach. 4. Review of Resident #20's medical record, showed: -Cognitively intact; -Diagnoses included type two diabetes mellitus, muscle weakness, and schizoaffective disorder (mental health condition that includes features of both schizophrenia and a mood disorder). Review of the resident's care plan, in use at the time of the survey, showed: -Focus: resident has an ADL self-care performance deficit; -Goal: resident will maintain current level of function in ADLs through the review date; -Interventions: encourage the resident to use bell to call for assistance. Observation on 11/18/24 at 10:10 A.M., showed the resident's call light attached to the resident's privacy curtain, out of reach of the resident. The resident was awake in his/her bed. During an interview on 11/18/24 at 10:11 A.M., the resident said he/she wanted to get out of bed but was not sure how to communicate to the staff because his/her call light was out of reach. Observation on 11/18/24 at 10:44 A.M., showed the resident's call light still attached to the resident's privacy curtain. During an interview on 11/18/24 at 10:47 A.M., the resident said he/she still wanted to get out of bed. 5. Review of Resident # 175's medical record, showed his/her diagnoses included stroke, muscle wasting, pressure wounds (wound that occur after prolonged pressure to the area), dehydration and failure to thrive. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's ADL needs. Observation and interview on 11/18/24 at 4:45 A.M., showed the resident's upper body lay on the fall mat, on the right side of the bed, and his/her lower body was on the bed. The resident was visible from the hallway. The push button call light was attached to the privacy curtain on the left side of the bed, approximately four feet from the floor. The resident was not able to communicate when asked questions regarding the call light. 6. Review of Resident #6's admission MDS, dated [DATE], showed: -Moderate cognitive impairment; -Always incontinent of bowel and bladder; -Required substantial assist from staff for toileting, personal hygiene, sitting to a standing position, and chair to bed transfers; -Diagnoses included Alzheimer's disease, eye disease, fractures and depression. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has a ADL self-care deficit related to decreased activity, weakness and functional decline; -Intervention: Encourage use of call light for staff assistance. Observation and interview on 11/18/24 at 4:47 A.M., showed the resident lay in the bed, in his/her room. When the resident was approached, he/she was tearful and appeared nervous. The resident was unable to identify where the call light was on his/her bed. The call light was attached the mattress, at the head of the bed, near the bed frame, not within reach of the resident. 7. Review of Resident #126's medical record, showed diagnoses included aphasia (language impairment), unspecified speech disturbances, anxiety, complete traumatic amputation at knee level to left lower leg and generalized muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed: -No speech - absence of spoken words; -Ability to express ideas and wants: Sometimes understands, responds adequately to simple, direct communication only; -Moderate cognitive impairment; -Upper and lower extremity impairment on both sides; -Substantial/maximal assistance required for roll left and right; -Dependent on assistance for sit to lying, lying to sitting on side of the bed, and chair/bed-to-chair transfer. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident has communication, history of previous trachea and vocal cord damage causing him/her to be nonverbal. He/She communicates by head nods, picture cards, pointing to words, and communication board; -Goal: Resident will be able to make basic needs known on a daily basis through the review date; -Interventions included: -Use alternative communication tools as needed; -Resident prefers to communicate in writing and gestures -Resident requires an assistive device to communicate. Ensure availability and functionality of adaptive communication equipment; -The resident is able to communicate by writing, using gestures. Observation on 11/18/24 at 5:42 A.M., showed the resident in bed. A bedside table with stacks of notebooks, paper, and a writing utensil, approximately four feet from the left side of the resident's bed, was not within reach. During an interview, the resident was nonverbal and nodded and shook his/her head in response to questions. The resident shook his/her head no, he/she cannot move from the bed on his/her own. Observations on 11/18/24 at 6:12 A.M., 7:05 A.M., and 10:05 A.M., showed the resident in bed. His/Her bedside table containing notebooks, paper, and writing utensil was positioned approximately four feet from the left side of the bed, not within reach. Observations on 11/19/24 at 10:52 A.M., 11:48 A.M., and 12:34 P.M., showed the resident in bed. His/Her bedside table containing notebooks, paper, and writing utensil was positioned approximately four feet from the left side of the bed, not within reach. During an interview at 12:34 P.M., the resident nodded to the paper and notebooks on the bedside table. He/She nodded yes, he/she can write and uses the communication devices on the table to communicate to staff. Observations on 11/19/24 at 1:35 P.M., 2:32 P.M., 3:30 P.M., 4:55 P.M., and 5:47 P.M., showed the resident in bed. His/Her bedside table containing notebooks, paper, and writing utensil was positioned approximately four feet from the left side of the bed, not within reach. Observations on 11/20/24 at 7:32 A.M., 9:58 A.M., 10:32 A.M., 11:44 A.M., and 1:10 P.M., showed the resident in bed. His/Her bedside table containing notebooks, paper, and writing utensil was positioned approximately four feet from the left side of the bed, not within reach. Observations on 11/21/24 at 7:52 A.M. and 9:22 A.M., showed the resident in bed. His/Her bedside table containing notebooks, paper, and writing utensil was positioned approximately four feet from the left side of the bed, not within reach. During an interview at 9:22 A.M., the resident shook his/her head no, he/she cannot reach his/her bedside table. He/She nodded his/her head yes, that he/she has trouble communicating with staff. He/She nodded his/her head yes, he/she can write and point to things, and it would be easier to communicate if he/she had the ability to write or point at a communication board. During an interview on 11/22/24 at 9:38 A.M., CNA J said the resident cannot transfer him/herself. He/She is nonverbal but is cognitively intact. At 11:15 A.M., CNA J said the resident communicates to staff by gesturing, nodding and shaking his/her head, and writing in his/her notebooks. During an interview on 11/22/24 at 12:09 P.M., CNA E said the resident requires assistance from staff to transfer him/herself out of bed. He/She cannot talk but can write. He/She points to things and can write in his/her notebooks to tell staff what he/she needs. Staff should ensure the resident's notebooks and communication devices are within reach. Staff should position the resident's bedside table next to his/her bed, within reach, before they leave the room. During an interview on 11/22/24 at 11:12 A.M., LPN H said the resident is alert and has difficulty expressing him/herself. He/She points at things to communicate and writes. Staff should ensure the resident's notebooks are within his/her reach. During an interview on 11/22/24 at 12:42 P.M., Assistant Director of Nurses (ADON) A said the resident is alert and oriented times three of four (person, place, time and situation). He/She cannot speak and communicates with gestures and by using a writing board. The resident's writing board should be within his/her reach at all times. If staff move the resident's communication items while providing care, they should ensure the items are put back within the resident's reach when they are finished. 8. During an interview on 11/22/24 at 10:47 A.M., LPN H and CNA/CMT G said staff should ensure call lights and other needed items are within a resident's reach before staff leave the room. It is not appropriate to clip a call light on a privacy curtain, outside of the resident's reach. 9. During an interview on 11/22/24 at 1:32 P.M., the Administrator said she expected staff to ensure call lights and other needed items are placed within a resident's reach before leaving the room. All staff are responsible for this. MO00245336 Surveyor: [NAME], [NAME] 46888 .

Based on interview and record review, the facility failed to follow general accounting principles by failing to employ proper bookkeeping techniques to track the amount of cash on hand used for resident withdrawals from the resident trust account. This affected 44 residents whose funds were handled by the facility. The census was 83. Review of the facility's petty cash daily log sheets, showed no ongoing tracking of the total amount of cash on hand at any given time and no monthly reconciliation. During an interview on 11/21/24 at 1:58 P.M., the Business Office Manager (BOM) said the facility keeps cash on hand for resident requests for cash. There is no set amount of cash kept on hand and the amount of cash available varies at any given time. The facility maintains a spreadsheet to show the date of cash requests and the amount withdrawn, but there is no running total to show how much money is in the cash box at any given time. She can calculate the amount that should be in the cash box by reviewing the resident trust fund account and subtracting pending transactions. They do not reconcile the petty cash at the end of the month, as this is tracked in the facility's accounting system. During the interview, the BOM reviewed the resident trust account system and said the facility should have a total of $338.00 on hand. She counted the money in the cash box, which totaled $388.00, a difference of $50.00. the BOM said she understands why it would be helpful to align to the petty cash report to show the total amount of cash on hand at any given time. During an interview on 11/22/24 at 1:32 P.M., the Administrator said she expects cash on hand to be reconciled routinely and appropriately tracked to ensure money is not misplaced.

42795 46888 Based on observation, interview and record review, the facility failed to ensure residents were changed in a timely manner (Residents #23, #25 and #44), failed to ensure residents received a minimum of two showers per week and activities of daily living (ADL) care as needed (Residents #2, #36, #45, #54, #66, #276 and #126), and failed to ensure residents were repositioned in bed as needed (Residents #126 and #41 ). The sample was 19. The census was 83. Review of the facility's ADL bathing policy, dated 7/21/22, showed: -Policy: nursing staff will assist in bathing residents to promote cleanliness and dignity. The charge nurse will be made aware of residents who refuse bathing; -Procedure: assist resident into the shower. Encourage them to hold onto to safety bars. Encourage resident to bathe him/herself and assist as needed. When resident has finished bathing instruct them to stand and ensure skin is free of soap. Assist with dressing and grooming as needed. Review of the facility's ADL shaving policy, dated 7/21/22, showed -Policy: the facility will provide aid with shaving as directed in the care plan. ADL care will include shaving to promote cleanliness and preserve dignity. Review of the facility's Skin Integrity policy, reviewed 7/5/24, showed: -Purpose: To establish best practice guidelines for skin integrity monitoring and maintenance to reduce potential risk of skin breakdown where clinically appropriate; -Incontinence care shall be provided in a timely after each episode of incontinence. 1. Review of Resident #23's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/26/24, showed: -Rarely or never understood; -Upper and lower extremity impairment; -Always incontinent of bowel and bladder; -Required maximum assistance from staff for toilet hygiene; -Diagnoses included heart disease, kidney disease, diabetes, stroke and dementia. Review of the resident's care plan, in used at the time of survey, showed: -Focus: The resident is at risk for urinary decline related to dementia; -Interventions: Provide peri-care after each incontinent episode; Assist to bathroom as needed; Use absorbent products as needed. During observation and interview on 11/17/24 at 9:00 A.M., the resident's Family Member A was providing peri-care to the resident. The family member removed the resident's brief and the resident's brief and bed pad were saturated with urine. Family Member A said he/she must clean the resident every day when he/she first arrives to the facility in the morning because the resident is left wet all night and the resident cannot communicate his/her needs. 2. Review of Resident #25's annual MDS, dated , 8/24/24, showed: -Moderate cognitive impairment; -Frequently incontinent of bowel and bladder; -Upper and lower extremity impairment; -Required maximum assist from staff with toilet hygiene; -Diagnoses included stroke, dementia, lung disease, eye disease and depression. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has an ADL self-care performance deficit related to fatigue, blindness, and occasional confusion: -Interventions: The resident requires maximum assist with toilet hygiene and personal hygiene. During observation and interview on 11/18/24 at 6:47 A.M., the resident lay in bed and Certified Nursing Assistant (CNA) N explained to the resident that he/she was going to provide peri-care. CNA N turned the resident to his/ her right side and the resident was wearing two briefs. Both of the briefs were moderately saturated. CNA N said he/she had last changed the resident at 1:00 A.M. CNA N said the resident urinates a lot and due to be being short staffed on nights, that is why CNA N had placed two briefs on the resident. 3. Review of Resident #44's quarterly MDS, dated , 8/25/24, showed: -Mild cognitive impairment; -Upper and lower extremity impairment; -Always incontinent of bowel and bladder; -Required maximum assist from staff for toilet hygiene; -Diagnoses included heart failure, diabetes, stroke, and depression. Review of the resident's care plan, in use at the time of survey, showed: -Focus: bowel and bladder incontinency noted, at risk for urinary tract infection (UTI), and skin breakdown; -Interventions: provide incontinence and perineal (cleansing of the genitals) care after each incontinent episode; Check resident before and after meals and as needed for incontinence episodes; Document incontinent status every shift. During observation and interview on 11/18/24 7:02 A.M., the resident lay in bed and CNA N explained to the resident that he/she was going to complete peri- care. CNA N turned the resident to his/ her right side and the resident was wearing two briefs. Both briefs were moderately saturated. The resident's incontinecet pad had a yellow ring and was saturated. CNA N removed the two briefs and cleansed the resident buttock region. CNA N said the resident does not like to be bothered at night so that is why he/she placed the double brief on the resident. The resident said, I have never said that. The last time CNA N checked the resident for incontinence was at 1:00 A.M. 4. During an interview on 11/18/24 at 7:02 A.M., CNA N said the residents are to be checked for incontinence every two hours. 5. During an interview on 11/22/24 at 8:45 A.M., CNA O said there are no residents for any reason that should be doubled briefed. The residents are to be checked for incontinence every two hours so residents don't develop skin breakdown or UTIs. 6. During an interview on 11/22/24 at 12:42 P.M., the Assistant Director of Nursing (ADON) said the residents are to be checked for incontinence every two hours to prevent any type of skin breakdown. It is never acceptable for a resident to wear two briefs. 7. Review of Resident #2's electronic medical record (EMR), showed: -Diagnoses included type two diabetes mellitus, major depressive disorder and end stage renal disease; -Moderately impaired cognition. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: resident has a ADL self-care performance deficit; -Goal: resident will maintain current level of function with ADLs through the review date; -Interventions: offer bathing/showering twice weekly and as necessary. During an interview on 11/17/24 at 8:20 A.M., the resident said that he/she feels there is not enough staff employed at the facility. He/She said staff never get him/her out of bed on time. He/She said it had been weeks since his/her last shower. During an interview on 11/17/24 at 8:31 A.M., the resident said he/she only receives one shower a week. He/She said he/she should be at least receiving two showers a week. The resident was observed to have white matter on his/her mouth and oily hair. 8. Review of Resident #36's EMR, showed: -Diagnoses included Alzheimer's disease and epilepsy; -Moderately impaired cognition. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: resident has a ADL self care performance deficit; -Goal: Resident will maintain current level of function through the review date; -Interventions: resident requires assistance with bathing/showering weekly and as necessary. Resident requires moderate assist/ staff participation with personal hygiene and oral care. During an interview on 11/17/24 at 8:38 A.M., the resident said staff do not assist him/her with shaving his/her facial hair. He/She would like his/her facial hair trimmed. Observation on 11/18/24 at 5:03 A.M., showed the resident's beard was thick and long. Observation on 11/19/24 at 3:29 P.M., showed the resident's beard was thick and had little specks of red matter in the hair. 9. Review of Resident #45's quarterly MDS, dated , 8/22/24, showed: -Cognitively intact; -Impairment to both upper extremities; -Partial assistance from staff for bathing; -Supervision form staff for shower transfers; -Diagnosis include Parkinson's disease (a neurological condition that causes tremors), schizophrenia (a mental disorder that distorts reality) and depression. Review of the resident's care plan, in use at the time of survey, showed; -Focus: ADL self-care performance deficit related to stiffness and decreased range of motion (ROM) to the resident's upper extremities; -Interventions: Offer bathing or showering twice weekly and necessary; Use simple instructions to promote independence. Review of the shower sheets, dated September and November, 2024, did not show completed showered sheets. During observation and interview on 11/17/24 at 8:05 A.M., 11/18/24 at 4:58 A.M., and 11/22/24 at 8:28 A.M., the resident's hair appeared very oily with large chunks of white flakes throughout his/her hair. The resident had anti-dandruff shampoo located in his/her room. He/She said staff do not use his/her anti-dandruff shampoo and said staff use body wash to clean his/her hair. The resident said he/she has difficulty washing his/her hair due to lack of mobility in his/her arms. The resident said he/she has not had a shower and his/her hair washed for about two weeks. He/She does not like the way his/her hair looks. During an interview on 11/22/24 at 9:00 A.M., CNA Q said the resident needs to be supervised with his/her showers and assistance with hair washing. The resident's hair should be washed every time the resident gets a shower. CNA Q was not aware the resident had anti-dandruff shampoo in his/her room. 10. Review of Resident #54's EMR, showed: -Diagnoses included acquired absence of left leg above the knee and history of falling; -Cognitively intact. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: the resident is limited assistance with bed mobility and transfers. Balance is poor. Resident is extensive assist with upper and lower body dressing and toileting; -Goal: resident will maintain current level of function with ADLs through the review date; -Intervention: offer bathing or showering twice weekly and as necessary. During an interview on 11/17/24 at 8:43 A.M., the resident said he/she does not remember the last time he/she received at shower. He/She said the facility is always short staffed and he/she felt like the staff did not have enough time to give him/her a shower. The resident was observed to have oily hair and his/her beard was unkempt. Shower sheets? 11. Review of Resident #66's quarterly MDS, dated [DATE] showed: -Cognitively intact; -Upper and lower extremity impairment; -Requires maximum assistance from staff for bathing; -Always incontinent of bowel and bladder; -Diagnoses included lung disease, heart failure and diabetes. Review of the resident's care plan, in use at the time of survey, showed: -Focus: ADL self-performance deficit related to shortness of breath and heart failure; -Interventions: Offer bathing or shower weekly or as necessary; Use simple instructions to promote independence. Review of the shower sheets, dated September and November, 2024 did not show completed showered sheets. During observation and interview on 11/17/24 at 9:14 A.M. and 11/19/24 at 12:00 P.M., the resident sat in his/her wheelchair in his/ her room. The resident raised his/her pant legs and exposed his/her lower legs. The resident's skin appeared extremely dry, leather-like and very thick. The resident said he/she picks at his/her skin to try to get the dead skin off. The resident said he/she has not received a shower in three weeks. The resident thinks it is due to his/her size that staff does not assist with his/her showers. The resident said his/her dry legs have been like that since he/she was admitted . During an interview on 11/22/24 at 9:00 A.M., CNA Q said the resident's legs have always been extremely dry. Residents should have showers twice a week. The resident requires a bariatric (large) shower chair and total assistance of two persons transferring into the shower. 12. Review of Resident #276's EMR, showed: -Diagnoses included low blood pressure, high cholesterol, and recent hip fracture; -Resident admitted on [DATE]. Review of resident nurse's progress notes, dated 11/4/24, showed: -Resident will need minimum to moderate assistance for toileting and showering. Review of the hospital discharge summary to the nurse at the facility, dated 11/4/24, showed: -Remove staples to right hip 14 days from the date of the surgery. Review of the Bath Schedule for South/South Beach, Day shift, the resident is scheduled for a shower on Monday and Thursday. During observation and interview on 11/17/24 at 8:42 A.M., the resident said he/she has incontinent episodes and he/she has not gotten a shower. He/She said there are people coming to visit and he/she would like to be clean. The resident has requested a shower. During observation and interview on 11/18/24 at 8:40 A.M., the resident said he/she did not get a shower yesterday. The resident's hair was tangled on the back of the resident's head. The resident wore the same shirt he/she wore the day before. During an interview on 11/19/24 at 12:48 P.M., the resident's power of attorney (POA) BB said the resident needs a shower. POA BB has mentioned to the staff the resident needed a shower, the staples have been out since 11/14/24 and there is no reason not to get a shower. During observation and interview on 11/20/24 at 7:15 A.M., the resident said he/she had an accident in bed last night. He/She said that bed was soaked with urine from the head to the foot of the bed. The staff removed the soiled linen and wiped down the back of the resident's body. At the foot of the bed, on the floor, there was a dried outline, approximately two feet in diameter with a liquid puddle in the middle, approximately a foot in diameter. During an interview on 11/21/24 at 7:35 A.M., the resident said he/she still has not gotten a shower. During an interview on 11/22/24 at 7:47 A.M., the resident he/she still has not gotten a shower. Observation on 11/22/24 at 7:52 A.M., showed shower sheets from the day before were in the cubby behind the desk. There was no shower sheet for the resident. 13. Review of Resident #126's quarterly MDS, dated [DATE], showed: -No speech - absence of spoken words; -Moderate cognitive impairment; -Rejection of care behavior exhibited 4-6 days, but less than daily; -Upper and lower extremity impairment on both sides; -Substantial/maximal assistance required for roll left and right; -Dependent on assistance for sit to lying and lying to sitting on side of the bed; -Diagnoses included aphasia (language impairment), kidney disease, diabetes and anxiety. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Activities of self-care performance deficit. Resident on staff one to two for ADL needs; -Interventions included: Bed mobility: Requires staff assistance to turn and reposition in bed. Bathing/showering: Offer bathing/showering twice weekly and as necessary. Bathing/showering: Provide sponge bath when a full bath or shower cannot be tolerated; -Focus: Resident has behaviors of refusal to get out of bed and turning and repositioning when in bed. Potential risk for impaired skin integrity, sciatic pain, and constipation; -Interventions included: If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed upon time. If resists with ADLs, offer reassurance, leave and return 5-10 minutes later and re-attempt care. Review of the resident's medical record, showed the resident was in the hospital from 10/5/24 to 10/16/24. Review of the facility's bath schedule, undated, showed the resident was scheduled for bathing on Tuesday and Thursday evenings. Review of the resident's shower sheets from 10/1/24 through 11/19/24, showed: -On 10/9/24, staff documented at the hospital, -No other shower sheets completed and no showers or bed baths documented as completed; -The resident missed a total of 12 showers or bed baths on days he/she was in the facility during this timeframe. Observations on 11/17/24 at 9:57 A.M. and 11:11 A.M., showed the resident seated upright on a low air loss (LAL) mattress with his/her back flush to the bed. A hospital band was on his/her right wrist. The resident's hair was unkempt and his/her beard was scruffy and unkempt. Observations on 11/18/24 at 5:42 A.M., 6:12 A.M., 7:05 A.M., and 10:05 A.M., showed the resident seated upright on a LAL mattress with his/her back flush to the bed. A hospital band was on his/her right wrist. The resident's hair was unkempt and his/her beard scruffy and unkempt. Observations on 11/19/24 at 10:14 A.M., 10:52 A.M., 11:48 A.M., and 12:34 P.M., showed the resident showed the resident seated upright on a LAL mattress with his/her back flush to the bed. During an interview at 12:34 P.M., the resident was nonverbal and nodded or shook his/her head in response to questions. The resident shook his/her head no, he/she is not comfortable. He/She pointed to his/her lower body and nodded his/her head yes when asked if his/her backside hurts. He/She shook his/her head no, he/she cannot turn him/herself and staff have not turned or repositioned him/her. He/She shook his/her head no, staff have not offered to get him/her out of bed and he/she nodded yes, he/she would like to get out of bed. Observations on 11/19/24 at 1:35 P.M., 2:32 P.M., 3:30 P.M., 4:55 P.M., and 5:47 P.M., showed the resident seated upright on a low air loss (LAL) mattress with his/her back flush to the bed. A hospital band was on his/her right wrist. The resident's hair was unkempt and his/her beard was scruffy and unkempt. During an interview at 12:24 P.M., the resident wasnonverbal and nodded or shook his/her head in response to questions. He/She shook his/her head no, he/she has not gotten a shower since he/she came back from the hospital, and has not received a full bed bath. He/She nodded yes, he/she wants to have a shower and his/her beard to be trimmed. Observations on 11/20/24 at 9:58 A.M., 10:32 A.M., 11:44 A.M., and 1:10 P.M., showed the resident seated upright on a low air loss (LAL) mattress with his/her back flush to the bed. During an interview on 11/22/24 at 9:38 A.M., CNA J said the resident is total care and does not like to get out of bed. Staff should turn him/her every two hours. During an interview on 11/22/24 at 12:09 P.M., CNA E said the resident requires assistance with bed mobility and transfers. He/She prefers to be out of bed on Tuesdays and Thursdays. The resident is total care. He/She is ok with getting bed baths or showers. During an interview on 11/22/24 at 9:49 A.M., Licensed Practical Nurse (LPN) H said the resident prefers to stay in bed. He/She is total care and requires staff assistance for bed mobility and transfers. He/She has a history of wounds. Staff should turn and reposition the resident every two hours to help with wound prevention. The resident prefers bed baths. He/She might refuse care if he/she is agitated, but usually, he/she is agreeable. 14. During an interview on 11/22/24 at 8:28 A.M., CNA E said residents are assigned showers by their room number. There is a shower list in the binder on the hall. Residents should get at least two showers a week, more if requested or needed. Once a shower is completed, the staff document and sign a shower sheet to give to the nurse. It is important for residents to get their showers to prevent sores, to be clean, and so they do not smell. 15. During an interview on 11/22/24 at 9:48 A.M., LPN H said that staff are made aware of their showers per the assignment sheet that is filled out by the nurse. There is also a shower list in the binder at the desk. If the resident is unable to get into a shower, the staff should give the resident a bed bath. Shower sheets are completed by the staff and nurse reviews. At times, there are staffing issues and the staff have to prioritize what resident needs to be showered, usually one-two residents on the list. LPN H was not aware Resident #276 requested a shower. His/Her shower should have been done on the assigned days. Residents need showers to help the circulation and healing of the body. 16. During an interview on 11/22/24 at 12:42 P.M., ADON A said she expected staff to provide showers to the residents. Staff is expected to follow a shower schedule and inform the nurse if a resident's shower was missed, or if the resident refuses. 17. During an interview on 11/22/24 at 1:34 P.M., the Administrator said she expected staff to follow the facility policy on bathing. Residents should receive at a minimum, two showers a week. 18. Review of Resident #41's EMR, showed: -Diagnoses included anemia, heart failure (the inability of the heart to pump oxygenated blood), high blood pressure, diabetes, high cholesterol, dementia and depression. Review of the resident's quarterly MDS, dated [DATE] showed: -Resident admitted on [DATE]; -Resident is dependent for toileting hygiene, showering, bathing, lower body dressing, rolling from right to left in bed, to get out of the bed, and all transfers; -Severe cognitive impairment. Review of the resident's care plan, dated 8/13/24, showed: -Focus: ADL self-care performance deficit due to weakness, shortness of breath, fatigue, and loss of appetite; -Goal: resident will maintain current level of function with ADL's through the review date; -Intervention: dependent on two for transfers with mechanical lift, turning and repositioning safely in bed. Observations on 11/18/24 at 4:18 A.M., 5:11 A.M. and 7:55 A.M., showed the resident in bed on his/her back, head facing the doorway. Observations on 11/19/24 at 10:15 A.M. and at 12:51 P.M., showed the resident in bed on his/her back. At 1:05 P.M., the resident was in bed, on his/her back, with staff attempting to feed the resident. At 2:22 P.M., the resident was in bed on his/her back. Observation and interview on 11/19/24 at 3:07 P.M., showed CNA M and CNA J entered the resident room, proceeded to provide care to the resident. After care completed, staff left the resident lying on his/her back. CNA M said the air mattress alternates the air from different areas to relieve pressure. Observations on 11/20/24 at approximately 8:20 A.M., 9:21 A.M., 10:11 A.M., 10:57 A.M. and 10:57 A.M., showed the resident in bed, on his/her back. During an interview on 11/22/24 at 8:28 A.M., CNA E said the resident required total care. The resident has to be checked as much as possible for incontinence and to be repositioned. Repositioning means that a resident is placed on their side or their back. The reason for turning and repositioning and incontinence is to prevent wounds, and so the resident does not smell. 19. During an interview on 11/22/24 at 10:41 A.M., LPN I said she expected staff to check the resident for incontinence and to turn and reposition the resident. A low air loss mattress is not a substitute for turning and repositioning, which helps with wound healing. 20. During an interview on 11/22/24 at 11:06 A.M., LPN H said staff should check and turn the resident frequently. A low air loss mattress is not a substitute for turning and repositioning. The benefit of turning and repositioning is to relieve the pressure on the resident's bottom and help healing of wounds. 21. During an interview on 11/22/24 at 12:42 A.M, ADON A said a low air loss mattress does not replace turning and repositioning the resident. She expected staff to make rounds every two hours, check for incontinence and to turn and reposition. 22. During an interview on 11/22/24 at 1:34 P.M., the Administrator said she expected staff to check on the residents every two hours and to turn and reposition the resident. The low air loss mattress is not a substitute for turning and repositioning. MO00237643 MO00244184 MO00245021 MO00244195 49992

Based on observation, interview, and record review, the facility failed to ensure a sufficient amount of nursing staff was available to meet the needs of residents, resulting in a resident left in bed (Resident #20), meals not delivered timely and served cold (Residents #54 and #40), residents not changed timely (Resident #25), and residents not receiving showers in accordance with their needs and preferences (Residents #20, #54, and #2). The sample was 19. The census was 83. 1. Review of the facility's Facility Assessment, revised 7/20/24, showed: -Assistance with activities of daily living (ADL) monthly average included: -Bed mobility sit to lying, mobility sit to stand, bathing, transfers, and toileting: 34 with supervision/partial/moderate assistance, and 30 dependent/maximum assistance; -Eating: 51 with set up assistance, 16 with supervision/partial/moderate assistance, and 7 dependent/maximum assistance; -Staff Type/Plan: -10 to 15 licensed nurses providing direct care (Registered Nurse (RN), Licensed Practical Nurse (LPN); -20 to 30 Certified Nurse Aides (CNAs); -No documentation of specific nurse staffing needs for each shift to ensure a sufficient number of staff based on the resident population. 2. During a group interview on 11/19/24 at 2:04 P.M., five out of five residents, whom the facility identified as alert and oriented, said there is not enough staff working across all shifts. There are problems with staff not getting residents out of bed and with residents not receiving their showers. These issues are due to lack of staff. One resident said when he/she asks for help from staff, sometimes the staff will say they can't help because there is not enough staff working and they are too busy. All five residents said the food is always cold and it takes a very long time for room trays to be passed out. 3. Review of employee time punches for day shift (7:00 A.M. to 3:30 P.M.) on 11/18/24, showed: -Three LPNs clocked in during day shift; -Two Certified Medication Technicians (CMTs) clocked in during day shift; -Four CNAs clocked in during day shift. 4. Review of Resident #20's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/14/24, showed: -Cognitively intact; -Upper and lower extremity impairment on both sides; -Dependent on assistance for sit to stand and chair/bed-to-chair transfers; -Diagnoses included heart disease, high blood pressure, muscle weakness, and depression. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: the resident has an ADL self-care performance deficit; -Goal: resident will maintain current level of function in ADLs through the review date; -Interventions: the resident requires supervision with limited assistance of one staff with showering, encourage the resident to use bell to call for assistance. Observation on 11/17/24 at 8:31 A.M., showed the resident with white matter on his/her mouth and oily hair. During an interview, the resident said he/she only receives one shower a week. He/She should be at least receiving two showers a week. Observation on 11/18/24 at 10:10 A.M., showed the resident's call light attached to the resident's privacy curtain out of reach of the resident. The resident was awake in his/her bed. During an interview, the resident said he/she wants to get out of bed but is not sure how to get ahold of the staff because his/her call light is out of reach. At 10:47 A.M., the resident remained in bed with his/her call light attached to his/her privacy curtain. The resident said he/she still wants to get out of bed. He/She is usually out of bed by this time. It appears the facility is short on staff this morning. 5. Review of Resident #54's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Set up assistance required for eating; -Diagnoses included heart disease, heart failure, and kidney failure. Review of the resident's medical record, showed diagnoses included acquired absence of left leg above the knee and history of falling. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: the resident is limited assistance with bed mobility and transfers. Balance is poor. Resident is extensive assist with upper and lower body dressing and toileting; -Goal: resident will maintain current level of function with ADLs through the review date; -Intervention: offer bathing or showering twice weekly and as necessary. Observation on 11/17/24 at 8:43 A.M., showed the resident with oily hair and an unkempt facial hair. During an interview, the resident said he/she does not remember the last time he/she received a shower. The facility is always short staffed and he/she feels like the staff does not have enough time to give him/her a shower. Observation on 11/18/24 at 7:59 A.M., showed staff brought a room tray cart out of the kitchen to the North Heritage hall. At 8:43 A.M., CNA/CMT G passed breakfast trays to the rooms on the North Heritage hall. He/She was the only employee passing out the room trays on the North heritage hall. At 9:01 A.M., the last food tray served to a resident. Food temperatures were obtained from a test tray on the North Heritage room tray cart and showed sausage measured at 87.7 degrees Fahrenheit (F), waffles at 93.2 degrees F, and oatmeal at 119.8 degrees F. During an interview on 11/18/24 at 9:13 A.M., the resident said his/her breakfast is terrible. The food is cold and the waffles are soggy. 6. Review of Resident #40's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Supervision or touching assistance required for eating; -Diagnoses included heart disease, kidney failure, diabetes, and depression. Observation on 11/18/24 at 8:05 A.M., showed a warming cart filled with breakfast trays unplugged by the nurse's station on the South and South Beach hall. At 8:15 A.M., CNA M began passing trays from the warming cart. During an interview, CNA M said he/she is the only aide on the South and South Beach halls. He/She is passing trays by him/herself because the facility is short on staff right now. At 8:59 A.M., CNA M delivered the last tray from the warming cart on the South hall. During an interview on 11/18/24 at 8:56 A.M., Resident #40 said his/her breakfast is cold. 7. Review of Resident #25's annual MDS, dated , 8/24/24, showed: -Moderate cognitive impairment; -Frequently incontinent of bowel and bladder; -Upper and lower extremity impairment; -Required maximum assist from staff with toilet hygiene; -Diagnoses included stroke, dementia, eye disease, and depression. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has an ADL self-care performance deficit related to fatigue, blindness, and occasional confusion; -Interventions: The resident requires maximum assist with toilet hygiene and personal hygiene. Observation on 11/18/24 at 6:47 A.M., showed the resident lay in bed and CNA N explained to the resident that he/she was going to provide personal care. CNA N turned the resident to his/her right side and the resident wore two briefs, one on top of the other. Both briefs were moderately saturated. During an interview, CNA N said the resident urinates a lot so he/she placed two briefs on residents who are incontinent and urinate frequently due to being short staffed on nights. It is difficult to change everyone every two hours when there is not enough staff. 8. Review of Resident #2's significant change MDS, dated [DATE], showed: -Moderate cognitive impairment; -Upper and lower extremity impairment on both sides; -Substantial/maximal assist required for bathing; -Dependent on assistance for chair/bed-to-chair transfers; -Diagnoses included seizure disorder, arthritis, and depression. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Resident has an ADL self-care performance deficit; -Goal: Resident will maintain current level of function with ADLs through the review date; -Interventions: Offer bathing/showering twice weekly and as necessary. During an interview on 11/17/24 at 8:20 A.M., the resident said he/she feels there is not enough staff employed at the facility. Staff never get him/her out of bed on time. It had been weeks since his/her last shower. 9. During an interview on 11/22/24 at 7:55 A.M., CNA/CMT F said the facility is shorthanded at times. When the facility is short on staff, showers cannot get done and meals run late. 10. During an interview on 11/22/24 at 10:54 A.M., CNA/CMT G said the facility is short staffed. The facility has many residents who have heavy care requirements. The facility has a lot of residents who are Hoyer (mechanical lift) transfers, which require two staff. Meal trays are passed by nursing staff, not dietary, and meal trays are late because nursing staff is short. On 11/18/24, the facility did not have enough staff working. Meals were late that day and he/she was the only aide on his/her hall, so he/she could not get everyone out of bed. When staffing is short, showers do not get done. 11. During an interview on 11/18/24 at 8:00 A.M., LPN R said it is difficult to obtain blood sugars, help pass trays on time, answer lights, assist residents out of bed, give medication to residents with gastrostomy tubes (g-tubes, a tube that has been surgically inserted into the abdomen and is used for liquid nutrition and medications), and administer narcotics in a timely manner when there is not enough staff. There currently is not a wound or treatment nurse, the floor nurses are also expected to complete wound treatments. There should be three nurses on day shift all the time. 12. During an interview on 11/22/24 at 9:49 A.M., LPN H said on day shift, there should be seven aides and four nurses. On evening shift, there should be six aides and four nurses. When the facility is short on staff, nurses will cover the floor as CMTs and CMTs will cover the floor as CNAs. Showers have not been getting done as often as they should due to being short on staff. Staff try to get as many showers done as they can, then pass along the remaining showers to the oncoming shift. Meal trays are going out late due to staffing shortages, and he/she hears complaints from residents about cold food. 13. During an interview on 11/21/24 at 9:57 A.M., the Staffing Coordinator (SC) said based on the census of over 80, the facility requires seven CNAs on day shift, six CNAs on evening shift, and five CNAs on night shift. The workload is reasonable with this amount of staff. If a CNA calls off, the CMT or SC may drop down to help on the floor. If a nurse calls off, one of the Assistant Director of Nurses (ADONs) will work the floor. When staff call off on the evening or night shift, the ADON or SC will be called to fill in. The SC cannot always help cover on night shift because he/she may have just worked a double on day and evening shift. 14. During an interview on 11/22/24 at 1:32 P.M., the Administrator said when staff call off, the SC will call in other staff. The SC or nurse managers will work on the floor, if needed. If the facility has to, they will offer bonuses for staff to pick up shifts. Ideally, the facility will have six CNAs and three nurses working on day shift, five CNAs and two nurses on evening shift, and four CNAs and two nurses on night shift. MO00229509 MO00244184 MO00244195 MO00245201 42795 46888

46888 Based on observation, interview, and record review, the facility failed to ensure room trays were delivered to residents at a safe and palatable temperature affecting six residents (Residents #54, #40, #70, #275, #276 and #274). The sample was 19. The census was 83. Review of the facility's food safety and food handling policy, revised 8/16/23, showed: -Policy: food handling practices shall be consistent with Food and Drug Administration (FDA) food code guidelines and comply with federal and state regulations governing food safety and prevention of foodborne illness; -Procedure: food handling practices shall be completed in a manner to protect food safety and avoid cross-contamination. Minimum internal temperatures for meat should be 145 degrees Fahrenheit (F). 1. Review of Resident #54's medical record, showed: -Diagnoses included acquired absence of left leg above the knee and history of falling; -Cognitively intact. Observation on 11/18/24 at 9:13 A.M., showed the resident seated upright on the side of the bed. A plate of food on his/her bedside table contained waffles and a bowl of oatmeal. During an interview the resident said his/her breakfast was terrible. He/She said the food is cold and the waffles are soggy. 2. Review of Resident #40's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/2/24, showed: -Supervision or touching assistance required for eating; -Diagnoses included heart disease, heart failure, high blood pressure, diabetes and depression. Observation on 11/18/24 at 8:56 A.M., showed the resident was seated upright in bed. A plate of food on his/her bedside table contained mechanical-soft sausage, waffles and a bowl of oatmeal. During an interview, the resident said his/her food is cold. 3. Review of Resident #70's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high blood pressure, high cholesterol, kidney failure and asthma. During an interview on 11/17/24 at 8:40 A.M., the resident said he/she eats meals in his/her room. He/She said the food is not good and the temperature is usually too cold. 4. Review of Resident #275's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included anemia (low iron in the blood), irregular heartbeat, high blood pressure, kidney failure, diabetes and asthma. During an interview on 11/17/24 at 8:05 A.M., the resident said he/she eats meals in his/her room. The food has no taste, there is no variety, and the food is cold. 5. Review of Resident #276's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high blood pressure, high cholesterol and a recent hip fracture. During an interview on 11/17/24 at 8:42 A.M., the resident said he/she eats meals in his/her room. He/She said the food is usually cold and is sometimes late. 6. Review of Resident #274's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included anemia, anxiety and abdominal infection. During an interview on 11/17/24 at 8:56 A.M., the resident said food is not always delivered at the same time and it is cold. He/She tries to eat in the dining room when possible. During an observation and interview on 11/17/24 at 8:18 A.M., showed the resident sat at a table in the dining room. Staff delivered a plate with waffles and sausage to the resident, which appeared to be uncooked. The resident said the waffles were cold, but he/she was hungry and was just going smother them with butter. 7. During a group interview on 11/19/24 at 2:04 P.M., five residents, whom the facility identified as alert and oriented, attended the group meeting and said the food is always cold and that it takes a very long time for room trays to be passed out. 8. Observation on 11/18/24, showed: -At 7:59 A.M., a warming cart come out of the kitchen and brought to the North heritage hallway and staff began to pass trays; -At 8:54 A.M., the warming cart sat on the North heritage hallway in the hallway with both doors open. The cart was not plugged in. Various trays on the cart had not been passed out to the residents. -At 8:56 A.M., the warming cart remained in the hallway with both doors open, not plugged in. No staff were near the cart; -At 9:01 A.M., staff passed the last resident tray on the North heritage hallway, a test trays food temperatures tested with a calibrated digital thermometer: -Sausage measured at 87.7 degrees Fahrenheit (F); -Waffles measured at 93.2 degrees F; -Oatmeal measured at 119.8 degrees F. 9. Observation on 11/20/24 at 8:24 A.M., showed a warming cart filled with breakfast trays unplugged by the nurse's station on the South/South beach hall. Certified Nursing Assistant (CNA) E moved the cart down the hallway, did not plug it in, and removed a tray from the warmer, leaving the door to the cart open. At 8:26 A.M., CNA E closed the door to the warming cart. CNA E moved the warming cart down the hall as he/she passed trays to resident rooms, opening and shutting the door of the warming cart as he/she went, leaving the warming cart unplugged. At 8:42 A.M., Dietary Aide P brought a tray containing two plates to the hall and told CNA E they were the last two plates to pass on the hall. Dietary Aide P set the tray of two plates on the bottom shelf of the beverage cart next to the warming cart. At 8:48 A.M., CNA E finished passing all trays on the hall, except one. Using a calibrated thermometer, the temperature of the food on the plate was obtained and showed the biscuit at 86.8 degrees F, scrambled eggs at 102 degrees F, and oatmeal at 116 degrees F. 10. Observation on 11/22/24 on 12:38 P.M., of lunch trays on the North hallway, showed: -Chili dog measured at 106.0 degrees F; -French fries measured at 95 degrees F. 11. During an interview on 11/22/24 at 9:49 A.M., LPN H said meal trays have been delivered late due to staffing. He/She does hear complaints about cold food from residents. 12. During an interview on 11/22/24 at 12:37 P.M., Dietary Aide K said he/she brings the warming cart out to the hall and plugs it in. The nursing staff are responsible for passing the trays. He/She said the warming cart should be plugged in and the door should remain closed to keep the food warm. Hot food should be served hot and cold food should be served cold. He/She would want his/her food served this way. 13. During an interview on 11/22/24 at 1:28 P.M., the Dietary Manager said dietary staff bring room tray carts out to the hallways and plug them in. The doors should be kept closed while passing trays. The nursing staff are responsible for passing hall trays. Food should be served in the appropriate temperature range. Hot food should be served hot and cold food should be served cold. 14. During an interview on 11/22/24 at 1:32 P.M., the Administrator said she expected food to be delivered to residents at a safe and palatable temperature. Warming carts brought out to the hallways should stay plugged in and the doors should stay closed after trays are removed. This would help with food temperatures on the hallways. MO00237643 49992

42795 Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with gastrostomy tubes (g-tube, a tube that is surgically inserted into the abdomen and is used for liquid nutrition and medications), wounds requiring treatments, peripherally inserted central catheter (PICC, a thin tube inserted into the vein that is utilized for medications and fluids) (Residents #126, #3, #14, #41 and #27). The facility failed to ensure staff used appropriate infection control practices for two residents when providing perineal care (peri care, cleansing of the genitals) (Residents #25 and #175). In addition, the facility failed to provide tuberculosis (TB) screening tests for five of five residents reviewed for TB testing (Residents #3, #66, #23, #45 and #12). The facility also failed to complete TB screening tests on two employees prior to employment at the facility (Employees S and T). The sample was 19. The census was 83. Review of the facility's Enhanced Barrier Precautions (EBP), reviewed 5/15/24, showed: -Policy: The facility may expand the use of personal protective equipment (PPE, isolation gowns and gloves) and refer to the use of gowns and gloves during high contact resident care activities that provides opportunities for transfer of MDRO to hands or clothing. The use of gowns and gloves for high contact care activities is indicated, when contact precautions do not otherwise apply, for facility residents with wounds and/or indwelling medical devices regardless of MDRO colonization (organisms are present but not causing any symptoms) as well as for residents with MDRO infection or colonization. -Procedure: Examples of high contact resident care activities requiring gown and glove use for EBP include: dressing, bathing or showering, transferring providing hygiene, changing lines, changing briefs or toileting, central line care (a flexible tube that is inserted into the vein), urinary catheter (a tube that is inserted into the bladder to drain urine), enteral tube (a surgical inserted tube in the abdomens that is used for liquid nutrition and medications), tracheostomy (a tube inserted into the windpipe that assists with breathing), wound care that requires a dressing; -Steps: Post signage on the door or wall outside the resident's room indicating the use of EBP; EBP signage should include information on high contact resident care activities that require the use of gown and gloves; PPE should be available inside of the resident's room. Review of the facility's Hand Hygiene policy, reviewed 4/28/22, showed: -Policy: The facility will provide guidelines to employees on proper handwashing and hand hygiene techniques that will aid in the prevention of the transmission of infections; -Procedure: Hand hygiene should be performed, before and after providing care, contact with blood, body fluids, or contaminated surfaces. Review of the facility's policy for Incontinent Care, reviewed 7/21/22, showed: -Policy: The facility will provide incontinent care as directed in the plan of care; -Procedure: -Gather supplies; -Identify resident and explain the procedure; -Provide privacy; -Place equipment in clean surface within reach; -Assist with positioning the resident; -Remove soiled brief and under pad by rolling the brief and under pad; -Cleanse perineal area (the area between the rectum and genitals) with perineal cleanser; -Remove soiled gloves, perform hand hygiene and apply clean gloves; -Apply clean brief and clothing; -Discard contaminated items; -Remove gloves and perform hand hygiene; -Reposition resident in a safe and comfortable position. Review of the Department of Health and Senior Services (DHSS) TB Screening for Long Term Care Residents flow chart, dated 3/11/14, showed: -No documentation of prior 2 step TB test: -Administer first step one week after admission; -Read results with 48-72 hours; -For negative results, administer second step within one to three weeks; -Read results within 48-72 hours; -For negative results, annual evaluation to rule out signs and symptoms of TB; -No further skin testing is required unless the resident is exposed or develops symptoms. -Documentation of 2 step TB test in the past with negative results; -For negative results, annual evaluation to rule out signs and symptoms of TB; -No further skin testing is required unless the the resident is exposed or develops symptoms. Review of the DHSS guidance for TB screening for long-term care employees, showed: -Employee accepts position (the hire date); -If no documentation of prior two-step tuberculin skin test (TST), administer TST first step prior to employment. Can coincide reading the results with the employee start date by administering TST two to three days prior to the employee start date); -Read results for first step TST within 48 to 72 hours of administration. (language impairment); 1. Review of Resident #126's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/4/24, showed: -Diagnoses included diabetes, hyperosmolality (high concentration of salt, glucose, or other substance in the blood) and hypernatremia (high sodium in the blood), kidney disease, malnutrition, and aphasia (language impairment); -Use of feeding tube. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident requires tube feeding related to dysphagia (swallowing disorder) and swallowing problem; -Interventions included EBP related to g-tube. Review of the resident's electronic Physician Order Summary (ePOS), showed: -An order, dated 11/17/24, for enteral feed order every shift for tube feeding, continuous enteral feeding, Formula: Jevity 1.5 (calorically-dense liquid formula); Rate: 80 milliliters (ml), start at 7:00 P.M. and run until 1:00 P.M., flush with 200 ml of water every four hours, monitor every shift; -An order, dated 11/17/24, for EBP related to g-tube while g-tube is in place. Observation on 11/17/24 at 9:57 A.M., showed an EBP sign posted outside the doorway to the resident's room. The resident lay on his/her back in bed with a tube feeding connected to his/her abdomen. Licensed Practical Nurse (LPN) H wore gloves while handling the tube near the resident's abdomen. LPN H did not wear a gown while he/she provided care to the resident's tube feeding. During an interview on 11/22/24 at 12:42 P.M., Assistant Director of Nurses (ADON) A said the resident has a tube feeding and he/she is on EBP. ADON A expected staff to wear gowns and gloves while providing care to the resident. 2. Review of Resident #3's quarterly MDS, dated , 10/4/24, showed: -The resident has a feeding tube; -Diagnosis included aphasia (inability to speak), quadriplegia (paralysis of all four extremities) and malnutrition (poor nutritional status). Review of the resident's physician order sheets (POS), showed: -A order, dated 6/22/23, infuse Osmolyte 1.5 ( type of high caloric liquid nutrition) at 60 mls via feeding tube; -An order, dated 6/10/24, EBP. Observation on 11/17/24 at 9:40 A.M., showed the resident had an EBP sign outside of the door and PPE in drawers in the resident's room. The resident lay in his/her bed. LPN I wore gloved hands and prepared the resident's tube feeding and flush on the resident's bedside table. LPN I removed the resident's bed covers and lifted the resident's gown to expose the resident's g-tube. LPN I flushed the residents g-tube with approximately 30 mls of water and then connected the resident's tube feeding to the resident's g-tube. LPN I's string ties from his/her sweatshirt touched the resident. LPN I then turned the tube feeding pump on. LPN I did not wear an isolation gown while accessing the resident's g-tube. During an interview on 11/22/24 at approximately 10:00 A.M., LPN I said staff should follow the EBP by wearing an isolation gown and gloves while providing care to the resident, because the resident has a g-tube. 3. Review of Resident #14's medical record, showed: -Diagnoses included dementia and type 2 diabetes mellitus; -Severe cognitive impairment. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: The resident has actual impairment to skin integrity; -Goal: resident will have minimum complications of wounds through the review date; -Interventions: Enhanced Barrier Precautions (EBP). Review of the resident's POS, showed: -An order, dated 6/10/24, for EBP during care; -An order, dated 11/17/24, for Medihoney Wound & Burn Dressing External Paste (wound dressings). Apply to coccyx topically every evening shift for wound care. Cleanse with normal saline/wound cleanser, apply Medihoney to wound bed and cover with border gauze daily; -An order, dated 11/17/24, for Medihoney Wound & Burn Dressing External Paste. Apply to left shin topically every evening shift for wound care. Cleanse with normal saline/wound cleanser, apply Medihoney to wound bed and cover with border gauze daily; -An order, dated 11/17/24, for Medihoney Wound & Burn Dressing External Paste. Apply to right medial knee topically every 24 hours as needed for skin. Cleanse area with normal saline/wound cleanser, apply Medihoney and cover with dry dressing; -An order, dated 11/17/24, for Medihoney Wound & Burn Dressing External Paste. Apply to right medial knee topically every evening shift for skin; -An order, dated 11/17/24, for Medihoney Wound/Burn Dressing External Paste. Apply to left outer ankle topically every evening shift for wound cleanse with wound cleanser, apply Medihoney and cover with dry dressing; -An order, dated 11/17/24, for Vaseline Petrolatum Gauze External Pad (Wound Dressings) Apply to left breast topically every evening shift for wound care. Cleanse with normal saline/wound cleanser, apply Vaseline gauze daily to wound and cover with Silicone Border Gauze; -An order, dated 11/17/24, for Zinc Oxide External Ointment 10%. Apply to buttocks/back topically every shift for skin management. Observation on 11/20/24, showed: -At 11:46 A.M., Hospice Aide L stood next to the right side of the resident's bed. He/She only wore gloves. CNA M walked into the resident's room and put on a pair of gloves and walked to the left side of the resident's bed. CNA M rolled the resident to position the resident, placing his/her hands on the resident's shoulder and hip; -At 11:50 A.M., CNA M rolled the resident to his/her right side. His/Her hands touched the resident as he/she positioned the resident. His/Her uniform touched the resident as he/she leaned up against the resident; - At 11:52 A.M., CNA M rolled the resident to his/her right side while Hospice Aide L continued to perform peri-care on the resident. 4. Review of Resident #41's EMR, showed: -A quarterly MDS, dated [DATE], showed his/her diagnoses included anemia, heart failure (the inability of the heart to pump oxygenated blood), high blood pressure, diabetes, high cholesterol, dementia and depression; -An order, dated 9/16/24, for EBP; -An order, dated 11/17/24, for treatment order to the resident's coccyx to cleanse the wound bed normal saline/wound cleanser and pat dry. Apply collagen powder to wound bed, cover with calcium alginate with silver and secure with island gauze every evening shift; -A care plan, revised 9/5/24, EBP related to wounds. Observation on 11/20/24 at 11:06 A.M., showed an EBP sign on the resident's room door. CNA M and CNA J entered the resident's room and proceeded to provide care to the resident. Neither CNA wore a gown. 5. Review of Resident #27's EMR, showed: -An entry MDS, dated [DATE], his/her diagnoses included infection of the intestine, atrial fibrillation (abnormal heart rhythm), and low iron; -An order, dated 11/13/24, 1. Empty drains every shift 2. Ceftriaxone (antibiotic) sodium intravenous solution reconstituted 2 grams (GM) every morning for 19 days 3. Micafungin (a medication to eliminate fungus in the blood) sodium intravenous solution 100-0.9 milligram/100 milliliters at bedtime for 20 days; -An order, dated 11/14/24, to change the PICC dressing on day shift every seven days for infection control; -An order, dated 11/17/24, to flush the PICC line with sodium chloride (normal saline) prior to administration of antibiotic therapy and every shift; -An order, dated 11/17/24, for EBP related to drains and PICC line. Observation and interview on 11/17/24 at 8:56 A.M., showed the resident in his/her room, with antibiotic flowing through a PICC line to the resident's right upper arm. He/She said the PICC line was inserted at the hospital for antibiotics because he/she had an infection in his/her stomach. There was sign on door to use EBP. Observation and interview on 11/18/24 at approximately 9:30 A.M., showed resident in his/her room. The resident said he/she had two drains in his/her stomach. He/She pulled the covers down and lifted his/her shirt, showing two drains inserted into his/her stomach. There was no sign on the door to use EBP. Observation on 11/19/24 at 10:00 A.M., showed an EBP sign and supplies on the outside of the resident's door. During an interview on 11/22/24 at 8:28 A.M., CNA E said EBP is to protect the resident and also the staff. If staff perform any care with a resident who has EBP, staff should wear a gown and gloves. Supplies should be hanging on the resident's door with a sign for EBPs. During an interview on 11/22/24 at 9:48 A.M., LPN H said EBP is for those residents who are quarantined for 7-10 days. During an interview on 11/22/24 at 10:41 A.M., LPN I said if there is a sign on the door, staff should follow the instructions. Residents who have EBP are the ones who receive tube feeding and have wounds. During an interview on 11/22/24 12:42 A.M., ADON A said the signs on the doors mean staff have to wear gown and gloves when providing care. Those residents who have wounds, intravenous (IV) ports, drains and a g-tube are placed on EBP. During an interview on 11/22/24 at 1:34 P.M., the Administrator said staff should follow EBP. 6. Review of Resident #25's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Frequently incontinent of bowel and bladder; -Upper and lower extremity impairment; -Required maximum assist from staff with toilet hygiene; -Diagnoses include stroke, dementia, lung disease, eye disease and depression. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has an activities of daily living (ADL) self-care performance deficit related to fatigue, blindness and occasional confusion: -Interventions: The resident requires maximum assist with toilet hygiene and personal hygiene. During observation and interview on 11/18/24 at 6:47 A.M., CNA N explained to the resident he/she was going to complete peri-care. CNA N applied gloves, lowered the resident's brief between the resident's legs and cleansed the resident's genitals. CNA N then turned the resident to his/her right side and the resident was wearing two briefs. Both briefs were moderately saturated. CNA N removed the two briefs and cleansed the resident's buttock area. CNA N removed his/her gloves and washed his/her hands. CNA N then touched the trash can with his/her bare hands and moved it to the other side of the resident's bed. CNA N did not perform hand hygiene after touching the trash can. CNA N then applied new gloves. A clean brief was applied to the resident by repositioning the resident side to side. With the same gloves on, CNA N opened the resident's closet and touched multiple clothing items. CNA N then took a shirt out of the resident's closet. CNA N removed the resident's shirt that he/she had on and applied and buttoned the resident's new shirt and with the same gloved hands. CNA N removed the gloves and did not wash his/her hands or perform hand hygiene. CNA N said he/she said he/she might have forgot some steps with hand hygiene and changing gloves. 6. Review of Resident #175's medical record, showed his/her diagnoses included stroke, dysphagia (difficulty swallowing), weakness and heart disease. Review of the resident's care plan, in use at the time of survey, did not address the resident's incontinence. Observation and interview on 11/19/24 at 11:17 A.M., showed the resident lay in bed. He/She told CNA O that his/her bottom hurt and he/she be cleaned. CNA O left the room to gather supplies and LPN I entered the room. CNA O applied clean gloves, removed the resident's brief and provided peri-care. LPN I assisted CNA O with turning the resident to his/her right side. The resident's buttock and rectal area were cleaned by CNA O. CNA O removed his/her gloves and did not perform hand hygiene. CNA O then applied new gloves, applied a clean brief, and repositioned the resident to his/her back. CNA O removed his/her gloves and left the room. CNA O did not perform hand hygiene when he/she removed his/her gloves prior to leaving the room. During an interview on 11/22/24 at 8:45 A.M., CNA O said staff should change their gloves and perform hand hygiene before placing a new pair of gloves on. It is not acceptable to touch the resident's clothing and help them get dressed with dirty gloves. During an interview on 11/22/24 at approximately 10:00 A.M., LPN I said staff should perform hand hygiene after removing gloves and when new gloves are applied. When in doubt, change gloves and perform hand hygiene. During an interview on 11/22/24 at 12:42 P.M., ADON A said she expected staff to use best infection control practices and wash their hands or use hand sanitizer after the soiled gloves are removed and new gloves are applied. 7. Review of the Resident #3's medical record, showed: -On 7/3/23, the resident received a TB test with no results documented; -No further TB testing or screening was documented. 8. Review of Resident #66's medical record, showed: -An admitted [DATE]; -No TB testing or screening was documented. 9. Review of Resident #23's medical record, showed: -An admitted [DATE]; -On 12/16/21, the resident received a TB test with no results documented; -No further TB testing or screening was documented. 10. Review of Resident #45's medical record, showed: -An admitted d of 11/13/23; -No TB testing or screening was documented. 11 Review of Resident #12's medical record, showed: -An admitted [DATE]; -On 12/16/21, the resident received a TB test with no results documented. During an interview on 11/22/24 at 12:42 P.M the ADON said the Infection Preventionist (IP) or the Director of Nursing (DON) are expected to complete the TB testing for the residents. TB testing and screening is expected to be completed when the resident is admitted and yearly. During an interview on 11/22/24 at 1:32 P.M. the Administrator said she expected the facility to follow the state guidelines due to the facility not having a policy for TB testing related to residents. The DON is responsible to track the TB tests and administer them. 12. Review of Employee S's employee file, showed: -Hire date 7/15/24; -TB first step administered on 10/23/24 and read on 10/26/24; -TB second step administered on 11/13/24 and read on 11/16/24. 13. Review of Employee T's employee file and time punches, showed: -Hire date 8/19/24: -TB first step administered 8/19/24; -TB first step read 8/24/24; -Employee worked on 8/19/24 and 8/21/24. During an interview on 11/21/24 at 2:17 P.M., the Human Resources (HR) Specialist said when a new employee is hired, the DON oversees the employee's TB test. The TB first step must be read within three days of it being administered and must be read before the employee starts working in the building. During an interview on 11/22/24 at 12:42 P.M., ADON A said all new hires must undergo two-step TB testing. The Charge Nurse, ADON, or DON can administer the TB first step and the results must be read within three days. Reading the test results in five days after the test is administered is too late. The TB first step must be read before the employee starts working in the facility. ADON A is not sure why the TB first steps were administered and read late for Employees S and T. During an interview on 11/22/24 at 1:32 P.M., the Administrator said the HR Specialist and DON are responsible for ensuring new hires undergo a two-step TB test. After administering the TB first step, the results must be read within 24 to 72 hours. The TB first step has be read before the employee can start working in the facility. The facility does not have a policy related to employee TB testing and they follow state guidelines. She expected the facility to follow state guidelines for staff TB testing. MO00245508 46888 49992

Based on interview and record review, the facility failed to designate one or more individuals with specialized training in infection prevention and control as the infection preventionist (IP) for the facility's infection control program. The census was 83. Review of the facility's Surveillance of Healthcare Associated Infections policy, reviewed 10/7/21, showed: -Policy: Surveillance for Healthcare Associated Infections (HAI) will be completed to calculate baseline rates, detect outbreaks, track progress, and to determine trends to help prevent the development or spread of infection; -Responsibility: Director of Nursing (DON), infection control designee, and licensed nurses. During an interview with on 11/20/24 at 2:00 P.M., the DON said she did not have the IP certificate completed. She had worked on it all night. The previous IP left about one month ago. During an interview on 11/22/24 at 1:34 P.M., the Administrator said she thought the DON completed the IP certification. The last IP left in September, 2024. She expected the facility to have a designated person to complete the training and receive certification.

Based on observation, interview and record review, the facility failed to treat three residents (Resident #174, Resident #23, and Resident #55) with dignity by leaving a resident exposed to the hallway, speaking to residents in an unprofessional manner when they referred to residents as feeders in front of residents, and staff stood over residents while assisting residents with their meal. The sample was 19. The census was 83. Review of the facility's Residents' [NAME] of Rights, showed your rights and protections as a nursing home resident: -As a nursing home resident, you have certain rights and protections under federal and state law that help ensure you get the care and services you need; -You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose. 1. Review of Resident #174's medical records, showed; -An admitted [DATE]; -Diagnosis that included: stroke, dysphagia (difficulty swallowing), weakness, and heart disease. Review of the resident's baseline care plan, in use at the time of survey, showed it did not address the resident's activity of daily living (ADL) needs. Observation on 11/18/24 at 5:41 A.M., showed the door to the resident's room opened and the resident visible from the hallway. The resident lay in bed with no covers, a hospital gown and his/her incontinent brief exposed. Multiple staff members walked past the resident's room and no staff entered the room to provide privacy to the resident. At 7:25 A.M., Certified Medicine Technician (CMT) G entered the resident's room, walked past the resident's bed, administered medication to the resident's roommate, and then left the resident's room. The resident remained with his/her covers off, his/her brief exposed, and the door remained opened. At 7:34 A.M., the resident's door to his/her room remained opened and the resident lay in bed with his/her covers off with his/her brief exposed. Licensed Practical Nurse (LPN) R entered the resident's room and covered the resident with a sheet and blanket. 2. Review of Resident #23's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/26/24, showed: -The resident is rarely or never understood; -Upper and lower extremity impairment; -Diagnoses included heart disease, kidney disease, diabetes, stroke, and dementia; -The resident dependent on staff for eating assistance. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has an ADL self-care performance deficit related to dementia; -Interventions: The resident is dependent with meals consumed and assisted in the dining room. During an observation and interview on 11/22/24 at 8:45 A.M., the resident sat in a Broda chair (a specialized reclining chair on wheels) in the main dining room. Certified Nursing Assistant (CNA) Q stood over to the resident with his/her hand on his/her hip and assisted the resident to eat a pureed diet. CNA Q said the resident required a lot of assistance with meals and the resident was a feeder. There were two other residents that sat near the resident and within hearing range of CNA Q. 3. Review of Resident #55's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -The resident has upper and lower body extremity impairments. -The resident is dependent on staff for eating. Review of the resident's face sheet, undated, showed diagnoses that included dystonia (a neurological movement disorder), weakness, depression, and anxiety. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has an ADL performance deficit related to being legally blind and generalized weakness; -Interventions: Provide finger foods when having difficulty with utensils. During an observation and interview on 11/22/24 at 8:47 A.M., showed the resident sat in his/her wheelchair in the main dining room. The resident moaned and had his/her eyes closed. CNA Q stood over the resident and fed the resident his/her pureed breakfast. CNA Q said the resident requires a lot of assistance with meals and the resident was a feeder. Two other residents sat near the resident and within hearing range of CNA Q. 4. During an interview on 11/22/24 at 8:55 A.M., CNA O said staff should sit down while assisting residents with their meals, it is a dignity issue. Staff are not to call residents feeders if they require assistance with their meals and it is disrespectful to call a resident that. If a resident is exposed and is visible from the hall. Staff should go in and see if the resident requires assistance and then cover the resident. 5. During an interview on 11/22/24 at 9:45 A.M., LPN I said staff are not to call residents feeders, and they should not be standing over the residents while assisting them to eat. Staff should cover the resident when a resident is exposed to the hallway. These are all dignity issues. 6. During an interview on 11/22/24 at 1:34 P.M., the Administrator said she would expect all staff to provide dignity to the residents. Residents are not to be called feeders. Staff are expected not to stand over the resident while assisting them with their meals and the staff is expected to cover the resident immediately when exposed to the hallway. MO00245336 MO00245508

Based on observation, interview and record review, the facility failed to ensure residents were assessed to self-administer medications and to ensure staff adequately supervised residents during medication administration (Residents #26 and #128). The sample was 19. The census was 83. Review of the facility's Medication Administration - General Guidelines, dated December 2017, showed: -Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so; -Administration: -Medications are administered in accordance with written orders of the prescriber; -When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared; -Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications; -The resident is always observed after administration to ensure that the dose was completely ingested. 1. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/2/24, showed: -Severe cognitive impairment; -Diagnoses included stroke, Alzheimer's disease, and dementia. Review of the resident's care plan, in use at the time of survey, showed no documentation the resident was assessed as able to self-administer his/her medications or take his/her medications without supervision. Review of the resident's medical record, showed no self-administration of medication assessment. Review of the resident's physician order summary (POS) and medication administration record (MAR) for November 2024, showed: -An order, dated 4/4/23, for thiamine hydrochloride (HCl) (used to treat vitamin deficiency) 100 milligram (mg), once daily. The 9:00 A.M. dose for 11/17/24 initialed as administered by Licensed Practical Nurse (LPN) H; -An order, dated 4/4/23, for folic acid (vitamin) tablet 1 mg, once daily. The 9:00 A.M. dose for 11/17/24 initialed as administered by LPN H; -An order, dated 5/13/23, for aspirin chewable tablet 81 mg, once daily. The 9:00 A.M. dose for 11/17/24 initialed as administered by LPN H; -An order, dated 5/13/23, for multivitamin tablet, one tablet once daily. The 9:00 A.M. dose for 11/17/24 initialed as administered by LPN H; -An order, dated 12/28/23, for amlodipine besylate (used to treat high blood pressure and prevent heart disease) oral tablet 5 mg, once daily. The 9:00 A.M. dose for 11/17/24 initialed as administered by LPN H; -An order, dated 9/5/24, for metformin HCl (used to lower blood sugar) 500 mg, one tablet twice daily. The 9:00 A.M. dose for 11/17/24 initialed as administered by LPN H. Observation on 11/17/24 at 11:37 A.M., showed the resident sat upright in bed with eyes closed. A cup contained five medications on his/her bedside table. 2. Review of Resident #128's significant change MDS, dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included stroke, anxiety, and depression. Review of the resident's care plan, in use at the time of survey, showed no documentation the resident assessed as able to self-administer his/her medications or take his/her medications without supervision. Review of the resident's self-administration of medication assessment, dated 10/15/24, showed the resident not capable of self administration of medication. Review of the resident's POS and MAR for November 2024, showed: -An order, dated 10/24/23, for aspirin chewable tablet 81 mg, once daily. The 9:00 A.M., dose documented as administered by Certified Medication Technician (CMT) BB; -An order, dated 10/24/23 for Celexa (antidepressant) oral tablet 20 mg, once daily. The 9:00 A.M., dose documented as administered by CMT BB; -An order, dated 10/24/23, for Nexium (used to treat acid reflux) oral capsule delayed release 40 mg, one capsule once daily. The 9:00 A.M., dose documented as administered by CMT BB; -An order, dated 10/24/23, for benztropine mesylate (used to treat tremors) oral tablet 1 mg, twice daily. The 9:00 A.M., dose documented as administered by CMT BB; -An order, dated 10/24/23, for Keppra (used to treat seizures) oral tablet 750 mg, give 1500 mg twice daily. The 9:00 A.M., dose documented as administered by CMT BB; -An order, dated 11/2/23, for senna (stool softener) tablet 8.6 mg, one tablet twice daily. The 9:00 A.M., dose documented as administered by CMT BB. -An order, dated 7/27/24, for hydrochlorothiazide (used to treat high blood pressure and fluid retention) oral capsule 12.5 mg, in the morning. The 9:00 A.M., dose documented as administered by CMT BB; -An order, dated 8/24/24, for anastrozole (used to treat breast cancer) coral tablet 1 mg, once daily. The 9:00 A.M., dose documented as administered by CMT BB; -An order, dated 10/15/24, for ferrous sulfate (used to treat iron deficiency) oral tablet 325 mg, one tablet twice daily. 9:00 A.M., dose documented as administered by CMT BB; -An order, dated 10/16/24, for Colace (stool softener) capsule 100 mg, one capsule twice daily. The 9:00 A.M., dose documented as administered by CMT BB. Observation on 11/20/24 at 8:53 A.M., showed the resident in bed with eyes closed. A cup contained seven medications on his/her bedside table. 3. During an interview on 11/22/24 at 7:55 A.M., Certified Nurse Aide (CNA)/CMT F said the facility does not have any residents who can self-administer their own medications in pill form. When passing medications, it is sometimes acceptable for staff to drop off a resident's medications and walk away, but only if the resident is more alert. Otherwise, staff must watch residents take their medication. Resident #26 is confused and cannot take his/her medications on his/her own. Resident #128's cognition is up and down, but he/she cannot take his/her mediations on his/her own. Residents #26 and #128 should be watched during mediation administration. 4. During an interview on 11/22/24 at 10:47 A.M., LPN I said there are no residents in the facility who can self-administer their medications. During medication administration, it is not acceptable for staff to drop off a resident's medication with the resident and walk away. Staff must watch residents take their medications for safety, so they don't choke. Residents #26 and #128 have confusion and must be watched taking their medications. 5. During an interview on 11/22/24 at 12:42 P.M., Assistant Director of Nurses (ADON) A said during medication administration, staff cannot drop off a resident's medication with the resident and then walk away. Staff must ensure a resident takes their medication by watching them take it. If a resident is sleeping during medication administration, staff should try to wake the resident. If the resident does not wake up, staff should discard the medication and come back later. Residents #26 and #128 should be supervised during medication administration.

Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected three residents who expired and had money in their accounts (Residents #133, #131, and #132). The census was 83. Review of the facility's Business Office - Resident Trust Fund Policy and Procedure, undated, showed: -Upon the discharge or passing of the resident, funds shall be disbursed as follows: --Medicaid residents: All personal funds must be reported to the State based on regulatory requirements involving estate recovery. These funds can only be released by the State or made payable directly to a mortuary to cover any unpaid funeral expense. A copy of an invoice reflecting the unpaid balance must be provided. 1. Review of Resident #133's resident fund account, showed the following: -Expired [DATE]; -Balance of $943.88; -TPL completed [DATE]. 2. Review of Resident #131's resident fund account, showed the following: -Expired [DATE]; -Balance of $361.88; -TPL completed [DATE]. 3. Review of Resident #132's resident fund account, showed the following: -Expired [DATE]; -Balance of $5,204.72; -TPL completed [DATE]. 4. During an interview on [DATE] at 12:51 P.M., the Business Office Manager (BOM) said when a Medicaid resident expires with funds left in their account, she is responsible for submitting the TPL to Medicaid within 30 days of the resident's death. She began working with the facility in [DATE] and she had to learn the facility's procedures for fund reconciliation. She is working on catching up on the TPLs. 5. During an interview on [DATE] at 1:32 P.M., the Administrator said she expects TPLs to be submitted for expired residents within the timeframes outlined in the State regulations and for their accounts to be closed out timely. She expects the BOM to follow up with this timely.

Based on observation, interview and record review, the facility failed to provide a safe, comfortable, homelike environment by failing to address water stains on the ceiling near the window, peeling wallpaper and flaking paint on the ceiling due to water damage in one resident room which two residents shared (Resident #23 and #174). The sample was 19. The census is 83. Review of Resident #23's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/26/24, showed: -The resident is rarely or never understood; -Diagnoses included heart disease, kidney disease, diabetes, stroke and dementia. Review of Resident #174's medical records, showed; -Diagnoses included stroke, dysphagia (difficulty swallowing), weakness and heart disease. Observation on 11/17/24 at 9:00 A.M., of Resident #23's and #174's room, showed the room had yellow ring stains on the ceiling above the window. The wall next to the bathroom had bubbled, peeled, and flaked paint. The ceiling near the doorway had flaked and bubbled paint. Family Member Z said when he/she came in on 11/5/24, it was raining hard outside and the staff had placed a bedspread on the windowsill to catch the water. Staff had turned the heat up on high to dry the water in the wall. When he/she would touch the drywall next to the sink, it was spongy and felt wet. No one came in to fix the walls or ceilings. Observations of Resident #23's and #174's room on 11/18/24 at 6:47 A.M. and 11/19/24 at 11:17 A.M., showed yellow ring stains on the ceiling above the window. The wall next to the bathroom had bubbled, peeled, and flaked paint. The ceiling near the doorway had flaked and bubbled paint. During an interview on 11/22/23 at 9:00 A.M., Certified Nursing Assistant (CNA) Q said the room that Resident #23 and Resident #174 shared, always leaks water. Staff always have to put bath blankets on the floor and windowsill to catch the leaking water. The flaking paint on the walls and ceiling are from water coming in the room when it rains. It has been like that for at least a couple of months. Staff verbally tell the maintenance staff when there is something broken or needs repair. During an interview on 11/22/24 at approximately 10:00 A.M., Licensed Practical Nurse (LPN) I said when a room or equipment need maintenance attention, staff can place a request in the computer. Not all staff have access to place the request. He/She was not aware any of water leaking issues in the residents' room. During an interview on 11/21/24 at 8:40 A.M., the Maintenance Director said he was aware of the ceiling stains and water leaking. He was waiting for the walls and ceiling to dry out and then he was going to repair it. He thought the leaking was coming from the roof because the roof is flat and does not drain very well. He did not think the wall and ceiling in the current condition was home-like. During an interview on 11/22/24 at 1:34 P.M., the Administrator said she expected repairs to be made in a timely manner. Staff is expected to ensure the residents have a home-like environment. MO00245336 MO00245508

Based on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges. The census was 83. Review of the facility's Discharge/Transfer - Involuntary policy, revised 10/7/21, showed: -Policy: Transfer and discharge includes movement of a resident to a bed outside of the facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility; -The policy did not provide any guidance related to notification to the Ombudsman regarding resident transfers and discharges. Review of the facility's Discharge Plan/Summary - Voluntary policy, revised 10/7/21, showed no guidance related to notification to the Ombudsman regarding resident transfers and discharges. During an interview on 11/13/24 at 12:29 P.M., the Ombudsman said he/she has not received monthly notification of transfers and discharges from the facility in about five to six months. During an interview on 11/21/24 at 9:20 A.M., the Social Services Director (SSD) said she began working for the facility in May 20224. She is responsible for notifying the Ombudsman of residents' transfers/discharges. She does not think she has sent the Ombudsman notification of transfer/discharge since she started but will double check. She usually sends the Ombudsman notification in the early part of the month for the month prior. During an interview at 9:55 A.M., the SSD said she checked and has not sent any notifications to the Ombudsman of transfers and discharges from the facility. During an interview on 11/22/24 at 1:32 P.M., the Administrator said she expected the Ombudsman to be notified of resident transfers and discharges monthly. The SSD is responsible for sending the notification to the Ombudsman.

Based on interview and record review, the facility failed to ensure one resident (Resident #403) was provided a safe discharge home, by failing to ensure medical equipment was provided on the day of discharge and failing to educate the resident and family member on the use of the medical equipment. The sample was 23. The census was 75. Review of the facility's discharge plan/summary policy, dated 11/1/2018, showed: -Policy: An interdisciplinary summary is completed on a resident upon discharge to assure the continuum care needs of the resident are met; -Guidelines: Upon notification of impending discharge, the Interdisciplinary Team (IDT) should be notified to allow staff the opportunity to educate and implement a safe discharge. Social work should coordinate the discharge planning process. Therapy may complete a home assessment to ensure a safe discharge and arrange any assistive equipment needed for home care. Education with the person accepting responsibility for the resident at home should be provided as necessary. Therapy should identify any needs for care at home. Education with the person accepting responsibility for the resident at home should be provided as necessary. Needed assistive devices should also be arranged. Appropriate referrals for home care should be made and coordinated with Social Services. Nursing should meet with the person responsible for the resident at home and provide instruction to that person(s) as appropriate in regard to medications and treatments to be continued at home. Referral should be ensured for home care as needed and coordinate same with Social Services. Any unused medications that are currently ordered after discharge may be sent with the resident prior to discharge, according to state regulations. There should be documentation in the Nurses Notes regarding resident status at the time of discharge. Review of Resident #403's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/20/24, showed: -Cognitively intact; -discharge date of [DATE]; -Diagnoses included morbid obesity, end stage renal disease (chronic irreversible kidney failure), diabetes, muscle wasting, and dependence on renal dialysis (process that removes waste and excess fluid from the blood); -Functional abilities: Dependent with toilet transfers, dependent on transferring from wheelchair to bed, dependent on lower body dressing, dependent on sitting up in bed. Review of the resident's Notice of Medicare Non-Coverage (NOMNC) showed: -Date of service coverage ending was 12/13/24; -The resident signed the notice on 12/11/24. Review of the resident's progress notes, showed: -A social service note, dated 12/18/24, resident received a NOMNC for last cover date of 12/13/24 with a planned discharge for 12/14/24. This writer arranged for resident to receive home health services with Durable Medical Equipment (DME) equipment. Writer was informed from several companies that they do not accept the resident's insurance. This writer then placed call to several other companies and received no assistance. This writer spoke with Medical Supply Company A, who states resident has received equipment (hospital bed and wheelchair) in 2022 and that he/she does not qualify for anything. This writer spoke with Medical Supply Company B who faxed results stating they can accommodate resident needs, but that he/she would not be able to get an extra-large bed or mattress at this time. This writer placed a call to the resident as he/she is currently in dialysis and explained that he/she would not get an extra-large bed and that other services could be delivered. Resident is in agreement as is this writer to continue to assist with discharge plans; -A note, dated 12/20/24 at 9:55 A.M., resident is going home from dialysis. Three days worth of medication given to resident. Resident was educated on the times and dates to take medication. Resident was educated on the importance of taking medication. Resident was transported to dialysis at this time. Belongings are with resident; -A social service note, dated 12/20/24 at 2:13 P.M., this writer placed call to Medical Supply Company B for DME as they informed this writer that resident's DME could be delivered. The heavy duty bed is not available, but a standard bed is available. Resident was informed of the concerns on 12/19/24 and stated that he/she would be okay. This writer spoke with DME company again on this date who informed this writer the bed could not be delivered until early next week due to having an ill driver, but the other DME would be delivered. Writer explained that resident will be available after 3:00 PM due to dialysis. This writer informed resident of concerns prior to leaving for discharge/dialysis. This writer will follow as needed; -A social service note, dated 12/20/24 at 3:57 P.M., Social Service Director placed call to the resident to assure discharge was successful. Resident stated he/she received a call from Medical Supply Company B stating they would not be able to deliver the Hoyer (full body mechanical lift) until next week, but the bedside commode and the wheelchair would in fact be delivered today. Resident states his/her son arranged for transportation to pick him/her up from dialysis and transport him/her home. Writer then placed call to Medical Supply Company B and was told the Hoyer pad was not ordered, and they are not allowed to deliver without one. This writer explained that resident in fact has a Hoyer pad at this time. This writer placed a call back to Medical Supply Company B, with no response. This writer then placed call to an oxygen equipment service and another Medical Supply Company, to no avail. This writer then spoke with the resident and informed him/her of findings. Resident states he/she can sleep in his/her son's bed, but the resident's concern is getting in and out for dialysis on Monday (12/23/24). Writer explained that calls would be made back to him/her on Monday from this writer to assure all needs are met. -The record did not contain follow up on Monday, 12/23/24 to ensure his/her needs were met. Review of the resident's physical therapy discharge notes, dated 1/2/25, showed: -Discharge recommendations: 24 hour care and wheelchair for safe functional mobility; -Total dependence on help with transfers. During an interview on 1/15/25 at 10:16 A.M., the Social Services Director said the resident had a planned discharge for 12/14/24, but the resident stayed beyond the date paying out of pocket. The Social Service Director started to set up the resident's discharge on 12/12/24, but had problems finding medical equipment companies that would work with the resident's insurance. The scheduled DME company reached out to the Social Services Director and said they would not be able to deliver the resident's medical equipment due to staffing issues. The resident was aware the medical equipment would not be able to be delivered, but was still eager to discharge home. The resident required a bariatric Hoyer lift, bariatric bed, and a bariatric bedside commode. The resident had a possible risk of not being able to get to his/her dialysis appointments due to not having a Hoyer lift. The Social Services Director did not believe it was a safe discharge. She attempted to have the resident stay for long term care, but the resident declined. She said the resident's discharge should have been hotlined. During an interview on 1/15/25 at 1:07 P.M., the Rehabilitation Director and Occupational Therapist (OT) said when the resident discharged from the facility, he/she still required maximum assistance from staff for transfers, toileting, and bathing. He/She was non-weight bearing on his/her right leg and required a Hoyer lift for transfers. The only way the discharge would have been safe is if someone was at the resident's apartment providing 24 hour care daily, the resident had a bariatric Hoyer lift in the home, or his/her son was able to do a maximum assist transfer to transfer the resident to his/her wheelchair or to the bedside commode. They said they did not educate any of the resident's family members on Hoyer lift transfers. During a phone interview on 1/15/25 at 1:42 P.M., the resident said the Social Services Director informed him/her on 12/20/24, the same day of his/her discharge, the bariatric bed ordered would not be able to be delivered to his/her apartment by the time he/she got home. She was not informed that the Hoyer lift would not be delivered. If he/she had known that, he/she might have stayed at the facility until the medical equipment could be delivered. He/She was not educated on how to use a Hoyer lift or on safe transfers before he/she left the facility. After he/she was discharged from the facility on 12/20/24, the only help he/she received was from his/her son's chore worker who came during the day to help his/her son. His/Her son was not able to help him/her transfer or use the bathroom. From 12/20/24 to 12/24/24, the Hoyer lift and bariatric bed were not delivered to the resident's apartment. The resident made it to his/her dialysis appointment at the hospital on 12/24/24 and was admitted inpatient in the hospital until 1/10/25. During an interview on 1/15/25 at 1:57 P.M., the Assistant Director of Nursing (ADON) said the resident required assistance from two to three staff with transfers due to his/her obesity. She would expect discharge planning to have been completed in a timely manner. She would expect staff to educate the resident and family members on the usage of medical equipment and safe transfers prior to the resident discharging. She would have expected the resident to be discharged from the facility with a Hoyer lift and bedside commode. She would expect staff to call the elder abuse hotline if a resident discharge is deemed unsafe. During an interview on 1/15/25 at 2:37 P.M., the Administrator said the Social Services Director and IDT team are responsible for planning and organizing resident discharges. The resident discharged back to his/her apartment with his/her son. The resident wanted to discharge from the facility on 12/20/24 and told facility staff that he/she would be sleeping on his/her son's bed until a bariatric bed could be delivered to his/her apartment. The Social Services Director informed the resident prior to his/her discharge date the resident's medical equipment would not be able to be delivered on 12/20/24. She said it was the resident's choice to discharge without medical equipment. She would have expected staff to document the resident had chosen to go against a safe discharge. She would expect the resident and resident's family members to be educated on safe transfers and how to use a Hoyer lift if the resident agrees to be educated. MO00246921

Based on interview and record review, the facility failed to ensure one resident (Resident #403) was provided a safe discharge home, by failing to ensure medical equipment was provided on the day of discharge and failing to educate the resident and family member on the use of the medical equipment. The sample was 23. The census was 75. Review of the facility's discharge plan/summary policy, dated 11/1/2018, showed: -Policy: An interdisciplinary summary is completed on a resident upon discharge to assure the continuum care needs of the resident are met; -Guidelines: Upon notification of impending discharge, the Interdisciplinary Team (IDT) should be notified to allow staff the opportunity to educate and implement a safe discharge. Social work should coordinate the discharge planning process. Therapy may complete a home assessment to ensure a safe discharge and arrange any assistive equipment needed for home care. Education with the person accepting responsibility for the resident at home should be provided as necessary. Therapy should identify any needs for care at home. Education with the person accepting responsibility for the resident at home should be provided as necessary. Needed assistive devices should also be arranged. Appropriate referrals for home care should be made and coordinated with Social Services. Nursing should meet with the person responsible for the resident at home and provide instruction to that person(s) as appropriate in regard to medications and treatments to be continued at home. Referral should be ensured for home care as needed and coordinate same with Social Services. Any unused medications that are currently ordered after discharge may be sent with the resident prior to discharge, according to state regulations. There should be documentation in the Nurses Notes regarding resident status at the time of discharge. Review of Resident #403's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/20/24, showed: -Cognitively intact; -discharge date of 12/20/24; -Diagnoses included morbid obesity, end stage renal disease (chronic irreversible kidney failure), diabetes, muscle wasting, and dependence on renal dialysis (process that removes waste and excess fluid from the blood); -Functional abilities: Dependent with toilet transfers, dependent on transferring from wheelchair to bed, dependent on lower body dressing, dependent on sitting up in bed. Review of the resident's Notice of Medicare Non-Coverage (NOMNC) showed: -Date of service coverage ending was 12/13/24; -The resident signed the notice on 12/11/24. Review of the resident's progress notes, showed: -A social service note, dated 12/18/24, resident received a NOMNC for last cover date of 12/13/24 with a planned discharge for 12/14/24. This writer arranged for resident to receive home health services with Durable Medical Equipment (DME) equipment. Writer was informed from several companies that they do not accept the resident's insurance. This writer then placed call to several other companies and received no assistance. This writer spoke with Medical Supply Company A, who states resident has received equipment (hospital bed and wheelchair) in 2022 and that he/she does not qualify for anything. This writer spoke with Medical Supply Company B who faxed results stating they can accommodate resident needs, but that he/she would not be able to get an extra-large bed or mattress at this time. This writer placed a call to the resident as he/she is currently in dialysis and explained that he/she would not get an extra-large bed and that other services could be delivered. Resident is in agreement as is this writer to continue to assist with discharge plans; -A note, dated 12/20/24 at 9:55 A.M., resident is going home from dialysis. Three days worth of medication given to resident. Resident was educated on the times and dates to take medication. Resident was educated on the importance of taking medication. Resident was transported to dialysis at this time. Belongings are with resident; -A social service note, dated 12/20/24 at 2:13 P.M., this writer placed call to Medical Supply Company B for DME as they informed this writer that resident's DME could be delivered. The heavy duty bed is not available, but a standard bed is available. Resident was informed of the concerns on 12/19/24 and stated that he/she would be okay. This writer spoke with DME company again on this date who informed this writer the bed could not be delivered until early next week due to having an ill driver, but the other DME would be delivered. Writer explained that resident will be available after 3:00 PM due to dialysis. This writer informed resident of concerns prior to leaving for discharge/dialysis. This writer will follow as needed; -A social service note, dated 12/20/24 at 3:57 P.M., Social Service Director placed call to the resident to assure discharge was successful. Resident stated he/she received a call from Medical Supply Company B stating they would not be able to deliver the Hoyer (full body mechanical lift) until next week, but the bedside commode and the wheelchair would in fact be delivered today. Resident states his/her son arranged for transportation to pick him/her up from dialysis and transport him/her home. Writer then placed call to Medical Supply Company B and was told the Hoyer pad was not ordered, and they are not allowed to deliver without one. This writer explained that resident in fact has a Hoyer pad at this time. This writer placed a call back to Medical Supply Company B, with no response. This writer then placed call to an oxygen equipment service and another Medical Supply Company, to no avail. This writer then spoke with the resident and informed him/her of findings. Resident states he/she can sleep in his/her son's bed, but the resident's concern is getting in and out for dialysis on Monday (12/23/24). Writer explained that calls would be made back to him/her on Monday from this writer to assure all needs are met. -The record did not contain follow up on Monday, 12/23/24 to ensure his/her needs were met. Review of the resident's physical therapy discharge notes, dated 1/2/25, showed: -Discharge recommendations: 24 hour care and wheelchair for safe functional mobility; -Total dependence on help with transfers. During an interview on 1/15/25 at 10:16 A.M., the Social Services Director said the resident had a planned discharge for 12/14/24, but the resident stayed beyond the date paying out of pocket. The Social Service Director started to set up the resident's discharge on [DATE], but had problems finding medical equipment companies that would work with the resident's insurance. The scheduled DME company reached out to the Social Services Director and said they would not be able to deliver the resident's medical equipment due to staffing issues. The resident was aware the medical equipment would not be able to be delivered, but was still eager to discharge home. The resident required a bariatric Hoyer lift, bariatric bed, and a bariatric bedside commode. The resident had a possible risk of not being able to get to his/her dialysis appointments due to not having a Hoyer lift. The Social Services Director did not believe it was a safe discharge. She attempted to have the resident stay for long term care, but the resident declined. She said the resident's discharge should have been hotlined. During an interview on 1/15/25 at 1:07 P.M., the Rehabilitation Director and Occupational Therapist (OT) said when the resident discharged from the facility, he/she still required maximum assistance from staff for transfers, toileting, and bathing. He/She was non-weight bearing on his/her right leg and required a Hoyer lift for transfers. The only way the discharge would have been safe is if someone was at the resident's apartment providing 24 hour care daily, the resident had a bariatric Hoyer lift in the home, or his/her son was able to do a maximum assist transfer to transfer the resident to his/her wheelchair or to the bedside commode. They said they did not educate any of the resident's family members on Hoyer lift transfers. During a phone interview on 1/15/25 at 1:42 P.M., the resident said the Social Services Director informed him/her on 12/20/24, the same day of his/her discharge, the bariatric bed ordered would not be able to be delivered to his/her apartment by the time he/she got home. She was not informed that the Hoyer lift would not be delivered. If he/she had known that, he/she might have stayed at the facility until the medical equipment could be delivered. He/She was not educated on how to use a Hoyer lift or on safe transfers before he/she left the facility. After he/she was discharged from the facility on 12/20/24, the only help he/she received was from his/her son's chore worker who came during the day to help his/her son. His/Her son was not able to help him/her transfer or use the bathroom. From 12/20/24 to 12/24/24, the Hoyer lift and bariatric bed were not delivered to the resident's apartment. The resident made it to his/her dialysis appointment at the hospital on [DATE] and was admitted inpatient in the hospital until 1/10/25. During an interview on 1/15/25 at 1:57 P.M., the Assistant Director of Nursing (ADON) said the resident required assistance from two to three staff with transfers due to his/her obesity. She would expect discharge planning to have been completed in a timely manner. She would expect staff to educate the resident and family members on the usage of medical equipment and safe transfers prior to the resident discharging. She would have expected the resident to be discharged from the facility with a Hoyer lift and bedside commode. She would expect staff to call the elder abuse hotline if a resident discharge is deemed unsafe. During an interview on 1/15/25 at 2:37 P.M., the Administrator said the Social Services Director and IDT team are responsible for planning and organizing resident discharges. The resident discharged back to his/her apartment with his/her son. The resident wanted to discharge from the facility on 12/20/24 and told facility staff that he/she would be sleeping on his/her son's bed until a bariatric bed could be delivered to his/her apartment. The Social Services Director informed the resident prior to his/her discharge date the resident's medical equipment would not be able to be delivered on 12/20/24. She said it was the resident's choice to discharge without medical equipment. She would have expected staff to document the resident had chosen to go against a safe discharge. She would expect the resident and resident's family members to be educated on safe transfers and how to use a Hoyer lift if the resident agrees to be educated. MO00246921

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards by not providing transportation to two residents' medical appointments (Resident #66 and Resident #12). The sample was 19. The census was 83. 1. Review of Resident #66's medical record, showed diagnoses that include diabetes, morbid obesity, shortness of breath, obstructive sleep apnea (a condition that cause breathing to slow down or stop during sleep), heart failure and difficulty walking. Review of the resident's progress notes, showed: -On 8/28/24 at 3:10 P.M., Follow up with the pulmonary doctor and neurosurgery doctor forwarded to social worker; -On 10/9/24 at 2:56 P.M., The resident's pulmonary doctor's appointment rescheduled for 10/23/24 at 12:30 P.M. The resident was notified of new appointment. Will arrange transport. During an interview on 11/19/24 at 1:50 P.M., Medical Assistant U at the resident's neurosurgeon office said the resident's appointment was scheduled 9/30/24 and the resident was listed as no show and a new appointment has not been rescheduled. During an interview on 11/19/24 at 2:02 P.M., Medical Assistant V at the resident's pulmonary doctor's office said the resident's appointment was for 10/23/24 and the resident was a no show and a new appointment has not been rescheduled. During an interview on 11/17/24 at 9:14 A.M., the resident said he/she has been missing his/her doctor's appointments. The facility told him/her that a special transportation unit is required due to his/her body size. He/She cannot go in the regular facility van. He/She requires to see the pulmonary doctor due to having breathing problems. The neurosurgery appointment was because he/she is having difficulty walking. During an interview on 11/20/24 at 9:28 A.M., the Social Service Director said she was not aware that the resident did not make it to his/her appointments. The resident does require a special van with a special lift due to his/her size. The transportation company needs at least three days prior notice for the appointments. 2. Review of Resident #12's medical record, showed diagnoses include Parkinson's disease (a neurological disorder that causes tremors), difficulty walking, falls and Alzheimer's disease. Review of the resident's progress notes showed on 10/16/24 at 2:37 P.M., received a call from neurology department, the resident's appointment on 11/5/24 was changed from 1:30 P.M. to 1:00 P.M. During an interview on 11/20/24 at 1:45 P.M., Medical Assistant W at the resident's neurology clinic said the resident had an appointment for 6/17/24, 7/2/24, and 11/5/24. All three appointments we noted as the resident being a no show. There were no current appointments for the resident. During an interview on 11/20/24 at 2:20 P.M., the Director of Social Services said she was not aware the resident had three appointments missed. She was not informed by nursing staff. During an interview on 11/21/24 at 8:45 A.M., Licensed Practical Nurse (LPN) R said nursing is to fill the transportation request and place it in the log book, and verbally inform the Social Worker. He/She was not aware the resident missed his/her neurology appointment. 3. During a group interview on 11/19/24 at 2:24 P.M., five residents, whom the facility identified as alert and oriented, attended the group meeting. Five residents said it takes a long time for facility staff to schedule their appointments. Two residents said they had missed appointments due to the facility not providing transportation. 4. During an interview on 11/22/24 at 8:20 A.M. Transportation Driver X said the nurses are responsible to fill out the transportation paperwork. A copy of the request stays with him/her and a copy stays in the book at the nurse's station. The nurses communicate the transportation information verbally. He/She works 6 days a week and needs 24 hour notice for appointments. 5. During an observation and interview on 11/20/24 at 9:28 A.M., the Social Service Director said the nursing staff is to inform her verbally and fill out a transportation request when appointments need to be made or there is one already established. The Social Worker obtained the transportation logbook, and it was empty. She does not know what happened to all the requests that were in the book. 6. During an interview on 11/22/24 at 1:34 P.M., the Administrator said she expected transportation to be arranged in a timely manner for all residents that have outside appointments. MO00244195

Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards by failing to identify one resident's wound and obtain a treatment order (Resident #14) and obtain proper skin care treatment orders for one resident (Resident # 66). The sample was 19. The census was 83. Review of the facility's Skin Integrity policy, reviewed 7/5/24, showed: -Purpose: to establish best practice guidelines for skin integrity monitoring and maintenance to reduce potential risk of skin breakdown where clinically appropriate; -Policy: Skin evaluations shall be completed upon admission and routinely, as per the care plan, to monitor skin integrity; Skin integrity risk factors will be evaluated upon admission and routinely, as per the care plan; Appropriate interventions will be initiated based on the risk factors identified; Lotion and moisture barrier products shall be available and applied as per the care plan; Minimize, as much as possible, any friction or vigorous rubbing of the skin while providing care; Any skin abnormalities noted shall be communicated to the licensed nurse; The licensed nurse shall notify the provider as needed for appropriate skin care orders; Staff shall be educated on skin integrity best practices. 1. Review of Resident #14's medical record, showed: -Diagnoses included dementia and diabetes; -Severe cognitive impairment. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: resident has actual impairment to skin integrity; -Goal: resident will have minimum complications of wounds through the review date; -Interventions: Enhanced Barrier Precautions (EBP, use of personal protective equipment (PPE, isolation gowns and gloves) and refer to the use of gowns and gloves during high contact resident care activities that provides opportunities for transfer of multi drug resistant organism (MDRO) to hands or clothing). Review of the resident's Physician Order Summary (POS), showed: -An order, dated 11/17/24, for Zinc Oxide External Ointment 10% (an ointment to treat and prevent skin irritation). Apply to buttocks/back topically every shift for skin management; -No order for the wound on the resident's left flank (side of a person's body between the ribs and hip). Review of the resident's most recent skin observation tool, dated 11/17/24, showed: -No documentation of the resident's wound on his/her left flank. Observation on 11/20/24 at 11:53 A.M., of the resident's skin, showed: -A wound dressing was observed on the resident's left flank. The wound dressing was not dated; -The wound had no drainage. The skin appeared to have a small break. The wound appeared to be shearing (skin that is removed when rubbed, moved or repositioned). During an interview on 11/22/24 at 10:47 A.M., Licensed Practical Nurse (LPN) I said he/she expected for wound treatments/dressings to be placed in accordance with the resident's POS. He/She expected for the resident's dressings to be dated. He/She was not aware of the resident's left flank injury. During an interview on 11/22/24 at 12:42 P.M., Assistant Director of Nursing (ADON) A said he/she expected wound treatments/dressings to be placed in accordance with a physician order. He/She expected the resident's dressings to be dated. He/She said the resident's lower flank wound should have an order for a dressing and should be covered. During an interview on 11/22/24 at 1:32 P.M., the Administrator said she expected wound treatments/dressings to be placed in accordance with a physician order. She expected the resident's dressings to be dated. 2. Review of Resident # 66's quarterly MDS, dated [DATE] showed: -An admitted [DATE]; -Cognitively intact; -Upper and lower extremity impairment; -Requires maximum assistance from staff for bathing; -Requires substantial assistance from staff for lower body dressing and putting on and taking off footwear; -Always incontinent of bowel and bladder; -Diagnoses included lung disease, heart failure and diabetes. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is at risk for impaired skin integrity and pressure ulcers (wounds that occur when pressure is applied for an extended period), related to dryness to both lower extremities and history of lymphedema (swelling); --Interventions: assess areas and initiate skin sheet, initiate treatment per order. Report progress and wound healing to the physician, with any changes or lack of response to treatment; -Focus: ADL self-performance deficit related to shortness of breath and heart failure; --Interventions: Offer bathing or shower weekly or as necessary. Use simple instructions to promote independence. Review of the resident's skin observation tools, showed: -On 10/15/24, no open areas; -On 10/22/24, no open areas; -On 10/29/24, right front lower leg, left front lower leg, right rear lower leg; feet have erosion; -On 11/5/24, right front lower leg, left front lower leg, right rear lower leg. Feet have erosion; --The skin observation tool did not address the type of skin condition of the resident's lower legs and feet. Review of the resident's POS, dated November 2024, showed: -An order, dated 3/28/24, Urea external cream 40% (cream used for dry skin), apply to feet and legs topically at bedtime. -An order, dated 11/17/24, apply warm towel around both lower extremities for 10 minutes, every night. Review of the shower sheets dated September and November, 2024 did not show the resident had showers completed by staff. During observations and interviews on 11/17/24 at 9:14 A.M., and 11/19/24 at 12:00 P.M., showed the resident sat in his/her wheelchair in his/ her room. The resident raised his/her pant legs and exposed his/her lower legs. The resident's skin appeared extremely dry, with multiple layers of dark and very thick flaky skin. The resident said he/she picks at his/her skin to try to get the dead skin off. He/She has not had a shower in three weeks. The resident said his/her legs have been like that since he/she has been at the facility. He/She also has some swelling to his/her legs at times. The cream that staff is using now is not working to treat his/her legs. The resident said his/her feet and legs look awful. When he/she went to the hospital on 8/27/24, the hospital doctor said the treatment was not doing anything because the cream is applied to dead skin and recommended the facility try to remove the dead skin off his/ her legs by gently scrubbing his/her legs. His/Her treatment orders or cream to his/her legs have been the same since he/she has been at the facility. The staff is aware of the condition of his/her legs and assist him/her with getting dressed and applying socks and shoes every day. Observation and interview on 11/19/24 at 4:00 P.M., LPN R said the floor nurses are responsible for weekly skin assessments and treatments. The skin assessments are to have anything that is abnormal included. The resident has had the same treatment to his/her legs and feet for a long time. LPN I removed the resident's socks and shoes. The resident's feet were extremely dry with white flaky skin. LPN R said the resident's legs and feet look the same and have not improved since he/she has been at the facility. During an interview on 11/22/24 at 9:00 A.M., Certified Nursing Assistant (CNA) Q said the resident has always had dry skin to his/her legs and feet and will apply lotion that is in the resident's room when the resident requests it. The resident does require assistance with dressing and putting on socks and shoes. During an interview on 11/22/24 at 9:45 A.M., LPN I said the resident has always had the same treatment order in place. The resident's legs have extremely dry thick non-viable skin to his/her legs. The resident needs a whirlpool treatment, but the facility does not offer that treatment. When a treatment has failed to help the resident's skin condition, the physician should be notified to get a different treatment order. He/She has no idea what foot erosion is, that was noted on the resident's skin observation tool. During an interview on 11/22/24 at 12:42 P.M., ADON A said she expected the weekly skin assessments to be accurate and include all skin issues. He/She did not know what was meant by foot erosion, that was documented on the resident's skin observation tool. He/She expected staff to obtain a different order from the physician for the resident's skin condition when the current treatment is not working. 46888

Based on observation, interview, and record review, the facility failed to ensure residents receive care consistent with professional standards to prevent pressure ulcers (injury to the skin and underlying tissue caused by pressure or friction) from developing and promote healing for one resident (Resident #6), who was admitted with a very red and excoriated buttock that developed into an unstageable pressure ulcer (depth of tissue loss cannot be determined due to covering with nonviable tissue). Staff failed to complete all skin assessments per their policy, ensure nurse's followed up and documented on concerns identified on shower/bath audit forms, ensure only licensed nurses applied treatments, notify the physician of skin concerns, and monitor the area of concern for changes. In addition, the facility failed to ensure they followed the wound company's physician order, to change one resident's treatment from every Monday,Wednesday,Friday to daily for one resident (Resident #15). Six residents were sampled for pressure ulcers and problems were identified with two. The census was 78. Review of the facility Skin Management Guidelines, Practice Guidelines, dated 2/2016 and revised on 7/2017, showed: Purpose: -To identify at risk residents for potential breakdown or ulcerations; -To prevent breakdown of tissue or ulcerations; -To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations; Risk Factors Include: -Impaired mobility; -Cognitive impairment; -Exposed skin to urinary or fecal incontinence; -Under nutrition, malnutrition, and hydration deficits; Newly admitted Residents: -Upon admission, all residents are assessed for skin integrity by completing an assessment and documenting in the electronic health record/EHR; -Following admission; the Braden Scale (an assessment tool) - quarterly, annually, and with change in condition, for their risk for development of pressure injury; -Certified nurse's aides (CNAs) will complete body audits. The body audits post shower will be turned into the licensed nurse to review for changes in skin condition; -Appropriate preventative measures will be implemented on all residents identified at risk and the interventions documented on the Care Plan. This may include: -Turn and reposition; -Pressure reduction surfaces for beds, wheelchairs, etc.; -Floating areas of concern such as heels when appropriate; -Separation of bony prominence's with a pillow or device when lying on side; -Promotion of clean, dry and well moisturized skin; -Reduction of shearing force by appropriate body mechanics when moving, turning or repositioning resident; Residents admitted with skin impairments will have: -Appropriate interventions implemented to promote healing; -A physician's order for treatment; -Wound location and characteristics documented in the EHR; -Referral to rehabilitation services; -Registered Dietician to assess nutritional needs; -Their family notified of presence of skin impairment; -Care plan implemented. A care plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment and the interventions implemented to promote healing and prevent further breakdown; -At Risk Review Meetings will be conducted to review/discuss: -New admissions with wounds present; -Residents identified at risk or with compromise. Review of the facility Notification of a Change in a Resident's Condition policy, dated 11/1/18 and reviewed on 4/28/21, showed: The attending physician and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations. Responsibility: -All licensed nursing personnel; Procedure: -Guideline for notification of physician/resident representative included: Onset of pressure ulcers. 1. Review of Resident #6's hospital transfer information, sent to the facility upon the resident's admission on 11/19/22, showed: Admission Information: -admitted (to hospital) of 10/31/22; Hospital Course: -Resident has chronic lower back/sacral/sacrum (the bone below the small of the back and above the coccyx pain; -Wound care team was consulted for skin breakdown to the buttock area, small open area remains with blanching (whitish coloration remains on the skin after pressure is applied) surrounding/peri-wound (the area/skin surrounding a pressure ulcer or wound) darkened tissue; Assessment and Plan: -Chronic lower back pain. Resident states he/she fell on to his/her tail bone at his/her previous facility; Wound Care Notes: 11/11/22 at 10:35 A.M.: Consulted for new skin breakdown to coccyx. Resident has darkened tissue which is blanchable. There is a small open area which is likely due to incontinence. For now there is a sacral dressing in place over site; -11/16/22 at 11:00 A.M.: Consulted for skin breakdown to buttock. Small open area remains with blanchable surrounding darkened tissue. Appears unchanged from last week. This open area was caused by excessive moisture. Meplix dressing (foam - absorbent dressing) is in placed at this time. On low air loss mattress (air mattress that reduces pressure) and turning schedule. Review of the resident's EHR showed: -admitted (to facility) Saturday 11/19/22, from the hospital; -Diagnoses of altered mental status, sacrococcygeal disorders (tailbone pain), fibromyalgia (a condition causing wide spread pain) and weakness. -No completed Skin Observation Tool completed by a nurse upon admission. Review of the resident's baseline care plan (completed upon admission), undated and received via e-mail on 12/14/22, showed: -Daily Preferences: Bed baths; -Personal Hygiene/Bathing/Toilet Use/Bed Mobility and Transfers: One person physical assist; -Always incontinent of bowel and bladder; -Skin Risk: Current skin integrity issues. The care plan did not specify the skin integrity issues; -Signed, but not dated, by the Assistant Director of Nurses (ADON) and Social Service Director. Review of the resident's Pressure Injury Risk assessment (used to determine a resident's risk of developing pressure ulcers), completed on 11/19/22, showed: -Ability to respond meaningfully to pressure-related discomfort: Slightly limited, responds to verbal commands but cannot always communicate discomfort or the need to be turned, or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities; -Degree to which skin is exposed to moisture: Occasionally moist, skin is occasionally moist, requiring an extra linen change approximately once a day;; -Degree of physical activity: Bedfast, confined to bed; -Ability to change and control position: Completely immobile, does not make even slight changes in body or extremity position without assistance; -Usual food intake: Probably inadequate; -Friction and shear: Problem, requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed, requiring frequent repositioning with maximum assistance; -Score: 11.0, indicating High Risk. Review of the resident's progress notes, dated 11/22/22 at 6:58 A.M. and completed by Nurse E, showed: Late note for 11/19/22. New admission came in with family members. Resident's chief complaint was that he/she fell about 3 months ago and his/her tail bone hurts. Body assessment completed from head to toe. No open areas were noted, but resident's buttock was very red and excoriated; -The nurse did not document if he/she had completed the facility Skin Observation Tool, or notified the resident's physician regarding the very red and excoriated buttock. Review of the resident's physician's order sheet (POS), dated 11/19/22 through 11/30/22, showed: -No treatments for the resident's buttock, sacrum, or coccyx from 11/19/22 through 11/28/22; -An order dated 11/29/22: Butt cream (barrier cream/helps to keep moisture or bowel movement off the skin), Baza cream (barrier cream) or other barrier cream of facility choice may be used to gluteal cleft (the grooves between the buttocks that begins just below the sacrum) three times a day for open area; -An order, dated 11/30/22: Wound care to coccyx: Cleanse with normal saline (salt/water solution) and apply Santyl (ointment that removes dead tissue) and foam dressing every day and as necessary. Review of the resident's treatment administration record (TAR), dated 11/19/22 through 11/30/22, and 12/1/22 through 12/2/22 (resident discharge date ), showed: -11/19/22 through 11/29/22: No treatments for the resident's buttock(s), sacrum, or coccyx. -An order, dated 11/19/22, for weekly skin checks by licensed staff on the night shift, showed: The night nurse completed on 11/23/22 and 11/30/22. No documentation noted on the TAR or in the progress notes by the night nurse completing the skin assessments. -An order dated 11/29/22: Butt cream, Baza cream, or other barrier cream of facility choice. May be used three times a day for open area. -An order dated 11/30/22: Wound care for coccyx. Cleanse with normal saline. Apply Santyl and foam dressing every day and PRN/as necessary. Review of the nurse's progress notes showed: -11/21/22 at 3:30 P.M.: Alert x 2-3 (based on the ability to recall one or more of the following: person, place, time and situation). Maximum assistance of 1-2 staff required for bed mobility and incontinent care; -11/22/22 at 1:27 A.M.: Resident alert and oriented x 2-3. Required maximum assistance of 1-2 with bed mobility and activities of daily living (ADLs/eating, personal hygiene, transfers, bathing, etc.). No complaints of pain or discomfort. Skin warm and dry to touch; -11/24/22 at 10:59 P.M.: Resident complained of back pain. Rated pain as a 6 on a scale of 1-10. Resident was incontinent of bowel and bladder; -11/30/22 at 3:47 P.M., and completed by the facility wound nurse: Initial assessment with the wound care company physician for unstageable pressure ulcer - Known, but not stageable due to coverage of wound bed by slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) and/or eschar (black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin). Wound measures 3.5 centimeter (cm) length by 1.3 cm width by 0.2 cm depth. Thick adherent black necrotic (dead) tissue: 15% (of the wound bed). Thick adherent devitalized (dead) necrotic tissue: 45% (of the wound bed). Slough: 40% (of the wound bed). Treatment plan was to place Santyl to wound bed and cover with gauze daily; -12/2/22 at 11:33 A.M.: Family present for discharge. Wound care education and demonstration provided as well as supplies and instructions on how to clean and dress wound, signs and symptoms of infections as well as when to notify physician. Spoke to Social Services regarding wound care visits at home. During an interview on 12/5/22 at 9:00 A.M., Nurse E said he/she was the day shift nurse. He/she reviewed his/her late progress note, dated 11/22/22 at 6:58 A.M., that referred to the resident on 11/19/22. Nurse E said the resident's coccyx area was red and excoriated, but not open when he/she first saw it on 11/19/22. He/she applied barrier cream, and told the evening shift nurse to call the physician about the coccyx area. Nurse E could not explain why he/she asked the evening shift nurse to call the physician since he/she had completed the assessment at 6:58 A.M. Nurse E said he/she should have called the physician himself/herself. He/she thought he/she had completed a Skin Observation Tool, but could not find one in the EHR. When a CNA completes a shower review form, the nurse was to review it. If there is anything abnormal documented by the CNA, the nurse should assess it and if necessary call the physician and notify the facility wound nurse. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review forms (completed by CNAs after giving a resident a bath/shower) and reviewed and signed by the charge nurse, showed: -11/21/22, completed by CNA B and signed by an unknown nurse on 11/21/22, showed CNA B circled the buttock on the anatomical figure. No other documentation was on the shower review form. There was no documentation in the nurse's progress notes regarding CNA shower review form; -11/23/22, competed by CNA B and signed by an unknown nurse on 11/23/22, showed the CNA circled the buttock on the anatomical figure. No other documentation was on the shower review form. There was no documentation in the nurse's progress notes regarding the CNA shower review form; -11/28/22, completed by CNA B and signed by an unknown nurse on 11/28/22, showed the CNA circled the buttock on the anatomical figure. No other documentation was on the shower review form. There was no documentation in the nurse's progress notes regarding the CNA shower review form. During an interview on 12/2/22 at 3:05 P.M., CNA B reviewed the Skin Monitoring: Comprehensive CNA Shower Review forms dated 11/21/22, 11/23/22 and 11/28/22. The CNA confirmed he/she completed the resident's bed baths on those days and circled the buttocks area on the anatomical figures. He/she was new at the facility, and did not know most of the nurse's by name. He/she said the resident did not have a lot of independent mobility, relied on staff to turn and reposition, and seems to have a lot of pain on his/her bottom. He/she said: -11/21/22: This was the first time he/she was assigned to the resident. He/she noticed something on the resident's bottom and turned on the overhead light. The resident's bottom (sacrum/coccyx area) was red and there was a small open area. He/she found the nurse (name unknown) who was busy passing medications. The nurse said he/she would check the area later, and for him/her to go ahead and apply zinc oxide (a cream/paste used as a preventative treatment and/or for stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough)). The nurse looked at the area later that evening and told him/her to keep putting the zinc oxide on it and he/she would call the resident's family; -11/23/22: One of the resident's family members were present. The resident's bottom was still red with an open area. There was no dressing on the area. He/she did not know if the open area was larger than on 11/21/22. He/she did not recall seeing necrotic tissue though. He/she and the resident's family member changed the resident and the family member applied the zinc oxide on the open area. He/she told the nurse (name unknown, but not the same nurse as 11/21/22) on duty again about what he/she observed. He/she was not sure if the nurse went into the room to assess the open area or not; -11/28/22: The resident's area did not have a dressing on it and it was red and puffy looking. It still had an open area, but he/she was not sure if it was larger than when he/she saw it on the previous dates. He/she did not recall if there was necrotic tissue or not. The resident complained of the area hurting more on 11/28/22 than previously. He/she cleaned the area and put the zinc oxide on it. The resident said it felt better after he/she cleaned it and applied the zinc oxide. He/she told the nurse (name unknown, but not the same nurse as on 11/21/22 or 11/23/22). Review of the resident's Skin Observation Tool, showed: -11/24/22 at 1:12 P.M., showed: Notes: Buttocks slightly reddened, no open areas noted to skin; -11/29/22 at 2:54 P.M., showed: Site: Sacrum, Type: Pressure, Measurements: 3.5 cm by 1.3 cm by 0.2 cm, 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 (damaged tissue under the surface of a wound)). Notes: Followed by wound care company physician. Treat daily with Santyl daily. Monitored daily by facility wound nurse and nursing staff. Review of the wound company evaluation and summary note, dated 11/29/22, showed: Focused Wound Exam (Site 1): -Unstageable (due to necrosis). Sacrum full thickness; -Etiology (cause/origin): Pressure; -Duration: Greater than 14 days; -Objective: Healing; -Wound Size (Length-Width-Depth): 3.5 cm by 1.3 cm by 0.2 cm; -Surface Area: 4.55 cm; -Exudate (drainage): Light serous (pale red or pink drainage); -Thick black necrotic tissue: 15%; -Thick devitalized necrotic tissue: 45%; -Slough: 40%; Dressing Treatment Plan: -Santyl apply once daily for 16 days; -Off-load wound. Reposition per facility protocol. Turn side to side and front to back in bed every 1-2 hours if able; Surgical Excesional Debridement Procedure: The wound was cleansed with normal saline and anesthesia was applied using topical benzocaine (ointment applied topically to relieve pain). Then with clean surgical technique, a #15 blade (surgical scalpel) was used to surgically excise (remove) devitalized tissue and necrotic subcutaneous (the layer just beneath the skin) tissues along with slough at a depth of 0.2 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable (dead tissue) in the wound bed decreased from 100% to 70%. A clean dressing was applied; Plan of Care: The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 42 days. This estimate is made with an 80% degree of certainty. Observation on 12/2/22 at 10:20 A.M., showed the resident lay in bed. The facility wound nurse positioned the resident onto his/her side and removed a dressing dated 12/2/22 from the resident's sacrum/coccyx area, revealing a pressure ulcer. The wound nurse said she did not feel comfortable staging pressure ulcers. She described the appearance of the pressure ulcer as having a red peri-wound and the wound bed being covered by 90% gray necrotic slough. She measured the pressure ulcer and said it was 4.2 cm by 2.9 cm. She had not been told that the resident admitted with a red coccyx/sacrum or a stage II pressure ulcer. The resident's family member was present at the time of the assessment. He/she said he/she saw the pressure ulcer at the hospital prior to the resident being discharged to the facility. The resident's pressure ulcer was red and had a small open area, but it did not look like this. There was no necrotic tissue and it was not as large as it was now. The wound nurse said the first time she saw the pressure ulcer was on 11/29/22, with the wound care company physician. It looked like it did at this time. During an interview on 12/5/22 at 11:05 A.M., the facility wound nurse said she had been the wound nurse since August 2022. She works Monday through Friday. She was not here on 11/19/22 (Saturday) when the resident was admitted . If a resident is admitted with a red area, pressure ulcer/wound and she is not here, the admitting nurse is responsible to complete a Wound Observation Tool/skin assessment and include a description and measurement. The admitting nurse should contact the physician for an order and enter it into the EHR, including the TAR. She and the Director of Nursing (DON) should be notified as well. Once a pressure ulcer or wound has been identified, only the nurses, not the CNAs, should be applying treatments. Nurses should assess the pressure ulcer or wound daily noting any changes including healing or deterioration. Had she been aware of the pressure ulcer upon admission, she would have ordered a low air loss mattress, contacted the physician and obtained a treatment order. During an interview on 12/5/22 at 12:00 P.M., the resident's physician, who was also the facility Medical Director, said she expects staff to follow the facility policy regarding pressure ulcers. Staff should complete a skin assessment when any new resident is admitted . She was not notified the resident was admitted with a red or open area on the coccyx/sacrum area. Had she been notified, she would have ordered zinc oxide every shift and given an order for staff to contact the wound company's physician for further assessment and treatment. It's important for nurses, not CNAs, to apply treatments. CNAs are not trained to assess pressure ulcers for changes. Any deterioration should be documented and either she or the wound company physician should be notified. She expects staff to document information about pressure ulcers/wounds in the resident's EHR. During an interview on 12/5/22 at 3:35 P.M., the DON said she expects staff to follow the facility policies. Upon admission, a skin assessment should be completed and documented. If there is an abnormal finding, staff should call the resident's physician. This includes redness, excoriation or an open area. CNAs can apply ointments and/or creams, but only as a pressure ulcer prevention. Once an area is identified, CNAs are no longer allowed to apply anything. It must be the nurse applying the treatment so the pressure ulcer can be monitored for healing or deterioration. Nurses should be documenting in the EHR any areas noted, treatments and assessments. She could not determine who the three nurses were that signed the shower review forms on 11/21/22, 11/23/22 and 11/28/28. She did not know why those nurses did not contact the resident's physician and/or document their follow-up in the EHR. 2. Review of Resident #15's quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 10/27/22, showed: -Cognitively intact; -Clear speech, distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Limited assistance of one person required for bed mobility and transfers; -Extensive assistance of one person required for toilet use, personal hygiene and bathing; -Functional limitation in range of motion in both upper and lower extremities; -Always incontinent of urine and bowel; -Diagnoses of high blood pressure, renal (kidney) insufficiency, stroke, and paraplegia (paralysis of the lower limbs); -Unhealed pressure ulcers (bedsores): Yes; -Two stage IV pressure ulcers. Review of the resident's care plan, completed on 9/24/22, showed: Focus: -ADL Function: Needs assistance with ADLs due to paraplegia and weakness. He/she is a total assist for transfers and utilizes a sit to stand lift (a machine used to transfer a resident that can bear weight while standing). He/she was 1-2 extensive assistance for bed mobility, personal care and grooming; -Incontinent of bowel and bladder; -At risk for delayed wound healing and decline in over all health. He/she was admitted with three pressure ulcers; -Impaired functional mobility as evidenced by muscle weakness and need to assist in personal care; Interventions: -Provide more assistance in the evening or at night when tired or in pain; -Assist with toileting needs/incontinence care on routine rounds and as needed; -Wound management company for wound care; -Perform treatment to wounds per current treatment order; -Follow pressure ulcer prevention guidelines to prevent additional skin problems, promote healing and prevent complications; -Sit to stand transfers and motorized wheel chair for mobility. Review of the resident's POS and TAR, dated 11/1/22 through 11/30/22, and 12/1/22 through 12/31/22, showed: -An order dated 11/4/22, and discontinued on 12/5/22, for Collagen Matrix- Silver Sheet (Collagen sheet/a treatment that aides in the formation of granulation (healthy) tissue) to the right and left buttock every Monday-Wednesday-Friday; -An order, dated 12/6/22, for collagen sheet daily. Review of the resident's Pressure Injury Risk assessments, showed on 12/5/22, a score of 13, or moderate risk to develop pressure ulcers. Review of the wound company evaluation and summary notes showed: On 11/1/22: Site 9: Stage IV Pressure Wound of the Right Buttock: -Etiology: Pressure; -Duration: Greater than 769 days; -Objective: Healing; -Wound Size: 1.8 cm by 0.4 cm by 0.4 cm; -Exudate: Light Serous; -Granulation Tissue: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply three times per week for 30 days; Site 10: Stage IV Pressure Wound of the Left Buttock: -Etiology: Pressure; -Duration: Greater than 770 days; -Objective: Healing; -Wound Size: 6.5 cm by 2.3 cm by 1.9 cm; -Exudate: Moderate serous; -Granulation Tissue: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply three times per week for 30 days; On 11/8/22 (Primary dressing order changed from Monday-Wednesday-Friday to daily on this date): Site 9: Stage IV Pressure Wound of the Right Buttock: -Wound Size: 1.6 cm by 0.4 cm by 0.4 cm; -Exudate: Light sero-sanguinous (thin/watery fluid that is pink in color); -Granulation Tissue: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply daily for 16 days; Site 10: Stage IV Pressure Ulcer of the Left Buttock: -Wound Size: 5.3 cm by 1.5 cm by 0.6 cm; -Exudate: Moderate Sero-sanguinous; -Granulation Tissue: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply daily for 16 days; On 11/15/22: Site 9: Stage IV Pressure Wound of the Right Buttock: -Wound Size: 2.1 cm by 0.3 cm by 0.5 cm; -Exudate: Light sero-sanguinous; -Thick adherent devitalized necrotic tissue: 20%; -Slough: 10%; -Granulation Tissue: 70%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply daily for 9 days; Site 10: Stage IV Pressure Ulcer of the Left Buttock: -Wound Size: 5.7 cm by 1.3 cm by 0.4 cm; -Exudate: Light sero-sanguiness; -Granulation Tissue: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply daily for 16 days; On 11/23/22, the resident's visit had to be rescheduled because the resident was out for dialysis (a treatment that does some of the things done by healthy kidneys); On 11/29/22: Site 9: Stage IV Pressure Ulcer of the Right Buttock: -Wound Size: 1.9 cm by 0.3 cm by 0.3 cm; -Exudate: Moderate serous; -Thick adherent devitalized necrotic tissue: 15%; -Slough: 15%; -Granulation Tissue: 70%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply once daily for 16 days; Site 10: Stage IV Pressure Ulcer of the Left Buttock: -Wound Size: 5.5 cm by 1.4 cm by 0.6 cm; -Exudate: Moderate Sero-sanguiness; -Granulation Tissue: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply daily for 16 days; On 12/6/22: Site 9: Stage IV Pressure Ulcer of the Right Buttock: -Wound Size: 1.2 cm by 0.5 cm by 0.3 cm; -Exudate: Moderate sero-sanguiness; -Thick adherent devitalized necrotic tissue: 10%; -Slough: 15%; -Granulation Tissue: 75%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply once daily for 9 days; -Surgical Excisional Debridement: Nonviable tissue decreased from 25% to 10%; Site 10: Stage IV Pressure Ulcer of the Left Buttock: -Wound Size: 5.2 cm by 1.0 cm by 0.5 cm; -Exudate: Moderate Sero-sanguiness; -Granulation: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply once daily for 9 days. Further review of the residnet's POS and TAR dated 11/1/22 through 11/30/22, and 12/1/22 through 12/31/22, showed, showed resident's treatment was not changed to daily on 11/8/22 as per the wound company's orders and was not changed to daily until 12/6/22. Observation on 12/5/22 at 9:50 A.M., showed the resident lay in bed prior to a skin assessment. The resident said his/her treatments should be completed two times a day, but most of the time they are doing his/her treatments every other day based on his/her dialysis days. He/she said staff completed his/her pressure ulcer treatments yesterday. During an interview on 12/8/22 at 9:13 A.M., the facility wound nurse said she makes rounds with the wound company physician weekly. He tells her at the time of the rounds if there will be any treatment changes. The wound care physician's assessment and notes are available for her review the day after he makes rounds. It is her job to review the physician's assessment and notes. She does not recall the physician telling her about the resident's treatment change from Monday-Wednesday-Friday to daily on 11/8/22, and must have missed the order change on his assessment and notes. She does remember the treatment order changing on 11/15/22, from Monday-Wednesday-Friday to daily. She must have forgotten to do it. It is her job to change the orders on the POS and TAR. During an interview on 12/8/22 at 10:58 A.M., the DON said, and the administrator and regional nurse consultant agreed, the facility wound nurse is responsible to make rounds with the wound company physician weekly, review his assessments and notes, and document any order changes in the resident's EHR, including the POS and TAR.

Based on observation, interview and record review, the facility failed to ensure that pain management is provided to residents who require such services when staff failed to inform the nurse and the physician that the resident experienced pain (Resident #15) and failed to provide pain management upon assessing the presence of pain (Resident #39). The census was 85. Review of the facility's Pain Management Guidelines, last reviewed 9/2017, showed: -Purpose: To attain and maintain the highest practicable level of well-being and to prevent or manage pain, the facility to the fullest extent possible will: a. Recognize when a resident is experiencing pain; b. Identify circumstances when pain can be anticipated; c. Evaluate existing pain and cause; -Practice Guidelines: 1. Upon admission, residents will be assessed for pain by using the Nursing Admission Assessment form; 2. Residents will be screened for pain by using the assessment from quarterly, annually and with a significant change and/or new onset of pain; a. Pain intensity and pain relief will be assessed prior to administration of medication and post pain medication administration to assess for effectiveness of pain medication; b. Those who cannot report pain may present with non-specific signs such as grimacing, increased confusion, restlessness, etc. To distinguish between pain and other signs or symptoms of distress ([CONDITION(S)], depression, etc.) it is imperative to assess resident to confirm signs and symptoms are indeed related to pain; 3. If any resident reports inadequate pain control, resident will have an assessment performed; 4. Following the pain evaluation, notify the physician of the findings; 5. Each resident identified for pain will have a Pain Management Care Plan. The Care Plan will have individualized interventions related to that resident's individual control of pain management. The Care Plan may include both pharmacological and non-pharmacological pain management interventions; 6. The Licensed Nurse will implement a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 7. The Interdisciplinary Team (IDT) will discuss the new onset of pain or change in resident pain at the daily stand-up meeting and the IDT Team conference; 8. The Licensed Nurse, when administering PRN pain medication, will record the drug administration and the following on the MAR: -Pain level prior to pain medication administration; -Pharmacological interventions attempted; -Non-pharmacological interventions attempted; -Follow-up observations post intervention to determine the effectiveness of PRN pain interventions. If resident is asleep or resting, document as an observation; -Note: Opioid medications are generally used for end-of-life pain relief and use may have careful titration and gradual dose reduction (GDR) attempts with ongoing communication with the prescribing physician related to optimal pain relief for the resident; -Note: PRN pain medications may be reviewed for the need for routinely scheduled orders. If PRN pain medication is not utilized more than two times during the month, the physician may be notified and medication discontinued; -Note: Those residents that chose hospice benefits for end-of-life care: Hospice assumes responsibility for the professional management of the resident in accordance to the hospice plan of care and will be utilized to manage resident pain relief to maintain comfort and dignity; 9. At any time through the process of Pain Management, the IDT may conduct an At-Risk Review Meeting on the resident, in conjunction with other Risk areas reviewed. Review of the Universal Pain Assessment Tool, provided by the facility on 10/29/21, showed the following: -This pain assessment tool is intended to help patient care providers assess pain according to individual patient needs. Explain and use 0-10 Scale for patient self-assessment. Use the faces or behavioral observations to interpret expressed pain when the patient cannon communicate his/her pain intensity; -0, no pain, alert/smiling; -1-2, mild pain, no humor/serious flat, can be ignored; -3-5, moderate pain, furrowed brow, pursed lips, breath holding, interferes with tasks; -6-7, moderate pain, wrinkled nose, raised upper lips, rapid breathing, interferes with concentration; -8-9, severe pain, slow blink, open mouth, interferes with basic needs; -10, worst pain possible, eyes closed, moaning, crying, bed rest required. 1. Review of Resident #15's medical record, showed: -A hospital discharge summary, dated 7/29/21, indicating the resident had a fractured humerus (the arm bone between your shoulder and your elbow) due to a fall at a different facility; -A pain assessment tool, dated 8/2/21, showed: -Current level of pain: No hurt; -Effects of pain on activities of daily living (ADL, self care activities): -Sleep: Yes; -Social activities, eating, physical activity and mobility, motions and intimacy: Unable to determine; -Treatments/modalities, describe all methods of alleviating pain and their effectiveness: Non-applicable. Review of the resident's electronic physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 8/3/21 for pain evaluation on every shift; -[MEDICATION(S)] ([CONDITION(S)] medication that can treat nerve pain) 100 milligrams (mg) three times per day for neurological pain; -[MEDICATION(S)] (muscle relaxant) 5 mg twice per day for spasms. Further review of the resident's e-POS, showed the following PRN medications available for use: -An order, dated 8/2/21, for acetaminophen (Tylenol) tablet 500 mg, give one tablet by mouth every six hours for pain; -An order, dated 8/2/21, for [MEDICATION(S)] (Narcotic, used to treat moderate to severe pain) tablet 50 mg, give one tablet by mouth every six hours for pain. Review of the admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/15/21, showed: -Date of admission, 8/2/21; -No cognitive impairment; -Required extensive assistance from staff for dressing, bed mobility and personal hygiene. Required total assistance from staff for transfers; -Presence of pain: Yes; -Pain intensity on a scale of 0-10: 5. Review of the resident's pain assessment tool, dated 8/25/21, showed: -Current level of pain: No hurt; -Effects of pain on ADL's: Unable to determine; -Treatments/modalities, describe all methods of alleviating pain and their effectiveness: None; -No other documentation of pain assessments or evaluations. Review of the resident's care plan, last reviewed on 9/10/21, in use during the survey, showed: -Focus: Resident is on Opioid pain medication related to pain; -Goal: Resident will be free from any discomfort or adverse side effects from pain medication through review date; -Interventions included: Administer pain medication as ordered. Monitor for altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting. Observe for adverse reactions with every interaction. Review pain medication efficacy. Assess whether pain intensity is acceptable to resident; -Focus: Resident has a self care performance deficit related to fracture of left upper extremity and use of arm sling. Resident is non-compliant with use of sling making bed mobility difficult; -Goal: Resident will maintain current level of function in specify bed mobility, transfers, eating, dressing, toilet use and personal hygiene; -Staff failed to individualize the goal to the resident; -Interventions included: Monitor/document/report to physician, any changes, any potential for improvement, reasons for self-care deficit, expected course, decline in function; -Staff failed to address specific interventions to decrease the difficulty and potential for pain when the resident is in bed and needs to be moved. During observation and interview on 10/25/21 at 9:40 A.M., the resident lay in bed and said he/she has pain routinely. Sometimes the pain is a 3 out of 10 and sometimes it is a 10 out of 10. He/she doesn't like to get out of bed due to the pain he/she has in his/her left shoulder. He/she has had this pain since before moving into the facility. Observation on 10/25/21 at 2:20 P.M., showed Certified Nurse Aide (CNA) M entered the room and said he/she needed to provide personal care for the resident. Observation of the resident on 10/25/21 at 2:36 P.M., showed the resident in bed and crying. He/she said when they move him/her, it hurts. Staff are not particular about thinking what might bother someone. They just want to get the job done so they don't take their time with him/her. He/she has to educate staff on how to do things. He/she cries when the pain gets to be too much from his/her shoulder being moved. Staff are not mindful that his/her shoulder hurts when moved and that's when he/she cries. Sometimes he/she can't stop crying when he/she wants to because it hurts so much. No one has talked to him/her about taking an as needed pain medication before personal care is provided. During an interview on 10/26/21 at 11:42 A.M., CNA N said the resident has a broken arm. He/she knows this because he/she was at the doctor's office when the doctor discussed it with the resident. The doctor said they could not do anything about it. The resident has pain in his/her arm and you have to be careful with his/her arm. During an interview on 10/26/21 at 11:47 A.M., Nurse L said if the resident is moved, it can be uncomfortable. The resident will say Hold on when he/she is getting uncomfortable. The resident will try to help with care as much as he/she can, but staff have to be careful with his/her shoulder. Review of the resident's October 2021 MAR, showed no as needed pain medication administered from 10/1/21 through 10/29/21. Review of the resident's October 2021 treatment administration record (TAR), showed no order or documentation of pain evaluations completed by staff. During an interview on 10/29/21 at 11:40 A.M., the social service director (SSD), said she was not aware of the resident having any pain. She only knew the resident was paralyzed on one side. During an interview on 10/29/21 at 1:30 P.M., the resident's physician said she was not aware the resident had any issues with pain. She would expect staff to assess and evaluate the resident's pain every shift and document it. She would expect staff to follow physician orders. If a resident is having pain, she needs to be made aware of it. During an interview on 11/3/21 at 3:10 P.M., the administrator said the resident admitted to the facility from the hospital with a fracture to his/her left upper arm. 2. Review of Resident #39's medical record, showed: -Admission on 2/23/20. Review of the e-POS showed;: -An order, dated 2/23/20, for pain evaluation, every shift for monitoring of patient's pain level; -An order, dated 2/24/20, for Tylenol 8 Hour Arthritis Pain Tablet Extended Release (Acetaminophen ER). Give one tablet by mouth every 12 hours PRN for pain. Review of the resident's MAR, showed: -On 2/27/20 at 6:30 A.M., pain level documented as a 4, no PRN pain medication documented as administered; -On 3/3/20 at 2:30 P.M., pain level documented as a 3, no PRN pain medication documented as administered; -On 3/6/20 at 6:30 A.M., pain level documented as a 4, no PRN pain medication documented as administered; -On 3/7/20 at 6:30 A.M., pain level documented as a 7, no PRN pain medication documented as administered; -On 3/7/20 at 2:30 P.M., blank, no recorded pain level documented; -On 3/8/20 at 6:30 A.M., pain level documented as a 5, no PRN pain medication documented as administered; -On 3/10/20 at 6:30 A.M., pain level documented as a 5, no PRN pain medication documented as administered; -On 3/18/20 at 2:30 P.M., blank, no documented pain level; -On 3/21/20 at 2:30 P.M., blank, no documented pain level; -On 3/24/20 at 6:30 A.M., pain level documented as a 5, no PRN pain medication documented as administered; -On 3/28/20 at 2:30 P.M. blank, no documented pain level; -On 3/30/20 at 2:30 P.M., blank, no documented pain level. During an interview on 10/29/21 at 2:30 P.M., the administrator said the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . MO 134

Based on observation, interview and record review, the facility charge nurse failed to follow acceptable nursing practices and provide appropriate care and services to one resident experiencing a change in condition. The nurse assessed the resident's blood sugar and got a reading of high, but felt the resident's blood sugar was low, because he/she was sweating, and administered [MEDICATION NAME] (a medication used to quickly raise blood sugar levels), which the resident did not have an order for [REDACTED]. The census was 74. During an interview on 2/13/20 at 8:20 A.M., the complaint reporter said at 3:09 A.M., he/she responded to the facility for a resident with difficulty breathing. The charge nurse said the resident was having breathing issues. The charge nurse took the resident's blood sugar reading and it was high (over 500). A normal blood sugar is 80-100. The charge nurse said he/she tried to call the resident's physician but he/she did not respond. The charge nurse administered 1 milligram of [MEDICATION NAME] intramuscularly (an injection into the muscle). The charge nurse re-checked the resident's blood sugar one hour later and it still read high. The resident's physician had not returned the call. The charge nurse then called the resident's responsible party who said to send the resident to the hospital. The charge nurse called 911, who responded to the facility. The reporter said he/she verified with the charge nurse that the nurse gave [MEDICATION NAME]. The charge nurse provided the reporter with the [MEDICATION NAME] vial and showed where he/she checked it out of the PYXIS (drug dispensing machine). The reporter said the sole purpose of [MEDICATION NAME] is to raise the blood sugar. If the resident's blood sugar was already elevated above 500, the nurse should have never administered [MEDICATION NAME] to the resident with an elevated blood sugar. An extremely high glucose level could cause [MEDICAL CONDITION] and respiratory distress. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/30/19, showed: -Severe cognitive impairment; -No behaviors; -Extensive assistance with activities of daily living; -Diagnoses of [MEDICAL CONDITIONS] (difficulty speaking), [MEDICAL CONDITION], stroke, dementia and [MEDICAL CONDITION] disorder. -No diagnoses of diabetes. Review of the resident's nurse's note, dated 2/13/20 at 7:58 A.M., showed a Certified Nurse Aide (CNA) summoned the charge nurse to the room at approximately 2:30 A.M. and said the resident was shaking and not responding. The charge nurse entered the room and observed the resident experiencing tremors, diaphoretic (sweating) and not responding when his/her name was called. The charge nurse called for assistance and an assessment was performed and vital signs were taken showing, blood pressure: 77/54 (normal 120/80), pulse: 153 (normal 60-100), respirations: 44 (normal 12-20) and temperature 106.6 (normal 98.6). The resident was given 2 liters of oxygen via nasal cannula. The resident's physician was called, 911 was called and the resident's family was notified. The Emergency Medical Technician (EMT) arrived and the nurse continued to assess the resident who had no signs of life. The EMT took over, assessed the resident and said the resident had no signs of life. The resident's time of death was called at 3:30 A.M. The Director of Nursing was made aware. Review of the resident's medical record, showed no documentation of the charge nurse administering [MEDICATION NAME] to the resident. Review of the resident's medication review report, dated 2/13/20, showed no order for [MEDICATION NAME]. During a telephone interview on 2/13/20 at 11:15 A.M., Nurse A said CNA B came to him/her at approximately 2:30 A.M. and said the resident did not look good. Nurse A said he/she went to the resident's room to assess the resident. The resident was shaking a lot and he/she got the resident's vital signs and applied oxygen to the resident. Nurse A said he/she thought the resident's blood sugar was low because the resident was sweating. He/she called the resident's physician but did not get answer and called the resident's family. Nurse A said she administered [MEDICATION NAME] after checking the resident's blood sugar, which read high and then checked it again after administering the [MEDICATION NAME] and it still read high. The resident did not have an order for [REDACTED]. He/she should have read the Medication Administration Record [REDACTED] During an interview on 2/13/20 at 11:26 A.M., CNA B said he/she was doing rounds at approximately 2:30 A.M. He/she walked into the resident's room and the resident did not look right and was shaking. The CNA left the room to get the nurse. He/she got vital signs on the resident and wrote them on the nurse's paper. The charge nurse did check the resident's blood sugar and it was high. The charge nurse did leave the room to get some medication. CNA B said he/she did not know what type of medication the charge nurse got, but he/she did observe the charge nurse administering the medication. Review of the facility's change in a resident's condition policy, dated 11/1/18, showed: -Policy: The attending physician and the resident's representative will be notified of a change in the resident's condition, per standards of practice and federal and/or state regulations; -Responsibility: All Licensed Nursing Personnel; -Procedure: Guideline for Notification of Physician/Resident Representative: -Significant change of unstable vital signs; -Glucometer (machine used to test the amount of glucose (sugar) in the blood) reading below 70 or above 200 unless specific parameters given by physician for reporting. Review of the facility Medication Administration General Guidelines, dated 2007, showed: -Policy: Medications are administered as prescribed in accordance with manufacturers' specification, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have familiarized themselves with the medication; -Medication Preparation: Prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED] -Medication Administration: Medications are administered in accordance with written orders of the prescriber. Obtain and record any vital signs as necessary prior to medication administration. During interviews and an observation the Director of Nursing (DON) said: -On 2/13/20 at 10:10 A.M., she was notified about the resident having a high blood sugar but was not aware [MEDICATION NAME] was administered: -On 2/13/20 at 10:20 A.M., the purpose of the [MEDICATION NAME] is to increase blood sugar levels. [MEDICATION NAME] should not be administered to a resident with a high blood sugar. The guidelines for medication administration should be followed and there should be an order for [REDACTED].>-On 2/13/20 at 11:10 A.M., Nurse A was called into the room by CNA B and took vitals. Nurse A took the blood sugar and it did read high. There was not a number because it was above the parameter of the machine (over 350). Nurse A did administer the [MEDICATION NAME] to the resident but the resident did not have an order. Nurse A should have assessed the resident properly and checked for an order: -On 2/13/20 at 12:30 P.M., they follow the manufacturer's guidelines on the Glucometer and the do a high/low test and log it (to ensure the machine is properly calibrated). She had to call Nurse A about four times to get the full story; -Observation on 2/13/20 at 1:10 P.M., showed the DON tested the calibration of the Glucometer and it was accurate; -On 2/14/20 at 11:14 A.M., she would expect the facility's policies to be followed. She did not know why Nurse A did not follow the policies. Nurse A must have been nervous: -On 2/19/20 at 11:30 A.M., the standard procedure is to call the resident's physician about a blood sugar high (too high to read). They do not have an actual policy. During an interview on 2/13/20 at 12:53 P.M., Physician C said the resident had diagnoses of stroke and [MEDICAL CONDITION]. The resident was on a tube feeding and they did check his/her blood sugar at times, but the resident was not on insulin and did not have an order for [REDACTED]. Administering [MEDICATION NAME] without knowing the proper blood sugar could have caused harm to the resident. MO 683