Every finding on record at Hunter Acres Caring Center

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 87.The facility did not provide a policy on the environment. 1. Observation on 08/04/25 at 10:24 A.M., of room [ROOM NUMBER] showed: - The bathroom door with a smeared brown substance; - Dirt and debris on the floor. 2.Observation on 08/04/25 at 10:35 A.M., of room [ROOM NUMBER] showed: - A spider web in the window seal. 3. Observation on 08/05/25 at 2:55 P.M., of room [ROOM NUMBER] showed: - The bathroom flooring peeled and separated from the subfloor; - A black substance on the upper portion of all of the bathroom walls and with a musty smell. 4. Observations on 08/06/25 at 9:45 A.M., and 08/07/25 at 10:05 A.M., of room [ROOM NUMBER] showed: - A baseball-sized hole in the wooden bathroom door; - A spiderweb in the window seal. 5. Observation on 08/07/25 at 10:00 A.M., of room [ROOM NUMBER] showed: - Missing trim around the air conditioner; - Spiderwebs in the corner next to the air conditioner unit; - A strong smell of urine in the room; - Dirt and debris all over the floor; - Paint peeled and chipped on the walls, the return vent covered in a gray/black substance, and a black substance on the top of the walls in the bathroom. 6. Observation on 08/07/25 at 10:15 A.M., of room [ROOM NUMBER] showed: - Paint and plaster peeled off the walls surrounding the toilet and the vent return covered in a gray/black substance in the bathroom. 7. Observation on 08/06/25 at 7:35 A.M of the 400 Hall Common Area showed: - Missing trim around the air conditioner; - Spiderwebs in the corner of room to the left of the T.V. During an interview on 08/07/25 at 12:45 P.M., the Maintenance Director said housekeeping staff had a daily checklist that told them what areas to clean. Staff turned the checklist into him/her at the end of the shift. Housekeeping staff did a deep clean every two weeks, which included dusting. He/She would not expect any spiderwebs to be in the facility. The floors were not able to be waxed due to the type of material of the flooring. He/She didn't know of any current issues. During an interview on 08/07/25 at 11:20 A.M., Housekeeping Staff L said there was a chart in the housekeeping closet that he/she went by to determine what to clean for the day. There was only housekeeping staff scheduled on the day shift. During an interview on 08/07/25 at 2:50 P.M., the Administrator said she would expect all residents to have a clean and homelike environment.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the insect population in the facility. The facility census was 86.Review of the facility's policy titled, Pest Control, dated May 2008, showed:- This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents;- Maintenance services assist, when appropriate and necessary, in providing pest control services.Review of the facility's Pest Control Invoices for May - August 2025 showed:- May 2025, June 2025, July 2025, and August 2025 service targeted the German roach and the house mouse;- No services targeted flies.Observations of the 200 Hall dining room showed:- On 08/04/25 at 12:20 P.M., and 08/05/25 at 12:20 P.M., an insect light trap on the wall of the dining room was plugged in but not turned on;- On 08/04/25 at 12:23 P.M., Resident #12 ate his/her food while two flies crawled on his/her dining table;- On 08/04/25 at 12:25 P.M., Resident #32 ate his/her food while three flies crawled on his/her dining table;- On 08/05/25 at 12:21 P.M., Resident #32 ate his/her food while four flies crawled on his/her dining table;- On 08/05/25 at 12:36 P.M., Certified Nurse Aide (CNA) E said the flies were bad today;- On 08/05/25 at 12:38 P.M., Resident #84 ate his/her food while flies buzzed around, and one fly crawled on his/her food on the plate;- On 08/06/25 at 8:21 A.M., Resident #32 ate his/her food while two flies crawled on his/her dining table;- On 08/07/25 at 1:37 P.M., CNA F swatted a fly with his/her hand as it flew around his/her face.During an interview on 08/07/25 at 1:45 P.M., CNA E said that flies were sometimes a problem this time of year and that staff used a fly swatter to keep them down. He/She did not know why the light trap was not turned on.During an interview on 08/07/25 at 12:00 P.M., the Director of Nursing (DON) said she expects the facility to be free of pests, including flies, and that the facility had contracted with a different pest control company this month.During an interview on 08/07/25 at 3:15 P.M., the Administrator said she would expect the facility to be free of pests, including flies.

Based on interview and record review, the facility failed to ensure the correct code status for one resident (Resident #2) out of 19 sampled residents and failed to address and receive an order for a code status for one resident (Resident #86) outside the sample. The facility census was 87. Review of the facility's policy titled, Advanced Directives, dated [DATE], showed:- Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or legal representative, about the existence of any written advance directives;- The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he/she chooses to do so;- Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative;- If the resident or representative indicates that he/she has not established advance directives, the facility staff will offer assistance in establishing advance directives;- Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff;- The Director of Nursing (DON) services or designee notifies the attending physician of the advance directives so that appropriate orders can be documented in the resident's medical record and plan of care;- The interdisciplinary team will review annually with the resident his/her advance directives to ensure that such directives are still the wishes of the resident during the annual assessment process and record in the medical record. - Changes or revocations of a directive must be submitted in writing to the administrator;- The administrator may require new documents if changes are extensive;- The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident's medical record and care plan.1. Review of Resident #2's medical record showed:- An admission date of [DATE];- An order for Full Code (in the event of a cardiac or respiratory arrest, a patient's healthcare team will perform all possible life-sustaining measures), dated [DATE], and discontinued on [DATE];- An order for Do Not Resuscitate (DNR - instructs healthcare professionals not to perform cardiopulmonary resuscitation (CPR) if a person's heart or breathing stops), dated [DATE].Review of the resident's Outside the Hospital Do Not Resuscitate Order (OHDNR) form, dated [DATE], showed:- Full Code hand-written with what appeared to be in highlighter ink across the form, dated and signed by the resident and his/her resident representative on [DATE].Review of the resident's Care Plan, dated [DATE], showed:- Full code status.Review of the facility's DNR binder showed:- A dark and hard-to-read copy of Resident #2's OHDNR form signed and dated by the resident, his/her responsible party, and the physician on [DATE];- Unable to read if Full Code was hand-written on the form with highlighter ink.During an observation and interview on [DATE] at 1:48 P.M., showed:- Licensed Practical Nurse (LPN) I reviewed the resident's scanned copy the resident's OHDNR signed by the resident, resident representative, and the physician on [DATE], with Full Code hand-written faintly on the form;- LPN I didn't know if the resident was a full code or a DNR.During an interview on [DATE] at 1:15 P.M., the Director of Nursing (DON) said she did not know why Resident #2's code status was changed to DNR but the resident had an OHDNR in the DNR binder.During an interview on [DATE] at 9:10 A.M., Resident #2's responsible party said the resident was a full code. The facility didn't discuss with him/her if the resident's code status should be changed.2. Review of Resident #86's medical record showed:- An admission date of [DATE];- No order for a code status;- No advance directive.Review of the resident's Care Plan, dated [DATE], showed:- Full code status.During an interview on [DATE] at 3:16 P.M., Resident #86 said he/she wanted to be a full code and wanted cardiopulmonary resuscitation (CPR) performed if he/she stopped breathing and/or heart stopped beating.During an interview on [DATE] at 1:48 P.M., LPN I said he/she looked in a resident's electronic medical record to determine a resident's code status by looking at the advance directive link at the top of the face sheet. The link went to the resident's actual documents scanned into the resident's chart regarding advance directives and code statuses.During an interview on [DATE] at 3:21 P.M., LPN H said he/she looked at the top of a resident's face sheet in the electronic medical chart for a code status order.During an interview on [DATE] at 2:50 P.M., the Administrator and DON said they would expect residents' code status orders to match the signed advance directive.

Based on interview and record review, the facility failed to attempt and ensure the physician responded to gradual dose reductions (GDRs) for medications for two residents (Residents #4 and #19) and failed to limit the use of as needed (PRN) psychotropic (medications that affect the mind, emotions, and behavior) medication orders for 14 days for one resident (Resident #19) out of five sampled residents. The facility census was 87.Review of the facility's policy titled, Medication Regimen Reviews (MRR), revised February 2025, showed: - The MRR includes a review of the medical record to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities, for example, the use of medication was inconsistent with accepted pharmaceutical services standards of practice, not supported by medical evidence, that impedes or interferes with achieving the intended outcomes of pharmaceutical services, ordered without clinical indication or in excessive dose, administered without adequate monitoring or in the presence of adverse consequences; and/or that appears to be inconsistent with the resident's stated preferences; - MRRs are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated depending on a resident's condition and/or risk for adverse consequences. - Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a medication irregularity that is deemed not life-threatening. The report contains resident's name, name of the medication, identified irregularity, and pharmacist's recommendation; - The consultant pharmacist provides the Director of Nursing (DON) services and Medical Director with a written, signed, and dated copy of all medication regimen reports; - Copies of MRR reports, including physician responses, are maintained as part of the permanent medical record; - The consultant pharmacist submits a quarterly report that includes a summary of key findings from MRRs, including status of the facility's pharmaceutical services, staff performance in complying with regulatory requirements related to medication utilization and monitoring, problem areas and irregularities noted (e.g. documentation errors, medication errors, etc.), recommended solutions for specific problem areas, follow-up reports relative to the facility's corrective action related to problem areas, and other pertinent information; - Upon receiving the MRR report from the pharmacist, the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them; - If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the Medical Director or (if the Medical Director is the physician of record) and the Administrator; - The facility includes a review of key issues related to medications and medication irregularities as part of the Quality Assurance and Performance Improvement (QAPI) program. Review of the facility's policy titled, Tapering Medications and Gradual Dose Reductions, revised February 2025, showed: - Residents who use psychotropic medications receive GDRs, unless clinically contraindicated, in an effort to discontinue these medications; - GDR refers to the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed at a lower dose or if a medication can be discontinued; - All medications are considered for possible tapering/GDR; - The staff and practitioner consider GDRs under certain circumstances, including when the resident's clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved, non-pharmacological interventions, including behavioral interventions, have been effective in reducing symptoms, or a resident's condition has not responded to treatment or has declined despite treatment; - Within the first year after a resident is admitted on a psychotropic medication or after the resident has been started on a psychotropic medication, the staff and practitioner will attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated; - After the first year, the facility will attempt a GDR at least annually, unless clinically contraindicated; - The time frames and duration of tapering/GDR attempts are based on relevant factors including other medications the resident is taking, underlying causes of symptoms, individual risk factors, and pharmacologic characteristics of the medications; - Some medications (e.g., antidepressants, sedative/hypnotics, opioids) may need more gradual tapering to minimize withdrawal symptoms or other adverse consequences; - For any individual who is receiving a psychotropic medication, the GDR may be considered contraindicated for reasons that include, but are not limited to the continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would likely impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; or the resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; - GDR attempts are documented in the medical record. The documentation includes the date of the GDR attempt, outcome of the dose reduction attempt, any return or worsening of symptoms, and plan regarding any future GDR attempts. Physician documentation contains the rationale for why GDR attempts are clinically contraindicated for the resident. 1. Review of Resident #4's August 2025 Physician Order Sheet (POS): - An admission date of 09/21/21; - Diagnoses of cerebrovascular disease (a group of disorders that affect blood vessels and blood supply to the brain), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, leading to problems with memory, thinking, and behavior), generalized anxiety disorder (excessive, uncontrollable worry about everyday things that persists for at least six months), and major depressive disorder (long-term loss of pleasure or interest in life); - An order for Abilify (an antipsychotic (a medication used to treat symptoms of psychosis) medication) 5 milligrams (mg) by mouth one time a day for mood disorder, dated 06/05/24, and discontinued 01/15/25; - An order for Abilify 5 mg by mouth one time a day related to major depressive disorder, dated 01/15/25. Review of the resident's MRR dated 10/02/24, showed: - Pharmacist requested a GDR for the Abilify 5 mg daily dose; - The physician failed to respond. During an interview on 08/07/25 at 10:50 A.M., the resident's Physician Assistant (PA) said he/she received the GDR requests directly from the pharmacist. He/She did not receive any GDR request to reduce Resident #4's Abilify on 10/02/24. 2. Review of Resident #19's August 2025 POS showed: - An admission date of 03/24/21; - Diagnoses of anxiety, major depressive disorder, opioid dependence, chronic pain, nausea, bipolar (a mental disorder that causes unusual shifts in mood), insomnia (difficulty sleeping), and restless leg syndrome; - An order for Ambien (a hypnotic medication to help sleep) 5 mg give 1.5 tablet by mouth every 24 hours PRN for insomnia, dated 06/05/24, and no end date; - An order for buspirone (an antianxiety medication) 10 mg by mouth three times a day related to anxiety disorder, dated 05/04/24; - An order for hydroxyzine (an antianxiety medication) 50 mg by mouth every eight hours PRN for anxiety, dated 10/09/24, and no end date; - An order for Rexulti (an antipsychotic medication) 1 mg by mouth once a day for depression, dated 06/06/24. Review of the resident's MMR showed: - On 11/04/24, 12/02/24, and 08/05/25, the pharmacist requested the physician review the hydroxyzine 50 mg every eight hours PRN for anxiety order extended past the 14 days without adequate review and documentation on a patient specific basis. The physician failed to respond; - On 04/01/25, the pharmacist requested the physician review the hydroxyzine 50 mg every eight hours PRN for anxiety order extended past the 14 days without adequate review and documentation on a patient specific basis. The physician signed and documented to maintain the current PRN order with the resident stable on the current dose on 08/06/25. The physician did not document the rationale for the resident's need of the PRN medication for longer than 14 days; - On 08/01/24 and 03/03/25, the pharmacist requested the physician review the Ambien 5 mg 1.5 tablet at night PRN order extended past the 14 days without adequate review and documentation on a patient specific basis. The physician failed to respond; - On 05/07/25, the pharmacist requested the physician review the buspirone 10 mg three times a day dose for a GDR. The physician failed to respond; - On 02/23/25, the pharmacist requested the physician review the Rexulti 1 mg daily dose for a GDR. The physician failed to respond. During an interview on 08/05/25 at 1:06 P.M., Resident #19 said that he/she went out of the facility to see a physician monthly and the physician addressed all his/her needs at that time, including medications he/she received. During an interview on 08/07/2025 at 10:11 A.M., the DON said Resident #19 went to an outside facility physician. The facility sent the pharmacy requests to the physician's office but never received anything back. The resident chose the physician he/she saw because he/she did not like the facility physician when it came to his/her medications. During an interview on 08/07/25 at 2:50 P.M., the DON and Administrator said as soon as the facility gets the pharmacy recommendations, the recommendations were sent to the physician, and when the documents were returned to the facility, they were entered into the resident's medical record as soon as possible. They would expect PRN psychotropic medications to have an acceptable end date and be reevaluated at the appropriate time frames. They would also expect MMRs completed by the pharmacy to be addressed by the appropriate physician when irregularities were identified and when GDRs need to be addressed or completed. During a phone interview on 08/14/25 at 8:50 A.M. Pharmacist G said he/she completed GDRs for psychotropic medications twice in the first year then once yearly. For PRN medications lasting longer than 14 days, he/she made sure the medications were used appropriately, still needed, and used for the appropriate duration. He/She physically completed the paper and gave it to the facility, usually DON, and told them to make a copy for them and give another to the provider. When the provider filled out the form and signed it, then the new change and start date would be entered for the medication in question. He/She completed the MMRs monthly and gave the facility a report each month with the recommendations. It would be up to the facility at that point to get the recommendations to the appropriate provider and to keep the recommendations in the resident's medical record. There should be a paper trail of the process, and the facility should be able to provide those papers at any time.

Based on interview and record review, the facility failed to follow their policy and procedure to complete Criminal Background Checks (CBC) and to check the Employee Disqualification List (EDL - a listing of individuals who have been determined to have abused, neglected, and/or misappropriated funds or property from a resident) prior to the hire date for three employees (Employees A, B, and C) out of ten sampled employees . The facility census was 86.Review of the facility's policy titled, Background Screening Investigations, dated March 2019, showed:- Background checks, reference checks, and criminal conviction checks on all potential direct access employees and contractors should be conducted. Background and criminal checks are initiated within two days of an offer of employment and completed prior to employment.Review of the facility's policy titled, Abuse Prevention Program, not dated, showed:- As part of the resident abuse prevention, the administration will conduct employee background checks.1. Review of Employee A's personnel file showed: - A hire date of 08/30/24;- No documentation of a CBC completed prior to the hire date;- No documentation of a EDL completed prior to the hire date;- The facility failed to perform the CBC and EDL prior to the hire date.2. Review of Employee B's personnel file showed:- A hire date of 11/04/24;- No documentation of a CBC completed prior to the hire date;- No documentation of a EDL completed prior to the hire date;- The facility failed to perform the CBC and EDL prior to the hire date.3. Review of Employee C's personnel file showed:- A hire date of 12/20/24;- No documentation of a CBC completed prior to the hire date;- No documentation of a EDL completed prior to the hire date;- The facility failed to perform the CBC and EDL prior to the hire date.During an interview on 08/07/25 at 3:10 PM, the Administrator said that the CBC and EDL should be done prior to employment.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a standardized assessment tool used in nursing homes to collect comprehensive information about residents' functional capabilities and health status) for two residents (Residents #38 and #46) out of 19 sampled residents. The facility census was 87. Review of facility's policy titled, Resident Assessments, dated October 2023, showed:- Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews;- The resident assessment coordinator is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments;- Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. 1. Review of Resident #38's Medical Record showed:- An admission date of 11/13/19;- Diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), intellectual disabilities (significant limitations in both intellectual functioning and adaptive behavior), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of the resident's PASRR Level II screening, dated 12/09/22, showed:- Resident with a serious mental illness and intellectual developmental disability or related condition. Review of the resident's annual MDS, dated [DATE], showed:- Not evaluated by a Level II PASRR. 2. Review of Resident #46's Medical Record showed:- An admission date of 10/28/21;- Diagnoses of schizophrenia, paranoid personality disorder (a mental health condition characterized by a pervasive distrust and suspicion of others, even when there is no valid reason to be suspicious), delusional disorders (a mental illness characterized by one or more persistent, false beliefs that last for at least one month), bipolar disorder, anxiety disorder, violent behavior, hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there), and homicidal ideations (thoughts or fantasies about killing another person). Review of the resident's PASRR Level II screening, dated 11/22/21, showed:- Resident with a serious mental illness. Review of the resident's annual MDS, dated [DATE], showed:- Not evaluated by a Level II PASRR. During an interview on 08/07/25 at 2:15 P.M., the MDS Coordinator said the PASRR Level II determination should be documented on the MDS. During an interview on 08/07/25 at 2:50 P.M., the Administrator and the Director of Nursing (DON) said they would expect the MDS to accurately reflect the resident's status.

Based on interview, observation, and record review, the facility failed to establish a care plan for two residents (Resident #38 and #69) out of 19 sampled residents. The facility census was 87.Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, showed: - The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. Review of Resident #38's medical record showed: - An admission date of 11/13/19; - Diagnoses of chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), sleep related hypoventilation (a breathing disorder where breathing becomes too shallow or slow during sleep, leading to insufficient oxygen and/or excessive carbon dioxide in the blood), shortness of breath, and nicotine dependence; - An order for bilevel positive airway pressure machine (BiPAP - a type of non-invasive ventilation used to assist with breathing) at bedtime for sleep apnea (repeated pauses in breathing during sleep), dated 06/05/24; - An order for oxygen at two liters per minute per nasal canula (a flexible tube inserted into the nostrils to provide supplemental oxygen) as needed for COPD, dated 06/05/24. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 06/19/25, showed: - Used a non-invasive mechanical ventilator. Review of the resident's Care Plan, revised 06/22/25, showed: - Did not address the BiPAP and oxygen use. During an observation and interview on 08/05/25 at 2:52 P.M., showed: - The resident's BiPAP machine sat on the bedside table and the oxygen concentrator sat at the head of the bed; - The resident said his/her BiPAP was used at night and oxygen when he/she was short of breath. 2. Review of Resident #69's medical record showed: - An admission date of 12/19/23; - Diagnoses of asthma and wheezing (breathing condition causing narrowing of airways making it more difficult to breath), pleural effusion (fluid in lung space), and insomnia (difficulty sleeping); - An order to apply continuous positive airway pressure (CPAP – delivers a continuous flow of air to open the airways) at a pressure of 14 at night and with naps for sleep apnea, dated 03/05/25. Review of the resident's annual MDS, dated [DATE], showed: - Used a non-invasive mechanical ventilator. Review of the resident's Care Plan, revised 06/06/25, showed: - Did not address the resident's CPAP use. Observation on 08/05/25 at 9:05 A.M., showed the resident's CPAP machine sat at the bedside. During an interview on 08/05/25 at 12:06 P.M., the resident said he/she wore his/her CPAP at night. He/She put it on sometimes by himself/herself and sometimes with staff assistance. During an interview on 08/07/25 at 11:00 A.M., the Care Plan Coordinator said he/she talked to staff, checked the residents' orders, and went to daily meetings to get information on the residents' current conditions. Oxygen needs, including BiPAP and CPAP use should be on the care plan. The care plans were updated when a resident went out to the hospital or for a physician's visit and came back with new orders, a change in condition, or quarterly. During an interview on 08/07/25 at 2:50 P.M., the Administrator and the Director of Nursing (DON) said they would expect the care plan to accurately reflect the resident's current condition, needs, and care areas. The care plan should be revised with a resident's change in condition.

Based on interview and record review, the facility failed to follow physician's written orders for one resident (Resident #2) out of 19 sampled residents. The facility census was 87. Review of the facility policy titled, Telephone Orders, dated February 2014, showed:- Verbal telephone order may only be received by licensed personnel;- Order must be reduced to writing by the person receiving the order and recorded in the resident's medical record;- The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information.1. Review of Resident #2's medical record showed:- An admission date of 12/08/21; - Diagnoses of congestive heart failure (CHF - a condition where the heart can't pump enough blood to meet the body's needs), type II diabetes mellitus (a chronic condition where the body doesn't use insulin properly, leading to high blood sugar levels), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), generalized anxiety disorder (excessive, uncontrollable worry about everyday things that persists for at least six months), mild cognitive impairment (a condition in which people have more memory or thinking problems than other people their age), and morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems).Review of the resident's August 2025 Physician Order Sheet (POS) showed: - An order for Seroquel (an antipsychotic (medications that treat psychosis, a condition where a person's perception of reality is impaired) medication) 25 milligram (mg) give 12.5 mg by mouth at bedtime, dated 05/15/25, and discontinued on 05/20/25;- An order discontinue the Seroquel 12.5 mg by mouth at bedtime, dated 05/20/25;- An order for Seroquel 25 mg 1/2 tablet by mouth at bedtime, dated 05/20/25, and discontinued on 06/19/25; - An order to discontinue Seroquel 12.5 mg by mouth at bedtime, dated 06/17/25.Review of the resident's Behavioral Health Note, dated 06/17/25, showed:- Resident continued to receive Seroquel 12.5 mg even though the medication was discontinued during last visit on 05/20/25.Review of the resident's Medication Administration Record (MAR), dated May 2025 - June 2025, showed:- The resident received Seroquel 25 mg 1/2 tablet at bedtime from 05/20/25 to 06/01/25, and 06/03/25 - 06/18/25;- Received 29 doses of the Seroquel 25 mg 1/2 tablet after discontinued.During an interview on 08/07/25 at 10:50 A.M., the behavioral Physician Assistant (PA) said he/she discovered during a visit on 06/17/25, the resident was still administered Seroquel. On the previous visit on 05/20/25, he/she had written an order to discontinue the Seroquel. He/She wrote another order to discontinue the Seroquel on 06/17/25.During an interview on 08/07/25 at 2:10 P.M., Licensed Practical Nurse (LPN) H said the nurse on duty received the orders for the residents on his/her hall. The orders were entered into the electronic medical record by the nurse on duty.During an interview on 08/07/25 at 2:50 P.M., the Administrator and the Director of Nursing (DON) said they would expect physician orders to be entered into the system accurately.During an interview on 08/14/25 at 3:28 P.M., the Administrator said their policies regarding written orders reflected the same practice as telephone and verbal orders. The written order was scanned into the electronic medical record after the order was entered by the nurse.

Based on observation, interview, and record review, the facility failed to put dietitian recommendations into place for one resident (Resident #4) out of four sampled residents that had excessive weight loss. The facility census was 87. Review of the facility policy titled, Weight Assessment and Intervention, dated March 2022, showed:- Residents are weighed upon admission and at intervals established by the interdisciplinary team;- Any confirmed weight change of five percent (%) or more since the last weight assessment will be reported to the dietitian in writing by nursing. Review of the facility policy titled, Nutritional Assessment, dated October 2017, showed:- The dietitian will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition;- The dietitian will determine an estimate of calorie, protein, nutrient, and fluid needs;- The dietitian will determine whether the resident's current intake is adequate to meet his/her nutritional needs;- The dietitian will determine special food formulations;- Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications;- Individualized care plans shall address the identified causes of impaired nutrition;- Individualized care plans shall address the resident's personal preferences;- Individualized care plans shall address goals and benchmarks for improvement;- Individualized care plans shall address time frames and parameters for monitoring and reassessment. 1. Review of Resident #4's medical record showed:- An admission date of 09/21/21;- Diagnoses of cerebrovascular disease (a group of disorders that affect blood vessels and blood supply to the brain), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, leading to problems with memory, thinking, and behavior), generalized anxiety disorder (excessive, uncontrollable worry about everyday things that persists for at least six months), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the resident's Weight Summary, dated 03/01/25 - 08/31/25, showed:- On 03/04/25, weight of 136.6 pounds (lbs);- On 04/02/25, weight of 135.6 lbs;- On 05/01/25, weight of 136.4 lbs;- On 06/06/25, weight of 124.2 lbs, an 8.94% weight loss in 30 days;- On 07/01/25, weight of 128.4 lbs;- On 08/01/25, weight of 129.0 lbs, a 5.56% weight loss in less than 180 days. Review of the resident's Dietician Assessment, dated 06/24/25, showed:- Weight of 124.2 pounds;- Nutritional plan to continue a mechanical soft diet with extra portions as needed with a divided plate, add a house supplement twice a day, and provide encouragement as needed at meals. Review of the resident's Physician Order Summary (POS), dated 08/07/25, showed:- An order for a regular diet with mechanical soft texture, regular/thin consistency, a divided plate, dated 07/09/24;- No order for a house supplement twice daily as recommended by the dietician. During an observation on 08/04/25 at 12:10 P.M., and 08/05/25 at 12:32 P.M., showed:- The resident fed him/herself using a divided plate;- The resident was not provided with extra portions of food and a house supplement;- The resident ate 75% of the meal and did not request additional servings;- Staff did not encourage the resident to eat;- Staff did not document the resident's food intake. During an interview on 08/07/25 at 2:10 P.M., Licensed Practical Nurse (LPN) H said the dietitian gave the order recommendations to the nurse on duty and they entered the orders into the electronic medical record. During an interview on 08/07/25 at 2:50 P.M., the Director of Nursing (DON) and the Administrator said they would expect dietician recommendations to be implemented. During a phone interview on 08/15/25 at 8:30 A.M., the Dietitian said the facility contacted him/her via phone or email. The nutrition recommendations were provided to the DON and the Dietary Manager. The DON or nurse designee would be responsible for changing the diet orders in the resident's electronic medical record.

Based on observation, interview, and record review, the facility failed to timely and effectively address significant weight loss for one resident (Resident #58) out of 20 sampled residents. The facility's census was 86. Review of the facility's policy titled, Weight Assessment and Intervention, revised March 2022, showed: - Any weight change of 5% of more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will notify the dietician; - Unless notified of significant weight change, the dietician will review the unit weight record monthly to follow individual weight trends over time.; - The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss=(usual weight - actual weight)/(usual weight) x 100]: For one month - 5% weight loss is significant; greater than 5% is severe. For three months - 7.5% weight loss is significant; greater than 7.5% is severe. For six months - 10% weight loss is significant; greater that 10% is severe; - Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietician, the consultant pharmacist, and the resident or resident's legal surrogate. Review of Resident #58's Electronic Medical Record (EMR) showed: - admitted on [DATE] - Admission weight was 215 pounds (lbs); - Diagnoses of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypertension (abnormally high blood pressure), diabetes mellitus (a chronic condition that affects the way the body processes glucose); - On 05/14/24 resident's weight was 215 lbs; - On 06/07/24 resident's weight was 211 lbs; - On 07/08/24 resident's weight was 192 lbs with a 23 lb and 10.7% weight loss in less than 60 days; - On 08/01/24 resident's weight was 163 lbs with a 52 lb and 24.2% weight loss in less than 90 days; - The resident had significant weight loss in less than 90 days. Review of the resident's Admission Dietary History and Initial Screening, dated 05/14/24, showed: - Mechanical diet; - Few/broken/poor condition of teeth/mouth sore; - Resident preferences for beverages: water and tea; - Resident likes: ice cream and chips. Review of the resident's Physician's Order Sheet (POS), dated August 2024, showed: - An order for mechanical soft diet, dated 05/14/24; - An order to change the diet to a regular diet, regular consistency and thin liquids, dated 07/09/24; - No other weight loss interventions. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument), dated 05/21/24, showed: - Severe cognitive impairment; - Required supervision for eating; - Weight 215 lbs; - No significant weight loss; - Mechanically altered diet. Review of the resident's care plan, dated 05/24/24 showed the care plan did not identify or address interventions related to the resident's weight loss. Review of the resident's Nutritional Progress Notes showed: - On 05/14/24, the resident received a mechanical diet and no current dislikes. Loved ice cream and chips; - On 07/09/24, the resident's diet was changed to a regular diet by the physician. Review of the Registered Dietician (RD) Care form, dated 07/19/24, showed: - Consult with resident; - The resident with a weight loss for the past 30 and 60 days; - Add large portions at breakfast every day; - Add ice cream or an extra item of choice every day x 30 days. Review of resident's Progress Notes showed: - On 05/18/24, the resident complained of bad teeth and says there was no food he/she could eat; - On 07/11/24, the resident was out with family. The family reported the resident ate 25%; - On 07/20/24, the resident still refused to eat meals or take medication. The resident told the nurse it had been a week without him/her having a drink of water. The resident had water at that time; - On 07/22/24, the resident moved to a new room and said he/she hadn't had anything to drink in months; - On 07/26/24, the resident refused medication and refused to eat. Multiple staff asked multiple times; - On 07/29/24, the resident continued to refuse medication and food; - On 07/31/24, Invega Sustenna (an antipsychotic medication) given related to unspecified dementia, severe with psychotic disturbance; - On 08/01/24, the resident continued to refuse medication and meals; - On 08/02/24, the resident slumped over in the chair and not responding. The resident was sent to the emergency room . - On 08/03/24, the resident admitted to intensive care unit with a diagnosis of acute kidney injury. Review of the resident's Behavioral Health (BH) Notes showed: - On 06/25/24, Psychiatric Physician's Assistant (PA) H documented the resident refused medications, to shower, to change clothes and refused care. The resident had paranoid thoughts and thought the staff were trying to poison him/her. The resident told other residents and people that the staff was withholding food from him/her. On interview there, was some confusion and the resident was somewhat circumstantial. The resident said people are trying to kill him/her and cut him/her open. Resident states he/she is not eating because they were putting poison in the food. The resident said no one would give him/her anything to drink. Gave the resident a cup and the resident said he/she did not want to drink out of the sink. He/She made several persecutory and delusional comments. The resident thought he/she was being poisoned. He/She thought staff were trying to kill him/her; - On 07/02/24, Psychiatric PA H documented the resident made several delusional comments. The resident began by saying something about some small children being in his/her room and this caused the resident to vomit every time he/she was in his/her room. The resident said something about a little girl trying to get in his/her bed. When asked if he/she knew where he/she was, the resident said it had changed since the last visit. The resident was quite delusional and would likely require an antipsychotic medication moving forward; - On 07/30/24, Psychiatric PA H documented that according to staff, the resident still had delusional thinking that lead to him/her refusing medical treatments and cares as well as food and medications. Ordered Invega Sustenna as he/she now had a guardian. The resident needed something to treat his/her delusional thinking as it was interfering with his/her hygiene and medical treatments and overall health. During an interview on 08/08/24 at 4:25 P.M., Certified Medication Technician (CMT) G said that the resident was able to feed himself/herself so staff did not assist. During an interview on 08/19/24 at 4:41 P.M., the Registered Dietician (RD) said he/she saw the resident on 07/19/24, and the resident was a tough case because he/she didn't want to eat. The RD recommended to add large portions and ice cream or an extra item of the resident's choice for 30 days on the 07/19/24 visit. During an interview on 08/08/24 at 5:00 P.M., the DON said the RD was scheduled to come every two weeks, but was only required to see the residents monthly. During an interview on 08/08/24 at 5:05 P.M., the Administrator said she would expect a resident with a significant weight loss to be seen by the RD at least monthly. During an interview on 08/20/24 at 1:11 P.M., the resident's physician said that he/she agreed with psychiatry that the resident's weight loss was related to his/her behaviors of refusing medications and meals. The resident was being watched carefully and the resident refused everything they tried to do for him/her.

Based on interview and record review, the facility failed to ensure staff provided the necessary care and services in accordance with professional standards of practice by failing to notify the physician immediately of one resident's (Resident #22) significant change in status and by failing to provide emergency treatment in a timely manner for one resident (Resident #58) out of two sampled residents. The facility's census was 86. Review of facility policy titled, Change in a Resident's Condition or Status, dated February 2021, showed: - The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment significantly, and/or a need to transfer the resident to a hospital/treatment center; - A significant change of condition is a major decline or improvement in the resident's status. 1. Review of Resident #22's medical record showed diagnoses of chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), stroke, diabetes mellitus (a chronic condition that affects the way the body processes glucose), and hypertrophic cardiomyopathy (a condition in which the heart muscle becomes abnormally thick making it hard for the heart to pump blood). Review of the resident's progress notes showed: - On 6/22/24 at 6:23 P.M., the resident lay in bed lethargic (lack of energy or sluggish) and skin felt warm to the touch. Resident used accessory muscles (muscles that provide assistance to the main breathing muscles when additional power is needed) to breathe. Lungs sounds were coarse with congestion throughout. Vital signs of blood pressure (BP) 86/55, heart rate (HR) 99, respirations (resp) 32, temperature (temp) 101.4 degrees Fahrenheit (F), oxygen saturation 84% on room air. Applied oxygen at 3 liter per minute (lpm) per nasal cannula (NC - a flexible tube used to administer supplemental oxygen through the nose). Blood sugar was 61. Fed resident dairy products and resident drank two cups of orange juice. - On 06/22/24 at 9:00 P.M., the resident's vital signs of BP 106/66, HR 107, resp 28, temp 102.5 F, oxygen saturation 84% on oxygen at 3 lpm per NC. Administered two Tylenol 325 milligram (mg) by mouth per as needed; - On 06/22/24 at 10:35 P.M., contacted the physician on call and received an order to send the resident to the hospital; - On 06/22/24 at 10:45 P.M., report was called to the hospital emergency room (ER) nurse; - On 06/22/24 at 11:00 P.M., the ambulance arrived to transport the resident to the hospital; - On 6/23/24 at 9:54 A.M., the resident was admitted to the intensive care unit (ICU) for possible sepsis (a life-threatening medical emergency that arises when the body's attempt to fight off an infection results in the immune system damaging tissues and organs). Would be on intravenous antibiotics; - On 7/01/24 at 1:45 P.M., the resident returned from the hospital stay via facility transport. No signs and symptoms of distress. No complaints voiced. The facility failed to notify the physician immediately of the resident's significant change of status. Review of the resident's hospital discharge summary, dated 7/01/24, showed: - The resident was admitted to ICU for acute and chronic respiratory failure with hypercapnia (occurs when the lungs cannot release enough oxygen into the blood or remove carbon dioxide from the blood causing multiple organ failure), septic shock (a widespread infection causing organ failure and dangerously low blood pressure), healthcare associated pneumonia (infection that causes inflammation and fluid in the lungs), abnormal urine analysis, acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), acute encephalopathy (inflammation of the brain), acute dehydration (the absence of enough water in the body), elevated D dimer (a piece of protein that is made when a blood clot dissolves). During an interview on 08/16/24 at 10:55 A.M., Licensed Practical Nurse (LPN) E said he/she worked the night of 06/22/24. He/She remembered sending Resident #22 out to the hospital, but did not remember the events leading up to the transfer. During an interview on 8/08/24 at 3:10 PM, LPN D said he/she would notify the Director of Nursing (DON) and the resident's provider if a resident was short of breath with an elevated temperature. He/She would implement the orders and follow up as needed. If an alert resident had a low blood sugar, he/she would have them drink a sugary drink or give them a snack. If an unresponsive resident had a low blood sugar, he/she would administer a glucagon (a hormone that raises blood sugar) injection. The physician would be notified. The blood sugar would be rechecked in 20 to 30 minutes. If the blood sugar had not increased, he/she would contact the physician. During an interview on 08/16/24 at 10:50 A.M., Nurse Practitioner (NP) F said he/she was on call the night of 06/22/24, and confirmed he/she was contacted by the facility at 10:30 P.M., regarding Resident #22's change in condition. He/She would have expected to be contacted immediately following the resident's assessment at 6:23 P.M., when the resident had a low oxygen level and an elevated temperature. The nurse completing the assessment should have checked Resident #22's oxygen level immediately after applying the oxygen. During an interview on 8/08/24 at 5:00 P.M., the Administrator said she would expect the physician to be notified immediately when a resident had a significant change in condition. 2. Review of Resident #58's medical record showed: - Severe cognitive impairment; - Diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), diabetes mellitus (a chronic condition that affects the way the body processes glucose), and asthma (a chronic lung disease that inflames and narrows the airways in the lungs). Review of the resident's progress notes showed: - On 08/02/24, at 6:25 P.M., earlier in the shift, the resident was found slumped over in his/her wheelchair and the resident's BP could not be obtained. The DON was notified of the resident's condition and gave instructions to send the resident to the ER. The nurse instructed the Certified Nurse Assistants (CNAs) to place the resident on the bed. The resident had excoriated areas to his/her abdominal folds and coccyx. The ambulance arrived and left with the resident at 5:36 P.M.; - On 08/03/24 at 9:43 A.M., the nurse spoke to the hospital and the resident was admitted to ICU with a diagnosis of acute kidney injury. Review of resident's hospital History and Physical, dated 08/02/24, showed: - The resident admitted with acute metabolic encephalopathy, septic shock, UTI, and acute kidney failure; - admitted to the ICU. During an interview on 08/06/24 at 3:30 P.M., LPN B said that he/she was notified by a CNA the resident was found unresponsive. He/She assessed the resident, was unable to obtain a BP, and called the DON. LPN B instructed the CNAs to move the resident to the bed to make it easier to get the resident on the stretcher when the ambulance came and to clean the resident up. The ambulance was called after the resident was cleaned up, which took about 20 minutes from the time the resident was found unresponsive and the ambulance was called. The resident became more responsive during care. LPN B tried again to check the resident's BP and it was really low. He/She did not remember what the BP reading was. During an interview on 08/08/24 at 4:02 P.M., LPN B said he/she contacted the resident's physician after he/she spoke with the DON. The resident was transferred to the bed and cleaned because he/she was soiled. During an interview on 08/07/24 at 9:07 A.M., the DON said she thought the ambulance was called while the nurse was still on the phone with her that evening. She would expect staff to call an ambulance for a resident who was unresponsive immediately after contacting her. During an interview on 08/19/24 at 9:54 A.M., NP F said he/she was contacted regarding Resident #58's status on 08/02/24 at 4:58 P.M. He/She did not specifically remember all the details of the call but did remember that he/she gave orders to send the resident to the ER. He/She did not feel it was appropriate to delay calling the ambulance in order to clean the resident up. The facility failed to provide emergency treatment in a timely manner. NP F gave an order to send the resident to theER on [DATE] at 4:58 P.M. LPN B instructed the CNAs to place the resident on the bed and provide incontinent care to the resident. LPN B did not call the ambulance until after the resident's incontinent care was provided. The resident was transported by ambulance to theER on [DATE] at 5:36 P.M. 49999

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 86. The facility did not provide a policy on the environment. 1. Observations on 08/05/24 at 10:21 A.M., and 08/08/24 at 1:05 P.M., of room [ROOM NUMBER] showed: - On 08/05/24 at 10:21 A.M., the bathroom wall to the left of the toilet with a three foot (ft.) area of scratched and/or peeled off paint. 2. Observations of the 300/400 Hall common area showed: - On 08/05/24 at 10:15 A.M., the ceiling tile and the vent near the 300 Hall covered in a brown/black substance, - On 08/05/24 at 10:17 A.M., the wall to the left of the exit door with a four ft. by one inch (in.) hole above the cove base; - On 08/08/24 at 2:10 P.M., a brown substance on the ceiling vent outside the 300/400 Hall. 3. Observation on 08/07/24 at 3:30 P.M., of room [ROOM NUMBER] showed a hole at the bottom of the outside bathroom door. During an interview on 08/08/24 at 2:58 P.M., the Maintenance Director said there were forms on each hall to fill out with what needed to be looked at. He/She didn't know of any current issues. During an interview on 08/08/24 at 4:40 P.M., the Administrator said she would expect all residents to have a homelike environment.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 36 opportunities with two errors made, resulting in an error rate of 5.56% for two residents (Resident #12 and #30) out of five sampled residents. The facility's census was 86. Review of the facility's policy titled, Administering Medications, dated April 2019, showed: - Medications are administered in accordance with prescriber orders, including any required time frame; - Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 1. Review of Resident #12's Physician Order Sheet (POS), dated August 2024, showed: - An order for Novolog FlexPen (a type of insulin - medication used to lower blood sugar) 5 units subcutaneously (an injection below the skin) with meals for diabetes mellitus (a chronic condition that affects the way the body processes glucose), dated 6/04/24; - An order for Novolog FlexPen per sliding scale subcutaneously before meals and at bedtime for blood sugar of 70-180 = 0 units, 181-240 = 4 units, 241-290 = 6 units, 291-340 = 8 units, and [PHONE NUMBER] = call the physician, for diabetes mellitus, dated 6/04/24. Observation of Resident #12's medication pass on 8/07/24 at 12:13 P.M., showed: - The resident's blood sugar was 102; - Licensed Practical Nurse (LPN) D did not administer the resident's scheduled Novolog 5 units before lunch; - The facility failed to administer the resident's Novolog insulin as ordered. During an interview on 8/07/24 at 12:20 P.M., LPN D said Resident #12 did not have any Novolog insulin in the building and it would have to be ordered from the pharmacy. 2. Review of Resident #30's POS, dated August 2024, showed an order for Crestor (cholesterol medication) 40 milligrams (mg) one tablet by mouth daily for hyperlipidemia (high cholesterol in the blood), dated 6/29/24. Observation of Resident #30's medication pass on 8/07/24 at 8:34 A.M., showed: - Certified Medication Technician (CMT) C did not administer Crestor; - The facility failed to administer the resident's Crestor as ordered. During an interview on 8/07/24 at 8:34 A.M., CMT C said the resident was out of Crestor and more would need to be ordered from the pharmacy. During an interview on 8/07/24 at 1:57 P.M., CMT C said the Crestor for Resident #30 had still not arrived. During an interview on 8/08/24 at 5:00 P.M., the Administrator said he/she would expect residents not to run out of medications. She would expect medication be ordered from the pharmacy prior to the resident running out. During an interview on 8/08/24 at 5:00 P.M., the Director of Nursing (DON) said she would expect residents not to run out of medications. She would expect medication to be ordered from the pharmacy prior to the resident running out.

Based on interview and record review, the facility failed to provide adequate supervision for one resident (Resident #1), who had impaired memory, poor judgement and insight, and was assessed as an elopement risk. On 11/04/23, during a supervised smoke break, the supervising staff person left the resident alone and the resident left the facility grounds. The resident was found in a city approximately 30 miles away. The facility census was 87. The Administration was notified on 11/07/23 of a Past Non-Compliance citation Immediate Jeopardy (IJ) which began on 11/4/23. Upon discovery, the facility staff conducted an investigation, implemented facility protocols, and in-serviced staff on protective oversight. The IJ was corrected on 11/04/23. Review of the facility's policy titled, Smoking Policy- Residents, dated August 2022, showed: - The facility has established and maintains safe resident smoking practices; - Smoking is only permitted in designated resident smoking areas, which are located outside the building; - Resident smoking status is evaluated upon admission. The evaluation includes ability to smoke safely with or without supervision per completed Safe Smoking Evaluation; - Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member or volunteer worker at all times while smoking. Review of the facility's policy titled, Elopement Precautions/Missing Resident, dated 2007, showed: - Prevention of residents leaving the facility without supervision when assessed to be an elopement risk and measures to take when a resident is found missing; - If a resident is found to be an elopement risk and the facility has a Special Care Unit, placement of the resident in the unit will be considered. If applicable, a more permanent interdisciplinary team decision can be determined; - Residents who are considered an elopement risk are to have their whereabouts confirmed at least every 30 minutes; - Residents who are demonstrating elopement attempts are to remain under constant surveillance until it is safe to return to 30 minute checks; - Residents who are assessed to be elopement risks shall have specific care plan interventions that identify how to manage the resident's elopement behavior; - If a resident is found missing, the charge nurse is immediately notified and an immediate search of the facility is to occur followed by a search of the facility grounds; - If the resident is not located within 15 minutes, the Administrator and/or the Director of Nurses (DON) is to be notified and all available staff will begin a fanned out search; - Any hazards that are close to the facility are assigned for monitoring by a search person and would include highways, railroad tracks, etc. where practicable; - If resident is not located with in 30 to 45 minutes, the local authorities are to be notified for assistance; - The family/power of attorney (POA) is notified and may provide assistance; - When it is necessary to call law enforcement authorities to search for a missing resident, the search will be under their supervision. The facility will maintain contact with the authorities until the resident is found. During an interview on 11/07/23 at 2:25 P.M., the DON said: - Residents were to be supervised at all times during smoke breaks. This requirement was not added to the policy, but it was the expectation following the removal of the key pad locks from the smoking area on the locked unit. 1. Review of Resident #1's medical record showed: - admitted [DATE] and re-entry admitted [DATE]; - Diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), auditory hallucinations (when a person hears voices or noises that don't exist in reality), depression (a constant feeling of sadness and loss of interest), anxiety (a feeling of worry, nervousness, or unease), visual hallucinations (when a person sees things that don't exist in reality), insomnia (difficulty falling or staying asleep), chronic pain, seizures (a sudden, uncontrolled burst of electrical activity in the brain), asthma (a respiratory condition in which a person's airways become inflamed and makes it difficult to breathe), and hypertension (high blood pressure); - The care plan, dated 04/24/23, showed the resident resided on the secured unit. He/she couldn't always make adequate or appropriate decisions. He/She needed direction and assistance to adequately complete care and make daily decisions. Memory was impaired and had poor judgement and insight. The resident preferred to smoke. Resident would smoke in the designated area. Staff would keep all smoking materials. If the resident had a visitor, the resident could smoke in the designated smoking area supervised by the visitor; - A Risk of Elopement/Wandering Review, dated 07/04/23, showed the resident was at risk for elopement/wandering. No other interventions on care plan regarding elopement/wandering other than what was included on 4/24/23 care plan. - A Safe Smoking Evaluation, dated 07/04/23, showed the resident was a safe smoker. Review of the resident's quarterly Minimum Data Set (MDS) (a federally mandated assessment tool completed by the facility), dated 10/18/23, showed: - Cognition intact; - Disorganized thinking (unclear or illogical flow of ideas, or unpredictable switching from subject to subject which comes and goes, and changes in severity); - Other behavioral symptoms such as pacing or verbal symptoms; - Independent with walking, dressing, bathing and toileting; - Required assistance with functional cognition. Review of the Nurse's Progress Notes, showed: -On 11/04/23, the resident was taken outside to smoke at 8:45 A.M. He/she was supervised by Certified Nurse Assistant (CNA) A. At 9:22 A.M., the resident opened the gate in the smoking area and left the facility. Staff looked for the resident outside and were unable to locate him/her. The facility administration, the physician, the police, and the resident's guardian were notified. At 4:10 P.M., the resident was found in a city approximately 30 miles away and was taken to the hospital. Review of the Facility's Follow up Investigation report showed: -On 11/04/23, at approximately 4:00 P.M., the resident was found in a city 30 miles away; -The resident said he/she left the facility and a friend brought him/her to the city; -CNA A said he/she knew the smoking policy, but was trying to watch Resident #1 and the other residents on the hall since the other CNA went on break; -Upon interview, CNA A admitted that he/she was not to the leave the resident alone during smoke breaks; -CNA A was terminated for not adhering to the facility's policy and procedures. During an interview on 11/07/23 at 2:10 P.M., Registered Nurse (RN) B said: - He/she was the charge nurse working on the day shift on 11/04/23; - He/she went outside for his/her smoke break at approximately 9:15 A.M.; - He/she saw the gate to the smoking area open; - He/she immediately went inside and saw CNA A and other staff sitting at a table; - He/she immediately assigned staff to start checking residents and found Resident #1 could not be located; - All available staff searched the facility and grounds for Resident #1; - The Administrator, DON, the resident's guardian, his/her parent, and the police were notified; - Residents were never allowed to smoke unsupervised. RN B said after the last annual survey the key pad locks were removed from the smoking area on the locked unit and the facility implemented that all residents were to be supervised in the smoking area. During an interview on 11/07/23 at 2:15 P.M., the facility's speech therapist said: -On 11/04/23, he/she was not at the facility but received an alert from the facility that Resident #1 was missing; -At approximately 3:45 P.M., he/she identified Resident #1 who sat on a bench in a city approximately 30 miles away from the facility; -He/she called out to the resident who was anxious, shaking and appeared relieved to see him/her and willingly got into his/her car; -The police were notified and met them at a parking lot; -The police took custody of Resident #1 and escorted him/her to a hospital emergency department for evaluation. During an interview on 11/07/23 at 2:25 P.M., the DON said: - Resident #1 currently resided at another long term care facility. The resident did not incur any physical injuries. During an interview on 11/07/23 at 3:00 P.M., the facility's Corporate Nurse said: -He/she conducted a disciplinary interview with CNA A; -CNA A said the facility's policy was that this resident must be supervised at all times and not to be left alone. Complaint MO00226893

Based on interview and record review, the facility failed to ensure code status (the type of treatment a person would or would not receive if their heart or breathing were to stop) was consistent throughout the medical record for one resident (Resident #49) out of 18 sampled residents. The facility's census was 84. Record review of the facility's Advance Directives policy, revised [DATE], showed: - The resdient has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy; - The facility defines the following in accordance with current OBRA definitions and guidelines: Do Not Resuscitate (DNR) - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used; - Legal Representative - (i.e. substitute decision-maker, proxy, agent) - a person designated and authorized by an advance directive or state law to make treatment decisions for another person in the event the other person becomes unable to make necessary health care decisions; - The director of nursing services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the resident's medical record and plan of care; - The resident's wishes are communicated to the residents direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the residents wishes in care planning meetings; - The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. 1. Record review of Resident #49's medical record showed: - Face sheet with an admitted [DATE] and full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) documented; - Physician's Order Sheet (POS), dated [DATE] to [DATE], with an order for full code; - Care plan, dated [DATE], documenting a full code status and a note dated [DATE] that states Reviewed resident's care plan. No changes noted at this time. signed by the MDS (Minimum Data Set - a federally-mandated assessment completed by the facility) Coordinator; - Care plan meeting form, dated [DATE], with no documentation of code status wishes or changes to the code status; - An OHDNR (Outside the Hospital DNR - do not resuscitate - form) signed by the resident's attending physician on [DATE] and signed by the resident's representative on [DATE]. During an interview on [DATE] at 1:30 P.M., Certified Nursing Assistant (CNA) E said he/she would ask the nurse whether a resident is full code or not. During an interview on [DATE] at 1:31 P.M., Certified Medication Technician (CMT) F said he/she would check the face sheet for the resident's code status. During an interview on [DATE] 1:35 P.M., Licensed Practical Nurse (LPN) G said he/she would check the advance directive tab in the resident's chart for code status. It should match everywhere in the chart: POS, face sheet, care plan. If someone were to change code status, the person making the change would change it in the chart. That used to be the social worker, but things have changed, so he/she was unsure of the current process. During an interview on [DATE] at 2:38 P.M., the Administrator and Director of Nursing (DON) said they would expect advanced directives to match on the face sheet, POS, care plan, and under the Advanced Directive tab. Staff should look at the POS should someone code. The process for code status changes would be for social services to copy the OHDNR, and the nurse should notify the physician to change the order on the POS and with the care plan. During an interview on [DATE] at 3:00 P.M., the DON said the resident was hospitalized and, when he came back, the resident and the family had different wishes for the resident's code status.

Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS-a federally mandated assessment tool) within the required time frames for three residents (Resident #15, #31, and #65) out of 18 sampled residents. The facility's census was 84. Record review of the facility's MDS Completion and Submission Timeframes, revised March 2017, showed: - Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes; - The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted in accordance with current federal and state guidelines; - Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. Record review of the RAI Manual showed: - For the Admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600); - The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next comprehensive assessment is due within 366 days after the ARD of the most recent comprehensive assessment; - For the Admission assessment, the Care Area Assessment (CAA) Completion Date (V0200B2) must be no later than than 13 days after the Entry Date (A1600). - For the Annual assessment, the CAA Completion Date (V0200B2) must be no later than 14 days after the ARD (A2300). 1. Record review of Resident #15's medical record showed: - An admitted [DATE]; - A comprehensive annual MDS assessment with ARD of 2/2/22 and completion date of 2/2/22; - A comprehensive annual MDS assessment with ARD of 1/9/23, CAA completion date of 3/17/23, and MDS completion date of 3/17/23; - No CAAs completed within 14 days of the ARD; - No comprehensive MDS assessment completed within 366 days of the last comprehensive assessment. 2. Record review of Resident #31's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with CAA completion date of 3/16/23, and MDS completion date of 3/16/23; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment within 14 days of admission. 3. Record review of Resident #65's medical record showed: - An admitted [DATE]; - A comprehensive annual MDS assessment with ARD of 1/11/22 and completion date of 1/13/22; - A comprehensive annual MDS assessment with ARD of 1/9/23, CAA completion date of 3/24/23, and MDS completion date of 3/24/23; - No CAAs completed within 14 days of the ARD; - No comprehensive MDS assessment completed within 366 days of the last comprehensive assessment. During an interview on 5/5/23 at 2:38 P.M., the Administrator, Director of Nursing (DON), and MDS Coordinator said they would expect the RAI manual to be followed for completion and submission of every MDS. They would also expect every MDS to be completed and submitted timely.

Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS-, a federally mandated assessment) within the required timeframe for eight residents (Resident #2, #14, #19, #39, #41, #48, #56, and #62) out of 18 sampled residents and three residents (Resident #27, #40, and #54) outside the sample. The facility's census was 84. Record review of the facility's MDS Completion and Submission Timeframes , Revised March 2017, showed: - Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes; - The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted in accordance with current federal and state guidelines; - Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. Record review of the RAI Manual showed: - The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next non-comprehensive assessment is due within 92 days after the ARD of the most recent OBRA assessment (ARD of previous OBRA assessment (Admission, Annual, Quarterly, Significant Change in Status, or Significant Correction assessment) + 92 calendar days); - The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. 1. Record review of Resident #2's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 11/2/22; - A quarterly MDS assessment with a completion date of 3/23/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 2. Record review of Resident #14's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 11/8/22; - A quarterly MDS assessment with a completion date of 3/24/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 3. Record review of Resident #19's medical record showed: - An admitted [DATE]; - A comprehensive annual MDS assessment with a completion date of 10/11/22; - A quarterly MDS assessment with a completion date of 3/24/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 4. Record review of Resident #27's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 11/22/22; - A quarterly MDS assessment with a completion date of 4/17/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 5. Record review of Resident #39's medical record showed: - An admitted [DATE]; - A comprehensive annual MDS assessment with a completion date of 10/11/22; - A quarterly MDS assessemnt with a completion date of 3/28/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 6. Record review of Resident #40's medical record showed: - An admitted [DATE]; - A comprehensive annual MDS assessment with a completion date of 11/22/22; - A quarterly MDS assessment with a completion date of 4/17/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 7. Record review of Resident #41's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 9/20/22; - A quarterly MDS assessment with a completion date of 3/22/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 8. Record review of Resident #48's medical record showed: - An admitted [DATE]; - A comprehensive annual MDS assessment with a completion date of 9/20/22; - A quarterly MDS assessment with a completion date of 3/22/22; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 9. Record review of Resident #54's medical record showed: - An admitted [DATE]; - A comprehensive annual MDS assessment with a completion date of 5/10/22; - A quarterly MDS assessment with a completion date of 11/8/22; - A quarterly MDS assessment with a completion date of 4/17/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 10. Record review of Resident #56's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 10/25/22; - A quarterly MDS assessment with a completion date of 3/28/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. 11. Record review of Resident #62's medical record showed: - An admitted [DATE]; - A quarterly MDS assessment with a completion date of 12/2/22; - A quarterly MDS assessment with a completion date of 3/27/23; - The facility failed to complete a quarterly MDS assessment within 92 days of the prior MDS assessment. During an interview on 5/5/23 at 2:38 P.M., the Administrator said he/she would expect MDSs to be completed in the appropriate timeframe. The MDS Coordinator is responsible to follow the timeframes in the RAI manual. 42699

Based on interview and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS- a federally mandated assessment) for four residents (Resident #4, #39, #49, and #56) out of 18 sampled residents. The facility's census was 84. 1. Record review of Resident #4's Physician Order Sheet (POS), dated April 2023, showed: - An order, dated 2/21/23, for Plavix (medication which helps prevent blood platelets from sticking together) 75 milligram (mg) by mouth daily. Record review of the resident's significant change MDS, dated [DATE], showed: - The resident received anticoagulant (a blood thinner which can reduce coagulation of blood, prolonging the clotting time) medication; - The resident's MDS did not reflect an accurate assessment of the medication. 2. Record review of Resident #39's POS, dated April 2023, showed: -An order, dated 10/23/18, for Plavix 75 mg by mouth daily. Record review of the resident's quarterly MDS, dated [DATE], showed: - The resident received anticoagulant medication; - The resident's MDS did not reflect an accurate assessment of the medication. 3. Record review of Resident #49's medical record showed: - An admitted [DATE]. Record review of the resident's POS, dated March 2023, showed: - An order, dated 2/16/23, to apply Silvadene (a medication used to treat burns or wound infections) dressed Adaptic (a non-adherent dressing) to bilateral heel ulcers, cover with 4 x 4 gauze and secure with Medipore tape (soft cloth surgical tape) BID (twice a day); - An order, dated 1/19/23, for heel boots to be worn at all times for pressure relief. Record review of the resident's wound clinic notes from the hospital, dated 1/19/23, showed: - Unstageable (depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed) pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) of both heels, identified upon admission on 12/2/22 after an inpatient hospital stay. Record review of the resident's comprehensive MDS assessment, dated 12/9/22, showed: - Section M - Skin Conditions - marked as two Stage I (non-blanchable redness of a localized area usually over a bony prominence) pressure ulcers/injuries present and zero unstageable pressure ulcers/injuries present. Record review of the resident's wound clinic notes from the hospital, dated 3/2/23, showed: - Stage III (wounds where the top two layers of skin, as well as fatty tissue, are affected) pressure ulcer of right heel; - Stage IV (deep wounds that may impact muscle, tendons, ligaments, and bone) pressure ulcer of left heel. Record review of the resident's quarterly MDS assessment, dated 3/7/23, showed: - Section I - Active Diagnoses - does not address pressure ulcer diagnoses; - Section M - Skin Conditions - marked as two Stage I pressure ulcers/injuries present and zero Stage III and Stage IV pressure ulcers present. 4. Record review of Resident #56's POS, dated April 2023, showed: - An order, dated 1/10/23, for aspirin (medication which helps prevent blood platelets from sticking together) 81 mg by mouth daily; - An order, dated 1/10/23, for Plavix 75 mg by mouth daily. Record review of the resident's quarterly MDS, dated [DATE], showed: - The resident received anticoagulant medication; - The resident's MDS did not reflect an accurate assessment of the medication. During an interview on 5/5/23 at 2:38 P.M., the Administrator, MDS Coordinator, and Director of Nursing said they would expect a resident's MDS to accurately reflect the current status of the resident. They would expect an anticoagulant not to be marked on the MDS for a resident on aspirin or Plavix. 46460 47447

Based on observation, interview, and record review, the facility failed to implement care plans with specific interventions to meet individual needs for three residents (Resident #38, #48, and #49) out of 18 sampled residents. The facility's census was 84. Record review of the facility's care plan titled, Care Plans, Comprehensive Person Centered, revised March 2022, showed: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment and no more than 21 days past admission; - The comprehensive , person-centered care plan includes measurable objectives and time frames, to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; - Services provided for or arranged by the facility and outlined in the comprehensive care plans are provided by qualified persons, culturally competent and trauma-informed; - Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making; - When possible, interventions address the underlying sources of the problem areas, not just symptoms or triggers; - The IDT reviews and updates the care plans when there has been a significant change, when desired outcome has not been met, readmission from hospital stay, and at least quarterly in conjunction with the required quarterly MDS assessment. 1. Record review of Resident #38's medical record showed: - An admitted [DATE]; - Diagnoses of sequelea of poliomyelitis (history of threatening disease caused by the polio virus that can affect a person's spinal cord causing paralysis or inability to move parts of the body), joint disorder of the right knee and difficulty walking; - A current order for Eliquis (an anticoagulant used to treat and prevent blood clots) 2.5 milligrams (MG) by mouth twice daily for for Deep Vein Thrombosis (DVT- a blood clot deep in the vein, usually in legs) prevention, ordered on 6/17/21; - Care plan did not address use of the anticoagulant or the possible side effects. 2. Record review of Resident #48's medical record showed: - An admitted [DATE]; - Diagnoses of Post Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and triggers may bring back memories, intense emotions and physical reactions), anxiety, major depressive disorder (long-term loss of pleasure or interest in life) and intellectual disabilities (below average intelligence and life skills before the age of 18); - Care Plan did not address diagnosis of PTSD. During an interview on 05/05/23 at 10:20 A.M., the Director of Nursing (DON) said she had spoken with Resident #48's sister, who said when the resident was a teenager, her parents needed a break and placed the resident in a girls group home, where she had been raped. During an interview on 5/05/23 at 10:35 A.M., the Assistant Director of Nursing (ADON) said she was unaware that the resident had PTSD until today when she was told of the history and what had happened. The resident is continent and showers herself so this had not been an issue. 3. Record review of Resident #49's medical record showed: - An admitted [DATE]; - Diagnoses of atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside the arteries), weakness, disorientation, and essential hypertension (high blood pressure); - A quarterly MDS assessment, dated 3/7/23, showed almost constant pain, rated at 7/10 (zero means no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain), making it hard to sleep and limiting daily activities; - An order for Tramadol (a pain medication) 50 milligram (mg) one tablet by mouth every six hours as needed for pain, dated 2/22/23; - An order for Tylenol (a pain medication) 325 mg, take two tablets by mouth every six hours as needed for pain, no date listed on Physician Order Sheet. Record review of wound clinic documentation showed: - Pain primarily in the left heel region, dated 1/19/23; - Heel ulcers remain quite sensitive, dated 3/10/23; - Patient reports heavy weights sensation in ankles and heels creating pain at night, dated 4/14/23; - Patient still notes pain and heaviness in feet, dated 4/21/23. During an interview on 5/2/23 at 2:42 P.M., the resident said his/her feet hurt a lot. During an interview on 5/5/23 at 10:25 A.M., the resident said he/she can't remember when he/she last had a pain medication and that he/she does have foot pain. Observation of the resident on 5/3/23 at 11:28 A.M. showed the resident grimacing and holding his/her leg stating his/her feet hurt. Certified Nursing Assistant (CNA) H entered the resident's room and said he/she would tell the Certified Medication Technician (CMT) he/she is having pain. Observation of the resident on 5/4/23 at 10:33 A.M. showed the resident grimacing and verbalizing pain during wound care. Record review of the resident's care plan, dated 12/2/22, showed pain related to wounds not addressed on the care plan. During an interview on 5/5/23 at 2:38 P.M., the Director of Nursing (DON) said she would expect a resident with a diagnosis of PTSD to be care planned with triggers and interventions, a resident on an anticoagulant should be care planned with interventions and possible side effects, and a resident with with an assessment of constant pain, addressed on the MDS, with painful wounds, should also be addressed on the care plan. 46460

Based on interview and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: Medicare requires SNFs to issue a SNFABN to beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary or considered custodial) Form 10055 for two residents (Resident #17 and #186) out of three sampled residents who remained in the facility when benefits were not exhausted. The facility's census was 84. 1. Record review of Resident #17's CMS Notice of Medicare Non-Coverage (NOMNC: Medicare requires SNFs to issue a NOMNC to beneficiaries no later than two days before covered services end) Form 10123 and SNF ABN forms showed: - The resident's skilled Medicare Part A services started on 2/02/23, ended on 2/21/23, and the resident remained in the facility; - The resident's representative signed the NOMNC on 2/17/23; - The facility failed to get verbal consent or provide the resident's representative with the SNF ABN form. 2. Record review of Resident #186's NOMNC and SNF ABN forms showed: - The resident's skilled Medicare Part A services started on 4/10/23, ended on 4/28/23, and the resident remained in the facility; - The resident's representative signed the NOMNC on 4/16/23; - The facility failed to get verbal consent or provide the resident's representative with the SNF ABN form. During an interview on 5/05/23 at 2:38 P.M. , the Administrator said he/she would expect the SNF ABN forms to be completed and signed prior to a resident's discharge from skilled Medicare services. The facility did not provide a policy.