Every finding on record at Ignite Medical Resort Kansas City, LLC

Based on observation, interview and record review the facility failed to ensure the environment of two sampled residents remained free of accident hazards when the facility failed to ensure oxygen stored in Resident #131's room was stored in accordance with NFPA 99, 1999 Edition, when one type E oxygen cylinder was stored unsecured on the floor in the resident's room and when the resident's room contained more than one emergency use type E oxygen cylinder, and when the facility failed to provide a safe gait belt transfer for Resident #12 when CNA B failed to securely place the gait belt around the resident's waist and also when CMT A grabbed Resident #12 under the arm during a transfer. This affected two of 18 sampled residents (Resident #131 and Resident #12. The facility census was 86. Review of the facility's Oxygen Storage policy dated May 2024, showed:-Fasten cylinders securely in an upright position. Review of NFPA 99, 1999 edition 8-3.1.11 Storage Requirements showed:8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors).(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:1. A minimum distance of 20 ft (6.1 m), or2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b)4.(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations.(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b)14.8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:CAUTIONOXIDIZING GAS(ES) STORED WITHINNO SMOKING19 CSR 30-86.022:2) General Requirements.(A) All National Fire Protection Association (NFPA) codes and standards cited in this rule: NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition; NFPA 13R, Installation of Sprinkler Systems, 1996 edition; NFPA 13, Installation of Sprinkler Systems, 1976 edition; NFPA 13 or NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies Up to and Including Four Stories in Height, 1999 edition; NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 edition; NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition; NFPA 101, The Life Safety Code, 2000 edition; NFPA 72, NationalFire Alarm Code, 1999 edition; NFPA 72A, Local Protective Signaling Systems, 1975 edition; NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition; and NFPA 101A, Guide to Alternative Approaches to Life Safety, 2001 edition, with regard to the minimum fire safety standards for residential care facilities and assisted living facilities are incorporated by reference in this rule and available for purchase from the National Fire Protection Agency, 1 Batterymarch Park, [NAME], MA 02269- 9101; www.nfpa.org; by telephone at (617) [PHONE NUMBER] or [PHONE NUMBER]. This rule does not incorporate any subsequent amendments or additions to the materials listed above.This rule does not prohibit facilities from complying with the standards set forth in newer editions of the incorporated by reference material listed in this subsection of this rule, if approved by the department. 1. Review of Resident #131's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/20/25 showed:-No cognitive impairment;-Substantial assistance from staff for Activities of Daily Living (ADL)s;-Incontinent of bowel and bladder;-Diagnoses included heart failure, pneumonia and respiratory failure. Review of the resident's care plan dated 2/8/26 showed:-The resident had an ADL self care deficit related to imitated physical mobility;-Respiratory impairment related to respiratory failure;-The resident used supplemental oxygen. Observation on 02/8/2026 at 7:58 A.M., showed:-The resident in bed with oxygen applied via nasal cannula;-Two oxygen concentrators in the residents room;-One type E cylinder of oxygen with the plastic seal over the valve sat on the floor in the resident's room unsecured;-One type E cylinder of oxygen with the plastic seal over the valve sat in an oxygen tank holder in the resident's room;-One empty type E cylinder of oxygen sat in an oxygen tank holder in the resident's room. Observation and interview on 02/8/2026 at 1:22 P.M., showed:-The resident in bed with oxygen applied via nasal cannula;-Two oxygen concentrators in the residents room;-One type E cylinder of oxygen with the plastic seal over the valve sat on the floor in the resident's room unsecured;-One type E cylinder of oxygen with the plastic seal over the valve sat in an oxygen tank holder in the resident's room;-One empty type E cylinder of oxygen sat in an oxygen tank holder in the resident's room.-The resident said he/she used oxygen to help his/her breathing;-The resident said he/she did not know why there were three portable oxygen tanks in his/her room;-The resident said the staff took care of the oxygen. During an interview on 02/11/2026 at 11:43 A.M., Certified Nurse's Aide (CNA) F said:-The CNAs and nurses got the oxygen tanks from the oxygen closet if the residents needed them;-Unsecured oxygen tanks should be put in an oxygen holder;-Extra oxygen tanks whether they empty or full should be taken back to the oxygen closet;-There should not be more than one portable oxygen tank in the resident's room;-Portable oxygen tanks should be secured and not sat on the floor. During an interview on 02/11/2026 at 12:17 P.M., Licensed Practical Nurse (LPN) H said:-The CNAs and nurses removed the oxygen tanks from the oxygen closet and returned oxygen tanks to the closet;-Portable oxygen tanks should not be sat on the floor;-Oxygen tanks should either be in an oxygen holder or in a holder on the back of the resident's wheel chair;-There should not be excessive oxygen that is not in use the resident's room. During an interview on 02/11/2026 at 02:37 P.M., the Director of Nursing (DON) said:-No unsecured oxygen tanks should be on the floor in Resident #131's room;-All oxygen tanks should be secured in an oxygen tank holder or the oxygen closet;-She said the was no limit to the number of oxygen tanks a resident could have in there room;-She expected staff to secure oxygen tanks if they were unsecured. During an interview on 02/11/2026 at 02:45 P.M., the Administrator said:-There was no limit to the number of oxygen tanks that could be stored in a resident's room;-Oxygen should be secured and not sat on the floor in a resident's room;-She expected staff to secure oxygen if they saw it was setting on the floor;-Resident #131 should not have unsecured oxygen in his/her room. Review of the facility's policy for Gait Belts (a specialized sturdy belt placed securely around a person's waist to assist with transfers), revised 4/2023, showed: - Gait belts should be used by all staff when ambulating or transferring a resident with an unsteady gait. - Apply the belt around the resident's waist, with the belt not touching the resident's skin. - Ensure the belt is not too tight; allow three fingers between belt and resident. - To transfer the resident, assist to standing position by holding belt at waist and pivot resident to the chair. - Care plan use of gait belt. 2. Review of Resident #12's care plan, initiated 12/21/25 showed: - The resident had an activity of daily living (ADL) self-care performance deficits and limitations in physical mobility relate to weakness, cardiomyopathy, protein calorie malnutrition, and a pressure ulcer on the sacrum. Required partial/moderate assistance with toileting and chair to bed transfers. - The care plan did not address the use of a gait belt. Review of the resident's Comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/27/25 showed: - Cognitive skills moderately impaired. - Dependent on the assistance of staff for toilet use. - Substantial to maximum assistance with transfers. - Frequently incontinent of bowel and bladder. - Diagnoses included cancer, dementia, and diabetes mellitus. - Had one Stage III (full thickness skin loss) pressure ulcer. - Had two falls with no injury. Observation on 2/10/26 at 11:33 A.M., showed: - Certified Nurse Aide (CNA) B sanitized, donned a gown and gloved, entered the resident's room and placed the resident's wheelchair by the bed and the resident locked the brakes. CNA B placed the gait belt around the resident's waist and grabbed each side of the gait belt under the resident's arms and the gait belt slid up in the front and back and was under the resident's arm pits and transferred the resident from his/her wheelchair to the bed and sat him/her down. - CNA B provided incontinent care to the resident and re-dressed the resident. - CNA B assisted the resident to sit on the side of the bed and placed the gait belt over the resident's breasts. CNA B grabbed each side of the gait belt and it slid up in the front and back and up under the resident's arm pits. CNA B tried three times to transfer the resident from the side of the bed to his/her wheelchair and was unable to do so. CNA B assisted the resident to lie down on the bed, removed his/her gown and gloves, washed his/her hands and left the room. - At 11:50 A.M., CNA B and Certified Medication Technician (CMT) B sanitized, gloved and donned gowns and entered the resident's room. - CNA B and CMT B assisted the resident to sit on the side of the bed. CNA B and CMT B placed one arm under the resident's arm pit and grabbed the back of the gait belt with their other hand and transferred the resident into his/her wheelchair. CNA B removed the gait belt During an interview on 2/11/26 at 2:32 P.M., the Administrator and the Director of Nursing (DON) said: - For a one person transfer with a gait belt, staff should place the gait belt under the resident's breasts, on the resident's waist and staff should grab the sides of the gait belt. - For a two person transfer with a gait belt, staff should place their hands on the front and the back of the gait belt. - Staff should not place their arm under the resident's arm pits to transfer them. - The gait belt should be tight enough for the resident's comfort level and would expect it to slide up. During an interview on 2/11/26 at 11:15 A.M., CNA B said: - He/She placed the gait belt on the resident per their preference, either over or under their breasts, but should not be over their chest. The gait belt should not slide up under the resident's arm pits. - The gait belt should not slide up in the front or back. - For a one person transfer with a gait belt, he/she placed one hand on the back of the gait belt and the other hand on the side of the gait belt towards the back. - For a two person transfer with a gait belt, he/she placed one arm under the resident's arm pit and grabbed the back of the gait belt with his/her other hand. - He/She had training on gait belt transfers but was unable to recall when it occurred. During an interview on 2/12/26 at 1:58 P.M., CMT B said: - The gait belt should be placed around the resident's waist; it should be under the resident's breasts. - The gait belt should not slide up in the front or back and should not slide up under the resident's arm pits. - For a one person transfer with a gait belt, he/she grabbed the gait belt on each side. - For a two person transfer with a gait belt, he/she placed one hand on the side of the gait belt and one hand on the back of the gait belt. - He/She should not have placed his/her arm under the resident's arm pit.

Based on observation, interview, and record review the facility failed to ensure resident's who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections when the facility failed to ensure staff properly clean catheter tubing for Resident #142 and when facility staff failed to wear Enhanced Barrier Precautions (EBP, an infection control strategy where staff wear a gown and gloves when providing direct care to residents with indwelling medical devices) for two Resident's #142 and #4. This affected two of 18 sampled resident's. The facility census was 86.Review of the facilities Catheter Care policy, dated January 2026, showed:- The purpose of catheter care is to prevent possible urinary tract infections from bacteria from spreading from the perineal area and external catheter into the bladder;- Begin cleaning starting at the ureteral meatus wiping away from the body;- The policy did not address using a single cleansing wipe more than once to clean the catheter tubing. Review of the facilities Enhanced Barrier Precautions (EBP) policy, dated March 2024, showed:- EBP expands personal protective equipment use beyond standard precautions when there is anticipated exposure to blood or body fluid;- Gowns and gloves are used during high-contact activities with increased risk for infections;- EBP is to be used when a resident was infected with a multidrug-resistant organism, wounds including any skin opening requiring a dressing regardless of MDRO colonization status, indwelling medical devices regardless of MDRO colonization status including but not limited to central lines, urinary catheters, feeding tubes, and tracheostomy/ventilators;- EBP will be followed when providing hygiene, changing linen, changing briefs or assisting with toileting, device care or use including but not limited to: urinary catheters (a thin tube inserted into the bladder , feeding tubes, and wound care. 1. Review of Resident #142's Care Plan, dated 2/9/26, showed:- The resident had a urinary catheter; - The resident required used of EBP due to an indwelling urinary catheter;- The resident had an activities of daily living self-care deficit due to limited physical mobility and required staff to care for indwelling urinary catheter. Observation on 02/10/2026 at 7:20 P.M. showed:- Signage indicating the need for EBP to be worn posted on the resident's door frame;- Certified Nursing Assistant (CNA) A provided catheter care for the resident;- CNA A sanitized hands and put gloves on, then picked up a trashcan in the resident's room with the same gloves on;- Another staff member brought a gown in for CNA A to wear and CNA A put the gown on;- CNA A did not change gloves and perform hand hygiene after picking up the trashcan before emptying the resident's urinary catheter drainage bag;- CNA A took off the gown and gloves and performed hand hygiene;- CNA A put new gloves on without putting a gown on;- CNA A cleaned the catheter tubing with a disposable cleansing wipe from the insertion site down approximately 3 inches, folded the soiled cleansing wipe and cleaned the catheter tubing from the insertion site approximately 3 inches;- CNA A walked around the resident's bed to get to the trashcan to throw the disposable cleansing wipe away then picked up the trashcan and carried it to the other side of the resident's bed;- CNA A did not change gloves after picking up the trashcan before putting a new incontinent brief on the resident. During an Interview on 02/10/2026 at 7:27 P.M. CNA A said:- He/she should have changed gloves after picking up the trashcan before providing care to the resident;- He/she did not know when EBP should have been worn;- He/she did not know that hand hygiene should be performed with every glove change;- It was okay for him/her to use a disposable cleansing wipe more than once while cleaning catheter tubing. During an Interview on 02/11/2026 at 1:36 P.M. CNA D said:- Hand hygiene should be perform with every glove change;- Hands should be washed and gloves should be changed after touching any objects in the resident's room before providing care to the resident;- Disposable cleansing wipes should not be folded and used more than once when cleaning catheter tubing. During an Interview on 02/10/2026 at 7:40 P.M. CNA E said:- Hands are supposed to be washed between each glove change;- He/she knows to wear EBP when caring for resident's when there is a sign posted on the resident's door;- Each disposable cleansing wipe should only be used once when cleaning catheter tubing. 2. Review of Resident #4's Significant change MDS, dated [DATE], showed:- The resident was cognitively intact; - The resident was dependent on staff regarding toileting hygiene;- The resident had diagnoses of urinary tract infection within the last 30 days, generalized muscle weakness, and neuromuscular dysfunction of bladder. Review of Resident #4's care plan, dated 11/26/25, showed:- The resident was at risk for urinary tract infection (UTI) due to having an indwelling urinary catheter;- The resident required the use of EBP due to wounds and indwelling urinary catheter;- The resident was dependent on staff for performing activities of daily living. Observation on 02/11/2026 at 1:22 P.M. showed: - CNA D entered the resident's room to empty his/her catheter drainage bag;- CNA D put on gloves but did not put on a gown;- The catheter bag and catheter tubing touched the floor while CNA D was moving the catheter tubing to collect the urine from the catheter tubing into the catheter drainage bag. During an Interview on 02/11/2026 at 1:36 P.M. CNA D said:- He/she should have worn a gown while emptying the resident's catheter bag;- Catheter tubing and catheter drainage bags should never touch the floor. During an Interview on 02/11/2026 at 2:19 P.M. the Infection Preventionist said:- EBP should be worn when providing direct care for residents with catheters;- Catheter tubing and catheter drainage bags should not touch the floor;- Hands should be either washed or sanitized between glove changes;- Hand hygiene and glove change should be performed after picking up a trashcan to move it before proving care for a resident;- Staff are trained and required to use EBP when there was a magnet on each door frame around eye level and there is an isolation cart outside of the resident's room. During an Interview on 02/11/2026 at 2:32 P.M. the Director of Nursing (DON) said:- EBP should be utilized when providing direct care for resident's with indwelling urinary catheters;- Catheter tubing and catheter bags should not touch the floor and if they do they should be changed;- He/she would have to check the facilities policy to determine if disposable cleansing wipes could be used multiple times while cleaning catheter tubing.

Based on observation and interview the facility failed to ensure the kitchen was in good repair and maintained the kitchen in a clean and sanitary manner when cooking and food prep areas where dirty with dust and food debris, and when repairs in the kitchen had not been completed. This had the potential to affect all residents who received a meal from the kitchen. The facility census was 86. The facility did not provide a policy on cleaning and repairs in the kitchen. Observation of the kitchen on 02/08/26 at 09:12 A.M. showed:-The grill with a thick layer of encrusted grease and food debris;-The shelf above the stove with a thick layer of grease and food debris;-The ceiling in the dish room with a round brown stain the size of a basketball with pieces of ceiling tile hanging down.Observation of the kitchen on 02/11/26 at 10:42 A.M. showed:-The grill with a thick layer of encrusted grease and food debris;-The shelf above the stove with thick layer of grease and food debris;-The ceiling in the dish room with a round brown stain the size of a basketball with pieces of ceiling tile hanging down;-The trays the residents were served meals on with missing pieces of tray that come off when touched;-The wheels and brakes on the two hot boxes with grease build up, dirt and debris;-The knobs on the steam table covered with food debris, grease and grime;-The vents on the sides of the refrigerator caked with dust.During an interview on 02/11/26 at 1:36 P.M., [NAME] A said:-The cooks are in charge of cleaning the grill;-The grill should be cleaned daily;-The grill should not have a buildup of encrusted grease and food debris.During an interview on 02/11/26 at 1:44 P.M., the Dietary Manager said:- The kitchen should be clean and in good repair;- The maintenance department is responsible for repairs to the kitchen;- The maintenance log should be utilized for maintenance requests;- The maintenance man quit two days ago and he/she new about the water stain in the dish room but it did not get fixed yet.During an interview on 02/11/26 at 2:08 P.M., the Registered Dietitian said:-The kitchen should be clean and in good repair;-The trays the residents eat from should be in good condition and not have pieces breaking off of them;-The dietary manager is in charge of ensuring the kitchen in clean.During an interview on 02/11/2026 at 02:45 P.M., the Administrator said:-The kitchen should be clean and in good repair;-The cleaning schedules should be followed in the kitchen;-The kitchen is responsible for ensuring that cleaning is done;-Maintenance should complete the repairs in the kitchen.

Based on record review, observation, and interview the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections when the facility failed to ensure staff wore enhanced barrier precautions (EBP, an infection control strategy where staff wear a gown and gloves when providing direct care to residents with wounds or indwelling medical devices) for Resident #142, and Resident #4 and failed to ensure dirty gloves were changed before providing catheter care for resident #142. Facility staff failed to provide a barrier between a resident's wound and the floor when performing a dressing change for resident #16. This affected three of 18 sampled residents. The facility census was 86. Review of the facilities Infection Control Policy dated May 2024, showed: - Perform hand hygiene when moving from contaminated body sites to clean body sites during resident care; - Perform hand hygiene after touching objects and medical equipment in immediate resident care area; - All staff had a responsibility to be aware of local and national policies, procedures and campaigns related to standard infection control precautions. Review of the facilities Enhanced Barrier Precautions (EBP) policy, dated March 2024, showed: - EBP expands personal protective equipment use beyond standard precautions when there is anticipated exposure to blood or body fluid; - Gowns and gloves are used during high-contact activities with increased risk for - EBP was used when a resident was infected with a multidrug-resistant organism, wounds including any skin opening requiring a dressing regardless of MDRO colonization status, indwelling medical devices regardless of MDRO colonization status including but not limited to central lines, urinary catheters, feeding tubes, and tracheostomy/ventilators; - EBP will be followed when providing hygiene, changing linen, changing briefs or assisting with toileting, device care or use including but not limited to: urinary catheters (a thin tube inserted into the bladder, feeding tubes, and wound care. 1. Review of Resident #142's Care Plan, dated 2/9/26, showed: - The resident had a urinary catheter; - The resident required used of EBP due to an indwelling urinary catheter; - The resident had an activities of daily living self-care deficit due to limited physical mobility. Observation on 2/10/26 at 7:20 P.M., showed a sign on the resident's door frame for EBP. The CNA A sanitize his/her hands and put on gloves, entered the resident's room. The CNA picked up a trashcan in the resident's room with gloved hands, set down the trashcan. Observation showed another CNA handed CNA A a gown. The CNA put on the gown and emptied the resident's catheter with the same gloves he/she used to move the trashcan. The CNA removed his/her gown and gloves, washed hand and applied a new pair gloves. The CNA did not don a gown. The CNA cleaned the catheter tubing from the insertion site, walked around the resident's bed picked up the trashcan and carried it to the other side of the bed. The CNA did not change his/her gloves or sanitize his/her hands. With the same gloves, the CNA placed a new brief on the resident. During an Interview on 02/10/2026 at 7:27 P.M. CNA A said: - He/she should have changed gloves after picking up the trashcan before providing care to the resident and hand hygiene completed with every glove change; - He/she did not know when EBP should have been worn; - It was okay for him/her to use a disposable cleansing wipe more than once while cleaning catheter tubing. During an Interview on 02/11/2026 at 1:36 P.M. CNA D said: - Hand hygiene should be performed with every glove change; - Hands should be washed and gloves should be changed after touching any objects in the resident's room before providing care to the resident; - Disposable cleansing wipes should not be folded and used more than once when cleaning catheter tubing. During an Interview on 02/10/2026 at 7:40 P.M. CNA E said: - Hands are supposed to be washed between each glove change; - EBP is to be worn when caring for resident's when there is a sign posted on the resident's door; - Each disposable cleansing wipe should only be used once when cleaning catheter tubing. 2. Review of Resident #4's Significant change MDS, dated [DATE], showed staff assessed the resident as the following: - Cognitively intact; - Dependent on staff for toileting hygiene; - Diagnoses of urinary tract infection within the last 30 days, generalized muscle weakness, and neuromuscular dysfunction of bladder. Review of Resident #4's care plan, dated 11/26/25, showed the resident: - At risk for urinary tract infection (UTI) due to having an indwelling urinary catheter; -Requires the use of EBP due to wounds and indwelling urinary catheter; -Dependent on staff for performing activities of daily living. Observation on 02/11/26 at 1:22 P.M., showed CNA D entered the resident's room, put on gloves, and emptied the resident's catheter. Observation showed the CNA did not don a gown and the catheter tubing touching the floor when the catheter bag was emptied. During an Interview on 02/11/2026 at 1:36 P.M. CNA D said: - He/she should have worn a gown while emptying the resident's catheter bag; - Catheter tubing and catheter drainage bags should never touch the floor. During an Interview on 02/11/2026 at 2:19 P.M. the Infection Preventionist said: - EBP should be worn when providing direct care for residents with catheters; - Catheter tubing and catheter drainage bags should not touch the floor; - Hands should be either washed or sanitized between glove changes; - Hand hygiene and glove change should be performed after picking up a trashcan to move it before proving care for a resident; - Staff know that a resident requires EBP when there is a magnet on each door frame around eye level and the isolation cart is outside of the resident's room. During an Interview on 02/11/2026 at 2:32 P.M. the Director of Nursing (DON) said: - EBP should be utilized when providing direct care for residents with indwelling urinary catheters; - Catheter tubing and catheter bags should not touch the floor and if they do, they should be changed; - He/she would have to check the facilities policy to determine if disposable cleansing wipes could be used multiple times while cleaning catheter tubing. What was the policy 3.Review of Resident #16's admission MDS, dated [DATE]., showed staff assessed the resident as followed: -Cognition Intact -Diagnoses of Diabetes -Requires substantial to maximal assistance to lower body mobility, dressing, and hygiene. Review of the resident care plan, dated 1/23/26 showed: -Goal was resident will be free from skin impairment and staff to educate the resident regarding diabetes and skin risks; -admitted on [DATE]; -At risk for skin concerns related to mobility and self-care debility; -Staff are to observe for signs/symptoms of open areas including, redness, pain, warmth to touch, drainage, and to notify nurse or provider of signs and symptoms present; Review of resident's wound assessment completed on 2/5/26 showed: - At high risk for skin breakdown; - Discovery of foot ulcer over a boney area to the left heel; - Circular area measuring 2.50 centimeters (cm) x 3.00 cm x 0.10 cm (L x W x D) in size where the center blistered area had opened exposing bright red tissue to the center of the wound and tissue surrounding the wound with redness. Review of the wound order treatment, ordered by the physician on 2/6/26., showed cleanse the left heel with normal saline of wound cleanser, pat dry and apply hydrofera blue, then cover with a border foam dressing three time a week on Monday, Wednesday, and Friday and as needed. Observation of the resident's treatment to left heel wound on 2/9/26 at 10:00 A.M., showed NP A entered the resident's room, applied gloves removed the resident's shoe and sock. Observation showed no dressing to the resident's heel. The NP sat the resident's left heel onto the floor without a barrier. The NP lifted the left heel, measured the wound, and rested the resident's heel back onto the floor without a barrier. During an interview on 2/9/26 at 10:30 A.M., NP A said he/she should have placed a barrier between the floor and the wound to prevent exposing the wound to bacteria and germs on the floor. During an interview on 2/9/26 at 11:30 A.M., the wound nurse said any open wound should not ever touch the floor. Ideally the resident should lay down so the foot wound on the bottom of the wound can be easily viewed and cared for properly. During an interview on 2/9/26 at 12:15 P.M., the Administrator said failure to place a barrier between an open wound and the floor is not acceptable and she would have expected during a treatment for NP A to have placed a barrier between the floor and wound for protection against dirt and bacteria. During an interview on 2/11/26 at 1:35 P.M., the Infection Preventionist said a barrier should be in place to protect an open wound from the floor.

Based on observation, interview, and record review, the facility failed to treat Resident #131 with dignity and respect when staff failed to assist the resident with trimming facial hair. This affected one of 18 sampled residents. The facility census was 86. Review of the facilities Resident Rights policy, dated May 2023, showed: - Resident's had rights to a dignified existence, self-determination, and communication; - The facility must protect and promote the rights of the resident's; - The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Review of the facility's Bathing policy dated April 2023, showed:-All residents are given a bath or shower in accordance with their preferences;-If no preference is voiced a bath or shower will be offered twice a week. Review of Resident #131's admission MDS a dated 10/20/25 showed:-No cognitive impairment;-Substantial assistance with showers and bathing;-Substantial assistance with personal hygiene;-Diagnoses included heart failure, pneumonia and respiratory failure. Review of the resident's care plan dated 2/8/26 showed:-The resident had an Actives of Daily Living (ADL) self-care deficit related to imitated physical mobility;-Respiratory impairment related to respiratory failure;-The resident required substantial assistance with showers and personal hygiene. Review of shower sheets for the resident's hall dated 2/2/26 through 2/9/26 showed no shower sheet or documentation that the resident had received a shower or shave was found. Review of shower refusal sheets for the resident's hall dated 2/2/26 through 2/9/26 showed no refusal or documentation to show the resident had been offered and refused a shower or shave. Observation and interview on 02/8/2026 at 9:18 A.M. showed:-The resident in his/her room in bed;-The resident's skin looked dry and flakey;-The resident's hair was disheveled and greasy;-The resident had facial hair;-The resident had body odor;-The resident said he/she had been at the facility since Tuesday and had not received a shower, bed bath or a shave;-The resident said the staff kept saying they would give him/her at least a bed bath and trim his/her facial hair but they never do it;-The resident said he/she is here because he/she needs help and he/she said he/she has not got the help he/she needed;-He/She said it made him/her feel self-conscious and uncomfortable because he/she had not been clean and groomed. During an interview on 02/8/2026 at 11:43 A.M., CNA F said:-Residents should get at least two showers per week or more if needed:-He/She worked with the resident 2 days last week and he/she did not get a shower when he/she worked;-The resident was here for respite care and only here for five days;-He/She would expect the resident to have at least one shower within that time;-The staff helped residents with grooming and shaving;-Residents should be well groomed and dignified;During an interview on 02/11/2026 at 12:18 P.M., LPN H said:-Residents should get at least two showers a week;-The residents can refuse showers:-If a resident refused a shower the staff filled out a form starting when and why the resident refused the shower;-Resident #131 was here only five days but still should have received a shower;-If resident #131 refused there should be a refusal in his/her record;-Residents that request to be shaved should get that help from the staff;-All residents should be well groomed and clean. During an interview on 02/11/2026 at 02:37 P.M., the DON said:-She expected resident's to be offered a shower at least twice per week;-Residents can refuse and there is a refusal form that should be completed;-She would expect Resident #131 to receive a shower during his/her five day stay;-She expected staff to assist residents with shaving if they asked;-Residents should be clean, dry and well groomed. During an interview on 02/11/2026 at 02:45 P.M., the Administrator said:-She expected residents to be offered a shower at least twice per week;-Residents can refuse and there is a refusal form that should be completed;-She expected staff to assist residents with shaving;-Resident should be clean, dry and well groomed. Intake 2708511

Based on observation, interview and record review the facility failed to ensure Resident #143 received insulin as with meals ordered when staff served the resident the noon meal tray at 12:05P.M. and administered insulin at 12:37 P.M. This affected on of 18 sampled residents. The facility census was 86. Review of the facility's Administration of Medication Policy dated 04/2023, showed:-Staff to read each order entirely;-Read label of medication three times;-If there is a discrepancy between Medication Administration Record (MAR) and label, check orders before administering medications;-Follow instructions written on label.Review of the facility's Pharmacy Services Policy dated 05/2024, showed:-Staff to follow specific monitoring related to medications, such as blood sugar;-Staff to follow specific timing and parameters of medications (e.g. before or after meals)Review of the facility's Insulin Administration Procedure Policy dated 05/2023, showed:-Insulin is only given with a practitioner order;-Objective is to safely and accurately inject insulin.Review of resident #143's POS dated 02/11/2026, showed NovoLOG FlexPen 100unit/ML. Instructions read to Inject 4 unit subcutaneously before meals for diabetics.Observation on 02/11/2026 between 11:40 A.M and 12:37 P.M showed LPN A:-Obtained blood glucose reading at 11:40 A.M.;-Meal tray delivered by dietary staff at 12:05 P.M. to the resident;-Administered 4 units of insulin to resident at 12:37P.M., after the resident had eaten the entire meal. During an interview on 02/11/2026 at 11:30A.M.,LPN A said that he/she was only responsible for blood glucose monitoring and insulin administration of two residents that shift for each meal. During an interview on 02/11/2026 at 9:45 A.M., the DON said:-Orders should be followed as written by staff administering medications;-Staff should read all orders entirely;-Staff should read medication packaging and labels to ensure accuracy;-Insulin should be administered when meal is delivered, before resident eats.

Based on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (AQDLs) received the necessary services to maintain good personal hygiene when staff used a soiled incontinence wipe to perform per-care and did not fully clean the peri-area, which affected one of the 18 sampled residents, (Resident #12). The facility census was 86. Review of the facility's policy for Perineal Care, reviewed 5/23 showed:- Perineal care is done daily and as needed for all residents requiring assistance and/or those residents with a Foley catheter (sterile tube inserted into the bladder to drain urine).Wash perineal area with peri wash and water using a washcloth. If appropriate, rinse with warm water. For males, retract foreskin if present, wash, dry and replace foreskin. When complete, remove gloves and cleanse hands. 1. Review of Resident #12's care plan dated 12/21/25, showed: - The resident had bowel incontinence. Check resident every two hours and assist with toileting as needed. Provide peri care after each incontinent episode. Provide skin care with each incontinent episode. - The resident experienced urinary/bowel incontinence related to diuretic medication use and impaired mobility. Check regularly and as needed to incontinence, change brief, change brief, provide appropriate skin/peri-care, apply moisture barrier cream, change clothing as needed after incontinent episodes. Review of the resident's Comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/27/25 showed:- Cognitive skills moderately impaired.- Dependent on the assistance of staff for toilet use.- Substantial to maximum assistance with transfers.- Frequently incontinent of bowel and bladder.- Diagnoses included cancer, dementia, and diabetes mellitus.- Had one Stage III (full thickness skin loss) pressure ulcer. Observation of Resident # 12 receiving incontinence care on 2/10/26 at 11:33 A.M., showed:- CNA B removed gloves, washed, and applied new gloves. CNA B removed the resident's pants and unfastened the wet and soiled brief. - CNA B wiped down one side of the groin, used a new wipe and wiped down the other side of the groin.- CNA B did not separate and clean all the skin folds.- CNA B turned the resident on his/her side and removed the soiled and wet dressing from the resident's sacrum (a large, triangular-shaped bone located at the base of the spine), dated 2/10/26. - CNA B wiped from front to back with fecal material, folded the wipe and wiped again with fecal material on the wipe. CNA B used a new wipe and wiped front to back with fecal material on the wipe, folded the wipe and wiped again with fecal material on the wipe. CNA B wiped twice more with a different wipe each time with a smear of fecal material on the wipe and folded each wipe and wiped again with a smear of fecal material on each wipe. CNA B used a new wipe and with the same area of the wipe, wiped back and forth to remove fecal material from the resident's buttocks. - CNA B removed the wet and soiled incontinent brief, removed his/her gloves, sanitized and applied new gloves and placed a clean incontinent brief under the resident and fastened it. CNA B assisted the resident to put his/her pants back on. During an interview on 2/12/26 at 11:15 A.M., CNA B said:- He/She should have cleaned all areas of the skin where urine or feces had touched.- When he/she provided peri care that was just urine, he/she folded the wipe. He/She should not have folded the wipe when cleaning fecal material. Observation on 2/10/26 at 7:31 P.M., showed:- CNA C sanitized, gloved and did not don a gown and entered the resident's room. CNA C used the gait belt and transferred the resident to the side of the bed and removed the resident's pants and wet incontinent brief. CNA C removed gloves, washed hands, and applied new gloves. - CNA C did not separate and clean all areas of the skin folds and turned the resident on his/her side. CNA C wiped from front to back with a smear of fecal material on the wipe. Used a new wipe and wiped the rectal area with a smear of fecal material on the wipe. CNA C used a new wipe and wiped again front to back.- CNA C removed the wet incontinent brief, removed gloves, washed hands and applied new gloves then placed a clean incontinent brief under the resident and fastened it. CNA C did not return the surveyor's phone call for an interview. During an interview on 2/11/26 at 2:32 P.M., the Director of Nursing (DON) said:- She expected staff to separate and clean all areas of the skin where urine or feces had touched.- Staff should not fold the wipe when cleaning fecal material.

Based on observation, interview and record review, the facility failed to ensure staff prepared foods in a form designed to meet the needs of individual residents when they did not ensure the puree (a texture-modified diet in which all foods have a soft, pudding-like consistency) food had a smooth and appropriate consistency. This affected one resident identified by the facility as having an order for a pureed diet (Resident #115). The facility census was 86. The facility did not provide the requested policy on pureed diets.1. Review of Resident #115's Discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/6/26 showed:-Moderate cognitive impairment;-Supervision with eating;-Mechanically altered diet;-Diagnoses included diabetes, dysphagia (difficulty swallowing, causing pain or choking) and asthma. Review of the resident's care plan dated 2/9/26 showed:-Moderate assistance with Activities of Daily Living;-The resident is on a pureed diet related to dysphagia.Review of the resident's Dietitian Evaluation dated 11/08/25 showed:-The resident was on a pureed diet;-The resident had problems swallowing.Review of the residents Physician's Order Sheet (POS) dated February 2026 showed Start date 2/6/26: Order for pureed diet. Observation of meal preparation for lunch on 02/11/26 at 11:01 A.M., showed:- [NAME] A began preparing the pureed lunch meal; - He/she placed two cups of the broccoli rice mixture into the food processor;- He/she then turned on the food processor and began adding ham broth and blended until it was the desired consistency;- The mixture was thick with visible pea sized chunks in it.Observation of meal preparation for lunch on 02/11/26 at 12:30 P.M., showed:- [NAME] A placed two cups of baked ham into the food processor;- He/she added ham broth and blended until it was the desired consistency;- The mixture was thick, sticky and hard to stir;- The Regional Dietary Manager told [NAME] A to remake the pureed ham;- [NAME] A placed two more cups of baked ham into the food processor;- He/she added ham broth and blended until it was the desired consistency;- The mixture was still thick;- [NAME] A placed the pureed ham on Resident #115's meal tray.Observation of lunch service on 02/11/26 at 12:53 P.M., showed Resident #115 being served his/her pureed meal that was thick and had chunks in it.Observation of the pureed lunch meal on 02/11/26 at 01:12 P.M., showed:- Pureed ham: thick and allowed a spoon to remain standing. The mixture had particles of ham, similar to the consistency of rice, that required chewing; - Broccoli rice mixture: thick and allowed a spoon to remain standing with pieces of rice that required chewing.During an interview on 02/11/26 at 1:36 P.M., [NAME] A said:- Pureed food should be a smooth, mashed potato like consistency with no chunks or particles; - He/she did not realize the pureed food was chunky. During an interview on 02/11/26 at 1:44 P.M., the Dietary Manager said:- Pureed food should be a smooth, pudding like consistency with no chunks or particles; - Pureed food should not require chewing;- He/she did not realize the pureed food was chunky. During an interview on 02/11/26 at 2:08 P.M., the Registered Dietitian said:- Pureed food should be a pudding like consistency;- There should be no particles in the pureed food;- The pureed food should not be thick and require chewing.During an interview on 02/11/2026 at 02:45 P.M., the Administrator said:-Residents are on a pureed diet if they have a problems with chewing or swallowing;-Adverse outcomes to not serving a correctly prepared pureed diet can be choking or death;-There should be no chunks of food that require chewing in a pureed diet.

Based on observation, interview, and record review, the facility failed to protect Resident#1's right to be free from abuse when he/she was hit in the face by another resident (Resident #2). Resident #1 sustained a laceration to the lower lip. Facility census was 79. On 1/9/25, the Administrator was notified of the past noncompliance which began on 1/1/2025. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected on 1/2/2025. Review of the facility's Abuse Policy, dated November 2018, showed: -Abuse is defined as an infliction of physical, sexual, or emotional injury or harm, including financial exploitation by any person, firm, or corporation; -This facility prohibits abuse, neglect, or mistreatment of residents. The facility will educate all employees upon hire and at least annually on the Abuse Policy and all components. The facility Administrator will be designated as the facility's Abuse Coordinator and is responsible for overseeing all components of the abuse policy; -The resident care plans will be reassessed on a regular basis and any necessary changes will be implemented as needed. Resident behaviors will be monitored regularly for any changes and any aggressive behaviors that might lead to abuse will be assessed and any necessary interventions will be implemented; -This facility will make every effort to identify residents who are at high risk for potential abuse of other residents. Facility staff will report immediately to facility administration any identified behaviors, injuries, bruises, and/or any concerns of potential abuse of residents; -If another resident is identified in the allegation, a licensed staff member will complete an evaluation of the resident's status and condition and notify the physician to determine if any treatment is necessary. Facility Administrator or designee will assess all of the relevant information to determine whether or not a discharge from the facility is needed. The resident will be prohibited from having any contact with the resident alleging abuse while the investigation is completed. The facility Administrator or designee will determine if further action and/or intervention is needed upon completion of the investigation. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 11/2/2024, showed: -He/She has the diagnoses of chronic embolism and thrombosis of left lower extremity (a condition where blood clots form in the deep veins of the leg, and can lead to long-term complications), mild cognitive impairment (the in-between stage between typical thinking skills and dementia), anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), cognitive communication deficit (a difficulty with communication that's caused by an underlying issue with cognition), supraventricular tachycardia (a faster than normal heart rate beginning above the heart's two lower chambers); -He/She scored 11 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates moderately impaired cognition skills; -He/She had adequate hearing, clear speech, makes self understood and able to understand others. He/She has displayed no behaviors. Review of Resident #1's comprehensive care plan, dated 1/1/2025, showed: -The resident occasionally refused care, medications, and treatments; -He/She had a history of displaying behaviors, including throwing his/her meal tray, yelling at staff and other residents, flipping off (rude hand gesture) staff, throwing medications in the trash). The resident was involved in physically aggressive behavior on 1/1/2025; -The resident was at risk for wandering and elopement. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -He/She has the diagnoses of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), orthopnea (discomfort when breathing while lying down flat), diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), hemiplegia/hemiparesis to left side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), carviovascular accident (CVA, a medical condition in which poor blood flow to the brain causes cell death), seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness), mass in lung (abnormal growth in lung), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), aortic aneurysm without rupture (a bulge in the aorta, the body's main artery, that can occur anywhere from the chest to the abdomen); -He/She scored 11 on the BIMS, indicating moderately impaired cognitive skills; -He/She had adequate hearing, clear speech, makes self understood and able to understand others. He/She has displayed no behaviors. Review of Resident #2's comprehensive care plan, dated 1/1/2025, showed: -The resident occasionally refused care, treatment and medications; -He/She had potential for behaviors (stealing things from the facility cafe, being sexually inappropriate with staff, yelling at other residents); -He/She was a risk for wandering and elopement. Review of the facility investigation, dated 1/1/2025, showed: -On 1/1/2025 , at approximately 2:45 P.M., Resident #1 was brought to the Administrator's office by staff. The staff member stated he/she did not witness anything, but that Resident #1 needed some help. The Administrator escorted the resident to the nurses' station. Some blood and a laceration (cut) were noted to the resident's lower lip. When asked what happened, Resident #1 stated that Resident #2 hit him/her in the face. Resident #1 stated he/she could not recall exactly what was said between the two. The physician was notified of the incident and treatment orders were obtained for the area to the lip. The resident was also offered counseling services but he/she declined; -During an interview, Resident #2 said that Resident #1 was sitting at Resident #2's table, and and asked Resident #2 to move away from the table. Resident #2 said he/she was tired of Resident #1 and hit him/her; -During an interview, Resident #3 said that he/she was in the dining room after bingo. Resident #1 liked to hang out at the back table by the window with his/her items. Resident #3 saw Resident #2 come in the dining room and head to the back table. He/She could hear Resident #1 ask Resident #2 something, but could not understand what was said. He/She then heard Resident #2 say I'm going to slap you and the next thing Resident #3 heard was Resident #1 whimper and put his/her hand to his/her face, saying he/she hit me. During an interview on 1/9/2025 at 1:07 P.M., Resident #1 said: -He/She declined to discuss the incident with Resident #2; -He/She confirmed that he/she was struck by another resident; -He/She also confirmed the facility offered counseling services, but he/she declined; -He/She felt safe in the facility. Review of the facility Staff Education sign in sheets showed that staff education on Resident to Resident Abuse and Prevention was completed on 1/1/25 and 1/2/25. During an interview on 1/9/25 at 1:40 P.M., the Administrator said: -The incident was very unexpected as neither resident has displayed physical behaviors while residing at the facility; -Staff have been educated on resident to resident abuse and prevention; -It is his/her expectation that residents refrain from acting out towards one another. It is also his/her expectation that staff be aware of the possibility of resident to resident abuse. MO247374

This deficiency was originally cited under F624, a tag that existed in version LTC 20.01 but no longer exists in version LTC 21.00, due to an upgrade based on regulation/IG changes. Per Alpine TG group's instruction, F624's content was moved to F621, a tag that is still present in LTC 21.00, in order to allow the event to upload. Refer to Event ID 1YDJ12 Based on observation, interview, and record review, the facility failed to ensure a safe and orderly discharge from the facility for five (5) out of the six (6) sampled residents (Resident #1, #2, #3, #4, and #5) when five (5) residents were discharged without proper orders, medications, home health services, dialysis services, and/or follow up appointments. The facility census was ninety 90. Review of the facility's policy for discharge to home, revised 04/2023, showed: - (3.) Social services will meet with the resident and/or family to set up outside services and equipment. - (4.) A discharge form is completed by all involved members of the IDT (interdisciplinary team) that explain the resident care needs at home. - (6.) Teaching will be done with the resident/family on any dressings or special tasks. - (8.) If necessary, therapy will provide any necessary instructions. - (9.) On the day of discharge, the nurse will review the discharge form as well as the medications with the family. - The nursing discharge note should include the time of discharge, destination, mode of transportation, disposition of personal belongings and medications and that all parties are aware of the discharge. Review of the facility's policy for hospital transfer, revised 04/2023, showed: - (1.) Notify the physician regarding a change in resident status and obtain an order for transfer to the hospital. 1. Review of Resident #1's Medical Record showed: - The Resident was admitted to the facility 10/25/2024 after a hospitalization for non-ST elevation myocardial infarction (heart attack). - The Resident was discharged to home on 11/04/24. - Provider order date: 10/25/2024 May be discharged with all medications. - Provider order date: 11/01/24 Patient okay to discharge. Home health to evaluate and treat for physical therapy, occupational therapy, and nursing. Primary care provider to follow. - The resident had thirty (30) medications prescribed at the time of discharge including antibiotics, pain medication, and breathing treatment medications for active pneumonia infection. - The Resident's Post-Discharge Resources lists Home Health Care as a resource the resident needed at the time of discharge. - The facility failed to provide the name, address, and/or phone number of any Home Health Agency. - The Resident's Medication Reconciliation indicated that the Resident was sent home with 11-16 medications. - No documentation to show the facility staff provided the Resident with medication names, pill counts, and/or patient education relating to the medications sent home with the Resident. - No documentation to show the facility staff scheduled follow-up visits and/or provided the resident with contact information for his/her cardiac (heart) or surgical providers. During an interview on 12/02/24 at 9:52 A.M., RN Casemanager: - They presented to Resident #1's home on 11/07/2024 for an in-home visit after the resident's Care Navigator initiated a referral to Case Management for an emergency visit. The Care Navigator initiated the referral when he/she became aware that the Resident had just had heart surgery and didn't have follow-up care scheduled or home health care set up. - The Resident had no understanding of his/her discharge plan. - The facility failed to initiate home health care or schedule follow-up visits for the Resident. - The facility failed to provide the Resident with prescriptions for necessary medications. - The facility sent the Resident home with seven (7) medication cards belonging to Resident #2 and one (1) medication card belonging to Resident #4. - The Resident had not taken any of his/her medications from the time of discharge until the in-home visit because he/she was confused by the medications that did not belong to him/her and didn't know what medications to take. - On 12/02/2024 at 12:17 P.M. the complainant provided pictures of Resident #2 and Resident #4's medication cards that had been sent home with Resident #1. - The scheduled an appointment for Resident #1 with his/her primary care physician (PCP) and at this appointment the PCP set up a cardiology follow-up for the Resident on 12/16/2024. 2. Review of Resident #2's medical record showed: - The resident was admitted on [DATE] and discharged to home on 11/04/2024. - Provider order date:10/16/2024 May be discharged with all medications. - Provider order date: 11/04/2024 Patient okay to discharge. Home health to evaluate and treat for physical therapy, occupational therapy, and nursing. Primary care provider to follow. - The resident was taking sixteen (16) prescribed medications at the time of discharge. - The resident's post-discharge resource needs included Home Health Care. - The facility failed to provide the name, phone number, and/or address to any home health care agency at the time of discharge. - The resident did not have any follow-up visits scheduled with any providers. - The resident was not sent home with any medications from the facility. - The resident had prescriptions sent to the pharmacy. - No documentation the facility staff provided the name, phone number, and/or address to the pharmacy where prescriptions were sent at the time of discharge. During an interview on 12/03/2024 at 12:48 P.M., Resident #2 said: - He/she was sent home without anything. - The facility failed to order necessary supplies for the resident prior to discharge, specifically a bed and lift for that the resident was required to use at home. - The facility failed to arrange dialysis care for the resident prior to discharge. - The facility failed to speak to the resident or his/her family about what medications would be required at home or when/how to take them. During an interview on 12/03/2024 at 12:48 P.M., family member #F6 said: - The facility said they had ordered a specialized bed and a lift and that these supplies would be delivered to the resident's home on 11/09/24. When no supplies arrived at the Resident's home, the family member called the facility to ask when they would be delivered. The facility told the family member that the supplies would now take 5 weeks to arrive. The resident's family was forced to find a bed and lift themselves with the help of home health and their local Lion's Club. - Resident #2 was supposed to receive dialysis services, but the facility failed to set this up. - The facility failed to provide discharge instructions to the resident and/or the family. The family member said that the nurse handed him/ser a sheet of paper and said, here, but that no explanation of the paperwork and no education was completed. - The facility failed to set up home health services for the resident. Family member F6 set that up for the resident. 3. Review of Resident #3's medical record showed: - The resident was admitted on [DATE] and left the facility AMA (against medical advice) on 10/16/2024 at 14:30, - The resident was taking twenty-seven (27) prescribed medications at the time he/she left the facility. During an interview on 10/23/2024 at 5:45 P.M, the resident said the facility told him/her that they sent prescriptions to the pharmacy after he/she left the facility. When the resident presented to the pharmacy to pick up the medications, the pharmacy informed him/her that no prescriptions had been received from the facility. 4. Review of Resident #4's medical record showed: - The resident was admitted to the facility on [DATE] and discharged to the hospital on 10/16/2024. - No documentation the facility staff obtained provider orders prior to discharging the resident to the hospital. - No documentation the facility staff provided discharge/transfer records for Resident #4. 5. Review of Resident #5's medical record showed: - The resident was admitted on [DATE] and discharged to home on 11/25/2024. - The facility failed to provide discharge/transfer records for Resident #5. During an interview on 12/03/2024 at 12:39 P.M., Resident #5 said: - The facility staff did not provide discharge instructions and/or education to him/her at the time of discharge. - Coming home from the facility was kind of a joke. He/she said that the facility was talking to him/her about a diagnosis they were unaware of and failed to provide him/her with information about the physical therapy exercises he/she should be doing at home. During an interview on 12/02/2024 at 12:59 P.M., CMT A said: - Medications are reviewed with the resident by the nurse prior to discharge. - When a resident is being discharged with medications, the staff are supposed to review each medication card as they are prepared for discharge. Resident's name, room number, medication, and the number of pills left in the card are supposed to be verified and documented in the resident's discharge record. During an interview on 12/02/2024 at 1:21 P.M., the facility's Social Services Designee said: - Discharge planning for residents include sending needed referrals for things such as home health care, physical therapy, and/or specialist providers. - If a resident required home health care at discharge, both the resident and the chosen home health care agency would be aware prior to the resident's discharge and that setting that up would be that facility's responsibility. - Sometimes insurance authorization can delay home health care, but that in that case the Resident's chart would be updated with the appropriate information when an approved agency is found, and the referral is sent. During an interview on 12/02/2024 at 1:32 P.M., the facility Administrator said: - When a resident is being discharged , a medication list is expected to be completed with the discharge instructions and that the nurse is expected to review each listed medication with the resident during discharge education. - During discharge teaching with the nurse, it is expected that the resident be educated on topics including: services that the resident was receiving while they were in the facility, services and care they will be receiving or should continue after returning home, and medications they are prescribed and how/when to take them. - If a follow-up appointment has been scheduled for a resident, it is expected that staff will list that appointment on the discharge instructions along with the provider's phone number. - If a resident leaves without their medications, or if there are medications with the resident's name on them that will not be sent home with the resident, these medications are expected to be destroyed by a nurse or CMT using Drug Buster. - If a resident is discharged requiring home health care, it is the facility's responsibility to arrange that care. - It is expected that when a resident leaves with medications, that those medications belong to the resident taking them home and that they be labeled with the appropriate resident's name. MO244845

Refer to Event ID 1YDJ12 Based on observation, interview, and record review, the facility failed to ensure a safe and orderly discharge from the facility for five (5) out of the six (6) sampled residents (Resident #1, #2, #3, #4, and #5) when five (5) residents were discharged without proper orders, medications, home health services, dialysis services, and/or follow up appointments. The facility census was ninety 90. Review of the facility's policy for discharge to home, revised 04/2023, showed: - (3.) Social services will meet with the resident and/or family to set up outside services and equipment. - (4.) A discharge form is completed by all involved members of the IDT (interdisciplinary team) that explain the resident care needs at home. - (6.) Teaching will be done with the resident/family on any dressings or special tasks. - (8.) If necessary, therapy will provide any necessary instructions. - (9.) On the day of discharge, the nurse will review the discharge form as well as the medications with the family. - The nursing discharge note should include the time of discharge, destination, mode of transportation, disposition of personal belongings and medications and that all parties are aware of the discharge. Review of the facility's policy for hospital transfer, revised 04/2023, showed: - (1.) Notify the physician regarding a change in resident status and obtain an order for transfer to the hospital. 1. Review of Resident #1's Medical Record showed: - The Resident was admitted to the facility 10/25/2024 after a hospitalization for non-ST elevation myocardial infarction (heart attack). - The Resident was discharged to home on [DATE]. - Provider order date: 10/25/2024 May be discharged with all medications. - Provider order date: 11/01/24 Patient okay to discharge. Home health to evaluate and treat for physical therapy, occupational therapy, and nursing. Primary care provider to follow. - The resident had thirty (30) medications prescribed at the time of discharge including antibiotics, pain medication, and breathing treatment medications for active pneumonia infection. - The Resident's Post-Discharge Resources lists Home Health Care as a resource the resident needed at the time of discharge. - The facility failed to provide the name, address, and/or phone number of any Home Health Agency. - The Resident's Medication Reconciliation indicated that the Resident was sent home with 11-16 medications. - No documentation to show the facility staff provided the Resident with medication names, pill counts, and/or patient education relating to the medications sent home with the Resident. - No documentation to show the facility staff scheduled follow-up visits and/or provided the resident with contact information for his/her cardiac (heart) or surgical providers. During an interview on 12/02/24 at 9:52 A.M., RN Casemanager: - They presented to Resident #1's home on [DATE] for an in-home visit after the resident's Care Navigator initiated a referral to Case Management for an emergency visit. The Care Navigator initiated the referral when he/she became aware that the Resident had just had heart surgery and didn't have follow-up care scheduled or home health care set up. - The Resident had no understanding of his/her discharge plan. - The facility failed to initiate home health care or schedule follow-up visits for the Resident. - The facility failed to provide the Resident with prescriptions for necessary medications. - The facility sent the Resident home with seven (7) medication cards belonging to Resident #2 and one (1) medication card belonging to Resident #4. - The Resident had not taken any of his/her medications from the time of discharge until the in-home visit because he/she was confused by the medications that did not belong to him/her and didn't know what medications to take. - On 12/02/2024 at 12:17 P.M. the complainant provided pictures of Resident #2 and Resident #4's medication cards that had been sent home with Resident #1. - The scheduled an appointment for Resident #1 with his/her primary care physician (PCP) and at this appointment the PCP set up a cardiology follow-up for the Resident on 12/16/2024. 2. Review of Resident #2's medical record showed: - The resident was admitted on [DATE] and discharged to home on [DATE]. - Provider order date:10/16/2024 May be discharged with all medications. - Provider order date: 11/04/2024 Patient okay to discharge. Home health to evaluate and treat for physical therapy, occupational therapy, and nursing. Primary care provider to follow. - The resident was taking sixteen (16) prescribed medications at the time of discharge. - The resident's post-discharge resource needs included Home Health Care. - The facility failed to provide the name, phone number, and/or address to any home health care agency at the time of discharge. - The resident did not have any follow-up visits scheduled with any providers. - The resident was not sent home with any medications from the facility. - The resident had prescriptions sent to the pharmacy. - No documentation the facility staff provided the name, phone number, and/or address to the pharmacy where prescriptions were sent at the time of discharge. During an interview on 12/03/2024 at 12:48 P.M., Resident #2 said: - He/she was sent home without anything. - The facility failed to order necessary supplies for the resident prior to discharge, specifically a bed and lift for that the resident was required to use at home. - The facility failed to arrange dialysis care for the resident prior to discharge. - The facility failed to speak to the resident or his/her family about what medications would be required at home or when/how to take them. During an interview on 12/03/2024 at 12:48 P.M., family member #F6 said: - The facility said they had ordered a specialized bed and a lift and that these supplies would be delivered to the resident's home on [DATE]. When no supplies arrived at the Resident's home, the family member called the facility to ask when they would be delivered. The facility told the family member that the supplies would now take 5 weeks to arrive. The resident's family was forced to find a bed and lift themselves with the help of home health and their local Lion's Club. - Resident #2 was supposed to receive dialysis services, but the facility failed to set this up. - The facility failed to provide discharge instructions to the resident and/or the family. The family member said that the nurse handed him/ser a sheet of paper and said, here, but that no explanation of the paperwork and no education was completed. - The facility failed to set up home health services for the resident. Family member F6 set that up for the resident. 3. Review of Resident #3's medical record showed: - The resident was admitted on [DATE] and left the facility AMA (against medical advice) on 10/16/2024 at 14:30, - The resident was taking twenty-seven (27) prescribed medications at the time he/she left the facility. During an interview on 10/23/2024 at 5:45 P.M, the resident said the facility told him/her that they sent prescriptions to the pharmacy after he/she left the facility. When the resident presented to the pharmacy to pick up the medications, the pharmacy informed him/her that no prescriptions had been received from the facility. 4. Review of Resident #4's medical record showed: - The resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. - No documentation the facility staff obtained provider orders prior to discharging the resident to the hospital. - No documentation the facility staff provided discharge/transfer records for Resident #4. 5. Review of Resident #5's medical record showed: - The resident was admitted on [DATE] and discharged to home on [DATE]. - The facility failed to provide discharge/transfer records for Resident #5. During an interview on 12/03/2024 at 12:39 P.M., Resident #5 said: - The facility staff did not provide discharge instructions and/or education to him/her at the time of discharge. - Coming home from the facility was kind of a joke. He/she said that the facility was talking to him/her about a diagnosis they were unaware of and failed to provide him/her with information about the physical therapy exercises he/she should be doing at home. During an interview on 12/02/2024 at 12:59 P.M., CMT A said: - Medications are reviewed with the resident by the nurse prior to discharge. - When a resident is being discharged with medications, the staff are supposed to review each medication card as they are prepared for discharge. Resident's name, room number, medication, and the number of pills left in the card are supposed to be verified and documented in the resident's discharge record. During an interview on 12/02/2024 at 1:21 P.M., the facility's Social Services Designee said: - Discharge planning for residents include sending needed referrals for things such as home health care, physical therapy, and/or specialist providers. - If a resident required home health care at discharge, both the resident and the chosen home health care agency would be aware prior to the resident's discharge and that setting that up would be that facility's responsibility. - Sometimes insurance authorization can delay home health care, but that in that case the Resident's chart would be updated with the appropriate information when an approved agency is found, and the referral is sent. During an interview on 12/02/2024 at 1:32 P.M., the facility Administrator said: - When a resident is being discharged , a medication list is expected to be completed with the discharge instructions and that the nurse is expected to review each listed medication with the resident during discharge education. - During discharge teaching with the nurse, it is expected that the resident be educated on topics including: services that the resident was receiving while they were in the facility, services and care they will be receiving or should continue after returning home, and medications they are prescribed and how/when to take them. - If a follow-up appointment has been scheduled for a resident, it is expected that staff will list that appointment on the discharge instructions along with the provider's phone number. - If a resident leaves without their medications, or if there are medications with the resident's name on them that will not be sent home with the resident, these medications are expected to be destroyed by a nurse or CMT using Drug Buster. - If a resident is discharged requiring home health care, it is the facility's responsibility to arrange that care. - It is expected that when a resident leaves with medications, that those medications belong to the resident taking them home and that they be labeled with the appropriate resident's name. MO244845

Based on interview and record review, the facility failed to employ a qualified director of food and nutrition services. This deficient practice had the potential to affect 87 of 87 residents who received meals prepared in the facility's only kitchen. The facility census was 84. Findings include: Review of the Dietary Manager's (DM) job description, titled Executive Chef, dated 01/08/23, revealed, . Must have Food Service Sanitation certification . Review of the DM's employee file revealed an original date of hire was September 2018. No training course document was included in the file. Review of the Dietary Schedule for 09/29/24 through 10/05/24 revealed the DM was listed as Manager. During an interview on 09/30/24 at 9:35 AM, the DM was asked how long she had worked as the dietary manager and if she was a certified dietary manager (CDM) or had other qualifying credentials as a dietary manager. The DM stated she had been employed at the facility for five years as a cook but had only been the dietary manager for nine months. The DM confirmed she did not have two or more years of experience in the position of director of food and nutrition services in a healthcare setting. The DM went on to say she was not a certified dietary manager and did not have any other qualifying credentials but was currently taking a course in food safety and management. During an interview on 10/01/24 at 9:54 AM, the General Manager was asked about DM's experience and credentials. The General Manager stated the DM was not a CDM but was currently in a course in food safety and management. The General Manager stated DM had been in the manager's position for nine months. During an interview on 10/02/24 at 11:28 AM, the Registered Dietitian (RD) confirmed she was not full-time, and the DM and assistant DM did not have two or more years of experience in the position of director of food and nutrition services in a healthcare setting. The RD confirmed the DM had not completed a course in food safety and management but is currently taking one.

Based on interview, record review, and facility policy review, the facility failed to provide written notification of a facility-initiated transfer to the resident and responsible party (RP) for two of five residents (Resident (R)19, R38, and R66) reviewed for hospitalization out of a total sample of 28. The failure had the potential to affect the residents and/or their representative concerning the reason for the transfer and the resident's appeal rights. The facility census was 84. Findings include: Review of the facility's Admission, Transfer, & Discharge policy, revised 05/2023, revealed, . Facility staff will document in the clinical record discharge information provided to the resident and the receiving organization, if applicable: the basis for the transfer . instruction provided to the resident and/or surrogate decision-maker prior to discharge . 1. Review of R38's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/24 and located in the MDS tab of the Electronic Medical Record (EMR), revealed an admitted [DATE]. A Brief Interview for Mental Status (BIMS) showed a score of 15 out of 15, indicating the resident's cognition was intact. The MDS recorded R38 had diagnoses that included metabolic encephalopathy, ileostomy status, and cirrhosis of liver. Review of R38's Health Status Note, dated 08/02/24 at 1:50 PM and located in the EMR under the Progress Note tab, revealed, . Patient is not feeling normal she stated that she has pain in her stomach, she have beeing [sic] vimoting [sic] and feeling dizzy . Review of R38's Health Status Note, dated 08/02/24 at 2:54 PM and located in the EMR under the Progress Note tab, revealed, . [name] the NP ordered to send the Patient to the hospital, Family has been Notified . Review of R38's Medication Administration Note, dated 08/02/24 at 3:10 PM and located in the EMR under the Progress Note tab, revealed, . sent to hospital . Review of R38's Transfer Form, dated 08/02/24 and located in the EMR under the Evaluation tab, revealed no appeal information or that the resident/representative was provided a written notice of transfer. Review of R38's Health Status Note, dated 09/07/24 at 4:39 PM and located in the EMR under the Progress Note tab, revealed, . Sent critical labs to NP [nurse practitioner] [name] Bun and creative were critical and NP ordered to send out. Resident went to [hospital name]. [Family member] notified. Resident left via ambulance at 1840 [6:40 PM] . Review of R38's Health Status Note, dated 09/07/24 at 11:04 PM and located in the EMR under the Progress Note tab, revealed, . Resident being admitted to [hospital] for UTI [urinary tract infection] and failed antibiotic treatment . Review of R38's Transfer Form, dated 09/07/24 and located in the EMR under the Evaluation tab, revealed no appeal information or that the resident/representative was provided with a written notice of transfer. During an interview on 10/02/24 at 4:43 PM, the General Manager was asked if R38 and her representative were provided with a written notice of transfer for R38's facility-initiated transfers to the hospital on 08/02/24 and 09/07/24. The General Manager stated, No, only verbal notices were provided for the transfer for [R38]. The General Manager confirmed written notice had not been given to any residents or their representatives. The General Manager stated, It's something they need to work on, and this will be a PIPs [performance improvement projects]. The General Manager provided a form titled Bed Hold Notice that encompassed the facility-initiated transfer information. The General Manager confirmed neither R38 nor her representative received the form. 42440 2. Review of R19s quarterly MDS, with an ARD of 08/28/24 and located in the MDS tab of the EMR revealed R19 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus and malnutrition. The MDS recorded R19 scored 11 out of 15 on the BIMS, which indicated moderately impaired cognition. Review of R19's Health Status Notes, found in the EMR under the Prog Notes tab, revealed: 11/27/23 - R19 went to the hospital for evaluation and was admitted on [DATE] for acute ischemic encephalopathy with hypoxia and CVA (cerebral vascular accident- stroke) with seizure. 11/30/23 - R19 was sent to the hospital and admitted for seizures and encephalopathy. 06/22/24 - R19 was sent to the hospital and admitted with pneumonia and a blood clot. Review of the Evaluations tab of the EMR revealed no documentation that R19 and his representative were provided with written notice of the transfers to the hospital and the reason for hospitalization . During an interview on 09/30/24 at 2:56 PM, R19 reported he had been hospitalized in the last year but could not recall when. During an interview on 10/02/24 at 4:50 PM, the Administrator stated neither R19 nor his representative received written notice of his transfers to the hospital. The Administrator stated the facility had given verbal notifications and needed to close the loop with the paper documentation.

Based on observation, interview, and record review, the facility failed to ensure a safe and orderly discharge from the facility for five (5) out of the six (6) sampled residents (Resident #1, #2, #3, #4, and #5) when five (5) residents were discharged without proper orders, medications, home health services, dialysis services, and/or follow up appointments. The facility census was ninety 90. Review of the facility's policy for discharge to home, revised 04/2023, showed: - (3.) Social services will meet with the resident and/or family to set up outside services and equipment. - (4.) A discharge form is completed by all involved members of the IDT (interdisciplinary team) that explain the resident care needs at home. - (6.) Teaching will be done with the resident/family on any dressings or special tasks. - (8.) If necessary, therapy will provide any necessary instructions. - (9.) On the day of discharge, the nurse will review the discharge form as well as the medications with the family. - The nursing discharge note should include the time of discharge, destination, mode of transportation, disposition of personal belongings and medications and that all parties are aware of the discharge. Review of the facility's policy for hospital transfer, revised 04/2023, showed: - (1.) Notify the physician regarding a change in resident status and obtain an order for transfer to the hospital. 1. Review of Resident #1's Medical Record showed: - The Resident was admitted to the facility 10/25/2024 after a hospitalization for non-ST elevation myocardial infarction (heart attack). - The Resident was discharged to home on 11/04/24. - Provider order date: 10/25/2024 May be discharged with all medications. - Provider order date: 11/01/24 Patient okay to discharge. Home health to evaluate and treat for physical therapy, occupational therapy, and nursing. Primary care provider to follow. - The resident had thirty (30) medications prescribed at the time of discharge including antibiotics, pain medication, and breathing treatment medications for active pneumonia infection. - The Resident's Post-Discharge Resources lists Home Health Care as a resource the resident needed at the time of discharge. - The facility failed to provide the name, address, and/or phone number of any Home Health Agency. - The Resident's Medication Reconciliation indicated that the Resident was sent home with 11-16 medications. - No documentation to show the facility staff provided the Resident with medication names, pill counts, and/or patient education relating to the medications sent home with the Resident. - No documentation to show the facility staff scheduled follow-up visits and/or provided the resident with contact information for his/her cardiac (heart) or surgical providers. During an interview on 12/02/24 at 9:52 A.M., RN Casemanager: - They presented to Resident #1's home on 11/07/2024 for an in-home visit after the resident's Care Navigator initiated a referral to Case Management for an emergency visit. The Care Navigator initiated the referral when he/she became aware that the Resident had just had heart surgery and didn't have follow-up care scheduled or home health care set up. - The Resident had no understanding of his/her discharge plan. - The facility failed to initiate home health care or schedule follow-up visits for the Resident. - The facility failed to provide the Resident with prescriptions for necessary medications. - The facility sent the Resident home with seven (7) medication cards belonging to Resident #2 and one (1) medication card belonging to Resident #4. - The Resident had not taken any of his/her medications from the time of discharge until the in-home visit because he/she was confused by the medications that did not belong to him/her and didn't know what medications to take. - On 12/02/2024 at 12:17 P.M. the complainant provided pictures of Resident #2 and Resident #4's medication cards that had been sent home with Resident #1. - The scheduled an appointment for Resident #1 with his/her primary care physician (PCP) and at this appointment the PCP set up a cardiology follow-up for the Resident on 12/16/2024. 2. Review of Resident #2's medical record showed: - The resident was admitted on [DATE] and discharged to home on 11/04/2024. - Provider order date:10/16/2024 May be discharged with all medications. - Provider order date: 11/04/2024 Patient okay to discharge. Home health to evaluate and treat for physical therapy, occupational therapy, and nursing. Primary care provider to follow. - The resident was taking sixteen (16) prescribed medications at the time of discharge. - The resident's post-discharge resource needs included Home Health Care. - The facility failed to provide the name, phone number, and/or address to any home health care agency at the time of discharge. - The resident did not have any follow-up visits scheduled with any providers. - The resident was not sent home with any medications from the facility. - The resident had prescriptions sent to the pharmacy. - No documentation the facility staff provided the name, phone number, and/or address to the pharmacy where prescriptions were sent at the time of discharge. During an interview on 12/03/2024 at 12:48 P.M., Resident #2 said: - He/she was sent home without anything. - The facility failed to order necessary supplies for the resident prior to discharge, specifically a bed and lift for that the resident was required to use at home. - The facility failed to arrange dialysis care for the resident prior to discharge. - The facility failed to speak to the resident or his/her family about what medications would be required at home or when/how to take them. During an interview on 12/03/2024 at 12:48 P.M., family member #F6 said: - The facility said they had ordered a specialized bed and a lift and that these supplies would be delivered to the resident's home on 11/09/24. When no supplies arrived at the Resident's home, the family member called the facility to ask when they would be delivered. The facility told the family member that the supplies would now take 5 weeks to arrive. The resident's family was forced to find a bed and lift themselves with the help of home health and their local Lion's Club. - Resident #2 was supposed to receive dialysis services, but the facility failed to set this up. - The facility failed to provide discharge instructions to the resident and/or the family. The family member said that the nurse handed him/ser a sheet of paper and said, here, but that no explanation of the paperwork and no education was completed. - The facility failed to set up home health services for the resident. Family member F6 set that up for the resident. 3. Review of Resident #3's medical record showed: - The resident was admitted on [DATE] and left the facility AMA (against medical advice) on 10/16/2024 at 14:30, - The resident was taking twenty-seven (27) prescribed medications at the time he/she left the facility. During an interview on 10/23/2024 at 5:45 P.M, the resident said the facility told him/her that they sent prescriptions to the pharmacy after he/she left the facility. When the resident presented to the pharmacy to pick up the medications, the pharmacy informed him/her that no prescriptions had been received from the facility. 4. Review of Resident #4's medical record showed: - The resident was admitted to the facility on [DATE] and discharged to the hospital on 10/16/2024. - No documentation the facility staff obtained provider orders prior to discharging the resident to the hospital. - No documentation the facility staff provided discharge/transfer records for Resident #4. 5. Review of Resident #5's medical record showed: - The resident was admitted on [DATE] and discharged to home on 11/25/2024. - The facility failed to provide discharge/transfer records for Resident #5. During an interview on 12/03/2024 at 12:39 P.M., Resident #5 said: - The facility staff did not provide discharge instructions and/or education to him/her at the time of discharge. - Coming home from the facility was kind of a joke. He/she said that the facility was talking to him/her about a diagnosis they were unaware of and failed to provide him/her with information about the physical therapy exercises he/she should be doing at home. During an interview on 12/02/2024 at 12:59 P.M., CMT A said: - Medications are reviewed with the resident by the nurse prior to discharge. - When a resident is being discharged with medications, the staff are supposed to review each medication card as they are prepared for discharge. Resident's name, room number, medication, and the number of pills left in the card are supposed to be verified and documented in the resident's discharge record. During an interview on 12/02/2024 at 1:21 P.M., the facility's Social Services Designee said: - Discharge planning for residents include sending needed referrals for things such as home health care, physical therapy, and/or specialist providers. - If a resident required home health care at discharge, both the resident and the chosen home health care agency would be aware prior to the resident's discharge and that setting that up would be that facility's responsibility. - Sometimes insurance authorization can delay home health care, but that in that case the Resident's chart would be updated with the appropriate information when an approved agency is found, and the referral is sent. During an interview on 12/02/2024 at 1:32 P.M., the facility Administrator said: - When a resident is being discharged , a medication list is expected to be completed with the discharge instructions and that the nurse is expected to review each listed medication with the resident during discharge education. - During discharge teaching with the nurse, it is expected that the resident be educated on topics including: services that the resident was receiving while they were in the facility, services and care they will be receiving or should continue after returning home, and medications they are prescribed and how/when to take them. - If a follow-up appointment has been scheduled for a resident, it is expected that staff will list that appointment on the discharge instructions along with the provider's phone number. - If a resident leaves without their medications, or if there are medications with the resident's name on them that will not be sent home with the resident, these medications are expected to be destroyed by a nurse or CMT using Drug Buster. - If a resident is discharged requiring home health care, it is the facility's responsibility to arrange that care. - It is expected that when a resident leaves with medications, that those medications belong to the resident taking them home and that they be labeled with the appropriate resident's name. MO244845

Based on observation, interview, and record review, the facility failed to ensure a safe and orderly discharge from the facility for five (5) out of the six (6) sampled residents (Resident #1, #2, #3, #4, and #5) when five (5) residents were discharged without proper orders, medications, home health services, dialysis services, and/or follow up appointments. The facility census was ninety 90. Review of the facility's policy for discharge to home, revised 04/2023, showed: - (3.) Social services will meet with the resident and/or family to set up outside services and equipment. - (4.) A discharge form is completed by all involved members of the IDT (interdisciplinary team) that explain the resident care needs at home. - (6.) Teaching will be done with the resident/family on any dressings or special tasks. - (8.) If necessary, therapy will provide any necessary instructions. - (9.) On the day of discharge, the nurse will review the discharge form as well as the medications with the family. - The nursing discharge note should include the time of discharge, destination, mode of transportation, disposition of personal belongings and medications and that all parties are aware of the discharge. Review of the facility's policy for hospital transfer, revised 04/2023, showed: - (1.) Notify the physician regarding a change in resident status and obtain an order for transfer to the hospital. 1. Review of Resident #1's Medical Record showed: - The Resident was admitted to the facility 10/25/2024 after a hospitalization for non-ST elevation myocardial infarction (heart attack). - The Resident was discharged to home on [DATE]. - Provider order date: 10/25/2024 May be discharged with all medications. - Provider order date: 11/01/24 Patient okay to discharge. Home health to evaluate and treat for physical therapy, occupational therapy, and nursing. Primary care provider to follow. - The resident had thirty (30) medications prescribed at the time of discharge including antibiotics, pain medication, and breathing treatment medications for active pneumonia infection. - The Resident's Post-Discharge Resources lists Home Health Care as a resource the resident needed at the time of discharge. - The facility failed to provide the name, address, and/or phone number of any Home Health Agency. - The Resident's Medication Reconciliation indicated that the Resident was sent home with 11-16 medications. - No documentation to show the facility staff provided the Resident with medication names, pill counts, and/or patient education relating to the medications sent home with the Resident. - No documentation to show the facility staff scheduled follow-up visits and/or provided the resident with contact information for his/her cardiac (heart) or surgical providers. During an interview on 12/02/24 at 9:52 A.M., RN Casemanager: - They presented to Resident #1's home on [DATE] for an in-home visit after the resident's Care Navigator initiated a referral to Case Management for an emergency visit. The Care Navigator initiated the referral when he/she became aware that the Resident had just had heart surgery and didn't have follow-up care scheduled or home health care set up. - The Resident had no understanding of his/her discharge plan. - The facility failed to initiate home health care or schedule follow-up visits for the Resident. - The facility failed to provide the Resident with prescriptions for necessary medications. - The facility sent the Resident home with seven (7) medication cards belonging to Resident #2 and one (1) medication card belonging to Resident #4. - The Resident had not taken any of his/her medications from the time of discharge until the in-home visit because he/she was confused by the medications that did not belong to him/her and didn't know what medications to take. - On 12/02/2024 at 12:17 P.M. the complainant provided pictures of Resident #2 and Resident #4's medication cards that had been sent home with Resident #1. - The scheduled an appointment for Resident #1 with his/her primary care physician (PCP) and at this appointment the PCP set up a cardiology follow-up for the Resident on 12/16/2024. 2. Review of Resident #2's medical record showed: - The resident was admitted on [DATE] and discharged to home on [DATE]. - Provider order date:10/16/2024 May be discharged with all medications. - Provider order date: 11/04/2024 Patient okay to discharge. Home health to evaluate and treat for physical therapy, occupational therapy, and nursing. Primary care provider to follow. - The resident was taking sixteen (16) prescribed medications at the time of discharge. - The resident's post-discharge resource needs included Home Health Care. - The facility failed to provide the name, phone number, and/or address to any home health care agency at the time of discharge. - The resident did not have any follow-up visits scheduled with any providers. - The resident was not sent home with any medications from the facility. - The resident had prescriptions sent to the pharmacy. - No documentation the facility staff provided the name, phone number, and/or address to the pharmacy where prescriptions were sent at the time of discharge. During an interview on 12/03/2024 at 12:48 P.M., Resident #2 said: - He/she was sent home without anything. - The facility failed to order necessary supplies for the resident prior to discharge, specifically a bed and lift for that the resident was required to use at home. - The facility failed to arrange dialysis care for the resident prior to discharge. - The facility failed to speak to the resident or his/her family about what medications would be required at home or when/how to take them. During an interview on 12/03/2024 at 12:48 P.M., family member #F6 said: - The facility said they had ordered a specialized bed and a lift and that these supplies would be delivered to the resident's home on [DATE]. When no supplies arrived at the Resident's home, the family member called the facility to ask when they would be delivered. The facility told the family member that the supplies would now take 5 weeks to arrive. The resident's family was forced to find a bed and lift themselves with the help of home health and their local Lion's Club. - Resident #2 was supposed to receive dialysis services, but the facility failed to set this up. - The facility failed to provide discharge instructions to the resident and/or the family. The family member said that the nurse handed him/ser a sheet of paper and said, here, but that no explanation of the paperwork and no education was completed. - The facility failed to set up home health services for the resident. Family member F6 set that up for the resident. 3. Review of Resident #3's medical record showed: - The resident was admitted on [DATE] and left the facility AMA (against medical advice) on 10/16/2024 at 14:30, - The resident was taking twenty-seven (27) prescribed medications at the time he/she left the facility. During an interview on 10/23/2024 at 5:45 P.M, the resident said the facility told him/her that they sent prescriptions to the pharmacy after he/she left the facility. When the resident presented to the pharmacy to pick up the medications, the pharmacy informed him/her that no prescriptions had been received from the facility. 4. Review of Resident #4's medical record showed: - The resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. - No documentation the facility staff obtained provider orders prior to discharging the resident to the hospital. - No documentation the facility staff provided discharge/transfer records for Resident #4. 5. Review of Resident #5's medical record showed: - The resident was admitted on [DATE] and discharged to home on [DATE]. - The facility failed to provide discharge/transfer records for Resident #5. During an interview on 12/03/2024 at 12:39 P.M., Resident #5 said: - The facility staff did not provide discharge instructions and/or education to him/her at the time of discharge. - Coming home from the facility was kind of a joke. He/she said that the facility was talking to him/her about a diagnosis they were unaware of and failed to provide him/her with information about the physical therapy exercises he/she should be doing at home. During an interview on 12/02/2024 at 12:59 P.M., CMT A said: - Medications are reviewed with the resident by the nurse prior to discharge. - When a resident is being discharged with medications, the staff are supposed to review each medication card as they are prepared for discharge. Resident's name, room number, medication, and the number of pills left in the card are supposed to be verified and documented in the resident's discharge record. During an interview on 12/02/2024 at 1:21 P.M., the facility's Social Services Designee said: - Discharge planning for residents include sending needed referrals for things such as home health care, physical therapy, and/or specialist providers. - If a resident required home health care at discharge, both the resident and the chosen home health care agency would be aware prior to the resident's discharge and that setting that up would be that facility's responsibility. - Sometimes insurance authorization can delay home health care, but that in that case the Resident's chart would be updated with the appropriate information when an approved agency is found, and the referral is sent. During an interview on 12/02/2024 at 1:32 P.M., the facility Administrator said: - When a resident is being discharged , a medication list is expected to be completed with the discharge instructions and that the nurse is expected to review each listed medication with the resident during discharge education. - During discharge teaching with the nurse, it is expected that the resident be educated on topics including: services that the resident was receiving while they were in the facility, services and care they will be receiving or should continue after returning home, and medications they are prescribed and how/when to take them. - If a follow-up appointment has been scheduled for a resident, it is expected that staff will list that appointment on the discharge instructions along with the provider's phone number. - If a resident leaves without their medications, or if there are medications with the resident's name on them that will not be sent home with the resident, these medications are expected to be destroyed by a nurse or CMT using Drug Buster. - If a resident is discharged requiring home health care, it is the facility's responsibility to arrange that care. - It is expected that when a resident leaves with medications, that those medications belong to the resident taking them home and that they be labeled with the appropriate resident's name. MO244845

Based on interview and record review the facility failed to provide written notification of the bed hold policy to the resident and responsible party (RP) for two of five residents (Resident (R)38 and R19) reviewed for hospitalization out of a total sample of 28. The failure had the potential to affect the residents planning on returning to the facility. The facility census was 84. Findings include: Review of the facility's policy titled, Bed Hold and Therapeutic Leave, revised 11/2018 and provided by the facility, revealed, . 2. For hospital leaves, the facility will hold a bed (not necessarily that specific bed) for up to 10 days during the hospitalization . On the 11th day, there is no requirement to hold a bed but the resident is still a resident and should receive the next available bed when they are ready to return, even if there is a waiting list . The policy did not include the cost per day or that the notice must be written. Review of the facility's Admission, Transfer, & Discharge policy, dated 07/2020 and revised 05/2023, revealed, . Upon admission, the resident/representative will be informed that if/when the resident is transferred to another health care facility, transferred within this facility, or discharged from this facility, the resident or his/her representative will be informed about the Facility Admission/Transfer/Discharge policies . regardless of the resident's payer source. At the time of move in, transfer to another health care facility or overnight visits outside the facility, the resident and/or representative will be provided with information on how to hold the resident's current room during their absence . 1. Review of R38's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 09/03/24 and located in the MDS tab of the Electronic Medical Record (EMR), revealed an admitted [DATE]. A Brief Interview for Mental Status (BIMS) showed a score of 15 out of 15, indicating the resident's cognition was intact. The MDS recorded R38 had diagnoses that included metabolic encephalopathy, ileostomy status, and cirrhosis of liver. Review of R38's Health Status Note, dated 08/02/24 at 1:50 PM and located in the EMR under the Progress Note tab, revealed, . Patient is not feeling normal she stated that she has pain in her stomach, she have beeing [sic] vimoting [sic] and feeling dizzy . Review of R38's Health Status Note, dated 08/02/24 at 1:54 PM and located in the EMR under the Progress Note tab, revealed, . [name] the NP ordered to send the Patient to the hospital, Family has been Notified . Review of R38's Medication Administration Note, dated 08/02/24 at 3:10 PM and located in the EMR under the Progress Note tab, revealed . sent to hospital . Review of R38's EMR revealed no documentation that a written notice of a bed hold was provided. Review of R38's Health Status Note, dated 09/07/24 at 4:39 PM and located in the EMR under the Progress Note tab, revealed, . Sent critical labs to NP [nurse practitioner] [name] Bun and creative were critical and NP ordered to send out. Resident went to [hospital name]. [Family member] notified. Resident left via ambulance at 1840 [6:40 PM] . Review of R38's Health Status Note, dated 09/07/24 at 11:04 PM and located in the EMR under the Progress Note tab, revealed, . Resident being admitted to [hospital] for UTI [urinary tract infection] and failed antibiotic treatment . Review of R38's Bed Hold Policy/Ombudsman Notification, dated 09/07/24 and located in the EMR under the Evaluation tab revealed no documentation that a written notice was provided or the cost per day for a bed hold. During an interview on 10/02/24 at 4:43 PM, the General Manager was asked if R38 or her representative were provided with a written notice of bed holds for R38's transfers to the hospital on 08/02/24 and 09/07/24. The General Manager stated, No, only a verbal notice was given for the bed holds for [R38]. The General Manager confirmed written notice had not been given to any residents or their representatives. The General Manager went on to say, It's something they need to work on, and this will be a PIPs [performance improvement projects]. The General Manager provided a blank form titled Bed Hold Notice that encompassed the bed hold transfer information. The General Manager confirmed R38 or her representative did not receive this form. 42440 2. Review of R19's Admission Packet, located in the EMR under the Misc tab, revealed R19 signed a Bed Reserve Policy on 06/30/23. The Bed Reserve Policy recorded, . Under normal circumstances, if you leave the facility for a hospitalization , you will be readmitted to the first available bed in a semi-private room. Under certain conditions, we can reserve your existing bed for you at your request, so when you return to the facility, you will have the same bed and room as before. Neither Medicare nor Medicaid will pay to hold your same bed if you are hospitalized . The Nursing Home Care Act requires a nursing facility to hold a bed for a maximum of ten days when you are hospitalized . The facility must hold a bed [not necessarily your specific bed] for up to 10 [ten] days during a hospitalization . On the 11th day there is no requirement to hold a bed, but you are still a Resident and will receive the next available bed when you are ready to return, even if there is a waiting list . In Missouri, . Neither a resident nor the responsible party is required to pay a nursing facility to hold a bed. If the resident/responsible person chooses to, he/she may pay a nursing facility in order to reserve the same bed the participant is leaving. A nursing home has an obligation to inform a resident or the responsible person that paying them to hold a bed is voluntary. When a resident is transferred to a hospital, the nursing home is required, both by federal statute and by federal regulation, to readmit the resident immediately upon the first availability of a bed in a semiprivate room . Review of R19's Health Status Notes, found in the EMR under the Prog Notes tab, revealed: 11/27/23 - R19 went to the hospital for evaluation and was admitted on [DATE] for acute ischemic encephalopathy with hypoxia and CVA (cerebral vascular accident- stroke) with seizure. 11/30/23 - R19 was sent to the hospital and admitted for seizures and encephalopathy. 06/22/24 - R19 was sent to the hospital and admitted with pneumonia and a blood clot. Review of R19's EMR revealed a quarterly MDS, with an ARD of 08/28/24 and located in the MDS tab revealed R19 had a BIMS score of 11 out of 15, which indicated moderately impaired cognition. During an interview on 09/30/24 at 2:56 PM, R19 reported he had been hospitalized in the last year but could not recall when. Review of the EMR revealed no documentation that the facility provided a written notice of the facility's bed hold policy upon any of the resident's transfers to the hospital. During an interview on 10/02/24 at 4:50 PM, the Administrator stated neither R19 nor his representative received bed hold papers when transferred to the hospital. The facility had given verbal notifications and needed to close the loop with the paper documentation.

Based on record review, interview, and facility policy review, the facility failed to perform ongoing neurological assessments when residents had unwitnessed falls, which could have resulted in head trauma, for three of three residents (Resident (R) 19, R222, and R226) reviewed for falls out of a sample of 28 residents. The lack of proper assessment could result in the facility potentially not noticing symptoms of head trauma and initiating interventions. The facility census was 84. Findings include: Review of the facility's Post-Fall Policy, revised/reviewed 05/2023, revealed, lf the resident reports hitting head, if there is any indication of head injury, or if ANY incident is un-witnessed, the neuro check protocol will be implemented, and reported to the physician. Review of the facility's Neurological Assessment procedure, dated 09/2019, revealed, . Neurological assessments are done upon physician order when indicated for a change of resident condition, unwitnessed fall and with all head injuries . Observe behavior and note any significant change from normal . Determine level of consciousness and responsiveness as compared to baseline . Determine orientation to person, place and time as compared to baseline . Determine capability of movement and strength of all extremities as compared to baseline . Check pupil size and reaction to light . Note speech to determine if it is clear, rambling, incoherent and absent as compared to Baseline . Check vital signs . 1. Review of R19's Prof tab of his electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. R19 had diagnoses which included repeated falls and a personal history of traumatic brain injury. Review of R19's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/28/24 and located in the MDS tab of the EMR, revealed R19 scored an 11 out of 15 on his Brief Interview of Mental Status (BIMS), which indicated moderately impaired cognition. Review of R19's Care Plan, located in the Care Plan tab of the EMR, revealed a focus area, initiated 07/04/23, . [R19] has experienced actual falls and is at risk for further falls related to impaired mobility, cognitive impairments, incontinence, polypharmacy . It contains an intervention to follow facility fall protocol, dated 07/04/23. Review of facility provided Incident Reports revealed R19 had unwitnessed falls on 01/14/24, 01/22/24, 02/01/24, 02/03/24, 02/11/24, 02/12/24, 03/02/24, 03/03/24, 03/17/24, 04/08/24, 04/18/24, 05/07/24, 05/31/24, and 09/16/24. Review of R19's Post Fall Neurological Evaluations, under the Evaluations tab of the EMR, revealed the facility completed one neurological evaluation following falls on 01/14/24, 01/22/24, 02/01/24, 02/03/24, 02/11/24, 03/02/24, 03/03/24, 04/08/24, 04/18/24, and 05/07/24. No Post Fall Neurological Evaluations were completed on 02/12/24, 03/17/24, 05/31/24, or 09/16/24. The Post Fall Neurological Evaluation included documentation of the resident's orientation and alertness, pupil responsiveness to light, vital signs, grip strength, appropriateness of verbalizations, and response to simple commands. Review of R19's Nurse Fall Checklists found under the Misc tab of the EMR, revealed partially completed checklists for falls on 02/01/24, 02/03/24, 02/11/24, 03/03/24, 04/08/24, and 04/18/24. The EMR contained no checklists for falls occurring 01/14/24, 01/22/24, 02/12/24, 03/02/24, 03/17/24, 05/07/24, 05/31/24, and 09/16/24. The checklists included areas to fill in for blood pressure, pulse, respirations, temperature, and oxygen saturation following a fall every 15 minutes for one hour, every 30 minutes for two hours, every hour for four hours, every four hours for 24 hours, and every shift for four shifts. The checklists did not contain areas to fill in for orientation and alertness, pupil responsiveness to light, vital signs, grip strength, appropriateness of verbalizations, and response to simple commands. During an interview on 09/30/24 at 2:57 PM, R19 stated he fell multiple times in the past year. During an interview on 10/02/24 at 3:45 PM, Licensed Practical Nurse (LPN) 3 stated when a resident fell , nurses immediately assessed them by doing a skin assessment and vital signs. LPN3 stated the nurses filled out an incident report, and if the resident hit their head or had an unwitnessed fall, nurses completed neurological assessments and filled out the Nurse Fall Checklist, which indicated when they checked the vital signs. The Nurse Fall Checklist asked for only vital signs, but a full assessment could be completed in the EMR. During an interview on 10/02/24 at 3:50 PM, Assistant Chief Nursing Officer (ACNO) 2 stated a complete neurological assessment was under the Evaluations tab. ACNO2 stated for the Nurse Fall Checklist, some nurses filled out the paper, which was then scanned into the EMR under the Misc tab, while others entered vital signs directly into the Wts [weights]/Vitals tab of the EMR. During an interview on 10/03/24 at 1:25 PM, the Director of Nursing (DON) stated she expected that nurses documented neurological assessments for any unwitnessed fall when a resident was confused or could not say if they hit their head. She stated she expected that the first neurological assessment includes all vital signs and pupil dilation, and neurological assessments were expected to be completed for 72 hours unless the resident went out to the hospital and a head scan showed head injury. The DON stated she felt that after nursing completed the first neurological assessment in the Evaluations tab of the EMR under Fall Risk Evaluation, they could then fill out the Nurse Fall Checklist, which contained blood pressure, pulse, respirations, temperature, and oxygen saturations but did not contain orientation and alertness, pupil responsiveness to light, vital signs, grip strength, appropriateness of verbalizations, and response to simple commands. She stated she kept a binder of the Nurse Fall Checklists. On 10/03/24 at 2:30 PM, the DON provided copies of R19's Nurse Fall Checklist sheets that she had in her binder. Completed checklists were provided for every fall; however, these checklists did not contain documentation neurological assessments had been completed per policy and current standards of practice. 36917 2. Review of R222's EMR Admission Record revealed that R222 was admitted on [DATE] and had diagnosis that included a compression fracture of T11-12 vertebra, subsequent encounter for fracture with routine healing, wedge compression fracture of fourth thoracic vertebra subsequent encounter for fracture with routine healing, other intervertebral disc degeneration, thoracic region, low back pain, malignant neoplasm of breast, absence of right breast. Review of R222's EMR Progress Notes tab, revealed on 10/01/24, R222 reported she had an unwitnessed fall and hit her head on the toilet on 09/29/24 at 5:23 PM. Review of R222's EMR Assessment tab, revealed a Neurological Evaluation Form, dated 09/29/24, where it was recorded a neurological evaluation was conducted on 09/29/24 at 11:07 PM. Further review of the EMR indicated no follow-up neurological assessments were conducted for R222's fall where she reported she hit her head. During an interview with R222 on 10/03/24 at 4:45 PM, R222 stated she was in the bathroom when she fell and hit her head on the toilet but did not get hurt in the fall. She stated she reported her fall to RN1. During an interview on 10/03/24 at 12:46 PM, Registered Nurse (RN) 1 stated the standard protocol for an unwitnessed fall is to assess the resident, complete an initial neurological evaluation, and then follow-up neurological assessments are to be conducted and documented every 15 minutes for at least 24 hours. When asked if the follow-up neurological assessment is completed if a resident says they did not hit their head, she said the assessment follow up assessments are still conducted. During an interview on 10/03/24 at 1:26 PM, the DON stated if an unwitnessed fall occurs and the resident is alert and oriented and says he/she did not hit their head, then a neuro check is not done. She said an initial evaluation form is to be completed on an unwitnessed fall with all vital sign checked, including pupil reactions and a muscle strength assessment. She said the follow-up neurological assessment form contains evidence of neurological vital checks every 15 minutes that included only the blood pressure, pulse, and temperature but not pupil reaction and muscle strength. She stated she would expect that all vital signs, including pupil reaction and strength, should be assessed and recorded on the neuro sheet. 3. Review of R226's EMR Admission Record tab revealed that R226 was admitted to the facility on [DATE] and had diagnosis that included a fracture of the right arm prior to admission, dementia, and confusion. Review of the EMR Progress Notes tab revealed R226 had an unwitnessed fall in the facility on 09/27/24. The progress notes documented that an initial neurological evaluation was conducted but no follow-up neurological assessments were conducted. During an interview on 10/03/24 at 12:46 PM, RN1 stated the standard protocol for an unwitnessed fall was to assess the resident, complete an initial neurological evaluation, and then follow-up neurological assessments are to be conducted and documented every 15 minutes for at least 24 hours. During an interview on 10/03/24 at 1:26 PM the DON stated if an unwitnessed fall occurs and the resident is alert and oriented and says he/she did not hit their head then a neuro check is not done. She stated an initial evaluation form is to be completed on an unwitnessed fall with all vital signs checked, including pupil reactions and a muscle strength assessment. She said the follow-up neurological assessment form contains evidence of neurological vital checks every 15 minutes that included only the blood pressure, pulse, and temperature but not pupil reaction and muscle strength. She stated she would expect that all vital signs, including pupil reaction and strength, should be assessed and recorded on the neuro sheet.

Based on record review, interviews, and facility policy review, the facility failed to 1.) document that residents were offered and provided education about the influenza vaccine during the influenza season for two of five residents (Resident (R) 8 and R35) reviewed for immunizations, and 2.) document that residents were offered and provided education about the pneumonia vaccine for four of five residents (R3, R8, R26, and R35) reviewed for immunizations. This had the potential for residents or their representatives not to make an educated decision regarding obtaining the immunizations at the facility which could lead to illness. The facility census was 84. Findings include: Review of the facility's Immunization Policy, revised/reviewed in 05/2023, revealed, . all admissions throughout the year will be offered the pneumovax injection as recommended by Centers for Disease control [CDC] and desired by the resident and approved by the primary care physician . CDC recommends adults aged [AGE] years old or older who have not previously received PCV or whose previous vaccination history is unknown should receive l [one] dose of PCV [either PCV20 or PCV15] . Each resident's . immunization status will be determined, if possible, prior to vaccination, and will be documented in the resident's clinical record in the [Immunization Record] . If the resident . have no information about immunization history, and none can be obtained from the designated primary care physician, the vaccine[s] will be offered and administered as indicated by the primary care physician . Prior to offering the influenza, pneumovax . vaccine[s], each resident and/or representative will receive current education regarding the benefits and potential side effects of the immunization . Residents . may refuse vaccinations. Vaccination refusal and reasons why will be documented by the facility in addition to education related to risk of refusing immunizations. 1. Review of R3's Prof (Profile) tab of her electronic medical record (EMR) revealed she was [AGE] years old. R3 was admitted to the facility on [DATE]. Review of R3's Immun (Immunizations) tab of her EMR revealed an undated consent refused entry for an unspecified pneumococcal immunization. The facility did not document any history that R3 had received pneumonia vaccines in the past. Review of R3's EMR revealed no signed declination of a pneumonia vaccine, no rationale for why R3 refused the vaccine, and no documentation that the facility provided education regarding the vaccine. 2. Review of R8's Prof tab of her EMR revealed she was [AGE] years old and was admitted to the facility on [DATE]. Review of R8's Immun tab of her EMR revealed an undated not eligible and an undated consent refused entry for influenza vaccines. Review further revealed an undated consent refused entry for an unspecified pneumococcal immunization. The facility did not document any history that R8 had received pneumonia vaccines in the past. Review of R8's EMR revealed no signed declinations for the pneumonia and influenza vaccines, no rationale for why R8 refused the vaccines, and no documentation that the facility provided education regarding the vaccines. 3. Review of R26's Prof tab of his EMR revealed he was [AGE] years old and was admitted to the facility on [DATE]. Review of R26's Immun tab of her EMR revealed an undated consent refused entry for an unspecified pneumococcal immunization. The facility did not document any history that R26 had received pneumonia vaccines in the past. Review of R26's EMR revealed no signed declination of a pneumonia vaccine, no rationale for why R26 refused the vaccine, and no documentation that the facility provided education regarding the vaccine. 4. Review of R35's Prof tab of his EMR revealed he was [AGE] years old and was admitted to the facility on [DATE]. Review of R35's Immun tab of her EMR revealed an undated not eligible and an undated consent refused entry for influenza vaccines. Review further revealed an undated consent refused entry for an unspecified pneumococcal immunization. The facility did not document any history that R35 had received pneumonia vaccines in the past. Review of R35's EMR revealed no signed declinations for the pneumonia and influenza vaccines, no rationale for why R35 refused the vaccines, and no documentation that the facility provided education regarding the vaccines. During an interview on 10/03/24 at 11:06 AM, the Infection Preventionist (IP) stated the facility asked all residents and/or their representatives if they wanted the influenza vaccine (during flu season) and pneumonia vaccine. She stated the facility had consent forms for the pneumonia vaccine but did not obtain signatures for refusals. The IP stated the facility used consents for flu shots from the pharmacy who provided the vaccinations as well as from the facility, and the consents asked for a signature for consent but not for refusal. She stated the facility had a new form for the 2024-25 flu season which included a signature for declinations. The IP stated when residents declined immunizations, nursing marked consent refused for the immunization, and if the resident stated they had received a vaccine in the past, nursing marked not eligible and tried to obtain the resident's immunization history. The IP reported she followed up and ensured resident records were updated and immunizations given if requested. During an interview on 10/03/24 at 12:08 PM, the IP verified no education provided to residents who declined influenza and pneumonia vaccines would be documented in the EMR, since this information was only documented on the consent forms. During an interview on 10/03/24 at 1:30 PM, the Director of Nursing (DON) stated she expected a resident's EMR to contain the reason they declined a vaccination and to include any education provided to the resident on the benefits/risks of the vaccination. She stated staff were expected to document any history of vaccines. On 10/03/24 at 5:00 PM, the DON stated she could not locate any documentation that R3, R8, R26, or R35 had received any recent influenza or pneumonia vaccines prior to admission to the facility.

Based on observation, interview, and record review, the facility failed to honor a resident request to not have certain staff provide care for one of one resident (Resident (R)26) reviewed for self-determination out of a total sample of 28. This failure had the potential to decrease R26's quality of life. The facility census was 84. Findings include: Review of the facility policy titled, Self-Determination, revised July 2024 and provided by the facility, revealed, Each resident who chooses to reside in this facility has the right to and the facility pledges to promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified as Resident Rights . The resident has a right to choose activities, schedules including but not limited to sleeping and waking times, health care and providers of health care services consistent with his/her interests, assessments, and plan of care and other daily life enhancement enrichment activities on a daily basis. Review of R26's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 08/28/24 and located in the MDS tab of the Electronic Medical Record (EMR), revealed an admitted [DATE]. A Brief Interview for Mental Status (BIMS) showed a score of 15 out of 15, indicating the resident's cognition was intact. The MDS recorded R26 was dependent on staff and had diagnoses of anxiety, acquired absence of right leg below knee, contracture of muscle, left lower leg, and contracture of unspecified hand. Review of R26's Care Plan, dated 08/18/23 and located in the EMR under the Care Plan tab, revealed, [R26] intermittently refuses cares, treatments, and/or medications, including repeated intermittent refusals of use of low air loss mattress for prevention of skin breakdown, repeated refusals of use of longer bed to accommodate his height, repeated refusals to use hand splint. An intervention included, Allow decision making, per resident rights, about treatment regimen, to provide sense of control. Review of R26's bowel continence documentation, dated 09/06/24 and 09/27/24, located in the EMR under the Task tab, revealed Certified Nurse Aide (CNA) 2 provided personal care to R26. Review of R26's September 2024 Medication Administration Record (MAR), located in the EMR under the Order tab, revealed Licensed Practical Nurse (LPN) 4 had administered medications to R26 on 09/06/24, 09/12/24, 09/13/24, 09/17/24, and 09/25/24. On 09/30/24 at 11:12 AM, R26 was awake in bed watching television. R26 stated he felt that two staff members, CNA2 and LPN4, did not like him because they were rude and disrespectful to him. R26 stated he reported them to the state Ombudsman and other facility staff. R26 stated he had requested those staff members not to give him care but in the last two months, CNA2 had provided care to him. R26 stated CNA2 was rude, and he felt that she purposefully threw away personal things he had accidentally dropped on the floor, such as his driver's license and denture cup. During an interview on 10/02/24 at 8:05 AM, the General Manager was asked about R26's report of rude staff, a CNA and nurse. The General Manager stated, Yes, she was aware of the complaint, and the staff members had received training. The General Manager went on to say these staff members had not provided care to R26 since his complaint. The General Manager was informed that R26 stated CNA2 had provided care recently. During an interview on 10/02/24 at 9:14 AM, the General Manager provided a coaching worksheet, dated 07/18/2024, for CNA2 and 7/24/2024 for LPN4. The General Manager went on to say R26's complaints were brought up during R26's July 2024 care plan conference. The General Manager stated she completed the coaching for CNA2 on 07/18/24 and the Assistant Director of Nursing (ADON) completed the coaching for LPN4 on 07/24/24. Review of the Coaching Sheet for CNA2, dated 07/18/24 and provided by the facility, revealed Goal: What is the objective of the coaching? . Discuss customer service and appropriateness of language when talking to all patients . Reality: What is happening that needs to be corrected? . Being mindful of tone in words spoken and thinking about what you want to say before speaking . Options: What are the possible courses of action to take? . Ask for your peer CNA to switch assignments or trade patients if a disagreement . Review of the Coaching Sheet for LPN4, dated 07/24/24 and provided by the facility, revealed Goal: What is the objective of the coaching? . To provide appropriate customer service, language and tone when communicating with guests . Reality: What is happening that needs to be corrected? . Deescalating the situation, be mindful of word usage and tone . Options: What are the possible courses of action to take? . Notify nurse management ASAP [as soon as possible] have a peer nurse trade patients with you . During an interview on 10/03/24 at 9:35 AM, the General Manager was asked how she became aware R26 did not want CNA2 to care for him. The General Manager stated R26 had informed her during one of their conversations. The General Manager stated she told R26 that CNA2 would not care for him. The General Manager said she let the staffing coordinator know to keep her off his care. The General Manager was asked if she was aware CNA2 cared for R26 twice in September 2024. The General Manager stated, No, but she would have to get with the staffing coordinator who did the scheduling. During an interview on 10/03/24 at 10:56 AM, the Staffing Coordinator was asked if she was aware of R26's staff complaint. The Staffing Coordinator stated, Yes, she was aware of LPN4 for the past few months, but only found out about CNA2 on 09/27/24. The Staffing Coordinator stated CNAs can switch rooms and nurses can manage it. The Staffing Coordinator stated LPN4 could schedule another nurse to give R26 his medication. The Staffing Coordinator was asked why the MAR reflected LPN4 had signed off on R26's MAR for medication administration. The EMR was reviewed. The Staffing Coordinator stated she was not aware that LPN4 was giving R26 his medications. During an interview on 10/03/24 at 1:34 PM, the Director of Nursing (DON) was asked when she became aware of R26 not wanting CNA2 to provide care. The DON stated on 09/27/24, during his care plan conference. The DON asked if the Ombudsman came in July 2024 and reported to the facility R26's complaint about CNA2 and LPN4. The DON states the Ombudsman only reported LPN4. The DON confirmed the July 2024 coaching worksheets were completed because of R26's complaint of CNA2 and LPN4's rude behavior towards him but again she was not aware of R26's complaint of CNA2. The DON was asked why LPN4 signed off on the MAR indicating she administered medications on 09/06/24, 09/12/24, 09/13/24, 09/17/24, and 09/25/24. The DON stated she thought perhaps LPN4 was having the other nurse give the medications to the resident after LPN4 signed off on it. During a follow up interview on 10/03/24 at 4:43 PM, the General Manager was asked why the staff coordinator was unaware R26 did not want CNA2 to provide him care until 09/27/24 but the coaching occurred 07/18/24. The General Manager stated she was not sure.

Based on observation, interview, and record review, the facility failed to ensure orders for ileostomy care were in place for one of one resident (Resident (R)38) reviewed for colostomy care out of a total sample of 28. This had the potential to have a negative effect on R38's skin and quality of life. The facility census was 84. Findings include: Review of the facility policy titled, Physician's Orders, dated 11/2020 and provided by the facility revealed, All medications will be administered as ordered by a health care professional authorized by the state to order medications . Orders for treatments will include: Description of treatment including use of topical medications, Frequency of treatment, Specific precautions or directions if needed, Clinical rationale for order (indication/diagnosis). Review of the facility policy titled, Colostomy- Ileostomy Care, dated 11/2018 and provided by the facility, revealed, . 13. Document changing of colostomy bag on TAR [treatment administration record] . Review of R38's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 09/03/24 and located in the MDS tab of the Electronic Medical Record (EMR), revealed an admitted [DATE]. A Brief Interview for Mental Status (BIMS) showed a score of 15 out of 15, indicating the resident's cognition was intact. The MDS recorded R38 had diagnoses that included metabolic encephalopathy, ileostomy status, and cirrhosis of liver. Review of R38's Care Plan, dated 09/02/24 and located in the EMR under the Care Plan tab, revealed, [R38] requires the use of an ileostomy. An intervention included, Provide ostomy care as per provider's orders. Review of R38's Physician Orders, located in the EMR under the Order tab, revealed no orders for R38's ileostomy. Review of R38's Care Management Note, dated 09/03/24 and located in the EMR under the Progress Note tab, revealed, . refusing OOB [out of bed] due to nausea and dizziness and colostomy is leaking . Review of R38's September and October 2024 TAR, located in the EMR under the Order tab, revealed the last time R38's ileostomy wafer and bag were documented as being changed was 09/08/24. On 09/30/24 at 10:58 AM, R38 was observed in bed awake watching television wearing a hospital gown. R38 stated she did not get out of bed much because her colostomy leaked. R38 stated she wore a hospital gown because it made it easier to clean up the leaks. On 10/02/24 at 8:35 AM, R38's wound on her abdomen was observed. A Nurse Practitioner (NP) removed the dressing, R38's ileostomy skin barrier was noted about one inch from the wound. Fecal matter was noted under the ileostomy skin barrier. As the Assistant Chief Nursing Officer (ACNO)2 measured the wound, she confirmed the fecal matter. During an interview on 10/02/24 at 8:42 AM, the NP was asked about the fecal matter and R38's complaint about feces leaking into wound during a prior interview. The NP confirmed the feces leaking would negatively impact the wound healing. The NP was asked if there should be ileostomy care orders, and the NP stated, Yes. The NP then reviewed the EMR and confirmed there were no orders for ileostomy care. The NP asked the Director of Nurse (DON) and ACNO2 what happened to the orders. The DON stated, Sometimes they drop off when she [R38] is sent to the hospital. During an interview on 10/03/24 at 2:41 PM, ACNO2 was asked about R38's ileostomy orders. ACNO2 stated R38 had gone to the hospital a few times lately and the orders dropped off. ACNO2 stated, The admission nurse should be checking the orders to ensure it's there.