Every finding on record at Heisinger Bluffs Healthcare Western Campus

Based on observation, interview and record review, facility staff failed to develop and implement a person-centered care plan to include use of compression stockings for edema for two residents (Residents #6 and #15), cleanliness and maintenance of oxygen equipment for two residents (Residents #15 and #81), and monitoring for risks of opioid administration for one resident (Resident #10) out of eight sampled residents. The facility census was 57.1. Review of the facility's policy titled Resident Centered Care Plan, dated 07/17/23, showed the facility will develop and implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and medical and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument process. Each resident's care plan will describe services that are to be furnished to attain or maintain the resident's highest practicable physical well-being. The care plan will incorporate identified problem areas and risk factors associated with identified problems. 2. Review of Resident #6's Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/09/26 showed staff assessed the resident as cognitively intact with diagnoses of congestive heart failure and blood clot. Review of the resident's care plan, dated 10/23/25, showed the care plan did not address the use of compression stockings for lower extremity edema.Review of the resident's physician order sheet (POS) showed an order, dated 02/19/26, for compression stocking (a tubular sleeve designed to provide even compression for general edema), to bilateral lower extremities. Apply in the morning and remove at bedtime.During an interview on 03/31/26 at 12:34 P.M., the resident said his/her feet and legs are swollen and staff assist him/her to put on compression stockings. Observation on 03/31/26 at 1:05 P.M., showed the resident had bilateral lower leg edema and wore compression stockings. 3. Review of Resident #10's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Severely cognitively impaired;-Diagnoses of hip and other fractures, altered mental status and delirium;-Opioids in use;-Dependent on staff for care and required substantial/maximum assistance with mobility.Review of the POS showed an order, dated 04/30/25, for hydrocodone-acetaminophen (opioids medication) 5-325 milligrams (mg) every six hours as needed for pain.Review of the resident's care plan, dated 02/18/26, showed the care plan did not address the risks associated with opioid administration. 4. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Moderately cognitively impaired;-Diagnoses of peripheral vascular disease, kidney insufficiency, respiratory failure, pneumonia, stroke and dementia;-Required continuous oxygen therapy.Review of the resident's POS showed:-07/19/24: Tubi-grips to both lower extremities, on in the morning and off at bedtime;-03/04/26: Oxygen at two to four liters per minute via nasal cannula as needed.Review of the resident's care plan, revised 02/05/26, showed oxygen administration and use of compression stockings for lower extremity edema administration were not addressed.Observation on 04/01/26 at 9:55 A.M., showed the resident wore a double pair of socks to both feet and did not have oxygen on. 5. Review of Resident #81's admission MDS, dated [DATE], showed staff assessed the resident as:-Severe cognitively impaired;-Diagnoses of atrial fibrillation, coronary artery disease and kidney insufficiency;-Shortness of breath.Review of the resident's care plan, dated 03/05/26, showed it did not address oxygen administration.Review of the resident's POS showed an order, dated 03/05/26, for oxygen at two to four liters per minute via nasal cannula as needed. Observation on 04/01/26 at 9:02 A.M., showed the resident wore oxygen while he/she ate breakfast in the dining room.Observation on 04/02/26 at 10:07 A.M., showed the resident wore oxygen in bed. 6. During an interview on 04/03/26 at 10:50 A.M., the Director of Nursing (DON) said the Minimum Data Set (MDS) Coordinator is responsible for developing and revising care plans. He/She said the nurse's sand an email or report changes verbally to the MDS Coordinator. The DON said care plans should include oxygen therapy, use of compression stockings, and medication risks to be monitored.During an interview on 04/03/26 at 11:05 A.M., the MDS Coordinator said he/she is the primary person responsible for generating and updating care plans. For new admissions, he/she uses the admission paperwork, orders and MDS Care Area Assessment summary to identify care plan needs. Changes for existing residents are communicated by the nurses. He/She said oxygen therapy, use of compression stockings and medication risks to be monitored should be care planned. The MDS Coordinator said he/she did not know why they had not been care planned.During an interview on 04/3/26 at 11:21 A.M., the Administrator said care plans are the responsibility of the charge nurse, MDS Coordinator, DON and Assistant Director of Nursing (ADON). He/She said oxygen therapy, use of compression stockings and medication risks to be monitored should be included on the care plan.

Based on interview and record review, facility staff failed to complete a Level I Pre-admission Screening (used to evaluate for the presence of psychiatric conditions to determine if a Pre-admission Screening and Resident Review (PASARR) level II screen is required) as required for one resident (Resident #7) out of 16 sampled residents with a new mental health diagnosis. The facility census was 62.1. Review of the facility's policy titled Resident Assessment-Coordination with PASARR Program, dated 09/24/24, showed a Negative Level I Screen-permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. Review showed-A record of the pre-screening shall be maintained in the resident's medical record;-The Social Services Director (SSD) shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority;-Any resident who exhibits newly evident or possible serious mental disorder, intellectual disability or related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. 2. Review of Resident #7's Level I Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability, or Related Condition, dated 03/30/23, showed the screening did not contain a diagnosis of Delusional Disorder.Review of the resident's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/18/25, showed staff documented the resident admitted to the facility on [DATE], and did not have a diagnosis of delusional disorder.Review of the resident's Annual MDS, dated [DATE], showed:-readmitted to the facility 04/21/25;-Not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition;-Psychotic disorder other than schizophrenia.Review of the resident's care plan, dated 10/10/25, showed:-Diagnosis of delusional disorders;-Behavioral health consultations as needed;-Observe for signs and symptoms of mania or hypomania, racing thoughts, euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked changes in need for sleep, agitation or hyperactivity.Review of the resident's face sheet showed a diagnosis of Delusional disorders.Review of the resident's medical record did not contain documentation the resident had been referred to the appropriate state-designated authority for Level II PASARR evaluation and determination due to new psychiatric diagnosis.During an interview on 04/03/26, at 11:00 A.M., the SSD said he/she is responsible for completing Level I and Level II PASARRs on the residents. The SSD said he/she did not submit a new Level I PASARR for the resident with the new diagnosis of delusional disorder because he/she thought a new Level I only had to be submitted when a resident had a geriatric hospital stay.During interview on 04/03/26 at 11:00 A.M., the administrator said the SSD is responsible for completing the Level I and Level II PASARRs for residents. The administrator said he/she was not familiar with the requirements for submission.

Based on interview and record review, facility staff failed to ensure one staff member (Registered Nurse (RN) A) had the required documentation to work in a long term care facility in Missouri. The facility census was 63. 1. Review of the facility policy's did not contain information to direct staff in regards to verification to be eligible to work in Missouri. Review of Registered Nurse A's employee file showed a hire date of 7/3/2014 as the Director of Nursing (DON). Review of RN A employee file did not contain documentation he/she was eligible to work at the facility. Review of RN A's earning statement, dated 4/27/25 through 5/10/25, showed RN A was paid for thirty two hours regular pay. During an interview on 6/6/25 at 8:31 A.M., the interim DON said he/she was asked to step in as interim DON because RN A needed some time off. He/She said multiple staff help do day to day tasks in RN A's absence and he/she does all mandatory meetings. During an interview on 6/6/25 at 8:39 P.M., the administrator said RN A is from another country and is on a school visa. He/She said RN A went to renew his/her nursing license on 4/30/25 and was unable to because there was an issue with his/her immigration paperwork. He/She said they immediately removed him/her from his/her position as the DON and got an interim DON. The administrator said RN A has helped with tasks like a science fair and reviewing referrals. RN A used his/her paid time off until he/she can get back in good standing. During an interview on 6/6/25 at 9:34 A.M., the human resources manager said RN A's license is inactive and he/she is taking PTO. He/She said RN A had a student visa and was unable to renew. He/She said he/she did not check RN A's Employment Eligibility Verification (a document required by the U.S. government to verify the identity and employment authorization of individuals hired for employment in the United States) to see if he/she could still be employed. He/She said Cross their mind they thought it would be handled quickly and just that RN A could not use his/her nursing license He/She said once it was brought to his/her attention RN A was no longer eligible to be employed, he/she terminated RN A. During an interview on 6/6/25 at 10:14 A.M., RN A said he/she came here from another country for school and had a renewable job permit. RN A said he/she sat out spring semester of 2024 and when he/she went to re-enroll in school for fall of 2024 he/she was told it was not renewable because he/she had lost his/her visa because he/she did not attend school in spring of 2024. He/She said he/she did not realize he/she was unable to legally work because his/her nursing license was still active. MO00254908

Based on interview and record review, facility staff failed to ensure the admission policy did not require the resident and/or responsible party to waive facility liability for loss or damage to personal belongings and failed to complete a Resident Inventory Listing for three residents (Resident #1, #2 and #3) out of three residents. The census was 59. 1. Review of the facility's Resident Personal Property policy, dated 11/2024, showe the resident is allowed to have personal belongings. Staff are directed to inventory and documented upon admission resident items and when replenished. Review of the facility's Resident Handbook policy, undated, showed the facility is not responsible for lost or missing items of any value. This includes, but is not limited to, personal effects such as jewelry, money, valuables, televisions, hearing aids, dentures, and eyeglasses. Review of the facility's Resident Inventory Listing form showed the form contained: -A list of types of belongings to be checked with blank areas for inventory not listed to be written in; -A signature and date line for the resident or legal representative upon admission and discharge; -A signature line and date line for the staff member completing the form upon admission and discharge. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/11/24, showed staff documented the resident was admitted to the facility on [DATE]. Review of the resident's medical record showed the Resident Handbook signed on 05/09/24, signed by the resident/responsible party and facility representative. The medical record did not contain documentation staff completed a Resident Inventory Listing form. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff documented the resident was admitted to the facility on [DATE]. Review of the resident's medical record showed a Resident Handbook signature page, dated 07/17/24, signed by the resident/responsible party and facility representative. The medical record did not contain documentation staff completed a Resident Inventory Listing form. 4. Review of Resident #3's Discharge MDS, dated [DATE], showed staff documented the resident was admitted to the facility on [DATE]. Review of the resident's medical record showed a Resident Handbook signature page, dated 10/14/24, signed by the resident/responsible party and facility representative. The medical record did not contain documentation staff completed a Resident Inventory Listing form. 5. During an interview on 12/18/24 at 9:55 A.M., Registered Nurse (RN) B said the nursing staff completed the inventory sheets upon admission. He/She said he/she did not know who was responsible to complete them for Resident #1, #2, or #3. During an interview on 12/20/24 at 8:08 A.M., the administrator said the nursing staff were responsible to complete the inventory sheets upon admission. He/She said he/she did not know who was responsible to complete the inventory sheets for Resident #1, #2 or #3 and could not locate the completed inventory sheets in the resident's medical records. He/She said there was no audit in place to ensure the inventory sheets were completed upon admission. He/She said the resident's or representative are provided with a resident handbook as part of the admission agreement. He/She said the resident and/or representative sign the Resident Handbook form, stating they have received a copy of the handbook, but he/she did not know if the resident and/or representative read through the entire pamphlet. He/She said the Resident Handbook did contain documentation the facility did not reimburse for missing or lost items. The administrator said he/she did not know it was a regulatory violation to not reimburse a resident for missing or lost items. During an interview on 12/20/24 at 8:09 A.M., the Director of Nursing (DON) said the nursing staff were responsible to complete the inventory sheets upon admission and the admission nurse would double check the sheets. The DON said he/she or the Assistant Director of Nursing (ADON) would be responsible to audit to ensure the process was completed. The DON said he/she did not know who was responsible to complete the inventory sheets for Resident #1, #2 and #3. The DON said he/she overlooked checking the resident's medical records to ensure staff had completed the inventory sheets. He/She said the resident's or representative are provided with a resident handbook as part of the admission agreement. He/She said the resident and/or representative do sign the Resident Handbook form, stating they have received a copy of the handbook, but he/she did not know if the resident and/or representative read through the entire pamphlet. He/She said the Resident Handbook did contain documentation the facility did not reimburse for missing or lost items. MO00246245

Based on interview and record review, facility staff failed to implement their grievance protocol for one resident (Resident #1) when he/she reported a missing cellular phone and staff did not document the results of the investigation for the missing cellular phone. The facility census was 59. 1. Review of the facility's Nursing Home Residents Rights policy, undated, showed staff were directed to provide prompt efforts to resolve grievances, and provide a written decision upon request. Review of the facility's Grievances Complaints, Recording and Investigating policy, undated, showed: -All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s); -The Grievance Officer/designee will record and maintain all grievance and complaints on the facility approved log; -Documentation of the investigation and actions taken in response will be maintained at the facility. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/11/24, showed staff documented the resident admitted to the facility on [DATE]. Review of the facilities investigation, dated 12/06/24, showed staff documented the resident's family member notified facility staff he/she attempted to contact the resident by cellular phone for several days and was unable to reach him/her via cell phone. The staff and the family member searched for the cellular phone and were not able to locate it. Review showed the facility did not have documentation a grievance form had been completed for the missing cell phone. During an interview on 12/18/24 at 9:43 A.M., the resident said he/she did have a phone, but it has been missing. He/She said he/she reported the missing phone to his/her family member, but not the staff. During an interview on 12/20/24 at 8:08 A.M., the administrator said the resident's family member reported the resident's cell phone was missing. He/She said he/she did not know if staff completed a grievance form for missing items or if one was given to the resident and/or the resident's representative. He/She said the facility did not have a designated grievance person, but they are looking at designating someone for the position. He/She said there was no paper trail when a resident reported a grievance. He/She said there was a potential a grievance could be overlooked, since there was no documentation of the reported grievance. He/She said staff verbally informed the resident and/or representative of the grievance resolutions. MO00246245

Based on observations, interviews, and record review, the facility staff failed to properly secure potentially hazardous chemicals and objects in three facility rooms on 100 hall and properly secure the medicine cart on 300 hall, in a manner to prevent accidents. Facility staff failed to transfer one resident (Resident #17) of three sampled residents safely in the mechanical lift. The facility census was 58. 1. Review of the facility's policies showed staff did not provide a storage of hazardous items policy. 2. Observation on 10/15/24 1:47 P.M. showed the 100 hall spa door open and unsecured and unattended. The spa contained a wound cleanser, adhesive remover and one tube of zinc oxide maximum strength cream. Observation on 10/15/24 at 2:03 P.M., showed the 100 hall laundry door open and unsecured and unattended. The laundry room contained one container of premoistened wipes with an ethyl alcohol-based cleaning formula. Observation on 10/16/24 8:58 P.M. showed the 100 hall supply room door unsecured and unattended. The supply room counter and unlocked cabinet contained: -Odor eliminator bottle, -Eight bottles of perineal cleanser; -25 finger nail clippers; -70 disposable razors; During an interview on 10/18/24 9:08 A.M., Certified Medication Technician (CMT) E said all potentially hazardous chemicals should be locked up and out of reach of the residents. He/She said a confused resident could ingest them which may cause sickness or worse. He/she said sharp objects could cut someone. He/she said chemicals, razors, and nail clippers could be dangerous in the wrong hands. He/she said it was the responsibility of all staff to make sure potiential hazardous chemcals and objects were properly secured. During an interview on 10/18/24 8:56 A.M., Registered Nurse (RN) K said all potentially hazardous chemicals should be locked up and out of reach of the residents. He/she said that a confused resident could get chemicals in their eyes and/or ingest the chemicals, causing sickness or poisoning. He/she said sharp objects could injury a resident or employee. He/she said that any one could properly secure the hazardous objects from the residents. During an interview on 10/18/24 9:19 A.M., the Director of Nursing (DON) said hazardous chemicals and sharp objects should be locked up and out of the reach of residents. He/she said that the residents could injure or poison themselves. He/she said chemicals, objects such as razors and nail clippers could be dangerous in the wrong hands. During an interview on 10/18/24 9:45 A.M., the administrator said hazardous chemicals and objects should be locked in a room or secured inside the room. He/she said the this is to prevent harm to the residents or staff. He/she said all staff had the responsibility to make sure hazards were properly secured and ultimately is the responsiblity of nursing and the adminstrator. 3. Review of the facility's Medication Storage policy, undated, showed: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The nursing staff shall be responsible for maintaining medication storage in a safe manner; -Compartments, including but not limited to carts, containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Review of the Medication Administration policy, undated, showed during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide, clearly visible to the nurse administering medications, and all outward sides must be inaccessible to residents and others passing by. 4. Observation on 10/17/24 at 8:46 A.M., showed RN D step away from the 300-hall medication cart and passed through a door that lead down the stairs. He/She did not lock the cart or keep the cart in visible view. Observation showed multiple resident and staff walked past the medication cart. Observation on 10/18/24 at 8:17 A.M., showed RN D step away from the 300-hall medication cart by the dining room and did not lock the cart or keep the cart in visible view. Observation showed multiple resident and staff walked past the medication cart. During an interview on 10/18/24 at 8:22 A.M., RN D said the medication cart should be locked or someone could get into it and take something. He/She said typically he/she locks the cart, but was in a hurry and got busy. He/She said it is his/her responsibility to ensure the cart is kept locked since he/she is responsible for the medications. During an interview on 10/18/24 at 9:18 A.M., the DON said staff responsible for medication administration are expected to keep the medication cart locked when he/she steps away from it to keep the contents safe and residents or others free from getting into the cart. During an interview on 10/18/24 at 9:41 A.M., the administrator said he/she would expect nursing to keep the medication cart locked when out of sight or when stepping away from it to keep unauthorized individuals from accessing it for safety. 5. Review of the facility's Safe Lifting of Residents policy, undated, showed floor-based lifts require a minimum of two person assist. The policy did not contain direction on how to complete a transfer with the lift. 6. Review of Resident #17's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/08/23, showed staff assessed the resident as: -Cognitively impaired; -Dependent on staff for all transfers. Observation on 10/16/24 at 10:43 A.M., showed CNA F and CNA G provided transfer assistance to the resident using a mechanical lift from the bed to a reclining wheelchair. CNA G lifted the resident from the bed and left the resident suspended in the air without hands on the resident while CNA F positioned the reclining wheelchair. During an interview on 10/16/24 at 11:03 A.M., CNA G said two staff should perform mechanical lift transfers. One staff member to operate the lift and the second staff member to guide the resident. He/She said its not safe to leave the resident suspended without someone holding onto them while they are in the air and it could scare the resident. The CNA said that there isn't much room in the resident's room to position the chair and work the lift around so staff does the best they can. During an interview on 10/16/24 at 11:13 A.M., CNA F said he/she knew it was not ok to leave the resident suspended but needed to get the wheelchair in place. If you leave a resident suspended, they might fall and get hurt. During an interview on 10/18/24 at 8:27 A.M., RN D said staff should never leave a resident suspended in the mechanical lift without a staff member holding them for safety. The resident could slip out of the sling or the lift could tip over. He/She said that staff should be trained prior to using the lift. During an interview on 10/18/24 at 9:18 A.M., the DON said two staff should use the hoyer to ensure the resident remains safe. One staff is to guide the lift and the other staff is to keep hold of the resident to keep the resident from getting hurt. He/She said there are routine trainings regarding lift safety and would expect staff to follow the training. During an interview on 10/18/24 at 9:41 A.M., the Administrator said the nursing department is responsible to ensure resident lifts are done correctly and would expect staff to hold onto a resident while suspended in the air during a mechanical lift transfer for safety. 50753

Based on observations and interviews, facility staff failed to maintain a professional standard of care when staff left medications at the dining room table and failed to ensure the resident took the medications for three residents (Resident #7, #19 and #26) of 17 residents. The facility census was 58. 1. Review of the facility's Medication Administration policy, undated, showed: -Medication will be administered by persons licensed or permitted by this state to prepare, administer and document the administration of medications; -Medications will be administered in accordance with the orders, including any required time frame; -Residents may self-administer their own medications only if the attending practitioner, in conjunction with the Interdisciplinary Care Planning team, has determined that they have the decision-making capacity to do so safely. Review of https://www.ncbi.nlm.nih.gov/book, Nursing Skills, Chapter 15: Oral Medication Administration, undated, showed Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) should remain with the patient until all medication has been swallowed before documenting to verify the medication has been administered. 2. Review of Resident #7's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/25/24, showed staff assessed the resident as cognitively intact. Observation on 10/16/24 at 7:58 A.M., showed the resident at the dining room table with a plastic medication cup in front of him/her with medication inside. The RN D walked away, passed medication to other residents and passed food trays. The RN did not remain with the resident whiled the resident took the medication. Observation on 10/17/24 at 8:18 A.M., showed the resident at the dining room table with a plastic medication cup in front of him/her with medication inside. The RN D walked away, passed other residents medication and food trays. The RN did not remain with the resident whiled the resident took the medication. Observation on 10/17/24 at 8:38 A.M., the resident poured the medication onto the table and took them one by one. Observation on 10/18/24 at 8:16 A.M., showed the resident at the dining room table with two other residents. Observation showed a plastic cup contained medication next to his/her breakfast. RN D sat in the dining room with his/her back to the resident whiel he/she assisted another resident. 3. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively impaired. Observation on 10/16/24 at 7:58 A.M., showed the resident at the dining room table with a plastic medication cup in front of him/her with medication inside. The RN D walked away, passed medications to other residents and passed food trays. The RN did not remain with the resident whiled the resident took the medication. 4. Review of Resident #26's Annual MDS, dated [DATE], showed staff assessed the resident as cognitively impaired. Observation on 10/16/24 at 7:58 A.M., showed the resident in the dining with a plastic medication cup of medication in front of him/her and a brown container with eye drops inside. He/She sat at a table with three other residents while RN D passed medication to other residents, passed breakfast trays and assisted other residents. The RN did not remain with the resident whiled the resident took the medication. Observation on 10/16/24 at 8:41 A.M., showed the resident took the medication but did not administer the eye drops. Observation on 10/16/24 at 8:51 A.M., showed RN D took the resident to the medication cart and administered the eye drops to the resident. Observation on 10/17/24 at 8:17 A.M., showed the resident in the dining room with a plastic medication container with medication in front of him/her at the table and a eye drops. The resident sat with another resident and a visitor. RN D did not monitor the administration of the medication before leaving the resident. Observation on 10/18/24 at 8:16 A.M., showed the resident at the dining room table with a cup of medication on his/her breakfast tray and eye drops. The RN did not remain with the resident whiled the resident took the medication. 5. During an interview on 10/18/24 at 8:27 A.M., RN D said staff should not put medication in front of residents then walk away or someone else could take them. He/She said it is the person administering medication responsibility to ensure the resident takes the medication as ordered. He/She said he/she only puts the medications in front of the residents he/she feels will take them on their own. During an interview on 10/18/24 at 9:18 A.M., the Director of Nursing (DON) said staff should make sure the resident takes his/her medications before walking away from them to ensure the resident gets their medication, keep another resident from getting and taking it and/or monitor for any adverse effects of the administration and medication. During an interview on 10/18/24 at 09:41 A.M., the administrator said he/she expects the staff to remain with the resident during administration of medication to ensure the resident takes the medication and keep someone else from taking it.

Based on observation, interviews, and record review facility staff failed to protect resident's private medical information by not closing the computers screens on two medication carts and one nurse desk. The facility census was 58. 1. Review of the facility's Resident Rights, dated 11/22/24, showed residents have the right to personal privacy and confidentiality of his or her personal and medical records. 2. Observation on 10/15/24 at 1:15 P.M., showed Licensed Practical Nurse (LPN) A left a medication cart on 200 hall unattended to administer medications. The computer screen on the medication cart open and visible to the public with residents medical information. During an interview on 10/15/24 at 1:30 P.M., LPN A said he/she should not have left the screen open on the computer. He/She staff are required to close the screen or lock it to protect resident's private medical information. 3. Observation on 10/16/24 at 10:41 A. M., showed a computer screen at the nurse's desk open and visible to the public with private resident medical information displayed. 4. Observation on 10/18/24 at 8:17 A.M., showed Registered Nurse (RN) D stepped away from a medication cart on 300 hall with the computer screen open and showed a medication for a resident. Observation showed four resident in proximity of the cart and a staff member walked by the cart. During an interview on 10/18/24 at 8:27 A.M., RN D said computer screens should be closed when stepping away from them to protect the residents information. He/She should have at least minimized it for resident privacy but was just going down the hall for a second. 5. During an interview on 10/18/24 at 9:18 A.M., the Director of Nursing (DON) said hall screens or medication cart screens should be closed or minimized to protect the privacy of residents medical information. Staff are educated monthly on privacy. During an interview on 10/18/24 at 9:42 A.M., the Administrator said computer screens should be closed if unattended. Doing so protects the residents private medical records. The DON is responsible to ensure staff are educated to protect the privacy of residents. I would not expect staff to leave the screens open. 43327

Based on interview and record review, facility staff failed to complete cognitive assessments for one resident (Resident #1) of two sampled residents who had unwitnessed falls. Facility staff failed to complete wound assessments for one (Resident #1) of two sampled residents. The facility census was 60. 1. Review of the facility's Falls Protocol Policy, undated, showed staff are directed for a post fall to conduct an assessment of the resident to include but not limited to physical, behaviors, cognitive and functional status. Review of the facility's Pressure Ulcer and Injury Prevention and Management policy, undated, showed staff are directed to assess the pressure ulcer or injury weekly. Review showed staff are to document the description of the ulcer/injury to include stage, measurements [length, width, depth], presence or absence of any tunneling or undermining, type of tissue [epithelia, granulation, slough, necrosis, etc.], presence or absence and type of drainage, surrounding tissue description, and presence or absence of pain with the ulcer/injury; 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 3/23/24, showed staff assessed the resident as follows: -Severe cognitive impairment; -Utilized a wheelchair; -Dependent for locomotion in wheelchair; -Had a fall one month prior to admission resulting in facture/s; -Had one stage two pressure ulcers (injury to skin and underlying tissue that results form prolonged pressure on the skin). Review of the resident's nurses' notes, dated 3/20/24 at 10:37 A.M., showed staff documented the resident was found on the floor near his/her bed. Staff documented the resident had attempted to transfer himself/herself from bed to wheelchair without assistance. Review of the resident's care plan, revised 3/26/24, showed staff assessed the resident had a fall and staff were directed to monitor, document, and report as needed and for 72 hours to medical director for signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, or agitation. Review of the resident's medical record did not contain documentation staff completed neurological checks for 72-hours after the 3/20/24 fall. During an interview on 5/9/24 at 1:52 P.M., Registered Nurse (RN) A said all unwitnessed falls require the resident to be assessed for cognitive changes for 72 hours. He/She said he/she does not know why they were not completed for the resident's unwitnessed fall. During an interview on 5/9/24 at 2:34 P.M., the administrator said he/she expects the facility fall protocol to be followed including but not limited to cognitive assessments when a resident has an unwitnessed fall. He/She said he/she does not know why neurological checks were not completed for his/her fall. Review of the resident's skin evaluation form, dated 3/11/24, showed staff documented skin issues on the resident's coccyx and the left lower extremity. Review of the resident's weekly wound assessments, dated 3/11, 3/19, 3/25, 4/1 and 4/8/2024, showed staff did not document the stage, measurements [length, width, depth], presence or absence of any tunneling or undermining, type of tissue, presence or absence and type of drainage, surrounding tissue description, and presence or absence of pain with the ulcer/injury for the resident's coccyx and the left lower extremity. During an interview on 5/9/24 at 12:34 the administrator said there are no measurements for the residents wound assessments and he/she does not know why. He/She said the nurses are responsible for the resident's wound assessments. He/She said He/She expects the nurses to follow the facility protocol on wounds and for measurements to be done weekly to track the wounds progress. During an interview on 6/17/24 at 12:59 P.M., R.N. B said the nurses are responsible for wound documentation weekly, as needed, or a specific order for a different frequency. He/She said he/she examines the body and if there are wounds present would document measurements, stage, depth, odor, tunneling, sloughing, and who was notified of the wound. He/She said it is important to document the wounds progression to monitor if it is healing or needs additional intervention. He/She said he/she does not know why the wound assessments were not completed correctly. MO00234837

Based on interviews and record review, facility staff failed to notify one resident's (Resident #1) physician or representative in a timely manner of an unwitnessed fall and a room change for one resident (Resident #1). The facility census was 58. 1. Review of the facility's fall protocol policy and procedure, undated, showed facility staff are directed the physician or practitioner and the resident representative will be notified of the fall and any change of condition of the resident. Review of the facility's room change policy and procedure, undated, showed facility staff are directed to inform the resident and the resident representative with issuance of notice for a room or roommate change arrangements and will be documented in the resident's record. 2. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/30/24, showed staff assessed the resident as: -Moderately cognitively impaired; -Fracture of the hip (a break in the thighbone (femur) of your hip joint), Dementia (the loss of cognitive functioning), -History of fall one month prior to admission with a fracture; -Anticuagulant use. Review of the facility's room change documentation, dated 2/12/24, showed the resident was moved rooms. Review of the resident's neurological checks, dated 2/17/24, showed staff documented they assessed the resident for an unwitnessed fall at 9:00 A.M. Review of the resident's nurses notes, dated 2/17/24 at 1:50 P.M., showed staff documented the resident's complained about his/her right eye pain at breakfast, eye noted to be slightly bloodshot. Resident ambulated back to his/her room with staff after breakfast without difficulty. On arriving in his/her room this nurse noted the lense from the resident's glasses was sitting on his/her bedside table. When resident was asked waht happened to hiis/her glasses, the resident stated he/she had fallen during the night and broke his/her glasses. No bruising noted at the time. The resident's representative came in to visit and resident reported to representative he/she had fallen. Glasses were found under the bed with frames bent. Resident very anxious after glasses were found with complaint of increased pain, noted that blood to right sclera had increased. Resident representative requested resident be evaluated in emergency room , sent by facility van for evaluation. During an interview on 2/27/24 at 10:59 A.M., the resident representative said he/she was not notified of the resident's room change, he/she and other family members went to visit the resident and had to ask where the resident had been moved too. He/She said he/she was not notified that the resident had a fall until he/she came to visit the resident and saw his/her eye was damaged and requested the resident be sent to the hospital due to increased pain. During an interview on 2/27/24 at 11:58 P.M., the administrator said the resident was moved on 2/12/24 to a private room because of Covid -19 (Coronavirus disease is an infectious respiratory disease caused by the SARS-CoV-2 virus.), he/she said if the resident is moved because of covid there would not be an official form like if there is a room change with a rate change but would expect to see the conversation in the nurses notes. He/She said the Social Services Director (SSD) is in charge of notifying resident's family and representatives of a room change. He/She said this might have not been done because the residents representative is in the building every day and there could have been a conversation about a room change. During an interview on 2/27/24 at 12:05 P.M., Registered Nurse (RN) A said the resident is very confused. He/She said around 7:00 A.M. on 2/17/24, the resident was at the breakfast table and his/her eye was blood shot, the resident said he/she fell last night on 2/16/24. He/She said that is when he/she contacted the physician for orders to send to the hospital and emergency medical services picked the resident up around 11:00 A.M. He/She said he/she had not contacted the resident representative prior to his/her arrival but would have. He/She said the nurse is in charge of contacting the physician and the resident representative after a fall. During an interview on 2/27/24 at 12:24 P.M., the SSD said he/she is often in charge of room change notifications but he/she is not here all the time and then the nurses are responsible for completing the room change notification. He/She said room change notifications should be documented in the nurses notes if they do not have an official form. He/She said room changes happen quickly and frequently on rehab because of covid, but he/she doubts the regulation is any different with notification of a room change because it is a rehab hall. During an interview on 2/27/24 at 1:20 P.M., the administrator said he/she expects both the physician and family to be notified once assessment is complete after a fall. MO00232017

Based on observation, interviews, and record reviews, the facility staff failed to maintain the kitchen in a clean and sanitary manner, to cover kitchen trash cans when not in use, to utilize hair restraints appropriately, and to properly store open food to prevent cross contamination and outdated usage. This failure had the potential to affect all residents. The census was 53. 1. Review of the facility's daily Kitchen Cleaning List, undated, showed: - Sweep under all storage racks in dry storage; - Clean and organize freezer; - Clean seals around walk-in cooler; - Clean both ovens including the racks and doors; - Sweep under all tables and coolers; - Wipe under slicer and the shelf under slicer. Review of the facility's End of Shift Cleaning Checklist, undated, showed: - Sweep and mop kitchenette; - Wipe steam table and lids; - Wipe off all countertops; - Wipe out microwave, even if you did not use it; - Sanitize all surfaces. Ex: Refrigerator door and handles. Review of the facility's daily Kitchen and Bakery Cleaning Chart, effective 4/12/21, showed staff are directed to wipe, clean, and sanitize all surfaces. Review of the facility's Weekly Cleaning policy, undated, showed: - On Sunday, the A.M. cook clean and organize seasoning shelf, the P.M. cook clean and organize under prep tables, the baker clean and organize shelves in the bakery; - On Wednesday, the P.M. cook wash can openers; - On Friday, the A.M. cook wipe, clean, and sanitize walls in the kitchen area; the P.M. cook wipe, clean, and sanitize walls in the hallway; the baker wipe, clean, and sanitize walls in the bakery area. Review of the facility's Monthly Cleaning policy, effective 4/12/21, showed: - By the 10th of the month, deep clean stove, take shelves and racks apart to clean, clean out prep table drawers; - By the 20th of the month, deep clean stove; - By the last day of the month; deep clean rational, take apart can opener from prep tables and send through the dishwasher. Observation on 7/18/23 at 1:40 P.M., of the main kitchen, showed: - Metal food preparation table with crumbs on second and third shelves. Further observation showed serving containers and cake pans stored inverted in the crumbs; - A metal table, with steamer, visibly dirty with white spots, crumbs, and brown buildup; - Can opener visibly dirty with crumbs and brown buildup; - Spice cabinet, located over a slicer and food preparation table, visibly dirty with fingerprints and smudges; - Double door refrigerator, located near the food preparation table, visibly dirty with crumbs in handles, orange chunks, and drips; - Metal food preparation table, located near the convection oven, visibly dirty with crumbs on bottom shelf. Further observation showed bulk food container sat on the shelf in the crumbs. Observation also the bulk food container, unlabeled, visibly dirty with crumbs and sticky to touch; - Column located between two food preparation tables visibly dirty with spots and drips; - Convection oven visibly dirty with crumbs and brown buildup; - Column, located between the stove and the convection oven, visibly dirty with spots, spatters, and dust buildup on top of outlets and light switch; - Green table visibly dirty with brown substance, red spots, red chunks, and crumbs. Further observation showed muffin tin sat uncovered on the green table; - Ice machine visibly dirty with crumbs, drips, and white substance on the lid and front; - Food preparation sink cabinet, located near the ice machine, with hole in the bottom shelf, red and brown substance and crumbs present. Further observation showed the shelf not smooth and washable, the hole in the bottom shelf measure 8 3/4 inch by 8 3/4 inch and the space under the cabinet visible and accessible. Observation also showed the handles to the cabinet sticky with a brown substance present. Observation on 7/18/23 at 3:01 P.M., of the second floor kitchenette, showed: - Food service refrigerator visibly dirty with spots and splatters on handles and doors on outside and visibly dirty with red spots and crumbs on the inside; - Cabinets, located under the oven and over the counters, visibly dirty with chunks; - Light switch over counter visibly dirty with brown and yellow substance; - Counter around sink with black substance; - Coffee pot visibly dirty with white substance at water reservoir; - Resident refrigerator visibly dirty with white drips and spots on the outside, ice dispenser with brown substance present, and visibly dirty with brown and red spots, chunks, and drips on the inside. Observation on 7/18/23 at 3:23 P.M., of the third floor kitchenette, showed: - Cabinet drawers, located near the stove, visibly dirty with brown chunks; - Microwave with food debris on top and sides. Observation on 7/19/23 at 11:15 A.M., of the main kitchen, showed: - Metal food preparation table with crumbs on second and third shelves. Further observation showed serving containers and cake pans stored inverted in the crumbs; - A metal table, with steamer, visibly dirty with white spots, crumbs, and brown buildup; - Can opener visibly dirty with crumbs and brown buildup; - Spice cabinet, located over a slicer and food preparation table, visibly dirty with fingerprints and smudges; - Double door refrigerator, located near the food preparation table, visibly dirty with crumbs in handles, orange chunks, and drips; - Metal food preparation table, located near the convection oven, visibly dirty with crumbs on bottom shelf. Further observation showed bulk food container sat on the shelf in the crumbs. Observation also the bulk food container, unlabeled, visibly dirty with crumbs and sticky to touch; - Column located between two food preparation tables visibly dirty with spots and drips; - Convection oven visibly dirty with crumbs and brown buildup; - Column, located between the stove and the convection oven, visibly dirty with spots, spatters, and dust buildup on top of outlets and light switch; - Green table visibly dirty with brown substance, red spots, red chunks, and crumbs. Further observation showed muffin tin sat uncovered on the green table; - Ice machine visibly dirty with crumbs, drips, and white substance on lid and front; - Food preparation sink cabinet, located near the ice machine, with hole in the bottom shelf, red and brown substance and crumbs present. Further observation showed the shelf not smooth and washable, the hole in the bottom shelf measure 8 3/4 inch by 8 3/4 inch and the space under the cabinet visible and accessible. Observation also showed the handles to the cabinet sticky with a brown substance present. Observation on 7/19/23 at 11:24 A.M., of the second floor kitchenette, showed: - Food service refrigerator visibly dirty with spots and splatters on handles and doors on outside and visibly dirty with red spots and crumbs on the inside; - Cabinets, located under the oven and over the counters, visibly dirty with chunks; - Light switch over counter visibly dirty with brown and yellow substance; - Counter around sink with black substance; - Microwave with food debris present on the inside top and sides; - Coffee pot visibly dirty with white substance at water reservoir; - Resident refrigerator visibly dirty with white drips and spots on the outside, ice dispenser with brown substance present, and visibly dirty with brown and red spots, chunks, and drips on the inside; - Toaster visibly dirty with crumbs. Observation on 7/19/23 at 11:30 A.M., of the third floor kitchenette, showed: - Cabinet drawers, located near the stove, visibly dirty with brown chunks; - Resident refrigerator visibly dirty on ice dispenser with brown substance; - Microwave with food debris on top and sides. During an interview on 7/19/23 at 1:15 P.M., the dietary manager (DM) and the dietary director (DD) said they are responsible to ensure the kitchen is maintained in a clean and sanitary manner. The facility has a policy for cleaning the kitchen, and the dietary staff are trained on the policy. The DM and DD said they try to use a cleaning schedule to maintain the cleanliness of the kitchen. The DM conducts audits on Monday through Fridays, but he/she does not document the audits. The DD also conducts audits, and he/she makes a list of his/her observations and files it. The DM and the DD said they discuss the audits with each other, but they do not conduct in-services with the dietary staff regarding their observations. They said they verbally mention their observations with the dietary staff. The DM and DD said it is expected the staff would clean the work stations and the kitchenettes after their shift and as needed. During an interview on 7/19/23 at 2:03 P.M., the administrator said the DD or their designee is responsible to ensure the kitchen is maintained in a clean and sanitary manner. She said the facility has a policy regarding cleaning the kitchen, and the DD is trained on the policy. The administrator said the kitchen should have a cleaning schedule, and it is expected staff would keep the kitchen clean. 2. Review of the facility's Dispose of Garbage and Refuse policy, dated 8/2017, showed: - Appropriate lids are provided for all containers; - The policy did not address utilization of trash can lids. Observation on 7/18/23 at 1:50 P.M., showed a trash can located near the cooking appliances, uncovered and not in use. Observation on 7/18/23 at 2:25 P.M., showed a trash can located near the dishwashing area, uncovered and not in use. Observation on 7/18/23 at 3:38 P.M., showed a trash can located near the dishwashing area, uncovered and not in use. Observation on 7/19/23 at 11:15 A.M., of the main kitchen, showed a trash located near the dishwashing area uncovered and not in use. Observation also showed a trash can located near the cooking appliances uncovered and not in use. During an interview on 7/19/23 at 1:15 P.M., the DM and the DD said the trash cans should have lids on them when they are not in use. The DM said trash cans should be covered at the end of the day when staff are no longer using the trash cans. The DM and the DD said they were not aware the trash cans should be covered throughout the day when staff are not actively using the trash cans. During an interview on 7/19/23 at 2:03 P.M., the administrator said the DD is responsible to ensure trash cans are maintained according to regulations. She said the facility has a policy, and the staff are trained on the policy. The administrator said it is expected the trash cans would be covered. 3. Review of the facility's Staff Attire policy, dated 9/2017, showed all staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Observation on 7/18/23 at 2:56 P.M., showed Cook T prepared the residents' dinner meal. Further observation showed the cook had a goatee which measured greater than 3/4 inch long and did not wear a beard guard. Observation on 7/19/12 11:30 A.M., showed dietary aide U placed the residents' lunch meal on the steam table, uncovered the containers, and took food temperatures. Further observation showed the dietary aid had a goatee which measured greater than 1/4 inch long and did not wear a beard guard. Observation also showed the dietary aid wore a hair net, but the hair net did not cover three inches of hair on the left side and neck area of the dietary aide's head. During an interview on 7/19/23 at 1:15 P.M., the DM and the DD said staff should wear hairnets and beard guards anytime they are in the kitchen, kitchenettes, and dining rooms. They said the all the staff's hair should be contained in the hairnet or beard guard. The DM and the DD said the facility has a policy regarding the use of hairnets and beard guards, and the dietary staff have been trained on the policy. During an interview on 7/19/23 at 2:03 P.M., the administrator said the DD or their designee is responsible to ensure the dietary staff utilize hairnets and beard guards appropriately. She said the facility has a policy on hairnets, and the staff is trained on the policy. The administrator said if staff have hair on their head or face then they should wear a hairnet or beard guard to ensure all the hair is covered. 4. Review of the facility's Food Storage: Dry Goods policy, dated 9/2017, showed: - All packaged and canned food items will be properly sealed; - Storage areas will be neat, arranged for easy identification, and date marked as appropriate. Review of the facility's Food Storage: Cold Foods policy, dated 4/2018, showed all foods will be stored wrapped or in covered containers, labeled, and dated, and arranged in a manner to prevent cross contamination. Review of the facility's daily kitchen and bakery cleaning chart, effective 4/12/21, showed staff directed to date, label, and rotate stock. Observation on 7/18/23 at 2:10 P.M., of the double door refrigerator showed a Ziploc bag with opened feta cheese undated. Observation on 7/18/23 at 2:15 P.M., of the food preparation table, showed a bulk container of a white substance unlabeled. Observation on 7/18/23 at 2:33 P.M., of the walk-in refrigerator, showed an open bag of Hawaiian rolls undated. Observation on 7/18/23 at 3:18 P.M., of the second floor resident refrigerator, showed: - An open container of ice cream with scoop unlabeled and undated; - An open bag of red raspberries undated. Observation on 7/18/23 at 3:23 P.M., of the third floor resident refrigerator, showed: - Breaded food item unlabeled and undated; - Pint of ice cream unlabeled and undated; - Bowl of yellow and brown food unlabeled and undated. Observation on 7/19/23 at 11:15 A.M., of the double door refrigerator showed a Ziploc bag with opened feta cheese undated. Observation on 7/19/23 at 11:17 A.M., of the food preparation table, showed a bulk container of a white substance unlabeled. Observation on 7/18/23 at 11:24 A.M., of the second floor resident refrigerator, showed: - An open container of ice cream with scoop unlabeled and undated; - An open bag of red raspberries undated. Observation on 7/19/23 at 11:30 A.M., of the third floor resident refrigerator, showed: - Breaded food item unlabeled and undated; - Pint of ice cream unlabeled and undated; - Bowl of yellow and brown food unlabeled and undated. During an interview on 7/19/23 at 1:15 P.M., the DM and the DD said they are responsible to ensure food is stored correctly in the kitchen. They said the facility has a policy on food storage, and staff are trained on the policy. The DM and the DD said all food should be protected, labeled, and dated when placed in storage. It is expected staff would correct any items they saw stored incorrectly. The DM and the DD said resident food is not stored separately from the facility food supplies. They said resident's food should have the resident's name, room number, and the date on each item. During an interview on 7/19/23 at 2:03 P.M., the administrator said the DD or their designee is responsible to ensure food is stored according to policy. She said the facility has a policy on food storage, and the staff is trained on the policy. The administrator said all food should be protected, labeled, and dated. She said resident food should be stored in a separate refrigerator from the facility's food. The administrator said the resident's food should be labeled with the resident's name.

Based on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to properly store razors, an oxygen tank, personal care chemicals and alcoholic beverages. In addition, staff failed to properly propel three residents (Resident #11, #29, and #34) in wheelchairs in a manner to prevent accidents. The facility census was 53. 1. Review of the facility's policies showed the facility did not provide a policy for oxygen storage. The Occupational Safety and Health Administration (OSHA) requirement, CFR 1926.350(a)(1) 6-7 and 9, securing compressed gas cylinders , shows: (a) Transporting, moving, and storing compressed gas cylinders. -(6) Unless cylinders are firmly secured on a special carrier intended for this purpose, regulators shall be removed and valve protection caps put in place before cylinders are moved. -(7) A suitable cylinder truck, chain, or other steadying device shall be used to keep cylinders from being knocked over while in use. -(9) Compressed gas cylinders shall be secured in an upright position at all times except, if necessary, for short periods of time while cylinders are actually being hoisted or carried. Review of the facility's Storage and labeling of Personal Care Items, undated, showed personal care items and products that may be hazardous to others will be stored in a manner that will minimize access by other residents. Such items may include but are not limited to: -Products that are not ingestible (i.e., hair spray, deodorants); -Razors, scissors, nail files, or other items that may be sharp. 2. Observation on 7/17/23 at 11:02 A.M., showed the REACH Hall supply room unlocked and unattended with a portable oxygen tank standing on end without support, a countertop plastic drawer full of razors, and an unsecured drawer that contained hand sanitizer. In addition, the unlocked cabinet contained a supply of: -After Shave labeled: CAUTION: DO NOT SWALLOW, Use only as directed and WARNING: NOT FOR CONSUMPTION, KEEP OUT OF REACH OF CHILDREN; -Effervescent Denture Cleanser labeled: WARNING: Do not place tablets or denture cleaning solution in mouth. Do not use to clean natural teeth. Keep this product out of reach of children. This product contains persulfates, which are known allergens. In case of accidental ingestion, seek professional assistance or contact the Poison Control Center immediately; -Shaving Cream labeled: WARNING: Avoid spraying in eyes. Contents under pressure. Use only as directed. Keep out of reach of children; -Moisturizer labeled: CAUTION: For external use only. Avoid contact with eyes. Keep out of reach of children. Observation on 7/18/23 at 11:43 A.M., showed the REACH Hall supply room unlocked and unattended with a countertop plastic drawer full of razors and an unsecured drawer of hand sanitizers; In addition, the unlocked cabinet contained a supply of: -After Shave labeled: CAUTION: DO NOT SWALLOW, Use only as directed and WARNING: NOT FOR CONSUMPTION, KEEP OUT OF REACH OF CHILDREN; -Effervescent Denture Cleanser labeled: WARNING: Do not place tablets or denture cleaning solution in mouth. Do not use to clean natural teeth. Keep this product out of reach of children. This product contains persulfates, which are known allergens. In case of accidental ingestion, seek professional assistance or contact the Poison Control Center immediately; -Shaving Cream labeled: WARNING: Avoid spraying in eyes. Contents under pressure. Use only as directed. Keep out of reach of children; -Moisturizer labeled: CAUTION: For external use only. Avoid contact with eyes. Keep out of reach of children. Observation on 7/19/23 at 8:46 A.M., showed the REACH Hall supply room unlocked and unattended with a countertop plastic drawer full of razors; In addition, the unlocked cabinet contained a supply of: -After Shave labeled: CAUTION: DO NOT SWALLOW, Use only as directed and WARNING: NOT FOR CONSUMPTION, KEEP OUT OF REACH OF CHILDREN; -Effervescent Denture Cleanser labeled: WARNING: Do not place tablets or denture cleaning solution in mouth. Do not use to clean natural teeth. Keep this product out of reach of children. This product contains persulfates, which are known allergens. In case of accidental ingestion, seek professional assistance or contact the Poison Control Center immediately; -Shaving Cream labeled: WARNING: Avoid spraying in eyes. Contents under pressure. Use only as directed. Keep out of reach of children; -Moisturizer labeled: CAUTION: For external use only. Avoid contact with eyes. Keep out of reach of children. 3. During an interview on 7/20/23 at 9:01 A.M., Certified nurse aide (CNA) R said razors should be in a box out of sight, and toiletries like mouthwash should be shut away. He/She said oxygen tanks should be locked up in the oxygen room or in an oxygen tank trolley. During an interview on 7/20/23 at 9:30 A.M., CNA M said disposable razors should not be kept in resident rooms. He/She said disposable razors should be kept locked up in the storage room, shower rooms, or medication room. During an interview on 7/20/23 at 9:10 A.M., Registered Nurse (RN) O said he/she does not allow his/her residents to have disposable razors. He/She said it is the expectation that disposable razors should not be kept in resident rooms. He/She said they should be kept in a locked storage room or be put in the sharps box. During an interview on 7/20/23 at 9:41 A.M., RN D said all razors and toiletries should be put in a closed cabinet in the supply room. He/She said oxygen tanks must be kept secured to prevent the tanks from falling over. During an interview on 7/20/23 at 11:55 A.M., the Director of Nursing (DON) and administrator said razors should be locked in storage and discarded in a sharps container after they are used. They also said all toiletries such as lotion, mouthwash, and after shave should be in closed cabinets. Oxygen tanks are to be kept in the locked oxygen closet and secured in a rack, if outside the closet the oxygen should be in an oxygen trolley. 4. Review of the facility's policies showed the facility did not provide a policy that directed staff on the safe and proper handling and/or storage of alcoholic beverages. Observation on 7/17/23 at 11:24 A.M., showed the third floor kitchenette refrigerator was unlocked and unattended by staff. Observation showed the refrigerator contained a box of five glass bottles of 5.0% alcohol/volume beer. Observation on 7/18/23 at 10:45 A.M., showed the third floor kitchenette refrigerator was unlocked and unattended by staff. Observation showed the refrigerator contained a box of five glass bottles of 5.0% alcohol/volume beer. Observation on 7/19/23 at 9:04 A.M., showed the third floor kitchenette refrigerator was unlocked and unattended by staff. Observation showed the refrigerator contained a box of five glass bottles of 5.0% alcohol/volume beer. During an interview on 7/19/23 at 2:20 P.M., RN O said the box of beer has been in the 300 hall fridge for several months. He/She said he/she was not sure where it came from. He/She said any resident who drinks must have a physician order that states how much and how often they can have it. He/She said that any resident who is capable of getting to and opening the fridge, would have access to the beer. During an interview on 7/20/23 at 9:01 A.M., CNA R said he/she never heard of a beer in the resident refrigerator in the dining area. He/She said a resident's beer would be in the medication room. During an interview on 7/20/23 at 9:30 A.M., CNA M said he/she was not aware there was a box of beer in the 300 hall kitchenette refrigerator. He/She said residents should not have access to alcohol unless they have a physician order. During an interview on 7/20/23 at 9:41 A.M., RN D said a resident's beer should be kept in the kitchen, where residents would not have access. During an interview on 7/20/23 at 11:55 A.M., the Administrator and DON said they were not aware that beer was being stored in the refrigerator on the third floor. They said alcohol should be stored in the locked refrigerator in the medication room. They said staff are expected to track any alcohol that comes in from family and those residents should have a physician order for the alcohol. 5. Review of the facility's Wheelchair Safety Policy, undated, showed: -Clinical staff will be educated in care of residents who require the use of a wheelchair to promote resident safety during transfer to the wheelchair and while the resident is being transported by staff; -Footrests should be applied to the wheelchair and used to support the residents' feet/legs when the resident is unable or not using their feet to help propel the wheelchair. 6. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 4/20/23 showed staff assessed the resident as: -Cognitively intact; -Diagnoses of fractures, multiple traumas, stroke, and hemiplegia; -Wheelchair use for locomotion. Observation on 07/20/23 at 09:19 A.M., showed CNA B propelled the resident in his/her wheelchair from the bathroom to his/her chair, without foot pedals. Further observation showed the resident's foot wear and wound boot skimmed the floor. 7. Review of Resident #29's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Diagnoses of stroke and hemiplegia; -Wheelchair use for locomotion. Observation on 07/17/23 at 10:31 A.M., showed RN O propelled the resident in his/her wheelchair from the dining room to his/her bedroom, approximately 25 feet while the resident's left foot skimmed the floor. 8. Review of Resident #34's annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of non-traumatic brain injury, arthritis, dementia, and Parkinson's; -Wheelchair use for locomotion. Observation on 07/19/23 at 06:48 A.M., showed Certified medication technician (CMT) P propelled the resident in his/her wheelchair to the bathroom, without foot pedals. Further observation showed the resident's socks skimmed the floor. 9. During an interview on 07/20/23 at 08:43 A.M., CMT/CNA B said a resident must have foot pedals on and keep hands and elbows in the ride at all times. It is never appropriate to propel a resident without pedals because they may not be able to keep their feet up and they could drag and it can get caught. He/She said staff would need to assist the resident if their feet are not staying on the pedals. During an interview on 7/20/23 at 9:01 A.M., CNA R said wheelchairs must have foot pedals so feet do not get run over. Without the pedals a resident could suffer breaks or bruises of the ankles, feet or toes. During an interview on 7/20/23 at 9:41 A.M., RN D said wheelchairs must have pedals for feet if staff is propelling the wheelchair. He/She said a resident could be flipped head over heels and get a concussion if their feet got caught. During an interview on 7/20/23 at 11:55 A.M., the DON and administrator said wheelchairs must be propelled with the pedals on, and there are signs to remind staff all over the building. Staff should assure the residents' feet are on the pedals, because all kinds of things could happen if they are not, such as fractures, falling out of the chair, or even death. 43024 47193

Based on interview, and record review the facility staff failed to communicate pharmacy recommendations to the physicians for six residents (Resident #2, #6, #13, #29, #34, and #41) to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility census is 53. 1. Review of the facility's Monthly Medication Regimen Review policy, not dated, showed: -The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent and minimize adverse consequences related to medication therapy to the extent possible; -The Consultant Pharmacist will perform a Medication Regimen Review (MMR) for every resident in the facility; -Routine reviews will be done monthly; -The pharmacist will report any irregularities to the attending physician and the facility's medical director, director of nursing (DON), and these reports must be acted upon; -The attending physician or medical director will document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. 2. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/21/23 showed staff assessed the resident as follows: -Diagnoses of anxiety depression chronic lower back pain, and chronic kidney disease; -Use of antidepressants, opioids and diuretics on seven of seven days during the look back period (seven day period before the assessment is completed to capture the status of a resident). Review of the resident's MMR note showed 12/31/2022 MMR completed - see MMR report. Review of the resident's medical record showed the following: -Did not contain documentation of the pharmacist's report or physician's response; -Did not contain MMRs past December 2022. 3. Review of Resident #6 quarterly MDS, dated [DATE] showed staff assessed the resident as follows: -Diagnoses of cancer, coronary artery disease (coronary arteries build up with plaque and narrow, limiting blood flow to the heart), heart failure, hypertension (high blood pressure), kidney failure, urinary tract infection, diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), anxiety, and respiratory failure; -Use of antidepressant, opioid, insulin, and diuretic seven of seven days in the look back period; -Use of antibiotics three of seven days in the look back period. Review of the resident's medical record showed the record did not contain documentation of the pharmacist's MMR. 4. Review of Resident #13's quarterly MDS, dated [DATE] showed staff assessed the resident as follows: -Diagnoses of Anxiety, Seizure disorder or Epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures); -Use of antidepressants seven of seven days during the look back period, and antipsychotic three of seven days in the look back period. Review of the resident's medical record showed the record did not contain documentation of the pharmacist's MMR. 5. Review of Resident #29 Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severely cognitively impaired;-Diagnoses of diabetes, coronary artery disease, epilepsy and depression; -Use of antidepressant and anticoagulant seven of seven days in the look back period; -Use of opioid one of seven days in the look back period. Review of the resident's MMR note showed 12/31/2022 MMR completed - see MMR report. Review of the resident's medical record showed the following: -Did not contain documentation of the pharmacist's report or physician's response; -Did not contain MMR's past December 2022. 6. Review of Resident #34's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnoses of arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age), dementia(a group of thinking and social symptoms that interferes with daily functioning), Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), and depression; -Use of antipsychotic, antianxiety and antidepressant seven of seven days in the look back period. Review of the resident's MMR note showed 12/31/2022 MMR completed - see MMR report. Review of the resident's medical record showed the following: -Did not contain documentation of the pharmacist's report or physician's response; -Did not contain MMRs past December 2022. 7. Review of Resident #41's annual MDS, dated [DATE], showed staff assessed the resident as follows: - Diagnosis of hypertension, anxiety, and depression; - Use of antianxiety and antidepressants seven of seven days in the look back period (seven day period before the assessment is completed to capture the status of a resident). Review of the resident's MMR note showed:-12/31/2022 MMR completed - see MMR report. Review of the resident's medical record showed the following: -Did not contain documentation of the pharmacist's report or physician's response; -Did not contain MMRs past December 2022. 8. During an interview on 7/20/23 at 9:10 A.M., Registered Nurse (RN) M said he/she worked day shift and had not seen pharmacy review resident medications. He/She said they may do them off site because he/she had occasionally seen notes on residents. He/She said the Assistant Director of nursing (ADON) was responsible for obtaining the recommendations and the physician responses. During an interview on 7/20/23 at 11:30 A.M., the ADON said pharmacy comes once a month to review medications, look at the medication carts and storage room. He/She said the pharmacist emails the recommendations to the facility and it is a combined effort before between the DON and herself to ensure they are completed, scanned, and have physician responses. During an interview on 7/20/23 at 11:55 A.M., the Administrator said it is a team effort between the ADON, DON, and himself/herself to ensure MMR's are getting done. He/She said pharmacy reviews resident medications monthly and then faxes or emails the recommendations to the office. Once the recommendations come in he/she said the physician is notified. He/She said physician notifications are expected to be done within seven days of receiving the pharmacy recommendations. He/She said MMRs and physician responses should then be scanned into the resident medical records. 43024 47193

Based on interview and record review, facility staff failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications for three residents (Resident #18, #34, and #41). The facility census was 53. 1. Review of the facility's Gradual Dose Reduction policy, undated showed the following: -After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. All medications shall be considered for possible tapering. Tapering that is applicable to antipsychotic medications shall be referred to as gradual dose reduction. Residents who use psychoactive drugs will receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. -Resident who use psychoactive drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. -Within the first year after a resident is admitted on an antipsychotic medication or after the resident has been started on an antipsychotic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated. 2. Review of Resident #18's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/30/23, showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities). -Received antipsychotic and antidepressant medications seven out of seven days in the look back period (seven day period of time before the assessment is completed to capture the status of a resident). Review of the resident's Physician Order Sheets (POS), dated July 2023, showed on order on 12/15/22 for Buspirone HCI (antianxiety medication) 10 mg (milligrams) BID (twice a day). Review of the resident's medical record showed the record did not contain documentation to show an attempt for a GDR for the resident's psychotropic medications or a clinical rationale by the physician to continue the medication without a GDR. 3. Review of Resident #34's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnoses of dementia, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors)and depression; -Use of antipsychotic, antianxiety and antidepressant seven of seven days in the look back period; Review of the resident's POS, dated July 2023 showed an order for Mirtazapine (to treat depression) 7.5 mg. Review of the resident's medical record showed the pharmacist recommended a GDR on 6/18/23. Further review showed the physician did not receive the GDR requests until 7/19/23. Further review of the resident's POS, dated July 2023 showed an order for Hydroxyzine (to treat anxiety) 50 mg. Review of the resident's medical records showed the pharmacist recommended a GDR on 5/14/23. Further review showed the physician did not recieve the GDR reguests until 7/19/23 and recommended a decrease to 25 mg. 4. Review of Resident #41's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnoses of anxiety and depression; -Use of antianxiety and antidepressant seven of seven days in the look back period. Review of the resident's POS, dated July 2023, showed an order on 12/19/22 for the following medications: -Lorazepam (sedative) 0.5 mg tablet daily for anxiety; -Sertraline HCL (antidepressant) 25 mg tablet daily for major depressive disorder and anxiety. Review of the resident's medical record showed the record did not contain an attempt for a GDR for the resident's psychotropic medications or a clinical rationale by the physician to continue the medication without a GDR. 5. During an interview on 7/20/23 at 9:15 A.M., LPN C said the ADON is responsible for bringing medication changes, and GDRs to the charge nurse after it is signed by the doctor. The charge nurse updates it in the system. LPN C said the night shift nurse does a medication audit weekly but is unsure what that consists of. During an interview on 7/20/23 at 11:30 A.M., the Assistant Director of nursing (ADON) said he/she believes GDRs have not been completed timely because the medication start dates changed when the facility switched pharmacies. During an interview on 7/20/23 at 12:01 P.M., the Director of Nursing (DON) said the expectation is to get GDR recommendations and signatures from the physician and then passed on to the nurses to make the changes within a week. He/She said recently they have had difficulty getting them back timely. During an interview on 7/20/23 at 12:00 P.M., the administrator said this process is a team effort currently, ever since the building was taken over in October, and they are working on it. The administrator said the Director of Nursing and Assistant Director of Nursing will take over the audit and monitoring of the process. After the GDRs are received they are will be given it to the charge nurse on the floor to update in the resident's chart. 43024 47193

Based on observation, interview, and record review facility staff failed to ensure medications were stored in a safe and effective manner for two out of three medication carts, and for one resident (Resident #18). The facility census was 53. 1. Review of the facility's Storage of Drugs and Biologicals, undated, showed staff were directed as follows: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. Observation on 7/17/23 at 11:56 A.M., showed the medication cart for the 300 hall, contained the following loose pills: -One small oval blue pill stamped with RDYL493; -One small oval white pill stamped with G4; -One small oval red pill; -One small round white pill; -One small round white pill stamped with 15; -One small round white pill stamped with C; -One small square tan pill stamped with 59; -One large round white pill. 4. Observation on 07/18/23 at 10:03 A.M., showed the medication cart for 200 hall, contained the following loose pills: -Two loose white pills stamped with L and G; -One loose yellow pill stamped with U; -Five red square gummies in clear zip lock bag, not labeled or dated. 5. Review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 6/30/23 showed staff assessed the resident as: -Cognitively intact; -Diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities). Observation of the medication cart on 200 hallway on 7/19/23 at 3:00 P.M., showed four red square gummies in clear zip lock bag, not labeled or dated with the resident's name printed on it. Review of the resident's Physician Order Sheet (POS), dated July 2023 showed an order dated 2/20/23 for CBD (Cannabidiol) gummy, up to 3 times a day as needed every 8 hrs for anxiety. During an interview on 7/19/23 at 3:01 P.M., LPN C said the gummies are CBD, which the resident's family brings in for him/her. The family member brings in a package and leaves a certain amount for the resident, then takes the rest home. The staff keep the gummies in a plastic bag so they are easier to count. The LPN said he/she is unsure of the dosage per gummy or if they have an expiration date. During an interview on 7/20/23 at 12:00 P.M., the Administrator and Director of Nursing (DON), the DON said I knew the gummies were up there, and that there was an order for them, however wasn't real sure the process for it. The DON did not know if there was a milligram amount on CBD. The administrator said, I thought it was just like an over the counter. The Administrator and DON both said they did not know or realize what the expectation was pertaining to CBD. 6. During an interview on 7/17/23 at 11:58 A.M., Registered Nurse (RN) M said he/she cleaned out the medication room and carts on Sunday 7/18/23. He/She said he/she tried to clean out the carts every day if he/she had a chance, but for sure once a week. He/She said when he/she found loose pills in his/her cart or needed to dispose of resident medications, he/she used a special solution that was kept in the medication storage room. He/She said there was not a place to document when loose pills were found. During an interview on 07/19/23 at 02:28 P.M., Licensed Practical Nurse (LPN) C said Certified medication technicians (CMT)s and nurses should be in charge of getting loose pills from the cart but there was no set schedule to clean it. During an interview on 7/20/23 at 11:55 A.M., the Administrator and Director of nursing (DON) said it was their expectation that medication carts and rooms were checked monthly by pharmacy, daily by charge nurses, and weekly by the DON. If loose pills were found it was their expectation that they were discarded in the medication destroyer. They said it was also their expectation that the charge nurse investigated why the loose pills occurred in order to prevent the issue from reoccurring. 43024

Based on interview and record review, the facility staff failed to provide written notice to a resident (Resident #68) or the resident's representative regarding the resident's transfers to the hospital. In addition, the facility staff failed to provide the resident a 30-day prior written notice of a date of discharge from the facility with the resident's appeal rights, failed to find appropriate placement for the resident, and refused to readmit the resident after a hospital stay. Further, the facility staff failed to provide written notice to residents or the residents' representatives regarding resident transfers to the hospital for three additional residents (Resident #54, #69, and #70). The facility census was 53. 1. Review of the facility's Facility Initiated Transfer/Discharge Requirements Policy, undated, showed when sending a resident to the Emergency Department - the medical record should include demonstration that resident and/or resident representative was provided discharge notice that includes reason for transfer/discharge, date, and location that resident was sent to, and information where additional information can be found. Review of the facility's Notice of Resident Transfer or Discharge Notice Form, undated, showed: -A fill-out line of the location for the transfer/discharge; -A fill-out line of the date of the transfer/discharge; -Checkboxes of the reason for the transfer/discharge; -A paragraph stating the physician was discussed and agreed upon by the physician, the right to appeal the decision and how to obtain assistance or appeal; -A signature line for the facility representative; and -A signature line for verification/receipt for Notice of Resident Transfer or Discharge for the resident or resident representative. 2. Review of the Resident's #68's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/12/23, showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use; -Required extensive assistance of one staff for locomotion; -Required supervision for personal hygiene; -Required set-up assistance to eat; -No limitations with balance or range-of-motion. -A wheelchair and a walker for mobility. Review of the resident's medical record showed the following: -admitted to the facility on [DATE]; -Transferred to the hospital on 3/25/23; -Returned to the facility on [DATE]; -Transferred to the hospital on 6/17/23; -Staff did not document they provided the resident and resident representative a discharge/transfer notice. During a telephone interview on 7/14/23, the ombudsman said the resident was in the hospital and the facility told the hospital social worker that he/she could not return to the facility due to lack of payment. The ombudsman said this resident did not get a 30-day notice or an alternative placement to accept the resident. During a telephone interview on 7/15/23 at 4:17 P.M., the Hospital Social Worker said the resident most likely had some significant cognitive issues that were not diagnosed . The social worker said essentially this resident was homeless, after being removed by the police and put up in a hotel until he/she became ill and was admitted to the hospital. The social worker said the facility was refusing to accept the resident back at this time, and the resident was refusing to accept any assistance to apply for funding of any kind, or to look into any funds that the resident may have. During an interview on 7/20/23 at 9:08 A.M., the Social Service Director and the Administrator said the resident had agreed to pay for his/her room at the facility after Medicare funding ended. They said the resident was unrealistic about returning home to his/her condemned property and refused to work with any social services, the ombudsman, the hospital staff or facility staff to arrange for payment or applications for assistance. The resident's family has been unwilling to assist with any discharge planning or with payments. The facility had arranged for the resident to transfer to an assisted living facility, and the resident had agreed to go, but at the last minute, the resident refused to leave. They said at this point no facility would accept the resident, and their facility is refusing to accept her back from the hospital. During an interview on 8/2/23 at 4:02 P.M., the Acting Administrator said the resident was not readmitted to the facility, and did not think a 30 day notice was issued, but would need to check with the administrator, who was out on leave of absence. During an interview on 8/3/23 at 8:48 A.M., hospital social worker said the resident remained at the hospital because no facility would accept the resident. He/She said the resident had not been issued a 30 day notice from the skilled nursing facility. During an interview on 8/3/23 at 8:56 A.M., the acting administrator said the resident's Medicaid application and been denied and as far as his/her understanding, the resident was getting assistance to re-apply. The acting administrator said a 30 day notice was not issued because, it would not do any good because our facility would have to keep the resident because no other place would take the resident. 3. Review of Resident #54's medical record showed the following: -discharged from the facility on 7/1/23; -Returned to the facility on [DATE]. -Staff did not document they provided the resident and resident representative a discharge/transfer notice. 4. Review of Resident #69's medical record showed the following: -Discharge from the facility on 6/14/23; -Did not readmit to the facility. -Staff did not document they provided the resident and resident representative a discharge/transfer notice. 5. Review of Resident #70's medical record showed the following: -Discharge from the facility on 2/13/23; -Did not readmit to the facility from this episode; -admitted to the facility for a new episode on 6/29/23; -discharged from the facility on 7/4/23; -Did not readmit to the facility. -Staff did not document they provided the resident and resident representative a discharge/transfer notices. 6. During an interview on 7/19/23 at 8:56 A.M., Registered Nurse (RN) A said when transferring a resident to the hospital, the resident was informed, as well as the resident representative, the physician, the Director of Nursing (DON) and the administrator. The charge nurse is responsible for preparing a face sheet, the current physician order sheet, and a summary of medical events leading up to the transfer. RN A said he/she was not sure what other paperwork was required, and any additional paperwork was the responsibility of social services, the business office manager, or the clinical liaison (acts as a mediator, who aids the communication between patients, family, and care professionals). During an interview on 7/19/23 at 2:28 P.M., Licensed Practical Nurse (LPN) C said the social worker is in charge of discharge paperwork for proper notifications. During an interview on 7/20/23 at 9:08 A.M., the Social Service Director and the Administrator said they did not realize there were required written notices for transfers to the hospital. During an interview on 7/20/23 at 9:41 A.M., RN D said charge nurses are responsible for some paperwork for emergency hospital transfers includes printing of the medication list, face sheet, and the transfer form called Interact which describes what has happened to the resident. RN D was not aware of additional required paperwork.

Based on observation, interview, and record review facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants during perineal care, when staff failed to perform appropriate hand hygiene, and glove changes for one resident (Resident #11), failed to perform appropriate incontinent care by wiping multiple times with the same area of the wipe for one resident (Resident #28), and when staff failed change and/or store oxygen tubing in a manner to prevent the spread of bacteria for three residents (Resident #7, #55 and #63). Additionally, the facility failed to ensure the two-step purified protein derivative (PPD) (skin test for TB) was completed in accordance with their policy and on file for five employees (Dietary cook G, Certified nurse aide (CNA) M, Licensed practical nurse (LPN) H, CNA I, MDS Coordinator N) out of ten employee files reviewed. The facility census was 53. 1. Review of the facility's Hand Hygiene Policy, undated, showed the following: -The facility promotes hand hygiene as a simple and effective method for preventing the spread of infections. Glove use is not a substitute for hand hygiene. All staff are to perform hand hygiene during all care activities and while working in all locations within the facility. -All staff are responsible for hand hygiene procedures: i. Before and after having direct contact with a resident's intact skin (taking pulse or blood pressure, performing physical examinations, lifting the patient in bed); ii. After contact with blood, bodily fluids or excretions, mucus membranes, non-intact skin, or wound dressings; iii. When hands move from a contaminated-body site to a clean body site during resident care; iv. Before and after wearing gloves. Review of the facility's Perineal Care procedure, undated, showed the following: -Wash and dry hands thoroughly; -Put on gloves; -Wash perineal area, wiping from front to back; -Continue to wash the perineum moving from inside outward to thighs. Rinse perineum thoroughly in the same direction, using fresh water and a clean washcloth; -Discard disposable items into designated containers; -Removed gloves; -Wash and dry hands thoroughly. 2. Review of the Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 4/20/23, showed staff assessed the resident as: -Cognitively intact; -Active diagnoses of hemiplegia (one-sided muscle paralysis or weakness); -Required assistance of two or more for toileting; -Continent of bowel and bladder. Observation on 07/20/23 at 09:19 A.M., showed Certified medication technician (CMT)/ CNA B did not wash or sanitize his/her hands in between a soiled glove change during perineal care for the resident. 3. Review of Resident #28's quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Required extensive assistance of two staff for bed mobility; -Totally dependent on two staff for toileting; -Always incontinent of bowel; -Frequent incontinent of bladder; -Active diagnoses of neurological bladder (lacking bladder control due to a brain, spinal cord or nerve problem). Observation on 7/18/23 at 12:48 P.M., showed CNA M and CNA Q entered the resident's room to provide perineal care. CNA M and CNA Q did not wash or sanitize their hands before they put on gloves. CNA M wiped the resident's back side three different times with the same portion of the wipe before he/she discarded it into the trash. CNA M used the same portion on the wipe when he/she wiped both sides of the resident's groin and then up the center. Further observation showed CNA M and CNA Q did not wash or sanitize their hands between soiled glove changes or before they left the resident's room. During an interview on 7/20/23 at 10:35 A.M., CNA M said staff are expected to wash hands before providing care, between providing care, with glove changes, and after providing perineal care. He/She said when providing perineal care staff should always wipe front to back and discard wipes after each wipe. During an interview on 7/20/23 at 10:32 A.M., Registered Nurse (RN) O said it was his/her expectation that staff wash their hands when entering the room, before and after care, with glove changes and before leaving the resident's room. He/She said staff should wipe the residents front to back and should throw away the wipes after each swipe. During an interview on 7/20/23 at 11:55 A.M., the Administrator and Director of nursing (DON) said they expected their staff to perform hand hygiene before providing perineal care, between glove changes, when gloves become soiled, after care and before leaving the residents room. He/She said it is their expectation that staff wipe resident's front to back and that wipes are discarded after each swipe. 4. Review of the facility's policies showed the facility did not provide a policy for changing or dating oxygen tubing. 5. Review of Resident #7's Quarterly MDS dated [DATE], showed staff assessed the resident as follows: -Utilized oxygen therapy; -Totally dependent on staff for toileting; -Required extensive one person physical assistince with transfers; -Uses a walker and wheelchair for mobility. Observation on 7/17/23 at 10:30 A.M., showed the resident sat in his/her recliner with oxygen on and the oxygen tubing lay across his/her bed and on the floor next to the resident's bed. Further observation showed oxygen tubing was not dated. Observation on 7/18/23 at 1:00 P.M., showed the resident sat in his/her recliner with oxygen on and the oxygen tubing lay across his/her bed and on the floor next to the resident's bed. Further observation showed oxygen tubing was not dated. Observation on 7/19/23 at 9:00 A.M., showed the resident sat in his/her recliner with oxygen on and the oxygen tubing lay across his/her bed and on the floor next to the resident's bed. Further observation showed oxygen tubing was not dated. 6. Review of Resident #55's Admission MDS, dated [DATE], showed staff assessed the resident did not utilize oxygen therapy. Review of the resident's medical record showed the record did not contain an order for oxygen therapy. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed the record did not contain scheduled oxygen tubing changes. Observation on 7/17/23 at 10:42 A.M., showed the resident sat in bed with a portable oxygen canister in the room. The tubing attached and stored coiled around the canister was not dated. Observation on 7/18/at 10:09 A.M., showed the resident stood by the bed with a portable oxygen canister in the room. The tubing attached and stored coiled around the canister was not dated. 7. Review of Resident # 63's medical record showed an order for oxygen therapy. Review of the resident's MAR and TAR showed the record did not contain scheduled oxygen tubing changes. Observation on 7/17/23 at 11:08 A.M., showed the resident sat in the recliner with an oxygen concentrator with tubing coiled and stored on the machine. The tubing attached to the concentrator was not dated. Observation on 7/18/23 at 10:11 A.M., showed the resident in bed with a nasal cannula on and attached to the concentrator. The oxygen tubing was not dated. 8. During an interview on 7/19/23 at 8:56 A.M., RN A said physician orders for oxygen did not come from the physician with orders for tubing changes. RN A said nursing staff administer treatments as indicated on the TAR. During an interview on 7/20/23 at 9:41 A.M., RN D said treatments are administered as ordered on the TAR. RN D said oxygen tubing changes would occur if in the orders on the TAR. During an interview on 7/20/23 at 11:55 A.M., the DON and administrator said oxygen tubing should be labeled and dated, and have zip-lock bag so when not being used the tubing doesn't hit the ground. They said oxygen tubing should be changed monthly, with an order for the changes and the order should be scheduled in the TAR. 9. Review of the facility's Pre-employment Medical Examination, undated, showed a physical examination within 30 days including a Mantoux test is required following an offer of employment. The Mantoux test results must be read prior to the first day of work. If there is no documented history of a negative Mantoux in the last 12 months the two-step method will be used. 10. Review of Dietary Cook G's employee file showed: -Hire date of 12/28/23; -First step PPD administered on 1/4/23, the file did not contain the results; -Second step PPD administered on 1/27/23 and read on 1/29/23. 11. Review of CNA M's employee file showed: -Hire date of 04/19/23; -First step PPD administered on 4/17/23 and read on 4/19/23; -The file did not contain documentation a second PPD dose was administered. 12. Review of LPN H's employee file showed: -Hire date of 12/12/22; -First step PPD administered on 12/12/22, the file did not contain the results; -The file did not contain documentation a second PPD was administered. 13. Review of CNA I's employee file showed: -Hire date of 12/5/22; -First step PPD administered on 12/7/22 and read on 12/9/22; -The file did not contain documentation a second PPD was administered. 14. Review of MDS Coordinator N's employee file showed: -Hire date of 4/24/23; -First step PPD administered on 4/22/23 and read on 4/24/23; -Second step PPD administered on 5/9/23, the file did not contain the results. 15. During an interview on 7/20/23 at 12:13 P.M., the Administrator said Human Resources (HR) administered the employees' first step before orientation, department heads are to get with their employees to read first step, administer second step and read results. HR goes behind and audits if the TB steps were completed or not. During an interview on 7/20/23 at 12:13 P.M., the DON said if a reading is missed on a first step, the facility must start over, same on the second step. He/She said TBs may not be getting done because of multiple competing priorities. 43024 47193

Based on observation, interview and record review, facility staff failed to assess for risk of bed rail entrapment, or obtain informed consent for bed rails for four residents (Resident #23, #33, #45, and #60). In addition, facility staff failed to obtain bedrail orders for one Resident (Resident #23). The facility census was 53. 1. Review of the facility's Bed Rails policy, undated, showed: This organization will take measure to develop and implement a strategy to minimize the possibility of resident entrapment and or injury while using bed rails. This will include an evaluation of the residents who have a need for or desire to use bed rails and that may have characteristics that place them at special risk for entrapment. The evaluation will also include inspection of the bed, mattress, and bed rail for risk of entrapment. A. Evaluate Equipment -Use the FDA Guide to Bed Safety to evaluate any spaces or gaps created using bed rails or mattresses. As a part of the facility's routine maintenance program, resident beds, mattresses, and attached equipment (including bed rails) are assessed on an annual or as needed basis; -The director of Engineering/Maintenance, or designee, will maintain documentation of bed inspections. B. Assess the Resident -The bed rail evaluation, including the entrapment risk component, is completed: admission, readmission, quarterly, and at any time there is a significant change in resident condition; -If the resident's evaluation identifies him or her as appropriate for use of bedrail(s), the following procedures will be followed: -Educate the resident/resident representative on the risks and obtain consent for use; the resident and/or resident representative consent for use of the bed rails will be documented in the resident's medical record; -The physician/practitioner will be notified and a specific order for the use of bed rails (identify how many/type of rails, which side or sides of the bed, and when they are to be in place) will be obtained; -The reason for the bed rails and their proper use will be integrated into the comprehensive care plan and revised as necessary; -The use of rails will be documented in the medical record. 2. Review of Resident #23's Admission Minimum Date Set (MDS), a federally mandated assessment, dated 7/5/23 showed staff assessed the resident as: -Cognitively Intact; -Required extensive assistance of one staff for bed mobility; -Required limited assistance of one staff for transfers; -Used bed rails. Review of the resident's medical record showed the record did not contain documentation staff completed an entrapment assessment, a signed consent, or obtained a physician's order for the use of side rails. Observation 7/17/23 at 11:32 A.M., showed bed rails raised on both sides of the resident's bed. During an interview on 7/18/23 at 11:24 A.M., the resident said he/she used the bedrails for mobility. 3. Review of Resident #33's admission MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Active diagnoses: pneumonia, depression and respiratory failure; -Bedrails used daily. Review of the resident's medical record showed the record did not contain documentation staff completed an entrapment assessment or a signed consent. Observation on 07/18/23 at 10:09 A.M., showed the resident in bed watching TV with bilateral rails in the upright position 4. Review of Resident #45's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively Intact; -Required extensive assistance of two staff for bed mobility and transfers; -Used bed rails. Review of the resident's medical record showed the record did not contain documentation staff completed an entrapment assessment or a signed consent. Observation 7/18/23 at 11:11 A.M., the resident in bed with the bed rails raised on both sides of the bed. During an interview on 7/18/23 at 11:11 A.M., the resident said he/she used the bedrails for mobility. 5. Review Resident #60's medical record showed the record did not contain documentation staff completed an entrapment assessment or a a signed consent. Observation on 7/17/23 at 11:40 A.M., showed bed rails raised on both sides of the resident's bed. During an interview on 7/18/23 at 10:04 A.M., the resident said he/she used the bedrails for mobility. 6. During an interview on 07/19/23 at 12:10 P.M., the assistant director of nursing (ADON) said their new system does not have a place for residents or resident representatives to sign a consent. During an interview on 07/19/23 at 12:12 P.M., the maintenance director said bed measurements are left up to the nurses upon admission and it is only required to be done again if a change occurs. During an interview on 07/19/23 at 02:28 P.M., Licensed practical nurse (LPN) C said the facility does not have bedrails, only half bars for mobility and positioning. He/she said he/she thinks maintenance does the entrapment assessments for the rails that is not something the nurses do. During an interview on 07/20/23 at 08:43 A.M., Certified Nurse aide (CNA) B said he/she is not aware of who does the assessments for bed rails and if the nursing staff were supposed to, he/she has never been taught that. During an interview on 7/20/23 at 9:10 A.M., Registered Nurse (RN) O said side rails are assessed on admission and reassessment reminders periodically pop up for nurses to complete. He/She said maintenance is responsible for maintaining, and measuring the rails. He/She said nurses are not responsible for measuring the side rails. He/She said he/she has never measured the side rails. During an interview on 7/20/23 at 10:35 A.M., CNA M said side rails are used to help residents in and out of bed and to help prevent from falling out of bed. He/She said it is important for staff to make sure the rails are in working order to prevent residents from falls, getting hung up in the rails, fingers from getting smashed, and getting arms caught. During an interview on 7/20/23 at 10:29 A.M., RN A said when a resident is admitted , assessments for resident use of bed rails are completed, and orders are entered for bed rail use. RN A said consents are obtained verbally, but no written consent with a signature is required. During an interview on 7/20/23 at 10:46 A.M., the ADON said residents have a bedrail assessment upon admission and quarterly. The ADON said consents for use of bedrails are verbal and in the baseline care plan. He/She said maintenance does measurements of the beds with bed rails to make sure the beds are standardized. During an interview on 7/20/23 at 11:55 A.M., the Director of Nursing (DON) and administrator said facility staff completes a bed rail assessment to make sure the resident is cognitively aware and can safely use the bed rails. They said the maintenance department does a check to assure the bed rails are up to code to prevent entrapments, but the measurements are not done while the resident is in bed. In addition, staff do obtain order for bed rails and the assessments, but do not have the resident sign a consent for bedrail use. Currently the staff uses the signature on the baseline care plan to indicate consent bedrails, but this is something the administrator and the DON want to fix. 43024 47193

Based on interview and record review, the facility staff failed to properly screen six new employees out of ten employee files reviewed in accordance with their policy, prior to employment to determine if any had a Federal indicator with the Nurse Aide Registry (NAR), Employee Disqualification List (EDL), the Criminal Background Check (CBC) and/or the Family Care Safety Registry (FCSR). The facility census was 53. 1. Review of the facility's Residents rights to freedom from abuse, neglect, and exploitation policy and procedure, dated 2022, showed, it is the purpose of this facility to ensure that all of the facility residents are free from abuse, neglect, misappropriation of their property, and exploitation. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the facility. The facility will not employ or otherwise engage individuals who: -Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; -Have had a finding entered into the state nurse aid registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or -Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. 2. Review of Registered Nurse (RN) F's employee file showed a hire date of 1/10/23. Further review showed the file did not contain: -NAR check until 5/15/23; -FCSR check until 5/15/23; -EDL check until 5/15/23. 3. Review of Dietary Cook G's employee file showed a hire date of 12/28/23. Further review showed the file did not contain: -NAR check; -FCSR check; -CBC check until 1/3/23; -EDL check until 3/10/23. 4. Review of Licensed Practical Nurse (LPN) H's employee file showed a hire date of 12/12/22. Further review showed the file did not contain: -NAR check; -FCSR check; -EDL check until 3/10/23. 5. Review of Certified Nursing Assistant (CNA) I's employee file showed a hire date of 12/5/22. Further review showed the file did not contain: -NAR check; -FCSR check; -EDL check until 3/10/23. 6. Review of Human Resources J's employee file showed a hire date of 12/6/22. Further review showed the file did not contain: -FCSR check; -NAR check; -EDL check until 3/10/23. 7. Review of Physical Therapy Assistant (PTA) K's employee file showed a hire date of 11/23/23. Further review showed the file did not contain a NAR. 8. During an interview on 07/20/23 at 12:13 P.M., the administrator said human resources was responsible for all pre-employment checks. There was an issue with the company they were contracting with to complete employment checks and realized they were not being conducted correctly. He/She was not aware of this issue until 48 hours ago. He/She said they only had to complete the NAR for nurse aides and CMTs. During an interview on 7/21/23 at 11:49 A.M., Human Resources L said when the facility was bought out the pre-employment checks were switched to the new company's contract. They did not realize they were not running the correct pre-employment checks. He/She said they got a new contract and began re-running all the required checks, including the NARs for everyone.

Based on interview and record review, the facility staff failed to provide one resident (Resident #68) a 30-day prior written notice of a date of discharge from the facility with the resident's appeal rights, failed to find appropriate placement for the resident, and refused to readmit the resident after a hospital stay. The facility census was 53. 1. Review of the facility's Notice of Resident Transfer or Discharge Notice Form, undated, showed: -A fill-out line of the location for the transfer/discharge; -A fill-out line of the date of the transfer/discharge; -Checkboxes of the reason for the transfer/discharge; -A paragraph stating the physician was discussed and agreed upon by the physician, the right to appeal the decision and how to obtain assistance or appeal; -A signature line for the facility representative; and -A signature line for verification/receipt for Notice of Resident Transfer or Discharge for the resident or resident representative. 2. Review of the Resident's #68's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/12/23, showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use; -Required extensive assistance of one staff for locomotion; -Required supervision for personal hygiene; -Required set-up assistance to eat; -No limitations with balance or range-of-motion. -A wheelchair and a walker for mobility. Review of the resident's medical record showed the following: -Transferred to the hospital on 6/17/23; -Staff did not document they provided the resident and resident representative a discharge/transfer notice. During a telephone interview on 7/14/23, the ombudsman said the resident was in the hospital and the facility told the hospital social worker that he/she could not return to the facility due to lack of payment. The ombudsman said this resident did not get a 30-day notice or an alternative placement to accept the resident. During a telephone interview on 7/15/23 at 4:17 P.M., the Hospital Social Worker said the resident most likely had some significant cognitive issues that were not diagnosed . The social worker said essentially this resident was homeless, after being removed by the police and put up in a hotel until he/she became ill and was admitted to the hospital. The social worker said the facility was refusing to accept the resident back at this time, and the resident was refusing to accept any assistance to apply for funding of any kind, or to look into any funds that the resident may have. During an interview on 7/20/23 at 9:08 A.M., the Social Service Director and the Administrator said the resident had agreed to pay for his/her room at the facility after Medicare funding ended. They said the resident was unrealistic about returning home to his/her condemned property and refused to work with any social services, the ombudsman, the hospital staff or facility staff to arrange for payment or applications for assistance. The resident's family has been unwilling to assist with any discharge planning or with payments. The facility had arranged for the resident to transfer to an assisted living facility, and the resident had agreed to go, but at the last minute, the resident refused to leave. They said at this point no facility would accept the resident, and their facility is refusing to accept her back from the hospital. During an interview on 8/2/23 at 4:02 P.M., the Acting Administrator said the resident was not readmitted to the facility, and did not think a 30 day notice was issued, but would need to check with the administrator, who was out on leave of absence. During an interview on 8/3/23 at 8:48 A.M., hospital social worker said the resident remained at the hospital because no facility would accept the resident. He/She said the resident had not been issued a 30 day notice from the skilled nursing facility. During an interview on 8/3/23 at 8:56 A.M., the acting administrator said the resident's Medicaid application and been denied and as far as his/her understanding, the resident was getting assistance to re-apply. The acting administrator said a 30 day notice was not issued because, it would not do any good because our facility would have to keep the resident because no other place would take the resident.

Based on interview, and record review, facility staff failed to accurately and consistently define pressure ulcer sites and conditions in a clear useful manner and failed to provide appropriate treatments to areas identified by staff and as ordered by the physician for one closed record review for resident (Resident #1) of three sampled residents. The facility census is 60. 1. Review of the facility's Pressure Ulcer Protocol, dated 02/21/2013, showed the following: -Nurse leader will assess and record the status of the pressure ulcer in the clinical record at least once a week. Weekly assessment will include wound measurements; -Nurse leader will notify the resident's physician if the ulcer shows signs of deterioration, fails to show progress in healing in any two week period, or show signs of increased redness, drainage , or odor. Review of Resident #1's hospital "Interfacility Transfer Form", dated 5/10/13 at 12:07 P.M. showed the following skin assessment: - Pressure ulcer on right buttocks which was debrided (removal of dead tissue surgically or with a chemical agent) and dressing changed twice a day; - Pressure ulcer on coccyx (tailbone), cover with nonadhesive [MEDICATION NAME](wound treatment) and [MEDICATION NAME] (wound dressing); - "Old" healing pressure ulcer area on right hip; - Small pressure ulcer on left hip, applied Aquaseal dressing. Review of the hospital's discharge instructions dated 5/10/13 showed wound care instructions as follows: -See instructions for right hip wound on medication list; -Apply small nonadhesive [MEDICATION NAME] to coccyx and change every 48 hours, rinse wound with normal saline (wound cleansing solution) with dressing changes. Review or the resident's hospital "Discharge Home Medication List", dated 5/10/13, showed the physician directed staff to complete the following for the resident's right hip pressure ulcer: -Apply Dakin's solution (half strength) topically twice daily. Pack right hip wound with 4 x 4 gauze soaked in half strength Dakins solution twice a day, cover with dressing. Review of the resident's Physician Orders (POS) dated 5/10/13 showed the physician directed facility staff as follows: -wound care per physician three times a day during day, evening, and night(no specification of treatment to be provided three times a day); -pack wound to right buttocks with 4 x 4 gauze soaked in Dakin's (wound care) solution, cover with dry 4 x 4 and [MEDICATION NAME] twice a day (day and evening); - Further review showed no treatment for [REDACTED]./13. Review of the resident's "Admission Observation" sheet dated 5/11/13 showed Licensed Practical Nurse (LPN) A documented the resident had one pressure ulcer to the sacrum (above the coccyx-tailbone) and one pressure ulcer to the right lower buttocks. LPN A did not document an assessment of the areas of right or left hip as identified on hospital records. Review of resident's Treatment Administration recorded (TAR) dated 5/2013 showed the following treatments: - Ordered date 5/10/13. Pack wound to right buttocks with 4 x 4 gauze soaked in Dakin's solution, cover with dry 4 x 4 and [MEDICATION NAME]. Treatment started 5/11/13; - Ordered date 5/10/13. Apply small nonadhesive [MEDICATION NAME]-XC dressing to coccyx and change every 48 hours. Review showed staff documented they completed the treatment 5/12 - 5/20. - No treatment to open area identified on left hip or right hip at hospital discharge on 5/10/13; - Staff are directed to provide "wound care" per physician A three times a day. The TAR did not give specific directions for wound location or medication/dressing to apply. Further review showed staff did not document they provided the "wound care" per physician A as follows: -5/16 evening shift NR, 5/18 evening shift NR, 5/24 night shift NR, 5/28 evening shift NR, 5/29 day shift NR , 5/29 evening shift NA . Review of the facility's Skin Condition Report, dated 5/11/13, showed the following: - On 5/11/13 at 7:34 P.M. LPN A documented a pressure ulcer on the right lower buttocks ("site 348"). "This observation was completed during a body check." LPN A did document further assessment of the area including measurements, drainage, odor, or stage to establish the facility's baseline assessment of the area in order to compare it to later assessments to show ongoing monitoring for improvement or decline; - On 5/11/13 at 7:34 P.M. LPN A documented a pressure ulcer on the sacrum ("site 651"). "This observation was completed during a body check." LPN A did document further assessment of the area including measurements, drainage, odor, or stage to establish the facility's baseline assessment of the area in order to compare it to later assessments to show ongoing monitoring for improvement or decline; -LPN A did not document any assessments of the pressure ulcers on the resident's right hip or left hip the resident's physician gave treatment orders for upon discharge from the hospital on [DATE]. Review of the facility's Skin Condition Report, dated 5/12/13, showed the following: - On 5/12/13 at 2:49 P.M. LPN A documented a pressure ulcer on the right lower buttocks (site 348). Wound present on admission. Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) measuring 5.0 cm x 4.0 cm x 0.75 cm. Wound base is 70% granulation tissue and 30 % slough. Undermining (destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface) from 9 o'clock to 10 o'clock. Deepest undermining 0.75 cm. Wound is egg shaped on the right ischium (lower back part of the pelvic bone); - On 5/12/13 at 2:40 P.M. LPN A documented a pressure ulcer on the sacrum (site 651). LPN A documented the resident had a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) measuring 2 cm x 2 cm x 0 cm. Wound was present on admission. Wound assessed as 95% granulation tissue(newly developed connective tissue), 5% slough (necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy); -On 5/12/13 at 2:57 P.M., LPN A documented on the right ischium (site 328) as a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) that measured 5 cm x 5 cm x 2 cm. Wound base 95% granulation tissue and 5% slough. Undermining from 8 o'clock to 5 o'clock. Deepest undermining 1.2 cm; - On 5/12/13 at 3:07 P.M. LPN A documented a Stage II pressure ulcer on left ischium measuring 1.5 cm x 1.5 cm x 0 cm (Site 332) . Wound was present on admission. Wound base not visible, pink wound base 100%, granulation tissue 100%, surrounding tissue normal. MD will not be notified of present status of this site, no recent changes to the treatment orders for this site. Review of the facility's Skin Condition Report, dated 5/14/13, showed the following: - On 5/14 at 2:58 P.M. showed LPN B documented a pressure ulcer on right lower buttocks (site 348). Area is now considered a stage II. The scarring measures same as measured last time, but actual open area is 3 cm x 2 cm, wound base 100% pink; -On 5/14/13 at 2:26 P.M. showed LPN B documented a pressure ulcer present on the sacrum (site 651). Stage II, wound base visible and 100% pink. LPN B did document further assessment of the area including measurements, drainage, odor to show ongoing monitoring for improvement or decline; - On 5/14/13 3:02 P.M. showed LPN B documented a right ischium pressure ulcer (site 328), stage III measuring 5 cm x 2.5 cm x 2.7 cm. 100% red wound base. MD notified of present status; -On 5/14/13 at 2:30 P.M. showed LPN B documented a pressure ulcer on the left ischium (site 332) . Wound base visible and 100% pink. Area is drying and appears to be healing. Site improvement noted. LPN A did document further assessment of the area including measurements, to show ongoing monitoring for improvement or decline. Review of resident's Treatment Administration recorded (TAR) dated 5/2013 showed the following treatments: - Ordered date 5/10/13. Apply small nonadhesive [MEDICATION NAME]-XC dressing to coccyx and change every 48 hours. Staff did not document further treatments to the area from 5/21 - 5/31/13; Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 05/17/13, showed staff assessed the resident as follows: -Memory problems; -Required extensive assistance of two or more staff with activities of daily living; -Indwelling Catheter (tube inserted into bladder to drain urine); -Incontinent of bowel; -[DIAGNOSES REDACTED]. -Required tube feedings; -Two stage II pressure ulcers - on admission; -One stage III stage pressure ulcer - on admission; -One stage IV pressure ulcer - on admission. Review of the "Residents Appointment Physician Note", dated 5/20/13 showed the the physician documented the following: -Assessment of the wound on the left greater trochanter (hip) showed the pressure ulcer had superficial skin loss in the previously healed wound ("was healed when last saw in hospital"); -Assessment of the left ischial tuberosity (lower buttock) showed it had marked exudates (drainage) and some necrosis (death) of the deep tissue, granulation tissue looked "less healthy" than previous exam; -Assessment of the sacral pressure ulcer showed it was deeper than previous exam; -Assessment of the right ischial tuberosity showed very superficial [MEDICATION NAME] loss. -"I am not pleased with the status of any of these wounds. I will adjust the wound care and re-evaluate in 2 weeks." -Treatment orders for pressure area of the coccygeal region, stage II. Change to thin [MEDICATION NAME] (wound treatment), change every 72 hours and as needed due to soiling; -treatment for [REDACTED]. -treatment for [REDACTED]. Change dressing three times a day, same solution and dressing; -treatment for [REDACTED]. Review of resident's TAR date 5/20/13, showed the following treatments: -Staff did not transcribe the physician directed treatment for [REDACTED]. Staff did not document they completed a treatment to the coccygeal area from 5/20 - 6/2/13; -Staff did not document the first treatment to the left ischial pressure ulcer until 5/23/13. Order reads apply [MEDICATION NAME] or thin [MEDICATION NAME] to left ischial tuberosity daily every three days. Review shows the treatment was documented by staff as not recorded (NR) on 5/29/13; - Review of TAR dated 5/2013 showed direction to cut a doughnut hole then cover with thick [MEDICATION NAME] to right trochanter "daily every three days" Treatments documented as NA?? on 5/26, NR on 5/29/13; -Staff are directed change wound to right buttocks, pack with 4 x 4 gauze soaked in Dakins solution, cover with dry 4 x 4 dressing and [MEDICATION NAME] dressing three times daily. Further review showed staff documented the treatment as NR 5/24 night shift, 5/28 evening shift, 5/29 day shift, and NA on 5/30 evening shift. Review of the resident wound record, dated 5/21/13, showed the following: -On 5/21/13 at 4:35 P.M. LPN B documented the resident had a pressure ulcer on the "right ischium" (Site 328) measuring 5 cm x 3 cm x 2.8 cm, faint odor, granulation tissue 50% and slough 50%, tunneling from 3- 4 o'clock, deepest tunneling point 2.8 cm, deterioration in site, physician notified. LPN B did not document assessments of the resident's other pressure ulcers to show ongoing monitoring for improvement or decline. Review of the resident wound record, dated 5/23/13, showed the following: -LPN B did not record an assessment of the resident's right buttock (site 348) pressure ulcer to show ongoing monitoring for improvement or decline; -LPN B documented a stage II on the resident's coccyx (Site 651) that measured 1 cm x 1 cm x 0.1 cm., no drainage, wound base visible, 100% pink, site improvement noted, recent changes made to this treatment site; -LPN B documented a stage II right ischium pressure ulcer (site 328) that measured 2.7 cm x 4 cm with a 1 cm x 1.5 cm purple area on the lateral side. Wound base 75% pink and 25% other color. Deterioration noted at this site. Physician notified; -LPN B documented a stage II left ischium pressure ulcer (Site 332) that measured 1.5 cm x 1.5 cm. Wound was present on admission. Wound base is visible, surrounding tissue is reddened; Review of the resident's Plan of care for pressure ulcers, dated 5/27/13(not completed until 10 days after completion of comprehensive assessment), showed the resident has existing pressure ulcers and is at risk for further skin breakdown. Staff interventions included: -assist with routine and as needed turning and repositioning; - monitor for worsening in pressure ulcer condition and notify the physician; - provide wound treatments per physician orders; - routinely monitor skin for signs/symptoms of further skin breakdown and conditions of current wounds. Review of the resident wound record, dated 5/28/13, showed the following: -LPN C documented a right lower buttocks pressure ulcer (site 348). "This area and the ischial ulcer recordings from admission have been transposed." This area is on the buttocks and has been getting the Dakin's solution treatment three times a day. LPN C did not document further clarification. Review of the resident wound record, dated 5/30/13, showed the following: -LPN C documented a stage II right lower buttocks pressure ulcer (Site 348) that measured 2.0 cm x 2.2 cm, foul odor as apparent. "This area is actually located on the right hip, not the lower buttocks". Area is less than 0.1 cm in depth. Area cleansed. Santyl applied, nickle thickness. 4 x 4 applied and secured with [MEDICATION NAME] (no physician orders found for change in treatment). Neighborhood nurse to notify physician regarding changes in treatment orders; -LPN C documented a stage II on coccyx (site 651) measuring 0.3 x 0.2 (no depth recorded). 100% granulation tissue. Area is a healing stage II. Unable to determine depth due to small size of pressure ulcer, [MEDICATION NAME] left off area. Skin prep applied. Neighborhood nurse will notify physician to obtain new treatment orders (no new orders are documented); -LPN C documented a stage III right ischium pressure ulcer (Site 328) that measured 5.1 cm x 2.5 cm x 2.1 cm. Wound base visible, 95% granulation and 5% slough; -LPN C documented a "new (first recording)" pressure ulcer on right front lateral hip (site 328). Wound not present on admission. Unable to stage due to slough/eschar covered. Wound base not visible. 90% slough, 10% eschar. Physician notified, wound care nurse notified. Santyl applied nickel thickness (no physician order found for treatment of [REDACTED]. Area covered with 4 x 4 and [MEDICATION NAME]. Neighborhood nurse will notify physician of new treatment orders - LPN C documented a left ischium pressure ulcer (Site 332). Unable to stage due to slough and/or eschar covered. Measures 1.7 cm x 2.0 cm, foul odor is apparent, drainage consistency is thin, moderate drainage is present, color is green and tan. Area was cleaned. Skin prep applied around the wound. Santyl (enzymatic wound dressing) applied nickle size thickness. 4 x 4 gauze applied and secured with [MEDICATION NAME] (no physician orders found for this change in treatment). Review of TAR dated 6/2013 showed staff did not document they provided the physician ordered treatment to coccyx from 6/1- 6/3/13. Review of a "Residents Appointment Physician Note", dated 6/3/13 showed the following: -The physician documented the resident had a pressure ulcer of coccygeal region, stage II; a pressure ulcer left greater trochanter (hip), stage I; a pressure ulcer of the left ischium, stage III; and a pressure ulcer to the right ischium, stage I. -Treatment: The greater trochanter wound and right ischial wound are to be treated with off-loading thick [MEDICATION NAME] with a doughnut hole then cover with [MEDICATION NAME]. The sacral wound should continue with [MEDICATION NAME] for the next 2-3 days then no further dressing. The left ischial wound should start [MEDICATION NAME] (or saf-gel) then pack with gauze and keep covered. -Examination: Wound left greater trochanter has superficial skin loss in the previously healed wound. Left ischial tuberosity much cleaner, healthier granulation tissue. Sacral healed. Right ischial tuberosity increased depth of injury. Review of a physician order dated 6/3/13 showed the physician directed staff to continue [MEDICATION NAME] to sacrum for one to two days then no dressing, change the treatment to right ischium and apply [MEDICATION NAME] gel two times daily. Review of TAR dated 6/2013 showed the following: -Staff documented they completed the [MEDICATION NAME] treatment to coccyx on 6/4/13 and 6/5/13, then discontinued. Review of the resident wound record, dated 6/4/13, showed staff documented the right ischium pressure ulcer (Site 328) had thick yellow/green drainage (no measurements). Applied [MEDICATION NAME] as ordered. Staff did not document assessments of the other pressure ulcers to show on-going monitoring for improvement or decline. Review of the resident wound record, dated 6/6/13 showed staff documented the following: -Pressure ulcer right lower buttock (site 348), foul odor, yellow/green drainage. Applied [MEDICATION NAME] gel to wound, soaked a 4 x 4 gauze with Dakin's solution and packed with wound. Covered with dry 4 x 4 gauze and covered with [MEDICATION NAME]. Wound pink in color and 3 cm in depth. Staff did not document measurements of the pressure ulcer. -Sacrum pressure ulcer (site 651), faint odor present, scant yellow drainage, placed [MEDICATION NAME] on sacrum and covered with [MEDICATION NAME] (treatment not ordered or documented). Wound is almost healed (no measurements documented); -Pressure ulcer on right ischium (site 328) had thick yellow/green drainage. [MEDICATION NAME] applied. Staff did not document further assessment of the pressure ulcer to show ongoing monitoring for improvement or decline; -Pressure ulcer on left ischium (site 332) . Wound site is healed. Wound site on "left hip" is healed; -Staff first assessed a new pressure ulcer on the resident's left lower buttock (site 340) that measured 2 cm x 2 cm x 0.5 cm, foul odor apparent, yellow /green drainage. [MEDICATION NAME] treatment applied. Staff did not document they notified the resident's physician of this newly identified pressure ulcer. Review of the TAR dated 6/10/13, showed staff did not document they provided the following treatment: [MEDICATION NAME] or thin [MEDICATION NAME] to left ischial tuberosity "daily every three days". Review of the resident's wound record, dated 6/12/13 2:48 P.M. showed staff documented the resident's pressure ulcer on sacrum (site 651) was healed. Review of the resident's wound record, dated 6/18/13 at 5:27 P.M., showed staff documented the pressure ulcer on left lower buttocks (Site 340) "is actually on the left ischium" area (site 332 identified as healed on the 6/6/13 assessment). Area is worsening, measures 2.3 cm x 2.5 cm x 0.8 cm, foul odor apparent, 90% slough and 10% eschar. Dr. notified and appointment scheduled for tomorrow. Review of the TAR showed the following: -Direction for staff to apply [MEDICATION NAME] or thin [MEDICATION NAME] to left ischial tuberosity "daily every three days". Review showed staff documented they did not administer the treatment on 6/19 and did not record they completed the treatment on 6/25. Review of the resident's Physician transfer appointment sheet dated 6/26/13 showed the physician directed staff to complete the following: -Continue [MEDICATION NAME] around right trochanter- cover with [MEDICATION NAME] (wound dressing) or equivalent; -bilateral ischial wound - pack with gauze (0.25% acetic acid) cover with dry gauze. Review of the TAR, dated 6/28/13, showed direction for staff to apply [MEDICATION NAME] or thin [MEDICATION NAME] to left ischial tuberosity daily every three days. Review showed staff did not record they completed the treatment on 6/28. Review of the resident's wound records, dated 7/4/13, showed staff documented the following: -Right lower buttocks (site 348) , "skin site is healed", measures 3.7 cm x 5 cm x 1 cm. area has increased in size, resident has been to physician three times since last assessment with minor [MEDICATION NAME] completed. Wound base is 100% pink. - Right ischium pressure ulcer (site 328), measured 4 cm x 2 cm x 2 cm. undermining from 10 - 12:00 o'clock deepest undermining 2 cm. -Left lower buttocks (site 340), measured 2.3 cm x 2.5 cm x 2.0 cm. Area has been debrided since last assessment. Wound has 90% slough and 10% [MEDICATION NAME] tissue. Review of MAR indicated [REDACTED] - applied [MEDICATION NAME] or thin [MEDICATION NAME] dressing to left ischial tuberosity once daily every three days. Documented as completed only on 7/1, 7/4, 7/7, 7/10/13; -applied soak gauze with acetic acid and cover, once daily to bilateral ischial wounds from 7/1 through 7/10/13. Review of the resident's wound record, dated 7/9/13, showed staff documented the following: - LPN B documented the resident's pressure ulcer on right lower buttocks (site 348) "was accidently marked as healed on last assessment charting", slight improvement noted, measures 3.7 cm x 5 cm x 0.6 cm, foul odor apparent, wound base 50% pink and 50% yellow base; -LPN B documented right ischium pressure ulcer (site 328) measuring 4.3 cm x 1.8 cm x 1.6 cm, 100% pink wound base; -LPN B documented wound on left lower buttocks (site 340) measured 2.3 cm x 2.5 cm x 1.8 cm, foul odor apparent, wound base 100% pink, no changes in site condition. Review of the resident's wound record, dated 7/16/13, showed staff documented the following: -LPN B documented the resident's right lower buttocks pressure ulcer (site 348) measured 3.7 cm x 4.8 cm x 0.4 cm. "area is declining", wound color is turning purple. Physician notified, to see physician tomorrow. Wound base 50% pink and 50% other. -LPN B did not document an assessment of the resident's right ischium (site 328) to show ongoing monitoring for improvement or decline. -LPN B documented the resident's pressure ulcer on the left lower buttocks (site 340) measured 2.8 cm x 3.0 cm x 1.8 cm. Physician office made aware last week of decline. The wound appeared unchanged. According to wound measurements from last Tuesday the wound is a little bit bigger. Wound base 20% pink and 80% black. Undermining noted at 3 and 5 o'clock. During an interview on 8/23/13 at 9:50 A.M. LPN D said that he/she was familiar with the resident, as he/she worked as a float on the unit quite a bit. The LPN said that he/she never really understood the TAR instructions "wound care per" physician A. The LPN said she understood it to refer to other treatment on TAR being completed, because it had no specific instructions. The LPN said he/she never attempted to get clarification on the order. During an interview on 8/23/13 at 11:28 A.M. at LPN A said that on the admission assessment the resident had only two identifiable pressure ulcers, one on the right buttocks and one on the coccyx. The LPN said that he/she documented the same site as right buttocks and right ischium. The LPN said that the measurements differed on each site because he/she made the first documentation (right lower buttocks) based on hospital records and second documentation (right ischium) based on actual assessment. The LPN did not know why staff continued to document differing wound assessments of the two sites. During an interview on 8/23/13 at 11:35 A.M. the Clinical Nurse Educator said that the electronic documenting program the facility used determined how the wound location site was labeled (like right ischium vs right lower buttocks), she said once a site was established in the system, whether in error or not, it could not be corrected, which added to the confusion of wound monitoring. During an interview on 8/23/17 at 3:42 P.M. the Director of Nursing (DON) said that the facility has used various nurses to monitor and measure wound condition. She said that the Assistant Director of Nursing (ADON) was taking over wound monitoring and measurement as a means of bringing greater consistency and continuity to the process. The DON said that she expected staff to provide treatments as ordered and directed in the TAR. The DON said that she would have expected staff to get clarification from the physician when orders directed staff to provide two differing simultaneous treatment to one wound area. MO 561

Based on resident, staff and physician interview and record review, the facility staff failed to assess and provide treatment to one resident (Resident #1) in a timely manner, after the resident injured his/her knee. Facility staff waited approximately one to one and one-half (1/2) hours before notifying the Physician and transferring the resident to the hospital after the resident injured his/her left patella (knee cap). The facility census was 18. 1. Review of the Resident #1's admission assessment showed staff admitted the resident to the facility on [DATE] for rehabilitation after a left knee surgery to repair a patella (knee cap) fracture and displacement. Review of the resident's interim plan of care, dated 3/08/12, showed staff were directed as follows: - Resident has a surgical wound to left knee; - Limited assistance with transfer and bed mobility; - History of falls; - Wound care; - Pain. During an interview on 3/16/12 at 3:30 P.M., Certified Nurse Aide (CNA) D said the following: - He/she answered the resident's call light at approximately 8:00 P.M. on 3/14/12; - The resident told CNA D that the resident hurt his/her leg; - He/she told the resident he/she would notify a nurse of the resident's concerns about his/her leg; - He/she notified Licensed Practical Nurse (LPN) A that the resident complained of leg and knee pain; - The ambulance arrived at the facility at approximately 10:00 P.M. to 10:30 P.M. to transfer the resident to the hospital. During an interview on 3/16/12 at 3:35 P.M., CNA C said the following: - He/she entered the resident's room to document the resident's bowel movements after CNA D left the resident's room; - The resident told CNA C that he/she hurt his/her knee, and told another CNA to notify a nurse; - CNA C said he/she notified the charge nurse of the resident's pain, however, the charge nurse said he/she had another resident to assess; - Staff are directed to notify the charge nurse "immediately" if a resident is injured or has a change in condition. During an interview on 3/16/12 at 3:45 P.M., LPN A said the following; - The resident ambulates with the use of a walker with stand-by assist, but sometimes transferred him/herself to go to the bathroom; - A CNA notified him/her the resident said his/her knee "popped and was hurting"; - He/she reviewed the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - The resident sat in his/her recliner and could not bend his/her knee; - He/she attempted to lower the foot rest of the recliner, but the resident said it caused pain to move the resident's leg; - He/she placed a pillow under the resident's knee; - When he/she attempted to move the resident's knee again, the resident cried out; - The resident told LPN A he/she called out for assistance but staff did not respond; - He/she notified the Physician by telephone at approximately 9:00 P.M. to 9:20 P.M.; - The resident said his/her leg, "started burning like fire"; - The Physician directed him/her to transfer the resident to the hospital; - LPN A said it took approximately an hour to an hour and one-half (1/2) from the time the CNA notified him/her that the resident complained of pain, until the time the ambulance arrived to transfer the resident to the hospital; - Staff are directed to notify the Physician when a resident has a change in condition; - Staff are able to contact the Physician at any time; - Staff are directed to assess a resident in the position where they find the resident before attempting to move a resident. During an interview on 3/16/12 at 4:20 P.M., LPN B said the following: - The resident contacted him/her by telephone at another facility, and said he/she could not get the attention of any staff at his/her facility; - LPN B attempted to reach staff by calling the resident's facility, but nobody answered the phone; - When LPN B could not contact staff at the resident's facility, he/she drove to that facility to notify the charge nurse that the resident needed assistance; - The resident appeared to be "upset"; - He/she did not assess the resident. During an interview on 3/20/12 at 10:50 A.M., Resident #1 said the following: - On 3/14/12, the resident transferred him/herself and walked from the bathroom to his/her recliner, using a walker; - He/she heard a "crack" or "pop" sound in his/her knee and felt warmth on his/her leg; - He/she pushed his/her call light to request assistance; - An aide entered his/her room approximately 15 minutes after he/she pressed his/her call light; - He/she told the aide he/she hurt his/her leg; - The aide told the resident he/she would notify a nurse; - That aide did not return to the resident's room; - Another aide entered the resident's room approximately ten minutes later, and he/she told the aide she hurt his/her knee; - That aide did not return to the resident's room; - He/she yelled and threw items that were within his/her easy reach at the room door to try and alert staff of his/her need for assistance. He/she said he/she threw; a tool to assist in reaching objects, a tool to assist in putting on socks, and a bottle of lotion. - When no staff members returned to his/her room, he/she called the phone number on a brochure on his/her table, and a staff member from another facility answered the phone. He/she told that staff member he/she had "done something" to his/her knee; - He/she told the staff member from the other facility that he/she needed assistance and could not get in contact with staff at his/her facility; - The staff member from the other facility attempted to contact staff at the resident's facility. The staff member at the other facility told the resident he/she would drive to the resident's facility as he/she could not reach staff; - Approximately 30 to 40 minutes after the first staff member entered his/her room, LPN A entered his/her room; - At that time, he/she heard LPN A tell the staff member from the other facility, to return to the other facility; - He/she told LPN A there is "something dreadfully wrong with my knee"; - LPN A told the resident that he/she "just needed to go to bed"; - Each time LPN A attempted to extend the resident's leg, "it hurt so bad I almost passed out"; - LPN A had one hand on the resident's knee and one hand on the foot rest of the recliner and pushed the resident's leg down; - There were "tears running down my face." He/she told LPN A, "It hurts, it hurts, it hurts;" - No other staff came into the room during that time; - He/she told LPN A to contact his/her Physician or he/she would call the police; - LPN A called the Physician; - When LPN A finished speaking with the Physician on the telephone, LPN A told the resident an ambulance would come to transfer him/her to the hospital; - It was approximately an hour and one-half (1/2) from the time he/she pushed his/her call light until the ambulance arrived at the facility; - The last few days of the resident's stay at the facility, staff said he/she could ambulate unassisted if he/she used his/her walker; - He/she "felt so helpless sitting there not having anyone answer what was going on. Nobody seemed to care;" Review of the resident's Individual Patient's Narcotics Record showed staff documented administering one tablet of [MEDICATION NAME]/APAP (an [MEDICATION NAME] opioid [MEDICATION NAME]) 10-325 milligrams (mg) on 3/14/12 at 7:00 P.M. Review showed staff did not record the administration of any pain medication after this dose. Review of the resident's Progress Notes showed staff recorded the following information about the resident's condition: - 3/14/12- 10:05 P.M.- Licensed Practical Nurse (LPN) A- reason for transfer-complaint that he/she thinks something pop in his/her knee and is causing excruciating pain and he/she is unable to bend the knee or stand on it. Physician was paged and gave an order to send resident to the emergency room for X-ray and evaluation. During an interview on 3/16/12 at 2:30 P.M., the Medical Director said he/she would expect staff to notify him/her if a resident had an injury or increase in pain. During an interview on 3/20/12 at 2:50 P.M., Housekeeper E said residents complain that staff take a long time to answer call lights. During an interview on 3/20/12 at 3:05 P.M., Registered Nurse (RN) F said the following: - Staff are directed to notify the Physician "immediately" if a resident has an injury or change in condition; - Staff can contact any Physician at any time; - He/she would expect all residents to have staff assistance with transfers and ambulation, unless the therapy department staff notified the nursing staff a resident was safe to ambulate alone; - There is one LPN on duty on each of the three floors of the facility on the evening shift; - If a nurse attempts to handle two serious medical situations at the same time, he/she would expect the nurse to ask for assistance from another nurse at the facility, or call 911. During an interview on 3/20/12 at 3:40 P.M., the Director of Nursing (DON) said the resident complained of "popping" in his/her knee "from time to time" and is anxious. He/she said the ambulance staff spent approximately 45 minutes transferring the resident from the resident's recliner into the ambulance. During a telephone interview on 3/21/12 at 1:00 P.M., LPN B said the resident contacted him/her by telephone on 3/14/12, while attempting to call the charge nurse of his/her own facility. He/she attempted to reach the facility "five or six times"for approximately ten minutes, before he/she drove to the resident's facility. The evening of 3/14/12 is the only time he/she has driven to another facility to check on a resident. The resident sounded "anxious and upset" during the telephone conversation with him/her. During a telephone interview on 3/26/12 at 1:45 P.M., the DON said the following: - There is one LPN on each of the three floors of the facility on the evening shift; - If a nurse attempts to handle two serious medical situations at the same time, he/she would expect the nurse to ask for assistance from another nurse at the facility, or call 911. During a telephone interview on 3/28/12 at 10:45 A.M., the Physician said the following: - He/she does not remember what time the facility staff contacted him/her regarding the resident, but did remember it to be late in the evening; - He/she waited approximately 45 minutes to one hour before he/she left his/her house to meet the resident at the hospital and when he arrived, the resident had been there a short time; - He/she assessed the resident between 3:00 P.M. and 4:00 P.M. on 3/14/12 and found the resident's knee swollen, however, the resident could ambulate with mild pain; - X-ray showed a fracture in the resident's patella. MO 512