Every finding on record at Jefferson Health Care

Based on observation, interview and record review, the facility failed to ensure a resident's environment was free from accident hazards, when one resident (Resident #1) was not secured appropriately with a lap belt in the facility van during transport on 9/8/25 and the resident was ejected from his/her wheelchair. The resident's face hit the console/cup holder in front of him/her, resulting in his/her lip bleeding and swelling and facial bruising. The resident was admitted to the hospital for observation. Facility staff did not call 911 or notify any facility staff at that time. The facility census was 64 residents. The Administrator was notified on 9/18/25 of the past noncompliance immediate jeopardy which began on 9/9/25. The facility immediately completed education for staff on the appropriate transportation policies and procedures. A checklist for transporting residents was put in place. Supervisor ride-along with drivers were instituted for training. A system of auditing the checklists was put in place. The IJ deficiency was corrected on 9/9/25.Review of the facility's undated policy of Transporting a Resident in the Facility Van Showed:-The wheelchair should be properly positioned in the vehicle, facing forward.-Wheelchair brakes should be locked appropriately.-Resident should be secured to the wheelchair using the vehicle seatbelt.-In case of an accident or emergency: immediately turn off the ignition; assure the safety of all passengers; the police should be notified; in the event of an injury, 911 should be called; the facility should be notified in the case of accident/emergency.1. Review of Resident #1's admission Record face sheet showed the resident was admitted to the facility on [DATE] with the following diagnosis: end stage renal (kidney) disease.Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning), dated 6/23/25, showed he/she was cognitively intact.Review of the resident's Care Plan Report, dated 1/27/25, showed-He/She had additional diagnoses of: Legally blind left eye; Partially blind right eye.-He/she had impaired visual function and was at risk for injury. Interventions included monitoring for decline in mobility, sudden visual loss, signs or symptoms of acute eye problems, and decline in ability to perform activities of daily living, double vision, hazy vision, blurred or tunnel vision. Provide large-printed material.-He/She was primarily independent with activities of daily living (ADLs) but had some weakness and unsteadiness. He/she had no lasting mobility deficits.-He/She was at risk for falls. Interventions included using a wheelchair for long distance mobility; he/she did ambulate independently to the bathroom in his/her room at times.Review of Transportation Driver A's Transporting a Resident in the Facility Van training, dated 8/4/25, showed:-He/She was able to park the van in a secure area to load/unload a resident.-He/She demonstrated proper wheelchair positioning inside the vehicle; wheelchair facing forward.-He/She demonstrated wheelchair safety by locking the brakes appropriately.-He/She was able to secure the wheelchair frame to the floor of the vehicle using the four point strap system; two straps in the front of the wheelchair and two straps in the back of the wheelchair. Never attached straps to removable parts of the wheelchair. Flipped buttons to adjust front straps and flipped switches on back strap box to adjust.-He/She demonstrated straps were tight without any slack in them.-He/She was able to secure a resident to the wheelchair using the seatbelt; always used the across chest belt and always used lap belts.-He/She was able to describe the facility policy in case of accident/emergency including immediately turning off the ignition; assuring the safety of all passengers; notifying the police; in the event of an injury to call 911; notifying the facility of accident/emergency; and the driver should remain with the vehicle, complete police report, return the vehicle back to the facility or oversee its transport to an alternate location. Review of the facility's Timeline of Events, dated 9/9/25, showed:-11:15 A.M., the Director of Nursing (DON) received a call from Dialysis Nurse A at the dialysis center stating the resident had reported receiving a facial injury during transport from the facility to the hospital for a scheduled procedure.-11:20 A.M., the DON and administrator called Transportation Driver A to obtain a statement of events during transport. He/she stated he/she was close to the facility and preferred to speak in person.-11:40 A.M., Transportation Driver A returned to the facility and gave a statement of events to the DON and administrator of what had occurred during the transport of Resident #1 from the facility to the hospital at approximately 8:45 A.M.-12:10 P.M., the DON called the dialysis center and spoke to Dialysis Nurse A requesting the resident be sent to the ED for a precautionary evaluation.-1:00 P.M., Self report called to the SA and full investigation initiated. Transportation Driver A was suspended during the investigation.-2:00 P.M., a call was received from Dialysis Nurse A stating the resident had agreed to go to the emergency department (ED) for evaluation and was sent via ambulance to the hospital.7:20 P.M., the hospital was called for an update to the resident's status and information given that the resident was still receiving scans and would likely return in the morning, but thus far all scans had been negative.Review of the Facility's Summary of Investigation, dated 9/9/25, written by the administrator showed:-The facility received a call from the dialysis center at 11:15 A.M. that the resident had swelling and bruising to his/her face asking if it was known what had happened.-Per the resident report at dialysis, he/she came out of his/her wheelchair and hit his/her face.-The driver returned to the facility at 11:40 A.M. and the DON and administrator spoke with him/her and immediately suspended him/her.-The driver reported slowing down and the resident slid out of his/her wheelchair. -Asked why the resident would slide out of his/her wheelchair, the driver reported he/she had secured the wheelchair but did not secure the resident in the chair.-When the driver was asked why, he/she stated, I don't know. I know how and that I should have, but I just didn't. and I knew what to do but didn't.-The driver reported the resident hit his/her face on the console of the van, his/her lip was bleeding after coming out of his/her chair.-The driver stopped at 7-11 to clean him/her up.-The driver was asked why he/she did not call 911 and notify the administrator, he/she stated, I don't know. But I knew I was supposed to.-At 12:10 P.M., the dialysis clinic was notified to send the resident to the ED for evaluation.-Resident was admitted for observation at the hospital.-At 7:20 P.M., the hospital was called for an update and informed the resident was still receiving scans and would likely return in the morning at the time all scans were negative.-On 9/10/25 at 5:00 A.M. the resident returned from the hospital with no major injuries.-The result of the investigation is the driver failed to perform safety procedures as trained.Review of the resident's hospital Patient Visit Report, dated 9/9/25, showed:-He/She was seen for facial contusion (bruise).-Motor vehicle collision with no serious injury.During an interview on 9/17/25 at 1:58 P.M., Resident #1 said:-On Tuesday, 9/9/25, he/she had an appointment in the morning at Hospital A.-Transportation Driver A was the driver and loaded him/her in the facility transport van, which was a minivan.-The driver strapped the wheelchair down on the van but did not put a seatbelt on the resident.-He/She was not able to secure the lap belt herself.-He/She did not tell the driver to put the lap belt on him/her.-His/Her wheelchair was secured in the back behind the two front seats.-When the driver was driving, he/she made a left turn from the facility parking lot.-Shortly after that, the driver made a quick hard right turn. He/she had been speeding.-He/She could not see the speedometer, but the driver was pushing the gas pedal hard.-At that point, he/she was ejected from his/her wheelchair, face forward and his/her face hit the center console of the van and hit his/her mouth on the cup holder.-When he/she was ejected, he/she flew forward, thrown out of the wheelchair and went straight to the impact.-He/She and the driver were the only ones in the van.-He/She hit the right side of his/her face and body and thought the cupholder went inside his/her mouth and pushed his/her face and cheekbone up. His/her right forearm was sore.-He/She was in that position for more than two minutes pinned on the floor.-He/She was screaming and crying, which the driver did not hear, because he/she had the radio turned up loudly.-When the driver saw he/she was down, he/she stopped the van, turned off the radio and came to his/her aid.-The driver got him/her back into his/her wheelchair and put the seatbelt on him/her.-The driver said, I am so sorry! Are you ok?-He/She was disoriented and said he/she was ok.-The driver pulled the van into a nearby 7-11 and asked the resident if he/she wanted something to drink, which he/she declined.-The driver left the resident in the van, went inside and quickly came back and handed him/her a napkin.-He/She did not know what to do with the napkin or what it was for.-The driver went ahead and took him/her to his/her appointment.-When they got to his/her appointment and checked him/her in, the driver took him/her to the bathroom and took a wet paper towel and helped him/her wipe the blood off his/her right hand and face.-After the appointment, the driver put him/her back in the van, made sure he/she had his/her seatbelt on and took him/her to his/her next appointment, which was dialysis.-Dialysis Nurse A saw the resident's face and asked him/her what happened.-Dialysis Nurse A called the facility and spoke to the DON and asked if he/she was aware the resident's face was black and blue and bloody, and blood had dripped on his/her hand.-The DON replied he/she was not aware of this. He/she told Dialysis Nurse A the resident should go to the emergency room.-After his/her dialysis was completed, an ambulance came and picked him/her up and took her to the hospital to the trauma unit.-The doctor there examined him/her and did an x-ray and said there were no broken bones and there was no concussion, so they were going to let him/her go home.-The hospital kept him/her overnight.-He/She still had some pain. He/She had bruises on his/her face and a swollen lip from the accident.During an interview on 9/17/25 at 2:15 P.M., Transportation Driver A said:-Resident #1 was not secured in her wheelchair when he/she fell.-He/She was slowing down and the resident slipped forward.-He/She was not speeding.-The resident hit his/her lip and that was all he/she noticed.-He/She did not call 911 or call the facility and tell anyone.-He/She did not call anyone at the facility and let them know what happened at the time.-He/She was in a hurry; he/she was feeling frustrated because he/she was told when he/she got back he/she was going to have to weigh residents and work on the floor, instead of what he/she was supposed to be doing.-He/She would not have been in a hurry if he/she had not been stopped four or five times by people telling him/her things he/she had to do when he/she got back.-He/She had been trained on how to properly secure residents in their wheelchairs in the van.-He/She normally did secure the residents in properly, but did not do it that day.-He/She did not know why.-He/She checked the resident out when he/she fell and helped him/her back in his/her wheelchair and they went on to his/her appointment.-He/She properly secured the resident in the van after the accident.Observation of the facility van on 9/18/25 at 11:15 A.M. showed:-There were three belts to use for securing residents.-There was a belt from the left side that would cross the resident's lap to secure to the van.-The wheelchair would sit behind and between the two front seats.During an interview on 9/18/25 at 11:20 A.M., the Maintenance Supervisor said:-He/She had completed Transportation Drive A's training relating to securing residents in the facility van.-Transportation Driver A had to demonstrate the provided training and he/she was able to do it correctly. He/she was able to describe the facility policy to immediately turn off the ignition, assure the safety of all passengers, notify the police, in the event of an injury, call 911 and notify the facility of an accident/emergency.-Transportation Driver A should have remained with the vehicle, completed a police report, and returned to the facility or oversee the van's transport to an alternate location.-His/Her expectation was any transportation staff would follow the facility policy and training.During an interview on 9/18/25 at 1:45 P.M., Dialysis Nurse A said:-The resident was alert and oriented and his/her vital signs were stable. He/she was a person of few words.-The resident had bruising on his/her cheek and chin.-During his/her treatment, the resident complained of headache and chest discomfort.-At first the resident said the driver swerved hard and then changed his/her story to say the driver had stopped abruptly.-The resident did not initially want to talk about it, then finally told him/her what had happened.-He/she and his/her manager looked at the resident and talked to the floor nurse, then called the facility DON and administrator together.-The facility DON and administrator were surprised to hear about the resident's injuries.-The facility DON asked him/her to send the resident to the hospital; he/she went via ambulance.During an interview on 9/18/25 at 3:00 P.M., the DON said:-The dialysis nurse contacted him/her.-Transportation Driver A said he/she had been trained and was rushing to put the resident in the van.-Transportation Driver A put the resident in the van around 6:30 A.M. to go to the hospital for a diagnostic test. -Transportation Driver A said there was no stop, the fall happened where the road curved.-They stopped at the 7-11 and got the resident some napkins to use to wipe his/her lip.-The resident kept saying he/she was ok and not to worry about it.-The resident was taken to his/her first appointment at the hospital and nobody there recognized anything wrong with him/her.-The transportation driver never called the facility to notify them of the fall.-The resident's dialysis appointment was near his/her first appointment, so he/she was taken to that.-Dialysis Nurse A called him/her and notified him/her of the accident.-Then he/she talked to the transportation driver.-He/She called the dialysis nurse back and he/she felt the resident was stable, so he/she said to send the resident to the hospital ED.-The resident went to the hospital ED at about 2:00 P.M.-He/She was called at about 7:00 P.M. by the hospital and informed they were keeping the resident overnight for observation and testing.-The resident returned to the facility at about 5:00 A.M. the next day.-Hospital transportation brought the resident back.-When the resident arrived back to the facility, they started doing neuro checks on the resident.During an interview on 9/18/25 at 3:20 P.M. the Administrator said it was his/her expectation that transportation staff would follow the facility policy and their training when securing residents in the van for transport and keep them safe. During an interview on 9/18/25 at 1:15 P.M., Physician A said it was his/her expectation that facility drivers would follow facility policies and safety procedures in place to keep residents safe during transporting. 2612443

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide Tuberculosis (TB-a communicable disease that affected the lungs, that was characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for three sampled residents (Residents #63, #57, and #33) out of five residents sampled for TB screening; failed to ensure nursing staff ensured clean techniques were followed when administering the residents medication by not cleaning a surface or laying down a barrier when placing medications on a resident's bedside tray table before administering them via feeding tube for one supplemental resident (Resident #2), and not cleaning equipment such as a blood pressure cuff (machine used to check a person's blood pressure) used during medication pass after each use; failed to ensure hand hygiene was incorporated during a tube feeding for sampled resident (Resident #33); and failed to ensure catheter drainage bags and tubing was not on the floor for one sampled resident (Resident #27) out of 16 sampled residents. The facility census was 64 residents. Review of the facility policy Screening Residents for Tuberculosis dated as revised August 2019 showed: -The facility screened all residents for TB. -Screening of new admissions or readmissions for TB is in compliance with state regulations Review of the facility's policy, Polices and Practices - Infection Control, dated July 2014 showed: -All personnel would have been trained on our infection control policies and practices upon hire and periodically thereafter. Review of the facility's policy, Cleaning and Disinfection of Resident-Care Items and Equipment, dated September 2022 showed: -Reusable items were to have been cleaned and disinfected between resident. Review of the facility's policy 'Indwelling (Foley) Catheter Insertion' , dated revised 8/2022 showed: -The purpose of this procedure is to provide guidelines for the aseptic insertion of an indwelling (Foley) urinary catheter. -There was no documentation on how to care for the catheter after it was inserted. -There was no documentation on infection control procedures when working with a catheter. 1. Review of Resident #63's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's TB testing showed: -His/Her first TST was administered on 6/5/24 with negative results but did not include the date it was read. -His/Her second TST was administered on 6/15/24 with negative results but did not include the date it was read. 2. Review of Resident #57's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's TB testing showed: -His/Her first TST was administered on 11/18/24 (approximately six months late) with negative results but did not include the date it was read. -His/Her second TST was administered on 11/25/24 with negative results but did not include the date it was read. 3. Review of Resident #33's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's TB testing showed: -No first step was documented. -His/Her second TST was dated 12/6/24 with no results. 4. During an interview on 4/4/25 at 11:31 A.M., the Infection Preventionist said Social Services lets him/her know when a resident needed TB testing. During an interview on 4/4/25 at 1:30 P.M., the Director of Nursing (DON) said: -The nurses were responsible for doing the first TST upon resident admission. -The order should generate on the Licensed Medication Administration Record (LMAR). -The administration of the TST and the results should be documented on the LMAR and on the immunization tab. -A second TST should be completed 10-14 days after the first TST. 39469 5. Observation on 4/2/25 at 8:30 A.M. of medication pass with Certified Medication Technician (CMT) D showed: -He/She went into a room to take a resident's blood pressure before administering a blood pressure medication. -After administering the the medication the CMT went down the hallway to administer more medications without cleaning/disinfecting the blood pressure cuff. During an interview on 4/2/25 at 8:45 A.M. CMT D said: -He/She did not realize he/she had not cleaned the blood pressure cuff after using it on the resident. -The facility had computer education that he/she sometimes did. -The facility did not have an annual skills fair or any kind of competency in the last year or so. 6. Review of Resident #2's face sheet showed he/she was admitted with the following diagnoses: -Gastrostomy status (a surgically placed tube that delivers nutrition, fluids, and medications directly into the stomach). Review of the resident's Care Plan dated 1/16/25 showed: - Enhanced barrier precautions (EBP - when a resident had an indwelling medical device such as a feeding tube a used of Personal Protective Equipment should be used, which also includes cleaning medical devices such as blood pressure cuffs after each use was required related to peg tube. -He/She had Hypertension. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed for care planning) dated 2/17/25 showed: -Staff was not able to evaluate cognition. -He/She was a Quadriplegic (a weakness in all four limbs). -He/She had a feeding tube. Review of the resident's Physicians Order Sheet dated April 2025 showed the following orders: -EBP precautions. -Carvedilol (medication used to treat high blood pressure) one tablet via G-tube two times a day for Hypertension (high blood pressure) hold if systolic blood pressure (the top number in a blood pressure reading that measures the pressure in your arteries when your heart beats, pumping blood into the arteries) was less than 100 or pulse (heart beats) was less than 50, dated 8/8/24. Observation on 4/2/25 at 9:00 A.M. of medication pass with Licensed Practical Nurse (LPN) A/Infection Preventionist (IP) showed: -He/She did not ensure there was a clean area (by cleaning/disinfecting) or placing a barrier such as a paper towel on the resident's bedside tray table to put the resident's medications on, before administering the medications via feeding tube. -He/She took the resident's blood pressure using a blood pressure cuff and did not clean/disinfect the cuff after using it on a resident who was on EBP. During an interview on 4/2/25 at 9:30 A.M. LPN A/IP said: -He/She should have placed a barrier or disinfected the bedside tray table before putting the resident's medications that were administered via feeding tube. He/She forgot. -He/She should have cleaned/disinfected the blood pressure cuff after each use whether or not the resident was on EBP. -He/She could not remember any competencies by the facility in the last year. -He/She had just started in the IP role. 7. Observation on 4/2/25 at 11:00 A.M. of medication pass with Registered Nurse (RN) A showed: -He/She had gone into a resident room to check a resident's blood pressure before administering a blood pressure medication. -He/She took the resident's blood pressure using a blood pressure cuff off his/her medication cart. -He/She returned the blood pressure cuff to the medication cart and went to the next resident without cleaning/disinfecting the cuff. 8. During an interview on 4/2/25 at 11:20 A.M. RN A said: -When sitting medications on a bedside tray table the person administering the medications should have cleaned the table with a disinfectant such as bleach wipes or placed a paper towel as a barrier. -This was especially important if a resident was on EBP. -Blood pressure cuffs and glucometers (machine used to check the level of sugar in their blood) should have been cleaned or disinfected after each use. During an interview on 4/4/25 at 1:30 P.M. the DON said: -When passing medications nursing staff should have ensured there was a clean barrier or cleaned surface to put medications or tube feeding supplies on. -When checking resident's blood sugar or blood pressures staff should have cleaned the machines after each use. -The facility had a computer program for employee training. -The nurse who trained new staff should have completed training about ensuring staff knew about infection control measures. -Since the last survey there had not been any competencies done. 51305 9. Review of Resident #33's Admission Record showed the resident was admitted with the following diagnoses: -Gastrostomy Status (surgical opening into the stomach for a feeding tube). -Dysphagia (difficulty swallowing). -Parkinson's Disease (a progressive neurological disorder characterized by a decline in nerve cells (neurons) in the brain, particularly those that produce dopamine, a neurotransmitter crucial for movement control). -Seizure Disorder or epilepsy (a neurological disorder characterized by recurrent, unprovoked seizures). -Dysarthria (when the muscles used for speech are weak or are hard to control). -Anarthria (the complete inability to produce speech). Review of the resident's annual MDS dated [DATE] showed the resident: -Had Parkinson's Disease. -Had a Seizure Disorder or epilepsy. -Had a Traumatic Brain Injury (an injury to the brain caused by an external force, like a blow or jolt to the head), -Enteral feeding (a method of providing nutrition directly into the gastrointestinal (GI) tract through a tube). -Feeding Tube (a medical device, usually a thin, flexible tube, used to deliver nutrition and fluids directly into the stomach or small intestine when a person cannot eat or drink safely by mouth). Review of the resident's Care Plan dated 12/30/24 showed: -Enhanced barrier precautions required for percutaneous endoscopic gastrostomy (peg-tube). -Peg tube continues to remain in place with Bolus Feeding as needed, and hydration. Review of the resident's Physician Order Sheet (POS) dated 4/2/25 showed: -Clean peg-tube tube site with cleanser apply split sponge. -Enhanced barrier precautions related to eternal feedings. Observation on 4/1/25 at 1:50 P.M. showed LPN B: -Did not sanitize the tabletop where he/she put supplies to initiate feeding. -Did not put a protective barrier down on the tabletop where he/she put supplies to initiate feeding. -Did not wash hands after touching peg tube area. During an interview on 4/4/25 at 9:37 A.M. LPN A said he/she should always wash hands before touching clean surfaces after working with contaminated surfaces. During an interview on 4/4/25 at 1:26 P.M. the DON and the Regional Operations Coordinator (ROC) said: -When administering tube feeding staff should wash hands prior to entering the room. -Should always wash hands before touching clean surfaces after working with contaminated surfaces. 10. Review of Resident #27's Admission Record showed the resident was admitted with the following diagnoses: -Retention of Urine (the inability to fully or partially empty the bladder, resulting in urine accumulating within the bladder). -Difficulty in walking. Review of the resident's annual MDS dated [DATE] showed the resident: -Was cognitively intact. -Had a catheter. Review of the resident's Care Plan dated March 2025 showed: -Enhanced barrier precautions required for suprapubic catheter. -The resident had a suprapubic catheter in place and was at risk for urinary tract infection and complications. Review of the resident's POS dated 4/2/25 showed: -Urinary catheter anchor was to be changed every night shift. -Urinary catheter drainage bag should be changed monthly on night shift. -Urinary catheter should be irrigated with 60 ml of sterile water every shift. Observation on 4/2/25 at 8:45 A.M. showed the resident: -Was in the bed with his/hers eyes closed. -The bed was in a low position. -The catheter bag was on the floor. Observation on 4/2/25 at 10:16 A.M. showed the resident: -Was in the bed with his/hers eyes closed. -The bed was in a low position. -The catheter bag was on the floor. Observation on 4/2/25 at 12:44 P.M. showed the resident: -Was sitting in the wheelchair and his/her feet were on top of catheter bag. -The catheter bag was dragging on the floor. Observation on 4/2/25 at 2:16 P.M. showed the resident: -Was in the bed with his/hers eyes closed. -The bed was in a low position. -The catheter bag was on the floor. Observation on 4/3/25 at 9:58 A.M. showed the resident: -Was in the bed with his/hers eyes closed. -The bed was in a low position. -The catheter bag was on the floor. During an interview on 4/4/25 at 9:13 A.M. Certified Nursing Assistant (CNA) A said: -Catheter bags should be placed toward the hip but not close to the feet. -Catheter bags should not be on the floor. -There should not be any kinks in the tube. During an interview on 4/4/25 at 9:37 A.M. LPN A said: -Catheter bags should not be on the floor. -Catheter bags on the floor are an infection control issue. During an interview on 4/4/25 at 1:26 P.M. the DON and the Regional Operations Coordinator (ROC) said: -There should have been a barrier between the floor and the catheter bag. -Catheter bags should never touch the floor. -Any nursing staff should have made sure the catheter bag was not on the floor.

Based on interview and record review, the facility failed to assess the resident's level of acuity including how many residents were dependent on transfers, bathing, feeding assistance, and level of care needs for the resident population to determine staffing needs. The facility census was 64 residents. 1. Review of the facility's Facility Assessment, revised date 8/2/24, showed: -The facility did not have documentation showing the base staffing levels were meeting the resident's acuity or care needs. -There was no documentation that showed the number of residents that were dependent on transfers. -There was no documentation that showed the number of residents that needed bathing assistance. -There was no documentation that showed the number of residents that needed feeding assistance. During an interview on 4/4/25 at 10:50 A.M. the Administrator and Director of Nursing (DON) said: -The Interdisciplinary Team (IDT) met to complete the facility assessment. -Staffing numbers were looked at daily. -The charge nurse would monitor staffing on the floor. -The DON was currently in charge of staffing. During an interview on 4/4/25 at 1:26 P.M. the DON and the Regional Operations Coordinator (ROC) said the facility assessment was the Administrator's responsibility.

Based on interview and record review the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed to drive Quality Assurance (QA) measures that addressed the staffing needs for the residents based on the Payroll Base Journals (PBJ) reports that triggered a low staffing alert for the second and fourth quarters in the year 2024. This failure had the potential to affect all residents who currently lived in the facility. The facility census was 64 residents. Review of the QAPI Program policy, revised 2019, showed: -The quality improvement committee involves members at all levels of the facility to provide oversight for the quality assurance program. -The functions of the quality improvement committee: --Determine quality improvement programs. -Areas that may be appropriate to monitor and evaluate include: --Clinical outcomes. --Complaints from residents and families. --Re-hospitalization s --Staff turnover and assignments. --Staff satisfaction. --Care plans. --State surveys and deficiencies. --MDS assessment data --Quality Indicators/measures. 1. Review of the PBJ report indicated a low weekend staffing in Quarter 2 of 2024 which showed the months of January, February, and March needed addressed. Review of the PBJ report indicated a low weekend staffing in Quarter 4 of 2024 which showed the months of July, August, and September needed addressed. During an interview on 4/4/25 at 10:50 A.M., the Administrator and the Director of Nursing (DON) said: -He/She had looked at the PBJ report, but he/she did not recall being below staffing requirements. -PBJ was reviewed by a team that included the Administrator, DON, Social Services Director, and Activities Director. The Medical Director was involved in the quarterly QA meetings. -The team reviewed the PBJ as part of the QA. -No Performance Improvement Projects (PIPs) were started for staffing. -The Administrator, DON, Business Office Manager, and other staff would help get residents up and feed them. -The DON was currently in charge of staffing. -The charge nurse would monitor staffing on the floor. -Managers would walk the halls every morning and throughout the day to check on the residents. -Staffing should have been addressed in the QA and QAPI meetings.

Based on observation, interview, and record review, the facility failed to ensure resident's prescribed medication were stored at the appropriate temperature, failed to ensure the medication room was clean, failed to ensure resident's prescribed medication had the date that it had been opened written on it, failed to ensure resident's medications were stored in a medication cart, and failed to ensure non medical objects were stored with the medications. The facility census was 64 residents. Review of the facility's policy, Medication Labeling and Storage, dated 2001 showed: -The facility stores all medications and biologicals in locked compartments under proper temperature controls. -The nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of the facility's policy, Administering Medications, dated April 2019 showed: -When opening a multi-dose container, the date opened was to have been recorded on the container. -Medications ordered for a particular resident may not have been administered to another resident. 1. Observation on 4/1/25 at 10:50 A.M. during medication pass with Licensed Practical Nurse (LPN)A/ Infection Preventionist (IP) showed Resident #16 had a container of Nystatin powder sitting on his/her nightstand which was prescribed for a different resident. Review of Resident #16's Physician's Order Sheet dated April 2025, did not show a physician's order for the Nystatin powder. During an interview on 4/1/25 at 10:55 A.M. LPN A/IP said: -Resident #16 should not have the Nystatin powder in the resident's room as it was not his/hers. -He/She did not see any reason for the powder and there was no physician's order for that powder. -Either staff left it in the resident's room or had borrowed it to use on him/her. -Staff know better than to borrow a different resident's medication or to leave it at bedside without an order. 2. Observation on 4/2/25 at 10:00 A.M. of the 100/300 hall medication room with LPN A/IP showed: -The floor was dirty with debris. -The only sink in the medication room was dirty and rusty. -There was a soiled cloth in the sink. -There were no paper towels to dry your hands after washing them. -The medication refrigerator's temperature was 50 degrees Fahrenheit (F) as verified by the nurse. -The following medications were in the medication refrigerator: --Tuberculin vial (a skin test used to determine if you have been exposed to the bacteria that cased tuberculosis - a serious infection that affects the lungs), opened without an opened date written on it. --Semglee insulin pen (a prescribed long acting medication used to treat high blood sugars). --Bagalar insulin pen ( a prescribed long acting medication used to treat high blood sugars). --Two Trulicity insulin pens (a prescribed weekly medication used to treat high blood sugars) which the box showed to store at 36 to 46 degrees F. --Three Avonex insulin pens (a prescribed medication used to treat high blood sugars) which the box showed to store at 36 to 46 degrees F. -In the medication cabinet was a unknown resident's set of dentures. 3. Observation on 4/2/25 at 11:00 A.M. of the medication room on 200/400 hall with Registered Nurse (RN) A showed the only sink in the medication room was dirty and rusty. 4. Observation on 4/2/25 at 11:10 A.M. of the nurses' medication cart on 200/400 with RN A showed a resident's prescribed bottle of liquid Nystatin 70 millimeters (ml) was opened without an opened date written on it. 5. During an interview on 4/2/25 at 10:30 A.M. LPN A/IP said: -He/She did not know who was responsible for cleaning the medication room and ensuring it was stocked with paper towels. -He/She did not know whose dentures were in the medication cabinet, but they should not have been in with the stock medications. -He/She thought the night nurse should have ensured the medication refrigerator was within temperature of 36 degrees F to 46 degrees F as it showed on the Refrigerator Control Log. -If the refrigerator was out of range staff should have turned it down then rechecked in in an hour. -Any medication that had been opened should have had the date that it was opened written on it. During an interview on 4/2/25 at 11:15 A.M. RN A said: -The medication room should have been cleaned and stocked daily by housekeeping observed by the nurse. -If a medication was opened it should have had the date that it was opened written on it. -If the medication refrigerator was not within temperature the maintenance department should have been notified and the medication moved to another refrigerator until the temperature was fixed or a different refrigerator was obtained. -No medications should have been left at a resident's bedside unless there was a physician's order to do so. During an interview on 4/4/25 at 9:45 A.M. Certified Nursing Assistant (CNA) B said: -If staff found medications at the bedside the medication should have been taken to the nurse. -He/She had found medications left at the bedside and turned them into the nurse a couple times in the past six months. During an interview on 4/4/25 at 10:00 A.M. Certified Medication Technician (CMT) B said: -Medications should not be left at bedside. -Any medication that had been opened should have the date it had been opened written on it. -The nurse was responsible for keeping the medication room cleaned and stocked. -He/She did not know who should have checked the temperature of the medication refrigerator. During an interview on 4/4/25 at 1:30 P.M. the Director of Nursing (DON) said: -Medications should never be left at bedside. -Any medication that had been opened should have the date it was opened written on it. -The nurse or CMT who had the medication cart should have ensured medications had the open dates written on them. -The charge nurse was responsible for ensuring the medication refrigerators were within temperature and the medication room was cleaned daily. -Housekeeping was responsible to ensure the medication rooms and sinks were cleaned daily as well as ensuring the hand soap and paper towels were stocked with a nurse watching. -Residents should never have another resident's medication in their room. -There should not have been dentures in the medication cabinet.

Based on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide COVID-19 (a highly contagious respiratory disease caused by a new coronavirus that emerged in December 2019) vaccines for five residents (Residents #2, #33, #54, #57, and #63) out of five residents sampled for immunizations. The facility census was 64 residents. Review of the facility's Coronavirus Disease (COVID-19) - Vaccination of Residents policy dated as revised May 2023 showed: -Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated. -The resident (or resident representative) can accept or refuse a COVID-19 vaccine and to change his/her decision. -COVID-19 education, documentation, and reporting are overseen by the infection preventionist. -Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. -Information is provided to the resident in a format and language that is understood by the resident or representative. -Residents must sign a consent to vaccinate form prior to receiving the vaccine. -A vaccine administration record is provided to the resident and a copy is filed in the resident record. 1. Review of Resident #57's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's vaccine records showed no documentation regarding the resident's Covid vaccine status. 2. Review of Resident #63's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's vaccine records showed no documentation regarding the resident's Covid vaccine status. 3. Review of Resident #2's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's vaccine records showed no documentation regarding the resident's Covid vaccine status. 4. Review of Resident #33's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's vaccine records showed no documentation regarding the resident's Covid vaccine status. 5. Review of Resident #54's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's vaccine records showed no documentation regarding the resident's Covid vaccine status. 6. During an interview on 4/4/25 at 11:31 A.M., the Infection Preventionist said: -Covid vaccine consents were in the admission packets. -Social Services got consent for vaccines and when the consents were signed, he/she let him/her know. During an interview on 4/4/25 at 1:30 P.M., the Director of Nursing (DON) said: -Resident Covid vaccines were part of the admission packet. -Social Services got consents for residents' Covid vaccines. -Once consent was obtained for Covid vaccines, the Infection Preventionist was responsible for administering them and documenting them in the immunization tab section of the residents' medical records.

Based on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide pneumococcal (pneumonia-lung inflammation caused by bacterial or viral infection) for three residents (Resident #57, #2, and #33) and influenza (flu - an infection of the respiratory system: nose, throat and lungs) vaccines for one resident (Resident #33) out of five residents sampled for immunizations. The facility census was 64 residents. Review of the facility's Influenza Vaccine policy dated as Revised August 2016 showed: -Between October 1st and March 1st each year, the influenza vaccine shall be offered to residents, unless the vaccine is medically contraindicated for the resident or they have already been immunized. -Prior to the vaccination, the resident (or resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. -Provision of such education shall be documented in the resident's/employee's medical record. -For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's/employee's medical record. -A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record. Review of the facility's Pneumococcal Vaccine policy dated as revised August 2016 showed: -All residents will be offered pneumonia vaccines to aid in preventing pneumonia infections. -Prior to or upon admission, residents will be assessed for eligibility to receive the pneumonia vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. -Assessments pneumonia vaccination status will be conducted within five working days of the resident's admission if not conducted prior to admission. -Before receiving a pneumonia vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumonia vaccine. -Provision of such education shall be documented in the resident's medical record. -Pneumonia vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumonia vaccination protocol. -Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumonia vaccination. -For residents who receive the vaccines, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. 1. Review of Resident #57's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's vaccine records showed the resident's pneumonia vaccine was pending historical. 2. Review of Resident #2's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's vaccine records showed the resident's pneumonia vaccine was pending historical. 3. Review of Resident #33's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's vaccine records showed no documentation regarding the resident's flu and/or pneumonia vaccine. 4. During an interview on 4/4/25 at 11:31 A.M., the Infection Preventionist said: -Flu and pneumonia vaccine consents were in the admission packets. -Social Services got consent for vaccines and when the consents were signed, he/she let him/her know. During an interview on 4/4/25 at 1:30 P.M., the Director of Nursing (DON) said: -Resident flu and pneumonia vaccines were part of the admission packet. -Social Services got consents for residents' flu and pneumonia vaccines. -Once consent was obtained for flu and pneumonia vaccines, the Infection Preventionist was responsible for administering them and documenting them in the immunization tab section of the residents' medical records.

Based on observation, interview, and record review, the facility failed to ensure a clean working environment while performing feeding tube care; failed to follow standards of practice when checking placement of a feeding tube for three sampled residents (Resident #33, #17 and #2) out of 16 sampled residents. The facility census was 64 residents. Review of the facility's undated policy, Verify Feeding Tube Placement Policy, showed: -Observe the external portion of the tube for movement of the ink mark with new tubes. -Prepare equipment at bedside, perform hand hygiene, apply gloves. -Verify tube placement via aspiration of gastric contents. -Place feeding tube on hold. Attach the syringe to the end of the feeding tube, draw back on the syringe slowly. Observe appearance of aspirate (stomach content). Slowly readminister aspirate content. -If the tube was displaced, obtain a physician's order to verify placement with X-ray. 1. Review of Resident #33's Admission Record showed the resident was admitted with the following diagnoses: -Gastrostomy Status (surgical opening into the stomach for a feeding tube). -Dysphagia (difficulty swallowing). -Parkinson's Disease (a progressive neurological disorder characterized by a decline in nerve cells (neurons) in the brain, particularly those that produce dopamine, a neurotransmitter crucial for movement control). -Seizure Disorder or epilepsy (a brain disorder that causes recurring, unprovoked seizures). -Dysarthria (the muscles used for speech are weak or are hard to control). -Anarthria (a medical condition characterized by the complete inability to produce speech). Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/18/24 showed the resident: -Was not cognitively intact. -Had Parkinson's Disease. -Had a Seizure Disorder or epilepsy. -Had a Traumatic Brain Injury (TBI an injury to the brain caused by an external force, like a blow or jolt to the head). -Had an Enteral feeding (a method of providing nutrition directly into the gastrointestinal (GI) tract through a tube). -Had a Feeding Tube (a medical device, usually a thin, flexible tube, used to deliver nutrition and fluids directly into the stomach or small intestine when a person cannot eat or drink safely by mouth). Review of the resident's Care Plan dated 12/30/24 showed: -Enhanced barrier precautions required for peg tube. -Received nutrition through peg tube and was at risk for aspiration. -Had a history of swallowing problems and had recent diet upgrade. -Peg tube continued to remain in place with Bolus Feeding as needed, and hydration. Review of the resident's Physician Order Sheet (POS) dated 4/2/25 showed: -Check tube feeding residual six times daily. -Clean percutaneous endoscopic gastrostomy (peg-tube) tube site with cleanser apply split sponge. -Enhanced barrier precautions related to eternal feedings. -Enteral: elevate head of bed 30 to 45 degrees at all times during feeding for at least 30 to 40 minutes after the feeding is stopped every shift. -Flush feeding tube with 200 milliliters (ml) of water five times per day. -Flush gastrostomy tube with 30 cubic centimeters (cc) of water before and after medication administered. -Glucerna 1.5 (a specialized medical food designed for people with diabetes or abnormal glucose metabolism, and for those at risk of disease-related malnutrition) bolus 250 cc four times per day flush with 120 cc water before and after each bolus. -May crush and combine medications. Observation on 4/1/25 at 1:50 P.M. showed Licensed Practical Nurse (LPN) B: -Measured out Tylenol 325 x 2 = 650 and Levodopa 25-100 into a plastic bag. -Crushed medication in a plastic bag then poured medication into cup with 2 cc of water -Stirred medication in the cup. -Sanitized his/her hands, put gloves on, put a gown on, and put a mask on. -Went into the resident's room. -Did not sanitize the tabletop where he/she put supplies to initiate feeding. -Did not put a protective barrier down on the tabletop where he/she put supplies to initiate feeding. -Checked the flange (plastic disc or bumper that secures the peg tube) to check placement of the tube by putting fingers behind it to check movement. -Did not wash his/her hands after touching peg tube area. -Did not measure tube length. -Checked the residual with a syringe and withdrew 60 cc residual fluid from stomach. -Did not give the 200 cc flush since there was so much residual. -Did the 30 cc of water before the medications. -Poured the medications into the syringe. -Then poured another 30 cc of water after the medications. Observation on 4/2/25 at 1:27 P.M. showed LPN B: -Resident would receive meal and medications at the same time. -Administered 1 250 ml can of Isosource 1.5. -Administered 120 ml water bolus before and after. -Measured out Tylenol 325 x 2 = 650 and Levodopa 25-100 into a plastic bag. -Crushed medication in a plastic bag then poured medication into cup with 2 cc of water. -Stirred medication in the cup. -Sanitized his/her hands, put gloves on, put a gown on, and put a mask on. -Went into the resident's room. -Sanitized the tabletop where he/she put supplies to initiate feeding. -Put a protective barrier down on the tabletop where he/she put supplies to initiate feeding. -Checked the residual with a syringe and withdrew 10 cc residual fluid from stomach. -Checked the flange to check placement of the tube by putting fingers behind it to check movement. -Did not measure tube length. -Flushed with 120 ml water bolus. -Gave medication. -Gave the resident his/her Isosource. -Gave another 120 ml water flush. -Then closed the tube. -Discarded gloves. -Washed hands with sanitizer and put new gloves on. -Wiped around the insertion area with the gauze that had wound cleaner on it. -Changed his/her glove on the left hand only. -Then put new clean gauze around the site and secured it with tape. -Then he/she dated the tape with a marker. -He/she pulled the residents shirt back over tube. 2. Review of Resident #17's Admission Record showed the resident was admitted with diagnoses of: -Hemiplegia (paralysis (loss of muscle function)) and Hemiparesis (partial paralysis or weakness) following unspecified Cerebrovascular disease (disease of the blood vessels in the brain, including stroke) affecting left dominant side. -Hyperlipidemia (high cholesterol (elevated level of fats in the blood)), unspecified. -Cerebral infarction due to embolism of unspecified cerebral artery (means a stroke cause by a blood clot). -Gastro-esophageal reflux disease (GERD, (stomach acid flows back up into the esophagus)) without esophagitis. -Dysphagia (inability or difficulty swallowing), oropharyngeal (middle part of the throat) phase. -Type 2 Diabetes Mellitus (high blood sugar levels) without complications. -Essential (primary) hypertension (high blood pressure). -Dysphagia, unspecified. -Aphasia (unable to verbally communicate). Review of the resident's Care Plan dated 1/7/24, showed: -Enhanced barrier precautions required for peg tube. -Requires tube (bolus) feedings due to dysphasia. -Had a peg tube for nutritional intake due to dysphasia. Review of the resident's admission MDS dated [DATE] showed the resident: -Was cognitively intact. -Had a feeding tube. Review of the resident's POS dated 4/2/25 showed: -Bolus Jevity 1.5 or Isosource 1.5 cal: 360 ml with 60 cc water flush before and after. May substitute with Nutren 1.5 three times a day for nutrition. -Change irrigation/flush tray daily on every night shift. -Crush medications and administer through G-tube every shift. -Enhanced barrier precautions related to enteral feedings. -Enteral: elevate head of bed 30 to 45 degrees at all times during feeding for at least 30 to 40 minutes after the feeding is stopped every shift. -Flush the peg tube with 60 ml of water before and after each bolus feeding five times a day. -G-tube site care: cleanse site with wound cleanser apply split sponge day and night. Every day shift for G-tube. Observation on 4/2/25 at 2:30 P.M. showed LPN B: -Administered medication the same time as Isosource. -Administered water flush 60 cc. -Administered 360 ml Isosource -Administered Baclofen 10 milligram (mg) tablet. -Crushed the medications and put them in a cup and poured 7.5 ml of water into the cup. -Sprayed dermal wound cleanser on the 4x4 gauze. -Put on a gown and mask. -Washed hands his/her hands. -Put a protective barrier down on table where tube feeding supplies was to be placed. -Put on gloves. -The resident was laying on the bed with his/her head propped up and eyes closed. -Pointed out the resident had a longer older tube. -Measured the residual. --No residual was obtained from the stomach. -Administered 60 cc water flush. -Administered medication. -Administered the Isosource. -The resident was still laying on the bed with head propped up and eyes closed while receiving Isosource. -Administered 60 cc water flush. -Changed his/her gloves. -Washed his/her hands. -Put on new gloves. -Changed the bandage. -Wiped around the insertion site with the gauze that had the spray on them until no residue would come off. -Changed his/her gloves. -Washed his/her hands. -Put two fingers behind the flange protector and said its snug to the skin. -Put new gauze around the insertion and new tape to hold it. -Looped up the tube and put it under the resident's shirt. -Removed gloves and washed his/her hands. During an interview on 4/4/25 at 9:37 A.M. LPN A said: -He/She checked for placement by using the amount of residual that comes out the residents peg tube. -Had orders to check for residual. -He/She would flush the tube then administer medications. -He/She would flush the tube again. -He/She would take off the old 4x4 dressing. -He/She would take off his/her gloves. -He/She would wash his/her hands and then put new gloves on. -Should always wash hands before touching clean surfaces after working with contaminated surfaces. During an interview on 4/4/25 at 1:26 P.M. the Director of Nursing (DON) and the Regional Operations Coordinator said: -Staff were to aspirate to check for placement of feeding tube. -Check the residual for placement of feeding tube. 39469 3. Review of Resident #2's Care Plan dated 1/16/25 showed to check tube placement prior to each bolus feeding. Hold if residual was greater than 100 ml and recheck in one hour. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was severely cognitively impaired. -He/She was totally dependent on staff for all cares. -He/She had Traumatic Brain Dysfunction (a dysfunction caused by an outside force,usually a violet blow to the head). -Quadriplegic (a paralysis or muscle weakness in all four limbs arms and legs). -He/She had tube feedings for nutrition (Gastrostomy - a surgically inserted tube into the stomach for liquid nutrition). Review of the resident's April 2025 Physician's Order Sheet showed the following orders: -NPO diet (nothing by mouth - withhold food and fluids). -Check tube placement prior to each bolus feeding (a single meal rather than continuous). Hold if residual was greater than 100 ml and recheck in one hour six times a day for feeding, dated 8/8/24. -Isosource 1.5 Calorie liquid nutrition give 250 ml via feeding tube six times a day for nutrition, dated 8/8/24. Observation on 4/2/25 at 9:30 A.M. of medication pass with LPN A/Infection Preventionist (IP) showed: -He/She did not clean the bedside tray table or place a clean barrier before laying down the medications and supplies. -He/She did not check for placement. -He/She checked for residual which was 0 and administered the resident's medications and liquid nutrition. During an interview on 4/2/25 at 9:30 A.M. LPN A/IP said: -He/She forgot to clean an area to lay down the supplies or place a barrier such as a paper towel to keep the area clean. -He/She did not know how to check for placement for the feeding tube. -He/She did not think the facility had provided education about feeding tubes. During an interview on 4/4/25 at 1:30 P.M. the DON said: -Nursing staff should have had a clean area or barrier when laying down feeding tube nutrition or medications. -Nursing staff should have checked placement of the feeding tube before administering medications or liquid nutrition. -There have not been any staff competencies since the last survey.

Based on interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNA's) had competencies to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three sampled employees (CNA L, CNA M, and CNA N). The facility census was 64 residents. Review of the facility policy showed: -There was no policy on file for Certified nursing assistant competencies. 1. Review of CNA L's employee file on 4/3/25 showed: -He/She was hired as a CNA prior to 9/22/23. -No competencies in the file. 2. Review of CNA M's employee file on 4/3/25 showed: -He/She was hired as a CNA on 3/28/24. -No competencies in the file. 3. Review of CNA N's employee file on 4/3/25 showed: -He/She was hired as a CNA prior to 9/22/23. -No competencies in the file. 4. During an interview on 4/4/25 at 1:25 P.M., the Director of Nursing (DON) and the Regional Operations Coordinator (ROC) said: -No skills fair had been conducted since they started less than a year ago. -No evidence showed that staff had been through any competency training's. -CNA L, CNA M, and CNA N did not have competencies in their employee files. -The staff should have competencies in their employee files.

Based on observation, interview and record review, the facility failed to have sufficient staff on the weekends to provide care and services for one sampled resident (Resident #35) and two supplemental resident's (Resident #12 and #272) out of 16 sampled residents. The facility census was 64 residents. Review of the facility's policy, Staffing, Sufficient, and Competent Nursing, dated 09/2020 showed: Sufficient Staffing: -Licensed nurses and certified nursing assistants are available 24 hours a day, seven days a week to provide competent resident care services including: --Assuring resident safety. --Attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident. --Assessing, evaluating, planning and implementing resident care plans. --Responding to resident needs. -A licensed nurse is designated as a charge nurse on each shift. --A licensed nurse may be a Licensed Practical Nurse (LPN), or Registered Nurse (RN). --A charge nurse is a licensed nurse with designated responsibilities that may include staff supervision, emergency coordination, provider or physician support and direct resident care. --The Director of Nursing Services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents. -A RN provides services at least eight consecutive hours every 24 hours, seven days a week. RN's may be scheduled more than eight hours depending on the acuity needs of the resident. -Licensed nurses are required to supervise nurse aides/nursing assistants and are scheduled in such a way that permits adequate time to do so. -Nurse aides/nursing assistants are individuals providing nursing or related services to residents in the facility, including those who provide services through an agency or under a contract with the facility. Licensed health professionals, registered dietitians, paid feeding assistants and individuals who volunteer to provide nursing or related services without pay are not considered nursing assistants and are not posted or reported as direct care staff. -Staffing numbers and skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment. -Factors considered in determining appropriate staffing ratios and skills include an evaluation of the diseases, conditions, physical or cognitive limitations of the resident population, and acuity. 1. Review of the facility's Facility Assessment, revised date 8/2/24, showed: -All Staff: --Full-time staff 62 members. --Part-time staff 15 members. --Pro re nata (PRN) staff 1 member. -Hours per a resident days: --Day shift had 3 RN, 2 LPN, and 4 Certified Nursing Assistance (CNA). --Evenings had 2 RN, 2 LPN, and 4 CNA. --Nights has 0 RN, 1 LPN, and 2 CNA. --The nursing staff works 12 hour shifts. -Dietary Staff: -- Day shift had 1 cook, 22 aides, 1 Dietary Manager, and 1 Registered Dietitian. --Evenings shift had 1 cook. -Rehab care staff: --Day shift had 1 Physical Therapist, 1 Occupational Therapist, 1 Speech Therapist, 1 Physical Therapist Assistant, and 1 Occupational Therapist Assistant. -Other Staff: --Day shift had 2 maintenance, 10 ancillary, 1 laundry, and 1 housekeeping. --Evening shift had 1 maintenance, 5 ancillary, 1 laundry, and 1 housekeeping. --Night shift had 1 laundry staff member. 1A. Review of the CMS Payroll Based Journal (PBJ) for the period of January 1, 2024, through March 31, 2024, showed the report was triggered for excessively low weekend staffing. 1B. Review of the Daily Staffing Sheets for January 2024 showed the following shortages for weekend staffing: -Requested January 2024 PBJ but did not receive. 1C. Review of the Daily Staffing Sheets for February 2024 showed the following shortages for weekend staffing: -Requested February 2024 PBJ but did not receive. 1D. Review of the Daily Staffing Sheets for March 2024 showed the following shortages for weekend staffing: -3/8/24 Night shift short one CNA 7:00 P.M.-7:00 A.M. -3/9/24 Day shift short one CNA and one CMT after 3:00 P.M. --Day shift short one CNA. --Night shift short two CNAs 7:00 P.M.-7:00 A.M. -3/10/24 Evening shift short one CNA from 7:00 P.M. -11:00 P.M. -3/10/24 Day shift short one CNA and one CMT after 3:00 P.M. --Day shift short one CNA. -3/16/24 Day shift short two CNAs. --Day shift short one Nurse. --Day shift short one CMT after 1:00 P.M. --Night shift short one CNA 7:00 P.M.-7:00 A.M. -3/17/24 Day shift short two CNAs. --Day shift short one Nurse. --Day shift short one CMT after 12:00 P.M. -3/23/24 Day shift short one CNA and CMT after 3:00 P.M. --Night shift short one CNA 7:00 P.M.-7:00 A.M. -3/24/24 Night shift short one CNA 7:00 P.M.-7:00 A.M. -3/30/24 Day shift short one CNA. --Day shift short one Nurse. --Day shift short one CMT. -3/31/24 Day shift short one CNA. --Day shift short one Nurse. --Day shift short one CMT. 2A. Review of the CMS PBJ for the period of July 1, 2024, through September 30, 2024, showed the report was triggered for excessively low weekend staffing. 2B. Review of the Daily Staffing Sheets for July 2024 showed the following shortages for weekend staffing: -7/6/24 Day shift short one CNA. -7/7/24 Day shift short one CNA. -7/21/24 Day shift short one nurse after 3:00 P.M.-7:00 P.M. --Day shift short one CNA. -7/20/24 Day shift short one CNA. -7/27/24 Day shift short one nurse. --Day shift short one CNA and half CNA 7:00 A.M.-3:00 P.M. -7/28/24 Day shift short one CNA. 2C. Review of the Daily Staffing Sheets for August 2024 showed the following shortages for weekend staffing: -8/11/24 Day shift short one CNA. -8/17/24 Day shift short two CNA. -8/18/24 Day shift short two CNA. 2D. Review of the Daily Staffing Sheets for September 2024 showed the following shortages for weekend staffing: -Requested September 2024 PBJ but did not receive. 3. Review of Resident #12's Admission Record showed the resident was admitted on [DATE], with the following diagnoses: -Difficulty with walking. -Muscle weakness. -Unsteadiness on his/her feet. Review of the resident's Care Plan dated 9/18/23, showed: -Supervision/some touching assistance with bed mobility. -The resident needs supervision, cues and set up when eating. -Moderate assistance needed with one staff member. -Encourage the resident to fully participate with each interaction. 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 12/5/24 showed the resident: -Was cognitively intact. -Used a wheelchair. -Needed supervision while eating, for oral hygiene, for toileting hygiene, and for dressing. -Needed substantial/maximal assistance for showering/bathing. -Needed partial/moderate assistance for lying to sitting on side of the bed, sit to stand, and transferring from a bed to a chair. During an interview on 4/4/25 at 9:13 A.M., Certified Nursing Assistant (CNA) A said: -CNA B was scheduled to be the bath aide but he/she was pulled to the floor to help get residents up. -He/She tagged team with CNA B to get residents up on time that needed assistance with eating. -He/She talked with the resident and told him/her that he/she was not able to get him/her up to go to the dining room for breakfast in time since they were short staffed. During an interview on 4/4/25 at 9:28 A.M., the resident said: -He/She had not eaten yet. -No one was there to get him/her up that morning. During an interview on 4/4/25 at 9:36 A.M., Licensed Practical Nurse (LPN) A said: -He/She was aware the staff were unable to get all the residents out of bed and to the dining room. -At that time there was total of two aides for the 100 and 300 halls. -One nurse was covering both 100 and 300 halls. -Both halls had high acuity levels of care and two aides, and one nurse was not enough staff to cover the resident's needs. -The resident should have been up and taken to breakfast. During an interview on 4/4/25 at 10:50 A.M., the Administrator and the Director of Nursing (DON) said: -He/She had looked at PBJ report, but he/she does not recall being below staffing requirements. -PBJ was reviewed by a team, the Administrator, DON, Interdisciplinary Team, Social Services Director, and Activities Director. -The team reviews the PBJ as part of quality assurance. -The Administrator, DON, Business Office Manager, and other staff would help get residents up and feed them. -DON was currently in charge of staffing. -The charge nurse would monitor staffing on the floor. -Managers would walk the halls every morning and throughout the day to check on the residents. 39469 4. Review of Resident #35 face sheet showed the following diagnoses: -Muscle weakness. -Hemiplegia (muscle weakness on one side of the body) on the left side. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was always incontinent. -He/She was cognitively intact. -He/She was totally dependent on staff for toileting. Review of the resident's care dated 1/8/25 showed: -Staff was to provide maximum assistance times one staff member for toileting. -The resident needed prompt response to all requests for assistance. Observation and interview with the resident on 3/31/25 at 8:55 A.M. showed: -The resident said he/she was wet and staff have not come in to check on him/her since night shift before 7:00 A.M. -At 9:02 A.M. a staff member came into the room and turned off his/her call light. -The resident turned the call light back on. -At 9:10 A.M. a second staff member came into the resident's room turned off the call light and told the resident someone would be in to help him/her. -At 9:43 A.M. a Certified Medication Technician (CMT) came into the room to give the resident medications. -The resident said he/she needed to be changed as he/she has been wet for a while. -The CMT did not change the resident. -At 10:25 A.M. the resident still had not been changed. -The resident smelled of urine. -At 10:30 A.M. staff came in to change the resident. During an interview on 3/31/24 at 2:00 P.M. CNA H said: -He/She was the only CNA working the floor today for the 100/300 halls. -They needed at least two staff and ended up pulling the two shower aides to work on the floor. -There had been times in the last few weeks when it took more than 30 minutes to answer the call light and the residents were angry. Observation on 4/4/25 at 11:58 A.M. showed there was a very strong odor of urine in the hallway coming from the resident's room. During an interview on 4/4/25 at 11:58 A.M. the resident said: -He/She had gone to the bathroom a couple of times in his/her brief. -Staff had not checked to see if he/she was wet since the change of shift about 7:00 A.M. -He/She could not do anything about the smell as he/she was unable to toilet self. -I know people can smell it and I'm ashamed. He/She had put his/her call light on, but staff would come in and turn off the call light saying they would be back to change him/her and sometimes it was more than an hour before they would come back. During an interview on 4/3/25 at 8:39 A.M. LPN C said: -On the 100/300 hall there should have been one nurse at the desk and one nurse working the floor. -He/She was working the floor and taking phone calls at the desk. -There should have been three CNA's working the floor on the 100/300 halls. -They had a lot of call ins this week and had been short staffed. -Call lights should have been answered within five minutes. -If a call light was not answered in less than 30 minutes it had been too long. -He/She had many complaints this week from the residents about the call lights not being answered timely and told the DON. 4. Review of Resident #272's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Fracture of left tibia (the shin bone that connects the knee to the ankle). -Hemiplegia. -Need for assistance with personal care. Review of the resident's care plan dated 2/28/25 showed: -He/She had impaired functional mobility related to left tibia fracture (brake) -He/She needed moderate assistance for dressing. -He/She needed maximum assistance for personal hygiene or toileting. -He/She needed maximum assistance to pivot from bed to wheelchair. -Staff were to respond promptly to all requests for assistance. Review of the resident's Admission Assessment MDS dated [DATE] showed: -He/She was cognitively intact. -He/She was always incontinent. -He/She needed partial assistance to dress. -He/She needed substantial assistance to toilet. -He/She was impaired on one side. -He/She needed substantial assistance to move from the bed into the wheelchair. -He/She was a hemiplegic. Observation on 3/31/25 at 9:00 A.M. of the resident showed; -His/Her call light had been on for four minutes. -The light was answered by a Housekeeper. -The resident told the Housekeeper he/she needed to get up with the hoyer into the wheelchair to get his/her hair done. -The Housekeeper turned off the resident's call light and said someone would be in to help him/her. -At 9:05 A.M. Dietary staff came in to get his/her breakfast tray. -The resident told the Dietary staff that he/she needed to get up as he/she had a hair appointment at 9:10 A.M. -The resident put on his/her call light. -At 9:12 A.M. a third staff member came into his/her room asked what he/she needed and turned off his/her call light saying someone will be in to help him/her. -The resident again put on his/her call light. -At 9:18 A.M. a staff member looked into the resident's room then continued to walk down the hall. -At 9:21 A.M. an unknown CNA came into the room to see what the resident needed. -The unknown CNA told the resident that he/she needed an extra staff person to get him/her up and changed and would be right back. -At 9:33 A.M. the unknown CNA and another unknown CNA came into the room to change the resident and get him/her up into the wheelchair. -At 9:45 A.M. the resident left his/her room dressed for the day in his/her wheelchair. During an interview on 3/31/25 at 9:25 A.M. the resident said: -He/She was very angry as it was taking the staff so long to get him/her up and dressed. -He/She had probably already missed his/her appointment to get his/her hair done as the appointment had been at 9:10 A.M. and he/she had started putting his/her call light on at 8:30 A.M. During an interview on 3/31/25 at 9:27 the resident's family member said: -It sometimes took the staff an hour to answer the call light. -Staff would look into the room, ask what the resident wanted, then turn off the call light and leave. -He/She had talked to the charge nurse about the staff not answering the call light timely and he/she was told they did not have enough staff. During an interview on 4/4/25 at 1:30 P.M. the DON said: -Call lights should have been answered in less than 10 minutes. -Staff should not have turned off the call light unless they were taking care of the resident's needs. During a telephone interview on 4/7/25 at 9:30 A.M. the Administrator said: -During survey all of the CNA's called in except one so he/she and the DON had to go out and work on the floor.

Based on observation, interview and record review, the facility failed to ensure oxygen tubing was stored in a sanitary condition for one sampled resident (Resident #32), and failed to ensure Continuous Positive Airway Pressure (CPAP - a machine that uses air pressure to keep breathing airways open while asleep) masks were stored in a sanitary condition for one sampled resident, (Resident #32) and one supplemental resident (Resident #276) out of 16 sampled residents. The facility census was 64 residents. Review of the facility's undated policy, Oxygen Administration Policy, showed: -Cannulas and masks should be changed weekly. -Oxygen cannulas, oxygen masks, CPAP masks, should be stored in a plastic bag when not in use. 1. Review of Resident #32's care plan dated 2/3/25 showed: -He/She was on continuous oxygen therapy for Hypoxia (the absence of enough oxygen in the tissues to sustain bodily functions). -He/She was on antibiotic therapy for Pneumonia with oxygen usage, resolved (2/17/25). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 2/6/25 showed: -He/She was on oxygen therapy. -CPAP therapy was not checked. -Pulmonary issues were not checked. -He/She was cognitively intact. Review of the resident's Physician's Order Sheet (POS) dated April 2025 showed the following orders: -Check the resident's oxygen saturation on room air for three consecutive days, every shift. -If the oxygen saturation was greater than 90% then discontinue oxygen by nasal cannula, dated 4/1/25. -Oxygen at two liters per nasal cannula (tubing that goes into your nose delivering oxygen) every shift to maintain oxygen saturation greater than 90%, dated 1/31/25. -Oxygen tubing was to have been changed weekly on Wednesday night shift, date and bag tubing when changed, dated 2/3/25. -There was no order for the resident to use the CPAP machine at night. Observation on 3/31/25 at 10:14 A.M. showed: -The resident's CPAP machine was on the floor, the mask was not in a bag. -The CPAP mask was not clear, it was tinged a tan color . -The resident's oxygen was not dated when it had been changed. During an interview on 3/31/25 at 10:15 A.M. the resident said: -He/She had just got over pneumonia after a course of antibiotics. -He/She did not remember when the staff had last changed the oxygen tubing. -He/She used the CPAP machine at night. -Staff had never cleaned the CPAP mask. Observation on 3/31/25 at 2:12 P.M. showed -The CPAP machine and mask were still sitting on the floor. -Oxygen tubing worn by resident did not have a date on it. Observation on on 4/3/25 at 9:00 A.M. showed: -The resident's oxygen tubing was sitting on the floor not in a bag. -The oxygen tubing did not have a date on it showing when it was changed. During an interview on 4/3/25 at 9:00 A.M. the resident said: -The physician said he/she did not need to wear the oxygen all the time. -The staff left oxygen at bedside and they would be checking his/her oxygen levels and he/she might have still needed the oxygen. -The CPAP machine was gone. 2. Review of Resident #276's face sheet showed he/she was admitted to the facility with the following diagnosis of Obstructive Sleep Apnea (intermittent airflow blockage during sleep). The resident's care plan was requested and not provided. Observation on 3/31/25 at 1:45 P.M. showed his/her CPAP machine and mask were sitting on the floor, not in a bag. Review of the resident's Admission MDS dated [DATE] showed: -He/She had Pulmonary issues (lung). -He/She had a CPAP. -He/She was cognitively intact. Review of the resident's POS dated April 2025 showed the following order apply CPAP at bedtime, dated 3/28/25. Observation on 4/3/25 at 9:00 A.M. showed his/her CPAP machine and mask were sitting on the floor, not in a bag. During an interview on 4/3/25 at 9:00 A.M. with the resident said: -He/She had just came to the facility on [DATE]. -He/She had asked an unknown Certified Nursing Assistant (CNA) about getting a table to put the CPAP on it at that time. During an interview on 4/3/25 at 9:10 A.M. Licensed Practical Nurse (LPN) A/Infection Preventionist said: -He/She had seen that the resident had a CPAP. -The CPAP and mask should not be on the floor. -The CPAP and mask should have been in a bag with the date on it, that it was provided. -The CPAP mask should have been cleaned every day, the nurse should have ensured it was cleaned. Observation and interview with the resident on 4/4/25 at 9:00 AM showed: -The CPAP machine was on a nightstand. -The CPAP mask was not in a bag. -The CPAP mask still had a tan color. -The resident said it has not been cleaned in the week that he/she has been at the facility. -The resident asked an unknown CNA to wash it a couple of times and it had not been done. 3. During an interview on 4/4/25 at 9:45 A.M. CNA B said: -Oxygen tubing should have been changed out every week on Sunday by the night nurse. -Oxygen equipment when not in use should have been in a bag. -Oxygen equipment like a CPAP machine should not have been on the floor. -He/She did not know who was responsible for cleaning the CPAP masks. During an interview on 4/4/25 at 10:00 A.M. Certified Medication Technician (CMT) B said: -Oxygen tubing or a CPAP machine should not have been on the floor. -Oxygen equipment should have been stored in a bag and dated when it was changed. -The Wednesday night nurse was responsible for changing out the oxygen equipment. -He/She did not know who was responsible for cleaning the CPAP mask. During an interview on 4/4/25 at 1:30 P.M. the Director of Nursing (DON) said: -Oxygen tubing or equipment should not have been on the floor. -The CPAP mask should have been cleaned daily by the nurse. -The night nurse was responsible for changing out the oxygen equipment and dating it when it was changed.

Based on interview and record review, the facility failed to complete discharge assessments timely when two supplemental residents who automatically triggered in the survey system (Residents #68 and #65) were discharged from the facility and failed to complete a death in facility assessment timely for one supplemental resident who automatically triggered in the survey system (Resident #4). The facility census was 64 residents. Review of the facility policy Resident Assessments dated as revised [DATE] showed: -Discharge assessments (return anticipated and return not anticipated) were required. -The Resident Assessment Instrument (RAI) User's Manual provides detailed information on timing and submission of assessments. Review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.19.1 dated [DATE] showed: -A death in the facility tracking record was required seven days after the resident's death. -A discharge assessment was required 14 days after a resident was discharged from the facility. 1. Review of the Centers for Medicare & Medicaid Services (CMS) electronic survey task of resident assessments for the facility showed: -Resident #68 was admitted on [DATE]. -His/Her most recent Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) was a quarterly dated [DATE] which was over 120 days old. Review of the resident's Social Services note dated [DATE] showed the resident discharged from the facility on [DATE]. During an interview on [DATE] at 8:07 A.M., the MDS Coordinator said: -The last MDS completed on the resident was a quarterly on [DATE]. -The resident discharged from the facility on [DATE] and he/she did not do the discharge MDS. -It was his/her fault that it was late. 2. Review of the CMS electronic survey task of resident assessments for the facility showed: -Resident #4 was admitted on [DATE]. -His/Her most recent MDS was a significant change dated [DATE] which was over 120 days old. Review of the resident's nurse's note dated [DATE] showed the resident passed away on [DATE]. During an interview on [DATE] at 8:07 A.M., the MDS Coordinator said: -The last MDS completed on the resident was a significant change MDS when he/she went on hospice (end of life care) on [DATE]. -The resident passed away on [DATE]. -He/She just missed it and did not do a death in facility assessment. 3. Review of the CMS electronic survey task of resident assessments for the facility showed: -Resident #65 was admitted on [DATE]. -His/Her most recent MDS was a quarterly dated [DATE] which was over 120 days old. Review of the resident's nurse's note dated [DATE] showed the resident discharged from the facility on [DATE]. During an interview on [DATE] at 8:07 A.M., the MDS Coordinator said: -The last MDS completed on the resident was a quarterly on [DATE]. -The resident discharged from the facility on [DATE]. -He/She did not do a discharge MDS on the resident. 4. During an interview on [DATE] at 8:07 A.M., the MDS Coordinator said: -When he/she started about a year ago, they were very behind on MDSs and he/she had a lot to catch up on. -He/She was the interim Director of Nursing (DON) for the month of [DATE]. -They switched to an electronic health record in [DATE] so he/she had to get whole new system in place switching from paper to electronic. -Normally a late assessment showed up red in the system as being late but that did not happen. -He/She does look at the transmission reports but he/she did not catch the discharge MDSs. -He/She pulls up an admission, discharge, and transfer (ADT) summary report in the electronic health record but if they didn't pull over to that report, he/she would not have done a discharge MDS. During an interview on [DATE] at 1:30 P.M., the DON said: -The MDS coordinator was responsible for doing a discharge MDS when a resident discharged from the facility or was deceased . -Discharges would have shown up on the ADT and then the information would have gone to the dashboard. -Discharges were also discussed in stand-up meetings.

Based on interview and record review, the facility failed to preclude any commingling (the mixing or blending of funds that should be kept separate) of resident funds with facility funds for five supplemental residents (Resident #172, #36, #173, #174, and #175) and one sampled resident (Resident #66). The facility census was 64 residents. Review of the facility policy Resident Trust Fund Management dated as revised [DATE] showed it did not address the improper practice of commingling resident funds with facility funds. 1. Review of an email dated [DATE] showed a refund of $56 was requested for Resident #172 in an email to the corporate business office dated [DATE]. Review of a form dated [DATE] that was attached to the printed email dated [DATE] showed a refund of $56 was due to the resident. Review of the facility accounts receivable aging report dated [DATE] showed the resident discharged from the facility on [DATE], the facility had $56.00 of the resident's private funds and had not returned them for over 210 days (the furthest back the report went). During an interview on [DATE] at 2:12 P.M., the Business Office Manager said: -The resident passed away on [DATE]. -This was resident money that was held in the facility operating account. -The $56 was due to MO HealthNet since the resident was deceased . 2. Review of the facility accounts receivable aging report dated [DATE] showed Resident #174 discharged from the facility on [DATE], the facility had $212.44 of the resident's private funds and had not returned them for over 210 days (the furthest back the report went). During an interview on [DATE] at 2:120 P.M., the Business Office Manager said: -There were rate adjustments from hospice (end of life care) and Medicaid that resulted in a credit for the resident. -The resident was discharged on [DATE]. -He/She should have sent the money back to the resident upon discharge. 3. Review of the facility accounts receivable aging report dated [DATE] showed Resident #66 was a current resident, the facility had $7,671.00 of the resident's private funds, and the facility had not returned them for over 210 days (the furthest back the report went). During an interview on [DATE] at 2:120 P.M., the Business Office Manager said: -The money was private resident funds. -The resident was spending down, Medicaid was pending, and he/she was not sure how to record it. 4. Review of the facility accounts receivable aging report dated [DATE] showed Resident #173 was a current resident, the facility had $10,260.00 of the resident's private funds and had not returned them for over 210 days (the furthest back the report went). During an interview on [DATE] at 2:10 P.M., the Business Office Manager said: -The money needed to go back to the resident. -The resident's Medicaid was pending. -The resident was approved for Medicaid. -A refund was requested from the corporate office on [DATE] to go to the resident but they had not provided the money back to the resident. 5. Review of the facility accounts receivable aging report dated [DATE] showed Resident #175 discharged from the facility on [DATE], the facility had $3,913.77 of the resident's private funds and had not returned them for over 210 days (the furthest back the report went). During an interview on [DATE] at 2:10 P.M., the Business Office Manager said: -The resident discharged in 2023. -The money should have been returned to the resident upon discharge.

Based on observation, interview, and record review, the facility failed maintain the dignity of three sampled residents, (Resident #35, #272, and #12), out of 16 sampled residents. The facility census was 64 residents. Review of the facility's Dignity policy revised 2/2021 showed: -Residents are treated with dignity and respect at all times. -The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continuous throughout the resident's facility stay. -Individual needs and preferences of the resident are identified through the assessment process. -Residents my exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility. -When assisting with care, residents are supported in exercising their rights. For example, residents are: --Encouraged to attend the activities of their choice, including religious, political, civic, recreational, or social activities. --Allowed to choose when to sleep, eat, and conduct activities of daily living. --Provided with a dignified dining experience. -Each resident should have been cared for in a manner that promoted and enhanced his/her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. -Demeaning practices and standards of care that compromise dignity were prohibited. -Staff were expected to promote dignity and assist residents by promptly responding to a resident's request for toileting assistance. 1. Review of Resident #35 face sheet showed the following diagnoses: -Muscle weakness. -Hemiplegia (muscle weakness on one side of the body) on the left side. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 12/23/24 showed: -He/She was always incontinent. -He/She was cognitively intact. -He/She was totally dependent on staff for toileting. Review of the resident's care plan dated 1/8/25 showed: -He/She had unrelieved anxiety at times. -Goal was to have the resident to be without fear or anxiety. -Staff was to provide support and encouragement as needed. -Staff was to provide maximum assistance times one staff member for toileting. -The resident needed prompt response to all requests for assistance. Observation and interview with the resident on 3/31/25 at 8:55 A.M. showed: -The resident said he/she was wet and staff have not come in to check on him/her since night shift before 7:00 A.M. -At 9:02 A.M. a staff member came into the room and turned off his/her call light. -The resident turned the call light back on. -At 9:10 A.M. a second staff member came into the resident's room turned off the call light and told the resident someone would be in to help him/her. -At 9:43 A.M. a Certified Medication Technician (CMT) came into the room to give the resident medications. -The resident said he/she needed to be changed as he/she has been wet for a while. -The CMT did not change the resident. -At 10:25 A.M. the resident still had not been changed. -The resident smelled of urine. -At 10:30 A.M. staff came in to change the resident. Observation and interview with the resident on 4/4/25 at 11:58 A.M. showed: -There was a very strong odor of urine in the hallway coming from the resident. -The resident said he/she has gone to the bathroom a couple of times in his/her brief. -Staff had not checked to see if he/she was wet since the change of shift about 7:00 A.M. this morning. -He/She said he/she could not do anything about the smell as he/she was unable to toilet self. -I know people can smell it and I'm ashamed. I have put on my call light but staff will come in and turn it off saying they will be back to change me and sometimes it's more than an hour before they come back. -Staff came in to change the resident at 12:02 P.M. During an interview on 4/3/25 at 8:39 A.M. Licensed Practical Nurse (LPN) C said he/she has had many complaints this week from the residents about the call lights not being answered timely and told the Director of Nursing (DON). 2. Review of Resident #272's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Fracture of left tibia (the shin bone that connects the knee to the ankle). -Hemiplegia. -Need for assistance with personal care. Review of the resident's care plan dated 2/28/25 showed: -He/She had impaired functional mobility related to left tibia fracture. -He/She needed moderate assistance for dressing. -He/She needed maximum assistance for personal hygiene or toileting. -He/She needed maximum assistance to pivot from bed to wheelchair. -Staff was to respond promptly to all requests for assistance. Review of the resident's Admission Assessment MDS dated [DATE] showed: -He/She was cognitively intact. -He/She was always incontinent. -He/She needed partial assistance to dress. -He/She needed substantial assistance to toilet. -He/She was impaired on one side. -He/She needed substantial assistance to move from the bed into the wheelchair. -He/She was a hemiplegic. Observation on 3/31/25 at 9:00 A.M. of the resident showed; -His/Her call light had been on for four minutes. -The light was answered by a Housekeeper. -The resident told the Housekeeper he/she needed to get up with the hoyer into the wheelchair to get his/her hair done. -The Housekeeper turned off the resident's call light and said someone would be in to help him/her. -At 9:05 A.M. Dietary staff came in to get his/her breakfast tray. -The resident told the Dietary staff that he/she needed to get up as he/she had a hair appointment at 9:10 A.M. -The resident put on his/her call light. -At 9:12 A.M. a third staff member came into his/her room asked what he/she needed and turned off his/her call light saying someone will be in to help him/her. -The resident put on his/her call light. -At 9:18 A.M. a staff member looked into the resident's room then continued to walk down the hall. -At 9:21 A.M. a CNA came into the room to see what the resident needed. -The CNA told the resident that he/she needed an extra staff person to get him/her up and changed and would be right back. -At 9:33 A.M. the CNA and another CNA came into the room to change the resident and get him/her up into the wheelchair. -At 9:45 A.M. the resident left his/her room dressed for the day in his/her wheelchair. During an interview at 9:25 A.M. on 3/31/25 the resident said: -He/She was very angry as it was taking the staff so long to get him/her up and dressed. -He/She had probably already missed his/her appointment to get his/her hair done as the appointment had been at 9:10 A.M. and he/she had started putting his/her call light on at 8:30 A.M. this morning. 51305 3. Review of Resident #12's Admission Record showed the resident was admitted on [DATE], with the following diagnoses: -Difficulty with walking. -Muscle weakness. -Unsteadiness on his/her feet. Review of the resident's Care Plan dated 9/18/23, showed: -Supervision/some touching assistance with bed mobility. -The resident needs supervision, cues and set up when eating. -Moderate assistance needed with one staff member. -Encourage the resident to fully participate with each interaction. Review of the resident's admission MDS dated [DATE] showed the resident: -Was cognitively intact. -Used a wheelchair. -Needed staff supervision for eating, and oral hygiene. -Needed partial/moderate assistance for lying to sitting on side of the bed, sit to stand, and transferring from the bed to a chair. During an interview on 4/4/25 at 9:13 A.M., CNA A said: -He/She talked with the resident and told him/her that he/she was not able to get him/her up to go to the dining room for breakfast in time since they were short staffed. During an interview on 4/4/25 at 9:28 A.M., the resident said: -He/She had not eaten yet. -No one was there to get him/her up. -It made him/her feel terrible and he/she wanted to go to the dining room to eat. -No one was there to get him/her up that morning. During an interview on 4/4/25 at 9:36 A.M., LPN A said: . -He/She was aware the staff were unable to get all the residents out of bed and to the dining room. -The resident should have been up and taken to breakfast. 4. During an interview on 4/4/25 at 10:50 A.M., the Administrator and the Director of Nursing (DON) said: -The Administrator, DON, Business Office Manager, and other staff would help get residents up and feed them. -DON was currently in charge of staffing. -The charge nurse would monitor staffing on the floor. -Managers would walk the halls every morning and throughout the day to check on the residents.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #35) had his/her brace applied to his/her contracted hand out of 16 sampled residents. The facility census was 64 residents. Review of the facility's policy, Physician Services, dated February 2021 showed: -Supervising the medical care of residents includes: -Prescribing therapy. 1. Review of Resident #35's face sheet showed he/she was readmitted to the facility on [DATE] with the following diagnoses: -Left side Hemiplegia (a muscle weakness on one side of the body). -Cerebral Infarction (Stroke -when the blood flow to the brain was disrupted, leading to brain damage). Review of the resident's Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff for care planning) dated 12/23/24 showed: -He/She was cognitively intact. -He/She was totally dependent on staff for cares. -He/She had Hemiplegia. -He/She had a Stroke. Review of the resident's care plan dated 1/30/25 showed: -Left upper extremity splint. -He/She had an activity of daily living deficit related to CVA affecting left nondominant side. -Splint to left hand for contracture prevention, dated 10/30/24. Review of the resident's April 2025 Physician's Order Sheet showed the following orders: -Occupational Therapy OT - (helps individuals improve the ability to participate in daily activities by addressing physical, cognitive, and emotional challenges) evaluate and treat as indicated, dated 10/2/24. -Resident to discharge from skilled OT due to reaching maximum potential, Resident to start working with Restorative Aide on 3/28/25. -Physical Therapy (PT - a treatment that helps you improve how your body performs) Evaluation and treat as indicated, dated 10/2/24. Observation on 3/31/25 at 12:32 P.M. of the resident showed: -His/her left hand was contracted (a tightening and shortening of a muscle). -There was an undated sign on the wall above the head of the resident's bed which showed Should have splint on in morning, off at bedtime. -His/Her splint was on the nightstand. During an interview on 3/31/25 at 12:35 PM the resident said: -He/She had asked twice today for the Certified Nursing Assistant (CNA) to put the splint/brace on him/her. -He/She could not put the splint on himself/herself. -Staff had not been putting the splint on him/her lately. -He/She was to have the splint applied to his/her left hand in the morning and taken off at night. -He/She was able to take off the splint but was not able to apply it. -He/She did not refuse to have the splint put on his/her arm. Observation on 4/1/25 at 10:30 A.M., 4/1/25 at 2:20 P.M., and 4/2/25 at 1:00 P.M., showed he/she did not have his/her splint on left hand. Observation and interview with the resident on 4/3/25 at 8:40 A.M. showed: -The resident was observed without the brace on his/her hand. -The resident said he/she had not had the brace on his/her hand for the last few days. -The Restorative Aide (RA - a person who works with individuals who need help regaining or maintaining skills and abilities after illness, injury, or surgery) was supposed to apply it in the morning and it had not been done. During an interview on 4/3/25 at 1:00 P.M. the RA said: -The resident would be released from PT next week and he/she would start working with him/her then. -Anyone who went into the room could have applied the splint, such as the Certified Nurses Aide (CNA) or the nurse. -He/She did not know who was ultimately responsible for ensuring the splint was applied to the resident. During an interview on 4/4/25 at 9:45 A.M. CNA B said: -The resident had a brace to wear on his/her hand, sitting on the nightstand. -He/She did not know when the resident was to wear the brace. -He/She did not put the brace on the resident. -He/She did not normally have a brace on. During an interview on 4/4/25 at 10:00 A.M. Certified Medication Technician (CMT) B said: -PT was responsible for ensuring a resident had a brace applied. -He/She could not remember if the resident had a brace. During an interview on 4/4/25 at 10:20 A.M. Licensed Practical Nurse (LPN) A/Infection Preventionist (IP) said: -He/She was not aware the resident had a brace. -A CNA could apply a brace. -Therapy was ultimately responsible for ensuring the resident had a brace applied to his/her hand. During an interview on 4/4/25 at 1:30 P.M. the Director of Nursing (DON) said: -The CNA could have put the brace on the resident. -Therapy or the Nurse were responsible to ensure the resident had the brace applied to his/her arm.

Based on interview and record review, the facility failed to provide written notification of a discharge to one sampled resident (Resident #277) out of 16 sampled residents when he/she was discharged out of 16 sampled residents. The facility census was 54 residents. 1. Review of Resident#277's Post Fall Investigation Report dated 10/2/25 showed the resident was discharged to the hospital. Review of the resident's entry tracking form showed the resident returned to the facility on [DATE]. During an interview on 4/4/25 at 10:50 A.M., Licensed Practical Nurse (LPN) A said the nurse who sent the resident out to the hospital was responsible for providing the discharge notice. During an interview on 4/4/25 at 1:30 P.M., the Director of Nursing (DON) said: -The nurse who was discharging the resident should have given the resident the discharge notice. -If the nurse didn't provide the discharge notice, Social Services should do it.

Based on observation, interview, and record review, the facility failed to ensure the smoking section of the care plan was up to date for one sampled resident (Resident #17) out of 16 sampled residents. The facility census was 64 residents. Review of the facility's policy 'Care Plans, Comprehensive Person-Centered', dated revised 3/2022 showed: -The care plan was to be prepared by an Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative. -The Facility's IDT will develop a comprehensive care plan for each resident in accordance with Minimum Data Set (MDS -a federally mandated assessment tool to be completed by facility staff for care planning) guidelines within 7 days of admission and longer then 21 days. -The IDT team reviews and updates the care plan: --When there has been a significant change in the residents condition. --When the desired outcome is not met. --When the resident has been readmitted to the facility from a hospital stay. --At least quarterly, in conjunction with the required quarterly MDS assessment. 1. Review of Resident #17's Admission Record showed the resident was admitted on [DATE], with a diagnosis of: -Hemiplegia (paralysis - loss of muscle function) and Hemiparesis (partial paralysis or weakness) following unspecified Cerebrovascular disease (disease of the blood vessels in the brain, including stroke) affecting left dominant side. -Cerebral infarction due to embolism of unspecified cerebral artery (means a stroke cause by a blood clot). -Aphasia (unable to verbally communicate). Review of the resident's Care Plan dated 1/7/24, showed: -Was a current tobacco user. -Resident will not suffer injury from unsafe smoking practices. -Conduct Smoking Safety Evaluation on admission and as needed. -There was no mention of the resident needing to be supervised while smoking. -There was no mention of the resident smoking indoors by the door that leads to the outside smoking area. Review of the resident's annual MDS dated [DATE] showed the resident: -Was cognitively intact. -Was a current tobacco user. Review of the resident's quarterly MDS dated [DATE] showed: -The resident was cognitively intact. -He/She was a current tobacco user. Review of the resident's Smoking assessment dated [DATE] showed: -He/She was to be supervised during smoking. -He/She had problems with balance, standing, and sitting with limited range of motion in arms and hands. -He/She had burns on skin, clothing, furniture, drops ashes on self, was unable to hold a cigarette safely, was unable to light a cigarette safely, was unable to extinguish a cigarette safely, and was unable to use an ashtray to extinguish a cigarette. -There was no mention of the resident smoking indoors by the door that leads to the outside smoking area. Review of the resident's progress note dated 2/4/25, showed: -The resident was found by staff smoking a cigarette by the vending machines. -The resident was brought up to the nurses station and the nurse took his/her cigarettes and explained that he/she is not to be smoking inside of facility. Review of the resident's progress note dated 3/6/25, showed: -Nurse was notified that the resident was smoking inside the building in the snack/soda room near the door to the hallway. -Staff tookthe cigarette away and told the resident that he will not be able to smoke here as he has continued to smoke in the building. Will refer resident's smoking privilege to management. During an interview on 4/3/25 at 1:58 P.M. maintenance staff said: -The resident was not restrictive from smoking. -Maintenance staff will take resident out at all smoking times. -The resident uses a smoking apron. -The maintenance staff will light it for him/her. -If it was cold and windy out the resident would not like to go outside. -He/She does likes to hold the cigarette, it is his/her security blanket. During an interview on 4/4/25 at 8:31 A.M., MDS Coordinator said: -He/She was responsible, or the nurses could update the residents' care plans. -Resident #17 had been caught inside smoking by the door that leads to the outside smoking area. -The resident should have an updated care plan for he/she to be supervised by staff when smoking. -The annual smoking assessment should be in the care plan. -There was no documentation in the care plan about the resident smoking inside the building. During an interview on 4/4/25 at 8:40 A.M., Social Services Director (SSD) said: -The resident had showed a decline in his/her smoking abilities since he/she had first arrived. -He/She had to be supervised by staff when smoking. -The care plan should show that the resident should wear a smoking bib. -The MDS Coordinator was responsible for updating the care plan. During an interview on 4/4/25 at 9:36 A.M., Licensed Practical Nurse (LPN) A said: -He/She had educated the resident the one time that he/she had caught the resident smoking inside the building. -He/She had notified the MDS Coordinator, SSD, and Director of Nursing (DON). -The resident now must be supervised by staff when smoking. -The MDS Coordinator was responsible for updating the care plan. -Nurses would take issues that arrived to the MDS Coordinator so that he/she would update the care plan. During an interview on 4/4/25 at 1:25 P.M., the DON and the Regional Operations Coordinator (ROC) said: -The smoking assessment should be in the care plan. -It should state in the care plan that the resident should wear a smoking bib. -It should state in the care plan that the resident should be supervised by staff while smoking. -It should state in the care plan that the resident was caught smoking in the building. -The MDS Coordinator and the Interdisciplinary Team (IDT) were responsible for the care plan. -The MDS Coordinator would update the care plan.

Based on observation, interview, and record review, the facility failed to implement fall prevention measures to reduce the hazards/risks as much as possible for one sampled resident, (Resident #16) out of 16 sampled residents. The facility census was 64 residents. Review of the facility's policy, Falls and Fall Risk, Managing, dated December 2007 showed: -Based on previous evaluations and current data, the staff would have identified interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. -The staff, with the input of the Attending Physician, would have identified appropriate interventions to reduce the risk of falls. -If falling recurs despite initial interventions, staff would have implemented additional or different interventions or indicate why the current approach remained relevant. -In conjunction with the Attending Physician, staff would have identified and implemented relevant interventions to try to minimize serious consequences of falling. -The staff would monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. -If the resident continues to fall, staff would re-evaluate the situation and whether it was appropriate to continue or change current interventions. -The staff and or physician would have documented the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. 1. Review of Resident #16's quarterly Minimum Data Set (MDS - a federally mandated assessment tool competed by facility staff for care planning), dated 12/30/24 showed: -He/She was cognitively intact. -He/She had Pulmonary issues (lung). -He/She had Heart Failure (a condition in which the heart does not pump blood as it should). -He/She had anemia (when the blood does not have enough red blood cells to carry oxygen throughout the body). Review of the resident's Care Plan dated 3/15/25 showed: -He/She was receiving an antibiotic for Urinary Tract Infection (UTI - an infection in any part of the urinary system), dated 3/15/25. --Give Cefpodoxime Proxetil (medication used to treat bacteria) tablet every 12 hours for UTI for seven days. --Notify the charge nurse if symptoms present. -He/She had a self-care performance deficit related to weakness, inability to ambulate, dated 9/16/24. -He/She was at risk for falls related to decreased safety awareness, dated 1/10/25. -Staff were to ensure call light was within reach. -Staff were to use a mechanical lift with the assistance of two staff to transfer the resident, dated 1/10/25. -He/She had an unwitnessed (non injury) fall on 7/1/24. --Resident was educated if tired to seek assistance to bed as he/she may have slipped out of wheel chair because he/she was asleep. -He/She had an unwitnessed (non injury) fall on 11/10/24. --He/She refused to wear briefs, had an episode of incontinence when he/she stood resulting with urine on the floor. --He/She was encouraged to wear briefs and wait for staff to assist with transferring. -He/She had an unwitnessed (non injury) fall on 12/1/24. --Placed bright colored tape on wheelchair breaks to remind resident to apply breaks on chair prior to self-transfer attempts. -He/She had an unwitnessed (non injury) fall on 12/7/24. --Educated staff to be aware of the resident sitting in front of shower room door as an indication of needing to toilet. -He/She had an unwitnessed (non injury) fall on 1/15/25. --Resident found on floor next to bed. --Resident was unsure of how fall occurred. --Resident was transferred back to bed via mechanical lift. --Resident had bruises on his/her right leg. --Root cause increased weakness. --Intervention was to have Physical Therapy evaluate the resident. -He/She had an unwitnessed (non injury) fall on 3/11/25. -Director of Nursing and Director of Rehabilitation in attendance. --Root cause lack of awareness of positioning. --Intervention keep bed in lowest position while resident was in bed. -He/She had an unwitnessed (non injury) fall on 3/28/25. --Resident said he/she had tried to reposition self in bed and rolled off the bed onto the floor. --Resident said he/she hit his/her head and was sent to hospital for evaluation. --Root cause was the resident attempted to reposition self. --Intervention was to obtain a bed cane bilaterally to assist with independent bed mobility. Review of the resident's Nurses' Notes dated 3/28/25 showed: -The resident had a fall and said he/she hit his/her head. when he/she fell from the bed rolling over trying to reposition. -Vital signs were done. -Resident expressed he/she hit his/her head. -No documentation of Neurological assessment (Neuro checks assessment of the nervous system including the brain) having been preformed. Review of the resident's Progress Notes (Incident report) dated 3/28/25 showed: -The resident's fall was reviewed in the Clinical Meeting. -The resident was transferred to the hospital for follow up. -The resident was transferred to hospital before Neuro checks were started. -Upon return the resident would be evaluated for bed positioning and mobility. Review of the resident's Unwitnessed Fall report dated 3/28/25 showed: -The resident was alert and oriented and able to state factors related to fall. -The resident was sent to the hospital so neuro checks were done initially, but not started due to emergent transfer. -Upon return from the hospital, the resident would be assessed by therapy for bed positioning and the need for adaptive equipment. Review of the resident's hospital discharge summary dated 3/30/25 showed: -Status post fall possibly secondary to a UTI. -Started resident on Macrobid for UTI (antibiotic used for UTIs). Observation on 3/31/25 at 9:45 A.M. showed: -The resident was in bed. -The resident's bed was not in the low position. -There was no fall mat beside the resident's bed. -There were no bed cane rails on the bed. During an interview on 3/31/25 at 9:45 A.M. the resident said: -He/She was able to use the call light. -He/She had fallen often while at the facility. -He/She had just came back from the hospital after a fall. -The hospital thought he/she had a UTI and started him/her on an antibiotic. -He/She did not know what precautions the facility had taken to prevent him/her from falling again. Review of the resident's Progress Notes dated 4/1/25 showed: -On 3/28/25 at 1:00 A.M. the resident had a fall, he/she was attempting to reposition self in bed and rolled out of the bed onto the floor. -The resident said he/she hit his/her head. -The resident was sent to hospital for evaluation. -Root cause attempting to reposition, he/she wanted to maintain his/her independence. -Intervention will obtain bed cane rails bilaterally to assist with independent bed mobility. Review of the April 2025 Physician's Order Sheet showed the following order bilateral cane rail for assistance with bed mobility, dated 4/1/25. Observation on 4/1/25 at 11:00 A.M. showed: -The resident was in bed watching television. -The resident's bed was not in the low position. -There was no fall mat by the resident's bed. -There were no cane rails on the resident's bed. During an interview on 4/2/25 at 8:30 A.M. Certified Medication Technician (CMT) D said: -He/She was not aware of any issues with the resident's call light. -He/She was not aware the resident had ever had a fall. -If the resident had a fall it would have been in his/her care plan. -He/She did not know what fall prevention measures were for the resident. Observation on 4/2/25 at 9:00 A.M. showed: -The resident was in bed. -The resident's bed was not in a low position. -There was no fall mat beside the resident's bed. -There were no bed cane rails on the resident's bed. During an interview on 4/2/25 at 1:00 P.M. Licensed Practical Nurse (LPN)A/Infection Preventionist (IP) said: -They had been short staffed at times. -The resident had fallen in the past and just got back from the hospital after a non-witnessed fall. -After a fall he/she would have done a set of vital signs then a neuro checks since the resident hit his/her head. -He/She was not able to find any neuro checks for the resident after the fall in the computer. -He/She would have expected there to have been fall preventions put in place such as a fall mat when the resident was in bed, the bed to be in the lowest position, and the bed cane rails to have been applied since there was a physician's order for them. -He/She would have expected the preventions to have been put in place the day the resident came back from the hospital on 3/30/25 or at the latest the next day. -None of the preventions were currently in place. Observation on 4/3/25 at 9:28 A.M. showed: -The resident was in bed. -The resident's bed was not in a low position. -There was no fall mat beside the resident's bed. -There were no bed cane rails on the resident's bed. During an interview on 4/3/25 at 10:00 the Maintenance Director said: -He/She had replaced the light in the resident's call light on 3/24/25. -He/She had received a physician's order on 4/1/25 to put cane rails on the resident's bed. -He/She usually would fix whatever the resident needed the same day but had not attached the rails to the resident's bed yet. Observation on 4/3/25 at 2:15 P.M. showed: -The resident was in bed. -The resident's bed was not in a low position. -There was no fall mat beside the resident's bed. -There were no bed cane rails on the resident's bed. During an interview on 4/4/25 at 1:30 P.M. the Director of Nursing (DON) said: -When a resident fell staff should notify the charge nurse. -The nurse should have done a head to toe assessment. -He/She would have expected the nurse to have done a Neuro checks unless the ambulance was right there and took the resident emergently to the hospital. -The nurse documented that Neuro checks were done, but he/she was not able to provide the documentation which showed it was completed. -He/She would have taken into account what the floor nurse would have advised for fall prevention measures. -The resident should have had a fall mat, the bed in the low position when in bed, and the cane rails applied the first day or so when the resident came back from the hospital. MO00251585

Based on observation, interview, and record review, the facility failed to assist two sampled residents with changing their briefs after going to the bathroom in a timely fashion for (Resident #35 and Resident #272) out of 16 sampled residents. The facility census was 64 residents. Review of the facility's policy, Dignity, dated February 2021 showed: -Each resident should have been cared for in a manner that promoted and enhanced his/her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. -Staff were expected to promote dignity and assist residents by; -Promptly responding to a resident's request for toileting assistance. Review of the facility's policy, Staffing, Sufficient,and Competent Nursing, dated August 2022 showed: -Licensed nurses and Certified Nursing Assistants (CNAs) were to have been available 24 hours a day, seven days a week to provide competent resident care services including: --Responding to resident needs. Review of the facility's policy, Call System, Resident, dated September 2022 showed: -Call for assistance were answered as soon as possible, but no later than five minutes. 1. Review of Resident #35 face sheet showed the following diagnoses: -Muscle weakness. -Hemiplegia (muscle weakness on one side of the body) on the left side. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 12/23/24 showed: -He/She was always incontinent. -He/She was cognitively intact. -He/She was totally dependent on staff for toileting. Review of the resident's care dated 1/8/25 showed: -Staff was to provide maximum assistance times one staff member for toileting. -The resident needed prompt response to all requests for assistance. Observation and interview with the resident on 3/31/25 at 8:55 A.M. showed: -The resident said he/she was wet and staff have not come in to check on him/her since night shift before 7:00 A.M. -At 9:02 A.M. a staff member came into the room and turned off his/her call light. -The resident turned the call light back on. -At 9:10 A.M. a second staff member came into the resident's room turned off the call light and told the resident someone would be in to help him/her. -At 9:43 A.M. a Certified Medication Technician (CMT) came into the room to give the resident medications. -The resident said he/she needed to be changed as he/she has been wet for a while. -The CMT did not change the resident. -At 10:25 A.M. the resident still had not been changed. -The resident smelled of urine. -At 10:30 A.M. staff came in to change the resident. During an interview on 3/31/24 at 2:00 P.M. with CNA H said: -He/She was the only CNA working the floor today for the 100/300 halls. -They need at least two staff and ended up pulling the two shower aides to work on the floor. -There have been times in the last few weeks when it took more than 30 minutes to answer the call light and the residents were angry. Observation and interview with the resident on 4/4/25 at 11:58 A.M. showed: -There was a very strong odor of urine in the hallway coming from the resident. -The resident said he/she has gone to the bathroom a couple of times in his/her brief. -Staff had not checked to see if he/she was wet since the change of shift about 7:00 A.M. this morning. -He/She said he/she could not do anything about the smell as he/she was unable to toilet self. -I know people can smell it and I'm ashamed. I have put on my call light but staff will come in and turn it off saying they will be back to change me and sometimes it's more than an hour before they come back. -Staff came in to change the resident at 12:02 P.M. During an interview on 4/3/25 at 8:39 A.M. Licensed Practical Nurse (LPN) C said: -On the 100/300 hall there should have been one nurse at the desk and one nurse working the floor. -He/She was working the floor and taking phone calls at the desk. -There should have been three CNA's working the floor on the 100/300 halls. -They have had a lot of call ins this week and had been short staffed. -Call lights should have been answered within five minutes. -If a call light is not answered in less than 30 minutes it has been too long. -He/She has had many complaints this week from the residents about the call lights not being answered timely and told the Director of Nursing (DON). 2. Review of Resident #272's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Fracture of left tibia (the shin bone that connects the knee to the ankle). -Hemiplegia. -Need for assistance with personal care. Review of the resident's care plan dated 2/28/25 showed: -He/She had impaired functional mobility related to left tibia fracture (brake) -He/She needed moderate assistance for dressing. -He/She needed maximum assistance for personal hygiene or toileting. -He/She needed maximum assistance to pivot from bed to wheelchair. -Staff was to respond promptly to all requests for assistance. Review of the resident's Admission Assessment MDS dated [DATE] showed: -He/She was cognitively intact. -He/She was always incontinent. -He/She needed partial assistance to dress. -He/She needed substantial assistance to toilet. -He/She was impaired on one side. -He/She needed substantial assistance to move from the bed into the wheelchair. -He/She was a hemiplegic. Observation on 3/31/25 at 9:00 A.M. of the resident showed; -His/Her call light had been on for four minutes. -The light was answered by a Housekeeper. -The resident told the Housekeeper he/she needed to get up with the hoyer into the wheelchair to get his/her hair done. -The Housekeeper turned off the resident's call light and said someone would be in to help him/her. -At 9:05 A.M. Dietary staff came in to get his/her breakfast tray. -The resident told the Dietary staff that he/she needed to get up as he/she had a hair appointment at 9:10 A.M. -The resident put on his/her call light. -At 9:12 A.M. a third staff member came into his/her room asked what he/she needed and turned off his/her call light saying someone will be in to help him/her. -The resident put on his/her call light. -At 9:18 A.M. a staff member looked into the resident's room then continued to walk down the hall. -At 9:21 A.M. a CNA came into the room to see what the resident needed. -The CNA told the resident that he/she needed an extra staff person to get him/her up and changed and would be right back. -At 9:33 A.M. the CNA and another CNA came into the room to change the resident and get him/her up into the wheelchair. -At 9:45 A.M. the resident left his/her room dressed for the day in his/her wheelchair. During an interview at 9:25 A.M. on 3/31/25 the resident said: -He/She was very angry as it was taking the staff so long to get him/her up and dressed. -He/She had probably already missed his/her appointment to get his/her hair done as the appointment had been at 9:10 A.M. and he/she had started putting his/her call light on at 8:30 A.M. this morning. During an interview on 3/31/25 at 9:27 the resident's family member said: -It sometimes takes the staff an hour to answer the call light. -Staff will look into the room, ask what the resident wants, then turn off the call light and leave. -He/She has talked to the Charge Nurse about the staff not answering the call light timely and he/she was told they did not have enough staff. During an interview on 4/4/25 at 1:30 P.M. the DON said: -Call lights should have been answered in less than 10 minutes. -Staff should not have turned off the call light unless they were taking care of the resident's needs.

Based on interview and record review, the facility failed to notify the resident timely that received Medicaid (program that helps with medical costs for some people with limited income and resources) benefits when the amount in the resident's account reached $200 less 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) of $5,909.25 for one person and that, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reached the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI for one supplemental resident (Resident #36). The facility census was 64 residents. Review of the facility policy Resident Trust Fund Management dated as revised [DATE] showed: -When a resident's account balance exceeds $4,800.00 (Note: This amount is currently when the balance is $5,909.25 and notification should be provided when they reach $200 from the limit.) in the Resident Fund Accounts, the Bookkeeper will advise the resident or fiduciary, in writing, that the resident may lose eligibility for Medicaid. -This balance should include any credit balance held in Accounts Receivable. -Maintain a copy of the notification letter in the resident's business office folder. 1. Review of Resident #36's quarterly statement for [DATE]-[DATE] showed: -The opening balance was $4,079.65. -On [DATE], the resident's balance was $7,634.83, which was more than $200 below the SSI limit of $5,909.25. -On [DATE], the resident's balance was $7,594.83. -On [DATE], the resident's balance was $7,602.11. -On [DATE], the resident's balance was $11,080.11. -On [DATE], the resident's balance was $11,238.11. -On [DATE], the resident's balance was $10,516.15. -On [DATE], the resident's balance was $10,486.14. Review of the resident's resident trust fund statement of account proof of receipt form dated [DATE] showed: -The attached quarterly statement was for [DATE]-[DATE]. -The resident signed the form on [DATE]. -Handwritten on the bottom showed a note that said, We discussed the balance of his/her account and the resource limit for Medicaid. Suggested he/she make a list of items to purchase with the Social Services Director. Review of the facility's list of expired residents who had a resident trust fund showed the resident passed away on [DATE]. Review of the facility's resident trust fund account balance dated [DATE] showed the resident: -Was on Medicaid. -Expired on [DATE]. -Had a balance of $14,882.56 During an interview on [DATE] at 8:00 A.M., the Business Office Manager said: -He/She gave the resident notice of SSI limit and talked to him/her on [DATE]. -The resident had been on Medicare A (insurance that covers inpatient hospital care, skilled nursing facility, hospice, lab tests, surgery, home health care for individuals [AGE] years of age or disabled) and balance went up when he/she ran the quarterly statement. -The resident was over the resource limit and then it went really high due to Medicare A.

Based on observation, interview, and record review, the facility staff failed to ensure therapy equipment was used in a safe manner, resulting in one sampled resident (Resident #2), who has [DIAGNOSES REDACTED]. resident plan of care to provide supervision to prevent avoidable accidents for one other sampled resident (Resident #10), who had a history of [REDACTED]. staff, and staff failed to develop an individualized interdisciplinary care plan with interventions to instruct staff on how to keep the resident safe from further injury, out of a total resident sample of 13 residents. The facility census was 61 residents. Record review of the facility's Accident and Incidents - Investigating and Reporting policy revised March 2004, showed: -Regardless of how minor an accident or incident may be, including injuries of an unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned; -An Accident or Incident Report Form must be completed for all reported accidents or incidents; -An employee witnessing an accident or incident involving a resident, employee, visitor, etc., must report such occurrence to his/her immediate supervisor as soon as practical; -The nurse supervisor/charge nurse must be immediately informed of accidents or incidents so that medical attention can be provided; -The nurse supervisor/charge nurse and/or department director or supervisor must conduct an immediate investigation of the accident or incident. -A completed form must be submitted to the Director of Nursing (DON) no later than 12 hours after the occurrence of the accident or incident. Record review of the rehabilitation company's Policies and Procedures for Therapy Modalities (a variety of treatment tools used by therapists to decrease pain, inflammation, and treat muscle strain) dated February 2008, showed a variety of modalities were available for clinical use, such as heat, cold, whirlpool, etc. All modalities were administered only after careful consideration of the indications/contraindications for use and a physician's orders [REDACTED]. -Modalities were to be used only after the patient had undergone an evaluation of the condition for which the modality was indicated; -A physician's orders [REDACTED]. -The patient was informed of the benefits and risks of the procedure. The patients consent was needed to administer the treatment; -The patient would be closely monitored and advised of the expected results and possible side effects; and -The therapist would follow accepted clinical procedures for modality application. Record review of therapy department's undated Risk Management Policy and Procedures showed: -Due caution was to be observed in the administration of physical modalities, and for heat and cold staff should: --Test the patient's sensation prior to administering modalities; --Use adequate protective toweling between the resident and hot packs to avoid burns; --Test the temperature of the hot pack machines as recommended; --Use appropriate precautions in consideration of the patient's age, skin condition, changes in mentation (mental/thought processes), physical and medical condition; and --Instruct patients to report uncomfortable, untoward (adverse) or unusual reactions to therapy; -Therapists (technicians) were responsible for ensuring equipment used in patient care was functioning properly, and the Therapists should work with the facility to establish a monitoring system and maintain records of maintenance in the department; -Equipment should be used according to manufacturer's recommendations and operated by those authorized to do so; -Incident reporting was to occur according to the facility's policy when reporting untoward incidents. The Therapist was required to notify his/her immediate supervisor of incidents within 24 hours of occurrence; -Factual documentation of incidents should be entered into the patient treatment record by the person directly involved. Record review of the undated manufacturer's Precautionary Instructions for the Hydrocollator included, but was not limited to, the following: -Caution: The thermostat is extremely sensitive and the slightest adjustment will alter the temperature several degrees. The recommended operating temperature is 160 degrees Fahrenheit (F) to 166 degrees F. The temperature of the water should be checked with a thermometer after every adjustment, before using the HotPacs (hot packs). Always allow sufficient time for the water temperature to stabilize. Record review of therapy's undated Hydrocollator Packs - Moist Heat Policy and Procedure showed moist heat may be used, as indicated, for treatment of [REDACTED]. The procedure included the following: -Obtain a physician's orders [REDACTED]. Towels or a commercial cover and a timer were needed for treatment; -Inspect the resident's area to be treated. Note the skin integrity, color, turgor (the skin's ability to change shape and return to normal (elasticity), and temperature; -Prepare packs with six to eight layers of toweling or a commercial cover. Additional padding may be necessary if the unit is very hot. If so, place an extra towel between the patient and the pack. If the patient's body exerts pressure on the pack, add additional layers of padding; -Place the pack on the area to be treated with a sheet over it to retain the heat; -Remain with the patient throughout the first session, checking the skin frequently and increasing or decreasing toweling as necessary; -After a normal response during the first session, check the skin occasionally or instruct the patient to check themselves if the procedure is to be done independently; -Remove the packs after 20-30 minutes and dry the area thoroughly; -Inspect the area treated. Hyperemia (increased blood flow to an area) is to be expected; -Elderly patients may require more toweling because of fragile skin; -Maintenance of the Hydrocollator tank included setting the thermostat to maintain the water at a constant temperature of 150-170 degrees Fahrenheit (F). There should be a thermometer available to test the water temperature. 1. Record review of Resident #2's physician's orders [REDACTED]. -The resident had [DIAGNOSES REDACTED]. -An order dated 11/2/12, for Physical Therapy (PT) to evaluate/treat the resident for therapeutic exercise and activity, neuro re-education, and pain modalities as needed (PRN) five times a week for four weeks; -An order dated 11/6/12, to add manual therapy PRN to the Physical Therapy Plan of Care (POC). Record review of the resident's quarterly Minimum Data Set (MDS)(a federally mandated assessment tool required to be completed by facility staff) dated 11/12/12, showed the resident: -Was mentally intact, understood others and was able to make himself/herself understood; -Required total assistance of one staff member for locomotion on and off the unit (the resident did not walk), toileting and bathing; -Required extensive assistance of two staff members for bed mobility; -Required total assistance of two staff members for transfers; -Had functional limitation in the range of motion (ROM - the range on which a joint can move) of the resident's upper and lower extremities on one side of his/her body; -Had [DIAGNOSES REDACTED]. -Had no pain; -had a history of [REDACTED]. -Had been receiving Physical, Speech and Occupational Therapies. Record review of the facility's Certified Nursing Assistant (CNA) Shower Assessment (skin) sheet dated 11/24/12, showed no documentation by the CNA which identified any skin issues at the time of the resident's bath/shower. The Charge Nurse's documented there was an area present on the fifth toe of the resident's left foot (related to the resident's diabetes) and treatment to the area had followed the resident's bath. Record review of the facility's Certified Nursing Assistant (CNA) Shower Assessment (skin) sheet dated 11/28/12, showed the resident had no skin issues. Record review of the facility's CNA Shower Assessment (skin) sheet dated 12/1/12, showed staff had noted a "blister" above the resident's left knee. The Charge Nurse assessment confirmed the resident had a blister. The resident was referred to the Wound Nurse and he/she was to be seen by the Wound Care Team that day. Record review of the facility's Report of Incident/Accident for Resident #2 showed: -The report was initiated on 12/1/12 at 10:30 A.M. by Licensed Practical Nurse (LPN) A; -The resident was noted to have a bruise with a quarter-sized eschar (a dry scab) area above his/her left knee. Documentation showed there were no signs of infection present, and the resident said, "Therapy placed a hot pack there and left it there too long. They've been treating it there (in Therapy)." First aid was provided; -The resident's physician was notified at 1:00 P.M.; -The event was identified as procedure-related and recommendations were to monitor the temperature and length of treatment for [REDACTED]. Record review of the facility's Root Cause Analysis of the Incident/Accident for the resident dated 12/4/12, showed: -On 12/1/12 staff had noted an area to the resident's left thigh while providing the resident care; -A possible cause of the injury, per the resident, was that therapy had left a heating pad on his/her leg too long; -The potential outcome for the resident was he/she could acquire infection related to his/her neuropathy. The resident could also have difficulty healing related to his/her poor appetite; -The recommended solutions included: --Updating the resident's wound care plan, and to continue to monitor the area along with the Wound Care Team; --Therapy would be responsible to start monitoring the temperature of the heating pads; --Administration would monitor flow sheets on a weekly basis. Record review of the Therapy Department's Hydrocollator Temperature Log dated 12/4, 6, and 7/12, showed the water temperature was 165 degrees F. During an interview on 2/27/13 at 2:17 P.M., the facility Administrator said: -He/she was informed by the Director of Nursing (DON) there had been a resident situation involving a contracted employee; -A resident had received a burn after having a warm moist pack treatment in Therapy; -The contracted staff had not reported the incident to the facility staff, did not document the hot pack treatment or the subsequent burn, and it was reported this employee had taken it upon himself/herself to put lotion on the wound and bandage it without contacting the resident's physician for orders; -Once informed of the situation, the nursing staff evaluated the resident and contacted his/her physician. Orders were received and the resident was seen by the Wound Care Team; -During the investigation, the contracted employee was placed on suspension and multiple staff members were interviewed. Following the completion of the investigation, the contracted employee's employment with the rehabilitation company was terminated. During an interview on 2/28/13 at 4:00 P.M., Physician A said: -He/she would include an order for [REDACTED]. -When Modalities were ordered, he/she expected the Therapy staff was qualified and knowledgeable in providing the therapy used; -He/she wouldn't necessarily withhold Modalities from a resident with diabetes or neuropathy. He/she would expect the resident to be assessed and treatments applied according to the resident's condition/needs; -If an injury or anything unusual occurred during therapy, he/she expected the Therapy staff to report such incidents to the Charge Nurse. The Charge Nurse in turn would complete an incident report about the event and follow the facility protocol for such events. If the Charge Nurse wasn't notified, Physician A didn't know how the nursing staff was to follow the protocol; -He/she would not expect Therapy staff to initiate wound care treatments. They should report the situation to the Charge Nurse and the nurse would contact the physician for treatment orders, if necessary; -He/she had been informed of the wound on Resident #2's left thigh, and believed he/she had ordered Silvadene (a topical, antibacterial cream) to be applied to the area and directed the resident be seen by the Wound Care Team; -Events such as this would be discussed/addressed individually during informal meetings in an effort to identify the root cause of the event and to help prevent recurrence in order to maintain resident safety; -Once the facility staff was made aware of the resident's injury, they took the necessary steps to investigate the event. During an interview on 2/28/13 at 4:15 P.M., Resident #2 said: -He/she received "a heat pack" to his/her leg, but couldn't recall why; -His/her leg was usually half numb and he/she didn't know that his/her leg was getting hot until it got "real hot;" -The Therapy staff saw it was burned and put cream on it, and they put a patch on it; -He/she was going to Therapy on a daily basis and the Therapy staff was checking on it and putting cream on it; -Therapy Staff Member A did it and got in trouble over it; -The first day when Therapy Staff Member A saw it happened, he/she put a dressing on it; -He/she thought it might have been a couple of weeks that ointment was applied to the area; -He/she had the hot moist pack the first time in the afternoon and it wasn't until the next day that the site started to burn. After a few days the site blistered and there was pus (drainage at the site of inflammation during infection); -The nursing staff started treating the wound and then the Wound Care Team saw him about it. Resident #2 said a scalpel was used to scrape the top of the wound off and this was done about four or five times; -Treatment to the area lasted maybe a couple of months; -A hot pack was never reapplied to his/her leg once it had been injured. During an interview on 3/1/13 at 12:30 P.M., Certified Nurse Aide (CNA) B said: -He/she was getting Resident #2 out of bed so he/she could shower on 11/28/12 and he/she noted a dressing above the resident's left knee; -The resident reported Therapy knew about the wound a day or two before the blister occurred; -He/she had done the resident's shower and he/she usually marked the body diagram on the bath sheet form, but there had been a ton of work to do that day and CNA B said he/she must have forgot to mark the sheet; -He/she believed the nursing staff already knew about the wound because nursing was the only ones he/she knew who used the type of dressing he/she found on the resident's leg that day; -He/she didn't ask the Charge Nurse if the dressing needed to be removed prior to giving the resident his/her shower. CNA B just covered the site/dressing with a garbage bag to protect the area and keep it dry and gave the resident his/her bath; -He/she thought he/she had told the Charge Nurse about the wound, but maybe not. During an interview on 3/1/13 at 1:25 P.M., Therapy Staff Member A said: -He/she had worked with Resident #2 because he/she had pain in his/her leg; -He/she obtained a hot pack and put it on the resident's left leg to help the resident's pain as he/she massaged the resident's leg; -The hot pack was on the resident's leg for about 20 minutes total, and the skin above the resident's left knee was a little red after the pack was removed, but he/she didn't think anything about it. A couple of days later he/she noticed a small fluid-filled blister at the site; -He/she went to tell the nursing staff, but was unable to find anyone, and he/she got busy and forgot about reporting it; -He/she felt awful about not reporting the situation and couldn't believe he/she didn't document the event either because it wasn't something that he/she usually did. He/she believed this unusual behavior was due to him/her being sick for a few days; -He/she had not observed the area daily and normally the resident had his/her pants on so it wouldn't always have been visible. He/she thought someone else would have reported the issue; -When he/she saw the blister, it was pea-size. He/she denied putting any "white cream" to the blister. Therapy Staff Member A said he/she had used a lotion (Keri-lotion) and applied it past the resident's knee and around the blister, but said he/she never applied the lotion directly on the blister; -A physician's orders [REDACTED]." This allowed the therapy staff to try different things to meet the resident's needs; -He/she knew he/she had done wrong by not documenting and reporting the blister, and he/she felt absolutely terrible about it; -Staff was supposed to document what was done and he/she didn't know why he/she hadn't documented the treatment or the outcome. Staff was supposed to report such things to nursing and the nursing staff would notify the physician and it would go from there; -Therapy staff can provide treatment to wounds but only with a physician's orders [REDACTED]. He/she did not remember completing a skills check list related to the use of the Hydrocollator or hot moist packs when he/she began employment with the therapy company. He/she assumed the licensed Physical Therapist would see how he/she used the equipment whenever that person was present during resident treatments in the therapy room; -Staff was taught to always check the integrity of the skin; -He/she had used hot moist pack in the past and he/she had been with the resident the entire time he/she had the hot pack on his/her leg; -To his/her knowledge the hot moist packs were only used on the resident one time; -The usual process when applying hot moist packs was to remove the pack from the machine and wrap them in a minimum of two covers. He/she would then apply the wrapped hot moist packs to the body affected body part. He/she would then consult with the resident to determine his/her tolerance to the therapy. After five minutes, he/she would check with the resident to see if the site was getting too hot and he/she would check the temperature of the resident's skin. If the resident had complaints at the site, then the hot moist pack would be removed, the skin assessed, another protective cover would be added and the hot moist pack would be reapplied as long as everything was okay; -There was redness at Resident #2's left leg when he/she had checked the site and the resident complained that it was warm, but the resident did not complain the site was burning; -The last thing he/she knew was Therapy Staff Member D had provided therapy for Resident #2 over the weekend and that's when he/she noticed the blister. Therapy Staff Member A said he/she wasn't aware of when the wound became more than just a blister, i.e., an opened wound with bruising around the area, etc. During an interview on 3/1/13 at 12:50 P.M., Therapy Staff Member B said: -The resident began receiving therapy per his/her request, and the therapy was being conducted in the therapy room; -Resident # 2 needed a lot of assistance, i.e., he/she required the maximum assistance of two staff members to get up out of his/her bed; -PT worked with the resident's lower extremities and Occupational Therapy worked with the resident's upper body; -On 11/28/12, he/she remembered seeing Therapy Staff Member A use a hot moist pack on Resident #2's left leg because the resident had complained of pain there; -Therapy Staff Member A informed the resident about the benefits of hot moist packs and received his/her permission prior to applying the hot pack to the resident's left leg; -Therapy Staff Member A placed a hot pack in two commercial covers and placed the hot pack onto the resident's left leg, above his/her knee; -When the resident complained that it was too hot, Therapy Staff Member A removed the hot moist pack and checked the resident's skin temperature; -Therapy Staff Member A explained to the resident why the hot moist pack was needed and as the resident had no further complaints, the hot moist pack was reapplied to the resident's left leg after another commercial cover was added to the hot pack. Therapy Staff Member B said the resident had no further complaints once the additional padding was added; -He/she knew of no burn or trauma to the resident's leg after the hot pack treatment was completed that day; -When the resident was gotten up the next day, he/she believed there was a small, flat burn at the hot moist pack site, and described the burn as what one might see if you burned yourself on the oven; -Therapy Staff Member A told Therapy Staff Member B he/she had been monitoring the burn to the resident's left leg because "it didn't appear as if nursing was doing anything about it;" -Therapy Staff Member A was noted to apply a white cream to the burn area and when asked why he/she was doing that, Therapy Staff Member B said, "it couldn't hurt;" -That Friday the burn was looking good, but on Monday there was a bruised area around the burn, and the top of the blister was gone and a scab was starting to form; -He/she knew of no other time the resident received any hot moist packs, and said that since this episode, staff had been instructed to obtain a specific order from the resident's physician related to the use of hot moist packs; -Therapy staff was expected to chart what they did for residents in the residents' therapy records and such documentation should include the treatment applied, the location of the treatment and the length of time (minutes) the treatment was applied; -If any resident received an injury as a result of a treatment, the therapy staff was to document it in the resident's medical record and report it to the Charge Nurse. Therapy Staff Member B said staff was also to document that they reported the event to the Charge Nurse in their notes as well; -The use of modalities was usually covered by a PRN order from the resident's physician, and it was left up to the therapy staff to determine which modality was to be used to meet the resident's needs; -If a modality was deemed inappropriate for a resident, that information was to be noted in the resident's plan of care; -He/she did not observe Therapy Staff Member A apply any dressing to the resident's burn. During an interview on 3/1/13 at 2:10 P.M., LPN A said: -When he/she observed this wound on 12/1/12, the wound was superficial, nickel-sized, open, and there was redness around the area; -The top layer of the wound was gone and the site was bloody; -He/she contacted the physician and received treatment orders to the wound. The wound nurse was notified and the resident was seen by the Wound Care Team on their next visit; -He/she knew of no formal communication process between the Therapy Department and the Nursing Department, and said nursing was not informed if/when hot moist packs were being used. If any issues arose during therapy, the therapy staff usually communicated verbally with nursing about them; -Staff knew to monitor and document on such an issue because it would have been documented on the 24-hour report sheet, a communication form used by nursing, and discussed during the change of shift report; -The resident would be placed on 72 hour charting as a means of monitoring the site. The CNA's would also be monitoring the resident's skin, i.e., twice weekly at bath time and they were also expected to monitor the resident for changes in condition while doing routine cares, such as when toileting the resident, changing clothes, getting up for the day or when aiding the residents to go to bed; -He/she didn't know why the nursing staff hadn't reported this wound to the charge staff any sooner than it was. He/she knew this resident usually had a lot of bruising and/or marks so it may have just got overlooked. During an interview on 3/8/13 at 3:40 P.M., Therapy Staff Member D said: -He/she was the staff to complete Resident #2's initial evaluation; -A few weeks later, he/she provided the resident his/her treatment (on a weekend), and a scab was noted to the resident's left lower thigh (above the resident's left knee); -The Charge Nurse was called to assess the wound and the resident said he/she acquired the wound from a hot pact treatment during Therapy; -He/she talked with Therapy Staff Member A about it, and told him/her that nursing was now taking care of the wound, and instructed Therapy Staff Member A to talk to the nursing staff about it the following Monday; -He/she said Therapy Staff Member A was an excellent practitioner and he/she didn't understand why this event wasn't reported to the nursing staff or documented in the resident's medical record. Therapy Staff Member D said he/she told Therapy Staff Member A the lines of communication between departments needed to be open and there was a discussion on what staff could do to improve on it; -He/she believed the Therapy Department Staff had received education regarding managing such events after the event became known; -Only Therapy Department Staff had access to the hot moist packs, and he/she said Therapy Staff Member A wasn't certain the wound came from the hot moist pack, but after evaluating the events, one had to assume it had been as the resident claimed; -The resident's wound was about the size of a walnut. It was covered with a dry scab and when he/she saw the wound, it was uncovered; -Therapy Staff Member A reported a topical ointment was being applied by him/her; -Hot moist packs are appropriate to use at times because muscles can get sore because of the treatment provided, and the hot moist packs help with the pain, and help to loosen the muscles being worked; -Therapy Staff didn't always document in the resident's charts daily, but they should document if/when untoward events occur; -Typically, nursing is responsible for handling wound care and Therapy Staff Member A's response to the event was not a normal one; -When hot moist packs were used on the elderly, on those with circulatory or sensory problems, the resident needed to be watched more closely. 2. Record review of the facility Falls policy dated 2003, showed directions for assessing the resident that included to: -Ask the resident what happened; -Determine if there were any witnesses; -Perform a head-to-toe assessment noting any signs of injury; -Determine the source of any pain or discomfort on examination. -Obtain vital signs, and if a head trauma was been sustained, begin neurological (neuro) checks (assessment of level of consciousness, pupil response, motor functions-hand grasps/extremities, pain response, and vital signs); -Examine the immediate environment for contributing factors; -Notify the attending physician and report any visible limitations, head trauma, or other changes in the resident condition; -Notify the resident's responsible party; -Implement physician orders; -Arrange diagnostic x-ray, if ordered; -Monitor for progress or deterioration in the resident's condition; -Document the transfer activities and time if the resident was transferred to the emergency room or hospital; -Implement additional safety precautions; -Document the facts on an incident report; -Update the resident's plan of care; and -Reassess the resident each shift for 72 hours and document findings. Record review of Resident #10's MDS dated [DATE], showed the resident: -Was able to express wants and needs. -Was able to understand others and able to express their wants and needs. -Had visual impairment and was able to see large print, but not regular print. -Was moderately cognitively impaired. -Had minimal depression. -Required limited assistance of one staff with dressing, toileting, transfers and bathing. -Required supervision with set up help for eating and personal hygiene. -Was steady at all times with balance during transition and walking. -Did not use mobility devices. -Had occasional incontinence of bowel and bladder. -Did not have pain indicators. -Was unable to determine past fall history. -Had not had any falls since admission or prior to the assessment. -Received seven days of antipsychotic medications (a drug for psychosis) since admission. -Received seven days of antianxiety medication (a drug for anxiety) since admission. -Received seven days of antidepressant medication (a drug for depression) since admission. -Received seven days of anticoagulant medication (a drug that prevents the clotting of blood) since admission. -Received seven days of diuretic medication (a drug that elevates the rate of urination) since admission. -Received speech, occupational and physical therapy. Review of the undated resident's plan of care showed: -The resident was identified as a moderate fall risk, and able to ambulate independently. -The staff was to assist the resident if he/she was unsteady on his/her feet. -The staff was to ensure that the resident was wearing proper shoes or non-skid slippers. -The staff was to keep the call light within reach and answer promptly. -Staff was to notify the nurse of any fall or injury before assisting the resident off of the floor. -The resident was to sit on the side of the bed a few minutes before getting up to the toilet. -Physical therapy/occupational therapy were to evaluate and treat as ordered. Record review of the resident's daily skilled nurse's notes dated 1/27/13, for the day and night shifts showed: -The resident was independent in bed mobility. -The resident was independent with transfer. -The resident was independent with locomotion. -The resident had unsteady gait. -The resident had a problem with balance. -The resident had weakness. -The MDS dated [DATE] stated the resident required limited assistance of one staff with dressing, toileting, transfers and bathing. Record review of the resident's incident/accident report dated 1/27/13, showed: -The resident fell on [DATE] at 1:50 P.M. -The resident was found sitting on the floor. -The mat was by the sink. -The resident was oozing blood from the back of the head. -The type of injury was a laceration. -The equipment involved was the floor mat. Review of the root cause analysis document dated 1/29/13, showed the recommended solutions: -(Name of the Physician) would do a medication review upon the next visit. -Resident education. Sit on side of bed for a few minutes before getting up. These were added as new interventions to the resident's care plan after the 01/27/13 fall. Review of the falls investigation worksheet dated 01/29/13, showed the resident was receiving antidepressants, antipsychotics, antihypertensives, antianxiety and laxatives medications. Further review showed the resident had received a new medication of Remeron, (an antidepressant) within the last 72 hours of the fall. Review of the medical considerations section showed the resident had anemia, depression, and bipolar. Review of the fall risk assessment and interventions dated 1/29/13, showed staff assessed the re

Based on observation, interview, and record review, the facility staff failed to provide adequate protective oversight and supervision and nursing care in accordance with the resident's condition for one sampled resident (Resident #3) who is diagnosed with [REDACTED]. resulting in an acute-on-chronic subdural hematoma (additional bleeding at the site of the previous subdural hematoma) after being left unsupervised by the facility staff. The facility staff failed to comprehensively assess and develop an individualized interdisciplinary care plan with interventions to instruct staff on how to keep the resident safe from further injury from falls. The facility staff further failed to determine interventions to prevent falls and failed to ensure interventions were utilized for one sampled resident (Resident #13) after the resident fell out of bed and suffered a left hip fracture; failed to report, investigate and put interventions in place after one sampled resident (Resident #4) slid off the side of his/her bed; and the facility staff failed to ensure fall interventions were utilized and functioning to assist in preventing falls for one sampled resident (Resident #2) who had frequent falls. The total sampled for the facility was 13 residents. The facility census was 78. Record review of the facility Falls policy dated 2003 showed directions include: -Assess: --Ask the resident what happened. --Determine if there were any witnesses. --Perform a head-to-toe assessment noting any signs of injury. --Determine the source of any pain or discomfort on examination. --Obtain vital signs, and if a head trauma has been sustained, begin neurological (neuro) checks (assessment of level of consciousness, pupil response, motor functions-hand grasps/extremities, pain response, and vital signs) --Examine the immediate environment for contributing factors, -Notify the attending physician and report any visible limitations, head trauma, or other changes in the resident condition. -Notify the resident's responsible party -- Implement physician orders. --Arrange diagnostic x-ray, if ordered. --Monitor for progress or deterioration in the resident's condition. --If the resident is transferred to the emergency room or hospital, document transfer activities and time. --Implement additional safety precautions. -Document facts on an incident report. --Update the resident's plan of care. --Reassess the resident each shift for 72 hours and document findings. 1. Record review of the resident's quarterly Minimum Data Set (a federally mandated assessment tool required to be completed by the facility staff for care planning), dated 4/13/12, showed the resident ('s): -Was severely cognitively impaired and delusional. -Had physical behavioral symptoms 1-3 times per week. -Had unclear speech and was rarely understood. -Required the limited staff assistance of one staff member with transfers, ambulation, dressing, and eating. -Required the extensive assistance of one staff member with bathing. -Had one non-injury fall in the last quarter. -Was incontinent of bowel and bladder. -Did not have pain indicators. Record review of the resident's Nurse's Notes dated 4/29/12 showed: -The resident was wandering on the unit. -The resident yelled out. -The resident was observed lying on the floor in another resident's room on his/her left side. -The resident denied pain and denied hitting his/her head. -The resident said he/she just got really tired. -The resident was assessed with [REDACTED]. -The resident's family member and physician were notified. Record review of the resident's fall risk assessment dated [DATE] showed staff assessed the resident's risk of falling as 18 (any score of seven or more considered higher risk for falls). : Record review of the resident's Monthly Summary dated 5/1/12 showed staff assessed the resident as: -Moving and/or speaking so slowly so other people notice or being so fidgety or restless. -Had independent bed mobility. -Required the limited assistance of staff for transfers, dressing, eating, and toilet use. --Had no significant changes and continued to wander, was resistant to cares at times, and was incontinent of bowel and bladder. Record review of the resident's physician's orders [REDACTED]. -The resident's [DIAGNOSES REDACTED]. --Osteoarthritis (also called degenerative joint disease-DJD; a breakdown of cartilage between the bones which can cause stiffness, pain, and reduced motion of the joints) of the right shoulder. --Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). --Dementia --Depakote sprinkles 125 mg: take one capsule by mouth at bedtime for mood stabilization. --Lexapro 20 mg: one tablet by mouth daily for depression. --Aricept 10 mg: one tablet by mouth daily at bedtime. --Ativan 0.25 mg: one tablet every six hours as needed for agitation. -Was a full code status. Record review of the resident's History and Physical report dated 5/24/12 showed: -Had no remarkable changes except for a right clavicle (collarbone) fracture after a fall. Record review of the resident's Nurse's Notes dated 5/26/12 at 10:15 A.M., showed: -The resident was lying in his/her roommate's bed. -The resident rolled to the edge of the bed then rolled off the bed to the floor before the nurse could get to the resident. -The resident did not hit his/her head. -The resident was assessed with [REDACTED]. -The resident's family member, the Director of Nursing (DON), and physician were notified. Record review of the resident's Nurse's Notes dated 6/30/12 at 5:30 P.M., showed: -At 5:10 P.M., the Certified Nursing Assistant (CNA) heard a noise as he/she walked out of another resident's room and found Resident #3 lying on his/her left side. -The resident was assessed to have a larger than golf ball size hematoma to the left forehead. -The resident was alert but would not follow simple commands. -The resident had a skin tear to his/her left elbow with facial grimacing with every movement. -911 was called and the resident was sent to the hospital. -The DON and physician were notified. Record review of the resident's Nurse's Notes dated 6/30/12 at 8:45 P.M., showed: -The resident returned from the hospital with his/her family members. -The resident had a quarter size abrasion in hairline and a bruised, knot on forehead. -The resident also had a left elbow dressing where he/she had a scratched area. Record review of the resident's Report of Incident/Accident form dated 6/30/12 completed by (Licensed Practical Nurse) LPN A showed: -At 5:10 P.M., the resident was found in the hallway laying on his/her left side. -An assessment of the resident revealed a larger than golf ball size hematoma to the left forehead and a skin tear to the left elbow. -The resident's eyes were open and he/she would not follow commands. -The resident had facial grimacing. -The fall was unobserved by the staff members. -The resident's family and physician were notified. -The resident had been sent to the hospital. Record review of the resident's Investigation of Incident Report dated 6/30/12 completed by the (Assistant Director of Nursing) ADON showed: -The resident had been found in the hallway. -The root cause of the fall was dementia and impaired equilibrium. -The resident was impulsive. -The resident needed to be kept in view of the staff. -The intervention (to prevent falls) was for staff to try to keep the resident in the a television room. Record review of the resident's Emergency Physician record completed by the hospital physician dated 6/30/12 showed the resident: -Had been found in the hallway at the facility. -Had a contusion to the scalp and a left elbow skin tear. -Had frequent falls. -Was disoriented to person, place, and time. -Had physician's orders [REDACTED]. Record review of the resident's untitled hospital CT scan report dated 6/30/12 showed the resident: -Had no head injury. Record review of the resident's hospital After Care Instructions dated 6/30/12 showed: -The resident had been seen for a head injury. -The resident should stay with someone for the next 24 hours to watch his/her behavior. Record review of the resident's Nurse's Notes dated 7/6/12 at 5:00 P.M., showed: -The resident had an unwitnessed fall in the dining room. -The CNA sat the resident down for dinner and turned to get a clothing protector. -The resident had gotten up, lost his/her balance, and fell to the floor. -The resident was assessed with [REDACTED]. -The family, supervisor and physician were notified. -The staff would continue to monitor the resident very closely. -The CNA was asked to monitor the resident very closely also. Record review of the resident's Monthly Summary dated 7/13/12 showed staff assessed: -Had disorganized thinking, short-term and long term memory problems, and had severely impaired cognition. -Had physical and verbal behavioral problems directed at others. -Rejected cares. -Required either the total assistance of staff or the limited assistance of staff with transfers. -Was totally dependent on staff for toilet use and bathing. -The resident's balance was unsteady. The staff would continue to monitor and assist the resident as needed. There were new orders for neurological checks on this shift and treatment orders had been implemented. --Note: The incident report and neurological checks were requested for the 7/6/12 fall but not received by the end of the survey. Record review of the resident's significant change MDS dated [DATE] showed the resident ('s): -Was severely cognitively impaired, delusional, and had hallucinations. -Had physical behavioral symptoms 1-3 times per week. -Had unclear speech and sometimes understood speech. -Required the limited staff assistance of one staff member with transfers, ambulation, dressing, and eating. -Required the extensive assistance of one staff member with bathing. -Had one non-injury fall and one injury fall in the last quarter. -Was incontinent of bowel and bladder. -Did not have pain indicators. Record review of the resident's Interdisciplinary Care Plan dated 7/18/12 showed staff planned the following interventions to address the resident's identified risk of falls: -Assess the resident's balance and monitor his/her gait and document the information. -Keep the resident's bed in the lowest position and the wheels locked. -Keep the call light within reach. -Ensure the resident was wearing non-slip footwear. -Complete a fall risk assessment quarterly. -In the event of a fall, assess for injury, give first aid as needed, and notify the family and physician. -Keep items within reach that the resident used frequently. -Keep room and hallway free of clutter and wipe up spills when they happen. -Provide assistance to the resident with all ADL cares. Assist the resident with ambulating. -Updated on 7/21/12: -The resident was sent to the emergency room for evaluation and treatment related to a fall. The resident was admitted to the ICU (Intensive Care Unit) unit at the hospital. Move the filing cabinet and rearrange the (television) room. -Updated on 7/30/12: -Updated on 8/2/12: --The resident was to wear a soft helmet to his/her head for safety. -Updated on 8/8/12: --The resident fell in the dining room and re-opened the stitched area (on his/her head). -Updated on 8/9/12: --Put a floor mat beside the resident's bed while in bed. --The resident was sent to the emergency room for evaluation and treatment. Record review of the resident's Nurse's Notes dated 7/21/12 at 9:00 A.M., showed: -The nurse's note was written by Licensed Practical Nurse (LPN) A. -The nurse was at the medication cart at 7:30 A.M. -He/she heard a thump in the television room. -He/she and CNA ran into the television room and found the resident on the floor. -The CNA ran to get the ADON and charge nurse to come to the secure care unit because the resident had fallen. -LPN B brought a wound care cart. -The ADON came to assist with assessing the resident. -The resident's family member, the DON, and the physician were notified. -The resident was bleeding from a gash on the right side of his/her head. -Pressure was held to the wound until the ambulance attendant arrived. -The resident would not respond to verbal stimuli. -The resident's pupils were small and non-responsive. -The resident apparently fell and hit the side of the filing cabinet. -He/she started responding to his/her name. -He/she did not cry out in pain. -He/she lay quietly on the floor until the ambulance attendants arrived. -The resident was transferred to the hospital via ambulance at 7:45 A.M. Record review of the resident's Investigation of Incident Report dated 7/21/12 completed by the ADON showed: -The resident was in the television room and got up to walk. -The resident fell and hit his/her head on the filing cabinet. -The root cause was the resident was impulsive and was unsafe to walk alone. -The resident was sent to the emergency room and was admitted to the hospital. -The interventions (to prevent falls) were the filing cabinet was moved and the resident was sent to the emergency room . Record review of the resident's hospital Emergency Physician Record dated 7/21/12 showed: -The resident was transferred from another hospital to this hospital for a Level II trauma (advanced emergent care for a potentially critically ill person). -The resident was found down by nursing home staff. -The clinical impression of the resident was an intercranial hemorrhage and cerebral contusion. -The resident had a three centimeter (cm) posterior scalp laceration that was closed with staples in the emergency room . -The resident was admitted to the hospital. Record review of the resident's Trauma/Surgical Critical Care Program History and Physical notes dated 7/21/12 showed the resident's: -Had an unwitnessed fall from a standing position. -Had a previous fall three weeks ago. -Head had a laceration that was closed by staples in the emergency room . -Had a bruise on his/her left forehead and a head laceration. -Was admitted to the intensive care unit (ICU). Record review of the resident's untitled hospital consulting physician's notes dated 7/21/12 at 9:42 P.M., showed the resident: -Had a less than five millimeter (mm) subdural hematoma with a small chronic four to five mm subdural fluid collection. -The resident had fallen from a standing position. -The resident had advanced dementia. Record review of the resident's Radiology Report dated 7/21/12 at 3:19 P.M. showed the resident: -Had a CAT scan of his/her head. -Had a subdural hematoma that measured up to 7 mm. Record review of the resident's Radiology Report dated 7/22/12 at 11:34 A.M. showed the resident: -Had a CAT scan of his/her head. -Had a subdural hematoma that measured approximately 7 mm in maximal diameter. Record review of the resident's Radiology Report dated 7/23/12 at 12:22 P.M. showed the resident: -Had a subdural hematoma that was not significantly changed in comparison to the CAT scan on 7/22/12. Record review of the resident's hospital untitled discharge summary dated 7/27/12 showed: -The resident was admitted for a subdural hematoma after a fall. The resident was transferred to this hospital after another hospital discovered the subdural hematoma. Initially, the resident would moan and occasionally verbalize, but did not answer any questions appropriately. The resident had a subdural hematoma that measured up to ten mm in maximal diameter. The resident was unable to take food or fluids by mouth. The resident had a nasogastric tube placed while in the hospital but was now tolerating a regular diet. The resident was discharged to the facility in stable condition. The resident was at his/her baseline cognitively. Record review of the resident's Nurse's Notes dated 7/27/12 at 12:30 P.M., showed: -The resident was readmitted to the facility -He/she was alert with some confusion noted. -He/she could answer yes and no to some commands. -He/she had six to seven staples in the right upper head with some bruising. -The staples needed to be removed in one week. -The left temporal head area, back of neck, and ear had yellow bruising. -He/she needed the assistance of one for ambulation. Record review of the resident's physician's orders [REDACTED]. -The had the following Diagnoses: [REDACTED]. -Left frontal and right parietal soft tissue hematoma. Record review of the resident's Resident Assessment Data Collection Form dated 7/27/12 showed the resident: -Was alert and oriented to himself/herself. -Was not alert and oriented to time and place. -Required the assistance of one staff member for ambulation. -Was weight bearing on his/her feet. Record review of the resident's POS dated August 2012 showed the listed [DIAGNOSES REDACTED]. --Hematoma. --Left frontal and right parietal soft tissue hematoma. -On 8/2/12, a physician's orders [REDACTED]. -On 8/9/12, a physician's orders [REDACTED]. Record review of the resident's Daily Skilled Nurses Note dated 8/1/12 showed say and night shift staff assessed: -The resident was up and going to meals in the dining room with the assistance of one staff member. Record review of the resident's Daily Skilled Nurses Note dated 8/2/12 showed day and night shift staff recorded: --The resident required the supervision of staff while ambulating. --The resident wandered. -Record review of the Physician's Telephone Orders sheet dated 8/2/12 showed the following physician's orders [REDACTED]. Record review of the resident's Daily Skilled Nurses Note dated 8/3/12 showed staff recorded: --The resident required the extensive assistance of staff with transfers, ambulation, and toilet use. --The resident required limited assistance of staff with bed mobility. Record review of the resident's Daily Skilled Nurses Note dated 8/4/12 showed staff recorded: --The resident required the extensive assistance of staff with bed mobility, transfers, and ambulation. --The resident had an unsteady gait, balance problems, and weakness. --Was incontinent of bowel and bladder. --Had a surgical wound and bruising. Record review of the resident's Daily Skilled Nurses Note dated 8/5/12 showed: Documentation by the day and night shift staff: --The resident was alert, had short term and long term memory problems with impaired decision making and disorganized thinking. --Had difficulty speaking. --The resident was totally dependent on staff for eating and toilet use. --The resident required the extensive assistance of staff with bed mobility, transfers, and ambulation. --The resident had an unsteady gait, balance problems, and weakness. --Was incontinent of bowel and bladder. --Had a surgical wound and bruising. -The written comments on the day shift showed: A bed alarm was added to the resident's bed due to trying to get up and out of bed. The resident was combative during incontinence care. A wheelchair alarm was added due to the resident pushing back with his/her feet when the wheelchair was locked. Record review of the resident's Daily Skilled Nurses Note dated 8/6/12 showed staff recorded: --The resident had an unsteady gait, balance problems, and weakness. --Was incontinent of bowel and bladder. --Had a surgical wound and bruising. -The resident needed to be monitored "at all times" when out of bed for fall precautions. -Note: The form had not been completed on the night shift. Record review of the resident's Daily Skilled Nurses Note dated 8/7/12 showed staff recorded: --The resident had an unsteady gait. --Was incontinent of bowel and bladder. -Documented by the night shift: --The resident had difficulty speaking. --The resident required limited assistance of staff with bed mobility, transfers, and toilet use. --The resident required supervision with ambulation and eating. -The written comments on the day shift showed: The resident's staples had been removed from his/her head wound. -The written comments on the night shift showed: The resident was up ad lib around the unit with the assist of one to observe his/her gait. Record review of the resident's Monthly Summary dated 8/7/12 showed the resident ('s): -Had unclear speech which was rarely understood. -Had adequate vision and hearing. -Had disorganized thinking, short-term and long term memory problems, and had severely impaired cognition. -Wandered. -Required the limited assistance of staff for bed mobility, eating, and transfers. -Was totally dependent on staff for dressing, toilet use and bathing. -Was always incontinent of bladder and bowel. --Left frontal and right parietal soft tissue hematoma. Record review of the resident's Daily Skilled Nurses Note dated 8/8/12 showed: -Documentation by the day and night shift staff: --Had a surgical wound. --The resident had an unsteady gait, balance problems, and weakness. --Was incontinent of bowel and bladder. --The resident had difficulty speaking. --The resident required limited assistance of staff with bed mobility, transfers, and toilet use. --The resident required supervision with ambulation and eating. Record review of the resident's Nurse's Notes dated 8/8/12 at 6:15 P.M., showed: -The nurse's note was written by LPN C. -LPN C heard a loud "bang" noise. -The resident was found lying on his/her right side on the floor in the dining room. -He/she had fallen out of a chair. -He/she had reopened the area to the right side of his/her skull where the staples had been removed the previous day. -The reopened area was cleaned and steri-strips were applied. -Neurological checks were initiated and were within normal limits. -Range of motion was performed and was within normal limits. -He/she was guarding his/her right shoulder and had facial grimacing. -Orders were obtained from the physician to x-ray the resident's right shoulder and the skull. -The resident's family member, house supervisor and DON were notified. -The resident was lying in bed with his/her eyes closed with no signs or symptoms of distress. -The staff would continue to monitor the resident. Record review of the resident's x-ray Patient Report dated 8/8/12 at 8:17 P.M., showed: -Four images were completed on the resident's skull. There was a suspicious possible fracture of the right zygomatic (cheek) bone. -Three images of the right shoulder were completed and no fractures were found. -It was recommended to follow up further with a CAT scan. Record review of the resident's Nurse's Notes dated 8/8/12 at 10:45 P.M., showed: -The x-ray service called and stated they were unable to send the x-ray report to the physician due to computer problems and technical support would be in at 8:00 A.M. tomorrow. Record review of the resident's Report of Incident/Accident form dated 8/8/12 completed by LPN D showed: -The resident was found on the floor in the secure care unit dining room in a right side laying position. -The resident was guarding his/her shoulder and had facial grimacing. -X-ray orders were obtained and neurological checks were initiated. -The resident's head laceration reopened. -The head laceration was cleansed and steri-strips were applied. -The fall was not witnessed. -The resident's family and physician had been notified. -Additional steps taken to prevent recurrence were as follows: The resident had an x-ray of the right shoulder and of the skull. -A protective helmet was applied. Record review of the resident's Investigation of Incident Report dated 8/8/12 completed by the ADON showed: -The resident had an unwitnessed fall in the dining room. -The root cause of the fall was the resident was impulsive. If someone moved by him/her then he/she wanted to move. -The interventions (to prevent falls): x-rays were ordered and a further CAT scan was suggested. The resident was sent to the emergency room . -At the bottom of the form showed: --The resident may need one on one supervision. --The resident may need to be in a wheelchair when up. --The resident was extremely impulsive. --A (soft) helmet needed to be ordered. Record review of the resident's Wandering Policy (15 minute check sheets) dated 8/7/12 through 8/9/12 showed: -The resident had 15 minute checks completed from 8:00 A.M. through 11:45 P.M. -The resident had 15 minute checks completed from 12:00 A.M. through 12:30 P.M. --Note: All 15 minute check sheets since 7/21/12 had been requested from the ADON, but had not been received by the end of the survey. Record review of the resident's Nurse's Notes dated 8/9/12 at 12:00 P.M., showed: -The resident's family was called with the x-ray results and a CAT scan or facial x-rays were recommended at this time. -The family member stated he/she would call back if he/she wanted to have further x-rays or CAT scans completed for the resident. Record review of the resident's Nurse's Notes dated 8/9/12 at 1:30 P.M., showed: -The resident's family and physician were called with the test results. -The resident's physician gave an order for [REDACTED]. Record review of the resident's Nurse's Notes dated 8/9/12 at 2:30 P.M., showed: -The resident was transported to the hospital by his/her family member. -The resident was alert and answered yes and no questions. Record review of the resident's hospital Neurosurgeon consult dated 8/9/12 at 11:18 P.M., showed: -The resident had a subdural hematoma. -The plan was to admit the resident to the ICU tonight and talk with his/her family about his/her baseline status to see if anything could be done to improve his/her status. -It was important to establish any advanced directives for the resident. Record review of the resident's hospital History and Physical report dated 8/10/12 at 4:12 P.M., showed: -The resident was transferred from another hospital to this hospital after a class II blunt trauma. -The resident had a fall from a chair on 8/8/12. -The resident's [DIAGNOSES REDACTED]. -He/she had a fall at the nursing home with an acute-on-chronic subdural hematoma. -The resident was transferred and was admitted to the ICU by the trauma surgery service and a consult with Neurosurgery related to the acute-on-chronic subdural hematoma was requested. Record review of the resident's hospital Physician's Notes dated 8/13/12 at 1:47 P.M., showed: -The resident had severe Alzheimer's dementia. -The resident had a fall from his/her chair in the nursing home on 8/8/12. -The resident's family member stated the resident fell 3 weeks ago also and had "not been quite the same since". Record review of the resident's hospital Discharge Summary dated 8/16/12 showed: -The resident's primary [DIAGNOSES REDACTED]. Record review of the resident's Daily Skilled Nurses Note dated 8/16/12 showed: -Documentation by the day and night shift staff: --The physical functioning of the resident had not been completed. --The resident had difficulty speaking -Documentation by the day shift staff: --The resident had weakness. -Documentation by the night shift staff: --The resident had an unsteady gait and balance problems. -The written comments on the day shift showed: --The resident returned via ambulance from the hospital on a stretcher. He/she had a catheter, skin tears to the chest, stomach, and abdomen area. His/her right and left forearms were red. His/her left and right wrists and right hip had bruising. His/her left temple area had yellow discoloration from a previous fall. Record review of the resident's Admission Care Plan dated 8/16/12 showed the resident: -Required the total assistance of staff for bathing, hygiene, dressing, grooming, and toileting. -Required the extensive assistance of staff with ambulation. -Was incontinent of bowel. -Had a Foley catheter. -Needed his/her needs anticipated and observe the resident for non-verbal cues of his/her needs. -Needed his/her call light within reach, needed to be encouraged to use his/her call light, the staff needed to assess the resident every 30 to 60 minutes, had a physical therapy referral, had a bed alarm on his/her bed, and his/her footwear needed to be assessed non-skid shoes to prevent falls. -Had a feeding tube which required monitoring for tolerance of the feedings. Needed his/her head of the bed elevated by 30 degrees. Needed to have oral hygiene two times per day. (Note: The resident was not readmitted with a feeding tube.) Record review of the resident's Nurse's Notes dated 8/16/12 at 12:00 P.M., showed: -The resident required extensive assistance with all ADL's and transfers. -See Daily Skilled Nurses Note dated 8/16/12 for admission information. Record review of the resident's physical therapy Initial Treatment Plan for Rehabilitation dated 8/17/12 showed: -The resident had the following Diagnoses: [REDACTED]. --Difficulty walking. --Muscle disuse atrophy (muscle wasting). --Dementia. --Depression. -The resident's prior level of function was he/she was ambulatory on the Secure Care Unit, dependent on the staff for ADL's, and did not use a wheelchair. -The resident demonstrated poor alertness and disorientation, was unable to make eye contact and had a poor response to his/her name. -Pertinent medical history: The resident was recently hospitalized for [REDACTED]. -Precautions: fall risk, mechanical soft diet, thickened liquids, and soft helmet. -The resident had poor strength in his/her lower legs and required maximum assistance with standing and balancing. -The resident required 100% of the therapist assistance for laying down to a sitting position, scooting, and going from a mat to a chair, going from a standing position to a sitting position and from a sitting position to a standing position. -The resident's long term goals were to increase lower extremity strength, perform bed mobility with minimum staff assistance, perform a sitting balance for ten minutes, and tolerate sitting in a chair for up to four hours per day. Record review of the resident's physical therapy Initial Treatment Plan for Rehabilitation dated 8/17/12 showed: -Pertinent medical history: The resident was recently hospitalized for [REDACTED]. -The resident demonstrated poor alertness and disorientation, was unable to make eye contact and had a poor response to his/her name. -The resident's prior level of function was he/she was ambulatory on the Secure Care Unit, dependent on the staff for ADL's, and did not use a wheelchair. -The resident's long term goals were to sit in a wheelchair with good body alignment and sit in a chair up to four hours per day. Record review of the resident's speech therapy Initial Treatment Plan for Rehabilitation dated 8/17/12 showed: -The resident was being seen for dysphagia (inability of difficulty swallowing). -The resident was recently hospitalized and had a Dobbhoff tube feeding for some time and was unable to take food or fluids by mouth. -The resident had a swallow study at the hospital and was able to discharge to the facility on a mechanical soft diet and nectar thick liquids. -The resident was evaluated and could swallow mechanical soft foods and nectar thick liquids with no signs and symptoms of aspiration with the consistency. -The resident required a diet of mechanical soft foods and nectar thick liquids. -The long term goal was to increase nutrition and hydration by mouth with safety and efficiency and increase the resident's quality of life. Observation on 8/20/12 at 8:50 A.M. showed: -The facility's Secure Care Unit (a locked unit which is to provide specialized care and services for residents diagnosed with [REDACTED]. -The Secure Care Unit had two resident rooms th

Based on observation, interview, and record review, the facility staff failed to protect a cognitively impaired resident (Resident #1) who resides on a secured unit from a resident on the same unit (Resident #2) who demonstrated willful intent to sexually assault Resident #1 on 8/2/11; and the facility staff failed to provide adequate supervision of Resident #2 who had a known history of sexually inappropriate behaviors and was involved in a prior incident with Resident #1 when staff saw Resident #2 lead Resident #1 into Resident #2's room and saw Resident #2 trying to pull down Resident #1's pants; the facility staff failed to assess either resident appropriately after the 8/2/11 incident and there was a lack of communication for all staff to be aware of which residents are to be supervised and how often supervision is to occur and of Resident #2's history of sexually inappropriate behaviors; the facility staff failed to develop and implement immediate interventions to prevent a future incident per the facility's "Abuse Prevention Program" when the previous incident occurred between Residents #1 and #2; and the facility staff failed to follow facility policy by not reporting the incident to local authorities or to the Elder Abuse and Neglect Hotline, out of 13 sampled residents. The census on the secured unit was 29 and the facility census was 78. Record review of the facility's "Abuse Prevention Program" dated 6/99 with a revision date of 3/06, showed the following: - "ELDER ABUSE, IT ' S A SHAME, IT ' S A TRAGEDY, IT ' S A CRIME, ZERO TOLERANCE." - Objective: --Zero tolerance of verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property, by employees, family members, visitors, or other residents; -- Establish an environment conducive to reporting any indications of abuse, neglect, mistreatment, or misappropriation of resident property; -- To develop and implement a system for identifying, investigating, preventing and reporting any incident, or suspected incident of abuse, neglect, mistreatment, or misappropriation of resident property. - Investigation of possible abuse, neglect, mistreatment, or misappropriation of property: -- If an incident occurs, or there is any reason to suspect that an incident might have occurred, of abuse, neglect, mistreatment, or misappropriation of resident property, the Administrator, or designee, will investigate; -- The person doing the investigation will complete a Resident Abuse/Neglect Investigation Report. It will not be necessary to complete an Incident Report; -- The Administrator will sign and maintain all completed Resident Abuse/Neglect Investigation Reports and all investigations will remain confidential, except that the findings and actions shall be reported according to state requirements; -- Any witnessed incidents, allegations of incidents, suspected incidents, including sources of unknown injuries, and known or reported misappropriation of resident property, are to be immediately reported to a supervisor or the charge nurse who will report the incident to the Administrator, or designee. Any person may also make a report directly to the Director of Nurses (DON) or Administrator, or their designees; -- If an alleged or suspected incident of abuse, neglect, mistreatment, or misappropriation of resident property occurs, the Administrator, or designee, will report to the following: -- The following information is to be completed by each facility in accordance with Federal, State, and Local Laws. For example, Arkansas requires reporting within 24 hours, Arizona requires Adult Protective Services be contacted and a written report of the investigation be sent to the State, Missouri requires a call be made to the Elderly Abuse and Neglect Hotline, etc.; -- Any person(s) observing, or having reason to suspect, resident abuse, neglect, mistreatment or misappropriation of resident property, is to report the findings to either their supervisor or the charge nurse. If the report is made to a supervisor who is not the charge nurse assigned to the resident involved, the charge nurse will be informed; -- The charge nurse will immediately assess the resident and determine and provide for any care needs. Any findings from the assessment of the resident are to be recorded in the nurse's notes in the medical record; -- The charge nurse is to notify the DON, or designee, of the report. The DON, or designee, shall notify the Administrator, or acting Administrator. As indicated, the DON, or designee, shall notify the resident, responsible party, and the physician of the incident. If a resident to resident incident occurs, the resident causing the mistreatment to another resident shall have their physician notified as well as their responsible party with appropriate action taken and documented; -- The charge nurse is to complete a Resident Abuse/Neglect Report. The charge nurse will request a written, signed, and dated statement from the person(s) reporting and/or witnessing the incident; -- The completed Resident Abuse/Neglect Report and written statements are to be forwarded to the Administrator, or designee, prior to the completion of the work period that the report occurred; -- When the accused or suspected individual is not an employee, while the investigation is being conducted, the accused individual will not be allowed to remain alone with the resident. It shall be the responsibility of the Administrator, or designee, to inform the individual of any limitation on visitation. If the accused individual is another resident, immediate interventions shall occur to prevent a future incident; -- All individuals participating in the investigation shall report their findings to the Administrator and complete the information in writing on the Resident Abuse/Neglect Investigation Report form; -- The Administrator shall keep the resident and his/her responsible party informed of the progress and the results of the investigation; -- The Administrator will involve the Social Service Designee in the investigative process to provide the necessary medically-related social services appropriate for the resident. - Prevention of Abuse, Neglect, Mistreatment, or Misappropriation of Property: -- The facility will have a system in place to prevent abuse. This system can only assure the Facility is doing all that is within its control to prevent occurrences and cannot give a guarantee that abuse will never occur; -- The facility will assure that all residents, responsible parties, and staff understand that there is zero tolerance of verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property by an employee or any other person known or unknown to the resident. - Employees will be screened, knowledgeable, and trained in matters of abuse prevention: -- Employees will be annually trained to recognize situations in which abuse is more likely to occur and how to intervene for prevention, such as: -- Characteristics of residents which have the potential to trigger an abusive incident like wandering into other resident rooms, known history of aggressive behavior, residents who guard their personal space, residents who resist care giving, residents with communication disorders, residents who startle easily due to lack of sight or hearing, heavy care residents dependent on staff for all needs, etc.. -Reporting of Known or Suspected Abuse, Neglect, Mistreatment, or Misappropriation of Resident Property: - What is reported? -- Witnessed events, which include, but are not limited to slapping, hitting, pinching, yelling at, cursing, threatening harassing, etc.; -- Unwitnessed events, which include, but are not limited to reports of abuse, neglect, mistreatment, misappropriation of property made by a resident, resident representative, visitor, employee; -- Indicators of potential abuse as in finding unwitnessed injuries such as skin tears, bruising, swelling, etc. - Who makes a report? -- A resident or a resident representative; -- An employee, volunteer, visitor, or anyone with knowledge of the incident, or possible incident. - How is a report made? -- Verbally to charge nurse; -- In writing to charge nurse; -- The charge nurse will complete a Resident Abuse/Neglect Report; -- The charge nurse will forward the Resident Abuse/Neglect Report to the DON, or designee, who will report to the Administrator; -- The Social Service designee, Administrator, and DON shall have an open door policy for reports, which may always be made directly. - When is a report made? -- Reports are to be made as soon as the incident, or potential incident, is made known; -- The Resident Abuse/Neglect Report is to be completed by the charge nurse by the end of the assigned work period; -- The DON, or designee, is to be informed prior to the end of work period and as soon as is practicable; -- The Administrator, or acting Administrator, is to be informed as soon as is practicable, and in no more than 24 hours. - What outside authorities are to be notified? -- The following are to be notified consistent with Federal, State, and Local Laws: (Area is blank). Record review of the facility's "Abuse Prevention Program Addendum C Employee Fact Sheet" dated 6/99 with a revision date of 3/06, showed the following: - As a Facility, we will actively protect our residents from abuse; - Reporting of abuse is mandatory for health care workers. As a Facility, we will report all allegations of abuse to the proper authorities; - As an employee of this Facility, you are required to report any witnessed or suspected events of abuse and must be aware that abusive acts will not be tolerated-zero tolerance; - ALL witnessed or suspected events as defined by this policy are to be reported regardless WHO is involved or suspected; - Abusive examples include striking, pinching, shoving, pulling, force-feeding, and various forms of sexual abuse including rape, forced sexual acts, fondling, and sexual harassment. Both intentional and unintentional acts of harm can be considered abuse; - Some situations increase the risk for an abusive event to occur. If a resident enters a room of another resident uninvited, the resident who lives in the room may become abusive to the wandering resident. Some residents become very protective of their personal space and their personal items and become abusive to those who get in their way. Employees must be alert to prevent situations that could lead to abuse and know how to redirect residents away from abusive situations; - This Facility has an Abuse Prevention Program to recognize the resident's right to be free of all forms of abuse as defined above and to inform each resident, family, visitor, and staff of zero tolerance for mistreatment of [REDACTED]. Failure to comply with the terms of the Abuse Prevention Program will be treated very harshly and may include termination. Abusive acts to any resident will result in reports to the authorities, reports to licensure and certification agencies, and may ultimately cause future employment in any long-term care facility to be impossible due to Federal and State laws. Record review of the facility's "Abuse Prevention Program Addendum H When to Contact Law Enforcement" dated 6/99 with a revision date of 3/06, showed the following: - When there is reasonable cause to believe a serious occurrence of resident abuse or misappropriation of resident property has occurred, the Facility Administrator (or his or her designee) should notify local law enforcement authorities immediately, in addition to notifying the Department of Health and Senior Services. Precautions should be taken to avoid disturbing any areas, which may be considered "crime scenes", and residents who are believed to have been the victims of sexual abuse should not be bathed prior to the police investigation; - If the Facility Administrator is uncertain whether law enforcement authorities need to be notified, the Administrator should consult with the Regional Operations Director, Nurse Consultant, or the Central Office for further direction. 1. Record review of Resident #1's face sheet showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].(a slowly progressive disease of the brain characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception), [MEDICAL CONDITION] (below normal function of the [MEDICAL CONDITION] which regulates metabolism), [MEDICAL CONDITION] (a [MEDICAL CONDITION] disease of the bones and joints), [MEDICAL CONDITION] joint disease (DJD-gradual wearing down of the bones and joint surfaces causing pain and swelling of the affected areas), [MEDICAL CONDITION] ([MEDICAL CONDITION] - a blood clot in a deep vein in the thigh or leg), and [MEDICAL CONDITION] (a sudden, violent, involuntary series of contractions of a group of muscles). Record review of the resident's "Cognitive Loss/Dementia" care plan dated 9/6/10, showed the following: - He/she had a [DIAGNOSES REDACTED]. - He/she had moderately impaired decision making; - Assess the resident's current cognitive abilities and losses and document; - Re-orient resident to time and place as needed; - When he/she is trying to express him/herself, assist him/her to find the word he/she is looking for when needed; - Allow time for slower thinking processes and repeat and rephrase as needed. Record review of the resident's "Communication" care plan dated 9/6/10, showed the following: - He/she had problems finding words to express him/herself due to dementia; - He/she often spoke in gibberish; - When spoken to, he/she often bursts out in laughter; - Assess resident's communication abilities on an on-going basis and document; - Become familiar with non-verbal cues, gestures, and body language used. Record review of the resident's "Activities of Daily Living (ADL)" care plan dated 9/6/10, showed the following: - He/she is extensive assist with dressing, toileting, personal hygiene, and bathing; - Monitor for safety and whereabouts frequently throughout shift, assure door alarms are working. Record review of the resident's "Behavior Problems" care plan dated 9/6/10, showed the following: - Assess problems and behaviors; - Monitor resident when he/she is in the lobby area with other residents; - Monitor resident for rummaging through others belongings and redirect as needed; - Educate new staff members as to resident's behaviors. Record review of the resident's "Fall" care plan dated 9/6/10, showed the following: - Monitor door alarms to ensure that they are on for wandering and redirect as necessary. Record review of the resident's Quarterly Activity Progress Notes dated 2/25/11, showed the following: - This resident continues to reside on the secured unit. He/she continues to be able to ambulate independently. He/she requires total assistance with other ADLs. He/she tries to feed him/herself. It takes staff supervision to see that he/she eats off his/her own plate. He/she does not communicate verbally. He/she will laugh and cry randomly. He/she wanders through the unit sometimes getting in trouble with other residents. One on one supervision required when he/she leaves the unit. Record review of the resident's Nurse's Notes dated 4/12/11 at 2:15 P.M., showed the following: - Resident continues to be tearful at times, increased episodes of intrusive behaviors (into other resident's rooms, belongings, meal trays). Picks up things off the nurse's medication carts and in the office. Difficult to redirect, becomes agitated at times. Record review of the resident's Quarterly Social Progress Notes dated 5/17/11, showed the following: - This resident continues to reside on the secured unit. He/she continues at the same physical and cognitive level. He/she spends his/her day wandering about the unit. He/she enjoys interacting with staff. He/she will laugh or cry spontaneously. Last week his/her daughter came to visit, but it is unclear whether he/she recognized his/her daughter. No hospitalization s. No issues except supervising resident so he/she won't go into other resident's rooms and move things or take things. Record review of the resident's Quarterly Activity Progress Notes dated 5/17/11, showed the following: - This resident continues to reside on the secured unit. He/she enjoys ambulating independently about the unit. He/she remains the same physically and cognitively. His/her attention span doesn't allow him/her to participate in activities for a long period of time. He/she needs to be supervised because he/she will go into other residents' rooms and take things or will take food off other people's trays. He/she needs one to one supervision off the unit. Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff to determine specific care needs) dated 5/20/11, showed the following: - He/she was rarely able to make self known; - He/she was rarely able to understand others; - He/she has short and long-term memory problems; - He/she was inattentive with disorganized thinking; - He/she wandered daily; - He/she was dependent on staff for dressing, toilet use, personal hygiene, and bathing. Record review of the resident's "Communication" care plan updated 5/24/11, showed the following: - He/she seldom speaks anymore; when he/she does it is gibberish; - It is difficult to judge if he/she understands what is being said to him/her. Record review of the resident's Nurse's Notes dated 7/25/11 at Noon-12:00 P.M., showed the following: - Resident found on floor in men's shower house. Record review of the resident's Nurse's Notes dated 8/2/11 at 8:00 A.M., showed Licensed Practical Nurse (LPN) B wrote the following: - This nurse was observing staff look for this resident for breakfast. This nurse observed staff enter Resident #2's room to look for the resident. When he/she was informed the resident was inside his/her (Resident #2's) room at approximately 7:30 A.M., Resident #1 was seen unclothed from waist down standing in the middle of the room with Resident #2 completely unclothed standing behind him/her. Resident #1 was taken to his/her room to be cleaned and clothed. Resident #1 will start on 15 minute checks to prevent him/her from wandering off unnoticed. Doctor A and Durable Power of Attorney (DPOA) notified. Will continue to monitor. Record review of Resident #1's Weekly Skin Check Worksheet-Nurse dated 8/2/11 and signed by the DON, showed the following: - Skin ok. Some dryness on lower extremities. No bruising or redness noted. (Note: Document was provided on 8/16/11 at 9:54 A.M. during a meeting with the Administrator, the DON, and Attorney A.) Record review of the resident's Nurse's Notes dated 8/3/11 at 6:00 A.M., showed Certified Medication Technician (CMT) A wrote the following: - Continues on every 15 minute checks to keep up with resident's whereabouts. Record review of the resident's Monthly Summary dated 8/4/11, showed the following: - He/she had unclear speech; - He/she was sometimes understood; - He/she had disorganized thinking; - He/she had long and short-term memory problems; - He/she was total dependent on staff for dressing, toilet use, and bathing. 2. Record review of Resident #2's History and Physical report from another facility in the State dated 9/8/08, showed the following: -The resident was unable to state why he/she had been brought to the hospital and where he/she lived; - The resident was brought to the hospital due to inappropriately touching a female resident on the breast; - The resident was to be admitted to the psychiatric unit for treatment for [REDACTED]. Record review of the resident's DA-124A/B and DA-124C forms, which is the Preadmission Screening and Resident Review (PASRR, a required form used by the Missouri Department of Health and Senior Services (DHSS) to meet the federal mandate, 42CFR483. SubpartC, and reviewed by the Missouri Department of Mental Health (DMH) if screening requirements are met to determine level of services appropriate for residents with serious mental illness or mental [MEDICAL CONDITION]), titled, "Initial Assessment" and "Level One Nursing Facility Pre-Admission Screening For Mental Illness/Mental [MEDICAL CONDITION] Or Related Condition", dated 9/12/08, from another facility in the State, showed the following: - The resident had [DIAGNOSES REDACTED]. - The resident had resided in a facility in another area of the State; - The form listed a Public Administrator (PA) who gave phone consent for the signature and dated 9/11/08; - He/she had a history of [REDACTED]. - He/she was on a behavioral unit; - He/she was oriented to person and place and alert with fair to poor memory; - He/she was moderately confused; - He/she wandered and was supervised for safety and controlled with medications. Record review of the resident's Nurse's Notes from another nursing facility dated 5/20/11 and untimed, showed the following: - The resident had been "aggravating another resident by touching her." - The staff redirected the resident away from the other resident and he/she was asked to leave the resident alone. Record review of the resident's Social Service Progress Notes from another facility dated 5/31/11, showed the following: - He/she is oriented to self, place, and somewhat to person; - He/she ambulates independently; - He/she has a history of inappropriate behaviors especially regarding touching females. Staff to redirect as needed. Record review of the resident's care plan from another nursing facility dated and signed 6/6/11, showed the following: - The resident made frequent inappropriate sexual comments directed towards female staff; - Remind the resident when behaviors/comments were inappropriate; - Encourage the resident to treat all staff respectfully; - Psychiatric consult as needed (PRN); - Stop cares and return later when the resident made comments/actions that were inappropriate; - Staff to redirect the resident when he/she was being inappropriate; - Staff to get the resident involved in activities to deter behavior. Record review of the resident's current facility's face sheet showed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. an individual's social functioning and/or ADLs), acid reflux (back-up of stomach acid/heartburn), anxiety (anticipation of impending danger accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus), and [MEDICAL CONDITION] (a mental state involving loss of contact with reality and causing deterioration of normal social functioning). The resident's face sheet showed a PA as the responsible party. Record review of the resident's Nurse's Notes showed the resident was admitted to the current facility on 6/9/11 at 10:30 A.M.. His/her admission medications included: -[MEDICATION NAME] (Hormone replacement therapy medication given to males to lower sexual desires) one milligram (mg) daily, -[MEDICATION NAME] (an antipsychotic) one mg three times a day (TID); -[MEDICATION NAME] 0.5 mg four times a day (QID) for anxiety; -Parsentine HCL 20 mg at bedtime for depression. (Note: The resident was alert and oriented to time and person only.) Record review of the resident's Initial Care Plan, dated 6/9/11 and completed by LPN B, showed the resident did the following: - Walked independently; - Fed him/herself; - Required supervision with personal hygiene needs; - Was able to communicate; - Was an elopement risk and would reside on a locked unit; - Staff to monitor and report behavior problems. (Note: The initial care plan failed to identify and have a plan of care for his/her history of sexually inappropriate behavior.) Record review of the resident's Admission MDS dated [DATE], showed the following about the resident: - He/she had clear speech; - He/she was able to make needs known; - He/she was able to understand others; - He/she had adequate vision and hearing; - He/she had not exhibited behavioral symptoms; - He/she had not exhibited wandering behaviors; - He/she was independent with ADL's. Record review of the resident's Psychological Well-Being Care Area Assessment (CAAs-a federally mandated comprehensive assessment) dated 6/15/11 and signed by the MDS Coordinator, showed the following: - The resident spends most of his/her time in his/her room, except for supervised smoke breaks and he/she does once in a while watch television in the common area, but not often; - The resident likes to keep to him/herself; - The resident has a history of sexual inappropriateness and requires monitoring. Record review of the resident's Social Progress Notes dated 6/15/11, showed the following: - The resident was admitted to the facility on [DATE] with two other residents from another nursing home; - The resident was alert and oriented to self, able to make needs known and ambulated independently; - The previous nursing home reported the resident had inappropriate behaviors towards the female staff. (Note: The Social Progress Notes reviewed on 8/10/11 showed no further entries regarding the resident's behaviors, the incident on 8/2/11 with Resident #1, or the incident which occurred in June or July 2011 where Resident #2 was observed taking Resident #1 into Resident #2's room.) Record review of the resident's care plan dated 6/20/11, showed the following: - He/she spends most of his/her time in his/her bed, but comes out for meals; - He/she has a history of sexual inappropriateness and required monitoring for behaviors; - All staff to approach the resident in a calm, friendly manner with a smile on their faces; - Encourage an activity program appropriate for his/her abilities and needs; - Encourage the resident to come out of his/her room, socialize with others and attend activities as able for stimulation; - Monitor the resident for increased agitation and resistiveness; - If the resident was observed doing anything sexually inappropriate, inform him/her that it was unacceptable behavior and to stop; - The resident cannot be in any female resident's room alone or have a female resident in his/her room; - If behavior was observed, separate the residents immediately and put both residents on every 15 minute checks; - If the resident was observed in his/her room alone doing anything sexual with him/herself, provide privacy. (Note: Record review of the resident's entire care plan showed no approach or intervention and/or updates that the resident was on 15 minute checks, any additional monitoring or increased staff supervision was needed or any additional approaches or interventions to include immediate interventions to prevent a future incident per the facility's "Abuse Prevention Program" regarding the incident which occurred in June or July 2011 where Resident #2 was observed taking Resident #1 into Resident #2's room and of the second incident that occurred again between Residents #1 and #2 on 8/2/11.) Record review of the resident's DA-124A/B and DA-124C forms titled, "Initial Assessment" and "Level One Nursing Facility Pre-Admission Screening For Mental Illness/Mental [MEDICAL CONDITION] Or Related Condition", dated 6/22/11, and signed by Doctor A and the DON, showed the following: - He/she was admitted to the facility on [DATE]; - He/she was taking [MEDICATION NAME] one mg by mouth (po) one daily; - He/she was oriented to person, alert, and had a fair memory; - He/she was moderately confused and withdrawn and minimally suspicious and combative; - He/she wandered and required supervision for safety; - He/she did not show signs or symptoms of a major mental disorder; - He/she had not ever been diagnosed as having a major mental disorder; - He/she was admitted to the nursing facility due to dementia; - He/she had serious problems in levels of functioning in the last six months (no details provided); - He/she had not received intensive psychiatric treatment in the past two years. Record review of the resident's 15 minute checks document titled, Jefferson Health Care Wandering Schedule dated 6/25/11 through 8/10/11, showed no documentation on the following dates and times: - 7/1/11 9:30 P.M. through 10:15 P.M.; - 7/2/11 7:15 A.M. through 2:45 P.M.; - 7/3/11 7:15 A.M. through 2:45 P.M.; - 7/6/11 12:30 P.M., 12:45 P.M., 1:30 P.M., 1:45 P.M., and 2:15 P.M.; - 7/10/11 6:30 A.M. through 2:15 P.M.; - 7/12/11 11:00 A.M. through 2:45 P.M.; - 7/13/11 7:15 A.M. through 2:15 P.M.; - 7/14/11 11:45 A.M. through 2:45 P.M.; - 7/15/11 11:45 A.M. through 2:15 P.M.; - 7/16/11 9:30 A.M. through 2:45 P.M.; - 7/17/11 9:30 A.M. through 2:45 P.M.; - 7/18/11 7:15 A.M. through 2:15 P.M.; - 7/19/11 12:00 P.M. through 2:45 P.M.; - 7/20/11 6:30 A.M. through 2:15 P.M.; - 7/27/11 10:45 P.M. through 11:45 P.M. Record review of the resident's Physician order [REDACTED]. -[MEDICATION NAME] one mg, one tablet daily; -[MEDICATION NAME] one mg BID; -[MEDICATION NAME] 250 mg, two tablets BID; -[MEDICATION NAME] 0.5 mg QID; -[MEDICATION NAME] HCL 20 mg one tablet at bedtime; -[MEDICATION NAME] 25 mg TID; - On 8/3/11, obtain a blood [MEDICATION NAME] level, discontinue the [MEDICATION NAME] and begin [MEDICATION NAME] 25 mg BID and every six hours PRN for agitation. The POS noted a clarification order on 8/3/11 for [MEDICATION NAME] 25 mg TID and every six hours PRN for 10 days for agitation. Record review of the resident's Behavior/Intervention Monthly Flow Record dated August 2011, showed the following: - Wandering as the resident's only behavior; - On 8/1/11 for the day, evening and night shift the resident had no wandering behavior; - On 8/2/11 for the day shift the resident wandered twice and was redirected and received 1:1, for the evening and night shift the resident had no wandering behavior; - On 8/3/11 for the day shift the resident wandered three times and was redirected and received 1:1, for the evening and night shift the resident had no wandering behavior; - On 8/4/11 for the day, evening and night shift the resident had no wandering behavior; - On 8/5/11 for the day, evening and night shift the resident had no wandering behavior; - On 8/6/11 for the day shift the resident had no wandering behavior, for the evening shift the resident wandered three times, received 1:1 and an activity, and the night shift showed no documentation, - On 8/7/11 for the day and evening shift the resident had no wandering behavior, and the night shift showed no documentation, - On 8/8/11 for the day shift the resident had no wandering behavior, for the evening shift the resident had wandered twice and was redirected, and the night shift showed no documentation, - On 8/9/11 for the day and evening shift the resident had no wandering behavior, and the night shift showed no documentation. (Note: The Behavior/Intervention Flow Record failed to identify the resident's sexually inappropriate behavior.) Review of the resident's Jefferson Health Care Wandering Schedule dated 8/2/11 showed documentation every 15 minutes from 12:00 A.M. until 11:45 P.M. for the location of the resident. The form showed: -at 6:00 A.M. the resident was in his/her room; -at 6:15 A.M. the resident was in his/her room; -at 6:30 A.M. the resident was in his/her room; -at 6:45 A.M. the resident was in his/her room; -at 7:00 A.M. the resident was in his/her room; -at 7:15 A.M. the resident was in his/her room; -at 7:30 A.M. the resident was in his/her room; -at 7: