Every finding on record at Independence Manor Care Center

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. Additionally, the facility staff failed to cleanse hands during medication pass, failed to clean shared equipment during medication pass, and failed to cleanse hands during meal service for one supplemental resident, (Resident #18) out of 12 sampled residents and seven supplemental residents. The facility census was 44 residents with a licensed capacity for 99 residents at the time of the survey. 1. Observation on 12/8/25 between 8:57 A.M. and 9:41 A.M during the initial facility Life Safety Code (LSC) kitchen inspection with the Dietary Manager (DM) showed there was a sanitizing-sink area, a chemical dish-washing machine, a hand-washing sink, and a steam table (also referred to as a hot food table, is specifically designed to hold food at steady, safe serving temperatures, and not designed to cook or warm foods from a raw state). Observation on 12/9/25 between 9:27 A.M. and 1:33 P.M. during the initial facility LSC walk-through inspection with the Maintenance Supervisor (MS) showed the following:-The city municipal water main supply entered the facility through a 4-inch main pipe in their east Mechanical Room.-The building was equipped with a complete fire sprinkler system with sprinkler heads located throughout the facility and a riser room (a fire sprinkler riser room is a dedicated space for fire protection equipment situated on an outside wall at grade with direct exterior access) located inside the Maintenance Office.-There was an ice machine room located just north of the front east nurse's desk.-Public restrooms were located by the front reception office hall with an additional employee restroom west of the east nurse's desk.-A medication room with sink was located behind each of the two separate nurse's desks.-There were housekeeping closets with floor mop sinks or ceramic service sinks (mop/service sinks are used in janitorial and maintenance areas to fill and empty mop buckets, clean mops, and dispose of dirty water), eyewash stations, two boilers, hot water storage tanks, a re-circulation pump, and hot/cold water piping throughout the five facility hallways.-There were at least 40 resident rooms with private and/or shared bathrooms and sinks throughout the four resident hallways.-There were two commercial clothes washers in the laundry area.-There were at least 3 shower rooms in the facility. Review of the facility's water-borne pathogen prevention program paperwork from a contracted source, in a binder entitled Legionella & Water Safety Program, dated 2/8/24 last Reviewed and Implemented 12/15/23 and provided by the MS, showed the following:-The initial introductory section containing a list of general definitions from the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standard 188 stated on the bottom of each page that the program expired on 2/1/25.-In the 13-page Environmental Assessment of Water Systems section the questions at A.14, B.3, C.6, C.9, C.10, D.1, D.2, D.3, and pages 9 through 13 were left blank.-On a page with the heading ERRATA (a list of errors in a printed work) that addressed ASHRAE 6.2.8, was five uncompleted sections, but documentation of a facility-specific risk assessment that considered the ASHRAE industry standard #188 was not found. -There was a diagram of the facility's water system with specific potential risk areas of growth within the building, but no assessments of each individual area's potential risk level were included.-A few pages had procedures for different control measures, but no documentation of any having been done.-There was no documentation included of any site log book being maintained with any dated cleanings, sanitizing, descaling, and inspections mentioned.-There was a 46-page educational PowerPoint section with one slide per page and lines underneath for the reviewers' names and/or initials and any handwritten notes, comments, questions, or concerns, all left blank. Review of a second, similar, updated version of the facility's water-borne pathogen prevention program paperwork from the same contracted source, entitled Water Management Plan, dated 3/15/25 and provided by the MS, showed the following:-After the Contents page there were 6 educational pages containing an Overview, 3 pages of definitions, a General Requirements list, and the names of the 3-person program team.-No signed and dated review page by their program team was found.-16 pages of numerous control measures to perform on various systems, components, and locations had overviews of each measure's task, a detailed explanation of that task (some with specific measurements to be taken with reading range parameters), and corrective measures to be initiated if results were unsatisfactory, but no documentation of any of the tasks having been performed. During an interview on 12/10/25 at 1:12 P.M. the Maintenance Supervisor said the following:-He/She was responsible for their water management plan.-They would take water temperatures and send samples to a lab for Legionella testing. -The 2nd section he/she provided was just not yet put with the first paperwork. During an interview on 12/12/25 at 1:33 P.M. the Administrator said the following:-They are supposed to have a committee that is responsible for the water management plan, but the MS oversees it. -The second section provided was not initially with the first because with the MS had two separate binders and it was not updated. -He/She had sat down and went through the assessments with the MS as best they could.-He/She did not think the MS had ever really grasped what the program is, what it requires, and how it works. 2. Review of the facility's policy, Handwashing/Hand Hygiene, dated August 2019 showed:-Staff was to use alcohol-based hand rub or soap and water for the following situations:-Before preparing or handling medications.-Before and after assisting a resident with meals. Review of the facility's policy, Infection Prevention and Control Program, dated 5/12/23 showed:-All staff were responsible for the following policies:-All reusable items and equipment requiring special cleaning shall be cleaned in accordance with current procedures.-Masks; clean daily by placing in warm, soapy water and soaking/agitating for five minutes. Mild dish detergent was recommended.-Rinse with warm water and allow it to air dry between uses. Review of the facility's policy, Assistance with Meals, dated July 2017 showed:-Facility Staff would serve resident trays and would help resident who require assistance with eating.-All employees who provide resident assistance with meals would have been trained and should demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. 3. Observation on 12/10/25 at 8:42 A.M. with Certified Medication Technician (CMT) B of the medication pass showed:-He/She took a pair of scissors out of the medication cart, used the scissors to cut open a medication package without cleaning them first.-He/She returned the scissors to the medication cart without cleaning them.-He/She went into Resident #38's room to administer the medication. -He/She did not cleanse his/hands after administering the medication patch to the resident.-He/She went into Resident #10's room to administer medications to the resident. -He/She took the resident's blood pressure, per physician's order before administering a blood pressure medication.-He/She assisted the resident to drink a cup of water while swallowing the medications.-He/She opened the resident's milk carton and assisted the resident to drink milk.-He/She put the resident's medication in pudding and assister him/her to eat the pudding.-He/She did not cleanse his/her hands after administering the medication and assisting the resident to drink.-He/She did not sanitize the blood pressure cuff after using it. During an interview on 12/10/25 at I 0:02 A.M. CMT B said:-The blood pressure cuff was used on several residents during the medication pass.-The blood pressure cuff should have been sanitized daily. -Staff should cleanse their hands before and after the medication pass, not after each resident.-The night Certified Nursing Assistant (CNA) cleaned the scissors.-He/She had received education on hand washing from the Director of Nursing (DON). 4. Review of Resident #18's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Dementia (a decline in mental ability severe enough to interfere with daily life, involving memory loss, thinking problems, reasoning issues, and personality changes).-Transient ischemic Attack (TIA- a temporary blockage of blood flow to the brain with stroke- like symptoms).-Convulsions (sudden, involuntary muscle contractions, causing uncontrolled shaking or stiffening). Muscle weakness. Review of the resident's comprehensive care plan dated 9/8/25 showed:-He/She was severely cognitively impaired.-Needing assistance with eating was not checked. Review of the resident's undated care plan showed the resident required assistance of one staff member to eat. Observation of meal service on 12/8/25 at 12:54 P.M. with CNA B showed:-He/She was assisting the resident with his/her lunch meal.-A resident across the table complained the sun was too bright coming through the window.-CNA B got up from the table to pull the curtain shut.-He/She did not cleanse his/her hands before returning to the table to assist the resident with his/her meal.-He/She moved a different resident's plate and feed that resident with his/her right hand.-He/She resumed assisting the resident with his/her right hand without cleansing his/her hand.-He/She readjusted his/her pants with both hands then resumed feeding the resident without cleansing his/her hands.-He/She readjusted his/her hair then resumed feeding the resident without cleansing his/her hands. During an interview on 12/8/25 at 1:02 P.M. CNA B said:-During meal service you should wash your hands before and after feeding the resident.-If you are between two residents you can feed them with separate hands.-If you touch anything besides the silverware for that resident you should cleanse your hands.-The DON had provided education on hand washing. During an interview on 12/10/25 at 10:02 A.M. CMT B said:-The DON has provided education on hand washing.-Staff should wash their hands before and after feeding each resident.-If you touched curtains, touched your pants, or touched your hair, you should have washed your hands or used hand sanitizer.- You should only feed one resident at a time and wash your hands after feeding them. During an interview on 12/10/25 at 1:45 P.M. License Practical Nurse (LPN) B said:-During meal service when assisting a resident to eat staff should cleanse their hands with soap and water or hand sanitizer before and after assisting the resident.-Staff should cleanse their hands if they touch anything other than the resident's silverware.-If staff touched curtains, their clothing, or their hair they should have cleansed their hands before continuing to feed the resident.-lf staff was feeding two residents they would use one hand to feed a resident and the other hand to feed the second resident, never use the same hand to feed both residents.-The DON has provided education about infection control measures upon hire, annually, and almost monthly and preformed spot checks to ensure staff was following the guideline. During an interview on 12/15/25 at 11:00 A.M. the DON said: -During meal service when assisting a resident to eat staff should cleanse their hands with soap and water or hand sanitizer before and after assisting the resident to eat.-Staff should cleanse their hands if they touch anything other than the resident's silverware.-If staff touched curtains, their clothing, or their hair they should have cleansed their hands before continuing to feed the resident.-If staff was feeding two residents, they would use one hand to feed a resident and the other hand to feed the second resident, never use the same hand to feed both residents.-He/She was also the Infection Preventionist and has provided education about infection control measures upon hire, annually, almost monthly and preformed spot checks to ensure staff was following the policies. -He/She was ultimately responsible for ensuring staff was following infection control measures.

Based on observation, interview, and record review, the facility failed to ensure staff were cleaning Continuous Positive Airway Pressure (CPAP- a machine to deliver pressurized air through a mask to keep airways open during sleep)/Bilevel Positive Airway Pressure (BiPAP - a machine that delivers two pressure levels of air-a higher one for inhaling and a lower one for exhaling through a mask) masks daily for three sampled residents (Resident# 33, # 35, and # 41), failed to ensure the resident's distilled water (water that has been purified) used in respiratory equipment was stored in a sanitary manner for two sampled residents (Resident #35 and #33), out of 12 sampled residents The facility census was 44 residents. Review of the facility's policy, CPAP/BiPAP Support dated March 2015 showed: -Machine cleaning; wipe machine with warm, soapy water and rinse at least once a week and as needed.-Humidifier; use clean distilled water only in the humidifier chamber.-Clean humidifier weekly and air dry.-To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly.Review of the facility's policy, Infection Prevention and Control Program, dated 5/12/23 showed:-All reusable items and equipment requiring special cleaning shall be cleaned in accordance with current procedures.-Masks; clean daily by placing in warm, soapy water and soaking/agitating for five minutes. Mild dish detergent was recommended.-Rinse with warm water and allow it to air dry between uses.1. Review of Resident #41's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Obstructive Sleep Apnea (a serious sleep disorder where breathing repeatedly stops and starts, most commonly due to airway blockage).Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning), dated 11/25/25 showed:-CPAP was not checked. -He/She was moderately cognitively impaired.Review of the December 2025 Physician's Order Sheet (POS) showed:-He/She had Sleep Apnea.-Did not show an order for CPAP or how to clean the machine or mask. Review of the resident's Care Plan dated 12/5/25 showed:-He/She had Sleep Apnea.-Did not show the resident used a CPAP machine. Observation and interview with the resident on 12/8/25 at 9:11 A.M. showed:-His/Her CPAP mask was sitting on the nightstand, not in a bag, not dated.-The CPAP mask had a light brown tinge around the perimeter of the mask.-The resident said he/she used the CPAP at night.-The resident did not know when the staff last cleaned the respiratory equipment last.Observation on 12/9/25 at 10:02 A.M. showed:-His/Her CPAP mask was sitting on the nightstand, not in a bag, not dated.-The CPAP mask had a light brown tinge around the perimeter of the mask.Observation on 12/10/25 at 11:07 A.M. showed:-His/Her CPAP mask was sitting on the nightstand, not in a bag, not dated.-The CPAP mask had a light brown tinge around the perimeter of the mask.2. Review of Resident #35's face sheet showed he/she was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a progressive lung disease that makes breathing difficult).Review of the resident's quarterly MDS dated [DATE] showed:-Used a CPAP was not checked. -He/She was cognitively intact.Review of the resident's December 2025 POS showed the following order:-CPAP at bedtime, dated 10/2/25. -The physician's orders did not include how or when to care for the mask.Review of the resident's care plan dated 10/2/25 showed he/she used a CPAP for Sleep Apnea.Observation and interview on 12/8/2025 at 10:43 A.M. showed:-His/Her CPAP mask was hanging over the headboard.-There was no bag for storage.-The CPAP had a compartment for distilled water for humidification which was half full. -There was an opened gallon jug of distilled water sitting on floor without an opened date on it.-He/She said the distilled water was used in the CPAP machine.-He/She said the staff cleaned the CPAP mask maybe a week or so ago.-He/She was not sure when they had cleaned the CPAP machine itself.-He/She said the distilled water jug was opened and staff sat it on the floor.Observation on 12/9/25 at 1:50 P.M. showed the jug of distilled water was sitting on the floor, opened with no date written on it and the CPAP mask was dangling from the headboard between the mattress and the bedframe touching both.3. Review of Resident #33's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-COPD.-Sleep Apnea.Review of the resident's care plan dated 11/3/25 showed:-He/She was on CPAP therapy related to Sleep Apnea.-He/She would adhere to the CPAP therapy.Review of the resident's quarterly MDS, dated [DATE] showed:-He/She was cognitively intact.-Use of a CPAP was not checkedReview of the December 2025 POS showed the following orders:-Check that there was sterile water in the bottle for humidified air every shift, change and date as needed, every shift.-Change Non-Invasive Ventilator hose (NIV- a breathing support method that delivers air through a mask instead of an invasive tube) every two weeks (this is a BIPAP- Bilevel Positive Airway Pressure machine which delivers two pressure levels of air a higher one for inhaling and a lower one for exhaling). Review of the resident's December 2025 Treatment Administration Record (TAR) did not show a place for the staff to document adding sterile water or for cleaning the hose.Observation and interview on 12/10/25 at 8:42 A.M. showed:-The residents CPAP mask was sitting on his/her nightstand, not in a bag, no date on it.-The CPAP machine had a reservoir for water, it was 3/4 full. -The gallon jug of distilled water was opened, had no lid, and was sitting on the floor.-The distilled water did not have a date that it had been opened written on it.-The resident said staff might clean the CPAP mask weekly.-The distilled water was used in his/her CPAP machine.During an interview on 12/10/25 at 1:45 P.M. License Practical Nurse (LPN) B said:-Resident should have had a physician's order for a CPAP and how to care for it, if they were on one. -There should have been documented in the residents' care plan and in their MDS that they used a CPAP/BiPAP machine.-He/She did not know where it would have been documented maybe on the TAR, and it was not.-CPAP mask should have been cleaned daily by nursing staff using soap and water.-After the CPAP mask was dry it should have been store in a clean bag with the date written on the bag with the date it was that it had been cleaned. -The CPAP mask should not have been hanging off the headboard or sitting on a nightstand.-Distilled water was kept in the resident's room.-After the distilled water was opened the staff should have written the date the water had been opened on it. -Distilled water should not have been sitting on the floor.-There should have been a lid for the opened distilled water. If it did not have a lid should have been discarded. -The nursing staff was responsible for ensuring respiratory equipment was cleaned and dated.-The Director of Nursing (DON) has provided education about infection control measures upon hire, annually, and almost monthly and preformed spot checks to ensure staff was following the guideline.During an interview on 12/15/25 at 11:00 A.M. the DON said: -CPAP mask should have been cleaned daily by nursing staff using soap and water, air dried, then put in a bag.-After the CPAP/BiPAP mask was dry it should have been store in a clean bag with the date written on the bag that it had been cleaned. -There should have been a physician's order for a resident to use the CPAP with instructions when and how to clean it. -The nurse who took the order was responsible for instructions on how to care for it. -If a resident had an order for a CPAP, then it should have been included in the MDS and care plan.-There should have been a physician's order for the CPAP.-Staff were not documenting when it was cleaned currently.-The CPAP mask should not have been hanging off the headboard or sitting on a nightstand.-After the distilled water was opened the staff should have written the date the water had been opened on it.-Distilled water should not have been sitting on the floor.-There should have been a lid for the opened distilled water. If it did not have a lid the distilled water should have been discarded.-Staff should have documented when equipment such as the CPAP or BiPAP mask were cleaned on TAR.-He/She was responsible for ensuring staff was cleaning the equipment and documenting that it was done. -He/She was also the Infection Preventionist and has provided education about infection control measures upon hire, annually, almost monthly and preformed spot checks to ensure staff was following the policies.

Based on interview and record review, the facility failed to notify two out of three sampled residents (Residents #12 and #14) sampled for funds that receive Medicaid (program that helps with medical costs for some people with limited income and resources) benefits when the amount in the residents' accounts reached $200 less ($5,868.80) than the Supplemental Security Income (SSI) resource limit (the maximum value of assets an individual or couple can own and still be eligible for benefits) resource limit for one person ($6,068.80) and notify them that they may lose eligibility for Medicaid or SSI if they reached the SSI limit for one person. The facility census was 44 residents.Review of the facility's policy titled, Accounting and Records of Resident Funds dated 2001 showed:-A representative of the business office was responsible for informing the residents:--If the balance in their personal funds account reached $200 less than the residents' SSI limit.--If the amount in the account reached the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.1. Review of Resident #14's census in the Electronic Health Records (EHR) showed the resident's primary payer source was Medicaid.Review of the resident's quarterly trust statements for 2025 showed:-An ending balance on 3/31/25 of $8,496.62.-An ending balance on 6/30/25 of $8,296.84.-An ending balance on 9/30/25 of $8,359.92Review of the Resident Trust current account balance dated 12/8/25 showed the resident had a balance of $8,285.31, which was $2,416.51 over the notification requirement limit.During an interview on 12/12/25 at 2:15 P.M., the resident said he/she did not know until today that he/she was over the SSI limit.2. Review of Resident #12's census in the EHR showed the resident's primary payer source was Medicaid.Review of the resident's quarterly trust statements for 2025 showed:-An ending balance on 3/31/25 of $6,108.95.-An ending balance on 6/30/25 of $6,069.02.-An ending balance on 9/30/25 of $6,141.99.Review of the Resident Trust current account balance dated 12/8/25 showed the resident had a balance of $6,210.20, which was $341.40 over the notification requirement limit.During an interview on 12/12/25 2:27 P.M., the resident said no one told him/her he/she was over the SSI limit and that he/she didn't know what it meant.3. During an interview on 12/12/25 at 9:42 A.M., the Business Office Manager said:-He/She had not sent any notifications regarding any residents reaching $200 less than the SSI resource limit for one person.-He/She was not aware that he/she had to provide notification when residents reached $200 less than the SSI resource limit.

Based on observation, interview and record review, the facility failed to review and revise resident care plans (a comprehensive, person-centered document detailing how a facility will meet a resident's medical, nursing, mental, and psychosocial needs) to include resident behaviors for one sampled resident (Resident #13) and/or have an correct diagnosis for ordered psychotropic (medication that affects a person's mental state) for one sampled resident (Resident #4) out of 12 sampled residents. The facility census was 44 residents.Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated December 2016, showed:-A comprehensive, person-centered care plan that included measurable objectives to meet the residents psychosocial (a person's mental, emotional, social, and spiritual well-being) was developed and implemented for each resident.Review of the facility's Behavioral Health Services policy, dated February 2019, showed:-Residents who exhibited signs of emotional/psychosocial distress received services and support that addressed their individual needs and goals for care.-The care plan included:--Measurable objectives.--Incorporate identified problem areas.--Incorporate risk factors associated with identified problems.--Reflect treatment goals, timetables and objectives in measurable outcomes.--Identify problem areas and their causes and develop interventions that are targeted and meaningful to the resident.1. Review of Resident #13's Face Sheet, undated, showed:-The resident was diagnosed with:--General anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed).--Bipolar disorder (a mental health condition causing extreme mood swings).--Schizophrenia (a disorder causing abnormal thinking, perception, and behavior, where people struggle to tell what's real from imagination).Review of the resident's admission Minimum Data Set (MDS- a comprehensive assessment tool used by nursing homes to care for residents' health, function, diagnoses, treatments, and needs), dated 12/13/24, showed the resident was severely cognitively impaired.Review of the resident's care plan dated 9/16/25, showed:-The resident had impaired thought processes related to dementia, schizophrenia. -There were no goals or interventions related the residents' behaviors regarding his/her baby dolls.Observations on 12/08/2025 from 10:49 A.M. to 11:28 A.M. the resident showed mild aggression toward other residents on three occasions who attempted to touch, take or move the four baby dolls on the table in front of him/her. The resident snatched the baby doll away from the other resident who was reaching for the baby doll but did not touch it. 2. Review of resident #4's face sheet, undated, showed:-The resident was diagnosed with:--Depression (a mood disorder causing persistent sadness and loss of interest in activities).--Insomnia (a sleep disorder making it difficult to fall asleep and stay asleep).Review of the resident's quarterly MDS, dated [DATE], showed the resident was severely cognitively impaired.Review of the resident's care plan, dated 10/17/25, showed the resident used antidepressant medication Trazodone (a prescription antidepressant medication) related to depression. Review of the resident's Physician Order Summary, dated December 2025, showed the resident was ordered:-Trazodone Oral Tablet 100 milligrams (MG-a unit of measure); give half tablet by mouth at bedtime for insomnia.3. During an interview on 12/15/2025 at 8:35 A.M., Certified Medication Technician (CMT) A said:-Resident #13 had some behaviors, mainly around the baby dolls.-He/She did not like anyone else to have the baby dolls.-Usually we just redirected him/her, or we redirected the other residents. -He/She was very possessive of the dolls.-He/She was not physically aggressive with the dolls or with other residents, because we were able to redirect before anything escalated.-He/She was unsure if there were interventions in the resident's care plan.-Resident #4's family was very particular about what psychiatric medications the resident was taking.-He/She was on trazodone for depression also.During an interview on 12/15/2025 at 9:02 A.M., Certified Nursing Assistant (CNA) A said:-Resident #4 had behaviors all the time surrounding the baby dolls.-He/She got very anxious at times.-He/She did not like other residents around the baby dolls.-We tried to calm him/her down, move him/her away from the situation, move the other person away from him/her.-There are also extra baby dolls which were offered to the other residents.-He/she was unsure what was in the resident's care plan.-Resident #4 had no behaviors, he/she stayed mostly in his/her room.-He/She doesn't sleep well.-He/She was unaware of what the resident was diagnosed with or what meds they were taking.During an interview on 12/15/2025 at 9:16 A.M., Licensed Practical Nurse (LPN) A said:-Resident #13 had some behaviors when providing cares and around the baby dolls.-He/She was possessive over the baby dolls.-Staff try to redirect the resident or redirect the other residents. -Staff distracted the other residents with other dolls or other items.-It should be care planned, but not sure if it was.During an interview on 12/15/2025 at 10:33 A.M., CMT B said:-Resident #4 loved his/her baby dolls.-He/She was very possessive over the dolls.-The staff were aware of the issues and kept a close eye on the resident.-If other residents tried to get on of the dolls the staff would redirect them or redirect the resident.-Resident #4 had mood swings but was not aggressive.-The resident saw the psychiatrist, but the family was not wanting the resident on a lot of medications.During a follow up interview on 12/15/2025 at 10:46 A.M., LPN A said:-Resident #4 had hallucinations but did not get physical.-He/She was easily redirected.-Interventions in the care plan were to redirect the resident. -The resident's family preferred not to have multiple anti-psychotic medications.-He/She was ordered Trazodone for depression, his/her family was aware and approved it.During an interview on 12/15/2025 at 1:35 P.M., the Administrator said:-Resident #4 was taking Trazodone for insomnia.-The resident's family was very picky about what anti-psychotic medications the resident was taking.-The resident had dementia and insomnia.-The physician orders said the Trazodone was for insomnia.-The care plan should match what the physician orders said.-Resident #13 liked his/her baby dolls and was possessive of them.-He/She was not aggressive toward other residents but did not like other residents to have them.-It should probably be care planned.

Based on observation, interview and record review, the facility failed to provide the ability to listen to books for one sampled resident (Resident #22) who had severely impaired vision and loved to read out of 12 sampled residents. The facility census was 44 residents. Review of the facility policy titled, Activity Programs dated 2001 showed:-Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well being of each resident.-Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.-The activities program is ongoing and includes facility-organized group activities, independent individual activities, and assisted individual activities.-The activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs.-The activity programs consist of individual, small group and large group activities that are designed to meet the needs and interests of each resident. -All activities are documented in the resident's medical record.1. Review of Resident #22's admission Record printed 12/12/25 showed:-The resident admitted to the facility on [DATE].-Some of the resident's diagnoses included a stroke, major depressive disorder (depressed mood most of the day and a loss of interest in normal activities and relationships), and dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes).Review of the resident's dependency on staff care plan dated 3/1/23 showed:-The problem identified was that the resident was is dependent on staff for meeting emotional, intellectual, physical and social needs related to dementia and multiple comorbidities.-The desired outcome included the resident would maintain involvement in cognitive stimulation and social activities as desired.-Interventions included:--Providing activities that are compatible with known interests, abilities, needs, and preferences and to adapt as needed (such as large print, holders if resident lacks hand strength, task segmentation).--Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary.Review of the resident's vision impairment care plan dated 3/1/23 showed:-The problem identified was that the resident impaired visual function related to bilateral cataracts (a clouding of the eye's natural lens, usually due to aging, which makes vision blurry, hazy, or less colorful).-The desired outcome included showing no decline in visual function.-Interventions included did not include adaptive equipment related to reading.Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/13/24 showed the resident was cognitively intact and reading was not very important to him/her.Review of the resident's care plan meeting dated 9/11/25 showed:-The resident had a diagnosis of dementia.-The resident was on an antidepressant medication for depression and ineffective coping related to long-term nursing home placement.-The resident had cataracts. -The resident had a stroke in 2023.Review of the resident's quarterly MDS dated [DATE] showed the resident was severely cognitively impaired.Review of the resident's activity assessment dated [DATE] showed:-The resident participated in bingo, a variety of games, food activities, exercise, outside activities, listening to music, watching television and movies, church services and sing along hymns.-It did not include anything related to reading or books.-It did not identify that activities should be modified to address his/her visual deficit.Review of the resident's Documentation Survey Reports dated October 2025, November 2025 and December 2025 through 12/12/25 showed audio books were not provided for the resident.During an interview on 12/8/25 at 10:01 A.M., the resident became tearful and said:-He/She had a big house and a library full of books that he/she loved to read.-He/She had had a stroke and was not able to read books anymore. -He/She was trying to be satisfied with his/her life at the nursing home, but he/she missed reading. -The facility did not have audio books that he/she could listen to. -He/She had not heard about an electronic reader.-He/She did not know if he/she had money to pay for an electronic reader but would very much like to have one. -His/Her daughter is his/her guardian and handles his/her money.-No one at the facility has asked her about his/her audio books or an electronic reader.Observation and interview on 12/10/25 at 12:06 P.M. showed:-The resident sitting at a table in the dining room, not participating in any activity.-The resident was not wearing glasses. -The resident said he/she would love to listen to audio books.-The Activities staff member had not asked him/her about audio books.During an interview on 12/12/25 at 12:51 P.M., the Activities Manager said the reason reading was marked as not very important to the resident on the MDS was because the resident could not see well.During an interview on 12/15/25 at 9:09 A.M., the Administrator said:-The resident should have been evaluated for his/her interest in activities. -They had a book club where the Activity Director would read aloud a chapter of a book to the residents a couple of times a week.-The Activity Director that was doing the reading quit and nothing was done for the resident since then related to reading. -There was another resident who listened to audio books from the public library who had passed away. They sent the audio books and audio machine back to the library. -The new Activity Director should have gotten an audio book player and audio books from the library for the resident, but they had not. -The resident has ample funds and could have purchased an electronic reader and that has not been done. -They should have done something for the resident to read books to him/her. During an interview on 12/15/25 at 10:30 A.M., the Activities Manager said:-They should have gotten audio books and an audio book reader for the resident from the library because it was free. -He/She was aware that the resident could not see.-He/She was not aware the resident wanted to listen to audio books. -He/She had not asked the resident if he/she would like the audio books from the library or an electronic reader and he/she should have.

Based on observation, interview and record review, the facility to ensure appropriate dental care when the facility failed to provide routine dental services to one sampled resident (Resident #13) out of 12 sampled residents. The facility census was 44 residents.Review of the facility's Availability of Services, Dental policy, dated August 2007, showed:-Oral healthcare and dental services were provide to each resident.-A list of available dentists was posted at each nurses' station.-A copy of the list was available from Social Services department.-Social services was responsible for making necessary dental appointments.-All requests for routine and emergency dental services were directed to the Social Services Department to assure appointments were made in a time manner.-Inquiries concerning the availability of dental services was referred to the Social Services Department of to the Director of Nursing (DON).1.Review of the resident's Face Sheet, undated, showed:-The resident was diagnosed with diabetes (a chronic condition where the body can't properly use or produce insulin, leading to high blood sugar), age related osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue) and need for assistance with personal care.Review of the resident's admission Minimum Data Set (MDS- a comprehensive assessment tool used by nursing homes to care for residents' health, function, diagnoses, treatments, and needs), dated 12/13/24, showed:-The resident was severely cognitively impaired.-The resident had no natural teeth or tooth fragment. -The resident had no obvious cavity or broken natural teeth.Review of the resident's quarterly MDS dated [DATE], showed:-The resident had no mouth or facial pain.-The resident had not difficulty chewing.Review of the resident's Care Plan (a plan that outlined specific health needs, preferences, goals, and actions taken to meet care needs), dated 9/16/25, showed the resident was totally dependent on staff for personal hygiene and oral care.Review of the residents Physician Order Summary, dated December 2025, showed there were no orders for dental care.Observation on 12/08/2025 at 9:16 A.M., showed:-The resident was in the common area. -He/She was sitting at a table in his/her wheelchair.-His/Her teeth were noted to be discolored with several missing teeth.During an interview on 12/08/2025 at 11:19 A.M., the resident's family member said:-He/She lived out of state and was unable to visit the resident frequently.-He/She was aware of missing teeth but was not made aware of any issues.-He/She stated he/she would follow up with the facility to be sure the resident received dental care.During an interview on 12/15/2025 at 8:35 A.M., Certified Medication Technician (CMT) A said:-He/She was unsure if the resident had seen a dentist.-The resident's family took her out for appointments, but not sure if that was for a dental visit. -He/She helped the resident brush his/her teeth every morning shift and evening if he/she was working.-He/She was unsure if the resident had decay or discoloration.-The resident had no complaints about mouth pain. During an interview on 12/15/2025 at 9:02 A.M., Certified Nursing Assistant (CNA) A said:-The aides helped the resident brush his/her teeth.-Usually, the night staff did it before the day shift came on.-The night shift also brushed his/her teeth at night before bed. -The resident had no complains about pain in mouth.-He/She was unsure if the resident saw the facility dentist.During an interview on 12/15/2025 at 9:16 A.M., Licensed Practical Nurse (LPN) A said:-The aides attempted to help brush the resident's teeth. -The resident was non-compliant, and she bit down on the toothbrush.-He/She was unsure if the resident saw the facility dentist. -We told the Social Services Designee (SSD) who needed to see the dentist and the Social Worker put the residents on a list to be seen. During an interview on 12/15/2025 at 10:25 A.M., the SSD said:-The dentist came to the facility and saw residents.-He/She let the dentist know who needed to be seen.-When he/she met the residents during admission he/she asked when they need to see the dentist.-He/She asked each resident again during care plan meetings.-The family and nursing staff were good about letting him/her know which memory care residents needed to be seen.-The resident had not been seen in a little while.-The resident had been here a couple of years.-There were no notes from the dentist showing if he/she had seen the resident. -He/She was unaware if the resident went out to the dentist.During an interview on 12/15/2025 at 1:35 P.M., the Administrator said:-He/She was unaware of the resident having any dental issues or mouth pain.-There is no record of the resident seeing the facility dentist.-He/She was unaware if the resident saw an outside dentist.-No staff or family members mentioned concerns about his/her teeth. -He/She would expect all resident's to receive required dental care.

Based on observation, interview and record review, the facility failed to store food in a manner that prevented the potential of foodborne illnesses by not dating food wrappers and containers after they were opened; by failing to document refrigerator and freezer temperatures; and by not documenting prepared hot food temperatures prior to serving to residents. The facility census was 44 residents.Review of the facility's Preventing Foodborne Illness - Food Handling policy, dated July 2014, showed:-Food was stored, prepared, handled and served so that the risk of foodborne illness was minimized.-Functioning refrigeration was monitored at designated intervals throughout the day and documented.Review of the facility's Food Preparation and Service policy, dated November 2022, showed:-Food and nutrition service employees prepared, distributed and served food in a manner that complied with safe food handling practices.-Potentially hazardous food or time/Temperature controlled for safety food required time/temperature control and monitoring.1.Observation on 12/08/25 at 9:23 A.M., showed two items in the reach-in cooler that had been opened and not labeled with an open date:-One gallon container of whole milk.-One pitcher of a beverage resembling apple juice.Observation on 12/08/25 at 9:30 A.M., showed two items in the dry storage area that had been opened and not labeled with an open dated:-One 12 count bag of flour tortilla shells with eight shells inside.-One opened bag of marshmallows dated 10/15, next to seven unopened bags of marshmallows with the same date.Review of the three-door fridge temperature log on 12/10/25 at 10:32 A.M. showed:-Evening shift temps were not taken on 12/9/25.-Morning shift temps were not taken on 12/10/25. Review of the two-door refrigerator temp log on 12/10/25 at 10:32 A.M. showed:-Evening shift temps were not taken on 12/9/25.-Morning shift temps were not taken on 12/10/25. Review of the freezer temp log on 12/10/25 at 10:32 A.M. showed:-Evening shift temps were not taken on 12/9/25.-Morning shift temps were not taken on 12/10/25. Review of the hot food temp log 12/10/25 at 10:32 A.M. showed:-Lunch meal temps were not taken on 12/9/25.-Morning meal temps were not taken on 12/10/25. During an interview on 12/10/25 at 9:15 A.M., the Head [NAME] said:-He/She checked the food temperatures for morning and noon meals.-He/She checked temps when food was put on the steam table and before it was served to the residents.-He/She checked fridge and freezer temperatures in the morning. -The evening crew checked them on their shift.-The temps were documented on the log hanging on the door of the units.During an interview on 12/10/25 at 9:38 A.M., the Dietary Manager said: -He/She or the staff monitored and recorded the refrigerator and freezer temps daily. -Temperatures were recorded on the log on outside of fridge.-The person cooking was responsible for temping the food.-He/She expected any opened food to have a label showing the date the package was opened.-The tortillas should have been dated when opened.-The marshmallows should have been dated more clearly.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) worked for eight consecutive hours per day, seven days a week for four or more days for the previous four quarters of the last fiscal year July 2022 through June 2023 and from November 16, 2023, through December 4, 2023, for this survey look back. The facility census was 54 residents. Review of the facility's Nursing Services-RN policy dated 11/23/2022 showed: -It was the intent of the facility to comply with RN staffing requirements. -The facility would utilize the services of a RN for at least eight consecutive hours per day seven days per week. -The facility would designate a RN to serve as the Director of Nursing (DON) on a full-time basis. -The DON may serve as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. -The facility was responsible for submitting timely and accurate staffing data through the Centers for Medicare and Medicaid Services (CMS) Payroll-Based Journal (PBJ) system. 1. Review of the PBJ of the fiscal year of quarter 4 of 2022 (July 1-September 30) showed no eight-hour consecutive RN coverage the following dates: -Three days in July: --Thursday 7/7/22. --Friday 7/8/22. --Thursday 7/24/22. -Three days in September: --Saturday 9/3/22. --Sunday 9/4/22. --Friday 9/30/22. Review of the PBJ of the fiscal year of quarter 1 of 2022 (October 1 through December 31) showed no eight-hour consecutive RN coverage the following dates: -Six days in October 2022: --Saturday 10/8/22. --Monday 10/17/22. --Tuesday 10/18/22. --Friday 10/21/22. --Saturday 10/22/22 --Sunday 10/23/22. -Four days in November 2022: --Friday 11/4/22. --Monday 11/7/22. --Saturday 11/26/22. --Sunday 11/27/22. -Six days in December 2022: --Saturday 12/10/22. --Sunday 12/11/22. --Friday 12/16/22. --Saturday 12/24/22. --Sunday 12/25/22. --Saturday 12/31/22. Review of the PBJ of the fiscal year of quarter 2 of 2023 (January 1-March 31) showed no eight-hour consecutive RN coverage the following dates: -Five days in January 2023: --Sunday 1/1/23. --Saturday 1/7/23. --Sunday 1/8/23. --Saturday 1/21/23. --Sunday 1/22/23. -Four days in February 2023: --Saturday 2/4/23. --Sunday 2/5/23 --Saturday 2/18/23. --Sunday 2/19/23. -Eight days in March 2023: --Saturday 3/4/23. --Sunday 3/5/23. --Saturday 3/11/23. --Sunday 3/12/23. --Saturday 3/18/23. --Sunday 3/19/23. --Saturday 3/25/23. --Sunday 3/26/23. Review of the PBJ of the fiscal year of quarter 3 of 2023 (April 1-June 30) showed no eight-hour consecutive RN coverage the following dates: -Seven days in April 2023: --Wednesday 4/5/23. --Monday 4/10/23. --Tuesday 4/11/23. --Saturday 4/15/23. --Sunday 4/16/23. --Saturday 4/29/23. --Sunday 4/30/23. ---Received documentation from the facility of RN coverage by the DON and/or the Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) Coordinator, who was an RN for the following three April dates from above: ----Wednesday 4/5/23. ----Monday 4/10/23. ----Tuesday 4/11/23. -Four days in May 2023: --Saturday 5/13/23. --Sunday 5/14/23. --Saturday 5/27/23. --Sunday 5/28/23 -Six days in June 2023: --Thursday 6/8/23. --Friday 6/9/23. --Saturday 6/10/23. --Sunday 6/11/23. --Monday 6/12/23. --Saturday 6/24/23. ---Received documentation from facility of RN coverage by the DON and/or the MDS Coordinator, for the following three June dates from above: ----Thursday 6/8/23. ----Friday 6/9/23. ----Monday 6/12/23. Review of staffing sheets from November 16, 2023, through December 4, 2023, showed no eight-hour consecutive RN coverage the following days: -Thursday 11/23/23. -Friday 11/24/23. -Saturday 11/25/23. -Sunday 11/26/23. During an interview on 12/7/23 at 8:55 A.M., the Administrator said: -The facility had three RN's which included the DON and the MDS Coordinator. -They just couldn't get any RN's to apply. -The non-administrative RN works every other weekend along with weekdays. -They have had in the past some agency coverage. During an interview on 12/11/23 at 10:05 A.M., the Staffing Coordinator said: -He/she had a monthly schedule that was a daily schedule for the shifts that the staff usually worked. -The daily schedule was put out at the nurse's station. -He/she tried to make up two weeks schedule at a time. -There was a spot at the top of the staffing sheet to put in the name of the RN who was working for that day. -There was RN coverage every other weekend that was not Administrative staff. -On the weekends that were not covered by a RN, the DON or the MDS Coordinator took turns covering. -Used to use agency staff to cover needed staffing openings except for RN's. -Have not used agency staffing since July 2023 except for the last couple of weeks with staff being off due to COVID-19. -Try to get own staff to work an extra shift before calling agency staff. -The facility did not use a staffing agency to cover the RN in vacancies. During an interview on 12/11/23 at 10:32 A.M., the DON said: -He/she had covered a weekend if there was no RN in the past. -At times it could have been every weekend in a month. -For most of this year he/she had not come in on a weekend very much. -He/she doesn't believe the facility had RN coverage every weekend for a long time. -He/she just had not been asked to cover on a weekend. -The facility had ads out for RN positions in an online staffing forum, have placed ads in the local newspaper and on social media. -Just have not had any RN's or nurses apply.

Based on observation, interview, and record review, the facility failed to employ sufficient dietary staff and support personnel with the appropriate competencies and skill sets to safely and effectively carry out the functions of the food and nutrition service, taking into consideration residents' dietary assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 54 residents with a licensed capacity for 99 residents at the time of the survey. 1. Review of the facility's dietary documentation for the month of December, 2023, provided by the Dietary Manager (DM), showed the following: -Meals were scheduled three time a day on menus that rotated on a four week basis. -Each meal had at least three main food items with a choice of beverage. -There were separate menus for mechanically altered and pureed textured diets. -Individual resident diet cards were used that addressed their different required textures, allergies, religious and/or cultural preferences, and any special instructions. -For residents who may not want the main meal scheduled there was an Always Available sheet with numerous additional items to choose from daily for lunch or dinner. -The staffing sheet for the month showed there was one cook, one dishwasher, and the DM scheduled for days, and one cook, one dishwasher, and a dietary aide scheduled for nights. Observation on 12/4/23 between 8:44 A.M. and 11:41 A.M. during the initial kitchen inspection showed there was one day cook, a dishwasher, and the DM present. During an interview on 12/4/23 at 9:43 A.M. the DM said the following: -The kitchen had been short-staffed for about a month. -There was also one dietary aide out with a long illness. -The day cook and him/her were covering extra shifts. -He/she was filling in doing dinner meal passes. During an interview on 12/4/23 at 11:33 A.M. the Day Cook said after food was transferred from the stove and/or oven to the steam table, the whole table was unplugged and it was physically taken from the kitchen to the back dining room with a large beverage cart and the table plugged in for the meal service there, and then it was returned to the kitchen and re-plugged in there for the front dining room's meal service. During an interview on 12/7/23 at 9:27 A.M. the DM said the following: -If they lost a staff member for some reason it could be weeks before they even got an applicant. -He/she was also very picky about whom they hired as well.

Based on observation, interview, and record review, the facility failed to retain operable thermometers in all refrigerators/freezers to confirm adequate temperature ranges; to maintain sanitary utensils, beverage dispensers, and food preparation equipment; to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards (cross-contamination); and to record the testing of the dishwasher machine's chemical solution balance for the sanitizing of eating/serving utensils, plates, and cups/mugs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 54 residents with a licensed capacity for 99 residents at the time of the survey. 1. Observations on 12/4/23 between 8:44 A.M. and 9:47 A.M. during the initial kitchen inspection showed the following: -There was unknown residue on the right side of the manual can opener blade. -There was no thermometer in the reach-in freezer. -A brown handled white rubber spatula blade was chipped on one edge. -The multi-juice soda gun (a soda gun system allows you to stream multiple beverage types through a single hose) and coffee dispensers' nozzles were stained. -A 4-drawer plastic storage unit had plastic cup lids in one drawer and plastic eating utensils in another, both drawers had lint and crumbs in the bottom. -The microwave had food splatters on the upper inside. -A 4-slice toaster had an overabundance of crumbs in the bottom. -The green and red cutting boards were excessively scored to the point of plastic bits flaking off. Observations on 12/4/23 between 11:27 A.M. and 12:03 P.M. during the kitchen meal pass inspection showed the following: -There was still an unknown residue on the right side of the manual can opener blade. -There was a Dish Machine Sanitizer Log sheet for Dec. '23 in a plastic sleeve on the wall next to the machine for recording the dishwasher's chemical balance that was yet to be filled out. -A 4-drawer plastic storage unit had plastic cup lids in one drawer and plastic eating utensils in another, both drawers had lint and crumbs in the bottom. -The microwave had food splatters on the upper inside. -A 4-slice toaster had an overabundance of crumbs in the bottom. -The green and red cutting boards were excessively scored to the point of plastic bits flaking off. During an interview on 12/4/23 at 11:43 A.M. the Day Dishwasher said that he/she checked the chemical balance for the dishwashing machine with test strips during the morning shift and the next dishwasher did it for the evening shift. Observations on 12/5/23 at 9:47 A.M. during the follow-up kitchen inspection showed the following: -There was no thermometer in the reach-in freezer with an accumulation of crumbs in the bottom. -An unknown residue remained on the right side of the manual can opener blade. -A brown handled white rubber spatula blade was chipped on one edge. -The microwave had food splatters on the upper inside. -A 4-slice toaster had an abundant amount of crumbs in the bottom. -The green and red cutting boards were excessively scored. During an interview on 12/5/23 at 9:51 A.M. the Dietary Manager (DM) said: -He/she did not see a thermometer in the reach-in freezer. -He/she would go get one from his/her office and put it inside. During an interview on 12/7/23 at 9:27 A.M. the DM said: -Staff notify him/her verbally if food preparation items are damaged and need replaced. -Food preparation items are cleaned after each use. -Food should be free from foreign substances. -Coffee dispenser nozzles are cleaned and the soda gun is soaked daily.

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. Additionally, the facility failed to ensure staff were following isolation (being apart from other people) policies for COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) positive residents for five sampled residents (Resident #17, #47, #50, #12, and #42) and one supplemental resident (Resident #43) out of 14 sampled residents and one supplemental residents; and to demonstrate standard infection control practices while performing incontinence care (assistance with clean up urine or feces) for one sampled resident (Resident #17). The facility census was 54 residents with a licensed capacity for 99 residents at the time of the survey. 1. Observation on 12/4/23 between 8:44 A.M. and 9:47 A.M. during the Life Safety Code (LSC) kitchen inspection showed a three-sink area, a chemical dish-washing machine, a sink food preparation table, a handwashing sink, and an ice machine. Observation on 12/5/23 between 10:51 A.M. and 1:21 P.M. during the facility LSC room-by-room inspections with the Director of Maintenance (DOM) showed the following: -There was a facility-wide fire sprinkler system. -There was a boiler room, two dining rooms, and a beauty shop. -There were at least 40 resident rooms with sinks and bathrooms, two bathhouses, janitor's closets with mop hopper sinks, and staff and public restrooms. Review of the facility's emergency preparedness manual entitled Emergency Preparedness - 2023, last reviewed on 2/23/23 and obtained from the front nurses station, with a 23-page section, Water Management Program to Reduce Legionella Growth and Spread in the Facility, revised on 6/13/22 by the Administrator, showed the following: -There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -There was no completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -There was no facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens. -There were facility maps showing water flow and locations throughout the facility along with a list of system details and outlets, but no assessments of each area's individual potential risk level. -There was no documentation of any site log book being maintained with any cleanings, sanitizings, descalings, and inspections mentioned. During an interview on 12/7/23 at 11:09 A.M., the DOM said the following: -He/she would run the water in vacant resident rooms on a weekly basis. -He/she also tested the water in those rooms and bathhouses for their PH (Potential for Hydrogen is a measure of how acidic/basic water is. The range goes from 0 - 14, with 7 being neutral. pHs of less than 7 indicate acidity, whereas a pH of greater than 7 indicates a base) content. Review of the facility's Legionella Testing Log, conducted and provided by the DOM, showed triannual testing of their water's PH Range and Chlorine Range for each hall from 12/1/22 through 12/1/23, but no guidance as to what the actual control limits were or what would be done if those limits were not met. During an interview on 12/7/23 at 11:41 A.M., the Administrator said the following: -The Legionella Program was in place when he/she started at the facility a little over a year ago. -He/she did not know who developed the program or how. 42955 2. Review of the facility's Perineal (area between the genitals and anus) Care Policy, dated February 2018, showed: -The purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition. -Preparation: --Review the resident's care plan. --Assemble the equipment and supplies needed. -Equipment and supplies included: --Wash basin. --Washcloths. --Personal protective equipment (PPE - gowns, gloves, mask as needed). -Procedure: --Place the equipment on the bedside stand, arrange supplies so they can be easily reached. --Wash and dry hands thoroughly. --Fill wash basin. --Fold bedspread or blanket toward the of the bed. --Raise the gown or lower the pajamas. --Put on gloves. --Wet washcloth and soap the skin. --Wash perineal area front to back. --Rinse wash cloth and gently dry the area. -Discard disposable items, remove gloves and discard. -Wash and dry hands thoroughly. Review of the facility Infection Prevention and Control Program policy, dated 5/12/23, showed: -The purpose of the policy was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infections. -All staff were responsible for following all policies and procedures related to the program. -A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. Review of the facility's Handwashing/Hand Hygiene policy, dated August 2019, showed: -The facility considered hand hygiene the primary means to prevent the spread of infection. -All staff followed the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. -Staff were to use an alcohol-based hand rub containing at least 62% alcohol; or soap and water for the following situations: --Before performing any non-surgical invasive procedures. --Before putting on sterile gloves. --Before moving from a contaminated body site to a clean body site during resident care. --After contact with a resident's intact skin. --After contact with blood or bodily fluids. --After handling used dressings, contaminated equipment, etc. --After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. --After removing gloves. -Hand hygiene was performed before applying non-sterile gloves. Review of Resident #17's face sheet, undated, showed the resident had the following diagnoses: -Stroke. -Dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory). -Muscle weakness. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/26/23, showed: -The resident scored a 00 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 and 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items were crucial factors in care planning decisions). --This indicated the resident was severely cognitively impaired. Review of the resident's Functional Abilities and Goals (section GG) dated 6/26/23 showed: -The resident required assistance for toileting. -The resident was totally dependent on staff for urinary incontinent care. -The resident was always incontinent of urine. Review of the resident's Care Plan, undated, showed the resident had bowel and bladder incontinence related to dementia and impaired mobility. Observation on 12/06/23 at 1:00 P.M., Certified Nursing Assistant (CNA) A and CNA B were performing incontinence care for the resident: -Both CNA's washed their hands and put gloves on. -CNA A pulled side room curtain down to bottom of bed and then moved bed out some. -CNA A did not change gloves or wash/sanitize hands. -Both CNA's removed the resident's disposable brief. -CNA B handed CNA A the wipes. -CNA A started cleaning the resident with same gloves which touched items in the room. -CNA A removed gloves but did not wash/sanitize hands. -CNA A put on new gloves. -CNA A cleaned the resident's buttocks and placed a new disposable brief next to the resident. -CNA A then re-wiped the resident's perineal area. -CNA A removed his/her gloves. -CNA A did not wash or sanitize his/her hands. -CNA A put on new gloves. -CNA A positioned the disposable brief under the resident. -Both CNA A and CNA B rolled the resident to the right side and pulled the disposable brief under the resident. -Both CNA A and CNA B fastened the disposable brief and repositioned the resident and made sure he/she was comfortable. -Both CNA A and CNA B removed their gloves and washed their hands. During an interview on 12/06/23 at 8:02 A.M., CNA A said: -He/she changed gloves all of the time when changing the resident. -He/she used sanitizer between taking off the soiled brief and putting on a clean one. During an interview on 12/07/23 at 9:24 A.M., CNA B said: -He/she checked and changed the resident every two hours. -He/she started the changing procedure by letting the resident know what he/she was about to do for the resident. -He/she turned the resident, wiped and put wipes in the trash can. -Then he/she put the clean brief back on the resident. -He/she changed gloves when they were soiled and after changing the resident. -He/she pulled the curtain closed before he/she started the procedure. -He/she closed curtains on the windows. During an interview on 12/07/23 at 10:44 A.M., Licensed Practical Nurse (LPN) A said: -CNA's were responsible for incontinence care, but anyone of the nursing staff could provide incontinence care. -The expectation was to take the resident to their room. -Wash hands and put gloves on. -Help the resident stand and move to the toilet or have them lay down in bed. -Take off old brief and remove gloves. -Put on new gloves, wipe the perineal area. -Remove gloves, wash hands and prepare new brief. -Put on new gloves and put on new brief, degloved and wash hands. During an interview on 12/11/23 at 11:22 A.M., the Director of Nursing (DON) said: -During peri-care he/she expected staff to change gloves every time they went from something dirty to something clean. -If staff touched something dirty, they should change their gloves. -Staff should remove their gloves after touching the curtain or the bed, sanitize and put on clean gloves. -He/she was unaware of when the last handwashing/hand hygiene training was but believed it was in the last couple of months. 3. Review of the facility's policy, Transmission-Based (Isolation) Precautions dated 2023 showed: -Residents on transmission-based precautions (precautions for diseases spread by direct or indirect contact) should remain in their rooms except for medically necessary care. -An order for transmission-based precautions/isolation would specify the type of precaution and the reason for the transmission-based precaution. -The duration would depend upon the infectious agent or organism involved. -Signage that included instructions for use of specific PPE would be placed in a conspicuous location out side the resident's room, wing or facility-wide. -Healthcare personnel caring for residents on Contact Precautions (precautions used to prevent the transmission of infectious agents, which were spread by direct or indirect contact with the patient or the patient's environment) would wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. -Donning (putting on) PPE upon room entry and discarding before exiting the room was done to contain pathogens (a virus that can cause disease), especially those that have implicated in transmission. Review of the facility's policy ,Infection Prevention and Control Program, dated 5/12/23 showed: -Hand hygiene should have been performed in accordance with out facility's established hand hygiene procedures. -Limit transport and movement of the resident outside the room to medically essential purposes. -Health Care Professionals who enter the room of a resident with confirmed COVID-19 infection should have adhered to standard precautions and use a N-95 respirator, gown, gloves, and eye protections. Review of the facility's COVID-19 Prevention, Response and Reporting policy, dated 5/12/23, showed: -Source control measures included: --A National Institute for Occupational Safety and Health (NIOSH) approved mask with an N95 (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) rating or higher. --A barrier face covering. --A well fitted face mask. -Source control was recommended for health care settings who had suspected or confirmed COVID-19 infections. -Staff who entered the room of a resident with a confirmed COVID-19 infection should use an approved N95 mask, gloves, gowns and eye protection. Review of Resident #47's quarterly MDS dated [DATE], showed: -The resident scored a 03 on the BIMS. --This indicated the resident was severely cognitively impaired. Review of the resident's care plan, dated 10/9/23, showed there was nothing noted regarding the resident's COVID-19 status. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated November 2023 showed no documentation of staff performing COVID-19 screenings or assessments. Review of the list of COVID-19 positive residents, undated, showed the resident tested positive for COVID-19 on 11/29/23. Review of the resident's MAR and TAR dated December 2023 showed no documentation of staff performing any COVID-19 screenings or assessments. Review of the resident's COVID-19 Assessment Sheets that were completed after the resident had tested positive for COVID-19 that indicated his/her symptoms showed: -There was no COVID-19 assessment completed that indicated the resident's symptoms on 11/29/23. -There was no COVID-19 assessment completed that indicated the resident's symptoms on 11/30/23. -There was no COVID-19 assessment completed that indicated the resident's symptoms on 12/1/23. -There was no COVID-19 assessment completed that indicated the resident's symptoms on 12/2/23. -There was no COVID-19 assessment completed that indicated the resident's symptoms on 12/3/23. -There was no COVID-19 assessment completed that indicated the resident's symptoms on 12/4/23. Observation on 12/4/23 at 9:33 A.M., showed: -The resident's room door was closed. -There was a supply cart outside of the room with gloves, shields, masks and gowns. -There was a piece of red paper posted outside the door that indicated to please report to the nurse's station before entering the room. Observation on 12/4/23 at 12:08 P.M., showed: -CNA A brought a lunch tray into the resident's room. -CNA A came back out of the room into the hall and took a gown out of the bin outside of the resident's room. -CNA A entered the resident's room and put on the gown. -He/she was wearing a N-95 mask. -He/she was not wearing gloves or a face shield. -He/she removed the gown in the hallway. -He/she took the gown down the hall and threw it away in a trash can in an unidentified room on the hallway. During an interview on 12/4/23 at 12:08 P.M., CNA A said he/she forgot to put on the PPE. Observation on 12/6/23 at 7:32 A.M., showed CNA B: -Delivered a breakfast tray to the resident's room. -He/She did not put on any PPE. -He/she returned to the hot food serving table and retrieved another tray and delivered it to another room which had a resident who had tested negative. -He/she was not observed to use hand sanitizer. -He/she walked back down the hall to the hot food serving table. -He/she picked up a tray and walked down the hall and entered room [ROOM NUMBER] which had a resident who had tested positive. --He/she did not put on any PPE. -He/she exited the room, walked down the hall toward the dining area, sanitized his/her hands then returned to the hot food serving table and continued to deliver trays to the residents in the dining room. 39469 4. Observation on 12/4/23 at 12:30 P.M. of the lunch meal in the main dining room showed: -Of the 15 residents in the dining room only two had worn a mask to the meal. -Residents who needed to have been fed were not six feet apart. -Staff were not observed encouraging the residents to wear a mask when they left the dining room. Review of the list of COVID-19 positive residents on 12/4/23 from the DON showed the following rooms had residents who had tested positive for COVID-19: -Rooms six, eight, 10, 11, 15, 16, 23, 24, 27, 29, 30, 32, 33, 44, 45, and 49. Observation on 12/4/23 at 1:21 P.M. showed: -room [ROOM NUMBER] had a red sign on the door, See Nurse before entering. -There was an isolation cart at the door. -The door was open and the resident was inside the room. -There was no sign showing what PPE was required to enter the room. Observation on 12/4/23 at 1:30 P.M. showed: -A resident came out of room [ROOM NUMBER] (positive for COVID-19) with his/her mask below his/her chin. -He/she started to talk to another resident from across the hall who had come out of their room (not positive). -The two residents were within one foot from each other. -A female staff member walked by the two residents and passed them on his/her way down the hallway. -When asked if the two residents were both negative for COVID-19 the staff member said no the resident who had come out of room [ROOM NUMBER] was positive and should not be out of his/her room. -The staff member then assisted each resident back to their room. Observation on 12/07/23 at 10:15 A.M. showed: -room [ROOM NUMBER]'s door was open with a resident inside. -There was a red sign on the door that indicated, See the Nurse. -There was an isolation cart outside the door. Observation on 12/4/23 at 1:40 P.M. showed Physical Therapist (PT) A: -Came out of room [ROOM NUMBER] with his/her soiled PPE in his/her hand. -He/she was looking up and down the hallway trying to find a trash can. During an interview on 12/4/23 at 1:45 P.M. PT A said: -He/she knew to remove his/her PPE when exiting a COVID-19 isolation room. -There was no sign on the door what staff was expected to wear for PPE when entering a COVID-19 isolation room, but he/she had education on what to wear. -There was no trash can in the room to throw his/her soiled PPE away. -He/she would have to find one. -He/she carried the soiled PPE down the hallway in his/her bare hand to find somewhere to throw it away. 37576 5. Review of Resident #50's admission record showed he/she admitted on [DATE] and readmitted on [DATE] with the following diagnosis: -Difficulty in walking dated 3/15/23. -Unsteadiness on feet dated 8/4/23. -Muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass) dated 11/2/23. -COVID-19 dated 11/27/23. Review of the resident's medical record showed he/she was diagnosed with COVID-19 on 11/27/23 and on isolation precautions until 12/7/23. Observation on 12/4/23 at 9:25 A.M., showed: -The resident's room door was open. -The resident was sitting in a wheelchair with a mask on over his/her mouth only. -A sign outside the door instructing visitors to report to the nurses' station before entering. -No sign that indicated any PPE that should be worn when entering the room. -There was not an isolation cart next to the resident's room door. -An isolation cart was across the hall. -Certified Medication Technician (CMT) A entered the room with a KN-95 mask on and gloves no other PPE on such as a protective gown. -CMT A gave the resident medication, removed his/her gloves in the room and washed his/her hands, then exited the room. During an interview on 12/4/23 at 9:26 A.M., CMT A said: -He/she had been gone a week and had just returned today. -He/she was not sure if room doors were supposed to be open or closed if a resident was COVID-19 positive. -This resident was a fall risk and that was probably why the door was open. During an interview on 12/4/23 at 9:31 A.M., the resident said: -He/she did not see staff wearing yellow covers when they come into the room. -He/she stayed in the room and sometimes wore a mask. -He/she ate meals in his/her room. Observation on 12/5/23 at 9:45 A.M., showed: -The resident's door was open. -The resident was in his/her wheelchair and wearing a KN-95 mask. -An unidentified staff member was in the resident's room without an isolation gown on. Observation on 12/6/23 at 10:45 AM the resident's door remained open. During an interview on 12/4/23 at 9:38 A.M., CMT C said: -If a resident was COVID-19 positive and on isolation precautions staff needed to wear the isolation gown, gloves and a KN-95 mask. -That was the PPE that was included in the isolation carts outside the rooms of the resident's who had tested positive for COVID-19. Observation on 12/4/23 at 9:28 A.M., showed CMT A went to a resident room that had an isolation cart outside the door and passed medications without putting an isolation gown on. 22727 6. Review of Resident #43's significant change MDS dated [DATE] showed the following staff assessment of the resident: -Was severely cognitively impaired. -Used a wheelchair. -Had a diagnosis of dementia. Review of the facility's list of residents who tested positive for COVID-19 in November 2023 and December 2023 showed the resident tested positive for COVID-19 on 11/27/23. Review of the resident's MAR dated November 2023 showed the resident was on contact precautions for COVID-19 every shift for COVID-19 positive for ten days beginning on the night shift on 11/27/23 through 11/30/23. Review of the resident's MAR dated December 2023 showed the resident was on contact precautions for COVID-19 every shift for COVID-19 positive for ten days 12/1/23 through the evening shift on 12/7/23. Review of the resident's undated care plan showed: -The resident had a diagnosis of COVID-19. -The resident required contact and droplet isolation precautions (precautions intended to prevent transmission of infectious agents which are spread by speaking, sneezing, or coughing) and other monitoring related to COVID-19 infection. -Instructions to staff to: --Encourage the resident to wear a mask if leaving his/her room. --Encourage the resident to stay in his/her room and away from other people as much as possible due to contact and droplet precautions. Observation on 12/4/23 at 10:30 A.M. showed: -The resident was sitting in his/her room in his/her wheelchair with his/her door open and was not wearing a mask. -There was a red sign on door frame outside the resident's room to report to the nurses' station before entering the room. -There was an isolation cart outside the resident's room. Observation on 12/4/23 at 10:32 A.M. showed: -The Maintenance Director knocked on the resident's door and entered the room. -The Maintenance Director had on a KN95 mask (personal protective equipment that protect against airborne particles and liquids). -The Maintenance Director did not wear any other personal protective equipment. -The Maintenance Director told the resident he/she was there to look at the resident's bed and to try to fix it. -The Maintenance Director got underneath the resident's bed and began to work on it while the resident remained in the room. During an interview on 12/11/23 10:36 A.M., the Maintenance Director said: -He/she did not know the resident was on isolation when he/she went into the resident's room to fix his/her bed. -He/she knew to wear PPE if there was a red sign and isolation cart outside a resident's room. -He/she did not think there was an isolation cart outside the resident's door when he/she entered to fix the resident's bed. During an interview on 12/11/23 at 11:15 A.M. the DON said anyone who went into a room of a resident who was COVID-19 positive expected to wear full PPE. 7. Review of Resident #12's care plan dated 7/21/23 showed (with undated updates): -The resident had a diagnosis of COVID-19. -The resident required contact and droplet isolation precautions and other monitoring related to COVID-19 infection. -The resident was resistive to wearing a mask due for COVID-19 precautions and was also resistive to staying in his/her room for COVID-19 isolation precautions. -Instructions to staff to: --Encourage the resident to wear a mask if leaving his/her room. --Encourage the resident to stay in his/her room and away from other people as much as possible (contact and droplet precautions). Review of the resident's significant change MDS dated [DATE] showed the following staff assessment of the resident: -Severely cognitively impaired -Rejected care one to three days in the past seven days. -Used a walker. -Had a diagnosis of dementia. Review of the facility's list of residents who tested positive for COVID-19 in November 2023 and December 2023 showed the resident tested positive for COVID-19 on 11/27/23. Review of the resident's Physician's Order Sheets (POS)s and MARs dated November 2023 and December 2023 showed no physician's order for contact precautions for COVID-19 every shift for COVID-19 positive for ten days. Observation on 12/4/23 showed: -At 11:01 A.M.: --There was a red sign on door frame outside the resident's room to report to the nurses' station before entering the room. --There was an isolation cart outside the resident's room. --The door was open. --The resident was not in his/her room. -At 11:14 A.M.: --The resident was sitting in a chair at a dining room table talking to Resident #42 and drinking a beverage. -The residents were sitting right next to each other with approximately one foot between them. -Neither residents were wearing masks. -Staff in the area did not say or do anything related to the residents being this close and without masks. -At 12:43 P.M., the resident was sitting in his/her room eating lunch and the door was open. During an interview on 12/4/23 at 12:47 P.M., CMT B said: -The resident was supposed to be in isolation. -It was hard to get the resident to stay in his/her room and it was hard to keep a mask on him/her. Observation on 12/4/23 showed: -At 1:18 P.M. and 2:24 P.M., the resident was sitting in his/her room and the door was open. -At 2:46 P.M.: --The resident walked to the nurses' station using his/her roller walker with no mask on. --CMT B told him he was supposed to stay in his/her room due to having COVID-19 and gave the resident a mask which he/she put on and walked back to his/her room. Observation on 12/5/23 showed at 9:58 A.M., the resident was in his/her room and the door was open. Observation on 12/6/23 showed: -At 6:56 A.M., the resident was the dining room at a dining room table without a mask on and was watching a movie. -At 7:00 A.M., --There was a red sign on the door frame outside the resident's room to report to the nurses' station before entering the room. --There was an isolation cart outside the resident's room. -Continuous observation from 9:28 A.M., to 10:57 A.M. showed: --The resident was sitting at a dining room table without a mask on and was talking to a staff member who had a KN-95 mask on. --The resident remained in the dining room watching television with no mask on. --No staff encouraged the resident to wear a mask or go back to his/her room. Observation on 12/7/23 showed: -At 9:57 A.M., the resident was in his/her room and the red sign and isolation cart were still present. -At 10:12 A.M.: --The resident walked into the dining room without a mask on. --A staff member went to the resident and gave him/her a medical mask and asked the resident to put it on. --The resident put on the mask and walked toward his/her room. -At 10:43 A.M., the resident walked into the dining room without a mask on. -At 10:44 A.M.: --Staff asked the resident to put on a mask. --Staff gave the resident a medical mask and he/she put it on. During an interview on 12/8/23 at 2:45 P.M., the DON said the resident had one COVID-19 symptom and that was a runny nose. During an interview on 12/11/23 at 10:29 A.M., CMT B said: -The resident stayed in his/her room at times. -They tried to re-direct the resident when he/she came out of his/her room. -They tried to keep a mask on him/her and to keep away from other residents. During an interview on 12/11/23 at 11:23 A.M., the DON said: -The residents who were on isolation should stay in their room with the door closed except if they were a fall risk. -Residents who were COVID-19 positive should not be outside of their room without a mask. -Staff was expected to encourage the residents who were COVID-19 positive to wear masks and go back to their rooms. -Residents who were COVID-19 positive should be kept six feet apart from others if out of their room. -The resident did not like to wear a mask. -He/She was not sure about getting the resident to go back to his/her room. -The resident would probably just walk back out of his/her room. -The resident was difficult to separate from other residents. -All residents who were COVID-19 positive should have a physician's order for 10 days of isolation. 8. Review of Resident #42's care plan dated 1/19/23 (with no updated date) showed: -The resident had a diagnosis of COVID-19. -The resident required contact and droplet isolation precautions and other monitoring related to COVID-19 infection. -Instructions to staff to: --Encourage the resident to wear a mask if leaving his/her room. --Encourage the resident to stay in his/her room and away from other people as much as possible. -The resident was a fall risk related to walking and balance problems with a history of falls. -The resident was unaware of safety needs. -The resident had a non-injury fall on 7/29/23. -The resident had a diagnosis of dementia. Review of the resident's significant change MDS dated [DATE] showed the following staff assessment of the resident: -Had short-term and long-term memory impairment. -Displayed no negative behaviors. -Did not wander. -Did not reject care. -Required supervision when using his/her wheelchair. -Had one non-injury fall since 7/8/23. Review of the resident's POS dated November 2023 showed no physician's orders related to COVID-19. Review of the resident's POS dated December 2023 showed physician's orders dated 11/29/23 for contact precautions due to COVID-19 positive for ten days. Review of the resident's physician's progress note dated 11/29/23 at 9:57 A.M. showed: -The resident was sitting in his/her wheelchair in the commons area. -Nursing staff informed the physician the resident was COVID-19 positive. -The nursing staff reported the resident had a cough and was non-compliant with isolation related to cognition. Review of the resident's inter-disciplinary notes dat

Based on observation, interview and record review, the facility failed to provide an ongoing program of activities to meet the interests as well as the physical, mental and psychosocial well-being for four sampled residents (Residents #17, #47, #30 and #42) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's Activity Evaluation Policy, dated June 2018, showed: -To promote the physical, mental and psychosocial well-being of the residents, an activity evaluation was conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities. -An activity evaluation was conducted as part of the comprehensive assessment to help develop any activities plan that reflected the choices and interests of the resident. -The residents activity evaluation was conducted to evaluate functional level, cognition and medical conditions that may affect the residents participation in activities. -The residents lifelong interests, spirituality, life goals and roles, strengths, needs and activity pursuit patterns and preferences were included in the evaluation. -The activities director was responsible for completing, directing and or delegating the completion of the activities component of the comprehensive assessment. -The activity evaluation was used to develop an individual activities care plan that allowed the resident to participate in activities of his/her choice and interests. 1. Review of Resident #17's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/26/23 showed: -The resident scored a 00 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions). --This showed the resident was severely cognitively impaired. -The resident was diagnosed with: --Dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking). --A stroke. --Hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing). Review of the resident's Individual Resident Daily Participation Record dated September 2023 showed: -On 9/5/23, 9/17/23 and 9/24/23 the resident participated in one-on-one activities. -On 9/5/23, 9/14/23 and 9/28/23 the resident participated in sports games. -On 9/27/23 the resident participated in one hospice activity. -On 9/29/23 the resident participated in one movie/TV activity. Review of the resident's Care Plan, dated 9/12/23, showed: -The problem identified was, the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to dementia and multiple comorbidities. -The goal was, the resident would maintain involvement in cognitive stimulation, social activities as desired through review date. -The approaches were: --Ensure that the activities the resident was attending were compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation); compatible with individual needs and abilities; and age appropriate. --Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. --Introduce the resident to residents with similar background, interests and encourage/facilitate interaction. --Invite the resident to scheduled activities. --The resident had impaired cognitive function or impaired thought processes related to dementia. --Engage the resident in simple structured activities that avoid overly demanding tasks. --Provide a program of activities that accommodates the resident's abilities. Review of the resident's Quarterly/Annual Participation Review, dated 9/25/23, showed: -The resident participated in some group activities and one on one activities. -The resident enjoyed watching TV with snacks, listening to music, playing games that involved balls and being read to. Review of the resident's Individual Resident Daily Participation Record dated October 2023 showed: -On 10/9/23 and 10/30/23 the resident participated in one-on-one visits. -On 10/9/23 the resident participated in exercise. -On 10/20/23 the resident participated in a movie or TV activity. -On 10/25/23 the resident participated in sing-along's and a hospice activity. -On 10/27/23 the resident participated in a sports game. Review of the resident's Individual Resident Daily Participation Record dated November 2023 showed: -On 11/3/23, 11/17/23 and 11/24/23 the resident participated in one-on-one activities. -On 11//5/23, 11/14/23 and 11/28/23 the resident participated in sports games. -On 11/27/23 the resident participated in a hospice activity. -On 11/29/23 the resident participated in a movie or TV activity. Observation on 12/05/23 at 10:18 A.M. showed: -Certified Nursing Assistants (CNA's) and other staff were doing activities with residents. -The resident was in front of the TV, no one asked if he/she wanted to participate in any type of game or activity. Observation on 12/05/23 at 10:46 A.M., showed CNA A moved the resident in his/her wheelchair from one table to the lunch table to get ready for lunch, which was to be served at 12:00 P.M. During an interview on 12/06/23 at 8:02 A.M., CNA A said: -He/she tried to get the resident involved as much as he/she could. -The resident liked music. -He/she tried coloring with the resident, but the resident didn't seem to have much interest. -The resident liked the music most, clapped his/her hands, tapped his/her feet and moved his/her head. -The resident did not show any restlessness. Observation on 12/06/23 at 7:04 A.M. showed: -The resident was sitting at table in his/her wheelchairs, awake, looking round. -Breakfast was to be served at 7:30 A.M. -The resident was not engaged in any form of activity. During an interview on 12/07/23 at 9:24 AM. CNA B said: -The resident liked music. -The resident liked snacks and to eat. -It was difficult for the resident to do activities. -The resident was stubborn and only participated when he/she wanted to. -He/She tried to keep the resident involved but the resident did not participate. During an interview on 12/07/23 at 10:44 A.M., Licensed Practical Nurse (LPN) A said: -The resident could not hold a conversation. -The resident liked to hum to himself/herself or to music. -The resident did not like activities. -Even when the resident was more mobile, he/she did not do activities. -The resident seemed content with being in the dining area and liked to be a people watcher. -The resident was constantly moving his/her hands. -Staff tried to get him/her to fold towels, but the resident was not interested. -The resident did not like to lay down. -The resident was going to do what he/she wanted to do. 2. Review of Resident #47's MDS dated [DATE] showed: -The resident scored a 03 on the BIMS. --This indicated the resident was severely cognitively impaired. -The resident was diagnosed with: --Dementia. --Depression (medical illness that negatively affects how a person felt, thought, acted). --Cardiorespiratory conditions (a range of serious disorders that affected the heart and lungs). Review of the resident's annual MDS Preferences for Routine and Activities (Section F), dated 1/9/23, showed: -It was somewhat important for him/her to have newspapers and magazines to read. -It was somewhat important for him/her to listen to music. -It was very important to do his/her favorite activities. -It was somewhat important to do things with groups of people. Review of the resident's care plan, dated 10/4/23, showed: -The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to dementia. -The resident would maintain involvement in cognitive stimulation, social activities as desired through review date. -All staff were to converse with the resident while providing care. -Provide a program of activities that was of interest and empowered the resident by encouraging/allowing choice, self-expression and responsibility. -The resident was an elopement risk related to wandering. --Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. Review of the resident's Individual Resident Daily Participation Record, dated October 2023, showed: -On 10/3/23 and 10/31/23 the resident participated in food/cooking activities. -On 10/3/23, 10/17/23 and 10/31/23 the resident participated in a coloring activity. -On 10/4/23, 10/6/23, 10/9/23 and 10/16/23 the resident participated in exercise. -On 10/4/23 the resident participated in a library/reading activity. -On 10/19/23 the resident participated in an entertainment activity. -On 10/20/23 the resident participated in a movie/television activity. -On 10/24/23 the resident participated in a hospice activity. -On 10/25/23 the resident participated in an evening activity and a sing-along activity. -On 10/27/23 the resident participated in a sports game activity. Review of the resident's Individual Resident Daily Participation Record, dated November 2023, showed: -On 11/1/23 the resident participated in a manicure activity. -On 11/1/23, 11/7/23, 11/16/23 and 11/22/23 the resident participated in an exercise activity. -On 11/6/23, 11/13/23, and 11/27/23 the resident participated in a coloring activity. -On 11/8/23, 11/21/23 and 11/22/23 the resident participated in a hospice activity. -On 11/8/23, 11/21/23 and 11/22/23 the resident participated in a sports game activity. -On 11/10/23 the resident participated in a movie/TV activity. -On 11/16/23 the resident participated in an entertainers activity. -On 11/22/23 and 11/29/23 the resident participated in an evening activity. Review of the resident's Individual Resident Daily Participation Record, dated December 2023, showed on 12/3/23, 12/4/23, and 12/7/23 the resident participated in one-on-one visits. Observation on 12/04/23 at 9:33 A.M., showed: -The resident's room door was closed. -There was no answer when the door was knocked on. Observation on 12/04/23 at 12:08 P.M., showed: -The resident was eating in his/her room. -The resident's TV was on, he/she was sitting on the bed with lunch on the bedside tray table. During an interview on 12/06/23 at 8:02 A.M., CNA A said: -The resident was on isolation in his/her room due to being COVID-19 (disease caused by a coronavirus, with symptoms of fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) positive. -When the resident was able to leave his/her room he/she liked bingo, tick tack toe and coloring. -Sometimes he/she just wanted to be in his/her room. -Not sure of any individual activities in room being done. During an interview on 12/07/23 at 9:24 A.M., CNA B said: -The resident liked to dance and color and would play bingo. -He/she liked snacks and puzzles. -He/she gave the resident color pages. During an interview on 12/07/23 at 9:38 A.M. Certified Medication Technician (CMT) B said: -The resident was kind of a busy body. -The resident was currently on isolation due to being COVID-19 positive. -He/she was unaware if activities staff went in the resident's room. -Before isolation the resident was very busy and active. During an interview on 12/07/23 at 10:44 A.M., LPN A said the resident: -Did not really like activities. -Liked to sit and look out the window. -Drank tea and coffee. -Used to be a bar fly before coming to the facility. -Flirted with other residents when he/she was in the common area. 3. During an interview on 12/07/23 at 1:31 P.M., the Activities Director said: -The Assistant Activities Director did most of the activities. -He/she helped with parties, events and did the activity planning. -He/she did all activity assessments with each resident. -He/she let CNA's know what the resident preferences were. -Twice a month he/she planned movies and snacks. -The CNA's did color pages and word searches with the residents. -The residents on the dementia unit enjoyed arts and crafts. -The residents on the dementia unit played bingo on Thursdays. -He/she printed off short stories, word searches and cross word puzzles for residents in isolation. -The activities assistant took something to them every day that he/she or the CNA's did with the residents. -He/she sanitized anything that was brought into and taken out of the resident's rooms. -Resident #47 liked big inflatable balls and any activity involving music and getting his/her hair done. During an interview on 12/11/23 at 11:22 A.M. the Director of Nursing (DON) said: -He/she would have to get with the activities director for specific information on individual residents. -The activities staff or CNA's did one on one activities or went in and read with the residents on isolation. -He/she expected the activities staff to bring activities to the residents on isolation on a daily basis. -He/she was aware the activities staff brought a ball in to one of the residents' room one day. 22727 4. Review of Resident #30's care plan dated 1/21/23 showed: -The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. -The goal was that the resident would maintain involvement in cognitive stimulation and social activities as desired. -Instructions to: --Encourage ongoing family involvement. --Invite the resident's family to attend special events, activities and meals. --Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. --Invite the resident to scheduled activities. --Provide the resident the activities calendar and notify the resident of any changes to the calendar of activities. --Thank the resident for attendance at activity function. -The resident required stand-by supervision with a walker for walking. -The resident required supervision to touching assistance of one staff to move between surfaces. -The resident could be resistive to cares related to dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes). -The resident had a communication problem related to a cognitive communication deficit. -The resident had impaired cognitive function and impaired thought processes related to dementia. -Some of the resident's diagnoses included an anxiety disorder (psychiatric disorder that involves extreme fear, worry and nervousness) and depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life). Review of the resident's psychiatrist progress note dated 6/15/23 showed: -The resident was impulsive and angry. -The resident did things like look for his/her parents. -The resident was confused. Review of the resident's activities initial review dated 8/7/23 showed: -The resident wished to participate in activities while in the home. -The resident did not wish to participate in group activities. -The resident participated in no activities, interests or hobbies. -The resident enjoyed visits with his/her spouse. -The resident wanted one-one-one activities with staff. -The resident did not like independent activities such as reading, doing puzzles, etc. -The resident was pleasantly confused. -The resident would need reminders of activities. -No prior interests, activities or hobbies were included. Review of the resident's activities quarterly participation review dated 11/12/23 showed: -Sometimes we can work with (the resident) one-on-one. -The resident had no favorite activities or interests. -The resident was disruptive and loud at times. Review of the resident's significant change MDS dated [DATE] showed the following assessment of the resident: -Did not have hearing impairment. -Wore glasses. -Had clear speech. -Usually understood others and others usually understood him/her. -The resident had long-term and short-term memory impairment. -Had moderately impaired decision-making skills, inattention and disorganized thinking. -Had no negative mood indicator or negative behaviors. -Participating in his/her favorite activities was somewhat important to the resident. -Had no range of motion impairment. -Used a walker. -Required supervision when transferring from one surface to another. -Required partial to moderate assistance when going from sitting down to standing. -Some of the resident's diagnoses included dementia, anxiety and depression. Review of the resident's Individual Resident Daily Participation Record dated November 2023 showed: -The resident participated actively in: --Resident Council once. --Arts and crafts once. --Hospice activity three times. --Movies/television once. --One on one visits three times. --Evening activity twice. -The resident had 21 days out of 30 with no documented activities. Observation on 12/4/23 showed: -At 11:16 A.M.: --The resident was sitting on the couch in the common area. --Music was playing on the television screen. --The resident was talking loudly (to no one in particular) but was not really understandable. --The resident started saying, La, la, la, la, la loudly. -At 12:37 P.M., the resident was having lunch in the dining room. -At 12:48 P.M., the resident was sitting at the dining room table leaning forward, with his/her hands are on his/her lap and his/her face is on top of his/her hands. -At 12:49 P.M., staff walked the resident out of the dining room and told the resident he/she could lie down for a nap. -At 1:18 P.M., the resident was in a recliner in his/her room with his/her eyes closed. -At 2:21 P.M., the resident was sitting at a dining room and was talking to a staff member. -At 2:34 P.M., the resident was talking to another resident. -At 2:36 P.M., staff pushed the resident that the resident was talking to out of the dining room, leaving the resident alone at the table with no activity. -At 2:47 P.M. through 2:58 P.M., the resident was talking incoherently to Resident #2. Observation on 12/5/23 at 9:58 A.M., the resident was asleep in his/her bed. Continuous observation on 12/6/23 from 9:37 A.M. to 10:55 A.M. showed: -At 9:37 A.M., the resident was asleep on a couch in the common area. -At 10:22 A.M., staff assisted the resident in getting up from the couch and walked him/her to dining room chair at a dining room table where the resident sat alone with no activity. -At 10:55 A.M., the resident was given a beverage. Continuous observation on 12/7/23 from 9:47 A.M. to 10:52 A.M. showed: -At 9:47 A.M.: --The resident was sitting on a couch in the common area and was singing La, la, la. --A Christmas movie was on the television. The resident was not watching the movie. --The resident said loudly Who is working on the stove? -At 10:40 A.M., the resident was singing La, la, la again. -The resident remained on the couch with no activity. Review of the resident's Individual Resident Daily Participation Records showed there was no record for the resident for December 2023. During an interview on 12/8/23 at 9:28 A.M., the Activity Director said: -He/she asked residents when they first came to the facility what their interests were. -If the resident could not provide the information, he/she tried to talk to family of the resident to get the information. -If there were staff who spent a lot of time with a resident, he/she asked them what the resident liked to do. -He/she tried to ask more details like what they like to read, what games they like, what television shows or movies they like, etc. -He/she did the activity assessments, progress notes and logged activity participation. -He/she had to work one-on-one with the resident. -The resident watched movies and ate snacks. -The resident's spouse visited. -The resident's spouse said the resident liked to knit and sew. -The resident did not want to do things he/she had offered the resident. -The resident yells out. -The Activity Assistant did sensory things with the resident in the past. -They currently did not have an activity assistant. -They did have a CNA who was on light-duty who was helping with activities. -There was a basket of towels the resident would mess with, but he/she had not seen it recently. During an interview on 12/11/23 at 10:29 A.M., CMT B said: -The resident liked to watch television, listen to live music and liked to talk to anybody. -The resident participated in activities at times. During an interview on 12/11/23 at 11:23 A.M., the DON said: -He/she did not know of anything that interested the resident. -Sometimes the resident would watch a movie. -He/she didn't think the resident understood how to participate in activities. -The resident talked but his/her words were incoherent. -Activities should get information on residents' previous hobbies. -Activities should be based on the resident's likes, dislikes and preference as much as possible. 5. Review of Resident #42's care plan updated 8/24/23 showed: -The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to dementia and cognitive deficits. -The goal was that the resident would maintain involvement in cognitive stimulation, social activities as desired through review date. -The resident needed assistance/escort to activity functions. -Instructions to: --Ensure the activities the resident was attending were compatible with physical and mental capabilities, known interests and preferences, individual needs and abilities. --Ensure the activities the resident was attending were adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation). --Ensure the activities the resident was attending were age appropriate. --Invite the resident to scheduled activities. --Provide the resident with materials for individual activities as desired. --Provide the resident an activities calendar and notify the resident of any changes to the calendar of activities. --Thank the resident for attendance at activity function. -The resident likes the following independent activities: (SPECIFY) - none were specified. Review of the resident's significant change MDS dated [DATE] showed the following staff assessment of the resident: -Did not have hearing impairment. -Wore glasses. -Had clear speech. -Usually understood others and others usually understood him/her. -The resident had long-term and short-term memory impairment. -Had no negative mood indicator or negative behaviors. -Used a wheelchair. -Had no range of motion impairment. -Some of his/her diagnoses included dementia and depression. -The activities that were somewhat important to him/her included music, pets, group activities and participating in his/her favorite activities. Review of the resident's quarterly activities participation review dated 10/12/23 showed: -The resident participated in group activities of his/her choice. -The resident sometimes participated in one on one activities and some parties. -The resident enjoyed morning exercise, some games, wheeling up and down the halls, book club, socializing with other residents and with staff and watching television and/or movies. -No information regarding prior hobbies or interests. Review of the resident's Individual Resident Daily Participation Record dated November 2023 showed: -The resident participated actively in: --Exercise 13 times. --Arts and crafts three times. --Hospice activity three times. --Television/Movie once. --Beauty salon twice. --Evening activity once. --Entertainment once. --Games twice. -The resident had 13 days out of 30 with no documented activities. Review of the facility's list of residents who were COVID-19 positive in November 2023 and December 2023 showed the resident tested positive for COVID-19 on 11/29/23. Review of the resident's Physician's Order Sheet (POS) dated December 2023 showed physician's orders for contact precautions/isolation dated 11/29/23 for ten days. Observation on 12/4/23 showed: -At 11:09 A.M.: --The resident was not in his/her room. --A red sign was on the wall outside the resident room that said to report to the nurses' station before entering the resident's room and there was an isolation cart outside the resident's room. -At 11:15 A.M., the resident was talking to Resident #12 in the dining room. -From 1:06 P.M. to 1:16 P.M.: --The resident self-propelled away from the dining room table and over to this writer/state surveyor. --The resident was talking but most of it did not make any sense. --The resident pointed to a flower painting on the wall and said it was pretty. --The resident offered this writer/state surveyor the food on the dining room table. --The resident started humming to the music on in the dining room. --The resident asked, Where was I going to go? -From 2:21 P.M. to 2:58 P.M.: --At 2:21 P.M.: ---The resident was in the dining room with his/her eyes closed with no activity. ---Staff tried to take the resident's vitals but the resident did not them want to. -At 2:37 P.M., staff took the resident's vitals. -At 2:47 P.M., the resident was talking to another resident. --The resident had no activities during the time of observation. Continuous observation on 12/5/23 from 9:54 A.M. to 10:37 A.M. showed: -At 9:54 A.M., the resident was sitting at a dining room table eating a honey bun and talking to another resident for a couple of minutes. -At 10:11 A.M., the resident was sitting in the dining room with no activity. -At 10:15 A.M., the resident propelled to a table where another resident was playing tic-tac-toe with staff and watched them play. -At 10:20 A.M., the resident propelled to another and talked to another resident. -At 10:33 A.M., the resident propelled to a table where a staff member was feeding another resident. -At 10:35 A.M., the resident propelled back to the original table with no activity. Continuous observation on 12/6/23 from 6:54 A.M. to 7:35 A.M. showed: -At 6:54 A.M., the resident was in his/her wheelchair in the dining room, propelling around holding an insulated coffee cup. -At 7:02 A.M., the resident was propelling around the dining room. -The resident stopped and asked another resident if it was time for breakfast. -The resident wheeled down the hall toward his/her room. -At 7:25 A.M., the resident returned to the dining room and sat in the dining room with no activity. -At 7:35 A.M., the resident was served breakfast. Continuous observation on 12/6/23 from 9:28 A.M. to 10:55 A.M. showed: -At 9:28 A.M.: --The resident was wheeling around in the dining room. --The resident stopped behind another resident where audio exercise instructions were playing. --Two residents were present in the area and were participating in the exercises. --No staff were in the area where the audio exercise instructions were playing. --The resident did not participate and wheeled away to another part of the dining room. -At 9:44 A.M., a staff member asked the resident if he/she wanted to play Jenga and the resident said no. -The resident propelled over by a table where three other residents were and then wheeled around the dining room. -At 10:24 A.M., the resident wheeled to the nurses' station, then over to a table where four other residents were sitting. -The resident wheeled to another table with no activity. Continuous observation on 12/07/23 from 9:45 A.M. to 10:52 A.M. showed: -At 9:45 A.M.: --The resident was in his/her wheelchair in the dining room where two staff and two other residents were. --The other two residents were coloring. --The resident had no activity. --The resident wheeled away from that table. -At 9:51 A.M., the resident wheeled up to another dining room where he/she sat alone with no activity. -At 9:58 A.M., the resident was propelling around in the dining room with no activity. -At 10:00 A.M., the resident was resting his/her head on the palm of his/her hand with his/her eyes closed. -At 10:06 A.M., the resident wheeled over to table where two staff and two other residents were, then wheeled toward one of the halls and then returned to the same table. -At 10:20 A.M., the resident was eating a honey bun. -At 10:28 A.M., the resident wheeled another table and was sitting with no activity. -At 10:40 A.M.: --The resident wheeled out of the dining room and down one of the halls. --The resident wheeled back into the dining room and sat next to another resident with no activity. Review of the resident's Individual Resident Daily Participation Records showed there was no record for the resident for December 2023. During an interview on 12/8/23 at 9:28 A.M., the Activity Director said: -He/she asked residents when they first came to the facility what their interests were. -If the resident could not provide the information, he/she tried to talk to family of the resident to get the information. -If there were staff who spent a lot of time with a resident, he/she asked them what the resident liked to do. -He/she tried to ask more details like what they like to read, what games they like, what television shows or movies they like, etc. -He/She did the activity assessments, progress notes and logged activity participation. -The resident did exercises about 80% of the time in morning and would watch if not actively participating. -The resident did some coloring and some arts and crafts, if encouraged. -The resident would stay at an activity for a while, may wander off but usually came back. -The resident's spouse is unable to visit very often. -The resident's spouse said the resident did housecleaning. -He/she gave the resident things, and he/she would mess with them, try to take it apart or put it together. During an interview on 12/11/23 at 10:29 A.M., CMT B said: -The resident liked to color. -The resident did not watch television. -They had crosswords available for something to do with the residents. During an interview on 12/11/23 at 11:23 A.M., the DON said: -It was difficult to get the resident to do anything. -He/she would have to brainstorm with staff to think of things the resident might do. -It was difficult to keep the resident's attention for any amount of time. -He/she saw the resident play a game with a ball in which he/she threw the ball and then wandered off. -The resident had conversations, but it usually didn't make any sense. -Activities should be based on the resident's likes, dislikes and preference as much as possible. -The activities staff or CNA's were the ones who were responsible for doing one on one activities with the residents on isolation.<B

Based on observation, interview, and record review, the facility failed to ensure the residents' prescribed medications were stored in the medication refrigerator; to ensure the residents' prescribed medications that had been opened, had the date written that they had been opened written on the container; and to ensure non medical items were not stored with the residents' medications. The facility census was 54 residents. Review of the facility's policy, Administering Medications, dated December 2012 showed: -The Director of Nursing Services would supervise and direct all nursing personnel who administer medications and/or have related functions. -When opening a multi-dose container, the date opened should have been recorded on the container. Review of the facility's policy, Storage of Medications, dated April 2007 showed: -Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. -Medications must be stored separately from food and must be labeled accordingly. -The nursing staff would be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 1. Observation on 12/5/23 at 3:30 P.M. of the medication refrigerator in the medication room with Licensed Practical Nurse (LPN) B showed: -A resident's Daptmomycin (an antibiotic) 500 milligram (mg) intravenously (IV medication administered through a tube through the skin into a vein) medication was in same refrigerator with the resident's food. -There was a separate medication refrigerator in the medication room. During an interview on 12/5/23 at 3:35 P.M. LPN B said: -The residents IV medication should not have been in the residents' refrigerator with the resident's opened food and drinks. -The IV medication should have been stored in the medication refrigerator not in the refrigerator with food in it. 2. Observation on 12/5/23 at 3:40 P.M. of the Cherry/Peach Certified Medication Technician (CMT) medication cart with CMT A showed: -A resident's prescribed Levetiracetam (an anti seizure medication) a 16 ounce bottle was opened without an opened date written on it. -Two resident's prescribed Potassium Chloride (a mineral supplement used to treat low levels of Potassium), 473 milliliter (ml) bottles were opened without an opened date written on it. -A 24 ounce bottle of chocolate syrup was in with the residents' medications. 3. Observation on 12/5/23 at 3:50 P.M. of the Orange hall CMT medication cart showed: -A residents prescribed Potassium Chloride, a 473 ml bottle was opened without an opened date written on it. 4. During an interview on 12/5/23 at 3:55 P.M. CMT A said: -Refrigerated medications should go in the medication refrigerator. -The resident's medications should have had a date it was opened written on it. -Who ever opened the medication should have written the date it was opened on it. -Each person who used the medication cart was responsible to keep it clean and there should not be other items in the medication cart, like the chocolate syrup. -The Director of Nursing (DON) was responsible to ensure the medications were taken care of as they should be. During an interview on 12/6/23 at 7:30 A.M. the DON said: -The resident's IV mediation should not have been in the resident's food refrigerator. -The IV medication should have went in the medication refrigerator. -Medications that have been opened should have had the date they were opened written on it. -If the chocolate syrup was used to give the medications it should have been in it's own compartment not in with the residents' medications. -The charge nurse should have been auditing the medication refrigerator and carts.

Based on interview and record review, the facility failed to include parameters for monitoring a resident's pulse when monitoring for medication administration and for failing to clarify a physician's order for administering an as needed blood pressure medication when the resident's blood pressure was elevated for one sampled resident (Resident #35) out of five residents sampled for medication review. The total sample was 14 residents. The facility census was 54 residents. Review of the facility's policy titled Medication Orders dated September 2014 showed it did not address parameters or order clarification. 1. Review of Resident #35's care plan dated 2/16/23 and updated on 7/30/23 showed the resident had high blood pressure and included instructions to staff to administer blood pressure medications as ordered and monitoring the resident's blood pressure. Review of the resident's consultant pharmacist's recommendation dated 6/13/23 showed instructions to add Do not crush to the resident's Flomax (tamsulosin) (used to improve urination in men with an enlarged prostate) order. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 10/26/23 showed the following staff assessment of the resident: -Moderately cognitively impaired. -Had a diagnosis of high blood pressure. Review of the resident's Medication Administration Record (MAR) dated November 2023 showed: -A physician's order dated 6/15/23-11/10/23 for Tamulosin 0.4 milligrams (mg), one capsule, one time a day. Do not crush. -A physician's order dated 11/10/23 for Tamulosin 0.4 milligrams (mg), two capsules, one time a day. --NOTE: The order did not include the instructions do not crush. -A physician's order for Amlodipine (a medication used to treat high blood pressure) 10 mg, one tablet one time a day and it included blood pressure and pulse monitoring (the time was not indicated for this order) with no parameters indicated. --On 11/4/23, the resident's blood pressure was 169/72. --On 11/5/23, the resident's blood pressure was 165/87. --On 11/18/23, the resident's blood pressure was 199/96. --On 11/19/23, the resident's blood pressure was 185/90. -A physician's order for Clonidine (a medication that lowers blood pressure and heart rate) 0.1 mg, give one tablet two times a day with no blood pressure parameters indicated. -A physician's order to monitor the resident's blood pressure two times a day. If the systolic blood pressure (SBP-The top number measures the pressure in the arteries when the heart beats) was less than 100, hold all blood pressure medications and notify the resident's physician. If the SBP was greater than 160, give as needed Clonidine. --On 11/4/23 during the A.M., the resident's blood pressure was 169/87. --On 11/5/23 during the A.M., the resident's blood pressure was 165/87. --On 11/18/23 during the A.M., the resident's blood pressure was 199/96. --On 11/18/23 during the P.M., the resident's blood pressure was 197/88. --On 11/19/23 during the A.M., the resident's blood pressure was 185/90. --On 11/25/23 during the P.M., the resident's blood pressure was 168/92. -No order for as needed Clonidine. -A physician's order dated 10/18/23-11/24/23 for Hydralazine (a medication used to treat high blood pressure) 50 mg, give one tablet four times a day with blood pressure and pulse monitoring. ---On 11/4/23 at 8:00 A.M., the resident's blood pressure was 169/87 --On 11/9/23 at 8:00 P.M., the resident's blood pressure was 165/84. --11/18/23 at 8:00 A.M., the resident's blood pressure was 199/96. --11/18/23 at 5:00 P.M., the resident's blood pressure was 197/88. --11/19/23 at 8:00 A.M., the resident's blood pressure was 185/90. --11/19/23 at 8:00 P.M., the resident's blood pressure was 162/98. -A physician's order dated 11/24/23 for Hydralazine 100 mg, give one tablet three times a day with blood pressure and pulse monitoring. -The resident's blood pressure medications were administered on every occasion above but no as needed Clonidine was administered on every occasion the resident's SBP was over 160 as there was no physician's order for as needed Clonidine. Review of the resident's notes dated November 2023 showed no notes regarding the resident's SBP being over 160 or anything about the as needed Clonidine order. Review of the resident's MAR dated December 2023 showed: -A physician's order dated 11/10/23 for Tamulosin 0.4 (mg), two capsules one time a day. --NOTE: The order did not include the instructions do not crush. -A physician's order for Amlodipine 10 mg, one tablet one time a day and it included blood pressure and pulse monitoring (the time was not indicated for this order) with no parameters indicated. -A physician's order for Clonidine 0.1 mg, give one tablet two times a day with no blood pressure parameters indicated. -A physician's order to monitor the resident's blood pressure two times a day. If the SBP was less than 100, hold all blood pressure medications and notify the resident's physician. If the SBP was greater than 160, give as needed Clonidine. --On 12/6/23 during the P.M., the resident's blood pressure was 187/96. -A physician's order dated 11/24/23 for Hydralazine 100 mg, give one tablet three times a day with blood pressure and pulse monitoring. --On 12/6/23 at 8:00 P.M., the resident's blood pressure was 187/96. --On 12/7/23 at 8:00 A.M., the resident's blood pressure was 167/78. -No order for as needed Clonidine. -The resident's blood pressure medications were administered on every occasion above but no as needed Clonidine was administered on every occasion the resident's SBP was over 160 as there was no physician's order for as needed Clonidine. Review of the resident's notes dated December 2023 showed no notes regarding the resident's SBP being over 160 or anything about the as needed Clonidine order. During an interview on 12/08/23 at 1:21 P.M., Licensed Practical Nurse (LPN) A said: -The resident had an as needed order for Clonidine in the past. -He/she didn't know if the as needed order was discontinued. -Nursing staff should have clarified the orders with the resident's physician. -The resident's physician has standing orders to be notified if a resident's SBP is under 100 or the pulse is under 60, and the medication held until the physician determined whether to go ahead and administer the medication or not. -The resident had an order for Flomax before going to the hospital. -When the resident returned from the hospital, whoever entered in the resident's orders picked a Flomax order that did not include Do not crush. -When the resident's SBP was above 160, he/she would have expected the Certified Medication Technicians to look for the as needed Clonidine order and notify the nurse that there was no as needed order. -Then the nurse should call the physician and clarify the order. -There were no standing orders for elevated SBP. During an interview on 12/11/23 at 11:23 A.M., the Director of Nursing (DON) said: -He/she would have to educate the nursing staff to pick the most recent order upon a hospital return and re-instate the one that said do not crush for Flomax as there were more than one orders in their system for Flomax for the resident. -If pulse and blood pressure were requested on the MAR, he/she would expect there to be parameters for both. -He/she would expect the nursing staff to call the doctor and verify the Clonidine orders as to whether there still should have been an as needed order.

Based on interview, and record review the facility failed to ensure there was documentation of the contracted hospice (end of life care) company's visits for one sampled resident, (Resident #29) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's policy, Coordination of Hospice Services, dated 11/23/22 showed: -The facility maintained written agreements with hospice providers that specify the care and services that were to have been provided and the process for hospice and the nursing home communication of necessary information regarding the resident's care. -The facility would maintain communication with hospice as it related to the resident's plan of care and services to ensure each entity was aware of their responsibilities. 1. Review of Resident #29's face sheet showed he/she was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that make it hard to breathe). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 10/20/23 showed: -He/She had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating he/she was moderately cognitively impaired. -He/she had Cardiorespiratory (heart and lung) conditions. -He/she had COPD. -He/she had a condition that may result in life expectancy of less than six months. -He/she was on hospice care. Review of the resident's Physician Order Sheet (POS) dated December 2023 showed: -The resident was admitted to a hospice company on 7/13/23 for COPD. -The resident was a Do Not Resuscitate (DNR no life saving measures if the heart stops) status. Review of the resident's undated care plan showed: -He/she had a DNR code status. -He/she was utilizing hospice services. Review of the resident's hospice collaboration log on 12/4/23 at 9:43 A.M. showed no documentation from 7/13/23 to 12/4/23. Review of the resident's hospice notebook for the resident on 12/4/23 at 9:45 A.M. showed: -Last documentation of cares done with the resident on Hospice sheet was 11/3/23. -There was only one sheet filled out documenting cares in the notebook from 7/13/23 to 12/4/23. During an interview on 12/6/23 at 1:30 P.M. Licensed Practical Nurse (LPN) A/Charge Nurse (CN) said: -They (facility staff) were given an oral report and never looked at the book. -They (facility staff) were not able to verify when the hospice staff visited the resident. -The resident was seen weekly by the hospice company. -There was documentation only on 11/3/23 of their visit. -They were to document what they did on their visits collaboration log each time they came. -The hospice nurse was to visit the resident at least weekly and as needed. -The Home Health Aide was to have come once or twice a week to bathe the resident. -It should have been on his/her care plan. -The Director of Nursing (DON) was ultimately responsible for ensuring documentation had been done. During an interview on 12/7/23 at 12:00 P.M. the resident said: -He/she has been on hospice services for a few months. -He/she did not know how often they came. -A nurse would come sometimes. -A Home Health Aide would come to bathe him/her once or twice a week. During an interview on 12/7/23 at 2:00 P.M. the Administrator said: -The hospice company was not doing weekly documentation. -There was no documentation from the hospice company since 11/3/23. -The DON was responsible to ensure the company was documenting their visits. During an interview on 12/11/23 at 11:15 A.M. the DON said: -The facility had a contract for hospice to provide services for the resident. -The hospice staff should have been documenting what was done during their visits. -The documentation should have been in the communication binder. -The hospice staff should have documentation for every time they visited the resident and they have not been doing it for this resident. -He/she was ultimately responsible and had not checked the documentation.

Based on observation, interview, and record review, the facility failed to ensure a resident's oxygen tubing was not on the floor; to ensure the plastic storage bag for the oxygen tubing was not on the floor; to ensure his/her nebulizer (a machine that turned liquid medication into a mist that was easily inhaled) was not on the floor; to ensure the resident's oxygen tubing was changed weekly with the date written on the storage bag for one sampled resident (Resident # 29) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's undated policy, Oxygen Tubing and Cannula (part of the oxygen tubing that goes into a person's nose) Storage Policy and Procedures, showed: -Oxygen Tubing and cannulas would be replaced weekly and as needed by the nursing staff. -When not in use Oxygen tubing or cannulas for each resident would be confined in a bag. -Any tubing or cannulas found on the floor would be replaced by the nursing staff immediately. -Storage bags would be dated as to the date the tubing and cannula were replaced. 1. Review of Resident #29's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 10/20/23 showed: -His/her Brief Interview for Mental Status (BIMS) score was 11 out of 15 indicating he/she was moderately cognitively impaired. -He/she had COPD. -He/she had a Cardiorespiratory (relating to both the heart and lungs) condition. Review of the resident's undated care plan showed: -He/she was on oxygen therapy related to an ineffective gas exchange. -Staff were to give medications as ordered. -He/she was on Hospice (end of life care). Review of the resident's Physician's Order Sheet (POS) dated December 2023 showed: -After each use, wipe the nebulizer mask with a clean damp cloth. -Rinse the nebulizer chamber with warm tap water and allow to air dry each shift, dated 1/1/23. -Change the nebulizer tubing and mask every Tuesday night shift, dated 3/14/23. -Oxygen at four liters per nasal cannula every shift, dated 4/19/23. -Change the oxygen tubing, bag, and humidifier every Tuesday night shift, dated 3/14/23. -Ipratropium and Albuterol (a combination medication used to treat COPD) 0.53(2.5) milligram) (mg)/3 mg one vial inhale orally every four hours related to COPD, dated 4/19/23. -Ipratropium and Albuterol 0.53(2.5)mg/3 mg one vial inhale orally every three hours as needed related to COPD, dated 4/19/23. Observation on 12/4/23 at 9:30 A.M. showed: -The resident was on four liters of oxygen. -He/she said staff change the tubing out every other week or so. -The floor in the corner of the resident's room was sticky. -The oxygen tubing was stuck to the floor and dated 11/7/23. -The oxygen tubing storage bag was stuck to the floor. -The nebulizer was stuck to the floor. Observation on 12/5/23 at 2:00 P.M. showed: -The floor was still sticky. -The oxygen tubing was stuck to the floor. -The oxygen tubing storage bag was stuck to the floor. -The nebulizer was stuck to the floor. Observation on 12/6/23 at 7:45 A.M. showed: -The floor was still sticky. -The date on the bag the Oxygen tubing was in was 11/7/23. -The oxygen tubing was stuck to the floor. -The oxygen tubing storage bag was stuck to the floor. -The nebulizer was stuck to the floor. During an interview on 12/6/23 at 7:45 A.M. Certified Nursing Assistant (CNA) C said: -The oxygen tubing was to have been changed on Tuesdays during the night shift. -The oxygen tubing was stuck to the floor. -The oxygen tubing storage bag was stuck to the floor. -The nebulizer was stuck to the floor. -The date on the oxygen tubing bag was 11/7/23. -The house keeper cleaned daily but the floor was very sticky. During an interview on 12/6/23 at 7:46 A.M. Certified Medication Technician (CMT) A said: -On Tuesday nights they change out the oxygen tubing. -The date on the oxygen tubing storage bag was 11/7/23. -The nebulizer should not be on the floor. -The oxygen tubing should not have been on the floor. -The oxygen tubing storage bag should not have been on the floor. -Housekeeping cleaned daily and should have cleaned that corner where the residents nebulizer was. During an interview on 12/6/23 at 10:15 A.M. Licensed Practical Nurse (LPN) A said: -Housekeeping cleaned the residents' rooms daily. -The floor should not have been sticky. -Oxygen tubing should not have been on the floor. -The oxygen tubing storage bag should not have been on the floor. -The nebulizer machine should not be on the floor. -On Tuesday nights the CNA's change the oxygen tubing. -The CNA's should have written the date on the bag when it was changed. During an interview on 12/11/23 at 11:15 A.M. the Director of Nursing (DON) said: -Oxygen tubing should have been changed weekly by the night CNA's on Tuesdays. -The date it was changed should have been written on the storage bag. -The nebulizer should never have been on the floor. -The oxygen tubing should never have been on the floor. -The oxygen tubing storage bag should have never been on the floor. -Housekeeping cleaned the floors daily it should not have been sticky. -The nurses were responsible to ensure the oxygen tubing, oxygen concentrator, and nebulizer were kept clean.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident # 42) had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #31) continued refusals to take his/her [MEDICATION(S)]; to ensure [MEDICATION(S)] was not given with other medications or foods according to the manufacturer's instructions for three sampled residents (Resident #39, #42, and #56) and to administer medications within one hour of the medication administration time for one sampled resident (Resident #56) out of 18 sampled residents. The facility census was 70 residents. Record review of the facility's policy, Medication Monitoring/Medication Management, dated August 2014 showed: -In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician prescribes, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. -When a resident receives a new medication the order was to have been evaluated for a written diagnosis. -The resident was not taking other medication, nutritional supplement, including herbal products, or foods that would be incompatible with the prescribed medication. Record review of the facility's policy, Medication and Treatment Orders, dated July 2016 showed orders for medications must include the clinical condition or symptoms for which the medication was prescribed. Record review of the facility's policy, Administering Medications, dated April 2019 showed: -The Director of Nursing (DON) Services supervises and directs all personnel who administer medications. -Medications were to be administered in accordance with the prescriber's orders, including any required time frame. -Medication administration times were determined by the resident's need and benefit. -Factors that were considered included; enhancing the optimal therapeutic effect of the medication and preventing potential medication or food interactions. -Medications were to be administered within one hour of their prescribed times unless otherwise specified. Record review of the manufacturer's undated instruction for [MEDICATION(S)] showed: -The medication should be taken on an empty stomach preferably 30 to 60 minutes before breakfast. -Products such as Iron, Calcium and Antacids lower the body's ability to absorb [MEDICATION(S)] so the medication should be taken four hours before or after taking these products. 1. Record review of Resident #42's Face sheet showed he/she was admitted on [DATE] with no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's May 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review the resident's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] was scheduled to be given at 8:00 A.M. --The resident was given [MEDICATION(S)] at 8:07 A.M. -[MEDICATION(S)] Sulfate was scheduled to be given at 8:00 A.M. --The resident was given [MEDICATION(S)] Sulfate at 8:07 A.M. -Multivitamin was scheduled to be given at 8:00 A.M. --The resident was given Multivitamin at 8:07 A.M. Observation on 5/13/22 from 7:30 A.M. to 8:30 A.M. of the morning medication pass with Certified Medication Technician (CMT) B showed: -The resident was at the table eating at 8:00 A.M. -The CMT gave the resident [MEDICATION(S)], [MEDICATION(S)] Sulfate, and a multivitamin which contained Calcium while he/she was eating. During an interview on 5/13/22 at 8:10 A.M. CMT B said he/she would not have done anything different. During an interview at on 5/13/22 at 9:00 A.M. Licensed Practical Nurse (LPN) C said: -[MEDICATION(S)] should be given an hour before meals. -It should not be given with any other medications. -It should have been scheduled at 6:00 A.M. and given by the night shift. 2. Record review of Resident #56's Face sheet showed he/she was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's May 2022 POS showed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's May 2022 EMAR showed: -[MEDICATION(S)] was to be given at 6:00 A.M. before breakfast. -The medication was signed off as given at 6:00 A.M. every day including 5/13/22. -The EMAR showed the medication was given at 7:39 A.M. Observation on 5/13/22 at 7:21 A.M. of medication pass showed: -CMT B gave the resident [MEDICATION(S)] at 7:21 A.M. -Breakfast was served to the resident at 7:35 A.M. -The resident began to eat breakfast as soon as it was served (less than 30 minutes from the time the medication was administered). 3. Record review of Resident #39's Face sheet showed he/she was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's May 2022 POS showed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M., dated 3/5/21. Record review of the resident's May 2022 EMAR showed: -[MEDICATION(S)] was to be given at 6:00 A.M. before breakfast. -The medication was signed off as given at 6:00 A.M. every day including 5/13/22. -The EMAR showed the medication was given at 7:21 A.M. on 5/13/22. Observation on 5/13/22 at 7:21 A.M. of medication pass showed: -CMT B gave the resident [MEDICATION(S)] at 7:25 A.M. -Breakfast was served to the resident at 7:30 A.M. -The resident began to eat breakfast as soon as it was served (less than 30 minutes from the time the medication was administered). During an interview on 5/13/22 at 12:01 P.M. Acting DON said: -[MEDICATION(S)] should not be given with any medications and before eating. -Education with the staff would need to be done. -The staff was expected to sign off the medication as soon as it was given. During an interview on 5/16/22 at 1:44 P.M. CMT B said: -[MEDICATION(S)] was always given at 6:00 A.M. -It should be given on an empty stomach. -It used to be given by the night shift. During an interview on 5/17/22 at 8:04 A.M. CMT A said: -There were three residents who were on [MEDICATION(S)]. -The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. -The night shift should have given it but they do not. -It flags on his/her shift to be given. -The resident will not take his/her medications until food is in front of him/her. Observation on 5/17/22 from 8:00 to 8:45 A.M. showed: -Breakfast was served at 8:05 A.M -The resident received his/her medication at the time the food was served. -The resident had taken two bites before swallowing the medication. 4. Record review of Resident #31's face sheet showed he/she was readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's March 2022 POS showed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. dated 2/3/22. Record review of the resident's March 2022 EMAR showed -The resident only took the medication once on 3/13/22. -The resident refused the medication the other 30 days. Record review of the resident's April 2022 POS showed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. dated 2/3/22. Record review of the resident's April 2022 EMAR showed the resident refused the medication all 30 days. Record review of the resident's May 2022 POS showed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. dated 2/3/22. Record review of the resident's May 2022 EMAR showed: -The resident only took the medication once on 5/1/22. -The resident refused the medication the other 16 days. During an interview on 5/17/22 at 8:04 A.M. CMT A said: -The resident had [MEDICATION(S)] ordered at 8:00 A.M. -He/she refused the [MEDICATION(S)] every day. -He/she had told the charge nurse a couple of months ago. -The nurse had notified the Physician. -The Physician had changed the prescription. -The resident still refused the [MEDICATION(S)]. -The resident has refused to take the [MEDICATION(S)] for three months. -The [MEDICATION(S)] was destroyed each day. -The resident was charged for it. -He/she did not know that you were not supposed to give [MEDICATION(S)] with other medications. -[MEDICATION(S)] should be given 30 minutes before meals. During an interview on 5/17/22 at 8:57 A.M. LPN A said: -[MEDICATION(S)] should be given one hour before eating. -It was difficult to get the residents on the locked unit to take medications. -It was best to attempt to give them their medications while they were sitting up or eating. -The resident refused to take his/her [MEDICATION(S)] every day. -The Physician was notified the resident refused to take his/her [MEDICATION(S)] and the Physician changed the order so the pill would look different. -The resident still refused to take his/her [MEDICATION(S)]. -It has been three months since the Physician had changed the order (2/3/22). -It should be on the care plan that the resident refused the [MEDICATION(S)]. -The Physician should have been called to discontinue the order. -He/she should have notified the Physician the [MEDICATION(S)] was refused daily. -The [MEDICATION(S)] was destroyed every day. -The resident was charged for it. Record review of the resident's undated care plan showed a consistent refusal of medical treatment, including any therapeutic changes to medications. During an interview on 5/17/22 at 2:25 P.M. the acting DON said: -[MEDICATION(S)] should not be given with any other medications. -[MEDICATION(S)] should be given on an empty stomach before meals. -There should have been a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -The nurse should have notified the Physician when a resident had refused a medication after one week.

Based on observation and interview, the facility failed to ensure a medication cart on the secured unit was locked while staff went into a resident's room to administer a medication. The facility census was 70 residents. Record review of the facility's policy, Administering Medications, dated April 2019 showed, during the administration of medications, the medication cart was to be kept closed and locked when out of sight of the medication nurse or aide. 1. During an interview on 5/13/22 at 11:55 A.M. Licensed Practical Nurse (LPN) A said on the secured unit staff have to be very careful because there were two residents who were shoppers and would take belongings that did not belong to them, including off the medication cart. Observation on 5/13/22 at 12:02 P.M. during the medication pass with LPN A showed: -The medication cart was left unlocked while he/she went into a resident's room to check the resident's blood sugar. -The unlocked medication cart was out of site for three minutes while his/her back was turned and he/she checked the resident's blood sugar. -During the time the nurse was in the resident's room one of the known shoppers was in the hallway within one foot of the unlocked medication cart looking at the items on top of the medication cart. -The medication cart was left unlocked a second time while he/she went into the resident's room to administer the resident's insulin. -The unlocked medication cart was out of site for two minutes while his/her back was turned and he/she administered the resident's insulin. -During the time the nurse was in the resident's room the same shopper was still in the hallway within one foot of the unlocked medication cart looking at the items on top of the medication cart. -He/she would not have done anything different during the medication administration. During an interview on 5/17/22 at 8:04 A.M. Certified Medication Technician (CMT) A said: -The medication cart should be kept locked at all times. -The residents would take things off of the cart. -Even when the cart was locked the residents have taken chocolate drinks off of the top of the cart. -There are a couple of shoppers who had known behaviors of taking things, including off the medication cart. During an interview on 5/17/22 at 8:57 A.M. LPN A said: -The medication cart should have always been locked as this was a Memory Care Unit. -The residents have behaviors where they take things that do not belong to them. During an interview on 5/17/22 at 2:25 P.M. the acting Director of Nursing (DON) said: -He/she would expect the medication carts to be kept locked. -The residents on the locked unit would mess with the cart if it was not locked.

Based on observation, interview and record review, the facility failed to meet sanitary conditions and practice sanitary procedures for food and non-food contact surface areas before, during and after food preparation tasks. This deficient practice of not keeping food and non-food contact surfaces sanitary could, potentially, promote microorganisms and bacterial growth which could adversely affect the health and well-being of the residents and staff who partake of the meals prepared by the dietary staff. The facility census was 70 residents at the time of the survey. 1. Observations on 5/11/22 at 8:34 A.M. during an initial brief tour of the kitchen and on 5/13/22 between 5:07 A.M. and 1:10 P.M. in the kitchen during the facility's kitchen inspection, showed the following: -A piece of juice dispensing equipment consisting of one hand-held gun with one nozzle connected to six different beverage tubes. All of the beverage tubes were dispensed through the one dispensing gun's nozzle. The flavors of the tubing were beverages of orange juice, fruit punch, cranberry juice, apple juice, and water. These nozzles were sticky with multi-colored debris on the inside and outside of the gun and nozzle. -The kitchen grill was black with burnt on food preparation debris and food. -The microwave oven had cooked on debris on the sides, on the top and bottom of the appliance. -The wooden cabinets located above the food processor were greasy and gritty to the sight and touch. During an interview on 5/13/22 at 1:08 P.M., the Dietary Supervisor said: -He/she thought that the beverage gun and nozzle was on the cleaning schedule along with the kitchen cabinets and microwave oven. -He/she acknowledged that the nozzles of the juice and beverage dispensing equipment was not listed on any cleaning schedules, but would be placed on one. -The kitchen cabinets were placed on the weekly cleaning schedule but did not know why they were still greasy and gritty. -He/she had not had time that day to clean the microwave oven. Review of the 2013 edition of the U.S. Department of Health and Human Services, Food and Drug Administration (FDA) Food Code, Chapter 4-701.10, showed, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED. Review of the 2013 edition of the U.S. Department of Health and Human Services, Food and Drug Administration (FDA) Food Code, Chapter 4-702.11, showed, UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be before use after cleaning. Review of the 2013 edition of the U.S. Department of Health and Human Services, Food and Drug Administration (FDA) Food Code, Chapter 6-601.11, showed, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on interview and record review, the facility failed to ensure they completed a check of the Employee Disqualification List (EDL) and/or Criminal Background Check (CBC) and/or the Nurse Aide (NA) Registry to ensure they did not have a Federal Indicator (FI-a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prior to hire for two sampled staff out of 10 staff sampled. The facility census was 70 residents. Record review of the facility's abuse prevention policy updated November 2017 showed: -A request for a CBC would be completed no later than two working days of the date an applicant for a position to have contact with residents is hired. -An EDL check would also be completed. -The policy did not address the NA registry. -The facility would not employ individuals who had been found guilty of abusing, neglecting or mistreating elders by a court of law. 1. Record review of the facility's list of employees hired since their last annual survey showed Employee D was hired on 4/6/22. Record review of Employee D's employee files showed his/her CBC was requested, the EDL was checked and the NA registry was checked for employee D on 5/17/22 (41 days after date of hire). 2. Record review of the facility's list of employees hired since their last annual survey showed Employee J was hired on 12/6/21. Record review of employee J's employee files showed the EDL was checked for Employee J on 12/7/21 (one day after date of hire). 3. During an interview on 5/17/22 at 11:03 A.M.: -The Administrator said they did not know they needed to check the EDL prior to hire if they did not have the results back from the Family Care Safety Registry (FCSR-helps to protect long-term care residents by providing background information on employees or prospective employees) prior to the employee's date of hire. -The business office manager said: --They were using the FCSR for EDL checks. --He/she did not know they should do an EDL check separate from FCSR if they did not have the results from the FCSR prior to the employee's date of hire. --Employee D's screenings were missed prior to hire so they ran them today.

Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR- an emergency procedure that is performed when a person's heartbeat or breathing has stopped), and failed to call emergency medical services (EMS) in a timely manner, for one sampled resident (Resident #4) with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 65 residents. The Administrator was notified on [DATE] at 12:46 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Record review of the facility's CPR policy, dated [DATE], showed: -Facility staff will provide care according to residents wishes and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -When appropriate, CPR will be initiated by facility staff and continue under paramedics/EMT's (Emergency Medical Services staff qualified to provide basic life support including CPR) arrive to relieve facility staff and take over the CPR procedure. -CPR will be attempted for any resident who is found to have no palpable pulse (the rhythmic dilation of an artery that results from beating of the heart measured by feeling the arteries of the wrist or neck) and/or no discernable respirations (observable breathing) unless there is a written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Code status will be obtained from the resident's physician for each resident upon admission. -Code status will be updated on the residents chart when/if changed. -Staff will be responsible for knowing the status of every resident for whom they have responsibility during each shift. -When a resident is found to be unresponsive staff will: --Call for help using call system or verbally alerting other staff on duty. --Verify code status (full code or DNR); if code status is not known and cannot be immediately determined assume full code. --Initiate emergency procedures, call 911, obtain equipment - hard surface, sphygmomanometer (blood pressure cuff), stethoscope (a medical instrument used in listening to sounds produced within the body, chiefly in the heart or lungs), oxygen, suction machine, disposable CPR mask (two way valve CPR mask). --If the resident is a full code a staff person initiates CPR according to the current Basic Life Support (BLS- a course that trains participants to promptly recognize several life-threatening emergencies, give high-quality chest compressions and deliver appropriate ventilation, i.e. breaths) guidelines and a second person acts as a messenger to assist the first staff person. --The messenger ensures stat to room ---is announced overhead and emergency personnel and physician is notified. --CPR will continue until EMS personnel arrive and take over the process. --One person may be designated as a recorder during the code to record details during the event. -Documentation should include: --Date and exact time condition change was observed. --Results of initial assessment including vital signs (body temperature, pulse rate, breathing rate and blood pressure) or absence of vital signs. --Exact time CPR was initiated. Exact time emergency personnel arrived and/or resident was transferred to hospital. --Physician and family notification. --Physician orders. --If resident expires, document time resident was pronounced dead. 1. Record review of Resident #4's Face Sheet showed: -Was admitted to the facility on [DATE]. -Had a code status of Full Code. Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning), dated [DATE], showed: -Was severely cognitively impaired. -Had no functional limitations in range of motion of his/her upper (neck, shoulders, arms, wrists, hands) or lower extremities (legs and feet). Record review of the resident's care plan, printed on [DATE], showed: -Was a full code (onset date [DATE]). -Wanted CPR or life saving measures to be performed. -Wanted chest compressions administered if found with no heartbeat. -Wanted resuscitation (the procedure of restoring to life, as in CPR). Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Nurse's Note, written by Registered Nurse (RN) A, dated [DATE] at 6:05 A.M., showed: -A Certified Nursing Assistant (CNA) summoned RN A to the resident's room. -The resident was without breath sounds and pulse. -RN A notified the Nurse Practitioner (NP- licensed, autonomous clinician focused on managing health conditions and preventing disease) for the resident's physician. -RN A notified the resident's family member. -The resident's family member stated he/she would get back with the facility regarding a funeral home. -RN A notified the Director of Nursing (DON). Record review of the resident's Nurse's Note, dated [DATE] at 2:34 P.M., showed the resident's body was released to a funeral home with the physician's permission at approximately 10:10 A.M. Record review of the resident's Nurse's Note, written by RN A, dated [DATE] at 1:15 A.M., showed -The note was a late entry for [DATE] at 5:35 A.M., -The CNA asked the nurse to assess the resident as CNA conveyed the resident may have expired. -RN A's assessment findings were: --The resident's body was cold to touch. --Heart tones (noises produced by the beating heart) were not present. --Breath sounds were not present. --Pulses bilaterally (both sides of the body) were not present. --The resident's extremities (outer limbs, i.e. arms and legs), upper and lower were completely fixed (tightened) and rigid (stiff). --His/Her skin color was ash (whitish gray). --His/Her nail beds (skin beneath the finger/toe nails) and lips were blue (signs of lack of oxygen). -RN A documented he/she reported all assessments to the resident's NP immediately. -The resident's NP told RN A to notify the resident's family. -RN A notified the resident's family immediately of the assessment findings. -The resident's son would call the facility regarding funeral home. -RN A conveyed the assessment findings and conversations to the DON. Record review of the facility Investigation Summary Form, dated [DATE], showed: -The date and time of the event was [DATE] at 5:35 A.M. -CPR was not initiated on the resident who was a full code. -The DON interviewed RN A on [DATE]. -Per RN A's admission, he/she did not perform CPR on the resident. -Per RN A's assessment he/she chose to notify the NP for the resident's physician instead of initiating CPR. -RN A was suspended and will be terminated when able to be reached by telephone. During an interview on [DATE] at 5:10 P.M., RN A said: -He/She had not been in the resident's room that night until at 5:35 A.M. CNA A told him/her that he/she thought the resident might be dead. -He/She immediately went to the resident's room. -He/She knew the resident was a full code. -The resident had no heart tones and no lung sounds, his/her lips were blue, he/she was cold to touch. -The resident was in rigor mortis (stiffening of the joints and muscles of a body a few hours after death, usually [MEDICATION(S)] from one to four days). -Instead of starting CPR, he/she called the NP. -The NP said to call the resident's family. -He/She asked the NP to have the resident's physician call him/her. -He/She and the resident's physician spoke on the telephone a short time later. -He/She asked the resident's physician if he/she agreed with his/her decision to not start CPR. -The resident's physician said, no it was not alright and that he/she should start CPR now. -The resident's physician was upset that he/she had not started CPR, said the resident was a full code and he/she had to start CPR right away. -He/She did not think CPR would have worked and made his/her own judgement call to not do CPR for the resident. -He/She knew the facility policy was to start CPR for all residents who were full code and to continue CPR until EMS arrived. -Later in the evening on [DATE], he/she called the NP and asked if he/she agreed with him/her not starting CPR for the resident. -The NP told him/her, no it was not alright and he/she should start CPR. During an interview on [DATE] at 9:14 A.M., CNA A said: -At 3:00 A.M. he/she checked on the resident and provided incontinence care for the resident. -At that time the resident was moving his/her arms and legs and he/she did not notice anything unusual at that time regarding the resident. -He/She returned to the resident's room at about 5:30 A.M. -He/She noticed the resident was not breathing. -He/She checked the resident's pulse at his/her wrist and found no pulse. -He/She immediately went and told RN A the resident may have passed. -He/She returned to the resident's room with RN A. -RN A checked the resident's pulse at his/her wrist and then at his/her neck. -RN A then looked at him/her with a sad expression which he/she took as him/her confirming that the resident had passed. -RN A did not do CPR. -RN A did not check the resident's vital signs in any other manner; RN A did not listen to the resident's chest with a stethoscope and did not take the resident's blood pressure. -RN A was in the resident's room with him/her for about two minutes and RN A did nothing further with the resident. -After two minutes CNA A was in and out of the resident's room getting supplies to clean the resident. -CNA B joined him/her and RN A in the resident's room. -RN A stayed in the resident's room while he/she and CNA B cleaned the resident up. -He/She did not see RN A touch the resident other than when he/she touched the resident's wrist and neck checking for a pulse. -He/She did not recall anything RN A said about the resident. -He/She did not recall the resident being warm or cold or the color of the resident's skin or lips. -He/She did recall that the resident's arms and legs were easy to move and were not stiff or rigid. -He/She and CNA B cleaned the resident up, including incontinence care and then he/she, CNA B, and RN A left the resident's room. -He/She did not know anything regarding what specific care the resident was to have when he/she found the resident was not breathing and did not have a pulse, other than to get the charge nurse, RN A. During an interview on [DATE] at 3:13 P.M., CNA B said: -At about 5:45 A.M. he/she noticed the charge nurse, RN A walking fast in the hallway. -A short time later he/she was in a room near the resident's room and heard RN A say that the resident was gone (that the resident had passed). -He/She was not in the resident's room with RN A. -He/She went to the resident's room at about 6:00 A.M. with CNA A and helped prepare the resident's body for the funeral home. -The resident was warm to touch; his/her arms and legs were very flexible, not stiff. -He/She did not recall the color of the resident's skin or lips. During an interview on [DATE] at 11:10 A.M., the DON said: -RN A called him/her on [DATE] at about 6:00 A.M. and told him/her the resident had passed away. -He/She spoke with the Administrator regarding the resident's code status and death and the Administrator advised him/her to notify the State regarding the resident's death and CPR not being done; he/she notified the State regarding the resident's death and CPR not being done. -He/She started an investigation regarding the occurrence. -He/She expected RN A to start CPR for the resident right away, ensure 911 was called and continue CPR until EMS arrived. -The facility policy is that if a resident who is a full code is found without pulse or breathing, CPR is to be immediately started and continued until EMS arrives and takes over CPR. During an interview on [DATE] at 12:08 P.M., the Administrator said: -The DON notified him/her by telephone on [DATE] at 8:28 P.M. that RN A had not started CPR on the resident in the early morning of [DATE]. -It was the policy of the facility to start CPR for residents who are full code, notify EMS and continue CPR until EMS arrives and takes over CPR. During an interview on [DATE] at 10:19 A.M., the resident's physician said: -RN A called the NP at 10:55 P.M. and asked if it was okay that he/she had not done CPR for the resident. -The NP told RN A that no, it was not okay and that he/she needed to start CPR. -The NP then called him/her and notified him/her regarding RN A not starting CPR for the resident. -He/She called RN A at 10:56 P.M. and told him/her that he/she had to do CPR for the resident and to start CPR now. -RN A said he/she did not do CPR for the resident because the resident was blue, cold and had rigor mortis, had last been seen by the CNA two hours prior and wanted to know if it was okay that he/she did not do CPR. -He/She said no, it was not okay and that RN A had to start CPR, go start CPR now, he/she did not care if it was two hours ago, start CPR now, do a code (provide emergency life-saving care). -He/She thought RN A had notified the NP about a current situation with the resident and was not aware the situation had occurred in the early morning. -He/She told RN A that the resident would have to be transferred to the hospital, RN A could not decide the resident was dead, this could only be determined after the resident was transferred to hospital since the resident was a full code. -He/She told RN A that RN A was not qualified to determine death or use the term rigor mortis. RN A could not decide CPR would be ineffective and could not decide to not do CPR. -He/She said RN A should have started CPR, notified EMS and the resident should have been transferred to hospital. -If he/she was at a facility when a resident needed CPR, he/she would not determine the resident was dead, he/she would tell the facility to do a code, start CPR, call 911 and have the resident transferred to hospital. -RN A told the physician EMS would not come to the facility because the resident was last seen two hours before he/she was found not breathing and without pulse. -He/She told RN A he/she did not care that it was two hours since someone had seen the resident before he/she was found not breathing, start CPR now, call EMS now, do a code. -He/She expected that CPR would always be immediately started for a full code resident; facility staff could not determine CPR would not be ineffective for a full code resident and could not decide to not do CPR. During an interview on [DATE] at 10:22 A.M., the NP said: -He/She got a call from RN A on [DATE] at 10:55 P.M. -RN A said the resident was blue, cold, and had rigor mortis and was it okay that he/she had not done CPR. -He/She told RN A to start CPR now. -He/She notified the resident's physician that RN A had not done CPR for the resident. -He/she thought RN A was talking about a current situation and provided instruction to begin CPR. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 775

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #2) out of four sampled residents was free from sexual abuse when two other sampled residents (Resident #1 and Resident #3) touched the resident in a sexual manner on four separate occasions. The facility census was 69 residents. Record review of the facility's Abuse and Neglect policy dated 11/2017, showed: -Each resident has the right to be from all types of abuse; -All residents have the right to be free from mental, physical and verbal abuse, neglect and exploitation. All allegations of suspected abuse/neglect/exploitation as defined in the policy, whether or not an actual injury occurred were to be reported immediately in compliance with state law and regulation; -Defined sexual abuse to include but not limited to sexual harassment, sexual coercion, or sexual assault; -During the ongoing nursing observation and communication with residents in the facility any and all allegations would be identified, documented and tracked for patterns and trends within the facility; -Any and all identified types allegations would be investigated; -The Director of Nurses (DON) and or designee was responsible for conducting an investigation and reporting the results to the proper authority; -The DON and or the Administrator would ensure all alleged or suspected allegations were investigated thoroughly by conducting staff/resident interviews, conducting resident assessments, making observations and reviewing records with all reports forwarded to the state agency within five working days of the allegation and -Should the event of an allegation meet or have the potential to meet one of the definitions stated within the policy on abuse or neglect, the Administrator would contact the state agency immediately or within no more than two hours. The investigation would proceed after reporting to the state agency. 1. Record review of Resident # 1's Face Sheet showed he/she was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. - [MEDICAL CONDITION] (inability to sleep). Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 2/18/18 showed he/she was cognitively impaired. Record review of the Resident #1's Departmental Notes showed: - On 3/10/18 at 2:43 P.M., Resident #1's roommate (Resident #3) had reported that Resident #1 had attempted to touch his/her private area inappropriately; - Resident #1 denied the accusation and described the roommate (Resident #3) as crazy and never shuts up; - The incident was reported to the weekend supervisor for investigation; - On 3/10/18 at 4:06 P.M., Resident #1 was placed fifteen minute checks related to the accusation of inappropriate sexual behavior; - On 4/11/18 at 4:20 P.M., Resident #1 spoke sexually inappropriately to staff and residents and was referred by the resident physician for a psychiatric evaluation; - On 4/17/18 at 7:48 P.M. Resident #1 was found touching a female resident (Resident #2) inappropriately by rubbing circles in his/her private area; - On 4/17/18 at 8:10 P.M., Resident #1 was placed on one staff person to one resident monitoring related to his/her sexual inappropriate behaviors and - On 5/25/18 at 9:25 A.M., Resident #1 was observed with his/her hands down Resident #2's pants. Record review of the resident's Patient Watch Sheet showed: - Monitoring every fifteen minutes of the resident by staff, had began 3/10/18 at 11:00 A.M., thru 3/14/18 ending at 2:45 P.M.; - There were no staff initials to indicate monitoring had taken place 3/11/18 3:15 P.M. to 6:45 P.M.; 3/12/18 10:45 A.M. to 2:30 P.M.; - On 3/10/18 at 6:00 A.M. the staff person initialed with an X and - The monitoring did not show what the resident was doing or where the resident was. Record review of resident's Electronic Completed Care Tasks Sheet showed: - He/she was on thirty minute care safety checks; - The entries had begun 3/22/18 and were completed 5/26/18 and - Facility staff had made multiple entries with the same date and time. Record review of resident's Care Plan dated 6/14/17 showed he/she: - Had sexually inappropriate behavior; - Could remain sexually active without being sexually inappropriate with staff and residents. - Had intervention to include: -- In-house psychiatry to treat quarterly and as needed; --Was to be removed from the public area when behavior was unacceptable; --Was to be provided privacy for sexual activity; --Was to receive a social services visit to evaluate when behaviors were reported and -On 4/17/18 had one staff person to one resident monitoring added for sexual inappropriateness. Record review of the resident's Medical Record showed: - The facility staff did not complete investigations for the incidents dated 3/10/18, 4/17/18 and 5/25/18; - The incidents on 3/10/18 and 4/17/18 had no resident interviews; - The incidents on 3/10/18 and had no staff interviews; - The monitoring was incomplete or not found; and - Assessments were not found. During an interview on 5/3/18 at 12:30 P.M., the Assistant Director of Nurses (ADON) said: - The resident had no history of inappropriate touching of a sexual nature and - The resident had a history of [REDACTED]. 2. Record review of Resident # 2's Face Sheet showed he/she was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. - Restlessness and agitation and - Difficulty in walking. Record review of the resident's Annual MDS dated [DATE] showed he/she: - Was severely cognitively impaired; - Required extensive assistance of one to two staff persons with locomotion, bathing, hygiene, toileting, dressing, eating and - Used a wheelchair. Record review of the resident's Departmental Notes showed: - On 3/11/18 at 1:59 P.M., the resident was at the table in the main dining room; - Resident #3 had approached Resident #2 and placed his/her hands under Resident's #2 shirt and fondled his/her breast; - Resident's #2 husband and weekend supervisor were notified and - On 4/17/18 at 8:55 A.M., Resident #2 was touched over his/her clothes by Resident #1, rubbing his/her private area in the dining room. Record review of the resident's Care plan dated 10/1/17 showed he/she: - Had cognitive impairment and - Had declined as of 4/5/17 and required a wheelchair, assistance with feeding and activities of daily living (ADL). Record review of the resident's Medical Record showed: - The facility staff did not complete investigations for the incidents dated 3/11/18, 3/21/18, 3/22/18, 4/17/18 and 5/25/18; - The incidents on 3/11/18, 3/21/18, 3/22/18, and 5/25/18 had no resident interviews; - The incidents on 3/11/18, 3/21/18 and 3/22/18 had no staff interviews; - The monitoring was incomplete or not found and - Assessments were not found. During an interview on 5/3/18 at 1:30 P.M., Licensed Practical Nurse (LPN) A said: - A Certified Nurses Assistant (CNA) had reported when he/she entered the dining room, he/she saw Resident #1 touching Resident #2's clothed groin area; - The CNA had separated the residents and told Resident #1 the behavior was inappropriate; - He/she had interviewed Resident #1 who denied the incident; - He/she had notified the DON and the ADON; - Resident #1 was sent to the hospital related to this incident and it was not the first time he/she had sexually inappropriate behaviors; - Resident #1 had a history of [REDACTED]. - Was unsure if the sexual behavior was care planned for Resident #1; - Resident #2 was not alert or oriented and was not aware of what had happened with Resident #1; - He/she had made notification to Resident #2's spouse; - He/she had made notification to Resident #2 spouse also when Resident #3 had sexually touched Resident #2 - Resident #1 and Resident #3 were roommates and were separated after an sexual allegation between the two; and - All incidents with Resident #2 occurred in the evening. During an interview on 6/12/18 at 11:13 A.M., Resident #2's Family Member B said: - The resident was not cognitively intact; - He/she was notified twice about the resident having his/her breast touched and - The resident would have smacked the other resident on the hand and told them not to touch him/her in that way. 3. Record review of Resident # 3's Face Sheet showed he/she was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. - Dementia ( general term for a decline in mental ability severe enough to interfere with daily life); - [MEDICAL CONDITION] and - Depression. Record review of the resident's Quarterly MDS dated [DATE] showed he/she: - Was cognitively impaired; - Required limited assistance of one facility staff person with locomotion, bathing, hygiene, toileting, and dressing and - Used a wheelchair. Record review of the Resident's #3 Departmental Notes showed: - On 3/10/18 Resident #3 alleged his/her roommate (Resident #1) had tried to give him/her oral sex; - On 3/11/18 at 9:55 A.M., Resident #3 was found on an empty bed at the end of the hall masturbating; - On 3/11/18 at 2:26 P.M., Resident #3 was caught with his/her hands under Resident #2 shirt in the dining room fondling his/her breasts; - On 3/21/18 3:54 P.M., Resident #3 was observed with his/her hands down Resident #2 shirt and - On 3/22/18 at 12:11 P.M., Resident #3 was under observation due to sexual behaviors with fifteen minute checks ordered until discharge to the hospital for psychiatric evaluation. Record review of the resident's Bed Check Monitoring Form showed: -On 3/11/18 at 11:30 A.M., monitoring began and ended on 3/15/18 at 3:00 P.M., and -There was no documentation on 3/11/18 from 3:30 P.M., to 6:30 P.M., 3/12/18 from 11:30 A.M., to 2:30 P.M., 3/13/18 12:30 P.M., to 2:30 P.M.; and 3/14/18 from 12:00 A.M., to 6:00 A.M. Record review of the resident's Patient Watch Form showed: - Monitoring every fifteen minutes of the resident by staff which began on 3/21/18 at 11:30 A.M. thru 3/22/18 ending at 7:00 A.M., and - The monitoring did not show what the resident was doing or where the resident was. Record review of the resident's undated Care Plan showed he/she: - Had socially and sexually inappropriate and disruptive behavior; - Was placed in constant observation as possible; - Was removed from the public area when the behavior was unacceptable and - Was educated about sociological appropriate norms. Record review of the resident 's Medical Record showed: - The facility staff had not completed investigations for the incidents dated 3/10/18, 3/11/18, and 3/21/18; - The incidents on 3/10/18, 3/11/18 and 3/21/18 had no resident or staff interviews; - The monitoring was incomplete or not found and - Assessments were not found. During an interview on 5/3/18 at 2:50 P.M., Registered Nurse (RN) A said: - The incident on 3/21/18 was on his/her shift; - He/she had heard the facility therapist yell Resident #3 name and looked up from the nurses station across to the dining room; - Resident #3 was observed to have pulled his/her hands out from under Resident #2's shirt; - Resident #2 was dependent for all care, cognitively unaware and usually placed in the dining room for staff to observe related to falls; - When Resident #3 was interviewed he/she said he/she had no idea; - He/she did not remember what was done next with Resident #3; - There was no incident report completed; - He/she was expected to document in the resident record for 72 hours after an incident of alleged sexual inappropriate touching and - He/she was aware; but did not witness additional incidents between Resident #2 and Resident #1 as well as the incident between Resident #1 and Resident #3. During an interview on 6/12/18 at 9:47 A.M., resident family member A said: - He/she was notified about the incidents between Resident #2 and Resident #3; - He/she was DPOA and Resident #3 signed his/her own paperwork; and - Resident #3 had no history of sexual behavior before. 4. During an interview on 5/3/18 at 1:56 P.M., the ADON said: - Investigations were not completed for the incident between Resident #1 and Resident #3 on 3/10/18 and for the incident between Resident #2 and Resident #3 on 3/11/18 and 3/21/18; and - The facility investigations did not include incident reports unless a resident was to have injury or a fall. During an interview on 5/3/18 at 2:18 P.M., the DON said: - The charge nurse was expected to complete an initial assessment, complete a department note for the resident medical record, place resident on one to one monitoring as appropriate and make notification to the resident family when a incident of resident to resident abuse is reported; - Witness statements were completed by the actual witness; - Interviews for the investigation were completed with residents involved in the incident; - There were no witness statements for the incident on 3/10/18 between Resident #1 and Resident #3 and -There were no witness statements for the incident on 3/11/18 and 3/21/18 between Resident #2 and Resident #3. During an interview on 5/31/18 at 1:20 P.M., LPN A said: - He/she was responsible and expected to complete a nursing departmental note in the resident medical record after an alleged incident and have witness statements completed by hose directly involved as able; - He/she was to report to the DON or Administrator any incidents of inappropriate touch and - The DON and Administrator were responsible for completing the investigation of reported incidents of abuse. During an interview on 5/31/18 at 1:27 P.M, Certified Medication Technician (CMT) A said: - He/she had not witnessed any incident of inappropriate touching of a sexual nature between residents and - He/she was responsible to report to the charge nurse any incident of inappropriate touching of a sexual nature. During an interview on 5/31/18 at 1:37 P.M., CNA A said he/she: - Had heard Resident #2 had a couple of incidents of inappropriate touching of a sexual nature; - Had not witnessed the incidents of inappropriate touching of a sexual nature; - Had heard the guy was sent out; - Was never given specific instructions on what to do to prevent the behavior of inappropriate touching of a sexual nature; and - Was responsible to closely watch like normal Resident #2. During an interview on 5/31/18 at 1:45 P.M., CNA B said he/she: - Had not witnessed incidents of inappropriate touching of a sexual nature between residents; - Had heard Resident #1 and Resident #3 had touched Resident #2 between the legs and Resident #1 had put his/her hand down Resident #2 pants; - Was not given specific instruction for intervention related to the incidents and takes care of the residents as he/she always does and - Was responsible if he/she were to witness a incident of inappropriate touching of sexual nature between residents to separate the residents and to report it to the charge nurse on the floor. During an interview on 5/31/18 at 2:00 P.M., the DON said: - On 3/10/18 the incident between Resident #1 and Resident #3 there was no investigation completed or report to the state agency and it should have been done; - On 3/11/18 the incident between Resident #3 and Resident #2 there was no investigation completed or report to the state agency and it should have been done; - On 3/21/18 the incident between Resident #3 and Resident #2 there was no investigation completed or report to the state agency and it should have been done; - On 4/17/18 the incident between Resident #1 and Resident #2 there was no investigation completed or report to the state agency and it should have been done; - The complete investigation should find out why the incident happened, should have resident interviews or resident observations if unable to interview, with statements if the residents feel safe or hurt, and notifications to the family and the physician; - The Administrator, the DON and the ADON were responsible for completion of the investigation and reporting to the state agency; - A resident to resident incident involved two residents and was determined to be sexual abuse by what was reported in the incident; - All incidents with Resident #1, Residents #2 and Resident #3 were of a sexual nature and - The incidents supported one staff person to one resident monitoring. During an interview on 5/31/18 at 2:37 P.M., RN A said: - Resident #2 was placed in his/her wheelchair in the middle of the dining room to place more facility staff eyes on him/her and - Staff were not always available; but with Resident #2 in the dining area he/she could be checked on between duties. During an interview on 5/31/18 at 3:10 P.M., the Administrator said: - The facility investigation should include what happened and why and should be documented in a nursing departmental note; - Notification should be made by nursing to the administrative staff (the Administrator, DON and or ADON) after each incident; - The aggressor of the incident should be placed on one to one observation and or sent out of the facility for an evaluation and - The facility should have reported the incidents with Resident #1, Resident #2 and Resident #3. During an interview on 6/12/18 at 2:15 P.M., the Administrator, the DON and the ADON said: - The charge nurses were responsible for identification of the incident, assessment, notification to responsible parties, physician and administrative staff; - Administrative staff included the Administrator, the DON and the ADON; - The Administrative staff was responsible for reporting to the state agency incidents of suspected abuse or neglect and completing the investigations; - Complete and thorough investigations include collection of witness statements, assessments, monitoring, interventions placed and determining why the incident may have happened; - The incident on 3/10/18 between Resident #1 and Resident #3 was reported to administrative staff on 3/12/18, the incident did not have a complete and thorough investigation.; - The incidents on 3/11/18 and 3/21/18 between Resident #2 and Resident #3 did not have a complete and thorough investigations; - The incidents on 4/17/18 and 4/25/18 between Resident #1 and Resident #2 did not have complete and thorough investigations; - The administrative staff were aware of the incidents on 3/10/18, 3/11/18 and 3/21/18, 4/17/18 and 4/25/18 and did not complete a thorough and comprehensive investigation and - The incidents dated 3/10/18, 3/11/18 and 3/21/18, 4/17/18 and 4/25/18 should have been investigated with staff and resident interviews, complete with assessment, monitoring, intervention and possible cause. During an interview on 6/21/18 at 8:15 A.M., CNA C said he/she: - Had heard about incidents, but had never witnessed incidents with Resident #1, Resident #2 and Resident #3; - Was told in an in-service to keep Resident #1, Resident #2 and Resident #3 separate and provide redirection; - Would report to the charge nurse any witnessed or reported incident after separation of residents; - Was in-serviced about reporting; - Was not provided specific instruction for monitoring Resident #1, Resident #2 or Resident #3; - Had never been asked to complete a patient watch; - 15 minute and 30 minute checks meant eyes were on the resident monitored and documentation of what the resident was doing is expected in real time and - One staff person to one resident monitoring meant the staff person was at the resident hip. During an interview on 6/21/18 at 8:51 A.M., CNA D said he/she: - Had not witnessed any incident with Resident #1, Resident #2 or Resident #3; - Was aware of the incidents with Resident #1, Resident #2 and Resident #3; - Was told to keep the three residents away from each other and keep an eye them to prevent a similar incident from happening; - 15 minute, 30 minute and hourly checks when ordered, were documented on paper and in real time.; - Was not given specific instructions to monitor Resident #1, Resident #2 or Resident #3 other than knowing where they were at and - Believed there was enough staff to watch the residents. During an interview on 6/21/18 at 9:10 A.M. LPN A said: - Resident #2 was never placed on monitoring or checks; - Resident #2 is watched closely related to his/her fall risk and usually in the dining room in vision of staff; and - Resident #3 had declined and no longer required monitoring. MO 579 MO 938

Based on observation, interview, and record review, the facility staff failed to ensure that one resident identified by the facility as a high risk for the development of pressure sores, and who was without pressure sores prior to the application of a cast to his/her lower extremity, did not develop pressure sores; follow the facility's policy related to the prevention of pressure ulcers, including the use of positional devices to prevent skin-to-skin contact and/or to alleviate pressure at bony prominences (knees and ankles); develop, consistently implement, and update an individualized plan of care to ensure staff's awareness of the resident's care needs; consistently assess, monitor, and document the condition of the resident's skin; identify, implement, and document compliance with interventions appropriate for the care of a person with a cast, including, but not limited to, repositioning, monitoring the skin at both ends of the cast, and providing sufficient support under the casted leg to alleviate pressure; assess and monitor changes in the resident's skin after he/she experienced a fall while his/her leg was still in a cast; and identify and monitor the resident for the increased potential for additional skin breakdown at other pressure points on the resident's body, including the coccyx and buttocks, as a result of the resident's altered mental status, [MEDICAL CONDITION] (loss of movement and/or sensation of one half of the body; usually a result of [MEDICAL CONDITION]/stroke), decreased mobility, increased dependence on the staff for his/her care needs, and his/her incontinence (loss of control over bowel and/or bladder function); for one sampled resident (Resident #1) out of 14 sampled residents. The facility census was 82 residents. Record review of the Nurse Assistant in a Long-term Care Facility Manual revised November 2001, showed: -A pressure ulcer was an inflammation, sore, or lesion that developed over areas where the skin and tissue underneath were injured due to a lack of blood flow and oxygen supply to an area of the body; -This lack of circulation usually happened because of continuous pressure on the skin over a bony prominence resulting from the way or length of time a resident was positioned; -Pressure was the main cause. Shearing occurred when the body slid on a surface that moves the skin in one direction and the underlying bones in the opposite direction. Other things such as heat, moisture, stool, urine, wrinkles from linen, and irritating substances, such as crumbs, can hasten the development of sores; -Most pressure ulcers were preventable with appropriate nursing care; -Pressure areas included the back of the head and ears, shoulder blades, backbone, elbows, crest of the pelvis, hipbones, coccyx (tailbone) region, buttocks, knee caps, inside and outside the knees and ankles, the heels, and the sides of the feet, especially over bunions (the bump that forms when your big toe points to the second toe; causes a bump on the inside edge of your toe); -Residents prone to forming pressure ulcers included elderly residents (due to sluggish circulation, poor hydration, poor nutrition and lack of exercise/mobility); paralyzed residents (because of sensory deficits and lack of mobility); thin and malnourished residents (because bony prominences were closer to the skin surface), obese residents (skin in contact with skin can break down, such as underneath the breasts, between the legs, and under abdominal folds); residents who were incontinent (constant dampness irritates the skin, and chemicals in stool and urine causes irritation); residents with chronic illnesses such as diabetes, kidney disease, [MEDICAL CONDITION], and residents who are immunocompromised (decreased ability to fight infection); -Prevention of Pressure Ulcers included preventing pressure by: --Changing the resident's position at least every two hours, or more frequently if indicated in the care plan; --Encouraging residents sitting in wheelchairs to raise themselves every ten to fifteen minutes; --Turning scheduled for residents who were helpless. The use of a turning sheet or lift sheet reduced friction to the skin, and the resident should not be positioned on the affected area; --Using anti-pressure devices, such as alternating air mattresses, air mattresses, mattress overlays or wheelchair pads, pillow, over-the-bed cradles, waterbeds, heel and elbow protectors and foot elevators to reduce pressure on the heels; -Observations to make about pressure ulcers included the location of the pressure ulcer, the condition of the skin, the skin temperature, the size of the wound, any drainage that may be present, and odor. Staff was to notify the charge nurse if the dressing became soiled or dislodged; -A pressure ulcer could be as stressful to the human body as major surgery, it was worth every effort to prevent one. For every minute it took to cause a pressure ulcer, it took weeks to heal. Record review of the facility's Prevention of Pressure Ulcers policy revised October 2010, showed: -The purpose of this procedure was to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors; -Pressure ulcers were usually found when a resident remained in the same position for an extended period of time, causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue; -The most common site of a pressure ulcer was where the bone was near the surface of the body, including the back of the head, around the ear, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes; -Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure ulcers were not treated when discovered, they quickly got larger, became very painful for the resident, and often times became infected; -Pressure ulcers were often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin, i.e., perspiration, feces, urine, wound discharge, soap residue, etc., decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition; -Once a pressure ulcer developed, it could be extremely difficult to heal. Pressure ulcers were a serious skin condition for the resident; -The facility should have a system/procedure to assure assessments were timely and appropriate, and changes in condition were recognized, evaluated, reported to the practitioner, physician, and family, and addressed; -The following information should be recorded in the resident's medical record: --The type of skin care given; --The date and time skin care was given; --The position in which the resident was placed; --The name and title of the individual who gave the care; --Any change in the resident's condition; --The condition of the resident's skin, i.e., the size and location of any red or tender areas; --How the resident tolerated the procedure or his/her ability to participate in the procedure; -General preventative measures included, but were not limited to: --Identifying risk factors for pressure ulcer development; --If a person was in bed, position changes were needed at least every two hours or more frequently, if needed; --If a special mattress was needed, staff was to use one that contained foam, air, gel, or water, as indicated; --Raise the head of the bed as little as possible and for as short a time as possible, and only as necessary for meals, treatments and medical necessity; --If a person was in a chair, position changes should be at least every hour; Foam, gel or air cushions should be used , as indicated, to relieve pressure; --When repositioning, reduce friction and shear by lifting (using appropriate technique and equipment) rather than dragging; --Ensure that the resident drinks plenty of fluids and eats a well-balanced diet; --Routinely assess and document the condition of the resident's skin per facility wound and skin care program for signs and symptoms of irritation or breakdown; --Immediately report any signs of a developing pressure ulcer to the supervisor; --The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate; -Risk factors included moisture; friction and shear; bed- or chair-fast; immobility; bowel and bladder incontinence; poor nutrition; and lowered mental awareness. Other risk factors included co-morbid conditions, such as end stage [MEDICAL CONDITIONS], diabetes, etc., medications, resident refusal of care and/or treatment, and the past history of a healed ulcer as there was a great chance of recurrent breakdown. 1. Record review of Resident #1's admission physician's orders [REDACTED]. -Apply orthotic (brace/splint) to the resident's left hand in the A.M. and remove it at bedtime due to contractures; -Low air loss mattress; comfort setting; check every shift (preventative measure); -High/low bed with landing pads for safety; and -Prop up the resident's heels bilaterally while in bed; use float heels; -Standing orders for every 30 minute checks and release every two hours for 15 minutes when restraints were used for self-protection. Record review of the resident's Braden Scale for Predicting Pressure Sore Risk, dated 2/23/12 showed the resident was at high risk for pressure sores due to occasionally moist skin, the resident being chair fast, having very limited mobility, and potential for friction and shearing with position changes. Note: A total score of 12 points or less represented "high risk" for pressure sores. The resident's score was 17. Record review of the resident's POS showed the following orders on 2/27/12: a lap belt on the resident when up in wheelchair for self-protection. Record review of the resident's Braden Scale for Predicting Pressure Sore Risk, dated 3/5/12, showed the resident was at high risk for pressure sores due to his/her very limited sensory perception; occasionally moist skin; the resident being chair fast; having very limited mobility, and actual problems with friction and shearing with position changes due to his/her increased dependence on staff for his/her mobility. Note: A total score of 12 points or less represented "high risk" for pressure sores. The resident's score was 13. Record review of the resident's Minimum Data Set (MDS)(a federally mandated assessment tool required to be completed by facility staff) dated 6/4/12, showed the resident: -Was understood and able to understand others; -Had moderate cognitive (thought processes) impairment; -Required the extensive assistance of one staff person for bed mobility, locomotion on and off the unit, dressing, personal hygiene, and bathing; -Required the total assistance of two plus staff persons for transfers and toileting; -Was only able to stabilize himself/herself with human assistance when moving from a seated to a standing position, when moving on and off the toilet, and when moving from surface to surface. The resident did not walk or turn around; -Had impairment of his/her upper extremities on one side of his/her body and had range of motion (ROM-the range on which a joint can move) impairment of both lower extremities; -Used a wheelchair for locomotion -Had the following Diagnoses: [REDACTED]. -Had frequent incontinence of his/her bowels and bladder; -Had no pressure ulcers, but was at risk for their development; -Was using no physical restraints, i.e., bed rails, trunk restraints, or limb restraints, but did use a restraint in his/her chair to prevent rising. Record review of the resident's Care Plan, dated 3/6/12, showed the resident: -Was at risk for impaired skin integrity related to shearing during independent repositioning, being wheelchair bound, episodes of bowel and bladder incontinence and impaired physical mobility, i.e., contractures and brace use, and the use of a seat belt while in a wheelchair; --Had an on-going goal of not experiencing any skin breakdown; --Interventions included: ---Encouraging frequent repositioning; Note: The parameters specified in the physician's standing orders were not included in the plan of care; ---Assess the skin with application and removal of orthotics (braces/splints) for signs and symptoms of skin breakdown/maceration (absorption of moisture by the skin); ---Assess the skin on shower days and during cares for open area or areas of redness. Staff was to report concerns to the charge nurse; ---Was to have his/her heels floated (elevated enough to not rest on the bed) while in bed; --Was to have his/her waist area assessed for skin breakdown related to the use of a seat belt. This was to be done upon the release of the seat belt. --All findings were to be documented and reported to the physician, as needed. -Was at risk of impaired mobility related to his/her stroke, i.e., left [MEDICAL CONDITION] (paralysis/weakness affecting one side of the body). The resident required the use of adaptive equipment for posture, required assistance for activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) and was dependent with transfers; --Had goals which included the resident would not become totally dependent for cares, would participate with his/her cares as able, and would not have injuries due to the contracture of his/her left upper extremity; --Interventions included: ---Supporting the resident's neck while in the wheelchair; ---Providing passive range of motion to the resident's right upper extremity; Note: The resident's left upper extremity was contracted and immobile; ---Note skin breakdown to the resident's right upper extremity due to contracture; Note: The resident's left upper extremity had contractures, but not to his/her right upper extremity; ---Using the Sit-to-Stand (S-S) lift with two staff assist for transfers. Staff was to use judgment if a mechanical lift would be needed for safety. Staff was to notify the charge nurse; ---Staff was to note any decline in the resident's abilities or participation; and -The resident was to have a brace applied to his/her left upper extremity, per orders. Record review of the resident's undated Nurse Aide Care Plan (CNA Care Plan) showed: -The resident used a wheelchair for mobility and required the assist of two staff and a mechanical lift for transfers; -The resident required the assistance of two staff members for positioning, and the resident was to be turned every two hours Note: The care plan showed the resident was to have a brace to his/her left lower extremity (LLE). There was no documentation showing when the use of the braces began. The use of positional devices (pillows, wedge cushions, etc.) to be used for proper body alignment was not documented nor was there any documentation showing what interventions staff was using to prevent skin break down, i.e., pillows and/or blankets between the resident's knees and ankles for positioning and to prevent pressure ulcers. There was no documentation showing the resident used a seat belt when in the wheelchair or that the resident needed to be checked every 30 minutes and released every two hours. Record review of the resident's Monthly Summary, dated 6/7/12, showed the resident had no skin issues. Note: None of the skin treatments/prevention interventions were marked as being used, although the resident had a low air loss mattress, used a cushion in his/her wheelchair, and was to be turned every two hours. Record review of the resident's Nurses' Notes, dated 6/16/12 through 6/18/12, showed the resident continued to experience pain and stiffness in his/her left lower extremity (LLE), and swelling continued in the area of the resident's left knee. The resident was transferred to the hospital for evaluation and the resident was found to have fractures of both bones of the lower leg (tibia and fibula). A cast was applied to the resident's left lower extremity at the hospital and the resident returned to the facility. The nursing assessment upon the resident's return to the facility showed the skin around the cast on the resident's left leg was intact and warm. Record review of the resident's Care Plan showed it was updated on 6/19/12 to show the resident had fractures of his/her left tibia and fibula and was at risk for infection and pain. He/she was non-weight-bearing on his/her left leg, required the use of a mechanical lift with two staff assist for transfers to his/her wheelchair, and a plaster cast had been applied to his/her left leg. The resident's goal was the fractures would heal without complication or pain within six to eight weeks. Staff was to evaluate this daily. Interventions showed to keep the resident's left leg elevated as much as the resident would allow and to transfer the resident with the assist of three staff, i.e., two to transfer and one to hold the resident's casted leg. Staff was to keep the cast clean and dry, monitor the circulation to the resident's leg by checking the toes every shift and monitor for signs and symptoms of infection, i.e., increased temperature, complaints of pain, numbness, poor circulation, odor, etc. Note: The care plan did not address the need to monitor the resident's skin at either end of the cast or how often this needed to be done. The care plan did it identify how the staff was to position the resident with his/her cast while he/she was in bed to prevent pressure areas from developing. Record review of the resident's Nurses' Notes, dated 6/20/12 at 9:00 P.M., showed there were new orders to have Occupational Therapy (OT) evaluate and treat the resident three times a week for correct and safe positioning, seating, and transfer. Two staff members were to perform the transfer and one staff member was to support the resident's casted left leg. The resident was to use a Broda chair (a chair that provides seating and positioning options that provides a comfortable way to sit) as long as he/she had the cast. Note: There was no documentation showing how staff positioned the resident's LLE while he/she rested in bed, i. e., if the LLE was elevated on pillows, nor was there documentation showing staff was monitoring the condition of the resident's skin at either end of the resident's cast. Record review of the resident's POS showed an order was received on 6/20/12 for the resident to be seated in a Broda chair for as long as there was a cast to his/her left lower extremity in a cast. Note: Neither the resident's care plan nor the CNA care plan reflected the resident's need/use of the Broda chair or if he/she needed supportive devices to maintain proper positioning when he/she was seated in the chair due to his/her [MEDICAL CONDITION] on the left side of his/her body. Record review of the resident's Nurses' Notes, dated 6/21/12, showed the resident complained of pain in his/her LLE. The resident was repositioned, his/her LLE was elevated and he/she received pain medication which was effective. Note: There was no documentation describing the condition of the resident's skin visible at either end of the cast on the resident's LLE or the condition of the resident's skin at his/her coccyx (tailbone)/buttocks, or whether the resident was being turned from side-to-side to alleviate pressure at his/her bony prominences. Record review of the resident's Nurses' Notes, dated 6/22/12, showed the foot of the resident's bed was slightly elevated and the resident's left leg was elevated on pillows, the resident's toes were pink and warm, pulses to the resident's LLE were present, and there was no [MEDICAL CONDITION] (swelling) present. Note: There were no skin assessments documented describing the condition of the resident's skin at either end of the cast on the resident's LLE, i.e., if the resident's skin was intact. Record review of the resident's Nurses' Notes, dated 6/23/12 showed: -At 5:30 A.M., the resident complained he/she "was uncomfortable all the time" but he/she "rested through the night." The skin around the resident's cast was described as "appropriate for color," and the foot of the resident's bed had been elevated and the resident's LLE propped up on pillows. There was no [MEDICAL CONDITION] noted to the resident's left foot and the resident's cast was clean and dry; -At 10:30 A.M., the resident's cast remained clean and dry, circulation was within normal limits, his/her skin was warm, dry and its color was within normal limits. He/she received pain medication and it was effective. -At 9:10 P.M., the resident's cast remained clean and dry, the circulation to the resident's left foot was within normal limits, and the resident had been medicated for pain once and it had been effective. Note: The condition of the resident's skin at either end of the resident's cast was not documented. Record review of the resident's Nurses' Notes, dated 6/24/12, showed: -At 7:00 A.M., the resident denied pain, his/her cast remained clean and dry, the circulation to the resident's toes remained within normal limits, and the foot of the resident's bed had been raised and the resident's LLE was elevated on pillows to provide comfort. The posterior side of the resident's cast was noted to be rubbing the resident's skin and it was tight. Physician A was notified. Orders were received to apply [MEDICATION NAME] ointment (a protectant ointment) to the back of the resident's thigh for comfort. This was to be completed every shift and as needed. -At 12:00 P.M., Physician A ordered the resident to be seen by his/her orthopedic (bone) physician as soon as possible on 6/25/12 to have his/her LLE cast cut down due to its rubbing on the back of the resident's leg. Circulation to the resident's toes remained within normal limits, and the cast remained clean and dry. The resident continued to receive pain medication as needed. Note: Documentation did not describe the condition of the resident's skin at top of the cast at the resident's posterior thigh nor were measurements of the involved area recorded. Record review of the resident's Nurses' Notes, dated 6/25/12, showed -At 1:30 A.M., the resident's cast remained clean and dry; [MEDICATION NAME] cream was applied to the resident's posterior left "calf" for comfort. The resident's LLE was elevated for comfort, circulation of the resident's toes was within normal limits, and the resident refused pain medication at that time. Note: Documentation did not show the condition of the skin at the resident's posterior thigh, i.e., if the skin was broken, how much skin was involved, etc.; -At 9:00 A.M., staff noted the resident's appointment with his/her orthopedic doctor was set for 11:00 A.M. that day; -At 1:30 P.M., the resident returned to the facility. A piece of felt material had been placed behind the upper posterior left leg cast. The circulation to the resident's toes was within normal limits, good color was noted, and the resident denied pain. Note: There was no documentation related to the condition of the resident's skin at his/her upper posterior thigh nor was there documentation in the resident's care plan. The CNA care plan did not instruct staff that a piece felt was to be placed behind the upper posterior left leg cast, did not instruct staff on how this piece of felt was to be used, how it was to be applied and how it was to be maintained. Record review of the resident's Wound Team notes, dated 6/26/12, showed: -The resident had a "traumatic" wound to his/her left thigh (which was labeled Site #1). The site: -Was slough (nonviable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) covered; -Measured 5.5 centimeters (cm) long x 0.5 cm wide x 0.1 cm deep; -Had scant serous (watery, clear, or slightly yellow/tan/pink drainage) drainage present. -Healing was listed as the objective for the Wound Team's treatment of [REDACTED]. -The long leg cast obscured some of the wound; -The treatment recommendations were to apply Santyl (an ointment used for the debridement of pressure ulcers) to the wound and cover the site with Vaseline gauze (absorbent gauze impregnated with petroleum jelly) daily. Record review of the resident's June POS showed the following orders were received on 6/26/12: -Discontinue the treatment to the resident's left thigh cast area; -Cleanse the left thigh with wound cleanser, apply Santyl and Vaseline gauze. Change daily and as needed (prn); -Embrace (a moisturizer/protectant ointment) to buttocks as needed for redness. Record review of the resident's Nurses' Notes showed there was no documentation entered into the resident's medical record by the nursing staff for three days, i.e., from 2:00 P.M. on 6/25/12 until 10:15 P.M. on 6/28/12. Record review of the resident's Nurses' Notes, dated 6/28/12 at 10:15 P.M., showed the resident had been effectively treated for [REDACTED]. was elevated on pillows for comfort. Note: Documentation did not reflect the condition of the skin at the resident's posterior upper thigh, didn't show if the felt applied to the posterior side of the resident's cast remained intact, or whether the resident's cast was continuing to cause irritation to the resident's skin. This entry was the only documentation recorded for that date. Record review of the resident's Nurses' Notes, dated 6/29/12, showed: -There was a late entry made for 6/26/12 showing the resident had been seen by the Wound Team because of the skin issues to the back of the resident's thigh caused by the resident's cast. Documentation showed a new treatment had been ordered and referred to the Wound Team's notes. There was no documentation in the nurses' notes describing the changes in the resident's skin condition. -At 8:05 P.M. on 6/29/12, the resident was found lying on the mat beside his/her bed. He/she denied pain and appeared to have no new injuries. The cast remained on the resident's left leg. Note: Documentation did not reflect the condition of the resident's skin at either end of the resident's cast, at the resident's buttocks and coccyx, or if the felt remained in place at the top of the resident's cast. Record review of the resident's Braden Scale for Predicting Pressure Sore Risk, dated 3/5/12, showed the resident was at high risk for pressure sores due to his/her very limited sensory perception; occasionally moist skin; the resident being chair fast; having very limited mobility, and actual problems with friction and shearing with position changes due to his/her increased dependence on staff for his/her mobility. Note: A total score of 12 points or less represented "high risk" for pressure sores. The resident's score was 13. Record review of the resident's Nurses' Notes, dated 6/30/12, showed: -At 3:35 A.M., the resident complained of pain (a 10/10: a ten on a 0-10 scale, zero meaning no pain and ten meaning the worst pain ever) at the back of his/her left leg at the cast line. He/she received pain medication and it was effective. Note: There was no documentation describing the condition of the resident's skin at this area nor was there documentation showing the presence/impact of the felt that had been applied to the top of the resident's cast by the resident's orthopedic physician. There was no documentation showing the resident's positioning had been changed to alleviate pressure to his/her posterior thigh and/or coccyx/buttocks; -At 10:00 A.M., the resident's cast remained clean and dry, and the circulation to the resident's foot remained within normal limits. The resident's LLE remained elevated. Note: Documentation did not reflect the condition of the resident's skin at his/her upper posterior thigh or if the resident had been turned; -At 1:00 P.M., the assessment of the resident's LLE remained unchanged. Documentation showed the resident was now receiving a treatment to his/her buttocks in addition to the care he/she was receiving at his/her left thigh. Note: The documentation did not include any assessment of the condition of the skin at the resident's left thigh or at his/her buttocks. Record review of the resident's Monthly Summary, dated 6/7/12, showed the resident had one Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough(dead tissue) or eschar (hard black dead tissue) may be present on some parts of the wound bed. Often includes undermining (a closed passageway under the surface of the skin that is open only at the skin surface. Generally, it appears as an area of skin ulceration at the margins of the ulcer with skin overlying the area) and tunneling (a passageway under the surface of the skin that is generally open at the skin level; however, most of the tunneling is not visible); used a pressure-relieving bed; was turned, repositioned and received nutritional and hydration interventions. He/she continued to wear a splint cast on his/her left leg due to fracture. Record review of the resident's Nurses' Notes, dated 7/1/12, showed: -There was a late nursing note entry for 6/30/12 at 8:00 P.M.: --The resident was noted to have three Stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) open areas to his/her left gluteal fold; --Documentation showed the wounds measured 1.0 centimeter (cm) x 0.5 cm x 0.2 cm at the left gluteal area, and 1.0 cm x 0.5 cm x 0.3 cm midline at the gluteal crease (crack of the bottom); --Documentation showed this condition change in the resident's skin was a result of the resident's decreased physical functioning, the presence of the cast to the resident's LLE, and increased moisture related to the resident's incontinence (loss of control of bowel and/or bladder functions); --Embrace ointment was applied per orders; -The resident was to be turned from side-to-side every two hours; --Peri-cares (care to the area between the anus and the genitalia) were to be provided after each episode of incontinence; --There was an open area at the resident's posterior left upper thigh caused by the resident's cast. This wound was being cleansed with wound cleaner. Santyl was to be applied followed by Vaseline gauze and then ABD (a thick wound dressing) packs were to be placed in the posterior cast area for comfort. Staff planned to give a report to the Wound Team nurse; -A late nursing note entry for 6/30/12 at 12:00 A.M.: --The resident complained of pain and was medicated; --He/she was repositioned from side-to-side; Note: There was no documentation showing the positional devices were used when the resident was repositioned for comfort and to help prevent further skin breakdown; --Documentation showed Embrace ointment was applied to the open areas and gluteal folds; -A late nursing note entry for 4:00 A.M., showed: --The resident was yelling "help me. My left leg hurts." The resident was medicated for pain and this was effective; --The circulation to his/her LLE remained within normal limits; Note: The staff did not document the location of the resident's pain to his/her left leg to verify if the resident's pain was related to his/her fractures or if it was due to the impairment of his/her skin. Record review of the resident's Nurses' Notes, dated 7/1/12 at 6:00 P.M., showed: -The nursing staff contacted Physician A related to the open wound on the resident's posterior left thigh, the open "Stage III " wound on his/her left buttock; as well as the open "Stage II" area present in the crease of both buttocks; -New wound treatment orders were received; -The physician also ordered the placement of an indwelling urinary catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) until the wounds were healed; -A new medication order was also received: Keflex (an antibiotic; used to treat infections) 500 milligrams (mg) by mouth three times a day for seven days due to the green slough that was present on the open area on the resident's posterior left thigh.

Based on observation, interview, and record review, the facility staff failed to complete a quarterly assessment on the continued use and appropriateness of a C-bar (a curved bar/bed cane used by people when transferring from the bed to a wheelchair) attached to the right side of a resident's bed by the therapy department, provide interventions to prevent the resident from further falls in which the resident was found on 8/23/12, with his/her left leg and arm on the bed and his/her head wedged between the mattress and the C-bar, and update the resident's fall care plan with new interventions to prevent further falls and to reflect the safety needs for one sampled resident (Resident #1) with a history of cerebellar vascular accident (CVA, stroke) with left side [DIAGNOSES REDACTED] (paralysis) and impaired safety judgement, and repeated falls when attempting to self-transfer, resulting in one fall on 6/16/12 which required hospitalization for a fractured left tibia and fibula; follow facility policy by notifying the therapy department after a fall to re-evaluate a resident who fell twice during a Hoyer lift (a mechanical device, with a sling attached, to lift and transfer a non-ambulatory resident) transfer for the safest way to transfer him/her, update the resident's transfer care plan with new interventions after each fall to prevent the resident from falling during a Hoyer lift transfer, and have interventions in place to instruct the staff and the resident on having the side rails down during a Hoyer lift transfer to prevent the resident from being suspended in the air higher than needed for one (Resident #7) sampled resident; and failed to have a system in place to assess a resident's wheelchair for protrusions to prevent the resident from obtaining possible injury when the protrusions were not covered for one sampled resident (Resident #4) with fragile skin out of 14 sampled residents. The facility census was 82 residents. Record review of the facility's Fall Risk Assessment form dated 1992, showed upon admission and quarterly (at a minimum) thereafter, staff were to assess the resident status in eight clinical condition parameters by assigning the corresponding score which best described the resident in the appropriate assessment column. Staff was to add the column of numbers to obtain the total score. If the total score was 10 or greater, the resident should be considered at "high risk" for potential falls. A prevention protocol was to be initiated immediately and documented in the resident's care plan. Record review of the facility's undated Residents Preference for Side Rails consent form included the following information: "I have been educated and informed that there could possibly be adverse effects related to the use of side rails. Some of these adverse effects could include, but are not limited to, pinching, bruising, skin tears, fractures, choking, entrapment and even death. After having been educated and informed of the risks, I prefer to use my side rails for my comfort and enhancement of my ability to turn over and move in bed. I understand that Physical Therapy (PT) will make an evaluation and further discussion may be warranted through their recommendation. PT will continue to screen the use of any side rails at (the facility) on a quarterly basis, or as changes arise or occur." The resident could choose to use one or two side rails or he/she could choose not to use any side rails. The form included signature and date lines for the resident as well as a witness. Record review of the facility's Un-witnessed Fall/Injury/Bruising Protocol dated 4/30/12, showed: -Upon becoming aware of an incident/injury/bruise, the charge nurse would complete an assessment and provide any immediate first aid treatments indicated; -Assessment included: --An initial "triage (the process of determining priority of medical treatment) /immediate need" assessment, which included the status of the resident's airway, breathing, circulation and consciousness. If an emergent status was noted, appropriate interventions would be initiated and first aid provided, as needed; --A complete head-to-toe assessment would be completed with a focus on the resident's neurological status (neuro - assessing for evidence of increased intracranial pressure or spinal cord injury), other areas of potential injury, i.e., skin/musculoskeletal symptoms such as edema, redness, pain, decreased range of motion, abnormality in joint/bone alignment, and change in sensation; signs and symptoms of acute illness/exacerbation of chronic illness, an assessment of the environment for any contributing factors to the fall/injury/bruise such as sharp objects, blunt areas that extremities might come into contact with on the table, bed, wheelchair; obstacles in the resident's path; placement of mechanical lift pads, gait belts, shoes, clothing, etc.; behaviors; as well as the resident's routine, including interactions with other residents; -An interview with the resident would be completed, if possible, to catch any potential medical issues or significant changes in the resident's status and/or to determine if medication administration may have contributed to the fall/injury; -The physician and responsible party were to be notified; -The findings of the investigation would be documented in the nurses' notes; -An incident report would be completed by the charge nurse, along with the Fall/Injury Investigation to assess for immediate interventions to promote safety and/or decrease the risk of injury; -The resident was to be assessed for changes, including vital signs and neuro status, during each shift for 72 hours. Any changes from baseline were to be reported to the physician and the responsible party immediately; -Residents with an injury, i.e., skin tears, abrasions, bruises, etc., would be assessed and documented on every shift until the areas were healed and/or resolved. The Administrator and the Director of Nursing (DON) were to be notified for further follow-up, as indicated; -Referrals to PT and Occupational Therapy (OT) would be made when appropriate; -All alleged information would be thoroughly investigated and documented. Information would be forwarded to the appropriate state agency by the facility Administrator and/or DON, as indicated. Record review of the facility's Fall/Injury Investigation Report form dated 4/2012, showed the following information was to be provided by the nurse completing the report: -The name of the resident and the date and time of the occurrence; -The date and score of the resident's most current Fall Risk Assessment, including whether the resident was identified as a fall risk; -What current interventions were being used to prevent/minimize injury, including bed and chair alarms, seat belts, side rails, high/low beds, landing mats, sleeves, and joint protectors. There was a section for other interventions not included in the list; -Whether the resident was currently receiving therapies and when the resident was last seen by a physician; -Whether the resident had been experiencing an acute infection, exacerbation of a chronic illness, increased behaviors, and decline in mobility or activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) function. There was a section for staff to identify any other signs/symptoms the resident may have had; -Whether the resident had received any of the following types of medications: --Antihistamines (drugs that combat the histamine (a chemical produced by the body) released during an allergic reaction); --Antihypertensives (medications used to treat high blood pressure); --Narcotics (controlled substances used to treat moderate to severe pain); --Hypoglycemics (medications used to treat high blood sugar levels); --Anti-seizure medications (used to help prevent seizures or to treat nerve pain); --Psychotropics (medications used to treat mental disorders); --Sedatives/Hypnotics (medications used to reduce tension and anxiety as well as induce sleep); --Diuretics (water pills - any drug that elevates the rate of urination); --Cathartics (medications that accelerate defecation); --Any new medications within the previous seven day; --Steroids/Corticosteroid (hormones used to treat inflammatory conditions) use within the previous 14 days; --Anticoagulant (medication that stops the blood from clotting) use within the previous 14 days; -If the resident had any recent laboratory (blood) draws, intravenous (IV's), or immunizations; -Staff was to circle any of the medications that were administered on an "as needed" (PRN) basis; -The method of mobility and level of assistance that was care planned for the resident, including whether the resident was ambulatory, used a wheelchair, gait belt, or other assistive devices such as a walker, cane, or a mechanical lift. Staff was to identify the level of assistance required for this, i.e., assistance of one or two staff, if TED hose (Thromboembolic disorder hose - special stockings designed to reduce the risk of developing blood clots in the legs) were in use, if the resident required weight-bearing assistance, of if the resident needed the use of a Sit-to-Stand (S-S) lift; -There was a section titled "Other" for any additional information the staff had for this section; -Staff was to identify the type of incident/occurrence it was, i.e., fall, skin tear, bruise, or other, and they were to describe the event and include the resident's explanation of the event, if possible; -The location of the event was to be noted as well as whether the resident was oriented or confused; -Staff was to note whether the resident's call light was within reach, if alarms were working, if there was compliance with the plan of care, if oxygen was in use, brakes were locked on the wheelchair, and/or if there were any other equipment concerns; -Staff was to identify if any injuries were consistent with the resident's behavior or environmental factors. Staff was also to note if there had been any recent changes in the resident's environment; -Staff was then to identify any immediate interventions that were initiated to reduce the risk of repeat events, including the following: bed and/or chair alarms, seat belt, education/re-education (resident), reorientation, side rails, high/low bed, landing mats, education/re-educations (staff), activity, sleeves (cloth shields used on the arms and legs to protect against skin damage), joint protectors, whether the resident was provided adaptive/personal equipment, i.e., a grabber (a piece of adaptive equipment used to extend the reach of a person with limited mobility), urinal, remote, etc. There was a section titled "Other" for staff to complete, if necessary; -Once the form was completed, the charge nurse was to sign and date it; -This form was then to be reviewed by the facility's Fall Assessment and Intervention Committee to verify the nurses' notes were complete; interventions were appropriate; the resident's care plan was updated; medication changes were noted; and that therapy referrals had been made. There was a section titled "Other" that could also be completed by the committee, if needed. 1. Record review of Resident #1's Preference for Side Rails form, signed 2/23/12, showed the resident chose not to use any side rails. Note: An undated Side Rail Communication form attached to the resident's side rail preference form showed the resident used an electric bed with a winged mattress and did not use side rails, however, nursing instructions on this same communication form showed the resident had a C-bar (a curved bar/bed cane used by people when transferring from the bed to a wheelchair) on the right side of his/her bed to assist the resident with bed mobility, i.e., in rolling to his/her right side or repositioning himself/herself thereby decreasing the possibility of skin breakdown. Record review of the resident's Fall Risk Assessment form dated 2/23/12, showed the resident: -Was alert and oriented to person, place and time (score of zero); -had a history of [REDACTED]. -Was chair bound and needed assist with elimination (score of two points); -Had adequate vision (score of zero); -Was unable to perform gait/balance testing (score of two points); -Was not evaluated for changes in his/her blood pressure when going from a lying to standing position (point total listed as N/A -not applicable); Note: While the resident was unable to stand, changes in his/her blood pressure could have been assessed by raising the head of the resident's bed and taking his/her blood pressure; -Took one or two of the medications listed within the seven days prior to the fall (score of two points); and -Had two diseases that predisposed him/her to falls, including stroke and Osteoporosis (score of two points). The resident's total score was 12. Note: A total score of 10 or above represented a high risk for falls. Record review of the resident's Care Plan showed the resident had sustained a fall on 2/24/12. The resident had been found on the floor at his/her bedside. Record review of the resident's Initial/Quarterly Occupational Therapy Restraint Screen dated 2/27/12, showed: -The resident was being evaluated for abnormal posture; -The resident's medical [DIAGNOSES REDACTED]. He she had functional communication and his/her ability to follow directions was intact; -The resident's safety awareness and judgment was impaired; -The reasons for the use of restraints included good postural alignment with wheelchair sitting and the use of a lap belt to discourage unassisted transfer attempts; -The resident had been placed in a tilt wheelchair with a pressure relieving cushion, a safety belt, and adjustable head and leg rests. The assessment noted these interventions met the resident's needs; -The resident had no history of falls from his/her wheelchair nor had he/she had any recent falls from his/her wheelchair; Note: The care plan reflected the resident had experienced a fall on 2/24/12; -The resident was able to reposition himself/herself when sitting in the wheelchair; -The resident was noted to be full weight-bearing, was dependent on the use of a mechanical lift for transfers, and did make attempts to transfer without assistance; -Recommendations which included continuing to use the devices already in place; -Restraint alternatives included therapeutic interventions to decrease fall risk including strengthening, modalities, and cognitive training. Note: Documentation did not show whether this assessment was an initial assessment or a quarterly assessment. Record review of the resident's Consent for Restrictive Devices form (revision date 11/20/06) showed the resident used a tilt wheelchair with a pressure relieving cushion, head and leg rests for good postural alignment, and a lap belt to discourage unassisted transfer attempts. This form was signed by the resident on 2/29/12. Record review of the resident's Fall Risk Assessment form dated 3/5/12 showed the resident: -Had intermittent confusion (four points); -had a history of [REDACTED]. -Was chair bound and needed assist with elimination (two points); -Had adequate vision (zero points); -Was unable to perform gait/balance testing (two points); -Was not evaluated for changes in his/her blood pressure when going from a lying to standing position (point total listed as N/A -not applicable); -The resident took three to four medications listed on the form, including antihypertensives, diuretics, and psychotropics (four points); and -Had two diseases that predisposed him/her to falls, including stroke and Osteoporosis (a decrease in bone mass and density and enlargement of bone spaces producing fragility) (two points). -The resident's total score was 18. Note: A total score of 10 or above represented a high risk for falls. Record review of the resident's Care Plan, dated 3/6/12 showed: -The resident had a recent history of falls, episodes of delirium (altered state of consciousness, consisting of confusion, distractibility, disorientation, disordered thinking and memory, defective perception - illusions and hallucinations), and was at risk for injury related to falls; -The resident's fall risk assessment score was 18 (high risk); -The resident's goal was that he/she would not injure himself/herself due to falls during the review period. This goal was noted to be "on-going;" -Interventions included: Transfer with a Sit-to-Stand (S-S) lift with two staff assisting; PT, as ordered; wheelchair for mobility; remind the resident of his/her fall risk; the resident was to have his/her call light when he/she was in his/her room; and a seat belt was to be used while the resident was in his/her wheelchair. Assessments for the continued use of the seat belt were to be completed at least quarterly. The resident's Fall Risk Assessments were also to be completed quarterly. Record review of the resident's Fall Risk Care Plan showed it was updated on 4/20/12 to reflect the resident had been found on the floor in front of his/her wheelchair in the his/her room. Note: There was no documentation if the resident's seat belt had been in use at the time of the fall. There were no updates to the interventions the staff was to use to help maintain the resident's safety. Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool required to be completed by facility staff), dated 6/4/12, showed the resident: -Was understood and able to understand others; -Had moderate cognitive (thought processes) impairment; -Required the extensive assistance of one staff person for bed mobility, locomotion on and off the unit, dressing, personal hygiene, and bathing; -Required the total assistance of two plus staff persons for transfers and toileting; -Required supervision and set-up help only for eating; -Was only able to stabilize himself/herself with human assistance when moving from a seated to a standing position, when moving on and off the toilet, and when moving from surface to surface. The resident did not walk or turn around; -Had impairment of his/her upper extremities on one side of his/her body and had range of motion (ROM - the range on which a joint can move) impairment of both lower extremities; -Used a wheelchair for locomotion -Had the following Diagnoses: [REDACTED]. -Had no falls since admission or since the prior assessment; Note: The resident had sustained falls since his/her prior assessment (on 4/20/12); -Received restorative therapy for range of motion; and -Was using no physical restraints, i. e., bed rails, trunk restraints, or limb restraints, but did use a restraint in his/her chair to prevent rising. Note: Documentation showed the resident had a C-bar attached to his/her bed to help with mobility and used a seatbelt on his/her wheelchair to help to remind the resident not to attempt self-transfers. Record review of the resident's Nurses' Notes, dated 6/16/12, showed: -At 8:30 P.M., the resident attempted to transfer himself/herself from the toilet without calling for assistance or without using the call light. The resident was found on the floor in a supine (face up) position. Resident said, "Help me up." Upon assessment, the resident's left lower extremity (LLE) was noted to be inverted (the condition of being turned or rotated inward) with swelling to his/her left knee. The resident demonstrated facial grimacing and said, "It really hurts." The resident's left arm was flaccid and contracted. The resident's right hand grip showed moderate strength. The resident was able to move his/her right lower extremity (RLE) upon command. The resident complained of pain with movement of his/her LLE; -At 8:35 P.M., Physician A was notified and orders were received to send the resident to the hospital for evaluation and treatment. Record review of the resident's Fall/Injury Investigation Report for the event that occurred on 6/16/12, showed: -The resident fell at 8:30 P.M.; -His/her most current Fall Risk Assessment had been completed on 3/5/12 and showed a score of 18. The resident was listed as a fall risk; -Current safety interventions included the use of a high/low bed; -The resident received restorative therapy three times a week and had last been seen by a physician on 6/9/12; -The resident was not experiencing any acute infections, exacerbation of chronic illnesses, increased behavior or any decline in mobility or ADL functioning; -There were no concerns related to medication use within four hours of the fall; -The resident needed the assistance of two staff members for mobility; Note: The method of mobility and the use of assistive devices for transfer were left blank by the facility staff; -The event was described as follows: The resident attempted to self transfer from the bathroom unassisted; -The resident was not able to verbalize why he/she didn't use the call light. He/she stated, "I don't know why I didn't use it." Note: The resident was noted to have moderate impairment of his/her cognitive functioning and had a past history of stroke with unilateral neglect (the inability to use of one half of the body due to muscle/nerve damage) of his/her left side; -The resident was noted to be oriented to himself/herself and showed confusion; -His/her call light was within reach; -Immediate interventions initiated to reduce the risk of repeat events (falls) included the use of a seat belt and a high/low bed, and the education/re-education of staff. Record review of the facility's Investigation of the resident's fall on 6/16/12 showed: -A new employee, who was not working on the resident's floor, noted the resident had been attempting to transfer himself/herself onto the toilet; -The new staff member helped the resident to transfer to the toilet without seeking the assistance of another staff person, then gave the resident his/her call light to ring when he/she was done and the staff member "went on (his/her) way;" -The resident was found on the floor of his/her bathroom. He/she was sent to the hospital for evaluation; -The DON and the resident's responsible party met during the resident's care conference and the situation was discussed. It was noted that the resident attempted to self-transfer on occasion. Note: The resident had been assessed as having moderate cognitive impairment. The Nurse Aide Care Plan did not show the resident was a fall risk or that the resident attempted to get up on his/her own, however, the care plan did include an undated entry showing the resident used landing pads, bed and chair alarms, i.e., interventions used to manage safety and/or fall risks. . There were no resident behaviors marked on the care plan nor did it show that any restraints (seatbelt) or enablers (assistive devices such as a side rail/C-bar) were in use. The resident's Care Plan and the Nurse Aide Care Plan showed the resident was to be transferred with a mechanical lift/S-S lift and required the assistance of two staff members. The investigation report showed the staff member (by himself/herself) helped the resident transfer to the toilet by, assuming what the resident told him/her was correct, i.e., he/she "did this all the time." Record review of the facility's re-education of the staff member showed the new CNA had transferred the resident by himself/herself when the resident was a "stand-pivot" transfer with the assist of two staff members. Staff was educated to the resident's Nurse Aide Care Plans (also known as the Activity of Daily Living (ADL) care plans), using two staff with transfers and a gait belt. Staff reported he/she had not been shown exactly where the care plans were located. The resident had told the staff member he/she could stand and help the staff so the staff member assumed it was fine. The resident was noted to be "in a hurry," so the staff member helped the resident into the bathroom. The staff member said he/she should have made sure and double checked. Record review of the resident's Fall Risk Care Plan showed: -It was updated on 6/16/12 and showed the resident had sustained a fall on 6/16/12 when he/she attempted a self-transfer while in the bathroom. The resident had been oriented to person only at the time of the event; -A new problem was added to the resident's care plan on 6/19/12 to address the resident's injuries related to his/her fall, i.e., fractures of his/her left tibia and fibula (the bones of the lower leg). It showed the resident was at risk for infection and pain. The resident was non-weight-bearing on his/her left leg and required the use of a mechanical lift and two staff members for transfers to his/her wheelchair. The resident had a plaster cast applied to his/her left leg. The resident's goal was the fractures would heal without complications or pain with daily assistance from the staff and the identified interventions. The goal was to be evaluated daily with resolution expected within six to eight weeks. Interventions included giving pain medications as ordered/indicated and monitoring their effectiveness; keeping the plaster cast clean and dry; checking the capillary refill in the resident's toes every shift; monitoring the resident's vital signs (blood pressure, pulse, respirations, and temperature) every shift; monitoring for signs and symptoms of infection; following up with the resident's orthopedic (bone) doctor as ordered; keeping the resident's left leg elevated as much as he/she would allow, and by transferring the resident with the assistance of three staff members using a mechanical lift. Note: The updated care plan did not show the resident should not be left unattended when using the toilet due to his/her level of orientation and his/her attempts to self-transfer. Record review of the resident's undated Nurse Aide Care Plan showed the resident: -Used a wheelchair; -Required the assistance of two staff members; -Used a mechanical lift for transfers (the brand name of a total body mechanical lift had been crossed off and the words "sit to stand" were hand written next to it); -Communicated verbally, had functional vision and hearing, and was incontinent of bowel and bladder; -Under the heading of contractures, upper and lower extremities were circled as was the word splints; -Wore TED hose during the day on his/her lower extremities bilaterally, and they were to come off at night; -Had a brace to his/her left lower extremity; and -Used landing pads, a bed and a chair alarm. Note: The section related to resident behaviors was left blank by the facility staff. There was no documentation on the Nurse Aide Care Plan that showed the resident had confusion, poor safety awareness and judgment, was a fall risk and should not be left unattended in the bathroom. Record review of the resident's nurses' notes dated 6/16/12-6/18/12, showed the resident: -Continued to experience pain and stiffness in his/her LLE, and swelling continued in the area of the resident's left knee; -Was transferred to the hospital for evaluation and the resident was found to have fractures of both of the bones in his/her left lower leg (tibia and fibula); -A cast was applied to the resident's left lower extremity at the hospital and the resident was returned to the facility; -The nursing assessment upon the resident's return to the facility showed the skin around the cast on the resident's left leg was intact and warm. Record review of the resident's updated care plan on 6/19/12, showed the resident: -Had fractures to his/her left tibia and fibula and was at risk for infection and pain, -Was non-weight bearing to his/her left lower leg, -Required the use of a mechanical lift with two staff assist for transfers to his/her wheelchair and a plaster cast had been applied to his/her left leg: -The goal was for resident's fractures to heal without complications or pain within six to eight weeks. The staff was to evaluate this daily; The Interventions were: -To keep the resident's left leg elevated as much as the resident would allow; -To transfer the resident with the assist of three staff members (two to transfer and one to hold the resident's casted leg); -Staff was to keep the cast clean and dry, to monitor the circulation to the resident's leg by checking the resident's toes every shift , and to monitor for signs and symptoms of infection by checking for increase in the resident's temperature, complaints of pain, numbness, poor circulation and odor. Record review of the resident's OT ADL Evaluation form dated 6/20/12, showed the resident: -Was seen for evaluation and treatment for [REDACTED]. -Was a fall risk and had a full cast to his/her left lower extremity; -Had left [DIAGNOSES REDACTED] (total paralysis of one side of the body that results from disease of or injury to the motor centers of the brain) and flex contractures (a permanent shortening of a muscle or joint in a flexed position) of his/her left upper extremity; -Needed positioning and safety aids related to an increase in the resident's dependence following a fall with injury; full left lower extremity cast dictated the need for a mechanical lift for transfers and the use of a Broda chair (a chair that provides seating and positioning options that provides a comfortable way to sit). Record review of the resident's physician's orders [REDACTED]. -Use a Hoyer (the brand name of a total body mechanical lift; hereafter referred to as a mechanical lift) for all transfers at all times - three staff members were needed to complete lift transfers as one individual needed to hold the cast on the resident's left lower extremity, and -The resident was to use a Broda chair for as long as his/her left lower extremity was in a cast. Record review of the resident's Impaired Physical Mobility Care Plan showed as of 6/20/12 staff was to use a mechanical lift (total body) for all transfers at all times, and the resident was to be seated in a Broda chair while his/her left lower extremity was in a cast. Note: The resident's care plan also continued to show staff was to use a S-S lift for transfers with the assistance of two staff members. The care plan did not reflect the resident's non-weight-bearing status and that he/she had poor safety awareness and judgment. Record review of the resident's Nurses' Notes dated 6/29/12, showed a CNA responded to an alarm coming from the resident's room at 8:05 P.M.. The resident was found on the floor mat next to his/her bed. The resident denied pain and appeared free of injury. A cast was noted to the resident's LLE. The resident appeared confused and staff noted this condition was "likely due to sundowners." (an ailment that causes the symptoms of confusion in the evening or when the sun is setting). The resident said he/she had been trying to get out of his/her bed. The bed was noted to be in low position with a mat present at the side of the bed. The call light was noted to be within the resident's reach. Note: There was no documentation related to the condition of the resident's left lower extremity after the fall nor were there any new interventions identified to help prevent the resident from having future falls. Record review of the resident's Fall Risk Assessment form dated 6/29/12, showed the resident: -Had intermittent confusion (four points); -had a history of [REDACTED]. -Was chair bound and needed assist with elimination (two points); -Had adequate vision (zero points); -Was unable to perform gait/balance testing (two points); -Was not evaluated for changes in his/her blood pressure when going from a lying to upright position (listed as N/A so no points scored); Note: While the resident was identified as unable to stand, he/she had made attempts to self-transfer and had fallen as a result. Changes in his/her blood pressure could have been assessed by raising the head of the residen

Based on interview and record review, the facility staff failed to provide care and services to promote the highest practicable physical well-being for four sampled residents (Residents #12, #4, #3, and #2) out of 14 sampled residents as evidenced by the staff's failure to: -Fully monitor Resident #12 following a procedure that had the potential to cause serious infection (multiple teeth extracted); Recognize the resident's concomitant (combined - use at the same time) use of [MEDICATION NAME] and [MEDICATION NAME] as a potential serious drug interaction; Identify the resident's combined use of [MEDICATION NAME] and [MEDICATION NAME] as a contributory factor for the resident's fall and subsequent hospitalization on [DATE] who was treated at that time for acute kidney failure; Obtain the resident's lab results as ordered by the physician; Develop plans of care that identified the significant potential risk to the resident related to the concomitant use of [MEDICATION NAME] and [MEDICATION NAME] (potential for a life-threatening elevation in the resident's potassium), as well as the impact of the removal of the resident's remaining teeth (17-19 teeth), i.e., the impact on the resident's ability to eat, his/her comfort level, potential for serious infection such [MEDICAL CONDITION], and the resident's use of antibiotics; and Notify the resident's physician of significant decreases in the resident's blood pressure as per the facility policy and physician orders. -Monitor and assess Resident #4 for changes in the resident's level of incontinence (loss of bowel and/or bladder control), the development of [MEDICAL CONDITION] (an infection of deep skin tissue) in the resident's left lower extremity (LLE), the development of [MEDICAL CONDITION] in both lower extremities, and the development of ulcers to the resident's lower extremities; failed to develop a plan of care related to the [MEDICAL CONDITION] in the resident's LLE, the presence of the [MEDICAL CONDITION] and wounds in the resident's lower extremities and their management; failed to update the resident's care plan to reflect the increased need for intervention related to the resident's incontinence; and failed to ensure the facility staff consistently and accurately documented the resident's condition. -Follow the facility policy and procedure to thoroughly investigate Resident #3's unwitnessed fall and/or injury and to fully document the facility's investigation of the resident's injury of unknown origin; failed to document on a daily basis the assessment, description, size, and the skin condition surrounding the injury of unknown origin on the resident's left lower extremity injury, a hematoma (a localized collection of blood from broken blood vessels) that developed into a [MEDICAL CONDITION] (an infection of deep skin tissue)/Contusion (traumatic injury of tissue without breakage of skin: Blood accumulates in the surrounding tissue producing pain, swelling, tenderness and discoloration); and failed to modify the care plan to reflect the resident's care needs. -Appropriately document the monitoring of the daily bowel movements for Residents #2. The facility census was 83 residents. Review of Arterial Pressure, as defined in the 20th Edition of Taber's Cyclopedic Medical Dictionary, copyright 2001, showed it was the pressure of the blood in the arteries. For a normal young person at physical and mental rest and in a sitting position, systolic blood pressure (the pressure during contraction of the ventricles, i.e., the bottom chambers of the heart) averages about 120 mm Hg; diastolic (the period of heart muscle relaxation, when blood is filling the chambers) pressure about 80 mm Hg. A wide range of normal variation was due to constitutional (the physical makeup and functional habits of the body), physical, and psychic (mental) factors. For older people, the pressures are higher. Review of the Physiology of the Kidney, as defined in the American Nephrology Nurses' Association Core Curriculum for Nephrology Nursing, Third Edition, copyright 1995, showed: The primary purpose of the kidney is to regulate the composition of blood (and other body fluids) as blood circulates through the kidneys. Specifically the kidney: -Removes end products of metabolism from the blood, such as urea, creatinine, and uric acid; -Regulates vascular and extravascular volume by controlling the amount of water that is excreted: -Regulates electrolyte balance of the body fluids; -Regulates acid-base balance of the body fluids; -Regulates blood pressure through he production of renin (an enzyme related to blood pressure control); -Regulates bone marrow production of red blood cells by secreting erythropoietin (a hormone); -Synthesizes vitamin D to its active form; -Secretes various hormones that help regulate renal blood flow. It also showed: -The glomerular (glomerulus - one of the capillary networks that is part of the filtration process in the kidney) filtration rate (GFR), normally about 125 milliliters (ml)/minute (min) in young healthy adults, depends on three factors: --Permeability (the condition that enables substances in the blood to pass into tissue spaces or into cells, or vice versa) and surface area of the glomerular capillary walls; --Mean (average) arterial blood pressure; --Net filtration pressure (pressure that allows fluid to shift out of or into the capillaries); and --A change in one or more of these factors will alter GFR. Review of Acute [MEDICAL CONDITION], as defined in the 20th Edition of Taber's Cyclopedic Medical Dictionary, copyright 2001, included the following: -Prerenal (non-kidney related) causes occur because of an inadequate blood flow to the kidney which can result because of the following: --Severe dehydration (the clinical consequences of negative fluid balance, i.e., fluid intake that fails to match fluid losses); --Prolonged [MEDICAL CONDITION] (a decrease of the blood pressure to below normal) which can be a result of conditions such as: ---Shock (a clinical syndrome marked by inadequate perfusion and oxygenation of cells, tissues, and organs, usually a result of marginal or markedly lowered blood pressure); Hemorrhage (episodes of bleeding that last more than a few minutes which compromise organ and tissue perfusion, or threaten life); Dehydration; [MEDICAL CONDITION] (a systemic [MEDICAL CONDITION] response to infection, in which there is: ----Fever (an abnormal elevation of temperature. The normal oral temperature ranges from 97.6 to 99.6 degrees Fahrenheit (F), but may vary based on the individual) or hypothermia (a body temperature less than 95 degree F); ----[MEDICAL CONDITION](an abnormally rapid heart rate, greater than 100 beat per minute (bpm) in adults); ----Tachypnea (abnormally rapid respirations); ----In many other diseases and conditions, such as: Renal ischemia (a temporary deficiency of blood flow to the kidney) or emboli (matter, i.e., blood clots, cholesterol-containing plaques, masses of bacteria, cancer cells, fat cells from the marrow of broken bones and injected substances that lodge in blood vessels and obstructs the circulation); Septic or cardiogenic shock (failure of the heart to pump an adequate supply of blood and oxygen to body tissues); and -Renal (specific to the kidney) causes result from injury to the kidney filtration system through which renal filtrate from the glomerulus flows and is changed to urine by reabsorption and secretion), and included conditions such as [MEDICAL CONDITION] (a form of inflammation primarily involving the glomeruli) and toxic injury to the kidneys such as from drugs or poisons; and -Postrenal (occurring after the kidney) causes resulted from obstruction to the urinary outflow, such as in the case of prostatic [MEDICAL CONDITION] (excessive growth of the prostate gland - a gland in males that surrounds the neck of the bladder and the urethra, i.e., the tube for the discharge of urine extending from the bladder to the outside); bladder outlet obstruction. Record review of the facility's Parameters for the Use of Antihypertensives and Monitoring of Blood Pressure, draft date of 4/28/10, showed the staff was to notify the physician if the resident's systolic blood pressure was less than 100 millimeters (mm) of mercury (Hg). This was to occur when a resident on antihypertensives was admitted or readmitted to the facility, when such medication was first started or when the medication dosage was changed. Staff was also directed to notify the physician if there were significant changes in the resident's blood pressure in comparison to his/her prior blood pressure control. Note: Medications falling under this policy included, but were not limited to, angiotensin converting enzyme (ACE) inhibitors, including [MEDICATION NAME], and diuretics (any drug that elevates the rate of urination), including [MEDICATION NAME] ([MEDICATION NAME], a potassium-sparing (conserving) diuretic). Note: The facility policy provided no direction related to the need for or frequency of laboratory testing. Record review of the facility's Lab and Diagnostic Test Results policy and procedure dated October 2010, showed: -The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. -The staff will process test requisitions and arrange for tests. -The laboratory, diagnostic provider, or other testing source will report test results to the facility. -A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition. -A nurse will try to determine whether the test was done as a routine screen or follow-up, to assess a condition change or recent onset of signs and symptoms, or to monitor a drug level. The reason for getting a test often affects the urgency of acting upon the result. If the resident has signs or symptoms of acute illness or condition change and he/she is not stable or improving, or there are no previous results or comparison, then the nurse will notify the physician promptly to discuss the situation, including a description of relevant clinical findings and the test results. -If the individual is stable or improving, and the results do not warrant immediate notification, the nursing staff may notify the physician routinely. -Note: The policy did not show the process for how staff would ensure lab results were obtained from the lab (for example: what the process would be if the lab did not send the lab results). 1. Record review of Resident #12's Physician's Orders Sheets (POS) identified the resident's original admitted to the facility as 2/1/11 and showed the resident had the following Diagnoses: [REDACTED].e., the bottom chambers of the heart); -[MEDICAL CONDITION] ([MEDICAL CONDITION] - a condition in which fatty material collects along the walls of the arteries. This fatty material thickens, hardens (forms calcium deposits), and may eventually block the arteries); -[MEDICAL CONDITION] (a slow heartbeat marked by a pulse rate below 60 beats per minute in an adult); -[MEDICAL CONDITION] ([MEDICAL CONDITION] - a disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body); -Hypertension (HTN - high blood pressure); and -Diabetes Mellitus (DM - a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin); and --medication orders [REDACTED] --[MEDICATION NAME] ([MEDICATION NAME]) 50 milligrams (mg), one tablet by mouth twice a day, i.e., in the A.M. and at noon; --[MEDICATION NAME] ([MEDICATION NAME] - a water pill that prevents the body from absorbing too much salt, allowing the salt and potassium to instead be passed in the urine; used to treat fluid retention ([MEDICAL CONDITION]) in people with [MEDICAL CONDITION], liver or some kidney disorders. This medication is also used to treat high blood pressure) 40 mg by mouth daily. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff) dated 2/8/11, showed the resident: -Had severe impairment of his/her cognition (thought processes); -Had no impairment of his/her range of motion; -Was unsteady when walking, but able to stabilize himself/herself without human assistance; -Used a cane; -Had fallen prior to admission, but not since admission; -Received a therapeutic diet; -Needed supervision, oversight, encouragement or cueing when the he/she walked in his/her room, walked in the halls, when moving on or off the unit, and with dressing and his/her personal hygiene; -Received antipsychotic (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat [MEDICAL CONDITION]), antianxiety and diuretic (any drug that elevates the rate of urination) medications. -The admission MDS included the following Diagnoses: [REDACTED]. Note: The section of the MDS related to the resident's oral/dental status was left blank by the facility staff. Review of the resident's Care Plan, beginning date of 2/12/11, showed the facility staff failed to develop a temporary care plan related to the extraction of the resident's teeth and its potential impact to the resident, such as alteration in the resident's comfort level, the potential for infection, the potential for impaired nutritional intake or the impact such a procedure might have on the resident's blood sugar. The resident's care plan did not reflect the use of potassium-sparing medication, the need to monitor the resident's potassium levels or address the potential serious drug interaction ([MEDICAL CONDITION]-an elevation of the potassium level in the blood. It is often a symptomless condition until very high levels of potassium are present in the blood. The precise condition at which cardiac or skeletal muscle toxicities arise varies greatly from patient to patient. Eventually muscular weakness, electrocardiographic (EKG) abnormalities, and intractable (irreversible) cardiac rhythm disturbances may result.) from the concomitant use of [MEDICATION NAME] and [MEDICATION NAME]. Record review of the resident's Physician's Orders dated 5/17/11, showed the resident was to receive [MEDICATION NAME] ([MEDICATION NAME]) 20 mg by mouth daily for high blood pressure, in addition to the [MEDICATION NAME] and [MEDICATION NAME], and the staff was to check the resident's blood pressure weekly (on Mondays). If the blood pressure was less than 100 mm Hg, the staff was to hold the antihypertensive medications and notify the resident's physician. Note: The website, Drugs.com showed a major drug interaction was possible with the combined use of [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]). Close monitoring was advised if ACE inhibitors (medications like [MEDICATION NAME]) were used with potassium-sparing diuretics (such as [MEDICATION NAME]), particularly in patients with renal impairment, diabetes, old age, worsening heart failure, and/or at risk for dehydration. Serum potassium and renal function should be checked regularly, and potassium supplementation should generally be avoided unless it was closely monitored. Patients should be given dietary counseling and advised to seek medical attention if they experienced signs and symptoms of [MEDICAL CONDITION] such as weakness, listlessness, confusion, tingling of the extremities, and irregular heartbeat. If [MEDICATION NAME] was prescribed with an ACE inhibitor, some investigators recommended that its dosage not exceed 25 mg/day. Note: The resident was an elderly person, was diabetic, had [MEDICAL CONDITION] and had recently had multiple (17-19) teeth removed. The resident's care plan was not updated to reflect the addition of the [MEDICATION NAME] to the resident's treatment plan nor did it identify the increased need to monitor the resident for signs or symptoms of [MEDICAL CONDITION]. Review of the resident's medical record showed there were no physician orders related to the regular monitoring of the resident's potassium. Record review of the resident's Physician's Orders dated 9/28/11, showed an order for [REDACTED]. Note: The resident's care plan was not updated to show the resident was to have multiple teeth removed or how the staff was to assist the resident to meet his/her needs related to the procedure or after the procedure. Record review of the resident's POS dated 10/1/11, included an admission date of [DATE] and the following Diagnoses: [REDACTED]. Record review of the resident's Physician's Orders dated 10/4/11 showed an order for [REDACTED]. Note: This order was received after the resident had his/her teeth pulled. The resident's care plan was not updated to show the resident had a significant number of teeth removed or how this procedure could impact the resident's well-being, such as the potential alteration in comfort, the potential impact on the resident's ability to consume fluids and/or food, the potential for infection or possible complications, such as bleeding or dry sockets (The socket is the hole in the bone where the tooth has been removed. After a tooth is pulled, a blood clot forms in the socket to protect the bone and nerves underneath. Sometimes that clot can become dislodged or dissolve a couple of days after the extraction. That leaves the bone and nerve exposed to air, food, fluid and anything else that enters the mouth. This can lead to infection and severe pain that can last for days). Record review of the resident's Nurse's Notes dated 10/4/11 at 7:15 P.M., showed the resident returned from his/her dental appointment at 4:15 P.M. with gauze in his/her mouth. The gauze was to be changed as needed. The resident's vital signs showed a blood pressure of 111/60, a pulse rate of 72 (beats per minute), respirations at 20 (breaths per minute) and a temp of 97.9 degrees (Fahrenheit). Record review of the resident's Nurse's Notes from 10/4/11 through 10/10/11, showed: -The staff regularly monitored the resident's temperature, but there was no documentation showing the remainder of the resident's vital signs were assessed, i.e. there were no blood pressures, pulses or respirations recorded in the Nurse's Notes; -The staff regularly evaluated the resident for adverse reactions related to the use of the antibiotic and regularly monitored the resident for complaints of pain or discomfort. However, there was little documentation that showed the staff assessed the resident's mouth for changes and/or for signs and symptoms of infection, except for the checking of the resident's temperature; Note: A person, particularly an elderly person, can have a systemic infection without having a fever. Often it's a drop in the blood pressure that signals this type of infection in the elderly as their immune system is compromised. -The resident was offered a soft diet at 2:00 P.M. on 10/5/11, but he/she preferred to drink. Note: The Nurse's Notes showed the resident's antibiotic prescription was completed at 10:00 A.M. on 10/10/11. There were no further entries in the Nurse's Notes until 10/13/11 when the resident was found on the floor in his/her room. Record review of the resident's Nurse's Notes dated 10/13/11, showed: -At 8:30 A.M., the resident was found laying on his/her back on the floor in his/her room. The resident was alert with full range of motion (ROM - the range on which a joint can move) of his/her extremities. There was no bruising or abrasions noted. The resident said he/she had felt weak and just sat down so he/she wouldn't fall. The resident denied hitting his/her head. His/her pupils were equal in size and reacted to light. The vital signs documented included a blood pressure of 93/77, a pulse of 79, respirations of 18 and a temperature of 96.7 degrees. The notation showed neurochecks (neurological checkpoints to monitor potential head trauma; assesses the person's level of consciousness, ability to move extremities, eye responses and change in pupil size, and vital signs) were started and showed the resident's blood pressure (BP) to be low at 93/47. Record review of the facility's Fall/Injury Investigation dated 10/13/11 at 8:30 A.M., showed: -The fall was unwitnessed; -The resident had been found laying on the floor by his/her recliner in his/her room. The resident explained he/she had felt weak so he/she sat down; -The resident was oriented; -His/her call light had not been within reach; -The resident's mobility status was to be up, as tolerated, with his/her walker; -Medication-related causes for the fall were listed as "none;" -The resident was not experiencing any acute changes in his/her status that may have contributed to the fall; and there were no changes in his/her environment or plan of care that were considered contributory to the resident's fall; -The section identifying the immediate interventions implemented to reduce the risk of repeat falls/injuries was left blank by the facility staff; -The Director of Nursing (DON)/Designee's comments/recommendations included the following: "educate patient - call light." Note: The section titled, Fall Assessment & Intervention Committee was left blank by the facility staff. Record review of the resident's Nurse's Notes dated 10/13/11, showed: -At 8:40 A.M., the resident's attending physician was contacted. There were no new orders received. Staff was instructed to observe the resident; -At 9:00 A.M., the resident's BP was extremely low at 71/41; Note: There was no documentation showing the resident's physician was notified of the low systolic BP, as defined in the facility's Parameters for the Use of Antihypertensives and Monitoring of Blood Pressure policy, i.e., notify the physician if the systolic BP was less than 100 mm Hg; -At 9:15 A.M., the resident's BP was low at 94/68; -At 10:00 A.M., the resident's BP was low at 94/50; -At 11:30 A.M., the resident's BP was low at 96/50; -At 2:30 P.M., the resident's BP was low at 94/68; -At 4:30 P.M., the resident's BP was low at 99/76; -At 10:30 P.M., the resident's BP was low at 92/48; Note: There was no documentation in the Nurse's Notes showing the resident's physician was notified of the resident's trend of low BPs nor was there any documentation of any changes having been made related to the reportable blood pressure parameters for this resident. Record review of the resident's Nurse's Notes dated 10/13/11 at 6:00 P.M., showed the resident was out of bed and to the dining room for his/her dinner. The resident voiced no complaints and no injuries were noted; the resident was moving all his/her extremities (MAE). The resident's vital signs included a blood pressure of 99/76, a pulse of 98, 18 respirations and a temperature of 97.7 degrees. His/her oxygen saturation was 94 percent. Note: There was no documentation showing the resident's physician had been notified the resident's systolic blood pressure was less than 100 mm Hg. Record review of the resident's Nurse's Notes dated 10/14/11 at 1:55 A.M., showed the resident's oxygen saturation was 94 percent on room air, his/her BP was 138/76, temperature was 98.1, pulse was 62 and respirations, even and unlabored, at 18. The staff continued monitoring the resident's neurological status and the documentation showed findings within normal limits. The resident's skin was warm and dry. He/she was able to move all extremities as per his/her usual. The resident was easily aroused from sleep and was responsive to the staff. He/she denied discomfort or pain at that time and the resident showed no signs or symptoms of being distressed. The resident's call light was within his/her reach. Record review of the documentation on the resident's Neurological Flow Sheet dated 10/14/11, showed the resident's blood pressure was low at 86/73 at 6:30 A.M.. Note: There was no documentation in the resident's medical record to indicate the resident's physician was notified the systolic blood pressure was less than 100 mm Hg or that the reportable BP parameters had been changed. Record review of the resident's Nurse's Notes dated 10/14/11 showed the following: -At 8:30 A.M., staff noted the resident had generalized weakness, complained of feeling weak and had a poor appetite. The resident's vital signs included a low blood pressure of 89/59, a pulse of 89, respirations of 19 and a temperature of 96.1 degrees. The resident's [MEDICATION NAME] and his/her [MEDICATION NAME] were held. -At 9:30 A.M., the resident's physician was notified of changes in the resident's condition, i.e., the resident's complaints of generalized weakness, the resident's low blood pressure and of the staff's holding of the resident's medication. The physician confirmed the holding of the A.M. doses of the [MEDICATION NAME] and [MEDICATION NAME]. He/she instructed the staff to give the noon dose of the [MEDICATION NAME]. A complete blood count (CBC - a blood test that determines the number, variety, percentage, concentration and quality of blood cells) and a basic metabolic panel (BMP - a blood test that measures sugar levels, electrolytes, fluid balance, and kidney function) were ordered to be drawn by the laboratory stat (immediately). The physician ordered that he/she be called that afternoon with updates on the resident's condition and if the resident's blood pressure was greater than 140/90; -At 9:40 A.M., the resident required the assistance of two to three staff to use the toilet. The resident was noted to have hand tremors. The laboratory was notified of the physician orders for the stat labs to be drawn. Record review of the documentation on the resident's Neurological Flow Sheet dated 10/14/11, showed the resident's blood pressure was low at 89/59 at 10:30 A.M.. Note: There was no documentation in the resident's medical record to indicate the resident's physician was notified the systolic blood pressure was less than 100 mm Hg. Record review of the resident's Nurse's Notes dated 10/14/11 showed the following: -At 12:30 P.M., the resident's blood pressure reading was 147/92. The [MEDICATION NAME] dose was given as per the physician orders. The resident continued to have a poor appetite and was provided assistance by a Certified Nursing Assistant (CNA); Note: There was no documentation in the resident's medical record that showed the physician was notified, as ordered, of the blood pressure greater than 140/90; -At 2:00 P.M., the resident's blood pressure was 103/50. The results of the stat blood draw had been received and staff left a message for the resident's physician. Record review of the resident's stat BMP collected on 10/14/11 at 11:57 A.M., showed the specimen was not hemolyzed, i.e., there was no red blood cell destruction (this can increase the potassium level through the release of intracellular potassium into the blood stream). The potassium, sodium, BUN and Creatinine results were called to Licensed Practical Nurse (LPN) F at 2:02 P.M. on 10/14/11 by the laboratory and included the following results: -The sodium (NA) level was critically low at 117 millimoles per liter (mmol/L - the mole is a unit of measurement used in chemistry to express amounts of a substance); Note: The laboratory's (lab's) normal range for NA was 134-145 mmol/L; -The potassium (K) level was critically high at 8.4 mmol/L, a potentially life-threatening level and reflected the probability of acute kidney failure; Note: The lab's normal range for K was 3.5-5.1 mmol/L; -The chloride (CL) level was low at 87 mmol/L; Note: The lab's normal range for CL was 97-107 mmol/L; -The carbon [MEDICATION NAME] (CO2) level was extremely low at 15 mmol/L and reflected a significant alteration in the resident's acid/base balance and potential kidney function impairment; Note: The lab's normal range for CO2 was 21-31 mmol/L; -The blood urea nitrogen (BUN) level was critically high at 85 mg/dL and reflected the possibility of acute kidney failure and/or severe dehydration (excessive loss of water from body tissues); Note: The lab's normal range for BUN was 7-25 mg/dL; -The creatinine level (CREA) level was critically high at 5.2 mg/dL and reflected the possibility of acute kidney failure; Note: The lab's normal range for CREA was 0.6-1.3 mg/dL; -The calcium (CA) level was essentially normal at 10.4 mg/dL; Note: The lab's normal range for CA: 8.6-10.3 mg/dL; -The estimated glomerular filtration rate (eGFR) was 11.6 milliliters/minute (ml/min) (a calculated number that reflected how much blood was being filtered by the kidney each minute; the lab showed no normal range; the resident's eGFR had been 77.5 on 2/3/11); Note: This level was extremely low and reflected acute [MEDICAL CONDITION] (sudden, rapid deterioration of renal function). Per the National Kidney Foundation's Disease Outcomes Quality Initiative (KDOQI) Guidelines (www.kidney.org), the stages of [MEDICAL CONDITION] were defined as follows: -Stage I kidney disease showed kidney damage with a GFR of greater than or equal to 90 ml/min; -Stage II showed kidney damage with a GFR of 60-89 ml/min; -Stage III showed a GFR rate between 30-59 ml/min; -Stage IV showed a severe decrease in the GFR rate, i.e., between 15-29 ml. min; -Stage V kidney disease showed kidney failure, i.e., less than 15 ml/min (or requiring [MEDICAL TREATMENT] (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood). Record review of the resident's stat CBC on 10/14/11 at 11:57 A.M., showed a white blood cell (WBC) count of 16.7, (16,700 cells/milliliter - The normal range was 4.5 - 10.5 X 10(3)/microliter (mL - a laboratory measure equal to one-millionth part of a liter). Note: This level was high which indicated the resident potentially had an infection. Record review of the resident's Nurse's Notes dated 10/14/11 showed the following: -At 2:15 P.M., the resident's physician returned the staff's call. New orders were received to transfer the resident to the hospital for evaluation; -At 2:30 P.M., the ambulance arrived and transported the resident to the hospital. A report was called to the hospital emergency room . Record review of the resident's Hospital Record notes showed on 10/15/11: -The impression of the resident's condition was acute kidney failure, [MEDICAL CONDITIONS] (low sodium levels in the blood), profound [MEDICAL CONDITION] (low blood pressure), electrolyte depletion, metabolic acidosis (any process that causes a decrease in the pH of the body as a result of the retention of acids, or the loss of [MEDICATION NAME] buffers), coagulapathy (a defect in the blood-clotting ability), leukocytosis (an increase int he number of white blood cells in the blood; occurs most commonly in disease processes involving infection, inflammation, trauma,or stress, but it also can result occasionally from the use of some medications) and [MEDICAL CONDITION] (an abnormal decrease in the platelet ([MEDICAL CONDITION] - cells that contribute to blood clotting) level); -The plan of care included intravenous (IV) [MEDICATION NAME] (to correct the metabolic acidosis), fluids, cultures, antibiotics, follow-up labs, and renal care (not urgent). -By 10/16/11, the resident's acute kidney failure was better, the [MEDICAL CONDITION] was decreasing, the metabolic acidosis had resolved and the resident's sodium level was improved. Record review of the resident's Physician's Order Sheet (POS) dated 10/20/11, showed orders, that included, but was not limited to, the following: -The resident was readmitted to the facility: -Staff was to check the resident's blood pressure twice a day times seven days, morning and evening. If the systolic blood pressure was less than 100 mm Hg, staff was to hold the anti-hypertensive medications and call the resident's physician. Once the above was completed, the resident's blood pressure was to be checked weekly on Mondays; and if the systolic blood pressure was less tha

Based on observation, interview, and record review, the facility staff failed to follow the facility's policies and provide the necessary care and services in accordance with current standards of practice to attain and/or maintain the highest practicable physical well-being of two residents (Residents #1 and #2) out of nine sampled residents who had central line [MEDICAL TREATMENT] access devices, and a recent and/or current bacterial infection. The facility staff failed to timely assess, monitor, document in the resident's medical record and notify the resident's physician regarding Resident #1's temporary central line [MEDICAL TREATMENT] access device and insertion site condition, and central line dressing changes, episodes of low blood pressure, little or no urine output, little or no food and fluid intake, and/or when the resident's medications were held and/or omitted; failed to accurately transcribe and administer to the resident 15 doses of an antibiotic ordered by the physician to treat the resident's urinary tract infection; failed to accurately develop and/or implement an individualized comprehensive care plan to include interventions specific to Residents #1 and #2's medical conditions and needs; failed to notify Resident #1's next-of-kin and/or emergency contact person when the resident had a significant change of condition; failed to educate staff to Residents #1 and #2's specific medical conditions and/or care needs; and failed to ensure appropriate sterile dressing supplies were available for staff to perform Residents #1 and #2's central line [MEDICAL TREATMENT] access device dressing changes. The facility's continued deficient practices resulted in Resident #1's urinary tract infection not being adequately treated, his/her central line insertion site to become infected and/or develop necrotic (dead) tissue, him/her to become dehydrated, have mental status changes, develop a bacterial infection in his/her blood, require transfer to an acute care hospital for intensive care where he/she died [MEDICAL CONDITION] (a severe illness in which the bloodstream is overwhelmed by bacteria which may lead to organ failure and death). In addition, the facility staff failed to accurately assess, monitor, and/or document in Resident #2's medical record, his/her central line [MEDICAL TREATMENT] access device and insertion site condition; failed to accurately transcribe the physician's orders for the resident's dressing change; and failed to follow current infection control standards of practice to maintain his/her central line [MEDICAL TREATMENT] access device. The facility's continued deficient practices to provide the necessary care and services to Resident #2 who also had a [DIAGNOSES REDACTED]. The facility identified a total of two residents, Residents #1 and #2, who had [MEDICAL TREATMENT] access devices and who also had a recent and/or current bacterial infection. The facility census was 88 residents. 1. Record review of the facility's undated policy titled, "Catheter Care, Urinary," showed the following information and staff instructions: - The purpose of this procedure is to prevent infection of the resident's urinary tract. - Check the urine for unusual appearance such as color, blood, etc. - Maintain an accurate record of the resident's daily output. - Review the resident's plan of care daily for changes. - Empty the collection bag at least every eight hours. - Observe the resident for signs and symptoms of urinary tract infections. Report findings to the staff/charge nurse immediately. - Urinary catheter care, any complaints, unusual findings, or observations should be reported to the staff/charge nurse and documented in the resident's medical record. Record review of the facility's 2005 policy titled, "Administration of Drugs," showed the following information and staff instructions: - Medications must be charted by the person administering the drugs immediately following administration. The date, time administered, dosage, etc. must be entered in the resident's medical record and signed by the person entering the date. - Should there be any doubt concerning the administration of medications, the physician's order must be verified before the medication is administered. Record review of the facility's 2007 policy titled, "Documentation of Medication Administration," showed the following information and staff instructions: - A nurse or a certified medication aide shall document all medications administered to each resident on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - Administration of medication must be documented immediately after (never before) it is given. - Documentation must include, as a minimum: Name and strength of the drug; dosage; method of administration; date and time of administration; reason(s) why the medication was withheld, not administered, or refused; and the signature and title of person administering the medication. Record review of the facility's 2007 policy titled, "Identifying and Managing Medication Errors and Adverse Consequences," showed the following information and staff instructions: - Policy statement: "The staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur." - The staff and practitioner shall strive to minimize consequences by following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; - The staff shall report clinically significant medication errors to the resident's attending physician immediately; - Nursing staff will document appropriately detailed accounts of any incidents on the appropriate report form; and - The Medical Director, Director of Nursing Services, and Consultant Pharmacist shall review medication errors as part of the facility's Quality Assurance process. Record review of the facility's 2008 policy titled, "Charting and Documentation," showed the following information and staff instructions: - Policy statement: "All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record." - "All incidents, accidents, or changes in the resident's condition must be recorded." - Documentation criteria: Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: The date and time the procedure/treatment was provided; the name and title of the individual(s) who provided care; the assessment data and/or unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment; notification of family, physician, or other staff, if indicated; and the signature and title of the individual documenting. Record review of the facility's 2010 policy titled, "[MEDICAL TREATMENT] Access Care," showed the following information and staff instructions: - Guidelines: Verify with state Nurse Practice Act regulations regarding scope of practice for licensed staff in the care of residents with [MEDICAL TREATMENT] devices; - [MEDICAL TREATMENT] access devices are surgically placed and removed; - Vascular access may be accomplished in one of three ways including the surgical placement of a central catheter; - Central catheters are generally inserted into the neck, chest, or groin area; - There is a higher rate of infection with central catheters than the other two types of vascular access for [MEDICAL TREATMENT]; and - Central [MEDICAL TREATMENT] catheters are recognized by the following characteristics: Two short catheters made from heavy, thick rubber exiting from the insertion site. The arterial catheter lumen is usually red and the venous one blue; and each catheter has a clamp and an end cap. - Care immediately following [MEDICAL TREATMENT] treatment: The dressing is done in the [MEDICAL TREATMENT] center post-treatment; and - "If the dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure. (Note: Check with State Nurse Practice Act to determine licensure and competency requirements.)" - Care of Central [MEDICAL TREATMENT] Catheters: The central catheter site must be kept clean and dry at all times. Bathing and showering are not permitted with this device; - [MEDICAL TREATMENT] catheters should be marked "for [MEDICAL TREATMENT] use only" so they are not confused with other types of central venous access devices; and - Those caring for the catheter site must wear a mask and gloves when doing so. - "Dressing changes, if ordered, should be done using sterile technique." - Documentation: "The general medical nurse should document in the resident's medical record every shift as follows: Location of catheter, condition of dressing (interventions if needed), if [MEDICAL TREATMENT] was done during the shift, any part of report from [MEDICAL TREATMENT] nurse post-[MEDICAL TREATMENT] being given, and observations post-[MEDICAL TREATMENT]." Record review of Mosby's 2009, eighth edition, Medical Dictionary showed the following information: - Proteus bacteria: A genus (bacterium species classification) of motile, gram-negative bacilli often associated with nosocomial (infections that are a result of treatment in a healthcare setting) infections, normally found in feces, water, and soil. - Proteus bacterial may cause urinary tract infections, [MEDICAL CONDITION] (kidney infection), wound infections, diarrhea, bacteremia (the presence of bacteria in the blood), and endotoxic (a toxin produced within some bacteria that is released only when the bacteria disintegrate) shock (a life-threatening condition). - M. morganii (a type of bacteria) was previously classified under the genus Proteus as Proteus morganii (P. morganii). In the late 1930's, M. morganii (also known as P. morganii) was identified as a cause of urinary tract infections. Record review of the facility's 2010 policy titled, "Central Venous Catheter Dressing Changes," showed the following information and staff instructions: - "The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings." - "Check the State's Nurse Practice Act for Licensed Practical Nurses (LPNs) regarding scope of practice for changing a central venous catheter dressing." - "A physician's order is not needed for this procedure." - "Apply and maintain "sterile" dressing on intravenous access devices. Dressings must stay clean, dry, and intact. Explain to the resident that the dressing should not get wet." - "Change dressing if any suspicion of contamination is suspected." - Catheter site care shall allow for the observation and evaluation of the catheter-skin junction and surrounding tissue. - Removal of old dressing is an aseptic, non-sterile procedure. - "Change transparent semi-permeable membrane dressings at least every seven days and as needed (PRN) when wet, soiled, or not intact." - If a gauze dressing is ordered by the physician it must be changed every 48 hours. - To replace a sterile dressing, obtain and use a sterile central venous catheter dressing change kit. - Assessment: Observe insertion site and surrounding area for complications. - The following information should be documented in the resident's medical record: - Date and time dressing was changed; - Location and objective description of insertion site; - Any complications and related interventions done; - Condition of sutures if present; - Type of dressing placed; - Any questions and/or education given to the resident; - Signature and title of person recording the data; - Report any signs and symptoms of complications to the supervisor, oncoming shift, and the resident's physician; and - Intervene as necessary. Record review of the facility's 2010 policy titled, "Blood Pressure, Measuring," showed the following information and staff instructions: - Review the resident's care plan to assess for any special needs of the resident. - Normal blood pressure, represented as a ratio or fraction (systolic/diastolic), is defined as a reading between ,[DATE] to ,[DATE]. - High blood pressure (hypertension) is defined as a reading over ,[DATE]. - Low blood pressure ([MEDICAL CONDITION]) is defined as a reading below ,[DATE]. - Any episodes of hypertension or [MEDICAL CONDITION] should be reported to the physician. - Staff should note any pertinent medications and/or recent changes of condition when reporting to the physician. - Report other information in accordance with facility policy and professional standards of practice. - The date and time the blood pressure was measured, the name and title of the individual who measured the blood pressure, the blood pressure reading, and the signature and title of the person recording the data should be recorded in the resident's medical record. - Wash and dry your hands thoroughly before and after the procedure. - Use personal protective equipment such as a gown and/or gloves as needed. Record review of the PubMed Health, National Center for Biotechnology Information (NCBI), a division of the National Library of Medicine (NLM) at the National Institutes of Health (NIH) dated 2010, public information website showed the following educational material: - [MEDICAL TREATMENT]: A process that uses a man-made membrane (dialyzer/filter) to remove wastes from the blood, restore the proper balance of electrolytes in the blood, and eliminate extra fluid from the body. The [MEDICAL TREATMENT] patient is connected to the dialyzer/filter machine by tubes attached to a [MEDICAL TREATMENT] access device such as a venous catheter. The patient's blood is slowly pumped from his/her body into the dialyzer, where waste products and extra fluid are removed. The filtered blood is then pumped back into the patient's body. Chronic kidney (renal) disease and acute [MEDICAL CONDITION] cause the kidneys to lose their ability to filter and remove waste and extra fluid from the body. - Venous catheter (central line [MEDICAL TREATMENT] access device) is a tube or catheter surgically placed in a vein in the neck, chest, or groin and used as a temporary [MEDICAL TREATMENT] access device. - Shock is a life-threatening condition that occurs when the body is not getting enough blood flow which can result in damage to multiple organs. A person in shock has extremely low blood pressure. Shock requires immediate medical treatment and can get worse very rapidly. Shock can be caused by any condition that reduces blood flow such as low blood volume from dehydration, certain medications that significantly reduce heart function or blood pressure, or changes in blood vessels from an infection. - Depending on the specific cause and type of shock, symptoms will include one or more of the following: anxiety or agitation/restlessness, bluish lips and fingernails, chest pain, confusion, dizziness, lightheadedness, or faintness, pale, cool, clammy skin, low or no urine output, profuse sweating, moist skin, rapid but weak pulse, shallow breathing, or loss of consciousness. -[MEDICAL CONDITION] or Septic shock (also known as [MEDICAL CONDITION], bacteremia, and Systemic [MEDICAL CONDITION] Response Syndrome (SIRS)) is a severe and serious bloodstream infection which occurs when a person's bloodstream is overwhelmed with bacteria from any type of bacteria. -[MEDICAL CONDITION] may lead to life-threatening low blood pressure caused by toxins released by the bacteria which may cause tissue damage and poor organ function. A blood test is often performed to confirm diagnosis. -[MEDICAL CONDITION] is caused by a bacterial infection that can begin anywhere in the body. Common places where a bacterial infection might start include the kidneys as a result of a urinary tract infection, the bowel (intestines), intravenous lines (venous catheters), surgical wounds, and sites of skin breakdown. - A change in mental status and fast and shallow breathing (hyperventilation) may be the earliest signs [MEDICAL CONDITION]. In general, symptoms [MEDICAL CONDITION] can include chills, confusion, decreased urine output, fever or low body temperature (hypothermia), hyperventilation, lightheadedness due to low blood pressure, a rapid heartbeat, shaking, a skin rash, or warm skin. -[MEDICAL CONDITION] is often life threatening, especially in people with a weakened immune system or with a chronic illness. - [MEDICAL CONDITION] (C. diff) infection is caused by an overgrowth of a bacteria normally present in the intestine. The overgrowth of bacteria may occur as a result of treatment with antibiotics for other types of bacterial infections. [DIAGNOSES REDACTED] bacteria release a powerful toxin that causes the lining of the colon (intestine) to become inflamed ([MEDICAL CONDITION]) and bleed. [DIAGNOSES REDACTED]icile infection is a common cause of diarrhea after treatment with certain antibiotic medications. [DIAGNOSES REDACTED] causes mild or severe diarrhea, dehydration, and in some cases the bacterium can get into the bloodstream and be life threatening. - [DIAGNOSES REDACTED] bacteria can spread or be transmitted from one person to another by contact as a result of fecal contamination such as from poor hand hygiene. The bacterium produces long-lived spores that can survive a long time outside the body on environmental surfaces as well, making it especially important to maintain good infection control practices. - The stool [DIAGNOSES REDACTED]icile toxin test detects harmful substances produced by the bacterium [MEDICAL CONDITION] in a stool sample. - [MEDICATION NAME] ([MEDICATION NAME]; an antibiotic medication) is usually used to treat the [DIAGNOSES REDACTED] infection, but [MEDICATION NAME] (an antibiotic medication) may also be used to treat [DIAGNOSES REDACTED]. [MEDICATION NAME] works by killing bacteria in the intestines. - [MEDICATION NAME] will not kill bacteria or treat infections in any other part of the body when taken by mouth. 2. Record review of Resident #1's facesheet showed: - The resident was his/her own responsible party. - His/her family member was his/her Durable Power of Attorney for Healthcare and Financial Decisions. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff) dated [DATE], showed: - He/she was admitted to the facility on [DATE]. - He/she was alert and oriented, ate independently, and was dependent on one staff for toileting and hygiene cares. - He/she did not have an indwelling urinary catheter. - He/she had no urinary tract infections in the last 30 days. - He/she did not have [MEDICAL CONDITION] (Sepsis). - He/she did not have a wound infection. - He/she was not on [MEDICAL TREATMENT]. - He/she had no problems eating, chewing, or swallowing. Record review of the resident's comprehensive care plan dated [DATE], showed the following information: - The resident was alert and oriented. - The nursing staff were instructed to monitor the resident's blood pressure as ordered by the physician and/or per nursing judgment and reported any abnormal findings. - The nursing staff were instructed to monitor and recorded the resident's response to medications. - The nursing staff were instructed to administer antihypertensive medications as ordered by the physician. - The nursing staff were instructed to evaluate the resident's level of consciousness for changes as evidenced by increased confusion, anxiety, fatigue, or decreased alertness, and notify the physician if any changes occurred. - The nursing and dietary staff were instructed to ensure the resident received his/her diet as ordered. - The nursing and dietary staff were instructed to report any noncompliance with his/her diet to his/her responsible party and physician. - The nursing and dietary staff were instructed to monitor and recorded the resident's meal intake percentages daily. - The nursing staff were instructed to serve the resident's meals, set-up, assist, and offer verbal cueing to maximize his/her intake to at least 75% every meal as much as possible. - Note: The resident's MDS dated [DATE], indicated the resident ate independently. - The nursing staff were instructed to offer the resident at least 360 cubic centimeters (cc) of fluid at each meal. - The nursing staff were instructed to monitor the resident for signs and symptoms of dehydration such as dry, cracked lips, dry skin, changes in baseline level of consciousness and vital signs. - The nursing staff were instructed to monitor the resident for signs and symptoms of an infection, not otherwise specified. - The nursing staff were instructed to monitor the resident for signs and symptoms of a urinary tract infection, not otherwise specified. - On [DATE], a problem was discontinued which was titled urinary incontinence/catheter and had associated goals and interventions for nursing staff to assess and monitor a urinary catheter. - The nursing staff were instructed to monitor the resident for changes in his/her cognition and/or changes in his/her physical well-being. Record review of the resident's medical record dated [DATE] to [DATE], showed: - He/she was discharged and transferred to an acute care hospital on [DATE], for a low hemoglobin (a protein in red blood cells that carries oxygen) level. He/she remained as an inpatient at the acute care hospital through [DATE], where he/she was treated for [REDACTED]. The severe [MEDICAL CONDITION] caused him/her to have acute renal (kidney) failure. He/she had a central venous [MEDICAL TREATMENT] catheter surgically placed in his/her right upper chest wall, and he/she started [MEDICAL TREATMENT] while still in hospital. He/she acquired and was treated for [REDACTED]. He/she had an indwelling urinary catheter. Record review of the resident's facesheet showed: - He/she was readmitted to the long-term care facility on [DATE]. - The resident was his/her own responsible party. - His/her family member was his/her Durable Power of Attorney for Healthcare and Financial Decisions. Record review of the resident's Nurse's Notes (NN) dated [DATE], showed: - He/she was alert and oriented. - He/she had a new [MEDICAL TREATMENT] "port" to his/her right chest. - He/she had an indwelling urinary catheter to promote wound healing. - He/she had a closed Stage II ulcer to his/her coccyx area which was pink in color. - He/she was a full code. - He/she was to begin an antibiotic for a UTI in the morning, on [DATE]. - Note: The resident did not have a UTI on admission, but yeast infection of his/her skin for which he/she was prescribed [MEDICATION NAME] (an antifungal medication) for five days. Record review of the resident's admission orders [REDACTED] - He/she was a full code. - He/she ate a regular textured, low concentrated sweet, no added salt diet. - He/she had an indwelling urinary catheter (Foley catheter), to promote healing of his/her coccyx/sacral wound, which the staff changed monthly and PRN; the staff performed catheter care every shift and PRN; the staff ensured his/her catheter was to dependent drainage and checked every shift. - an order for [REDACTED]. - an order for [REDACTED]. - an order for [REDACTED]. Staff held the medication if his/her systolic blood pressure was below 100. - A PRN order for [MEDICATION NAME] ([MEDICATION NAME]; an anti-nausea medication) if he/she was nauseated. - an order for [REDACTED]. and 8:00 P.M. to monitor his/her medications used to treat his/her hypertension. - He/she had a Stage I pressure ulcer (a persistent area of skin redness without a break in the skin that does not disappear when pressure is relieved) present on admit. - He/she had past and current medical conditions and [DIAGNOSES REDACTED]. Record review of the resident's comprehensive care plan revised on [DATE], [DATE], and [DATE], showed the following information: - Note: There were no problems, goals, or interventions related to the resident's central line [MEDICAL TREATMENT] access device and/or included staff instructions to assess, monitor, and/or document the resident's insertion site condition and care, and/or central line dressing changes. - The resident was alert and oriented. - The nursing staff were instructed to monitor the resident's blood pressure as ordered by the physician and/or per nursing judgment and reported any abnormal findings. - The nursing staff were instructed to monitor and recorded the resident's response to medications. - The nursing staff were instructed to administer antihypertensive medications as ordered by the physician. - The nursing staff were instructed to evaluate the resident's level of consciousness for changes as evidenced by increased confusion, anxiety, fatigue, or decreased alertness, and notified the physician if any changes occurred. - The nursing and dietary staff were instructed to ensure the resident received his/her diet as ordered. - The nursing and dietary staff were instructed to report any noncompliance with his/her diet to his/her responsible party and physician. - The nursing and dietary staff were instructed to monitor and record the resident's meal intake percentages daily. - The nursing staff were instructed to serve the resident's meals, set-up, assist, and offer verbal cueing to maximize his/her intake to at least 75% every meal as much as possible. - Note: The resident's MDS dated [DATE], indicated the resident ate independently. - The nursing staff were instructed to offer the resident at least 360 cc of fluid at each meal. - The nursing staff were instructed to monitor and record the resident's intake and output every shift. - The nursing staff were instructed to monitor the resident for signs and symptoms of dehydration such as dry, cracked lips, dry skin, changes in baseline level of consciousness and vital signs. - The nursing staff were instructed to monitor the resident for signs and symptoms of an infection, not otherwise specified. - The nursing staff were instructed to monitor the resident for signs and symptoms of a urinary tract infection, not otherwise specified. - A problem which was titled urinary incontinence/catheter and had associated goals and interventions for nursing staff to assess and monitor the resident's urinary catheter due to his/her history of recurrent urinary tract infections. - Note: The resident was re-admitted on [DATE], with an indwelling urinary catheter. - The nursing staff were instructed to monitor the resident for changes in his/her cognition and/or changes in his/her physical well-being. - The nursing staff were instructed to ensure the resident was up and ready for [MEDICAL TREATMENT] three times a week as ordered. - The nursing staff were instructed to monitor the resident's [MEDICAL TREATMENT] shunt located in his/her arm and notify his/her physician if there were any complications. - Note: The resident did not have a [MEDICAL TREATMENT] shunt (a [MEDICAL TREATMENT] fistula; a surgically created connection between an artery and a vein). He/she had a central line [MEDICAL TREATMENT] catheter located in his/her upper chest wall. Record review of the resident's significant change MDS dated [DATE], showed: - He/she was admitted to the facility on [DATE]. - He/she was alert and oriented, ate independently, and was dependent on one staff for toileting and hygiene cares. - He/she had an indwelling urinary catheter, - He/she received [MEDICAL TREATMENT]. - He/she had no urinary tract infections in the last 30 days. - Note: The resident was treated for [REDACTED]. - He/she did not have [MEDICAL CONDITION] (Sepsis). - He/she did not have a wound infection. - He/she had no problems eating, chewing, or swallowing. Record review of the resident's NN dated [DATE] through [DATE], showed: - His/her Foley catheter remained patent to dependent drainage and he/she had clear yellow urine output in his/her drainage bag. - There was no and/or incomplete documentation by the nursing staff regarding the resident's central line [MEDICAL TREATMENT] catheter and/or [MEDICAL TREATMENT] as instructed by the facility's 2010 policy titled, "[MEDICAL TREATMENT] Access Care: "The general medical nurse should document in the resident's medical record every shift as follows: Location of catheter, condition of dressing (interventions if needed), if [MEDICAL TREATMENT] was done during the shift, any part of report from [MEDICAL TREATMENT] nurse post-[MEDICAL TREATMENT] being given, and observations post-[MEDICAL TREATMENT]." Record review of the resident's POS dated [DATE] through [DATE], showed the following orders and information: - He/she remained a full code. - He/she continued to eat a regular textured, low concentrated sweet, no added salt diet. - He/she left the facility every Monday, Wednesday, and Friday, and was transported to a local [MEDICAL TREATMENT] clinic for [MEDICAL TREATMENT] at 3:00 P.M. - An order dated [DATE], for [MEDICATION NAME] (an antihypertensive medication) every day at 8:00 A.M. - An order dated [DATE], for [MEDICATION NAME] (an antihypertensive medication) every day at 8:00 A.M. - Note: The instructions to the staff , on his/her [DATE] POS and dated [DATE], to hold the [MEDICATION NAME] if his/her systolic blood pressure was below 100, was no longer part of the order, and there were physician's orders to change the order. - A PRN order dated [DATE], for [MEDICATION NAME] ([MEDICATION NAME]; an anti-nausea medication) if he/she was nauseated. - An order dated [DATE], for his/her blood pressure and pulse to be obtained at 8:00 A.M. to monitor his/her medications used to treat his/her hypertension. - Note: The instructions to the staff, on his/her [DATE] POS and dated [DATE], to obtain the resident's blood pressure and pulse at 8:00 P.M. were no longer part of the order, and there were no physician's orders to change the order. - An order dated [DATE], which was not written on and/or discontinued on his/her November POS, for his/her Foley catheter and related orders to be discontinued. - Note: Record review of the resident's medical record, wound log, and wound documentation showed: On [DATE], he/she was assessed to have a healing Stage II or continued Stage I which was a persistent redness of the skin involving his/her closed coccyx/sacral pressure ulcer located along his/her buttocks crease in the area of his/her tailbone. The resident's healing Stage II pressure ulcer was closed and was unavoidable due to the resident's diagnoses, on-going medical conditions, and related treatments such as [MEDICAL TREATMENT]. The healing Stage II sacral/coccyx pressure ulcer was a non-facility acquired wound present on the resident's re-admission to the facility on [DATE]. - On [DATE], his/her physician ordered [MEDICATION NAME] (a zinc oxide-based barrier cream that protects against moisture and minor irritation) cream to be applied topically to the resident's affected areas of his/her buttocks crease and tailbone to protect the skin against moisture and irritation. Record review of the resident's Medication Administration Records (MAR) dated [DATE] to [DATE], showed the following orders and information: - An order dated [DATE], for [MEDICATION NAME] (an antihypertensive medication) every day at 8:00 A.M. was documented as held four times and was not documented as offered and/or held and/or given one time. There was no documentation on the MAR indicated [REDACTED]. - An order dated [DATE], for [MEDICATION NAME] (an antihypertensive medication) every day at 8:00 A.M. was documented as held one time and was not documented as offered and/or held and/or given ten times. There was no documentation on the MAR indicated [REDACTED]. - Note: The instructions to the staff , on his/her [DATE] POS and dated [DATE], to hold the [MEDICATION NAME] if his/her systolic blood pressure was below 100, was no longer part of the order, and there were physician's or