Based on interview and record review, the facility failed to provide Cardiopulmonary Resuscitation (CPR) for one of 15 sampled residents, (Resident #63), who was a full code. On [DATE] the resident's visiting family member alerted staff to the resident's room stating the resident had a seizure and was gasping for air. Licensed Practical Nurse (LPN) B arrived and found the resident was not breathing and had no pulse or lung sounds present, and then observed the resident with agonal breathing (abnormal, slow, gasping breaths that happen when death is close, or the heart has stopped). LPN B asked the resident's family member if he/she wanted him/her to begin CPR and informed the family member the resident was gasping, because he/she was trying to get oxygen to his/her brain. Approximately 3-4 minutes after being asked, the family member told LPN B not to perform CPR because it's not what the resident wanted. LPN B did not perform CPR, and the resident passed away at the facility. The facility census was 61.The Administrator was notified on [DATE], of Past Non-Compliance Immediate Jeopardy which occurred on [DATE]. The Administrator immediately began an investigation, suspended the LPN pending the investigation, completed audits of code status of all current residents, all licensed nurses and certified nurse aides (CNAs) were inserviced regarding when to perform CPR, what CPR entailed, what DNR was, and how to verify code status. Color coded dots were added to residents' doors for code status. The IJ was corrected on [DATE].Review of the facility's policy for Emergency Procedure - Cardiopulmonary Resuscitation (CPR), revised February 2018, showed:- Personnel have completed training on the initiation of CPR and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest (SCA).- SCA is a loss of heart function due to abnormal heart rhythms (arrhythmias). Cardiac arrest occurs soon after symptoms appear. It is the leading cause of death among adults.- Victims of cardiac arrest may initially have gasping respirations or may appear to be having a seizure. Training in BLS includes recognizing presentations of SCA. -The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse.-If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: it is known that a do not resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death.- If the resident's DNR status is unclear, CPR will be initiated until it is determined there is a DNR or physician's order not to administer CPR. - If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff member to activate the emergency response system (code) and call 911. Instruct a staff member to retrieve the automatic external defibrillator. Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. - Continue with CPR/BLS until emergency medical personnel arrive. Review of the resident's Durable Power of Attorney (DPOA), dated [DATE], showed the resident listed his/her spouse as the agent and the DPOA was not invoked. Review of the resident's medical records showed the resident admitted on [DATE]. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed:- Verbal Order, dated [DATE], for the resident to be a Full Code. -Diagnoses included Paroxysmal Atrial Fibrillation (irregular, rapid heart rhythm that starts and stops suddenly, typically lasting less than 7 days and resolving without intervention), Intracardiac Thrombosis (blood clot formed within the heart's chambers), Shortness of Breath, Congestive Heart Failure, and Ventricular Tachycardia (cardiovascular disorder in which fast heartrate occurs in the ventricles of the heart. Review of the resident's baseline care plan, dated [DATE] showed:- Discharge plan - discharge to home.- Code status - Full Code. Review of the Brief Interview for Mental Status, dated [DATE], showed: -Social Services Director (SSD) completed the interview. -Resident interview score: 14- indicating Cognitively Intact- Little to no impairment. Review of the resident's Transportable Physician Orders for Patient Preferences (TPOPP/POLST), dated [DATE], showed:- In the event that he/she has no pulse and is not breathing he/she requests staff attempt Resuscitation/CPR. - If he/she has a pulse and is breathing, he/she requests for staff to provide full treatment with the goal to attempt to sustain life by all medically effective means. Provide appropriate medical treatments as indicated in an attempt to prolong life, including intubation, advanced airway interventions, mechanical ventilation, and defibrillation/cardioversion, including intensive care. - The resident's spouse was named as the emergency contact. - In the section for information and signatures the SSD documented the information on the form was discussed with Resident #63. - The resident printed and signed his/her name on the TPOPP form.- The physician signed the form on [DATE]. Review of the resident's admission record face sheet showed Code Status: Full Code Record review of the resident's progress note, dated [DATE], showed:-Called to the resident's room at 10:02 A.M., the resident was in bed, but very short of breath. Oxygen saturation (amount of oxygen in the blood) was 90% on 2L/NC (two liters of oxygen via nasal cannula). Increased the oxygen to three liters via nasal cannula and the resident's oxygen saturation increased to 95%. Blood pressure was 126/84, pulse 106, respirations 34. The resident stated he/she felt a little better after increasing the oxygen to three liters. The resident's respirations decreased to 22. Assured the resident the nurse would be back later to check his/her vital signs again. -At 11:15 A.M., called to the resident's room by a family member, who stated, the resident had a seizure. No seizure was noted. The resident was in his/her recliner not breathing, had no heart sounds or pulse, and no lung sounds at that time. The resident gasped several times after the nurse got to the room and had no heart or lung sounds. LPN B asked the resident's family member if he/she wanted him/her to begin CPR and informed the family member the resident was gasping, because he/she was trying to get oxygen to his/her brain. Approximately 3-4 minutes after being asked, the family member told LPN B not to perform CPR because it's not what the resident wanted. LPN B did not perform CPR, and the resident passed away at the facility. During an interview on [DATE] at 11:54 A.M., the SSD said:- When a resident admits to the facility with a code status, he/she reviews the code status with the resident or responsible party to verify that is what they want. - When Resident #63 was admitted , he/she requested to be a full code. The resident signed the TPOPP on [DATE] in his/her presence. During an interview on [DATE] at 12:41 P.M., Certified Medication Technician (CMT) A said:-He/She worked on [DATE] with LPN B. -When LPN B and he/she entered the resident's room, the resident was having trouble breathing. -The family member present said he/she was the DPOA and the resident would not want CPR. -No one went and verified the resident's code status, and no one performed CPR. -Later, when he/she looked in the system, and saw the resident was a full code. During an interview on [DATE] at 5:53 P.M., LPN B said: - He/She was aware the resident was a Full Code.- On [DATE] the resident told him/her that morning he/she wanted to be a DNR.- He/She was busy and did not have time call the physician or the DON about the resident changing his/her mind about CPR.- The visiting family member, who he/she believed was the DPOA, came out into the hallway and said the resident was having a seizure. - LPN B grabbed the vital sign equipment and went to the resident's room. - The resident was in his/her recliner and had no pulse and no lung sounds.-The resident started having agonal breathing (abnormal, slow, gasping breaths that happen when death is close, or the heart has stopped) and LPN B explained to the family member the resident was trying to get oxygen to his/her brain.- LPN B asked the family member, whom he/she believed was the DPOA, if he/she wanted LPN B to perform CPR and the family member stood there for three to four minutes making his/her decision and then told him/her not to perform CPR because the resident would not want it. - LPN B said now that he/she had time to think about the situation, he/she felt like he/she should have started and followed through with CPR. During an interview on [DATE] at 9:29 A.M., Registered Nurse (RN) A said:- If a resident was not breathing or does not have a pulse, the staff who are CPR certified, should check the code status and start CPR.- What should have happened for Resident #63 was for the nurse to assess the resident, and when the resident did not have any respirations or a pulse, start CPR and call a code, regardless of what the family member said. The staff are required to follow the physician's order. During an interview on [DATE] at 11:38 A.M., Certified Nurse Aide (CNA) F said: -To verify the resident's code status, he/she would look at the resident's door to see if they had a green dot (full code) or a red dot (DNR). -There was also a code status book at the nurse's station, and he/she could also check on the computer. - If he/she observed a resident not breathing or had no pulse, he/she would check the resident's code status, notify the Charge Nurse (CN), and get the crash cart. During an interview on [DATE] at 1:41 P.M., CNA H said if he/she found a resident breathing or no pulse, he/she would verify the resident's code status, notify the CN and check the resident for a pulse or respirations. During an interview on [DATE] at 10:09 A.M., the DON said at the in-service on [DATE]:- If a resident is full code, has trouble breathing or does not have a pulse, the staff should check the code status, get the crash cart and start coding the resident. -It does not matter if the family is in the room or not. -Staff were informed the code status can be found on the color-coded dot outside of the room, the code book at the nurse's station and in the resident's electronic medical record. During an interview on [DATE] at 12:23 P.M., the Administrator said:- The staff should have verified the resident's code status and started CPR. - If a resident wants to change their code status, he/she would have to fill out a new TPOPP form and staff would need to obtain the physician's signature and new order. - Resident #63 was a full code and LPN B should have provided CPR. During an interview on [DATE] at 5:13 P.M., the Medical Director said Resident #63 was a Full Code and staff should have initiated CPR when they found the resident without a pulse or respirations.
Every finding on record at Laverna Manor Health & Rehabilitation
Savannah, Missouri · CCN 265787
23 findings across 9 inspections, in the inspector's own words, 6 of them at actual harm or above.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.
Inspection of March 16, 2026
10 findingsBased on observation, interview, and record review, the facility failed to ensure residents were served food that was palatable, attractive, and at safe and appetizing temperature during meal service, and additionally the facility failed to follow menus. This affected 8 of 15 sampled residents (Residents #10, #12, #18, #15, #4, #32, #49, and #58). The facility census was 61.Review of facility policy Food Temperatures, undated, showed:- All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit (F);- All cold food items must be stored at a temperature of 41 degrees F;- Temperatures should be taken periodically to assure hot foods stay above 135 degrees Fahrenheit and cold foods stay below 41 degrees F during the holding and plating process and until food leaves the service area;- Foods should be transported as quickly as possible to maintain temperatures for delivery and service. If food transportation time is extensive, food should be transported using a method that maintains temperatures (i.e. hot/cold carts);- Hold foods at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods to keep food out of the temperature danger zone;- Foods sent to the units for distribution will be transported and delivered to unit storage areas to maintain temperatures at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods. -There was nothing in the facility meal policies indicating how sandwiches should be prepped for delivery or storage. Review of facility policy Menu Planning, undated, showed:- A substantial evening meal consisting of three or more menu items will be offered, one of which includes high quality protein;- No guidance on lunch or breakfast menu planning was provided in the policy. -No guidance on a choice of meat at breakfast meals. 1. Review of Resident Council Meeting notes, dated November 2025 to March 2026, showed: - Food was not always hot and menu planning lacked variety; - There was a lack of fresh salads and fresh fruit; - Too many occurrences of hamburgers on the schedule. -No resolution of concerns was documented in the meeting notes. Review of the Alternate Menu, undated, showed the following menu items are available on request: Hamburgers with or without cheese, deli sandwich, grilled cheese, peanut butter and jelly sandwich, hotdogs, cold cereal, mashed potatoes with or without gravy, soup of the day, toast, hard boiled eggs, scrambled eggs, and items that were made over the last 48 hours if available. Review of the Cycle menu, dated Fall/Winter, showed:- The cycle menu consisted of four weeks of menus rotated over a 28-week schedule.- Breakfast menus were the same each week. Every Sunday in the 28-week schedule will always have the same menu and Monday will have the same breakfast menu each week for the 28-week schedule. All days of the week follow this format. - Meat was offered three out of seven days on the breakfast menu. Sunday and Wednesday bacon offered and sausage patty offered on Saturdays. There were no other meat items or varieties offered on the other days.- 50% of the 28 cycle meals served for dinner consisted of sandwiches as the main course.- 26 out of 28 cycle dinner desserts have chilled fruit or a similar variation of a fruit product served.- 5 out of 56 lunch and dinner entrees included a salad;- Hamburgers or cheeseburgers which are on the alternate menu are also scheduled once each week as a regular entrée.- Ice cream was offered once and sherbet twice during the 28-day cycle menu. 2. Observation in the dining room on 3/13/26 at 7:25 A.M., showed:- The breakfast menu posted showed chilled assorted juice, assorted cold cereal, assorted hot cereal, cheese omelet, buttered biscuit with jelly, milk, and beverage;- Resident #10 asked Dietary [NAME] B if he/she could have some bacon. Dietary [NAME] B responded that the bacon was not on today's menu and did not offer any substitute for the bacon or any other option. Review of Resident #10's Quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), dated 2/5/26, showed the resident was cognitively intact. During an interview on 3/13/26 at 7:35 A.M., Resident #10 said he/she was very disappointed that he/she could not get any bacon and really wanted to enjoy his/her breakfast with some meat after just receiving new dentures. During an interview on 3/13/26 at 6:50 A.M., Dietary [NAME] B said that residents always ask about meat for breakfast and want it served more frequently than it was currently scheduled on the cycle menu 3. Review of Resident #32's Quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 3/10/26 at 10:37 A.M., the resident said the food was terrible and the facility needed better options for residents. The alternate menu was nothing but fast food items like hamburgers and hot dogs. He/She would like a salad and the menu to be healthier. The salad suggestion comes up at resident council meetings, but it always gets ignored. He/She was very frustrated with the situation. 4. Review of Resident #58's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/08/26, showed the resident was cognitively intact and had a diagnosis of diabetes. Review of the resident's care plan, dated 01/14/26, showed:- Staff are to provide small frequent meals rather than three large ones and encourage the resident to avoid fried or fatty foods;- Staff are to encourage intake of foods rich in iron such as green leafy vegetables, eggs, nuts, and grains; - The resident had a mood problem related to anxiety and depression;- Staff are to regulate protein and potassium intake related to renal failure. During an interview on 03/11/26 at 7:40 A.M., the resident said: - He/She wasn't happy with the food situation, how everything was ordered by management, and how the Dietary Manager doesn't have much say in what food was ordered and provided to the residents;- He/She felt that budget wise, the facility served a lot of sandwiches and the residents don't prefer them;- Salads were very rare and when they did have a salad it was mainly head lettuce and a few chunks of tomato if the residents are lucky. Beautiful salad would be wonderful;- The facility runs out of things like condiments and salad dressings so fast;- He/She had recently been served a taco salad with no chips, no sauces, and no salad dressings to put on it. Basically, a salad without dressing. Review of the Menu Substitution Log, dated May 2025 to March 2026, showed the menu did not list the missing chips and salsa required for a Taco Salad entrée which was on the menu during the cycle. No suitable substitute was annotated in the log to utilize in place as substitution for chips and salsa During an interview on 03/12/26 at 3:23 P.M., the Dietary Manager said: - The facility received the menu from the corporate staff and can make suggestions and requests but since they would be transitioning to the spring menu, they haven't made any changes;- The facility typically did not run out of the dressings or condiments, but recalled recently in the last month the taco salad had an issue with no chips or salsa. The chips and salsa hadn't been on the spreadsheet and we didn't have them. They should have have been ordered according to the menu but we didn't. 5. During an interview on 03/13/26 at 9:30 A.M., Resident #49 said: - He/She was a diabetic and needed more protein in his/her diet which was lacking at the facility;- The facility served so many carbs it made it hard to control his/her blood sugar. 6. During an interview on 3/13/26 at 9:30 A.M., the Dietary Manager (DM) said: - Menu decisions are made by the Registered Dietician (RD), and he had to get approval for all menu changes. The main factors that go into a cycle menu are nutrition and financial budget.- They try to serve fresh salads to the residents for lunch or dinner at least weekly.- If we don't have an item scheduled on the menu such as meat, we don't have the authority to add it to the menu just because it was requested by a resident. - He felt the menu was very repetitive and didn't represent a home like menu because there are too many sandwiches scheduled. During an interview on 03/13/26 at 2:35 P.M., the Administrator said: - The residents should be able to have salads, fruits, or healthier options if they wish;- Diabetic residents should be able to have higher protein and lower carb options. During an interview on 03/13/26 at 2:56 P.M., the Director of Nursing (DON) said: - The residents should be able to have salads, fruits, and healthier menu options like a chef's salad if the facility can provide it;- A diabetic resident should be able to have higher protein and lower carb options available to them. 7. Observation in the dining room on 3/12/26 at 5:15 P.M., showed all residents served one unsliced deluxe club sandwich per resident in a plastic bag on a plate. Review of Resident #18's Quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), dated 3/13/26, showed;- The resident had moderate cognitive impairment;- Diagnoses included: Stroke, anemia, coronary artery disease (heart disease), Alzheimer's Disease, anxiety disorder, and depression. During an interview on 3/12/26 at 5:20 P.M., the resident said sandwiches were often placed in plastic sandwich bags and recently the club sandwich, which was served to him/her during the evening meal, was hard to get out of the bag with his/her hands, but he/she could handle it eventually. He/She would prefer the sandwich be served on a plate without the plastic, because his/her stroke makes it hard to use hands to open the small packages. During an interview on 3/13/26 at 9:30 A.M., the DM said we put the sandwiches in the plastic bags to keep them from getting soggy, we don't want to just place it on a plate with potato chips and soup. 8. Observation in the kitchen on 3/13/26, showed Dietary [NAME] A:- At 5:45 A.M., prepared all hot breakfast items (biscuits, oatmeal, and cheese omelets) completed cooking, placed in metal containers with foil covers, and stored in the oven at 5:45 A.M. - At 6:35 A.M., all hot food items removed from the oven, no temperatures were taken by kitchen staff. - At 6:42 A.M., food items of cheese omelets, oatmeal, and biscuits traveled via elevator to the first floor and placed on the steam line; -No observations the DM checked the food temperatures. Observation in the dining room on 3/13/26 at 7:00 A.M., showed Dietary [NAME] B uncovered the hot food items on the steam line, cheese omelets, oatmeal, and biscuits and did not take any temperatures of the hot or cold food items prior to serving to residents. No observation the DM checked the food temperatures. Observation on the 200 Hall on 3/13/26 at 8:08 A.M., showed:- The breakfast test tray, which was the last tray served to residents on the halls, was received by the surveyor, two hours and 23 minutes after the food items were cooked in the kitchen. - The biscuit was 88.7 degrees F and would not melt the margarine provided as a condiment when spread on the biscuit. The biscuit was not hot by taste and was dry and greasy with the lukewarm margarine used as a condiment spread. Expected temperature was 120 degrees F.- The cheese omelet was 134.0 degrees F, but visually the food item was crumbled up scrambled eggs with one ball of cheese in the mixture measuring one millimeter in diameter. Visually it did not resemble a cheese omelet, but instead scrambled eggs. The texture was dry and tasteless.- Milk temperature was at 52.2 degrees F.- Orange Juice temperature was at 60.3 degrees F. During an interview on 3/13/26 at 8:14 A.M., Certified Nurse Assistant (CNA) G said the cheese omelet did not look at all what he/she would expect a cheese omelet to look like. He/she would expect a cheese omelet to have a shape to it and contain cheese, not be crumbled up and dry. 9. Observation during lunch in the dining room on 3/13/26 at 12:20 P.M., showed: - Menu listed main course as chicken salad on a croissant.- There were no croissants on the steam line for making the chicken salad sandwich.- Dietary [NAME] B prepared sandwiches on the steam line. He/she used a ice cream scoop to place a portion of chicken salad in the middle of a plain piece of white bread and then placed a second piece of white bread on top of the chicken salad. Visually the bread completely obscured the ball of chicken salad and showed as a lump underneath and in the middle of the top piece of the bread. The chicken salad wasn't evenly spread onto the bread and the bread wasn't toasted or sliced to increase the visual appeal of the meal to compensate for not having the original menu item which was a croissant. -Residents were observed in the dining room only taking one bite of the chicken salad on white bread and the chicken salad had not been touched in the center of the bread. 10. Review of Resident #12's Annual MDS, dated [DATE], showed the resident was cognitively intact and had a diagnosis of malnutrition. During an interview on 3/10/26 at 10:47 A.M., the resident said he/she ate in his/her room for most meals and the food was often cold when it gets to him/her. He/She did not feel comfortable asking staff to routinely warm the food up, because it happens so frequently. The cold food makes meals very unappetizing for him/her. 11. Review of Resident #15's Annual MDS, dated [DATE], showed the resident had moderate cognitive impairment. During an interview on 3/10/26 at 9:32 A.M., the resident said often the food was cold and maybe once a month they will get warm mashed potatoes and gravy, but that was a long time to wait. It was frustrating. He/She had reported the concern to the staff. The menu was just rotated, nothing was new, just shuffled up menu items. Lots of times the food was cold and soggy and the meat was so dry you can't swallow it. 12. Review of Resident #4's Quarterly MDS, dated [DATE], showed the resident was cognitively intact and had a diagnosis of malnutrition. During an interview on 3/10/26 at 2:30 P.M., the resident said:- The food was not hot when he/she gets it in the dining room and had reported it to the staff.- The meat was not tender. - The facility served a lot of broccoli and it was overcooked. - Overall he/she was not satisfied with the food served at the facility. 13. Review of Resident #49's Quarterly MDS, dated [DATE], showed the resident was cognitively intact and had a diagnoses of anemia and diabetes. During an interview on 3/10/26 at 11:42 A.M., the resident said:- The cheeseburgers and hamburgers are served burnt. The bottom of the lasagna was burnt the other day. -The meat was sometimes tough to eat and the green beans were undercooked. They are rubbery. - It made him/her feel like he/she did not want to eat. -He/She had to try and pick through the meal plate for something good to eat at mealtimes. 14. During an interview on 3/13/26 at 9:30 A.M., the Dietary Manager (DM) said: - Food temperatures should be taken after cooking is complete, when food goes to the steam line, prior to serving the first resident and periodically while food is on the steam line during the meal service. The only time temperatures are written down into a log is when the food item is completely cooked to the correct temperature. The other temperature checks are not logged anywhere but he has witnessed his staff taking temperatures at other times but can't prove that they do it all the time since it's never recorded anywhere. - A cheese omelet should be an egg patty with some cheese on it. The residents do not like cheese on their eggs at all, they say it makes the eggs greasy. During an interview on 3/13/26 at 1:48 P.M., the Administrator said: - Meals should be appealing and appropriate to a resident's diet. Plastic bags are probably used for sanitary reasons for the residents, but it was not very homelike.- Expectations for taking food temperatures would be they are taken at the steam table prior to serving, check them as hall trays go out, and upon completing the preparation of all food items in the kitchen.- She would expect the variety of breakfast main courses would be driven by resident preferences and the planned menu. Feedback from residents were given to the RD so the menu can be adjusted to their preferences. - She was normally informed of food substitutions at the morning meeting, but this week with the state surveyors on site we have not had our meeting so any substitutions that have been made she was not informed. - If the facility is out of croissants for a meal they can be purchased locally or a suitable substitution of equal nutritional value offered. During an interview on 3/23/26 at 3:18 P.M., the RD said: - Cyclical menus cover seasons such as Fall/Winter and Spring/Summer. Fifty percent of the calories are for carbohydrates, 20% protein, and 30% fat with some minor variances allowed.- The goal was to hit 2800-3000 calories a day. More eggs in the morning for protein and more calcium in it for the wheelchair residents.- She expected staff to follow the menu as planned and she had contracts in place to support the food items required. The main challenges with the menus were the Medicare reimbursement was not going up, but food prices are going up quickly which can cause an issue. She worked with owners and representatives of facilities to address any shortfalls.- The menu was repeated for breakfast each week. Each day of the week has the same menu each week to help the residents with orientation so they can more easily remember events based on what they remember having for breakfast. The variety in the menu comes into play during lunch and dinner planning.- The reason meat was only offered three days a week for breakfast was the culture of the residents at the facility don't need to eat meat each day. That type of eating was from the generation that consisted of farmers. The menu though can be adjusted to cater to individuals if they want bacon each day, then the staff could make some bacon each day for that resident. - If a resident was a diabetic and they don't want to eat eggs for each meal there really isn't a substitute planned into the breakfast menu other than hot cereal. The resident will naturally gravitate to eating items that aren't as healthy for them and don't have the necessary protein if they eat meat instead of eggs. - Biscuits don't need to be served at 120 degrees F but they need to be served hot enough to melt butter or margarine to maintain a good taste for the resident.- Assorted hot cereal was a place holder for the menu and it means anything the cook decides to rotate into the menu for that day. The choices could be oatmeal or cream of wheat to name a few. These should be annotated on the daily menu for the residents and not listed as assorted hot cereal since only one cereal was being brought up to the serving line for each breakfast.- The menu contained so many sandwich entrees for dinner to provide residents with more starches and we try to limit the number of sandwiches we serve on the cycle menu.- The lack of variety for dinner desserts was due to the fruit requirement we have for residents, so it gets loaded up for the dinner menus to serve chilled fruit. Baked goods are normally at lunch for dessert. - The staff could do better about handling substitutes such as missing croissants and putting more effort into presentation especially when serving sandwiches on plain white bread. His/Her intention was to provide a healthy portion for residents with a good presentation. These are issues she would address with the staff.
Based on observation, interview, and record review, the facility failed to ensure the services provided or arranged by the facility met professional standards of quality, when the facility failed to obtain an order to flush a peg tube (a tube placed in the stomach to provide a route to deliver nutrition, medications and fluids) for Resident #6, failed to ensure Resident #1 had a Physician's order for Hospice (end of life care), and failed to ensure a resident (Resident #39) who required crushed medication had an order for their medications to be crushed. These failures affected three of 15 sampled residents. The facility census was 61. 1.Review of the facility's policy for Maintaining Patency of a Feeding Tube (Flushing), revised November 2024, showed: - The purpose of this procedure is to maintain patency of a feeding tube. - Verify that there is a physician's order for this procedure. - For maintaining patency of a feeding tube: Flush enteral feeding tube every four hours with 30 milliliters (ml.), or prescribed amount, of warm water during continuous feeding. - Flush enteral feeding tubes with 30 ml., or prescribed amount, of warm water before and after intermittent feedings. - Flush enteral feeding tube with 15 ml., or prescribed amount, of warm water before and after administration of medications. If administering more than one medication, flush with 15 ml., or prescribed amount, of warm water between each medication. - Flush with 30 ml., or prescribed amount, of warm water after checking gastric residual volume. Review of Resident #6's Quarterly MDS (Minimum Data Set), a federally mandated assessment completed by facility staff, dated 3/25/26, showed -Not cognitively intact; -Dependent on nursing staff for all cares; -Diagnoses included stroke, inability to swallow, and required tube feedings for nutritional needs. Review of the resident's Physician Order Sheet (POS), dated March 2026, showed: - Start date: 8/16/25 - Enteral Feed Order every 24 hours for diet - Enteral Feed order: Two Cal HN 50 ml./hour for 20 hours. Water flush with 200 ml. every four hours. - Start date: 4/8/25 - Enteral Feed Order - every shift for gastrostomy. Check tube placement before initiation of formula, medication administration, and flushing tube. - No order to flush the tube before or after medications, how much water to use to flush the tube or how often. Review of the resident's Medication Administration Record (MAR), dated March 2026, showed: - Enteral Feed Order every 24 hours for diet - Enteral Feed order: Two Cal HN 50 ml./hour for 20 hours. Water flush with 200 ml. every four hours.- Enteral Feed Order - every shift for gastrostomy. Check tube placement before initiation of formula, medication administration, and flushing tube. -No order to flush the tube before or after medications, how much water to use to flush the tube or how often. Observation and interview on 3/12/26 at 8:30 A.M., showed: - Registered Nurse (RN) A administered medication with 10 ml. of water to flush the tube before and after the medication. - RN A said he/she thought if you were giving more than one medication, you had to flush with more water. There should have been an order to flush the tube with water before and after medications. There was no order to flush the tube before or after medications, or how much water to use to flush the tube, or how often. During an interview on 3/13/26 at 3:54 P.M., the Director of Nursing (DON) said there should be a physician's order to flush the peg tube with water, how much to use, and when. 2. Review of Resident #1's admission MDS, dated [DATE], showed: - Cognitive skills moderately impaired. - Required substantial to maximum assistance with toilet use, showers, and lower extremity dressing. - Required partial to moderate assistance with upper extremity dressing and transfers. - Occasionally incontinent of urine. - Always continent of bowel. - Diagnoses included dementia, anxiety, depression, and muscle weakness. Review of the resident's face sheet showed the resident's primary payer was Hospice. Review of the resident's POS, dated March 2026, showed the resident did not have an order for Hospice. Review of the resident's Electronic Medical Record showed a hospice order, dated 3/11/26, and hospice was to be notified if pain medication was not being given to the resident. There was no admission/start date for hospice services located in the resident's electronic medical record. During an interview on 3/13/26 at 9:29 A.M., RN A said the resident was admitted on Hospice, but there should still be a physician's order for it. During an interview on 3/13/26 at 3:54 P.M., the DON said there should be a physician's order for a resident to be on Hospice. 3. Review of the facility's General Guidelines for Medication Administration, dated August 2020, showed: -Crushing tablets may require a physician's order: -The instructions for crushing medications should be included on residents orders and on residents medication administration record (MAR) so that all personnel administering medications are aware of the need. Review of Resident #39's care plan, revised 1/9/25, showed: -The resident was not cognitively intact; -The resident was taking medication for depression; -The resident had a communication problem related to dementia. Review of the resident's Oder Summary Report, dated 3/13/26, showed the resident did not have an order for medications to be crushed. Review of the resident's Medication Administration Record (MAR), dated March 2026, showed no instructions for the resident's medications to be crushed. Observation on 03/12/2026 at 7:49 A.M., showed: -Certified Medication Technician (CMT) B prepared medications for the resident; -CMT B crushed the resident's anastrozole (a medication used to treat or prevent breast cancer in postmenopausal women); -CMT B crushed the resident's furosemide (a medication used to treat fluid retention); -CMT B crushed the resident's gabapentin (a medication used to treat nerve pain); -CMT B crushed the resident's paroxetine (a medication used to treat depression); -CMT B crushed the resident's Vitamin D; -CMT B crushed the resident's aspirin (a medication used to treat atrial fibrillation, a condition causing irregular heartbeat); -CMT B crushed the resident's Echinacea (a herbal medication used to support the immune system); -Placed crushed meds in pudding and administered the medications to the resident. During an interview on 3/12/2026 at 8:15 A.M., CMT B said: -He/she remembered which residents needed their medications crushed; -There was not an order for the medications to be crushed for the resident; -There should have been an order in the resident's medical record for medications to be crushed so if a new staff member had to pass meds they would know which residents would need their medications crushed. It was much easier for the resident to swallow the pills if they were crushed. During an interview on 3/13/2026 at 10:48 A.M., RN A said: -There should have been an order for medications to be crushed; -Usually, an order was put in during admission that medications may be crushed if needed. During an interview on 3/13/2026 at 11:00 A.M., the Infection Control Nurse said: -Residents were usually given a may crush medications if needed: order during admission; -Resident #39 did not have that order in their medical record. During an interview on 03/13/2026 at 3:15 P.M., the DON said residents that required medications to be crushed should have a physicians to do so.
Based on observation, interview, and record review, the facility failed to ensure staff discarded expired medications and biologicals stored in the North medication room and in the North nurse's cart per policy, failed to date opened bottles of Lorazepam (used to treat anxiety) per policy for four of 15 sampled residents (Resident #1, #5, #59, and #67), and failed to date an opened vial of Tuberculin (TB) Purified Protein Derivative (PPD, a skin test used to help diagnose tuberculosis infection) per policy, and failed to date an opened insulin pen for one resident (Resident #56) Additionally, the staff failed to regularly check the refrigerator temperatures that contained medications and failed to defrost the freezer per policy. The facility census was 61. Review of the facility's policy for Storage of Medications, revised 12/2025, showed: -The facility stores all drugs and biologicals in a safe, secure, and orderly manner. -Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. -The nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the facility's policy for Storage of Medications, revised 8/20, showed: -Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 degrees Fahrenheit and 46 degrees with a thermometer to allow temperature monitoring. -Medications that should be frozen are stored in the freezer at -13 degrees Fahrenheit to 14 degrees Fahrenheit. -The facility should maintain a temperature log in the storage area to record temperatures at least once a day or in accordance with the facility policy. -The nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating. -The nurse will check the expiration date of each medication before administering it. -No expired medication will be administered to a resident. Review of the manufacturer guidelines for liquid Lorazepam oral concentrate (medication used to treat anxiety) showed that once the bottle was opened the liquid Lorazepam was good for 90 days when stored properly. 1. Observation and interview on 3/12/26 at 9:24 A.M., of the North Medication Room showed: -A small refrigerator on top of a normal size refrigerator. The freezer had a large amount of ice buildup. The small refrigerator did not have a temperature log. -Registered Nurse (RN) A said the night nurse should check the temperature on the refrigerators and should be defrosting the freezers. The Certified Medication Technicians (CMTs) and nurses check the medication carts for expired medications. -Resident #67 had an opened vial of Lorazepam that did not have a date when opened. It was filled on 1/19/26. The box read should be discarded 90 days after opening. -Resident #5 had an opened vial of Lorazepam that was not dated when opened. It was filled by pharmacy on 10/4/25. The box said it should be discarded 90 days after opening. -Resident #1 had an opened vial of Lorazepam that did not have a date when it was opened. It was filled on 2/16/26. The box said it should be discarded after 90 days. -Licensed Practical Nurse (LPN) A said the Lorazepam should be dated when opened. -A house stock vial of Tuberculin (TB) Purified Protein Derivative did not have a date when it was opened. LPN A said it should have been dated when opened and discarded after 30 days per policy. During an observation and interview on 3/12/26 at 10:31 A.M., of the North Nurse's cart showed: -Resident #59 had an opened vial of Lorazepam that did not have a date when it was opened. The box said it expired 90 days after opening. -The pharmacy label was removed from a Narcan Nasal Spray. The Narcan Nasal spray had with an expiration date of February 2026 and had no resident's name on the bottle. -An opened bottle of Multivitamin expired 2/2026. -LPN A said the nurses should check the carts for expired medications and make sure they are clean and organized daily. The medications should have a pharmacy label on them. Staff should not use medications that are expired, they should be destroyed. 2. Observation on 03/11/2026 at 3:12 P.M., showed: -The refrigerator in the memory care unit medication storage room did not have a log to keep track of the temperature of the refrigerator; -The refrigerator contained insulin pens, suppositories, soda for the residents, and Ensure (a supplemental drink used for those with limited nutritional intake). 3. During an interview on 03/11/2026 at 3:12 P.M., CMT D said: -There was usually a log to keep track of the medication refrigerator temperatures hung on the medication refrigerator; -CMTs were responsible for checking the medication refrigerator temperature daily. During an interview on 03/13/2026 at 8:58 A.M., CMT B said: -The medication refrigerator temperature should have been checked daily; -Sometimes checking the medication refrigerator temperature gets forgotten. During an interview on 03/13/2026 at 10:48 A.M., RN A said Medication refrigerator temperatures should be checked daily. During an interview on 03/13/2026 at 2:51 P.M., the Administrator said medication refrigerators temperatures should be checked daily by the CMTs. During interviews on 03/13/2026 at 3:15 P.M. and 03/13/26 at 3:54 P.M, the Director of Nursing (DON) said: - Medication refrigerator temperatures should be checked daily by the CMTs. -The CMTs are responsible for documenting the refrigerator temperatures and freezer temperatures in the medication room. -Lorazepam should be dated when opened. -Staff should not use expired medications; they should be destroyed -She should be checking the medication room and the medication carts for expired medications weekly and the nurses and CMTS should be checking as they pass their medications. -Housekeeping was responsible to defrost the freezer. 4. Review of the manufacturer guidelines for Degludec insulin pen showed the pen is only good for 56 days after opening. Review of Resident #56's care plan, dated 1/27/25, showed: -The resident was dependent on staff for meeting physical, emotional, and intellectual needs; -The resident had Type Two Diabetes (a chronic condition where the body does not produce enough insulin) and was dependent on insulin. Review of the resident's Order Summary Report, dated March 2026, showed: the resident had an order for insulin Degludec (a long-acting basal insulin) 14 units subcutaneous at bedtime for type two diabetes. Observation on 03/11/2026 at 3:12 P.M., showed the resident's Degludec insulin pen was opened with no date listing the day the insulin pen was opened in the memory care unit medication cart. During an interview on 03/11/2026 at 3:12 P.M., CMT D said the insulin pen should have been dated when it was opened so staff would know how long the pen is good for. During an interview on 03/13/2026 at 8:58 A.M., CMT B said insulin pens should be dated when they are first opened. During an interview on 03/13/2026 at 10:48 A.M., RN A said insulin pens should have the date they are opened on them so staff will know when the medication expires. During an interview on 03/13/2026 at 3:15 P.M., the DON said insulin pens should be dated when they are opened.
Based on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety, when facility staff failed to observe proper hairnet procedures in the kitchen, failed to monitor food items for expiration dates, and failed to properly monitor food cooking and serving temperatures. This affected all residents in the facility. The facility census was 61. Review of facility policy Food Temperatures, undated, showed:- The temperatures of all food items will be taken and properly recorded prior to service of each meal;- All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit;- All cold food items must be stored at a temperature of 41 degrees Fahrenheit;- Temperatures should be taken periodically to assure hot foods stay above 135 degrees Fahrenheit and cold foods stay below 41 degrees Fahrenheit during the holding and plating process and until food leaves the service area;- Pork should be cooked to a minimum of 145 degrees Fahrenheit;Review of facility policy Food Safety and Sanitation, undated, showed: - Employees are required to have hair restraints and should cover all hair on the head;- [NAME] nets are required when facial hair is visible;- All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored;- When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food;- Leftovers are used within 72 hours (or discarded). - Perishable foods with expiration dates should be used prior to the use by date on the package;Observation of the kitchen on 3/10/26 at 8:30 A.M., showed:- Refrigerator had stored tuna casserole expired on 3/9/26;- Refrigerator had stored sliced cheese wrapped in plastic, expired on 3/7/26;- Refrigerator had stored seven containers of whipped topping individual portions in two ounce plastic cups, expired on 3/3/26;- Refrigerator had stored 16 containers of individual portions of salad dressing in two ounce plastic cups prepared on 3/4/26, expired on 3/7/26; - Refrigerator had stored Miracle Whip 16oz jar, opened on 10/21/25, expired on 3/9/26.Observation of the kitchen on 3/12/26 starting at 3:15 P.M., showed:- Garnish plastic container with sliced tomatoes and pickles with use by date of 3/11/26 expired;- Bowl of sliced strawberries in juice, 8 ounces, with plastic wrap covering bowl, not labeled or dated;- Dietary [NAME] A not wearing a beard net over moustache while preparing deluxe club sandwich;- Dietary Assistant A not wearing a beard net over beard and not wearing a hairnet under his/her ballcap. A substantial amount of uncovered hair was exposed on both sides of his/her head from under the ball cap;- Refrigerator stored mustard, one gallon plastic container, opened on 10/21/25, expired on 2/13/26;- 3:26 P.M., pre-cooked bacon removed from package and placed in oven to cook for evening meal;- 3:50 P.M., bacon removed from the oven and no temperature check was taken by Dietary [NAME] A.Observation in the kitchen on 3/13/26 starting at 5:45 A.M., showed:- Dietary [NAME] B placed completed breakfast food items into the oven and recorded completed cooking temperatures;- 6:35 A.M., biscuits, cheese omelets, and oatmeal items all in metal containers and covered with tin foil removed from oven and placed in heating cart to transport to the first floor dining room. No food temperatures taken;- 6:42 A.M., all breakfast items placed on the steam line in the dining room (cheese omelet, biscuits, oatmeal) in metal containers with covered foil to maintain temperature so they could be served hot.During an interview on 3/13/26 at 6:55 A.M., Dietary [NAME] B said the residents always ask about meat for breakfast, they want more than we have scheduled on the menu.Observation in the dining room on 3/13/26 at 7:00 A.M., showed:- Food was uncovered and ready to serve on the steam line and no temperatures taken before serving the first meal to the residents.Observation in the kitchen on 3/13/26 at 7:00 P.M., showed dietary staff cleaning, handling leftovers, and washing dishes without hairnets and beard nets being worn.During an interview on 3/13/26 at 9:45 A.M., the Dietary Manager (DM) said:- For leftovers we only keep items for three days and then they must be discarded as soon as they are expired;- Temperatures should be taken of food items when they are doing cooking, when they are removed from the oven prior to service, and just prior to serving from the steam line;- Opened containers and packages should have date opened and date expired written on package;- Training for staff is done by daily on-the-job training, no formal training schedule established;- Hairnets are required of all kitchen staff and visitors to the kitchen. If there is facial hair growth they must wear a beard net as well. A ballcap can be worn but a hairnet must be underneath it covering all of the hair.During an interview on 3/13/26 at 1:45 P.M, the Administrator said:- Leftovers should be discarded when they are expired per facility regulations;- Hairnets and beard nets are required during kitchen operations;- Items should be properly labeled and sealed in the refrigerator.
Based on interview and record review, the facility failed to establish an antibiotic stewardship program that included consistent monitoring by facility staff for antibiotic use protocols and a system to monitor antibiotic use when the facility failed to keep a consistent record of antibiotic use for four residents at the facility (Residents #29, #43, #49, and #66). This had the potential to affect all residents. The facility census was 61. Review of the facility's Antibiotic Stewardship policy, dated December 2024, showed the purpose of the antibiotic stewardship program was to monitor the use of antibiotics in the facility's residents with seven core elements which included leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. Tracking to include how and why antibiotics are used, the amount of antibiotics used, and tracking adverse outcomes from antibiotics. Education of staff, residents and family regarding the use of antibiotics. Review of the facility's antibiotic stewardship and infection surveillance book showed no tracking of antibiotic use or infection surveillance for the August 2025, September 2025, October 2025, February 2026, and March 2026. Review of clinical progress notes showed the following residents were on antibiotics in the month of March 2026:-Resident #29 was started on Cephalexin for Urinary Tract Infection (UTI) on 03/10/2026;-Resident #43 was started on Cefpodoxime for Upper Respiratory Infection (URI) on 03/07/2026;-Resident #49 was started on Trimethoprim for UTI on 03/02/2026;-Resident #66 was started on Cefpodoxime for URI on 3/9/26. During an interview on 03/12/2026 at 3:45 P.M., the Infection Control Nurse said:- The facility's Director of Nursing (DON) was also the Infection Control Nurse from May 2025 to November 2025;- The infection surveillance and antibiotic stewardship tracking should be an ongoing process since this information changed so frequently;- Infection surveillance and antibiotic stewardship should have been completed for August 2025, September 2025, October 2025, and February 2026. During interviews on 03/13/2026 at 8:29 A.M. and 2:51 P.M., the Administrator said:-When the current Infection Control Nurse took over, she noticed the missing antibiotic stewardship data for August, September, October of 2025, February 2026, and March 2026.-A performance improvement plan was put into place.-The Infection Nurse had been working more as a nurse on the floor and less time to the Infection Prevention role. -The infection surveillance and antibiotic stewardship binder should have been kept up to date;-The infection surveillance and antibiotic stewardship tracking for February and March of 2026 should have been completed. During an interview on 03/13/2026 at 3:15 P.M., the DON said:- The infection surveillance and antibiotic stewardship binder should have been kept up to date;- The infection surveillance and antibiotic stewardship tracking for February and March of 2026 should have been completed. During an interview on 03/13/2026 at 11:00 A.M., the Infection Control Nurse said:- She was working on the mapping and tracking of the antibiotic stewardship and infection surveillance for February and March of 2026;- She had to work as a charge nurse frequently and had not had time to complete the antibiotic stewardship and infection surveillance for February and March 2026, and should kept up to date weekly for surveillance and tracking.
Based on interview and record review, the facility failed to issue advanced beneficiary notice of non-coverage form to notify one resident (Resident #66) of changes in coverage to items and services covered by Medicare and/or by the Medicaid State plan and failed to notify one resident (Resident #70) of their right to appeal a notice of non-coverage of items and services covered by Medicare and/or by the Medicaid State plan, affecting two out of 15 sampled residents. The facility census was 61.Request of facility policy Medicare Advance Beneficiary and Medicare Notice not provided.1.Review of Resident #70's electronic medical record and Beneficiary Protection Notification Review, dated 3/11/26, showed:- A physician's order for the resident's last covered day for Medicare Part A service was 9/25/25;- Progress notes showed the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted on 9/25/25.- The facility was unable to show that a Notice of Medicare Non-Coverage (Form CMS 10123-NOMNC - A form that informs the resident on their right to appeal and how to ask for an immediate appeal) was issued to the resident.2. Review of Resident #66's electronic medical record and Beneficiary Protection Notification Review, dated 3/11/26, showed:- A physician's order for the resident's last covered day for Medicare service was 3/6/26; - Progress notes showed the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted on 3/6/26; -The facility was unable to show that a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN - A form that explains to the resident what coverages are no longer covered and the cost associated with continuing those coverages. Additionally, this form allows the resident to indicate the preference with continuing or stopping therapeutic services) was signed by the resident.During an interview on 3/12/26 at 9:45 A.M., the Social Services Director said she was responsible for completing these forms and she was unable to find the missing documents for Resident #70 and #66. During an interview on 3/13/26 at 1:25 P.M., the Administrator said residents should be notified when they have a notice of Medicare non-coverage and their right to appeal. Additionally, all of the associated documents should be on file for review.
Based on interview and record review, the facility failed to electronically transmit Minimum Data Set assessments (MDS, a federally mandated assessment completed by the facility) in a timely manner and in accordance with guidelines for one resident (Resident #60) out of 15 sampled residents. The facility census was 61.Review of the facility's policy, MDS Completion and Submission Timeframes, revised July 2017, showed:- Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes;- The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to Centers for Medicare & Medicaid Services (CMS) in accordance with current federal and state guidelines;- Timeframes for completion and submission is based on the current requirements published in the Resident Assessment Instrument Manual.Review of the Resident Assessment Instrument (RAI) Manual for assessment transmission showed the following:- Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date;- All other MDS assessments must be submitted within 14 days of the MDS completion date.Review of Resident #60's medical record showed: - A quarterly MDS assessment with a care plan completion date of 02/03/26;- The quarterly MDS assessment transmitted and accepted on 03/12/26 (37 days late).During an interview on 03/13/26 at 9:40 A.M., the Regional Nurse Consultant said:- She had been responsible for the MDS for the past month and a half and the resident's quarterly MDS was late;- The previous MDS coordinator quit around mid-January and the facility utilized an outside vendor that just notified them yesterday there were sections of the MDS that were incomplete;- She fixed the sections yesterday and sent the completed MDS;- A performance improvement project (PIP) was done mid-February concerning the MDS. During an interview on 03/13/26 at 2:35 P.M., the Administrator said MDS assessments should be completed and sent within the required timeframes.
Based on observation, interview, and record review, the facility failed to ensure a resident with an indwelling catheter (a thin tube inserted into the bladder through the urethral opening to drain urine), received the appropriate care and services to prevent urinary tract infections to the extent possible, when the facility staff failed to ensure proper urinary catheter care was performed for one (Resident #29) of 15 sampled residents. The facility census was 61.Review of the facility's Urinary Catheter Care policy, dated September 2014, showed:- Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward;- The facility's policy did not address the use of disposable wipes when providing catheter care. Review of Resident #29's admission Minimum Data Set (MDS), a federally required assessment tool completed by facility staff, dated 1/22/26, showed the resident:- not cognitively intact;- dependent on staff for carrying out activities of daily living;- had diagnoses of non-Alzheimer's dementia, anxiety, and depression. Review of the resident's care plan, dated 1/9/26, showed the resident:- resided on the memory care unit;- received hospice care;- incontinent of bowel and required staff assistance for personal hygiene and grooming. Review of the resident's order summary report, dated 3/13/26, showed the resident had an order for cephalexin 500 milligrams (mg) twice a day every 12 hours by mouth for a urinary tract infection from 3/10/25 to 3/24/26. Observation on 03/10/2026 at 2:20 P.M., showed:- Certified nursing assistant (CNA) C and CNA D performed catheter care on the resident;- CNA D used a disposable cleansing wipe to clean the resident's catheter tubing and wiped the catheter tubing towards the catheter insertion site;- CNA D used a new disposable cleansing wipe to clean the resident's catheter tubing and wiped the catheter tubing towards the catheter insertion site. During an Interview on 03/12/2026 at 10:40 A.M., CNA C said when performing catheter care the tubing should be cleaned with a disposable cleansing wipe, wiping away from the catheter insertion site down the catheter tubing. During an Interview on 03/12/2026 at 11:00 A.M., CNA D said:- He/she knew better than to clean the catheter tubing towards the catheter insertion site;- He/she should have cleaned the catheter tubing wiping away from the catheter insertion site. During an Interview on 03/13/2026 at 8:58 A.M., Certified Medication Technician (CMT) B catheter tubing should be cleaned by wiping away from the catheter insertion site. During an Interview on 03/13/2026 at 10:48 A.M., Registered Nurse (RN) A said catheter tubing should be cleaned by wiping away from the catheter insertion site. During an Interview on 03/12/2026 at 3:45 P.M., the Infection Control Nurse said catheter tubing should be cleaned by wiping away from the catheter insertion site. During an Interview on 03/13/2026 at 3:15 P.M., the Director of Nursing (DON) said catheter tubing should be cleaned by wiping away from the catheter insertion site.
Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure enhanced barrier precautions (EBP) (a strategy to decrease transmission of multidrug resistant organisms where staff wear a gown and gloves during high contact care for residents with wounds and/or indwelling medical devices) when providing direct care for a resident that had an indwelling urinary catheter (a thin tube inserted into the bladder through the ureteral opening to drain urine) (Resident #29) and additionally, when the staff failed to clean the port of an insulin pen prior to attaching the needle which affected Resident #69. The facility census was 61. Review of the facility's Enhanced Barrier Precautions policy, dated 2/3/26, showed: - EBP is indicated for residents with wound and/or indwelling medical devices such as urinary catheters and feeding tubes; - For residents whom EBP is indicated, EBP should be utilized during the following high-contact resident care activities: dressing, transferring, bathing, providing hygiene, and changing briefs or assisting with toileting; - Facility should ensure personal protective equipment (PPE) and alcohol based hand rub are readily available to staff. 1. Review of Resident #29's admission Minimum Data Set (MDS), a federally required assessment tool completed by facility staff, dated 1/22/26, showed: -The resident was not cognitively intact; -The resident was dependent on staff for carrying out activities of daily living; -Had a indwelling urinary catheter; -The resident had diagnoses of Non-Alzheimer's Dementia, anxiety, and depression. Review of the resident's care plan, dated 1/9/26, showed: - The resident resided on the memory care unit; - The resident received hospice care; - The resident was incontinent of bowel and had an indwelling urinary catheter. Observation on 03/11/2026 at 2:38 P.M. showed: - Certified Nursing Assistant (CNA) E and Certified Medication Technician (CMT) D transferred the resident from his/her wheelchair to the bed; - CNA E and CMT D did not utilize EBP (glove and a gown) while transferring the resident; - CNA E touched the resident's brief to see if the brief needed changed without wearing gloves or a gown. During an interview on 03/11/2026 at 3:12 P.M., CMT D said he/she should have worn EBP while transferring the resident. During an interview on 03/11/2026 at 3:17 P.M., CNA E said: - He/she should have worn EBP when transferring the resident; - He/she should have worn gloves when checking to see if the resident's brief needed to be changed. There were no gloves in the resident's room. During an interview on 03/13/2026 at 8:58 A.M., CMT B said: - EBP should be worn when providing direct care to residents with a catheter; - Gloves should be worn when checking to see if a resident's brief needs to be changed. During an interview on 03/13/2026 at 10:48 A.M., Registered Nurse (RN) A said: - EBP should be worn when providing direct care to residents with a catheter; - Gloves should be worn when checking to see if a resident's brief needs to be changed. During an interview on 03/12/2026 at 3:45 P.M., the Infection Control Nurse said: - EBP should be worn when proving direct care to a resident with a catheter, such as when transferring a resident; - Gloves should be worn when checking to see if a resident's brief needs to be changed. During an interview on 03/13/2026 at 3:15 P.M., the Director of Nursing (DON) said: - EBP should be worn when providing direct care to residents with a catheter; - Gloves should be worn when checking to see if a resident's brief need to be changed. 2. The facility did not provide a policy for how to use an insulin pen. Review of record showed manufacturer guideline for Basaglar KwikPen suggests that all insulin pens be swabbed with an alcohol wipe for 15 seconds, allow to dry, prior to attaching the needed to the insulin pen. Review of Resident #69's Physician Order Sheet (POS) dated March 2026 showed a start date: 3/3/26 - Basaglar KwikPen Solution Pen-injector, inject 50 units daily for diabetes mellitus. Review of the resident's Medication Administration Record (MAR), dated March 2026 showed Basaglar KwikPen Solution Pen-injector, inject 50 units daily for diabetes mellitus. Observation on 3/12/26 at 8:22 A.M., showed: - CMT A sanitized his/her hands, applied gloves, and attached the needle to the insulin pen. CMT A did not clean the tip of insulin pen with alcohol pad prior attaching the needle. - CMT A primed the insulin pen with two units of insulin then dialed it to 50 and administered to the resident at 8:26 A.M. During an interview on 3/13/26 at 3:38 P.M., CMT A said he/she did not know if the port of the insulin pen should have been cleaned with an alcohol wipe before he/she attached the needle. During an interview on 3/13/26 at 9:29 A.M., RN A said staff should clean the port of the insulin pen with an alcohol wipe before they attached the needle. During an interview on 3/13/26 at 3:54 P.M., the DON and the Regional Nurse Consultant (RNC) said staff should clean the port of the insulin pen with an alcohol wipe before they attach the needle.
Inspection of December 12, 2025
3 findingsBased on interview, and record review, facility staff failed to properly transfer one resident (Resident #1), in a safe manner, when the staff failed to ensure the resident's sling was securely connected to the mechanical lift (a mechanical device used to safely lift and transfer people with limited mobility, like the elderly or disabled, from one surface (bed, chair, toilet) to another, using a sling for full-body support, preventing caregiver strain and patient falls) when transferring the resident, and the resident fell from the lift to the floor causing pain to the resident's shoulders and left hip. The facility census was 55. Review of the facility's Safe Lifting and Movement of Residents policy, dated July 2017, showed:-In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis; -Staff will document resident transferring and lifting needs in the care plan; -Such assessment shall include a resident's preferences for assistance, resident's mobility/degree of dependency, resident's size, weight-bearing ability, cognitive status, if the resident is usually cooperative with staff and resident's goals for rehabilitation; -Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices;-Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary; -Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents; -Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques; -Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hour a day while batteries are being recharged. -Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, residents with lifting and movement needs will be provided with single-resident use disposable slings. -Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. -All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints. -Safe lifting and movement of residents is part of an overall facility employee health and safety program, which involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies, addresses reports of workplace injuries, provides training on safety/ergonomics/proper use of equipment, and continually evaluates the effectiveness of workplace safety and injury-prevention strategies. 1. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated 9/6/25, showed:-The resident had adequate hearing, unclear speech, was sometimes able to make self understood and usually understands others;-He/She scored one on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents), indicating severely impaired cognitive functioning;-He/She required substantial to maximum assistance with all Activities of Daily Living (ADLs), including dressing, bathing, personal hygiene and transfers. Review of the comprehensive care plan, dated 12/3/25, showed:- Staff were supposed to help the resident with bathing and showering, turn and reposition in bed, getting dressed, required extensive assistance of two staff with mechanical lift to move between surfaces;-The resident required assistance of one staff for locomotion;-He/She had impaired cognitive functioning related to stroke and Alzheimer's Disease;-He/She had difficulty communicating;-He/She was a moderate risk for falls and the staff were supposed to ensure the resident was secure and safe in the mechanical lift before moving him/her;- The resident had pain related to hemiparesis (weakness of one side of the body).Review of a progress note dated 12/4/25 at 5:00 P.M. Primary Care Physician (PCP) A documented: -Staff called and stated the resident was dropped four feet from a mechanical lift;-It was reported the resident was in significant pain and it appeared the resident had deformities; -An order was given to send the resident to the hospital, however the facility did not want to do that;-We will write an order for pain medication;-Mobile x-rays are not as good as x-rays obtained at he hospital and could miss fractures. Review of the resident's Physician Order Sheet (POS), dated 12/5/25, showed:-An order for Hydrocodone-Acetaminophen Oral Tablet 5-325 Milligrams (MG) Give one tablet by mouth three times daily for pain. Review of the facility investigation, dated 12/4/25 showed: -On 12/3/25 at approximately 3:35 P.M., CNA A and CNA B were getting the resident up to go shower;-Both CNA's used the mechanical lift and sling to get resident up from the bed and into the shower chair;-CNA A was maneuvering the lift and CNA B was guiding and holding the resident;-They turned from the bed toward the shower chair without incident;-As they turned the rest of the way, they saw the sling strap move and come up over the corner of the lift bar;-Both CNA's grabbed for the resident who fell through their hands to the floor;-LPN A was notified and entered the room to assess the resident;-The mechanical lift used during the transfer was an Invacare Reliant 600 Hoyer lift;-The mechanical lift was assessed by maintenance staff on 12/3/25 and it was found to be in normal working order.Review of the resident's Physician Order Sheet (POS), dated 12/5/25, showed an order for Hydrocodone-Acetaminophen (a highly addictive medication for severe pain) Oral Tablet 5-325 Milligrams (MG) Give one tablet by mouth three times daily for pain. Review of Resident #1's Face Sheet on 12/9/25, showed:-He/She diagnoses include: Cerebral infarction due to embolism of cerebral artery (damage to tissues in the brain due to a loss of oxygen to the area, stroke), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath), dysphagia (difficulty swallowing), aphasia (a language disorder that affects a person's ability to communicate), hemiplegia and hemiparesis following cerebral infarction affecting dominant right side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing a significant impairment in daily life), insomnia, pain, abnormal involuntary movements, anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), polyneuropathy (occurs when multiple peripheral nerves become damaged. Symptoms include problems with sensation, coordination, or other body functions), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), seizures (a burst of uncontrolled electrical activity between brain cells (neurons, nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness).Review of the user manual for the mechanical lift on 12/10/25 at 9:15 A.M., showed:-When elevated a few inches off the surface of the stationary object, and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar;-Be sure to check the sling attachments each time the sling is removed and replaced to ensure that it is properly attached before the patient is removed from the bed or chair; -Place the straps of the sling over hooks of the hanger bar;-Match the corresponding colors on each side of sling for an even lift of the patient;-Invacare lift hanger bars have three hookup points per side;-The middle hookup is only used for slings that have three sets of straps per side;-The patient's arms should be inside of the straps;-Do not use slings and patient lifts of different manufacturers; -When moving the patient, lift away from the bed, turn the patient so that he/she faces assistant operating the lift; -The legs of the lift must be in the maximum open position and shift handle locked in place for optimum stability and safety;-If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed;-When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately;-Ensure the legs of the lift (with patient) are in the open position;-Move the wheelchair into position;-Engage the rear wheel locks of the wheelchair to prevent movement of the chair;-Use the straps or handles on the side and the back of the sling to guide the patient's hips as far back as possible; -Position the patient over the seat with their back against the back of the chair;-Begin to lower the patient either by opening the control valve or by pressing the down button;-With one assistant behind the chair and the other operating the patient lift, the assistant behind the chair will pull back on the grab handle (on select models) or sides of the sling to seat the patient well into the back of the chair; -Leave the sling in place in the seat for proper positioning. During an interview on 12/10/25 at 11:19 A.M., the Resident said:-The staff were using a mesh sling as they were getting ready to take him/her to the shower;-It hurt when he/she fell and it was scary. During an interview on 12/10/25 at 11:29 A.M., LPN A said:-Staff called him/her to the resident's room and he/she observed the mechanical lift facing toward the window of the room and CNA A and B in the resident's room;-The legs of the lift were open, and the resident was laying on the floor in between the legs:-He/She recalled the mechanical lift the CNA's used had four sling hook ups, not six;-The two hooks by the resident's head and shoulders were still attached to the lift;-The hooks on one side of the bottom of the lift were attached;-The lower left hook of the sling was not attached to the mechanical lift; -Staff told him/her that the sling came undone during the transfer but were unsure how; -The CNA's told him/her when they went to turn the resident in the lift, the sling must have swung up and come undone;-After the fall, the resident complained of pain, shoulder to shoulder, and pain in the left hip;-The resident hit his/her shoulder on one of the legs of the mechanical lift when he/she fell;-HE/She called the physician who gave the order to send the resident to the hospital for x-rays and evaluation;-Administration told LPN A to get stat (right away) mobile x-rays at the facility;-LPN A informed the physician of this, and he/she agreed if the mobile x-ray could be done within an hour. During an interview on 12/10/25 at 1:17 P.M., CNA A said:-CNA A and CNA B were using the lift with four sling hookups and a green sling for the resident;-The resident was on the bed and the staff were getting ready to transfer the resident to the shower chair; -CNA B hooked the loops on the left side of the sling to the mechanical lift and CNA A hooked the loops on the right side of the mechanical lift;-After all the loops were hooked to the lift, the CNA A and B got ready to move the resident;-CNA A was holding and maneuvering the mechanical lift and CNA B was helping guide the resident while in the sling;-When they went to turn the resident toward the shower chair, the loop on the left, lower side of the sling came up and over the lift bar, and the resident fell from the sling;-He/She recalled the resident swayed in the swing a bit during the transfer, but not more than a usual mechanical lift transfer;-The resident fell between the legs of the lift and hit his/her left shoulder on one of the legs; During an interview on 12/10/25 at 2:55 P.M., CNA B said:-CNA A and CNA B were using the brown mechanical lift with the six sling hookups to transfer the resident from his/her bed to the shower chair;-They had to use this particular lift because it was the only lift that used a mesh bath sling; -CNA A and CNA B placed the mesh sling underneath the resident while he/she was on the bed;-CNA A hooked up the loops on the sling to the mechanical lift on the right side and CNA B hooked the loops of the sling on to the left side;-CNA A moved the mechanical lift and CNA B supported and guided the resident while he/she was being transferred;-While CNA A and B turned the lift toward the shower chair, a loop on the left side of the sling came off of the mechanical lift; -The resident slid from the sling to the floor, hitting his/her shoulder on one of the legs of the lift;-CNA B covered the resident with a blanket and stayed with him/her, while CNA A went to get the charge nurse. During an interview on 12/10/25 at 3:19 P.M., the Primary Care Physician (PCP) A said:-On 12/3/25, the facility staff notified him/her by phone the resident had fallen from a mechanical lift during a transfer, from a height of approximately four feet; -The nurse informed him/her the resident was experiencing pain and he/she gave the nurse the order to send the resident to the hospital for x-rays; -The nurse informed the physician the administration of the facility stated the resident would not be going to the hospital but will have x-rays taken at the facility by a mobile unit;-He/she gave an order to re-instate the resident's pain medication due to reports the resident was in pain from the fall. -He/She saw the resident the next day and the resident's x-rays were negative for fractures.During an interview on 12/10/25 at 3:20 P.M., the Director of Nursing (DON) said:-He/She was notified on 12/3/25 the resident had fallen from a mechanical lift while staff were transferring the resident form the bed to a shower chair; -The staff stated, while moving the resident from the bed to the shower chair, a loop on the sling became unhooked from the lift and the resident slid from the sling to the floor; -It was her expectation that staff ensure the sling was securely attached to the mechanical lift before transferring a resident. During an interview on 12/12/25 at 2:05 P.M., the Administrator said it was his/her expectation that staff check to make sure the resident and sling were securely attached to the mechanical lift before transferring the resident. Intake 2684304
Based on interview and record review the facility failed to ensure two sampled residents (Resident #2 and Resident #3) had the right to be free from misappropriation when staff failed to follow protocol and conduct an investigation when each resident had missing fentanyl pain patches and staff did not account for the missing patches. The facility census was 55.Review of the facility provided policy titled, Storage of Controlled Substances, dated 8/2020 showed:-Any discrepancy in controlled substance counts is reported to the Director of Nursing immediately; -The Director or Designee investigates and makes every reasonable effort to reconcile all reported discrepancies.1. Review of Resident #2's Medical Record showed:-He/She admitted to the facility on [DATE]-He/She had a diagnoses of Anoxic Brain injury (brain damage caused by complete loss of oxygen to the brain), major depressive disorder, quadriplegia, convulsions, low heart rate, and atrial fibrillation; -He/She had significant cognitive loss; -He/She was dependent on staff for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself);Review of the Physician's Order Sheet (POS) dated November 20205 showed:-Physician's order for Fentanyl (a highly addictive pain medication) transdermal patch 72 hour, 12 micrograms (mcg)/hour (hr), apply one patch transdermally (on the skin) in the morning every 3 days for pain, Ordered 11/20/25 and discontinued 11/26/25;-Physician's order for Fentanyl transdermal patch 72 hour, 12 micrograms (mcg)/hour (hr), apply one patch transdermally (on the skin) in the morning every 3 days for pain, cover Fentanyl patch with transparent dressing: ordered 11/26/2025.Review of the Medication Administration record (MAR), dated November 2025 showed:-A patch was placed on the resident's right front shoulder on 11/20/25 at 4:39 P.M.; -Patch placed on right upper arm on 11/23/25 at 4:18 P.M.; -On front left shoulder 11/26/25 at 6:00 A.M; -A patch was placed on the resident's front right shoulder on 11/27/25 at 8:57 A.M Review of Nurse Progress Notes dated 11/23/25 at 6:05 P.M. showed: -The resident did not have his/her patch that was applied 11/20/25 on;-The nurse and the Certified Nurse Aide (CNA) looked through the linens, under the bed and the surrounding areas;-The fentanyl patch was not found;-A message was left for management staff in a communication application;-A new patch was applied to the resident's upper outer right arm and covered it with a tegaderm (a clear adhesive dressing). During an interview on 12/10/25 at 1:30 P.M. Licensed Practical Nurse (LPN) A said:-On 11/23/25 Resident #2's patch was not on when he/she went to place a new patch; -He/She notified the Director of Nursing (DON) via a communication application the patch was missing; -It is not part of medication patch orders to check the patch daily; -He/She looked for the patch in the bedding and on the floor;-The DON, Assistant DON or the Administrator did not ask him/her any questions about the missing patch;-He/She is not aware any investigation was done.2. Review of Resident #3's Medical Record showed:-He/She admitted to the facility on [DATE];-He/She had diagnoses of: Heart disease, falls, atrial fibrillation, pain, unspecified dementia and anxiety.-He/She has mild cognitive loss. Review of the resident's comprehensive care plan dated 9/24/25 showed:-He/She was received pain medication for chronic pain; -The resident will verbalize adequate relief of pain; -The staff were supposed to administer the resident's pain medication as ordered; -Evaluate the effectiveness of pain interventions;-He/She needed moderate assistance of staff for ADLs.Review of the resident's December MAR showed and order dated 12/6/25 for Fentanyl transdermal patch 72 hour 12mcg/hr, apply 1 patch in the afternoon every 3 days for pain and remove per schedule. During an interview on 12/10/25 at 3:00 P.M. Resident #3 said:-He/She was in a lot of excruciating pain 12/9/25; -He/She had a pain patch applied after his/her bath on 12/6/25 but the patch was not there when the nurse put his/her new patch on, on 12/9/25; -The nurse got a new patch applied on the afternoon of 12/9/25 and his/her pain was much better on 12/10/25;-He/She was not asked any questions about his/her patch missing.During an interview on 12/9/25 at 3:20 P.M. the DON said:-She was aware a Resident #2's pain patch was missing after a shower; -She did not do an investigation where everything was written down; -Pain patches should be removed and placed in a special dissolving agent to dispose of the patch;-Pain patches should be counted at the beginning and ending of every shift, like other narcotic medications;-She was not aware Resident #3's pain patch was missing. During an interview on 12/10/25 at 3:50 P.M. the Medical Director said:-He would expect to be notified of missing narcotics; -He would expect the facility staff to notify him, or the Nurse Practitioner if a patch was not in place at the time of change;-He was not notified that Resident #2 and #3 had Fentanyl patches missing and unaccounted for.During an interview on 12/11/25 at 2:55 P.M. the [NAME] President of Clinical Operations said:-She would expect staff to look for the patch, ask the resident, report the missing patch to the Administrator and complete an investigation and progress note;-She was not aware two patches were recently not in place on residents when time to apply a new patch.During an interview on 12/11/25 at 3:05 P.M. the Administrator said:-She would expect an investigation to be done if patches are missing at the time of change; -She was aware that two patches were missing on the day they were to be changed and the old patches were unaccounted for; -She was notified after the fact of the missing patches; -She would expect there to be documentation of the missing patch and the investigation that followed. Intake 2669296Intake 2658063
Based on observation, interview and record review, the facility failed to follow physician's orders for one resident (Resident #1)when the physician ordered for the resident to be sent to the hospital for X-rays and an evaluation after the resident fell from a mechanical lift sling and experienced pain, and was not. The facility census was 55.Review of the facility's undated policy titled, Medication Orders, showed: -The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders;-Supervision by a Physician: Each resident must be under the care of a Licensed Physician authorized to practice medicine in the state and must be seen by the Physician at least every sixty (60) days;-A current list of orders must be maintained in the clinical record of each resident;-Orders must be written and maintained in chronological order; -When recording treatment orders, specify the treatment, frequency and duration of the treatment. 1.Review of Resident #1's Face Sheet on 12/9/25, showed:-He/She had the diagnoses of cerebral infarction due to embolism of cerebral artery (damage to tissues in the brain due to a loss of oxygen to the area, stroke), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath), dysphagia (difficulty swallowing), aphasia (a language disorder that affects a person's ability to communicate), hemiplegia and hemiparesis following cerebral infarction affecting dominant right side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing a significant impairment in daily life), insomnia, pain, abnormal involuntary movements, anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), polyneuropathy (occurs when multiple peripheral nerves become damaged. Symptoms include problems with sensation, coordination, or other body functions), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), seizures (a burst of uncontrolled electrical activity between brain cells (neurons, nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated 9/6/25, showed:-The resident had adequate hearing, unclear speech, was sometimes able to make self-understood and usually understands others;-He/She scored one on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents) indicating the resident had severely impaired cognitive functioning;-He/She required substantial to maximum assistance with all Activities of Daily Living (ADLs), including dressing, bathing, personal hygiene and transfers. Review of the comprehensive care plan, dated 12/3/25, showed:-Interventions related to ADLs, bathing and showering, required extensive assist of one to two staff to turn and reposition in bed;-The resident required extensive assistance of two staff with a mechanical lift to move between surfaces:- The resident had limited physical mobility and required assistance of one staff for locomotion using a wheelchair:- The resident had impaired cognitive functioning related to stroke and Alzheimer's Disease:- The resident had difficulty communicating;- Was at moderate risk for falls, the facility staff were supposed to ensure resident was securely and safely in mechanical lift before moving him/her;- The resident experienced pain related to hemiparesis (weakness on one side of the body). Review of the progress note dated 12/3/25, Licensed Practical Nurse (LPN) A showed:-12/3/25 at 4:54 P.M. This nurse was called to resident's room by Certified Nurses Assistant (CNA) A who stated the nurse was needed in the room;-The resident was laying on the floor, between the feet of the mechanical lift;-A blanket was over the resident, and the resident was not moving or making any noise with no complaints of pain;-The resident was not able to respond in long worded sentences but responded with simple yes and no answers;-The resident was assessed, and blood pressure was within normal limits for this resident;- A skin assessment was completed, checked range of motion that was within normal limits for this resident;-No complaints of pain or shortness of air;-Provider was notified, guardian was notified of the fall;-Director of Nursing (DON) was notified and resident was assisted back to bed;-The resident's physician provided an order to send the resident to the hospital and obtain two view thoracic (mid back) and lumbar (lower back) spine x-ray of left hip STAT (immediately)-- X-rays were obtained;-The resident was resting in bed with call light within reach;-Fall was witnessed and resident did not hit head. Review of the progress note dated 12/4/25, Primary Care Physician (PCP) A documented: -Patient was examined;-Staff called and stated he/she was dropped four feet from a mechanical lift;-It was reported the resident was in significant pain and it appeared he/she had deformities;-An order was given to send him/her to the hospital, however the facility did not want to do that.-Mobile x-rays are not as good as hospital x-rays and could miss fractures being seen. During an interview on 12/10/25 at 11:29 A.M., LPN A said:-He/She was the charge nurse on 12/3/25 when Resident #1 fell from the mechanical lift; -When entering the room after being called by staff, LPN A observed the mechanical lift was facing toward the window, feet open, and the resident laying in-between the legs of the lift;-The resident was covered by a blanket;-LPN A began assessing the resident;-Staff informed LPN A the hooks on the sling had come undone, but they are unsure how this happened;-The resident complained of pain across his/her shoulders and in left hip;-The resident hit his/her shoulder on one of the legs of the lift when he/she fell, and also landed on his/her left hip;-LPN A called PCP A who gave the order to send the resident to the hospital for x-rays and evaluation;-LPN A was informed by facility corporate personnel and the administrator that the facility would not be sending the resident out for x-rays but will be calling for mobile x-rays to come to the facility;-LPN A informed PCP A of the instructions from the administration;-PCP A agreed only if mobile x-rays could be taken within the hour. During an interview on 12/10/25 at 3:19 P.M., PCP A said:-Facility staff notified him/her on 12/3/25 the resident had fallen approximately four feet from a mechanical lift and hit his/her shoulder and left hip during the fall; -PCP A gave the order to send the resident to the hospital for x-rays and evaluation; -A short time later, facility staff notified him/her the facility administrator gave staff instructions to not send the resident to the hospital but the resident would receive mobile x-rays at the facility;-He/She was unaware why this decision was made;-He/She disagreed with this decision, as mobile x-rays are not as good as ones taken in a hospital, but agreed if the mobile x-rays could be taken within the hour; -It was his/her expectation that orders given to facility staff be followed unless it would be a risk to the resident's life to send the resident to the hospital;-He/She expected if a resident's had a fall from that height, they should be sent to the hospital every time for evaluation. During an interview on 12/10/25 at 2:44 P.M, the Medical Director (MD) said he/she would absolutely expect facility staff to follow an order given by a physician. Not doing so is unacceptable. During an interview on 12/9/25 at 3:20 P.M., the Director of Nursing (DON) said:-He/She started at the facility in July 2025 as a floor nurse, then became the DON in September 2025. -It was his/her expectation that staff follow orders given by a physician;-He/She is unsure why staff did not follow the order given to send the resident to the hospital for x-rays after the resident fell from the mechanical lift. During an interview on 12/12/25 at 2:05 P.M., the Administrator said:-He/She expected staff to use the mobile x-ray services that the facility had a contract with;-If they physician gives an order to send a resident to the hospital for x-rays, the nurse should inform the physician that the facility uses mobile x-ray services, and x-rays will be completed at the facility. Intake 2684304
Inspection of August 11, 2025
1 findingBased on interview and record review, the facility failed to protect one cognitively impaired resident's (Resident #1) right to be free from abuse when staff found Resident #2 in Resident #1's bed with his hand on Resident #1's genital area. This deficient practice affected one of three residents sampled. The facility census was 78. The administrator was notified on 8/6/25 at 2:04 P.M. of an Immediate Jeopardy (IJ) which began on 7/31/25. The IJ was removed on 8/6/25 as confirmed by surveyor on-site verification.Review of the facility provided Policy Abuse Prevention Program, dated 2001 and revised 2011, showed:-Residents have the right to be free of abuse, neglect, misappropriation, and exploitation. This includes but is not limited to verbal, mental, sexual, or physical abuse; -As part of the resident abuse prevention, the administration will: protect residents from abuse by anyone including facility staff, other residents, consultants, and visitors;-Our facility will not condone any form of resident abuse or neglect;-Abuse is the willful infliction of injury, unreasonable confinement, or intimidation with resulting physical harm, pain, or mental anguish. 1.Review of Resident #1's Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 7/15/25, showed: -Significant cognitive impairment, clear speech, usually understood, physical symptoms (such as hitting, kicking and pinching) directed at others 1-3 days of 7 days, and rejected care 1-3 days of 7 days, no wandering.-Diagnoses included: Dementia (a disease that affects the brain causing memory loss), without behavior disturbance, asthma, high blood pressure, psychosis (seeing /hearing and believing things that are not based in reality), anxiety, and Alzheimer's Disease. Review of the resident's Comprehensive Care Plan, dated 7/15/25, showed: -The resident had impaired cognitive function and/or impaired thought processes related to Alzheimer's Dementia;-She had difficulty making decisions, and had long and short term memory loss;-Staff should use the resident's preferred name, identify themself at each interaction, face the resident when speaking and make eye contact;-Reduce any distractions, such as turn off the television/radio, and close the door;-The resident understands consistent, simple, direct sentences. Provide the resident with necessary cues; stop and return if he/she became agitated;-Ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Present just one thought, idea, question or command at a time.Review of the resident's July 2025 progress notes showed: -On 7/31/2025 at 6:07 A.M.: The night shift nurse called to report that a male resident had been found by the Certified Medication Technician (CMT) in Resident #1's room, lying in bed with her and his hand in Resident #1's pants, but outside of the brief. Resident #1 was not observed to be alarmed or in distress at the time. The residents were quickly separated and Resident #2 was removed from Resident #1's room and redirected. A physical exam of Resident #1 was immediately completed to ensure safety and no injury; with no signs of bruising, swelling or other sign of injury. The spouse and the doctor were to be notified this morning as well as other resident family and doctor. Staff were increasing monitoring for this resident to ensure safety and mental/emotional wellness;-7/31/2025 at 7:22 A.M.: It was reported from the previous shift, that a resident of the opposite sex was found in this resident's bed lying next to her. It was stated that Resident #2 had his hand down Resident #1's pants, moving it in a back & forth motion. It was reported the nurse on the previous shift examined Resident #1's bikini area and found no abrasions, bruising, or any other injuries. Resident #1 showed no distress/agitation. Resident #1 was very calm, resting quietly with eyes closed; -7/31/2025 at 10:41 A.M.: Resident #1's spouse notified of the incident;-7/31/2025 at 12:03 P.M.: Notified the resident's Primary Care Physician office nurse of incident.Review of Resident #2's Quarterly MDS, dated [DATE], showed: -Significant cognitive impairment, no behaviors, and partial/moderate assist of staff with Activities of Daily Living (ADLs: tasks completed in a day to care for oneself);-Diagnoses included: Respiratory failure, dementia with behavioral disturbance, high blood pressure, anxiety, bipolar disorder (a mental illness with significant shifts in mood, energy and function), and tremor. Review of the resident's Comprehensive Care Plan, dated 6/26/25, showed: -The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to his/her cognitive deficits; -He wound wander around the unit, as he was disoriented to place, with impaired safety awareness; -Staff were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books;-Provide structured activities such as toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. -The resident resided on the secure SCU; -The resident may become inappropriate, such as excessive groping/touching with other female residents/care staff. He will be monitored with no unwanted/undirected episodes of groping/feeling behaviors towards others by review date;-Administer medications as ordered and monitor/document for any side effects and effectiveness;-Staff to intervene as necessary to protect the rights and safety of others;-Approach and speak to him in a calm manner;-Divert his attention;-Remove him from the situation and take him to an alternate location as needed; -Monitor his behavior episodes and attempt to determine any underlying cause;-Consider the location, time of day, persons involved, and situations, when behaviors occur;-Document his behavior and potential causes; -One on one activities should be held in public, open areas such as in the dining room or day room of the SCU; -Staff were to have a second person with them whenever private care is required for the resident.Review of the resident's July- August 2025 Progress Notes showed: -On 7/31/2025 at 6:03 A.M.: the night shift nurse reported the resident had been found by the CMT in another resident's room, lying in bed with her and his hand down the other resident's pants, on the outside of the brief. The other resident was not observed to be alarmed or in distress at the time. The residents were quickly separated and Resident #1 was removed from the other resident's room and was easily redirected. He was placed on 15-minute checks for closer monitoring to ensure safety;-On 7/31/2025 at 11:13 A.M.: the resident's Primary Care Physician was notified of the incident that occurred during the night shift.-On 8/1/2025 at1:57 P.M.: the resident began to question the staff about something that happened; asked what was going on, and said it was not good. Also said something happened that was not very good. The nurse sat with the resident and he began to calm down and was in good spirits at the end of conversation.During an interview on 8/5/25 at 3:53 P.M., CMT A said:-He/She assisted Resident #2 to get ready for the day at 5:30 A.M. and the resident laid back in his bed; -He/She then took linen and trash out, noting that Resident #1 was in bed at approximately 5:35 A.M.; -When he/she returned to the SCU, he/she found Resident #2 in Resident #1's bed;-He/She found Resident #2 in bed with Resident #1 at approximately 5:45 A.M. on 7/31/25;-Resident #1 was on her back and Resident #2 was on his right side facing Resident #1;-Resident #2 had his hand on the brief on Resident #1's private areas, rubbing in a circular motion;-Resident #1's brief was intact and she was barely awake and drowsy; -Resident #1 was not speaking or crying; -CMT A said stop, we need to leave the room; -Resident #2 got up and walked to him/her saying he was sorry and did not know; -He/She took Resident #2 back to her room and notified the charge nurse of the incident;-On 7/29/25 he/she was working with Resident #2 when he became aggressive and attempted to pull his/her uniform pants down and he/she left the area and another staff member assisted Resident #2. During an interview on 8/6/25 at 3:15 PM Licensed Practical Nurse (LPN) A said:-He/She was the day shift Charge Nurse on 7/31/25; -He/She was informed Resident #2 was found in bed with Resident #1 and staff could not tell if Resident #2's hand was inside the brief of Resident #1, but Resident #2 was moving his hand in Resident #1's bikini area; -The night nurse had done a skin assessment on Resident #1 and found no injuries.During an interview on 8/6/25 at 1:12 P.M., LPN B said:-He/She was on call 7/31/25 and was notified at 5:57 A.M. of the incident between Resident #1 and #2; -He/She was notified by the charge nurse, Resident #2 had been removed from Resident #1's room, returned to his room and another nurse was completing Resident #1's skin assessment.During an interview on 8/5/25 at 2:50 P.M., Certified Nurse Aide (CNA) A said: -Resident #2 did not usually go into other rooms; -Resident #2 would hold hands with other residents once in a while; -Resident #2 was kind of handsy when he would give hugs, like rubbing his hands up and down your back; he was a feely person, like when he walked up to you, he would rub your arm or hold your hand, but never saw him touch anyone inappropriately. During an interview on 8/6/25 at 2:00 P.M., the Administrator said:-He/She interviewed CNA A and CNA B in regard to the incident between Resident #1 and Resident #2; -He/She did not believe it was abuse as he/she was unsure why Resident #2 had gotten into bed with Resident #1. During a follow up interview on 8/6/25 at 2:30 P.M., CNA B said:-On 7/31/25 there were two CNAs (CNA A and CNA B) and one CMT on the SCU;-On the day shift there are two CNAs and a CMT scheduled on the SCU.During an interview on 8/5/25 at 1:29 P.M., Resident #1's Family Member A said: -He/She was notified the morning the incident occurred;-He/She did not understand how another resident got into Resident #1's room to the point of getting into bed with her and having his hand down the resident's pajamas; -When Resident #1 moved in he/she told the facility three things; one - the resident must be kept clean, two - he/she wanted the resident safe, and three - do not abuse the resident., but that is what happened. The facility did not keep Resident #1 safe;-The Administrator and Director of Nursing (DON) said nothing happened, because the other resident's hand was not inside her clothes, and that the other resident was only in there maybe 10 minutes. A lot can happen in 10 minutes;-He/She did not feel like there was enough staff to prevent this kind of incident from happening again;-Resident #1 was abused. She never would have allowed that if she was in her right mind. During an interview on 8/5/25 at 2:44 P.M., Resident #1 said: -She did not like when the other resident was in bed with her; -Resident #2 had touched down her waist, it did not hurt much and she did not like it; -She was a little bit afraid.During an interview on 8/5/25 at 2:56 P.M. Resident #2 said:-He/She was not sure if he/she had the right bed or the wrong one;-He/She did not know if he/she had gotten into another resident's bed;-He/She did not know where he/she was; -He/She did not know if something happened.During an interview on 8/5/25 at 3:27 P.M., the Interim DON said:-The MDS Coordinator was on call and notified of the incident between Resident #1 and #2; -He/She was told Resident #2 had been found lying in bed with Resident #1; Resident #2 had his hand on Resident #1's front bikini area on top of the resident's brief; -A skin assessment was completed on Resident #1 and nothing was found; -Resident #2's room is across the hall from Resident #1, so he may have been confused and went to the wrong room; -Both residents remained in the same rooms after the incident; -The police were not notified of the incident;-He/She spoke with Resident #2's Primary Care Physician (PCP) on 8/5/25 and requested a medication review; -The PCP adjusted Resident #2's medication on 8/5/25. During an interview on 8/6/25 at 2:35 P.M., Resident #2's PCP said:-He/She was called Monday August 4, 2025, in regards to the incident between Resident #1 and Resident #2.-He/She saw Resident #2 early morning on 8/5/25, and medication adjustments were made; -Resident #2 did not remember any of the incident on 7/31/25.-He/She believed residents on Special Care Communities need closer monitoring for safety and behaviors. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). 2577793
Inspection of June 13, 2025
1 findingBased on observation, interview, and record review, the facility failed to assure one resident (Resident #2) was free from misappropriation of his/her property when the resident's narcotic medications were found missing from the facility. The facility census was 58. Review of the undated facility abuse policy included: Our residents have the right to be free from abuse, neglect, misappropriation or resident property and exploitation. Review of the Controlled Substances policy, revised April 2019, showed: - Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift; - Upon receipt: the nurse receiving the medication and the individual delivering the medication verify the name, dose and quantity of each controlled substance being delivered. Both individuals sign the controlled substance record of receipt. - At the end of each shift: Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse doing off duty determine the count together. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately; - The director of nursing (DON) investigates all discrepancies in controlled medication reconciliation to determine the cause and identify and responsible parties and reports the findings to the administrator; 1. Review of Resident #2's Face Sheet, dated 6/13/25, showed diagnoses of depression, dementia, heart disease, and low back pain; Review of the resident's Medication Administration Record (MAR), dated 6/13/25, showed the resident was taking Oxycodone 5mg tablets by mouth every 8 hours routinely; Review of the facility's investigation, dated 5/22/25, showed: - No allegation stated as to why investigation was prompted; - No alleged perpetrator was identified; - The local police department was contacted; - A search of the facility and interviews with all nurses who had access to controlled substance Oxycodone was conducted with no outcomes; - Investigative interviews by the DON focused on failure to follow up on pharmacy orders not delivered, when in fact the Oxycodone order had been delivered and verified by facility staff. - The investigation did not address inventory procedures by staff prior to the missing medications or why the discovery of the missing medications happened in the middle of the shift instead of at shift change; - No clear identification of the process failures which led to the diversion of a controlled substance; - No explanation as to why the investigation was inconclusive, and the allegation could not be verified; - Corrective actions to be taken include narcotic count process strengthening and in-servicing with staff; During an interview on 6/13/25 at 10:45 A.M., LPN A said: - During the incident of the missing Oxycodone medication LPN A was not involved in the turnover of the medications or medication counts. His/her personal policy is to count all drugs including full cards when coming on and going off shift to ensure all drugs are accounted for. The old policy had changed and now everyone is required to count all narcotic medications as well as full cards in stock; - He/she said that if the medication counts were done correctly, the shift and amount of the missing drugs would have been identified and someone could have been held accountable. No one had been counting the full sheets of narcotics, so it was impossible to tell exactly when the medications went missing. During an interview on 6/13/25 at 3:30 P.M., the Administrator said: - The previous process which was in place at the time of the drug inventory discrepancy was for staff to count the in use sheets of pills but not count the full sheets in stock that had not had any pills administered from. The count sheets and the pills would be accessible to all the staff who had access to the controlled drugs. Inventories would be done at the end of each shift jointly by staff; - Now the process is that the count sheets are annotated on a inventory sheet and kept separate from the stock so they can not be removed from the inventory. All pills in use and in storage are counted at the end of each shift in order to catch any overall discrepancy in stock rather than a discrepancy from just the active pill sheet; - The previous DON who conducted the investigation of the missing controlled drugs was no longer employed by the facility; - The medication expectation by staff is all pill sheets that have not been issued and ones that are in use, are counted at the end of each shift; - She is not certain, but it looks like 60 pills of Oxycodone 5mg tablets are missing from the inventory as of 5/21/25 at 10:00 P.M and they were confirmed received into the facility on 5/4/25; - The resident's medications that are missing have been replaced with the emergency stock so that he/she never missed a required dose of Oxycodone medication; During an interview on 6/16/25 at 9:00 A.M., Police Officer A said: - The preliminary investigation through interviews indicated the facility did not have any inventory controls over the controlled medication to properly identify when and who was responsible for losing or taking the 5mg Oxycodone at the facility. - He/she said the evidence that was gathered had shown the drugs were most likely taken by a staff member. MO254681
Inspection of May 5, 2025
1 findingBased on interview and record review, the facility failed to keep one resident (Resident #1) safe from sexual abuse when another resident (Resident #2) ran his/her hand up the inside of Resident #1's thighs and grabbed his/her genital area. The facility census was 61. On 5/5/25, the Administrator was notified of the past noncompliance which began on 4/14/25. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented including: Resident #1 and #1 were seperated immediately, the facility staff assessed both residents and neither resident had injuries, Resident #2 was placed on 1:1 monitoring on 4/14/25, Resident #2's physician ordered Sertraline (a medication to treat anxiety and depression) for Resident #2, Abuse training was started for staff on 4/15/25. The noncompliance was corrected on 4/17/25. Review of the facility's Abuse Prevention Program policy, dated July 2017, showed: -Residents have the right to be free from abuse. This includes, but is not limited to freedom from sexual abuse; -As part of the resident abuse prevention, the administration will: Protect residents from abuse by anyone including, other residents; -Abuse is defined as the willful infliction of injury, confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. 1. Review of Resident #1's medical record on 5/5/25 showed: - Diagnoses included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), dementia with agitation (a group of thinking and social symptoms that interferes with daily functioning), delusional disorder (a mental illness characterized by the presence of one or more delusions that persist for at least a month). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 2/20/25, showed: - He/She had adequate hearing, unclear speech, is sometimes understood and sometimes makes self understood; -He/She scored zero on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients), indicated severely impaired cognition; -He/She displays wandering behavior and rejection of care. Review of the residents comprehensive care plan, dated 4/3/25, showed interventions related to wandering and requiring a secure environment, aggression, cognition, communication and hospice. 2. Review of Resident #2's medical record on 5/5/25 showed: - Diagnoses included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), traumatic subdural hemorrhage (a collection of blood between the dura mater (the outermost layer of the brain's covering) and the brain itself, often caused by head trauma.), mild cognitive impairment (the in-between stage between typical thinking skills and dementia). Review of the resident's quarterly MDS, dated [DATE], showed: -He/She had adequate hearing, clear speech, understands others and usually makes self understood; -He/She scored 1 on the BIMS, indicating severely impaired cognition. Review of the resident's comprehensive care plan, dated 4/14/25, showed interventions related to wandering and need for a secure environment, behavior problem related to sexual outbursts and grabbing staff (staff are to redirect the resident when making inappropriate comments, provide distractions). Review of the facility investigation showed that on 4/14/25 at approximately 5:30 P.M., the residents were in the common area of the memory care unit, waiting for dinner to be served. Certified Medication Technician (CMT) A was at the medication cart across the common area from the seating area, preparing to pass medications with dinner. CMT A observed Resident #2 sitting in a recliner and Resident #1 walking in the common area. As Resident #1 walked passed Resident #2, Resident #2 reached out, ran his/her hand up between Resident #1's thighs and lightly squeezed his/her genital area. CMT A separated the two residents and notified the charge nurse. Both residents were assessed an no injuries were noted. Due to their declined cognition, neither resident was able to provide information regarding the incident. The physician and responsible parties were notified of the incident the evening of 4/14/25. Resident #2 was placed on 1:1 supervision. Resident #2 was receiving antibiotics for a urinary tract infection at the time of the incident. Approximately two weeks prior to the incident, Resident #2's family expressed concerns the resident was too sedated and they physician decreased the resident's Risperdal (medication used to treat a variety of mental health conditions). When notified of the incident on 4/14/25, the physician gave the facility orders to start Resident #2 on Sertraline. The facility also initiated abuse and neglect education for all staff on 4/15/25. The physician assessed the residents again on 4/17/25, and gave the facility orders to restart Resident #2's Risperdal. During an interview on 5/5/25 at 2:38 PM, CMT A said: -On 4/14/25 at approximately 5:30 P.M., CMT A was getting the evening medications ready at the medication cart in the dining area of the common area. Resident #2 was sitting in a recliner in the front part of the common area near the television. CMT A observed Resident #1 walking through the common area. As Resident #1 walked by Resident #2, Resident #2 reached out, ran his/her hand up between Resident #1's thighs and then grabbed his/her groin area. Resident #1 did not react and continued walking past Resident #2 and through the common area. CMT A had resident #1 come sit by the medication cart and then called the charge nurse to come to the memory care unit. During an interview on 5/5/25 at 3:10 P.M., the Director of Nursing said: -The residents were immediately separated and assessed; -Staff education on abuse and neglect was started on 4/14/25 and concluded on 4/17/25; -Resident #2 was placed on one to one supervision; -The physician was contacted the evening of the incident on 4/14/25 and gave orders to start Sertraline and Risperdal; -The physician assessed the resident at the facility on 4/15/25; -The physician assessed the resident again on 4/17/25 and gave orders to increase Resident #2's Risperdal. During an interview on 5/5/25 at 3:20 P.M., the Administrator said: -The resident was removed from one to one supervision on 4/21/25 as the resident has had no additional behaviors; -The facility approached Resident #2's family about in-patient placement at a geriatric behavioral health facility. The family declined, elected to see if the recent medication adjustments were effective. MO252749
Inspection of October 10, 2024
4 findingsBased on observation, record review, interview, review of the RAI [Resident Assessment Instrument] manual, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for five out of 23 sampled residents (Residents (R) 37, R29, R30, R34, and R57) reviewed for MDS. The coding failures have the potential to affect the appropriate care planning and provision for the residents.The facility census was 57. Findings include: During an interview on 10/10/24 at 3:15 PM, the Director of Nursing (DON) stated the facility used the RAI Manual. Review of the facility policy titled Comprehensive Assessments, revised March 2022, revealed .Policy Interpretation and Implementation. 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. Review of the October 2023 RAI Manual showed on page N-8: Coding Tips and Special Populations .- Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as N0415E, Anticoagulant. Regarding smoking on page J-26: J1300: Current Tobacco Use Item Rationale Health-related Quality of Life -The negative effects of smoking can shorten life expectancy and create health problems that interfere with daily activities and adversely affect quality of life. Planning for Care -This item opens the door to negotiation of a plan of care with the resident that includes support for smoking cessation. -If cessation is declined, a care plan that allows safe and environmental accommodation of resident preferences is needed. Steps for Assessment 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. DEFINITION TOBACCO USE Includes tobacco used in any form. 1. Review of R37's Admission Record from the electronic medical record (EMR) Profile tab revealed a facility admitted [DATE] with medical diagnoses that included atrial fibrillation, congestive heart failure (CHF), pleural effusion, anxiety disorder, and epilepsy During observations on 10/07/24 at 12:30 PM and 10/08/24 at 11:30 AM, R37 was in the courtyard smoking. Review of R37's EMR Progress Notes revealed on 12/03/23 a practitioner note that showed: .Social History: Nicotine: Current every day cigarette user. 0.5 packs per day Cigarette smoker for [AGE] years . Review of R37's EMR MDS tab revealed the annual MDS with an Assessment Reference Date (ARD) of 12/30/23 did not show R37 used tobacco. Review of R37's EMR Assessments tab revealed a quarterly smoking evaluation, dated 10/03/23, that showed R37 was a safe smoker; and a smoking evaluation on 07/03/24 that showed the resident was a safe independent smoker and the facility would keep the smoking materials. Another smoking evaluation, effective 10/04/24, showed that R37 was appropriate for unsupervised smoking and was able to maintain his own smoking materials. During a telephone interview on 10/10/24 at 1:50 PM regarding the tobacco use coding, the MDS Coordinator (MDSC) stated, It might have been an oversight because he does smoke. 2. Review of R29's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included chronic obstructive pulmonary disease (COPD), cerebral infarction, contractures, hemiplegia, and hemiparesis of dominant side. Review of R29's quarterly MDS with an ARD of 03/17/24, an admission MDS with an ARD of 05/02/24, and a quarterly MDS with an ARD of 08/01/24 showed R29 received anticoagulation medication. Review of R29's EMR Orders tab for current and historical anticoagulant physician's orders showed no results. R29 did have orders for two anti-platelet medications, aspirin, and Plavix. 3. Review of R30's Admission Record from the EMR Profile tab showed a facility admitted [DATE], readmission on 06/02/21, with medical diagnoses that included dementia, type II diabetes, acute respiratory failure, and lymphocytosis. Review of R30's annual MDS with an ARD of 03/29/24 and quarterly MDS with an ARD of 09/26/24 showed R30 was receiving an anticoagulant medication. Review of R30's EMR Orders tab for current and historical anticoagulant (blood thinner) physician's orders showed no results. R30 did currently receive a low dose aspirin (antiplatelet medication) for atherosclerotic heart disease. 4. Review of R34's Admission Record from the EMR Profile tab showed a facility admitted [DATE], readmission on 08/15/24, with medical diagnoses that included cerebral infarction, dementia, cervical fracture, femur fracture, and tibia fracture. Review of R34's admission MDS with an ARD of 08/22/24 and five-day admission MDS with an ARD of 09/25/24 both showed R34 received anticoagulation medication. Review of R34's EMR Orders tab for current and historical anticoagulant physician orders showed only an anticoagulation medication that discontinued 01/06/23. During a telephone interview on 10/10/24 at 11:54 AM, the MDSC stated she was now aware that there was an issue with anticoagulation medication coding. The MDSC commented that So, we have an outside company, they audit our MDS, and they told me to do it that way. [Clarified, to code aspirin but not Plavix as anticoagulation medication]. When asked if the MDSC used a facility policy or the RAI Manual, the MDSC responded, We do have an RAI Manual, but that company does audits and on average I get one email a week with suggestions. I should verify the suggestions with RAI Manual then go through the patient's chart and documents. 35693 5. Review of R57's undated Admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R57 was admitted to the facility on [DATE]. R57's diagnoses included acute on chronic combined systolic and diastolic congestive heart failure, atherosclerotic heart disease, and supraventricular tachycardia. Review of an MDS located in the EMR under the MDS tab, with an ARD of 09/17/24 indicated R57 was taking an anticoagulant agent. Review of R57's active Orders located in the EMR under the Orders tab revealed an order dated 09/07/24, for aspirin low dose oral tablet delayed release 81 mg (antiplatelet agent) but no order for an anticoagulant agent. During an interview on 10/07/24 at 1:15 PM and a second interview on 10/10/24 at 11:54 AM, the MDSC stated she received advisement from a consulting group that aspirin should be coded as an anticoagulant, so she had been coding all residents on aspirin as anticoagulant on the MDS assessment. During an interview on 10/10/24 at 1:05 PM the Administrator stated she expected the MDS to be an accurate assessment of the resident condition.
Based on record review, interview, and policy review, the facility failed to protect the resident's right to be free from physical abuse for one of four residents (Resident (R) 42) reviewed for abuse out of 23 sample residents when R23, with a history of hitting another resident, hit R42 in the shoulder unprovoked. This failure had the potential to affect all the residents on the secured unit who were at risk of abuse. The facility census was 57. Findings include: Review of the facility's policy titled, ''Abuse Prevention Program,'' revised 10/16, revealed our residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation. 1. Review of R42's ''Admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, depression, and psychotic disorder. Review of R42's admission ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/02/24 revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated R42 was severely cognitively impaired. 2. Review of R23's ''Admission Record'' located in the ''Profile'' tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's, major depressive disorder, insomnia, and restlessness and agitation. Review of R23's quarterly ''MDS'' with an ARD of 07/02/24 revealed a BIMS score of one out of 15 which indicated R23 was severely cognitively impaired. Review of R23's care plan, located under the ''Care Plan'' tab of the EMR and dated 07/20/24, revealed ''The resident has potential to be physically aggressive related to dementia.'' Interventions in place were to intervene when the resident became agitated to prevent escalation, document and report any signs or symptoms of danger to self or others, offer resident a distraction or offer space and reassurance to de-escalate. Review of a ''Nurse's Notes'' located in the EMR under the ''Notes'' tab, revealed no documentation related to the incident that occurred on 09/28/24 between R42 and R23. Review of the undated Follow-up Investigation Report provided by the facility revealed the conclusion of the allegation was verified through the investigation. During an interview on 10/09/24 at 2:03 PM, Hospitality Aide (HA) 1 stated R23 could be sweet but she could change with the flip of a switch. She stated R23 could get angry and cuss at you. HA1 stated she had not had any behavior for about a month before the incident on 09/28/24. HA1 stated on that day it was somewhere between 12:30 PM and 12:45 PM because she was picking up hall trays after lunch when she heard R42 yelling. She stated she walked down the hall towards R42's room and observed R23 standing right outside the doorway. She stated R42 was just inside the room by the doorway. HA1 stated she redirected R23 and sat her down by the nurse's station and asked R23 what happened, and she said, she was trying to vote. She stated she went back and spoke with R42 who said R23 came into her room and just hit her on the shoulder with a closed fist. She said R42 made a knuckle when she told her that R23 hit her. HA1 stated R42 said R23 never said anything and just hit her. HA1 stated she reported it to Licensed Practical Nurse (LPN) 1 who was in the west hall at that time. During an interview on 10/10/24 at 1:27 PM, LPN1 stated an aide came to her on 09/28/24 that a resident hit another resident, but she could not remember who the residents were. She said she was told the names at the time it was reported to her. She stated she went to the unit and assessed both residents' arms, but she did not document that she completed a skin assessment, or a progress note about what occurred because she forgot. She stated she did notify the Director of Nursing (DON), but she was overwhelmed that day. During an interview on 10/10/24 at 1:27 PM, the DON stated she was unsure what happened because she was out of town. She said the Administrator handled the investigation. During an interview on 10/10/24 at 3:34 PM, the Administrator stated she was notified about the incident on 09/28/24 and she got to the facility shortly after it was reported to her. She said she spoke with the aide who told her that R23 went into R42's room, who was in her bathroom, and when R42 came out she told R23 to leave and R23 hit R42. The Administrator stated R42 said R23 took her hand and pushed it up against her chest area. She said they did substantiate that the allegation occurred. She stated R23 was placed on 1:1 supervision until she was discharged for a psychiatric evaluation. MO242786
Based on record review, interview, and policy review, the facility failed to ensure two of two residents (Resident (R) 29 and R61) reviewed for discharge to the hospital were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer, out of 23 sample residents. This failure has the potential to affect the residents by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. The facility census was 57. Findings include: Review of the facility's policy titled, Transfer or Discharge Notice, revised December 2016, showed: .Policy Interpretation and Implementation .2. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility .3. The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. A statement of the resident's rights to appeal the transfer or discharge, including: (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; e. The facility bed-hold policy; f. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; g. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); h. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies); and i. The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices . 1. During an interview on 10/08/24 at 9:38 AM, R29 stated she had gone to the hospital in June for kidney stones. When asked if she had received a written notice of transfer that stated where and why she was being transferred she stated, No. Review of R29's Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE] with medical diagnoses that included chronic obstructive pulmonary disease (COPD), cerebral infarction, contractures, hemiplegia, and hemiparesis of dominant side. Review of R29's EMR Census tab showed no hospitalization s in June but there was a hospitalization in April. Review of R29's EMR Progress Notes tab showed: 4/24/2024 08:13 [8:13 AM] Nurse's Note. Note Text: this nurse called hospital to speak with charge nurse for update on resident condition. Spoke with [Name], RN [Registered Nurse]. She states resident was admitted through the ER [emergency room ] yesterday evening .she states there are no plans to d/c [discharge] resident today. Review of R29's EMR Miscellaneous tab, Progress Notes tab, and Assessments tab showed no evidence of the provision of a written notice of transfer. 2. Review of R61's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included cystitis, dementia, and uterine cancer. Review of R61's EMR Census tab showed a hospital leave effective 07/20/24. Review of R61's EMR Progress Notes tab showed: Effective Date: 07/26/2024 15:48 [3:48 PM] Type: Nurse's Note. Note Text: Remains in the hospital and Effective Date: 07/21/2024 11:00 [AM] Type: Nurse's Note. Note Text: Resident was transported to the ER after she was found outside last night . Review of R61's EMR Miscellaneous tab, Progress Notes tab, and Assessments tab showed no evidence of the provision of a written notice of transfer. During an interview on 10/10/24 at 11:20 AM in response to a request for evidence of the provision of written transfer notices, the Administrator provided policies and stated she was unable to find any documentation regarding the written notice of transfer provision. During an interview on 10/10/24 at 12:30 PM regarding the emergent transfer process, RN1 stated, I get the order to transfer to the ER. Print out the face sheet and med [medication] list. Call EMS [Emergency Medical Services]. Notify the Director of Nursing and family [clarified, this notification is by phone] - if emergent situation. If not emergent, we will generally talk to the family, you know, do you want them transferred, some families don't; but for emergencies we send them, then call. After they leave, we call the ER and give the report. When asked if there was anything provided in writing regarding the transfer to the resident and representative, RN1 responded, We tell them on the phone, generally speaking, it's just a verbal we get from the family. If it's not emergent we give them a written bed hold, but nothing in writing regarding the transfer. When asked to see the notice provided, RN1 provided two sheets, one a bed hold notice, and one was a transfer notice. When asked about the transfer notice, RN1 stated, Well, yes, after the fact we do use it. [Name] Social Services usually does that. During an interview on 10/10/24 at 12:37 PM, the Social Services Director (SSD) reviewed the transfer notice and asked about the provision of the form; the SSD stated, If I'm here I will help them out. If I'm not here the nursing staff would do this. Nursing staff is supposed to do the bed hold - contact family for verbal consent if not here. The SSD reviewed R61's EMR and stated it wasn't done. Once she got to the hospital there was no contact. The SSD reviewed R29's EMR and stated, There is nothing.
Based on record review, interview, and review of facility policy, the facility failed to ensure two of two residents (Resident (R) 29 and R61) reviewed for facility initiated emergent transfer to the hospital received a written bed hold notice that included all required information of 23 sample residents. This failure had the potential to contribute to possible denial of re-admission and loss of the residents' home following a hospitalization for residents transferred to the hospital. The facility census was 57. Findings include: Review of the facility's policy titled, Bed-Holds and Returns, revised March 2017, showed: Policy Statement. Prior to transfers and therapeutic leaves, residents or resident representative will be informed in writing of the bed-hold and return policy. Policy Interpretation and Implementation.3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. the rights and limitations of the resident regarding bed-holds; b. the reserve bed payment policy as indicated by the state plan (Medicaid resident); c. the facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and d. the details of the transfer (per the notice of transfer) . 1. During an interview on 10/08/24 at 9:38 AM, R29 stated she had gone to the hospital in June for kidney stones. When asked if she had received a written bed hold notice, she stated, No. I was there three days. Review of R29's Admission Record from the electronic medical record (EMR) Profile tab revealed a facility admitted [DATE] with medical diagnoses that included chronic obstructive pulmonary disease (COPD), cerebral infarction, contractures, hemiplegia, and hemiparesis of dominant side. Review of R29's EMR Census tab showed no hospitalization s in June but there was a hospitalization in April. Review of R29's EMR Progress Notes tab showed: 4/24/2024 08:13 [8:13 AM] Nurse's Note. Note Text: this nurse called hospital to speak with charge nurse for update on resident condition. Spoke with [Name], RN [Registered Nurse]. She states resident was admitted through the ER [emergency room ] yesterday evening . she states there are no plans to d/c [discharge] resident today. Review of R29's EMR Miscellaneous tab, Progress Notes tab, and Assessments tab showed no evidence of the provision of a written bed hold notice. 2. Review of R61's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included cystitis, dementia, and uterine cancer. Review of R61's EMR Census tab showed a hospital leave effective 07/20/24. Review of R61's EMR Progress Notes tab showed: Effective Date: 07/26/24 15:48 [3:48 PM] Type: Nurse's Note. Note Text: Remains in the hospital and Effective Date: 07/21/24 11:00 [AM] Type: Nurse's Note. Note Text: Resident was transported to the ER after she was found outside last night . Review of R61's EMR Miscellaneous tab, Progress Notes tab, and Assessments tab showed no evidence of the provision of a written bed hold notice. During an interview on 10/10/24 at 11:20 AM in response to a request for evidence of the provision of written bed hold notice, the Administrator provided policies and stated she was unable to find any documentation regarding the written bed hold notice. During an interview on 10/10/24 at 12:30 PM regarding the emergent transfer process, RN1 stated, I get the order to transfer to the ER. Print out the face sheet and med [medication] list. Call EMS [Emergency Medical Services]. Notify the Director of Nursing and family [clarified, this notification is by phone] - if emergent situation. If not emergent, we will generally talk to the family, you know, do you want them transferred, some families don't; but for emergent we send them, then call. After they leave, we call the ER and give the report. When asked if there was anything provided in writing regarding the transfer to the resident and representative, RN1 responded, We tell them on the phone, generally speaking, it's just a verbal we get from the family. If it's not emergent we give them a written bed hold . During an interview on 10/10/24 at 12:37 PM, the Social Services Director (SSD) reviewed the bed hold form and was asked about the provision of the form; the SSD stated, If I'm here I will help them out. If I'm not here the nursing staff would do this. Nursing staff is supposed to do the bed hold, contact family for verbal consent if not here. The SSD reviewed R61's EMR and stated it wasn't done. Once she got to the hospital there was no contact. The SSD reviewed R29's EMR and stated, There is nothing.
Inspection of July 25, 2024
1 findingBased on observation, interview, and record review, the facility failed to provide adequate supervision of one cognitively impaired resident (Resident #1) with a known elopement risk and history. On 7/18/24, the resident became combative when staff attempted to redirect the resident back inside the facility from an outside activity, made multiple attempts to leave the facility unassisted, reached the facility parking lot in one attempt, and threw objects out the dining room window. On 7/20/24, the resident eloped out of a dining room window (six feet from the bottom of the windowsill to the grass below) around 4:00 P.M. and was brought back into the facility. The resident was placed on one-on-one at that time until the dining room windows could be secured. The facility staff did not continue the one-on-one or secure the resident's bedroom window. The resident removed his/her window screen and went out his/her second story window (approximately 13 feet 5 inches above the paved sidewalk below) between 8:15 P.M. - 8:23 P.M. on 7/20/24, resulting in sustained fractures to both heels and his/her lumbar spine 1 (L1). The facility census was 58. The Director of Nursing was notified on 7/24/24 at 3:23 P.M. of an Immediate Jeopardy (IJ) which began on 7/20/24. The IJ was removed on 7/24/24 as confirmed by surveyor onsite verification. Review of facility policy, Accidents and Incidents - Investigating and Reporting, revised July 2017, showed: -All accidents or incidents involving residents, employees, visitors, vendors, etc , occurring on facility premises shall be investigated and reported to the administrator. Review of facility policy, Wandering and Elopements, revised March 2019, showed: -The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; -If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety; -If an employee observes a resident leaving the premises, he/she should attempt to prevent the resident from leaving in a courteous manner, get help from other staff members in the immediate vicinity, if necessary; and instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. Review of facility policy, Safety and Supervision of Residents, undated, showed: -Supervision/Adequate supervision: refers to the intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident; -The facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities; -When accident hazards are identified, the Quality Assurance Performance Improvement (QAPI)/Safety committee shall evaluate and analyze the cause of the hazards and develop strategies to mitigate or remove the hazards to the extent possible; -The care team will target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices; -Implementing interventions to reduce accident risks and hazards shall include, communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, ensuring that interventions are implemented, documenting interventions; -Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 1. Review of Resident #1's admission face sheet, dated 7/24/24, showed: -He/She was admitted to the facility on [DATE]; -Diagnoses included dementia (condition involving loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), and infection of the bladder. Review of the resident's progress notes, dated 7/15/24-7/17/24, showed staff documented: -On 7/15/24, resident was admitted to the facility; -On 7/16/24, Licensed Practical Nurse (LPN) D wrote the resident was wandering on the unit, but easily redirected; -On 7/17/24, LPN C wrote the resident was exit seeking frequently throughout the day. Review of the resident's baseline care plan, dated 7/17/24, showed: -The resident was at risk for falls; -He/She was cognitively impaired; -He/She was independent with mobility, transfers, and ambulating; -He/She required assistance with personal hygiene, dressing, eating, and toilet use. Review of the resident's Elopement Risk Evaluation, dated 7/17/24, showed facility staff assessed the resident as having a score of 18.0, indicating he/she was a high risk to wander. Review of the resident's fall risk assessment, dated 7/17/24, showed facility staff assessed the resident as having a score of 8.0, indicating he/she was a low risk to fall. During an interview on 7/24/24 at 8:54 A.M., LPN B said he/she spoke with resident's daughter when the resident was admitted to the facility who told him/her they had a hard time keeping the resident inside at home and they could not figure out how to keep the resident inside and was barricading the resident inside while at home. During an interview on 7/23/24 at 3:52 P.M., Certified Medication Technician (CMT) C said: -He/She met the resident when he/she first arrived at the facility on 7/15/24 and noted the resident was very active for a resident with dementia and had been very exit seeking; -When he/she worked with the resident on the unit, the resident would follow him/her around while he/she passed medications. During an interview on 7/24/24 at 4:00 P.M., the Activity Aide said: -He/She worked on 7/18/24 in the activity department and was doing a water balloon fight with the residents; -Resident #1 went out the special care unit courtyard door during the activity, so he/she tried to incorporate the resident into the activity; -The resident initially participated, but then said, 'oh cars' and he/she was going home and started walking towards the cars in the parking lot; -He/She and Certified Nurse Aide (CNA) B went after the resident and redirected the resident into the facility front door, because when they tried redirecting the resident into the building via the courtyard gate, the resident became combative; -After the resident initially attempted to elope into the parking lot from the balloon fight, he/she observed the resident elope from the special care unit into the courtyard two more times with the resident stating he/she was going home. This occurred within a few minutes of the resident being escorted back into facility, as he/she was still outside with other residents engaged with the balloon fight. During an interview on 7/23/24 at 2:09 P.M., CNA B said: -He/She worked the special care unit a lot; -On 7/18/24 the resident went to the door to attempt to get out. He/She was standing next to the activity assistant to help block the resident and the resident bulled (pushed) his/her way through CNA B and other the staff to go out the door; -The resident walked out of the courtyard door on 7/18/24 during an activity. During an interview on 7/24/24 at 10:48 A.M., LPN C said: -On 7/18/24 there was an activity that occurred outside and the resident went out with the rest of the residents. It took three staff members to redirect the resident back through the front doors of the facility due to the resident being combative and staff had to use their bodies as a block to try and guide the resident back inside the facility; -On 7/18/24 during the day shift the resident pushed on the courtyard door three times and the door at the end of the hallway to the main nursing unit one to two times. Review of the resident's progress notes, dated 7/18/24 at 4:24 P.M., showed LPN C wrote the resident had been exit seeking for the last hour. He/She had been pushing the alarmed doors open and rushing out of the door into the courtyard. He/She opened windows and attempted to get out the various windows. The resident did not redirect easily. He/She became aggressive and combative when redirected back into the unit. The primary care physician (PCP) made aware of exit seeking and elopement plus behaviors. New orders were received for Depakote and as needed Trazodone. The resident received medication and it made him/her calmer. Contact made with the family. Review of the resident's physician's orders, dated July 2024, showed: -Order started 7/18/24, Depakote Sprinkles oral capsule delayed release sprinkle 125 mg, give 125 mg by mouth three times a day for agitation and anxiety related to dementia with agitation; -Order started 7/18/24, Trazodone HCL tablet, give 50 mg by mouth every 12 hours as needed for agitation and anxiety related to dementia with agitation. Review of the resident's Medication Administration Record (MAR), dated July 2024, showed: -Order started 7/18/24 at 4:00 P.M., Depakote Sprinkles 125 mg was administered on 7/18 at P.M. dose, 7/19 at A.M., Midday, and P.M. dose, and on 7/20 at AM, Midday, and P.M. dose. -Order started 7/18/24 at 4:15 P.M., Trazodone HCL Tablet 50 mg as needed medication was administered on 7/18/24 at 7:15 P.M., on 7/19/24 at 7:04 P.M., and on 7/20 at 3:38 P.M. During an interview on 7/23/24 at 1:44 P.M., CMT A said: -He/She worked with Resident #1 on 7/18/24 and 7/19/24; -The resident had been exit seeking on 7/18/24 by going to doors; -The resident had to be redirected away from the doors; -The resident bulled (pushed) his/her way through the courtyard door to go out with activity staff into the courtyard; -The resident also got one window open on Thursday (7/18/24) on the south wall in the dining room next to the kitchenette, he/she threw a stuffed animal out the window. At that time, the south window did not have a screen on it; -When the family was called about opening the dining room window and throwing stuff out, the family stated the resident had the same type of windows in his/her home; -After the resident's three attempts to exit the building and making it to the parking lot on 7/18/24, staff contacted the physician and got an order for Depakote and Trazodone and kept a close eye on the resident.; -The resident had not been placed on one on one supervision on 7/18/24. During an interview on 7/23/24 at 1:37 P.M., CNA A said: -On 7/18/24, the resident was observed throwing things out the South window in the dining room next to the kitchenette and staff moved a table in front of that window to deter the resident. During an interview on 7/23/24 at 2:18 P.M., CNA C said: -He/She was working on the special care unit the day Resident #1 moved into the facility; -The family had indicated the resident had been trying to exit seek at home; -On 7/18/24, CNA C saw the resident remove the screen to the dining room window, and throw blankets and shoes out the open window. The staff redirected the resident. During an interview on 7/24/24 at 10:48 A.M., LPN C said: -He/She had been working with the resident since he/she admitted to the facility; -The resident had been observed to be exit seeking when he/she pushed on doors a few times and went to windows in the dining room; -On 7/18/24, he/she observed the resident get the window open in the dining room that was next to the kitchenette. That window had a sign on it that said do not open; -He/She immediately called the Administrator on 7/18/24 and advised that they needed to get maintenance, because the resident was going to get out through the window; -He/She saw the Administrator and DON come into the unit and check the windows on 7/18/24, including pushing on the resident's room window. The Administrator and DON could not get the bedroom window to open when they pushed on it; -To prevent the resident from going to the window next to the kitchenette, he/she pushed a table over in front of it. During an interview on 7/23/24 at 1:37 P.M., CNA A said: -He/She last worked with the resident on 7/19/24 and the resident slept most of the day; -The resident would go around and touch the window curtains, but did not attempt to open the curtains; -The resident would wander and he/she would go in and out of other resident rooms and over by the door to the courtyard. During an interview on 7/23/24 at 1:44 P.M., CMT A said he/she worked with the resident on 7/19/24 and the resident displayed no exit seeking behaviors. Review of the resident's progress notes, dated 7/20/24 at 4:04 P.M., showed LPN B wrote the resident was exit seeking. CNA heard a noise and saw the resident making it out the dining room window. The resident was initially seen laying on the ground outside of the window. The resident immediately got to his/her feet and started walking away. The nurse remained inside and kept the resident in line of sight while CNA staff went outside after him/her and were able to redirect the resident back inside. Once inside, the resident had 3 skin tears to his/her left hand, side of his/her palm, tip of index finger, and base of ring finger on the underside of his/her palm. The resident was alert and orientated to baseline. He/She moved all extremities with no expression of discomfort. He/She denied pain. Neurological assessments were initiated. The resident's PCP, and family were notified. The DON was notified. One-on-one care started and as needed Trazodone was given to the resident. Review of the resident's 15 minute check log, dated 7/20/24, showed documentation of fifteen minute checks began at 4:00 P.M. and ended 8:30 P.M. During an interview on 7/23/24 at 2:09 P.M., CNA B said: -On 7/20/24, the resident went to every window and attempted to open the window in the dining room; -On 7/20/24, he/she heard a noise and looked over and saw the resident slip out of the window that was to the right of the bird cage in the dining room around lunch time; -He/She ran outside into the courtyard and out of the gate to intercept the resident; -The resident was found with a cut on his/her hand; -When the resident went out of the window, he/she had taken the screen off; -After the resident made it out of the dining room window, the resident was placed on one-on-one supervision by the Director of Nursing with CNA C designated as his/her specific staff; -On 7/20/24, CNA C sat with resident the rest of the shift until 6:30 P.M. During an interview on 7/23/24 at 2:18 P.M., CNA C said: -He/She was working with the resident on 7/20/24 and the resident paced in the dining room and kept touching or messing with the windows and staff would redirect him/her; -He/She did not see the resident go out the window the afternoon of 7/20/24, but CNA B notified him/her the resident went out of the dining room window, and he/she went outside with CNA B to get the resident back in; -He/She noted the resident had cut his/her hand; -After the resident went out the window CNA C had to do 15-minute checks on the resident and he/she sat with the resident in his/her room until he/she woke up. The DON put the 15-minute checks in place until the maintenance staff secured the window in the dining room. - He/She was assigned to stay with resident until the end of his/her shift at 6:30 P.M. During an interview on 7/24/24 at 8:54 A.M., LPN B said: -He/She worked with the resident on the day shift on 7/20/24 around 4:00 P.M. when the resident went out the window the first time. CNA B took off running and called for CNA C. Both CNA B and CNA C took off outside the building through the courtyard door; -He/She went to the dining room window and observed the resident, was right outside the window and in the process of standing up; -The resident went out the window to the right of the bird cage in the dining room; -He/She completed an assessment of the resident and found injuries to his/her index finger, ring finger, and cuts to his/her hand. He/She notified the DON. The DON instructed him/her to start one on one checks on the resident and he/she completed the neurological checks. The DON also said maintenance staff was coming out to see what he/she could do to prevent the incident; -One-on-one meant, one staff was designated to monitor and observe only one resident and this was done until the maintenance staff had been in the facility to secure the windows in the dining room; -He/She administered an as needed medication of Trazodone to the resident and he/she got sleepy; -He/She and other staff rearranged the dining room and he/she parked his/her medication cart in front of the windows; -CNA C was the staff member assigned to be with the resident for one-on-one supervision until the maintenance man was able to secure the windows in the dining room. Then the resident went to 15-minute checks; -The facility did not have a one-on-one form, so he/she issued a 15-minute check sheet for staff to document the resident observations during the one on one with resident. -The resident slept for thirty minutes after administering the as needed medication, then got up and wandered around and touched and attempted to push on the dining room windows to open them. -Maintenance staff came while he/she was there as he/she remembered seeing the maintenance staff's cart out and heard maintenance drilling. -He/She did not know if maintenance secured the resident's bedroom window. During an interview on 7/24/24 at 9:30 A.M., the DON said: -He/She was notified of the first elopement by LPN B when the resident went out of the dining room window at 4:09 P.M -He/She had advised staff during the initial call received after the first elopement on 7/20/24, the resident needed to be one on one until windows were secured; -He/She notified maintenance staff to come fix and secure the dining room windows after he/she was notified the resident got out on the afternoon on 7/20/24; -The maintenance staff only secured the dining room windows; -He/She expected one on one supervision to include one staff to one resident and to maintain visual observation of resident; -He/She expected the one-on-one supervision to end after maintenance secured the dining room windows and go to 15-minute checks. During an interview on 7/24/24 at 10:12 A.M., Maintenance said: -He/She received a phone call from the DON at 4:30 P.M. (on 7/20/24) and was asked to secure all the dining room windows; -He/She found four metal brackets and screwed them into the windows in the dining room. He/She was not sure what time he/she secured the dining room windows; -He/She was not told to and did not secure the bedroom window at that time. Observation on 7/24/24 at 10:05 A.M. showed the facility regional administrative staff measured the window in the dining room to the right of the bird cage. The measurement read six feet from the bottom of the windowsill to the grass below. During an interview on 7/23/24 at 3:40 P.M., LPN A worked the evening shift, but on a different hall and said he/she had been told in shift change report that a resident on the unit had got out a window in the dining room area earlier in the day and had bandages to his/her finger. Observation on 7/24/24 at 10:05 A.M. showed the facility regional administrative staff measured the window in the dining room to the right of the bird cage. The measurement read six feet from the bottom of the windowsill to the grass below. During an interview on 7/24/24 at 9:18 A.M., CNA E said: -He/She started his/her shift on 7/20/24 at 6:30 P.M. -The resident was a newer resident that he/she had met briefly and was told the resident had been a wanderer; -He/She had been told during shift report the resident had gotten out the window earlier in the day and he/she had been put on one on one until the windows had been fixed; -Maintenance staff had been to facility and fixed windows prior to him/her starting the shift by bolting the windows in the dining room; -He/She had been told the resident was well versed in the facility's type of windows, because the resident had the same type at home; -The resident was on 15-minute checks from the time he/she started his/her shift at 6:30 P.M., -He/She completed 15-minute checks on the resident at 8:15 P.M. The resident had been out in the hallway where he/she could see the resident; -He/She was in with another resident for approximately fifteen minutes when he/she received a phone call from CNA D who had been working on the other hall about the resident being found outside on the ground and his/her bedroom window being open; -He/She hurried to Resident #1's room. He/she looked out of the resident's window that did not have a screen and saw the resident laying on the ground; -All of the resident's belongings were laying around the resident; -Maintenance came in to secure the dining room windows prior to their shift starting at 6:30 P.M.; -The resident was sitting up on top of clothes laying with his/her legs half in grass and his/her upper body half on pavement. During an interview on 7/23/24 at 3:40 P.M., LPN A said: -The evening of 7/20 (around 8:23 PM), he/she had stepped outside and found the resident laying on top of clothing with shoes scattered around him/her. He/She checked his/her phone log and had called the administrator at 8:23 P.M. -The resident was positioned on his/her left side laying underneath an exterior sprinkler piping; -He/She immediately called the administrator and emergency medical responders; -When he/she looked up, the window above the resident was open on the second floor; -The resident had band aids on his/her arm from the previous elopement, that he/she was picking at and had a skin tear to the resident's forearms and blood on the forearms; -The resident began kicking at staff, so he/she removed the resident's shoes; -CNA E called to alert staff that was working on the special care unit; -He/She had not seen the resident before. He/she was working on the floor off the unit; -CNA E told him/her that he/she had been doing fifteen minute checks on the resident due to the elopement attempt from earlier in the day, and last saw the resident at 8:15 P.M.; -The resident tried to get up; -CMT C came down to assist and some dietary staff also came out to courtyard. During an interview on 7/23/24 at 3:20 P.M., CNA D said: -He/She found the resident laying on his/her left side with elbow propped up on ground when he/she went outside facility to smoke at back patio while working on the evening of 7/20/24 (the second time the resident went out the window); -The resident appeared loopy and disorientated and was not able to tell him/her what had happened; -He/She was with LPN A when he/she discovered the resident. LPN A called the facility administrator and 911; -He/She stayed with resident; -He/She noted the bedroom window above was completely open; -He/She called CNA E who had been working on the unit and CNA E came to the window and the CNA stuck his/her head out of the window; -The resident was observed to have a skin tear and a little bit of blood; -He/She was not responsible for the resident and did not know if the resident was on one-on-one observations. CNA E told him/her the resident had been on fifteen-minute checks after getting out a different window and jumping up and running earlier in the day. During an interview on 7/23/24 at 3:52 P.M., CMT C said: -He/She had observed the resident going to locked doors and try to push the locked doors open; -He/She had worked two to three shifts with the resident, but was not working on the special care unit on 7/20/24; -He/She received a call from LPN A about the situation where the resident was outside on the ground and went to the courtyard to assist; -When he/she first observed Resident #1 in the courtyard the resident was laying on ground with his/her top half laying in the grass and his/her legs on the cement; -He/She observed the resident was bleeding from his/her left arm; -He/She knelt down to assess injuries with LPN A and ensure the resident did not close his/her eyes or attempt to get up; -He/She had been aware from shift report that the resident had gone out the window earlier in day; -On 7/20/24 he/she observed the resident's window above to be completely open and there was no screen in the window; -He/She had not observed the resident successfully exit the special care unit while working with him/her previously on the special care unit; -He/She was aware the facility had bolted all the windows in the dining room and of fifteen minute checks until the windows were secured in place after the resident had eloped through the dining room window earlier in the day. The 15 minute checks were in place until the resident was found on the ground in the courtyard. -He/She did not know what time the windows were secured, but stated it was after 5:30-6:00 P.M. that the resident went from being one on one observation to every fifteen minute checks. Review of the resident's progress notes, dated 7/21/24 at 11:03 P.M., showed Registered Nurse (RN) A wrote the resident was transported to the emergency room (ER) after he/she was found outside last night. Review of the hospital medical record, dated 7/23/24, showed: -7/20/24, Patient seen in ER with abrasions on hands and skin tear on left arm, skin tear measuring 5 centimeters (cm) with abrasion and left index finger, and mild bruising and swelling of left index finger; -He/She was admitted to hospital on 7/20/24 at 9:07 P.M.; -A computerized tomography scan (CT scan) showed the resident had a comminuted (a fracture that often splinters) fracture involving the L1 vertebra, comminuted fracture of the left calcaneus (heel of the left foot) and severely comminuted fracture of the anterior (front), central, posterior (back) portions of right calcaneus (heel) on the right foot. Observation on 7/23/24 at 11:51 A.M., showed: -Maintenance staff measured the base of the resident's windowsill to ground to measure 13 feet 5 inches; -The resident's room was on the second level at the back of the facility and his/her bedroom window was located at the corner of the building; -Beneath the resident's window was a paved sidewalk next to patch of grass and green metal piping that jutted out from the building. During an interview on 7/24/24 at 10:12 A.M., Maintenance said: -He/She received a call at 8:26 P.M. to come back to facility to secure the bedroom window. During an interview on 7/24/24 at 9:30 A.M., DON said: -He/She was notified of the second elopement out of his/her bedroom window by the administrator at 8:23 P.M.; -Staff on the unit assessed the other window in the bedroom and observed the window was not an issue and was not able to be opened when pushed on or attempted to turn the hand crank without the knob. The screen was in place; During an interview on 7/23/24 at 11:51 A.M., Maintenance said: -The windows in the resident's rooms did not have cranks to turn to open the windows, the cranks had been removed from all the windows prior to his/her start of employment with the facility a year ago. -The resident's bedroom window did have a screen in the window that was clipped in with clips that fasten the screen to the window frame. During an interview on 7/23/24 at 1:36 P.M., the DON said: -No windows on the special care unit had cranks to open the windows; -The window screen in Resident #1's room was secured with four clips; -Resident #1's room was at the corner of the building on the second level looking down over the courtyard and grass. During an interview on 7/23/24 at 2:31 P.M., the hospital social worker said: -The resident incurred fractures to the lumbar region and both feet. -The resident was going on hospice and was now bed bound as a result of the injuries from going out the window;. -The resident had significant change in status and was barely talking. During an interview on 7/23/24 at 2:35 P.M., the hospital physician said: -Based on Resident #1's fractures the resident's injuries would have been incurred from a jump or fall from a greater height; -The resident was at high risk for Achilles rupture and required surgery; -The resident was not able to bear weight and was currently bed bound. -Anticipate and meet resident needs; -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter, remove any potential causes if possible. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO239409, MO239285, MO239283, and MO239364
Inspection of February 10, 2023
1 findingBased on observation, interview, and record review, the facility failed to keep one resident (Resident #1) free from abuse when a staff member used his/her cell phone to answer a video call through Snapchat with multiple other people who he/she did not know. During the call, the staff member flipped the camera from himself/herself to the resident who stood naked in the shower room. One of the people on the call recorded this. The resident did not give consent to the video and the resident's family said the resident would be embarrassed and angry if he/she knew someone had taken a video of him/her in the shower and then proceeded to post it to a social media platform and feared that if the resident were to be notified of the video, it would be harmful to his/her mental health and the resident's anxiety and depression would increase to the point of needing hospitalization . The facility census was 57. The administrator was notified on 2/9/23 at 5:26 P.M., of an Immediate Jeopardy (IJ) which began on 2/4/23. The IJ was removed on 2/10/23 as confirmed by surveyor on-site. Review of the facility's Abuse and Neglect Policy-Prevention Program, dated April 2021, showed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone, including: facility staff. 2. Develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. 4. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. Review of the facility's Phones, Faxes and Mail Systems policy, dated December 2018, showed: - Cellular phones and/or wireless communication devices should be off or on silent during working hours and are not to be used, unless approved by the Administrator and then only for work purposes. - All personal phone calls and messages must be handled during breaks unless approved by the Administrator. Review of the facility's Social Media policy, dated December 2018, showed: - Social media includes all means of communicating or posting information or content of any sort on the Internet, including to an employee's own or someone else's web log/blog, journal or diary, personal web site, social networking or affinity web site, web bulletin board or chat room, whether or not associated or affiliated with the facility, as well as any other form of electronic communication. - Employees are forbidden to comment in any way or post pictures of a current or previous residents and/or potential referrals. - Social media platforms will be used only within the legal, ethical and professional boundaries established by state and federal privacy laws, professional standards and facility policy. - Improper use of email and Internet services is strictly prohibited. Examples of improper use include, but are not limited to: d. Posting or sharing any unauthorized images of the facility, residents, family or events on social media or a public forum. h. Using language or conveying information on a social media or a public forum that violates the privacy or dignity of any resident or patient, or group of residents/patients. Review of the facility's Cameras and Other Recording Devices in the Workplace policy, dated December 2018, showed: - The facility prohibits employee possession or use of cameras and audio/video recording devices in the workplace and requires that employees turn off all cameras and audio/video recording functions on any personal electronic communication device anytime they are in any organization work area. Taking pictures or making audio/video recordings at organization events or work-related activities off premises is also prohibited. - Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities. - Resident image means the likeness of a resident captured through still photography, videotaping, digital imaging, scans, audio recording, etc. - Staff may not take or release images or recordings of any resident without express written consent obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigation of abuse, neglect or emergencies. - Transmitting unauthorized images of any resident through email, Internet, or social media is considered a violation of resident rights. Any image or recording taken that may be construed as humiliating or demeaning to a resident or residents is considered resident abuse and will be reported and investigated as such. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 11/7/22, showed: - Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients) score of 15. This score indicates no cognitive impairment. - Independent with activities of daily living (ADLs), such as dressing, eating and personal hygiene. - Requires only supervision and oversight for bathing. - No behaviors noted. - Diagnoses of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), panic disorder (an anxiety disorder where a person regularly has sudden attacks of panic or fear), insomnia (persistent problems falling and staying asleep), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the resident's comprehensive care plan, dated 11/9/22, showed: - Required stand by assistance in the shower, as he/she was a risk for falling. He/she was able to shower without assistance from staff. - Experiences episodes of anxiety and insomnia. Takes medication for anxiety and depression. Review of the undated video recording showed: - The video posted to Snapchat on an unknown date. It was six seconds. - At 0:00 seconds, the video starts with an image of a person wearing a yellow face mask, a pink and white shirt with REDSKINS in black letters. A shower curtain rod and shower curtain are partially visible behind this person. - At 0:03 seconds, the video then shows the resident, standing in a shower room. He/she was not wearing any clothing. - The resident was speaking in the video, but unable to determine what he/she said. During an interview on 2/8/23 at 11:15 A.M., the Social Services Designee said: - Identified the individual shown in the beginning of the Snapchat video as NA A. - Confirmed the resident shown in the Snapchat video was Resident #1. - The resident would be mortified and angry if he/she knew NA A had recorded him/her in the shower and posted to a social media platform. During an interview on 2/8/23 at 11:15 A.M., the Administrator said: - Identified the individual shown at the beginning of the Snapchat video as NA A. - Confirmed the resident shown in the Snapchat video was Resident #1. - NA A worked the day shift, 6:00 A.M. to 6:00 P.M. - The administrator said the resident would be angry and embarrassed by the video. Review of staffing sheets and schedules for 2/4/23 showed NA A worked on 2/4/23 from 6:00 A.M. to 6:00 P.M. Review of the shower sheet for 2/4/23 showed Certified Nurse Aide (CNA) B signed the shower sheet indicating he/she provided a shower to the resident on 2/4/23, not NA A. During an interview on 2/9/23 at 4:36 P.M., NA A said: - Did not know how long he/she had worked at the facility, but since at least December 2022. - He/she worked 12 hours shifts, usually 6:00 A.M. to 6:00 P.M. - He/she gave showers and assisted residents with other care, such as dressing. - He/she had worked with the resident multiple times, including assisting in the showering. - He/she assisted the resident in the shower on 2/4/23. - He/she took the video of the resident in the shower. - He/she confirmed the video was taken on 2/4/23. - He/she had his/her phone in his/her pocket and it kept ringing. The resident asked him/her to stop the phone from ringing. NA A took the phone from his/her pocket and answered it. It was as group call from Snapchat. He/she did not know how many people or the identities of the persons on the call with him/her. After answering the call, he/she realized the phone was recording the call and tried to turn it off as soon as possible. He/she did not realize the video had posted to Snapchat. - An unknown person who was also on the call recorded the video from Snapchat. - He/she did not fill out a shower sheet after assisting the resident with a shower, and asked another CNA, CNA B, to fill out the shower sheet. During an interview on 2/10/23 at 11:10 A.M., Licensed Practical Nurse (LPN) B said: - He/She worked on 2/4/23 from 6:00 A.M. to 6:00 P.M. - He/she was assigned to North Hall and NA A was assigned to [NAME] Hall. - NA A came over to North Hall a few times during the shift. - He/she knew the resident and had worked with him/her several times. The resident would be sad and embarrassed if he/she knew someone took a video of him/her in the shower then posted it to a social media platform. The resident struggled with anxiety and the knowledge of the video would cause the resident's anxiety to increase to the point he/she may need an increase of medication or hospitalization . During an interview on 2/9/23 at 11:45 A.M., LPN A said: - He/she knew the resident and had worked with him/her multiple times. - The resident would be so embarrassed to know a staff member recorded him/her in the shower then posted it to a social media platform. - The resident had a lot of anxiety. He/she would most likely not trust staff to assist him/her again if he/she knew about the NA taking the video. During an interview on 2/9/23 at 4:00 P.M., the resident's family member said: - The resident would be embarrassed and angry if he/she knew someone had taken a video of him/her in the shower and then proceeded to post it to a social media platform. - The resident had a long history of anxiety and depression. The family member feared that if the resident were to be notified of the video, it would be harmful to his/her mental health and the resident's anxiety and depression would increase to the point of needing hospitalization . - The resident had resided at the facility for six years and would no longer be able to trust the staff to assist him/her with care. During an interview on 2/10/23 at 12:50 P.M., the Administrator said: - She expected staff not have their cell phones on them while working. - She expected employees to abide by the abuse and neglect and social media policies. - Staff are not to take pictures or videos of residents and are not to post them to social media. At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to a D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. MO213689
Inspection of March 30, 2015
1 findingBased on observation, interview and record review the facility failed to assess one resident's (Resident #1) skin appropriately at the time of admission and follow up on the assessment to assure the resident had the appropriate treatment and interventions in place to treat the skin and prevent further skin breakdown. Staff failed to assess the resident's skin after the resident complained of pain in his/her buttocks and told staff that he/she felt the bars in the bed. Staff failed to take the resident off a bedpan and allowed the resident to lay on the bedpan for up to six hours, resulting in an unstageable pressure ulcer on the resident's buttocks in the shape of the bedpan. Staff failed to follow up on the unstageable pressure ulcer after it was identified and reported to the wound care nurse and did not provide any additional skin care measures to prevent any other skin issues or treat the existing skin issue. The facility failed to assure staff were providing basic care needs including perineal care and repositioning for up to six hours for the resident, on the day the unstageable wound occurred. The facility census was 108. 1. Review of the facility's undated wound care policy showed: - The purpose of the wound care policy is to prevent, identify, and treat wound issues upon admission of a pressure ulcer risk assessment and quarterly thereafter by the care plan team and a thorough head to toe skin assessment is to be completed by the charge nurse. Direct care staff are to report skin issues to the charge nurse observed during daily routine cares and twice weekly during bathing. Upon discovery of a skin issue the charge nurse is to report findings to the wound care nurse and the primary care physician, obtain labs as indicated, initiate vitamin regimens, and use the treatment protocol as directed by the physician. The resident can expect appropriate treatment to protect the skin integrity and the appropriate care to treat any issues. Staff members will be knowledgeable in the care of stage I, II, III, IV, unstageable and suspected deep tissue injury pressure ulcers, venous, arterial, diabetic ulcers and other definitions of a pressure ulcer. A pressure ulcer is a localized injury to the skin and or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in a combination with a shear and/or friction. A number of contributing or compounding factors are associated with pressure ulcers. The facility's definition of a stage II pressure ulcer was partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open ruptured serum filled blister. The facility's definition of a suspected deep tissue injury showed it was a purple or maroon localized area of discolored intact skin or blood filled blister due to damage of the underlined soft tissue from pressure and/or shear the area may be preceded by tissue that is painful for mushy boggy warmer or cooler as compared to adjacent tissue. The wound may further evolve and become covered by eschar (dead tissue). Review of Resident #1's discharge orders from the hospital dated 3/11/15, showed: - Wound care for the abdominal folds/inner thighs/buttocks: cleanse well with soap and water, pat dry and apply a thin layer of Sensicare/[MEDICATION NAME] powder paste (moisture barrier to protect and heal skin and antifungal powder to treat yeast on the skin) to all areas; - Double layer of gauze to abdominal folds to reduce skin contact; - Perirectal area; cleanse well with soap and water, pat dry and apply a thin layer of Sensicare/[MEDICATION NAME] powder paste to all areas; - Right lower posterior leg: apply A&D ointment, cover with an abdominal pad, secure with gauze/netting daily. Review of the resident's the initial care plan dated 3/11/15, showed: - High risk for pressure ulcers; - Moisture barrier and heel protectors; - Did not indicate any other interventions. Review of the physician order [REDACTED]. - Wound care, peri rectal area: cleanse gently. Pat dry, apply thin layer of Sensicare daily as a barrier; Right lower posterior leg; apply A&D ointment, cover with an abdominal pad, secure with gauze/netting daily. - [MEDICATION NAME] (blood thinner) four milligrams (mg) daily; - Aspirin 81 mg daily; - [DIAGNOSES REDACTED]. Review of the admission records to the facility dated 3/11/15, showed: - Diagram showed two areas on the resident upper buttocks and one on the resident left upper thigh, with a description as sheared open areas; - Did not indicate the size of the wound. Review of the bowel and bladder incontinence assessment dated [DATE], showed the resident had a history of [REDACTED]. Review of the pressure ulcer risk assessment dated [DATE], showed the resident was at high risk for skin breakdown and a prevention protocol should have been initiated immediately. Review of the daily skilled nurse note dated 3/11/15, at 9:50 P.M., showed: - Did have skin concerns, dime sized skin tear to lower extremity area. Dependent for all care. Skin pink warm and dry, open wound and bruise; (the note did not indicate where the open wound or bruise were located). During an interview on 3/30/15, at 10:45 A.M., Registered Nurse (RN) A said: - The resident had three open areas on the buttocks on admission; - He/she did not measure the open areas; - Staff told him/her the wound care nurse would measure and assess the areas the following day; - The facility had the wound nurse and a contracted wound care agency do all the measurements, on all the residents with wounds in the facility to provide consistency on wound measurements; - The three open areas were pea size and the wound beds were wet. During an interview on 3/30/15, at 12:08 P.M., Licensed Practical Nurse (LPN) A said: - The resident left the facility and went to the emergency room (ER) prior to his/her shift on 3/12/15, because of [MEDICAL CONDITION] activity; - The resident returned to the facility from the ER the evening of 3/12/15; - He/she assisted the resident into bed around 11:00 P.M.; - He/she assessed the resident's skin, including the resident's buttocks and did not notice any skin issues; - Around midnight the resident complained of pain in his/her buttocks; - The resident said he/she felt the bars on the bed; - Staff assisted the resident to a chair and he/she denied pain and rested; - He/she did not use a pain scale or assess the resident's buttocks to assure there were not any skin issues when the resident complained of pain and prior to assisting the resident to the chair. Review of the assessment record dated 3/12/14, showed: - Patient returned to the hospital on [DATE], for [MEDICAL CONDITION] activity; - Eyes fixed and dilated and the resident did not respond to painful stimuli. Review of the nurses' progress note dated 3/12/15, at 5:00 P.M., showed: - The resident returned from the hospital emergency room via an ambulance. Review of the daily skilled nurse note dated 3/12/15 at 9:30 P.M., showed: - Did have skin concerns; - Complained of pain in his/her back and buttocks; - The resident said "I can feel the bar in the bed." Staff transferred the resident to a chair where the resident rested until 3:00 A.M.; - Open wound and bruise; (the note did not indicate where the open wound or bruise were located). Review of the daily skilled nurse note dated 3/13/15, showed: - Scattered bruising (the note did not indicate where the bruising was located); - Sore on buttocks being treated by the facility; - Pitting [MEDICAL CONDITION] (note did not indicate where the [MEDICAL CONDITION] was); - Legs on pillows; - Resident not feeling well. Review of the nursing notes dated 3/13/15 3:15 P.M., showed: - Urinary catheter removed; - Buttocks still broke down with bleeding in some areas that were excoriated; - New areas on buttocks with bruising and tenderness; - Cleaned area after the urinary catheter was removed. During an interview on 3/26/15, at 12:08 P.M., RN B said: - He/she saw the resident on 3/13/15, between 8:00 A.M., and 10:00 A.M., to give the resident a breathing treatment and an insulin shot; - Around 4:30 P.M. he/she went to remove the resident urinary catheter, per the physician order [REDACTED]. - The resident had an area on the right and left buttocks, human hand size on each buttock that looked like a diaper rash but not broke down; - The resident had, what looked like yeast (red and slightly raised areas) areas in the resident's abdominal folds; - He/she found the resident on the bedpan and the resident did have a red bruising area from laying on the bedpan; - The red and bruised area surrounded the buttocks, in the shape of the bedpan; - He/she did not know who put the resident on the bedpan or how long the resident laid on the bedpan; - He/she applied moisture barrier to the resident's buttocks and positioned the resident on his/her side; - The resident had a lot of [MEDICAL CONDITION] in lower extremities and back; - He/she notified the on call wound nurse who was in the facility of the skin issue for follow up. During an interview on 3/26/15, at 12:27 P.M., LPN B said: - He/she worked as the facility's wound care nurse; - On 3/13/15, around 4:30 P.M., RN B reported the resident did have a red area on his/her buttocks, after RN B took the resident off the bedpan; - The red area appeared to be fading; - He/she did not know the resident had any skin issues upon admission, except gaulding on the buttocks from the admission orders [REDACTED] - He/she should have been notified of the skin issues by staff after the admission assessment; - If the resident had open areas, he/she would have assessed the area to assure the appropriate wound care treatment and interventions were in place for the resident's needs; - He/she only knew the resident had gaulding from the initial physician orders, at the time of the admission; - He/she planned to see the resident on 3/16/15, when the contracted wound consultant came to the facility; - Facility staff did not know how long the resident laid on the bedpan; - He/she never assessed the resident's skin the entire time the resident was at the facility. During an interview on 3/26/15, at 12:53 P.M., CNA B said; - After breakfast on 3/13/15, he/she, CNA C and CNA D assisted the resident to bed with a mechanical lift; - They provided perineal care to the resident and the resident's buttocks were slightly red from sitting on the chair but the resident did not have any other skin issues on the buttocks; - Between 4:00 P.M., and 4:30 P.M., RN B told him/her the resident had red and purple marks on the resident's buttocks from a bedpan; - He/she did not know who or when someone put the resident on the bedpan; - LPN B/wound nurse told him/her, he/she did get notified; - He/she, RN B and CNA A, were the only nursing staff who worked the unit after 2:30 P.M., until RN B identified the resident's skin issue on the resident's buttocks. During an interview on 3/26/15, at 3:23 P.M., CNA A said: - He/she worked the evening shift on 3/13/15; - He/she did not do walking rounds on the resident during shift change at 2:30 P.M.; - He/she did the walking rounds on another hall; - He/she saw the resident's buttocks around 4:30 P.M.; - The resident's buttocks had a red ring in the shape of a bedpan; - He/she could see the resident had been on the bedpan for a while; - After dinner that evening the area on the resident's buttocks turned bright red with bruising. During an interview on 3/30/15, at 12:45 P.M., RN B said; - 3/13/15, the resident seemed tired and confused; - He/she saw the resident at lunch time to give the resident insulin; - He/she did not provide peri care to the resident at that time; - The resident used the call light frequently but did not use it that day; - After he/she found the skin issue caused by the bedpan, he/she found LPN B who was the facility wound nurse and the nurse on call that day in the hall; - LPN B passed out meal trays and they stopped and talked in the hall; - He/she reported the resident had an indentation on his/her buttocks from the bedpan and the area was bruising; - He/she did not report the area because it appeared to be fading. Review of the communication form dated 3/14/15, showed: - The resident had a change in condition. He/she was lethargic and mini [MEDICAL CONDITION]; - Returned from the hospital on [DATE], after going to the emergency room for a [MEDICAL CONDITION]; - Resident would not stay awake and swallow food; - Resident had a urinary tract infection [MEDICAL CONDITION]; - Mini [MEDICAL CONDITION] and decompensating (declining rapidly) per his/her body. During an interview on 3/26/15, at 10:46 A.M., CNA G said: - On 3/14/15, the resident appeared tired and did not eat lunch when RN B fed the resident; - RN B asked him/her to give the resident a bath because he/she planned on calling the doctor and the resident needed to go to the hospital; - He/she gave the resident a bed bath and the resident had a red ring about an inch wide around the entire buttocks; - The ring looked like road rash with pieces of skin pushed away; - He/she told RN B about the wound and RN B told him/her the skin issue had already been reported. Review of the nurses' progress note dated 3/14/15, at 2:35 P.M., showed: - Orders received from the physician to send the resident to the emergency room . Review of the hospital emergency room records dated 3/14/15, showed: - INR 2.8 (test used to determine the thickness of the blood) (therapeutic INR 2.0 to 3.5); - Physician's notes included, the nurse found a sore on the resident's buttocks in the shape of a bedpan. Observation of the photographs taken on 3/14/15, at the hospital showed: - A bright red line on the outer right buttocks approximately six inches long and one inch wide with a sheered area in the middle of the wound approximately six inches long and one centimeter (cm) wide in the shape of a bedpan; - Buttocks appeared red and gaulded; - Upper thighs below the buttocks, red and gaulded approximately two inches long and the entire width of the lower buttocks, with one open area on the left thigh that appeared sheared and approximately one half inch long and one cm wide; - Bright red area on left thigh, approximately three inches below the left buttock, approximately six inches across and one inch wide in the shape of a bedpan; - Left outer thigh, continuing around the entire left buttock, bright red line with bruising and sheering, approximately eight inches long and one inch wide in the shape of a bedpan; - Area on left upper buttocks, bright red line, approximately one cm wide and four inches long in the shape of a bedpan; - The entire wound surrounding the buttocks in the shape of a bedpan appeared unstageable related to tissue damage. Review of hospital notes dated 3/16/15, showed: - Two small ulcers in the mid lower abdominal fold; - Purple ring that is somewhat blanchable, surrounding the entire coccyx area; - Large purple and black shears with granulation present in the wound bed; - Sheared area and discoloration to both lateral buttocks; - Possibly from a bedpan, the patient did not recall. Review of the hospital notes dated, 3/17/15, showed: - Pressure ulcer on the buttocks, non blanching purple line around the buttocks. Review of the hospital notes dated 3/19/15, showed: - Deep red oval marking over the buttocks, with a generalized red rash. Review of the hospital notes dated 3/20/15, showed: - Pressure ulcer 5.7 cm by 3.2 cm; - Eschar (necrotic tissue) present on admission. During an interview on 3/30/15, at 3:00 P.M., the director of nursing (DON) said: - All of management including the wound care nurse is given a copy of each new residents physician orders [REDACTED]. - If a resident is admitted with a skin issue, even when orders are in place, the wound care nurse needed to assess the skin issue that day or by the following day; - She expected the wound care nurse to measure any wounds and assure the resident did have the appropriate treatment in place for any skin issues; - If a resident did not have the appropriate treatment in place, the physician is notified to inquire about further orders for treatment options; - She expected nursing staff to assess the skin of a new resident during the admission and report and document any new issues the facility was not aware of; - She expected nursing staff to measure or do a comparative measurement with any skin issue findings; - She expected staff to include a description of any skin issue in the assessment; - She expected staff to notify management staff, including the wound care nurse with any new skin issues to assure proper follow up is completed; - She expected staff to monitor residents who are on a bed pan and residents should not be left on a bedpan for extended period of time; - She did not know the resident had any skin issues from a bed pan, until two days after the resident discharged from the facility to the hospital when the wound care nurse told her; - She did not investigate the issue because she did not know staff left the resident on the bed pan for an extended period of time; - She expected staff to use a verbal or non verbal pain scale (scale to indicate the severity of the pain) when a resident complained of pain; - She did expect staff to assess the physical area were the resident complained of pain; - She did not think it was possible nursing staff from another unit put the resident on the bedpan and forgot to take the resident off the bedpan; - She expected residents who are at risk or have skin issues to have the problem/potential problem care planned with appropriate interventions in place and the plan of care updated as needed to meet the resident needs; - She did not know why all the staff of 3/13/15, denied putting the resident on the bedpan and why staff did not reposition or do a wet bed check on the resident for several hours. 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