Every finding on record at John Knox Village Care Center

Based on interview and record review, the facility failed to report an allegation of possible resident to resident abuse on 8/22/26 related to an incident involving Resident #1 and Resident #2 out of three sampled residents. The facility census was 118. Review of the facility Abuse Policy dated 05/12/26 showed: -The Administrator will assure to notify the appropriate state agency as required by regulation, law and section 1150 of the Social Security Act. Review of the Center for Medicaid Services F609 implementation 10/24/22 showed: -Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 1.Review of Resident #1's face sheet showed he/she was admitted [DATE] with a diagnosis of dementia. Review of Resident #2's face sheet showed he/she admitted [DATE]. Review of local law enforcement report dated 08/21/26 showed:-Facility staff had reported Resident #2 was found in Resident #1's room. Resident #2 was fully naked with one hand on his/her genitalia and the other hand down Resident #1's adult brief; -Resident #1 was listed as the victim and Resident #2 as the suspect;-State agency contacted. During an interview on 08/22/26 at 10:10 A.M., the Administrator said:-Neither Resident #1 nor Resident #2 remembered the incident;-He/She believed that since there was no injury, and neither resident could remember the event, or required any medical treatment, and the family did not want Resident #1 sent to the hospital that he/she had to report the event within 24 hours not the 2-hour window for suspected abuse. During an interview on 08/24/26 at 3:30 P.M., The Administrator and the Director of Nurses (DON) said: -On 08/21/26 the night shift staff had called and reported Resident #2's hand was in Resident #1's adult brief;-The house supervisor contact local law enforcement;-He/She was responsible for reporting the incident;-He/She had initially thought they had 24 hours to make the report. -He/She should have called the state agency as the regulation required while he/she investigated the abuse allegation. 3173665

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #1) was fully informed of his/her care prior to receiving the care out of three sampled residents. The facility census was 117 residents. On 4/30/25 the Administrator was notified of the past non-compliance which occurred on 4/28/25. Facility staff were educated on resident rights and resident's right to informed care. The deficiency was corrected on 4/29/25. Review of the facility's policy titled Resident Rights dated 1/3/23 showed: -Residents had the right to receive service with reasonable accommodation of their individual needs and preferences except when their health and safety, or that of another resident's, would be endangered. -Residents had the right to be informed of all aspects of their care including to participate in the planning of their care and treatment and any changes in care and treatment. -Residents also had the right to refuse treatment and to be informed of the consequences of such refusal. 1. Review of Resident #1's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Presence of Cardiac Pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions). -Encounter for Surgical After Care Following Surgery on the Circulatory System. Review of the resident's care plan dated April 2025 showed: -The resident had admitted to the facility following a pacemaker placement on 4/2/25. -The staff were to assist with bathing and hygiene as indicated. -The resident needed partial to moderate assistance from staff with toilet transfers. -The resident was at risk for developing skin problems with the intervention for staff to apply a moisture barrier as needed. Review of the resident's Physician Order Sheet (POS) dated April 2025 showed no order for any type of barrier cream (a topical formulation used to place a barrier between the skin and contaminants that may irritate the skin). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 4/12/25 showed: -The resident was cognitively intact. -The resident needed partial/moderate assistance (helper does less than half the effort) with toileting hygiene. Review of the facility's abuse allegation investigation dated 4/28/25 showed: -On the morning of 4/28/25 the resident had reported to Physical Therapist (PT) A that he/she had been sexually violated by one of the Certified Nurses Aide (CNA)'s on 4/25/25. -During the Director of Nursing (DON) interview with the resident, the resident stated the following: --A CNA had come to help him/her out of the bathroom. --The CNA stated, I noticed there is barrier cream. --The CNA proceeded to put the cream on the resident's perineal (area extending from the anus to the vulva in the female and to the scrotum in the male) area. --The resident felt that the way that the CNA had placed the cream on the resident was assault. --The barrier cream had started to burn, so he/she started yelling and crying for the nurse to come help him/her. --The nurses assisted him/her in cleaning off the barrier cream and the nurse had stated to him/her that he/she was hoping he/she doesn't make a big deal about this, the CNA was trying to help. -The DON had tried to explain to the resident that applying barrier cream was facility protocol for skin protection. -The resident had stated understanding of the practice, but still felt violated. -CNA A had told the DON the following: --He/She had been watching the hallway for another CNA who was on break. --He/She had responded to the resident's call light from the bathroom. --He/She saw that there was barrier cream in the resident's bathroom. -He/She noticed that the resident's buttocks was reddened, so he/she applied the barrier cream to the resident. --He/She had been told by the resident that the resident was sensitive to creams. --He/She reported that he/she was unaware of the resident's sensitivity due to the resident being on a different hall than he/she worked. -Register ed Nurse (RN) A told the DON the following: --CNA A had assisted the resident off the toilet while the assigned CNA was on break. --When CNA A came out of the resident's room, the resident started crying and stated that the cream was burning. --RN A assisted the resident in cleaning off the cream on the resident's buttocks. --The resident had not reported to RN A that he/she had felt violated at any time during that interaction. --RN A had told the resident that CNA A was just being helpful but the resident had not agreed and continued to state that the cream burned. -In conclusion the investigation the following was found: --The facility acknowledged that the resident felt violated by the fact that CNA A had applied the barrier cream to the resident's perineal area. --The application of a skin barrier cream was standard nursing protocol for any resident with incontinence. --The resident had a reddened buttocks upon admission, so the application of the barrier cream would have been standard protocol. --The facility felt that CNA A could have more clearly stated that he/she was going to apply the barrier cream to the resident's perineal area. --If CNA A had appropriately informed the resident, then the resident may have felt more comfortable. During an interview on 4/30/25 at 9:15 A.M. the resident said: -The incident occurred on 4/25/25 sometime in the morning. -He/She was really upset about the whole situation. -He/She had been in the bathroom and had used his/her call light to get assistance. -CNA A had come into the to help him/her. -CNA A was not the CNA that had been assigned to him/her that day. -CNA A had used barrier cream and had placed it in the resident's perineal area. -No care staff person had ever used barrier cream on him/her before. -He/She had asked CNA A why he/she was applying the barrier cream. -CNA A responded by shrugging his/her shoulders and did not answer his/her question. -The barrier cream had started to burn so he/she had asked RN A to assist him/her in removing the cream from his/her perineal area. -The barrier cream was really painful and felt CNA A had assaulted him/her. During an interview on 4/30/25 at 10:00 A.M. RN A said: -The resident did not have barrier cream ordered on his/her POS. -He/She was unsure who placed the barrier cream in the resident's bathroom. -Care staff were trained to put barrier cream on resident's who received incontinent care. -He/She felt like CNA A had not done anything wrong because that is what the care staff were trained to do. -CNA A had been covering the hall for the other CNA who was on break at that time. -That interaction was most likely the first time CNA A, and the resident had. -CNA A was normally assigned to a different hall. -The resident had not reported to him/her that CNA A had made the resident uncomfortable or that he/she felt violated in any way. During an interview on 4/30/25 at 10:22 A.M. CNA A said: -He/She had been covering the resident's hall because the other CNA had gone on break. -The resident had placed his/her call light on, and he/she was responding to the light. -The resident had needed assistance with toileting hygiene and getting out of the bathroom. -He/She saw the resident had barrier cream on the back of the resident's toilet. -He/She had applied the barrier cream because the resident's buttocks was reddened. -He/She had applied the barrier cream to the resident's buttocks only. -Around lunchtime the resident had yelled at him/her and had stated that his/her skin was sensitive. -That was the first time he/she had ever assisted the resident. -He/She had no further interaction with the resident after the resident had confronted him/her. During an interview on 4/30/25 at 10:59 A.M. PT A said: -The resident had reported to him/her that CNA A had made the resident uncomfortable when CNA A had applied the barrier cream to his/her perineal area. -The resident had said he/she had not felt right about and didn't feel the barrier cream was necessary. -The resident had spoken to the nurse on 4/25/25 about the situation. -The resident had planned to speak with the social worker on 4/29/25 about the situation. -CNA A had just been doing his/her job by applying the barrier cream to the resident's perineal area. During an interview on 4/30/25 at 11:39 A.M. CNA A said: -He/She felt like he/she had informed the resident of the application of the barrier cream. -The resident had not reported to him/her that he/she was sensitive to creams prior to the application of the barrier cream. -The application of barrier cream to a resident with pink/reddened skin was normal facility protocol. During an interview on 4/30/25 at 11:53 A.M. CNA B said: -He/She had worked with the resident prior to the resident's discharge. -He/She had not used barrier cream with the resident, but the resident had never needed his/her assistance in the bathroom. -The resident was supposed to have barrier cream applied after bathroom use. -All care staff were to inform all residents of any care that they were going to receive. -It is a resident's right to be informed of all care. -If CNA A had not informed the resident of the application of the barrier cream, then CNA A should have informed the resident. During an interview on 4/30/25 at 11:58 A.M. RN B said: -It was facility protocol for resident who received incontinent care to get barrier cream during incontinence care. -Residents were to be informed of the care they are receiving prior to the received of the care. -There would not be any reason for a resident to not be informed of any care received. -Informed care is one of the resident's rights. -He/She expected all care staff to inform residents of their care. -If CNA A had not informed the resident of the use of barrier cream, then CNA A should have informed the resident appropriately. During an interview on 4/30/25 at 12:09 P.M. the DON said: -He/She felt like CNA A had not verbally explained the use of the barrier cream well enough to the resident. -The use of barrier cream for residents who were incontinent was standard protocol. -He/She expected CNA A to use the barrier cream with the resident, due to the resident having a reddened buttocks. -He/She expected all care staff to inform residents of the care they were providing for all residents. -He/She would expect staff to inform residents of their care in a manner that was appropriate for each resident. MO00253421

Based on observation, interview, and record review, the facility failed to ensure infection control standards of practices including hand hygiene were incorporated during wound care for one sampled resident (Resident #77); and failed to ensure Enhanced Barrier Precautions (EBP-strategy to decrease transmission of infections and/or cross-contamination during high-contact care activities for residents in nursing homes that include wearing gowns, gloves and at times a face mask) were used for one sampled resident (Resident #19) with a Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) out of 23 sampled residents. The facility census was 112 residents. Review of the facility's Hand Hygiene policy review dated 2/19/2024 showed: -Proper hand hygiene is used for the prevention of transmission of infectious diseases. All healthcare personnel are required to perform hand hygiene in accordance with Centers for Disease Control and prevention (CDC) recommendation. -Reduce transmission of organisms from resident to resident, resident to staff, staff to resident. -All associates are required to perform hand hygiene by using alcohol-based hand rub or wash with soap and water for the following: --Immediately before touching a resident/patient. --After touching a resident/patient or the residents /patients immediate environment. --Before and after using gloves. --When going from a soiled body site to a clean body site on the same patient. Review of the facility's policy Infectious Disease-Precautions dated 10/3/24, showed: -The facility would ensure that the resident/associate environment remains as free of communicable/infectious disease as possible. -EBP was a strategy to reduce the spread of Multi-Drug Resistant Organisms (MDRO- microorganism that are resistant to multiple classes of antibiotics and antifungals). -EBP required the use of a gown and gloves for certain residents during high contact care activities. -Residents with indwelling medical devices (Foley catheters) should be placed on EBP during high contact resident care activities. -High contact resident care activities included care or use of urinary catheters. 1. Review of Resident #77's Admission Record showed the resident was admitted on [DATE], with the following diagnoses: -An unstageable pressure injury (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) of the right heel. -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). 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: -Had Dementia. -Was at risk for pressure injury. -Had an unstageable pressure injury. -The resident was severely cognitively impaired. Review of the resident's Physician Order Sheet (POS) dated 1/9/25 showed: -New pressure injury to the right heel. --Monitor for heel suspension boots or bunny boots being placed on the resident's feet at all times. -New pressure injury to his/her right lateral foot. -New pressure injury to his/her left medial foot. -Pressure injury on the resident's right heel apply Santyl (an ointment used to remove damaged tissue from chronic skin ulcers) and cover with silver alginate and an abdominal (ABD) pad then wrap, daily until the wound had healed. -Deep tissue injury (a type of pressure injury that occurs when soft tissue is damaged by pressure or shear forces. It can appear as a discolored area of skin, a blood-filled blister, or a combination of both) to the left medial foot. Apply skin prep to intact skin, cover with an ABD pad then wrap, daily until the wound had healed. -Deep tissue injury to the right lateral ankle that had opened. Apply Santyl cover with silver alginate and an ABD pad, daily until the wound had healed. -Traumatic injury to his/her right knee. Apply Santyl cover with a dry 2x2 gauze. Apply skin prep around the wound and secure the dressing with foam tape, daily until the wound had healed. Review of the resident's Care Plan dated 1/9/25 showed: -The resident was at risk for skin problems. -He/she had acquired a Stage III (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure injury on his/her right heel. -He/she had acquired a laceration to his/her right lower leg. Observation on 1/13/25 at 9:06 A.M. showed Registered Nurse (RN) B: -Set up wound care supplies on a table with a barrier, including scissors. --The scissors were not cleaned prior to putting them on the table. -Put on a gown. -Entered the resident's room and washed his/her hands. -Put a trash bag into the trash can. --Did not wash or sanitize his/her hands. -Put on gloves. -Placed a barrier under the resident's feet and legs. -Removed the resident's bunny boots. -Removed dressings from the resident's right knee. --Did not wash or sanitize his/her hands. -Removed the ACE wrap from the resident's left leg. -Cut the old dressing off of the resident's left leg. --Did not wash or sanitize his/her hands. --Did not sanitize the scissors. -Removed the ACE wrap from the resident right leg. -Cut the old dressing off of the resident's right leg. --Did not wash or sanitize his/her hands. --Did not sanitize the scissors. -Obtained a package of sanitary wipes, opened the package and removed a wipe, wet it and applied soap. -Washed the resident's left and right leg and right knee with the wipe. -Obtained a new wipe and again wet it with water. -Wiped off the resident's left and right leg and right knee with the wipe. -Removed gloves, washed his/her hands and put on new gloves. -Applied skin prep around the resident's right knee wounds, applied Santyl and silver alginate then covered with gauze pad and foam tape. --Removed his/her gloves, put hand in his/her pocket to obtain the keys to the treatment cart, opened the resident's room door, obtained more supplies from the treatment cart, closed the resident's door and placed the supplies on the table. ---Did not wash or sanitize his/her hands, put on new gloves. -Applied Santyl and silver alginate to the resident's right ankle and heel wounds then covered them with a gauze pad, ABD pad and wrapped the resident's right leg with gauze wrap and then the ACE wrap. --Did not wash or sanitize his/her hands. ---Moved the table with his/her gloved hands and then continued with wound care with the same gloves on. -Applied skin prep to the resident's left ball of foot under the great toe covered with an ABD pad and wrapped the resident's left leg with gauze wrap and then the ACE wrap. -Removed the barrier from under the resident's feet and legs. -Put the bunny boots back on the resident. -Put all unused supplies on the top of the treatment cart. --Did not sanitize the scissors and put the back into the treatment cart. During an interview on 1/13/25 at 11:58 A.M. RN B said: -He/she had not had any in servicing on wound care. -He/she worked with the Nurse Practitioner every week. -In service meetings could have happened when he/she had not been in the facility. -Meetings were conducted once a week to discuss resident wounds. -He/she should have washed his/her hands before working with the resident after touching the trash can. -He/she should have washed his/her hands between wounds. -He/she should have washed his/her hands after they had been soiled by touching objects in the room including the table and door and after putting his/her gloved hand into his/her pocket to get the treatment cart key to get more supplies. -He/she should have washed his/her hands before putting on gloves, and with glove changes. -He/she had training within the year about EBPs. During an interview on 1/13/25 at 12:19 P.M., RN A said: -Hands should be washed before working with a resident, between residents, and when going from a dirty to clean area. -Hands should be washed before wound care, before applying any ointments, and with glove changes. -Hands should be washed between different wounds. -Hands should be washed if they have been soiled. -In service meetings were held every few months. -Hand hygiene had been covered in the computer training's. -The manager would come by and have educational training talks with them every few months about different topics and he/she would sign a document stating they have discussed it. -Enhanced barrier precautions and transmission-based precautions were covered in the computer training's and the manager would discuss them. During an interview on 1/13/25 at 1:33 P.M., the Administrator said: -He/she expected staff to follow the hand washing policy. -He/she expected staff to wash their hands before providing wound care services. -He/she expected staff to wash their hands between wounds if the resident had multiple wounds. -He/she expected staff to wash their hands as much as needed. -He/she expected staff to wash their hands every time they were soiled. 51150 2. Review of the Resident #19's admission MDS dated [DATE], showed: -The resident was admitted to the facility on [DATE]. -The resident was cognitively intact. -The resident had an indwelling Foley catheter. During an interview on 1/9/25 at 10:59 A.M., the resident said: -The staff changed his/her Foley catheter the previous evening. -The staff did not wear a gown while changing his/her Foley catheter the previous evening. -He/she was unaware if staff wore a gown during other previous catheter changes or cares. Observation on 1/13/25 at 9:43 A.M., of Foley catheter care by Licensed Practice Nurse (LPN) B, showed: -LPN B prepared his/her supplies and entered the resident's room. -LPN B did not apply a gown before entering the resident's room. -An EBP sign was posted outside of the resident's room. -The EBP sign posted outside of the resident's room stated that staff must wear gloves and a gown when performing cares on the resident. -An EBP cart with supplies was sitting in the hallway, approximately 50 feet from the resident's room. -LPN B proceeded to complete catheter care without a gown. During an interview on 1/13/25 at 9:57 A.M., LPN B said: -He/she would not have done anything differently when performing catheter care on the resident. -He/she felt that he/she performed the catheter cares correctly and applied the appropriate infection control measures during the cares. During an interview on 1/13/25 at 10:44 A.M., Certified Nurse Assistant (CNA) A said: -If a resident had certain infections, staff members were required to use EBP when giving resident cares. -He/she had not been educated by the facility about when and how to use EBP. -EBP consisted of gloves, gown, and a mask. During an interview on 1/13/25 at 12:00 P.M., LPN A said: -EBP should be used when performing cares on residents with wounds and catheters. -He/she was educated by the Assistant Director of Nursing (ADON) and Director of Nursing (DON) on EBP procedures. -When performing catheter care on a resident, the staff member should wear gloves and a gown. During an interview on 1/13/25 at 1:33 P.M., the Administrator said: -The facility was in the new phases of planning EBP procedures. -The staff was educated on the EBP policies. -The facility was in the process of deciding exactly when EBP should be used. -He/she would expect staff to use EBP when performing Foley catheter cares on a resident. -He/she would expect staff to wear both gloves and a gown when performing catheter cares on a resident.

Based on interview and record review, the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, Form CMS-10055) was provided for two of two residents (Residents #75 and #89) who resided at the facility, to inform them that skilled services may not be paid by Medicare, Part A; the amount of their potential financial liability if they decided to continue to receive services; and applicable claim appeal rights. The facility census was 112 residents. Review of the facility's SNF Liability Notice Policy, dated 1/1/18 and revised 1/9/25, showed: -If the facility believes during a resident's stay that Medicare will not pay for skilled nursing or rehabilitative services the facility will notify the resident/legal representative in writing and explain: --Why specific services may not be covered. --The beneficiary's potential liability for payment for non-covered services. --The beneficiary's right to have a claim submitted to Medicare and standard claim appeal rights that apply if the claim is denied by Medicare. -This notice will be fulfilled by use of the SNF ABN (Form CMS - 10055). The facility: --Must keep a copy of the SNF ABN, Form CMS-10055 on file. --Must file a claim when requested by the beneficiary. --May not charge the resident for Medicare covered Part A services while a decision is pending. 1. Review of Resident #75's SNF Beneficiary Notification Review form showed: -The resident's last expected covered day for Medicare Part A services was 10/16/24. The resident had benefit days remaining for the year. -The facility initiated the discharge from Medicare Part A services and the resident continued to reside in the facility. -There was no documentation the resident was asked if they wanted to continue services or that a SNF ABN was provided to the resident or representative. 2. Review of Resident #89's SNF Beneficiary Notification Review form showed: -The resident's last expected covered day for Medicare Part A services was 10/31/24. The resident had benefit days remaining for the year. -The facility initiated the discharge from Medicare Part A services and the resident continued to reside in the facility. -There was no documentation the resident was asked if they wanted to continue services or that a SNF ABN was provided to the resident or representative. 3. During an interview on 1/9/25 at 11:14 A.M. the Administrator said: -A former Social Services Associate (SSA) was responsible for providing beneficiary notices for residents ending Medicare Part A services and had benefit days remaining. -The former SSA never let anyone know he/she had questions related to the notices and didn't realize he/she needed to present the SNF ABN notice to residents who remained in facility after Medicare Part A services were expected to end. -The SNF ABN notices were never provided for Residents #75 or #89 and there was no documentation they were asked if the residents wanted to continue services. During an interview on 1/13/25 at 10:47 A.M. SSA A said: -He/She and the previous SSA were responsible for presenting the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123 and the SNF ABN, Form CMS-10055 to residents when Medicare, Part A was no longer expected to pay for services and there were benefit days remaining. -A SNF ABN form was supposed to be provided when the resident continued to stay in the facility. -The previous SSA, who had provided Residents #75 and #89 with beneficiary notices, had not worked very long at the facility and was trained by a Social Worker who was now retired. -He/She wasn't aware the previous SSA hadn't provided the SNF ABN form as required. During an interview on 1/13/25 at 1:35 P.M. the Administrator said the SNF ABN was required when Medicare Part A services were expected to end and the resident continued to reside in the facility.

Based on interview and record review, the facility failed to review and revise a resident's person-centered care plan when it failed to address a pressure injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for one sampled resident (Resident #18) out of 23 sampled residents. The facility census was 112 residents. Review of the facility's policy, Care Plan-Baseline and Comprehensive revised 1/3/23, showed: -The comprehensive assessment and resulting care plan were completed through work of an interdisciplinary care plan team. -The Minimum Data Set (MDS- A federally mandated assessment instrument completed by facility staff for care planning) nurse (Registered Nurse (RN)/Licensed Practical Nurse (LPN)) facilitated the care plan decision making. -The care plan would include conditions that affected the resident's health and safety, which included, but were not limited to alterations in skin. -The comprehensive care plan needed to be updated as problems, interventions, and goals changed for the resident. -The charge nurse updated the care plan in the Electronic Medical Record (EMR) after acute events, including, but not limited to, alterations in skin and new diagnosis. -The care plans were to be individualized to each resident's health status. -The care plans were to be accurate regarding a resident's health status. 1. Review of Resident #18's quarterly MDS dated [DATE], showed: -The resident was readmitted to the facility on [DATE]. -The resident had moderate cognitive impairment. -The resident had a Stage III pressure injury (a full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). -The resident was at risk for pressure injuries. Review of the resident's care plan dated 5/8/24 to present, showed: -The resident had a diagnosis of pressure injury to his/her left buttock, stage III. -The resident had a diagnosis of pressure injury to his/her right buttock, stage III. -Note: The resident's pressure injuries were not addressed on his/her care plan as a problem nor did the pressure injuries have goals or interventions. During an interview on 1/8/25 at 11:35 A.M., the resident said he/she believed he/she had pressure injuries on his/her bottom. During an interview on 1/13/25 at 10:44 A.M., Certified Nurse Assistant (CNA) A said the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were responsible for updating a resident's care plan when needed. During an interview on 1/13/25 at 11:48 A.M., the MDS Coordinator said: -Everyone was responsible for updating a resident's care plan when needed. -The facility wound nurse was responsible for ensuring that a resident's pressure injury was on his/her care plan. -A resident's care plan should reflect a pressure injury and be updated when a pressure injury was found on a resident, as soon as possible. During an interview on 1/13/25 at 12:00 P.M., LPN A said: -The MDS Coordinator was responsible for updating a resident's care plan when needed. -A resident's care plan needed to reflect if a resident had a pressure injury. -A resident's care plan should be updated if a resident acquired a new pressure injury. -The nurses looked at a resident's care plans when performing treatments on a resident's pressure injury. During an interview on 1/13/25 at 12:12 P.M., facility wound care nurse said: -The resident did have pressure injuries on his/her buttocks area. -The MDS Coordinator was responsible for updating a resident's care plan when needed. -Pressure injuries should be addressed on a resident's care plan. -He/she was unaware of the facility's policy on the time frame to address a pressure injury on a resident's care plan. During an interview on 1/13/25 at 1:33 P.M., the Administrator said: -If a pressure injury was found by a nurse, that nurse would be responsible for updating a resident's care plan to address the pressure injury. -He/she would expect a resident's pressure injury to be addressed on his/her care plan.

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment such as Continuous Positive Airway Pressure (CPAP - a method of noninvasive ventilation assisted by a flow of air delivered at a constant pressure throughout the respiratory cycle) masks were cleaned and stored in a sanitary condition for one sampled resident (Resident #18); and failed to ensure respiratory face masks and tubing were kept covered when not in use for one sampled resident (Resident #412) out of 23 sampled residents. The facility census was 112 residents. A CPAP equipment storage policy was requested by the facility and not provided. Review of the facility's policy titled Oxygen Administration reviewed on 7/24/24 showed: -The oxygen cannula/mask should be stored in a plastic bag when not in use. -Oxygen supplies were replaced weekly (every seven days). Label and date supplies. 1. Review of Resident #18's admission Minimum Data Set (MDS- A federally mandated assessment instrument completed by facility staff for care planning) dated 1/26/24, showed: -The resident had moderate cognitive impairment. -The resident was using a CPAP machine on admission to the facility and while a resident at the facility. Review of the resident's care plan dated 5/8/24 to present showed: -The resident had a diagnosis of Obstructive Sleep Apnea (a condition that occurs when the airway becomes narrow as the muscles relax during sleep which reduces oxygen in the blood and causes arousal from sleep). -The resident was unable to maintain his/her oxygen saturation levels while sleeping and used a CPAP machine. Observation on 1/8/25 at 11:37 A.M. showed: -The resident's CPAP machine and mask were laying on his/her dresser. -The CPAP mask was not covered. During an interview on 1/8/25 at 11:40 A.M., the resident said: -He/she used the CPAP machine at night. -He/she never recalled the staff placing the CPAP mask in a bag when not in use. Observation on 1/9/25 at 10:51 A.M., showed: -The resident's CPAP machine and mask were laying on his/her dresser. -The CPAP mask was not covered. Observation on 1/13/25 at 10:35 A.M., showed: -The resident's CPAP machine and mask were laying on his/her dresser. -The CPAP mask was not covered. During an interview on 1/13/25 at 10:44 A.M., Certified Nursing Assistant (CNA) A said: -The charge nurse was responsible for storing the CPAP machine and mask when not in use in a resident's room. -He/she was unaware of the proper storage policy for CPAP equipment and mask but he/she believed the mask was supposed to be stored in a plastic bag. During an interview on 1/13/25 at 12:00 P.M.,Licensed Practical Nurse (LPN) A said: -The charge nurses were responsible for proper storage of CPAP mask and equipment when not in use in a resident's room. -CPAP masks were supposed to be stored in a plastic bag when not in use. During an interview on 1/13/25 at 1:33 P.M., the Administrator said: -The staff that removed a resident's CPAP mask was the one responsible for the proper storage of the mask when not in use. -He/she would expect that a CPAP mask that was in a resident's room and not in use be stored in a plastic bag. 51303 2. Review of Resident #412's Face Sheet showed he/she was admitted on [DATE] with diagnoses that included: -Pulmonary embolism (a blockage in a lung artery caused by a blood clot that travels from another part of the body). -Pneumonia (inflammation of one or both lungs with consolidation). -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety) -Emphysema (a chronic lung condition that damages and enlarges the lungs' air sacs, causing breathing difficulties. -Acute and chronic respiratory failure, (a situation where a patient with a pre-existing chronic respiratory condition like emphysema experiences a sudden and significant worsening of their breathing difficulties often triggered by an acute event like an infection) with hypoxia (the absence of enough oxygen in the tissues to sustain bodily functions). Review of the resident's care plan dated 12/17/24 showed: -The resident was unable to maintain oxygen saturation above 92% and required oxygen therapy with interventions to include: --Administer oxygen therapy as ordered. --Change tubing weekly and as needed. --Check/fill humidifier if present. --Observe for signs of breathing difficulty, irregular breathing pattern, high respiratory rate, low oxygen saturation, dusky color, cool/moist skin. --Report abnormal findings to physician as indicated. Review of the resident's admission MDS dated [DATE] showed: -He/She was cognitively intact. -He/She was receiving oxygen. Review of the resident's Physician Order (PO) listing dated January 2025 showed: -Keep tubing off the floor. -Oxygen at 2 liters per nasal cannula (NC) continuous. -Oxygen at 2 to 4 liters per minute per nasal cannula as needed for shortness of breath. Observation on 1/7/25 at 12:14 P.M. showed: -The resident was up in his/her recliner with the oxygen on at 2 liters per NC. -The oxygen tubing was lying on the floor. -The nebulizer mask was on the heat register and not bagged. Observation on 1/9/25 at 10:38 A.M. showed: -The resident was in his/her recliner with eyes closed and oxygen was noted on at 2 liters per NC. -The oxygen tubing was on the floor. -The nebulizer mask was at the bedside not bagged. -The nebulizer bag was dated 1/1/25. Observation on 1/9/25 at 11:51 A.M. showed: -The resident was out of his/her room. -The nebulizer mask was on the heat register not bagged. -The nasal cannula tubing was bunched up under the handle of the concentrator and not bagged. Observation on 1/13/25 at 8:59 A.M. showed: -The resident was resting in his/her recliner with oxygen on at 2 liters per NC. -The nebulizer mask was open to air and lying on the heat register. -The oxygen tubing and plastic bag for the NC was on the floor. -The oxygen tubing for supplement oxygen tank on the back of the wheelchair was in a bag dated 1/2/25. --NOTE: This was more than seven days. Observation on 1/13/25 at 12:44 P.M. showed: -The resident was up in his/her recliner with oxygen on at 2 liters per NC. -The oxygen tubing and storage bag were on the floor. During an interview on 1/13/25 at 12:07 P.M. LPN B said: -Oxygen was an order and only nurses change the tubing and were responsible to bag when not in use. -Oxygen storage was the responsibility of the nurse. -CNA's do not touch the respiratory tubing. -Tubing or respiratory bags found on the floor would be changed with new tubing/bag. During an interview on 1/13/25 at 1:33 P.M. the Administrator said: -The staff member that removed the oxygen tubing or nebulizer mask was responsible for placing it in the bag. -Oxygen tubing and nebulizer mask(s) were to be stored in a dated zip lock bag when not in use. -Respiratory tubing/equipment was changed weekly and as needed. -The night shift supervisor was responsible for the weekly change of respiratory tubing and dated the bags. -He/She expected if oxygen tubing or the bag was on the floor it would be changed out for new tubing and bag. -The night shift supervisor was responsible to audit oxygen tubing was changed weekly.

Based on interview and record review, the facility staff failed to follow the facility guidelines for using mechanical lifts by transferring one sampled resident, (Resident #1) out of three sampled residents, using an incorrect sling for this resident on a Hoyer lift, (a medical device used to assist lifting and transferring individuals with limited mobility), which caused him/her to slip from the sling onto the floor without injury. The facility census was 116 residents. The Administrator was notified on 7/16/24 of Past Non-Compliance which occurred on 7/2/24. An all nursing staff in-service was completed on resident transfers by 7/9/24. The deficiency was corrected 7/9/24. Review of the undated facility General Guidelines for Using Mechanical Lifts showed: -Two people were always to be used when using a Hoyer lift. -Staff were to make sure to use the correct size sling. -The correct size was noted on the resident profile. -The sling was to be left in the resident's room so the correct size would be available` when needed. -All slings were color coded: orange for small; yellow for medium; blue for large; black for extra large. -If a change was needed in the size of a sling, the charge nurse should be informed and/or the restorative aide so the resident could be reevaluated. -If the sling was missing, staff should check the clean linen room or the bath house. -If staff were unable to find the correct size or type, a charge nurse, a restorative aide (RA), manager or house supervisor should be informed in order to obtain the correct size. Review of the undated hygiene sling product description showed: -The hygiene sling was designed in order to assist with dressing and undressing when lifting to and from the toilet, as these lifting situations were often difficult for caregivers. -There was a large opening around the buttocks, so dressing and undressing could be done during the lift procedure. Review of the undated universal sling product description showed: -The sling provided an upright sitting posture and supports the entire back up to the neck. -The sling was available in different sizes. -It was important to choose the correct size to achieve the highest level of comfort and safety. -A sling which is too large increases the risk of the patient sliding out of it. 1. Review of Resident #1's facility admission Face Sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Abnormal posture. -Lack of coordination. -Generalized muscle weakness. -Need for assistance with personal care. -Unsteadiness on feet. -Difficulty in walking. Review of the resident's Care Plan Report dated 5/28/24 showed -He/She was at risk for falls related to his/her need for assistance. -He/She had impaired balance and mobility and was non-ambulatory. -He/She was unable to get out of bed. -Interventions included moderate to maximum assistance with transfers, using stand/pivot technique and gait belt. He/She also used the Hoyer lift with two staff in assisting as needed when he/she was weak. Review of the resident's Nurse's Note, written by Licensed Practical Nurse (LPN) A, dated 7/2/24 at 4:14 P.M. showed: -The resident was sitting in his/her recliner and requested to be put to bed. -He/She was assisted by two staff using a large hygiene sling and a Hoyer lift. -The resident slipped through the large hygiene sling and hit his/her head on the floor with his/her feet following. -The nurse was alerted to the incident and went to the resident's room. -The resident was on his/her back and had a blanket under his/her head. -The nurse immediately called the facility emergency medical system (EMS) to dispatch an ambulance. -The resident's vital signs were checked. -The resident was able to tell the nurse where he/she was and his/her name. -The EMS arrived an stabilized the resident's neck with a brace. -The resident was assisted onto a stretcher and then transported to the hospital. Review of LPN A's Witness Statement dated 7/2/24 at 4:14 P.M. showed: -Certified Nursing Assistant (CNA) B and CNA C were using a Hoyer lift to transfer the resident to his/her bed. -Both CNAs stated they used the hygiene sling that was already under the resident. -CNA B was using the remote device to lift the resident up. -CNA C was on the other side about to hold the hygiene sling to transport to the bed. -Before CNA C could grab onto the hygiene sling, the resident slipped through the open part of the hyginesling and fell on to the floor. -CNA C put a rolled blanket under the resident's head and CNA B alerted the nurse. Review of the resident's patient profile dated 7/8/24, which had been in use showed he/she had been using a small sling for the Hoyer lift. During an interview on 7/12/24 at 11:25 A.M., the Assistant Director of Nursing (ADON) said: -The hygiene sling used for the resident should absolutely not have been used because it was way too big for him/her. -There was a list with 42 residents who used lifts which showed which lift should be used. -Staff were not to assume that just because a sling was with the resident it is the correct one to use. -Staff were trained on use of the Hoyer lift in their orientation. During an interview on 7/12/24 at 11:45 A.M., CNA A said: -Hygiene slings had a hole in the back to keep the sling off sores or injuries, where the other slings did not. -The Hoyer lift only would lift the residents about three feet in the air, to clear the bed. -The hygiene sling was only used for one resident, which was not Resident #1. -It is possible that the slings could have gotten mixed up or they ran out of clean slings. -He/She did not think the hygiene sling should have been used with this resident, and typically it was not used for him/her. It never should have been used with him/her. During an interview on 7/12/24 at 12:15 P.M., Restorative Aide (RA) A said: -He/She did the training of staff on the use of the Hoyer lift and slings. -Staff would have been trained on the full-body slings and vests, and possibly the hygiene slings. -The hygiene sling was to be used with the Hoyer lift. -The hygiene sling was for people so they could use the restroom, since it had a hole in the back. -The staff possibly grabbed the wrong sling to use. -Only one resident in the facility used the hygiene sling, because he/she had a lower back wound. -The resident should not have had the hygiene sling used for him/her. -The resident profiles were updated daily and they showed which type of sling a resident used. -The facility had annual training on the use of the Hoyer lift. -All slings were green in color and they had different colored tags on the back ; orange for small; yellow for medium; blue for large; and black for extra large. Only the tag color would be different. -The staff got four to five inservices a year on use of the lifts. -A resident's weight was used to determine sling size. During an interview on 7/12/24 at 12:55 P.M., CNA B said: -He/She was on the sixth day of his/her orientation at the facility. -He/She was not assigned to the resident, but went to that hall to assist. -He/She had been oriented on using the Hoyer lift and the different sling sizes. -The two staff knew the difference between the types of slings. -The type of sling the resident used was on the patient profile. -There were two staff using the lift. -When they moved the resident, it was from his/her recliner chair to the bed. -The sling was already on the resident's chair. -When they hooked the sling to the lift, it looked like a regular sling. -The sling was hooked to the lift correctly. -The resident had been lifted high enough to clear her bed. -The lift had not been turned when the resident fell out. He/She fell out almost immediately. -The resident's head hit the ground first. -He/She ran out of the room and got the nurse, while CNA C stayed with the resident. Then the nurse came and took over. During an interview on 7/12/24 at 1:20 P.M., the Therapy Manager said: -Therapy was not involved in determining the size lift or sling that should be used with a resident. -Their department had not worked with this resident. -They would check the slings to make sure which one was appropriate for which resident if consulted. -The expectation would be that the correct sling would be used for each resident. During an interview on 7/12/24 at 1:45 P.M., Certified Medication Technician (CMT) A said: -He/She had gotten the resident up at 5:30 A.M. the morning of the fall, because he/she requested to get up. -The hygiene sling was already under the resident, probably because he/she liked to use the toilet at times. -He/She was not sure if the sling had been the correct size or not, but it was the one that was in his/her room. -He/She probably should have checked when he/she put the sling on the resident. -The resident lifted without any trouble into his/her chair. -All of the slings look alike except the different color tags, which would not easily be seen if the resident was in the chair. They would have had to leaned him/her forward to check it. -The staff get a printed resident profile which would state the resident's sling size. -Staff would have access to a resident profile even if he/she was not assigned to that staff for care. -The expectation was that the size of the sling would be checked before lifting a resident. During an interview on 7/12/24 at 2:05 P.M., LPN A said: -He/She was the nurse that evening on the resident's hall. -The resident was already on the floor when he/she entered the room. -He/She checked the resident's vital signs and asked the resident questions to determine orientation. -The CNAs said the resident hit his/her head, but the resident denied it. -The resident had no visible injury, but he/she decided to send him/her to the hospital for evaluation. -Staff were supposed to check the slings when they lifted a person. -Sling size was determined by the resident's weight. -He/She was not sure who determined the residents' sling sizes. -Only one resident in the facility used the hygiene sling. -All resident slings were kept in the RA gym, but if a correct one was not available, they could be gotten from the laundry. -CNAs would have access to sling size on a resident's profile, located at the front of each hall. -The only thing that could have been done differently would have been to check the sling size under the resident to make sure it was correct. -The hygiene sling was probably used without a second thought, since it was already on the resident's chair. During an interview on 7/16/24 at 11:16 A.M., CNA C said: -The resident said he/she had to go to the restroom. -He/She brought CNA B with him/her to move the resident from his/her recliner to his/her bed. -They hooked the sling to the hooks on the lift and he/she moved behind the lift to move it. -CNA B controlled the lift. -When they rolled the lift back, the resident fell through the hole in the sling. -The sling was a hygiene sling and the wrong size. -He/She did not think to check the sling. -They should have checked to make sure the sling was correct, but it was already on the resident's chair. -It was a lesson for him/her to always check. -He/She had previously been educated on the use of the Hoyer lift and the slings. -He/She stayed with the resident and CNA B went to get the nurse. -The nurse checked the resident and the paramedics were there to get the resident within a minute. During an interview on 7/16/24 at 1:00 P.M., the Director of Nursing (DON) said: -The resident had a fall with no injury. -There were two staff members present using the Hoyer lift. -The resident slid out of the sling. -On new hire orientation, training was given regarding the Hoyer lift. -The staff involved were fairly new, and chose to use the sling involved because it had already been used. -They were not sure who initially used that sling with the resident. -All resident profiles were updated to show the correct size and color sling to be used for each resident. -It was his/her expectation that there would be two staff using the lift and each should check to make sure the correct size and color sling are being used when transferring a resident. During an interview on 7/16/24 at 1:30 P.M., the Administrator said: -He/She would expect the staff to read the resident's profile and know which size and type of sling a resident should use. -The staff had been prepared these types of accidents could happen. MO00238470

Based on observation and interview, the facility failed to keep the Dry Storage (DS) room, walk-in refrigerator, and walk-in freezer floors clean; to retain operable thermometers in all refrigerators/freezers to confirm adequate temperature ranges; to maintain sanitary utensils and food preparation equipment; to change the deep fryer oil in a timely manner; to properly measure and document hot food temperatures at the ovens and/or stoves to ensure they were suitably cooked, and cook longer if needed, to lessen the chance of bacterial contamination; to maintain plastic plate covers and utensils in good condition to avoid food safety hazards (cross-contamination); and to separate damaged foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 105 residents with a licensed capacity for 375 residents at the time of the survey. 1. Observation on 6/26/23 between 8:40 A.M. and 11:21 A.M. during the initial kitchen inspection showed the following: -A manual can opener blade in the Ingredient Room had paper scraps on it. -A green handled knife on a magnetic wall mounted rack had a streaked substance on one side and rust on the other. -There was paper, cardboard, and a 2-pack of club crackers on the floor under the racks in the DS room. -There were two 6 pound (lb.) 12 ounce (oz.) cans of applesauce that were both dented on their bottom rims, a 6 lb. 11 oz. can of crushed pineapple dented on a lower side, a 6 lb. 8 oz. can of fruit cocktail dented on its top rim, and a 6 lb. 10 oz. can of tomato sauce with a large dent on the side on the large can dispenser rack in the DS room. -There was an assortment of various sized dented cans separated on a lower bakers rack shelf against the wall. -There were strips of paper, plastic, a wrapped frozen sandwich, food crumbs, and a thermometer on the floor under racks in the walk-in freezer. -There was no thermometer in either side of a black side-by side refrigerator in the main kitchen area. -The cooking oil in a deep fryer was so dark the bottom basket resting racks could not be seen. -There were eight black plate warmer covers on a rack near the dishwashing area that were cracked and/or chipped on their edges. -There were several grapes, four butter pods, and two cans of soda under the racks in the southeast walk-in refrigerator. -There were four metal blade spatulas with white plastic handles that were chipped, cracked, and/or melted. -The special texture diet food pans were pulled from the oven to go to the steam table in the dining room without having their temperatures measured. -The regular texture lasagna was pulled from the oven and placed on a cart for transport to the dining room steam table without having its temperature measured. During an interview on 6/26/23 at 11:19 A.M. the Day Cook said they used the deep fryer for chicken strips, French fries, and sometimes special orders. Observations on 6/28/23 at 12:01 P.M. in the Main Dining room showed meal service had started and foods were being plated and passed to the residents. During an interview on 6/28/23 at 11:20 A.M. the Dietary Manager (DM) said the cooks were supposed to take and log the food temperatures when it got to the steam tables in the dining room. During an interview on 6/29/23 at 11:20 A.M. the DM said the following: -The dishwasher aides were responsible for cleaning floors after each shift at least twice a day. -When any dietary staff inform him/her about damaged food preparation items they discard them and replace. -Damaged food stuff items were separated out and either returned or thrown away depending on when they were found. -He/she would expect food to be free of foreign substances. -The fryer oil was to be filtered every day and changed twice a week. -The cooks were educated to measure and log the hot food temperatures in the dining room at the steam table before meal service. -All refrigerators should have thermometers inside.

Based on observation, interview, and record review, the facility failed to ensure residents oxygen and equipment were stored in a sanitary manor for three sampled residents (Resident #2, #34, and #65); and to ensure physician orders for oxygen supplementation were clarified and carried out as intended for one sampled resident (Resident #61) out of 21 sampled residents. The facility census was 105 residents. Review of the facility's policy, Oxygen Administration and Proper Storage dated 1/31/23 showed: -This procedure was performed by a Registered Nurse (RN) or Licensed Practical Nurse (LPN). -An order for the administration of oxygen must have been obtained from a physician. -Oxygen supplies were to have been replaced weekly (every seven days). -Label and date supplies. -Respiratory equipment was to have been checked each shift. -Check and clean oxygen equipment, masks, tubing and cannulas at regular intervals usually needed every eight hours. -When not in use, masks and cannulas should have been stored in a clear plastic bag. -The procedure was to have been documented on the appropriate nursing form. 1. Review of Resident #2's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Shortness of breath. -Aphasia following cerebral infarction (when a person was unable to comprehend or unable to formulate language because of a stroke (damage to the brain). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 4/13/23 showed: -The Brief Interview for Mental Status (BIMS) was not done as the resident was rarely or never understood. -He/she was totally dependent on staff for all activities of daily living. -Did not show he/she was short of breath. -Did not show he/she had respiratory treatments. Review of the resident's Physician's Order Sheet (POS) dated June 2023 showed the following order for the resident: -Ipratropium (a medication used to help open up the airways in the lungs) 0.5 milligram (mg). -Albuterol (a medication used to prevent and treat difficulty breathing) 3 mg (2.5 mg base/ 3 milliliter (ml) nebulization (a small machine that turns liquid medicine into a mist that can be easily inhaled) solution inhalation, Duoneb (a combination of medications) breathing treatment every six hours as needed, dated 6/11/20. Observation on 6/26/23 at 9:00 A.M. showed the resident's nebulizer mask was on the night stand not in a bag. Observation on 6/28/23 at 10:00 A.M. showed the resident's nebulizer mask was on the night stand not in a bag. Observation on 6/30/23 at 1:28 P.M. showed the resident's nebulizer mask was on the night stand not in a bag. During an interview on 6/30/23 at 1:30 P.M. the resident was non verbal and not able to answer questions. Review of the resident's Treatment Administration Record (TAR) dated June 2023 did not show documentation of when the tubing or nebulizer mask was last changed. 2. Review of Resident #34's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure with Hypoxia (an impairment of gas exchange between the lungs and blood causing hypoxia - an absence of enough oxygen in the tissues to sustain bodily functions). Review of the resident's care plan dated 3/17/23 showed: -He/she was unable to maintain oxygen saturation at times. -He/she received oxygen titrated up to five liters per mask or nasal cannula to keep oxygen saturation (the amount of oxygen circulating in the blood. Normal levels range from 95 to 100 percent) above 92%. -Staff was to administer oxygen therapy and respiratory treatments as ordered. -Staff was to change nebulizer tubing and mask or mouthpiece weekly. Review of the resident's quarterly MDS dated [DATE] showed: -The resident's BIMS score was 12 out of 15 indicating he/she was moderately cognitively impaired. -He/she was totally dependent on staff for activities of daily living. -He/she had respiratory failure. -He/she was on oxygen therapy. Review of the resident's POS dated June 2023 showed the following orders: -Ipratropium 0.5 mg- Albuterol 3 mg (2.5 mg base)/3 ml nebulization for wheezing /shortness of air/respiratory distress every six hours as needed dated 4/11/23. -Oxygen at 2 liters/minute per nasal cannula as needed, dated 4/11/23. -Keep oxygen tubing off of the floor as needed, dated 4/11/23. Observation on 6/26/23 at 2:52 P.M. showed: -The resident's nebulizer mask was in a bag dated 5/11/23. -The resident's oxygen tubing was hanging from the oxygen concentrator. -The resident's oxygen tubing was not in bag. -The resident's oxygen tubing did not have a date on it. Observation on 6/28/23 at 9:50 A.M. showed: -The resident's nebulizer mask was in a bag dated 5/11/23. -The resident's Oxygen tubing was laying on the floor. -The resident was out of his/her room. Observation on 6/29/23 at 2:00 P.M. showed: -The resident's nebulizer mask was in a bag dated 5/11/23. -The resident's Oxygen tubing was laying on the floor. -The resident was out of his/her room. During an interview on 6/29/23 at 3:00 P.M. the resident said he/she did not want to be interviewed as it might get someone in trouble. Review of the resident's TAR dated June 2023 showed: -Staff was to keep tubing off of the floor, order had not been assigned administration times in the Date Range Specified. -No documentation was done. -No documentation the oxygen tubing or nebulizer mask had been changed. 3. Review of Resident #65's face sheet showed he/she was admitted to the facility on [DATE] with a dignosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's quarterly MDS dated [DATE] showed: -His/Her BIMS score was 13 out of 15 indicating he/she was cognitively intact. -He/She needed extensive assistance with activities of daily living. -He/She had COPD. -Oxygen therapy was not marked. -Respiratory treatment was not marked. Review of the resident's POS dated June 2023 showed the following orders: -Albuterol sulfate (medication used to treat and prevent wheezing and shortness of air) 2.5 mg/3 ml solution for nebulization, one vial as needed every four hours, dated 5/9/23. -Albuterol sulfate 2.5 mg/3 ml solution for nebulization, one vial at hour of sleep, dated 5/10/23. -Oxygen to keep oxygen saturation greater than 92%, dated 6/13/23. Review of the resident's TAR dated June 2023 showed: -Oxygen was administered once on 6/14/23. -There was no documentation the oxygen tubing was changed. -There was no documentation the nebulizer tubing was changed. Observation on 6/26/23 at 2:52 P.M. showed: -The resident was going to therapy. -The Certified Nursing Assistant (CNA) changed the resident's oxygen from the concentrator to a portable oxygen tank. -The CNA put the oxygen tubing on the concentrator handle. -The oxygen tubing was not in a bag. -The oxygen tubing was not dated. -The resident's nebulizer mask was in a bag dated 5/11/23. During an interview on 6/26/23 at 2:54 P.M. the resident said: -That was how the staff kept his/her oxygen tubing and nebulizer. -They were not usually kept in a bag. -If it was marked 5/11/23 then that was the last time it was changed. Observation on 6/30/23 at 9:50 A.M. showed: -The oxygen tubing was laying on the oxygen concentrator. -The oxygen tubing was not in a bag. -The nebulizer mask was laying on the nebulizer machine not in a bag. -The nebulizer mask did not have a date on it. 4. During an interview on 6/29/23 at 10:50 A.M. Certified Medication Technician (CMT) A said: -The CNAs change out the oxygen tubing weekly. -The oxygen tubing should be in a bag with the date and initials of the person who changed it out. -The oxygen tubing change should be documented on the TAR. During an interview on 6/30/23 at 11:55 A.M. LPN C said: -The night shift CNAs change out the oxygen tubing weekly. -The tubing should be in a bag with the date it was changed and the initials of the person who changed it out. -He/She was not sure where it was charted maybe on the TAR. During an interview on 7/5/23 at 1:08 P.M. the Director of Nursing (DON) said: -Oxygen tubing should be in a bag when not in use. -Oxygen tubing should be changed weekly. -Staff was expected to document on the TAR when the oxygen tubing which would have included tubing for the nebulizer was changed. -The oxygen tubing should have been dated and initialed when it was changed. -The charge nurse would have been responsible for ensuring this was done. 19016 5. Review of Resident #61's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses that included: -Pleural Infusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor heart function or inflammation). -Vascular dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Dependence on supplemental oxygen. Review of the resident's POS dated June 2023 showed the resident had orders for: -Oxygen at 2 liters (L) per minute/by nasal cannula (NC - a device consisting of a lightweight tube in which one end splits into two prongs which are placed in the nostrils from which air and oxygen flow) at hour of sleep (HS) starting 5/7/21. -Continuous Positive Airway Pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open during sleep) at home settings (between 6 and 14 centimeters (cm) H2O) at therapeutic range as needed starting 1/27/21. -Oxygen through NC changed to 2 L/NC while resting during the day and every HS starting 6/27/23. Review of the resident's quarterly MDS dated [DATE] showed: -The resident was moderately cognitively impaired. -The resident was on oxygen therapy. Review of the resident's Oxygen and CPAP Care Plan, updated 6/27/23 showed: -The resident was unable to maintain oxygen saturation levels. -CPAP at home settings as needed with all naps and sleep. -Interventions were for: --Oxygen on at 2L/NC at all times. --Monitor for signs of breathing difficulty, irregular breathing pattern, extreme respiratory rate, low oxygen saturation, dusky or bluish color, and cool/moist skin. --Assess lung sounds daily if ordered. --Administer oxygen therapy and respiratory treatments as ordered. --Report abnormal findings to physician. Review of the Resident Profile sheet on the wall of the resident's hallway, dated 6/28/23 showed: -CPAP at night. (Note. It did not specify CPAP as needed). -There was no mention of when oxygen through NC was to be used. During an interview on 6/27/23 at 11:04 A.M. Family Member A said: -He/she had recently spoken with the Nurse Practitioner (NP) about the resident being more lucid (alert and clear thinking) when he/she was using his/her oxygen and discussed with the NP that the resident have supplemental oxygen during the day. -He/she was told the resident should now have orders for supplemental oxygen at all times throughout the day hours as well as at night. Observation on 6/28/23 at 9:00 A.M. showed: -The resident was in his/her room sitting quietly in his/her recliner with feet raised, head slightly bent downward and eyes half closed. -The resident was not using supplemental oxygen. Observation on 6/29/23 at 10:21 A.M. showed: -The resident was sitting quietly in his/her recliner with his/her head downward, feet raised and eyes half-closed. -The resident was not using supplemental oxygen. Observation on 6/29/23 at 11:05 A.M. showed family Member B went into the resident's room and was overheard saying the resident's oxygen was not on and was supposed to be on all the time according to Family Member A. Observation on 6/29/23 at 11:24 A.M. showed: -The resident was sitting in his/her recliner with feet up and no supplemental oxygen on. -Two CNA's who were in the resident's room assisted the resident to bed and applied the resident's NC at 11:30 P.M. once the resident was in bed. During an interview on 6/29/23 at 11:30 A.M. Family Member B said Family Member A told him/her the resident's oxygen was to be on at all times during the day as well as during night hours. Observation on 6/30/23 at 7:20 A.M. showed: -The resident was in his/her recliner with legs up. Two pillows were behind his/her head and the resident's head faced downward and eyes were closed. -The resident was not using supplemental oxygen. Observation on 7/5/23 at 10:00 A.M. showed: -The resident was in his/her recliner with feet raised and head faced downward and eyes closed. -He/she was not using supplemental oxygen. During an interview on 7/5/23 at 10:03 A.M. Agency CNA A said: -He/she worked at the facility multiple times a month. -He/she had never seen the resident use supplemental oxygen during the day while in his/her chair. He/she was to have the oxygen on at night and while in bed during the day. -The only Resident Profile sheet available on 7/5/23 was dated 6/28/23. -The profile sheet should show the resident's current oxygen needs and be updated daily with any new changes. During an interview on 7/5/23 at 10:19 A.M. LPN C said: -The resident's orders showed oxygen at 2 L/NC while resting during the day and at night. -He/she thought while resting meant when the resident was in bed. That probably should be more specific. -The resident had an order to check his/her oxygen saturation levels each shift which was twice daily. If oxygen saturation levels go below 92 percent the resident should be assisted to use the oxygen. -The resident's care plan showed the resident was to have oxygen on at all times. -The resident's physician orders, care plan and Resident Profile sheet information should all match and all staff should know what they were supposed to do regarding the resident's oxygen use. During an interview on 7/5/23 at 12:34 P.M. the NP said: -The resident had current orders for oxygen at 2 L/NC while resting during the day and every night. -If the resident was resting in his/her chair or in his/her bed he/she should have the oxygen applied. The order was for anytime the resident was resting and he/she didn't only rest while in bed. It would not hurt for the resident to wear the oxygen continuously all day. During an interview on 7/5/23 at 1:04 P.M. the DON said: -If an order read the resident should have oxygen at 2 L/NC while resting during the day and every night the resident should have it on any time the resident was resting, including when the resident was resting in his/her chair. -Documentation should be consistent related to oxygen orders, the care plan, and Resident Profile information.

Based on observation, interview, and record review, the facility failed to ensure the residents prescribed narcotic (a drug or other substance that affects mood or behavior) medications were documented as counted and the narcotic count was verified to be accurate at the beginning and end of each shift by two nursing staff. The facility census was 105 residents. Review of the facility's policy, Controlled Substance (medications that have to potential for abuse) Count, dated 4/8/23 showed: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances were subject to record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. -This procedure was to have been performed by Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Medication Technician (CMT). -At each shift change, or when keys were transferred, a physical count of all Control (C)IIs - CVs (Narcotics) that were stored in a double-locked compartment and refrigerated items was conducted and documented. -Two licensed nurses were required for CIIs and CIIIs documentation. -All Nurses and CMTs were to have completed controlled substance count sheet before and after each shift and for each change of assignment. -All nurses and CMTs were to have signed after each count. -The oncoming and off going Nurse/CMT were to have signed the count sheet at the same time the keys were exchanged. -If a discrepancy was noted, complete the count to ensure the remainder was accurate. -Conduct a thorough search of the medication and/or treatment cart for the missing medication. -Review the Electronic Medication Record (EMR) to ensure the documented administrations match the controlled substance count record for that medication. -If unable to correct the discrepancy, notify the supervisor immediately. -No staff was allowed to leave until the supervisor provides additional direction. -All staff was expected to remain on the unit until the supervisor arrives. 1. Observation on 6/30/23 at 6:40 A.M. of the 200/300 medication cart with LPN D showed: -He/she had pre signed the narcotic card count sheet before the day shift nurse counted with him/her. -The day nurse came at 6:50 A.M. -The narcotic card count sheet showed 13 cards of narcotic pills. -The actual count of narcotic cards was 12. -LPN D verified the count. During an interview on 6/30/23 at 6:50 A.M. LPN D said: -He/she had signed the previous shift at midnight not with the off going nurse at change of shift. -He/she should not have pre signed the narcotic count sheet until he/she had counted and signed with the on coming day shift nurse. -He/she did not know why there was 12 cards and 13 signed on the sheet. -He/she would go get another nurse to sign the correct amount. -Maybe should tell the Charge Nurse. During an interview on 6/30/23 at 7:25 A.M. LPN D said: -There should have been two nurses counting the narcotic cards which should match the number of pages with narcotics on them. -Each narcotic page should have the same number of pills on it as it showed on the narcotic page. -The oncoming and off-going nurses should count together and sign at the time they completed the count. 2. Review of the Narcotic Count Sheet dated 6/14/23 to 6/30/23 for the E hall medication cart on 6/30/23 at 7:40 A.M. showed: -There were two shifts per day, 16 shifts in this time frame. -Six shifts were signed by one nurse. -Two shifts were not signed by any nurse. -The columns included on the narcotic count sheet signature page were date, shift, off going nurse, oncoming nurse, staff count, additions, subtractions, and end count; -On June 14th A.M. shift the count was 14 cards. -On June 14th P.M. shift the count was 14 cards. -On June 15th A.M. shift the count was 14 cards. -On June 15th P.M. shift, one medication was subtracted, the count was 13 cards. -On June 16th A.M. shift the count was 13 cards. -On June 16th P.M. shift the count was 14 cards. -On June 17th A.M. shift, one medication was subtracted, the count was 13 cards. -On June 17th P.M. shift the count was 13 cards. -On June 18th A.M. shift the count was 13 cards. -On June 18th P.M. shift the count was 13 cards. -On June 19th A.M. shift the count was 13 cards. -On June 19th P.M. shift, one medication was added, three medications were subtracted, the count was 11 cards. -On June 20th A.M. shift the count was 11 cards. -On June 20th P.M. shift the count was 12 cards. -On June 21st A.M. shift the count was 12 cards. -On June 21st P.M. shift the count was 11 cards. -On June 22nd A.M. shift the count was 11 cards. -On June 22nd P.M. shift one medication was added, the count was 12 cards. -On June 23rd A.M. shift the count was 12 cards. -On June 23rd P.M. shift the count was 12 cards. -On June 24th A.M. shift the count was 12 cards. -On June 24th P.M. shift the count was 12 cards. -On June 25th A.M. shift the count was crossed out. -On June 25th P.M. shift the count was blank. -On June 26th A.M. shift the count was 12 cards. -On June 26th P.M. shift, subtracted one card, the count was 11 cards. -On June 27th A.M. shift the count was 11 cards. -On June 27th P.M. shift the count was 11 cards. -On June 28th A.M. shift the count was 11 cards. -On June 28th P.M. shift the count was 11 cards. -On June 29th A.M. shift the count was blank. -On June 29th P.M. shift two cards were added, the count was 13. -On June 30th A.M. shift the count was 13 cards. -The night shift nurse pre signed the count sheet. -The actual count was 12 cards verified with the nurse. 3. Review of the Narcotic Count Sheet dated June 23rd to June 30th for the CD hall medication cart on 6/30/23 at 10:00 A.M. showed: -There were two shifts per day, 13 shifts in this time frame. -Two shifts were signed by one nurse. -On June 23rd A.M. shift two cards were added, the count was 16 cards. -On June 23rd P.M. shift the count was 16 cards. -On June 24th A.M. shift no documentation. -On June 24th P.M. shift no documentation. -On June 25th A.M. shift the count was 16 cards. -On June 25th P.M. shift one card was subtracted, the count was 15 cards. -On June 26th A.M. shift the count was 15 cards. -On June 26th P.M. shift, the count was 15 cards. -On June 27th A.M. shift the count was 15 cards. -On June 27th P.M. shift the count was 15 cards. -On June 28th A.M. shift the count was 15 cards. -On June 28th P.M. shift the count was 15 cards. -On June 29th A.M. shift, the count was 15 cards. -On June 29th P.M. shift added one card, the count was 16 cards. -On June 30th A.M. shift the count was 15 cards. -The actual count was 16 cards verified by the Assistant Director of Nursing (ADON). NOTE: There were multiple discrepancies in the count on the narcotic sheet that were not addressed with documentation on the narcotic count sheet. During an interview on 6/30/23 at 8:00 A.M. the ADON said: -Two nurses should count the narcotics one oncoming and one off going. -Staff should not have pre signed the narcotic count sheet before the other nurse got here. -If the count was not correct the nurse should have notified the supervisor. -He/she had verified the count was off and would have the Director of Nursing (DON) adjust it. 37576 4. Review of the B, C, D, E, and F halls on the 100 Unit medication carts narcotic count sheets showed the following: -The B hall narcotic count sheets dated 6/5/23 at 7:00 A.M.-7:00 P.M. to 6/30/23 at 7:00 A.M., shifts showed: --Two signatures per shift for a total of four signatures a day. --Nine signatures out of 94 opportunities were not signed. --On 6/6/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/6/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/11/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/11/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/11/23 7:00 P.M.-7:00 A.M. on coming not signed --On 6/18/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/26/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/27/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/30/23 off going 7:00 A.M.-7:00 P.M. was Pre-signed by off going Registered Nurse (RN) C. -The C hall narcotic count sheets dated 5/29/23 7:00 A.M.-7:00 P.M. to 6/30/23 7:00A.M., shifts showed: --Two signatures per shift for a total of four signatures a day. --23 signatures out of 130 opportunities were not signed. --On 6/6/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/6/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/10/23 7:00 P.M.-7:00 A.M. on coming not signed. --On 6/11/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/11/23 7:00 A.M.-7:00 P.M. on coming not signed --On 6/11/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/11/23 7:00 P.M.-7:00 A.M. on coming not signed. --On 6/12/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/14/23 7:00 P.M.-7:00 A.M. on coming not signed --On 6/15/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/15/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/16/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/17/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/18/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/18/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/22/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/22/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/24/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/24/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/25/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/26/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/27/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/30/23 7:00 A.M.-7:00 P.M. on coming not signed. -The D hall narcotic count sheets dated 5/29/23 7:00 A.M.-7:00 P.M. to 6/30/23 7:00 A.M., shifts showed: --Two signatures per shift for a total of four signatures a day. --33 signatures out of 130 opportunities were not signed. --On 5/29/23 7:00 A.M.-7:00 P.M. off going not signed. --On 5/30/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 5/30/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/5/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/5/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/9/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/11/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/11/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/12/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/12/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/13/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/13/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/14/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/14/23 7:00 P.M.-7:00 A.M. on coming not signed. --On 6/15/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/15/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/15/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/15/23 7:00 P.M.-7:00 A.M. on coming not signed --On 6/16/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/17/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/17/23 7:00 P.M.-7:00 A.M. on coming not signed. --On 6/18/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/18/23 7:00 P.M.-7:00 A.M. on coming not signed --On 6/22/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/23/23 7:00 P.M.-7:00 A.M. on coming not signed. --On 6/24/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/24/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/24/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/24/23 7:00 P.M.-7:00 A.M. on coming not signed. --On 6/25/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/25/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/25/23 7:00 P.M.-7:00 A.M. on coming not signed. --On 6/30/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/30/23 off going 7:00 A.M.-7:00 P.M. was Pre-signed by on-coming RN C. -The E hall narcotic count sheets dated 6/12/23 7:00 A.M.-7:00 P.M. through 6/30/23 7:00 A.M., shifts showed: --Two signatures per shift for a total of four signatures a day. --14 signatures out of 74 opportunities were not signed. --On 6/12/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/13/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/13/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/13/23 7:00 P.M.-7:00 A.M. on coming not signed. --On 6/14/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/16/23 7:00 A.M.-7:00 P.M. on coming not signed. --On 6/16/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/17/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/18/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/20/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/21/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/22/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/26/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/27/23 7:00 P.M.-7:00 A.M. off going not signed. -The F hall narcotic count sheets dated 6/12/23 7:00 A.M.-7:00 P.M. to 6/30/23 7:00 A.M., shifts showed: --Two signatures per shift for a total of four signatures a day. --Five signatures out of 74 opportunities were not signed. --On 6/20/23 7:00 P.M.-7:00 A.M. on coming not signed. --On 6/21/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/26/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/26/23 7:00 P.M.-7:00 A.M. off going not signed. --On 6/27/23 7:00 A.M.-7:00 P.M. off going not signed. --On 6/30/23 off going 7:00 A.M.-7:00 P.M. was Pre-signed by off going RN C. During an interview on 6/30/23 at 6:57A.M., RN C said he/she pre-signed F and B halls medication narcotic count sheets for going off shift while waiting for the on-coming nurse to arrive. 5. During an interview on 7/5/23 at 1:08 P.M. the DON said: -The narcotic count should have been done with the on coming and off going nurses. -The nurses should have counted together and signed together. -Staff should not have pre signed the narcotic count sheet before the other person got to work. -There should have always been two signatures. -If the card count was not equal to the number of cards the staff should have corrected it. -If the card count was off the house supervisor should have been notified. -The charge nurse was responsible to ensure the narcotic count was correct.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a secure, sanitary, temperature appropriate environment. The facility census was 105 residents. Review of the facility's policy, Storage of Medications, dated 11/1/2014 showed: -The purpose was to ensure that the community stored all drugs and biologicals under proper conditions of security, segregation and environmental control at all times. -Medications were to have been stored primarily in a locked mobile medication cart which was accessible only to licensed nursing personnel. -Storage of other medication would be in a locked area. -The medication cart was to have been kept locked at all times when not in use or in direct view of the nurse. -Drugs requiring refrigeration were to have been stored separately in a refrigerator which was locked or in a locked medication room and was used exclusively for medication and medication adjuncts, such as juice or applesauce. -The inside temperature of the refrigerator in which drugs were to have been stored would be maintained within 36 to 46 degree Fahrenheit (F) range. -A thermometer would be kept in the refrigerator for monitoring temperature ranges. -Medication refrigerators would be cleaned by community licensed personnel on a regular basis to ensure that there was no accumulation of frost, foreign matter or soiled material. -The nursing staff on all shifts and all units was directly responsible for maintaining proper cleanliness of all medication storage areas and mobile medication carts. -Medication carts and refrigerators would be cleaned at least weekly, based upon a posted schedule in the medication area. -All spills would be cleaned immediately. 1. Review of the Daily Refrigerator Temperature Log on 200 unit dated April 2023 showed: -The normal temperature range of the refrigerator was 35 to 40 degree F. -Adjust the refrigerator temperature if not between 35 to 40 degree F. -Notify Supervisor that the temperature was outside the range. -The refrigerator's temperature had not been checked 15 out of 30 opportunities. -The temperature once was 42 degrees F. -There was no documentation the temperature had been adjusted. -There was no documentation the Supervisor had been notified. Review of the Daily Refrigerator Temperature Log on 200 unit dated May 2023 showed the refrigerator's temperature had not been checked 19 out of 31 opportunities. Review of the Daily Refrigerator Temperature Log on 200 unit dated June 2023 showed the refrigerator's temperature had not been checked 15 out of 30 opportunities. Review of the Daily Refrigerator Temperature Log on 200 unit dated July 2023 (on July 5)showed no documentation. 2. Observation on 6/28/23 at 10:26 A.M. of the medication cart on BDE hallway showed: -The medication cart was unlocked for ten minutes. -Two residents walked by within two feet of the medication cart. -There was no nursing staff observing the cart. 3. Observation on 6/30/23 at 6:50 A.M. of the medication refrigerator on the 200 hallway with Licensed Practical Nurse (LPN) D showed the temperature was 50 degrees F. -There was a can of beer with a resident's name on it in the medication refrigerator. -There was a food refrigerator sitting next to the medication refrigerator. -The temperature was verified by LPN D to have been 50 degrees F. -There were two thermometers in the refrigerator which showed the same temperature. -There was a temperature log attached to the front of the medication refrigerator that showed the following instructions; -The temperature should have been 35 to 40 degrees F. -Staff was to adjust the refrigerator temperature if it was not between 35 - 40 degrees F. -Staff was to notify the supervisor if that temperature was outside of the range. -When the temperature log was completed it should have been sent to the unit manager. 4. Observation on 6/30/23 at 7:00 A.M. of the Medication room on 200 hallway with LPN D showed: -An unknown person's lower set of dentures was in a plastic bag hanging on the bulletin board. -The resident's pill cups used for medication were in a drawer with a used electric razor. 5. Observation on 6/30/23 at 7:20 A.M. of the Medication room refrigerator on 200 hallway showed: -The temperature was 52 degrees F. -There were two thermometers in the refrigerator. -The temperature was verified by LPN D. During an interview on 6/30/23 at 7:25 A.M. LPN D said: -He/she did not know what the temperature of the medication refrigerator should have been. -He/she had not ever checked it. -He/she did not know who was responsible for ensuring the medication refrigerator temperatures were being checked or what to do if it was out of range. 6. Observation on 6/30/23 at 7:30 A.M. of the Medication refrigerator on 200 hall medication room with the Assistant Director of Nursing (ADON) showed the following medications in the medication refrigerator that belonged to residents which had a physician's order: -One box of Tuberculin (a skin test to determine if a person has Tuberculosis) 10 tests. --The manufacture's directions on the box said to store at 35 to 46 degrees F. -Zioptan eye drops (a medication used to treat high blood pressure in the eye) two envelopes. -Six Lantus insulin (a long acting insulin used to lower a person's blood sugar) pens. -One Tresiba insulin (a long acting insulin used to lower a person's blood sugar) pen. -Two Levimir insulin (a man-made form of a hormone that was produced in the body used to treat diabetes) pen. -Five Humalog (a insulin used to treat high blood sugars) pens. -One Tresiba 10 milliliter (ml) vial expiration date 6/13/23. -Five Lorazepam (a controlled substance used to treat seizures or used to relieve anxiety) 30 ml vials. -Two boxes of Trulicity (a once weekly medication used to treat high blood sugars) with one pen in each box. --The manufacture's directions on the box said to store at 36 to 46 degrees F. -One box of Trulicity with three pens in it. -Two boxes of Trulicity with two pens in it. -48 Bisacodyl (a medication used to treat constipation)10 milligram (mg) suppositories. -24 Tylenol (medication for pain relief or increased temperatures) suppositories. -Three bottles of Latanoprost (medication used to treat glaucoma - a group of eye conditions that can cause blindness) eye drops a 2.5 ml bottle. During an interview on 6/30/23 at 8:00 A.M. the ADON said: -The night nurse should have checked the temperatures for the medication refrigerators. -The House Supervisor was responsible for ensuring it was done. -A resident's beer should have been in the food refrigerator. -He/she did not know whose dentures were hanging on the bulletin board but they should not have been there. -The Medication carts should always be locked when not within sight of the nurse. -The used electric razor should not have been in a drawer with the medication cups. -There should not have been any expired medications. -The refrigerator temperatures should have been checked daily and if out of range reported to maintenance. 7. Observation on 6/30/23 at 8:15 A.M. of the C/D hallway Certified Medication Technician (CMT) medication cart with the ADON showed: -The top two drawers were dirty with multi colored debris. -Bleach wipes were in the same compartment as a resident's EVO (an eye supplement) eye supplements. -A resident's physician prescribed Polyethylene (a medication used to treat constipation) 238 gram (gm) container was opened without an opened date written on it. -A resident's physician prescribed Refresh (a medication that lubricates and moisturizes the eyes) eye drops a 15 ml bottle was opened without an opened date written on it. -A resident's physician prescribed Erythromycin (an antibiotic used to treat infections) eye ointment one ounce tube was opened without an opened date written on it. -The top of the medication cart was dirty with rust around the outside. -The second drawer was dirty with a yellow sticky substance in the bottom of the drawer. -The fourth drawer was dirty with a brown food substance in the bottom of the drawer. During an interview on 6/30/23 at 8:30 A.M. the ADON said: -Staff should have dated open bottles of medications. -The drawers were not clean. -Whoever used the medication carts should ensure they were cleaned at the end of their shift. -The shift supervisor should have ensured the carts were cleaned regularly. 8. During an interview on 7/5/23 at 1:08 P.M. the Director of Nursing (DON) said: -The temperature of the medication refrigerator should have been checked by the charge nurse on the night shift at shift change. -The temperature should have been checked daily. -The temperature should be what the facility policy stated. -The refrigerator should not have been 50 degree F or above. -If the temperature in the refrigerator was above 50 degrees F they should have moved the medication to another refrigerator. -Staff should have notified the house supervisor or maintenance. -Beer should not have been in the medication refrigerator. -There should not have been a plastic bag with dentures in it in the medication room. -The dentures should have been given to the Social Worker so they could have figured out who they had belong to. -There should not have been a used electric razor in with the medication pill cups. -Bleach wipes should not have been in with the medications. -The staff member who was assigned to the medication cart should have cleaned it. -Prescription medications should have had a date that they were opened written on it. -Medication carts should have been locked if the CMT or nurse was not in front of the cart.

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 by not changing their gloves at appropriate times, by not washing their hands between glove changes, by not cleaning scissors after each use and by failing to wash or sanitize their hands between each resident during wound care for four sampled residents (Resident #96, #80, #33, and #89) out of 21 sampled residents; and to provide Tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for two sampled residents (Resident #39 and #96) out of five residents sampled for TB. The facility census was 105 residents. Review of the facility's gloving policy with a review date of 1/18/19 showed: -Proper gloving, in addition to proper handwashing, is used for the prevention of transmission of infectious diseases that might be transmitted through blood and body fluids and contact with hazardous materials. -All associates are required to wear gloves when: --coming in contact with blood, body fluids, non-intact skin, and mucous membranes. --Coming in contact with hazardous chemicals or potentially infectious materials, such as trash and soiled linens. -Wash hands before putting on gloves. -When ready to remove gloves dispose in a trash container. -Wash hands (Sani-wipes may be used when doing multiple glove changes on same care, as long as hands are not visibly soiled). Review of the facility's Hand Hygiene policy with review date of 1/3/23 showed: -Proper hand hygiene is used for the prevention of transmission of infectious disease. -All healthcare personnel are required to perform hand hygiene by using alcohol-based hand rub or wash with soap and water for the following indications: --Immediately before touching a resident. --After touching a resident or the resident's immediate environment. --Before and after using gloves. --After contact with body fluids: blood, urine, feces, oral secretion, mucous membranes, or non-intact skin or handling items potentially contaminated with body fluids. --When going from a soiled body site to a clean body site on the same patient. Review of the facility's Tuberculosis Test for Residents policy, with review date of 6/7/23, showed: -All residents newly admitted to the facility from the hospital or community are required to obtain a Mantoux Purified Protein Derivative (PPD- a two-step skin test used as a method to diagnose silent TB infection). -All skin results were documented in millimeters (mm) of induration. -Administration of the first step TB skin test was documented in the Electronic Medical Record (EMR). -TB skin test results were read by a licensed nurse on the night shift. -Results were recorded on the EMR. -The second test was administered within 10-14 days of the initial TB skin test. -Administration of second TB skin test was recorded on the residents EMR. -Results of the second TB skin test was read by a licensed nurse on the night shift. -Results were recorded on the EMR. 1. Review of Resident #96's Admission Record showed he/she admitted to the facility on [DATE] with the following diagnoses: -Stroke. -Peripheral Vascular Disease (PVD-fatty deposits and calcium building up in the artery walls cause narrowing of blood vessels and reduce blood flow to the limbs). Review of the resident's undated Care Plan showed: -He/she was at risk for skin problems related to pressure and incontinence. -He/she admitted with a Stage III (full-thickness skin loss extending into the tissue beneath the skin, forming a small crater) pressure ulcer to his/her coccyx (small triangular bone at the base of the spinal column in humans). Review of the resident's Admission Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 5/22/23 showed: -His/Her cognition was severely impaired. -He/she was at risk for developing a pressure ulcer (PU-localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). -Had one Stage III PU present on admission. Review of the resident's nursing note dated 5/15/23 at 8:16 P.M., showed he/she had a Stage II (partial-thickness skin loss involving the epidermis and dermis) to his/her coccyx and upper buttocks that measured 2.0 centimeters (cm) length by 0.5 cm wide. Review of the resident's wound care note dated 5/17/23 at 8:42 P.M., showed: -The wound Nurse Practitioner (NP) was seeing the resident. -The Stage III PU to the coccyx measured 3.60 cm length by 2.33 cm wide by 0.1 cm deep. Observation of the resident's wound care on 6/28/23 at 1:42 P.M., showed: -Registered Nurse (RN) B set up supplies on a clean barrier. -Washed his/her hands and donned gloves. -Picked up and moved the fall mat from the side of the resident's bed. -Raised the resident's bed with the same gloves on. -Removed the resident's blanket and rolled the resident toward him/her to remove resident's pants and brief. -Removed the old foam dressing from the resident's wound without changing gloves or washing/sanitizing hands and re-gloving. -The wound NP took measurements of the resident's PU. -RN B removed his/her gloves and washed hands and re-gloved. -Cleaned the resident's coccyx area wound with wet wipes and soap and water. -Removed his/her gloves, washed his/her hands and re-gloved. -Picked up the trash can and moved it to the side of the bed. -Cleaned the resident's buttock without changing gloves or washing/sanitizing hands and re-gloving. -Removed his/her gloves washed his/her hands and re-gloved, cleaned the resident's coccyx area again with wound cleanser. -Applied skin prep around the resident's wound edges and applied Santyl (ointment that helps remove dead skin tissue and aid in wound healing) with a cotton tipped applicator to the resident's coccyx wound. -Cut Calcium Alginate (a fluid absorbing dressing) with silver to fit without cleaning/sanitizing scissors. -Covered the resident's coccyx wound with folded ABD pad (a thick absorbent pad dressing) and secured with foam tape. -Re-taped the resident's brief and pulled his/her pants back up. -Lowered the resident's bed. -Put protective boots on the resident. -Removed his/her gloves did not wash hands. -Put used supplies in trash. -Placed the fall mat back next to the resident's bed and put call light on bed positioning bar. -Washed hands and put unused/re-usable supplies back in resident's bags in treatment cart. -Did not clean/sanitize scissors. 2. Review of Resident #80's Admission Record showed he/she admitted on [DATE] with the following diagnoses: -Vascular dementia (is a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of vital oxygen and nutrients). -PVD. -Non-pressure chronic ulcer other part right foot with fat layer exposed. -Non-pressure chronic ulcer other part right foot limited to breakdown of skin. -Unspecified open wound to left foot, subsequent encounter (any encounter after the active phase of treatment). -Cellulitis (a common and potentially serious bacterial skin infection) of left toes. Review of the resident's wound care note dated 1/13/23 at 12:04 P.M., showed: -Wound NP saw the resident weekly for chronic ulcers to both his/her feet. -His/her left medial foot ulcer measured 1.99 cm length by 0.89 cm wide by 0.1 cm deep. -His/her left top foot ulcer measured 2.42 cm length by 3.79 cm wide by 0.1 cm deep. -His/her right lateral foot wound measured 6.45 cm length by 2.46 cm wide by 0.1 cm deep. Review of the resident's care plan dated 2/27/23 showed: -The resident was at risk for skin problems related to pressure, decreased circulation and fragile skin. - The resident had chronic ulcers to both of his/her feet. Review of the resident's wound care note dated 5/26/23 at 9:00 A.M., showed: -His/her left top foot ulcer measured 2.59 cm length by 1.60 cm wide by 0.1 cm deep. -His/her right lateral foot ulcer measured 7.40 cm length by 4.18 cm wide by 0.1 cm deep. -His/her right medial foot ulcer measured 6.22 cm length by 3.76 cm wide by 0.1 cm deep. -He/she had a chronic ulcer/rash to his/her right lower leg with open areas had extended and now measured 12.06 cm length by 8.71 cm wide by 0.1 cm deep. -Weeping edema (swelling) right lower leg not noted previously. Review of the resident's wound care note dated 6/23/23 at 2:32 A.M., showed: -His/her left top foot ulcer measured 1.47 cm length by 2.79 cm wide by 0.1 cm deep. -His/her right lateral foot ulcer measured 6.48 cm length by 1.91 cm wide by 0.1 cm deep. -His/her right medial foot ulcer measured 3.86 cm length by 2.79 cm wide by 0.1 cm deep. -He/she had chronic ulcer/rash to right lower leg with open areas had improved and now measured 5.80 cm length by 3.41 cm wide by 0.1 cm deep. Observation on 6/28/23 at 2:12 P.M., of the resident's wound care showed RN B: -Washed his/her hands. -Did not glove. -Placed a disposable Chux pad under the resident's legs and on bedside table. -Pushed the resident's pants leg up, and placed supplies on clean barrier on table. -The resident decided to use the restroom before starting treatment. -RN B put gloves on and got the resident clean briefs and pants, and got resident's pant legs back up. -Continued getting more supplies out of treatment cart did not change gloves or wash/sanitize hands. -Removed gloves washed hands and re-gloved, raised bed up with gloves on. -Removed resident's socks and ace wraps from his/her legs. -Took scissors which were not cleaned from previous resident's treatment, and cut bulky Kerlix gauze wraps from both legs. -The resident's right foot had white macerated areas with reddened non-skin areas with drainage on medial side of his/her foot and heel, lateral side of foot and end of toe areas. -The resident's left foot area had white macerated areas with reddened non-skin areas with drainage around around toe areas. -Cleaned the areas to the resident's both feet with wipes and soap and water then with wound cleanser and gauze. -Did not change gloves, wash/sanitize hands and re-glove. -Applied A&D (vitamin A & D) with zinc cream to the resident's reddened areas of both feet, and calcium alginate dressing on areas. -Applied moisturizer gel to bilateral legs to protect from wraps. -Removed gloves threw used supplies in trash. -Opened Kerlix gauze packages and ABD packages. -Re-gloved without wash/sanitizing hands. -Placed ABD pad over the resident's toe area of right foot and wrapped Kerlix around. -Placed ABD on the resident's medial & lateral sides of right foot and continued to wrap foot to knee. -Removed gloves did not wash/sanitize hands and re-gloved. -Secured Kerlix with tape at top of Kerlix and over toe areas. -Applied ace wrap around the resident's right foot and up leg to knee and secured. -Did the same dressings and wraps for the resident's left foot. -Placed socks back on the resident's feet. -Lowered the bed. -Picked up trash bag. -Washed hands. -Put unused supplies and scissors on treatment cart. -Did not clean/sanitize scissors. 3. Review of Resident #33's Admission Record showed he/she admitted on [DATE] with the following diagnoses: -Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). -Dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning). -Diabetes Mellitus II [condition that affects the way the body processes blood sugar (glucose)]. Review of the resident's wound care note dated 3/3/23 at 2:13 P.M., showed: -Resolving blister right medial foot, bunion area 0.8 cm length by 0.5 cm wide. -Treatment initiated. Review of the resident's wound care note dated 3/8/23 at 7:14 P.M., showed: -Wound NP now seeing resident weekly. -Wound to the resident's right medial foot, bunion area 1.10 cm length by 0.87 cm wide by 0.1 cm deep. -Treatment applied. Review of the resident's wound care note dated 4/26/23 at 9:29 P.M., showed: -Wound to the resident's right medial foot, bunion area 0.83 cm length by 0.64 cm wide by 0.1 cm deep. -Treatment changed to Medi-Honey (a brand name wound product-it hastens the healing process) to wound bed. Review of the resident's Quarterly MDS dated [DATE] showed: -His/Her cognition was severely impaired. -Was at risk for developing PU. -Had one Stage III PU not present on admission. Review of the resident's Care Plan dated 5/16/23 showed: -At risk for skin problems related to pressure, decreased circulation and fragile skin. -Current Stage III pressure ulcer to right medial foot. -Black heel suspension boots at all times. -Treatments as ordered. Review of the resident's Physician Order sheet (POS) dated June 2023 showed: -Pressure injury to the resident's right medial foot, bunion area. -Wash area with soap and water and clean wound with wound wash. -Apply Medi-honey to wound bed. -Apply zinc oxide (type of medication to treat or prevent minor skin irritations) to peri wound (the edges of a wound). -Cover with Kerracel Alginate (brand name for Calcium Alginate-a fluid absorbing dressing), then thickness of gauze. -Apply skin prep (protective substance to protect skin from tape and adhesive dressings) and secure dressing with foam tape. -Change dressing daily and as needed (PRN) until resolved. Review of the resident's wound care note dated 6/23/23 at 1:50 P.M., showed: -Wound to the resident's right medial foot, bunion area 0.87 cm length by 0.91 cm wide by 0.2 cm deep. -Treatment applied. Observation of the resident's wound care on 6/28/23 at 3:07 P.M., showed: -RN B setting up supplies on a clean barrier. -Did not clean/sanitize scissors from using with previous resident's treatment. -Pre-cut the calcium alginate without washing/sanitizing hands or putting gloves on. -Resident in bed with protective boots on. -Washed hands and put on gloves then moved fall mat away from the resident's bed. -Removed resident's protective boot and resident's sock. -Removed foam dressing from resident's foot without changing gloves and washing/sanitizing hands. -Used wet wipes with soap and water to clean wound area. -Placed new trash bag in trash can without removing gloves or washing/sanitizing hands and re-gloving, then cleaned wound area with wound cleanser. -Removed gloves, did not wash/sanitize hands and re-gloved. -Placed the Medi-Honey on the Calcium Alginate and placed on wound bed. -Placed 2x2 gauze on wound and covered with foam dressing. -Replaced sock and protective boot. -Placed fall mat next to bed with same gloves. -Removed gloves, washed hands put unused supplies on treatment cart. -Did not clean/sanitize scissors. During an interview on 6/28/23 at 3:15 P.M., the Wound NP said: -The resident had a Dermatologist appointment set up to see if the feet areas were more related to possible fungal or bacteria and if there may be other treatment options. -The resident's feet get better then skin issues return. -The resident served in military for years and he/she said spent a lot of time in the trenches. 4. Review of Resident #89's Admission Record showed he/she admitted on [DATE] with the following diagnoses: -Dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning). -Diabetes Mellitus II. Review of the resident's Care Plan undated showed: -At risk for skin problems related to pressure, incontinence and thin fragile skin. -Skin would remain without breakdown over the next 90 days. -Dated 6/19/23: scratch on top of his/her left foot. Review of the resident's POS dated June 2023 showed: -Weekly skin assessment and record findings dated 5/22/23. -Bunny boots (soft padded feet protectors) while in bed or resting in recliner/wheelchair dated 5/22/23. -Hospice consult dated 6/12/23. -Wound care orders for trauma to top of left foot dated 6/30/23 showed: --Wash area with soap and water and clean wound with wound wash. --Apply Triple Antibiotic Ointment (TAO) to wound bed. --Cover with thickness of gauze. --Apply skin prep to peri wound and secure dressing with foam tape. --Complete treatment three times weekly and PRN until resolved. Review of the resident's nurses note dated 6/30/23 at 8:40 A.M., showed: -Wound NP saw resident on 6/28/23 for assessment and treatment of wound to top of left foot. -Resident had a traumatic injury to top of his/her left foot measuring 2.03 cm length by 2.55 cm wide by 0.1 cm deep. -Unit nurse believes he/she scratched his/her foot on a foot peddle of wheelchair as he/she had been observed taking off socks and fidgeting with the peddles. Observation of the resident's wound care on 6/28/23 at 3:24 P.M., showed: -RN B place Chux barrier under the resident's left foot while resident was sitting in a tilt broda chair with padded foot rests. -Washed hands and gloved. -RN B removed the resident's sock with gloves on did not change gloves or wash/sanitize hands and re-glove. -Cleaned the area with wound cleanser. -Removed gloves did not wash hands. -Cut foam dressing tape, did not clean scissors from last resident usage. -Took TAO, 2x2 gauze, and skin prep out of the treatment cart. -Put gloves on without washing hands. -Applied skin prep, TAO, and 2x2 gauze and foam dressing tape. -Replaced the resident's sock. -Removed gloves and washed hands. -Area on top medial of left foot abrasion reddened, but not opened. 5. During an interview on 6/30/23 at 10:15 A.M., Licensed Practical Nurse (LPN) A said: -When doing resident cares he/she washed his/her hands and put gloves on when he/she entered the room. -Change gloves when going from dirty to clean areas and wash/sanitizes hands. -If touched anything else in room while doing cares changed gloves, wash/sanitize hands and re-gloved. -When doing dressing changes/wound care he/she washed/sanitized hands and put gloves on. -Removed old dressing. -Removed gloves, washed/sanitized his/her hands and re-gloved. -If touched other objects in room while doing the dressing changes/wound care he/she would change gloves, wash/sanitize hands and re-gloved. -Always clean/sanitize scissors before and after each use and between residents. During an interview on 6/30/23 at 10:25 A.M., RN B said: -When doing wound care he/she washed his/her hands and put gloves on when entered room. -Puts wound care supplies on a clean barrier. -Washed/sanitized his/her hands and puts gloves on and removes old dressings. -If using scissors place on barrier. -When remove old dressings change gloves wash/sanitize hands and re-glove. -Do wound treatments if gloves get ointment or creams on remove, wash/sanitize, and re-glove. -Scissors should be cleaned/sanitized before and after use and always between residents. -Change gloves and wash/sanitize hands from dirty to clean areas with resident cares. During an interview on 7/5/23 at 1:08 P.M., the Director of Nursing (DON) said: -Hands should be washed all the time, when entering rooms, gloving, between glove changes and when finish cares. -Wash/sanitize hands when changing gloves and re-gloving. -When wearing gloves do not touch other objects not related to the care without removing gloves and washing/sanitizing hands. -Scissors should be cleaned/sanitized with bleach wipes before and after using and between residents. 42955 6. Review of the Resident #39's admission MDS dated [DATE], showed: -The resident scored a 15 on the Brief Interview for Mental Status (BIMS - an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions). --This showed that the resident was cognitively intact. Review of the resident's EMR dated June 2023, showed the resident's diagnoses included: -Chronic Obstructive Pulmonary Disease, unspecified (COPD - (a disease process that decreases the ability of the lungs to perform ventilation). -Type 2 Diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). -High blood pressure. Review of the resident's Medication Administration Record (MAR)/Treatment Administration Record (TAR) dated June 2023, showed: -The resident's first dose of the TB skin test was administered on 4/21/23. -The resident's first dose of the TB skin test was read on 4/21/23. -The resident's second dose of the TB skin test was administered on 4/28/23. -The resident's second dose of the TB skin test was read on 4/30/23. -NOTE: This showed the first TB was read on the same date it was administered. 7. Review of Resident #96's admission MDS, dated [DATE], showed: -The resident scored a 04 on the BIMS. -This showed the resident was severely cognitively impaired Review of the resident's EMR, undated, showed the resident was diagnosed with: - Vascular dementia (an impaired supply of blood to the brain). -Hemiplegia (a severe or complete loss of strength) and hemiparesis (one-sided muscle weakness) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side. Record review of the residents MAR/TAR dated June 2023, showed: -The resident's first dose of the TB skin test was administered on 5/16/23. -The resident's first dose of the TB skin test was read on 5/16/23. -The resident's second dose of the TB skin test was administered on 5/23/23. -The resident's second dose of the TB skin test was read on 5/25/23. -NOTE: This showed the first TB was read on the same date it was administered. 8. During an interview 6/30/23 at 8:55 A.M., Admissions Coordinator A said: -The night shift nurses completed TB on new residents. -Resident TB skin tests and results were documented on the MAR/TAR. -He/she was unable to find any other documentation showing that Resident #39 and Resident #96 had TB read on a different date than what was on the MAR/TAR. During an interview on 6/30/23 at 10:30 A.M., the DON said: -TB tests were administered to residents upon admission. -Administered tests were documented on the MAR/TAR -Read dates were also documented on the MAR/TAR. -Charge nurses were responsible for assuring the residents received TB tests and for reading them. -He/She expected all residents to have at TB tests administered upon admission and documented on the MAR/TAR. -Results should be read 48-72 hours after administration and documented with results also on the MAR/TAR. -He/She did not expect to have TB tests given and read on the same day.

Based on interview and record review, the facility failed to ensure physician orders for a sit to stand (a device designed to help people stand and transfer when the person can bear some body weight but lacks strength and/or muscle control to independently rise to a standing position) transfer with two staff were followed and clarified with the physician and to ensure the resident orders and Resident Profile sheet were updated when the resident's transfer status changed following an injury during a sit-to-stand transfer for one sampled resident (Resident #61) out of 21 sampled residents. The facility census was 105 residents. Review of the facility's Fall Prevention Program Procedure Guide, updated 5/11/23, showed the facility would use interventions and efforts to prevent residents from falling and injuring themselves while maintaining their right to function as independently as possible. 1. Review of Resident #61's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses that included: -History of falling. -Orthostatic hypotension (a condition in which the blood pressure suddenly drops when standing from a seated or lying position with common symptoms being lightheadedness or dizziness upon standing). -Hemiplegia (paralysis on one side of the body) after stroke affecting left side. -Lack of coordination. -Unsteadiness on feet. -Abnormalities of gait and mobility. Review of the resident's Alteration in Self-Care Care Plan, updated 10/11/22 showed: -The resident was unable to get out of bed. -The resident got up with a sit to stand lift, medium vest and two staff at all times. Mechanical lift (a device that allows a person to be lifted for transfer) used as needed with two staff, effective 9/2/20. Review of the resident's Physical Therapy (PT) Plan Progress and Discharge Summary, dated 2/28/23 showed: -The resident received five treatment services from 2/22/23 through 2/28/23. -PT assessed the resident and provided training to caregivers regarding set up for resident sit-to-stand lift to achieve optimal posture with no complaints of pain during transfers. -On 2/28/23 the goal was met for the caregivers to assist the resident to use the sit-to-stand lift with the resident's feet in the correct position without instructions/cues to promote increased comfort and reduce the risk of injury to the resident while on the sit-to-stand. Review of the resident's physician orders, dated June, 2023, showed orders for a sit-to-stand machine with two staff and medium vest and mechanical lift as needed with two staff and medium sling starting 10/27/21. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 6/15/23 showed the resident: -Was moderately cognitively impaired. -Required extensive one-person physical assistance with transfers. -Was not steady and was only able to stabilize with assistance when moving from a seated to a standing position and when transferring from surface to surface. Review of the resident's Incident Report, dated 6/25/23 showed: -On 6/25/23 at 6:00 A.M. the resident was using a sit to stand to be transferred to a chair. The resident picked up his/her left foot and his/her shin scrapped across the sit-to-stand device. -The resident could not remember the incident to give an account of what happened during the transfer. -A five centimeter (cm) by two cm by zero cm (depth) skin tear was sustained on the resident's left lower leg front (shin bone). -The physician was notified. -The resident's left lower leg area was elevated, cleansed and dressed. Review of the resident's wound care note, dated 6/26/23 at 4:11 P.M. showed: -Seeing resident for a report of a new skin tear on his/her left shin acquired during transfer with sit-to-stand lift. -Wound expected to heal with no issues. Nursing to monitor daily for continued healing. -In talking with nurse and Certified Nurses Aide (CNA) all are in agreement that the resident was becoming weaker and no longer safe for transfer with sit-to-stand lift. -Resident to be transferred with mechanical lift. -Profile updated with change. Review of the resident's Social Services Care Plan meeting note, dated 6/27/23 at 12:03 P.M. showed: -The family attended the resident's care plan meeting along with the Social Worker and Director of Nursing (DON). -They discussed the skin tear of 6/25/23 and the circumstances of how it occurred. -Therapy screening was last completed 6/7/23 and there were no indications of any issues. -The resident will now use a mechanical lift for transfers for increased safety and injury prevention related to increased weakness. Review of the resident's Alteration in Self-Care Care Plan, updated 6/27/23, showed: -The resident was non-ambulatory. -The resident required the use of a mechanical lift with medium sling and assistance of two with transfers. During an interview on 6/27/23 at 11:04 A.M. Family Member A said: -The resident had been using a sit-to-stand device for three years and had an accident while using it on 6/25/23 at 6:00 A.M. -The family noticed the resident had been getting weaker and it had become more difficult for the resident to transfer with the sit-to-stand, but the family had not reported these concerns to facility staff because he/she thought the facility should be proactively evaluating the resident for their transfer safety. -The DON told him/her the resident's foot slipped during the sit-to-stand transfer causing a skin tear. -The resident was now to be transferred using a mechanical lift. Review of the resident's Incident Follow-up Report, dated 6/28/23 showed: -The Nurse Practitioner ordered X-rays due to discomfort post skin tear which were negative for injury. -The wound team evaluated the injury on 6/26/23. -The resident changed from a sit-to-stand lift to a mechanical lift for safety and therapy recommendation. -The resident's care plan and resident profile were updated. -A care plan meeting was held on 6/27/23 with the family. -Therapy thought the change from sit-to-stand to mechanical lift would be appropriate even though the resident's therapy screen on 6/7/23 did not indicate any major changes. Review of the Resident's Profile sheet, dated 6/28/23 located on the wall at the end of the resident's hall, showed beside the resident's name: -Mechanical lift, medium sling. Assist times two with verbal cueing. -Must have on shoes when on sit-to-stand with transfers. During an interview on 7/5/23 at 9:27 A.M. Physical Therapist A said: -The resident was seen by PT from 2/22/23 through 2/28/23 as a result of a request from nursing because the resident wasn't tolerating the sit-to-stand lift. -The resident was currently on Restorative Aide (RA - services that help maintain a person's physical and cognitive abilities) services for range of motion. -The resident was assessed using the sit-to-stand with staff from both clinical teams and CNAs received training between 2/22/23 and 2/28/23 for increased safety during transfers. -He/She discussed with the CNAs if the resident had left foot pain or had a urinary tract infection (UTI) staff could use the mechanical lift for the resident instead. -The resident was last evaluated for appropriateness of the sit-to-stand on 2/28/23. -All residents were screened for therapy monthly and that included talking with staff about the resident. -When there were completely new changes in a resident an evaluation was completed. The resident was not re-evaluated for the mechanical lift after the sit-to-stand accident because he/she was already on a mechanical lift as needed status. -The facility's sit-to-stand policy was changed several months ago from two staff being present during the sit-to-stand lifts to one staff person and all nursing and therapy staff were in-serviced on the new policy. During an interview on 7/5/23 at 10:03 A.M. Agency CNA A said: -He/she worked multiple times each month at the facility and had been told in shift report that the resident's transfer status had changed from a sit-to-stand lift to a mechanical lift. -The Resident Profile sheets were located on the wall at the end of each resident hall and that was what he/she used for his/her reference when providing cares and to know how a resident was supposed to be transferred. -He/she didn't know why the Resident Profile sheet showed the resident's transfer as both mechanical lift and sit-to-stand. The Resident Profile sheet should accurately show the residents' transfer status. -He/she had been told by the charge nurse months ago that only one CNA was required for a sit-to-stand lift. If two staff were required for any particular resident for sit-to-stand transfers it would show assist times two on the Resident Profile sheet. During an interview on 7/5/23 at 10:19 A.M. Licensed Practical Nurse (LPN) C said: -He/she was told a few days to a week ago in shift report the resident's status was now a mechanical lift, and before that it was a sit-to-stand. -Only one staff was needed to transfer residents using a sit-to-stand. -It looked as if the resident's previous care plan (dated 10/11/22) showed two staff were to be present when the resident used the sit-to-stand. -The resident's current orders, dated 10/27/21, still showed sit-to-stand with two staff and mechanical lift as needed with two staff. -The Resident Profile sheet showed mechanical lift with two staff and sit-to-stand with the resident wearing shoes. -Probably the sit-to-stand should be taken off the Resident Profile sheet until therapy can re-evaluate to see if the resident is safe to use the sit-to-stand. During an interview on 7/5/23 at 12:34 P.M. the Nurse Practitioner said: -If the resident's physician orders says staff should transfer the resident on the sit-to-stand with two staff then he/she expected staff to follow the order as written and there should be two staff when assisting the resident with the sit-to-stand. -The orders for a lift would have reflected therapy recommendations because that was who evaluated the resident's transfer abilities. -The resident's transfer status changed within the past week to 10 days. Apparently, the resident didn't feel safe during a sit-to-stand transfer and was flailing and injured his/her left leg and is now transferring with the use of a mechanical lift. -The resident's current orders should be for a mechanical lift. -If the sit-to-stand transfer status was still showing on the resident's orders then nursing might not have gotten the orders changed in the e-chart. During an interview on 7/5/23 at 1:04 P.M. the DON said: -Months ago the facility policy on sit-to stand was changed to show that one staff member could do sit-to-stand transfers. -The resident's orders showing two staff with the sit-to-stand probably didn't get changed when the facility policy changed. The resident's orders and care plan should have been updated at the time to reflect the facility's changed policy. -CNAs should go by the Resident Profile sheet when transferring residents. The Resident Profile sheet should show the resident's current status as a mechanical lift for transfers. -Nurses go by the Resident Profile sheet and the resident's care plan to find the residents' transfer status. -The resident's orders, care plan and profile should accurately reflect the resident's transfer status. During an interview on 7/5/23 at 2:57 P.M. CNA B said: -He/she was getting the resident up the morning of 6/25/23 around 6:00 A.M. and first sat the resident up on the side of the bed. -The resident was positioned onto the sit-to-stand as he/she normally was every morning and at first had no complaints. -Half-way through the sit-to-stand transfer the resident suddenly jerked his/her left foot up, saying the left foot hurt. The resident's left shin hit the top edge of the plastic front leg protector resulting in a scratch to the left shin. -He/she reported the incident to the charge nurse and they discussed using a mechanical lift after that. -He/she had reported to the charge nurse once before within the past six months that the resident had complained of both feet hurting and the resident's arms hurting when holding onto the sit-to-stand. At that time the resident was re-evaluated for his/her transfer status. Therapy educated the staff and said at the time the resident was still appropriate for the sit-to-stand lift. -Several months ago staff were educated that the sit-to-stand policy had changed and staff could transfer residents on the sit-to-stand with one person. -The resident's current transfer status of mechanical lift should be what was on the Resident Profile sheet. That was what CNAs use to know how they are supposed to transfer residents.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accident hazards, when the facility failed to keep chemicals locked and out of reach of residents, and failed to provide supervision for one sampled resident (Resident #1) out of five sampled residents. On 12/5/21 the resident accessed the facility shower room and obtained an unopened bottle of cleaning solution from the unlocked unsecured cabinet. He/she took the bottle to his/her room and drank 3/4 of the cleaning solution. The facility census was 135 residents. The Administrator was notified on 12/8/21 at 3:30 P.M. of an Immediate Jeopardy (IJ) which began on 12/5/21. The IJ was removed on 12/9/21, as confirmed by surveyor onsite verification. Record review of the facility's Infection Prevention and Control-Environmental Services-Housekeeping Policy and Procedures, dated 1/29/2020, showed: -Chemicals must always be either in his/her possession or locked in the appropriate cabinet. -This protects residents from potential exposure to harmful chemicals. Record review of the Safety Data Sheet for Virex TB (disinfectant cleaner), dated 9/28/20, showed: -Ingestion may be irritating to mouth, throat, and stomach. Symptoms may include stomach pain and nausea/vomiting. -Immediately drink one to two glasses of water or milk. Drink milk, egg whites or gelatin solution. If not available drink large quantities of water. -Seek immediate medical attention. -Keep out of reach from children. -May cause damage to organs through prolonged or repeated exposure. 1. Record review of Resident #1's undated Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnosis: -Depressive episodes (are periods of low mood, feeling sad and loss of interest and can interfere with daily functioning). -Altered mental status (a disruption in how the brain works that causes a change in behavior). -Cognitive communication deficit (trouble reasoning and making decisions while communicating, trouble remembering their conversations and experiences). -Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). Record review of the resident's Clinical Note, dated 7/13/21, showed: -He/she wanted to kill him/herself and the only way to do that was to stop eating. -He/she was very depressed. -Physician and family were notified. -New order for [MEDICATION(S)] 50 milligrams (mg) tablet, give one tablet daily starting 7/13/21 for [CONDITION(S)]. -Placed on 30 minute checks for 72 hours. -Referral to behavioral health. Record review of the resident's Psychological Progress Note, dated 7/22/21, showed: -Diagnosis of anxiety (a feeling of worry, nervousness, or unease, typically about imminent event or something with an uncertain outcome) and major depressive disorders. -Moderate cognitive decline. -Symptoms present were anger, appetite disturbance, depression, nervous, worried, stressed, anxiety, irritability, and sleep disturbance. -Interventions were focus on reframing, adjustment and behavior cuing regarding his/her adjustment to care center. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning), dated 9/14/21, showed: -He/she was severely cognitively impaired. -Wandered one to three days a week. -Verbal behaviors toward others one to three days a week. -Feeling down, depressed, tired, little energy, trouble concentrating, or hopeless two to six days a week. Record review of the resident's Care Plan, dated 6/16/21, to present showed: -The resident was at risk for exhibiting psychosocial, mood, and/or behavioral symptoms related to diagnosis of depression and voiced thoughts of suicide upon admission. -Document behaviors and provide interventions for safe environment as needed. -Referral of mood/behavior indicates to Psychologist or Psychiatrist. -Report any suicidal tendencies to nursing supervisor so monitoring can occur. If high risk exists, place under constant supervision until transfer can be arranged. -Monitor for sad, unhappy feelings or thoughts. -Assess changes in mental status. -Starting 12/6/21, one time weekly assess and record behaviors. -Touch hands/shoulder to show caring or provide comfort. -Provide one to one interaction, read a story/talk about events. --No care plan noted for wandering around the facility. Record review of the resident's Psychological Progress Note, dated 10/7/21, showed: -His/her last date of therapy was 9/16/21, due to resident was not able to participate in therapy. -His/her neurocognitive impairment was too advanced for psychology. -Resident was not considered to be at risk for harm to self or others. Record review of the facility Incident Report, dated 12/5/21, showed: -Approximately 8:30 P.M., Resident #1 was seen by Certified Nursing Assistant (CNA) A in Resident #3's room vomiting in the sink. -CNA A notified Registered Nurse (RN) A of the resident vomiting. -RN A assessed Resident #1 and escorted him/her back to his/her room to get cleaned up. -RN A notified the House Supervisor by phone of the resident being sick. -The resident had told RN A about drinking 3/4 of a bottle of cleaner and pointed to the bottle on his/her sink. -RN D called 911 for Emergency Medical Services (EMS) to transport the resident to the hospital. -RN A and RN D prepared the resident for transfer to the hospital. -The resident was continually vomiting, cool to touch, and had altered mental status, oxygen was applied at two liters via nasal cannula. -EMS arrived at 9:00 P.M. to transport the resident to the hospital. -The bottle of cleaner was sent with the resident to the hospital. -The bottle of cleaner had a screw cap and not the spray nozzle, it appeared to be a new bottle. -The Director of Nursing (DON), the resident's physician, and family were notified of the incident. -The hospital were notified of the possible suicide attempt. Record review of the written statement, dated 12/5/21, by CNA A showed: -At approximately 8:00 P.M., he/she found Resident #1 crying in Resident #3's room. -He/she asked the resident what was wrong and the resident stated, that he/she was upset. -He/she tried to offer comfort to the resident. -Asked the resident if he/she could do anything for the resident and he/she stated no. -About 20 minutes later during rounds, he/she saw Resident #1 vomiting in Resident #3's sink. -He/she called down the hall for the nurse. -The nurse came and got the resident and took him/her to his/her room. During interview on 12/7/21 at 3:14 P.M., CNA A said: -Resident #1 was in Resident #3's room when he/she was making rounds at shift change at 7:00 P.M. -He/she was making rounds again around 8:00 P.M. when he/she heard crying. -He/she went into the room and tried to console Resident #1 and see if there was anything he/she could do to help the resident. -He/she informed the resident he/she would be back to check on him/her. -About 20 to 30 minutes later he/she went to check on Resident #1 when he/she found the resident vomiting in the sink. -He/she called down the hall for RN A to come to the room because the resident was vomiting. -He/she never saw Resident #1 leave Resident #3's room during that time. Record review of Resident #1's Clinical Note written by RN A, dated 12/6/21 at 3:37 A.M., showed: -He/she was notified by CNA A at 8:30 P.M., Resident #1 was not feeling well and was vomiting in Resident #3's sink. -He/she went to assess Resident #1 and escorted the resident to his/her room. -The House Supervisor was notified by phone the resident was not well. -Resident admitted to him/her and the House Supervisor that he/she drank this and pointed to a bottle of cleaner on top of his/her sink. -The resident also verbalized that he/she wanted to kill himself/herself. -The bottle of cleaner had about 1/4 of the solution remaining. -The House Supervisor told him/her to send the resident to the hospital immediately. -The resident continually vomited and had cold and clammy skin, was pale in color, had altered mental status while getting ready for transfer to the hospital. -Oxygen was placed on the resident due to oxygen level being 74% (normal is 90% to 100%) -EMS arrived and the resident was transferred to the hospital with the bottle of cleaner. -The bottle of cleaner was noticed to have a screw cap and not a spray nozzle and appeared to be a new bottle of cleaner. -The resident's Physician, DON, and family were notified of the incident. -All potentially hazardous cleaning materials were removed and locked up away from the residents. -The hospital called at 2:00 A.M., said the diagnosis was confirmed as poison ingestion. During an interview on 12/9/21 at 9:39 A.M., RN A said: -CNA A called for help down the C hall. -He/she went to see why CNA A needed help. -He/she went into Resident #3's room and found Resident #1 vomiting in the sink. -He/she took the resident back to his/her room to get cleaned up. -That was when he/she saw the bottle of cleaner sitting on the resident's sink. -The resident was very neat and nothing was ever on his/her sink. -He/she asked the resident if he/she drank the cleaner and the resident said yes, he/she drank 3/4 of the bottle of cleaner and chased the cleaner with his/her supplement drink to make sure the cleaner went down. -He/she called the House Supervisor and notified him/her of the incident. -He/she called 911 for EMS while CNA B was sitting with the resident. -He/she notified the resident's physician and family of the incident. -He/she prepared the resident for transport to the hospital. -He/she had staff do a sweep of the area for any and all chemicals and cleaners and locked them up. -He/she notified the DON and the Administrator of the incident. During an interview on 12/7/21 at 3:33 P.M., CMT/CNA B said: -Resident #1 was not in his/her room during rounds. -Resident #1 was in Resident #3's room during rounds. -He/she had just put a different resident to bed when RN A notified him/her of Resident #1 drinking the cleaning solution. -He/she stayed with the resident while RN A and RN D made phone calls and got the resident paperwork around for transfer to the hospital. -He/she had worked with the resident before and the resident would get confused and upset, but not to where he/she would need to be watched for self-harm. -The resident had a room change that affected him/her in a negative way. During an interview on 12/8/21 at 10:15 A.M., Resident #3 said: -Resident #1 had declined in the last year. -He/she did not see Resident #1 drink the cleaner and Resident #1 did not say anything about drinking the cleaner. During an interview on 12/8/21 at 11:25 A.M., family member A said: -Resident #1's dementia had progressed more in the last year. -The resident had been seeing things that were not true. -Resident #1 did say, what's the point of living since his/her illness is progressing but had no plan. During an interview on 12/7/21 at 3:04 P.M., CNA C said: -He/she did not know about the incident until he/she had seen another CNA crying. -He/she usually worked days and was asked to stay over to help with the resident. -The cleaner was left in the bath house so the shower and chair could be cleaned after each resident was given a shower. -The cleaner bottles were to be kept in a locked cabinet in the bath houses. -Resident #1 was able to get in and out of the bath houses. He/she could walk when he/she wanted, and wheeled all around the facility in his/her wheelchair other times. During an interview on 12/7/21 at 3:25 P.M., CNA D said: -The cleaner was usually left out in the bath house in an unlocked unsecured area for cleaning after each shower. Observation of the Memory Care Unit with the DON on 12/8/21 at 2:16 P.M., showed: -A large note on the back of the bath house door saying all chemicals and cleaners must be in a locked cabinet at all times. -The bath house on the D hall had a small white cabinet that looked to be locked, but all one had to do was pull on the handle and the cabinet opened. -The closet was unlocked and open. -A nightstand had two drawers unlocked. -The cabinet, night stand drawers, and closet had the following contents: --Seven containers of bleach wipes. --Two unopened bottles of shower cleaner. --Two packages of sani hand wipes. --Two bottles of [MEDICATION(S)] protectant spray. --One container of germicidal sani cloth wipes. --Seven bags of [MEDICATION(S)] cream bath soap. ---Warning labels on the bottles said to keep out of reach of children. Call poison control if ingested. -The bath house on the F hall had a small white cabinet on the wall that was locked with the key hanging from a chain attached to the cabinet. -The closet was unlocked and open. -Night stand was also unlocked. -The cabinet, closet and nightstand had the following contents: --One bag of [MEDICATION(S)] cream that was opened. --Six bags of adult wet wipes. --Two bottles of [MEDICATION(S)] protectant. ---Warning labels on the bottles said to keep out of reach of children. If swallowed, get medical help or contact a poison control center immediately. During an interview on 12/8/21 at 2:16 P.M., the DON said: -The cleaners should not be in the closet, cabinet or nightstands. -The cabinet on the D hall needed to be fixed so the lock would work. -Note: He/she left both bath houses with the chemicals and cleaners still in the cabinet, closet and nightstand and did not lock the chemicals up. During an interview on 12/9/21 at 12:16 P.M., RN B said: -Chemicals and cleaners should be locked up at all times unless staff are using them and must be in the staff member's possession. -He/she was educated back in January on chemical storage. During an interview on 12/9/21 at 12:30 P.M., CNA E said: -He/she used the cleaner after each residents shower to clean the shower and shower chair. -The cleaner should be locked up when not in use after each cleaning and not out in the open. -The cleaner should have been locked up and not left out. During an interview on 12/9/21 at 1:35 P.M., the DON said: -No chemicals or cleaners should be left out in the bath house. -The chemicals and cleaners are to be kept in locked cabinets when not in use. During an interview on 12/8/21 at 9:58 A.M., the physician said: -Back in July Resident #1 said he/she would stop eating for self-harm, but had no other plan. -Resident #1 did not really want to hurt himself/herself. -He/she referred Resident #1 for behavioral health and placed the resident on depression medication along with 30 minute checks for 72 hours. -The resident had stabilized and was doing well. -He/she visited with the resident on 12/4/21 and the resident was in a good mood and smiling, he/she just had his/her hair cut, no signs of depression at that time. -The resident could have lucid moments but they were very far and few. -He/she could answer questions but might not give the right answer but would answer the question. -He/she thought the resident had a delusion or hallucination. -The cleaners and chemicals should always be locked up and out of the residents reach. During an interview in 12/9/21 at 2:01 P.M., the Administrator said: -He/she was not sure why the cleaner was left in the bath house. -The cleaner should have been in a locked cabinet or closet. -All chemicals and cleaners should be locked up out of the residents reach all of the time. -The resident had a cognitive decline since being admitted to the facility due to his/her disease process. -The resident was still in the hospital waiting for a geriatric psychiatry bed to open up for evaluation and treatment before coming back to the facility. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations(s). MO 233

Based on observation, interview, and record review, the facility failed to keep the dry storage and walk-in refrigerator & freezer floors clean; failed to retain thermometers in all refrigerators to confirm adequate temperature ranges; failed to maintain sanitary utensils; failed to safeguard against foreign material or mold possibly getting into food and/or beverages; failed to keep trash and garbage receptacles lidded; failed to change deep fryer oil in a timely manner; failed to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; failed to follow correct hair hygiene practices; and failed to ensure the proper refrigeration of foodstuff. These deficient practices potentially affected all residents who ate food from the kitchen. The facility's census was 135 residents with a licensed capacity for 375. 1. Observations during the Kitchen inspections on 8/24/21 between 8:45 A.M. and 11:57 A.M. showed the following: -The Dry Storage room had sugar and salt packets, an applesauce cup, and two potato chips on the floor, and a large, unlidded garbage can was sitting on its lid. -The walk-in freezer #1 had a sticky substance on the floor. -The walk-in refrigerator #2 had a lettuce leaf on the floor. -In the Ingredient Room there was a white plastic spork in a utensil drawer adjacent to the manual can opener that had sticky, yellowish stains on it, as did the bottom of the drawer. -The powder milk bin across from an oven had an approximately 1 ¼ inch metal shaving inside. -An open 1-gallon jug of teriyaki sauce on the bottom shelf of large herb and spice rack read, refrigerate after opening on its label. -The white and green cutting boards next to a large, unlidded square trashcan were heavily scored to the point of plastic bits felt on their surfaces. -There was no thermometer in reach-in refrigerator #6. -The deep fryer's oil was so dark in color the bottom grates inside could not be seen. -A metal ladle next to scoops on a food preparation table had food bits on the handle. -A red handled 2-ounce scoop on the shelf of a tall rack across from the coffee machine had some plastic flaking off the handle. -The large ice machine had brownish mold in two spots on the upper white plastic guard under the lid. -There was no thermometer in the small, resident refrigerator in the dining area between Fuschia and Evening [MEDICATION(S)] Lanes. -There was no thermometer and excess ice build-up in the small, resident refrigerator in the dining area between Forest and Elm Lanes with excess ice build-up. -The black side-by-side refrigerator in the middle of the kitchen had no thermometers in either side. -At 11:33 A.M., there were still orange and grape juice puddles from breakfast under the juice machine nozzles. -Morning Supervisor B had no hairnet on and the one on a dietary aide did not cover the front and side hairlines for 1 - 2 inches. -A day cook was frying chicken tenders and French fries in the deep fryer. -The white microwave in the staff cafeteria kitchenette had food splatters all over the inside and chunks of food and paper debris on the glass turntable plate. -A 4-slice toaster in the main resident dining room had an abundance of crumbs inside. Observations during the follow-up Kitchen inspection on 8/25/21 between 9:01 A.M. and 9:59 A.M. showed the following: -The Dry Storage room had an applesauce cup on the floor, and a large, unlidded garbage can was sitting on its lid. -The walk-in freezer #1 had a sticky floor. -In the Ingredient Room was a white plastic spork in a utensil drawer adjacent to the manual can opener that had sticky, yellowish stains on it, as did the bottom of the drawer. -An open 1-gallon jug of teriyaki sauce on the bottom shelf of large herb and spice rack read, refrigerate after opening on its label. -The white and green cutting boards next to a large, unlidded square trashcan were heavily scored to the point of plastic bits felt on their surfaces. -There was no thermometer in reach-in refrigerator #6. -The deep fryer's oil was so dark in color the bottom grates inside could not be seen. -A red plastic handled 2-ounce scoop on the shelf of a tall rack across from the coffee machine had some plastic flaking off the handle. -The large ice machine had brownish mold in two spots on the upper white plastic guard under the lid. -The black side-by-side refrigerator in the middle of the kitchen had no thermometers in either side. -The white microwave in the staff cafeteria kitchenette had food splatters all over the inside and chunks of food and paper debris on the glass plate. -A 4-slice toaster in the main resident dining room had an abundance of crumbs inside. Observations during the follow-up Kitchen inspection on 8/26/21 at 1:03 P.M. showed the following: -The deep fryer's oil was so dark in color the bottom grates inside could not be seen. -A day cook was frying French fries in the deep fryer. -There was a 35 pound jug of liquid clear canola frying shortening (oil) in the Dry Storage room that was light amber in color. During an interview on 8/26/21 at 1:05 P.M., Morning Supervisor A said the following: -He/She had worked at this facility for about [AGE] years. -The deep fryer was used on a daily basis, usually for alternate food choices. -He/She believed the deep fryer oil was changed about every other day. -The oil currently in the deep fryer was very dark. During an interview on 8/26/21 at 1:09 P.M., Day Cook A said that he/she did not know the last time the deep fryer grease was changed. During an interview on 8/27/21 at 2:07 P.M., the Director of Dining and Event Services said the following: -The walk-in refrigerator and freezer floors were to be swept daily and deep cleaned weekly, usually by the morning dietary staff. -The deep fryer was used daily, but only lightly, and the oil would be monitored based on its color, viscosity, and the amount of food debris in it. -The deep fryer oil should be skimmed daily and changed at least every other week. -The deep fryer oil should not be so dark that the grates at the bottom cannot be seen. -Foreign materials like metal and plastic should certainly be kept out of food or drink. -He/She would expect trash and garbage cans to lidded when not in use to reduce the likelihood of pests. -If the label on foodstuff read, refrigerate after opening it should be done. -Ice machines should absolutely be free of mold. -He/She was not aware that refrigerators and freezers were required to have a thermometer inside to confirm correct temperatures were maintained. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: -Chapter 4-101.11: Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated wear washing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. -In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.

Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for five sampled residents (Residents #3, #4, #6, #7 and #8) out of five residents sampled for quarterly MDS review. The facility census was 135 residents. Record review of the facility's Resident Assessment (RAI) Process policy dated 7/2/20 showed: -The RAI process was mandated process that required resident assessments. -The resident assessments should be completed upon admission, quarterly, annually and with a significant change of the resident's status. -The MDS nurses (titles are Resident Assessment Coordinators (RAC)) were responsible for submitting the MDSs to the state database. 1. Record review of Resident #3's MDSs showed: -The last MDS completed was a quarterly MDS dated [DATE]. -A quarterly MDS dated [DATE] that was not completed. 2. Record review of Resident #4's MDSs showed: -The last MDS completed was a quarterly MDS dated [DATE]. -A quarterly MDS dated [DATE] that was not completed. 3. Record review of Resident #6's MDSs showed: -The last MDS completed was an annual MDS dated [DATE]. -A quarterly MDS dated [DATE] that was not completed. 4. Record review of Resident #7's MDSs showed: -The last MDS completed was an admission MDS dated [DATE]. -A quarterly MDS dated [DATE] that was not completed. 5. Record review of Resident #8's MDSs showed: -The last MDS completed was a quarterly MDS dated [DATE]. -A quarterly MDS dated [DATE] that was not completed. During an interview on 8/27/21 at 11:53 A.M., the Clinical Compliance Manager said the resident's MDS was completed but it was not locked and was not submitted. 6. During an interview on 8/27/21 at 11:53 A.M., the Clinical Compliance Manager said: -He/She reviews the MDSs periodically (less than monthly) to ensure they were completed and submitted. -Residents #3, #4, #6 and #7's quarterly MDSs were not completed. -One of their Resident Assessment Coordinators (RAC) had been off for a while. -They just hired a new RAC. During an interview on 8/30/21 at 8:41 A.M., RAC B said: -One of the RACs was gone for three months so they were behind on completing MDSs. -A new RAC was in training now. -Quarterly MDSs were supposed to be done every 92 days. During an interview on 8/30/21 at 8:52 A.M. RAC A said: -One of the RACs had been out for months so he/she and another RAC were helping do the MDSs from the other unit. -The late MDSs happened when one of the RACs took his/her vacation, followed by another RAC taking his/her vacation and some of the MDSs just got missed. -They have a new RAC to replace the RAC that had been gone for a while. -They have a calendar they use to keep track of when quarterly MDSs are due.

Based on observation, interview and record review, the facility failed to post the actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPN's), and Certified Nursing Assistants (CNA's)/Certified Medication Technicians (CMTs) directly responsible for resident care per shift in locations throughout the facility for view by residents and the public, and failed to develop a policy to address the Federal requirement for posting of staffing. The facility census was 135 residents. 1. Record review and observation of the staff posting for 8/26/21, 8/27/21, and 8/30/21 showed: -The posting detailed the licensed nurses on duty but did not show if the nurses were RNs or LPNs and did not show the total numbers of hours worked for the RNs and the LPNs on duty. -The posting detailed the CNAs and CMTs on duty but did not show the total numbers of hours worked for the CNAs and CMTs. During an interview on 8/30/21 at 12:48 P.M. the Director of Nursing (DON) said: -The Staffing Department posts the staffing sheets. -The sheets show how many nurses, CNAs and CMTs are on duty. During an interview on 8/30/21 at 1:02 P.M. the DON said: -The staffing sheets showed the nurses, CNAs and CMTs on duty. -The staffing sheets showed nurses and did not show RNs and LPNs. -The total number of hours for RNs, LPNs and CNAs/CMTs was not posted. -Going forward the facility would post the actual total hours for RNs, LPNs, and CNAs/CMTs at the beginning of each shift. During an interview on 8/30/21 at 2:20 P.M., the DON said the facility had no policy regarding posting of staffing.

Based on observation, interview and record review, the facility failed to ensure medications and biologicals (therapeutic substance, such as a vaccine or drug) were secure and inaccessible to unauthorized staff and residents by leaving medication carts and treatment carts unlocked; to ensure the medication cart was clean and sanitary, and to ensure there were no loose pills or other objects in the medication carts. The facility census was 135 residents. Record review of facilities Medication Administration policy dated 5/11/2010 revised 7/11/2018 showed the medication carts are to be kept closed and locked when out of sight of the medication nurse or medication aid. Record review of the facility's policy, Use of the Medication Cart, revision date 1/1/2006 showed: -The medication cart was to be locked at all times when not in use. -The staff was not to leave the medication cart unlocked or unattended in the resident care areas. -The licensed nurse would maintain a clean top surface of the medication cart while passing medications and clean and replenish the medication cart after each use. 1. Observation on 8/27/21 at 6:10 A.M., on the 100 unit showed: -The Certified Medication Technician (CMT) medication cart was unlocked. -The nurse medication cart was unlocked. -There were three residents in wheelchairs in the common area near the nurse medication cart. -There were two residents sitting at a table in the common area. -One unidentified Certified Nursing Assistant (CNA) walked past the unlocked nurse medication cart. -No other staff were in the area. Observation on 8/27/21 at 6:13 A.M., on the 100 unit showed: -An unidentified Registered Nurse (RN) came into the unit walking past both the unlocked carts and spoke to a resident at the table. -The RN left the area and brought a blanket to the resident. Observation on 8/27/21 at 6:17 A.M., on the 100 unit showed the night shift supervisor walked past the CMT medication cart while it was unlocked. Observation on 8/27/21 at 6:20 A.M., on the 100 unit showed RN E came to the common area and locked both the nurse and CMT medication carts. Observation on 8/27/21 at 6:40 A.M., on the 100 unit showed: -RN E removing an item from the nurse medication cart and left the cart unlocked. -RN E left the common area where the unlocked nurse medication cart was. -Residents were still in the common area near the unlocked nurse medication cart. -CNA's were bringing residents to the tables in the common area. Observation on 8/27/21 at 6:50 A.M., on the 100 unit showed: -Several day shift staff arriving on the 100 unit and passing by the unlocked nurse medication cart. -Residents were still sitting at tables across from the unlocked nurse medication cart. Observation on 8/27/21 at 6:58 A.M., on the 100 unit showed RN E was back at the nurse medication cart and locked it. 2. Observation on 8/27/21 at 6:14 A.M. of the 300 unit showed: -Two medication carts unlocked with no nurse in sight with seven residents in the general area. -Two treatment carts that contained topical medication (medications as drugs in oil or water-based, semi-solid bases for skin surface use)unlocked with no nurse present, and seven residents in the general area. During an interview on 8/27/21 at 6:18 A.M. RN A said medication carts and treatment carts are to be locked when not attended. Observation on 8/27/21 at 6:18 A.M. showed: -RN A locked both medication carts and one treatment cart. -One treatment cart was left unlocked and unattended with seven residents in the general area. Observation on 8/27/21 at 6:43 A.M. showed one treatment cart on the 300 unit remained unlocked. Ten residents were in the immediate area. 3. Interview on 8/27/21 at 10:52 A.M. 300 unit manager said medication carts and treatment carts are to be locked when not being used by the nurse or CMT. During an interview on 8/27/21 at 11:07 A.M. CMT A said: -Medication carts are locked anytime he/she leaves it. -He/she was not responsible for treatment carts, but they are to be locked when unattended. During an interview on 8/27/21 at 11:08 A.M. RN B said medication carts and treatment carts are to be locked when not attended by the nurse. During an interview on 8/30/21 at 9:37 A.M., Licensed Practical Nurse (LPN) B on the 100 unit said: -When a nurse leaves a medication cart it should never be left unlocked. -If notice another nurse's medication cart unlocked when no nurse at it he/she would lock it. During an interview on 8/30/21 at 9:44 A.M., 400 unit manager said he/she: -Expects a nurse to lock a medication cart when leaving it. -Expects a nurse to lock any medication cart that he/she may notice is unlocked. During an interview on 8/30/21 1:57 A.M., the Director of Nursing (DON) said: -It is his/her expectation that medication carts are to be locked when left unattended. -It is his/her expectation that treatment carts are to be locked when left unattended. -It is his/her expectation that another nurse passing an unlocked medication cart or treatment cart would lock it and let the nurse know he/she had locked it. 4. Observation on 08/27/21 at 7:05 A.M. of the medication cart on Hallway E with RN B showed: -There was an orange pill loose in one of the drawers. -There was a tack in a medication cup with the resident's medications. -There was a pair of rusty scissors in the same drawer as the resident's medications. -There was a brown raised substance in the bottom of a drawer that contained a resident's medications. During an interview on 8/27/21 at 7:20 A.M., RN B said: -There should not have been any loose pills in the medication cart. -There should not be any tacks in the medication carts. -There should not have been dirty scissors in the same drawer as the resident's medications that had been ordered by a physician. -The nursing staff was responsible for ensuring the drawers of the cart were kept clean. During an interview on 8/27/21 at 8:20 A.M. the 400 hallway Unit Manager said: -There should not have been any loose pills in the medication cart. -The alcohol wipes should not have been in the same compartment as the residents medication. -There should not be any tacks in the medication carts. -There should not have been dirty scissors in the same drawer as the resident's medications that had been ordered by a physician. -The nursing staff was responsible for ensuring the drawers of the cart were kept clean as the staff used them. -The cart should not have been dirty as they had just been cleaned that week. During an interview on 8/27/21 at 9:20 A.M. RN F. said: -There should not have been any loose pills in the medication cart. -The alcohol wipes should not have been in the same compartment as the residents medication. -There should not be any tacks in the medication carts. -There should not have been dirty scissors in the same drawer as the Resident's medications that had been ordered by a physician. -The nursing staff was responsible for ensuring the drawers of the cart were kept clean as they used them. During an interview on 8/30/21 at 3:00 P.M. the DON said: -There should not have been any dirty scissors, loose pills, or tacks in the medication carts. -The drawers should have been clean. -The medication carts should have been cleaned each shift and as needed. -The Charge Nurse or CMT would have been responsible for ensuring the medication carts were kept clean.

Based on interview and record review the facility failed to complete and update as needed and at least annually a facility-wide assessment that included the necessary staff competencies needed to meet the needs of the residents, and failed to develop a Facility Assessment policy. A total of 27 residents were selected for review. The facility census was 135 residents. 1. Record review of the undated Facility Needs Assessment showed: -An incomplete document with completion of only Section 3.1, Centers for Medicaid and Medicare Services (CMS-the Federal certification agency) 672 (Resident Census and Condition - a Federal form completed by the facility for the survey team that represents the current condition of residents at the time of completion) Review/Analysis, Section 3.2 Diseases/Conditions, Physical/Cognitive Disabilities Analysis, Section 3.3 Special Care and Practices, Section 6.1 Physical Space/Equipment Inventory, Physical Space/Equipment Inventory/Needs, Section 6.2 Dietary Needs Assessment/Analysis, Hazard and Vulnerability Assessment Tools and a Summary of Hazards Analysis. -The document did not contain information regarding the staff competencies that were necessary to provide the level and types of care needed for the resident population and an analysis of all personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care. During an interview on 8/30/21 at 1:00 P.M., the Director of Nursing (DON) said: -The pages provided to the survey team upon request for the Facility Assessment were the only pages of the assessment. -Individual staff competencies had been kept up to date but the staff competency portion of the Facility Assessment had not been completed or updated. -The facility management staff would complete and update the Facility Assessment.

Based on interview and record review, the facility failed to complete an annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for one sampled resident (Resident #5) out of one resident sampled for annual MDS review. The facility census was 135 residents. Record review of the facility's Resident Assessment (RAI) Process policy dated 7/2/20 showed: -The RAI process was mandated process that required resident assessments. -The resident assessments should be completed upon admission, quarterly, annually and with a significant change of the resident's status. 1. Record review of Resident #5's MDSs showed: -An annual MDS was completed 7/21/20. -The last MDS completed was a quarterly MDS dated [DATE]. -An annual MDS dated [DATE] that was not completed. During an interview on 8/27/21 at 11:53 A.M., the Clinical Compliance Manager said: -He/She reviews the MDSs periodically (less than monthly) to ensure they were completed and submitted. -Resident #5's annual MDS was not completed. -One of their Resident Assessment Coordinators (RAC) had been off for a while. -They just hired a new RAC. During an interview on 8/30/21 at 8:52 A.M., RAC A said: -One of the RACs had been out for months so he/she and another RAC were helping do the MDSs from the other unit. -The late MDSs happened when one of the RACs took his/her vacation, followed by another RAC taking his/her vacation and some of the MDSs just got missed. -They have a new RAC to replace the RAC that had been gone for a while. -They have a calendar they use to keep track of when an annual MDS is due.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when Certified Nurse Aide (CNA) B pushed the resident into a chair, holding him/her down by the shoulders, resulting in the resident becoming agitated, bruising on his/her neck, and blood on his/her lip, out of three sampled residents. The facility census was 151 residents. The facility staff was notified on 1/8/21 of Past Non-Compliance which occurred on 1/6/21. Upon discovery, staff suspended the employee on 1/6/21, conducted an investigation, and notified appropriate parties. On 1/7/21, the Administrator identified through the facility investigation CNA B physically abused the resident, CNA B was terminated. Facility staff reviewed their abuse and neglect policies, and in-serviced all employees on abuse and neglect. Record review of the facility's policy dated 1/30/19, titled Freedom from Abuse, Neglect, and Exploitation, showed: -It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property and all residents, staff, families, visitors, volunteers and resident representatives are encouraged and supported in reporting any suspected acts of abuse, neglect, misappropriation of resident property, or exploitation. -All allegations/suspicion of abuse were reported immediately and thoroughly investigated. -Abuse included but was not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraints not required in treating the resident's medical symptoms. -Each resident had the right to be free from all types of abuse, including mental abuse. -Willful: means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Injury of unknown source: An injury should be classified as an injury of unknown source when both of the following conditions were met: --The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and --The injury was suspicious because of the extent of the injury or the location of the injury (e.g., the injury was located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. 1. Record review of Resident #1's facility face sheet showed he/she admitted to the facility 4/23/20 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Dementia with Behavioral Disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems. -Cognitive Communication Deficit (difficulty with thinking and how someone uses language). -Vascular Dementia (brain damage caused by multiple strokes). -Adjustment Disorder (a group of symptoms, such as stress, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event. -Hearing loss. -Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life. -Bed Confinement Status (the inability to get up from bed without assistance, ambulate or to sit in a chair or wheelchair. -Age Related Physical Debility (a condition of weakness of mind and body usually associated with advanced age, characterized by the inability to remember simple, recent events, general confusion and bewilderment, and increasing debility). -History of multiple fractures of bone. Record review of the resident's care plan dated 4/23/20 showed: -Resident was at risk for falls, with interventions that included: --Not leaving the resident alone in the room in his/her wheelchair. --Recline broda chair (tilted wheelchair) when resident was not eating. -Cognitive skills for daily decision making were impaired, with interventions that included: --Break tasks into short segments, provide verbal reminders. -Resident had an alteration in self care, requiring staff assist related to: -- Extensive assistance required for transfers, positioning, eating, bathing, ambulation. Record review of the resident's most recent quarterly MDS (Minimum Data Set - a federally mandated assessment tool used by facilities for care planning) dated 10/13/20 showed: -Brief Interview of Mental Status (BIMS score of 00 which indicated severe cognitive impairment). -Resident required extensive assistance for Activities of Daily Living (routine activities people do every day without assistance), such as: --Bed mobility. --Transfers. --Toileting. --Bathing. --Eating. Record review of the resident's facility Weekly Skin Assessments showed: -On 12/30/20 he/she had multiple bruises/skin discoloration on both his/her upper and lower extremities, both his/her arms were wrapped with sleeves, and he/she had a skin tear on his/her right leg. -On 1/7/21 he/she had multiple bruises/skin discoloration on both his/her upper and lower extremities, both his/her arms were covered with geri (protective) sleeves, he/she was noted to have a small developing bruise to his/her left cheek, and a bruise to his/her left neck approximately 3.5 centimeters (cm) by 4.5 cm. Record review of the resident's bath/shower sheets, completed by facility staff during routine bathing showed: -On 1/2/21 he/she had bruising noted on both his/her lower extremities and a dressing noted his/her right lower arm. -On 1/7/21 he/she had no issues noted. Record review of the resident's facility investigation dated 1/7/21 showed: -On 1/6/21 at approximately 11:05 P.M., Licensed Practical Nurse (LPN) C heard yelling coming from a resident's room. --When LPN C went to the room, he/she witnessed CNA B physically shoving the resident back down into his/her chair. --When LPN C instructed CNA B to stop touching the resident and back up, he/she refused to do so. --CNA B informed LPN C that he/she was not going to let anybody spit in his/her face. --LPN C was finally able to remove the resident from the room. --LPN C then contacted the House Supervisor, Registered Nurse (RN) A. --CNA B was sent home pending investigation and per policy. --RN A and LPN C were able to calm the resident down and assess him/her for injuries. --LPN C was attempting to show RN A bruising on the left side of the resident's neck and what looked like blood on his/her lower lip. --Resident was shaking his/her arms and seemed agitated. --RN A attempted to talk to the resident and tried to look closer at his/her neck, but he/she kept flinching when RN A leaned toward him/her. --Director of Nursing (DON) was notified per policy. --Local police department notified with report completed. Observation on 1/8/21 at 9:00 A.M., showed the resident: -Verbalizations were nonsensical, while he/she was eating breakfast. -Had uneven skin tone, multiple visible areas of ecchymosis (a discoloration of the skin resulting from bleeding under the skin, typically caused by bruising) on both arms and hands; several pin point scratches on his/her face, particularly around his/her mouth; multiple discolorations around his/her face and neck which were not bruising; and a quarter size fading purple bruise on his/her left lateral neck area. -Waving his/her hands in a batting motion constantly, when Certified Medication Aide (CMT) D lowered the resident's shirt collar to reveal his/her bruised area. -Was agitated and attempted to push away, grab and hit CMT D. -Had grabbed his/her own right hand and left a red mark. During an interview on 1/8/21 at 9:10 A.M., CMT D said: -He/she cannot remember if the resident had the bruise or not. -He/she felt as though the bruise was several days old. -The staff should have noted something like the bruise on the bath/shower sheets. -The resident had history of aggression and agitated with cares, and he/she picked and scratched his/her face often. During an interview on 1/8/21 at 9:20 A.M., RN A said: -He/she was here on Monday, 1/4/21, and the resident did not have the bruise on the neck. -The areas around the resident mouth periodically come up, and are not from any injury. -This day 1/8/21 was his/her first day back since 1/4/21, and he/she noticed the bruise on the neck. During an interview on 1/8/21 at 9:30 A.M., Restorative Aide F said: -He/she first saw the bruise on the resident's neck on 1/7/21. -He/she had never noticed bruises on the resident except on his/her hands from when he/she was agitated with cares. -The resident had been agitated all week. -The resident picked and scratched at his/her face, and he/she has a couple of spots on his/her face right now. During an interview on 1/8/21 at 9:35 A.M., RN G said: -The bruise on the resident's neck was not there on Tuesday, 1/5/21. During an interview on 1/8/21 at 9:37 A.M., LPN J said: -Yesterday, 1/7/21, when he/she came in, the night nurse from 1/6/21, LPN C, told him/her about the incident. -As far as restraining the resident, he/she thinks that the CNA B was probably holding Resident #1 down in self defense. -The resident would become very combative frequently. -The resident always had a lot of bruises and skin tears related to his/her combativeness. -A bruise could have been self inflicted, he/she had done this a lot. -The scratches above his/her lip happened frequently and were self inflicted. During an interview on 1/8/21 at 12:20 P.M., Physician A said: -The facility called right away about the incident on 1/6/21. -He/she was so surprised that this happened, as the unit manager was continually doing education with the staff regarding how to deal with difficult residents and behaviors. -He/she did not know CNA B, but had not heard anything negative about him/her. -He/she certainly would not condone CNA B approach with the resident. During an interview on 1/9/21 at 1:55 P.M., LPN C said: -He she was working the overnight shift on 1/6/21. -He/she heard two voices way down the hall. -He/she found CNA B standing next to the resident's bed behind the resident's broda chair. -CNA B was pushing the resident down in the chair as the resident was, he/she thought, trying to get up. -CNA B had his/her hands on the resident's shoulders, then the resident's arms and CNA B, said no one spits in my face. -The resident was yelling too. -LPN C repeatedly told CNA B to let go of the resident and he/she started wheeling the resident out of the room. -LPN C told CNA B there was another CNA that would take over. -LPN C stated he/she had to remove CNA B's hands from the resident. -LPN B could not believe he/she wouldn't let go of the resident in the chair. -The resident had a bruise on the left side of his/her neck and a little blood on his/her lip, where he/she thinks the resident had bit his/her tongue. -The broda chair was reclined and the resident was leaning up in his/her chair. During an interview on 1/11/21 at 12:15 P.M., CNA B said: -As he/she entered the resident's room on 1/6/21, the resident had one arm in his/her nightgown when he/she had started to lean forward in his/her chair. -The resident was a fall risk. -He/she braced the resident so the resident would not fall. -The resident spit at him/her. -The resident continued to try and get up out of the chair, so he/she went to the back of the chair and tried to position the resident and have the resident stay in his/her chair. -He/she just knew that the resident was going to fall. -He/she knew the resident already had a bad arm, so he/she pushed down on the resident shoulders. -He/she did not hurt the resident at all. -The nurse came in and said another CNA would come in. -He/she was sent home. During an interview on 1/14/21 at 2:25 P.M., the resident Durable Power of Attorney said: -The resident was seen frequently. -The family sometimes communicated with the resident using a white board, and sometimes, the family was unable to communicate with the resident. -The resident may have been fighting the staff that were trying to care for him/her. -The resident was very confused sometimes, and others he/she had intermittent confusion. MO 192

Based on observation, interview and record review, the facility failed to keep one sampled resident (Resident #1) free from physical abuse when one staff member forced the resident to bed resulting in bruising to his/her left upper arm, left lower flank, and his/her right outer arm out of three sampled residents. The facility census was 229 residents. The Administrator was notified on 1/28/20 of Past Non-Compliance which occurred on 1/26/20. On 1/26/20, the Administrator identified Agency Certified Nurses Aide (CNA) A physically abused the resident. Upon discovery, staff suspended the employee on 1/26/20, conducted an investigation, notified appropriate parties, and placed a do not return status to the staffing agency on CNA A on 1/26/20. Facility staff reviewed their abuse and neglect policies, and in-serviced all employees on abuse and neglect. Staff corrected the deficient practice on [DATE]. Record review of the facility policy for Freedom from Abuse, Neglect and Exploitation dated 1/7/02, reviewed 1/30/19, showed: -The policy was developed to maintain an environment where residents are free from abuse. -The definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. -Applicants including agency staff are screened for a history of abuse, neglect or mistreatment of [REDACTED]. -Upon hire, all associates will receive information and training regarding abuse and neglect. -Education is ongoing annually and as needed. 1. Record review of Resident #1's Face Sheet dated 1/26/20, showed he/she was admitted on [DATE] with the following Diagnosis: [REDACTED]. -Dementia without Behavioral Disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). -Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety or fears that are strong enough to interfere with one's daily activities). Record review of the resident's Care Plan dated 7/18/16, showed to following: -He/she ambulates independently on the locked dementia unit with a steady gait. -Provide a quiet atmosphere with one to one support during periods of increased anxiety. -Remove him/her to a quiet, calm setting as needed. -Reassure, redirect, or re-approach as needed. Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff and used for care planning) dated 12/24/19, showed the following: -He/she was rarely/never understood. -His/her speech was unclear and slurred or mumbled words. -He/she was unable to complete the interview. -His/her cognitive skills for daily decision making is severely impaired and never/rarely makes decisions. -He/she was able to sometimes make his/herself understood and understand others responds adequately to simple, direct communication only. -Needs supervision only when walking. -Needs extensive assist with toilet use of one staff member. Record review of the resident's undated Care Profile showed the following: -He/she ambulates independently. -He/she goes to bed and turns independently. -He/she was incontinent provide peri care each time toileted. -He/she was a fall and elopement risk and on [MEDICAL CONDITION] precautions. -He/she was very fearful of water. -Give a stroller to walk with to keep the resident from pushing other residents. -Check clothing for foreign objects. -Non-skid socks daily. Record review of the resident's Skin assessment dated [DATE] at 6:01 A.M., showed the resident's skin was intact with no bruising or discoloration. Record review of the resident's Clinical Nursing Note dated 1/26/20, showed the following: -At approximately 1:15 A.M., Agency Licensed Practical Nurse (LPN) A was sitting at the nursing desk to chart. -LPN A heard Resident #1 screaming very loudly. -The resident normally speaks no louder than a whisper. -LPN A observed Agency CNA A standing on a floor mat in the resident's room with his/her arms wrapped around the resident from behind. -The resident had a grip on the roommate's Broda chair. -CNA A, then took his/her right arm and put it under the resident's right arm and jerked upward, forcing both of their arms up in the air. -CNA A, threw the resident into his/her bed with his/her head on one corner and his/her feet on the opposite corner. -CNA A, picked up the resident again and threw him/her back down to lay him/her straight. -LPN A, immediately informed the CNA A that he/she witnessed what he/she did to the resident. -CNA A started defending his/herself saying he/she was trying to change the resident and get him/her to bed but he/she was wobbly and he/she had trouble. -LPN A asked CNA A to leave the resident's room. -LPN A notified his/her supervisor of the incident. -As LPN A, LPN B and Registered Nurse (RN) A entered the resident's room, the resident was sitting on his/her bed rocking back and forth saying no more, please no more. -LPN A and LPN B tried to assess the resident but he/she was still shaking and did not want to be touched. -The resident was usually very loving and liked to hold hands and give hugs. -At 5:45 A.M., LPN A and CNA B assisted the resident in getting dressed for the day. -The resident was noted to have dark area, not usually there on his/her left eye, and reddened area across the bridge of his/her nose. -The resident would not let anyone touch these areas. -The resident also had fresh bruising to his/her left arm, right rib area, dark purple area on the left lower flank and red welts on the top of his/her back between his/her shoulder blades. Record review of the resident's Skin assessment dated [DATE] at 11:20 A.M., showed the following injuries: -Bruising in corner of his/her right eye. -Small round purple bruising noted to inside of his/her left upper arm. -Large dark purple bruise noted to his/her left lower flank. -Large purple bruise noted to his/her right outer arm. -Both cheeks were red and a slight red mark on the bridge of his/her nose. -Red scratches noted on his/her left shoulder. Record review of the Charge Nurse RN B's Note dated 1/26/20, showed the following: -CNA A started his/her shift great. -He/she got his/her assignment, profile, shift change report and went on with assisting residents with bedtime activities of daily living. -Regular staff provided CNA A support as needed. -However, as the shift progressed, CNA A required more and more encouragement to keep up with resident needs as they arose. -There were moments that CNA A became defensive and hesitant to perform his/her duties up to standards. -CNA A had requested to try another assignment which was granted. -CNA A was reassigned to the Alzheimer's Unit at 10:30 P.M. Record review of LPN A's written statement dated 1/26/20, showed the following: -He/she was at the nursing desk preparing to chart. -He/she heard a normally very quiet resident screaming loud in his/her room. -He/she approached Resident #1's room and witnessed CNA A basically man-handling the resident. -CNA A had the resident in a full Nelson Hold (one or both arms are used to encircle the opponent's arm under the armpit and secured at the opponent's neck). -The resident had his/her right hand clutching the Broda chair beside him/her. -CNA A took his/her own right arm and put it under the resident's right arm and jerked the resident's arms up in the air freeing the resident from the Broda chair. -Then CNA A proceeded to throw the resident into the bed. -CNA A then picked up the resident back up and threw him/her into bed again in a straight position. -LPN A stated We will not have forceful abusive behavior here. I have been watching for a few minutes and I saw it all. -The CNA A stated I was putting the resident in the bed because he/she would not stay there. -LPN A informed CNA A that the resident does not have to stay in bed if he/she does not want to. -LPN B went and notified the House Supervisor RN A. -On entering the resident's room with LPN B and RN A, the resident was sitting up on the side of his/her bed repeating no more, no more, please no more. -LPN A and LPN B examined the resident for injuries. -Multiple red and warm areas and some bruising noted. -The resident was flinching and pulling away from the staff which is not normal behavior. -LPN A and LPN B agreed to let the resident relax a bit, then will reattempt a skin assessment again. Record review of the written statement from House Supervisor RN A date 1/26/20, showed the following: -He/she was called to the Alzheimer's Unit about 1:20 A.M. on 1/26/20. -LPN A and LPN B were in the resident's room assisting him/her to ambulate out to the day area. -CNA A was in the resident's bathroom. -He/she, LPN A and LPN B stepped out of the resident's room and LPN A told him/her what he/she seen. -After LPN A told him/her what he/she had seen, he/she told CNA A that he/she would need to leave the facility. -This was at 1:25 A.M. -LPN B called security. -Security, LPN B and he/she walked CNA A to the lobby. -CNA A went to his/her car but it was probably five minutes before he/she drove out of the parking lot. Observation on [DATE] at 2:11 P.M., showed the following: -The resident was calm and ambulating around the common area. -He/she had a small round purple bruising noted to inside of his/her left upper arm. -He/she had a large dark purple bruise noted to his/her left lower flank. -He/she has a large purple bruise noted to his/her right outer arm. During an interview on [DATE] at 3:38 P.M., the Director of Nursing (DON) said the following: -The police were called and a report was made. -The resident was calm today and let the police take pictures of his/her bruises. -The resident was agitated after the incident but no medications were given. -The staff sat and talked to the resident to help calm him/her down. -The resident had not mentioned anything about the incident. -The facility does not have any cameras in or outside the facility. -CNA A was escorted out of the facility and was put on a list to never return to this facility. -The agency service was notified of the incident and the allegation of abuse. -The resident's physician and family were notified of the incident. Record review of the resident's Skin assessment dated [DATE] at 1:00 P.M., showed the following injuries: -Right outer arm purple bruise measures 2.0 centimeters (cm) X 1.4 cm. -Left lower flank purple bruise measures 1.8 cm X 3.9 cm. -Left upper arm purple bruise measures 0.6 cm X 0.2 cm. -Large yellow/faded purple bruise right upper arm. Record review of a telephone statement by LPN B dated [DATE], showed the following -He/she was working the front half of 300 unit. -In early A.M. LPN A came through the door from the back and said You need to get back here now! -He/she want over to LPN A and he/she said, He/she is hurting him/her, I saw him/her grab him/her. -He/she told LPN A to get CNA A out of the room now. -He/she called the house supervisor RN A. -He/she went to the back half of the unit, and the resident was sitting on his/her bed and he/she sat down next to him/her. -CNA A was not in the room, but came out of the resident's bathroom. -LPN A and LPN B took the resident out of the room and helped him/her to recliner. -RN A showed up and CNA A was speaking loudly to RN A saying he/she did not like being accused of abuse. -At that time, LPN A said I saw you do it. -CNA A continued to be upset with RN A. -LPN B called security because he/she was afraid for RN A. -LPN B went back over to sit with the resident in the day area. -Security came and told CNA A to get his/her things and asked where he/she was parked and walked to the front door with CNA A, RN A and LPN B walked behind them. Record review of CNA A's written statement dated 1/28/20, showed the following: -He/she was assigned to work 6:45 P.M. to 7:00 A.M. at the facility. -On Saturday 1/25/20, he/she worked in the memory section of the building. -He/she started out on one side of memory section on a whole different assignment. -in the middle of the shift he/she was informed that he/she would be reassigned to the back side of memory section. -Which gave him/her the responsibility of the resident. -He/she was given report by CNA B. -He/she was told in report which residents were continent, incontinent, who was a Hoyer lift, and who to get up last on the get up list. -He/she was making his/her 12:00 A.M. rounds when he/she entered the resident's room. -He/she was told the resident was incontinent and must be checked every two hours. -The resident was asleep until he/she began to speak and tell the resident his/her name and that he/she was going to clean him/her up. -He/she was not told that the resident was ambulatory. -He/she raised the resident's bed up and began to remove his/her soiled brief. -The resident became combative with him/her. -The resident was throwing his/her arms and legs everywhere including trying to get out of bed. -He/she proceeded to cautiously and as safe as possible lift the resident's legs up and back in bed and place his/her hip against the resident's hip while he/she swings wildly at him/her. He/she putting the resident's legs back in bed he/she hears the nurse's voice saying Oh no we do not do it like that then the nurse ran off. -He/she continued to try and keep the resident from falling off the bed while completing his/her peri care. -At no point did the resident stand up. -The resident however attempted a couple of times to throw his/her legs off the raised bed while he/she was cleaning him/her. -He/she was not told the resident could stand and there was a Hoyer lift in his/her room. -So, he/she automatically thought the resident could not walk. -In report he/she was only told that the resident ambulate to chair. -He/she was only given a verbal report, that he/she wrote notes down for. -No one tried to assist him/her. Record review of the Police Report dated 1/30/20, showed the following: -Officer responded to the facility on [DATE] at about 12:02 P.M. -The officer responded to the resident's room to observe and photograph any injuries. -He/she observed one bruise to his/her left side and left arm, and a large (size of a baseball) to his/her right upper arm. -He/she attempted to contact CNA A through his/her employer on 1/28/20 at 10:30 A.M. -The investigation is ongoing and has been turned over to a detective. During an interview on 1/28/20 at 10:37 A.M., CNA A said the following: -He/she was not give a care plan for the residents, -CNA B gave a verbal report on how residents transfer, cares needed and morning routine. -He/she went into the resident's room to see if the resident was incontinent of bowel and bladder. -He/she did not turn on the lights because the roommate was sleeping and he/she did not want to wake him/her. -He/she went to get supplies to change the resident. -He/she was trying to move the floor mat when the resident woke up. -He/she told the resident that he/she was going to clean him/her up. -He/she removed the brief to clean the resident. -He/she did not want to get bowel movement all over the bed and floor. -He/she did not want to have to clean up bowel movement everywhere. -The resident was wildly trying to get off the bed. -The bed was raised and he/she was trying to keep the resident from falling. -He/she tried to keep the resident in the bed with his/her hip against the bed. -He/she picked up the resident's legs and put them back in bed. -The resident yelled then. -He/she told the resident what he/she was doing. -He/she did not know the resident cognitive status. -LPN A said we do not do thing like that. -The resident was never standing, his/her legs were just handing off the bed. -The resident was trying to sit up. -He/she did not know the resident could stand of he/she would have let the resident stand up. -He/she had worked at the facility many of times but this is the first time on the memory unit. -He/she was just trying to keep the resident from falling. -He/she was moved because there was only one aide on the back side. -He/she had no problems with the nurse on the front side of the memory unit. During an interview on 1/28/20 at 11:42 A.M., LPN A said the following: -When CNA A first came to the back part of the memory care he/she had problems with CNA A. -CNA B gave CNA A a profile sheet on the resident and started to make rounds. -CNA A was messing with his/her phone during report. -He/she was told to put the phone up as his/her phone was not allowed out on the floor. -CNA A's phone rang during report and he/she answered the phone. -He/she told CNA A to give him/her the phone and CNA A replied you have no right to take my phone. -He/she explained to the CNA A that he/she was in charge of the unit and he/she could take the phone as it is in the policy. -CNA A put his/her phone in his/her pocket. -He/she was watching CNA A to see what kind of care he/she was giving the resident. -When CNA A was about to catch up to where he/she was standing he/she went to sit down at the nurse's desk. -It was only him/her and CNA A on the unit at that time. -CNA B was on break at the time of the incident. -When he/she heard the resident yell he/she went to the room to check and see what was going on. -The resident was standing on the floor mat facing the window. -The resident had a brief and gown on while standing on the floor mat. -CNA A had his/her arms around the resident's waist. -The resident had a hold of the Broda chair with his/her right hand. -CNA A was trying to get the resident to let go of the Broda chair but the resident would not let go of the Broda chair. -When all of a sudden CNA A jerked up on the resident's right arm and threw the resident into the bed. -It all happened so fast. -He/she stopped CNA A and removed him/her from the room and had CNA A sit at a long table in the common area. -He/she went to the double door and yelled for help. -He/she was able to see the resident's room and CNA A while yelling for help. -He/she followed CNA A into the resident's room saying he/she had to wash his/her hands and went into the bathroom and closed the door. -CNA A came out of the bathroom and never washed his/her hands because the sink is in the resident's room not the bathroom. -He/she escorted CNA A back out of the resident's room. -Nothing was said to the resident by CNA A at that time. -He/she works the memory care unit most of the time and has never worked with CNA A before. -LPN B, RN A and Security escorted CNA A off the unit and out of the facility. During an interview on 1/28/20 at 1:55 P.M., the resident's family member said the following: -The resident gets great care at the facility. -He/she had no concerns about the incident. -The facility did a great job taking care of the resident after the incident. During an interview on 1/28/20 at 2:15 P.M., LPN C said the following: -He/she had been in-serviced on abuse and neglect on Sunday and Monday. -The facility has in-services monthly and annually on various topics. -He/she would separate the parties involved in the incident. -Notify the house supervisor, DON and administrator of the incident. -He/she would assess the residents for injuries and interview the residents. -Notify the physician and families. -He/she would follow physician's orders if gives. -He/she would call the police if a crime was committed. -Report to the state within two hours. During an interview on 1/28/20 at 3:27 P.M., the physician said the following: -No one should force cares on a resident. -If the resident refuses cares try again later or have another staff member try to assist the resident. -No resident should be forced into bed. -No staff member should leave bruises on a resident during cares. -He/she would expect the staff member to leave the resident alone and try again later. During an interview on 2/5/20 at 7:52 A.M., CNA B said the following: -He/she gave CNA A a profile sheet on the residents CNA A would be taking care of and tried to get CNA A to do his/her rounds since it was time. -All CNA A wanted to do was stand around a talk on his/her phone and to LPN A and CNA B instead of taking care of the residents. -He/she was on break when everything happened but after his/her break he/she stayed with the resident so the nurses could get everything done involving the incident. -The resident was shaking so, he/she just tried to calm the resident and assure him/her he/she was safe. MO 9[AGE] & MO 014

Based on interview and record review, the facility failed to transcribe physician admission comfort care oxygen orders to the physician order [REDACTED]. As a result the portable oxygen tank was found empty and the resident went for an undetermined amount time without supplemental oxygen and was found hypoxic (oxygen deficient) and his/her oxygen saturations measured in the 70's (normal 95-100%) out of five sampled residents. The facility census was 235 residents. 1. Record review of Resident # 1's Face Sheet showed he/she was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. - Postural Kyphosis of the [MEDICATION NAME] Region ( a round back where the spine curves forward); - Acute [MEDICAL CONDITION] (when not enough oxygen passes from the blood to the lungs) with Hypercapnia (excessive carbon [MEDICATION NAME] in the blood stream caused by inadequate respiration); - Collapsed Vertebrae of the neck and lower back (compression fracture resulting from the collapse of the spine) and - Failure to thrive (progressive functional decline). Record review of the resident's Hospice (end of life care) Physician order [REDACTED].M. showed he/she: - Was to admit to the facility Hospice wing for caregiver relief and the resident family was unable to provide care in the resident home; - Had a primary [DIAGNOSES REDACTED]. - Was ordered oxygen one to five liters (a unit of measurement) for comfort care. Record review of the resident's Physician Certification of Terminal Illness for Medicare Hospice 90 Day Benefit dated 12/12/17 showed he/she had: - Severe [MEDICAL CONDITION] due to scoliosis (abnormal sideways curvature of the spine); - Used supplemental oxygen at home and - Severe back pain. Record review of the resident's Hospice Initial Plan of Care dated 12/12/17 showed he/she: - Was ordered oxygen through the durable medical equipment supplier; -Had dyspnea (difficult or labored breathing) with increasing respiratory rate; - Had history of decreasing oxygen saturation levels to the 80's; - Had declined intubation (a tube to assist with breathing) and a [MEDICAL CONDITION] (a ventilator machine which enables breathing); - Had arrived calm, cooperative, alert to self, place and time; - Had crackles noted to the right lung with diminished bases, and the left lung was clear with diminished bases; - Had respirations labored at 22 breaths per minute (normal 12-16 breaths per minute) to the high twenties with increased pain and -Had an oxygen saturation at 83% on room air and oxygen was applied at two to three liters per nasal cannula (tubing connected to oxygen supply to provide air) which increased the oxygen saturation to the low 90's. Record review of the resident's Hospice Initial and Comprehensive Nursing assessment dated [DATE] showed: - He/she had respirations of 22 breaths per minute and had shortness of breath; - Oxygen saturations with two to three liters of oxygen through a nasal cannula were 94% and - He/she had answered questions or provided response by smiling and shaking his/her head. Record review of the resident's facility Clinical Notes dated 12/12/17 at 5:27 P.M. showed he/she: - Had admitted to Hospice services with the primary [DIAGNOSES REDACTED]. - Had clear speech; - Was alert and oriented with some impairment; - Had chronic back pain; - Had respiration rate of 22 breaths per minute and - Had an oxygen saturation level on room air of 83% and with two liters per nasal cannula had an oxygen saturation of 96%. Record review of the resident's facility Physician Note dated 12/12/17 showed he/she had: - Had intermittent dyspnea relieved by supplemental oxygen by nasal cannula; -Had back pain and fatigue and - Had [MEDICAL CONDITION] and was oxygen dependent related to kyphoscolosis. Record review of the resident's Hospice Nursing Update assessment dated [DATE] showed he/she: - Had respirations of 60 breaths per minute and were labored in nature; - Was nonverbal; - Had oxygen saturations of 90 % with two to three liters of oxygen per nasal cannula and - Respirations decreased with the [MEDICATION NAME] (narcotic pain medication) administration. Record review of the resident's facility Clinical Note dated 12/13/17 at 1:57 P.M., showed he/she: - Had a respiration rate of 60 breaths per minute and - Had an oxygen saturation level with two liters per minute of 93%. Record review of the resident's facility Physician Note dated 12/13/17 showed: - He/she was seen for comfort care and had significantly declined with diminished lung sounds, severe tachypnea (abnormal and rapid), breathing about 40 breaths per minute with prominent accessory muscles (muscles of the shoulder girdle and chest wall that in addition to the intercostal muscles and the diaphragm which are utilized by people with respiratory distress to help the flow of air in and out of the lungs) and had minimal response; - Was reported by family members to have not received any oxygen throughout the night and there was an empty oxygen cylinder at the bedside that the nasal cannula was attached to; - The resident was hypoxic (oxygen deficient) in the morning and measured in the 70's oxygen saturations and - Was ordered pain management for dyspnea improvement. Record review of the facility investigation dated 12/14/17 showed: - Licensed Practical Nurse (LPN) A completed the form; - The resident was admitted on [DATE] at 5:15 P.M., with oxygen saturations of 83% and was placed on oxygen through a portable tank while waiting for delivery for the oxygen concentrator from the durable medical equipment supplier; - The concentrator arrived to the facility at 5:30 P.M.; - The resident oxygen saturations had decreased to 71% and human error had occurred; - The oxygen supply was not changed from the portable tank to a continuous supply by using the concentrator causing potential discomfort to the resident; - The facility and Hospice staff were educated not to use the portable oxygen tanks and were to go to the central supply to get a oxygen concentrator until the durable medical equipment was delivered and - The Hospice wing would store a oxygen concentrator on the unit. Record review of the resident's facility TAR dated 12/1/17 to 12/31/17 showed: - The admission orders [REDACTED] - The order for comfort care oxygen was not recorded. During an interview on 5/16/18 at 11 A.M., LPN B said: - All residents on the Hospice wing were provided comfort care oxygen; - Comfort care oxygen could be provided at one to five liters to any resident; - Comfort care oxygen was not titrated to monitor saturation levels, oxygen was titrated to resident comfort and - Comfort care oxygen was not required to be on even when the nasal cannula was in place. During an interview on 5/16/18 at 11:43 A.M., Registered Nurse (RN) A said: - The resident had no order for continuous oxygen; - He/she had observed the portable oxygen tank and - He/she stood by his/her note that the resident was in no distress and there was no indicators that the resident was in need of increased supplemental oxygen at that time. During an interview on 5/16/18 at 12:10 P.M., the Nurse Practitioner said: - Comfort care oxygen was ordered for symptomology (objective signs of duress or distress) for hospice residents; - Comfort care oxygen usage was not based on resident saturation levels; - Comfort care oxygen usage was determined by subjective nursing assessment; - The standard of nursing practice would have been to monitor the resident oxygen; - The facility staff should have switched the resident from the portable tank to the concentrator and noticed the portable tank was empty and - The resident had a terminal disease and the nonuse of comfort care oxygen did not hasten the resident's death. During an interview on 5/16/18 at 12:15 P.M., the LPN A said: - The resident family had contacted him/her the day of the incident; - He/she had found the resident on admission had not arrived with oxygen on nor had he/she received his/her oxygen concentrator from the durable medical equipment supplier when the admitting facility nurse and hospice nurse had placed the resident on a portable oxygen tank; - The concentrator had arrived at the facility and the resident had not been switched over from the portable oxygen tank; - It was unknown how long the resident was without oxygen and - Portable oxygen tanks provide air supply for approximately four to five hours depending upon the air flow. During an interview on 6/5/18 at 10:15 A.M., the Director of Nurses (DON) said: - The resident's lack of receiving oxygen may have caused the resident discomfort; but did not result in the death or prolonged harm of the resident; - The resident arrived without oxygen; - The resident was ordered comfort care oxygen with one to five liters for comfort only; - The comfort oxygen was not transcribed to the POS or the TAR and should have been and - The resident had a history of [REDACTED]. During an interview on 6/5/18 at 12:31 P.M., RN B said: - He/she managed the facility Hospice wing; - RN C was the facility admission nurse for the resident; -The Hospice nurse was responsible for writing the orders on paper and then the facility nurse was expected to transcribe the orders to the facility POS, MAR, and TAR; - The facility nurse should have transcribed the order for comfort care oxygen to the physician order [REDACTED]. - Comfort care oxygen of one to five liters was an as needed order, should the resident exhibit restlessness, shortness of air, abnormal respirations or have had the appearance of being uncomfortable; - Comfort care oxygen was used for signs and symptoms only; - Facility staff should have noticed the portable oxygen tank had no air flow and - The admitting facility nurse should have set-up the concentrator for the resident and if the admitting nurse failed to do so, the responsibility would move to the next shift nurse. During an interview on 6/5/18 at 11:11 A.M., the Hospice Administrator said: - The resident had portable oxygen in use and on when the Hospice staff left the facility Hospice wing; - The resident was stable and a concentrator had been ordered; - The concentrator had arrived several hours after admission and - Orders for comfort care oxygen were nonspecific and made with a large range for comfort only. During an interview on 6/5/18 at 1:11 P.M., the facility RN C said: - He/she had admitted the resident with the Hospice nurse to the facility Hospice wing; - The resident was placed on comfort care oxygen with a portable oxygen tank; - The resident did not have a concentrator at bedside on admission; - He/she had heard the concentrator arrived before his/her shift ended and - He/she was responsible for transcription of Hospice orders to the facility POS, MAR, and TAR. During an interview on 6/5/18 at 1:33 P.M., the Hospice Medical Director said he/she: - Had admitted the resident with [MEDICAL CONDITION] related to scoliosis; - Had reviewed the facility documentation completed by the facility nurses showing the resident was comfortable on 12/13/17 between 6:00 A.M. and 7:00 A.M.; - Had arrived to the facility about 8:30 A.M., and was told by the Hospice nurse the resident had not received any oxygen; - The resident was ordered comfort care oxygen, not to prolong life but to relieve feelings of suffocation; - Comfort care oxygen does not mean a need, even when the resident was hypoxic. Comfort care oxygen was for resident comfort based on the nursing assessment; - Oxygen saturations were not required to be charted for comfort care orders and saturations did not reflect the need for oxygen; - The resident admitted from the hospital after recommendation for Hospice; -The resident was terminal, admitted with multiple concerns and declined rapidly fast and - Standard nursing practice would have expected for facility staff to monitor oxygen when in use. During an interview on 6/5/18 at 2:15 P.M.; the Administrator and the DON said: - The resident had admitted on [DATE] for Respite care (temporary care of a dependent elderly person in order to provide relief for their usual caregivers) and Respite did not require charting of vital signs unless a significant change was noted and - The resident admitted to general in patient status on 12/13/17. During an interview on 6/5/18 at 2:48 P.M., LPN B said he/she: - Had worked the morning of 12/13/18; - The resident had family present upon arrival; - The resident nor family did not report concerns; - Had not gone into the room and physically checked the resident oxygen and -The resident showed no signs of discomfort. During an interview on 6/5/18 at 5:00 P.M., Hospice RN A said he/she: - Had not participated in the resident admission; - Was assigned as the resident Hospice nurse case manager; - Had first met the resident the morning of 12/13/17 and resident's spouse was at bedside; - The resident had high respirations; - The concentrator was at the bedside, plugged in and turned on; - The resident nasal cannula was attached to the portable oxygen tank that was empty behind the resident bed; - The portable oxygen tank was a standard size and - The resident was ordered comfort care oxygen by the admitting the Hospice nurse. During an interview on 6/5/18 at 6:49 P.M., Hospice RN B said he/she: - Was the admitting Hospice care nurse; - The resident had admitted for m the hospital and arrived with no oxygen; - The resident respiration were high when oxygen via nasal cannula was placed on the resident by a portable oxygen tank; - The resident was ordered comfort care oxygen at one to five liters and - Had ordered a concentrator through the durable medical equipment supplier. During an interview on 6/6/18 at 8:00 A.M., Family Member #1 said he/she: - Had told the facility staff on 12/12/17 that the concentrator had arrived and requested the facility staff to transfer the resident from the portable oxygen tank to the concentrator before departure from the facility; - Had visited the resident at 6:30 A.M. before work when family member #3 had said the resident was not doing well; - Was unaware if a family member had told a nurse about the resident discomfort throughout the early morning and - Was notified by family member #2 the resident had been without oxygen throughout the night. During an interview on 6/6/18 at 1:31 P.M., Family Member #2 said he/she: - Was present when the resident had admitted ; - Was present on 12/12/17 when the durable medical equipment supplier had delivered the concentrator, plugged it in and turned it on; - Had asked the facility nurse to transfer the resident from the portable oxygen tank to the concentrator before leaving on 12/12/17; - Had arrived before 10:00 A.M. on 12/13/17 and - The Hospice nurse had checked the concentrator and noticed the resident was still connected to the portable oxygen tank and the portable oxygen tank was empty. During an interview on 6/7/18 at 10:00 A.M., Family Member #3 said he/she: - Was present when the resident admitted to the facility 12/12/17; - The resident did not speak much; - Did not remember who had plugged in the concentrator; - Had arrived early on 12/13/17 and was the first one there; - The resident did not seem good, he/she did not talk and was weak; - The resident was not gasping for air and was not breathing any heavier than usual; - Had thought one of the family member had noticed the portable oxygen tank was empty; - Had not gotten a facility nurse; - The resident was half way normal for him/her; - The resident only answered with yes or no answers; - The resident was not what he/she was the week before; - Had lost his/her notes about the problem when whoever was supposed to be watching did not notice the resident did not have oxygen and - The facility was not interested in making the resident better and was just trying to keep the resident alive. MO 412

Based on observation, interview, and record review, the facility failed to identify and report to the physician one sampled resident's (Resident #20) progressive weight loss of 86.9 pounds, or 42.6% of body weight, from 10/22/11 to 1/1/12, and who received diuretic (an agent that increases the secretion of urine) medications, resulting in hospitalization with a [DIAGNOSES REDACTED]. [REDACTED]. plan for the resident; of 27 sampled residents. The facility census was 273 residents. Record review of the facility's policy titled "Clinical Service Standards, Policy and Procedures, Nursing Procedure Guide, Weight Measurement," last revised 12/31/08, showed nursing procedures will be performed according to acceptable nursing practice guidelines, and the purpose of taking weight measurement is to obtain an accurate weight of each resident. -All residents are weighted monthly or more frequently according to physician order, nursing judgment, or dietician judgment; -All residents receiving skilled care get weekly weights; -Make sure the scale balances at zero pounds by turning the calibration screw; -Ensure resident clothing is not excessive causing potential weight variances. If resident is unwilling to be weighed without excessive clothing, notify the charge nurse to determine an adjustment to make to the recorded weight for these items; -If a resident refuses weighing, notify the charge nurse; -Ensure the weight is permanently recorded in the "Weight Book," -When the resident is in a wheelchair, place the empty wheelchair on the scale and record it's weight, and then place the wheelchair with the resident in it and weigh them, and subtract the weight of wheelchair from the total weight of the resident and the wheelchair. Note: The policy did not instruct staff to re-weigh the resident when there was a major discrepancy from the previous weight. Record review of the 2005 Drug Handbook, showed [MEDICATION NAME], also known as [MEDICATION NAME] is a diuretic (an agent that increases the secretion of urine) or a water pill: -Is used to reduce the swelling and fluid retention caused by various medical problems, including heart of liver disease, which causes the kidneys to get rid of unneeded water and salt from the body; -Potential adverse reactions include volume depletion, dehydration and fluid and electrolyte imbalances; -Nursing considerations include the following: --"Monitor weight, blood pressure and pulse rate routinely with long-term use and during rapid [MEDICATION NAME]. [MEDICATION NAME] can lead to profound water and electrolyte depletion." --"Monitor fluid intake and output and electrolyte, blood urea nitrogen (BUN), and carbon [MEDICATION NAME] levels frequently." --"Monitor elderly patients, who are especially susceptible to excessive diuresis, because circulatory collapse and [MEDICAL CONDITION] complications are possible." Record review of the 2005 Drug Handbook, showed [MEDICATION NAME] is a thiazide diuretic and an antihypertensive medication that increases sodium and water excretion by inhibiting sodium and chloride re-absorption in the kidney. Potential adverse reactions include volume depletion, dehydration and fluid and electrolyte imbalances. Record review of the 2005 Drug Handbook, showed Ramipril is an antihypertensive medication used to treat high blood pressure. Potential adverse reactions include the increase of BUN and creatinine (a blood test that measures kidney function; and abnormal levels may indicate kidney disease); and nursing considerations include to monitor the [MEDICAL CONDITION] in legs and feet every day, weigh daily, and [MEDICAL CONDITION]. Review of the government website MedlinePlus at nlm.nih.gov in regard to [MEDICAL CONDITION] and diuretics showed: -When a person has heart failure the heart does not pump strongly enough and that causes fluids to build up in the body; -If a person drinks too many fluids it can cause symptoms of swelling, weight gain and shortness of breath; -Limiting how much a person drinks and how much salt (sodium) a person takes in can help prevent these symptoms. -As heart failure gets worse, a person may need to limit the fluids they drink to six to nine cups a day (about 1 1/2 to 2 liters). -Diuretics help the body get rid of extra fluid and [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME] are common diuretics. -It is recommended that a person with heart failure weigh themselves every day and if the weight goes up more than two to three pounds in a day or 5 pounds in a week they should let the Doctor know; also call the doctor if a person loses a lot of weight. Review of the website www.merckmanuals.com, regarding [MEDICAL CONDITION] (the level of sodium in the blood is too high), showed an elevated sodium has many causes, but dehydration is most common, including not drinking enough fluids, diarrhea, kidney dysfunction and taking diuretics. 1. Record review of Resident #20's Face Sheet, showed the resident was admitted from home on 6/2/11 for non-skilled care, with [DIAGNOSES REDACTED]. -Cardiac [MEDICAL CONDITION] (irregular heartbeat); -Dysphagia (a symptom of one-side weakness and difficulty swallowing related to stroke); -Pneumonia and respiratory abnormalities; -Type II Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin); -[MEDICAL CONDITION] (a type of lung disorder, such as [MEDICAL CONDITION] or chronic [MEDICAL CONDITION], in which the upper or lower airway is chronically obstructed); -[MEDICAL CONDITION] (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception); -Late effects of [MEDICAL CONDITION] disease with [MEDICAL CONDITION] (a symptom of one-side weakness after a stroke); -Hypertension (high blood pressure); -[MEDICAL CONDITION] (a condition where the blood does not carry enough oxygen to the body); -Malignant neoplasm (tumor or growth); [MEDICAL CONDITION] of the large intestine; -Unspecified protein-calorie [MEDICAL CONDITION]; -Intestinal infection [MEDICAL CONDITION] ([MEDICAL CONDITION] - an intestinal bacterial infection). Record review of the resident's facility Medical Record, History and Physical dated 6/3/11, showed: -The resident said he/she had "No problems" and said that he/she felt "good;" -The physician listed the resident's current [DIAGNOSES REDACTED]. Record review of the resident's Nutritional assessment dated [DATE], with a written notation on the document dated 8/23/11, showed: -The resident was consuming a regular diet as ordered; -He/she had a [DIAGNOSES REDACTED]. -He/she had a history of [REDACTED]. -The resident's nutritional analysis showed he/she weighed 179 pounds and his/her usual body weight was 195 pounds, two years ago; -The area to be completed for weight loss history was left blank; -The calorie needs of the resident per day varied and was calculated at 2280 calories per day; -The resident needed protein grams of 81 grams per day; -The resident's fluid intake requirement was 2430 cubic centimeters (cc) per day; -The dietary needs section area of the document was not completed. Record review of the resident's physician's progress note dated 8/23/11, showed: -The resident stated he/she occasionally had shortness of breath that usually resolved spontaneously, and denied any chest pain, headache, difficulty urinating, numbness, and pain; -The resident had a past medical history of [REDACTED]. -The physician order [REDACTED]. -A dietary consult was ordered to monitor the resident's nutrition. Record review of the resident medical record, showed no documentation the staff weighed the resident between 8/23/11 to 9/1/11 as ordered in the physician's 8/23/11 progress notes. Record review of the resident's updated nutritional assessment completed by the Registered Dietician (RD) on 8/23/11, showed the following: -The resident currently weighed 163.8 pounds; -Since admission the resident had lost 18 pounds; -The resident was consuming eating 75-100% of meals; -The resident was consuming a mechanical soft with nectar thickened liquids diet; -The resident was receiving a nutritional supplement (Boost) twice a day; -The resident was taking the diuretic [MEDICATION NAME] when he/she was admitted to the facility, then on 7/25/11 the [MEDICATION NAME] was increased; -According to the Dietician, the resident's weight loss "appears to be secondary to the diuresis (increase of urine production from the diuretic medication)." Record review of the resident's electronic medical record weight sheets showed: -On 9/1/11 the resident weighed 171.1 pounds; -On 9/2/11 the resident weighed 176.5 pounds. Record review of the resident's physician's progress notes dated 9/19/11, showed: -The resident stated he/she felt fatigued and had intermittent dyspnea (shortness of breath) for two days, which resolved itself; -The resident refused to go to the hospital; -The resident was assessed with [REDACTED]. -The physician's plan was to increase the resident's dose of [MEDICATION NAME], and see that both of the resident's feet are elevated at bedtime. Record review of the resident's physician's progress note dated 10/1/11, showed: -The resident was seen by the physician per staff request; -The resident stated he/she "made very minimal urine today," with no known worsening factors; -The resident had two plus bilateral pedal [MEDICAL CONDITION] ([MEDICAL CONDITION] of both of the resident's feet); -The assessment and plan was the resident had [MEDICAL CONDITION], oliguria (diminished amounts of urine formation), and "it appears patient is having worsening [MEDICAL CONDITION] recommended to transfer to ER hospital for further evaluation and management." Record review of the resident's electronic medical nurses notes on 10/1/11 at 11:14 A.M., showed the staff did not document that they notified the resident's physician of the resident's weight gain of 17.4 pounds in one month. Record review of the resident's electronic medical record weight sheet showed: -On 10/1/11 the resident weighed 188.5 pounds; -On 10/5/11 the resident weighed 184.8 pounds. Record review of the resident's nurses notes entry on 10/10/11, showed a late entry dated 10/7/11 stating: -The Certified Nursing Assistant (CNA) reported to the charge nurse that the resident had not had any urine output all evening; -The CNA reported that the day shift CNA also reported that the resident had not had any urine output during the day shift either; -The charge nurse observed the resident drank at least 480 cc of fluid at meal time; -The resident's physician was notified of the resident's little to no urinary output; -The resident's lower legs had 2 to 3 plus [MEDICAL CONDITION] (one plus [MEDICAL CONDITION] produces a barely detectable depression when a finger is pressed into the skin and there is immediate rebound; two plus [MEDICAL CONDITION] produces a slight indentation and takes 15 seconds to rebound, and three plus [MEDICAL CONDITION] produces a deeper indentation and takes 30 seconds to rebound); -A physician's orders [REDACTED]. Record review of the resident's hospital discharge summary dated 10/16/11, showed: -The resident was admitted from the facility for altered mental status and weight gain; -The resident was found to have [MEDICAL CONDITION] and fluid overload; -The resident had three plus bilateral lower extremity [MEDICAL CONDITION] ([MEDICAL CONDITION] to both of his/her lower extremities); -The resident had acute kidney injury related to decreased intake; -They discussed with the resident's family placing the resident on a feeding tube, but the family decided to continue to let the resident eat, despite the high aspiration risk; -The resident's hospital weight on 10/12/11 was 198.6 pounds; -His/her discharge [DIAGNOSES REDACTED]. Record review of the resident's electronic medical record weight sheet dated 10/17/11, showed the resident weighed 201.4 pounds. Record review of the resident's electronic medical record nurse's notes on 10/17/11 at 12:53 P.M., showed: -The night shift nurse reported that the resident's weight was up three pounds from the prior day; -The resident had no order for his/her [MEDICAL CONDITION] diagnosis; -The physician was phoned and given the information about the weight gain; -The physician ordered for the resident to begin taking [MEDICATION NAME] 40 milligrams (mg) twice a day; -The physician's orders [REDACTED]." Record review of the resident's electronic medical record clinical note by the Registered Dietician dated 10/17/11 at 5:07 P.M., showed: -The resident was readmitted [DATE] after a hospitalization ; -There was no readmission weight on the nursing assessment; but the resident's October 2011 weight was 201 pounds; -The last month the resident weighed 185 pounds; -The resident had bilateral lower leg swelling ([MEDICAL CONDITION]); -The resident had a new physician's orders [REDACTED]. -The resident had a [DIAGNOSES REDACTED]. -The resident was on a mechanical soft diet with nectar thick liquids; -The resident was previously on Boost (a nutritional supplement) twice a day and had the same diet consistency; -The resident previously was on daily weight monitoring due to fluid concerns; -It appeared that the resident's weight gain if the weight was correct may be may be due to "fluid issues;" -There was little information in the resident's medical record from his/her recent hospital stay; -A recommendation to continue his/her diet as ordered; -His/her meal intake was from 50% to 100% according to his/her meal log; -They would expect to see weight loss due to diuresis; -Based on the resident's meal intake "the resident may not need oral nutritional supplements;" -They would watch the resident's weights and meal intake as needed. Record review of the resident's electronic medical record weight sheets showed the resident: -On 10/22/11 weighed 203.8 pounds; and -On 10/25/11 weighed 200.1 pounds. Record review of the resident's electronic medical documented by the Registered Dietitian dated 10/29/11 at 12:26 P.M., showed that the resident's October weight of 202 pounds was an error and he/she needed the correct weight. Record review of the resident's electronic medical record weight sheet dated 11/10/11, showed that the resident weighed 200.5 pounds; a weight gain of 5.4 pounds in one day, and the clinical notes did not show the physician was notified of the resident's weight gain. Record review of the resident's treatment record dated 11/10/11, showed the resident weighed 200.8 pounds. Record review of the resident's treatment record dated 11/1/11 to 11/3/11, showed no documentation of the resident's daily weight according to the physician's orders [REDACTED]. Record review of the resident's electronic medical record weight sheet and treatment record dated 11/20/11 at 7:02 A.M., showed the resident weighed 185.4 pounds; a weight loss of 13.7 pounds in four days or 6.9% of his/her body weight, and there was no notation in the clinical notes that the physician was notified of the 13.7 pound weight loss. Record review of the resident's electronic medical record clinical note dated 11/21/11 at 7:41 A.M., documented by the Certified Dietary Manager, showed: -The resident's daily weight today was 189 pounds; -There were no significant weight changes according to the Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff) protocol based on daily weights, one month, and six months ago, but his/her weight did fluctuate; -The daily weights this month ranged from 185 pounds to 201 pounds, which appear "due to diuresis;" -See also the Registered Dietician notes date 10/17/11, followed by the psychiatrist notes of 10/1/11; -The resident was sent to the hospital emergency room for bright red blood in his/her urine on 9/18/11; -On 9/19/11, the resident was started on antibiotics; -The resident was sent to the emergency room for evaluation and treatment of [REDACTED]. -The resident had medication changes of his/her [MEDICATION NAME]; -The resident was on a mechanical soft, no added salt, with nectar thickened liquids diet; -The resident eats in the day area with supervision for aspiration; -The resident's meal intake varied from 50% to 100%; -Staff will continue his/her current plan of care at this time. Record review of the resident's quarterly MDS dated [DATE], showed the resident: -Was unable to complete the staff assessment for mental status interview; -Required extensive staff assistance with one person physical assistance in the areas of bed mobility, locomotion on and off the unit, and dressing; -Was totally dependent on two or more for transfers and toilet use; -Required limited assistance of one staff person for eating; -Required extensive of one staff person for personal hygiene; -Was always incontinent of bladder and frequently incontinent of bowel; -Has no signs or symptoms of possible swallowing disorders, -Weighted 189 pounds, and had experienced no weight loss of 5% or more in one month or 10% or more in the last six months; Record review of the resident's electronic medical record weight sheet and treatment record dated 11/24/11 at 6:12 A.M., showed the resident weighed 176.1 pounds; a weight loss of 9.3 pounds in four days, or 5% of his/her body weight, and there was no notation in the clinical notes that the physician was notified of the resident's 9.3 pound weight loss. Record review of the resident's electronic medical record weight sheet dated 11/25/11 at 7:11 A.M., showed the resident weighed 173.4 pounds; a weight loss of 2.7 pounds in one day, or 1.5% of his/her body weight, and there was no notation in the clinical notes that the physician was notified of the 2.7 pound weight loss. Record review of the resident's treatment record dated 11/26/11, showed the resident weighed 172 pounds; a 1.4 pound weight loss in one day or a .8% loss of his/her body weight. Record review of the resident's electronic medical record weight sheets showed: -On 11/27/11 at 6:36 A.M., the resident weighed 170.2 pounds; a weight loss of 3.2 pounds in two days, or 1.8% of his/her body weight, and there was no notation in the clinical notes that the physician was notified of the 3.2 pound weight loss; -On 11/29/11 at 6:15 A.M., the resident weighed 164.5 pounds; a weight loss of 5.7 pounds in two days, or 3.3% of his/her body weight, and there was no notation in the clinical notes that the physician was notified of the 5.7 pound weight loss; -On 11/30/11 at 6:54 A.M., the resident weighed 163.9 pounds; a weight loss of .6 pounds in one day, a loss of 37.5 pounds in one month since 11/1/11, or 18.6% of his/her body weight; and there was no notation in the clinical notes that the physician was notified of the 37.5 pound weight loss in the month of November 2011. Record review of a physician's progress note dated 11/30/11, showed: -The resident stated he/she was eating better, and had plus one bilateral pedal [MEDICAL CONDITION]; -The resident [MEDICAL CONDITION] appears to be stable; -No document in the progress note regarding the resident's 37.5 pound weight loss during the month of November. Record review of the resident's physician's orders [REDACTED].M., to: -Obtain vital signs every shift for seven days, and fax daily to the physician's office; -Check BNP (brain natriuretic peptide - a test for [MEDICAL CONDITION]; the test measures the amount of the BNP hormone in your heart; and BNP is made by the heart and shows how well the heart is working); -Check weekly weights on every Thursday and the fax results to the resident's physician office. Record review of the resident's electronic medical record weight sheet dated 12/1/11 at "00:00," showed the resident weighed 183.40 pounds; a weight gain of 19.5 pounds in one day, and no notation in the resident's clinical notes to show the resident was re-weighed and the resident's physician was notified of the 19.5 pound weight gain in one day. Record review of the resident's current medications on the December 2011 monthly physician order [REDACTED]. -[MEDICATION NAME] (an antihypertensive medication) 25 mg one tablet by mouth twice a day, (hold if systolic blood pressure less than 100 or heart rate less than 55), -Ramipril 10 mg by mouth daily; -[MEDICATION NAME] ([MEDICATION NAME]) 40 mg, one tablet twice a day, marked to given at 9:00 A.M. and 5:00 P.M., ordered on [DATE]; -An entry with a line marked through the entry for "Daily weight," with an entry noting to "Weigh Weekly" 11/30/11, with no directions for "weekly weights, on every Thursday, and fax results to the resident's physician office." Record review of the resident's physician's orders [REDACTED].M., to: -Discontinue current [MEDICATION NAME] order; -Start [MEDICATION NAME] 12.5 mg twice a day for hypertension; -Hold [MEDICATION NAME] if systolic blood pressure less than 100 or heart rate less than 55; -Start [MEDICATION NAME] 12.5 mg daily for blood pressure/hypertension. Record review of the resident's physician's orders [REDACTED].M., to: -Discontinue current [MEDICATION NAME] orders; -Start tablets [MEDICATION NAME] 25 mg daily for Hypertension (an increase from 12.5 mg to 25 mg daily); -Check the labs BMP and BNP on 12/9/11 for [MEDICAL CONDITION] and HTN. Record review of the Nursing 2005, 25th Edition Drug Handbook, showed: -A drug-to-drug interaction is possible when [MEDICATION NAME] is given with [MEDICATION NAME] as it may cause excessive diuretic response resulting in serious electrolyte abnormalities or dehydration. Record review of nurse's notes dated 12/8/11 at 8:44 A.M., showed there was a care plan meeting on 12/7/11 with the resident's family member, and they asked about the resident's [MEDICAL CONDITION]. The Unit Manager explained how [MEDICAL CONDITION] works in the body and how it contributes to the [MEDICAL CONDITION]. Record review of the resident's physician's orders [REDACTED]. -A hand written physician's telephone order dated 12/11/11 at 3:30 P.M., to give the resident [MEDICATION NAME] 4 mg as needed to treat nausea and vomiting, and to increase fluids; and -A hand written physician's dated 12/12/11 at 11:32 A.M. to give the resident [MEDICATION NAME] one or two tablets three times a day as needed for diarrhea for seven days, for the resident to have Gatorade as needed, and for [MEDICATION NAME] 4 mg every four hours as needed. Record review of the resident's POS showed a hand written physician's orders [REDACTED].M., to give [MEDICATION NAME] one or two tablets three times a day as needed for diarrhea. Record review of a nurse's note dated 12/30/11 at 2:14 P.M., showed: -The resident has new orders to discontinue the ace wrap with bulk gauze to both of his/her lower extremities; -The resident's extremities were noted to be free from [MEDICAL CONDITION], and staff will continue to monitor. Record review of the resident's treatment record dated 12/1/11 to 12/31/11, showed a physician's orders [REDACTED]. weights were completed. Record review of unit weight sheet dated 1/2/12, showed the resident weighed 116.9 pounds; a weight loss of 66.5 pounds since 12/1/11; and loss of 36% of his/her body weight. Record review of the resident's nurse's notes dated 1/4/12 at 3:08 P.M., showed: -The CNA stated the resident was acting different and not responding to stimuli; -The facility asked the Nurse Practitioner to see the resident; -The lab called back with "critical labs." Record review of the resident faxed laboratory results dated [DATE], showed: -The lab results sodium level were "critically" high at 164 mmol/l (normal range is 135-146 mmol/l); -The resident's BUN was high at 89 (normal 6-22), and [MEDICATION NAME] was high at 2.4 (normal 0.7 to 1.4). Record review of the resident's physician's progress notes dated 1/4/12, and completed by APRN B, showed: -The Nurse Practioner was called to the resident's bedside this morning regarding the resident's decrease in his/her level of consciousness. The resident would not respond to verbal stimulus, and he/she had [MEDICAL CONDITION] and was under diuresis, and labs were ordered; -The resident had no [MEDICAL CONDITION]; -The resident was assessed as having acute dehydration with [MEDICAL CONDITION]; -The plan was to send the resident to the emergency department per the family request. Record review of the resident's physician's orders [REDACTED].M., to send the resident to the emergency room to evaluate and treat. Record review of the resident's hospital records showed: -The resident 124.7 pounds when weighed on 1/5/12 at 12:42 P.M. Record review of the hospital records, Nutrition Consult dated 1/5/12, showed: -The resident weighed 198.6 pounds on the 10/12/11 clinic visit, and the ideal body weight was 160 pounds; -The resident was weighed 121.6 pounds on 1/4/12, which was a weight loss of 77 pounds in 12 weeks (a weight loss of 38.8%), and on on 1/5/12 at 12:42 P.M. his/her weight was 124.7 pounds after the resident was rehydrated; -The resident's status was severely nutritionally compromised with an estimated energy needs of 1600 to 1800 calories a day; -IV fluids were being infused to the resident when in the hospital at 200 milliliters (ml)/hour; -Due to the resident's excessive weight loss, if the resident was unable to consume adequately by mouth, enternal nutrition (tube feeding) should be considered for the resident. Record review of a hospital progress note dated 1/9/12 at 9:42 A.M., the resident's family requested the resident receive one liter of water by mouth every day when he/she was discharged to the facility, because the resident had been admitted to the hospital repeatedly for dehydration. Record review of the resident's hospital discharge summary for his/her hospital stay between 1/4/12 and 1/11/12, showed: -The resident was transferred to the emergency room for altered mental status and found to have multiple electrolyte abnormalities, to be dehydrated, and to have an infiltrate (a substance passes into or through a substance or a space) on his/her chest x-ray; -The resident had a free water deficit calculated at 9.7 liters on admission, and aggressive fluid replacement with intervenous (IV) fluids was started. Record review of the facility's unit weights dated 1/11/12, showed the resident upon admission to the facility from the hospital weighed 132.6 pounds. Record review of the resident's care plan contained in the electronic medical record on 1/12/12, showed the a problem that the resident was receiving diuretic medication on a regular basis, with a goal that diuresis would be achieved without evidence of dehydration, with the following staff interventions: -For the CNA to weigh the resident daily; -To look for signs of dehydration and electrolyte imbalance such as dry tongue/lips, dizziness upon standing, muscle cramping, and abnormal laboratory results; -Monitor laboratory results for abnormal findings; -For skilled nursing to respond promptly to calls for assistance to the toilet; and to -"Assist resident to select/wear clothes this is easily removed to reduce the risk of wetting accidents." Observation of the resident during the breakfast and lunch meals on 1/12/12 and 1/13/12, showed staff was feeding the resident and the resident was not able to eat or drink independently. Record review of the resident's physician's orders [REDACTED].M., to: -Check the resident's CBC, BMP, BNA today due to [MEDICAL CONDITIONS], and [MEDICAL CONDITION]; -Start [MEDICATION NAME] 0.1 mg three times a day for hypertension, and -Hold the resident's [MEDICATION NAME] if systolic BP is less than 110 or heart rate less than 55 beats a minute. Record review of the resident's physician's orders [REDACTED]. ([MEDICATION NAME]) to 20 mg orally twice a day. Record review of the resident's nurse's notes dated 1/15/12 at 4:09 P.M., showed: -The resident's family member approached staff stating the resident was not responding to him/her; -Staff attempted to arouse the resident but were unsuccessful, and the family wanted staff to call the physician. Record review of the resident's physician's orders [REDACTED].M., for the resident to be transported to the hospital for evaluation and treatment, and did not address why the resident was evaluated at the hospital. During an interview on 1/13/12 at 8:30 A.M., Licensed Practical Nurse (LPN) V said: -He/she was very familiar with the resident and had taken care of him/her since his/her admit to the facility in June 2011; -He/she was not aware of any other episodes or previous periods of decrease in level of consciousness; -The physician and "all of the staff" were well aware of the resident's significant weight loss; -He/she and "all of the staff" were encouraging the resident to drink fluids; -He/she was not working the days preceding the resident's most recent admit and did not know how the resident appeared just before transfer to the hospital for dehydration. During an interview on 1/13/12 at 8:50 A.M., the facility Medical Director, and the resident's primary care physician, said: -The resident had a new onset of [MEDICAL CONDITION] about eight or nine months ago; -The resident was being treated with diuretics ([MEDICATION NAME]) for the [MEDICAL CONDITION] and he/she had prescribed the [MEDICATION NAME] (a diuretic) to treat the hypertension; -He/she was surprised by the lab result of the elevated Sodium on admission to the hospital on [DATE]; -He/she was aware the resident had decreased the amount of oral fluids he/she was taking and had ordered the staff in December 2011 to increase the resident's fluids and offer Gatorade as needed; -He/she was not aware of the significant weight loss that had occurred and was disappointed that the staff failed to follow the physician's orders [REDACTED]. -He/she would have likely or probably changed or slowed the medications (the ordere