Every finding on record at Hillcrest Care Center Inc

Based on observation and interview, the facility failed to ensure the dumpster was maintained to keep pest out and/or to keep garbage contained in the dumpster. This deficient practice had the potential to affect all residents in the facility. The facility was 81. The facility did not provide a policy for maintaining the dumpster. Observations on 01/19/26 at 10:05 A.M., and 1:00 P.M., of the outside trash dumpster showed;- Each dumpster lid was open with visible garbage bags, boxes, and other miscellaneous debris inside. Observations on 01/20/26 at 11:24 A.M., and 2:02 P.M., 1/21/26 at 8:22 A.M., 11:44 A.M., and on 01/22/26 at 8:14 A.M., and 10:11 A.M., of the outside trash dumpster showed:- The left-side dumpster lid was open with visible garbage bags, boxes, and other miscellaneous debris inside. Observation on 01/21/26 at 9:38 A.M., of the outside trash dumpster showed:- Housekeeper A discarded a bag of trash into the dumpster and did not close the lid. During an interview on 01/21/26 at 9:42 A.M., Housekeeper A said he/she never closed the dumpster lids after throwing away trash and had not been told to do so. During an interview on 01/21/26 at 11:48 A.M., Housekeeper B said trash lids should be closed each time a staff member threw away trash or anything else in the dumpster. During an interview on 01/22/26 at 11:07 A.M., the Dietary Manager (DM) said staff should close the dumpster lids after discarding trash and debris into it. During an interview on 01/22/26 at 11:11 A.M., the Maintenance Supervisor (MS) said staff should close the dumpster lids after discarding trash and debris into it. During an interview on 01/22/26 at 12:21 P.M., the Administrator said staff should close the dumpster lids after discarding trash and debris into it.

Based on observation, interview and record review, the facility failed to treat residents with dignity and respect when staff stood over three residents (Residents #21, #33, and #36) and fed the residents during meals and left one resident (Resident #80) with no privacy and exposed during his/her wound care, out of 18 sampled residents. The facility census was 81.Review of the facility's policy titled, Resident Rights, undated, showed:- Each resident shall be treated with consideration, respect a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. 1. Observation on 01/20/26 at 12:07 P.M., of the main dining room showed:- Certified Nursing Assistant (CNA) N stood over and fed Resident #36 during the noon meal. Observation on 01/20/26 at 5:03 P.M., of the cafe dining room showed:- CNA M stood over and fed Resident #21 during the evening meal. Observation on 01/20/26 at 5:20 P.M., showed:- CNA M stood over and fed Resident #33 during the evening meal. 2. Observation of Resident #80's wound care on 01/21/26 at 10:51 A.M., showed:- CNA K and Registered Nurse (RN) J entered the room to perform the resident's wound care; - CNA K and RN J did not close the curtains to the window and the sidewalk was visible through the window;- CNA K and RN J did not close the privacy curtain around the resident;- CNA K and RN J removed the resident's brief;- RN J opened the resident's door and exited the room to obtain additional supplies while the resident lay with his/her front peri area uncovered and exposed;- RN J did not pull the privacy curtain prior to opening the door to exit the room;- CNA K did not close the privacy curtain around the resident;- RN J opened the resident's door, entered the room while the resident lay with his/her front peri area uncovered and exposed, and performed wound care. During an interview on 01/21/26, at 1:45 P.M., RN J said he/she should pull the window curtain closed before care, as well as the privacy curtain before leaving the room to obtain more supplies. During an interview on 01/22/26, at 11:40 A.M., the Director of Nursing (DON) said she would expect staff to close the window curtain, as well as the privacy curtain before providing care to any resident. Staff should be seated at eye level to feed residents during meals, not standing. During an interview on 01/22/26, at 11:48 A.M., the Administrator said she would expect staff to close window shades, as well as privacy curtains during care. Staff should be sitting at eye level when helping feed residents in the dining room. During an interview on 01/27/2026 at 7:01 A.M., CNA M said he/she always stood when feeding the residents in the dining room.

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to the resident and/or the resident's representative in writing at least two calendar days before discharge from skilled services. This notice informs the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting the financial liability for those services. This practice affected two residents (Residents #43 and #100) out of three sampled residents. The facility census was 81.The facility did not provide a policy regarding SNF ABN forms. 1. Review of Resident #43's medical record showed:- The resident discharged from skilled Medicare services on 01/16/26, and remained in the facility;- No documentation the resident and/or the representative received a SNF ABN;- The facility failed to provide the SNF ABN form to the resident and/or the representative at least two calendar days before the skilled Medicare services ended. 2. Review of Resident #100's medical record showed:- The resident discharged from skilled Medicare services on 11/11/25, and remained in the facility;- No documentation the resident and/or the representative received a SNF ABN;- The facility failed to provide the SNF ABN form to the resident and/or the representative at least two calendar days before the skilled Medicare services ended. During an interview on 01/21/26 at 2:49 P.M., the Social Services Designee (SSD) said he/she was unaware that the SNF ABN form needed to be filled out for residents that elected to stay in the facility. During an interview on 01/22/26 at 12:00 P.M., the Administrator said if a resident discharged from skilled Medicare services and remained in the facility, the resident and/or the resident representative should receive a SNF ABN.

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 81. The facility did not provide a homelike environment policy. Observations on 01/19/2026 at 10:34 A.M., 01/20/2026 at 6:00 P.M., 01/21/2026 at 11:35 A.M., and 01/22/26 at 11:21 A.M., of the nurse's station area, showed: - One ceiling fan over the cafe area with a buildup of dirt and debris; - Two ceiling fans over the bird cage area with a buildup of dirt and debris and missing fan blades; - Two skylight (roof installed window) outer edges over the cafe area with a buildup of dust and debris; - Two skylight outer edges over the nurses' station with a buildup of dust and debris. Observation on 01/19/2026 at 12:34 A.M. and 01/20/2026 at 6:05 P.M., of the main dining room, showed: - An approximate one foot (ft.) by two ft. area near the double doors on the left-side with peeled areas of paint. - A four ft. linear (straight line) piece of corner molding on the left-side held together with two strips of medical tape against the wall. - An approximate one ft. by two ft. area near the double doors on the right-side with peeled areas of paint; - A nickel size hole in the wall above the handrail near the double doors on the right side. Observations on 01/19/2026 at 1:34 P.M., 01/20/2026 at 3:34 P.M., 01/21/2026 at 11:12 A.M., and 01/22/26 at 10:21 A.M., of the 200 hall, showed: - Several one-to-two inch (in.) long areas of exposed sheetrock and peeled paint on the wall behind the headboard of bed 2 by the window in room [ROOM NUMBER]; - A missing corner piece of base board with exposed sheetrock and peeled paint by bed 1 near the door in room [ROOM NUMBER]; - Three areas of peeled wallpaper on the left-side wall near room [ROOM NUMBER]; - Three ft. of peeled wallpaper by a large canvas painting between room [ROOM NUMBER] and room [ROOM NUMBER]; - Two ft. of peeled wallpaper by a brown-framed wooden picture near room [ROOM NUMBER]. Observations on 01/19/2026 at 1:38 P.M., 01/20/2026 at 3:39 P.M., 01/21/2026 at 11:22 A.M., and 01/22/26 at 10:16 A.M., showed: - An approximate four in. by six in. area of exposed sheetrock and peeled paint on the hallway wall below a cork-like bulletin board located by the laundry room door entrance. Review of the Maintenance Repair Log, dated 11/01/25 through 01/21/26, showed: - No documentation of areas of concern addressed. During an interview on 01/21/2026 at 9:42 A.M., Housekeeper A said any repairs should be written down on the maintenance log located at the nurse's station. He/She had not seen anything to write down that needed repaired. During an interview on 01/21/2026 at 11:48 A.M., Housekeeper B said any repairs should be written down on the maintenance log located at the nurse's station. He/She had not seen anything to write down that needed repaired During an interview on 01/22/26 at 10:00 A.M., Certified Nurse Aide (CNA) F said he/she filled out a request on the maintenance logbook. If it was something that maybe was a danger to the residents, he/she would verbally tell the nursing department or the maintenance staff. During an interview on 01/22/26 at 10:05 A.M., CNA G said he/she would go to the nurse's station and fill out a request on the maintenance logbook. If it was an emergency, then he/she would go straight to the maintenance staff to make it a priority. During an interview on 01/22/26 at 10:15 A.M., Licensed Practical Nurse (LPN) I said the areas of concern near the nurse's station were probably the housekeeping and maintenance departments combined. He/She did not know how the areas were cleaned. He/She said staff should put anything related to repairs in the maintenance book located at the nurse's station. During an interview on 01/22/26 at 11:35 A.M., the Assistant Director of Nursing (ADON) said he/she would expect the staff to fill out a maintenance request on the logbook. If it was detrimental (bad) or dangerous he/she would expect the staff come and get the ADON and/or Director of Nursing (DON) and let them know so the concern could be addressed immediately. During an interview on 01/22/26 at 12:25 P.M., the Housekeeping Supervisor (HS) said the housekeeping department was responsible for cleaning the commons area and should assist the maintenance department when needed. During an interview on 01/22/26 at 12:30 P.M., the Maintenance Supervisor (MS) said he/she is responsible for cleaning the commons area and has shut down the ceiling fans totally, due to the fan blades being broke. He/She reviewed the logbook every other day. MS said sometimes staff just tell him/her in passing what needs repaired. However, he/she would rather there be an entry in the logbook due to having a record of needed and completed repairs. During an interview on 01/22/26 at 12:41 P.M., the Administrator said she would expect staff to write down any needed repairs on the maintenance log and for documentation purposes. By doing so allows the MS to prioritize the repairs needed to be completed in a timely manner.

Based on interview and record review, the facility failed to document, obtain a signature, and/or send notification in writing to the resident and/or the resident's representative of a transfer or discharge to a hospital, including the statement of appeal rights or the name, address, or the telephone number of the Office of the State Long Term Care Ombudsman (advocate for the resident in nursing facilities) within the transfer and discharge notices and bed-hold policy (the holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) for four residents (Residents #3, #5, #19 and #34) out of five sampled residents. The facility census was 81. The facility did not provide a transfer/discharge policy. Review of the facility's policy titled, Bed Hold Guidelines, undated, showed:- The facility will notify all residents and/or their representative of the bed hold guidelines;- This notification shall be given on admission to the facility, at the time of transfer to the hospital, and at the time of non-covered therapeutic leave;- If the resident or resident representative wants to hold the bed, a signed authorization must be obtained with each discharge;- If the resident or resident representative does not choose to hold the bed, the bed will be released and any personal belongings must be picked up within three days;- Bed holds are strictly voluntary:- If the bed is not held and is not available when the resident wants to be re-admitted , the resident's name will be placed on a waiting list for the next available bed. 1. Review of Resident #3's medical record showed:- admitted 0n 08/26/25;- The resident transferred to the hospital on [DATE], and returned on 09/17/25;- The resident transferred to the hospital on [DATE], and returned on 09/30/25. Review of the resident's Transfer/Discharge and Bed Hold Guidelines forms, dated 09/09/25 and 09/24/25, showed:- No selected bed-hold preference;- No daily bed-hold rate;- No signature from the resident and/or the resident's representative;- No documentation the information was provided in writing to the resident and/or the resident's representative. 2. Review of Resident #5's medical record showed:- admitted on [DATE];- The resident transferred to the hospital on [DATE], and returned on 09/28/25. Review of the resident's Transfer/Discharge and Bed Hold Guidelines forms, dated 09/24/25, showed:- No selected bed-hold preference;- No daily bed-hold rate;- No signature from the resident and/or the resident's representative;- No documentation the information was provided in writing to the resident and/or the resident's representative. 3. Review of Resident #19's medical record showed:- admitted on [DATE];- The resident transferred to the hospital on [DATE], and returned on 11/10/25. Review of the resident's Transfer/Discharge and Bed Hold Guidelines forms, dated 11/06/25, showed:- No selected bed-hold preference;- No daily bed-hold rate;- No signature from the resident and/or resident's representative;- No documentation the information was provided in writing to the resident and/or the resident's representative. 4. Review of Resident #34's medical record showed:- admitted on [DATE];- The resident transferred to the hospital on [DATE], and returned on 11/18/25. Review of the resident's Transfer/Discharge and Bed Hold Guidelines forms, dated 11/06/25, showed:- No selected bed-hold preference;- No daily bed-hold rate;- No signature from the resident and/or resident's representative;- No documentation the information was provided in writing to the resident and/or the resident's representative. During an interview on 01/21/26 at 10:00 A.M., the Assistant Director of Nursing (ADON) said the charge nurse should fill out the paperwork and give it to the resident or the responsible party upon discharge to for a signature. If the responsible party was not present, a phone call should be made informing him/her of the transfer and a letter should be mailed for a signature. There should be documentation the resident or the representative received the bed hold and the transfer/discharge information. During an interview on 01/22/26 at 10:20 A.M., Licensed Practical Nurse (LPN) I said when a resident was sent to the hospital, the nursing staff filled out the bed hold form and sent it with the resident. A copy was made and the Social Service Director (SSD) would get the copy. The SSD would get in contact with the resident's representative. I the resident could sign, then he/she signed it at that time. However, if the resident couldn't sign it, two nurses would sign the form. During an interview on 01/22/26 at 10:28 A.M, the SSD said he/she did not send a notification letter to the responsible representative to be signed or filled out. He/She did keep a copy of the transfer/discharge and bed-hold paperwork. During an interview on 01/22/26 at 12:10 P.M., the Administrator said the charge nurse on duty should fill out the transfer/discharge and bed-hold paperwork. If the resident could sign, a copy was made and given to the SSD. If the resident was unable to sign, the SSD should notify and send the paperwork to the responsible representative. The paperwork should also have documentation showing it was mailed to the responsible representative for his/her signature. There should be a bed-hold choice selected and a daily room rate on the forms.

Based on observation, interview, and record review, the facility failed to ensure staff used acceptable infection control procedures and practices for wound care for four residents (Residents #1, #19, #51 and #80) out of five sampled residents. The facility also failed to ensure ice chest carts were monitored to prevent access to residents and visitors without staff assistance for two residents (Residents #14 and #77) outside the sample. These deficient practices could potentially affect all residents. The facility census was 81.Review of the facility's policy titled, Enhanced Barrier Precautions (EBP) to Infection Control Guidance, dated March 2024, showed:- To prevent broader transmission of multidrug resistance organisms (MDRO) and to help protect residents with chronic wound and indwelling devices. EBP should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed;- Residents with indwelling medical devices including urinary catheter or with a wound, regardless of their MDRO status require EBP;- Use EBP when providing high-contact resident care activities such as: transferring residents from one position to another; providing hygiene; changing briefs or assisting with toileting; caring for or using an indwelling medical device; or performing wound care;- Gloves and putting on and taking off gowns are required when conducting high-contact resident care activities. Gloves and gown should be removed and discarded after each resident care encounter. Review of the facility's policy titled, Glove Use, dated, May 2015, showed:- To ensure safe and proper food handling during food preparation and service. The food code states that food items should not be handled with bare hands;- Gloves should be removed when changing or walking away from specific tasks and hands should be washed;- Hands should be washed after handling dirty dishes, after disposing of trash or food, and when changing tasks. The facility did not provide an ice chest policy. 1. Observation of Resident #19's wound care on 01/20/26 at 1:55 P.M., showed:- EBP signage on the resident's door;- Personal protective equipment (PPE) stored just inside the resident's room on the bathroom door;- Licensed Practical Nurse (LPN) I and Certified Nurse Assistant (CNA) F performed hand hygiene, put on gloves, did not put on gowns, and entered the resident's room;- LPN I provided the wound treatment to the resident. Observation of Resident #51's wound care on 01/21/26 at 8:54 A.M., showed:- No EBP signage on the resident's door;- PPE stored just inside the resident's room on the bathroom door;- Registered Nurse (RN) J and CNA L performed hand hygiene, put on gloves, did not put on gowns, and entered the resident's room;- RN J cleaned the wound;- RN J removed the gloves, did not perform hand hygiene, and left the room to obtain additional supplies;- RN J did not perform hand hygiene, put on gloves, did not put on a gown, and entered the resident's room;- RN J provided wound treatment to the resident. Observation of Resident #1's wound care on 01/21/26 at 10:30 A.M., showed:- EBP signage on the resident's door;- PPE stored just inside the resident's room on the bathroom door;- RN P performed hand hygiene, put on gloves, a mask, and a gown;- RN P performed the resident's wound care, removed the gloves, performed hand hygiene, did not remove the gown, exited the room, walked into the hallway to the treatment cart and obtained supplies, re-entered the resident's room, performed hand hygiene, put on clean gloves, did not put on a clean gown, and continued the wound treatment;- RN P removed the gloves, performed hand hygiene, did not remove the gown, exited the resident's room, walked to the linen cart to retrieve hygiene wipes, performed hand hygiene, put on clean gloves, did not put on a clean gown, and continued to provide incontinent care to the resident. Observation of Resident's #80's wound care on 01/21/26 at 10:51 A.M., showed:- No EBP signage on the resident's door;- PPE stored just inside the resident's room on the bathroom door;- RN J and CNA K performed hand hygiene, put on gloves, and did not put on a gown;- CNA K rolled the resident and RN J cleaned the wound;- RN J removed gloves, did not perform hand hygiene, and left the room to obtain additional supplies;- RN J entered the resident's room, did not perform hand hygiene, put on gloves, and did not put on a gown;- RN J provided the wound treatment to the resident. During an interview on 01/22/26 at 10:05 A.M., CNA F said residents with wounds should have EBP signage to let staff know the resident had a wound, catheter, a feeding tube or something like that. CNA F said he/she should have worn a gown when assisting with wound care but just forgot today. During an interview on 01/22/26 at 10:20 A.M., LPN I said staff only wear the gowns in the resident's room that had an infection. Staff did not wear a gown to provide a wound treatment for residents. During an interview on 01/22/26 a 11:20 A.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said staff should perform hand hygiene prior to entering a resident room and after exiting a resident room. During an interview on 01/22/26 at 11:30 A.M., the DON and ADON said staff that were providing care for residents on EBP should remove the gown before exiting the resident's room. 2. Observation on 01/19/26 at 3:32 P.M., of Resident #77 showed:- The ice chest cart sat unmonitored on the 200 Hall;- Resident #77 opened the lid on the ice chest cart;- He/She picked up the ice scoop and reached inside the ice chest with his/her bare hand;- He/She scooped ice into his/her beverage container three times;- He/She held the beverage container over the ice;- Pieces of ice fell back into the ice chest after it touched his/her beverage container;- He/She left the ice chest lid opened and returned to his/her room;- He/She returned to the ice-chest and closed the lid;- No staff present. Observations on 01/20/26 at 12:41 P.M., of Resident #14 showed:- The ice chest cart sat in the cafe area;- Resident #14 sat in the cafe area with a visitor near the nurses' station;- The visitor took the resident's beverage container off the table, walked to the ice chest cart, and opened the lid;- The visitor picked up the ice scoop and reached inside the ice-chest with his/her bare hand;- The visitor scooped ice in the resident's beverage container;- The visitor closed the ice-chest lid;- The visitor returned to the cafe area and placed the resident's beverage container on the table;- Two charge nurses sat behind the nurses' station, two nurse assistants picked up meal trays, and a housekeeper swept the floor in view of the ice-chest and observed the visitor put ice in the resident's beverage container;- Staff did not intervene. During an interview on 01/22/26 at 11:44 A.M., the DON and ADON said they would expect the ice chest to be removed, ice discarded and refilled with fresh ice if a resident and/or visitor was witnessed using it other than staff. During an interview on 01/22/26 at 12:05 P.M., the Administrator said she would expect staff to sanitize their hands before entering and after exiting a resident's room. She would expect staff providing care to residents on EBP to remove the gown before exiting a resident's room.

Based on interview and record review, the facility failed to ensure 26 residents out of 27 sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26) were free of misappropriation of their property when Bookkeeper A utilized resident trust accounts and resident cash for his/her own personal use totaling $20,110. The facility census was 84. The administration was notified on 03/28/25 of the Past Non-Compliance which occurred between 02/06/25 through 02/10/25. On 02/06/25, upon notification, the facility administrator started an investigation, notified the police department and the Department of Health and Senior Services of the misappropriation. The non-compliance was corrected on 02/10/25, as the facility completed disciplinary action for Bookkeeper A, in-serviced staff on the facility's policy and procedure on misappropriation and refunded residents' the amounts misappropriated. Review of the facility's policy entitled, Abuse Prohibition Protocol Manual, dated November 2016, showed: -Misappropriation of resident property defined as deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money with the resident's consent; -Employees are educated on Abuse Protocol upon hire and annually. Review of facility policy entitled, Instructions for Daily Cash Box Duties and Reconciliation, undated, showed: -Cash box is for residents' personal use and facility shopping for residents only and cash is not to be used to pay bills or reimburse family members; -Cash box reconciliations must be turned in by 4:00 P.M. each day; -Each cash withdrawal must be listed on the reconciliation report; -Three signatures are required on the reconciliation report (Business Office Manager, Administrator or designee and a witness); -A completed and signed disbursement log with a reason for the cash request must be listed; -A yes or no must be entered if the facility shopped for the resident or not. If cash was used by the facility to shop for the resident, the resident or legal representative must sign the disbursement logt to give consent to shop for the resident. Signed receipts must be attached; -If cash is given directly to the resident, the resident must sign the disbursement log. If the resident makes a mark or the signature is not legible, two witness signatures are required; -Do not enter personal spending as the reason for cash disbursement. Must have more detail like shopping at Walmart, vending machine cash or snacks, etcetera; -Cash tickets must be entered in the computer system for each cash withdrawal before sending in the reconciliation form. Review of the facility's investigation summary dated, 02/25/25, showed: -On 02/06/25, Social Services Assistant (SSA) B notified Resident #1's family of the resident's trust account (RTA) getting low on money. Resident #1's family said there was no way this was possible as Bookkeeper A said in January 2024 the RTA had thousands of dollars in it. Resident #1's family said the resident had no concept of money and he/she always takes the resident to the store to buy what the resident needs and the resident's craft items. SSA B said he/she would inform the Administrator so the account could be looked into; -On 02/06/25, Administrator contacted the facility's Financial Consultant (FC) regarding the concern and an audit was started. In-Service was also started regarding Abuse/Neglect Protocol. Bookkeeper A had been out of the facility on leave since 01/17/25. All staff informed Bookkeeper A was not to be in the building pending the investigation. Locks on the bookkeeping office and front office doors were changed; -On 02/10/25, the audit by FC identified seven possible RTAs for misappropriation. Reports were made to Department of Health and Senior Services (DHSS), law enforcement, the local ombudsman and family representatives regarding the possible misappropriation; -On 02/11/25, RTA audits completed and identified five resident RTAs affected (Residents #1, #2, #3, #4 and #5), who had no previous cash withdrawals until after Bookkeeper A took over. Bookkeeper A took the position in 05/2023. Bookkeeper A failed to respond to multiple facility attempts for a statement and termination process was started; -On 02/12/25, Bookkeeper A notified by voicemail employment had been terminated. The five affected residents' family representatives were notified funds were reimbursed; -On 02/13/25, Resident #6 was reimbursed due to facility being unable to determine if there resident requested money, as the request was not signed off per facility policy; -On 02/18/25, facility informed by Resident #8's family to move his/her funds into Resident #7's RTA as Resident #8 had passed. Investigation revealed Resident #7 and Resident #8 did not have RTAs set up. Family member informed facility he/she had given $100 to Bookkeeper A to put $50 in Resident #7's RTA and $50 in Resident #8 RTA. Receipt was found for the $100 but funds were not deposited into the petty cash account in order for a check to be written to the RTA. A second family member of Resident #7 and Resident #8 said he/she had also given $100 to Bookkeeper A and was not given a receipt as he/she met Bookkeeper A in the hallway. 1: Review of Resident #1's face sheet showed: -admitted [DATE]; -Diagnoses of intellectual disabilities, dementia, depression and insomnia; -Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment instrument completed by the staff), dated 01/20/25, showed moderate cognitive impairment. Review of Resident #1's RTA statement from 01/01/23 through 02/10/25 in conjunction with facility cash box disbursement logs showed: - Resident #1 had multiple cash withdrawals labeled personal spending starting 12/13/23 and ending 11/11/24 totaling $1346; -Cash box disbursement log signed by resident and Bookkeeper A; - No witness signature as per the facility policy. 2: Review of Resident #2's face sheet showed: -admitted [DATE]; -Diagnoses of cerebral infarction (stroke), major depressive disorder, epilepsy (seizure disorder), dementia and anxiety. -Significant change MDS, dated [DATE], showed moderate cognitive impairment. Review of Resident #2's RTA account statement from 01/01/23 through 02/10/25 in conjunction with facility cash box disbursement logs showed: - Resident #2 had multiple cash withdraws labeled personal spending starting 01/24/24 and ending 01/15/25 totaling $1254; -Cash box disbursement log signed by resident and Bookkeeper A; - No witness signature as per the facility policy. 3: Review of Resident #3's face sheet showed: -admitted [DATE]; -Diagnoses of paranoid schizophrenia (disorder characterized by persistent delusions of persecution, distrust and hallucinations), depression and dementia; -Quarterly MDS, dated [DATE], showed moderate cognitive impairment. Review of Resident #3's RTA account statement from 01/01/23 through 02/10/25 in conjunction with facility cash box disbursement logs showed: - Resident #3 had multiple cash withdraws labeled personal spending starting 01/23/24 and ending 01/10/25 totaling $899; -Cash box disbursement log signed by resident and Bookkeeper A; - No witness signature as per the facility policy. 4: Review of Resident #4's face sheet showed: -admitted [DATE]; -Diagnoses of chronic obstructive pulmonary disease (COPD-lung disease that blocks air flow making it difficult to breath), dementia, personality disorder, depressive episodes, hallucinations and paranoid schizophrenia; -Quarterly MDS, dated [DATE], showed moderate cognitive impairment. Review of Resident #4's RTA account statement from 01/01/23 through 02/10/25 in conjunction with facility cash box disbursement logs showed: - Resident #4 had multiple cash withdraws labeled personal spending starting 10/19/23 and ending 01/09/25 totaling $1436; -Cash box disbursement log signed by resident and Bookkeeper A; - No witness signature as per the facility policy. 5: Review of Resident #5's face sheet showed: -admitted [DATE]; -Diagnoses of hypertension (high blood pressure), major depressive disorder, and dementia; -Quarterly MDS, dated [DATE], showed severe cognitive impairment. Review of Resident #5's RTA account statement from 01/01/23 through 02/10/25 in conjunction with facility cash box disbursement logs showed: - Resident #5 had multiple cash withdraws labeled personal spending starting 12/11/23 and ending 01/15/25 totaling $430; -Cash box disbursement log signed by resident and Bookkeeper A; - No witness signature as per the facility policy. 6: Review of Resident #6's face sheet showed; -admitted [DATE]; -Diagnoses of schizophrenia, Parkinsonism (condition causing slowed movements, rigidity and stiffness), depressive episodes, dementia, and anxiety' -Significant change MDS, dated [DATE], showed moderate cognitive impairment. Review of Resident #6's RTA account statement from 01/01/23 through 02/28/25 in conjunction with facility cash box disbursement logs showed: - Resident #6 had multiple cash withdraws labeled personal spending starting 01/08/24 and ending 01/10/25 totaling $420; -Cash box disbursement log signed by resident and Bookkeeper A; - No witness signature as per the facility policy. 7: Review of Resident #7's face sheet showed: -admitted [DATE]; -Diagnoses of hypertension, dementia, anxiety disorder, restlessness and agitation; -Significant change MDS, dated [DATE], showed severe cognitive impairment. Review of Resident #7's RTA showed account created on 02/20/25 after the discovery of the misappropriation. 8: Review of Resident #8's face sheet showed: -admitted [DATE]; -date of death [DATE]; -Diagnoses of atrial fibrillation (irregular, rapid heart rate), femur fracture, hearing loss, major depressive disorder and anxiety disorder. Review of Resident #8's RTA showed account created on 02/20/25 after the discovery of the misappropriation. Review of facility cash receipt book audits, dated 03/03/25 through 03/07/25, where Bookkeeper A signed the receipts, showed: -On 03/03/25, Resident #9's room and board paid by the resident's representative with funds not deposited for the receipts given and no receipts for deposits from September 2024 through January 2025 with a total of $12885; - A receipt for Resident #10 of $50 but no RTA account, no petty cash deposit and no RTA deposit record; - A receipt for Resident #11 of $30 but no RTA account, no petty cash deposit and no RTA deposit record; -Receipts for Resident #12 totaling $160 but no RTA account, no petty cash deposit and no RTA deposit record; -Receipts for Resident #13 totaling $260 with no petty cash deposit and no RTA deposit; -Receipts for Resident #14 totaling $200 with no RTA account, no petty cash deposit and no RTA deposit record; -Receipts for Resident #15 totaling $100 with no petty cash deposit and no RTA deposit; -Receipt for Resident #16 of $20 but no RTA account, no petty cash deposit and no RTA deposit record; -Receipt for Resident #17 of $50 with no petty cash deposit and no RTA deposit and resident; -Receipt for Resident #18 of $100 with no RTA account, no petty cash deposit and no RTA deposit record; -Receipts for Resident #19 totaling $60 with no RTA account, no petty cash deposit and no RTA deposit record; -Receipt for Resident #20 of $20 with no RTA account, no petty cash deposit and no RTA deposit record: -Receipt for Resident #21 of $60 with no RTA account, no petty cash deposit and no RTA deposit record; -Receipt for Resident #22 of $40 with no RTA account, no petty cash deposit and no RTA deposit record; -Receipt for Resident #23 of $20 with no RTA account, no petty cash deposit and no RTA deposit record; -Receipt for Resident #24 of $20 with no RTA account, no petty cash deposit and no RTA deposit record; -Receipt for Resident #25 of $50 with no RTA account, no petty cash deposit and no RTA deposit record; -Receipt for Resident #26 of $30 with no RTA account, no petty cash deposit and no RTA deposit record. 9: Review of Resident #9's face sheet showed: -admitted [DATE]; -Diagnoses of intellectual disabilities, schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions), parkinsonism, and depression; -Significant change MDS, dated [DATE], showed severe cognitive impairment. 10: Review of Resident #10's face sheet showed: -admitted [DATE]; -date of death [DATE]; -Diagnoses of vascular dementia (decline in thinking due to decreased blood flow to areas of the brain), malignant neoplasm of the liver (liver cancer), pain and type 2 diabetes mellitus (high blood sugars). 11: Review of Resident #11's face sheet showed: -admitted [DATE]; -date of death [DATE]; -Diagnoses of lung cancer, liver cancer and bone cancer. 12: Review of Resident #12's face sheet showed: -admitted [DATE]; -date of death [DATE]; -Diagnoses of hypertension, chronic kidney disease requiring dialysis, hypertension, diabetes and atrial fibrillation; -Significant change MDS, dated [DATE] showed moderate cognitive impairment. 13: Review of Resident #13's face sheet showed: -admitted [DATE]; -Diagnoses of Brown-Sequard syndrome (lesion in one (lateral) half of the spinal cord resulting in a specific pattern of symptoms on one side of the body), hypertension, congestive heart failure (heart doesn't pump blood as well as it should) and major depressive disorder; -Significant change MDS, dated [DATE], showed cognitively intact. 14: Review of Resident #14's face sheet showed: -admitted [DATE]; -date of death [DATE]; -Diagnoses of schizophrenia, vision loss, anxiety disorder, COPD and depression. 15: Review of Resident #15's face sheet showed: -admitted [DATE]; -date of death [DATE]; -Diagnoses of hypertension, dementia, chronic kidney disease and major depressive disorder; -Significant change MDS, dated [DATE], showed moderate cognitive impairment. 16: Review of Resident #16's face sheet showed: -admitted [DATE]; -Diagnoses of heart failure, posterior displaced type II dens fracture (a break through a specific part of C2, the second bone in the neck), restlessness and agitation, chronic kidney disease and Parkinson's. 17: Review of Resident #17's face sheet showed: -admitted [DATE]; -date of death [DATE]; -Diagnoses of cerebral infarction (stroke), anxiety disorder, fracture of part of the neck of the femur (break in neck of femur bone, the long bone of the leg), depression, hypertension, atrial fibrillation and chronic kidney disease. 18: Review of Resident #18's face sheet showed: -admitted [DATE]; -discharged [DATE]; -Diagnoses of intellectual disabilities, chronic kidney disease, depression, schizoaffective disorder and anxiety. 19: Review of Resident #19's face sheet showed: -admitted [DATE]; -Diagnoses of chronic lymphocytic leukemia of B-cell type (blood cancer affecting white blood cells), anxiety disorder, insomnia and pain; -Quarterly MDS, dated [DATE], showed severe cognitive impairment. 20: Review of Resident #20's face sheet showed: -admitted [DATE]; -Diagnoses of Alzheimer's dementia, depression, anxiety disorder and hypertension; -Quarterly MDS, dated [DATE], showed severe cognitive impairment. 21: Review of Resident #21's face sheet showed: -admitted [DATE]; -Diagnoses of Parkinson's, dementia, schizoaffective disorder, major depressive disorder and anxiety disorder; -Significant change MDS, dated [DATE], showed severe cognitive impairment. 22: Review of Resident #22's face sheet showed: -admitted [DATE]; -date of death [DATE]; -Diagnoses of stroke, amyotrophic lateral sclerosis(Lou Gehrigsdisease, weaknes muscles and impacts physical function), chronic kidney disease, diabetes and depression. 23: Review of Resident #23's face sheet showed: -admitted [DATE]; -date of death [DATE]; -Diagnoses of COPD, depression, supraventricular tachycardia (rapid heart rate), dependence on oxygen and hypertension. 24: Review of Resident #24's face sheet showed: -admitted [DATE]; -discharged [DATE]; -Diagnoses of hypertension, history of breast cancer and overactive bladder. 25: Review of Resident #25's face sheet showed: -admitted [DATE]; -date of death [DATE]' -Diagnoses of COPD, atrial fibrillation, difficulty swallowing, anxiety, hypertension with heart failure and stroke; -Significant change MDS, dated [DATE], showed moderate cognitive impairment. 26: Review of Resident #26's face sheet showed: -admitted [DATE]; -Diagnoses of Parkinson's, dementia, anxiety and schizoaffective disorder; -Significant change MDS, dated [DATE], showed moderate cognitive impairment. During an interview on 02/25/25 at 11:00 A.M., Resident #1 said he/she never gets money from the facility. The resident said his/her family takes him/her shopping or they buy and bring him/her what she needs. Resident said Bookkeeper A has had him/her sign forms before but he/she was not sure what they were for. Resident said he/she did not receive any money from Bookkeeper A. During an interview on 02/25/25 at 11:10 A.M., Resident #2 said he/she has not gotten any cash from the facility and mainly stays in bed in his/her room. Resident #2 said Bookkeeper A has come to his/her room and had him/her sign forms at different times but never received any cash. The resident said he/she was not sure what the forms were for. During an interview on 02/25/25 at 11:19 A.M., Resident #3 said he/she has never asked for or received any money from the facility since he/she has been there. Bookkeeper A comes in at times and has him/her sign a form but he/she was not sure what it was for and did not receive money. During an interview on 02/25/25 at 11:27 A.M., Resident #4 said the facility does shop for him/her. The resident said he/she never asks for money other than for a few dollars occasionally to get a soda or candy bar. Resident #4 said Bookkeeper A has come to his/her room to have him/her sign a form but has not received any money after signing the form. During an interview on 02/25/25 at 11:38 A.M., Resident #5 said he/she never requests money out of his/her account and has never received any money from Bookkeeper A. Resident said Bookkeeper A has come to his/her room and had him/her sign a form, but he/she was not sure what it was and received no money after signing it. During an interview on 02/25/25 at 11:49 A.M., Resident #6 said he/she is able to go to the office to get money if he/she needs it. Resident #6 said Bookkeeper A has come to his/her room before and had him/her sign a form but did not receive any money after signing the form. During an interview 02/25/25 at 1:45 P.M., SSA said he/she had not seen Resident #1, Resident #2, Resident #3, Resident #4 or Resident #5 in the business office requesting money and is not sure they would even know how. SSA said he/she had not seen these residents ever having money on them. During and interview on 02/25/25, FA said Bookkeeper A received the appropriate training in regards to how RTAs are to be handled. Facility policy requires two witness signatures any time cash is given out of the cash box. When cash is received in the office for a resident account, a receipt should be given and the money should be deposited and the residents' RTA updated with the deposited amount. During an interview on 02/25/25 the Administrator said when a resident receives cash, the resident is to sign the log, as well as the person handing out the money, as well as a witness. The Administrator said it is never okay for an employee to take funds from a resident. Review of Bookkeeper A's employee filed showed he/she completed the facility bookkeeping training on 05/31/23. During an interview on 03/25/25 at 2:00 P.M., the Police Department said multiple attempts have been made to get an interview with Bookkeeper A before presenting the evidence to the prosecuting attorney. Bookkeeper A has not cooperated in speaking with the police department and has hired an attorney. Complaint# MO00249344

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 80. The facility did not provide a homelike environment policy. 1. Observations on 10/21/24 at 12:11 P.M.,10/22/24 at 10:41 A.M., and 10/23/24 at 10:54 A.M., of the screened-in designated smoking area showed: - Several dead insects and bird droppings lay on top of several two-by-four wood shelf supports; - A buildup of cigarette ashes in the cracks and crevices on the floor; - Scattered cigarette butts, leaves, and dirt lay on the floor; - A N95 (respiratory protective device) mask lay on the floor; - A broom lay against the brick column near the smoking receptacle. 2. Observations on 10/21/24 at 12:18 P.M., 10/22/24 at 10:53 A.M., and 10/23/24 at 10:59 A.M., showed several cigarettes butts lay on the ground located on the outside sitting area of the courtyard. 3. Observations on 10/21/24 at 12:46 P.M., and 10/22/24 at 10:59 A.M., of the 500 Hall showed: - Several areas of peeled wallpaper with exposed sheetrock on the right-side wall by the bed located near the window in room [ROOM NUMBER]; - A missing protective outlet covering with two cords plugged into an electric receptacle located on the left-side of the bed near the door located in room [ROOM NUMBER]; - Several areas of peeled paint and exposed sheetrock behind the headboard of the bed near the door and the bed near the window located in room [ROOM NUMBER]; - A three foot (ft.) area of peeled paint and exposed sheetrock located on the left-side of the heating/cooling unit by the bed located near the window in room [ROOM NUMBER]; - Several areas of peeled paint and exposed sheetrock located on the left-side wall beside the brown recliner located in room [ROOM NUMBER]; - Several areas of peeled paint and exposed sheetrock located on the right-side walls next to a flat screen television and near the bathroom door located in room [ROOM NUMBER]; - A large hole in the wall located behind the door upon the entrance of room [ROOM NUMBER]; - Several areas of peeled paint and exposed sheetrock located behind the headboard of the bed located near the window in room [ROOM NUMBER]. 4. Observations on 10/21/24 at 12:58 P.M., and 10/22/24 at 12:06 P.M., of the left-side of the Dining Room showed: - Several areas of dark scuff marks at the bottom and middle section of the wall located near the wall-mounted electric fly/insect trap; - Several areas of dark scuff marks on the bottom and middle section of the left-side wall located near the two wooden double doors; - Several areas of dark scuff marks on the bottom section of the right-side wall located near the two wooden double doors and the window facing the courtyard; - A large area of dark scuff marks on the bottom and middle section of the wall located below the thermostat; - A missing corner piece of trim with exposed discolored areas on the wall located near the thermostat and a facility layout sign. 5. Observations on 10/21/24 at 1:08 P.M., and 10/22/24 at 12:26 P.M., of the kitchen's Dish Return door showed a large hole with missing sheetrock and trim on the bottom left-side of the door frame. 6. Observations on 10/23/24 at 1:06 P.M., and 10/24/24 at 10:08 P.M., of the 300 hallway showed a build-up of 15 shoe-shaped black grime markings on a 20 ft. section of the tiled floor located between room [ROOM NUMBER] and the dining room entrance. 7. Observations on 10/24/24 at 9:17 A.M., of the Laundry Room, showed: - Several articles of cluttered and piled-up miscellaneous clothing; - A build-up of lint, grime, dirt and dust located behind the washing machine bay; - A large area of missing dry wall and peeled paint from water damage within the wall located behind the washers; - One yellow mop bucket filled with stagnant (inactive) dirty water located by the sink; - One five-gallon white bucket filled with soiled linens and dirty water located by the sink; - Miscellaneous trash located in the drainage basin (sink) area of the eye wash station. Review of the Maintenance Work Order Form binder, dated 08/23/24 - 10/22/24, showed no documentation of areas of concern addressed. During an interview on 10/23/24 at 2:42 P.M., Housekeeper A said he/she verbally told the maintenance person if there were any environmental issues in the facility. There was also a maintenance book at the nurse's station for staff to write down any issues found during rounds. He/She did not know who was responsible for cleaning and sweeping the designated smoke area and/or picking up the cigarette butts on the floor and the outside grounds. During an interview on 10/23/24 at 2:42 P.M., Kitchen Employee B said he/she would let the Dietary Manager know if there were any issues that needed to be addressed to maintenance for repair. He/She has not noticed any environmental issues such as scuff marks or holes on the dining room/kitchen walls to be reported or addressed. During an interview on 10/24/24 at 8:53 A.M., the Administrator said she would expect staff to write down any environmental concerns on the maintenance log to be addressed in a timely manner by the maintenance department. She would expect the designated smoke area to be free of cigarette butts and ashes, dead insects, bird droppings and other debris. She would also expect the outside sitting area in the courtyard be free of cigarette butts and debris. During an interview on 10/24/24 at 10:44 A.M., the Maintenance Supervisor (MS) said he/she would expect staff to write down any environmental issues on the maintenance log to be addressed in a timely manner. The floor technician was responsible for cleaning the screened-in designated smoke area, picking up cigarette butts, and maintaining the outside grounds to be free of debris once a week. During an interview on 10/24/24 at 12:02 P.M., Housekeeper E said there was a floor technician for the facility and he/she had been covering in the laundry department this week. Spot mopping was done sometimes.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for four residents (Residents #7, #20, # 46 and #279) out of four sampled residents. The facility's census was 80. The facility did not provide a transfer/discharge policy. 1. Review of Resident #7's medical record showed: - The resident transferred to the hospital on 07/04/24, and was readmitted to the facility on [DATE]; - The resident transferred to the hospital on 08/17/24, and was readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on 07/04/24 and 08/17/24. 2. Review of Resident #20's medical record showed: - The resident transferred to the hospital on 06/07/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 09/10/24, and readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfers to the hospital on 06/07/24 and 09/10/24. 3. Review of Resident #46's medical record showed: - The resident transferred to the hospital on 07/23/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 08/19/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 09/20/24, and readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfers to the hospital on 07/23/24, 08/19/24 and 09/20/24. 4. Review of Resident #279's medical record showed: - The resident transferred to the hospital on 07/27/24, and was readmitted to the facility on [DATE]; - The resident transferred to the hospital on 10/06/24, and was readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on 07/27/24 and 10/06/24. During an interview on 10/23/24 at 8:43 A.M., the Assistant Director of Nursing (ADON) said nursing should fill out a transfer/discharge form prior to a resident going to the hospital. A copy of the transfer/discharge form should be given to the Social Service Designee (SSD) and kept for documentation purposes. During an interview on 10/23/24 at 8:45 A.M., the Administrator said transfer/discharge forms were not completed and/or kept for documentation purposes. The SSD was responsible for keeping up with the transfer/discharge forms. During an interview on 10/23/24 at 3:00 P.M., the SSD said he/she had not been following up with the transfer/discharge forms for residents that were sent to the hospital and admitted . 46521 48532

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of their bed hold policy at the time of transfer to the hospital for four residents (Residents #7, #20, #46, and #279) out of four sampled residents. The facility census was 80. The facility did not provide a bed hold policy. 1. Review of Resident #7's medical record showed: - The resident transferred to the hospital on 07/04/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 08/17/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. 2. Review of Resident #20's medical record showed: - The resident transferred to the hospital on 06/07/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 09/10/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. 3. Review of Resident #46's medical record showed: - The resident transferred to the hospital on 07/23/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 08/19/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 09/20/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. 4. Review of Resident #279's medical record showed: - The resident transferred to the hospital on 07/27/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 10/06/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. During an interview on 10/23/24 8:43 A.M., the Assistant Director of Nursing (ADON) said nursing should be filling out a bed-hold policy form prior to a resident going to the hospital. A copy of the bed hold form should be given to the Social Service Designee (SSD) and kept for documentation purposes. During an interview on 10/23/24 8:45 A.M., the Administrator said the bed hold policy forms were not being completed by nursing and/or kept for documentation purposes. The SSD was responsible for keeping up with the bed hold policy forms. During an interview on 10/23/24 at 3:00 P.M., the SSD said he/she had not been following up with the bed hold policy forms for residents that were sent to the hospital. 46521 48532

Based on observation, interview and record review, the facility failed to document the type, the stage, the measurements, and the characteristics of the facility acquired injury for two residents (Residents #38 and #46) out of two sampled residents. The facility census was 80. Review of the policy titled, Pressure Ulcer, Care and Prevention of, undated, showed: - The purpose of this policy is to prevent and treat further breakdown of pressure sores; - The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measure to prevent pressure ulcers; - Observe skin. Any persistent reddened area that remains after pressure is relieved is a high risk area to a pressure ulcer to begin. 1. Review of Resident #38's significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 08/24/24, showed: - admitted to the facility on [DATE]; - Severely impaired cognitive skills; - Impaired on one side on upper and lower extremity; - Dependent on staff for bathing, toileting and personal hygiene; - Required substantial to maximal assistance of staff for bed mobility; - Incontinent of bowel and bladder; - At risk for pressure ulcers; - Pressure reducing mattress for bed; - Pressure reducing cushion for chair; - Pressure ulcer care. Review of the resident's medical chart showed: - Diagnoses of atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow), hypertension (high blood pressure), cerebral vascular accident (CVA - stroke), and depression (a mental health condition that involves a prolonged low mood or loss of interest in activities). Review of the resident's Physician Order Sheets (POS), dated October 2024, showed: - No orders for skin care related to the resident's left buttock. Review of the resident's Braden (a tool used to assess a patient's risk of developing pressure ulcers) Scale, dated 8/28/24, showed: - The resident at moderate risk for skin breakdown. Review of the resident's care plan, dated 08/28/24, showed: - At risk for altered skin integrity related to limited mobility and incontinence. Review of the resident's nurses notes, dated 10/21/24 - 10/24/24, showed: - On 10/23/24, a skin assessment was done this afternoon with an open area to the left buttock, the physician's office notified, and a new order for skin prep (a procedure that involves cleansing the skin with an antiseptic to reduce the risk of infection) to the area twice daily until healed; - No documentation of the type, the stage, the measurements, and the characteristics of the injury to the resident's left buttock. Review of the resident's Weekly Skin Assessments showed: - On 10/02/24, the skin intact; - On 10/06/24, the skin intact; - On 10/14/24, redness to the buttock with barrier cream to the buttock; - On 10/14/24, skin intact with redness to the buttock; - On 10/23/24, skin prep to the left buttock twice daily to the small open area. Observation of the resident on 10/23/24 at 1:25 P.M., showed: - The resident had a small open injury to his/her left buttock. During an interview on 10/23/24 at 1:27 P.M., Certified Nurse Assistant (CNA) G and CNA I said the nurses applied some cream to the resident's bottom. CNA G and CNA I said today was the first time they had seen the injury to the resident's left buttock. During an interview on 10/23/24 at 1:30 P.M., Licensed Practical Nurse (LPN) F said the resident did not have a treatment to his/her bottom. LPN F said she did not know the resident had any open areas to his/her bottom until this afternoon. During an interview on 10/23/24 at 1:38 P.M., the Director of Nursing (DON) said the resident did not have a topical treatment to his/her buttocks. She had not assessed the resident's skin. During an interview on 10/23/24 at 2:35 P.M., the DON said the resident had an open area the size of a pencil eraser and she just now put an order in for skin prep to that area. During an interview on 10/24/24 at 8:40 A.M., the Assistant Director of Nursing (ADON) said the nurses were responsible for the weekly skin assessments. The nurses should be including the measurements when they complete the skin assessment. The CNA's should report anything unusual with the skin at the time they see it on any resident. The CNA's reported the resident's skin issue on 10/23/24. 2. Review of Resident #46's quarterly MDS, dated [DATE], showed: - admitted to the facility on [DATE]; - Severely impaired cognitive skills; - Dependent on staff for bathing, dressing, toileting, personal hygiene and bed mobility; - At risk for pressure ulcers; - Pressure reducing mattress for bed; - Pressure reducing cushion for chair; - No pressure ulcer and or other skin impairments. Review of the resident's medical record showed: - Diagnoses of anemia (lack of healthy red blood cells), coronary artery disease (CAD - damage or disease of the heart's major blood vessels), heart failure (when the heart muscle does not pump blood as well as it should), peripheral vascular disease (circulation disorder that affects blood vessels outside of the heart and brain, often those that supply the arms and legs) and hypertension. Review of the resident's POS, dated October 2024, showed: - An order to skin prep the bilateral heels and float, dated 07/31/24. Review of the resident's care plan, last updated 10/08/24, showed: - At risk for altered skin integrity related to limited mobility. Review of the resident's nurses' notes, dated 10/21/24 - 10/24/24, showed: - No documentation of any skin conditions with the type, the stage, the measurements, and the characteristics of an injury. Review of the resident's Braden Scale, dated 8/24/24, showed: - The resident at mild risk for skin breakdown. Review of the resident's Weekly Skin Assessments showed: - On 10/03/24, the left heel was soft and the right heel had an unstageable wound; - On 10/11/24, heels soft and skin prep to the bilateral heels for protection; - On 10/18/24, firm heels. Observation of the resident on 10/24/24 at 9:45 A.M., showed: - The resident lay in his/her bed and his/her heels lay directly on the mattress; - The left heel with no skin issues. The right heel with an approximate nickel size eschar (dead tissue that forms over healthy skin) injury with peeling dry skin on the peri-wound (the skin surrounding a wound); - LPN C applied skin prep to both heels and did not float the heels; - Three blue heel protectors (pressure relieving, heel protective devices) and two small purple heel protectors lay in a chair in the resident's room. During an interview on 10/24/24 at 12:10 P.M., LPN F said he/she had been applying skin prep to the resident's heels for awhile, however he/she had not put the heel protectors on the resident's feet. During an interview on 10/24/24 at 12:17 P.M., Certified Medication Technician (CMT) J said he/she thought the heel protectors were the resident's. During an interview on 10/24/24 at 12:19 P.M., CNA K said the resident did not ever have the heel protectors on when staff got him/her up in the mornings, and staff did not put them on the resident when he/she was up out of the bed. During an interview on 10/24/24 at 1:19 P.M., the ADON said skin assessments should be completed weekly with measuring, staging, and descriptions to be included. During an interview on 10/24/23 at 1:22 P.M., the DON said the nurses, herself, and the ADON were responsible for the skin assessment to be completed and to be accurate. When the assessments were completed, they should be documented by the nurse with measurements and staging as well of any wounds.

Based on interview and record review, the facility failed to provide documentation of communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for two residents (Residents #6 and #32) out of two sampled residents and one resident (Resident #11) outside the sample. The facility census was 80. Review of the facility's policy titled, Dialysis, Care of a Resident Receiving, undated, showed: - Care of the arteriovenous (AV) shunt/fistula/graft (a surgically created connection between an artery and a vein used for hemodialysis): keep the area clean and dry; feel for the thrill (a palpable murmur that feels like a ringing phone) sensation daily; inspect the access site for redness, swelling, or warmth; watch for bleeding after dialysis; monitor signs of infection; checking the thrill sensation; nurses will check the thrill daily and document daily, this will be documented on the resident's treatment record; at the AV site, feel for a pulse. The pulse is the blood flow through the access; if no thrill sensation is felt, notify the physician; - Communication between the facility and the dialysis unit: the Dialysis Communication Record will be sent with the resident on each dialysis visit; all care concerns in the last 24 hours will be addressed, including last medications given and facility contact person; the dialysis unit will complete the lower portion of the report to include weight prior to and after dialysis, any labs completed, medication given, follow up information and any new physicians' orders; the lower portion will be signed by the dialysis nurse and returned to the facility; these records will be maintained in the medical record. 1. Review of Resident #6's Physician's Order Sheet (POS), dated October 2024, showed: - admitted [DATE]; - An order for dialysis Tuesday, Thursday and Saturday, dated 03/11/19; - An order to check the shunt to the left upper extremity (LUE) for bruit (an audible vascular sound associated with turbulent blood flow) and thrill every shift, dated 11/27/18. Review of the resident's medical record showed: - Diagnoses of end stage renal disease (ESRD - when the kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis, hypertension (high blood pressure), and anemia. Review of the resident's care plan, revised 03/07/24, showed: - The resident required dialysis; - At risk for complications related to renal failure (the kidneys lose the ability to remove waste and balance fluids); - Palpate for the thrill over the shunt site per order; - Dialysis Communication form on dialysis days. Dialysis nurses to fill out the bottom section and send back to the facility for review by the nurse; - Resident received dialysis every Tuesday, Thursday and Saturday. Review of the Dialysis Communication log, dated July 2024-October 2024, showed: - For July 2024, 13 missed out of 13 opportunities for the completion of the Dialysis Communication forms; - For August 2024, 14 missed out of 14 opportunities for the completion of the Dialysis Communication forms; - For September 2024, 12 missed out of 12 opportunities for the completion of the Dialysis Communication forms; - For October 2024, 10 missed out of 11 opportunities for the completion of the Dialysis Communication forms. 2. Review of Resident #11's POS, dated October 2024, showed: - admitted [DATE]; - An order for dialysis on Monday, Wednesday, and Friday, dated 10/05/22; - An order to check the AV fistula every shift, dated 10/05/22. Review of the resident's medical record showed: - Diagnoses of chronic kidney disease stage 3 (mild to moderate kidney damage), dependence on renal dialysis, hypertension, atherosclerotic heart disease of native coronary artery without angina (hardening of the arteries), atrial fibrillation (irregular heartbeat when the upper chambers beat too fast), and presence of cardiac pacemaker (an implanted device to monitor and regulate heart rate). Review of the resident's care plan, revised 10/16/24, showed: - The resident needed dialysis; - Feel for the thrill over the shunt site; - Listen for the bruit over the shunt site; - Communication form sent to dialysis. Dialysis nurses to fill out the bottom section and send back to the facility for review by the nurse; - Resident received dialysis every Monday, Wednesday and Friday. Review of the Dialysis Communication log, dated July 2024-October 2024, showed: - For July 2024, 14 missed out of 14 opportunities for the completion of the Dialysis Communication forms; - For August 2024, 12 missed out of 12 opportunities for the completion of the Dialysis Communication forms; - For September 2024, 13 missed out of 13 opportunities for the completion of the Dialysis Communication forms; - For October 2024, 9 missed out of 10 opportunities for the completion of the Dialysis Communication forms. 3. Review of Resident #32's POS, dated October 2024, showed: - admitted [DATE]; - An order for dialysis Tuesday, Thursday and Saturday, dated 07/19/22; - An order to check the shunt to the LUE for the bruit and thrill every shift, dated 05/13/24. Review of the resident's medical record showed: - Diagnoses of chronic kidney disease, stage 4 (severe kidney damage) with ESRD dependence on renal dialysis, hypertension, and other acute kidney failure. Review of the resident's care plan, revised 08/09/24, showed: - The resident required dialysis; - All routine and baseline lab work will be drawn and monitored by the facility, any nonroutine lab work will be monitored by dialysis; - Communication form sent to dialysis with the resident. Dialysis to fill out the bottom section and send back to the facility for review by the nurse; - Monitor and report signs of localized infection; - Monitor and report signs of systemic infection. Review of the Dialysis Communication log, dated July 2024-October 2024, showed: - For July 2024, 13 missed out of 13 opportunities for the completion of the Dialysis Communication forms; - For August 2024, 14 missed out of 14 opportunities for the completion of the Dialysis Communication forms; - For September 2024, 12 missed out of 12 opportunities for the completion of the Dialysis Communication forms; - For October 2024, 8 missed out of 11 opportunities for the completion of the Dialysis Communication forms. During an interview on 10/22/24 at 4:17 P.M., Licensed Practical Nurse (LPN) F said the facility just started doing the dialysis communication logs again. During an interview on 10/22/24 at 4:20 P.M., the Assistant Director of Nursing (ADON) said all the dialysis communication documents were scanned into the residents' electronic medical records (EMR) when completed. The facility noticed they were not getting done and they were still not scanned into the EMR. During an interview on 10/22/24 at 4:24 P.M., the Director of Nursing (DON) said she was not aware of the time frame of when they noticed the dialysis communication logs were not being completed to when the new forms were implemented. During an interview on 10/23/24 at 2:01 P.M., Resident #32 said he/she went to dialysis and was there yesterday. The dialysis communication log was not sent with him/her to dialysis. He/she didn't remember the nursing staff at the facility checking for the thrill and bruit or checking the dressing when he/she returned from dialysis. During an interview on 10/23/24 at 4:01 P.M., Resident #6 said the facility did send a piece of paper for him/her to take to dialysis. The facility did not check for the thrill and bruit, but the staff did check the dressing. During an interview on 10/24/24 at 12:22 P.M., LPN F said the dialysis communication log was normally faxed to the front office when Resident #32 came back from dialysis. Resident #32 had bandages to be removed from the dialysis shunt site the next day. Nursing should check for the bruit and thrill every day. A nurse checked the dressing when Resident #32 came back from dialysis. 48532

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year and failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions) of two nurse aides sampled. The facility census was 80. The facility did not provide a nurse aide in-service education policy. Review of the facility assessment, revised September 2024, showed: - Required in-service training for nurse's aides: 1. Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; 2. Include dementia management training and resident abuse preventions training; 3. Address areas of weakness as determined by the facility assessment and address the special needs of residents to as determined by the facility staff; 4. For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. 1. Review of the facility's June 2023 through June 2024 in-service records, showed: - Certified Nurse Aide (CNA) C's hire date of 06/23/23; - CNA C attended nine hours and 30 minutes of in-services; - CNA C did not attend an annual competency in-service on Dementia Care. 2. Review of the facility's July 2023 through July 2024 in-service records, showed: - CNA D's hire date of 07/11/23; - CNA D attended seven hours of in-services; - CNA D did not attend an annual competency in-service on Dementia Care. During an interview on 10/24/2024 at 8:54 A.M., the Director of Nursing (DON) said nurse aid education training should include Dementia Care. Nurse aides should have 12 hours of education training to meet the annual in-service requirement. During an interview on 10/24/2024 at 8:56 A.M., the Administrator said nurse aid education training should include Dementia Care. Nurse aides should have 12 hours of education training to meet the annual in-service requirement.

Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure the safety of one resident (Resident #1). On 08/01/24 at 3:00 A.M., the facility failed to initiate a search for Resident #1 and implement the facility policy for missing residents when staff noticed the resident's call light on, but the room was empty. On 08/01/24 at 6:45 A.M., during morning medication pass, staff noted Resident #1 was not in his/her room. The staff finished the medication pass and reported to the charge nurse. On 08/01/24 at 8:00 A.M., the staff began searching for the resident and found the resident outside lying on the ground in the courtyard. The resident fell down outside in the late evening on 07/31/24, and lay on the ground until 08/01/24 at 8:15 A.M. The facility census was 84. On 08/08/24 at 4:00 P.M., the Administrator was notified of the past non-compliance immediate jeopardy (IJ) which began on 08/01/24. The facility immediately conducted an investigation and inserviced staff on the Elopement-Missing Resident policy. The IJ was corrected on 08/01/24. Review of the facility's undated policy, Elopement-Missing Resident, directed staff to: - Determine when resident was last seen, description of clothing, and where last seen; - Notify all departments and begin a thorough search of the facility and grounds, including bathrooms, closets, storage areas, and crawl spaces; - Search streets and neighborhood adjacent to the facility; - Notify the Director of Nursing and the Administrator; - Notify the physician; - Notify the responsible party and request notification if the resident makes contact with them; - If absence exceeds 30 minutes, notify local law enforcement, give dispatcher the following information, name, age, sex, description of the resident and clothing description, time discovered missing, last seen, physical or mental impairments, if harmful to self and/or others, home address, address of relatives and/or friends, and photograph of resident; - When located, notify all appropriate people/agencies; - Assess for injuries. Review of Resident #1's medical record showed admission to the facility on [DATE] with diagnoses of amyotrophic lateral sclerosis (a neurological disorder that affects motor neurons, the nerve cells in the brain and spinal cord that control voluntary muscle movement and breathing), transient ischemic attack (TIA, a mini stroke), depression, chronic kidney disease stage 2 (develops when the kidneys become less effective over time due to damage), high blood pressure, and diabetes mellitus type 2 (a condition that affects the way the body processes blood sugar). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 06/17/2024 showed: - Cognition intact; - Minimum difficulty with hearing, no hearing aides; - No speech, absence of spoken words; - Impaired vision, corrected with glasses; - Usually understands and is understood; - Independent with personal hygiene, toileting, feeding self, bed mobility, transfer, ambulation with use of walker; - Continent of bowel and bladder. Review of the resident's care plan, dated 06/19/24, showed: - Resident has difficulty making self understood, no speech. Has electronic communication device for expressing self. Gestures with thumbs up and thumbs down; - At risk for falls; - Independent with dressing, toileting, and personal hygiene; - Assist of one staff for bathing; - Continent of bowel and bladder; - Resident walks with the assistance of a walker with assist one staff member to stand at times. Review of the resident's progress notes showed; - On 08/01/24 at 8:15 A.M., the resident was found in the courtyard laying on his/her back on the sidewalk; - Abrasions to left great toe, right foot on hallux (the joint where the big toe meets the foot), right outer knee, right knee cap, right inner knee area, to both right and left elbows, and an approximately 3 centimeters (cm) x 3 cm abrasion to crown of head; - Notified physician and family. Physician order received to send to emergency room (ER). Review of the ER visit, dated 08/01/24, showed: - Presents to ER after a fall at the facility in which he/she resides; - Resident reports hitting his/her head with no loss of consciousness; - Complains of right arm and right leg pain, small abrasion to scalp, no visible laceration; - X-ray of both hips, tibia (bone between knee and ankle), fibula (bone located with tibia between knee and ankle), knee, and chest showed no abnormalities. Observations on 08/08/24 at 11:30 A.M. showed: - A double glass door to the courtyard; - The sidewalk paved with concrete extending all the way around the courtyard in a circle pattern; - A bench in the back side of the yard with multiple bushes and trees obstructing the view of the entry door; - The entire sidewalk circling the courtyard with cracks and rough spots. During an interview on 08/08/24 at 12:30 P.M., Resident #1 said on 08/01/24 at 10:00 P.M. he/she went outside into the courtyard to pray the Rosary. He/she fell over a crack in the sidewalk and laid on the ground for eleven hours. He/she said it was hot when the sun started coming up and the bugs were really bad. The resident said he/she had not seen staff at 11:30 P.M., he/she was not in the facility at that time. During an interview on 08/08/24 at 12:05 P.M., Certified Medication Technician (CMT) C said he/she had arrived to work at approximately 1:40 A.M. (on 08/01/24). He/she had not seen the resident upon arrival. CMT C said he/she told the Director of Nurses (DON), who was working the night shift, that Resident #1's door was open, with the light on and the resident was not in the bed. He/she asked the DON if the resident was on leave of absence (LOA). The DON informed him/her no, the resident had returned to the facility earlier that evening. At approximately 6:00 A.M., CMT C reported to Licensed Practical Nurse (LPN) D that he/she was starting to pass medications and noted Resident #1's bed was still untouched and the resident's breakfast tray was in his/her room untouched. Later in the shift, CMT C said he/she saw other staff members bring the resident in from the courtyard stating the resident had fallen. During an interview on 08/08/24 at 11:15 A.M., the DON said he/she last saw Resident #1 at approximately 11:30 P.M., walking towards his/her room, but did not see him/her leave the room after that time. The DON said CMT C questioned him/her if the resident was on LOA around 3:00 A.M., and he/she told CMT C no, the resident had been out on LOA earlier in the day, but had returned. The CMT did not ask where the resident was or report at that time he/she had not seen the resident since arrival to work. The DON said if she had known at that time the resident had not been seen in the facility, she would have immediately taken action and began a search. The DON said at the end of his/her shift, he/she was still not aware the resident had not been seen. During an interview on 08/08/24 at 11:20 A.M., LPN B said he/she had last seen Resident #1 between 11:30-11:45 P.M. During an interview on 08/08/24 at 12:20 P.M., LPN D said he/she arrived to work at approximately 6:45 A.M. to 7:00 A.M. While in another resident's room, CMT C informed LPN D that he/she had not seen Resident #1 since his/her shift started. He/she then left the other resident's room and checked Resident #1's bathroom, checked the log out record for the resident and saw the resident had been signed back in from LOA the previous night at 8:00 P.M. At that time, he/she called the resident's family and asked if the resident was with them. The family said they brought him/her back the previous evening. LPN D immediately alerted other staff the resident had not been seen for several hours. Shortly after, the Medical Records staff found the resident laying out in the courtyard on his/her back. LPN D said the resident was laying in the back of the courtyard on his/her back in the grass with knees bent and barefoot. The resident was alert with scrapes noted on his/her right great toe, right foot, both knees and elbows, and an abrasion to the back of the head. The left side of the resident's shirt and pants were wet. After he/she assessed the resident, staff assisted to a standing position and ambulated the resident to his/her room. LPN D then notified the physician and received orders to send the resident to the hospital for an evaluation. The resident's family was notified and transported the resident to the ER. During an interview on 08/08/24 at 1:55 P.M., the Medical Records staff said he/she came to work on 08/01/24 at 6:45 A.M. LPN D asked if he/she had seen Resident #1. He/She went to the resident's room and saw the light on his/her computer and the bed pulled back. The Medical Records staff went to the courtyard because the resident likes to go out there. The staff found the resident laying on his/her back wearing shorts and a t-shirt. The staff called for the nurse and LPN D assessed the resident and assisted to ambulate back into the facility. The resident's head was red and his/her shirt was wet, not sure if it was urine or sweat. During an interview on 08/08/24 at 11:10 A.M., the Administrator said the facility does not have a policy addressing a specific time each resident should be accounted for, monitoring is based upon need. During the investigation, it was discovered the resident had been on a leave of absence and returned to the facility on [DATE] at 8:00 P.M. The resident was last seen on 07/31/24 at 11:30 P.M. at the nurses station. CMT C told the DON that the resident was not in his/her room and asked if he/she was on LOA. The DON said he/she was not on LOA and had returned the previous evening. No one actually went to look for him/her at that time. She said she would have expected the staff to search for the resident at 3:00 A.M. when the resident was not seen or in his/her room. Complaint #MO239905

Based on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADLs) when the residents did not receive a minimum of two showers per week for six residents (Resident #7, #26, #33, #48, #57, and #65) out of 18 sampled residents. The facility's census was 75. The facility did not provide a policy related to shower frequency. 1. Review of Resident #7's medical record showed: - An admitted [DATE]; - Diagnoses of hypertension (high blood pressure), multiple rib fractures on the right side, lumbar spinal stenosis (narrowing of the spinal cord), essential tremor (disorder that causes rhythmic shaking), low back pain, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and psychotic disorder (mental disorder characterized by a disconnection from reality) with hallucinations. Review of the resident's significant change Minimum Data Set (MDS, a federally mandated assessment to be completed by the facility), dated 07/04/23, showed: - Cognitive status moderately impaired; - Limited assistance of one staff for dressing; - Supervision for personal hygiene; - Physical assistance of one staff for part of bathing. Review of the resident's shower sheets for June 2023 through August 25, 2023 showed: - In June, no shower sheets provided; - In July, resident received a shower on 07/14/23 and refused a shower on 07/28/23; - In August, resident received a shower on 08/18/23; - Shower sheets showed two showers documented and one documented refusal out of 24 opportunities, a total of 21 opportunities for showers missed. Observation on 08/23/23 at 8:37 A.M. and 08/24/23 at 01:30 P.M. showed resident lying in bed with eyes closed and hair appeared unkempt and greasy. During an interview on 08/25/23 at 8:19 A.M., the resident said he/she does not receive showers twice a week. The resident said he/she tries to bathe as much as possible in the sink due to requiring assistance with showers, but not receiving them. 2. Review of Resident #26's medical record showed: - An admitted [DATE]; - Diagnoses of unspecified dementia, cognitive communication deficit, general anxiety disorder (severe, ongoing anxiety that interferes with daily activities), major depressive disorder (MDD, a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Diabetes Mellitus (DM) (a condition that affects the way the body processes blood sugar), and muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive status not intact; - Limited assistance of one staff for dressing; - Extensive assistance of one staff for personal hygiene; - Bathing did not occur during review period. Review of the resident's shower sheets for June 2023 through August 25, 2023 showed; - In June, no shower sheets provided; - In July, resident received a bed bath on 07/05/23 and a shower on 07/11/23; - In August, resident received showers on 08/01/23, 08/07/23, 08/10/23, 08/14/23, and 08/21/23. - Shower sheets showed seven showers documented out of 24 opportunities, a total of 18 opportunities for showers missed. 3. Review of Resident #33's medical record showed: - An admitted [DATE]; - Diagnoses of dementia, diabetes, diabetic neuropathy (nerve damage causing pain that can occur from diabetes), major depressive disorder and peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs). Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Independent with set up for dressing; - Supervision for personal hygiene; - Independent with set up for showers; Review of the resident's care plan, last revised 07/07/23, showed: - Resident at risk for falls due to unsteady gait; - Resident requires limited assistance with bathing. Review of the resident's shower sheets for June 2023 through August 25, 2023 showed: - In June, resident received a shower on 06/08/23; - In July, resident received a shower on 07/02/23, 07/10/23, 07/20/23 , 07/27/23, and 07/31/23; - In August, resident received a shower on 08/03/23, 08/14/23, and 08/23/23; - Shower sheets showed nine showers documented out of 24 opportunities, a total of 15 opportunities for showers missed. During observation and interview on 08/23/23 at 9:47 A.M., resident lay in bed and hair appeared greasy. The resident said he/she does not get showered twice a week but that would be nice. The resident said look how greasy my hair is. During an interview on 08/24/23 at 11:51 A.M., the resident said he/she got a shower on 8/23/23, but prior to that it had been at least a week. The resident said he/she does not get showered twice a week, but that would be nice. 4. Review of Resident #48's medical record showed: - An admitted [DATE]; - Diagnoses of unspecified dementia, adult failure to thrive, hypertension (HTN, high blood pressure), chronic kidney disease (disease of the kidneys leading to kidney failure), pressure ulcer of unspecified buttock, and polyosteoarthritis (pain, stiffness, or swelling in multiple joints). Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive status not intact; - Extensive assistance of two staff for dressing; - Extensive assistance of two staff for personal hygiene; - Physical help in part of two staff for bathing. Review of the resident's shower sheets for June 2023 through August 25, 2023 showed: - In June, no shower sheets provided; - In July, resident received a shower on 07/06/23 and bed baths on 07/10/23, 07/25/23, and 07/31/23; - In August, resident received showers on 08/07/23, 08/10/23, 08/21/23, and bed baths on 08/14/23 and 08/17/23; - Shower sheets showed nine showers documented out of 24 opportunities, a total of 15 opportunities for showers missed. During an interview on 08/25/23 at 10:55 A.M., the resident's Power of Attorney said he/she was unsure of when or if the resident receives showers. 5. Review of Resident #57's medical record showed: - admitted on [DATE]; - Diagnoses of intracerebral hemorrhage (stroke), osteoarthritis (flexible tissue at end of bones wear down) in left shoulder and dermatophytosis (highly contagious fungal infection of the skin). Review of Resident #57's quarterly MDS, dated [DATE], showed: - Cognitive status intact; - Independent for dressing; - Physical assist of one staff member for hygiene; - Physical assist of one staff member for bathing. Review of the resident's shower sheets for June 2023 through August 25, 2023 showed: - In June, Resident received a shower on 06/01/23, 06/08/23, 06/14/23, 06/16/23, 06/21/23, and 06/28/23; - In July, Resident received a shower on 07/05/23, 07/19/23, 07/22/23, and 07/26/23 and one documented refusal on 07/30/23; - In August, Resident received showers on 08/02/23, 08/09/23, and 08/16/23; - Shower sheets showed 14 showers documented out of 24 opportunities, a total of 10 opportunities for showers missed. Review of the resident's care plan showed: - Resident had resisted care and showers; - All refusals should be documented. During an interview on 08/24/23 at 12:35 P.M., Resident #57 said at one time, he/she had gone weeks without getting a shower. Observation on 08/24/23 at 12:35 P.M., showed the resident's hair was greasy. During an interview on 08/25/23 11:52 A.M., Resident #57 said that he/she had not had a shower since 08/16/23. Resident said he/she wished to receive two showers a week. Observation on 08/25/23 at 11:52 A.M. showed the resident's hair was greasy. 6. Review of Resident #65's medical record showed: - An admitted [DATE]; - Diagnoses of mild intellectual disability (deficient in intellectual function), chronic pain, abnormalities of gait and mobility, osteoporosis (weak and brittle bones), rheumatoid arthritis (inflammatory disorder affecting many joints) and major depressive disorder. Review of the resident's significant change MDS, dated [DATE], showed: - Cognitively intact; - Limited assistance of one staff for dressing; - Limited assistance of one staff for personal hygiene; - Bathing did not occur during review period. Review of the resident's shower sheets for June 2023 through August 25, 2023 showed: - In June, resident received showers on 06/03/23, 06/07/23, 06/10/23, 06/14/23, and 06/17/23; - In July, resident received showers on 07/02/23, 07/11/23, 07/12/23, and refused on 07/14/23. Resident received showers on 07/15/23, 07/17/23, 07/21/23, 07/25/23, and 07/28/23; - In August, resident received showers on 08/01/23, 08/05/23, 08/08/23, 08/15/23, and 08/18/23. - Shower sheets showed 18 showers documented and one shower refusal out of 24 opportunities, a total of 5 opportunities for showers missed. During an interview on 08/25/23 at 11:22 A.M., the resident said he/she gets showers, but maybe not always twice a week. The resident said the staff help change clothes at times and he/she requires assistance for showers. Observation on 08/25/23 at 11:22 A.M. showed the resident wore the same clothes from 08/23/23 through 08/25/23. The resident's hair was greasy. During an interview on 08/24/23 at 2:10 P.M., Licensed Practical Nurse (LPN) F said residents should be getting two showers a week and they have scheduled days in the shower book. The certified nursing assistant (CNA) fills out a shower sheet for the resident when showered and the nurse must sign off on it. The shower sheets are then put into the basket and picked up by the Director of Nursing (DON). If a resident refused a shower, there should still be a shower sheet filled out for the refusal and it should be signed off by the resident, the CNA and a nurse. During an interview on 08/24/23 at 2:12 P.M., CNA G said residents should get two showers a week and shower days are noted in the shower book. A shower sheet should be filled out and turned into the nurse to be signed off. If a resident refuses a shower, then they attempt 2-3 times to get the resident to shower. If the resident continues to refuse, then the charge nurse and DON are notified of the refusal. The resident should sign off on the shower sheet that they refused. The shower sheets are turned into nursing to sign off on. During an interview on 08/25/23 at 1:20 P.M., the Assistant Director of Nursing (ADON) said he/she would expect showers to be given at least twice a week. The showers should be documented on the shower sheet and signed off by the nurse and turned in. Shower refusals should also be documented and turned in as well. 42699 47678

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This affected four residents (Resident #21, #24, #39, and #48) out of 18 sampled residents and two residents (Resident #55 and #76) outside the sample. The facility's census was 75. Review of the facility's undated Pest Control policy showed: - The facility will have a pest control contract which provides frequency treatment of the environment for pests and allow for additional visits when problem is detected; - Monitoring the environment will be done by the facility staff; - Pest control problems will be reported promptly. 1. Review of Resident #21's medical record showed: - admitted on [DATE]; - Diagnoses of traumatic brain injury, gastrostomy (a surgical opening into the wall of the stomach to allow tube feeding), Parkinson's disease (a disorder of the central nervous system that affects movement and causing tremors) and cerebral Infarction (stroke). Observations of Resident #21 showed: - On 8/23/23 at 9:30 A.M., six flies observed on the resident's pant leg and shirt; - On 8/24/23 at 12:33 P.M., two flies observed on the resident's pant leg; - On 8/25/23 at 9:30 A.M., four flies observed on the resident's pant leg; - On 8/25/23 at 9:38 A.M., three flies on divider curtain of the resident's room; - On 08/25/23 at 9:38 A.M., Registered Nurse (RN) A waved hand over the resident to prevent flies from landing on the resident's abdomen during care of gastrostomy tube. 2. Review of Resident #24's medical record showed: - admitted on [DATE]; - Diagnoses of weakness, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and neurocognitive disorder with Lewy bodies (type of progressive dementia that leads to a decline in thinking, reasoning and independent function). Observations of Resident #24 showed: - On 08/23/23 at 10:03 A.M., one fly crawling on the resident's left arm and three flies on the resident's blanket; - On 08/23/23 at 02:14 P.M., three flies buzzing the resident's body; - On 08/24/23 at 10:35 A.M., three flies on the resident's blanket. 3. Review of Resident #39's medical record showed: - admitted on [DATE]; - Diagnoses of hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness, but without complete paralysis) following cerebral infarction (stroke) affecting left side, muscle weakness, and shortness of breath. Observation of Resident #39 showed on 08/23/23 at 01:48 PM, a fly buzzing the resident's face. 4. Review of Resident #48's medical record showed: - An admitted [DATE]; - Diagnoses of unspecified dementia, adult failure to thrive, hypertension (HTN, high blood pressure), chronic kidney disease (disease of the kidneys leading to kidney failure), pressure ulcer of unspecified buttock, and polyosteoarthritis (pain, stiffness, or swelling in multiple joints). Observation on 08/25/23 at 10:15 A.M. showed Resident #48 with one fly flying around and landing on the resident's face twice. Certified Nursing Assistant (CNA) B used hand to wave fly away. 5. Review of Resident #55's medical record showed: - admitted on [DATE]; - Diagnoses of paranoid schizophrenia (serious mental disorder in which people interpret reality abnormally), diabetes mellitus (group of diseases that result in too much sugar in the blood), and dementia (group of thinking and social symptoms that interferes with daily functioning). Observation of Resident #55 showed on 08/24/23 at 12:25 P.M., a fly crawled on the resident's napkin in the dining room while the resident was eating. 6. Review of Resident #76's medical record showed: - admitted on [DATE]; - Diagnoses of heart failure (chronic condition in which the heart doesn't pump blood as well as it should) and hypertension (high blood pressure). Observation of Resident #76 showed: - On 08/23/23 at 10:30 A.M., one fly crawling on the resident's face; - On 08/24/23 at 10:37 A.M., one fly crawling on the resident's blanket. During an interview on 08/24/24 at 1:27 P.M., the Maintenance Supervisor said that the maintenance/pest control log is checked every morning so that issues can be addressed. The staff record any issues in the log, but at times just pass issues along by word of mouth. The log upon observation only contained one issue for August and the Maintenance Supervisor said when a page gets full, he/she just gets rid of that page. He/she does not keep the pages to show what work was reported and that it has been completed. During an interview on 8/25/23 at 9:36 A.M., RN A said even though the exterminator had been there, the flies were terrible, especially with residents that eat in their own rooms or have feeding tubes. During an interview on 08/25/23 at 10:05 A.M., RN H said any work orders or pest issues are to be recorded in the log book. The maintenance supervisor then checks the book each morning to address any issues. Observation on 08/25/23 at 10:10 A.M. of the maintenance log book did not show any reports of pest concerns regarding flies. During an interview on 08/25/23 at 10:20 A.M., CNA C said the flies have been bad for the last month and Resident #48 is unable to keep them from landing on his/her face due to range of motion limitations. Observation on 08/25/23 at 10:58 A.M. showed an unknown visitor swatting flies with a fly swatter in the common area on 200 hall. During an interview on 08/25/23 at 1:20 P.M., the Administrator said she would expect the facility to have an effective pest control practice with regard to flies and felt like it had been addressed by use of lights, keeping doors closed, picking up trash, staff with fly swatters and having the exterminator come more frequently. 46460

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This had the potential to affect all residents. The facility's census was 75. The facility did not provide a policy. Observation on 08/23/23 at 09:58 A.M. showed missing corner bead from the floor to the ceiling in room [ROOM NUMBER] near bed one. Observation on 08/23/23 at 10:05 A.M. showed the privacy curtain between the residents' beds in room [ROOM NUMBER] with patches of light brown colored soiling along with dark brown splatter-like soiling at the bottom of the curtain. Observation of room [ROOM NUMBER] on 08/24/23 at 12:24 P.M. showed: - Corner bead and corner bead trim missing from floor to ceiling near bed one; - Approximately four feet of cove base missing from the interior wall. During an interview on 08/24/23 at 12:24 P.M., the resident in room [ROOM NUMBER] said it had been like that for a very long time. During an interview on 08/24/23 at 1:27 P.M., the Maintenance Supervisor said that the maintenance/pest control log is checked every morning so that issues can be addressed. The staff record any issues in the log, but at times just pass issues along by word of mouth. The log upon observation only contained one issue for August and the Maintenance Supervisor said when a page gets full, he/she just gets rid of that page. He/she does not keep the pages to show what work was reported and that it has been completed. Observation on 08/25/23 at 09:10 A.M. showed exposed metal corner bead on approximately the lower two foot of corner in room [ROOM NUMBER] near bed one. During an interview on 08/25/23 at 09:11 A.M., the resident in room [ROOM NUMBER] said the exposed metal had been there since before he/she moved into the room in March of this year. During an interview on 08/25/23 at 10:05 A.M., Registered Nurse (RN) H said any work orders or pest issues are to be recorded in the log book. The maintenance supervisor then checks the book each morning to address any issues. Review on 08/25/23 at 10:10 A.M. of the maintenance log book showed no reports of the missing corner bead or corner bead trim, no reports of the missing cove base or loose cove base and no reports of the soiled privacy curtain. Observation on 08/25/23 at 12:57 P.M. showed a wavy, unsecured four foot section of cove base on the wall next to the mechanic room by the dining room. During an interview on 08/25/23 at 1:20 P.M., the Administrator said she would expect corner bead, corner bead trim, and cove base to be in place and replaced if missing.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for three residents (Resident #7, #24, and #71) out of 18 sampled residents. The facility's census was 75. Review of the facility's policy titled, Discharge/Transfer of Resident, undated, showed: - Purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Notice of transfer or discharge to be provided as necessary; - Bed hold forms to be provided as necessary. 1. Review of Resident #7's medical record showed: - Transferred and admitted to the hospital on 08/12/23 and readmitted to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 2. Review of Resident #24's medical record showed: - Transferred and admitted to the hospital on 07/04/23 and readmitted to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 3. Review of Resident #71's medical record showed: - Transferred and admitted to the hospital on 06/07/23 and readmitted to the facility on [DATE]; - Transferred and admitted to the hospital on 07/07/23 and readmitted to the facility on [DATE]; - Transferred and admitted to the hospital on 07/28/23 and readmitted to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. During an interview on 08/23/23 at 10:06 A.M., the Social Services Designee (SSD) said he/she has a log of the transfers/discharges, but the forms are not being filled out. During an interview on 08/25/23 at 01:04 P.M., Registered Nurse (RN) A said he/she does not do anything as far as a transfer/bed hold form when someone goes out to the hospital. If there are forms that are supposed to be filled out, he/she is uneducated about that. During an interview on 08/25/23 at 1:20 P.M., the Administrator said she would expect transfer/discharge forms to be issued and signed when a resident transfers out to the hospital. 46460

Based on interview and record review, the facility failed to inform the resident and family or legal representative of their bed hold policy at the time of transfer to the hospital for three residents (Resident #7, #24, and #71) out of 18 sampled residents. The facility's census was 75. Review of the facility's policy titled, Discharge/Transfer of Resident, undated, showed: - Purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Notice of transfer or discharge to be provided as necessary; - Bed hold forms to be provided as necessary. 1. Review of Resident #7's medical record showed: - Transferred and admitted to the hospital on 08/12/23 and readmitted to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the facility bed hold policy at the time of transfer. 2. Review of Resident #24's medical record showed: - Transferred and admitted to the hospital on 07/04/23 and readmitted to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the facility bed hold policy at the time of transfer. 3. Review of Resident #71's medical record showed: - Transferred and admitted to the hospital on 06/07/23 and readmitted to the facility on [DATE]; - Transferred and admitted to the hospital on 07/07/23 and readmitted to the facility on [DATE]; - Transferred and admitted to the hospital on 07/28/23 and readmitted to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the facility bed hold policy at the time of transfer. During an interview on 08/23/23 at 10:06 A.M., the Social Services Designee (SSD) said he/she has a log of the transfers/discharges, but the bed hold notice forms are not being filled out. During an interview on 08/25/23 at 01:04 P.M., Registered Nurse (RN) A said he/she does not do anything as far as a transfer/bed hold form when someone goes out to the hospital. If there are forms that are supposed to be filled out, he/she is uneducated about that. During an interview on 08/25/23 at 1:20 P.M., the Administrator said she would expect bed hold notices to be issued and signed when a resident transfers out to the hospital. 46460

Based on interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for two residents (Resident #23 and #71) out of 18 sampled residents. The facility's census was 75. Review of the facility's policy titled, Care Plan Comprehensive, undated, showed: - An individualized comprehensive care plan that includes measurable goals and timeframes will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; - The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set - a federally mandated assessment completed by the facility); - The interdisciplinary care plan team is responsible for the periodic review and updating of care plans when a significant change in the resident's condition has occurred; at least quarterly; and when changes occur that impact the resident's care (i.e., change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment.) 1. Review of Resident #23's face sheet showed: - admitted on [DATE]; - Diagnoses of dementia (group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance, psychosis (mental disorder characterized by a disconnection from reality), moderate intellectual disabilities (slower in social and daily living skills), and shortness of breath. Review of the resident's quarterly MDS assessment, dated 05/30/23, showed: - Primary Medical Condition in Section I (I0020B) coded as dementia with behavioral disturbance; - Oxygen therapy in Section O (O0100C) coded as being in use in the seven-day look back period. Review of the resident's physician's orders showed an order to wear oxygen during the day to maintain oxygen saturation (level of oxygen in the blood) greater than 91%. Continuous oxygen at three liters at night, dated 10/09/19. Review of the resident's care plan showed it did not address: - Dementia problems, interventions, and goals; - Shortness of breath or oxygen use. 2. Review of Resident #71's medical record showed: - admitted on [DATE]; - Diagnoses of intellectual disabilities, edema (swelling caused by too much fluid trapped in the body's tissues), chronic kidney disease (CKD - a condition characterized by a gradual loss of kidney function over time), and renal agenesis (a condition that is present at birth that is an absence of one or both kidneys.) Review of the resident's physician's orders showed: - An order for a 1500 milliliter (ml) fluid restriction daily as needed, dated 06/22/23 and discontinued on 08/24/23; - A new order for a 1500 ml fluid restriction per day, 320 ml with each meal, 100 ml with each med pass, and 220 ml during the day, dated 08/24/23. Review of the resident's progress notes, dated 07/07/2023 at 03:04 PM., showed a telephone call placed to emergency room and spoke with staff who stated resident was being admitted with diagnoses of dehydration and chronic kidney failure (occurs when the kidneys suddenly fail due to an injury, medication, or illness in someone with chronic kidney disease). Review of the resident's care plan showed it did not address: - CKD problems, interventions, and goals; - Fluid restriction. During an interview on 08/24/23 at 04:55 P.M., Registered Nurse (RN) D said he/she doesn't know why Resident #71 has a PRN (as needed) fluid restriction order and doesn't know what the parameters would be. He/She could not find an order for fluid restriction in the hospital discharge summary, but assumes it is because Resident #71 was hospitalized with chronic CKD. During an interview on 08/25/23 at 01:20 P.M., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and MDS Coordinator said they would expect chronic kidney disease with a fluid restriction, dementia, and oxygen use to be addressed on the care plan. The MDS Coordinator said usually the nurses or the ADON will give him/her resident updates, so he/she can update their care plans.

Based on observation, interview and record review the facility failed to protect one cognitively impaired resident (Resident #1) from sexual abuse when staff found Housekeeping Staff (HKS) A, nude from the waist down, on the bed leaning over Resident #1. The facility census was 68. The Administration was notified on 10/12/2022 of a Past Non-Compliance Immediate Jeopardy (IJ) which began on 10/8/2022. On 10/8/2022, the Director of Nurses (DON) was notified HKS A sexually abused Resident #1. Staff immediately assessed the resident and notified the police and ambulance. They removed HKS A from the Facility, and started an investigation. Facility staff was in-serviced on abuse and neglect policies and protocols. The IJ was corrected on 10/8/2022. Record review of the facility's Abuse and Neglect Policy dated 11/28/2016 showed: - The resident has a right to be free from abuse, neglect, misappropriation of resident property, exploitation, including freedom from corporal punishment, involuntary seclusion and any physician or chemical restraint not required to treat the resident's medical symptoms; - The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment: - Thoroughly investigate the alleged violation; - Prevent further abuse, neglect, exploitation and mistreatment while the investigation is in progress; - Take appropriate corrective action. 1. Record review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 8/17/2022 showed: - An admitted [DATE]; - The resident is severely cognitively impaired; - The resident requires extensive assistance with activities of daily living (ADLs). Record review of Resident #1's Physician Order Sheet (POS), dated 10/17/2022, showed diagnoses included Encephalomyelitis (an attack of inflammation in the brain and spinal cord that damages the protective covering of nerve fibers), acute respiratory disease (fluid buildup in the lungs) and a mood disorder (mental and behavioral disorder) due to the encephalomyelitis. Record review of Resident #1's Care Plan dated 5/20/2022 showed: - The resident requires extensive assistance with all activities of daily living; - The resident is cognitively impaired and is not always able to communicate her needs. Record review of the facility's investigation dated 10/8/2022, showed: - Certified Nurse Aide (CNA) C noticed Resident #2's call light and went to respond; - Upon entering the room, Resident #2 informed CNA C there was someone in Resident #1's bed with no pants on; - CNA C saw the curtain had been partially closed but observed the shadow of someone in Resident #1's bed. The shadow was leaning over the resident; - CNA C immediately pulled back the curtain and yelled what are you doing; - CNA C observed HKS A, nude from the waist down, leaning over Resident #1; - HKS A gave no response to the CNA's yelling, and instead slid off the bed to the floor, briefly leaned against the bed, then fell into a fetal position; - CNA C said he/she was able to confirm at that time, HKS A had no pants on and his/her genitals were exposed; - CNA C said the resident's adult brief had been pulled to one side, exposing his/her genitals; - CNA C said he/she had placed a new adult brief on Resident #1, placed the resident in bed, and covered the resident with their covers approximately one hour prior to this incident; - HKS A got up, got dressed and left the room when CNA A stepped to the hall to get help; - CNA C informed the charge nurse who then notified the Assistant Director of Nursing (ADON); - The charge nurse, Registered Nurse (RN) B told staff to escort HKS A from the building; - The ADON notified the DON; - An investigation was started, the police and ambulance were called and the resident was sent to the ER; - HKS A was terminated immediately and has not been back to the facility. In an interview on 10/12/2022 at 10:30 A.M., the DON said the resident is cognitively impaired. The Resident has a difficult time communicating with others due to his/her diagnosis of Encephalomyelitis. In an interview on 10/12/2022 at 1:30 P.M., Resident #2 said he/she saw a man/woman with their pants down trying to get on Resident #1's bed. Resident #2 said Resident #1 was not making any sound, but that he/she yelled at the HKS A what are you doing and turned on the call light to get help. Resident #2 said CNA C was there in less than a minute. In an interview on 10/12/2022 at 1:45 P.M., CNA C said, at approximately 9:00 P.M. he/she asked Resident #1 if he/she wanted to go to bed and the Resident said no. A short while later, the Resident was asked again and agreed to go to bed. CNA C placed a new brief on the resident and placed the resident in the bed in a low position, covered her and left the room. A few moments later, CNA C saw HKS A walk down the hall toward the Resident's room, but thought nothing of it as he/she had laundry in hand. CNA C heard the call light for Residents' #1 and #2 room and went to check on them. Upon entering the room, Resident #2 said there is someone in Resident #1's bed. At the same time, CNA C saw a shadow of a man/woman on top of Resident #1. CNA C said she immediately pulled back the partially closed privacy curtain and found HKS A in the bed with no pants on. He/She also saw Resident #1's adult brief had been pulled to the side exposing his/her genitals. CNA C said he/she yelled at HKS A and watched him/her slide off the bed to the floor and lie in a fetal position naked from the waist down. HKS A told CNA C that he/she must have passed out. CNA C said he/she walked to the hall and screamed for the charge nurse to assist. During that time, HKS A dressed, called someone on a cell phone and left the room. CNA C said Resident #1 was not exhibiting any behaviors. In an interview on 10/12/2022 at 2:45 P.M., the Administrator said HKS A had recently moved from the dietary department to housekeeping and there had never been any reports of anything like being sexually inappropriate with residents. In an interview by phone on 10/17/2022 at 7:00 P.M., RN B said there was a commotion in the hallway and CNA C was yelling for help and telling RN B about HKS A in Resident #1's room with no pants and in the resident's bed. She immediately told staff to escort HKS A from the facility and he/she called the ADON, physician, Police and Ambulance. RN B also told another nurse on the hall to go assess Resident #1 for visible injuries. Complaint #MO208110 & MO208111

Based on interview and record review, the facility failed to properly assess, monitor and notify the physician for a resident who exhibited signs and symptoms of a significant change and the resident subsequently died on [DATE]. The facility also failed to properly perform cardio [MEDICAL CONDITION] resuscitation for the resident. (Resident #1). The census was 74. 1. Review of Resident #1's facility face sheet, showed an admission date of [DATE], with [DIAGNOSES REDACTED]. -[MEDICAL CONDITION] (a condition where the heart cannot pump enough blood to meet the body's needs); -High blood pressure; -Chronic [MEDICAL CONDITIONS] (a disease that affects the arteries in the lungs and the right side of the heart); -Kidney failure; -Diabetes; -[MEDICAL CONDITION]. Review of the resident's discharge summary, dated [DATE], from a hospital, showed the symptoms were resolved from chief complaints of diarrhea, abdominal pain, vomiting, dehydration and acute [MEDICAL CONDITION]. The resident was in stable condition when discharged and a full code status. The discharge instructions showed to contact the physician if the following symptoms occurred: -Nausea/vomiting; -Shortness of breath; -Change in or no urine; -Loss of appetite/fluid intake; -Change in behavior. Review of the resident's outside the hospital do-not-resuscitate order (a form which authorizes emergency medical personnel to withhold or withdraw cadiopulmonary resuscitation), dated [DATE], showed the resident signed the revocation provision. The resident's request of a full code status included the understanding that in the event that he/she suffered cardiac or respiratory arrest, this provision will take effect and medical procedure to restart the resident's breathing or heart functioning will be instituted. The provision was signed by attending physician. Review of the facility's "Condition Change, Resident" policy, dated ,[DATE], showed the following: -Purpose: to observe, record and report any condition change to the attending physician so proper treatment will be implemented; -Equipment: Blood pressure cuff, stethoscope, thermometer and flashlight; -Guidelines: After all resident changes in physical or mental function, monitor the following: observe for personality changes; observe for alterations in consciousness; observe for generalized weakness; observe for speech disorder; observe for gait; posture or balance disorder; take vital signs and include temperature; observe for dyspnea or variations in respiration (irregular); observe for flushing or cyanosis; -Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If unable to reach the attending physician or the physician on call, call the facility medical director for emergency situations; -Complete an incident, accident or risk management report per facility guidelines; -Notify resident's responsible party; -Monitor resident's condition frequently until stable. Review of the resident's physician orders, dated [DATE] through [DATE], showed the following: -[MEDICATION NAME] (treats bacterial infections) 500 milligrams (mg) by mouth every 8 hours for 11 days; -[MEDICATION NAME] (treats [MEDICAL CONDITION] and heart rhythm problems) 0.125 mg (milligrams) by mouth daily; -[MEDICATION NAME] (helps reduce the workload of the heart) 12.5 mg by mouth twice a day; -[MEDICATION NAME] (reduces high blood pressure) 10 mg by mouth twice a day; -Imdur (increases blood and oxygen supply to the heart) 30 mg by mouth daily; -[MEDICATION NAME] (diuretic) 40 mg by mouth daily; -Spirolactone (diuretic) 25 mg by mouth twice a day; -[MEDICATION NAME] (treats heart rhythm problems) 400 mg by mouth twice a day; -[MEDICATION NAME] (treats depression) 30 mg by mouth daily; -[MEDICATION NAME] (treats anxiety) 0.5 mg by mouth three times a day as needed; -Oxygen 2 liters (L) continuous by nasal cannula; -Blood glucose checks four times a day: when below 60 mg/dL or above 400 mg/dL call the physician; -[MEDICATION NAME](lowers blood sugar) with sliding scale: 200 - 250 mg/dL = 4 units; 251 - 300 mg/dL = 6 units; 301 - 350 mg/dL = 8 units; 351 - 400 = 10 units; -Blood sugar below 60 mg/dL give [MEDICATION NAME] gel; -[MEDICATION NAME] (lowers blood sugar) 5 units at bedtime; -Up with one person assistance and rehabilitation potential is good. Review of the resident's NN and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -On [DATE] at 3:30 P.M., the resident arrived at the facility alert and orient. The resident received 2 liters (L) of oxygen by a nasal cannula, with an oxygen saturation level (SpO2) (measurement of the amount of oxygen in blood) of 94% (normal range 90% to 100%) and a heart rate (HR) of 83 (normal ,[DATE] beats per minute). The resident used a walker to ambulate with one person assistance to transfer; -On [DATE] at 11:30 P.M., the resident denied pain or discomfort, no signs of distress or discomfort and rested quietly. The resident's SpO2 was at 97% on 2L of oxygen and HR 70; -On [DATE] at 9:00 A.M., the resident was alert and orientated and able to voice wants and needs. The resident was noted to be smiling. Staff verified physician's orders [REDACTED]. Staff were told the resident "bottoms out" on blood sugars (blood sugar drops quickly and below normal levels). The resident's SpO2 was at 97% on 2L of oxygen and HR 82; -On [DATE], between 7:00 P.M. and 7:00 A.M., the resident was alert and orient. The resident ambulated with walker as tolerated with one person assistance. The resident had no complaints of pain and no signs or symptoms of acute distress. No vital signs were noted on evening/night shift; -On [DATE] at 6:00 A.M., blood glucose level was 60 mg/dL (normal 70 to 115). The resident received orange juice and milk; -On [DATE] at 6:35 A.M., the resident's blood glucose level was at 96 mg/dL; -On [DATE] at 11:00 A.M., the resident's blood glucose level was at 106 mg/dL; -On [DATE] at 6:30 P.M., the resident went to the main dining room for the noon and evening meal and socialized with staff. The resident's blood glucose level was noted to be within normal limits The resident denied nausea or vomiting. Family visited with results of positive interaction. No vital signs noted on the day/evening shift; -On [DATE] between 7:00 P.M. and 7:00 A.M., the resident complained to LPN G of vomiting. The resident's SpO2 was 96% on 2L of oxygen and HR 93. The resident's blood glucose level was at 155 mg/dL at 8:00 P.M.; -On [DATE] at 6:00 A.M., blood glucose level of 134 mg/dL; -On [DATE] at 8:00 A.M., the resident refused breakfast. RN A reminded the resident of his/her [DIAGNOSES REDACTED]. -On [DATE] at 9:00 A.M., showed the resident's blood glucose level at 160 mg/dL. The resident said he/she did not feel good. RN A asked the resident several specific questions to find out why he/she did not feel good. The resident did not know why he/she did not feel good. RN A encouraged the resident to report a specific complaint. RN A said, due to the self induced vomiting and displayed behavior changes, with calling the nurse loudly then whispering, he/she planned to contact the physician for a psych evaluation; -On [DATE] at 10:30 A.M., the resident asked to go to bed. RN A and an aide assisted in a moderate level, two person transfer with the resident to his/her bed. The resident's SpO2 was 95% on 2L of oxygen and HR 88; -On [DATE] at 11:00 A.M., the resident had two visitors (VT R and VT S) who came with certified medication technician (CMT) D to RN A and said the resident was not responding. RN A and CMT D went to the resident's room and the resident responded and took his/her scheduled medications. RN A took the resident's blood glucose test. certified nurses aide (CNA) B reported to RN A the resident refused his/her lunch meal. RN A reminded the resident about his/her diabetic diagnoses; -On [DATE] between 11:00 A.M. and 12:15 P.M., the visitors met with RN A and told him/her the resident wanted to go to the hospital. RN A told the visitors that the CMT had just informed him/her of the resident's request. RN A said the resident told the CMT he/she wanted to go to the hospital because he/she could not urinate. RN A said to the visitors that not being able to urinate was not a valid medical reason to call 911 without other signs and symptoms. The visitors asked for an honest assessment of the resident's condition. RN A said the resident's vital signs were stable and there was nothing new that had developed since admission except for the concern of the resident not eating with his/her [DIAGNOSES REDACTED]. -On [DATE] at 12:15 P.M., CNA B reported to RN A the resident still felt bad. LPN C instructed CNA B to get a set of vital signs; -On [DATE] at 12:25 P.M., CNA B told LPN C the resident's SpO2 was 81% on 2L of oxygen and the resident's hands were cold. LPN C went to the resident's room and then reported to RN A that the resident's skin was not cyanotic (lacking oxygen), the SpO2 was 88% on 2L of oxygen and HR 68. LPN C suggested to RN A to switch the nasal cannula to a mask because the resident was mouth breathing; Review of the MAR, showed the blood glucose test results for [DATE] at 11:00 A.M., taken by RN A were 197 mg/dl. Review of Licensed Practical Nurse (LPN) F's statement, provided by the facility, dated [DATE], showed the resident was fine all day and participated in activities. On the evening of [DATE], a resident's family member approached LPN F and said the resident did not look right. LPN F was not assigned to the resident, but he/she said the assigned nurse was busy at the time. LPN F assessed the resident and said the resident's vital signs were stable. Family member (FM) Q said the [MEDICATION NAME] (medication used to reduce anxiety) should not be scheduled three times a day, but only as needed up to three times a day. LPN F called the physician and received a new order as requested. LPN F still felt FM Q was concerned about the resident. LPN F and FM Q went and asked the resident if he/she wanted to go to the hospital. The resident told them, "I don't know". FM Q said after medication was out of the resident's system, he/she will feel better. LPN F said the resident was not in distress at the time of the assessment. LPN F told the resident's nurse (LPN M) of the situation. Review of the 24 hour nursing log, provided by the facility, dated [DATE] between 7:00 P.M. and 7:00 A.M., showed FM Q brought concerns about the resident not acting right. The FM Q said he/she thought it was from the [MEDICATION NAME]. During an interview on [DATE] at 1:50 P.M., LPN M said he/she did not remember the conversation on [DATE], with LPN F regarding the family member and the resident's medications. During an interview on [DATE] at 2:34 P.M., certified nursing aid (CNA) K said he/she took the resident to the dining room for breakfast at about 7:00 A.M. on [DATE]. CNA K said the resident did not appear to be in any distress. He/She knew something was different the next day when he/she saw the resident already in a wheelchair and in the dining room at 7:00 A.M. on [DATE]. The resident told CNA K that he/she did not feel good. CNA K said the resident looked pale. CNA K said on [DATE] at about 12:00 P.M., he/she met with the resident's visitors and got the impression that the family thought the resident was getting better. During an interview on [DATE] at 11:09 A.M., Nurse Aide (NA) I said he/she offered to take the resident to dinner on the evening of [DATE], but the resident declined. NA I brought the dinner tray into the resident's room, but the resident did not eat his/her dinner. NA I said there were snacks on his/her bedside table, but the resident did not eat them. NA I said on [DATE], during the night shift, he/she saw the resident stick his/her fingers in his/her throat to vomit. When NA I asked the resident why he/she was making himself/herself throw up, the resident responded and said it made him/her feel better. NA I told LPN G, the resident's stomach hurt. NA I said the resident used the call light almost every 15 to 30 minutes and wanted to sit up. NA I said the resident had dry heaves and vomited most of the night. NA I helped the resident onto a bedpan early in his/her shift (about 10:00 P.M.) to urinate because he/she was too weak to ambulate to the restroom. NA I said there was very little urine in the bedpan. NA I did not report the small amount of urine to the nurse because it was early in his/her shift when the resident urinated, he/she expected the resident to urinate more throughout the shift. During an interview on [DATE] at 1:50 P.M., CNA H said he/she saw the resident stick his/her fingers in his/her throat to vomit and told LPN G. CNA H said the nurse seemed aggravated because he/she just gave the resident his/her night medications. CNA H saw the medications in the trash can where the resident had vomited. CNA H said the resident asked to sit up through the night and would then vomit on his/her own. CNA H said he/she helped the resident onto a bedpan at about 11:00 P.M. and again at about 1:30 A.M. to urinate because he/she was too weak to ambulate to the restroom. CNA H said there was very little urine in the bedpan, both times. During an interview on [DATE] at 10:46 A.M., CNA J said the resident did not sleep the night of [DATE]. CNA J said the resident sat on the edge of his/her bed and complained of nausea and vomiting most of the night. During an interview on [DATE] at 12:10 P.M. and on [DATE] at 8:55 P.M., LPN G said on [DATE] at about 10:00 P.M., when asked, the resident denied he/she caused himself/herself to vomit and continued to complain of nausea. LPN G instructed the resident not to force vomiting because it could injure his/her esophagus. LPN G offered to give the resident non-medicated items, such as crackers or soda, to settle the resident's stomach; the resident refused. LPN G asked the resident if he/she wanted to go to the hospital; the resident refused. LPN G said, "Anybody that sticks their finger down their throat to make themselves throw up is considered a change in condition, but since I haven't had (him/her) before I didn't know if this was normal for (him/her)". LPN G said he/she was not told of a history of behavorial problems in the change of shift report prior to his/her shift. LPN G said there was no change in condition because the resident vomited prior to his/her shift and then throughout the night. LPN G said the resident had "[MEDICAL CONDITION] episodes" through the night, such as calling staff into the room, but then forgetting what he/she called them in for, the self induced vomiting and when the resident said he/she was unable to lift his/her head on his/her own on the morning of [DATE]. He/She did not document the resident's medications being thrown up for the night of [DATE]. LPN G said on the morning of [DATE], the resident did not want to get out of bed. He/She said the resident did not complain of not being able to urinate, but that the night shift did have to empty the resident's [MEDICAL CONDITION] bag because it was very full. During an interview on [DATE] at 11:50 A.M., CNA B said when he/she came in on [DATE] at 6:15 A.M., the resident had dried vomit on him/her and on the bed covers. CNA B got the resident out of bed to clean him/her before breakfast. When CNA B transferred the resident with one person assist and a walker, the resident went down on his/her knees due to weakness. CNA B yelled for someone to help get the resident up into a wheelchair. Certified medication technician (CMT) D helped CNA B put the resident into a wheelchair. CNA B told RN A about the weakness of the resident. CNA B wheeled the resident into the dining area. The resident would yell, "Help me, help me!" and then would give a faint yell. CNA B told RN A that something was wrong with the resident because he/she acted different. After his/her 10:00 A.M. break, the resident would not speak, he/she would just roll his/her eyes therefore CNA B went straight to RN A to tell him/her of what the resident did. RN A said the resident was faking his/her illness. CNA B said he/she passed out lunch trays and went to the resident but could not wake him/her up. CNA B said the resident was "white as a ghost with blue lips". CNA B went and told RN A and the nurse continued to say the resident was faking his/her illness. CNA B said RN A then went on his/her lunch break at 12:30 P.M. CNA B said he/she went to get the vital signs, but could not get a reading on the automatic blood pressure cuff machine. CNA B said he/she readjusted the cuff twice and still could not get a reading. The SpO2 was 81% on 2L of oxygen. CNA B said after he/she heard LPN C tell RN A to get a mask for the resident, he/she left and went into the resident's room and found the resident with no mask on, yellow skin color and "no life" in the resident. CNA B said he/she ran to the break room and told RN A the resident passed away. He/She did not know who else to tell about his/her concerns because it was a weekend and he/she already told both nurses. During an interview on [DATE] at 1:50 P.M., CMT D said he/she was assigned to the resident and noticed the resident was weaker than the day before ([DATE]). The resident was able to transfer with only stand by assistance on [DATE], but on [DATE] the resident could not transfer with her/his own weight. CMT D said the resident was very lethargic. He/She said the resident had trouble swallowing all of his/her morning scheduled medications on [DATE] which was different from the day before. The resident and the bed were a mess from dried vomit. The resident did not vomit up the morning medications. CMT D said on [DATE] at about 11:00 A.M., the resident's visitors told him/her that the resident was not responding to them. CMT D said he/she went to get RN A and they both went into the resident's room. CMT D said RN A did not talk or assess the resident. CMT D said RN A used the blood glucose test on the resident then left the room. The resident told CMT D that he/she wanted to go to the hospital because he/she could not urinate. CMT D went to the nurse's desk and told RN A about the resident's request and that he/she could not urinate. CMT D said RN A told him/her, "Noted", but did not go to the resident to assess. Prior to the code, things were not taken as seriously as they should have been because the resident was dramatic about some things, but had underlining issues. During an interview on [DATE] at 2:36 P.M., CMT L said on the morning of [DATE], he/she heard the resident hollering at the nurse's desk then the resident would be very quiet, then would holler again. During an interview on [DATE] at 1:05 P.M., Registered Nurse (RN) A said on [DATE], the resident was very quiet and stayed to himself/herself. RN A checked on the resident from time to time and said the resident was not very social. There were no signs or symptoms of behavioral problems. There were no urination problems on [DATE]. RN A said he/she was told in report, by LPN G, that the resident's [MEDICAL CONDITION] bag had ruptured due to a very large bowel movement during the night shift (,[DATE]-,[DATE]). RN A said he/she was not told of any medications being vomited up by the night nurse. He/She was told the resident was vomiting by self induction. He/She was told the resident refused breakfast and refused to get out of bed, but the resident did not voice any certain complaint. He/She had the aide encourage the resident to get up for breakfast. CNA B got the resident up and brought him/her to the dining area. RN A said LPN C informed him/her that the resident would talk loudly to call LPN C over, but when LPN C went to the resident, the resident would whisper. RN A said this was a new behavior for the resident. The resident did the same to him/her. When RN A asked the resident and said you were talking loudly just a little while ago, the resident then told RN A that she/he did not feel good. RN A said he/she and CNA B took the resident to his/her room to go to bed. CNA B tried to transfer the resident to the restroom before taking him/her to bed but the resident did not get up with the one person and asked to go to bed. With the help of RN A, the resident was able to transfer from the wheelchair to the bed. Once the resident was in bed, he/she assessed the resident and said everything was normal. RN A said the resident did not talk to him/her and he/she concluded the resident was depressed. RN A said the visitors told him/her they could not get the resident to respond to them. He/she entered the room at about 11:00 A.M., the resident stared at them. RN A said while he got the resident's blood glucose test, CMT D gave the resident his/her pills. RN A did not assess the resident at this time because the complaint was that the resident would not respond and RN A said the resident responded, by opening his/her eyes, when the nurse entered the room. The resident was talking to the visitors when he/she left to finish his/her blood glucose test with the other residents and did not remember what the conversation was about. RN A said the visitors started to push the issue about sending the resident to the hospital. RN A told them there was a long process to send someone to the hospital including an ambulance fee. RN A said he/she would have to research the issue because he/she would have to call the doctor, then get an order, then there's the paperwork and then the ambulance. RN A said the ambulance staff would then determine if the resident needed to go to the hospital. CNA B demanded the resident be sent to the hospital. RN A said CNA B had been "hounding me" all morning about the resident who had no basic signs or symptoms of problems. In his/her frustration with CNA B, he/she told LPN C to handle the problem. RN A said CNA B was a very hard worker but a very big exaggerator. LPN C did not get a blood pressure. LPN C offered to go and get a blood pressure on the resident, but RN A said, "no" because he/she had other issues to discuss with the resident which included when and how much the resident last urinated. During an interview on [DATE] at 11:05 A.M., LPN C said he/she went into the resident's room to get a SpO2 reading. The first reading was 85%. LPN C said he/she rubbed the resident's fingers to warm them and was able to get a reading between 86% and 88%. LPN C said he/she did not converse with the resident but the resident did open his/her eyes once. LPN C did not think the resident was in distress, even though his/her O2 sat was under 90%, because he/she did not know the resident and the low reading could be normal for the resident. He/She did not know the resident's [DIAGNOSES REDACTED]. During an interview on [DATE] at about 10:45 A.M., VT R said the resident, who they have known for [AGE] years, did not look good and was not breathing well when the when they were visiting. VT R said when the resident went in and out of consciousness, VT S went to get the nurse. VT R said CMT D gave the resident his/her scheduled medications and RN A did not do much then left. RN A approached them when they were leaving and asked if the resident was known to fake his/her illness. VT R said to RN A that he/she did not think that of the resident. VT R told RN A that the resident told him/her that he/she wanted to go to the hospital because he/she could not urinate, but RN A just kept talking about how the resident was faking his/her illness. VT R asked RN A how the resident was doing and RN A answered that the resident will probably be going home soon. VT R said the resident's death was unexpected. During an interview on [DATE] at 4:02 P.M., Physician (Ph) N (the residents prior attending physician) said he/she had known the resident for many years. The resident had multiple medical problems but had never known the resident to fake an illness. Ph N said all of the illnesses had been real and were all documented. Ph N said he would expect the staff to call the on-call physician when a problem occurred with the resident. During an interview on [DATE] at 9:33 A.M., Ph O (a weekend oncall facility physician)said he expected the resident's nurse to assess the resident when the nurse was told the resident's oxygen saturation had dropped to 81%. He/She expected the nursing staff to call when the oxygen saturation could not get above 88%. During an interview on [DATE] at 7:37 A.M. and at 8:45 A.M., the DON said she expected her staff to call the physician first, the ambulance (if needed) second, the family third, the DON fourth and the Administrator fifth. The DON said that was not what happened with the resident's situation. She would expect when there was a change in condition staff should notify the physician. The facility had enough good rapport with the physicians that when the resident wanted to go to the hospital, the physician would have been okay with the resident going because it would be better to be safe than sorry. The DON said the resident was new to the facility and it would have been better to send him/her to the hospital, especially if he/she complained he/she couldn't urinate. She expected the staff to call the on-call physician on the weekends. RN A worked at the facility for [AGE] years and knew to call the medical director when there was a medical problem. The physician's phone numbers were at the nurse's desk. The DON said there was a backboard on the crash cart. During an interview on [DATE] at 3:30 P.M., on [DATE] at 1:16 P.M., on [DATE] at 11:11 A.M. and [DATE] at 3:26 P.M., the Administrator said she expected staff to call the physician for a change in condition, immediately. If the resident complained he/she did not feel good, could not urinate and requested to go to the hospital then the resident had a change in condition and the physician should have been called. The Administrator said she would expect the staff to call the physician when the resident vomited his/her medications. The Administrator said the situation with the resident was considered a change in condition to everyone. The Administrator said the situation was like a "domino effect, there were so many nurses that failed to call the physician with changes in condition" that the facility had an inservice on identifying change in condition and when to notify the physician for all of the nursing staff. Review of the resident's NN and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -On [DATE] at 12:55 P.M., CNA B ran up to RN A and told him/her the resident was "gone". RN A went to the resident and confirmed the resident was not breathing and had no apical pulse (checking the heart rate with a stethoscope) . RN A said the resident's skin was not cyanotic (lacking oxygen) and the forehead was warm to touch; -On [DATE] between 12:55 P.M. and 1:30 P.M., upon receiving full code status, RN A and two CMT's initiated cardio [MEDICAL CONDITION] resuscitation (CPR). RN A supported the resident's head, one CMT did compressions and the other manned the ambu bag. LPN C remained at the nurse's desk to call 911, the family and the physician. Emergency Medical Service (EMS) arrived after about four minutes and took over the CPR. The staff assisted with the transfer of the resident to the gurney and EMS left at 1:30 P.M. During an interview on [DATE] at 1:05 P.M., Registered Nurse (RN) A said after CNA B told him/her the resident was "gone" he/she went to the room and waited to find out from LPN C what the code status was for the resident. RN A said he/she did not want to do anything until he/she found out. RN A said either CMT D or CNA B was in the room before he/she arrived. He/She took the resident's apical and carotid pulse and did not find a pulse. RN A said the aides tried to get a blood pressure but were unable to get a reading. Once LPN C came and said the resident was a full code, the staff repositioned him/her in the bed and CMT D started compressions. RN A went to the head of the bed and positioned the resident's head to get his/her airway open. RN A said fluid came out of the resident's nose and mouth with every compression. When the crash cart arrived, CMT L handed RN A the ambu bag. RN A said CNA E took over with compressions after CMT D. RN A said he/she wished he/she went right away to the resident's room when LPN C told him/her about the resident's 88% O2 sat rather than finishing the 15 minutes of his/her lunch break. During an interview on [DATE] at 1:50 P.M., CMT D said he/she arrived with RN A first when the code was called. He/She told RN A that CPR needed to be started. RN A asked how, with so much fluid flowing from the resident's mouth? CMT D lowered the bed and started chest compressions while RN A waited. CMT D yelled for the crash cart. CMT D was scared because RN A appeared to be frozen. When the crash cart arrived, RN A manned the ambu bag then CNA E helped with the ambu bag. CMT D said when he/she was tired CNA E took over the compressions while RN A continued to man the ambu bag. The vomit smell was very strong and large amounts of fluid came out filling the ambu bag. During an interview on [DATE] at 2:34 P.M., certified nursing aid (CNA) K said on [DATE], RN A and him/her were in the break room when CNA B came in and said he/she's "gone". CNA K said RN A ran out of break room, then CNA K followed about three minutes later to see if he/she could help. CNA K assisted with cleaning out the ambu bag because with every compression, volumes of fluid came out of the resident's nose and mouth and filled the ambu bag. CNA K said CNA E was doing compressions upon his/her arrival, but CMT D initiated the compressions. CNA K said RN A helped with the ambu bag. During an interview on [DATE] at 1:45 P.M., CNA P said, when he/she arrived at the resident's room, he/she told RN A, CMT D and CNA E that the resident needed to be on a hard surface, but thought, "I didn't want to be bossy". CNA P said the bed kept bouncing with resident and CMT D's elbows would bend during the compressions. CNA P said RN A did not say anything to correct the way the CPR was being performed. During an interview on [DATE] at 3:30 P.M., on [DATE] at 1:16 P.M., on [DATE] at 11:11 A.M. and [DATE] at 3:26 P.M., the Administrator said she was not aware of any staff member in the facility that was current on their CPR certification. The Administrator said she did not require her staff to be CPR certified. She expects the staff to use a back board or hard surface when performing CPR. The Administrator verified there were only three staff members who have a current CPR certification card. Of those staff members, none were working at the time of the resident's [MEDICAL CONDITION]. Review of the facility's "Cardiopulmonary Resuscitation (CPR)" policy, dated ,[DATE], showed the following: -Basic responsibility: Licensed nurse and any person in the facility who is CPR certified; -Purpose: To ventilate and establish circulation on a resident with absence of respirations and pulse; -Equipment: 1. [MEDICAL CONDITION] board or hard surface; -Procedure: Note: Specific procedures for CPR are revised frequently; verify procedure with the American Heart Association and/or the American Red Cross in your area; -Circulation: Determine pulselessness. If resident is pulseless: -Make sure resident is on a hard surface; i.e., backboard or on the floor. Review of the resident's Certificate of Death, file dated [DATE], showed the cause of death as natural, with underlying cause: [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED] (deterioration of the heart muscle). *The higher classification merited due to the violation's effect on the resident. *Note: At the time of the survey, on [DATE], the violation was determined to be at the immediate and serious jeopardy level "J". Based on interviews and record reviews, it was determined the facility had implemented corrective action to address and lower the violation at the time. Per the facility's plan of correction, an official policy and procedure was developed and implemented for the facility. Licensed nursing staff inservices were conducted on policies and procedures addressing proper procedure for conducting an assessment and immediately notify the physician, the DON/ADON when there is a significant change in the resident's physical, mental, or psychosocial status. The nursing staff were inserviced regarding resident condition changes and nursing communication to include DON notification. Licensed