Every finding on record at La Belle Manor Care Center

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for three sampled residents (Resident #4, #8 and #20), in a review of 13 sampled residents. The facility census was 35. Review of the Resident Assessment Instrument (RAI) Manual, version 1.18.11, dated October 2023, showed the following: -Medicare and Medicaid participating long-term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status; -The RAI process has multiple regulatory requirements. Federal regulations require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts; -Admission refers to the date a person enters the facility and is admitted as a resident. Completion of an OBRA Admission assessment must occur in any of the following admission situations: when the resident has never been admitted to this facility before; OR when the resident has been in this facility previously and was discharged return not anticipated; OR when the resident has been in this facility previously and was discharged return anticipated and did not return within 30 days of discharge; -It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the Interdisciplinary Team (IDT) completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment; -Cognitive patterns: The items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information and whether the resident has signs and symptoms of delirium. These items are crucial factors in many care-planning decisions; -Preferences for customary and routine activities: The intent of items in this section is to obtain information regarding the resident's preferences for their daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences. The information obtained during this interview is just a portion of the assessment. Nursing homes should use this as a guide to create an individualized plan based on the resident's preferences and is not meant to be all-inclusive. Review of the facility's policy, Electronic Transmission of the MDS, revised 08/27/23 showed the following: -All staff members responsible for completion of the MDS receive training on the assessment process, computer entry, and transmission process, in accordance with the MDS 3.0 RAI instruction manual, before being permitted to use the MDS computer system. A copy of the MDS 3.0 RAI instruction manual is maintained by the resident assessment coordinator; -Staff members are trained on updates/revisions to the MDS 3.0 form and software upgrades as they are released. Such training is provided by the corporate staff and/or computer software vendor; -The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data. 1. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/28/25, showed the following: -Cognitively intact; -Diagnosis of heart failure, pneumonia, arthritis and depression; -Section D, mood, social isolation was coded as never (choices are never, rarely, sometimes, often, always, resident declines to respond, resident unable to respond); -Section F, Activity Preferences, for all activities: having things to read, listen to music you like, be around animals such as pets, keep up with the news, doing things with groups of people, doing favorite activities, going outside when the weather is good and participate in religious activities/practices; all marked very important (choices are very important, somewhat important, not important at all, important but can't do or no choice, or no response); -The resident was the primary respondent for Section F; -Section GG, Functional Abilities and Goals, showed the resident was dependent on staff for upper body dressing and required partial to moderate assistance for rolling left and right; -Section I, Diagnosis, the resident had a diagnosis of pneumonia; -Section J, Pain Management, received scheduled pain medication regimen was marked no; -Section N, Medications, high-risk drug classes: use and indication, is taking hypoglycemic (medication to treat diabetes and/or lower blood sugar (the amount of sugar in the blood)) and indicated was check marked; -Section O, Special Treatments, Procedures, and Programs: Restorative Nursing Program was indicated as completed three out of seven days for active range of motion. Review of the resident's electronic health record showed no documentation of pneumonia for the observation period of the assessment. The resident was on scheduled pain medication including metadone hydrochloride (a narcotic pain reliever used to treat chronic pain) 10 milligrams three times a day with an order start date of 02/06/24, did not take a hypoglycemic medication and was not on a formal restorative program. During an interview on 05/27/25 at 10:32 A.M., the resident said the following: -He/She stayed in his/her room by choice due to a condition related to the resident's knee and very seldom left the room; -He/She chose to eat all meals in his/her room; -He/She used the bed rail to turn independently from left to right and can dress the upper portion of his/her body; -The only activity he/she participated in was independently watching television in his/her room and will go outside and go home during the summer. Observation on 05/27/25 at 10:32 A.M., showed the resident sitting up awake in his/her room watching television and playing a game on his/her phone. Observation on 05/28/29 at 10:17 A.M., showed the resident sitting up awake in his/her room watching television and used the side rail to reposition himself/herself in bed. Observation on 05/28/25 at 6:00 P.M., showed the resident sitting up in his/her bed eating supper and watching television. Observation on 05/29/25 at 9:33 A.M., showed the resident sitting up in his/her bed watching television. 2. Review of Resident #8's electronic health record showed the resident admitted to the facility on [DATE]. Review of the resident's discharge MDS, dated [DATE], showed a discharge with return anticipated status. Review of the resident's MDS schedule showed the resident returned to the facility on [DATE] (three days after discharge with return anticipated MDS submission). Review of the resident's electronic health record (EHR) showed the following: -The resident was hospitalized from 01/24/25 to 01/27/25 and transferred from the facility; -The resident became physically aggressive with staff on 01/27/25; -The resident refused a shower/bath on 01/31/25; -The resident refused to go to dialysis on 01/28/25 and 02/01/25. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Re-entry to the facility on [DATE] after a short-term general hospital stay; -admitted [DATE]; -Diagnosis of end stage renal disease (where the kidneys lose the ability to remove waste and balance fluids) with dialysis (treatment that cleans the blood when the kidneys are not functioning properly); -Section D, Mood, social isolation is coded as never (choices are never, rarely, sometimes, often, always, resident declines to respond, resident unable to respond); -Section E, Behavior, no behavior symptoms or rejection of cares (inaccurate based on documentation in the resident's EHR); -Section F, Activity Preferences, for all activities: having things to read, listen to music you like, be around animals such as pets, keep up with the news, doing things with groups of people, doing favorite activities, going outside when the weather is good and participate in religious activities/practices; are all marked very important (choices are very important, somewhat important, not important at all, important but can't do or no choice, or no response); -The resident was the primary respondent for Section F. During an interview on 05/27/25, at 12:08 P.M., the resident said the following: -He/She stayed in his/her room by choice due the noise and activity up on the other unit; -He/She liked being in a section and room all by himself/herself as no one bothered him/her or wandered in and out of his/her room; -He/She did not care for activities or groups of people and liked to stay in his/her room and watch television. Observation on 05/27/25 at 12:08 P.M., showed the resident sitting at the back dining room table (where he/she eats on a daily basis by choice), eating lunch. Observation on 05/28/25 at 11:20 A.M., showed the resident sat in his/her recliner in his/her room sleeping. Observation on 05/28/25, at 6:50 P.M. showed the resident sat in his/her recliner in his/her room watching television. Observation on 05/29/25 at 9:28 A.M., showed the resident was out of the facility at dialysis. 3. Review of Resident #20's electronic health record showed the following: -admitted to the facility on [DATE]; -Had a Durable Power of Attorney as responsible party; -Transferred from the facility to the hospital on 01/13/25 and was hospitalized . Review of the resident's discharge MDS, dated [DATE], showed a discharge with return anticipated status. Review of the resident's MDS schedule showed the resident returned to the facility on [DATE] (three days after discharge with return anticipated MDS submission). Review of the resident's EHR, showed the following: -The resident was hospitalized until 01/16/25 and then transferred back to the facility; -The resident was transferred from the facility to the hospital on 01/20/25 and was hospitalized . Review of the resident's discharge MDS, dated [DATE], showed a discharge with return anticipated status. Review of the resident's EHR, showed the resident was hospitalized until 01/24/25 and then transferred back to the facility. Review of the resident's MDS schedule showed the resident returned to the facility on [DATE] (four days after discharge with return anticipated MDS submission). Review of the resident's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Re-entry to the facility on [DATE] after a short-term general hospital stay; -admitted [DATE]; -Diagnoses included dementia and hip fracture; -Section F, Preferences for Daily Routine, for all preference: choosing what clothing to wear, take care of personal belongings or things, choose type of bathing, snacks between meals, choose own bedtime, have family involved in discussions about your care, using the phone in private and having a place to lock your things and keep them safe; are all marked very important (choices are very important, somewhat important, not important at all, important but can't do or no choice, or no response); -Section F, Activity Preferences, for all activities: having things to read, listen to music you like, be around animals such as pets, keep up with the news, doing things with groups of people, doing favorite activities, going outside when the weather is good and participate in religious activities/practices; are all marked very important (choices are very important, somewhat important, not important at all, important but can't do or no choice, or no response); -The resident was the primary respondent for Section F. During an interview on 05/27/25, at P.M., the resident said the following: -He/She does not care to use the phone in privacy, who would he/she talk to, no one ever called; -He/She could care less if any of his/her belongings were locked up, what does he/she have that anyone would want; -He/She did not care if he/she went to activities with people, he/she liked to watch TV in his her room; -He/She did not read anything because he/she preferred watching TV Observation on 05/27/25 at 11:22 A.M., showed the resident sat up awake in his/her wheelchair in his/her room with the television on and at the sink washing his/her face. Observation 05/28/25 at 10:23 A.M., showed the resident lay awake in bed watching television. Observation on 05/28/25 at 6:38 P.M., showed the resident sat up awake in his/her wheelchair in his/her room waiting to be put to bed for the evening. Observation on 05/29/25 at 9:24 A.M., showed the resident sitting up in his/her wheelchair in the dining room. During an interview on 05/30/25 at 1:08 P.M., the activities director said the following: -She completed section F and sometimes the MDS coordinator completed the section if she was unable to get it done and the MDS needs to be completed; -She asked all of the questions in section F when doing a resident interview; -People with altered cognition can sometimes answer the questions in section F and should be given the opportunity to answer the questions; -The MDS should be coded correctly; -She felt like she coded the MDS correctly; -She had been trained on how to complete the MDS. During an interview on 05/30/25, at 12:42 P.M., the MDS coordinator said the following: -She used the RAI manual for MDS completion; -To complete the MDS, she does record review and interviews with staff and the resident; -When a resident goes to the hospital, their next assessment should be an admission assessment, regardless if they transferred from the facility or not; -The activities director completes section F of the MDS if available, if not available, she will complete section F after interviewing the resident. During an interview on 05/30/25 at 1:13 P.M., the Director of Nursing (DON) said the MDS should be coded correctly following the RAI manual. During an interview on 05/30/25 at 1:39 P.M., the administrator said the MDS should be coded correctly.

Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for four residents (Resident #3, #10, #14 and #26), in a review of 13 residents. The facility census was 35. Review of the undated facility policy, Comprehensive Care Plan Policy, showed the following: -A comprehensive care plan is a detailed document outlining a resident's agreed-upon goals of care and the planned activities for their medical, nursing and allied health care. It reflects shared decisions made with the resident, their caregivers and family, about tests, interventions, treatments and other activities needed to achieve these goals. This plan is a dynamic, living document that's updated as the resident's condition changes, ensuring all healthcare team members are informed of the latest critical information; -Key aspects of a comprehensive care plan: a. Resident-centered: the plan prioritizes the resident's goals and preferences, reflecting their individual needs and wishes; b. Multidisciplinary: it involves collaboration among various healthcare professionals, including doctors, nurses, therapists, and other specialists; c. Dynamic and evolving: the plan is regularly updated as the resident's condition changes, ensuring it remains relevant and accurate; d. Accessible: it should be readily available to all members of the healthcare team, facilitating seamless communication and continuity of care; e. Focus on outcomes: the plan outlines measurable goals and activities aimed at improving the resident's health and well-being. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 03/13/25, showed the following: -Dependent on staff for bed mobility and hygiene; -Always incontinent of bowel and bladder; -Diagnoses included Alzheimer's disease and dementia. Review of the resident's care plan, last reviewed 05/27/25, showed the following: -The resident had an activities of daily living (ADL) self-care performance deficit related to limited mobility; -The resident required assistance of one to two staff with personal hygiene and toileting. (The care plan did not include documentation to show the resident was always incontinent of bowel and bladder.) Observation on 5/28/25 at 9:53 A.M., showed Nurse Assistant (NA) B and NA C transferred the resident to bed. The resident was incontinent of bowel and bladder. NA B and NA C provided incontinence care for the resident. 2. Review of Resident #10's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnoses included paraplegia (paralysis of lower limbs and body) and respiratory failure (not enough oxygen in the body); -No documentation to show the resident used oxygen. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed the following: -Diagnoses included hypertension (high blood pressure), paraplegia and acute respiratory failure with hypoxia (low levels of oxygen); -Oxygen via nasal cannula (NC) (prongs placed in the nose to deliver oxygen) on 2 to 4 liters, for oxygen saturation (the percentage of oxygen-carrying blood in the body) less than 92 percent (%) every night shift (ordered 5/15/25). Review of the resident's Medication Administration Record (MAR), dated May 2025, showed staff monitored and documented the resident's oxygen saturation every night and administered oxygen per NC as ordered. Review of the resident's care plan, last reviewed 05/05/25, showed the care plan did not include documentation to show the resident required oxygen at night to keep oxygen saturation above 92%. During interview on 05/28/25 at 10:16 A.M., the resident said he/she only used his/her oxygen at night. Observation on 05/29/25 at 9:33 A.M., showed the resident lay in bed with his/her oxygen on per NC. 3. Review of Resident #14's Readmission MDS, dated [DATE], showed the following: -Cognition is intact; -Diagnoses included paraplegia, peripheral vascular disease (a condition where the blood flow is restricted due to narrowed or blocked blood vessels)and non-pressure, chronic ulcer of skin (open sore or wound caused by poor blood flow); -Not at risk for pressure ulcer; -No unhealed pressure ulcer; -Care area assessment showed no documentation of a wound vac (a medical device that uses suction to help difficult-to-heal wounds close faster). Review of the resident's May POS showed an order for left midline gluteus and posterior left thigh wound: Cleanse with wound cleanser, apply strips of duoderm extra thin (adhesive occlusive wound covering) to wound border. Wound vac 125 mmHg negative pressure continuous. Black granufoam (type of wound dressing used with a wound vac) to wound bed. Cover with drape. Track pad away from wound, do not place track pad directly over the wound, and do not place any foam directly on good skin, every day shift every Mon, Wed, Sat for wound care. Review of the resident's care plan, last revised 05/27/25, showed the following: -No documentation to show resident required a wound vac; -At risk for pressure ulcers related to paraplegia; -Administer treatments as ordered; -Skin breakdown 07/23/24 of right foot inner 4th toe. Observation in the resident's room on 05/27/25 at 10:20 A.M., showed a wound vac sat on the resident's bedside table. During an interview on 05/27/25 at 10:20 A.M. the resident said the wound vac had been taken off since Saturday (05/24/25) due to odor and staff were completing wet to dry dressings (a type of dressing/wound care) until his/her wound clinic appointment on 05/28/25. During an interview on 05/28/25 at 10:00 A.M., the resident said he/she just returned from the wound clinic and the wound vac was re-applied. Observation on 05/28/25 at 10:00 A.M. showed the wound vac was in place, powered on and attached to the resident. Observation on 05/29/25 at 9:50 A.M. showed the resident in bed sleeping; a wound vac was in place, attached to the resident. 4. Review of Resident #26's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Diagnoses include coronary artery disease (damage or disease in the heart's major blood vessels), hypertension (high blood pressure) and dementia (a group of thinking and social symptoms that interferes with daily functioning); -No indication of oxygen use. Review of the resident's May 2025 POS showed an order for oxygen for oxygen saturation of less than 90 % or complaints of dyspnea (shortness of breath) with an order start date of 05/21/25. Review of the resident's care plan, revised on 05/27/25, showed no documentation to address oxygen usage. During an interview on 05/27/25 at 11:08 A.M., the resident said he/she had been in the hospital recently and needed the oxygen after being hospitalized . He/She uses the oxygen quite a bit, but mainly at night and puts it on himself. Observation on 05/27/25 at 11:08 A.M., showed the resident sat in his/her room on the side of the bed with the oxygen concentrator running and the oxygen tubing draped over the urinal hanging on the resident's raised side rail. Observation on 05/28/25 at 10:22 A.M., showed the resident sat in his/her room on the side of the bed with the oxygen concentrator running and the oxygen tubing draped over the urinal hanging on the resident's raised side rail. Observation on 05/28/25 at 5:40 P.M. showed the resident sat in the dining room waiting for supper, his/her oxygen concentrator in the resident's room was running with the oxygen tubing draped over the urinal hanging on the resident's raised side rail. Observation on 05/29/25 at 9:34 A.M., showed the resident lay in bed sleeping with the oxygen concentrator running and the oxygen tubing draped over the urinal hanging on the resident's raised side rail. During an interview on 06/03/24 at 4:29 P.M., Licensed Practical Nurse (LPN) P said the MDS/Care plan coordinator was responsible for the comprehensive care plans and should address all areas needed to care for the resident. During an interview on 05/30/25 at 12:42 P.M., the MDS/Care plan coordinator said the following: -She develops the comprehensive care plan after the admission MDS; -The care plan should reflect the most current level of care to be provided for the resident; -The comprehensive care plan should include things like Enhanced Barrier Precaution (EBP) use, oxygen therapy and wound vac use for wounds. During an interview on 05/30/25 at 1:13 P.M., the Director of Nursing (DON) said the following: -The MDS/Care plan coordinator usually does the comprehensive care plan; -The care plan should reflect the most current level of care for the resident and include items like oxygen use, EBP use, bowel and bladder status, wound treatment to include wound vac and anything that would impact the care provided. During an interview on 05/30/25 at 1:39 P.M., the administrator said she would expect the care plan to reflect the current level of care needed to be provided for the resident. 42592 49528

Based on observation, interview and record review, the facility failed to update and revise problems and interventions on resident care plans to reflect current care needs for three residents (Resident #10, #4 and #1) in a sample of 13 residents and failed to include Resident #20's responsible party and Durable Power of Attorney (DPOA) in his/her care planning decision making. The facility census was 35. Review of the undated facility policy, Resident Plan of Care, showed the following: -It is the policy of the facility to initiate a resident's plan of care on admission, by charge nurse, that is located in the electronic health record; -The MDS Coordinator follows electronic health record for date of plan of care to be completed. The facility did not provide a care plan revisions policy. 1. Review of Resident #10's Annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 02/23/25, showed the following: -Cognitively intact; -Diagnoses included paraplegia (paralysis of lower limbs and body) and pressure ulcer (localized skin and soft tissue injury) of unspecified buttock, unspecified stage (the severity and depth of tissue damage caused by the ulcer); -Had one stage two pressure ulcer (partial thickness skin loss appearing as a shallow open sore) and one stage three (deep wound where the skin in completely damaged exposing fatty tissue beneath) pressure ulcer; Review of the resident's Physician Order Sheet (POS), dated May 2025, showed the following: -On 05/14/25, apply thin layer of Calmoseptine (barrier cream to protect the skin from moisture) to protect skin surrounding wound. Do not get ointment in the wound bed. Apply 0.125 percent (%) Dakins (antiseptic solution to treat and prevent infections in wounds) moistened gauze, dry gauze, abd (absorbent dressing) pads, tape. Be sure to pack area of depth and undermining on left ischium (lower back portion of the hip bone), every morning and at bedtime for wound care; -No documentation of an order for Enhanced Barrier Precautions (EBP) (an infection control intervention in nursing homes designed to reduce the transmission of multidrug-resistant organisms (MDROs). Review of the resident's care plan, last reviewed 05/05/25, showed the following: -The resident has three Stage IV ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling) on coccyx (tailbone), left and right gluteal cleft (the crease between the buttocks) or potential for pressure ulcer development related to history of ulcers, immobility; -Left ischial (paired bone in the pelvis that forms part of the hip bone) wound, cleanse area with soap and water, pat dry, apply Calmoseptine to wound edges and calcium alginate silver (type of absorbent dressing that contains silver) to wound bed, cover with ABD pad and tape or silicone border, change daily and as needed (PRN); right ischial wound - apply Calmoseptine twice a day and PRN. Keep weight off affected area at all times. Limit time in wheelchair, up for meals only (dated 02/27/25); -Staff failed to update the resident's care plan with current wound care orders and listed no documentation regarding EBP. 2. Review of Resident #4's annual MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Cognitively intact; -No behaviors or rejection of cares; -Participates in the restorative nursing program three out of seven days for active range of motion (ROM); -No antibiotic use. Review of the resident's care plan, revised on 05/05/25, showed the following: -The resident has a psychosocial well-being problem potential related to social isolation related to pandemic coronavirus (COVID-19, an infectious disease caused by the SARS-CoV-2 virus) and nursing home lock down; -The resident has unplanned/unexpected weight loss related to acute illness being COVID-19; -The resident has a behavior problem; will slide himself/herself out of his/her wheelchair when he/she wants to lay down and if staff do not come immediately to call light; -The resident has limited physical mobility related to weakness and knee joint replacement with restorative to work with the resident two to three times weekly for gentle ROM upper and lower. During an interview with the resident, on 05/27/25 at 10:32 A.M., the resident said the following: -He/She stays in bed most of the time due to issues with his/her right knee; -He/She is losing weight on purpose by watching what he/she eats; he/she used to be 500 pounds and now is 300 something by choice, not due to any illness; -He/She stays in his/her room most of the time by choice and will go out to his/her house during the summer; -He/She does not have a restorative program; -He/She has had urinary tract infections in the past few months but has not had COVID for quiet some time; -He/She was not confined to his/her room by the facility and can come and go as he/she pleases. Review of the resident's electronic health record for the past twelve months showed no diagnoses of COVID, no behaviors of sliding himself/herself purposefully from the wheelchair, no orders for isolation to his/her room, no restorative program and no unplanned weight loss related to acute illness/COVID. The resident's care plan did not accurately reflect the resident. 3. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Dependent on staff for bed mobility and transfers; -Has one Stage II pressure ulcer (Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister). Review of the resident's care plan, last reviewed 05/05/25, showed the following: -The resident has a pressure ulcer or potential for pressure ulcer development related to mobility; -Administer treatments as ordered and monitor for effectiveness; -The resident's care plan did not identify the need for or the use of EBP when providing care for the resident. Review of the resident's POS, dated May 2025, showed the following: - Cleanse the right ankle daily with normal saline or wound cleanser and pat dry, apply Urgoclean (wound dressing that aids in the continuous removal of slough and wound debris) dressing to wound base, cover with optifoam (a foam dressing) dressing everyday shift for wound care (dated 05/13/25); -No diagnoses of a pressure ulcer or documentation of an order for EBP. 4. Review of Resident #20's face sheet showed the resident had a family member as the responsible party and Durable Power of Attorney (DPOA). The resident was admitted on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident has severe cognitive impairment; -Diagnoses of dementia. Review of the resident's care plan showed the last revision date was 05/27/25. During an interview on 05/27/25, at 2:50 P.M., the resident's DPOA said the following: -He/She lived quite a distance from the facility and did not visit the resident much; -He/She was unaware if the resident has ever had a care plan meeting as he/she had never been notified of the meetings or invited to attend a care plan meeting; -He/She would like to be notified of the resident's care plan meeting, and if possible, could be on a conference call to discuss the resident. Review of the resident's electronic health record, for the prior 12 months, showed no documentation regarding an explanation that the participation of the resident and their resident representative was determined not practicable for the development of the resident's care plan. During an interview on 06/03/24 at 4:29 P.M., LPN P said the MDS/Care plan coordinator updated the care plans to reflect the current level of care. During an interview on 05/30/25 at 12:42 P.M., the MDS/Care plan coordinator said the following: -She was usually the one that updated the care plans, the nurses can, but they do not usually update them; -If an issue was no longer a problem, it should be resolved on the care plan; -The care plan should be up to date and reflect the most current level of care to be provided for the resident. During an interview on 05/30/25 at 1:13 P.M., the Director of Nurses said the following: -All nursing was responsible for updating the care plans; -The MDS/Care plan coordinator also updated the care plans; -If an issue was no longer a problem it should be resolved on the care plan; -The care plan should reflect the most current level of care for the resident. During an interview on 05/30/25 at 1:39 P.M., the administrator said she would expect the care plan to be updated as needed to reflect the current level of care to be provided to the resident. 42592

Based on observation, interview, and record review, the facility failed to provide restorative nursing services as recommended to assist one resident (Resident #3), in a review of 13 residents, and two additional residents (Resident #18 and #24), with mobility and/or limited range of motion (ROM) to attain or maintain their highest level of functioning. The facility census was 35. Review of the undated facility policy, Restorative Nursing Program Policy, showed the following: -Non-skilled rehabilitation: Restorative nursing provides non-skilled rehabilitative care with focus on maintaining or improving daily living skills; -Restorative aides and nurses must be trained. Registered nurses (RNs) or licensed practical nurses (LPNs) will provide supervision; -Daily documentation of restorative activities is required. Specific interventions and time spent must be documented; -The program needs to be reviewed and adjusted as needed. The RN/LPN typically review monthly and the resident care team review quarterly. 1. Review of Resident #18's Physician's Orders, dated April 2025, showed the resident was discharged from skilled physical therapy on 04/01/25. Review of the resident's Functional Maintenance Program (FMP; also known as the restorative nursing program) referral, dated 04/02/25, showed to perform bilateral upper and lower extremity exercises with weights and ambulate distance as tolerated with front wheeled walker two times a week. During an interview on 05/30/25 at 10:35 A.M., the Physical Therapist said if a resident needed restorative services after discharge from skilled therapy, therapy completed the FMP with directions for the the restorative program. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/16/25, showed the following: -Severe cognitive impairment; -Diagnosis of Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors); -Limited ROM bilateral lower extremities; -Partial/moderate staff assistance for lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit-to-lying/lying-to-sit on the side of the bed, sit to stand transfer, chair/bed-to-chair transfer and toileting transfer; -Did not walk; -Mobility per wheelchair; -Participated in the restorative nursing program three out of seven days for active ROM. Review of the resident's Care Plan, revised on 04/23/25, showed the following: -The resident had an ADL self-care performance deficit related to disease process Parkinson's disease; -The resident required assistance from one or two staff to dress, with personal hygiene, for toileting and to move between surfaces; -Encourage the resident to participate to the fullest extent possible with each interaction; -The resident was high risk for falls related to gait/balance problems; -The resident had a fall with no injury related to poor balance. -Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Review of the facility's Restorative Nursing Program binder (where the FMP participation was documented) showed no evidence the resident received restorative nursing treatments or participated in the FMP since discharge from skilled physical therapy on 04/01/25. Observation on 5/27/25 at 11:25 A.M. showed the resident self-propelled in his/her wheelchair to the dining room for lunch. Observation on 05/28/25 at 5:15 P.M. showed the resident self-propelled his/her wheelchair to the dining room for supper. Observation on 05/29/25 at 11:20 A.M. showed the resident self-propelled his/her wheelchair to the dining room for lunch. During an interview on 05/30/25 at 9:33 A.M., the resident said no one from the nursing staff did any therapy or walked with him/her. 2. Review of Resident #24's annual MDS, dated [DATE], showed the following: -Cognitively intact; -No ROM limitations; -Used a walker for independent ambulation; -Independent with upper and lower body dressing, sit to lying, lying to siting on side of bed, sit to stand, chair/bed-to-chair transfers and toilet transfers; -Supervision for shower/bathing and tub/shower transfers; -Participated in the restorative nursing program three of seven days for active ROM. Review of the resident's Physician's Orders, dated May 2025, showed an order to discharge from skilled occupational therapy and skilled physical therapy services as of 05/16/25 and start a FMP for ambulation and strengthening activities. Review of the resident's FMP referral, dated 05/16/25, showed orders for the resident to walk with a rollator (a four wheeled walker with a seat) in the hallway, distance to tolerate, and resident to complete 15 repetitions of heel raises, marching, mini-squats and hip abduction with walker with supervision daily. Review of the resident's Care Plan, revised on 05/27/25, showed the following: -Diagnosis of Parkinsonism (various conditions that cause symptoms similar to Parkinson's Disease that can include symptoms such as tremors, stiffness of the arms and legs, difficulty walking and loss or weakness of movement); -The resident was at moderate risk for falls related to deconditioning; -Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; -The resident had a fall with no injury related to unsteady gait. Review of the facility's Restorative Nursing Program binder showed no documentation the resident received restorative nursing treatments or participated in the FMP as ordered since discharge from skilled physical therapy on 05/16/25. Observation on 5/27/25 at 11:15 A.M. showed the resident walked unassisted with a rollator to the dining room for lunch. Observation on 05/28/25 at 5:10 P.M. showed the resident walked unassisted with a rollator to the dining room for supper. Observation on 05/29/25 at 11:20 A.M. showed the resident self-propelled in his/her wheelchair to the dining room for lunch. During an interview on 05/30/25 at 9:30 A.M., the resident said he/she did not have therapy, it stopped a few weeks ago. He/She used to go to the room for therapy, but since that stopped, all he/she did was walk himself/herself to places in the building. Nursing staff did not do any exercises with him/her and did not typically walk with him/her. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -Diagnosis of Alzheimer's disease; -Severely impaired cognition; -Dependent with bed mobility, bathing, personal hygiene, dressing, eating and transfers; -Restorative nursing program provided three of the last seven days. Review of the resident's Functional Maintenance Program referral, dated 5/9/25, showed the following: -Physical therapy completed the referral for the functional maintenance program; -Perform generalized range of motion (ROM) to hips and knees for flexion/extension, abduction/adduction for ten reps each motion to tolerance to reduce right lower extremity (RLE) pain and prevent further contracture formation; -Five times a week. Review of the resident's Physician Orders, dated May 2025, showed no orders for the Functional Maintenance Program. Review of the facility's Restorative Nursing Program binder showed no documentation the resident received restorative nursing services after his/her FMP referral on 5/9/25. Review of the resident's Care Plan, updated 5/17/25, showed the following: -The resident had an activity of daily living (ADL) self-care performance deficit related to limited mobility; -The resident will improve current level of function in ADLs through the review date; -The resident required assistance from one to two staff to eat, toilet, bed mobility and transfers; -Encourage the resident to participate to the fullest extent possible with each interaction. 4. During an interview on 05/30/25 at 11:29 A.M. and 06/09/25 at 2:19 P.M., the Restorative Aide (RA) said the following: -She was the only RA; -She did not work 05/27/25 or 05/28/25 and had worked in the special care unit as a staff member on 05/29/25 and was off today (05/30/25); -She was pulled to work on the floor almost daily for the last few months and had not been able to do the restorative program; -When she was able to perform restorative services, she documented the minutes in the restorative binder; -No staff performed restorative services for the residents if she was not able. During an interview on 05/30/25 at 9:00 A.M., the Director of Nursing (DON) said the following: -The facility had a restorative program; -She tried not to pull the RA to the floor as a CNA but sometimes it was necessary; -According to the staff assignments for the month of May, the RA only performed restorative services on two days; -If the RA was pulled to work the floor as a CNA, there was not a back up assigned to perform restorative services. 42592

Based on observation, interview, and record review, the facility failed to assess seven residents (Residents #10, #3, #20, #189, #9, #36, and #35), in a review of 13 sampled residents, for risk of entrapment from bed rails prior to installation, and failed to review the risk and benefits of the bed rails with the resident or resident representative and obtain consent prior to installation. The facility census was 35. Review of the Food and Drug Administration's Guide of Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling; -Assessment by the patient's health care team will help to determine how best to keep the patient safe; -Potential risks of bed rails may include strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress, more serious injuries from falls when patients climb over rails, skin bruising, cuts, and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet; -When bed rails are used, perform an on-going assessment of the patient's physical and mental status and closely monitor high-risk patients; -A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety; -Reassess the need for using bed rails on a frequent, regular basis. 1. Review of Resident #10's face sheet showed the resident was his/her own responsible party. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 2/23/25, showed the following: -Cognitively intact; -Diagnoses include paraplegia (inability to voluntarily move the lower extremities), vision deficits and kidney disease; -Range of motion limitations to the lower extremity on one side of the body; -He/She was dependent for bed mobility and transfers. Review of the resident's Care Plan, revised on 05/05/25, showed the following: -He/She had an activities of daily living (ADLs) self-care performance deficit related to right below the knee (BKA) amputation, impaired balance and stage IV wounds (deep wound reaching muscles, ligaments or bone); -The resident required assistance from two staff to turn and reposition in bed every two hours and as necessary; -The resident used mobility bars to maximize independence with turning and repositioning in bed; -The resident required a mechanical lift with two staff for transfers. Observation on 05/27/25 at 2:53 P.M., showed the resident lay on his/her back in bed. The resident had one-half bed rails in the raised position on both sides of his/her bed. Observation on 05/28/25 at 10:16 A.M., showed the resident lay awake in bed watching television. The resident had one-half bed rails in the raised position on both sides of his/her bed. Observation on 05/28/25, at 12:00 P.M., showed the following: -The resident lay on his/her back in bed watching television; -Licensed Practical Nurse (LPN) O and the Assistant Director of Nursing (ADON) completed the resident's dressing change and incontinence care; -The resident used the bed rails to assist in turning and positioning during the dressing change and incontinence care. Observation on 05/29/25, at 9:15 A.M., showed the resident lay in bed with his/her eyes closed. The resident had one-half bed rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident and obtained consent prior to installation. 2. Review of Resident #3's face sheet showed the resident's family member was his/her responsible party. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Diagnoses include Alzheimer's disease, dementia, and anxiety; -Range of motion limitations to upper and lower extremity on both sides; -He/She was dependent for bed mobility and transfers. Review of the resident's Care Plan, revised on 05/27/25, showed the following: -He/She had an activities of daily living (ADLs) self-care performance deficit related limited mobility; -The resident required assistance from two staff to turn and reposition in bed every two hours and as necessary; -The resident required one or two staff to move between surfaces; (The resident's care plan did not identify the resident had bed rails on his/her bed.) Observation on 05/27/25, at 2:53 P.M., showed the resident lay on his/her back in bed. The resident had one-half bed rails in the raised position on both sides of his/her bed. Observation on 05/28/25, at 9:53 A.M., showed staff transferred the resident with the mechanical lift to bed. The resident had one-half bed rails in the raised position on both sides of his/her bed. Staff provided incontinence care to the resident. The resident did not use the bed rails to assist in turning as staff provided his/her care. Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident's representative and obtained consent prior to installation. 3. Review of Resident #20's face sheet showed the resident's family member was the resident's responsible party. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident has severe cognitive impairment; -Diagnoses include hip fracture and dementia; -Range of motion limitations lower extremity one side; -He/She rolled left and right independently; -Staff provided partial/moderate assistance for sit to lying, lying to sitting on side of the bed; -Staff provide substantial/maximum assist for sit to stand, chair/bed-to-chair and toilet transfers. Review of the resident's Care Plan, revised on 05/27/25, showed the following: -He/She had an activities of daily living (ADLs) self-care performance deficit related to dementia and impaired balance; -The resident had a fall with no injury related to poor balance; (The care plan did not address the resident's transfer status or bed mobility. The resident's care plan did not identify the resident had bed rails on his/her bed.) Observation on 05/28/25 at 10:11 A.M., showed the resident lay awake in bed watching television. The resident had one-half bed rails in the raised position on both sides of his/her bed. Observation on 05/28/25 at 6:38 P.M., showed the following: -Certified Nursing Assistant (CNA) N and Nurse Assistant (NA) E transferred the resident to bed with the sit-to-stand mechanical lift; -Staff raised the one-half bed rails on both sides of the bed; -The resident used the bed rails to assist in turning and positioning while staff provided incontinence care. Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident's representative and obtained consent prior to installation. During an interview on 06/03/25, at 11:14 A.M., the resident's responsible party said the facility never contacted him/her related to bed rail use or asked him/her to give consent for bed rails to be used on the resident's bed. 4. Review of Resident #189's face sheet showed his/her family member was designated as the resident's emergency contact. The resident's responsible party was not identified. Review of the resident's admission MDS, dated [DATE], showed the following: -Diagnosis include heart failure (a chronic condition in which the heart does not pump blood as well as it should); -Independently rolls left to right, sit to lying, lying to sitting on the side of the bed, chair/bed-to-chair transfer and sit to standing position. Review of the resident's Care Plan, revised on 05/28/25, showed the following: -The resident had an ADL self-care performance deficit related to confusion, dementia and impaired balance; -The resident required assistance from one or two staff to turn and reposition in bed every two hours and as necessary; -He/She required assistance from one or two staff to move between surfaces; -The resident had limited physical mobility related to weakness, recent hospitalization , dementia and anxiety; -Provide supportive care and assistance with mobility as needed; (The resident's care plan did not identify the resident had bed rails on his/her bed.) Observation on 05/28/25, at 10:27 A.M. and 11:23 A.M., showed the resident lay awake in bed. The resident had one-half bed rails in the raised position on both sides of his/her bed. Observation on 05/28/25, at 11:38 A.M., showed the following: -The resident lay awake in bed; -The resident had one-half bed rails in the raised position on both sides of his/her bed; -NA B, NA C and CNA D performed incontinence care for the resident. The resident held onto the bed rails as staff turned him/her side to side when providing care. Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident's representative and obtained consent prior to installation. 5. Review of Resident #9's face sheet showed he/she had a guardian. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Diagnoses included progressive neurological condition, Alzheimer's disease, dementia, and seizure disorder; -Severe cognitive impairment; -He/She was independent with bed mobility; -He/She required supervision with transfers. Review of the resident's Care Plan, revised 03/19/25, showed the following: -Unsteady gait; -He/She needed assistance from one staff with ADLs. (The resident's care plan did not address bed mobility and did not identify the resident had bed rails on his/her bed.) Observation on 05/27/28 at 10:32 A.M. showed the resident lay in bed on his/her right side. The resident had one-half bed rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident's representative and obtained consent prior to installation. 6. Review of resident #36's face sheet showed he/she had a legal guardian. Review of the resident's admission MDS, dated [DATE], showed the following: -Diagnoses included dementia, left hip fracture, and hypertension; -Severe cognitive impairment; -He/She required moderate assistance with bed mobility; -He/She required maximum assistance with transfers. Review of the resident's Care Plan, revised 03/12/25, showed the following: -The resident had an ADL self-care performance deficit related to dementia and limited mobility due to left hip fracture; -Alteration in musculoskeletal status related to left hip fracture; -High risk for falls related to gait/balance problems; -He/She was dependent of one to two staff for transfers; -He/She required assistance of one staff to turn, reposition in bed; (The resident's care plan did not identify the resident had bed rails on his/her bed.) Observation on 05/27/25 at 10:38 showed the resident sat in his/her recliner. The resident had one-half bed rails in the raised position on both sides of his/her bed. Observation on 05/29/25 at 3:00 P.M. showed the resident in his/her wheelchair in his/her room. The resident had one-half bed rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident's representative and obtained consent prior to installation. 7. Review of Resident #35's face sheet showed he/she had a legal guardian. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Diagnoses included progressive neurological condition ( a condition in which the brain and nervous system function gradually declines) and dementia; -Severe cognitive impairment; -He/She was independent with bed mobility; -He/She required supervision with transfers. Review of the resident's Care Plan, revised 03/06/25, showed the following: -The resident had an ADL self-care performance deficit related to Alzheimer's disease; -The resident was able to transfer himself/herself; (The resident's care plan did not address bed mobility and did not identify the resident had bed rails on his/her bed.) Observation on 05/27/25 at 10:32 A.M. and 05/29/25 at 3:00 P.M. showed the resident walked in the hallway. The resident had a one-half bed rail raised on the right side of his/her bed. Review of the resident's medical record showed no documentation staff assessed the resident for risk of entrapment from the bed rails prior to installation, and no documentation staff reviewed the risk and benefits of the bed rails with the resident's representative and obtained consent prior to installation. 8. During an interview on 05/29/25, at 4:03 P.M., the DON said she had not done any bed rail assessments, obtained informed consent, provided education to families or completed quarterly evaluations related to bed rail use. She was not aware that was her responsibility. During an interview on 05/29/25, at 2:00 P.M., the Administrator said the DON was responsible for obtaining consent for bed rails and for any ongoing education, assessments and evaluations. 42592 49528

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 27 opportunities observed, 10 errors occurred, resulting in a 37.0% error rate, which affected one resident (Resident #10) in a review of of 13 sampled residents and three additional residents (Resident #15, #32 and #28). The facility census was 35. Review of the facility's undated policy, titled Policy for Medication Administration, showed it did not address crushing medications. Review of the facility's undated policy, Insulin Pen Usage, showed before each use, prime the pen to remove air bubbles and ensure a clear needle. Review of the Humalog Kwik pen package insert showed if you do not prime the insulin pen before each injection, you may get too much or too little insulin. Turn the dose knob to select two units, hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. Repeat the priming procedure if you did not see insulin at the tip of the needle. Review of the Fiasp FlexTouch pen package insert showed if you do not prime before each injection, you may get too much or too little insulin. Turn the dose selector to select two units, hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top, hold the pen with the needle pointing up and press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin repeat the above steps. 1. Review of Resident #10's May 2025 Physician Order Sheets (POS) showed the following: -Diagnoses of type 2 diabetes mellitus with other circulatory complications (condition in which the body has trouble controlling blood sugar and damage the blood vessels leading to circulatory complications); -Accucheck (blood glucose test) three times daily and at bedtime; -Humalog KwikPen Insulin (insulin Lispro) (fast acting injectable medication to control blood sugar (the amount of sugar in the blood)) insulin pen, 100 units/ml; amount per sliding scale (a dose amount to be determined based on the Accucheck); if blood sugar is 210-219 give one unit, if blood sugar is 220-229 give two units, if blood sugar is 230-239 give three units, if blood sugar is 240-249 give four units, if blood sugar is 250 to 259 give five units, if blood sugar is 260-269 give six units, if blood sugar is 270-279 give seven units, if blood sugar is 280-289 give eight units, if blood sugar is 290-299 give nine units, if blood sugar is 300-310 give 10 units, if blood sugar is 311-320 give 11 units, if blood sugar is 321-330 give 12 units, if blood sugar is 331-340 give 13 units, if blood sugar is 341-350 give 14 units, if blood sugar is 351-360 give 15 units, if blood sugar is 361-370 give 16 units, if blood sugar is 371-380 give 17 units and if blood sugar is 381-390 give 18 units subcutaneous. Review of the resident's May 2025 medication administration record (MAR) showed the following: -Accucheck three times daily and at bedtime; scheduled for 7:30 A.M., 11:00 A.M., 4:30 P.M., and 8:00 P.M.; -Humalog KwikPen Insulin (insulin Lispro) insulin pen, 100 units/ml; amount per sliding scale; scheduled for 7:30 A.M., 11:00 A.M., 4:30 P.M., and 8:00 P.M. Observation on 05/28/25 at 4:27 P.M. showed the following: -Licensed Practical Nurse (LPN) K obtained the resident's Accucheck with results of 259 milligrams per deciliter (mg/dL) and determined Humalog sliding scale insulin dose was to be five units; -LPN K removed the resident's Humalog flex pen from the top medication cart drawer, removed the lid, cleaned the tip with an alcohol pad and attached a new sterile needle; -LPN K did not prime the insulin pen; -LPN K dialed five units of Humalog insulin for sliding scale and administered the medication in the resident's subcutaneous tissue of the abdomen. 2. Review of Resident # 15's May 2025 POS showed the following: -Diagnoses of type 2 diabetes mellitus; -Accucheck three times daily (TID); -Fiasp (fast acting insulin used to manage blood sugar levels) five units sub-q twice daily at 8:00 A.M. and 5:00 P.M. Review of the resident's May 2025 MAR showed the following: -Accucheck three times daily (TID) at 8:00 A.M., 5:00 P.M. and 8:00 P.M.; -Fiasp five units sub-q twice daily; scheduled for at 8:00 A.M. and 5:00 P.M Observation on 05/28/25 at 4:45 P.M. showed the following; -LPN K obtained the resident's Accucheck with a blood glucose reading of 197 mg/dL; -LPN K removed the resident's Fiasp FlexTouch pen from the top medication cart drawer, removed the lid, cleaned the tip with an alcohol pad and attached a new sterile needle; -LPN K did not prime the insulin pen; -LPN K dialed up five units of Fiasp insulin and administered the medication in the resident's subcutaneous tissue of the abdomen. During an interview on 05/28/25 at 4:55 P.M. LPN K said she was not aware that insulin pens needed to be primed with two units prior to giving the desired amount of insulin. 3. Review of drugs.com for Donepezil (medication used to treat Alzheimer's disease) showed the following: -Donepezil tablets should be swallowed whole; do not crush, break or chew; -Crushing the tablet can lead to increased rate of absorption, leading to a higher concentration in the body than intended, increased risk of side effects or even overdose. 4. Review of drugs.com for K-Dur (potassium supplement) showed the following: -K-Dur should not be crushed; -Crushing the tablet can cause the drug to release all at once, leading to a sudden increase in potassium levels, can cause digestive tract injuries and can increases the risk of side effects. 5. Review of Resident #32's May 2025 POS showed the following: -Diagnoses included infection of the mouth, malignant neoplasm of the left breast (breast cancer), unspecified dementia, hypokalemia (low level of potassium in the blood); -Amoxicillin (antibiotic) 875 mg orally (PO) twice daily (BID); -Calcium (supplement) 600 mg with vitamin D (supplement) PO BID; -Donepezil 10 mg, two tablets PO in the evening; -K-Dur 20 milliequivalents (meq) PO three times daily (TID). Review of the resident's May 2025 MAR showed the following: -Amoxicillin 875 mg PO to be given at 8:00 A.M. and 5:00 P.M.; -Calcium 600 mg with vitamin D to be given at 8:00 A.M. and 5:00 P.M.; -Donepezil 10 mg, two tablets PO to be given at 5:00 P.M.; -K-Dur 20 meq PO to be given at 8:00 A.M., 12:00 noon, and 5:00 P.M. Observation on 05/28/25 at 7:45 P.M. showed the following: -Certified Medication Technician (CMT) L removed from the medication cart, medication cards of Amoxicillin 875 mg, Donepezil 10 mg and K-Dur 20 meq, labeled for the resident; -CMT L removed a stock bottle of calcium 600 mg plus vitamin D from the medication cart; -CMT L poured one calcium 600 mg with vitamin D into a medication cup; -CMT L popped out one amoxicillin 875 mg, two Donepezil 10 mg tablets and one K-Dur 20 meq into the medication cup. CMT L then poured all the medications into a plastic sleeve, crushed the medications and placed the crushed medications in a medication cup with applesauce; -CMT L administered all of the crushed medications in applesauce to the resident at one time and not separately; -CMT L also crushed and administered medications that were not supposed to be crushed. 6. Review of drugs.com for Tylenol Arthritis (pain medication, also called Tylenol 8 Hour) showed the following: -Tylenol Arthritis should be swallowed whole; do not crush, chew, split or dissolve; -Tylenol Arthritis is an extended release medication, designed to be released into the body gradually over an extended period; -If Tylenol Arthritis is crushed, you will disrupt the extended-release mechanism; this can lead to a shorter duration of activity, increased risk of side effects and overdose. 7. Review of Resident #28's May 2025 POS showed the following: -Diagnoses included unspecified dementia with anxiety disorder, GERD and pain unspecified; -Alprazolam (medication to treat anxiety disorders, panic disorders and anxiety caused by depression) 0.25 mg PO BID; -Famotidine (medication used to treat and prevent ulcers in the stomach and intestines) 20 mg PO BID; -Tylenol arthritis (pain medication) 650 mg PO BID. Review of the resident's May 2025 MAR showed the following: -Alprazolam 0.25 mg PO to be given BID at 12:00 noon and at 5:00 P.M.; -Famotidine 20 mg PO to be given BID at 8:00 A.M. and 5:00 P.M.; -Tylenol 8 hour arthritis pain oral tablet, extended release 650 mg to be given two times a day for pain, scheduled at 8:00 A.M. and 5:00 P.M. Observation on 05/28/25 at 8:10 P.M. showed the following: -CMT L removed from the medication cart narcotic lock box, a medication card of alprazolam 0.25 mg, labeled for the resident; -CMT L removed from the medication cart, a medication card of famotidine 20 mg, labeled for the resident; -CMT L removed from the medication cart, a stock bottle of Tylenol 8 Hour, 650 mg; -CMT L popped out one alprazolam 0.25 mg and one famotidine 20 mg from the medication cards and placed them in a medication cup. CMT L removed one Tylenol 8 Hour 650 mg from the stock bottle and placed it into the medication cup; CMT L then poured all of the medications into a plastic sleeve, crushed all of the medications and then placed the crushed medications in a medication cup with applesauce; -CMT L administered all of the crushed medications in applesauce to the resident at one time and not separately; -CMT L also crushed and administered medications that were not supposed to be crushed. During an interview on 05/30/25 at 1:13 P.M. the Director of Nursing (DON) said she would expect the insulin pens to be primed prior to dialing up the resident's dose. During an interview on 05/30/25 at 1:39 P.M. and 06/09/25 at 1:51 P.M. the administrator said the following: -She was not sure about the procedure for priming insulin pens; -She would not expect extended release or enteric coated medications to be crushed.

Based on observation and interview, the facility failed to timely destroy expired medications. The facility census was 35. 1. Observation of the licensed nurses medication cart on 05/28/25 at 2:30 P.M. showed the following: -One bottle of ketoconazole 2% shampoo labeled for Resident #3, had an expiration date of 12/2022; -One tube of Aspercreme (topical pain relief cream), labeled for Resident #6, had an expiration date of 03/2025; -One bottle of Murine ear drops (wax removal drops), labeled for Resident #2, had an expiration date of 08/2024; -One stock (facility's supply) tube of hydrocortisone 1% cream had an expiration date of 03/25; -One stock bottle of nystatin powder (an antifungal medication) had an expiration date of 09/30/23; -One stock bottle of stoma adhesive had an expiration date of 02/01/25; -One stock tube of Aspercreme had an expiration date of 12/2024. During an interview on 05/28/25 at 3:00 P.M., Licensed Practical Nurse (LPN) K said the charge nurses check the licensed nurses cart for outdated medications randomly. During an interview on 05/30/25 at 1:13 P.M., the Director of Nursing (DON) said the following: -Expired medications should not be in the medication carts; -Certified Medication Technicians (CMTs) and the licensed nurses should check the medication carts weekly; -The pharmacist should check all medication carts and the medication room monthly. During an interview on 05/30/25 at 1:39 P.M., the Administrator said the following: -Expired medications should not be in the medication carts; -The pharmacist was to check the carts monthly; -She was not aware if or when nursing staff was to check the carts for outdated medications. 49528

Based on observation, interview, and record review, the facility failed to maintain two of two ice machines free of a buildup of debris; failed to ensure refrigerated food items were covered, labeled and dated; and failed to ensure trash cans were covered when not in use. The facility census was 35. 1. Review of the facility policy, Ice Handling and Cleaning, dated 2020, showed the following: -Guideline: Ice will be stored and served to residents in a sanitary manner; -Ice will be handled, transported and stored to protect against contamination; -Ice machine will be wiped down daily with sanitizer; -Ice machine will be emptied at least quarterly and thoroughly cleaned with an approved sanitizer to remove any settlement or mineral buildup in the ice discharge area and the floor of the machine. Observation on 5/27/25 at 9:49 A.M. of the kitchen ice machine showed black debris and reddish rusty-colored debris visible inside the unit along the door hinge over the ice stored below. The exhaust vent on the exterior of the unit had a heavy buildup of dark fuzzy debris on the rear vent cover. Observation on 5/27/25 at 2:09 P.M. of the staff breakroom ice machine showed reddish rusty-colored debris visible inside the unit around several screw heads and along the door hinge over the ice stored below. An area of crusty white and green debris was visible on the metal hinge strip inside the unit in one corner. During an interview on 5/28/25 at 8:38 A.M., the Dietary Manager said the following: -Staff used the ice machine in the staff breakroom to obtain ice for residents; -Dietary and/or housekeeping staff wiped the exterior of the ice machines down monthly; -The vendor performed maintenance on the unit but she was unsure how often this was completed; -Dietary staff cleaned and sanitized the inside of the ice machine when the volume of ice was low. Staff last performed this process the second week of April; -The black debris inside the kitchen ice machine was always visible. The black debris and the red areas came off a little when staff cleaned the unit. Dietary staff cleaned the exhaust vent on the back of the unit monthly. She was aware there was a buildup of fuzzy debris on the vent; -She was unaware the breakroom ice machine had a buildup of red rusty debris inside the unit. Staff cleaned this unit monthly. During an interview on 5/28/25 at 2:22 P.M., the Maintenance Supervisor said the following: -The vendor maintained the ice machines; -He was unsure who was responsible for cleaning the ice machines; -Maintenance was not responsible for cleaning either unit. 2. Review of the facility policy, Labeling and Dating Foods (Date Marking), dated 2020, showed the following: -All foods stored with properly labeled according the following guidelines; -Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date; -Prepared food or opened food items should be discarded when: -The food item does not have a specific manufacturer expiration date and has been refrigerated for seven days; -The food item was leftover for more than 72 hours; -The food item was older than the expiration date. Observation on 5/27/25 at 10:18 A.M. of the Special Care Unit (SCU) refrigerator showed the following: -A 12-ounce blueberry-flavored sports drink was mostly empty and was not dated or labeled to show a resident or staff name; -A small bowl of an unknown white creamy substance was uncovered and was not labeled or dated; -A small disposable plastic cup held small pieces of cut-up fruit. The fruit was starting to turn brown and dry up. The cup was not covered, labeled or dated. Observation on 5/28/25 at 8:32 A.M. of the SCU refrigerator showed the following: -A 12-ounce blueberry-flavored sports drink was mostly empty and was not dated or labeled to show a resident or staff name; -A small bowl of an unknown white creamy substance was uncovered and was not labeled or dated; -A small disposable plastic cup held small pieces of cut-up fruit. The fruit was starting to turn brown and dry up. The cup was not covered, labeled or dated; -One cupcake with blue icing sat inside on the shelf and was not covered or dated; -One plastic beverage cup with brown liquid was not covered, labeled or dated. During an interview on 5/28/25 at 8:38 A.M., the Dietary Manager said the following: -Staff in the SCU and housekeeping staff check the SCU refrigerator for outdated items. She checked the refrigerator two to three times a week for proper labeling, dating, food covers and any items that needed to be discarded; -The SCU needed some plastic wrap and labels so food items were properly stored; -The brown liquid in a cup was probably a resident's supplement shake, and the cupcakes were leftover from the recent holiday weekend. 3. Observation on 5/27/25 at 10:23 A.M. showed a trash can sat near the dish machine in the kitchen. The can was partially full of food debris and paper trash and was uncovered. There were no staff actively working in the dish machine area of the kitchen. A second trash can sat near the convection oven. The lid was removed and the can was partially full of food waste and paper trash. There were no staff utilizing the trash can for food preparation. During an interview on 5/28/25 at 8:38 A.M., the Dietary Manager said trash cans should be covered with a lid when not in use.

Based on observation, interview and record review, the facility failed to implement the facility's policy to address Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) standards and failed to implement a water management team and parameters for findings related to water monitoring. The facility failed to ensure nursing staff performed appropriate hand hygiene during care for two residents (Residents #2 and #189), in a review of 13 sampled residents, and for two additional residents (Resident #23 and #31), failed to utilize Enhanced Barrier Precautions (EBP) (infection control measures designed to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes and other long-term care facilities) per facility policy during wound care for one sampled resident (Resident #1). The facility census was 35. 1. Review of the facility's undated policy, Legionella Policy and Water Management, showed the following: -As part of the infection prevention and control program, our facility has a water management program, overseen by the maintenance department and the water management team; -The water management team included the administrator, maintenance, Director of Nursing (DON) and medical director; -The team is to identify areas in the water system where Legionella can grow and spread in order to reduce the risk of Legionnaire's disease; -The Centers for Disease Control and Prevention (CDC) water prevention toolkit and ASHRAE recommendations have been used in developing a water management program; -Measures used to control the spread of Legionella: diagram of where control measures are applied, monitor control limits, documentation of the program; -The Water Management Program will be reviewed at least annually/or as needed if: the control limits are consistently not met, a major maintenance project, water service change, any diagnosis of disease associated with the water system. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following: -The bacterium Legionella can cause a serious type of pneumonia called LD (Legionnaire's disease) in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the undated, Centers for Disease Control and Prevention Legionella Environmental Assessment Form showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F and Legionella become dormant below 68 degrees F. The state agency requested, but the facility provided no documentation to show the facility's water management program was reviewed at least annually per facility policy. The state agency requested, but the facility provided no documentation to show that the water management team, with the specific required staff members, actively held meetings. Review of water temperatures, obtained by the state agency on 05/28/25, showed the following water temperatures fell between 77 and 113 degrees, where Legionella generally grows well: -At 12:45 P.M., the Special Care Unit (SCU) room [ROOM NUMBER], hot water faucet temperature was 108.1 F (too cool); -At 12:48 P.M., the SCU room [ROOM NUMBER], hot water faucet temperature was 102.4 F (too cool); -At 12:51 P.M., the SCU dining room, cold water faucet temperature was 80.6 F (too warm) and hot water faucet temperature was 109.6 F (too cool); -At 1:00 P.M., the central hall, room [ROOM NUMBER], hot water faucet temperature was 105.5 F (too cool); -At 1:03 P.M., the central hall, room [ROOM NUMBER], cold water faucet temperature was 80.6 F( too warm) and hot water faucet temperature was 106.5 F (too cool); -At 1:15 P.M., the southeast hall, shower sink, hot water faucet temperature was 104.4 F (too cool). During an interview on 05/29/25 at 11:45 A.M., the infection preventionist (IP) said the following: -The water management team consisted of the administrator, DON, IP, maintenance director, housekeeping supervisor and the medical director; -Water management meetings were conducted with Quality Assurance (QA) meetings; -The Maintenance Director checked the water temperatures; -Maintenance and housekeeping flush the lines of sinks, showers, and tubs in rooms not in use. During an interview on 05/29/25 at 2:20 P.M., the Maintenance Director said the following: -The water management team met monthly with safety walks throughout the facility; he did not have documentation of these meetings; -His role was to check the water temperatures and flush the unused water supplies, check the boiler room and showers for standing water; he did not have documentation of those checks; -Hot water should not be over 122 degrees and had to be at least 109 degrees; -He started checking the cold water temperatures in November; -He did not know what ASHRAE was; -The facility had developed the water management team and obtained the CDC packet. During an interview on 05/29/25 at 2:45 P.M. and 06/09/25 at 1:51 P.M., the Administrator said the following: -The facility used the CDC tool kit, but not the ASHRAE guidelines that the policy referred to due to the expense of the ASHRAE guidelines; -The Maintenance and Housekeeping Supervisors do safety rounds and flush lines and report anything abnormal verbally to her; there was no written documentation of this being completed; -They have discussed water management in the QA meetings. 2. Review of the facility's undated policy, Infection Control, showed the following: -Purpose: to ensure precautions are taken when caring for residents regardless of their diagnosis or presumed infection status; -Procedure: Hand washing; staff will wash hands: -After touching blood, body fluids, secretions, excretions and contaminated items whether or not gloves are worn; -Immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to another resident or environments; -Between tasks and procedures on the same resident to prevent cross contamination of different body sites; -Plain soap should be used for routine hand washing; -An antimicrobial agent or waterless antiseptic agent can be used for specific circumstances (e.g. control of outbreaks or hyper-endemic infection); -Gloves: Staff will wear clean, non-sterile gloves when touching blood, body fluids, secretions, excretions and contaminated items; -Before touching mucous membranes and broken skin; -Gloves will be changed between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms; -Gloves will be removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident; -Hands should be washed immediately after removal of gloves to avoid transfer of microorganisms to other residents or environments. 3. Review of Resident #23's quarterly Minimum Data Set (MDS) , a federally mandated assessment instrument completed by facility staff, dated 05/12/25, showed the following: -Always incontinent of bowel and bladder; -Moderate assistance with toileting and personal hygiene. Review of the resident's care plan, revised 05/27/25, showed the following: -The resident had an activities of daily living (ADL) self-care performance deficit related to Alzheimer's disease; -Totally dependent on one or two staff for personal hygiene; -The resident required assistance of one staff for toileting. Observation on 05/27/25 at 11:00 A.M. showed the following: -Certified Nurse Assistant (CNA) J was in the shower room with the resident; -CNA J wore gloves and removed a urine soaked incontinence brief from the resident; -While wearing the same soiled gloves, CNA J assisted the resident to put on compression hose and house shoes; -With the same soiled gloves, CNA J assisted the resident to stand and provided peri-care with wash cloths then pulled up the resident's new incontinence brief and clean pants; -CNA J removed his/her gloves, and without washing his/her hands, assisted the resident to walk to the dining room, touching the resident's gait belt and walker. 4. Review of Resident #31's quarterly MDS, dated [DATE], showed the following: -Continent of bowel and bladder; -Supervision with toileting; -Moderate assistance with personal hygiene. Review of the resident's care plan, revised 05/27/25, showed the following: -The resident had bladder incontinence related to Alzheimer's disease; -Staff to clean peri area with each incontinence episode. Observation on 05/27/25 at 11:20 A.M. showed the following: -CNA J entered the resident's room and without washing his/her hands with soap and water or using hand sanitizer, put on gloves; -The resident lay in bed and was incontinent of urine; -CNA J unfastened the resident's urine soiled incontinence brief and cleaned the resident's perineum with wash cloths, then rinsed the perineum; -While wearing the same gloves he/she wore to provide peri-care, CNA J rolled the resident to his/her right side and touched the resident's left hip with his/her gloved hands; -With his/her left-hand, CNA J washed and rinsed the resident's buttocks. With the same gloved hand, he/she touched a tube of barrier cream, removed cream from the tube and applied it to his/her soiled gloved hand and then applied the barrier cream to the resident's buttocks; -CNA J removed his/her gloves and removed the urine soiled linens from the resident's bed with his/her bare hands; -Without washing his/her hands or using hand sanitizer, CNA J put on clean gloves, and put a clean incontinence brief and pants on the resident as he/she rolled the resident back and forth in bed. During an interview on 05/27/25 at 2:25 P.M., CNA J said the following: -Staff should wash hands before and after providing cares, when soiled and when changing gloves; -Staff should change gloves before and after cares and when soiled; -He/She should have changed his/her gloves, and washed his/her hands after peri-care and before touching clean items. Observation on 05/29/25 at 9:15 A.M. showed the following: -CNA A wore gloves and rolled the resident to his/her right side, rolled a urine soaked bed pad up under the resident, rolled a clean bed pad under the wet bed pad, and cleaned urine from the resident's left buttock with wet wash cloths; -While wearing the same gloves, CNA A rolled the resident partially to his/her left side, touched the resident's right thigh with his/her gloves, and provided front pericare; -CNA A continued to roll the resident onto his/her left side by touching the resident's right hip with the same gloves he/she wore when providing peri-care and removed the urine soaked bed pad. CNA A did not remove his/her gloves and covered the resident with the top sheet and cover; -While wearing the same soiled gloves, CNA A got clean clothes from the resident's closet, put a new incontinence brief and pants on the resident and covered the resident; -CNA A removed his/her gloves, did not perform hand hygiene, and went out to the hall; -CNA A returned to the resident's room, did not perform hand hygiene and put on new gloves; -CNA A assisted the resident to sit up, removed the resident's gown and put on a clean shirt. CNA A applied deodorant to the resident, put house shoes and a gait belt on the resident, and assisted the resident to stand with a walker and walk to the door. During an interview on 05/29/25 at 9:38 A.M., CNA A said the following: -He/She was to perform hand hygiene before providing care, when hands were soiled during care, when changing gloves, and after providing care; -He/She should change his/her gloves if his/her gloves were soiled; -He/She was not aware he/she should change his/her gloves when only cleaning urine during incontinence care. 5. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -Dependent on staff for toileting hygiene, chair/bed-to-chair transfers, rolling left and right, changing positions from sitting to lying and lying to sitting on the side of the bed; -Needed partial to moderate assistance from staff for upper body dressing; -Always incontinent of bowel and bladder. Review of the resident's care plan, revised 05/05/25, showed the following: -He/She had limited physical mobility and was totally dependent on two staff for toilet use; -He/She had functional bladder incontinence; -Clean peri-area with each incontinence episode. Observation on 05/28/25 at 8:15 P.M., showed the following: -Nurse Assistant (NA) E and NA F entered the resident's room; -NA E did not wash his/her hands before donning gloves; -NA E removed the resident's incontinence brief that was soiled with urine and feces; -NA E performed peri-care to the resident's buttocks; -NA E did not change gloves and performed front peri-care; -NA E removed his/her gloves, did not perform hand hygiene, and put on a new pair of gloves. NA E put a clean incontinence brief on the resident, removed the resident's shirt, obtained mineral cream from a container with his/her gloved fingers, put mineral cream on the resident's back, arms, and chest, and put a new gown on the resident. -NA E removed his/her gloves and used hand sanitizer (NA E did not wash his/her hands with soap and water as directed in facility policy after providing incontinence care.) During an interview on 05/30/25 at 12:05 A.M., NA E said the following: -He/She should wash his/her hands after performing any resident care; -He/She should change gloves anytime they became visually soiled or when moving from a dirty area to a clean area during peri-care; -He/She should change gloves after providing incontinence care, and should not touch clean items with soiled gloves. 6. Review of Resident #189's admission MDS, dated [DATE], showed the following: -Partial/moderate assistance from staff for toileting hygiene and lower body dressing; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, revised on 05/28/25, showed the following: -The resident had an ADL self-care performance deficit related to confusion, dementia and impaired balance; -He/She required assistance from one or two staff to dress and for toileting. Observation on 05/28/25 at 11:38 A.M. showed the following: -The resident lay in bed; -The resident's incontinence brief, fitted sheet, cloth pad and mattress were soiled with urine; -NA B and CNA D, did not perform hand hygiene before donning gloves; -NA B performed front peri-care for the resident; -NA B removed his/her gloves, did not wash his/her hands, and put on a new pair of gloves; -CNA D performed peri-care to the resident's buttocks; -Neither CNA D nor NA B wiped any other areas of the resident's skin that were soiled with urine, including the resident's legs or back; -CNA D removed the resident's incontinence brief and placed it in a bag, removed the wet fitted sheet and cloth pad and placed them on the bare mattress at the end of the bed; -NA C put the urine soiled bedding in a bag; -The mattress had a visible wet spot from where the urine saturated bedding had been in contact with the mattress; -While wearing the same gloves used to provide peri-care and to handle the soiled linens, NA B and CNA D rolled the resident to his/her back against the urine soiled mattress and dressed the resident; -NA B and CNA D removed their gloves, did not perform hand hygiene, and put on new gloves; -NA B and CNA D made the resident's bed without disinfecting or cleaning the urine from the mattress; -NA B removed his/her gloves, did not perform hand hygiene, and left the resident's room; -CNA D removed his/her gloves and used hand sanitizer. (CNA D did not wash his/her hands with soap and water as directed in facility policy.) During an interview on 05/28/25, at 5:18 P.M., CNA D said the following: -He/She should wash his/her hands before and after providing any care; -He/She should wash his/her hands or use hand sanitizer before putting on gloves, when changing gloves, and after removing gloves; -Staff should not place a resident on a urine soiled mattress without placing a barrier between the soiled mattress and the resident's skin; -He/She did not perform hand hygiene before applying gloves or in between glove changes when providing care for the resident. 7. During interview on 05/30/25 at 1:13 P.M., the Director of Nursing (DON) said the following: -Staff should wash their hands before and after resident contact, before and after providing care, before applying gloves, in between glove changes, and after removing gloves; -Staff should wear gloves when providing any care to a resident; -Staff should change their gloves after providing care, when gloves becoming dirty or are visibly soiled, and in-between front and back pericare; -Staff should remove soiled gloves and wash their hands with soap and water prior to touching clean items; -Staff could use hand sanitizer for hand hygiene, but should wash their hands with soap and water after using hand sanitizer two or three times during care. During an interview on 05/30/25 at 1:39 P.M., the Administrator said the following: -Staff should wash their hands before any procedure, in between cares, during care if hands become soiled, and when changing gloves; -Staff should wear gloves when providing direct resident care. 8. Review of the facility's undated policy, Enhanced Barrier Precautions (EBP), showed the following: -EBP is an infection control strategy to reduce the transmission of multidrug-resistant organisms (MDROs) and other infections in nursing homes. EBP expands on Standard Precautions by requiring gowns and gloves during specific high-contact resident care activities for residents at increased risk of MDRO acquisition or those known to be colonized or infected with an MDRO; -EBP focuses on targeted use of personal protective equipment (PPE) (gowns and gloves) during specific high-contact activities, rather than requiring them for all residents; -Activities like dressing, bathing/showering, transferring, and device care are examples of high-contact activities where EBP is used; -EBP is generally intended to be in place for the duration of a resident's stay or until the risk factors (e.g., wound or device) are resolved; -Residents may require EBP if they have an MDRO infection or colonization, have wounds or indwelling medical devices, or are deemed at higher risk by the facility; -Gowns, staff will wear a clean, non-sterile gown to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. 9. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Dependent on staff for bed mobility and transfers; -Has one Stage II pressure ulcer (partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer). Review of the resident's care plan, last reviewed 5/5/25, showed the following: -The resident had a pressure ulcer or potential for pressure ulcer development related to mobility; -Administer treatments as ordered and monitor for effectiveness; -The resident's care plan did not identify the need for or the use of EBP when providing care for the resident. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed an order to cleanse daily with normal saline or wound cleanser and pat dry, apply Urgoclean (wound dressing that aids in the continuous removal of slough and wound debris) dressing to wound base, cover with optifoam (a foam dressing) dressing every day shift for wound care; Observation on 5/30/25 at 9:32 A.M., showed the following: -EBP supplies hung on the outside of the resident's room door; -Licensed Practical Nurse (LPN) P pushed the treatment cart into the resident's room, applied hand sanitizer to his/her hands and put on gloves. LPN P did not put on a gown; -LPN P gathered dressing supplies from the treatment cart and placed them directly on the resident's bed without a barrier; -LPN P removed the heel protector, sock and dressing from the resident's right outer ankle; -Wearing the same gloves, LPN P placed clean gauze under the resident's right foot, picked up a bottle of wound cleanser, sprayed the dime-sized wound and removed the packing from the wound; -LPN P removed his/her gloves, applied hand sanitizer and put on new gloves; -LPN P cut a small piece of Urgoclean dressing and applied it to the wound; -LPN P applied an optifoam dressing to cover the wound; -LPN P removed his/her gloves, did not wash or sanitize his/her hands, then dated the dressing with a pen, and put socks and the heel protector on the resident's foot. During interview on 5/30/25 at 9:42 A.M., LPN P said residents with catheters or wounds usually have enhanced barrier precautions. He/She forgot to put on a gown prior to performing the resident's dressing change. He/She should have placed the dressing supplies on a barrier but the resident had his/her breakfast on the bedside table. He/She should wash his/her hands and change gloves when going from a dirty task to a clean task, before he/she started a procedure and when the procedure was complete. During interview on 05/30/25 at 1:13 P.M., the DON said staff should use EBP on any resident with a wound. 42592 49528

Based on observation, interview and record review, facility staff failed to develop and consistently implement a regular maintenance program, including routine inspections of bed frames, mattresses and bed rails, to identify areas of possible entrapment for seven residents (Resident #10, #3, #20, #189, #9,#36, and #35), in a review of 13 sampled residents. The facility census was 35. The facility did not have a policy related to risk of entrapment with resident beds. Review of the Food and Drug Administration's (FDA) Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised [DATE], showed the following: -Between 1985 and [DATE], 803 incidents of patients getting caught, trapped, entangled or strangled in beds with rails were reported to the U.S. FDA; -Of those reported, 480 died and 138 had non-fatal injuries; -Most patients were frail, elderly or confused; -Potential risks of bed rails may include strangulation, suffocation, bodily injury or death when patients or parts of their body are caught between rails and mattresses, more serious injury from falls when patients climb over rails, skin bruising, cuts and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet. 1. Review of resident #10's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated [DATE], showed the following: -Cognitively intact; -Diagnoses include paraplegia (paralysis that affects the lower half of the body) and vision deficits; -Range of motion limitations lower extremity one side; -He/She was dependent for bed mobility and transfers. Review of the resident's care plan, revised on [DATE], showed the following: -He/She has an activities of daily living (ADLs) self-care performance deficit related to right below the knee (BKA) amputation and impaired balance; -The resident required assistance of two staff to turn and reposition in bed every two hours and as necessary; -The resident uses mobility bars to maximize independence with turning and repositioning in bed; -The resident requires mechanical lift with two staff for transfers. Observation on [DATE], at 12:00 P.M., showed the resident lay on his/her back in bed watching television. The resident had one-half bed rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment. 2. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Range of motion limitations to upper and lower extremity on both sides; -He/She was dependent for bed mobility and transfers. Review of the resident's care plan, revised on [DATE], showed the following: -He/She has an activities of daily living (ADLs) self-care performance deficit related limited mobility; -The resident required assistance from two staff to turn and reposition in bed every two hours and as necessary; -The resident requires one or two staff to move between surfaces; (The care plan did not address bed rails.) Observation on [DATE], at 9:53 A.M., showed staff transferred the resident with the mechanical lift to bed. The resident had one-half bed rails in the raised position on both sides of his/her bed. Staff provided incontinence care to the resident. The resident did not use the bed rails to assist in turning during cares. Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment. 3. Review of resident #20's quarterly MDS, dated [DATE], showed the following: -Range of motion limitations lower extremity one side; -He/She rolled left and right independently; -Staff provide partial/moderate assistance for sit to lying, lying to sitting on side of the bed; -Staff provide substantial/maximum assist for sit to stand, chair/bed-to-chair and toilet transfers; Review of the resident's care plan, revised on [DATE], showed the resident ADL self-care performance deficit related to dementia and impaired balance. (The care plan did not address bed rails.) Observation on [DATE] at 10:11 A.M., showed the resident lay awake in bed watching television. The resident had one-half bed rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment. 4. Review of Resident #189's admission MDS, dated [DATE], showed the resident was independent to roll left to right, sit to lying, lying to sitting on the side of the bed, chair/bed-to-chair transfer and sit to standing position. Review of the resident's care plan, revised on [DATE], showed the following: -The resident required assistance from one or two staff to turn and reposition in bed every two hours and as necessary; -He/She required assistance from one or two staff to move between surfaces; -The resident had limited physical mobility related to weakness, recent hospitalization , dementia and anxiety. (The resident's care plan did not address bed rails.) Observation on [DATE], at 11:23 A.M., showed the resident lay awake in bed. The resident had one-half bed rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment. 5. Review of Resident #9's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -He/She was independent with bed mobility; -He/She required supervision with transfers. Review of the resident's care plan, revised [DATE], showed the resident needed one staff to assist with ADLs. (The care plan did not address bed rails.) Observation on [DATE] at 10:32 A.M. showed the resident lay in bed on his/her right side. The resident had one-half bed rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment. 6. Review of Resident #36's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -He/She required moderate assistance with bed mobility; -He/She required maximum assistance with transfers. Review of the resident's care plan, revised [DATE], showed the following: -High risk for falls related to gait/balance problems; -He/She was dependent of one to two staff for transfers; -He/She required assistance of one staff to turn, reposition in bed; (The care plan did not address bed rails.) Observation on [DATE] at 10:38 showed the resident had one-half bed rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment. 7. Review of Resident #35's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -He/She was independent with bed mobility; -He/She required supervision with transfers. Review of the resident's care plan revised [DATE], showed the following: -The resident has an ADL self-care performance deficit related to Alzheimer's disease; -The resident was able to transfer himself/herself. (The care plan did not address bed rails.) Observation on [DATE] at 10:32 A.M. and [DATE] at 3:00 P.M. showed the resident had a one-half bed rail in the raised position on the right side of his/her bed. Review of the resident's medical record showed no documentation staff conducted an inspection of the resident's bed frame, mattress or bed rails to identify areas of possible entrapment. 8. During an interview on [DATE], at 2:30 P.M., the Maintenance Director said the following: -He and the Housekeeping/Laundry Supervisor measured all the resident beds (with bed rails) once and wrote them on a piece of paper; -They only measured the beds one time but not recently, maybe within the last year; -He was not aware routine inspection of the bed rails was something that needed to be done. Review of an untitled and undated document, provided by the Housekeeping/Laundry Supervisor on [DATE], showed a list of numbers (identified by the Housekeeping/Laundry Supervisor as room numbers) and three areas (rail, headboard, foot) with measurements next to each. During an interview on [DATE], at 2:45 P.M., the Housekeeping/Laundry Supervisor said the following: -She and the Maintenance Supervisor measured all the resident beds with bed rails one time within the last 12 months; -The number on the provided document was the room number and the three areas with entries was the length in inches between the bed rails and head/foot board to the mattress; -She unaware the measurements needed to be done routinely. During an interview on [DATE], at 2:30 P.M., the Administrator said the following: -The Maintenance Supervisor and the Housekeeping/Laundry Supervisor measured all of the beds with bed rails for risk of entrapment; -The measurements were done only once; -Maintenance and housekeeping/laundry staff were responsible to obtain the measurements on a routine basis. 42592 49528

Based on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, for two residents (Resident #8 and #20) in a review of 13 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (a decline or improvement in two or more assessed areas of resident status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status, and required interdisciplinary review and/or revisions of the care plan. The facility census was 35. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, Chapter 2, revised October 2023, showed the following: -The SCSA is a comprehensive MDS assessment for a resident that must be completed when the Interdisciplinary team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an admission assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT's determination was made that the resident had a significant change; -A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan; - When a resident's status changes and it is not clear whether the resident meets the SCSA guidelines, the nursing home may take up to 14 days to determine whether the criteria are met; -After the IDT has determined that a resident meets the significant change guidelines, the nursing home should document the initial identification of a significant change in the resident's status in the clinical record; -An SCSA is appropriate when: 1. There is a determination that a significant change (either improvement or decline) in a resident's condition from their baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent quarterly assessments and the resident's condition is not expected to return to baseline within two weeks. Review of the facility's policy, Electronic Transmission of the MDS, revised 08/27/23, showed the following: -All staff members responsible for completion of the MDS receive training on the assessment process, computer entry, and transmission process, in accordance with the MDS 3.0 RAI instruction manual, before being permitted to use the MDS computer system. A copy of the MDS 3.0 RAI instruction manual is maintained by the resident assessment coordinator; -Staff members are trained on updates/revisions to the MDS 3.0 form and software upgrades as they are released. Such training is provided by the corporate staff and/or computer software vendor; -The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data. 1. Review of Resident #8's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Mobility devices use include a walker; -Independent with eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, all transfers, and walking 10 feet, 50 feet and 150 feet. Review of the resident's electronic health record showed the resident was away from the facility and hospitalized from 01/24/25 - 01/27/25. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Mobility devices used include a wheelchair and walker (change, requiring more assistance from the previous assessment); -Set-up assistance from staff needed for eating and to roll left and right (change, decline in these areas from the previous assessment); -Supervision from staff to complete upper body dressing, put on/take off footwear and sitting to lying transfers (decline in these areas from the previous assessment); -Partial/moderate staff assistance for oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, personal hygiene, lying to sitting on the side of the bed, sit to stand transfer, chair/bed-to-chair transfers, toilet transfer, tub/shower transfer, walking 10 feet, wheeling 50 feet and wheeling 150 feet (decline in these areas from the previous assessment); -This assessment met the criteria of an SCSA and should have been completed as an SCSA assessment, but instead, was completed as an admission assessment. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Mobility devices use include a walker (change, improvement, requiring less assistance from the previous assessment); -Independent with eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, all transfers, and walking 10 feet, 50 feet and 150 feet (change, improvement in these areas from the previous assessment); -This assessment met the criteria of an SCSA and should have been completed as an SCSA assessment, but instead, was completed as a quarterly assessment. 2. Review of Resident #20's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Mobility devices include a walker and wheelchair; -No range of motion impairment; -Set-up assistance from staff needed for eating and oral hygiene; -Supervision from staff to complete toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, toilet transfers, tub/shower transfers and walking 150 feet; -Independent with rolling left and right, sit to lying transfer, lying to sitting on the side of the bed, sit to stand transfer, chair/bed-to-chair transfers, walking 10 and 50 feet, wheeling 50 and 150 feet; -Occasionally incontinent of bowel and bladder. Review of the resident's electronic health record showed the resident was away from the facility and hospitalized [DATE] - 01/16/25 with a hip fracture and 01/20/25 - 01/24/25 with a small bowel obstruction. Review of the resident's admission MDS, dated [DATE], showed the following: -Severely impaired cognition (change, decline from previous assessment); -Diagnosis of hip fracture; -Mobility devices of wheelchair only (change, requiring more assistance from the previous assessment); -Functional impairment one side lower extremity (change, decline from previous assessment, resident's ability decreased); -Set-up assistance from staff for eating; -Supervision from staff for rolling left and right (change, decline from previous assessment, resident requiring more assistance); -Partial/moderate assistance from staff for oral hygiene, sit to lying transfer and lying to sitting on the side of the bed (change, decline from previous assessment, resident requiring more assistance); -Substantial/maximum assistance from staff for upper body dressing, sit to stand transfer, chair/bed-to-chair transfer and toilet transfer (change, decline from previous assessment, resident requiring more assistance); -Dependent on staff for toileting, shower/bathe self, lower body dressing, put on/take off footwear, personal hygiene, tub/shower transfer and wheeling 50 and 150 feet; -Walking did not occur (change, decline from previous assessment, resident requiring more assistance); -Always incontinent of bowel and bladder (change, decline from previous assessment, resident with decreased ability); -This assessment met the criteria of an SCSA and should have been completed as an SCSA assessment, but instead, was completed as an admission assessment. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Independently rolls left and right (change, improvement from previous assessment, resident requiring less assistance); -Dependent on staff for sit to stand transfer, chair/bed-to-chair transfer, toilet transfer and upper body dressing (change, decline from previous assessment, resident requiring more assistance); -This assessment met the criteria of an SCSA and should have been completed as an SCSA assessment, but instead, was completed as a quarterly assessment. During an interview on 05/30/25 at 12:42 P.M., the MDS coordinator said the following: -She was responsible for completing the MDS assessments; -She had received training on the completion of an MDS; -She followed the RAI manual to determine the assessment type needed to be completed; -When a resident returns from the hospital, an admission assessment was completed regardless if the resident was a resident before hospitalization ; -A significant change MDS was completed when there was a change, good or bad, in two or more areas of the MDS; -Resident #8 and #20 went to the hospital and came back so they needed an admission assessment completed. During an interview on 05/30/25 at 1:13 P.M., the Director of Nursing (DON) said the MDS assessments should follow the RAI manual. During an interview on 05/30/25 at 1:39 P.M., the administrator said the MDS should be the correct assessments by the RAI manual.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #438), in a review of fifteen sampled residents, received his/her divalproex sodium delayed release (DR) (a medication to treat epilepsy and mood disorders) medication in the proper form, when staff crushed and administered the medication. Further review showed Certified Medication Technician (CMT) A entered an order to crush the resident's medications without consulting the charge nurse, Director of Nursing, or the physician. The facility census was 36.Review of the facility's undated policy, titled Policy for Medication Administration, showed it did not address crushing medications.Review of the facility's policy, Policy for following Physician Orders, revised 08/29/24, showed the policy did not address who could obtain and enter physician orders. 1. Review of drugs.com for divalproex sodium DR showed the following:-Swallow the capsule or tablet whole and do not crush, chew, break, or open it;-Not all medications are suitable for crushing. Drugs that should not be crushed are DR. These are controlled release and are designed to release medicine over an extended period to allow less frequent administration. Crushing may mean a fatal dose is released. Review of Resident #438's face sheet showed he/she had a diagnosis of restlessness and agitation. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/21/25, showed the following:-Cognitively intact;-No difficulty swallowing. Review of the resident's July 2025 Physician Order Summary (POS) showed the following:-Divalproex sodium oral tablet DR 250 milligrams (mg), give one tablet by mouth three times daily, start date 05/14/25;-Crush medications per resident's request, created and started 07/22/25 at 3:00 P.M., to end indefinite; order confirmed by CMT (certified medication technician) A. Review of the resident's nurses' progress notes, dated 07/22/25, showed no documentation staff contacted the physician regarding a request for an order to crush the resident's medications, including his/her divalproex sodium DR or that an order had been received.During an interview on 07/23/25 at 4:06 P.M., the resident said the following:-He/She always had a hard time swallowing his/her pills;-He/She had not asked staff to crush his/her medications. Observation on 07/23/25 at 12:03 P.M., showed the following:-CMT A removed the resident's medication card of divalproex sodium delayed release 250 mg from the medication cart;-CMT A popped out one divalproex sodium DR 250 mg from the medication card and placed it into a medication cup;-CMT A then poured the tablet into a plastic sleeve, crushed the medication, and placed the crushed medication in a medication cup with applesauce;-CMT A administered the crushed medication in applesauce to the resident;-CMT A crushed and administered medication that was not supposed to be crushed. During an interview on 07/23/25 at 1:38 P.M., CMT A, said the following:-The former DON allowed him/her to put medication orders and crush orders into the computer;-The resident said he/she was having trouble swallowing, so CMT A put an order in the computer for medications to be crushed;-He/She had taken it upon him/herself to put the order in to crush the resident's medications;-He/She did not consult the charge nurse, the Director of Nursing, or the physician prior to adding the order;-The physician was unaware staff crushed any of the resident's medications;-He/She attended an in-service on crushing medications;-Only a few medications were discussed as not being able to be crushed during the in-service. He/She did not read the list of medications during the in-service and he/she did not get a copy of the list of medications which should not be crushed;-He/She did not check the resident's medication list before entering the crush order;-He/She did not realize that DR stood for delayed release. During an interview on 07/23/25 at 1:19 P.M., the facility's pharmacist said the following:-Divalproex sodium DR should not be crushed because it was a delayed released medication;-There could be complications administering divalproex sodium DR crushed. The medication was intended to be released evenly over a period of time. If the medication was administered in a crushed form, the medication would be absorbed too quickly and would not be absorbed as intended;-There were substitutions for this medication if the resident had issues with swallowing;-The other forms would be liquid or crystals. During an interview on 07/24/25 at 10:28 A.M., the DON said the following:-All medication orders should be entered by a Licensed Practical Nurse (LPN) or Registered Nurse (RN);-The order for crushing the resident's medications should have come from the physician;-She did not believe the facility had a policy regarding crushing medications;-She had conducted an in-service for medications which could not be crushed;-Divalproex sodium DR should not have been crushed. It was on a list of non-crushable medications shared with staff during the in-service training;-Crushing divalproex sodium DR would have affected the way the medication was released;-It was inappropriate for the CMT to enter orders to crush medications. During an interview on 07/24/25 at 10:42 A.M., the Administrator said the following:-Any orders for medications or crushing medications should be entered by an LPN or RN;-She would have expected the physician to be contacted for an order to crush a resident's medication;-If staff had any question regarding medications being crushed, the RN should call the physician;-It was not appropriate to crush divalproex sodium DR. The medication was on the do not crush list that was given in an in-service conducted by the DON on 07/10/25;-She would expect nursing to contact the physician if a resident was having trouble swallowing medication and get a new order for a liquid or granules;-There was a potential for harm if a resident was given a medication that should not have been crushed;-It was not appropriate for a CMT to put in a physician order to crush a resident's medications. During an interview on 07/24/25 at 9:51 A.M., the resident's primary care physician said the following:-Divalproex sodium DR oral tablets were not crushable;-Medication orders should be entered by an LPN or RN;-No staff contacted her before entering the order;-A CMT should not be entering medication orders for any resident;-Administering a crushed divalproex sodium DR would interfere with the medications absorption rate. The medication would be absorbed at a quicker rate than intended.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #10), in a review of 13 sampled residents, and one additional resident (Resident # 15) who received insulin injections, were free from significant medication errors. Staff failed to prime (remove the air from the needle and cartridge) the Humalog Kwik pen (prefilled pen of fast acting insulin (medication injected under the skin used to treat diabetes)) and Fiasp FlexTouch pen (prefilled pen of fast acting insulin) needle as instructed by the manufacturer prior to administration of the medication, potentially affecting the amount of insulin dispensed with each dose. The facility census was 35. Review of the facility's undated policy, Insulin Pen Usage, showed before each use, prime the pen to remove air bubbles and ensure a clear needle. Review of the Humalog Kwik pen package insert showed if you do not prime the insulin pen before each injection, you may get too much or too little insulin. Turn the dose knob to select two units, hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. Repeat the priming procedure if you did not see insulin at the tip of the needle. Review of the Fiasp FlexTouch pen package insert showed if you do not prime before each injection, you may get too much or too little insulin. Turn the dose selector to select two units, hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top, hold the pen with the needle pointing up and press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin repeat the above steps. 1. Review of Resident #10's May 2025 Physician Order Sheets (POS) showed the following: -Diagnosis of type 2 diabetes mellitus; -Humalog KwikPen insulin pen, 100 units/milliliter (ml); amount per sliding scale (a dose amount to be determined based on the accucheck). If blood sugar is 210-219, give 1 unit; if blood sugar is 220-229, give 2 units; if blood sugar is 230-239, give 3 units; if blood sugar is 240-249, give 4 units; if blood sugar is 250 to 259, give 5 units; if blood sugar is 260-269, give 6 units; if blood sugar is 270-279, give 7 units; if blood sugar is 280-289, give 8 units; if blood sugar is 290-299, give 9 units; if blood sugar is 300-310, give 10 units; if blood sugar is 311-320, give 11 units; if blood sugar is 321-330, give 12 units; if blood sugar is 331-340, give 13 units; if blood sugar is 341-350, give 14 units; if blood sugar is 351-360, give 15 units; if blood sugar is 361-370, give 16 units; if blood sugar is 371-380, give 17 units; and if blood sugar is 381-390, give 18 units subcutaneous. Observation on 5/28/25 at 4:27 P.M. showed the following: -Licensed Practical Nurse (LPN) K obtained the resident's blood sugar level with results of 259 milligrams per deciliter (mg/dL) and determined Humalog sliding scale insulin dose was to be 5 units; -LPN K obtained the resident's Humalog flex pen from the top medication cart drawer, removed the lid, cleaned the tip with an alcohol pad and attached a new needle; -LPN K did not prime the insulin pen; -LPN K dialed 5 units of Humalog insulin for sliding scale and administered the medication in the resident's abdomen. 2. Review of Resident #15's May 2025 POS showed the following: -Diagnosis of type 2 diabetes mellitus -Fiasp (fast acting insulin) 5 units twice a day at 8:00 A.M. and 5:00 P.M. Observation on 5/28/25 at 4:45 P.M. showed the following; -LPN K obtained the resident's Fiasp FlexTouch pen from the medication cart drawer, removed the lid, cleaned the tip with an alcohol pad and attached a new needle; -LPN K did not prime the insulin pen; -LPN K dialed up 5 units of Fiasp insulin and administered the medication in the resident's subcutaneous tissue of the abdomen. 3. During an interview on 5/28/25 at 4:55 P.M., LPN K said he/she was unaware the insulin pens needed to be primed. During an interview on 05/30/25 at 1:13 P.M., the Director of Nursing said the following: -Staff was to prime insulin pens; -Staff was to administer insulin in accordance with facility policy, physician orders, and manufacturer guidelines. During an interview on 5/30/25 at 1:39 P.M., the Administrator said nursing staff was to prime and administer insulin pens as recommended by the manufacturer's recommendations.

Based on observation, interview, and record review, the facility failed to post required nurse staffing information, which included the resident census and total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The facility census was 35. Review of the facility's undated policy, Posting Daily Staffing, showed the following: -The direct care staff for the facility shall be posted daily across from the nursing desk between the Southeast and Southwest hall; -The charge nurse shall complete this at the beginning of each shift; -The number of each category shall be posted along with the actual hours worked and the census for each shift; -The completed forms shall be given to Director of Nursing to keep for at least 18 months. 1. Review of the facility daily staffing sheets for nursing staff for May 2025 showed the following: -On 05/01/25, the daily staffing sheet for nursing staff did not include the number of staff or actual hours worked for registered nurse (RN), licensed practical nurse (LPN), certified medication technician (CMT), certified nurse assistant (CNA), nurse assistant (NA) or the census for the day or evening shift; -No completed daily staffing sheet for nursing staff for 05/02/25 and 05/03/25; -On 05/04/25, the daily staffing sheet for nursing staff did not include the number of staff or actual hours worked for RN, LPN, CMT, CNA, NA or the census for the day or evening shift. -No completed daily staffing sheet for nursing staff for 05/05/25 through 05/09/25; -On 5/10/25, the daily staffing sheet for nursing staff did not include the number of staff or actual hours worked for RN, LPN, CMT, CNA, NA or the census for the day or evening shift. -No completed daily staffing sheet for nursing staff for 05/11/25 through 05/26/25. Observation on 05/27/25 at 10:30 A.M. and 4:00 P.M., showed the daily staffing sheet for nursing staff did not include the number of staff or actual hours worked for RN, LPN, CMT, CNA, NA or the census for the day or evening shifts. Observation on 05/28/25 at 10:00 A.M., 2:18 P.M. and 8:30 P.M. showed the incomplete daily staffing sheet for 5/27/25 remained posted. There was no staffing posted for 05/28/25. During an interview on 05/29/25 at 12:00 A.M., the Assistant Director of Nursing (DON) said the charge nurse was responsible for updating the daily staffing sheet for nursing staff each shift. During an interview on 06/03/25 at 4:29 P.M., LPN P said the Director of Nursing (DON) was responsible for updating the daily staffing sheet. During an interview on 05/30/25 at 1:13 P.M., the DON said the following: -The posted nurse staffing should be up to date; -She was not sure who was responsible for filling out the posted staffing sheets; -The completion of the posted nurse staffing had fallen through the cracks; -She received the completed staffing sheets and knew the posted staffing was not getting done. During interviews on 05/28/25 at 2:50 P.M. and 05/30/25, the Administrator said the following: -The posted staffing sheets should be up to date; -Usually the charge nurse completed the daily staffing sheet and gave the sheets to the DON to save.

Based on interview and record review, the facility failed to ensure one resident (Resident #7), of nine sampled residents,was free from physical restraints after the resident presented with verbal behaviors. Staff forced the resident to sit in a wheelchair by physically pushing the resident down into a wheelchair when the resident refused to walk to his/her room. The resident was normally able to ambulate independently. Once in the wheelchair, staff physically removed the resident's hands when the resident held onto the wheels of the chair to prevent staff from moving him/her. Staff placed footrests on the wheelchair when the resident used his/her feet to prevent the chair from moving so that staff could transport the resident to his/her room. The facility census was 41. The facility did not provide a policy on physical restraints upon request. 1. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/23/24, showed the following: -The resident was cognitively intact; -No behaviors present; -He/She was independent with ambulation; -Diagnoses of epilepsy (chronic brain disorder that causes repeated seizures, which are abnormal electrical discharges in the brain) and unspecified lack of expected normal physiological development in childhood. Review of the resident's Care Plan, dated 2/23/24, showed the following: -The resident was resistive to the nurse at times related to anxiety, with example of showering without his/her family member present; -Allow the resident to make decisions about treatment regimen to provide sense of control; -Encourage as much participation/interaction by the resident as possible during care activities; -Give clear explanation of all care activities prior to and as they occur during each contact; -Monitor the resident and his/her family member's behaviors towards each other; -Praise the resident when behavior is appropriate; -The resident liked coloring in adult coloring books, listening to music on his/her phone with headphones, walking to the country store, playing Bingo weekly, and going on outings. Review of the resident's Social Services Note, dated 11/13/24 at 9:16 A.M., showed the following: -The resident was out of control cursing and yelling; -He/She was scheduled to go to a physician's appointment but the resident's family member was unable to take the resident and the facility transporter was off; -The resident was so angry and couldn't control himself/herself and went off on everybody; -The resident thought someone should be called in on their day off to take him/her, when the staff told the resident no, the resident became angrier; -The resident went all over the facility cursing and did not stop; -Other residents were doing activities in the north dining room when the resident started cussing. The staff asked the resident to stay in his/her room until the resident cooled off; -The Social Services Director called the resident's guardian, but the guardian had to do something else and had to go. Review of the resident's Nurse Note, dated 11/13/24 at 11:15 A.M., showed the following: -The nurse asked the resident to go to his/her room several times; -The resident said he/she was waiting for Tylenol, which the nurse explained the resident could not have Tylenol at that time because the resident received it with morning medications and it was too soon; -The nurse asked the resident again to go to his/her room as the resident was being disruptive and had been asked by multiple staff; -The resident refused to go to his/her room on his/her own; -The nurse attempted to assist the resident into a standing position by hooking the nurse's right arm under the resident's left arm and was unable to get the resident to move, so the nurse asked for assistance from Certified Medication Tech (CMT) G; -The nurse and CMT G were able to assist the resident into a standing position using the same technique, one staff member one each side of the resident with their arms looped with the resident; -The resident continued to be resistive as the staff attempted to walk the resident to his/her room. At that time the nurse went behind the resident and held onto his/her hips while CMT G walked backwards in front of the resident holding his/her hands, while the staff continued to ask the resident to go to his/her room on his/her own so they didn't have to continue to disrupt the other residents this way and it was disrespectful to the other residents; -The staff and resident got in front of the nurses' station, then the resident refused to move his/her feet any further and began pushing her body against the nurse. CMT G hugged the resident around the waist to keep the resident in a standing position and asked another staff member to get a wheelchair; -The resident said the staff didn't know the other half of why he/she was upset and the nurse said the resident could tell them when he/she was in his/her room; -The nurse instructed the resident to sit in the wheelchair so they could continue down to his/her room, but the resident resisted, the staff applied pressure to resident's shoulders and upper thighs and lowered him/her into the chair; -The staff took the resident down to his/her room with resistance, as the resident kept grabbing the wheels and causing the chair to stop; -Once in the resident's room; -The staff locked the brakes on the wheelchair and left the room. During an interview on 11/14/24 at 12:00 P.M., Licensed Practical Nurse (LPN) E said the following: -The staff canceled the resident's appointment because his/her transportation was not available; -The resident was upset because he/she was looking forward to the trip; -The resident started cussing, yelling, stomping in the hallways, and slammed doors; -Another resident tried to go to the restroom but Resident #7 followed him/her into the restroom, so staff told the resident to stay out and give the other resident some privacy; -The nurse told the resident he/she was being rude and disrespectful to the other residents and asked the resident to go to his/her room until they could help the resident through the frustration, however, the resident said, no; -The Social Services Director asked the resident to go back to his/her room so they could talk and the resident said no; -Licensed Practical Nurse (LPN) E placed one hand on the resident's upper arm and another at the waist and guided the resident towards his/her room; -The resident suddenly stopped and refused to go any further; -LPN E went to get a CMT for assistance; -The resident sat in a high back chair in the back dining room and refused to move; -Both staff members wrapped an arm around both of the resident's arms and assisted him/her to stand up from the chair; -Both staff members guided the resident across the dining room and at the nurses' station the resident stopped; -The CMT G took both resident's hands and LPN E put both hands on the resident's waist to guide the resident towards his/her room, but the resident wouldn't move and instead attempted to fall backwards; -LPN E told the resident to stop and another employee obtained a wheelchair; -LPN E placed the wheelchair behind the resident and told him/her to sit down, but the resident refused; -LPN E placed his/her hand on the resident's shoulder and pushed down, so the resident sat down; -LPN E and the CMT G took the resident down to his/her room via wheelchair; -The staff left the resident in his/her room with another resident present. During an interview on 11/14/24 at 12:50 P.M., the resident said the following: -The resident was mad because an appointment was canceled again; -He/She was waiting at the nurses' station for Tylenol but the staff told him/her to go back to his/her room; -The resident told the staff he/she did not want to and was waiting on Tylenol but LPN E made him/her go anyway by force, leading him/her down the hall and pushing him/her in a wheelchair to the room. The resident did not want to go to his/her room; -LPN E told the resident to stay in his/her room until the resident could calm down; -The resident was not scared of staff, he/she was mad because he/she had to go back to his/her room; -He/She felt the staff treated him/her like a child but he/she was an adult. During an interview on 11/14/24 at 3:45 P.M., the Director of Nursing said the following: -The resident was cussing and yelling around other residents who were participating in activities; -The staff asked the resident to go to his/her room and calm down multiple times; -The staff got the resident up and the resident stood still; -The staff got a wheelchair for him/her to sit down; -LPN E and CMT G acted the way he/she expected; -The staff did not attempt any other interventions because the resident was not redirectable. During an interview on 11/14/24 at 4:15 P.M., and 11/27/24 at 11:00 A.M. the Administrator said the following: -The resident did have behaviors; -He/She previously had behaviors of yelling and cussing at the Administrator; -When the resident was in these moods, the resident did not redirect easily; -The behaviors were almost like a tantrum; -In the past, the resident became so mad that he/she punched the wall and door in his/her room; -The staff have told the resident the behavior was inappropriate and not tolerated; -The administrator expected staff to attempt other interventions on the resident's care plan before physically taking the resident to his/her room. During an interview on 11/15/24 at 2:18 P.M., the resident's Nurse Practitioner said the following: -He/She witnessed the resident's behavior on 11/13/24; -Several staff members spoke with the resident about going to his/her room because he/she was upsetting the other residents but the resident refused; -Two staff attempted to get the resident to walk but he/she refused; -The two staff members got the resident to sit in the wheelchair and started toward his/her room; -The resident put his/her feet down on the floor to prevent the staff from going any further so the staff put footrests on the wheelchair to prevent the resident from putting his/her feet down; -The staff started again but the resident grabbed hold of the wheels to prevent it from going any further; -The staff took the resident's hands off the wheels and continued to his/her room. MO245107

Based on interview and record review, the facility failed to ensure one resident (Resident #7) with a developmental delay and learning disability, in a review of nine sampled residents, received person centered interventions to address behaviors affecting others that did not make the resident feel like staff were treating him/her like a child. Staff told the resident to go to his/her room when the resident displayed disruptive behaviors. The staff physically took the resident to his/her room even when the resident refused instead of attempting other interventions to address the resident's behaviors. The facility census was 41. The facility did not provide a policy on providing care and services for residents with behavioral issues upon request. 1. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/23/24, showed the following: -The resident was cognitively intact; -No behaviors present; -He/She was independent with ambulation; -Diagnoses of epilepsy (chronic brain disorder that causes repeated seizures, which are abnormal electrical discharges in the brain) and unspecified lack of expected normal physiological development in childhood. Review of the resident's Care Plan, dated 2/23/24, showed the following: -The resident was resistive to the nurse at times related to anxiety, with example of showering without his/her family member present; -Allow the resident to make decisions about treatment regimen, to provide sense of control; -Encourage as much participation/interaction by the resident as possible during care activities; -Give clear explanation of all care activities prior to and as they occur during each contact; -Monitor the resident and his/her family member's behaviors towards each other; -Praise the resident when behavior is appropriate; -The resident liked coloring in adult coloring books, listening to music on his/her phone with headphones, walking to the country store, playing Bingo weekly, and going on outings. Review of the resident's Behavior Note, dated 5/18/24 at 2:19 P.M., showed the following: -The resident asked staff to take a photo of him/her to send to a friend online; -The staff explained, they were unable to take the photo; -The resident said it was the person he/she was dating and the person wanted naked photos; -The resident denied sending any photos. Review of the resident's Social Services Note, dated 5/20/24 at 4:02 P.M., showed the following: -The resident carved on the back of his/her room door because he/she was mad; -The social services director called the guardian regarding the resident's behaviors of carving in the door and asking staff to take pictures for a person online; -The guardian said maybe he/she should take the resident's the phone and tablet. Review of the resident's Care Plan showed no updates following the residents behaviors on 5/18/24 and 5/20/24. Review of the resident's Nurse Note, dated 7/11/24 at 3:35 P.M., showed the following: -The resident was upset with social services regarding a trip to visit a family member in the hospital; -The resident cursed at staff and was upset with a family member. Review of the resident's Social Service note, dated 7/11/24 at 4:00 P.M., showed the following: -The resident went into the social services director's office screaming and demanding the staff member to call his/her guardian about going with a sibling to see a parent at the hospital; -The social services director explained the guardian approved for the resident to leave with another family member; -The resident yelled, the family member needed to stay out of his/her business and the resident was done with the guardian. Review of the resident's Care Plan showed no updates following the resident's behaviors on 7/11/24. Review of the resident's Social Services Note, dated 7/31/24 at 1:47 P.M., showed the following: -The resident went to the Social Service Director's office and said a resident of the opposite sex asked him/her to go to bed with him/her; -He/She was all over the other resident the day before; -The staff instructed the resident to stay away from the other resident. Review of the resident's Social Services Note, dated 8/5/24 at 1:47 P.M., showed the following: -The resident kept approaching a staff member from the kitchen and wanted the staff member to come help the resident in his/her room; -The resident wore only a bra and underwear, asking the staff member why he/she recently started working at the facility; -The administration told the kitchen staff to give the resident's snacks to the nurse to give to the resident. Review of the resident's Care Plan, dated 8/5/24, showed the following: -The resident has potential to be physically and verbally aggressive (hitting walls, slamming doors, using profanity), related to anger/temper; -Analyze times of day, places, circumstances, triggers, and what de-escalated behavior and document; -Give the resident as many choices as possible about care and activities; -The resident liked everything to be his/her way and becomes angry when asked to do something, i.e., to come out of his/her room during the day, triggers for physical aggression; -Monitor/document/report as needed any signs/symptoms of resident posing danger to self and others; -Psychiatric consult as indicated; -Redirect resident to his/her room to calm down so it does not interrupt other residents; -The resident had a behavior problem talking inappropriately about sex; -Explain to the resident that it is inappropriate for him/her to be in a state of undress in the building other than in his/her room or shower and that anytime anyone enters his/her room, the resident should be completely dressed; -The resident sometimes speaks of sex and wanting the young staff from kitchen to come into his/her room. He/She was in a state of undress; -The resident wanted to run around the building with inappropriate clothing that was not covering him/her. The staff redirected the resident to his/her room to dress appropriately. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 8/23/24, showed the following: -The resident was cognitively intact; -No behaviors present; -He/She was independent with ambulation; -Diagnoses of epilepsy (chronic brain disorder that causes repeated seizures, which are abnormal electrical discharges in the brain) and unspecified lack of expected normal physiological development in childhood. Review of the resident's Nurse Note, dated 9/11/24 at 1:16 P.M., showed the resident wore a night gown all day with a tear on the underarm allowing the side of his/her chest to be exposed. The resident was defiant even when the Administrator and Director of Nursing (DON) attempted to instruct the resident on rationale to change. The resident did not change out of the gown. Review of the resident's Nurse Note, dated 9/12/24 at 11:46 A.M., showed the following: -The resident pushed a resident in a wheelchair forcefully and allowed the other resident to go freely in the wheelchair; -The staff attempted to redirect the resident about the dangers in this, but the resident remarked back he/she did this all the time and became defiant; -The staff instructed the resident to get dressed as he/she was in night clothes, the resident said this was his/her home and he/she could dress as he/she pleased; -The staff attempted to explain as that was true, they were in a group setting and the resident needed to respect others as well. Review of the resident's social services note, dated 9/13/24 at 2:30 P.M., showed the following: -The Social Services Director spoke with the resident's guardian, regarding the resident's behavior that week and asked about who was coming to see the resident for an independent living facility (ISL); -The guardian said they were waiting on a court date for the resident's family member to take guardianship. Review of the resident's nurse note, dated 9/22/24 at 12:46 A.M., showed the following: -The resident came up to the nurses' station asking for Tylenol; -The nurse asked the resident why he/she was not in bed and the resident said he/she and another resident were watching a movie; -The nurse told the resident that it was midnight and the resident proceeded to argue with the nurse and said, it was not midnight but a little after 11:00 P.M.; -The nurse showed the resident the time on his/her personal cell phone and the resident said he/she only followed the time on his/her own phone; -The nurse told the resident he/she needed to go to bed because it was late and the television was supposed to be turned off at 10:00 P.M., per the DON; -The resident said the DON was not his/her parent; -The nurse said he/she would talk with the Administrator about the resident being told to go to bed every night; -The resident continued to argue with the nurse then stormed off to another resident's room. Review of the resident's Care Plan showed no additional interventions were added regarding the resident's behaviors on 9//11/24, 9/12/24 and 9/22/24. Review of the resident's medical record showed no documentation the physician was notified of the resident's behaviors on 9/11/24, 9/12/24 and 9/22/24. Review of the resident's Social Services Note, dated 11/13/24 at 9:16 A.M., showed the following: -The resident was out of control cursing and yelling; -He/She was scheduled to go to a physician's appointment, but the resident's family member was unable to take the resident and the facility transporter was off; -The resident was so angry and couldn't control himself/herself and went off at everybody; -The resident thought someone should be called in on their day off to take him/her, when the staff told the resident no, the resident became angrier; -The resident went all over the facility cursing and did not stop; -Older residents were doing activities in the north dining room when the resident started cussing, the staff asked the resident to stay in his/her room until the resident cooled off; -These behaviors happened most every day, the resident always said he/she would tell his/her family; -The Social Services Director called the resident's guardian, but the guardian had to do something else and had to go. Review of the resident's nurse note, dated 11/13/24 at 9:45 A.M., showed the nurse heard the resident cussing from the hallway, so the nurse told the resident that the language was not appropriate at the facility, however, the resident did not acknowledge the nurse was talking and continued down the hallway. Review of the resident's Nurse Note, dated 11/13/24 at 10:07 A.M., showed the following: -The resident said his/her family member could not take the resident to an appointment and asked the staff to call the Restorative Aide (RA) as the resident tried to get hold of the RA to see if he/she could take the resident to the appointment; -The staff explained social services would be in the facility and could help the resident; -The resident waited at every room the staff member entered and upon coming out of the rooms, asked for phone numbers of other staff and he/she wanted to go to the appointment; -The staff attempted to rationalize with the resident that they were doing all they could do on short notice; -The resident woke up another resident after the staff asked him/her not to do this. Staff attempted to reinforce this resident could not help Resident #7. Review of the resident's Nurse Note, dated 11/13/24 at 11:15 A.M., showed the following: -The nurse asked the resident to go to his/her room several times; -The resident said he/she was waiting for Tylenol; the nurse explained the resident could not have Tylenol at that time because the resident received it with morning medications and it was too soon; -The nurse asked the resident again to go to his/her room as the resident was being disruptive and had been asked by multiple staff; -The resident refused to go to his/her room on his/her own; -The nurse attempted to assist the resident into a standing position by hooking the nurse's right arm under the resident's left arm and was unable to get the resident to move, so the nurse asked for assistance from Certified Medication Tech (CMT) G; -The nurse and CMT G were able to assist the resident into a standing position using the same technique, one staff member one each side of the resident with their arms looped with the resident; -The resident continued to be resistive as the staff attempted to walk the resident to his/her room. At that time the nurse went behind the resident and held onto his/her hips while the CMT G walked backwards in front of the resident holding his/her hands, while the staff continued to ask the resident to go to his/her room on his/her own so they didn't have to continue to disrupt the other residents this way and it was disrespectful to the other residents; -The staff and resident got in front of the nurses' station, then the resident refused to move his/her feet any further and began pushing her body against the nurse. CMT G hugged the resident around the waist to keep the resident in a standing position and asked another staff member to get a wheelchair; -The resident said the staff didn't know the other half of why he/she was upset and the nurse said the resident could tell them when he/she was in his/her room; -The nurse instructed the resident to sit in the wheelchair so they could continue down to his/her room, but the resident resisted, the staff applied pressure to resident's shoulders and upper thighs and lowered him/her into the chair; -The staff took the resident down to his/her room with resistance, as the resident kept grabbing the wheels and causing the chair to stop; -Once in the resident's room, the nurse asked him/her what was the other half of why he/she was upset, the resident refused to say; -The staff locked the brakes on the wheelchair and left the room; -The nurse returned five minutes later and took the wheelchair out of the room. The resident was in bed. Review of the resident's Activity Note, dated 11/14/24 at 9:23 A.M., showed the following: -On 11/13/24 the resident asked administration why the housekeepers could not transport him/her to the appointment; -The staff told the resident, the housekeepers had never transported anyone before and they were not able to do so; -The resident became irate with everyone in the building, cussing out the administrator and DON; -The Activity Director was in the morning activity and could hear the resident screaming at the Administrator and DON through the double doors over the music playing; -The resident went through the double doors and turned around to scream at the DON; -The Activity Director asked the resident to not cuss in front of the other residents because it was visibly upsetting them and making them agitated and a little frightened of the resident due to the outburst. The resident said he/she didn't care; -The resident was beyond the point of reason; -The staff redirected the resident several times but the resident did not care; -The outburst lasted from 9:00 A.M. until 12 P.M. Review of the resident's care plan showed no updates or interventions added regarding the resident's behaviors on 11/13/24. During an interview on 11/14/24 at 12:00 P.M., Licensed Practical Nurse (LPN) E said the following: -The staff canceled the resident's appointment because his/her transportation was not available; -The resident was upset because he/she was looking forward to the trip; -The resident wanted other staff members contacted to provide transportation because the facility's transportation driver had a day off; -None of the other staff were available to transport the resident to the appointment; -The resident started cussing, yelling, stomping in the hallways, and slammed doors; -Another resident tried to go to the restroom but Resident #7 followed him/her into the restroom, so staff told the resident to stay out and give the other resident some privacy; -The nurse told the resident he/she was being rude and disrespectful to the other residents and asked the resident to go to his/her room until they could help the resident through the frustration, however, the resident said, no; -The Social Services Director asked the resident to go back to his/her room so they could talk and the resident said no; -LPN E placed one hand on the resident's upper arm and another at the waist and guided the resident towards his/her room; -The resident suddenly stopped and refused to go any further; -He/She went to get a CMT for assistance; -The resident sat in a high back chair in back dining room and refused to move; -Both staff members wrapped an arm around both of the resident's arms and assisted him/her to stand up from the chair; -Both staff members guided the resident across the dining room and at the nurses' station the resident stopped; -CMT G took both of the resident's hands and LPN E put both hands on the resident's waist to guide the resident towards his/her room, but the resident wouldn't move and instead attempted to fall backwards; -LPN E told the resident to stop and another employee obtained a wheelchair; -LPN E placed the wheelchair behind the resident and told him/her to sit down, but the resident refused; -LPN E placed his/her hand on the resident's shoulder and pushed down, so the resident sat down; -LPN E and the CMT G took the resident down to his/her room via wheelchair; -The staff left the resident in his/her room with another resident present; -Around 2:30 P.M., the resident was up walking in the dining room, calm and quiet; -The staff did not attempt any other interventions because the resident was not redirectable; -The resident was dependent on on another resident for emotional support and guidance; -The other resident had a stroke in July 2024, which affected his/her speech and mobility; -The other resident was moved from next door to Resident #7 to the front hall, so the other resident would have more privacy and could focus on rehab; -Resident #7 was able to walk to the front hall to see the other resident but it was an adjustment; -When the resident was not redirectable, then the staff were supposed to tell the resident to go to his/her room. During an interview on 11/14/24 at 12:50 P.M., the resident said the following: -The resident was mad because an appointment was canceled again; -He/She was waiting at the nurses' station for Tylenol (pain medication), but the staff told him/her to go back to his/her room; -The resident told the staff he/she did not want to and was waiting on Tylenol but LPN E made him/her go anyway by force, leading him/her down the hall and pushing him/her in a wheelchair to the room; -LPN E told the resident to stay in his/her room until the resident could calm down; -The resident was not scared of staff, he/she was mad because he/she had to go back to his/her room; -He/She felt the staff treated him/her like a child but he/she was an adult. During an interview on 11/14/24 at 1:32 P.M., the Social Services Director said the following: -He/She scheduled the appointment and the resident's family member said he/she would take the resident to the appointment; -The transportation driver was off because no residents were scheduled for transportation; -The resident's family member called the morning of the appointment to report he/she was not available to transport the resident; -When the resident did not get his/her way, the resident exploded and became loud, cussing and other behaviors; -On 11/13/24, the resident went into the Administrator's office and started cussing and yelling at the Administrator; -The Administrator told the resident his/her behavior was inappropriate and go to his/her room; -The resident refused so the staff had to work with him/her to get the resident in his/her room. During an interview on 11/14/24 at 3:45 P.M., the Director of Nursing said the following: -The resident was cussing and yelling around other residents who were participating in activities; -The staff asked the resident to go to his/her room and calm down multiple times; -The staff got the resident up and the resident stood still; -The staff got a wheelchair for him/her to sit down; -LPN E and CMT G acted the way he/she expected; -The staff did not attempt any other interventions because the resident was not redirectable. During an interview on 11/14/24 at 4:15 P.M., and 11/27/24 at 11:00 A.M. the Administrator said the following: -The resident did have behaviors; -He/She previously had behaviors of yelling and cussing at the Administrator; -When the resident was in these moods, the resident did not redirect easily; -The behaviors were almost like a tantrum; -In the past, the resident became so mad that he/she punched the wall and door in his/her room; -The staff have told the resident the behavior was inappropriate and not tolerated; -The administrator expected staff to attempt other interventions listed on the resident's care plan before physically taking the resident to his/her room. During an interview on 11/15/24 at 2:18 P.M., the resident's Nurse Practitioner said the following: -He/She witnessed the resident's behavior on 11/13/24; -Several staff members spoke with the resident about going to his/her room because he/she was upsetting the other residents but the resident refused; -Two staff attempted to get the resident to walk but he/she refused; -The two staff members got the resident to sit in the wheelchair and started toward his/her room; -The resident put his/her feet down on the floor to prevent the staff from going any further so the staff put footrests on the wheelchair to prevent the resident from putting his/her feet down; -The staff started again but the resident grabbed hold of the wheels to prevent it from going any further; -The staff took the resident's hands off the wheels and continued to his/her room; -Staff never asked the Nurse Practitioner to evaluate or assess the resident for behaviors; -He/She never saw the resident have this type of behavior previously. During an interview on 11/15/24 at 2:51 P.M., the resident's physician said the following: -The DON and other nurses kept him/her informed about the resident's behaviors; -When the resident did not sleep well his/her behaviors became worse; -He/She did not make any changes in the resident's medication orders or recommend therapy yet, but would when he/she thinks it was necessary and would benefit the resident. MO245107

Based on record reviews, document review, and interviews, the facility failed to timely complete the admission Minimum Data Set (MDS) for 3 (Residents #21, #34, and #36) of 5 sampled residents reviewed for resident assessments. Findings included: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, specified, The Admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day if: - this is the resident's first time in this facility, OR, - the resident has been admitted to this facility and was discharged return not anticipated, OR - the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge. A review of Resident #21's medical record indicated the facility readmitted the resident on 03/30/2023. A review of Resident #21's admission MDS with an Assessment Reference Date (ARD) of 04/06/2023 revealed the assessment was signed as completed on 05/19/2023. A review of Resident #34's Admission Record indicated the facility readmitted the resident on 04/21/2023. A review of Resident #34's admission MDS with an ARD of 04/28/2023 revealed the assessment was signed as completed on 07/11/2023. 42883 A review of Resident #36's Admission Record revealed the facility admitted Resident #36 on 03/28/2023. A review of Resident #36's admission MDS with an ARD of 04/10/2023 revealed the assessment was signed as completed on 06/06/2023. In an interview on 08/29/2023 at 1:39 PM, the MDS/Care Plan (CP) Coordinator stated she knew she was behind on completing MDS assessments. The MDS/CP Coordinator stated she did not like being behind, but knew it was totally 100% her fault the MDS assessments were not being completed. She stated she was unsure of why the MDS assessment was not completed, but stated it should have been. During an interview on 08/30/2023 at 1:42 PM, the Director of Nursing (DON) stated she expected MDS assessments to be timely, and acknowledged the facility had a problem with that. According to the DON, the MDS assessments were not completed timely, and she was unsure why. In an interview on 08/30/2023 at 2:11 PM, the Administrator stated MDS assessments should be completed on time.

Based on record reviews, document review, and interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments for 3 (Residents #21, #34, and #36) of 5 sampled residents reviewed for resident assessments. Findings included: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, specified, The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. A review of Resident #21's medical record indicated the facility readmitted the resident on 03/30/2023. A review of Resident #21's medical record revealed the last completed Minimum Data Set (MDS) was an admission MDS with an Assessment Reference Date (ARD) of 04/06/2023. A review of Resident #34's Admission Record indicated the facility readmitted the resident on 04/21/2023. A review of Resident #34's medical record revealed the last completed MDS was an admission MDS with an ARD of 04/28/2023. 42883 A review of Resident #36's Admission Record revealed the facility admitted Resident #36 on 03/28/2023. A review of Resident #36's medical record revealed the last completed MDS was an admission MDS with an ARD of 04/10/2023. In an interview on 08/29/2023 at 1:39 PM, the MDS/Care Plan (CP) Coordinator stated she knew she was behind on completing MDS assessments. The MDS/CP Coordinator stated she did not like being behind, but knew it was totally 100% her fault the MDS assessments were not being completed. She stated she was unsure of why the MDS assessment was not completed, but stated it should have been. During an interview on 08/30/2023 at 1:42 PM, the Director of Nursing (DON) stated she expected MDS assessments to be timely, and acknowledged the facility had a problem with that. According to the DON, the MDS assessments were not completed timely, and she was unsure why. In an interview on 08/30/2023 at 2:11 PM, the Administrator stated MDS assessments should be completed on time.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure staff developed a care plan to address the needs of 3 (Residents #21, #36, and #140) of 12 sampled residents. Findings included: A review of the facility's policy titled, Resident Plan of Care Policy & Procedures, revised 05/18/2023, revealed, It is the Policy of [facility name] 1) To initiate Residents plan of care on admission by Charge Nurse, and placed in careplan binder located at each nursing desk for Charge Nurse and C.N.A. [certified nursing assistant] access to insure resident getting needs met. 1. A review of Resident #36's Admission Record revealed the facility admitted Resident #36 on 03/28/2023, with diagnoses including dementia with psychotic disturbance and anxiety disorder. A review of Resident #36's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/2023, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #36 received antipsychotic medication for seven days during the assessment period. A review of Resident #36's comprehensive care plan revealed the resident did not have a care plan to address the use of an antipsychotic medication. In an interview on 08/29/2023 at 1:56 PM, MDS/Care Plan (CP) Coordinator stated she was not sure how she missed care planning Resident #36 for antipsychotic medication use, since it was identified on the April 2023 MDS assessment. She stated she just missed it. The MDS/CP Coordinator stated it was important to care plan antipsychotic use to ensure staff knew to monitor for signs and symptoms related to the medication. During an interview on 08/30/2023 at 1:42 PM, the Director of Nursing stated she would expect the resident's care plan to be reflective of the care received. In an interview on 08/30/2023 at 2:11 PM, the Administrator stated she was not aware the resident was not care planned for their antipsychotic use. Per the Administrator, she would expect the resident's use of an antipsychotic medication to be care planned. 2. A review of Resident #140's Admission Record, revealed the facility readmitted the resident on 08/16/2023, with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure, emphysema, essential hypertension, and shortness of breath. A review of Resident #140's Progress Notes, dated 08/16/2023 at 2:35 PM, revealed Resident #140 would readmit to the facility on palliative care. A review of Resident #140's comprehensive care plan revealed the resident did not have a care plan to address the resident received palliative care. In an interview on 08/29/2023 at 1:56 PM, the Minimum Data Set (MDS)/Care Plan (CP) Coordinator stated she missed care planning Resident #140 for palliative care. The MDS/CP Coordinator stated the resident's palliative care should have been care planned but she missed it. She stated it was important to ensure it was on the care plan, so staff knew how to care for Resident #140 properly and honored the resident's wishes for palliative care. During an interview on 08/30/2023 at 1:52 PM, the Director of Nursing stated she would have expected the resident's need for palliative care should have been care planned. In an interview on 08/30/2023 at 2:11 PM, the Administrator stated she would expect the resident's needs for palliative care to be care planned. 28196 3. A review of an Admission Record indicated the facility admitted Resident #21 on 01/31/2022 with diagnoses that included stage 4 pressure ulcer of sacral region, displaced intertrochanteric fracture of left femur, and reduced mobility. A review of Resident #21's 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/06/2023, revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had an indwelling catheter and was always incontinent of bowel. A review of Resident #21's comprehensive care plan revealed the resident did not have a care plan to address the use of their indwelling urinary catheter. During an observation on 08/28/2023 at 10:23 AM, Resident #21 was observed to have an indwelling urinary catheter. In an interview on 08/29/2023 at 1:39 PM, the MDS/Care Plan (CP) Coordinator stated she did not know why Resident #21's indwelling catheter was not care planned other than she just missed it. During an interview on 08/30/2023 at 1:42 PM, the Director of Nursing (DON) stated the MDS/CP Coordinator was responsible for ensuring all things related to a resident's care was included on the care plan immediately. The DON indicated she was not aware Resident #21's catheter was not care planned but it should have been. Per the DON, Resident #21 has had the urinary catheter since they were admitted . According to the DON, not care planning Resident #21's catheter could lead to the resident getting a urinary tract infection if the staff were unaware of how to care for the catheter. In an interview on 08/30/2023 at 2:12 PM, the Administrator stated her expectation was for care plans to be updated for the care areas and treatments specific for that resident. The Administrator indicated she was unaware Resident #21's catheter was not care planned but it should have been. Per the Administrator, the negative outcome of the resident's catheter not being care planned was that the resident could develop sepsis (a life-threatening medical emergency caused by the body's overwhelming response to an infection) if not cared for properly.

Based on interview and record review, the facility failed to notify the physician for one resident(Resident #1), in a review of four sampled resident, when staff noticed a change in the resident's condition. Resident #1 was on palliative care (comfort care) when staff identified blisters/ulcerations near the resident's genital area on 10/13/22. There was no documentation staff notified the resident's physician until 10/24/22. The facility census was 46. Review of the facility's policy for notification of physician and/or nurse practitioner (NP), revised on 2/15/21, showed the following: -It was the facility's objective to inform the physician and/or the NP of changes in resident condition which is out of the normal range for that specific resident; -If unable to reach the attending physician in regards to medical necessity of a resident, the nurse must contact the medical director for further direction; -The director of nursing (DON) must be notified if there were any changes in a resident's condition that was out of the normal for that particular resident. -The charge nurse would notify the physician/NP for the need to obtain orders or change orders to provide optimal care of a resident. 1. Review of Resident #1's care plan, dated 10/7/22, showed the following: -He/She had actual impairment to his/her skin integrity related to fragile skin; -He/She was on palliative care; -Staff were to monitor/document location, size, and treatment of any skin injury; -Staff were to report any abnormalities, failure to heal, and signs/symptoms of infection to the resident's physician. Review of the resident's progress note, dated 10/13/22 at 12:51 A.M., showed Licensed Practical Nurse (LPN) A documented the resident appeared to have three blisters above his/her genitalia area. The blisters appeared to have been popped with yellowish colored drainage. The resident said the blisters itched occasionally. (Review showed no documentation staff notified the resident's physician or the NP of the blisters.) Review of resident's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 10/14/22, showed the following: -His/Her cognition was severely impaired; -He/She was dependent of one to two staff for all activities of daily living (ADLs); -He/She was always incontinent of bowel and bladder. -There was no documentation to show the resident had skin problems. Review of the resident's skilled charting documentation, dated 10/14/22 at 10:46 A.M., showed the resident had three blisters above his/her genital area. (Review showed no documentation staff notified the resident's physician or the NP of the blisters.) Review of resident's EMR (electronic medical record), showed there was no further documentation of the blisters on the resident's genitalia and/or that staff notified the physician and/or the NP for treatment until 10/24/22 at 11:20 A.M. Review of resident's progress notes, dated 10/24/22 at 11:20 A.M., showed perineal blisters were noted. Staff notified the resident's physician, and received an order for Zovirax cream (antiviral medication used to treat cold sores/fever blisters) to be applied six times a day to perineal blisters for five days. Review of resident's physician's orders, dated 10/24/22, showed the following: -Calmoseptine to bilateral buttocks every shift for protection (start date was 10/24/22); -Zovirax cream 5% cream; apply to peri blisters topically four times a day for herpes (virus) for five days; to make six times daily, add mid afternoon and after midnight (start date was 10/24/22). During an interview on 1/31/23 at 2:40 P.M., Licensed Practical Nurse (LPN) B said staff should report blisters to the physician when found for treatment orders. He/She reviewed the resident's record and did not see where staff notified the resident's physician of the blisters (prior to 10/24/22). During an interview on 1/31/23 at 8:10 P.M., LPN A said he/she was not 100% sure what the policy was for notifying physicians of change in condition, but during training, he/she was instructed to contact physicians with changes in resident status whether be from a fall, pain, and etc. He/She remembered the resident had open areas on his/her bottom and was using Calmoseptine (moisture barrier ointment). He/She understood Calmoseptine cream was a nursing intervention and did not notify the physician when he/she identified the blisters and used the Calmoseptine cream. He/She did not think the Calmoseptine cream was working so an order was obtained for Acyclovir (Zovirax) cream. The resident's physician was not notified of the blistered areas until 10/24/22. The resident dug (scratched) at the area. Looking back on the situation, he/she should have notified the physician and obtained orders for treatment when the blisters were first noted. During an interview on 1/31/23 at 2:54 P.M., the Director of Nurses (DON) said she reviewed the resident's medical record and noted the blisters were found on 10/13/22, but no treatment was initiated until 10/24/22. There was no documentation to show staff notified the resident's physician of the blisters (prior to 10/24/22). She thought blisters on the genital area would have been uncomfortable and she would have expected staff to notify the physician and obtain orders for treatment upon finding the blisters. During an interview on 1/31/23 at 4:00 P.M., the Administrator said she expected staff to notify the resident's physician with any changes in condition and obtain orders if warranted. MO208969

Based on interview and record review, the facility failed to ensure one additional resident (Resident #31) was free from significant medication errors when staff administered Resident #32's medications to Resident #31. Resident #31 became lethargic and unresponsive and was sent to the emergency room by ambulance for treatment and subsequently hospitalized . The facility census was 41. 1. Review of the facility's Administration of Drug Policy Statement showed medications ordered for one resident may not be administered to another resident. 2. Review of the Certified Medication Technician (CMT), student manual, 2008 Revision, showed the following: -Medication cards are used in some facilities to identify medications when it is necessary to remove them from their original container prior to administration; -If a medication leaves the original packaging and is not administered at once, it must have a medication card with it at all times; -Items found on the card include full name of resident, room number of resident, name of the medication, dosage and strength of the medication, times of administration, dated the medication was ordered, and physician's name. -To avoid medication errors, remember the five Rights of Medication Administration; the right resident, the right drug, the right dose, the right route, and the right time. 3. Review of Resident #32's physician order [REDACTED]. -[MEDICATION NAME] (an antipsychotic medication used to treat [MEDICAL CONDITION]) 100 milligram (mg) tablet, three tablets, two times daily; -[MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] reflux disease) 20 mg capsule before breakfast; -Carvedilol (medication used to treat high blood pressure) 6.25 mg tablet twice daily; -[MEDICATION NAME] 5 (stool softener) mg tablet twice daily; -[MEDICATION NAME] (medication used to prevent or treat low potassium levels) 10 micro equivalents tablet one time daily; -[MEDICATION NAME] (medication used to treat high blood pressure and [MEDICAL CONDITION]) 40 mg tablet once daily; -Multivitamin one tablet daily; -[MEDICATION NAME] (an antiulcer medication) 1 gram before meals and at bedtime. Review of the Nursing Drug Handbook 2011, 31st edition Wolters Kluwer/Lippincott Williams and Wilkins showed the following for [MEDICATION NAME]: -Used for [MEDICAL CONDITION] and severely ill patients non-responsive to other therapies; -Dosage for an adult included: initially 12.5 milligrams (mg) to 25 mg once or twice daily; -Adjust dose upward 25 mg to 50 mg daily 300 to 450 mg daily by the end of two weeks; -Adverse reactions included drowsiness, sedation, dizziness, [MEDICAL CONDITION], [MEDICAL CONDITIONS], hypertension, [MEDICAL CONDITION] and respiratory arrest; -Overdose signs and symptoms included altered state of consciousness, drowsiness, [MEDICAL CONDITION], coma, [MEDICAL CONDITION] respiratory depression or failure, hypersalivation, aspiration pneumonia, cardiac arrhythmias and [MEDICAL CONDITION]; -Actions included: onset unknown, peak 2.5 hours, duration four to 12 hours. 3. Review of Resident #31's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 6/25/15, showed the following: -[DIAGNOSES REDACTED]. -No cognitive impairment; -No [MEDICAL CONDITION]; -Was understood and understands others; -No mood disorder; -No behavior impairment; -He/she did not reject care; -No swallowing disorder. Review of the resident's Physicians Order Sheet (POS), dated 9/1/15 to 9/30/15, showed the following: -The resident's [DIAGNOSES REDACTED]. -[MEDICATION NAME] (antipsychotic) 5 mg tablet daily; -[MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] disorders and [MEDICAL CONDITION] disorder) 250 mg one tablet every morning; -[MEDICATION NAME] 500 mg tablet at bedtime; -Levetiracetem (medication used to treat [MEDICAL CONDITION] disorders) 500 mg tablet two times daily. -Regular diet. Review of the resident's nurses notes, dated 9/7/15, showed the following: -At 9:49 A.M., communication with the physician; -At 10:00 A.M., communication with family/next of kin/power of attorney; -At 10:02 A.M., orders received to monitor vital signs every eight hours. Monitor blood pressure and notify if the blood pressure decrease below 100/60. Monitor for respiratory depression or decreased level of consciousness. Hold morning medications; -At 10:08 A.M., transfer to hospital summary: The resident received anther resident's medication. Resident became lethargic with decrease level of consciousness. Notified the physician, received new orders. Notified the physician of change in level of consciousness. New orders received to send the resident to the hospital for evaluation. Staff assisted the resident to bed and oxygen applied as ordered. Notified the Director of Nursing (DON) and Administrator of incident and new orders. Ambulance personnel arrived, transferred the resident to the gurney and oxygen reapplied. Facility staff provided EMTs with resident's face sheet, medication record, guardianship papers, and list of the medication that the resident received. The ambulance transported the resident to the hospital. Review of the facility's investigation for the resident, reported by the Director of Nurses (DON), dated 9/7/15, showed the following: -Resident #31 received Resident #32's medication; -Staff gave the medications at the dining room table due to Resident #31 demanding his/her medications; -The medication error occurred due to Certified Medication Technician (CMT) K stopped in the middle of a medication pass with resident #32 and set up Resident #31 medications; -CMT K picked up the wrong medication cup belonging to Resident #32 and gave them to Resident #31; -CMT K noticed immediately that the wrong medications were given to Resident #31 and notified his/her charge nurse immediately; -The resident continued to eat his/her breakfast; shortly after the the resident became sluggish; -Certified Nurses Assistance (CNA) B and CNA N completed a finger sweep to clear the food out of the resident's mouth and his/her loose fitting teeth that were coming out; -CNA B said the resident was not showing signs of choking and the resident just become sluggish and food was starting to come out of his/her mouth; -Resident #31 continued to decline; -Staff escorted Resident #31 to his/her room and placed him/her in his/her bed for ease of transfer for Emergency Medical Service (EMS) personnel; -Vital signs at that time showed a drop in oxygen saturation and staff applied oxygen to the resident; -EMS personnel arrived on the scene and assumed care; -CNA B said the resident was gurgling as the EMT personnel were rolling the resident out of the building; -Resident #31 was transferred to the hospital by the ambulance; -Licensed Practical Nurse (LPN) L called report to the hospital for update. He/she was told the resident vomited in the ambulance; -It was apparent that the resident choked on food; -CNA B, CNA N and LPN L clarified the resident did not have a gag reflex at that time; -Staff reported to the hospital personnel resident did not have a gag reflex; -The facility's plan of correction for medication error was relayed to CMT K that he/she will not stop in the middle of a medication pass for another resident until the person he/she is working with is completed. During a telephone interview on 10/7/15 at 10:33 A.M., CMT K said on 9/7/15, the medication cart was located in the dining room. During breakfast time approximately 8:00 A.M., unable to recall the specific time, he/she set up Resident #32's medications and proceeded to walk to Resident #32's room. At the same time, Resident #31 began to yell out he/she wanted his/her medications. He/she said he/she sat the container with Resident #32's medications on top of the medication cart. He/she set up Resident #31's medications and sat the container on top of the medication cart as well. He/she said he/she grabbed the wrong medications from on top the medication cart. He/she said he/she administered the wrong medications to the wrong resident. He/She said Resident #31 received all of Resident #32's daily and twice daily medications. He/she said he/she realized the error immediately and notified the charge nurse. He/she said the resident changed from his/her normal self to unresponsive in approximately ten minutes. He/she said certified nurse assistants (CNA)s swept the resident's mouth for food. He/she said he/she did not know if the resident choked. No staff attempted to induce vomiting or a [MEDICATION NAME] maneuver (abdominal thrusts an emergency technique to help clear the airway). During a telephone interview on 10/7/15 at 4:52 P.M., LPN L said on 9/7/15, he/she did not know the exact length of time between the medication error and when CMT K reported the error to the charge nurse. LPN D said he/she was at the resident's side within two minutes after he/she received report of the medication error. The resident appeared to be sleeping in his/her chair at the dining room table. He/she said the resident did not have a gag reflex and no response when he/she swept the resident's mouth for foreign objects. LPN L said the resident did not vomit. He/she said the resident had no cyanosis (a bluish color to the skin or lips due to poor circulation or inadequate oxygenation of the blood); the resident's skin remained warm and pink. He/she said the resident did not have any respiratory distress (difficulty in breathing), other than the resident's oxygen saturations dropped to 89 percent, (normal values 95 to 100 percent, below 90 percent is abnormal). He/she said it did not appear the resident choked. He/she said no staff told him/her the resident choked. During an interview on 9/14/15 at 2:45 P.M., CNA B said between 8:00 A.M. and 8:30 A.M. during breakfast, CMT K looked upset. He/she said CMT K said a medication error occurred. CNA B said he/she looked in the dining room and CNA N took vital signs on Resident #31. He/she said the resident was lethargic. He/she said the resident's eyes were glassy. He/she said the resident had a food pocket on the left side of his/her mouth. He/she said he/she did a finger sweep to remove the food pocket. The resident was unable to focus. He/she said CMT K notified LPN L and CNA N. LPN L said to lay the resident down. Registered Nurse (RN) F told staff not to lay the resident down. Staff propelled the resident to the shower room/bathroom. Review of the LPN L's statement, dated 9/7/15, showed the following: -At 8:20 A.M., Resident #31 had received another resident's medication; -Vital signs included blood pressure 106/60 (normal 120/80), pulse 93 (normal 60-100), respiration rate 16 (normal 12-20), temperature 97.2 (normal 98.6), oxygen saturation (O2 sat) 95 percent (normal 95-100); -Staff notified the Family Nurse Practitioner (FNP) of the medication error and that the resident was lethargic; -Staff received new orders to monitor vital signs every eight hours, monitor for decreased level of consciousness and respiratory depression. Hold the resident's morning medications; -Staff took the resident down the hallway to the resident's room; -LPN L performed a finger sweep on the resident with no reflex noted; -LPN L instructed staff to assist the resident to bed; -Staff notified the FNP of increased lethargy, and received orders to transfer the resident to the hospital; -Vital signs taken-blood pressure 135/68, heart rate 98, respiration rate 14, O2 sat 88%, temperature 97; -Staff assisted the resident to bed; -Staff applied oxygen at two liters per minute per nasal cannula; -LPN L notified the charge nurse, the DON, and the Administrator. A message left for the resident's guardian; -The ambulance arrived; -The resident responsive to painful stimuli only making snoring sounds; -LPN L notified the DON, Administrator and FNP resident transferred to a hospital (located closer to the facility) due to short distance and the condition of the resident. Review of the ambulance district activity report, dated 9/7/15 showed the following: -Unit arrived on scene at 9:01 A.M.; -Chief complaint drug overdose, second complaint unresponsive/respiratory distress; -The report showed the ambulance was dispatched to the facility for Resident #31 who had received another resident's medication- [MEDICATION NAME] (name brand for Carvedilol), [MEDICATION NAME],, and [MEDICATION NAME]; -The resident lay in bed unresponsive with shallow grunting respirations; -The EMTs moved the resident to the ambulance cot, applied oxygen 15 liters per non rebreather mask, loaded the resident into their ambulance and transported immediately; -The EMTs initiated an intravenous (IV) line immediately; -A cardiac monitor showed sinus [MEDICAL CONDITION](an abnormal rapid heart rate); -The resident's respiratory status began to deteriorate; -The EMTs bagged (artificial ventilation performed with a respirator bag) the resident and administered [MEDICATION NAME] (used to reverse the effects of narcotics) 1 milligram (mg) per IV at 9:19 A.M. with no response; -Ten minutes later, another of the EMTs administered another dose of [MEDICATION NAME] 1 mg; -The resident did have some grunting at that point, he/she began to breathe on his/her own. His/her oxygen saturation went up to 99% on non-rebreather mask at 15 liters; -He/She then began to deteriorate; the EMTs began to bag the resident; -The EMTs suctioned the resident two times due to vomiting; -The resident's pupil's very sluggish, almost non-responsive, motor cortex stimulation very flaccid; -The resident arrived at the hospital at 9:43 A.M.; -The EMT report showed EMTs were not told by the facility nursing staff, until after the resident arrived at the hospital, that the nursing home staff relayed they did try to induce vomiting; -The EMT report did not show the resident choked. Review of the emergency room report, dated 9/7/15 showed the following: -History of the present illness showed the resident received the wrong medication at a nursing home. He/She received [MEDICATION NAME] and Potassium. At the time of the evaluation, he/she was pretty somnolent (drowsy, sleepy) and drowsy; -Reason for admission: Accidental overdose; -The physical exam showed blood pressure 126/76, heart rate 100. Resident awake but not alert, resident confused; lungs clear to auscultation bilaterally without wheeze, heart rate regular without murmurs; oropharynx clear; -The impression and plan included altered mental status change, accidental overdose of [MEDICATION NAME], chronic urinary infections and chronic malnutrition; -There is a question if the resident could still have a foreign body back in his/her oropharynx; -At 10:35 A.M., a single view chest x-ray showed a small bilateral pleural effusion (excessive fluid buildup around the lungs) with patchy bibasilar airspace patches, which may represent atelectasis (a complete or partial collapse of a lung or lobe of lung) versus airspace disease. Review of the resident's hospital progress notes showed the following: -A computed tomography (CT), dated 9/7/15 at 2:43 P.M., showed no plural effusion, there are bibasilar consolidative changes, a right [MEDICAL CONDITION] nodule and a hiatal hernia; -Hospital records, dated 9/8/15, showed impression of an aspiration pneumonia, accidental medication administration and chronic urinary tract infection; -Hospital records, dated 9/9/15, showed impression of an accidental medication overdose, the resident was doing better. The physician thought he/she may have aspirated a little bit. During an interview on 9/14/15 at 4:05 P.M., the DON said she expected CMTs to pass medications to one resident at a time before moving on to the next resident. During an interview on 9/14/15 at 4:35 P.M. the Administrator said she expected staff to follow the facility policy's for passing medications. Complaint #MO 6

Based on observation, interview and record review, the facility failed to provide care and ensure safety of one resident (Resident #1) who used an alternating air mattress and fell out of bed sustaining injuries, including a facial laceration requiring 12 sutures, in a review of six sampled residents. The facility census was 53. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/5/12, showed the following: -Rarely/never understands; -Severely impaired cognitive skills; -Total dependence of two staff members with bed mobility and transfers; -Impairment of both upper and lower extremities; -At risk for pressure areas; -Pressure reducing device for bed; -One fall since prior assessment with no injury; -Bed rails used less than daily. Review of nurses note, dated 6/27/12, late entry from 1/13/12, showed the nurse walked past the resident's room and observed the resident not in bed. Upon inspection it was discovered the resident was lying on the floor. The resident had been placed in bed per certified nurse assistant and social service designee. The air mattress inflated and deflated and caused the resident to roll out of bed onto the floor. No injuries were observed. Review of the care plan, updated 3/26/12, showed the following: -Requires extensive assist with all activities of daily living (ADLs) due to decline in condition and post cerebral vascular accident (CVA); -Risk for repeated falls due to Alzheimer's and generalized weakness; hoyer lift at all times, two transfer assist and air mattress to bed; maintain bed in low position; -On 1/3/12, fall, rolled out of bed, mat at bedside and check resident frequently. Review of the resident's medical record showed no further documentation addressing the mattress inflating and deflating or interventions to prevent future accidents related to the mattress. Review of 72-hour fall monitoring showed the following: -On 3/18/12 at 5:45 A.M., the resident was found on floor on his/her left side facing bed with all linens and pillow with him/her. The blankets were covering the lower body then wrapped around and below head, incontinent pad in place. When looking at bed, the mattress appears to have an incline to it, looking as though he/she had slid out of bed to floor. No apparent injuries. -On 3/18/12 at 10:00 A.M., the resident had 3 centimeter (cm) x 3 cm bruise to left side of head. Review of the care plan showed the following handwritten entries: -On 3/18/12, fall from bed, air mattress deflated and inflated, side rails up times two; -On 3/25/12, continue to check frequently. Side rails up times two at all times per family request. Review of 72-hour fall monitoring showed the following: -On 6/17/12 at 7:30 A.M., the Certified Nursing Assistant (CNA) dressed resident in bed turned around to pull wheelchair closer to bed, air mattress deflated and caused the resident to roll off side of bed and struck head on floor. Bruises/swelling to right forehead. Spoke with CNA concerning use of resident's bed rail. Bed rail needs to go back up immediately and remain up until resident ready to get out of bed. CNA had turned around to pull wheelchair closer to bed before leaving room to get help with hoyer lift. When air mattress deflated it caused the resident to roll over side of bed and onto floor. Resident lying on floor on right side, bleeding noted from forehead. Lacerations to forehead 4.5 cm, 2.5 cm, and 5.4 cm. Lacerations to both elbows. Raised area 4.5 cm x 3 cm to right medial calf. The resident moans at times when pressure applied to forehead. Raised area to right forehead 4.5 cm x 6.5 cm. Assisted to bed per three staff. Bleeding noted to right nare. Review of nurses note showed: -On 6/17/12 at 7:50 A.M., new orders to send the resident to emergency room for evaluation of head injury; -On 6/17/12 at 2:30 P.M., the resident returned to the facility and transferred to bed. Side rails up. Dressing intact to forehead. Sutures to be removed in 6 to 8 days. Dressing changed daily. Steri-strips intact to bridge of nose and both elbows. 12 sutures intact to forehead; -On 6/20/12 at 5:00 P.M., 12 steri strips remain intact to forehead. Ecchymotic (bruising) area continues to face; -On 6/23/12 at 4:00 P.M., sutures removed from forehead; -On 6/25/12 at 9:00 A.M., steri strips remain intact to forehead and small amount of bleeding observed. Ecchymotic areas resolving to face. Review of the care plan showed the following handwritten entries: -On 6/17/12, fall out of bed, leave rails up while dressing, and send to emergency room for evaluation; -6/17/12, fall out of bed. Ensure side rails up at all times. Interview on 6/27/12 at 11:30 A.M., the Director of Nursing said the resident was on an air mattress. If the mattress deflated, the bed could have got away from the wall causing the cord to become unplugged from the wall or the staff could have hit the cord with their foot causing the cord to come loose from the wall causing the mattress to deflate. If staff had to step away from the resident's bed while providing care he/she would expect staff to have the side rails up. The staff would know how to provide care to the resident by the care plan. No staff had come to him/her regarding concerns with the resident's mattress. The resident is totally dependent and needs to be secure in the middle of the bed at all times. He/she did not think it was possible that the mattress to deflated and inflated per the care plan dated 3/18/12. The side rails were put in place after the resident fell out of bed on 3/18/12. Interview on 6/27/12 at 1:47 P.M., Licensed Practical Nurse (LPN) C said the resident's air mattress is always circulating air in and out to remove the resident from pressure areas. Depending on where you are looking from the mattress can look deflated or inflated. Interview on 6/27/12 at 11:08 A.M., CNA E said that on 6/17/12 he/she was getting Resident #1 dressed and had his/her side rail down. He/she turned around from the resident to grab his/her wheelchair out of the corner of the room and the air mattress deflated and flipped the resident out of bed. He/she said the resident's side rails did not have to be up while staff were in the room. He/she said the resident fell out of bed because of the mattress. He/she had told the Director of Nursing that the mattress was not safe and the resident needed a low bed. The Director of Nursing had told him/her that the resident needed the mattress because the resident was prone to pressure areas. He/she said he/she would keep the side rail up at all times now to prevent this from happening again until a second staff member arrived in the resident's room. Interview on 7/3/12 at 7:00 A.M., CNA E said when he/she said the bed had deflated he/she said the plug had come out of the wall. The resident's mattress has a certain hardness and does not inflate or deflate. The bed can be moved up or down and can get caught on the cord and can get unplugged. He/she has not received special instructions on caring for a resident on an air mattress. Review of the owner's manual for the Direct Supply Panacea Air APL Mattress, provided by the DON, showed the following: -The operating modes of the mattress included alternating pressure and low air loss; -Alternating pressure operating mode provides 10 minute loading and unloading cycle designed to maintain low interface pressures throughout the mattress, to redistribute peak interface pressures during the cycle; -An audio-visual alarm is sounded in the event of low pressure; -A properly sealed mattress will continue to support a resident for approximately one hour without power. During a telephone interview on 7/3/12 at 9:30 A.M., the Director of Nursing said the following: -Resident #1 is on an alternating air mattress; -When staff documented in the resident's record the air mattress inflated and deflated, staff were referring to the motion of the alternating air mattress; -At the time of the resident's fall in March 2012, the resident's bed was positioned next to the wall and she believed staff positioned the resident too close to the edge of the bed which caused the mattress to shift and the resident fell from the bed; -After the resident's second fall in March 2012, she provided one-on-one education to the staff who provided care for the resident to ensure the resident was positioned correctly in the bed when staff were providing care. -CNA E did not receive training on how to properly position the resident in bed, when the DON provided one-on-one education after the resident's second fall from the bed; -CNA E should have put up the resident's side rail when he/she stepped away from the resident to get the wheelchair; -CNA E said the mattress was alternating when the resident fell from the bed on 6/17/12. The mattress did not deflate to the bed frame. Complaint #MO

Based on observation, interview and record review, facility staff failed to adequately assess and monitor pain by not comprehensively assessing pain for one sampled resident (Resident #1) who received pain medication; failed to assess pain and document the resident's pain intensity level before and after administering as needed pain medication for one sampled resident (Resident #1); failed to follow the facility policy and procedure for assessment and documentation of pain and pain medication administration for one sampled resident (Residents #1) of 12 sampled residents reviewed. The facility census was 51. 1. Review of the Pain Assessment and Management Policy and Procedure, dated 12/09/09, showed the following: -Every resident will have a formal pain assessment done upon admission and will be re-assessed on re-admission, and upon change in condition. Every resident will be assessed for pain every scheduled med pass and once thru out the night. Residents experiencing pain must be treated immediately using non-pharmacological and/or pharmacological methods to maximize function and promote quality of life; -With every schedule med pass the resident will be assessed for pain by the Certified Medication Technician (CMT) or nurse passing the medications. Pain will be rated and charted in the Medication Administration Record. The facility will use the FACES Pain Rating Scale, Nurmeric Rating Scale, or the Pain Assessment in Advanced Dementia (PAINAD) Pain Scale; -Appropriate actions will be taken immediately using non-pharmacological and/or pharmacological measures. Any trend noted will be reported by the CMT to the charge nurse, for follow-up with the physician and the MDS Coordinator. 2. Review of Resident #1's pain evaluation, undated, showed the following: -The following nonverbal/noncognitive signs which could indicate the presence of pain: grimacing/distorted face, frowning/scowling, tightly shut lips, wrinkled brow, turned down mouth, moaning, screaming, fitgeting and irritability; -The pain is relieved by frequent position changes and Tylenol and [MEDICATION NAME] N-100 as needed at times; -The resident has a [DIAGNOSES REDACTED]. May also present as an intact or open/ruptured blister) areas on his/her right and left buttocks which would give reason to believe the resident would be in pain; -Pain is increased by sitting; -The left buttock was coded as frequent, external and chronic pain; -The right buttock was coded as frequent, external and chronic pain. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Makes self undertood and usually understands others; -Scored 4 out of a possible 15 on his/her Brief Interview for Mental Status examination, indicating he/she was severely cognitively impaired in his/her abilities for daily decision making; -The resident had a arterial and venous ulcers present; -No pain management. Review of the resident's care plan showed the care plan did not address the resident's pain or include interventions/approaches for pain management. Review of Resident #1's Physician order [REDACTED]. -[DIAGNOSES REDACTED]. -[MEDICATION NAME] HCL 50 mg tab, take 1 tab by mouth every 6 hours as needed for pain; -Tylenol 325 mg tab, take 2 tabs by mouth every 4 hours as needed for pain or elevated temperature. Review of the Medication Administration Record [REDACTED] -Pain Evaluation per facility policy (8:00 A.M., 12:00 P.M., 4:00 P.M., 8:00 P.M., and 10:00 P.M.) showed the resident had pain on 11/8/11 at 8:00 A.M., rated at a three. 11/01/11 thru 11/07/11 the resident was shown as having no pain; -[MEDICATION NAME] HCL 50 mg tablet as needed for pain was given on 11/8/11 at 9:00 A.M. for complaint of pain, and follow up was done at unknown time with comment of "quieter;" -Tylenol 325 mg tablet (2 tablets) as needed for pain was given on 11/6/11 at 2:00 A.M., on 11/7/11 at 12:30 (A.M. or P.M. not indicated) for general pain, on 11/7/11 at 4:30 P.M. and no reason given, and on 11/8/11 at 1:45 P.M. for complaint of pain. No results were documented. Review of the 72 hour fall monitoring sheet, dated 10/23/11 at 6:20 A.M., showed the resident was on the floor close to the door. He/she had bruising and swelling of his/her right wrist and left hand and had 2 centimeter abrasion to his/her right shoulder. Observation on 11/8/11 at 5:40 A.M., showed the resident had Stage II areas on his/her right and left inner buttocks. Certified Nurse Assistant (CNA) E and CNA F cleansed the resident's buttocks where the Stage II ulcers were located with a wash cloth and the resident was hollering out loud. Observation on 11/8/11 at 9:35 A.M., showed Registered Nurse B (RN) provided treatment to the open areas on the resident's right shin and right lower inner leg. RN B said the area to the right lower inner leg had just developed. During the treatment to the open areas, the resident said "Ow, it hurts." While RN B wiped the open areas on the resident's bottom, the resident yelled out "Oh my god, my bottom hurts." The resident continued to holler as RN B wiped over the Stage II areas on the resident's buttocks. The resident had facial grimacing and yelled out when he/she was sitting back down in the recliner. The resident also complained of shoulder and right arm pain. The resident was positioned in bed and RN B asked the resident if his/her legs and bottom hurt. The resident said "sort of" and RN B asked the resident if he/she would like Tylenol, and the resident said "yes." RN B returned to the resident's room and said the Certified Medication Technician (CMT) had already given the resident [MEDICATION NAME] at 9:00 A.M.. RN B said he/she didn't know why the resident got this medication, he/she was not aware the resident had received pain medication. Observation on 11/8/11 at 1:50 P.M., showed CNA E and CNA F laid the resident down in bed and provided the resident with catheter care. The resident was yelling out while staff provided care. The resident's scrotum was bright red. Observation on 11/9/11 at 7:50 A.M., showed the Assistant Director of Nursing (ADON)provided peri/catheter care to the resident. The resident was flinching his/her face and his/her legs jerked during the care. The resident yelled out when the ADON washed his/her inner upper thigh and scrotum. The resident's scrotum was bright red. The ADON asked the resident if he/she hurt and the resident said "a little." The ADON said the resident was really gaulded and really red and he/she needed to get something to treat this area. The resident yelled out and grimaced when his/her left arm was moved. CNA E said the resident had complained of left arm pain since the past weekend. The ADON said the resident was always yelling out, he/she would even yell out during an accucheck. Observation on 11/9/11 at 9:45 A.M., showed CNA G touched the resident's right arm and the resident said "My arm is not moving right." He/she said he/she doesn't know why his/her arm hurts. CNA G and CNA E assisted the resident to his/her bed and as he/she was sitting down, he/she said "Oh, it hurts when I sit down." During interview on 11/9/11 at 10:15 A.M., CNA E said he/she would report to the charge nurse residents that were hollering out, moaning, and/or rubbing body parts. He/she would ask the nurse or med tech for pain medications or hot pack. CNA E was not aware of interventions for pain according to the care plan. During interview on 11/9/11 at 11:45 A.M., RN B said the following: -When staff try to identify whether a resident is experiencing pain or pain can be anticipated depends on the resident's [DIAGNOSES REDACTED]. -The resident is assessed for pain while doing treatment, you can ask if the resident is in pain or watch for grimacing. Watch for non-verbal signs such as moaning and groaning; -Pain management interventions are on the care plan, during rounds the CNAs are notified of the residents in pain and how to deal with paticular pain and let the charge nurse know if pain medications are needed; -If the resident complains of pain, he/she documents in the nurses notes, and if the CNA told the med tech, it would be documented in the MAR; -If the CMT gives medications, they need to reassess the resident's pain every 30 minutes to two hours and record the results on the MAR. During interview on 11/9/11 at 12:00 P.M., CNA G said he/she had reported to the charge nurse that the resident was rubbing his/her right arm in pain. During interview on 11/9/11 at 12:30 P.M., RN B had said he/she had not received any report about the resident having pain today. During interview on 11/9/11 at 12:10 P.M., the Director of Nursing said he/she relies on the charge nurse and med techs to provide correct assessment and reassessments for pain. CMT should be telling the charge nurse when a resident has received pain medication and the CMT should follow up on the resident's response to any pain medication given. During interview on 11/9/11 at 11:10 A.M., the MDS Coordinator said the resident always tells him/her he/she does not have pain. If you suspect a resident had pain, you would see the resident yelling out, saying "ow" or grimacing if they were in pain. The interventions for someone in pain would be assessing if he/she had pain medications and how often the pain medications were scheduled and find out why the resident is having pain. The CNAs need to let the charge nurse know when the resident is in pain. The Director of Nursing lets the MDS coordinator know if the resident's information on the MDS needs to be updated.

This deficiency is uncorrected. For previous examples, see Statement of Deficiencies dated 11/09/11. Based on observation, interview and record review, facility staff failed to follow the facility Pain Assessment and Management Policy and Procedures when staff failed to administer pain medication immediately (per facility policy) following the resident's verbal complaints of pain; failed to update the resident's care plan with pain management interventions for arthritis and leg pain; and failed to effectively monitor and assess for pain for one resident (Resident #30) in a review of eight sampled residents. The facility census was 51. 1. Review of the Pain Assessment and Management Policy and Procedure, dated 12/09/09, showed the following: -Every resident will have a formal pain assessment done upon admission and will be re-assessed on re-admission, and upon change in condition. Every resident will be assessed for pain every scheduled med pass and once thru out the night. Residents experiencing pain must be treated immediately using non-pharmacological and/or pharmacological methods to maximize function and promote quality of life; -With every schedule med pass the resident will be assessed for pain by the Certified Medication Technician (CMT) or nurse passing the medications. Pain will be rated and charted in the Medication Administration Record. The facility will use the FACES Pain Rating Scale, Numeric Rating Scale, or the Pain Assessment in Advanced Dementia (PAINAD) Pain Scale; -Appropriate actions will be taken immediately using non-pharmacological and/or pharmacological measures. Any trend noted will be reported by the CMT to the charge nurse, for follow-up with the physician and the MDS Coordinator. 2. Review of Resident #30's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/20/11, showed the following: -Usually makes self understood and usually understands others; -Scored 6 out of a possible 15 on his/her Brief Interview for Mental Status examination, indicating he/she was severely cognitively impaired in his/her abilities for daily decision making; - Totally dependent on staff for bed mobility, transfers, dressing, personal hygiene and bathing; - Functional limitation in range of motion: upper extremity, impairment on both sides; lower extremity, impairment on both sides; -On a scheduled pain medication regimen; -Received as needed pain medications; -Received non-medication intervention for pain; -Frequently in pain; -Pain makes it hard to sleep at night; -Pain intensity was moderate. Review of Care Area Assessment (CAA) Summary, dated 11/20/11, showed pain triggered on the MDS, and staff checked that pain would be addressed in the care plan. The facility identified the following in the CAA summary: -Pain made it hard to sleep at night; -Pain is frequent; -Disease and conditions that may cause pain was amputation; -Pain disturbs sleep and limits day-to-day activities; -The resident has complained of pain with his/her bladder. Staff will continue to monitor for pain and pain intervention. Review of the care plan, dated ongoing 11/23/11, showed discomfort or pain related to [MEDICAL CONDITION]. Administer medication as prescribed, assist patient to find glasses each morning and as needed, monitor for irritation: redness, tears or infection and report to physician and keep room free from UV lighting due to sensitivity. Review of the physician's orders [REDACTED]. Tylenol 325 milligrams (mg), two tablets two times a day, and Tylenol 325 mg, two tabs every 4 hours as needed for pain/fever. Observation on 12/21/11 at 9:00 A.M. showed Certified Nurse Assistant (CNA) E and CNA L prepared the resident to transfer from his/her wheelchair to bed. The resident was moaning "ow" and making low groans. CNA E asked the resident what was wrong and the resident did not answer. The resident leaned forward and said "ow" and "ouch," and his/her breathing was labored. The resident was groaning and saying "ow" with labored breathing during the transfer. The staff laid the resident down to bed and bent the resident's right knee to remove his/her pants and the resident yelled out. CNA E asked the resident if he/she would like pain medication, and the resident said he/she would like [MEDICATION NAME] the other "stuff" doesn't work. During interviews on 12/21/11 at 9:45 A.M., the Assistant Director of Nursing (ADON) said the resident did not have a pain assessment done yet, it was recorded on a piece of paper. The piece of paper was dated 11/28/11 and had the resident's first name with "yes" written beside it. The ADON said the resident was in pain, his/her legs were contracted and will moan with transfers and complain of his/her eyes hurting. The resident receives routine Tylenol. The Director of Nursing (DON) said the resident's care plan had not been updated with interventions addressing the resident's pain. He/she expects the CNA to tell the charge nurse as soon as possible when a resident is in pain. Review of the care plan, dated ongoing 11/23/11, showed the care plan did not include pain management interventions for the treatment of [REDACTED]. Observation on 12/21/11 at 9:50 A.M., Certified Medication Technician (CMT) M was outside Resident #30's room preparing the resident's morning medications, which included two routine Tylenol. CMT M entered the resident's room and gave the resident his/her morning medication and raised the head of the resident's bed and the resident said "ow" and complained of the back of his/her head hurting. The resident rated his/her pain as a nine and told CMT M he/she had asked [MEDICATION NAME]. CMT M told the resident he/she didn't [MEDICATION NAME] paper and offered to get a hold of the resident's physician. During interview on 12/21/11 at 9:50 A.M., CMT M said the following: -No staff had reported to him/her that the resident was in pain on 12/21/11; -The resident receives two routine Tylenol which usually keeps the resident out of pain most of the time; -The resident has Tylenol as needed when he/she complains of pain; -There was supposed to be a pain scale in the medication book to use when assessing residents for pain, but the pain scale was not in the book yet. He/she just asks the residents if they are in pain and usually follows up to see if the resident still has pain on the next medication pass or sometimes before that. He/she is suppose to ask the resident if they are still in pain one-half hour to two hours after administering the medication, depending on the severity of pain. Review of the Pain Evaluation on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., 12:00 noon, 4:00 P.M. and 8:00 P.M. Staff documented on 12/21/11, that the resident rated his/her pain as a nine in the 8:00 A.M. space. Routine Tylenol was given at 9:00 A.M. During interview on 12/21/11 at 10:10 A.M., CNA E said if a resident complained of pain or was making noises or faces, he/she would let the nurse know and go back one-half hour to 45 minutes later to see if the resident was still in pain. He/she had reported the resident's pain to CMT M. He/she did not report the resident's pain to the charge nurse. The resident does a lot of noise making and hardly ever complains of pain. During interview on 12/21/11 at 10:12 A.M., Registered Nurse (RN) N, the charge nurse, said this was the first time this morning he/she had heard the resident was in pain. The resident doesn't typically complain of pain. Routine Tylenol usually takes care of the resident's pain. The routine Tylenol was ordered for arthritis. When any resident complains of pain, you want to treat the pain immediately. He/she said maybe the routine Tylenol wasn't taking care of the resident's pain any longer. He/she would notify the physician. During interview on 12/21/11 at 10:25 A.M., the ADON said all residents had been assessed for pain and pharmacological and non-pharmacological interventions. Resident #30 will complain of pain but also groans and that is how staff know he/she is in pain. The resident's pain is mostly in his/her legs which are contracted, and he/she wears a brace on the left leg. Review of the care plan, dated ongoing 11/23/11, showed it did not include pain management interventions for the treatment of [REDACTED]. Record review of a new physician's orders [REDACTED].M., showed an order for [REDACTED]. Record review of nurses' notes, dated 12/21/11 at 10:30 A.M., showed the resident complained of pain all over especially in neck area. Resident states Tylenol doesn't do anything. New order for [MEDICATION NAME] received. During interview on 12/21/11 at 11:55 A.M., CMT M said he/she hadn't given the resident the [MEDICATION NAME] yet because the facility just received orders. Observation at 12/21/11 at 11:56 A.M., showed the CMT asked the DON if they had pain medication in the "Stat box" (a box used for emergency medications), and the DON said "yes." During interview on 12/21/11 at 12:00 P.M., the MDS Coordinator said he/she had only addressed the resident's eye pain in the care plan because this was the only pain the resident had complained of at the time. He/she was not aware of any other pain the resident was having. He/she said the care plan is updated quarterly and if there are any changes between that time, the DON or ADON lets him/her know of changes in resident care. Observation on 12/21/11 at 12:15 P.M., showed CNA E and Nurse Assistant (NA) O provided pericare and dressed the resident. The resident complained of not feeling very well. As CNA E and NA O sat the resident up to the side of the bed, the resident said "ow" and complained of his/her bottom hurting and told the CNA he/she was in pain. CNA E and NA O transferred the resident from his/her bed to the wheelchair and took the resident to the dining room for lunch. Observation on 12/21/11 at 12:45 P.M., showed CMT M gave the resident [MEDICATION NAME]. CMT said the ADON just returned with the medication because there was not any in the Stat box.