Every finding on record at Grand Manor Health Care Center

Based on interview and record review, facility staff failed to follow their abuse policy when staff failed to report a resident to resident altercation between two residents (Resident #1 and Resident #2) to Administration, resulting in a failure to conduct an investigation into the altercation on 08/05/2026 at approximately 6:55 A.M. Resident #1 sustained an injury above his/her left eye and scratches to his/her right forearm when Resident#1 and #2 had a second altercation on 08/25/2026. The sample was 6. The census was 100. Review of the facility's Abuse and Neglect policy, revised 06/12/24, showed the following:-Purpose: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Definitions:-When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated:-The Licensed Nurse will:-Respond to the needs of the resident and protect him/her from further incident;-Notify the Administrator or designee;-Notify the attending physician, resident's family/legal representative, and Medical Director;-Monitor and document the resident's condition, including response to medical treatment or nursing interventions;-Document actions taken in the medical record;-Complete an incident report if indicated;-Revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse;-The Administrator or designee will:-Administrator/Designee will complete an administrative investigation to include personal statements from staff and residents involved in a situation that has any type of accusations of abuse either staff or resident abuse, any unexpected medical emergency, or when the administrative staff feel uncomfortable in any situation involving resident care or treatment or staff treatment;-Refer to the State Operations Manual (SOM) for reporting and utilize the Abuse Neglect Reporting Decision Tree to assess the particular incident. Best practice is toinclude the SOM and Decision Tree with the investigation. Should the incident be areportable event, notify the appropriate agencies immediately: as soon as possible,but no later than 24 hours after discovery of the incident. In the case of seriousbodily injury, no later than 2 hours after discovery or forming the suspicion. Shouldthe event not be reportable continue and complete the investigation with allsupporting information and place file with all investigations;-The administrative investigation will consist of any pertinent information describing the situation being investigated, the names of all staff and residents involved, the root cause of the incident, the recommendations from the investigation including the facts that prove or disprove the alleged situation occurred, the plan of correction or action by the administrative staff, all statements attached from residents and staff involved and any training or education that the administration feels needs to be provided to staff or residents to ensure education has been provided to prevent future similar situations;-The Administrative Investigation will also include a review of the resident's record toensure that the documentation reveals that the legal guardian and/or responsibleparty was notified (if applicable), the physician was made aware, the resident wasfully assessed, interventions and physician's orders were followed, the resident wasre-evaluated, and the Plan of Care was updated to reflect the change in medical orbehavioral status;-The facility Director of Nursing (DON)/Designee will ensure all clinical details and supportive plan of care interventions are completed for the administrative investigation;-Within five working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified;-The facility will take steps to prevent mistreatment while the investigation is underway; -Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused resident's condition shall beimmediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees in the facility. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/22/2026, showed the following:-Moderate cognitive impairment;-No behaviors exhibited;-Diagnoses include high blood pressure, depression, bipolar disorder (psychiatric illness characterized by both manic and depressive episodes, or manic ones only), psychotic disorder (mental disorder characterized by a disconnection from reality), schizophrenia (breakdown in relation between thought, emotion and behavior leading to faulty perception, inappropriate actions and feelings) and post traumatic stress disorder (PTSD, mental health condition that's caused by an extremely stressful or terrifying event). Review of the resident's progress notes, showed the following:-Licensed Practical Nurse (LPN) A documented: On 08/05/2026 at 6:55 A.M., Resident #1 came to the nurse's station and tried to push Resident #2, who was in his/her wheelchair, out of the Resident #1's way. Resident #2 did not want Resident #1 to push his/her wheelchair. Resident #2 stated, get out of my way, and Resident #1 then hit Resident #2 on the right hand and ran down the hall. Call placed to physician; made aware both residents were separated, and placed on a 1:1; call placed to the responsible party (RP), no answer message on answering service;-DON documented: On 08/05/2026 at 11:08 A.M.:-Skin warm and dry, skin color within normal limits and skin turgor is normal;-Skin issue #1:-New skin issue, location: Face.-Laterality/Orientation: Left;-Issue type: Other skin issue;-Other skin issue description: Hematoma (Collection of blood beneath the skin);-Wound acquired in-house; -Skin issue #2:-New skin issue, location: Right outer wrist;-Other skin issue description: scratches;-Progress: New: New wound;-Wound acquired in-house.-Social Services Director (SSD) documented: On 08/05/2026 at 11:18 A.M., SSD met with resident. The resident stated that another resident hit him/her SSD asked what happen the resident stated that he/she was laying down and resident #2 came in his/her room and hit him/her out of nowhere. The resident stated that he/she did let the staff know what happened. SSD asked the resident how he/she is feeling today he/she stated I'm okay I just don't understand why Resident #2 came into his/her room and hit me. SSD informed the resident that the IDT team is working on that situation. SSD asked the resident if he/she felt safe here in the facility and he/she stated I can't answer that right now;-DON documented: On 08/05/2026 at 8:14 P.M., Resident reported around 11:30 A.M., that he/she had a physical altercation with Resident #2. During the investigation, the resident stated Resident #2 came into his/her room and started hitting him/her. The resident then stated he/she took the bedside table and pushed it into Resident #2. The resident then allowed this nurse to complete a skin assessment. A small nodule observed over his/her left eye and some scratches observed on his/her right wrist. The resident stated that he/she does not remember how he/she got the scratches. Physician aware of this situation and stated the resident is in a manic phaseand needs to go to the hospital. Voicemail left for guardian. Resident agreed to go to the hospital. Two Emergency Medical Technicians (EMT) arrived at the facility around 4:30 P.M. The resident was transported to the hospital. Review of the resident's care plan on 08/12/2026 in use at the time of the survey, showed:-Problem:-Resident is at risk of being physically aggressive related to poor impulse control;-On 08/05/2026 the resident hit another resident that did not want to be pushed by him/her resulting in injury above left eye and on right wrist;-Goal: Maintain safe interactions with peers and refrain from physical aggression through the review date, date initiated 08/05/2026;-Interventions:-Guardian notified emergency room (ER) for evaluation and treatment and to monitor for escalating behaviors;-Redirect before physical contact occurs, date initiated 08/05/2026;-Reinforce waiting his/her turn and respecting personal space, date initiated 08/05/2026;-Separate from peers when escalating, date initiated 08/05/2026;-Monitor recurring conflicts with specific residents, date initiated 08/05/2026;-Notify provider of recurrent aggression, date initiated 08/05/2026;-Medication review, date initiated 08/05/2026;-Staff education on de-escalation and interventions, date initiated 08/05/2026;-Treat injuries per physician orders, date initiated 08/05/2026;-Hospital for evaluation and treatment, date initiated 08/05/2026. Review of an email sent from the resident to SSD, showed: -The resident sent an email to SSD on 08/05/2026 at 10:02 A.M.;- At 7:50 A.M. I was attacked by Resident #2.;- When the incident took place, I was in bed.-Resident #2 barged through my door got out of his/her wheelchair and hit me.;- I am swollen.;-SSD forwarded the email to the Administrator on 08/05/2026 at 11:32 A.M. During an interview on 08/11/2026 at 11:50 A.M., Resident #1 said Resident #2 came into his/her room in his/her wheelchair while he/she was lying on his/her bed. Resident #1 said that Resident #2 hit Resident #1's head on his/her eye and nose. Resident #1 said he/she shoved his/her bedside table at Resident #2 and told him/her to get out of his/her room. A staff member came and removed Resident #2 out of his/her room. The resident did not know the name of the staff member that removed Resident #2 from his/her room. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior not exhibited;-Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others): Behavior not exhibited;-Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds): Behavior of this type occurred one to three days;-Diagnoses included diabetes, Alzheimer's, dementia, seizure disorder, depression, psychotic disorder, schizophrenia, and Post Traumatic Stress Disorder (PTSD). Review of the resident's progress notes, showed the following:-LPN A documented: On 08/05/2026 at 6:55 A.M., This resident was sitting at the nurse's station talking to the staff, waiting to go to his/her doctor's appointment, when Resident #1 came up and tried to squeeze in between this resident and another resident. He/She tried to push the other resident out of the way, which this resident did not want him/her to do. This resident stated get out of my way, Resident #1 resident hit this resident on the hand and ran down the hall. Both residents were separated. A call was placed to the physician and made aware of the incident; also, a call was placed to the (RP), who was made aware;-SSD documented: On 08/05/2026 at 4:10 P.M., SSD went and interviewed resident due to a resident-to-resident altercation with another resident. SSD asked resident if he/she hit the other resident., He/She stated what you are talking about. Resident #1 hit me but now you are going to ask me did I hit him/her. I don't want to talk about that no more. The resident became upset so SSD changed the topic. SSD asked resident if he/she felt safe here at the facility and the resident stated that he/she does now. Resident stated he/she was going downstairs so he/she could smoke. Review of the resident's care plan on 08/12/2026, in use at the time of the survey, showed:-Problem: Resident has manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. These behaviors include verbal aggression, yelling, threatening language;-Goal: Minimize episodes of inappropriate behaviors that can affect others, revised on 08/07/2026;-Interventions: -Assist resident in addressing root cause of change in behavior or mood as needed, initiated, 01/29/2026; -Give positive feedback for good behavior, Initiated, 01/29/2026;-Problem: Resident is verbally aggressive related to ineffective coping skills, mental and emotional illness, poor impulse control, initiated 04/29/2026;-Goal: The resident will demonstrate effective coping skills through the review date, revised 08/07/2026;-Interventions: -Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document, initiated 04/29/2026; -Encourage resident to identify triggers and early warning signs of self-harm urges, initiated 04/29/2026; - Encourage verbal expression of feelings through open-ended questions, initiated 04/29/2026; -Establish a therapeutic rapport; use active listening and nonjudgmental communication, initiated 04/29/2026; -Redirect from overstimulating environments or peer conflicts promptly. Maintain calm, non-confrontational communication approach. Provide personal space and reduce stimulation during escalation. Encourage verbalization of frustration appropriately. Increase staff awareness/supervision during hallway and peer interactions. Separate from triggering residents. Reinforce appropriate coping and behavioral expectations. Document aggressive behaviors including triggers and response to interventions. Monitor for early signs of agitation. ER for evaluation and treatment. 1:1 monitoring for 72 hours. Increase activities, revised 05/22/2026; -Remove resident from situations when escalation begins. Use calm, non-threatening communication. Set clear, firm behavioral limits. Redirect early signs of escalation. Avoid confrontational interactions. Monitor for patterns of escalation identify and document triggers limit high risk interactions encourage movies or sports when agitated monitor medication effectiveness notify provider of continued aggression despite med changes psych consult as indicated document all aggressive incidents, revised 05/05/2026;-Problem: Resident is physically aggressive towards residents and staff related to anger, poor impulse control, initiated 04/29/2026;-Goal: Resident will demonstrate effective coping skills through the review date, revised 08/07/2026;-Interventions:-Monitor/document/report as needed (PRN) any signs and symptoms of resident posing danger to self and others, initiated 04/29/2026;-Showed no documentation regarding the resident-to-resident altercation on 08/05/2026 or interventions implemented. During an interview on 08/11/2026 at 12:41 P.M., Resident #2 denied any physical altercations with Resident #1. 3. During an interview on 08/13/2026 at 9:55 A.M., LPN A said on 08/05/26 around 6:55 A.M. Resident #2 was up at the nurse's station because he/she was going to go to an appointment. Resident #1 came up to the nurse's station and grabbed the wheelchair and tried to push it out of his/her way while resident #2 was trying to move. Resident #1 hit Resident #2's hand and then took off running to his/her room. The ADON came off the elevator right after it happened and LPN A told her what just happened and that Resident #2 was trying to go after Resident #1. The ADON redirected Resident #2 back to the nurse's station. LPN A said Resident #2 did not go into Resident #1's room. Resident #2 was in the hallway when he/she was redirected back to the nurse's station by the ADON. He/She placed both residents on 1:1 monitoring. He/She informed the ADON that the resident's were placed on 1:1 monitoring. The reason he/she placed Resident #2 on 1:1 monitoring was because he/she does not forget, and he/she was worried Resident #2 would go after Resident #1 because he/she had hit his/her hand. He/She provided 1:1 monitoring for Resident #2 until day shift came in. He/She was not sure what staff member was providing the 1:1 monitoring for Resident #1 but said it was someone from the day shift. He/She gave report to LPN B and informed him/her about the incident and that the residents were on 1:1 monitoring. Both residents were on monitoring 1:1 when he/she left. Resident #2 did not go to the appointment on 08/05/2026 because it ended up being canceled. During an interview on 08/13/2026 at 10:39 A.M., LPN B said there was an incident on 08/05/2026 prior to him/her arriving to his/her shift. LPN A told him/her that Resident #1 hit Resident #2 on his/her hand at the nurse's station, both residents were separated and both residents continued on 15 minute monitoring. All the residents on the floor are on 15 minute checks 24 hours a day. LPN A did not tell him/her that the resident's were placed on 1:1 monitoring. Neither resident was on 1:1 monitoring during his/her shift. He/She was not at the facility when the incident happened. He/She was not aware of any additional physical altercations between the resident's on his/her shift. The day shift is from 7:00 A.M. to 3:00 P.M. During an interview on 08/17/2026 at 8:09 A.M., CNA C was working on 08/05/2026 and was standing by the nurse's station when he/she heard Resident #1 yelling, don't come in my room. He/She went down to Resident #1's room and observed Resident #2 propelling himself/herself into Resident #1's room. Resident #2's wheelchair was halfway through the doorway and Resident #1 was over by his/her bed across the room telling Resident #2 to get out of his/her room. He/She told Resident #2 that they needed to get out of Resident #1's room and Resident #2 told CNA C that he/she was going to get him/her talking about Resident #1 and repeated that statement several times. He/She yelled for assistance and LPN B and another CNA arrived and helped redirect Resident #2 out of Resident #1's room. He/She did not see the residents make physical contact. He/She was not aware of any altercation between the two resident's at the nurses station that morning prior to his/her shift. He/She was not aware of Resident #2 going back to Resident #1's room that day. The nurses usually inform them if resident's have had any resident to resident altercations. Resident #1 and Resident #2 was not on 1:1 monitoring during her shift of 7:00 A.M. to 3:00 P.M. During an interview on 08/13/2026 at 12:46 P.M., the SSD said after there was a resident to resident altercation. She was told there was an altercation between Resident #1 and Resident #2 and that Resident #2 hit Resident #1. She did not remember who told her about the altercation. When she is told there was an altercation she does the interviews with the residents at that time so she does not forget to interview them. She asked Resident #2 if he/she hit resident #1 because she was told that Resident #2 went into Resident #1's room and hit Resident #1. She did not recall being told that Resident #1 hit Resident #2's hand at the nurses station. She documented what the residents reported to her in the progress note she wrote for each resident. She was not aware of either resident being on 1:1 monitoring. During an interview on 08/13/2026 at 1:12 P.M., the Administrator said if there is a resident to resident altercation he expected staff to first separate the residents and make sure both residents are safe. If it is a verbal altercation staff should redirect the residents and offer to take them out to smoke, activities or coffee. If it is a physical altercation the nurse completes a skin assessment, and a pain assessment. Both verbal and physical altercations the nurse will complete a risk management incident report on both residents. Notifications to the physician, RP, and Administrator are documented in the progress note and risk management incident report. The Administrator said he should be notified of any resident-to-resident altercations immediately no matter what time it is. The Administrator notifies Department of Health and Senior Services (DHSS) and police if needed. Behavior monitoring is completed each shift for 72 hours post incident to monitor if there are any new issues with skin, pain or behaviors. The behavior monitoring is documented in progress notes. The Administrator said all resident's on the unit are on 15 minute monitoring. The Administrator said he has been at the facility for three weeks and was unsure if there was a system in place for IDT team to identify if interventions are not working. The Administrator said if interventions are not working or if someone continues to demonstrate aggressive behaviors, they may be placed on 1:1 monitoring instead of the 15 minute check monitoring. He said when 1:1 monitoring is done it is documented on a paper sheet and would also be documented in the progress notes in the behavior post follow up progress notes. The Administrator said determining if a resident is placed on 1:1 monitoring would be a decision the Administrator and DON would make and then discuss it with the IDT team. The Administrator said the IDT team consists of all the department heads. The Administrator reviewed the progress notes from the resident to resident altercation between Resident #1 and Resident #2 on 08/05/2026 at 6:55 A.M. The Administrator said putting both residents on 1:1 monitoring is not typical and most of the time not necessary. The Administrator said he was not aware of two altercations and did not believe there were two altercations that happened between Resident #1 and Resident #2 on 08/05/2026. The Administrator said he did not believe any staff members observed Resident #2 in Resident #1's room. Was he aware of the two altercations? I changed the color to purple above showing that he was not aware of the two altercations. I had the word incident and changed it to altercations. Let me know if I need do anything else with it. During an interview on 08/13/2026 at 2:03 P.M., the ADON said: LPN A told her about the incident at the nurse's station that happened on 08/05/2026 at 6:55 A.M. when she arrived on the unit on 08/05/2026 a little before 7:00 A.M. Resident #2 was going down the hallway towards Resident #1 who was also in the hallway. The ADON redirected both resident's and Resident #2 went to the nurse's station and Resident #1 when to his/her room. ADON said she did not see any injury to Resident #1's face when she redirected him/her in the hallway. The ADON said Resident #1 and Resident # 2 did not make contact with each other in the hallway. The ADON reviewed the progress note on 08/05/2026 at 6:55 A.M. and said that LPN A did not tell her that the residents were placed on 1:1 monitoring. LPN A said she was not aware of an incident later that day with Resident #2 going into Resident #1's room and hitting Resident #1. ADON looked at risk management and said there was only one resident to resident altercation that was entered on 08/05/2026. During an interview on 08/14/2026 at 10:40 A.M., the DON said on 08/05/2026 Resident #1 reported to the SSD around 10:00 A.M. that Resident #2 came into his/her room and attacked Resident #1 for no reason. The DON said she did a skin assessment for Resident #1 and observed a knot above his/her left eye and scratches on top of his/her right forearm. The DON said she interviewed Resident #2 and he/she denied hitting Resident #1 or going into Resident #1's room. The DON said she called LPN A and asked if he/she had witnessed anything between Resident #1 and Resident #2. LPN A told her that morning before day shift arrived Resident #1 came up to the nurse's station and tried to move Resident #2's wheelchair and Resident #2 told Resident #1 to leave him/her alone and Resident #1 hit Resident #2's hand and then ran to his/her room. LPN A did not report that Resident #1 was hit at any point in time during the incident that morning. Her investigation she interviewed Resident #1, Resident #2 and LPN A. The DON said she did not interview any of the Certified Nurse Aide's (CNA)'s. The DON said when Resident #1 reported that Resident #2 hit him/her the DON could only take his/her word. The DON confirmed that Resident #1 hitting Resident #2's hand was considered a resident to resident altercation. The DON confirmed that Resident #2 going into Resident #1's room and hitting him/her is a resident to resident altercation. The DON said the resident's were not on 1:1 monitoring. The DON said she assumed they were both the same incident and did not investigate it any further after speaking with LPN A. The DON said if LPN A would have voiced concerns that Resident #2 would go after Resident #1 after the incident at the nurses station they would have placed Resident #2 or Resident #1 on 1:1 monitoring. DON said that LPN A should have reported the resident to resident altercation that happened at the nurse's station to her and the Administrator when it happened that morning. The DON said she should have interviewed the CNA's that were working that day. During an interview on 08/14/2026 at 11:38 A.M., the Administrator said the SSD forwarded an email she had received from Resident #1 on 08/05/2026 at 11:32 A.M. and that is how he found out about the incident with Resident #2 going into Resident #1's room. The Administrator reported the incident to DHSS at 12:35 P.M. During an interview on 08/14/2026 at 11:41 A.M., the Regional Director of Operations (RDO) said when there is a resident to resident altercation she expected for staff to separate the resident's immediately and make sure they are safe. Complete an assessment of the residents for any injuries, notify the physician, RP and the abuse coordinator which is the Administrator. An investigation to be started that included staff and resident interviews and a timeline of events created. The interviews and time line are documented and kept with the investigation. The nurse should make notifications to the physician and RP and document the notifications in the risk management incident report and progress note. A description of the resident to resident altercation should be documented in the progress note with the notifications. The immediate intervention(s) should be put in place such as a room change or 1:1 monitoring. A nurse can initiate 1:1 monitoring if needed. All resident's on the unit are on 15 minute monitoring so that would not be considered a new intervention. An evaluation to be completed to see if there was a need for increased monitoring. If the resident's roommate is not the aggressor, the aggressor should be put on 1:1 monitoring until a viable intervention is put in place such as another facility or a psychiatric consult. The aggressor would be put on 1:1 monitoring to ensure all resident's including the aggressor remained safe. If 1:1 monitoring was initiated, it would be documented in the progress note and who was providing the 1:1 monitoring would be documented in the risk management incident. The progress note should reflective of the incident along with if any injuries were obtained, immediate interventions and notifications. T She was not notified of the incident that happened at the nurse's station on 08/05/2026 between Resident #1 and Resident #2. She was notified of the incident on 08/05/2026 when Resident #1 notified SSD of Resident #2 entering his/her room and hitting Resident #1. She expected to be notified of all resident to resident altercations including the incident that occurred at the nurses station on 08/05/2026 During an interview on 08/14/2026 at 12:12 P.M., the Administrator, DON, ADON, RDO, and Regional Nurse Consultant (RNC) expected staff to be knowledgeable of and to follow facility policies and procedures. During an interview on 08/14/2026 at 12:20 P.M., the DON said: -She was not aware of the resident to resident altercation that happened at the nurse's station on 08/05/2026. She believes There were two separate incidents between Resident #1 and Resident #2 on 08/05/2026. 3135348

Based on interview and record review, the facility failed to honor the rights of residents to choose their own physician when the facility discontinued services with Physician A, who provided care to 30 residents. Three of the residents were sampled and one expressed the desire to continue care with Physician A (Resident #8). The sample was 10. The census was 101.The Administrator was notified on 05/28/26 at 2:20 P.M., of the past non-compliance, which occurred on 03/25/26. The facility provided training and in-servicing for all staff regarding the facility's resident rights policies and Physician A has been reinstated to the facility as of 05/16/26. The deficiency was corrected on 05/16/26. Review of the facility's Resident Rights policy, dated 09/21/25, showed the following:-Purpose: To ensure that resident rights are protected;-Resident Rights Under Social Security Act: Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside facility. Facility must protect and promote rights of each resident, including each of the following rights:--Notice of Rights and Services: Facility must inform resident both orally and in writing in a language that resident understands of his or her rights and all rules and regulations governing resident conduct and responsibility during the stay in facility;--Free Choice:---Resident has the right to:----Choose a personal attending physician;----Be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect Resident's well-being; and----Unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment. Review of Resident #8's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/4/26, showed the resident cognitively intact. Review of the resident's Social Service (SS) notes showed the following:-On 03/25/26 at 12:01 P.M., SS talked to the resident and inform him/her that his/her Primary Care Physician (PCP) will be changing from Physician A to Physician B. The change of PCP paperwork was signed;-On 05/18/26 at 2:52 P.M., the resident was informed that Physician A will be back practicing in the facility and SS asked the resident do you want to back under him/her as your PCP, the resident said yes. Review of the resident's medical record, showed Physician A listed as the resident's PCP. During an interview on 05/28/26 at 1:55 P.M., the resident said he/she did not want to change to Physician B. He/She wanted to stay with Physician A, but he/she did not have a choice. He/She was glad to be back with Physician A. During an interview on 05/28/26 at 2:06 P.M., the Administrator said she expected resident rights to be honored and the resident rights policy to be followed as written. 2797338

Based on interview and record review, the facility failed to provide supervision to one resident (Resident #2), when the facility did not initiate a Code Purple (missing resident), per facility policy, when Resident #2 failed to return to the facility for dinner and evening medications and did not return all night. The resident signed out at 8:30 A.M. on the morning of [DATE] with an expected return time of 5:25. The resident did not return to the facility and per the facility policy, staff should have initiated a Code Purple when the resident did not return at the expected time and staff couldn't contact the resident. When the resident did not return for dinner or medications that evening, staff did not initiate a Code Purple. The resident did not return on the night shift and staff did not initiate a Code Purple or a search. Per the hospital records, the resident was found on [DATE] at approximately 8:30 A.M., face down, next to a wall, unresponsive in a puddle of water. The resident had a history of falls and returning from leave of absences intoxicated. The facility did not provide care plan interventions for staff to follow regarding the resident returning from leaves of absences intoxicated. The resident expired at the hospital on [DATE]. The sample was six and the census was 106.The Administrator was notified on [DATE] at 4:06 P.M. of the immediate jeopardy (IJ) past non-compliance, which occurred on [DATE]. On [DATE], the Administrator became aware of the incident. The facility provided training and in-services for all staff regarding the facility's resident safety, outside pass, behavior emergency, incidents/accidents, when to notify management, drug/alcohol, and abuse/neglect policies. The IJ was corrected on [DATE]. Review of the facility's Resident Outside Pass (OSP) policy, revised [DATE], showed:-Purpose: To ensure the facility provides education and treatment/medications to the resident's responsible party upon the resident's absence from the facility to ensure continuity of care while the resident is out of the facility, therefore allowing for a successful out of the facility visit without negative effects on the resident.-If the resident is his/her own responsible party, the facility will obtain the following information: a. Where to contact the resident in the event of an emergency; b. Who will be transporting the resident; c. How long the resident will be absent from the facility; d. When the resident will return to the facility; e. Any additional information which requires the facility to further provide care;-Twenty-four-hour advance notice of the resident's absence from the facility is requested for continuity purposes;-Orders will be obtained to allow the resident to go on OSP with or without medications as determined by the primary care physician;-The nurse/designee will complete the OSP form prior to the resident leaving the facility;-In the event the resident does not return at the time given, the facility will attempt to contact the resident/resident's responsible party to verify the resident's return;-If the facility cannot contact the resident, the facility will then follow the Code Purple procedures. Review of the facility's Elopements and Wandering Resident's policy, revised [DATE], showed: -Any staff member becoming aware of a missing resident alerted personnel using facility approved protocol;-Code purple meant elopement outside of facility;-The designated facility staff looked for the resident;-If the resident was not located in the building or on the grounds, the Administrator or designee notified the police department and served as the designated liaison between the facility and the police department.- The Director of Nursing (DON) or designee notified the physician and family member or legal representative;-The police were given a description and information about the resident; -All parties where notified of the outcome when the resident was located;-Appropriate reporting requirements to the state agency would be conducted. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:-Moderate cognitive impairment;-No behaviors noted;-No mobility device;-Supervision or touching assistance with activities of daily living (ADLs) and transfers;-Diagnoses included: diabetes, acute kidney failure, depression, and high blood pressure. Review of the resident's progress notes, showed on [DATE] at 10:50 P.M., front desk staff reported the resident fell outside. The resident was on the ground on the back patio. He/She was responsive and smelled of alcohol. Range of motion (ROM) was within normal limits. Wheelchair used to assist the resident to his/her room. The resident said he/she lost his/her balance. He/She was assisted to bed. Neurological (neuro) checks started. Review of the resident's post fall evaluation, dated [DATE] at 11:00 P.M., showed-Unwitnessed fall;-Location: Patio;-Other activity: The resident smelled of alcohol;-No injuries noted;-No clinical suggestions. Review of the resident's elopement risk assessment dated [DATE] showed the resident was not an elopement risk. Review of the resident's progress notes, showed on [DATE] at 9:30 A.M., the resident said he/she fell outside last night. The resident said he/she did not report the fall, because the nurse did not ask him/her if he/she fell. He/She said he/she fell on the sidewalk leading to the front door. He/She landed on his/her elbows and knees and hit the top of his/her forehead. He/She had two scratches on the back of his/her left forearm. ROM within normal limits. Neuro checks started. Review of the resident's post fall evaluation, dated [DATE] at 1:46 P.M., showed:-Unwitnessed fall;-Location of fall: Patio;-Other activity: Resident was intoxicated;-No injuries noted;-No clinical suggestions. Review of the resident's progress notes, showed:-On [DATE] at 11:05 P.M., the resident was sitting in a chair in the lobby. He/She was alert. His/Her speech was slurred and gait was unsteady. His/Her eyes were red and his/her face was flushed. He/She said he/she drank alcohol. He/She declined assistance to his/her room. No acute concerns noted. Front desk staff notified the nurse of any changes;-On [DATE] at 1:21 A.M., the resident arrived on the floor via elevator. His/Her gait was slow and unsteady. He/She was assisted to his room and to bed by two staff. Review of the resident's care plan in use during the survey showed:-Problem: The resident was at risk for falls due to acute pain. He/She had a fall risk score of six (initiated [DATE]);-Interventions: Staff anticipated the resident's needs. Educated the resident about safety reminders and what to do if fall occurred. Followed facility fall protocol.Reviewed information on past falls and attempted to determine cause of falls. Recorded possible root causes. Altered and removed any potential causes if possible. Educated resident/family/caregivers/Interdisciplinary team (IDT) as to causes (initiated [DATE]). Social services consulted with resident regarding alcoholism and possible support groups (initiated: [DATE]);-Problem: The resident had a fall on [DATE]. He/She had two scratches on the left forearm;-Interventions: Staff assessed vitals per facility protocol. Notified legal guardian of any falls or updates to fall risk for resident (initiated [DATE]). Provided activities that promoted exercise and strength building where possible.Provided one-to-one activities if bedbound;-No documentation the resident returned from leave of absence (LOA) intoxicated and what staff were supposed to do when this occurred. Review of the resident's sign out sheet, showed on [DATE] at 8:30 A.M., the resident signed out to smoke outside. The expected return time/date was 5:25, no date noted. The actual return date/time was blank. Review of the resident's progress notes, showed:-On [DATE] at 8:50 P.M., the resident signed out of facility this morning and remained on LOA. The Assistant Director of Nursing (ADON) was notified. Staff continued to monitor and would document his/her return;-On [DATE] at 7:28 A.M., the resident was outside facility the entire night shift. At 9:05 A.M., staff received a call from the hospital social worker. He/She said the resident was found unresponsive on the corner of city streets (approximately two miles away from the facility). The resident was in critical condition. The hospital social worker inquired about the resident's next of kin (NOK). The resident did not have NOK. The ADON was notified. At 10:23 A.M., the resident's physician was notified. At 10:24 A.M., the ADON noted he/she called the hospital social worker. The social worker said the resident was in critical, but in stable condition. He/She was admitted for cardiac arrest while on LOA. The resident signed him/herself out at 8:30 A.M. on [DATE]. The resident did not have a cellphone. The resident has left the faciity on extended outside pass in the past. The hospital social worker would follow up. At 11:07 A.M., the hospital social worker called and said the resident was deceased . At 12:08 P.M. the resident's physician was notified. Review of the resident's hospital Discharge summary, dated [DATE], showed:-The resident was found face down, next to a wall, unresponsive in a puddle of water. He/She was cold to the touch and pulseless. It was unclear how long he/she was down. Paramedics suspected the resident fell off a small ledge he/she slept on. He/She received cardiopulmonary resuscitation (CPR) for 30 minutes and was intubated prior to hospital transport;-The resident was admitted to the emergency room on [DATE] at 8:45 A.M.;-The resident had scattered abrasions to his/her face and extremities;-The resident was unresponsive and put on a ventilator (a medical machine that acts as life support to breathe for patients who cannot breathe effectively on their own);-The resident expired on [DATE], time unknown. During an interview on [DATE] at 10:02 A.M., Certified Nursing Assistant (CNA) F said he/she worked from 3:00 P.M. to 11:00 P.M. on [DATE]. He/She did rounds at 3:00 P.M., and the resident was not in his/her room. He/She did rounds at 5:00 P.M. and still did not see the resident. Certified Medication Technician (CMT) G said the resident was not in his/her room during the medication pass. The resident did not usually miss dinner. When CMT G passed meds at 7:00 P.M., the resident was not in his/her room. They started to worry. CMT G told the nurse the resident was not in his/her room. They were told the resident signed out on the day shift. Staff thought he/she left with family. The resident usually signed out and smoked on the back patio. He/She rarely left the facility. At 11:00 P.M., CNA F told the nurse the resident still had not returned. He/She did not know what staff were supposed to do if a resident did not return from LOA. He/She did not initially know what Code Purple meant. When residents returned to the facility intoxicated staff notified the nurse and CMT. He/She could not recall the resident being intoxicated. He/She was in-serviced on abuse/neglect and other things. During an interview on [DATE] at 10:23 A.M., CMT G said he/she worked from 3:00 P.M. to 11:00 P.M. on [DATE]. An aide asked him/her if he/she saw the resident. The resident's breakfast and lunch were still in his/her room at 5:00 P.M. The resident was not in his/her room for the 5:00 P.M. medication pass. CMT G asked the nurse and an aide if they saw the resident. The nurse and aide said the resident would Pop up soon. The resident was not in his/her room during the 8:00 P.M. medication pass. It was unusual for the resident to not be in his/her room. CMT G asked the receptionist if the resident signed out. He/She could not remember what the receptionist said. CMT G went back to the second floor. The nurse called around looking for the resident. He/She did not know what the nurse found out. The resident always returned from LOA. The resident was usually on the patio or in his/her room. Staff were supposed to initiate a Code Purple and search for the resident. He/She searched around the building, but not outside. The nurse did not call a Code Purple. He/She did not know if anyone searched the neighborhood for the resident. The resident did drink alcohol. Staff had to pick him/her up off the ground a couple of times. He/She thought other residents were bringing the resident beer. The last time the resident was drunk was a few months ago. If a resident was intoxicated, he/she held their medications and notified the nurse. During an interview on [DATE] at 12:24 P.M., Licensed Practical Nurse (LPN) D said he/she worked until 11:00 P.M. He/She notified the ADON when the resident did not return to the facility by 9:00 P.M. The ADON told him/her to document it. He/She did not know he/she was supposed to call a Code Purple. The ADON did not tell him/her to call a Code Purple. During an interview on [DATE] at 12:11 P.M., LPN A said the resident was not in the building when his/her shift started at 11:00 P.M. He/She documented the resident was not in the building and notified the ADON. He/She called the receptionist and he/she said the resident signed out of the facility at 8:30 A.M. The residents are supposed to return to the facility by 10:00 P.M. It was common for residents to leave the building and not return. When residents did not return from LOA, staff were supposed to notify the administrator, Director of Nursing (DON), family, and try to contact the resident. The resident did not have a number on file. A Code Purple was for missing residents. During a Code Purple, staff searched the facility for the resident. If a resident was not in the building, staff drove around the neighborhood to look for him/her. LPN A did not initiate a Code Purple, because the resident was not in the building when his/her shift started. He/She received a call from the hospital social worker on [DATE]. He/She was not sure what time the social worker called. The social worker wanted to know if the resident had NOK. The social worker said the resident was found unresponsive and was in critical condition. The resident had returned to the facility intoxicated in the past. Sometimes the resident could not make it back into the facility. He/She had to help pick the resident up off ground in the alley behind the facility. Staff put the resident in a wheelchair and brought him/her into the facility. During an interview on [DATE] at 10:43 A.M., CNA E said he/she worked from 11:00 P.M. to 7:00 A.M. on [DATE]. The CNAs and nurses completed rounds. He/She did not remember the incident. The resident was usually in the facility. If a resident did not return from LOA, CNA E notified the nurse and called a code. During an interview on [DATE] at 11:26 A.M., CNA H said he/she usually worked from 7:00 A.M. to 3:00 P.M. The CNAs and nurses completed rounds. He/She was not sure who the resident was assigned to on [DATE]. He/She could not remember what happened on [DATE]. He/She did not remember if the resident was in the building during his/her shift. When a resident did not return from LOA, he/she notified the nurse. During an interview on [DATE] at 9:11 A.M., the Social Worker said the resident did not have any behaviors. The Social Worker was not aware the resident had returned to the facility intoxicated. If a resident had a substance abuse issue, she would offer Alcoholics Anonymous (AA) groups or drug treatment. If a resident had substance abuse issues and was his/her own responsible party, he/she could still go out on LOA. They cannot force residents to stay in the facility. If staff suspected a resident was intoxicated, they notified the Administrator, and it was discussed in the IDT meeting. During an interview on [DATE] at 11:51 A.M., the Administrator said she was the ADON when the incident occurred. On [DATE] between 10:00 P.M. and 11:00 P.M., the nurse informed her the resident was not in the building. She told the nurse to document it and keep her posted. The nurse did not call her again. The residents are supposed to return from LOA by 10:00 P.M. When residents do not return from LOA, staff should check the sign out book to determine their expected return time. Then, staff should notify the supervisor, contact the resident and/or their family. If the resident was not alert and oriented, staff searched the neighborhood for the resident. The resident did not have a number on file. She was not sure if the resident had a cellphone. The resident was alert and oriented and had no issues. He/She usually returned on time from LOA. A Code Purple was called when a resident did not return from LOA or eloped. During a Code Purple, staff called the police, notified the family, searched for the resident, documented the incident and in-serviced staff. She thought the Code Purple was not initiated, because the resident had stayed out overnight before and he/she was his/her own responsible party. During an interview on [DATE] at 2:12 P.M., the Physician's Social Worker said the facility reported the resident was intoxicated through the exchange on [DATE]. It was reported after hours and was sent to a provider. On [DATE] at 1:02 P.M., the Physician was notified the resident had a fall with no injuries and no information about the resident being intoxicated. The Physician's note mentioned chronic cannabis as a diagnosis. The Physician gave an order to see psychiatry services. On [DATE], the facility reported the resident was LOA with family, taken to the hospital and expired in the emergency department. It was unclear who reported the information to the Physician. 2801020

Based on interview and record review, facility staff failed to follow their abuse policy when staff failed to report a resident to resident altercation to Administration, resulting in a failure to conduct a thorough investigation into the altercation, in which one resident sustained an injury underneath his/her eye (Residents #1 and #2). The sample was four. The census was 111.Review of the facility's Abuse and Neglect policy, dated 6/12/24, showed the following:-Purpose: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Definitions:-Physical Abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Physical abuse also includes corporal punishment, which is physical punishment used as a means to correct or control behavior;-Procedure for Response and Reporting Allegations of Abuse, Neglect and Exploitation:-Any owner, operator, employee, manager, agent, or contractor of the facility can report an allegation of abuse/neglect/exploitation to the abuse agency hotline without fear of retaliation;-When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated:--The Licensed Nurse will:---Respond to the needs of the resident and protect him/her from further incident;---Notify the Administrator or designee;---Complete an incident report if indicated;---Revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse;--The Administrator or designee will:---Administrator/Designee will complete an administrative investigation to include personal statements from staff and residents involved in a situation that has any type of accusations of abuse either staff or resident abuse, any unexpected medical emergency, or when the administrative staff feel uncomfortable in any situation involving resident care or treatment or staff treatment;---Refer to the State Operations Manual (SOM) for reporting and utilize the Abuse-Neglect Reporting Decision Tree to assess the particular incident. Should the incident be a reportable event, notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than two hours after discovery or forming the suspicion;---The administrative investigation will consist of any pertinent information describing the situation being investigated, the names of all staff and residents involved, the root cause of the incident, the recommendations from the investigation including the facts that prove or disprove the alleged situation occurred, the plan of correction or action by the administrative staff, all statements attached from residents and staff involved and any training or education that the administration feels needs to be provided to staff or residents to ensure education has been provided to prevent future similar situations;---The administrative investigation will also include a review of the resident's record to ensure that the documentation reveals that the legal guardian and/or responsible party was notified (if applicable), the physician was made aware, the resident was fully assessed, interventions and physician's orders were followed, the resident was re-evaluated, and the plan of dare was updated to reflect the change in medical or behavioral status;---The facility Director of Nursing (DON)/Designee will ensure all clinical details and supportive plan of care interventions are completed for the administrative investigation;---Within five working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/5/25, showed the following:-Moderate cognitive impairment;-No moods or behaviors exhibited;-Diagnoses include anemia (a condition where the blood lacks enough healthy red blood cells to carry adequate oxygen to the body) and end stage renal disease (ESRD, the final permanent stage of chronic kidney disease where kidneys can no longer function on their own to filter waste and excess fluids). Review of the resident's nurse's notes, showed the following:-On 1/26/26 at 9:33 P.M., staff documented at about 4:20 P.M., Resident #1 was sitting at the television area. Resident #2 was seen hitting Resident #1 with his/her walking cane. Resident #1 sustained a slight bruise/cut on the side of his/her left eye. The area was cleansed with wound cleanser, triple antibiotic ointment was applied and covered with a bandage. Resident #1's family and the DON and Assistant Director of Nursing (ADON) were made aware;-On 1/28/26 at 12:14 P.M., staff documented the resident was in bed resting. The resident complained of a headache and was given medication for the pain. The resident said he/she wanted to go hospital to be seen following altercation with another resident. The resident was transferred to the hospital for further evaluation. The resident's family was notified upon resident being transferred. A message was left for the resident's physician and the DON was made aware. Review of the resident's care plan, showed no documentation regarding the resident-to-resident altercation. Review of Resident #2's quarterly MDS, dated [DATE], showed the following:-No cognitive impairment;-No behaviors exhibited;-Diagnoses included anemia, congestive heart failure, high blood pressure, and Alzheimer's disease. Review of the resident's nurse's note, dated 1/26/26 at 9:21 P.M., showed staff documented at about 4:20 P.M., the resident was seen at the television area hitting another resident with his/her walking cane. The residents were separated and Resident #2 was taken to the nursing station. A message was left for the resident's family and the DON and ADON were made aware. Review of the resident's care plan, showed no documentation regarding the resident-to-resident altercation. During an interview on 2/2/26 at 12:40 P.M., the resident said he/she was in a fight in the city a while ago. The resident said he/she did not remember any other altercation. Review of Resident #4's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment. During an interview on 2/3/26 at 7:55 A.M., Registered Nurse (RN) A said he/she was giving care to a resident in their room when he/she overheard a loud commotion going on and stepped outside the room to see what was happening. He/She heard Resident #4 asking Resident #2 why he/she hit Resident #1 with his/her cane. RN A did not see the altercation; however, Resident #1 had a cut under his/her left eye. RN A took Resident #2 to the nursing station and called the DON, the physician and family members. He/She was not asked to write a statement regarding the altercation. During an interview on 2/3/26 at 9:05 A.M., Resident #4 said Resident #1 was watching television in the common area and Resident #2 came up and started hitting Resident #1 with his/her cane. There was no exchange of words between the residents. Resident #2 just started hitting Resident #1. Resident #4 was not interviewed by the facility staff or asked to write a statement about the incident. During an interview with the DON and Administrator on 2/2/26 at 12:22 P.M., the DON said she expected staff to follow the facility's abuse and neglect policy as written. She was told Resident #2 had a fall and his/her cane accidently hit Resident #1. She read the nurse's notes in Resident #1's medical record but did not read the notes in Resident #2's record. She should have reviewed Resident #2's nurse's notes as well. She did not obtain statements about the altercation. The Administrator was said she was not aware of the altercation. The altercation should have been reported to her and then reported to the state agency within two hours. The Administrator and DON should have conducted a thorough investigation into the altercation. 2729169

Based on observation, interview and record review, the facility failed to ensure recipes were followed while preparing pureed meals. The facility had eight residents on pureed meals. The sample was six. The census was 112. Review of the facility's Dietary Food Preparation Policy, dated 7/5/23, showed the following:-Standardized Recipes: Standardized recipes will be used for all product prepared;-Procedure: -Use standardized recipes provided with menu cycle; -The Dietary Manager will monitor and check routinely the cooks' use of recipes. If favorite recipes are added to the recipe file, they must be written, standardized and approved by the Registered Dietitian; -Pureed recipes are found in the recipe binder. Observation on 9/30/25 at 12:20 P.M., showed [NAME] A took four, four-ounce scoops of diced chicken, placed it in a blender and blended for approximately 10 seconds, then added one slice of white bread and continued to blend. While blending, [NAME] A added water. [NAME] A said he/she did not know how much water he/she was adding and blended for approximately one minute. Observation after blending, showed the chicken breast to have small lumps of meat and was not smooth. [NAME] A poured the mixture into a tin pan. [NAME] A did not have a recipe present during the preparation. Review of the facility's Pureed Herb Roasted Chicken recipe, dated 2024, showed the following:-10 Servings: two tablespoons of chicken base, two cups of water and one pound and 14 oz of herb roasted chicken;-Dissolve chicken base in water to make chicken broth. Place prepared chicken in a washed and sanitized food processor. Gradually add broth and blend until smooth. Observation on 9/30/25 at 12:25 P.M., showed [NAME] A took six, four-ounce scoops of diced potatoes and placed them into a blender and blended. While blending, he/she added water. [NAME] A said he/she did not know how much water he/she was adding and blended for approximately 40 seconds. Observation after blending showed the potatoes were smooth. During an interview on 9/30/25 at 12:26 P.M., [NAME] A said he/she has been at the facility for 14 years and he/she did not feel he/she needed to look at a recipe. Observation on 10/1/25 at 1:10 P.M, showed [NAME] B took ten, eight-ounce scoops of diced carrots, five slices of white bread and one quarter cup of melted margarine and placed it into a blender and blended for about one minute. Observation after blending showed a smooth consistency. [NAME] B had the recipe present during meal preparation. During an interview on 10/1/25 at 1:12 P.M, [NAME] B said he/she always added bread to make the mixture smooth. Review of the facility's Pureed Candied Carrots recipe, dated 2024, showed the following:-10 servings: One quart and one cup of candied carrots and a quarter cup of margarine. Description: No Bread;-Place prepared vegetables and margarine in a sanitized food processor and blend until smooth. During an interview on 10/1/25 at 2:03 P.M., the Dietary Manager (DM) said he/she could not find a recipe for mashed potatoes. DM said cooks should look at recipes during meal preparation. DM said he/she did not know why the cooks did not follow the recipe or have them present during meal preparation. During an interview on 10/1/25 at 2:06 P.M., the Regional Dietary Manager (RDM) said he/she expected all recipes to be followed as written. RDM said this will ensure the proper nutrition for the residents. RDM said the recipes are kept in a binder in the kitchen for reference. During an interview on 10/3/25 at 10:50 A.M., the Administrator said the recipes should be present and followed during meal preparation. 2623652

Based on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when another resident charged and hit him/her in the arm (Residents #1 and #2). The sample was six. The census was 112.The Administrator was notified on 10/3/25 at 10:43 A.M., of the past non-compliance, which occurred on 9/24/25. The facility provided in-servicing for all staff regarding the facility's abuse and neglect policy with emphasis on monitoring behavioral residents. The deficiency was corrected on 9/25/25. Review of the facility's Abuse and Neglect Policy, dated 6/12/24, showed the following:-Purpose: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well- being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed the following:-Moderate cognitive impairment;-No behaviors;-No impairment to extremities; -Required partial to moderate assistance with activities of daily living (ADLs);-Diagnoses of anemia (a condition where there is a lower-than-normal amount of red blood cells or hemoglobin in the blood), high blood pressure and schizophrenia (a serious brain disorder that involves a distorted sense of reality, affecting thought processes, emotions, and behavior). Review of the resident's care plan, dated 9/24/25, showed the following:-Problem: The resident was involved in a resident-to-resident altercation with his/her roommate;Intervention: The resident will be moved to a different room and monitored closely when in common areas with other residents. Review of the resident's nurse's note, dated 9/24/25 at 11:03 P.M., showed the resident came to a chair in the hallway by nurse's station to sit. The resident's roommate walked calmly past desk then ran towards him/her hitting him/her on the arms. The resident kicked the other resident. The two were separated with assist from other staff. The resident said he/she did not know why his/her roommate had done that. The resident was assessed for injury. The resident had no swelling, open areas or skin discoloration. The resident said he/she is ok. A call was made to notify the Director of Nursing (DON) and Administrator. During an interview on 9/30/25 at 11:50 A.M., the resident said feels safe at the facility. He/She did not know why his/her former roommate attacked him/her. Review of Resident #2's face sheet, showed his/her diagnoses of morbid obesity and schizophrenia. Review of the resident's care plan, dated 9/24/25, showed the following:-Problem: The resident was involved in a resident-to-resident altercation with his/her roommate where he/she was the aggressor;-Intervention: The resident and his/her roommate will be separated. The resident will be monitored when in common area. The resident will be placed on one-on-one protective oversight until seen by psychiatrist. Review of the resident's nurse's notes, dated 9/24/25, showed the following:-11:03 P.M., the resident walked past the nurse's station then ran to his/her roommate (who was) sitting in a chair in the hallway. The resident started hitting him/her on his/her arms. The resident's roommate kicked him/her in the arm. Both residents were separated. The resident continually looked for the other resident. The resident was removed from the view of his/her roommate. The resident went into his/her room scratching and biting on his/her arm. The resident showed staff scrape to left scalp and temporal area. There was no active bleeding. The resident was threatening to hit his/her head on the wall and cut his/her throat The resident was encouraged out of his/her room to be monitored. The police and ambulance called for transport to the hospital. The resident refused treatment for area;-11:18 P.M., spoke with the resident's sibling, guardian, and left message with the resident's family member. The resident's doctor was called and reported behaviors and self-inflected injuries. The resident was sent out to hospital. The resident sat calmly with police awaiting ambulance. The DON and Administrator were called;-11:48 P.M., the ambulance here for the resident. The resident ambulated and got on stretcher without assist. The police escorted with resident. During an interview on 9/30/25 at 7:43 A.M., the resident said he/she was doing fine. The resident said he/she hit his/her roommate because he/she felt the roommate was watching him/her as he/she slept and he/she was frightened. The resident said he/she does not want to harm anyone or him/herself again. Observation at that time showed the resident was monitored by staff. During an interview on 9/30/25 at 11:10 A.M., Certified Medication Technician (CMT) D said there were no concerns with either resident since the altercation. CMT D said he/she was inserviced on the abuse and neglect policy. The residents should be separated immediately and reported to the charge nurse immediately. During an interview on 9/30/25 at 11:20 A.M., Licensed Practical Nurse (LPN) E said neither resident has had any further behaviors. LPN E said he/she was inserviced on the abuse and neglect policy. He/She should separate residents and report immediately. During an interview on 10/3/25 at 10:46 A.M, the Administrator said Resident #2 has been pleasant with no other issues with any residents. The resident is encouraged to engage in activities which he/she is enjoying. There are no concerns with Resident #1. 2627186

Based on interview and record review, the facility failed to provide services and/or treatment to increase or prevent reduction of range of motion. The facility failed to ensure one resident received recommended restorative therapy exercises after being discharged from skilled nursing therapy (Resident #3). The sample was six. The census was 112.Review of the facility's Restorative Nursing Program, dated 4/30/24, showed the following:-Purpose: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level;-Definition: Restorative Nursing Program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning;-Policy: -Restorative Nursing:-1. Cognitive and physical functioning of all residents will be assessed in accordance with the facility's assessment protocols;-2. The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment, goals, and preferences;-3. The discharging therapist, Restorative Nurse, or designated licensed nurse will communicate to the appropriate restorative aide, the provisions of the resident's restorative nursing plan, providing any necessary training to carry out the plan;-4. Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting in the Electronic Health Record. Review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/23/25, showed the following:-No cognitive impairment;-No moods or behaviors;-No impairment to extremities;-Partial to moderate assistance with activities of daily living (ADL);-Diagnoses of congestive heart failure, high blood pressure and hemiplegia (a form of severe, complete paralysis on one side of the body, including the face, arm, and leg, typically caused by a brain or spinal cord injury). Review of the resident's Discharge Occupational Therapy Summary, dated 2/21/25, showed the following:-Discharge Recommendations: Resident to be discharged to this skilled nursing facility with recommendations of Restorative Nursing Program. Review of the resident's care plan, dated 7/10/25, showed the following:-Problem: Resident has an ADL self-performance deficit with regards to impaired balance;-Intervention: Active Range of Motion (AROM) program resident to complete bilateral upper extremities (BUE) strength with three to six pound weights at 20 repetitions times three or as tolerated. Review of the resident's September Order Summary Report, showed an order, dated 7/18/25, for Restorative AROM program for resident to complete BUE strength with three to six pound weights at 20 repetitions times three or as tolerated every Monday. Wednesday and Friday. During an interview on 9/30/25 at 1:59 P.M., the resident said he/she has not been receiving restorative therapy with weights. The resident said he/she would like it to help build his/her strength. Review of the Restorative Nursing Program binder, showed no documentation of the weights order recommendation. During an interview on 10/1/25 at 9:52 A.M., Certified Nurse Aide (CNA) C said he/she has only been the restorative aide for about two- and one-half months. CNA C said the therapy department will give the order for restorative therapy to the Assistant Director of Nursing (ADON) and he/she will give him/her a list of orders for each resident. CNA C was not aware of the resident having order to lift weights. During an interview on 10/1/25 at 10:05 A.M., the ADON said there was another person was over saw the restorative program and he/she resigned about three weeks ago. The ADON said this is when she took over. The ADON got a list of orders from the Therapy Director. The ADON said this order must have been overlooked. During an interview on 10/1/25 at 10:12 A.M., the Director of Nursing (DON) said she expected all restorative orders obtained from the Therapy Director to be completed and ordered or recommended. The DON did not know why this order was overlooked. During an interview on 10/3/25 at 10:47 A.M., the Administrator said she expected the restorative orders to be followed as written. The Administrator said there has been turnover with the restorative aide position. 2623652

Based on observation, interview and record review, the facility failed to ensure one resident was provided with adequate supervision and staff oversight. On 9/23/25, a resident was left unsupervised in the back unsecured area during a smoking break and the resident wandered away from the facility (Resident #1). The sample was six. The census was 112. The Administrator was notified on 10/3/25 at 10:43 A.M., of the past non-compliance, which occurred on 9/23/25. The facility provided in-servicing for all staff regarding the facility's elopement and wandering policy with emphasis on monitoring residents during smoke times. The deficiency was corrected on 9/25/25. Review of the facility's Elopements and Wandering Residents policy, last reviewed on 6/12/24, showed:-Purpose: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk;-Definitions: Elopement: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so;-Policy: Preventing Elopements: -1. The facility is equipped with door locks/alarms to help avoid elopements; -2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner; -3. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary; -4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: -1. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team; -2. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan; -3. Interventions to increase staff awareness of the resident's risk, modify the resident's behaviors, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff; -4. Adequate supervision will be provided to help prevent accidents or elopements; -5. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly; -6. The effectiveness of interventions will be evaluated and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff;-Procedure for Locating Missing Resident: -1. Any staff member becoming aware of a missing resident will alert personnel using approved protocol: Code [NAME] = Elopement from facility; -2. The designated facility staff will look for the resident; -3. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The Administrator or designee should also notify the company's corporate office; -4. Director of Nursing (DON) or designee shall notify the physician and family member or legal representative; -5. Police will be given a description and information about the resident, include photos; -6. All parties will be notified of the outcome once the resident is located; -7. Appropriate reporting requirements to the State Survey agency shall be conducted; Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed the following:-Moderate cognitive impairment;-No behaviors;-No impairment to extremities; -Required partial to moderate assistance with activities of daily living (ADLs);-Diagnoses of anemia (a condition where there is a lower-than-normal amount of red blood cells or hemoglobin in the blood), high blood pressure and schizophrenia (a serious brain disorder that involves a distorted sense of reality, affecting thought processes, emotions, and behavior). Review of the resident's nurse's note, dated 9/23/25, showed the following:-10:29 P.M., the resident did not return to floor for night medications. Areas of the first floor searched including bathrooms and patio areas. Other resident rooms, showers rooms, and bathrooms on the second and third floors were checked. Other residents were asked about the resident, and none had seen him/her since the last smoke break. Staff said they had seen the resident on and off the floor throughout evening, sitting in dining room and in the lobby. The resident was engaging in activities in activity room until it closed. The Director of Nursing (DON) was called, and a message was left;-10:59 P.M., Areas outside of the building were checked for the resident. The Assistant Director of Nursing (ADON) was called and reported the resident was unable to be found. Spoke with the DON and the Administrator was called. The staff drove around the outer streets around the facility. Called to speak with the resident's family and they had not heard from the resident. The family was notified the resident was not found in facility. The police were called to file a report;-11:30 P.M., Spoke with the police officer to file a report on the resident. The resident's family member phone number was given. Review of the resident's nurse's note, dated 9/24/25, showed the following:-12:48 A.M., the doctor was called and left message to inform him/her the resident left facility and has not returned;-7:00 A.M., the resident's location remains unknown. There were no sightings noted this overnight shift;-10:11 A.M., the resident was found by activity staff not far from the facility. The resident said he/she was feeling caged and just walked away while out smoking. The resident said that he/she did not sign out, which he/she said that he/she is aware that he/she was supposed to. The resident said that he/she continued to walk and was in fear that the community would not take him/her back, so he/she was waiting for a local business to open so they could assist him/her with calling the community. The resident said that he/she just sat out all night with the local bums. The resident denies having any sexual activity while out, denies being hurt or falling. The resident allowed this writer and DON to assess his/her back, arms, legs, and torso only. A small burn to right forearm, the resident said that he/she burned him/herself with a cigarette days ago and did not report it. There were no further skin impairments noted, no complaint of pain or discomfort at this time. The resident was made aware of the need to be placed on a secured unit at this time and he/she verbalizes understanding. The resident has been placed on the third floor until further evaluation. The resident's family was made aware and allowed to speak with resident. The resident's doctor was made aware. The resident's elopement risk, smoking, and skin assessments will be updated. Review of the resident's care plan, dated 9/24/25, showed the following:-Problem: The resident had an episode of leaving the community without making staff aware. The resident said he/she felt like he/she was caged;-Intervention: The resident has been moved to the third floor secured unit for protective oversight. The resident will be allowed to go down for smoking or activities with an escort only. Face checks and intensive monitoring will be completed per facility protocol. During an interview on 9/30/25 at 11:50 A.M., the resident said he/she is fine and feels safe. The resident said he/she just wanted to go for a walk and see the city. The resident said he/she will not walk off again. Observation at that time showed the resident was pleasant and calm. During an interview on 10/1/25 at 12:09 P.M. Certified Medication Technician (CMT) F said he/she went to look for the resident around 7:30 P.M. to administer the resident's 8:00 P.M. medications. CMT F said he/she asked the charge nurse if he/she had seen the resident. The charge nurse said to look downstairs. CMT F said he/she looked downstairs but could not find the resident. CMT F said he/she went to take a break which lasted about 20 minutes and he/she tried to find the resident and still could not find the resident. CMT F said he/she told the charge nurse and they started to search for the resident but could not locate him/her. CMT F said he/she was inserviced on the facility's elopement policy and when they are smoking in an unsecured area, residents need to be monitored. During an interview on 10/1/25 at 4:26 P.M., Licensed Practical Nurse (LPN) G said about 7:00 P.M., CMT F said he/she could not locate the resident to administer the resident's medication. LPN G said the resident usually sat in the first-floor common area waiting for a smoke break. LPN G said the resident never wandered off like this before. LPN G said they started a search for the resident and followed the proper elopement protocol. LPN G said he/she was recently inserviced on the facility's elopement protocol to ensure to monitor residents when smoking in unsecured areas. During an interview on 10/2/25 at 8:36 A.M., Receptionist H said the resident was at the reception desk wanting a cigarette, so he/she gave the resident a cigarette. The resident went to go smoke with Certified Nurse Aide (CNA) G and some other residents outside. After about 30 minutes, CNA G and some other residents came in, but Resident #1 stayed outside. Receptionist H said he/she did not see the resident come in later. Receptionist H said he/she was recently inserviced on the elopement policy and to ensure residents are monitored while smoking in an unsecured area. During an interview on 10/2/25 at 1:26 P.M., CNA G said he/she took the resident outside with other residents around 9:00 P.M. to smoke. The resident seemed fine. CNA G did not see the resident come in later. CNA G was inserviced on the elopement policy and monitoring residents while outside in an unsecured area. During an interview on 10/3/25 at 10:43 A.M., the Administrator said the last employee was inserviced on 9/25/25 regarding the facility's elopement policy with an emphasis on monitoring residents in unsecured areas. There have been no concerns with the resident since the incident. 2627186

Based on interview and record review, the facility failed to meet professional standards when staff failed to administer and document medications as order by the physician for three residents. (Resident #10, Resident #12 and Resident #15). The sample was 13. The census was 111. Review of the facility's Transcription of Orders/Following Physician's Order Policy, dated 5/18/24, showed the following: -Purpose: The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders. -Procedure: A. Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in residents' electronic medical records in orders section; B. The Licensed/Registered Nurse will check the emergency kit to verify if the medication is present in the facility to begin immediately. If the medication is not available, the facility may contact the backup pharmacy to deliver the medication sooner. If the medication is unable to be started within 24 hours of the order, the prescribing physician will be notified, and further orders will be obtained. If a stat medication is ordered, the physician will be made aware of facility availability in the case that an alternative is needed. Review of the facility's Medication Administration Policy, dated 6/26/24, showed the following: -Purpose: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. It is the policy of this facility to ensure the safe and effective administration of all medications by utilizing best practice guidelines; -Policy: General Medication Administration Process: -Sign Medication Administration Record (MAR) after administered. For those medications requiring vital signs, record the vital signs onto the MAR; -If medication is a controlled substance, sign narcotic book; -Report and document any adverse side effects or refusals; -Correct any discrepancies and report to nurse manager. 1. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/3/25, showed the following: -No cognitive impairment; -No moods or behaviors; -No impairment to extremities; -Mobility device of walker and wheelchair; -Supervision with activities of daily living (ADLs) -Diagnoses of orthopedic condition and depression. Review of the resident's care plan, dated 5/21/25, showed the following: -Problem: The resident has a potential for behavior problem; -Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Review of the resident's Order Summary Report, dated 6/3/25, showed the following: -3/10/25, Duloxetine HCl Oral Capsule Delayed Release Particles (used to treat depression and anxiety) 40 milligrams (mg), give two capsules by mouth one time a day related to pain; -3/10/25, Famotidine Oral Tablet (to treat stomach ulcers) 20 mg, give 20 mg by mouth one time a day for heartburn; -3/10/25, Hydroxychloroquine Sulfate Oral Tablet (to treat inflammatory conditions, including rheumatoid arthritis) 400 mg, give one tablet by mouth in the morning related to bilateral post traumatic osteoarthritis of the hip. Review of the resident's May 2025 MAR, showed the following: -Duloxetine HCl Oral Capsule: left blank on 5/13, 5/18, 5/31/25; -Famotidine Oral Tablet: left blank on 5/12, 5/16-19, 5/21, 5/25-26/25; -Hydroxychloroquine Sulfate Oral Tablet: -Staff documented 9=See Progress Notes: 5/1-2, 5/5-7, 5/9, 5/12, 5/15, 5/16, 5/19, 5/20, 5/24, 5/26, 5/28-30/25; -Left blank on: 5/13, 5/18 and 5/31/25; -Review of the resident's progress notes, showed no documentation regarding the medication. During an interview on 6/3/25 at 10:25 A.M., the resident said he/she had a problem getting all his/her medications. He/She had been told the facility did not have his/her pain medications. 2. Review of Resident #12's quarterly MDS, dated [DATE], showed the following: -No cognitive impairment; -No behaviors; -Supervision with ADLs; -Diagnoses of high blood pressure, End Stage Renal Disease (ESRD) (the final, irreversible stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without dialysis or kidney transplantation), anxiety and depression. Review of the resident's care plan, dated 4/8/25, showed the following: -Problem: The resident has a potential for a behavior problem regards to anxiety and depressive disorder; -Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Review of the resident's Order Summary Report, dated 6/3/25, showed the following: -5/20/24, Nortriptyline (used to treat depression) HCl Oral Capsule 25 mg, give one capsule by mouth at bedtime related depression; -5/20/24, Melatonin Oral Tablet 3 mg, give two tablet by mouth at bedtime related to insomnia; -5/20/24, Amlodipine Besylate Oral Tablet 10 mg, give one tablet by mouth one time a day related to stroke. Review of the resident's May 2025 MAR, showed the following: -Nortriptyline HCl Oral Capsule: Left blank on 5/5, 5/13-22, 5/24-26 and 5/31/25; -Melatonin Oral Tablet: Left blank on 5/5, 5/13-22, 5/24-26 and 5/31/25; -Amlodipine Besylate Oral Tablet: Left blank on 5/13 and 5/19-23/25. During an interview on 6/3/25 at 9:45 A.M., the resident said he/she did not get his/her Nortriptyline medication at night. He/She said there were some other medication he/she did not get, but he/she was not sure of the names of the medications. 3. Review of Resident #15's Facesheet, showed the following: -Date of admission: [DATE]; -Diagnoses of heat failure and acute kidney failure. Review of the resident's care plan dated 6/17/25, showed the following: -Problem: The resident has altered cardiovascular status; -Intervention: Assess for chest pain every (specify). Enforce the need to call for assistance if pain starts. Review of the resident's Order Summary Report, dated 6/17/25, showed the following: -7/12/24, Hydralazine HCl Oral Tablet (used to treat high blood pressure) 25 mg, give one tablet by mouth three times a day for hypertension; -This order was discontinued on 6/6/25. -6/6/25, Hydralazine HCl Oral Tablet 25 mg, give three tablets by mouth three times a day for hypertension; -7/12/24, Isosorbide Dinitrate Oral Tablet (used to prevent angina (chest pain) caused by coronary artery disease) 20 mg ,give one tablet by mouth three times a day for hypertension; -This order was discontinued on 6/6/25; -6/6/25, Isosorbide Dinitrate Oral Tablet 20 mg ,give one and one half tablets by mouth three times a day for hypertension. Review of the resident's June MAR, showed the following: -7/12/24, Hydralazine HCl Oral Tablet 25 mg, one tablet three times a day: -7:00 A.M.: Left blank on 6/1-4/25, 9=See progress notes: 6/5/25; -12:00 P.M.: Left blank on 6/1-4/25, 9=6/5/25; -8:00 P.M.: Left blank on 6/1-3/25; -6/6/25, Hydralazine HCl Oral Tablet 25 mg, three tablets three times a day: -12:00 P.M.: 9=6/6, Left blank: 6/14; -8:00 P.M.: 9=6/6, Left blank: 6/16. Review of the resident's progress notes showed no documentation regarding the medication. -7/12/24, Isosorbide Dinitrate Oral Tablet 20 mg ,give one tablet by mouth three times a day: -7:00 A.M., Left blank on 6/1-4/25, 9=6/5/25; -12:00 P.M., Left blank on 6/1-4/25, 9=6/5/25; -8:00 P.M., Left blank on 6/1-3/25; -6/6/25, Isosorbide Dinitrate Oral Tablet 20 mg ,give one and one half tablets by mouth three times a day: -12:00 P.M., 9=6/6, 6/14, left blank; -8:00 P.M., 9=6/6, 6/16, left blank; -Review of the resident's progress notes showed no documentation regarding the medication. During an interview on 6/16/25 at 10:42 A.M., the resident said he/she did not get his/her blood pressure medication all the time. The resident said there had been times when the medications had been missed. 3. During an interview on 6/6/25 at 1:05 P.M., Licensed Practical Nurse (LPN) C said when a medication was administrated the MAR should be initialed. If the medication was not administered the MAR should be noted as refused or unable to administer and documented in the resident's medical record. If the medication was not available, one should try the emergency kit for the medication. 4. During an interview on 6/17/25 at 1:54 P.M., the Director of Nursing (DON) said she would expect the Medication Administration Policy and Physician Order Policy to be followed as written. The DON said staff should initial the MAR after administering the medication and document if the medication was not administered. If the MAR was not initialed the medication was not given and the physician order was not followed. The Administrator agreed with the DON. MO00255890 MO00253530 MO00255054

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure resident rooms were free from mice (Resident #17, Resident #15 and Resident #16). The sample was 13. The census was 111. Review of the facility's Pest Control policy, last reviewed 5/14/24, showed: -Purpose: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents; -Definition: Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats); -Policy: Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. Review of the facility's pest control invoices showed the following: -5/13/25, Treated interior kitchen, laundry for spiders and occasional invaders. Service interior rodents' stations of rodent activity, gave blue boards to maintenance and fruit fly traps; -5/20/25, Treated interior kitchen, laundry for spiders and occasional invaders. Service interior rodents' stations and dropped off traps to maintenance for rodent activity; -5/27/25, Treated interior kitchen, laundry for spiders and occasional invaders. Service interior rodents' stations with minimal rodent activity at the time of service Review of video footage received by the Department of Health and Senior Services (DHSS) on 5/7/25, showed a mouse climbing down a window screen in a resident's room. Review of a photograph received by the DHSS on 5/7/25, showed three mice on a glue trap next to the resident's bed. 1. Review of Resident #17's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/11/25, showed the following: -No cognitive impairment; -No behaviors; -Supervision with activities of daily living; -Diagnoses of diabetes, depression and schizophrenia (a serious mental health condition that affects how people think, feel and behave). During an interview on 6/16/25 at 7:15 A.M., the resident said he/she always saw mice in his/her room. The resident said he/she saw a mouse last night and one this morning. Observation of the resident's room at that time showed no signs of mice droppings. 2. Review of Resident #15's Facesheet, showed the following: -Date of admission: [DATE]; -Diagnoses of heart failure and acute kidney failure, During an interview on 6/16/25 at 10:42 A.M., the resident said he/she saw mice in his/her room all the time. Observation of the resident's room at that time, showed dirty sticky traps in the corner of the room. 3. Review of Resident #16's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No behaviors; -Partial /Moderate assistance with ADLs; -Diagnoses of anemia(a condition where the body doesn't have enough healthy red blood cells to carry adequate oxygen to the body's tissues), high blood pressure, and schizophrenia. During an interview on 6/17/25 at 7:40 A.M., the resident said he/she saw mice in his/her room at night. The resident said last night a mouse ran across the floor in his/her room. Observation of the resident's room, showed no signs of mice droppings. 4. Observation on 6/2/25 at 8:36 A.M. of the Dietary Manager's Office located in kitchen, showed a dead mouse in a box trap. 5. During an interview on 6/2/25 at 1:30 P.M., Housekeeper (HK) A said he/she saw mouse droppings when cleaning resident rooms on the second floor each day. HK A said he/she reported the sightings to the Housekeeping Supervisor. HK A said he/she had been with the facility a little over a year and the mice concern had not gotten better. He/She had not been instructed to do anything differently to resident rooms after reporting the droppings. During an interview on 6/16/25 at 8:50 A.M., HK B said he/she cleaned resident rooms on the third floor. He/she would clean bathrooms and other areas and would often see mouse droppings. He/She reported this to the Housekeeping Supervisor. He/She had not been instructed to do anything differently to resident rooms after reporting the droppings. 6. During an interview on 6/16/25 at 8:24 AM., the Maintenance Director said the facility just recently upgraded the service with the pest control company. Previously, the facility was responsible for maintaining the inside pest program. With the upgraded service, the pest control company would replace the mouse traps outside and now monitor the inside of the building to include changing out the inside traps and a detailed walk through. The pest control technician would be there on 6/17/25. This was the earliest they could come out. 7. During an interview on 6/17/25 at 2:04 P.M., the Administrator said the Maintenance Director was in responsible for the pest control program. The Administrator said she was not sure why it took so long to get the upgraded services. MO00253893 MO00253412 MO00255523 MO00253530 MO00253104 MO00255890 MO00255792

Based on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of transfer and discharge and failed to provide a written notice of transfer/discharge for one resident (Resident #4) when the resident was transferred to another facility. The sample was four. The census was 114. Review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, dated 5/14/24, showed the following: -Purpose: -Establish policy and procedure regarding the transfer/discharge of residents; -Definitions: -Facility-initiated transfer or discharge: A transfer or discharge which the resident objects to, which did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences; a. Consent to or Agreement with the discharge or transfer means that the resident or their legally authorized representative has consented to or agreed with the transfer or discharge; b. Consent or agreement of the resident means that resident, with sufficient mental capacity to fully understand the effects and consequences of the transfer or discharge, consents to or agrees with the transfer or discharge; c. Legally authorized representative means a duly appointed guardian or attorney-in-fact who has current and valid power to make health care decisions or the resident; d. Any consent shall be documented in the medical record. -Transfer and discharge: Includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. Specifically, transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility. Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. Refusal to admit a former resident shall not constitute a discharge if the former resident has been absent from the facility for more than ninety days. -Notice of Discharge or Transfer: A. Who Must Receive Notice; Before any resident is transferred or discharged under a Facility-Initiated Transfer or Discharge, the Facility must: 1. Notify the resident and the resident representative the reason for the transfer or discharge in writing in a manner they understand; 2. Notify a representative of the Office of the State Long-Term Care Ombudsman. a. A copy of the discharge/transfer notice shall be sent to the Ombudsman at least 30 days in advance of the discharge or as soon as possible; b. In the case of an emergency or immediate discharge, copies shall be sent to Ombudsman. This notice shall be sent when practicable and a monthly list is acceptable and should include if the resident's return is expected. B. What Notice Must Include: The written notice shall include the following information: 1. Reason for the transfer or discharge; 2. Effective date of the transfer or discharge; 3. Location to which the resident is being transferred or discharged , including specific address; 4. Resident's right to appeal the transfer or discharge notice to the state agency within 30 days of the receipt of the notice; 5. That if the resident files an appeal, they can remain in the facility unless and until a hearing official finds otherwise. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/17/25, showed the following: -admitted [DATE]; -Short and long term memory ok; -No moods or behaviors; -No impairment to extremities; -Partial/Moderate assistance with activities of daily living; -Diagnoses of high blood pressure, diabetes, stroke and seizure disorder. Review of the resident's facesheet, showed he/she was his/her own responsible party. Review of the resident's Social Service note, dated 3/25/25 at 4:11 P.M., showed the Social Service Director (SSD) spoke with resident's family member concerning his/her transfer to another facility; he/she had no objections and will follow-up once the transfer is complete. Review of the resident's nurse's note, dated 3/26/25 at 7:39 P.M., showed the resident discharged to another facility by taxi cab, accompanied by facility staff. The resident expressed disappointment with having to move to another facility. The resident medications was sent by administrator for safety. The resident's remainder of belongings will be sent to new facility in the morning. Review of the resident's medical record, showed no documentation of transfer/discharge notice. During an interview on 4/10/25 at 2:19 P.M., the SSD said the transfer was initiated by the Corporate staff. The SSD said he/she spoke with the resident's family member but did not speak with the resident about the discharge/transfer. During an interview on 4/11/25 at 8:13 A.M., the Administrator said the resident has been at the facility about three years. The resident was incarcerated for being a sex offender. He/She had gotten out then had a stroke and came to the facility. The Administrator said when the resident came to the facility, she did not know the facility could not have sex offenders as residents. The Director of Operations (DOO) contacted her, could not remember when, and asked if the facility had any sex offenders. The Administrator said they had one, Resident #4. The DOO said they could not have a sex offender in the building due to the locations of schools and churches in the area. The Administrator was told she had to discharge the resident to another facility. The Administrator said she did not speak with the resident, did not issue a discharge notice to the resident and did not contact the Office of the State LTC Ombudsman. The Administrator said she was not aware of the facility discharge policy from memory. She just swapped the resident for another resident from the other facility. The Administrator said the resident did not exhibit any behaviors. During an interview on 4/11/25 at 9:26 A.M., the DOO said there was a concern with a sex offender at another one of his/her facilities. When he/she did an audit and put in the facility's address, a sex offender was located at the facility, Resident #4. The facility could not have a sex offender, so the resident had to be moved to another facility. The DOO said he/she expected the Administrator to follow the facility's policy on discharge/transfer and to follow the proper protocol.

Based on observation, interview and record review, the facility failed to ensure the safety of one resident with a diagnoses of diabetes and substance abuse, who left the building unnoticed for leave of absence (LOA). Staff last saw the resident on 3/31/25 at approximately 1:00 P.M. to 2:00 P.M. It was approximately seven hours until staff realized the resident was gone. Staff did not administer ordered afternoon and evening insulin (a hormone that helps your body use blood sugar for energy) injections (Resident #2). The sample was four. The census was 114. The Administrator was notified on 4/17/25 at 9:00 A.M., of the past non-compliance, which occurred on 3/31/25. The facility provided in-servicing for all staff regarding the facility's Resident's Outside Pass Policy and Elopement and Wandering Policy. The facility also updated Resident #2's care plan. The deficiency was corrected on 4/2/25. Review of the facility's Resident Outside Pass Policy (OSP), date 6/29/23, showed the following: -Purpose: -To ensure that the facility provides education and treatment/medications to the resident/resident's responsible party upon the resident's absence from the facility to ensure continuity of care while the resident is out of the facility therefore allowing for a successful out of the facility visit without negative effects on the resident. -Procedure: -If the resident is their own responsible party, the facility will obtain the following information: -a. Where to contact the resident in the event of an emergency; -b. Who will be transporting the resident; -c. How long the resident will be absent from the facility; -d. When the resident will return to the facility; -e. Any additional information that requires the facility to further provide care. -The charge nurse/designee will complete the OSP form prior to the resident leaving the facility; -In the event that the resident does not return to the facility at the time given to the facility, the facility will attempt to contact the resident/resident's responsible party to verify the resident's return. -If the facility is not able to contact the resident/resident's responsible party, the facility will then follow the CODE PURPLE (elopement while outside of the facility) procedures. Review of the facility's Elopement and Wandering Resident's Policy, dated 6/12/24, showed the following: -Purpose: -This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk; -Elopement: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. -Procedure for Locating Missing Resident: -1. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol. -Code White= Elopement from facility; -Code Purple= Elopement while outside the facility (on OSP or doctor's appointment, etc.); -2. The designated facility staff will look for the resident; -3. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The Administrator or designee should also notify the company's corporate office; -4. Director of Nursing (DON) or designee shall notify the physician and family member or legal representative; -5. Police will be given a description and information about the resident; include any photos; -6. All parties will be notified of the outcome once the resident is located; -7. Appropriate reporting requirements to the state survey agency shall be conducted. Review of Resident #2's face sheet, showed the following: -Diagnoses of diabetes and substance abuse in remission; -The resident was his/her own responsible party. Review of the resident's March Physician Order Summary, showed the following: -3/26/25, Insulin Aspart Injection (a rapid-acting insulin used to control blood sugar levels in people with diabetes) Solution 100 Unit/Milliliters (ml), inject seven units subcutaneously (involves injecting insulin into the fatty tissue layer beneath the skin) with meals for diabetes. Review of the resident's nurse's note, dated 3/31/25 at 12:50 P.M., showed late entry, the resident in bed resting, no distress noted. The resident received scheduled accucheck (blood glucose monitoring). The resident educated on the importance of signing out of facility if he/she wanted to go to the store or any other place outside of facility. This nurse had previously seen resident going to store across from facility. Review of the resident's Medication Administration Record (MAR), dated 3/31, showed blanks for the 4:00 P.M. and 8:00 P.M. dosages. Review of the resident March Order Summary, showed the following: -3/26/25, Insulin Glargine Subcutaneous (a long-acting type of insulin that works slowly, over about 24 hours) Solution, inject 25 units subcutaneously at bedtime for diabetes. Review of the resident's MAR, dated 3/31/25, showed a blank for the 8:00 P.M. dosage. Review of the facility's LOA book, located at the front receptionist desk, showed the following: -Date: 3/31/25; -Time: 3:17 P.M.; -Destination and/or contact number: friend; -Expected date/time return: blank; -Signature of person accepting responsibility: Resident's name; -Actual time of return: blank; -Staff Initials: blank. Review of the resident's nurse's note, dated 4/1/25 at 12:00 A.M., showed a late entry, At approximately midnight (12:00 A.M.) made aware that the resident did not notify the previous nurse on day shift nurse of going LOA. Night shift nurse who had also worked day shift said he/she made the resident aware that he/she always must sign out and notify nursing so that medications can be sent with the resident. Upon receiving this information, the DON was immediately made aware, as well as Administrator and code white for elopement activated per policy. The police were notified and case number received by this Registered Nurse (RN). The DON and Administrator was made aware. The resident's physician was phoned and awaited a call back. The resident was phoned, awaited a call back. The complete facility was searched for resident. The resident's room appears to have drawers cleared out of room and DON made aware. Review of the resident's nurse's note, dated 4/1/25 at 3:30 A.M., showed staff spoke with resident's friend who said, Y'all not doing nothing for (him/her) anyway so why do (he/she) need to come back. Made him/her aware we would prefer to speak with the resident regarding his/her personal health care. The resident's friend became angry and said, I can't make (him/her) talk to you and hung up the phone. Several attempts were made by the staff to speak with the resident to encourage him/her to come pick up medications without success. Observation on 4/7/25 at 10:45 A.M., showed the resident in the common area, in a wheelchair and monitored by staff. During an interview at that time, the resident said he/she was fine and did not want to say where he/she had been. Review of the resident's nurse's note, dated 4/7/25, showed the following: -11:00 A.M., the resident arrived at the facility via staff transport via wheelchair. When resident arrived, upon cleaning him/her up, he/she had dried up bowel movement from the top of his/her perineal area all the way to his/her ankles. The resident has open area on the inner left and right thigh, that wasn't there when he/she left. This area is open and raw. He/She has a sore on the top of his/her left foot that has a scab on it; -11:06 A.M., The resident's physician was contacted with reference to resident's return to facility. Orders were received to send the resident out for evaluation. During an interview on 4/7/25 at 1:15 P.M., Certified Nurse Aide (CNA) A said he/she worked the night shift, 11:00 P.M. to 7:00 A.M. on 3/31 through 4/1/25. When he/she came on shift, he/she did rounds and the resident was not in his/her room. CNA A said he/she asked RN B if he/she had seen the resident. RN B did not know where the resident was. During an interview on 4/7/25 at 2:07 P.M., RN B said he/she came on shift at 2:00 P.M. on 3/31/25. RN B said he/she and did not get in report the resident was LOA. Towards the end of the shift, at an unknown time, CNA A came to him/her and said the resident was not in his/her room. RN B said he/she could not speak as to when the resident was last seen. RN B said the resident had a scheduled accu-check that evening but it was not completed. RN B did not think to locate the resident or find out if the resident was gone. RN B said he/she was recently inserviced on the facility OSP and Elopement Policy. During an interview on 4/8/25 at 9:45 A.M., Receptionist C said he/she worked the reception desk on the 3/31/25 evening shift, from 3:00 P.M. to 11:00 P.M. Receptionist C said the resident did not sign out with him/her before leaving. The protocol to go outside or LOA is to sign out at the nurse's station then sign out with the receptionist. The resident's name, time leaving and expected time of return should be on the sign out sheet. Receptionist C said sometimes a telephone number to be reached at will be left and sometimes not. The resident did not come back on his/her shift. It was about 10:00 P.M. or 11:00 P.M. before anyone realized the resident was gone. Receptionist C said he/she was inserviced on the facility's OSP and Elopement Policy. During an interview on 4/8/25 at 12:37 P.M. CNA D said he/she was assigned to the resident on 3/31/25 on the 3:00 P.M. to 11:00 P.M. shift. When he/she came on shift, he/she did not see the resident. CNA D said in fact, he/she did not see the resident the entire shift. CNA D assumed the resident was out in the smoking area. About 9:00 P.M., he/she told RN B he/she had not seen the resident. RN B said he/she had not seen the resident either. CNA D should have tried to lay eyes on the resident during his/her shift. During an interview on 4/9/25 at 9:05 A.M., Licensed Practical Nurse (LPN) E said earlier during the day on 3/31/25, he/she educated the resident on signing out before leaving the facility. LPN E said the last time he/she saw the resident was about 1:00 P.M. to 2:00 P.M. and the resident was in bed. LPN E did not sign out the resident later in the day on 3/31/25. LPN E said when he/she came back to work the night shift, 11:00 P.M. to 7:00 A.M. on 3/31 through 4/1/25, CNA A said he/she did rounds and did not see the resident. LPN E asked RN B about the resident and he/she said the resident was maybe downstairs. RN B said he/she did not realize the resident was not in bed. LPN E said he/she was recently inserviced in the facility's elopement policy. During an interview on 4/7/25 at 10:19 A.M., the DON and Administrator said RN B should have tried to locate the resident and administer his/her insulin as ordered. The DON said a blank spot on the MAR means the medication was not administered. The DON and Administrator said the CNA and charge nurse should have been doing rounds at the beginning of the shift to locate all residents. The Administrator said the LOA form should have been filled out completely by the receptionist with the time leaving, expected time back, and possibly a number where the resident could be reached. The Administrator said she has already inserviced staff on the facility's OSP and Elopement Policies.

Based on interview and record review, the facility failed to have a system in place to ensure residents' individual trust fund accounts were not allowed to go into a negative balance. The facility managed funds for 61 residents. A sample of eight residents were chosen and the deficient practice affected six residents (Residents #8, #30, #37, #64, #66 and #78). The census was 104. Review of the facility's Resident Trust Policy, dated 2/2/24, showed the following: -Purpose: Complete Procedures on Resident Trust Responsibilities; -Negative Balances in Resident Accounts; -On the last day of every month the Resident Trust Clerk must confirm that all transactions for the month have been posted and then should run a Current Account Balance report from the banking system on the last day of the month to verify resident balances. If any resident has a negative balance on the last day of the month a positive adjustment must be posted in the banking system to make their balance zero. The banking system batch should be labeled Negatives to Fund in the batch description. The state agency will cite the facility for any overdrawn resident accounts so this step is very important. Review of the facility's Resident Trust Transaction History, dated 5/1/24 through 9/13/24, showed the following: -Resident #8: 9/10/24, negative balance ($456.23); -Resident #30: 9/3/24, starting negative balance ($50.00) through 9/4/24, negative balance ($1038.00); -Resident #37: 9/4/24, negative balance ($126.47); -Resident #64: 9/3/24, starting negative balance ($29.97) through 9/4/24, negative balance ($5444.00); -Resident #66: 9/4/24, negative balance ($898.00); -Resident #78: 9/4/24, negative balance ($212.00). During an interview on 9/13/24 at 12:04 P.M., the Business Office Manager (BOM) said the resident trust accounts should never go into the negative and she was aware of the negative balances. The BOM said the reason for the negative balances was the facility was waiting to become representative payee for some residents. This would fix the negative balances. At that time the Administrator said she was aware and agreed with the BOM.

Based on interview and record review, the facility failed to complete and maintain monthly account reconciliations of the facility's bank statements for two months. The census was 104. Review of the facility's Resident Trust Policy, dated 2/2/24, showed the following: -Purpose: Complete Procedures on Resident Trust Responsibilities; -Resident Trust Bank Reconciliation: A reconciliation of the bank statement module must be completed monthly. This will be completed by the facility's staff accountant responsible for the facility's financials. The reconciliation must be done by someone other than the Resident Trust Clerk. Review of the facility's resident trust accounts, showed no documentation of bank statement reconciliation's from January 2024 and April 2024. During an interview on 9/13/24 at 12:05 P.M., the Business Office Manager (BOM) and the Administrator said the previous owners of the facility no longer allowed access to the bank statements. The BOM said she thought she had copies of the bank statements. The new owners took over in May 2024.

Based on interview, record review, and policy review, the facility failed to issue one of three residents (Resident (R) 84) or their responsible party out of a total sample of 26 residents a bed hold notice when R84 was sent to the emergency room . This failure could leave a resident to believe they would not be allowed to return when hospital ready from Findings include: Review of the facility policy titled, Bed Hold Policy, last revised 11/06/23 stated, .When a resident is discharged to the hospital . the Facility will provide to the resident or their legal representative, a copy of the Bed Hold Policy. Review of R84's Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed he was initially admitted on [DATE] for long-term care. Among his diagnoses on his Face Sheet were Type 2 diabetes mellitus and dementia. Review of R84s's most recent Quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) on 06/23/24 revealed his Brief Interview of Mental Status (BIMS) was an 11, indicating he was moderately cognitively impaired. Review of the Documents tab of the EMR revealed there were no documents uploaded reflecting a bed hold form was provided to R84 when he was sent out on 06/06/24 because he had missed two sessions of dialysis. An interview was attempted with R84 however the resident did not respond to questioning. During an interview on 09/12/24 at 1:05 PM the Social Services Director (SSD) verified that no bed hold notice was provided to R84 upon transfer to the hospital.

Based on interview, record review and policy review, the facility failed to notify the Ombudsman of a transfer for one of three residents (Resident (R) 84) out of a total sample of 26 residents. Findings include: Review of the facility's policy titled, Resident Transfer/ Discharge, Immediate Discharge, and Therapeutic Leave Policy last revised 05/14/24, indicated, . Who Must Receive Notice. In the case of an emergency or immediate discharge, copies shall be sent to the Ombudsman. In Section III. r their legal representative, a copy of the Bed Hold Policy. Review of R84's Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed he was initially admitted on [DATE] for long-term care. Among his diagnoses on his Face Sheet were Type 2 diabetes mellitus and dementia. Review of R84s's most recent Quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) on 06/23/24 revealed his Brief Interview of Mental Status (BIMS) was an 11, indicating he was moderately cognitively impaired. Review of the Documents tab of the EMR revealed there were no documents uploaded reflecting a transfer information was provided to the Ombudsman when R84 was sent out on 06/06/24 because he had missed two sessions of dialysis. An interview was attempted with R84 however the resident did not respond to questioning. During an interview on 09/12/24 at 1:05 the Social Services Director (SSD) verified that no transfer notice was provided to the Ombudsman when R84 transferred to the hospital. During an interview with the Administrator and Director of Nursing on 09/13/24 at 2:00 PM confirmed they were unaware the transfer information was not being sent to the Ombudsman.

Based on record review, interview, and policy review, the facility to provide one of one residents (Residents (R) 81) a Centers for Medicare and Medicaid Services (CMS) for Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) when he completed his Medicare A therapy services. This failure to provide the CMS for SNF ABN prevented the resident from knowing he had days remaining under Medicare A. Findings include: Review of the facility's policy titled, Advanced Beneficiary Notice implemented 01/01/24 stated, .The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). [sic] Contents of the form shall comply with related instructions and regulations regarding the use of the form. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary (SNF ABN), Form CMS-10055. Record review of R81's Face Sheet, located in the Profile tab of the electronic medical record (EMR) was admitted to the facility for long-term care and was being skilled in therapy after a hospital stay. Further review revealed the Social Services Director (SSD) issued a Notice of Medicare Non-Coverage 08/21/24 and the resident signed it for himself. His last covered day was 08/23/24. R81 remained in the facility and reverted back to Medicaid. Several attempts to interview R81 were made to interview with R81 however he did not wish to speak me. During an interview with the SSD on 09/10/24 at 3:58 PM, he stated he did not know he was supposed to use both forms for a resident that had Medicare A days available, and the facility team had determined the resident had returned to his prior level of function.

Based on interview, record review, and facility policy review, the facility failed to ensure each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for two of six residents (Resident (R) 30 and R1) reviewed for unnecessary psychotropic medications. Findings include: Review of the facility's policy titled, Use of Psychotropic Medication Policy last revised 06/26/24 revealed Purpose: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication .13. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. 1. Review of R30's undated Admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R30 was admitted to the facility on [DATE]. R30's diagnoses included schizophrenia, unspecified. The Admission Record did not include a diagnosis related to depression. Review of an admission Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 06/19/24 indicated R30 had a Brief Inventory of Mental Status score (BIMS) of 15 out of 15 indicating R30 was cognitively intact. The MDS also indicated R30 had one psychiatric diagnosis, schizophrenia, and was taking an antipsychotic agent and an antidepressant agent during the last seven days prior to the ARD. Review of the most recent Comprehensive Care Plan, located in the resident EMR under the Care Plan tab, initiated 08/22/24, indicated a focus area of the resident is at risk for adverse reaction r/t [related to] polypharmacy, with the goal that the resident will be free of adverse drug reactions through the review date. The interventions included If resident has more than one prescribing MD [Medical Director] < ensure that each physician has the full list of meds available, including OTC [over the counter] and PRN [as needed] meds, while ordering. Request physician to review and evaluate medications. Review pharmacy consult recommendations and follow up as indicated. The Comprehensive Care Plan also included a focus area of the resident uses antidepressant medication. The interventions included Monitor/document side effects and effectiveness Q-Shift. Monitor/document/report PRN adverse reactions to antidepressant therapy. Review of R30's active Orders located in the EMR under the Orders tab revealed an order dated 07/25/24 for mirtazapine (an antidepressant medication) 7.5 milligram (mg), amitriptyline (an antidepressant medication) 25 mg dated 07/23/24, sertraline (an antidepressant medication) 50 mg dated 06/06/24, and duloxetine (an antidepressant medication) 30 mg (an antidepressant medication) dated 06/07/24. The orders for mirtazapine, sertraline and duloxetine had an indication of schizophrenia. The order for amitriptyline had an indication for diabetes mellitus. R30's active orders did not indicate an order to monitor for antidepressant adverse effects. R30's active orders included two orders dated 06/06/24 for two antipsychotic medications with the same mechanism of action; risperidone (an antipsychotic medication) 1 mg and lurasidone (an antipsychotic medication) 40 mg, with an indication for schizophrenia. Review of R30's Medication Administration Record (MAR) for August 2024 and September 2024, located in the EMR under the Orders tab in Reports revealed no evidence of monitoring for antidepressant adverse effects. Review of a document titled -Psychiatric Progress Note dated 09/14/23 and provided by the Director of Nursing (DON) revealed a diagnostic impression which included major depressive disorder and paranoid schizophrenia. A review of two psychiatric progress notes, dated 10/12/23 and 11/10/23, revealed a diagnostic impression which included schizophrenia and depression. The treatment recommendations on all three notes indicated R30 should continue with duloxetine and lurasidone treatment. Review of a document titled Consultant Pharmacist's Medication Regimen Review dated 08/15/24 and provided by the DON, revealed the clinical pharmacist had indicated the order for amitriptyline had an inappropriate diagnosis attached to the order in the EMR and that the indication should be changed to major depressive disorder. The document had a follow-through response, dated 08/19/24, to change the indication for amitriptyline to pain. Review of the facility's pharmacy drug regimen reviews for the last 12 months did not reveal any additional pharmacy recommendations related to R30's antipsychotic or antidepressant agents. During an interview on 09/11/24 at 10:30 AM the DON stated for R30 the amitriptyline order should not be read for diabetes and the other antidepressants (mirtazapine, sertraline and duloxetine) should not have an indication of schizophrenia. She stated she was not sure why R30 was ordered the antidepressants and why they were listed with an indication of schizophrenia. The DON could not determine why R30 was also on risperidone and lurasidone combined. The DON stated if the care plan included side effect monitoring, then there should be an order and documentation in the MAR for side effects. During an interview on 09/12/24 at 1:47 PM the Clinical Pharmacist stated for R30 he would consider risperidone and lurasidone as polypharmacy because they are from the same drug class, and staff should be monitoring for antidepressant side effects. He stated the indications for the antidepressants need clarification and should be for a diagnosis the resident has. He stated he had submitted a recommendation with the August reviews for the amitriptyline indication. 2. Review of R1's undated Admission Record, located in the Profile tab of the EMR revealed R1 was admitted to the facility on [DATE]. R1's diagnoses included abnormal weight loss, but did not include a diagnosis related to depression or mood. Review of a quarterly MDS located in the EMR under the MDS tab with an ARD of 06/24/24 indicated R1 had a BIMS of 3 indicating R1 was cognitively severely impaired. The MDS indicated an active diagnosis of malnutrition but did not indicate any psychiatric diagnoses. The MDS indicated R1 was taking an antidepressant during the last seven days prior to the ARD. Review of the most recent Comprehensive Care Plan, located in the resident EMR under the Care Plan tab, initiated 08/16/24, indicated a focus area for malnutrition with interventions which included Administer medications as ordered. Monitor/document for side effects and effectiveness. The Comprehensive Care Plan did not include any further focus areas that addressed antidepressant medications. Review of R1's active Orders' located in the EMR under the Orders tab revealed an order for mirtazapine (an antidepressant medication) with an indication for mood disorder and escitalopram (an antidepressant medication) with an indication for mood disorder. Review of all active orders revealed no order to monitor for antidepressant adverse effects. Review of R1's MAR for August 2024 and September 2024, located in the EMR under the Orders tab in Reports revealed no evidence of monitoring for antidepressant adverse effects. Review of R1's Progress Notes located in the EMR under the Progress Notes tab revealed a nutrition note dated 07/31/24 that referred to the addition of supplement and a Remeron (mirtazapine) order to increase appetite. During an interview on 09/11/24 at 10:30 AM the DON acknowledged that R1's mirtazapine order should have been ordered with an indication for appetite stimulation not mood disorder and there should be side effect monitoring for the antidepressant medications.

35693 Based on medical record reviews, staff interviews and facility policy review, the facility failed to maintain complete and accessible medical records for three of 31 sampled residents ((R)6, R9 and R47) whose electronic medical records (EMRs) were reviewed for the recertification and complaint survey. Specifically, the EMRs for R6, R9 and R47 contained no current care plans following the facilities migration from one electronic medical record system to another. This meant the Certified Nurse Aids could not access a current Plan of Care to provide appropriate care and services. As well as failed to ensure the one out of eight residents (R95) medication prescription was accurately documented in the medical record. The findings include: Review of the facility policy titled, Medical Records, dated 02/2024 revealed, .The facility shall maintain medical records on each resident that are complete, accurately documented, accessible and organized. In an interview with the Administrator and Regional Director of Operations (RDO) on 09/09/24 at 3:50 PM revealed the facility had recently changed ownership and have adopted a new EMR system. They stated most of the resident's data had been migrated to the new EMR but they are still scanning hard copy chart data. They confirmed each resident should have a current care plan in the EMR. 1.a. Record review of R6's Face Sheet found in the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] from a closing sister facility. R6's diagnoses included paranoid schizophrenia, anxiety disorder, history of ETOH abuse, and sepsis. Review of R6's quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 06/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15 points indicating that R6 was cognitively intact. R6 was ambulatory without a wheelchair for short distances, however he had one in his room for longer distances/appointments. R6 was independent with most Activities of Daily Living (ADLs) and he required only standby assistance and reminders from staff. R6 had behaviors of impulsivity and poor safety awareness. The EMR review failed to include a current and active care plan for R6 since his move from the closed sister facility in December 2023. b. Record review of R9's Face Sheet found in the Profile tab of the EMR that revealed he was admitted to the facility on [DATE] with diagnoses including moderate intellectual disabilities and hemiplegia to unspecified site following unspecified cerebrovascular disease, and mood disorder. Review of R9's annual MDS Assessment with an ARD of 07/12/24 revealed a Brief Interview for Mental Status BIMS score of eight out of a 15indicating moderate to severe cognitive impairments. R9 was ambulatory per himself in a wheelchair, and he required moderate staff assistance with Activities of Daily Living (ADLs). R9 also exhibited behaviors intermittently, primarily refusals to bathe/shower, and a tendency to become loud and aggressive with staff that tried to clean him up anyway. Review of the current EMR failed to include a current and implemented care plan for R9. c. Review of R47's undated Admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R47 was admitted to the facility on [DATE]. R47's diagnoses included chronic kidney disease, polyneuropathy, essential hypertension, age-related cognitive decline, anemia, and muscle weakness. Review of R47's Medical Diagnosis, located in the Diagnosis tab of the EMR, revealed R47 also had a diagnosis of major depressive disorder, pain in the right leg, and alcohol abuse with intoxication, unspecified. Review of a quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 07/15/24 indicated R47 had a Brief Inventory of Mental Status score (BIMS) of 15 indicating R47 was cognitively intact. The MDS also indicated R47 was independent for almost all activities of daily living. Review of the most recent Comprehensive Care Plan, located in the resident EMR under the Care Plan tab, initiated 05/24/24, indicated only two focus areas: one for advanced directives for code status and a second for no known allergies. Review of a document titled Care Plan provided by the Administrator from MatrixCare, last reviewed/revised 05/01/24, revealed focus areas for behavioral symptoms related to intoxication, activities, nutritional status, behavioral symptoms related to resisting care, mood state, psychosocial well-being, pain, psychotropic drug use, falls risk, activities of daily living, and cognitive loss/dementia. In an interview with the Administrator and Director of Nurses (DON) on 09/12/24at 12:15 PM they confirmed the three residents above did not have current, accurate and accessible care plans in the current EMR for staff to access and implement. They confirmed the migration to the new electronic system had not been an easy transition, but they stated they were still working thru the changes .we fix things as we find them in chart audits . 2. Review of the facility's policy titled, Pharmacy Services Policy, revised 05/18/24, revealed Pharmaceutical Services refers to: The process (including documentation, as applicable: of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding, dispensing, packing, labeling, distributing, administering, monitoring responses to, using and/or disposing of all medications, biological, chemicals .Policy: The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Review of R95's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R95 was admitted to the facility on [DATE] with diagnoses which included Crohn's disease, unspecified, without complications. Review of R95's quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 07/10/24, revealed R95 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R95 was cognitively intact. The MDS indicated R95 was coded for pain, with a frequency of Almost constantly. Review of an Order, located in the Order tab of the EMR and dated 08/28/24 revealed an order for oxycodone-acetaminophen oral tablet 7.5/325 milligram (mg). Review of R95's Medication Administration Record (MAR), dated 08/24 and located under the Reports tab in the EMR, revealed R95 received four days of oxycodone-acetaminophen oral tablet 7.5-325 mg, from 08/28/24 to 08/31/24. Review of R95's MAR dated 09/24 and located under the Reports tab in the EMR, revealed R95 received 11 days of oxycodone-acetaminophen oral tablet 7.5-325 mg, from 09/01/24 to 09/11/24. During observations on 09/11/24 at 6:00 AM Licensed Practical Nurse (LPN) 4 was observed during medication administration punching a half tablet of oxycodone 15 mg from a blister packet that contained 51 of 90 half tablets of oxycodone 15 mg to fulfill the oxycodone/acetaminophen 7.5-325 mg order for R95. During an interview on 09/11/24 at 6:00 AM LPN4 stated the oxycodone 15 mg half tablet was what she had been administering to R95 for pain since before her recent hospitalization and that was what the pharmacy had sent. LPN 4 stated orders entered in the EMR were automatically transmitted electronically to the pharmacy for dispensing. LPN4 was unable to determine how the pharmacy sent a card for oxycodone 15 mg half tablets rather than the oxycodone-acetaminophen 7.5-325 mg tablets order found in the EMR. During an interview on 09/11/24 at 10:30 AM the DON stated the original physician's order for R95 was for oxycodone 7.5 mg without acetaminophen. The DON stated she did not know why the order was entered as oxycodone 7.5 mg with acetaminophen 325 mg. The DON acknowledged that she had entered the order in error. She stated the pharmacy filled the order from the original order sent to the pharmacy by the physician, not the order sent electronically by the facility via the EMR.

Based on observation, interview, record review and policy review, the facility failed to ensure nursing staff properly stored a residents BiPAP mask when not in use for one of one sampled resident (Resident (R) 32). Findings include: A review of the facility's policy titled CPAP/BiPAP Cleaning Policy revised 05/14/24 revealed, BiPAP mask should be cleaned daily after use, dry well and cover with plastic bag or completely enclosed in machine storage when not in use Review of R32's Admission Record, located in the Profile tab of the electronic medical record (EMR) revealed readmission to the facility on [DATE] and with diagnosis of respiratory failure, sleep apnea and chronic obstructive pulmonary disease (COPD). Review of R32's Admission Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 07/14/24, revealed the Brief Interview for Mental Status (BIMS), revealed a score of 15 out of 15 which indicated no cognitive impairment. The resident was coded as receiving noninvasive mechanical ventilator (BiPAP). During observations on 09/10/24 at 12:35 PM, and on 09/12/24 at 9:45 AM the resident's BiPAP mask was lying on top of the table at the bedside uncovered. R32 said she used her BiPAP machine daily and that staff covered it in a plastic bag one time but have not covered it since then. During an observation and interview on 09/12/24 at 9:45 AM with Licensed Practical Nurse (LPN)1 and LPN3 observed R32 in bed with BiPAP mask lying on top of the bedside table uncovered. R32 said she used her BiPAP machine last night and they use to store it in a bag, but they have not for a while. LPN1 said the BiPAP mask should be stored in a bag and LPN3 also said it was supposed to be in a bag and asked if there was a bag placed by the mask to be stored in but there was not. During an interview on 09/12/24 at 12:19 PM the Regional Director of Operations (RDO) stated BiPAP masks should be cleaned after use and bagged when not in use.

Based on interview and record review, the facility failed to provide a medication to one of eight sampled residents (Resident #1) whose diagnosis included human immunodeficiency virus (HIV, a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases) and progressive multifocal leukoencephalopathy (PML, a disease of the white matter of the brain, caused by a virus infection (polyomavirus JC) that targets cells that make the myelin sheath-the material that insulates nerve cells) when the resident was admitted to the facility on [DATE] and was not given their Biktarvy (contains three antiviral medications). The resident was discharged to the hospital on [DATE] when he/she was unable to respond. The resident expired at the hospital. The census was 87. The administrator was notified on [DATE] at 5:56 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's undated Following Physician Orders policy showed: -Procedure: -When a medication order is received the Charge Nurse receiving the order will write the order on the right-side of the Physician Order Sheet (POS); -In addition, a telephone order sheet will be completed. The yellow copy is taped in the chart, the white copy goes to medical records, and the pink copy goes to the Director of Nursing (DON). If this is a routine order the Nurse will write the order in the box on the left side of the Physician Orders Sheet (POS) as well; -A nurse's note is written when an order is received, as to why the order was obtained and that the order was carried out; -The Nurse will fax the top copy of the POS, or write on a new Order form, to the pharmacy to be filled; -The Nurse will write the order on the Medication Administrator Record (MAR), with the date the order is received; -The time of administration is recorded on the POS and the MAR (observing dosing intervals as appropriate to the medication); -The Nurse will monitor the pharmacy deliveries to ensure that the medication is received. If the pharmacy has not delivered the medication before the end of that nurse's shift, the nurse will communicate to the next shift to monitor for the medication; -If the medication is not received on the same day that it is faxed, the Nurse will call the pharmacy to ascertain the reason for delay; -The nurse will notify the Physician of the delay; -The nurse will document the delay and the reason for the delay in the nurse's notes; -When the medication is received the Nurse will ensure that it is administered in a timely fashion as ordered; -The Nurse will ensure that after the medication is administered, the MAR is initialed properly, according to the five rights and three checks to ensure the correct medication was given; -Stock medications that are available from the facility emergency kit (E-kit) will be used to start the resident on their regimen; -Any physician order that the facility cannot obtain and carry out in a timely manner, the Charge Nurse will inform the ordering doctor and make the appropriate documentation in the resident chart; -Should it be determined that a medication error has occurred either by omission, an incorrect medication administration, wrong time, wrong dosage, or wrong patient, the Physician is to be notified immediately and informed. Review of Resident #1's paper chart, from the resident's prior Missouri facility, showed -Rehabilitation Hospital discharge and clinical summary information, dated [DATE], showed the resident was treated at the medical hospital for PML, which has a very severe and high mortality risk, and the treatment was to continue the daily Biktarvy medication. Instructions were given for the resident to follow-up with the Infectious Disease (ID) Case Manager at the hospital, to set up appointments. The resident was to follow up for ID, neuro-immunology, general neurology, cardiology, and nephrology. The resident's discharge medication list included Biktarvy, dapsone, metoprolol (treats high blood pressure), Miralax (treats constipation), ibuprofen, and acetaminophen; -Facility's written admission orders, dated [DATE], showed Biktarvy [DATE] milligrams (mg), one tablet daily, for HIV and dapsone 100 mg daily for HIV. Review of the facility's contract pharmacy's medication delivery sheet, dated [DATE], showed 30 tablets of Biktarvy were delivered to the resident's former Missouri facility, which closed on [DATE]. Review of the resident's referral email, dated [DATE] at 11:05 A.M., from the company's Illinois facility Administrator, and sent to the facility's Admissions Coordinator (AC) D, with three electronic medical record attachments, showed: -Physician order report, dated [DATE], start date of [DATE], with a list of 26 physician orders that included the following medication order: -Biktarvy tablet, [DATE] mg, one tablet at 8:00 A.M.; -Face Sheet (a document which gives a resident's personal demographics, emergency contact details, and medical diagnoses). There was no diagnosis of PML on the face sheet. -[DATE] at 10:41 A.M., Social Services documented the resident's referral packet was emailed to their Missouri facility, per family's request to be closer to home. During an interview on [DATE] at 12:20 P.M., the Illinois facility's Director of Nursing (DON) (from the resident's previous facility) said they sent the resident's discharge paperwork with the resident, when they transported him/her to the Missouri facility ([DATE]). Review of an email, dated [DATE] at 12:30 P.M., sent from the Illinois facility Administrator to the surveyor, was a copy of the IL facility's Discharge Plan, Instructions, and Recap of Stay (the resident's IL facility discharge summary), dated [DATE], and a copy of the resident's POS, dated [DATE]. The IL Administrator said this discharge summary and POS were sent with the resident on [DATE], to his/her new facility. The discharge summary showed: -Initial admission to Illinois facility was [DATE]; -discharge date [DATE] to the Missouri facility; -Contact Illinois facility social services designee, telephone number written in, for any questions; -Comments: Biktarvy [DATE] mg daily; -Non-ambulatory and assistance needed with activities of daily living (ADLs); -Alert, oriented, comprehends questions and commands and has accurate recall; -Copy of electronic Physician Order Sheets, dated [DATE], included the following medication orders: -Biktarvy tablet, [DATE] milligram (mg), one tablet at 8:00 A.M. During an interview on [DATE] at 3:00 P.M., AC D said the Illinois facility emailed the resident's electronic referral, with the medical attachments, but he/she did not have a copy of the email. Once he/she uploads the resident's International Classification of Diseases codes (ICD-9 codes, diagnosis coding system) into the resident's electronic medical record and forwards the medical record attachments, which include the Face Sheet, history and physical (H&P, a record of the physical exam, brief historical information, and medical diagnoses), and physician's orders, to the facility's Medical Records employee, to upload into the resident's electronic medical record, the email is deleted. AC D said he/she received a copy of the resident's H&P and went through it. AC D said he/she did not upload or add any of the referral information into the resident's electronic medical record, because he/she was locked out of the electronic medical record at that time. AC D said he/she forwarded the referral packet to this facility's Medical Records employee for uploading into the resident's electronic medical record. During an interview on [DATE] at 3:20 P.M., Medical Records (MR) E said he/she never received the resident's referral packet. Review of the resident's electronic progress note, dated [DATE] at 1:29 P.M., showed the DON documented the resident was transferred from their sister facility with belongings. The resident denied pain or discomfort during transfer. The resident was up in the wheelchair, propelling self on and off the unit. The oncoming nurse was made aware of the new resident and vital signs were obtained. Review of the resident's paper nurse's notes, dated [DATE] (no time), showed Licensed Practical Nurse (LPN) F documented the resident was a new admission, alert and oriented two to three, with some confusion at times. Family aware of resident's transfer with medications and belongings. Resident was pleasant, quiet, and propelled self in wheelchair on the unit. Vital signs were within normal limits and oxygen saturation was 100% on room air. Awaiting return call from the resident's physician. Review of the resident's care plan showed: Problem Start Date: [DATE] for diagnosis of HIV. Goal: Resident will remain free of infection and maintain skin integrity while preventing transmission through next review date. Interventions: Administer HIV medications as ordered. Coordinate with Center for Infectious Disease to ensure agreement of plan of care. Monitor for side effects of medication. The most common side effects include nausea, vomiting, diarrhea, fever, loss of appetite, hair loss, cough, headache, stomach pains, tiredness, runny nose, insomnia (difficulty sleeping), joint pain, rash, dizziness, muscle pain, and hypersensitivity reaction. Liver toxicity is common to all treatment regimens and should be monitored by regular blood work including liver enzymes. Observe for signs and symptoms of high fever, dehydration, or malnutrition, unstable or changing vital signs, concerns over failure to take medications prescribed, increasing depression and report to MD. Provide information about the disease process and support psychosocial adjustment; -The care plan showed no problems, goals, or interventions related to the resident's diagnosis of PML or of complications related to not receiving his/her Biktarvy medication Review of the facility's paper Medication Administrator Record (MAR), dated [DATE], showed: -No order for Biktarvy [DATE]mg through [DATE]; -Biktarvy [DATE] mg, start date of [DATE], with documentation the medication was not given on [DATE] because it was not available, and the nurse was aware. --Documentation for [DATE] through [DATE], showed the Biktarvy was not available, without documentation the nurse or physician was made aware. Review of the resident's paper nurse's note, dated [DATE] 3:00 P.M. to 11:00 P.M., showed LPN F documented a call was placed to the pharmacy related to the resident's medications and Pharmacy Technician (PT) G said the resident's medications would be out on the next run. Review of the resident's paper nurse's note, dated [DATE], (no time), showed LPN F documented: -The resident's medications arrived, but there was no Biktarvy. LPN F called the pharmacy and spoke with pharmacist (RPh) H, who said it was too soon to refill the medication because a 30-day supply of the resident's Biktarvy was sent out on [DATE] (to previous facility). -There was no documentation of physician notification reporting the medication was unavailable and was not going to be given as ordered; -There was no documentation the DON or Administrator was notified; -There was no documentation of family notification; -There were no further paper nurse's notes documented until [DATE]. Review of the resident's paper nurse's note, dated [DATE] (no time), showed Registered Nurse (RN) I documented: -They were still unable to locate the resident's paper chart. Resident still not in the system. The resident's physician was notified the resident's medication (no name of medication documented) was unavailable, and pharmacy said a medication refill was too soon. Resident was up in the wheelchair, alert to self, no signs or symptoms of pain or discomfort, afebrile (free from fever), temperature (T) 97.9 degrees Fahrenheit (normal range, 97 degrees to 99 degrees Fahrenheit), pulse (HR) 76 (normal range is 60 to 100 beats per minute), and blood pressure (BP) was 130/ (diastolic reading was illegible). Normal range, systolic ,d+[DATE] and diastolic ,d+[DATE]). -There was no documentation of the physician's response to no available Biktarvy; -There was no documentation the DON or Administrator was notified there was no Biktarvy During an interview on [DATE] at 10:10 A.M., PT G said they had no clear record of the resident being at the facility until [DATE]. The Biktarvy order was sent to them on [DATE] and they tried to fill it, but it was over the facility's approved amount. During an interview on [DATE] at 1:38 P.M., the Illinois facility's Administrator said their Accounts Receivable (AR) Specialist, who is shared by both facilities, said she delivered the resident's original paper chart to the Missouri facility on [DATE]. During an interview on [DATE] at 2:45 P.M., Missouri Pharmacy Supervisor (PS) O said she investigated the situation and spoke with RPh H. PS O said they had no record of anything from the facility until [DATE], when the resident's orders were received electronically from the facility. Therefore, there could not have been a phone call between the facility nurse, PT G and RPh H, on [DATE]. There were no orders in the system, so there was no order there to talk about. RPh H canceled the resident's Biktarvy order on [DATE] because it was rejected in the system, for the high dollar amount. It won't let the pharmacists process orders that are over the facility limit. RPh sent a fax to the facility on [DATE], regarding the Biktarvy being over the facility amount and requiring approval from the DON or Administrator to be processed. They received no return fax or verbal approval from the facility for the Biktarvy. Review of the resident's electronic and paper progress notes, [DATE]-[DATE], showed no documentation regarding the medication being over the facility limit and requiring Administrator or DON approval to send. There was no documentation a fax arrived from the pharmacy, indicating the Biktarvy was over the facility's monetary limit and required DON or Administrator approval to send. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -admitted [DATE]; -The resident was unable to complete the cognition interview; -Functional self-care abilities: -Independent with bed mobility, moving from sitting to lying flat, moving from lying on back to sitting up on side of bed without back support, feeding self, wheeling self in wheelchair for 50 feet and making two turns, wheeling self in wheelchair for 150 feet within a corridor; -Staff supervision or touching assistance with oral hygiene and upper body dressing; -Partial/moderate staff assistance with bathing self, lower body dressing, personal hygiene, and toilet transfers; -Dependent on staff for toileting hygiene; -Diagnoses included deep venous thrombosis (DVT, a blood clot in one or more of the deep veins in the body, usually the legs), renal failure (kidney disease), hyperkalemia (a high level of potassium in the blood) and malnutrition. Review of the facility's paper MAR, dated [DATE], showed: -Biktarvy had nursing staff initials circled, from [DATE] through [DATE], indicating the medication was not given. -There was one written note, on the back side of the MAR, dated [DATE], which said the medication was not there and the nurse was notified. Review of the resident's electronic progress notes, dated [DATE], showed: -2:48 P.M., a call was placed to the resident' physician, to review medications, and awaiting a return call; -3:22 P.M., physician called back and received a new order for a consult at the ID clinic. During an interview on [DATE] at 2:36 P.M., Certified Nurse Aide (CNA) M said the resident seemed tired and was sleepy on Sunday, [DATE], was not talking much, and would just look at her/him. CNA M said he/she thought he/she was just tired. CNA M said he/she put the resident in a Geri chair (a large, padded chair designed to help seniors with limited mobility) that day because the resident was sliding out of the wheelchair. The resident ate some of his/her lunch and he/she laid the resident down after lunch. Review of the resident's electronic progress note, dated [DATE], showed LPN F documented: -1:17 P.M., the resident appeared to be having a dry cough, was lethargic, fatigued, alert, unable to eat, and unable to respond when spoken to; just looked at staff. Vital signs were 98.9 (T), 18 (respirations), 129 (HR), and ,d+[DATE] (BP). The physician was notified, and order received to send the resident to the hospital. The resident's family was notified; -2:39 P.M., ambulance arrived to transport the resident to the hospital. During an interview on [DATE] at 1:00 P.M., LPN F said on [DATE] between 10:00 A.M. and 12:00 P.M., the resident had increased weakness, was no longer oriented, and was not talking. The resident had a change in condition. LPN F notified the physician and sent the resident to the hospital. During an interview on [DATE] at 1:57 P.M., CNA K said he/she cared for the resident twice. Once shortly after admission and on the day they sent him/her out to the hospital. When he/she first cared for the resident, he/she could stand on one side and pivot, was able to talk, but did not talk a lot, was using a urinal, and helped with rolling in bed. On [DATE], sometime after 10:00 A.M., the resident did not look good, wasn't helping with anything, made no eye contact, and was not responding when spoken to. CNA K told the nurse there was a change in the resident's condition. Review of the hospital record, dated [DATE], showed the family spoke with the resident on [DATE] and he/she was at baseline. On [DATE], family went to visit and the resident was unable to speak and was slow to respond in any manner. On [DATE], the resident was unresponsive and brought to the emergency room . The family reported he/she took Biktarvy at the facility, alternate information indicates he/she was not getting Biktarvy. Upon arrival to the Emergency Department, the resident had hypertension (high blood pressure), was tachycardic (heart rate over 100 beats per minute), and elevated blood urea nitrogen (BUN, tests kidney function) 73 (normal range ,d+[DATE]). His/Her diagnoses included altered mental status secondary to progressive PML, HIV, acute kidney injury on chronic kidney disease, hypernatremia (a high concentration of sodium in the blood), concern for neurostorming (paroxysmal sympathetic hyperactivity, a complication of severe brain injury which is characterized by episodes of hypertension, tachycardia, tachypnea, diaphoresis, fever, and dystonic posturing). The resident expired on [DATE]. During an interview on [DATE] at 2:36 P.M., the resident's ID Physician N, (who treated the resident during his/her hospitalization from [DATE] through [DATE]), said he/she felt very strongly the resident not being on the Biktarvy was a contributing factor in the resident's death. The resident died from complications from the uncontrolled PML infection. The resident needed to be on HIV medication daily, for the rest of his/her life, to maintain the immune system. Without the Biktarvy, his/her immune system was too weak, so the virus was allowed to infect the brain and spread. The resident's only chance of surviving was for him/her to stay on the Biktarvy. Review of the DON's typed investigation summary, dated [DATE], showed: -On [DATE], the DON called their pharmacy manager, regarding the need for the residents' physicians orders and medication lists, for the many residents who were recently admitted to their facility when their sister facility was evacuated. The pharmacy manager said they were working on this for all the facilities who admitted the evacuees. -On [DATE], the resident's original paper chart arrived, and the nurse was able to admit the resident into their electronic system and order his/her medications via the computer. -On [DATE], the resident's medications arrived from the pharmacy, except for the Biktarvy. LPN F called the pharmacy technician and was told it was too soon to refill and they could not send it out until after [DATE], because a 30-day supply had been sent to their sister facility on [DATE] and the cost was billed to that facility, due to non-coverage by insurance. LPN F asked them to send it to the facility, as they had no idea where the original medication was due to the unforeseen circumstances of the facility's closure. The technician said the cost of the medication exceeded the facility's dollar amount and they would have to ensure payment before the medication could be sent out. -On [DATE], the resident's Biktarvy remained unavailable due to non-coverage by insurance and current non-payment issues with the facility. -On [DATE], the resident's facility physician was notified and said to call the ID Center to see it that physician could get the medication. The ID clinic was called and said they would need to see the resident first, since the resident had not been seen there since 2020. The facility's transportation department was told to call the clinic back to schedule an appointment and arrange transportation. -On [DATE] staff noted the resident had a poor appetite and was not going out to smoke, which he/she looked forward to daily. During an interview on [DATE] at 1:00 P.M., LPN F said the facility in Illinois brought the resident to the building. The resident only came with three medication bubble cards in a white trash bag. One was folic acid, and he/she could not recall what the other two were. LPN F said he/she called the Illinois facility three times, to get report from the resident's nurse, but they either left him/her on hold, hung up, or did not answer the phone. LPN F called the resident's facility physician and got admission orders for the bubble cards the resident came with. LPN F told the DON and the Administrator the resident's paper chart did not come with the resident. The Administrator said she was going to call their corporate office. LPN F said he/she did not think to call the pharmacy to ask them what medications the resident was on, because he/she thought the resident was only taking the three medications he/she came with. LPN F said the resident was alert and oriented, but did not ask him/her about his/her medications. LPN F put all the resident's orders in the next day, when his/her chart came. The Biktarvy did not come, so he/she called the pharmacy and was told it was too early to reorder. LPN F said he/she could not do anything about that and could not recall if he/she notified the physician or not. LPN F did not look through the resident's chart, because the resident's diagnoses were on his/her Face Sheet. During an interview on [DATE] at 1:55 P.M., LPN F said the resident had lived on an unlocked floor at the facility which closed. LPN F went there to find residents' medications, who admitted to their facility from there, but found none. LPN F spoke with PT G, who knew they had no Biktarvy, but said it was too soon to send more. LPN F said he/she called the physician but did not recall what he said. During an interview on [DATE] at 1:40 P.M., LPN J said the CMT did not notify him/her the resident was not getting the Biktarvy. LPN J called the resident's physician to get an order for a consult to the ID clinic. (There was no paper or electronic nurse's note, from LPN J, regarding a call to the resident's physician for an order for an ID consultation.) During an interview on [DATE] at 12:32 P.M., the resident's facility physician said he did not see the resident at the facility, before the resident was discharged to the hospital. The physician was out of town until [DATE], and a nurse called him during that time (date unknown). The nurse said the resident's Biktarvy was unavailable. Biktarvy is a special medication for HIV. He told the nurse to call the ID physician, the one who ordered it, to let them know so they can switch to another medication. The physician said he was not told the resident had PML and the nurses should notify him, the same day any medication is not available to be given. During an interview on [DATE] at 11:30 A.M., LPN F said they did not get the resident's paper chart until [DATE], but they had his/her physician order sheets, which were in the resident's electronic medical record. He/She added the Biktarvy to the MAR then, the day the resident was admitted . The resident came to the facility with no Biktarvy. Review of an email to the surveyor, dated [DATE] at 1:09 P.M., from RPh L with the facility's Missouri pharmacy, showed they did not receive admission medication orders for the resident until [DATE], and the orders were submitted electronically. Per the facility's rules, they did not send the Biktarvy because it flagged for a high dollar amount. Per the pharmacy's protocol, they faxed the facility a notice to have the Administrator or DON sign the approval form and return it. They did not receive the signed approval form, to send the Biktarvy. Email attachments showed: -[DATE], delivery receipt of the Biktarvy to the resident's former Missouri facility; -[DATE], electronic physician orders, from the facility, for the resident's Biktarvy; -[DATE] at 10:25 P.M., fax confirmation of the notice sent to the facility which said the Biktarvy medication exceeded the facility's maximum dollar amount and authorization from the DON/Administrator was required, prior to dispensing the medication; -[DATE], delivery receipt for the resident's other medications. The Biktarvy was not delivered. During an interview on [DATE] at 12:30 P.M., the DON said their resident's medical charts were not completely electronic, as they continued to use paper charts. All MARs and Treatment Administration Records (TARs) were paper. Neither the resident's discharge packet, nor the resident's paper chart came with the resident on [DATE], when he/she was transferred from the Illinois facility back to Missouri. The Illinois facility did not tell them about the resident's Biktarvy medication, and he/she came with none. If she knew the resident was on Biktarvy, she would not have admitted the resident because it costs thousands of dollars and Medicaid does not cover the cost. The resident came with nothing, and they could not put his/her orders into the electronic medical record until the resident's paper chart was found and delivered to them. The resident could not tell you about his/her care or medications. The resident's parent visited (date unknown) and told them about the resident's brain infection, which was why the resident was not him/herself anymore. The resident initially admitted to the previous Missouri facility sister facility on [DATE], and the pharmacy sent them a 30-day supply of the Biktarvy on [DATE]. The pharmacy said it was too early to be delivered here, before [DATE]. Additionally, the Biktarvy, which cost $4,000.00 per month, exceeded the facility's maximum designated dollar amount, so the pharmacy would not send it. They also would not send it because their sister Missouri nursing home, which closed on [DATE], had not paid for the Biktarvy sent to them on [DATE]. There was no substitute for Biktarvy, so a replacement could not be ordered. Additionally, they did not know which ID Clinic or ID Physician, was following the resident, because they did not get the resident's paper chart until [DATE]. During an interview on [DATE] at 10:38 A.M., the DON said she recalled being told something about the pharmacy not sending the Biktarvy, because their sister facility had not paid them the $4,000 owed for the Biktarvy delivered on [DATE]. However, she never spoke with the pharmacy about the resident's Biktarvy and never received a fax from the pharmacy, regarding the resident's Biktarvy. The facility has 4 or 5 faxes and there is no telling where the fax went. During an interview on [DATE] at 3:13 P.M., the Administrator said she did not recall when she became aware the resident was not receiving his/her Biktarvy. She did not recall seeing a fax from the pharmacy, regarding the resident's Biktarvy needing Administrator approval because the cost was over their limit, and the pharmacy did not call her for approval. She recalls calling the pharmacy once, but they were out and did not get back with her. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00230073

Based on observation, interview, and record review, the facility failed to protect all residents in the facility by not following acceptable infection control practice recommendations for COVID-19 from the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS). These failures had the likelihood to expose all residents in the facility to COVID-19, resulting in serious harm or death. The facility failed to screen all staff for signs and symptoms of COVID-19, prevent staff who reported as sick with symptoms of COVID-19 from providing care to residents beginning [DATE], and allowed staff to care for residents on the same day they were tested positive for COVID-19. The facility further failed to screen surveyors for symptoms of COVID-19 on [DATE]. The facility failed to ensure COVID-19 positive residents remained in their rooms or wore protective facial coverings, failed to ensure staff wore personal protective equipment (PPE) appropriately in an attempt to prevent the spread of [MEDICAL CONDITION]. The facility failed to ensure all staff changed PPE and performed hand hygiene when exiting resident rooms and prior to entering another resident room. As a result of the identified non-compliance, the Administrator was notified on [DATE] at 5:20pm of the Immediate Jeopardy (IJ) related to the facility's failure to follow the CDC guidance and recommendations and CMS Regulatory Requirements for COVID-19. The IJ was found to have started on [DATE] with the failures to appropriately screen staff for signs and symptoms of COVID-19 and prevent staff who were ill and/or COVID-19 positive from caring for the residents. Findings include: During an initial observation at the staff and visitor screening entrance of the facility on [DATE] at approximately 8:45am, Guest Services (GS1) obtained temperatures from visitors who entered the facility, but did not screen the two Surveyor visitors for symptoms of a respiratory infection, such as cough or sore throat and did not screen for international travel within 14 days or potential contact with known or suspected COVID-19. During an interview on [DATE] at 9:00am, the Administrator reported the facility housed COVID-19 positive and negative residents together on both the second and third floors and indicated COVID-19 positive residents were not kept on a separate unit. The Administrator provided Resident COVID 19 Positive Test a document that indicated on [DATE], the number of residents who tested positive for COVID-19 was 55 and nine of those residents died . The Administrator indicated two staff were confirmed as positive for COVID-19, however a number of other staff had reported symptoms of COVID-19 and were ordered to be tested by their private physician and the results of those tests were not known. The local St. Louis Health Department and staff physicians provided guidance as to when staff were able to return back to work within the facility. The facility's Employee Screening Tool and Temperature Log (tools used to screen and log staff and visitors for symptoms and fever associated with COVID-19) were provided by the Administrator on [DATE]. On [DATE], review of the facility's screening tools from [DATE]-[DATE] indicated the following: -,[DATE], ,[DATE] and [DATE]: staff/visitor's temperatures were taken, but no screenings for signs or symptoms of COVID-19 were documented. -[DATE] at 12:10am: a visitor refused to have a temperature taken and staff documented no temperature or screenings for signs or symptoms of COVID-19 were completed. -[DATE]: 22 staff/visitor temperatures were taken, but no other screening for COVID-19 was documented. -,[DATE], [DATE]: Laundry (Ldy1), no screenings documented for signs or symptoms of COVID-19 and on [DATE] also no temperature documented. -[DATE]: Maintenance (M1), no screening documented for signs or symptoms of COVID-19. -[DATE]: Nurse Aide (NA3), no temperature or screening documented for signs and symptoms of COVID-19. -[DATE]: NA4, no temperature or screening documented for signs and symptoms of COVID-19. -[DATE]: NA5, no temperature or screening documented for signs and symptoms of COVID-19. -[DATE]: Licensed Practical Nurse (LPN3), no temperature or screening documented for signs and symptoms of COVID-19. -[DATE]: NA6, no screening documented for signs and symptoms of COVID-19. -[DATE]: NA1, no screening documented for signs and symptoms of COVID-19. -,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], [DATE]: Certified Medication Aide (CMA2), no documentation of being screened. The facility provided a staff list entitled Grand Manor Staff COVID 19 Positive Test which indicated CMA2 expired in the hospital on [DATE]. Review of the Time Detail Report for CMA2 indicated she worked ,[DATE], then used sick time on [DATE] and on ,[DATE] and [DATE] used vacation time, then worked ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] (for three hours) and used 4.5 hours of vacation time, worked ,[DATE], then on [DATE] she used sick time and did not work. On [DATE] she worked 5.25 hours, then did not work again. -[DATE]: CMA1, no temperature documented. -[DATE]: Ldy2, no temperature or screening for signs or symptoms of COVID-19. -[DATE]: LPN3, no temperature documented. -,[DATE], [DATE]: NA8, no screenings were documented, no temperature documented. The Time Detail Report showed on [DATE], she worked 11:00pm-7:15am and on [DATE], she worked 11:00pm-7:45am. The facility provided a letter from NA8's physician that indicated on [DATE], NA8 was seen in the clinic and had signs and symptoms of COVID-19 and had been recently exposed to the infection. -,[DATE], ,[DATE], [DATE]: NA7, no screening documented for signs and symptoms of COVID-19 and on [DATE] also no temperature documented. The facility provided a letter from NA7's physician that indicated on [DATE] NA7 was evaluated for symptoms that represented COVID-19. NA7 was advised to self-isolate at home until seven days had passed since the symptoms first appeared. NA7's Time Detail Report indicated she cared for residents the day prior to the evaluation for symptoms by her physician and worked on the seventh day following the evaluation and the facility did not screen her for symptoms of COVID-19 or for a temperature. -,[DATE], [DATE]: CMA3, no screening or temperatures were documented. The Time Detail Report indicated on ,[DATE] and [DATE], CMA3 worked from 6:30am-2:45pm. The facility provided a letter from a physician at the Infectious Diseases Division of a local emergency department that indicated CMA3 was evaluated in the emergency roiagnom on [DATE] (the same day she cared for residents in the facility) and this letter stated CMA3 was evaluated in the (hospital ER) on [DATE]. She tested positive for COVID-19 and was advised not to return to work for at least the next fourteen days. This quarantine time-period begins on [DATE]. -HSKP5: ,[DATE], ,[DATE], ,[DATE], [DATE], no screening for signs or symptoms of COVID-19, ,[DATE], [DATE], no temperature or screening for signs or symptoms of COVID-19. The facility provided a [DIAGNOSES REDACTED]-COV2 presumptive positive test result for COVID-19 collected on [DATE] with a reporting result date of [DATE], indicating that HSKP5 worked while positive for COVID-19. During an interview on [DATE] at 11:11am, NA8 reported she tested positive for COVID-19 on [DATE]. She stated she went to work on [DATE] and had her temperature taken when she entered the building, but was not asked any questions related to feeling sick. She stated, He was the receptionist who took my temperature, but he didn't ask no questions. She said she felt sick, body aches, no taste, no smell but said she did not have a fever so she went ahead and worked and cared for residents. I was working sick when I told my charge nurse, but she said if I left work I would have to have a doctor's statement in order to come back. There was only me and the nurse and nobody showed up to work so I stayed. I stayed and worked that night, then called my doctor the next day and went and got tested . She indicated her COVID-19 test result was positive. She further indicated she feared for her health because the facility did not supply her with goggles or a N95 mask, but instead was making their own masks with paper towels and rubber bands. She stated, my co-worker passed away, (CMA2), she had [MEDICAL CONDITION]. They weren't letting anybody stay home sick. This could have been prevented she stated. Review of the CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease2019 (COVID-19) in Healthcare Settings, dated [DATE], showed the following: -Screen all healthcare professionals (HCP) at the beginning of their shift for fever and symptoms consistent with COVID-19. -Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. -Fever is either measured temperature >100.0 degrees Fahrenheit or subjective fever. Respiratory symptoms consistent with COVID-19 are cough, shortness of breath, and sore throat. During a tour of the facility on [DATE], the following observations and interviews were made on the second and third floor, resident areas, at the following times: -9:15am, the Administrator wore a surgical mask, but did not wear eye protection, gown or gloves while on the second floor. -9:15am, LPN1 on the second floor near the nursing station, wore a surgical mask instead of a N95 mask, face shield, but did not wear a gown or gloves. LPN1 indicated the facility provided PPE to nursing staff about two months ago. She left her N95 mask in her car because she has problems breathing and prefers to only wear a surgical mask. -9:15am, HSKP2 and HSKP3 mopped the hall on the second floor and wore goggles and masks, but did not wear gowns or gloves. -9:15am, NA1 on the second floor near resident rooms, wore a surgical mask, gown and face shield, but did not wear a N95 mask or gloves. NA1 said she did not wear the N95 mask because it was hot and fogged up her glasses. She further stated she had worked with both positive and negative COVID-19 residents and did not wear the N95 mask and she treated all residents as if they were COVID-19 positive. She said the facility had COVID-19 positive residents that she cared for prior to the facility having issued the N95 masks to staff. -at approximately 9:15am and 2:00pm, R08 a positive COVID-19 resident was in the hall on the second floor, and roamed near the nursing station, stood in front of and leaned on the nursing station and was not wearing a mask or facial covering. LPN1 did not attempt to direct R08 to wear a facial cover. -9:30am, HSKP1 on the second floor, wore a surgical mask, but did not wear a N95 mask, gown, eye protection or gloves. -9:43am, LPN2 on the second floor, exited a resident room and wore a surgical mask, face shield, her gown was open in the front and exposed her uniform and she did not wear gloves. LPN2 stated she had been in a positive COVID-19 resident room and had administered a medication. She further indicated she had a N95 mask and would change into that mask. LPN2 walked behind the nursing desk and removed the surgical mask then donned a N95 mask. -9:43am, HSKP1 on the second floor, entered R01's room who tested positive for COVID-19, HSKP1 wore a surgical mask instead of a N95 mask and wore a gown, face shield and gloves. HSKP1 removed a bag of trash from a trash can and did not sanitize or remove her gloves prior to touching items on R01's bedside table. She then exited the room and obtained a cloth from the housekeeping cart and went back into the same room and did not remove or change any personal protective equipment (PPE) or sanitize her gloves. HSKP1 went to R02, a negative COVID-19 tested resident and began wiping R02's bedside table. HSKP1 did not change PPE or sanitize her hands prior to going back to R01's side of the room and she wiped R01's bedside table using the same cloth. -10:00am, HSKP2 and HSKP3 mopped the hall on the third floor and wore goggles and masks, but did not wear gowns or gloves. -10:30am, GS1 reported she screened all staff who entered the facility for a day shift. She also handed out surgical type masks and eye protection to staff. -1:30pm, LPN1 on the second floor, entered the room of R03, a negative COVID-19 resident who was coughing. LPN1 wore a surgical mask instead of a N95 mask and wore a gown, face shield and gloves. She, while approximately one foot away from R03, bent down and provided care to R03 who sat in a wheelchair. After checking R03's blood sugar, LPN1 stood next to R03, approximately in the middle of the room and removed her PPE gown, then carried it over toward the door and placed it in the trash. LPN1 then walked over and washed her hands in R03's sink that was located in the middle of the room, put on clean gloves and then exited the room. -1:34pm, NA2 on the second floor, exited the room of R04 and did not perform hand hygiene or don gloves prior to entering the room of R05. NA2 then exited R05's room and did not perform hand hygiene. NA2 said gloves were not required to be worn and sanitizer was not needed. -1:50pm, CMA1 on the third floor, entered R06's room and administered medications to R06, then exited the room and pushed the medication cart down the hall. CMA1 did not wear gloves and did not perform hand hygiene after working with R06. -1:54pm, HSKP4 on the third floor, wore a surgical mask and a gown that appeared soiled and pilled while he cleaned R07's room, bathroom and removed the trash. HSKP4 did not wear a N95 mask or eye protection. HSKP4 reported he did not know if the facility had N95 masks, he did not have one to wear and preferred not to wear eye protection. He cleaned both positive and negative COVID-19 resident rooms wearing the same protective equipment and did not change or alter his PPE between resident rooms. -2:00pm, R09 ambulated up and down the halls on the third floor and in front of the nursing station and was not wearing a facial covering. Nursing staff in the area did not attempt to direct R09 to wear a facial covering. -4:00pm, the Director of Nursing (DON) reported the second and third floors contained both positive and negative COVID-19 tested residents. All staff who worked in the common areas outside of resident rooms were expected to wear eye protection, gowns and either a surgical mask or N95 mask, but not gloves. In resident rooms, staff needed to wear all PPE and prior to exiting a resident room staff needed to remove the gown, gloves and perform hand hygiene prior to exiting the room. -4:37pm, the Nurse Consultant reviewed some of the staff screening sheets and indicated staff did not document they completed the proper screening for staff to ensure symptoms of COVID-19 were screened prior to allowing staff to work. The Grand Manor Room Roster dated [DATE], provided by the Administrator who indicated a + or Neg next to the resident's names indicated R08 was positive for COVID-19 and R09 was negative for COVID-19. The CDC guidance, dated [DATE], entitled Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings indicated the following: HCP (Healthcare Professionals) (see Section 5 for measures for non-HCP visitors) who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. The CDC Coronavirus/2019 guidance entitled Preparing for COVID-19:Long-term Care Facilities, Nursing Homes directs the following guidance: Dedicate space in the facility to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Assign dedicated HCP to work only in this area of the facility. Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, prioritize for testing, transfer to COVID-19 unit if positive). Closely monitor roommates and other residents who may have been exposed to an individual with COVID-19 and, if possible, avoid placing unexposed residents into a shared space with them. The facility provided a policy entitled STRATEGIES TO PREVENT THE SPREAD OF COVID-19 IN THE FACILITY CDC MEMO DATED [DATE] RECEIVED [DATE] which directed staff to restrict residents with a fever or acute respiratory symptom to their room. If they must leave their room for a medical appointment, they are to wear a facemask and gloves. If coughing with droplets, wear disposable eye protection. Handwashing was to be completed for 20 seconds before and after contact with residents, after contact with contaminated surfaces or equipment, and after removing personal protective equipment. The policy did not indicate what types of PPE facility staff needed to wear in the different areas of the facility or when working with residents.

Based on interview and record review, the facility failed to routinely assess the skin underneath a removable bandage with an ankle fracture per physician's orders [REDACTED]. The resident developed necrotic skin tissue and decreased circulation to the left foot. The facility also failed to routinely assess one resident with a toe fracture (Resident #2) out of three sampled residents with a fracture. The census was 98. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/20/13, showed the following: -Short and long term memory loss; -Total dependence on two people for bed mobility and transfers; -Total dependence on one person for dressing, eating, toilet use and personal hygiene; -No skin or ulcer treatments. Review of the resident's physician order [REDACTED].M., for a stat x-ray of the left ankle and foot and an order at 4:00 P.M., to send the resident to the emergency room for evaluation. Review of the resident's nurse's notes, showed the following: -On 4/21/13: -At 6:15 A.M., left ankle swollen and tender to touch. No discoloration noted. Vital signs temperature was 98.2 degrees Fahrenheit (normal 98.6), pulse was 78 (normal 60 to 100 beats per minute), respirations were 18 (normal 12 to 20 per minute), blood pressure was 134/76 (normal 110/60); -At 11:00 A.M., received an order for [REDACTED]. -At 3:45 P.M., the nurse practitioner was notified of the x-ray results and he/she gave an order to send the resident to the hospital for evaluation; -At 5:20 P.M., the resident left the facility with emergency medical services; -At 10:00 P.M., the resident returned to the facility by ambulance. The resident had a splinted cast in place to the left leg and foot, secured with an ace bandage (a stretchable bandage used to create localized pressure). Follow up appointment with the orthopedic clinic (phone number and address noted) in two days. No vital signs noted. Review of the resident's radiology report dated 4/21/13, showed the left ankle had an acute [MEDICATION NAME] fibula (bone between the knee and ankle) and a medial malleolar (the bony prominence on either side of the ankle) fracture. Review of the resident's care plan, updated 4/21/13, showed the following: -The resident had a fracture to the left ankle and foot. He/she was at risk for pain; -Obtain and monitor labs, diagnostic test as ordered and notify the physician and follow up as indicated; -No information regarding assessing or monitoring the left ankle for skin condition, temperature, color, swelling or abnormal changes; -No information regarding an ace bandage or bandage changes. Further review of the resident's nurse's notes, showed the following: -4/22/13, during the 11:00 P.M. to 7:00 A.M. shift, the resident had an ace bandage dry and intact to his/her left lower extremity. The resident had a fractured fibula, no complaints of pain. Vital signs, temperature was 98.0, pulse 104, respirations were 28, blood pressure was 131/63; -4/23/13 at 6:55 A.M., the resident was closely monitored for fracture, pain level assessed. Vital signs, temperature was 98.2, pulse was 76, respirations were 18 and blood pressure was 121/75; -4/23/13 at 11:00 A.M., the resident had a broken fibula to the left foot. A follow up appointment was made with the orthopedic clinic for 4/26/13. The orthopedic clinic manager said the splint was sufficient for now, until the resident can be seen on 4/26/13. [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication) 600 milligrams (mg) was given to the resident for swelling and the extremity was elevated during the shift; -4/23/13 at 8:00 P.M., the resident's vital signs were stable. Skin warm and dry to touch. The site to the left, lower extremity had a splinted cast in place with an ace bandage (no documentation of an assessment of the left fractured ankle); -4/24/13, no documentation regarding an assessment of the left ankle fracture; -4/25/13 at 6:16 A.M., the resident's temperature was 98.7, pulse was 69, respirations were 18 and blood pressure was 126/59. The resident's pain level was assessed and controlled. The resident remained on close monitoring for a fracture (no documentation of an assessment of the left fractured ankle); -4/25/13 at 8:30 P.M., the resident's temperature was 99.0, pulse was 104, respirations were 22, blood pressure was 129/79, (no documentation of an assessment of the left fractured ankle); -4/26/13 (no time noted), the resident was resting quietly in bed. No complaints of pain or discomfort. No additional swelling or bruising noted. Vital signs: temperature was 98.4, pulse was 98, respirations were 20 and blood pressure was 72. Review of the resident's orthopedic clinic, patient after-visit summary, showed the following: -Office visit 4/26/13, 9:00 A.M.; -[DIAGNOSES REDACTED]. -Instructions: left chronic fibula fracture. Please wear ace bandage for compression and splint for a total of six weeks. Please (in bold letters) remove daily for hygiene and skin check. No need for follow up with orthopedics. No weight bearing for six weeks on left leg. Further review of the resident's nurse's notes, showed the following: -4/26/13 (no time noted), the resident's appointment with the orthopedic physician at the orthopedic clinic was rescheduled for 5/3/13. (No documentation to show the resident actually left the facility and went to the orthopedic clinic and was sent back to the facility with new instructions or that the physician was notified); -4/26/13 at 7:00 P.M., the resident's temperature was 98.7, pulse was 94, respirations were 20, and the blood pressure was 100/63. Staff gave medication for pain and it was effective, ace bandage intact to the "RLE" (right lower extremity) (no documentation of an assessment of the left fractured ankle). -4/27/13, no documentation regarding an assessment of the left ankle fracture; -4/28/13 at 4:00 A.M., the ace bandage to the right lower extremity was intact, pain medication given. The resident's temperature was 97.6, pulse was 88, respirations were 18 and blood pressure was 121/76 (no documentation of an assessment of the left fractured ankle); -4/29/13 through 4/31/13, no documentation regarding an assessment of the left ankle fracture; -5/1/13 at 9:00 A.M., no signs or symptoms of distress noted. The ace bandage remained intact to the "RLE" (no documentation of an assessment of the left fractured ankle); -5/2/13 through 5/11/13, no documentation regarding an assessment of the left ankle fracture. Further review of the resident's POS, showed an order, dated 5/4/13, for the resident to follow up with the orthopedic physician at the senior center. (There was no documentation to show the resident had this follow up appointment) Further review of the resident's nurse's notes, showed the following: -5/12/13 at 6:30 A.M., Nurse C wrote, a certified nurse aide (CNA) called him/her into the room because the CNA did not feel comfortable getting the resident out of bed due to the resident having a fracture. The nurse assessed the left foot and ankle. The foot was wrapped in an ace bandage. When the nurse slightly lifted the foot it "felt loose." The nurse put boots on the resident and the supervisor was made aware of the concern. During an interview on 5/30/13 at 12:51 P.M., Nurse C said he/she just started working at the facility. That was his/her first night working alone out of orientation. He/she trained on the day shift for three to four days and no one ever said the resident had a fracture. A CNA came to Nurse C that morning and said he/she didn't feel comfortable getting the resident out of bed. Nurse C looked at the resident's foot and said the leg felt "funny." When the nurse picked the resident's foot up the resident grimaced in pain. The foot was wrapped in an ace bandage. The CNA said the ace bandage had been on the resident since he/she'd been at the facility. When Nurse C documented the resident's foot was loose, he/she meant the foot was "lifeless." "It was just there." Further review of the resident's nurse's notes, showed the following: -5/12/13 at 10:00 A.M., (Written beneath a 5/15/13, nurse's note), Nurse A wrote, late entry, a CNA told the nurse the resident had a swollen extremity. Pain medication and [MEDICATION NAME] was given for inflammation. The extremity was elevated. An appointment was in place with an orthopedic physician for 5/16/13. During an interview on 5/29/13 at 12:35 P.M., Nurse A said on 5/12/13 at 10:00 A.M., the resident's left foot was swollen a lot of times. The CNA didn't know that. There was nothing different about the left foot to Nurse A. He/she did not unwrap the ace bandage to assess the foot or check for a pulse. He/she could only see the resident's toes. As far as Nurse A knew, no one unwrapped the bandage. Further review of the resident's nurse's notes, showed the following: -5/14/13 (no time noted), the resident's physician was notified of the resident's left foot being discolored, fluid filled and swollen. The resident will be seen at the hospital for evaluation; -5/14/13 at 10:15 P.M., the resident was admitted to the hospital with [REDACTED]. -5/15/13 (no time noted), (Late entry) showed staff called the doctor to notify him/her the resident's left foot was swollen and discolored. The doctor instructed staff to send the resident out to be evaluated. Review of the resident's weekly skin assessments and treatment administration records, showed no documentation regarding the left ankle. During an interview on 5/29/13 at 12:00 P.M., Nurse B said on 5/14/13, he/she assessed the resident's foot. The toes were fluid filled and the top of his/her foot had a raised area. The big and little toes had a reddish discoloration. Nurse B thought the foot might have had an infection. When he/she looked at the foot earlier, Nurse B did not unwrap the ace bandage. He/she just lifted the bandage. Further review of the resident's POS, showed the following: -An order to send the resident out to the hospital to be evaluated (no date noted); -No order for an ace bandage to the left ankle or to re-wrap the bandage daily. During an interview on 5/14/13 at 4:34 P.M., Emergency Medical Technician (EMT) E said the EMTs responded to the facility for a report of a swollen foot. The EMTs met with the nurse who said the resident's foot was swollen since yesterday. The resident had a brace half way up his/her leg and an ace bandage on as well. The EMT removed the ace bandage and saw an obvious ankle fracture. The resident had multiple wounds to his/her leg. The resident's toes were black, indicating necrosis (death of soft tissue). The resident had a weak to no pulse in his/her foot. The nurse said he/she had no idea what happened. Review of the resident's hospital record, showed the following: -Date of arrival: 5/14/13; -Assessment: Left lower extremity was dark purple, cold to touch; sensory deficit to pain was noted from the mid calf down. Skin break down with ulceration (a sore on the skin) noted. An old fracture to left ankle and gangrene (death of soft tissue due to obstructed circulation) of the left foot; -The ace wrap was removed today. The foot was blue/black with bullous (blister or bubble like) formation. The left ankle was grossly deformed with multiple blisters of the foot and ankle. Multiple areas of necrosis were noted. Orthopedic and vascular physicians agreed on non surgical treatment. -Physical exam: the left lower extremity was obviously deformed with significant swelling and [MEDICAL CONDITION] to the left ankle. There was no palpable (felt by touch) or dopplerable (ultrasound) pulse. The resident's toes, back of his/her foot, ankle and heel were black and gangrenous in appearance. A large drainage bullae (a blister) was on the top of his/her foot. During an interview on 5/15/13 at 8:16 A.M., the hospital social worker said when the hospital staff took the ace bandage off, they found the resident's foot to be gangrenous, grossly deformed and pulseless. The ace bandage looked as if it had not been removed for the past three weeks. The family opted to keep the resident with comfort measures only and decided not to have surgery to amputate the resident's foot. During an interview on 5/22/13 at 9:45 A.M., Nurse A said the nurse was supposed to look at and assess an area that was fractured each shift. The nurses should unwrap the bandage to see if it was swollen and document the assessment in the nurse's notes. The nurses did an incident follow up for 72 hours, information was passed on to each shift so staff can follow up and assess accordingly. Regarding this resident, the nurses should have documented on the fracture or any area of concern for more than 72 hours. "It fell through the crack." Staff should document on a fracture until it was resolved. During an interview on 5/22/13 at 11:55 A.M., the Director of Nurses (DON) and Assistant DON (ADON) said no one unwrapped the resident's ace bandage. If someone did, they did not document it. The nurses should have unwrapped the bandage and looked at the resident's foot. During an interview on 5/30/13 at 3:26 P.M., the DON said the facility received an order from the orthopedic clinic on 4/26/13, regarding the resident. The paperwork was at the back of the resident's chart. When a resident was seen by an outpatient physician, the paperwork should be given to the charge nurse when the resident returned. If the charge nurse did not receive paperwork, he/she should call the outpatient physician to follow up and see what took place and what else needed to be done. During an interview on 6/3/13 at 9:50 A.M., the resident's physician said the following: -It was normal procedure for staff to assess an area that was fractured for pain, swelling, discoloration, pulse and skin condition; -Rewrapping and assessment should be based on what the orthopedic physician ordered; -Staff should monitor a fractured area regularly and change the bandage based on what the orthopedic physician instructed; -If the orthopedic physician said to change the dressing and assess the area daily, the facility staff should have done that; -If staff were assessing the resident's foot daily, they would have known before three weeks that the resident's foot needed attention. 2. Review of Resident #2's face sheet, showed [DIAGNOSES REDACTED]. Review of the resident's care plan, updated 5/2/13, showed no documentation regarding a left toe fracture. Review of the resident's POS, dated 4/9/13 through 5/8/13, showed on 5/7/13, an order to x-ray the left foot and ankle. Review of the resident's nurse's notes, showed the following: -5/7/13 (no time noted), the resident's family member notified the staff of bruising to the resident's left foot. The doctor was notified of the bruising to the left foot. (No further description of the bruised foot or vital signs); -5/7/13 at 4:00 P.M., the x-ray staff were at the facility; -5/7/13, during the 3:00 P.M. to 11:00 P.M. shift, the resident was lying in bed. The resident had a bruise to the left foot, pedal pulse was positive (normal is positive), the capillary refill was less than three seconds (checks for blood circulation, normal is less than three seconds), the resident was able to move his/her extremities and had no complaints of pain. (No vital signs documented). Review of the resident's radiology report, dated 5/7/13, showed the left foot had a non-displaced [MEDICAL CONDITION] proximal phalanx (toe). Further review of the resident's POS, showed on 5/8/13, a [DIAGNOSES REDACTED]. Further review of the resident's nurse's notes, showed the following: -5/8/13 during the 7:00 A.M. to 3:00 P.M. shift, the resident's x-ray was completed, the physician was notified and new orders were given to buddy tape the resident's toes together and follow up with a podiatrist. The podiatrist will be in on 5/20/13, for evaluation and treatment; -5/8/13, during the 3:00 P.M. to 11:00 P.M. shift, the resident's left foot, fifth proximal phalanx was buddy taped to the next toe, per physician order. Capillary refill was less than three seconds, no complaints of pain. Temperature was 98.2, pulse was 74, respirations were 18 and the blood pressure was 110/70; -5/9/13, during the 3:00 P.M. to 11:00 P.M. shift, the resident's fifth toe was buddy taped to the toe next to it, the capillary refill was less than three seconds, no complaints of pain; -5/10/13 through 5/14/13, no documentation regarding the left toe fracture; -5/15/13 at 2:00 A.M., the resident's fifth toe remained taped to the fourth toe, no redness or swelling noted and no complaints of pain; -5/16/13 at 3:30 A.M., the resident had no complaints of pain. No redness or swelling noted to the left foot. The fifth toe remained taped to the fourth toe. Temperature was 97.8, pulse was 72, respirations were 18 and the blood pressure was 129/84; -5/16/13 (no time noted), the resident's fifth toe remained buddy taped to the toe next to it. Capillary refill less than three seconds. No complaints of pain, no swelling or redness noted; -5/16/13 (no time noted), swelling noted to the left foot. Fourth and fifth phalanx, buddy taped. The capillary refill was less than three seconds. The resident denies pain. Will continue to monitor; -5/17/13 at 9:00 A.M., the resident denied pain to the left fourth and fifth toes, no swelling noted, the capillary refill was less than three seconds. The foot was cleansed with soap and water, the fourth and fifth toes were buddy taped and rewrapped. No redness or discoloration noted; -5/17/13 during the 7:00 A.M. to 3:00 P.M. shift, the resident was in no acute distress, his/her pedal pulse was positive to the left foot. No complaints of pain; -5/17/13 (7:45 P.M.), the resident returned to the facility with his/her daughter with complaints of chest pain. The resident was lethargic, wet and clammy. The resident was transported to the hospital by ambulance. Review of the resident's treatment administration record, showed no documentation regarding the left foot until 5/22/13. During an interview an interview on 5/30/13 at 2:40 P.M., the ADON said she only knew of the buddy tape being changed once when she changed the tape. It was documented. During an interview on 6/3/13 at 9:40 A.M., Physician D said buddy tape should be changed every few days. It was a very good idea for staff to assess the area for pain, swelling and discoloration and this should be documented. 3. During an interview on 5/22/13 at 11:55 A.M., the DON and ADON said the following: -When there was a change in condition, the nurse should document an assessment, the assessment should include the site, if pain was present, amount of swelling, and discoloration; -The nurse should monitor, assess and document every shift until the problem was corrected, and longer than 72 hours if something was going on. 4. The facility did not have a policy and procedure for assessing a resident with a fracture or a change in condition. MO 799 MO 344 MO 357