Every finding on record at Fountain Care at Sunset Hills

Based on interview and record review, the facility failed to notify one resident's physician and obtain treatment orders for skin issues/wounds they identified on a skin check upon the resident's admission on [DATE]. As of 12/23/25, when the resident passed away, the facility had not contacted the resident's physician regarding the skin issues/wounds, had not received treatment orders and had not documented the skin issues/wounds on the electronic treatment administration record (TAR) for on-going monitoring and assessment. Three residents were sampled for wounds, and problems were identified with one (Resident #1). The census was 84.Review of the facility's Skin Program Policy and Procedure revised 12/2023, showed:Purpose: The purpose of the skin program is to ensure that every resident's skin condition is observed/evaluated on admission and a comprehensive and interdisciplinary care plan is developed and maintained to treat actual and/or prevent potential skin problems;-Policy: All residents are observed/evaluated upon admission and PRN (as necessary/needed) for actual and/or potential skin problems. All residents will receive an individualized preventative skin plan of care at the time of admission. All residents with skin problems will receive an active skin plan of care at admission. Skin Care team meetings will be held weekly to address all ulcers and any other pertinent skin problems;-Procedure:-The nurse assesses/evaluates all residents upon admission. The initial skin observation/evaluation is a full body audit and completion of the Braden Scale Pressure Risk Evaluation in Wound Rounds;-A Baseline Plan of Care is initiated and individualized by the Interdisciplinary Team (IDT) within 48 hours post admission;-Residents admitted to the facility with skin areas/pressure ulcers will have treatment orders initiated upon admission/re-admission;-The nurse/designee will notify the resident's responsible party if the resident is admitted /readmitted from the hospital or another healthcare facility with a skin ulcer and document notification in the clinical record. Review of the facility LPN (Licensed Practical Nurse) Job Description, undated, showed:-Reports to: Director of Nursing (DON)/Assistant Director of Nursing (ADON)/Supervisor;-Definition: The LPN is part of and functions in the context of the Nursing Department. The LPN is responsible for the direct and indirect care for residents experiencing medically complex conditions, general medical conditions, rehabilitation and/or wound care needs;-Responsibility and Tasks:-Documents on the delivery of health care and nursing process in accordance with specific unit standards and facility nursing policy;-Maintains accurate resident care records and documents pertinent data reflecting the use of the nursing process and critical thinking skills;-Performs administration and documentation of medication, internal nutrition, and performs treatments, as per physician's orders, and in accordance with policies, procedures, and licensure scope and standard of practice;-Keeps the DON informed of the residents' status and related matters;-Assures that each resident's attending physician is promptly notified of any significant change in the resident health condition. Review of the resident's admission face sheet, located in the electronic healthcare record (EHR), showed an admission date of 12/19/25. Review of Resident #1's Baseline Care Plan, completed by LPN N, dated 12/19/25 and located in the EHR, showed:-Dependent for: Toileting/hygiene, shower/bathing, personal hygiene, and roll left and right;-Level of Consciousness: Alert;-Cognitive Status: Cognitively impaired;-Always incontinent of bowel and bladder;-Current skin integrity issues: Yes;-Skin Risk: See skin assessment. Review of the resident's progress note's, located in the EHR, showed:-12/19/25 at 9:00 P.M., skin check documented by LPN N: Skin Issue #002: Location: Front right medial (toward the middle) lower leg. Issue Type: Open lesion. Length: 1.0 centimeter (cm) x Width: 1.0 cm. Skin Issue #003: Right lateral (to the side) calf. Issue type: Open lesion. 0.3 cm x 0.5 cm. Skin Issue #004: Location: Right great toe. Issue Type: Diabetic foot ulcer. 0.5 cm x 0.2 cm. Skin Issue #006: Location: Peri-anal (the skin between the genitals and surrounding the anus). Redness;-12/19/25 at 10:30 P.M.: Resident admitted to facility from hospital. Resident is alert and oriented x 3 (person, place, time). Body assessment done. Resident has some redness to groin, sheering (the skin moves in opposite direction causing friction or pressure leading to tissue damage). Areas noted to front right shin, back of right ankle and right big toe;-The progress notes showed no documentation the resident's physician was contacted for treatment orders for the skin issues identified on the right shin, back of right ankle and right big toe. Review of the resident's physician's order sheet (POS), located in the EHR, showed no treatment orders for the skin issues identified in LPN N's progress note dated 12/19/25 at 9:00 P.M. Review of the resident's treatment administration record (TAR, where nurses initial treatments are completed as ordered) dated 12/1/25 through 12/23/25, and located in the EHR, showed no documentation to monitor and/or treat the skin issues identified in LPN N's progress note dated 12/19/25 at 9:00 P.M. During an interview on 1/23/26 at 11:27 A.M., LPN N said he/she was the resident's admission nurse on Friday 12/19/25, and he/she documented the skin check in the progress note. He/She reviewed the skin check and said he/she documented skin issue #002 on the front right medial lower leg as open, but now he/she was not sure if it was open or not. There was a dressing on the area he/she removed, cleaned with soap and water and covered it with a dry dressing. Skin issue #003, the right lateral calf may have been open; it probably was open. Skin issue #004, the right great toe had a black necrotic (dead or dying tissue) area on the tip of the toe, on the skin, right below the toenail. Skin issue #006, the peri-anal area was red, but did not have any open areas. He/She applied protective dressings on the right lateral leg, the right lateral leg, and the right great toe. He/She applied barrier cream (a protective cream used to keep moisture/feces off the skin) to the peri-anal area. He/She should have documented each skin issue on the TAR for on-going monitoring but totally forgot. He/She attempted to contact the physician on 12/19/25, about the skin issues, but did not document that. He/She worked Saturday 12/20/25, and Sunday 12/21/25, as well, but did not attempt to contact the physician on those days. He/She did replace the resident's dressings on those days, but did not document that. He/She did not recall if he/she worked Monday 12/22/25. During a telephone interview on 1/24/26 at 7:10 A.M., LPN J said he/she worked the unit where the resident resided and remembered the resident. If a resident had a skin issue/treatment it should be on the TAR. The TAR is what prompts him/her to know a resident has a skin issue and/or treatment. He/She did not know the resident had any skin issues. During a telephone interview on 1/24/26 at 7:25 A.M., LPN K said when he/she looks at the TAR, it will tell him/her what residents have a skin issue that needs to be assessed or treated. If it is not on the TAR, he/she would not know about the skin issue. During an interview on 1/27/26 at 8:48 A.M., LPN H said if a resident is admitted with any abnormal skin areas or pressure ulcers, he/she would measure the areas, describe them and document it in the progress notes. He/She would contact the physician for new orders and document those in the progress notes, the POS and TAR. If the physician did not call back, he/she would cover the area with a basic dressing and pass it along in the shift report. He/She would document any attempts to contact the physician in the progress notes. If a treatment order is not on the TAR, he/she would not know to do the treatment or monitor the area. During an interview on 1/22/26 at 1:48 P.M., the facility Wound Care Nurse said the resident was admitted after she left on Friday 12/19/25. She was off Saturday, Sunday and Monday and returned to work on Tuesday 12/23/25. She was going to assess the resident's skin that morning, but the resident had just passed away. When she is not at the facility, the admitting nurse is responsible to complete the skin check upon admission. She reviewed the skin check completed by LPN N. The LPN should have contacted the physician for treatment orders and documented the skin issues along with the treatment orders on the POS, TAR and in the progress notes. If the LPN attempted to contact the physician, it should have been documented. The LPN should have attempted to contact the physician on Saturday and Sunday as well. During an interview on 1/23/26 at 9:33 A.M., the DON said LPN N should have contacted the resident's physician and received treatment orders for each of the skin issues the resident had. Any new treatment orders should be documented on the TAR. The TAR prompts other nurses on other shifts to provide on-going assessment and treatment. She would have expected the LPN to have made more than one attempt to contact the physician and documented those attempts in the progress notes. 2699783

Based on observation, interview and record review, the facility failed to communicate and attempt to resolve one resident's refusal to take medications scheduled at 8:00 A.M., because he/she was sleeping. Review of the resident's 1/2026 medication administration record (MAR) from 1/1/26 through 1/26/26, showed the resident did not receive eight of eight medications scheduled at 8:00 A.M. on 10 separate days, and two of three doses of one medication scheduled at 8:00 A.M. every Wednesday (Resident #8). The facility also failed to ensure one resident (Resident #2) with a new order for Azithromycin (antibiotic) for pneumonia received the first dose timely. The antibiotic was available in the facility Electronic Emergency Kit (E-Kit, a dispensing system located at the facility containing commonly used medications) but the first dose was not administered for approximately 15 hours after being ordered. The facility also failed to ensure that same resident did not run out of two medications that required a physician's prescription before the pharmacy could deliver the medications. In addition, the facility failed to ensure one resident (Resident #1) promptly received Vancomycin (antibiotic) for clostridium difficile (C-diff, a bacterium that can cause severe diarrhea and colitis (inflammation of the colon)). The pharmacy delivered the Vancomycin to the facility on 1/20/26 at 11:00 A.M., but staff did not administer the first dose until 1/23/26. Eleven residents were sampled and problems were identified with three. The census was 84.Review of the facility's Electronic Emergency Kit For First Dose and Emergency Medications policy, dated 11/2021, showed:-Policy: The facility may use the E-Kit for first dose and emergency medications, where permitted by regulation or law;-Procedures: -The E-Kit may be used by authorized facility staff to access first dose and emergency medications, per regulation and applicable law;-Only authorized licensed facility personnel who have received training, have access to medications in the E-Kit;-Upon receipt of a new medication order, facility staff should obtain the total number of doses necessary to cover the period of time from the administration of the first dose until it is expected to become available from the pharmacy. Review of the facility Controlled Substance Prescriptions policy, dated 11/2021, showed:-Policy: Medications included in the Drug Enforcement administration classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations;-Before a controlled drug can be dispensed, the pharmacy must be in receipt of a prescription from a person lawfully authorized to prescribe;-Additional supplies of controlled drugs are ordered by the facility from the provider pharmacy. Re-orders for controlled substances should be made allowing appropriate time for the pharmacy to obtain the prescription and to assure adequate supply is on hand. Review of the facility's Medication Administration policy last reviewed 1/2024, showed:-Purpose: To administer the following: Right medication, right dose, right dosage form, right route, right resident and right time;Procedure: -Document the following as applicable: Administration of the medication on the MAR as soon as medications are given. Omitted dose by circling your initials in the appropriate block on the MAR (the facility has an electronic MAR and omitted doses are number coded by the certified medication technician (CMT), licensed practical nurse (LPN) or registered nurse (RN)). Reason for omission in the Nursing Progress Notes or on the back of the MAR. PRN (as necessary/needed) medication, reason for administration, and effectiveness in the Nursing Progress Notes or on the back of the MAR;-Notify physician of changes in resident or with refusal of medication. Review of the facility Miscellaneous Special Situations - Unavailable Medications policy dated 11/2021, showed:-Policy: Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. The facility must make every effort to ensure that medications are available to meet the needs of each resident;-Procedures: -The pharmacy staff shall: Call or notify staff that the ordered product(s) is/are unavailable. Notify nursing when it is anticipated that the drug(s) will become available. Suggest alternative, comparable drug(s) and dosage of drug(s) that is/are available, which is covered by the resident's insurance;-Nursing staff shall: Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available. If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. Obtain a new order and cancel/discontinue the order for the non-available medication. 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/31/25 and located in the electronic healthcare record (EHR), showed:-Makes Self Understood: Understood;-Ability To Understand Others: Understands;-Moderately impaired cognition;-Rejection of Care - Presence and Frequency: Behavior not exhibited;-Diagnoses of: High blood pressure, peripheral vascular disease (narrowing of the arteries causing poor circulation), renal (kidney) insufficiency/renal failure/or end-stage renal disease (ERSD), diabetes, hyperkalemia (high potassium level), stroke, and unspecified atrial fibrillation (A-Fib, irregular heart rate/rhythm);-Special Treatments, Procedures, and Programs: Hemodialysis (dialysis, a process of filtering the blood of a person whose kidneys are not working normally). Review of the resident's care plan, located in the EHR, showed: -7/2/24: Focus: Renal failure related to ERSD. Goal: Will have no signs/symptoms of complications related to fluid deficit. Interventions: Give medications as ordered by the physician. Monitor for signs/symptoms of hypervolemia (fluid overload often leading to symptoms like selling, high blood pressure and shortness of breath) or hypovolemia (fluid depletion that can cause weakness, fatigue and dizziness);-7/2/24: Focus: Dialysis related to renal failure. Goal: Will have no sighs/symptoms of complications from dialysis. Interventions: Encourage resident to go to scheduled dialysis appointments on Tuesday, Thursday and Saturday-7/2/24: Focus: Congestive Heart Failure (CHF, a chronic condition that affects the heart's ability to pump blood efficiently). Goal: Will be free from peripheral edema (swelling, usually in the lower limbs). Will have clear lung sounds, regular heart rate and rhythm. Interventions: Give cardiac medications as ordered;-7/2/24: Focus: Hypertension (high blood pressure). Goal: Will remain free from signs/symptoms of hypertension. Interventions: Give anti-hypertensive medications as ordered. Monitor for side effects such as increased heart rate;-7/2/24: Focus: Resistive to care related to refusing medications/care at times. Goal: Will cooperate with care. Interventions: Allow resident to make decisions about treatment regime, to provide sense of control. If possible, negotiate a time for activities of daily living so the resident participates in the decision-making process. Provide resident with opportunities for choice during care provision;-12/9/25: Focus: Impaired cognition. Goal: Will be able to communicate basic needs daily. Interventions: Communicate with the resident regarding capabilities and needs. The resident needs assistance with decision making. Review of the resident's physician's order sheet (POS), located in the EHR, showed:-12/19/25: Carvedilol (used to treat high blood pressure) 3.125 milligrams (mg), one tablet every 12 hours;-12/19/25: Apixaban (used to prevent blood clots/strokes) 5 mg, one tablet two times a day;-12/19/25: Sodium bicarbonate (baking soda) 650 mg, one tablet daily for ESRD;-12/20/25: Amiodarone HCI (used to keep the heart beating normally) 200 mg, give one tablet daily for arrythmia (irregular heartbeat);-12/20/25: Atorvastatin Calcium (used to lower cholesterol) 80 mg daily for hyperlipidemia (elevated levels of lipids (fats, oils, waxes and certain vitamins));-12/20/25: Losartan Potassium (used to treat high blood pressure) 25 mg, one time a day;-12/20/25: [NAME]-Vite (a multivitamin specifically formulated for use by patients on dialysis), give one tablet daily;-12/23/25: Sevelamer (used to treat high phosphate levels in residents with chronic kidney disease who are on dialysis) 800 mg, give two tablets three times a day;-12/24/25: Cholecalciferol (vitamin D3, helps to absorb calcium and phosphorus) 1.25 mg, one time a day every Wednesday. Review of the resident's MAR, located in the EHR, showed CMT O documented a code 7 (sleeping) at 8:00 A.M. on 1/3/26, 1/5/26, 1/6/26, 1/7/26, 1/9/26, 1/10/26, 1/14/26, 1/15/26, 1/17/26, and 1/26/26, for the following medications: -Carvedilol, apixaban, sodium bicarbonate, amiodarone HCI, atorvastatin calcium, losartan potassium, [NAME]-Vite, and sevelamer;-CMT O documented a code 7 at 8:00 A.M on 1/7/26, and 1/14/26, for the Cholecalciferol. During an interview on 1/27/26 at 8:16 A.M., CMT O said he/she works mostly on the hall where the resident resides and administers his/her medications on the days he/she works. He/She works 7:00 A.M. until 3:00 P.M. and administers the resident's 8:00 A.M. medications. The resident is asleep a lot of the time when he/she passes the 8:00 A.M. medications. The resident prefers to sleep until around noon and does not want to take the 8:00 A.M. medications. The resident does not refuse his/her afternoon medications. He/She had told the nurse, but not the Director of Nursing (DON) or the physician about the resident frequently refusing to take the 8:00 A.M. medications CMT O had not asked the resident if he/she wanted his/her medications scheduled later in the day. CMT O did not know if the nurse had discussed the medication times with the resident. During an interview on 1/27/26 at 8:48 A.M., LPN H said he/she obtains the resident's blood glucose level and administers his/her insulin every morning around 8:00 A.M. The resident is usually asleep, but will wake up. LPN H had not been told by any CMT the resident was not taking his/her 8:00 A.M. medications. Had he/she been made aware the resident was not taking his/her medications, he/she would have tried to give the medications himself/herself when he/she takes his/her glucose level and administers the insulin. LPN H could also ask the resident if he/she would prefer his/her medications at a more suitable time for him/her. During an interview on 1/27/26 at 9:30 A.M., LPN B said if a resident does not take medications for any reason, he/she should be notified. If the resident does not take medications because he/she prefers to sleep, then he/she would contact the physician to see if the medication administration times could be changed to accommodate the resident. During an interview on 1/27/26 at 10:35 A.M., the DON said she was not aware the resident had been refusing to take his/her 8:00 A.M. medications. The CMT should have informed the nurse. Had she been made aware, she would have discussed adjusting the administration times to accommodate his/her sleeping schedule. If the resident agreed, she would contact the physician about changing the medication administration times. It's important for the resident to take his/her medications. 2. Review of Resident #2's quarterly MDS dated [DATE] and located in the EHR, showed:-Adequate hearing and vision;-Speech Clarity: Clear speech - distinct intelligible words;-Makes Self Understood: Understood;-Ability To Understand Others: Understands;-Cognitively intact;-Rejection of Care - Presence and Frequency: Behavior not exhibited;-Diagnoses of: Non-Alzheimer's dementia, anxiety, depression and bipolar disorder (a mental disorder characterized by periods of depression and abnormally elevated mood). Review of the resident's care plan, located in the EHR, showed:-Focus: Communication problem related to confusion, disorganized thought processes and speech patterns. Goals: Will improve communication function as evidenced by decrease in disorganized thoughts and ability to finish thoughts without cueing. Interventions: Anticipate needs. Allow adequate time to respond;-Focus: Delirium or an acute confusional episode. Goals: Will be free from signs/symptoms of delirium (changes in behavior, mood, cognitive function, communication, level of consciousness, restlessness). Interventions: Monitor/record/re[ort new onset signs/symptoms of delirium. Provide medications to alleviate agitation. Review of the resident's POS, located in the EHR, showed:-12/24/25: Valium (anti-anxiety medication) 2.5 mg every morning and bedtime-12/26/25: Amphetamine-dextroamphetamine/Adderall (used to treat ADHD (attention deficit hyperactivity disorder, a neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, impulsivity, and emotional dysregulation that are excessive and pervasive) 10 mg tablet one time a day for ADHD. Review of the resident's MAR, located in the EHR, showed:-Amphetamine-dextroamphetamine 10 mg at 6:00 A.M.: Staff documented a 9 ( other/see progress notes, indicates the medication was not administered) on 1/19/26, 1/20/26, 1/21/26, and 1/22/26. The MAR was blank on 1/23/26;-Valium 0.25 mg at 8:00 A.M. and 8:00 P.M.: Staff coded a 9 on 1/20/26 and 1/21/26 at 8:00 A.M. and 8:00 P.M. Review of the resident's progress notes, located in the EHR, showed:-1/19/26 at 5:17 A.M.: Amphetamine-dextroamphetamine, medication on order;-1/20/26 at 5:54 A.M.: Amphetamine-dextroamphetamine, medication on order;-1/20/26 at 8:32 A.M.: Valium, need new script;-1/20/26 at 9:35 P.M.: Valium, on order, nurse is aware;-1/21/26 at 6:08 A.M.: Amphetamine-dextroamphetamine, awaiting pharmacy delivery;-1/21/26 at 8:15 A.M.: Valium, on order, need new script, nurse is aware;-1/21/26 at 9:01 P.M.: Valium, on order;-1/22/26 at 6:20 A.M.: Amphetamine-dextroamphetamine, awaiting pharmacy delivery. Review of a radiology report located, in the EHR, showed:-Examination Date: 1/21/26 at 8:32 A.M.;-Reported Date: 1/21/26 at 9:46 A.M.;-Impression: Focal pneumonia. Follow-up recommended. Review of the resident's progress note, dated 1/21/26 at 8:27 P.M., showed chest x-ray results reported to physician, positive for pneumonia. New order to start Azithromycin. Review of the resident's POS, showed:-1/22/26: Azithromycin 250 mg, give two tablets one time only on day one, then one tablet daily for four days, for infection. Review of the resident's MAR showed:-1/22/26: Azithromycin 250 mg two tablets one time only. Staff documented the Azithromycin was administered on 1/22/26 at 12:02 P.M., more than 15 hours after receiving the physician's order on 1/21/26 at 8:27 P.M. Review of medications in the facility E-Kit, showed the E-Kit contained 10 tablets of Azithromycin 250 mg. During an interview on 1/22/26 at 8:44 A.M., the resident said he/she had not been feeling too good because he/she had pneumonia, and staff told him/her they had not received his/her antibiotics yet. He/She had also been out of his/her Adderall for about five days. During an interview on 1/23/26 at 9:33 A.M., the DON said she expected staff to check the E-Kit when there is a new antibiotic ordered, and if it is available the antibiotic should be started. Azithromycin is available in the E-Kit. If the medication had been not available in the E-Kit, she would have expected the nurse to have contacted the physician to see if he wanted to start a different antibiotic that was available or wait until the pharmacy delivered the original antibiotic. This should all be documented in the resident's progress notes. During an interview on 1/24/26 at 7:00 A.M., LPN K said the resident did not receive his/her Valium and amphetamine-dextroamphetamine because his/her prescription ran out, and they needed a new prescription from the physician to be sent to the pharmacy. LPN K had not spoken to the pharmacy or the physician about the medications being out of stock, but he/she thought the day shift nurse had. During a telephone interview on 1/26/26 at 2:21 P.M., a pharmacy representative said when a facility notifies them a medication is running out, the pharmacy will inform the facility if a new prescription is needed before the medication can be refilled and delivered. The facility is responsible to contact the physician and have the prescription sent to the pharmacy so it can be delivered. The pharmacy did not receive the new prescription from the physician for amphetamine-dextroamphetamine until 1/23/26, and the medication was delivered to the facility on 1/24/26 at 8:00 A.M. The pharmacy received a new prescription for the Valium on 1/21/26, and the medication was delivered to the facility on 1/22/26 at 12:00 P.M. During an interview on 1/27/26 at 8:48 A.M., LPN H said if he/she had received the results of the resident's chest x-ray confirming pneumonia, he/she would contact the physician. If the physician ordered an antibiotic like Azithromycin, he/she would check the facility E-Kit and if available he/she would start the antibiotic at that time. Medications such as amphetamine-dextroamphetamine and Valium are sent to the facility by the pharmacy in bubble cards (each tablet is sealed in a plastic bubble and has to be popped out). When there are about 10 pills left in the card, he/she would contact the pharmacy and reorder the medication, so it does not run out. If the pharmacy says the medication will require a new prescription before it can be delivered, then the nurse is supposed to contact the physician so a new prescription can be sent to the pharmacy. Ideally, a resident should not run out of a medication. During an interview on 1/27/26 at 9:30 A.M., Nursing Supervisor LPN B, said they usually get chest x-ray results quickly after the chest x-ray is obtained. If the results showed an abnormal, like pneumonia, he/she would contact the physician right away. If the physician ordered an antibiotic, he/she would check the E-Kit and if available give the antibiotic. If it was available in the E-Kit, there would be no reason to wait until the next day to start the antibiotic. If a medication like amphetamine-dextroamphetamine or Valium is running out, he/she would contact the pharmacy when there are about 10 pills left in the card. If the pharmacy says a new prescription is required before the medication can be delivered, he/she would contact the physician at that time and request the new prescription be sent to the pharmacy so the medication wouldn't run out. During an interview on 1/27/26 at 10:35 A.M., the DON said there is a color change on the bubble card that should prompt the CMT or nurse to contact the pharmacy so a medication can be reordered and delivered before the medication runs out. The pharmacy will let the nurse know if the medication requires a new prescription and if so, she expected the nurse to contact the physician to have the new prescription sent to the pharmacy. She did not know why the prescriptions were not sent to the pharmacy prior to the amphetamine-dextroamphetamine and Valium running out. If the system worked as, it should, no resident should run out of their medication. 3. Review of Resident #1's admission face sheet, located in the EHR, showed an admission date of 12/19/25. Review of the resident's hospital admission orders, dated 12/19/25 and located in the EHR, showed the resident was admitted to the hospital on [DATE] with a diagnoses of C-diff and an order to administer Vancomycin 125 mg daily for four days. Review of the resident's MAR, located in the EHR, showed an order dated 12/20/25, for Vancomycin 125 mg, give one capsule daily at 6:00 A.M. for four days. Staff documented a code 9 (other/see progress notes) on 12/20/25 and 12/21/25. Review of the resident's progress notes, located in the EHR, showed:-No documentation as to why the resident did not receive his/her Vancomycin on 12/20/26;-12/21/26 at 6:31 A.M.: Vancomycin pending delivery. During a telephone interview on 1/26/26 at 2:21 P.M., a pharmacy representative said the pharmacy delivered 4 doses of Vancomycin 125 mg to the facility on [DATE] at 11:00 A.M. During an interview on 1/27/26 at 10:35 A.M., the DON said when a medication is coded as a 9, she expected staff to document the reason in the progress notes. When medications were delivered to the facility on a weekend, the pharmacy will normally take the entire delivery, for all the nurse's stations, to just one nurse's station. The nurse that receives the delivery should ensure any medications for residents on different halls are promptly delivered to those nurse's stations. If the Vancomycin was delivered on 12/20/25 at 11:00 A.M., she would have expected staff to have administered the medication that day. 2655549

Based on interview and record review, the facility failed to notify one resident's physician and obtain treatment orders for a pressure ulcer/injury (localized damage to the skin that usually occur over a bony prominence as a result of pressure) on one resident's coccyx (tailbone) that was identified on a skin check upon the resident's admission on [DATE]. As of 12/23/25, when the resident passed away, the facility had not contacted the resident's physician, had not received treatment orders and had not documented the pressure ulcer/injury on the electronic treatment administration record (TAR) for on-going monitoring, assessment and treatment. Three residents were sampled for wounds, and problems were identified with one (Resident #1). The census was 84.Review of the facility Skin Program Policy and Procedure revised 12/2023, showed:Purpose: The purpose of the skin program is to ensure that every resident's skin condition is observed/evaluated on admission and a comprehensive and interdisciplinary care plan is developed and maintained to treat actual and/or prevent potential skin problems;-Policy: All residents are observed/evaluated upon admission and PRN (as necessary/needed) for actual and/or potential skin problems. All residents will receive an individualized preventative skin plan of care at the time of admission. All residents with skin problems will receive an active skin plan of care at admission. Skin Care team meetings will be held weekly to address all ulcers and any other pertinent skin problems;-Procedure:-The nurse assesses/evaluates all residents upon admission. The initial skin observation/evaluation is a full body audit and completion of the Braden Scale Pressure Risk Evaluation in Wound Rounds;-A Baseline Plan of Care is initiated and individualized by the Interdisciplinary Team (IDT) within 48 hours post admission;-Residents admitted to the facility with skin areas/pressure ulcers will have treatment orders initiated upon admission/re-admission;-The nurse/designee will notify the resident's responsible party if the resident is admitted /readmitted from the hospital or another healthcare facility with a skin ulcer and document notification in the clinical record. Review of the facility's LPN (Licensed Practical Nurse) Job Description, undated, showed:-Reports to: Director of Nursing (DON)/Assistant Director of Nursing (ADON)/Supervisor;-Definition: The LPN is part of and functions in the context of the Nursing Department. The LPN is responsible for the direct and indirect care for residents experiencing medically complex conditions, general medical conditions, rehabilitation and/or wound care needs;-Responsibility and Tasks:-Documents on the delivery of health care and nursing process in accordance with specific unit standards and facility nursing policy;-Maintains accurate resident care records and documents pertinent data reflecting the use of the nursing process and critical thinking skills;-Performs administration and documentation of medication, internal nutrition, and performs treatments, as per physician's orders, and in accordance with policies, procedures, and licensure scope and standard of practice;-Keeps the DON informed of the residents' status and related matters;-Assures that each resident's attending physician is promptly notified of any significant change in the resident health condition. Review of the resident's admission face sheet, located in the electronic healthcare record (EHR), showed an admission date of 12/19/25. Review of the resident's Baseline Care Plan, completed by LPN N, dated 12/19/25 and located in the EHR, showed:-Dependent for: Toileting/hygiene, shower/bathing, personal hygiene, and roll left and right;-Level of Consciousness: Alert;-Cognitive Status: Cognitively impaired;-Always incontinent of bowel and bladder;-Current skin integrity issues: Yes;-Skin Risk: See skin assessment. Review of the resident's progress note's, located in the EHR, showed:-12/19/25 at 8:10 P.M.: Braden Scale (an assessment tool used for predicting pressure injuries). Moisture (skin): Constantly moist. Activity: Chairfast. Resident is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Friction and shear: Problem. Score of 11 (indicates is at a high risk to develop pressure sores/injuries);-12/19/25 at 9:00 P.M., skin check documented by LPN N: Skin Issue #005: Location coccyx. Issue Type: Pressure ulcer/injury. 4.0 centimeters (cm) x 0.3 cm x depth 0.5 cm. -12/19/25 at 10:30 P.M.: Resident admitted to facility from hospital. Resident is alert and oriented x 3 (person, place, time). Body assessment done. Resident has some redness to groin, sheering (the skin moves in opposite direction often caused friction or pressure leading to tissue damage) and opened area to coccyx. Areas noted to front right shin, back of right ankle and right big toe;-The progress notes showed no documentation the resident's physician was notified regarding the resident's coccyx pressure ulcer and/or if a treatment was obtained. Review of the resident's physician's order sheet (POS), located in the EHR, showed no treatment order for the pressure ulcer on the coccyx identified in LPN N's progress note dated 12/19/25 at 9:00 P.M. Review of the resident's TAR dated 12/1/25 through 12/23/25, showed no treatment order for the pressure ulcer identified in LPN N's progress note dated 12/19/25 at 9:00 P.M. During an interview on 1/23/26 at 11:27 A.M., LPN N said he/she was the resident's admission nurse on Friday 12/19/25, and he/she documented the skin check in the progress note. He/She reviewed the skin check and said he/she documented skin issue #005 on the coccyx. The pressure ulcer was red and open. He/She cleaned the pressure ulcer and applied barrier cream (a protective cream used to keep moisture/feces off the skin). He/She should have documented the pressure ulcer on the TAR for on-going monitoring but forgot. He/She attempted to contact the physician on 12/19/25, about the skin issues, but did not document that. He/She worked Saturday 12/20/25, and Sunday 12/21/25, as well, but did not attempt to contact and the physician on those days. He/She did replace the resident's dressings on those days, but did not document that. He/She did not recall if he/she worked Monday 12/22/25. During a telephone interview on 1/24/26 at 7:10 A.M., LPN J said he/she worked the unit where the resident resided and remembered the resident. If a resident had a pressure ulcer/treatment it should be on the TAR. The TAR is what prompts him/her to know a resident has a skin issue and/or treatment. He/She did not know the resident had a pressure ulcer on his/her coccyx. During a telephone interview on 1/24/26 at 7:25 A.M., LPN K said when he/she looks at the TAR, it will tell him/her what residents have a pressure ulcer that needs to be assessed or treated. If the pressure injury was not on the TAR, he/she would not know about it. During an interview on 1/27/26 at 8:48 A.M., LPN H said if a resident is admitted with any abnormal skin areas or pressure ulcers, he/she would measure the areas, describe them and document it in the progress notes. He/She would contact the physician for new orders and document those in the progress notes, the POS and TAR. If the physician did not call back, he/she would cover the area with a basic dressing and pass it along in the shift report. He/She would document any attempts to contact the physician in the progress notes. If a treatment order is not on the TAR, he/she would not know to do the treatment or monitor the area. During an interview on 1/22/26 at 1:48 P.M., the facility Wound Care Nurse said the resident was admitted after she left on Friday 12/19/25. She was off Saturday, Sunday and Monday and returned to work on Tuesday 12/23/25. She was going to assess the resident's skin that morning, but the resident had just passed away. When she is not at the facility, the admitting nurse is responsible to complete the skin check upon admission. She reviewed the skin check completed by LPN N. LPN N should have contacted the physician for treatment orders and documented the pressure ulcer along with the treatment order on the POS, TAR and in the progress notes. If the LPN attempted to contact the physician, it should have been documented. The LPN should have attempted to contact the physician on Saturday and Sunday as well. During an interview on 1/23/26 at 9:33 A.M., the DON said LPN N should have contacted the resident's physician and received treatment orders for the pressure ulcer on the coccyx. Any new treatment order should be documented on the TAR. The TAR prompts other nurses on other shifts to provide on-going assessment and treatment. She would have expected the LPN to have made more than one attempt to contact the physician and documented those attempts in the progress notes. 2699783

42795 Based on observation, interview and record review, the facility failed to maintain resident rooms and resident-use areas in the facility in a clean and homelike manner. Concerns were noted with three of 18 sampled residents' rooms (Residents #9, #195 and #194), and multiple resident-use areas on the Fountain Hall. The facility census was 89. Review of the facility's Cleaning and Disinfecting of Environmental Surfaces and Equipment policy, revised July 2024 showed: -Reusable items such as durable medical equipment shall be disinfected after each use and between residents; -Housecleaning surfaces (e.g. floors, tabletops) will be cleaned on a regular basis, when spills occur, and when the area is visibly soiled; -Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g. daily, three times per week) and when surfaces are visibly soiled; -Walls, blinds, and window curtains in resident care areas will be cleaned when these surfaces are visibly soiled. Review of the facility's Housekeeping Aide Job Description, revised 1/27/09, showed: -Responsibilities including dusting furniture, light fixtures, window ledges, vacuuming and wet mopping of all floors, and cleaning and storing equipment properly; -All housekeeping staff assigned to a designated area should ensure the entire area is clean, safe, orderly, and attractive at all times. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/13/25, showed: -Cognitively intact; -Wheelchair for mobility; -Diagnoses included anxiety, depression, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). Observation and interview on 4/21/25 at 11:57 A.M., showed the resident sat in bed in his/her room. The bed was positioned against the wall and the resident leaned against the wall. The wall had fingerprints and smears along the length of the bed. A hand sanitizer dispenser was located near the foot of the bed, with drips visible on the wall. A clothing hanger lay on the floor in front of the closet and a pair of used medical gloves lay on the floor in front of the vanity. Small debris and dirt lay along the edges of the walls. Crumpled paper trash lay under the bed along with small debris and dust. The resident said housekeeping does clean the room, but they do not move anything or get into the edges, they just sweep and mop the easy to reach areas of the floor. He/She did not know the last time his/her wall was wiped down. Observation on 4/23/25 at 7:00 A.M., and 4/24/25 at 6:59 A.M., of the resident's room, showed the resident's bed positioned against the wall. The wall had fingerprints and smears along the length of the bed. A hand sanitizer dispenser was located near the foot of the bed and drips were visible on the wall. Small debris and dirt lay along the edges of the walls. Crumpled paper trash lay under the bed along with small debris and dust. 2. Review of Resident #195's medical record showed: -An admitted [DATE]; -Diagnoses included: Fournier gangrene (a flesh-eating disease that and infection that affects the genitals), necrotizing fasciitis (a bacterial infection that destroys tissue under the skin), dependence on renal (kidney) dialysis (a medical procedure that cleanses the blood of its impurities), muscle weakness, obesity, assistance with personal care and hygiene. Observations and interviews on 4/21/25 at 11:10 A.M., 4/22/25 at 7:04 A.M., and 4/24/25 at 10:12 A.M., in the resident's room, showed the floor was dark grey had clear film with a dried liquid spill. While walking in the resident's room, the floor felt sticky. The resident room has an air vent on the in the wall near the floor. The air vent was dented and missing pieces. The pieces that remained of the vent were covered with approximately one half an inch of dust. The resident had small pieces of trash and crumbs behind his/her bed and nightstand. The resident said the housekeeper mops the floors daily, but multiple staff members complain about the floors being sticky when they enter his/her room. The air vent has been in that condition since he/she was admitted to the facility. The resident said he/she thinks it is as clean as it is going to get. 3. Review of Resident #194's medical record showed: -An admitted d of 4/7/25; -Diagnoses included end stage renal disease, dependence on renal dialysis, diabetes, absences of right and left leg below the knee. Observations and interviews on 4/21/25 at 10:55 A.M., 4/23/25 at 6:35 A.M., and 4/24/25 at 10:15 A.M., in the resident's room, showed dust and small pieces of dry wall were behind the bed on the floor, nightstand and recliner. The baseboards around the room had dust and crumb particles. The wall behind the resident's bed had paint chipped and small pieces of dry wall missing. While walking in the residents' room, the floors felt sticky. The resident said the housekeeper comes in and mops the floors daily. The resident has not observed housekeeping staff move furniture or sweep behind the bed. The walls have been chipped since he/she was admitted to the facility. The resident said the room could use some improvements. 4. Observations on 4/21/25 at 12:05 P.M. and on 4/22/25 at 7:03 A.M., showed a shower room at the end of the Fountain Hall located near the nurse's station. A foul odor was noted at the doorway of the shower room, and observation of the toilet showed it was filled with urine and blocked from use by a rolling shower chair. 5. Observation on 4/21/25 at 12:18 P.M. showed an activity room on the Fountain Hall containing four dining tables with chairs and two mechanical lifts parked along the west wall. A smashed piece of bread and a number of smashed candy pieces were under the dining tables. Observation on 4/22/25 at 7:20 A.M. showed an activity room on the Fountain Hall containing four dining tables with chairs and two mechanical lifts parked along the west wall. A smashed piece of bread and a number of smashed candy pieces were noted under the dining tables. A corrugated cardboard coffee cup sleeve and other plastic trash were on the floor in the southeast corner of the room. Observation on 4/23/25 at 7:20 A.M. showed an activity room on the Fountain Hall containing four dining tables with chairs and two mechanical lifts parked along the west wall. A smashed piece of bread and a number of smashed candy pieces were under the dining tables. 6. Observations of the facility elevator on 4/21/25 at 11:38 A.M. and on 4/22/25 at 9:04 A.M., showed the lower third of the walls on the elevator with carpeting in place. There were numerous holes, scrapes, and cuts were noted in the walls' carpeting. An overhead vent inside the elevator cab was loaded with dust and debris. 7. Observation on 4/22/25 at 7:31 A.M., of room [ROOM NUMBER], showed food debris on the floor surrounding the resident's bed. Food debris was caked on the resident's fall mat. Observation on 4/23/25 at 6:27 A.M., of room [ROOM NUMBER], showed food debris on the floor surrounding the resident's bed. Food debris was caked on the resident's fall mat. 8. Observation on 4/22/25 at 5:55 A.M., of room [ROOM NUMBER], showed trash and food debris on the ground surrounding the resident's bed. The floor and the resident's fall mat were sticky. Observation on 4/23/25 at 6:26 A.M., of room [ROOM NUMBER], showed trash and food debris on the ground surrounding the resident's bed. The floor and the resident's fall mat were sticky. 9. Observation on 4/23/25 at 8:12 A.M., of room [ROOM NUMBER], showed the floor in the room was sticky and had trash in various areas. Observation on 4/24/25 at 9:22 A.M., of room [ROOM NUMBER], showed the floor in the room was sticky and had trash in various areas. 10. During interview on 4/24/25 at 8:51 A.M. Housekeeper P said housekeeping staff are instructed to clean resident rooms and resident-use areas in the facility every day, including removal of trash and food items that may have been left by residents after use. The housekeeping department is fully staffed and each housekeeper is designated to an area or hall for each day of the week. 11. During an interview on on 4/24/25 at 9:55 A.M., Housekeeper Q said he/she cleans the rooms daily by sweeping the floors, cleaning the baseboards, wipes the bedside table and cleans the bathroom. He/She will move the furniture to clean behind it when needed. If the floors seem sticky Housekeeper Q will clean the floor with bleach water. If there are any issues with the walls or equipment in the room, he/she will notify someone in maintenance department. 12. During an interview at 4/24/25 at 10:25 A.M., the Housekeeping Supervisor said the housekeeping staff are responsible for cleaning the resident rooms daily. Floors are mopped and swept, trash is removed, tables and counters are wiped down with a disinfectant. If the resident's floors are sticky, then the resident's room needs to be mopped with clear water, or the cleaner used for the floor needs to be diluted. The housekeeper is to spend fifteen to twenty minutes a day in each room cleaning. A room that is not clean is not homelike. The residents should all have a clean and tidy room. 13. During an interview on 4/24/25 at 10:34 A.M., the Maintenance Director said he was not aware of Resident #195's broken air vent. The nurses should have reported that to him and he would have taken care of it. He said Resident #194's walls need to be painted and patched. He was aware of the chipped areas on the walls but had not gotten to it yet. Resident rooms should be in clean and in good repair. 14. During an interview on 4/24/25 at 11:27 A.M., the Administrator said she would expect the housekeeping staff to clean the all the resident rooms to the best of their ability and whatever the resident will allow them to clean. Rooms are expected to be clean and in good repair. Resident-use areas in the facility are also expected to be maintained in a clean and homelike manner. MO00251317 MO00253121 44948 46888

Based on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for one out of three narcotic books reviewed. The census was 89. Review of the facility's Controlled Substance Storage policy, revised January 2018, showed: -Policy: Medications included in the Drug Enforcement Administration (DEA) classifications as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations; -At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented on the shift verification of controlled substance count. 1. Review of the Complex Hall Controlled Substance Shift change count sheet, dated 3/1 through 3/31/25, showed: -Eight out of 62 shifts have no nurse signature on the shift change count; -Twenty-two out of 62 shifts only have one nurse signature on the shift change count; 2. Review of the Complex Hall Controlled Substance Shift change count sheet, dated 4/1 through 4/21/25, showed twenty-three out of 42 shifts only have one nurse signature on the shift change count. 3. During an interview on 4/23/25 at 9:15 A.M., Certified Medication Technician (CMT) S said most of the nursing staff work twelve-hour shifts. The narcotic sheets are to be signed by one oncoming and one off-going nursing staff member every shift, every day. 4. During an interview on 4/24/25 at 11:27 A.M., the Director of Nursing said she expected the nurses and CMTs to count narcotics with one oncoming staff member and one off-going staff member every shift, every day. She expected the count to be clear and accurate and indicate if the staff member worked twelve or eight hour shifts.

Based on observation, interview and record review, the facility failed to keep the kitchen equipment clean and floors free of trash and grime. The census was 89. Review of the facility's kitchen department sanitation policy, dated 1/2021, showed: -Purpose: to ensure a clean and sanitary work environment; to promote and protect food safety; and, to maintain compliance with federal, state, and local guidelines and regulations governing food sanitation and safety; -Policy: the department sanitation shall be maintained in a manner to support procedures for food safety. Staff shall be responsible for daily and weekly cleaning assignments as determined by the Dietary Manager and/or his/her designee. Cleaning assignments shall include all equipment, storage areas, walls, floors and refrigeration units. Cleaning of equipment condensers, lighting fixtures, vents, etc. shall be completed by the Maintenance Department as determined by the Administrator. Review of the facility's kitchen cleaning schedule, undated, showed: -Daily Cleaning: oven, deep fryer, floors, and refrigerators. 1. Observation on 4/21/25 of the kitchen, showed: -At 10:47 A.M., the refrigerator labeled 1 had a liquid spill on the ground inside the refrigerator; -At 10:50 A.M., the deep fryer had a caked on sticky substance; -At 10:51 A.M., the oven/stove top had food debris and build up. The side of the oven closest to the deep fryer had a caked on sticky substance. The floor underneath the oven/stovetop had a black liquid build up; -At 10:55 A.M., the floor behind the ice machine had trash and grime build up. 2. Observation on 4/23/25 of the kitchen, showed: -At 6:42 A.M., the deep fryer had caked on sticky substance; -At 8:48 A.M., the refrigerator labeled 1 had a liquid spill on ground inside the refrigerator; -At 8:50 A.M., the oven/stove top had food debris and build up. The side of the oven closest to the deep fryer had a caked on sticky substance. The floor underneath the oven/stovetop had a black liquid build up; -At 8:51 A.M., the floor behind the ice machine had trash and grime build up. 3. During an interview on 4/24/25 at 9:39 A.M., Dietary Aide E said the floors should be swept and mopped after each meal service. The deep fryer, oven, and stove are to be cleaned by the cook. Walk-in floors are to be cleaned by all staff. 4. During an interview on 4/24/25 at 9:42 A.M., the Dietary Manager said all staff are expected to clean the kitchen. He said kitchen cleaning has not been getting done appropriately. The daily cleaning logs were also not signed off by staff. He expected the kitchen floors and appliances to be clean. Cooking appliances and floors are to be cleaned daily. 5. During an interview on 4/24/25 at 12:01 P.M., the Administrator said she expected the kitchen and kitchen appliances to be clean. She expected the dietary staff to sign off on the daily cleaning logs. 6. During an interview on 5/1/25 at 12:21 P.M., the Administrator said the daily cleaning logs were not signed off by the dietary staff. She expected the cleaning tasks to be completed and the cleaning logs to be initialed by the staff member who cleaned.

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 thee residents (Residents #195, #15, and #24) who required EBP for wounds requiring treatment or centrally inserted devices used for dialysis (the process of filtering the blood for individuals with kidney failure). In addition, the facility failed to ensure newly admitted residents were provided a two-step Mantoux Purified Protein Derivative (PPD, used to test for tuberculosis (TB) infection) tuberculin test per facility policy, for four of five residents sampled for TB testing (Resident's #80, #195, #1, #84). The census was 89. 1. Review of the facility's EBP policy, revised February 2025, showed: -EBP are used in conjunction with standard precautions and expands the use of personal protective equipment (PPE) to donning (application) of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff and clothing; -EBP are indicated for residents with any of the following: -Infection or colonization (presence or growth of bacteria without showing signs of illness) with a CDC targeted MDRO when contact precautions do not otherwise apply; -Wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO; -Chronic wounds include, but are not limited to, unhealed pressure wounds (a wound cause by prolong pressure), diabetic foot ulcers (wound), unhealed surgical wounds, and venous stasis ulcers (wounds that are cause by damaged veins in the legs); -Indwelling medical devices that examples include central lines (a surgically inserted thin tube inserted into a large vein), urinary catheters (a tube that drains the bladder), feeding tubes (a surgically inserted tube that is placed in the abdomen and is used for medications and liquid nutrition), and tracheostomies (a surgically inserted tube that is placed in the windpipe to assist with breathing); -EBP should be used for any residents who meet the above criteria, whenever they reside in the facility; -For residents whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: -Dressing; -Bathing or showering; -Transferring; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use: central line, urinary catheter, feeding tube, and tracheostomy; -Wound care: any skin opening requiring a dressing; -The facility has discretion on how to communicate to staff which residents require the use of EBP; -PPE for EBP is only necessary when performing high-contact care activities and may not need to be donned prior to entering the room. Review of the facility's EBP sign, placed outside resident rooms who require EBP, showed: -Stop, EBP; -Everyone must clean their hands before and after leaving the room; -Wear gloves and gown for the following high contact resident care areas: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, central line, urinary catheter, feeding tube and tracheostomy. 2. Review of Resident #195's medical record, showed: -Diagnoses included: Fournier gangrene (a flesh-eating disease and infection that affects the genitals), necrotizing fasciitis (a bacterial infection that destroys tissue under the skin), dependence on renal (kidney) dialysis, muscle weakness, and assistance with personal care and hygiene. -No care plan available for review; -An order dated 3/27/25, for EBP related to dialysis port and wound to genitals. Observation and interview on 4/21/25 at 11:32 A.M., showed an EBP sign posted outside of the resident's door. The resident sat in his/her wheelchair in his/her room. A Hoyer (full body mechanical lift) pad was positioned underneath the resident. The resident said he/she received dialysis and has a wound that requires a dressing located to his/her genitals that the nurses changed every day. The resident informed Certified Medicine Technician (CMT) I that he/she need to be move up into the wheelchair and felt as though he/she was slipping. CMT I and Licensed Practical Nurse (LPN) F attached the Hoyer pad to the Hoyer lift and repositioned the resident in the wheelchair. The resident said he/she still was not comfortable. LPN F and CMT I placed the resident onto his/her bed by using the Hoyer lift. LPN F said the resident required a larger Hoyer pad. At 11:50 A.M., the resident lay in bed, Certified Nursing Assistant (CNA) G, CNA H and LPN F removed the smaller Hoyer pad and applied the larger Hoyer pad underneath the resident by turning the resident side to side. The resident's abdomen and legs touched CNA G's, CNA H's and LPN F's uniform top and bottoms. The resident was then placed into his/her wheelchair by CNA G, CNA H and LPN F using the Hoyer lift. Staff did not wear an isolation gown while providing direct care to the resident. 3. Review of Resident #15's medical record, showed: -Diagnoses included: Dependence on renal dialysis, diabetes, hemiparesis (numbness to one side of the body), and hemiplegia (paralysis to one side of the body) and assistance with personal care and hygiene; -The resident's care plan, used at the time of survey, did not address EBP; -An order dated 2/13/25, EBP related to central line dialysis access. Observation on 4/22/25 at 11:59 A.M., showed an EBP sign posted outside the resident's door. The resident sat in a recliner with a Hoyer pad underneath him/her, in his/her room. The resident requested to be placed in bed. CNA J and CNA K entered the resident's room with a Hoyer lift and attached the Hoyer pad to the Hoyer lift. The resident was placed in his/her bed. While the resident lay in bed, CNA J and CNA K removed the resident's Hoyer pad by turning the resident side to side. CNA J and CNA K then removed the resident's soiled brief and provided perineal care (cleansing of the genitals and rectum). Staff did not wear an isolation gown while providing direct care to the resident. 4. During an interview on 4/24/25 at 9:19 A.M., LPN L and CNA G said staff should be wearing an isolation gown, mask, and gloves when providing care to the residents that have the EBP sign on their door. EBP is for residents that have dialysis, wounds, urinary catheters and central lines. Staff should be wearing EBP while providing care to Resident #195 and Resident #15. 5. Review of Resident #24's medical record, showed diagnoses included hemiplegia and hemiparesis following intracranial hemorrhage (bleeding in the brain), aphasia (inability to accurately form spoken words) following cerebral infarction (stroke), and high blood pressure. Review of the resident's active physician orders, showed: -Orders to cleanse the resident's right lower leg with soap and water, apply calcium alginate (a natural, absorbent dressing used for managing wounds with heavy drainage), and cover with bordered gauze once per day for the resident's wound; -Orders for EBP to be utilized due to the presence of a wound. Observation on 4/22/25 at 7:50 A.M. showed CNA M and CNA N entered Resident #24's room in order to transfer the resident from bed into his/her wheelchair via a Hoyer lift. Neither CNA donned a gown or gloves prior to providing care for the resident during the transfer. Neither CNA cleaned the mechanical lift after the resident had been safely transferred into his/her wheelchair. During interview on 4/24/25 at 8:53 A.M., CNA M said staff are expected to follow the EBP sign placed on resident doors when applicable based on the resident's treatment. CNA M said a gown and gloves are required for all direct care including emptying a urinary catheter, providing a bed bath, assisting with wound care, or transferring the resident. During interview on 4/24/25 at 10:18 A.M. LPN O said he/she had never really been in-serviced on EBP, but that it applies to direct care provided to residents with a wound, catheter, dialysis port, or similar open areas on the body. Staff should wear a gown and gloves when providing direct care to residents, including transfers. 6. During an interview on 4/24/25 at 11:27 A.M., the Administrator and the Director of Nursing (DON) said they would expect staff to follow the signs on the resident's door for EBP. Staff are expected to wear an isolation gown and gloves when providing direct care to the residents that meet the EBP criteria. 7. Review of the facility's TB Testing and Screening- Residents policy, dated 10/18/01, showed: -Residents will be screened for TB through use of the tuberculin skin test (TST), obtaining a chest x-ray, or through completion of the TB symptom screening/risk assessment; -Initial testing situations for TST: No TST result: Perform a two-step baseline TST; -Upon admission, when a TST is indicated, a nurse will administer the PPD intradermally (under the skin); -If a two-step is required and the first step TST result is negative, then the second step TST should be administer 1-3 weeks after the first step TST was read; -The results of all test should be read within 48-72 hours. 8. Review of Resident #80's medical record, showed: -admitted on [DATE]; -No two-step PPD available for review. 9. Review of Resident #195's medical record, showed: -admitted on [DATE]; -A first and second step PPD administer on the same day, on 2/20/25, and documented as read negative on the same day. 10. Review of Resident #1's medical record, showed: -admitted on [DATE]; -No two-step PPD available for review. 11. Review of Resident #84's medical record, showed: -admitted on [DATE]; -No two-step PPD available for review. 12. During an interview on 4/24/25 at 11:26 A.M., the Administrator and DON said nursing staff are responsible for resident admission PPDs. They would expect staff to follow the facility policy on resident PPDs. 42795 44948

46888 Based on observation, interview and record review, the facility failed to ensure residents receiving dialysis (medical procedure that filters blood when the kidneys are unable to) received breakfast before dialysis. The facility identified 11 residents as receiving dialysis. Of the 11, four were included in the sample of 20 and issues were identified with two residents (Residents #15 and #80). The census was 89. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/25, showed: -Cognitively intact; -Receives dialysis while a resident; -Diagnoses included type 2 diabetes and kidney failure. Review of the resident's Physician Order Sheet (POS), dated 4/21/25, showed an order, dated 2/13/25, in house dialysis Tuesday, Thursday and Saturday. During an interview on 4/22/25 at 12:23 P.M., the resident said he/she never gets breakfast before he/she goes to in-house dialysis and has to wait until dialysis is over to eat. He/She said by the time dialysis is over, he/she is starving. During observation and interview on 4/24/25 at 6:48 A.M., the resident sat in a recliner at the facility's dialysis center. The resident was connected to the dialysis machine. The resident said he/she did not receive breakfast prior to coming to dialysis. 2. Review of Resident #80's admission MDS, dated [DATE], showed: -Cognitively intact; -Receives dialysis while a resident; -Diagnoses included diabetes and kidney failure. Review of the resident's POS, dated 4/21/25, showed an order, dated 1/28/25, in house dialysis Tuesday, Thursday and Saturday. During an interview on 4/22/25 at 11:41 A.M., the resident said he/she never receives breakfast before he/she leaves for dialysis. He/She generally is taken to dialysis between 5:00 A.M. to 5:30 A.M. The resident would like to eat prior to dialysis because he/she is very hungry in the morning. During observation and interview on 4/24/25 at 6:15 A.M., the resident sat in a recliner at the facility's dialysis center. The resident was not connected to the dialysis machine. The resident said he/she did not receive breakfast prior to coming to dialysis. The resident said he/she was very hungry and wanted some pancakes. During an interview on 4/24/25 at 6:20 A.M., the Dialysis Center Registered Nurse (RN) V said the residents are not provided a breakfast meal prior to coming to dialysis and did not think the kitchen staff were in the building yet when the residents left for dialysis. Dialysis Center RN V also said dialysis residents are not allowed to eat during dialysis. During an interview on 4/24/25 at 7:15 A.M., Licensed Practical Nurse (LPN) W said there are no staff in the kitchen by the time the residents are sent to dialysis. Breakfast is never provided to the dialysis residents prior to their treatments. He/She thinks a meal should be provided prior to dialysis so the residents' blood sugars do not drop. The residents who have early morning dialysis should not have to wait until lunch to eat. During an interview on 4/24/25 at 9:50 A.M., the Dietary Manager said dietary staff do not come into work until around 6:00 A.M. Breakfast does not get cooked until them. Residents who go to dialysis in the morning should get breakfast. During an interview on 4/24/25 at 11:27 A.M., the Administrator said she expected the dietary staff to prepare breakfast for the residents who have early morning dialysis.

Based on interview and record review, the facility failed to ensure services provided met professional standards by not performing accurate and timely skin assessments for one resident, in accordance with the facility's policy (Resident #96). The sample size was 20. The census was 89. Review of the facility's Skin Program Policy and Procedure, revised, 1/15/25, showed: -Purpose: The purpose of the skin program is to ensure that every resident's skin condition is observed and evaluated on admission and comprehensive and interdisciplinary care plan is developed and maintained to treat actual and or prevent potential skin problems. -Policy: All residents are observed and evaluated upon admission and as needed for actual and/or potential skin problems. All residents will receive an individualized preventive skin plan of care at the time of admission. -Procedure: The nurse assesses and evaluates all residents upon admission; The initial skin observation and evaluation is a full body audit and completion of the Braden Scale (an assessment to determine if a resident is at risk for developing a pressure ulcer (a wound that occurs with prolonged pressure)); Residents admitted to the facility with skin areas and pressure ulcers will have treatment orders initiated upon admission and re-admission; The Director of Nursing (DON) or designee is to review all residents weekly with skin ulcers for condition of wound, treatment changes, and additional barriers to healing will be documented weekly using the Wound-Weekly Observation Tool in the electronic medical record and/or refer to the wound care specialist progress notes in the electronic medical record; Each resident will be assessed and evaluated a minimum of weekly by the Skin Observation Tool in the electronic medical record. Review of Resident #96's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/3/25, showed: -admitted , 2/27/25; -Cognitively intact; -Skin conditions: Is the resident at risk for developing a pressure ulcer?: Yes; Does the resident have a Stage 1 (skin is unbroken but red and inflamed) or higher unhealed pressure ulcer?: No. Review of the resident's medical record, showed: -discharge date , 3/28/25; -Diagnoses included muscle weakness, dementia, diabetes and help with personal care. Review of the resident's care plan, in use while the resident resided at the facility, showed: -Focus: The resident has a potential for skin impairment due to diabetes; -Interventions: Follow the facility's procedures and protocol for the prevention and treatment of skin breakdown. Review of the resident's Treatment Administration Record (TAR), dated 2/27/25 through 2/28/25 and 3/1 through 3/28/25, showed no order for skin assessments. Review of the resident's weekly skin observations, showed: -On 2/27/25 at 8:15 P.M., Pressure ulcer; Location not identified; Stage 2 (skin is broken on the top layers of skin only); Measurements: 2 centimeters (cm) length, 2 cm width, and 0.2 cm depth; -On 3/13/25 at 11:47 A.M., A newly identified pressure to the sacrum (tailbone area) 2 cm length and 2 cm width; -On 3/24/25 at 12:28 P.M., Pressure ulcer to coccyx (tailbone); Stage 3 (injury that extends down to the tissue under the skin): Appearance: slough (non-viable tissue that is yellow or tan in color) present; Measurements: length 1.6 cm, width 1.8 cm, depth 1.5 cm, moderate amount of serosanguinous (pink, clear) drainage, odor present. -No further skin assessments were available for review. During an interview on 4/22/25 at 12:47 P.M., the Wound Nurse said all residents get a weekly skin assessments completed by the floor nurse. It should be on the resident's TAR to be completed. The Wound Nurse said she did the first observation on admission and the resident had a Stage 2 pressure wound to his/her coccyx. The assessment on 3/13/25 was not accurate as the wound being newly identified. She expected staff to be timely on the weekly skin assessment since the resident had an open area on admission. During an interview on 4/24/25 at 11:27 A.M., the DON said she expected staff to complete accurate skin assessments weekly and as needed. The wound assessments are expected to be completed to ensure the wound is responding to the current treatment orders and to check for anything that has newly developed. MO00250419

46888 Based on observation, interview and record review, the facility failed to ensure dependent residents received activities of daily living (ADL) care (Residents #195, #194 and #58). The sample was 20. The census was 89. Review of the facility's personal care needs policy, dated 1/24, showed: -Protocol: the facility strives to promote a healthy environment and prevent infection by meeting the personal care needs of the residents. The facility also provides the needed support when the resident performs their ADLs. The Interdisciplinary Plan of Care (IPOC) will address the individual needs and preferences of the resident. Personal care and ADL support will be provided according to the resident Plan of Care. Personal care and support include but is not limited to the following: ambulation, assistance with meals, bath/shower, catheter care, denture care, grooming/dressing, mouth care, nail care, peri care, repositioning, shampoo, shaving, and toileting; -Procedure: develop and implement individualized interventions. Communicate interventions to the staff and provide training as needed. Document in the progress notes if an exception to the established plan of care occurs: refusals. 1. Review of Resident #195's medical record, showed: -admitted [DATE]; -Diagnoses included fournier gangrene (a type of necrotizing fasciitis or gangrene affecting the external genitalia or perineum), necrotizing fasciitis (a bacterial infection that destroys tissue under the skin), dependence on renal (kidney) dialysis (a medical procedure that cleanses the blood of its impurities), muscle weakness, obesity, assistance with personal care and hygiene. Review of the resident's baseline care plan, dated 2/20/25 showed the resident requires set up or clean up assistance with bathing, showering and shower transfers. Review of the Rehab Assignment Sheet, showed the resident's scheduled shower days as Monday and Thursday on the evening shift. Review of the resident's Comprehensive Certified Nursing Assistant (CNA) Shower Review sheets, showed: -On 4/3/25, the resident was in dialysis, signed by CNA and the Charge Nurse; -On 4/7/25, type of hygiene care provided by staff was not addressed, signed by CNA; -On 4/10/25, the resident received a bed bath, signed by CNA; -On 4/11/25, the resident received a bed bath, signed by the CNA and the Charge Nurse; -On 4/14/25, the resident received a bed bath, signed by the CNA; -On 4/17/25, the resident received a bed bath, signed by CNA; -No further shower sheets were provided. Review of the resident's progress notes, showed: -On 4/14/25 at 2:34 P.M., the resident is being sent to the hospital for right arm swelling; -On 4/20/25 at 3:51 P.M., the resident returned to the facility by ambulance. During observation and interview on 4/21/25 at 11:10 A.M., and 4/23/25 at 7:26 A.M., the resident said he/she had not had a shower the entire time he/she has been at the facility. He/She occasionally gets wiped down but never a shower. The resident had an unshaven face with approximately one half inch beard hair length and his/her face was oily. The resident's feet and legs had flakes of dry skin. The resident said he/she has lots of folds and crevices to his/her skin and gets yeast rashes. The resident said he/she needs a good shower. The resident said he/she sweats a lot and can smell him/herself. The resident thinks because of his/her size, the facility cannot accommodate him/her in the shower and he/she requires a Hoyer lift (a specialized machine used for resident transfers) for transfers. 2. Review of Resident #194's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/7/25, showed: -admitted [DATE]; -Cognitively intact; -Requires maximum assist from staff for bathing and showering. Review of the resident's medical record, showed diagnoses included end stage renal disease, dependence on renal dialysis, diabetes, absences of right and left leg below the knee. Review of the resident's care plan, in use at the time of survey, showed: -Focus: the resident has an ADL performance and/or mobility deficit related to amputations, balance impairment and chronic medical conditions; -Interventions: staff is to provide assistance with ADLs as needed or by the resident's request; ADL self performance and mobility may fluctuate due to medical conditions. Review of the Rehab Assignment Sheet, showed the resident's scheduled shower days as Tuesday and Friday on the day shift. Review of the resident's Comprehensive CNA Shower Review sheets, showed: -On 4/8/25, the type of hygiene care provide by staff was not addressed, signed by the CNA and Charge Nurse; -On 4/11/25, the type of hygiene care provide by staff was not addressed, signed by the CNA and Charge Nurse; -On 4/15/25, the resident received a bed bath, signed by the CNA and Charge Nurse; -On 4/18/25, the type of hygiene care provided by staff was not addressed, signed by the CNA; -On 4/22/25, the resident received a bed bath, signed by the CNA and Charge Nurse. During observation and interview on 4/21/25 at 10:55 A.M., the resident said he/she received one bed bath and no showers since he/she has been at the facility. The resident said his/her hair and beard is longer than he/she would like and is having his/her own barber come in and groom his/her beard and cut his/her hair. The resident said there is no reason that he /she cannot get in the shower. The resident shares a bathroom with a resident next door and the resident next door does not want Resident #194 to use the shower. The resident is told by facility staff that he/she has to use the shower room down the hall but they currently do not have any shower chairs with wheels. The resident does not want bed baths. He/She only wants showers. He/She has told staff that multiple times. Observation on 4/23/25 at 9:00 A.M., showed the Rehab Hall shower room had one shower chair with wheels. At 9:03 A.M., Fountain Hall had one shower chair with wheels. At 9:43 A.M., Complex Hall shower room had two shower chairs with wheels. During an interview on 4/23/25 at 6:21 A.M., the resident said staff came into his/her room on 4/22/25 and offered the resident a shower but the staff member never returned to give the resident a shower. During an interview on 4/24/25 at 6:40 A.M., the resident said he/she was incontinent of diarrhea the night before and his/her bottom smelled so bad that he/she stood up at the sink in the bathroom and cleaned his/her bottom him/herself. The resident said he/she needs to take a shower. During an interview on 4/24/25 at 8:37 A.M., CNA R said residents should get showers or bed baths twice a week. Shower sheets are filled out and are given to the nurse to sign once the shower is completed. Resident #195 would need to go the shower room down the hall to receive a shower due to his/her size. CNA R was not aware the resident was only receiving bed baths. The resident moves around well and could easily take a shower. The facility has always had a shower chair in the building. Staff should honor what the resident requests. 3. Review of Resident #58's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Personal hygiene: dependent on staff; -Shower/bathing: maximum assistance from staff; -Diagnoses included dementia and chronic obstructive pulmonary disease (COPD). Review of the resident's care plan, in use at the time of the survey, showed: -Focus: resident is at risk for ADL self-care performance deficit; -Goal: resident will maintain or improve current level of function through the review date; -Interventions: know that assistance with ADLs may vary. Assist with ADLs as needed. Encourage resident to discuss feelings about self-care deficit. Encourage resident to participate to the fullest extent possible with each interaction. Encourage resident to use bell to call for assistance. Monitor/document/report any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Review of the Rehab Assignment Sheet, showed the resident's scheduled shower days as Monday and Thursday on the day shift. Review of the resident's April shower sheets, showed: -On 4/14/25, the resident was given a bed bath; -On 4/17/25, the resident was given a bed bath. Observation on 4/21/25 at 11:32 A.M., showed the resident in his/her bed awake. The resident's hair was oily. The resident's nails had matter underneath. Observation on 4/21/25 at 12:42 P.M., showed the resident was seated on his/her bed. The tray table was up to the resident's shoulders. The resident was eating meat with his/her hands. The resident did not have cutlery. Observation on 4/22/25 at 7:20 A.M., showed the resident in his/her bed. The resident's hair was oily. The resident's nails had matter underneath. The resident's hands had caked on substance. Observation on 4/22/25 at 7:46 A.M., showed the resident seated on his/her bed. The resident did not have cutlery and ate cream of wheat with his/her hands. Observation on 4/23/25 at 6:28 A.M., showed the resident in his/her bed awake. The resident's hair was oily. The resident's nails had matter underneath. The resident's hands had caked on substance. 4. During an interview on 4/24/25 at 9:19 A.M., Licensed Practical Nurse (LPN) L said the residents' showers or bed baths are to be provided twice a week. That includes shaving and nail care. Dialysis residents can get showers. The dialysis ports just need to be covered with plastic. The CNA and the Charge Nurse are required to sign the shower sheets when the task is completed. If the resident refuses bathing or showering, staff should have another staff member, or the Charge Nurse reapproach the resident and offer the shower again. If a resident continues to refuse, then the resident should sign the shower sheet that they refused. Residents' hands should be cleaned after meals. Staff should assist residents with opening up silverware and ensure meals are set up on the side tables so residents can reach their plates. 5. During an interview on 4/24/25 at 11:27 A.M., the Administrator and the Director of Nursing said they expected staff to provide showers or bed baths twice a week. The CNA is expected to fill out the shower sheets clearly and accurately. When the bath or shower is complete, the CNA is expected to have the Charge Nurse sign it. Nail care and shaving is expected to be provided with the residents' bath or shower. Staff are expected to honor the resident's request for a shower instead of a bed bath. Staff are expected to wash resident's hands after meals. Staff are expected to set up resident meals and ensure residents have cutlery to use. M00250419

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than 5%. Out of 27 opportunities observed, four errors occurred, resulting in a 14.81% error rate (Resident #44 and Resident #58). The census was 89. Review of the facility's Medication Administration policy, reviewed January 2024, showed: -Purpose: -To administer the following: -Right medication; -Right dose; -Right dosage form; -Right route; -Right resident; -Right time; -Procedure: -Read the Medication Administration Record (MAR) for the ordered medication, dose, dosage form, route, and time; -Review the resident's allergies; -Verify the pharmacy prescription on the drug and the manufacturer's identification system matches the MAR; -Verify that any further medication identifiers match the label and the medication; Identifiers may include, but are not limited to -Drug size; -Shape; -Color. -Verify the correction medications , expiration date, dose, dosage form, route and time again by comparing to MAR before administering; -Administer oral medications with a full glass of water unless otherwise ordered; -Remain with the resident until all medication is taken. 1. Review of Resident #44's medical record, showed his/her diagnoses included chronic pain, neuropathy (pain and numbness to the extremities), dementia, muscle weakness and chronic kidney disease. Review of the resident's Physician Order Sheets (POS), dated 4/22/25, showed: -An order dated 12/9/24, gabapentin (medication to treat neuropathy) 300 milligrams (mgs), give two capsules, twice a day; -An order dated 12/3/24, Cholecalciferol (Vitamin D) 1000 units, give one tablet, once a day; -An order dated 12/3/24, Cyanocobalamin (Vitamin B12) 100 micrograms (mcgs), give one tablet, once a day. Observation on 4/22/25 at 8:13 A.M., showed Certified Medication Technician (CMT) T prepared the resident's medication at the medication cart. CMT T entered the resident's room and set the cup of oral medication on the resident's bedside table and left the room. CMT T administered only one cap of gabapentin. CMT T did not administer Cholecalciferol and Cyanocobalamin. 2. Review of Resident #58's medical record, showed his/her diagnoses included high blood pressure, dementia and heart disease. Review of the resident's POS, dated 4/22/25, showed an order, dated 12/20/23, hydralazine (medication used to treat high blood pressure), give 100 mg by mouth, one time a day. Observation on 4/22/24 at 8:24 A.M., showed CMT T prepared the resident's medication at the medication cart. CMT T removed one tablet from a medication card containing hydralazine 50 mg with instructions to give 2 tablets. CMT T crushed the resident's medication and mixed it with applesauce. CMT entered the resident's room and administered the medication to the resident. CMT T administered only one of the hydralazine 50 mg tablets. During an interview on 4/24/25 at 9:15 A.M., CMT U said medications should be given as directed by the physician orders. All medication should be doubled checked by following the six rights of medication administration. The medication card should be compared to the physician orders on the MAR. There are stickers provided by pharmacy that staff can place on the medication card with additional instructions to ensure the correct dose is given. 3. During an interview on 4/24/25 at 11:27 A.M., the Administrator and the Director of Nurses said they expected staff to follow the physician orders accurately and completely when administering the residents' medications.

Based on observation, interview and record review, the facility failed to ensure food was served at a palatable, safe, and appetizing temperature during tray service by failing to maintain the temperature of hot food at least at 120 degrees Fahrenheit (F). This affected 2 of 20 sampled residents (Residents #15 and #34). The census was 89. Review of the facility's meal service temperature policy, dated 1/2019, showed: -Purpose: to ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service; -Policy: foods shall be provided at point of service to support resident/patient satisfaction. Temperatures of hot food shall be supported to promote service temperatures of hot foods to about 120 degrees F and cold foods to below 50 degrees F. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/25, showed: -Cognitively intact; -Receives dialysis while a resident; -Diagnoses included type 2 diabetes and kidney failure. During an interview on 4/21/25 at 11:07 A.M., the resident said sometimes food is delivered cold. 2. Review of Resident #15's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included type 2 diabetes and muscle weakness, During an interview on 4/21/25 at 11:58 A.M., the resident said food is often served too cold. 3. Observation on 4/22/25 at 12:52 P.M., of lunch trays on the 200 hallway, showed: -Chicken measured at 108.1 degrees F and was lukewarm; -Potato casserole measured at 105 degrees F and was lukewarm. 4. During an interview on 4/24/25 at 9:39 A.M., Dietary Aide E said food should be delivered at a safe and palatable temperature. 5. During an interview on 4/24/25 at 9:42 A.M., the Dietary Manager said food should be delivered at a safe and palatable temperature to prevent illness. If food is too cold, staff should reheat the food. He said temperature logs were not completed once the room trays left the kitchen. 6. During an interview on 4/24/25 at 12:01 P.M., the Administrator said food should be delivered at a safe and palatable temperature. She expected staff to check to ensure the food is at a safe and palatable temperature before delivering it to the residents. 7. During an interview on 5/1/25 at 12:21 P.M., the Administrator said temperature logs for the room trays were not completed by staff, after the trays left the kitchen. She expected staff to check to ensure the food is at a safe and palatable temperature before delivering it to the residents.

Based on observation, interview and record review the facility failed to follow acceptable nursing practice when the facility's staff left medication in two residents' room (Resident #194 and Resident #44), who did not have a physician order for self-administration or medications to be left at the bedside. The sample was 20. The census was 89. Review of the facility's Bedside Medication Storage policy, revised January 2018, showed: -Policy: Bedside medication storage is permitted for residents wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team; -Procedures: A written order for the bedside storage of medications is present in the resident's medical record; Bedside storage of medications in indicated on the resident Medication Administration Record (MAR) and in the care plan for the appropriate medications; The resident is instructed in the proper use of bedside medications; The nursing staff checks for usage of the medications by the resident; All nurses and aides are required to report to the Charge Nurse on duty any medications found on the bedside not authorized for bedside storage. Review of the facility's Medication Administration policy, reviewed January 2024, showed staff is to remain with the resident until all medication is taken. 1. Review of Resident #194's admission Minimum Data Set, (MDS),a federally mandated assessment instrument completed by facility staff, dated 4/7/25, showed: -Cognitively intact; -Diagnoses include diabetes, high blood pressure, kidney failure and atrial fibrillation (an irregular heartbeat). Review of the resident's care plan did not address if the resident is identified as being able to self-administer medications or medications can be left at the resident's bedside. Review of the resident's medical record, showed: -No self-administration of medication assessment completed. Review of the resident's Physician Order Sheet (POS), dated 4/21/25, showed; -No order the resident can self-administer medications; -No order for any medication to be left at the bedside; Observation and interview on 4/23/25 at 6:21 A.M., showed the resident lay in bed. Next to the bed was the resident's bedside table that had a clear medicine cup with 2 large round white pills, one white capsule, one half of a white tablet, and a small white round tablet. The resident said the medications were his/her 4/22/25 evening medications. The resident thought he/she took them but must have fallen asleep. The resident said staff leave medications at his/her bedside all the time. This will happen even when the resident is sleeping. During an interview on 4/23/25 at 6:40 A.M., Licensed Practical Nurse (LPN) W said the resident did not receive any morning medications and the medication in the medicine cup was from 4/22/25. The resident did not have an order to self-administer his/her own medications or for medications to be left at bedside. 2. Review of Resident #44's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included anemia (blood that is low in iron), heart disease, high blood pressure, kidney failure, seizure disorder, anxiety, major depressive disorder (a mood disorder) and depression. Review of the resident's care plan did not address if the resident is identified as being able to self-administer medications or medications can be left at the resident's bedside. Review of the resident's medical record showed: -No self-administration of medication assessment completed. Review of the resident's POS, dated 4/21/25, showed; -No order the resident can self-administer medications; -No order for any medication to be left at the bedside; -An order, dated, 4/21/25, azithromycin 250 milligrams (mgs) (antibiotic), give two tablets, daily; -An order, dated, 12/3/24, Zofran (medication to treat nausea) 4 mg, give one tablet every 6 hours as needed; -An order, dated, 12/3/24, aspirin 81 mg, give one tablet daily; -An order, dated, 12/3/24, cetirizine 10 mg, (medication used to treat allergy symptoms) give one tablet daily; -An order, dated, 12/3/24, pramipexole 0.125 mg (medication used to treat restless legs), give one tablet daily; -An order, dated, 2/17/25, duloxetine 30 mg (medication used to treat depression) give one tablet, twice daily; -An order, dated, 12/3/24, buspirone 10 mg (medication used to treat major depressive disorder), give one tablet, twice daily; -An order, dated, 12/9/24, gabapentin 300 mg (medication used to treat nerve pain) give two capsules, twice a day; -An order, dated, 4/21/25, guaifenesin 600 mg (cough medicine), give 2 tablets, every twelve hours; -An order, dated, 12/3/24, levetiracetam 750 mg (medication used to prevent seizures), give one tablet, every twelve hours; -An order, dated, 2/3/25, metoprolol tartrate 75 mg (medication used to treat high blood pressure), give one tablet, twice a day; -An order, dated, 12/3/24, lorazepam 0.5 mg, (medication used to treat anxiety), give one tablet, twice a day; -An order, dated, 12/9/25, ferrous sulfate 325 mg, (a supplement used to treat anemia), give one tablet, daily. -An order, dated, 12/4/25, allopurinol 100 mg, (a medication used to treat inflammation of the joints), give one tablet, daily; -An order, dated, 12/3/24, magnesium oxide 400 mg (a supplement), give one tablet, daily. Observation on 4/22/25 at 8:13 A.M., showed Certified Medication Technician (CMT) T prepared the resident's medication at the medication cart, including azithromycin, Zofran, aspirin, cetirizine, pramipexole, duloxetine, buspirone, gabapentin, guaifenesin, levetiracetam, metoprolol tartrate, lorazepam, ferrous sulfate, allopurinol, and magnesium oxide. CMT T entered the resident's room and set the cup of oral medication on the resident's bedside table and left the room. CMT T did not observe the resident take his/her medication. CMT T only administered only one capsule of gabapentin. During an interview on 4/23/25 at 6:40 A.M., LPN W said when medications are administered to the resident, the staff member is required to watch the resident take all their medication. Medications should not be left in the resident's room to take later. There is an assessment that is completed by the nurses to determine if the resident can safely take their own medications. There should be physician orders for the medications to left at bedside and the resident can self-administer. During an interview on 4/23/25 at 9:15 A.M., CMT S said there are no residents in the building who self-administer their own medication. It is required to have a physician order to leave medications at bedside and for residents to self-administer. The staff member administering the medication should watch the resident take their medications in case they choke on it or they don't throw it away. 3. During an interview on 4/24/25 at 11:27 A.M., the Director of Nursing said she expected staff to watch the resident take all of their medication and not leave it for the resident to take later. She expected the appropriate assessment to be completed for residents who desire to self-administer. There are no residents in the building who self-administer their own medications.

Based on observation, interview and record review the facility failed to ensure call lights were accessible for two residents (Residents #15 and #58). The sample was 20. The census was 89. Review of the facility's call light protocol policy, dated 1/2022, showed: -Purpose: to respond to resident/patient's request and needs; -Procedure: answer call light in a reasonable amount of time. Respond to request. When unable to meet request, obtain assistance from caregiver that can meet request. Assist resident/patient as needed to a comfortable position with call light within reach. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/25, showed: -Cognitively intact; -Diagnoses included type 2 diabetes, kidney failure, and hemiplegia (muscle weakness) and hemiparesis(partial paralysis) following cerebral infarction(stroke) affecting left non-dominant side. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: the resident has left side hemiplegia; -Goal: the resident will maintain optimal status and quality of life within limitations imposed by hemiplegia/hemiparesis through review date; -Interventions: educate the resident to use scanning (move eyes across affected side) to prevent neglect/injury to affected side. Give medications as ordered. Monitor/document for side effects and effectiveness. Observation on 4/22/25 at 11:13 A.M., showed the resident in his/her room seated in his/her wheelchair. The resident was awake. The resident's call light was out of reach. During an interview on 4/22/25 at 11:27 A.M., the resident said his/her call light is not always in his/her reach. He/She said staff will put his/her call bell on his/her paralyzed side. He/She has been waiting to be put in bed. He/She has been in a chair all day at dialysis (medical procedure that filters blood) and said his/her bottom hurt. Observation on 4/22/25 at 11:47 A.M., showed Certified Nursing Assistant (CNA) J walked into the resident's room to assist the resident after the resident called out when he/she walked by the resident's room. 2. Review of Resident #58's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included dementia and chronic obstructive pulmonary disease (COPD, an ongoing lung condition caused by damage to the lungs). Review of the resident's care plan, in use at the time of the survey, showed: -Focus: resident is at risk for activities of daily living (ADL) self-care performance deficit; -Goal: resident will maintain or improve current level of function through the review date; -Interventions: encourage resident to use call bell for assistance. Observation on 4/21/25, showed: -At 11:31 A.M., the resident lay in bed, awake. His/Her call light was on the ground out of reach. The resident said he/she was thirsty and hungry; -At 12:42 P.M., an unidentified nursing staff walked into the resident's room to deliver his/her lunch. He/She put the resident's call light in reach before leaving the room. Observation on 4/22/25, showed: -At 8:21 A.M., Certified Medication Technician (CMT) T was in the resident's room, taking resident's blood pressure. The resident's call light was on the ground out of reach; -At 8:22 A.M., CMT T walked out of the room and back to medication cart to document the blood pressure reading and to get the resident's medication. He/She walked back into the room and administered the resident's medication and walked back out to the medication cart; -At 8:33 A.M., CMT T went into resident's room and closed the door to provide care; -At 8:35 A.M., CMT T walked out of resident's room, leaving the door open. The resident's call light was on the ground, out of reach; -At 8:40 A.M., CNA J walked past the resident's room, peering into the resident's room; -At 9:01 A.M., the resident's call light was still on the ground and out of reach. The resident was awake in his/her bed, struggling to reposition himself/herself; -At 9:11 A.M., CNA K walked into room and gave the resident his/her call light and repositioned the resident. During an interview on 4/24/25 at 9:36 A.M., CNA G said call lights should be in reach of the resident. Staff should ensure call lights are in reach of residents before leaving the resident's room. If a resident has paralysis, staff should ensure the resident's call light is in reach of the resident's dominant side. During an interview on 4/24/25 at 12:01 P.M., the Administrator and Director of Nursing (DON) said the call light should be in reach of the resident. Staff should ensure call lights are in reach of residents before leaving the resident's room. If a resident has paralysis, staff should ensure the resident's call light is in reach of the resident's dominant side.

Based on observation, interview and record review, the facility failed to make accessible for examination, the results of the most recent survey, certifications, and complaint investigations of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility available to residents, visitors, and resident representatives. The sample was 20. The census was 89. Review of the facility's Resident [NAME] of Rights, showed the facility shall retain and make available for public inspection at the facility to facility personnel, residents, their families or legal representatives and the general public, a list of names, addresses and occupations of all individuals who have a property interest in the facility as well as a complete copy of each official notification from the division of aging of violations, deficiencies, licensure approval, disapprovals, or a combination of these, and responses. This includes, as a minimum, statements of deficiencies, copies of plans of correction, acceptance or rejection notice regarding the plans of correction and revisit inspection reports. Observation on 4/23/25 at 10:29 A.M., of the two survey binders, located in the front entrance, showed: -The most recent annual survey statement of deficiencies (SOD) dated 10/13/23 with no corresponding plan of correction (POC); -The interim inspection SOD dated 2/20/24 with no corresponding POC; -The interim inspection SOD dated 7/23/24 with no corresponding POC; -No SOD or POC for the interim inspection completed on 10/21/24; -The interim inspection SOD dated 12/3/24 with no corresponding POC. During an interview on 4/23/25 at 1:52 P.M., with nine residents who represent the resident council, one resident said he/she was aware of the location of the survey results binder. All other residents said they were not sure where they would look to review the survey results from the prior annual survey and interim inspections. During an interview on 4/24/25 at 11:26 A.M., the Administrator said she would expect the statement of deficiencies and plans of correction from the prior survey, to include any interim inspections completed in that time frame, to be available to the residents.

See deficiency cited at Event ID #172413 Based on interview and record review, staff failed to implement a system to ensure facility staff communicated a report on residents' conditions to agency staff prior to their shifts and failed to direct agency staff where to find the binder containing instructions on residents' care needs. The facility failed to ensure one resident's (Resident #18) care plan instructions for staff reflected the resident's assessed needs, including use of mechanical lift for transfers. On 12/17/24 around 12:00 P.M., an unknown nurse directed Certified Nurse Aide (CNA) C to transfer the resident from his/her bed without communication of the resident's need for mechanical lift transfer. CNA C utilized a gait belt, instead of using a Hoyer lift (mechanical lift). The resident fell during the transfer and sustained fractures to his/her ribs, legs, and left ankle. The resident's physician said staff failed to notify him/her of the incident until later in the evening. EMS did not transfer the resident to the hospital until 10:08 P.M. and reported the resident was hard to arouse. Additionally, the facility failed to appropriately respond to a resident's (Resident #17) change of condition and failed to contact the resident's physician. The resident had multiple falls between 12/6/24 and 12/10/24. The sample was 2. The census was 96.

Based on interview and record review, staff failed to implement a system to ensure facility staff communicated a report on residents' conditions to agency staff prior to their shifts and failed to direct agency staff where to find the binder containing instructions on residents' care needs. The facility failed to ensure one resident's (Resident #18) care plan instructions for staff reflected the resident's assessed needs, including use of mechanical lift for transfers. On 12/17/24 around 12:00 P.M., an unknown nurse directed Certified Nurse Aide (CNA) C to transfer the resident from his/her bed without communication of the resident's need for mechanical lift transfer. CNA C utilized a gait belt, instead of using a Hoyer lift (mechanical lift). The resident fell during the transfer and sustained fractures to his/her ribs, legs, and left ankle. The resident's physician said staff failed to notify him/her of the incident until later in the evening. EMS did not transfer the resident to the hospital until 10:08 P.M. and reported the resident was hard to arouse. Additionally, the facility failed to appropriately respond to a resident's (Resident #17) change of condition and failed to contact the resident's physician. The resident had multiple falls between 12/6/24 and 12/10/24. The sample was 2. The census was 96. The Administrator was notified on 1/14/25 at 5:32 P.M., of an immediate jeopardy (IJ) which began on 12/17/24. The IJ was removed on 1/16/25 as confirmed by surveyor on-site verification. Review of the facility's Change in Condition and When to Notify the Physician policy (undated), showed: -Purpose: To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a resident's condition; -When there is a change in condition, the physician must be notified. Below are examples of what is considered a change in condition: -Altered mental status: Includes sudden change in mental status or loss of consciousness; -Edema: Abrupt onset or increased amount; -Falls: All falls; -Nurses must assess residents frequently for change in condition. If a change is observed, check vital signs and note anything different with the resident. Relay the information to the physician.; -Make sure to document physician called, signs and symptoms observed, family notification and all interventions taken. Review of the facility's Fall programs policy and procedure, reviewed 1/2023, showed: -Purpose: To identify all resident who have a high risk for falls and to ensure adequate interventions are in place to prevent major injury; -Policy: An investigation of all falls will be completed by the Director of Nursing (DON)/designee and submitted to the interdisciplinary team (IDT) committee for review; -Fall risk evaluation (UDA) will be completed on every resident upon admission/re-admission by the nurse on shift the resident is admitted on ; -When a resident is identified as being at a high risk for falls, this will be identified on the baseline care plan upon admission and the fall intervention notes on the [NAME] (gives a brief overview of each resident); -When a resident within the facility falls, the nurse will assess/evaluate the resident and document in the electronic medical record. Neuro checks will be initiated for all un-witnessed falls, residents who hit their head. 1. Review of Resident #18's PT Discharge summary, dated [DATE], showed: -Total assistance/Hoyer (mechanical transfer) on 6/6/23, resident refused on 6/19/23, and unable to complete on 6/29/23; -Instructed nursing caregivers in positioning maneuvers and safety precautions. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/17/24, showed: -admitted [DATE]; -Moderate cognitive impairment; -Diagnoses included stroke, major depressive disorder and repeated falls; -Upper and lower extremity impairment on one side; -Substantial to maximum assistance with mobility; -Transfers: Dependent on staff for lying to sitting on the side of the bed. Sit to stand not attempted due to medical condition or safety concerns; -No falls since admission. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident had an activities of daily living (ADL) self-care performance deficit due to activity intolerance; -Interventions: The resident required extensive assistance by one staff to turn and reposition in bed and move between surfaces; -Focus: The resident was at risk for falls due to deconditioning, stroke, and right-side weakness; -Interventions: Anticipate and meet the resident's needs. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; -The care plan did not instruct staff to utilize the Hoyer lift for transfers. Review of the resident's progress notes, showed: -On 12/9/24 at 7:12 P.M., resident seen by physician for chronic pain. New order for tramadol (used for short term relief of chronic pain) 50 milligram (mg), twice daily (BID) given; -On 12/17/24 at 5:30 P.M., staff monitored the resident for pain to ankle. He/She complained of pain to ankle this morning. At 8:40 P.M., the resident said his/her ankle was hurting. He/She was being assisted from bed and heard a pop. Oncoming nurse notified. At 8:56 P.M., the nurse received report the CNA on day shift attempted to transfer the resident and heard a pop. The resident had been in severe pain in bilateral lower extremities. The areas were painful to touch, and right leg appeared swollen. He/She complained of pain to left leg, but no bruising present in either extremities. The resident rated pain ten out of ten. Resident's physician notified of events. He/She gave orders to increase tramadol 50 mg BID to 100 mg BID and obtain three view x-ray of right ankle to rule out fracture/dislocation. X-ray technician said he/she would come out on 12/18/24. The resident remained in bed. His/Her vitals were stable with no acute distress noted. At 9:40 P.M., order received from physician to send resident to hospital. The resident responded to painful stimuli but did not answer questions. Resident transported to hospital by Emergency Medical Services (EMS). Review of the resident's EMS report, dated 12/17/24, showed: -At 10:08 P.M., EMS responded to the facility for a resident with an altered mental status. The resident was laying in his/her bed. Staff said the resident heard a loud pop during a transfer earlier in the day. He/She had been lethargic since. The resident was lethargic and hard to arouse. The resident was very large and an additional EMS personnel were called to transfer resident from bed. The resident was given oxygen. He/She became hypotensive (having low blood pressure) during transport to hospital. At 10:43 P.M., the resident's blood pressure was 58/33. Review of the resident's hospital records, showed -admitted on [DATE] at 10:46 P.M.; -According to EMS, the resident had a history of stroke, alert and oriented times three and almost completely bedbound; -The resident was given vasopressor (used to treat low blood pressure shock); -The resident said he/she fell. He/She could not remember what happened before or after the fall; -Right and left lower extremity range of motion decreased due to pain; -X-rays revealed both femurs (thigh bones) were fractured in the wider part, near the middle of the bone. The bone was broken in multiple pieces due to significant trauma. Fractures of the distal left tibia and fibula (break in the lower leg bone which requires immediate medical attention. Usually caused by a fall or hard blow to the leg, or sudden twist of the leg). Fracture of left calcaneal (heel bone), bruise on right thigh and rib fractures of the left first rib, right third, fifth and sixth ribs; -The resident had brittle bones; -The resident was admitted to the intensive care unit until blood pressure stabilized. Review of the facility's investigation dated 12/20/24, showed: -On 12/17/24 at approximately 12:00 P.M., agency CNA C reported he/she went into the resident's room to provide incontinence care. He/She changed the resident and cleaned him/her up. CNA C put the gait belt on the resident and sat him/her up on the side of the bed. The wheelchair was adjacent to the bed. CNA C told the resident he/she was going to stand him/her up. The resident said okay. They stood for a split second and CNA C heard a pop from down below. He/She thought it was the resident's knee or ankle. CNA C helped the resident back into bed with the gait belt; -The resident was transferred to the hospital later in the evening; -The resident was diagnosed with multiple bone fractures; -Nursing staff was in-serviced on safe transfers; -No documented conclusion to the investigation. During an interview on 1/10/25 at 12:00 P.M., CNA C said the nurse (he/she didn't know the nurse's name) told him/her to get the resident out of bed on 12/17/24. The nurse said the resident was going to say he/she could not walk or stand, but get him/her up anyway. The nurse did not provide the agency CNA with instruction on the appropriate method to transfer the resident. CNA C entered the resident's room around 12:00 P.M. The resident said he/she did not get out of bed. He/She did not want to get up. CNA C told the resident the nurse said he/she had to get up. CNA C lowered the resident's bed then put the wheelchair next to it. He/She used the gait belt to sit the resident up on the side of the bed. The resident stood up and said Oh. CNA C heard a pop and used the gait belt to sling the resident back on the bed. CNA C retrieved a Hoyer pad and was going to get help to transfer the resident. The resident did not want to be transferred. He/She was complaining of pain in his/her legs. CNA C went to get the nurse. The Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) F assessed the resident's legs. They said they would wait and see how it looked later. CNA C was transferred to another hall. The nurse did not tell CNA C if the resident was a one or two person assist. CNA C did not ask anyone how the resident should be transferred. Agency staff are supposed to get report from the Charge Nurse at the start of their shift. Sometimes the facility is short staffed, and they do not give report. He/She did not get report on the day of the incident. LPN F asked the resident why he/she did not tell CNA C he/she was a Hoyer lift transfer. The resident's legs buckled when he/she stood up. CNA C grabbed the resident with the gait belt, quickly. The resident's legs did not look out of place. CNA C did not know about the binder at the nurse's station. During an interview on 1/9/25 at 2:27 P.M., LPN A said he/she was assisting another resident when CNA C told him/her he/she was transferring the resident and heard a pop. The resident was complaining of pain. He/She told CNA C to ask the ADON to assist him/her. The ADON and LPN F said the resident did not need x-rays. They instructed the Certified Medication Technician (CMT) to give the resident pain medication. The ADON and LPN F said they notified the physician. LPN A assessed the resident. He/She is not sure what time he/she assessed the resident. During shift change, the evening nurse and LPN A assessed the resident for pain. He/She complained of pain in his/her left and right ankle. His/Her pain was a ten. The oncoming nurse contacted the physician. The physician increased the resident's tramadol to 100 mg and ordered an x-ray. The x-ray technician could not come out until the following day. The physician gave an order to send the resident to the hospital. He/She was bedbound. The resident was a two person assist with a Hoyer lift. During an interview on 1/10/25 at 11:11 P.M., the ADON said CNA C said he/she sat the resident up on the side of the bed. When the resident stood up, CNA C heard a pop. The resident complained of pain in his/her right ankle. When the ADON entered the resident's room, the resident was laying in bed and LPN F was assessing his/her right ankle. He/She had range of motion (ROM) in his/her right ankle. The ADON left the room to get the charge nurse. She is not sure if the physician was notified immediately after the incident. She is certain he was contacted later in the evening. The physician ordered an x-ray. She thinks the resident was a two person assist with a Hoyer lift. She did not see a Hoyer lift in the resident's room when she entered. She remembered seeing a gait belt on the bed or in CNA C's hand. She is not sure if the resident could bear weight prior to this incident. Agency staff are supposed to get report prior to shift change. Review of the binder containing care instructions for residents, dated 1/14/25, showed for Resident #18: -Transfer: The resident required extensive assist by 1 staff to move between surfaces. Upon return from hospital, use mechanical lift and two staff assist (updated 12/19/24). During an interview on 1/10/25 at 12:55 P.M., LPN F said he/she was stopped in the hall by CNA C. He/She entered the resident's room and the resident was laying in the bed. The resident complained of pain in his/her right ankle. He/She had ROM in his/her right ankle. The CNA attempted to transfer the resident by him/herself. LPN F did not ask the resident if he/she fell. He/She cannot remember if the resident was a one or two person assist. He/She did not remember seeing a gait belt or Hoyer lift in the resident's room. He/She does not remember if the resident's physician was notified. The nurse assigned to the resident would have been responsible for notifying the physician. The facility used agency staff often. Agency staff were supposed to view the binder at the nurse's station. The binder contained information about the residents. There was not a system in place to verify if they reviewed the binder. During an interview on 1/10/25 at 1:33 P.M., the resident's physician said staff notified him of the incident later in the evening. He/She gave an order to increase pain medication to 100 mg and obtain an x-ray. Staff said the resident was still complaining of pain and he/she told them to send the resident to the hospital. He/She is not sure what time staff contacted him/her. He/She tried to figure out severity based on the report from the staff. Staff said the resident was in pain. He/She was not aware of the severity of the injuries. He/She did not think a simple fall would cause the resident's injuries. The gait belt could have caused the rib fractures. Maybe he/she fell, twisted his/her legs, causing the femur fractures. The resident's injuries are not consistent with the CNA's story. He/She expected staff to give him a thorough report. The resident was bedbound and he/she did not know why they got him/her up. During an interview on 1/13/25 at 9:51 A.M., the Staffing Coordinator said CNA C was sent to another hall, because someone was sick and had to leave. Agency staff are supposed to get report from the Charge Nurse at the start of their shift. She does not know if they receive any training. During an interview on 1/13/25 at 10:23 A.M., the DON said agency staff are supposed to get a verbal report from the Charge Nurse about their assignments. There is a binder at each nurse's station with the residents' [NAME], which includes the residents' ADL needs. It is updated as needed or with a change of condition. There is not a system in place to ensure agency staff are getting report and reviewing the binder. During an interview on 1/13/25 at 1:04 P.M., the Administrator and ADON said the fractures occurred when CNA C attempted to transfer the resident. The resident stayed in bed most of the time. Agency staff should get report prior to their shift. 2. Review of Resident #17's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included rectal cancer, cirrhosis of the liver, depression and muscle weakness; -History of falls; -No falls in two-six months prior to admission; -Independent with transfers; -Supervision with personal hygiene and toileting; -Partial to moderate assistance with showers; -He/She used a walker. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: The resident had an ADL self-care performance deficit due to impaired mobility, weakness, chronic health conditions. He/She was often non-compliant with asking for assistance prior to moving about; -Interventions: Staff discussed with resident/family/power of attorney any concerns related to loss of independence, decline in function. Encouraged the resident to discuss feelings about self-care deficit. Encouraged the resident to participate to with each interaction. Encouraged the resident to use call light for assistance. Monitored/documented/reported as needed (PRN) any changes, potential for improvement, reasons for self-care deficit, expected course, and declines in function; -Focus: The resident is at risk for falls due to cirrhosis, cancer, non-compliance, incontinence with generalized weakness, impulsivity, and impaired safety awareness; -Interventions: Resident educated on proper use of call light for assistance. Resident educated on rising slowly and using grab bars when transitioning from sitting to standing. Educated the resident/family/caregivers about safety reminders and what to do if fall occurred. Reviewed information on past falls and attempted to determine cause of falls. Recorded possible root causes. Altered/removed any potential causes if possible. Review of the resident's post fall evaluation, dated 12/6/24, showed: -Fall details: The fall occurred on 12/06/2024 at 5:30 A.M. in the resident's bathroom. The fall was unwitnessed. The resident was in a hurry to grab something to get back on the toilet. The resident had a skin tear and said his/her head hurt. The resident's physician notified on 12/6/24; -Contributing Factors: The lighting was poor and there was fluid spilled on floor. He/She was not using cane/walker as instructed; -Vitals: Temperature 97.9, blood pressure 118/71, pulse 80, respirations 18; -Pain: The resident complained of head pain. Pain indicated via facial expressions and non-verbal sounds. Pain level was an eight out of ten. Review of the resident's progress notes, showed: -On 12/6/24 at 8:38 A.M., the resident fell in his/her bathroom. He/She had a skin tear to left front knee with head injury and pain to left side of head. Family notified. At 9:43 A.M., the resident refused vital signs. He/She said he/she was fine. He/She denied pain to head and/or knee. Skin tear cleansed and dressing applied. His/Her knee was slightly swollen. No shortening noted. He/She was able to move his/her knee without discomfort; -On 12/7/24 at 6:00 A.M., the resident was continued on incident follow up (IFU). His/Her vital signs were stable and strong at baseline. He/She was neurologically alert and oriented. He/She was educated to ask for help when moving around; -On 12/8/24 at 6:08 P.M., the resident was on IFU following a fall. He/She fell to left side had a skin tear to his/her left knee. He/She denied pain. Discoloration noted to area near left eye. He/She said it happened a while ago; -On 12/9/24 at 10:37 A.M., the resident denied pain and discomfort related to fall. The resident was assessed. Both eyes were black in color. Neuro checks and hand grips were equal. He/She continued to be on the toilet. At 12:57 P.M., the resident refused peri care and clothes change. At 3:13 P.M., staff assisted the resident to bed. He/She remained in bed for 45 minutes, then got up and sat on the toilet all shift; -On 12/10/24 at 5:20 A.M., resident on IFU due to fall. Both eyes were almost swollen shut. He/She denied pain. Neuro checks were within normal limits. His/Her vitals were temperature 97.5, pulse 72, respirations 16, blood pressure 110/68. At 10:04 A.M., the resident was seated on the floor in his/her room. He/She said he/she was seeing dogs and cats. He/She was assisted to stand and sit in chair. He/She demanded to use the bathroom. Two staff assisted the resident to the toilet. He/She was weak and confused/delusional due to falls. Both eyes were swollen shut. He/She needed assistance of two staff to stand up. The resident's physician and family were notified. At 12:55 P.M., the resident was assessed after morning meeting for facial swelling. He/She was on the floor in his/her room. He/She said he/she was tripped by the dogs or cats running around in his/her room. CNAs assisted the resident off the floor. He/She fell two more times within ten minutes. His/Her facial and leg swelling were noticeable. He/She often sat on the toilet with his/her head between his/her legs. Staff called 911. Review of the resident's EMS report, dated 12/10/24 at 10:12 A.M., showed: On arrival, staff said the resident had multiple falls over the last week. He/She had increased weakness the last few days. The resident was usually up walking around. He/She was not able to walk the last four to five days. Staff noticed his/her eyes swollen shut this morning. The resident complained of pain in his/her face, neck, genitals, and leg. He/She was transported to the hospital. EMS personnel observed the resident on the toilet in his/her room. He/She complained of pain all over. He/She said he/she had fallen and hit his/her head multiple times. He/She was weak the last three days. EMS personnel observed major facial swelling and bruising in multiple stages on his/her face. His/Her eyes were swollen shut. The resident said he/she had been unable to see for two days. A mass the size of a golf ball protruded from his/her abdomen. His penis and testicles were extremely swollen and infected. He/She had pitted edema in his/her lower extremities. The resident was transported to the hospital. Review of the resident's hospital records, showed: -admitted on [DATE] at 10:44 A.M.; -Scalp swelling/hematoma. No facial fractures. The resident was unkept. Penis and testicle swelling due to cirrhosis. No traumatic injuries found. Review of the facility's investigation, dated 12/10/24, showed: -LPN G's written statement, undated: The resident refused vitals. He/She was sitting on the toilet. LPN G informed the night shift to monitor the resident's knee. He/She had a skin tear. The nurse said it looked red and swollen. The resident denied pain. LPN G said I believed (his/her) word although not completely sure. I believe I spoke to family. The second day the resident said he/she was fine. He/She was up in the hallway talking to himself. Staff assisted the resident with a shower. He/She should have documented these things; -CNA H's written statement: On 12/6/24 he/she was assigned to the resident. He/She checked on the resident several times during his/her shift. The resident sat on the toilet the entire shift. He did not eat his meals. He declined assistance. He/She checked on the resident prior to end of shift at 6:30 P.M. and he was still on the toilet. On 12/8/24, when CNA H entered the resident's room, he was sitting on the toilet. The resident was very confused. He thought he was at the hospital; -No documented conclusion. During an interview on 1/9/25 at 2:28 P.M., LPN B said he/she worked with the resident on 12/9/24 and 12/10/24. The resident fell often. He had a fall the weekend before 12/10/24 and sustained two black eyes. He/She did not know if the fall was witnessed. On 12/9/24, the resident had a fall around 9:00 A.M. He/She entered the resident's room to obtain vitals. The resident's eyes were black and blue. He was on the toilet. He refused to let LPN B change his clothes. LPN B and two other staff assisted the resident from the toilet to bed. The resident stayed in bed for 45 minutes, then sat back on the toilet. He was on the toilet the entire shift. On 12/10/24 at approximately 9:00 A.M., he/she entered the resident's room to obtain vitals. He was weak, and his eyes were swollen shut. LPN B notified the DON. When LPN B returned to the resident's room, he was on the floor, by the recliner. The resident said the cats and dogs made him fall. He could not stand up without assistance. Two CNAs assisted him off the floor. The resident requested to use the bathroom. The CNAs cleaned the resident up and he/she was sent to the hospital. The resident had rectal cancer and would sit on the toilet with his head between his legs. Sometimes, the resident sat on the toilet for an entire 12-hour shift. Prior to 12/10/24, the resident was mobile and walked around the facility. The resident often refused care and medication. The physician was aware the resident refused care, had falls and was sitting on the toilet for hours every day. During an interview on 1/13/25 at 11:21 A.M., CNA E said the resident was very weak and confused on 12/9/24. His eyes were black and swollen. He could not see. CNA E told him, he/she had to assist him because he could not see. The resident kept getting up and trying to go to the bathroom. He would not let staff help him. The resident was not combative. He was delusional. The resident would not let staff clean him up. CNA E removed the resident's dirty clothes and he put them back on. The resident has cancer and is embarrassed about it. Staff tried to get the resident to use briefs and he refused. He is not sure if the resident's doctor was notified of his change in condition. During an interview on 1/14/25 at 11:20 A.M., CMT D said he/she usually passed meds and provided care sometimes. The resident received his/her stool medication at 12:00 P.M. On 12/7/24, CMT D noticed the resident's face was red. On 12/8/24, the resident was confused and did not want to lay down. His eyes were black and blue. CMT D told LPN G the resident's face was getting worse. LPN G said the resident fell earlier in the morning. LPN G did not assess the resident or notify the physician. On 12/9/24, the resident's eyes were swollen shut. CMT D notified LPN B. LPN B assessed the resident. The resident was sitting on the toilet with his head between his legs. The resident was weak and could not open his eyes. CMT D, LPN B and a CNA helped the resident from the toilet to the bed. The resident stayed in bed for 45 minutes then returned to the toilet. The resident was alert and oriented times three (to person, place and time) at baseline. He could ambulate and transfer without assistance. During an interview on 1/13/25 at 9:23 A.M., the physician's social worker said according to the physician's notes, he/she saw the resident on 11/12/24. The physician went to see the resident on 12/11/24 and he was not at the facility. The physician received a voicemail on 12/6/24 at 7:46 A.M., from LPN A. LPN A said the resident fell, hit his head, and had a skin tear on his knee. On 12/10/24 at 12:05 P.M., LPN B informed the physician the resident was being sent out to the hospital. The physician was not notified of falls on 12/8/24 and 12/9/24. The physician was not aware the resident refused care and sat on the toilet for hours. During an interview on 1/13/25 at 1:10 P.M., the Administrator and ADON said when a resident falls and hits their head, the physician is notified, and neuro checks are completed for 72 hours. The nurses complete the neuro checks. She does not know when Resident #17's swelling started. They were aware of the falls on 12/10/24 but were not informed of the other falls. 3. During an interview on 1/13/25 at 1:10 P.M. and 1/14/25 at 7:00 P.M., the Administrator said nursing staff are responsible for updating the care plans. Resident #18's care plan should have been updated. If Resident #17's eyes were swollen, the physician should have been notified and he/she should have been sent out. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the G level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00246395 MO00246450 MO00246460 MO00246790 MO00246791 MO00246793 MO00246843

Based on interview and record review, staff failed to implement a system to ensure facility staff communicated a report on residents' conditions to agency staff prior to their shifts and failed to direct agency staff where to find the binder containing instructions on residents' care needs. The facility failed to ensure one resident's (Resident #18) care plan instructions for staff reflected the resident's assessed needs, including use of mechanical lift for transfers. On 12/17/24 around 12:00 P.M., an unknown nurse directed Certified Nurse Aide (CNA) C to transfer the resident from his/her bed without communication of the resident's need for mechanical lift transfer. CNA C utilized a gait belt, instead of using a Hoyer lift (mechanical lift). The resident fell during the transfer and sustained fractures to his/her ribs, legs, and left ankle. The resident's physician said staff failed to notify him/her of the incident until later in the evening. EMS did not transfer the resident to the hospital until 10:08 P.M. and reported the resident was hard to arouse. Additionally, the facility failed to appropriately respond to a resident's (Resident #17) change of condition and failed to contact the resident's physician. The resident had multiple falls between 12/6/24 and 12/10/24. The sample was 2. The census was 96. The Administrator was notified on 1/14/25 at 5:32 P.M., of an immediate jeopardy (IJ) which began on 12/17/24. The IJ was removed on 1/16/25 as confirmed by surveyor on-site verification. Review of the facility's Change in Condition and When to Notify the Physician policy (undated), showed: -Purpose: To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a resident's condition; -When there is a change in condition, the physician must be notified. Below are examples of what is considered a change in condition: -Altered mental status: Includes sudden change in mental status or loss of consciousness; -Edema: Abrupt onset or increased amount; -Falls: All falls; -Nurses must assess residents frequently for change in condition. If a change is observed, check vital signs and note anything different with the resident. Relay the information to the physician.; -Make sure to document physician called, signs and symptoms observed, family notification and all interventions taken. Review of the facility's Fall programs policy and procedure, reviewed 1/2023, showed: -Purpose: To identify all resident who have a high risk for falls and to ensure adequate interventions are in place to prevent major injury; -Policy: An investigation of all falls will be completed by the Director of Nursing (DON)/designee and submitted to the interdisciplinary team (IDT) committee for review; -Fall risk evaluation (UDA) will be completed on every resident upon admission/re-admission by the nurse on shift the resident is admitted on ; -When a resident is identified as being at a high risk for falls, this will be identified on the baseline care plan upon admission and the fall intervention notes on the Kardex (gives a brief overview of each resident); -When a resident within the facility falls, the nurse will assess/evaluate the resident and document in the electronic medical record. Neuro checks will be initiated for all un-witnessed falls, residents who hit their head. 1. Review of Resident #18's PT discharge summary, dated 6/29/23, showed: -Total assistance/Hoyer (mechanical transfer) on 6/6/23, resident refused on 6/19/23, and unable to complete on 6/29/23; -Instructed nursing caregivers in positioning maneuvers and safety precautions. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/17/24, showed: -admitted [DATE]; -Moderate cognitive impairment; -Diagnoses included stroke, major depressive disorder and repeated falls; -Upper and lower extremity impairment on one side; -Substantial to maximum assistance with mobility; -Transfers: Dependent on staff for lying to sitting on the side of the bed. Sit to stand not attempted due to medical condition or safety concerns; -No falls since admission. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident had an activities of daily living (ADL) self-care performance deficit due to activity intolerance; -Interventions: The resident required extensive assistance by one staff to turn and reposition in bed and move between surfaces; -Focus: The resident was at risk for falls due to deconditioning, stroke, and right-side weakness; -Interventions: Anticipate and meet the resident's needs. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; -The care plan did not instruct staff to utilize the Hoyer lift for transfers. Review of the resident's progress notes, showed: -On 12/9/24 at 7:12 P.M., resident seen by physician for chronic pain. New order for tramadol (used for short term relief of chronic pain) 50 milligram (mg), twice daily (BID) given; -On 12/17/24 at 5:30 P.M., staff monitored the resident for pain to ankle. He/She complained of pain to ankle this morning. At 8:40 P.M., the resident said his/her ankle was hurting. He/She was being assisted from bed and heard a pop. Oncoming nurse notified. At 8:56 P.M., the nurse received report the CNA on day shift attempted to transfer the resident and heard a pop. The resident had been in severe pain in bilateral lower extremities. The areas were painful to touch, and right leg appeared swollen. He/She complained of pain to left leg, but no bruising present in either extremities. The resident rated pain ten out of ten. Resident's physician notified of events. He/She gave orders to increase tramadol 50 mg BID to 100 mg BID and obtain three view x-ray of right ankle to rule out fracture/dislocation. X-ray technician said he/she would come out on 12/18/24. The resident remained in bed. His/Her vitals were stable with no acute distress noted. At 9:40 P.M., order received from physician to send resident to hospital. The resident responded to painful stimuli but did not answer questions. Resident transported to hospital by Emergency Medical Services (EMS). Review of the resident's EMS report, dated 12/17/24, showed: -At 10:08 P.M., EMS responded to the facility for a resident with an altered mental status. The resident was laying in his/her bed. Staff said the resident heard a loud pop during a transfer earlier in the day. He/She had been lethargic since. The resident was lethargic and hard to arouse. The resident was very large and an additional EMS personnel were called to transfer resident from bed. The resident was given oxygen. He/She became hypotensive (having low blood pressure) during transport to hospital. At 10:43 P.M., the resident's blood pressure was 58/33. Review of the resident's hospital records, showed -admitted on [DATE] at 10:46 P.M.; -According to EMS, the resident had a history of stroke, alert and oriented times three and almost completely bedbound; -The resident was given vasopressor (used to treat low blood pressure shock); -The resident said he/she fell . He/She could not remember what happened before or after the fall; -Right and left lower extremity range of motion decreased due to pain; -X-rays revealed both femurs (thigh bones) were fractured in the wider part, near the middle of the bone. The bone was broken in multiple pieces due to significant trauma. Fractures of the distal left tibia and fibula (break in the lower leg bone which requires immediate medical attention. Usually caused by a fall or hard blow to the leg, or sudden twist of the leg). Fracture of left calcaneal (heel bone), bruise on right thigh and rib fractures of the left first rib, right third, fifth and sixth ribs; -The resident had brittle bones; -The resident was admitted to the intensive care unit until blood pressure stabilized. Review of the facility's investigation dated 12/20/24, showed: -On 12/17/24 at approximately 12:00 P.M., agency CNA C reported he/she went into the resident's room to provide incontinence care. He/She changed the resident and cleaned him/her up. CNA C put the gait belt on the resident and sat him/her up on the side of the bed. The wheelchair was adjacent to the bed. CNA C told the resident he/she was going to stand him/her up. The resident said okay. They stood for a split second and CNA C heard a pop from down below. He/She thought it was the resident's knee or ankle. CNA C helped the resident back into bed with the gait belt; -The resident was transferred to the hospital later in the evening; -The resident was diagnosed with multiple bone fractures; -Nursing staff was in-serviced on safe transfers; -No documented conclusion to the investigation. During an interview on 1/10/25 at 12:00 P.M., CNA C said the nurse (he/she didn't know the nurse's name) told him/her to get the resident out of bed on 12/17/24. The nurse said the resident was going to say he/she could not walk or stand, but get him/her up anyway. The nurse did not provide the agency CNA with instruction on the appropriate method to transfer the resident. CNA C entered the resident's room around 12:00 P.M. The resident said he/she did not get out of bed. He/She did not want to get up. CNA C told the resident the nurse said he/she had to get up. CNA C lowered the resident's bed then put the wheelchair next to it. He/She used the gait belt to sit the resident up on the side of the bed. The resident stood up and said Oh. CNA C heard a pop and used the gait belt to sling the resident back on the bed. CNA C retrieved a Hoyer pad and was going to get help to transfer the resident. The resident did not want to be transferred. He/She was complaining of pain in his/her legs. CNA C went to get the nurse. The Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) F assessed the resident's legs. They said they would wait and see how it looked later. CNA C was transferred to another hall. The nurse did not tell CNA C if the resident was a one or two person assist. CNA C did not ask anyone how the resident should be transferred. Agency staff are supposed to get report from the Charge Nurse at the start of their shift. Sometimes the facility is short staffed, and they do not give report. He/She did not get report on the day of the incident. LPN F asked the resident why he/she did not tell CNA C he/she was a Hoyer lift transfer. The resident's legs buckled when he/she stood up. CNA C grabbed the resident with the gait belt, quickly. The resident's legs did not look out of place. CNA C did not know about the binder at the nurse's station. During an interview on 1/9/25 at 2:27 P.M., LPN A said he/she was assisting another resident when CNA C told him/her he/she was transferring the resident and heard a pop. The resident was complaining of pain. He/She told CNA C to ask the ADON to assist him/her. The ADON and LPN F said the resident did not need x-rays. They instructed the Certified Medication Technician (CMT) to give the resident pain medication. The ADON and LPN F said they notified the physician. LPN A assessed the resident. He/She is not sure what time he/she assessed the resident. During shift change, the evening nurse and LPN A assessed the resident for pain. He/She complained of pain in his/her left and right ankle. His/Her pain was a ten. The oncoming nurse contacted the physician. The physician increased the resident's tramadol to 100 mg and ordered an x-ray. The x-ray technician could not come out until the following day. The physician gave an order to send the resident to the hospital. He/She was bedbound. The resident was a two person assist with a Hoyer lift. During an interview on 1/10/25 at 11:11 P.M., the ADON said CNA C said he/she sat the resident up on the side of the bed. When the resident stood up, CNA C heard a pop. The resident complained of pain in his/her right ankle. When the ADON entered the resident's room, the resident was laying in bed and LPN F was assessing his/her right ankle. He/She had range of motion (ROM) in his/her right ankle. The ADON left the room to get the charge nurse. She is not sure if the physician was notified immediately after the incident. She is certain he was contacted later in the evening. The physician ordered an x-ray. She thinks the resident was a two person assist with a Hoyer lift. She did not see a Hoyer lift in the resident's room when she entered. She remembered seeing a gait belt on the bed or in CNA C's hand. She is not sure if the resident could bear weight prior to this incident. Agency staff are supposed to get report prior to shift change. Review of the binder containing care instructions for residents, dated 1/14/25, showed for Resident #18: -Transfer: The resident required extensive assist by 1 staff to move between surfaces. Upon return from hospital, use mechanical lift and two staff assist (updated 12/19/24). During an interview on 1/10/25 at 12:55 P.M., LPN F said he/she was stopped in the hall by CNA C. He/She entered the resident's room and the resident was laying in the bed. The resident complained of pain in his/her right ankle. He/She had ROM in his/her right ankle. The CNA attempted to transfer the resident by him/herself. LPN F did not ask the resident if he/she fell . He/She cannot remember if the resident was a one or two person assist. He/She did not remember seeing a gait belt or Hoyer lift in the resident's room. He/She does not remember if the resident's physician was notified. The nurse assigned to the resident would have been responsible for notifying the physician. The facility used agency staff often. Agency staff were supposed to view the binder at the nurse's station. The binder contained information about the residents. There was not a system in place to verify if they reviewed the binder. During an interview on 1/10/25 at 1:33 P.M., the resident's physician said staff notified him of the incident later in the evening. He/She gave an order to increase pain medication to 100 mg and obtain an x-ray. Staff said the resident was still complaining of pain and he/she told them to send the resident to the hospital. He/She is not sure what time staff contacted him/her. He/She tried to figure out severity based on the report from the staff. Staff said the resident was in pain. He/She was not aware of the severity of the injuries. He/She did not think a simple fall would cause the resident's injuries. The gait belt could have caused the rib fractures. Maybe he/she fell , twisted his/her legs, causing the femur fractures. The resident's injuries are not consistent with the CNA's story. He/She expected staff to give him a thorough report. The resident was bedbound and he/she did not know why they got him/her up. During an interview on 1/13/25 at 9:51 A.M., the Staffing Coordinator said CNA C was sent to another hall, because someone was sick and had to leave. Agency staff are supposed to get report from the Charge Nurse at the start of their shift. She does not know if they receive any training. During an interview on 1/13/25 at 10:23 A.M., the DON said agency staff are supposed to get a verbal report from the Charge Nurse about their assignments. There is a binder at each nurse's station with the residents' Kardex, which includes the residents' ADL needs. It is updated as needed or with a change of condition. There is not a system in place to ensure agency staff are getting report and reviewing the binder. During an interview on 1/13/25 at 1:04 P.M., the Administrator and ADON said the fractures occurred when CNA C attempted to transfer the resident. The resident stayed in bed most of the time. Agency staff should get report prior to their shift. 2. Review of Resident #17's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included rectal cancer, cirrhosis of the liver, depression and muscle weakness; -History of falls; -No falls in two-six months prior to admission; -Independent with transfers; -Supervision with personal hygiene and toileting; -Partial to moderate assistance with showers; -He/She used a walker. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: The resident had an ADL self-care performance deficit due to impaired mobility, weakness, chronic health conditions. He/She was often non-compliant with asking for assistance prior to moving about; -Interventions: Staff discussed with resident/family/power of attorney any concerns related to loss of independence, decline in function. Encouraged the resident to discuss feelings about self-care deficit. Encouraged the resident to participate to with each interaction. Encouraged the resident to use call light for assistance. Monitored/documented/reported as needed (PRN) any changes, potential for improvement, reasons for self-care deficit, expected course, and declines in function; -Focus: The resident is at risk for falls due to cirrhosis, cancer, non-compliance, incontinence with generalized weakness, impulsivity, and impaired safety awareness; -Interventions: Resident educated on proper use of call light for assistance. Resident educated on rising slowly and using grab bars when transitioning from sitting to standing. Educated the resident/family/caregivers about safety reminders and what to do if fall occurred. Reviewed information on past falls and attempted to determine cause of falls. Recorded possible root causes. Altered/removed any potential causes if possible. Review of the resident's post fall evaluation, dated 12/6/24, showed: -Fall details: The fall occurred on 12/06/2024 at 5:30 A.M. in the resident's bathroom. The fall was unwitnessed. The resident was in a hurry to grab something to get back on the toilet. The resident had a skin tear and said his/her head hurt. The resident's physician notified on 12/6/24; -Contributing Factors: The lighting was poor and there was fluid spilled on floor. He/She was not using cane/walker as instructed; -Vitals: Temperature 97.9, blood pressure 118/71, pulse 80, respirations 18; -Pain: The resident complained of head pain. Pain indicated via facial expressions and non-verbal sounds. Pain level was an eight out of ten. Review of the resident's progress notes, showed: -On 12/6/24 at 8:38 A.M., the resident fell in his/her bathroom. He/She had a skin tear to left front knee with head injury and pain to left side of head. Family notified. At 9:43 A.M., the resident refused vital signs. He/She said he/she was fine. He/She denied pain to head and/or knee. Skin tear cleansed and dressing applied. His/Her knee was slightly swollen. No shortening noted. He/She was able to move his/her knee without discomfort; -On 12/7/24 at 6:00 A.M., the resident was continued on incident follow up (IFU). His/Her vital signs were stable and strong at baseline. He/She was neurologically alert and oriented. He/She was educated to ask for help when moving around; -On 12/8/24 at 6:08 P.M., the resident was on IFU following a fall. He/She fell to left side had a skin tear to his/her left knee. He/She denied pain. Discoloration noted to area near left eye. He/She said it happened a while ago; -On 12/9/24 at 10:37 A.M., the resident denied pain and discomfort related to fall. The resident was assessed. Both eyes were black in color. Neuro checks and hand grips were equal. He/She continued to be on the toilet. At 12:57 P.M., the resident refused peri care and clothes change. At 3:13 P.M., staff assisted the resident to bed. He/She remained in bed for 45 minutes, then got up and sat on the toilet all shift; -On 12/10/24 at 5:20 A.M., resident on IFU due to fall. Both eyes were almost swollen shut. He/She denied pain. Neuro checks were within normal limits. His/Her vitals were temperature 97.5, pulse 72, respirations 16, blood pressure 110/68. At 10:04 A.M., the resident was seated on the floor in his/her room. He/She said he/she was seeing dogs and cats. He/She was assisted to stand and sit in chair. He/She demanded to use the bathroom. Two staff assisted the resident to the toilet. He/She was weak and confused/delusional due to falls. Both eyes were swollen shut. He/She needed assistance of two staff to stand up. The resident's physician and family were notified. At 12:55 P.M., the resident was assessed after morning meeting for facial swelling. He/She was on the floor in his/her room. He/She said he/she was tripped by the dogs or cats running around in his/her room. CNAs assisted the resident off the floor. He/She fell two more times within ten minutes. His/Her facial and leg swelling were noticeable. He/She often sat on the toilet with his/her head between his/her legs. Staff called 911. Review of the resident's EMS report, dated 12/10/24 at 10:12 A.M., showed: On arrival, staff said the resident had multiple falls over the last week. He/She had increased weakness the last few days. The resident was usually up walking around. He/She was not able to walk the last four to five days. Staff noticed his/her eyes swollen shut this morning. The resident complained of pain in his/her face, neck, genitals, and leg. He/She was transported to the hospital. EMS personnel observed the resident on the toilet in his/her room. He/She complained of pain all over. He/She said he/she had fallen and hit his/her head multiple times. He/She was weak the last three days. EMS personnel observed major facial swelling and bruising in multiple stages on his/her face. His/Her eyes were swollen shut. The resident said he/she had been unable to see for two days. A mass the size of a golf ball protruded from his/her abdomen. His penis and testicles were extremely swollen and infected. He/She had pitted edema in his/her lower extremities. The resident was transported to the hospital. Review of the resident's hospital records, showed: -admitted on [DATE] at 10:44 A.M.; -Scalp swelling/hematoma. No facial fractures. The resident was unkept. Penis and testicle swelling due to cirrhosis. No traumatic injuries found. Review of the facility's investigation, dated 12/10/24, showed: -LPN G's written statement, undated: The resident refused vitals. He/She was sitting on the toilet. LPN G informed the night shift to monitor the resident's knee. He/She had a skin tear. The nurse said it looked red and swollen. The resident denied pain. LPN G said I believed (his/her) word although not completely sure. I believe I spoke to family. The second day the resident said he/she was fine. He/She was up in the hallway talking to himself. Staff assisted the resident with a shower. He/She should have documented these things; -CNA H's written statement: On 12/6/24 he/she was assigned to the resident. He/She checked on the resident several times during his/her shift. The resident sat on the toilet the entire shift. He did not eat his meals. He declined assistance. He/She checked on the resident prior to end of shift at 6:30 P.M. and he was still on the toilet. On 12/8/24, when CNA H entered the resident's room, he was sitting on the toilet. The resident was very confused. He thought he was at the hospital; -No documented conclusion. During an interview on 1/9/25 at 2:28 P.M., LPN B said he/she worked with the resident on 12/9/24 and 12/10/24. The resident fell often. He had a fall the weekend before 12/10/24 and sustained two black eyes. He/She did not know if the fall was witnessed. On 12/9/24, the resident had a fall around 9:00 A.M. He/She entered the resident's room to obtain vitals. The resident's eyes were black and blue. He was on the toilet. He refused to let LPN B change his clothes. LPN B and two other staff assisted the resident from the toilet to bed. The resident stayed in bed for 45 minutes, then sat back on the toilet. He was on the toilet the entire shift. On 12/10/24 at approximately 9:00 A.M., he/she entered the resident's room to obtain vitals. He was weak, and his eyes were swollen shut. LPN B notified the DON. When LPN B returned to the resident's room, he was on the floor, by the recliner. The resident said the cats and dogs made him fall. He could not stand up without assistance. Two CNAs assisted him off the floor. The resident requested to use the bathroom. The CNAs cleaned the resident up and he/she was sent to the hospital. The resident had rectal cancer and would sit on the toilet with his head between his legs. Sometimes, the resident sat on the toilet for an entire 12-hour shift. Prior to 12/10/24, the resident was mobile and walked around the facility. The resident often refused care and medication. The physician was aware the resident refused care, had falls and was sitting on the toilet for hours every day. During an interview on 1/13/25 at 11:21 A.M., CNA E said the resident was very weak and confused on 12/9/24. His eyes were black and swollen. He could not see. CNA E told him, he/she had to assist him because he could not see. The resident kept getting up and trying to go to the bathroom. He would not let staff help him. The resident was not combative. He was delusional. The resident would not let staff clean him up. CNA E removed the resident's dirty clothes and he put them back on. The resident has cancer and is embarrassed about it. Staff tried to get the resident to use briefs and he refused. He is not sure if the resident's doctor was notified of his change in condition. During an interview on 1/14/25 at 11:20 A.M., CMT D said he/she usually passed meds and provided care sometimes. The resident received his/her stool medication at 12:00 P.M. On 12/7/24, CMT D noticed the resident's face was red. On 12/8/24, the resident was confused and did not want to lay down. His eyes were black and blue. CMT D told LPN G the resident's face was getting worse. LPN G said the resident fell earlier in the morning. LPN G did not assess the resident or notify the physician. On 12/9/24, the resident's eyes were swollen shut. CMT D notified LPN B. LPN B assessed the resident. The resident was sitting on the toilet with his head between his legs. The resident was weak and could not open his eyes. CMT D, LPN B and a CNA helped the resident from the toilet to the bed. The resident stayed in bed for 45 minutes then returned to the toilet. The resident was alert and oriented times three (to person, place and time) at baseline. He could ambulate and transfer without assistance. During an interview on 1/13/25 at 9:23 A.M., the physician's social worker said according to the physician's notes, he/she saw the resident on 11/12/24. The physician went to see the resident on 12/11/24 and he was not at the facility. The physician received a voicemail on 12/6/24 at 7:46 A.M., from LPN A. LPN A said the resident fell , hit his head, and had a skin tear on his knee. On 12/10/24 at 12:05 P.M., LPN B informed the physician the resident was being sent out to the hospital. The physician was not notified of falls on 12/8/24 and 12/9/24. The physician was not aware the resident refused care and sat on the toilet for hours. During an interview on 1/13/25 at 1:10 P.M., the Administrator and ADON said when a resident falls and hits their head, the physician is notified, and neuro checks are completed for 72 hours. The nurses complete the neuro checks. She does not know when Resident #17's swelling started. They were aware of the falls on 12/10/24 but were not informed of the other falls. 3. During an interview on 1/13/25 at 1:10 P.M. and 1/14/25 at 7:00 P.M., the Administrator said nursing staff are responsible for updating the care plans. Resident #18's care plan should have been updated. If Resident #17's eyes were swollen, the physician should have been notified and he/she should have been sent out. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the G level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00246395 MO00246450 MO00246460 MO00246790 MO00246791 MO00246793 MO00246843

Based on interview and record review, the facility failed to follow their abuse policy by thoroughly investigating in a timely manner allegations of resident to resident altercations (Residents #15 and Resident #16, and Residents #10 and Resident #11). The sample was 10. The census was 98. Review of the facility Abuse, Neglect, Exploitation or Mistreatment Policy, dated 5/1/2018, showed the following: -Policy: -The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately; -The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard resident; -The facility's leadership will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law. -Component: Identification: -Staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect; -Physical assault/abuse: 1. Hitting; 2. Slapping; 3. Pinching; 4. Kicking; 5. Controlling behavior through corporal punishment. -Investigation: -The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken. If the alleged abuse or neglect involves serious physical harm to the resident, please contact the Regional [NAME] President of Operations. You may be directed to contact the Legal Department. The Legal Department will determine whether to direct an investigation so as to protect the results of such investigation from third-party discovery. In the event another resident, a family member or visitor is accused of abuse against a resident, the facility will intervene and take appropriate steps to safeguard the patient/resident during and after the investigation; -The facility conducts an internal investigation through the Legal Department, if applicable, and reports the results to enforcement agencies within five working days or as prescribed by state law. Enforcement agencies include but are not limited to the state's survey and certification agency; -Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions; -The investigation may include but is not limited to the following: -Identification and removal of the alleged perpetrator; -Identification of the alleged victim; -Type of alleged abuse; -Where and when the incident occurred; -Written summaries of interviews with individuals having first-hand knowledge of the incident. NOTE: Employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated and signed by the interviewer. -Resolution/outcome; -Measures taken to prevent future incidents; -All documents pertaining to the investigation must be complied and stored in the administrator's office; -Notify and release the results of the investigation as prescribed by law. Contact the Legal Department with any questions regarding what can and cannot by produced (If the investigation was privileged by an attorney in the Legal Department, consult with the attorney before any investigation documents are provided to the authorities); -Refer patients/residents to private or public community agencies/hospitals/medical centers that provide or arrange for the evaluation/examination of abuse victims as prescribed by law; such examinations should be conducted for any allegation of rape, sexual assault/molestation or coercion. Take measures to protect materials, items that may be needed for investigation, such as clothing sheets; -Take measures to ensure confidentiality to the extent practicable. 1. Review of Resident #15's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/26/24, showed the following: -No cognitive impairment; -Other symptoms of behaviors not directed towards others: one to three days; -Supervision to moderate assistance with activities of daily living (ADLs); -Congestive heart failure, high blood pressure and dementia. Review of the resident nurse's note, dated 11/30/24 at 2:18 P.M., showed this nurse was at desk and heard yelling. The nurse stood up and seen this resident hit another resident with an open hand. The resident was up ambulating in hallway. This resident stopped in middle of hall and stated I will break your neck to another resident. At this time other resident pushed this resident back and this resident hit the other resident with an open hand. There was no injury noted. A call was placed to the resident's family. The resident's physician was notified with report of resident to resident altercation. A new order was received to send the resident to the hospital for evaluation. During an interview on 12/3/24 at 10:05 A.M., the resident said he/she was fine and did not remember the altercation. Review of Resident #16's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Delusions; -Supervision with ADLs; -Diagnoses of high blood pressure, end stage renal disease and hip fracture. Review of the resident's nurse's notes, date 11/30/24 at 2:24 P.M., showed the nurse was at nurse's station and heard two residents yelling. The nurse stood up and seen this resident being hit with an open handed on chin. There were no injury noted. The resident refused to go to hospital. The resident's physician was notified of the altercation. During an interview on 12/3/24 at 9:59 A.M., the resident said he/she was fine and had no concerns. The resident said he/she did not remember the altercation. During an interview on 12/4/24 at 12:06 P.M., Licensed Practical Nurse (LPN) A said Resident #15 was walking down the hall and Resident #16 said something like, I will break your neck. Resident #15 hit Resident #16 with an open hand across the face. The residents were separated. LPN A said he/she contacted Director of Nursing (DON), and both residents' physicians. LPN A said he/she did not know if an investigation was started or if the state agency was contacted. Review of the residents' medical records, showed no documentation of the Administrator, DON, or ADON being notified regarding the altercation. 2. Review of Resident #10's admission MDS, dated [DATE], showed the following: -No cognitive impairment; -No moods or behaviors; -Dependent with ADLs; -Diagnosis of stroke. Review of the resident's nurse's notes, dated 12/1/24 at 11:17 A.M., showed this nurse heard screaming coming from resident's room. Upon entering the room, the resident's roommate (Resident #11) was assaulting him/her by hitting him/her in the face several times causing his/her glasses to break. After separating the residents, this resident was visibly upset but otherwise no apparent injuries. The resident's family was notified and wanted him/her evaluated in the emergency room. The resident's physician was notified and the ambulance was notified of need for transport to the hospital. During an interview on 12/2/24 at 8:41 A.M., the resident said yesterday, 12/1/24, he/she was laying in his/her bed and his/her roommate (Resident #11) came over and asked did he/she want to fight. The resident said he/she said no. Resident #11 came over and started hitting him/her in his/her upper left arm and in his/her face with a fist. The resident said the staff came in to stop him/her. Review of Resident #11's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No moods or behaviors; -Partial to moderate assistance with ADLs; -Diagnoses of high blood pressure and dementia. Review of the resident's nurse's notes, date 12/1/24 at 3:29 P.M., showed the nurse was called to resident's room due to screams for help. Upon entering room, the nurse found this resident hitting his/her roommate (Resident #10) in the face and trying to pull him/her out of the bed. This resident was brought out of the room to nurses station and the resident's physician was called. An order was received to transfer to the resident to the hospital for evaluation. The ambulance was notified of need for transport. The resident's representative was notified and messages were left for a return call. During an interview on 12/2/24 at 11:19 A.M. Certified Medication Technician (CMT) B said he/she just left the resident's room and he/she was fine. CMT B said about five minutes later, he/she heard Resident #10 screaming and went into the room. Resident #10 was half off the bed and his/her roommate (Resident #11) was in his/her wheelchair hitting Resident #10 with his/her fist. The charge nurse came to assist with separating the residents. Resident #11 was taken to the nurse's station and Resident #10 was assessed by the charge nurse. CMT B said he/she was not asked to write a statement until today. CMT B said she just wrote the statement. CMT B said the charge nurse notified the receptionist and he/she sent a group chat to management. CMT B said in his/her experience, an investigation should have been started immediately. During an interview on 12/3/24 at 12:05 P.M., Licensed Practical Nurse (LPN) C said he/she went to the residents' room after hearing screaming. LPN C said he/she found the two residents doing a tug of war with a cane. LPN C asked what happened and Resident #10 said Resident #11 asked him/her if he/she wanted to fight. Resident #10 said Resident #11 starting hitting him/her in the face with his/her fist and broke his/her glasses. LPN C said the broken glasses were found in the bed. LPN C said he/she did not have the phone numbers of the Administrator, DON, or ADON. LPN C told the receptionist and the receptionist sent a group chat to them. LPN B did not write a statement or start an investigation. He/She was told management does the investigations. During an interview on 12/3/24 at 12:24 P.M., Receptionist D said LPN C called him/her and said the residents were being sent out to the hospital. Receptionist D said he/she sent a group text message at 10:46 A.M. on 12/1/24. The text went to the Administrator, DON, ADON and other management. The ADON responded back at 11:16 A.M. and said it needed to be reported to the state agency. Receptionist D said he/she told LPN C. LPN C said he/she does not report incidents. During an interview on 12/3/24 at 12:38 P.M., the ADON said on 12/1/24 at 11:15 A.M., he/she got a text message regarding the incident. The ADON said he/she responded the incident needed to be reported to the state agency. The ADON said the Administrator or the Social Service Director (SSD) would start the investigation and report to the state agency. The ADON said an investigation and a report to the state agency was not started until 12/2/24 when the surveyor entered the building and asked about the altercation. During an interview on 12/3/24 at 12:51 P.M., the SSD said he/she received a text message from Receptionist D saying there was a resident to resident altercation. SSD said he/she suggested Resident #11 be brought up to the second floor to keep the residents separated. Both of the residents were sent to the hospital. The SSD said at 11:16 A.M., the ADON sent a text message saying the Administrator or the SSD would start the investigation and report the altercation to the state agency. SSD said he/she did not start an investigation and did not know how to report it to the state agency. Review of the residents' medical records, showed no documentation of the Administrator, DON, or ADON being notified regarding the altercation. 3. During an interview on 12/3/24 at 1:27 P.M., the DON said she did not start the investigations of the resident to resident altercations until 12/2/24. The DON said she did not remember getting a call regarding the altercations. At that time, the new Administrator said she has only been with the facility less that 24 hours, however she expected the facility's policy to be followed as written. MO00245921 MO00245984 MO00245986

Based on interview and record review, the facility failed to follow their abuse policy by thoroughly investigating in a timely manner allegations of resident to resident altercations (Residents #15 and Resident #16, and Residents #10 and Resident #11). The sample was 10. The census was 98. Review of the facility Abuse, Neglect, Exploitation or Mistreatment Policy, dated 5/1/2018, showed the following: -Policy: -The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately; -The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard resident; -The facility's leadership will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law. -Component: Identification: -Staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect; -Physical assault/abuse: 1. Hitting; 2. Slapping; 3. Pinching; 4. Kicking; 5. Controlling behavior through corporal punishment. -Investigation: -The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken. If the alleged abuse or neglect involves serious physical harm to the resident, please contact the Regional [NAME] President of Operations. You may be directed to contact the Legal Department. The Legal Department will determine whether to direct an investigation so as to protect the results of such investigation from third-party discovery. In the event another resident, a family member or visitor is accused of abuse against a resident, the facility will intervene and take appropriate steps to safeguard the patient/resident during and after the investigation; -The facility conducts an internal investigation through the Legal Department, if applicable, and reports the results to enforcement agencies within five working days or as prescribed by state law. Enforcement agencies include but are not limited to the state's survey and certification agency; -Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions; -The investigation may include but is not limited to the following: -Identification and removal of the alleged perpetrator; -Identification of the alleged victim; -Type of alleged abuse; -Where and when the incident occurred; -Written summaries of interviews with individuals having first-hand knowledge of the incident. NOTE: Employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated and signed by the interviewer. -Resolution/outcome; -Measures taken to prevent future incidents; -All documents pertaining to the investigation must be complied and stored in the administrator's office; -Notify and release the results of the investigation as prescribed by law. Contact the Legal Department with any questions regarding what can and cannot by produced (If the investigation was privileged by an attorney in the Legal Department, consult with the attorney before any investigation documents are provided to the authorities); -Refer patients/residents to private or public community agencies/hospitals/medical centers that provide or arrange for the evaluation/examination of abuse victims as prescribed by law; such examinations should be conducted for any allegation of rape, sexual assault/molestation or coercion. Take measures to protect materials, items that may be needed for investigation, such as clothing sheets; -Take measures to ensure confidentiality to the extent practicable. 1. Review of Resident #15's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/26/24, showed the following: -No cognitive impairment; -Other symptoms of behaviors not directed towards others: one to three days; -Supervision to moderate assistance with activities of daily living (ADLs); -Congestive heart failure, high blood pressure and dementia. Review of the resident nurse's note, dated 11/30/24 at 2:18 P.M., showed this nurse was at desk and heard yelling. The nurse stood up and seen this resident hit another resident with an open hand. The resident was up ambulating in hallway. This resident stopped in middle of hall and stated I will break your neck to another resident. At this time other resident pushed this resident back and this resident hit the other resident with an open hand. There was no injury noted. A call was placed to the resident's family. The resident's physician was notified with report of resident to resident altercation. A new order was received to send the resident to the hospital for evaluation. During an interview on 12/3/24 at 10:05 A.M., the resident said he/she was fine and did not remember the altercation. Review of Resident #16's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Delusions; -Supervision with ADLs; -Diagnoses of high blood pressure, end stage renal disease and hip fracture. Review of the resident's nurse's notes, date 11/30/24 at 2:24 P.M., showed the nurse was at nurse's station and heard two residents yelling. The nurse stood up and seen this resident being hit with an open handed on chin. There were no injury noted. The resident refused to go to hospital. The resident's physician was notified of the altercation. During an interview on 12/3/24 at 9:59 A.M., the resident said he/she was fine and had no concerns. The resident said he/she did not remember the altercation. During an interview on 12/4/24 at 12:06 P.M., Licensed Practical Nurse (LPN) A said Resident #15 was walking down the hall and Resident #16 said something like, I will break your neck. Resident #15 hit Resident #16 with an open hand across the face. The residents were separated. LPN A said he/she contacted Director of Nursing (DON), and both residents' physicians. LPN A said he/she did not know if an investigation was started or if the state agency was contacted. Review of the residents' medical records, showed no documentation of the Administrator, DON, or ADON being notified regarding the altercation. 2. Review of Resident #10's admission MDS, dated [DATE], showed the following: -No cognitive impairment; -No moods or behaviors; -Dependent with ADLs; -Diagnosis of stroke. Review of the resident's nurse's notes, dated 12/1/24 at 11:17 A.M., showed this nurse heard screaming coming from resident's room. Upon entering the room, the resident's roommate (Resident #11) was assaulting him/her by hitting him/her in the face several times causing his/her glasses to break. After separating the residents, this resident was visibly upset but otherwise no apparent injuries. The resident's family was notified and wanted him/her evaluated in the emergency room . The resident's physician was notified and the ambulance was notified of need for transport to the hospital. During an interview on 12/2/24 at 8:41 A.M., the resident said yesterday, 12/1/24, he/she was laying in his/her bed and his/her roommate (Resident #11) came over and asked did he/she want to fight. The resident said he/she said no. Resident #11 came over and started hitting him/her in his/her upper left arm and in his/her face with a fist. The resident said the staff came in to stop him/her. Review of Resident #11's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No moods or behaviors; -Partial to moderate assistance with ADLs; -Diagnoses of high blood pressure and dementia. Review of the resident's nurse's notes, date 12/1/24 at 3:29 P.M., showed the nurse was called to resident's room due to screams for help. Upon entering room, the nurse found this resident hitting his/her roommate (Resident #10) in the face and trying to pull him/her out of the bed. This resident was brought out of the room to nurses station and the resident's physician was called. An order was received to transfer to the resident to the hospital for evaluation. The ambulance was notified of need for transport. The resident's representative was notified and messages were left for a return call. During an interview on 12/2/24 at 11:19 A.M. Certified Medication Technician (CMT) B said he/she just left the resident's room and he/she was fine. CMT B said about five minutes later, he/she heard Resident #10 screaming and went into the room. Resident #10 was half off the bed and his/her roommate (Resident #11) was in his/her wheelchair hitting Resident #10 with his/her fist. The charge nurse came to assist with separating the residents. Resident #11 was taken to the nurse's station and Resident #10 was assessed by the charge nurse. CMT B said he/she was not asked to write a statement until today. CMT B said she just wrote the statement. CMT B said the charge nurse notified the receptionist and he/she sent a group chat to management. CMT B said in his/her experience, an investigation should have been started immediately. During an interview on 12/3/24 at 12:05 P.M., Licensed Practical Nurse (LPN) C said he/she went to the residents' room after hearing screaming. LPN C said he/she found the two residents doing a tug of war with a cane. LPN C asked what happened and Resident #10 said Resident #11 asked him/her if he/she wanted to fight. Resident #10 said Resident #11 starting hitting him/her in the face with his/her fist and broke his/her glasses. LPN C said the broken glasses were found in the bed. LPN C said he/she did not have the phone numbers of the Administrator, DON, or ADON. LPN C told the receptionist and the receptionist sent a group chat to them. LPN B did not write a statement or start an investigation. He/She was told management does the investigations. During an interview on 12/3/24 at 12:24 P.M., Receptionist D said LPN C called him/her and said the residents were being sent out to the hospital. Receptionist D said he/she sent a group text message at 10:46 A.M. on 12/1/24. The text went to the Administrator, DON, ADON and other management. The ADON responded back at 11:16 A.M. and said it needed to be reported to the state agency. Receptionist D said he/she told LPN C. LPN C said he/she does not report incidents. During an interview on 12/3/24 at 12:38 P.M., the ADON said on 12/1/24 at 11:15 A.M., he/she got a text message regarding the incident. The ADON said he/she responded the incident needed to be reported to the state agency. The ADON said the Administrator or the Social Service Director (SSD) would start the investigation and report to the state agency. The ADON said an investigation and a report to the state agency was not started until 12/2/24 when the surveyor entered the building and asked about the altercation. During an interview on 12/3/24 at 12:51 P.M., the SSD said he/she received a text message from Receptionist D saying there was a resident to resident altercation. SSD said he/she suggested Resident #11 be brought up to the second floor to keep the residents separated. Both of the residents were sent to the hospital. The SSD said at 11:16 A.M., the ADON sent a text message saying the Administrator or the SSD would start the investigation and report the altercation to the state agency. SSD said he/she did not start an investigation and did not know how to report it to the state agency. Review of the residents' medical records, showed no documentation of the Administrator, DON, or ADON being notified regarding the altercation. 3. During an interview on 12/3/24 at 1:27 P.M., the DON said she did not start the investigations of the resident to resident altercations until 12/2/24. The DON said she did not remember getting a call regarding the altercations. At that time, the new Administrator said she has only been with the facility less that 24 hours, however she expected the facility's policy to be followed as written. MO00245921 MO00245984 MO00245986

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #3) received care consistent with professional standards and facility policy to prevent and/or treat pressure ulcers (a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). The facility identified small break down on the resident's buttocks on 5/25/24. The area was not staged at that time. No treatment order was obtained and treatments were documented as provided from 5/25/23 until 7/3/24. Licensed nursing staff failed to complete weekly skin assessments between the dates of 6/15/24 and 7/3/24. On 7/3/24, a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but the bone, tendon or muscle is not exposed) was discovered. Staff failed to identify and treat the pressure ulcer until it had already progressed to a stage III. The sample size was 4. The census was 92. Review of the facility's Skin Program Policy and Procedure, implemented April 2023, showed: -Purpose: The purpose of the skin program is to ensure that every resident's skin condition is assessed on admission and a comprehensive and interdisciplinary care plan is developed and maintained to treat actual and/or prevent potential skin problems; -Policy: All residents are assessed upon admission and as needed (PRN) for actual and/or potential skin problems. All residents will receive an individualized preventative skin plan of care at the time of admission. All residents with skin problems will receive an active skin plan of care at admission. Skin Care team meetings will be held weekly to address all ulcers and any other pertinent skin problems; -Procedure: -The nurse assesses/evaluates all residents upon admission. The initial skin assessment is a full body audit and completion of the Braden Skin Risk Assessment (standardized assessment to determine risk for skin breakdown) in the electronic medical record. After admission the Braden Skin Risk Assessment will be completed weekly x 3 weeks and then a minimum of quarterly, a significant change of condition and annually; -Residents admitted to the facility with skin areas/pressure ulcers will have treatment orders initiated upon admission/re-admission. -Director of Nursing (DON)/Designee to review all residents weekly with skin ulcers for condition of wound, treatment changes, and additional barriers to healing and will document weekly using the Wound-Weekly Observation Tool (Licensed Nurse) in the electronic medical record; -State tested Nurse Aide (STNA) will complete the Bath/Shower Report Sheet with each resident's scheduled bath/shower. Each resident will be assessed/evaluated a minimum of weekly by the nurse using the Skin Observation Tool in the electronic medical record; -The Nurse/Designee will notify the resident's responsible party if the resident is admitted /readmitted from the hospital or another healthcare facility with a skin ulcer and document notification in the clinical record. The nurse/designee will continue to notify/update the physician, resident/sponsor weekly of progress/lack of progress of healing of all stage III and 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) ulcers, and surgical wounds. Resident/Sponsor will be educated by the nurse on skin care and the prevention of skin injury PRN. All education as well as the resident/sponsor response will be documented in the clinical record. Review of the Resident #3's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 6/13/24, showed: -admitted [DATE] and readmitted on [DATE]; -Cognitively intact; -Upper and lower extremity impairment on one side; -Incontinent of bladder and has a colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall); -Diagnoses include: anemia (decrease in number of red blood cells), diabetes, hemiplegia (paralysis on one side of the body), seizures, and malnutrition; -Determination of Pressure Ulcer Risk: Clinical assessment. Risk of Pressure Ulcers: Yes; -Does resident have one or more unhealed pressure ulcers at Stage 1 or higher: No. Review of the resident's Braden skin risk assessment, completed on 11/23/23, showed high risk. No further Braden skin risk assessments were completed. Review of the resident's electronic Physicians Order Sheet (ePOS) showed an order, dated 3/2/24, for weekly skin assessment every week on (day). Please complete weekly skin assessment. Review of the resident's care plan, in use at the time of the investigation, showed: -Focus dated 5/2/24: Resident has potential impairment to skin integrity related to hemiplegia, Below Knee Amputation (BKA), and diabetes; -Goals: Resident will maintain or develop clean and intact skin by the review date; -Interventions: Follow facility protocols for treatment of injury, educate resident/family/caregivers of causative factors and measures to prevent skin injury, identify/document potential causative factors and eliminate/resolve where possible; -Focus, undated: Resident has functional bladder incontinence related to physical limitations; -Goals: Resident will remain free from skin breakdown due to incontinence and brief use through the review date; -Interventions: Clean perineal area with each incontinence episode; -The presence of pressure ulcers not included in the care plan. Review of the resident's shower sheets, reviewed for the month of May 2024, showed perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to the charge nurse immediately. Forward any problems to the DON for review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities: -On 5/2/24, refused hand written on the form; -On 5/6/24, no skin areas identified as abnormal looking; -On 5/8/24, bed bath written on the form. No skin areas identified as abnormal looking; -On 5/13/24, bed bath written on the form. No skin areas identified as abnormal looking; -On 5/15/24, no skin areas identified as abnormal looking; -On 5/18/24, no skin areas identified as abnormal looking; -On 5/23/24, refused shower and bed bath written on the form; -On 5/29/24, bed bath written on the form. A hand drawn star over the buttocks area of the body chart. Barrier cream applied, hand written on the form. The form was signed by the Certified Nursing Assistant (CNA) and charge nurse. Neither signature legible. The signature line for the DON was not signed. Review of the resident's skin assessments for May 2024, showed: -A skin assessment, dated 5/19/24, No new skin issues noted by this nurse; -A skin assessment, dated 5/25/24, Site: Sacrum (buttocks area), small break down on the sacrum. New suspected pressure ulcer/Deep tissue Injury (DTI, Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister). Applied triad cream (barrier cream) and foam dressing to sacrum. Review of the resident's progress notes, dated May 2024, showed: -A note, dated 5/25/24 at 11:23 A.M., showed CNA notified charge nurse of skin break down on sacrum. Charge nurse applied triad cream and covered with foam dressing; -No further documentation of wound care or assessment; Review of the resident's ePOS, dated May 2024, showed: -No physician order for the triad cream and/or foam dressing documented; -No treatment order obtained for the sacrum. Review of the resident's shower sheets, reviewed for the month of June 2024, showed perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to the charge nurse immediately. Forward any problems to the DON for review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities: -On 6/4/24, no skin areas identified as abnormal looking; -On 6/8/24, no skin areas identified as abnormal looking; -On 6/11/24, no skin areas identified as abnormal looking; -On 6/14/24, no skin areas identified as abnormal looking; -On 6/18/24, no skin areas identified as abnormal looking; -On 6/22/24, no skin areas identified as abnormal looking; -On 6/25/24, no skin areas identified as abnormal looking; -On 6/29/24, no skin areas identified as abnormal looking. Review of the resident's skin assessments, for the month of June 2024, showed: -A skin assessment, dated 6/1/24, barrier cream applied to buttock and offered turning and repositioning during rounds; -A skin assessment, dated 6/8/24, no new skin issues; -A skin assessment, dated 6/15/24, skin intact; -No skin assessments documented for 6/22/24 or 6/29/24 and no further skin assessments documented in June. Review of the resident's ePOS, dated June 2024, showed no treatment orders for the buttocks/sacrum wound. Review of the resident's shower sheets, reviewed for the dates of July 1 through 20, 2024, showed perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to the charge nurse immediately. Forward any problems to the DON for review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities: -On 7/2/24, no skin areas identified as abnormal looking; -On 7/6/24, no skin areas identified as abnormal looking; -On 7/9/24, no skin areas identified as abnormal looking; -On 7/13/24, no skin areas identified as abnormal looking; -On 7/16/24, no skin areas identified as abnormal looking; -On 7/20/24, no skin areas identified as abnormal looking. Review of the resident's progress notes, for the dates of July 1 through 19, 2024, showed: -A progress note, dated 7/3/24 at 2:58 P.M., the resident had an open area to his/her coccyx (buttocks area), plan of care ongoing. Measurements: 3 x 6 x 0.2. The resident expressed no other needs at this time. Physician and family notified; -No other progress notes regarding the wound were documented. Review of the resident's ePOS, dated for the dates of July 1 through 19, 2024, showed: -An order, dated 7/4/24, Santyl (collagenase, a topical medication used for removing damaged or burned skin) external ointment 250 unit/gram (gm) (Collagenase). Apply to coccyx topically one time a day for wound care. Clean the area with soap and water, Normal saline/pat dry, apply Santyl ointment with calcium alginate (absorbent dressing) to the wound base, do not put on skin, skin prep the perineal area, cover with border foam dressing daily and as needed until resolved. Review of the resident's skin assessments, for the dates of July 1 through 19, 2024, showed: -A skin assessment, dated 7/6/24, no new issues to report. -No further skin assessments documented. Review of the facility's Wound Rounds report, for the dates of July 3 through 16, 2024, showed the following for the resident: -On 7/3/24 at 2:47 P.M., facility acquired Stage III pressure ulceration on coccyx measures 3 cm by 6 cm by 0.30 cm; -On 7/9/24 at 8:04 A.M., facility acquired Stage III pressure ulcer 3 cm by 6 cm by 0.30 cm; -On 7/16/24 at 8:04 A.M., facility acquired Stage III pressure ulcer. 1 cm x 1.0 x 0.30 cm; -No documentation the resident had a pressure ulcer identified prior to 7/3/24. Observation on 7/19/24 at 1:00 P.M., showed Licensed Practical Nurse (LPN) E completed a skin assessment. A bordered dressing was present and intact on his/her sacrum dated 7/19/24. During an interview on 7/19/24 at 1:15 P.M., LPN E said resident skin assessments are correlated with their shower days and completed by the assigned nurse or the wound nurse. During an interview on 7/19/24 at approximately 2:00 P.M., LPN G said he/she is the wound care nurse while the primary wound care nurse is out of town. The resident had a small pressure ulcer on his/her sacrum. The dressing was changed today and it was almost healed. The wound company Nurse Practitioner (NP) comes in on Monday. LPN G said he/she was not sure what happened or how the resident got the open area. During an interview on 7/23/24 at 9:45 A.M., the Administrator said she would have expected staff to complete and document skin assessments as ordered. Regarding when the area was identified in May, the treatment would depend on if the area was opened. It was just a red area and barrier cream was applied until it was later identified as a pressure ulcer and a treatment was ordered. There should have been a skin assessment completed and documented between 6/15/24 and 7/3/24. The staff are educated to document any red, open areas, and scars. She would expect the area to be identified and treated prior to being classified as a Stage III pressure ulcer. The wound nurse is currently not available to answer any questions. During an interview on 7/23/24 at 12:48 P.M., the wound care company NP said their company does not currently see the resident. He/She would expect by the time an open area becomes a Stage III that the facility would have the wound care company help them manage it. On 7/23/24 at 1:00 P.M., an attempt to interview the physician was made. No call back from the physician received. MO00237180

Based on interview and record review, the facility failed to ensure one resident (Resident #104) with a diagnosis of dysphagia (difficulty swallowing) was served food in the proper consistency to prevent choking. Staff reported the resident was routinely served a whole, hardboiled egg for breakfast. On [DATE], the resident was found unresponsive in the first-floor dining room. Cardio Pulmonary Resuscitation (CPR, a lifesaving technique used when breathing or heartbeat has stopped) was started and a piece of hard boiled egg, approximately 2 inches in diameter, was removed from the resident's mouth. The resident expired at the facility. The census was 97. The Administrator was notified on [DATE] at 4:00 P. M., of an Immediate Jeopardy (IJ) past noncompliance which began on [DATE]. The facility implemented a process and inserviced staff on ensuring food is served from the kitchen matching the food tickets, the requirement that eggs must be cut up, setting up resident trays, and cutting food for the residents. Nursing is to read the ticket when passing trays and ensure the food is the correct consistency before serving. The IJ was corrected on [DATE]. Review of Resident #104's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated [DATE], showed: -Brief Interview for mental status (BIMS, a screen for cognitive impairment) score: 12 out of a possible 15. A BIMS score of ,d+[DATE], showed the resident had moderately impaired cognition; -Eating: required partial/moderate assistance. Helper does less than half of the effort; -Swallowing disorders: none checked; -Diagnoses included: non-traumatic brain dysfunction (injuries to the brain that was not caused by an external physical force to the head), stroke, seizure disorder, traumatic brain injury (TBI, is an injury that affects how the brain works), and lung disease. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Resident was at risk of impaired nutritional status related to dysphagia with texturized diet order and history of significant weight loss with malnutrition diagnosis; -Goal: Resident will maintain nutritional sufficiency by eating greater than 50% of meals with no swallowing difficulties through next review date; -Interventions: provide diet/supplements as ordered; observe resident during mealtimes for chewing and or swallowing difficulties. Review of the physician order sheet, in use at the time of survey, showed: -Regular diet, mechanical soft texture (a type of texture-modified diet for people who have difficulty chewing and swallowing. Foods may be pureed, ground, finely chopped, or blended to make eating safer) regular consistency. Review of the nutrition/dietary progress note dated [DATE], showed regular diet, mechanical soft; no citrus (orange juice, oranges, limes, lemons, grapefruit, or blueberries), dislikes pork. Review of the resident's progress notes, showed: -On [DATE] at 2:05 P.M., late entry for [DATE] at 8:25 A.M., Certified Nurse Aide (CNA) was in the hallway outside the dining area waving his/her arms. The nurse went to dining room to assess why the CNA was obtaining the nurse's attention, noted resident bluish in color and without a pulse. The resident was taken to his/her room quickly while code blue and 911 was called. Resident was transferred to floor via two staff members. CPR was started until a faint pulse noted. Emergency Medical Service (EMS) arrived at facility while resident had faint thready pulse. EMS took and controlled the scene upon their arrival; -On [DATE] at 2:40 P.M., resident was found unresponsive. Code was called over head by Certified Medication Technician (CMT). The nurse and other nursing staffed ran to assist with the code. CPR was started by nursing staff. EMS arrived 10 minutes after the call was made. EMS began life saving measures. Time of death was called at 9:01 A.M. Review of the handwritten statement, written by Cook A, dated [DATE], showed the resident was served toast, hot cereal, and boiled eggs. Yesterday, the resident asked Cook A if he/she could get boiled eggs again. That is what he/she was served, as the resident requested it. Review of a handwritten statement, written by CNA B, dated [DATE], showed CNA D asked CNA B to get the nurse, so CNA B waved his/her hands at the nurse. The nurse asked if it was Resident #104. CNA B and CNA D took the resident to his/her room. The nurse cleaned food out of the resident's mouth after he/she was in bed. Then, the resident was moved to the floor. Staff started CPR and checked his/her code status, did the code page, and called an ambulance for the resident. During an interview on [DATE] at 10:20 A.M., CNA B said on [DATE] he/she took the resident's tray into the dining room and there were two hard boiled eggs on his/her tray. CNA B said he/she did not cut up the eggs. The resident always had hard boiled eggs and he/she normally picked up the eggs and ate them him/herself. Review of a handwritten statement, written by CNA D, dated [DATE], showed CNA D passed the trays in the dining room, and he/she saw the resident feeding him/herself. He/she noticed the resident was leaned over to the left side of the wheelchair. CNA D called the resident's name a few times and the resident did not respond. CNA D checked and the resident's pulse was faint. CNA D looked out the dining room door and saw CNA B in the hall and told him/her to get the nurse. CNA D pushed the resident back in his/her wheelchair so it would be easier to run/push him/her to his/her room. As CNA D pushed/ran down the hall to the resident's room, the nurse told the Certified Medication Technician (CMT) to call a code and 911. CNA D helped the day and night nurse get the resident into bed, by that time nurses from all the floors were coming in to assist. During an interview on [DATE] at 9:26 A.M., CNA D said the resident was on a mechanical soft diet. He/She would ask for and get hard boiled eggs. The resident usually picked up the whole egg and ate it. When CNA D went around to collect the trays, he/she noted the resident leaned to the left side. His/Her color was pale and he/she had a faint pulse. CNA D went to the doorway and called CNA B to get the nurse. Review of the handwritten statement, written by CMT E, dated [DATE], showed CMT E was at the nurse's station around 8:20 A.M., listening to report about the residents. CNA B was at the end of the hallway by the dining room, waving his/her hands. Licensed Practical Nurse (LPN) C went down the hallway asking, what's wrong? Is it Resident #104?. CNA B replied yes. LPN C yelled down the hall to check the code status. CMT replied he/she was a full code. LPN C told CMT E to call a code and 911. LPN C and other staff performed CPR until EMS arrived. During an interview on [DATE] at 9:00 A.M., CMT E said the meal trays arrive to the floor on a cart. Nursing passes the trays out to the residents. If a resident was on a mechanical soft diet, the food will come on a divided plate or a regular plate, it depends on the resident's preference. The meal ticket will say mechanical soft diet. Resident #104 was on a mechanical soft diet. Review of a typed statement by LPN C dated [DATE], showed LPN C arrived on the floor at 8:15 A.M., while receiving report, CNA B was at the end of the hall near the dining room, waving his/her hands. LPN C stood up and started to go towards CNA B. LPN C asked what was wrong, then asked if it was Resident #104. CNA B replied yes. LPN C started to run towards the CNA and resident. Another nurse was behind LPN C with the crash cart. The resident appeared blue and unresponsive. LPN C turned to CMT and said, call a code and 911. Staff took the resident into his/her room. LPN C swept the resident's mouth and removed all visible food. Staff transferred the resident to bed then to the floor. Other nurses, supervisor, and staff started to arrive and assist with code. CPR was started immediately and continued until EMS arrived. EMS and police arrived in 10 minutes. During an interview on [DATE] at 10:38 A.M., LPN C said he/she did not know if the resident ate breakfast or not. He/She did have food on his/her face and clothing. He/She checked the resident's mouth and there was no food or particles. He/She was in the hall when staff were bringing the resident into his/her room from the dining room. Staff placed the resident into bed. LPN C went to the resident's room and he/she had a pulse at that time. Staff then moved the resident from bed to the floor to start CPR when, shortly thereafter, a pulse was no longer noted. Review of the handwritten statement, written by LPN G, dated [DATE], showed at 8:20 A.M. LPN G was giving report to the oncoming nurse, LPN C. While giving report, CNA B waved his/her hands in the air to get our attention. The oncoming nurse yelled, is it Resident #104? The aides wheeled the resident down the hall, as LPN G and the other nurse ran to the resident. LPN G stopped immediately and grabbed the crash cart, while CMT E called the code and called 911. When staff got to the room, LPN G, LPN C and CNA B moved the resident to the bed and then immediately to the floor. Staff began CPR and ambu bagged (disposable mask used for resuscitation) the resident. While performing CPR, LPN G observed what looked like a piece of egg come out of the resident's mouth. Staff continued CPR until the EMS arrived and took over. Review of the written statement, written by LPN F, dated [DATE], showed the Manager on Duty (MOD) and a CNA walked onto the unit and asked for the crash cart. LPN F asked what was going on. MOD stated that a code blue was called. LPN F and MOD immediately left the unit with the crash cart. Once they arrived on the unit where the code was called, the nurse said they had begun CPR. Upon entering the room, LPN F observed the resident on the floor, pale and the chest was not rising and falling. LPN F asked staff who was performing CPR what happened. They said they did not know. LPN F asked if the resident was eating and if he/she aspirated. Nurses performing CPR stated he/she was eating breakfast. One of the nurses was relieved of CPR by LPN F. After 30 compressions, instructed the other nurse to give two breathes. Performed second set of compressions, asked for two breathes to be given and noticed the chest did not expand. The other nurse stated that they had checked the resident's mouth and there was nothing. Another nurse at this point relieved LPN F from chest compressions, and during the nurses second set of compressions, LPN F noticed something white in the ambu mask and a piece of egg flew out. The mask was removed from resident's mouth and there was a boiled egg that was broken in half in the resident's mouth. Another nurse swept egg out of the resident's mouth and they re-started CPR. EMS arrived and took over the code. The resident expired at 9:00 A.M. During an interview on [DATE] at 12:06 P.M., LPN F said at first nothing was in the resident's mouth, after the third set of compressions, something white was noted in the mask. It had half of a hard-boiled egg and egg yolk. The resident was on a mechanical soft diet. During an interview on [DATE] at 2:17 P.M., Registered Nurse (RN) N said, he/she heard the code called and ran towards the elevator to go to the other unit. When he/she got to the room, there were two people in the room, they were in the process of putting the resident on the floor. Once the resident was on the floor, staff started CPR. When staff pressed down to give compressions, the resident had egg in his/her mouth. This happened about three times. The first time, there was a large amount, the second and third time it was a small amount; two to three small fragments, it looked like chewed deviled eggs. The resident did not vomit the eggs up, there was no salvia, the egg was just there. RN N removed the egg from the resident's mouth, and they continued with CPR. During an interview on [DATE] at 2:40 P.M., RN O said he/she heard the code called and ran towards the elevator to go to the other unit. When he/she got to the room, the resident was on the floor. The resident's color was grayish. RN N started compressions. When they switched and RN O started compressions; big hunks of egg came out of the resident's mouth. One piece of white was whole and was approximately two inches in diameter. Staff wiped the resident's mouth to get the egg out. RN O felt the resident was choking on egg. The resident may have vomited some of the egg up, but RN O said his/her impression was the egg may have been in the resident's trachea and with the compressions and bagging, it may have just come out. At one point there was a pulse on the pulse ox. When EMT got there they said they had a pulse, and they took over. Review of the ambulance run report, showed: -The unit was notified on [DATE] at 8:30 A.M.; -The unit was dispatched to the facility, for a resident with a chief complaint of cardiac arrest. When EMS arrived on the scene and entered the facility, were directed to the patient's room. When we entered the room, observed the patient lying supine (on back) on the floor while staff was performing chest compression as well as ventilations via Bag Valve Mask (BVM, disposable mask used for resuscitation). The patient's skin color was extremely pale, and his/her overall appearance was extremely poor. We were informed the arrest was witnessed but staff could not give a specific account of events leading to the arrest. Separate staff members stated different times regarding how long the patient had been in cardiac arrest, but it was ultimately determined that he/she had been in this state for approximately 15 minutes. Another staff member stated they believed the patient had choked on food causing him/her to asphyxiate (choke) which led to his/her cardiac arrest. Staff had little additional information regarding the patient. We then relieved staff of their CPR efforts. CPR was reinstated and the cardiac fast patches were placed onto his/her torso. The initial cardiac rhythm observed by EMS was asystole (flat line, when the heart's electrical system fails, causing the heart to stop pumping) Cardiac resuscitation efforts were initiated per protocol. Multiple attempts at securing an advanced airway were unsuccessful due to the amount of food lodged in the patient's airway. The food appeared to be a hard boiled egg. Suctioning was performed multiple times and a significant amount of food was removed from the airway. Ultimately, it was determined to secure the patient's airway using an I-Gel 4 (airway). At no point during our resuscitative efforts did the patient present with a cardiac rhythm other than asystole. When we approached the 20-minute mark of resuscitation efforts, medical control at the hospital was contacted and informed of our current code status. After that was determined, resuscitation effort was discontinued, and the time of death was called at 9:00 A.M. During an interview on [DATE] at 10:00 A.M., the Director of Dietary Services said dietary is made aware of the resident's diet by the diet communication form. The nursing staff will complete the form and give it to dietary. Sometimes staff or a resident will stop her in the hall or call dietary if the resident is on a special diet or has a request. Dietary is responsible for assembling the food on the trays and checking the meal tickets. The trays are placed on the cart and delivered to the units. Nursing staff deliver the trays to the residents, and they should check the meal ticket with the plate being served. They are the second set of eyes. If nursing serves a tray without reading the ticket, and there was a problem, it will fall on nursing. If a resident was on a mechanical soft diet, dietary would smash hard boiled eggs, or split the egg and nursing would set it up from there. During an interview on [DATE] at 3:20 P.M., the Administrator said hard boiled eggs should be served cut up or chopped for a mechanical soft diet. MO00229010

Based on interview and record review, staff failed to assess a resident with aphagia and a continuous tube feeding when the resident had emesis and a change of behavioral/physical changes. Review of the resident's progress notes showed no documentaion regarding an assessment, monitoring or physician notification of the resident's change of condition and emesis. Three residents with changes in condition were sampled and problems were found with one (Resident #2). The census was 90. Review of the facility's Enteral Feedings (tube feeding) policy, dated ,d+[DATE] and last reviewed on ,d+[DATE], showed: -Protocol: To minimize the risk of aspiration (inhaling food/fluid into the lungs), the head of a resident/patient's bed will be elevated 30 to 45 degrees while enteral feeding is infusing; -Procedure: Continuous Feeding/Infusion Pump: -Notify the Physician if gastric residual (aspiration of the stomach contents at intervals is recommended to ensure the feeding is not backing up due to a possible obstruction) is greater that 50 cubic centimeters (cc, one cc is equivalent to one ounce) or as ordered by Physician; -Document the following: -Tube feeding placement verification; -Time tube feeding initiated; -Resident/patient tolerance; -Amount of gastric residual, as applicable. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Short and long term memory problem; -Extensive assistance of one person required for bed mobility and dressing; -Extensive assistance of two (+) persons required for transfers, toilet use, personal hygiene and bathing; -Total dependence on one person required for eating; -Diagnoses of stroke, high blood pressure, aphasia (loss of the power of speech, or of appropriate use of words), hemiplegia (paralysis affecting one side of the body)/hemiparesis (weakness affecting one side of the body); -Nutritional Approach: Feeding tube -Proportion of total calories received through feeding tube: 51% or more; -Average fluid intake per day by feeding tube: 501; -Individual minutes resident received skilled speech therapy in the last 7 days: 45 minutes. Review of the resident's care plan, showed; -No focus or interventions identified regarding gastrostomy tube (g-tube)/gastrostomy tube feeding. Review of the resident's physician's order sheet showed: -[DATE]: Jevity 1.5 (liquid nutritional supplement/tube feeding) at 75 cc's an hour via pump (tube feeding pump). Flush with 100 cc's of water every 6 hours; -[DATE]: Nothing by mouth. Review of the resident's medication administration record (MAR) and treatment administration record (TAR), dated [DATE] through [DATE], showed: -MAR: -No start date: Jevity 1.5 at 75 cc's an hour on days and nights; -On [DATE] at night showed Nurse M initialed the tube feeding was administered; -TAR: -Check and record residuals every day and night shift. On [DATE], day shift, Nurse M initialed the residual had been checked, but the amount of residual, if any, had not been documented on the TAR -On [DATE] for night shift, the initials showed AG2 (agency nurse) had checked for residual, but the amount, if any, had not been documented on the TAR; -A routine daily blood pressure at 7:00 A.M. On [DATE], showed the resident's blood pressure was ,d+[DATE]. Review of the resident's progress notes showed the following: -No Nurse's progress notes on [DATE], until Nurse E documented a late entry progress note at 8:53 P.M.; --[DATE] at 7:23 A.M., late entry documented by Nurse E for [DATE] at 8:53 P.M.: This Nurse called to patient's room. CNA stated Resident #2 doesn't look right. Upon entering the room this Nurse noted patient to be sitting in his/her bed with head of bed at a 90 degree angle. Resident's eyes were open, unable to visualize rise or fall of chest or abdomen. No audible breath sounds detected. Able to detect faint left carotid artery pulse. Sternum rub (using the fingers to vigorously rub the sternum (breast bone in the center of the chest). Upon sternum rub resident noted to take in a deep inhalation, resident did not exhale. CNA that called resident to bedside instructed to have CNA in hallway call overhead code to room. Supervising Nurse was on his/her way to hall when he/she brought the crash cart (contains equipment to perform CPR). By the time Supervising Nurse entered the room the resident had been transferred to the floor to start CPR immediately. 911 was called immediately by Supervising Nurse. This nurse with two CNAs continued CPR until EMS arrived. CPR taken over by EMS and continued to perform all life saving measures until 9:34 P.M. when final time of death was pronounced. Supervising Nurse placed call to family and physician to make aware of death. DON aware of death. Review of the resident's EMS report, showed: -The facility notified the EMS unit on [DATE] at 8:54 P.M.; -Response Times: -At scene (facility) 9:00 P.M.; -At patient 9:01 P.M.; -Narrative: -Upon arrival, staff found to be providing CPR on patient; -Staff is switched out of compression and ventilations (EMS staff took over CPR); -Patient noted to have orange vomit coming out of mouth and is noted on patient's clothes and chest; -Staff states patient found to be unresponsive and barely breathing just before calling EMS; -Nurse states that around ,d+[DATE] (5:00 P.M. or 6:00 P.M.) patient was noted to have aspirated and was suctioned and patient was doing better; -Nurse states the patient is not verbal and has a g-tube (feeding tube) due to inability to swallow after a stroke; -Decision was made to terminate recession attempts at 9:31 P.M. Review of the resident's MDS tracking record, showed the resident died on [DATE]. During an interview on [DATE] at 10:30 A.M., CNA K said he/she worked on the day shift and evening shift on [DATE]. That morning he/she helped CNA G take care of the resident. The resident had not thrown-up, but he/she noticed a difference in the resident. The resident was not showing any emotion and was not fidgety like he/she normally was. Normally when staff tried to turn the resident, he/she would resist by pushing against the bed rail. He/She did not do that. CNA K and CNA G told Nurse M something was not right with the resident. Nurse M did go in and check on the resident who was acting a bit more his/her normal self at that time. He/She was not asked to take any vitals. He/She went back to his/her own group after helping CNA G. Later that day, between 5:00 P.M. and 6:00 P.M., CNA J told him/her the resident had vomited. He/She did not see it. That was only what CNA J told him/her. Nurse M was still on duty at the time and CNA J said he/she told Nurse M about the resident vomiting. About an hour after CNA J told CNA K about the resident vomiting, the resident's roommate had turned on his/her call light for Resident #2. He/She went in and the roommate said the resident was gurgling. He/She checked the resident and he/she was kind of dry heaving, like he/she was going to throw-up. He/She yelled down the hall for Nurse E who came to the room and told him/her to go and call a code (an event involving cardiopulmonary arrest (heart stops beating) to a patient requiring staff to rush to the specific location and begin immediate resuscitative efforts) on the intercom. During an interview on [DATE] at 8:54 A.M., CNA J said he/she worked on the resident's hall on the evening of [DATE]. He/She was not assigned to the resident that evening. An hour or two hours prior to the resident being coded, the resident's roommate had turned on the call light. The roommate said Resident #2 had thrown-up. He/She did not know where the resident's CNA was so he/she answered the call light and began to clean the resident up. The resident's head of bed was up and he/she had a moderate amount of emesis in his/her mouth and on his/her chest and gown. CNA J put the resident's tube feeding pump on hold while he/she cleaned him/her. The resident did not look good and seemed to be kind of out of it. Normally the resident never talked, but seemed to be alert to what was going on and he/she would resist being turned and repositioned. This time he/she was just awake and did not resist being turned and repositioned. The day shift nurse (7:00 A.M. to 7:00 P.M.) came in while he/she was cleaning the resident. He/She told the nurse about the emesis and the resident just did not seem right. He/She had not worked there long and he/she did not know the nurse's name. He/She did not see the nurse assess the resident and the nurse did not give him/her any directives to turn the tube feeding pump off or obtain vitals. CNA G (CNA assigned to the resident) came in and took over and he/she left. He/She did not see the resident again until later when the resident coded. When he/she got to the room the resident was not breathing and not responding at all. The resident had a small amount of emesis on his/her mouth and gown. He/She can't recall if the head of the bed was up or down at that time. CNA J, CNA G and Nurse E, the night shift nurse (7:00 P.M. to 7:00 A.M.), placed the resident onto the floor. Nurse E started CPR. They continued the CPR until EMS arrived. During a telephone interview on [DATE] at 12:00 P.M., Nurse L said he/she worked on [DATE] from 7:00 A.M. to 7:00 P.M., and the resident was assigned to him/her. He/She did not recall CNA G or CNA K saying anything was abnormal about the resident. No one told him/her the resident had an emesis. Had they told him/her, Nurse L would have turned off the tube feeding pump, obtained vitals, listened to the resident's bowel and lung sounds and told the Nurse Supervisor to determine if the resident needed to go to the hospital. He/She would have documented this in the progress notes. He/She did not notice anything unusual about the resident except the resident was not kicking his/her legs around the bed, which he/she normally did. During a telephone interview on [DATE] at 8:05 A.M., Nurse E said he/she came to work on [DATE] around 7:00 P.M. He/She received report from Nurse L. Nurse L did not tell him/her anything about the resident having a change in condition or emesis and neither did the CNAs. It would have been very pertinent to have known that during report. Had he/she been made aware, he/she would have immediately checked on the resident. If his/her tube feeding pump was on, Nurse E would have turned it off and placed the resident's head of bed at 90 degrees. He/She would have assessed the resident by getting a set of vitals, listening to the resident's lungs, obtaining an O2 sat (a device that measures the oxygen in the blood) and calling the physician to see if an x-ray was needed to determine if the resident aspirated. He/She would have document his/her actions in the progress notes. Later that shift, CNA J motioned him/her to the resident's room, telling him/her the resident did not look right. There was no rise/fall in the resident's chest and no carotid pulse. The tube feeding pump was on. He/She turned it off and disconnected it so they could transfer the resident onto the floor to start CPR. He/She did not see any emesis in the resident's mouth, chest or gown. He/she did not suction the resident, but EMS did when they arrived. He/She wrote the progress note for [DATE] at 8:53 P.M. During a telephone interview on [DATE] at 6:00 A.M., the EMS report was reviewed with Nurse E. The nurse said he/she recalled the resident having his/her stomach contents come up after they began chest compressions. He/She suctioned the resident, but did not document it. He/She did not recall telling EMS the resident had an emesis between 5:00 P.M. and 6:00 P.M., was suctioned, and doing better. He/She said no one told him/her at shift change about any change in condition with the resident. It was possible CNA J told him/her about the emesis between 5:00 P.M. and 6:00 P.M. At that time, he/she was called to the room and CPR was initiated and then reported it to EMS. He/She did not recall doing that, but it is possible. During an interview on [DATE] at 6:43 A.M., Nurse B, the Nurse Manager, said he/she was in the building on the evening of [DATE]. At the shift change no one reported to him/her the resident had an emesis between 5:00 P.M. and 6:00 P.M., or that the resident was suctioned as a result. He/She made facility rounds when he/she came to work. When he/she rounded he/she walked the halls and looked in every room to make sure everyone was ok. He/She made rounds on the resident's hall around 7:45 P.M. He/She did not go into the resident's room, but recalls the resident being in bed with the head of the bed up. He/she appeared to be sleeping. He/She did not see any emesis on the resident and could not say if the resident's tube feeding pump was on or off. Later that evening, Nurse E called him/her and said they had initiated a code. He/She immediately went to the unit got the crash cart and took it to the resident's doorway. Nurse E and CNAs J and K had the resident on the floor performing CPR. He/She did not go into the room so he/she did not know if the resident had another emesis or not. During a telephone interview on [DATE] at 12:32 P.M., the Medical Director, who was also the resident's assigned physician, said he did not recall anyone contacting him about the resident having a change in condition including an emesis. He would have expected staff to stop the tube feeding and assess the resident. The assessment should have included vitals, lung and bowel sounds, O2 sat, assessment of the abdomen for distention (bloating and swelling in the abdomen area), and check for tube feeding residual. Had they contacted him, he would have ordered the tube feeding to remain off and ordered a KUB (kidney, ureters and bladder x-ray) to determine if the resident had an ileus (intestinal obstruction, symptoms include abdominal distention, sick stomach and vomiting). He would have expected this to have been documented in the progress notes. During an interview on [DATE] at 1:58 P.M., the Director of Nursing said if a CNA reported a change in condition she expected the Physician to be notified and the nurse should complete an assessment and document it in the progress notes. If the resident had an emesis, she would have expected staff to immediately turn off the tube feeding pump, keep the head of the bed raised, assess the resident's bowel sounds, obtain vitals and call the physician and family. This should all be documented in the progress notes. The resident's care plan should have addressed the resident's tube feeding. Anything above 60 cc's of tube feeding residual would require turning off the tube feeding pump and notifying the physician, but she was not sure. She did not know why staff were not recording residual amounts. She would check with the Medical Director about residual amounts and when to turn off the tube feeding pump and contact the physician. MO00221105

Based on interview and record review, the facility failed to follow their abuse policy to protect all residents from harm when management staff failed to suspend an employee, per facility policy, after an allegation of abuse was made. The resident called his/her family, crying, on the evening of 8/2/23 and reported the disrespectful comments made by Certified Medication Technician (CMT) D. The family then reported this information to Nurse B who reported the incident to the administrator. The facility investigation was started on 8/2/83 by the Director of Nursing and completed on 8/3/23. CMT D was not suspended per policy until Certified Nursing Assistant (CNA) H and CNA I were finally interviewed on 8/8/23 and the administrator learned the resident had been upset and crying when the incident occurred and refused to take medications from CMT D. CMT D continued to work at the facility on 8/3/23, 8/5/23, 8/6/23, and 8/7/23. The facility census was 90. Review of the facility Abuse, Neglect, Misappropriation of Resident Property, and Injury of Unknown Origin policy, dated 8/17/16 and last revised on 8/1/22, showed: Prevention and Reporting: 1. The Administrator has primary responsibility in the facility for implementation of the abuse/neglect program; a. The facility will follow all state and federal guidelines on preventing abuse, neglect program; b. The facility encourages and supports all residents, staff and families in feeling free to report any suspected acts of abuse, neglect, misappropriation or injury of unknown origin. The facility takes all measures possible to ensure that residents, staff and families are free from fear of retribution if reports or incidents are filed with the facility; c. Reports of abuse will be promptly reported and thoroughly investigated. Additionally the facility should immediately report all such allegations to Administrator/designee and to the DHSS. In cases where crime is suspected staff should also report the same to local law enforcement; 2. The facility prohibits the mistreatment, neglect, and abuse of residents by anyone including staff, family, friends, etc.; 3. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse, neglect and/or mistreatment; 4. The facility has implemented the following processes in an effort to provide residents a safe and comfortable environment; 5. The Shift Supervisor (Charge Nurse, Nurse Manager or Administrator) is identified as responsible for immediate initiation of the reporting process; 6. The Administrator and Director of Nursing (DON) are responsible for investigation and reporting. They are also ultimately responsible for the following: a. Implementation; b. Ongoing monitoring; c. Reporting; d. Investigation; e. Tracking and trending; 7. Implementation and ongoing monitoring consists of the following: a. Screening; b. Training; c. Prevention; d. Identification; e. Protection; f. Investigation; g. Reporting/Response; Definitions: Abuse includes: -Intimidation with resulting physical harm or mental anguish; -Verbal Abuse: Oral, written, or gestured language that includes disparaging and derogatory terms to the resident or their families or within their hearing distance, to describe resident, regardless of their age, ability to comprehend or disability; -Mental Anguish: Psychosocial outcomes resulting from the willful action including, but not limited to: Fear of a person, depression and crying; Mental and Emotional Abuse: Includes, but is not limited to, humiliation, harassment, and threats of punishment; Prevention: -Staff members, residents, family members and others are encouraged to report concerns, incidents, and grievances without fear of retribution; Protection: -Provide for the immediate safety of the resident upon identification of suspected abuse, neglect, and mistreatment. Means of protection include, but are not limited to: -Immediate suspension of suspected employee(s) pending outcome of the investigation; Investigation: -Employees Suspension from Duty: -Any time an allegation is made involving abuse, neglect or mistreatment of a resident which names a specific employee, laws and regulations are specific about protecting all residents from harm, which means suspending the employee until the completion of the investigation; -The employee is not to remain on duty, and is not to be assigned to any other area of the facility; -The Administrator, or in his/her absence, the DON, Assistant Director of Nursing, or Charge Nurse, in that order, must relieve the employee of his/her duties until the investigation is completed. If the allegation is substantiated the employee will be terminated immediately; Reporting/Response: -Any person witnessing or having knowledge of alleged violation involving abuse or neglect are to notify the Administrator or DON immediately. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/19/23, showed: -Moderately impaired cognition; -Rejection of Care: Behavior not exhibited; -Extensive assistance of one person required for bed mobility, dressing, and toilet use; -Extensive assistance of two (+) persons required for personal hygiene and bathing; -Diagnoses of anemia (a deficiency of oxygen-carrying components in the blood), high blood pressure, renal (kidney) insufficiency, hemiplegia (paralysis affecting one side of the body)/hemiparesis (weakness affecting one side of the body) and malnutrition; -Medications: Received antidepressants 7 of the last 7 days. During an interview on 8/7/23 at 9:07 A.M., the resident said he/she only had a problem with one staff member regarding abuse and/or neglect, and that was CMT D. One day last week the CMT was saying rude and disrespectful things to the resident and threatened him/her. The CMT said things like CMT D could wipe and clean his/her own ass, but the resident could not. The CMT told the resident he/she was never going home. CMT D could take out the resident by giving the wrong medication. After the interaction, the resident refused to take medication from CMT D. All of this upset the resident, and he/she was crying when he/she called his/her family to tell them what happened. He/She had not seen the CMT since that day and did not know if CMT D still worked at the facility. He/She said CMT D better never come in his/her room again because after what CMT D said, the resident will never take any medication from him/her again. The resident did not know if other employees heard what CMT D said to him/her. Review of the facility's investigation on 8/7/23, showed: -A written statement from CMT D dated 8/2/23: -About 4:30 P.M., he/she asked staff if the resident had been touched all day because the resident said he/she had not been cleaned all day. CMT D was told the resident had been cleaned up, and the staff who cleaned him/her up were still there. CMT D and the staff who had cleaned the resident up went to the resident's room and told him/her he/she had been cleaned up. The resident flipped out, began cursing, called them names and threatened to kick their assess. Around 6:30 P.M., the resident's family came in and the resident said something to them. The family asked CMT D what happened. He/She began to tell the family what happened, when the resident began yelling a curse word at him/her. The resident's family said the resident told them CMT D said he/she was going to put something in his/her pills. The CMT denied saying anything of the nature; -A written statement from Nurse B dated 8/2/23: -Resident expressed to this nurse that CMT D was disrespectful to him/her. Resident said the CMT said, I will give you something to take you out of here. When asked what provoked this, resident said CMT D is always disrespectful like this. Resident did admit to going off on CMT D. The CMT had said other hurtful and disrespectful things like CMT D could wash (his/her) ass, but could the resident? or CMT D could use the restroom, but could the resident? No, the resident couldn't even move. Resident said he/she didn't want the CMT to give him/her pills any more; -Resident statements taken on 8/3/23 and documented by the DON showed: -Six residents, including the resident and his/her roommate were interviewed. Only Resident #3 said he/she had a problem with CMT D; -The DON's investigation conclusion statement, dated 8/3/23, showed: -Resident #3 expressed concern that CMT D was disrespectful. Interviewed several residents that resided on the same division as Resident #3. No concerns were verbalized. CMT D was permanently removed from that assignment. Resident had history of refusing medications and showers and then call family and to inform them staff were not offering to shower him/her. No other residents had any issues with CMT D. Most residents interviewed enjoyed his/her personality; -Conclusion: possible personality conflict between resident and CMT D. CMT D would be placed on a permanent assignment on another unit; -No other staff interviews were conducted as part of the facility investigation. During an interview on 8/7/23 at 10:15 A.M., the Administrator said she was not made aware of the resident's allegations until 7:14 P.M., on 8/2/23. CMT D called her and said the resident was going off on him/her and he/she was going upstairs. At 7:19 P.M. Nurse B called and reported the resident's family came in upset because the resident said CMT D had made disrespectful remarks to the resident. She had Nurse B speak to the resident and put the phone on speaker so she could hear what the resident said. All she remembered was the resident said CMT D was disrespectful to him/her. She was not aware about the specific remarks that Nurse B documented on 8/2/23 in his/her written report. There were never any previous complaints regarding the CMT. The CMT was not sent home or temporarily suspended. It was close to shift change when she found out. At the time, she was not aware the resident said anything other than the CMT was disrespectful. The DON began an investigation the next day and has since completed her investigation. She is not aware of any problems that were found, other than the resident said the CMT disrespected him/her. They scheduled CMT D to work on a different floor since this occurred to avoid any more confrontations. During an interview on 8/7/23 at 10:55 A.M., with the Administrator the facility investigation was reviewed. She was not aware of CMT D's alleged remarks in Nurse B's written statement. She had not reviewed the investigation until now and had she been aware of those alleged remarks, she would have directed staff to immediately obtain the CMT's statement then send him/her home with instructions to not return pending the outcome of the investigation. She is responsible to ensure investigations are completed timely, thoroughly and follow the facility policy. She is also responsible to review the completed investigations. During an interview on 8/7/23 at 11:13 A.M., CMT D said on 8/2/23, he/she was assigned to administer medications on the resident's floor. Around 4:30 P.M., the resident told CNA H he/she had not been cleaned up all day. CMT D knew CNA I had cleaned the resident up a few hours prior. He/She found CNA I and CNA H and CMT D went to the resident's room so CNA I could remind the resident he/she had been cleaned up. When they got there to tell the resident about being cleaned up earlier, the resident began calling CMT D all kinds of names, and cursed at him/her. Later at about 6:30 P.M., he/she was speaking to the resident's family outside the resident's room. The family said the resident said CMT D had not cleaned the resident up all day and was going to give the resident pills to take him/her out. He/She found CNA I again to verify to the family members they had cleaned the resident up. He/She never yelled at the resident, never said anything about the resident not being able to wipe (his/her) own ass, never said anything disrespectful and never threatened to give the resident pills to take him/her out. The resident had a history of yelling and cursing at staff. When the resident was like that, CMT D just walked away until he/she calmed down. CMT D did not get into confrontations with the resident. During an interview on 8/8/23 at 6:43 A.M., Nurse B said he/she was the building supervisor on 8/2/23. Around 6:45 P.M. or 7:00 P.M., Nurse F brought the resident's family member to him/her. The family member had a complaint and wanted to let Nurse B know about it. The family said the resident had called them and said CMT D told the resident he/she was going to give the resident something to take the resident out of here. Nurse B took that to mean CMT D was going to give the resident a medication to take him/her out. When Nurse B spoke to the resident, the resident said the same thing. The resident said CMT D made all kinds of derogatory remarks including remarks about not being able to take care of himself/herself. Nurse B said he/she spoke to CMT D that day. CMT D said it all began around 4:00 P.M. CMT D gave Nurse B a written statement. CMT D did not say anything about CNA H and CNA I being present. He/She did not interview Nurse F, CNA H or CNA I. During an interview on 8/8/23 at 7:01 A.M.,, CNA H said he/she worked 7:00 P.M. to 7:00 A.M., but came in on 8/2/23 around 3:00 P.M. He/She was assigned to care for the resident. Around 4:30 P.M. or 5:00 P.M., the resident was mad, because staff had not cleaned up the resident that day. He/She told CMT D who said CNA I had cleaned the resident up earlier that day. He/She, CNA I and CMT D went to speak to the resident to remind the resident CNA I had cleaned him/her earlier that day. The resident did not seem upset at the time. Later that evening the family came in, but he/she was on break when they arrived. When he/she spoke to the family they said the resident was upset. The resident was crying. He/She saw the resident get emotional before, but never saw the resident cry. The resident did not say exactly what happened. He/She did not see CMT D get into an altercation with the resident. He/She was only in the resident's room with CMT D when CNA I came in to remind the resident he/she had been cleaned earlier that day. No one interviewed CNA H until yesterday. Review of CNA H's written statement dated 8/7/23, showed he/she did not hear CMT D talk to the resident in a bad manner. However, on 8/2/23, he/she did witness the resident to be very upset. During an interview on 8/8/23 at 7:15 A.M., CNA I said he/she worked on 8/2/23. Between 4:00 P.M. and 5:00 P.M., he/she heard CMT D say the resident refused to take his/her medications. CNA I did not know why at that time. Later, the resident was rowdy and said he/she did not like CMT D. He/She asked the resident why, but the resident did not say at that time. Around 5:30 P.M. or 6:00 P.M., he/she heard CMT D and the resident arguing. They were yelling at each other. He/She heard CMT D tell the resident he/she could wipe his/her ass, but the resident could not wipe his/her own ass. He/She did not hear CMT D say anything about giving the resident anything to take the resident out. He/She did not report this to Nurse F who was on duty, because Nurse F was right there too. He/She assumed Nurse F heard it. He/She was present when the resident's family came in and heard the family accuse CMT D of telling the resident he/she was going to give the resident something to take him/her out. No one interviewed CNA I until yesterday. Review of CNA I's written statement dated 8/7/23, showed he/she did not hear the it (the interaction between CMT D and the resident). He/She heard what the resident told his/her family. On 8/8/23, CNA I added to the initial statement he/she heard CMT D tell the resident, At least I can wipe my own ass. Review of the resident's medication administration record dated 8/1/23 through 8/7/23, showed the resident took all of his/her medications each day at each administration time with the exception of six of six scheduled evening medications on 8/2/23: -Four at 4:00 P.M.; -One at 5:00 P.M.; -One at 6:00 P.M.; -CMT D coded these medications as 2 (drug refused). Review of CMT D's time card, showed the CMT worked the following dates and times: -8/2/23: In at 7:05 A.M., out at 7:33 P.M.; -8/3/23: In at 6:59 A.M., out at 5:32 P.M.; -8/4/23: Was not scheduled; -8/5/23: In at 7:11 A.M., out at 8:35 P.M.; -8/6/23: In at 7:04 A.M., out at 8:35 P.M.; -8/7/23: In at 7:02 A.M., out at 8:40 P.M. During an interview on 8/7/23 at 1:15 P.M., the Administrator said he/she did not know CNA H and CNA I were present during some or all of the alleged altercation that occurred between the resident and CMT D. CNA H and CNA I should have been interviewed as part of the facility investigation. During a telephone interview on 8/10/23 at 12:32 P.M., the Medical Director said he expected the facility to follow their abuse and neglect policy. During a telephone interview on 8/10/23 at 1:00 P.M., the Administrator and DON said the facility did not know about the alleged incident between CMT D and the resident until the resident's family came in. CNA I should have immediately reported hearing CMT D tell the resident he/she could not wipe his/her own ass immediately. He/She should not have assumed Nurse F overheard the interaction. Had they both been made aware they would have sent CMT D home immediately. He/She would have been removed from the schedule until the investigation had been completed. CMT D was terminated on 8/8/23 after they were aware of what CNA I had heard CMT D say.

See the statement of deficiencies at Event ID LYSA12. Based on observation, interview and record review, the facility failed to provide adequate protective oversight, when staff failed to respond to the door alarm, and search for a cognitively impaired resident who eloped from the facility (Resident #13). The facility also failed to ensure staff had access and were able to use the wander control tester for two residents with a wander control (electronic monitoring device) (Residents #25 and #30). The facility failed to ensure two emergency exit doors were closed with alarms activated. The facility also failed to ensure one treatment cart had a functioning lock and failed to lock a medication cart when unattended by staff. The resident sample was 30. The census was 103. The administrator was notified on 9/28/22 at 10:20 A.M. of an Immediate Jeopardy (IJ) which began on 8/10/22. The IJ was removed on 9/10/22 as confirmed by surveyor onsite verification. Review of the facility's elopement prevention and management policy, reviewed 1/5/21, showed: -Protocol: The facility defines elopement as follows: when a cognitively impaired resident/patient leaves the physical structure of the facility unattended and without staff knowledge or not within residents sight; -Purpose: To identify residents/patients at risk for unsafe wandering and exit seeking behavior; -To develop individualized prevention and management interventions based on assessment; -Procedure: Complete admission assessments as applicable; -Review and evaluate assessments; -Develop individualized interventions and communicate to staff; -Provide staff training and resident/patient and family education; -Review baseline care plan and/or interdisciplinary plan of care as needed; -Initiate the missing resident protocol if unable to locate a resident/patient; -Reassess and/or re-evaluate resident/patient if elopement is unsuccessful or successful; -Review plan of care as needed; -Protocol: Facility recognizes that elopement prevention is an interdisciplinary process that must include the cognitively impaired resident/patient and family. The facilities will implement individualized interventions to strive to prevent elopement; -Procedure: Develop individualized interventions which include, environmental modifications; -Protocol: The facility team will assess the environment to identify potential risks associated with elopement. Facility interventions will be developed and implemented to reduce the risk of elopement and/or hazards associated with elopement; -Procedure: Assess the security of potential internal environmental risk factors including, but not limited to: -Elevators; -Exit doors; -Screens; -Stairwells; -Windows; -Maintain door alarms and wander control systems in proper working order; -Review and correct deficiencies in practices as they relate to the following, including, but not limited to: -Cueing devices/monitors; -Resident/patient identification systems; -Response to alarms; -Testing of alarms; -Maintain a current protected list of names and photographs of resident/patients identified at risk for elopement. Assure picture contains the following information: -Name; -Description; -Height; -Weight; -Age; -Pertinent medical information; -Protocol: The interdisciplinary team will re-evaluate cognitively impaired residents/patients who have attempted, unsuccessfully or successfully, to leave the facility without staff knowledge. With the assistance of the resident/patient and family, individualized interventions will be developed and initiated to manage the elopement behavior; -Procedure: Determine the following: -Was the resident trying to leave the facility; -If yes, ask the resident where and why were trying to go; -Re-evaluate assessments as applicable which may include, but are not limited to the following: -Elopement evaluation; -Brief Interview for Mental Status (BIMS) evaluation; -Activities assessment; -Determine if there is a pattern to the exit seeking behavior; -Review and/or update the elopement evaluation; -Include resident/patient/family in development of the plan of care; -Review and revise individualized interventions that may prevent further elopement attempts; -Discuss revised interventions with the resident/patient and family and provide education as needed; -Communicate interventions to staff and provide training as needed; -Evaluate and document effectiveness of revised interdisciplinary interventions; -Review and revise plan of care as needed. 1. Review of Resident #13's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/24/22, showed: -The Brief Interview for Mental Status (BIMS) was not done; -Severely impaired cognition; -Rarely understood; -Diagnoses included hyperlipidemia (high cholesterol), aphasia (inability to comprehend or formulate language), stroke, anxiety and depression; -No behaviors; -Required supervision with transfers, bed mobility, dressing and hygiene; -Independent with eating and toileting. Review of the resident's elopement risk assessment, dated 3/17/22, showed a score of 0; the resident was not at risk for elopement. Review of the resident's care plan, in use during survey, showed: -Focus: Cognitive deficit related to stroke with aphasia; -Goal: Resident will accept reorientation, recognize family, accept reminders, make eye contact, respond to name and locate room; -Interventions: Call resident by name with each interaction and monitor respond, verbalization or eye contact; -Explain all procedures prior to doing; -Face resident when speaking, establish eye contact and encourage resident to maintain eye contact throughout conversation; -Monitor resident response to simple direct communication for appropriateness; -Provide reorientation and cueing as needed (PRN); -Reassurance and emotional support provided PRN; -Allow resident ample time to respond during conversation; -Staff will allow ample time for resident to respond to questions/conversations; -Staff will keep communication clear and simple; -No documentation of the resident's elopement risk and use of wander control system. Review of the resident's progress notes, showed: -On 8/10/22 at 6:32 A.M., the nurse was at the nurses station passing medications when someone rang the doorbell to the side door. The CNA opened the door and the resident was standing at the door and walked into building. This nurse checked resident at nurses station for injuries and vitals signs obtained. No injuries noted. Resident rang door bell at 5:32 A.M. Message left for physician to make aware and message left for family to call facility. Resident sitting at nurses station, will continue to monitor; -On 8/10/22 at 6:56 A.M., 15 minute safety checks started at 5:40 A.M.; -On 8/10/22 at 11:24 A.M., resident sitting in dining room at this time. This nurse checked the wander control system at the exit door to make sure it was working properly and wander control system was then applied to the resident's left wrist without difficulty. Review of the facility's undated investigation, showed in the early morning of 8/10/22, the resident went to the outside door on Complex, the unit where he/she lives. The resident went to the outside door, which is alarmed. Since it is an exit, the door has the standard fire protection; meaning that if the door has pressure for more than 15 seconds, the door will open and the alarm will sound. That is what happened. Since the time was approximately 5:10 A.M., the staff on shift were tending to other residents. The staff heard the sound of alarm, but did not respond immediately. Approximately 10-15 minutes later, the resident returned to the door and began to knock on the door and sound the alarm. The staff responded to the door alarm and brought him/her inside. Review of the resident shows no bruising, scratching, or anything out of the normal. When the administrator and DON talked, the decision was made to put him/her on 15 minute checks. At approximately 3:00 P.M., he/she was taken off of the safety checks because he/she was no longer exit seeking, was displaying his/her baseline behaviors, and we had the wander control system on him/her, which was being checked by the nurses to ensure it was working properly. Review of the resident's POS, dated 8/1/22 through 8/31/22, showed an order, dated 8/19/22, to check wander control system every shift. Review of the resident's MAR, dated 8/1/22 through 8/31/22, showed no documentation the wander control system was checked on 8/20/22 and 8/23/22 on the day shift. Observation and interview on 8/22/22 at 11:30 A.M., showed the resident in bed. He/she was alert to self. The wander control system was on the resident's left wrist. The resident was asked his/her name and the resident responded with uh-uh. During an interview on 8/23/22 at 1:35 P.M., LPN O said he/she came that morning on 8/10/22 at 7:00 A.M., and the night nurse reported the resident got out. He/she was told the alarm sounded. If the door is pushed for 15 seconds, it will unlock. LPN O was told the resident was outside for 40 minutes. The resident was administered the wander control system on the same day. LPN O believed it was 4 or 5 in the morning when the resident eloped. He/she had never eloped or wandered before. He/she is unable to speak, so the nurse did an assessment and there was no injuries. During an interview on 8/24/22 at 1:00 P.M., the administrator said he was aware the resident left. Staff did not respond to the alarm because they were assisting other residents. During an interview on 8/24/22 at 1:19 P.M., LPN P said the resident is unable to express him/herself or his/her needs. He/she attempts to speak, but it is stuttering. During an interview on 8/25/22 at 9:05 A.M., LPN O said the resident cannot communicate, write, or point out things as means to express him/herself. Staff have to hold the resident's hands and guide him/her. During an interview on 8/26/22 at 7:52 A.M., the administrator and DON said they would expect staff to respond to the alarm. They should stop what they are doing and answer the alarm. No one searched for the resident. The DON was aware the resident had a wander control system. During an interview on 8/31/22 at 8:30 A.M., the resident's daughter said the resident was not able to verbally communicate and cannot express his/her needs. The daughter added, anything could have happened to (him/her). (He/she) could have been assaulted and would have no way of telling anyone what happened. No one knew (he/she) was gone. 2. Review of Resident #25's face sheet, showed: -An admitted [DATE]; -Diagnosis included alcohol abuse, diabetes, nicotine dependence, anxiety and history of falls. Review of the resident's baseline care plan, dated 8/24/22, showed: -Mobility devices used: [NAME] and wheelchair; -Level of consciousness: Alert; -Cognitive Status: Cognitively intact; -Does the resident have a history of falls?: No; -Is the resident an elopement risk?: No; Review of the resident's elopement assessment dated [DATE] at 11:16 P.M., showed; -Elopement score: One; -Category: At risk; -Clinical suggestions: Apply personal safety device; Utilize exit alarm; Notify staff of elopement risk. Review of the resident's POS, showed an order, dated 8/28/22, to check wander control system placement to right ankle and test every shift. Review of the resident's progress notes, dated 8/29/22 at 7:16 P.M. showed: At approximately 5:00 P.M. the CNA informed the nurse the resident was outside of building on the parking lot. The resident was brought back in to the facility by the CNA. The resident did have a wander control system on his/her ankle. The resident was placed on every 15 minute checks. During observation and interview on 8/30/22 at 9:35 A.M. the resident stood in the hall and a right ankle device was observed. LPN X was aware of the resident eloping the evening before, because he/she was working at the time of the elopement. LPN X was not able to find the device to check the wander control system device and had no idea where it was. He/she was informed the device was on and working. 3. Review of Resident #30's, admission MDS, dated [DATE], showed: -No cognition assessment; -Can wheel self at least 150 feet independently in corridor or similar space; -Uses manual wheelchair; -Diagnosis included Alzheimer's disease and dementia. Review of the resident's elopement assessment, dated 8/29/22, showed: -An elopement score: One; -Category: At risk; -Clinical suggestion: Notify staff of elopement risk; Personal safety alarm device applied; Exit alarms utilized. Review of the resident's POS, showed an order, dated 8/29/22, for wander control system to left ankle, check placement and function every shift. Observation on 8/30/22 at 9:50 A.M., showed the resident sitting in a wheelchair in the Fountain hall dining room with a wander control system device on his/her left ankle. 4. During observation and interview on Fountain Hall on 8/30/22 at 9:45 A.M., the two exit doors that led out onto the resident smoking area were observed fully open. The smoking area was observed with a tall black rod iron fencing surrounding the area. No gate to leave the area was observed and LPN A said the doors were left open because a staff member must have taken a resident out to smoke, and both doors should remain closed. LPN A was aware Resident #30 had a wander control system in place but did not know where the box was to check the device and was unsure how to check the device. He/she was told in report that the device was applied on evening shift and that it was working. During an interview on 8/30/22 at 1:45 P.M., the DON said all staff are expected to know how to check the wander control system device and be able to trouble shoot if needed. Staff need to be in serviced and education provided on wander control system devices such as checking the device to make sure it is functioning, since it is a task on the MAR and or the TAR to be completed by nursing staff. They only have one device to check the wander control system and they will be ordering more, one for each hall. The doors out onto the smoking area on Fountain hall are expected to be closed and secure. 5. Observation and interview on 8/23/22, 8/24/22, 8/26/22, and 8/30/22, showed: -On 8/23/22 at 12:40 P.M., the delayed egress exit door on Fountain hall that lead out to the enclosed smoking patio was propped open. LPN GG asked another employee to close the door. LPN GG said someone went out and forgot to lock it when they left to smoke. They are supposed to keep the door closed and locked; -On 8/24/22 at 11:50 A.M., the delayed egress exit door on Fountain that lead out to the enclosed smoking patio was propped open; -At 1:07 P.M., the delayed egress exit door on Fountain was propped open, as well as the outside door to enclosed smoking patio; -On 8/30/22 at 10:26 A.M., the delayed egress exit door on Fountain Hall was pulled closed, but the door did not latch and it was not alarmed. At 10:48 P.M., Certified Medication Technician (CMT) J said they need a key to set the alarm for the door, but since there is always someone here, staff can just tell the resident to go out, so they can smoke. The employees and residents go out to smoke on the enclosed patio. During an interview on 8/26/22 at 7:52 A.M., the administrator said he would expect the doors to be closed at all times with the alarm active. Staff are aware to keep the doors closed. They've done in-servicing on this. 6. Review of the facility medication storage policy, dated November 2021, showed: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Procedures: Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. During an observation and interview on the Complex hall on 8/24/22 at 10:47 A.M., the DON completed an accucheck (blood glucose monitoring) on a resident and returned to the treatment cart that was locked. The DON proceeded to ask LPN O where his/her keys were so that he/she could unlock the cart. LPN O said You weren't supposed to lock the cart because we have no key for that cart. LPN O said the treatment cart has not had a key since July. LPN O said she reported it to the past DON in July, but did not follow up with pharmacy. LPN O said to ensure safety that the residents don't get into the treatment cart, staff will turn the cart around, facing the wall. Interim Maintenance Director/CNA L was observed opening the treatment cart with a screwdriver. The treatment cart contained multiple vials of insulin, multiple insulin pens, insulin syringes, lancets (used with glucose monitors), multiple types of topical ointments, cards of medicine, a bottle of hydrogen peroxide and four bottles of liquid Valproic Acid (anti-seizure medication). The DON said she was not aware the cart did not have a key and the maintenance person was unlocking the cart. She would expect staff to have notified her, since she is the new DON, and the administrator about the cart and the key being missing. All medication carts and treatment carts are expected to be locked when unattended by staff. Observations of the treatment cart on Complex hall on 8/25/22 at 2:45 P.M. and on 8/29/22 at 10:05 A.M., showed the cart unattended, unlocked and facing outwards to the hall. One resident walked past the unlocked cart. During an interview on 9/2/22 at 11:54 A.M., a pharmacy representative at Pharmacy K, said the pharmacy was not aware of the of the medication lock problem until last week when an e-mail was sent from the facility. Observation and interview on Fountain hall on 8/29/22 at 11:20 A.M., showed the medication cart positioned in the dining room unattended and unlocked. LPN A said the cart was where they keep extra medication cards and some narcotics. Multiple residents walked and propelled themselves in their wheelchairs into the dining room, passing the unlocked cart. The cart contained multiple cards of medications and a secure lock box where the narcotics were held. LPN A said the medicine cart should be locked at all times when unattended by staff. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00205483 MO00205888 MO00203513 MO00265331

Based on observation, interview and record review, the facility failed to provide adequate protective oversight, when staff failed to respond to the door alarm, and search for a cognitively impaired resident who eloped from the facility (Resident #13). The facility also failed to ensure staff had access and were able to use the wander control tester for two residents with a wander control (electronic monitoring device) (Residents #25 and #30). The facility failed to ensure two emergency exit doors were closed with alarms activated. The facility also failed to ensure one treatment cart had a functioning lock and failed to lock a medication cart when unattended by staff. The resident sample was 30. The census was 103. The administrator was notified on 9/28/22 at 10:20 A.M. of an Immediate Jeopardy (IJ) which began on 8/10/22. The IJ was removed on 9/10/22 as confirmed by surveyor onsite verification. Review of the facility's elopement prevention and management policy, reviewed 1/5/21, showed: -Protocol: The facility defines elopement as follows: when a cognitively impaired resident/patient leaves the physical structure of the facility unattended and without staff knowledge or not within residents sight; -Purpose: To identify residents/patients at risk for unsafe wandering and exit seeking behavior; -To develop individualized prevention and management interventions based on assessment; -Procedure: Complete admission assessments as applicable; -Review and evaluate assessments; -Develop individualized interventions and communicate to staff; -Provide staff training and resident/patient and family education; -Review baseline care plan and/or interdisciplinary plan of care as needed; -Initiate the missing resident protocol if unable to locate a resident/patient; -Reassess and/or re-evaluate resident/patient if elopement is unsuccessful or successful; -Review plan of care as needed; -Protocol: Facility recognizes that elopement prevention is an interdisciplinary process that must include the cognitively impaired resident/patient and family. The facilities will implement individualized interventions to strive to prevent elopement; -Procedure: Develop individualized interventions which include, environmental modifications; -Protocol: The facility team will assess the environment to identify potential risks associated with elopement. Facility interventions will be developed and implemented to reduce the risk of elopement and/or hazards associated with elopement; -Procedure: Assess the security of potential internal environmental risk factors including, but not limited to: -Elevators; -Exit doors; -Screens; -Stairwells; -Windows; -Maintain door alarms and wander control systems in proper working order; -Review and correct deficiencies in practices as they relate to the following, including, but not limited to: -Cueing devices/monitors; -Resident/patient identification systems; -Response to alarms; -Testing of alarms; -Maintain a current protected list of names and photographs of resident/patients identified at risk for elopement. Assure picture contains the following information: -Name; -Description; -Height; -Weight; -Age; -Pertinent medical information; -Protocol: The interdisciplinary team will re-evaluate cognitively impaired residents/patients who have attempted, unsuccessfully or successfully, to leave the facility without staff knowledge. With the assistance of the resident/patient and family, individualized interventions will be developed and initiated to manage the elopement behavior; -Procedure: Determine the following: -Was the resident trying to leave the facility; -If yes, ask the resident where and why were trying to go; -Re-evaluate assessments as applicable which may include, but are not limited to the following: -Elopement evaluation; -Brief Interview for Mental Status (BIMS) evaluation; -Activities assessment; -Determine if there is a pattern to the exit seeking behavior; -Review and/or update the elopement evaluation; -Include resident/patient/family in development of the plan of care; -Review and revise individualized interventions that may prevent further elopement attempts; -Discuss revised interventions with the resident/patient and family and provide education as needed; -Communicate interventions to staff and provide training as needed; -Evaluate and document effectiveness of revised interdisciplinary interventions; -Review and revise plan of care as needed. 1. Review of Resident #13's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/24/22, showed: -The Brief Interview for Mental Status (BIMS) was not done; -Severely impaired cognition; -Rarely understood; -Diagnoses included hyperlipidemia (high cholesterol), aphasia (inability to comprehend or formulate language), stroke, anxiety and depression; -No behaviors; -Required supervision with transfers, bed mobility, dressing and hygiene; -Independent with eating and toileting. Review of the resident's elopement risk assessment, dated 3/17/22, showed a score of 0; the resident was not at risk for elopement. Review of the resident's care plan, in use during survey, showed: -Focus: Cognitive deficit related to stroke with aphasia; -Goal: Resident will accept reorientation, recognize family, accept reminders, make eye contact, respond to name and locate room; -Interventions: Call resident by name with each interaction and monitor respond, verbalization or eye contact; -Explain all procedures prior to doing; -Face resident when speaking, establish eye contact and encourage resident to maintain eye contact throughout conversation; -Monitor resident response to simple direct communication for appropriateness; -Provide reorientation and cueing as needed (PRN); -Reassurance and emotional support provided PRN; -Allow resident ample time to respond during conversation; -Staff will allow ample time for resident to respond to questions/conversations; -Staff will keep communication clear and simple; -No documentation of the resident's elopement risk and use of wander control system. Review of the resident's progress notes, showed: -On 8/10/22 at 6:32 A.M., the nurse was at the nurses station passing medications when someone rang the doorbell to the side door. The CNA opened the door and the resident was standing at the door and walked into building. This nurse checked resident at nurses station for injuries and vitals signs obtained. No injuries noted. Resident rang door bell at 5:32 A.M. Message left for physician to make aware and message left for family to call facility. Resident sitting at nurses station, will continue to monitor; -On 8/10/22 at 6:56 A.M., 15 minute safety checks started at 5:40 A.M.; -On 8/10/22 at 11:24 A.M., resident sitting in dining room at this time. This nurse checked the wander control system at the exit door to make sure it was working properly and wander control system was then applied to the resident's left wrist without difficulty. Review of the facility's undated investigation, showed in the early morning of 8/10/22, the resident went to the outside door on Complex, the unit where he/she lives. The resident went to the outside door, which is alarmed. Since it is an exit, the door has the standard fire protection; meaning that if the door has pressure for more than 15 seconds, the door will open and the alarm will sound. That is what happened. Since the time was approximately 5:10 A.M., the staff on shift were tending to other residents. The staff heard the sound of alarm, but did not respond immediately. Approximately 10-15 minutes later, the resident returned to the door and began to knock on the door and sound the alarm. The staff responded to the door alarm and brought him/her inside. Review of the resident shows no bruising, scratching, or anything out of the normal. When the administrator and DON talked, the decision was made to put him/her on 15 minute checks. At approximately 3:00 P.M., he/she was taken off of the safety checks because he/she was no longer exit seeking, was displaying his/her baseline behaviors, and we had the wander control system on him/her, which was being checked by the nurses to ensure it was working properly. Review of the resident's POS, dated 8/1/22 through 8/31/22, showed an order, dated 8/19/22, to check wander control system every shift. Review of the resident's MAR, dated 8/1/22 through 8/31/22, showed no documentation the wander control system was checked on 8/20/22 and 8/23/22 on the day shift. Observation and interview on 8/22/22 at 11:30 A.M., showed the resident in bed. He/she was alert to self. The wander control system was on the resident's left wrist. The resident was asked his/her name and the resident responded with uh-uh. During an interview on 8/23/22 at 1:35 P.M., LPN O said he/she came that morning on 8/10/22 at 7:00 A.M., and the night nurse reported the resident got out. He/she was told the alarm sounded. If the door is pushed for 15 seconds, it will unlock. LPN O was told the resident was outside for 40 minutes. The resident was administered the wander control system on the same day. LPN O believed it was 4 or 5 in the morning when the resident eloped. He/she had never eloped or wandered before. He/she is unable to speak, so the nurse did an assessment and there was no injuries. During an interview on 8/24/22 at 1:00 P.M., the administrator said he was aware the resident left. Staff did not respond to the alarm because they were assisting other residents. During an interview on 8/24/22 at 1:19 P.M., LPN P said the resident is unable to express him/herself or his/her needs. He/she attempts to speak, but it is stuttering. During an interview on 8/25/22 at 9:05 A.M., LPN O said the resident cannot communicate, write, or point out things as means to express him/herself. Staff have to hold the resident's hands and guide him/her. During an interview on 8/26/22 at 7:52 A.M., the administrator and DON said they would expect staff to respond to the alarm. They should stop what they are doing and answer the alarm. No one searched for the resident. The DON was aware the resident had a wander control system. During an interview on 8/31/22 at 8:30 A.M., the resident's daughter said the resident was not able to verbally communicate and cannot express his/her needs. The daughter added, anything could have happened to (him/her). (He/she) could have been assaulted and would have no way of telling anyone what happened. No one knew (he/she) was gone. 2. Review of Resident #25's face sheet, showed: -An admitted [DATE]; -Diagnosis included alcohol abuse, diabetes, nicotine dependence, anxiety and history of falls. Review of the resident's baseline care plan, dated 8/24/22, showed: -Mobility devices used: [NAME] and wheelchair; -Level of consciousness: Alert; -Cognitive Status: Cognitively intact; -Does the resident have a history of falls?: No; -Is the resident an elopement risk?: No; Review of the resident's elopement assessment dated [DATE] at 11:16 P.M., showed; -Elopement score: One; -Category: At risk; -Clinical suggestions: Apply personal safety device; Utilize exit alarm; Notify staff of elopement risk. Review of the resident's POS, showed an order, dated 8/28/22, to check wander control system placement to right ankle and test every shift. Review of the resident's progress notes, dated 8/29/22 at 7:16 P.M. showed: At approximately 5:00 P.M. the CNA informed the nurse the resident was outside of building on the parking lot. The resident was brought back in to the facility by the CNA. The resident did have a wander control system on his/her ankle. The resident was placed on every 15 minute checks. During observation and interview on 8/30/22 at 9:35 A.M. the resident stood in the hall and a right ankle device was observed. LPN X was aware of the resident eloping the evening before, because he/she was working at the time of the elopement. LPN X was not able to find the device to check the wander control system device and had no idea where it was. He/she was informed the device was on and working. 3. Review of Resident #30's, admission MDS, dated [DATE], showed: -No cognition assessment; -Can wheel self at least 150 feet independently in corridor or similar space; -Uses manual wheelchair; -Diagnosis included Alzheimer's disease and dementia. Review of the resident's elopement assessment, dated 8/29/22, showed: -An elopement score: One; -Category: At risk; -Clinical suggestion: Notify staff of elopement risk; Personal safety alarm device applied; Exit alarms utilized. Review of the resident's POS, showed an order, dated 8/29/22, for wander control system to left ankle, check placement and function every shift. Observation on 8/30/22 at 9:50 A.M., showed the resident sitting in a wheelchair in the Fountain hall dining room with a wander control system device on his/her left ankle. 4. During observation and interview on Fountain Hall on 8/30/22 at 9:45 A.M., the two exit doors that led out onto the resident smoking area were observed fully open. The smoking area was observed with a tall black rod iron fencing surrounding the area. No gate to leave the area was observed and LPN A said the doors were left open because a staff member must have taken a resident out to smoke, and both doors should remain closed. LPN A was aware Resident #30 had a wander control system in place but did not know where the box was to check the device and was unsure how to check the device. He/she was told in report that the device was applied on evening shift and that it was working. During an interview on 8/30/22 at 1:45 P.M., the DON said all staff are expected to know how to check the wander control system device and be able to trouble shoot if needed. Staff need to be in serviced and education provided on wander control system devices such as checking the device to make sure it is functioning, since it is a task on the MAR and or the TAR to be completed by nursing staff. They only have one device to check the wander control system and they will be ordering more, one for each hall. The doors out onto the smoking area on Fountain hall are expected to be closed and secure. 5. Observation and interview on 8/23/22, 8/24/22, 8/26/22, and 8/30/22, showed: -On 8/23/22 at 12:40 P.M., the delayed egress exit door on Fountain hall that lead out to the enclosed smoking patio was propped open. LPN GG asked another employee to close the door. LPN GG said someone went out and forgot to lock it when they left to smoke. They are supposed to keep the door closed and locked; -On 8/24/22 at 11:50 A.M., the delayed egress exit door on Fountain that lead out to the enclosed smoking patio was propped open; -At 1:07 P.M., the delayed egress exit door on Fountain was propped open, as well as the outside door to enclosed smoking patio; -On 8/30/22 at 10:26 A.M., the delayed egress exit door on Fountain Hall was pulled closed, but the door did not latch and it was not alarmed. At 10:48 P.M., Certified Medication Technician (CMT) J said they need a key to set the alarm for the door, but since there is always someone here, staff can just tell the resident to go out, so they can smoke. The employees and residents go out to smoke on the enclosed patio. During an interview on 8/26/22 at 7:52 A.M., the administrator said he would expect the doors to be closed at all times with the alarm active. Staff are aware to keep the doors closed. They've done in-servicing on this. 6. Review of the facility medication storage policy, dated November 2021, showed: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Procedures: Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. During an observation and interview on the Complex hall on 8/24/22 at 10:47 A.M., the DON completed an accucheck (blood glucose monitoring) on a resident and returned to the treatment cart that was locked. The DON proceeded to ask LPN O where his/her keys were so that he/she could unlock the cart. LPN O said You weren't supposed to lock the cart because we have no key for that cart. LPN O said the treatment cart has not had a key since July. LPN O said she reported it to the past DON in July, but did not follow up with pharmacy. LPN O said to ensure safety that the residents don't get into the treatment cart, staff will turn the cart around, facing the wall. Interim Maintenance Director/CNA L was observed opening the treatment cart with a screwdriver. The treatment cart contained multiple vials of insulin, multiple insulin pens, insulin syringes, lancets (used with glucose monitors), multiple types of topical ointments, cards of medicine, a bottle of hydrogen peroxide and four bottles of liquid Valproic Acid (anti-seizure medication). The DON said she was not aware the cart did not have a key and the maintenance person was unlocking the cart. She would expect staff to have notified her, since she is the new DON, and the administrator about the cart and the key being missing. All medication carts and treatment carts are expected to be locked when unattended by staff. Observations of the treatment cart on Complex hall on 8/25/22 at 2:45 P.M. and on 8/29/22 at 10:05 A.M., showed the cart unattended, unlocked and facing outwards to the hall. One resident walked past the unlocked cart. During an interview on 9/2/22 at 11:54 A.M., a pharmacy representative at Pharmacy K, said the pharmacy was not aware of the of the medication lock problem until last week when an e-mail was sent from the facility. Observation and interview on Fountain hall on 8/29/22 at 11:20 A.M., showed the medication cart positioned in the dining room unattended and unlocked. LPN A said the cart was where they keep extra medication cards and some narcotics. Multiple residents walked and propelled themselves in their wheelchairs into the dining room, passing the unlocked cart. The cart contained multiple cards of medications and a secure lock box where the narcotics were held. LPN A said the medicine cart should be locked at all times when unattended by staff. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00205483 MO00205888 MO00203513 MO00265331 42795

Based on observation, interview and record review, the facility failed to maintain safe water temperatures, between 105 degrees Fahrenheit (F) and 120 degrees F, for the residents at the facility. The facility replaced their boiler on 1/6/21 and failed to monitor water temperatures to ensure they were within safe limits. At the time the boiler was changed, the facility did not employ a maintenance supervisor to oversee the maintenance department. In addition, the facility had not routinely measured water temperatures to ensure they were within safe and comfortable limits since 7/7/20. Five cognitively impaired residents were identified, who were physically able to gain access to the bathroom sink and/or shower rooms (Residents #600, #604, #601, #602 and #603). Water temperatures in the resident's bathroom, which was accessible to the resident, registered up to 136 degrees F. In addition, an unlocked and accessible shared bathroom/shower room on the Spectrum hall had a water temperature at the sink that measured 140 degrees F. The resident sample was eight. The census was 69. The administrator was notified on 1/15/21 at 2:55 P.M., of an Immediate Jeopardy (IJ) which began on 1/15/21. The IJ was removed on 1/15/21, as confirmed by surveyor onsite verification. 1. Review of the facility's water temperature log, showed the last documented facility wide temperature check, on 7/7/20: -Spectrum A hallway: water temperature of 111 degrees F; -Spectrum B hallway: water temperature of 113 degrees F; -Complex A hallway: water temperature of 111 degrees F; -Complex B hallway: water temperature of 109 degrees F; -Fountain hallway: water temperature of 112 degrees F; -Laundry room: water temperature of 112 degrees F; -Dietary room: water temperature of 111 degrees F. 2. During an interview on 1/1/21 at 9:00 A.M., the administrator said the following: -There is a leaking pipe on the Complex unit; -They had someone come look at it yesterday, but a plumber will have to come do the repair; -They could not get a plumber out on New Year's Eve and will set up the repair on Monday; -The rooms have hot water, but it takes several minutes of running the water, for the water to get hot; -The water does get hot after running for several minutes; -She will have the maintenance director go in and take water temps today and have staff take water temps every shift until Monday. During an interview on 1/1/21 at 9:40 A.M., the administrator called back to report the following: -There is an issue with water temperatures on the Complex unit; -There is hot water on the other units; -She and the maintenance director are going to the facility now. Review of the water temperatures faxed to The Department of Health and Senior Services (DHSS) on Monday 1/4/21 at 2:43 P.M., showed: -Water temperatures taken on the Complex hall only, on 1/1 through 1/4/21; -All water temperatures measured between 52 and 58 degrees F. 3. During the entrance conference on 1/15/21 at 8:45 A.M., the administrator said the facility replaced the boiler on 1/6/21. No residents or staff had notified her of cold water any longer, so she assumed there were no issues with water temperatures. No staff had been monitoring the water temperatures since the boiler had been replaced. The facility had no active maintenance staff. The last and most recent maintenance director was terminated on 12/30/20. An outside maintenance company was actively onsite to complete repair work to the boiler and facility pipes. The facility had no policy, procedure or active plan in place to monitor water temperatures at this time. She had been working with corporate to update policies and procedures for the facility. 4. Review of Resident #600's medical record, showed the following: -Resided on the Spectrum hall; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 1/6/21 and in use at the time of the survey, showed: -The resident has impaired cognitive function/dementia or impaired thought process: -Cue, reorient and supervise as needed; -The resident has an activity of daily living self-care performance deficit related to disease [MEDICAL CONDITION]: -Bathing/showering: The resident requires (specify what assistance) by (X) staff with (specify bathing/showering) (specify frequency) and as necessary. Toilet use: The resident requires (specify assistance) by (X) staff for toileting. Transfer: The resident requires (specify what assistance) by (X) staff to move between surfaces (specify frequency) and as necessary. Review of the physician admission history and physical, dated 1/8/21, showed: -History of falls, weakness and recent hip repair; -Alert and oriented to self and place, and experienced confusion. Observation on 1/15/21 at 11:15 A.M., showed the resident asleep in his/her bed. His/her wheeled walker noted at the bedside. During an interview on 1/15/21 at 11:30 A.M., Licensed Practical Nurse (LPN) C said he/she worked for an agency company, but worked at the facility on several occasions. He/she usually worked on the Spectrum hall. The resident was able to access the sink in his/her bedroom independently. He/she shares the bathroom with the room next door. If a resident used water that was too hot, the resident could experience burns. A confused resident may not understand or remember to stay away from hot water. The resident was confused and had dementia, he/she wandered the hallway at times with a wheeled walker. Often the resident stayed in his/her room and ambulated freely. Observation on 1/15/21 at 11:45 A.M., showed the resident's bathroom sink water measured 136 degrees F with a calibrated dial thermometer. The water noted to be steaming. Observation and interview on 1/15/21 at 2:33 P.M., showed the resident lay in his/her bed and appeared to be sleeping. Certified Nursing Assistant (CNA) B said the resident uses the restroom by him/herself and washes his/her hands afterward. The resident is a little confused, he/she mainly putters around in his/her room during the day. Observation on 1/15/21 at 5:05 P.M., showed the resident awake in his/her room and sat in a chair. He/she watched TV with his/her wheeled walker in front of him/her. 5. Review of Resident #604's medical record, showed the following: -Resided on Spectrum hall; -[DIAGNOSES REDACTED]. -Identified by facility staff as confused, forgetful and pleasant; -Ambulated with a wheeled walker. Observation on 1/15/21 at 3:10 P.M., showed the resident noted to wander the rehabilitation hallway. The resident appeared confused, and said where is my room, what am I doing here? He/she used a wheeled walker. A staff member walked the resident back to his/her room. 6. Review of Resident #601's medical record, showed the following: -Resided on the Complex hall; -[DIAGNOSES REDACTED]. -Needs limited staff assistance with daily care of bathing and hygiene; -Able to voice wants and needs; -Propels self in wheelchair with limited assistance. Observation on 1/15/21 at 10:26 A.M., showed the resident's bathroom sink water measured 132 degrees F with a calibrated dial thermometer. The water noted to be steaming. The resident said a few weeks ago the facility had issues with the water and it had been too cold. Now the water steamed when running in the sink bathroom. He/she will turn on the cold water to make it more comfortable. He/she will take showers in the shower room at times in the hallway. Observation on 1/15/21 at 5:05 P.M., showed the resident noted to be in the hallway in his/her wheelchair with staff. 7. Review of Resident #602's medical record, showed the following: -Resided on Spectrum hall; -[DIAGNOSES REDACTED]. -Staff assistance of one for daily hygiene; -English language is not primary language; -Ambulates freely. Observation on 1/15/21 at approximately 3:30 P.M., showed the resident lay in bed. 8. Review of Resident #603's medical record, showed the following: -Resided on Spectrum hall; -[DIAGNOSES REDACTED]. -Able to self-propel in a wheelchair; -Able to make his/her needs known. Observation and interview on 1/15/21 at 11:15 A.M., showed the resident in his/her wheelchair and watched TV. He/she said staff assisted him/her with bathing, but he/she could use his/her bathroom sink. During an interview on 1/15/21 at 11:30 A.M., LPN C said the resident was able to access the sink in the bedroom independently. Observation and interview on 1/15/21 at 11:45 A.M., showed the sink water measured 136 degrees F with a calibrated dial thermometer. The water noted to be steaming. The resident said he/she had a stroke and his/her right side is weak. 9. During an interview on 1/15/21 at 3:50 P.M., CNA B said he/she had been employed by the facility and worked mostly on the Spectrum hall. He/she identified four residents that could independently access the sinks in their bathrooms and also experience some forgetfulness or confusion, Residents #600, #602, #603 and #604. He/she added that Residents #600 and #604 were confused and forgetful and often wandered the hallways. Staff often had to redirect these residents back to their rooms. Resident #602 did not speak English well and it was difficult to communicate with him/her. Staff did not use a communication board and had been using pictures or hand gestures, sometimes the resident seemed confused. Resident #603 needed help with his/her hygiene, and experienced occasional forgetfulness, but was able to make his/her needs clearly known. 10. Observation on 1/15/21, showed the following random water temperature observations obtained with a calibrated dial thermometer: -At 10:20 A.M., the sink in the Spectrum hallway resident shower room measured 140 degrees F. The bathroom door noted to be unsecured and accessible to facility residents; -At 10:40 A.M., the sink in the Complex hall shower room measured 130 degrees F. The administrator observed the surveyor check the running water temperature. The administrator said it's steaming, and I see the reading is 130 degrees. She had not received any complaints from staff or residents regarding water temperatures since the boiler had been repaired. She assumed since there had been no complaints, there had been no water temperature issues. The water repair company was onsite and the administrator will notify the repairman immediately. 11. During an interview on 1/15/21 at 11:00 A.M., the boiler serviceman and the administrator said the water tanks would be immediately drained. The service company is sending a second person to assist in draining all tanks. The administrator said all showers and bathing had been suspended until the water temperatures are stabilized. The hallway shower rooms on the Spectrum and Complex side had been closed. The administrator and management team are beginning to check water temperatures in random rooms and the shower rooms as the tanks refill. 12. During an interview on 1/15/21 at 1:17 P.M., the physician for Resident #600, and also the facility medical director, said the resident was admitted to the facility for frequent falls. He/she is pleasantly confused and ambulates freely with a wheeled walker. If the facility had water temperatures too hot, a resident that is confused or had decreased feeling, could be at a higher risk of burn injuries. 13. During an interview on 1/15/21 at 4:45 P.M., the administrator said the water tanks had been drained. Staff had been in-serviced on the acceptable water temperature range of 105 degrees to 120 degrees. Note: At the time of the survey revisit, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview and record review, it was determined the facility had implemented corrective action to address and lower the violation at that time. A final revisit will be conducted to determine if the facility is in substantial compliance with the participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State Law (Section 198.0261 RSMo) requiring that prompt remedial action be taken to address Class I violation(s). MO 925

Based on interview and record review, the facility failed to provide basic life support, including Cardiopulmonary Resuscitation (CPR), for one resident subject to related physician orders [REDACTED]. The resident had a decline in condition and a hospice consult was requested, but no hospice evaluation had been completed. Hospice reported that communication with the resident's responsible party indicated the resident still wanted to be a full code and family was not going to sign the Do Not Resuscitate (DNR) order. The resident was found unresponsive by a Certified Nurse Aide (CNA) who reported it to the nurse. The nurse failed to check the medical record for the resident's code status, initiate CPR or call 911. The facility failed to follow the resident's full code order and wishes. The resident expired and no CPR was performed, for one of eight sampled residents (Resident #106). The census was 69. The administrator was notified on [DATE] at 1:47 P.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's CPR Policy, dated [DATE] and revised on [DATE], showed: -Equipment: CPR Board, Laerdal mask (device used to safely deliver rescue breaths during a [MEDICAL CONDITION] or respiratory arrest), oxygen set up, and airway, goggles, gloves, suction equipment; -Procedure: -Determine consciousness (tap or gently shake resident and shout Are you okay?); -Check for breathing and pulse. If breathing or pulse are absent, call for help (call 911) and push call light. Move resident to hard surface (floor) or place CPR board under resident. Take no more than 10 seconds to check for a pulse; -Initiate CPR, (If resident is No CPR, CPR will not be initiated. If status is unknown, begin CPR); -Circulation-External cardiac compression consists of rhythmic application of pressure over the lower third of the sternum, but never over the xyphoid process (the cartilaginous section at the lower end of the sternum). Place the long axis of the heel of your hand next to the third finger. This now allows for correct placement of the hand for external cardiac compression; -Airway-To open the airway, position the resident on his/her back and tilt (hyperextend) their head back as far as possible. To maintain this, place one hand under the neck and lift up; using the other hand on the forehead, tilt the head back. This maneuver moves the tongue and jaw upward and forward, preventing the tongue/jaw from obstructing the airway passage. (If airway becomes obstructed during procedure, it may become necessary to suction resident to clear airway.) If cervical spine injury is suspected-open airway using a jaw thrust; -Breathing-The next step in the CPR procedure is breathing, or ventilation. Having the head and neck hyper extended, pinch the nostrils closed with the thumb and second finger of hand on forehead. Opening your mouth wide and placing it over the resident's mouth, form an airtight seal. Exhale forcefully into the resident's mouth, removing your mouth to allow for exhalation passively. Adequate ventilation is assured when the breather can see the chest rise and fall with every breath, hear the exhaled breath with their ear, and feels the breath on their cheek. To adequately ventilate and expand the lungs, immediately give two full breaths at the rate of 1 second per breath. Pause between each breath for you to take a breath. (May use Laerdal mask, ambu bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately, and oxygen when providing ventilation); -Note: 1. Keep fingers off the chest wall during compression to prevent the pressure from being dissipated; 2. Place the heel of the second hand on top of the first hand; 3. Maintain good body mechanics, your shoulders should be directly over the resident's sternum; 4. Keep arms straight and elbows locked; 5. Apply firm, heavy rhythmic pressure to depress sternum down about two inches; 6. Never remove the heel of the hand from the chest, but pressure on the sternum should be completely released so the sternum returns to normal position, allowing the heart to fill; 7. Allow complete chest recoil after each compression; -Compression breathing rates and rations: The ratio of chest compression to ventilation based on number of rescuers (one person versus two people); -One person rescue-When there is one resuscitator, the ratio of compression to ventilation is 30:2. Administer two full breaths after each series of 30 cardiac compressions. This rate is maintained by counting .1 and, 2 and 3 and, etc., (push down as your say the number and come up as you say and), then delivering 2 full lung inflations within 5 seconds. Avoid excessive ventilation. Never interrupt CPR technique for more than 5 seconds. Provide chest compressions of adequate rate (at least 100/minute); -Two person CPR-One rescuer is positioned at the victim's side and performs chest compressions. The other rescuer remains at the victims head, keeps the air way open, monitors the carotid pulse (a pressure signal acquired over the carotid artery's major blood vessel in the neck), if the rescuer is a healthcare provider, to assess the effectiveness of chest compressions, and provides rescue breathing. The compression/ventilation ratio for 2 rescuer adult CPR is 30:2. This ratio is the number of compressions and 2 breaths until a breathing (tracheal) tube is inserted. Take 1 second for each rescue breath. The victim exhales between the 2 breaths and during the first chest compression immediately after the second breath. Performing chest compressions is tiring. Rescuers should rotate positions every 2 minutes. Change quickly, interrupting chest compressions interrupts circulation; -Reassessment during 2 rescuer CPR-During 2 rescuer CPR the rescuer giving breaths must assess the effectiveness of chest compressions and must periodically check for signs of circulation. To assess the effectiveness of chest compressions, feel for a pulse during chest compressions. If you do not feel a pulse, the rescuer performing chest compressions will need to compress more deeply or forcefully. To determine if the victim has signs of circulation, stop chest compressions for no more than 10 seconds after the first minute of CPR (or according to the protocol at your facility). When chest compressions are stopped, the rescuer at the victim's head opens the airway and looks, listens, and feels for adequate breathing or coughing. Both rescuers look for movement. The rescuer at the victim's head should also feel for a carotid pulse. If signs of circulation (including a pulse) return, chest compressions are no longer required. Rescue breathing may still be needed. If no signs of circulation are detected, continue chest compressions and check for signs of circulation every two minutes; -Document the resuscitation, including the time CPR was started, time of emergency medical services (EMS) notification, time of each intervention, and arrival of EMS personnel; -Provide information to EMS personnel and assist as necessary; -Reduce environmental overcrowding, remove excess furniture and if appropriate, ask people to leave the area; -Notify responsible parties and provide them with information as to what hospital the resident will be taken to (usually the closest to the facility). Review of Resident #106's face sheet, located in the facility's electronic medical record (EMR), showed: -Code status: Full Code. Review of the resident's care plan, dated [DATE] and in use during the survey, showed: -Focus: Resident wishes to be a full code; -Interventions: Code status will be reviewed in care plan meetings and updated as needed. Review of the resident's Five Wishes, dated, signed and notarized [DATE], showed: -When the times comes that he/she is very sick and not able to speak for him/herself, he/she wants the following wishes, and any other direction he/she have given to his/her Health Care Agent, to be respected and followed: -Close to death: If his/her doctor and another health care professional both decide that he/she is likely to die within a short period of time, and life-support treatment would only delay the moment of my death: -The resident checked: He/she wanted to have life-support treatment if his/her doctor believed it could help. But he/she wanted his/her doctor to stop giving him/her life-support treatment if it is not helping his/her health condition or symptoms; -In a coma and not expected to wake up or recover: -The resident checked: He/she wanted to have life-support treatment; -Permanent and severe brain damage and not expected to recover: -The resident checked he/she wanted to have life-support treatment; -In another condition under which he/she would not wish to be kept alive (please leave the space blank if you have no other condition to describe): The resident left blank. Review of the resident's physician's orders [REDACTED]. Review of the resident's progress notes, showed: -On [DATE] at 10:34 P.M., resident has slept throughout the day on day shift and evening shift. When resident name is called he/she wakes up and goes back to sleep. Resident shows little to no interest to eating. This nurse tried to encourage resident to eat and attempted to feed resident at lunch and dinner, resident ate 10% at lunch and no dinner and drank 100% of liquids at dinner and went back to sleep. Resident voices no complaints of pain or discomfort. He/she has had no urine output on evening shift. Call placed to physician to notify change in condition. Awaiting return call. This nurse made the assistant Director of Nursing (ADON) aware of resident's change in condition. ADON stated that he/she would follow up with the physician in the morning to receive an order for [REDACTED].>-On [DATE] at 9:04 A.M., spoke with resident's family member regarding his/her change in condition. Family member said he/she is aware of him/her not being where he/she was prior to his/her last hospital stay and he/she wants to speak with his/her friend about hospice. Call placed to physician to obtain hospice order, awaiting return call. Resident currently lying in bed resting. Poor appetite noted. No acute distress; -On [DATE] at 9:15 A.M., received return call from physician's office, new order received on behalf of nurse practitioner for hospice evaluate and treat; -On [DATE] at 2:30 P.M. (Late Entry) spoke with hospice marketing consultant (HMC) regarding order from the physician. HMC said he/she would call the resident's family. Resident's information faxed to hospice per request; -On [DATE] at 3:29 P.M., (Late Entry) received message from HMC at hospice stating he/she spoke with the resident's family member and were setting up an appointment on [DATE] for hospice to evaluate. Further review of the resident's physician orders, showed an order dated [DATE] at 4:00 P.M., for hospice to evaluate. Further review of the resident's progress notes, showed: -On [DATE] at 4:30 P.M., (Late Entry) received a call from the resident's family member, informed of resident's condition (refusing meals, refusing care, skin breakdown). Discussed in length resident's change in condition and answered questions regarding hospice; -On [DATE] at 8:40 A.M., spoke with resident's family this morning, who said he/she has a meeting with hospice later today. Resident currently lying in bed, resting with eyes closed, arouses easily to verbal stimuli. Not eating breakfast at this time, drank little milk for this nurse, no complaints of pain/discomfort noted at this time. No acute distress; -On [DATE] at 10:49 P.M., resident slept through evening shift. Did not eat at dinner or drink. Hospice evaluated resident and was admitted to hospice. HMC from hospice stated that the hospice nurse would be out to the facility either tonight or in the morning for admission. resident continues to decline. Vital signs, blood pressure ,[DATE] (normal is ,[DATE] through ,[DATE]), pulse 99 (normal 60 through 100), respirations 24 (normal 12 through 20), Temperature 98.6 degrees Fahrenheit (normal 97.8 through 99.1), oxygen saturation level (percentage of oxygen in the blood) 64% (normal 95% through 100%). Resident placed on 2 liters of oxygen per nasal cannula. Will continue to monitor and pass on to night shift that if any changes in condition to contact the Director of Nursing (DON) and hospice nurse; -On [DATE] at 4:08 P.M., this resident expired today at 3:00 P.M., hospice notified. Awaiting call from medical doctor for cause of death. Attempted to notify family member, left message, DON made aware; -On [DATE] at 4:22 P.M., spoke with the resident's family member and he/she stated he/she signed the papers for hospice this morning around 1:00 A.M., and sent to hospice. The resident is a hospice patient as far as he/she is concerned. Further review of the resident's EMR physician's orders [REDACTED]. During an interview on [DATE] at 11:47 A.M., Hospice Registered Nurse A, said the resident is still showing as pending in their computer system. Hospice did have a meeting on Friday, [DATE], via Zoom with his/her family member, (he/she lives out of state), and reviewed hospice services. The family member emailed the consent for the evaluation back on [DATE] at 12:38 A.M., so the resident was never officially on hospice. The nurse never made it there to evaluate him/her and he/she died before they could get there. HMC did a Zoom meeting with the family, after he/she found the patient was not appropriate to sign his/her own consent. Before officially on hospice, you have to have a nurse evaluate, but you can't do that until the consent has been signed. Hospice Nurse A said at the time of consent, the hospice company does talk about code status, whether to change or not. They did have a copy of his/her five wishes, signed on [DATE]. No nurse went to the facility, only the HMC to set up a Zoom meeting with his/her family member. The resident is not officially admitted to hospice until the consent is signed, the family member had not signed a DNR. His/her documentation shows him/her as a full code. During an interview on [DATE] at 2:45 P.M., the DON said since coming back from the hospital, the resident had not been himself/herself, and showed a decline. The ADON and she visited with the resident. He/she didn't want to eat, he/she offered to assist, and the resident said No. The physician suggested he/she go on hospice. The DON said she talked to the resident's family member and he/she agreed. Hospice came in and evaluated him/her and said yes, he/she would be a good candidate for hospice, they visited on [DATE] at around 3:00 P.M. The resident was his/her own responsible party, the resident's family member was his/her emergency contact and very close, the resident does pretty much what the family member wants, he/she will go along with it. They were told on Friday, [DATE], from the two people who were here from hospice, they were going to have the family member sign the paperwork to have the resident on hospice, and they were waiting for him/her to sign the paperwork. The DON said the next day, [DATE], she was on call, and got a call from Licensed Practical Nurse (LPN) C about ,[DATE]:00 P.M., and he/she said the resident had transitioned. He/she told the nurse to call hospice and let them know. The nurse said the hospice nurse called and said he/she would be in around 5:00 P.M., to see him/her. The DON said she told the nurse to call and let them know the resident had a change in condition and they might need to come sooner. The nurse said he/she talked to the family member, because he/she did not know what his/her code status was, and the family member confirmed he/she was hospice. The DON said he/she was not in the room when hospice went in to do their evaluation. She was told they were going to do a Zoom call with the resident and his/her family member, the HMC and the hospice nurse. During an interview on [DATE] at 9:09 A.M., the Hospice Manager Registered Nurse (RN) said there were two hospice care consultants (marketers) at the facility on Friday, [DATE]. If the resident had a change of condition, the facility should have notified the physician. If they would have called hospice, he/she would have told them to call the physician. The facility nurse could look at the resident's physician order [REDACTED]. LPN C said the resident was not taking his/her pills very well, and never mentioned he/she had any other symptoms. The resident had passed away before the hospice nurse could get there. The resident's family member emailed everything back to hospice, and said he/she was not signing the DNR, because the resident had stated multiple times he/she did not want to be a DNR. During an interview on [DATE] at 9:19 A.M., the resident's family member said hospice did discuss code status with him/her and they knew the resident was to stay a full code. When he/she passed away, hospice had not taken over yet. He/she was able to talk to the resident on Friday through a meeting with him/her and hospice. He/she was confused during the meeting and he/she thought the hospice office manager was a minister. The resident's family member said he/she didn't feel comfortable discussing code status at that time due to the resident's confusion, but he/she did not feel the need to question the resident's intent regarding code status because he/she had filled out his/her code status in November, 2020. That was pretty recent, and he/she expressed his/her desire to be full code then. During an interview on [DATE] at 9:45 A.M., the facility medical director said all resident or responsible party code status choices should be upheld until a signed document showed differently. The charge nurse is responsible to check the chart and be aware of the resident's code status if found unresponsive. If the resident is a ordered a full code, CPR should be initiated. A resident can be enrolled on hospice services and choose to remain a full code, the choice is up to the resident or the responsible party and the facility should uphold the decision. During an interview on [DATE] at 10:27 A.M., LPN C said on Saturday morning, [DATE], the resident was in a deep sleep, would not eat, or take his/her medications. He/she said he/she did give the resident his/her insulin. During the change of shift, around 3:00 P.M., CNA B said the resident had expired. LPN C said to him/her, No way, we were just in there! They went to his/her room, and could not get any vital signs. He/she immediately went to the desk and called hospice. He/she had called hospice earlier and wanted to know if they wanted to discontinue any of his/her medications, because he/she was told in report the resident was on hospice. When the resident passed, he/she called hospice, then called the DON, and the DON said he/she is hospice, the hospice physicians would do everything else. The evening shift nurse came in, and a couple nurse aides and nurse went to the resident's room and got him/her presentable. LPN C headed to his/her car, and got an overhead page for him/her. The evening shift nurse said hospice called back and said they had not picked the resident up on their case load. That changes everything, without him/her being on hospice, he/she should have administered CPR instead of letting him/her be. It had already been 40 minutes since he/she died . The DON said to treat him/her as hospice because we all thought he/she was hospice. LPN C said he/she called the family member, and the family member said he/she signed the paperwork and emailed it to hospice at 1:00 A.M. He/she did not ask the family member about the resident's code status. Residents can be on hospice and not be a DNR, it just depends on the person, but he/she had never known anyone to be on hospice that was not a DNR. Everyone he/she talked to at the facility told him/her the resident was hospice. The day before, the resident had a Zoom meeting with hospice, and he/she was under the assumption the family member was going to admit him/her. On the 24 hour report it all said hospice. When the resident passed, he/she called and told the DON and told her he/she had transitioned. (When asked what transitioned meant, LPN C defined it as expired) The DON said to call hospice. The code status is in the resident's chart, but he/she was under the assumption the resident was hospice. After the resident had expired, he/she was making his/her nurse's note, about ,[DATE] minutes later, looked in the chart, and noticed he/she was a full code. I thought the status changed when he/she became hospice. He/she only took a temperature that morning, no other vital signs were taken. He/she did not recall an order to admit to hospice, only an order to evaluate. The resident's doctor thought he/she was hospice too, when he/she called for the cause of death, he/she said he/she would go with the [DIAGNOSES REDACTED]. During an interview on [DATE] at 11:25 A.M., the DON said staff know a resident's code status by looking in the physicians' orders. This is documented both in the EMR and a paper copy is available on the floor. She would expect staff to check a resident's code status. She was not aware of any training provided to agency staff regarding code status. The nurse did call her the day the resident passed, but the nurse did not say he/she had expired. He/she said the resident had transitioned. The DON took that to mean the resident had a change in condition and she told the nurse to get a hold of hospice to get things rolling. She did not understand transition to mean expired and it is never used that way in the medical field. Even if a resident is on hospice, staff should still check the resident's code status because you can be on hospice and be a full code. Note: At the time of the survey revisit, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review, it was determined the facility had implemented corrective action to address and lower the violation at that time. A final revisit will be conducted to determine if the facility is in substantial compliance with the participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State Law (Section 198.0261 RSMo) requiring that prompt remedial action be taken to address Class I violation(s). MO 690

Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when the facility failed to ensure wounds were assessed and treatments applied as ordered. In addition, the facility failed to provide wound care and failed to ensure antibiotic medications were administered as ordered for a wound that had become infected. This resulted in a delay in identification and treatment of [REDACTED]. The wound was not staged by the facility until a week later and was identified as a stage III at that time. The wound showed symptoms of infection and required hospitalization 10 days after first documented by the facility. The hospital staged the wound as a stage IV and ordered the administration of antibiotics. This affected one of 24 sampled residents (Resident #154). The census was 69. Review of the facility undated Best Practices Wound Care Guidelines, showed: -Prevention: -Daily skin inspection; -Cleanse soiled skin with approved cleanser; -Minimize moisture exposure; -Reposition at least every two hours; -Complete bath sheets as scheduled; -Address nutrition and hydration; -For all wound care, always follow physician's orders [REDACTED].>-Stage III (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed) Slough (moist dead tissue) may be present but does not obscure the depth of tissue loss. May include undermining or tunneling (a wound that has progressed to form passageways underneath the surface of the skin); -Stage IV (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed) Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling); -Complete weekly measurements and documentation. Notify family and physician weekly of progress and document. Observation of Resident #154's skin on 9/17/20 at 9:00 A.M., during the annual survey, showed a right buttocks pink area noted with no Drainage. No coccyx or sacrum wound. Review of the resident's September 2020 treatment record, showed a treatments order dated 9/4/20 for a treatment to the right buttocks wound. Review of the resident's care plan, in use at the time of the investigation, showed: -Focus: Activities of daily living (ADL) self-care performance deficit due to cerebral [MEDICAL CONDITION] (fluid build-up in the brain); -Interventions: Dependent on staff to meet all ADL needs. Totally dependent on 2 staff for repositioning and turning in bed at least every two hours and as necessary. Totally dependent on staff for personal hygiene and oral care. Requires skin inspection at least every shift. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse; -Focus: Pressure injury to Right Buttock due to immobility; -Interventions: Administer treatments as ordered and monitor for effectiveness. See orders for specific treatment type and frequency. Assess/record/monitor wound healing weekly measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician. Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of the facility weekly wound tracking worksheet, showed the following for the resident; -On 11/13/20, identified as a having a pressure injury (pressure ulcer, injury to the skin and/or underlying tissue, as a result of pressure or friction), the staging not identified, location sacrum, no comments in regard to the wound description and no measurements. No documentation to show the date the wound was first identified. Review of the resident's progress notes, showed: -On 11/14/20 at 7:04 A.M., writer assisted with personal care. Wound on sacrum is now tunneling. Approximately quarter size opening. Tissue surrounding area is yellowish. Resident appears to experience pain during care. Changed wound dressing, cleansed wound, applied wet to dry dressing. Will report off to day nurse; -On 11/18/20 at 3:38 P.M., (the next note regarding the sacrum wound), showed resident is alert and orientated to him/herself, he/she is unable to voice any of his/her comments or his/her concerns. Remains incontinent of bowel and bladder, and he/she has received care for all his/her incontinent episodes during this shift. Continues to have a noted pressure ulcer to his/her coccyx. Area has been cleaned with normal saline with Santyl (prescription medicine that removes dead tissue from wounds so they can start to heal) applied and covered with a clean dry dressing; -No documentation of the presence of a sacrum/coccyx wound prior to 11/14/20; -No further wound description. No coccyx/sacral wound staging and/or measurements documented. Review of the resident's physician's orders [REDACTED].>-On 10/14/20 and discontinued 11/14/20, an order for [REDACTED].>-On 11/14/20, an order for [REDACTED].>-On 11/14/20, make sure certified nurse's assistants (CNAs) are turning resident every two hours; -On 11/14/20, an order for [REDACTED]. -On 11/25/20, weekly skin assessment on Wednesday; -No order for a sacral wound treatment prior to 11/14/20. Review of the resident's November 2020 Treatment Administration Record (TAR), for the dates of 11/1/20 through 11/23/20, showed: -A treatment start date of 11/14/20, for Santyl Ointment 250 unit/gram. Apply to sacrum topically every shift for wound care. Cleanse with normal saline/wound cleanser, apply Santyl and foam dressing daily and as needed; -Treatment not documented as completed on the evening shift, on 11/16/20 and on night shift on 11/23/20; -An order dated 11/14/20, make sure CNAs are turning resident every two hours for wound care management. Not documented as completed on 11/15/20 at 8:00 A.M., 10:00 A.M., 12:00 P.M. and 2:00 P.M. On 11/18/20 at 4:00 P.M., 6:00 P.M., 10:00 P.M., and 12:00 A.M. On 11/19/20 at 10:00 P.M., and at 12:00 A.M., and on 11/20/20 at 2:00 P.M. Further review of the facility weekly wound tracking worksheet, showed the following for the resident: -On 11/20/20, identified as having a pressure injury, president the previous week, documented as a stage III pressure ulcer, sanguineous drainage (blood tinged drainage). No further wound description or measurements. No documentation to show the date the wound was first identified. Further review of the resident's progress notes, showed: -On 11/24/20 at 10:28 A.M., resident presents with a wound to his/her coccyx that has serosanguineous fluid and slothing (dead tissue separating from living tissue). No odor present, yet hasn't begun to heal. Low grade fever that has been treated with medication. Called Physician with the okay to send to hospital for possible septic/infection (a potentially life-threatening condition caused by the body's response to an infection); -On 11/24/20 at 12:28 P.M., resident has been transferred to the hospital for wound treatment of [REDACTED]. Review of the resident's hospitalization record, dated 11/24/20, showed: -Patient is nonverbal. Apparently had fever last P.M., and again this A.M, and when changing his/her sacral wound, felt it was worse, so patient was sent to Emergency Department (ED). In ED, workup including COVID-19/influenza swab was negative, but Computer Tomography (CT) abdomen/pelvis showed evidence of sacral osteo[DIAGNOSES REDACTED] (an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue infections); -Assessments/Plan: Stage IV sacral pressure injury, complicated by coccygeal osteo[DIAGNOSES REDACTED]. Will initiate [MEDICATION NAME] (antibiotic), [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic), given location of wound, and likely contamination of wound with fecal material; -After visit summary for hospitalization visit on 11/24/20 through 11/28/20, showed: -Start [MEDICATION NAME] 2,000 milligram (mg) for home infusion. Inject one dose by intravenous IV, into the vein) injection every 8 hours for 37 days; -Start [MEDICATION NAME] ([MEDICATION NAME]) 500 mg tablet by mouth three times daily; -Start [MEDICATION NAME] 750 mg for home infusion. Inject one does intravenous injection every 12 hours for 37 days; -Antibiotic has been suscribed to take at home. Using an antibiotic the wrong way can make your infection stronger and harder to treat. You can help prevent this problem by doing the following: -Take it exactly as prescribed; -Do NOT skip doses; -Finish the prescription even if you feel better. Further review of the resident's physician orders, showed: -Wound care treatment orders remained the same as prior to the hospitalization ; -On 11/29/20, an order for [REDACTED].>-On 11/29/20, an order for [REDACTED].>-On 11/29/20, an order for [REDACTED].>-On 12/2/20, an order for [REDACTED].>-On 12/2/20, an order to turn and reposition, side to side every two hours; -On 12/8/20, coccyx: Clean with wound cleanser, skin prep peri-wound (wound edges), calcium alginate (a highly absorbent, biodegradable alginate dressing derived from seaweed. Alginate dressings maintain a physiologically moist microenvironment that promotes healing) to wound bed, cover with bordered foam gauze daily and as needed if soiled/dislodged; -On 12/4/20, an order to increase the dose of [MEDICATION NAME] HCl Solution to 1.25 grams, intravenously every 12 hours, stop date 1/4/21; Further review of the resident's progress notes, showed: -On 11/28/20 at 12:00 P.M., communication note: -Braden Evaluation (Braden scale, used for predicting pressure ulcer risk): Sensory perception completely limited, Score: 11.0-Result: High Risk; -Moisture: Occasionally moist; -Activity: Bedfast; -Mobility: Completely immobile; -Skin warm & dry, skin color within normal limits (WNL), Resident has current skin issues. Pressure Ulcer/Injury. Skin Issue Location: sacrum. Pressure Ulcer/ Injury Stage: Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) tissue in the wound bed). Wound Exudate (drainage): Sanguineous. Peri Wound Condition: WNL. Dressing Saturation: Moderate (26-75%). Wound odor noted. No tunneling, no undermining. Tissue: Painful; -On 11/28/20 at 9:44 P.M., Resident arrived back at facility about 9:00 P.M., with two emergency medical technicians to transfer. Sacral wound dressing intact, double lumen catheter (peripherally inserted central catheter used to administer IV medications or fluids) placed in right upper chest, dressing clean, dry, and intact no signs of distress or infiltration noted. Resident nonverbal, but can blink once for yes and twice for no. No other skin concerns at this time. All meds verified by previous nurse and faxed to pharmacy. Notified pharmacy of intravenous (IV) antibiotics and awaiting delivery of all medications. Further review of the resident's November 2020 TAR, for the dates of 11/29/20 through 11/30/20, showed: -A treatment start date of 11/14/20, for Santyl Ointment 250 unit/gram. Apply to sacrum topically every shift for wound care. Cleanse right buttock with normal saline/WC, apply Santyl and foam dressing daily and as needed; -Treatment not documented as completed two out of six opportunities. Review of the resident's November 2020 Medication Administration Record [REDACTED] -An order dated 11/29/20 for [MEDICATION NAME] HCl Solution 750 mg/150 ml, administer 750 mg IV every, 12 hours for osteo[DIAGNOSES REDACTED] for 37 Days. Not documented as administered in November; -An order dated 11/29/20 for [MEDICATION NAME] Tablet 500 MG, three times a day, for infection for 37 days, not documented as administered three of five opportunities; -An order dated 11/29/20 for [MEDICATION NAME] HCI Solution 2GM/100ML, use 2000 mg IV every 8 hours for infection for 37 days, not documented as administered three of five opportunities. Further review of the resident's progress notes, showed: -On 11/29/20 at 6:30 A.M., order administration note, [MEDICATION NAME] HCI Solution 750 mg/150 ml. Administer 750 mg IV every 12 hours for osteo[DIAGNOSES REDACTED] for 37 Days ordered: No documentation why the medication was not administered as ordered; -On 11/29/20 at 1:38 P.M., order administration note, [MEDICATION NAME] HCI Solution 2 gm/100 ml, administer 2000 mg IV every 8 hours for infection for 37 Days: Medication is not here made a call to the doctor and to the pharmacy and it will be on the next run and the doctor said resume order when it comes in; -On 11/29/20 at 1:40 P.M., order administration note, [MEDICATION NAME] Tablet 500 mg, give 500 mg via [DEVICE] three times a day for infection for 37 Days: Medication is not here, made a call to the doctor and to the pharmacy and it will be on the next run and the doctor said resume order when it comes in Review of the pharmacy delivery manifest, dated 11/30/20, showed the resident's [MEDICATION NAME], 750 mg for every 12 hours, a signed delivery receipt at 12:04 A.M. Review of the resident's MAR, dated 12/1/20 through 12/31/20, and reviewed on 12/14/20, showed: -An order dated 11/29/20 for [MEDICATION NAME] HCl Solution 750 mg/150 ml, administer 750 mg IV every, 12 hours for osteo[DIAGNOSES REDACTED] for 37 Days. Discontinued 12/2/20 at 9:47 P.M.; -Not documented as administered three out of four scheduled opportunities; -On 12/1/20 at 6:00 P.M., see progress note: Resident continues to need [MEDICATION NAME] trough (lab used to test if [MEDICATION NAME] blood level is at a therapeutic range) this nurse contacted lab at 4:30 P.M., was on hold for 1 hour and 30 minutes with no answer. [MEDICATION NAME] not administered; -On 12/2/20 at 6:00 A.M., documented as held; -On 12/2/20 at 6:00 P.M., see progress note: Not given; -No [MEDICATION NAME] administered on 12/3/20; -An order dated 12/4/20 for [MEDICATION NAME] HCl Solution to 1.25 grams, intravenously every 12 hours: -Initiated on 12/4/20 at 6:00 P.M., and administered as ordered; -An order dated 11/29/20 for [MEDICATION NAME] Tablet 500 MG, three times a day, for infection for 37 days, not documented as administered eight of 42 opportunities; -An order dated 11/29/20 for [MEDICATION NAME] HCI Solution 2GM/100ML, use 2000 mg IV every 8 hours for infection for 37 days, not documented as administered 11 of 42 opportunities. Further review of the resident's progress notes, showed: -On 12/1/20 at 7:34 A.M., on IV [MEDICATION NAME] and [MEDICATION NAME] due to osteo[DIAGNOSES REDACTED] Infection. He/she continues to have a large sacral wound with treatment orders in place and is to be turned and repositioned every two hours with the use of pillows for comfort and support being turned to his/her left and right sides only; -On 12/1/20 at 7:48 A.M., [MEDICATION NAME] trough is to be drawn today 30 minutes before his/her 6:00 P.M. dose; -On 12/1/20 at 7:31 P.M., resident continues to need [MEDICATION NAME] trough. This nurse contacted lab at 4:30 P.M., was on hold for 1 hour and 30 minutes with no answer. [MEDICATION NAME] not administered; -On 12/2/20 at 6:26 A.M., [MEDICATION NAME] trough needs to be drawn. Lab will draw today before next dose is administered; -On 12/2/20 at 11:18 A.M., new order received from physician for wound clinic to evaluate/treat. Call placed to lab to reschedule [MEDICATION NAME] trough, unsuccessful at getting through. Will continue to try; -On 12/2/20 at 1:04 P.M., lab here to draw labs on resident. Physician aware of missed [MEDICATION NAME] trough, new order received to draw twice weekly, noted and scheduled; -On 12/2/20 at 10:18 P.M., [MEDICATION NAME] trough lab results faxed to pharmacy. Awaiting recommendations from pharmacy in the A.M.; -On 12/3/20 at 4:26 A.M., [MEDICATION NAME] Trough Lab Results (5.6, low, normal range 10-20 ) received from lab. Lab results faxed to pharmacy. This writer called the pharmacy to report results and notify that lab results were being faxed. Pharmacist stated that the pharmacist on duty tomorrow morning would receive results and call with dosage recommendations in the A.M. Review of the resident's [MEDICATION NAME] trough lab result, dated 12/2/20, showed a low result of 5.6. Further review of the resident's progress notes, showed: -On 12/4/20 at 11:34 A.M., this nurse received in shift report that resident no longer had orders for [MEDICATION NAME]. This nurse called the pharmacy to find reasons that resident was not receiving his/her ordered [MEDICATION NAME] anymore and this nurse was told that medication was not supposed to be discontinued but dose was supposed to be Increased from 750 mg to 1.25 grams. Physician was called and Informed of situation and new orders for 1.25 gram [MEDICATION NAME] have been updated. Resident is to receive 1.25 gram per his/her right chest port every 12 hours. Review of the wound clinic's initial visit progress note, dated 12/4/20, showed: -Wound assessment: Wound #2 Medial Coccyx is an acute Stage III Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 6 cm (centimeter) length x 5 cm width x 3 cm depth. Undermining has been noted at 9:00 o'clock (location when compared to a face of a clock) and ends at 1:00 o'clock with a maximum distance of 3.4 cm. There is a moderate amount of serosanguineous drainage noted. Wound bed has 1-25% slough, 76-100% bright red granulation (new tissue growth); no eschar (dry, dead tissue) and no [MEDICATION NAME] (a process where [MEDICATION NAME] cells migrate upwards and repair the wounded area) present; -Treatment: A skin/subcutaneous tissue level excisional/surgical debridement (surgical removal of dead disuse). Post Debridement. Measurements: 6 cm length x 5 cm width x 3.1 cm depth. Observation and interview on 12/15/20 at 11:05 A.M., showed the resident positioned in bed, slightly on his/her left side. The CNA pulled the curtain around the bed, lowered the head of the bed and pulled the covers down. Staff rolled the resident onto his/her right side. The dressing on the resident's coccyx area coming loose. The CNA reported it to the nurse. Licensed Practical Nurse (LPN) F came into the room. The outer dressing on the coccyx was removed. The center of the wound had packed gauze. The nurse said he/she was not going to remove the packing, he/she was changing the outer dressing. The wound had defined edges. The visible part of the wound appeared pink and moist. No odor. LPN F measured the wound as 8 cm by 4 cm, depth was not measured. The nurse cleaned the outer wound with normal saline, dried the area, applied skin prep and a border gauze dressing. The nurse wrote on the dressing 12/15/20 and said he/she did not see any measurements documented and he/she did not want to remove the gauze because he/she did not want to disturb the wound. The soiled packed gauze remained under the newly changed and dated dressing. Several attempts were made to contact the resident's physician to ask questions regarding the resident's care at both the office and on his/her cell phone. Multiple messages were left with no return call, the final attempt was made on 12/22/20 at 2:25 P.M. During an interview on 11/17/20 at 11:33 A.M., the administrator said wounds should be tracked on the tracking form and include measurements and physician's orders [REDACTED]. The nurse caring for the resident should call if it has not arrived, and should notify the physician if not available. If the resident missed a dose and the nurse should notify the physician. MO 944 MO 793 MO 760

Based on observation, interview and record review, and in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for 2019 Novel Coronavirus Disease (COVID-19), the facility failed to protect residents in the facility by not following acceptable infection control practices for COVID-19. The facility failed to have a plan for how residents in the facility who develop COVID-19 will be handled. When residents in the facility were identified as having COVID-19, the facility designated the Fountain View hall as the COVID-19 unit. On [DATE], the first in-house residents were reported to have positive COVID-19 results and remained in their rooms with residents negative for COVID-19 (Resident #400, #401, #406, #503 and #508). On [DATE], there were 12 residents positive for COVID-19 who resided in the facility on the Fountain View hall, after the Fountain level was converted into the COVID-19 unit (Resident #400, #401, #402, #403, #404, #405, #406, #407, #408, #409, #410, and #411). Twenty-two additional residents, negative for COVID-19, remained on the Fountain View hall after it was transitioned into the COVID-19 unit. A total of eight residents negative for COVID-19 had a roommate that tested positive for COVID-19 (Resident #501, #502, #503, #504, #505, #506, #507, and #508). A resident known by staff to be positive for COVID-19 (Resident #400) was observed to not wear a mask and walk the unit, past rooms that contained residents negative for COVID-19. The nurse responsible for the resident failed to redirect the resident. Two residents positive for COVID-19, who also had one or more roommates negative for COVID-19, were observed to be actively coughing in the room with their roommate(s) present (Resident #401 and #408). In addition, staff were observed to allow a resident negative for COVID-19 to enter the COVID-19 unit to utilize a bathroom when a private bathroom was available to the resident in their room (Resident #600). This resident later tested positive for COVID-19. The census was 89. The administrator was notified on [DATE] at 2:05 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the CDC's, Preparing for COVID-19 in Nursing Homes, updated [DATE], showed: -Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19. As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP); -Regularly review CDC's Infection Control Guidance for Healthcare Professionals about COVID-19 for current information and ensure staff and residents are updated when this guidance changes; -Implement Source Control Measures: Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility. Cloth face coverings should not be placed on anyone who has trouble breathing, or anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance; -Provide supplies necessary to adhere to recommended infection prevention and control practices: -Prioritizing gowns for activities where splashes and sprays are anticipated (including aerosol-generating procedures) and high-contact resident care activities that provide opportunities for transfer of pathogens to hands and clothing of HCP; -If extended use of gowns is implemented as part of crisis strategies, the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohorted in the same area of the facility and these residents are not known to have any co-infections; -Identify space in the facility that could be dedicated to monitor and care for residents with COVID-19: -This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19; -Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use; -Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive); -Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of testing. They should not be placed in a room with a new admission nor should they be moved to the COVID-19 care unit unless they are confirmed to have COVID-19 by testing. While awaiting results of testing, HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents; -Have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them); -Additional information about cohorting residents and establishing a designated COVID-19 care unit is available in the Considerations for the Public Health Response to COVID-19 in Nursing Homes (Responding to Coronavirus (COVID-19) in Nursing Homes); -Evaluate and Manage Residents with Symptoms of COVID-19: Actively monitor all residents upon admission and at least daily for fever (temperature equal to or greater than 100.0 degrees Fahrenheit) and symptoms consistent with COVID-19. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions as described below: -If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, follow the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. This guidance should be implemented immediately once COVID-19 is suspected: -Residents with suspected COVID-19 should be prioritized for testing; -Residents with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom; -Residents with COVID-19 should, ideally, be cared for in a dedicated unit or section of the facility with dedicated HCP; -As roommates of residents with COVID-19 might already be exposed, it is generally not recommended to place them with another roommate until 14 days after their exposure, assuming they have not developed symptoms or had a positive test; -Residents with known or suspected COVID-19 should be cared for using all recommended personal protective equipment (PPE), which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. Cloth face coverings are not considered PPE and should not be worn when PPE is indicated; -Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection; -If a resident requires a higher level of care or the facility cannot fully implement all recommended infection control precautions, the resident should be transferred to another facility that is capable of implementation. Transport personnel and the receiving facility should be notified about the suspected [DIAGNOSES REDACTED]. Review of the facility's undated Infection Control Standard Precautions - Handout policy, showed: -All employees must be continually aware of possible contact with communicable diseases because nursing homes are required by law to admit residents who are suffering from communicable disease. Often these communicable disease are not detected, and employees may be at risk of exposure unknowingly. Therefore, standard precaution should be taken with all residents. Standard precautions are those precautions used in caring for residents in the facility. Standard precautions consider all blood and bodily fluids as potentially infectious. It is mandatory that all staff follow these precautions in order to prevent the development and transmission of infectious diseases; -The policy did not address COVID-19 and/or precautions to be taken if a resident is suspected or positive for COVID-19. Review of the facility's Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance) policy, updated [DATE], showed: -The decision to discontinue transmission-based precautions for patients with confirmed COVID-19 infection should be made using a symptom-based strategy. The time period used depends on the patient's severity of illness and if they are severely immunocompromised; -The policy did not address when to place a resident positive for COVID-19 on transmission-based precautions and/or what precautions are required for a resident positive for COVID-19. During an interview on [DATE] at 10:00 A.M., Director of Nursing (DON) PP said the infection control policies provided have not changed. He/she is not sure if the facility has a policy specific to COVID-19 or specific to a COVID-19 unit, but he/she will check. At 2:00 P.M., DON PP said he/she was not able to find a policy specific to COVID-19 or a COVID-19 unit. 1. Review of the facility's list of COVID-19 residents (all positive since first case on [DATE]), showed: -The first positive case identified was a resident tested in the emergency room ; -Following notification from the hospital of the positive case, all residents were tested on [DATE]; -On [DATE], three residents COVID-19 test results returned positive. Review of the facility census, dated [DATE], showed two of the residents identified on the list of COVID-19 residents as positive on [DATE], remained in the facility, Residents #400 and #401. Review of Resident #400's COVID-19 lab report, showed: -Collection date: [DATE]; -Reported date: [DATE] (Sunday) at 10:01 A.M.; -Results: Positive. Review of Resident #401's COVID-19 lab report, showed: -Collection date: [DATE]; -Reported date: [DATE] (Sunday) at 7:02 P.M.; -Results: Positive. Further review of the facility census, dated [DATE], showed: -Resident #400 resided in a three resident room and had two roommates, Residents #406 and #503; -Resident #401 resided in a room with one roommate, Resident #508. Review of Resident #406's medical record, showed: -[DIAGNOSES REDACTED]. -A one page care plan, dated for admission date of [DATE]: Resident chose to be a do not resuscitate (DNR) code status. Goal: Wishes will be followed. Interventions: Do not initiate cardiopulmonary resuscitation (CPR) if found without heart beat or respirations. Notify physician/family of status: -No further focus areas, goals or interventions listed. Review of Resident #503's medical record, showed: -[DIAGNOSES REDACTED]. -No comprehensive care plan; -A baseline care plan, dated [DATE], treatments per physician order, oxygen at 2 liters. Review of Resident #508's medical record, showed: -[DIAGNOSES REDACTED]. -A COVID-19 test collected [DATE] and reported [DATE], negative; -A care plan, in use at the time of the investigation: At risk for [MEDICAL CONDITION] ([MEDICAL CONDITION], lung disease) complications. Goal: Remain free of secondary complications. Intervention included to monitor for signs and symptoms of infection. Further review of facility's list of COVID-19 residents (all positive since first case on [DATE]), showed: -Resident #406 test positive for COVID-19 on [DATE]; -Resident #503 not identified as being positive for COVID-19; -Resident #508 not identified as being positive for COVID-19. Observation of the Fountain View hall on [DATE] at 10:35 A.M., showed Resident #400 walked down the hall with no mask on. Certified Medication Technician (CMT) WW redirected the resident back to his/her room. The resident resided in the middle bed, with Resident #406 in the bed closest to the room door and Resident #503 closest to the window. No residents wore masks, all residents visible from the doorway and the beds within 6 feet of each other. Observation of Resident #401's room, showed the resident resided in the bed closest to the door and the door remained opened. Resident #508 resided in the room. Both residents visible from the door. Resident #401 actively coughing. Neither resident wore a mask. During an interview on [DATE] at 9:10 A.M., the Infection Control Preventionist (ICP) said if a COVID-19 test was done by the lab, the swab would be done, paperwork completed and specimen would be sent to lab. The turnaround time for getting results back is ,[DATE] days. The ICP was not sure if the results are called back or if the results are faxed. The 25th was a Sunday, and he/she does not know if the lab communicates with the facility on the weekend or not. If the results were faxed, the nurse on duty would get the results and take the results to the appropriate nurse's station. With agency nurses here it is hard to say what they would do. The door to where the fax machine is located is kept closed but not locked. Anyone can go there to get the results. The nurse on duty would know to look for lab results by someone in management communicating this to them. He/she does not know if the DON had communicated this to staff or not. Once a nurse gets a fax, they deliver it to the floor nurse. Positive results are called to the doctor, family, and residents are notified. If the resident's test was done by the lab, the resident should be notified the same day the results came back. The ICP was not aware of residents waiting to be notified. 2. Review of the facility layout, showed: -Fountain View hall located on the lower level; -room [ROOM NUMBER] and 118 located on either side of the hall, at the top end of the hall, and closest to the entrance to the hall; -room [ROOM NUMBER] and 100 located on either side of the hall and at the far end of the hall; -The dining room located at the far end of the hall, behind the nurse's station; -Spectrum hall located on the upper (main) level; -Complex hall located on the upper (main) level. Further review of facility's list of COVID-19 residents (all positive since first case on [DATE]), showed the following residents tested positive for COVID-19: -Resident #400: Results received [DATE]; -Resident #401: Results received [DATE]; -Resident #402: Rapid test on [DATE]; -Resident #403: Rapid test on [DATE]; -Resident #404: Rapid test on [DATE]; -Resident #405: Rapid test on [DATE]; -Resident #406: Rapid test on [DATE]; -Resident #407: Rapid test on [DATE]; -Resident #408: Rapid test on [DATE]; -Resident #409: Rapid test on [DATE]; -Resident #410: Rapid test on [DATE]; -Resident #411: Rapid test on [DATE]. Review of the facility census, dated [DATE], showed: -32 residents resided on the Fountain View hall; -12 residents identified as positive for COVID-19, located at various locations throughout the hall and located in rooms at the top end and far end of the hall; -20 residents who tested negative for COVID-19 resided on the hall at various locations. During an interview on [DATE] at 12:45 P.M., DON PP said there was one resident on the Fountain View Hall who was COVID-19 positive that wandered into other resident's rooms, Resident #400. To prevent the resident from wandering into rooms of resident's negative for COVID-19, the dining room was utilized so the resident could wander freely, while keeping the other residents safe. This resident's bed had been moved into the dining room. Review of Resident #400's medical record, showed: -[DIAGNOSES REDACTED]. -No comprehensive care plan; -A baseline care plan for admitted [DATE], resident is non-compliant with mask. He/she roams the halls daily. No intervention listed; -COVID-19 test, collection date: [DATE], results reported: [DATE], positive. Observation on [DATE] at 1:45 P.M., showed there was one resident in the dining room at the end of the hall, behind the nurse's station. The door was closed. The resident would go from one chair to the next and walked around the room. The resident walked up to the door that was transparent, and looked down the hall towards the staff and residents. Outside the dining room was a cart with PPE supplies. No trash receptacle located inside or outside the dining room for staff to dispose of used PPE. No sign on the door to identify the area as an isolation area or to identify what PPE is required to enter the area. A staff member identified the resident as Resident #400. During an interview on [DATE] at 3:30 P.M., DON PP said the whole first floor, Fountain View hall, will be quarantined for COVID-19. Several residents on the Fountain View hall and two residents on the Complex hall have tested positive for COVID-19. They would be putting a zipper wall barrier on the Fountain View hall to isolate it from the rest of the facility. Resident #400 has slept in the dining room for the past two days. 3. Observation on [DATE] at 3:45 P.M., showed Housekeeper CCC put on full PPE and entered a resident room on Fountain View hall. He/she exited the room with gown on, removed his/her gown in the hall and placed it in a trash bin. He/she then pushed his/her cart down the hall. No hand hygiene performed after removing his/her gown. During an interview on [DATE] at 5:35 P.M., Nurse P said he/she had been told to assume the whole floor is positive for COVID-19. Staff are to wear gowns, do hand hygiene, and keep their mask on. Staff are to change gowns after caring for the residents and discard of PPE in the resident's room before exiting the room. During an interview on [DATE] at 6:00 P.M., the ICP said all the residents who have tested positive for COVID-19 would be on the Fountain View hall and all other residents on Fountain View hall are presumed to be positive for COVID-19. Staff had been instructed to treat all residents as if they were COVID-19 positive. Staff is to utilize full PPE, gowns, masks, eye protection and gloves. Resident #400 will be moving back to his/her room. During an interview on [DATE] at 7:00 P.M., DON PP and the Director of Clinical Operations said all residents on the first floor are presumed to have COVID-19. Staff will utilize full PPE. 4. Further review of the facility census, dated [DATE], showed: -Facility census 89; -All 12 residents, identified as positive for COVID-19, resided on Fountain View hall; -Census on Fountain View hall, 34; -A total of 22 residents negative for COVID-19 resided on the Fountain View hall; -A total of 8 residents negative for COVID-19, Resident #501, #502, #503, #504, #505, #506, #507, and #508; had roommates that tested positive for COVID-19; -The location of rooms that contained residents positive for COVID-19 varied throughout the Fountain View hall. Review of Resident #501's medical record, showed: -[DIAGNOSES REDACTED]. -No comprehensive care plan provided. Review of Resident #502's medical record, showed: -[DIAGNOSES REDACTED]. -No comprehensive care plan; -A baseline care plan for admitted d [DATE], [DIAGNOSES REDACTED]. Review of Resident #503's medical record, showed: -[DIAGNOSES REDACTED]. -No comprehensive care plan; -A baseline care plan, dated for admitted [DATE], treatments per physician order, oxygen at 2 liters. Review of Resident #504's medical record, showed: -[DIAGNOSES REDACTED]. -A care plan, in use at the time of the investigation showed: Medical [DIAGNOSES REDACTED]. Goal: Be free of signs and symptoms of respiratory infections. Interventions included: Identify and eliminate sources of respiratory irritation. Monitor for difficulty breathing on exertion. Monitor for symptoms of respiratory insufficiency. Review of Resident #505's medical record, showed: -[DIAGNOSES REDACTED]. -A care plan, in use at the time of the investigation showed: -Medical [DIAGNOSES REDACTED]. Goal: Will not have an exacerbation of [MEDICAL CONDITION]. Approaches included: Apply oxygen as needed. Monitor for cough, note if productive or non-productive, notify physician of change in respiratory status; -At risk for aspiration related to history of aspiration pneumonia prior to admission. Goal: Will not exhibit signs and symptoms of aspiration. Approaches included: Apply oxygen should resident aspirate. Review of Resident #506's medical record, showed: -[DIAGNOSES REDACTED]. -A care plan, in use at the time of the investigation showed: At risk for pneumonia related to influenza A. Goal: Pneumonia will be resolved. Interventions included: Monitor, document and report symptoms of pneumonia. Review of Resident #507's medical record, showed: -[DIAGNOSES REDACTED]. -A care plain, in use at the time of the investigation showed: Potential for psychosocial well-being problem related to visitation restrictions secondary to COVID-19. Goal: Will not suffer ill effects. Interventions included: Encourage and offer alternate means of communication with family and friends. Review of Resident #508's medical record, showed: -[DIAGNOSES REDACTED]. -A COVID-19 test collected [DATE] and reported [DATE], negative; -A care plan, in use at the time of the investigation showed: Showed at risk for [MEDICAL CONDITION] complications. Goal: Remain free of secondary complications. Intervention included to monitor for signs and symptoms of infection. 5. Observation of Fountain View hall and review of the list of residents positive for COVID-19, on [DATE] at 10:35 A.M. through 11:30 A.M., showed: -As staff exit the elevator from the main level to the lower level, the COVID-19 unit is located to the right. A plastic barrier with a zipper separated the hall from the elevator area. A sign on the door COVID UNIT and a sign posted to identify full PPE required. A cart with PPE located outside the unit; -Tour of the hall, showed 16 of the 20 room doors opened or partially opened to the hall; -No signs on the individual room doors to identify which rooms contained residents on transmission based precautions. Carts with PPE located at various locations throughout the hall; -Observation of room [ROOM NUMBER], showed three residents resided in the room. The room door open, all residents visible from the hall and no residents wore a mask. The resident located closest to the window listed as positive for COVID-19. The other two residents in the room negative for COVID-19. The curtain partially closed between the resident in the bed closest to the window and the other two residents, but all residents fully visible from the door. Resident #502, identified as negative for COVID-19, located in the center bed with the resident identified as positive for COVID-19 located in the bed next to him/her. The room directly across the hall contained residents negative for COVID-19, with the room door open. Review of a list of residents positive for COVID-19, provided on [DATE], showed Resident #502 tested positive for COVID-19 on [DATE]. Continued observation of Fountain View hall and review of the list of residents positive for COVID-19, on [DATE] at 10:35 A.M. through 11:30 A.M., showed: -room [ROOM NUMBER] contained one resident positive for COVID-19. The room door partially opened; -room [ROOM NUMBER] contained three residents. The room door closed. The resident residing in the bed closest to the door and the middle bed identified as positive for COVID-19. The resident in the bed closest to the window, negative for COVID-19; -room [ROOM NUMBER] contained two residents. The room door closed. The resident closest to the door negative for COVID-19, the resident closest to the window identified as positive for COVID-19; -room [ROOM NUMBER] contained three residents. Resident #506 sat at the doorway in a wheelchair, wore a mask and was identified as negative for COVID-19. Staff stood at a medication cart directly in front of the room. Three residents resided in the room. The resident closest to the door and in the center bed negative for COVID-19. The resident closest to the window positive for COVID-19. All three residents visible from the door. Only Resident #506 wore a mask. The resident in the bed closest to the window, identified as positive for COVID-19, did not wear a mask, and actively coughing a dry cough; -Observation at this time, showed Resident #400, identified as positive for COVID-19, walked down the hall without a mask within 3 feet of Resident #506. Certified Medication Technician (CMT) WW redirected Resident #400 back to his/her room. Resident #400 located in a room with two roommates, the resident in the bed closest to the window negative for COVID-19, the other two residents positive for COVID-19. CMT WW closed the door as he/she exited, returned to the medication cart and did not change gloves or perform hand hygiene before continuing to prepare medications for administration; -room [ROOM NUMBER] contained two residents. The room door closed. The resident closest to the door identified as positive for COVID-19. The resident closest to the window, Resident #507, negative for COVID-19. Review of a list of residents positive for COVID-19, provided on [DATE], showed Resident #507 tested positive for COVID-19 on [DATE]. Continued observation of Fountain View hall and review of the list of residents positive for COVID-19, on [DATE] at 10:35 A.M. through 11:30 A.M., showed: -room [ROOM NUMBER] contained two residents. The room door opened. The resident in the bed closest to the door positive for COVID-19 and actively coughing. The resident in the bed closest to the window negative for COVID-19. Both residents visible from the door. Neither resident wore a mask; -room [ROOM NUMBER] contained one resident positive for COVID-19. The room door opened to the hall; -Observation showed Resident #600, identified as negative for COVID-19, propelled down the hall towards the exit to the hall. He/she wore a facemask. He/she propelled past room [ROOM NUMBER] as the resident in the bed closest to the door, identified as positive for COVID-19, actively coughed with no mask on. Resident #600 propelled to the plastic barrier, unzipped it and looked out. Review of a list of residents positive for COVID-19, provided on [DATE], showed Resident #600 tested positive for COVID-19 on [DATE]. 6. During an interview on [DATE] at 11:00 A.M, Licensed Practical Nurse (LPN) XX said he/she is agency staff. He/she is the nurse for all residents on the Fountain View hall. Today is his/her first day. No one explained to him/her what PPE should be worn on the unit or what PPE should be changed when going into different rooms. He/she would wear the same PPE in all rooms, except gloves which he/she would change in all rooms. He/she would change gloves/gown if he/she provided direct care. He/she believed all residents on the floor were positive for COVID-19. During an interview on [DATE] at 11:15 A.M., CNA YY said full PPE is required for the entire Fountain View hall. He/she changes gloves in each room and changes his/her gown every other room. If providing direct care, then he/she changes his/her gown then as well. Observation on [DATE] at 11:20 A.M., showed CNA ZZ came out of room [ROOM NUMBER], a room that contained a resident positive for COVID-19, removed his/her gloves and applied new gloves without sanitizing his/her hands. He/she did not remove or change his/her gown. He/she then walked down the hall towards the plastic barrier, unzipped the barrier and grabbed a handful of charts from someone on the other side. He/she held the charts against his/her isolation gown and took them down to the nurse's station before returning to the far end of the hall. During an interview at this time, CNA ZZ said he/she should change gown and gloves when exiting a room only if he/she provides care. Otherwise, he/she can continue to wear the same PPE into multiple rooms. 7. Observation on [DATE] at 11:25 A.M., showed Resident #400, identified as positive for COVID-19, walked down the hall from his/her room located at the end of the hall to the nurse's station. LPN XX located at the nurse's station and did not redirect the resident back to his/her room. He/she then started to walk back up the hall past multiple rooms which contained residents negative for COVID-19 with their doors opened. The resident wore no mask. CMT WW redirected the resident to his/her room and then continued to pass medications. Resident #400 immediately re-exited the room and walked all the way down the hall, from the far end near the nurse's station to the plastic barrier, with no mask on. He/she walked past LPN XX and Resident #506, who sat in his/her doorway and was negative for COVID-19. LPN XX looked up at the resident, but did not redirect him/her to his/her room. During an interview on [DATE] at 11:30 A.M., Resident #506 said his/her roommate is positive with COVID-19 and this morning he/she was very short of breath. He/she reported to LPN XX that his/her roommate was having difficulty breathing and LPN XX scolded him/her saying he/she does not know what he/she is talking about and to mind his/her own business. His/her roommate has been short of breath and coughing a lot lately. He/she tries to help his/her roommate, but when he/she cannot, he/she gets the nurse. 8. During an interview on [DATE] at 2:00 P.M., DON PP said the determination to leave the residents negative for COVID-19 with the residents positive for COVID-19 on Fountain View hall was a choice made between Interim administrator/admissions coordinator OO, the regional director of clinical operations and him/herself. The choice was made so residents could stay in their own rooms. Medical Director UU was not involved in that decision. Medical Director UU's last day working for the facility will be [DATE]. Medical Director VV starts on [DATE]. During an interview on [DATE] at 3:45 P.M., Physician Representative GGG, a representative of Medical Director UU, said Medical Director UU does not recall the facility involving him/her in any decisions regarding placement of residents in the COVID-19 unit. During an interview on [DATE] at 4:20 P.M., Administrator QQ said they are in the process of separating out the COVID-19

Based on interview and record review, the facility failed to ensure a resident with a full code order was assessed and Cardiopulmonary Resuscitation (CPR, life-sustaining measures in the event that the heart stops beating) performed after he/she became unresponsive for one of three sampled residents (Resident #30). The nurse did not perform CPR on the resident after being notified at least twice, that the full code resident was unresponsive. The resident expired. The census was 106. Review of Resident #30's authorizations, consents, and acknowledgement forms, dated [DATE], showed he/she initialed and signed acknowledgement that he/she received, read or had read to him/her, and understood the facility's policy and state requirements for advance directives and elected not to execute any advance directive at that time. The resident acknowledged the understanding that facility staff would respond to medical emergencies with CPR measures and a full code would be instituted. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Brief interview for mental status (BIMS, a brief screener for cognition), score of 15 (cognitively intact); -[DIAGNOSES REDACTED]. -Required supervision of one with bed mobility. Review of the resident's care plan, dated [DATE], showed the following: -At risk for weight loss related to malnutrition, recent history of perforated (pierced) [MEDICAL CONDITIONS] reflux disease (condition in which acidic stomach contents leak backwards from the stomach into the esophagus), and depression; -Strict isolation for [MEDICAL CONDITION] (infection caused by an antibiotic resistant strain of staph bacteria) bacteremia; -Required assistance with activities of daily living related to generalized weakness. Further review of the resident's medical record, showed a face sheet, dated [DATE], listing the resident's code status as full code. Review of the resident's physician's orders [REDACTED]. During an interview on [DATE] at 6:18 A.M., Certified Nurse Aide (CNA) FF said he/she started his/her shift at 11:00 P.M. on [DATE], without getting report from the outgoing staff, and conducted rounds. CNA FF checked on the resident who was awake. CNA FF asked him/her if he/she needed anything and the resident shook his/her head to indicate no. CNA FF emptied the resident's urinal and moved on. The resident was in and out of sleep throughout CNA FF's shift and did not have any shortness of breath or change in condition. He/she conducted rounds a second time, between 1:00 A.M. and 1:30 A.M., during which time, he/she emptied the resident's urinal again and got the resident some ice water. CNA FF checked on the resident approximately every two hours during rounds. At around 4:00 A.M., CNA FF was walking past the resident's room and saw Nurse O in with the resident. CNA FF went in and asked the resident if he/she needed anything. The resident shook his/her head to indicate no. CNA FF checked to see if the resident was wet. The resident was dry. Between 5:45 A.M. and 6:45 A.M., CNA FF conducted his/her last rounds. At approximately 6:20 A.M., Nurse O asked CNA FF for assistance with another resident. CNA FF remained in that room until right before he/she clocked out at 7:08 A.M., without seeing Resident #30 again. Review of the resident's nurses notes, dated [DATE] at 4:20 A.M., showed the nurse flushed both ports, and they flushed well. The resident was given water and he/she coughed. Potentially needed a swallow evaluation. Weak, but alert and smiles. Staff did not document vital signs. During an interview on [DATE] at 10:10 A.M., Nurse O said his/her shift on [DATE] began at 11:00 P.M. Nurse O got report from the outgoing nurse, who did not mention any issues or pass on any instructions regarding the resident. From 11:30 P.M. to 12:30 A.M., Nurse O conducted rounds. He/she looked in on the resident, who was asleep and breathing normally. Nurse O was the only charge nurse on duty in the Spectrum unit for the 11:00 P.M. to 7:00 A.M. shift from [DATE] into [DATE]. He/she charted until 4:00 A.M. and then got up and conducted rounds again between 4:00 A.M. and 4:30 A.M. Nurse O flushed the resident's peripherally inserted central catheter line, sat down and talked with the resident, expressing shock over his/her degree of weight loss in the three or four days of Nurse O's absence from the facility. The resident said, I know. Nurse O told him/her that his/her weight loss and apparent physical weakness were alarming. Nurse O planned on contacting his/her physician about it. Nurse O could see the resident was weak because he/she normally only held his/her head tilted downward while asleep. That morning the resident did not raise his/her head while awake and moved it very little. Nurse O gave him/her some water, he/she drank some and began coughing. Nurse O made a notation to consider having him/her undergo a swallow test. At around 6:40 A.M., Nurse O went to get a glucose meter reading on another resident and found that resident unresponsive. Nurse O alerted CNA FF and they attended to him/her. He/she got a pulse, but no blood pressure. Because the wrist monitor he/she used sometimes gave inaccurate blood pressure readings, he/she felt the resident might just need some (blood) volume. Nurse O called 911 and then contacted the resident's physician who did not want anything done for the resident, whose code status was do not resuscitate. By the time paramedics arrived, the physician had already called time of death for the other resident. Review of the fire district report, dated [DATE], showed notification of an emergency at 6:50 A.M. Paramedics arrived on the scene at 6:57 A.M. and reached the resident at 7:00 A.M. At 7:15 A.M., the paramedics were finished. During an interview on [DATE] at 12:10 P.M., CNA GG said on [DATE], he/she started his/her shift at 7:00 A.M., and went to the Complex unit, in order to look at the staff schedule posted and find out what his/her assignment was for the day. CNA GG then started making rounds and decided to check on the resident, even though he/she was not assigned to provide the resident's care. CNA GG provided his/her care on the previous day and recalled the resident was in pain and had not looked good. At around 7:15 A.M., CNA GG found the resident propped up in bed. He/she appeared to be in the same position he/she was in during CNA GG's shift the day before. The resident's head was slumped down. CNA GG called the resident's name and got no response. He/she did not respond when CNA GG touched him/her. The resident still had his/her nasal cannula on. CNA GG did not check his/her vital signs. CNA GG asked CNA HH to check the resident. During an interview on [DATE] at 1:09 P.M., CNA HH said he/she was just coming on duty when CNA GG approached him/her and asked him/her to go and look in on the resident, because the resident did not look right. It was approximately 7:15 A.M. CNA HH went to see the resident. He/she was laying supine (lying horizontally with the face and torso facing up) with his/her head tilted down and to the right. CNA HH called out his/her name and touched his/her shoulder. The resident did not respond. Nurse O was sitting at the nurse's station filling out paperwork. CNA HH went and asked Nurse O to check on the resident, because he/she was unresponsive. CNA HH grabbed the resident's chart, looked through it, and informed Nurse O that the resident was a full code. CNA HH got out the paperwork on him/her for the paramedics and went back down to the room to await Nurse O's arrival. CNA HH was unsuccessful in a second attempt to rouse the resident. Nurse O did not come to the room. CNA HH went back to Nurse O and told Nurse O a second time that the resident was unresponsive and was a full code. During an interview on [DATE] at 9:56 A.M., the Police Sergeant said he was talking to Nurse O close to 7:20 A.M., when CNA HH approached them and informed Nurse O the resident appeared to have passed away. The Sergeant followed Nurse O into the resident's room. Nurse O took the resident's vital signs. The resident had a living temperature, but no pulse. Nurse O said the resident was a full code, but he/she was not going to perform CPR on the resident, because he/she did not know what time the resident passed away. The Sergeant used his radio to call for the paramedics to return, because he was alarmed by Nurse O's decision not to perform CPR. Further review of the resident's nurses notes, dated [DATE] at 7:15 A.M., showed the resident was deceased per Certified Medication Technician (CMT) and CNA. Weekend supervisor and day shift here. Staff did not document any vital signs. Review of the resident's police department investigative report, dated [DATE], showed at approximately 7:22 A.M., the Sergeant requested for emergency medical services (EMS) to respond. During an interview on [DATE] at 10:10 A.M., Nurse O said at 7:15 A.M., CNA GG and CNA HH approached the nurse's station and announced that the resident was dead. There were no other nurses at the nurses' station. Nurse O was working on paperwork regarding the passing of the other resident and did not hear CNA HH say the resident was a full code. His/her mind was on completing the paperwork. Had day shift not been in the facility, Nurse O would have immediately jumped on it and been pumping on the resident. He/she assumed someone else was taking care of it, believing that the first person on the scene was responsible for performing CPR. During an interview on [DATE] at 1:09 P.M., CNA HH said the second or third time he/she urged Nurse O to check on the resident, Nurse O informed him/her that he/she was calling the other resident's family. Nursing Supervisor II heard CNA HH say the resident was unresponsive and full code. Nursing Supervisor II said, What room? CNA HH gave the resident's room number and Nursing Supervisor II ran to get the crash cart. During an interview on [DATE] at 1:32 P.M., Nursing Supervisor II said on [DATE], he/she had started work at either 5:45 A.M. or 6:00 A.M., but was unaware anything was going on with the resident until he/she was walking down the hall to the Spectrum unit nurses' station (time unknown) and a CNA (identity unknown) informed him/her the resident was unresponsive. Nursing Supervisor II reached the nurses' station and asked about the resident's code status. CNA HH checked and said it was full code. Nurse O was on the phone. Nursing Supervisor II told the staff present to get the crash cart. No one moved, so Nursing Supervisor II ran to get the crash cart, which was ,[DATE] feet from the nurses' station. By the time Nursing Supervisor II rounded the corner with it, the paramedics had arrived, so they performed CPR on the resident instead of Nursing Supervisor II. During an interview on [DATE] at 10:10 A.M., Nurse O said Nursing Supervisor II had gone to get the crash cart and paramedics were in the building when Nurse O got up to go check on the resident at 7:30 A.M. At that point, Nurse O realized Nurse M was not in the resident's room performing CPR. Nurse M was down the hall administering medications. When Nurse O entered the resident's room, the resident was lying on his/her back in bed and was cold, but without rigor mortis (stiffening of the joints or muscles which occurs a few hours after death). The resident's face was off color. It was pale and his/her fingers were blue. Nurse O took the resident's vital signs, prior to the paramedics entering the room, and found he/she had no pulse or blood pressure. His/her temperature was 97.1 degrees Fahrenheit (F; normal range, 97 to 99 degrees F). Further review of the resident's police department investigative report, dated [DATE], showed the Police Officer on the scene interviewed Nurse O who said no life saving measures were taken on the resident when Nurses O went in and assessed the resident's vital signs. The officer later asked Nurse O why no life saving measures were taken on the resident and Nurse O said, I don't know. Review of the resident's fire district report, dated [DATE], showed someone requested Emergency Medical Services (EMS) for the resident and paramedics were dispatched via ambulance at 7:26 A.M. Paramedics were enroute at 7:28 A.M., and arrived at the facility at 7:32 A.M. They reached the resident at 7:35 A.M. There was no staff in the room. The paramedics were met by a police officer. The resident was pulseless, apneic (not breathing), and cold to the touch. The paramedics requested staff send the nurse to the room. Staff informed them the resident was a full code. The nurse said staff found the resident pulseless and apneic at 7:15 A.M. Staff did not start CPR at that time. Down time prior to administration of CPR for the first time was 30 minutes. The resident remained pulseless, apneic, and asystole (no electrical activity from the heart and therefore no blood flow) in three leads. A hospital physician authorized EMS to terminate resuscitation efforts. During an interview on [DATE] at 7:54 A.M., Paramedic JJ said on [DATE], he/she and Paramedic KK were dispatched to the facility for an obvious death. Upon arrival, there were no staff members in the resident's room. They were met by a police officer. Paramedic JJ and Paramedic KK went to the resident's bedside and saw no obvious signs of death; there was no blood pooling or rigor mortis. The resident's cold skin could have been due to the ambient temperature in the room or issues with the surface temperature of the skin, or just a sign of circulatory cessation. Consequently, there was no indication that they should not perform CPR. The paramedics had to track people down, in order to ask about the resident's code status. They found a CNA, who informed them he/she was off duty. They asked him/her to get a nurse to the room. The length of time spent waiting for the nurse (actual time unknown) prompted Paramedic JJ to start CPR. The police officer was the one who gave the paramedics a timeframe of events which occurred prior to their arrival. When Nurse O entered the room, he/she said he/she thought the resident was a full code. No one was certain. Staff had to go pull the resident's paperwork and check. Nurse O did not report any vital signs to the paramedics. Either the police officer or Nurse O said that no CPR was started prior to the arrival of paramedics. Paramedic JJ was concerned about the facility's failure to provide basic care to the resident. During an interview on [DATE] at 8:00 A.M., Paramedic KK said he/she ran an electrocardiogram (diagnostic tool that measures and records the electrical activity of the heart) three lead strip on the resident and found him/her to be asystole. The resident was also pulseless, apneic (not breathing), and his/her skin was cold to the touch; not hot and not room temperature. Paramedic KK decided to perform CPR, because there were no obvious signs of death. The resident's body was still pliable and his/her temperature was not below 96 degrees F. The compressions were easy, but there was no reaction from the resident to the CPR. During an interview on [DATE] at 2:27 P.M., Nurse M said when he/she started his/her shift at 7:00 A.M. on [DATE], staff informed him/her that two residents had passed away. Nurse O never asked Nurse M to perform CPR on the resident or to assist Nurse O in any way. Further review of the resident's nurses notes, dated [DATE] at 7:30 A.M., showed staff went to see the resident. CPR not started. No pulse, no blood pressure. Temperature 97.1 degrees F. Crash cart called and EMS coming down the hall. Placed on monitors. Two rounds of cardiac compressions done. Asystole ([MEDICAL CONDITION] rhythm in which there is no discernible electrical activity on the ECG monitor). 7:42 A.M., pronounced expired. During an interview on [DATE] at 11:21 A.M., the Director of Nursing (DON) said the CNAs at the facility were not certified in CPR. Consequently, the charge nurses were solely responsible for performing CPR on residents. In that situation, the CNAs were to get the crash cart and the resident's chart. Upon learning that a resident was unresponsive, the charge nurse was expected to directly go to the resident, assess him/her and immediately perform CPR if the resident's code status was full code. The only exception would be if the charge nurse was in the middle of an emergency situation. Filling out paperwork on a deceased resident did not constitute an emergency situation. If another nurse was performing CPR, then the unit charge nurse should still provide assistance. Review of the facility's policy titled Resuscitation of Patients/Residents With and Without Automatic External Defibrillation (AED) dated [DATE], showed CPR was to be performed in the presence or absence of an AED. Appropriate staff in the immediate area was to respond and call or designate a person to call 911 or locally appropriate emergency number, follow practice guidelines for CPR by initiating resuscitation on full code residents with and without AED, as appropriate and in accordance with the resident's advance directives. Staff was to assist with basic life support. Staff was to verify transportation of the emergency cart to the resident's room. Review of the facility's policy titled Respiratory Care Department's Role in Cardiopulmonary Resuscitation updated [DATE], showed staff were to quickly gather all of the necessary equipment and supplies, don the appropriate personal protective equipment, establish a patent (unobstructed) airway, and begin ventilation. If indicated, staff should begin cardiac compressions. Staff were to assist other personnel with resuscitation tasks as appropriate. Once initiated, resuscitation must continue until it was no longer necessary because the resident's spontaneous efforts returned and were adequate, or emergency medical services took over resuscitation for transport to the hospital, or a physician ordered that the efforts be stopped. During an interview on [DATE] at 2:15 P.M., the DON said when the corporate office revised a facility policy, they notified the facilities via e-mail. However, sometimes there was a lag period prior to the facility receiving notification. Initially, administrative staff notified supervisory staff who then would speak to staff about the policy. There was no documentation of the date the corporate office provided notification regarding the [DATE] revision of the policy, titled Respiratory Care Department's Role in Cardiopulmonary Resuscitation. There was no documented in-service on the updated policy prior to [DATE]. She did not know whether or not that policy was meant to replace the policy titled Resuscitation of Patients/Residents With and Without Automatic External Defibrillation (AED), dated [DATE], or which policy was in effect when the resident became unresponsive on [DATE]. During an interview on [DATE] at 9:15 A.M., Physician LL did not recall staff providing notification that the resident had become weak. Staff should have notified him/her because vital signs should have been taken. The accepted procedure for a full code resident was that upon learning the resident was unresponsive, the charge nurse should have immediately gotten the crash cart, gone in and checked the resident's vital signs. If he/she was still breathing, then staff should have started CPR and called 911. A staff person should have called a code over the intercom, so that all available staff could respond and provide assistance. All of that should have taken place within a few minutes of the resident becoming unconscious and once paramedics arrived, then they could have taken over. Six minutes was too long to wait before starting CPR, because the resident could expire. Even if another nurse had performed CPR, Nurse O should have gone in and assisted that nurse. Two people could perform CPR. Note: At the time of the abbreviated survey, the violation was determined to be an immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined that the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility developed a plan of correction which included continued in-servicing of all staff on the cardiopulmonary resuscitation (CPR) policy and process. Code status will be reviewed quarterly and with significant change, in order to validate that residents' code statuses remain accurate, as part of the care planning process. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote the facility has complied with state law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations. MO 497

Based on observation, interview and record review, the facility failed to provide protective oversight and supervision for a newly admitted , confused resident, with a very unsteady gait, that left the facility in the middle of the night, via an unalarmed fire door, and was found and picked up by a passerby in a truck. The passerby returned the resident to the facility. Staff were unaware the resident left the building. The resident sustained [REDACTED].#10). The census was 112. Observation of the north front side of the facility, on 1/28/15 at 9:00 A.M., showed a two lane road with a narrow shoulder, approximately 4 feet wide, and a three way intersection that began at the west end of the building. The front lawn area met the shoulder of the two lane road (no curb), with a shallow drainage ditch, approximately 5 feet from the shoulder. A 4 foot high white iron fence enclosed a rectangular area, approximately 98 feet long and 40 feet wide, of the facility's front west yard. The two lane road ran parallel to the fence, separated by a narrow patch of yard approximately 11 feet wide. The east end of the fenced area had an exit gate, facing the road. The gate opened and closed with a slide metal latching system. There was no lock on the gate. Review of Resident #10's behavioral health hospital record, fax dated 1/23/15 at 12:57 P.M. to the facility, showed the following: -Hospital admission date of [DATE], with discharge date of [DATE]; -Reason for admission, danger to self; -Wound care notes, dated 1/14/15 at 7:50 P.M. showed healing reddened area to upper right aspect of his/her back, bruising to bilateral forearms and hands and skin tear to right arm; -Psychiatric evaluation, dated 1/15/15, showed the resident with history of dementia and behavioral disturbances admitted to the psychiatric unit for acute exacerbations of mood instability and aggressive behavior at home. The resident had three strokes in November 2014 which exacerbated his/her cognitive decline. The resident is an unreliable, poor historian, oriented to self only with medical history of [REDACTED]. -Nursing note, dated 1/19/15 at 5:59 P.M., showed resident did not go to sleep until 5:00 A.M. and monitored within line of sight at all times; -Nursing note, dated 1/20/15 at 4:05 A.M., showed resident confused and confusion seems to increase at night; remains within line of sight for safety; -Nursing note, dated 1/20/15 at 5:59 P.M., showed the resident did not interact with peers, ambulated well with stand-by assist and monitored within line of sight at all times; -Nursing assessment, dated 1/20/15 at 12:44 P.M. showed auditory/visual hallucinations, posturing, restlessness, pacing, increasing agitation and aggression; -Mental status per physician progress notes [REDACTED].M., showed the resident appears delusional, alert and oriented to self but not to place, date, or situation and insight and judgment is impaired; -Physical assessment note, dated 1/23/15 at 1:00 A.M. and at 3:43 A.M., showed the resident sleeping, easy to arouse; -Coping skills assessment, dated 1/23/15 at 9:00 A.M., showed the resident had difficulty dealing with stress, ineffective problem solving and poor decision making; -Fall risk assessment, dated 1/23/15, showed the resident at high risk for falls due to alteration in gait or balance, alteration in mental status and received anti-epileptic (medications used for seizure disorder and behavioral disturbances) and benzodiazepine (anti-anxiety medications) medications; -Precautions implemented, dated 1/23/15 at 9:00 A.M., aspiration, assault, violence, elopement, bleeding and fall risk; -Observation precautions, dated 1/23/15 at 9:00 A.M., showed the resident within line of sight. Review of the facility's admission nursing data collection tool, dated 1/23/15, no time, showed the following: -Resident arrived at 2:00 P.M. and admitted (Spectrum B unit); -Section 2, Identified Prior Risks, showed resident was a wanderer with behavior problems; -Section 8, Neurological/Cognition, showed short-term memory problem and moderately impaired decision making; -Section 8, Mood Assessment, showed sundowners (a phenomenon associated with increased confusion and restlessness, in people with some form of dementia, that occurs when the sun goes down) handwritten under the comments section; -Section 8, Behavior Assessment, showed wandering, physical behavior symptoms, verbal behavior symptoms, delusions. The psychotropic medication box showed no psychotropic medications ordered (resident was receiving two antipsychotic medications: Seroquel three times daily and Haldol as needed for agitation); -Nursing comment section showed the resident admitted with a 1 inch skin tear to the right forearm, multiple areas of purpura (red or purple discoloration) to his/her body, resident walking around and unsteady at times, needs cueing to slow down. Review of the nursing admission fall risk evaluation, dated 1/23/15, no time, showed the resident scored a 12 (10 or higher is at risk). The handwritten intervention to prevent the resident from falling, showed the resident's call light was to be within reach at all times. Review of the nursing admission risk of elopement/wandering review, dated 1/23/15, no time, showed yes was checked for the following: -Resident ambulates independently, with or without use of an assistive device; -Resident wanders aimlessly at times; -Resident's family has voiced concerns that would indicate the resident may have wandering tendencies to try and leave; -Summary of review showed the resident was at risk for elopement/wandering, as evidenced by: (no remarks were written in). -Appropriate interventions initiated were: Staff aware of resident's wander risk and wanderguard (electronic monitoring bracelet device that activates an alarm when the resident approaches a door that has been equipped with this system) placed. -Care plan was updated. Review of the nursing admission interim care plan, dated 1/23/15, no time, showed the resident had physical and verbal aggressive behaviors, sundowners, and was an elopement risk. No interventions for these identified problems, were written on the plan of care. Review of the admission physician order [REDACTED]. -[DIAGNOSES REDACTED]. -Wanderguard to right wrist; -Seroquel 25 milligrams (mg) three times daily; -Haldol 0.5 mg, as needed for increased agitation, three times daily; -Xanax (anti-anxiety medication) 0.5 mg, give one dose now (no time). Review of the nurse's notes, dated 1/23/15 at 5:00 P.M., showed the resident became agitated after his/her family member left. The physician was called to reconcile the resident's admitting orders and an order for [REDACTED]. The medication was given and at 6:00 P.M. was not effective. The resident was walking in the hallway, with a walker, and attempting to leave the facility. The resident said, I want to go home and I want to leave. Several attempts were made, with little success, to redirect the resident. A wanderguard, for safety, was placed on the resident's right wrist. During an interview on 2/11/15 at 3:10 P.M., Nurse H, assigned to the resident on Spectrum B (the far end of the west wing on the second floor of the building) said he/she worked a double shift, the evening shift and the night shift, on 1/23/15 through 1/24/15. The resident's family member arrived with the resident at 1:30 P.M., and stayed with the resident until it was time for dinner. Nurse H attended a meeting and arrived late, between 4:30 P.M. or 4:45 P.M., to the Spectrum B nursing station located at the end of the west wing hallway. During the narcotic count, he/she looked at the electronic door lock indicator box, located above the north fire exit door next to the nursing station. The red number 15 was lit up in the box, indicating the door was locked and alarmed. The administrator, Director of Nursing (DON) and Assistant DON (ADON) were together in a room (no time given), when Nurse H told them the resident's family member just left the building and the resident was now trying to leave the building. Administration said OK and gave no further instructions. Nurse H gave the resident Xanax at 5:00 P.M., but the resident continued to wander and make attempts to leave the building. The resident was taken to the dining room, at the far south-east end of the building. Nurse M, from Spectrum A (the front half of the second floor west wing near the front entrance doors), was assigned to the dining room that evening. Nurse M notified Nurse H the resident was feisty, would not stay in the dining room and kept trying to get out of the facility's exit doors. Nurse M placed a wanderguard on the resident and placed him/her on close observation. Nurse M called the DON, between 5:00 P.M. and 6:00 P.M., to report the resident's behavior and that a wanderguard had been placed on the resident. Nurse M placed the resident on close observation during dinner. The resident calmed down after dinner, and had only tried to exit the doors when he/she went by them on the way to and from the dining room. The resident was never placed on one to one observation because that must be done by the DON. Nurse M closed the two sets of fire doors on the hallway after dinner, to keep the resident at the end of the hall (on Spectrum B) because the certified nursing assistants (CNAs) were busy helping residents to bed. Spectrum B begins after the second set of fire doors, at room 211; the resident's room. The doors stayed closed from about 6:00 P.M. or 7:00 P.M., until 8:00 P.M. or 9:00 P.M. The resident stayed close to the nursing station, situated at the end of the hallway, for the remainder of the evening shift. There were four CNAs for the entire west wing (Spectrum A and Spectrum B) until 7:00 P.M. During an interview on 2/17/15 at 10:08 A.M., CNA O said he/she worked a double shift, the evening shift on 1/23/15 through the night shift on 1/24/15, on Spectrum A. He/she considered the resident his/her responsibility because all the CNAs, on the west wing, work together as a team on the evening shift. The resident became very agitated right before dinner, after his/her family member left, and began pacing and yelling, I want out of here, I want to go home and You can't keep me here. During an interview on 2/11/15 at 4:30 P.M., Nurse M said he/she was the evening shift nurse on 1/23/15 for Spectrum A, not Spectrum B, yet the DON gave him/her the wanderguard, around 4:30 P.M., to place on the resident. Nurse M saw the resident and his/her family member walking toward the dining room, so he/she put the wanderguard on the resident, in front of the family member. Nurse M went to be with the residents in the dining room (on Complex unit), because Nurse H was working on Spectrum B admissions. The resident did not stay long in the dining room, probably because the resident's family member had left the building. The resident got up, left the dining room and tried to pull on the exit door handles to leave the building. The doors did not open because of the wanderguard. Nurse M said because of this behavior, and because the resident walked very well, he/she told CNA H (assigned to the Complex unit) the resident needed to be one on one during dinner. Nurse M called Nurse H , from the Complex Unit, and told him/her the resident was trying to get out the doors and was placed on one on one observation. The resident continued to try and get out the doors, so when they returned to the west wing, Nurse M told CNA I (CNA assigned to Spectrum A, not Spectrum B) the resident was to be on one to one observation. Nurse M called the DON, sometime after 6:00 P.M., and told him they were having problems with the resident trying to leave and that the resident was currently on one to one observation with CNA I. Nurse M recalled the DON asking if the wanderguard had been placed, but could not recall anything else. Nurse M closed both sets of fire doors when the resident eventually returned to Spectrum B. CNA I did not remain with the resident when the resident returned to Spectrum B. Nurse M did not tell Nurse H the resident was to remain on one to one observation at all times, indefinitely, or that the DON had placed the resident on one to one observation. Nurse M said if the resident was one on one in the dining room, that told him/her the resident needed to be watched. Nurse M said he/she was not the boss of the building. During an interview on 2/17/15 at 10:08 A.M., CNA O said it took 30 to 45 minutes, sometime after dinner, to get the resident away from the front doors and back down the hall to his/her area (Spectrum B). CNA O said they (CNA O and the resident's assigned CNA) took turns staying with the resident, throughout the evening shift, which was not difficult because they were fully staffed. Neither Nurse M nor Nurse H said the resident was supposed to be on one to one observation. Further review of the nurse's notes, dated 1/23/15 at 8:00 P.M., showed the CNAs were taking turns sitting at the nurse's station with the resident. The resident was up walking in the hallway and occasionally forgot his/her walker. Frequent rounds/safety checks were done. During an interview on 2/11/15 at 3:10 P.M., Nurse H said there were three CNAs for the entire west wing, from 7:00 P.M. until 11:00 P.M. and there were two CNAs on the night shift. The two night shift CNAs took the resident to his/her bed, between 11:15 P.M. and 11:30 P.M. During an interview on 2/11/15 at 4:30 P.M., Nurse M said he/she did not see the resident, after the fire doors were closed, until about 11:15 P.M. The resident was sitting at the Spectrum B nursing station with a CNA sitting beside him/her. Further review of the nurse's notes, dated 1/23/15 at 11:00 P.M., showed the resident was assisted to bed by two CNAs without incident. The resident attempted several times to get out of bed. A CNA stayed with the resident until the resident was calmed. Frequent rounds continued for safety. During an interview on 2/11/15 at 3:10 P.M., Nurse H said the resident was content after the two CNAs put him/her to bed; he/she got up only once. During an interview on 2/11/15 at 12:47 P.M., CNA J (assigned to the resident on night shift 1/24/15) said Nurse H told him/her the resident was new and needed to be closely watched. The nurse did not say the resident was on one to one observation. Nurse H came to the resident's room, around 12:00 A.M., and asked why CNA J remained in the room with the resident. CNA J told Nurse H the resident was continuing to get out of bed and walk without his/her walker. Nurse H said, OK, somebody had to say with him/her. CNA J said they were not staffed for one on one observation, so Nurse H meant that someone had to stay with the resident until he/she fell asleep. There was only one CNA assigned to Spectrum A and one CNA assigned to Spectrum B (CNA O). CNA J and CNA O took turns staying with the, so they could get their rounds done and take care of the other residents. Further review of the nurse's notes, dated 1/24/15 at 1:30 A.M., showed the resident was pleasantly confused and walked up and down the hallway. A CNA sat with the resident again, until he/she quieted and lay down. The resident was assisted back to bed by two CNAs. Staff would continue to monitor. During an interview on 2/17/15 at 10:08 A.M., CNA O said no one was assigned to provide the resident with one on one observation and Nurse H never said the resident was on one to one observation. Nurse H said someone needed to watch the resident closely. CNA O and CNA J both took turns staying with the resident until 2:45 A.M., when CNA J needed help with a resident in another room. This was the second time the resident in the other room had put on the call light and he/she required the assistance of two staff. CNA O said Resident #10 had been asleep for 45 minutes when they left the room, was breathing heavily, had no body movement, and his/her eyes were closed. CNA O looked at his/her watch and it was 2:47 A.M. when they left the resident's room. They were in the other room for exactly 15 minutes, when they heard the front door wanderguard alarm sound. They exited the other resident's room and saw Resident #10, coming in from the front door and being escorted to the Spectrum A nursing station. During an interview on 2/10/15 at 5:08 P.M., Nurse R (Spectrum A night shift nurse) said no one was assigned to the resident, and he/she was not on one to one observation. A resident could not be on one to one observation with only two CNAs for the whole hall. Nurse R was up and down the hall several times throughout the night and saw the resident in his/her room several times. The resident was sitting on the side of the bed, at about 2:45 A.M., bending over as if picking something off the floor. Nurse R did not see a CNA in the room at that time. The resident was escorted back into the building, with the front door wanderguard alarm sounding, at exactly 3:02 A.M., according to his/her wrist watch. Further review of the nurse's notes, dated 1/24/15 at 2:55 A.M., showed the resident rested quietly in bed and frequent rounds, for safety, continued. During an interview on 2/11/15 at 12:47 P.M., CNA J said Nurse H checked on the resident about every 30 minutes. The resident in another room needed the assistance of two staff, at about 3:00 A.M., so both CNAs went to care for the resident. Resident #10 was asleep at the time. CNA J did not know Nurse H left for a cigarette break. No one was aware the fire door had become unlocked. No one heard Resident #10 walk down the hallway and open the fire door at the end of the hall. They were both in another resident's room, for about 15 minutes, when the front door wanderguard alarm sounded. Nurse S (first floor nurse) came upstairs during the time the resident had been escorted back inside the building and said he/she heard a door slam downstairs. During an interview on 2/11/15 at 3:10 P.M., Nurse H said the clock on the wall was broken and he/she was not wearing a watch. He/she saw the resident lying in bed awake, at 2:45 A.M. or 2:55 A.M., and CNA O was talking and standing near the resident. He/she told CNA O, from the door way, that he/she was going on break. Nurse H continued to the Spectrum A nursing station, sat down at the nursing station, and talked with Nurse R, for about five to ten minutes, while waiting for first floor CNA Q to come up for a cigarette break. There was no direct view of the hallway as the Spectrum A nursing station was not in the middle of the hallway. There was a mirror on the wall, to see down the hall, but the mirror was not easy to use. When CNA Q arrived, they both went out the front door for their break. They saw a red or white pick-up truck pull into the facility parking lot (facility lot entrance was on the east side of the building) and slowly drove around the entire building. The truck stopped in front of the building, at which time Nurse H ran back into the building to get his/her drink that he/she left behind at the Spectrum A nursing station (not far from the front doors of the facility). Upon returning to the outside, Nurse H saw CNA Q standing at the door of the truck, with the passenger door open, and asked if the person sitting in the passenger seat was one of our residents. Nurse H said yes, saw the resident's hand was bleeding and he/she seemed weak, so he/she ran back inside to get a wheelchair. CNA Q assisted the resident back into the building and sat him/her in a chair at the Spectrum A nursing station. The wanderguard alarm at the front door sounded when the resident walked though the front doors. Nurse H did not question the driver of the pick-up truck and did not get his license plate number. The resident was wearing a full set of flannel pajamas and slippers. The nursing staff addressed the resident's bleeding hand, obtained vital signs and called 911. During this time, Nurse S from the first floor, had arrived at the nursing station (looking for CNA Q) and said he/she heard a bang downstairs, like a door had slammed. Nurse R walked to the end of the west wing hall and found the exit door, at the end of the hall next to the nursing station on the north side of the building, slightly ajar and not alarmed. He/she used the door key to re-arm the door, but the door alarm would not re-set. Nurse H returned to the door, to re-set the alarm with his/her door key, but the alarm and lock would not re-set. There was no red 15 in the box, no light at all in the box. The nurses did a head count of all residents in the building and checked all of the exit doors. The therapy door, at the end of the west hall, was locked. During an interview on 2/17/15 at 9:20 A.M., CNA Q said he/she and Nurse H had just walked out the front door to smoke a cigarette. He/she saw a truck pull into the parking lot from the road in front of the building, it passed in front of the building and then came back around the front from the west side of the building and stopped in front. Nurse H had gone back inside to retrieve his/her cigarette and returned after the truck was already stopped in front of the building. The driver said Does this guy belong to you? It was about 3:00 A.M. The driver said he found the resident a little ways down, from where he dropped the resident off, and said the resident had fallen because his/her hand was bleeding. He pointed to the end of the building toward the west drive way area. CNA Q said the resident was outside the fenced in area. The man in the truck left as soon as the resident was assisted out of the truck. CNA Q did not get the man's name or license plate number. CNA Q did not see the truck stop and pick up the resident. The temperature was chilly and the resident appeared exhausted. The resident might have fallen while trying to get out of the gate or stumbled when he/she reached the little ditch just outside of the fenced in area. The resident needed physical assistance to get back into the building as he/she was very unsteady. Further review of the nurse's notes, dated 1/24/15 at 3:15 A.M., showed the resident was brought to the facility's front door by a man in a truck who saw the resident stumbling around in the front of the facility near the road. The resident was assisted into the facility by CNA Q. The resident was assessed by Nurse R and had bleeding lacerations to the first, second and third digits of the left hand and a small abrasion to the left temple. The resident's blood pressure was 154/69 (normal range, 90 to 140 systolic/60 to 90 diastolic) and body temperature was 97.8 degrees Fahrenheit. The resident was unable to sit upright, became very pale, and occasionally stared off when spoken to. The 911 emergency number was called at 3:23 A.M. Emergency Medical Services (EMS) arrived at 3:45 A.M. and transported the resident to the emergency room . The physician's answering service was called at 4:00 A.M., the DON was notified at 4:05 A.M., the administrator was notified at 4:15 A.M. and the resident's daughter was notified at 4:30 A.M. During an interview on 2/17/15 at 11:40 A.M., Nurse T (Complex night shift nurse) said he/she was called over to Spectrum A shortly after 3:00 A.M. on 1/24/15, by Nurse H, to assist with the emergency situation. The resident was sitting in a chair with the staff hovering over the resident, caring for his/her bleeding hand. The resident was leaning over and was not able to sit up straight, and was falling out of the chair. Nurse H asked Nurse T to call the daughter. Nurse T first called the DON, then the administrator and then the daughter. The administrator said to check all the doors in the building. The doors that were found unlocked were the Spectrum B exit door near the nursing station, the corresponding exit door at the bottom of the stairwell that led to the first floor, and the fire door by the dining room on the first floor. The middle fire door on the first and second floors was not checked until the administrator arrived, as the staff did not have a key to deactivate the door alarms, had they gone off. Nurse T said the resident was not on one to one observation because the Complex nurse was responsible for the facility assignment sheets. If a resident was to be on one to one observation, then management would call and notify the Complex nurse. One on one observation would be documented on the assignment sheet and a CNA would be assigned to the resident. Nurse T was not notified that the resident was on one to one observation. During an interview on 2/10/15 at 5:08 P.M., Nurse R said Nurse H did not know how the resident had gotten out of the building, as the wanderguard was working, no one saw the resident leave the building and no alarms had gone off. Nurse R walked down to the end of the hall to check the exit door, on the north side of the hall next to the nursing station, and found the door ajar. Nurse R opened the door, shut the door, and tried to re-set it, but it did not re-set. The therapy door at the end of the hall was locked. The resident was found by a man in a truck that saw the resident in the front of the building, stumbling around, on the side of the road. The gate to the fenced in area in front was unlatched. Nurse S, from the first floor, had just come upstairs when the resident was being escorted back into the building. Nurse S had just heard the outside door slam shut and heard a noise in the stairwell, when he/she was downstairs. During an interview on 2/18/15 at 4:45 P.M., Nurse S (night shift nurse for the first floor) said he/she went upstairs to look for CNA Q and saw CNA Q walking back inside the building, holding onto the resident. Nurse S said he/she did not hear anything downstairs, prior to him/her going upstairs. He/she immediately returned to the first floor to check all of the doors that led to the outside and found three doors unlocked. There was one resident, on the first floor, that wore a wanderguard for elopement risk. During an interview on 2/17/15 at 11:40 A.M., Nurse T (Complex night shift nurse) said he/she went through the unlocked fire door at the end of the hall, down the two flights of stairs to the first floor, and went outside via the glass door (door unlocked from the inside but locked from the outside) that led to the patio and lawn fenced-in area on the west front side of the facility. He/she walked the sidewalk that led to the gate that exits the area, in front of the road. The gate was open about three inches and no blood was found on the gate, sidewalk or stairwell. During an interview on 1/28/15 at 10:32 A.M., the DON said the resident was admitted on the afternoon of 1/23/15 and identified as an elopement risk. The resident said he/she wanted to go home and tried to follow his/her family member out the door. A nurse called him at 6:54 P.M. to report that the resident was trying to get out all the doors. The DON said he told the nurse to put the resident on one to one observation for several hours. Nurse M, on evening shift, put the resident on one to one observation. Nurse H was the resident's nurse on night shift. Nurse H knew the resident was on one to one observation. During an interview on 1/28/15 at 11:15 A.M., the Administrator said the facility had their annual fire alarm inspection done, by an independent private company, on 1/22/14 and they disconnected and reconnected wires in the front alarm box during this procedure. One of the wires was not reconnected well and came loose, which caused the door alarms to not function. An electric company was called in immediately and they found the problem and fixed it. The facility's doors were checked weekly, for function, by the director of maintenance. Review of the electric company's paper work, dated 1/24/15 with a start time of 6:30 A.M., showed they checked delay egress doors and found a loose wire connection in relay controller. The wire was reconnected and all delay egress doors were checked. Review of the facility's door check sheets, showed the facility doors were last checked on 1/19/15. The Spectrum section of the form did not show all of the doors on Spectrum A and Spectrum B. The form showed the following Spectrum doors were OK: -Dining room; -Nursing station; -Hall; -Blank (no location) -Lobby. During a tour, on 2/3/15 at 9:30 A.M., the facility's maintenance director showed the following doors that were deactivated on 1/24/15: -Spectrum B, exit door by the second elevator (middle of west wing hall) on the north side of the building; -Spectrum B, exit door at end of hall across from the nursing station, on the north side of the building, leading to the stairwell that descends to the first floor, via two flights of stairs; -Exit door on south side of the therapy room, at the end of the second floor west wing, that opens to an outside stairway that leads to the ground level on the back side of the building; -First floor, exit door that opens to the stairwell (that goes to the second floor fire door across from the nursing station) and leads to the glass door that opens to the outside patio; -First floor, door at end of west hall, in the dining room, on south side of the building; -First floor, exit door in middle of the west hall, north side of building, that leads to the front courtyard; -First floor, door at the end of dietary hall that leads to the back, south side of the building. Review of the hospital records, dated 1/24/15, showed the resident arrived at the emergency room at 4:03 A.M. and was discharged at 8:14 A.M. The resident had no idea how he/she sustained the injuries to his/her hand. The resident received six sutures to the left fifth digit, seven sutures to the left fourth digit, and seven sutures to the left third digit. The resident also sustained an abrasion to the left side of his/her forehead. During an interview on 1/29/15 at 2:57 P.M., the resident's daughter said the facility called her on 1/24/15 at 4:00 A.M. and said they found the resident where he/she had fallen outside in a fenced area at 2:00 A.M. with lacerations on his/her hand and a gash on his/her head. They were not sure how he/she got out. The resident had 20 stitches and the cuts went down to the tendons. The resident would have had to have gone down two flights of steps to go out the door that was not hooked up. Staff said they found the resident in the cold with his/her hands open. The resident was in the grass and trying to climb over the gate. There was a gate in the fence, and if he/she went through the gate, the resident would have been at the highway. During an interview on 2/18/15 at 12:55 P.M., the resident's physician said she learned of the resident's elopement on 1/26/15 when she came to the facility. The resident was alert and oriented to self, had no insight and poor judgment. The resident was in danger when he/she eloped from the facility. Review of the facility's investigation summary and signed by the Administrator, dated 1/27/15, showed through a lack of communication between the aides and the nurse assigned to that hall, the resident was left unattended for a period of 5 to 10 minutes, allowing the resident the opportunity to elope. Review of the facility's elopement policy, revision date 9/2011, showed a procedure for staff to initiate after a resident is considered missing. The facility did not have a policy and procedure to implement for residents at risk of leaving the building. MO 611 MO 753

Based on interview and record review, the facility failed to assess, monitor and notify the physician of the resident's decline in condition and decreased food and fluid intake in a timely manner for one of 23 sampled residents, including three closed records (Resident #23). The resident became lethargic, had abnormal lab values, weight loss and developed gangrene to the right foot. The census was 114. 1. Review of Resident #23's closed medical record, showed the following: -A laboratory report dated 3/9/11 (prior to admission), showed a sodium level (measurement of electrolyte balance and evaluation of dehydration) of 142 (normal range 133-148), Blood Urea Nitrogen (BUN-to evaluate kidney function and hydration status) of 31 (normal range 7-27), creatinine level (evaluate kidney function) of 1.3 (normal range 0.5 to 1.5) and glucose (blood sugar) of 72 (normal range 60-115); -Transfer records from a previous nursing facility dated 5/11/11, showed [DIAGNOSES REDACTED]. -A May 2011 face sheet, showed an admission date of [DATE]; Review of the resident's May 2011 physician's orders [REDACTED]. -Skin assessment every Tuesday; -Accuchecks (measurement of blood sugar) every week on Monday; -House nutritional supplements (HNS) three times a day (TID-10:00 A.M., 3:00 P.M. and 7:00 P.M.); -[MEDICATION NAME] (a diuretic) 40 milligrams (mg) at 8:00 A.M.; -KCL (potassium supplement) 20 milliequivalent (mEq) at 8:00 A.M.; -[MEDICATION NAME] (used to treat [MEDICAL CONDITION] disorder) 4 milliliters (ml) TID (6:00 A.M., 12:00 P.M. and 8:00 P.M.); -[MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) 2 mg at 8:00 A.M.; -Aspirin (medication used to treat [MEDICAL CONDITIONS] and HTN) 81 mg at 8:00 A.M. Review of the resident's interim plan of care dated 5/11/11, showed the following: -Provide pressure device; -Turn and reposition; -Inspect skin according to facility protocol; -Monitor nutritional intake; -Nutritional drinks between meals; -Accuchecks every week with [MEDICATION NAME] (insulin) at night. Review of a weight record, showed the following; -5/11/11 admission weight of 180 pounds; -5/12/11 weight of 176.3 pounds; -5/13/11 weight of 174.7 pounds; -5/16/11 weight of 169.6 pounds; -5/23/11 weight of 170.0 pounds. Review of a nutritional evaluation completed by a registered dietician, dated 5/18/11, showed the following: -Calculation of estimated nutritional needs: caloric needs-1920 calories per day and fluid needs of 1920 cc's per day; -"unplanned weight loss, food/beverage intake fair"; Review of the nurse's notes dated 5/11/11 through 5/26/11, showed the following: -5/11 (no time), total dependence on staff for transfer, extensive assistance for bed mobility and toileting, limited assistance with eating. CNA assisted with first meal. Resident held a glass of fluid to his/her mouth and drank, refused to use utensils to feed. Ate 50% of meal. -5/12 and 5/13/11, extensive to total assistance for activities of daily living; -5/14 through 5/25/11, staff did not document on the resident's well-being or contact with the resident's physician. Review of the resident's May 2011 weekly skin assessments, showed the following: -5/10/11, left upper shin scab noted, open to air, dry skin to face, treatment in progress; -5/17/11, left shin scabbed area, open to air, left elbow scabbed area, open to air, right upper extremities, two small reddish senile purpura (fragile blood vessels), pink skin on gluteus (buttock), skin protectant applied; -5/24/11, some redness on inner buttocks, protective skin ointment applied, areas on left leg, healed, also arm. Review of the resident's May 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -Accucheck 5/16/11 registered 157; -Accucheck 5/23/11 registered 141; -HNS on 5/22 at 7:00 P.M., zero consumed; -HNS on 5/23 at 7:00 P.M., no documentation; -HNS on 5/24 and 5/25 TID, staff documented offered, not consumed; -On 5/25/11 at 8:00 A.M., [MEDICATION NAME] 40 mg, KCL 20 mEq and Aspirin 81 mg not administered. Staff documented the resident "would not wake up for med pass"; -On 5/25/11 at 12:00 P.M., [MEDICATION NAME] 4 ml not administered. Staff documented the resident "would not wake for med pass". Review of the resident's May 2011 consumption record, showed the following: -5/22/11, no documented breakfast and lunch consumption, recorded 480 cubic centimeters (cc) of fluids offered during the shift, unknown consumption; -5/22/11, zero consumption of supper, 200 cc of fluids offered during the shift, unknown consumption; -5/23/11, resident refused breakfast and lunch, recorded 480 cc of fluids offered during the shift, unknown consumption; -5/23/11, zero consumption of supper, no fluids offered during the shift; -5/23/11, Certified Nurse Aide (CNA) E documented on the back of the consumption record, resident hasn't eaten anything or drank anything since he/she has been admitted ; -5/24/11, resident refused breakfast and lunch, recorded 480 cc of fluids offered during the shift, unknown consumption; -5/24/11, no documented supper consumption or fluids offered; -5/25/11, no documented breakfast or lunch consumption or fluids offered; -5/25/11, zero consumption of supper, no fluids offered; -5/26/11, resident refused breakfast and lunch, recorded 480 cc of fluids offered during the shift, unknown consumption. Further review of the resident's nurse's notes dated 5/26/11 at 12:40 P.M., showed the following: -An incontinent episode prior to lunch of cloudy, rust colored urine in moderate amount; -Lunch appetite poor; -Taken to room for evaluation; -Vital signs: temperature 96.9, pulse 55, respirations 18, blood pressure 165/85 and oxygen saturation level at 96% on room air; -Resident's shoes removed to show a small circle of bright red blood noted on the outer portion of sock; -Nurse assessed the right foot as ischemic (decrease in blood supply) from the top of the foot to all toes, heel not involved. Color ranging from violet to dark purple; -Staff unable to palpate pedal (foot) or popliteal (behind the knee) pulses; -Physician called and resident sent to the hospital 911 for evaluation. Review of hospital emergency room records dated 5/26/11, showed the following: -Resident transferred from the nursing facility where he/she was found to be lethargic; -Chief complaint: Gangrene (lack of blood flow) of the right foot, acute [MEDICAL CONDITION] with metabolic acidosis (build up of acid in the body, can be caused by severe dehydration), [MEDICAL CONDITION] (high blood sugar), leukocytosis (elevated white blood cell count usually due to infection); -Sodium 157; -BUN 114; -Creatinine 3.1; -Glucose 537; -[MEDICATION NAME] Time/International Normalized Ratio (PT/INR, measurement of the clotting ability of five plasma coagulation factors and is commonly ordered in conjunction with the management of [MEDICATION NAME] anticoagulant therapy). PT measurement of 80.4 (normal range 11.5-14.7) and INR measurement of 11 (therapeutic level 2-3); -White blood cells 28.2 (Normal range 4.1-10.2) -Resident started on antibiotics as well as insulin drip and admitted to Intensive Care Unit; During an interview on 6/6/11 at 1:15 P.M., CNA J said he/she cared for the resident on the day shift 5/25/11. That was the second occasion to work with the resident. CNA J dressed the resident that morning including compression stockings and did not observe anything unusual about the resident's feet. CNA J used a mechanical lift to transfer the resident out of bed that morning because the resident did not want to bear weight. During the shift, the resident refused breakfast and lunch, closed his/her lips tightly and shook his/her head side to side. The resident only took a few sips of liquid at mealtime. CNA J said he/she did not document consumption that day, but it was poor. CNA J said during incontinent episodes, the resident's urine did not appear unusual. He/she would tell the nurse if the resident's urine looked unusual. During an interview on 6/7/11 at 2:45 P.M., CNA K said he/she cared for the resident during the evening shift of 5/25/11. CNA K had cared for the resident on several occasions. He/she described the resident as non-verbal but would respond to yes/no questions and smile. When first admitted , the resident was eating. The last week the resident would only take two or three spoonfuls of food, drink 1/2 carton of milk and a glass of water. CNA K said the resident lay in bed when his/her shift began. Staff left the resident in bed for supper because he/she was weak. CNA K said during incontinent episodes the resident's urine did not appear unusual. CNA K did not observe discoloration to the resident's feet. During the shift, the resident was quiet and did not show signs of facial grimacing or pain. During an interview on 6/6/11 at 3:40 P.M., CNA H said he/she cared for the resident on the night shift of 5/25/11 into the morning of 5/26/11. CNA H said that was the first occasion to work with the resident. During the shift, CNA H said at 1:00 A.M. and 3:30 A.M., he/she checked the resident. The resident was not incontinent during the shift so only needed to be repositioned. The resident showed no signs of discomfort or pain. CNA H recalled the resident as restless and did not want the sheet over his/her feet. The feet showed no bruising or discoloration. The resident lay in bed when CNA H finished his/her shift. During an interview on 6/9/11 at 1:10 P.M., Nurse O said he/she works the night shift and could not recall why he/she would have stayed over to administer day time medications. He/she did recall the resident not waking up for the medication pass on 5/25/11. Nurse O said he/she shook the bed, called the resident's name and touched the resident's arm, but he/she did not awaken. The only other thing to do was a sternal rub but the resident was breathing so, he/she did not do that. Therapy came in at that time and could not get the resident to wake. Nurse O said if a resident does not receive the scheduled medication, the medication is circled with an explanation written on the back of the MAR. Nurse O informed the charge nurse of the missed medications. Nurse O did not call the physician and did not know if the charge nurse did or not. During an interview on 6/6/11 at 8:00 A.M., CNA F said 5/26/11 was the first occasion to work with the resident. The resident did not eat breakfast. The speech therapist attempted to feed the resident but food slid out of his/her mouth. Prior to lunch the resident urinated blood tinged urine. The urine did not get on the resident's sock so he/she did not notice at that time anything about the resident's foot. At lunch, the resident looked pale, vital signs were taken. CNA F and CNA N lay the resident in bed and noticed the purple foot with an open area on top. CNA F called Nurse G to evaluate the foot. CNA F did not know if the resident's refusal to eat was out of the ordinary for him/her. CNAs F and N transferred the resident with a gait belt prior to lunch. The resident stood and pivoted. When CNA's F and N transferred the resident after lunch CNA F said the transfer took more effort from the CNA's with the gait belt for the resident to be able to stand and pivot. During an interview on 6/6/11 at 8:23 A.M., Nurse G said 5/26/11 was the first occasion to work with the resident. He/she said at lunch, staff reported the resident didn't look well, was not eating and not swallowing. Nurse G did vital signs and instructed the CNA's to lay the resident down for further assessment. When Nurse G saw the resident's right foot, it was dark purple, all toes were involved. The planter aspect (sole of the foot) half way to mid foot area was dark purple. Nurse G contacted the nurse supervisor on duty, Nurse I. Nurse I assessed the resident's foot and instructed Nurse G to contact the physician. During an interview on 6/3/11 at 12:40 P.M., Nurse I said when he/she assessed the resident's right foot on 5/26/11, the entire right foot had a purplish blue color and looked septic. He/she could find no pulse and immediately instructed staff to call the physician. During an interview on 6/7/11 at 9:35 A.M., the Director of Nursing (DON) said she would expect residents to receive all ordered medications. If a resident missed a dose, she would expect staff to inform the physician. The DON said unit managers review the consumption records weekly. Staff should have notified the charge nurse and herself when the resident refused meals for several days. The physician should have been notified when the resident refused meals and lost ten pounds. The DON said if staff notified the physician of the resident's missed medications, meal refusals and weight loss, it should be documented in the nurse's notes. During an interview on 6/8/11 at 3:25 P.M., the resident's primary care physician, Physician L, said he/she took vacation 5/22 through 5/30/11. He/she would expect the facility to contact the on-call physician, Physician M, when the resident could not be aroused, refused meals and lost weight. Physician L said he/she saw the resident in the hospital. The resident had gangrene in his/her foot. During an interview on 6/9/11 at 10:45 A.M., Physician M said he/she did not recall the resident or the situation and could provide no information. MO 611