Every finding on record at Friendship Village Sunset Hills

Based on observation, interview and record review, the facility failed to establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation for ten out of ten narcotic count books reviewed. This had the potential to affect all residents with controlled substance orders. The census was 132. Review of the facility's Controlled Substances policy, original date 8/19, showed: It is the policy of Friendship Village to ensure compliance with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. -Only authorized licensed nurses that are permanent employees of Friendship Village or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. ***No agency nurse is allowed to carry narcotic keys or administer narcotics to any resident. -Controlled substances must be counted upon delivery. The nurse receiving the order must count the controlled substances together with Shift Supervisor. Both individuals must sign the designated narcotic record. -Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. -Nursing staff must count controlled drugs at the end of each shift, for each eight hour or 12-hour shift. The nurse coming on duty and the nurse going off duty must complete the count together. They must document and report any discrepancies to the Shift Supervisor and Director of Nursing (DON) immediately. -The Director of Nursing shall investigate all discrepancies in Controlled Substance reconciliation to determine the cause and identify any responsible parties and shall give the Administrator a written report of such findings. 1. Observation and review of the 1a Certified Medication Technician (CMT) cart narcotic book on 1/24/25 at 6:18 A.M., showed: -The slot for the off-going nurse for the night shift entry (1/23-1/24/25) was pre-signed prior to the count being performed; -At 6:33 A.M., the narcotics for the cart had not been counted with the on-coming nurse or CMT; -At 6:40 A.M., the on-coming CMT F pulled the narcotic cards out of the box and reviewed the narcotic sheets in the book, with no other staff member present; -At 6:47 A.M., review of the 1a CMT narcotic book showed the initials of CMT F present in the nurse on-coming and nurse off-going slots for the day shift entry (1/24/25). Review of the controlled drug count sheets for the 1a CMT cart, dated 1/1/25 through 1/24/25, on 1/24/25 at 8:49 A.M., showed: -Nurse initials documented under Off under 3:00 P.M. shift change entry for 1/24/25. -No outgoing staff signature for two of 70 opportunities; -No incoming staff signature for two of 70 opportunities; -No documentation under # of Packages, for two of 70 opportunities. 2. Review of the controlled drug count sheets for the 1a Nurse cart, dated 1/1/25 through 1/24/25, on 1/24/25 at 8:53 A.M., showed: -No outgoing staff signature for 20 of 70 opportunities; -No incoming staff signature for 15 of 70 opportunities; -No documentation under # of Packages, for 11 of 70 opportunities. 3. Review of the controlled drug count sheets for the 1b Nurse cart, dated 1/1/25 through 1/24/25, on 1/24/25 at 9:01 A.M., showed: -No outgoing staff signature for 17 of 70 opportunities; -No incoming staff signature for 14 of 70 opportunities; -No documentation under # of Packages, for nine of 70 opportunities. 4. Review of the controlled drug count sheets for the 1c CMT cart, dated 1/1/25 through 1/24/25, on 1/24/25 at 9:04 A.M., showed: -Nurse Initials documented under Off at 3:00 P.M. shift change entry for 1/24/25; -No outgoing staff signature for six of 70 opportunities; -No incoming staff signature for four of 70 opportunities. 5. Review of the controlled drug count sheets for the 3c CMT cart, dated 1/1/25 through 1/24/25, on 1/24/25 at 9:12 A.M., showed: -Nurse Initials documented under Off at 3:00 P.M. shift change entry for 1/24/25; -No outgoing staff signature for eight of 70 opportunities; -No incoming staff signature for nine of 70 opportunities; -No documentation under # of Packages, eight of 70 opportunities. 6. Review of the controlled drug count sheets for the 3a Nurse cart, dated 1/1/25 through 1/24/25, on 1/24/25 at 9:14 A.M., showed: -Nurse Initials documented under Off at 3:00 P.M. shift change entry for 1/24/25; -No outgoing staff signature for 18 of 70 opportunities; -No incoming staff signature for 11 of 70 opportunities. 7. Review of the controlled drug count sheets for the 2c Nurse cart, dated 1/1/25 through 1/24/25, on 1/24/25 at 9:22 A.M., showed: -No outgoing staff signature for 17 of 70 opportunities; -No incoming staff signature for 11 of 70 opportunities; -No documentation under # of Packages, for five of 70 opportunities. Review of the controlled drug count sheets for the 2c Nurse cart, dated 1/1/25 through 1/27/25, for 1/24/25 through 1/27/25, on 1/27/25 at 8:57 A.M., showed: -No outgoing staff signature for one of nine opportunities; -Number of packages already documented under # of Packages, for 3 PM shift count on 1/27/25. 8. Review of the controlled drug count sheets for the 2a CMT cart, dated 1/1/25 through 1/24/25, on 1/24/25 at 9:25 A.M., showed: -No outgoing staff signature for 14 of 70 opportunities; -No incoming staff signature for 11 of 70 opportunities; -No documentation under # of Packages, for seven of 70 opportunities. Review of the controlled drug count sheets for the 2a CMT cart, dated 1/1/25 through 1/27/25, for 1/24/25 through 1/27/25, on 1/27/25 at 8:52 A.M., showed: -No outgoing staff signature for two of nine opportunities; -No incoming staff signature for two of nine opportunities; -No documentation under # of Packages, for one of nine opportunities. 9. Review of the controlled drug count sheets for the 2c CMT cart, dated 1/1/25 through 1/24/25, on 1/24/25 at 9:27 A.M., showed: -No outgoing staff signature for 10 of 70 opportunities; -No incoming staff signature for six of 70 opportunities; -No documentation under # of Packages, for three of 70 opportunities. Review of the controlled drug count sheets for the 2c CMT cart, dated 1/1/25 through 1/27/25, for 1/24/25 through 1/27/25, on 1/27/25 at 8:55 A.M., showed: -No outgoing staff signature for two of nine opportunities; -No documentation under, # of Packages, for one of nine opportunities. 10. Review of the controlled drug count sheets for the 2a Nurse cart, dated 1/1/25 through 1/27/25, on 1/27/25 at 8:50 A.M., showed: -No outgoing staff signature for 17 of 80 opportunities; -No incoming staff signature for 16 of 80 opportunities; -No documentation under # of Packages, for 16 of 80 opportunities. 11. During an interview on 1/28/25 at 10:15 A.M., the DON and Administrator said the narcotic count should be done at the beginning and at the end of each shift with two staff. The book should be signed at the time the count is completed, not presigned. They would not expect there to be blank spots on the narcotic sheets.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity, in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life when staff failed to serve a requested alternate meal and told the resident to wait until the next meal (Resident #91), failed to serve a resident timely after the tablemates were served (Resident #109). The facility staff also failed to answer a resident after asking staff several times (Resident #44) and staff entered the resident rooms without knocking on the door (Residents #67, #102 and #110). The sample was 26. The census was 132. Review of the facility's Resident Rights: Accommodation of Needs and Preferences and Homelike Environment policy, dated August 2019, showed: -It is the policy of the facility to identify and provide reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents. Residents have the right to retain and use personal possessions to promote a home like environment and to support each resident in maintaining their independence. The facility will provide a safe, clean, comfortable and home-like environment allowing the resident to use his or her personal belongings to the extent possible. Review of the facility's Quality of Life-Dignity policy, dated 8/19, showed: -It is the policy of the facility to ensure that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents' private space and property will be respected at all times. Staff will knock and request permission before entering resident rooms. 1. Review of Resident #91's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/23/24, showed: -Moderate cognitive impairment; -Upper body impairment one side; -Uses walker and wheelchair for mobility; -Supervision for eating and personal hygiene; -Diagnoses include cancer, malnutrition, osteoporosis (bones become extremely porous and are subject to fracture and slow healing), high blood pressure and depression. Review of the resident's current care plan, showed: -Problem: Resident has nutritional problem. Inadequate oral intake related to cognitive impairment; -Goal: Resident will have increased oral intake to meet estimated nutrition and hydration needs and weight will remain stable; -Interventions: Provide diet per physician order, provide nutrition supplement per physician orders, and monitor weights per physician orders. Review of the resident's electronic Physician's Orders Sheet (ePOS), showed: -An order, dated 1/24/25, regular diet. Review of the resident's meal ticket, dated 1/24/25, showed: -Diet: Regular; -Texture: Regular; -Allergies: Eggplant; Other-Lobster. Observation on 1/22/25 at 11:50 A.M., showed the resident sat in the dining room with two other residents. At the time of the resident's request, none of the residents at the table had been served food. The resident told Dietary Aide S he/she would like a bacon, lettuce and tomato (BLT) sandwich for lunch. The dietary aide said he/she could have it tonight with dinner and asked the resident if he/she wants chips or french fries as a side. Dietary Aide S told the resident he/she will put it on the dinner ticket. Observation on 1/22/25 at 12:07 P.M., showed the resident served with a plate of the lunch choice, pasta con broccoli. The two other residents seated at the table were served BLT sandwiches and french fries. During an observation and interview on 1/22/25 at 12:15 P.M., showed the resident ate approximately 25% of the food on his/her plate. The resident pushed the food away from him/her. The two residents at the table were still eating their BLT sandwiches. The resident said he/she was not sure why Dietary Aide S told him/her to wait for dinner to get a BLT. The resident guessed it was because he/she already had ordered this option. During an interview on 1/23/25 at 12:58 P.M., Food Service Manager T contacted the staff member who passed out hall trays on 1/22/25 evening shift. The resident received a half peanut butter and jelly sandwich and a half cordon bleu with mashed potatoes for dinner. During an interview on 1/24/27 at 11:40 A.M., Dietary Supervisor U said the residents can get anything on the a la carte menu until the kitchen closes, which is around 6:30 P.M. There would be no reason to make them wait. If they asked for something else at lunch, they should get it at lunch. Dietary Supervisor U said he/she is not sure why a resident would be told to wait for the next meal to get a requested alternate food item. During an interview on 1/28/25 at 10:15 A.M., the Director of Nursing (DON) and Administrator said the residents can have something else whenever they want, even after they order something. They should not be told to wait. That is not dignified. 2. Review of Resident #109's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Uses wheelchair for mobility; -Supervision or touching assistance for eating (Helper provides cues or touching/steadying assistance as resident completes activity); -Diagnoses include acid reflux, diabetes, malnutrition, dementia and depression. Review of the resident's current care plan, showed: -Problem: Resident has potential for cognitive impairment; -Goal: Resident's nutritional status will remain stable as evidenced by adequate oral intake to meet estimated nutrition and hydration needs and no significant weight change through next review. Review of the resident's ePOS, showed: -An order, dated 11/04/24, regular diet. Review of the resident's lunch meal ticket, dated 1/24/25, showed: -Diet: Regular; -Texture: Regular; -Beverages: [NAME] (chocolate nutritional milk) milk-4 full ounces (oz) -Food Adds: Fresh fruit-1 serving, Yogurt-1 each. Observation in the dining room on 1/22/25, showed: -At 11:33 A.M., staff in the dining room brought out plates of food to different residents at different tables. Resident #109 sat at a table with two other residents. The resident had a cup of water, a cup of juice, and a cup of chocolate milk in front of him/her. -At 11:37 A.M., one of the residents at the table had food brought to him/her. Resident #109 and the other resident sat without food. -At 11:52 A.M., a dietary staff member at the table with Resident #109 and other resident to get food order. The resident who was served ate all of his/her food and has his/her head down with his/her eyes closed. -At 11:58 A.M., dietary staff passed out cookies and ice cream to residents at other tables. Resident #109 and the other resident at table still did not have food. -At 12:01 P.M., dietary staff brought the other resident at the table his/her food. The resident ordered the lunch choice of pasta con broccoli. Resident #109 still without food. -At 12:01 P.M., dietary staff brought Resident #109's lunch plate and set it in front of the him/her, but out of reach of the resident. The resident was not served fruit. The dietary aide cut the meatloaf on the resident's plate and walked away with the plate out of the resident's reach. -At 12:06 P.M., staff member went to the resident and straightens out his/her chair and put the resident's food in front of him/her. The resident began to eat. During an interview on 1/28/25 at 10:15 A.M., the DON and Administrator said the residents at the same table should be served at approximately the same time, unless one resident got there later than someone else at the table. It is not dignified for a resident to have to wait more than thirty minutes after someone at their table received their food at their table to get their food. They expected everyone to be served as close together as possible and their order should be taken at approximately the same time. 3. Review of Resident #44's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included heart disease, high blood pressure, hip fracture, peripheral vascular disease and benign prostatic hyperplasia; -Impairment to one side of the lower extremity; -Uses wheelchair. Review of the resident's care plan, in use during survey, showed: -Problem: Resident has slightly impaired cognition presumably related to post hospitalization . Alert and oriented x 2-3 with some forgetfulness; -Goal: Resident will maintain or improve level of cognitive functioning over the next 90 days; -Intervention: Use a calm, slow approach; -Explain all procedures before beginning and repeat during procedure as necessary; -Encourage activity programs for added stimulation; assist as necessary; -Provide activity calendar and newsletter; -Provide reorientation and redirection as needed; -Problem: Resident has impaired communication-receptive related to very hard of hearing. He/She has cochlear implant to left ear and wears hearing aide to right ear. Able to communicate with speaker increased volume; -Goal: Resident will correctly interpret conversation during visits and will ask to repeat or speak louder when conversation is not heard or understood; -Interventions: When conversing with him/her allow adequate time; do not rush or supply words; -Resident to wear hearing aides to ears; -Speak slowly and enunciate clearly; -Use different words to say the same thing if not understood; -Establish eye contact and face him/her prior to communication; -Reduce environmental distractions, turn off T.V., close door, low noise; -Use step by step instructions. Segment tasks as needed to slow pace; -Speak slowly and clearly using short and simple phrases; -Repeat/rephrase questions as needed. Observation on 1/22/25 at 5:56 P.M., showed the resident sat at a dining room table after dinner was served. Several residents remained in the dining room waited to be transported back to their room. The resident called out to staff nearby, when are you taking me back to my room. Staff did not speak to the resident. A Certified Nurse Aide (CNA) entered the dining room and began to transport a resident out of the dining room. The resident said, are you taking me back to my room. The CNA continued to transport the other resident in the wheelchair without speaking to Resident #44. The resident continued to ask staff who entered and exited the dining room if they were taking him/her back to their room. Staff did not speak to the resident. During an interview on 1/28/24 at 10:15 A.M., the Administrator said it would not be dignified to ignore a resident when they ask a question. 4. Review of Resident #67's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Diagnosis include high blood pressure, kidney failure, high cholesterol, Alzheimer's disease, anxiety and depression. Observation on 1/23/25 at 6:40 A.M., showed CNA A entered the resident's room and did not knock on the door or introduce himself/herself. 5. Review of Resident #102's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnosis include anemia (low iron in the blood), seizure, anxiety and depression. Observation on 1/23/25 at 6:47 A.M., showed CNA A entered the resident's room and did not knock on the door or introduce himself/herself. 6. Review of Resident #110's admission MDS, dated [DATE], showed: -Slurred speech; -Rarely or never understood; -Sometimes understand direct communication; -Diagnoses included kidney failure, aphasia (loss of speech), dementia, anxiety and depression. Observation on 1/27/25 at 8:49 A.M., showed CNA B and CNA C entered the resident's room. The roommate was present in the shared room. CNA B and CNA C did not knock on the door or introduce themselves. During an interview on 1/28/25 at 8:19 A.M., CNA D said when entering a resident's room, staff should knock on the resident's door and introduce themselves. It does not matter if the resident is cognitive or not, staff should still provide dignity and privacy. During an interview on 1/28/25 at 8:24 A.M., Licensed Practical Nurse (LPN) E said all staff should knock before entering a resident's room and say their name. Knocking on the door shows respect for the resident's privacy. During an interview on 1/28/25 at 10:12 A.M., the DON said staff are trained at the time of hire and randomly about residents' rights and dignity. Staff should knock before entering a resident's room. During an interview on 1/28/25 at 10:26 A.M., the Administrator said she expected staff to follow the facility's policy on resident rights and dignity. 44950 49992

Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors. Staff failed to administer a medication for one resident with a diagnosis of obstructive uropathy (occurs when urine flow is blocked, causing urine to build up in the kidneys) who required the medication to empty their bladder and increase urination (Resident #29). Staff failed to administer several doses of a medication used to treat anxiety for one resident (Resident #110). Staff also administered an expired medication, used to treat Parkinson's disease (an age-related degenerative brain condition) for over a week. The medication was ordered to be given twice a day. The bottle showed the medication expired October 2024 (Resident #227). These failures put residents at risk for significant medication errors that went undetected and unreported to the physician, resulting in potential for compilations related to missed doses and administering expired medications. The sample was 26. The census was 132. Review of the facility's policy Charting of Medication Administration, dated 8/2019, showed: -Purpose: To ensure proper documentation of medication administration, results, or refusal. Accurate documentation allows the nurse and other health care providers to communicate with one another and improves medication safety; -Procedure: If a prescribed drug is not given or refused by the resident, the time block is initialed by the nurse, and a circle is placed around the nurse's initials. A note of the explanation is recorded by the nurse on the back of the medication sheet or in the electronic medication administration record. If the medication is delayed, record the medication on the record that the medication was held, and the reason. Update the physician for further directions. 1. Review of Resident #29's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 11/8/24, showed: -Severe cognitive impairment; -Diagnoses included Alzheimer's disease, seizures, high blood pressure, end stage renal failure, and obstructive uropathy. Review of the resident's physician order, dated January 2025, showed: -An order on 12/8/24, for bethanechol chloride (helps to cause urination and emptying of the bladder) five milligram (mg) tablet, two tablets (10 mg) by mouth three times per day, at 7:00 A.M., 11:30 A.M., and 4:30 P.M., for urinary retention. Last dose on 1/27/25. Review of the resident's Medication Administration Record (MAR), dated January 2025, showed: -Bethanechol chloride 10 mg, start date 12/8/24. Staff to administer during breakfast, lunch, and dinner; -On 1/5/25 at 10:21 A.M. and 12:52 P.M., staff documented medication not available. Staff initialed the medication was administered during dinner.; -On 1/6/25 at 8:56 A.M., 12:51 P.M. and 4:47 P.M., staff documented medication not available. Staff noted the medication was reordered from the pharmacy; -On 1/7/25 at 8:32 A.M., staff documented the medication was on hold. The pharmacy was notified. Staff initialed the medication was administered during lunch and dinner; -On 1/8/25-1/14/25, staff initialed the medication was administered during breakfast, lunch, and dinner; -On 1/15/25 at 11:20 A.M., staff documented medication not available. At 12:56 P.M., staff documented the medication was on hold. Staff initialed the medication was administered during dinner. During an interview on 1/27/25 at 11:33 A.M., the Director of Nursing (DON) said the resident received his/her medication from the Veteran's Administration. The medication was not available. The facility kept bethanechol in their stock medications. She would have expected staff to utilize stock medications until the medication was received. The resident's physician was not notified of the missed doses. She would have expected staff to notify the physician. During an interview on 1/27/25 at 2:39 P.M., the Medical Director said he/she would expect staff to notify him/her of multiple missed doses of medication. Multiple missed doses of the medication would worsen the symptoms controlled by the medication. 2. Review of Resident #110's Admission MDS, dated [DATE], showed: -admitted [DATE]; -Slurred speech; -Rarely or never understood; -Sometimes understand direct communication; -Diagnosis include, kidney failure, aphasia (loss of speech), dementia, anxiety, and depression. Review of resident's Physician Orders, dated 1/27/25 showed: -An order dated 11/27/24 for Clonazepam (a medication used to produce calming effect on the brain which helps reduce anxiety) 1 mg tablet by mouth three time a day for anxiety. Review of the resident's MAR, dated [DATE], showed: -Morning doses for 1/19, 1/20, 1/21, and 1/22 were not given; -Midday doses for 1/19, 1/20, 1/21, and 1/22 were not given; -Evening doses for 1/21 were not given; -The notes page showed the comments for the omitted (not given) doses were on hold, none in Pyxis (automated dispensing medication machine) waiting for refill, and taken from Emergency access medication kit (EKit). Review of the resident's nurse notes showed: -No entry the medication was not given and the reason. -No entry the physician or the family were notified. During an interview on 1/24/25 at 12:03 P.M. Certified Medication Technician (CMT) F opened the medication cart and verified there was no clonazepam available for the resident. He/She reported the nurse was made aware. During an interview on 1/24/25 at 12:17 P.M., Licensed Practical Nurse (LPN) I said he/she was not aware the resident did not receive the doses of clonazepam. During an interview on 1/24/25 at 12:45 P.M., the DON said she was now aware the resident did not receive the ordered clonazepam. When the CMT identified a medication was not available they were to fill out a Stop N Watch and give the completed form to the charge nurse. The practice was when the first dose was missed, contact the pharmacy. If the resident missed three doses, then staff were to call the physician. During an interview on 1/27/25 at 2:39 P.M., the Medical Director said he/she would expect to be notified when a resident had not received their medications. The adverse reactions of the resident not receiving his/her medication was not harmful, but it could exacerbate the symptoms that were being treated. During an interview on 1/28/25 at 10:26 A.M., the Administrator said she would expect the staff to follow the facility's medication administration policy. 3. Review of Resident #227's electronic medical record (EMR) showed: -admitted [DATE] -Diagnosis: Parkinson's Disease with Axial Motor Symptoms (AMS, affects trunk and core muscles) Review of the resident's Interim Care Plan, dated 1/13/25, showed: -Problem: Resident's interim admitting diagnosis list: Parkinson's Disease with AMS; -Goal: Review diagnosis list, discuss full care planning with Interdisciplinary Team to promote highest level of function for 30 days; -Review diagnosis and treatment list, enter and review physician's orders, order medications as needed. Review of the resident's electronic Physician Order Sheet (ePOS) showed: -An order, dated 1/14/25, Rytary 36.25 mg-145 mg capsule, extended release. (Carbidopa-levodopa) 36.25-145 mg by mouth twice daily for Parkinson's. Review of the resident's Treatment Administration Record (TAR), on 1/24/25, showed: -Rytary 36.25 mg-145 mg capsule, extended release. (Carbidopa-levodopa) 36.25-145 mg by mouth twice daily for Parkinson's; Diagnosis/Reason: Parkinson's. -AM dose marked as given 1/15/25, 1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/21/25, 1/22/25, 1/23/25, and 1/24/25; - Rytary 36.25 mg-145 mg capsule, extended release. (Carbidopa-levodopa) 36.25-145 mg by mouth twice daily for Parkinson's; Diagnosis/Reason: Parkinson's. -Late PM dose marked as given 1/14/25, 1/15/25, 1/16/25, 1/17/25, 1/19/25, 1/20/25, and 1/22/25; -Late PM dose not marked as given 1/18/25, 1/21/25, and 1/23/25. During an observation and interview on 1/24/25 at 8:50 A.M., LPN I said the resident was admitted a week and a half ago and the family brought a bottle of Rytary into the facility to administer to the resident. The 1A nurse medication cart showed the resident had a bottle of Rytary in a compartment with the resident's other medications. The expiration date on the bottle showed October 2024. LPN I verified the expiration date and said he/she was not aware the medication was expired. He/She would have the family bring in a new bottle. During an interview on 1/24/25 at 11:45 A.M., the DON said when a resident was admitted , the admission nurse took physician orders and reviewed with family or the resident. After the review was complete, the nurse called the physician to have the medications verified. The medications were then ordered from the pharmacy. If the family brought in the medication, the nurse was expected to verify the medication was the same dose ordered by the physician. She would expect staff to check the expiration date. Expired medications should not be given because they do not know the effectiveness and it may have the opposite effect if expired. The DON said the nurse gave today's morning dose of the medication after the surveyor reviewed the cart and saw the expired bottle. The nurse disposed of the bottle and then pulled the medication from the facility's stock medications. The DON said she could not remember why the family brought it in instead of getting the medication from the pharmacy. After the expired medication was found, the nurse was instructed to call the physician and complete a 72 hour medication watch to notice the expiration date. During an observation and interview on 1/27/25 at 10:26 A.M., LPN I opened the 1A nurse medication cart. The resident had a bottle of Rytary medication that was not expired. LPN I said the family brought in a new bottle and the family told the facility the family was putting samples in the bottle or something like that. LPN I said that did not matter you had to go by what was marked on the bottle. During an interview on 1/27/25 at 2:39 P.M., the Medical Director said he/she would expect staff not to administer expired medications. The physician said usually there were no adverse effects from receiving expired medications, but the resident may not get the effectiveness of the medication if it was expired. During an interview on 1/28/25 at 10:15 A.M., the Administrator said staff should check medication bottle expiration dates when admitting a resident or accepting medication from the resident's family. She would expect staff to check the expiration date on the medication bottle prior to administering the medication as well. 46967 49992

Based on interview and record review, the facility failed to ensure each nurse aide had no less than twelve hours of in-service education per year based on their individual performance review and calculated by their employment date rather than the calendar year, for eight of 10 sampled Certified Nursing Assistants (CNA) and Certified Medication Technicians (CMT). The census was 132. Review of the facility's Compliance Education and Training Policy, dated 7/1/2019, showed: -Purpose: The purpose of this policy is to standardize the requirements for initial orientation, ongoing training, focus training, and corrective training in order to educate employees and non- employees on compliance with laws regulations and facility policies and procedures, and to promote accountability; -Policy statement: The facility requires that all employees receive training on compliance with laws, regulations, facility policies and procedures, and standards of conduct. Non-employees including board members, vendor representatives, contractors, students, and volunteers who regularly work at the facility or have access to Protected Health Information are also required to receive similar training. Individuals have the responsibility and obligation to act in accordance with federal and state regulations, to know and understand the facility policies and procedures that govern their responsibilities, and to understand the consequences of failure to comply with these requirements. 1. Review of the Facility Assessment Tool, undated, completed by the facility, showed: -Effective Communication done annually in Relias (an education software); -Resident Rights and facility responsibilities done upon hire, annually in Relias, and as needed; -Abuse, Neglect, and Exploitation done upon hire, annually in Relias, and as needed; -Infection Control done upon hire, annually in Relias, and as needed; -State-approved training program for feeding assistants done in-house and led by the Infection Preventionist; -Recognizing a change in the resident's condition done upon hire, annually in Relias, and as needed; -Cultural Competency done in Relias annually; -Caring for persons with Dementia, Alzheimer's and Cognitive Impairments done upon hire, annually in Relias, and as needed. 2. Review on 1/27/24 at 11:40 A.M., of a stack of in-service trainings provided by the facility, showed documented number of hours for each in-service provided and individualized tracking records for individual staff. Review of CNA A's employee file, showed date of hire 8/15/19. In-service tracking provided based on hire date, showed 5.15 hours of in-service training provided during the 8/15/23-8/15/24 tracking period. Review of CNA J's employee file, showed date of hire 7/9/20. In-service tracking provided based on hire date, showed 11.35 hours of in-service training provided during the 7/9/23-7/9/24 tracking period. Review of CNA K's employee file, showed date of hire 3/25/21. In-service tracking provided based on hire date, showed 11.1 hours of in-service training provided during the 3/25/23-3/25/24 tracking period. Review of CNA L's employee file, showed date of hire 9/23/21. In-service tracking provided based on hire date, showed 10.85 hours of in-service training provided during the 9/23/23-9/23/24 tracking period. Review of CNA M's employee file, showed date of hire 7/21/22. In-service tracking provided based on hire date, showed 9.5 hours of in-service training provided during the 7/21/23-7/21/24 tracking period. Review of CNA N's employee file, showed date of hire 6/9/22. In-service tracking provided based on hire date, showed 3.35 hours of in-service training provided during the 6/9/23-6/9/24 tracking period. Review of CNA O's employee file, showed date of hire 11/30/23. In-service tracking provided based on hire date, showed 8.35 hours of in-service training provided during the 11/30/23-11/30/24 tracking period. Review of CMT P's employee file, showed date of hire 9/28/18. In-service tracking provided based on hire date, showed 10.85 hours of in-service training provided during the 9/28/23-9/28/24 tracking period. 3. During an interview on 1/28/25 at 7:10 A.M., the Administrator said she would expect staff to have the 12 hours of annual education. Staff should be trained on those items outlined in the facility assessment and those trainings required by the federal and state guidelines.

Based on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection prevention and control when staff failed use proper hand hygiene while providing care for two of three sampled residents observed for incontinence care (Residents #110 and #44). The census was 132. Review of the facility's Hand Hygiene policy, dated 8/19, showed: -Purpose: hand hygiene is required in order to reduce the spread of potentially dangerous infectious agents and to reduce the risk of colonization or infection for health care workers that could be potentially acquired from the resident; -Policy Statement: It is the policy of this facility that hand hygiene will be provided consistent with best practices. Hand hygiene (hand washing and/or alcohol based hand rub (ABHR) includes the use of ABHR instead of soap and water in all clinical situations except when the hands are visibly soiled (blood or bodily fluids) or after caring for a resident with known or suspected Clostridium (C.) difficile or norovirus infection during an outbreak, or if infection rates of C. difficile infection are high; In these circumstances soap and water should be used. Review of the facility's Perineal Care for a Male/Female with Handwashing, effective 7/1/2023, showed: -Perform hand hygiene after removing gloves; -A. Cover all surfaces of the hands with hand sanitizer; -B. Rub together until hands are dry. 1. Review of Resident #110's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 12/4/24, showed: -Slurred speech; -Rarely or never understood; -Sometimes understand direct communication; -Always continent of bladder, frequently incontinent of bowel; -Diagnoses included kidney failure, aphasia (loss of speech), dementia, anxiety and depression. Review of the resident's care plan, dated 12/24/24, showed the resident has an alteration in elimination as related to frequently incontinent of bowel, usually continent of bladder. He/She requires dependence for all aspects of toileting. Observation on 1/27/25 at 8:49 A.M., showed Certified Nursing Assistant (CNA) B and CNA C put on gloves in the resident's room, to provide incontinence care to the resident. CNA A assisted CNA B to transfer the resident into bed with the Hoyer (a mechanical device used to assist staff with transferring residents who are totally dependent on staff) lift. After the resident was placed on the bed, CNA C asked CNA B to assist turning the resident on his/her left side, removing the Hoyer pad and lowering the resident's pants, and detaching the brief on one side. The resident was turned to the right side, the CNA lowered the resident's pants, and detached the brief. The resident was placed on his/her back. The resident was turned to his/her right, and the urine soiled brief was pushed between the resident's legs toward his/her backside. CNA C, using wipes, cleaned the front peri area, wiping from front to back. While on his/her right side, CNA B cleaned the resident's left buttock. The resident was turned to the left side, CNA C cleaned the right buttock and removed the soiled brief, and the resident was placed on his/her back. CNA B and CNA C removed their gloves. CNA B applied hand sanitizer, before putting on another pair of gloves. CNA C did not use hand sanitizer before putting on another pair of gloves. CNA C assisted CNA B with turning the resident to the right. While placing a clean brief, CNA C noted the resident may have a bowel movement. Using wipes, CNA C cleaned the stool from around the anus. CNA C removed his/her gloves and did not use hand sanitizer before putting on the new gloves. CNA C assisted CNA B to turn the resident to his/her left side. CNA B said it looked like the resident was still trying to have a bowel movement. CNA B cleaned the stool from around the anus and the resident was placed on his/her back and the brief was pulled to the front of the resident. CNA B and CNA C removed their gloves, neither using sanitizer, and each CNA put on another pair of gloves. The resident's pants were pulled back up and the resident was placed in his/her chair with the Hoyer Lift. 2. Review of Resident #44's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -Lower extremity impairment one side; -Frequently incontinent of bowel and bladder; -Diagnoses include hip fracture, benign prostatic hyperplasia (BPH, enlarged prostate) and high blood pressure. Review of the resident's care plan, dated 10/24/24, showed: -Category: Resident is on Enhanced Barrier Precautions (EBP) related to wounds; -Resident will maintain EBP without complications and will be free from new infection over the next 90 days; -Practice appropriate hand washing in between care and when visibly soiled. Ensure access to alcohol based hand sanitizer in rooms. Observation on 1/27/25 at 9:25 A.M., showed CNA G and CNA H donned gowns and gloves and entered the resident's room. CNA G assisted CNA H to transfer the resident into bed with the Hoyer lift. CNA G and CNA H removed their gloves and donned new gloves. Hand hygiene was not performed. CNA G unfastened the resident's brief and wiped the resident's inner thighs and front to back of the resident's private area. CNA G removed his/her gloves and donned new gloves. He/She did not perform hand hygiene. CNA H assisted CNA G to roll the resident to his/her right side. CNA G wiped the resident's buttock area and removed the resident's brief and a soiled dressing to the resident's buttock area. CNA G removed his/her gloves and donned new gloves. He/She did not perform hand hygiene. CNA G placed a new brief under the resident and applied barrier cream to the resident's buttock and inner thigh. CNA G did not change his/her gloves and rolled the resident to his/her back. CNA G and CNA H fastened the resident's brief and assisted the resident into his/her wheelchair with the Hoyer lift. CNA G and CNA H removed their gloves and gowns and left the resident's room. 3. During an interview on 12/27/25 at 12:51 P.M., CNA R said whenever staff change gloves, they should use hand sanitizer or if they can, wash their hands. Using hand sanitizer helps to prevent germs from spreading. 4. During an interview on 1/28/25 at 8:24 A.M., Licensed Practical Nurse (LPN) E said that staff should use hand sanitizer every time they remove gloves. Staff still need to wash their hands too. 5. During an interview on 1/28/25 at 10:15 A.M., the Director of Nurses (DON) said staff should wash their hands upon entrance to a room, gather supplies, and perform hand hygiene before care is provided. Staff should also perform hand hygiene in between glove changes because hands could be contaminated. 6. During an interview on 1/28/25 at 10:26 A.M., the Administrator said she expected staff to follow the infection control and hand hygiene policies. 49992

Based on observation, interview and record review, the facility failed to ensure residents were provided therapeutic diets as recommended by the physician and the Registered Dietician (RD), for one resident with weight loss (Resident #109). The facility failed to provide the resident's fortified chocolate milk for two observed meals. The facility also failed to provide the extra items listed on the meal ticket. The sample was 26. The census was 132. Review of Resident #109's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Uses wheelchair for mobility; -Weight: 163 pounds (lbs); -Supervision or touching assistance for eating (Helper provides cues or touching/steadying assistance as resident completes activity); -Diagnoses include acid reflux, diabetes, malnutrition, dementia and depression. Review of the resident's current care plan, showed: -Problem: Resident has potential for cognitive impairment; -Interventions: None listed -Goal: Resident's nutritional status will remain stable as evidenced by adequate oral intake to meet estimated nutrition and hydration needs and no significant weight change through next review. Review of the resident's electronic medical record (EMR), showed: -A progress note, dated and signed by the RD on 12/18/24 at 10:33 A.M., Resident reviewed for gradual weight loss. 163 lbs to 155.8 lbs. Cognitive impairment has affect his/her appetite and attention to stay on feeding task at meals. History of moderate protein-calorie malnutrition and diabetes. Spoke with resident today. Attempted to obtain preferences from resident. Spoke with spouse on the phone. Discussed moving resident to assist side of dining room and starting Glucerna (supplement) every day. Spouse in agreement. Will monitor supplement acceptance and weight per physician order. Refer to RD as needed; -A progress note, dated and signed by the RD on 1/23/25 at 1:27 P.M., Nutrition Review: Resident's weight 154 lbs remains down from usual body weight of 160-165 lbs. Last month resident started to receive more oversight, cueing, and encouragement at meals when spouse is not present. Due to resident's cognition, he/she requires reminders and directions to continue to self-feed on optimal amount. Talked to resident's spouse in dining room today. The spouse voiced concerns about resident's assistance need to prepare and complete a meal (assist putting in teeth, encourage/cue him/her through meal). Spouse requested some favorite food items be added. Spoke to Director of Nursing (DON) regarding spouse's concerns. Added items of preference (fruit, yogurt, milk) to meals. Staff have trialed resident on fortified chocolate milk. The resident has consistently drunk milk. Will add preferences to tray ticket and plan of care. Placed on weekly weights to monitor. Review of the resident's current care plan, showed it was not updated with the resident's preferences for fruit, yogurt and milk. Review of the resident's physician orders, dated 1/25, showed an order, dated 11/04/24, regular diet. Review of the resident's meal ticket, dated 1/24/25, showed: Breakfast: -Diet: Regular; -Texture: Regular; -Beverages: [NAME] (fortified chocolate milk) milk-4 full ounces (oz); -Food Adds: Fresh fruit-1 serving. Lunch: -Diet: Regular; -Texture: Regular; -Beverages: [NAME] milk-4 full oz; -Food Adds: Fresh fruit-1 serving, -Yogurt-1 each. Dinner: -Diet: Regular; -Texture: Regular; -Food Adds: Fresh fruit-1 serving. Observation in the dining room on 1/22/25, showed: -At 11:33 A.M., the resident sat at a table with two other residents. The resident had a cup of water, a cup of juice, and a cup of chocolate milk in front of him/her; -At 11:52 A.M., the resident gave his/her food order; -At 12:01 P.M., dietary staff brought the resident's lunch plate and set it out of reach of the resident. The resident was not served fruit. The dietary aide cut the meatloaf on the resident's plate and walked away with the plate out of the resident's reach; -At 12:06 P.M., a staff member went to the resident and straightened out his//her chair and put the resident's food in front of him/her. The resident began to eat; -At 12:15 P.M., the resident ate approximately 25% of his/her lunch. Licensed Practical Nurse (LPN) V goes to the resident's table and instructed the resident he/she needs to eat. LPN V attempted to help the resident but the resident said he/she was done eating. Observation in the dining room on 1/23/25, showed: -At 11:28 A.M., the resident sat with his/her spouse at a table with two residents. -At 11:42 A.M., the resident was brought his/her lunch plate of the entree of the day. The resident was also brought a cup of soup and a bowl of applesauce. Yogurt was not provided. -At 12:14 P.M., the RD was at the table with the resident and his/her spouse. The RD told the spouse that she was told by staff the resident was not eating or his/her intake was decreasing when the spouse was not here. The spouse told the RD the other day, the resident sat and staff assisted other residents around him/her and not him/her. The spouse also reported that when he/she was not there, the resident only gets one plate of the entree and not the extras like he/she was supposed to get. The spouse said he/she would not be able to be at the facility tomorrow. The RD said he/she would talk to staff to ensure they assist the resident and that he/she had the extras when the spouse was not here. Observation in the dining room on 1/24/25, showed: -At 11:29 A.M., the resident sat in the dining room at a different table with different tablemates closer to the kitchenette. The resident had chocolate milk, juice, and a water cup in front of him/her; -At 11:32 A.M., the resident's food was brought to him/her. The resident was served tortellini in red sauce with Brussel sprouts. There were no extra sides or applesauce with the entree; -At 11:40 A.M., the resident ate cake. A staff member said, Look at you all doing good and you made me feed you this morning. The resident pushed his/her pasta away from him/her. The resident ate approximately 25% of his/her lunch. No further verbal cues or assistance were provided. Observation in the dining room on 1/27/25 at 8:30 A.M., showed the resident sat in the dining eating breakfast. The resident had a cup of orange juice and a cup of water. The resident did not have fortified chocolate milk. The resident had two plates for breakfast. One appeared to be a type of bread dessert. The resident did not have fruit. Observation on 1/27/25 at 8:50 A.M., showed the resident had a full cup of fortified chocolate milk on his/her bedside table. The resident was not in his/her room. Observation on 1/27/25 at 9:20 A.M., showed the resident was brought back to his/her room by the Certified Nursing Assistant (CNA). The cup of chocolate milk was still on the resident's bed side table. During an interview on 1/27/25 at 9:22 A.M., CNA G said the chocolate milk in the resident's room was probably brought down from breakfast but he/she was not sure. During an interview on 1/27/25 at 10:05 A.M., LPN X said the Certified Medication Technician (CMT) hands out the special chocolate shake during medication pass. Observation on 1/27/25 at 11:50 A.M., showed the full cup of fortified chocolate milk on the resident's bed side table. Observation on 1/27/25 at 11:53 A.M., showed CNA G entered the dining room with a full cup of fortified chocolate milk and put the cup in the kitchenette. The cup of chocolate milk that was in the resident's room was no longer on the resident's bed side table. Review of the Medication Administration Record, dated 1/25, showed no order or documentation of administration of [NAME]. Observation in the dining room on 1/27/25, showed: -At 11:52 A.M., the resident sat in the dining room for lunch service. The resident sat at the table by the kitchenette. The resident had a cup of juice and a cup of water. The resident did not have a cup of the fortified chocolate milk. The resident sat with two other residents who are both eating. The resident did not have his/her food; -At 12:03 P.M., a dietary staff brought the resident's food and placed the plate in front of the resident. The resident has a cheeseburger and French fries. The resident did not have fruit or any other sides. The resident backed himself/herself up from the table in his/her wheelchair. No staff offered to assist him/her; -At 12:05 P.M., the resident started to eat. CNA G was at the resident's table. CNA G pushed in the resident's wheelchair under the table and locked his/her wheelchair. CNA G cut the resident's cheeseburger into four pieces and walked away from the table. The resident ate his/her French fries; -At 12:20 P.M., the resident ate a few French fries. The resident did not eat any of his/her cheeseburger. He/She ate all of the apple cobbler dessert. No other verbal cues were provided by staff. During an interview on 1/28/25 at approximately 8:40 A.M., the RD said she expected staff to follow instructions and recommendations. The resident's spouse wants the resident to sit in different spots and will change what he/she wants the facility to do for the resident. The RD expected the resident to have the [NAME] milk and have different options offered that are listed on the meal ticket. She expected staff to offer an alternate if the resident did not appear to be eating. The resident did not have to eat if he/she did not want to. The resident was just on her watch list for weight loss. During an interview on 1/28/25 at 10:15 A.M., the DON and Administrator said the dietary staff should be aware of the dietician recommendations and should follow them. They expected the dietary staff to follow what is on the meal ticket. The DON said dietary should notify nursing if the resident did not have his/her fortified chocolate milk. The resident should get it as recommended by the dietician.

Based on observation, interview and record review, the facility failed to ensure residents receive care consistent with professional standards. Staff failed to complete a documented assessment and documented notifications to the physician and family regarding a resident's knee wound. Staff also failed to obtain a physician's order for a dressing to the resident's right knee (Resident #110). The sample size was 26. The census was 132. Review of the facility's Prevention and Treatment of Skin Breakdown policy, dated 8/2019, showed: -Policy: It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure injuries; To implement preventative measures; and to provide appropriate treatment modalities for wounds according to the industry standards of care. -Procedure: Monitoring of skin integrity. Skin will be observed daily with care by the nursing assistant. If any skin concerns are noted, they are to be reported immediately to the designated nurse. Weekly skin audits on the bath or shower day will be performed by the licensed nurse. When a wound is found, notify the physician/nurse practitioner, the resident representative, and notify the supervisor. Review of the resident #110's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/24, showed: -admitted [DATE]; -Slurred speech; -Rarely or never understood; -Sometimes understands direct communication; -Diagnoses include kidney failure, aphasia (loss of speech), dementia, anxiety, and depression. Review of the resident's skin assessment, dated 12/6/24, showed: -A partial thickness wound, skin tear to the right lateral knee. Review of the resident's skin assessment, dated 12/13/24, showed: -The skin tear had healed. The nurse noted the skin tear was unremarkable and closed the report. Review of the resident's shower sheet, dated 1/21/25, showed: -A scabbed area to the right knee. Review of the resident's shower sheet, dated 1/23/25, showed: -A scabbed over area to the right lateral knee. Review of the January 2025 progress notes showed no documentation about a wound or dressing to the resident's right knee, prior to 1/27/25. Review of the physician's orders sheet (POS) showed no treatment orders for the resident's right knee in January 2025, prior to 1/27/25. Review of the resident's treatment record, dated January 2025, showed: -No treatment order for the right knee. Observation and interview on 1/27/25 at 8:49 A.M., during the resident's care, showed a small bandage on the resident's right knee. The only viewable markings on the bandage was 1/23. Certified Nursing Assistant (CNA) B and CNA A said they were not aware of the dressing to the right knee and were not able to read the numbers on the dressing. During an interview on 1/27/25 at 9:11 A.M., Licensed Practical Nurse (LPN) I said that he/she was unaware of the resident having a wound to the right knee, that required a dressing. LPN I assessed the resident's right knee, removed the dressing, and cleaned the wound. During an interview on 1/27/25 at 10:23 A.M., LPN I said he/she left a message for the doctor regarding the wound, phoned the family about the wound, and notified the Director of Nursing (DON). During an interview on 1/28/25 at 8:19 A.M., CNA D said that he/she assists the residents with their showers and documents any sores or wounds on the shower sheet, which is turned into the charge nurse. He/she said if the sore is not treated, it could get worse or infected. During an interview on 1/28/25 at 8:24 A.M., LPN E said that the CNAs fill out the shower sheets and let him/her know if there are any skin issues with the resident. The manager or the DON performs the weekly skin assessments. Wounds have to be treated so they do not get worse or infected. During an interview on 1/27/25 at 2:39 P.M., the resident's physician said that she would expect staff to notify her as soon as possible if there is an alteration in skin integrity. During an interview on 1/28/25 at 10:12 A.M., the DON said the CNAs fill out a shower sheet on the resident's shower day and note issues with the skin. The CNAs can also fill out a Stop n Watch (a communication form) and turn the form into the nurse to notify him/her of a new skin issue. During an interview on 1/28/25 at 10:26 A.M., the Administrator said she expected the staff to follow the policies on skin and wounds.

Based on observation, interview and record review, the facility failed to ensure resident care plans were updated and accurate to reflect resident needs. This failure affected three of four sampled residents, whose care plan did not identify self-harm (Resident #96) sexual behaviors (Resident #109) and hospice services (Resident #29). The sample was 26. The census was 132. Review of the facility's Care Planning policy, dated [DATE], showed: -Policy: It is the policy of the facility for the Care Planning/Interdisciplinary Team to develop and to implement a person-centered comprehensive care plan for each resident to meet the resident's preferences and goals, and to address medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment; -A comprehensive care plan for each resident is developed within seven days of completion of the comprehensive resident assessment; -The resident's care plan must be reviewed after each Omnibus Budget Reconciliation Act (OBRA) assessment, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions; -Using the policy: It is the policy of the facility for care plans to be used in developing the resident's daily care routines and will be available to staff who have responsibility for providing care or services to the resident; -Completed care plans are placed in the resident's electronic medical chart; -Certified Nursing Assistants (CNAs) are responsible for reporting to the Nurse Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved; -Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and/or the Minimum Data Set ((MDS), a federally mandated assessment instrument completed by facility staff) Assessment Coordinator; -Changes in the resident's condition must be reported to the MDS Assessment Coordinator so a review of the resident's assessment and care plan can be made; -Documentation in the medical record must address the resident's subjective statements as well as the staff's objective assessments and observations of the resident's physical, mental, and psychosocial functioning. 1. Review of Resident #96's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -Occasionally incontinent of bladder, always incontinent of bowel; -Diagnoses include Alzheimer's, stroke, anxiety, depression, and malnutrition. Review of the resident's progress notes showed: -A progress note, dated [DATE] at 10:14 A.M., Continued slurred speech as reported by staff. Strong bilateral hand grips. Independent with transfers and ambulation using walker; -10:00 A.M. family present, informed of assessment. Family has declined for resident to be sent to emergency room . States I think it is behaviors related to needing medication adjustments, you know he/she has a long psych history. Message left for psychiatrist and Nurse Practitioner (NP) regarding this matter. Awaiting return calls; -2:20 P.M. Resident noted standing in doorway with no pants on holding pink scissors in right hand. Two cuts noted across left writs and several scratches noted to right wrist (Resident has dug nails in his/her wrist scratching up his/her arm). Call placed to family informing of situation and that resident will be sent out. (Family said) The resident has been to the hospital before for this, also asked have they discontinued his/her valium (sedative medication used to treat anxiety). Family informed at this time; it is beyond this nursing home's care. Physician present, resident assessed and stated twice I want to kill myself; -3:00 P.M. routine Seroquel (antipsychotic medication used to treat schizophrenia (chronic mental illness characterized by significant disruptions in thought processes, perceptions, emotions, and behaviors), bipolar disorder (a chronic mental health condition characterized by extreme shifts in mood, energy, and activity levels), and depression), Zyprexa (antipsychotic medication, used to treat schizophrenia and bipolar disorder) and PRN (as needed) Trazadone (used to treat depression) administered. Resident 1 to 1 at this time. Vital signs obtained. Emergency Medical Services (EMS) called for transport; -3:13 P.M. Wander guard removed; -3:19 P.M. Report called to hospital triage; -3:40 P.M. EMS present for transport to hospital; -A progress note, dated [DATE] at 4:05 P.M., Resident's son/daughter called and asked what can be done to keep resident from going to the hospital. Advised son/daughter that it is out of my control and resident has to go to the hospital. The Medical Director is here and states he/she needs to be hospitalized . Son/Daughter asked if they found 24 hour ,d+[DATE] care could the resident be discharged from the hospital and return to the facility. Son/Daughter advised that no decision like that could be made at this time, any decision regarding the resident's readmission cannot be made at this time, it will depend on his/her treatment plan and behaviors. Family voiced understanding and will be meeting the resident at the hospital; -A progress note, dated [DATE] at 8:16 P.M., Resident was initially sent and admitted to the hospital on [DATE] after an attempted suicide (cut his/her wrist with scissors) for psychiatry stabilization. CT (computerized tomography scan) head suggestive of subacute infarction (stroke). Urinalysis was suggestive of urinary tract infection (UTI) and completed five days of ceftriaxone (antibiotic). Resident was transferred to behavioral health center on [DATE] as he/she remained actively suicidal. After medication adjustments and agreed upon 24-hour private duty caregivers, resident was discharged . Resident's son/daughter plans to follow up with hospice care once resident gets resettled into the facility; -1:10 P.M. Transferred via EMS. Accompanied by private duty caregiver. Resident was readmitted to facility from behavioral health center but transferred to 2nd floor. Alert and oriented ,d+[DATE] (not to place or time, only to self and situation) with soft speech. Asking about location of spouse who has been deceased approximately [AGE] years and has been the source of depression. Denies pain. Denies suicidal ideations; -A progress note, dated [DATE] at 6:19 A.M., Resident lying down in bed, resting comfortably. Sitter in room. No signs of suicidal ideations. Poor appetite. No nausea/vomiting/diarrhea. Review of the resident's Psychiatric Consultations showed: -A follow up evaluation, dated [DATE], Resident seen for dementia with depression, anxiety, and a history of psychosis. Significant anxiety documented [DATE] throughout the day shift but improved since then. Supervisor reports patient frequently approaches the desk with various concerns and he/she has been very anxious, complains of constipation, and then he/she has diarrhea. Resident knows his/her son/daughter has been very busy with his/her house and resident wishes his/her son/daughter would visit. Resident knows her month and day of birth but not the year. Next visit ,d+[DATE] weeks; -A follow up evaluation, dated [DATE], Resident seen for dementia with depression, anxiety, and a history of psychosis. Resident was seen in the presence of his/her private duty nurse who reports resident has been resting and awakened shortly before I entered. Resident was anxious and obsessed with his/her clothes being twisted. I adjusted his/her t-shirt and blouse and resident continued to complain of this. Review of the resident's care plan, in use during the survey, showed: -Problem: Resident has impaired cognition related to Alzheimer's. Resident is alert and oriented ,d+[DATE] (time and place) with memory loss, forgetful, confusion, and anxiety. Has companions provided by family, that comes to sit with him/her at times. Can become tearful at times. Enjoys going for walks, playing bingo, and going outside; -Goal: Resident will maintain current level of cognitive functioning; -Action: Identify baseline cognition, use a calm, slow approach, provide reorientation and redirection as needed; -The resident's suicide attempt was not mentioned in the care plan; -Problem: Resident is at risk for elopement related to wandering and episodes of increased anxiety. Resident is able to walk independently with his/her walker around facility. Also, up in wheelchair propelled by feet at times, and by staff/companion at times. History of verbalizing suicidal ideation. Followed by psych. Also encouraged to speak with psychotherapist. Resident has been noted to voice accusations critical of staff related to his/her impaired cognition and dementia. Wander guard in place; -Goal: Resident will not leave facility unescorted; -Action: Monitor behaviors to determine causes and patterns, staff to make frequents checks of resident to ensure his/her safety, companions frequently during the week, Interdisciplinary Team (IDT) to assign risk level after assessment and determine plan of care; -The resident's suicide attempt was not mentioned in the care plan. During an interview on [DATE] at 11:22 A.M., Licensed Practical Nurse (LPN) V said the resident has a private caregiver that the family hired. The CNAs still go in and check on the resident. The resident gets very anxious and upset especially if alone and has a history of self-harm. The resident was sent out last month because he/she was at his/her room door with pair of scissors in his/her hands and had cuts on the other arm. During an interview on [DATE] 9:20 A.M., CNA H said the resident has not had any behaviors toward staff. The resident tells staff he/she hears voices. Staff tell the resident, he/she is ok and staff redirect. CNA H believes the resident has all plastic silverware now after he/she returned from the hospital. The resident has not tried to hurt himself/herself since he/she came to this unit after readmission from hospital. The resident has a sitter but the aides still do rounds. During an interview on [DATE] at 10:05 A.M., LPN X said to his/her knowledge the resident does not have any restrictions as far as silverware or other sharp items. The resident has 24 hour sitters. The sitters are aware of the resident's self-harm behavior. LPN X said there a note of self-harm under the skin tab for the resident that the CNAs can see. They will chart behaviors. During an interview on [DATE] at 10:15 A.M., the Director of Nursing (DON) and Administrator said if the resident has known behaviors such as a history of self-harm those behaviors should be on the care plan. The DON said if the resident has a family hired sitter, that should also be on the care plan. They would expect the staff to communicate with the sitter and update them with any new information on the resident. If something is on the care plan then it would be on the CNA care guide and vice versa. 2. Review of Resident #109's MDS, dated [DATE], showed: -Severe cognitive impairment; -Uses wheelchair for mobility; -Incontinent of bowel and bladder; -Diagnoses include acid reflux, diabetes, malnutrition, dementia, and depression. Observation on [DATE] at 9:20 A.M., showed CNA G entered the resident's room to provide care. When CNA G informed the resident that he/she was there to take the resident to the bathroom, the resident was overheard saying to CNA G, Oh, I have a pretty one to grab onto today. CNA G did not respond and propelled the resident into the bathroom. During an interview on [DATE] at 9:20 A.M., CNA H said the resident has a lot of behaviors. The resident fights, kicks, and wants to be touchy, like rub on staff. CNA H said he/she was informed when the resident was admitted that the resident acts like that. The resident makes comments like the one that was just made to CNA G. He/She thinks the resident got kicked out of his/her previous facility for being touchy. Sometimes the resident will try to grab the staff's bottom area during care. When the resident starts to kick, there will have to be two staff in there because the resident is so tall. CNA H said this morning the resident was playing with his/her private area when CNA H and CNA G were trying to provide incontinence care. Then the resident began to kick when they tried to redirect the resident. The resident is able to be redirected and normally stops the behavior. The nurses and management are aware. They tell aides to chart the behavior and to redirect the resident. During an interview on [DATE] at 9:22 A.M., CNA G said the resident says inappropriate stuff and in a sexual nature when staff provide incontinence care. Sometimes staff use two staff; it depends on the morning. Sometimes staff can just propel the wheelchair in the bathroom and he/she will use the urinal. Some days the resident is combative. The resident had to have two aides this morning. Staff chart the behaviors in the medical record and tell the nurse. Staff redirect. The resident is not that aggressive and is easy to redirect. This morning the resident had his/her hand on his/her genitals during incontinence care, so CNA G said he/she just politely removed the resident's arm. CNA G said sometimes reminding the resident of his/her spouse gets the behavior to stop. The resident has not been physically aggressive just verbally aggressive. During an interview on [DATE] at 10:05 A.M., LPN X states the resident has sexual behaviors sometimes. The resident is a nice person. The CNAs do report the resident is grabby. They did not report that any words were said to them today. The behaviors have been since he/she was admitted . The resident was like this before the resident got here. There have been multiple care plan meetings with his/her wife. The first one he/she did not remember so had another one a couple weeks later with the resident's wife and daughter. The CNAs redirect the resident. LPN X would expect behaviors to be on the care plan. At the time of the last care plan meeting, the resident had not had the behaviors a lot but they have increased since the last meeting. LPN X said care plans are done by the MDS coordinator. The care plan meeting includes the nurse manager, therapy, and dietary. The MDS coordinator does not attend. The nurse manager give the MDS coordinator any updates. The nurse will also update the plan of care for the CNAs to be aware of any behaviors. Care plan meetings are done upon admission and quarterly. The family calls to schedule the meeting. Review of the resident's care plan, in use during the survey, showed: -Problem: Impaired cognition related to overall decline in cognition; As evidenced by being alert and oriented to self. Resident is pleasant and cooperative; -Goal: Will be able to express needs and wants through facilitated communication at resident's level of cognitive function; -Intervention: Bring out to area of activity to enhance socialization, identify self upon entering room, explain all procedures prior to beginning in simple direct terms. -No problems noted on the care plan related to the resident's sexually inappropriate behaviors. Review of the resident's medical record showed: -A progress note, dated [DATE] at 10:49 A.M., Resident voiced sexually explicit comment to CNAs while touching himself/herself. CNAs attempted to redirect resident but then he/she became resistive towards care. CNAs were able to divert behaviors with music and drink prior to pericare. After care, resident attended activities. During an interview on [DATE] at 10:15 A.M., the DON and Administrator said if the resident has known behaviors such as sexual behaviors with comments and grabbing at staff, those behaviors should be on the care plan especially if they have been occurring since admission. If the behaviors increase or decrease, that should also be noted on the care plan. Or there just may be a note of the history if they make inappropriate comments to staff or grab at staff. 3. Review of Resident #29's progress notes, on [DATE], showed at 2:58 P.M., the resident signed up for hospice. At 4:53 P.M., hospice was present. New hospice orders received and noted. Review of the resident's physician orders, dated [DATE], showed and order on [DATE] to admit to hospice. Review of the resident's hospice care plan in use during the survey, showed: -admitted [DATE]; -Diagnosis of terminal senile degeneration of the brain (a general term for a group of neurological disorders that cause a gradual decline in cognitive function); -Related diagnoses included hypertensive heart disease with heart failure, congestive heart failure, muscle weakness, seizures, benign brain tumor, urine retention, dysphagia, falls and acid reflux; -The resident was alert and oriented to self; -Hospice visited on Mondays, Wednesdays, and Thursdays; -Services provided at each visit: Hospice staff transferred the resident with two person assist to wheelchair, provided nail care, shaved facial hair, provided peri/incontinence care, showered the resident, documented food/liquid intakes, completed skin assessment and updated the floor Nurse and Nurse Supervisor of any changes, took out trash at end of visit. Review of the resident's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -Prognosis: A chronic disease which may result in a life expectancy of less than six months. Review of the resident's care plan in use during the survey, showed no documentation of hospice services and the care they provided. During an interview on [DATE] at 11:33 A.M., the DON said the resident's care plan should have been updated to include hospice and the care they provided. She is not sure why it was missed. 4. During an interview on [DATE] at 10:15 A.M. the Administrator and DON said the management or Interdisciplinary Team is responsible for updating care plans. They would have expected the residents' care plans to be updated to reflect self-harm behaviors, sexual behaviors and hospice services. 44950 46967

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, four errors occurred, resulting in a 13.33% error rate (Residents #60 and #98). Staff did not measure a medication in powder form on a level surface, provided a bottle of nasal spray to a resident and did not stop the resident at the ordered doses, crushed a medication that should not have been crushed and left crushed medications unattended on the medication cart. The census was 132. Review of the facility's Medication Administration, policy dated 8/19, showed: -Purpose: To clearly define Drug Administration policies in accordance with all applicable laws and standards of practice. Review of the facility's Crushing Medications policy, dated 8/19, showed: -Purpose: To enable the resident who has difficulty swallowing to take medications orally. Review of the facility's Medications Not to be Crushed list, revised 7/19, showed: -Ezetimibe (to treat high cholesterol) tablet not be crushed due to manufacturers recommendation. 1. Review of the resident #60's medical record, showed: -Diagnoses included renal disease, diabetes, congestive heart failure, atrial fibrillation (the heart beat is irregular), dementia, and depression; -An order, dated 11/14/24, Psyllium husk (to assist the bowels) 2.6 grams/4.1 gram oral powder by mouth daily for bowel health; -An order, dated 11/14/24, Flonase Allergy Relief 50 micrograms (mcg) nasal spray, two sprays into each nostril once daily for allergies. During a medication administration observation, on 1/24/25 at 7:27 A.M., Certified Medication Technician (CMT) Q held a 30 cc medication cup up over the medication cart and poured the Psyllium husk powder into the cup and shifted the contents to measure the amount. Then poured the powder into a cup and mixed with water. CMT Q gathered the remainder of medications and approached the resident and handed the resident the bottle of Flonase. The resident removed the top and sprayed each nostril a total of four times, alternating between nostrils. CMT Q intervened at that point and took the bottle from the resident. The resident consumed the contents of the cup of dissolved powder. 2. Review of the resident #98 medical record, showed: -Diagnosis of osteoporosis (softening of the bone), atherosclerotic heart disease (hardening of the blood vessels), high cholesterol, kidney failure, atrial fibrillation, and dementia; -An order, dated 1/23/24, May crush medication if not contraindicated; -An order, dated 1/25/24, for Ezetimibe 10 milligrams (mg) by mouth every morning. During a medication administration observation on 1/24/25 at 7:48 A.M., CMT Q crushed the Ezetimibe tablet with the resident's other medications, mixed with pudding and approached the resident in the dining room. The resident said he/she wanted to wait until after his/her meal. CMT Q returned to the medication cart (med cart), placed the medicine cup with the crushed medications in the ice tray sitting on top of the med cart. CMT Q said, I need to keep it cold. CMT Q then left the medication cart, with the crushed medication still in the ice tray. He/She walked approximately 100 feet into the dining area where the medication cart was no longer in sight. During an interview on 1/28/25 at 8:06 A.M., CMT F said that residents should not administer their own medications without an assessment by the nurses to show the resident is able to do safely. There was list in the narcotic count book on the medication cart that contained a list of medications that could not be crushed. If staff were unable to administer medication to a resident, the medications were to be placed in a paper cup with the date, time, resident's initials, covered with another cup and secured in the medication cart. Medication should never be left unattended. When pouring a liquid or a powder medication, the medication cup should be placed on the medication cart, not up in the air. During an interview on 1/28/25 at 8:24 A.M., Licensed Practical Nurse (LPN) E said when preparing powder medication, the medication cup should be place on top of the cart, then pour the medication and measure by bending to come to eye left with the cup instead of bringing the cup to eye level. Staff should only crush medication when there was an order. During an interview on 1/28/25 at 10:12 A.M., the Director of Nursing said she expects staff to administer medication as ordered and to follow the facility's policies and procedures. Medication should never be left unattended. During an interview on 1/28/25 at 10:26 A.M., the Administrator said she would expect to staff follow the facility's policy on medication administration.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents was free from physical abuse by an agency Certified Nurse Aide (CNA). Review of a video, showed on the morning of 3/17/24, agency CNA A stood at Resident #1's bedside. He/She had one hand behind the resident's neck and with the other, pulled on the resident's leg towards a sitting position. The resident hit the CNA. With his/her right hand, CNA A punched the resident in the neck. He/She then loudly said, Stop. Why did you do that? The census was 136. On 04/12/24 9:49 A.M., the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 03/17/24. On 03/17/24, the administrator was notified of the incident and an investigation was started. CNA A was sent home and placed on the do not return list. Facility staff received education on Freedom from Abuse and Neglect. The IJ was corrected on 3/18/24. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property Policy, dated 10/2022, showed the following: -Preface: It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms; -Training Components: -Abuse Policy Requirements: It is the policy of this facility that all new and existing employees are educated on all forms of abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, injuries of unknown source, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms. Training shall include prohibiting and prevention, identification, recognition, reporting and understanding behavioral symptoms that may increase risk of abuse and neglect in order to properly respond. Review of Resident #1's care plan, dated 2/27/24, showed the following: -Problem: The resident has a history of resisting care and services. The resident has dementia and does not always understand what is being requested. The resident has become increasingly combative with staff and resistive with care. The resident is very difficult to redirect; -Goal: The resident will accept redirection during episodes of inappropriate behavior; -Approach: Introduce yourself upon contact, make eye contact, approach from front, explain all procedures prior to beginning. During periods of inappropriate behavior, use a consistent, calm, firm approach. Use the resident's name to help divert inappropriate behavior. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/13/24, showed the following: -Severe cognitive impairment; -No moods or behaviors; -No impairment to the upper and lower extremities; -Dependent with activities of daily living (ADLs); -Diagnoses of dementia and Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of the facility's investigation, dated 3/17/24, showed at approximately 9:00 P.M. on Sunday, 3/17/24, the Administrator was notified by the resident's family they had viewed a video from the camera they have in the resident's room and saw the day shift CNA punching or pushing the resident back on the bed as the CNA was assisting him/her up the morning of 3/17/24 at 9:24 A.M. The family requested this CNA no longer take care of the resident. The Administrator went to the facility to check on the situation. The nursing staff assessed the resident and found him/her to have no bruises or abrasions at that time. The resident is confused at baseline. The nursing agency was contacted to inform them of the issue with CNA A. The resident's family was informed early Monday (3/18/24) morning that CNA A would not be coming back to the facility. The resident was assessed and he/she appeared to be at his/her baseline. During an interview on 4/12/24 at 11:10 A.M., Family Member F said on 3/17/24 at approximately 9:30 P.M., he/she looked at video footage from his/her phone and saw CNA A hit the resident on the morning of 03/17/24 at 9:24 A.M. He/She called Family Member G immediately and told him/her what happened. Family Member F said he/she was very upset after watching the video footage. During an interview on 4/11/24 at 2:00 P.M., Family Member G said Family Member F called him/her on 3/17/24 at approximately 9:30 P.M. and told him/her what happened. He/She emailed the Director of Nursing immediately about the incident. He/She did not want CNA A giving care to the resident going forward. Review of a video, showed on the morning of 3/17/24 at 9:24 A.M., agency CNA A stood at the resident's bedside. He/She had one hand behind the resident's neck and with the other, pulled on the resident's leg towards a sitting position. The resident hit him/her. With his/her right hand, CNA A punched the resident in the neck. He/She then loudly said, Stop. Why did you do that? CNA A walked into the other room, coughing. During an interview on 3/26/24 at 12:54 P.M., CNA A said he/she was getting the resident dressed on 3/17/24 at 9:24 A.M. The resident has a history of being combative during care. CNA A said the resident hit him/her in the throat and he/she hit the resident back. CNA A said he/she did not mean to hit the resident. CNA A did not report the incident to the Charge Nurse because he/she did not think of it at the time. He/She was not familiar with the facility's abuse and neglect policy. During an interview on 4/1/24 at 9:20 A.M. Licensed Practical Nurse (LPN) B said he/she had not previously worked with CNA A. LPN B said as the day went on, CNA A seemed to be nonchalant and uncaring with his/her assignment and other staff members. Due to this behavior, he/she decided to send the CNA home. He/She did not remember the time and did not find out about the incident until later that night on 3/17/24. Review of CNA A's timesheet, showed he/she clocked out on 3/17/24 at 10:55:58 A.M. Central Standard Time. During an interview on 4/11/24 at 11:47 A.M., the Staff Coordinator (SC) said he/she looked at CNA A's performance review and he/she had 4.40 out of five score on the reviews. The agency staff have to physically read the facility's abuse and neglect policy before accepting a shift. This will show the agency staff have read and acknowledge the facility's policy. Review of CNA A's employee file, showed he/she read and accepted the facility's abuse and neglect policy on 3/14/24. During an interview on 4/12/24 at 11:50 A.M., LPN D said he/she was inserviced a couple of weeks ago on abuse and neglect, but did not remember the date, and again today on the facility's abuse and neglect policy. He/She said one should immediately report the hitting of a resident to the Director of Nursing or the Unit Manger. During an interview on 4/12/24 at 1:59 P.M., the Medical Director said he/she expected the facility CNAs and staff and agency CNAs to follow the facility's abuse and neglect policy. During an interview on 3/19/24 at 8:25 A.M., the Administrator said she expected facility staff and agency staff to follow the facility's abuse and neglect policy. MO00233320

Based on interview and record review, the facility failed to ensure one of three sampled residents, who had a change in condition, was monitored and assessed, according to professional standards, by a licensed nurse throughout the night. The resident was sent to the hospital the next morning, intubated (tube inserted through the mouth and into the lungs so the person can be placed on a ventilator to assist with breathing) in the emergency room (ER) for respiratory failure (a condition in which the blood does not have enough oxygen), and admitted to the intensive care unit (ICU) for respiratory failure, atrial fibrillation (an irregular and rapid heartbeat) and septic shock (the most severe complication of sepsis and carries a high mortality) (Resident #2). The census was 129. Review of the facility's Acute Change of Condition policy, dated 8/2019, showed: -It is the policy of this facility to promptly identify, evaluate, and address a resident's change in condition, and to: -Immediately notify the resident and/or the resident representative and the resident's physician when a significant change in the resident's physical, mental, or psychosocial status occurs (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); -Licensed nurses will notify the resident and/or their representative and the resident's physician when condition changes occur; -Licensed nurses will also document these notifications in the medical record; -A key component of competency is a Certified Nurse Aide's (CNA) or licensed nurse's ability to identify and address a resident's change in condition. Facility staff should: -Be aware of each resident's current health status and regular activity; -Be able to promptly identify changes that may indicate a change in health status; -Once identified, staff should demonstrate effective actions to address a change in condition, which may vary depending on the staff who is involved. For example, a CNA who identifies a change in condition may document the change on a short form and report it to the Registered Nurse (RN) Manager. Whereas an RN who is informed of a change in condition may conduct an in-depth assessment, and then call the attending practitioner; -These competencies are critical in order to identify potential issues early, so interventions can be applied to prevent a condition from worsening or becoming acute. Without these competencies, residents may experience a decline in health status, function, or need to be transferred to a hospital; -Facility staff are expected to know how to identify residents' changes in conditions, and what to do once one is identified. -Procedure: -1. Assessment and Recognition: -Licensed Nurses will examine, assess, and document/report the following baseline information: -Vital signs; -Neurological status; -Level of consciousness; -Cognitive and emotional status; -Cardiopulmonary status; -Musculoskeletal, gastrointestinal, genito-urinary, skin, and sensory organ status. -Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and will collect appropriate information to report to the physician; -Phone calls to attending or on-call physicians should be made by a prepared nurse who has collected pertinent information, including the resident's current symptoms and status, onset, duration, and severity of the change in condition. -2. Cause Identification: -The nursing staff will contact the physician based on the urgency of the situation; -The Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status; -The Physician should ask questions to clarify the situation; e.g., vital signs, physical findings, and description of symptoms; -The nursing staff and Physician will discuss possible causes based on resident history, current symptoms, medication regimen, and existing test results. -3. Treatment/Management: -The Physician will authorize appropriate treatments; -The Nurse will repeat any verbal orders to the Physician to ensure accurate transcription; -If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the Attending Physician will authorize transfer to an acute hospital or another appropriate setting; -The staff will monitor and will document the resident's progress and responses to treatment, and the physician will adjust treatment accordingly; -The Physician will monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized. Review of Resident #2's list of diagnoses on the Face Sheet, showed: -Chronic obstructive pulmonary disease (COPD, obstruction of air flowing through the airways, in and out of the lungs, is permanent, and becomes worse over time); -Chronic diastolic (congestive) heart failure (CHF, heart unable to pump enough blood to meet the body's needs); -Chronic kidney disease, stage 3A (moderate kidney damage); -Permanent atrial fibrillation (irregular, rapid heart rate which may cause heart palpitations, fatigue, shortness of breath, arterial blood clots and stroke); -Generalized anxiety disorder; -Major depressive disorder. Review of the resident's care plan, dated 10/5/23, showed: -No documentation of goal(s), or interventions, related to a history of nausea and vomiting, and order for as needed Zofran (a prescription medication that prevents nausea and vomiting); -No documentation of goal(s), or interventions, related to diagnosis of COPD, asthma, and as needed order for oxygen therapy; -No documentation of goal(s), or interventions, related to diagnosis of CHF and heart failure; -No documentation of goal(s), or interventions, related to diagnosis of anxiety disorder. Review of the resident's primary care visit, dated 11/10/23, showed the following: -The resident was frail, elderly and thin; -No nausea or vomiting; -Normal breath sounds with no cough, shortness of breath, or wheezing; -Cardiovascular with normal rate, rhythm, heart sounds, and no murmur; -No depression, nervousness, or anxiousness; -Alert and oriented to person, place and time; -Primary visit diagnoses listed as: -Moderate persistent asthma without complications. -Hypertensive heart with chronic diastolic congestive heart failure and permanent atrial fibrillation; -Chronic Stage 3A kidney disease. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/08/23, showed: -Cognitively intact; -Independent with eating; -Minimal assistance with upper body dressing and personal hygiene; -Maximum assistance with sit to stand transfers, chair to bed transfers, and toilet transfers; -Wheelchair for mobility; -Frequently incontinent of bowel and bladder; -Primary medical condition: debility and cardiorespiratory conditions; -Other active diagnoses: heart failure, hypertension, renal failure, COPD, anxiety, and major depression. Review of the resident's Physician Order Sheet, dated 11/8/23, showed: -Ondansetron HCI 4 milligram (mg) tablet (generic for Zofran), by mouth, every 6 hours as needed for nausea and vomiting, last dose 12/17/2023; -Geri-Lanta (used for symptoms of acid indigestion, stomach upset, heartburn) 200 mg-200 mg-20 mg/5 milliliters (ml) oral suspension, 30 ml by mouth every 6 hours as needed for indigestion. No last dose listed; -Meclizine (antihistamine used to prevent and treat nausea, vomiting, and dizziness) 25 mg chewable tablet by mouth every 12 hours, as needed for dizziness. No last dose listed; -Levalbuterol (opens airways to make breathing easier) solution for nebulization (device that turns the liquid medication into an aerosol that is breathed in through the mouth and nose) 3 (ml) inhalation every 6 hours as needed for shortness of breath/wheezing. No last dose date listed; -Oxygen therapy-2 liters per minute per nasal cannula, as needed for shortness of breath. Review of the resident's Vital Stats, dated 10/1/23 through 12/31/23, for the most recent documented vital signs, showed: -11/28/23 at 3:59 P.M., pulse 90 and blood pressure 111/60; -12/26/23 at 9:23 A.M., temperature 98.7. Review of the resident's progress notes, dated 12/26/23 at 4:37 P.M., showed a rapid COVID test was performed due to possible exposure and was negative, with no COVID symptoms noted. During an interview on 1/24/24 at 3:40 P.M., Licensed Practical Nurse (LPN) A said she worked for an agency and did not know if he/she cared for the resident prior to the evening of 12/26/23. He/She worked four hours that evening, from about 7:30 P.M. to 11:30 P.M. The resident's family member brought the resident back to the facility around 7:30 P.M. and said the resident was not him/herself. The nurse went into the resident's room and got his/her vital signs but could not recall if any of the vitals were abnormal. The resident vomited, about a handful amount, while the family member was still there. The resident thought maybe he/she had COVID and started to panic and cry. The nurse consoled the resident and said he/she would try to get something for the emesis. LPN A called the Physician, to report the emesis, but could not recall if the Physician gave him/her an order for Zofran or if the resident already had the order. The nurse gave the Zofran and said it was effective because he/she checked on the resident at least three more times and the resident was still sitting up in his/her recliner, sleeping. LPN A said no CNA reported anything about the resident to him/her that evening. LPN A did not document the Zofran because he/she did not know how to document a PRN (as needed) in the facility's electronic medical record. Nurse A did not know why he/she did not write a nurse's note. The night nurse was told about the resident's emesis and about the Zofran, during their verbal change of shift report. Sometime the next day, he/she was called by the facility's Director of Nursing (DON), who said the resident was sent to the hospital that morning and they needed documentation on what he/she did while he/she was there. Nurse A returned to the facility and wrote a late entry, after 5:00 P.M., on 12/27/23. Review of the resident's Medication Administration Record (MAR), dated December 2023, showed an order for Zofran 4 mg, as needed every 6 hours for nausea and vomiting, with last dose documented as given at 5:51 A.M. on 12/17/23. There was no documentation the Zofran was given on 12/26/23 or 12/27/23. During an interview on 1/25/24 at 3:16 P.M., Nurse Practitioner (NP) B said she was on call for the hospital physician's group, for the holiday, from the evening of 12/26/23 until the morning of 12/27/23. She was not the resident's Nurse Practitioner and did not know the resident. Their calls are documented, but they do not put the exact time of the call in their report, but she knew the call came in before 11:00 P.M. on 12/26/23 because that is when she filed her first on-call report for the night. The nurse who called from the facility reported the resident was vomiting and had just been given Zofran. There were no signs of distress reported. NP B said they pretty much stop there, and do not give additional orders, unless the emesis looks like coffee grounds or if there is blood in the emesis. The nurses know they are to call back if the vomiting persists or there is a change in status. There were no further phone calls about the resident. During an interview on 1/25/24 at 12:00 P.M., CNA C said he/she was the resident's 12-hour night shift aide, from 7:00 P.M. to 7:00 A.M., on 12/26/23 to 12/27/23. CNA C had taken care of the resident many times before, but normally did not work on the resident's floor. Around 8:30 P.M. on 12/26/23, the resident said his/her stomach was upset, thought he/she had eaten too much, and wanted to go to the bathroom. CNA C helped the resident to the bathroom. The resident had some diarrhea, more gas than diarrhea, and had projectile vomiting that filled the bathroom sink basin almost halfway. CNA C said he/she showed the large amount of emesis, in the sink, to evening nurse, LPN A, who responded, Oh my goodness. CNA C helped the resident back to the recliner, where the resident always slept, and there was more projectile vomiting. It was mostly thin liquid and mucous, no solids, and about a large coffee cup amount. LPN A returned and gave the resident some Zofran. The nurse asked if he/she had vomited again, and the aide said yes. LPN A said they needed to keep an eye on the resident. The resident had emesis again, around 10:30 P.M., about 1.5 hours after the Zofran. It was mostly dry heaving and about one-half cup of emesis that was clear yellowish. CNA C was not concerned because COVID-19 was going around the facility, and the resident said he/she ate too much at the family visit. The resident was also chugging ice water. CNA C told LPN A about the yellow emesis, a smaller amount, and the nurse thought the Zofran had helped. Around 11:30 P.M., the resident was snoring, so he/she turned the lights and television off. CNA C told the oncoming night shift nurse, LPN E, about the resident's emesis episodes, that the resident was sleeping well, and told the nurse he/she would keep an eye on the resident. LPN E said okay, and to let him/her know if anything changed. CNA C said he/she checked on the resident every hour and at 3:00 A.M., the resident was vomiting and dry heaving again. There was about a coffee cup full of clear like emesis in the resident's bath/emesis basin and the resident was having a hard time getting his/her breath. The recliner's footrest was lowered, so the resident could sit up straight to breathe better, and the aide rubbed the resident's back to calm him/her down. CNA C told the resident he/she was going to ask the nurse if the resident could have more Zofran. LPN E said he/she was going to check to see if the resident could have more Zofran. At 4:00 A.M. the resident was awake and playing the slot machine game on his/her tablet, which was the resident's normal routine. The aide asked if he/she wanted to get cleaned up and change clothes for the morning, because the resident was too sick to get out of his/her clothes that evening. This had become somewhat of a pattern, as the resident was frequently too exhausted at the end of the day, and only wanted to fall asleep in the recliner without changing into pajamas. The resident did not know if he/she wanted to go to breakfast and said he/she would call when ready to get cleaned up. CNA C asked if the nurse had brought something for him/her, but the resident said he/she had not seen the nurse. CNA C hunted the nurse down and the nurse said he/she gave the resident something an hour ago. Around 5:20 A.M., CNA C noticed the resident had not turned on his/her call light, which was unusual. The resident always wanted to get cleaned up around 5:00 A.M., regardless. CNA C said the resident's condition really got bad after 5:00 A.M., when he/she found the resident leaned over, recliner feet down, bath basin in his/her lap, making a groaning type noise, and appeared to be trying to throw up but nothing was coming up. The resident could barely talk, but said, I don't want to get up. I can't stop throwing up. My stomach hurts so bad. CNA C ran into the hall, the nurse was maybe seven rooms away, and CNA C said, Hey, come here. The nurse said, I'll be there in a minute. CNA C went back into the room, and the resident was drooling. CNA C stayed with the resident. CNA C also rinsed out the resident's emesis basin and gave it back. The aide left the room at 5:45 A.M., walked the whole unit, but could not find the night nurse. The day shift nurse, LPN D, arrived early that morning and was putting his/her stuff up. CNA C told LPN D he/she needed someone to look at the resident. LPN D said, okay, let me put my stuff up, clock in, and find the night nurse. CNA C went back to check on the resident and found the resident with the recliner footrest back up and the basin on his/her stomach. CNA C told the resident LPN D had arrived and was going to check on him/her. At 6:20 A.M., still no LPN E, the night nurse, was seen. CNA C went back to the resident's room, where the resident was still sitting with his/her feet up, the basin on the stomach, and eyes were closed. The resident said no when asked if the nurse had been in. CNA C said he/she would be right back and went to the nursing station to tell the oncoming day shift CNAs the resident was sick and was not going to breakfast. At about 6:30 A.M., both the night nurse and the day nurse were at the nursing station getting report. CNA C said out loud, to both nurses, that the resident did not look good, had been throwing up all night, was sweating, and someone needed to see the resident. LPN D wrote it down and said he/she was going to get a COVID-19 swab and see the resident. CNA C did not think the resident's condition was serious, because the resident said he/she probably ate too much at the family outing and because the resident had been up all-night vomiting before, last summer, when he/she returned from a family graduation party. During an interview on 1/25/24 at 3:35 P.M., LPN E said he/she worked for a nursing agency and did not recall working with the resident before. LPN E worked on the resident's unit from 10:30 P.M. on 12/26/23, to 6:30 A.M., on 12/27/23. He/She received report from the evening shift nurse, LPN A, who said the resident had some emesis, a fever, had been given Zofran, the family had been notified, and the physician had said to monitor the resident. LPN E said he/she saw the resident at the beginning of the night shift, somewhere between 10:30 P.M. and 11:00 P.M., and the resident was fine. The aides saw the residents throughout the night shift. The resident's CNA reported nothing about the resident all that night, until after 6:00 A.M. that morning, when LPN E was on the hall, passing early morning medications. CNA C said the resident had emesis and he/she had cleaned it up. CNA C never said the resident had episodes of emesis throughout the night. LPN E said he/she checked on the resident and saw no emesis, as the aide had cleaned it up. The resident was resting and he/she did not talk to the resident because as an Agency nurse, I don't know their baseline. LPN E said, I know (he/she) was okay and was in no type of distress at all. LPN E said the resident was afebrile (without fever) but could not recall if it was a forehead scanned temperature, or other, because it was so long ago. LPN E said the resident's oxygen saturation was above 93. The day shift nurse, LPN D, was already there, as he/she had arrived early, and LPN E told LPN D about the vomiting. LPN E said there were too many things to be done at that facility, at change of shift, so by the time the oncoming nurse hits the floor, a lot of time has passed. LPN E did not recall if he/she documented anything on the resident. LPN E was at the nursing station all night, until it was time to pass the early morning medications. The facility camera would show he/she did not disappear during the night and that CNA C never reported anything to him/her during the night. LPN E said he/she did not check on the resident during the night because he/she had help. The aides do rounds every two hours and he/she counted on them to tell him/her if anything changed. Review of the resident's Vital Stats, showed no documentation for 12/27/23. Review of the resident's progress notes, showed: -12/27/23 at 11:13 A.M., LPN D spoke with physical therapist at 8:15 A.M. who said the resident did not look well. Resident checked on and observed labored breathing, audible wheezing, diaphoresis (excessive sweating due to an underlying health condition or medication), skin warm to touch, pale complexion, and a small amount of emesis. Oxygen saturation was 81% on room air. Oxygen applied at 4 liters per nasal cannula and oxygen saturation two minutes later was 65%. Call placed to 911, non-breather mask applied and oxygen increased to 6 liters. Resident's daughter called and informed of imminent transport to the emergency room (ER). The fire department arrived to transport the resident to the ER; -12/27/23 at 5:56 P.M., for event date 12/26/23, LPN A noted, on 12/26/23 at approximately 7:30 P.M., the resident arrived to the facility, accompanied by an out of state family member. The family member reported, at approximately 8:00 P.M., that the resident was not feeling well. LPN A assessed the resident, blood pressure was 147/81, pulse 89, respirations 20, and temperature was 98.3. A cough was noted, which was also reported by the family member. The resident had one episode of emesis at approximately 8:05 P.M. and PRN Zofran 4 mg was given. The Zofran was ineffective as the resident had another emesis at approximately 8:15 P.M. and a call was placed to the Nurse Practitioner to report the cough and two episodes of emesis. No new orders were received, and the oncoming nurse was made aware. During an interview on 1/24/24 at 8:13 A.M., Physical Therapy Assistant (PTA) F said he/she entered the resident's room, at about 8:10 A.M. on 12/27/23, to take the resident to therapy. The resident was usually up and in the dining room before 8:00 A.M., but he/she was still in the recliner with a blanket on. PTA F asked if he/she wanted to go to therapy. The resident said no, I don't feel well, but he/she had difficulty speaking and it was hard to understand the words. The resident did not look good and was pale. The PTA went to LPN D and told him/her the resident needed to be looked at. LPN D went to the resident's room right away. During an interview on 1/25/24 at 9:56 A.M., LPN D said he/she worked the 12-hour day shifts and knew the resident very well. The resident always slept in the recliner because he/she could no longer lay flat and breathe well, due to worsening COPD and heart failure. Since the resident's last hospitalization in November 2023, the resident no longer wanted to leave his/her room and would be panting like a marathon runner after just going to the bathroom. There were times he/she did not go to the dining room for breakfast and would be so exhausted by evening, he/she would not change into pajamas. The resident had frequent hospitalization s in 2023. LPN D recalled sending the resident out one time for bad wheezing and another time for respiratory difficulty. The resident was also sick to his/her stomach often and would spit up small amounts into tissues. During change of shift report, on 12/27/23, LPN E reported the resident returned from visiting family, on the evening shift, and was not feeling well. The resident had emesis, but there were no complaints during the night. LPN D did not know if LPN E checked on the resident during the night. PTA F came to LPN D, around 8:15 A.M., and said the resident did not look well. LPN D went to the resident's room, heard the resident's wheezing when he/she entered the room, and tried to wake the resident. LPN D had a hard time getting the resident to come around and did not recall the resident speaking at all. The resident's skin was warm and his/her oxygen saturation was in the 80s. He/She applied supplemental oxygen, via a nasal cannula, and when the resident's oxygen saturation was checked again, it was 65. 911 was called, a re-breather mask was applied, and the oxygen level was increased. LPN D said he/she always gets a resident's vital signs in an emergency, because report must be given to Emergency Medical Service (EMS) upon their arrival. LPN D did not recall what the resident's vital signs were and did not know why he/she did not document them in the resident's chart. LPN D noted some emesis on the resident's shirt, about the size of tennis ball, and the resident's pants were wet. The resident had been incontinent of urine, and it had overflowed the brief, but the resident was a heavy wetter, due to a diuretic. They did not clean the resident before EMS arrived because it was not a priority. LPN D was too concerned with the resident hanging on. Review of the resident's Situation, Background, Assessment, Recommendation (SBAR, a communication tool that helps provide essential, concise information, usually during crucial situations) form, completed by LPN D, dated 12/27/23 at 10:55 A.M., showed: -Situation: Labored breathing, started on 12/27/23, has worsened, has occurred before and was hospitalized ; -Vital Signs: none listed; -Pulse oximetry (finger monitoring device for a quick and non-invasive technique that measures the oxygen saturation in the blood) %: 65 on room air; -Mental Status: Decreased level of consciousness (sleepy, lethargic); -Functional Status: Weakness; -Respirator Evaluation: short of breath (SOB), abnormal lung sounds, labored or rapid breathing; -Cardiovascular Evaluation: ox checked off for: Not clinically applicable to the change in condition being reported; -Abdominal/Gastrointestinal Evaluation: Nausea and/or vomiting; -Appearance: Complexion pale, diaphoretic, labored breathing, nausea and vomiting; -Do not resuscitate (DNR) box was checked. Review of the resident's EMS run sheet, dated 12/27/23, showed EMS was on the scene at 8:39 A.M. for a patient with difficulty breathing and was met by staff in the hall who said the patient began vomiting last night and they were afraid he/she may have aspirated this morning. Staff said the resident was normally oriented times four (aware of self, place, time, and the situation around them). The [AGE] year-old patient was sitting in a chair, with vomit on his/her shirt, and was incontinent of urine. The resident was alert but slow to respond, confused, and oriented times two (aware of self and place). EMS heard audible full lung crackles from across the room. The resident's skin was hot to touch with a racing pulse. The resident was satting at 82% on the facility's non-rebreather mask. EMS switched to their mask, increased the oxygen to 15 liters/minute, and the resident was satting at 89%. Vitals were taken upon move to ambulance. Intravenous fluids were started in the ambulance and the patient was placed on continuous positive airway pressure (CPAP, a non-invasive positive pressure ventilation that helps improve the work of breathing and oxygenation for those with cardiopulmonary complaints related to primary respiratory or cardiovascular complaints), which raised his/her oxygen saturation to 92%. Heart rate was between 120 and 180 and tympanic temperature read 103.4. Code sepsis was called to the hospital while in route because the patient met sepsis criteria. EMS arrived at 9:07 A.M. to the ER. Review of the resident's Hospital Discharge Summary, dated 1/6/24, showed: -12/27/23: The resident came to the ER with shortness of breath and altered mental status. The resident had multiple episodes of vomiting last night and was getting more dyspneic (difficulty breathing) and hypoxic (inadequate oxygen delivery to the tissues either due to low blood supply or low oxygen content in the blood). Per EMS the resident was normally alert and oriented (A and O) times four but was A and O one to two in the ER. Resident was febrile to 103.4 on route to hospital. The resident was intubated (tube inserted through the mouth and into the lungs so the person can be placed on a ventilator to assist with breathing) upon arrival to ED, blood cultures taken for suspected sepsis (from pneumonia or urinary tract infection) and started on intravenous antibiotics. Medications were given for septic shock. The resident's blood pressure began to deteriorate. The resident's code status was DNR, but family wanted the resident treated and intubated in the ER; -12/28/23: Overnight the resident remained on ventilator support, was tachycardic (an abnormally rapid heart rate), hypotensive (abnormally low blood pressure), and required medications for this. The resident remained oliguric (low urine output) with worsening metabolic acidosis (acid build up in the body). Blood cultures showed Haemophilus influenza and infectious disease was consulted. During an interview, on 2/7/24 at 3:17 P.M., the Administrator said staff did not follow the facility's change in condition policy and LPN A, the evening shift nurse, should have documented he/she gave the Zofran, on the resident's MAR. During an interview, on 2/7/24 at 3:17 P.M., the Director of Nursing said she did not expect LPN E, the night shift nurse, to check on the resident during the night because the information LPN E received in report, from LPN A, was that the Zofran given by LPN A had fixed the resident's problem. She also said the nurses chart by exception (a method of medical documentation in which nurses only provide notes if there are deviations from a resident's norm or baseline) but would have liked to have seen a note by LPN E, regarding the resident's emesis status on his/her shift. During an interview on 1/26/24 at 9:56 A.M., the resident's Physician said she heard nothing about what happened to the resident until the next morning, on 12/27/23, and was told they had been checking on the resident through the night. The nurse called the Nurse Practitioner on call, the evening before, and was told the resident was given Zofran. The Physician said when there is a change in condition, and the resident was not at his/her baseline, the licensed nurse should monitor the resident. The resident should have been monitored through the night. The physician said, There were two episodes of vomiting, then (he/she) was resting comfortably, and next (he/she) is unwell in the morning. Did they examine (him/her) again, after the first two episodes of vomiting, did they do a physical examination of the resident, because I would expect that. MO00230537

Based on observations, interviews, facility document review, and facility policy review, the facility failed to maintain 3 of 3 ice and water dispensers in the first, second, and third-floor beverage areas used for residents and staff. This had the potential to affect all 131 residents who resided in the facility at the time of the survey. Findings included: Review of the Nugget Ice Machines Installation, Operation and Maintenance Manual, revised in December 2017, indicated, If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. If required, an extremely dirty ice machine may be taken apart for cleaning and sanitizing. Sanitizing procedure indicated Note: Sanitizing must be performed on adjacent surface areas not contacted by the water distribution system. Step 5 Remove the top cover to the ice chute and pour the sanitizer/water solution into the evaporator. Step 6 Replace the ice chute cover and allow the ice machine to stand for 30 minutes. Review of the facility's undated policy titled, Food and Beverage Standard Operating Procedures, revealed, Equipment is washed, rinsed, and sanitized after each use to ensure the safety of food served to residents. Employee who use equipment will be responsible for washing and sanitizing removable parts after each use. Review of a documented titled Ice Dispenser Cleaning, dated 2023, indicated the last time staff documented the ice dispenser in the first-floor beverage center was cleaned was on 08/08/2023. The document showed the last time staff documented the ice dispenser in the second-floor beverage center was cleaned was on 07/18/2023. The document showed the last time staff documented the ice dispenser in third floor beverage center was cleaned was on 07/20/2023. During a concurrent observation and interview on 09/26/2023 at 10:21 AM, the third-floor beverage area ice and water dispenser spout was observed with pink, brown, and black substances inside the dispenser spout. Lead Dietary Aide (LDA) #6 observed the ice dispenser spout and indicated there were dirty pink, brown, and black substances inside the dispenser spout, and the spout needed cleaned. She indicated the maintenance department was responsible for cleaning the machines. During a concurrent observation and interview on 09/26/2023 at 10:27 AM, the second-floor beverage area ice and water dispenser spout was observed with brown and tan substances inside the dispenser spout. When Food Service Supervisor (FSS) #7 wiped the dispenser spout with a clean paper towel, brown and black substances were observed on the paper towel from the spout. She indicated the dispenser spout needed to be cleaned. During a concurrent observation and interview on 09/26/2023 at 10:31 AM, the first-floor beverage area ice and water dispenser spout was observed with brown and black substances inside the dispenser spout. When FSS #7 wiped the dispenser spout with a clean paper towel, brown, black, and pink substances were observed on the paper towel from the dispenser spout. She indicated the spout needed to be cleaned. She stated she expected the dispenser spouts to be cleaned. She indicated the maintenance department was responsible for cleaning the machines. During an interview on 09/27/2023 at 1:11 PM, Food Service Manager (FSM) #5 stated the kitchen staff, servers, and food service supervisors were responsible for cleaning the grates in the drip tray and the water marks on the stainless steel on the outside of the ice machines but everything else was maintenance's responsibility, including the dispenser spout since it had to be disassembled to be taken out. He stated maintenance was supposed to be cleaning the spout two to three times per month. During an interview on 09/28/2023 at 7:40 AM, the Maintenance Supervisor (MS) stated he cleaned the ice machines every two to three months. He stated he thought dietary cleaned the dispenser spouts. During an interview on 09/28/2023 at 9:41 AM, the MS stated it was a miscommunication between him and the dietary department about who was responsible for cleaning the dispenser spout. He stated he expected the ice and water dispenser spouts to be cleaned and properly maintained. During an interview on 09/28/2023 at 10:03 AM, the Director of Nursing stated she never observed the dispenser spouts. She stated the MS, or the maintenance technician were responsible for cleaning the dispenser spouts. She stated she did not know how often they were required to be cleaned. She stated she expected the ice and machine dispenser spouts to be cleaned and maintained. During an interview on 09/28/2023 at 10:36 AM, the Administrator stated maintenance was responsible for cleaning the dispenser spouts. She stated the dispenser spouts should be checked on a weekly basis by maintenance, but the MS cleaned the dispenser spouts every two to three months. She stated she expected to maintain clean food and beverage equipment.

Based on interviews, record review, and facility policy review, the facility failed to develop comprehensive care plans that addressed resident care needs for 2 (Resident #97 and Resident #229) of 27 sampled residents. Specifically, Resident #97 did not have a care plan to address their diagnosis of diabetes mellitus and use of insulin and Resident #229 did not have a care plan to address the use of an indwelling urinary catheter. Findings included: Review of facility policy titled, Comprehensive Care Plan, dated August of 2019, revealed, The policy of this facility is that each resident will have a person-centered comprehensive care plan developed and implemented to meet their preferences and goals and to address the resident's medical, physical, mental, and psychosocial needs. 1. A review of Resident #97's Profile Face Sheet indicated the facility admitted Resident #97 on 01/28/2022 with a diagnosis that include type 2 diabetes mellitus. A review of Resident #97's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/04/2023, revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #97 had an active diagnosis of diabetes mellitus and received insulin injections daily during the 7-day review period. Review of Resident #97's care plan revealed no evidence of a care plan that addressed the resident's diagnosis of diabetes mellitus or use of insulin. During an interview with Licensed Practical Nurse (LPN) #28 on 09/27/2023 at 11:02 AM, she stated she expected a resident with a diagnosis of diabetes and who required insulin to have those concerns addressed in a care plan. During an interview with Social Worker #36 on 09/27/2023 at 1:49 PM, she stated the MDS Coordinators initiated the care plans for diagnoses, behaviors, and/or medications. During an interview with MDS Coordinator #37 on 09/28/2023 at 11:38 AM, she stated a resident who was diabetic and used insulin should have a care plan that addressed those issues. She went on to say the MDS Coordinators initiated all the care plans. During an interview with MDS Coordinator #38 on 09/28/2023 at 12:05 PM, she stated Resident #97 should have a care plan for their diagnosis of diabetes and their insulin use. She said those items were missed, and a care plan was not done. During an interview with the Director of Nursing on 09/28/2023 at 12:11 PM, she stated Resident #97 should have a care plan for their diagnosis of diabetes and their insulin use. During an interview with the Administrator on 09/28/2023 at 1:07 PM, she said Resident #97 should have a care plan for their diagnosis of diabetes and their insulin use. 40141 2. A review of Resident #229's Profile Face Sheet indicated the facility admitted the resident on 12/30/2021 with diagnoses that included nondisplaced hemiplegia (paralysis on one side of the body) following cerebral infarction (stroke), fracture of left femur, left artificial hip joint, and retention of urine. A review of Resident #229's physician's orders revealed an order dated 12/30/2021 to place an indwelling catheter one time for urinary retention, with a stop date of 01/01/2022. A review of Resident #229's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/06/2022, revealed Resident #229 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required extensive assistance with toilet use, had an indwelling urinary catheter, and was continent of bowel. Review of Resident #229's Interim Care Plan, with a start date of 12/30/2021, revealed the resident was incontinent of bowel and bladder. The care plan did not address the use of an indwelling urinary catheter for resident. A review of Resident #229's NP [Nurse Practitioner] Follow Up Visit document, dated 01/19/2022, indicated the resident's indwelling urinary catheter was discussed with facility staff and a physician approved to leave the resident's catheter in for the discharge home. During an interview on 09/27/2023 at 3:58 PM, Licensed Practical Nurse (LPN) #19 stated Resident #229 had an indwelling urinary catheter while the resident resided in the facility. During an interview on 09/28/2023 at 10:04 AM, LPN #25 said the nurses had access to care plans. LPN #25 stated the nurses could add or remove problems or care areas and interventions. LPN #25 said the nurses would be responsible for adding an indwelling urinary catheter to the care plan and if the nurses did not add it then the MDS Coordinator could add it to the resident's care plan. During an interview on 09/28/2023 at 10:45 AM, LPN #8 stated the nurses and the MDS Coordinators had the ability to update the care plans. LPN #8 said if an indwelling urinary catheter was placed while the resident was in the facility and it the indwelling urinary catheter had to remain in place, then she would expect the indwelling urinary catheter to be added to the care plan. During an interview on 09/28/2023 at 10:52 AM, the Director of Nursing (DON) stated the indwelling urinary catheter should have been addressed in Resident #229's care plan. The DON stated she expected care plans to be updated with any changes. She said the resident's indwelling urinary catheter should have been added to the care plan when the physician's order was obtained. During an interview on 09/28/2023 at 11:19 AM, the Administrator stated she expected an indwelling urinary catheter to be addressed in a resident's care plan.

Based on interview, record review, and facility policy review, the facility failed to ensure medications were reconciled to ensure a safe discharge for 1 (Resident #229) of 3 sampled residents reviewed for discharge requirements. Findings included: Review of a facility policy titled, Discharge Summary, dated August 2019, indicated Objective of the Discharge Summary policy To ensure the facility communicates necessary information to the resident, continuing care provider and other authorized persons at the time of an anticipated discharge. The policy specified, When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). A review of Resident #229's Profile Face Sheet indicated the facility admitted the resident on 12/30/2021 with diagnoses that included nondisplaced hemiplegia (paralysis on one side of the body) following cerebral infarction (stroke), fracture of left femur, left artificial hip joint, and retention of urine. Per the Profile Face Sheet, the resident discharged home with home health on 01/20/2022. A review of Resident #229's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/06/2022, revealed Resident #229 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated there was an active discharge plan already occurring for the resident to return to the community. A review of Resident #229's Interim Care Plan, with a start date of 12/30/2021, that specified the resident had a current discharge plan to return home with family. A review of Resident #229's physician's orders revealed an order, dated 12/30/2021, for Lovenox (a blood thinner) 40 milligrams (mg) per 0.4 milliliter (ml) subcutaneous (just below the skin) every morning for anticoagulant, with the last dose to be administered on 01/16/2022 and a stop date of 01/18/2022. The physician's orders showed another order, dated 01/19/2022, to discharge home with medications on 01/20/2022. A review of a nursing Interdisciplinary Notes, dated 01/18/2022 and signed by Licensed Practical Nurse (LPN) #19, revealed the physician was present to assess the resident and gave a new order to discontinue the resident's use of Lovenox. A review of Resident #229's Nursing Facility Discharge Instructions, dated 01/20/2022, revealed a discharge medication list for the resident that did not include Lovenox. A review of a nursing Interdisciplinary Notes, dated 01/20/2022 and electronically signed by LPN #21, revealed Resident #229 had discharged home, and the family called with some questions and wanted to go over the medication list. LPN #21 indicated she reviewed the medication list with the family. During an interview on 09/27/2023 at 3:58 PM, LPN #19 indicated if a medication was discontinued then it should be discontinued out of the computer, pulled from the medication cart, and placed in the medication room to be returned to the pharmacy. LPN #19 stated the Lovenox for Resident #229 must not have been pulled from of the medication cart. During an interview on 09/27/2023 at 4:07 PM, LPN #21 indicated she discharged Resident #229 from the facility. LPN #21 indicated the medications would have been given to the resident and the driver who had driven the resident home. LPN #21 stated Resident #229's family had called after the discharge and LPN realized she sent the Lovenox instead of another medication. LPN #21 indicated she explained to the family the Lovenox had been discontinued and to not administer it to the resident. LPN #21 indicated when a medication was discontinued it was to be pulled off the medication cart, placed into a bin in the medication room, and would be picked up by the pharmacy. LPN #21 stated the Lovenox had not been pulled from the medication cart. LPN #21 stated medications were reconciled at the time of discharge by pulling the medications from the medication cart, then counting the medication and comparing the medications to the discharge physician orders. She said the resident then signed a sheet and then the medications and the sheet went with the resident. During an interview on 09/28/2023 at 10:30 AM, the Previous Administrator, who was the Administrator at the time of the incident, indicated the discharge process started upon admission. The Previous Administrator indicated the Lovenox should not have been sent home with Resident #229, and the medications on the medication list were the only ones that should have been sent home with the resident. During an interview on 09/28/2023 at 10:52 AM, the Director of Nursing (DON) indicated if the resident had a physician order for a medication, then it could be sent home and if a medication had been discontinued then the medication should have been pulled from being sent home with the resident. The DON indicated Resident #229's Lovenox should not have been sent home with the resident. The DON indicated the nurse did not reconcile the medications. The DON indicated she expected for the nurse to reconcile medications upon a resident's discharge from the facility. During an interview on 09/28/2023 at 11:19 AM, the Administrator indicated she expected the nurses to reconcile the medications to ensure the ordered medications were sent home with the resident.

Based on observations, interviews, record review, and facility policy review, the facility failed to provide services to residents who were unable to carry out activities of daily living (ADLs) necessary to maintain good grooming and personal hygiene for 1 (Resident #35) of 2 sampled residents reviewed for assistance with ADL care. Specifically, Resident #35 had fingernails that were long and dirty, and the resident did not receive showers according to their plan of care. Findings included: Review of a facility policy titled, Nail Care, dated August 2019, revealed Purpose - To promote cleanliness, safety and a neat appearance. - To observe skin condition on fingers and toes. Review of a facility policy titled, AM [morning] Care, dated August 2019, revealed It is the policy of this facility to provide the necessary morning care and services based upon the comprehensive assessment of a resident and consistent with the resident's needs and choices, or order to maintain or improve resident's ability to carry out the activities of daily living. The policy indicated, Purpose - To prepare the resident for their day-- To maintain oral health and bodily hygiene - To provide for physical comfort - To maintain the resident's desired physical appearance - To observe the resident's physical and emotional state. The policy indicated Procedure 1. Review resident specific plan of care interventions, assistance, devices, supplies and instructions, and 4. Follow resident preferences as stated in the care plan. A review of Resident #35's Profile Face Sheet revealed the facility admitted Resident #35 on 06/13/2023 with diagnoses that included cerebrovascular disease, polyosteoarthritis, and hypertension. Review of Resident #35's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/20/2023, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive staff assistance with dressing, personal hygiene, and bathing. Review of Resident #35's care plan with a start date of 06/24/2023, indicated the resident had a self-care deficit for ADL performance. Interventions specified the resident would receive showers two times per week as tolerated and fingernail and toenail care as needed. Review of records titled Comprehensive CNA [Certified Nursing Assistant] Shower Review for the month of September 2023, revealed staff documented Resident #35 received a shower 09/12/2023 and 09/26/2023. The 09/26/2023 entry indicated staff clipped the resident's nails on their right hand and filed the nails on the resident's left hand. The record showed staff documented Resident #35 refused a shower on 09/19/2023. During a concurrent observation and interview on 09/25/2023 at 10:29 AM, Resident #35 was observed lying bed and the resident's fingernails on their righthand were about 1/4 inch to 1/2 inch in length and extended over the tip of the resident's fingers, with a brown and black dirty substance underneath the resident's nails. The resident stated no one cleaned their fingernails. Resident #35 stated, getting a shower was hit or miss and their last shower was on 09/21/2023. During a concurrent observation and interview on 09/26/2023 at 9:33 AM, Resident #35 was observed lying bed and the resident's fingernails on their righthand were about 1/4 inch to 1/2 inch in length and extended over the tip of the resident's fingers, with a brown and tan substance underneath the resident's nails. Licensed Practical Nurse (LPN) #21 observed Resident #35's fingernails and stated that when a resident was not diabetic, the CNAs should cut the resident's fingernails on the resident's shower days. She indicated the resident's nails were long and dirty. She stated Resident #35 was going to get a shower today and she would make sure their nails got cut and cleaned. During an interview on 09/28/2023 at 10:13 AM, the Director of Nursing stated CNAs were responsible for cleaning and trimming the nails on the residents' shower days. She stated Resident #35 was supposed to receive showers two times per week. She stated there were assignment sheets at each nurse's station, and the nurses should ensure showers were completed. She stated nail care should be provided with showers and as needed. She stated she expected a resident's nails to be trimmed and cleaned and showers to be provided according to the care plan and when a resident desired. During an interview on 09/28/2023 at 10:32 AM, the Administrator stated showers should be given two times a week, unless the resident refused. She stated she did not know why Resident #35's showers were not given. She stated CNAs should provide showers according to the resident's care plan and document any refusals. She stated LPN #27 was responsible for monitoring that showers were completed. She stated nailcare should be provided as needed, and CNAs and nurses should check a resident's nails daily. She stated she expected residents to receive showers timely and nails to be cleaned and trimmed. During an interview on 09/28/2023 at 11:23 AM, LPN #27 indicated she monitored shower sheets to ensure residents received showers. She stated recently residents had not been getting showers as they should, so she completed a staff training approximately two weeks ago about providing showers timely. She stated showers should be provided according to the resident's care plan, at least two times a week, and nail care should be provided as needed and on shower days.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure hand hygiene was performed during wound care for 1 (Resident #52) of 2 sampled residents reviewed for pressure ulcers/injuries. Findings included: Review of a facility policy titled, Hand Hygiene Policy, dated August 2022, indicated, Perform hand hygiene in the following situations. a. When coming on duty and going off duty. b. Before and after touching a resident or their environment. c. Before putting on gloves. d. After removing gloves. e. After removing personal protective equipment (PPE) f. When moving from a contaminated body site to a clean body site during resident care. Review of a Profile Face Sheet indicated the facility admitted Resident #52 on 03/17/2022 with diagnoses that included congestive heart failure, chronic kidney disease, and Alzheimer's disease. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/30/2023, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. According to the MDS, Resident #5 had one unhealed Stage 2 pressure ulcer. Review of Resident #52's care plan with a start date of 03/17/2022, revealed the resident's bilateral heels were soft and boggy, but closed. Interventions directed staff to provide treatments to the areas as ordered and apply pressure reducing boots when the resident was in their wheelchair. Review of Resident #52's active physician's orders revealed an order dated 03/31/2023 that directed staff to apply a protective barrier spray to the right heel twice a day and an order dated 07/19/2023 that directed staff to apply a protective barrier spray to the resident's left heel twice a day. An observation of Resident #52's wound care was made on 09/27/2023 beginning at 9:49 AM. Licensed Practical Nurse (LPN) #19 applied gloves, removed the non-skid sock from the resident's left foot, cleansed the resident's left heel with moistened gauze, and dried the heel with a dry gauze. While wearing the same gloves, LPN #19 obtained the bottle of protective barrier spray and sprayed the resident's left heel. LPN #19 then removed the non-skid sock from the resident's right foot, cleansed the right heel with a moistened gauze, and dried the resident's heel with a dry gauze. While wearing the same gloves, LPN #19 obtained the bottle of protective barrier spray and sprayed the resident's right heel. LPN #19 reapplied the resident's left non-skid sock then the right non-skid sock and applied the bilateral pressure reducing boots. At the conclusion of the wound treatment, LPN #19 removed her gloves and performed hand hygiene. During an interview on 09/27/2023 at 11:34 AM, LPN #19 stated the facility's process for hand hygiene and glove use during wound treatment was to wash hands, apply gloves, change gloves in between wounds if there was more than one wound, and when finished with wound care, remove gloves and use hand sanitizer. LPN #19 said she did not change gloves when moving from the left to right heel or after cleansing the wounds. She acknowledged touching the bottle of Skin Prep spray while wearing the same gloves worn for wound cleansing. During an interview on 09/27/2023 at 2:33 PM, the Infection Preventionist (IP) was informed of the wound care observation and that only one pair of gloves was used, and the IP indicated that was not appropriate. The IP stated she would expect staff to perform hand hygiene, apply gloves, remove both socks, clean the left and right heels, then perform hand hygiene and apply new gloves before handling the protective barrier spay bottle. During an interview on 09/27/2023 at 4:37 PM, the Director of Nursing (DON) said gloves should have been changed between treatments for the left heel and right heel. The DON stated she expected staff to change gloves between clean and dirty tasks during wound care. The DON stated the wound care observation indicated there was an infection control issue. During an interview on 09/28/2023 at 11:29 AM, the Administrator indicated she expected staff to sanitize or wash hands between dirty and clean tasks when providing wound care.

Based on interviews, record review, and facility policy review, the facility failed to ensure pain medication was timely administered for 1 Resident #32) of 1 sampled resident reviewed for pain management. Findings included: The facility's policy titled, Pain Management, dated August of 2019, revealed, It is the policy of the facility that all residents will be assessed for presence, absence or history of pain on admission, quarterly, with a significant change in status and with the new onset of pain or discomfort, in order to plan a plan a pain management program for an acceptable level of resident comfort whenever possible. Review of Resident #32's Profile Face Sheet indicated the facility most recently readmitted the resident on 01/22/2021 with diagnoses that included osteoarthritis, unspecified fractures of the thoracic vertebrae, and chronic pain. Review of Resident #32's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/17/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident received as needed (PRN) pain medication. Review of Resident #32's care plan with a start date of 03/02/2021, revealed the resident had an alteration in comfort/pain related to osteoporosis and spinal stenosis. Interventions directed staff to administer pain medications as scheduled and upon request. Review of Resident #31's physician's orders revealed an order dated 02/14/2023, that directed staff to administer tramadol (a narcotic pain medication) 50 milligrams (mg), every eight hours as needed for pain and an order dated 09/12/2023, that directed staff to administer Tylenol Extra Strength 1,000 mg, twice daily for pain. On 09/25/2023 at 3:08 PM, Resident #32 was interviewed while lying in bed in their room. The resident said they had been waiting for pain medication to be provided by staff for about twenty minutes. At 3:22 PM, the resident activated their call light again to request pain medication. At 3:23 PM, Licensed Practical Nurse (LPN) #11 answered the call light and asked the resident to describe their pain. The resident rated the pain an 8 on a scale of 0 to 10, with 10 being the worst pain possible, and requested pain medication. LPN #11 left the room, returned within five minutes, and stated she had checked the physician's orders. LPN #11 told the resident that their scheduled Tylenol was not due for administration but indicated that the resident had an order for PRN tramadol. She told the resident that Certified Medication Technician (CMT) #13 had the keys to the medication cart and was on break and she could not locate the CMT so she could not obtain the pain medication. LPN #11 did not offer any non-pharmacological pain management interventions to the resident. During an interview on 09/25/2023 at 5:18 PM, Resident #32 said they received the tramadol about five minutes ago. This was approximately two hours after the resident had initially requested pain medication from LPN #11 in the presence of the surveyor. On 09/26/2023 at 11:24 AM, LPN #14 said if a resident complained of pain, the nurse assessed the pain and checked to see if there were PRN pain medications ordered. She said if the CMT was available, the CMT would administer the PRN pain medication. She said the nurse could also give the medication but would need to get the keys for the medication cart from the CMT. On 09/26/2023 at 4:39 PM, an interview was conducted with CMT #13. CMT #13 said that on 09/25/2023 she came back from break around 3:00 PM. CMT #13 said the resident told LPN #11 they were in pain and the nurse told her the resident needed a pain pill around 3:00 PM. She said she went to ask the resident if they wanted tramadol. She said during her break she did not take the keys to the medication cart with her, she put them inside a narcotic count book and placed the book in the medication room. She said she told LPN #11 where the keys were before she went on break and said LPN #11 was doing something at that time but said, okay. CMT #13 said no one contacted her while she was on break on 09/25/2023. On 09/27/2023 at 9:31 AM, the Director of Nursing (DON) said CMTs should give the keys to the medication cart to the charge nurse before they go on break. She said if they stayed in the building and needed to be contacted, CMTs could be called on their cell phone. She said if the CMT left the building, they should give the keys to the charge nurse. She said the nurse could call the CMT during their break and they could come back from break to give the medication if needed. The DON said if pain medication was needed and the CMT could not be found, the LPN could call the supervisor and get the backup keys that could be used for accessing the medication cart. The DON said if a resident told staff they were in pain, the nurse and CMT should assess the resident, check the electron Medication Administration Record, and administer ordered and available pain medication. She said her general expectation for response time would be within 15 to 30 minutes of a resident's request for pain medication, depending on what the CMT or nurse was doing. On 09/27/2023 at 10:09 AM, the Administrator said resident complaints of pain should be reported to a nurse, and the nurse should assess the resident and give prescribed pain medication. She said the nurse as well as the CMT should have access to the medication cart. She said the CMT should give keys to the medication cart to the charge nurse when they took a break.

Based on interviews, record review, and facility document and policy review, the facility failed to investigate and determine causative factors of falls to help prevent and/or reduce the risk of further falls for 2 (Residents #429 and Resident #100) of 6 sampled residents reviewed for accidents. Findings included: A review of the facility's policy titled, Strategies for Managing Falls, dated August 2019, revealed, It is the policy of this facility to evaluate each resident immediately after a fall. Further review of the policy indicated, 7. Notify the interdisciplinary team and perform team huddle to investigate and discuss fall and possible causes. 1. Review of Resident #429's Profile Face Sheet revealed the facility most recently readmitted the resident on 03/19/2023 with diagnoses that included dementia without behavioral disturbance, Alzheimer's disease, anxiety disorder, and major depressive disorder. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/25/2023, revealed Resident #429 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #429 required extensive assistance with bed mobility, transfers, and toilet use. According to the MDS, the resident was not steady and was only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, moving on and off a toilet, and during surface-to-surface transfers. Review of Resident #429's care plan with a start date of 04/24/2023, indicated the resident was at risk for falls related to dementia, a recent fall with fracture, anxiety, and narcotic pain medication. Interventions directed staff to keep the call light, fluids, and personal items within reach; keep the resident's room well-lit and clutter free; provide assistance of two staff during transfers with a mechanical lift; answer the resident's call light quickly; and keep the resident involved in activities and socialization. Review of an incident report for Resident #429 dated 04/28/2023 at 2:00 PM, revealed Certified Occupational Therapy Assistant (COTA) #42 was in Resident #429's room to assist the resident with therapy. Per the incident report, Licensed Practical Nurse (LPN) #21, who was present in the resident's room caring for Resident #429's roommate, heard COTA #42 say, Oh, no. The incident report revealed LPN #21 observed COTA #42 lower the resident to the floor. The incident report indicated Resident #429 stated, I was sliding out of my chair. Review of the incident report revealed no evidence of causal factors for the fall were identified. Review of an incident report for Resident #429 dated 06/09/2023 at 10:00 AM, revealed Certified Nursing Assistant (CNA) #39 lowered the resident to the floor by the weight scale. The incident report indicated the resident stated, I slid down. Review of the incident report revealed no evidence of causal factors related to the fall were identified. Review of Resident #429's nursing progress note, dated 06/09/2023 at 9:28 PM, revealed the resident had a fall earlier in the day and was now complained of pain with movement. Per the progress note, a nurse assessed the resident and noted the resident's right knee was swollen, the resident's hip was rotated outward. The progress note indicated the physician was notified and directed the staff to obtain an x-ray. Review of Resident #429's nursing progress note, dated 06/10/2023 at 6:44 AM, revealed the resident's x-ray results revealed the resident had sustained an acute displaced fracture of the right femoral diaphysis (thigh bone). During an interview on 09/27/2023 at 8:20 AM, LPN #27 stated she was the 1st floor nursing manager. She stated the facility just started to conduct root cause analysis to determine causal factors for residents' falls in the last few weeks. She said falls were discussed during the interdisciplinary team (IDT) meetings, but staff did not complete the falls checklist that helped identify the root cause. LPN #27 stated the plan going forward was that the nurse with knowledge of the incident would be responsible for identifying the root cause and then the IDT will meet to review the fall. During an interview on 09/28/2023 at 1:12 PM, the Director of Nursing (DON) said that after a fall occurred an incident report that described what staff saw and what the resident stated happened was completed along with a fall checklist, and the physician and family were notified. The DON said the day after a resident fell the IDT met to determine what fall prevention interventions should be implemented and the care plan was updated during that meeting. She said the completion of the fall checklist assisted staff in determining the root cause and a checklist was to be completed after every fall. She said she just realized on 09/21/2023 that the fall checklist was not being completed after each resident fall. She said that after Resident #429's fall on 04/28/2023, staff should have attempted to figure out what led the resident to slip out of their wheelchair. During an interview on 09/28/2023 at 1:26 PM, the Administrator stated it was the facility's goal for staff to investigate falls and identify the root cause along with appropriate interventions to prevent further falls. 46258 2. A review of Resident #100's Profile Face Sheet revealed the facility admitted the resident on 02/16/2022 with diagnoses that included mild cognitive impairment and arthritis. A review of a significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/19/2023, revealed Resident #100 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #100 required extensive assistance with bed mobility, transfers, locomotion on and off the unit, and toilet use. The MDS indicated Resident #100 used a wheelchair for mobility. According to the MDS, Resident #100 was not steady and was only able to stabilize with staff assistance when moving from seated to standing position, moving on and off a toilet, and during surface-to-surface transfers. A review of Resident #100's care plan with a start date of 08/04/2023, indicated Resident #100 was at risk for falls related to poor safety awareness and decision-making abilities, forgetting to wear their shoes, and forgetting to use their walker at times. A review of an incident report for Resident #100 dated 07/30/2023, revealed the resident was found in the dining room, lying on their left side with their back against the wall. The incident report indicated the resident had a hematoma to their left forehead. Per the incident report, Resident #100 was not able to state what happened, but stated they were walking without their walker, and complained of pain in their buttocks area. The section of the incident report titled, Contributing/Environment factors, was not completed. A review of Resident #100's Interdisciplinary Notes, dated 07/30/2023, revealed Resident #100 was sent to the emergency room (ER) after the fall and hospitalized . The Interdisciplinary Notes dated 08/08/2023, indicated the resident returned to the facility from the hospital where they were admitted for a subdural hematoma and a left sided pubic ramus fracture from a fall (on 07/30/2023). During an interview with Licensed Practical Nurse (LPN) #33 on 09/28/2023 at 8:26 AM, she stated that on 07/30/2023 she heard a noise coming from the dining room. She stated Resident #100's walker was observed about five feet away from where Resident #100 was found lying on the floor. LPN #33 said she assessed Resident #100, and it was determined emergency services needed to be called. Upon review of the incident report with LPN #33, she stated she did not know why the contributing/environmental factors section of the incident report was not completed. LPN #33 stated she remembered very little about the fall. During an interview with the Director of Nursing (DON) on 09/28/2023 at 12:11 PM, she stated a fall checklist should have been completed after the fall and this would have provided more information. The DON stated Resident #100 had a very short attention span and probably got up and left the group as they often did. The DON agreed the investigation of the fall was not complete.

Based on observation, interview and record review, the facility failed to follow the facility's policy for wound management and ensure one resident who admitted to the facility with intact skin did not develop a significant pressure ulcer (injury to the skin and underlying tissue, primarily caused by prolonged pressure on the skin). The facility failed to ensure the pressure ulcer was monitored with weekly assessment and wound tracking. The resident's wound worsened and the facility failed to ensure successful notification the primary physician timely. (Resident #1). The sample was 3. The census was 127. Review of the undated pressure ulcer prevention and management policy, showed: -Program objectives: -The health center will implement the pressure ulcer prevention and management program which includes the required key components; -The health center will implement quality assessment and assurance activities to monitor effectiveness of the program; -The health center will have ongoing training for staff on pressure ulcer prevention; -The health center must implement each key component outlined in the document; -Skin management and wound prevention program required components: -Each resident's skin is assessed upon admission and is documented in the clinical record; -A standardized assessment for skin risk: Braden (used to early identification of patients at risk for forming pressure sores) scale is completed upon admission; -All risk factors are care planned with at least one intervention per risk factor; -Positioning/pressure reduction devices are in place for resident's with actual or high risk skin breakdown; -Weekly skin assessments are completed and documented by licensed staff; -An audit process is assigned and in place to ensure completion of weekly skin assessments; -Certified nurse aides (CNAs) are required to document resident skin appearance at the time of the resident's scheduled bath or shower; -An audit process is in place to ensure completion of the skin assessments at the time of the resident's bath/shower; -Employee counseling for CNAs is completed for non-compliance of skin assessments; -Weekly wound rounds are conducted that include stage, description, measurement, progress and treatments; -A weekly wound report is completed and turned into the Administrator; -The physician is notified for any new wound or worsening wound and this is documented in the clinical record; -The resident's family is notified of any new wound or worsening wound and this is documented in the clinical record; -All new facility acquired pressure areas will be investigated and include both the clinical/medical component and facility process; -Communication is in place to notify dietician of wound development or wound healing concerns; -There is a dietary review within one week of any new wound or worsening of the wound; -Documentation of dietary review of residents with wound and impact of nutrition related to the wound; -At time of admission: -All residents will be assessed for pressure ulcer risk at the time of admission using a standardized scale in the electronic medical record (EMR): -All risk factors are identified; -Ongoing assessment and monitoring of effectiveness: -A skin risk assessment tool will be completed on admission, quarterly and at the time of a significant change; -A communication system to inform direct caregivers of the care plan interventions and risk is communicated through the use of care cards on each resident and during shift report; -The physician will be notified of any tissue intolerance of skin conditions requiring interventions; -A skin check will be completed weekly by a nurse and kept as part of the clinical record; -A skin check will be completed daily with all personal care and documented with the shower or bath. The CNA must document in the electronic system in the body check section after a bath/shower has been given; -For an actual pressure ulcer: -Pressure ulcers are assessed to location, stage, size, shape, depth, size and depth of tracking, the surrounding tissue and any drainage, wound bed, wound edges and any related pain. The pressure ulcer healing sheet will be initiated by the nurse supervisor or nursing management; -The initial status is documented in the medical record and a narrative note or form is acceptable; -The resident and the responsible party is notified and documented in the clinical record; -The registered dietician will assess for nutritional interventions and develop a plan as indicated; -The physician is notified and treatment is initiated as ordered; -Update 24 hour report and share new wound development information and positioning plan and/or other interventions during shift report. The care plan updated or revised; -With one week and then weekly, the interdisciplinary (IDT) risk team reviews all new pressure ulcers and care plans. Representatives ensure all risk factors are documented in medical record and care planned. The new wound is added to the wound report worksheet log (not part of the medical record); -A documented investigation of all facility acquired pressure wounds will be conducted; -Daily monitoring is to be in place to assess the effectiveness of the plan of care and to ensure the care plan is followed; -Weekly progress will be documented by the nurse to assess location, stage, size, shape, depth size, and depth of tracking, the surrounding tissue, any drainage, wound bed, wound edges and any related pain; -One nurse should perform all pressure ulcer assessments for all residents when possible; -If progress is not noted in three weeks or deterioration is present, the physician is notified for treatment order review; -For Stage III (full-thickness skin loss potentially extending into the subcutaneous tissue layer) or Stage IV (exposing underlying muscle, tendon, cartilage or bone) pressure ulcers, consider referral to a wound specialist; -Quality Assurance: -All new pressure ulcers are added to a wound report worksheet log; -The IDT risk team representative reviews all new pressure ulcers and monitors progress weekly; -Complex care report is printed monthly and prevalence of Stage I - IV pressure ulcers, high and low risk is reviewed and pressure ulcers are investigated. The investigation includes evaluation of standards and implementation of the care plan; -Pressure ulcer trends are shared with staff through routine meetings and inservices and the communication boards. Review of Resident #1's interdisciplinary notes, showed: -On 4/22/22 at 10:55 A.M., an admission note: the resident arrived with family to the facility. The resident is alert and oriented (A&O) x 4 (to self, place, time and event). He/she is pleasant and cooperative with the staff. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Call placed to the physician to verify admission and orders; -On 4/22/22 at 11:58 A.M., the physician verified admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the admission physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An order: Braden scale every week for 3 weeks; -An order: Weekly skin check; -An order: Keep right knee immobilizer in place until seen by orthopedist, may remove for hygiene. Review of the interim care plan, dated 4/22/22, showed: -Problem: Potential for skin breakdown related to immobility; -Goal: His/her skin will remain intact or improve if there are noted areas of concern within 30 days; -Approach: Address areas of concern in the skin assessment and treatment charting. Preventive measures for maintaining skin integrity are turn and reposition per facility policy, incontinent care as needed and barrier cream. Review of the admission skin evaluation form, dated 4/22/22 at 5:43 P.M., showed: -Site: right knee; -Type: surgical; -Treatment: leave dressing intact until orthopedics follow up appointment on 5/3/22; -Care planned: blank; -Turning and repositioning program: inapplicable; -Surgical wound care: inapplicable; -Surgical wound: inapplicable; -Type of pressure reducing mattress: blank. Review of the admission Braden scale, dated 4/22/22, showed a score of 15, no/low risk to develop pressure ulcer/injury. Review of the facility wound report, dated 4/23/22, showed: -admitted with wound to the right knee; -Wound type: incision; -Last measurements: blank; -Current measurements: 15 centimeters (cm) x 5 cm and 13 sutures; -Treatment: blank; -Interventions: blank; -Odor yes/no (Y/N): blank; -Drainage yes/no (Y/N): blank; -Date healed: blank Further review of the interdisciplinary notes, dated 4/23/22 at 12:13 P.M., showed the resident seen for skilled services related to a total right knee replacement. He/she is A & O x 4 and refused all care except incontinence care during the shift. He/she refuses to get up from the chair. Vital signs are stable. Knee immobilizer noted in place per order and removed for hygiene. Review of the physician history and physical, dated 4/27/22, showed: -History of present illness: total knee replacement, high blood pressure and dementia; -Neurological: right knee replacement; -Mental status: A & O to person. Review of the skin evaluation form, dated 4/27/22 at 11:27 P.M., showed: -General skin check completed: no new issues; -Site: blank; -Type: blank; -Treatment: blank; -Care planned: blank; -Length: blank; -Width: blank; -Depth: blank; -Pain level: blank; -Drain type: blank; -Color: inapplicable; -Odor: inapplicable; -Amount: inapplicable -Turning and repositioning program: inapplicable; -Surgical wound care: inapplicable; -Surgical wound: inapplicable; -Type of pressure reducing mattress: blank. Further review of the interdisciplinary notes, showed: -On 4/28/22 at 1:04 A.M., the resident continued to receive skilled nursing services related to total right knee replacement. Immobilizer in place and the resident continued to refuse to allow staff to assess the incision site. Pain medication provided related to right knee pain. The resident is A & O x 4 and able to make needs known; -On 4/28/22 at 2:26 P.M., the night shift nurse reported to current day shift nurse the complained of his/her bottom hurting. Further review of the medical record, showed no skin evaluations after the reported buttock pain on 4/28/22. Further review of the medical record, showed no shower or bath sheets from 4/22/22 through the resident's discharge on 5/10/22. Further review of the interdisciplinary notes, dated 4/29/22 at 11:19 A.M., showed the resident at times is A & O x 1 and writer attempted to re-orient the resident and the resident became angry. Incontinence care provided and an area of denuded (loss of the epidermis (second layer of skin), caused by exposure to urine, feces, body fluids, wound drainage or friction) skin noted to the right buttock. Barrier ointment applied. No family notification of the skin changes. Further review of the medical record, showed no skin evaluation form following observation of the denuded skin on 4/29/22. No documentation of physician notification of the change in skin condition. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 4/29/22, showed: -admitted [DATE]; -Moderate cognitive impairment; -Refused care 1-3 days; -Required extensive assistance of two for bed mobility, transfers, dressing and toilet use; -Frequently incontinent of bowel and bladder; -Frequent presence of pain which made it hard to sleep at night and limited day to day activities; -Pain intensity rated as an 8 on a scale of 1 to 10; -No pressure ulcers on admission; -Surgical wound care; -At risk for pressure ulcers; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment administration record (TAR), dated 4/2022, showed: -An order dated 4/30/22 for a Braden scale every week for 3 weeks and scheduled for the day shift on 4/30/22. Noted as blank on 4/30/22. Review of the facility's wound report, dated 5/2/22, showed the resident was not listed on the report. Further review of the interdisciplinary notes, showed: -On 5/2/22 at 5:47 P.M., the resident noted to be drowsy and some medications held. The resident treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical therapy noted the resident had left sided weakness. Vital signs stable. The resident noted A & O x 1-2 and dozes off mid-sentence at times; -On 5/3/22 at 11:23 A.M., the writer notified in report the resident had open areas to the buttocks. The writer and nurse supervisor assessed the areas. Noted 4 [MEDICATION(S)] AG (primary dressing indicated for moderate to highly exuding (draining) chronic and acute wounds where there is infection or an increased risk of infection) in place to the buttocks. The dressings removed and large open area noted. Wounds Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister)/III, scant (small amount) serosanguineous (thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells) drainage noted to bilateral (both) buttocks. The wounds cleansed. The left buttock measured 10.5 centimeters (cm) x 1.0 cm. The right buttock measured 9 cm x 6.0 cm. Barrier ointment applied with abdominal dressing to cover. The staff instructed no briefs in the bed and the resident turned every two hours and as needed. A low air loss mattress (LAL, an air mattress designed to prevent and treat pressure wounds) ordered. The physician notified and new orders given for [MEDICATION(S)] (topical ointment to help prevent and treat wound infections) and cover with abdominal pad (ABD, a highly absorbent dressing that provides padding and protection for large wounds) twice a day to the buttocks. Order sent to the pharmacy. Further review of the interim care plan, updated on 5/3/22, showed: -Problem: Right buttock 9 cm x 6 cm, Left buttock 10.5 cm x 10 cm; -Goal: poor participation with therapy and feeding him/herself; -Approach: LAL mattress applied, non-compliant with getting up and staff and physician encourage the resident to get out of bed. Review of the 5/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 5/3/22 for Pro-stat amino acids (complete protein providing a high mix of essential and non-essential amino acids) take 30 milliliters (ml) three times a day; -An order, dated 5/3/22 for Ensure plus (concentrated calories and protein to help patients gain or maintain healthy weight) take 8 ounces twice daily; -An order, dated 5/3/22 for air mattress and check for proper inflation every shift; -An order, dated 5/3/22 for no briefs on while in bed; -An order, dated 5/3/22 to cleanse the buttocks with normal saline, apply [MEDICATION(S)] 1% topical cream, twice daily to bilateral buttocks and cover with ABD pads. Change as needed for pressure. Further review of the medical record, showed no registered dietician assessment and no wound specialist consultation. Review of the skin evaluation form, dated 5/3/22 at 11:39 A.M., showed: -Origin date: 5/3/22; -Site: Right buttock; -Category: blank; -Type: blank; -Treatment: blank; -Description: blank; -Occurred where: blank; -Treated where: blank; -Care planned: blank; -Cause: not applicable; -Size: -Length: 9 cm; -Width: 6 cm; -Depth: blank; -Pain level: blank -Wound edge: blank; -Undermining: blank; -Sinus tract: blank; -Eschar: blank; -Slough: blank; -Granulation: blank; -Drainage type: serous; -Color: inapplicable; -Odor: inapplicable; -Amount: scant; -Stage: inapplicable; -Pressure reducing chair: inapplicable; -Pressure reducing bed: inapplicable -Nutrition hydration intervention: inapplicable; -Nutrition shakes: inapplicable; -Nutrition protein supplement: inapplicable; -Nutrition multivitamin: inapplicable; -Ulcer care: inapplicable; -Dressing with or without topical medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -Ointments medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -Preventive protective skin care: inapplicable; -Turned frequency in hours: blank; -Type of pressure reducing mattress: blank. Review of the skin evaluation form, dated 5/3/22 at 11:41 A.M., showed: -Origin date: 5/3/22; -Site: Left buttock; -Category: partial thickness wound; -Type: other; -Treatment: blank; -Description: slough (yellow stringy dead tissue) present on coccyx (tailbone) and buttocks with discolored areas at gluteal (thigh and buttock) folds; -Occurred where: blank; -Treated where: blank; -Care planned: blank; -Cause: not applicable; -Size: -Length: 10.5 cm; -Width: 10 cm; -Depth: blank; -Pain level: blank -Wound edge: blank; -Undermining: blank; -Sinus tract: blank; -Eschar: blank; -Slough: blank; -Granulation: blank; -Drainage type: serous; -Color: inapplicable; -Odor: inapplicable; -Amount: light; -Stage: inapplicable; -Pressure reducing chair: inapplicable; -Pressure reducing bed: yes; -Turning and repositioning program: yes; -Nutrition hydration intervention: inapplicable; -Nutrition shakes: inapplicable; -Nutrition protein supplement: inapplicable; -Nutrition multivitamin: inapplicable; -Ulcer care: inapplicable; -Dressing with or without topical medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -Ointments medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -Preventive protective skin care: inapplicable; -Turned frequency in hours: blank; -Type of pressure reducing mattress: blank. Review of the treatment administration record (TAR), dated 5/22, showed: -An order, dated 5/3/22 to cleanse buttock wounds with normal saline, apply [MEDICATION(S)] 1% to the buttocks bilaterally and cover with ABD pad. Change twice daily and as needed for pressure; -On 5/3/22, evening shift documented not administered, [MEDICATION(S)] was unavailable. Review of the physician visit note on 5/4/22, showed the resident A & O x 3 and no documented skin issues. Further review of the interdisciplinary notes, showed: -On 5/5/22 at 6:28 A.M., a nursing note: the resident continues to require daily skilled nursing services for total right knee replacement. Incontinent of loose stools x 3 during the shift, perineal care provided. The dressing changed to the buttocks two times, no drainage noted. He/she is turned and repositioned every two hours and no briefs worn in bed; -On 5/6/22 at 2:18 A.M., a nursing note: the resident remained on observation for total right knee replacement. Two staff assistance needed with care and assist with repositioning every two hours due to a decubitus ulcer to the buttocks from loose stools. He/she is compliant with care; -On 5/6/22 at 11:01 A.M., a nursing note: the resident A & O x 3 and cooperative with care. The buttock dressing in place per orders, area appears improved and granulation (primary type of tissue that will fill in a wound that is healing) tissue noted throughout. LAL mattress in place and turned every 2 hours and as needed. His/her appetite is poor and fluids encouraged. Further review of the wound report, dated 5/7/22, showed the resident was not listed on the wound report. Review of the Braden scale, dated 5/7/22, showed a score of 10, or high risk to develop pressure injury. Further review of the interdisciplinary notes, showed: -On 5/7/22 at 8:18 P.M., called to the resident's room by the aide related to soilage to dressings. Dressing change per orders. Bilateral wounds noted on both right and left buttocks and dressing applied per physician orders. Wound noted to inner legs right and left upper areas near the groin. The left buttock wound appeared dark black, no drainage or odor noted. The resident noted to have poor appetite during the shift. Wound to left buttock approximately measured 13 cm x 11 cm, black area measured 8.5 cm x 8 cm. The right buttock wound approximately measured 10.6 cm x 8 cm with a tan center that measured 6 cm x 3.5 cm. The wound to the groin area measured 9.5 cm x 7 cm and appeared pink. Message left for the resident's physician; -On 5/7/22 at 10:37 P.M., the nurse on duty reported family concerns related to the resident's wounds. Writer assisted the floor nurse with dressing changes and wound measurements with a review of past documentation regarding the wound. Unable to discuss the resident's condition or care due to the current family visiting is not listed as the resident's responsible party. Writer spoke with staff and ensured the resident is being turned every two hours as needed and a LAL mattress is functional. The floor nurse called and left a message for the physician regarding the wound changes; -On 5/8/22 at 2:40 P.M., the resident is A & O x 4 but also seemed a bit despondent. Writer and the resident discussed participation in care and importance to turn and reposition every two hours. The resident acknowledged understanding and also stated he/she wanted to die, his/her psychiatric consult is pending. Dressing to the buttocks per order. Site is with unstageable (known but not stageable due to coverage of wound bed by slough and/or eschar at the time of admission) area at the center, granulation tissue present to outer edges of the wound bed. The [MEDICATION(S)] treatment appeared to be [MEDICATION(S)] the unstageable area with the wound edges sloughing off to reveal granulation tissue. Turned and repositioned every two hours, LAL mattress in place; -No documented attempted physician contact or additional physician contact attempted. Review of the monthly nursing summary, dated 5/9/22 at 6:34 P.M., showed: -Mental status: alert, confused and orientation fluctuates over the course of the day; -Emotion: withdrawn, hostile, interferes with care and expresses according to situation; -Behavior problems: self-neglect, uncooperative and negative statements; -Positioning: assist of two or more staff, repositioned every two hours and pressure reducing/relieving mattress used; -Bathing: bed bath, total care and physical help with activity; -Eating: limited assist, poor intake below 50%; -Bladder/Bowel: incontinent of bladder and bowel; -Skin: pressure ulcers Stage III, IV and unstageable. Further review of the interdisciplinary notes, showed: -On 5/11/22 at 7:54 A.M., late entry for 5/10/22 for 7:00 A.M., to 7:00 P.M., the resident's physician to the facility to see the resident during the morning shift. The physician discussed with the resident the need to get out of bed and therapy participation. Ordered treatment completed to buttocks. The resident's blood pressure noted to be low, the physician notified and new orders received for STAT (immediate) laboratory orders; -On 5/10/22 at 11:59 P.M., the vital signs noted in the medical record, oxygen saturation at 93%. Reviewed the STAT laboratory results. The physician was updated and notified of the STAT laboratory results. New order given to send the resident to the emergency room for evaluation and treatment. Emergency services called. The resident's heart rate irregular and blood pressure dropping, the paramedics to transport to the closest hospital. Review of the hospital admission emergency room visit note, dated 5/10/22 at 6:48 P.M., showed: -History of present illness: the patient presents to the emergency room with generalized body aches reported to begin today. Per emergency medical services (EMS), the patient has a large ulcer on his/her sacrum. The patient reports pain and feels weak; -Physical exam: -Cardiovascular: [CONDITION(S)] (irregular, fast heartbeat) present; -Skin: Large decubitus ulcer to the sacrum, Stage II. No noted infection or swelling; -Decision making: patient with new onset [CONDITION(S)] secondary from [CONDITION(S)] (body's overactive and extreme response to an infection). [CONDITION(S)] likely related to pneumonia. Admit to the hospital for treatment. Review of the inpatient hospital pelvis computed tomography (CT, an imaging method that uses x-rays to create cross-sectional pictures of the area between the hip bones) scan, dated 5/10/22, showed: -Abdominal wall: a sacral decubitus ulcer with soft tissue gas extending to the lower sacrum/coccyx. There is no well formed drainable abscess (pocket of infection). There is faint [CONDITION(S)] (narrowing) of the coccyx suspicious for [CONDITION(S)]; -Assessment and Plan: Acute problem: -Generalized weakness, acute metabolic [CONDITION(S)] (neurological disorder, caused by a systemic body chemistry imbalance) and acute [CONDITION(S)] secondary to severe [CONDITION(S)] secondary to community-acquired pneumonia and suspected [CONDITION(S)] of the sacrum and coccyx, acute [MEDICATION(S)] (bladder infection) and acute diarrhea; -Physician consults: infectious disease and neurosurgery; -Intravenous (IV, hollow tube inserted into a blood vessel to provide medications and fluids) antibiotics; -IV fluids for hydration; -Inhaled medications; -Images of the lumbar (lower back) spine and sacrum ordered of further evaluation; -Cultures ordered; -Severe [CONDITION(S)] criteria. Review of the inpatient operative report, dated 5/13/22, showed: -Date of operation: 5/13/22; -Preoperative Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -Postoperative Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -Procedure performed: sharp excisional debridement and bone biopsy for sacral ulcer; -Findings: the wound measured 12 cm x 14 cm x 6 cm and contained necrotic skin, fat, muscle and bone. During an interview on 6/1/22 at 1:25 P.M., Licensed Practical Nurse (LPN) A said he/she worked with the resident a few times. The resident was A & O x 1-2 and needed total staff assistance for care. The resident developed a wound to the sacrum/coccyx and it started as a Stage II. The last time LPN A saw it, the wound had developed necrotic tissue and was a Stage III or unstageable. If a resident reports buttock pain, the area should be assessed and documented. If a wound worsens, the physician should be notified for new orders. If the physician does not call back in a few hours, the nurse should call again and also notify the nursing management for assistance. All aides should document showers or bed baths on paper shower sheets and notify the nurse of any changes in skin condition. During an interview on 6/1/22 at 1:30 P.M., Registered Nurse (RN) B said he/she was not the resident's charge nurse but recalled the resident had developed a large sacral wound. The aides are responsible to complete a bath/shower sheet for each resident and turn the sheet into the charge nurse. The nurse signs the shower sheet and turns that into nursing management. The unit floor manager is responsible to document weekly wound measurements. If a resident has a wound, the wound should be reflected on the wound report weekly. During an interview on 6/1/22 at 1:46 P.M., the Director of Nursing said all residents should receive a bath/shower twice a week. The aides are responsible to document the showers on the shower sheets and turn the form into the charge nurse. If a resident does not have a shower sheet completed, the resident did not receive a bath or shower. If a resident refuses a bath or shower, the nurse should document that refusal in the medical record. The DON was not aware the resident had no shower/bath sheets. If there are concerns reported on the shower sheet, the charge nurse should notifiy the DON and unit manager. When the resident reported bottom pain, the nurse should have conducted a skin assessment and documented the findings. All wounds should be documented on the weekly wound report. The resident should have been ordered and provided a LAL mattress at the time of the complaint of buttock pain. If a physician does not call back timely regarding a change in a wound, the facility can call the medical director or telemed services for additional care and orders. The floor unit managers are responsible to document all weekly wound reports and measurements, and ensure all current wounds are documented on the weekly wound report. During an interview on 6/2/22 at 2:38 P.M., the resident's physician said he saw the resident at the facility several times before the discharge. The resident admitted to the facility from a different long-term care facility, following a total right knee replacement. He/she was to receive physical therapy, occupational therapy and planned to discharge back home. The resident did not want to participate in therapy or move out of the bed or wheelchair. The physician educated the resident and his/her family on the importance of participating in therapy and moving out of the bed and wheelchair to prevent wound development. The staff document showers/baths and notify the nurse of skin changes. If a wound worsens, the staff should call him, and if he does not respond, the facility staff can call the medical director for orders. All wounds should be documented on the weekly wound report for tracking. Wounds that are a Stage III or greater should be evaluated by a wound physician for treatment. The resident refused to allow him to assess the wound. MO 566

Based on observation, interview and record review, the facility failed to ensure staff followed physician's orders and the facility policy regarding elevated blood sugars. The facility identified 15 residents with orders for routine blood sugar checks (accu-checks). Of those 15, two had elevated blood sugars that exceeded the physician's parameters and the facility policy and problems were found with both (Residents #56 and #62). In addition, the facility failed to ensure staff completed the 72 hour fall follow-up neurological and vital sign form after two residents had falls with suspected head injuries (Residents #23 and #59). The census was 108 with 85 in certified beds. Review of the facility policy on [MEDICAL CONDITION], dated 8/19, showed: Purpose: To prevent complications with [MEDICAL CONDITION]; Definition: -[MEDICAL CONDITION] is the technical term for high blood glucose (blood sugar). High blood glucose happens when the body has too little insulin or when the body can't use insulin properly; Procedure: -Glycemic recommendations for older adults include: Healthy (90-130), complex (90-150) and very complex (100-180); -Results less than 70 or greater than 400 need immediate follow-up; -Determine with physician/extender what individualized parameters should be and incorporate into care plan; -Notify practitioner immediately of low blood glucose levels less than 70 or as indicated per physician's parameters; -Notify as soon as possible for glucose levels between 70-100, over 250 or if signs or symptoms of [MEDICAL CONDITION] or poor intake; -Document all appropriate information in medical record. 1. Review of Resident #56's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/1/19, showed: -[DIAGNOSES REDACTED]. -Received insulin 7 of the past 7 days. Review of the resident's current handwritten physician's order sheet (POS), showed: -Accu-checks four times a day; -7/19/19: If the blood sugar is above 400, give another 10 units of insulin. The order did not show when staff should notify the physician; -7/25/19: Send resident to hospital due to lethargy, confusion, elevated blood sugar and low blood pressure; -8/22/19: Accu-checks before meals and at hour of sleep. (MONTH) administer insulin after meals. If the blood sugar is 120 or less, notify the physician. The order did not show when staff should contact the physician for an elevated blood sugar. Review of the resident's Medication Administration Record [REDACTED]. Staff failed to document they notified the physician or obtained a follow-up blood sugar for 12 of the 19 blood sugars that exceeded 400 and seven of the 11 blood sugars that exceeded 500. Review of the resident's MAR for (MONTH) 2019, showed his/her blood sugar exceeded 400, two times and exceeded 500, three times. Staff failed to document they notified the physician or obtained a follow-up blood sugar for both blood sugars above 400 and for one of the three blood sugars above 500. 2. Review of Resident #62's quarterly MDS, dated [DATE], showed: -[DIAGNOSES REDACTED]. -Received insulin 7 of the past 7 days. Review of the resident's current POS, showed: -5/7/19: Accu-checks two times a day; -5/29/19: Call physician if the blood sugar is less than 60 or above 400. Review of the resident MAR for (MONTH) 2019, showed his/her blood sugar exceeded 400, three times. Staff failed to document they notified the resident's physician or obtained a follow-up blood sugar for two of those three times. 3. During an interview on 8/28/19 at 10:00 [NAME]M., the Director of Nurses (DON) said she expects staff to follow the physician's order on blood glucose parameters and if there is no order, staff should follow the facility policy. The policy requires staff to contact the physician for a blood glucose level above 400. Staff should report a blood glucose level above 400 soon after it is obtained. She expects staff to obtain follow-up on blood glucose levels to ensure the blood glucose level is trending back down. This should be done about 30 minutes after giving any routine or newly ordered insulin. If the blood glucose is not trending back down, she expects staff to call the physician again. 4. Review of Resident #23's significant change in status MDS, dated [DATE], showed: -Physical assistance of one person required for bed mobility, transfers and walking in room; -[DIAGNOSES REDACTED]. -Two falls since last assessment. Review of the resident's 72 hour fall follow up neurological and vital sign form, dated 7/10/19, showed; --Instructions: Complete with all unwitnessed falls or fall with suspected or confirmed head injury. Perform at time of fall, every 15 minutes times three, hourly times four, every four hours times five, and at every shift during the next 48 hours; -Time of fall: 1:25 P.M.; -Staff completed neurological assessments 10 of 19 required times on the assessment form. Review of the resident's 72 hour fall follow up neurological and vital sign form, dated 8/3/19, showed; --Instructions: Complete with all unwitnessed falls or fall with suspected or confirmed head injury. Perform at time of fall, every 15 minutes times three, hourly times four, every four hours times five, and at every shift during the next 48 hours; -Time of fall: 12:00 [NAME]M.; -Staff completed neurological assessments four of 19 required times on the assessment form. Review of the resident's 72 hour fall follow up neurological and vital sign form, dated 8/5/19, showed; --Instructions: Complete with all unwitnessed falls or fall with suspected or confirmed head injury. Perform at time of fall, every 15 minutes times three, hourly times four, every four hours times five, and at every shift during the next 48 hours; -Time of fall: 3:50 P.M.; -Staff completed neurological assessments 11 of 19 required times on the assessment form. 5. Review of Resident #59's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Two falls since last assessment. Review of the resident's medical record, showed: -[DIAGNOSES REDACTED]. -An order, dated 10/25/18, for resident to be up with walker/wheelchair and assist times two; -An interdisciplinary note, dated 6/27/19, showed staff documented the resident fell while performing an unassisted transfer from the wheelchair to his/her bed. The resident hit his/her head on the night stand. Resident assessed for injury and none noted. His/her physician and family were notified regarding the incident. Review of the resident's 72 Hour Fall Follow Up Neurological and Vital Sign Flow Sheet, dated 6/28/19, showed: -Instructions: Complete with all unwitnessed falls or fall with suspected or confirmed head injury. Perform at time of fall, every 15 minutes times three, hourly times four, every four hours times five, and at every shift during the next 48 hours; -Staff documented vital signs and completion of neurochecks every 15 minutes times three, hourly times four, and every four hours times three; -Staff failed to document vital signs or neurochecks every four hours times two, or during day shift on 6/29/19. Review of the resident's interdisciplinary notes, dated 6/29/19, showed staff documented the resident was found on his/her right side, on the fall mat next to his/her bed. Resident assessed for injury and none noted. Further review of the resident's 72 Hour Fall Follow Up Neurological and Vital Sign Flow Sheet, dated 6/28/19, showed: -Staff failed to document vital signs or neurochecks during day shift on 6/29/19; -Staff failed to document neurochecks on the evening shift on 6/29/19; -Staff documented vital signs and completion of neurochecks during day shift on 6/30/19; -Staff failed to document vital signs or neurochecks on evening shift on 6/30/19. 6. During an interview on 8/28/19 at 10:24 [NAME]M., Nurse [NAME] said nursing staff must obtain a resident's vitals and perform neurological checks for the 72 hours following a fall in which the resident hits their head. Staff should complete all neurochecks and obtain all vitals at the time intervals indicated on the 72-hour fall follow-up sheet, on which nursing staff is expected to document their findings. Head injuries may not always present right away, and that is why neurochecks are performed for 72 hours following a fall. This documentation should be in the resident's chart to ensure there is no injury. 7. During an interview on 8/27/19 10:04 [NAME]M., the DON said she expects the 72 hour fall follow up neurological and vital sign flow sheet to be completed. There should be no blank spaces.