Every finding on record at Hillside Health Care Center

Based on interview and record review, the facility failed to ensure one resident's (Resident #2) right to be free from abuse was not violated when Resident #1 stabbed the resident multiple times with a screwdriver. On 07/30/26, Resident #1 stabbed Resident #2 with a screwdriver, resulting in Resident #2 sustaining three stab wounds to his/her upper arm and one stab wound to his/her chest. Resident #2 was hospitalized and diagnosed with a hemopneumothorax (when air and blood enter the space between the lung and chest wall) and required surgery. In addition, the facility failed to provide continuous intense one on one monitoring for one resident (Resident #4) with a history of being physically aggressive towards other residents, who rolled away in his/her wheelchair and punched another resident (Resident #3) in the face. The sample was 11. The census was 150. The Administrator was notified on 08/06/26 at 9:43 A.M. of the Immediate Jeopardy (IJ) past non-compliance, which occurred on 07/30/26. All staff and vendors have been in-serviced on protective oversight and vendor monitoring, including securing tools while onsite and removing any hazardous risk factors as needed. The deficiency was corrected on 08/04/26. Review of the facility's Abuse and Neglect policy, dated 06/12/24, showed the following:-Purpose: It is the policy of this facility to report all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, are reported immediately to the Administrator of the facility and other appropriate agencies in accordance with current state and federal regulations within prescribed time frames; -Definitions: --Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology;--Physical Abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. 1. Review of Resident #1's medical record, showed the following:-admission date 06/23/26;-Diagnoses included brief psychotic disorder (a short-term mental health condition), schizophrenia (a chronic and severe mental health disorder that affects how a person thinks, feels, and behaves), schizoaffective disorder (a chronic mental health condition combining symptoms of schizophrenia (such as hallucinations or delusions) and a mood disorder (such as depression or mania)), bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, and activity levels), anxiety disorder, depression, and post-traumatic stress disorder (PTSD, a mental health condition that can develop after experiencing or witnessing a terrifying, shocking, or dangerous event). Review of the resident's care plan, in use at the time of the survey, showed the following:-Problem: On 07/30/26, the resident became physically aggressive toward another resident during an interpersonal conflict involving perceived criticism, loud music complaints, comments regarding sagging pants, and frustration related to cigarette availability. The resident left the smoking area, retrieved a concealed screwdriver from his/her room, returned, and stabbed another resident in the arm and back, resulting in serious injury. Emergency Medical Services responded. The police were involved and the other resident hospitalized for his/her injury;-Interventions: Intervene immediately when the resident becomes involved in verbal disagreements with staff and peers. Remove the resident from escalating situations and provide a calm environment. Encourage the resident to report concerns to staff rather than confronting peers directly. Separate the resident from individuals involved in conflict as indicated. Assess for possession of unauthorized items, contraband, or potentially dangerous objects according to facility's policy. Maintain a safe environment and report safety concerns immediately. Review of the resident's nurse's notes, dated (Late Entry) 07/31/26, showed the following:-At 8:34 A.M., the resident became agitated that he/she did not have cigarettes and did not like what another resident told him/her about being disrespectful. The resident left the smoke room and came back with a screwdriver he/she stole from a vendor and stabbed another resident in the upper left arm and left flank (upper check) area. The resident's guardian was notified;-At 10:39 A.M., tried to leave a message for the resident's physician that the resident was going to jail for assault. The physician's voicemail box was full. An email will be sent to the resident's physician. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/03/26, showed the following:-Cognitively intact;-No moods or behaviors exhibited;-Diagnoses included high blood pressure, high cholesterol, seizure disorder, anxiety disorder, and depression. Review of the resident's care plan, in use at the time of the survey, showed the following:-Problem: The resident was the victim of a resident-to-resident assault resulting in stab wounds to the left arm and left flank, requiring hospitalization;-Intervention: Monitor interpersonal interactions during smoking times, outdoor activities, and common areas. Intervene early with verbal disagreements. Separate involved residents at first sign of escalation. Encourage resident to report concerns immediately. Notify nursing and social services of recurrent concerns. Review of the resident's nurse's note, dated (Late Entry) 07/31/26 at 8:37 A.M, showed the resident was injured during an altercation with another resident. The resident was sent to hospital for evaluation of injuries to upper left arm and left flank area. Review of the resident's hospital record, dated 07/30/26, showed the following:-History of presenting illness: Trauma. Weapon was a screwdriver;-Injuries: Stab wound to left upper arm x three, stab wound to left back chest, abrasion to right knee, left hemopneumothorax;-Surgery performed, chest tube placed on 07/31/26 and removed on 08/02/26;-discharged back to facility on 08/03/26. Observation on 08/05/26 at 8:15 A.M., showed the resident with a bandage to his/her upper chest and five bandages to his/her abdominal area. During an interview, the resident said Resident #1 was bullying staff and started talking inappropriately to staff. Resident #2 and Resident #1 started arguing and Resident #1 left and came back with a screwdriver and started stabbing Resident #2. He/She was in the hospital for a few days. He/She did not know where Resident #2 got the screwdriver. During an interview on 08/05/26 at 2:12 P.M., Activity Aide (AA) A, said after the incident on 07/30/26, Resident #8 told him/her that he/she told staff that Resident #1 had the screwdriver. Resident #8 said staff did not believe him/her. AA A said he/she reported this information to Licensed Practical Nurse (LPN) B. Review of Resident #8's quarterly MDS, dated [DATE], showed the following:-Moderately cognitively intact;-No behaviors;-Diagnoses include TBI, anxiety disorder, and depression. During an interview on 08/06/26 at 8:30 A.M., the resident said he/she saw Resident #1 with the screwdriver the day before the incident on 07/29/26. He/She yelled out to staff that Resident #1 had the screwdriver. He/She told the charge nurse about the screwdriver, but could not remember the charge nurse's name. During an interview on 08/06/26 at 9:14 A.M., LPN B said he/she was on the ground floor when he/she heard the announcement for the third floor. When he/she arrived at the third floor, Resident #1 was being detained. No one told LPN B about a screwdriver.During an interview on 08/05/26, the Maintenance Director said on 07/29/26, he brought a vendor to the behavioral unit on the third floor. They left the area for a short time, leaving the vendor's tools behind on the unit. It is suspected this is where Resident #1 obtained the screwdriver. Since the Maintenance Director started months ago, he said it was the expectation of the facility for staff to accompany vendors throughout the building and did not specify if there were expectations for vendors to secure their tools while providing services. During an interview on 08/06/26 at approximately 9:40 AM, the Administrator said it was expected for staff to accompany outside vendors throughout the facility. 2. Review of Resident #3's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-No moods or behaviors;-Supervision with ADLs;-Diagnoses included high blood pressure, diabetes, stroke, and schizophrenia (a severe, chronic brain disorder that alters how a person thinks, feels, and acts). Review of the resident's care plan, in use at the time of the survey, showed the following:-Problem: The resident is at risk for injury related to resident-to-resident altercations. He/She was physically assaulted by another resident while using the hallway telephone and responded by striking the other resident in self-defense. The incident places him/her at risk for recurrent altercations, physical injury, emotional distress, and impaired sense of safety within the facility;-Interventions: Assess resident immediately following any altercation for pain, injury, neurological changes, and emotional distress, document findings and notify the provider of significant changes. Continue to monitor him/her for delayed signs or symptoms of injury, including swelling, bruising, pain, or changes in neurological status, and report abnormalities. Provide comfort measures to the resident. Review of the resident's nurse's note, dated 07/27/26 at 7:19 P.M., showed the resident was observed using the telephone in the hallway when another resident approached him/her and began yelling profanities. The other resident then struck this resident. The resident responded by striking the other resident. Nursing staff immediately intervened and separated both residents. The resident was assessed immediately following the altercation. The resident was alert and responsive and denied pain and injury. Head-to-toe assessment revealed no swelling of the left eye at the time of assessment. No acute distress was noted. The resident was reassured and monitored for any delayed signs or symptoms of injury. A cold compress was offered and applied on the area. The resident will continue to be monitored for any change in condition or behavior. During an interview on 08/06/26 at 1:12 P.M., the resident said while he/she was on the telephone, Resident #4 came up and started cursing and hitting him/her, so he/she hit Resident #4 back. The resident said he/she felt safe at the facility. Observation at that time showed no visual bruising. Review of Resident #4's quarterly MDS, dated [DATE], showed the following:-Moderately cognitive intact;-No behaviors;-Supervision with ADLs;-Diagnoses included congestive heart failure, high blood pressure, and stroke. Review of the resident's care plan, in use at the time of the survey, showed the following:-Problem: The resident is at risk for impulsive and physically aggressive behaviors related to impaired judgment, poor impulse control, and behavioral changes secondary to traumatic brain injury;-Interventions: Provide one on one monitoring to ensure protective oversight when necessary. Reduce environmental stimuli when resident appears overstimulated or agitated. Reinforce appropriate behaviors with praise and positive feedback. Review of the resident's nurse's note, dated 07/27/26 at 7:19 P.M., showed the resident was observed seated near the nurse's station with nursing staff. The resident attempted to apply oxygen via a nasal cannula/concentrator that did not belong to him/her. Staff intervened to prevent the use of another resident's oxygen equipment. The resident became increasingly agitated and attempted to grab the nasal cannula from the staff's hands but was unsuccessful. The resident then propelled him/herself rapidly away from the nurse's station in his/her wheelchair. Multiple attempts by the nursing staff to redirect the resident and encourage him/her to slow down were unsuccessful. As the resident rounded the corner, he/she encountered Resident #3, who was using the telephone. The resident began yelling profanities at Resident #3. Per the resident's own statement, he/she struck Resident #3, who then struck the resident in return, causing the resident's wheelchair to tip over. A nursing assessment was completed immediately following the incident. The resident denied pain. The resident refused staff assistance with returning to his/her wheelchair and independently transferred him/herself back into the wheelchair. An assessment revealed swelling to his/her left eye, a small skin tear noted beneath the left eye extending toward the cheek, and bleeding noted from the mouth. The resident remained verbally aggressive toward staff throughout the assessment. The resident requested transfer to the hospital and independently called 911. A partnering nurse also notified emergency medical services per the resident's request. The resident will continue to be monitored pending Emergency Medical Services evaluation and transfer. The resident said Resident #3 is always on the telephone, and he/she hit him/her in the head. During an interview on 08/06/26 at 1:38 P.M., the resident said he/she was fine. Observation at that time showed no visual bruising on the resident. The resident was being monitored by CNA G. At that time, CNA G said the resident had been on one on one for at least three months due to physical behaviors. During an interview on 08/06/26 at 1:09 P.M., Licensed Practical Nurse (LPN) F said another resident has a nasal cannula, and the resident tried to put it on. The resident rolled away. Resident #3 was on the telephone with his/her family, and the resident went up and hit him/her in the head. Resident #3 hit him/her back and the resident's wheelchair flipped over. The resident did not have one on one monitoring at the time of the incident, but there were staff around. The resident is on one on one because he/she tries to fight everyone. During an interview on 08/07/26 at 12:00 P.M., the DON said Resident #4 is on one on one for aggression towards others. The DON said a resident on one on one should have a dedicated person with him/her at all times for protective oversight and to prevent abuse. The DON did not know why a dedicated staff member was not with the resident at the time of the altercation with Resident #3. 3. During an interview on 08/07/26 at 12:30 P.M., the Administrator said she expected the facility's to be followed as written. The staff members should have been immediately suspended and escorted out of the building pending an investigation when Resident #11 made an allegation of abuse. This would have prevented other potential alleged abuse. Resident #4 should have had a dedicated staff member for one on one monitoring when the altercation occurred with Resident #3. Resident #4 was supposed to have been on one on one monitoring at that time for ongoing physical aggression. If Resident #4 had been on one on one monitoring, it could have redirected from the altercation. 312362431236373125043 31193423119194

Based on interview and record review, the facility failed to receive authorization from a resident's financial power of attorney to withdraw money from his/her resident trust account (Resident #9). The facility held accounts for 126 residents. The census was 150. Review of the facility's Resident Trust Policy, dated 03/01/17, showed the following:-Purpose: admission Requirements Regarding Resident Trust: Upon admission authorization to hold resident funds must be presented to the resident, guardian, or legal representative and must be signed by them if they choose to have the facility manage the resident funds.-General Information Regarding Responsibilities of Holding Resident Funds: Personal funds of the resident shall be used exclusively for the resident, which must be authorized in writing. The individuals who can authorize such transactions may be the resident, his/her legal guardian, or a legal representative (who may not be an employee at the facility, including the administrator). Review of Resident #9's quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 07/03/26, showed the following:-Cognitively intact;-Mood and verbal behaviors;-Partial/Moderate assistance with activities of daily living;-Diagnoses include: high blood pressure, diabetes, and Alzheimer's Disease. Review of the resident's medical record showed guardianship documentation, dated 11/06/24, naming Family Member (FM) C as Durable Power of Attorney (DPOA) (a legal document that lets you name a trusted person, called your agent, to make financial or medical decisions for you. It stays valid even if you become sick or hurt and cannot make choices on your own) for the resident. Review of the resident's Trust Statement, received on 08/06/26 at 3:51 P.M., showed withdrawals on 07/02/26 and 07/14/26 for purchases of cigarettes. Review of the resident's financial record showed no documentation of authorization from FM C for the withdrawals. During an interview on 08/06/26 at 3:00 P.M., the resident said he/she has not authorized any transactions from his/her resident trust account. During an interview on 08/06/26 at 2:00 P.M., FM C said the resident has dementia and is very confused. He/She is unable to authorize funds to be taken out of his/her account and is unaware that he/she has money in the account. During an interview on 08/07/26 at 10:09 A.M., the Business Office Manager (BOM) said he/she started with the facility on 07/09/26. He/She was not familiar with the resident's transactions. During an interview on 08/07/26 at 10:21 A.M., the administrator said the facility has a list of smokers which the resident is listed. A check is cut to purchase cigarettes for the list of residents. The Administrator said the resident's DPOA is the only person who may authorize to have any funds to be withdrawn from the resident's trust account. The Administrator said the facility's policy should have been followed and an authorization from the DPOA should have been obtained. 3136673

Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the Department of Health and Senior Services (DHSS) not later than 2 hours after the allegation is made, after one resident (Resident #10) made an allegation of being choked and slapped by two employees. The sample was 11. The census was 150. Review of the facility's Abuse and Neglect Policy dated, 06/12/24, showed the following:-Purpose: It is the policy of this facility to report all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and other appropriate agencies in accordance with current state and federal regulations within prescribed time frames. -Definition: --Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology;--Physical Abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Physical abuse also includes corporal punishment, which is physical punishment used as a means to correct or control behavior.-Procedure for Response and Reporting Allegations of Abuse, Neglect and Exploitation: Any owner, operator, employee, manager, agent, or contractor of the facility can report an allegation of abuse, neglect, exploitation to the abuse agency hotline without fear of retaliation. When suspicion of abuse, neglect, exploitation or reports of abuse, neglect, exploitation occur the following procedure will be initiated:--Refer to the State Operations Manual (SOM) for reporting and utilize the Abuse-Neglect Reporting Decision Tree to assess the particular incident. Best practice is to include the SOM and Decision Tree with the investigation. Should the incident be a reportable event, notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the Incident. In the case of serious bodily injury, no later than two hours after discovery or forming the suspicion. Should the event not be reportable continue and complete the investigation with all supporting information and place file with all investigations. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/25/26, showed the following:-Cognitively intact;-No moods or behaviors;-Dependent with activities of daily living;-Diagnoses include quadriplegia (the partial or total loss of use in all four limbs and the torso, usually caused by damage to the cervical spinal cord or brain), seizure disorder, anxiety disorder, and depression. Review of the resident's nurse's notes dated 07/04/26 at 6:30 P.M., showed it was reported by the charge nurse the resident said two Certified Nurse Aides (CNAs) choked and backhanded him/her multiple times in the mouth. The resident reported CNA D choked him/her and CNA E back handed him/her in the face because he/she didn't want to go to bed. A skin assessment was done, physician called and family notified. The Administrator and Director of Nursing (DON) were notified. The two CNAs alleged of abuse removed from floor pending investigation. Review of the facility's investigation, dated 07/04/26, showed no documentation the allegation was reported to the state agency. Review of the state survey agency database showed no self-reports from the facility regarding the allegation involving Resident #11 on 07/04/26. During an interview on 08/07/26 at 12:28 P.M., the Administrator said she expected the facility's policy to be followed, which would include reporting allegations of abuse within the required time frame. She did not know what happened with this situation not being reported to DHSS. A report was sent to the DHSS hotline, but she did not know why the report did not go through. She could not show any documentation the allegation was reported. 3134860

Based on interview and record review, the facility failed to follow their abuse and neglect policy by not immediately suspending two Certified Nurse Aides (CNAs) who were accused of allegedly choking and slapping one resident (Resident #10). The sample was 11. The census was 150. Review of the facility's Abuse and Neglect policy, dated 06/12/24, showed the following:-Purpose: It is the policy of this facility to report all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Definition: --Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology;--Physical Abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Physical abuse also includes corporal punishment, which is physical punishment used as a means to correct or control behavior;-Procedure for Response and Reporting Allegations of Abuse, Neglect and Exploitation: Any owner, operator, employee, manager, agent, or contractor of the facility can report an allegation of abuse, neglect, exploitation to the abuse agency hotline without fear of retaliation. When suspicion of abuse, neglect, exploitation or reports of abuse, neglect, exploitation occur the following procedure will be initiated:--The Licensed Nurse will:---Respond to the needs of the resident and protect him/her from further incident;---Remove the accused employee from the resident care area;--The Administrator or designee will:---Suspend the accused employee pending completion of the investigation. Review of the facility's Intense Monitoring policy, dated 04/30/24, showed the following:-Purpose: To ensure a system is in place for residents who require increased monitoring for crisis, behavioral and psychiatric issues;-Procedure: Residents who require more intensive monitoring due to crisis, behavioral, psychiatric symptoms will be monitored by the facility staff;-Definitions:-One to One: Monitoring a designated employee assigned by a facility supervisor. Residents who require intensive monitoring of one on one will have a dedicated staff member within eyesight.-Intensive Monitoring:Intensive monitoring is provided as periodic (e.g. hourly, every two hours, or every shift) check by a facility staff member;Residents may require more intensive monitoring based on their crisis, behavioral, psychiatric issues. The level of Intensive Monitoring shall be identified by the specific situation or resident assessment;Residents who are showing poor impulse control including crisis, behavioral, psychiatric issues, such as, verbal/physical aggression, elopement ideations, suicidal/homicidal ideations, and decompensation mentally or crisis may be placed on intensive monitoring or one-to-one or two-to-one (within eyesight of staff) monitoring at the discretion of the administrative staff or facility supervisor;Based on the assessment of the resident at the discretion of the administrative staff of Facility Supervisor, either intensive monitoring, one to one or two to one;Residents who require intensive monitoring of one to one will have an assigned employee within eyesight until resident has stabilized or returned to prior level of function. Educated on the reasoning for the intensive monitoring, including triggers and interventions for that specific resident. The employee will interact with the resident throughout to receive therapeutic interventions;The facility's Interdisciplinary Team will address the residents' behavioral concerns and ensure interventions are in place to address the residents' needs (i.e. psychiatry follow up, counseling, medical needs, etc.). Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/25/26, showed the following:-Cognitively intact;-No moods or behaviors;-Dependent with activities of daily living (ADLs);-Diagnoses included quadriplegia (the partial or total loss of use in all four limbs and the torso, usually caused by damage to the cervical spinal cord or brain), seizure disorder, anxiety disorder, and depression. Review of the resident's nurse's note, dated 07/04/26 at 6:30 P.M., showed it was reported by the charge nurse the resident said two CNAs choked and backhanded him/her multiple times in the mouth. The resident reported CNA D choked him/her and CNA E backhanded him/her in the face because he/she didn't want to go to bed. A skin assessment was done, the physician called and the family notified. The Administrator and Director of Nursing (DON) were notified. The two CNAs alleged of abuse were removed from the floor pending investigation. Review of the facility's investigation, dated 07/04/26, showed no documentation CNA D and CNA E were suspended immediately pending investigation. Review of CNA D's and CNA E's timecard for 07/04/26, showed they clocked out at 10:22 P.M. During an interview on 08/06/26 at 10:27 A.M., the DON said she removed the staff members to another floor, but they were not escorted out of the building and suspended pending an investigation. The staff members should have been suspended pending investigation. During an interview on 08/07/26 at 12:30 P.M., the Administrator said she expected the facility's policies to be followed as written. The staff members should have been immediately suspended and escorted out of the building pending an investigation when Resident #11 made an allegation of abuse. This would have prevented other potential alleged abuse. 3134860

Based on observation, interview and record review, the facility did not follow their policy when Resident #161signed out of the facility, did not return, and the facility failed to initiate a Code Purple (missing person) per policy. The resident's guardian did not give permission for the resident to sign him/herself out. Per facility policy, when the resident failed to return to the facility for dinner and evening medications and did not return all night, staff should have initiated a Code Purple. The resident signed out at 3:55 P.M. on 05/08/26 to go outside, with no expected return time listed. Staff found the resident's wheelchair outside and could not locate the resident. Staff did not document attempts to locate the resident from 05/08/26 through 05/11/26 and did not document their communication with law enforcement. Per the resident's hospital records, the resident arrived in the emergency room (ER) on 05/11/26 at 8:20 P.M. and said he/she had been assaulted and was experiencing right ring finger pain and a broken nail. The resident tested positive for marijuana and cocaine. The sample was seven and the census was 145. Review of the facility's Elopement and Wandering Residents policy, revised 06/12/24, showed: -Purpose: The facility ensured residents who exhibited wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care;- Elopement occurred when a resident left the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so;- The facility was equipped with door locks/alarms to help avoid elopements;-Alarms were not a replacement for necessary supervision. Staff were to be vigilant in responding to alarms in a timely manner;-The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary;- Residents were assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team;-The interdisciplinary team evaluated the unique factors contributed to risk and developed a person-centered care plan;-Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards were added to the resident's care plan and communicated to appropriate staff;-Any staff member becoming aware of a missing resident alerted personnel using facility approved protocol;- Code purple meant elopement outside of facility;-The designated facility staff looked for the resident;-If the resident was not located in the building or on the grounds, the Administrator or designee notified the police department and served as the designated liaison between the facility and the police department.- The Director of Nursing (DON) or designee notified the physician and family member or legal representative;-The police were given a description and information about the resident;-All parties where notified of the outcome when the resident was located;-Appropriate reporting requirements to the state agency would be conducted. Review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, dated 06/12/25, showed:-Therapeutic leave meant absences for purposes other than required hospitalization;-If a resident did not return from therapeutic leave as expected, documentation in the medical record should show evidence the facility attempted to contact the resident and resident representative. The facility's sign-out/leave of absence policy was requested during the entrance conference of the investigation on 5/13/26. During an interview on 05/13/26 at 3:19 P.M., the Administrator said they did not have a sign-out/leave of absence policy. Review of Resident #161's Electronic Medical Record (EMR), showed:-admitted [DATE] from a skilled nursing facility;-Cognitively intact;-Diagnoses included diabetes, bipolar disorder (a mental health condition characterized by extreme, shifts in mood, energy, and activity levels), schizophrenia (a chronic brain disorder that cause people to interpret reality abnormally), chronic respiratory failure, personality disorder (mental health condition characterized by rigid, inflexible patterns of thinking, feeling, and behaving), intellectual disabilities (a neurodevelopmental condition characterized by significantly below-average intelligence alongside major deficits in adaptive daily living skills) and muscle weakness. Review of the resident's PASSR Level II evaluation, dated 01/12/26, showed:-The resident's parent was his/her legal guardian and his/her sibling was the co-guardian;-Previous level II completed in 2020 showed an extensive history of psychiatric issues and substance use with numerous hospitalizations. Behaviors included outburst, poor impulse control, periods of increased anxiety and agitation. Displayed inappropriate expression of feelings with ineffective problem solving. He/She engaged in high-risk behaviors and displayed poor decision-making skills with some attention seeking behavior. The resident eloped from the hospital in 2020-The resident's needs could be met at a nursing facility;-The facility provided a behavior support plan, structured environment (provided personal space, gave instructions at the resident's level of understanding and established a consistent routine), and personal support network;-Environmental supports to prevent elopement was blank. Review of the resident's EMR showed no admission paperwork from the transferring nursing home. Review of the resident's EMR showed the resident's admission minimum data set (MDS), a federally mandated assessment completed by facility staff was in progress. Review of the resident's elopement evaluation, dated 05/05/26, showed no identified risk of elopement. Review of the resident sign-out log, dated 05/08/26, showed:-The resident signed out at 3:55 P.M. to go outside;-The resident provided a contact number;-Sign in time was blank. Review of the resident's care plan in use during the survey, showed:-Problem: The resident was noncompliant with the facility sign-out policy. On 05/08/26 left the facility without proper authorization/safety measures (date initiated: 05/08/26);-Interventions: Staff reinforced importance of signing out appropriately, educated the resident on the facility sign-out policy and safety concerns of leaving the facility (date initiated: 05/10/2026). Review of the resident's progress notes, showed:-On 05/09/26 at 12:22 A.M., Licensed Practical Nurse (LPN) F noted the resident signed him/herself out of the facility. Staff were not aware. He/She said he/she was going with his/her boyfriend. The resident left his/her wheelchair in the front of the building. At 12:24 A.M., the resident's power of attorneys (POA) were notified. At 12:52 P.M., LPN A noted the resident did not return to facility on his/her shift. The resident's guardian requested a call every shift with updates on the resident's status;-There was no documentation of attempts to locate the resident, any contact with law enforcement, or updates to the guardian each shift as requested. Review of the resident's care plan in use during the survey, showed:-Problem: The resident had bipolar disorder (date initiated: 05/10/2026);-Interventions: Staff monitored mood, behaviors, sleep patterns, and changes in mental status, observed for signs of depression, mania, agitation, impulsiveness, or anxiety, administered psychotropic medications as ordered and monitored for side effects;-Problem: The resident had diabetes (date initiated: 05/10/26);-Interventions: Staff monitored blood glucose levels as ordered and reported abnormal results to the physician and administered diabetic medications/insulin as prescribed;-Problem: The resident had schizophrenia (date initiated: 05/10/2026);-Interventions: Staff assessed for suicidal ideation, aggression, or self-harm behaviors, administered antipsychotic medications as ordered and monitored for effectiveness and side effects; Review of the resident's medication administration report (MAR), dated May 2026, showed on 05/09/26, 05/10/26 and 05/11/26 all medications were documented with a 1 (absent from home without meds).-Aripiprazole (antipsychotic medication) oral tablet 20 milligrams (mg). Give 1.5 tablet by mouth once a day, at 9:00 A.M. for depression. Staff documented a 1 (absent from home without meds) on 05/09/26, 05/10/26 and 05/11/26;-Spironolactone (used as a potassium-sparing diuretic (water pill)) oral tablet 25 mg. Give one tablet by mouth once a day, at 9:00 A.M. for high blood pressure. Staff documented a one on 05/09/26, 05/10/26 and 05/11/26;-Carbamazepine (used to control certain types of epileptic seizures, manage bipolar disorder, and relieve nerve pain) oral tablet 200 mg. Give one and a half tablet by mouth twice a day, at 9:00 A.M. and 5:00 P.M. for major depressive disorder. Staff documented a one on 05/09/26, 05/10/26 and 05/11/26;-Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated (used as a daily maintenance treatment for asthma and chronic obstructive pulmonary disease (COPD))100-50 micrograms. One inhalation orally twice a day, at 9:00 A.M. and 5:00 P.M. for COPD. Staff documented a one on 05/09/26, 05/10/26 and 05/11/26. Review of the resident's hospital record, dated 05/11/26, showed:-The resident arrived at the ER on [DATE] at 8:20 P.M. via ride share;-The social worker documented Missouri court records showed guardianship was established in 2020;-The resident arrived for right ring finger pain and a broken nail. The resident said he/she was pushed and did not want to talk about it. The resident said he/she left his/her nursing home a few days prior due to safety concerns. He/She was not happy with the care received at the nursing home. He/She stayed with a friend. ER staff contacted the resident's guardian;-The resident's guardian said the resident eloped from the nursing home on [DATE]. He/She was not notified when the resident signed out of the facility. He/She was concerned about the resident's missed medications and for his/her safety. The resident did drugs when he/she was in the streets. The resident solicited people on social media for sexual behaviors. The facility said they were not aware the resident had a guardian and needed to be on a locked unit. The facility said they filed a missing person report with the police department;-The hospital social worker spoke with the resident. The resident confirmed he/she was assaulted. He/She said he/she walked outside at night and did not know where he/she was. He/She was close to the ER because the ride was about five minutes. The resident did not know the perpetrator's name. The resident said Alternatives to Living in Violent Environments (ALIVE) (non-profit organization that provides counseling, emergency sanctuary, and critical support services to adults impacted by domestic and intimate partner violence) provided the ride to the ER;-The hospital contacted the police department because the resident's guardian told them the facility said they filed a missing person's report. They called the police to verify the information. They did not have a missing person report on file. They arrived at the ER and spoke to the resident about the assault allegation. The resident refused to cooperate or answer questions;-The resident's urine drug screen was positive for marijuana and cocaine;-X-rays of the resident's right hand were negative for new fractures;-Discharge diagnoses were bizarre behavior, schizophrenia and diabetes;-The resident was discharged back to the facility on [DATE] with a new order for placement on secured unit. Review of the resident's progress notes, showed:-On 05/12/26 at 9:21 P.M., the resident was readmitted to the facility from the hospital. The resident's diagnosis was pain in the finger. The resident arrived via ambulance. He/She was alert and oriented. The resident was moved to the secured unit due to elopement risk. Staff initiated location monitoring. The resident's physician and guardian were notified of resident's return. Review of the resident's elopement evaluation, dated 05/12/26 at 9:25 P.M., showed:-The resident had a history of elopement;-The resident did not wander;-A risk for wandering/elopement was identified;-No interventions or clinical suggestions were selected. Review of the resident's care plan in use during the survey, showed no documentation of the resident's elopement risk and interventions. Review of the facility's investigation not dated, showed:-A copy of the resident sign-out log for 05/08/26;-Incident report dated 05/08/26 at 9:00 P.M.;-Incident description: The resident signed him/herself out of facility against facility policy. Unable to give description of resident. The incident was unwitnessed;-Immediate action taken: The resident's physician (05/08/26 at 10:34 P.M.), responsible party (05/08/26 at 10:35 P.M.), and police (no time or date noted) were notified;-Predisposing physiological signs: Non-compliance;-A handwritten note (not dated or signed) read the administrator said she informed the resident's physician he/she signed out. The physician said the resident would be okay;-No summary, staff statements, in-services or conclusion were included in the incident report. Observation on 05/14/26 at 10:01 A.M., showed the resident propelled throughout the secured unit. He/She refused to answer any questions. During an interview on 05/14/26 at 12:05 P.M., LPN A said he/she worked on the first floor from 7:00 A.M. to 3:00 P.M. on 05/08/26 and 05/09/26. He/She was notified on 05/09/26 the resident signed out on 05/08/26 and did not return. LPN F told him/her the resident's guardian was notified, and all protocols were followed. If the resident had returned during his/her shift, he/she would have documented it. If a resident does not return by midnight, staff should notify the responsible party, DON and Administrator. He/She did not know what determined if law enforcement should be called. Residents with guardians had to have permission to sign out. They could go to appointments or sit outside with a staff escort. All residents had to stop at the front desk to sign out. The receptionist was supposed to get report before allowing a resident to sign out. During an interview on 05/14/26 at 12:23 P.M., Certified Nursing Assistant (CNA) B said he/she usually worked the day shift, on the first floor. He/She worked the day shift on 05/08/26 and evening shift on 05/09/26. He/She was assigned to the resident both days. Staff were supposed to do rounds every one to two hours. On 05/08/26, he/she saw the resident earlier in the day. At 2:45 P.M., he/she told the nurse the resident went downstairs and did not return to the floor. He/She did not see the resident around dinner time. LPN F looked for the resident. LPN F said he/she would check the sign-out log. CNA B told LPN F the resident had a guardian. Staff searched inside and outside the building. They could not locate the resident. He/She was not sure what LPN F did after they could not locate the resident. CNA B continued to assist other residents. He/She did not see the resident on 05/09/26. Residents were supposed to return to the facility by 10:00 P.M. If a resident did not return from leave of absence (LOA), he/she notified the nurse and followed their direction. During an interview on 05/14/26 at 12:58 P.M., Receptionist E said he/she was the receptionist for a month. He/She usually worked from 7:00 A.M. to 3:00 P.M. Another receptionist worked from 3:00 P.M. to 7:00 P.M. The other receptionist was out sick. They also had receptionists that worked as needed. He/She was not at work when the resident signed out and did not return. He/She was told the resident could leave as long as he/she signed out. He/She did not remember who said the resident could sign out. The residents could not leave after 8:00 P.M. There was always someone at the front desk. The front door was always locked. Someone had to let the residents in and out. There was not a list at the front desk to show which residents had a guardian. He/She asked the Administrator or medical records clerk if the residents could sign out. During an interview on 05/15/26 at 9:27 A.M., LPN F said the resident signed out to go outside on 05/08/26. The resident told the receptionist he/she was his/her own responsible party. The resident was gone for a long time. He/She did rounds at 11:30 P.M. Residents were supposed to return to the facility by midnight. The resident did not return. He/She looked for the resident inside the facility. He/She called the resident's guardian at 11:00 P.M. or 11:30 P.M. on 05/08/26. He/She notified the DON, Administrator and physician when he/she realized the resident was not allowed to sign out. He/She was instructed to call the police. The police arrived and took LPN F's information. The police gave him/her a police report number. He/She tried to contact the resident. The number the resident provided did not work. He/She did not have a car and could not go look for the resident. LPN F arrived for his/her shift on 05/09/26 and was informed the resident still had not returned to the facility. The Administrator said the resident signed out against medical advice and it was not elopement. LPN F was told a man picked the resident up. He/She did not know the resident had a guardian until he/she eloped. He/She had never worked with the resident before. The facility did not provide information on new admits. The facility did not tell staff assigned to the first floor which residents had a guardian. He/She assumed if the resident was on the first floor they did not have to have permission to sign out. He/She should have documented all this information. During an interview on 05/14/26 at 12:41 P.M., Certified Medication Technician D said he/she worked from 11:00 P.M. to 7:00 A.M. on 05/08/26. He/She was assigned to the resident. He/She did face checks at the start of his/her shift. The nurse said the resident signed out and did not return. The resident did not return during his/her shift. He/She did not know if staff searched for the resident. He/She did not know when residents were supposed to return from LOA. He/She would notify a nurse if a resident did not return from LOA. He/She did not know what the resident sign-out policy was. CNAs did not know which residents had a guardian until notified by the nurse. During an interview on 05/14/26 at 12:34 P.M., CNA C said he/she worked from 3:00 P.M. to 11:00 P.M. on 05/09/26. He/She was assigned to the resident. He/She was not aware the resident signed out and did not return. If a resident did not return from LOA, he/she notified the nurse. The residents were supposed to return to the facility by 6:00 P.M. Staff were supposed to get permission from the guardian before the resident signed out. During an interview on 05/19/26 at 10:15 A.M, Registered Nurse G said he/she spoke with the hospital social worker on 05/11/26. He/She did not document the conversation with the social worker. He/She heard the resident left with a man in a pickup truck. The resident told him/her about rating men on dating apps. The resident said the men were going to take him/her to dinner. He/She did not report the information. He/She could not remember what happened two weeks ago. He/She was not sure what time residents were supposed to return to the facility. He/She thought it might be midnight. When residents did not return from LOA, staff notified the guardian and police. The first floor was not a locked unit. The residents did not have to have permission to sign out. During an interview on 05/14/26 at 1:05 P.M., the Assistant DON said she was off from 05/07/26 to 05/10/26. She was notified of the incident upon her return. When a resident was transferred from another facility they were supposed to get paperwork from the other facility. Sometimes facilities did not send the paperwork. Staff were supposed to request the information from the transfer facility. If a resident had a guardian, it was documented on their face sheet and in their EMR. Someone from corporate was responsible for referrals and updating the resident's EMR. The resident's guardian had to give the resident permission to sign out. Staff found out residents were off the unit when they did rounds. There was an elopement risk binder and a guardian list at the front desk. The receptionist was supposed to ask the nurse before he/she allowed a resident to sign-out. If a resident did not return from LOA, she notified the physician and guardian. She would get addresses from the guardian, go through the chain of command and notify the Department of Health and Senior Services. During an interview on 05/14/26 at 1:19 P.M., the DON said she had been the interim DON since February 2026. She was aware the resident had a guardian. Staff were supposed to ask the guardian if the resident could sign him/herself out of the facility. She did not know if the resident's guardian gave him/her permission to sign-out. The resident signed out to go outside, then left the premises. LPN F notified her the resident was missing on 05/08/26 around 6:00 P.M. She told LPN F to do a head count, search the facility, notify the guardian and physician and call the police to file a report. The number the resident listed on the sign out sheet was not a working number. She did not have the police report number and could request it. The Administrator completed an investigation. All this information should have been documented in the resident's record. During an interview on 05/13/26 at 3:19 P.M., the Administrator said the resident was on the first floor. He/She did not elope. He/She signed out against medical advice. He/She told staff no one was going to stop him/her. Someone picked him/her up. He/She was a new admit. Staff did not know where to look for him/her. Staff contacted the resident's guardian and physician when he/she signed out. It should have been documented. When the resident did not return, staff notified the resident's guardian, physician and police. The facility did not file a missing person report. There was no indication the resident needed to be on a secure unit. The resident had a right to leave. 3011033 3011434

Based on observation, interview and record review, the facility failed to ensure allegations involving abuse were reported within the required two-hour time frame, following a resident-to resident altercation, resulting in an injury (Resident #131). The sample size was 15. The census was 149. Review of the facility's Abuse and Neglect Policy, revised 6/12/2024, showed:-It is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of Resident #131's quarterly MDS (Minimum Data Set, a federally mandated resident assessment instrument), dated 4/6/26, showed:-The resident is cognitively intact;-Medical diagnoses including dyskinesia (a movement disorder characterized by involuntary, erratic, and uncontrollable muscle movements like writhing, fidgeting, or head bobbing), tinea unguium (onychomycosis, a contagious fungal infection of the nail bed, typically caused by dermatophytes, leading to thickened, yellowed, brittle, or crumbling nails), and schizophrenia (a chronic, severe brain disorder affecting thinking, emotions, and behavior, often involving hallucinations, delusions, and disorganized speech). Review of the resident's progress notes, showed:-A note from 4/27/26 at 1:00 A.M. indicating the nurse on the floor had noted the resident to be at the door of his/her room calling for help from the nurse. A large amount of blood was coming from two lacerations to the resident's forehead, who reported the resident's roommate hit him/her with a trashcan. The residents were separated by staff, and both were sent to the hospital for evaluation;-A note from 4/27/26 at 7:58 A.M. indicating the resident had returned from the hospital for evaluation with dissolvable stitches to both forehead lacerations. Review of the facility's submitted report of the incident, showed the report was submitted on 4/27/26 at 2:01 P.M. Review of the facility's Incidents and Accidents report, dated 4/21/26 through 4/28/26, showed the incident between Resident #131 and the other resident listed as occurring on 4/27/26 at 1:15 A.M. During an observation and interview on 4/28/26 at 9:21 A.M., the resident said on the evening of 4/26/26, a resident attacked him/her while asleep in bed. The resident woke up to the resident screaming and swinging at him/her with a trash can. Resident #131 was struck at least twice with the trash can before he/she was able to leave the room and contact staff for help. Staff immediately separated the residents and provided emergency treatment to two lacerations to the resident's head. During observations, two lacerations, each measuring approximately four inches long, were noted to the resident's forehead with stitches in place to both lacerations. During an interview on 4/28/26 at 10:53 A.M., the Administrator said the incident was reported to her when it occurred early in the morning on 4/27/26 around 1:00 A.M. The Administrator said she had fallen back asleep after receiving the call and missed the two-hour reporting timeframe. The Administrator expected all allegations of abuse resulting in injury to be reported to Department of Health and Senior Services DHSS as required by state and federal regulations. 29957632994684

Based on observation, interview and record review, the facility failed to provide behavioral health care services to address one resident's (Resident #84) known history of self-harming behavior. The facility failed to develop and implement care plan interventions related to the self-injurious behaviors, failed to develop a safety plan for the resident, and to timely refer the resident to psychiatric services, resulting in self-mutilating behaviors of biting off his/her fingers when he/she became frustrated or angry. The facility also failed to address one resident's aggressive behavior and pulling the facility fire alarm multiple times. (Resident #39) The sample was 33. The census was 149. The Administrator was notified on 4/23/26 at 10:06 A.M, of an immediate jeopardy (IJ) which began on 4/21/26. The IJ was removed on 4/23/26 as confirmed by surveyor on-site verification. Review of the facility's Behavioral Emergency Policy, last revised 9/23/25, showed:-Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not coerced, punished, or disciplined for staff convenience;-Principles: As part of this commitment, leadership explicitly adopts the following principles and values regarding physical holds and the administration of medication: -Use of physical holds and administration of medication is seen as safety intervention of last resort, rather than a treatment interventions per se, and its usage should be a crisis event; -An organization's philosophy of giving the highest priority to all non-violence is to be articulated in all policies, procedures, and practices; -Practices that are sensitive to those with a history of trauma are to be in place; -Key models are to be identified that support a culture of individual empowerment and recovery that is supportive, compassionate, and non-punitive; -An environment of care is to be created that is welcoming, attractive, and as adaptable as possible;-Interventions: -Non-Physical and Proactive: It is the policy of the facility to provide a safe environment and provide humane care to all residents. Non-Physical interventions are the first choice as an intervention unless safety issues demand immediate physical intervention. The facility's approved early interventions crisis prevention techniques will be used to de-escalate conflict when possible. Care will be guided by residents' plan of care and based on the strategies taught by Crisis Prevention Institute non-violent crisis intervention, or the current company guidance, and will help to respond to difficult behaviors in the safest and most effective way possible. Proactive management for our residents is the best plan. All staff should recognize when the resident has become or can become a danger to themselves or someone else. De-escalation techniques shul be utilized as first resort;-Steps for crisis intervention: -Should the resident exhibit extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident to resident altercations which did not respond to the non-violent crisis intervention, the following steps will occur: -The licensed nursing staff and or nursing administration will assess the resident who is displaying signs of crisis, ensuring that safety of the resident and other is the priority. Monitoring of the resident will be initiated, if appropriate; -The facility's Administrative Team will assess to see if the resident's need can continue to be met safely or when the resident continues to be appropriate for placement at the facility; -The facility will notify the physician or psychiatrist of the behaviors emergency. Should the resident require additional hospitalization, coordination of care will occur with the physician and or psychiatrist with receiving hospital to ensure transfer of patient specifics. The guardian, family, or responsible part will be notified of the situation, including current status, hospitalization or other specifics, if applicable; -If the resident is unable to be redirected or is personally requesting a as needed (PRN) medication for mood stabilization, the resident will be given PRN medication per physician orders; If the resident receives an oral, intramuscular mood stabilizing medication, the licensed nurse will document the administration and effectiveness; -The licensed nurse will document the behavioral emergency in the medical record; -The licensed nurse is responsible for notify the administration, physician, and or psychiatrist, an responsible party; -The licensed nurse will document the behavioral emergency in the medical record; -The interdisciplinary team will ensure the care plan is updated if appropriate; -The administrative team will review the in incident to determine root cause and review the situation for contributing factors, Reviewing staff responses and documentation to ensure that the situation is reflected clearly; -Each of the residents who have an increased potential for aggressive behavior toward self or other or show a a history of harm to self or other will have an assessment completed upon admission or prior to the use of approved hold techniques; -The Psychosocial post incident impact questionnaire will be completed during the admission process, and as needed; -Persons providing staff training must be qualified as evidenced by education, training, and experience in techniques used to address individual's behaviors;-Post-Incident:A post incident review with staff members involved shall take place following the procedure tin order to determine: -Any improvements that could be made to reduce the likelihood of reapplication; -Any improvements in the procedure that could have made the event less traumatic; -Assess any trauma reaction on the part of the staff; -Identify what led to the incident and what could be done differently; Root cause determination; -Ascertain that the individual's physical well-being, psychological comfort and right to privacy were addressed; -If identified, offer supportive services for the residents; -The team shall review modifications to the treatment plan made during the crisis and develop a plan;-At regular intervals the facility will review incidents to obtain root cause analysis which will facilitate improvements of care management and further prevention of incidents. Review of the facility's Intensive Monitoring policy, last revised, 4/30/24, showed:-Purpose: To ensure a system is in place for residents who require increased monitoring for crisis, behavioral, and psychiatric issues;-Procedure: Resident who require more intensive monitoring due to crisis, behavioral/psychiatric symptoms will be monitored by the facility staff;-Definitions: -Intensive monitoring is defined as periodic (hourly, every Two hours, or ever shift) check by a facility staff member; -One to one monitoring a designated employee assigned by a facility supervisor. Residents who require intensive monitoring of one to one will have a dedicated staff member within eyesight;-Intensive monitoring: -Residents may require more intensive monitoring based on their crisis, behavioral, psychiatric issues; The level of intensive monitoring shall be identified b the specific situation or resident assessment; -Residents who are showing poor impulse control including crisis, behavioral, psychiatric issue, such as, verbal/ physical aggression, elopement ideations, suicidal/homicidal ideations, and decompensation mentally or crisis may be placed on intensive monitoring o on-to one or two to one (within eyesight of staff) monitoring at the discretion of the administrative staff or facility supervisor; -Based on the assessment of the resident at the discretion of the administrative staff of facility supervisor, either intensive monitoring, one to one or two to one; -Residents who require intensive monitoring of one to one will have an assigned employee within eyesight until the resident has stabilized or returned to prior level of function. Educated on the reasoning for the intensive monitoring, including trigger and interventions for that specific resident; The employee will interact with the resident throughout to receive therapeutic interventions; -The facility's interdisciplinary team will address the residents' behavioral concerns and ensure interventions are in place to address the residents' needs (psychiatry follow up, counseling, medical needs, etc) -Once the resident has stabilized and/or returned to prior level of function, the facility's interdisciplinary team will meet to discuss determination of discontinuations of intensive monitoring; -The facility staff will document the intensive monitoring in the resident's electronic medical record (EMR). 1.Review of Resident #84's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/25/26, showed:-Cognitively intact;-Behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds): Behavior of this type occurred one to three days;-Impact on the resident: Does the behavioral symptoms put the resident at significant risk for physical injury: Yes; Does any of the behavioral symptoms significantly interfere with the resident's care: Yes.-Diagnosis includes quadriplegia (partial or complete loss of sensation and movement in all four limbs), neurogenic bladder (inability to urinate on own), depression, and anxiety. Review of the resident's Preadmission Screening and Resident Review (PASSR) , updated 1/30/26, showed:-Prior PASSAR evaluation completed on 04/08/2020. The resident was hospitalized at that time. Resident admitted after he/she bit his/her right index finger to the point that the bone fractured. He/She had been discharged from the hospital on 3/23/2020, then returned to the hospital due to persistent hand pain. Diagnosed with bite wound infection and recurrent urinary tract infection (UTI). Required intravenous (IV) antibiotics for treatment. He/She again developed a wound on his/her index finger, due to biting himself/herself. Requires wound care for this issue. Totally dependent on others for all aspects of personal hygiene and activities of life (AOL). Per nursing facility staff report, the resident has been difficult to deal with due to verbally abusive behaviors. Resident is quadriplegic and is unable to behave in a physically aggressive manner. Frequently hostile to staff, is described as rude and displays a sense of entitlement. Can be very demanding of staff. Requires wound care to his/her index finger and right middle finger. Staff reported he/she will be provided with mental health follow-up as soon as he/she can be worked into the schedule. The resident wants to go to each smoke break. Becomes angry and agitated if this does not occur. Staff reported he/she wants to go back to living with his/her father and does not plan to remain at the nursing facility on a long-term basis;-Psychiatric assessment: Per nursing facility staff report, they are not aware of the resident making any threats to harm himself/herself. Does inflict self-harm by biting his/her middle or index finger on a routine basis. Resident's needs could be met at the nursing home. Review of the resident's care plan showed no listed interventions for self-injury behaviors in January or February 2026. Review of the resident's physician order sheets (POS), dated 04/19/26, showed:-An order dated 01/12/26, may have psychiatric services as needed;-No order for behavioral monitoring. Review of the resident progress notes showed:-On 01/12/26 at 6:46 P.M, the resident was admitted to the facility, skin intact, no complaint of pain or discomfort at this time;-On 01/15/26 at 11:11A.M., blood was noted all over the resident's bed and his/her mouth. The right-hand middle finger was bleeding and missing multiple layers of skin. Pressure applied to the finger. The Certified Nursing Assistant (CNA) was assisting the resident with getting cleaned up, and the CNA witnessed the resident biting his/her finger. The resident did not verbalize why he/she was biting his/her finger. The resident's finger was dressed, and the physician was notified and gave antibiotic orders; At 11:40 A.M., the physician called back and gave order to send the resident to the hospital for self-inflicted wound;-On 01/15/26 at 8:06 P.M., the resident returned from the hospital with new orders for antibiotics. The resident was placed in chair near the nurses' station;-On 01/17/26 at 5:00 A.M, Wound Care Note: The resident is new to wound care services, injury to right middle finger due to resident biting finger due to being frustrated;-On 01/31/26 at 6:21 A.M., the resident remains verbally abusive to staff and cursing at staff. Encouraged resident to stop, but the resident acted as though he/she did not hear the nurse; Redirection unsuccessful;-On 02/16/26 at 1:13 P.M., the resident wound to right hand has opened up due to biting it. The resident was sent to the hospital.-On 02/16/26 at 8:15 P.M., (late entry) Wound Care Note: The resident's right hand middle finger has now developed a large fissure and open laceration to the bone, the finger feels unstable and barely attached; The resident was sent to the hospital;-On 02/24/26 at 6:55 P.M., the resident returned from the hospital. Resident's second finger on right hand unwrapped, finger intact, bruising, scabbing and open areas noted; -On 02/25/26 at 8:10 P.M., Wound Care Note: the resident was seen for laceration for right finger; The wound has improved no visible fissure, scabs noted, color looks good;-On 03/02/26 at 9:20 A.M., the resident was sent to the hospital for biting his/her finger causing it to bleed uncontrollably; The resident said he/she bit his/her finger so that he/she could smoke a cigarette; The resident was sent to the hospital;-On 3/02/26 at 4:26 P.M., the resident returned from the hospital, the resident denied pain and is sitting near the nurse's station;-On 03/04/26 at 10:11 A.M., the resident was sent to the hospital due to the resident biting his/her right-hand finger and bone is exposed. The resident said he/she will continue to bite his/her finger until it falls off. The resident is on 15-minute checks until the ambulance arrives;-On 03/05/26 at 7:18 A.M., the resident was observed biting his/her fingers causing a laceration. The resident said he/she was hungry and did not eat at the hospital. Treatment was completed. Tylenol was administered. Staff will continue to monitor for protective oversight; Review of the resident's care plan, last updated 03/06/26, showed-Focus: The resident is at risk for the following symptoms related to the diagnosis of anxiety, cursing, hollering, leg shaking, moving around in or frequently getting up and down from the chair, nail biting, nervousness, pacing on the unit, restlessness, shaky voice, sweating and toe tapping; -Desired outcome: The resident will have decreased sign and symptoms related to anxiety through next review date;-Interventions: Be aware of your body stance and facial expressions when you approach me; Closely watch the resident for signs of anxiety and act before I lose control; Do not argue or tell me that they are wrong when I am upset; Do not get into a power struggle with the resident; Don't get to close and remember personal space; Offer activities to keep me from getting bored and provide an opportunity to release energy in a healthy way; Offer non-invasive coping mechanisms first to try to reduce anxiety level; Assist with finding the cause of the anxiety;-Focus: At the time of Preadmission Screening and Resident Review (PASRR), a federally mandated requiring that all individuals applying to or living in nursing facilities are screened for serious mental illness, the resident is deemed safe for admission to the skilled facility;-Desired outcome: The resident will remain safe in the facility;-Interventions: Daily living skill training; Develop personal support network; Implement activities of daily living programs; Medically related social services; Pharmacy services; Physician services; Provisions of a structured environment; The resident will be in the least restrictive environment while maintaining protective oversight; Structured socialization;-Focus: The resident is at risk for self-directed violence;-Interventions: Assess suicidal/self-harm thoughts, intent, plan, and means; Collaborate with resident to develop a written safety plan; Encourage the resident to adhere to prescribed medication; Encourage the resident to identify trigger and early warning signs of self-harm urges; Encourage verbal expression of feelings through open ended questions; Establish a therapeutic rapport, use active listening and non-judgmental communication; Maintain a safe environment by removing sharp objects, belts, cords, and toxic substances; Promote physical activities as tolerated; Refer to therapy and psychiatric services as appropriate; Reinforce and praise adaptive coping behaviors; Teach and praise the adaptive coping behaviors; teach and practice alternative coping skills (deep breathing, call a friend, mindfulness and journaling). Review of the resident's, electronic medical record (EMR), dated 4/22/26, showed no safety plan in place or specific interventions identified related to the resident's behaviors of biting him/herself. Review of the resident progress notes showed:-On 03/08/26 at 7:32 P0.M., the resident cursed at a CNA. The resident was upset that the CNA propelled another resident into the dining room before him/her. The resident was informed that name calling was not appropriate. The resident continued to curse;-On 03/11/26 at 8:23 P.M., Wound Care Note: The resident was seen today for laceration to right hand middle finger. Part of the affected finger removed with the dressing change. The resident was sent to the hospital.-On 03/17/26 at 6:39 P.M., the resident returned from the hospital and cursed at staff and wanted to go home. Resident's family member called; Will monitor; Review of the residents' Psychiatry Nurse Practitioner (NP) QQ notes, dated 03/17/26, showed:This is an initial encounter. Patient is noted to be anxious, irritable, withdrawn, avoiding eye contact, and not forthcoming in responding to most assessment questions. He/She is alert person, place and time, currently sitting in his wheelchair. The resident has a history of spinal cord injury with paralysis since 2007. Chart reviews note a history of depression and anxiety, however, he/she refused to discuss his/her psychiatric history during the encounter. Chart review indicates a history of verbal aggression as well as self-harm, including biting his/her finger in the past to the point of fracturing a bone. He/She reportedly becomes irritable and angry with staff related to his significant physical limitations. He/She cannot engage physically. The resident remained focused on wanting to get out of here and get downstairs. He/She appears well cared for, and there were no reports or observations of psychotic symptoms. Chart has been reviewed.Assessment overview: All relevant and available laboratory results have been reviewed, and the patient's medication list has been reconciled. Staff are to contact me with any significant behavioral or emotional concerns, as well as with any questions regarding psychotropic (medications that stabilize mood). Will follow up with the patient on a routine basis;Plan of treatment overview: Staff to monitor any self-harm behaviors and report any concerns promptly. Review of the resident progress notes showed:-On 03/18/26 at 9:19 AM., Wound Care Note: The resident was not seen due to surgical dressing is not to be removed until follow up visit with outside physician;-On 04/15/26 at 8:28 P.M., the resident was seen for right hand finger laceration. The finger has been fully amputated and is fully healed;-On 04/16/26 at 7:39 P.M., the resident bit his/her hand causing excessive bleeding; The resident was sent to the hospital;-On 04/21/26 at 5:10 P.M., the resident arrived back to the facility: the resident is able to make needs known; The resident denies any pain or discomfort: Orders verified by the physician; Plan of care ongoing;-On 04/22/26 at 1:31 P.M., new skin issue right hand fifth digit (pinky finger). The resident was sent to the hospital;-On 04/22/26 at 4:59 P.M., the resident returned to the facility. The resident can make needs known. The physician was notified, and all orders were verified; The resident is agitated and has chronic behaviors to hurt self or others; The resident is chronically disruptive and refuses care.-No documentation of behavioral interventions in place;-No documentation that psychiatry was notified of the resident's ongoing self-harming behaviors;-No documentation that the resident's primary care physician was notified of the resident's ongoing self-harming behaviors. Review of the resident's record showed no further psychiatry notes from the resident's Psychiatry Nurse Practitioner after 3/17/26. Review of the hospital psychiatrist's note dated, 04/21/26 at 6:43 A.M. showed:-Psychiatric diagnoses: Delirium (sudden onset of confusion) resolving and anti-social personality disorder (ASPD, a mental health condition defined by a long-term pattern of manipulation, exploiting, or violating the rights of others).-Additional associated complications: Agitation, violence, self-injurious behavior, impulse control problems, and poor insight and judgement.- Plan: Continuous 1:1 observation indicated: Yes. The resident is at risk of harm to self if not placed on 1:1 observation. During an interview on 04/19/26 at 8:06 P.M., Hospital Registered Nurse (RN) LL said during the 04/16/26 hospitalization, the resident was in wrist restraints, had a sitter and a camera monitoring system was in the hospital room. The resident was hallucinating and trying to bite his/her right hand dressing off. The resident was admitted to the hospital because he/she had completely bit off his/her right ring finger and it could not be reattached. During an interview on 04/22/26 at 1:05 P.M., CNA H said the resident was admitted on evening shift on 4/21/26. The resident was cursing at the ambulance drivers and having a fit on arrival to his/her room. CNA H went to the kitchen and made the resident a peanut butter and jelly sandwich. The resident was happy at that time. CNA H would check on the resident every 15 minutes and keep the resident's door open until he/she left at 11:00 P.M. The resident remained in his/her room alone during the evening shift. The resident started biting his/her right hand and removing the surgical wrap with his/her teeth. CNA H attempted to stop the resident from biting his/her hand. CNA H said he/she told LPN I about the residents' behaviors. The resident should have been on 1:1 a long time ago. The resident has always had behaviors of self-mutilation and yelling at staff. During an interview on 04/22/26 at approximately 4:00 P.M., Licensed Practical Nurse (LPN) I said he/she worked on 04/21/26, evening shift and night shift. The resident returned from the hospital prior to her getting to the facility. He/She was already at the facility. LPN I saw the resident around 3:00 or 4:00 P.M. at the start of the shift. The resident seemed okay in his/her room. The resident voiced no complaints or concerns at that time. The resident had some verbal outbursts, but that was normal. LPN I did not receive report and did not know who received report from the hospital. The resident was always yelling out. He/She had an ace bandage on his/her hand, but LPN I could not remember which hand, but though it was the right. The resident was not on any enhanced monitoring or 1:1. LPN I was not told the resident was to be on 1:1. No one was assigned to do those. No aides reported any behavior, and night shift got the resident up. LPN I was not aware the resident was starting to bite bandages off of his/her hand. No one reported any behavior or anything. LPN I left after his/her shift at 8:00 AM. on 4/22/26. The resident was sitting in his/her chair, waiting for the dining room to open. The resident was not doing anything out of the ordinary, just talking to people as they go by. LPN I did not look at the resident's right hand bandage at the end of his/her shift. LPN I was aware the resident had self -harm behaviors. If LPN I saw the resident chewing on his/her fingers, he/she would have sent him/her to the hospital. During an interview on 04/22/26 at 12:07 P.M. and 12:17 P.M., the Restorative Aide (RA) V said the resident was out on the patio on 4/22/26 at approximately 9:30 A.M. RA V had to go downstairs and get a smoking apron and an ashtray in order for the resident to smoke. By the time RA V got back with the smoking apron and ashtray, the resident had bit his/her finger off. Activities Aide PP was with the resident, supervising the smoking break. RA V was not aware of any interventions for the resident's self -harm behaviors. RA V was aware the resident had bit his/her fingers off before. RA V was not informed of any 1:1 monitoring for the resident. Everyone in the building knew about the resident's behaviors. The resident did not participate in activities. During an interview 04/22/26 at 12:17 P.M., CNA A said the resident was out on the patio at about 9:30 A.M. on 4/22/26, and he/she started to yell because he/she wanted to smoke immediately. Certified Medicine Technician (CMT) F brought the resident in from the patio because the resident was being disruptive and upsetting the other residents located on the patio. CNA A was not aware of any 1:1 intervention for the resident. During an interview on 04/22/26 at 12:45 A.M. Activities Aide (AA) PP said he/she did not witness the resident bite his/her finger off. AA PP said he/she was out with the residents on the patio for a smoke break at approximately 9:30 A.M. The resident was cursing because he/she wasn't getting his/her cigarette lit fast enough. CMT F removed the resident from the patio because he/she was disruptive and placed him/her in the hall near the patio door. AA PP spoke with CMT F briefly about what they were going to eat for lunch. When CMT F went back inside the resident had bit his/her finger off. AA PP was aware the resident bit off his/her fingers off in the past. The resident had behaviors all the time, like calling staff racial slurs and that he/she was going to rape their children, especially if the resident did not get his/her way. AA PP was not aware of any special interventions for the resident. The residents did not participate in any activities. AA PP would see the resident sitting in the hall sometimes. During an interview on 04/22/26 at 12:58 P.M., CMT F said he/she heard the resident yelling and cursing on the patio on 4/22/26 while he/she was passing medication. CMT F brought the resident out from the patio and there was no blood on the resident at that time. CMT F placed the resident in the hall near the patio door. CMT F went back out on the patio to speak with Activities Aide PP, and when he/she walked back in to assist the resident back to his/her room, the resident had bit his/her pinky finger off and it was laying on the floor. CMT F said it was less than two minutes he/she left the resident unattended. CMT F was not aware of any 1:1 intervention for the resident. During interviews on 04/22/26 at 5:41 P.M., and on 04/24/26 at 12:10 P.M., LPN E said he/she knew the resident was taken to the patio to smoke and then he/she was notified by CMT F that the resident had bit his/her pinky finger off and it was laying on the floor. That was the first time LPN E observed the resident harming him/herself. The only intervention that LPN E knew about the resident's behaviors was to send the resident to the hospital. LPN E said staff should be documenting every shift that the resident is having ongoing behaviors. Staff should also notify the psychiatrist and primary care physician of the resident's ongoing behaviors. Staff should also notify the DON and the Administrator of resident behaviors. The Psychiatric NP comes in once a week or more frequently if the staff call him/her. During an interview on 04/19/26 at 10:30 A.M., CNA KK and CNA MM said the resident always chewed on his/her dressing and fingers on his/her right hand. The resident could move his/her arms and neck to where he/she could reach his/her right hand. The resident constantly yelled and cussed at staff. The resident would also hit him/herself in the head. The resident would mainly be upset about smoke breaks and wanted to go out when it wasn't the designated smoke time. The resident has never been on 1:1 or 15-minute checks. The resident would request to sit in the hall near the nurses' station. CNA KK and CNA MM said the resident was difficult to care for and they didn't really know how to deal with the resident. Everyone in the building knew about his/her behavior. CNA KK and CNA MM were not aware of any special interventions that were in place for the resident. During an interview on 04/20/26 at 7:55 A.M., CNA OO said the resident would be left alone in his/her room and be heard yelling and cursing from the hall. The resident's bed was against the wall and the resident would bang on the wall. The resident was always upset, and he/she wanted to smoke all the time. If you told the resident it wasn't time to smoke, he/she would get even madder. The resident was difficult to communicate with, and CNA OO would try to verbally calm the resident down. CNA OO always told the nurses about his/her behaviors and was not aware of interventions in place that kept him/her from biting his/her fingers. During an interview on 04/20/26 at approximately 12:00 P.M., the Social Service Director said she did not know the resident well and had only been working at the facility for about one month. During an interview on 04/20/26 at 12:33 P.M., Wound Nurse NN said it was reported that the resident always was chewing his/her right hand dressing off. The resident was admitted without an index finger to his/her right hand. The resident was frequently left alone in his/her room when he/she visited the resident. Wound Nurse NN was not aware of any special intervention for staff to monitor the resident. The resident was always heard yelling and cursing from his/her room. During an interview on 04/20/26 at 2:45 P.M., CNA JJ said the resident could raise his/her arms and chew on the dressings that were on the right hand. The resident had frequent outbursts. The resident would get mad if there were no cheese on his/her eggs, and he/she would strike his/her head with his/ her arms and start cursing at the staff. Everyone knew about the resident's behavior. CNA JJ would have the resident sit in the hall near the nurses' station. If CNA JJ saw the resident bite his/her hand or try to hit him/herself in the head, CNA JJ would try to intervene and stop the resident. There were no special interventions in place for the resident's self-mutilation. The resident was not on 1:1 or frequent checks. During an interview on 04/21/26 at 5:25 A.M., LPN I said he/she was aware the resident had bit his/her fingers previously. Nursing staff should document all behaviors that the residents have, and notify the psychiatrist and primary physician of ongoing behaviors. LPN I was aware he/she did not have very good documentation of the resident's behaviors. The resident needed stronger medication to stabilize his/her moods. LPN I did not reach out to the psychiatrist when the resident had his/her outbursts because the resident was always difficult to deal with, and his/her behaviors were nothing new. During an interview on 04/22/26 at 11:42 A.M. the Social Service Designee said when the resident was first admitted to the facility, not much was known about him/her. After a couple of weeks, they had to send him/her out because he/she was nibbling on his/her fingers. When he/she came back, the finger was wrapped. The resident does not like to talk to people. She did not know what the residents' [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure three residents (Residents #100, #49, and #111) were free from resident-to-resident abuse. Resident #1 had a documented history of behavior problems. On 4/14/26, Resident #1 displayed changes in behavior and hit Resident #100. The altercation resulted in injuries to Resident #1's face. On 4/17/26, Resident #1 hit Resident #49 and a physical altercation later took place, resulting in Resident #1 sustaining fractured ribs and Resident #49 sustaining a fractured hand. Resident #1 also hit Resident #111 in the face with a closed fist, resulting in Resident #111 experiencing pain. The sample was 333. The census was 149. Review of the facility's Abuse and Neglect policy, reviewed 6/12/24, showed:-Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology;-Physical Abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Physical abuse also includes corporal punishment, which is physical punishment used as a means to correct or control behavior;-Policy: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences;-Training: New employees will be educated by the department manager, or designee, on issues related to abuse prohibition practices and abuse reporting requirements during initial orientation. Annual education and training will be provided to all existing employees. Front line supervisors will provide education as situations arise;-Prevention: The facility will provide resident, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution, and will provide feedback regarding the concerns that have been expressed. The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur;-Identification: The facility will identify events, occurrences, patterns and trends that may constitute mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property as defined above;-Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedure for reporting/response as described below;-Protection: The facility will protect residents from harm during an investigation;-The facility will identify and correct by providing interventions in which abuse, neglect or misappropriation of resident property is more likely to occur. This will include; assessment of the physical environment, which may make abuse or neglect more likely to occur, such as more secluded areas in the facility, the deployment of staff on each shift in sufficient numbers to meet the resident's needs and that the staff are knowledgeable of resident care needs. Supervisors should identify inappropriate behaviors such as; derogatory language and neglectful care. Prevention will also include assessment care planning and monitoring of residents with needs or behaviors which may lead to conflict or neglect. The facility will identify events, patterns and trends that may constitute abuse and investigate thoroughly, notifying the Administrator and the proper authorities. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/15/26, showed:-Diagnoses included stroke, heart disease, heart failure, hypertension (high blood pressure), kidney failure, pneumonia, diabetes, hyperlipidemia (high cholesterol), traumatic brain injury, schizophrenia (serious mental illness that affects how a person thinks, and behaves), asthma, and respiratory failure;-Severe cognitive impairment;-No verbal or physical behaviors exhibited;-Use of walker and wheelchair;-Received antipsychotic and antidepressant medication in the last seven days. Review of the resident's care plan, in use during survey, showed:-Problem: Resident has a history of behavior problems including delusional thoughts and accusatory behaviors. Has a history of accursing staff and peers of choking/hurting him/her. Power of Attorney (POA) confirmed this history and believes a family member that visits triggers this behavior. On 12/16/25, resident throws him/herself on the floor as a behavior;--Interventions:---Administer medications as ordered;---Monitor/document for side effects and effectiveness;---Anticipate and meet his/her needs;---Educate resident/family/caregiver on successful coping and interaction strategies;---Encourage resident to express feelings appropriately;---Explain/reinforce why behavior is inappropriate and/or unacceptable;-Problem: Resident is at risk for physical aggression related to diagnosis and history;--Interventions:---Assess and anticipate resident's needs: food, thirst, toileting need, comfort level, body positioning, and pain;---Communication: Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encouraging seeking out of staff member when agitated. Review of the resident's lab results, dated 4/13/26, showed:-Collection date: 4/9/26;-Received date: 4/10/26;-Reported date: 4/13/26 at 3:19 P.M.;-Susceptibility: Escherichia coli (E. coli);--Colony Count: 50,000-99,000 (indicates a significant urinary tract infection (UTI)). Review of the resident's progress notes, showed:-On 4/14/26 at 9:00 A.M., new order for Augmentin (amoxicillin, an antibiotic) 875-125 milligram (mg) twice a day for five days, for UTI, all appropriate parties notified;-On 4/15/26 at 10:23 P.M., resident in bed, no signs of acute distress noted. Remains on antibiotic for UTI without adverse side effects noted. Able to make needs known. Refused skin assessment two times. This nurse observed a raised area to right side of forehead, an abrasion to the bridge of the nose and swelling noted to the right side of face, right cheek and eye. Resident would not allow a better assessment. Plan of care ongoing;-On 4/16/26 at 10:55 A.M., resident remains on antibiotic therapy for infection. No adverse reactions noted. Resident afebrile (no fever), no pain or discomfort noted. Fluids encouraged;-No documentation of increased behaviors before 4/9/26;-No documentation of a reason/rationale for urinalysis obtained on 4/9/26;-No documentation of an incident or physical altercation on 4/14/26. Review of Resident #100's quarterly MDS, dated [DATE], showed:-Diagnoses included anemia, heart disease, heart failure, high blood pressure, kidney failure, and hyperkalemia (high potassium);-Cognitively intact;-No verbal or physical behaviors exhibited;-Use of a walker and wheelchair. Review of the resident's care plan, in use during survey, showed:-Problem: On 4/14/26, resident was the recipient of physical aggression from another resident;--Interventions: Resident assessed for pain and injury. Skin assessment performed. Review of the resident's psychosocial post-incident impact note, dated 4/15/26 at 2:09 P.M., showed no documentation of what type of incident occurred. During an interview on 4/22/26 at 6:08 P.M., Resident #100 said he/she was in the hall with his/her roommate when Resident #1 came up. Resident #1 stood up and knocked Resident #100's hat off his/her head. Resident #100 did not touch Resident #1. Staff came running down before he/she could do anything. Review of the facility's investigation, showed:-Date and approximate time of incident: 4/14/26 at 4:00 P.M.;-Type of incident: Physical aggression not involving head;-Persons involved in the incident: Resident #1 and Resident #100;-Witness: Certified Medication Technician (CMT) Y;-Was this investigation completed for a behavior emergency: Yes;-Investigative narrative note: Resident #100 was trying to get in his/her room and Resident #1 was trying to get in the room. Resident #1 began hitting Resident #100; -Conclusion/outcome for investigation: Resident #1 was the aggressor and was sent out for evaluation;-Care plan changes and interventions: Resident #1 assessed for pain and injury, ensure protective oversight;-Was there a physical altercation: Yes;-Has the resident had any ongoing concerns: Yes;-In conclusion of this investigation, it is reasonable to believe that this injury was not caused by abuse or neglect and was not preventable and is not previous ongoing problem that the facility could have foreseen due to prior history: Yes. Review of CMT Y's interview from the facility's investigation, dated 4/14/26, showed CMT Y saw Resident #1 fighting. Resident #100 was trying to get into his/her room and Resident #1 was sitting in front of the room. They were fighting. Resident #1 was standing up, hitting Resident #100. Certified Nurse Aide (CNA) H broke it up. Review of CNA H's interview from the facility's investigation, dated 4/14/26, showed CNA H saw Resident #1 stand up and punch Resident #100 several times. CNA H ran up behind and grabbed Resident #1. Not sure what led to the situation of Resident #1 hitting him/her. Review of Resident #1's psychosocial post-incident impact note from the facility's investigation, dated 4/15/26 at 2:05 P.M., showed:-Resident was the aggressor in an incident;-Why were you trying to hurt yourself or others: I was angry;-What coping skills have you identified that you utilize and do you feel they are working: I'm just not gonna say nothing no more;-What do you feel we can do or change to allow your coping skills to be more effective: I do not know;-What do you feel you could have done differently in the situation: Not fought with him/her;-Do you feel safe: Yes;-Do you feel you need to talk to someone: No;-Can you identify at least one staff member that you feel safe with to share your thoughts/feels with? Who: No. 2. Review of Resident #1's care plan, updated on 4/15/26, showed:-Problem: On 4/14/26, resident engaged in physical aggression with another resident due to other resident blocking the door;--Interventions: Resident assessed for pain and injury. Skin assessment performed;-Problem: On 4/17/26, resident engaged in physical aggression with two other residents due to believing that another resident killed his/her baby;--Interventions: Assessed for pain and injury. Skin assessment performed. Resident to emergency room for change in mental status;-Problem: Resident engaged in physical aggression with two other residents;--Interventions: Resident will voice feelings with staff. Staff will continue to redirect resident and encourage positive behaviors. Staff will identify triggers to reduce physically aggressive episodes;-The care plan did not identify what specific triggers could potentially increase physically aggressive episodes and did not identify specific strategies for staff to use when redirecting the resident. Review of the resident's progress notes, showed:-On 4/17/26 at 7:09 P.M., resident in hallway striking other residents. Resident verbally aggressive with staff and residents, refusing vital signs and assessment. Resident being sent to emergency room for change in mental status per Director of Nursing (DON);-On 4/17/26 at 7:58 P.M., a psychosocial post-incident impact note. Resident was the aggressor in an incident. Resident was asked do you have any other needs or items that you would like addressed: I want out of here;-On 4/17/26 at 8:28 P.M., skin check. Skin warm and dry, skin color within normal limit, and turgor is normal;--Skin issue: New skin issue;--Location: Forehead;--Laterality/orientation: Right;--Additional location information: Above eye;--Issue type: Bruising;--Wound acquired In-house;--Exact date: 4/14/26;--Measurements: Not document as part of this assessment;--Reason measurements not documented as part of this assessment: Bruising without opening;-On 4/17/26 at 9:38 P.M., physician made aware of resident behavior and transfer to emergency room;-On 4/18/26 at 1:57 A.M., resident transferred to emergency room per stretcher on ambulance for evaluation and treatment. Review of the resident's hospital record, showed:-admission date: 4/18/26;-History of present illness: Resident presenting with altered mental status (AMS) and bruising to his/face reportedly after altercation at Skilled Nursing Facility. Patient desaturated (drop in blood oxygen level) in the emergency department to 84% (normal 95% to 100%) on room air and Computed Tomography Pulmonary Embolism (CTPE) was obtained with findings of acute left posterior 10th and 11th rib fractures;-Fracture of multiple ribs of left side: Left posterior 10th and 11th rib (bottom-back area of the ribcage, just above the waist) fractures;--Minimally displaced on imaging;--admitted to Intensive Care Unit (ICU) for oxygen requirement/rib score (predicts pulmonary outcome from rib fracture);-discharge date : [DATE]. Review of Resident #49's quarterly MDS, dated [DATE], showed:-Diagnoses included coronary artery disease, high blood pressure, non-Alzheimer's dementia, seizure disorder, anxiety;-No cognitive impairment;-No verbal or physical behaviors exhibited;-Use of wheelchair. Review of the resident's progress notes, showed:-On 4/18/26 at 6:14 P.M., staff documented the resident has complaint of pain to right hand, swelling noted, physician notified. New order for x-ray to right hand. All appropriate parties notified;-No documentation of cause or events that led to the resident's complaints of hand pain and swelling. Review of the resident's physician order summary (POS), dated April 2026, showed an order, dated 4/18/26, for imaging for right hand, two views, one time. Sent for imaging on 4/18/26. Review of the resident's x-ray results, dated 4/19/26, showed:-Examination date: 4/18/26;-Reported date: 4/19/26;-Procedure: Right hand, two view;-Findings: Images of the right hand are submitted. There is an acute fracture of the neck of the fourth metacarpal (the bone in the hand connecting the ring finger to the wrist) with approximately 50 degrees of volar angulation (fracture deformity where the distal bone fragment tilts toward the palm side of the hand) and mild displacement. There is associated soft tissue swelling;-Conclusion: Acute fracture of the right fourth metacarpal neck. Review of Resident #49's interview from the facility's investigation, dated 4/18/26, showed Resident #1 came into their room and closed the door behind him/her. Resident #49 stated that he/she was attempting to leave out. Resident #49 said, What's up, to Resident #1. Resident #1 stated, What can be up. Resident #1 proceeded to grab the wheelchair pedal and hit Resident #49 on his/her right hand. Resident #49 then got up and pushed Resident #1 over his/her bed and a few other items laying around. Resident #49 then left the room and proceeded down the hallway. Once Resident #49 came back up to the floor and passed Resident #1 again, Resident #1 attempted to swing on him/her again and he/she ducked the swing. Review of the resident's care plan, updated 4/19/26, showed:-Problem: On 4/17/26, resident was the recipient of physical aggression by another resident;--Interventions: Resident assessed for pain and injury. Skin assessment performed. During an interview on 4/24/26 at 8:34 A.M., Resident #49 said he/she was roommates with Resident #1, but not anymore. The first incident happened when Resident #1 swung on him/her and he/she threw the resident on the ground. Resident #1 was standing at the time in between the bed and dresser. He/She even tried it with the resident down the hall. When Resident #1 returned to the room, Resident #49 was sitting on the bed. Resident #1 came in and hit him/her with a wheelchair foot pedal on his/her right hand. After Resident #1 hit him/her with the foot pedal, Resident #49 jumped up and punched Resident #1. Resident #1 was laughing and said, I'll be back. No staff entered the room. Resident #49 reported it to staff and they did not come when the incident occurred. Review of Resident #111's modified quarterly MDS, dated [DATE], showed:-No cognitive impairment;-Diagnoses included non-traumatic spinal cord dysfunction, anemia, high blood pressure, neurogenic bladder (lack of bladder control), hyperlipidemia, malnutrition, depression,-No verbal or physical behaviors exhibited;-Use of wheelchair. Review of the resident's progress notes, showed:-On 4/22/26 at 7:34 A.M., psychosocial post-incident impact note. Resident was involved in an incident as the victim. The note did not include a description of the incident. Review of the resident's POS, dated April 2026, showed an order, dated 4/18/26, for imaging to skull - complete. Sent for imaging on 4/18/26. Review of the resident's x-ray results, dated 4/18/26, showed:-Examination date: 4/18/26;-Reported date: 4/18/26;-Procedure: Skull complete, minimum four views;-Findings: The bony calvarium (top part of the skull) appears intact, with no fracture identified;-Conclusion: Unmarkable skull. Review of Resident #111's interview from the facility's investigation, undated, showed per Resident #111, when he/she got off the elevator, Resident #1 said he/she killed his/her kid or baby and swung on him/her. Per Resident #111, he/she did not know what he/she was talking about. During an interview on 4/24/26 at 9:23 A.M., Resident #111 said the fight was out in the hallway. Resident #1 punched him/her on the left side of the face with a closed fist. It still hurts. Review of the facility's investigation, showed:-Date and approximate time of incident: 4/17/26 at 3:00 P.M.;-Type of incident: Physical aggression not involving head;-Persons involved in the incident: Resident #1 aggressor. Resident #49 and #111 victims;-Witness: Resident witness and CNA X;-Was this investigation completed for a behavior emergency: Yes;-Investigative narrative note: Resident #1 thought that Resident #111 killed his/her baby and hit him/her in the head. No injuries noted. During our investigation and getting statements, we found out that Resident #1 had hit Resident #49 in the hand with a wheelchair pedal in their room. This was unwitnessed. Assessments completed, family, and physician notified. Resident #1 sent to the hospital. X-rays for Resident #49 ordered and awaiting results;-Conclusion/outcome for investigation: Resident #1 was the aggressor and hit both residents unprovoked. It is noted that Resident #1 has a UTI and is on antibiotics for it;-Care plan changes and interventions: Care plan updated, room changes when Resident #1 returns to the facility;-Was there a physical altercation: Yes;-Has the resident had any ongoing concerns: Yes;-Steps taken to prevent further occurrence of the issue: Room/unit moves;-In conclusion of this investigation, it is reasonable to believe that this injury was not caused by abuse or neglect and was not preventable and is not previous ongoing problem that the facility could have foreseen due to prior history: Yes. Review of CNA X's interview from the facility's investigation, undated, showed CNA X said he/she helped his/her co-worker stop Resident #1 from jumping on Resident #111. As they were escorting Resident #1 down the hall, Resident #49 hit him/her in the head. Resident #49 told Resident #1 he/she was going to get him/her when he/she comes back in the room that night. Review of Resident #1's witness interview, dated 4/18/26, showed Resident #1 said Resident #111 got off the elevator and went past Resident #1 and Resident #1 swung on Resident #111 for no reason at all, hitting him/her in the head. Resident witness screamed for help and the aides came and stood in between them separating them. They escorted Resident #1 to 1 South nurse's station to watch him/her. While taking Resident #1 to the nurse's station, Resident #49 was rolling by and Resident #1 started hitting Resident #49 as he/she rolled by. 3. During an interview on 4/22/26 at 5:41 P.M., Licensed Practical Nurse (LPN) E said Resident #1 was originally placed on the 3rd floor locked unit for behaviors. He/She was moved to the 1st floor, where he/she was pleasant. On 4/9/26, a UA was ordered because the resident was not acting normally. Then, he/she was fighting. He/She had a systemic UTI, which was affecting him/her. Staff sent him/her out to the hospital. The resident returned to the facility today at 5:00 P.M. and already attacked LPN E. LPN E attempted to remove the resident's bandage to complete a skin assessment and the resident scratched LPN E. During an interview on 4/23/26 at 2:50 P.M., LPN BB said Resident #1 was being different. He/She was on antibiotics for UTI when he/she went to the hospital. After the resident returned to the facility, he/she was placed on increased monitoring. During an interview on 4/24/26 at 10:16 A.M., the Director of Nurses (DON) said if there was an altercation, there would be monitoring of the resident for 72 hours. She would have to check the policy, but this monitoring is a nursing standard. During an interview on 4/24/26 at 3:38 P.M., the Administrator said she expected residents to be free from abuse and for staff to follow the facility's Abuse and Neglect policy. If a resident displayed a change in behavior or had an increase in behaviors, she would expect staff to continue to monitor the resident and document it in the medical record. Following the physical altercations, the resident was supposed to be on increased monitoring from staff. 298380229875162987523

Based on observation, interview, and record review, the facility failed to thoroughly assess and monitor two residents after resident-to-resident altercations resulted in injuries (Residents #49 and #111). Resident #49 received an x-ray to the right hand on 4/18/26 with results reported on 4/19/26. The facility failed to review the x-ray results until 4/24/26, which showed a fracture to the right hand. The facility failed to follow physician's orders for a hand splint and ice. The facility failed to initiate neuro checks for Resident #111 after being struck on the head during an altercation. Resident #111 had complaints of pain as late as 4/24/26. In addition, the facility failed to provide wound treatment for two residents (Residents #120 and #113). The sample size was 33. The census was 149. Review of the facility's Intensive Monitoring policy, reviewed 4/30/24, showed:-Procedure: Residents who require more intensive monitoring due to crisis, behavioral/psychiatric symptoms will be monitored by the facility staff;-Intensive monitoring: Intensive monitoring is provided as periodic (hourly, every two hours, or every shift) check by a facility staff member;-Residents may require more intensive monitoring based on their crisis, behavioral, psychiatric issues. The level of Intensive Monitoring shall be identified by the specific situation or resident assessment;-Residents who are showing poor impulse control including crisis, behavioral, psychiatric issues, such as, verbal/physical aggression, elopement ideations, suicidal/homicidal ideations, and decompensation mentally or crisis may be placed on intensive monitoring or one-to-one or two-to-one (within eyesight of staff) monitoring at the discretion of the administrative staff or facility supervisor;-Based on the assessment of the resident at the discretion of the administrative staff of Facility Supervisor, either intensive monitoring, one to one or two to one;-Residents who require intensive monitoring of one to one will have an assigned employee within eyesight until resident has stabilized or returned to prior level of function. Educated on the reasoning for the intensive monitoring, including triggers and interventions for that specific resident. The employee will interact with the resident throughout to receive therapeutic interventions;-The facility's Interdisciplinary Team will address the residents' behavioral concerns and ensure interventions are in place to address the residents' needs (psychiatry follow up, counseling, medical needs, etc.);-Once the resident has stabilized and/or returned to prior level of function, the facility's Interdisciplinary Team will meet to discuss determination of discontinuation of Intensive Monitoring;-The facility staff will document the intensive monitoring in the residents Electric Medical Record. Review of the facility's wound treatment management policy, last revised 5/3/24, showed:-Purpose: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatment in accordance with current standards of practice and physician orders;-Policy:--Wound treatments will be provide in accordance with physician orders, including cleansing method, type of dressing and frequency of dressing change;--In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders;--Treatment decisions will be based on cause of the wound, characteristics of the wound, size, volume and characteristics of drainage, presence of pain, presence of infection condition of the tissue in the wound bed, condition of the skin surrounding the wound bed;--Location of wound;--Goals and preferences of the resident or representative;--Treatment will be documented on the treatment administration record (TAR) or in the electronic health record;--The effectiveness of treatment will be monitored through ongoing assessments of the wound. 1. Review of Resident #49's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/1/26, showed:-Diagnoses included coronary artery disease, high blood pressure, non-Alzheimer's dementia, seizure disorder, anxiety;-No cognitive impairment;-No verbal or physical behaviors;-Uses wheelchair;-No scheduled pain medication regimen in the last five days;-Pain frequency: occasionally;-Pain intensity: 2/10;-Antidepressant administered in the last seven days. Review of facility's investigation, dated 4/18/26, showed Resident #49 stated Resident #1 came into their room and closed the door behind him/her. Resident #49 stated that he/she was attempting to leave out. Resident #49 said what's up to Resident #1. Resident #1 stated, what can be up. Resident #1 proceeded to grab the wheelchair pedal and hit Resident #49 on his/her right hand. Resident #49 then got up and pushed Resident #1 over his/her bed and a few other items laying around. Resident #49 then left the room and proceeded down the hallway. Once Resident #49 came back up to the floor and passed Resident #1 again, Resident #1 attempted to swing on him/her again and he/she ducked the swing. Review of the resident's care plan, in use during survey, updated 4/19/26, showed:-Problem: On 4/17/26, resident was the recipient of physical aggression by another resident;-Interventions: Resident assessed for pain and injury; Skin assessment performed. Review of the resident's progress notes, showed:-On 4/18/26 at 6:14 P.M., resident has complaint of pain to right hand, swelling noted, physician notified. New order for x-ray to right hand. All appropriate parties notified;-On 4/18/26 at 7:01 P.M., skin check: New skin issue;--Location: right dorsum right hand;--Issue type: other skin issue;--Description: Swelling wound acquired in-house;--Painful: no. Review of the resident's physician order sheet (POS), dated April 2026, showed an order dated, 4/18/26, hand 2-views- right, one time. Review of the resident's x-ray results, showed:-Examination date: 4/18/26;-Reported date: 4/19/26;-Procedure: Hand 2 view- RT (right);-Findings: images of the right hand are submitted. There is an acute fracture of the neck of the fourth metacarpal (sub capital or boxer's fracture, the bone in the hand connecting the ring finger to the wrist) with appropriately 50 degrees of volar angulation (fracture deformity where the distal bone fragment tilts toward the palm side of the hand) and mild displacement. There is associated soft tissue swelling. The remaining hand is intact. There is mild joint degeneration;-Conclusion: Acute fracture of the right 4th metacarpal neck. During an interview on 4/24/26 at 8:34 A.M., Resident #49 said he/she was roommates with Resident #1, but not anymore. The first incident happened when Resident #1 swung on him/her and he/she threw the resident on the ground. Resident #1 was standing at the time in between the bed and dresser. When Resident #1 returned to the room, Resident #49 was sitting on the bed. Resident #1 came in and hit him/her with a wheelchair foot peddle on his/her right hand. Resident #49 pointed out the peddle that was used was on the floor under the bed frame. The foot peddle was already off, so he/she grabbed it. After Resident #1 hit him/her with the foot peddle, Resident #49 said he/she jumped up and punched Resident #1. The punch was nothing bad because his/her hand was hurting. Resident #1 was laughing and said, I'll be back. No staff entered the room. Resident #49 reported it to staff and told them to come get him/her. They did not come when the incident occurred. The resident said his/her right hand continued to hurt. No one did anything and it was still swollen. Resident was asked to hold both hands straight out, with palm of hands facing down. The resident's right hand was noticeably more swollen than the left hand in the knuckle area of the hand. The resident was asked if he/she was able to close the hand into a fist. He/she could not. It hurt too bad and still hurts today. The resident attempted to close hand into a fist; however, the right hand was only cupped. During an interview on 4/24/26 at 8:35 A.M., the Assistant Director of Nursing (ADON) said she was aware of the incident between Resident #1 and Resident #49. She was not aware of the x-ray results. She read the results in the medical record. The ADON said she would expect the results to had been reviewed when it was completed on 4/18/26. She would notify ortho and the physician at that time. During an interview on 4/24/26 at 9:07 A.M., Registered Nurse (RN) EE said he/she was not aware of the resident's hand fracture, and the resident did not have complaints of pain. During an interview on 4/24/26 at 9:08 A.M., Licensed Practical Nurse (LPN) BB said if a resident had an order for an x-ray, it was passed on report and the results were somewhere in the record, under results. If the x-ray technician came, they would let each other know that the resident had an x-ray and keep checking the results. If they did not come, they would pass that on report. Everyone checked for results and once everything was in, they would contact the doctor to receive further instructions if there was an issue. If the results were within normal limits, they would fax the results. During an interview on 4/24/26 at 9:09 A.M., LPN E said the resident was supposed to have a hand x-ray. He/She was asked if he/she was aware of the results. LPN E said no. During an interview on 4/24/26 at 9:15 A.M., the ADON said Resident #49 had an orthopedic appointment, so the physician was aware of the results. The ADON would expect on-going monitoring of the resident's hand. It should be documented, but the nurse was monitoring it. During an interview on 4/24/26 at 9:18 A.M., LPN BB said he/she became aware of the fracture today. He/She was aware of the altercation that occurred. He/She asked Resident #49 if he/she was doing alright and the resident said, I'm fine. He/She monitored the resident's hand but did not document it. When the incident happened, he/she was off and did not work for a few days. During an interview on 4/24/26 at 9:30 A.M., LPN E said Resident #49 did not have complaints of pain. He/She completed the regular/daily rounds and the resident did not report anything. LPN E monitored the hand at the time of the x-ray. It was swollen, but the swelling went down. He/She looked at the hand and it was not as swollen. It was not daily. Resident #49 is completely self and would let them know. He/She did his/her normal joking, but did not say they were in pain. He/She did not know Resident #49 was in pain until now. He/She asked the resident if he/she was in pain, and the resident said yes. During an interview on 4/24/26 at 9:49 A.M., the ADON said there was an appointment slip that showed the resident had an orthopedic appointment on 4/30/26. The ADON was unaware of who completed the form, made the appointment, or contacted the physician. Review of the resident's transportation referral, showed:-Appointment date: 4/30/26 at 10:20 A.M.;-Type of doctor: Orthopedic;-Reason for appointment or special instructions: Fracture to finger on right hand. During an interview on 4/24/26 at 10:40 A.M., Physician DD remembered the incident. He/She was notified and ordered an x-ray to Resident #49's right hand. He/She was aware of the results of the x-ray, but did not remember who called him/her. He/She ordered hand splint, ice, and an ortho consult. He/She would expect the orders to be followed for the splint, ice, and ortho appointment. He/She would expect staff to continue to monitor and assess for pain until the resident's ortho appointment. The fracture was not considered emergent and was seen by ortho. Depending on the age of the patient, it may just be splint and monitoring for pain. He/She would expect the resident to wear a splint to reduce mobility and further injury. 2. Review of Resident #111's modified quarterly MDS, dated [DATE], showed:-No cognitive impairment;-Diagnoses included non-traumatic spinal cord dysfunction, anemia, high blood pressure, neurogenic bladder, hyperlipidemia, malnutrition, depression,-No verbal or physical behaviors;-Uses wheelchair;-No scheduled pain medication regiment in the last five days. Review of the resident's care plan, in use during survey, showed:-Problem: On 4/17/26, resident was the recipient of physical aggression by another resident;-Desired outcome: Ensure protective oversight is provided;-Interventions: Resident assessed for injury and pain. Skin assessment performed. Review of the facility's investigation, an undated interview, showed per Resident #111, when he/she got off the elevator, Resident #1 said he/she killed his/her kid or baby and swung on him/her. Per Resident #111, he/she did not know what he/she was talking about. Review of the resident's progress notes, showed:-On 4/18/26 at 12:01 A.M., Skin check: skin warm and dry, skin color within normal limits, and turgor is normal. No skin issues identified;-On 4/18/26 at 7:04 P.M., Skin check: skin warm and dry, skin color within normal limits, and turgor is normal. No skin issues identified. Review of the resident's POS, dated April 2026, showed: -An order, dated 12/11/24, Acetaminophen Oral tablet 325 mg, give two tablets by mouth every four hours as needed for pain;-An order, dated 4/18/26, skull complete, minimum four view. Sent for imaging on 4/18/26. Review of the resident's MAR, dated April 2026, showed:-An order, dated 12/11/24, Acetaminophen Oral tablet 325 mg, give two tablets by mouth every four hours as needed for pain, showed no documentation of administration between 4/1/26 through 4/24/26. Review of the resident's x-ray results, showed:-Examination date: 4/18/26;-Reported date: 4/18/26;-Procedure: Skull complete, min 4V (minimum four views);-Findings: The bony calvarium appears intact, with no fracture identified. There are no suspicious lytic (destruction of cells) or sclerotic lesions (hardened bone). There is grossly normal mineralization. No focal soft tissue abnormality is identified;-Conclusion: Unmarkable skull. Review of the resident's medical record, showed no documentation of neuro checks or on-going monitoring of the resident's injury and pain after 4/18/26. During an interview on 4/24/26 at 9:23 A.M., Resident #111 said the fight was out in the hallway. Resident #1 punched him/her in the face. He/She was struck on the left side of the face. It still hurts too. Resident #1 used a closed fist. Resident #111 did not hit Resident #1. Staff came and got the resident after Resident #1 struck him/her. During an interview on 4/24/26 at 9:30 A.M., LPN E said Resident #111 did not have complaints of pain. He/She completed the regular/daily rounds and the resident did not report anything. During an interview on 4/24/26 at 10:40 A.M., Physician DD said if a resident was struck in the head, he would have expected staff to initiate neuro checks. They were expected to routinely assess and monitor the resident's face for any changes. During an interview on 4/24/26 at 10:16 A.M., the DON said she would expect there to be 72 hour monitoring following resident to resident altercation but would have to verify the policy. It was a standard nursing judgement. If staff made the ortho appointment and was aware of the Resident #49's fracture, she would expect it to be documented. The monitoring should include if there was limited mobility, if resident needed help, or pain medications. Would expect the physician to be notified. She would expect documentation if there were suggestions or orders from the physician, suggestions or what to monitor until the resident's ortho appointment. She would expect the same for Resident #111. Staff was expected to monitor for pain and swelling. 3. Review of Resident #120's quarterly MDS, dated [DATE], showed:-Mild cognitive impairment;-Independent with bed mobility and ambulation;-Requires set up from staff for upper and lower body dressing and bathing;-Diagnoses included heart disease, heart failure, depression, anxiety, kidney disease and Parkinson's disease. Review of the resident's care plan, in use at the time of survey, showed;-Focus: The resident is as risk for limited physical mobility related to Parkinson's disease;-Interventions: The resident does not require any assistive device and ambulates independently;-Focus: The resident is at risk for impairment to skin;-Interventions: Follow facility protocol for treatment of injury; Monitor and document location, size, and treatment of skin injury; Report abnormalities, failure to heal or signs and symptoms of infection. Review of the resident's progress notes, showed on 4/17/26 at 12:13 P.M., the resident signed him/herself out and walked out of the building. Staff members found the resident on the ground outside of the facility. The resident was sent to the hospital. Review of the resident's TAR, showed:-An order, with a start date 4/18/26, cleanse right hand sutures with normal saline (salt water), apply triple antibiotic ointment (TAO) for two days then cover with Vaseline daily until healed.-The treatment was documented as completed 4/8 through 4/23/24;-The treatment did not include applying dressing. During observation on 4/19/26 at 9:50 A.M., 4/20/26 at 2:30 P.M., and 4/21/26 at 8:05 A.M. the resident had a white surgical dressing to his/her right hand. During an interview 4/19/26 at 9:50 A.M., the resident said he/she has had the same dressing on since the hospital. No staff member has removed it or applied any type of ointment. During an interview on 4/23/26 at approximately 2:00 P.M., the resident no longer had dressing on his/her right hand and said he/she removed it him/herself because the same dressing was on for several days. The resident said he/she had been washing his/her right hand with soap and water. The hospital informed the resident that the sutures were self-dissolving. During an interview on 4/24/26 at 12:10 P.M., LPN E said he/she had been changing the dressing daily to the resident's right hand and did not have a marker to write the date on the dressing. All nurses were responsible for completing treatments and dressing changes. 4. Review of Resident #113's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Dependent on staff for putting on and taking off footwear and lower body dressing;-Requires substantial to maximum assist with bathing and toileting hygiene;-Diagnosis included high blood pressure. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident has an activities of daily living (ADL's, bathing, dressing and toileting) self care performance deficit related to weakness and immobility related to pain;-Focus: The resident requires physical assistance by staff with his ADLs: bed mobility, toileting, transfers, ambulation, dressing, bathing and personal hygiene.-The care plan did not address the resident's toe wound. Review of the resident's progress notes, showed:-On 4/1/26 at 11:32 A.M., the resident's right second toenail on his/her right foot came off during resident care; The wound was cleansed with wound cleaner; Wound gel was applied; ABD pad (a specialized dressing) was applied and wrapped with Coban (a specialized stretchy wrap);-On 4/20/26 at 3:24 P.M., the resident has a facility acquired open wound to his/her second toe nailbed on his/her right foot.-No further documentation or description of the resident's right second nailbed toe wound. Review of the resident's TAR, dated April 2026, showed:-An order with a start date 4/2/26, clean wound to right foot with wound cleaner, apply wound gel, cover with ABD and wrap with Coban daily;-The treatment was documented as completed on 4/2 through 4/24/26. Observation on 4/20/26 at 7:55 A.M. and 4/22/26 at approximately 3:00 P.M., showed the resident did not have dressing to his/her right foot second toe. The second toe nail bed was scabbed over with no drainage. The resident said a staff member was removing his/her bed sheet and his/her toenail got caught and pulled the toenail off. The resident said that the staff was only dressing the toe for the first couple of days after the incident happened and then the nurse decided to leave the toe wound open to air. During an interview on 4/24/26 at 12:10 P.M., LPN BB said the resident had current treatment orders for his/her right foot, second toe. The last few days LPN BB had been leaving the dressing open to air. LPN BB didn't think she was signing off the dressing change was completed but wasn't sure. All nurses were responsible for completing and documenting the wound treatments. During an interview on 4/22/26 at 9:32 A.M., the DON was not made aware of the incident with the resident's toe on his/her right foot. Staff was expected to inform her of any new skin issues because she was also the Wound Nurse. She would expect staff to reach out to her regarding adding or discontinuing treatments. 5. During an interview on 4/24/26 at 3:41P.M., the DON said she would expect staff to follow the physician orders and document the wound treatments only when completed. If a wound treatment is changed for any reason, there should be new orders placed in the electronic medical record (EMR). Intake: 2987516

Based on observation, interview, and record review, the facility failed to implement and maintain an effective pain management regimen when the facility failed to assess, monitor, and address pain for two residents (Residents #49 and #90). Resident #49 sustained a fracture to the right hand on 4/18/26, without documentation of pain monitoring and was not offered or administered pain medication between 4/18 through 4/24/26. The facility failed to ensure Resident #90's order for oxycodone (an opioid prescribed to treat moderate to severe pain) was filled and delivered timely for six days. As a result, Residents #49 and #90 had unrelieved pain. The sample size was 33. The census was 149.Review of the facility's Pain Management policy, revised 6/26/24, included:-Policy: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain;-Recognition of pain: In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will:-Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated;-Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (after a fall, change in behavior or mental status, new pain or an exacerbation of pain);-Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences;-Facility staff will observe for nonverbal indicators which may indicate the presence of pain;-Facility staff will be aware of verbal descriptors a resident may use to report or describe their pain;-Pain Assessment: The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain;-Asking the patient to rate the intensity of his/her pain using a numerical scale, a verbal or visual descriptor that is appropriate and preferred by the resident;-Current prescribed pain medications, dosage and frequency, including medication assisted treatment for opioid use disorder;-The resident's goals for pain management and his/her satisfaction with the current level of pain control;-Pain Management and Treatment: Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission;-The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goals;-Non-pharmacological interventions will include but are not limited to:-Environmental comfort measures (adjusting room temperature, smoothing linens, comfortable seating, assistive devices or pressure redistributing mattress and positioning);-Loosening any constrictive bandage, clothing or device;-Applying splinting (pillow or folded blanket);-Physical modalities (cold compress, warm shower/bath, massage, turning and repositioning);-Exercises to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility;-Cognitive/behavioral interventions (music, relaxation techniques, activities, diversions, spiritual and comfort support, teaching the resident coping techniques and education about pain);-Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. 1.Review of Resident #49's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 4/1/26, showed:-No cognitive impairment;-No scheduled pain medication regimen in the last five days;-Pain frequency: occasionally;-Pain intensity: 2/10.Review of a facility investigation, dated 4/18/26, showed the resident was in an altercation with another resident. The other resident hit Resident #49 on his/her right hand with a wheelchair foot pedal. Review of the resident's progress notes, showed:-On 4/18/26 at 6:14 P.M., resident has complaint of pain to right hand, swelling noted, physician notified. New order for x-ray to right hand. All appropriate parties notified;-On 4/18/26 at 7:01 P.M., skin check: New skin issue;--Location: Right dorsum right hand;--Issue type: Other skin issue;--Description: Swelling wound acquired in-house;--Painful: No. Review of the resident's physician's orders sheet (POS), dated April 2026, showed:-An order, dated 11/25/25, assess for pain every shift;-An order, dated 2/16/26, acetaminophen tablet 325 milligrams (mg), give two tablets by mouth every four hours as needed for fever;-An order, dated 2/16/26, acetaminophen tablet 325 mg, give two tablets by mouth every four hours as needed for pain related to pain in left shoulder;-An order dated, 4/18/26, x-ray of hand 2-views- right, one time; -No physician's orders for splint and ice to the right hand. Review of the resident's care plan, in use during survey, updated 4/19/26, showed:-Problem: On 4/17/26, resident was the recipient of physical aggression by another resident;-Interventions: Resident assessed for pain and injury. Skin assessment performed. Review of the resident's Medication Administration Record (MAR), dated April 2026, showed:-An order, dated 11/25/25, assess for pain every shift, showed:-On 4/18 through 4/22/26, staff documented 0 for pain level on all three shifts;-On 4/23/26, staff documented 0 for pain level for day and night shift. Evening shift showed blank; -An order, dated 2/16/26, acetaminophen tablet 325 mg, give two tablets by mouth every four hours as needed, showed no documentation of administration between 4/1 through 4/24/26. Review of the resident's x-ray results, showed:-Examination date: 4/18/26;-Reported date: 4/19/26;-Procedure: Hand 2 view- RT (right);-Findings: images of the right hand are submitted. There is an acute fracture of the neck of the fourth metacarpal (sub capital or boxer's fracture, the bone in the hand connecting the ring finger to the wrist) with approximately 50 degrees of volar angulation (fracture deformity where the distal bone fragment tilts toward the palm side of the hand) and mild displacement. There is associated soft tissue swelling. The remaining hand is intact. There is mild joint degeneration;-Conclusion: Acute fracture of the right 4th metacarpal neck. Observation and interview on 4/24/26 at 8:34 A.M., showed Resident #49 said after the altercation with Resident #1, his/her right hand continued to hurt. No one did anything and it was still swollen. Resident #49's right hand was noticeably more swollen than the left hand in the knuckle area of the hand. The resident was asked if he/she was able to close the hand into a fist. He/she could not. The resident said it hurts too bad and still hurts today. The resident attempted to close his/her hand into a fist; however, the right hand was only cupped. Observation and interview on 4/24/26 at 8:35 A.M., showed the assistant Director of Nursing (ADON) said she was aware of the incident between Resident #1 and Resident #49. She was not aware of Resident #49's x-ray results. She read the results in the medical record at that time. ADON said she would expect the results to have been reviewed when the x-ray was completed on 4/18/26. She said she would notify orthopedics (ortho, a medical specialty focused on diagnosing, treating and preventing injuries and diseases of the skeletal system, including bones, joints, muscles and nerves) and the physician at the time. During an interview on 4/24/26 at 9:07 A.M., Registered Nurse EE said he/she was not aware of the resident's hand fracture, and the resident did not have complaints of pain. During an interview on 4/24/26 at 9:08 A.M., Licensed Practical Nurse BB said if a resident had an order for an x-ray, it was passed on in report and the results were somewhere in the record, under results. If the x-ray technician came, they would let each other know that the resident had an x-ray and keep checking the results. If they did not come, they would pass that on in report. Everyone would continue to check for results and once everything was in, they contact the doctor to receive further instructions if there was an issue. If the results were within normal limits, they would fax the results to the doctor. During an interview on 4/24/26 at 9:15 A.M., the ADON said he/she would expect on-going monitoring of the resident's hand. It should have been documented, but the nurse was monitoring it. During an interview on 4/24/26 at 9:18 A.M., LPN BB said he/she became aware of the fracture on 4/24/26. He/she was aware of the altercation that occurred. He/she asked Resident #49 if he/she was doing alright and the resident said, I'm fine. He/she monitored the resident's hand but did not document it. During an interview on 4/24/26 at 9:30 A.M., LPN E said the resident did not have complaints of pain. He/she completed the regular/daily rounds, and the resident did not report anything. LPN E monitored the hand at the time of the x-ray. It was swollen, but the swelling went down. He/she looked at the hand, and it was not as swollen. It was not monitored daily. The resident is completely self and would let them know if he/she was in pain. The resident did his/her normal joking and did not say they were in pain. LPN E did not know the resident was in pain until now. LPN E asked the resident if he/she was in pain and the resident said yes. During an interview on 4/24/26 at 9:49 A.M., the ADON said there was an appointment slip that showed the resident had an orthopedic appointment on 4/30/26. The ADON was unaware of who completed the form, made the appointment, or contacted the physician. During an interview on 4/24/26 at 10:16 A.M., the Director of Nursing (DON) said she would expect there to be 72-hour monitoring following a resident-to-resident altercation but would have to verify the policy. It was a standard nursing judgement. If staff made the ortho appointment and were aware of the fracture, she would expect it to be documented. The monitoring should include if there was limited mobility, if the resident needed help, or pain medications. She would expect the physician to be notified. She would expect documentation if there were orders from the physician, suggestions or what to monitor until the resident's ortho appointment. During an interview on 4/24/26 at 10:40 A.M., Physician DD remembered the incident. He/she was notified and ordered an x-ray to Resident #49's right hand. He/she was aware of the results of the x-ray but did not remember who called him/her. He/she ordered hand splint, ice, and an ortho consult. He/she would expect the orders to be followed for the splint, ice, and ortho appointment. He/she would expect staff to continue to monitor and assess for pain until the resident's ortho appointment. 2. Review of Resident #90's face sheet, showed diagnoses included reduced mobility, pain in left shoulder and left knee, chronic pain syndrome (pain lasts for months after an injury or after healed) and diabetes. Review of the resident's admissions MDS, dated [DATE], showed:-Impaired cognition;-Maximal assistance from staff for activities of daily living (ADLs);-Receives scheduled pain medication regimen. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident has left shoulder pain; resident will sometimes decline as needed (PRN) medications;-Outcome: The resident will not have an interruption in normal activities due to pain through the review date;-Interventions: Administer pain medications, anticipate the need for pain medication and respond immediately to any complaint of pain. Monitor for signs and symptoms of pain, record pain characteristics quality (sharp, burning ect.) location, and duration, monitor for non-verbal expressions breath sounds (rapid, deep, shallow), facial expressions, sounds (grunts, shouts out, squirmy), body language; -Problem: The resident has onset/long term pain;-Outcome: No plan in place;-Interventions: No plan in place. Review of the residents' MAR, dated March 2026, showed:-An order dated 9/11/24. Tylenol Extra strength PO tablets 500 mg, every four hours (Q4H);-No medication given to resident for the month of March;-An order, dated 5/23/24. Assess pain every shift;-Zero pain documented for 91 of 91 shifts. Review of the resident's electronic physician's order sheet (ePOS), dated April 2026, showed:-An order, dated 3/4/26. Refer to another provider for left shoulder pain, injections;-An order, dated 2/12/26. Refer resident to an ortho for left shoulder pain;-An order, dated 9/11/24. Tylenol Extra strength oral (PO) tablets 500 milligrams(mg) every four hours;-An order, dated 10/1/25. The resident requests to see an ortho doctor for left shoulder pain;-An order, dated 5/23/24. Assess pain every shift. Review of the residents' MAR, dated April 2026, showed:-An order, dated 9/11/24, Tylenol Extra strength PO tablets 500 mg, Q4H;-No medication given to resident for the month of April;-An order, dated 5/23/24, assess pain every shift;-Zero pain documented for 63 of 63 shifts. Review of the resident's Pain Management progress note, dated 4/16/26, showed chief complaints of bilateral shoulder pain and bilateral knee pain for several years. Prescription for hydrocodone (pain medication) 5 mg with Tylenol 325 mg PO tablet, every evening and as needed for 15 days. Prescribed 15 tablets. Review of the resident's POS, dated April 2026, showed no order for hydrocodone 5 mg with Tylenol 325 mg, every evening and as needed for 15 days. During an interview on 4/22/26 at 11:42 A.M., the resident said he/she saw a pain doctor for his/her left shoulder and should have received pain medications at night and every day but did not. During an interview on 4/22/26 at 10:10 A.M., CMT S said the resident had pain around his/her shoulder. CMT S said the resident did not express any discomfort today. During an interview on 4/22/26 at 10:11 A.M., CNA T said the resident received a pain pill every day. Most of the pain was in the shoulder or belly. During an interview on 4/22/26 at 10:10 A.M., LPN R, said the resident took Celebrex (muscle relaxer), that just started, and Hydrocodone (opioid narcotic) every day for pain. During an interview on 4/22/26 at 2:04 P.M., the Director of Physical and Occupational Therapy said the resident was picked up for pain control and management in 2025 but later discharged in December after he/she reached their full potential. During an interview on 4/24/26 at 3:41 P.M., the DON said she would expect staff to follow policy and procedures set by the facility. The DON said that the Assistant Director of Nursing (ADON) and DON were responsible for auditing physician's orders. She would expect staff to notify the medical doctor related to any new changes or orders from referral physicians.

Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect by failing to ensure staff communicated with residents in an appropriate and respectful manner for three residents (Residents #12, #71, and #73). The facility also failed to ensure privacy was provided for one resident during care (Resident #86). In addition, the facility failed to ensure staff followed the facility's cell phone policy, while providing care to one resident (Resident #133). The sample size was 33. The census was 149. Review of the facility's promoting resident dignity policy, dated 9/21/25, showed:-Purpose: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality;-Procedure: Every resident has a right to be treated with dignity and respect. All staff will speak to and treat all residents with dignity and respect. Speak respectfully to residents; avoid discussions about residents that may be overheard. Staff members do not talk to each other while performing a task for the resident as if the resident is not there. Conversation should be resident focused and resident centered. Review of the facility's electronic devices in the workplace policy, dated 4/25/25, showed:-Purpose: To ensure that all electronic devices used at work are used for the benefit of patient care and their use does not violate the privacy of our residents;-The use of electronic devices while at work is strictly prohibited, unless the device is being used for conducting facility business and to perform your daily assignments. 1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/26, showed:-Diagnoses included anorexia, bipolar disorder (mood disorder that causes mood swings), post-traumatic stress disorder (PTSD), and major depressive disorder;-Cognitively intact. During an interview on 4/19/26 at 9:22 A.M., the resident said staff talked down to him/her and the residents on his/her hallway. He/She felt like staff did not treat him/her like an adult. 2. Review of Resident #71's quarterly MDS, dated [DATE], showed:-Diagnoses included chronic kidney disease, disorganized schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), bipolar disorder, anxiety, and major depressive disorder;-Cognitively intact. Observation on 4/20/26 at 12:29 P.M., showed the resident came out of his/her room to the nurse's station. He/She told Certified Nursing Assistant (CNA) T that he/she was still hungry after eating lunch. CNA T told the resident he/she would call dietary to bring him/her more food. Dietary Aide II came to the nurse's station and in front of the resident, told CNA B that he/she was too busy to get the resident food, and CNA T needed to go down to the kitchen and get the food himself/herself. The resident started to cry and said I'm hungry. Why can't you bring me food? Dietary Aide II ignored the resident and walked back off the hallway. During an interview on 4/20/26 at 12:42 P.M., the resident said the interaction between CNA T and Dietary Aide II made him/her feel sad and like he/she was a burden to staff for asking for food. During an interview on 4/24/26 at 7:29 A.M., the Regional Certified Dietary Manager said if a resident told a staff member they were hungry, dietary staff should get the resident food. If the staff member was busy, they should have found another staff member to bring the resident food. He expected staff to speak to residents in a dignified manner. During an interview on 4/24/26 at 9:37 A.M., Licensed Practical Nurse (LPN) N said it was not appropriate to talk in front of the residents in a way that made it sound like they could not be helped. He/She said staff should speak in a dignified manner to the residents. During an interview on 4/24/26 at 8:40 A.M., the Nurse Manager said there was a dignity issue amongst facility staff all over the building. He/She expected staff to speak in private and not in front of the resident if they had time concerns or felt like they could not assist the resident. She expected staff to speak to and in front of residents in a dignified manner. 3. Review of Resident #73's quarterly MDS, dated [DATE], showed:-Diagnoses included chronic kidney disease, schizophrenia, bipolar disorder, anxiety, and major depressive disorder;-Cognitively intact. Observation on 4/21/26 at 9:27 A.M., showed CNA B in the resident's room standing right inside the door. Both the resident and CNA B were screaming at each other. LPN D walked up to the doorway and told CNA B to stop screaming at the resident. CNA B said to LPN D the resident was not going to speak to him/her like that and then left the resident's room and walked down the hallway towards the nurse's station. During an interview on 4/21/26 at 9:33 A.M., CNA B said he/she went into the resident's room to ask him/her a question, and the resident started to yell at him/her. CNA B said he/she yelled right back at the resident to match the resident's energy. He/She knew he/she shouldn't speak that way to the residents. During an interview on 4/24/26 at 4:01 P.M., the Administrator and Director of Nursing (DON) said they expected staff to speak to residents in a dignified manner. They said it was not appropriate for staff to scream at residents. 4. Review of Resident #86's quarterly MDS, dated [DATE], showed:-Diagnoses included Alzheimer's disease, dementia, muscle weakness/wasting, and chronic kidney disease;-Severe cognitive impairment. Observation on 4/20/26 at 7:45 A.M., showed the resident sitting on the edge of his/her bed. The door to the resident's room was open and the privacy curtain was tucked away. CNA M stood in front of the resident and changed the resident from pajamas to clothing. The resident's breasts were exposed to the hallway. During an interview on 4/24/26 at 10:23 A.M., CNA M said he/she was in a hurry to get residents up, because the night shift had not gotten any of the residents up. He/She should have closed the resident's door before getting the resident undressed to ensure the resident's dignity and privacy were upheld. During an interview on 4/24/26 at 4:01 P.M., the DON and Administrator said before a resident was changed, staff should ensure the bedroom door was closed and the privacy curtain was in place. 5. Observation on 4/21/26 at 8:41 A.M., showed Certified Medication Technician (CMT) G at the medication cart outside of the first-floor dining room. CMT G was heard talking while standing at the medication cart. He/She wore an earpiece in his/her ear. CMT G stood at the medication cart, administering medications to residents and was heard from approximately 20 feet away. He/She continued to have a conversation and continued to repeat, I need my money. CMT G administered medications to a resident in room [ROOM NUMBER] and was heard continuing the conversation on the phone from inside the resident's room. Observation on 4/21/26 at 8:46 A.M., showed a sign posted on the wall on the 100 South unit. The sign read, no Bluetooth zone. Better care starts with full attention. Reminder no phones in residential areas. Review of Resident #133's quarterly MDS, dated [DATE], showed:-Diagnoses included heart failure, anxiety, and depression;-Cognitively intact. During an interview on 4/21/26 at 1:03 P.M., Resident #133 said he/she resided on 100 South. The facility tried to put up a sign regarding cell phone use, but staff did not care. He/She heard a CMT on the phone this morning and he/she was fussing while on the phone. 6. Observation on 4/22/26 at approximately 1:30 P.M., showed CNA CC sat sitting at the one main nurses' station laughing and looking at his/her cell phone during a video call. A voice from the video call could be heard. Residents were observed walking past the nurses' station. 7. During an interview on 4/21/26 at 1:03 P.M., ten residents from the resident council confirmed they saw staff with an earpiece or Air pods, talking on the phone. It was every day and weekends. Staff continued to talk on the phone and ignored the residents. During an interview on 4/24/26 at 3:38 P.M., the Administrator and DON said expected residents to be treated in a dignified manner. They expected staff to refrain from using the telephone while assisting residents and passing medications. The Administrator said they were not supposed to be on the phone. It was an ongoing issue. There was a policy. 1619729

Based on interview and record review, the facility failed to ensure resident petty cash was available upon request, seven days a week, and to ensure requests were honored as soon as possible, no later than the same day for amounts less than $100.00 ($50.00 for Medicaid residents) or three banking days for amounts $100.00 ($50.00 for Medicaid residents) or more (Resident #133). This deficiency had the potential to affect all residents who had a resident trust account. The facility identified 124 residents with funds in the resident trust account. The census was 149.Review of the facility's Resident Trust policy, dated 3/1/17, showed:-The facility shall allow the residents access to their personal possessions and funds during regular business hours, Monday through Friday;-The facility will maintain a resident petty cash fund for resident trust transactions only. The petty cash clerk will be a facility employee designated by the Administrator at each facility. The petty cash clerk will be someone other than the Resident Trust Clerk and the Administrator and will not be authorized to sign checks. Requests for amounts larger than fifty dollars ($50.00) should be directed to the Resident Trust Clerk;-When a resident requests a cash withdrawal from his/her personal funds, the petty cash clerk will first verify that the funds are available. This is to be done by obtaining an Open Balance report from the Resident Trust Clerk;-Funds must be made accessible to the residents during regular business hours, Monday through Friday;-The policy failed to specify that requests for less than $100.00 ($50.00 for Medicaid residents) should be honored within the same day, and requests of $100.00 ($50.00 for Medicaid residents) or more should be honored within three banking days. 1. During a group interview on 4/21/26 at 1:03 P.M., nine out of nine residents, whom the facility identified as alert and oriented, said they can withdraw funds on Fridays. One resident said if a resident needed money on a Tuesday, they would not be able to get it. 2. During an interview on 4/19/26 at 9:20 A.M., Resident #133 said he/she had issues with the resident trust. The Business Office Manager (BOM) decided when he/she wanted to give out the residents' money. The beginning of the month, the resident wanted to withdrawal $60.00 for clothing and was told no. The BOM did not explain why and he/she never explained why. The resident was only able to get money out of his/her account once a week. During an interview on 4/23/26 at 12:47 P.M., Resident #133 said he/she received money on Friday afternoons when the BOM goes to the bank. If a resident needed more than $100.00, they need a one-day notice. Two weeks ago, he/she was not able to receive $60.00 for shopping. He/She received $50.00, instead. He/She received $50.00 on the first of the month and the next week he/she received $35.00. He/She explained to the BOM that he/she needed clothes and laundry was slow. During an interview on 4/21/26 at 10:47 A.M., the BOM said the resident did not come down for money last week. He/She never withdrew more than $50.00. The resident's last request was for $35.00 on 4/10/26. He/She did not request $50.00 on 4/10/26. On 4/6/26, he/she requested $50.00 and received $50.00. 3. During an interview on 4/22/26 at 11:42 A.M. Licensed Practical Nurse (LPN) D said residents should be able to get their money out whenever they want. The residents on the 300 hall men's unit were able to pull their money out on Thursdays, but the residents on the 300 hall women's unit had to wait until Fridays. 4. During an interview on 4/21/26 at 10:47 A.M., the BOM said there was petty cash on hand for the residents. The cash is from the resident trust account and it was replenished weekly. Banking days were Monday through Friday, from 9:00 A.M. to 5:00 P.M. The residents could get their money during that time. A resident could receive up to $50.00 per day. If they wanted more than that, they would have to complete a written request. Sometimes residents did major shopping and in that case, they would receive a check for the amount they needed. The amount varied, so it depended on how much the resident needed. If the BOM gave out cash for the week and only had a couple of hundred dollars left, a check request would be completed for a request of a larger sum of money. It depended on how much money was left and who still needed money. The residents could withdraw money before the weekend if they knew they are going out. If someone needed money on a Saturday, the BOM would drive up to the facility and give them the money. 5. During an interview on 4/24/26 at 3:38 P.M., the Administrator said banking was open at the facility Monday through Friday. The money was distributed weekly. Residents were able to come down for banking as well. On Saturdays, money was left at the front desk. If the resident had the funds in the account to withdrawal $30.00, they should be able to get that amount, if requested. If a resident requested more than $50.00, they would receive a check. The Administrator was not aware of any issues from residents regarding access to funds.

Based on interview and record review, the facility failed to provide and maintain complete accounting records, including the petty cash kept on hand, for the resident trust account for 12 out of 12 months. The facility failed to ensure monthly bank statements were added and reviewed monthly during the reconciliation. In addition, the facility failed to ensure quarterly statements were accurate for all residents with a trust account after new bank accounts were established. The facility failed to include debits and credits for the entire month of December 2025, leaving residents without accurate and complete quarterly statements for 10/1/25 through 12/31/25 and 1/1/26 through 3/31/26. This affected 11 out of 11 residents sampled for funds (Resident #133, #155, #9, #123, #55, #66, #1, #108, #117, #120, and #14). The facility identified 124 residents with a resident trust account. The census was 149. Review of the facility's Resident Trust policy, dated 3/1/17, showed:-The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed. These funds shall be safeguarded by the facility using complete and separate accounting principles, which precludes any commingling (mixing of funds belonging to one party with funds belonging to another party) of resident funds with facility funds;-The facility will maintain a resident petty cash fund for resident trust transactions only;-On a daily basis, usually at the end of the day, the Resident Trust Clerk must enter into electronic medical record (EMR) all transactions into and out of the petty cash box;-When the petty cash box needs to be replenished, the Resident Trust Clerk must reconcile the cash left in the box;-Resident Trust Reconciliation: A reconciliation of the bank statement, checkbook, and electronic record trust funds module must be completed monthly. This will be completed by staff accountant responsible for the facility's financials. The reconciliation must be done by someone other than the Resident Trust Clerk;-On the first day of every month, the Resident Trust Clerk must reconcile a list of all checks that were written from the resident trust account during the prior month. The list should include the date, check number, payee, and amount of the check. This list should be kept on the Public P drive under your facility named folder in a trust folder. An email will be sent to the management company's staff accountant responsible for your facility's reconciliation once it is updated. The bank statement should be sent as soon as it is received to account as soon as it is received;-When all corrections have been made, the management accountant reconciling the bankstatement will post the interest earned for that month to all the residents and fill out a check request for any items that are to be funded by the facility to trust account;-When the reconciliation is complete the management accountant will send to the resident trust clerk a copy of the completed reconciliation and bank statement, which should be filed in the monthly resident trust folder or binder;-Resident statements: A detailed written account of transactions affecting each resident's trust account shall be maintained and made available upon request. All accounts shall be reconciled monthly. The individual financial record shall be made available by statements on a quarterly basis;-The resident trust clerk is responsible for sending out quarterly statements;-Make copies of all statements and date stamp them with date they were mailed. Resident trust clerk will complete and sign the mailing confirmation and present to administrator to sign before emailing to Director of Business Office. Retain the copies for your files;-Statements should be sent to the resident and his/her guardian or legal representation. 1. Review of the facility's bank statements for the resident trust on 4/20/26, showed the facility provided 12 reconciled bank statements which covered April 2025 through March 2026. The monthly reconciled bank statements did not include the petty cash kept on hand or monthly bank statements. During an interview on 4/21/26 at 10:47 A.M., the Business Office Manager (BOM) said he/she reconciled the resident trust every month. The facility had petty cash on hand for the residents. The cash was from the resident trust account and it was replenished weekly. He/She believed he/she had access to the bank statements and they were included in the reconciliation, but then confirmed the statements were not in the resident trust binder. The bank statements go to corporate; not to the facility or to the BOM. The BOM was responsible for completing the reconciliation and corporate completed the audits. Petty cash was not added to the resident trust reconciliation. Petty cash had a separate reconciliation. The replenish amount was $1800.00 at least once a week. During the interview, the BOM counted the petty cash in the cash box, which amounted to $410.00. 2. During a group interview on 4/21/26 at 1:03 P.M., two out of 10 residents, whom the facility identified as alert and oriented, said they did not receive quarterly statements from the facility. 3. Review of Resident #133's quarterly statement, dated 10/1/25 through 12/31/25, showed:-On 11/12/25, a debit in the amount of $921.50 to close the account. Transaction description showed owner change on 11/12/25;-On 12/9/25, account closed, $0 balance;-No further account debits and credits documented after 12/9/25. Review of the resident's quarterly statement, dated 1/1/26 through 3/31/26, showed on 1/1/26, a beginning balance of $692.56. During an interview on 4/21/26 at 10:47 A.M., the BOM said there were no residents with concerns regarding their trust account. When asked about Resident #133, the BOM said the resident bought a note pad in which he/she wrote down balances. Somehow, the resident's account was off. They printed out the resident's quarterly statement and went over it. The differences got resolved and the resident kept a copy of the statement. It was the individual statement from Resident Fund Management Services (RFMS). During an interview on 4/23/26 at 12:47 P.M., the resident said he/she did not receive quarterly statements. He/She asked for an audit because his/her account does not sync with him/her. He/She kept a log of his/her trust account in a notebook. The amounts he/she tracked were different from the amounts tracked by the BOM. He/She told the BOM the amounts were different, but the BOM just looked at the resident like he/she did not know what the resident was talking about. 4. Review of Resident #155's quarterly statement, dated 10/1/25 through 12/31/25, showed:-On 11/12/26, a debit in the amount of $5,748.10 to close the account. Transaction description showed owner change on 11/12/25;-On 12/9/25, account closed, $0 balance;-No further account debits and credits documented after 12/9/25. Review of the resident's quarterly statement, dated 1/1/26 through 3/31/26, showed on 1/1/26, a beginning balance of $6,342.51. 5. Review of Resident #9's quarterly statement, dated 10/1/25 through 12/31/25, showed:-On 11/12/25, a debit in the amount of $151.37 to close the account. Transaction description showed owner change on 11/12/25;-On 11/12/25, account closed, $0 balance;-No further account debits and credits documented after 12/8/26. Review of the resident's quarterly statement, dated 1/1/26 though 3/31/26, showed on 1/1/26, a beginning balance of $26.29. 6. Review of Resident #123's quarterly statement, dated 10/1/25 through 12/31/25, showed-On 11/12/25, a debit in the amount of $3,474.50 to close the account. Transaction description showed owner change on 11/12/25;-On 11/12/25, account closed, $0 balance;-No further account debits and credits documented after 12/8/25. Review of the resident's quarterly statement, dated 1/1/26 through 3/31/26, showed on 1/1/26, a beginning balance in the amount of $2,178.80. 7. Review of Resident #55's quarterly statement, dated 10/1/25 through 12/31/25, showed:-On 11/12/25, a debit in the amount of $7,764.92;-On 11/12/25, account closed, $0 balance;-On 12/1/25, $0.02 interest paid;-On 12/3/25, a credit in the amount of $1,505.00;-On 12/8/25, a debit in the amount of $1,505.02 to close the account;-No further account debits and credits documented after 12/8/25. Review of the resident's quarterly statement, dated 1/1/26 through 3/31/25, showed on 1/1/26, beginning balance of $6,107.71. 8. Review of Resident #66's quarterly statement, dated 10/1/25 through 12/31/25, showed:-On 11/12/25, a debit in the amount of $3,288.01 to close the account. Transaction description showed owner change on 11/12/25;-On 12/1/25, $0.01 interest paid;-On 12/8/25, a debit in the amount of $0.01 to close account;-No further account debits and credits documented after 12/8/25. Review of the resident's quarterly statement, dated 1/1/25 through 3/31/25, showed on 1/1/26, a beginning balance of $4982.35. 9. Review of Resident #1's quarterly statement, dated 10/1/25 through 12/31/25, showed:-On 11/12/25, a debit in the amount of $5,461.38 to close the account. Transaction description showed owner change on 11/12/25;-On 12/1/25, $0.02 interest paid;-On 12/9/25, a debit in the amount of $0.02 to close account;-No further account debits and credits documented after 12/9/26. Review of the resident's quarterly statement, dated 1/1/26 through 3/31/26, showed on 1/1/26, a beginning balance of $6,602.60. 10. Review of Resident #108's quarterly statement, dated 10/1/25 through 12/31/25, showed:-On 11/12/25, a debit in the amount of $2,954.05 to close the account. Transaction description showed owner change on 11/12/25;-On 12/1/25, $0.01 interest paid;-On 12/9/25, a debit in the amount of $0.01 to close account;-No further account debits and credits documented after 12/9/25. Review of the resident's quarterly statement, dated 1/1/26 through 3/3/25, showed on 1/1/26, a beginning balance of $7,557.64. 11. Review of Resident #117's quarterly statement, dated 10/1/25 through 12/31/25, showed:-On 11/12/25, a debit in the amount of $36,151.67 to close the account. Transaction description showed owner change on 11/12/25;-On 12/1/25, $0.12 interest paid;-On 12/9/25, a debit in the amount of $0.12 to close account;-No further account debits and credits documented after 12/9/25. Review of the resident's quarterly statement, dated 1/1/26 through 3/31/26, showed on 1/1/26, a beginning balance of $36,475.28. 12. Review of Resident #120's quarterly statement, dated 10/1/25 through 12/31/25, showed:-On 11/12/25, a debit in the amount of $10,145.46 to close the account. Transaction description showed owner change on 11/12/25;-On 12/1/25, $0.03 interest paid;-On 12/9/25, a debit in the amount of $0.03 to close account;-No further account debits and credits documented after 12/9/25. Review of the resident's quarterly statement, dated 1/1/25 through 3/31/25, showed on 1/1/26, a beginning balance of $9.045.56. 13. Review of Resident #14's quarterly statement, dated 10/1/25 through 12/31/25, showed:-On 11/12/25, a debit in the amount of $1,150.53 to close the account. Transaction description showed owner change on 11/12/25;-On 12/8/25, account closed, $0 balance;-No further account debits and credits documented after 12/8/25. Review of the resident's quarterly statement, dated 1/1/26 through 3/31/26, showed on 1/1/26, a beginning balance of $767.49. During an interview on 4/21/26 at 10:47 A.M., the BOM said there was a change in bank accounts. The facility was under new ownership as of 9/15/25, so the bank account was closed and a new account was opened at a different bank. The BOM did not know the date of when the bank account closed and opened. The BOM checked Resident #14's quarterly statement. He/She did not know why the closing amount was different from the beginning balance on 1/1/26. He/She checked the account on the computer and confirmed there were additional transactions that did not show on the quarterly statements. The transactions appeared on the individual ledger on RFMS. The BOM said he/she should have sent out two quarterly statements. There were two RFMS accounts after the new accounts were set up. He/She did not know there were two sets and the records did not pull over from the old bank. The quarterly statements did not include transactions after the account closed. Review of Resident #14's individual RFMS statement, reviewed on 4/21/26, showed:-On 12/8/25, a debit in the amount of $50.00;-On 12/22/25, a debit in the amount of $50.00;-On 12/22/25, a debit in the amount of $430.00;-On 12/24/25, a debit in the amount of $50.00;-On 12/30/25, a debit in the amount of $24.09;-On 12/30/25, a balance of $767.49. 14. During an interview on 4/24/26 at 3:38 P.M., the Administrator said she expected the monthly reconciliation to include monthly bank statements and petty cash. Corporate also had oversight over the resident trust. She expected residents and/or guardians to receive quarterly statements, and they should be accurate. If a resident had a question about their account, the Administrator expected staff to assist the resident with accounting for their personal funds.

Based on observation and interview, the facility failed to ensure a clean and homelike environment by failing to ensure the 300 south hallway shower room was clean, the 300 south sitting room had a broken television removed, the 200 hallway was free from odors and the floors were clean, the 300 south bathrooms had working soap dispensers and towel holders, and room [ROOM NUMBER] had broken floor tiles and a television on the floor removed. The sample size was 33. The census was 149. Review of the facility's housekeeping deep cleaning policy, dated 6/29/23, showed:-Purpose: To ensure all rooms are clean;-Policy: Deep cleaning is to be completed as scheduled. This includes complete pull-outs of furniture in rooms, wall cleaning, floor cleaning (scrubbing and waxing included), restrooms to be cleaned and disinfected, cob webs removed, beds and rails to be cleaned, sprinkler heads to be cleaned, light covers to be clean and free of bugs, over -bed light covers to be cleaned and free of bugs, sink clean, windows to be cleaned and ensure no spider webs, drapes and curtains to be cleaned (including privacy curtains), call lights to be clean and free from dust/dirt build-up, floors at closets and doorways are to be free from wax/dirt build up, etc.;-Daily Cleaning: Pick up all trash and put into trash can and empty. Dust mop or sweep floor. Surfaces are to be cleaned including wall smudges, light and call light and side tables, head/ foot board/side rails of beds, windows. Clean bathroom using the same cleanser/disinfectant wall smudges, lights, and call switches, and support rails. Use Honey Bowl to clean inside, outside toilet tank, seat and bowl. Clean shower rooms inside the shower, around the shower, and the base boards in the room. 1. Observation of the 300 south hallway shower room, showed:-On 4/20/26 at 7:37 A.M., the toilet had brown and yellow matter on it. The bathtub was dirty with hair. The floor was dirty with debris in various areas;-On 4/20/26 at 12:13 P.M., the toilet had brown and yellow matter on it. The bathtub was dirty with hair;-On 4/21/26 at 5:31 A.M., the toilet had brown and yellow matter on it. The bathtub was dirty with hair. During an interview on 4/24/26 at 11:30 A.M., Housekeeper Q said the bathrooms were cleaned twice a day and as needed. He/She said the toilet, bathtub/shower, and floors were to be cleaned. During an interview on 4/24/26 at 1:16 P.M., Certified Nursing Assistant (CNA) B said since the new ownership took over the facility, the housekeeping staff hours had been cut. He/She said the bathrooms were not being cleaned as often as they should be. During an interview on 4/24/26 at 4:05 P.M., the Administrator said housekeeping staff were responsible for cleaning bathrooms and resident rooms. She expected housekeeping staff to clean the 300 south shower room once a day and as needed. 2. Observation of the 300 south hallway sitting room, showed:-On 4/19/26 at 8:49 A.M., the television on the wall was smashed with a cracked screen; -On 4/21/26 at 10:18 A.M., the television on the wall was smashed with a cracked screen. During an interview on 4/24/26 at 10:19 A.M., the Maintenance Director said he was aware of the broken television in the 300 south hallway sitting room. He would expect for the television to be removed and replaced. During an interview on 4/24/26 at 4:05 P.M., the Administrator said maintenance staff was responsible for fixing broken appliances. If they were unable to fix the appliance, she expected them to come to her so she could order a new appliance. She expected for the television on the 300 south hallway to be taken down and replaced. She said the television had been broken since 2/1/26 when a resident threw a chair at it. 3. Observation of the 200 hallway, showed:-On 4/20/26 at 10:53 A.M., a strong urine odor and sticky floors in the main hallway and sitting room;-On 4/21/26 at 5:13 A.M., a strong urine odor and sticky floors in the main hallway and sitting room;-On 4/23/26 at 8:27 A.M., a strong urine odor and sticky floors in the main hallway and sitting room. During an interview on 4/24/26 at 11:30 A.M., Housekeeper Q said floors and the sitting room on the 200 hallway should be cleaned and free from odors. He/she said the housekeeping department was short staffed so the sitting room was only cleaned once a day. He/She said there were residents on the 200 hallway that went to the bathroom in the sitting room instead of the bathroom. During an interview on 4/24/26 at 4:05 P.M., the Administrator said housekeeping staff was responsible for cleaning the building. Nursing staff cleaned bodily fluids and then housekeeping staff came behind them to sanitize the area. She expected the 200 hallway to be free from odors. She expected the floor to be clean and not sticky. She said there were residents on the 200 hallway that went to the bathroom in the sitting room instead of the bathroom so the urine odor could be hard to get rid of. 4. Observations on 4/19/26 at 9:43 A.M., 4/20/26 7:44 A.M., and 4/24/26 at 10:39 A.M., showed on 300 South, the first shower room had a detached paper towel and soap dispenser. There were no paper towels or soap bottles for residents to wash their hands. During an interview on 4/24/26 at 10:39 A.M., Maintenance Worker FF said housekeeping was responsible for the soap and paper towel holders. The residents ripped them off the wall. The front desk had a plan to keep them stocked. 5. Observations on 4/19/26 at 9:48 A.M., 4/20/2026 7:47 A.M., and 4/24/26 at 10:39 A.M., showed room [ROOM NUMBER] had four tiles removed, visible from the doorway and another tile removed from in front of the bed. The removed tiles were laid out on the floor. A television was on the floor next to the window with a cord in the walkway. 6. During an interview on 4/24/26 at 10:58 A.M., the Maintenance Director said the tiles removed and left on the floor in room [ROOM NUMBER] did not make it a homelike environment. He needed some adhesive glue to put the tiles back on the floor. He was not informed or saw a work order for the soap dispenser or paper towel holder removed in the first shower room. He was unaware the second shower room had holes in the wall where the toilet paper holder used to be. During an interview on 4/10/26 at 12:32 P.M., the Administrator said maintenance was responsible for fixing things that were broken. Housekeeping staff was responsible for cleaning the facility. The Administrator said she expected the removed tiles to be picked up off the floor and removed from residents' area. Loose tiles could cause other residents to trip or other residents to throw them. She expected the broken paper towel holder and soap dispenser to be fixed. The second shower room with the toilet paper holder missing should have been fixed, and the holes patched. 2983889

Based on interview and record review, the facility failed to send the Office of the State Long-Term Care (LTC) Ombudsman a copy of the notice of resident discharges in January, February, and March 2026. The census was 149. Review of the facility's Resident Transfer, Discharge, Immediate Discharge, and Therapeutic Leave policy, last revised 4/28/25, showed:-Purpose: Establish policy and procedure regarding the transfer/discharge of residents. To ensure no inappropriate discharges are made and that no discharges are made in an unsafe manor;-Notice of discharge or transfer:--Who must receive notice:---Notifying the representative for the Office of the State Long-Term Ombudsman;----A copy of the discharge transfer notice shall be sent to the Ombudsman at least 30 days in advance of the discharge or as soon as possible;----In the case of an emergency or immediate discharge, copies shall be sent to the Ombudsman. This notice shall be sent when practicable and a monthly list is acceptable and should include if the resident's return is expected. Review of the facility's admission and Discharge Report, dated 7/16/24 through 4/19/26, showed:-January 2026: 13 residents discharged ;-February 2026: 20 residents discharged ;-March 2026: 22 residents discharged . During an interview on 4/21/26 at 1:18 P.M., the Ombudsman said their office has not received any transfer or discharge notices from the facility for January, February, and March 2026. During an interview on 4/21/26 at approximately 1:30 P.M., the Social Service Director said she had only worked at the facility for about two weeks and she had not sent any discharge transfer notices to the Ombudsman since working at the facility. She thought the Social Service Designee had been sending them. During an interview on 4/21/26 at 1:40 P.M., the Social Service Designee said she had not been sending the transfer or discharge notices to the Ombudsman's office. The previous SSD was responsible for sending them. During an interview on 4/21/26 at approximately 2:00 P.M., the Administrator said she expected the Social Services Director or the Social Service Designee to send the required documentation of discharges and transfers to the Ombudsman's office.

Based on observation, interview, and record review, the facility failed to ensure food was served to residents at a safe and palatable temperature, affecting six out of 33 sampled residents (Residents #3, #5, #12, #78, #110, and #148). The census was 149. Review of the facility's dietary food preparation policy, dated 7/5/23, showed:-Food Temperatures: Foods will be served at proper temperature to ensure food safety;-If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature;-Warm foods should measure at 135 degrees Fahrenheit (F). 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/1/26, showed:-Diagnoses included type two diabetes;-Cognitively intact. During an interview on 4/20/26 at 7:27 A.M., the resident said the food tasted terrible and was always cold. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed:-Diagnoses included chronic kidney disease;-Moderately impaired cognition. During an interview on 4/19/26 at 10:43 A.M., the resident said food was most always cold when it was delivered to him/her. 3. Review of Resident #12's quarterly MDS, dated [DATE], showed:-Diagnoses included anorexia (eating disorder);-Cognitively intact. During an interview on 4/19/26 at 9:22 A.M., the resident said the food was most always served cold. He/She said he/she had an eating disorder, and it did not help that the food was cold, which made him/her not want to eat it. 4. Review of Resident #78's quarterly MDS, dated [DATE], showed:-Cognitively intact. During an interview on 4/19/26 at 8:57 A.M., the resident said the food was served cold a lot of the time. 5. Review of Resident #148's quarterly MDS, dated [DATE], showed:-Moderately impaired cognition. During an interview on 4/20/26 at 8:48 A.M., the resident said the food could sometimes be cold. 6. Observation on 4/19/26 at 9:01 A.M., of the 300 south hallway breakfast, showed:-Breakfast was served in Styrofoam boxes;-Sauage patty measured 81.5 degrees Fahrenheit (F) and was cold;-Scrambled eggs measured 80.7 degrees F and were cold;-Cream of wheat measured 118 degrees F and was cold. Observation on 4/20/26 at 12:01 P.M., of the 200 hallway lunch, showed:-The room tray cart was uncovered and the plates had no coverings;-Pasta with meat measured 120 degrees F and was lukewarm;-Mixed veggies measured 108 degrees F and were cold. 7. During an interview on 4/24/26 at 7:29 A.M., the Regional Certified Dietary Manager said he would expect food to be delivered to residents at a safe and palatable temperature. He would expect staff to return food to the kitchen if it was too cold. 8. During an interview on 4/24/26 at 10:32 A.M., [NAME] O said the facility policy was to deliver food to the residents at a safe and palatable temperature to avoid sickness. 9. During an interview on 4/24/26 at 10:45 A.M., the Administrator said she would expect food to be delivered to residents at a safe and palatable temperature. 28058152978916

Based on observation, interview, and record review, the facility failed to ensure the kitchen equipment was clean and floors were free of trash and grime. The sample size was 33. The census was 149. Review of the facility's Dietary - Equipment operations, Infection Control, and Sanitation policy, dated 2/2/24, showed:-The dietary staff shall maintain the sanitation of the dietary department through compliance with written, comprehensive cleaning schedules developed for the facility by the Dietary Manager;-Refrigerator walk-in: Weekly cleaning. Thoroughly sweep all floor areas and corners. Mop floor and drain area. Scrub any hard-to-clean areas using a sanitizing solution and scouring pad;-Deep fryer: Once a month, or as needed, the cook with the assistance of the Dietary Manager will clean and disinfect the deep fryer. The grease will be drained from the deep fryer through the bottom. A valve is turned on which allows the grease to drain through into a plastic 5-gallon bucket. The grease is then taken out to the side of the building and poured into a drain beside the kitchen and the lid put back on the drain. A solution of hot water and degreaser is fixed. With this solution and a brush, the outside of the deep fryer is cleaned;-Floors: Sweep and mop daily. 1. Observation on 4/20/26, of the kitchen, showed:-At 6:42 A.M., the dry storage room had trash and debris on the floor;-At 6:47 A.M., the second walk in refrigerator had a liquid spill on the floor and food debris under the storage racks;-At 6:48 A.M., the deep fryer had dark grease with food debris on the inside of the fryer. The sides of the deep fryer had sticky grease build up;-At 6:49 A.M., the floors under the oven, deep fryer, and ice machine had a dark substance build up. 2. Observation on 4/21/26, of the kitchen, showed:-At 5:20 A.M., the dry storage room had trash and debris on the floor;-At 5:21 A.M., the second walk in refrigerator had a liquid spill on the floor and food debris under the storage racks;-At 5:23 A.M., the deep fryer had dark grease with food debris on the inside of the fryer. The sides of the deep fryer had sticky grease build up. 3. Observation on 4/22/26, of the kitchen, showed:-At 1:39 P.M., the deep fryer had dark grease with food debris on the inside of the fryer. The sides of the deep fryer had sticky grease build up;-At 1:46 P.M., the floors under the oven, deep fryer, and ice machine had a dark substance build up. 4. During an interview on 4/24/26 at 7:29 A.M., the Regional Certified Dietary Manager said he would expect the kitchen appliances to be cleaned. He said the cook was responsible for cleaning the appliances after every use. He would expect the floors in the kitchen to be cleaned and free from trash and debris. He said all dietary staff were responsible for sweeping and mopping the floors. 5. During an interview on 4/24/26 at 10:32 A.M., [NAME] O said cooks were responsible for cleaning the kitchen appliances at least once a day. He/She said all dietary staff were responsible for sweeping and mopping the floors. 6. During an interview on 4/24/26 at 10:45 A.M., the Administrator said she expected the kitchen appliances to be cleaned. She said the cooks were responsible for cleaning kitchen appliances. She would expect the floors in the entire kitchen to be cleaned and free from trash and debris.

Based on observation, interview, and record review, the facility failed to ensure the pest control program was effective in preventing mice, which affected three out of 33 sampled residents (Residents #48, #12, and #78). The census was 149. Review of the facility's pest control program policy, dated 5/14/24, showed:-Purpose: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents;-Policy: Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. Facility will ensure that appropriate chemicals are used to control pests but can be used safely inside the building without compromising resident health. Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated. Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations. Facility will ensure that the outside pest service also treats the exterior perimeter of the facility and any outlying buildings or structures, i.e. dumpster area, etc. Review of the facility's pest control logs showed on 4/15/26, 4/8/26, 3/31/26, 3/25/26, and 3/19/26, the facility was treated by the pest control company and mouse traps were replaced. 1. Review of Resident #48's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/10/26, showed:-Diagnoses included schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), chronic pain syndrome, and mild intellectual disabilities;-Moderately impaired cognition. During an interview on 4/24/26 at 1:16 P.M., Licensed Practical Nurse (LPN) D and Certified Nursing Assistant (CNA) B said housekeeping staff hours were cut when the new ownership took over the facility. They said the current housekeepers did not clean the resident rooms as frequently as they should. They said there was a mouse problem and indicated that the resident's room is where mice were seen the most. CNA B said the resident did not like people going through his/her things, so his/her belongings did not get cleaned. Observation and interview on 4/24/26 at 1:29 P.M., showed the resident sat on the edge of his/her bed. A squeaking noise could be heard near the resident's dresser. A mouse trap behind the resident's dresser had a live mouse in it. The clothing in the resident's bottom drawer had brown sprinkle shaped substance on them. Food and trash wrappers were in the drawer. The resident said mice were always around his/her room and crawled on him/her at night. During an interview on 4/24/26 at 1:25 P.M., Maintenance FF came into the room to dispose of the mouse and said the resident's room was a hotspot for mice due to the resident's belongings not being cleaned. 2. Review of Resident #12's quarterly MDS, dated [DATE], showed:-Diagnoses included anorexia, bipolar disorder (mood disorder that causes mood swings), post-traumatic stress disorder (PTSD), and major depressive disorder;-Cognitively intact. Observation and interview on 4/20/24 at 12:42 A.M., showed the resident's room had brown sprinkle shaped matter in the closet. The resident said he/she had seen mice in his/her room. He/She said most recently two mice were caught in the glue trap in his/her room. 3. Review of Resident #78's quarterly MDS, dated [DATE], showed:-Diagnoses included paranoid schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), anxiety, and insomnia;-Cognitively intact. During an interview on 4/19/26 at 8:57 A.M., the resident said there were mice all over the place on the 300-south hallway. He/She said he/she had seen mice in the hallway. 4. Observation on 4/24/26 at 9:44 A.M., of the 300-south hallway, showed a mouse ran across the floor and into the medication storage room. CNA B said there were mice all over and pointed out mouse droppings on the floor, in the corner of the medication storage room. 5. During an interview on 4/24/26 at 11: 18 A.M., Pest Control Technician P said his/her company came out every week to treat the facility. He/She said the company was focusing on mice. He/She said they had gone from catching 30 mice a week to 10 a week. He/She said the facility had been recommended to keep resident rooms clean and free from food trash to avoid mice. He/She said the mouse traps had a 30-day life span before they needed to be replaced. 6. During an interview on 4/24/26 at 4:20 P.M., the Administrator said she would expect facility staff and maintenance staff to follow the recommendations from the pest control company to deter mice. She would expect staff to inform her and the Maintenance Director if they were seeing mice or mouse droppings. She would expect staff to assist residents in keeping their rooms free from food trash. 29838892805815

Based on interview and record review, the facility failed to ensure residents were allowed to exercise their right to choose their attending physician when the facility discontinued services with Physician RR and failed to permit Physician RR to continue providing care within the facility, resulting in residents being required to transition to a different physician for two residents (Residents #133 and #139). The sample size was 33. The census was 149. Review of the facility's undated admission Agreement, showed:-Resident rights: Facility has delivered, and Resident acknowledges receipt of a document entitled ''Nursing Home Resident Rights that describes Resident's rights at Facility. Resident also acknowledges that Facility has orally explained these rights in terms Resident can reasonably be expected to understand. The rights of Resident do not include any proprietary, legal or equitable interest in the properties of Facility;-Selection of Healthcare Professionals by Resident: Resident may select, or have selected on his/her behalf, qualified healthcare professionals who conform to Facility's policies and rules and applicable laws and regulations. Resident must have, select, or have chosen on his/her behalf a personal physician licensed in Missouri who is responsible for resident's total care and will be available, or whose agent will be available, at all times for notification of significant changes in Resident's clinical condition. Facility may require that the healthcare professional be credentialed by Facility. Resident agrees that any expense for such services shall be borne by resident. 1. Review of Resident #133's quarterly Minimum Data Set (MDS , a federally mandated assessment instrument completed by facility staff), dated 3/8/26, showed the following:-Cognitively intact;-Diagnoses included anemia, heart failure, high blood pressure, stroke, anxiety, depression, and psychotic disorder. Review of the resident's face sheet, showed:-Original admission date of 8/3/12;-Physician DD was documented as the resident's primary physician;-Nurse Practitioner SS was documented as alternate physician;-Resident is his/her own responsible party. During an interview on 4/22/26 at 1:20 P.M., the resident said he/she had received the letter from the facility regarding Physician RR. Other residents were upset, including Resident #133 because they had Physician RR for so many years. He/She heard the nursing staff discussing Physician RR and the only complaint he/she heard was that Physician RR did not return calls fast enough. Review of facility's physician letter, dated 4/10/26, and signed by the administrator, showed:-Physician RR continues to fail to sign orders, complete Medicare certification, and timely enter progress notes;-The facility has asked residents under his/her care to transition to alternative physicians;-The admission Agreement provides that, if a physician fails or refuses to meet applicable statutory or regulatory requirements, the facility may assist the resident in selecting another physician to ensure the resident's care needs are met. During an interview on 4/23/26 at 12:47 P.M., Resident #133 said staff came around with a letter. He/She asked what happened to Physician RR, but he/she was ignored. He/She asked social services, and he/she said it was Physician DD now. 2. Review of Resident #139's face sheet, showed:-Original admission date of 11/24/24;-Physician DD was documented as the resident's primary physician;-Resident is his/her own responsible party. Review of Resident #139's quarterly assessment MDS dated [DATE], showed the following:-Cognitively intact;-Diagnoses included high blood pressure, anxiety, depression, schizophrenia (a chronic severe brain disorder characterized by symptoms like hallucinations, delusions and disorganized thinking), post-traumatic stress disorder, and asthma. During an interview on 4/24/26 at 2:25 P.M., Resident #139 said quite a few residents wanted to keep Physician RR. They automatically enrolled them to see Physician DD whether they wanted to or not. The resident did not want to put up a fight. If Physician RR returned, that would be great. He/She had a rapport with Nurse Practitioner SS for nine years. 3. During a group interview on 4/21/26 at 1:03 P.M., nine residents said they dropped Physician RR about a month ago. They passed a sheet to residents that said they were not using Physician RR, and they had a new doctor. 4. During an interview on 4/23/26 at 11:02 A.M., the Director of Nursing (DON) said to his/her understanding, Physician RR did not sign orders or return phone call. The DON had been working at the facility since October or November 2025, and he/she had only seen Physician RR in the facility once. The DON was asked if he/she could provide specific examples of how it impacted resident care. To his/her knowledge, care was not delayed. They could not reach Physician RR, so they contacted Nurse Practitioner SS, who worked with Physician RR. Nurse Practitioner SS was easier to reach. Physician RR was no longer the facility's primary physician as of last month. 5. During an interview on 4/23/26 at 12:33 P.M., Licensed Practical Nurse (LPN) E said Resident #133 and Resident #139 wanted to keep Physician RR. There was a third resident that loved Physician RR. They met the new physician, but they had a rapport with Physician RR. 6. During an interview on 4/24/26 at 10:16 A.M., the DON said there were no residents that expressed feelings about not having Physician RR anymore. Physician RR was difficult to get ahold of and get in contact with. It was easier to talk to Nurse Practitioner SS. 7. During an interview on 4/24/26 at 3:38 P.M., the Administrator said the residents received 30 days' notices that the primary physician was changed. Residents were able to continue to see Physician RR, but not in the facility. They had to go to Physician RR's office. She would expect the residents to choose their own physician and they could choose to see Physician RR, but outside the facility. The only resident that wanted to continue to see Physician RR was Resident #133. He/he was given the option to see Physician RR, just not at the facility. Intake: 2797362

Based on interview and record review, the facility failed to routinely notify residents receiving Medicaid benefits when the amount in the resident's account was within $200.00 of the resource limit for seven residents (Resident #117, #66, #55, #1, #108, #120, and #155). The facility identified 124 residents with a resident trust account. The census was 149. Review of the facility's Resident Trust policy, dated 3/1/17, showed the resident trust clerk must monitor account balances. Missouri Medicaid residents are allowed to keep only a total of their state's allowable limit (Missouri is $6068.80, effective 7/1/2025) in non-exempt resources. Any Medicaid resident who is within $200.00 of these allowed amounts should be notified in writing that he/she is within $200.00 of the allowable non-exempt resource limit set forth and may lose their eligibility if they accumulate excess funds. The Administrator and facility Social Worker should be advised of all account balances at this limit for follow up. 1. Review of Resident #117's balance notification letters, dated May, July, August, and September 2025, showed:-May 2025, guardian notified at 3:39 P.M. Guardian states they will set up a trust;-July 2025, spoke with guardian again at 2:04 P.M. and the guardian states that a trust will be set up, but cannot provide a time frame;-August 2025, spoke with guardian, stated they still plan to set up a trust and may be able to give timeline next month;-September 2025, spoke with guardian about burial plan and guardian will check to see if he/she have a burial plan balance. Review of the resident's trial balance, reviewed 4/21/26, showed a balance of $36,353.13. Review of the resident's Resident Fund Management Service (RFMS) statements, showed:-On 11/3/25, balance of $1,484.00;-On 11/13/25, ownership transfer credit of $36,201.67;-On 1/2/26, balance of $38,000.28;-On 2/2/26, balance of $36,466.39;-On 3/2/26, balance of $36,429.22;-On 4/1/26, balance of $36,368.13. Review of the resident's balance notification letters, dated January 2026 through April 2026, showed:-February 2026, no letter;-On 3/23/26, left message for guardian;-On 4/22/26, left message for guardian on 4/22/26 at 2:42 P.M. During an interview on 4/24/26 at 8:31 A.M., the resident said he/she had $35,000.00 in his/her trust account. When asked how he/she wanted to use the funds, he/she said he/she wanted to give the money to his/her adult child. During an interview on 4/24/26 at 3:38 P.M., the Administrator said she was aware of the resident's balance and the facility was trying to spend it down. 2. Review of Resident #66's trial balance, reviewed 4/21/26, showed a balance of $11,697.61. Review of the resident's RFMS statements, showed:-On 11/15/25, ownership transfer credit of $3,288.01;-On 1/2/26, balance of $4,983.24;-On 2/2/26, balance of $6,624.31;-On 3/2/26, balance of $8,315.65;-On 4/1/25, balance of $10,007.61. Review of the resident's balance notification letters, dated January 2026 through April 2026 showed:-On 1/28/26, spoke on 1/31/26 at 2:13 P.M., said he/she will see what he/she can do;-February 2026, no letter;-On 3/23/26, will pay private pay room and board for uncovered months;-April 2026, no letter. During an interview on 4/24/26 at 3:38 P.M., the Administrator said if a resident and/or guardian decided the resident's payor source would switch to private pay, she expected there to be documentation of the discussion, to include with whom they spoke and confirmation that the resident and/or guardian received an explanation of cost for private pay. 3. Review of Resident #55's trial balance, reviewed 4/21/26, showed a balance of $7,818.82. Review of the resident's RFMS statements, showed:-On 11/13/25, ownership transfer credit of $7,764.92;-On 1/2/26, balance of $7,655.71; -On 2/2/26, balance of $7,665.63;-On 3/2/26, balance of $7,950.13;-On 4/1/26, balance of $7,768.82. Review of the resident's balance notification letters, dated January 2026 through April 2026, showed:-January 2026, no letter;-February 2026, no letter;-On 3/23/26, left message for family member;-On 4/22/26, letter signed by the resident. 4. Review of Resident #1's trial balance, reviewed 4/21/26, showed a balance of $6,824.62. Review of the resident's RFMS statements, showed:-On 11/3/25, balance of $1,341.00;-On 11/1325, ownership transfer credit of $5,461.38;-On 1/2/26, balance of $7,983.02;-On 2/2/26, balance of $7,784.56;-On 3/2/26, balance of $8,965.25;-On 4/1/26, balance of $5,595.62. Review of the resident's balance notification letters, dated January 2026 through April 2026, showed:-On 1/28/26, left a message for his/her family member about his/her spend down on 1/31/26 at 10:15 A.M.;-February 2026, no letter;-March 2026, no letter;-April 2026, no letter. 5. Review of Resident #108's trial balance, reviewed 4/21/26, showed a balance of $9,832.12. Review of the resident's RFMS statements, showed:-On 11/13/25, ownership transfer credit of $2,954.05;-On 1/2/26, balance of $7,559.20;-On 2/2/6, balance of $9,610.89;-On 3/2/26, balance of $9.729.99;-On 4/1/26, balance of $9,782.12. Review of the resident's balance notification letters, dated January 2026 through April 2026, showed:-On 1/28/26, called resident's family member, who said he/she will do what he/she can before the end of February 2026;-February 2026, no letter;-On 3/23/26, left message for resident's family member;-April 2026, no letter. 6. Review of Resident #120's trial balance, reviewed 4/21/26, showed a balance of $7,922.84. Review of the resident's RFMS statements, showed:-On 11/13/25, ownership transfer credit of $10,145.46;-On 1/1/26, balance of $11,164.56;-On 2/2/26, balance of $8,759.42;-On 3/2/26, balance of $8,471.07;-On 4/1/26, balance of $7,922.84. Review of the resident's balance notification letters, dated January 2026 through April 2026, showed:-On 1/28/26, spoke with resident's family member on 1/31/26 at 12:50 P.M. about spend down said he/she will send a gift card and clothes along with receipt;-February 2026, no letter;-On 3/23/26, left message for guardian;-April 2026, no letter. 7. Review of Resident #155's trial balance, reviewed 4/21/26, showed a balance of $6,403.78. Review of the resident's RFMS statements, showed:-On 11/3/25, balance of $1,587.00;-On 11/13/25, ownership transfer credit of $5,748.10;-On 1/2/26, balance of $7,962.94;-On 2/2/26, balance of $6,286.17;-On 3/2/26, balance of $6,535.40;-On 4/1/26, balance of $6,353.78. Review of the resident's balance notification letters, dated January 2026 through April 2026, showed:-On 1/28/26, wants to do pre-paid burial plan for his/her spend down. Resident signed letter;-February 2026, no letter;-On 3/23/26, resident currently in hospital;-On 4/22/26, the letter signed by the resident. 8. During an interview on 4/24/26 at 3:38 P.M., the Administrator said she expected staff to ensure resident trust balances remained under the maximum limit for Medicaid residents. She did not know what the facility's policy was regarding balance notification letters or what to do if there was no response from the resident and/or resident's guardian. She expected staff to assist residents and/or their guardians in obtaining supplies or clothing that the resident could use to spend down their funds.

See F686 cited under Event ID 4F7E12 Based on observation, interview and record review, the facility failed to follow the facility's policy regarding wound care when staff failed to ensure continued wound care treatments following a hospitalization with an identified pressure injury (a localized area of skin damage that develops when prolonged pressure is applied to the body) to the tailbone (sacrum) upon discharge for one resident (Resident #14). The failure resulted in the worsening of the identified sacral wound and the development of two additional pressure injuries. Staff failed to ensure accurate documentation, notify the physician of worsening wounds since hospitalization and obtain wound care orders. In addition, staff failed to ensure timely wound dressing change to identified saturated dressings (Resident #16). The census was 145.

See F697 cited under Event ID 4F7E12 Based on observation, interview and record review, the facility failed to implement an effective pain management regime for two sampled residents (Resident #18 and #14). Staff failed to notify ensure Resident #18, who experienced pain related to metastatic breast cancer with osseous (bone) involvement, most severe over bilateral lower extremities, received pain medications as ordered by the physician and failed to notify the primary physician when pain medications were not delivered from the pharmacy and of medications available in the emergency kit. The resident experienced uncontrolled pain and was transferred to the hospital two days after admission to the facility. For Resident #14, the facility staff failed to provide effective pain relief when, during care, staff removed wound dressings which were adhered to the wound sites. The resident had so much pain, he/she was observed to cry and requested Certified Nurse Aide (CNA) D spray over the counter Bactine (relieves the pain and itch of minor cuts, scrapes and burns on contact) onto the buttock wound sites. The sample was 16. The census was 145.

Based on observation, interview and record review, the facility failed to follow the facility's policy regarding wound care when staff failed to ensure continued wound care treatments following a hospitalization with an identified pressure injury (a localized area of skin damage that develops when prolonged pressure is applied to the body) to the tailbone (sacrum) upon discharge for one resident (Resident #14). The failure resulted in the worsening of the identified sacral wound and the development of two additional pressure injuries. Staff failed to ensure accurate documentation, notify the physician of worsening wounds since hospitalization and obtain wound care orders. In addition, staff failed to ensure timely wound dressing change to identified saturated dressings (Resident #16). The census was 145. Review of the Wound Management Policy, revised 10/24/22, showed: -Purpose: provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers; -Definitions: -Pressure ulcer: any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. Pressure ulcers usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed; -Procedure: Assessment: -A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident; -Upon identification of a wound the licensed nurse will: -Measure the wound (length, width and depth); -Initiate a wound monitoring record sheet: -A wound monitoring record will be completed for each wound; -If the wound monitoring record is not used, documentation will be recorded within the medical record which may include nursing notes, treatment records or care plans; -An assessment of care needs for pressure ulcer and wound management will be made with emphasis on, but not limited to: -Identifying risk factors; -Treatment; -Mechanical offloading and pressure reducing devices; -Reducing skin friction, sheer, and moisture; -Nutritional status; -Evaluating and modifying interventions for a resident with an existing PU/PI; -Wound Management: -The attending physician will be notified to advise on appropriate treatment promptly; -The licensed nurse will notify the responsible party of the presence of a pressure ulcer; -Dietary contact will be made for nutritional assessment; -Rehabilitation services will be contacted for appropriate devices or pressure redistributing devices; -A licensed nurse will develop a care plan for the resident based on recommendations of dietary, rehabilitation and the attending physician; -Per physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management; -The attending physician and interdisciplinary team (IDT) will be notified of: -New pressure ulcers or wounds; -Pressure ulcers or wounds that do not respond to treatment; -Pressure ulcers or wounds that worsen or increase in size; -Complaints of increased pain, discomfort or decrease in mobility by a resident; -Signs of ulcer sepsis, presence of exudates (drainage), odor or necrosis (black, firm tissue), if not already noted by the physician; -Residents refusing treatment; -Certified Nurse Aides (CNAs) will complete body checks on resident's shower days and report unusual findings to the licensed nurse; -Documentation: -New pressure ulcers or wounds will be documented on the 24 hour log and an incident report will be completed by the licensed nurse; -Wound documentation will occur at a minimum of weekly until the wound is healed, documentation will include: -Location of wound; -Length, width, and depth measurements recorded in centimeters (cm); -Direction and length of tunneling (a channel or tunnel that forms beneath the surface of a wound, extending into deeper tissue) or undermining (a separation of the wound edges from the underlying tissues, creating a space or pocket beneath the wound surface; -Appearance of the wound base; -Drainage amount and characteristics including color, consistency and odor; -Appearance of wound edges; -Description of the peri-wound condition or evaluation of the skin adjacent to the wound; -Presence or absence of new epithelium at the wound rim; -Presence of pain; -IDT will document the discussions and recommendations for: -Pressure ulcers and wounds that do not respond to treatment; -Pressure ulcers and wounds that worsen or increase in size; -Complaints of increased pain, discomfort or decrease in mobility by a resident; -Signs of ulcer sepsis, presence on exudate, odor or necrosis; -Residents refusing treatment; -Licensed nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis; -Document notifications following a change in the resident's skin condition; -Update the resident's care plan as necessary. 1. Review of Resident #14's medical record, showed: -Original admission: 1/27/25; -Diagnoses included: quadriplegia (paralysis in all limbs), Parkinson's (a neurodegenerative disease causing muscle weakness and loss), diabetes, anxiety, muscle wasting, and reduced mobility; -Able to make needs and wants known. Review of the progress notes, showed: -On 2/3/25 at 11:26 P.M., a nurse note: the resident remained up in his/her wheelchair. Staff offered to assist to bed to encourage wound healing; -On 2/5/25 at 1:15 P.M., a nurse note: the resident said he/she was short of breath and complained of a sore throat and coughed thick, yellow mucus, complaint of minor chest pain. Vital signs: blood pressure 140/70 (normal, 120/80), temperature 101.3 degrees (normal range, 97.1-98.6 degrees Fahrenheit (F)), pulse 116 beats per minute (bpm) (normal range, 60-80 bpm) and oxygen saturation fluctuating between 87-90 percent (normal range, 90-100%). The physician notified and new orders to send to the emergency room for evaluation and treatment. Review of the February Treatment Administration Record (TAR), dated 2/1/25 through 2/28/25, showed: -An order, dated 2/6/25: enhanced barrier precautions related to wounds; -An order, dated 1/28/25: Triad Hydrophilic (used to create a moist wound environment, that promotes healing and debridement (removal of dead tissue) wound dressing paste. Apply to right buttock and left thigh twice a day for wound. Discontinued 2/7/25. Documented as completed twice a day, until discharged to the hospital on 2/6/25. Review of the hospital discharge summary, dated 2/12/25, showed: -admitted to the hospital: 2/5/25; -Diagnoses: Pneumonia and sepsis; -Wound dressing paste: apply one application topically twice a day to right buttock and left thigh wounds; -Wound care instructions: -Incontinent associated dermatitis (IAD, skin damage associated with incontinence) bilateral (both sides) buttocks; -Dressing status: open to air; -Site assessment: fragile, painful and pink; -Shape/pattern: irregular; -Peri-wound assessment: fragile, painful; -Interventions: cleansed, protective ointment; -Wound status: unchanged; -Non-staged description: partial thickness;. -Pressure injury to coccyx: -Dressing status: open to air; -Site assessment: Fragile, painful; -Shape/pattern: Irregular; -Peri-wound assessment: Fragile, painful; -Interventions: cleansed, protective ointment; -Pressure injury Stage: II (partial thickness skin loss, appearing as a shallow, open ulcer with a red or pink wound bed, or as an intact or open/ruptured blister); -Measurements: length 3 cm x width 4 cm; -Margins: Undefined edges; -Wound status: Unchanged;. -Medication list at discharge: -Hydrophilic cream (used to treat and prevent dry, rough and itchy skin): one application topically twice a day to the right buttock and left thigh wounds. -Nutrition orders: -Juven (high protein supplemental drink) twice a day, with breakfast and dinner. Review of the facility's admission assessment, dated 2/12/25, showed: -admitted from: hospital; -Skin assessment: -Color: normal; -Temperature: warm; -Turgor: normal (skin returns promptly); -Skin issues: no; -Physician actions: no new orders; -Were the list of medications from the hospital compared with the medications the resident was taking at home: yes; -Was the physician notified if any discrepancies were noted during the medication reconciliation: yes, reconciliation necessary, physician agreed with new medications prescribed by hospital. Review of the admission progress note, a late entry, dated 2/12/25 at 10:16 A.M., showed: -The resident is chairfast. Skin color is normal, skin is warm and dry. No skin issues present. Review of the February TAR, dated 2/1/25 through 2/28/25, showed no wound care orders and no documentation of treatments completed after re-admission on 2/12/25. Review of the re-admission Physician Order Sheet (POS), showed: -An order dated 2/13/25: wound care specialist to eval and treat if indicated; -No orders noted for Juven. Review of the Braden (a tool used to determine the person's risk to develop pressure injury) score, dated 2/17/25, showed: -Sensory perception: ability to respond to pressure related discomfort: 3, slightly limited; -Moisture: degree to which skin is exposed to moisture: 3, occasionally moist; -Activity: degree of physical activity: 2, chairfast; -Mobility: ability to change and control body position: 1, completely immobile; -Nutrition: probably inadequate: 2, rarely eats a complete meal; -Friction and shear: 2, potential problem; -Score: 13, moderate risk. Review of the progress notes, dated 2/17/25 at 1:25 P.M., showed a weekly skin observation note: late entry: the skin color is normal. Skin temperature is dry and warm. Skin turgor is normal as skin returns promptly. Skin issues present, refer to assessment. Review of the weekly skin assessment, dated 2/17/25 at 1:25 P.M., showed: -Skin color: normal; -Skin temperature: dry and warm; -Skin turgor: normal, skin returns promptly; -Skin issues: yes; -Skin condition: -Right buttock: incontinent associated skin dermatitis; -Left buttock: incontinent associated skin dermatitis; -Sacrum: reddened area; -No additional progress notes included. Review of the progress note, dated 2/17/25 at 2:50 P.M., showed: -A medication administration note: hydrocodone 5 milligram (mg)-325 mg (a narcotic pain reliever for moderate pain) administered for coccyx pain; -No additional notes regarding assessments, treatment or physician notification. Review of a nurse progress note, dated 2/20/25 at 2:37 P.M., showed the resident continued therapy and cooperative with care. The dressing on the coccyx changed and well tolerated. Redness noted to the groin, applied powder. The resident turned and repositioned in bed. (Note: Review of the February TAR, dated 2/1/25 through 2/28/25, showed no wound care orders and no documentation of treatments completed.) Review of the skilled nursing note, dated 2/20/25 at 2:41 P.M., showed: -Alert to person, place, time and situation; -Skin integrity: -No new changes to skin integrity noted; -Wound care: -The resident has treatable wounds -No further description as to number, type, location; -Dressing changed as per treatment orders: unselected; -Dressing change not required: unselected; -Changed were noted to wound: unselected. Review of the POS, showed: -An order, dated 2/20/25: wound consult to treat related to open area on the coccyx; -No orders noted for Juven supplement. Review of the progress notes, dated 2/23/25, showed: -At 11:45 A.M.,: pain to the bottom, barrier cream applied; (Note: the resident did not have any order for barrier cream) -At 1:34 P.M., medication note: Hydrocodone 5 mg, one tablet administered for buttock pain. Review of the weekly skin assessment, dated 2/24/25, showed: -Skin color: normal; -Skin Temperature: dry and warm; -Skin turgor: normal, returns promptly; -Skin issues: yes; -Skin condition: site: -Right buttock: incontinent associated dermatitis; -Left buttock: incontinent associated dermatitis; -Sacrum: reddened area; -Note: skin is normal. Temperature is dry and warm. Skin turgor is normal as skin returns promptly. Skin issues present, refer to assessment for more information. Review of the progress notes on 2/28/25, showed: -At 12:44 P.M., a nurse note: pain assessment every shift: buttock pain; -No noted further assessment documented; -At 1:21 P.M., a medication administration note: Hydrocodone administered for buttock pain; -At 5:30 P.M., a late physician visit note: no notification of wound or skin impairment to buttocks. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/2/25, showed: -Cognitively intact; -Range of motion impaired upper and lower extremities; -Dependent of staff for hygiene, bathing, dressing, bed mobility and transfers; -Diagnosis included: Parkinson's disease, malnutrition, anxiety and depression; -At risk for PU; -Unhealed PU: no; -Other problems: moisture associated skin damage (MASD, skin inflammation and erosion caused by prolonged exposure to moisture such as sweat, urine, stool and wound drainage); -Skin treatments: pressure reducing device for chair and bed, ointments applied other than to feet. Review of the POS in effect on 3/2/2025, showed: -No orders for a pressure reducing device in the resident's bed including a low air loss mattress (LAL, used to distribute weight and prevent wound development). Review of the progress notes, dated 3/2/25 at 10:22 P.M., showed a behavior note: the resident refused medication and agitated when staff unable to assist him/her. The resident threatened to call emergency services. Complaints of pain in wounds, administered pain medication and repositioned on his/her side for comfort. The resident refused to allow the nurse to dress the wounds and wanted the area left open to air and stated the bandages sting. Review of the weekly skin assessment, dated 3/3/25, showed: -Skin color: normal; -Skin temperature: dry and warm; -Skin turgor: normal, skin returns promptly; -Skin issues: yes; -Skin condition: -Right buttock: incontinent associated dermatitis; -Left buttock: incontinent associated dermatitis; -Sacrum: reddened area; -Note: skin color is normal. Temperature is dry and warm. Skin turgor is normal as skin returns promptly. Skin issues present. See assessment for more information; -No documented physician notification of skin issues. Review of the care plan, revised on 3/3/25, showed: -Focus: the resident has a self-care deficit. The resident at times refuses to be placed in bed; -Goal: maintain current level of function; -Interventions: the resident is totally dependent on staff for repositioning and turning in bed, dependent on staff for personal hygiene, toileting and transfers; -Focus: the resident has actual or potential skin impairment; -Goal: the resident will maintain intact skin; -Interventions: staff follow facility protocols for treatment of injuries, staff identify and document causative factors and eliminate/resolve where possible, keep skin clean, dry and intact. Use lotion on dry skin. Focus: nutritional problem: -Goal: the resident will comply with diet for weight loss; -Interventions: RD to monitor, staff serve ordered diet and administer medications as ordered. Review of the weekly skin observation, dated 3/10/25, showed: -Skin color: normal; -Skin temperature: dry and warm; -Skin turgor: normal, returns promptly; -Skin issues: yes; -Skin condition: -Right buttock: incontinent associated dermatitis; -Left buttock: incontinent associated dermatitis; -Sacrum: reddened area; -Note: skin color is normal. Skin temperature is dry and warm. Turgor is normal as skin returns promptly. Skin issues present, see assessment for details; -No documented physician notification of skin issues. Review of the physician visit note, dated 3/10/25 at 11:16 A.M., showed no documented notification of skin issues. Review of the progress notes, dated 3/12/25 at 9:52 A.M., showed a Registered Dietician (RD) note: skin intact. Review of the weekly skin assessment, dated 3/17/25, showed: -Skin color: normal; -Skin temperature: dry and warm; -Skin turgor: normal, returns quickly; -Skin issues: yes; -Skin condition: -Right buttock: incontinent associated dermatitis; -Left buttock: incontinent associated dermatitis; -Sacrum: reddened area; -Note: the skin is normal. Skin temperature is dry and warm. Skin turgor is normal as skin returns promptly. Skin issues present. Refer to assessment for more information; -No documented physician notification. Review of the physician visit progress notes, dated 3/18/25 at 12:50 P.M., showed no notification of skin issues or concerns, and no documentation of any refusals to see WCP in his/her record. Observation and interview on 3/19/25 at 9:00 A.M., showed the resident up in the motorized wheelchair. He/She said he/she returned to the facility from the hospital on 2/12/25. Before the hospital stay, staff applied cream to his/her bottom. During the hospital stay, the hospital applied a cream treatment to his/her bottom and took photos of the wounds. Since he/she returned to the facility on [DATE], staff had not applied any treatments to his/her bottom. He/She is incontinent of bowel and used a catheter. His/Her bottom hurts and staff said he/she had wounds. He/She had not seen a wound specialist. At times, a nurse would apply gauze to his/her buttocks. When aides remove the gauze, it is painful. He/She does not like to lie down after getting up, because staff will not get him/her back up for meals, and he/she will remain in bed until the next day. The resident's bed did not have a LAL in place and the center of the mattress was noted to be sunk in. Observation and interview on 3/20/25 at 7:30 A.M., showed the resident awake in bed. He/She lay on a standard mattress. CNA D and CNA E assisted the resident onto his/her side and exposed the buttocks. Noted to the sacrum, on his/her left and right buttock were multiple white gauze pads and foam dressings secured by gauze, undated and no staff initials were observed. Blood was noted to various areas of the gauze. CNA D and E said oh my God, (he/she) is bleeding, these are stuck to (him/her), CNA D used a warm soapy washcloth and squeezed the water onto the adhered gauze pads and slowly removed the gauze from the resident's skin. The resident yelled oh God, that hurts CNA D and E apologized and continued to remove the bandages. The resident requested the aides spray Bactine (pain relieving over the counter spray) spray and said the spray helps numb it. CNA D cleansed the entire buttock area and sprayed the area with Bactine. CNA E said he/she cared for the resident last week and reported the open wounds to the nurse. At 7:42 A.M., CNA E left the room and re-entered with Licensed Practical Nurses (LPN) B and C. LPN B said he/she worked the night shift and staff did not notify him/her of the wounds. He/She turned the resident in bed. The resident did not have active wound care orders. LPN C said he/she had just received report from LPN B. LPN B had not reported any skin issues. Both LPN B and C said the resident had various open areas and dark wounds to the buttocks, several areas were noted to be actively bleeding. LPN B and C added the resident had no current wound care orders and did not know how the dressings were applied to the resident's buttocks. The resident should have wound care orders to apply any treatments. The resident will be seen by the wound care specialist today. Review of the March TAR, dated 3/1/25-3/31/25, showed no wound care orders or treatments. Observation and interview on 3/20/25 at 7:55 A.M., showed the Assistant Director of Nursing (ADON) entered the resident's room. She asked the resident if he/she would be seen by the wound care specialist and the resident consented. Outside of the resident's room, the ADON said he/she has worked as the floor and she was familiar with the resident. The resident frequently refuses to lie down between meals and had refused to be assessed by the Wound Care Plus Nurse Practitioner (WCP NP). The resident refused to allow staff to apply ointments to the wounds. The ADON said the weekly skin assessments should be accurate to the current skin condition. The care plan should reflect the current skin condition. All refusals should be documented in the medical record. The resident did not have any current wound care orders as of his/her re-admission on 2/12/25. The hospital wound orders should have been carried over to the facility TAR and POS. She noted the hospital orders were missed. The ADON said the resident's bottom had various open areas noted to be bleeding and several dark wounds. The initial re-admission skin assessment should have accurately reflected the skin condition and staff should have documented the wounds appropriately including measurements and the physician should have been notified. The ADON said the WCP NP would be coming today to assess the resident's wounds. The resident did not have a LAL in use and the facility would apply a LAL if the WCP NP ordered one. The facility did not apply LAL to residents at risk to develop pressure wounds, but relied on assessment from the WCP team. Observation and interview on 3/20/25 at 9:47 A.M., showed the WCP NP said this was the first time she saw the resident since his/her re-admission in February. She had been told by the facility the resident had previously refused WCP consult. She did not speak to the resident regarding the refusal. The WCP NP obtained the following: -Right buttock: 6.0 cm x 4.2 cm x 0.2 cm. Slough (yellow, stringy moist unhealthy tissue that impedes health and can increase risk of infection) 15 percent (%), granulation (new, pink healing tissue) 60%; -Sacrum: 5.6 cm x 5.0 cm x 0.2 cm. Slough 10%, 50% granulation; -Left buttock: 5.5 cm x 4.5 cm x 0.2 cm. Slough 25%; -All wounds are considered Stage III (involves full thickness skin loss with damage or necrosis (black, hard dead tissue) of subcutaneous tissue (fat), presenting as a deep crater, but without exposure to bone, tendon or muscle) pressure injuries; -New orders: Clean wounds daily with wound cleanser, apply Santyl (used to debriding (removing dead tissue) from wounds), cover with calcium alginate (CA, used to absorb wound drainage and promote a healing wound environment), and staff apply a LAL mattress. The resident educated on importance of lying down and off-loading between meals. During an interview on 3/20/25 at 12:04 P.M., CNA F said he/she noted the buttock wounds three weeks ago. He/She told the nurse. The wounds were smaller at that time. The resident does not like to lie down during the day. The resident's current mattress is not an LAL and is sunk in the middle of the mattress. He/She had assisted with the resident's care the last few weeks and noted saturated dressings to the buttock wounds. He/She reported saturated dressings and the mattress to the nurse. During an interview on 3/26/25 at 10:07 A.M., the Regional Therapy Director said the resident received therapy two to three times a week at the facility and had not missed any sessions. The resident is dependent on staff for bed mobility and transfers. She is not familiar with the therapy department staff determining resident mattress recommendations, and said it is usually a nursing and wound care team task. Therapy would make bed mobility recommendations such as side rails. The resident is very limited in bed mobility and unable to turn and reposition himself/herself due to quadriplegia. 2. Review of Resident #16's admission MDS, dated [DATE], showed: -readmitted [DATE]; -Able to make needs and wants known; -Needs staff assistance for bed mobility, dressing and toileting; -Frequently incontinent of urine and always incontinent of bowel; -Diagnoses included: severe protein malnutrition, pressure ulcer right hip, left hip, left heel, muscle wasting, and kidney failure. Review of the POS, showed the following wound care orders, dated 1/25/25: -An order to the left heel: cleanse with hydrochlorous acid (used as an antibacterial cleanser), apply CA and cover with bordered gauze. Change daily and as needed (PRN); -An order, to the left posterior (back) thigh: cleanse with hydrochlorous acid, apply CA and cover with bordered gauze. Change daily and as needed (PRN); -An order, to the right posterior thigh: cleanse with hydrochlorous acid, apply CA and cover with bordered gauze. Change daily and as needed (PRN). Review of the February and March 2025 TAR noted treatments completed as ordered. Review of the WCP NP, visit notes, dated 3/13/25, showed: -Left heel: -Measurements: 0.6 cm x 0.6 cm x 0.2 cm; -Slough: 10%; -Stage III; -Left posterior thigh: -Measurements: 3.5 cm x 2.0 cm x 0.2 cm; -Slough: 5% -Stage III; -Status: stayed the same compared to previous visit; -Right thigh posterior: -Measurements: 5.0 cm x 9.8 cm x 0.2 cm; -Slough 20% -Stage III; -Left lateral thigh: -Measurements: 0.7 cm x 0.8 cm x 2.8 cm; -Slough 15%; -Stage III; -Orders remain the same, change dressing daily and as needed for saturation and soiling. Observation and interview on 3/19/25 at 8:50 A.M., showed the resident lay in bed on a LAL mattress. He/She said he/she was admitted to the facility with multiple wounds. He/She had been seen by the WCP NP weekly. The facility staff do not change the dressings daily and his/her wound dressings had not been changed for several days. CNA G assisted the resident onto his/her side and exposed the buttocks. CNA G said oh, those are draining onto the bed pad. A saturated wound dressing was noted to the right and left posterior thigh, the left lateral thigh and the left heel wound noted as uncovered and no dressing in place. CNA G said he/she would notify the nurse. The saturated dressings were undated and had no staff initials observed on the dressings. Review of the progress notes on 3/19/25 at 11:20 A.M., showed no documentation of wound care or saturated dressings changed. Observation and interview on 3/19/25 at 11:39 A.M., showed the resident in bed. He/She said the nurse had not changed the wound dressings that were observed earlier in the morning. During an interview on 3/19/25 at 1:30 P.M., the resident said the nurse just changed the saturated dressings a few minutes ago. 3. During an interview on 3/20/25 at 1:08 P.M., the Director of Nursing (DON) said the facility does not have a wound care nurse and the floor charge nurses are expected to complete wound care orders. Admission skin assessments should be accurate and reflect the current skin status. Hospital discharge orders should be carried over into the facility orders and verified by the physician. Weekly skin assessments should be an accurate account of current skin conditions. The DON said she discovered Resident #14's wound care orders had not been continued after his/her re-admission on 2/12/25. He/She forgot to add the missed wound care orders onto the February POS. The resident had no current wound care orders prior to WCP NP seeing the resident today. The wounds had worsened since the hospital re-admission. The resident refuses to lie down between meals. Aides should not apply any form of medication to residents without orders and consulting with the charge nurse. All refusals should be documented in the progress notes. All saturated dressings should be changed within an hour of staff notifying the nurse. Leaving saturated dressings on a wound could increase the risk of infection. Residents at risk to develop, or those that have, wounds should have a LAL mattress to help prevent development or worsening of wounds. Staff are expected to obtain orders upon the discovery or changes to a wound. MO00250558 MO00250724 MO00250777 44950

Based on observation, interview and record review, the facility failed to follow the facility's policy regarding wound care when staff failed to ensure continued wound care treatments following a hospitalization with an identified pressure injury (a localized area of skin damage that develops when prolonged pressure is applied to the body) to the tailbone (sacrum) upon discharge for one resident (Resident #14). The failure resulted in the worsening of the identified sacral wound and the development of two additional pressure injuries. Staff failed to ensure accurate documentation, notify the physician of worsening wounds since hospitalization and obtain wound care orders. In addition, staff failed to ensure timely wound dressing change to identified saturated dressings (Resident #16). The census was 145. Review of the Wound Management Policy, revised 10/24/22, showed: -Purpose: provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers; -Definitions: -Pressure ulcer: any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. Pressure ulcers usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed; -Procedure: Assessment: -A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident; -Upon identification of a wound the licensed nurse will: -Measure the wound (length, width and depth); -Initiate a wound monitoring record sheet: -A wound monitoring record will be completed for each wound; -If the wound monitoring record is not used, documentation will be recorded within the medical record which may include nursing notes, treatment records or care plans; -An assessment of care needs for pressure ulcer and wound management will be made with emphasis on, but not limited to: -Identifying risk factors; -Treatment; -Mechanical offloading and pressure reducing devices; -Reducing skin friction, sheer, and moisture; -Nutritional status; -Evaluating and modifying interventions for a resident with an existing PU/PI; -Wound Management: -The attending physician will be notified to advise on appropriate treatment promptly; -The licensed nurse will notify the responsible party of the presence of a pressure ulcer; -Dietary contact will be made for nutritional assessment; -Rehabilitation services will be contacted for appropriate devices or pressure redistributing devices; -A licensed nurse will develop a care plan for the resident based on recommendations of dietary, rehabilitation and the attending physician; -Per physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management; -The attending physician and interdisciplinary team (IDT) will be notified of: -New pressure ulcers or wounds; -Pressure ulcers or wounds that do not respond to treatment; -Pressure ulcers or wounds that worsen or increase in size; -Complaints of increased pain, discomfort or decrease in mobility by a resident; -Signs of ulcer sepsis, presence of exudates (drainage), odor or necrosis (black, firm tissue), if not already noted by the physician; -Residents refusing treatment; -Certified Nurse Aides (CNAs) will complete body checks on resident's shower days and report unusual findings to the licensed nurse; -Documentation: -New pressure ulcers or wounds will be documented on the 24 hour log and an incident report will be completed by the licensed nurse; -Wound documentation will occur at a minimum of weekly until the wound is healed, documentation will include: -Location of wound; -Length, width, and depth measurements recorded in centimeters (cm); -Direction and length of tunneling (a channel or tunnel that forms beneath the surface of a wound, extending into deeper tissue) or undermining (a separation of the wound edges from the underlying tissues, creating a space or pocket beneath the wound surface; -Appearance of the wound base; -Drainage amount and characteristics including color, consistency and odor; -Appearance of wound edges; -Description of the peri-wound condition or evaluation of the skin adjacent to the wound; -Presence or absence of new epithelium at the wound rim; -Presence of pain; -IDT will document the discussions and recommendations for: -Pressure ulcers and wounds that do not respond to treatment; -Pressure ulcers and wounds that worsen or increase in size; -Complaints of increased pain, discomfort or decrease in mobility by a resident; -Signs of ulcer sepsis, presence on exudate, odor or necrosis; -Residents refusing treatment; -Licensed nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis; -Document notifications following a change in the resident's skin condition; -Update the resident's care plan as necessary. 1. Review of Resident #14's medical record, showed: -Original admission: [DATE]; -Diagnoses included: quadriplegia (paralysis in all limbs), Parkinson's (a neurodegenerative disease causing muscle weakness and loss), diabetes, anxiety, muscle wasting, and reduced mobility; -Able to make needs and wants known. Review of the progress notes, showed: -On 2/3/25 at 11:26 P.M., a nurse note: the resident remained up in his/her wheelchair. Staff offered to assist to bed to encourage wound healing; -On 2/5/25 at 1:15 P.M., a nurse note: the resident said he/she was short of breath and complained of a sore throat and coughed thick, yellow mucus, complaint of minor chest pain. Vital signs: blood pressure 140/70 (normal, 120/80), temperature 101.3 degrees (normal range, 97.1-98.6 degrees Fahrenheit (F)), pulse 116 beats per minute (bpm) (normal range, 60-80 bpm) and oxygen saturation fluctuating between 87-90 percent (normal range, 90-100%). The physician notified and new orders to send to the emergency room for evaluation and treatment. Review of the February Treatment Administration Record (TAR), dated 2/1/25 through 2/28/25, showed: -An order, dated 2/6/25: enhanced barrier precautions related to wounds; -An order, dated 1/28/25: Triad Hydrophilic (used to create a moist wound environment, that promotes healing and debridement (removal of dead tissue) wound dressing paste. Apply to right buttock and left thigh twice a day for wound. Discontinued 2/7/25. Documented as completed twice a day, until discharged to the hospital on 2/6/25. Review of the hospital Discharge summary, dated [DATE], showed: -admitted to the hospital: 2/5/25; -Diagnoses: Pneumonia and sepsis; -Wound dressing paste: apply one application topically twice a day to right buttock and left thigh wounds; -Wound care instructions: -Incontinent associated dermatitis (IAD, skin damage associated with incontinence) bilateral (both sides) buttocks; -Dressing status: open to air; -Site assessment: fragile, painful and pink; -Shape/pattern: irregular; -Peri-wound assessment: fragile, painful; -Interventions: cleansed, protective ointment; -Wound status: unchanged; -Non-staged description: partial thickness;. -Pressure injury to coccyx: -Dressing status: open to air; -Site assessment: Fragile, painful; -Shape/pattern: Irregular; -Peri-wound assessment: Fragile, painful; -Interventions: cleansed, protective ointment; -Pressure injury Stage: II (partial thickness skin loss, appearing as a shallow, open ulcer with a red or pink wound bed, or as an intact or open/ruptured blister); -Measurements: length 3 cm x width 4 cm; -Margins: Undefined edges; -Wound status: Unchanged;. -Medication list at discharge: -Hydrophilic cream (used to treat and prevent dry, rough and itchy skin): one application topically twice a day to the right buttock and left thigh wounds. -Nutrition orders: -Juven (high protein supplemental drink) twice a day, with breakfast and dinner. Review of the facility's admission assessment, dated 2/12/25, showed: -admitted from: hospital; -Skin assessment: -Color: normal; -Temperature: warm; -Turgor: normal (skin returns promptly); -Skin issues: no; -Physician actions: no new orders; -Were the list of medications from the hospital compared with the medications the resident was taking at home: yes; -Was the physician notified if any discrepancies were noted during the medication reconciliation: yes, reconciliation necessary, physician agreed with new medications prescribed by hospital. Review of the admission progress note, a late entry, dated 2/12/25 at 10:16 A.M., showed: -The resident is chairfast. Skin color is normal, skin is warm and dry. No skin issues present. Review of the February TAR, dated 2/1/25 through 2/28/25, showed no wound care orders and no documentation of treatments completed after re-admission on [DATE]. Review of the re-admission Physician Order Sheet (POS), showed: -An order dated 2/13/25: wound care specialist to eval and treat if indicated; -No orders noted for Juven. Review of the Braden (a tool used to determine the person's risk to develop pressure injury) score, dated 2/17/25, showed: -Sensory perception: ability to respond to pressure related discomfort: 3, slightly limited; -Moisture: degree to which skin is exposed to moisture: 3, occasionally moist; -Activity: degree of physical activity: 2, chairfast; -Mobility: ability to change and control body position: 1, completely immobile; -Nutrition: probably inadequate: 2, rarely eats a complete meal; -Friction and shear: 2, potential problem; -Score: 13, moderate risk. Review of the progress notes, dated 2/17/25 at 1:25 P.M., showed a weekly skin observation note: late entry: the skin color is normal. Skin temperature is dry and warm. Skin turgor is normal as skin returns promptly. Skin issues present, refer to assessment. Review of the weekly skin assessment, dated 2/17/25 at 1:25 P.M., showed: -Skin color: normal; -Skin temperature: dry and warm; -Skin turgor: normal, skin returns promptly; -Skin issues: yes; -Skin condition: -Right buttock: incontinent associated skin dermatitis; -Left buttock: incontinent associated skin dermatitis; -Sacrum: reddened area; -No additional progress notes included. Review of the progress note, dated 2/17/25 at 2:50 P.M., showed: -A medication administration note: hydrocodone 5 milligram (mg)-325 mg (a narcotic pain reliever for moderate pain) administered for coccyx pain; -No additional notes regarding assessments, treatment or physician notification. Review of a nurse progress note, dated 2/20/25 at 2:37 P.M., showed the resident continued therapy and cooperative with care. The dressing on the coccyx changed and well tolerated. Redness noted to the groin, applied powder. The resident turned and repositioned in bed. (Note: Review of the February TAR, dated 2/1/25 through 2/28/25, showed no wound care orders and no documentation of treatments completed.) Review of the skilled nursing note, dated 2/20/25 at 2:41 P.M., showed: -Alert to person, place, time and situation; -Skin integrity: -No new changes to skin integrity noted; -Wound care: -The resident has treatable wounds -No further description as to number, type, location; -Dressing changed as per treatment orders: unselected; -Dressing change not required: unselected; -Changed were noted to wound: unselected. Review of the POS, showed: -An order, dated 2/20/25: wound consult to treat related to open area on the coccyx; -No orders noted for Juven supplement. Review of the progress notes, dated 2/23/25, showed: -At 11:45 A.M.,: pain to the bottom, barrier cream applied; (Note: the resident did not have any order for barrier cream) -At 1:34 P.M., medication note: Hydrocodone 5 mg, one tablet administered for buttock pain. Review of the weekly skin assessment, dated 2/24/25, showed: -Skin color: normal; -Skin Temperature: dry and warm; -Skin turgor: normal, returns promptly; -Skin issues: yes; -Skin condition: site: -Right buttock: incontinent associated dermatitis; -Left buttock: incontinent associated dermatitis; -Sacrum: reddened area; -Note: skin is normal. Temperature is dry and warm. Skin turgor is normal as skin returns promptly. Skin issues present, refer to assessment for more information. Review of the progress notes on 2/28/25, showed: -At 12:44 P.M., a nurse note: pain assessment every shift: buttock pain; -No noted further assessment documented; -At 1:21 P.M., a medication administration note: Hydrocodone administered for buttock pain; -At 5:30 P.M., a late physician visit note: no notification of wound or skin impairment to buttocks. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/2/25, showed: -Cognitively intact; -Range of motion impaired upper and lower extremities; -Dependent of staff for hygiene, bathing, dressing, bed mobility and transfers; -Diagnosis included: Parkinson's disease, malnutrition, anxiety and depression; -At risk for PU; -Unhealed PU: no; -Other problems: moisture associated skin damage (MASD, skin inflammation and erosion caused by prolonged exposure to moisture such as sweat, urine, stool and wound drainage); -Skin treatments: pressure reducing device for chair and bed, ointments applied other than to feet. Review of the POS in effect on 3/2/2025, showed: -No orders for a pressure reducing device in the resident's bed including a low air loss mattress (LAL, used to distribute weight and prevent wound development). Review of the progress notes, dated 3/2/25 at 10:22 P.M., showed a behavior note: the resident refused medication and agitated when staff unable to assist him/her. The resident threatened to call emergency services. Complaints of pain in wounds, administered pain medication and repositioned on his/her side for comfort. The resident refused to allow the nurse to dress the wounds and wanted the area left open to air and stated the bandages sting. Review of the weekly skin assessment, dated 3/3/25, showed: -Skin color: normal; -Skin temperature: dry and warm; -Skin turgor: normal, skin returns promptly; -Skin issues: yes; -Skin condition: -Right buttock: incontinent associated dermatitis; -Left buttock: incontinent associated dermatitis; -Sacrum: reddened area; -Note: skin color is normal. Temperature is dry and warm. Skin turgor is normal as skin returns promptly. Skin issues present. See assessment for more information; -No documented physician notification of skin issues. Review of the care plan, revised on 3/3/25, showed: -Focus: the resident has a self-care deficit. The resident at times refuses to be placed in bed; -Goal: maintain current level of function; -Interventions: the resident is totally dependent on staff for repositioning and turning in bed, dependent on staff for personal hygiene, toileting and transfers; -Focus: the resident has actual or potential skin impairment; -Goal: the resident will maintain intact skin; -Interventions: staff follow facility protocols for treatment of injuries, staff identify and document causative factors and eliminate/resolve where possible, keep skin clean, dry and intact. Use lotion on dry skin. Focus: nutritional problem: -Goal: the resident will comply with diet for weight loss; -Interventions: RD to monitor, staff serve ordered diet and administer medications as ordered. Review of the weekly skin observation, dated 3/10/25, showed: -Skin color: normal; -Skin temperature: dry and warm; -Skin turgor: normal, returns promptly; -Skin issues: yes; -Skin condition: -Right buttock: incontinent associated dermatitis; -Left buttock: incontinent associated dermatitis; -Sacrum: reddened area; -Note: skin color is normal. Skin temperature is dry and warm. Turgor is normal as skin returns promptly. Skin issues present, see assessment for details; -No documented physician notification of skin issues. Review of the physician visit note, dated 3/10/25 at 11:16 A.M., showed no documented notification of skin issues. Review of the progress notes, dated 3/12/25 at 9:52 A.M., showed a Registered Dietician (RD) note: skin intact. Review of the weekly skin assessment, dated 3/17/25, showed: -Skin color: normal; -Skin temperature: dry and warm; -Skin turgor: normal, returns quickly; -Skin issues: yes; -Skin condition: -Right buttock: incontinent associated dermatitis; -Left buttock: incontinent associated dermatitis; -Sacrum: reddened area; -Note: the skin is normal. Skin temperature is dry and warm. Skin turgor is normal as skin returns promptly. Skin issues present. Refer to assessment for more information; -No documented physician notification. Review of the physician visit progress notes, dated 3/18/25 at 12:50 P.M., showed no notification of skin issues or concerns, and no documentation of any refusals to see WCP in his/her record. Observation and interview on 3/19/25 at 9:00 A.M., showed the resident up in the motorized wheelchair. He/She said he/she returned to the facility from the hospital on 2/12/25. Before the hospital stay, staff applied cream to his/her bottom. During the hospital stay, the hospital applied a cream treatment to his/her bottom and took photos of the wounds. Since he/she returned to the facility on 2/12/25, staff had not applied any treatments to his/her bottom. He/She is incontinent of bowel and used a catheter. His/Her bottom hurts and staff said he/she had wounds. He/She had not seen a wound specialist. At times, a nurse would apply gauze to his/her buttocks. When aides remove the gauze, it is painful. He/She does not like to lie down after getting up, because staff will not get him/her back up for meals, and he/she will remain in bed until the next day. The resident's bed did not have a LAL in place and the center of the mattress was noted to be sunk in. Observation and interview on 3/20/25 at 7:30 A.M., showed the resident awake in bed. He/She lay on a standard mattress. CNA D and CNA E assisted the resident onto his/her side and exposed the buttocks. Noted to the sacrum, on his/her left and right buttock were multiple white gauze pads and foam dressings secured by gauze, undated and no staff initials were observed. Blood was noted to various areas of the gauze. CNA D and E said oh my God, (he/she) is bleeding, these are stuck to (him/her), CNA D used a warm soapy washcloth and squeezed the water onto the adhered gauze pads and slowly removed the gauze from the resident's skin. The resident yelled oh God, that hurts CNA D and E apologized and continued to remove the bandages. The resident requested the aides spray Bactine (pain relieving over the counter spray) spray and said the spray helps numb it. CNA D cleansed the entire buttock area and sprayed the area with Bactine. CNA E said he/she cared for the resident last week and reported the open wounds to the nurse. At 7:42 A.M., CNA E left the room and re-entered with Licensed Practical Nurses (LPN) B and C. LPN B said he/she worked the night shift and staff did not notify him/her of the wounds. He/She turned the resident in bed. The resident did not have active wound care orders. LPN C said he/she had just received report from LPN B. LPN B had not reported any skin issues. Both LPN B and C said the resident had various open areas and dark wounds to the buttocks, several areas were noted to be actively bleeding. LPN B and C added the resident had no current wound care orders and did not know how the dressings were applied to the resident's buttocks. The resident should have wound care orders to apply any treatments. The resident will be seen by the wound care specialist today. Review of the March TAR, dated 3/1/25-3/31/25, showed no wound care orders or treatments. Observation and interview on 3/20/25 at 7:55 A.M., showed the Assistant Director of Nursing (ADON) entered the resident's room. She asked the resident if he/she would be seen by the wound care specialist and the resident consented. Outside of the resident's room, the ADON said he/she has worked as the floor and she was familiar with the resident. The resident frequently refuses to lie down between meals and had refused to be assessed by the Wound Care Plus Nurse Practitioner (WCP NP). The resident refused to allow staff to apply ointments to the wounds. The ADON said the weekly skin assessments should be accurate to the current skin condition. The care plan should reflect the current skin condition. All refusals should be documented in the medical record. The resident did not have any current wound care orders as of his/her re-admission on [DATE]. The hospital wound orders should have been carried over to the facility TAR and POS. She noted the hospital orders were missed. The ADON said the resident's bottom had various open areas noted to be bleeding and several dark wounds. The initial re-admission skin assessment should have accurately reflected the skin condition and staff should have documented the wounds appropriately including measurements and the physician should have been notified. The ADON said the WCP NP would be coming today to assess the resident's wounds. The resident did not have a LAL in use and the facility would apply a LAL if the WCP NP ordered one. The facility did not apply LAL to residents at risk to develop pressure wounds, but relied on assessment from the WCP team. Observation and interview on 3/20/25 at 9:47 A.M., showed the WCP NP said this was the first time she saw the resident since his/her re-admission in February. She had been told by the facility the resident had previously refused WCP consult. She did not speak to the resident regarding the refusal. The WCP NP obtained the following: -Right buttock: 6.0 cm x 4.2 cm x 0.2 cm. Slough (yellow, stringy moist unhealthy tissue that impedes health and can increase risk of infection) 15 percent (%), granulation (new, pink healing tissue) 60%; -Sacrum: 5.6 cm x 5.0 cm x 0.2 cm. Slough 10%, 50% granulation; -Left buttock: 5.5 cm x 4.5 cm x 0.2 cm. Slough 25%; -All wounds are considered Stage III (involves full thickness skin loss with damage or necrosis (black, hard dead tissue) of subcutaneous tissue (fat), presenting as a deep crater, but without exposure to bone, tendon or muscle) pressure injuries; -New orders: Clean wounds daily with wound cleanser, apply Santyl (used to debriding (removing dead tissue) from wounds), cover with calcium alginate (CA, used to absorb wound drainage and promote a healing wound environment), and staff apply a LAL mattress. The resident educated on importance of lying down and off-loading between meals. During an interview on 3/20/25 at 12:04 P.M., CNA F said he/she noted the buttock wounds three weeks ago. He/She told the nurse. The wounds were smaller at that time. The resident does not like to lie down during the day. The resident's current mattress is not an LAL and is sunk in the middle of the mattress. He/She had assisted with the resident's care the last few weeks and noted saturated dressings to the buttock wounds. He/She reported saturated dressings and the mattress to the nurse. During an interview on 3/26/25 at 10:07 A.M., the Regional Therapy Director said the resident received therapy two to three times a week at

Based on observation, interview and record review, the facility failed to implement an effective pain management regime for two sampled residents (Resident #18 and #14). Staff failed to notify ensure Resident #18, who experienced pain related to metastatic breast cancer with osseous (bone) involvement, most severe over bilateral lower extremities, received pain medications as ordered by the physician and failed to notify the primary physician when pain medications were not delivered from the pharmacy and of medications available in the emergency kit. The resident experienced uncontrolled pain and was transferred to the hospital two days after admission to the facility. For Resident #14, the facility staff failed to provide effective pain relief when, during care, staff removed wound dressings which were adhered to the wound sites. The resident had so much pain, he/she was observed to cry and requested Certified Nurse Aide (CNA) D spray over the counter Bactine (relieves the pain and itch of minor cuts, scrapes and burns on contact) onto the buttock wound sites. The sample was 16. The census was 145. Review of the facility's Pain Management Policy, revised 10/24/22, included: -Purpose: To ensure accurate assessment an management of the resident's pain; -Policy: A Licensed Nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Facility Staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain; -Procedure: --Pain Assessment: ---A Licensed Nurse will assess each resident for pain upon admission. ---The Licensed Nurse will complete Pain Assessment, or a substantively similar form, for residents identified as having pain within 8 hours of admission. ---The IDT Committee review the Pain Assessment for each newly admitted resident identified by the Licensed Nurse to have pain and at least quarterly thereafter. ---The Licensed Nurse will develop a care plan for pain management, including non pharmacological interventions. ---Pain Flow Sheet, or a substantively similar form, will be completed every shift for new residents for the first seventy-two (72) hours following admission. ---After medications/interventions are implemented, re-evaluate the resident's level of pain within one hour. ---A Licensed Nurse will reassess the resident for pain quarterly and eventfully. --Pain Management ---The Licensed Nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR). ---Nurses will complete the Pain Flow Sheet for residents receiving PRN pain to evaluate the effectiveness of the medication regimen. ---The Licensed Nurse will assess the resident for pain and document results on the MAR each shift using the 1-10 pain scale. ---The shift pain score will indicate the highest pain level that occurred on that shift. ---If there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician for a review of medications. ---Nursing Staff will implement timely interventions to reduce the increase in severity of pain. ---Nursing Staff will provide education to residents and families as to appropriate expectations for pain management. ---The Nursing Staff will attempt to become familiar with cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain. ---Pain Management Tool to audit and assess the success of the Pain Management Program. ---Nursing Staff will also utilize non-pharmacological interventions by adjusting the resident's environment to reduce pain. --Documentation ---Pain Assessments will be maintained in the resident's medical record. ---The Licensed Nurse will document resident's pain and response to interventions in the medical record on the weekly summary and as indicated on the progress notes. ---The Licensed Nurse will update the care plan for pain management with any change in treatment and/or medication. ---Upon admission, quarterly, and eventfully the IDT Committee will meet to review the resident's Pain Assessment. The IDT Committee will document the following: -Summary of event causing the pain; -Root cause analysis; -Referrals, as necessary; -Interventions to prevent future pain Review of the Ordering and Receiving Controlled Medication Policy, dated 1/20, showed: -Policy: --Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and record keeping requirements in the nursing care center, in accordance with federal and state laws and regulations. The nursing care center obtains and keeps current and on file any permits required by state agencies. Procedures: --The director of nursing and the consultant pharmacist monitors for compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized, licensed nursing and pharmacy personnel have access to controlled medications. --Medications listed in Schedules II, III, IV and V are dispensed by the pharmacy in readily accountable quantities and containers designed for easy counting of contents. When possible, injectable controlled substance medications are dispensed in ampoules or vials of the smallest available dosage unit. (Note: Refer to state regulations, as particular states do not require Schedule V medications to be dispensed in accountable quantities and containers.) --The pharmacy or the nursing care center prepares an individual resident controlled substance record/receipt/log for each controlled substance medication prescribed for a resident as applicable per state law. This log is placed in the MAR or narcotic book to be counted every shift. The nursing care center may designate a particular medication, which is not mandated as a controlled substance by state or federal laws and subject to abuse or diversion, to be handled under these procedures for controlled medications. (Note: Refer to state regulations, as particular states do not require this documentation for Schedule V medications.) The following information is completed: -Name of resident -Prescription number -Medication name -Medication strength (if designated) -Dosage form of medication -Date received -Quantity received -Name of person receiving the medication supply --The Drug Enforcement Agency (DEA) requires that a pharmacy must have a valid prescriber signed prescription in order to dispense controlled substances. A valid written prescription requires patient name, drug name and strength, quantity to dispense, directions for use, date and signature of the prescriber. (Refer to Section 2.2-Controlled Substance Medication Orders). In an emergency situation, verbal authorization may be given by the prescriber to the pharmacist for a new order as described by state law. (Refer to Section 3.4 Emergency Pharmacy Service and Emergency Kits (E-Kits)) --Refill Requests for CIII-CV, and Partial Fill Requests for CII -If one or more refills (CIII-Vs) or a partial fill quantity (CIIs) remains: -Written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand. -If only one refill remains ([NAME]-Vs) or only a partial fill quantity remains (CII), the pharmacy will simultaneously dispense the remaining fill, and, if necessary proactively seek out a new, complete prescription from the prescriber for future use. The facility may be asked to contact the prescriber for a new prescription upon request for a medication with no remaining fills available. 1. Review of Resident #18's electronic medical record (EMR), showed: -Admission: 3/6/25; -discharged : 3/8/25; -Diagnoses include malignant neoplasm left breast, malignant neoplasm of liver, and acute respiratory failure with hypoxia. Review of the hospital discharge record, showed: -Hospital Course: Acute respiratory hypoxia (not enough oxygen in the tissues in your body) secondary to progression of metastatic breast cancer. -Cancer related pain: Diffuse pain related to metastatic breast cancer with osseous (bone) involvement, most severe over bilateral lower extremities. Regimen was adjusted to morphine extended release (ER) (opioid that treats moderate to severe pain) 15 milligram (mg) twice a day (BID) and oxycodone (opioid that treats moderate to severe pain) 10 mg every 6 hours as needed (PRN), continued on scheduled Tylenol 1000 mg three times a day (TID), gabapentin (used to treat nerve pain) 300 mg BID, and added Flexeril (muscle relaxer used to treat pain and stiffness) 5 mg TID PRN. -Medications at hospital discharge included: -Morphine ER 15 mg BID (last given 3/6/25 at 11:42 A.M.); -Oxycodone 10 mg every 6 hours PRN (last given 3/6/25 at 12:47 P.M.); -Flexeril 15 mg TID PRN (last given 3/6/25 at 11:42 A.M.); -Gabapentin 300 mg BID (last given 3/6/25 at 9:05 A.M.); -Tylenol 1000 mg TID (last given 3/6/5 at 9:05 A.M.). Review of the admission assessment, dated 3/6/25 at 5:40 P.M., showed: -Date of arrival: 3/6/25; -Time of arrival: 5:35 P.M.; -Was physician notified of the resident's admission: Yes; -Were the resident's medications reviewed with the physician: Yes; -Were there any significant medication issues found during review: No; -Level of consciousness: Alert to situation, time, place; -Mood: Flat; -Pain: Does the resident report pain currently: No; -Most recent pain level: 8 3/7/25 at 6:42 A.M.; -Pain plan: Blank -Admission Actions: Physician/Nurse Practitioner (NP) notified of admission assessment; -Physician/NP Actions: No new orders; -Drug Regime Review (DRR): 3/6/25 at 9:00 P.M.; -Was the list of medications from the hospital compared with the medications the resident was taking at home: Yes; -Was the physician notified if any discrepancies were noted during medication reconciliation: No differences noted; -Were all medications reviewed to ensure that proper labs were ordered: Yes; -Select most accurate statement: Statement by nurse that admission DRR completed with no significant issues identified. Review of the resident's pain assessment, dated 3/6/25 at 6:09 P.M., showed: -Have you had pain or hurting at any time in the last 5 days: Yes; -How much of the time have you experienced pain or hurting over the last 5 days: Frequently; -Pain Effect on sleep: Frequently; -Pain interference with therapy activities: Frequently; -Pain interference with day-to-day activities: Frequently; -Verbal descriptor: Severe; -Staff assessment for pain: None of these signs observed or documented (non-verbal, vocal complaints, facial expressions, protective body movements); -Frequency with which resident complains or shows evidence of pain or possible pain: Daily; -Pain Management: Describe treatment, any side effects, effectiveness: ineffective; -Received PRN pain medications: Blank; -Received non-medication intervention: Blank. Review of the resident's care plan, did not address his/her potential for pain. Review of the resident's Pain Level Summary, showed: -3/6/25 at 9:25 P.M., 0/10 pain; -3/7/25 at 6:42 A.M., 8/10 pain; -3/7/25 at 6:46 P.M., 10:35 P.M., and 11:33 P.M., 0/10 pain; -3/8/25 at 3:38 A.M. and 6:48 A.M., 0/10 pain; -3/8/25 at 10:57 A.M., 1:39 P.M., and 2:03 P.M., 10/10 pain. Review of the resident's Physician Order Sheet (POS), included: -An order, dated 3/6/25, Morphine 15 mg. Give 1 tablet by mouth every 12 hours for pain; -An order, dated 3/6/25, Oxycodone tablet 10 mg. Give one tablet by mouth every 6 hours as needed for pain; -An order, dated 3/6/25, Cyclobenzaprine (Flexeril) 5 mg. Give one tablet every 8 hours as needed for muscle spasms; -An order, dated 3/7/25, Gabapentin 300 mg. Give 300 mg by mouth two times a day for pain; -An order, dated 3/6/25, Tylenol 1000 mg. Give 1000 mg by mouth three times a day for pain. Review of the resident's, March 2025, Medication Administration Record (MAR), showed: -Morphine 15 mg: -Showed given 3/6/25 at 9:00 P.M. and 3/7/25 at 9:00 P.M.; -Marked 9 (other/see progress notes) 3/7/25 at 9:00 A.M. and 3/8/25 at 9:00 A.M. -Oxycodone tablet 10 mg: -Medication not administered to the resident. -Cyclobenzaprine (Flexeril) 5 mg: -Medication not administered to the resident. -Gabapentin 300 mg by mouth two times a day for pain. -3/7/25 at 9:00 A.M., Medication marked 5. No progress note related to medication not administered. -Tylenol 1000 mg by mouth three times a day for pain: -3/7/25 2:00 P.M. Not given. Marked 5 (Hold/See progress note). Review of the resident's electronic medical record (EMR), showed: -An administration note dated 3/7/25 at 3:03 P.M., New admit medication (Tylenol) will be delivered 3/7/25; -An administration note, dated 3/8/25 at 12:47 P.M., Morphine sulfate. Medication on order, pharmacy notified; -An administration note, dated 3/8/25 at 1:39 P.M., Morphine sulfate. Medication on order from pharmacy/new admit. Review of the resident's EMR, showed: -A progress note, dated 3/6/25 at 5:40 P.M., resident was admitted from hospital on 03/06/2025 at 5:35 P.M. Resident is alert. Oriented to place time situation. Mood is flat. Resident is not able to report pain at this time. Physician/Nurse Practitioner notified of admission assessment findings and no new orders noted. Refer to full assessment for more information; -A progress note, dated 3/7/25 at 6:33 A.M., resting in bed No signs of acute distress noted. Complained of general discomfort. Scheduled pain medication given with effectiveness. Plan of care ongoing; -A progress note, dated 3/8/25 at 4:38 A.M., monitoring for new admission status. Remains alert and oriented. Able to make needs known. Resident is making adjustments to new environment; -A progress note, dated 3/8/25 at 3:15 P.M., resident sent to hospital for uncontrolled pain. Physician, family, Director or Nursing (DON) aware. Review of the facility's Controlled II Emergency Medication Kit, showed: -Morphine Sulfate 100 mg/5 milliliter (ml) solution 30 ml; -Fentanyl (used to treat severe pain) 25 mcg patch; -Oxycodone 5 mg tab; -Oxycodone/Apap (Tylenol) (used to treat moderate to moderately severe pain) 5/325 mg tab and 10/325 mg tab; -Hydrocodone/Apap (used to treat moderate to severe pain): 5/325 mg tab, 7.5/325 mg tab, and 10/325 mg tab. Review of the facility's Controlled III-V Emergency Medication Kit, showed: -APAP/Codeine #3 (used to treat moderate to moderately severe pain); -Tramadol (used to treat moderate to severe pain) 50 mg. Review of the Situation-Background-Assessment-Request (SBAR), dated 3/8/25 at 1:11 P.M., showed: -Situation- Patient in severe pain related to recent lumpectomy, breast cancer: -Started on 3/8/25; -Since started it has gotten worse; -Things that make the condition/symptom worse: unmedicated/pharmacy has not delivered; -Things that make the condition/symptom better: medication; -Treatment for last episode: new admit; -Background: -Resident in nursing home for post-acute care; -Primary diagnosis: left breast cancer; -Other pertinent history: neoplasm liver, neoplasm of vocal cords; -Assessment: -Registered Nurse (RN): Think the problem may be uncontrolled pain; -Licensed Practical Nurse (LPN): The resident appears in excruciating pain; -Request: -Suggest or Request: Transfer to the hospital -Nursing notes: Resident has facial grimacing and furrowed brow in relation to severe pain from lumpectomy/other cancer. -Reported to primary care clinician: 3/8/25 at 1:00 P.M. Observation and interview on 3/19/25 at 11:30 A.M., showed Licensed Practical Nurse (LPN) H open the narcotic box in the nurse medication cart. Resident #18 had one card of Oxycodone with 30 out of 30 pills and one card of Morphine 15 mg with 28 out of 28 pills. (The issue date of the medications was March 8, 2025.) Review of the narcotic book showed nothing signed out for the resident. LPN H said there was an emergency kit (e-kit), but he/she was not sure where it is located. When a resident is a new admission, it typically takes pharmacy about an hour to get medications sent to the facility. During an interview on 3/19/25 at 12:04 P.M., LPN A said if a resident is a new admission and they do not have the medication at the facility, then the nurse can pull the medication from the e-kit. There is a controlled medication e-kit and a regular one. LPN A said when the resident was admitted , the facility did not have his/her medications. They were waiting on the doctor to approve it because pharmacy would not send the medication without doctor approval. LPN A believes the medication was sent to the facility after the resident was at the hospital because he/she never received the medication while he/she was at the facility. The medication was still listed as pending while he/she was here. The resident was sent to the hospital because of his/her pain and the facility not being able to manage it. During an interview on 3/19/25 at 12:46 P.M., the Pharmacist said the facility sent the order for the resident's Morphine 15 mg and Oxycodone 10 mg on 3/6/25 at 1:30 P.M. Usually, if the medication is not covered, there is a billing issue like trying to refill too soon or it is on back order. The Pharmacist believes the morphine was on back order, a card was sent to the facility and now it is on back order again. The Pharmacist said their system shows the pharmacy sent the resident's Morphine and Oxycodone to the facility on [DATE] at approximately 11:00 A.M. Typically, once an order is received, the pharmacy can get it to the facility within an hour. The pharmacy is local. During an interview on 3/19/25 at approximately 1:00 P.M., the controlled log inventory sheet for controlled medication sent from the pharmacy to the facility from 3/1/25 to 3/14/25 was requested from the DON. At 1:42 P.M., the DON said no controlled medication had come in or out for the first floor from 3/1/25 to 3/14/25. During an interview on 3/20/25 at 3:50 P.M., LPN K said he/she admitted the resident to the facility. LPN K did not know what the resident was admitted for , but the resident had a left breast mastectomy. The resident had orders for two different narcotics. He/She called the physician because the hospital did not send the prescriptions. The resident did not get either medication while he/she was here. LPN K is not sure why he/she signed off on giving the medication. LPN K might have just checked it as given to get the screen off red so the admission could be completed. LPN K did not remember giving the resident any morphine. During an interview on 3/20/25 at 11:50 A.M., Certified Nursing Assistant (CNA) I said the resident was at the facility for about a day. The resident called 911 to get out of the facility. CNA I said things were chaotic when the resident was admitted . They could not find things like the resident's oxygen concentrator so he/she thinks the resident got frustrated that they could not do things as quick as the resident would like. Then they had to change out his/her bed. Then the next thing they know, the resident is on the ambulance. The resident did not say what brought him/her to the facility but still complained of pain when he/she left. The resident had complained of pain since he/she got there. The resident just looked tired. The resident was constantly grimacing and said his/her lower back hurt. The resident was always complaining of pain. CNA I remembered the nurse telling the resident that he/she could not have anything else, because it was not time yet and the resident still had a couple hours to go. The resident called his/her son/daughter once and CNA I talked to them. The family member said the resident was uncomfortable. The resident was just having a lot of pain. During an interview on 3/20/25 at 12:28 P.M., Certified Medication Technician (CMT) F said the resident was not there very long. CMT F only went in once when the resident's bathroom call light was going off and did not remember if he/she gave the resident any medications. CMT F did not remember why he/she would not have given the resident a Tylenol. CMT F said when a 5 is charted in the MAR, then a progress note should be entered. The resident was just very quiet. During an interview on 3/20/25 at 12:45 P.M., LPN K said he/she did not really remember the resident. LPN K said the CMT gave the resident his/her medications. When asked about the MAR, LPN K said the resident did get morphine. The resident complained of back pain. The morphine was pulled from the medication cart on his/her card,. It may have been a liquid dose, LPN K cannot recall off hand if it was a liquid or pill form. LPN K said he/she did not pull anything from the e- kit and is unsure if the resident had pain medicine. When a medication is pulled from the e-kit, the pharmacy has to give a code to access the e-kit. During an interview on 3/20/25 at 12:57 P.M., the DON said when a resident is admitted , the nurse is expected to complete the admission assessment and verify medications with the physician. The medications are put in the EMR and then the pharmacy should receive it. If the facility does not have a medication, then she expected the nurse to call the pharmacy. She also expected the nurse to notify management, like the Assistant Director of Nursing (ADON), and the physician. If the medication is a controlled pain type medication and the pharmacy says they do not have a prescription, then get the prescription sent to the pharmacy and sign it out from the e-kit. Once signed out, then the pharmacy sends it. If it is not in the e-kit, staff should call the physician and try to get an order for something different. She expected nursing staff to call the physician and get something else for the resident's pain. She is not sure if Tylenol is stock or not. The DON is not sure of the process but believes when the e-kit is open, the nurse calls the pharmacy to get a code which unlocks the kit. The resident was admitted with pain. She received a call on Saturday the resident wanted to go back to the hospital because his/her pain was uncontrollable. The nurse called the physician and sent him/her out. The DON did not get a call prior to that related to the resident. Staff should have called the physician immediately when the medication did not arrive. She and the ADON reviewed the resident's admission on 3/7/25 and this did not come up. The DON expected a resident's pain to be reassessed within the hour. She would not expect staff to document they gave a medication if they did not actually give the medication. During an interview on 3/20/25 at 1:35 P.M., the ADON said they look at the missed medication report every day. The report is generated by what code is entered and a report can be pulled. The resident was there about a day and a half. The resident came late in the day. For the resident's pain medication, they have a narcotic e-kit with morphine. E-kits are kept on the first floor, and there is one box with a combination code. The process is to call the pharmacy. The pharmacy will give a combination to that box and they will approve doses until they deliver the meds. They have morphine in the e-kit. The nurses should have called the physician to get an order for the liquid pain medication. A nurse should not document a medication was given if the medication was not in the building and should not borrow any medications from other residents. The nurses have access to what is in the e-kit as it is on the e-kit box. When staff pull out of the e-kit, it is faxed to the pharmacy, then the pharmacy would know what to replace. The nurse should document a progress note if the e-kit was accessed for a medication. During an interview on 3/20/25 at 9:45 A.M., the NP said he/she did not have a chance to assess the resident in person. The resident came and went. Usually when a patient comes, they send medications, but they did not have the chance. The resident was in bad shape. They did not get a call from the pharmacy regarding the resident's pain medications. The facility did not call either. If a patient needs pain medication, the NP expected a phone call. They have to let the doctor know. They always look for another option if the resident does not have ordered pain medication. If a resident has pain and is not covered/available, then the doctor will give an alternate prescription. 2. Review of Resident #14's medical record, showed: -readmitted [DATE]; -Diagnoses included: quadriplegia (paralysis in all limbs), Parkinson's (a neurodegenerative disease causing muscle weakness and loss), diabetes, anxiety, muscle wasting, and reduced mobility; -Able to make needs and wants known. Review of the hospital's discharge summary, dated 2/12/25, showed: -admitted : 2/5/25; -Diagnoses: Pneumonia and sepsis; -Wound dressing paste: apply one application topically twice a day to right buttock and left thigh wounds; -Wound care instructions: -Incontinent associated dermatitis (IAD, skin damage associated with incontinence) bilateral (both sides) buttocks; -Dressing status: open to air; -Site assessment: fragile, painful and pink; -Shape/pattern: irregular; -Peri-wound assessment: fragile, painful; -Interventions: cleansed, protective ointment; -Wound status: unchanged; -Non-staged description: partial thickness; -Pressure injury to coccyx: -Dressing status: open to air; -Site assessment: Fragile, painful; -Shape/pattern: Irregular; -Peri-wound assessment: Fragile, painful; -Interventions: cleansed, protective ointment; -Pressure injury Stage: II (partial thickness skin loss, appearing as a shallow, open ulcer with a red or pink wound bed, or as an intact or open/ruptured blister); -Measurements: length 3 cm x width 4 cm; -Margins: Undefined edges; -Wound status: Unchanged. Review of the facility admission assessment, dated 2/12/25, showed: -admitted from: hospital; -Pain: does the resident report pain currently: no; -Most recent pain level: 8; -Pain plan: -Focus: the resident has acute/chronic pain; -Goal: pain will be minimized with the use of scheduled and/or PRN meds; -Interventions: administer analgesia as ordered, anticipate needs for pain relief, evaluate effectiveness of pain interventions. Review of the POS, showed: -An order dated, 2/13/25: Hydrocodone-Acetaminophen 5 mg/325 mg (a narcotic pain reliever for moderate pain). Take one tablet three times a day for pain; -Documented administered as ordered. -No order for Bactine Spray. Review of the care plan, updated 2/14/25, showed: -Focus: the resident is on pain management therapy; -Goal: free of any discomfort or side effects from pain medication; -Interventions: administer medication as ordered, assess for effectiveness. Ask physician to review medication if side effects persist and monitor for falls. Review of the progress note, dated 2/17/25 at 2:50 P.M., showed: -A medication administration note: hydrocodone 5 mg-325 mg administered for coccyx pain; -No additional notes regarding assessments, treatment or physician notification. Review of the progress note, dated 2/23/25, showed: -At 11:45 A.M., pain to the bottom, barrier cream applied; -At 1:34 P.M., medication note: Hydrocodone 5 mg/325 mg, one tablet administered for buttock pain; -No additional notes or physician notification. Review of the progress notes, dated 2/28/25, showed: -At 12:44 P.M., a nurse note: pain assessment every shift: buttock pain; -No noted further assessment documented; -At 1:21 P.M., a medication administration note: Hydrocodone administered for buttock pain; -At 5:30 P.M., a late physician visit note: no notification of wound or skin impairment to buttocks. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/2/25, showed: -Cognitively intact; -Diagnosis included: Quadriplegia, Parkinson's disease (a progressive neurodegenerative disorder that affects the brains ability to control body movements), malnutrition, anxiety and depression; -Takes routine pain medication. Review of the progress note, dated 3/20/25, showed: -At 6:37 A.M., a medication administration note: Hydrocodone 5 mg-325 mg administered. Observation and interview on 3/20/25 at 7:30 A.M., showed the resident awake in bed. He/She lay on a standard mattress. CNA D and CNA E assisted the resident onto his/her side and exposed the buttocks. Noted to the sacrum, on the left and right buttock were multiple white gauze pads and foam dressings secured the gauze in place. Blood was noted to various areas of the gauze. CNA D and E said oh my God, (he/she) is bleeding, these are stuck to (him/her), CNA D used a warm soapy washcloth and squeezed the water onto the adhered gauze pads and slowly removed the gauze from the resident's skin. The resident yelled oh God, that hurts and noted to be crying. CNA D and E apologized and continued to remove the bandages. The resident requested the aides spray Bactine (pain relieving over the counter spray) spray and said the spray helps numb it. CNA D cleansed the entire buttock area and sprayed the area with Bactine. Review of the progress notes, showed no pain assessment or physician notification of the increased pain related to wounds. During an interview on 3/20/25 at 1:08 P.M., the DON said the aides should report pain to the nurse immediately. If the resident is expressing pain and tearful, the aides should stop and get the nurse immediately. Aides should not administer over the counter spray pain medications. All medications should be on the POS. The nurse is responsible to provide a pain assessment, document and administer pain medication. If the resident did not have an order for a PRN pain medication, the physician should be contacted to obtain an order. MO00249622 MO00250935 44950

Based on observation, interview and record review, the facility failed to implement an effective pain management regime for two sampled residents (Resident #18 and #14). Staff failed to notify ensure Resident #18, who experienced pain related to metastatic breast cancer with osseous (bone) involvement, most severe over bilateral lower extremities, received pain medications as ordered by the physician and failed to notify the primary physician when pain medications were not delivered from the pharmacy and of medications available in the emergency kit. The resident experienced uncontrolled pain and was transferred to the hospital two days after admission to the facility. For Resident #14, the facility staff failed to provide effective pain relief when, during care, staff removed wound dressings which were adhered to the wound sites. The resident had so much pain, he/she was observed to cry and requested Certified Nurse Aide (CNA) D spray over the counter Bactine (relieves the pain and itch of minor cuts, scrapes and burns on contact) onto the buttock wound sites. The sample was 16. The census was 145. Review of the facility's Pain Management Policy, revised 10/24/22, included: -Purpose: To ensure accurate assessment an management of the resident's pain; -Policy: A Licensed Nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Facility Staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain; -Procedure: --Pain Assessment: ---A Licensed Nurse will assess each resident for pain upon admission. ---The Licensed Nurse will complete Pain Assessment, or a substantively similar form, for residents identified as having pain within 8 hours of admission. ---The IDT Committee review the Pain Assessment for each newly admitted resident identified by the Licensed Nurse to have pain and at least quarterly thereafter. ---The Licensed Nurse will develop a care plan for pain management, including non pharmacological interventions. ---Pain Flow Sheet, or a substantively similar form, will be completed every shift for new residents for the first seventy-two (72) hours following admission. ---After medications/interventions are implemented, re-evaluate the resident's level of pain within one hour. ---A Licensed Nurse will reassess the resident for pain quarterly and eventfully. --Pain Management ---The Licensed Nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR). ---Nurses will complete the Pain Flow Sheet for residents receiving PRN pain to evaluate the effectiveness of the medication regimen. ---The Licensed Nurse will assess the resident for pain and document results on the MAR each shift using the 1-10 pain scale. ---The shift pain score will indicate the highest pain level that occurred on that shift. ---If there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician for a review of medications. ---Nursing Staff will implement timely interventions to reduce the increase in severity of pain. ---Nursing Staff will provide education to residents and families as to appropriate expectations for pain management. ---The Nursing Staff will attempt to become familiar with cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain. ---Pain Management Tool to audit and assess the success of the Pain Management Program. ---Nursing Staff will also utilize non-pharmacological interventions by adjusting the resident's environment to reduce pain. --Documentation ---Pain Assessments will be maintained in the resident's medical record. ---The Licensed Nurse will document resident's pain and response to interventions in the medical record on the weekly summary and as indicated on the progress notes. ---The Licensed Nurse will update the care plan for pain management with any change in treatment and/or medication. ---Upon admission, quarterly, and eventfully the IDT Committee will meet to review the resident's Pain Assessment. The IDT Committee will document the following: -Summary of event causing the pain; -Root cause analysis; -Referrals, as necessary; -Interventions to prevent future pain Review of the Ordering and Receiving Controlled Medication Policy, dated 1/20, showed: -Policy: --Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and record keeping requirements in the nursing care center, in accordance with federal and state laws and regulations. The nursing care center obtains and keeps current and on file any permits required by state agencies. Procedures: --The director of nursing and the consultant pharmacist monitors for compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized, licensed nursing and pharmacy personnel have access to controlled medications. --Medications listed in Schedules II, III, IV and V are dispensed by the pharmacy in readily accountable quantities and containers designed for easy counting of contents. When possible, injectable controlled substance medications are dispensed in ampoules or vials of the smallest available dosage unit. (Note: Refer to state regulations, as particular states do not require Schedule V medications to be dispensed in accountable quantities and containers.) --The pharmacy or the nursing care center prepares an individual resident controlled substance record/receipt/log for each controlled substance medication prescribed for a resident as applicable per state law. This log is placed in the MAR or narcotic book to be counted every shift. The nursing care center may designate a particular medication, which is not mandated as a controlled substance by state or federal laws and subject to abuse or diversion, to be handled under these procedures for controlled medications. (Note: Refer to state regulations, as particular states do not require this documentation for Schedule V medications.) The following information is completed: -Name of resident -Prescription number -Medication name -Medication strength (if designated) -Dosage form of medication -Date received -Quantity received -Name of person receiving the medication supply --The Drug Enforcement Agency (DEA) requires that a pharmacy must have a valid prescriber signed prescription in order to dispense controlled substances. A valid written prescription requires patient name, drug name and strength, quantity to dispense, directions for use, date and signature of the prescriber. (Refer to Section 2.2-Controlled Substance Medication Orders). In an emergency situation, verbal authorization may be given by the prescriber to the pharmacist for a new order as described by state law. (Refer to Section 3.4 Emergency Pharmacy Service and Emergency Kits (E-Kits)) --Refill Requests for CIII-CV, and Partial Fill Requests for CII -If one or more refills (CIII-Vs) or a partial fill quantity (CIIs) remains: -Written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand. -If only one refill remains ([NAME]-Vs) or only a partial fill quantity remains (CII), the pharmacy will simultaneously dispense the remaining fill, and, if necessary proactively seek out a new, complete prescription from the prescriber for future use. The facility may be asked to contact the prescriber for a new prescription upon request for a medication with no remaining fills available. 1. Review of Resident #18's electronic medical record (EMR), showed: -admission: [DATE]; -discharged : 3/8/25; -Diagnoses include malignant neoplasm left breast, malignant neoplasm of liver, and acute respiratory failure with hypoxia. Review of the hospital discharge record, showed: -Hospital Course: Acute respiratory hypoxia (not enough oxygen in the tissues in your body) secondary to progression of metastatic breast cancer. -Cancer related pain: Diffuse pain related to metastatic breast cancer with osseous (bone) involvement, most severe over bilateral lower extremities. Regimen was adjusted to morphine extended release (ER) (opioid that treats moderate to severe pain) 15 milligram (mg) twice a day (BID) and oxycodone (opioid that treats moderate to severe pain) 10 mg every 6 hours as needed (PRN), continued on scheduled Tylenol 1000 mg three times a day (TID), gabapentin (used to treat nerve pain) 300 mg BID, and added Flexeril (muscle relaxer used to treat pain and stiffness) 5 mg TID PRN. -Medications at hospital discharge included: -Morphine ER 15 mg BID (last given 3/6/25 at 11:42 A.M.); -Oxycodone 10 mg every 6 hours PRN (last given 3/6/25 at 12:47 P.M.); -Flexeril 15 mg TID PRN (last given 3/6/25 at 11:42 A.M.); -Gabapentin 300 mg BID (last given 3/6/25 at 9:05 A.M.); -Tylenol 1000 mg TID (last given 3/6/5 at 9:05 A.M.). Review of the admission assessment, dated 3/6/25 at 5:40 P.M., showed: -Date of arrival: 3/6/25; -Time of arrival: 5:35 P.M.; -Was physician notified of the resident's admission: Yes; -Were the resident's medications reviewed with the physician: Yes; -Were there any significant medication issues found during review: No; -Level of consciousness: Alert to situation, time, place; -Mood: Flat; -Pain: Does the resident report pain currently: No; -Most recent pain level: 8 3/7/25 at 6:42 A.M.; -Pain plan: Blank -admission Actions: Physician/Nurse Practitioner (NP) notified of admission assessment; -Physician/NP Actions: No new orders; -Drug Regime Review (DRR): 3/6/25 at 9:00 P.M.; -Was the list of medications from the hospital compared with the medications the resident was taking at home: Yes; -Was the physician notified if any discrepancies were noted during medication reconciliation: No differences noted; -Were all medications reviewed to ensure that proper labs were ordered: Yes; -Select most accurate statement: Statement by nurse that admission DRR completed with no significant issues identified. Review of the resident's pain assessment, dated 3/6/25 at 6:09 P.M., showed: -Have you had pain or hurting at any time in the last 5 days: Yes; -How much of the time have you experienced pain or hurting over the last 5 days: Frequently; -Pain Effect on sleep: Frequently; -Pain interference with therapy activities: Frequently; -Pain interference with day-to-day activities: Frequently; -Verbal descriptor: Severe; -Staff assessment for pain: None of these signs observed or documented (non-verbal, vocal complaints, facial expressions, protective body movements); -Frequency with which resident complains or shows evidence of pain or possible pain: Daily; -Pain Management: Describe treatment, any side effects, effectiveness: ineffective; -Received PRN pain medications: Blank; -Received non-medication intervention: Blank. Review of the resident's care plan, did not address his/her potential for pain. Review of the resident's Pain Level Summary, showed: -3/6/25 at 9:25 P.M., 0/10 pain; -3/7/25 at 6:42 A.M., 8/10 pain; -3/7/25 at 6:46 P.M., 10:35 P.M., and 11:33 P.M., 0/10 pain; -3/8/25 at 3:38 A.M. and 6:48 A.M., 0/10 pain; -3/8/25 at 10:57 A.M., 1:39 P.M., and 2:03 P.M., 10/10 pain. Review of the resident's Physician Order Sheet (POS), included: -An order, dated 3/6/25, Morphine 15 mg. Give 1 tablet by mouth every 12 hours for pain; -An order, dated 3/6/25, Oxycodone tablet 10 mg. Give one tablet by mouth every 6 hours as needed for pain; -An order, dated 3/6/25, Cyclobenzaprine (Flexeril) 5 mg. Give one tablet every 8 hours as needed for muscle spasms; -An order, dated 3/7/25, Gabapentin 300 mg. Give 300 mg by mouth two times a day for pain; -An order, dated 3/6/25, Tylenol 1000 mg. Give 1000 mg by mouth three times a day for pain. Review of the resident's, March 2025, Medication Administration Record (MAR), showed: -Morphine 15 mg: -Showed given 3/6/25 at 9:00 P.M. and 3/7/25 at 9:00 P.M.; -Marked 9 (other/see progress notes) 3/7/25 at 9:00 A.M. and 3/8/25 at 9:00 A.M. -Oxycodone tablet 10 mg: -Medication not administered to the resident. -Cyclobenzaprine (Flexeril) 5 mg: -Medication not administered to the resident. -Gabapentin 300 mg by mouth two times a day for pain. -3/7/25 at 9:00 A.M., Medication marked 5. No progress note related to medication not administered. -Tylenol 1000 mg by mouth three times a day for pain: -3/7/25 2:00 P.M. Not given. Marked 5 (Hold/See progress note). Review of the resident's electronic medical record (EMR), showed: -An administration note dated 3/7/25 at 3:03 P.M., New admit medication (Tylenol) will be delivered 3/7/25; -An administration note, dated 3/8/25 at 12:47 P.M., Morphine sulfate. Medication on order, pharmacy notified; -An administration note, dated 3/8/25 at 1:39 P.M., Morphine sulfate. Medication on order from pharmacy/new admit. Review of the resident's EMR, showed: -A progress note, dated 3/6/25 at 5:40 P.M., resident was admitted from hospital on [DATE] at 5:35 P.M. Resident is alert. Oriented to place time situation. Mood is flat. Resident is not able to report pain at this time. Physician/Nurse Practitioner notified of admission assessment findings and no new orders noted. Refer to full assessment for more information; -A progress note, dated 3/7/25 at 6:33 A.M., resting in bed No signs of acute distress noted. Complained of general discomfort. Scheduled pain medication given with effectiveness. Plan of care ongoing; -A progress note, dated 3/8/25 at 4:38 A.M., monitoring for new admission status. Remains alert and oriented. Able to make needs known. Resident is making adjustments to new environment; -A progress note, dated 3/8/25 at 3:15 P.M., resident sent to hospital for uncontrolled pain. Physician, family, Director or Nursing (DON) aware. Review of the facility's Controlled II Emergency Medication Kit, showed: -Morphine Sulfate 100 mg/5 milliliter (ml) solution 30 ml; -Fentanyl (used to treat severe pain) 25 mcg patch; -Oxycodone 5 mg tab; -Oxycodone/Apap (Tylenol) (used to treat moderate to moderately severe pain) 5/325 mg tab and 10/325 mg tab; -Hydrocodone/Apap (used to treat moderate to severe pain): 5/325 mg tab, 7.5/325 mg tab, and 10/325 mg tab. Review of the facility's Controlled III-V Emergency Medication Kit, showed: -APAP/Codeine #3 (used to treat moderate to moderately severe pain); -Tramadol (used to treat moderate to severe pain) 50 mg. Review of the Situation-Background-Assessment-Request (SBAR), dated 3/8/25 at 1:11 P.M., showed: -Situation- Patient in severe pain related to recent lumpectomy, breast cancer: -Started on 3/8/25; -Since started it has gotten worse; -Things that make the condition/symptom worse: unmedicated/pharmacy has not delivered; -Things that make the condition/symptom better: medication; -Treatment for last episode: new admit; -Background: -Resident in nursing home for post-acute care; -Primary diagnosis: left breast cancer; -Other pertinent history: neoplasm liver, neoplasm of vocal cords; -Assessment: -Registered Nurse (RN): Think the problem may be uncontrolled pain; -Licensed Practical Nurse (LPN): The resident appears in excruciating pain; -Request: -Suggest or Request: Transfer to the hospital -Nursing notes: Resident has facial grimacing and furrowed brow in relation to severe pain from lumpectomy/other cancer. -Reported to primary care clinician: 3/8/25 at 1:00 P.M. Observation and interview on 3/19/25 at 11:30 A.M., showed Licensed Practical Nurse (LPN) H open the narcotic box in the nurse medication cart. Resident #18 had one card of Oxycodone with 30 out of 30 pills and one card of Morphine 15 mg with 28 out of 28 pills. (The issue date of the medications was March 8, 2025.) Review of the narcotic book showed nothing signed out for the resident. LPN H said there was an emergency kit (e-kit), but he/she was not sure where it is located. When a resident is a new admission, it typically takes pharmacy about an hour to get medications sent to the facility. During an interview on 3/19/25 at 12:04 P.M., LPN A said if a resident is a new admission and they do not have the medication at the facility, then the nurse can pull the medication from the e-kit. There is a controlled medication e-kit and a regular one. LPN A said when the resident was admitted , the facility did not have his/her medications. They were waiting on the doctor to approve it because pharmacy would not send the medication without doctor approval. LPN A believes the medication was sent to the facility after the resident was at the hospital because he/she never received the medication while he/she was at the facility. The medication was still listed as pending while he/she was here. The resident was sent to the hospital because of his/her pain and the facility not being able to manage it. During an interview on 3/19/25 at 12:46 P.M., the Pharmacist said the facility sent the order for the resident's Morphine 15 mg and Oxycodone 10 mg on 3/6/25 at 1:30 P.M. Usually, if the medication is not covered, there is a billing issue like trying to refill too soon or it is on back order. The Pharmacist believes the morphine was on back order, a card was sent to the facility and now it is on back order again. The Pharmacist said their system shows the pharmacy sent the resident's Morphine and Oxycodone to the facility on 3/8/25 at approximately 11:00 A.M. Typically, once an order is received, the pharmacy can get it to the facility within an hour. The pharmacy is local. During an interview on 3/19/25 at approximately 1:00 P.M., the controlled log inventory sheet for controlled medication sent from the pharmacy to the facility from 3/1/25 to 3/14/25 was requested from the DON. At 1:42 P.M., the DON said no controlled medication had come in or out for the first floor from 3/1/25 to 3/14/25. During an interview on 3/20/25 at 3:50 P.M., LPN K said he/she admitted the resident to the facility. LPN K did not know what the resident was admitted for , but the resident had a left breast mastectomy. The resident had orders for two different narcotics. He/She called the physician because the hospital did not send the prescriptions. The resident did not get either medication while he/she was here. LPN K is not sure why he/she signed off on giving the medication. LPN K might have just checked it as given to get the screen off red so the admission could be completed. LPN K did not remember giving the resident any morphine. During an interview on 3/20/25 at 11:50 A.M., Certified Nursing Assistant (CNA) I said the resident was at the facility for about a day. The resident called 911 to get out of the facility. CNA I said things were chaotic when the resident was admitted . They could not find things like the resident's oxygen concentrator so he/she thinks the resident got frustrated that they could not do things as quick as the resident would like. Then they had to change out his/her bed. Then the next thing they know, the resident is on the ambulance. The resident did not say what brought him/her to the facility but still complained of pain when he/she left. The resident had complained of pain since he/she got there. The resident just looked tired. The resident was constantly grimacing and said his/her lower back hurt. The resident was always complaining of pain. CNA I remembered the nurse telling the resident that he/she could not have anything else, because it was not time yet and the resident still had a couple hours to go. The resident called his/her son/daughter once and CNA I talked to them. The family member said the resident was uncomfortable. The resident was just having a lot of pain. During an interview on 3/20/25 at 12:28 P.M., Certified Medication Technician (CMT) F said the resident was not there very long. CMT F only went in once when the resident's bathroom call light was going off and did not remember if he/she gave the resident any medications. CMT F did not remember why he/she would not have given the resident a Tylenol. CMT F said when a 5 is charted in the MAR, then a progress note should be entered. The resident was just very quiet. During an interview on 3/20/25 at 12:45 P.M., LPN K said he/she did not really remember the resident. LPN K said the CMT gave the resident his/her medications. When asked about the MAR, LPN K said the resident did get morphine. The resident complained of back pain. The morphine was pulled from the medication cart on his/her card,. It may have been a liquid dose, LPN K cannot recall off hand if it was a liquid or pill form. LPN K said he/she did not pull anything from the e- kit and is unsure if the resident had pain medicine. When a medication is pulled from the e-kit, the pharmacy has to give a code to access the e-kit. During an interview on 3/20/25 at 12:57 P.M., the DON said when a resident is admitted , the nurse is expected to complete the admission assessment and verify medications with the physician. The medications are put in the EMR and then the pharmacy should receive it. If the facility does not have a medication, then she expected the nurse to call the pharmacy. She also expected the nurse to notify management, like the Assistant Director of Nursing (ADON), and the physician. If the medication is a controlled pain type medication and the pharmacy says they do not have a prescription, then get the prescription sent to the pharmacy and sign it out from the e-kit. Once signed out, then the pharmacy sends it. If it is not in the e-kit, staff should call the physician and try to get an order for something different. She expected nursing staff to call the physician and get something else for the resident's pain. She is not sure if Tylenol is stock or not. The DON is not sure of the process but believes when the e-kit is open, the nurse calls the pharmacy to get a code which unlocks the kit. The resident was admitted with pain. She received a call on Saturday the resident wanted to go back to the hospital because his/her pain was uncontrollable. The nurse called the physician and sent him/her out. The DON did not get a call prior to that related to the resident. Staff should have called the physician immediately when the medication did not arrive. She and the ADON reviewed the resident's admission on [DATE] and this did not come up. The DON expected a resident's pain to be reassessed within the hour. She would not expect staff to document they gave a medication if they did not actually give the medication. During an interview on 3/20/25 at 1:35 P.M., the ADON said they look at the missed medication report every day. The report is generated by what code is entered and a report can be pulled. The resident was there about a day and a half. The resident came late in the day. For the resident's pain medication, they have a narcotic e-kit with morphine. E-kits are kept on the first floor, and there is one box with a combination code. The process is to call the pharmacy. The pharmacy will give a combination to that box and they will approve doses until they deliver the meds. They have morphine in the e-kit. The nurses should have called the physician to get an order for the liquid pain medication. A nurse should not document a medication was given if the medication was not in the building and should not borrow any medications from other residents. The nurses have access to what is in the e-kit as it is on the e-kit box. When staff pull out of the e-kit, it is faxed to the pharmacy, then the pharmacy would know what to replace. The nurse should document a progress note if the e-kit was accessed for a medication. During an interview on 3/20/25 at 9:45 A.M., the NP said he/she did not have a chance to assess the resident in person. The resident came and went. Usually when a patient comes, they send medications, but they did not have the chance. The resident was in bad shape. They did not get a call from the pharmacy regarding the resident's pain medications. The facility did not call either. If a patient needs pain medication, the NP expected a phone call. They have to let the doctor know. They always look for another option if the resident does not have ordered pain medication. If a resident has pain and is not covered/available, then the doctor will give an alternate prescription. 2. Review of Resident #14's medical record, showed: -re-admitted [DATE]; -Diagnoses included: quadriplegia (paralysis in all limbs), Parkinson's (a neurodegenerative disease causing muscle weakness and loss), diabetes, anxiety, muscle wasting, and reduced mobility; -Able to make needs and wants known. Review of the hospital's Discharge summary, dated [DATE], showed: -admitted : 2/5/25; -Diagnoses: Pneumonia and sepsis; -Wound dressing paste: apply one application topically twice a day to right buttock and left thigh wounds; -Wound care instructions: -Incontinent associated dermatitis (IAD, skin damage associated with incontinence) bilateral (both sides) buttocks; -Dressing status: open to air; -Site assessment: fragile, painful and pink; -Shape/pattern: irregular; -Peri-wound assessment: fragile, painful; -Interventions: cleansed, protective ointment; -Wound status: unchanged; -Non-staged description: partial thickness; -Pressure injury to coccyx: -Dressing status: open to air; -Site assessment: Fragile, painful; -Shape/pattern: Irregular; -Peri-wound assessment: Fragile, painful; -Interventions: cleansed, protective ointment; -Pressure injury Stage: II (partial thickness skin loss, appearing as a shallow, open ulcer with a red or pink wound bed, or as an intact or open/ruptured blister); -Measurements: length 3 cm x width 4 cm; -Margins: Undefined edges; -Wound status: Unchanged. Review of the facility admission assessment, dated 2/12/25, showed: -admitted from: hospital; -Pain: does the resident report pain currently: no; -Most recent pain level: 8; -Pain plan: -Focus: the resident has acute/chronic pain; -Goal: pain will be minimized with the use of scheduled and/or PRN meds; -Interventions: administer analgesia as ordered, anticipate needs for pain relief, evaluate effectiveness of pain inte

37672 Based on observation, interview and record review, the facility failed to obtain and follow physician orders for wound care for two sampled residents (Residents #89 and #72). Both residents required hospitalization for assessment and treatment of wound conditions, including amputations. The census was 151. The Administrator was notified on 7/12/24 at 10:49 A.M., of an immediate jeopardy (IJ) that began on 7/1/24. The IJ was removed on 7/12/24 as confirmed by surveyor on-site verification. Review of the wound management policy, revised 10/24/22, showed: -Purpose: To provide a system for the treatment and management of residents with wounds including non-pressure ulcers; -Definitions: -Arterial Ulcer- an ulceration that occurs as the result of arterial occlusive disease when no pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis (death). Arterial/ischemic (lack of blood flow) ulcers may be present in persons with moderate to severe peripheral vascular disease (PVD, poor blood flow in the lower extremities), generalized arteriosclerosis (stiffening and thickening of the blood vessels) or vascular disease elsewhere. The arterial ulcer is characteristically painful, usually occurs in the distal (farther area) portion or the lower extremity, and may be over the ankle or bony area of the foot; -Procedure: -Assessment: -A licensed nurse will perform a skin assessment upon admission, re-admission, weekly and as needed (PRN) for each resident; -Upon identification of a new wound the licensed nurse will: -Measure the wound (length, width, depth); -Initiate a wound monitoring record sheet; -A wound monitoring record will be completed for each wound; -If the wound monitoring record is not used, documentation will be recorded within the medical record which may include nursing notes, treatment records or care plans; -Implement a wound treatment per physician's order; -An assessment of care needs for wound management will be made with emphasis on, but not limited to: -Identifying risk factors; -Treatment; -Mechanical off-loading and pressure reducing devices; -Reducing skin friction, sheer and moisture; -Nutritional status; -Evaluating and modifying interventions for a resident with an existing skin injury; -Wound management: -The physician will be notified to advise on appropriate treatment promptly; -The nurse will notify the responsible party of the presence of a skin injury; -Dietary contact will be made for nutritional assessment; -Rehabilitation services will be contacted for appropriate devices or pressure redistributing devices; -A nurse will develop a care plan for the resident based on recommendations from dietary, rehabilitation and the physician; -Per physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management; -Per attending physician order, the nursing staff will initiate treatment and utilize interventions for wound management; -The attending physician and interdisciplinary team (IDT) will be notified of: -New wounds; -Wounds that do not respond to treatment; -Wounds that increase in size; -Complaints of increased pain, discomfort or decrease in mobility; -Signs of ulcer sepsis (infection), odor, necrosis, if not already noted by the attending physician; -Certified Nurse Aides (CNA) will complete body checks on resident shower days and report unusual findings to the nurse; -Documentation: -New wounds will be documented on the 24 hour log and incident report will be completed by the nurse; -Wound documentation will occur a minimum of weekly until the wound is healed. Documentation will include: -Wound location; -Length, width and depth measurements in centimeters (cm); -Direction and length of tunneling (wound extends deeper into the tissue) and undermining (separation of the wound edges from the surrounding healthy tissue) if applicable; -Appearance of the wound base; -Drainage amount and characteristics including color, consistency and odor; -Appearance of wound edges; -Description of the peri-wound (skin surrounding the wound) condition or evaluation of the skin adjacent to the wound; -Presence or absence of new skin growth at wound rim; -Presence of pain; -IDT will document discussion and recommendation for: -Wounds that do not respond to treatment; -Wounds that worsen or increase in size; -Complaints or increased pain, discomfort or decrease in mobility by a resident; -Signs of ulcer sepsis, presence on drainage, odor or necrosis; -Residents refusing treatment; -Nurses will document effectiveness of current treatment in the medical record on a weekly basis; -Document notifications follow a change in skin condition; -Update the care plan as necessary. 1. Review of Resident #89's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/1/24, showed: -No cognitive impairment; -No behaviors; -Diagnoses included heart failure, high blood pressure, diabetes, malnutrition, anxiety, bipolar (episodes of emotional highs and lows), and asthma; -Has surgical wounds; -Receives oxygen; -Uses wheelchair; -No Range of Motion (ROM) to the upper and lower right and left extremity; -Occasionally incontinent of bowel and bladder; -Weight: 445 pounds; -Skin and ulcer treatments: -Pressure reducing device for chair; -Pressure reducing device for bed; -Nutrition or hydration intervention to manage skin problems; -Surgical wound care; -Application of nonsurgical dressings (with or without topical medications) other than to feet; -Applications of ointments/medications other than to feet. Review of the care plan, in use during survey, showed: -Focus: Resident is resistive to care related to wound healing and ADLs; he/she has been observed removing his/her dressings to his/her foot and abdomen/chest; -Goal: Will cooperate with care; -Interventions: Education provided on cleanliness of his/her dressings and skin/hygiene; -Reported; he/she will pick at his/her wounds to his/her abdomen and chest placing removed skin and tissue into his/her mouth. States that he/she is cleaning off his/her fingers to prevent smearing blood onto his/her clothing; -Staff to educate and remind him/her importance of leaving his/her dressings in place until time for changes; -Focus: He/She is on antibiotic therapy related to infection. Doxycycline (treat and prevent infections) Hyclate Oral Tablet 100 milligrams (mg). Give 100 mg by mouth two times a day for infection until 5/12/24; -Goal: He/She will be free of any discomfort or adverse side effects of antibiotic therapy; -Interventions: Administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness every shift; -Monitor/document/report as needed adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia (loss of appetite), and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat); -Monitor/document/report as needed signs/symptoms of secondary infection related to antibiotic therapy: oral thrush (white coating in mouth, tongue), persistent diarrhea, and vaginitis/itchy perineum/whitish discharge/coating of the vulva/anus; -Focus: He/She has potential/actual impairment to skin integrity; -Abdomen midline: Trauma; -Sternum: Trauma; -Right groin abscess,1/20/24, full thickness; -Anterior nose, full thickness: Resolved 5-15-24; -Right shin, cellulitis (skin infection): Resolved 5-29-24; -Left thigh; -Goal: Affected areas will show adequate progress towards healing; -Interventions:11/20/23: Chest wound bleeding due to the resident scratching at site. Education provided by nurse and wound nurse in importance of not scratching at site; -6/19/2024: Multivitamin plus minerals daily; -6/19/2024: Pro stat (protein supplement) 30 milliliters (ml) by mouth, twice a day for skin integrity; -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short; -Educate resident/family/caregivers of causative factors and measures to prevent skin injury; -Encourage good nutrition and hydration in order to promote healthier skin; -He/She needs pressure relieving mattress to protect the skin while in bed; -He/She needs pressure relieving cushion to protect the skin while up in chair; -Keep skin clean and dry. Use lotion on dry skin; -Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration (softening of the skin due to moisture) to physician; -Treatment per physician's orders. -Weekly treatment documentation; -Wound care to evaluate and treat as indicated; -Focus: Resident has diabetic ulcer of the right lateral foot, left heel related to diabetes, lack of sensation to affected area, and poor glycemic control; -Goal: Affected areas will show adequate progress towards healing through; -Interventions: 10/26/23: Arterial Doppler with ankle brachial index (ABI, compares the blood pressure in the upper and lower limbs) for bilateral symptoms: Pain, edema, skin breakdown, with chronic non-healing wound with drainage to right foot. Diagnosis of ulcer of limb/non-healing wound; -Avoid mechanical trauma: Constrictive shoes, cutting and trimming corns and calluses, adhesive tapes, improper shaving, and vigorous massage; -Monitor blood sugar levels; -Monitor/document wound: Size, depth, and margins: peri wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, and gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated; -Monitor/document/report as needed any signs/symptoms of infection: [NAME] drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, and fever; -Monitor/document/report as needed changes in wound color, temperature, sensation, pain, or presence of drainage and odor; -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations; -Wound care to evaluate and treat as indicated; -Focus: He/She has bladder incontinence, activity intolerance, impaired mobility, poor toileting habits; -Goal: Resident will be continent during waking hours and he/she will remain free from skin breakdown due to incontinence and brief use; -Interventions: Brief use: Resident uses disposable briefs. Change as needed; -Clean perineal area (peri-area, area between the genitals and the anus) with each incontinence episode; -Encourage fluids during the day. Review of the resident's electronic physician order sheet (ePOS), showed: -An order, dated 5/6/24: wound care to right foot, cleanse with normal saline (NS) or Vashe (wound cleanser), pat dry, apply Santyl (used to remove dead tissue), nickel thick, edge to edge of wound bed, cover with calcium alginate (dressings are used on moderate to heavily exudative wounds during the transition from debridement to repair phase of wound healing) cut to fit cover with bordered gauze every day shift and as needed for soiling and unscheduled removal; -An order, dated 5/6/24: wound treatment to groin. Cleanse with Vashe, pat dry, apply Santyl nickel thick, edge to edge to wound bed, cover with calcium alginate cut to fit, cover with abdominal (ABD) pad every day shift and as needed for soiling and unscheduled removal; -An order, dated 6/19/24: Pro stat, 30 ml by mouth, twice a day for skin integrity; -An order, dated 6/27/24: for size E Tubi grips (elasticated, multi-purpose bandage used for compression) to bilateral feet for dressing security; -An order, dated 6/30/24: Wound care to left heel: Cleanse back of left heel with Vashe, pat dry, apply Santyl to wound bed only, apply calcium alginate to wound bed, only then cover with border gauze dressing every day shift for wound care management and as needed for wound care management for soiling and unscheduled removal; -An order, dated 7/3/24: Doxycycline Hyclate Oral Tablet 100 mg. Give one tablet by mouth two times a day related to cellulitis of unspecified part of limb for seven days; -An order, dated 7/3/24: for Levofloxacin (Levaquin, antibiotic) 750 mg. Give one tablet by mouth every evening shift for wound for seven days; -An order, dated 7/3/24: arterial Doppler (ultrasound to check blood flow in large arteries and veins) to right lower extremity for wound; -An order, dated 7/3/24: Wound care: Sternum (long, flat bone of the chest). Cleanse with wound cleanser or NS, pat dry, apply silicon bordered gauze every three days, every day shift for wound care. Chart nurse's notes if patient removes dressings and picks at open areas and as needed for soiling or unscheduled removal; -An order, dated 7/4/24: Wound care: Abdomen midline. Cleanse with Vashe, pat dry, apply xeroform (sterile, fine mesh gauze) to wound bed only, then apply silicone bordered gauze, every day shift, every three days for wound treatment. Chart in nurse's notes if patient removes dressings and picks at wounds and as needed for soiling and unscheduled removal; -An order, dated 7/6/24: Mupirocin external ointment (used to treat secondarily infected traumatic skin lesions) 2 percent (%). Apply to right hand/third digit topically two times a day for paronychia (infection of the tissue adjacent to a nail) until 7/12/24. Soak right hand third digit in soapy water, dry, and apply ointment; -An order, dated 7/6/24: Right third finger: Paronychia. Soak right hand and fingers in warm soapy water for 15 minutes, dry, apply mupirocin ointment two times a day for infection of right hand third digit Paronychia until 07/12/2024, twice daily and PRN; -No treatment orders for the Abdomen right lower quadrant. Review of the resident's June 2024 Treatment Administration Record (TAR), showed: -An order, dated 6/1/24: Treatment: Left Heel: Cleanse back of left heel with NS, pat dry, apply calcium alginate and cover with border gauze dressing every day shift for wound care management. Entries on 6/1, 6/4, 6/11, 6/14, 6/15, 6/17, 6/22, 6/27, and 6/28/24 were blank. It was discontinued on 6/29/24; -An order, dated 6/1/24: Wound: Left thigh. Cleanse with NS, pat dry, apply calcium alginate, and cover with border gauze dressing every day shift. Entries on 6/1, 6/4, 6/11, 6/14, 6/15, 6/17, 6/22, 6/27, 6/28, and 6/28/24 were blank. The order was discontinued on 6/29/24; -An order, dated 5/7/24: Wound: Right foot. Cleanse with NS or Vashe, pat dry, apply Santyl nickel thick edge to edge of wound bed, cover with calcium alginate cut to fit cover with bordered gauze every day shift. Entries on 6/1, 6/4, 6/11, 6/14, 6/15, 6/17, 6/22, 6/27, and 6/28/24 were blank; -An order, dated 6/1/24: Wound: Abdomen midline. Cleanse with wound cleanser or NS, pat dry, apply bordered gauze every day shift for wound treatment. Entries on 6/1, 6/4, 6/11, 6/14, 6/15, 6/17, 6/22, 6/27, and 6/28/24 were blank; -An order, dated 5/7/24: Wound treatment: Groin. Cleanse with Vashe, pat dry, apply Santyl nickel thick edge to edge to wound bed, cover with calcium alginate cut to fit, cover with ABD pad every day shift. Entries on 6/1, 6/4, 6/11, 6/14, 6/15, 6/17, 6/22, 6/27, and 6/28/24 were blank; -An order, dated 6/1/24: Sternum. Cleanse with wound cleanser or NS pat dry apply bordered gauze every day shift. Entries on 6/1, 6/4, 6/11, 6/14, 6/15, 6/17, 6/22, 6/27, and 6/28/24 were blank. Review of the progress notes, showed: -On 6/3/24 at 11:03 A.M., Nurse Practitioner (NP) notified of wound care not done on 5/31/24 and 6/1/24. No new orders received at this time; -On 6/10/24 at 12:12 P.M., NP notified of the refusal of all medications and care on 6/8/24 and 6/9/24. No new orders received at this time; -On 6/11/24 at 12:22 P.M., NP notified of missing wound care and Santyl and rivaroxaban (blood thinner) on 6/10/24. No new orders received at this time; -On 6/12/24 at 11:30 A.M., NP notified of missing wound care on 6/11/24. NP also notified of resident being hospitalized with medications for missing medications after day shift 6/11/24; -On 6/15/24 at 12:45 P.M., NP notified of missing wound care and insulin injections on 6/14/24. No new orders received; -On 6/16/24 at 4:29 P.M., NP notified of missed medication (lactulose, treats constipation and liver disease) and wound care on 6/15/24. No new orders received at this time; -On 6/18/24 at 12:15 P.M., NP notified of missed wound care on 6/17/24. Care ongoing, no new orders received; -On 6/24/24 at 12:12 P.M., NP notified of missing wound care on 06/22/24. Care ongoing, no new orders received; -On 6/29/24 at 10:32 A.M., NP notified of missing wound care on 6/27/24 and 6/28/24. Care ongoing, no new orders received. Review of the wound report, dated 6/26/24, showed: -Abdomen- midline: Trauma; -Measurement: 11.4 cm x 4.7 cm x 0.3 cm; -Acquired; -Sternum: Trauma; -Measurement: 2.8 cm x 4 cm x 0.2 cm; -Acquired; -Right groin: Full thickness (damage extends below the epidermis and dermis (all layers of the skin) into the subcutaneous tissue (fat) or beyond (into muscle, bone, or tendons); -Measurement: 1.2 cm x 1.2 cm x 0.2 cm; -Acquired; -Right lateral foot: Diabetic [NAME] (system for classifying diabetic ulcers) grade 2 (Deep ulcer without abscess or osteomyelitis); -Measurement: 3.9 cm x 5.9 cm x 0.3 cm; -No documentation of acquired or admitted with; -Left heel: Diabetic [NAME] grade 2; -Measurement: 3.2 cm x 4.1 cm x 0.5 cm; -No documentation of acquired or admitted with; -Left thigh: Resolved. Review of the resident's July 2024 TAR, showed: -An order, dated 5/6/24: wound care to right foot cleanse with NS or Vashe, pat dry, apply Santyl, nickel thick, edge to edge of wound bed, cover with calcium alginate cut to fit cover with bordered gauze every day shift. Treatment marked as other/see progress notes on 7/1 and 7/2/24; blank entries on 7/4 and 7/5/24; -An order, dated 5/6/24: wound treatment to groin. Cleanse with Vashe, pat dry, apply Santyl nickel thick, edge to edge to wound bed, cover with calcium alginate cut to fit, cover with ABD pad every day shift. Treatment marked as other/see progress notes on 7/1 and 7/2/24; blank entries on 7/4 and 7/5/24; -An order, dated 6/30/24: Wound care to left heel: Cleanse back of left heel with Vashe, pat dry, apply Santyl to wound bed only, apply calcium alginate to wound bed, only then cover with border gauze dressing every day shift for wound care management and as needed. Treatment marked as other/see progress notes on 7/1 and 7/2/24; blank entries on 7/4 and 7/5/24; -An order, dated 7/3/24: Wound care: Sternum. Cleanse with wound cleanser or NS, pat dry, apply silicon bordered gauze every three days, every day shift for wound care. Chart nurse's notes if patient removes dressings and picks at open areas and as needed for soiling or unscheduled removal; blank entry on 7/4/24. -An order, dated 6/1/24: Wound care: Sternum. Cleanse with wound cleanser or NS, pat dry, apply bordered gauze every day shift. Treatment marked as other/see progress notes on 7/1 and 7/2/24. Treatment administered on 7/3/24 and discontinued on 7/3/24; -An order, dated 7/4/24: Wound care: Abdomen midline. Cleanse with Vashe, pat dry, apply xeroform to wound bed only, then apply silicone bordered gauze, every day shift, every three days for wound treatment. Chart in nurse's notes if patient removes dressings and picks at wounds and as needed; blank entries on 7/4/24 for scheduled treatment; -An order, dated 6/30/24: Wound care: Abdomen midline. Cleanse with Vashe, pat dry, apply silicone bordered gauze every day shift. Treatment marked as other/see progress notes on 7/1 and 7/2/24. Treatment was administered on 7/3/24 and discontinued on 7/3/24. Review of the progress notes, showed: -On 7/1/24 from 12:12 to 12:14 P.M., the resident refused wound treatments to the following areas: -Abdomen midline: -Left heel: -Groin. -Right foot -Sternum. -On 7/2/24 from 2:38 P.M. to 2:39 P.M., health care provider (HCP) notified by this nurse, he/she was not able to carry out treatment orders; physically impossible related to nurse to patient ratio for the following treatment areas: -Abdomen midline: -Left heel: -Groin. -Right foot -Sternum. Review of the wound report, dated 7/3/24, showed: -Abdomen- midline: Trauma; -Measurement: 19.7 cm x 9.9 cm x 0.2 cm; -Acquired; -Sternum: Trauma; -Measurement: 1.5 cm x 2.0 cm x 0.2 cm; -Acquired; -Right groin: Full thickness; -Measurement: 1.3 cm x 1.6 cm x 0.2 cm; -Acquired; -Right lateral foot: Diabetic [NAME] grade 2; -Measurement: 3.8 cm x 5.2 cm x 0.3 cm; -Acquired; -Left heel: Diabetic [NAME] grade 2; -Measurement: 3.5 cm x 2.0 cm x 0.2 cm; -Acquired; -Abdomen, Right lower quadrant: Trauma; -Measurement: 3.9 cm x 3.3 cm x 0.2 cm; -Acquired. Review of a wound care note, dated 7/3/24, showed: Wound care NP rounded with Licensed Practical nurse (LPN) S to discuss with staff importance of treatment changes, and skin care. Wound culture pending. Spoke with the physician regarding wound. Physician recommends levofloxacin 750 mg once daily for seven days. Nurse to ensure that treatment are being changed daily. Arterial Doppler with ABI. MolecuLight (wound imaging device that allows clinicians to visualize bacteria and measure wounds) positive of bacteria. Debridement (removal of damaged tissue) completed. Treatment plan updated. Observation and interview on 7/8/24 at 9:39 A.M., showed the resident in bed, calling out for help. He/She sat up in bed, attempting to get up, but was unsuccessful. He/She did not have clothing on. He/She appeared obese with a pannus stomach (extra skin and fat deposits hang from the stomach or belly area on the abdomen) with several wounds that were actively bleeding onto to the floor. One wound appeared to be large, dark, and necrotic on the lower part of the stomach. The resident said he/she was unable to get up and was not able to hit his/her call light because it was stuck. Observation of the call light showed the cord was wrapped up and underneath the leg of a night table. The DON entered the room to assist the resident. The resident said it was an hour since nursing last checked on him/her. There was a room odor of urine, and resident's bed and sheets were wet. The DON closed the resident's door. The resident told the DON that he/she had not received any treatments in four days. At 9:48 A.M., the resident sat in his/her wheelchair across from his/he bed. He/She said staff were able to assist him/her to his/her wheelchair. He/She was bleeding on the abdomen because he/she had wounds on his/her stomach and did not get treatments in the last four days. The resident lifted up his/her gown and showed several wounds, size ranging from pen size to approximately two inches in length, that were red, inflamed and bleeding. He/She was told staff would be in to do his/her treatment. Flies were observed in the room. There was an odor of urine and feces in the room. Dried blood noted on the floor next to the resident's bed. At 11:58 A.M., the resident sat in the hall across from the nurse's station. The resident had a bedside table in front of him/her and ate his/her meal. Staff said the resident wanted to go to the hospital. At 12:23 P.M., the resident sat in his/her wheelchair across from the nurse's station. He/She wore a hospital gown with his/her pannus exposed from underneath the hospital gown. The lower stomach had weeping with a large amount of clear fluid that dripped onto the floor. Both feet were wrapped and the resident wore shoes. The resident said he/she was going to the hospital because of his/her feet. Emergency Medical Technicians (EMTs) arrived and assisted the resident with standing and pivoting to the stretcher from his/her wheelchair. At 12:27 P.M., the EMTs lifted the stretcher and resident was taken into the elevator. Review of the progress notes, showed: -On 7/8/24 at 12:00 P.M., NP notified of missing wound care on the dates of 7/5/24, 07/6/24, and 07/7/24. Care on-going, no new orders received; -On 7/8/24 at 6:03 P.M., the resident was escorted via gurney by four persons to hospital due to infection to wounds; -At 6:05 P.M., resident alert and oriented upon leaving the facility, noted clear drainage from the abdomen with cavity continuously draining. During an interview on 7/9/24 at 10:26 A.M., NP X said he/she has seen the resident's wounds when they were exposed. There is a wound nurse that comes in and changes the dressings. At the time, the resident had cellulitis and he/she was given medications. He/she had wounds on his/her right leg. Sometimes he/she needed intravenous (IV) antibiotics, but not recently. The wound nurse was taking care of him/her. NP X had not been notified of the resident's missed treatments; the specialized wound NP would get notified. NP X did not know about the changes with the resident's Levaquin order. He/She was not aware of the Doppler that was missed on 7/5/24. He/She would expect staff to notify the physician, reschedule and document it. He/She would expect all orders to be followed and treatments to be completed timely and as needed. During an interview on 7/10/24 at 7:47 A.M., Certified Medication Technician (CMT) OO said he/she sent the resident to the hospital in the past. The resident scratches his/her stomach a lot. He/She does not like to take care of him/herself, and does not like showers. The resident's nails get dirty from scratching, CMT OO offered to give the resident a shower. CMT OO observed the resident's stomach and it was bleeding, and there were no bandages. CMT OO and the wound nurse applied the wound treatments at that time. During an interview on 7/10/24 at 7:58 A.M., Certified Nurse Aide (CNA) TT said he/she had worked for the facility for two weeks. If he/she were to find any wounds or skin issues, he/she would report it to the nurse. During an interview on 7/10/24 at 9:11 A.M., a Registered Nurse (RN) at the hospital said the resident was currently on IV medications, Vancomycin (antibiotic), Cefepime (treats bacterial infections), and Flagyl (antibiotic). Incision and drainage (I&D) to both of his/her feet will be completed, but there were no orders for surgery. The physicians have talked about surgery as an option. The resident's abdomen is very inflamed, and he/she had developed cellulitis. The nurse was in the room with the hospital wound care team during the treatment and the resident's stomach was still draining, red, inflamed, scaling on the outside skin, but it was oozing from the wound. The I&D will possibility occur on 7/10/24. The nurse added that the hospital staff wondered how the resident's stomach became so itchy and irritated. The wound culture was still pending. Review of the hospital record, dated 7/9/24, showed: -Reason for consult: Foot wounds worsening; -Resident with a past medical history (PMH) of resected atrial myxoma (tumor that is found in the top chambers of the heart), bipolar disease, factor five Leiden (blood clot disorder), deep vein thrombosis (DVT, blood clots), open heart surgery, high blood pressure, obstructive sleep apnea (OSA), personality disorder, type two diabetes, morbid obesity, presented from nursing home with complaints of wounds to his/her bilateral feet that are painful and have purulent drainage. He/She has chills and fever. He/She also has some abdominal skin wounds over his/her stomach. He/She states he/she scratches his/her abdomen a lot. We are being asked to see patient in consultation for further evaluation of his/her wounds; -Assessment/Plan: Bilateral diabetic foot wounds and abdominal wounds: -Check blood culture; -Vancomyacin, Cefepime, Flagyl, I&D, and surgery consult; -Wound nurse consults. During an interview on 7/10/24 at 9:35 A.M., the DON said LPN S is the treatment nurse. LPN S does the wounds on Monday through Friday and turns in the wound report to the DON. If LPN S is unavailable to complete treatments, the DON or Assistant Director of Nursing (ADON) would be available. The DON will let staff know if LPN S was not there. There are also two ADONs in the facility. It was reported the nurses were not able to complete treatments, but it only happened once. If the nurses cannot get the treatment done, they report it to the DON or the on-coming nurse if there is a shift change. The expectation is either of the nurses will do the wound care. The DON will assist nurses with wound care. The DON is working on enforcing that treatments are completed. Wounds that are not treated can result in sepsis, infection, injury, or death. She would expect there to be a progress note if the resident refuses care and staff should call the physician. She would speak to the resident and report it to the physician. It was reported the resident would take bandages off and pick at his/her wounds. They educated him/her to not take it off or pick. He/She would say, I am not going to stop. The DON told nursing to document it or if the resident would say no. The DON was not aware of lack of staffing being a reason the treatments were not completed. If it's an on-going issue, then staff need to document it. If the resident was scratching, staff should still do the wound care. If the resident says no, staff should document it and follow up. The DON did not know why the resident was ordered Levaquin and Doxycycline. The DON confirmed she saw the resident in his/her room prior to being transported to the hospital. When the DON observed the resident, he/she did not have on a gown. He/She sat on the bed and wanted to get into his/her wheelchair. She told the resident she would do his/her wound care. The resident wanted to go to the hospital for his/her foot. The DON wanted to look at it, but the resident said no. The DON ended up doing his/her treatment to the feet. His/her foot was necrotic. There was no odor and a moderate amount of clear drainage. He/she did not have complaints of pain. The resident did not have any bandages to his/her abdomen, but they were on his/her feet. The resident requested to go to the hospital as a first option even though the DON wanted to solve the issue. It was not reported to the DON that he/she missed treatments on 7/2/24. Nursing will have to be educated. During an interview on 7/10/24 at 1:25 P.M., the hospital RN said the resident had a positive wound culture. He/She had a blood infection. Infectious disease (ID) will monitor his/her antibiotics. He/She is scheduled for the I&D on Friday (7/12/24) on the feet. During an interview 7/11/24 at 7:29 A.M., LPN S said he/she had been doing wound care in the facility since 6/13/24. He/She works Tuesday through Friday and every other weekend on the floor and he/she continues to complete the treatments. The nurses text LPN S when there is a new wound. The floor nurses are supposed to complete the skin assessments daily. It will pop up on the TAR to let them know the resident needs a skin assessment. The Nurses are expected to check the medical record before they leave in case there is a skin assessment due. Skin assessments are completed weekly. If aides see any issues, they are expected to notify the nurse, document on the assessment, and report to LPN S. Staff have said they will not do the treatments. If a resident is found without a treatment, he/she would expect the charge nurse should apply treatments if LPN S is not here. Staff should document if the resident refused and try to negotiate. If the wound is draining, he/she would expect to be notified and assess it. The reside

Based on observation, interview and record review, the facility to failed to provide appropriate administration of enteral (passing through the intestine) nutrition for a resident who was dependent upon a gastrotomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach) (Resident #22). Resident #22's physician's orders showed 40 milliliters (ml)/hour (hr) via g-tube continuously and water flushes 175 ml every four hours. On [DATE], the tube feeding machine was not set in the English language and infused at a rate of 140 ml/hour. Staff failed to ensure the g-tube machine settings were accurately set at 40 ml/hour during medication and treatment administrations and failed to report its language settings to management. The resident received approximately 400 cubic centimeters (cc) of feeding between 7:56 A.M. to 10:46 A.M., causing the resident to experience severe vomiting and he/she was transported to the hospital. The facility also failed to ensure g-tube site treatments were completed as ordered for one resident (Resident #45). The facility also failed to ensure staff completed a self-administration medication assessment and physician's orders to self administer medications via g-tube. The facility identified three residents dependent on a gastrotomy tubes. The census was 151. The administrator was notified on [DATE] at 2:56 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility's Feeding Tube-Site Care policy, dated [DATE], showed: -Purpose: To inspect and prevent skin breakdown and complications for resident's with feeding tubes; -Policy: Site care will be provided twice daily until healed in the post-operative period following the feeding tube insertion; -The site of a well-established enteral feeding tube will be inspected daily for signs and symptoms of irritation, gastric leakage, or infection; -Procedure: Explain the procedure to the resident; -Wash hands. -Don (put on) gloves; -Remove old gauze if present; -Inspect the site for irritation, drainage or leakage; -Using a washcloth, gently clean around the site with warm water and mild soap; -Rinse the area with water and dry well; -Place a gauze drainage sponge around the site if needed for irritation, drainage, or leakage; -A smear of blood or a bit of clear yellow drainage is normal following post-operative insertion. Notify the Attending Physician if drainage has increased, is cloudy, yellow or green, has a foul odor, or if the skin surrounding the site is irritated. Review of the facility's Physician's Orders policy, dated [DATE], showed: -Policy: The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary; -Medication orders will include the following: -Name of the medication; -Dosage; -Frequency; -Duration of order; -The route and the condition/diagnosis for which the medication is ordered, if applicable; -Treatment orders will include the following: A description of the treatment, including the treatment site, if applicable; -The frequency of treatment and duration of order (when appropriate); -The condition/diagnosis for which the treatment is ordered; -Other orders will include a description complete enough to ensure clarity of the physician's plan of care; -Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline; -Supplies/medications required to carry out the physician order will be ordered; -Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the Medication Administration Record (MAR)/Treatment Administration Record (TAR) binders. Review of the facility's Medication-Self Administration policy, [DATE], showed: -Policy: Residents who request to perform medication self administration will be assessed for capability. The assessment of medication self administration will ensure a clinically appropriate, effective process for the resident to provide self care. The Facility is responsible to ensure medications are administered as ordered by the Attending Physician even when self administered; -Procedure: During the admission process, residents will be asked if they wish to self administer medications; -Those residents who wish to self administer medications will be assessed during the admission process to ensure they have the necessary knowledge and skill(s) to safely self administer medications; -Additional assessments will be completed at least quarterly based on OBRA timeframes; -A referral for physical therapy/occupational therapy may be necessary to assess the resident for the necessary eye hand coordination and cognitive skills for medication self administration; -Based on clinical judgment, a Licensed Nurse may reassess a resident related to the safe self administration of medications as needed; -The resident must be able to demonstrate the following -Knowledge of medications and medication schedule; -The ability to read the medication label and manufacturer's insert; -Self-administration techniques including use of packaging, reading label, opening containers; -Ability to administer medication properly, e.g., insulin/syringe, eye drops, inhalers; -Residents requesting to self-administer hand held nebulizers will be required to demonstrate their ability to safely and effectively use the hand?held nebulizers without the assistance of a Licensed Nurse; -Agree to comply with Facility policy related to the self-administration of medication. -The Licensed Nurse will inspect the contents of the medication containers for evidence that the resident may not unable to self-administer medications (i.e., non-drug items stored in pill container, different medications mixed together, medications which have expired or appear to be deteriorating) -If the resident is assessed as clinically appropriate for medication self-administration, by the Interdisciplinary team (IDT), the Licensed Nurse obtains a physician's order for self-administration of selected medications; -The resident's record should contain documentation that demonstrates that he/she was part of the IDT process in determining whether self-administration is safe and appropriate; -Medications specifically excluded from self-administration for any reason must be specified in the Attending Physician's order; -Self-administration is only permitted if approved in writing by the Attending Physician, which may be in the form of an order; -The IDT develops and implements a care plan for medication self-administration; -This care plan is reviewed at least quarterly with each reassessment based on OBRA timeframes; -The care plan will identify: -Where the medications are stored; -Education for resident/family regarding medication self-administration process, specific medication information and safe, effective use of medications; -Obtaining medication; -Administering medication according to physician order; -How Licensed Nurses will validate that medications are taken as ordered by the attending physician; -How non-compliance and/or refusal to take medications will be managed; -If the IDT and Attending Physician do not approve self-administration of medications, the resident or their representative will be informed, and the reason will be documented in the medical record; -If the IDT team and Attending Physician approve self-administration of medications, the medications will be placed in a secured drawer or cabinet that is easily accessible to the resident; -Controlled drugs (i.e., narcotics, hypnotics, etc.) are not to be left for open access to the resident; -The Administrator/Director of Nursing Services or designee ensures the resident has access to a secure container for proper medication storage if the medications are not stored on the medication cart; -The Licensed Nurse on each shift ensures that medications are taken as ordered by the Attending Physician and documents on the MAR; Refusals and/or non-compliance with self-administration of medications as ordered by the Attending Physician is documented on the MAR and in the nurses' notes; -All self-administered medications will have pharmacy labels with complete directions for use of the medication; -No labels may read as directed; -Non-prescription (over the counter, OTC) medications may be allowed if the medical label is intact; -A resident may withdraw from being able self-administer medications at any time; -Residents will be re-evaluated if any member of the IDT suspects non-compliance with the self-administration authorization or any change in the resident's cognitive status; -The Attending Physician is notified of habitual and/or frequent non-compliance or refusal of medication self-administration; -In the case of suspected medication non-compliance (e.g. dosage in excess of the amount anticipated, loss of therapeutic control or suspected drug toxicity) the nursing staff will complete an assessment. The Attending Physician will be notified if the resident is no longer deemed appropriate for self-medication administration. The Licensed Nurse will obtain orders as necessary; -Documentation: The physician's order approving the self-administration of medication will be maintained in the resident's medical record; -The Assessment for self-Administration of Medications will be maintained in the resident's chart; -Self-administration of medications will be documented in the resident's Care Plan and the MAR. 1. Review of Resident #22's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included anemia, aphasia (language disorder), cerebral palsy (congenital disorder of movement, muscle tone, or posture), dementia, quadriplegia (paralysis of all four limbs), seizure disorder; -Impairment on both sides of the upper and lower extremities; -Weight of 97 pounds; -Feeding tube; -51% or more total calories received through parenteral (nutrition given through the vein) or tube feeding; -Average fluid intake per day by tube feeding: 500 cubic centimeters (cc) or more. Review of the resident's care plan, in use during the survey, showed: -Focus: Resident has history of diagnosis aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs) at risk for respiratory complications. Shortness of breath returned on [DATE], with tube feeding continues, has history of drooling [DATE] diagnosis of postnasal drip, diagnosis of dysphagia (difficulty swallowing) [DATE]. Weight lost noted. History of g-tube becoming dislodged. History of nausea and vomiting. History of weight variances; -Goal: Resident will have clear lungs, no signs and symptoms of aspiration; -Interventions: Assess level of care every shift and as needed (PRN); -Change tube feeding formula to 2 CAL HN (calorie and protein dense nutrition to support patients with volume intolerance and/or fluid restriction) related to emesis (vomiting) and increase residual (the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding); -Check for aspiration, hold tube feeding if residual greater than 60 cc and inform physician; -Cleanse g-tube site daily and cover with dry dressing; -Dietician to evaluate as needed; -Flush g-tube as ordered; -Head of board (HOB) elevated at 45 degrees at all times; -Medication as ordered for nausea/vomiting; -Monitor for shortness of breath, choking, labored respirations, lung congestion; -Monitor input every shift; -Monitor tolerance to tube feedings; -Nothing by mouth (NPO); -Scopolamine (a medication used to manage and treat postoperative nausea and vomiting and motion sickness) patch every 72 hours; -Sent to hospital for g-tube replacement. Review of the resident's Physician's Orders Sheet (POS), dated [DATE] showed: -An order, dated [DATE], cleanse g-tube site with normal saline (NS)/DWD (dermal wound cleanser); cover with dry dressing every night shift for g-tube; -An order, dated [DATE], check residual, if greater than 60 cc hold feeding and call physician every shift for enteral feeding; -An order, dated [DATE], for Scopolamine patch 72 hour. Apply one application transdermal every 72 hours for drooling; -An order, dated [DATE], for Vitamin D liquid. Give 2000 unit via g-tube one time a day for vitamin D deficiency; -An order, dated [DATE], for Glycolax Powder (Polythylene Glycol 3350, used to treat constipation). Give 17 gram via PEG-tube one time a day for constipation. Mix with 6 ounces of water until completely dissolved; -An order, dated [DATE], for Senna Syrup (used to relieve constipation). Give 8.6 mg via g-tube two times a day for constipation; -An order, dated [DATE], Multivitamin Liquid (multiple vitamins-minerals). Give 5 ml via PEG-tube one time a day for vitamin deficiency; -An order, dated [DATE], for Keppra (used to treat seizures) Solution 100 milligram (mg). Give 10 ml via g-tube three times a day for seizures; -An order, dated [DATE], enteral feed every shift. Hold tube feeding one hour after each medication pass every shift; -An order, dated [DATE], enteral feed, three times a day, 30 ml water before and after medication; -An order, dated [DATE], g-tube charting to include inspection of site, how the g-tube flushes, any redness/pain/drainage, toleration of feeding and medications every shift for g-tube charting; -An order, dated [DATE], for Valproic Acid (anticonvulsant to treat seizures) solution. Give 30 milliliters via g-tube three times a day for seizure; -An order, dated [DATE], ensure HOB is elevated at 45 degree angle at all times. Hold tube feeding pump for any activities of daily living (ADLs) requiring flat bed. Run tube feeding pump after patient is re-positioned at 45 degrees after ADLs every shift for prevention of aspiration; -An order, dated [DATE], for 2 CAL tube feeding at 40 ml/ hr continuously per pump every shift for g-tube feeding status; -An order, dated [DATE], enteral feed every 4 hours. Free water flush 175 ml every four hours. Push slowly he/she has a history emesis. Monitor tolerance. Observation on [DATE] at 10:19 A.M., showed the resident in his/her room. He/She lay in the bed, which was lowered to floor. The HOB was at 45 degrees and his/her eyes were closed. The resident was covered with a blanket. The tube feeding machine showed it was on hold and beeped continuously. The tube feeding stand showed 2.0 CAL container hung with handwritten documentation ,d+[DATE] at 3:00 A.M., and 40 cc on the bottle. A full flush bag was hung with handwritten documentation [DATE]. The tubing was not connected, and lay across on the tube feeding stand. The end was not capped or covered. At 10:44 A.M., no beeping was heard from tube feeding machine upon entering room. The tubing was connected to the resident and the tube feeding machine showed it was set to infuse at 40 ml/ hr. The flush showed 175 ml every four hours. There was approximately 750 cc of fluid remaining in the 2.0 CAL bottle. There was dried tube feeding fluid on the floor around the tube feeding stand and on the metal stand. The resident had dried white substance around his/her facial hair. At 4:53 P.M., there was approximately 550 cc of fluid remaining in the 2.0 CAL bottle. The machine showed it was infusing at 40 ml/ hr and 175 cc of flush every four hours. Observation and interview on [DATE] at 7:56 A.M., showed the resident in bed, positioned on his/her left side. There was approximately 900 cc remaining in the 2.0 CAL bottle that was hung. The tube feeding machine screen showed the settings were not in English language. There were no words written in English on the screen. The machine showed a rate of 140 ml/hr. There was no written documentation on the 2.0 CAL bottle or flush bag. The flush bag showed approximately 600 cc remaining. At 10:46 A.M., staff was in the room with the resident. Certified Nurse Aide (CNA) V said he/she provided the resident with peri care. The resident was in bed with eyes closed. The tube feeding machine screen showed no words in the English language and a rate of 140 ml/hr. There was approximately 500 cc of fluid left in the 2.0 CAL bottle. At 11:01 A.M., upon entering room, CNA V said the resident just vomited. There was a small amount of emesis on the resident's lower half of face and neck which was a light beige in color. The resident continued to cough until thick saliva excreted from his/her mouth onto his/her lower face, neck, and bed pillow. At 11:03 A.M., the surveyor asked Licensed Practical Nurse (LPN) S to assess the g-tube machine. LPN S was asked if the 140 ml/hr on the machine was correct. He/She said the tube feeding was not supposed to be at 140 ml/hr. He/She did not work on the floor often, but the last time the rate was 40 or 60 ml/hr. CNA V began to clean the resident's face. LPN S was asked to check the residual. LPN S attempted to change the settings on the g-tube machine, but was not successful. LPN S turned off the g-tube machine and exited the room to get supplies. There was tube feeding fluid on the floor next to the stand. The Assistant Director of Nursing (ADON) BB entered the room and assessed the g-tube machine. She did not know what language the g-tube machine was set on. She attempted the change the settings, and was successful with changing the language setting back to English. ADON BB later exited the room. LPN S returned to the room and disconnected the tube feeding from the resident to complete the residual check. The syringe showed approximately 10 ml of fluid. LPN S said night shift is responsible for hanging the g-tube and checking the settings on the machine. The machine stops when the bottle is empty on night shift. The resident has a history of aspiration. He/She also becomes dizzy and nauseous, that was why he/she had the sticker behind his/her ear. If he/she received 140 ml/hr of feeding, he/she would have projectile vomiting. The resident was observed with a round sticker behind his/her ear. LPN S began to press buttons on the tube feeding machine and cleared the machine. The settings were returned to English. LPN S exited the room to report to the Director of Nursing (DON). At 11:18 A.M., the resident began to cough and gag until he/she vomited. The light beige colored vomit poured out of the resident's mouth, covering his/her upper torso. At 11:20 A.M., LPN S entered the room and saw the emesis. He/She said the emesis was the same color as the tube feeding and the resident threw up half the bottle. LPN S said the emesis was definitely from the tube feeding. LPN S checked the resident's vitals. The resident's oxygen saturation was 93% on room air, heart rate showed 112, the blood pressure was ,d+[DATE] and his/her temperature was 97.5 degrees Fahrenheit (F). LPN S said they may have to send the resident to the hospital because the g-tube was infusing at 140 cc/hr and he/she had a history of aspiration. At 11:29 A.M., Restorative Aide W and CNA V entered the room. ADON BB entered the room with a suction machine. Restorative Aide W started to clean the resident and said (he/she) never vomited like this before. This is not normal. At 11:40 A.M., LPN S said he/she spoke to the Nurse Practitioner and reported the resident threw up half the bottle. The resident will be transported to the hospital. LPN B came into the room and assessed the resident's lung and bowel sounds. He/She said the lungs sounded clear. LPN B said he/she gave the resident's g-tube medication at 8:40 A.M. Review of the resident's MAR, dated [DATE] and [DATE], showed: -An order, dated [DATE], cleanse g-tube site with NS/DWD; cover with dry dressing every night shift for g-tube, showed completed on [DATE], during the night shift by LPN C; -An order, dated [DATE], enteral feed every four hours free water flush 175 ml every four hours. Push slowly he/she has a history emesis and monitor tolerance was documented as administered on [DATE] at 1:00 A.M. and 5:00 A.M. by LPN C; -An order, dated [DATE], for Valproic Acid solution. Give 30 milliliters via g-tube three times a day for seizure was documented as administered on [DATE] at 6:00 A.M. by LPN C; -An order, dated [DATE], to change graduate and syringe daily one time a day was documented as completed on [DATE] at 6:00 A.M. by LPN C. During an interview on [DATE] at 6:42 A.M., LPN C said he/she worked the night shift. The night shift staff hang the tube feeding if ordered as continuous. He/She did not notice it was in a weird language and the rate of the feeding is preset. LPN C said all you should be pressing is the run or stop. The resident did not have any vomiting during the shift. The feeding normally runs at 40 ml/hr. Sometimes the aides will stop the machine when they provide care and then restart the feeding after care. The feeding should run slowly since the resident is prone to vomiting. Review of the resident's MAR, dated [DATE], showed: -An order, dated [DATE], enteral feed, three times a day, 30 ml water before and after medication documented as administered on the day shift by LPN B; -An order, dated [DATE], enteral feed every 4 hours free water flush 175 ml every four hours. Push slowly he/she has a history emesis. Monitor tolerance was documented as administered at 9:00 A.M. by LPN B; -An order, dated [DATE], for Senna Syrup. Give 8.6 mg via g-tube two times a day for constipation was documented as administered at 9:00 A.M. by LPN B; -An order, dated [DATE], for Vitamin D liquid. Give 2000 unit via g-tube one time a day for vitamin D deficiency was documented as administered at 9:00 A.M. by LPN B; -An order, dated [DATE], for Glycolax Powder (Polythylene Glycol 3350). Give 17 gram via PEG-tube one time a day for constipation. Mix with 6 ounces of water until completely dissolved was documented as administered at 9:00 A.M. by LPN B; -An order, dated [DATE], Multivitamin Liquid (multiple vitamins-minerals). Give 5 ml via PEG-tube one time a day for vitamin deficiency was documented as administered at 9:00 A.M. by LPN B; -An order, dated [DATE], for Keppra Solution 100 milligram (mg). Give 10 ml via g-tube three times a day for seizures as documented as administered at 9:00 A.M. by LPN B. Review of the resident's MAR, dated [DATE], showed: -An order, dated [DATE], for 2 CAL tube feeding at 40 ml /hr continuously per pump every shift for g-tube feeding status documented as completed on the day shift by LPN A; -An order, dated [DATE], check residual, if greater than 60 cc hold feeding and call physician every shift for enteral feeding documented as completed on the day shift by LPN A; -An order, dated [DATE], ensure HOB is elevated at 45 degree angle at all times. Hold tube feeding pump for any ADLs requiring flat bed. Run tube feeding pump after patient is re-positioned at 45 degrees after ADLs every shift for prevention of aspiration documented as completed on the day shift by LPN A; -An order, dated [DATE], enteral feed every shift. Hold tube feeding one hour after each medication pass every shift documented as completed on the day shift by LPN A; -An order, dated [DATE], G-Tube charting to include inspection of site, how the g-tube flushes, any redness/pain/drainage, toleration of feeding and medications every shift for g-tube charting documented as completed on the day shift by LPN A. During an interview on [DATE] at 1:36 P.M., LPN A said he/she worked the day shift and arrived at 7:30 A.M. after night shift left. When he/she arrived, report was received from LPN C. LPN A did not notice problems with the g-tube machine LPN C reported to LPN A that the resident had emesis during the night shift. LPN B started the tube feeding and they normally cut the g-tube machine off at that time LPN A said he/she worked on the South end at the time the feeding. LPN A was not aware of any issues with the machine. LPN A later clarified his/her statement and said he/she was in the room with LPN C when LPN C hung the 2.0 CAL bottle. LPN C hung the tube feeding bottle and made sure the water was there. LPN A said he/she did not look at the tube feeding machine. He/She only looked at the resident to check if he/she was breathing. LPN C also did not report anything to LPN B at that time. LPN C came out of the room and started giving report. LPN A said if he/she saw a g-tube did not have correct setting for infusion or if the settings were in a different language, he/she would shut down the machine. LPN A said he/she did not know how to change the settings, so he/she would shut it down and report to the ADON or DON. LPN A would go back to the medical record and check the physician's orders. The resident has a history of emesis and has it all the time. LPN A said he/she did not check the resident's residual. LPN B checked it. LPN A was not in the room with LPN B at the time and was not sure if there was any residual. LPN A said they had a skilled check list they had to complete. During an interview on [DATE] at 2:07 P.M., LPN B said he/she saw the resident this morning. LPN B confirmed the screen on the tube feeding machine was set in a language that he/she did not understand. He/She shut the machine off at 10:00 A.M. because it was in another language. LPN B did not report it because there was an emergency with another resident who was calling for the nurse. He/She could not recall what the rate settings were on the tube feeding machine, but did not remember seeing it set to infuse at 140 ml/ hr. He/She administered the resident's medication right before 10:00 A.M. The resident had approximately 25 ml of residual. There was no gagging, vomiting, or coughing. LPN B did turn the machine off, but did not turn it back on. The next time he/she saw the resident, it was at 11:30 A.M. and the nurses were in the room at the time. He/She did not know who turned the machine back on. LPN B did not have orientation or in-service/education prior to [DATE]. Review of the resident's hospital record, dated [DATE], showed: -Reason for visit: Nausea and vomiting; -Diagnosis: Nausea and vomiting; -Provider notes: Resident with past medical history significant for cerebral palsy, quadriplegia, seizures, and anemia. Sent to the emergency room for nausea and vomiting. Patient is non-verbal and contracted baseline. Per Emergency Medical Service (EMS), too much feeding today. Patient was also given an additional 100 ml and vomited. Patient appears to be stable at this time; -X-ray (used to generate images of tissues and structures inside the body) of the chest and computed tomography (CT, a medical imaging technique used to obtain detailed internal images of the body) scan of abdomen and pelvis were unmarkable. Will discharge patient back to facility. During an interview on [DATE] at 6:30 A.M., LPN GG said the resident receives continuous tube feeding. He/She has occasional emesis. Night shift nurses are responsible for g-tube care, such as changing out dressings, syringes, and inspecting the tube feeding sites. When a resident has orders for continuous tube feeding, 23 hours on and one hour off, the hour off is to account for time used for medication administration. He/She has not been in-serviced recently on tube feeding. During an interview on [DATE] at 10:00 A.M., the DON said the licensed nurses are responsible for hanging the tube feeding container and ensuring the machine settings and infusion rates are accurate, but the resident is on a continuous feed, so nursing should check the machine. If nursing completed their rounds, they would know if there was an issue with the machine. It was reported to the DON on [DATE] at 10:50 A.M. that the resident's machine was set in another language and set to infuse at 140 ml/hr. It is not acceptable for nursing to document tube feeding orders, treatments, and check and assess the resident and machine settings on the MARs if it was not done. Nursing is expected to check the MAR, orders, and placement. It is not acceptable to document it if it was not completed. It was not reported to the DON that the machine was turned off. When it was reported, the ADON got the machine back in English. There were no reports of CNAs changing the machine. If a CNA was providing care, they can pause it. She expected nursing to have reported the machine was set in another language when it was discovered. She expected the 2.0 CAL bottle to have documentation of the date, infuse rate, time it was hung, and staff initials. The DON said the results of the g-tube infusing at 140 ml/hr instead of 40 ml/hr could have a fatal outcome. During an interview on [DATE] at 11:51 A.M., Nurse Practitioner (NP) X said it was reported to him/her this morning the resident went to the hospital on [DATE]. He/She said 140 ml/hr was a big jump. It was too high and there is an aspiration risk, but it depends on the resident's size and position. He/She expected nursing to follow physician's orders. During an interview on [DATE] at 7:29 A.M., LPN S said the infuse rate of 140 ml/hr was too much. The resident is tiny and he/she could barely tolerate 40 ml/hr. Observation on [DATE], [DATE], [DATE] and [DATE], showed: -On [DATE] at 7:41 A.M., showed the resident in bed. Tube feeding infuse rate set at 40 ml/hr. There was a full container of 2.0 CAL with handwritten with only date of ,d+[DATE]. There was approximately 400 cc remaining in the flush bag, with a handwritten date of ,d+[DATE]; -On [DATE] at 10:50 A.M., the resident was in bed with eyes open. Tube feeding infuse rate set at 40 ml/hr. There was approximately 900 cc of fluid remaining in the 2.0 CAL bottle. The bottle was hung without any handwritten documentation of date, time, rate, or staff initials. There was approximately 480 cc of water in the flush bag. The flush bag did not have any written documentation; -On [DATE] at 11:00 A.M., the resident was in bed with his/her eyes closed. Tube feeding infuse rate set at 40 ml/hr. There was approximately 450 cc of fluid remaining in the 2.0 CAL bottle. The bottle was hung with handwritten documentation that showed a date of ,d+[DATE] and 40 ml. There was approximately 450 cc of water in the flush bag. The flush had written documentation that showed a date of ,d+[DATE] and 175 ml. The time was not documented on the 2.0 CAL bottle or flush bag. -On [DATE] at 8:25 A.M., the resident was in bed with eyes open. Tube feeding infuse rate was set at 40 ml/hr. There was approximately 700 cc of fluid remaining in the 2.0 CAL bottle. The bottle was hung with handwritten documentation that showed [DATE] at 10:00 P.M. and 40 ml/hr. There was approximately 700 cc of water remaining in the flush bag. There was no handwritten documentation on the flush bag. During an interview on [DATE] at 11:18 A.M., the Administrator and DON said they expected nursing to check the tube feeding machine and ensure the infuse rate displayed is accurate upon entering room. They expected nursing to document the 2.0 CAL bottle with date, rate, time it was hung, and staff initials. They expected staff to follow physicians orders and accurately document on the MARs/TARs. During an interview on [DATE] at 3:30 P.M., the Administrator said the facility did not have a policy and procedures that addressed how to set up the tube feeding pump, hanging the feeding container, or expectations for nursing staff. 2. Review of Resident #45's quarterly MDS, dated [DATE], showed the following: -Diagnoses included severe protein-calorie malnutrition (inadequate intake of food containing calories and proteins), anorexia, gastroparesis (muscles in the stomach not functioning properly which causes the stomach to not empty), gastric ac

37672 Based on interview and record review, the facility failed to keep one resident with epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures) free from a significant medication error, when the facility failed to administer the ordered Keppra (used to prevent seizures). The resident experienced a grand mal seizure (a tonic-clonic seizure, causing the loss of consciousness and violent muscle contractures) with fall at the facility and he/she sustained a fracture of the right proximal fibular shaft (lower leg outer bone) (Resident #14). In addition, staff administered Ambien (a sedative) to Resident #69, for which he/she had a known medication allergy. The census was 151. The Administrator was notified on 7/12/24 at 12:45 P.M., of an immediate jeopardy (IJ) which began on 4/17/24. The IJ was removed on 7/12/24 as confirmed by surveyor on-site verification. Review of the Medication Administration Policy, revised 10/24/22, showed: -Purpose: to provide practice standards for safe administration of medication for residents in the facility; -Policy: -Medication will be administered by a licensed nurse per the order of an attending physician or licensed practitioner; -Medications must be given to the resident by the licensed nurse preparing the medication or as consistent with state law; -Medications are not to be left at bedside; -Documentation: -The time and dose of the drug or treatment administered to the resident will be recorded in the medication record by the person who administered the drug or treatment; -The recording will include the date, the time and dosage of the medication or type of the treatment. 1. Review of Resident #14's medical record, showed: -admitted : 6/18/20. -discharged to hospital: 4/17/24; -readmitted : 4/21/24; -Diagnoses included: Fracture of the right fibula (readmitted with), epilepsy, intellectual disability, dementia, schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly) and anxiety. Review of the electronic physician order sheet (ePOS), showed an order, dated 3/4/24: Keppra (levetiracetam) oral solution 100 milligrams (mg)/milliliter (ml). Give 20 ml by mouth twice a day related to convulsions. Review of the pharmacy shipping manifest, dated 4/13/24 at 4:27 P.M., showed Levetiracetam 100 mg/ml solution delivered to the facility. Review of the April 2024 medication administration record (MAR), showed: -An order, dated 3/4/23: Keppra oral solution 100 mg/ml. Give 20 ml twice a day related to unspecified convulsions. Scheduled daily at 9:00 A.M. and 5:00 P.M. -On 4/16/24: -At 9:00 A.M., documented as given; -At 5:00 P.M., documented as 9 or see progress notes. Review of the progress notes, showed: -On 4/16/24 at 5:15 P.M.: give Keppra 100 mg/ml, give 20 ml twice a day. Not available, on order. Review of the April 2024 MAR, showed: -On 4/17/24: -At 9:00 A.M., documented as given; -At 5:00 P.M., documented at 9 or see progress notes. Review of the progress notes, showed: -On 4/17/24 at 5:30 P.M., Keppra 100 mg/ml, give 20 ml twice a day. Not available; -On 4/17/24 at 11:49 P.M., staff notified of the resident lying face down on the bathroom floor seizing, halfway in the bathroom and in the hallway, saturated with urine. Observed in a grand mal seizure, lasted approximately 3-4 minutes. He/She continued to lie on the floor making a snoring sound, difficult to rouse. The physician was notified and new orders to send to the emergency room (ER) for evaluation and treatment. Review of the ER history and physical, dated 4/18/24 at 2:24 P.M., showed: -Briefly admitted for breakthrough seizure. Corroborating information helped us determine the patient was likely not receiving daily Keppra due to the facility running out of medication. He/She was found to have a right lower extremity fibular fracture. The patient was seen by Orthopedics and placed in an air boot with weight bearing as tolerated allowances; -Subjective: Per Emergency Medical Services (EMS) report and patient, the facility had apparently ran out of the prescribed liquid Keppra, and he/she had not been taking it for an unclear period of time. Per EMS it was around three days, and per patient, he/she had not received it in over two weeks. He/She arrived to the ER, was lethargic and post-ictal (altered state of consciousness after an epileptic seizure) state, he/she received a Keppra load of 4500 mg and alertness improved over time, and no seizure activity was noted. The patient stated, he/she did not receive the prescribed liquid Keppra as the facility ran out and were unable to obtain refills. On chart review the patient had to prior ED visits due to seizures, with similar presentation in which the facility ran out of Keppra. He/She was discharged with liquid Keppra at that time and Keppra levels at those times were low and corresponded with a lack of adherence. The facility was contacted and staff reported no supply issue with Keppra; -Assessment and plan: -History of epilepsy: patient has longstanding history of epilepsy, previous neurology note, showed the patient is supposed to be on liquid Keppra. Appears to be provoked in setting of Keppra nonadherence per discussion with EMS and patient. Since arrival at the ED, no further seizures; -Plan: Keppra and carbamazepine (used to treat seizure disorders) levels ordered. Carbamazepine level normal, awaiting Keppra level. Review of the hospital emergency physician note, dated 4/19/24 at 3:07 A.M., showed: -History of present illness: history of intellectual disability, convulsion disorder, epilepsy and anxiety. To ER for witnessed seizure lasting several minutes. Per EMS, the facility has been out of liquid Keppra for an unknown amount of time. Complaint of pain in the right leg; -Physical exam: -Head, ear, nose and throat (HENT): hematoma (an area of pooled blood) to the left outer eyebrow; -Decision making: -Diagnoses: fall, seizure like activity, hematoma to the left eyebrow and right sided leg pain; -Plan: therapeutic Keppra load, imaging of right leg and facial bone; -Emergency Department (ED) course: -At 1:23 A.M.: 4,500 mg of Keppra given in fluids; -At 1:53 A.M.: 4,500 mg of Keppra administration was stopped; -At 3:50 A.M.: Orthopedics consulted; -At 4:15 A.M.: reviewed imaging, the patient has a right fibular fracture. Facial imaging is negative; -At 5:42 A.M.: patient will be admitted for management of seizure-like activity. Review of the hospital levetiracetam level, resulted 4/20/24 at 2:12 A.M., showed: -Levetiracetam level: value: below 2; -Reference range: 10-40 microgram/milliliter (ug/mL); -Flag: low (L). Review of the hospital neurology progress note, dated 4/20/24 at 7:28 A.M., showed: -Subjective: Levetiracetam level came back undetectable from admission labs, this essentially definitively shows etiology of seizure medication nonadherence; -Hospital course: Per EMS and family, the facility ran out of Keppra and the resident had not taken the medication for three days, per the patient, it has been two weeks. When the hospital primary team called the facility, it was stated the facility did not have issues with medication supply. On previous admissions July 2023 post seizure, it was determined to have Keppra non-adherence at those times; -Recommendations: -Keppra level undetectable which strongly suggests non-adherence to prescribed Keppra regimen; -Resuming antiseizure regimen will likely resolve episode as this was an effective regimen in the past. Review of the hospital discharge summary, dated 4/20/24 at 12:23 P.M., showed: -Hospital course: Neurology was consulted for the seizures and determined to be related to missed doses of Keppra. In discussions with the family and the facility, it was confirmed he/she missed two doses of the Keppra. Keppra level at the hospital came back low, confirming the missed doses. During a phone interview on 7/12/24 at 10:11 A.M., CMT XX said that he/she attempted to give the resident his/her ordered Keppra, but it was not available on the cart around 4/16/24. The resident was getting the liquid form of Keppra. He/She reported to an unknown nurse the resident was out of the medication. He/She was off the next day. When he/she returned the following day, he/she noted the medication was still not available. The staff from the day before had documented on the MAR the medication was given. He/She called the pharmacy, and the pharmacy said the medication was not sent. He/She told the nurse, who was working on a different floor, about the Keppra not being available and to get the medication from the e-kit. He/She called the pharmacy, told them the medication was not available and was not delivered. The pharmacy stated the medication would be delivered the evening of 4/17/24. When the charge nurse returned to the floor, the resident was experiencing a seizure. Management conducted an investigation, and he/she was in-serviced on 4/18/24. During an interview on 7/9/24 at 10:59 A.M., the former regional nurse, said the facility was notified by the hospital physician regarding the Keppra level was low and not measurable. The facility conducted an investigation and discovered the resident did not receive two to three doses of ordered Keppra. The facility conducted in-servicing immediately. Review of the facility in-services regarding medication administration, dated 4/18/24 through 5/29/24, following the resident's seizure and hospitalization , showed nine of 19 currently employed Licensed Practical Nurses (LPN) were in-serviced. No current employed graduate nurses (GN) were in-serviced and one currently employed Registered Nurse (RN) was not in-serviced. During an interview on 7/9/24 at 11:11 A.M., the Minimum Data Set (MDS) Coordinator said he/she assisted management with in-servicing on missed medication, medications not available and expectations on what staff should do if medications are not available. In-servicing was done for a month. New staff had been hired at the facility. She is unaware if the new staff had been in-serviced. During an interview on 7/10/24 at 6:30 A.M., LPN GG said he/she works night shift. There is no Certified Medication Technician (CMT) on night shift. The nurses administer medications as needed on night shift. If a medication was not on the medication cart, he/she would double check the cart, check the emergency kit (e-kit, supply of emergency stock medications), and contact the pharmacy. He/She has never used the e-kit and he/she is unsure what medications it contains. If the medication cannot be administered, he/she would notify the resident's responsible party and physician. On the MAR, he/she would document other, see progress notes, and he/she would make a note as to why the medication was not administered. During an interview on 7/11/24 at 11:47 A.M., Graduate Practical Nurse (GPN) FF said if he/she could not find a resident's medication on the medication cart, he/she would check the storage room. If he/she could not locate the medication in the storage room, he/she would order the medication from the pharmacy. If the pharmacy could not deliver the medication the nurse needed to notify the DON and access the e-kit for the medication. He/She has not had any training on e-kits. He/She does not have access to an e-kit and does not know what an e-kit is. He/She asked if an e-kit is where narcotic medications are stored. During an interview on 7/11/24 at 12:06 P.M., LPN HH said CMTs and nurses are responsible for medication administration. If a medication is not on the cart, staff should check the storage room, call the pharmacy, and call the doctor. Staff could pull the medication from the e-kit, if possible. He/She does not have access to the facility's e-kits. During a interview on 7/9/24 at 10:26 A.M., the nurse practitioner said, Keppra is an important medication used to prevent the occurrence of seizures. If Keppra doses are missed, the resident could experience a seizure. If Keppra is missed, the medical provider should be notified. 2. Review of Resident #69's resident's hospital record, showed: -Admission: 9/27/23; -Discharge: 11/6/23; -Known allergies: Xanax (sedative), Ziprasidone (antipsychotic), Seroquel (antipsychotic), Geodon (antipsychotic), Ambien (sedative), Wellbutrin (antidepressant), and Venlafaxine (antidepressant). Review of the resident's quarterly MDS, a federally mandated assessment instrument completed by facility staff, dated 5/10/24, showed: -Mild cognitive impairment; -No behaviors; -Diagnoses included high blood pressure, wound infection, septicemia (blood infection), hip fracture, anxiety, depression; -Administered anti-depressant, hypnotic, anticoagulant, opioids in the past seven days; -Drug regimen review: Yes, issues found during review. Review of the medical record, showed: -admitted [DATE]; -Allergies: Flu Virus Vaccine, Venlafaxine, Ambien, Geodon, Wellbutrin, Xanax; -An order, dated 5/30/24, Ambien Oral Tablet 5 mg. Give 5 mg by mouth every 24 hours as needed for insomnia for 30 Days. Order was discontinued on 6/11/24; -The June 2024 MAR, showed Ambien oral tablet 5 mg. Give 0.5 (half) tablet by mouth every 24 hours as needed for insomnia was administered on 6/30/24. Review of the care plan, in use during survey, showed: -Focus: Resident is on sedative/hypnotic therapy related to insomnia; -Goal: Will be free of any discomfort or adverse side effects of hypnotic use; -Interventions: On 4/2/2024: -The Nurse Practitioner (NP) has provided education to resident regarding his/her sleeping habits. Encouraged to avoid caffeine after lunch and all alcohol; -Administer sedative/hypnotic medications as ordered by physician; -Evaluate other factors potentially causing insomnia, for example: environment (excessive heat, cold, or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy; -Monitor/Document/Report as needed (PRN) for following adverse effects of Sedative/Hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fractures, dizziness. Review of the resident's July 2024 ePOS, showed an order, dated 6/25/24: Ambien oral tablet 5 mg. Give 0.5 mg tablet by mouth every 24 hours as needed for insomnia. Review of the resident's July 2024 MAR, showed Ambien oral tablet 5 mg. Give 0.5 tablet by mouth every 24 hours as needed for insomnia. Noted as administered on 7/13/24 and 7/14/24. Review of the resident's progress notes, showed: -On 7/13/24 at 10:40 P.M., Ambien oral tablet 5 mg. Give 0.5 tablet my mouth every 24 hours as needed for insomnia. PRN administration was effective; -On 7/15/24 at 5:44 A.M., Ambien oral tablet 5 mg. Give 0.5 tablet my mouth every 24 hours as needed for insomnia. PRN administration was effective; -No further documentation on the resident's allergy to Ambien or symptoms after administered Ambien. Observation and interview on 7/11/24 at 10:45 A.M., showed the resident in bed, eyes closed, and he/she briefly opened them. The resident said he/she was sleeping and usually slept a lot during the day. He/She did not have trouble sleeping at night; -On 7/15/24 at 8:07 A.M., the resident lay in bed; eyes closed. -On 7/16/24 at 1:23 P.M., the resident in bed and said he/she did not have a problem sleeping during the day. He/She was told he/she had an allergy to some psychotropic medications. The surveyor named off medications from the resident's allergy list. He/She was unsure if he/she was allergic to Ambien or Xanax, and he/she was unsure what the allergy symptoms were. The resident confirmed he/she was allergic to flu shot vaccines for sure. During an interview on 7/15/24 at 10:47 A.M., LPN S said the resident was not a heavy sleeper. He/She naps a lot during the day. He/She will wake up and do whatever he/she wants, maybe smoke and then go back and nap. During an interview on 7/16/24 at 8:53 AM, CMT YY said staff should automatically know to check for allergies. When he/she administers medications, he/she checked the resident's name, medication name and allergy list. CMT YY said the allergy list shows in the resident's medical record at the top, and all allergies are in RED font. If the medication was ordered and listed on their allergies, he/she would report it to the nurse. During an interview on 7/16/24 at 11:18 A.M., the Director of Nurses (DON) said nursing is responsible for re-capping and ensuring orders are accurate. If there are allergies, it is in red in the medical record. It is on the profile, and staff should note any allergies. She would expect staff to contact the physician if a resident was ordered a medication that was on the allergy list. Nursing should not administer the medication and notify the physician. It should be documented if the physician was notified. The DON was not aware if an assessment was completed or what type of symptoms the resident has with use of Ambien. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the D level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00234902 40290

Based on interview and record review, the facility failed to ensure one resident received care consistent with professional standards and facility policy to prevent and/or treat pressure ulcers (a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). The facility failed to ensure wound treatments were completed as ordered, and failed to notify the attending wound Nurse Practitioner (NP) of the missed treatments. The resident was sent to the hospital and received a surgical debridement of a sacral (tailbone) wound. The facility failed to administer ordered antibiotics for a 6 week time frame, which were ordered by the hospital infectious disease (ID) physician (Resident #72). The sample size was 30. The census was 151. Review of the wound management policy, dated 10/24/22, showed: -Purpose: to provide a system for the treatment and management of residents with wounds including pressure ulcers; -Policy: a resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing; -Definitions: -Pressure ulcer: any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers usually occur over bony prominences and re-graded or staged to classify the degree of tissue damage observed; -Wound management: -The attending physician will be notified to advise on appropriate treatment promptly; -The licensed nurse will notify the responsible party of a pressure ulcer; -Rehabilitation services will be contacted for appropriate devices or pressure redistributing devices; -Per physician orders, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management; -The physician and interdisciplinary team (IDT) will be notified of: -New pressure wounds; -Pressure wounds that do not respond to treatment; -Pressure wound that worsen or increase in size; -Complaints of increased pain, discomfort or decreased mobility by the resident; -Signs of wound sepsis (severe infection), presence of drainage, odor, necrosis (black, firm dead skin) if not already noted by the physician; -Residents who refused treatment; -Certified Nurse Aides (CNA) will complete body checks on the resident's shower days and report unusual findings to the nurse; -Documentation: A. New wounds will be documented on the 24 hour log and an incident report will be completed by the nurse; B. Wound documentation will occur weekly until the wound is healed. Documentation will include: -Wound location; -Length, width, and depth measurement recorded in centimeters (cm); -Direction and length of tunneling (wound extends deeper into the tissue than its surface, creating a channel) or undermining (separation of the wound edges from the surrounding healthy tissue, often creating a pocket under the wound surface); -Appearance of the wound base; -Drainage amount, characteristics such as color, consistency and odor; -Appearance of wound edges; -Description of the peri-wound (skin next to the wound) condition; -Presence of absence of new epithelium (skin) at the wound edge; -Presence of pain; C. IDT will document discussion and recommendations for: -Pressure wounds that do not respond to treatment; -Pressure wounds that worsen or increase in size; -Complaints of increased pain, discomfort of decrease in mobility by the resident; -Signs of sepsis, drainage, odor or necrosis; -Residents refusing treatment; D. Nurses will document effectiveness of current treatment in the medical record; E. Document notifications following a change in the resident's skin condition; F. Update the care plan as needed. Review of Resident #72's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 4/9/24, showed: -Cognitively intact; -Staff provide substantial to maximal assistance for toileting, transfers, showers, dressing and bed mobility; -Diagnoses included heart failure, high blood pressure, diabetes, cerebral palsy (a group of conditions that affect movement and posture), malnutrition, anxiety and depression; -Has a Stage 1 pressure injury (observable, pressure related alteration of intact skin with non-blanchable redness of a localized area): 1; -At risk for pressure injury; -Unhealed pressure injury; -Stage 3 pressure ulcer (full thickness tissue loss. Subcutaneous fat maybe visible, but bone, tendon or muscle is not exposed. Slough (yellow, stringy tissue) maybe present): 3 -Number present on admission or re-admission: 3; -Stage 4 pressure ulcer (full thickness loss, with exposed bone): 1 -Number present on admission or re-admission: 1 -Unstageable ulcer: (a wound that occurs due to prolonged pressure, full tissue loss which the depth of the wound of bed sore is completely obscured by eschar (black, dead tissue) number of unstageable ulcers: 1 -Number of these ulcers that were present on admission or re-admission: 0; -Skin and ulcer treatment: -Pressure reducing device for chair and bed; -Turn and repositioning program; -Nutrition and hydration interventions; -Pressure ulcer care; -Application of nonsurgical dressing other than to feet; -Application of ointments or medications other than to feet. Review of the May 2024, Treatment Administration Record (TAR), showed the following physician order: -An order, dated 3/16/24: Santyl ointment (used to remove dead tissue from a wound) 250 milligram (mg) to coccyx every day shift. Undocumented and blank on 5/1 and 5/2. Review of the progress notes, showed no documentation regarding the missed treatment or physician notification. Review of the facility wound report, showed on 5/3/24: -Location: Coccyx; -Stage: IV; -Treatment: Santyl, calcium alginate (highly absorptive dressing) and dressing; -Measurements: length (L) 6.9 centimeter (cm) x 9.8 width (w) cm x 0.6 depth (d) cm; -Acquired. Review of the May 2024, TAR, showed: -An order, dated 3/16/24: Santyl ointment 250 mg to coccyx every day shift. Undocumented and blank on 5/4; -An order, dated 5/7/24: Gentamycin ointment (topical ointment for bacterial skin infections) 0.1%, apply to coccyx every day shift for 30 days. Undocumented and blank on 5/7. Review of the progress notes, showed no documentation regarding the missed treatments or physician notification. Review of the facility wound report, dated 5/9/24, showed: -Location: Coccyx -Stage: IV; -Treatment: Santyl, calcium alginate and gentamycin; -Measurements: 6.8 cm (l) x 9.8 cm (w) x 1.5 cm (d); -Acquired. Review of the May 2024, TAR, showed: -Gentamicin ointment 0.1 %, apply to coccyx everyday shift for 30 days. Undocumented and blank on 5/10 and 5/15; -Santyl ointment 250 mg to coccyx every day shift. Undocumented and blank on 5/10. Review of the progress notes, showed on 5/13/24 at 2:48 P.M., a nurse note: NP notified about missing wound care on 5/10/24, 5/11/24 and 5/12/24. No new orders at this time. Review of the facility wound report, dated 5/15/24, showed: -Location: Coccyx -Stage: IV; -Treatment: Santyl, calcium alginate and gentamycin; -Measurements: 12.3 cm (l) x 6.6 cm (w) x 2.8 cm (d); -Acquired. Review of the specialized wound report, dated 5/16/24, showed: -Wound state: open; -Cause: Pressure; -Wound cause: at facility; -Measurements: 7.2 cm (l) x 8.6 cm (w) x 0.7 cm (d); -Tissue type: -Granulation type: 65 %; -Slough: 15 %; -Pressure versus non-pressure: -Is the patient or patient's body part immobile: yes; -Did nursing staff note it is directly from positioning: yes; -Was the patient's affected body part immobile recently (last 2 weeks) prior to wound development: yes; -Wound details: pressure ulcer/pressure injury; -Pressure injury: Stage IV; -Exudate volume: moderate: wound is wet and drainage covers 25-75 % of the dressing: -Exudate type: serosanguineous (clear, slightly blood tinged) drainage; -Undermining: yes from 12 o'clock to 2 o'clock position; -Wound orders: -Clean with saline or vashe (wound cleanser), use to irrigate and scrub the wound bed. Apply Santyl and calcium alginate to wound base, cut to fit inside the wound edges, do not place on skin. Cover with bordered gauze. Change daily, for soiling and saturation -Notes: Debridement to remove unhealthy tissue and stimulate healing; -Measurements post procedure: 7.4 cm (l) x 8.5 cm (w) x 1.0 cm (d). Review of the May 2024, TAR, showed: -Gentamicin ointment 0.1 %, apply to coccyx everyday shift for 30 days. Undocumented and blank on 5/18; -Santyl ointment 250 mg to coccyx every day shift. Undocumented and blank on 5/18. Review of the progress notes, showed: -On 5/21/24 at 12:25 P.M., a nurse note: NP notified of missing wound care on 5/18/24. No new ordered received; -On 5/21/24 at 5:57 P.M., a nurse note: call placed to pharmacy due to being out of gentamycin ointment for coccyx. The pharmacy stated would attempt to send two tubes as the wound needed more than 1 gm at dressing changes. The insurance may not cover, wound measurements sent to aid in obtaining medication. Gentamycin to arrive tomorrow morning due to pharmacy closing at 5:00 P.M. Review of the specialized wound progress note, dated 5/23/24, showed: -Wound state: open -Cause: Pressure; -Wound cause: at facility; -Measurements: 7.3 cm (l) x 9.3 cm (w) x 1.0 cm (d); -Tissue type: -Granulation type: 70%; -Slough 10%; -Pressure versus non-pressure: -Is the patient or patient's body part immobile: yes; -Did nursing staff note it is directly from positioning: yes; -Was the patients affected body part immobile recently (last 2 weeks) prior to wound development: yes; -Wound details: pressure ulcer/pressure injury; -Pressure injury: Stage IV; -Exudate volume: moderate: wound is wet and drainage covers 25-75% of the dressing: -Exudate type: serosanguineous drainage; -Peri-wound texture: friable (tissue that is easily irritated, more prone to inflammation and damage); -Length, width and depth: stayed the same compared to previous visit; -Undermining: yes from 12 o'clock to 2 o'clock position; -Wound orders: -Clean with saline or vashe, use to irrigate and scrub the wound bed. Apply Santyl and calcium alginate to wound base, cut to fit inside the wound edges, do not place on skin. Cover with bordered gauze. Change daily, for soiling and saturation. Review of the May 2024, TAR, showed: -Gentamicin ointment 0.1 %, apply to coccyx everyday shift for 30 days. Undocumented and blank on 5/27; -Santyl ointment 250 mg to coccyx every day shift. Undocumented and blank on 5/27. Review of the progress notes, dated 5/28/24 at 11:50 A.M., a nurse note: NP notified of missing wound care on 5/27/24. No new orders received. Review of the specialized wound progress note, dated 5/29/24, showed: -Wound state: open -Cause: Pressure; -Wound cause: at facility; -Measurements: 6.7 cm (l) x 12.6 cm (w) x 1.9 cm (d); -Tissue type: -Granulation type: 70%; -Slough 10%; -Pressure versus non-pressure: -Is the patient or patient's body part immobile: yes; -Did nursing staff note it is directly from positioning: yes; -Was the patients affected body part immobile recently (last 2 weeks) prior to wound development: yes; -Wound details: pressure ulcer/pressure injury; -Pressure injury: Stage IV; -Exudate volume: moderate: wound is wet and drainage covers 25-75% of the dressing: -Exudate type: serosanguineous drainage; -Peri-wound texture: friable; -Length, width and depth: stayed the same compared to previous visit; -Undermining: yes from 12 o'clock to 2 o'clock position; -Wound orders: -Clean with saline or vashe, use to irrigate and scrub the wound bed. Apply Santyl and calcium alginate to wound base, cut to fit inside the wound edges, do not place on skin. Cover with bordered gauze. Change daily, for soiling and saturation; -Assessment notes: debridement for removal of unhealthy tissue and promote wound healing; Wound measurement after debridement: 14.2 cm (l) x 10.6 cm (w) x 6.7 cm (d). Debrided 60%. Review of the facility wound report, dated 5/30/24, showed: -Location: Coccyx -Stage: IV; -Treatment: Santyl, calcium alginate and gentamycin; -Measurements: 6.7 cm x 12.6 cm x 1.9 cm; -Acquired. Review of the progress notes, showed on 5/30/24 at 9:48 A.M.: a nurse note: care plan held and discussed medical decline. Guardian agreed to hospice services. Review of the May 2024 TAR, showed: -Gentamicin ointment 0.1 %, apply to coccyx every day shift for 30 days. Undocumented and blank on 5/31; -Santyl ointment 250 mg to coccyx every day shift. Undocumented and blank on 5/31 Review of the progress notes, dated 6/1/24 at 10:53 P.M., showed a nursing note: resident experienced vomiting and left sided abdominal pain. Resident requested to go to the hospital. Per physician, send to the hospital for evaluation and treatment. Review of hospital discharge summary, dated 6/8/24, showed: -Overview: admitted : 6/2/24; -discharged : 6/8/24; -Problems: -Active problem: decubitus ulcer, Stage 4 with infection; -Details of hospital stay: -Chronic osteomyelitis (bone infection) of the sacrum (coccyx) post multiple debridements with wound vacuum, who presented to the emergency department (ED) with abdominal pain. The legal guardian stated he/she was concerned regarding the pain and worsening wound. The patient was noted to be hypotensive (low blood pressure). Upon ED arrival, found to have sepsis (blood infection) and increasing sacral ulcer size and could not rule out sacroiliac septic arthritis. Wound cultures were obtained and sent. The patient was administered broad spectrum antibiotics. Surgical team was consulted and patient was taken to the operating room for debridement; -Hospital course: -Sepsis: infected sacral ulcer; -Osteomyelitis: chronic osteomyelitis of sacrum with multiple surgical debridements of the sacral ulcer. Imaging showed mild enlargement of sacral ulcer. On 6/4/24 surgical debridement. Wound care service placed wound vacuum. Infectious diseases guided antibiotic treatments and bone culture positive for multiple bacterium. Antibiotics at discharge Doxycycline 100 mg twice a day for two weeks and Ciprofloxacin (antibiotic) and Flagyl (antibiotic) for six weeks; -Post discharge: wound vac care and ordered blood testing in six weeks. Fax results of ordered blood testing to infectious diseases; -Discharge to long term facility. Review of the facility re-admission progress note, showed: -On 6/8/24 at 8:36 P.M.: readmitted from hospital today at 3:45 P.M. Oriented to person, place and time. Resident is bedfast. The physician/NP approves of the plan of care; -On 6/9/24 at 9:53 P.M., give metronidazole (antibiotic) 500 mg, give one tablet 3 times a day for wound. On order, new prescription; -On 6/9/24 at 4:52 A.M., the resident had new order for antibiotic, still awaiting on call back from physician to verify orders; -On 6/9/24 at 2:52 P.M.: an order: wound to coccyx, cleanse with normal saline or vashe, pat dry, apply Santyl nickel thick edge to edge of the wound bed, apply Gentamycin ointment to wound bed, cover with calcium alginate, cut to fit, cover with bordered gauze, for every day shift. Physician called and orders unable to be verified, a protective covering applied instead; -On 6/9/24 at 7:42 P.M., spoke to the physician and he does not want a stop date on the two antibiotics; -On 6/9/24 at 9:39 P.M., Doxycycline 100 mg, take two time a day for 14 days, Ciprofloxacin 750 mg twice a day, order needs to be verified; Review of the June 2024 MAR and TAR, showed: -On 6/9/24: Ciprofloxacin 750 mg, Doxycxyline 100 mg and Metronidazole 500 mg not administered; -On 6/9 and 6/10/24: Santyl ointment 250 mg, not administered on 6/9 and 6/10: -On 6/9/24: Coccyx clean with NS apply Santyl nickel thick, apply Gentamycin to wound bed, cover with calcium alginate cut to fit, cover with bordered gauze, every day shift. Not administered, noted as blank. Review of the progress notes, showed: -On 6/10/24 at 2:54 P.M., Santyl ointment 250 mg, apply per TAR every day shift for 30 days. On order; -On 6/11/24 at 12:23 P.M., NP notified of missed wound care and Santyl administration on 6/10/24. No new orders given; -On 6/12/24 at 11:30 A.M., NP notified of missed wound care on 6/11/24. No new orders received. Review of the June 2024 MAR and TAR, showed: -On 6/14/24: Ciprofloxacin 750 mg, Doxycxyline 100 mg and Metronidazole 500 mg not administered; -On 6/14/24: Coccyx clean with NS apply Santyl nickel thick, apply Gentamycin to wound bed, cover with calcium alginate cut to fit, cover with bordered gauze, every day shift. Noted as blank. Review of the progress notes, showed: -On 6/15/24 at 12:44 P.M., NP notified of missed wound care on 6/14/24. No new orders received; -On 6/16/24 at 4:24 P.M., NP notified of missed wound care on 6/15/24. No new orders received. Review of the June 2024 MAR and TAR, showed: -On 6/17/24: Ciprofloxacin 750 mg, Doxycxyline 100 mg and Metronidazole 500 mg not administered. Noted as blank; -On 6/17/24: Coccyx clean with NS apply Santyl nickel thick, apply Gentamycin to wound bed, cover with calcium alginate cut to fit, cover with bordered gauze, every day shift. Not administered. Review of the progress notes, showed: -On 6/17/24 at 7:47 P.M., Ciprofloxacin 750 mg on order; -On 6/18/24 at 12:12 P.M.,: NP notified of missed wound care on 6/17/24. No new orders. Review of the ePOS, showed a note on 6/19/24: Ciprofloxacin 750 mg: NP states 8 days was long enough for medication. Review of the progress notes on 6/19/24, showed no documented order or NP visit note regarding the discontinuation of the ordered Ciprofloxacin 750 mg antibiotic. Review of the June 2024 MAR and TAR, showed: -On 6/22/24: Ciprofloxacin 750 mg stopped on 6/19/24, Doxycxyline 100 mg and Metronidazole 500 mg not administered; -On 6/22/24: Coccyx, clean with NS apply Santyl nickel thick, apply Gentamycin to wound bed, cover with calcium alginate cut to fit, cover with bordered gauze, every day shift. Not administered. Review of the progress notes, showed on 6/24/24 at 12:09 P.M., NP notified of missed wound care on 6/22/24. No new orders given. Review of the June 2024 MAR and TAR, showed: -On 6/27/24 and 6/28/24: Ciprofloxacin 750 mg, Doxycxyline 100 mg and Metronidazole 500 mg not administered; -On 6/27/24 and 6/28/24: Coccyx clean with NS apply Santyl nickel thick, apply Gentamycin to wound bed, cover with calcium alginate cut to fit, cover with bordered gauze, every day shift. Noted as blank. Review of the progress notes, showed: -On 6/29/24 at 10:30 A.M.,: NP notified of missed wound care on 6/27 and 6/28/24. No new orders given; -7/2/24 at 2:28 P.M.,: Coccyx wound: physician notified writer unable to carry out wound care orders related to nurse to resident ratio; -On 7/7/24 at 5:07 P.M.,: nurse notified by aide that resident's catheter (hollow tube placed in the bladder to drain urine) contained pus (yellow, thick drainage). Voiced sore throat and hoarse voice, requested to go to hospital, stated feeling ill all day. Physician notified and new orders send to hospital for evaluation and treatment. During an interview on 7/09/24 at 10:26 A.M., the physician's NP said he provided care for the resident the last several months. The resident is seen by the wound care specialist weekly. Neither he nor the physician had been notified of missed wound treatments or the missed ordered antibiotics. If wound treatments are missed, the wound care specialty team should be notified first, then the physician or NP. During an interview on 7/10/24 at 9:35 A.M., the Director of Nursing (DON) said the facility wound nurse completes wound rounds with the specialty provider weekly. She also completes all wound care treatments during the week. On the weekends, the Charge Nurses are responsible to complete the ordered treatments. All missed wound treatments should be reported to the wound care team, if seen by them or by the physician. If a resident is ordered to take an antibiotic for a wound, the resident should remain on the antibiotic until discontinued by the ID physician. There should be no missed treatments. The risk of untreated wounds could be infection, and further injury. If a resident refused treatments, then staff should notify the MD, and document in the record. During an interview on 7/11/24 at 7:29 A.M., the facility Wound Nurse said the facility staff had major issues completing wound care in May. She had been the facility wound nurse about two months. She works Tuesdays through Friday as the wound nurse. She works every other weekend as a floor nurse. When she completed audits, she observed multiple wound treatments had not been completed. The nurses should assess skin daily. The resident was on antibiotics for wounds from a hospital stay in June. The antibiotic was prescribed by the ID physician, it would have been very important for the resident to finish those. The staff documented in the physician order, that an NP stopped the ordered antibiotic, and it was stopped incorrectly. During an interview on 7/11/24 at 9:23 A.M., the specialty wound care NP said she expected staff to administer wound care orders and medications as written. If residents resist wound care, staff should re-approach and if the resident continued to refuse, staff should document. Blanks on the TAR indicate a treatment was not done. The physician, NP or herself should be told when treatments are not done. She has educated staff multiple times of the importance of completing wound treatments. Resident #72 is totally dependent on staff for care. She and the facility's wound care nurse frequently provided hygiene care due to the resident being heavily soiled. The resident was in the hospital in June for worsening of the sacral wound. The hospital ID (Infectious Disease) physician prescribed antibiotics for an extended time, the facility should have administered those as ordered. Antibiotics are important for wound healing. Santyl is used to clean out the dead tissue in a wound. If Santyl is not administered as ordered, the wound is not debrided and dead tissue remaining in the wound bed can contribute to infection beginning. During an interview on 7/17/24 at 3:16 P.M., the resident's physician said neither he nor the NPs were notified of missed wound care or questions regarding stopping the ID physician ordered antibiotics. The ID physician should have been contacted regarding stopping the ordered antibiotic. The resident is seen weekly by the wound care NP. The resident was sent to the hospital in June and received a surgical debridement of the sacral wound. The ID physician ordered the antibiotic and Flagyl for 6 weeks to treat various bacteria in the wound. MO00237027

40290 Based on observation, interview, and record review, the facility failed to identify one resident's significant weight loss of -24.93% in a timely manner, resulting in delayed identification of interventions to support the resident's nutritional status (Resident #127). The facility failed to ensure three residents with significant weight loss were provided with therapeutic diets, supplemental food items, alternative food items, and/or feeding assistance to address weight loss (Residents #127, #123, and #50). The sample was 30. The census was 151. Review of the facility's Nutrition/Hydration Management policy, revised 10/24/22, showed: -Purpose: To ensure that each resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible based on the resident's comprehensive assessment. To ensure that a resident receives a therapeutic diet when there is a nutritional problem; -Policy: -The concept of nutrition management is an interdisciplinary process. The key components of this system are: -a. Maintaining nutritional status as indicated by clinical measures such as body weight, biochemical measure, and hydration; -b. Developing an individual nutrition/hydration program based on individual assessed needs; -c. Implementing the nutrition/hydration program; -d. Identifying new instances of unplanned weight loss or gain; and -e. Ongoing assessment, monitoring, and evaluation of the effectiveness of the nutrition/hydration management program; -The goal of any nutrition/hydration management process is to improve quality of life. The goal of the interdisciplinary team is to promptly identify a resident with nutrition/hydration at risk factors and develop and effective management program; -Procedure included: -A comprehensive care plan is developed by the interdisciplinary team that addresses nutrition/hydration and an individualized nutrition/hydration management program based on individualized assessed need; -The nutrition/hydration management program may address the following; -The factors contributing to actual or potential causes for inadequate nutrition or hydration status; -Specific modification in the resident's meal plan including food from outside the facility and/or special food activities; -Pertinent socialization and recreation factors; -Dining locations and the type and level of dining assistance required; and -Position, cueing/assistance, and adaptive equipment needed. Review of the facility's Therapeutic Diets policy, revised 10/24/22, showed: -Purpose: To ensure that the facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders; -Policy: Therapeutic diets are diets that deviate from the regular diet and require a physician order. Per the physician order, therapeutic diets are planned, prepared and served in consultation with the Dietitian; -Procedure: -The nursing staff is responsible for communicating the physician's order for a therapeutic diet to the dietary department in writing; -The therapeutic diet will be reflected on the resident's tray card. -The Dietary Manager will periodically review the resident's tray card and the physician's dietary orders to ensure that the information is consistent. 1. Review of Resident #127's medical record, showed: -admitted [DATE]; -Diagnoses included malnutrition, abnormal weight loss, dysphagia (difficulty swallowing), cognitive communication deficit, depression, anxiety, hallucinations, diabetes, heart failure, high blood pressure, kidney failure, and muscle wasting and atrophy. Review of the resident's electronic physician order sheet (ePOS), showed: -An order, dated 9/1/23, for Remeron (antidepressant) Sol Tab oral disintegrating tablet, 15 milligrams (mg.), one tablet by mouth at bedtime for depression; -An order, dated 9/26/23 through 1/12/24 for health shake three times daily with meals for weight loss; -An order, dated 9/26/23 through 1/15/24 for Ensure (nutritional supplement) oral liquid, one can by mouth three times a day for supplement. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/23, showed: -Moderate cognitive impairment; -Supervision or touching assistance required for eating. Review of the resident's medical record, showed: -On 12/5/23, weighed 181.4 pounds (lbs.); -A physician order, dated 12/30/23, for ice cream with meals; -On 1/5/24, weighed 169.8 lbs; -The resident had a significant weight loss of -6.39% between 12/5/23 and 1/5/24. Review of the resident's physician progress note, dated 1/8/24, showed the resident eating poorly, refusing to drink Ensure sometimes. Staff informed patient likes food from outside, home food. Family brings food sometimes. Review of the resident's ePOS, showed an order, dated 1/24/24, for megestrol acetate (medication used to treat loss of appetite) oral tablet 20 mg., give 40 mg. orally one time a day for appetite stimulant. Review of the resident's physician progress note, dated 2/5/24, showed resident eating very poorly. Staff informed patient likes food from outside, home food. Family brings food sometimes. Patient lost 10 lbs. in 30 days. Continue Remeron, Megestrol, Ensure. Talked to patient's family, he/she wants gastrointestinal (GI) tube (a tube surgically inserted into the stomach to provide hydration, nutrition, and medications). Will consult GI. Review of the resident's weights, showed on 2/6/24, the resident weighed 170.2 lbs. Review of the resident's physician progress note, dated 3/4/24, showed resident continuing to refuse his/her foods. Staff informed he/she only eats food from outside of the facility when his/her family brings it. Watched him/her during lunch, did not take a single bite. Eating very poorly, limited activity. Continue Remeron, Megestrol. Facility trying to contact a GI. Review of the resident's weights, showed on 3/5/24, the resident weighed 169.6 lbs. Review of the resident's physician progress note, dated 3/26/24, showed talked to resident about his/her family's recommendation for GI tube as he/she is not eating or drinking. Resident said no GI tube. Eating very poorly, very limited activity. Continue Remeron, Megestrol. Facility trying to contact GI. Review of the resident's ePOS, showed an order, dated 3/28/24, for Ensure with meals (scheduled to be administered at 7:00 A.M., 12:30 P.M., and 5:30 P.M.). Review of the resident's weights, showed on 4/5/24, he/she weighed 171.2 lbs. Review of the resident's physician progress notes, showed: -On 4/8/24, the physician documented the resident's family called to inform he/she no longer wants to put in the GI tube. Family will bring food more often so resident will eat. Resident does not eat food from facility. Continue Remeron, Megestrol, Ensure. Family does not want GI tube anymore. Family will bring food from outside as resident only eats that. Resident does not drink Ensure; -On 5/6/24, the physician documented the resident with low appetite. Does not eat food from facility. Continue Remeron, Megestrol, Ensure. Consult Registered Dietician (RD). Review of the resident's weights, showed on 5/7/24, he/she weighed 172.5 lbs. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -No behaviors exhibited; -Independent with eating; -Weight: 173 lbs. Review of the resident's quarterly dietary profile, signed by the Dietary Manager (DM), dated 5/22/24, showed: -Percentage intake: 100%; -Current nutritional supplement: Ensure; -Appetite: Good; -Likes: Turkey with dressing, burger with cheese, tenders. Dislikes: Broccoli. Review of the resident's weights, showed: -On 6/3/24, weighed 170.5 lbs.; -On 6/5/24, weighed 129.5 lbs. -The resident had a significant weight loss of -24.93% between 6/3/24 and 6/5/24. Review of the resident's speech therapy evaluation, dated 6/4/24, showed: -Reason for referral/current illness: Dysphagia due to decline in oral/pharyngeal (related to the pharynx, the conductive structure located in the midline of the neck) function, risk for weight loss, safety awareness, weight loss, and signs/symptoms of dysphagia; -Recommendations: Mechanical soft texture, thin liquids. Occasional supervision. Review of the resident's ePOS, showed an order, dated 6/4/24, for regular diet, mechanical soft texture. Review of the resident's medical record, showed: -On 6/7/24, the nurse documented the resident observed chewing fish during meal time, then proceeded to spit chewed fish into a small plastic bag. Resident asked about behavior and stated, I don't know what I'm doing. I won't do it again. RD notified; -On 6/7/24, the RD documented significant weight loss triggering -41 lbs. in two days. Talked to nursing and current weight appears correct. 41 lb. weight loss not possible so questioning the weights before 6/5/24 at this point. Resident receiving regular, mechanical soft with ice cream and Ensure with meals. Resident needs supervision and encouragement. Per nursing, resident chewed up fish and then did not eat it today. Now working with speech therapy. Resident is a picky eater and sometimes refusal of supplementation noted. Receiving Megestrol and Remeron, both have potential for appetite stimulation; -On 6/9/24, the nurse documented the resident observed during meal consumption this morning. Resident observed placing full spoon of oatmeal in mouth, chews it, and spits it back onto spoon. Resident places chewed oatmeal onto plate, separates it from what has not been chewed. Resident asked if there were any issues swallowing. Resident stated, I don't know. Resident provided chocolate Ensure and tolerated Ensure well without issues; -On 6/13/24, the nurse documented the resident provided with Ensure this morning, poor meal consumption, less than 25%. Nurse continues to encourage and educate resident; -Staff documented Ensure, Remeron, and Megestrol as administered per physician order on the June 2024 medication administration record (MAR). Review of the resident's care plan, in use at the time of survey and reviewed 7/8/24, showed: -Focus: Resident has an activities of daily living (ADL) self-care performance deficit; -Interventions included: resident needs limited assistance of one for eating; -Focus: Resident has nutritional problem or potential nutritional problem related to diet restrictions; -Interventions included: Due to resident declining to consume his/her Ensure, order discontinued. Monitor weight as directed. Provide and serve diet as ordered, regular diet, mechanical soft texture, regular consistency. Provide and serve supplements as ordered: ice cream with meals. Staff reports of family with outside foods and he/she consumes with no complaints, encourage resident choose food from dietary that he/she enjoys, offer him/her snacks of his/her choice throughout the day and evenings. Weight at same time of day and record, resident is weighed during the day with the use of his/her wheelchair; -The care plan failed to identify the resident's poor intake of food served at the facility, increased intake of meals eaten with family, and his/her behavior of chewing food and spitting it out, and to identify interventions to address the behavior. Review of the resident's diet card, undated, showed Regular diet checked at the top of the card. No documentation of physician-ordered supplemental ice cream or Ensure. Likes and dislikes not documented. Observation on 7/8/24 at 10:28 A.M., showed the resident seated in a wheelchair. The resident appeared thin with pronounced collar bones and jaw bones. During an interview, the resident exhibited some confusion. He/She said he/she ate breakfast. He/She was unable to answer questions when asked about his/her meal intake and weight loss. Observation of lunch on 7/8/24 at 11:57 A.M., showed the resident sat at a table in the dining room. Staff served the resident mechanical soft Salisbury steak, mashed potatoes with gravy, a scoop of vegetables, and a carton of Ensure. No ice cream served to the resident. The resident consumed less than 25% of each food item and pushed his/her food around the plate. Staff provided the resident with two meat and cheese sandwiches. The resident took bites of one sandwich and spit the food onto his/her plate. Licensed Practical Nurse (LPN) D approached the resident and asked if he/she was spitting his/her food out and the resident said no. LPN D walked away, and the resident continued to take bites of the sandwich and spit it back onto the plate. At 12:21 P.M., LPN removed the resident's plate and encouraged him/her to drink the Ensure. At 12:29 P.M., the resident finished the Ensure. Observation on 7/8/24 at 4:54 P.M., showed the resident on his/her left side in bed with a plate of whole egg rolls and noodles. No ice cream served to the resident. No Ensure observed. No staff in the resident's room to supervise or provide encouragement. The resident used his/her hands to rip up the food and put it in his/her mouth, spitting bits of food out of his/her mouth while he/she chewed. Observation of lunch on 7/9/24 at 12:07 P.M., showed the resident sat in the dining room. Staff served the resident a chopped-up meat patty, mashed potatoes with gravy, mixed vegetables, a cup of ice cream, and a carton of Ensure. The resident took bites of his/her food and spit it back onto the plate. Staff did not offer alternatives or encourage the resident during the meal. At 12:26 P.M., staff removed the resident's plate. In total, the resident consumed the entire cup of ice cream, approximately 30% of the meat, and a couple bites of vegetables. Observation of lunch on 7/12/24 at 11:43 A.M., showed the resident sat in the dining room. Staff served the resident a mechanical soft fish patty, spaghetti, sliced carrots, and a piece of cake. No ice cream served to the resident. No Ensure observed. The resident pushed the food around on his/her plate. Staff provided the resident with two meat and cheese sandwiches. The resident consumed some of both sandwiches, spitting the remainders of the sandwiches onto his/her plate. In total, the resident consumed just over one whole sandwich. Observation on 7/15/24 at 11:44 A.M., showed the resident sat in the dining room with a whole hamburger and crinkle-cut fries. No ice cream served to the resident. No Ensure observed. The resident used his/her hands to rip up the hamburger and put it in his/her mouth, spitting bits of food out while he/she chewed. Observation on 7/15/24 at 7:06 A.M., showed Certified Nurse Aide (CNA) E brought the resident to the shower room by the elevators on the first floor to have him/her weighed. CNA/Restorative Aide (RA) W entered the shower room and said he/she would leave the resident in his/her wheelchair and put him/her on the scale to obtain the weight. CNA E said no, he/she needed to get the wheelchair weight first. CNA E transferred the resident out of his/her wheelchair into a regular chair, then weighed the wheelchair on the scale. The wheelchair weighed 34.4 lbs. CNA E transferred the resident back to his/her wheelchair and positioned him/her on the scale. The scale showed 164.6 lbs. After subtracting the wheelchair weight, the resident's weight was determined to be 130.2 lbs. During an interview on 7/15/24 at approximately 7:10 P.M., CNA E said CNA/RA W has been obtaining the weights for all residents in the facility. The weights were not obtained properly. Minutes ago, RA W wanted to weigh the resident in his/her wheelchair and that is not correct. The resident has visibly lost a lot of weight over the past few months. CNA E has talked to the resident's doctor and psychiatrist about the weight loss. Someone recommended a GI tube, but the resident or his/her family said no. A month ago, the resident began spitting out his/her food. The resident loves snacks, such as oatmeal pies and chocolate bars. He/She is supposed to be getting ice cream from dietary, but hasn't been. During an interview on 7/15/24 at 11:28 A.M., CNA/RA W said he/she was he/she is responsible for obtaining weights on the residents in the facility at the beginning of each month. The facility has two stationary scales on the first floor, and a chair scale that CNA/RA W can bring to the other floors of the facility. He/She uses different scales every time he/she weighs different residents. Whichever scale he/she uses changes by resident or day, depending on what is closer at the time he/she obtains a resident's weight. He/She saw Resident #127 losing weight and getting smaller over the past few months, but the numbers on the scale stayed the same, so he/she went with that. Recently, he/she realized the chair scale wasn't calibrated, and he/she doesn't know how to calibrate it, so he/she told the MDS Coordinator. During an interview on 7/15/24 at 2:48 P.M., CNA R said the resident used to be bigger and has lost a lot of weight since admission. He/She used to receive a mechanical diet. They switched his/her diet to regular last month and that's when he/she started spitting out his/her food. He/She eats well when his/her family comes to visit. His/Her average meal intake is about 50%. He/She is supposed to get ice cream at all meals, but dietary only gives out ice cream on certain days. The Certified Medication Technicians (CMTs) give the resident Ensure. During an interview on 7/16/24 at 7:11 A.M., CNA EE said the resident has lost a lot of weight. For a while now, he/she has been chewing up his/her food and spitting it out. He/She doesn't like the food served at the facility. He/She needs to be served new foods instead of the same foods served over and over at the facility. When he/she doesn't eat, staff should offer him/her something else. The problem is that dietary staff don't send the right food texture or the right food items. When nursing calls down to the kitchen to ask for the right items or request something different, dietary staff gets mad. The only food they will send up as an alternative is a cold cut sandwich. During an interview on 7/15/24 at 12:32 P.M., the Social Services Director (SSD) said the resident has dementia and has good and bad days. Sometimes the resident eats and sometimes he/she spits out his/her food. His/Her meal intake depends on who is there as well. He/She can eat a bunch when with family and eats well with them. He/She prefers food from outside of the facility. The SSD was not aware the resident had a significant weight loss. Weight loss is a topic discussed in the weekly interdisciplinary (IDT) meetings. She recalled them discussing the resident's weight loss before and people mentioned getting the resident more shakes. During an interview on 7/16/24 at 9:30 A.M., the DM said the resident has been chewing his/her food and spitting it out. He/She eats well when his/her family comes to visit. He/She is supposed to receive a mechanical diet, not a regular diet. During the interview, the DM reviewed the resident's diet card, which showed regular diet. The DM said the resident's diet card had been changed by someone else, and he did not know who. Dietary staff should not change the diet cards and should always go by physician-ordered diet. The DM saw the resident when he/she was first admitted to the facility and the resident has visibly lost weight since then, and he/she is thin. The resident's weight has gone south and the DM does not know why. The resident eats well when his/her family comes to visit. The DM attends the IDT meetings, which are held weekly. The resident's weight loss was discussed during an IDT meeting one time and has not been mentioned since then. During an interview on 7/16/24 at 11:09 A.M., the Speech Therapist (ST) said the resident was referred to her for an evaluation in June 2024, and she completed a swallow evaluation. The resident has been having issues with swallowing. He/She has been expelling his/her food, but not always. His/Her diet was downgraded to mechanical soft because he/she does not have enough teeth. She expects the resident to receive a mechanical soft diet. If dietary serves the resident whole foods, nursing staff usually chop up the food for the resident. The resident has been spitting out his/her food, which is a fairly new behavior. If the food is something the resident likes, he/she will eat it. During an interview on 7/16/24 at 10:20 A.M., the MDS Coordinator said residents are weighed monthly by CNA/RA W. If there is a discrepancy, the resident may be moved to weekly weights. She does not know how Resident #127's significant weight loss was missed. Maybe staff was using a different wheelchair to weigh the resident. Maybe the resident was weighed using the chair scale, which was messing up a lot on people. When the weight loss was noted, she had the resident re-weighed to verify the weight was correct, and it was. The scales in the facility were recalibrated. When staff saw the resident was losing weight, but the numbers on the scale stayed the same, she would think staff should report it to the nurse. The resident doesn't always drink his/her Ensure and some CNAs have to take the time to sit with him/her and coax him/her to drink it. His/Her family can get the resident to eat. The MDS Coordinator was not aware of the resident's spitting out food while eating. She expects the resident to receive a mechanical soft diet as ordered. If the resident requests a regular texture diet, she expects nursing staff to let the ST know so she can evaluate the resident. If the resident was not eating, she expected staff to offer different types of foods and to get him/her something he/she wants. She expected the resident to be served ice cream at meals, per physician order. She attends the weekly IDT meetings. She does not recall discussing the resident's weight loss in the IDT meetings. 2. Review of Resident #123's medical record, showed: -Rarely understood; -Staff provide maximum assistance for toileting, dressing, hygiene and eating; -Diagnoses included: quadriplegia (paralysis of all four limbs), mild protein calorie malnutrition, dysphagia, muscle weakness, and abnormal weight loss. Review of the care plan, in use during the survey, showed: -Focus: The resident has a diagnosis of adult failure to thrive due to decline in health; -Goal: The resident will have needs met by staff; -Interventions: Staff will assist the resident to consume food and fluids; -Focus: The resident is at risk for dehydration related to memory impairment, decline in condition and poor fluid intake; -Goal: The resident will be adequately hydrated; -Interventions: Assess the need for fluids during rounds and meal times, Keep fluids at the bedside and staff assist with fluid consumption; -Focus: Nutritional problem; -Goal: Maintain adequate nutritional status as evidenced weight gain; -Interventions: Serve diet as ordered, provide and serve supplements as ordered, staff encourage fluids, weigh at the same time of day. Review of the current ePOS, showed a diet order: Regular diet, pureed texture, upon request mechanical soft diet with assistance from restorative therapy aide. Review of the resident's monthly weights, showed: -February 2024: 91.2 lbs. -March 2024: 87.0 lbs. Review of the ePOS, showed an order, dated 3/18/24 for Ready Care (nutritional supplement) 120 milliliters (ml), three times a day. Review of the monthly weights, showed: -April 2024: 82.5 lbs; -May 2024: 80.0 lbs. Review of the resident's dietary notes, showed: -On 5/6/24 at 1:58 P.M., the resident continued on a pureed diet. He/She receives shakes three times a day, Ready Care 2.0 at 120 ml three times a day, Juven (protein supplement) and liquid protein 30 ml as supplement. The resident assisted by staff at meal times, intake fair at times. Current weight 80 lbs., reflecting a 3.1% loss in 30 days and 12.3% in 90 days. Increased calorie and protein needs secondary to malnutrition, weight loss and low body mass index (BMI, a measure of body fat based on height and weight). Speak with physician and family regarding non-oral nutrition; -On 5/7/24 11:27 A.M., addendum to review note on 4/6/24: Discussed with IDT regarding recommendations. The resident's family declined both tube feeding and hospice services. Recommend discontinue shakes and replace with Ready Care 120 mls three times a day with meals in addition to currently ordered Ready Care. Review of the ePOS, showed an order, dated 5/8/24, for Ready care 2.0 ml, give 120 ml, three times a day. Review of the May 2024 MAR, showed: -An order, dated 3/18/24, for Ready care 2.0, 120 ml three times a day. Scheduled daily at 9:00 A.M., 1:00 P.M., and 5:00 P.M. Staff documented administered daily all times; -An order, dated 5/8/24, for Ready care 2.0, 120 ml three times a day. Scheduled daily at 9:00 A.M., 1:00 P.M., and 5:00 P.M. Staff documented administered daily all times. Review of the resident's June 2024 monthly weights, showed: 82.3 lbs.; Review of the June 2024 MAR, showed: -An order, dated 3/18/24, for Ready care 2.0, 120 ml three times a day. Scheduled daily at 9:00 A.M., 1:00 P.M., and 5:00 P.M. Staff documented administered daily all times; -An order, dated 5/8/24, for Ready care 2.0, 120 ml three times a day. Scheduled daily at 9:00 A.M., 1:00 P.M., and 5:00 P.M. Staff documented administered daily all times. Review of the dietary note, dated 6/7/24 at 11:23 A.M., showed weight on 6/3/24: 82.3 lbs BMI 15.1 underweight. Significant weight loss -8.9 lbs. Noted weight has remained overall stable since 3/28/24. Receiving puree diet order, may have a mechanical soft diet with restorative aide. Receiving Ready Care 120 ml three times a day, new order given on 5/8/24 for additional ready care 120 ml three times a day with meals. Resident's family declined tube feeding support and hospice services. Multiple interventions in place for nutrition support. Stability guarded with multiple comorbidities and disease progression. Observations on 7/8/24, showed: -At 10:41 A.M., the resident asleep in his/her chair. He/She appeared thin; -At 12:04 P.M., noted in the main dining room, at the assisted dining room table. CNA ZZ mixed all food together to feed the resident. Used a spoon, and the resident took two bites of food. CNA ZZ left the table to assist staff. At 12:19 P.M., CNA ZZ returned to the table, offered the resident another spoonful of food. The resident spat out the food. CNA ZZ cleaned the resident's face and pushed the resident toward the nurses station. No supplements were offered at the meal. CNA ZZ did not offer a warm meal or alternative to the resident. Observation on 7/9/24 at 7:58 A.M., showed the resident in his/her chair at the nurse's station. Staff offered and assisted the resident to drink Ensure. The resident consumed 50% of the container. Review of the resident's July 2024 monthly weight, showed the resident weighed 84.6 lbs. Observation on 7/15/24 at 8:50 A.M., showed the resident awake on the edge of the bed. The breakfast plate sat on the table next to the door, away from the resident. The plate contained uneaten eggs and meat. CNA/RA W said he/she and another CNA were the only aides on the floor at the time. He/She had not fed the resident but a bite or two, because other residents needed help. The resident is thin. No supplements were provided on the tray. CNA/RA W did not know where to get the supplements or if the resident was ordered supplements. During an observation and interview on 7/16/24 at 8:43 A.M., CNA/RA W weighed the resident. CNA/RA W placed the resident, who was seated in his/her wheelchair, onto the shower room scale. The weight was 173.8 lbs in his/her chair. RA W said the chair weighs 94.8 lbs. The resident's current weight was 79 lbs. The resident had lost an additional 5.6 lbs. since the beginning of the month. He/She weighs all the residents at the beginning of the month and documents in the medical records. The resident had lost weight. He/She had observed staff give the resident a bite or two, then leave to provide care to another resident, and do not return to assist Resident #123 to finish eating. Observation on 7/16/24 at 7:55 A.M., showed the resident in the dining room at the assisted table. He/She was served a pureed breakfast plate at 7:58 A.M. RA W fed the resident. No supplement noted with the breakfast meal. During an observation and interview on 7/16/24 at 9:35 A.M., the DM said the resident's meal ticket showed a pureed diet and 2.0 supplement. He and the kitchen staff do not put supplements on the meal trays. Nursing was responsible to provide all nutritional supplements. Resident #123 required staff assistance to eat. Staff should obtain the supplement from the medication room. Residents with weight loss should be discussed in the daily stand-up rounds. He was not aware Resident #123 experienced significant weight loss. He ordered supplements and if nursing staff do not have supplements or have low supply, he should be notified, and would order more. 3. Review of Resident #50's medical record, showed: -Diagnoses included malnutrition, nutritional deficiency, diabetes, anemia, high blood pressure, depression, bipolar disorder (mood disorder), and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves); -A physician order, dated 11/1/22, for regular diet, regular texture, regular consistency. Directions: Boost (nutritional supplement) twice daily between meals. Review of the resident's medication and treatment administration records, showed no order for Boost. Review of the resident's quarterly dietary profile, signed by the DM, dated 1/11/24, showed: -Appetite: Good; -Likes: Finger food, cheese sandwiches. Dislikes: Pork loin. Review of the resident's weights, showed: -On 3/8/24, weighed 163.6 lbs.; -On 4/5/24, weighed 150.0 lbs.; -The resident had a significant weight loss of -8.31% between 3/8/24 and 4/5/24; -On 5/3/24, weighed 147.0 lbs. -The resident had a significant weigh loss of -10.15% between 3/8/24 and 5/4/24. Review of the resident's RD note, dated 5/7/24, showed 9.9% weight loss in 90 days. Regular diet, Boost in between meals. Intake records indicate 25-100% consumed. No change warranted. Review of the resident's weights, showed on 6/3/24, the resident weighed 149.5 lbs. Review of the resident's RD note, dated 6/7/24, showed significant weight loss, 8.6% in three months. Overall stable for two months. Regular diet with Boost twice daily. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors exhibited; -Independent with eating; -No weight loss. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Residents needs supervision with his/her ADLs; -Interventions: Resident is supervised with his/her ADLs: Eating; -Focus: Resident has nutritional problem or potential nutritional problem related to no teeth; -Goal: Resident will maintain adequate nutritional status as evidenced by maintaining weight within baseline, no signs/symptoms of malnutrition, and consuming at least 50% of at least three mails daily through review date; -Interventions included: Provide and serve diet as ordered, regular diet, regular texture, regular consistency. Provide and serve supplements as ordered, Boost twice daily between meals. Weigh at same time of day and record, resident is weighed during the day at the standing scale; -The care plan failed to identify the resident's significant weight loss. Review of the resident's diet card, undated, showed a regular diet. Staff did not document the Boost or [TRUNCATED]

37672 Based on observation, interview and record review, the facility failed to ensure a resident with chronic obstructive pulmonary disease (COPD, a chronic lung disease which airflow is constricted and makes it difficult to breathe) symptoms, received ordered oral steroids. The resident continued to have audible wheezing and the facility obtained a STAT (immediate) chest x-ray. The facility did not obtain or report the results to the physician and the x-ray results reflected pneumonia. The resident experienced a change in condition on 7/13/24, was sent to the hospital, where he/she received steroids. He/She was diagnosed with a COPD exacerbation and ordered steroids and two separate antibiotics (Resident #4). In addition, the facility also failed to obtain physician orders for continuous positive airway pressure machines (C-PAP, a machine which provides a mild continual airflow pressure to maintain an open airway, used to treat sleep apnea) for two residents diagnosed with sleep apnea (sleep disorder in which breathing repeatedly stops and starts) (Residents #42 and #89). The census was 151. Review of the physician order policy, revised 10/24/22, showed: -Purpose: To ensure that all physician orders are complete and accurate; -Policy: Medical record department will verify that physician orders are complete, accurate and clarified; -Procedure: Physician orders will include the following: -Name of the medication, treatment; -Dosage, frequency and duration of the order; -The route, condition and diagnoses for which the medication/treatment is ordered. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/15/24, showed: -readmitted : 1/22/23; -Severe cognitive impairment; -Upper and lower extremity paralysis; -Staff provide substantial to maximum assistance for toileting, transfers, dressing and hygiene; -Diagnoses included: stroke, cancer, heart failure, vascular disease, diabetes, dementia, and COPD; -No respiratory therapy provided in the last seven days; -No respiratory treatments provided. Review of the care plan, in used during the survey, showed: -Focus: The resident has a diagnosis of COPD and is at risk for shortness of breath and respiratory failure related to lung cancer; -Goal: The resident will be free of respiratory infection; -Interventions: Staff administer respiratory medications as ordered, monitor for difficulty breathing, monitor and document any signs of respiratory infection and notify the nurse and physician of changes. Review of the progress notes showed: -On 6/26/24 at 10:41 A.M., a nurse note: The resident complained of shortness of breath. Oxygen saturation at 90% (normal 90-100% breathing room air). Breathing treatment given per orders. Nurse practitioner (NP) onsite, assessed the resident and new orders given for chest x-ray; -On 6/26/24 at 2:07 P.M., a nurse note: The resident refused breakfast and lunch. Snacks offered and declined. Staff offered and encouraged fluids, the resident stated he/she was not hungry; -On 6/26/24 at 6:35 P.M., a nurse note: Chest x-ray results received, diagnoses of pneumonia. New orders received: Vantin (antibiotic) 100 milligrams (mg) twice a day for seven days and Medrol dose pack (a titration lowering medication dose) as directed: (4 mg dose pack schedule: Day 1: take 2 tablets before breakfast, 1 after lunch, 1 after dinner, 2 at bedtime; Day 2: take 1 tablet before breakfast, 1 after lunch, 1 after dinner, 2 at bedtime; Day 3: take 1 tablet before breakfast, 1 after lunch, 1 after dinner, 1 at bedtime; Day 4: take 1 tablet before breakfast, 1 after lunch, 1 at bedtime; Day 5: take 1 tablet before breakfast and 1 at bedtime; Day 6: take 1 tablet before breakfast. Review of the electronic physician order sheet (ePOS), showed an order, dated 6/27/24: Medrol (used to treat inflammation) tablet 4 mg. Review of the June Medication Administration Record (MAR), showed: -An order, dated 6/27/24: -Medrol 4 mg: Give 2 tablets in the morning, scheduled at 9:00 A.M., documented as 9 or see progress notes; -Medrol 4 mg: Give 1 tablet in the afternoon, scheduled at 12:00 P.M., documented as 9, or see progress notes. Review of the progress notes on 6/27/24 at 2:51 P.M., showed a nurse note: Medrol 4 mg, awaiting pharmacy delivery. Review of the June MAR, showed: -An order, dated 6/27/24: -Medrol 4 mg: Give 1 tablet in the evening, scheduled at 5:00 P.M., documented as given; -Medrol 4 mg: Give 2 tablets at bedtime, scheduled at 9:00 P.M.,, documented on 6/27/24 as given; -An order, dated 6/28/24: -Medrol 4 mg: Give 1 tablet in the morning, scheduled at 9:00 A.M., documented as given; -Medrol 4 mg: -Medrol 4 mg: Give 1 tablet in the afternoon, scheduled at 12:00 P.M., documented as given; -Medrol 4 mg: Give 1 tablet in the evening, scheduled at 5:00 P.M., documented as given; -Medrol 4 mg: Give 2 tablets at bedtime, scheduled at 9:00 P.M.,, documented as given; -An order, dated 6/29/24, showed: -Medrol 4 mg: Give 1 tablet in the morning, scheduled at 9:00 A.M., documented as given; -Medrol 4 mg: Give 1 tablet in the afternoon, scheduled at 12:00 P.M., documented as given; - Medrol 4 mg: Give 1 tablet in the evening, scheduled at 5:00 P.M., documented as given; - Medrol 4 mg: Give 1 tablet at bedtime, scheduled at 9:00 P.M., documented as given; -An order, dated 6/30/24, showed: -Medrol 4 mg: Give 1 tablet at 9:00 A.M., 12:00 P.M., and 9:00 P.M., documented as given. Review of the July MAR, showed: -An order, dated 7/1/24: -Medrol 4 mg: take 1 tablet at 9:00 A.M., 12:00 P.M., documented as given on 7/1/24 and 7/2/24. Review of the progress notes, showed on 7/5/24: -At 12:53 P.M., a nursing note: The resident observed with abdominal breathing, family at bedside. The resident denies shortness of breath. Breathing treatment given. Physician notified; -At 1:07 P.M., the physician provided new orders for a STAT chest x-ray and Prednisone (anti-inflammatory) at 50 mg day 1, 40 mg day 2, 30 mg day 3, 20 mg day 4, 10 mg day 5, then discontinue. Review of the nurse practitioner visit note, dated 7/5/24 at 8:30 P.M., showed: -Chief complaint: Completed antibiotics for pneumonia on 7/4/24, with reported shortness of breath. Increased shortness of breath and abdominal muscle use; -Duration: Chronic condition; -Respiratory: Complaint of dyspnea (shortness of breath, difficulty breathing), accessory abdominal muscle use, non-productive cough, shallow respirations, diminished breath sounds and mild expiratory wheezing; -Labs: STAT chest x-ray ordered; -Plan: New order Prednisone 10 mg burst- give 50 mg one time a day, then taper off. Medrol 4 mg- give 2 tablets at bedtime for COPD and Trelegy Elliptia inhalation (bronchodilator, opens lung airways) 1 inhalation once a day for COPD. Review of the ePOS, showed: -An order, dated 7/5/24: Ipratropium-albuterol inhalation (used to treat shortness of breath, and open the airways) 0.5-2.5 mg/3 milliliter (ml) solution. Inhale 3 ml twice a day; -An order, dated 7/5/24: STAT chest x-ray. Review of the progress note, showed: -On 7/5/24 at 11:13 P.M., a nursing note: X-ray technician here to obtain chest x-ray. Results pending. No signs or symptoms of distress noted. Review of the ePOS, showed an order, dated 7/5/24: Medrol 4 mg, give 2 tablets a day at bedtime. Review of the July 2024 MAR, showed: - An order, dated 7/5/24: Medrol 4 mg, give 2 tablets a day at bedtime at 9:00 P.M.,; -Documented as given on 7/1/24 and 7/2/24; -Documented as 9 or see progress notes on: 7/3/24 and 7/4/24; -No progress note documented to reflect the non-administration on 7/3/24 or 7/4/24. Review of the July MAR, showed: -An order dated, 7/6/24 for: Prednisone give once a day at 9:00 A.M., scheduled: -Prednisone 50 mg day 1, on 7/6/24: blank, undocumented; -Prednisone 40 mg day 2, on 7/7/24: blank, undocumented; -Prednisone 30 mg day 3, on 7/8/24: blank, undocumented; -Prednisone 20 mg day 4, on 7/9/24: blank, undocumented: -Prednisone 10 mg day 5, on 7/10/24: blank, undocumented; -Prednisone 5 mg day 6, on 7/11/24: blank, undocumented. Review of the progress notes, showed: -On 7/6/24 at 8:20 P.M., a nurse note: Medrol 4 mg- medication not available; -On 7/8/24 at 12:11 P.M., a nurse note: Nurse practitioner notified of missing Prednisone on the dates of 7/6/24 and 7/7/24. No new orders received; -No documentation regarding STAT chest x-ray results. During an interview on 7/8/24 at 2:02 P.M., the resident's next of kin (NOK) said the resident was diagnosed with pneumonia and recently finished antibiotics. He/She wanted another chest x-ray done earlier in the week and had not be told the results. The NOK said he/she was very concerned because he/she could hear the resident wheezing and a wet cough. The nursing staff were unable to tell him/her if the x-ray had been completed or if the results were reported. He/She was concerned the pneumonia is not completely treated. Review of the progress notes, showed: -On 7/8/24 at 8:46 P.M., a nurse note: Medrol dose pack completed; -On 7/10/24 at 8:37 P.M., a medication note: Medrol 4 mg - medication pending from pharmacy. During an interview on 7/11/24 at 10:26 A.M., the NP said he was familiar with the resident's care. The resident has a history of COPD and chronic pneumonia. He expected staff to administer medications as ordered. If a medication were not available, he expected staff to notify the physician or the NP. Prednisone is a steroid used to reduce inflammation. After checking communications with the facility, the NP said the office had not been notified of the chest x-ray results from 7/5/24 or the missed Prednisone doses from 7/6/24 thru 7/11/24. Review of the progress notes, showed: -On 7/13/24 at 4:02 A.M., the resident complained of pain, Tylenol (pain reliever) given. Audible wheezing heard. Oxygen saturations at 91% room air. Breathing treatment given. Head of bed elevated; -On 7/13/24 at 4:15 A.M., the resident further assessed. Noted to have abdominal breathing, wheezing, moist lung sound, gurgling and desating (oxygen levels drop) physician called and message left. Oxygen saturation dropped to 85%, head of bed at high position, oxygen started at 3 liters per minute (LPM)/ nasal cannula (NC, hollow tube to the nose, used to deliver oxygen); -On 7/13/24 at 4:30 A.M., a weekly skin note: skin assessment done, bed bath given before resident left; -On 7/13/24 at 4:32 A.M., a nurse note: Ambulance called for transportation to emergency room (ER) for evaluation and treatment. Arrival approximately 20 minutes; -On 7/13/24 at 4:50 A.M., a nurse note: Ambulance arrived, resident to ER; Review of the hospital visit summary, dated 7/13/24, showed: -Reason for visit: Shortness of breath; -Diagnosis: COPD exacerbation; -Discharge medications: -Amoxicillin 875-125 (combination antibiotic) mg: Take one tablet every 12 hours; -Azithromycin (antibiotic) 250 mg: Take 2 tablets for one day, then 1 tablet daily for 4 days, start taking on 7/13/24; -Prednisone 20 mg: Take 40 mg daily for 4 days-start taking on 7/13/24. Review of the progress notes, showed: -On 7/13/24 at 11:17 P.M., nursing note: The resident alert and responsive. Assisted to bed by two staff. Coarse lung sounds and breathing treatment given as ordered. Oxygen saturation at 93% room air. The nurse notified the NOK no new medications were ordered. Review of the ePOS, showed: -An order, dated 7/14/24: Prednisone 40 mg, take one tablet daily for 4 days; -An order, dated 7/14/24: Azithromycin 250 mg, take 2 tablets for one day, then 1 tablet daily for 4 days; -An order, dated 7/14/24: Amoxicillin 875-125 mg, take one tablet every 12 hours. Review of the progress notes, dated 7/14/24 at 5:42 P.M., showed a nursing note: -Prednisone 40 mg tablet- give one every evening for respiratory infection. Medication pulled from E-kit (emergency medication supply); -This administration was not documented on the July MAR; -Amoxicillin 875-125 mg-give one tablet every 12 hours for 4 days. Medication pulled from E-kit; -At 8:57 P.M., the resident remains on antibiotics and Prednisone. Denies pain and no signs or symptoms of discomfort. Review of the July 2024 MAR, showed: -An order, dated 7/14/24: Prednisone 40 mg: take one every evening for respiratory infection. Documented as zero 0, on 7/14/24, 7/15/24. Documented as 5 or digoxin (heart medication) level on 7/16/24. -An order, dated 7/14/24: Amoxicillin 875-125 mg. Give 1 tablet every 12 hours for 4 days for respiratory infection. Documented as administered at 9:00 A.M., and 9:00 P.M., daily; -An order, dated 7/15/24: Azithromycin 250 mg: take 1 in the morning for respiratory infection. Documented as administered at 9:00 A.M., on 7/14/24, 7/15/24, 7/16/24 and 7/18/24; On 7/15/24 at 9:25 A.M., the Regional Nurse provided the chest x-ray, completed on 7/5/24 at 4:41 P.M. The results are as follows: -Date of service: 7/5/24; -Time: 4:41 P.M., -Indication: Congestion; -Findings: Patchy infiltrates in the left upper and lower lobe; -Impression: Patchy left sided pneumonia; -No physician signature or acknowledgement of the results. During an interview on 7/16/24 at 11:16 A.M., the Director of Nursing (DON) and Administrator said after review of the chest x-ray results from 7/5/24, it appeared the physician was not notified of the results. Staff should follow up with the imaging results the next day or if ordered STAT, within a few hours of the testing. If ordered medications are not available, staff should pull the medication from the E-kit. If the medication is not available in the E-kit, the pharmacy should be called for an emergency delivery. Staff should notify the physician or nurse practitioner if medications are not available or missed. During an interview on 7/17/24 at 3:10 P.M., the resident's Physician said the resident has lung cancer, COPD exacerbation and chronic pneumonia. He did not receive any communications from the facility regarding missed medication doses or the STAT chest x-ray results. He expected staff to follow up with the imaging company for results and report those to him or the NP. If medications are not available at the facility, the pharmacy should be called. The DON and Administrator should obtain the medications. He should be notified to order a different medication if needed. Prednisone is used to reduce inflammation quickly. The resident should have received the Prednisone, but he/she did receive the antibiotics. The Physician is unsure if the Prednisone would have prevented the change in condition or hospitalization . 2. Review of Resident #42's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Diagnoses include heart failure, high blood pressure, asthma, respiratory failure; -Receives oxygen therapy. Review of the resident's care plan, in use during survey, showed: -Focus: COPD, C-PAP used during resting hours due to shortness of breath; -Interventions: Resident will use C-PAP during his/her resting hours; -Monitor his/her oxygen saturation as directed. Review of the resident's ePOS, dated July 2024, showed: -An order, dated 5/28/24: Does the resident experience shortness of breath while lying flat or avoids lying flat (utilizes pillows) due to shortness of breath? Every shift for COPD; -An order, dated 5/28/24: Resident is at risk for malnutrition related to COPD, atrial fibrillation (Afib, abnormal heartbeat), congestive heart failure (CHF), rheumatoid arthritis (RA), high blood pressure. Interventions: Registered Dietician (RD) to evaluate as needed, weights as needed, labs as needed, medications as ordered; -No physician's orders for use of the C-PAP machine. Review of the resident's July 2024 MAR, showed: -Does the resident experience shortness of breath while lying flat or avoids lying flat (utilizes pillows) due to shortness of breath? Every shift for COPD, showed: -On 7/1, 7/3, 7/4, and 7/7/24 at 6:00 A.M., staff documented yes; -On 7/9 and 7/10/24 at 2:00 P.M., staff documented yes; -On 7/1 through 7/11/24 at 10:00 P.M., showed no shortness of breath. Observation and interview on 7/11/24 at 9:15 A.M., showed resident in room, in bed. The resident had a C-PAP machine on the night table. He/She said the aides assist him/her every night with the C-PAP. The mask lay on the night table, uncovered. Observation on 7/15/24 at 10:49 A.M., the resident's C-PAP mask on the resident's bed uncovered. The machine lay on the resident's night table. It was not in use. During an interview on 7/15/24 at 3:00 P.M., Licensed Practical Nurse (LPN) SS said sometimes staff assist with the C-PAP or the resident can do it him/herself. The resident is still awake when LPN SS leaves at 11:00 P.M., so he/she is not using it yet. During an interview on 7/16/24 at 8:28 A.M., the resident said he/she uses the C-PAP every night. He/She turned off the machine at 7:00 A.M. and starts it at 11:30 P.M. The aides put water in the machine and they turn it on. The CPAP mask was uncovered on top of the seat of the resident's wheelchair. 3. Review of Resident #89's annual MDS, dated [DATE], showed: -No cognitive impairment; -Diagnoses included: heart failure, hypertension (HTN, high blood pressure), hyperlipidemia (HLD, high level of lipids (fat particles) in the blood), diabetes, malnutrition, anxiety, bipolar (mental disorder where the person experiences manic highs to depressive lows), and asthma; -Received oxygen. Review of the resident's care plan, in use during survey, showed: -Focus: Resident has a diagnosis of COPD; -Interventions: Resident uses Bilevel positive airway pressure (bi-pap, machine that helps with breathing) at bedtime related to COPD and obstructive sleep apnea. Review of the resident's ePOS, dated July 2024, showed: -An order, dated 4/2/24, resident is at risk for malnutrition related to COPD, diabetes, chronic pain, depression, HTN, and HLD. Registered dietician to evaluate as needed, weights as needed, labs as needed, and medications as ordered; -An order, dated 4/9/24, Does the resident experience shortness of breath while lying flat or avoids lying flat (utilizes pillows) due to shortness of breath? Every shift for COPD; -No physician's orders for use of C-PAP; -No physician's orders for use of oxygen therapy. Review of the resident's MAR, dated July 2024, showed: -Does the resident experience shortness of breath while lying flat or avoids lying flat (utilizes pillows) due to shortness of breath? Every shift for COPD, showed: -On 7/1, 7/5, and 7/7/24 during the day shift, staff documented yes; -On 7/1 and 7/7/24 during the evening shift, showed no shortness of breath; -On 7/2, 7/6, and 7/7/24 during the night shift, staff documented yes. Review of the resident's progress notes, showed: -On 6/14/24 at 6:32 A.M., resting in bed. No signs of acute distress noted. Remains on increased observation after readmission. Breathing even and unlabored with C-PAP on. Activities of Daily Living (ADLs) performed by staff. No concerns or complaints voiced; -On 7/3/24 at 2:09 A.M., resident resting quietly in bed. Leg thrown over side. Resident is not wearing C-PAP mask. Encouraged to do so. Review of the resident's nurse practitioner notes, showed on 7/5/24 at 5:39 P.M., patient needs new tubing for C-PAP machine. During observation and interview on 7/08/24 at 9:39 A.M., the resident was in room with the oxygen machine turned on and set at 3 liters (L) per nasal cannula. The tubing was on the floor. The resident had a C-PAP machine on his/her night table. The mask was uncovered. Observation 7/08/24 at 4:56 P.M., and 7/9/24 at 8:00 A.M., showed the resident was in the hospital. The oxygen machine in the room remained on at 3 L. The oxygen tubing was on the floor. The C-PAP mask was uncovered on the night table. During an interview on 7/15/24 at 2:53 P.M., Restorative Aide W said to his/her understanding, the resident only used oxygen at night. During an interview on 7/15/24 at 3:00 P.M., LPN SS said the resident used oxygen, but it was only as needed. During an interview on 7/15/24 at 3:27 P.M., LPN S said the resident did not use oxygen. His/Her C-PAP was broken. The cord broke on Sunday evening, on 7/7/24, the day before the resident went to the hospital. Observation of the cord showed a tear, approximately half an inch. There should be orders for use of C-PAP and the settings. 4. During an interview on 7/16/24 at 11:18 A.M., the DON said she would expect there to be an order for use of C-PAP machine. If resident was admitted with C-PAP, she would expect nursing to notify the physician to obtain orders. The settings and diagnosis for use of C-PAP should be documented on the orders. If the resident's C-PAP was broken, Central Supply could be an option for obtaining another tube. She would expect staff to have notified the physician for the use of oxygen therapy and document it in the medical record.

40865 Based on observation, interview and record review, the facility failed to maintain temperatures in resident accessible areas at or below 81 degrees Fahrenheit (F) and/or meet the comfort needs of residents for three of three resident floors. On 7/28/23, temperatures in the facility ranged from 82 degrees F to 90 degrees F. Resident #1 who is on oxygen and has Chronic Obstructive Pulmonary Disease (COPD-lung disease) reported he/she was hot. His/her window air conditioner registered 90 degrees, his/her portable air conditioner blew a fuse and with the fans blowing, the room temperature measured 88.8 degrees F. Residents #2 and #3 were in a room with an air conditioner unit, that was unplugged. The plug of the unit appeared burnt and unsafe for use. There were no fans in the room. The temperature in the room measured 88.8 degrees F. Both residents complained of being hot and asked for the air conditioner to be plugged in. Staff were not provided with special instructions related to the elevated temperatures and possible side effects of the heat on the residents. Residents are at risk for serious harm due to the extreme temperatures, in conjunction with their medical conditions (Residents #1, #2, #3, #4, #10, #5, #6, #8, #14, #9 and #15). The facility census was 156. The administrator was informed on 7/28/23 at 5:05 P.M. of an Immediate Jeopardy (IJ), which began on 7/28/23. The IJ was removed on 7/29/23, as confirmed by surveyor on-site verification. Review of the facility's Disaster and Fire Manual Extreme High Temperatures Policy, undated, showed: -Should the temperatures in this facility rise above the following upper limits for relative humidity and temperature, the facility shall be evacuated in coordination with the public health department: -It's too hot if: -Humidity is greater than 40% at 80 degrees F; -Humidity is greater than 5% at 85 degrees F; -Humidity is at 0% at 90 degrees F or higher; -Otherwise, the following procedures shall be implemented, as high temperatures create the potential for hazardous conditions: -Monitor residents for intake and output of fluids. Encourage and offer fluids frequently; -Shade windows exposed to direct sunlight; -Monitor residents for signs of discomfort and adverse physical symptoms such as hyperthermia (the condition of having a body temperature greatly above normal), heat stroke (the most serious heat-related illness. It occurs when the body can no longer control its temperature) or heat exhaustion (heavy sweating, Weakness or tiredness, cool, pale, clammy skin; fast, weak pulse, muscle cramps, dizziness, nausea or vomiting, headache, fainting); -High risk residents will be monitored closely. High-risk residents include those with heart, circulatory or respiratory problems, those taking diuretics (medications that remove water or salt from the body), anticholinergics (drugs that can turn off the system in the body that causes the fight and flight reaction), sedatives (medications that slow the brain's activity) and hypnotics (medications used to induce, extend, or improve the quality of sleep, and to reduce wakefulness during sleep); -Check resident's temperature and vital signs at least every 4-6 hours; -Dress residents in lightweight clothing, when possible; -Monitor air temperatures at least every 2 hours between 8am and 10pm, in resident areas; -Provisions will be made for an adequate supply of fans for residents' rooms; -If mechanical problems occur in sections of the building or in resident's rooms, transfer residents to areas of the facility that are better ventilated and cooler in temperature. If complete utility failure occurs and temperatures in the facility become extreme, begin procedure for complete evacuation to alternative facilities. Review of the facility's policy, Resident Rooms and Environment, Revised October, 2022 showed: -Purpose: To provide residents with a safe, clean, comfortable and homelike environment; -Policy: The facility provides residents with a safe, clean, comfortable and homelike environment. Facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk; -Procedure: Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: *Cleanliness and order; *Comfortable temperatures. Review of the local temperatures for the week of 7/24/23 through 7/28/23, showed: -7/24/23, a temperature of 91 degrees F; -7/25/23, a temperature of 97 degrees F; -7/26/23, a temperature of 95 degrees F; -7/27/23, a temperature of 99 degrees F; -7/28/23, a temperature of 100 degrees F. 1. During an interview on 7/28/23 at 11:50 P.M., the Human Resources Director said they just found out the temperatures were high in the building that morning. They were pushing fluid hydration with water stations, placed extra fans on all the floors and had shut down the smoking and day rooms on all the floors. They were out buying some more portable air conditioners to place in the areas where the building was hot. 2. Observation of the secured 300 North hall on 7/28/23 at 12:30 P.M., showed the following: -A portable air conditioning unit at the southwest corner of the hallway; -Several fans placed along the hallway; -Several residents seated in wheelchairs and chairs outside their doors; -The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 83.4 degrees F. 3. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/23, showed: -Cognitively intact; -Independent with walking, transfers, dressing and personal hygiene; -Special treatment: Oxygen therapy; -Diagnoses of COPD, dependence on supplemental oxygen, high blood pressure and shortness of breath. Review of the resident's care plan dated 7/25/23, showed the following: -Focus: The resident has oxygen therapy. He/She has COPD and is prone to pleurisy (an inflammation of the lining of the lungs (pleura) that causes sharp chest pains); -Goal: He/She will have no sign and symptoms of poor oxygen absorption; -Interventions: Monitor for signs and symptoms of respiratory distress and report to medical doctor as needed: respirations, pulse oximetry (a test used to measure oxygen level), increased heart rate, restlessness, headaches, lethargy (lack of energy), confusion, hemoptysis (coughing up blood), pleuritic pain (chest pain), skin color. May have oxygen at 2-5 liters as needed. Monitor/document breathing patterns. Report abnormalities to medical doctor. Observation and interview on 7/25/23 at 12:45 P.M., showed, the resident had a small window air conditioner in his/her room. The room was large with four beds. The illuminated digital display on the air conditioner read 90 degrees F and warm air blew out of it. There was an unplugged portable air conditioner on the floor adjacent to the bed. There were two fans, one on his/her bedside table and one on the floor across from his/her bed. There was an oxygen concentrator (a medical device that gives extra oxygen) in the corner across from his/her bed. The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 87.6 degrees F. The resident said his/her room had been hot for a long time. He/She complained to staff and they brought the portable air conditioner to the room, but it blew the fuses and staff had to unplug it. The fans did not help cool the room down. Staff offered to move him/her to another room a while ago, but not recently. He/She had COPD and used oxygen and it hurt to breathe in the heat sometimes. As he/she talked, he/she started to wheeze. He/She said he/she needed his/her inhaler. During an interview on 7/28/23 at 1:05 P.M., Certified Medication Technician (CMT) E said the resident complained about the heat in his/her room several times. They had tried to put a portable air conditioner in there, but it blew the fuses. They could not move him/her to another room, because the residents did not all get along with each other and they did not all like the rooms at the same temperature. They put portable air conditioners and fans in the hallways, but it was still hot in the building sometimes. They closed down the day room because it was too hot in there, but they were not given any special instructions on what to do with residents when the temperatures were warm. 4. Observation of the secured 300 South hall on 7/28/23 at 1:25 P.M., showed the following: -A portable air conditioning unit at the southwest corner of the hallway. The illuminated digital display of 84 degrees F, showed on front of the air conditioner; -Several residents sat in wheelchairs and chairs outside their doors; -There was a cart with a container of water on it, but no cups; -The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 88.0 degrees F at the end of the hallway. 5. Review of Resident #2's annual MDS, dated [DATE], showed: -Moderately cognitively impaired; -Limited assistance of one staff needed for bed mobility, transfers, dressing and personal hygiene; -Extensive assistance of one staff needed for toileting; -Used a wheelchair; -Special treatment: Oxygen therapy; -Diagnoses included COPD, shortness of breath, dependence of supplemental oxygen. Observation and interview on 7/25/23 at 1:35 P.M., showed the resident sat on his/her bed in a brief and a t-shirt eating lunch from his/her bedside table. His/her room felt very warm and the wall mounted air condition/heater (PTAC) was unplugged. The plug appeared to be burnt and unsafe for use. The front of the unit was pulled away and leaned against the wall. The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 88.8 degrees F. The resident asked the surveyor to plug the air conditioner in and said he/she was Damned hot. A staff member entered the room and the surveyor asked if he/she knew anything about the air conditioner and if it worked. The staff member said he/she did not know anything about the air conditioner; only that it was hot in the room. There was no other cooling devices in the room. The resident said he/she would like a fan, but no one offered one. 6. Review of Resident #3's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -Limited assistance of one staff needed for bed mobility, transfers, dressing, toileting and personal hygiene; -Used a wheelchair; -Diagnoses included conversion disorder with seizures (condition where a mental health issue disrupts how the brain works) and chronic heart disease. Observation and interview on 1:40 P.M., showed the resident (Resident #2's roommate) lay in his/her bed in a brief and a t-shirt with no sheets on his/her bed. He/She had no water on his/her bedside table. He/She said he/she was hot and wanted a fan. Staff had not offered him/her a fan. 7. Review of Resident #4's annual MDS, dated [DATE], showed: -Cognitively intact; -Independent with walking and transfers; -Diagnoses included high blood pressure and unspecified asthma. Observation and interview on 7/28/23 at 12:55 P.M., showed the resident had a small window air conditioner in his/her room. The illuminated digital display of 84 degrees F, showed on the front of the air conditioner. The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 86 degrees F. There was no fan in the room. The resident said he/she felt hot in the room. He/She would like a fan, but no one asked if he/she wanted one. He/She did not know he/she could ask for one. The room was okay at night, but it was too hot during the day. It would get so hot it made him/her feel sick to his/her stomach and it was hard to breathe sometimes. 8. Review of Resident #10's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Limited assistance of one staff needed for transfers; -Used a wheelchair; -Special treatment: Oxygen; -Diagnoses included COPD, chronic respiratory failure with hypoxia (hypoxemic respiratory failure happens when there is not enough oxygen in blood), dependence on supplemental oxygen, shortness of breath, obstructive sleep apnea (sleep disorder where a blockage in the airway keeps air from moving through the windpipe while asleep) and high blood pressure. Observation and interview on 7/25/23 at 12:35 P.M., showed the resident sat in his/her wheelchair in the hallway close to the portable air conditioner. He/She said it was too hot to stay in his/her room. It had been so hot the last few days he/she felt like throwing up. It was hard to sleep at night. They could not eat or watch television (TV) in the day room so there was nothing to do but sit in the hallway all day. It made everyone angry and it was hard to not get into trouble. 9. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -Independent with walking, transfers, dressing and personal hygiene; -Diagnoses included pulmonary embolism (blockage in a lung artery), schizophrenia (a serious mental illness which affects the way you think, feel and behave) and altered mental status. Observation and interview on 7/28/23 at 1:40 P.M., showed the resident lay in bed in his/her room. The PTAC was on, but the room felt hot. The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 89.0 degrees F. There was no other cooling device in the room. The resident said he/she was hot and would like a fan. 10. Review of Resident #6's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Independent with walking, transfers, dressing and personal hygiene; -Diagnoses included hypertensive heart disease without heart failure, acute kidney failure and high blood pressure. Observation and interview on 7/28/23 at 3:15 P.M., showed there was a small air conditioner in the window of the resident's room. It was set on the highest level. The bed by the window could get air, but the privacy curtain blocked the bed by the door from getting air. The resident's bed was located by the door. The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.4 degrees F. The resident said he/she was hot. No one offered a fan and the resident did not know he/she could ask for one. 11. During an interview on 7/28/23 at 1:15 P.M., Housekeeper F said the temperature could get very hot in the building sometimes. Today was the first time he/she saw them close down the day rooms. The high temperatures could be dangerous for some of the residents. 12. During an interview on 7/28/23 at 3:55 P.M., CMT K said when the temperatures got warm they were supposed to let management or maintenance know and give out ice water. He/She did not have any other instructions to follow if the temperatures rose. He/She did not know where they would get extra fans if the residents wanted them. 13. Observations of the second floor resident areas, showed: -At 12:36 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 81 degrees F in the entry way; -At 12:37 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 80.3 degrees F at the nurses' station where a portable fan was in use; -At 12:34 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 83.9 degrees F in the hallway outside room [ROOM NUMBER] where a portable fan was in use; -At 12:48 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 84 degrees F in the day room by room [ROOM NUMBER]. Six residents sat in the day room and were positioned in front of a portable cooling unit and watched TV; -At 12:55 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.8 degrees F in the dining room where three residents sat; -At 12:56 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 83.9 in front of the portable unit in the dining room; -At 1:03 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.5 degrees F by the second floor hydration station; -At 1:04 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.3 degrees F in the hallway outside room [ROOM NUMBER]. 14. Review of Resident #8's admission MDS, dated [DATE], showed: -Moderate cognitive impairment; -Independent with walking and transfers, required limited staff assistance with dressing and personal hygiene; -Diagnoses included stroke, high blood pressure and dementia. Observation and interview of the resident on 7/28/23 at 12:40 P.M., showed: -Room temperature of 82 degrees F and the door to the room was open to the hallway; -The resident sat in a chair in his/her room; -The resident said he/she was hot; -He/She had not been able to get the PTAC to work; -The PTAC was on cool/high fan and set to 66 degrees F; -No other cooling devices were in the room. 15. Observation and interview of Resident #14 on 7/28/23 at 1:16 P.M., showed: -The resident sat in the Day Room and watched TV; -The temperature in the room was 86.5 degrees F; -The resident said all of the thermometers were broken; -He/She was hot; -He/She tried to stay in his/her room to stay cool. 16. Observation and interview of Resident #9 on 7/28/23 at 1:14 P.M., showed: -The resident sat in his/her wheelchair next to the window in the second floor Day Room by room [ROOM NUMBER]; -The resident wore a long sleeved shirt, flannel pants, socks and shoes; -The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 89.5 degrees F; -He/She said he/she was hot, but would deal with it. 17. During an interview on 7/28/23 at 12: 57 P.M., Certified Nurse Aide (CNA) L and CNA M both said they had not received any special instructions on how to care for residents in excessive heat. 18. Observations of the first floor resident areas, showed: -At 1:29 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 86 degrees F in the hallway by room [ROOM NUMBER]; -At 1:30 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.2 at the nurses' station on the south hall. 19. Review of Resident #15's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Independent with walking, transfers and person hygiene; -Diagnoses included diabetes, stroke and depression. Observation and interview on 7/28/23 at 4:08 P.M., showed: -The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 84.6 degrees F in the resident's room; -He/She said he/she was most comfortable in his/her room; -It has been hot in the facility since April or May. Portable units and fans had been purchased about a month ago. 20. During an interview on 7/28/23 at 3:53 P.M., a resident who wished to remain anonymous said the main dining room was cooler than on his/her hall. It had been uncomfortably warm in the facility for sometime. 21. During an interview on 7/28/23 at 2:30 P.M., the Administrator said One Main Hall and Three South Hall were audited for temperatures and were found to be at 82 degrees F. Staff were putting fans up there and portable air units were being purchased. Hydration stations were also set up. Staff were to begin interviewing residents regarding their comfort and provide interventions. This was the first time they had temperatures which were higher than what the facility's policy allows. Temperatures have been taken on all resident halls and One Main and Three South are the only two that were out of range. Residents on the Third floor kept turning their PTAC units off. Staff were to monitor hourly on the floors which were out of range. She had asked that all halls be monitored hourly. 22. During an interview on 7/28/23 at 3:30 P.M., CMT I said no one told him/her to do anything differently for the residents when the temperatures were hotter. It could get very warm in some areas of the building. 23. During an interview on 7/28/23 at 3:35 P.M., the Dietary Manager said he fixed an air conditioning unit on the Second floor about a month ago. The room units were not working. He took them out, washed them and changed the filters. The temperature in the kitchen had been extremely high over the last three days. Yesterday he overheard staff and residents complain about it being too hot. Yesterday was the hottest day yet. They offered residents ice cream and soda to help stay cool. They also made sure water and ice were available on each floor. 24. Observation in the main dining room on 7/28/23 at 3:50 P.M., showed: -Six residents sat at tables and watched TV; -The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.8 degrees F in the middle of the room; -The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 81.3 degrees F in the very back of the room. 25. During an interview on 7/28/23 at 3:57 P.M., CMT H said it was hot on the third floor yesterday. He/She was hot, so the residents must've been too. He/She had not received any specific guidance related to excessive heat. 26. During an interview on 7/28/23 at 4:12 P.M., CMT J said everyone complained about the air. It was warm in the building. If it was hot outside, it was hot inside. It has been warm inside the building all week. He/She had not received any specific guidance related to excessive heat. 27. Observation of the second floor dining room on 7/28/23 at 4:17 P.M., showed 23 residents sat at tables and watched TV. The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.4 degrees F. 28. Observations of the first floor on 7/28/23, showed: -At 6:54 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 82 degrees F by the main nurses' station; -At 6:55 P.M., The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 82.4 degrees F by the portable cooling unit in the hallway outside of room [ROOM NUMBER]; -At 6:56 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 82.3 degrees F in the hallway outside room [ROOM NUMBER]. 29. Observations of the second floor on 7/28/23, showed: -At 4:19 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 86.3 degrees F in the hallway outside room [ROOM NUMBER]; -At 4:20 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 86.6 degrees F in the hallway near a fan outside room [ROOM NUMBER]; -At 4:21 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 86.4 degrees F in the Day Room near room [ROOM NUMBER]; -At 4:23 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.3 degrees F in the hallway outside room [ROOM NUMBER]; -At 6:57 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 83.0 degrees F at the nurses' station; -At 6:58 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 81.7 degrees F in the dining room; -At 7:00 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 82.3 degrees F in the hallway by room [ROOM NUMBER]; -At 7:01 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 84.2 degrees F in the day room near room [ROOM NUMBER], where six residents sat and watched TV; -At 7:03 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 83.9 degrees F in the hallway by room [ROOM NUMBER]; -At 7:04 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.6 degrees F in the day room near room [ROOM NUMBER], where Resident #14 sat and watched TV. 30. Observations for the secured South 300 floor on 7/28/23, showed the following: - At 4:15 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.6 degrees F in room [ROOM NUMBER]; -At 4:20 P.M., the the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 84.5 degrees F in the hallway, adjacent to the nurse's station; -At 6:45 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.0 degrees F in room [ROOM NUMBER]; - At 6:50 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 83.6 degrees F in the hallway, adjacent to the day room. 31. Observations for the secured North 300 floor on 7/28/23, showed the following: -At 4:25 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 87.8 degrees F in the hallway outside room [ROOM NUMBER]; -At 7:10 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 86.0 degrees F in the hallway, adjacent to the nurse's station on the southwest hall; -At 7:15 P.M., the the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85 degrees F in the southeast, hallway adjacent to the smoking area. 32. During an interview on 7/28/23 at 7:28 P.M., the Corporate Nurse said more portable cooling units had arrived and were being put on the resident halls. The HVAC (heating, ventilation and air conditioning) company was picking up parts and expected to arrive at the facility within 30 minutes. 33. During an interview on 7/28/23 at 7:30 P.M., the Regional Director of Maintenance said one side of the building was cooled by PTACs. The other side used individual window air conditioners. They used roof top units for the common areas and a condenser unit and air handler for the ground floor. When the temperature reached 100 degrees outside it was difficult for the system to cool the building. They brought in portable units to cool down the common areas and were bringing in more. They did not always know if there was a problem in the building unless staff reported it. Then they could go out and buy more units. He did not know there was a problem in the building until that day. Staff needed to be educated to report to Administration and Maintenance when there were problems with the cooling and heating systems. The individual air conditioners in the resident rooms may have been too small to cool the entire room. There might be a problem with the privacy curtains preventing the air from circulating in the room. They could buy fans for the residents, but they needed to know if the residents wanted or needed fans. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level L. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the F level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00222139 MO00222158

See deficiency cited at event Q04512. Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #800) received prompt treatment and care after the resident fell and dislocated his/her shoulder. Facility staff failed to obtain an in-house x-ray ordered by the resident's physician in a timely manner or obtain further evaluation and treatment timely when the resident complained of pain and his/her shoulder was assessed by nursing staff as having deformity with redness to right shoulder with swelling to entire arm. The sample was 13. The census was 119. Review of the facility's Discharging a Resident Without a Physician's Approval policy, revised 10/2012, showed: -A physician's order should be obtained for all discharges, unless a resident or representative is discharging himself/herself against medical advice; -Policy interpretation and implementation: -Should a resident or his/her representative, request an immediate discharge, the resident's attending physician will be promptly notified; -The order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record no later than 72 hours after the discharge; -If the resident or representative insists upon being discharged without the approval of the attending physician, the resident and/or representative must sign a Release of Responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members. -The policy did not state if a resident called 911 for medical assistance, this would result in leaving AMA without the option to return to the facility. Review of Resident #800's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/21/22, showed: -admitted on [DATE]; -Adequate vision and hearing; -Resident understood and understands others; -Cognitively intact; -No mood issues; -No behavior exhibited; -No rejection of care exhibited; -Pain management: On a scheduled medicine regimen - Received as needed (PRN) pain meds in last five days; -Recent surgery requiring active skilled nursing facility care: Yes; -Surgical procedures: Repair fractures of the shoulder. Review of a daily nursing report, dated 9/13/22, included the following: -3-11 shift; -Behaviors/Interventions: Resident #812 tripped Resident #800 onto the floor with a dislocated shoulder. Review of the resident's progress notes, showed the following: -On 9/13/22 at 5:03 P.M., this nurse and Assistant Director of Nursing (ADON) on the floor addressing an unrelated situation when the resident screamed. The nurse observed the resident on the floor 15 feet away. The resident stated Resident #812 hit him/her in the mouth. The resident then stated Resident #812 tripped him/her. The resident complained of right arm pain. The resident was assessed, the MD was called awaiting return call. X-ray vendor to be called for x-ray; -At 5:08 P.M., the resident's weekly skin observations showed skin color was other, refer to assessment for more information. No swelling or broken skin noted; -At 5:18 P.M., staff alerted the nurse the resident was on the floor complaining of pain to his/her right shoulder. He/she stated he/she was tripped and hit the floor. Skin assessment completed. Call placed to physician for notification and next steps. Staff awaiting return call; -At 5:40 P.M., the ADON gave report to the nurse. The resident stated he/she wanted to go to the hospital for right arm pain. Staff made the resident aware they were waiting for the physician to call back. Staff explained they could not send him/her out without a physician's order. The resident told staff he/she would call EMS himself/herself. Staff explained he/she had the right to do so, but it would be going against medical advice; -On 9/14/22 at 7:41 A.M., the resident complained of right arm/shoulder and facial pain related to fall. Resident has raised area, redness and swelling to right cheek and deformity with redness to right shoulder with swelling to entire arm. Call placed to x-ray vendor for right shoulder, humerus (a long bone located in the upper arm, between the shoulder joint and elbow joint), elbow, forearm and facial bones. Ordered STAT. During observation and interview on 9/14/22 at 9:30 A.M., and at 1:28 P.M., the resident said at approximately 4:30 P.M. the previous day, he/she was tripped by another resident and hit his/her head and shoulder. Staff told the resident he/she would get an x-ray the day before, but he/she still had not gotten one. The pain was getting worse. He/she wanted to go to the hospital, but staff told him/her no. He/she was going to call 911 and have them take him/her to the hospital, but the staff told him/her if he/she did this, they would make him/her sign a paper saying he/she was doing this AMA and kick him/her out of the facility. When the resident called 911, he/she was told a nurse would need to call on his/her behalf. Around 8:00 P.M., when other nurses came to the unit, they said the resident needed to go out, but were told if he/she left it would be AMA. Staff tried to reach the doctor several times, but he was not calling back. Last night, the resident called EMS and the police arrived at the facility. He/she tried to talk to them and showed the police his/her arm. A nurse intervened and said he/she was canceling the EMS request because they were awaiting an x-ray. The police left and the resident could not make a report. The resident said his/her pain was at an 8 or 9 on a scale of 1-10 (0 indicating no pain and 10 indicating worst pain ever felt). He/she cried all night. When he/she moved his/her shoulder, it made a clicking sound. It hurt for the resident to blink. The resident had a golf ball sized swollen area with bruising on his/her right cheek and his/her right arm appeared reddish and swollen. The resident's shoulder appeared out of place. Observation on 9/14/22 at 1:43 P.M., showed two EMS representatives and Nurse K walked into the resident's room. The resident showed the EMS representatives his/her shoulder. An EMS representative said the resident's shoulder was dislocated. During an interview on 9/14/22 at 1:50 P.M., Nurse K said the resident hadn't been at the facility very long. Nurse K said it was not his/her call to send the resident out earlier, but he/she believes the resident should have been sent out last evening after he/she injured his/her shoulder. The resident's shoulder appeared to be dislocated. During an interview on 9/14/22 at 3:41 P.M., the Director of Nursing (DON) said she did not witness the resident injuring his/her shoulder. Resident #812 was ahead of Resident #800 when the DON walked down the hall on 9/13/22 to leave the unit. She turned her back to the residents to enter the code for the door and heard Resident #800 scream and was on the floor. Resident #800 said Resident #812 hit him/her in the mouth and tripped him/her. ADON B said he/she was going to handle the situation so the DON left the unit. She did not see the resident again because she left the building shortly thereafter. ADON B called the physician's exchange three times because this occurred after hours and did not receive a call back. The DON called the resident's doctor directly twice and it went straight to voicemail. The resident said if he/she wasn't sent to the hospital, he/she would call 911 himself/herself. There was a previous discussion that the resident has the right to call 911. The facility must have a doctor's order before a resident can be sent to the hospital. If a resident went to the hospital without an order, they would be going AMA. The DON was not aware the resident called 911. The resident's doctor did not call back until this morning. ADON B offered to make the resident comfortable while they waited for orders, but the resident was adamant he/she wanted to go to the hospital. The facility took action by getting an x-ray. If a resident's shoulder was dislocated, she would expect they would need more medical attention than what could be provided at the facility. Her understanding was that a confirmation of a dislocated shoulder was needed before the resident could be sent out. This directive came from above her. The DON agreed the resident waited a long time before he/she received treatment. During an interview on 9/14/22 at 3:20 P.M., ADON B said he/she and the DON were up on the floor just prior to the resident falling. They had just left the unit when they heard a cry and looked through the window and saw the resident on the floor. They immediately went back in to see what happened. The resident claimed another resident had tripped him/her causing him/her to fall. When he/she entered the unit, the resident was on the floor grimacing and when asked what happened he/she said Resident #812 had tripped him/her. The ADON assessed him/her and thought something was wrong with his/her arm. It was red and did not move right. The resident was talking okay and did not complain of pain to him/her. The nurse ordered an x-ray and notified the resident's physician and family. The nurse did not put the x-ray in as STAT. When he/she left at 6:30 P.M., the x-ray company had still not responded. They did not send him/her to the hospital because they needed a physician's order to do this and his/her hands were tied because the physician had not called back. They should have called him/her or the physician again if the resident complained of increased pain. When the ADON came back to work on 9/14/22, he/she found out the x-ray company never showed up. They called the x-ray company who said they never got the order. To his/her knowledge, the resident was told he/she would be AMA if he/she called 911 and went to the hospital. At the facility, residents cannot call 911 or go to the hospital on their own. Medically, they have to go through a physician or a nurse. During an interview on 9/14/22 at 4:08 P.M., Certified Medication Technician (CMT) D said he/she was working the floor the prior evening when the resident fell . He/she did not see the resident actually fall, but heard him/her cry out. The CMT was at the desk and the resident was down closer to the dining room. He/she saw the resident on the floor. The resident said Resident #812 stuck out his/her foot and tripped him/her causing him/her to fall to the floor. The resident complained of pain in his/her shoulder and said it was dislocated. The arm did not look normal. It looked like something was sticking out of his/her skin. At that point ADON B and the DON came into the unit and assessed the resident. The CMT did not know what the resident told them, as he/she left the resident at that point. The resident continued to complain of pain and held his/her arm through the night. The CMT gave him/her some extra strength Tylenol, as that is all they were allowed to give him/her per his/her physician's orders. The nurse on duty mentioned he/she wondered when the x-ray vendor was going to come and passed the information onto the oncoming shift. During an interview on 9/14/22 at 4:30 P.M., the corporate nurse said it is not the facility's policy to discharge residents AMA if they call 911. He/she said the resident has a history of dislocating his/her shoulder. He/she had an accident prior to coming to the facility and never got it fixed. She would have expected staff to call the x-ray company back if they had not shown up. Sometimes they had a problem with the x-ray company coming out after hours due to the area. The DON called her around 6:00 P.M., and told her the resident had fallen, the physician had been called and gave an order for an x-ray. The physician told the staff not to send the resident out until the arm was x-rayed. She told staff they needed to follow physician's orders and her understanding was he said do not send him/her out. Review of the resident's care plan, dated 9/14/22, showed the following: -Focus: Resident complained of right arm/shoulder and facial pain related to fall. Resident has raised area, redness and swelling to right cheek and deformity with redness to right shoulder with swelling to entire arm. Call placed to x-ray company for right shoulder, humerus, elbow, forearm and facial bones. Ordered STAT (immediately). Staff report resident stated another resident tripped him/her; -Goal: Resident will not have severe injuries/abuse through next review; -Interventions: Call placed to x-ray company for right shoulder, humerus, elbow, forearm and facial bones. Assess for pain/injuries. Give pain medication as needed. Inform administration/Director of Nursing (DON)/Assistant DON about incident/resident's status; -Focus: Resident is at risk for falls related to antidepressant medications; -Goal: The resident will be free of injury related to falls; -Interventions: Anticipate and meet the resident's needs as needed. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Resident ambulates independently; -Review of the care plan on 9/14/22 at 2:21 PM, showed it did not contain a focus area of the resident purposely dislocating his/her right shoulder for attention and wanting to go to the hospital. Review of the resident's hospital records, dated 9/15/22, showed the following: Hospital note included: Currently the patient's complaining of pain in the right shoulder, the pain is sharp, moderate, worse with movement, no radiation, patient denies LOC (loss of consciousness); -Physical exam: Right cheek erythema (superficial reddening of the skin, usually in patches, as a result of injury or irritation). Right shoulder ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising with deformity), tender to touch, range of motion limited by pain, right forearm below elbow ecchymosis; -A radiology report dated 9/14/22, with findings of the humeral head (the top of the humerus - upper arm bone) is anteriorly (an anterior shoulder dislocation is an injury in which the bone of the upper arm, called the humerus, is dislocated from the shoulder joint), and inferiorly (a condition in which the head of the humerus is detached from the shoulder joint). No visible fracture. Facial bones: No acute osseous abnormality demonstrated; -Progress notes showed on 9/14/22 at 4:36 P.M., the resident's right shoulder was reduced back. During an interview on 9/15/22 at 6:30 A.M., Nurse C said he/she worked overnight on 9/14/22. No one told him/her the resident fell when he/she arrived to work. The resident dislocated his/her shoulder previously on a different floor and they thought he/she was trying to get out of the facility. The nurse on duty on the resident's floor called over on the night in question and asked him/her what he/she should do about the resident. He/she told the other nurse to send him/her to the hospital if he/she was complaining about pain. That nurse wanted to send the resident out, but had been given instructions to not send out until orders were received. Facility administration wants nurses to contact the doctor and notify the DON and ADON before sending residents out. If the resident complained of pain and only had Tylenol, he/she would send the resident out because an x-ray could be obtained at the hospital. The staff were waiting for the resident's physician to come see him/her the next day. During an interview on 9/15/22 at 7:20 A.M., ADON A said he/she had already left for the day when the resident fell . Staff contacted him/her that evening to say the resident had fallen and they thought his/her shoulder was dislocated. He/she thought the ADON and DON had taken care of it since they were still there when it happened. If the resident fell , he/she would assess that resident, call the physician, ask for an x-ray and if the arm was visibly dislocated, would have sent him/her out to the hospital. He/she would use his/her nursing judgement. As a nurse, had he/she been there, he/she would have sent him/her out. During an interview on 9/15/22 at 8:06 A.M., Staffing Coordinator L said he/she was told there was a resident to resident altercation and Resident #800 was brought downstairs to defuse the situation. When he/she saw the resident he/she thought the resident should go to the hospital. Staffing Coordinator L called up to the unit and was told by ADON B the resident was known to pop his/her shoulder out of place and wasn't going to be sent to the hospital. The resident said he/she was in a lot of pain and needed to go to the hospital. The resident's arm looked red was turning purple and the resident was holding it. During an interview on 9/15/22 at 11:10 A.M., Nurse F said staff told him/her the resident was tripped by another resident and fell on [DATE]. The evening nurse already called for an x-ray. On 9/14/22 when he/she found out the x-ray had not been done, he/she attempted to call two x-ray companies the facility used and neither one had an order for the x-ray. When he/she assessed the resident that night, his/her arm was swollen. He/she tried to call the resident's physician again, but got the exchange. They said the physician would not be available until 7:00 A.M., so he/she left a message. At 7:00 A.M., he/she attempted to call the physician again and the person who answered said the physician was out at another facility and would not be able to be reached until 9:00 A.M., but they would send him a text. The physician texted him/her at 7:35 A.M., after he/she left for the day and said he/she called the facility and ordered an x-ray STAT. He/she waited to get an order from the physician because he/she would never send a resident to the hospital without a physician's order. During an interview on 9/15/22 at 9:03 A.M., the social worker for the resident's physician said the physician attempted to call the facility back four to five times on 9/13/22, but was unable to reach anyone. An order for an x-ray was given on 9/14/22 at 8:10 A.M. An order to send the resident to the hospital was given at 1:14 P.M. on 9/14/22. During an interview with the administrator and corporate nurse on 9/15/22 at 2:09 P.M., the corporate nurse residents have the right to go to the hospital if they want, but EMS has said they will not transport just because a resident wants to go. Review of the facility's investigation, provided to DHSS on 9/15/22 and completed by the corporate nurse, included the following: -Resident will purposefully dislocate his/her shoulder in an attempt to seek attention and go to the hospital due to drug seeking behaviors. Resident will also refuse treatment at times; -On 9/13/22 at approximately 5:05 P.M., the resident stated another resident hit him/her in the mouth. The resident then stated the other resident tripped him/her; -Upon assessment the resident complained of right arm pain. Arm was assessed and range of motion was within normal limits. Upon inspection, there was not any abnormalities of the right arm or shoulder. The physician was called and orders were placed for an x-ray; -On 9/13/22 at approximately 5:40 P.M., the resident stated he/she wanted to go to the hospital for right arm pain. Resident was informed the physician was called and an order was needed to send the resident to the hospital; -The doctor did not order the resident to be sent to the hospital; -Call placed to resident's physician to discuss concerns about resident's incident on 9/13/22. The physician said he was aware the resident had an incident involving his/her right shoulder. The physician said he gave the order to obtain an x-ray in house rather than sending the resident immediately to the hospital; -This was because someone with chronic dislocation like the resident does not need to be immediately sent. It is more cost effective and better for the resident to obtain in house mobile x-ray company unless it is obvious the resident is going to need medical attention; -Conclusion: No order was given by the physician to send resident to the hospital, orders were obtained for x-ray in the A.M. MO00207024

See deficiency cited at event Q04512. Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #800) received adequate pain management (pharmalogical and/or non-pharmalogical) after he/she fell and dislocated his/her shoulder. The sample was 13. The census was 119. Review of the facility's undated Pain-Clinical Protocol, showed: -The physician and staff will identify individuals who have pain or who are at risk for having pain; -This includes reviewing known diagnosis and conditions that commonly cause pain; -It also includes a review for any treatments that the resident is receiving for pain, including complementary and non-pharmacologic; -The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain; -The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern and severity; -Staff will use consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level; -The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated: for example wound care, ambulation or repositioning; -The physician will order appropriate medication interventions to address the individual's pain; -For the individuals who is receiving opioid analgesics, the physician will order a regimen of laxatives and other measures to prevent constipation; -The staff will reassess the individual's pain at regular intervals for acute pain or significant changes in levels of chronic pain; -The staff will evaluate and report the resident's use of standing and PRN analgesics. Review of Resident #800's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/21/22, showed: -admitted on [DATE]; -Adequate vision and hearing; -Resident understood and understands others; -Cognitively intact; -No mood issues; -No behavior exhibited; -No rejection of care exhibited; -Pain management: On a scheduled medicine regimen - Received as needed (PRN) pain meds in last five days; -Surgical procedures: Repair fractures of the shoulder. Review of a daily nursing report, dated 9/13/22, included the following: -3-11 shift; -Behaviors/Interventions: Resident #812 tripped Resident #800 onto the floor with a dislocated shoulder. Review of the resident's progress notes, showed the following: -On 9/13/22 at 5:03 P.M., this nurse and Assistant Director of Nursing (ADON) on the floor addressing an unrelated situation and the resident screamed. This nurse then observed the resident on the floor. The resident then stated that Resident #812 tripped him/her. The resident was complaining of right arm pain. The resident was assessed, the MD was called awaiting return call. X-ray vendor to be called for x-ray; -At 5:18 P.M., staff alerted the nurse the resident was on the floor complaining of pain to his/her right shoulder. Call placed to physician for notification and next steps. Staff awaiting return call; -At 5:40 P.M., the ADON gave report to the nurse. The resident stated he/she wanted to go to the hospital for right arm pain. Staff made the resident aware they were waiting for the physician to call back. Staff explained they could not send him/her out without a physician's order. The resident told staff he/she would call EMS himself/herself. -On 9/14/22 at 7:41 A.M., the resident complained of right arm/shoulder and facial pain related to fall. Resident has raised area, redness and swelling to right cheek and deformity with redness to right shoulder with swelling to entire arm. Call placed to x-ray vendor for right shoulder, humerus (a long bone located in the upper arm, between the shoulder joint and elbow joint), elbow, forearm and facial bones. Ordered STAT. Review of the resident's care plan, dated 9/14/22, showed the following: -Focus: Resident complained of right arm/shoulder and facial pain related to fall. Resident has raised area, redness and swelling to right cheek and deformity with redness to right shoulder with swelling to entire arm. Call placed to x-ray company for right shoulder, humerus, elbow, forearm and facial bones. Ordered STAT (immediately). Staff report resident stated another resident tripped him/her; -Goal: Resident will not have severe injuries/abuse through next review; -Interventions: Call placed to x-ray company for right shoulder, humerus, elbow, forearm and facial bones. Assess for pain/injuries. Give pain medication as needed. Inform administration/Director of Nursing (DON)/Assistant DON about incident/resident's status; -Focus: Resident has episodes of pain from 9/14/22 right dislocated shoulder; -Goal: Pain will be minimized with the use of scheduled and/or PRN pain meds; -Interventions: Administer analgesic (pain medication) as per orders/PRN. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor/document for side effects of pain medication. Monitor/record pain characteristics. Quality (i.e. sharp, burning), Severity (1-10 scale). Anatomical location, onset, duration. Aggravating factors and relieving factors. The above care plan info had an initiation date of 9/13/22 and a revised date of 9/14/22. Additionally, the care plan showed: Focus: Resident has episodes of pain 8/14/22 right dislocated shoulder. Initiated on 7/12/22 and revised on 8/15/22; Goal: Pain will be minimized with the use of scheduled and/or PRN pain meds through review; Interventions: Administer analgesia as per orders /PRN. Evaluate the effectiveness of pain interventions Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea; vomiting; dizziness and falls. Report occurrences to the physician. Monitor/record pain characteristics: Quality (e.g. sharp, burning); Severity (1 to 10 scale). Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. Sent to hospital for evaluation of shoulder. X-ray shoulder. Review of the care plan on 9/14/22 at 2:21 PM, showed it did not contain a focus area of the resident purposely dislocating his/her right shoulder for attention and wanting to go to the hospital or having a history of drug abuse. During observation and interview on 9/14/22 at 9:30 A.M., and at 1:28 P.M., the resident said at approximately 4:30 P.M. the previous day, he/she was tripped by another resident and hit his/her head and shoulder. Staff told him/her they would get him/her ice but did not give it to him/her. The pain was getting worse. He/she wanted to go to the hospital, but staff told him/her no. He/she was going to call 911 and have them take him/her to the hospital, but the staff told him/her if he/she did this, they would make him/her sign a paper saying he/she was doing this AMA and kick him/her out of the facility. The resident said his/her pain was at an 8 or 9 on a scale of 1-10 (0 indicating no pain and 10 indicating worst pain ever felt). He/she cried all night. When he/she moved his/her shoulder, it made a clicking sound. It hurt for the resident to blink. The resident had a golf ball sized swollen area with bruising on his/her right cheek and his/her right arm appeared reddish and swollen. The resident's shoulder appeared out of place. Observation on 9/14/22 at 1:43 P.M., showed two EMS representatives and Nurse K walked into the resident's room. The resident showed the EMS representatives his/her shoulder. An EMS representative said the resident's shoulder was dislocated. During an interview on 9/14/22 at 3:41 P.M., the DON said she did not witness the resident injuring his/her shoulder. She heard Resident #800 scream and was on the floor. Resident #800 said Resident #812 hit him/her in the mouth and tripped him/her. ADON B said he/she was going to handle the situation so the DON left the unit. She did not see the resident again because she left the building shortly thereafter. ADON B called the physician's exchange three times because this occurred after hours and did not receive a call back. The DON called the resident's doctor directly twice and it went straight to voicemail. The resident's doctor did not call back until this morning. ADON B offered to make the resident comfortable while they waited for orders, but the resident was adamant he/she wanted to go to the hospital. If a resident's shoulder was dislocated, she would expect they would need more medical attention than what could be provided at the facility. The DON agreed the resident waited a long time before he/she received treatment. During an interview on 9/14/22 at 3:20 P.M., ADON B said he/she and the DON were up on the floor just prior to the resident falling. They had just left the unit when they heard a cry and looked through the window and saw the resident on the floor. They immediately went back in to see what happened. The resident claimed another resident had tripped him/her causing him/her to fall. When he/she entered the unit, the resident was on the floor. The resident was grimacing and when asked what happened he/she said Resident #812 had tripped him/her. The ADON assessed him/her and thought something was wrong with his/her arm. It was red and did not move right. The resident was talking okay and did not complain of pain to him/her. The nurse ordered an x-ray and notified the resident's physician and family. They could only give the resident Tylenol if that was on his/her orders. They did not send him/her to the hospital because they needed a physician's order to do this and his/her hands were tied because the physician had not called back. They should have called him/her or the physician again if the resident complained of increased pain. During an interview on 9/14/22 at 4:08 P.M., Certified Medication Technician (CMT) D said he/she was working the floor the prior evening when the resident fell . He/she did not see the resident actually fall, but heard him/her cry out. The CMT was at the desk and the resident was down closer to the dining room. He/she saw the resident on the floor. The resident said Resident #812 tripped him/her causing him/her to fall to the floor. The resident complained of pain in his/her shoulder and said it was dislocated. The arm did not look normal. It looked like something was sticking out of his/her skin. At that point ADON B and the DON came into the unit and assessed the resident. The CMT did not know what the resident told them, as he/she left the resident at that point. The resident continued to complain of pain and held his/her arm through the night. The CMT gave him/her some extra strength Tylenol, as that is all they were allowed to give him/her per his/her physician's orders. During an interview on 9/14/22 at 4:30 P.M., the corporate nurse said the resident had a history of dislocating his/her shoulder. He/she had an accident prior to coming to the facility and never got it fixed. If the resident complained of pain, they would try to give him/her the ordered medications for pain. The DON called her around 6:00 P.M., and told her the resident had fallen, the physician had been called and gave an order for an x-ray. The physician told the staff not to send the resident out until the arm was x-rayed. She told staff they needed to follow physician's orders and her understanding was he said do not send him/her out. Review of the resident's electronic physician's order sheet for September 2022, showed the following: -Assess pain every shift; -Dicyclomine HCL 20 mg, give 1 tablet per Gastrostomy-tube (G-tube, a tube inserted through the stomach that brings nutrition directly to the stomach), every six hours as needed for pain; -Acetaminophen tablet 500 mg, via G-tube every 6 hours as needed for pain. Moderate- take 1-2 tablets by mouth every 6 hours as needed; -Gabapentin Solution 250 mg/5millliters (ml), give 6 ml via G-tube three times a day for pain. Review of the resident's medication administration records, showed the following: -On 9/13/22 at 5:00 P.M., 6 ml of gabapentin administered; -On 9/13/22 at 8:16 P.M., pain level documented at a 9. Acetaminophen 500 mg administered; -Staff did not document whether the medication was effective or not effective. -On 9/14/22 at 12:52 A.M., Pain level documented at a 9. Dicyclomine HCL 20 mg not administered. Code of 9: Other-See progress notes; -On 9/14/22 at 2:16 A.M., pain level documented at an 8. Acetaminophen 500 mg administered; -Staff did not document whether the medication was effective or not effective. Review of the resident's progress notes on 9/14/22, showed no documentation of the resident complaining of pain or reason Dicyclomine HCL was not administered. Review of the resident's hospital records, dated 9/15/22, showed the following: Hospital note included: Currently the patient's complaining of pain in the right shoulder, the pain is sharp, moderate, worse with movement, no radiation, patient denies LOC (loss of consciousness); -Physical exam: Right cheek erythema (superficial reddening of the skin, usually in patches, as a result of injury or irritation). Right shoulder ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising with deformity), tender to touch, range of motion limited by pain, right forearm below elbow ecchymosis; -A radiology report dated 9/14/22, with findings of the humeral head (the top of the humerus - upper arm bone) is anteriorly (an anterior shoulder dislocation is an injury in which the bone of the upper arm, called the humerus, is dislocated from the shoulder joint), and inferiorly (a condition in which the head of the humerus is detached from the shoulder joint). No visible fracture. Facial bones: No acute osseous abnormality demonstrated; -Progress notes showed on 9/14/22 at 4:36 P.M., the resident's right shoulder was reduced back without using any sedation or pain medications. During an interview on 9/15/22 at 6:30 A.M., Nurse C said he/she worked overnight on 9/14/22. No one told him/her the resident fell when he/she arrived to work. The nurse on duty on the resident's floor called over on the night in question and asked him/her what he/she should do about the resident. He/she told the other nurse to send him/her to the hospital if he/she was complaining about pain. That nurse wanted to send the resident out, but had been given instructions to not send out until orders were received. Facility Administration wants nurses to contact the doctor and notify the DON and ADON before sending residents out. During an interview on 9/15/22 at 8:06 A.M., Staffing Coordinator L said he/she was told there was a resident to resident altercation and Resident #800 was brought downstairs to defuse the situation. When he/she saw the resident he/she thought the resident should go to the hospital. Staffing Coordinator L called up to the unit and was told by ADON B the resident was known to pop his/her shoulder out of place and wasn't going to be sent to the hospital. The resident said he/she was in a lot of pain and needed to go to the hospital. The resident's arm looked red was turning purple and the resident was holding it. During an interview on 9/15/22 at 11:10 A.M., Nurse F said staff told him/her the resident was tripped by another resident and fell on [DATE]. The resident did not complain of pain to him/her but did to the CMT. When he/she assessed the resident that night, his/her arm was swollen. During an interview with the administrator and corporate nurse on 9/15/22 at 2:09 P.M., the corporate nurse said she talked to Nurse F about the appearance of the resident. The resident did not complain of pain and there was no visible problem with the resident's shoulder. The resident slept through the night. The following morning, on 9/14/22, Nurse F noticed the redness and swelling on the resident's arm and a knot on the resident's face. If a resident is complaining of pain, then EMS should be called, which to her knowledge is what was done. Review of the facility's investigation, provided to DHSS on 9/15/22 and completed by the corporate nurse, included the following: -He/she will purposefully dislocate his/her shoulder in an attempt to seek attention and go to the hospital due to drug seeking behaviors. Resident will also refuse treatment at times; -On 9/13/22 at approximately 5:05 P.M., the resident stated another resident hit him/her in the mouth. The resident then stated the other resident tripped him/her; -Upon assessment the resident complained of right arm pain. Arm was assessed and range of motion was within normal limits. Upon inspection, there was not any abnormalities of the right arm or shoulder. The physician was called and orders were placed for an x-ray; -On 9/13/22 at approximately 5:40 P.M., the resident stated he/she wanted to go to the hospital for right arm pain. Resident was informed the physician was called and an order was needed to send the resident to the hospital; -The doctor did not order the resident to be sent to the hospital; -The physician said the resident had Tylenol and Gabapentin (anticonvulsant and nerve pain medication) to control the resident's pain. The resident did not need anything stronger. -Conclusion: No order was given by the physician to send resident to the hospital, orders were obtained for x-ray in the A.M. Resident was provided pain medication per orders that were effective. During an interview on 9/15/22 at 9:03 A.M., the social worker for the resident's physician said the physician attempted to call the facility back four to five times on 9/13/22, but was unable to reach anyone. An order for an x-ray was given on 9/14/22 at 8:10 A.M. An order to send the resident to the hospital was given at 1:14 P.M. on 9/14/22. MO00207024

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #800) received prompt treatment and care after the resident fell and dislocated his/her shoulder. Facility staff failed to obtain an in-house x-ray ordered by the resident's physician in a timely manner or obtain further evaluation and treatment timely when the resident complained of pain and his/her shoulder was assessed by nursing staff as having deformity with redness to right shoulder with swelling to entire arm. The sample was 13. The census was 119. Review of the facility's Discharging a Resident Without a Physician's Approval policy, revised 10/2012, showed: -A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Policy interpretation and implementation: -Should a resident or his/her representative, request an immediate discharge, the resident's attending physician will be promptly notified; -The order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record no later than 72 hours after the discharge; -If the resident or representative insists upon being discharged without the approval of the attending physician, the resident and/or representative must sign a Release of Responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members. -The policy did not state if a resident called 911 for medical assistance, this would result in leaving AMA without the option to return to the facility. Review of Resident #800's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/21/22, showed: -admitted on [DATE]; -Adequate vision and hearing; -Resident understood and understands others; -Cognitively intact; -No mood issues; -No behavior exhibited; -No rejection of care exhibited; -Pain management: On a scheduled medicine regimen - Received as needed (PRN) pain meds in last five days; -Recent surgery requiring active skilled nursing facility care: Yes; -Surgical procedures: Repair fractures of the shoulder. Review of a daily nursing report, dated 9/13/22, included the following: -3-11 shift; -Behaviors/Interventions: Resident #812 tripped Resident #800 onto the floor with a dislocated shoulder. Review of the resident's progress notes, showed the following: -On 9/13/22 at 5:03 P.M., this nurse and Assistant Director of Nursing (ADON) on the floor addressing an unrelated situation when the resident screamed. The nurse observed the resident on the floor 15 feet away. The resident stated Resident #812 hit him/her in the mouth. The resident then stated Resident #812 tripped him/her. The resident complained of right arm pain. The resident was assessed, the MD was called awaiting return call. X-ray vendor to be called for x-ray; -At 5:08 P.M., the resident's weekly skin observations showed skin color was other, refer to assessment for more information. No swelling or broken skin noted; -At 5:18 P.M., staff alerted the nurse the resident was on the floor complaining of pain to his/her right shoulder. He/she stated he/she was tripped and hit the floor. Skin assessment completed. Call placed to physician for notification and next steps. Staff awaiting return call; -At 5:40 P.M., the ADON gave report to the nurse. The resident stated he/she wanted to go to the hospital for right arm pain. Staff made the resident aware they were waiting for the physician to call back. Staff explained they could not send him/her out without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff explained he/she had the right to do so, but it would be going against medical advice; -On 9/14/22 at 7:41 A.M., the resident complained of right arm/shoulder and facial pain related to fall. Resident has raised area, redness and swelling to right cheek and deformity with redness to right shoulder with swelling to entire arm. Call placed to x-ray vendor for right shoulder, humerus (a long bone located in the upper arm, between the shoulder joint and elbow joint), elbow, forearm and facial bones. Ordered STAT. During observation and interview on 9/14/22 at 9:30 A.M., and at 1:28 P.M., the resident said at approximately 4:30 P.M. the previous day, he/she was tripped by another resident and hit his/her head and shoulder. Staff told the resident he/she would get an x-ray the day before, but he/she still had not gotten one. The pain was getting worse. He/she wanted to go to the hospital, but staff told him/her no. He/she was going to call 911 and have them take him/her to the hospital, but the staff told him/her if he/she did this, they would make him/her sign a paper saying he/she was doing this AMA and kick him/her out of the facility. When the resident called 911, he/she was told a nurse would need to call on his/her behalf. Around 8:00 P.M., when other nurses came to the unit, they said the resident needed to go out, but were told if he/she left it would be AMA. Staff tried to reach the doctor several times, but he was not calling back. Last night, the resident called EMS and the police arrived at the facility. He/she tried to talk to them and showed the police his/her arm. A nurse intervened and said he/she was canceling the EMS request because they were awaiting an x-ray. The police left and the resident could not make a report. The resident said his/her pain was at an 8 or 9 on a scale of 1-10 (0 indicating no pain and 10 indicating worst pain ever felt). He/she cried all night. When he/she moved his/her shoulder, it made a clicking sound. It hurt for the resident to blink. The resident had a golf ball sized swollen area with bruising on his/her right cheek and his/her right arm appeared reddish and swollen. The resident's shoulder appeared out of place. Observation on 9/14/22 at 1:43 P.M., showed two EMS representatives and Nurse K walked into the resident's room. The resident showed the EMS representatives his/her shoulder. An EMS representative said the resident's shoulder was dislocated. During an interview on 9/14/22 at 1:50 P.M., Nurse K said the resident hadn't been at the facility very long. Nurse K said it was not his/her call to send the resident out earlier, but he/she believes the resident should have been sent out last evening after he/she injured his/her shoulder. The resident's shoulder appeared to be dislocated. During an interview on 9/14/22 at 3:41 P.M., the Director of Nursing (DON) said she did not witness the resident injuring his/her shoulder. Resident #812 was ahead of Resident #800 when the DON walked down the hall on 9/13/22 to leave the unit. She turned her back to the residents to enter the code for the door and heard Resident #800 scream and was on the floor. Resident #800 said Resident #812 hit him/her in the mouth and tripped him/her. ADON B said he/she was going to handle the situation so the DON left the unit. She did not see the resident again because she left the building shortly thereafter. ADON B called the physician's exchange three times because this occurred after hours and did not receive a call back. The DON called the resident's doctor directly twice and it went straight to voicemail. The resident said if he/she wasn't sent to the hospital, he/she would call 911 himself/herself. There was a previous discussion that the resident has the right to call 911. The facility must have a doctor's order before a resident can be sent to the hospital. If a resident went to the hospital without an order, they would be going AMA. The DON was not aware the resident called 911. The resident's doctor did not call back until this morning. ADON B offered to make the resident comfortable while they waited for orders, but the resident was adamant he/she wanted to go to the hospital. The facility took action by getting an x-ray. If a resident's shoulder was dislocated, she would expect they would need more medical attention than what could be provided at the facility. Her understanding was that a confirmation of a dislocated shoulder was needed before the resident could be sent out. This directive came from above her. The DON agreed the resident waited a long time before he/she received treatment. During an interview on 9/14/22 at 3:20 P.M., ADON B said he/she and the DON were up on the floor just prior to the resident falling. They had just left the unit when they heard a cry and looked through the window and saw the resident on the floor. They immediately went back in to see what happened. The resident claimed another resident had tripped him/her causing him/her to fall. When he/she entered the unit, the resident was on the floor grimacing and when asked what happened he/she said Resident #812 had tripped him/her. The ADON assessed him/her and thought something was wrong with his/her arm. It was red and did not move right. The resident was talking okay and did not complain of pain to him/her. The nurse ordered an x-ray and notified the resident's physician and family. The nurse did not put the x-ray in as STAT. When he/she left at 6:30 P.M., the x-ray company had still not responded. They did not send him/her to the hospital because they needed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They should have called him/her or the physician again if the resident complained of increased pain. When the ADON came back to work on 9/14/22, he/she found out the x-ray company never showed up. They called the x-ray company who said they never got the order. To his/her knowledge, the resident was told he/she would be AMA if he/she called 911 and went to the hospital. At the facility, residents cannot call 911 or go to the hospital on their own. Medically, they have to go through a physician or a nurse. During an interview on 9/14/22 at 4:08 P.M., Certified Medication Technician (CMT) D said he/she was working the floor the prior evening when the resident fell . He/she did not see the resident actually fall, but heard him/her cry out. The CMT was at the desk and the resident was down closer to the dining room. He/she saw the resident on the floor. The resident said Resident #812 stuck out his/her foot and tripped him/her causing him/her to fall to the floor. The resident complained of pain in his/her shoulder and said it was dislocated. The arm did not look normal. It looked like something was sticking out of his/her skin. At that point ADON B and the DON came into the unit and assessed the resident. The CMT did not know what the resident told them, as he/she left the resident at that point. The resident continued to complain of pain and held his/her arm through the night. The CMT gave him/her some extra strength Tylenol, as that is all they were allowed to give him/her per his/her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/14/22 at 4:30 P.M., the corporate nurse said it is not the facility's policy to discharge residents AMA if they call 911. He/she said the resident has a history of dislocating his/her shoulder. He/she had an accident prior to coming to the facility and never got it fixed. She would have expected staff to call the x-ray company back if they had not shown up. Sometimes they had a problem with the x-ray company coming out after hours due to the area. The DON called her around 6:00 P.M., and told her the resident had fallen, the physician had been called and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She told staff they needed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, dated 9/14/22, showed the following: -Focus: Resident complained of right arm/shoulder and facial pain related to fall. Resident has raised area, redness and swelling to right cheek and deformity with redness to right shoulder with swelling to entire arm. Call placed to x-ray company for right shoulder, humerus, elbow, forearm and facial bones. Ordered STAT (immediately). Staff report resident stated another resident tripped him/her; -Goal: Resident will not have severe injuries/abuse through next review; -Interventions: Call placed to x-ray company for right shoulder, humerus, elbow, forearm and facial bones. Assess for pain/injuries. Give pain medication as needed. Inform administration/Director of Nursing (DON)/Assistant DON about incident/resident's status; -Focus: Resident is at risk for falls related to antidepressant medications; -Goal: The resident will be free of injury related to falls; -Interventions: Anticipate and meet the resident's needs as needed. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Resident ambulates independently; -Review of the care plan on 9/14/22 at 2:21 PM, showed it did not contain a focus area of the resident purposely dislocating his/her right shoulder for attention and wanting to go to the hospital. Review of the resident's hospital records, dated 9/15/22, showed the following: Hospital note included: Currently the patient's complaining of pain in the right shoulder, the pain is sharp, moderate, worse with movement, no [CONDITION(S)], patient denies LOC (loss of consciousness); -Physical exam: Right cheek [CONDITION(S)] (superficial reddening of the skin, usually in patches, as a result of injury or irritation). Right shoulder ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising with deformity), tender to touch, range of motion limited by pain, right forearm below elbow ecchymosis; -A radiology report dated 9/14/22, with findings of the humeral head (the top of the humerus - upper arm bone) is anteriorly (an anterior shoulder dislocation is an injury in which the bone of the upper arm, called the humerus, is dislocated from the shoulder joint), and inferiorly (a condition in which the head of the humerus is detached from the shoulder joint). No visible fracture. Facial bones: No acute osseous abnormality demonstrated; -Progress notes showed on 9/14/22 at 4:36 P.M., the resident's right shoulder was reduced back. During an interview on 9/15/22 at 6:30 A.M., Nurse C said he/she worked overnight on 9/14/22. No one told him/her the resident fell when he/she arrived to work. The resident dislocated his/her shoulder previously on a different floor and they thought he/she was trying to get out of the facility. The nurse on duty on the resident's floor called over on the night in question and asked him/her what he/she should do about the resident. He/she told the other nurse to send him/her to the hospital if he/she was complaining about pain. That nurse wanted to send the resident out, but had been given instructions to not send out until orders were received. Facility administration wants nurses to contact the doctor and notify the DON and ADON before sending residents out. If the resident complained of pain and only had Tylenol, he/she would send the resident out because an x-ray could be obtained at the hospital. The staff were waiting for the resident's physician to come see him/her the next day. During an interview on 9/15/22 at 7:20 A.M., ADON A said he/she had already left for the day when the resident fell . Staff contacted him/her that evening to say the resident had fallen and they thought his/her shoulder was dislocated. He/she thought the ADON and DON had taken care of it since they were still there when it happened. If the resident fell , he/she would assess that resident, call the physician, ask for an x-ray and if the arm was visibly dislocated, would have sent him/her out to the hospital. He/she would use his/her nursing judgement. As a nurse, had he/she been there, he/she would have sent him/her out. During an interview on 9/15/22 at 8:06 A.M., Staffing Coordinator L said he/she was told there was a resident to resident altercation and Resident #800 was brought downstairs to defuse the situation. When he/she saw the resident he/she thought the resident should go to the hospital. Staffing Coordinator L called up to the unit and was told by ADON B the resident was known to pop his/her shoulder out of place and wasn't going to be sent to the hospital. The resident said he/she was in a lot of pain and needed to go to the hospital. The resident's arm looked red was turning purple and the resident was holding it. During an interview on 9/15/22 at 11:10 A.M., Nurse F said staff told him/her the resident was tripped by another resident and fell on [DATE]. The evening nurse already called for an x-ray. On 9/14/22 when he/she found out the x-ray had not been done, he/she attempted to call two x-ray companies the facility used and neither one had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she tried to call the resident's physician again, but got the exchange. They said the physician would not be available until 7:00 A.M., so he/she left a message. At 7:00 A.M., he/she attempted to call the physician again and the person who answered said the physician was out at another facility and would not be able to be reached until 9:00 A.M., but they would send him a text. The physician texted him/her at 7:35 A.M., after he/she left for the day and said he/she called the facility and ordered an x-ray STAT. He/she waited to get an order from the physician because he/she would never send a resident to the hospital without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 9/15/22 at 9:03 A.M., the social worker for the resident's physician said the physician attempted to call the facility back four to five times on 9/13/22, but was unable to reach anyone. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. An order to send the resident to the hospital was given at 1:14 P.M. on 9/14/22. During an interview with the administrator and corporate nurse on 9/15/22 at 2:09 P.M., the corporate nurse residents have the right to go to the hospital if they want, but EMS has said they will not transport just because a resident wants to go. Review of the facility's investigation, provided to DHSS on 9/15/22 and completed by the corporate nurse, included the following: -Resident will purposefully dislocate his/her shoulder in an attempt to seek attention and go to the hospital due to drug seeking behaviors. Resident will also refuse treatment at times; -On 9/13/22 at approximately 5:05 P.M., the resident stated another resident hit him/her in the mouth. The resident then stated the other resident tripped him/her; -Upon assessment the resident complained of right arm pain. Arm was assessed and range of motion was within normal limits. Upon inspection, there was not any abnormalities of the right arm or shoulder. The physician was called and orders were placed for an x-ray; -On 9/13/22 at approximately 5:40 P.M., the resident stated he/she wanted to go to the hospital for right arm pain. Resident was informed the physician was called and an order was needed to send the resident to the hospital; -The doctor did not order the resident to be sent to the hospital; -Call placed to resident's physician to discuss concerns about resident's incident on 9/13/22. The physician said he was aware the resident had an incident involving his/her right shoulder. The physician said he gave the order to obtain an x-ray in house rather than sending the resident immediately to the hospital; -This was because someone with chronic dislocation like the resident does not need to be immediately sent. It is more cost effective and better for the resident to obtain in house mobile x-ray company unless it is obvious the resident is going to need medical attention; -Conclusion: No order was given by the physician to send resident to the hospital, orders were obtained for x-ray in the A.M. MO 024

Based on observation, interview and record review, the facility failed to ensure pain management was provided consistent with professional standards of practice and the comprehensive care plan, by failing to ensure one resident (Resident #403) was provided with pain medication and a pain management referral as requested by the physician. The sample was 13. The census was 119. Review of the facility's undated Pain-Clinical Protocol, showed: -The physician and staff will identify individuals who have pain or who are at risk for having pain; -This includes reviewing known diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -It also includes a review for any treatments that the resident is receiving for pain, including complementary and non-pharmacologic; -The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain; -The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern and severity; -Staff will use consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level; -The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated: for example wound care, ambulation or repositioning; -The physician will order appropriate medication interventions to address the individual's pain; -For the individuals who is receiving opioid analgesics, the physician will order a regimen of laxatives and other measures to prevent constipation; -The staff will reassess the individual's pain at regular intervals for acute pain or significant changes in levels of chronic pain; -The staff will evaluate and report the resident's use of standing and PRN analgesics. Review of Resident #403's admission minimum data set (MDS), a federal mandated assessment instrument completed by facility staff, dated 4/7/22, showed: -Cognitively intact; -Extensive assistance required for bed mobility, transfer, dressing, toilet use and personal hygiene; -Pain management: -At any time in the last 5 days, has the resident been on a scheduled pain medication regimen: Yes; -Received PRN pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -Received non-medication interventions for pain: No; -Pain interview: -Presence of pain: Yes; -Pain frequency: Frequently; -Had pain made it hard to sleep at night: Yes; -Have you limited your day-to-day activities because of pain: Yes; -Pain intensity: 10; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Care area assessment summary: Pain triggered as a care area and indicated as care planned by the facility. Review of the resident's care plan, dated 3/25/22, showed: -Focus: The resident had acute/chronic pain diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Date initiated 3/25/22; -Goal: Pain will be minimized with the use of scheduled and/or as needed pain medications; -Interventions: Administer analgesia as per orders/as needed. Anticipate the residents need for pain relief and respond immediately to any complaint of pain. Follow-up with pain management as ordered. Monitor/record/report to nurse resident complaints of pain or request for pain treatment. Review of the resident's admission pain assessment, dated 3/25/22, showed: -Should pain admission assessment be conducted? Yes; -Resident was alert and oriented to person, place and time; -Current pain level was a 10 out of 10 scale (0 equals no pain 10 equals the worse pain); -Had acute and chronic pain; -Pain will be minimized with the use of scheduled and/or as needed (PRN) pain medications; -Anticipate the residents need for pain relief and respond immediately to any complaints of pain; -Report to nurse resident's complaints of pain or request for pain medication. Review of the resident's electronic physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order dated 3/25/22, for acetaminophen (Tylenol) 500 milligram (mg) every 6 hours as needed for moderate pain; -An order dated 3/25/22, for [MEDICATION(S)] (narcotic pain medication 5 mg every 6 hours as needed; -An order dated 5/1//22, for [MEDICATION(S)] HCI (an opiate analgesic used to treat moderate or severe pain) tablet 100 mg. Give 100 mg by mouth every 8 hours as needed for pain; start after [MEDICATION(S)] runs out. Review of the resident's progress notes, showed on 4/22/22 at 12:33 P.M., staff documented a call placed for pain management, but the office was closed. No further documented attempts to contact pain management. During an interview on 6/22/22 at approximately 1:00 P.M., the Assistant Director of Nursing (ADON) said the reason pain management was contacted was because of the residents reports of uncontrolled pain. Review of the resident's medical record, showed no documentation pain management was involved in the resident's care. Further review of the resident's ePOS, showed no order to follow-up with pain management. During an interview on 6/22/2022 at 2:00 P.M., Physician Representative M, the assistant for Physician N, said: -On 4/6/22, the physician wrote a script for [MEDICATION(S)]; -In May the physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -The physician would expect the resident to receive medications as ordered. Also, would expect to be notified if issues arise with medications; -Pharmacy calls the physician for medication issues. The pharmacy had not called the physician with concerns related to the resident's pain medications; -The physician ordered the facility to follow up with pain management. Review of the resident's May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 5 mg by mouth every 6 hours as needed for pain start date, 3/25/2022: Documented as administered 5/1/22 and on 5/22/22; -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's June 2022 MAR, reviewed on 6/21/22, showed: -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 5 mg by mouth every 6 hours as needed for pain start date, 3/25/2022: No documentation the medication administered for the month of June 2022; -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 6/21/22 at 10:45 A.M., showed the resident in bed, with his/her feet on top of a pillow. The resident said he/she can have Tylenol for pain control, but he/she has had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she was told the [MEDICATION(S)] was unavailable. The Tylenol was not effective in controlling the pain. He/she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The pain kept him/her from sleeping at night. The resident had facial grimacing during the interview. On 6/22/2022 at 9:50 A.M., he/she said that he/she asks every night for pain medication and only gets Tylenol, which was not effective. During an interview on 6/22/22 at 9:20 A.M., Certified Medication Technician (CMT) L said the resident had orders for [MEDICATION(S)]. When the medication ran out, the resident was to start [MEDICATION(S)] for pain control. CMT L could not find any card of [MEDICATION(S)] in the medication cart. The resident has not had any [MEDICATION(S)] for a while and he/she did not know why it was not reordered. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident complained of pain at 6:15 A.M., and was given Tylenol. The CMT L would expect the medications to be reordered and available for the resident. CMT L would expect the nurse to be informed of the need to reorder any medications or issues with getting any medications. Per the MAR, the resident was getting [MEDICATION(S)] and then [MEDICATION(S)] until May 24. During an interview on 6/22/22 at 12:30 P.M., Licensed Practical Nurse (LPN) A said he/she was just informed the [MEDICATION(S)] was not in the medication cart. The last [MEDICATION(S)] was given on May 24, 2022. There was an active order for this medication. He/she called the pharmacy and they said there was no issues with the medication and it will be sent stat (immediately). LPN A would expect the medication to be ordered from the pharmacy and available for the resident. LPN A would expect the CMTs to notify the nurse of unavailable medications or the delivery of medications. During an interview on 6/22/22 at approximately 1:00 P.M., the ADON said she would expect staff to administer pain medication if requested by the resident and as ordered. If a medication was not available, she would expect staff to call the pharmacy for a refill, stat. If staff are unable to obtain the medication, she would expect staff to inform the physician and ask for alternative in the meantime. If the resident has Tylenol or other over the counter medications (OTC), they would be offered. During an interview on 6/22/22 at approximately 1:30 P.M., the administrator said he would expect residents to receive pain medication as ordered. If unavailable, he would expect nursing to order the medication from pharmacy. If unavailable to obtain, physician should be aware of the issue. Also, he would expect the nurse/CMT to the let the DON and/or administrator know of any issue. Staff should offer other medications until the requested medication was available. He was unaware of this issue related to the resident's [MEDICATION(S)]. MO 737

Based on observation, interview and record review, the facility failed to ensure a resident received appropriate person-centered care and met their highest practicable psychosocial well-being when the facility failed to provide assessment and mental health services for one sampled resident with a known history of suicidal ideation and attempts (Resident #68). The facility failed to address the family's concerns when they made the facility aware, on more than one occasion, the resident was exhibiting increased anxiety related to past sexual abuse. The facility failed to obtain information regarding the resident's history of trauma, including the stressors and triggers of the trauma. The resident stated he/she jumped out a third floor window in an attempt to commit suicide. This resulted in the resident sustaining a broken back and two broken legs on 4/2/22. The resident returned to the facility on [DATE] and the facility failed to implement any interventions to support the resident's mental and emotional well-being. On 4/27/22 the resident was sent to the hospital after making several attempts to wrap the call light cord around his/her neck. The sample was 7. The census was 124. The administrator was informed on 4/28/22 of an Immediate Jeopardy (IJ), which began on 4/27/22. The IJ was removed on 5/2/22 as confirmed by surveyor on-site verification. Review of the facility's Behavioral Health Services policy, revised February 2019, showed: -Policy Statement: The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practical, physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care; -Policy Interpretation and Implementation; 1. Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care; 2. Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care; 3. Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse or post-traumatic stress disorder, will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavoidable; 4. Staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress; 5. Staff training regarding behavioral health services includes, but is not limited to; a. recognizing changes in behavior that indicate psychosocial distress; b. implementing care plan interventions that are relevant to the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] c. monitoring care plan interventions and reporting changes in condition; d. protocols and guidelines related to the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 6. Behavioral health services are provided by staff who are qualified and competent in behavioral health and trauma-informed care; 7. Staff are scheduled in sufficient numbers to manage resident needs throughout the day, evening and night. Review of Resident #68's medical record, showed: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care), dated 5/4/16, showed: -The resident met the federal definition of Serious Mental Illness (SMI) but does not require specialized services. Please incorporate the lesser intensity services into the resident's care plan; -Does this person show any signs or symptoms of major mental disorder? Yes, lability of mood and disorganization of thoughts; -Has this person ever been diagnosed as having a major mental disorder? Yes, [CONDITION(S)] disorder with [CONDITION(S)]; -Is the primary reason for nursing facility placement due to dementia, including Alzheimer's disease or related disorder? No; -Has the person had serious problems in levels of functioning in the last six months? Yes; -Has the person received intensive psychiatric services in the past two years? Yes. Review of the resident's progress notes, showed: -12/2/16 at 3:39 P.M., Report from social services stated resident was asked if he/she was having any suicidal thoughts and if so, how would he/she act on them. Resident stated that he/she is not currently having suicidal, however, if he/she was, he/she would use a razor. Staff for oncoming shift made aware; -1/26/17 at 11:45 P.M., Resident came to this nurse and stated that he/she is feeling suicidal. When asked what his /her plan was, resident stated he/she would cut his/her wrist. Call placed to the psychiatrist. Received new orders to send to the hospital for a psychiatric evaluation. The psychiatrist said he would call the hospital and let them know the resident was coming; -5/24/18 at 1:02 P.M., Resident informed this nurse that he/she had been waking in the middle of the night with suicidal ideation. The resident stated that he/she has formulated a plan and if he/she were to try to commit suicide, he/she would cut him/herself. The resident denied any thoughts at the present moment. The nurse spoke to the psychiatrist and he has informed this nurse to monitor the resident for signs of increased depression and to notify him of any changes in mood or behavior. Social services has been made aware; -3/31/19 at 1:40 P.M., Resident made this nurse aware that he/she was feeling suicidal. Resident stated that he/she was talking to some of the residents about it while smoking. When asked what his/her plan was, he/she stated he/she did not know. When asked why he/she felt that way, resident stated he/she only received one [MEDICATION(S)] (anxiety medication) last night. Resident encouraged to always come to staff when feeling suicidal or depressed. Resident was asked again why he/she feels that way and he/she stated he/she spoke to his/her parent last night and told the parent, [OBSCENITY] you. Resident then stated that his/her parent wanted to talk about what was bothering him/her but he/she did not. Resident also stated that he/she does not like to talk about his/her feelings. Resident was asked what would make him/her feel better and resident stated a soda and [MEDICATION(S)]. Medication and soda given to resident. Will continue to monitor mood; -12/1/20 at 3:10 P.M., Social worker met with resident to follow up from an earlier suicide assessment that was completed earlier today. SW discussed the suicide assessment score with the resident. SW reviewed three questions and answers with the resident that he/she answered. About once a week and a couple of times a month. 1. I thought about killing myself. Answer: about once a week. Resident states he/she had not thought about killing self weekly, just twice a month because of his/her parent's temper; 2. I thought about how I would kill myself. Answer: About once a week. Resident states, I have no plans to kill myself. Resident states he/she has thought about it before about two weeks ago, but not on how he/she would follow through; 3. I thought about when I would kill myself. Resident states he/she thought about dying today because his/her parent thinks the resident is dying or if the resident leaves the facility, he/she will do bad things. SW spoke to the resident about coping skills that he/she used to decrease thoughts of killing self. Resident says he/she reads books, talks with peers and sits in the kitchen looking out of the window. Resident states the coping skills are effective. SW will reach out to the psychiatrist to share suicide assessments and answers; -7/13/21 at 8:20 A.M., The resident refused to allow staff to get him/her up and dressed for parent's funeral today and stated he/she did not feel like getting up and did not want to go to the funeral. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/2/21, showed: -Cognitively intact; -Feeling down and depressed occurred never or one day; -Experienced delusions; -Verbal behaviors toward others occurred one to three days per week; -Wandering occurred one to three days per week; -Not receiving psychological therapy. Review of the resident's Psychiatric Follow-Up Evaluation, dated 10/18/21, showed: -Content of thought within normal limits; -Poor insight, judgement and decision making skills; -Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Assessment: Patient doing well. Review of the resident's progress notes, dated 11/1/21 at 6:18 P.M., showed this writer notified the medical director regarding this resident's disruptive, destructive and combativeness towards staff and peers. Received new order to send to the hospital for psychiatric care and behavioral management. Review of the resident's quarterly MDS, dated [DATE], showed: -Mild cognitive impairment; -Exhibited no behaviors; -Not receiving psychological therapy. Further review of the resident's progress notes, dated 2/21/22 at 3:36 P.M., showed the Social services director (SSD) received a call from the resident's sibling regarding his/her overall care and was concerned about incidents told to him/her by the resident. Review of the resident's annual MDS, dated [DATE], showed: -Cognitively intact; -Wandered one to three days per week; -Does wandering place the resident at significant risk of getting to a potentially dangerous place? Yes. -Not receiving psychological therapy. Review of the resident's medical record, showed staff did not document a Wandering Assessment prior to 3/1/22. Further review of the resident's progress notes, showed: -3/22/22 at 12:28 P.M., SSD spoke with the resident's sibling/representative, who requested a care plan meeting and informed the facility that he/she is now the appointed Power of Attorney (POA, a legal document that allows someone to act on behalf of someone else); -3/23/22 at 1:43 P.M., SSD met with the MDS coordinator and the resident's POA for care planning purposes. Outside counseling was discussed as a method to assist with the resident's past traumas and how they trigger him/her. POA discussed the possibility of transferring the resident to a different state to be closer to family. Resident does not currently want to go. SSD stated staff can monitor the resident's desires on this matter. MDS coordinator addressed the resident's need for a specialty care unit if he/she were to transfer due to current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 4/28/22 at 10:48 A.M., the SSD said the resident's sibling/POA contacted her and expressed concerns because the resident was becoming increasingly agitated and anxious. She made a referral to a counseling service at that time. She could not recall if she followed up on the referral. Review of the SSD's email exchange regarding counseling services for the resident, provided by the SSD on 4/28/22 at approximately 12:30 P.M., showed: -On 3/23/22 at 10:07 P.M., an email to the counseling services: Can we add Resident #68 to your client list? -On 3/27/22 at 7:18 P.M., a response from counseling services: To add someone on to services, you will need to submit their face sheet, a doctor's order, and the consent from the guardian/POA either online or by fax. I've courtesy copied (counseling service staff), who can help you with any questions during the process; -On 3/28/22 at 8:40 A.M., the SSD sent an email to the Director of Nursing (DON): Are we able to get a doctor's order for counseling services for Resident #68?; -No further email exchanges. During an interview on 4/28/22 at 2:12 P.M., the resident's sibling/POA said he/she never received a call regarding a referral for counseling services. Further review of the resident's progress notes, showed: -3/29/22 at 3:01 P.M., Resident's sibling/POA called SSD to discuss concerns raised by a phone call from the resident yesterday evening. Resident sounded full of anxiety and urgency in needing sibling to call him/her back. SSD stated a visit was just completed and after observation, the resident appeared to be at his/her baseline. The sibling was concerned because the resident was not alert and oriented to his/her location regarding state (resident knew he/she was at the facility but thought he/she was in a different state). SSD explained that due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . However, this information would be passed along to the MDS coordinator and nursing team. -4/2/22 at 3:24 P.M., This nurse was sitting at the nurse's station when this nurse heard another resident scream the resident's wheelchair was by the window. This nurse immediately ran into the resident common area where seating and vending machines are located. When glancing quickly over the common area, the resident was not seen. This nurse, certified medication technician (CMT) and certified nursing assistant (CNA) immediately began to do room checks. As room checks were being completed a code yellow (code for a missing resident) was called. The nurse and CMT then ran off the unit while the CNA stayed on the unit. This nurse and CMT then ran out of the facility and around the building looking for the resident. This nurse could see the CNA from the third floor and said the resident was on the roof. This nurse, CMT and another CMT from another hall ran into the back of the building and up the stairs to the third floor. Two men working at the facility attempted to open the windows but they would not open. Staff went to a lower level, then one of the men was able to open one window. The nurse and CMT from another floor climbed out of the window and saw the resident lying on his/her left side with some blood on the rocks near his/her face. Staff then threw a sheet and a blanket out of the window and the CMT from the other hall covered him/her up. Emergency medical services (EMS) arrived and came through the window. They applied a c-collar (a medical device used to support a person's neck) to the resident's neck and rolled him/her onto a backboard and carried him/her back into the building. This incident occurred between 12:10 P.M. and 12:12 P.M. Review of the resident's hospital record, showed: -Patient was admitted on [DATE] at 12:52 P.M.; -Chief Complaint, fall; -Patient with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient attempting to escape his/her psychiatric facility and drive to Cincinnati jumped off the third story window onto the second floor balcony. Injuries include L2 (second vertebra in lower back), L5 (fifth lumbar spine vertebra) burst fracture with retropulsion (any vertebral fracture fragment displaced into the spinal canal, potentially causing spinal cord injury), L1 superior end plate deformity (portion of the spinal cord), right [NAME] fracture (a type of break of the shinbone that happens near the ankle), left medial malleolus fracture (bump that protrudes on the inner side of the ankle), comminuted talus fracture (fracture due to high energy impact and are frequently open fractures), gluteal (general region of the buttock) hematoma, celiac artery dissection (a type of arterial dissection), left external iliac dissection (disease caused by trauma) and nasal bone fracture. Review of the facility's Self-Report Investigation, dated 4/7/22, showed: -At 12:10 P.M., a code yellow was called for third floor south. It was communicated that the resident was missing and staff started checking rooms and facility grounds. The resident was observed on the second floor balcony at about 12:14 P.M. Resident stabilized by staff by 12:20 P.M., approximately. At about 12:30 P.M., the resident was transported by EMS to the hospital; -Staff and Resident Interviews; -Interview with Resident #76: Resident states that he/she went into the 300 south lounge to get some chips, and stood by the vending machine next to the window. While at the vending machine, he/she could not see the machine because the wind coming through an open window was blowing his/her hair into his/her face. He/she closed the window and noticed Resident #68's wheelchair at that window. Resident stated he/she went to the hall and yelled, Resident #68's wheelchair is at the window. I don't see (him/her); -A resident psychosocial well-being assessment was performed on other residents on the 300 hall locked behavioral unit and none expressed concerns about feeling unsafe, wanting to self-harm or fearfulness of others; -CNA A saw the resident in room [ROOM NUMBER] at approximately 11:40 A.M. on 4/2/22; -CMT B, Nurse C and CNA A stated Resident #76 yelled out that Resident #68's wheelchair was in the 300 South lounge area but Resident #68 was not in the 300 south lounge at approximately 12:10 P.M.; -Findings: Resident #68 is alert and oriented with a primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident is cognitively intact; -Conclusion: -Resident #68 lives on the locked behavioral unit on the third floor since 5/23/16 for most of his/her residency in the facility. Resident is noted to be alert and oriented to person, place and time, cognitively intact and his/her own responsible party; -Since inception, the facility has had multiple levels of security to ensure resident safety to include magnet locks with keypad access and mechanical stops on all windows to prevent windows from fully opening to prevent potential incidents; -The facility's investigation concludes that Resident #68 exited the facility from the third floor window attempting to gain access to the second floor balcony. As a result, sustained multiple injuries. Further interview of the resident and review of hospital records indicate that his/her intention was to exit the facility and drive to Cincinnati; -Resident #68 has not displayed any recent negative behaviors that may include sadness, isolation, suicidal ideation, exit seeking or aggression; -It was found that Resident #68 was able to circumvent the mechanical stop that was preventing the window from fully opening. Our investigation was unable to prove how the resident was able to remove the mechanical stops as no items or foreign devices were found at the window or near the resident outside where he/she was found. Upon inspection of the window, it was found that a screw was lying on the right side of the window sill. The screw that was originally placed on the left side of the window was bent upward showing signs the window was forced upward to be able to be opened; -All windows on the locked behavioral unit were audited and checked for safety immediately, and subsequently all windows in the building were audited and deemed safe with mechanical stops in place. Environmental audits are on-going, all staff were educated on signs of psychosocial distress, elopement and resident safety, elopement and psychosocial assessments performed. During an interview on 4/27/22 at 9:54 A.M., Resident #68 said about a week ago, he/she was depressed and jumped from the third floor window in an attempt to kill him/herself. He/she jumped and landed on the first floor balcony and broke his/her back and legs. The window was a three panel window and he/she was able to open the window with no difficulties. He/she thought it happened around 1:00 P.M. No staff or residents were present when he/she decided to jump out of the window. He/she did not inform anyone the day of the incident that he/she was depressed and planned to try to commit suicide. He/she had not told the SSD about his/her plans. When asked if the resident spoke with the SSD about any of his/her concerns or any issues over the last six to eight months, the resident replied No. At the moment, he/she was not feeling suicidal or depressed. Review of the resident's Wandering Risk Assessment, dated 4/2/22, showed; -High risk to wander; -Has history of wandering; -Has medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Has wandered in the past month. Further review of the resident's progress notes, showed: -4/14/22 at 3:32 P.M., the resident was readmitted from the hospital with multiple fractures and a turtle brace (Used to stabilize the spine after surgery or in the event of a spinal fracture to promote healing and decrease pain) to be worn at all times. Pins in the ankles and bruises from face to extremities, neck, thighs, back, total care, Hoyer (mechanical lift), bed rest, alert and oriented to person, place and time. Bed in low position; -4/14/22 at 11:54 P.M., the resident observed removing bandages, cast and tractions (a set of mechanisms for straightening broken bones or relieving pressure on the spine and skeletal system) in bilateral legs. Resident was advised to stop but was not compliant. Suture sites are now bleeding actively, bandages placed on site at this time. Ambulance has been called and awaiting transport to hospital at this time to rebandage and recast fracture sites; -4/15/22 at 5:47 A.M., resident returned from the hospital at this time. Alert and aware of surroundings. Review of the resident's Significant Change MDS, dated [DATE], which included the PHQ-9 assessment (Patient Health Questionnaire-9, assessment for depression), showed in the last 14 days: -Feeling down, depressed or hopeless? Yes, one day; -Poor appetite or overeating? Yes, one day; -Feeling bad about yourself-or that you are a failure or have let yourself or your family down? Yes, two to six days; -Thoughts that you would be better off dead, or of hurting yourself in some way? Yes, two to six days. During an interview on 4/28/22 at 10:48 A.M., the SSD said she worked at the facility since December 2021. She was responsible for the social services assessments. She also conducted Trauma Assessments, Initial Psychosocial Assessments and was responsible for the social services portion of the MDS. The MDS coordinator updated care plans when new issues arise. If it is an emergency situation, department heads can update the care plan. She was not sure why the resident fell from the window. She does rounds with residents on a daily basis and has been in communication with the resident's family member. The family member/POA would contact her and tell her the resident was agitated and would make statements. She explained to the resident's family member that due to resident's diagnoses, this was his/her baseline behavior. The resident never mentioned being depressed or suicidal. The family member/POA told the SSD the resident was dealing with past trauma and inquired about additional services for the resident, as he/she was becoming increasingly anxious. The SSD did not ask the family member what those past traumas were about. She told the family member she would follow up. Around 3/23/22, the family member/POA called her again because the resident was making concerning statements. The SSD said she did not ask the family members about the concerning statements. However, she told staff to watch the resident because he/she was agitated. The doctor was not notified about the resident's family concerns about his/her change of condition. She could not recall which staff she told to monitor the resident. The SSD inquired about an outside counseling service, but the DON was supposed to follow-up with the provider and she was not sure if the DON followed up. Nursing handles psychiatric services. The SSD said her own memory was not good so she wrote down information on note pads. On 2/21/22, the family member/POA called the SSD to discuss the resident's increasingly anxious behaviors. At that time, she told staff to monitor the resident closely. On 3/22/22, she spoke with the resident's family member/POA, who requested a care plan meeting. On 3/23/22, she met with the resident's family member/POA and the MDS coordinator. At that time, she did not discuss the resident's triggers or past trauma. On 3/29/22, she spoke with the resident after receiving another call from the family member/POA, and the resident was pleasant. The resident was alert and oriented and could make his/her needs known. She could not recall if she spoke with the resident's physician regarding the concerns the resident's family brought up about the increasingly anxious behaviors. Review of the resident's care plan, updated on 4/17/22, reviewed on 4/28/22 at 7:50 A.M., showed: -Focus: Resident is an elopement risk/wanderer related to history of attempts to leave facility unattended; -Goal: The resident's safety will be maintained through the next review date. He/she will not leave the facility without supervision; -Interventions: Assess for fall risk. Identify pattern of wandering. The resident's triggers for wandering/eloping are de-escalated by medication administration. Monitor for fatigue and weight loss; -Focus: The Resident has impaired cognitive function at times related to Alzheimer's disease; -Goal: The resident will be able to communicate basic needs on a daily basis through the next review date; -Interventions: Administer medications as ordered. Ask simple yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Monitor and document any changes in cognitive function. Reminisce with the resident inquiring about family/friends. The resident needs supervision with all decision making; -The care plan did not address suicidal ideation or behaviors related to anxiety or agitation as of 4/28/22 at 7:50 A.M. Further review of the resident's progress notes, showed on 4/18/22 at 4:47 A.M.: -Monitoring during night. Alert and oriented during shift. Multiple attempts to remove upper body brace by resident. Unable to redirect. Places self on mattress to floor. Denies any pain or discomfort. Resident stated multiple times, Just let me die. I'm all broken. Denies hearing voices. Right lower extremities warm to touch. Some noted swelling. No active bleeding. Morning medication as ordered. Resident up in recliner; -No documentation staff notified the resident's physician of the resident's statements. During an interview on 4/28/22 at 2:09 P.M., the DON said the in-house psychiatric nurse practitioner (NP) was at the facility on 4/22/22 and she asked the NP to see the resident. Review of the resident's psychiatric evaluation, dated 4/22/22, showed: -Chief Complaint: The resident is being seen to establish with new psychiatric provider. He/she recently jumped out of the window of his/her third floor room. Facility relayed that patient told hospital staff he/she was attempting to elope out of state. He/she is calm and appears comfortable. He/she agrees to speak with this author; -Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Social History: History was provided by the resident, who is not a reliable historian; -Thought Content: Absent of suicide or homicidal intent; -Judgment: Poor; -Insight: Poor; -Memory: Impaired; -Orientation: Alert and oriented to self; -Assessment: The resident exhibits latency in thought and speech. He/she answers with one word answers. Suspect long complicated psychiatric history and multiple self harming events and suicidal attempts but he/she is not forthcoming or may not recall. At this time, the resident denies thoughts of hurting him/herself. He/she denies all mood and psychotic symptoms. Will need to review chart further and attempt to collect a better history from a collateral source. As he/she is new to this author, baseline has not yet been established. Complexity of his/her mental condition is severe. Functionality is low. Further review of the resident's progress notes, showed: -4/27/22 at 10:08 P.M., resident asked staff member for a knife or gun so he/she could kill him/herself. Resident was yelling at staff, cussing them out, calling them names. Resident was trying to climb out of bed, continued to pull the call light out of wall. When asked to stop, he/she would just yell; -Staff did not document notifying the resident's physician of the change in status; -4/28/22 at 2:31 A.M., Nurse H was given in report from off going agency nurse resident has been verbalizing killing him/herself and placed call light around neck multiple times in an attempt to strangle self. Call placed to MD to make aware. MD ordered transfer to the hospital for a psychiatric evaluation. During an interview on 4/28/22 at 2:12 P.M., the resident's family member/POA said the resident had been at the facility for six years. He/she was placed at this particular facility because of suicidal ideation. While in the community, the resident attempted suicide. Over the years, the resident had experienced anxious behavior while at the facility. Behaviors included wandering, physical behaviors directed towards staff and other residents. When he/she becomes anxious, he/she tends to flee. The resident was also dealing with past traumas of alcohol and sexual abuse. This was communicated with the previous social worker, the social worker would schedule an appointment with the psychiatrist. Within the last eight months, the resident's behaviors have increased. When he/she spoke with the resident recently, the resident said he/she had not seen a psychiatrist and had not spoken to the social worker. The family member/POA contacted the current SSD to speak with her about behavioral services for the resident. The SSD told him/her she would look into outside services for the resident. A little over a month ago, the resident called the representative and appeared to be experiencing anxious behaviors. Again, she spoke with the SSD, who told him/her she would look into services. The SSD also told the representative she spoke with the resident, and the resident appeared to be fine. The approach from the facility was, Everything was okay. In March 2022, the representative contacted the SSD and requested a care plan meeting. During the care plan meeting, the family member/POA told the SSD and the other staff member present the resident was dealing with past traumas related to alcoholism and physical and sexual abuse. A few days before the resident jumped from the window, he/she visited with the resident and the resident appeared anxious. The representative told staff at the facility the resident was exhibiting behaviors. He/she could not recall who he/she spoke with, but they said they would continue to monitor the resident. The family member/POA then received a call from the facility informing him/her the resident went out of the window and landed on the second floor balcony. When the resident returned, the representative spoke with the DON, who told the representative the facility would refer the resident to the in-house psychiatric nurse practitioner. On 4/28/22, the family member/POA received a call from the facility informing him/her the resident was sent to the hospital for suicidal ideation. During an interview on 4/28/22 at 9:11

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent and implement appropriate interventions for one resident who experienced a fall resulting in a fractured wrist and shoulder (Resident #8) due to the staff leaving the resident's side. In addition, the facility failed to provide adequate supervision for an elopement (leaving the premises or a safe area without authorization and/or any necessary supervision to do so) from a secured unit (Resident #32). In addition, the facility failed to provide oversight for one resident with a history of falls (Resident #82). The facility failed to ensure the residents environment remained free of accident hazards when staff failed to ensure the soiled utility room, where hazardous material is stored, was locked and inaccessible to residents. Also, the facility failed to complete a smoking assessment for one resident (Resident #43). The sample was 24. The census was 121. 1. Review of the facility's Fall Evaluation and Prevention policy, revised 8/2020, showed: -Purpose: To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents; -Policy: The facility will evaluate residents for their fall risk and develop interventions for prevention. The goal is to prevent falls if possible and avoid any injury related to falls. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed; -Intervention suggestions for fall prevention included place bed in lowest position and lock wheels; -Education of staff related to fall prevention, includes: -Providing a safe environment for residents; -Cause and risk factors for falls as well as the interventions to manage risk; -Safe transferring techniques; -Use of assistive devices. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 10/5/21, showed: -No cognitive impairment; -Total dependence of two (+) person physical assist required for bed mobility, transfers, locomotion; -Total dependence of one person physical assist required for toilet use; -Required extensive assistance of one person physical assist for personal hygiene; -No upper or lower impairment; -Diagnoses included [CONDITION(S)] ([CONDITION(S)], kidney disease), high blood pressure, seizures, anxiety, depression, [CONDITION(S)] (a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), [CONDITION(S)] (serious mental illness that affects how a person thinks, feels, and behaves), [CONDITION(S)], restlessness and agitation and repeated falls; -One fall with injury since last assessment. Review of the resident's quarterly fall risk assessment, dated 11/23/21, showed the resident identified as moderate risk for falling. Review of the resident's progress notes, dated 12/18/21, showed: -At 7:12 A.M., at 4:52 A.M., nurse called to room by CNA. Observed resident on bed, right side, dangling off bed. CNA stated he/she went to wet his/her towels and the resident rolled. Resident assessed, bed lowered, and resident was able to roll back onto bed. Range of motion to upper extremities, complained of discomfort when resident's left arm extended. Given [MEDICATION(S)] (pain medication). Scheduled for [CONDITION(S)] this morning, leave of absence to [CONDITION(S)]; -At 11:01 A.M., it was reported the resident was hanging on the side of the bed and complained of his/her left elbow hurting. Resident went out to [CONDITION(S)]. Physician notified of incident and that resident received [MEDICATION(S)] for pain. Received call from [CONDITION(S)] and informed that resident requested to go to the emergency room (ER) for complaint of left arm and hip pain. Resident transferred to ER from [CONDITION(S)]. Time of call was 9:11 A.M; -At 3:13 P.M., report received from ER. Resident had fracture to left shoulder and left wrist. Resident will return to facility with left shoulder splint. Resident also has urinary tract infection ([CONDITION(S)]) and will be on antibiotics; -At 5:40 P.M., the resident returned to the facility from the hospital with a fractured left shoulder and left wrist. Sling in place. Resident stable with minimal pain. Physician notified of resident's return and medications verified. Review of the facility's investigation form, signed by the DON on 12/19/21, showed: -Date and time of occurrence: 12/18/21, 6:59 A.M.; -Detailed description of original allegation/event: Staff nurse was called to room by assigned CNA. While activities of daily living (ADL) care was being provided, the CNA walked to wet a towel when this resident rolled onto the right side, dangling out of the bed; -Assessment of resident/description of injury: Left arm pain; -Resident interview summary: Resident reported he/she tried to turn while the CNA went to walk away; -Immediate resident protection initiated: Resident's bed was moved along the side of the wall. Half side rails were intact and floor mat on the floor; -Summary of investigation findings: Resident rolled onto right side of bed, dangled along the side of the bed. Was assisted onto the bed. While staff was assessing this resident's range of motion, resident complained of pain to left arm. Pain management was given prior to this resident leaving for scheduled [CONDITION(S)] appointment. Review of the resident's care plan, showed: -Focus: On 6/1/20, resident lowered to floor by staff. Resident has history of leaning to left side while in bed. On 8/11/21, rolled out of bed onto the floor, attempted to get money off of the floor. Noted bruise to head; -Goals: Resident will call when he/she needs assistance with ADLs. He/she will remain free from injury related to poor ADL mechanics; -Interventions included bed in lowest position, side rails removed, mat placed on floor to left side. Two person assist with transfers; -Focus: Resident has limited physical mobility related to weakness, has poor trunk control, history of leaning to left side of bed, history of refusing to get out of bed; -Goals: Resident will remain free of complications related to immobility, including fall related injury through next review date. Resident will maintain current level of mobility transfer with two assistance using a gait belt from surface to surface. He/she refuses to transfer using a Hoyer lift; -Interventions included: Hoyer lift (mechanical lift) for transfers. Staff position resident for proper alignment while in bed. Resident requires assistance of two staff members and a gait belt for transfers. -Focus: 12/18/21 fractured to left proximal humerus (portion of the arm bone between shoulder and elbow, closest to the shoulder) and left distal radius (end portion of the forearm, closest to the wrist) fracture; -Interventions included: No weight bearing status to left arm, maintain left shoulder in sling. Bed in lowest position when not providing care. Don't leave unattended with side rails down. Left hand brace. Mat to left side of bed. Two person assist with transfers. -Focus: Resident is at risk for falls. Resident keeps bed in a high position and needs reminders to call for help; -Goals: Resident will be free of injury related to falls; -Interventions: Educate on fall risk as needed. Two quarter-length side rails to aide in bed mobility and repositioning. Encourage resident to keep bed in low and locked position. Two person assist with transfers; -The care plan did not specify type of staff assistance and number of staff required for personal care and toileting. Observation on 1/18/22 at 1:01 P.M., showed the resident on a stretcher, wheeled into his/her room by two staff. Staff used a sliding board to transfer the resident from the stretcher to his/her bed. Staff raised a quarter-length side rail on the left side of the resident's bed, and left the room. The right side of the resident's bed was flush to the wall. The resident's bed was positioned approximately 3 feet above the floor. No fall mat was on the floor. The resident's left wrist was in a brace. During an interview, the resident said he/she fell out of bed recently because the bed was too high. When he/she fell , his/her left wrist hit the air-conditioning unit. Observation on 1/19/22 at 12:54 P.M., showed the resident lay on his/her back in bed with a quarter-length side rail raised on the left side of the bed. The resident's bed was positioned approximately 3 feet above the floor. No fall mat was on the floor. Observation on 1/20/22 at 12:28 P.M., showed the resident seated upright in bed with a quarter-length side rail raised on the left side of the bed. The resident's bed was positioned approximately 3 feet above the floor. No fall mat was on the floor. During an interview on 1/25/22 at 7:19 A.M., the DON and administrator said prior to Resident #8's fall on 12/18/21, the resident required one person to assist with personal care. The DON said she investigated the resident's fall. During the investigation, the DON discovered the CNA walked away from the resident while the resident's bed was raised in a high position. Before providing care, CNAs should gather all materials needed before they enter the resident's room. If the CNA forgot something, they should have called for another employee to come help them. At minimum, the resident's bed should have been lowered when the CNA walked away. 2. Review of the facility policy, titled Elopement Prevention, revised 7/2021, defined elopement as having occurred when a resident left the facility without the expressed knowledge or approval of the facility or an authorized representative of the facility. The Centers for Medicare and Medicaid Services (CMS) defined elopement as leaving the facility premises or a safe area without authorization such as an order for discharge or leave of absence. Residents identified as being at risk for elopement were to have an individualized plan of care developed and implemented which attempted to reduce their elopement or flight risk. In response to an actual elopement attempt, if staff placed the resident on increased supervision, then they were to document safety checks in the clinical record/electronic medical record (EMR) each shift for the duration of the increased supervision. Review of Resident #32's wandering/elopement assessment, dated 8/2/21, showed the resident was assessed as having the potential/being at low risk for wandering or elopement. Review of the resident's undated diagnosis sheet, included the following diagnoses: [CONDITION(S)], paranoid [CONDITION(S)] (a subtype of [CONDITION(S)] characterized by the presence of auditory hallucinations or prominent delusional thoughts about persecution or conspiracy), restlessness and agitation, sexual disorders, mood [affective] disorder (a mental health disorder in which a person experiences long periods of extreme happiness, extreme sadness or both), intellectual disabilities, problems related to lifestyle (self-damaging behavior) and sexual dysfunction not due to a substance or known physiological condition. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/4/21, showed the following: -Cognitively intact; -Psychosis: hallucinations; -Wandering behavior occurred one to three days; -Required supervision of one for locomotion off of the unit; -No mobility devices. Review of the resident's care plan, showed no identified elopement risk or preventative interventions. Review of the resident's progress note, dated 1/5/22 at 10:10 P.M., showed the resident kept going to the door, saying he/she was going to leave. Staff redirected the resident to his/her room several times. The resident went back to the door, so the nurse called the resident's parent to inform him/her of the resident's behavior. The resident told the responsible party that the resident no longer wanted to be at the facility. The resident agreed to go back to his/her room. At 11:13 P.M., the administrator received a call from staff saying the resident was returned to the facility by his/her parent, who said the resident described getting out of the locked unit behind a worker. The resident, who was alert and oriented times two (to person and place), did not exhibit any signs of distress and had no bruises, scratches or discolored skin. Review of MapQuest.com showed the resident walked 1.2 miles to the store. Review of the weather history for 1/5/22 at 9:51 P.M., showed the temperature was 21 degrees Fahrenheit. Further review of the resident's care plan, updated 1/6/22, showed the following: -The resident had a guardian; -Psychiatric consult as needed; -At risk for falls related to potential adverse effects from taking medications to manage symptoms of [CONDITION(S)] and hypersexuality (pathologically increased sexual behaviors/obsessive fixation on sex); -The resident could be resistant to care and required redirection from making sexual remarks toward staff; -1/6/22, episode of elopement related to the resident being anxious (stating he/she wanted to get out of the facility). Review of the facility's investigation form, dated 1/11/22, showed on 1/5/22 at about 10:00 P.M., certified medication technician (CMT) R last saw the resident at or around 10:00 P.M. No alarm sounded on the unit, indicating that someone left the unit. The night supervisor saw a woman walking into the facility and asked if she needed help, the woman said that between 10:31 P.M. and 10:38 P.M., a store clerk had called and put the resident on the phone. The resident asked to be picked up. The woman was returning him/her to the facility. She said the resident appeared to be anxious. The two CMTs later said they heard the resident speaking about wanting a girlfriend. They denied hearing the resident mention that he/she wanted to leave the facility or saying he/she was going to leave. The certified nurse aide (CNA) on duty in the unit did not interact with the resident during the entire shift. The resident said he/she was mad, because the the girls were breaking his/her heart, he/she needed to get out and clear his/her mind. After eloping, the resident got cold while walking, went to Walgreens and asked the store clerk to call his/her parent. The resident said he/she did not tell anyone he/she hated the facility and was going to leave, that the elopement was unplanned. During an interview on 1/20/22 at 2:45 P.M., CMT Q said on the night in question, the other CMT left for the night at 8:00 P.M. A little before 10:00 P.M., the resident started going back and forth, to the doors leading out of the unit. He/she did it three times. The resident was saying that he/she wanted leave the facility and go home. Staff tried to redirect him/her, but the resident said he/she did not want to be there anymore. It was the first time, in CMT Q's three months working at the facility, that CMT Q heard the resident express the desire to leave. At 9:45 P.M., staff got the resident's family member on the phone, to assist in their efforts to redirect the resident, by allowing the resident to speak to him/her. CMT Q last saw the resident at around 10:15 P.M. After walking the resident to his/her room, CMT Q went to the bathroom and then sat at the nursing station for the remainder of his/her shift. He/she was gathering his/her things, preparing to go home, when the nursing supervisor escorted the resident back onto the unit at around 11:05 P.M. During an interview on 1/19/22 at 1:05 P.M., Nurse R said he/she was not familiar with the resident. On the night in question, there were four staff members on duty in the unit: Nurse R, two CMTs and a CNA. The resident kept coming up to the nurse's station to talk and asking about dinner. After dinner, at around 8:00 P.M., the resident started going to the doors leading out of the unit. He/she did that two or three times, looking out through the windows in the doors. The last time he/she went to the doors, he/she did not seem to want to come away from them. Someone suggested having the resident talk to his/her parent. At that point, he/she was not upset. Nurse R only heard the resident say something about leaving to his/her family member over the phone. Nurse R heard the resident say that he/she wanted to go home. After that phone call, the resident went to his/her room. That was the last time Nurse R saw the resident, prior to his/her elopement. Nurse R sat at the nurse's station with CMT Q throughout the remainder of the shift and charted. Nurse R had only gotten up once to use the bathroom at around 9:00 P.M. Nurse R was shocked when the night supervisor returned the resident to the unit, saying his/her family member picked the resident up from a store. Nurse R had not seen the resident leave the unit and did not know he/she was gone. During an interview on 1/18/22 at 2:15 P.M., the resident said he/she was upset on the night of his/her elopement, but did not recall expressing to staff the intent to leave. He/she just saw a female staff person (name unknown) leaving and followed her out of the locked unit. The resident was able to get to the first floor unobserved and walked past the security guard seated at the receptionist desk (when the guard was looking down) and exited the facility via the front door. During an interview on 1/28/22 at 2:56 P.M., the Director of Nursing (DON) said when a resident expressed the intent to leave a secure unit and engaged in behaviors such as repeatedly going to the doors leading out of the unit despite redirection, staff were expected to put the resident on 15 minute checks and notify the receptionist at the front desk. There should be photographs of all residents, identified as being at risk for elopement, posted at the receptionist desk. The increased level of supervision should continue, as long as the behaviors and expressed desire to leave continued. During an interview on 1/25/22 at 8:13 A.M., the administrator said the facility alarms and door locks were tested and were fully functional. When a resident on a secured unit expressed the intent to leave and/or repeatedly went to the doors leading out of the unit, it was the responsibility of staff on the unit to ensure the resident did not continue to stand by the doors and maintain line-of-sight supervision or increase monitoring to 15 minute checks. One out of the four staff on duty on the unit said the resident was at the door, saying he/she wanted to leave. None of them admitted to the resident exiting the unit behind them. They each said they had gone to the bathroom and consequently did not see the resident elope or know the resident was missing, until his/her return to the unit. Seated at the receptionist desk near the facility entrance was a security guard, contracted via a private security company, who was so hard of hearing that one had to stand in front of him/her and shout in order to be heard. The security guard did not see the resident walk out of the facility. As a contracted security guard, he/she would not have known if someone leaving was a visitor or resident, since there was no cut off time at night for visitation and there was not enough time to thumb through the elopement book every time someone left. After the resident eloped, the facility began posting pictures at the receptionist desk of residents at risk for elopement. The resident was at risk for harm, out in the community unsupervised, due to his/her cognitive impairment and mental health issues. During an interview on 1/24/22 at 2:54 P.M., Psychiatric Nurse Practitioner (NP) S said he/she was new to the facility and had not yet met the resident due to the facility Covid lockdown and NP S recently contracting Covid. NP S had performed a chart review. Part of the resident's cognitive impairment impacted his/her impulsivity, judgment, personality and the reward system in the brain. Consequently, the resident had no insight and poor judgment. He/she also had a history of sexually inappropriate behavior. The resident was very much so at risk for harm out in the community unsupervised due to the cognitive impairments and poor judgment posing a risk for him/her engaging in risky and/or impulsive behaviors. The resident was childlike and consequently could be induced to do things that the average person would not do. The resident's behaviors of saying he/she wanted to leave and repeatedly going to the doors leading out of the unit warranted one-to-one staff supervision. 3. Review of Resident #82's medical record, showed: -admitted [DATE]; -Diagnoses included stroke, [CONDITION(S)] (paralysis of one side of the body), depression and anxiety; -A quarterly fall risk assessment, dated 9/16/21, showed the resident identified as high risk for falling. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Required extensive assistance of one person physical assist for bed mobility; -Total dependence of two (+) person physical assist for transfers; -Upper and lower extremities impaired on one side; -Two or more falls since last assessment. Review of the resident's care plan, showed: -Focus: Resident is at risk for falls. Gait/balance problems, diagnosis of stroke with left side weakness. Resident is non-ambulatory. On 6/29/21, noted on the floor with no injuries. On 9/27/21, reported he/she fell out of bed. On 10/2/21, noted on mat next to bed with no injuries; -Goals: Resident will not have significant injuries related to falls through next review; -Interventions included mat to right side of bed. Observation on 1/18/22 at 12:14 P.M., showed the resident seated upright in bed. No fall mats were on the floor. During an interview, the resident said he/she is paralyzed on the left side and requires staff to assist with transfers. He/she has had a million falls, and none resulted in injury. Observation on 1/18/22 at 1:23 P.M., 1/19/22 at 12:45 P.M., 1/20/22 at 12:39 P.M. and 5:56 P.M., and 1/21/21 at 7:27 A.M., showed the resident in bed. No fall mats were on the floor. During an interview on 1/24/22 at 10:08 A.M., CNA G said he/she works at the facility full time and knows the residents well. He/she requires one staff to physically assist with transfers and he/she requires total care for other ADLs. CNA G was not sure if the resident had a history of falls or requires fall interventions, such as a fall mat. The resident is always in bed when he/she is not at [CONDITION(S)]. He/she requires two people to assist with repositioning and personal care. Before providing personal care, staff should gather all items needed in advance, such as a water basin, towels, soap, clothes and bags. During care, they might have to raise a resident's bed in order for staff to reach them. When care is completed, staff should lower the resident's bed. Staff should not leave a resident in a bed raised in a high position because the resident could roll and fall. If a resident is at risk for falls, staff should place a fall mat next to their bed when they are finished providing care. Residents have care plans in their electronic medical record, but CNAs are informed of fall interventions when they receive report from the nurse. During an interview on 1/24/22 at 9:16 A.M., Nurse B said Resident #82 requires staff assistance with transfers and ADL care. He/she had a fall from his/her wheelchair, but the nurse could not recall if there were any other falls. The resident has side rails as a fall intervention. He/she has a history of falls, usually because he/she rolls over when trying to reach something. The resident does not get out of bed too much. He/she requires one staff person to assist him/her with personal care and bed baths. When staff is going to provide care, they should prepare everything in advance and gather their supplies, such as towels and ointments. If everything is ready in advance, staff would have no reason to leave a resident unattended. If staff need assistance or additional items during care, they should call for help. It would not be appropriate to walk away while a resident is in a bed raised in a high position. The resident's fall interventions include a fall mat, side rails, and keeping the bed in a low position. Interventions are reflected on a resident's care plan. Fall interventions and care needs are communicated to CNAs during report. During an interview on 1/27/22 at 12:04 P.M., the resident's physician/facility medical director said he expected staff to always put a resident in a safe position before leaving the room. The aide should have ensured the resident was in a secure position before leaving. His expectation is for staff to follow the resident's care plan for interventions, put in place by the facility. 4. During an interview on 1/25/22 at 7:19 A.M., the DON and administrator said following a resident's fall, the interdisciplinary team (IDT) gets together to discuss appropriate interventions. Old interventions are assessed to see what worked and what did not. They try to identify the root cause of a resident's fall so they can put the proper interventions in place. Fall interventions are documented on the resident's care plan and should be resident-specific. The care plan is updated by the MDS coordinator or nurses. Fall interventions are communicated to department heads during the weekly IDT meetings, and when the charge nurse gets report before each shift. 5. Review of the facility's Sharp Object Disposal policy, reviewed 7/2014, showed: -General: All sharps including needles, syringes, scalpels, and razors are disposed of in an appropriate sharps container; -Guidelines: 1. All sharps are dropped into the sharps container needle first. Never cut or recap a needle; 2. Never place your hand in a sharps container; 3. When a sharps receptacle is ¾ full, the nurse is responsible for alerting the responsible department to replace the container, or to replace the container themselves; 4. When the new sharps receptacle is replaced, make sure it is secured into place and the opening is facing outward; 5. If the nurse is responsible for removing the filled sharps receptacle, place the receptacle in the designated place for appropriate storage based on state and federal guidelines. Review of the facility's census report, dated 1/18/22, showed 39 residents occupied the first floor. Observation of the first floor on 1/18/22 at 11:59 A.M., showed the soiled utility room door open with no staff present. Three uncovered trashcans were filled with soiled linens. A red biohazard tub was open and filled with an overflow of full sharps containers, approximately 6 inches above the top of the biohazard tub opening. Observation of the first floor on 1/19/22, showed: -At 6:44 A.M., the soiled utility room door open with no staff present. Two trash bags were filled with soiled linens and four full sharps containers in an open biohazard tub; -At 12:42 P.M., the soiled utility room door open with no staff present. Three uncovered trashcans were filled with soiled linens. A red biohazard tub was open and filled with full sharps containers. The top sharps container was uncovered and filled with syringes and other materials; -At 12:46 P.M., CNA G entered the soiled utility room and dropped soiled linens into a trashcan. He/she pulled the door as he/she exited the room and left the door ajar; -At 12:52 P.M., CNA H opened the soiled utility room door and allowed a resident to enter the room while the CNA supervised. The resident exited and CNA shut the door all the way. Observation of the first floor on 1/20/22 at 12:21 P.M., showed the soiled utility room with two uncovered trashcans filled with soiled linens. A red biohazard tub was open and filled with an overflow of full sharps containers, approximately eight inches above the top of the biohazard tub opening. CNA G entered the soiled utility room and dropped soiled linens into a trashcan. He/she exited the room and left the door ajar. At 12:38 P.M., CNA G entered the soiled utility room and dropped off soiled linens. He/she closed the door upon exiting the room. During an interview on 1/24/22 at 10:08 A.M., CNA G said the soiled utility room is hazardous because it is where used sharps and soiled linens go. The soiled utility room should be locked at all times and inaccessible to residents due to safety reasons. Upon exiting the soiled utility room, staff should make sure the door closes behind them. During an interview on 1/24/22 at 9:16 A.M., Nurse B said used razors and syringes are placed in sharps containers. When sharps containers are full, the nurses put them in a red biohazard tub in the soiled utility room. Sharps containers should be locked. Residents should not have access to the soiled utility room due to the hazardous materials stored in the room. Staff must ensure the door to the soiled utility room closes behind them. During an interview on 1/25/22 at 7:19 A.M., the DON and administrator said used razors and syringes are disposed of in sharps containers. When the sharps container is full, it should be locked and placed in a biohazard box in the soiled utility room. The soiled utility room should be accessible to residents. Staff should ensure the soiled utility room is locked behind them. 5. Review of Resident #43's medical record, showed diagnoses included paranoid [CONDITION(S)] and nicotine dependence. Review of the resident's Smoking Assessment, dated 9/17/21, showed the resident was safe to smoke with supervision. Review of the resident's care plan, updated on 10/29/21, showed: -Focus: The resident enjoys smoking and has the potential for smoking related injuries such as [CONDITION(S)] to his/her skin and clothes. He/she has wet lungs (Acute respiratory distress syndrome (ARDS) is a medical condition in which the lungs are not working properly and oxygen blood levels are too low) frequently and has refused all smoking substitutes offered; -Goal: The resident will remain free from injury related to smoking through the next review; -Interventions: Resident is a supervised smoker and will only smoke in the designated areas on the unit. Instruct him/her about the policy on smoking. Observe clothing and skin for signs of cigarette [CONDITION(S)] and notify charge nurse immediately if it is suspected that the resident violated the facility smoking policy. Review of the resident's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Moderate cognitive impairment; -Exhibited delusions, verbal behaviors and rejection of care one to three days per week; -Required limited assistance of one staff for locomotion on the unit. Review of the resident's medical electronic record, last reviewed on 1/25/22 at approximately 1:00 P.M., showed the Smoking Assessment 39 days overdue-due 12/17/21. During an interview on 1/25/22 at 1:50 P.M., the administrator and DON said smoking assessments should be done upon admission, annually and quarterly. The administrator provided a Smoking Assessment for the resident with a handwritten date of 1/13/22. MO 525

Based on observation, interview and record review, the facility failed to ensure staff were able to provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care in accordance with physician's orders [REDACTED]. status when needed. The facility failed to obtain an ordered code status for 13 residents (Residents #13, #77, #103, #67, #75, #26, #54, #104, #126, #87, #88, #97 and #32), failed to ensure residents'/resident representatives wishes for code status matched the physician ordered code status for two residents (Residents #107 and #114), failed to ensure one resident's code status was ordered timely after admission (Resident #40) and failed to ensure a process for staff to know a resident's code status in the event of electrical or electronic medical record outage. This had the potential to affect all residents who resided in the facility. The sample was 29. The census was 146. The administrator was notified on [DATE] at 1:43 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's untitled policy, dated [DATE], provided as the facility's policy and procedure for resident code status and advanced directives, showed: -While awaiting a physician's orders [REDACTED]. to refuse CPR (DNR, do not resuscitate). At minimum, a verbal declination of CPR by a resident, or if applicable a resident's representative, should be witnessed by two staff members. While the physician's orders [REDACTED]. -Advance directives: The right to formulate an advance directive applies to each and every resident and facilities must inform residents of their option to formulate advance directives. If a resident has a valid advance directive, the facility's care must reflect the resident's wishes as expressed in their directive; -Facility Policies: Facility policies should address the provision of basic life support and CPR, including: -Directing staff to initiate CPR when cardiac or respiratory arrest occurs for residents who do not show obvious clinical signs of irreversible death and who have requested CPR in their advanced directives or who have not formulated an advanced directive or who do not have a valid DNR order; -The policy failed to identify the process to document code status and to assure the code status is congruent and available during electronic medical record down time. 1. Review of Resident #13's electronic physician order [REDACTED]. Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE]. Review of the social service signed code status binder, located in the social service office, showed no signed code status. During an interview on [DATE] at 7:41 P.M., the Social Service Director (SSD) said he/she obtained verbal wishes for a full code on [DATE]. 2. Review of Resident #77's ePOS, reviewed on [DATE], showed no ordered code status. Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE]. Review of the social service signed code status binder, located in the social service office, showed full code, signed [DATE]. During an interview on [DATE] at 7:41 P.M., the SSD confirmed the resident's code status form was signed on [DATE] as a full code. There was no order for the full code in the ePOS. 3. Review of Resident #103's ePOS, reviewed on [DATE], showed no ordered code status. Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE]. 4. Review of Resident #67's ePOS, reviewed on [DATE], showed no ordered code status. Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE]. 5. Review of Resident #75's ePOS, reviewed on [DATE], showed no ordered code status. Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE]. Review of the social service signed code status binder, located in the social service office, showed no signed code status. 6. Review of Resident #26's ePOS, reviewed on [DATE], showed no ordered code status. Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE]. 7. Review of Resident #54's ePOS, reviewed on [DATE], showed no ordered code status. Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE]. 8. Review of Resident #104's ePOS, reviewed on [DATE], showed no ordered code status. Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE]. 9. Review of Resident #126's ePOS, reviewed on [DATE], showed no ordered code status. Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE]. 10. Review of Resident #87's ePOS, reviewed on [DATE], showed no ordered code status. Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE]. Review of the social service signed code status binder, located in the social service office, showed no signed code status. 11. Review of Resident #88's ePOS, reviewed on [DATE], showed no ordered code status. Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE]. 12. Review of Resident #97's ePOS, reviewed on [DATE], showed no ordered code status. Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE]. 13. Review of Resident #32's ePOS, reviewed on [DATE], showed no ordered code status. Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE]. 14. During an interview on [DATE] at 8:56 [NAME]M., the SSD said she is responsible to obtain a resident's code status wishes upon admission. If she is off work, the charge nurse is responsible. 15. During an interview on [DATE] at 10:07 [NAME]M., the Director of Nursing (DON) said resident code statuses are reviewed during the quarterly care plan meetings. A resident without a code status should have been identified as not having a code status at the quarterly meeting. 16. Review of Resident #107's ePOS, showed an order dated [DATE], for full code. Observation on [DATE] at approximately 9:15 [NAME]M., showed Licensed Practical Nurse (LPN) I passed medications to residents on the hall. A staff person came out of the resident's room and asked LPN I to call Assistant Director of Nursing (ADON) [NAME] ADON A came to the floor, then two staff members came out of the resident's room and told LPN I the resident expired and time of death was 9:21 [NAME]M. No CPR was performed. LPN I continued to pass medications to residents on the hall. During an interview on [DATE] at 10:08 [NAME]M., LPN I said he/she needed to look in the computer to know the resident's code status. LPN I looked in the computer and said he/she was having trouble finding the code status, but I know the resident is a DNR, otherwise staff would have done CPR. At 10:15 [NAME]M., LPN I said Nurse Practitioner (NP) W was the person who came to him/her to call ADON [NAME] The resident was on hospice and was a DNR. The ePOS said full code, but the resident is on hospice. During an interview with ADON A at this time, he/she said he/she was called to the floor. NP W was in to see the resident and he/she did not hear heart or lung sounds. He/she also checked and did not hear anything. The resident was a DNR and the death was expected. During an interview on [DATE] at 10:20 [NAME]M., the administrator said she would check into the resident's code status. She was pretty sure the code status was changed in the hospital to a DNR. Code status should be updated and accurate. The nurse who admitted the resident should make sure the code status is updated. The administrator went to the second floor and talked with staff about the resident's code status. ADON A got the hospice binder out of the office and said the resident came back from the hospital as a full code. NP W talked with the guardian and the code status was changed to DNR. The administrator said she would expect the code status on the form and the electronic chart to match. It would be the nurse who admits a resident who is responsible to enter the code status into the electronic medical record. If a residents code status is changed after a resident is admitted , it would be the nurse who was on duty at the time the code status was changed to enter the information into the computer. Review of the signed code status form, located inside the hospice binder, showed a DNR form signed [DATE] by the guardian. During an interview on [DATE] at approximately 12:00 P.M., Hospice Case Manager S said the resident went on hospice on [DATE] and he/she believed the resident was already a DNR. If hospice obtained the DNR order, they would take the order to the hospice medical director and have the order signed. Hospice would set up a binder and the information would be in the binder at the facility. If they believed the facility already had the resident as a DNR, they would not do this. If the resident was already a DNR at the facility, the facility would be responsible to maintain the order for DNR. During an interview on [DATE] at 1:32 P.M., NP W, the NP for the Medical Director, said the resident was a DNR. When the resident admitted last week, he/she saw him/her the day after. He/she discussed hospice with Guardian Y. Guardian Y then changed the resident to a DNR. Usually he/she would give a verbal order or he/she will put the order for the DNR into the system. Then staff send the code status sheet to the Medical Director for signature. He/she was not sure if that was done for the resident. He/she gave the verbal order for the DNR. Once the order was given, the order should be entered into the computer and faxed over to the Medical Director's office. He/she talked with ADON A, LPN N and Staff X last week about the DNR order. During an interview on [DATE] at 2:27 P.M., Guardian Y said he/she prepares the DNR form and the form is based on a questionnaire he/she receives from the physician. He/she has a signed questionnaire for the resident signed by the physician from the hospital. Review of the signed questionnaire, faxed on [DATE] at 2:38 P.M., showed it contained questions about the resident's condition and no order for code status. 17. Review of Resident #114's medical record, showed an order dated [DATE], for full code. Review of the social service signed code status binder, located in the social service office, showed a signed code status sheet dated [DATE], for DNR. During an interview on [DATE] at 11:31 [NAME]M., LPN H said he/she is the nurse for the resident. Everything is in the computer. Staff know a code status by looking in the computer. 18. Review of Resident #40's ePOS, showed an order dated [DATE], for DNR. Review of the social service signed code status binder, located in the social service office, showed a signed code status sheet dated [DATE], for full code. Further review of the social service signed code status binder, showed a signed code status for a DNR not obtained until [DATE]. 19. During an interview on [DATE] at 8:56 [NAME]M., the SSD said she is responsible to obtain the signed code status sheets. After it is signed, she used to make a copy and place it in the paper chart, but the facility no longer has paper charts. She now keeps them in a binder in her office. Some care coordinators will ask for a copy of them as well. If a copy is not given to the care coordinator, then the copy in her office is the only copy. When she is not at work, her office is locked. If staff needed to access the code status binder when she is not at the facility, the maintenance staff and administrator have a key to the office and would have to come down and unlock it. She is just now learning how to scan the signed code status sheets into the electronic medical record. She would expect the physician order [REDACTED]. 20. During an interview on [DATE] at 10:07 [NAME]M., the DON said resident code statuses are reviewed during the quarterly care plan meetings. A resident with an incongruent code status should have had this identified during the quarterly care plan meeting. 21. During an interview on [DATE] at 10:34 [NAME]M., LPN [NAME] said the facility has no paper charts. When asked where advanced directives were located, he/she said good question, he/she would have to get back to the surveyor on that. During an interview on [DATE] at 11:31 [NAME]M., LPN H said everything is in the computer. Staff know a resident's code status by looking in the computer. During an interview on [DATE] at 11:36 [NAME]M., LPN Q said the residents' code status is in the electronic medical record. That is the only place it is located, since the facility went electronic. During an interview on [DATE] at 3:17 P.M., Care Coordinator B and LPN C said if a resident ceased to have signs of life, they would check them to verify no vital signs. They then come to the electronic medical chart to see if the resident was a full code. If they were a full code, they would start CPR. If the computers were down, they were not sure where they would look. If a resident is a new admission, upon admission the step of obtaining a code status order is part of the admission process. If a code status changes, staff document in progress notes, but they have to contact social services. Staff need to have the conversation with the resident or representative witnessed. Social services usually changes the documentation of code status. During an interview on [DATE] at 3:18 P.M., LPN J said if a resident ceased to have signs of life, he/she would call a code over the intercom and at the same time have someone check the resident's code status. Code status is checked in the computer. During an interview on [DATE] at 3:19 P.M., Certified Nursing Assistant (CNA) D said if a resident were to cease having signs of life, he/she would get the nurse. He/she is new and is not sure how to know a resident's code status. During an interview on [DATE] at 3:26 P.M., CNA BB said if he/she found a resident unresponsive or expired, he/she would check to see if they had a pulse, then run and tell the charge nurse. During an interview on [DATE] at 3:28 P.M., CNA CC said if he/she found a resident unresponsive or maybe expired, he/she would run out and check the code status in the electronic chart. If the resident was a full code, he/she would page overhead and run back to start CPR. If the resident was a DNR, he/she would just tell the charge nurse the resident expired. During an interview on [DATE] at 3:28 P.M., LPN [NAME] said if he/she found a resident with no signs of life, he/she would try some lifesaving measures initially and yell code. If it is found the resident was a DNR on the computer, he/she would stop life saving measures. He/she has been at the facility for 4 years. If the computers go down, he/she would not be able to check the code status. The computers have gone down in the past on several occasions. They are down for an hour or so at a time. If he/she does not know the code status, he/she is doing CPR. 22. During an interview on [DATE] at 4:20 P.M., with the administrator and DON, the DON said upon admission, if a resident did not come with an order for [REDACTED]. When asked who was responsible for making sure a resident has a code status, the DON said she was not sure she knew how to answer that. She knew the SSD plays a role in it. Code status is on the electronic physician order [REDACTED]. Each nurse's station has a binder with a care card for each resident and that is where code status is documented. They heard some staff did not know where to find the code status, so the care coordinators are in-servicing staff right now. If the computers go down, staff are to refer to the care card. She would expect the advanced directives policy be followed. If the policy requires two witnesses to a DNR request from the resident or family, this would be documented in the nurse's notes. She would expect the facility policy to address how code status will be documented. Staff should be aware of the care cards. Observation and interview on 1 south and 1 Main on [DATE] at 4:46 P.M., showed a CNA binder at the nurses stations. LPN J said the CNA care card binders have been at the nurse's station, he/she would have never thought to look there for a resident's code status. Observation and interview on 2 south on [DATE] at 4:35 P.M., showed Care Coordinator B walked down the hall with a binder in his/her hand and said it was the CNA care card binder that will be kept in the cabinet on 2 south. The care coordinators are in-servicing staff now on the location of the CNA care card binders. He/she will also be doing an audit. Observation and interview on 2 Main on [DATE] at 4:35 P.M., showed the care card binder at the nurses station. LPN [NAME] said he/she did not know how often the CNA care card binders are updated and he/she had never looked in the binder. Review of the binder at this time, showed 13 residents documented in the binder without a code status identified. Observation and interview on 3 south on [DATE] at 4:30 P.M., showed LPN F pulled up a resident's care card in the computer and said there is no care card on paper. During observation and interview on 3 main on [DATE] at 4:35 P.M., LPN G said he/she knew there was a book on the left side of the wall, in the cubby, but he/she was unsure which book was the CNA care card book. LPN G asked another staff member to get the book down for him/her because he/she could not reach the book. Staff got the book down and it was not the CNA care card binder. The staff person got down a second book and it was the CNA care card binder. The book showed some of the residents who resided on the floor missing from the book, Residents #95, #70, #5, #393 and #50. 23. During an interview on [DATE] at 5:41 P.M., the administrator said the Quality Assurance and Performance Improvement team had not identified code status as an issue. The facility switched over from paper charting to the electronic records and they had not identified the location of resident code statuses as an issue. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level [MI] Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the F level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one resident who had a diagnostic procedure canceled due to the resident not having a next of kin who was able to be contacted. The facility failed to take steps to assist the resident to find an individual to make medical decisions for the resident. This resulted in the resident having a delay in the diagnosing of symptoms. The resident had a change of condition, went to the hospital and was diagnosed with [REDACTED].#124). One resident had a change in condition documented and no further documented assessments for approximately 12 hours, when the resident expired (Resident #144). In addition, staff failed to communicate blood sugar levels that were out of range to the physician for one resident (Resident #68). The sample was 29. The census was 146. Review of the facility's Change in Condition policy, dated ,[DATE], showed: -It is the responsibility of licensed staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental or psychosocial status; -Acute change in condition is sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional status that, without intervention, may result in complications or death; -Non-urgent change in condition is a deviation from a patient's baseline in physical, cognitive, behavioral or functional status that is not reasonably expected to result in complications or death or may be a persistent or intermittent result of the patient's diagnosed disease state; -Upon identification of any change in condition, licensed nursing personnel will contact the resident's attending physician/on-call physician/practitioner to notify him/her of the change. Acute changes in condition should occur immediately upon recognition while non-urgent changes should occur no later than 72 hours from the noted change; -All notifications should be preceded by an appropriate physical, mental or psychosocial assessment to enable the physician to make adequate and appropriate treatment and/or transfer decision; -Following notification of the physician, licensed nursing personnel will contact the resident's responsible party to inform him/her of the change. For acute changes in condition, this should occur immediately when practicable and after addressing the resident's immediate needs and for non-urgent changes in condition, the notification should occur within 72 hours of the noted change; -All notification should be documented to include: Date and time, name of the individual contacted, specific reasons for the notification, any specific responses that were given by the person contacted; -The policy did not address documentation and follow up of the resident's condition after the initial identification. 1. Review of Resident #124's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated [DATE], showed: -Rarely understood; -[DIAGNOSES REDACTED]. -Signs and symptoms of [MEDICAL CONDITION] present; -Wandering exhibited in the last ,[DATE] days; -Independent with bed mobility and transfers; -Supervision with dressing, eating, and hygiene. Review of the resident's care plan, updated [DATE] and in use during the survey, showed: -Focus: Resident has impaired cognition function related to dementia: -Goal: Resident will maintain current level of cognitive function through the review date. Resident will be able to communicate basic needs on a daily basis through the review date; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; -Focus: Resident has communication problem: -Goal: Resident will be able to make basic needs known; -Interventions: Encourage him/her to continue stating thoughts even if he/she is having difficulty. Focus on a word or phrase that makes sense, or responds to the feeling he/she is trying to express. Review of the resident's labs, showed: -On [DATE], a hemoglobin (red blood cell count) result of 7.8; -Hemoglobin reference range, ,[DATE]. Review of the resident's electronic physician orders [REDACTED]. -An order dated [DATE], for STAT (immediately) stool guaiac (lab test used to determine if there is blood in the stool), [DIAGNOSES REDACTED].>-An order dated [DATE], for clear liquids, no food the entire day, for pre-procedure order for colonoscopy (diagnostic procedure used to diagnose conditions of the intestines) scheduled [DATE], related to [MEDICAL CONDITION]; -An order dated [DATE], for nothing by mouth (NPO) after midnight for procedure; -An order dated [DATE], for gastrointestinal appointment for colonoscopy related to [MEDICAL CONDITION]; -An order dated [DATE], for pre-procedure orders for colonoscopy [DATE]. On [DATE] start low fiber diet. On [DATE], hold iron complex. On [DATE], hold blood thinner ([MEDICATION NAME]). On [DATE], start clear liquid diet. Give [MEDICATION NAME] (liquid medication used to evacuate the colon and intestine of all stool) 1 liter (L) at 5:00 P.M., 8 ounces (oz) every 15 minutes. On [DATE] nothing by mouth (NPO) except: give another liter of [MEDICATION NAME] at 4:00 [NAME]M., 8 oz every 15 minutes. (MONTH) take medications with sips of water; -An order dated [DATE], for [MEDICATION NAME] solution reconstituted 236 gram (gm). Give 1 L by mouth one time only related to [MEDICAL CONDITION] for three days. Give 8 oz every 15 min minutes until first liter is completed. Give another liter the following at morning at 4:00 [NAME]M.; -An order dated [DATE], to discharge to hospital for evaluation and treatment. Review of the resident's progress notes, showed: -No documentation staff attempted to contact the next of kin to inform of the change in condition or needed STAT laboratory test. No documentation staff notified social services if contact could not be made; -On [DATE] at 3:02 P.M., resident up and about on unit. Assisted with activities of daily living (ADLs). Respiration even and non-labored. Lung sounds clear. Abdomen soft and round with active bowel sounds times four quadrants. Resident informed that a stool collection is needed today. Specimen placed inside of toilet to obtain stool sample; -On [DATE] at 8:56 [NAME]M., (23 days after the order to obtain the stool sample, ordered on [DATE] STAT) call placed to lab pending guaiac stool. He/she did not see specimen results, but will contact supervisor to see where is specimen is waiting; -On [DATE] at 2:43 P.M., called placed to hospital regarding instructions to prep related to colonoscopy scheduled for [DATE]. No answer received at this time. Left message. Will await call. No documentation staff attempted to contact the next of kin for consent of the diagnostic procedure or notified social services if contact could not be made; -On [DATE] at 8:55 [NAME]M., resident is up and about on unit. Remains NPO related to colonoscopy scheduled today at 11:00 [NAME]M. Completed [MEDICATION NAME] as ordered. Tolerated well. Remains alert and oriented times two. Respirations even and non-labored. Lung sounds clear times two. Abdomen soft and round with active bowel sounds times four quadrants. Gait and balance steady; -On [DATE] at 10:56 [NAME]M., spoke to hospital staff. He/she informed writer that the resident's colonoscopy scheduled for [DATE] was not performed due to his/her cognitive deficits. He/she was unable to tell them if he/she had drank the prep prior to coming for the procedure, he/she could not verbalize understanding of the procedure or why it needed to be performed. He/she stated the resident was alert and oriented to person only. He/she also stated that he/she attempted to reach his/her emergency contacts and no one answered either number. Staff informed them that they would make Nurse Practitioner W aware of the conversation; -On [DATE] at 11:09 [NAME]M., notified Nurse Practitioner W of the conversation from hospital staff. He/she stated that he/she was aware and has been unsuccessful in locating a family member to give consent for the procedure. No documentation staff notified social services that contact with the next of kin for consent could not be made; -On [DATE] at 6:59 P.M., resident holding on to railing walking down the hall, holding onto railing to assist with balance, at times was given a wheelchair to use and after sitting in the wheelchair for short periods of time, would get up to continue to walk; -On [DATE] at 11:14 P.M., resident holding on to railing walking down the hall, gait extremely unsteady and requires more assistance than usual. Nurse Practitioner W notified about change in condition. No documentation staff attempted to contact the next of kin regarding the change in condition or notified social services if contact could not be made; -On [DATE] at 11:31 P.M., resident was noted lowering him/herself to the floor in the hallway during dinner. Resident has required frequent help transferring with unsteady gait. No injury noted at this time. Nurse Practitioner W contacted with no new orders; -On [DATE] at 3:17 P.M., resident was observed sitting down on the floor x 2 today. Resident assisted off of the floor onto a wheelchair as his/her gait is unsteady and bilateral lower extremities weakness noted as his/her legs buckled under him/her when staff assisted him/her off of the floor. Resident encouraged to use the wheelchair to propel him/herself so he/she does not fall. Resident re-directed back to his/her wheelchair a couple of times as he/she was observed getting out of the wheelchair trying to walk. Resident sits back in the wheelchair when re-directed; -On [DATE] at 9:33 P.M., resident is noted in bed watching TV. He/she is able to make needs known and required frequent help with transfer and ambulation this shift. Resident does not pick feet up off the ground at times. He/she is sliding feet and shuffling feet quite often. No complaints of pain voiced at this time; -On [DATE] at 10:59 P.M., while walking down the hall, resident holds furniture and the railings. Wheelchair offered to resident, however he/she does not sit in the chair; -On [DATE] at 2:58 P.M., resident is alert/responsive to person, up ambulating slowly on the unit. Resident encouraged to sit down on the hallway bench from time to time and he/she has been compliant with that request. Resident's gait is slow, unsteady; -On [DATE] at 2:27 P.M., resident continues to sit on the floor throughout shift which is care planned for resident. Resident also continues to hold on to railing walking down the hallway and does not walk upright; -On [DATE] at 10:59 P.M., resident was noted with large bowel sitting at anal opening while lying on his/her side during Certified Nurse Aide (CNA) round. The bowel was the size of a baseball. No distress was noted from resident. No signs/symptoms of pain nor discomfort noted. Resident did refuse CNA assistance. This writer showered resident, provided fresh linen and encouraged fluids since bowel was noted hard and formed. Vital signs are within normal limits for this resident at this time; -On [DATE] at 11:00 [NAME]M., resident received orders from Nurse Practitioner W to be discharged to the hospital for evaluation and treatment. Follow up with [MEDICAL CONDITION] management and overall decline. No documentation staff attempted to contact the next of kin regarding the resident being sent to the hospital or notified social services if contact could not be made; -On [DATE] at 2:22 P.M., received call from nurse at hospital; the resident is being admitted to the hospital with [REDACTED]. Review of the resident's medical record, showed no social services notes regarding an attempt to locate next of kin or someone with decision making capabilities for the resident. Further review of the resident's labs, showed: -On [DATE], hemoglobin 7.9; -On [DATE], hemoglobin 8.3; -On [DATE], hemoglobin 7.4; -On [DATE], hemoglobin 7.9; -On [DATE], hemoglobin 8.0; -Reference range of ,[DATE]. Review of the resident's fecal occult blood immunochemical (a test that detects hidden blood in the stool and screens for [MEDICAL CONDITION]) lab result, showed: -Collection date of [DATE] (20 days after the STAT order was obtained); -Reported date of [DATE]; -Result: negative. Review of the resident's physician's progress notes, showed: -On [DATE]: History of Present Illness: Resident with continued weight loss and poor appetite. Often refusing to eat meals even when he/she is brought to the dining room. He/she recently went for a colonoscopy, but was unable to get consent for procedure, family was unable to be contacted, so they sent him/her back to the facility. He/she denies any pain at this time; -On [DATE]: History of Present Illness: Resident with continued weight loss over the last few months. His/her appetite has been poor and he/she often refuses to go to meals. He/she is noted to have some weight loss of ten pounds over the last month; -On [DATE]: History of Present Illness: Per nursing discussion: vital signs, weight loss has been at a steady decline, no hospitalization s in the last month. Decline cognitive and physical status. Resident is noted to still not be eating regularly. He/she also has been noted to be laying on the floor, which has been a regular behavior for him/her lately; -On [DATE]: History of Present Illness: Resident had some weight loss with generalized allover decline over the last few months. His/her dementia has been worsening and he/she has been experiencing failure to thrive. Lately he/she has not been able to get up. He/she has been noted to lay on the couch and urinate on him/herself. He/she has increased incontinence of fecal and urine. His/her [MEDICAL CONDITION] markers have come back elevated; -Plan: Sent to hospital for evaluation due to weight loss and generalized decline; -On [DATE]: History of Present Illness: Resident recently readmitted to the facility following hospitalization for fecal mass, intussusception of the intestine and severe malnutrition. He/she was sent out due to further decline with mobility and mentation, [MEDICAL CONDITION] work-up. Computed tomography (CT, scan makes use of computer-processed combinations of many X-ray measurements taken from different angles). He/she received laparoscopic right colectomy (a surgical procedure to remove all or part of your colon). Since he/she has been back at the facility, he/she has been improving as far as his/her mentation and eating habits. Review of the resident's hospital records, dated [DATE] through [DATE], showed: -admitted on [DATE]; -Primary discharge Diagnosis: [REDACTED].>-Secondary discharge Diagnosis: [REDACTED]. -History of present illness: Resident with untreated [MEDICAL CONDITION], dementia, [MEDICAL CONDITION] disorder, and high blood pressure, who lives in a nursing home and had weight loss and worsening mental status. Nursing home sent him/her to hospital for [MEDICAL CONDITION] work up. His/her liver enzymes were normal. Vital signs are within normal range. Urinalysis (test to detect urinary tract infections) was negative. CCT scan showed long segment intussusception extending from the distal ileum (the end of the small intestine before it transitions into the large intestine) to the ileocecal valve (sphincter muscle valve that separates the small intestine from the large intestine). He/she was admitted for evaluation and possible surgical treatment. Patient was admitted with intussusception and he/she underwent [MEDICATION NAME] prep with multiple enemas in preparation for colonoscopy prior to surgical intervention; -By [DATE], patient had not been adequately prepped despite persistent bowel prep/enemas, so the decision was made to precede with operating room for laparoscopic right colectomy. During an interview on [DATE] at 2:53 P.M., Licensed Practical Nurse (LPN) N said the resident did not receive a colonoscopy, because the resident was not able to give consent for the procedure. He/she was his/her own responsible party. He/she had a family member, but they could not be reached. His/her information was also sent to the hospital and they were unsuccessful in getting information. The resident had a steady decline before (MONTH) 2019 and it was hard to get to the bottom of what was going on, because he/she did not have anyone to sign for him/her. It was hard to send him/her to the hospital. He/she is a poor historian and does not have anyone to talk for him/her. Obtaining a public administrator was not that simple; however, LPN N did not know how that worked. LPN N remembered Nurse Practitioner W asked someone at the hospital regarding how they could obtain consent for the resident. During an interview on [DATE] at 4:00 P.M., the Director of Social Services said she might have heard about the resident in need of someone to consent for him/her. She was not aware that due to the resident not having anyone to consent for him/her, he/she was not able to proceed with the colonoscopy appointment. If a resident was able to make decisions at the time of admission and later declined and they could no longer make medical decisions, they would call the next of kin. The Director of Social Services was not aware of what the next step would be if there was a resident without a next of kin. She did not know if there was a facility policy that addressed guardianship. She had never contacted a public administrator at any point since she had been employed with the facility, nor assisted anyone with guardianship at any point in her career as a social worker, and did not know the process. During an interview on [DATE] at 9:18 [NAME]M., Nurse Practitioner W confirmed that the resident needed the colonoscopy; however, he/she could not consent. He/she needed an acute reason to go to the hospital. The hospital was not going to keep him/her at first. He/she had a cousin that was listed, but there was no answer. That also happened at the doctor's office and at the hospital. He/she could not consent. During an interview on [DATE] at 5:26 P.M., the Director of Nursing (DON) said if the physician said to reach out to the family and get a guardian, or get the social worker and the Ombudsman involved to see what the options were, the facility would have done that. There was no sense of urgency, but there was a conversation about the issue. The nurse practitioner attended the clinical meetings and spoke with the physician about the resident. The nurse practitioner had a lot to do with the resident receiving the surgery. The DON was not aware of the colonoscopy appointment in (MONTH) 2020 and if there would be an issue with the resident giving consent. That would be the physician's determination. If they had a resident that could no longer make decisions, they would go through the Ombudsman. There is a lot of legal ramifications to make decisions for a resident. The DON was not aware of the process of how to obtain guardianship if a resident could not make decisions and did not have family. She was not aware that the Social Services Director did not know the process. The DON said she would have to follow up with the social services director and the administrator to get more information. 2. Review of Resident #144's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -Poor appetite for ,[DATE] days; -No behaviors; -Total staff dependence for hygiene, toileting and eating; -Diagnoses: [REDACTED]. Review of the resident's progress notes, showed: -A nursing note, dated [DATE] at 8:37 P.M., audible crackles heard from the resident's bedside. Nurse Practitioner (NP) called and new orders received for a STAT complete blood count (CBC, determines general health status and screens for and monitors for a variety of disorders including [MEDICAL CONDITION]) and complete metabolic panel (CMP, measurement of blood sugar, electrolytes, fluid balance, kidney and liver function). Vital signs are temperature of 100.3 (normal 97.8 through 99.1), pulse 132 (normal 60 through 100), respirations 20 (normal) and blood pressure ,[DATE] (normal ,[DATE] through ,[DATE]); -No further nursing progress notes located to show further assessment after the resident's change in condition or further contact with the medical providers; -A nursing progress note, dated [DATE] at 8:50 [NAME]M., the resident noted to be in his/her bed unresponsive. Upon further assessment, he/she observed to be pulseless (no pulse) and no respirations. An emergency code called per facility policy and 911 notified. Cardiopulmonary resuscitation initiated. Emergency medical services (EMS) arrived approximately 20 minutes later. Electrocardiography (ECG, monitors and records the heart rate and rhythm) attached to the resident by EMS staff. The resident noted to have no heart rhythm and had an asystole (full cardiac flat line, no heart contraction) heart pattern. The paramedic onsite called EMS dispatch and had been notified to call the resident's time of death at 8:55 [NAME]M. The resident's guardian called and his/her family notified. The Coroner notified; -The resident's remains released to funeral home at 12:00 P.M. During an interview on [DATE] at 11:19 [NAME]M., LPN Q said he/she had arrived at the facility to work day shift at 7:00 [NAME]M., on the morning of [DATE]. He/she received report from the night shift nurse and the resident had been alive at that time, appeared to be normal color and had not appeared to be in distress. He/she and the night shift nurse walked the unit during report. The night shift nurse reported the resident had been ordered to receive a hospice evaluation and had received oxygen. He/she completed shift change report and began his/her medication pass at the resident's room. When he/she administered medication to the resident's roommate, he/she looked at the resident and observed the resident was not breathing. The resident had been a full code and CPR was started. The resident had expired within an hour of his/her shift starting. The resident did not have hospice evaluation orders and did not receive a hospice evaluation. There had been a chest X-ray completed and blood work, LPN Q had not been notified of any results. He/she had not notified the resident's physician of any STAT results. During an interview on [DATE] on 1:25 PM Certified Nursing Assistant (CNA) O said he/she had cared for the resident on Friday [DATE]. He/she had assisted the resident with his/her breakfast and lunch. The resident ate in the dining room and sat in his/her Geri-chair (medical reclining chair). The resident did not have any issues with swallowing or coughing. No abnormal behaviors. During an interview on [DATE] at 4:28 P.M., the DON said the resident had been a full code. If the staff note a change in condition, she expected the nurses to provide frequent assessments and document assessments in the resident's medical record at least every two hours. The nurses should have notified the physician of additional changes and the ordered laboratory values. The facility received the ordered blood work late and the resident had expired before the staff could notify the physician. The facility provided in-servicing to all the nurses regarding when a resident experienced a change in condition. There should have been more nursing notes regarding assessments from the time of discovery to the time of the resident's death. 3. Review of the Resident #68's MDS, dated [DATE], showed the following: -Cognitively intact; -Required one staff person assistance from staff with hygiene, toileting and bed mobility; -Required two staff person assistance for dressing and transfers; -[DIAGNOSES REDACTED]. Review of the resident's ePOS, showed the following: -An order, dated [DATE], for [MEDICATION NAME] (fast acting insulin). Administer by a sliding scale three times daily, with meals, the blood glucose level (BGL) and insulin units (u) amounts as follows; -BGL ,[DATE], give 5 u; -BGL ,[DATE], give 7 u; -BGL ,[DATE], give 9 u; -BGL ,[DATE], give 11 u; -BGL 351- 400, give 13 u and call the physician. Review of the resident's Medication Administration Record [REDACTED] -At 6:00 [NAME]M.: -On [DATE], 359 BGL, 13 units given, no documentation regarding physician notification; -On [DATE], 400 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 365 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 382 BGL, 13 units, no documentation regarding physician notification; -At 12:00 P.M.: -On [DATE], 364 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 375 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 400 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 372 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 356 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 397 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 359 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 382 BGL, 13 units, no documentation regarding physician notification; -At 5:00 P.M.: -On [DATE], 382 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 388 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 397 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 382 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 389 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 383 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 388 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 381 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 400 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 400 BGL, 13 units, no documentation regarding physician notification; -On [DATE], 389 BGL, 13 units, no documentation regarding physician notification. During an interview on [DATE] at 5:30 P.M., the DON said she expected staff to follow physician's orders [REDACTED].

Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for two residents (Resident #40 and #118). This resulted in tissue decline and larger measurements of a pressure ulcer for one resident when he/she readmitted from the hospital and the facility failed to obtain treatment orders and assess the wound for two days. The facility identified four residents as having pressure ulcers, two were included in the sample of 29 and issues were found with both. The census was 146. Review of the facility's Skin Ulcer-Wound policy, dated 8/15/18, showed: -All caregivers are responsible for preventing, caring for and providing treatment for [REDACTED].>-Licenses staff will, upon admission, perform a head to toe body audit within 2 hours of admission. The findings will be documented in the resident's clinical record; -Licensed staff members will, upon admission, complete a risk scale weekly for the first four weeks and after admission for each resident at risk, then quarterly, or whenever there is a change in condition; -Licensed staff will complete a head to toe skin assessment weekly and as needed; -Staff will institute a plan for any resident who has potential for skin breakdown or whose condition is deteriorating, this may include: Turn and reposition every two hours as appropriate, pressure reduction surfaces for beds and wheelchairs, promotion of clean/dry/well moisturized skin. 1. Review of Resident #40's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/15/19, showed: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Extensive assistance with bed mobility, transfers, dressing, eating, toileting and hygiene; -At risk for pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction); -No pressure ulcers at time of admission. Review of the resident's Braden assessments (assessment used to determine risk for pressure ulcers), dated 9/8/19 and 12/16/19, showed the following: -On 9/18/19, a score of 17, at risk; -On 12/16/19, a score of 8, very high risk. Review of the resident's electronic physician order [REDACTED]. Apply to coccyx (tail bone) topically one time a day every three days. Review of the resident's care plan, dated 10/10/19 and in use during the survey, showed no documentation of the resident's pressure ulcer, interventions, goals, or stage of the pressure ulcer. Review of the resident's progress notes, dated 12/1/19 through 12/12/19, showed no documentation of the resident's pressure ulcer. Review of the facility's weekly wound report, dated 12/6/19 through 12/12/19, showed the following: -Onset date: 12/9/19; -Stage: Stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough (dead tissue), may also present as an intact or open/ruptured blister); -New Measurements: -Length: 0.4 centimeter (cm); -Width: 0.5 cm; -Depth: 0.1 cm; -Cite: coccyx; -Acquired: In-house; -Treatment: Duoderm, change every three days and as needed. Review of the resident's treatment administration record (TAR), dated 12/1/19 through 12/12/19, showed: -On 12/9/19, the order for Duoderm dressing, apply to the coccyx one time a day every three days: Blank; -On 12/12/19, the order for Duoderm dressing, apply to the coccyx one time a day every three days, documented as administered as ordered. Review of the resident's hospital record, dated 12/12/19, showed: -admitted to the hospital on [DATE]; -Active pressure ulcer sacrum (tail bone area): Assessment date 12/12/19; -Present on admission: Yes; -Wound measurement to sacrum on 12/12/19: -Length: 4.5 cm; -Width: 5 cm; -Depth: 0.2 cm; -discharged from the hospital on [DATE]. Review of the resident's medical record, showed the resident re-admitted to the facility on [DATE]. Further review of the resident's ePOS, showed: -An order dated 12/18/19, for Venelex Ointment (Balsam Peru-Castor Oil). Apply to sacrum topically every day shift, every two days for pressure ulcer. Clean with normal saline or wound cleaner, skin prep (protective barrier wipe) to periwound (intact skin around wound edges), apply Venelex ointment to wound bed and cover with foam dressing and apply to sacrum topically as needed for pressure ulcer; -An order dated 12/18/19, for foam Dressing Bordered Pad (wound dressings). Apply to sacrum topically every day shift, every two days for pressure ulcer after skin prepping and applying Venelex and apply to sacrum topically as needed for pressure ulcer. Review of the resident's progress notes, dated 12/18/19 at 12:12 P.M., showed staff and hospice nurse at bedside for evaluation and treatment of [REDACTED]. Periwound macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) and denuded skin (loss of the epidermis (top layer of skin), caused by exposure to urine, feces, body fluids) noted. Hospice nurse and nurse practitioner (NP) agreed on treatment plan change due to decline to tissue and larger measurement. Venelex and foam dressing, change every two days and as needed, noted and implemented. Further review of the resident's medical record, showed physician orders [REDACTED]. Further review of the resident's TAR, dated 12/16/19 through 12/31/19, showed: -On 12/18/19 and 12/20/19, foam Dressing Bordered Pad, apply to sacrum topically every day shift, every two days: blank. Not documented as applied until 12/22/19; -On 12/18/19 and 12/20/19, Venelex Ointment, apply to sacrum topically every day shift, every two days: blank. Not documented as applied until 12/22/19; -No documentation of any wound treatment applied to the sacrum/coccyx area after readmission on 12/16/19 until 12/22/19. During an interview on 12/19/19 at 2:40 P.M., Licensed Practical Nurse (LPN) N said the pressure ulcer was found somewhere between 12/7/19 through 12/20/19. It was before he/she went to the hospital and the treatment order came soon after it was discovered. During an interview on 12/20/19 at 5:26 P.M., the DON said she would expect there to be documentation of the resident's pressure ulcer. She would expect staff to follow physician's orders [REDACTED]. 2. Review of Resident 118's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Two staff person assist for activities of daily living; -Upper/lower extremity impairment of both sides; -Wheelchair for mobility; -One Stage III pressure ulcer; -One unstageable pressure ulcer (depth of the wound is unable to be determined); -[DIAGNOSES REDACTED]. Further review of the resident's MDS records, showed: -discharge date of [DATE]; -Entry date of 11/30/19. Review of the resident's Braden assessments, showed the following: -On 5/20/19, a score of 14, moderate risk; -On 11/11/19, a score of 15, at risk; -On 11/30/19, a score of 13, moderate risk. Review of the resident's ePOS, showed: -An order dated 6/14/17, for a low air loss mattress for pressure prevention; -An order dated 12/2/19 for Santyl ointment (a [MEDICATION NAME] ointment, the medical removal of dead, damaged, or infected tissue), 250 unit/gram. Apply to right ischium (area of the skin where the leg connects to the buttocks) topically every night shift for wound care. Clean with normal saline or wound cleaner. Apply Santyl ointment, nickel thick, pack lightly with calcium alginate (absorbent product) and cover with dry dressing; -An order dated 12/11/19, for Santyl ointment (a [MEDICATION NAME] ointment, the medical removal of dead, damaged, or infected tissue), 250 unit/gram. Apply to left ischium topically every night shift for wound care. Clean with normal saline or wound cleaner. Apply Santyl ointment, nickel thick, pack lightly with calcium alginate and cover with dry dressing. Review of the resident's care plan, in use during the survey, showed: -Problem: Resident has a history of having a healed unstageable pressure ulcer to the right ischium. He/she is at risk for developing other pressure related areas due to refusing to offload the area, incontinent of bowel and requiring assistance with turning and repositioning while in bed. He/she refuses to return to bed once he/she gets up into the motorized wheelchair and stays up for prolonged periods of time. On 10/15/19, stage II ulcer to right ischium; -Approach: Skin will remain intact through review date. Inform resident/family/caregivers and physician of any new area of skin breakdown. Instruct/assist him/her with shifting his/her weight in wheelchair on a frequent basis. Needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. Monitor/document/report as needed any changes in skin status. Treatment to right ischium as ordered, inform physician if treatment plan is unsuccessful; -Further review of the care plan, showed the care plan not updated with a pressure area to left ischium. Review of the resident's wound analysis report, right ischial, showed: -On 12/4/19, (length, width, depth) 1.3 cm, 1 cm, 1.1 cm, stage III pressure injury; -On 12/11/19, 1 cm, 1 cm, 0.7 cm, stage III pressure injury; -On 12/18/19, 0.8 cm, 1 cm, 0.5 cm, stage III pressure injury. Review of the resident's wound analysis report, left ischial, showed: -On 12/4/19, 2.5 cm, 2.5 cm, 0.4, unstageable due to non-removable dressing/device; -On 12/11/19, 3 cm, 2.5 cm, 0.6 cm, unstageable due to non-removable dressing/device; -On 12/18/19, 3.5 cm, 2.7 cm, 0.8 cm, stage III pressure Injury. During an interview on 12/18/19 at 11:45 [NAME]M., Nurse Practitioner W said the resident was hosptalized on [DATE] and returned with a worsened wound from the hospital. He/she went from a stage II to a stage III. The area on his/her left side worsened. Observation on 12/19/19 at 7:57 [NAME]M., showed LPN N complete a dressing change for Resident #118. LPN N said he/she was the treatment nurse for the building. The resident's air mattress alarmed, turned off and then immediately kicked back on. The resident said this happens, there is a short. Staff have to come back in to fix it when it turns off. Observation of the front control panel of the air mattress, showed three buttons cracked through the plastic cover and exposed the inner workings of the machine. Certified Nurse Assistant (CNA) K assisted LPN N to reposition the resident to the left side. A brown substance visible on the outside of the dressing on the resident's left ischium and bowel movement visible on the resident's buttocks. LPN N removed the soiled dressing. He/she removed his/her gloves, washed his/her hands and went to the treatment cart. He/she mixed Santyl and collagen together in a medication cup and obtained a boarder dressing, gauze and wound cleanser. LPN N washed his/her hands and applied gloves. Wound bed yellow and pink in color. LPN N cleansed the wound with wound cleanser. Bowel movement continued to be visible on the resident's buttocks. LPN N applied the collagen and Santyl mix to the wound bed with an applicator. He/she removed his/her gloves, washed his/her hands, dated the border dressing, applied gloves and placed the dressing on the wound to the resident's left ischium. Bowel movement continued to be on the resident's buttocks. The air mattress turned off again. The resident said LPN N must have hit the cord, so the air mattress turned off. The resident's air mattress had gone flat. LPN N adjusted the electrical cord and the air mattress turned back on. The resident said the bed does this at times, ever since he/she got it. CNA K said the dysfunction of the air mattress might happen at night and no one would know. As staff assisted the resident to reposition in bed, the bowel movement fell out of the resident's rectum and fell on to the bed. Staff cleansed the resident's buttocks, assisted the resident to get positioned in bed and prepared to get the resident up for breakfast. During an interview on 12/20/19 at 4:02 P.M., the resident said if you bump the bed, it will deflate. The bed stayed deflated as long as thirty minutes at a time, and it is very uncomfortable when the bed deflated. During an interview on 12/20/19 at 4:07 P.M., LPN UU said he/she was aware the bed deflates when the plug is bumped. During an interview on 12/20/19 at 3:11 P.M., the Maintenance Director said any staff person can report an environment concern to maintenance. Maintenance staff complete room audit check sheets periodically. The sheets were part of the Quality Assurance and Performance Improvement (QAPI) plan. He would expect staff to report issues with an air mattress. Maintenance was not aware of the issue. No staff reported this issue as of this time. During an interview on 12/19/19 at 4:10 P.M., the DON said when the resident's bed gets pushed against the wall and the bed hits the plug, it deflates, LPN N is part of the wound team, is aware of the settings on the air mattress and if the bed is functioning as it should. On 12/20/19 at 2:36 P.M., the DON said if a resident had bowel movement on his/her buttocks during a treatment, she would expect it be cleaned prior to applying the new treatment.

Based on interview and record review the facility failed to obtain laboratory tests as ordered for one of three sampled residents. When hospitalized , the resident had critical laboratory values, required emergent treatment and was subsequently admitted to the intensive care unit. (Resident #1) The census was 145. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/28/11, showed the following: -Total dependence on staff for completion of all activities of daily living (ADLs); -[DIAGNOSES REDACTED]. -Presence of two venous/arterial ulcers; -Received an anticoagulant medication. Review of the resident's physician's progress note, dated 4/26/11, showed the resident received [MEDICATION NAME] (a blood thinning medication) 8 milligrams (mg) daily at bedtime. Review of the resident's physician order [REDACTED]. -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Full Code -Obtain international normalized ratio (INR) (a blood test for monitoring the effectiveness of blood thinning medications) daily; -Obtain complete blood count (CBC) (laboratory test to screen for [MEDICAL CONDITION]) weekly. Review of the resident's care plan, dated 5/12/11, showed staff had not addressed that the resident received an anticoagulant medication ([MEDICATION NAME]) or had a [DIAGNOSES REDACTED]. Review of the resident's POS, dated 5/14/11, showed an order to continue to hold [MEDICATION NAME] 7 mg and repeat [MEDICATION NAME] (PT) (a blood test that evaluates the ability of blood to clot properly) and INR on 5/16/11. Review of the resident's PT/INR results, dated 5/17/11, showed a PT of 20.7 (normal value is 11.9-14.0) and INR of 1.75 (normal value is 0.8-1.2). Review of the resident's POS, dated 5/17/11, showed the following orders: -Venous and arterial doppler study (a test that evaluates the blood flow in veins and arteries) of the bilateral lower extremities; -Start [MEDICATION NAME] 4 mg every evening; -Obtain PT/INR in two days on 5/19/11; -Discontinue daily PT/INR. Review of the resident's medical record, showed no PT/INR results dated 5/19/11. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -He/She received [MEDICATION NAME] 4 mg daily at bedtime, from 5/17/11 through 5/30/11; -On 5/19/11, staff did not initial the entry for PT/INR as done. Review of the resident's venous and arterial doppler study results, dated 5/26/11, showed [MEDICAL CONDITION] (probably chronic/non-occlusive) of the bilateral lower extremities. Review of the resident's CBC results, obtained on 5/27/11, showed a hemoglobin (a protein in red blood cells that carries oxygen) of 8.8 (normal value is 14.0-18.0) and a hematocrit (the percentage of blood that is made up of red blood cells) of 26.2 (normal value is 40.0-54.0). Review of the resident's nurse's notes, showed the following: -On 5/28/11 at 11:30 A.M., staff noted the resident's fingertips as purplish-blue in color and cold. Staff administered oxygen at 1.5 liters (L) and would continue to monitor. Staff documented no notification of the resident's physician or resident's vital signs (blood pressure, pulse, respirations and temperature); -On 5/28/11 at 2:15 P.M., staff noted no changes in condition. The resident's color had improved slightly. Staff would report to oncoming nurse. No further assessment or vital signs documented; -On 5/28/11 at 10:45 P.M., staff received a physician's orders [REDACTED]. No further assessment of the resident's condition documented. Review of the resident's POS, dated 5/28/10, showed staff received an order to obtain a CBC and report the results to physician ASAP. Review of the resident's nurse's notes showed the following: -On 5/29/11 at 8:00 A.M., the resident's oxygen saturation read 96% (normal value is greater than 90 percent). The color in his/her fingertips returned to normal. The resident showed no acute distress. No further assessment or vital signs documented. -On 5/30/11 at 9:00 A.M., staff noted the resident's fingertips to be bluish in color. Staff notified the resident's physician and received no new orders. No assessment of the resident documented. No further assessment of the resident's condition documented on 5/30/11. Review of the resident's medical record, showed no documentation the CBC was obtained as ordered on [DATE] and called to the physician ASAP. Review of the resident's physician's progress note, dated 5/31/11, showed a [DIAGNOSES REDACTED]. The physician described the resident as lethargic, weak and dehydrated. Review of the resident's POS, dated 5/31/11, showed an order to transfer the resident to the hospital for evaluation and treatment. Review of the resident's nurse's notes showed the following: -On 5/31/11 at 2:00 P.M., staff received physician's orders [REDACTED]. No further assessment documented. -On 5/31/11 at 2:45 P.M., ambulance personnel transported the resident to an emergency room . Review of the resident's hospital admission history and physical, dated 6/1/11, showed on 5/31/11, when emergency medical services arrived at the facility, the resident's systolic blood pressure (top number of blood pressure reading) read in the 60s (normal reading is 100-120). Staff reported the resident's mental status had decreased over the past couple of weeks. Upon admission to the emergency room , the resident had a critically elevated PT of 126.4 (normal value is 11.9-14.0), an elevated INR of greater than 8.0 (normal value is 0.8-1.2) and had been receiving [MEDICATION NAME] 4 mg daily at the facility. He/She required a Vitamin K (makes the blood clot) injection and one unit of fresh frozen plasma (liquid portion of human blood). His/Her CBC results obtained in the emergency room showed hemoglobin readings of 6.4 and 8.4 and hematocrit readings of 18.7 and 26.4. [DIAGNOSES REDACTED]. He/She received two units of packed red blood cells. The resident required admission to the intensive care unit. Review of Delmar's Manual of Laboratory and Diagnostic Tests showed, a PT greater than 30, INR greater than 4.5 is at high risk for hemorrhage. A PT greater than 40 is critical. Patient must be closely monitored for signs and symptoms of bleeding in feces, hematuria (blood in urine), bleeding from catheter sites, and [MEDICATION NAME] bleeding Intravenous vitamin K is given to correct the high [MEDICATION NAME] level. During an interview on 7/13/11 at 2:10 P.M., Assistant Director of Nurses (ADON) A said the laboratory showed, no CBC had been obtained on 5/28/11. She suspected the CBC had not been obtained because a CBC had been obtained on 5/27/11. During an interview on 7/14/11 at 11:15 A.M. and 4:40 P.M., ADON A said the laboratory showed no PT/INR had been obtained on 5/19/11. She said the PT/INR should have been obtained on 5/19/11, as ordered. The facility had no policy for the monitoring of PT/INR results when a resident received [MEDICATION NAME] therapy. During an interview on 8/17/11 at 10:25 A.M., the resident's physician said staff should have obtained the PT/INR as ordered, for 5/19/11 and the CBC as ordered, on 5/28/11. Staff should have monitored the resident for bleeding since he/she received [MEDICATION NAME]. Nurses may need more training about proper assessment of a resident prior to notifying the physician. MO 677