Every finding on record at Lebanon North Nursing & Rehab

Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to document accurate wound assessments, obtain and update orders timely, follow physician orders, provide treatment as ordered, and care plan for one resident (Resident # 1) with a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). The facility census was 71. Review of an undated facility policy titled Wound Care and Treatment showed the following:-There must be a specific order for the treatment;-Documentation of the treatment should be done immediately after the treatment;-Staff should conduct on going skin assessments with weekly documentation of status;-The care plan should reflect the current status of the wound and appropriate goals and approaches;-The dietician should be consulted if a wound is present;-The quality assurance nurse should be consulted when the following exist:-Multiple stage 2 wounds (partial thickness loss of the skin with exposed dermis, appearing as a shallow, open ulcer with a red-pink wound bed or an intact or ruptured fluid filled blister);-Stage 3 wound (full thickness tissue loss where subcutaneous fat is visible, but muscle, tendon, or bone is not exposed) or greater;-No improvement in existing wounds following 2-to-3-week plan of care. Review of an undated facility policy titled Physician Orders, showed the following:-Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors;-Treatment orders should specify what is to be done, amount, frequency, and duration of treatment. Review of an undated facility policy titled Charting and Documentation showed the following: -The purpose of these guidelines is to provide: -A complete account of the resident's care, treatment, response to care, signs, symptoms, as well as the resident's progress;-Guidance to the physician in prescribing appropriate medications and treatments; -The facility with a tool for measuring the quality of care provided to the resident; -Nursing services personnel with a record of the physical and mental status of each resident; -Assistance in the plan of care for each resident; -The elements of quality medical nursing care; -A legal record that protects the resident, physician, nurse, and the facility; -An information source for resident changes; -Chart all pertinent changes in the resident's condition, reaction to treatments, medications, as well as routine observations; -Be concise, accurate, and complete; -Document only the facts and chart as often as necessary and as the need arises; -Document daily treatments and vital signs; -Lab work documentation should include: -Date and time the specimens were obtained; -Name of the person; -Date and time specimens were forwarded to the lab; -Date and time the results were obtained; -Date and time the physician was notified of the lab results; -Refusal of treatment documentation should include: -Date and time treatment was attempted; -Treatment attempted; -Resident's response and reason for the refusal;-Name of person attempting to administer treatment;-Documentation that the resident was informed of the purpose of the treatment and the consequences of not receiving the care;-Document each time the resident refuses treatment, the resident condition, and any adverse effects due to the refusal;-Date and time the physician was notified as well as the physician response;-All pertinent observations;-Skin lesion documentation should include:-Specific location of the skin problem; -Number, size, degree, and measurement of pressure sores;-Documentation that skin surfaces are looked at regularly for the resident at risk or exhibiting a skin problem; -Clear indication of contributing factors to the development of the skin condition;-Documentation of the cause of the pressure sores developed in house and substantiation of preventative interventions;-Any changes in the resident's condition or response to treatment;-Date of occurrence of a skin problem and date the problem was solved; -Progress, deterioration, or the development of new problems; -Use of special creams, lotions, medications, or devices; -The cause of any wound; -Miscellaneous documentation should include any time the physician or family is called as well as their response and each time a physician visits a resident. 1. Review of Resident #1's face sheet (document that gives a resident's information at a quick glance) showed the following:-admission date of 09/11/25;-Diagnoses included pressure induced deep tissue damage (localized injury to skin and underlying soft tissue caused by prolonged pressure) of the sacrum (a large, triangular bone at the base of the spine), diabetes mellitus (metabolic disorder characterized by high blood sugar due to the body's inability to produce insulin), and high blood pressure. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 03/31/26, showed the following:-Cognitively intact;-No behaviors or rejection of care;-Resident had four stage 3 pressure ulcers (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling);-Resident dependent on staff for showers, toileting and transfers. Review of the Resident's care plan, dated 05/21/26, showed the following:-Resident had fragile skin related to age and medications, dated 09/25/25;-Resident dependent on staff for activities of daily living (ADL – fundamental self-care tasks such as hygiene, dressing, eating, toileting, and mobility) dated 09/25/25; -I refuse care at times, dated 09/25/25;-Resident at risk for behavioral episodes related to left sacral wound, dated 09/25/26;-Facility staff will report behavior changes, combative behavior, or aggression to the nurse, dated 03/24/26;-Combative or physically aggressive behaviors will be reported to the physician for assessment, dated 03/24/26;-Resident had pain related to wounds, dated 09/25/25;-Resident had a stage 3 pressure injury to the right lateral (side) heel (wound healed on 05/25/26, care plan not updated) and right lateral malleolus (ankle bone), dated 04/10/26; -Resident had a stage 4 pressure injury ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling) to sacrum, dated 04/10/26; -Wound vacuum (vac) to the sacrum to be changed as ordered, dated 05/21/26;-Resident noncompliant with staying off sacrum, dated 04/10/26;-Measure and document wound size, depth, and undermining regularly, dated 04/10/26; -Monitor wounds for signs of infection (redness, warmth, drainage, odor, increased pain), dated 04/10/26;-Perform dressing changes to sacral and heel wounds daily and as needed per physician orwound care orders, dated 04/10/26; -Reinforce education frequently due to non-compliance, dated 04/10/26;-Staff will monitor skin during cares and anytime skin is exposed, dated 03/24/26; -Skin assessments to be done weekly by the nurse, dated 03/24/26; -Nurse will monitor for signs and symptoms of infection and report to the physician as needed, dated 03/24/26. Review of the resident's physician order sheet (POS) showed the following orders:-An order dated 09/25/25, for behavior monitoring; 0-none, 1-yelling, 2-hallucination, 3-hitting, 4-biting, 5-pacing, 6-crying, 7-reject care, 8-disrobing, 9-wandering, 10-rummaging, 11-sexual inappropriateness, 12-exit seeking, 13-sleep disturbances, 14-isolating self, 15-delusions, 16-crawling out of bed, 17-disruptive noises, 18-cursing, 19-paranoia, 20-describe, document every shift;-An order, dated 05/18/26, to cleanse sacral wound with wound cleanser, apply skin prep (protective barrier wipes) to the peri-wound (tissue/skin around the wound), apply xeroform (non-adherent wound dressing) to the wound bed to cover the bone, cover with black foam, wound vac at 125 millimeters mercury (mmHg) continuous therapy to the base of the wound, secure with transparent film, change three times per week (Monday, Wednesday, and Friday) and as needed;-An order, dated 05/27/26, to cleanse the right lateral malleolus with wound cleanser, apply skin prep to peri wound, apply collagen particles (dressing for deep or heavily draining wounds) to wound bed and cover with bordered gauze, every other day and as needed. Review of a nurse's note dated 06/01/26, at 1:47 P.M. showed RN F documented the following:-Wound vacuum changed this shift;-Resident's sacral wound had red beefy tissue with no drainage, bleeding, or minimal odor;-Resident had some pain with turning but not during cleansing and treatment of wound;-The sacral wound measured 5.7 centimeters (cm) by 2.3 cm with no tunneling (passageways underneath the service of the skin) or undermining (wound open underneath the border of the wound);-Right lateral malleolus wound had no open area upon treatment. Review of an outside wound company note dated 06/03/26, no time indicated, showed the following:-Stage 4 sacral pressure ulcer that measured 5.6 cm by 2.3 cm by 0.3 cm with unattached wound edges. Sacrum improved despite measurements. The wound had 10% epithelial tissue (uttermost layer of skin that regenerates to close a wound), 60% granulation tissue (new tissue that forms on the healing surface of a wound), and 30% slough (necrotic (dead) tissue) with a moderate amount of serosanguineous drainage (yellowish drainage with small amounts of blood);-Sacral wound treatment orders were not changed from the previous visit;-Stage 3 right lateral malleolus pressure ulcer resolved. New treatment order: Apply skin prep daily for seven days and continue preventative care;-New deep tissue injury (DTI- Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the left heel that measured 3.2 cm by 1.5 cm by 0.1 cm. New treatment recommendations for the left heel: cleanse with wound cleanser, apply skin prep, leave open to air daily and as needed, strict offloading with heel protector boots, and close monitoring for progression to open ulcer;-New stage 1 (an observable, pressure-related alteration of intact skin presenting as a defined area of persistent redness in lightly pigmented skin) pressure ulcer to the right lateral malleolus that measured 1.5 cm by 1 cm by 0.1 cm with skin intact. New recommendations to cleanse with wound cleanser, apply skin prep, leave open to air daily and as needed, strict offloading with prevalon boots (medical device to prevent bedsores and offload heel pressure), and close monitoring for progression to open ulcer. Review of care plan showed no updates related to new wounds, Prevalon boots, or new treatment recommendations. Review of the resident's nursing progress note dated 06/03/26, at 8:51 P.M. showed a nurse documented the following:-Wound care provider rounds;-Resident treated for right lateral malleolus wound, sacral wound, and new wound to the left heel;-Wounds stable at this time;-Treatment orders to cleanse with wound cleanser and apply skin prep and leave open to air;-Provider notified and in agreement with new orders and continuation of wound vac orders;-Educated resident on need to offload pressure but he/she wants to lay on back;-Offered Prevalon boots but resident refused stating they cause pain. Review of the resident's POS showed the following orders:-An order dated 06/03/36, to cleanse left heel with wound cleanser, apply skin prep, and leave open to air daily, discontinued on 06/04/26;-An order dated 06/04/26, to cleanse the right malleolus with wound cleanser, apply skin prep to peri wound, and leave open to air daily;-An order dated 06/04/36, to cleanse left heel with wound cleanser, apply skin prep, and leave open to air daily for preventative. (No order indicated for Prevalon boots) Review of the resident's skin assessment dated [DATE], showed the following:-The resident had treatment orders for his/her right lateral malleolus which continued to get smaller and near the healing stage;-Wound vac to buttocks, which is getting smaller in size & depth;-Resident had area to left lower extremity edema (swelling). Review of the resident's dietician progress note dated 06/05/26, showed the following:-The resident continued to have three wounds on his/her sacrum, left heel and right ankle;-The sacral wound had a wound vac in place;-Nurse reported that all of the resident's wounds were healing. -Resident receives 45 milliliters (ml) Prostat (liquid protein supplement) daily and has 120ml very high calorie (VHC) supplement four times daily. Review of the resident's POS showed the following orders:-An order dated 02/08/26, for Prostat 45 ml twice daily;-An order dated 05/01/26, for Boost VHC liquid, 120 ml four times daily for malnutrition. Review of the resident's outside wound company note dated 06/10/26, no time indicated, showed the following:-Stage 4 sacral pressure ulcer that measured 6.5 cm by 4 cm by 0.4 cm with unattached wound edges and undermining (wound open underneath the border of the wound) of 0.5 cm at 6 o' clock to 8 o' clock. The wound had 10% epithelial tissue, 60% granulation tissue, and 30% slough (dead tissue) with a moderate amount of serosanguineous drainage. The wound was stable and treatment orders were not changed from previous visit;-Stage 2 right lateral malleolus pressure ulcer that measured 0.5 cm by 0.5 cm by 0.1 cm with a moderate amount of serosanguinous drainage. New treatment order to cleanse with wound cleanser, apply skin prep to peri wound, apply calcium alginate (highly absorbent wound dressing) to the base of the wound and secure with bordered dressing daily and as needed;-DTI to the left heel that measured 4.5 cm by 3.3 cm by 0.1 cm with no drainage. No new treatment orders;-DTI to the right buttocks that measured 4.3 cm by 4.3 cm by 0.1 cm with no drainage. New treatment recommendations to cleanse with wound cleanser, apply skin prep to the peri wound, and leave open to air;-New stage 3 pressure ulcer to the left fifth toe that measured 1 cm by 0.5 cm by 0.1 cm with a moderate amount of serosanguinous drainage and 30% granulation tissue and 70% slough. New treatment recommendations to apply skin prep to the peri wound, apply calcium alginate to base of the wound, and secure with bordered dressing daily and as needed;-New stage 3 pressure ulcer to the left fifth metatarsal (long bones in the middle foot that connect the ankle to the toes foot that measured 2 cm by 1.1 cm by 0.2 cm with moderate amount of serosanguinous drainage and 50% granulation tissue and 50% slough. New treatment recommendations to apply skin prep to the peri wound, apply calcium alginate to base of the wound, and secure with bordered dressing daily and as needed. Review of the resident's nurse progress note dated 06/10/26, at 10:04 A.M. showed the following:-The outside wound company assessed the resident's wounds today;-The resident had pressure ulcers to his/her sacrum (tailbone), right buttock, left fifth metatarsal, left fifth toe, left heel, and right lateral malleolus;-Recommendation to continue treatment for sacrum and left heel wounds;-New treatment recommendations: 1. Right lateral malleolus-cleanse with wound cleanser, skin prep peri wound, apply calcium alginate and cover with bordered gauze daily and as needed. 2. Left fifth toe - cleanse with wound cleanser, apply skin prep to the peri wound, apply calcium alginate and cover with bordered gauze daily and as needed. 3. Left 5th metatarsal - cleanse with wound cleanser, apply skin prep to the peri wound, apply calcium alginate and cover with border gauze daily and as needed. 4. Right buttock-cleanse with wound cleanser, apply skin prep to peri wound, leave open to air.-Provider notified and in agreement with recommendations;-Medication Administration Record (MAR) updated;-All parties were aware of the new orders and wound conditions. Review of the resident's care plan showed no updates related to new wounds. Review of the resident's POS showed the following orders:-An order dated 06/11/26, to cleanse the left fifth metatarsal with wound cleanser, apply skin prep to peri wound, apply calcium alginate and cover with border gauze daily and as needed;-An order dated 06/11/26, to cleanse the left fifth toe with wound cleanser, apply skin prep to peri wound, apply calcium alginate and cover with border gauze daily and as needed;-An order dated 06/11/26, to cleanse the right buttocks with wound cleanser, apply skin prep to peri wound, and leave open to air daily and as needed;-An order dated 06/11/26, to cleanse the right lateral malleolus with wound cleanser, skin prep peri wound, apply calcium alginate and cover with bordered gauze daily and as needed. Review of a skin assessment dated [DATE], showed treatment orders in place for right lateral malleolus which continues to be getting smaller and near healing stage. Wound vac to buttocks, which is getting smaller in size & depth. Resident has area to left lower extremity edema and small area peeling on outer right ankle with 2 small areas on right toe and outer pad. (No notification to physician or treatment orders for 2 small areas on right toe and outer pad). Review of a nursing progress note dated 06/13/26, at 3:15 A.M., showed Wound Change: Resident had been observed pulling at wound vacuum seal and digging stool out of rectum. Wound was bleeding pretty heavy, and bleeding was staunched. Will call wound NP for new orders as resident states that wound vacuum is not working. Cleansed wound thoroughly and placed temporary dressing. Review of June POS showed the following:-An order dated 06/13/26, to cleanse sacral wound with wound cleanser and apply skin prep to peri wound. Apply hydrofera blue (foam dressing to promote wound healing) to undermining and wet to dry to inner wound daily and as needed (Wound care note dated 06/17/26 showed facility contacted NP on 06/14/26 and hydrofera blue, but no wet to dry dressing ordered, wound vac order was not discontinued on POS until 6/26/26). Review of a nursing progress note dated 06/14/26, at 3:17 p.m., showed resident has stayed in bed all this shift and resident does not like to be turned however we do continue to encourage resident to do so. Resident has treatment orders in place to bottom, left leg and heel and right outer foot with dressings in place.Review of a nursing progress note dated 06/14/26, at 10:28 P.M. showed wound dressing change: Resident sacral wound cleansed. Some bleeding noted and beefy red tissue noted. Resident continues to pull wedges loose and refuses to turn side to side. Resident shows decline in right buttock and has open blister where resident prefers to lay. Spoke to the wound care company again this shift who states to obtain labs. Called NP for physician who agreed with orders for new lab draws and urinalysis with culture and sensitivity. (No notification, wound assessment, or new treatment order documented for open blister) Review of June POS showed no order for labs or urinalysis. Review of an outside wound company note dated 06/17/26, showed the following:-On 6/14/26, no time indicated, facility staff notified NP of wound vacuum to sacrum filling up with blood. Wound vacuum removed and new treatment orders of hydrofera blue, ABD, and secure with tape recommended. Discussed with facility about notification to physician regarding increased bloody drainage and to recommend labs for a complete blood count (CBC), complete metabolic profile (CMP), and a prothrombin time and International Normalized Ratio (PT/INR – blood test to measure how long it takes your blood to clot);-A stage 4 sacrum pressure ulcer measuring 8.2 cm by 5 cm by 0 cm with unattached wound edges and undermining of 0.4 cm at 6 o'clock to 8 o'clock;-Sacrum is worsening and wound has 50% granulation tissue, 20% slough, and 30% exposed bone with a heavy amount of sanguineous drainage;-Assessment showed sacral wound had increased size and visible bone which had not been present for a few weeks. Bloody drainage noted from wound bed and concerned due to frequency needed of dressing change. Necrotic tissue that was not present last week. Wound concerning due to change from last assessment;-Sacrum treatment is to cleanse with wound cleanser, apply skin prep to peri wound with hydrofera blue, secure with absorbent dressing (ABD – dressing used to keep wounds dry) and secure with tape. Staff should follow recommendations if hospital does not provide treatment orders;-A stage 2 right lateral malleolus pressure ulcer measuring 1.8 cm by 1.7 cm by 0.2 cm with a moderate amount of serosanguinous drainage;-Right lateral malleolus was worsening and had 10% epithelial, 40% granulation, and 50% slough;-New treatment order to right malleolus to cleanse with wound cleanser, apply skin prep to peri wound, use Santyl (an ointment used to debride ulcers) and calcium alginate, secure with bordered gauze and change daily and as needed. Follow recommendations if hospital does not provide treatment orders;-A worsening DTI to the left heel measuring 7 cm by 6.6 cm by 0.1 cm with no drainage. Wound has increased in size and had fluid filled blister;-New treatment for the left heel to cleanse with wound cleanser, apply skin prep and secure with bordered gauze daily and as needed;-An unstageable wound to the right buttocks measuring 8 cm by 6.5 cm by 0.1 cm with no drainage;-Right buttocks wound had 10% epithelial, 80% eschar and 10% slough;-Right buttocks now an unstageable wound and increased in size;-New treatment order to right buttocks to cleanse with wound cleanser, apply skin prep to peri wound, use Santyl (an ointment used to debride ulcers) and hydrofera blue, secure with bordered gauze and change daily and as needed. Follow recommendations if hospital does not provide treatment orders;-A stage 3 pressure ulcer to the left fifth toe measuring 0.6 cm by 0.6 cm by 0.1 cm with no drainage and 100% epithelial tissue;-New recommendations to the left fifth toe to apply skin prep and leave open to air daily and as needed;-A stage 3 pressure ulcer to the left fifth metatarsal foot measuring 1.0 cm by 1.0 cm by 0.1 cm with no drainage and 100% epithelial tissue;-New treatment recommendations to the left fifth toe to apply skin prep and leave open to air daily and as needed.-Provider recommended to send resident to the hospital for a Magnetic Resonance Imaging (medical test that uses powerful magnets to create images of the body)of the sacrum and the foot to rule out infection and CBC, CMP, and PT/INR. Discussed concerns with DON and NP for resident's physician and they agreed. Review of June 2026 POS showed no updated orders. Review of a nursing progress note dated 06/17/26, at 11:17 A.M., Director of Nursing (DON) came to this nurse asking to have the resident sent to the emergency room. Nurse did call emergency medical services, and they will be sending an ambulance. DON reports the provider was called and orders received to send the resident out due to unstable wounds. This nurse was told by the wound care provider that the wounds have doubled in size since the last visit on 6/10/26. Wound care provider reports that resident has wounds on the left heel, coccyx and left hip, and one on the sacrum was reported to nurse as showing signs of unstable wounds. It was requested that the provider would need them to do an MRI and labs. Review of a nursing progress note dated 06/17/26, at12:18 P.M. showed, nurse completed transfer form. Resident sent to hospital for evaluation following round with wound care provider nurse practitioner. Review of a hospital transfer form dated 06/17/26, showed resident sent to hospital due to deteriorating wounds, malnourishment, and dehydration. Resident had stage 4 to coccyx, DTI to right hip, DTI to left heel. Review of a hospital discharge note dated 06/26/26 showed resident discharged with a diagnosis of abscess of the liver. MRI of the left foot showed a well circumcised soft tissue mass measuring 3.4 cm by 1.9 cm by 1.7 cm with a suspicion of osteomyelitis (bone infection). Resident had a stage 4 sacral wound, unstageable right hip wound, unstageable left heel wound, and a right ankle wound. Wound care orders noted as the following:-Cleanse coccyx wound daily and as needed with normal saline and gauze and allow to dry. Apply a thin layer of moisture barrier cream to peri wound. Apply Santyl nickel thickness to the wound bed and cover lightly with Dakins (antiseptic cleanser) moistened gauze. Cover with ABD and secure with tape;-Cleanse left heel wound daily and as needed with normal saline and gauze and allow to dry. Apply Aquacel Ag (wound drainage absorbent product) cut to fit on the wound bed. Cover wound with ABD and secure with kerlix wrap (gauze bandage roll) and tape;-Cleanse the right ischial tuberosity (bone prominence at the base of the pelvis) every 48 hours and as needed with normal saline and gauze and allow to dry. Apply thin layer of citric acid barrier cream to peri wound, cover wound bed with a thin layer of xeroform (non-adherent bandage), then ABD, secure with tape;-Cleanse the left medial leg twice daily and as needed with Chlorhexidine Gluconate (CHG-antiseptic) wipes and allow to dry. Apply thin layer of Venelex (topical medication) ointment to wound bed and leave open to air;-Vancomycin (antibiotic) 1250 milligrams (mg), inject one dose intravenously (IV) every 12 hours for 20 days. Review of a nursing progress note dated 06/26/26, at 2:20 P.M. showed resident arrived at facility via ambulance transport on stretcher. Resident has wounds to coccyx, right ischial tuberosity, left medial leg and left heel. Wound care orders were received in hospital paperwork. Resident is taking Vancomycin for wound infection. Physician approved all orders as written from the hospital. Physician contacted and made aware. Review of a nursing admission assessment dated [DATE], at 2:20 P.M. showed the resident had dry skin with a heel issue noted. Resident had applications of dressings and ointments to feet. He/she had pressure ulcers and abrasions and see skin assessment for further information. Review of a nursing wound assessment dated [DATE],at 2:20 P.M. showed the resident had wounds to buttocks, coccyx, and bilateral lower extremities that were present on admission. The following wounds were listed:-Coccyx-wound bed meaty and red measuring 8.4 cm by 6.5 cm by 0.5 cm;-Right buttock-100% Eschar measuring 8.0 cm by 5.5 cm;-Back left leg-abrasion measuring 11.0 cm by 1.0 cm;-Top left foot-abrasion measuring 1.0 cm by 1.0 cm;-Left heel-1/2 eschar measuring 7.0 cm by 5.5 cm;-Right outer ankle-abrasion with some eschar measuring 2.0 cm by 2.6 cm;-Unidentified wound described as unstageable with no tunneling or undermining and slough wound bed with scant serosanguinous drainage;-Additional description of wound (unspecified) on assessment stated some wounds have eschar and some are meaty; -Continue same treatment orders and physician notified of resident's wound status.(five wounds identified on assessment and only one unknown wound assessed) Review of June 2026 POS showed the following orders:-An order dated 02/08/26, for Prostat 45 ml twice daily, discontinued 06/26/26;-An order dated 05/01/26, for Boost VHC liquid, 120 ml four times daily for malnutrition, discontinued 06/26/26;-An order, dated 05/18/26, to cleanse sacral wound with wound cleanser, apply skin prep to peri wound, xeroform to wound bed to cover bone, cover with black foam, wound vacuum at 125 mmHg continuous therapy to the base of the wound, secure with transparent film, change three times per week (Monday, Wednesday, and Friday) and as needed, discontinued on 06/26/26; (discontinued per nursing progress notes on 06/13/26)-An order dated 06/11/26, to cleanse the left fifth metatarsal with wound cleanser, apply skin prep to peri wound, apply calcium alginate and cover with border gauze daily and as needed, discontinued 06/26/26;- An order dated 06/11/26, to cleanse the left fifth toe with wound cleanser, apply skin prep to peri wound, apply calcium alginate and cover with border gauze daily and as needed, discontinued 06/26/26;-An order dated 06/11/26, to cleanse the right buttocks with wound cleanser, apply skin prep to peri wound, and leave open to air daily and as needed, discontinued 06/26/26;-An order dated 06/11/26, to cleanse the right lateral malleolus with wound cleanser, skin prep peri wound, apply calcium alginate and cover with bordered gauze daily and as needed, discontinued 06/26/26;-An order dated 06/04/36, to cleanse left heel with wound cleanser, apply skin prep, and leave open to air daily for preventative, discontinued 06/26/26;-An order dated 06/26/26, to cleanse the left heel with normal saline, pat dry, apply aqualcel ag to wound bed, cover with ABD and secure with kerlix wrap and tape, change daily and as needed;-An order dated 06/26/26, cleanse the left medial leg with wound cleanser, pat dry, apply thin layer of Venelex ointment to wound bed and leave open to air, twice daily and as needed; (order from hospital indicated CHG for wound cleansing)-An order dated 06/26/26, cleanse the right ischial tuberosity with normal saline, pat dry, apply thin layer of citric acid barrier cream to peri wound, cover wound bed with a thin layer of xeroform and then ABD, secure with tape, change every other day and as needed;-An order dated 06/26/26, to cleanse coccyx wound with normal saline and pat dry. Apply thin layer of moisture barrier cream to peri wound, apply Santyl in nickel sized thickness to wound bed, cover with lightly 1/4 strength Dakins moistened gauze, cover with ABDand secure with tape, change daily and as needed;-An order dated 06/27/26, for vancomycin solution, 1.25 grams intravenously every 12 hours, for a diagnosis of unspecified open wound of the right foot.(No wound care orders for identified 'unstageable' wounds in 06/26/26 wound assessment to the right outer ankle or top of the left foot) Review of the resident's care plan showed no updated interventions or changes related to wounds. Review of a nursing progress note dated 06/27/26, at 4:54 P.M. showed resident has wounds to coccyx, buttocks and bilateral feet. (No wound care orders or assessment for wounds on right foot or left toes) Review of a nursing progress note dated 06/28/26, at 11:49 A.M. showed resident has wounds to buttocks, feet and coccyx have treatments in place per orders. (No wound care orders or assessment for wounds on right foot or left toes) Review of a nursing progress note dated 06/29/26, at 4:38 P.M. showed resident has wounds to buttocks, feet and coccyx has treatments in place per orders. (No wound care orders or assessment for wounds on right foot or left toes) Review of a nursing progress note dated 06/29/26, 11:47 P.M. showed treatment to coccyx, left heel and left medial leg not completed related to aquacel ag, venelex ointment, and Dakin's solution not available. Notified DON and instructed to put a wet to dry dressing to coccyx. DON will contact pharmacy in the morning. (No physician notification documented and no order for wet to dry dressings) Review of a nursing progress note dated 06/30/26, at 4:27 P.M. showed resident has wounds to coccyx, buttocks and bilateral feet. (No wound care orders or assessment for wounds on right foot or left toes) Review of June 2026 medication administration record (MAR) showed the following:-No behaviors or rejection of care noted;-Wound care completed as ordered with no refusals except on the following:-On 06/15/26, no documentation of wound care provided;-On 06/29/26, due to wound[TRUNCA

1.Please refer to event ID 1E31E4-H3, exit date 06/05/26, for details. Complaints #2987175 and #2988229.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical restraint when staff physically restrained one resident (Resident #2) while assisting him/her back to the special care unit by holding the resident's arms behind his/her back resulting in the resident being upset and crying. The facility census was 77.Review of a facility policy titled Resident Rights, undated, showed the following:-It is the intent of the facility to promote and ensure the highest standards of conduct and reliability by its employees and consultants to in turn produce environments in the facility that promote the highest standards of care and security for our residents and families we serve;-The exercise of resident rights shall be free from restraint, interference, coercion, discrimination or reprisal;-Each resident shall be free from mental and physical abuse;-Residents have the right to be free from any physical or chemical restraint except when used to treat a specified medical symptom as a part of a total program of care to assist the resident in attaining and maintaining highest practicable level of physical, mental, or psychosocial well-being;-The use of restraints must be authorized in writing by physician for a specified period of time or when necessary, in an emergency to protect the resident from injury to self or others, in which case restraints may be authorized by professional personnel so designated by the facility. The action shall be reported immediately to the resident's physician and an order obtained which shall increase reason for restraint, when restraint may be removed, type of restraint and any other action required;-When restraints are indicated, only devices that are the least restrictive for the resident and consistent with the resident's total treatment program shall be used;-Each resident shall be treated with consideration, respect a full recognition of his/her dignity and individuality. Review of the facility's Abuse Prevention Policy and Procedure Checklist,revised11/28/16, showed the following:-The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restrain not required to treat the resident's medical symptoms;-The intent of this requirement is for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical restraints for discipline or convenience and prohibits the use of physical restraints to unnecessarily inhibit a resident's freedom of movement or activity. 1.Review of Resident #2's face sheet (admission information at a glance) showed the following:-admission date of 07/14/25;-Diagnoses that included bipolar II disorder (mental health condition characterized by depressive episodes and hypomania (elevated, irritable, or energetic moods)), anxiety disorder, personality disorder, epilepsy (seizure disorder), and parkinsonism (movement symptoms such as slow movements, stiffness, walking and balance problems, and tremor). Review of the resident's care plan, revised 10/28/25, showed the following:-Socially inappropriate/disruptive behavioral symptoms as evidenced by rejecting cares at times;-Assess whether behavior endangers the resident and/or others and intervene if necessary;-Avoid over-stimulation (noise, crowding, other physically aggressive residents);-Convey an attitude of acceptance toward the resident;-Maintain a calm environment and approach to the resident;-When resident begins to become socially inappropriate/disruptive, provide comfort measures for basic needs ( such as pain, hunger, toileting, too hot/cold, etc.)-Resident has difficulty understanding others related to mental health issues and intellectual disabilities;-Ask resident to repeat what has been said to confirm the message was understood;-Face the resident when speaking;-Obtain resident's attention before speaking;-Repeat phrases as needed and rephrase if necessary;-Speak clearly and adjust tone as needed;-Resident has disorganized thinking or is incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, unpredictable switching from subject to subject) related to mental health problems;-Assess factors that may be associated with signs and symptoms of delirium such as time of symptom onset, change in mood, change in social situations, use of restraint;-Be calm and reassuring in approaching resident;-Orient to person, place, and time. Speak quietly, slowly, and repetitively;-Provide a quiet, well-lit, calm environment, Surround resident with familiar objects.(Staff did not care plan use related to specific physical restraint use on the resident for behaviors.) Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/20/26, showed the following:-Cognition was severely impaired;-Independent with functional abilities to move from sitting to lying down, standing, and walking. Review of the resident's progress note, dated 01/20/26, showed the following:-Resident was alert to self and knew his/her name;-Autistic and can have episodes with behaviors where he/she wants medications now, covered up now, or his/her meal tray picked up now, or he/she will throw personal belongings at times such as throwing his/her coloring papers at staff and then throwing them on the floor. The resident will come back and apologize for his/her behavior;-Able to make needs know and knows when he/she has an accident and needs staff to come;-Enjoys comic books and superheroes coloring pages and likes to watch game shows;-Up ad lib (on own) around the unit and does not make attempts to seek exiting unit. Review of the resident's physician's orders, dated 01/06/26 to 02/06/26, showed there was no physician's order for a physical restraint for behaviors. Review of the resident's progress notes showed staff did not document regarding use of a restraint when the resident returning from the business office and to the special care unit. During an interview on 02/06/26, at 2:20 P.M., Nurse Aide (NA) B said the following:-He/she was in the business office with the resident while on a call with Social Security;-When the call ended, he/she and the Business Office Manager (BOM) tried to get the resident to go back to the unit but the resident refused;-The BOM had been printing out pictures of [NAME] and the more you give the resident, the more he/she wants;-The resident had a temper tantrum and he/she escalated in the business office;-The resident got more upset and angry but this was not at the point, he/she restrained him/her;-Outside the business office, the resident began swinging his/her arms hitting him/her several time on his/her head and at that point, my training in behavioral health kicked in and took my arms, wrapped them around the resident from his/her back underneath the arms, like tucked them behind his/her mid-back and restrained him/her so he/she could not hit him/her. It upset the resident and he/she began crying;-The BOM did not tell him/her to let the resident go and was beside him/her all the way to the unit;-The resident cried the whole time;-He/she did not hurt the resident and in the unit, he/she released the resident;-He/she didn't have training here about what to do when a resident was having behaviors but had training in previous jobs;-The Director of Nursing (DON) called him/her to his/her office and was told not to do that. During interview on 02/06/26, at 1:57 P.M., Certified Nurse Aide (CNA) E said the following:-He/she witnessed the incident with the resident and NA B last week when he/she was in the dining room;-He/she observed NA B yell, Yes, you are! and NA B got behind the resident, put his/her arms behind his/her back like being arrested and it raised up the resident's shoulders;-The resident cried as he/she walked with his/her hands held up behind him/her behind his/her back like being arrested;-The BOM walked beside them and he/she saw the way NA B did this to the resident;-The BOM did try to calm the resident down but it was not appropriate for staff to touch and or restrain him/her;-Back on the unit when the resident threw fits and threw stuff like his/her coloring pages at staff. They were to scoot to the side of the nurses' desk when the resident does this;-They were to let the resident settle down, take a break and then try again;-He/she talked to the DON about NA B. During an interview on 02/06/26, at 9:50 A.M., CNA D, who worked on the dementia unit, said the following:-NA B recently inappropriately restrained the resident by holding his/her arms and hands behind his/her back like he/she was being arrested;-The NA had his/her arms intertwined with the resident's arms to keep the resident's arms and hands from moving;-The resident was upset and crying;-He/She heard the resident tell the NA No I'm not going, and the NA responded to the resident by saying Yes you are;-The situation happened in the dining room area at the front entrance to the facility;-NA B held the resident's arms and hands behind his/her back the entire way while walking him/her from the BOM's office until he/she got to the special care unit;-CNA E told LPN F and the DON about the situation and the DON informed him/her that he/she would handle it. During interview on 2/9/26 at 12:00 P.M., the DON said the following:-Holding a resident's hands behind their back may or may not be considered abuse;-It depended on the intent;-Holding a resident's arms and hands behind their back would not necessarily be considered abuse if there are no marks left on the resident;-Staff saw what happened between the resident and NA B and thought it was resident abuse, so he/she spoke with LPN F, and the two of them determined that it was not abuse or restraining a resident;-The DON and LPN F ruled out abuse and neglect on their own;-He/She completed verbal counseling with NA B;-The DON did not complete an investigation of the allegation;-NA B was not written up, but he/she was informed that he/she cannot physically restrain a resident's arms and hands behind their back. During an interview on 02/18/26, at 3:43 P.M., the Facility Physician said the following:-Facility staff should not physically restrain any resident unless they are aggressive against staff, and they are exhibiting behaviors that could bring danger to their self or others;-The resident does not have a physician's order for physical restraints, but he/she does have a chemical restrain ordered for agitated behavior;-He/She felt the situation with the resident and NA B was excessive and not acceptable;-He/She considers NA B holding the resident's arm and hands behind his/her back and walking him/her from the BOM's office to the special care unit a physical restraint. During an interview on 02/06/26, at 11:35 A.M., the Administrator said the following:-An employee, NA B, had inappropriate behavior and the DON talked to him/her;-They were not to restrain the resident or put anyone's hands behind their back. They would consider it a restraint;-She would not expect NA B to use technique that Department of Corrections used. #2735227

Based on interview and record review, the facility failed to ensure all residents received treatment and care in accordance with professional standards of practice when the facility failed to administer medications as ordered, failed to obtain ordered labs in a timely fashion, failed to timely assess and document changes of conditions, and failed to notify the physician of missed medications, out of range labs, and changes of conditions in a timely manner for one resident (Resident #1) who was hospitalized due to his/her change of condition. The facility staff also failed to follow physician orders regarding daily weights, failed to complete fluid restriction monitoring, and failed to update the resident's care plan intervention for one resident (Resident #5) with a diagnosis of congestive heart failure (CHF- impaired heart function). The facility census was 70. Review showed the facility did not provide a policy regarding monitoring weights for residents. 1. Review of Resident #1's face sheet (brief look at resident information) showed the following information: -admission date of 01/09/26; -Diagnoses include CHF, cardiomyopathy (progressive disease of the heart muscle that causes the walls to enlarge, thicken, or stiffen), and disorder of kidney and ureters. Review of the resident's admission weight, dated 01/12/26, showed the resident weighed 147 pounds. Review of the resident's comprehensive Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 01/22/26, showed the following information: -Cognitive impairment; -No shortness of breath; -Required diuretic (helps kidneys remove excess salt (sodium) and water from the body through urine) medication. Review of the resident's weight, dated 01/26/26, showed the resident weighed 135.2 pounds. Review of the resident's care plan, revised 05/06/26, showed the following information: -Monitor for signs and symptoms of cardiac (heart) distress such as shortness of breath, chest pain, and dizziness. Report abnormalities to the physician; -Administer medications as ordered. Monitor for effectiveness and adverse effects; -Encourage limitation of salt intake; -Assess for edema (swelling). If edema is present, encourage the resident to elevate his/her legs; -Auscultate (listen to with a stethoscope) his/her lungs for breath sounds; -Monitor weight as directed by the physician; -Administer medications as ordered; -Monitor intake and output as ordered. Review of the resident's April 2026 Physician Order Sheet (POS) showed the following information: -An order, dated 01/09/26, for metolazone (diuretic) 5 milligrams (mg) by mouth (po) daily at 8:00 A.M.; -An order, dated 01/09/26, to monitor weight monthly unless otherwise indicated; -An order, dated 03/12/26, for hydrochlorothiazide (diuretic) 25 mg po daily at 8:00 A.M. Review of the resident's April 2026 Medication Administration Record (MAR) showed the following information: -On 04/01/26, staff noted hydrochlorothiazide 25 mg tablet was not administered with a reason of on hold; -On 04/01/26, staff noted metolazone 5 mg tablet not administered with a reason of on hold. Review of the resident's progress notes, dated 04/01/26, showed staff did not document in the notes the reason for the held medication, or physician notification of the held medications. Review of the resident's weight log, dated 04/05/26, showed the resident weighed 135.8 pounds. Review of the resident's April 2026 MAR showed the following information: -On 04/07/26, staff noted hydrochlorothiazide 25 mg tablet not administered with a reason of on hold; -On 04/07/26, staff noted metolazone 5 mg tablet not administered with a reason of on hold. Review of the resident's progress notes, dated 04/07/26, showed staff did not document in the notes the reason for the held medication, or physician notification of the held medications. Review of the resident's April 2026 POS showed the following information: -The order for metolazone was discontinued on 04/07/26; -The order for hydrochlorothiazide 25 mg po daily at 8:00 A.M. was discontinued on 04/07/26; -An order, dated 04/07/26, for hydrochlorothiazide 25 mg tablet, give 0.5 tablet po daily at 8:00 A.M. Review of the residents April 2026 MAR, dated 04/08/26 through 04/10/26, showed staff noted hydrochlorothiazide 25mg 0.5 tablet not administered with a reason of on hold. Review of the resident's progress notes, dated 04/08/26 through 04/10/26, showed staff did not document in the notes the reason for the held medication, or physician notification of the held medications. Review of the resident's April 2026 POS an order, dated 04/11/26, for metolazone 2.5 mg po daily at 8:00 A.M. Review of the residents April 2026 MAR, dated 04/11/26 and 04/12/26, showed the following: -Staff noted hydrochlorothiazide 25mg 0.5 tablet not administered with a reason of on hold; -Staff noted metolazone 2.5mg tablet was not administered with a reason of on hold. Review of the resident's progress notes, dated 04/11/26 to 04/12/26, showed staff did not document in the notes the reason for the held medication, or physician notification of the held medications. Review of the resident's April 2026 MAR showed the following information: -On 04/14/26, staff noted hydrochlorothiazide 25 mg 0.5 tablet not administered with reason of on hold; -On 04/14/26, staff noted metolazone 2.5 mg tablet not administered with reason of on hold. Review of the resident's progress notes, dated 04/14/26, showed staff did not document in the notes the reason for the held medication, or physician notification of the held medications. Review of the resident's April 2026 MAR showed the following information: -On 04/17/26, staff noted hydrochlorothiazide 25 mg 0.5 tablet not administered with reason of on hold; -On 04/17/26, staff noted metolazone 2.5 mg tablet not administered with reason of on hold. Review of the resident's progress notes, dated 04/17/26, showed staff did not document in the notes the reason for the held medication, or physician notification of the held medications. Review of the residents' April 2026 MAR showed the following information: -On 04/19/26, staff noted hydrochlorothiazide 25 mg 0.5 tablet was not administered with reason of on hold; -On 04/19/26, staff noted metolazone 2.5 mg tablet not administered with reason of on hold. Review of the resident's progress notes, dated 04/19/26, showed staff did not document in the notes the reason for the held medication, or physician notification of the held medications. Review of the resident's progress notes, dated 04/24/26, showed the Nurse Practitioner (NP) was at the facility and ordered a urine sample to be collected. (Staff did not document the reason for the ordered lab or if the NP had been notified of the held medications.) Review of the resident's April 2026 MAR showed the following information: -On 04/24/26 through 04/26/26, staff noted hydrochlorothiazide 25 mg 0.5 tablet not administered with reason of on hold; -On 04/24/26 through 04/26/26, staff noted metolazone 2.5 mg tablet was not administered with reason of on hold. Review of the resident's progress notes, dated 04/25/26 through 04/26/26, showed staff did not document in the notes regarding missed medication, notification regarding the missed medication administrations, or the lab results. Review of the resident's April 2026 POS showed an order, dated 04/27/26, for creatinine and microalbumin (a urine test used to check kidney health) lab. (The order was transcribed three days after the resident's progress note, dated 04/24/26, showed the NP ordered the urine test.) Review of the resident's urine lab results, received by facility on 04/29/26, showed the resident's albumin and creatinine ratio was 46 (normal range is less than 30. The higher ratio can indicate an early sign of kidney damage, frequently related to high blood pressure or diabetes.) Review of the resident's progress notes, dated 04/27/26 through 04/30/26, showed staff did not document in the notes regarding the lab results or physician notification of the results. Review of the resident's progress note dated 05/05/26, at 9:32 A.M., showed staff noted the urine results were received and faxed to the physician six days after being received. (Staff did not document the labs being out of normal range.) Review of the resident's May 2026 MAR showed the following information: -On 05/05/26 through 05/06/26, staff noted hydrochlorothiazide 25 mg 0.5 tablet not administered with reason of on hold; -On 05/05/26 through 05/06/26, staff noted metolazone 2.5 mg tablet not administered with reason of on hold. Review of the resident's progress notes, dated 05/05/26 through 05/06/26, showed staff did not document in the notes the reason for the held medication, or physician notification of the held medications. Review of the resident's May 2026 MAR showed the following information: -On 05/09/26 through 05/10/26, staff noted hydrochlorothiazide 25 mg 0.5 tablet was not administered with reason of on hold; -On 05/09/26 through 05/10/26, staff noted metolazone 2.5 mg tablet not administered with reason of on hold. Review of the resident's progress notes, dated 05/09/26 through 05/10/26, showed staff did not document in the notes the reason for the held medication, or physician notification of the held medications. Review of the resident's May 2026 MAR showed the following information: -On 05/12/26 through 05/14/26, staff noted hydrochlorothiazide 25 mg 0.5 tablet not administered with reason of on hold; -On 05/12/26 through 05/14/26, staff noted metolazone 2.5 mg tablet not administered with reason of on hold. Review of the resident's progress notes, dated 05/12/26 through 05/14/26, showed staff did not document in the notes the reason for the held medication, or physician notification of the held medications. Review of the resident's monthly weights, dated 05/12/26, showed the resident weighed 150.6 pounds (a weight gain of 14.8 pounds). Review of the resident's progress notes, dated 05/05/26 to 05/12/26, showed staff did not document follow-up with the physician regarding the faxed labs that were out of range, the held medications, or the weight gain. Review of the resident's progress note dated 05/12/26, at 2:30 A.M., showed the following: -The resident complained of shortness of breath and cough at the beginning of the writer's shift, around 6:00 P.M., -The resident's lungs were assessed. The upper lobes were clear, and the lower lobes were diminished; -Staff notified the physician 6:47 P.M. who ordered a breathing treatment of prednisone (corticosteroid used to rapidly suppress the immune system and reduce inflammation), and chest X-ray; -Staff notified the resident's family. (Staff did not document notifying the physician regarding the resident's weight gain, lab results, or missed medication administrations.) Review of the residents May 2026 POS showed the following information: -An order, dated 05/12/26, for prednisone 20 mg tablet, give two tablets po once a day at 8:00 P.M.; -An order, dated 05/12/26, for ipratropium-albuterol (fast acting bronchodilator that quickly relaxes the muscles in the airway); 2.5 mg/3 milliliters (ml); inhale one vial every four hours at 12:00 A.M., 4:00 A.M., 12:00 P.M., and 4:00 P.M.; -An order, dated 05/13/26 for benzonatate (cough suppressant) 100 mg tablet three times a day at 8:00 A.M., 12:00 P.M., and 4:00 P.M. Review of the resident's progress note, dated 05/13/26, showed staff did not document follow-up regarding the x-ray and additional monitoring of the resident's condition. Review of the resident's progress note dated 05/14/26, at 6:23 A.M., showed the following information: -At 4:00 A.M., the night shift nurse went into the resident's room to answer the call light. The resident had been incontinent of bowel and urine, and the nurse left the room to seek assistance from certified nursing assistants (CNAs); -After exiting the room, additional staff notified the nurse the resident's lips and nail beds were cyanotic (blue), and the resident was experiencing confusion; -Vital signs were 150/81 millimeters of Mercury (mm/Hg) blood pressure (normal range of 120/80 mm/Hg), 117 pulse (normal range of 60-100 beats per minute (bpm)), 20 respirations (normal range of 12 to 18 breaths per minute), and 86% oxygen saturation (normal range 95%-100%). Staff placed three liters of oxygen on the resident and his/her oxygen sat returned to 96%; -Staff notified emergency medical services (EMS) at 4:19 A.M. who arrived at 4:40 A.M., for transport to the hospital; -Staff notified the primary care physician (PCP) and the family. Review of the resident's progress note dated 05/14/26, at 4:51 P.M., showed the resident admitted to the hospital with diagnoses of hyperkalemia (high blood potassium), hyponatremia (low blood sodium occurs when excess water dilute the body's sodium causing cells to swell), pleural effusion ( abnormal buildup of excess fluid between the layers of the pleura), and anasarca (severe, generalized fluid retention and widespread swelling across the body.) Review of the Provider Transition of Care Visit, dated 05/22/26, showed the following information: -The resident was admitted to the hospital on [DATE] after being found hypoxic with chest discomfort and worsening bilateral (both) lower extremity edema; -The residents' admitting diagnoses included heart failure with pulmonary edema, cardiogenic shock complicated by acute kidney injury, on top of chronic kidney disease; -CAT scan suggestive of pleural effusion, comprehensive atelectasis (partial or complete collapse of a lung), body wall edema (occurs when excess fluid gets trapped in the tissue layers, caused by generalized edema), and small volume ascites (a buildup of excess fluid in the abdominal cavity). He/she is severely hyponatremic, hyperkalemic, and had metabolic acidosis (characterized by buildup of acid in the body); -The resident required intravenous (within the vein) diuretic therapy; -The resident was discharged back to the facility on [DATE]. Review of the resident's weight for readmission, dated 05/25/26, showed the resident weighed 118.8 lbs. During an interview on 06/05/26, at 1:40 P.M., CNA A said the following: -If a resident exhibited a change of condition, he/she would immediately notify the nurse. After notifying the nurse, the nurse was expected to perform an assessment, make any necessary notifications, and document; -He/she was responsible for completing the monthly weights. After he/she obtained the weights, he/she reported the results to the Director of Nursing (DON) and the DON would document the weights and/or get back with him/her in a couple of days for a re-weigh if something looked off; -Residents with CHF were expected to be weighed daily; -He/she was not sure if the resident was a daily weight; -It would be concerning if a resident with CHF had a 14-pound weight gain in a month. The physician should be notified of that amount of weight gain; -If a lab result came back out of normal range, the nurse was expected to notify the physician; -All medications should be administered per physician orders; -He/she believed there would be consequences and/or side effects if a resident missed more than a week's work of cardiac (heart)/ diuretic medications. Missing those types of medications could lead to fluid retention and other medical concerns. During an interview on 06/05/26, at 2:45 P.M., Certified Medication Technician (CMT) B said the following: -All medication should be administered per physician orders; -If a medication was on hold, there would be a specific order in the POS stating so; -There are side effects to CHF residents not receiving their cardiac/diuretic medications including fluid retention/ overload and shortness of breath. The physician should always be notified when medications are not administered; -If a resident complained of shortness of breath, he/she would obtain an oxygen saturation on the resident and notify the nurse; -He/she provided nebulizer treatments to the resident on 05/14/26 due to complaints of shortness of breath. At that time the resident's oxygen saturation was running 91%. He/she did not assess for edema as the resident was fully clothed, but did notify the nurse on duty of the resident's status but was unaware if the nurse followed up; -Residents with CHF should be weighed daily and assessed for edema. If the resident has a weight gain of over two pounds in a day, the physician should be notified. During an interview on 06/05/26, at 3:20 P.M., Licensed Practical Nurse (LPN) C said the following: -When a resident had a change of condition, nurses were expected to perform an assessment, document that assessment, and notify the physician and family; -Residents with CHF are expected to be weighed daily. He/she is not sure if the resident is a daily weight; -It would be concerning if a resident with CHF had a 14-pound weight gain in a month, he/she would notify the physician for that; -If a lab result came back out of normal range, the nurse receiving the lab results was expected to notify the physician; -All medications should be administered per physician orders; -If a resident missed weeks' worth of cardiac and diuretic medications, that would cause side effects such as fluid overload. The physician should always be notified of missed medication administration; -He/she was not aware the resident had missed several medications; -If a medication was on hold, there would be a specific order in the POS, showing so; -If he/she became aware of a resident with a CHF diagnosis complaining of shortness of breath, weight gain, edema, and cough; he/she would notify the physician and ask for the resident to be sent to the hospital. During an interview on 06/22/26, at 2:20 P.M., the NP said the following: -A resident with CHF should be weighed daily unless stable; -A stable CHF resident could be weighed weekly; -He/she should be notified of a weight gain of 2 pounds in one day or 5 pounds in a week; -When he/she saw the resident around 05/12/26, he/she ordered for the resident to have his/her weights obtained daily. That did not happen; -Even missing a week's worth of cardiac and diuretic medications could cause significant adverse effects in the resident; -He/she was not notified of the resident's lab results, weight gain, and/or the missed medication administrations; -He/she expected to be notified regarding lab results, weight gain, and missed medication administration. During an interview on 06/05/26, at 3:45 P.M., the DON said the following: -All medications were expected to be administered per physician orders. If a medication was not administered, the physician should be notified; -All resident's with CHF were expected to be weighed daily and/or per physician orders; -If a resident had a change of condition, staff were expected to accurately assess the resident, document the assessment, and make necessary notifications; -She was not aware the resident's medications had not been administered for extended periods of time; -She was not aware of the resident's weight gain; -She was expected to track the weights, and when she saw a weight gain, she would recommend a re-weigh; -Lab results were expected to be reported to the physician immediately. The facility was in-between lab companies during the time of this resident's labs, and they received the results via mail. Whoever received the results should have immediately called the physician instead of faxing. During an interview on 06/05/26, at 4:15 P.M., the Administrator said the following: -She expected all medications to be administered per physician orders; -She expected the physician and families to be notified if a resident is not receiving their medication and/or has a change of condition; -She expected staff to obtain weights per physician orders; -She expected daily weights for residents with CHF. 2. Review of Resident #5's face sheet (brief look at resident information) showed the following information: -admission date of 10/17/25; -Diagnoses include CHF, lung cancer, and high blood pressure. Review of the resident's quarterly MDS, dated [DATE] , showed the following information: -Resident cognitively intact; -Shortness of breath while lying flat; -Resident on a diuretic medication. Review of the resident's care plan, revised 01/09/26, showed the resident's weight will be taken and recorded monthly unless otherwise indicated. Review of the resident's hospital discharge note, dated 04/10/26, showed the following: -The resident readmitted to the facility with a diagnosis of CHF exacerbation (sudden worsening of heart failure symptoms); -Diet instructions showed a 2-gram sodium diet and a 1500 milliliter (ml) fluid restriction; -Resident should weigh daily before eating or drinking and call the health care provider if weight increased by two pounds in one day or three to five pounds in a week. Review of the resident's nursing progress note, dated 04/11/26, showed the following: -On 04/10/26, at 10:50 P.M., the resident returned from the hospital; -Resident was alert and oriented with a weight of 244 pounds; -Diet was regular 2 gm no added salt with 1500 ml fluid restriction; -Resident noted with 2-3+ pitting edema (swelling caused by excess fluid in the body tissues) noted in legs; -Diagnosis of CHF and acute kidney injury; -Staff notified physician and medication reviewed and approved. Review of the resident's April 2026 POS showed the following information: -An order, dated 10/17/25, for weight monthly unless otherwise indicated; -An order, dated 11/15/25, for weekly weights for four weeks; -An order, dated 11/28/25, for spironolactone (diuretic) 25 milligram (mg) tablet once daily; -An order, dated 04/11/26, for torsemide (diuretic) 20 mg tablet, take one tab twice daily; -An order, dated 04/11/25, for a 1500 milliliter (ml) daily fluid restriction. -An order, dated 04/11/26, for a regular 2 gm no added salt diet. (Staff did not transfer the order for daily weight and provider notification parameters from the hospital discharge order to the facility physician orders. ) Review of the resident's care plan, dated 01/09/26, showed staff did not update the care plan with the daily weights, new diet, or fluid restriction. Review of the resident's April 2026 POS showed staff initialed the 1500 ml fluid restriction was in place. Staff did not document tracking of the resident's fluid intake. Review of the resident's nursing progress note dated 04/12/26, at 2:15 P.M., showed the following: -The nurse discussed the importance of fluid restriction and trying to be compliant with the resident; -Resident verbalized understanding and said that he/she was trying to write down how much he/she was drinking, but it was difficult; -2+ pitting edema noted to lower extremities. Review of the resident's nursing progress note dated 04/12/26, at 11:34 P.M., showed the resident had 3+ pitting edema and continued 1500 ml fluid restriction and 2 gm diet. Review of the resident's April 2026 MAR showed a weekly weight of 237.6 pounds (loss of 6.4 pounds ) on 04/13/26. Review of the resident's April 2026 MAR, dated 04/20/26, showed staff noted no Hoyer pads (sling used to assist in resident transfer and obtain weights) available for weighing resident. Review of the resident's progress notes, dated 04/20/26, showed staff did not document follow-up with regarding not having the Hoyer sling, or reporting the inability to weight the resident to the nurse. Review of the resident's April 2026 POS, dated 04/27/26, showed a weekly weight of 262.2 pounds (a gain of 24.6 pounds). Review of the resident weight log showed staff did not document any additional weights taken for the month of April 2026. Review of the resident's April 2026 progress notes showed staff did not document physician notification of 24.6-pound weight gain in two weeks. Review of the resident's fluid intake log, dated April 2026, showed staff did not document the resident's fluid intake for the month. Review of the resident's May 2026 MAR , dated 05/04/26, showed the resident refused to be weighed. Review of the resident weight log, dated 05/06/26, showed the resident weighed 262.6 pounds. Review of May 2026 MAR, dated 05/11/26, showed the resident weighed 229.6 pounds. Review of resident's weight log and progress notes showed staff did not document regarding a reweigh due to the resident's weight fluctuation. Review of the resident's May 2026 MAR, dated 05/18/26, showed the resident refused to be weighed on 05/18/26. Review of the resident's progress note, dated 05/20/26, showed the Registered Dietician (RD) documented the following: -A current weight of 229.6 pounds; -Resident's weight shows significant fluctuations over six months; -Several weights are in the 230's and several are in the 260's with no specific pattern; -Staff report resident weighed by a Hoyer and was unsure why weight varied so much; -Nurse and med tech confirm that 230's is a more accurate weight and resident eats good; -No edema noted, but resident had several diuretics on medication list; -Resident on a 1500 ml fluid restriction; -Intake for only seven meals had been documented since 04/28/26, but most were taken 76-100%; -Will continue to monitor weight trends. Review of the resident's nursing progress note, dated 05/21/26, showed the resident was seen by his/her physician and had orders to maintain fluid restriction at 1500 to 1600 ml and continue daily weights, if gain greater than 3 pounds a day call cardiology. Review of the resident's May 2026 POS showed the following information: -The order for weekly weights discontinued on 05/23/26; -An order, dated 05/23/26, for daily weights, if gain greater than 3 pounds in one day, staff should call cardiology. Review of the resident weight record, dated 05/25/26, showed a weight of 239.2 pounds. Review of the resident progress notes showed staff did not document physician notification of 10-pound weight gain since 05/11/26. Review of May 2026 MAR showed the following: -On 05/26/26, resident refused weight check; -On 05/27/26, resident weighed 240 pounds (a .8-pound gain); -On 05/28/26, resident weighed 240.2 (a .2-pound gain); -On 05/29/26, resident refused weight check; -On 05/30/26, resident refused weight check; -On 05/31/26, resident refused weight check. (The weight log showed staff did not document any other weights taken for the month of May 2026.) Review of the resident's fluid intake log, dated for May 2026, showed staff did not document regarding the resident's fluid intake. During interviews on 06/04/26, at 11:25 A.M., and 06/05/26, at 1:27 P.M., the resident said the following: -He/she was recently in the hospital for fluid retention; -He/she was supposed to be getting weighed daily, but the facility was not doing it; -Staff weigh him/her with the Hoyer; -He/she refused a weight on 06/02/26 due to family visit, but had not refused any other weights; -He/she was currently on fluid restriction and had to count how much fluid he/she consumed. During an interview on 06/04/26, at 1:40 P.M., CNA A said the following: -He/she completed the monthly resident weights and gave them to the Assistant Director of Nursing (ADON) or DON; -The ADON and DON will provide a list of weights that need to be done monthly; -He/she was not responsible for entering the weights in the resident medical record; -It would be concerning if a CHF resident had over 14-pound weight gain in a month; -The nurse should contact the physician about weight gain; -Fluid restriction should be indicated in the resident's chart; -CHF residents should be on fluid restriction; -The resident was weighed monthly using a Hoyer lift; -Staff cannot really monitor fluid restriction so the residents are educated about it. During an interview on 06/22/26, at 2:20 P.M., the NP said the following: -Resident should have been on daily weights and fluid restriction; -He/she began following the resident care at the beginning of May and daily weights should have been completed since that time; -The facility never notified him/her of weight changes; -He/she would want to be notified of a 24-pound weight gain in two weeks. During an interview on 06/05/26, at 1:30 P.M., the MDS Coordinator said the following: -He/she was responsible for the MDS and care plans; -The care plan was updated every three months during care plan meetings and during MDS updates; -Dietary updates the care plan with any diet or fluid restriction orders; -A resident with CHF should have that diagnosis and interventions included on the care plan; -Weights, edema, and medications should be included in the care plan. During an interview on 06/05/26, at 10:13 A.M., the RD said the following: -Residents with CHF were usually on weekly or daily weights; -The residents with CHF should be weighed often so he/she can monitor it; -Staff should be monitoring fluid intake for residents on fluid restriction. During an interview on 06/05/26, at 12:15 P.M., the DON said the following: -All resident's with CHF were expected to be weighed daily and/or per physician orders; -She was expected to track the weights, and when she saw a weight gain, she would recommend a re-weigh; -Staff should notify the physician of a weight gain of 2 pounds in a day or 5 pounds in 3 days for CHF residents; -A CHF resident with abnormal weight gain should be assessed for edema or shortness of breath; -The nurse should monitor for any weight gain or loss; -The nurse should be documenting weight refusals and notifying the physician; -The resident is on fluid restriction but is noncompliant; -The CNAs advise the nurse what fluids residents on fluid restriction have consumed; -Fluid intake should be documented in the vital sign section of the resident medical record. During an interview on 06/05/26

Based on observation, interview, and record review, the facility failed to ensure all residents maintained acceptable parameters of nutritional status when staff failed to monitor weight loss, failed to update the care plan with new interventions to prevent future weight loss, and failed to notify the physician and registered dietician (RD) of weight loss for one resident (Resident # 3) who had severe weight loss. The facility census was 70. Review of the facility policy titled Nutritional Risk Interventions, dated May 2015, showed the following:-The individual condition of each resident at nutritional risk must be considered when instituting nutritional intervention;-Unacceptable parameters of nourishment include weight loss, clinical signs and symptoms of malnutrition, and abnormal lab results;-Unplanned weight loss would include: 5% weight loss in one month is significant with greater than 5% being severe; 7.5% weight loss in three months is significant with greater than 7.5% being severe; and 10% weight loss in 6 months is significant with greater than 10% being severe;-Indicators of potential malnutrition include, but not limited to pale skin, dull eyes, swollen lips, poor skin turgor, swollen gums, swollen dry tongue, cachexia (metabolic disorder that causes significant weight loss and muscle loss), and wasting muscles. Review of a facility policy titled Charting and Documentation, undated, showed weight documentation should include weight variations as they occur, reason for the weight variation, date and time the physician is notified as well as the response, and what is being done about the weight variations. 1. Review of Resident #3's face sheet (brief resident profile sheet) showed the following information:-admission date of 01/18/19;-Diagnoses included vascular dementia (decline in thinking and memory skills caused by reduced blood flow to the brain) and diabetes mellitus (metabolic disorder). Review of the resident's care plan, revised 01/04/25, showed the following information:-Resident able to feed self; -Staff should observe, document, and report to the physician any changes in mood or behaviors which may include a decrease in meal intake;-Provide scoop dish for all meals; -Encourage oral intake of food and fluids; -Resident should receive peanut butter and jelly with all meals;-Resident on a regular diet; -Monitor and record weight. Notify physician and family of significant weight change; -Interventions will be initiated as needed for adequate nutrition. Review showed the facility did not provide any dietary notes or nutrition assessment related to resident. Review of the resident's March 2026 Physician Order Sheet (POS) showed the following:-An order, dated 03/08/24, to weigh resident monthly unless otherwise indicated;-An order, dated 03/08/24, to provide a scoop dish with all meals;-An order, dated 01/29/26, for a regular diet with half peanut butter and jelly with lunch and dinner. Review of the resident's weights showed on 03/04/26 the resident weighed 182 pounds. Review of the resident's progress note, dated 03/12/26, showed the resident went to the assisted dining room for all meals and was assisted by staff to eat. Review of the resident's progress note, dated 03/17/26, showed the resident fed him/herself and often ate in the dining room with other residents. Review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 03/23/26, showed the following information:-Severe cognitive impairment;-Resident weight 182 pounds;-Required set up and clean up assistance for eating;-Resident did not have a loss of 5% or more in last month or 10% or more in last six months. Review of the resident's care plan, revised 03/31/26, showed staff added resident on hospice services. Review of the resident's March 2026 weight records showed no additional weights for the resident. Review of the resident's progress note, dated 04/05/26, showed the resident was lethargic, not eating, not drinking, and not taking medications on this day. Review of the resident's progress note, dated 04/08/26, showed the following: -Resident awake at lunch and staff tried to feed the resident;-Resident would not wear dentures, so it was hard to chew food;-A trial diet of puree and honey thickened liquids was tried, and the resident ate all food with minimal difficulty. Review of the resident's change of condition progress note, dated 04/09/26, showed due to resident recent decline, a diet change made yesterday to a puree consistency with honey thick liquids. Hospice nurse gave orders to add snack pudding twice daily between meals and add house shake, thickened to honey thick, with all meals. Review of the resident's April 2026 POS showed the following:-The order, dated 03/08/24, to provide a scoop dish with all meals was discontinued on 04/08/26.-An order, dated 04/09/26, for a puree diet with honey thickened liquids;-An order, dated 04/09/26, to add pudding snack twice daily;-An order, dated 04/09/26, to add house shakes with all meals;. Review of the resident's care plan, revised 03/31/26, showed staff did not update the care plan to reflect the new dietary interventions implemented on 04/09/26. Review of the resident's nursing progress note, dated 04/11/26, showed resident pale, gaunt, with sunken eyes and protruding cheek bones and ribs. Resident appeared to have lost weight over the past couple weeks. (Staff did not document physician, registered dietician (RD) or hospice notification related to apparent weight loss or an attempt to weigh resident.) Review of the resident's nursing progress note, dated 04/11/26, showed the resident offered fluids at meals and in between. Resident was also getting pudding between meals and house shakes at meals. Review of the resident's progress note, dated 04/16/26, showed the resident had been more alert and up for all meals, eating 100% while being fed by staff. Hospice changed diet since the resident had improved. Diet upgraded to mechanical soft and will continue with honey thickened liquids at this time until told otherwise, dietary notified. Review of the resident's April 2026 POS showed the following:-An order, dated 04/16/26, for a mechanical soft diet with honey thickened liquids. The order was later discontinued on 04/21/26;-An order, dated 04/21/26, for a regular diet with thin liquids with Kennedy cup (spillproof cup) and scoop plate for all meals. Review of the resident's care plan, revised 03/31/26, showed staff did not update the care plan to reflect the new dietary interventions implemented on 04/11/26, 04/16/26, and 04/21/26. Review of the resident's progress note, dated 04/22/26, showed hospice updated resident diet to regular diet with thin liquids. Meals to be served in a scoop plate and drinks in a Kennedy cup. Review of the resident's weight records showed staff did not document a weight for the resident in April 2026. Review of the resident's April 2026 progress notes and April 2026 Medication Administration Record (MAR) showed staff did document any weights or weight refusals by the resident. Review of the resident's progress note, dated 05/06/26, showed the following: -Resident cannot hold head up and feed self;-This nurse downgraded diet to puree consistency and resident will continue to eat in assisted room and will need to be fed meals. Review of the resident's May 2026 POS showed an order, dated 05/06/26, for a puree diet with Kennedy cups with all meals. Review of the resident's care plan, revised 03/31/26, showed staff did not update the care plan to reflect the new dietary interventions implemented on 05/06/26. Review of the resident's progress notes, dated 05/07/26 through 05/31/26, showed staff did not document in the resident's notes related to the resident's diet changes or weight loss. Review of the resident weights showed staff did not document resident weights taken in May 2026. Review of the resident's May 2026 progress notes and May 2026 MAR showed staff did not document any weights or weight refusals by the resident. Review of a list of residents weight record showed a weight of 137.8 pounds on 06/01/26. (Resident had a 44.2-pound weight loss since March.) Review of the resident's progress notes, dated 06/01/26 through 06/04/26, showed staff did not document in the resident's notes related to weight loss, physician or RD notification to the physician, or updates to the care plan. Observation on 06/04/26, at 12:20 P.M., showed the following: -Resident in the assistive dining room with three bowls of food, an ice cream cup, a mighty shake, and a Kennedy cup on the table;-Resident was picking up a bowl of pureed food and eating out of it;-Resident observed to have brown food on beard, around nose, and on shirt;-An aide sat next to the resident and assisted another resident at the table with lunch;-The resident picked up a bowl of food and placed his/her face in the bowl attempting to eat;-The aide instructed the resident to use a spoon;-Resident ate all food in bowls and had ice cream left;-The aide assisted resident with the ice cream;-Resident ate 100% of meal. During an interview on 06/05/26, at 10:13 A.M., the RD said the following:-He/she came to the facility three times a month;-He/she checked the weight list three times monthly before visits;-He/she would ask the facility to reweigh the resident if a weight appeared off;-Hospice residents were followed by him/her and have recommendations made;-The resident had a decline a couple months ago, but appeared to have rebounded;-He/she had asked the facility to obtain a weight on the resident, and they obtained it this month;-The facility usually did not contact him/her for significant weight loss except to notify him/her during facility visits;-He/she did not know the resident had a weight loss until today. During an interview on 06/04/25, at 1:40 PM, Certified Nursing Assistant (CNA) A said the following:-He/she completed the monthly weights and gave a copy to the Assistant Director of Nursing (ADON) or Director of Nursing (DON);-ADON or DON provided a list of weights needed for the month;-He/she did not enter the weights into the electronic medical record;-The nurses were responsible for tracking weight changes;-The resident was down a couple pounds, but he/she didn't eat the amount of snacks he/she used to;-The resident used to eat a lot of snacks so they started rationing snacks;-The resident did not require any assistance with eating or meals;-Nurses should review the resident's percentage of meal intake if they had weight loss;-Some residents with weight loss should have a shake, but sometimes they don't get them from kitchen. During an interview on 06/04/26, at 2:45 P.M., CMT B said the following:-The resident appeared to be losing weight and his/her clothes appeared larger;-He/she would try to cue the resident to eat at mealtimes;-He/she provided the resident with snacks at times;-Nurses should notify the physician of a 40-pound weight loss. During an interview on 06/05/26, at 11:03 A.M., Certified Medication Technician (CMT) E said the resident appeared to have lost weight over the last couple months. His/her cheeks appeared sunken in, and the overall body looked thinner. During an interview on 06/05/26, at 11:30 A.M., Licensed Practical Nurse (LPN) C said the following:-Monthly weights were completed on the 1st through the 3rd of the month; -He/she would notify the physician and the dietician and ask for supplements for a resident with weight loss;-A resident with a 44-pound weight loss in two months would be concerning and should have been reweighed to verify;-The resident fluctuates on his/her meal intakes and sometimes requires assistance at mealtimes. During an interview on 06/05/25, at 12:23 P.M., LPN D said the following: -The resident could feed him/herself at meals;-Staff would assist the resident if help was needed at mealtimes;-The resident received snacks;-A resident with a 40-pound weight loss should be reweighed;-The physician should have been notified of the weight loss;-The RD will make recommendations for residents with weight loss;-All residents on the unit are weighed the same day, and hospice weighed residents on their service; -He/she gave the DON all the weights; -He/she thought the weights were getting done. During an interview on 06/05/26, at 1:30 P.M., the MDS Coordinator said the following:-He/she was responsible for the MDS and care plans;-Care plans were updated every three months during the care plan meetings;-Dietary was responsible for putting dietary orders onto the care plan. During an interview on 06/22/26, at 2:20 P.M., the Nurse Practitioner (NP) said the following:-The resident had a decline a couple months ago and was placed on hospice;-The staff thought the resident would pass, but he/she rebounded;-Staff did not notify him/her of the resident's weight loss;-He/she talked to the RD when the weight loss was discovered recently;-Interventions should be put in place for residents with weight loss;-He/she was having trouble with the facility obtaining weights or reevaluating abnormal weights. During an interview on 06/05/26, at 12:15 P.M., the DON said the following:-The aide responsible for checking the resident's weight was out for four months; -The weights were off, and the staff had to do reweight while the aide was off work;-The nurse should monitor residents for weight loss or gain;-The RD also monitors weight changes;-The physician should be notified of a resident with weight loss;-Staff should reweigh a resident if the weight appeared off;-The resident's weight should have been reviewed, and the physician and dietician should have been notified. During an interview on 06/05/26, at 2:15 P.M. the Administrator said staff should be monitoring weights and notifying the physician about weight loss. Complaint #3028575

Based on observation, interview, and record review, the facility failed to ensure a complete and effective pain management program was in place for each resident when staff failed to care plan regarding pain and pain interventions, administer pain medications as ordered, accurately document dosage of pain medication administered, and document follow-up physician notification of unrelieved pain and ordered pain medications not provided for one resident (Resident #5). The facility census was 76. Review of facility policy titled Pain Management, undated, showed the following:-Assess all residents for pain upon admission, quarterly, annually, and as part of daily care;-Use evidence-based age-appropriate pain assessment tools such as the numeric rating scale;-Assess both verbal and nonverbal indicators of pain;-Document detailed pain characteristics to include location, intensity, frequency, onset, duration, and impact on sleep, appetite, and social interactions;-Collaborate with the resident to establish realistic, person-centered pain management goals;-For managing pain, monitor for effectiveness and side effects.1. Review of the Resident #5's face sheet showed the following information:-admission date of 02/06/26;-Diagnoses included fracture to the upper and lower end of the fibula (slender bone running parallel to the tibia(shinbone) on the outside of the lower leg), cardiomyopathy (a disease of the heart muscle that impairs its ability to pump blood), and obesity.Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool filled out by facility staff), dated 02/12/26, showed the following:-Cognitively intact;-Independent mobility;-Experiences pain that affects his/her sleep.Review of the resident's care plan, dated 02/09/26, showed staff did not care plan related to the resident's identified pain. Review of the resident's February 2026 Physician Order Sheet (POS) showed the following:-An order, dated 02/06/26, to assess pain every shift, using a 0 to 10 pain scale;-An order, dated 02/06/26, for hydrocodone-acetaminophen (a prescription, controlled combination medication used to treat moderate to severe pain) 5-325 milligram (mg); 1 to 2 tablets by mouth (PO) every six hours as needed (PRN).Review of the resident's pain scale, dated 02/06/26, showed the following:-Day shift documented a pain scale of 0 out of 10; -Night shift documented a pain scale of 6 out of 10. Review of the resident's February 2026 Medication Administration Record (MAR) showed the following:-On 02/06/26, at 7:34 P.M., staff administered hydrocodone-acetaminophen 5/325, 1 to 2 tablets for pain. Staff did not indicate if they administered one or two tablets;-Staff noted administration somewhat effective;-Staff did not document the resident's pain level after administration. Review of the resident's progress note dated 02/06/26, at 8:42 P.M., showed the following:-The resident complained of constant stabbing and throbbing pain at an 8 out of 10 pain level to his/her right leg/foot and back;-The resident took hydrocodone-acetaminophen 5/325 mg, 1-2 tabs PRN. The resident reported the medication provided some relief. Staff did not document if one or two tablets were administered. -Staff did not document physician notification of the unrelieved pain. Review of the resident's pain scale, dated 02/07/26, showed the following:-Day shift documented a pain scale of 5 out of 10;-Night shift documented a pain scale of 4 out of 10. Review of the resident's February 2026 MAR showed the following:-On 02/07/26, at 10:02 A.M., staff administered hydrocodone-acetaminophen 5/325 mg 1-2 tablets for pain with administration effective. Staff did not indicate if one or two tablets were administered; -On 02/07/26, at 4:19 P.M., staff administered hydrocodone-acetaminophen 5/325 mg 1-2 tablets for pain with administration effective. Staff did not indicate if one or two tablets were administered. Review of the resident's progress note, dated 02/07/26, showed staff did not document related to the resident's pain. Review of the resident's pain scale, dated 02/08/26, showed the following:-Day shift documented a pain scale of 8 out of 10;-Night shift documented a pain scale of 7 out of 10. Review of the resident's February 2026 MAR showed the following:-On 02/08/26, at 11:37 A.M., staff administered hydrocodone-acetaminophen 5/325 mg 1-2 tablets for pain with administration effective. Staff did not indicate if one or two tablets were administered;-On 02/08/26, at 5:24 P.M., staff administered hydrocodone-acetaminophen 5/325 mg 1-2 for pain rated 8 out of 10 with administration effective. Staff did not indicate if one or two tablets were administered; -On 02/08/26, at 11:04 P.M., staff administered hydrocodone-acetaminophen 5/325 mg 1-2 tablets for pain with administration effective. Staff did not indicate if one or two tablets were administered. Review of the resident's progress note dated 02/08/26, at 1:48 P.M., showed the following:-The resident complained of constant stabbing and throbbing pain at an 8 out of 10 pain level to his/her right leg/foot and back;-The resident took hydrocodone-acetaminophen 5/325 mg, 1 tablet PRN. The resident reported the medication provided some relief.-Staff did not document offering a second tablet or physician notification of the unrelieved pain.Review of the resident's progress note dated 02/08/26, at 9:17 P.M., showed the following:-The resident's family member called the facility reporting the resident was in pain and had been waiting over an hour for his/her call light to be answered;-Staff reminded the resident the pain medication was not scheduled and it was PRN and he/she needed to request the medication rather than expecting it;-Staff told the resident that he/she believed the physician would visit with him/her on 02/09/26 and staff would notify the physician that the resident's pain medication was not effective for six hours.Review of the resident's pain scale, dated 02/09/26, showed the following:-Day shift documented a pain scale of 8 out of 10;-Night shift documented a pain scale of 7 out of 10.Review of the resident's February 2026 MAR showed the following:-On 02/09/26, at 1:21 PM, staff administered hydrocodone-acetaminophen 5/325 mg 1-2 tablets for pain with administration effective. Staff did not document if one or two tablets were administered.Review of the resident's progress note dated 02/09/26, at 2:54 P.M., showed the following:-The resident complained of constant stabbing and throbbing pain at a level of 8 out of 10 in his/her right leg/foot and back;-The resident took hydrocodone-acetaminophen 5/325 mg PRN and reported getting some relief from the medication.-Staff did not document physician notification unrelieved pain.Review of the resident's February 2026 MAR showed the following:-On 02/09/26, at 4:41 P.M., staff administered hydrocodone-acetaminophen 5/325 mg 1-2 tablets for pain with administration ineffective. Staff did not document if one to two tablets were administered or physician notification of the unrelieved pain; -On 02/09/26, at 7:20 P.M., staff administered hydrocodone-acetaminophen 5/325 mg 1-2 tablets for pain with administration effective. Staff did not document if one or two tablets were administered. Review of the resident's February 2026 POS showed the following:-An order, dated 02/09/26, discontinuing hydrocodone-acetaminophen 5/325 mg, 1-2 tablets po every 6 hours PRN;-An order, dated 02/10/26, for hydrocodone-acetaminophen 5/325 mg, 2 tablets po every 6 hours PRN.-An order, dated 02/10/26, for Belbuca (buprenorphine hcl- a long-acting opioid buccal (inside the cheek) film used to manage severe, persistent pain that requires around -the-clock treatment) 300 microgram (mcg) tablet, buccally every 12 hours at 8:00 A.M. and 8:00 P.M.Review of the resident's care plan, dated 02/09/26, showed staff did not update the care plan to reflect the resident's pain and medication change to address the pain. Review of the resident's pain scale, dated 02/10/26, showed the following:-Day shift documented a pain scale of 10 out of 10;-Night shift documented a pain scale of 8 out of 10.Review of the resident's February 2026 MAR showed the following:-On 02/10/26, at 4:33 A.M., staff administered hydrocodone-acetaminophen 5/325 2 tablets for pain with administration effective; -On 02/10/26, at 12:19 P.M., staff administered hydrocodone-acetaminophen 5/325 2 tablets for a 10 out of 10 pain level with administration effective; -On 02/10/26, at 6:57 P.M., staff administered hydrocodone-acetaminophen 5/325 2 tablets for pain with administration effective; -On 02/10/26, at 8:00 P.M., staff did not administer the resident's Belbuca due to the medication being unavailable.Review of the resident's progress note dated 02/10/26, at 10:35 P.M., showed the following:-The resident complained of pain in his/her right leg/foot and back with a pain level of 8 out of 10;-The resident took hydrocodone-acetaminophen 5/325 mg PRN every 6 hours and reported some relief from the medication.-Staff did not document physician notification the medication Belbuca being unavailable.Review of the resident's pain scale, dated 02/11/26, showed the following:-Day shift documented a pain scale of 7 out of 10;-Night shift documented a pain scale of 6 out of 10.Review of the resident's February 2026 MAR showed the following:-On 02/11/26, at 12:36 A.M., staff administered hydrocodone-acetaminophen 5/325 2 tablets for pain with administration effective; -On 02/11/26, at 9:05 A.M., staff administered hydrocodone-acetaminophen 5/325 2 tablets for a 10 out of 10 pain level with administration effective; -On 02/11/26, at 8:00 A.M. and 8:00 P.M., staff documented that Belbuca was not administered due to it being unavailable.Review of the resident's progress note dated 02/11/26, at 2:05 P.M., showed the following:-The resident complained of pain in his/her right leg/foot and back with a pain level of 8 out of 10;-The resident took hydrocodone-acetaminophen 5/325 mg PRN every 6 hours and reported some relief from the medication.-Staff did not document physician notification regarding the medication Belbuca being unavailable.Review of the resident's February 2026 POS showed the following:-An order, dated 02/11/26, discontinued Norco 5/325 mg, 2 tablets po every 6 hours PRN; -An order, dated 02/11/26, for Norco 7.5/325 mg, 1.5 tabs x 2 doses every six hours PRN, until hydrocodone-acetaminophen 5/325 was in stock.Review of the resident's pain scale, dated 02/12/26, showed the following:-Day shift documented a pain scale of 7 out of 10;-Night shift documented a pain scale of 9 out of 10.Review of the resident's February 2026 MAR showed the following:-On 02/12/26, at 8:16 A.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs x 2 doses for pain with administration effective; -On 02/12/26, at 7:08 P.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs x 2 doses for pain with administration somewhat effective;-On 02/12/26, at 8:00 A.M., staff documented the Belbuca was not administered due to it being unavailable.Review of the resident's progress note dated 02/12/26, at 4:05 P.M., showed the following:-The resident complained of pain in his/her right leg/foot and back with a pain level of 8 out of 10;-The resident took hydrocodone-acetaminophen and reported some relief from the medication.-Staff did not document physician notification of Belbuca being unavailable.Review of the resident's progress note dated 02/13/26, at 1:29 A.M., showed staff received new orders to discontinue Belbuca and start Butrans (a 7-day patch used for around the clock treatment of severe chronic pain that requires long term opioid treatment when other options are inadequate) patch, 10 micrograms (mcg) weekly for pain.Review of the resident's care plan, dated 02/09/26, showed staff did not update the care plan to reflect the resident's pain and medication change to address the pain. Review of the resident's progress note dated 02/13/26, at 3:45 P.M., showed the following:-The resident complained of pain in his/her right leg/foot and back with a pain level of 8 out of 10;-The resident took hydrocodone-acetaminophen with some relief.Review of the resident's pain scale, dated 02/13/26, showed the following:-Day shift documented a pain scale of 7 out of 10;-Night shift documented a pain scale of 6 out of 10.Review of the resident's February 2026 MAR showed the following:-On 02/13/26, at 12:01 A.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs x 2 doses for pai with administration effective;-On 02/13/26, at 11:12 A.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs x 2 doses for pain with administration effective; -On 02/13/26, at 7:08 P.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs x 2 doses for pain with administration effective. Review of the resident's February 2026 POS showed an order, dated 02/13/26, for Butrans (buprenorphine) 10 mcg, apply one patch transdermally (on the skin) once a week starting on 02/14/26.Review of the resident's pain scale, dated 02/14/26, showed the following:-Day shift documented a pain scale of 7 out of 10;-Night shift documented a pain scale of 6 out of 10.Review of the resident's February 2026 MAR showed the following:-On 02/14/26, at 7:40 A.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs x 2 doses for pain with administration effective; -On 02/14/26, at 5:22 P.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs x 2 doses for pain with administration somewhat effective;-On 02/14/26, at 11:58 P.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs x 2 doses for pain with administration was effective; -On 02/14/26, at 8:00 P.M., staff did not administer the Butrans patch and noted it to be discontinued.Review of the resident's February 2026 Physician's Orders Sheet showed staff did not document the order for a Butrans patch discontinued. Review of the resident's medical record showed the staff, physician, or physician representative did not document discontinuing the Butrans patch.Review of the resident's progress notes, dated 02/14/26, showed staff did not document related to the resident's pain, medication changes, or physician notifications.Review of the resident's pain scale, dated 02/15/26, showed the following:-Day shift documented a pain scale of 7 out of 10;-Night shift documented a pain scale of 6 out of 10.Review of the resident's February 2026 MAR showed the following:-On 02/15/26, at 3:34 A.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs x 2 doses for pain with administration effective.Review of the resident's progress note dated 02/15/26, at 11:55 P.M., showed the following:-The resident complained of pain in his/her right leg/foot and back with a pain level of 8 out of 10;-The resident took Norco and reported some relief from the medication.-Staff did not document physician notification of the continued pain or the Butrans patch being discontinued.Review of the resident's pain scale, dated 02/16/26, showed the following:-Day shift documented a pain scale of 4 out of 10;-Night shift documented a pain scale of 0 out of 10.Review of the residents' February 2026 MAR showed the following:-On 02/16/26, at 4:28 A.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs x 2 doses for pain with administration effective; -On 02/16/26, at 11:48 P.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs x 2 doses for pain with administration effective. Review of the resident's progress note dated 02/16/26, at 10:32 A.M., showed the following:-The resident complained of pain in his/her right leg/foot and back with a pain level of 8 out of 10;-The resident took hydrocodone-acetaminophen and reported some relief from the medication.-Staff did not document physician notification of the unrelieved pain.Review of the resident's February 2026 POS showed the following:-An order, dated 02/16/26, for Butrans (buprenorphine) 10 mcg/hour; apply one patch transdermally (on the skin) once a week and administration due on 02/21/26.Review of the resident's pain scale, dated 02/17/26, showed the following information:-Day shift documented a pain scale of 5 out of 10;-Night shift documented a pain scale of 6 out of 10.Review of the residents' February 2026 MAR showed on 02/17/26, at 7:37 P.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs for pain with administration effective. Review of the resident's progress note dated 02/17/26, at 1:40 P.M., showed the following:-The resident complained of pain in his/her right leg/foot and back with a pain level of 8 out of 10;-The resident took hydrocodone-acetaminophen and reported some relief from the medication;-Staff did not document physician notification of the unrelieved pain. Review of the resident's February 2026 POS showed the following:-An order, dated 02/17/26, for hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs x 2 doses discontinued;-An order, dated 02/17/26, for hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs every 6 hours PRN.Review of the resident's pain scale, dated 02/18/26, showed the following:-Day shift documented a pain scale of 6 out of 10;-Night shift documented a pain scale of 5 out of 10.Review of the residents' February 2026 MAR showed the following:-On 02/18/26, at 6:23 A.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs for pain with administration effective;-On 02/18/26, at 8:00 P.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs for pain with administration effective. Review of the resident's progress note dated 02/18/26, at 3:05 P.M., showed the following:-The resident complained of pain in his/her right leg/foot and back with a pain level of 8 out of 10;-The resident took hydrocodone-acetaminophen and reported some relief from the medication.-Staff did not document physician notification of the unrelieved pain.Review of the resident's pain scale, dated 02/19/26, showed the following:-Day shift documented a pain scale of 5 out of 10;-Night shift documented a pain scale of 5 out of 10.Review of the resident's February 2026 MAR showed the following:-On 02/19/26, at 10:12 A.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs for pain with administration effective.Review of the resident's progress note dated 02/18/26, at 10:23 P.M., showed the following:-The resident complained of pain in his/her right leg/foot and back with a pain level of 8 out of 10;-The resident took hydrocodone-acetaminophen and reported some relief from the medication.-No physician notification documented.-Staff did not document physician notification of the unrelieved pain.Review of the resident's pain scale, dated 02/20/26, showed the following:-Day shift documented a pain scale of 5 out of 10;-Night shift documented a pain scale of 5 out of 10.Review of the residents' February 2026 MAR showed the following:-On 02/20/26, at 1:29 A.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs for pain with administration effective; -On 02/20/26, at 3:40 P.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs for pain with administration effective; -On 02/20/26, at 10:19 P.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs for pain with administration effective. Review of the resident's progress note dated 02/20/26, at 3:02 P.M., showed the following:-The resident complained of pain in his/her right leg/foot and back with a pain level of 8 out of 10;-The resident took hydrocodone-acetaminophen and reported some relief from the medication.-Staff did not document physician notification of the unrelieved pain.Review of the resident's pain scale, dated 02/21/26, showed the following:-Day shift documented a pain scale of 0 out of 10;-Night shift documented a pain scale of 0 out of 10.Review of the resident's February 2026 MAR showed the following:-On 02/21/26, at 3:35 P.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs for pain with administration effective; -On 02/21/26, at 11:02 P.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs for pain with administration was effective; -On 02/21/26, at 8:00 P.M., staff administered the Butrans patch. (The first documentation of staff administering the Butrans patch.)Review of the resident's progress notes, dated 02/21/26, showed staff did not document regarding the resident's pain.Review of the resident's pain scale, dated 02/22/26, showed the following:-Day shift documented a pain scale of 0 out of 10;-Night shift documented a pain scale of 0 out of 10.Review of the resident's February 2026 MAR showed the following:-On 02/22/26, at 8:01 A.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs for pain with administration effective; -On 02/22/26, at 7:36 P.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs for pain with administration effective. Review of the resident's progress notes, dated 02/22/26, showed staff did not document regarding the resident's pain.Review of the resident's pain scale, dated 02/23/26, showed the following:-Day shift documented a pain scale of 6 out of 10.Review of the resident's February 2026 MAR showed the following:-On 02/23/26, at 3:40 A.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs for pain with administration effective; -On 02/23/26, at 11:43 A.M., staff administered hydrocodone-acetaminophen 7.5/325 mg 1.5 tabs for pain with administration effective. Review of the resident's progress notes dated 02/23/26, at 4:52 P.M., showed the following:- The resident discharged home;-Staff did not document regarding the resident's pain management.During an interview on 05/13/26, at 1:00 P.M., the resident said the following:-He/she had throbbing pain in his/her left ankle/foot due to a fracture;-The staff did not enter his/her room, unless he/she called them in;-He/she had to wait extended periods of time for the staff to answer his/her call light, at least 30 to 45 minutes, every time he/she was in need of medication;-The staff did not ask him/her his/her pain level unless he/she specifically asked for pain medication;-After administering his/her pain medication, the staff did not re-enter the room and follow up on his/her unrelieved pain;-Staff did not notify the doctor or his/her family regarding the unrelieved pain;-At times he/she would complain of 8 to 10 level of pain.-He/she believes this is why the staff let his pain continue to be unrelieved. During an interview on 04/16/26, at 3:19 P.M., Certified Nursing Assistant (CNA) D said the following:-When a resident complained of pain, he/she reported to the nurse, and the nurse administered available pain medication;-The resident complained of generalized pain frequently and required pain medication often;-The resident stayed in his/her room and rarely came out. During an interview on 04/16/26, at 3:50 P.M., Certified Medication Technician (CMT) E said the following:-If a resident complained of pain, he/she checked to see if the resident has an available over the counter pain medication to administer. He/she asked the resident their level of pain and descriptors of pain;-The nurses were responsible for administering narcotics;-He/she had experienced issues with resident's medications being out of stock;-If a resident's medication was unavailable, it was documented as such. The nurses contacted the pharmacy to find out the reason why the medication was not at the facility;-The facility has an e-kit (an emergency medication kit) and unavailable medications can be pulled from the kit;-If a resident complains of constant 8 out of 10 pain, he/she would tell the nurse, and the nurse would contact the doctor for a dose increase or assessment;-He/she documented the pain level in the MAR and re-evaluated the pain level after medication administration.During an interview on 04/16/26, at 4:00 P.M., Licensed Practical Nurse (LPN) G said the following:-The resident frequently complained of generalized pain;-He/she did not recall what medications the resident was prescribed;-He/she believed some of the resident's buccal medications were unavailable due to insurance not covering the medication;-The Director of Nursing (DON) handled any insurance and pharmacy issues. The DON was responsible for documenting any concerns regarding insurance or pharmacy issues;-Unavailable medications can be pulled from the e-kit;-If a medication was not in the E-kit, he/she was expected to call the pharmacy and physician for an alternative medication;-Nurses perform pain assessments and document the results every shift;-He/she was unsure if the resident's pain was unrelieved;-Pain level and description should be documented in the progress notes;-The resident's pain should be re-evaluated and documented in the MAR after the medication administration. During an interview on 04/16/2,6 at 4:29 P.M., the DON said the following:-The resident complained of pain in his/her back and legs, but she believed it to be more anxiety related;-The resident experienced pain, but it was not horrendous amounts where he/she could not function. The DON sometimes assessed the resident herself and did not witness extreme amounts of pain;-No level of pain was acceptable;-If a resident complained of pain, staff should administer their pain medication;-She was unaware of the resident going without pain medication;-If the resident missed any medication, it was probably due to an insurance issue, but she did not recall specifically;-The resident should have received all of his/her pain medications as prescribed;-Nurses can pull medications from the e-kit and/or call the pharmacy if a medication is unavailable;-It is out of a CNA's scope to ask a resident their pain scale. They should report to the nurse when a resident complains of pain;-She expected nurses to assess, address, document, and notify the physician of unrelieved pain every shift;-Pain level and description should be documented in the progress notes;-The resident's pain should be re-evaluated and documented in the MAR after the medication administration. During an interview on 04/16/26, at 5:38 P.M., the Administrator said the following:-She expected pain medications to be administered as prescribed;-She expected the physician to be notified of unrelieved pain;-She expected the pharmacy to be contacted when medications are unavailable;-She expected all aspects of pain to be re-evaluated and documented.

Review of the undated facility policy Resident Rights showed the following:-Always be provided with the highest level of care and service;-Each resident shall be treated with consideration, respect a full recognition of his/her dignity and individuality, including care of his/her personal needs.1. Review of Resident #4's face sheet (gives basic profile information) showed the following information:-admission date of 04/04/25;-Diagnoses included pain in right hip, generalized anxiety disorder, pain in left shoulder, age-related osteoporosis with current pathological fracture (condition that occurs when severely weakened, low-density bone breaks due to minimal trauma, such as a minor fall, bending, or coughing), insomnia (difficulty falling or staying asleep), pain, unspecified, nicotine dependence. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 01/10/26, showed the following information:-Cognitively intact;-Setup or clean-up assistance for eating, personal hygiene, and oral hygiene;-Substantial to maximal assistance for toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear, rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer;-Walking none attempted due to medical condition or safety concerns;-Uses a wheelchair and/or scooter; Review of the resident's care plan, last updated 08/25/25, showed the following information:-Allow choices for care;-Staff to provide care according to the physician medical orders;-Handle gently and try to eliminate any environmental stimuli;-Monitor and record any non-verbal signs of pain (guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal);-Position for comfort with physical support as necessary;-At risk for pressure ulcers related to incontinence and decreased bed mobility;-Use absorbent, skin-friendly pads/briefs to maintain personal hygiene and dignity;-Allow resident to choose options (activities in the morning vs. afternoon);-Requires assistance with activities of daily living;-Encourage to do as much for self as possible;- Offer as much assistance as needed to complete tasks;-Break tasks into smaller simple steps if needed;-Has urinary incontinence;-Provide incontinence care after each incontinent episode. Review of the resident's progress notes showed the following:- On 01/05/26 at 7:37 A.M., the resident was observed yelling from his/her room, requesting assistance from the certified nurse aide (CNA) to get out of bed. Call light was activated. CNA responded and assisted the resident. After being placed in bed for 10 minutes, the resident began yelling again, requesting assistance to get out of bed. The resident was assisted safely with transfer. Will continue to monitor and ensure call light is within reach;-On 01/06/26 at 12:37 P.M., the resident was able to make needs known. Resident mostly continent of bowel and bladder with pads and briefs used. Sitting up in wheelchair in room;-On 01/07/26 at 3:36 P.M., the resident often yells and screams for help if not helped right away. Self-propels wheelchair, does not walk;-On 01/08/26 at 2:19 A.M., the resident yells/screams for help if not helped right away. Does not walk;-On 01/08/26 at 8:51 A.M., the resident is mostly continent of bowel and bladder with pads and briefs used. The resident is a one to two person assist with transfers and cares. Record review of the Resident Council meeting minutes, dated 01/29/26, showed call lights not being responded to on time. No further details provided. During an interview on 02/06/26, at 12:26 P.M., Resident #4 said the following:-He/She has asked Nurse Aide (NA) B several times to do something for him/her and NA B says he/she will, but never comes back;-One day recently, he/she asked NA B to help him/her get ready to smoke for the scheduled smoke break, but NA B ignored him/her, so Resident #4 asked another certified nurse aide (CNA)to assist him/her. As he/she was telling the other CNA that he/she asked NA B for assistance multiple times, NA B walked by and stopped at the end of the hall and yelled at him/her, saying Don't be putting things in my mouth. He/She said his/her response back to NA B was I'm not, but NA B continued to yell like crazy at him/her from the linen closet in the hall;-NA B has a chip on his/her shoulder;-NA B does not have any compassion in him/her and you have to have compassion to work here;-He/She is not afraid of NA B, but he/she thinks NA B might lash out or hit or strike him/her because he/she has the potential to do that because of the way he/she comes across;-NA B is the rude master, the master of rudeness;-Resident #4 has not talked to staff about NA B;-When he/she asks for help, CNA E tells him/her to be quiet because he/she is waking up the other residents;-The only way to get the staff's attention is to yell;-Resident #4 and CNA C weighed one of Resident #4's depends (an incontinence brief) about a month ago because staff had not assisted him/her with changing it all day;-They weighed the wet depends on a scale in the dining room, and it weighed one pound; -He/She told LPN J, LPN S, and the DON how much it weighed and they all pretty much said oh well;-He/She did not have any depends yesterday and no one comes in to check on him/her. He/she would like to be taken care of;-Staff get him/her up and leave him/her in the chair all day;-When needing something, he/she will ask staff, and they tell him/her to wait and then no one comes back to help; -He/She is always out of depends each month, so staff will use depends which are too big or too small;-They are always running out of his/her depends and residents are not allowed to have a full package of depends in their rooms. During an interview on 02/09/26, at 2:53 P.M., Resident #4 said the following:-When his/her pants get soaked from the depend getting too full he/she can smell it and it makes him/her aggravated;-He/She does not like to smell like urine;-When he/she starts smelling like urine he/she asks to be changed. Staff say they will be back and then they never come back;-CNA D comes in around 2:00 P.M., and changes him/her;-Other staff have to know that he/she has to pee during the day. During interview on 02/06/26 at 9:50 A.M., Certified Nurse Assistant (CNA) D said the following:-He/She witnessed Nurse Aide (NA) B backtalk Resident #4 when asked to help him/her get ready for his/her smoke break;-CNA E heard Resident #4 ask NA B twice to assist him/her with getting ready for the smoke break and NA B told the resident both times he/she was busy;-Resident #4 told CNA D that NA B would not get him/her ready for the smoke break and asked CNA E to assist and he/she did;-NA B was standing in the hall and yelled back at Resident #4 I never said I would not help you, so stop putting words in my mouth. During an interview on 02/06/26, at 1:10 P.M., the DON said the following:-It is not appropriate for staff to tell him/her to be quiet when he/she yells out at night because of back pain due to his/her mattress;-Staff encourage the resident to use his/her call light;-If the resident pushes his/her call light and it is not answered as soon as he/she thinks it should have been, he/she should not be yelling out because it would disturb other residents;-If his/her call light goes off, staff would send an aide to check on him/her;-Resident #4 has not complained to him/her about his/her call light not being answered;-Staff is using what is available to them for Resident # 4 because he/she did not want to go without a depend/brief. During an interview on 02/06/26, at 1:56 P.M., CNA E said the following:-The resident yells out about his/her cigarette breaks and does not want to be late;-Staff tell Resident #4 he/she is not the only resident they have to care for;-The resident does not use the call light, he/she screams for staff to help instead;-When the resident is in bed he/she screams because he/she wants to get up and go smoke;-If he/she does not get Resident #4 up for the 9:00 A.M. cigarette break, the resident will yell out. During an interview on 02/06/26, at 2:00 P.M., CNA C said the following:-He/She did assist Resident #4 with weighing his/her depend as he/she came on for his/her shift;-Resident #4 said he/she had not been changed all day;-The resident's wet depend had soaked through his/her pants;-The depend was weighed on the scale in the dining room and it weighed 1.3 pounds;-The resident laughed about it, but CNA C felt that it was a defense mechanism to help him/her emotionally;-He/She informed LPN S about the weight of the depend;-The facility was also out of wipes that day, so he/she used wet paper towels and wet washcloths to clean Resident # 4 up;-Several residents do not have enough depends, including Resident #4. It did not use to be that way, but now the facility is frequently out of depends and wipes;-Last Thursday, Resident #4 did not have the right size of depends. The resident uses an extra-large to 2X size, but the only size of depends he/she had to use was large, and it was snug on him/her;-CNA C feels like dayshift staff ignores Resident #4 because he/she is vocal. During an interview on 02/06/26, at 10:08 A.M., LPN F said residents may be left soiled at night because some mornings when he/she comes in the residents are soaking wet. During an interview on 02/06/26, at 1:10 P.M., the DON said the following:-The facility does have a shortage of depends and when it is close to delivery day the supply get shorter;-The DON has been combating with the aides because there has not been enough depends;-The DON orders the depends and supplies every two weeks unless there are five weeks in the month then he/she orders every three weeks;-He/She is over budget on depends;-Staff place the depends in resident rooms, so they have been instructed to only take in a few at a time and not a full package;-The facility received a shipment yesterday, but not everything came in;-The only depends/briefs that came in yesterday were the bariatric ones;-He/She is not aware of resident's being left soiled;-Staff should check and change residents every two hours;-If he/she goes over budget he/she has to get approval from the administrator;-The administrator has never denied him/her to order supplies even if he/she is over budget;-If the staff get low on something he/she puts it on the list for the next order. During an interview on 02/06/26, at 1:56 P.M., CNA E said he/she is concerned with the depends supply and not having enough depends/briefs. The supply issue impacts the residents that get up out of bed. During an interview on 02/06/26, at 2:00 P.M., CNA C said the following:-Last week the facility did not have any large gloves, so he/she had to use a different size;-On Thursday he/she was told the delivery truck came but they only received size 5 x depends;-The staff had to use pull ups on one resident because they did not have any depends for him/her;.-LPN S went to Walmart and bought a couple of bags of depends;-The facility has had supply issues for a couple of months now;-He/She has had to put the 5X size of depends on some residents that did not need that size because that was all that was available;-The night shift is pretty short staffed. 2. Review of Resident #5's face sheet (admission information at a glance), showed the following:-admission 7/28/25;-Diagnoses that included osteoporosis, anxiety disorder, depression, hypothyroidism (low thyroid) neuralgia(intense, sharp, burning, or electric shock-like pain caused by damaged or irritated nerves and neuritis (inflammation of a nerve or general inflammation of the peripheral nervous system ,chronic obstructive pulmonary disease (progressive , long-term lung disease making it difficult to breathe), pneumonia, mild cognition impairment. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 12/18/25 showed the following:-intact cognition;-requires substantial/maximal assistance. Helper lifts or holds trunk or limbs and provides more than half the effort;-frequently incontinent of urine and bowel;-On antipsychotic (used to manage psychosis (set of symptoms indicating loss of contact with reality, characterized primarily by hallucinations and delusions), schizophrenia (chronic, severe brain disorder that distorts how a person thinks, feels, acts, and perceives reality), bipolar mania (abnormally elevated extreme mood, energy, or activity lasting at least 7 days or requiring hospitalization), and severe depression. Review of the resident's care plan revised 11/11/25, showed the following:-Impaired mobility;-Approaches included: Staff assist with turning and repositioning every 2 hours as needed if unable to do so on own, two staff to assist with transfers, able to propel own wheelchair; usually refuses a shower;-At risk for bowel and bladder incontinence:-Approaches included: staff to assist res to the bathroom every two hours and PRN;-Have Anxiety:-If have a panic attack or anxiety episode, attempt to redirect the resident to something that will change their focus, Use a calm voice and approach during anxiety attack;-Prefer to stay in room and have little socialization/activity interest with others;-Approaches included: Allow time to reminiscing of past life experiences, offer emotional support as needed, remind of activities in the facility;-Psychosocial well-being; wishes his/her children would come and see him/her;-Approaches included: allow time to vent feelings about limited family contact, monitor for signs of depression, sadness, and isolation; Staff to provide conversations while in room providing care, preferred to stay in his/her own room. Review of the resident's progress notes, showed the following:-On 12/13/25, resident is alert and able to make needs know, puts on call light if has slight urine incontinence and after a few minutes starts yelling out help. Resident prefers to stay in his/her room and away from other residents. Room door stays closed at all times and stays closed at all times;-On 12/14/25, resident was incontinent of bowel and bladder and will put on call light for changes and wears briefs. Eats meals in room per choice.-On 12/15/25, the resident eats all meals in his/her room. If he/she goes just the least little bit, can be demanding after a few minutes and starts yelling out Help. Resident prefers to stay in his/her room and can be demanding after a few minutes and starts yelling out. Prefers to stay in his/her room and away from other residents. Door stays closed at all time and must knock before entering this door;-On 1/9/26, the resident refused care this shift by staff. Staff do rounds every two hours and the resident refuses at times saying he/she is dry and refuses to let staff check him/her. During interview on 2/6/26 at 11:00 A.M., Resident #5 said the following:-He/she felt like NA B was rude when he/she was having a conversation about his/her personal life with CNA O while they were changing him/her; -NA B was talking over him/her;-CNA O was helping with changing him/her;-He/she did report this to LPN J who said he/she would not allow NA B in his/her room anymore;-NA B talking about his/her personal life made the resident feel uncomfortable; -NA B had not been in his/her room since it happened over a week ago;-He/she was not afraid of NA B but did not want him/her touching him/her since it would make him/her feel uncomfortable. During interview on 2/10/26 at 4:37 P.M., CNA L said the following:-They were to respect the residents as they wanted to be respected by them and how they wanted to be treated;-Staff were not to talk about their personal life around residents;-They were not to talk over the residents during personal cares;-NA B was not really rude to residents but may come off wrong to some of them. During interview on 2/10/26 at 2:40 P.M., CMT (Certified Medication Technician) N said the following:-Residents should be treated with respect and not yelled at;-Care partners should not talk about personal lives and talk over residents to another care partner while providing care. During interview on 2/6/26 at 9:55 A.M., Licensed Practical Nurse (LPN) J said the following:-Resident #5 had complained about Nurse Aide (NA) B being rude to him/her;-Resident #5 said he/she did not want NA B to change him/her;-Certified Nurse Aide (CNA) O had assisted NA B with Resident #5's care and they had an inappropriate conversation with each other while assisting with the care;-NA B was high strung, impatient with residents and other staff;-NA B was talking about all his/her dates and dating life with CNA O while providing incontinence care;-Staff should not talk about their intimate personal lives in front of the residents;-LPN J did not write the incident up yet since he/she wanted NA B to sign the form;-Residents had complained about NA B being rude to them;-He/she had observed him/her say in front of the nurse's desk, My God, (resident's name), what do you want now? and seemed impatient;-LPN J told NA B it was not acceptable to talk that way;-Other residents did not want NA B in their room too;-He/she told the DON, wound care nurse, and administrator about NA B and they said they would take care of it. During interview on 2/10/26 at 5:10 P.M., LPN F said the following:-Dignity and respect is treating everyone as he/she wanted to be treated;-Approach residents as they wanted to be;-staff should not yell in anger or frustration, and may need to walk away and remove themselves for a few minutes;-staff should not talk about personal lives around the residents or talk over them doing personal cares. During interview on 2/6/26 at 12:30 P.M. and 2/10/26 at 5:39 P.M., the Director of Nursing said the following:-Other staff say NA B can be rather loud;-Other residents have not complained to him about NA B but one resident (Resident #5) complained to CNA L who reported to him that the resident said NA B and another aide were talking over him/her about their dating life;-He had not talked to NA B about this but will plan to talk to NA B the next time he worked with NA B;-Staff should not talk over a resident during care. Staff should talk with them and engage them in conversation during cares;-For dignity and respect, staff were not to belittle anyone and treat residents as you want to be treated;-Staff were not to yell at anyone but can raise voice for them to hear you;-Staff should not talk over residents during personal cares such as to another coworker but rather talk to the resident;-Staff were not to talk about their personal lives. During interview on 2/6/26 at 11:35 A.M., the administrator said the following:-LPN J reported to her that NA B and another aide were talking about his/her intimate personal life to another nurse aide while providing personal care to a resident, which was wrong;-She thought LPN J had addressed this with both NA B and CNA O;-Both were discussing something about personal dating life;-The resident did not care about hearing their personal dating life;-She was unaware of any other residents who don't want NA B in their room to do personal cares;-There were no write ups or counseling in their personnel files, and they do put write ups in a file.-She would expect staff to treat residents with dignity and respect.3. Review of the Resident #6's face sheet (a document that gives a resident's information at a quick glance) showed the following:-An admission date of 06/07/25; -Diagnoses included paraplegia (partial or complete loss of motor and sensory function in the lower half of the body); depression, and chronic pain.Review of the resident's care plan, revised on 12/16/25, showed the following:-Staff should encourage resident to do as much as possible for self;-Staff should offer assistance as needed;-Resident had a mood disorder;-Staff should not argue, confront, or argue against his/her thoughts;-Staff should main a calm environment and approach with the resident.Review of the resident's quarterly MDS dated [DATE] showed the following:-Cognitively intact;-Dependent on staff for showering, toileting, transfers, and bed mobility;-Independent with mobility using a wheelchair.During an interview on 02/05/26, at 10:50 A.M., Resident #6 said the following: -He/she recently asked Nurse Aide (NA) B to remake his/her bed because it was not made correctly;-NA B got irritated at him/her, walked off, and started using his/her phone;-NA B was rude and his/her tone and gestures were not good;-NA B did not come back and remake his/her bed;-NA B just walked past him/her and would ignore him/her.During interview on 02/06/26 at 9:50 A.M., Certified Nurse Assistant (CNA) D who worked on the dementia unit, said the following:-Nurse Aide (NA) B recently inappropriately restrained Resident #2 by holding his/her arms and hands behind his/her back like he/she was being arrested;-The NA had his/her arms intertwined with Resident #2's arms to keep Resident #2's arms and hands from moving;-Resident #2 was upset and crying;-He/She heard resident #2 tell the NA No I'm not going and the NA responded to Resident #2 by saying Yes you are;-One of the kitchen staff members and CNA E witnessed the altercation;-The situation happened in the dining room area at the front entrance to the facility;-Resident # 2 and the NA were in the business office manager's (BOM's) office, and he/she probably seen it happen, he/she for sure would have heard it;-NA B held Resident #2's arms and hands behind his/her back the entire way while walking him/her from the BOM's office until he/she got to the special care unit; -He/She is not sure why NA B had Resident #2 out of the special care unit because Resident #2 has a hard time going back into the unit;-Resident #2 is not normally taken out of the special care unit, so he/she is not sure why he/she was in the BOM's office;-CNA E told LPN F and the DON about the situation and the DON informed him/her that he/she would handle it;-NA B was moved out of the special care unit and CNA D was put in the unit in his/her place.4. During an interview on 02/10/26, at 6:25 P.M., the Administrator said the following:-Staff should not tell residents to be quiet;-He/She would expect staff to respect the resident's wishes;-Staff should not yell at residents or talk over them, they should talk to the residents and not talk about their personal life;-He/She would expect staff to remake a resident's bed and accommodate a resident if they were asked by the resident to remake the bed;-Staff should not ignore residents.Complaint 2735227

Based on observation, interview, and record review, the facility failed to provide an ongoing activities program for all residents based on comprehensive assessments and care plans when, staff failed to provide an activity program for the 17 residents who lived on the special care unit (SCU - hall with residents who have dementia and are at risk to exit seek reside) and failed to complete comprehensive assessments regarding preferred activities for two residents (Resident #2 and #3). The facility census was 70. Review showed the facility did not provide a policy regarding the activity program. 1. Observations on the SCU throughout the day on 06/03/26, 06/04/26, and 06/05/26, showed no activity calendar posted, no observations of any activity supplies, or activities in the SCU. Observation on 06/05/26, at 8:45 A.M., showed four residents sitting in wheelchairs around the nurses' station in the SCU. The residents were not engaged in any activity or interactions. 2. Review of Resident #2's face sheet (admission information at a glance) showed the following:-admission date of 09/30/85;-Diagnoses included quadriplegia (partial or total paralysis of all four limbs), anxiety disorder, and Alzheimer's disease (progressive, irreversible brain disorder that slowly destroys memory and thinking skills). Review of the resident's care plan, revised 02/17/26, showed the following:-The resident had an absence of personal contact with family and friends related to long term residence in facility, cognitive impairment and inability to speak;-Resident will be invited to facility events and activities to help increase involvement in facility life;-Resident was unable to participate in most activities. Review of the resident's record showed staff did not have a documented activity assessment completed and did not have any documentation regarding activity attendance. Observation on 06/03/26, at 1:14 P.M. showed the following: -The resident sat in reclining wheelchair in his/her room with eyes closed and the television on. The resident was not watching or engaged with the television.-There was no activity calendar posted in the resident's room. Observation on 06/04/26, 10:21 A.M., showed the resident sat in a wheelchair in his/her room with eyes closed. No activities offered at that time. Observation on 06/05/26, 8:41 A.M., showed the resident sat in a wheelchair in his/her room with eyes closed. Observation on 06/05/26, at 10:10 A.M., showed the resident sat in his/her room with eyes closed. 3. Review of Resident #3's face sheet showed the following information:-admission date of 01/18/19;-Diagnoses included vascular dementia (decline in thinking and memory skills caused by reduced blood flow to the brain) and diabetes mellitus (metabolic disorder). Review of the resident's care plan, revised 03/31/26, showed the following:-Resident had physical behavioral symptoms toward others such as hitting, kicking, pushing, and scratching;-Resident will attend community outings, group activities, and outdoor activities at own discretion;-Activities will work with nursing to encourage activities of interest to the resident;-Resident had behavioral symptoms not directed to others;-Resident liked to participate in bingo, crafts, and smoke breaks;-Resident will review the activity calendar daily. Review of the resident's record showed staff did not have a documented activity assessment completed and did not have any documentation regarding activity attendance. Observation on 06/04/25, at 10:19 A.M., showed the following: -The resident sat in a wheelchair in his/her room. The resident chewed on a straw and yelled hey;-The resident then wheeled his/her wheelchair to the bed and threw a blanket on the floor;-There was no activity calendar posted in the resident's room. Observation on 06/05/26, at 10:09 A.M., showed the resident sat in his/her wheelchair in the hallway and another resident walked up and down the hallway. 4. During an interview on 06/04/26, at 1:40 P.M., Certified Nurse Assistant (CNA) A said the following:-The facility does not have an activity director;-They had an activities person, but they pulled him/her to work the floor as a CNA a couple months ago;-The Social Worker does bingo on Monday, Wednesday, and Friday outside of the unit. During an interview on 06/04/26, at 2:45 P.M., Certified Medication Technician (CMT) B said the following:-The facility had not had activities for a while, maybe a month;-The activity director was pulled to work on the floor as a CNA;-The bingo offered yesterday, outside the SCU was the first activity in a month; -Residents have coloring pages to complete for an activity;-Residents appear to be more intrusive, have increased pacing in the unit, and appear more agitated without activities. During an interview on 06/05/26, at 11:30 A.M., Licensed Practical Nurse (LPN) C said the following:-The facility has not had an activities director for the last few weeks;-The person that worked in human resources tried to help with activities when he/she had time;-He/she did not think the facility offered enough activities for the residents;-The residents in the SCU do not have any activities;-The assistant activity director quit a couple of months ago;-Residents on the SCU get bored which can lead to increased behaviors. During an interview on 06/05/26, at 12:53 P.M., LPN D said the following:-There was someone doing activities, but he/she was pulled to floor;-The assistant activities director was still working but did not come to the SCU;-The residents were bored and had nothing to do which caused increased behaviors on the unit;-There had not been any activities at the SCU for at least two years;-There was no activities director at the facility for a month;-They have had an activity called pretty nails on Tuesdays for the residents. The SCU staff provide this activity for the residents;-The residents would have nothing if the staff did not provide the pretty nails activity; -The facility had bingo and ice cream this week, but have not had anything for the residents for a long time. The SCU residents were not included in the bingo and ice cream. No alternate activities for the SCU. During an interview on 06/05/26, at 12:15 P.M., the Director of Nursing (DON) said the following:-The facility had the bookkeeper and another person who assisted with activities; -The previous activity director was now in a role as a nurse assistant;-The SCU activities included popcorn, watching movies, and a balloon toss;-The aides were currently providing unknown activities on the unit.

Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for two residents (Resident #4 and Resident #5). The facility census was 76. Review showed the facility did provide a policy regarding bathing.1. Review of Resident #4's face sheet (brief look at resident information) showed the following:-admission date of 10/17/25; -Diagnoses include repeated falls, muscle weakness, irregular heartbeat, and heart failure.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 01/23/26, showed the following information:-Cognitively intact;-Required substantial to maximum assistance from staff for bathing, dressing, and mobility.Review of the resident's care plan, dated 01/29/26, showed staff did not care plan regarding bathing preferences and/or assistance level for bathing.Review of the resident's comprehensive Certified Nursing Assistant (CNA) Shower Review Sheets, dated 03/01/26 through 04/05/26, showed on 03/06/26, the resident received a shower. No other shower review sheets were provided that documented any additional showers or refusals by the resident.Review of the resident's hospital discharge paperwork show the resident admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. Review of the resident's comprehensive CNA Shower Review Sheets, dated 04/10/26 through 04/16/26, showed on 04/12/26, the resident received a shower. No other shower review sheets were provided that documented any additional showers or refusals by the resident. During an interview on 04/16/26, at 10:22 A.M., the resident said the following:-He/she has only received six showers since his/her admission in January of 2026;-The staff say the resident refuses showers, but he/she does not unless it is a holiday or they offer the shower during nighttime hours; -Staff did not offer a shower two times a week, but this is his/her preference. During an interview on 04/16/26, at 3:19 P.M., CNA D said he/she was unaware of the resident ever refusing to take a shower.During an interview on 04/16/26, at 4:00 P.M., Licensed Practical Nurse (LPN) G said he/she was unaware of the resident ever refusing to take a shower. 2. Review of Resident #5's face sheet showed the following information:-admission date of 02/06/26;-Diagnoses include fracture to the upper and lower end of the fibula (slender bone running parallel to the tibia (shinbone) on the outside of the lower leg), cardiomyopathy (a disease of the heart muscle that impairs its ability to pump blood), and obesity. Review of the resident's admission MDS, dated [DATE] showed the following information:-Cognitively intact;-Requires partial to moderate assistance from staff for bathing;-Independent for mobility.Review of the resident's care plan, dated 02/09/26, showed no bathing preferences and/or assistance level for bathing.Review of the resident's Comprehensive CNA Shower Review sheets, dated 02/01/26 through 02/23/26 (discharge) showed no shower review sheets were provided that documented showers provided or refusals by the resident.Review of the resident's nurses' notes, dated 02/01/26 through 02/23/26 (discharge), showed staff did not document any bathing refusals.During an interview on 04/16/26, at 3:19 P.M., CNA D said he/she was unaware of the resident refused showers.During an interview on 04/16/26 at 4:00 P.M., LPN G said he/she was unaware of the resident refusing showers.3. During an interview on 04/16/26, at 3:19 P.M., CNA D said the following information:-Residents should be offered two showers per week;-If a resident refuses, a bed bath should be offered;-If the resident continued to refuse, the refusal should be documented on the shower review sheet and turned into the nurse;-There was only one shower aide for the facility and other aides help out from time to time.During an interview on 04/16/26, at 4:00 P.M., LPN G said the following:-All residents should be offered two showers a week;-There were staffing issues at the facility, and he/she believed this affected the number of showers being offered;-Staff documented refusals on the shower sheets, if residents frequently refused, he/she would document that in a progress note.During an interview on 04/16/26, at 4:29 P.M., the Director of Nursing (DON) said the following information:-She expected all residents to be offered two showers per week;-Staffing has affected the ability to offer residents two showers per week, but the residents should be offered at least one now that staffing is more stable;-All shifts should assist with getting showers caught up;-Residents should be showered according to their preference (frequency and time of day);-If a resident refused, staff were expected to fill out the shower review sheet and turn it into the nurse.During an interview on 04/16/26, at 5:38 P.M., the Administrator said the following:-She expected staff to offer all residents at least two showers per week;-If a resident refused a shower, she expected staff to document the refusal. Complaint #2742822

Based on observation, interview, and record review, the facility failed to ensure all residents had a comfortable environment when staff failed to address the mattress of one resident (Resident #4) that had a dip in which caused difficulty with position and sleeping, and contributed to the resident's pain. A sample of three residents was selected for review. The facility census was 77.Review of a facility policy titled Pain Management Policy and Procedure, with no date, showed the following information:-The purpose is to establish procedures for identifying, assessing, treating, and monitoring pain in long-term care residents, supporting individualized and effective pain management strategies while promoting safety and regulatory compliance;-Include both pharmacologic and non-pharmacologic strategies in the care plan;-Review and update the care plan regularly or as needed;-Document assessment findings, interventions, and resident response. 1. Review of Resident #4's face sheet (gives basic profile information) showed the following information:-admission date of 04/04/25;-Diagnoses included pain in right hip, generalized anxiety disorder, pain in left shoulder, age-related osteoporosis with current pathological fracture (condition that occurs when severely weakened, low-density bone breaks due to minimal trauma, such as a minor fall, bending, or coughing), insomnia (difficulty falling or staying asleep), and pain, unspecified. Review of the resident's care plan, updated 08/25/25, showed the following information:-Complains of chronic pain related to right hip;-Acknowledge to the resident that his/her pain is unique and believable;-Assess effects of pain on the resident (disturbances in sleep, activity, self-care, appetite, and psychosocial);-Monitor and record any non-verbal signs of pain (guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal);-Position for comfort with physical support as necessary.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 01/10/26, showed the following information:-Cognitively intact;-Substantial to maximal assistance for rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer;-Received scheduled pain medication;-Received as needed pain medications;-History of pain;-Pain frequency almost constantly;-Occasional sleep disturbance due to pain;-Pain interferes with day-to-day activities almost constantly;-Rates pain as 8 on a pain scale of 0 to 10;-Pain described as severe.Review of the resident's progress notes showed on 01/05/26, at 7:37 A.M., the resident was observed yelling from her room, requesting assistance from the certified nurse aide (CNA) to get in bed. During an interview on 02/06/26, at 12:26 P.M., the resident said the following:-He/She gets in the hole in his/her bed and cannot get out of it once he/she is in the hole;-He/She cannot sleep decent at night because of the hole in his/her bed;-The hole in his/her bed hurts his/her back;-They do not fix his/her bed, and they know what is going on with it because she has told several staff about it;-He/She yells because her bed feels like it is going to snap her in two, but staff keep telling him/her to be quiet;-He/She was not trying to be rude by yelling, but his/her back hurts and he/she cannot lay in the bed any longer;-The bed is not good. It has a dip in it, and it hurts his/her back.During an interview on 02/09/26, at 2:53 P.M., the resident said the following:-There is a dip in the bed itself;-The bed hurts his/her lower back bad, and he/she yells at staff to get him/her up;-The bed/mattress has hurt his/her back for several months.During an interview on 02/06/26, at 2:00 P.M., CNA C said the following:-The resident complains about his/her back hurting;-The resident does complain about his/her hips and back hurting and he/she complains of his/her mattress hurting her because of a dip in it that he/she falls into;-The resident's mattress is not a mattress that you can flip over or turning around;-There is not a physical hole in the mattress, it is a dip or crease area in the mattress;-The resident was sleeping in his/her recliner for a few nights a while back to see if it would help, but the recliner is gone now. During an interview on 02/06/26, at 1:10 P.M., the Director of Nursing (DON) said the following:-The resident slides down in his/her bed and staff keep repositioning him/her;-He/She yells out at night because he/she slips down into the hole in his/her bed, but the DON thinks it is the way the resident lays in his/her bed;-The DON has not observed or inspected the resident's mattress, but other staff have;-It should be in the maintenance book if anything is wrong with his/her bed;-The mattresses are all the same, so it is probably just his/hers with the hole that dips down;-The resident should have a mattress that he/she is comfortable in and that does not hurt his/her back.During an interview on 02/10/26, at 6:25 P.M., the Administrator said the following:-He/She is not aware of the resident's bed hurting his/her back;-Staff could have changed the mattresses out if it was causing the resident pain;-He/She was not aware that the resident yelled out at night due to his/her bed hurting his/her back;-He/She would expect staff to let the nurse, DON, and/or housekeeping know if a resident has a concern with their bed.

Based on interview and record review, the facility failed to ensure all allegation of possible abuse were reported to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff did not report an allegation of staff to resident abuse/restraint involving one resident (Resident #2) to DHSS. The facility census was 77. Review of the facility's Abuse Prevention Policy and Procedure Checklist, revised11/28/16, showed the following:-The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms;-The intent of this requirement is for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical restraints for discipline or convenience and prohibits the use of physical restraints to unnecessarily inhibit a resident's freedom of movement or activity.1.Review of Resident #2's face sheet (admission information at a glance) showed the following:-admission date of 07/14/25;-Diagnoses that included bipolar II disorder (mental health condition characterized by depressive episodes and hypomania (elevated, irritable, or energetic moods)), anxiety disorder, personality disorder, epilepsy (seizure disorder), and parkinsonism (movement symptoms such as slow movements, stiffness, walking and balance problems, and tremor).Review of the resident's care plan, revised 10/28/25, showed the following:-Socially inappropriate/disruptive behavioral symptoms as evidenced by rejecting cares at times;-Assess whether behavior endangers the resident and/or others and intervene if necessary;-Avoid over-stimulation (noise, crowding, other physically aggressive residents);-Convey an attitude of acceptance toward the resident;-Maintain a calm environment and approach to the resident;-When resident begins to become socially inappropriate/disruptive, provide comfort measures for basic needs ( such as pain, hunger, toileting, too hot/cold, etc.)-Resident has difficulty understanding others related to mental health issues and intellectual disabilities;-Ask resident to repeat what has been said to confirm the message was understood;-Face the resident when speaking;-Obtain resident's attention before speaking;-Repeat phrases as needed and rephrase if necessary;-Speak clearly and adjust tone as needed;-Resident has disorganized thinking or is incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, unpredictable switching from subject to subject) related to mental health problems;-Assess factors that may be associated with signs and symptoms of delirium such as time of symptom onset, change in mood, change in social situations, use of restraint;-Be calm and reassuring in approaching resident;-Orient to person, place, and time. Speak quietly, slowly, and repetitively;-Provide a quiet, well-lit, calm environment, Surround resident with familiar objects; Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/20/26, showed the following:-Cognition was severely impaired;-Independent with functional abilities to move from sitting to lying down, standing, and walking.Review of the resident's progress note, dated 01/20/26, showed the following:-Resident was alert to self and knew his/her name;-Autistic and can have episodes with behaviors where he/she wants medications now, covered up now, or his/her meal tray picked up now, or he/she will throw personal belongings at times such as throwing his/her coloring papers at staff and then throwing them on the floor. The resident will come back and apologize for his/her behavior;-Able to make needs know and knows when he/she has an accident and needs staff to come;-Enjoys comic books and superheroes coloring pages and likes to watch game shows;-Up ad lib (on own) around the unit and does not make attempts to seek exiting unit.During an interview on 02/06/26, at 2:20 P.M., Nurse Aide (NA) B said the following:-He/she was in the business office with the resident while on a call with Social Security;-When the call ended, he/she and the Business Office Manager (BOM) tried to get the resident to go back to the unit but the resident refused;-The BOM had been printing out pictures of [NAME] and the more you give the resident, the more he/she wants;-The resident had a temper tantrum and he/she escalated in the business office;-The resident got more upset and angry but this was not at the point, he/she restrained him/her;-Outside the business office, the resident began swinging his/her arms hitting him/her several time on his/her head and at that point. NA B said my training in behavioral health kicked in and took my arms, wrapped them around the resident from his/her back underneath the arms, like tucked them behind his/her mid-back and restrained him/her so he/she could not hit him/her. It upset the resident, and he/she began crying;-NA B said he/she wanted to keep him/her and everyone else safe;-The BOM did not tell him/her to let the resident go and was beside him/her all the way to the unit;-He/she was not aggressive and did not hurt the resident and in the unit, he/she released the resident;-He/she didn't have training here about what to do when a resident was having behaviors but had training in previous jobs;-The Director of Nursing (DON) called him/her to his/her office and was told not to do that and was not written up for it. During an interview on 02/06/26, at 1:57 P.M., Certified Nurse Aide (CNA) E said the following:-He/she witnessed the incident with the resident and NA B last week when he/she was in the dining room;-They should have never taken the resident out of the locked unit;-He/she observed NA B yell, Yes, you are! and NA B got behind the resident, put his/her arms behind his/her back like being arrested and it raised up the resident's shoulders;-The resident cried as he/she walked with his/her hands held up behind him/her behind his/her back like being arrested;-The BOM walked beside them and he/she saw the way NA B did this to the resident;-The BOM did try to calm the resident down but it was not appropriate for staff to touch and or restrain him/her;-He/she reported this incident to the DON about NA B and the resident. Review of the facility records showed staff did not document notification of DHSS regarding the allegation of abuse in the form of restraint use with not order, no care plan, and for staff benefit. Review of DHSS records showed the facility did not self-report the allegation of abuse in the form of restraint use with not order, no care plan, and for staff benefit.During an interview on 02/10/26, at 4:37 P.M., CNA L said the following:-Staff were to report directly to the DON of any abuse and neglect and this was to be reported to Department of Health and Senior Services (DHSS) within two hours;-This included reporting staff restraining a resident such as holding arms down or behind them or swing arms like on dementia unit. Staff should leave the resident alone a bit to calm down and then re-approach them or have another staff come to help calm the resident.During an interview on 02/10/26, at 2:40 P.M., Certified Medication Technician (CMT) N said the following:-A restraint was to hold a residents' hands, tie them down with something, put them in a wheelchair and put on the wheelchair brakes, shut their door and keep them in their room for examples;-For any allegation of abuse and neglect, even if staff physically restrain a resident, they were to report to the charge nurse and DON immediately and then report this within two hours to the state.During an interview on 02/06/26, at 10:26 A.M., Licensed Practical Nurse (LPN) F who worked on the dementia unit, said the following:-The administrator and the business office manager witnessed NA B had an incident with the resident;-The resident was upset about not getting his/her coloring pages. NA B put the resident's hands behind his/her back like handcuffs with his/her arms on each side and walked the resident to the unit;-If staff witness any abuse and/or neglect, they were to report this to the DON whether they were here in the building or not. If after hours, they were to notify the Administrator. They were to notify them within one hour and to report to the state within two hours. During interviews on 02/06/26, at 12:30 P.M., and on 02/09/26, at 12:00 P.M., the DON said the following:-The incident with the resident and NA B happened sometime last week;-CNA D and CNA E reported to him they saw the resident irate and out of control;-NA B was trying to keep the resident's hands from hitting other people in the main dining room, he could not say what residents were in the dining room;-NA B tried to hold both the resident's hands and/or arms;-The aides said NA B was restraining the resident and it looked like NA B was holding his/her arms down;-The state was not contacted regarding the allegation;-He and LPN F ruled out abuse and neglect on their own;-Abuse and neglect should be reported to the DON and Administrator and then reported to the state within two hours. During interviews on 02/06/26, at 11:35 A.M., and on 02/10/26, at 6:25 P.M., the administrator said the following:-An employee, NA B, had inappropriate behavior and the DON talked to him/her;-They were not to restrain the resident or put anyone's hands behind their back. They would consider it a restraint;-For abuse/neglect, staff were to report to the DON;-The DON should have looked into it and called the state with a self-report within 2 hours; -The abuse and neglect policy included information about restraints. #2735227

Based on interview and record review, the facility failed to ensure all allegation of possible abuse were investigated timely with steps to protect all residents implemented during the investigation when the facility failed to complete a full and documented investigation, including steps taken protect resident during the investigation, of an allegation of staff to resident abuse/restrain involving one resident (Resident #2}). The facility census was 77.Review of the facility's policy Abuse Prevention Policy and Procedure Checklist, revised11/28/16, showed the following:-The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms;-The intent of this requirement is for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical restraints for discipline or convenience and prohibits the use of physical restraints to unnecessarily inhibit a resident's freedom of movement or activity;-The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation, and mistreatment from occurring while the investigation is in progress;-Take appropriate corrective action, as a result of investigation findings. 1.Review of Resident #2's face sheet (admission information at a glance) showed the following:-Admit 7/14/25;-Diagnoses that included Bipolar II disorder (mental health condition characterized by depressive episodes and hypomania (elevated, irritable, or energetic moods), anxiety disorder, personality disorder, epilepsy (seizure disorder), parkinsonism (movement symptoms such as slow movements, stiffness, walking and balance problems, and tremor).Review of the facility's policy Abuse Prevention Policy and Procedure Checklist, revised11/28/16, showed the following:-The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms;-The intent of this requirement is for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical restraints for discipline or convenience and prohibits the use of physical restraints to unnecessarily inhibit a resident's freedom of movement or activity;-The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation, and mistreatment from occurring while the investigation is in progress;-Take appropriate corrective action as a result of investigation findings.1.Review of Resident #2's face sheet (admission information at a glance) showed the following:-admission date of 07/14/25;-Diagnoses that included bipolar II disorder (mental health condition characterized by depressive episodes and hypomania (elevated, irritable, or energetic moods)), anxiety disorder, personality disorder, epilepsy (seizure disorder), and parkinsonism (movement symptoms such as slow movements, stiffness, walking and balance problems, and tremor).Review of the resident's care plan, revised 10/28/25, showed the following:-Socially inappropriate/disruptive behavioral symptoms as evidenced by rejecting cares at times;-Assess whether behavior endangers the resident and/or others and intervene if necessary;-Avoid over-stimulation (noise, crowding, other physically aggressive residents);-Convey an attitude of acceptance toward the resident;-Maintain a calm environment and approach to the resident;-When resident begins to become socially inappropriate/disruptive, provide comfort measures for basic needs ( such as pain, hunger, toileting, too hot/cold, etc.)-Resident has difficulty understanding others related to mental health issues and intellectual disabilities;-Ask resident to repeat what has been said to confirm the message was understood;-Face the resident when speaking;-Obtain resident's attention before speaking;-Repeat phrases as needed and rephrase if necessary;-Speak clearly and adjust tone as needed;-Resident has disorganized thinking or is incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, unpredictable switching from subject to subject) related to mental health problems;-Assess factors that may be associated with signs and symptoms of delirium such as time of symptom onset, change in mood, change in social situations, use of restraint;-Be calm and reassuring in approaching resident;-Orient to person, place, and time. Speak quietly, slowly, and repetitively;-Provide a quiet, well-lit, calm environment, Surround resident with familiar objects; Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/20/26, showed the following:-Cognition was severely impaired;-Independent with functional abilities to move from sitting to lying down, standing, and walking.Review of the resident's progress note, dated 01/20/26, showed the following:-Resident was alert to self and knew his/her name;-Autistic and can have episodes with behaviors where he/she wants medications now, covered up now, or his/her meal tray picked up now, or he/she will throw personal belongings at times such as throwing his/her coloring papers at staff and then throwing them on the floor. The resident will come back and apologize for his/her behavior;-Able to make needs know and knows when he/she has an accident and needs staff to come;-Enjoys comic books and superheroes coloring pages and likes to watch game shows;-Up ad lib (on own) around the unit and does not make attempts to seek exiting unit.During an interview on 02/06/26, at 2:20 P.M., Nurse Aide (NA) B said the following:-He/she was in the business office with the resident while on a call with Social Security;-When the call ended, he/she and the Business Office Manager (BOM) tried to get the resident to go back to the unit, but the resident refused;-The BOM had been printing out pictures of [NAME] and the more you give the resident, the more he/she wants;-The resident had a temper tantrum and he/she escalated in the business office;-The resident got more upset and angry but this was not at the point, he/she restrained him/her;-Outside the business office, the resident began swinging his/her arms hitting him/her several time on his/her head and at that point, my training in behavioral health kicked in and took my arms, wrapped them around the resident from his/her back underneath the arms, like tucked them behind his/her mid-back and restrained him/her so he/she could not hit him/her. It upset the resident and he/she began crying;-NA B wanted to keep him/her and everyone else safe;-The BOM did not tell him/her to let the resident go and was beside him/her all the way to the unit;-He/she did not the resident and in the unit, he/she released the resident;-The DON called him/her to his/her office and was told not to do that and was not written up for this.During an interview on 02/06/26, at 1:57 P.M., Certified Nurse Aide (CNA) E said the following:-He/she witnessed the incident with the resident and NA B last week when he/she was in the dining room;-They should have never taken the resident out of the locked unit;-He/she observed NA B yell, Yes, you are! and NA B got behind the resident, put his/her arms behind his/her back like being arrested and it raised up the resident's shoulders;-The resident cried as he/she walked with his/her hands held up behind him/her behind his/her back like being arrested;-The BOM walked beside them and he/she saw the way NA B did this to the resident;-The BOM did try to calm the resident down but it was not appropriate for staff to touch and or restrain him/her;-He/she reported this incident to the DON about NA B and the resident.Review of the facility records showed the facility did not provide a written investigation of the allegation of abuse/restraint. During interviews on 02/06/26, at 12:30 P.M., and 02/09/26, at 12:00 P.M., the DON said the following:-The incident with Resident #2 and NA B happened sometime last week;-No investigation was completed regarding the allegation;-He and LPN F ruled out abuse and neglect on their own.During interviews on 02/06/26, at 11:35 A.M., and on 02/10/26, at 6:25 P.M., the administrator said the following:-An employee, NA B, had inappropriate behavior and the DON talked to him/her;-For abuse/neglect, staff are to report to the DON and he should have looked into it;-Abuse and neglect policy includes information about restraints;-She would have expected the DON to do a written investigation;-It is the DON's or her responsibility to determine if it is an abuse situation. MO 2735227

Based on interview and record review, the facility failed to ensure all residents were able to remain in the facility, unless there was documented cause for transfer and proper discharge notice given, when the facility failed to allow one resident (Resident #3) to return to the facility from a hospitalization without re-evaluation by staff or written discharge notice. The facility census was 76. Review of the facility policy titled Discharge/Transfer of a Resident, undated, showed the following:-The purpose was to provide a safe departure from the facility and to provide sufficient information for aftercare of the resident;-Staff should explain discharge guidelines and reason to resident and give a copy of the Transfer and Discharge Notice as required;-The attending physician is required to write a discharge order;-Ask physician if medications are to be sent to the resident;-Complete a discharge summary and post discharge plan of care that includes a list of medications with instructions and instructions for post discharge care;-Have the resident/responsible party sign discharge summary and post discharge care form. Give a copy of the form to the resident/representative and place signed form in the record;-Notify business office and administration of discharge.1. Review of Resident #1's face sheet (document that gives resident's information at a quick glance) showed the following:-admission date of 02/12/25;-discharge date of 03/04/26;-Diagnoses included congestive heart failure (CHF - impaired heart function), diabetes mellitus (DM - metabolic disease), morbid obesity, and high blood pressure. Review of the resident's care plan, revised 12/01/25, showed the following: -Resident planned to remain in the skilled nursing facility and had no plans to discharge at this time;-Resident and family do not want to be asked about returning to the community on all assessments.-Staff did not update the care plan to show a change in the resident's desire or need to discharge from the facility.Review of the resident's nursing progress note dated 02/19/26, at 7:12 A.M., showed the resident complained about not being able to breathe and had a deep moist cough. Resident passed out briefly. Resident agreed to go to the emergency room. Emergency Medical Services (EMS) contacted and advised of resident's size and need for extra help. Resident left for the emergency room at 7:10 A.M. (Staff did not document providing the resident with a bed hold, transfer notice, or discharge notice.)Review of the resident's nursing progress note dated 02/19/26, at 5:25 P.M., showed the nurse contacted the emergency room and was advised the resident was admitted . The hospital was unable to advise on the length of stay. (Staff did not document regarding a discharge or inability to take the resident back.)Review of the resident's hospital progress note, dated 02/23/26, showed the resident was admitted to the hospital from a skilled nursing facility for evaluation of shortness of breath and episodes of syncope (fainting). He/she had been admitted to the hospital from the emergency room on [DATE]. (Staff did not document regarding a discharge or inability to take the resident back.)Review of a fax to the facility from the hospital social worker, dated 02/23/26, showed an update on resident condition and a note that said, Are you planning to accept patient back at discharge?During an interview on 03/05/26, at 9:30 A.M., the Hospital Social Worker said the following: -The resident had been transferred to their facility from the original hospital the resident was sent to;-The hospital contacted the facility to let them know the resident was ready to return to the facility;-The facility said they would not take the resident back;-The facility did not give a written discharge notice. Review of the resident's medical record showed staff did not document the resident returned to the facility, an evaluation of the resident in the hospital for return, written notice of discharge, or written documentation supporting the facility was not able to care of the resident. Review of the resident's February 2026 Physician Order Sheet (POS) showed staff did not document a discharge order received.During an interview on 04/16/26, at 2:10 P.M., Licensed Practical Nurse (LPN) C said the following: -A resident discharge required a physician order;-The order to discharge is given to the Social Worker to schedule equipment rental and a follow up physician appointment;-A resident will receive a copy of medication orders, pharmacy recapitulation, and a discharge summary note;-The resident went to the hospital due to a change in condition and never came back. During interviews on 04/15/26, at 12:40 P.M., and on 04/16/26, at 4:29 P.M., the Director of Nursing (DON) said the following: -The resident could not come back to the facility due to resident weight being over 600 pounds;-He/she reported the facility did not have the resources to care for the resident;-The resident had gained over 100 pounds since admission to the facility;-It took four to five staff to turn him/her;-The hospital called the Administrator and he/she explained the facility did not have the equipment to care for the resident. During an interview on 04/16/26, at 4:30 P.M., the Social Worker said the following: -He/she was not at the facility when the resident was sent to the hospital;-He/she was unaware the resident was not returning to the facility;-The DON informed him/her the resident would not be returning to the facility;-The resident was discharged due to the facility was unable to adequately care for him/her;-He/she tried to plan discharges ahead of time. He/she would have a discussion with the resident about home medical equipment, home health, and a follow up physician appointment;'-He/she contacted numerous bariatric facilities to try to find the resident placement, but was unsuccessful. During an interview on 04/16/26, at 5:40 P.M., the Administrator said the facility was unable to meet the needs of the resident due to gaining an excessive amount of weight. He/she had asked the social worker to look for another placement for the resident. Complaint #2795069

Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to complete timely and complete skin assessments, failed to document accurate wound assessments, failed to obtain and update orders timely, failed to follow physician orders, failed to provide treatment as ordered, and failed to care plan wounds for two residents (Resident # 1 and # 9) of three sampled residents, with a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). The facility census was 77.x Review of the facility policy titled Wound Care and Treatment, undated, showed the following:-There must be a specific order for the treatment;-Documentation of the treatment should be done immediately after the treatment;-Staff should conduct on going skin assessments with weekly documentation of status;-The care plan should reflect the current status of the wound and appropriate goals and approaches;-The quality assurance nurse should be consulted when the following exist:-Multiple stage 2 wounds (partial thickness loss of the skin with exposed dermis, appearing as a shallow, open ulcer with a red-pink wound bed or an intact or ruptured fluid filled blister);-Stage 3 wound (full thickness tissue loss where subcutaneous fat is visible, but muscle, tendon, or bone is not exposed) or greater;-No improvement in existing wounds following two to three weeks plan of care. Review of the facility policy titled Charting and Documentation, undated, showed the following:-The purpose of the guidelines is to provide a complete account of the resident's care., treatment, response to care, signs, symptoms, as well as the resident's progress; provide guidance to the physician in prescribing appropriate medications and treatments; provide the facility with a tool for measuring the quality of care provided to the resident; provide nursing services personnel with a record of the physical and mental status of each resident; assistance in the plan of care for each resident; provide the elements of quality medical nursing care; provide a legal record that protects the resident, physician, nurse, and the facility; and provide an information source for resident changes;-Chart all pertinent changes in the resident's condition, reaction to treatments, medications, as well as routine observations;-Be concise, accurate, and complete;-Document only the facts and chart as often as necessary and as the need arises;-Document daily treatments and vital signs;-Lab work documentation should include date and time the specimens were obtained;name of the person; date and time specimens were forwarded to the lab; date and time the results were obtained; and date and time the physician was notified of the lab results;-Refusal of treatment documentation should include date and time treatment was attempted; treatment attempted; resident's response and reason for the refusal; name of person attempting to administer treatment; and documentation that the resident was informed of the purpose of the treatment and the consequences of not receiving the care;-Document each time the resident refuses treatment, the resident condition, and any adverse effects due to the refusal; date and time the physician was notified as well as the physician response;-Skin lesion documentation should include specific location of the skin problem and number, size, degree, and measurement of pressure sores; any changes in the resident's condition or response to treatment; date of occurrence of a skin problem and date the problem was solved; progress, deterioration, or the development of new problems; use of special creams, lotions, medications, or devices; and the cause of any wound; -Miscellaneous documentation should include any time the physician or family is called as well as their response and each time a physician visits a resident. 1. Review of Resident #1's face sheet (document that gives resident's information at a quick glance) showed the following:-admission date of 10/16/25;-Diagnoses included high blood pressure, depression, and generalized edema (widespread fluid accumulation in the body's tissues). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/22/26, showed the following:-Cognitively intact;-Resident had impairment to one side of the upper and lower extremities;-Required substantial assistance with dressing, showers, and toileting;-Resident at risk for pressure ulcer development;-Resident did not have any unhealed pressure ulcers;-Resident dependent on staff for bed mobility, and transfers. Review of the resident's care plan, revised 01/27/26, showed the following:-Resident had fragile skin related to age and medications;-Staff will monitor skin during cares and anytime skin is exposed;-Skin assessments to be done weekly by the nurse;-Nurse will monitor for signs and symptoms of infection and report to the physician as needed;-Resident required one to two staff assistance with activities of daily living (ADL – fundamental self-care tasks such as hygiene, dressing, eating, toileting, and mobility) and cares.(Staff did not care plan related to wounds or wound care.) Review of the resident's admission assessment, dated 10/16/25, showed the resident had areas of dark hard eschar (thick, dry, black or brown layer of dead tissue that forms over severe pressure ulcers) to the left heel. Review of the resident's initial wound assessment, dated 10/16/25, showed the following:-Resident had black, hard eschar on the left heel and a reddened buttock that was present on admission;-No drainage or odor noted;-Interventions to include pressure reducing device for bed, turning and repositioning, and heel protectors; -No change in treatment;-Physician notified. Review of the resident's nursing progress note, dated 10/17/25, showed the resident admitted on [DATE] with dark hard eschar on the left heel measuring 2 centimeters (cm) x 2 cm. Review of the resident's October 2025 Physician Order Sheet (POS) showed an order, dated 10/16/25, for Desitin (barrier cream) paste, apply twice daily and as needed to buttock and coccyx (tail bone) for a diagnosis of pain. (Staff did not document orders for treatment of identified area on the resident's heel.) Review of the resident's weekly skin assessment, dated 10/23/25, showed skin was intact with no issues. The right and left foot had no issues and treatment marked as not applicable. Review of the resident's nurse practitioner visit note, dated 10/23/25, showed the following:-Resident had a left heel wound with dry eschar without redness around site;-Right posterior thigh had a superficial linear open area with no drainage and possibly from the resident's brief;-See nursing wound documentation for measurements;-Diagnosis for this visit was pressure injury of the left heel, unstageable (full thickness skin loss where the base is completely covered by eschar);-Plan is to apply barrier paste to open area on the right posterior thigh three times daily and as needed, outside facility wound care consult, and heel protectors on always in bed. Review of the resident's medical record showed staff did not document a weekly skin assessment documented for 10/30/25. Review of resident's medical record showed staff did not document additional wound assessments for October 2025. Review of the resident's October 2025 nursing progress notes showed staff did not complete additional documentation related to the resident's left heel. Review of the resident's nursing progress note, dated 11/04/25, showed the resident said staff were not turning him/her and getting him/her off his/her bottom due to the sores on the bottom. He/she said that the staff are not changing his/her bandages on the wound like they are supposed to be doing. Review of the resident's medical record showed staff did not document a weekly skin assessment for 11/06/25. Review of the resident's nurse practitioner visit note, dated 11/06/25, showed the following:-Resident had a left heel wound with dry eschar without redness around site;-Coccyx did not have an open area;-Left buttock had an open superficial wound with a pink, moist wound bed and no sign of infection;-See nursing wound documentation for measurements;-Plan for wound care company to see resident for buttock wounds, low air loss mattress, and clean left buttock and coccyx wound with wound cleanser and cover with foam dressing daily. Review of the resident's nursing progress note, dated 11/07/25, showed the nurse practitioner visited resident on 11/06/25 and emailed orders for a low air loss bed, outside facility wound care consult, and treatment order for left buttock and coccyx wound. Review of the resident November 2025 POS showed the following:-An order, dated 10/16/25, for Desitin paste, apply twice daily and as needed to buttock and coccyx for a diagnosis of pain;-An order, dated 11/07/25, for the left buttock and coccyx wound to be cleansed with wound cleanser and covered with foam dressing daily;-An order, dated 11/07/25, for a low air loss bed;-An order, dated 11/07/25, for wound care consult to evaluate and treat buttock wounds. Review of the resident's November 2025 TAR showed the following:-An order, dated 11/07/25, for the left buttock & coccyx wound to be cleansed with wound cleanser daily and cover with foam dressing completed as ordered except on the following dates:-On 11/09/25, staff noted administered due to no time;-On 11/23/25, staff noted not administered due to not done on this shift. Review of a nursing progress note dated 11/10/25, showed the resident's low air low mattress came arrived. Review of the resident's weekly skin assessment, dated 11/13/25, showed skin was intact with no issues. The right and left foot had no issues and treatment marked as not applicable. Review of the resident's monthly resident summary, dated 11/15/25, showed general skin condition was good. (The summary did not mention wound to coccyx/left buttocks or left heel.) Review of the resident's weekly skin assessment, dated 11/20/25, showed skin was intact with no issues. The right and left foot had no issues and treatment marked as not applicable. Review of the resident's weekly skin assessment, dated 11/27/25, showed resident had an existing non-foot skin issue. The right and left foot had no issues. Treatment in place and effective. (Staff did not document related to the location or details of an existing skin issues.) Review of resident's medical record showed staff did not document wound assessments for November 2025. Review the resident's November 2025 nursing progress notes showed staff did not document further progress notes related to the left heel or coccyx/left buttock wound. Review of the resident's wound care company note, dated 12/02/25, showed the following:-Wound to the coccyx had improved and was measuring smaller with less drainage. Will continue same treatment of calcium alginate (highly absorbent dressing), border foam, and change every other day. (The facility did not have an order for wound care to the coccyx indicating calcium alginate was being used.); -The coccyx wound measured 8.9 cm by 8.3 cm. Wound indicated to be a stage 2 pressure ulcer. Wound care orders indicated as cleanse with hypochlorous acid (a cleanser that is used in wound care to fight infections), irrigate and scrub the wound bed, protect peri wound area with skin protectant, apply calcium alginate to wound base, and cover with a bordered foam dressing every other day and as needed.(The wound care company did not address the resident's left heel wound.) Review of the resident's December 2025 showed staff did not document additional nursing progress related to the left heel or coccyx/left buttock wound. Review of the resident's wound care company note, dated 12/09/25, showed the following:-Wound to coccyx improved and skin was now intact;-Staff should continue using foam dressing as a protectant;-Wound resolved. Review of the resident's nursing readmission note, dated 12/20/25, showed the resident had a left heel pressure area covered by eschar. Review of the resident's POS showed the following orders for December 2025:-An order, dated 12/30/25, to cleanse the left heel with wound cleanser and pat dry, and apply Thera honey (wound dressing), and dressing every other day;-An order, dated 12/30/25, to cleanse the right heel with wound cleanser and pat dry. Apply skin prep to heel and cover with dressing every 3 days. Review of the resident's December 2025 TAR showed on 12/30/25 and 12/31/25, staff did not complete the ordered treatment to left and right heel on 12/30/25 or 12/31/25. Review of the resident's January 2026 POS showed the following;-An order dated, 11/07/25, for the left buttock and coccyx wound, cleanse with wound cleanser, and cover with foam dressing daily. The order was discontinued on 01/23/26;-An order, dated 12/30/25, to cleanse the left heel with wound cleanser and pat dry. Apply Thera honey and dressing every other day;-An order, dated 12/30/25, to cleanse the right heel with wound cleanser and pat dry. Apply skin prep to heel and cover with dressing every 3 days. The order was discontinued on 01/26/26. Review of a dietician note, dated 01/12/26, showed staff reported the resident had a pressure ulcer on the left heel. Review of the resident's progress notes, dated January 2026, showed staff did not document regarding left heel wound. Review of the resident's nursing progress note, dated 02/03/26, showed the wound care company saw resident and completed wound treatments. Wound care company nurse reported left heel debrided (remove damaged tissue) and to continue current treatment. He/she also drained the large blood blister from foot. Treatment to right ball of foot was to cleanse with wound cleanser, pat dry, and apply Thera honey and dressing every other day. Review of the resident's wound care company progress note, dated 02/03/26, showed the following:-Initial visit for wounds on both feet;-Nurse said wound to left heel had been there for several weeks and was stable eschar;-Left foot pressure wound unstageable and measured 3 cm by 3.4 cm by 0.1 cm;-Treatment orders indicated to cleanse the left foot with hypochlorous acid and protect the peri wound area with skin prep. Place calcium alginate in the wound bed and fill wound with Medi honey. Cover with a bordered foam dressing every other day and apply a Tubi grip (compression stocking) to left extremity;-Wound to right sole appeared over the weekend;-Right foot wound appeared to be a blood blister that had opened and measured 4.1 cm by 4.2 cm by 0.2 cm;-Right foot wound was a stage 3 pressure ulcer;-Treatment orders indicated as cleanse with hypochlorous acid and protect the peri wound area with skin prep. Place calcium alginate in the wound bed and cover with a bordered foam dressing every other day and apply Tubi grip to right extremity. Review of a February 2026 POS showed the following: -An order dated 12/30/25, to cleanse the left heel with wound cleanser and pat dry. Apply Thera honey and dressing every other day (order not updated to current order 02/03/26 to include calcium alginate and Tubi grip);-An order dated 02/03/26, to cleanse the right ball of the foot with wound cleanser and pat dry. Apply Thera honey and dressing every other day. (Order did not include skin protectant or Tubi grips and Medi honey not indicated in new order) Review of the resident's nursing progress note, dated 02/04/26, showed the wound care company at facility and debrided the left heel. Right foot at ball had a large blood blister which was drained. Nurse completed wound care today and the measurements for the left heel were 3 cm by 3 cm by 0.5 cm with no signs of infection or drainage. Right ball of foot measured 5 cm by 3 cm with no depth, drainage, or sign of infection noted. During an interview on 02/05/26, at 10:36 A.M. Licensed Practical Nurse (LPN) J said the following:-The resident had a wound on the resident's right foot that measured 5 cm by 3 cm wide which had been a blood blister;-On the resident's left heel, wound care plus debrided and this measured 3 cm by 3cm by 0.5 cm;-They did a treatment every other day on the left heel;-The resident was on a bariatric bed (for larger, heavier residents) with air loss mattress;-They try to to keep an eye on these wounds;-They do weekly skin assessments. During interview on 02/09/26, at 11:10 A.M., Nurse Aide (NA) B said the following:-He/she went to assist LPN J to do wound dressing changes on the resident;-On the ball of the resident's left heel, the date on the bandage was 01/13/26, 13 days before that day;-The wound care company came in soon after to see the resident. During interview on 02/06/26, at 1:25 P.M., the Director of Nursing (DON) said the following:-The physician sees the resident and his/her notes were sent to them and they scan them into the electronic medical record. The wound care company came weekly and dressing changes were done as ordered and prescribed by the charge nurses;-They do keep soft boots on the resident's feet and sometimes the resident kicks them off;-He was not aware of a problem with wound care supplies. During an interview on 02/10/26, at 12:38 P.M., the wound care company nurse practitioner said the following:-He/she started seeing the resident last week for a left heel wound and a right sole of the foot blister;-The staff told her the left heel blister had been there for several months;-The staff were applying skin protectant to the left heel which was covered in dry eschar;-The blister to the right sole of the foot was approximately 4 cm by 4 cm;-Both wounds were debrided on the initial visit. 2. Review of Resident #9's face sheet showed the following:-admission date of 09/11/25;-Diagnoses included pressure induced deep tissue damage of sacral region (localized injury to skin and underlying soft tissue caused by prolonged pressure over tailbone), diabetes mellitus (metabolic disorder characterized by high blood sugar due to the body's inability to produce insulin), and high blood pressure. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Resident had one stage 2 pressure ulcers, 3 stage 3 pressure ulcers, and one unstageable pressure ulcer;-Resident dependent with showers, toileting, and transfers Review of the resident's care plan, revised 09/25/25, showed the following:-Resident had thin and fragile kin due to age and medications;-Resident had pain related to wounds;-Resident dependent on staff for activities of daily living (ADL). Review of the resident's current POS showed the following orders:-An order, dated 09/11/25, to cleanse buttock wound with wound cleanser and apply Santyl to wound bed, apply wet dry dressing, and secure with tape twice daily;-An order, dated 09/22/25, for wound care company to evaluate and treat buttocks wound, left great toe, and right heel ulcer;-An order, dated 09/22/25, to clean left heel ulcer with wound wash and skin prep daily;-An order, dated 09/23/25, for magnetic resonance imaging (MRI) of sacrum/coccyx to rule out osteomyelitis (infection of the bone);-An order, dated 11/07/25, for a low air loss mattress;-An order, dated 12/06/25, to cleanse the left lower extremity with wound cleanser and apply Santyl to wound bed, apply wet to dry dressing, and secure with tape, change twice daily. Review of the resident's wound care company progress note, dated 12/02/25, showed the following:-Wound to sacrum improved this week measuring smaller with less drainage;-Sacrum wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad and change daily;-Sacrum was a stage 3 pressure ulcer that measured 7.6 cm by 4.1 cm with a large amount of serosanguineous (thin, watery pink to light red fluid) drainage;-Left heel wound deteriorated and measured larger with nonviable tissue present;-Incorrect dressing on left heel upon arrival, resident had calcium alginate and Tegaderm on;-Left heel was an unstageable deep tissue injury and measured 1.9 cm by 1.5 cm with moderate serosanguinous drainage;-Left heel wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad and change daily;-Left calf was a stage 3 pressure wound and measured 5 cm by 2.1 cm by 0.2 cm with large amount of serosanguinous drainage;-Left calf wound had improved from previous week;-Left calf wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad and change daily;-Right foot had incorrect dressing of calcium alginate upon arrival;-Right foot was a stage 3 pressure ulcer and measured 2.1 cm by 2.7 cm by 0.9 cm and had moderate serosanguineous drainage;-Right foot wound had deteriorated since last week visit;-Right foot wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue and cover with a bordered gauze dressing and change daily. Review of the resident's December POS showed staff did not update the physician orders to reflect the wound care orders from wound care company. Review of the resident's weekly skin assessment, dated 12/04/25, showed the resident had a left foot/ankle issue with treatment in place. Resident had treatment to the buttocks and had an area to lower extremity. Staff noted treatment effective Review of a wound care company progress note dated 12/09/25 showed the following:-All wounds had incorrect treatment;-Facility was using a wet to dry dressing instead of calcium alginate or hydrofera blue;-Wound to sacrum had deteriorated this week measuring larger;-Sacrum wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad and change daily;-Sacrum was a stage 3 pressure ulcer that measured 8 cm by 4.6 cm by 0.8 cm with a large amount of serosanguineous drainage;-Left heel wound improved from previous visit-Left heel was an unstageable deep tissue injury and measured 1.2 cm by 1.3 cm with moderate serosanguinous drainage;-Left heel wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad and change daily;-Left calf wound improved from previous visit;-Left calf wound is stage 3 pressure ulcer that measured 5.4 cm by 1.7 cm by 0.7 cm with large amount of serosanguinous drainage;-Left calf wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad and change daily;-Right foot was a stage 3 pressure ulcer and measured 1.8 cm by 1.6 cm by 0.6 cm and had moderate serosanguineous drainage;-Right foot wound had improved since last week visit;-Right foot wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a bordered gauze dressing and change daily. Review of the resident's December POS showed staff did not update the physician orders to reflect the wound care orders from wound care company. Review showed the facility did not a skin assessment for 12/11/25. Review the resident's December 2025 TAR showed the following:-On 12/14/25, staff did not document completion of the ordered treatment to the buttock, the left heel, and lower left extremity; -On 12/12/25, staff document treatment to lower left extremity not completed due to running out of time. Review of the resident's nursing progress note, dated 12/14/25, showed the resident had a couple pressure areas on the left outer side of his/her foot that were not open with boot in place. Wound care company in this day and did wound care. Review of the resident's nursing progress note, dated 12/15/25, showed the resident had a couple pressure areas on the left outer side of his/her foot that were not open with boot in place. Wound care company in this day and did wound care. Review of the resident's wound care company progress note, dated 12/16/25, showed the following:-Wound to sacrum had improved this week;-Sacrum wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad and change daily;-Sacrum was a stage 3 pressure ulcer that measured 7.6 cm by 3.7 cm by 0.9 cm with a large amount of serosanguineous drainage;-Left heel wound improved from previous visit-Left heel was an unstageable deep tissue injury and measured 1.7 cm by 1.1 cm with moderate serosanguinous drainage;-Left heel wound care will change to cleanse wound with hypochlorous acid, apply hydrogel and then apply hydrofera blue,and cover with a super absorbent pad, wrap with kerlix and change daily;-Left calf wound improved from previous visit;-Left calf wound is stage 3 pressure ulcer that measured 6.1 cm by 2 cm by 0.3 cm with large amount of serosanguinous drainage;-Left calf wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad and change daily;-Right foot was a stage 3 pressure ulcer and measured 1.6 cm by 1.8 cm and had moderate serosanguineous drainage;-Right foot wound had deteriorated since last week visit;-Right foot wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a bordered gauze dressing and change daily; Review of the resident's December 2025 POS showed staff did not update the orders to reflect the orders from the wound care company orders. Review of the resident's nursing progress note, dated 12/17/25, showed the resident had a couple pressure areas on the left outer side of his/her foot that were not open with boot in place. Review of the resident's weekly skin assessment, dated 12/18/25, showed resident had a right foot/ankle issue with treatment in place and an existing non-foot skin issue. Review of the resident's wound care company progress note, dated 12/23/25, showed the following:-Wound to sacrum had improved this week;-Sacrum wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad and change daily;-Sacrum was a stage 3 pressure ulcer that measured 7.2 cm by 3.7 cm by 1.2 cm with a large amount of serosanguineous drainage;-Left heel wound improved from previous visit-Left heel was an unstageable deep tissue injury and measured 1.1 cm by 0.9 cm with moderate serosanguinous drainage;-Left heel wound care will continue to cleanse wound with hypochlorous acid, apply hydrogel and then apply hydrofera blue, and cover with a super absorbent pad, wrap with kerlix and change daily;-Left calf wound improved from previous visit;-Left calf wound is stage 3 pressure ulcer that measured 3.1 cm by 2.2 cm with large amount of serosanguinous drainage;-Left calf wound care will change treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad, wrap with kerlix, and change daily;-Right foot was a stage 3 pressure ulcer and measured 1.8 cm by 1.9 cm and had moderate serosanguineous drainage;-Right foot wound had deteriorated since last week visit;-Right foot wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a bordered gauze dressing and change daily. Review of the resident's weekly skin assessment, dated 12/25/25, showed resident had an existing non foot skin issue and no issues with right and left feet or ankles. Treatment in place and effective. Review of the resident's wound care company progress note, dated 12/30/25, showed the following:-Wound to sacrum had improved this week;-Sacrum wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad and change daily;-Sacrum was a stage 3 pressure ulcer that measured 5.6 cm by 4.5 cm by 0.8 cm with a large amount of serosanguineous drainage;-Left heel wound improved from previous visit-Left heel was an unstageable deep tissue injury and measured 0.9 cm by 0.8 cm with moderate serosanguinous drainage;-Left heel wound care will continue to cleanse wound with hypochlorous acid, apply hydrogel and then apply hydrofera blue, and cover with a super absorbent pad, wrap with kerlix and change daily;-Left calf wound improved from previous visit;-Left calf wound is stage 3 pressure ulcer that measured 1.6 cm by 1.0 cm with large amount of serosanguinous drainage;-Left calf wound care will change treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad, wrap with kerlix, and change daily;-Right foot was a stage 3 pressure ulcer and measured 2.0 cm by 1.3 cm and had moderate serosanguineous drainage;-Right foot wound had deteriorated since last week visit;-Right foot wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a bordered gauze dressing and change daily. Review of the resident's December 2025 notes showed staff did not document additional information regarding the resident's wounds. Review of the resident's January 2026 POS showed the following:-An order, dated 09/11/25, to cleanse buttock wound with wound cleanser and apply Santyl to wound bed, apply wet dry dressing, and secure with tape twice daily;-An order, dated 01/31/26, to cleanse the buttock wound with wound cleanser and apply moistened hydrofera blue (foam dressing infused with medication) to wound bed, apply wet to dry dressing, and secure with tape, change twice daily;-An order, dated 12/06/25, to cleanse the left lower extremity with wound cleanser and apply Santyl to wound bed, apply wet to dry dressing and secure with tape, change twice daily;-An order, dated 01/31/26, to cleanse the left lower extremity wound with wound cleanser and apply moistened hydrofera blue to wound bed, apply wet to dry dressing and secure with tape, change twice daily;-An order, dated 02/06/26, to cleanse the right lateral foot with wound cleanser and apply moistened hydrofera blue to wound bed, apply wet to dry dressing and secure with tape, change twice daily. (The POS did not reflect the most recent wound company treatment orders.) Review of the resident's wound care company progress note, dated 01/06/26,showed the following:-Wound to sacrum had improved this week;-Sacrum wound care will continue same treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad and change daily;-Sacrum was a stage 3 pressure ulcer that measured 2.0 cm by 6.2 cm by 1.0 cm with a large amount of serosanguineous drainage;-Left heel wound improved from previous visit-Left heel was an unstageable deep tissue injury and measured 0.4 cm by 0.4 cm with moderate serosanguinous drainage;-Left heel wound care will continue to cleanse wound with hypochlorous acid, apply hydrogel and then apply hydrofera blue, and cover with a super absorbent pad, wrap with kerlix and change daily;-Left calf wound improved from previous visit;-Left calf wound is stage 3 pressure ulcer that measured 6.1 cm by 1.9 cm with large amount of serosanguinous drainage;-Left calf wound care will continue treatment to cleanse wound with hypochlorous acid, apply hydrofera blue, and cover with a super absorbent pad, wrap with kerlix, and change daily;-Right foot was a stage 3 pressure ulcer and measured 1.3 cm by 1.6 cm and had moderate serosanguineous drainage;-Right foot wound had deteriorated since last week visit;-Right foot wound care will continue same treat

Based on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of one resident (Resident #4), when staff failed to notify the nurse and physician of a pattern of missed doses of medications in the morning, when staff failed to try to reapproach the resident for medication administration when the resident had refused, and when staff failed to administer medication per ordered parameters. The facility census was 70.Review of the facility policy titled Medication Administration, undated, showed the following:-Medications are given to benefit the resident's health as ordered by a physician;-Staff should administer medications and record the medication was given on the medication sheet;-Staff should document a resident's refusal of medication and note the date, time, and what occurred.(The policy did not address steps to take when a resident refused or missed a medication.) 1. Review of Resident #4's face sheet showed the following:-admission date of 10/06/21;-Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that cause inflamed airways and airflow blockage), high blood pressure, and dementia (loss of memory, language problem solving and other thinking abilities severe enough to interfere with daily life). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 05/29/26, showed the following:-Moderate cognitive impairment;-Resident received a diuretic (a substance that promotes diuresis by causing the kidneys to expel excess salt and water through urine) and anticoagulant (blood thinner) medication. Review of the resident's May 2026 Physician's Orders (POS) showed the following orders:-An order, dated 05/17/23, for Eliquis (anticoagulant) 5 milligram (mg) tablet, give one tablet twice daily;-An order, dated 02/19/26, for furosemide (diuretic) 40 mg tablet, give one tablet daily. Staff should hold if systolic blood pressure (SBP) is less than 110 millimeters of Mercury (mm/Hg);-An order, dated 05/17/22, for metoprolol tartrate (blood pressure medication) 25 mg tablet, give one half tablet twice daily. Staff should hold medication if SBP less than 120 mm/Hg. Review of the resident's May 2026 Medication Administration Record (MAR) showed the following:-On 05/02/26, at 8:00 A.M., staff noted Eliquis not administered due to resident refusal;-On 05/02/26, at 8:00 A.M., staff noted furosemide not administered due to resident refusal;-On 05/02/26, at 8:00 A.M., staff noted metoprolol tartrate not administered due to resident refusal. Review of the resident's progress notes showed staff did not document notification of the nurse or physician of the refused medication on 05/02/26. Review of the resident's May 2026 MAR showed the following:-On 05/03/26, at 8:00 A.M., staff noted Eliquis not administered due to resident refusal;-On 05/03/26, at 8:00 A.M., staff noted furosemide not administered due to resident refusal;-On 05/03/26, at 8:00 A.M., staff noted metoprolol tartrate not administered due to resident refusal. Review of the resident's progress notes showed staff did not document notification to the nurse or physician of the refused medication on 05/03/26. Review of the resident's May 2026 MAR showed the following:-On 05/04/26, at 8:00 A.M., staff noted Eliquis not administered due to resident refusal;-On 05/04/26, at 8:00 A.M., staff noted furosemide not administered due to resident refusal;-On 05/04/26, at 8:00 A.M., staff noted metoprolol tartrate not administered due to resident refusal. Review of the resident's progress notes showed staff did not document notification to the nurse or physician of the refused medication on 05/04/26. Review of the resident's May 2026 MAR showed the following:-On 05/09/26, at 8:00 A.M., staff noted furosemide not administered due to medication on hold. Staff noted SBP of 142 mm/Hg/(Orders did not indicate to hold medication for this SBP reading);-On 05/09/26, at 8:00 A.M., staff noted metoprolol tartrate not administered due to medication on hold. Staff noted SBP of 142 mm/Hg (Orders did not indicate to hold medication for this SBP reading). Review of the resident's progress notes showed staff did not document notification to the nurse or physician of the refused medication on 05/09/26. Review of the resident's May 2026 MAR showed the following:-On 05/13/26, at 8:00 A.M. and 8:00 P.M., staff noted Eliquis not administered due to resident refusal;-On 05/13/26, at 8:00 A.M., staff noted furosemide not administered due to resident refusal;-On 05/13/26, at 8:00 A.M. and at 8:00 P.M., staff noted metoprolol tartrate not administered due to resident refusal. Review of the resident's progress notes showed staff did not document notification to the nurse or physician of the refused medication on 05/13/26. Review of the resident's May 2026 MAR showed the following:-On 05/15/26, at 8:00 A.M., staff noted Eliquis not administered due to resident refusal;-On 05/15/26, at 8:00 A.M., staff noted furosemide not administered due to resident refusal;-On 05/15/26, at 8:00 A.M., staff noted metoprolol tartrate not administered due to resident refusal. Review of the resident's progress notes showed staff did not document notification to the nurse or physician of the refused medication on 05/15/26. Review of the resident's May 2026 MAR showed the following:-On 05/23/26, at 8:00 A.M., staff noted Eliquis not administered due to resident asleep;-On 05/23/26, at 8:00 A.M., staff noted furosemide not administered due to resident asleep;-On 05/23/26, at 8:00 A.M., staff noted metoprolol tartrate not administered due to resident asleep. Review of the resident's progress notes showed staff did not document notification to the nurse or physician of the medication not administered or any reattempts to administer on 05/23/26. Review of the resident's May 2026 MAR showed the following:-On 05/25/26, at 8:00 A.M., staff noted Eliquis not administered due to resident in bed sleeping and would not wake;-On 05/25/26, at 8:00 A.M., staff noted furosemide not administered due to resident in bed sleeping and would not wake;-On 05/25/26, at 8:00 A.M., staff noted metoprolol tartrate not administered due to resident in bed sleeping and would not wake. Review of the resident's progress notes showed staff did not document notification to the nurse or physician of the medication not administered or any reattempts to administer the medication on 05/25/26. Review of the resident's May 2026 MAR showed the following:-On 05/27/26, at 8:00 A.M., staff noted Eliquis not administered due to resident refusal;-On 05/27/26, at 8:00 A.M., staff noted furosemide not administered due to resident refusal;-On 05/27/26, at 8:00 A.M., staff noted metoprolol tartrate not administered due to resident refusal. Review of the resident's progress notes showed staff did not document notification to the nurse or physician of the refused medication on 05/27/26. Review of the resident's May 2026 MAR showed the following:-On 05/28/26, at 8:00 A.M., staff noted Eliquis not administered due to resident in bed sleeping and did not want to get up this morning;-On 05/28/26, at 8:00 A.M., staff noted furosemide not administered due to resident in bed sleeping and did not want to get up this morning;-On 05/28/26, at 8:00 A.M., staff noted metoprolol tartrate not administered due to resident in bed sleeping and did not want to get up this morning.; Review of the resident's progress notes showed staff did not document notification to the nurse or physician of the refused medication on 05/28/26. Review of the resident's May 2026 MAR showed the following:-On 05/29/26, at 8:00 A.M., staff noted Eliquis not administered due to resident in bed sleeping and would not wake;-On 05/29/26, at 8:00 A.M., staff noted furosemide not administered due to resident in bed sleeping and would not wake;-On 05/29/26, at 8:00 A.M., staff noted metoprolol tartrate not administered due to resident in bed sleeping and would not wake;-On 05/29/26, at 8:00 P.M., staff noted metoprolol tartrate administered with SBP of 118 mm/Hg. (Order indicated to hold medication with SBP below 120 mm/Hg.) Review of the resident's progress notes showed staff did not document notification to the nurse or physician of the medication not administered, any reattempts to administer, or the reason for administering medication when outside of parameters on 05/29/26. Review of the resident's May 2026 MAR showed the following:-On 05/31/26, at 8:00 A.M., staff noted Eliquis not administered due to resident doesn't want to get up to take;-On 05/31/26, at 8:00 A.M., staff noted furosemide not administered due to resident doesn't want to get up to take;-On 05/31/26, at 8:00 A.M., staff noted metoprolol tartrate not administered due to resident doesn't want to get up to take. Review of the resident's progress notes showed staff did not document notification to the nurse or physician of the medication not administered or any reattempts to administer on 05/31/26. During an interview on 06/04/26, at 2:45 P.M., Certified Medication Technician (CMT) B said the following:-All medications should be administered per physician orders;-The physician should be notified of any missed medication administration. During an interview on 06/05/26, at 11:03 A.M., CMT E said the following:-Medications should be administered per physician orders;-There should be a physician order to hold a medication;-He/she had tried to wake residents when asleep to administer medication multiple times;-He/she would notify the nurse if the resident did not wake up to take medications;-The nurse should notify the physician if a resident refused medication or it was not administered;-Some residents complained about not receiving medications at times. During an interview on 06/05/26, at 11:30 A.M., Licensed Practical Nurse (LPN) C said the following:-All medications should be administered per physician orders;-If a medication is on hold, there will be a specific order in the POS, showing so;-The nurse and physician should be notified of a resident missing medications. During an interview on 06/05/26, at 12:15 P.M., the Director of Nursing (DON) said the following:-All medications were expected to be administered per physician orders. If a medication was not administered, the physician should be notified;-If a medication is on hold, there will be a specific hold order in the POS;-She was not aware the resident's medications had not been administered for extended periods of time;-He/she reviewed the MAR's once a month and had noticed a lot of medications on hold or refused;-The staff should keep trying to administer the medications and then note all refusals and physician notification in progress notes. During an interview on 06/05/26, at 2:15 P.M., the Administrator said the following:-She expected all medications to be administered per physician orders;-She expected the physician and families to be notified if a resident is not receiving their medication. Complaint #2988229 and #3001514

Based on observation, interview, and record review, the facility failed to ensure all residents received specialized rehabilitative services as needed when staff failed to provide a therapy evaluation and therapy services as care planned and ordered for one resident (Resident #4) and when staff failed to document therapy services provided or refused for one resident (Resident #5). The facility census was 76. Review of the facility policy titled Physician Orders, undated, showed the following information:-Physician orders are needed for physical therapy (PT), speech therapy (ST), and occupation therapy (OT) evaluations and therapy; -Therapy orders are to be renewed every 30 days, which may be recorded on the therapy notes.Review showed the facility did not provide a policy regarding providing and documenting physical therapy visits.1. Review of Resident #4's face sheet (brief look at resident information) showed the following:-admission date of 10/17/25;-Diagnoses included repeated falls, muscle weakness, irregular heartbeat, and heart failure.Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 01/23/26, showed the following:-Cognitively intact;-Required substantial to maximum assistance from staff for bathing, dressing, and mobility.Review of the resident's care plan, dated 01/29/26, showed ST/PT/OT may evaluate and treat as needed.Review of the resident's hospital discharge paperwork, dated 04/10/26, showed an order for PT evaluation and treatment.Review of the resident's April 2026 Physician Order Sheet (POS) showed an order, dated 04/11/26, for PT/OT/ST to evaluate and treat.Review of the resident's progress notes, dated 04/11/26 through 04/18/26, showed staff did not document a PT evaluation or the resident participating in PT. Review of the resident's PT Notes, dated 04/10/26 to 04/18/26, showed staff did not document a PT evaluation or PT participation. During an interview on 04/15/26, at 10:22 A.M., the resident said the following:-The facility used to provide him/her with physical therapy;-He/she felt he/she was not strong enough to go home because the facility was not offering him/her PT like they are supposed to.During an interview on 04/16/26, at 3:19 P.M., Certified Nursing Assistant (CNA) D said the following:-The resident had a recent decline. Prior to the resident's hospitalization, he/she was a two-person assist for transfers, but now required a mechanical lift;-He/she believed the resident received therapy services.During an interview on 04/16/26, at 4:00 P.M., the Director of Rehabilitation/Physical Therapist Assistant (DOR/PTA) said he/she was unaware of the resident having an order for physical therapy. During an interview on 04/16/26 at 4:00 P.M., Licensed Practical Nurse (LPN) G said the following:-The resident received therapy services prior to his/her hospitalization;-He/she was unsure if there was a physician order for the resident to receive therapy services or if the resident currently received therapy services.During an interview on 04/16/26, at 4:29 P.M., the Director of Nursing (DON) said the following:-The resident had been in and out of therapy services;-She was unsure if the resident had a current physician order to receive therapy services;-Due to the resident's recent decline, it would be beneficial if the resident received therapy services.2. Review of Resident #5's face sheet showed the following:-admission date of 02/06/26;-Diagnoses included fracture to the upper and lower end of the fibula (slender bone running parallel to the tibia(shinbone) on the outside of the lower leg), cardiomyopathy (a disease of the heart muscle that impairs its ability to pump blood), and obesity.Review of the resident's admission MDS, dated [DATE], showed the following information:-Cognitively intact;-Required partial to moderate assistance from staff for bathing;-Independent for mobility.Review of the resident's February 2026 POS showed an order, dated 02/08/26, for PT evaluation and plan of care. Treatment approaches may include therapeutic exercises, neuromuscular (nerves/muscles) reeducation, gait training, group therapeutic procedures, therapeutic activities, and wheelchair management training 5 times a week for 4 weeks.Review of the residents' physical therapy note, dated 02/08/26, showed an initial assessment completed and indicated the resident would receive physical therapy for decreased dynamic balance and decreased static balance and strength impairments. PT five times a week for four weeks needed to increase lower extremity range of motion and strength, increase independence with gait, functional activity tolerance, coordination, and safety and awareness. Without therapeutic intervention, the resident was at risk for immobility and further decline in function and falls;Review of the resident's care plan, dated 02/09/26, showed staff did not update the care plan to reflect the new PT orders. Review of the residents' physical therapy notes showed the following:-On 02/09/26 to 02/18/26, staff did not document PT services received or refused; -On 02/19/26, staff noted the resident received PT and continued with the initial goals;-On 02/20/26 to 02/22/26, staff did not document PT services received or refused; -On 02/23/26, the resident discharged home.Review of the resident's nurses noted, dated 02/09/26 to 02/22/26, showed staff did not document the resident received any PT services or the any resident refusals of PT services. During an interview on 04/16/26, at 3:19 P.M., CNA D said he/she was unsure if the resident received therapy during his/her stay. During an interview on 04/16/26, at 4:00 P.M., the DOR/PTA said the following:-The resident admitted with an ankle fracture and received PT;-The resident completed his/her authorized therapy benefits and left the facility;-The resident did not have many daily therapy notes possibly due to the filing a Notice of Medicare Non-Coverage (NOMNC - a notice given to residents two days prior to Medicare covered services ending).During an interview on 04/16/26, at 4:00 P.M., LPN G said the following:-He/she was unsure if the resident received therapy services during his/her stay;-The resident refused cares often;-If the resident was supposed to receive therapy and refused, it should have been documented in the PT notes;-He/she was unsure if there was physician order for the resident to receive therapy services.During an interview on 04/16/26, at 4:29 P.M., the DON said she did not believe the resident was compliant with therapy services. 3. During an interview on 04/16/26, at 3:19 P.M., CNA D said the following:-If any resident had an order to receive therapy services, they should be receiving it;-If a resident refused therapy services and/or visits, staff should document in the progress notes; -Typically for residents to receive therapy services, there must be a physician's order, and/or staff can request an evaluation from therapy.During an interview on 04/16/26, at 4:00 P.M., DOR/PTA said the following:-Nursing communicates therapy orders to him/her and the orders can be found in the electronic medical record (EMR);-He/she scheduled the physical therapist to conduct evaluations after orders are received;-He/she checks the EMR every morning for new orders;-Therapy orders were discussed in the morning meetings;-He/she completes a daily therapy note after each visit in the therapy notes;-The physical therapist completes a progress note after every tenth visit.During an interview on 04/16/26 at 4:00 P.M., LPN G said the following:-In order for residents to receive therapy services, the nurses contact the physician for an order, the order is entered into the medical record and then communicated with the therapy department;-If a resident had an order for therapy services, they should be receiving it;-When a resident discharged back to the facility from the hospital, the DON reviewed all new orders and entered them into the medical record;-If he/she believes a resident could benefit from therapy services, he/she would contact the physician for an order and also notify the therapy department for evaluation. During an interview on 04/16/26, at 4:29 P.M., the DON said the following:-If a resident refused therapy, it should be documented in the PT notes and the care plan;-When a resident discharged back to the facility from the hospital, two nurses along with the DON, review the orders and communicate any new therapy orders with the therapy department;-All residents should receive therapy services according to their physician orders;-If a resident frequently refused services, she expected to see it documented in the progress notes and the therapy notes.During an interview on 04/16/26, at 5:38 P.M., the Administrator said the following:-She expected all residents to receive services according to their physician orders;-If a resident frequently refused any type of care or service, staff should document the refusal in the progress and therapy notes. Complaint #2742822

Based on observation, interview, and record review, facility staff failed to ensure residents were free from accidents when the facility failed to have a process in place to ensure staff were aware of the care planned needs of each resident resulting in the fall of one resident (Resident #1), resulting in a laceration and neck fracture, when staff provided cares alone when care planned for two staff present during cares. The facility had a census of 80.Review of a facility policy titled, Care Plan Comprehensive, not dated, showed the following information:-A comprehensive care plan for each resident is to be developed and maintained that identifies the highest level of functioning the resident may be expected to attain;-The care plan will be oriented to prevent avoidable decline in functioning and manage risk factors to the extent possible or indicating the limits of such interventions.Review of a facility's checklist form titled, Fall Prevention Intervention Care Plan, dated June 2006, showed the following checklist measures:-Ask resident every one to two hours if they need to use the bathroom;-Answer call lights promptly;-Remind the resident to ask for assistance;-Eliminate side rails and bedside commodes;-Individualize toilet schedule and/or bowel and bladder re-training;-Reorient the resident to surroundings frequently;-Visually check the resident every two hours or more often as determined by the care team;-Eliminate potential hazards;-Assess the environment to maximize safety.Review showed the facility did not provide a policy regarding falls or accidents.1. Review of Resident #1's face sheet (basic information sheet) showed the following:-admission date of 08/06/24;-Diagnoses included depression (a group of conditions associated with the elevation or lowering of a person's mood, such as depression or bipolar disorder), persistent mood disorder (persistent feelings of depression), history of urinary tract infections (UTI), and a history of falls.Review of the resident's Minimum Data Sheet (MDS- a federally mandated assessment tool completed by facility staff), dated 10/15/25, showed the following:-The resident had severe cognitive impairment;-The resident had impairment of both sides of the upper and lower extremities;-The resident was dependent on staff for personal cares, bed mobility, and transfers. Review of the resident's care plan, dated 10/23/25, showed the following:-The resident had impaired mobility requiring dependence on staff for all activities of daily living (ADLs- activities related to personal cares including bathing, showering, dressing, getting in and out of bed or a chair, walking, toileting, and eating);-The resident had increased risk for falls;-Interventions included two staff assistance with bed mobility. Staff to turn and reposition the resident every two hours as needed if resident unable to do so on his/her own;-Two staff Hoyer lift (mechanical lift used for resident who cannot bear weight) transfer assistance;-Two staff assistance for ADL's.Review of the resident's Fall Event Report, dated 11/17/25, showed the following:-A fall was noted on 11/17/25. at 4:54 A.M.;-The fall was witnessed;-Resident rolled into the floor during dressing; -Resident had a three-inch laceration on the top middle of his/her head with a knot forming;-Staff to have all supplies next to them during cares;-The location of the fall was noted as the resident's room;-Assessment showed the resident exhibited/complained of pain to the top of his/her head;-The pain scale was noted as a 1 out of 10 (mild pain);-The resident had full range of motion without pain or limitations;-The resident was noted as lethargic/drowsy.During an interview on 11/20/25, at 1:42 P.M., Nurse Aide (NA) D said the following: -He/she was providing care to the resident on 11/17/25, when the resident fell from bed;-Certified Nurse Aide (CNA) G was present in the room assisting the resident's roommate when the fall occurred;-The NA was providing peri-care and changing the resident's clothing. The resident was positioned on his/her left side away from him/her on the bed;-The NA turned his/her head from the resident to grab peri-care supplies;-The resident rolled away from him/her while looking away, falling from the bed to the floor between the bed and the wall;-The NA did not see the resident fall from the bed or how he/she landed. He/She heard the resident hit the floor with a thump;-The bed was positioned at the NA's waist height;-The NA observed the resident on the floor on his/her stomach;-The NA immediately responded to the resident and observed the resident bleeding from an approximately three inch cut on the top of his/her head. He/She did not notice any other injuries at that time;-CNA G immediately left the room and notified the Assistant Director of Nursing (ADON):-The ADON immediately responded to the room and took over care of the resident;-The resident typically required one staff assistance for care and two staff assistance for Hoyer transfers. He/She usually provided one person care to the resident;-He/She did not know how many staff were required for care according to the care plan. He/she did not know what was indicated in the resident's care plan;-If the resident's care plan indicated two staff for care, two staff should be present for the care to ensure the resident received proper care and to prevent the resident from rolling out of bed during cares;-If additional items were needed requiring staff to divert attention from the resident, staff are to position the resident on their back prior to looking away. He/She thought he/she rolled the resident on his/her back;-If he/she would have been more focused, the fall could have been prevented. Review of the resident's progress notes showed the following:-On 11/17/25, at 5:51 A.M., the ADON documented the resident rolled out of bed and into the floor during morning cares. The resident had a three-inch laceration on the top of his/her head with a knot. The resident's vital signs were stable. The resident was assisted out of the floor and into a geriatric chair (reclined, cushioned chair). The head wound was cleansed and dressed. The Director of Nursing (DON) requested a skull series (x-ray series of the skull). The resident was sent to the hospital;-On 11/17/25, at 10:59 A.M., a nurse documented the resident returned from the hospital. The resident returned with instructions to wear a cervical collar (neck brace) at all times;-On 11/17/25, at 1:34 P.M., a nurse documented the resident had a closed non-displaced fracture of the posterior arch of the first cervical vertebra (neck fracture);-On 11/17/25, at 6:32 P.M., a nurse documented a fall follow-up showed the resident remained on observation following his/her fall on 11/17/25. The resident had soreness when rolled and moved. The resident was unable to be moved from bed for meals due to soreness and pain. The resident was fed in bed by staff.Review of the resident's Hospital After Visit Summary, dated 11/17/25, showed the following:-The resident was seen for a fall;-The resident received imaging tests of the spine and head;-The resident had a neck fracture and head laceration.Observations on 11/20/25, at 12:00 P.M., and 1:18 P.M., of the resident showed the following: -The resident was in his/her bed with his/her eyes closed;-The resident's bed was in a low position with a fall mat on each side of the bed;-The resident had a neck brace in place holding the resident's head in position;-The resident had a large, scabbed area on the top of his/her head with no bleeding noted.During an interview on 11/20/25, at 12:53 P.M., CNA A said the following: -Staff providing direct care to residents should have all needed materials for care within reach. If needed items are out of reach or require staff to leave the area of care, staff are to position the resident safely, lower the bed to the lowest position, and place a fall mat prior to attention being directed from the resident or leaving the area;-Care should be provided based on the care plan;-Staff providing direct care were responsible for ensuring care is implemented according to the care plan.During an interview on 11/20/25, at 1:00 P.M., CNA B said the following: -Prior to providing care, staff are to ensure all needed supplies are at the foot of the resident's bed and in reach. If additional items are needed or are out of reach, staff should inform the resident of the additional items needed, position the resident safely in bed, lower the bed to the lowest position, and obtain the items needed;-If two staff are present for cares, one staff should remain with the resident while the second staff obtained the needed items;-The care plan should be followed. If two staff are indicated, both staff should be actively present for the care provided to ensure resident safety. The staff providing care are responsible for implementing assistance according to the care plan.During an interview on 11/20/25, at 1:10 P.M., NA C said the following: -He/She learned in report, the resident fell from bed resulting in a cut on top of his/her head requiring staples and a neck fracture;-Since the resident has returned to the facility following the fall, the resident was not eating as much and had increased pain;-The resident typically required two staff for personal cares;-If two staff were required for care, both should be present for the cares and actively participating int he care provided. One staff is usually on one side of the bed and the second staff on the opposite side to ensure resident safety;-If staff need to leave the room during cares or must grab something out of reach, the resident should be safely positioned in the bed and lower the bed to the lowest position prior to diverting attention from the resident;-Care should be provided according to the care plan. Staff providing cares are responsible for ensuring the care plan is followed.During an interview on 11/20/25, at 2:03 P.M., Licensed Practical Nurse (LPN) E said the following: -The resident fell a few days ago. The resident had a neck fracture requiring a cervical collar and a two-centimeter cut on the top of his/her head requiring two staples;-Report showed the resident fell out of bed;-NA D was the staff providing care at the time of the fall. CNA G was present in the room at the time of the fall;-The resident required two staff assistance for transfers and personal cares typically required one staff;-He/She was unsure of what the care plan indicated for the resident's personal cares'-The care plan should be followed;-If two person cares are indicated, two staff should be actively present and providing the care for the resident. The two staff would ensure proper care, assistance for rolling the resident and holding positioning of the resident during care to prevent and mitigate fall risk.;-If staff are providing solo care and require additional items or assistance, they are to turn the call light on to get additional assistance while continuing to monitor and provide care for the resident to ensure safety. Staff should not divert attention from the resident during cares;-The resident's fall could have been prevented with a second person being present while cares were being provided;-Since the fall the resident has not wanted to get out of bed or be placed in his/her Broda wheelchair (a wheelchair with additional support through combination of tilt, recline, and adjustment);-Staff providing care are responsible for ensuring cares are provided safely and according to the care plan.During an interview on 11/20/25, at 2:20 P.M., Certified Medication Tech (CMT) F said the following: -He/She observed the resident on the floor between his/her bed and the wall. The resident's bed was at approximately waist height. The resident was bleeding from the top of his/her head;-NA D said he/she was providing personal cares to the resident, turned to grab something, and the resident rolled out of bed;-He/She did not know if the resident was care planned for one or two staff assistance for personal cares;-Residents should never be left unattended during cares. Staff should put the bed in the lowest position prior to leaving the immediate area to grab supplies or items needed that were not already in reach;-The care plan should be followed;-If two staff are required for cares, both staff should be participating in the care given to ensure safety. If two staff are not present when required, it would increase risk of a possible fall or injury if the resident is not actively being watched;-The staff providing direct care are responsible for ensuring the care plan is followed and proper safety procedures are implemented.During an interview on 11/20/25, at 2:33 P.M., the Social Services Director (SSD) said care plans should be followed to ensure resident safety. The DON and ADON were responsible for communicating the care plan needs of the residents to nursing staff.During an interview on 11/20/25, at 3:05 P.M., the ADON said the following: -NA D and possibly CNA G were in the resident room at the time of the fall. CMT F reported to him the resident's fall and immediately responded to the resident's room;-The resident was on the floor between his/her bed and the wall. The resident was on his/her right side. The resident had a three-inch laceration to the top of his/her head;-The resident was non-verbal and could not describe what occurred-The resident was sent to the hospital for further evaluation. A neck fracture was identified at the hospital;-NA D reported he/she was providing personal cares to the resident at the time of the fall;-NA D said he/she had his/her hand on the resident, reached for a shirt, and the resident rolled off the bed away from him/her;-The resident was generally one staff assistance for personal care and two staff assistance for transfers;-Staff should ensure all needed supplies are in reach before providing care;-Care should be provided according to the care plan. If the care plan indicated two staff are required for care, two staff should be participating in the care. Staff should be familiar with the care plan before providing care;-The charge nurse, ADON, and DON were responsible for ensuring staff are knowledgeable of care plan requirements for residents;-There would be increased concern for resident safety if the care plan were not followed. During an interview on 11/20/25, at 3:26 P.M., the DON said the following: -The resident fell on [DATE]. The ADON reported the resident rolled out of bed and hit his/her head. The resident was sent to the hospital for further evaluation;-She interviewed NA D following the fall. NA D said he/she was providing peri-care to the resident at the time of the fall. He/She turned from the resident to grab a shirt and while turned, the resident rolled out of bed;-CNA G was present in the room assisting another resident. The bed was at a waist high position at the time of the fall. The resident hit his/her head when he/she fell on the floor. -The DON said the resident had a two-centimeter laceration which required two staples on the top of his/her head and a neck fracture;-The resident required two staff for transfers and one staff for personal care;-Staff providing direct care should have all supplies within reach prior to providing care. If additional supplies were needed or items were not in reach staff should request assistance from the second staff in the room;-If the care plan required two staff for care, two staff should be present during cares to ensure resident safety;-The care plan should be followed;-The staff providing care are responsible for being knowledgeable of the care plan needs;-The MDS Coordinator, DON, and ADON were responsible for ensuring the care plan requirements are relayed to CNA's, CMT's, and other nursing staff;-The fall could have been prevented if proper procedures were followed.During an interview on 11/20/25, at 2:52 P.M., the Medical Director said the following: -The facility contacted one of his Nurse Practitioners (NP H) on 11/17/25 regarding the resident's fall;-Facility staff reported the resident had a three-inch laceration to the top of his/her head. The facility requested the resident be sent for x-rays;-The resident was dependent on staff for personal care;-He would expect the resident to receive two staff assistance for cares as he/she was dependent on staff for cares.During an interview on 11/20/25, at 5:00 P.M., the Administrator said the following: -She was informed of the resident's fall on 11/17/25, around 5:00 A.M., by the ADON;-The resident rolled out of bed during cares;-The resident had a laceration which required staples and a neck fracture;-NA D turned from the resident to grab peri-care supplies. While the NA was turned, the resident rolled out of the bed;-CNA G was present in the room at the time if the incident assisting another resident;-She did not know what the care plan indicated for number of staff required for personal cares for the resident;-The care plan should be followed and properly implemented;-NA D should have positioned the resident on his/her back prior to grabbing supplies to prevent the resident from falling;-The MDS Coordinator, DON, ADON, and charge nurses were responsible for ensuring nursing staff are aware of the care plan needs of each resident and implementing the care plan appropriately.Complaint 2669590

Based on interview, and record review, the facility failed to provide care that reflected the resident's wishes as expressed by the residents advance directives (written instruction, such as a living will or durable power of attorney, relating to the provision of health care when the individual is incapacitated) when the facility failed to ensure one resident's (Resident #1) Do Not Resuscitate order (DNR- refers to a medical order issued by a physician or other authorized practitioner that directs healthcare providers not to administer cardiopulmonary resuscitation (CPR - a medical intervention used to restore circulatory and/or respiratory function)) was clearly and consistently documented in the resident's chart resulting in staff providing CPR when the resident wished to be a DNR. The facility census was 80. Review of the facility's policy titled Advance Directive, undated, showed the following information:-Upon admission of a resident to the facility, the social services designee (SSD) will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive;-Upon admission of a resident, the SSD will inquire of the resident, and/or his/her family members, about the existence of any written advance directives;-Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab;-DNR indicates that in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no CPR or other life-saving methods are to be used. 1.Review of Resident #1's face sheet (brief look at resident information) showed the following information:-admission date of [DATE];-Code status (refers to the level of medical interventions a person wishes to have started if their heart or breathing stops) as a full code (wished to receive CPR);-Diagnoses include pneumonia (infection that inflames the air sacs in one or both sides of the lungs), metabolic encephalopathy (occurs when problems with your metabolism cause brain dysfunction), kidney failure, and sepsis (a life-threatening complication of an infection).Review of the resident's Advanced Directives tab in the Electronic Medical Record (EMR) showed the following:-A DNR was scanned and loaded into the system on [DATE];-The scanned in DNR was signed by the resident and physician and dated [DATE].Review of the resident's Physician's Orders, dated [DATE] to [DATE], showed an order, dated [DATE], for resident to be code status of no CPR (DNR). Review of the resident's care plan, last updated [DATE], showing the resident had a code status of DNR. Review of the resident's 5-Day Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated [DATE], showed the resident had severe cognitive impairment. Review of the resident's progress note dated [DATE], at 10:30 P.M., showed the Assistant Director of Nursing (ADON) noted the following information:-Around 9:15 P.M., he/she went into the resident's room to administer medication and found the resident struggling to breath and foaming at the mouth;-The resident was barely responsive, and his/her pulse was barely palpable (able to be touched or felt). The resident's oxygen saturation (the percentage of hemoglobin in the blood that is carrying oxygen, typically read using a pulse oximeter) would not read;-The resident was a full code;-Staff notified emergency services (EMS) and as the ADON was getting off the phone with EMS, the resident became completely unresponsive and had stopped breathing with no pulse;-Staff began CPR and completed several rounds of CPR prior to EMS arrival;-EMS arrived and took over CPR. The fire department also arrived onsite and continued CPR for 45 minutes, when EMS asked to call the resident's family;-Family was notified of the situation. CPR continued, EMS then phoned the hospital and waited for a doctor to call the time of death. While waiting for the doctor to respond, there was a pulse indicated on the monitors, so EMS loaded the resident up for transport to the emergency department at 10:20 P.M.During an interview on [DATE], at 1:27 P.M., the ADON said the following:-The resident was admitted to the facility for a couple of weeks;-He/she was working night shift on [DATE], and was going into the resident's room to administer his/her medication;-Upon entering the room, the resident was lying in bed and had foam coming out of his/her mouth;-He immediately checked the resident's code status on the resident's face sheet, which indicated the resident was a full code (CPR);-He checked the resident's Advanced Directives tab in the EMR as well, and nothing was in the system at the time, showing the resident was a DNR;-He checked the resident's sticker on his/her door, showing a green dot which indicated full code (CPR);-He called EMS and began CPR;-Medical records is responsible for scanning and loading DNR's into the residents EMR. They also should communicate with the staff when they become aware of a signed DNR;-DNR orders should be loaded into the EMR immediately, upon being signed.During an interview on [DATE], at 9:39 A.M., Certified Nursing Assistant (CNA) A said the following:-Staff were aware of a resident's code status by the dot sticker on the resident's door. If the dot was green, that meant full code (CPR). If the dot was red, that meant no code (DNR). The staff may also check on the resident's face sheet;-He/she believed medical records was who updates the code status of a resident;-He/she believed the resident's code status on the face sheet, indicated that he/she had a DNR;-Information should match in all areas including face sheet, door, and the care plan.During an interview on [DATE], at 2:54 P.M., CNA B said staff are aware of a resident's code status by the dot sticker on the resident's door, but sometimes when the resident was a newer admission, their status doesn't get updated as timely. A red dot indicated no code (DNR), and a green dot indicated full code (CPR).During an interview on [DATE], at 10:57 A.M., Licensed Practical Nurse (LPN) C said the following:-He/she was not present at the time of the incident and is not sure of what the resident's code status was without looking;-Code status can be found on the resident's face sheet, as well as in the EMR under the Advance Directives tab;-There has been a delay in records being scanned and uploaded into the EMR. Due to this he/she ensures that he/she obtains that information during shift report.During an interview on [DATE], at 12:55 P.M., Medical Records Staff said the following information:-Code status can be found by looking in the resident's EMR, the resident's door sticker, or by getting report when the resident is admitted to the facility;-She typically uploads the records, but there has been a delay lately due to him/her being pulled to work on the floor;-She did have the resident's signed DNR timely but was unable to upload it into the EMR timely. During an interview on [DATE], at 1:08 P.M., the Director of Nursing (DON) said the following:-Code status can be found in the resident's EMR and under the Advanced Directives tab. Additionally the status can be found on the resident's door sticker, and the face sheet;-She expected all areas of information to match;-Previously Medical Records Staff and/or Social Services Staff that took care of code status updates;-Sometimes there is a delay in documents being scanned and loaded into the system;-Any newly admitted resident is considered a full code (CPR) until a DNR order is signed. The DNR order will take effect on the date it is signed.During an interview on [DATE], at 2:02 P.M., the Administrator said the following:-Code status can be found on the resident's face sheet, sticker dot on their door, and under the Advanced Directives tab in the EMR;-She expected all areas of information, to match.Complaint #2632714

Based on interview and record review, the facility failed to ensure all residents were treated in a dignified manner, when staff withheld one resident's (Resident #1's) belongings, and would not return them timely, after the resident displayed behaviors. The facility census was 75.Review of the facility policy titled Resident's Rights, undated, showed the following:-The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility;-The resident has the right to exercise his/her rights as a resident of the facility and as a citizen or resident of the United States;-The resident has the right to be free of interference, coercion, discrimination and reprisal form the facility in exercising his/her rights, and be supported by the facility in the exercise of his/her rights;-The resident may retain personal possessions as space permits, unless to do so would infringe on the rights of others. 1. Review of Resident #1's face sheet (admission data) showed the following:-admission date of 07/14/25;-Diagnoses included bipolar disorder (mental health condition characterized by extreme shifts in mood, energy, ranging from highs to lows), anxiety disorder (excessive and persistent worry and fear), personality disorder (long lasting disruptive patterns of thinking, behavior, mood and relating to others), epilepsy (sudden surges of electrical activity in the brain that leads to convulsions or loss of consciousness and changes behavior), intellectual disabilities (limitations in learning, thinking, and problem-solving skills), and Parkinson's disease (progressive nervous system disorder that affects movement). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/04/25, showed the following information:-Memory problems, moderately impaired cognitive skills, inattention, and disorganized thinking;-Physical and verbal behaviors the last four to six days towards others;-Partial assistance with oral, personal and toileting hygiene, upper and lower body dressing;-Substantial assistance with showers and personal hygiene. Review of the resident's July 2025 Progress Notes showed the following:-On 07/14/25, at 4:41 P.M., the resident admitted to the facility. The resident was able to make needs known, had behaviors. Resident has tantrums and will throw his/her belongings if he/she doesn't get his/her way. Resident likes to color and likes puzzles and superheroes at times if you cannot redirect the resident;-On 07/17/25, at 3:27 P.M., resident alert to self and staff anticipates all needs and cares. Resident can be aggressive with staff and combative. He/she does throw his/her belongings and will have tantrums if not getting his/her way. If he/she is having behaviors, he/she enjoys coloring and puzzles;-On 07/19/25, at 9:02 A.M., the resident screaming and crying in dining hall. When asked to go to his/her room he/she started screaming louder and threw his/her coloring pages and toys in the hall, slamming the door. Review of the resident's August 2025 Progress Notes showed the following:-On 08/01/25, at 4:57 P.M., the resident was up in the hallway pacing a lot during this shift and wanting his/her coloring pages and certain coloring pages. Resident was redirected multiple times. Resident did not get aggressive or angry;-On 08/02/25, at 9:45 P.M., resident had been screaming all of this shift, throwing items into the hall and in room, cussing, hitting, and refusing to take medication. Staff unable to redirect;-On 08/09/25, at 10:32 A.M., resident behaviors continue including screaming, throwing items into the hall and at the staff, and other resident, and slamming door to room. Difficult to administer medications. Resident not easy to redirect. Review of the resident's care plan, revised on 08/05/25, showed the following:-Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by rejecting cares at times. Staff will assess whether the behavior endangers the resident and or others and intervene as necessary. Avoid over-stimulation. Convey attitude of acceptance toward the resident. Maintain a calm environment and approach to the resident. When resident becomes socially inappropriate/disruptive, provide comfort measures for basic needs;-Resident at risk for loneliness related to behaviors towards others. Staff will allow resident to have control over situations, if possible. Identify relationships that resident could draw on. Involve resident with those who have shared interests. Provide activity calendar. Place resident in position of almost certain success in an activity;-Resident has difficulty understanding others related to mental health issues and intellectual disabilities. Staff will ask resident to repeat what he/she what has been said to confirm the message was understood. Staff will face the resident when speaking. Staff will obtain resident's attention before speaking. Staff will speak clearly and adjust tone as needed;-Resident has impaired decision making related to behaviors towards others and reject cares. Encourage resident to verbalize feelings, concerns and fears. Give objective feedback when appropriate decisions are made. Discuss future options to improved decision making. Respect resident's rights to make decisions. Review of Certified Nurse Aide (CNA) D's written statement dated 08/11/25, at 11:31 A.M., showed CNA D went to B wing to see if the resident received the coloring books he/she had gotten for the resident and was told no because the resident hit CNA I. CNA I made the statement if the resident keeps fucking around with me, CNA I will take the resident's bed out and the resident can sit on the fucking floor. Review of CNA B's written statement dated 08/11/25, no time, showed CNA B had heard CNA I say to the resident that CNA I would take everything out of the resident's room and the resident would be left with nothing but his/her bed if he/she didn't stop acting up.Review of Housekeeper E's written statement dated 08/12/25, at 10:58 A.M., showed yesterday he/she went to B wing and he/she saw the resident get upset about something and the resident threw his/her backpack and CNA H picked it up and took it away.Observation and interview on 08/14/25, at 9:53 A.M., with the resident showed the following:-Staff were removing a television from the resident's room;-The resident sat on his/her bed, rocking;-The resident spoke in short repetitive, phrases;-During the interview the resident was fixated on the television being removed from his/her room;-The resident would say often, where did my tv go, what did they do;-The resident also had multiple papers on his/her bed and appeared very proud of the papers. He/she would ask staff that came in/out of the room to make copies for him/her. During an interview on 08/14/25, at 1:07 P.M., Certified Medication Tech (CMT) A said it would be against the resident's rights to take away their stuff. During an interview on 08/14/25, at 1:25 P.M., CNA B said the following:-The resident will throw things out of his/her room, and staff will take the resident's belongings and put them in a closet where the resident is not able to get his/her belongings until the resident stops misbehaving;-On 08/09/25, he/she heard CNA I around lunch time, say that if the resident didn't stop misbehaving, CNA I was going to take everything out of the resident's room except his/her bed;-Last week CNA I took the resident's papers, bookbag, and spiderman and would not give them back to the resident. The resident asked for them back about five minutes after they were taken, and CNA I told the resident he/she was not getting them back to throw them at CNA I again. The resident got angry and stomped off to his/her room and slammed the door. The resident would constantly ask for his/her stuff back. Licensed Practical Nurse (LPN) C would not give them back to the resident. -Taking a resident's belongings is against their rights. During an interview on 08/14/25, at 1:43 P.M., LPN C said the following:-When the resident throws things out of his/her room, staff will place them on the counter at the nurses' station. The resident comes out and asks for them and staff remind him/her not to throw them and the resident takes his/her belongings;-It would against the resident's rights to take his/her belongings. During an interview on 08/14/25, at 1:54 P.M., CNA D said the following:-The resident has behaviors where he/she throws books and other things into the hall;-He/she has seen CNA I and LPN C take the resident's belongings;-When the resident's belongings are taken, he/she throws a fit because he/she can't have his/her stuff back and it increases the behaviors;-It's never appropriate to take a resident's belongings; It's against their rights;-He/she doesn't remember the exact dated, but he/she purchased coloring books for the resident. A few days later he/she came to the unit to see if the resident liked the books and CNA I came into the dining room, where several residents were eating. He/she asked CNA I about the coloring books and CNA I said the resident wasn't getting the fucking shit. He/she asked another staff what was going on and the other staff said the resident had punched CNA I in the face and that's why the resident can't have the coloring books. CNA I also said if the resident keeps fucking around with him/her, CNA I said he/she would take everything out of the resident's room, including the resident's bed and the resident could sit on the fucking floor. During an interview on 08/14/25, at 2:28 P.M., Housekeeper E, said the following:-He/she had been in the unit cleaning, when the resident had thrown stuff into the hall, and the staff will take the things and put them at the nurses' station, on the floor so the resident is not able to get them back. He/she has seen CNA H and CNA I take the resident's backpack and spiderman and put them at the nurses' station;-He/she has witnessed LPN C say to staff, the resident threw his/her stuff into the hall, go get it and put it away;-On 08/11/25, around 8:30 A.M., he/she was cleaning on the unit, and the resident came out of his/her room and asked LPN C if he/she would cover the resident up as he/she wanted to lay down and watch TV. LPN C said the resident was old enough to cover him/herself up. The resident went to his/her room and began to throw things out of the room into the hall. Housekeeper E was up the hall from the resident's room, so he/she could see and hear everything. CNA H aggressively opened the resident's door, and asked the resident what his/her deal was, and why was the resident behaving like this as the resident knew he/she would lose his/her stuff. CNA H took all of the resident's belongings and put them at the nurses' station and the resident began to get upset and cry. During an interview on 08/14/25, at 2:55 P.M., the Assistant Director of Nursing (ADON) said the following:-It was not appropriate to take a resident's belongings, or threaten to take a resident's belongings. That would be against their rights;-He/she has heard if the resident throws things. It would not be appropriate to threaten or take belongings if resident misbehaves;-He/she has heard the resident throws things into the hall and the staff put the items at the nurses' station to hold until the resident de-escalates;-He/she said taking the resident's belongings to hold is a gray area. If the staff give the belongings back it's more stuff for the resident to throw;-He/she would expect staff to use interventions when the resident is having behaviors, talk to the resident, and see what's going on;-Taking a resident's belongings is against their rights, but holding the belongings until the resident is ready to have it back is lessening what the resident has to throw ;-The staff should give the resident's belongings back if the resident asks for them. During an interview on 08/14/25, at 2:55 P.M., CMT F said the following:-It would not be appropriate to threaten to take a resident's items;-He/she has seen the resident's coloring books at the nurses' station;-He/she has seen the resident slam doors. The resident seems to do this more at night. During an interview on 08/14/25, at 3:29 P.M., CNA G said the following:-It was not appropriate to take a resident's belongings from them;-He/she usually works the 2 to 10 shift so when He/she arrives to the unit, the Resident comes to him/her to get the resident's belongings back. Sometimes he/she has to hunt for the resident's belongings because they might be at the nurses' station, but usually they're in the locked closet;-He/she has found the resident's drawings, backpack, and stuff he/she's thrown when the resident has been upset;-He/she has heard the resident ask staff for his/her belongings and they will tell him/her no. This has been going on since the resident was admitted ;-He/she doesn't know which staff is taking it, but the resident will obsess on his/her belongings until they're returned;-It's against the resident's rights to take their belongings. During interviews on 08/14/25, at 8:55 A.M. and 4:45 P.M., the Director of Nursing (DON) said the following:-It was not appropriate to take a resident's belongings when they're misbehaving;-The resident does throw things and he/she questioned staff about taking the resident's belongings and they reported only putting them in the storage room until meal times were over;-It was not appropriate to tell a resident they're not getting their belongings back. If a resident asks for their belongings staff should return them. During an interview on 08/14/25, at 5:07 P.M., the Administrator said staff should never threaten to take resident's belongings away. That is against the resident's rights. Complaint #2587324

Based on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency (Department of Health and Senior Services - DHSS) when staff failed to report allegations of verbal abuse and involuntary seclusion involving one resident (Resident #1) to management and DHSS in a timely fashion. The facility census was 75.Review of the facility policy titled Abuse Prohibition Protocol Manual, revised January 2017, showed the following:-Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property;-The Administrator or designee must report to the State Survey agency no later than two hours after the allegation is made if the event involved abuse or resulted in injury;-All residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation;-Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend, or disability;-Physical abuse is defined as hitting, slapping, pinching, kicking, biting, etc. It also includes controlling a resident's actions through personal punishment;-Report immediately, within two hours, if the events that cause the allegation involve abuse or result in serious bodily injury. Review of the facility's policy titled, Resident's Rights, undated, showed resident shall not be subjected to physical, sexual, or emotional injury or harm. 1. Review of Resident #1's face sheet (admission data) showed the following:-admission date of 07/14/25;-Diagnoses included bipolar disorder (mental health condition characterized by extreme shifts in mood, energy, ranging from highs to lows), anxiety disorder (excessive and persistent worry and fear), personality disorder (long lasting disruptive patterns of thinking, behavior, mood and relating to others), epilepsy (sudden surges of electrical activity in the brain that leads to convulsions or loss of consciousness and changes behavior), intellectual disabilities (limitations in learning, thinking, and problem-solving skills), and Parkinson's disease (progressive nervous system disorder that affects movement). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/04/25, showed the following information:-Memory problems, moderately impaired cognitive skills, inattention, and disorganized thinking;-Behaviors the last four to six days of physical and verbal towards others. Review of the resident's care plan, revised on 08/05/25, showed the following:-Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by rejecting cares at times. Staff will assess whether the behavior endangers the resident and or others and intervene as necessary. Avoid over-stimulation. Convey attitude of acceptance toward the resident. Maintain a calm environment and approach to the resident. When resident becomes socially inappropriate/disruptive, provide comfort measures for basic needs;-Resident at risk for loneliness related to behaviors towards others. Staff will allow resident to have control over situations, if possible. Identify relationships that resident could draw on. Involve resident with those who have shared interests. Provide activity calendar. Place resident in position of almost certain success in an activity;-Resident has difficulty understand ding others related to mental health issues and intellectual disabilities. Staff will ask resident to repeat what he/she what has been said to confirm the message was understood. Staff will face the resident when speaking. Staff will obtain resident's attention before speaking. Staff will speak clearly and adjust tone as needed;-Resident has impaired decision making related to behaviors towards others and reject cares. Encourage resident to verbalize feelings, concerns and fears. Give objective feedback when appropriate decisions are made. Discuss future options to improved decision making. Respect resident's rights to make decisions. Review of Certified Nurse Aide (CNA) D's written statement dated 08/11/25, at 11:31 A.M., showed CNA said he/she had personally witnessed a towel put into the resident's door to keep him/her locked in his/her room. The CNA said he/she had reported this to his/her nurse on duty for C wing and he/she stated he/she didn't want to get int the middle of things. CNA D went to B wing to see if the resident received the coloring books he/she had gotten for the resident and was told no because the resident hit CNA I. CNA I made the statement if the resident keeps fucking around with me, CNA I will take the resident's bed out and the resident can sit on the fucking floor. CNA D was told by a Housekeeper E that he/she had heard CNA I say that CNA I would put the resident in a head lock if the resident touches CNA I again. Review of CNA B's written statement dated 08/11/25, no time, said CNA B had heard CNA I say to the resident that CNA I would take everything out of the resident's room and the resident would be left with nothing but his/her bed if he/she didn't stop acting up.Review of DHSS records showed the facility reported the allegations of abuse on 08/12/25, at 10:32 A.M. (approximately 24 hours after staff suspected abuse).During an interview on 08/14/25, at 1:07 P.M., Certified Medication Tech (CMT) A said the following:-Placing a towel on the resident's door could be considered a restraint and could also prevent the resident from leaving the room, which would be seclusion;-He/she would report any suspected abuse to the charge nurse;-He/she knows the State is to be called within two hours of suspecting abuse. During an interview on 08/14/25, at 1:25 P.M., CNA B said the following:-He/she has seen towels at the top of the resident's door. A few weeks ago, Registered Nurse (RN) J told staff they could not put a towel at the top of the door as this could prevent the door from opening. He/she has seen CNA I and CNA H, put the towel on top of the door. He/she knows a couple other night staff have placed the towel on the door to cut down on the noise it makes when the resident slams the door;-On 08/09/25, he/she heard CNA I, around lunch time, say that if the resident didn't stop misbehaving, CNA I was going to take everything out of the resident's room except his/her bed;-He/she had heard from others CNA I had cursed at the resident;-Threatening a resident, or cursing at a resident is disrespectful and abusive;-He/she wrote the statement on 08/11/25 and put it under the Director of Nursing's (DON) door as he/she felt like CNA I was doing things he/she should not be doing. He/she reported the incident to Licensed Practical Nurse (LPN) , but he/she didn't know if LPN C had done anything so he/she wrote the statement;-He/she reports abuse to his/her charge nurse. He/she knows the abuse is supposed to be reported to the state in three days. During an interview on 08/14/25, at 1:43 P.M., LPN C said the following:-No staff have reported abuse to him/her regarding the resident;-If abuse is reported to him/her, she has staff write out statements, tells the DON immediately and the Administrator;-Abuse should be reported to the state within two hours; During an interview on 08/14/25, at 1:54 P.M., CNA D said the following:-CNA I said the resident wasn't getting the fucking shit (coloring books).;-CNA I also said if the resident kept fucking around with him/her, CNA I would take everything out of the resident's room, including the resident's bed and the resident could sit on the fucking floor;-He/she looked for the nurse to report the incident, but did not find the nurse and got busy so the incident was not reported; -He/she has seen a washcloth on top of the resident's door one time and he/she didn't think the resident could push the door open as it was tight;-It would not be appropriate to put a wash cloth in the door as it could be a restraint or involuntary inclusion;-He/she has told a nurse about the towel and a few hours later it was taken out, he/she believes Registered Nurse (RN) J was told about the incident and RN J removed the towel;-If he/she suspects abuse, he/she reports it to the nurse, and it's supposed to be reported to the state within two hours;-Cursing around residents would be verbal abuse and should be reported. Threatening to take a resident's belongings could be abuse as well and should be reported. He/she wrote a statement on 08/11/25 and placed it under the DON's door. During an interview on 08/14/25, at 2:28 P.M., Housekeeper E, said the following:-On 08/11/25, around 10:30 A.M., he/she arrived to the unit and saw a towel wedged at the top of the resident's door, and some of the towel was hanging on both sides of the door a few inches. The door would not open. The resident was at the door, crying and saying help me, my door is stuck. The resident could not get the door to open. The door was open about an inch, so there was a crack;-He/she told CNA D and another aide about the incident and they said they would report it to the charge nurse. He/she could not locate the DON;-Putting a towel in the door could be considered a restraint or seclusion;-Threatening a resident is abuse;-He/she did go to the Assistant Director of Nursing (ADON) about the towel situation right after it happened, and wrote a statement;-He/she knows abuse is supposed to be reported to the state, but not sure about the timeframes. During an interview on 08/14/25, at 2:55 P.M., the ADON said the following:-It was not appropriate to curse at a resident or make threats. This would be verbal abuse;-Putting a towel on a resident's door, if if hinders the door from opening, and keeping the resident in the room would be considered a restraint and involuntary seclusion;-He/she found out about the towel issue on Monday or Tuesday, late morning or early afternoon. Two aides told him/her about the incident. The aides asked if it would be appropriate to put a towel on the door so the resident could not get out and he/she told them know. He/she told the DON. The DON was already aware of it and heading to the unit to remove the towel;-Staff should be reporting suspected about to the charge nurse, ADON or the DON;-Staff are to report abuse to the State within two hours. He/she doesn't know if this incident was reported timely as he/she was told the DON was taking care of things.During an interview on 08/14/25, at 3:29 P.M., CNA G said the following:-Putting a towel on the door could be considered a restraint, and or involuntary seclusion if the resident was not able to get out;-He/she has seen multiple staff put towels up there, mainly the day shift;-He/she reports abuse to the charge nurse, and they're supposed to report to the State within 24 hours. During interviews on 08/14/25, at 8:55 A.M. and 4:45 P.M., the DON said the following:-it would not be appropriate for staff to make threats towards residents. This could be abuse;-He/she found the statements under the door when he/she came in 08/11/25;-The aides reported the concerns to LPN C. He/she was not sure when they reported it to the nurse, and the nurse never notified him/her of the allegations of abuse;-He/she would expect the nurse to notify him/her and the Administrator immediately;-They're required to call the state within two hours. During an interview on 08/14/25, at 5:07 P.M., the Administrator said the following:-Staff should never threaten to hurt a resident or curse at that resident, that is abuse;-If staff witness abuse or suspect abuse, they should take it to the supervisor immediately;-An aide should report to their charge nurse and the charge nurse should be reporting to the DON;-They are required to report abuse to the state within two hours;-Two staff reported suspected abuse, and wrote out statements, they put those under the DON's door. It wasn't reported timely;-Staff should not be putting a towel on any resident's door. He/she was not aware of a towel ever being put on the door to keep a resident in their room, That would be a restraint and involuntary seclusion. Complaint #2587324

1. Please refer to event ID26CF12, exit date 07/23/24, for details. MO00239179 Based on observation, interview, and record review, the facility failed to ensure all residents were kept as free from possible accident hazards as possible when the facility staff failed to fully secure one resident (Resident #1) in a wheelchair during transport in the facility's van resulting in a fracture of the resident's leg. The facility census was 54. Review showed the facility did not provide a policy and procedure, or a job description, specific to transporting residents in the facility van. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following information: -admitted [DATE]; -Diagnoses included hypertension (high blood pressure), congestive heart failure (CHF - chronic condition in which the heart doesn't pump blood as well as it should), and left leg amputation at the hip. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/06/24, showed the following information: -Cognitively intact; -Left leg amputation; -Dependent on staff for transfers from bed to wheelchair. Review of the resident's care plan, revised 07/23/24, showed the following information: -Resident at risk for falls due to weakness, decreased functional ability, chronic pain, and left leg amputation; -Extensive assistance needed for dressing, bathing, and toilet hygiene; -Total assistance needed for transfers and mobility. Review of the facility's Transport Incident Report, dated 07/17/24, showed the following: -On 07/09/24, staff were transporting resident back to the facility; -Transportation Staff A and Transportation Staff B loaded the resident into the back of the van in his/her electric wheelchair; -Transportation Staff A strapped down all four wheels on the resident's wheelchair. Transportation Staff A did not strap the resident's shoulder/lap seat belt in place; -Transportation Staff A reported three other residents were loaded in the front of the van and three wheelchairs were placed in the back of the van, in front of the resident's wheelchair; -Transportation Staff A was not able to strap the resident's shoulder/lap belt due to the three wheelchair's being stacked over the seatbelt strap that was located on the floor of the van; -During transport, the resident slid out of his/her wheelchair when the van stopped at a stop sign, hitting his/her knee on his/her leg rest of the wheelchair; -Transportation Staff A stopped the van and Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair; -Transportation Staff A remained next to the resident during the remainder of the transport. Review of the facility's signed statement by Transportation Staff A, dated 07/16/24, showed the following: -On 07/09/24, Transportation Staff B loaded the resident into the back of the van. Transportation Staff A strapped down all four wheels, but did not strap the shoulder/lap belt on the resident; -Transportation Staff A proceeded to assist in loading three other residents into the front bench seat of the van. Transportation Staff A placed all three wheelchairs in the back of the van next to the resident; -Transportation Staff A began driving the van back to the facility. When he/she stopped at a stop sign, he/she heard the resident yelling. Transportation Staff A stopped the van and went to the back of the van and saw the resident had slid out of his/her wheelchair seat, leaning forward, with his/her knee up against the leg rest of his/her wheelchair; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair and did not not secure the resident's shoulder/lap belt. -Transportation Staff A remained in the back of the van, next to the resident during the remainder of the trip. During an interview on 07/19/24, at 1:00 P.M., Transportation Staff A said the following: -On 07/09/24, he/she was transporting residents back and forth to the fairgrounds; -Transportation Staff B loaded the resident in the back of the van. Transportation Staff A strapped down all four wheels. Transportation Staff A then assisted Transportation Staff B in loading three additional residents in the front bench seat and then placing three wheelchairs in the back of the van next to the resident; -After placing the additional wheelchairs in the van, Transportation Staff A was not able to secure the shoulder/lap belt on the resident due to the wheelchairs being in the way of the belt; -They were driving back to the facility, stopped at a stop sign, and then heard the resident; -He/she stopped the van and went to the back of the van and saw the resident had slid out of his/her chair, leaning forward, up against the other wheelchairs with his/her knee resting on the leg rest of his/her wheelchair; -Transportation Staff A and Transportation Staff B pulled the resident back into his/her wheelchair and Transportation Staff A remained next to the resident the remainder of the trip allowing Transportation Staff B to drive back to the facility; -He/she received van transportation training on hire a few months ago by another transportation driver which included locking the wheels on the wheelchair, anchoring the wheelchair with four corner straps, and securing the resident with the shoulder/lap safety belt. Review of the facility's a signed statement by Transportation Staff B, dated 07/16/24, that showed the following: -On 07/09/24, Transportation Staff B loaded the resident into the van and Transportation A strapped down the resident's wheelchair, but did not buckle the shoulder/lap safety belt; -While Transportation Staff A was driving, the resident slid down off his/her wheelchair onto his/her footrest; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair and Transportation Staff A stayed in the back of the van with the resident; -Transportation Staff B drove back to the facility. During an interview on 07/19/24, at 1:22 P.M., Transportation Staff B said the following: -He/she loaded the resident into the back of the van and Transportation Staff A strapped down the wheelchair, but did not buckle the lap/shoulder safety belt. Transportation Staff B and Transportation Staff A then loaded three other residents into the front bench seat of the van placing three wheelchairs in the back of the van next to the resident; -Transportation Staff A was driving when they heard the resident yell. Transportation Staff A stopped the van, got out, and checked on the resident. Transportation Staff B then got out and saw the resident had slid out of his/her seat onto his/her footrest; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair. Transportation Staff A stayed in the back of the van and Transportation Staff B drove back to the facility; -Transportation B was hired to be a transportation driver. He/she received van transportation training a few years ago by another transportation driver which included locking the wheels on the wheelchair, anchoring the wheelchair with four corner straps, and securing the resident with the shoulder/lap safety belt. Observations on 07/19/24, at 2:10 P.M., of the facility van showed the van would accommodate one wheelchair. There were four-point straps and shoulder/lap belt on the floor in the back of the van. During an interview on 07/19/24, at 11:40 A.M., the resident said on 07/09/24, him/her and some of the other residents got to attend Senior Days at the fair. He/she remembered being loaded in the back of the van and remembered Transportation Staff A put both straps across his/her waist, but does not remember if both straps were placed coming back. Transportation Staff A drove over two large potholes in the road and it bounced him/her out of his/her seat in the wheelchair. He/she hit his/her right knee on the folded wheelchairs that were piled up in front of him/her. Transportation Staff A stopped the van and immediately came to the back of the van to check on him/her. Transportation Staff B then came to the back, and they were both able to lift the resident back up into his/her wheelchair seat. Transportation Staff A rode in the back of the van the rest of the way to the facility to make sure the resident did not fall again. Hitting his/her knee was painful. The nurse gave him/her pain medication and it helped, but as time went on the swelling and bruising started and the pain became worse. Review of the resident's nurses' notes, dated 07/09/24, showed Licensed Practical Nurse (LPN) C notified the physician of the incident and received orders for a portable x-ray of the right leg and left hand. Review of the resident's July 2024 Physician Order Sheet (POS) showed an order, dated 07/09/24, to obtain a portable x-ray of right leg and left hand. Review of resident's portable x-ray report, dated 07/10/24, showed a report of no acute findings. Review of the resident's nurses' notes, dated 07/15/24, showed LPN A notified the physician of bruising, swelling, and pain to resident's right leg and left hand. Review of the resident's nurses' notes, dated 07/16/24, showed the physician spoke with the Director of Nursing (DON) and requested an update on the bruising, swelling, and pain level of the resident. Review of the resident's July 2024 POS showed an order, dated 07/16/24, to send resident to the hospital for repeat x-ray of right leg and left hand. Review of the hospital Emergency Department Report, dated 07/16/24, showed a diagnosis of closed fracture of proximal end of right tibia (broken lower leg). Review of the resident's July 2024 POS showed the following: -An order, dated 07/17/24, to schedule MRI for right leg and left hand; -An order, dated 07/17/24, to schedule orthopedic appointment. During an interview on 07/19/24, at 12:40 P.M., the resident's physician said on 07/09/24, facility staff transported the resident to and from the fair for Senior Days. When returning to the facility, the resident fell out of his/her wheelchair while in the transportation van, hitting his/her right knee on the folded wheelchair in front of his/her. The physician did not know if the resident was properly secured during transportation. He/she ordered a portable x-ray the same day which did not show a fracture. He/she repeated the x-ray five days later, which then showed a fracture to the resident's leg. During an interview on 07/19/24, at 1:25 P.M., the Social Services Assistant (SSA) said that he/she is the supervisor for Transportation Staff A and Transportation Staff B. Both received training prior to SSA taking over the supervisor position. The driver should secure all wheelchairs with the four straps provided in the van and they should put the shoulder/lap safety belt on the resident. Everyone in the van should wear a seatbelt. During an interview on 07/25/24, at 10:10 A.M LPN A said the transportation staff should buckle up residents when transported in the facility van. During an interview on 07/25/24, at 1:40 P.M., the MDS Coordinator said the following: -The transportation staff are both certified nurse aides; -The transportation staff should ensure the front and back wheels on a resident's wheelchair are strapped correctly; -Staff should place the seat belt across a resident's wheelchair and buckle it; -It is not safe if staff did not buckle the seat belt. During an interview on 07/25/24, at 2:55 P.M., the DON said the following: -Staff load up a resident in the facility van and secure them; -Staff use the facility van's seat belts and floor straps to secure a resident in the van. During an interview on 07/17/24, at 1:40 P.M., with the former Administrator and the DON, the former Administrator said that he/she was notified of the incident the following day (07/10/24). The former Administrator said he/she was told that the resident had been strapped in except the top buckle had not been placed. A portable x-ray was obtained that reported no fracture initially. A repeat x-ray that was obtained 07/16/24 and showed a fracture to the resident's leg. The Administrator said the facility did not have a specific policy regarding van transportation. During an interview on 07/25/24, at 2:55 P.M., the current Administrator said she expected the staff to place the seat belt on residents for safety when transported in the van. MO00239377

1. Please refer to event ID26CF12, exit date 07/23/24, for details. MO00239179 Based on observation, interview, and record review, the facility failed to ensure all residents were kept as free from possible accident hazards as possible when the facility staff failed to fully secure one resident (Resident #1) in a wheelchair during transport in the facility's van resulting in a fracture of the resident's leg. The facility census was 54. Review showed the facility did not provide a policy and procedure, or a job description, specific to transporting residents in the facility van. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following information: -admitted [DATE]; -Diagnoses included hypertension (high blood pressure), congestive heart failure (CHF - chronic condition in which the heart doesn't pump blood as well as it should), and left leg amputation at the hip. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/06/24, showed the following information: -Cognitively intact; -Left leg amputation; -Dependent on staff for transfers from bed to wheelchair. Review of the resident's care plan, revised 07/23/24, showed the following information: -Resident at risk for falls due to weakness, decreased functional ability, chronic pain, and left leg amputation; -Extensive assistance needed for dressing, bathing, and toilet hygiene; -Total assistance needed for transfers and mobility. Review of the facility's Transport Incident Report, dated 07/17/24, showed the following: -On 07/09/24, staff were transporting resident back to the facility; -Transportation Staff A and Transportation Staff B loaded the resident into the back of the van in his/her electric wheelchair; -Transportation Staff A strapped down all four wheels on the resident's wheelchair. Transportation Staff A did not strap the resident's shoulder/lap seat belt in place; -Transportation Staff A reported three other residents were loaded in the front of the van and three wheelchairs were placed in the back of the van, in front of the resident's wheelchair; -Transportation Staff A was not able to strap the resident's shoulder/lap belt due to the three wheelchair's being stacked over the seatbelt strap that was located on the floor of the van; -During transport, the resident slid out of his/her wheelchair when the van stopped at a stop sign, hitting his/her knee on his/her leg rest of the wheelchair; -Transportation Staff A stopped the van and Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair; -Transportation Staff A remained next to the resident during the remainder of the transport. Review of the facility's signed statement by Transportation Staff A, dated 07/16/24, showed the following: -On 07/09/24, Transportation Staff B loaded the resident into the back of the van. Transportation Staff A strapped down all four wheels, but did not strap the shoulder/lap belt on the resident; -Transportation Staff A proceeded to assist in loading three other residents into the front bench seat of the van. Transportation Staff A placed all three wheelchairs in the back of the van next to the resident; -Transportation Staff A began driving the van back to the facility. When he/she stopped at a stop sign, he/she heard the resident yelling. Transportation Staff A stopped the van and went to the back of the van and saw the resident had slid out of his/her wheelchair seat, leaning forward, with his/her knee up against the leg rest of his/her wheelchair; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair and did not not secure the resident's shoulder/lap belt. -Transportation Staff A remained in the back of the van, next to the resident during the remainder of the trip. During an interview on 07/19/24, at 1:00 P.M., Transportation Staff A said the following: -On 07/09/24, he/she was transporting residents back and forth to the fairgrounds; -Transportation Staff B loaded the resident in the back of the van. Transportation Staff A strapped down all four wheels. Transportation Staff A then assisted Transportation Staff B in loading three additional residents in the front bench seat and then placing three wheelchairs in the back of the van next to the resident; -After placing the additional wheelchairs in the van, Transportation Staff A was not able to secure the shoulder/lap belt on the resident due to the wheelchairs being in the way of the belt; -They were driving back to the facility, stopped at a stop sign, and then heard the resident; -He/she stopped the van and went to the back of the van and saw the resident had slid out of his/her chair, leaning forward, up against the other wheelchairs with his/her knee resting on the leg rest of his/her wheelchair; -Transportation Staff A and Transportation Staff B pulled the resident back into his/her wheelchair and Transportation Staff A remained next to the resident the remainder of the trip allowing Transportation Staff B to drive back to the facility; -He/she received van transportation training on hire a few months ago by another transportation driver which included locking the wheels on the wheelchair, anchoring the wheelchair with four corner straps, and securing the resident with the shoulder/lap safety belt. Review of the facility's a signed statement by Transportation Staff B, dated 07/16/24, that showed the following: -On 07/09/24, Transportation Staff B loaded the resident into the van and Transportation A strapped down the resident's wheelchair, but did not buckle the shoulder/lap safety belt; -While Transportation Staff A was driving, the resident slid down off his/her wheelchair onto his/her footrest; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair and Transportation Staff A stayed in the back of the van with the resident; -Transportation Staff B drove back to the facility. During an interview on 07/19/24, at 1:22 P.M., Transportation Staff B said the following: -He/she loaded the resident into the back of the van and Transportation Staff A strapped down the wheelchair, but did not buckle the lap/shoulder safety belt. Transportation Staff B and Transportation Staff A then loaded three other residents into the front bench seat of the van placing three wheelchairs in the back of the van next to the resident; -Transportation Staff A was driving when they heard the resident yell. Transportation Staff A stopped the van, got out, and checked on the resident. Transportation Staff B then got out and saw the resident had slid out of his/her seat onto his/her footrest; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair. Transportation Staff A stayed in the back of the van and Transportation Staff B drove back to the facility; -Transportation B was hired to be a transportation driver. He/she received van transportation training a few years ago by another transportation driver which included locking the wheels on the wheelchair, anchoring the wheelchair with four corner straps, and securing the resident with the shoulder/lap safety belt. Observations on 07/19/24, at 2:10 P.M., of the facility van showed the van would accommodate one wheelchair. There were four-point straps and shoulder/lap belt on the floor in the back of the van. During an interview on 07/19/24, at 11:40 A.M., the resident said on 07/09/24, him/her and some of the other residents got to attend Senior Days at the fair. He/she remembered being loaded in the back of the van and remembered Transportation Staff A put both straps across his/her waist, but does not remember if both straps were placed coming back. Transportation Staff A drove over two large potholes in the road and it bounced him/her out of his/her seat in the wheelchair. He/she hit his/her right knee on the folded wheelchairs that were piled up in front of him/her. Transportation Staff A stopped the van and immediately came to the back of the van to check on him/her. Transportation Staff B then came to the back, and they were both able to lift the resident back up into his/her wheelchair seat. Transportation Staff A rode in the back of the van the rest of the way to the facility to make sure the resident did not fall again. Hitting his/her knee was painful. The nurse gave him/her pain medication and it helped, but as time went on the swelling and bruising started and the pain became worse. Review of the resident's nurses' notes, dated 07/09/24, showed Licensed Practical Nurse (LPN) C notified the physician of the incident and received orders for a portable x-ray of the right leg and left hand. Review of the resident's July 2024 Physician Order Sheet (POS) showed an order, dated 07/09/24, to obtain a portable x-ray of right leg and left hand. Review of resident's portable x-ray report, dated 07/10/24, showed a report of no acute findings. Review of the resident's nurses' notes, dated 07/15/24, showed LPN A notified the physician of bruising, swelling, and pain to resident's right leg and left hand. Review of the resident's nurses' notes, dated 07/16/24, showed the physician spoke with the Director of Nursing (DON) and requested an update on the bruising, swelling, and pain level of the resident. Review of the resident's July 2024 POS showed an order, dated 07/16/24, to send resident to the hospital for repeat x-ray of right leg and left hand. Review of the hospital Emergency Department Report, dated 07/16/24, showed a diagnosis of closed fracture of proximal end of right tibia (broken lower leg). Review of the resident's July 2024 POS showed the following: -An order, dated 07/17/24, to schedule MRI for right leg and left hand; -An order, dated 07/17/24, to schedule orthopedic appointment. During an interview on 07/19/24, at 12:40 P.M., the resident's physician said on 07/09/24, facility staff transported the resident to and from the fair for Senior Days. When returning to the facility, the resident fell out of his/her wheelchair while in the transportation van, hitting his/her right knee on the folded wheelchair in front of his/her. The physician did not know if the resident was properly secured during transportation. He/she ordered a portable x-ray the same day which did not show a fracture. He/she repeated the x-ray five days later, which then showed a fracture to the resident's leg. During an interview on 07/19/24, at 1:25 P.M., the Social Services Assistant (SSA) said that he/she is the supervisor for Transportation Staff A and Transportation Staff B. Both received training prior to SSA taking over the supervisor position. The driver should secure all wheelchairs with the four straps provided in the van and they should put the shoulder/lap safety belt on the resident. Everyone in the van should wear a seatbelt. During an interview on 07/25/24, at 10:10 A.M LPN A said the transportation staff should buckle up residents when transported in the facility van. During an interview on 07/25/24, at 1:40 P.M., the MDS Coordinator said the following: -The transportation staff are both certified nurse aides; -The transportation staff should ensure the front and back wheels on a resident's wheelchair are strapped correctly; -Staff should place the seat belt across a resident's wheelchair and buckle it; -It is not safe if staff did not buckle the seat belt. During an interview on 07/25/24, at 2:55 P.M., the DON said the following: -Staff load up a resident in the facility van and secure them; -Staff use the facility van's seat belts and floor straps to secure a resident in the van. During an interview on 07/17/24, at 1:40 P.M., with the former Administrator and the DON, the former Administrator said that he/she was notified of the incident the following day (07/10/24). The former Administrator said he/she was told that the resident had been strapped in except the top buckle had not been placed. A portable x-ray was obtained that reported no fracture initially. A repeat x-ray that was obtained 07/16/24 and showed a fracture to the resident's leg. The Administrator said the facility did not have a specific policy regarding van transportation. During an interview on 07/25/24, at 2:55 P.M., the current Administrator said she expected the staff to place the seat belt on residents for safety when transported in the van. MO00239377

1. Please refer to event ID26CF12, exit date 07/23/24, for details. MO00239179 Based on observation, interview, and record review, the facility failed to ensure all residents were kept as free from possible accident hazards as possible when the facility staff failed to fully secure one resident (Resident #1) in a wheelchair during transport in the facility's van resulting in a fracture of the resident's leg. The facility census was 54. Review showed the facility did not provide a policy and procedure, or a job description, specific to transporting residents in the facility van. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following information: -admission date of 12/18/19; -Diagnoses included hypertension (high blood pressure), congestive heart failure (CHF - chronic condition in which the heart doesn't pump blood as well as it should), and left leg amputation at the hip. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/06/24, showed the following information: -Cognitively intact; -Left leg amputation; -Dependent on staff for transfers from bed to wheelchair. Review of the resident's care plan, revised 07/23/24, showed the following information: -Resident at risk for falls due to weakness, decreased functional ability, chronic pain, and left leg amputation; -Extensive assistance needed for dressing, bathing, and toilet hygiene; -Total assistance needed for transfers and mobility. Review of the facility's Transport Incident Report, dated 07/17/24, showed the following: -On 07/09/24, staff were transporting resident back to the facility; -Transportation Staff A and Transportation Staff B loaded the resident into the back of the van in his/her electric wheelchair; -Transportation Staff A strapped down all four wheels on the resident's wheelchair. Transportation Staff A did not strap the resident's shoulder/lap seat belt in place; -Transportation Staff A reported three other residents were loaded in the front of the van and three wheelchairs were placed in the back of the van, in front of the resident's wheelchair; -Transportation Staff A was not able to strap the resident's shoulder/lap belt due to the three wheelchair's being stacked over the seatbelt strap that was located on the floor of the van; -During transport, the resident slid out of his/her wheelchair when the van stopped at a stop sign, hitting his/her knee on his/her leg rest of the wheelchair; -Transportation Staff A stopped the van and Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair; -Transportation Staff A remained next to the resident during the remainder of the transport. Review of the facility's signed statement by Transportation Staff A, dated 07/16/24, showed the following: -On 07/09/24, Transportation Staff B loaded the resident into the back of the van. Transportation Staff A strapped down all four wheels, but did not strap the shoulder/lap belt on the resident; -Transportation Staff A proceeded to assist in loading three other residents into the front bench seat of the van. Transportation Staff A placed all three wheelchairs in the back of the van next to the resident; -Transportation Staff A began driving the van back to the facility. When he/she stopped at a stop sign, he/she heard the resident yelling. Transportation Staff A stopped the van and went to the back of the van and saw the resident had slid out of his/her wheelchair seat, leaning forward, with his/her knee up against the leg rest of his/her wheelchair; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair and did not not secure the resident's shoulder/lap belt. -Transportation Staff A remained in the back of the van, next to the resident during the remainder of the trip. During an interview on 07/19/24, at 1:00 P.M., Transportation Staff A said the following: -On 07/09/24, he/she was transporting residents back and forth to the fairgrounds; -Transportation Staff B loaded the resident in the back of the van. Transportation Staff A strapped down all four wheels. Transportation Staff A then assisted Transportation Staff B in loading three additional residents in the front bench seat and then placing three wheelchairs in the back of the van next to the resident; -After placing the additional wheelchairs in the van, Transportation Staff A was not able to secure the shoulder/lap belt on the resident due to the wheelchairs being in the way of the belt; -They were driving back to the facility, stopped at a stop sign, and then heard the resident; -He/she stopped the van and went to the back of the van and saw the resident had slid out of his/her chair, leaning forward, up against the other wheelchairs with his/her knee resting on the leg rest of his/her wheelchair; -Transportation Staff A and Transportation Staff B pulled the resident back into his/her wheelchair and Transportation Staff A remained next to the resident the remainder of the trip allowing Transportation Staff B to drive back to the facility; -He/she received van transportation training on hire a few months ago by another transportation driver which included locking the wheels on the wheelchair, anchoring the wheelchair with four corner straps, and securing the resident with the shoulder/lap safety belt. Review of the facility's a signed statement by Transportation Staff B, dated 07/16/24, that showed the following: -On 07/09/24, Transportation Staff B loaded the resident into the van and Transportation A strapped down the resident's wheelchair, but did not buckle the shoulder/lap safety belt; -While Transportation Staff A was driving, the resident slid down off his/her wheelchair onto his/her footrest; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair and Transportation Staff A stayed in the back of the van with the resident; -Transportation Staff B drove back to the facility. During an interview on 07/19/24, at 1:22 P.M., Transportation Staff B said the following: -He/she loaded the resident into the back of the van and Transportation Staff A strapped down the wheelchair, but did not buckle the lap/shoulder safety belt. Transportation Staff B and Transportation Staff A then loaded three other residents into the front bench seat of the van placing three wheelchairs in the back of the van next to the resident; -Transportation Staff A was driving when they heard the resident yell. Transportation Staff A stopped the van, got out, and checked on the resident. Transportation Staff B then got out and saw the resident had slid out of his/her seat onto his/her footrest; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair. Transportation Staff A stayed in the back of the van and Transportation Staff B drove back to the facility; -Transportation B was hired to be a transportation driver. He/she received van transportation training a few years ago by another transportation driver which included locking the wheels on the wheelchair, anchoring the wheelchair with four corner straps, and securing the resident with the shoulder/lap safety belt. Observations on 07/19/24, at 2:10 P.M., of the facility van showed the van would accommodate one wheelchair. There were four-point straps and shoulder/lap belt on the floor in the back of the van. During an interview on 07/19/24, at 11:40 A.M., the resident said on 07/09/24, him/her and some of the other residents got to attend Senior Days at the fair. He/she remembered being loaded in the back of the van and remembered Transportation Staff A put both straps across his/her waist, but does not remember if both straps were placed coming back. Transportation Staff A drove over two large potholes in the road and it bounced him/her out of his/her seat in the wheelchair. He/she hit his/her right knee on the folded wheelchairs that were piled up in front of him/her. Transportation Staff A stopped the van and immediately came to the back of the van to check on him/her. Transportation Staff B then came to the back, and they were both able to lift the resident back up into his/her wheelchair seat. Transportation Staff A rode in the back of the van the rest of the way to the facility to make sure the resident did not fall again. Hitting his/her knee was painful. The nurse gave him/her pain medication and it helped, but as time went on the swelling and bruising started and the pain became worse. Review of the resident's nurses' notes, dated 07/09/24, showed Licensed Practical Nurse (LPN) C notified the physician of the incident and received orders for a portable x-ray of the right leg and left hand. Review of the resident's July 2024 Physician Order Sheet (POS) showed an order, dated 07/09/24, to obtain a portable x-ray of right leg and left hand. Review of resident's portable x-ray report, dated 07/10/24, showed a report of no acute findings. Review of the resident's nurses' notes, dated 07/15/24, showed LPN A notified the physician of bruising, swelling, and pain to resident's right leg and left hand. Review of the resident's nurses' notes, dated 07/16/24, showed the physician spoke with the Director of Nursing (DON) and requested an update on the bruising, swelling, and pain level of the resident. Review of the resident's July 2024 POS showed an order, dated 07/16/24, to send resident to the hospital for repeat x-ray of right leg and left hand. Review of the hospital Emergency Department Report, dated 07/16/24, showed a diagnosis of closed fracture of proximal end of right tibia (broken lower leg). Review of the resident's July 2024 POS showed the following: -An order, dated 07/17/24, to schedule MRI for right leg and left hand; -An order, dated 07/17/24, to schedule orthopedic appointment. During an interview on 07/19/24, at 12:40 P.M., the resident's physician said on 07/09/24, facility staff transported the resident to and from the fair for Senior Days. When returning to the facility, the resident fell out of his/her wheelchair while in the transportation van, hitting his/her right knee on the folded wheelchair in front of his/her. The physician did not know if the resident was properly secured during transportation. He/she ordered a portable x-ray the same day which did not show a fracture. He/she repeated the x-ray five days later, which then showed a fracture to the resident's leg. During an interview on 07/19/24, at 1:25 P.M., the Social Services Assistant (SSA) said that he/she is the supervisor for Transportation Staff A and Transportation Staff B. Both received training prior to SSA taking over the supervisor position. The driver should secure all wheelchairs with the four straps provided in the van and they should put the shoulder/lap safety belt on the resident. Everyone in the van should wear a seatbelt. During an interview on 07/25/24, at 10:10 A.M LPN A said the transportation staff should buckle up residents when transported in the facility van. During an interview on 07/25/24, at 1:40 P.M., the MDS Coordinator said the following: -The transportation staff are both certified nurse aides; -The transportation staff should ensure the front and back wheels on a resident's wheelchair are strapped correctly; -Staff should place the seat belt across a resident's wheelchair and buckle it; -It is not safe if staff did not buckle the seat belt. During an interview on 07/25/24, at 2:55 P.M., the DON said the following: -Staff load up a resident in the facility van and secure them; -Staff use the facility van's seat belts and floor straps to secure a resident in the van. During an interview on 07/17/24, at 1:40 P.M., with the former Administrator and the DON, the former Administrator said that he/she was notified of the incident the following day (07/10/24). The former Administrator said he/she was told that the resident had been strapped in except the top buckle had not been placed. A portable x-ray was obtained that reported no fracture initially. A repeat x-ray that was obtained 07/16/24 and showed a fracture to the resident's leg. The Administrator said the facility did not have a specific policy regarding van transportation. During an interview on 07/25/24, at 2:55 P.M., the current Administrator said she expected the staff to place the seat belt on residents for safety when transported in the van. MO00239377

Based on observation, interview, and record review, the facility failed to ensure all residents were kept as free from possible accident hazards as possible when the facility staff failed to fully secure one resident (Resident #1) in a wheelchair during transport in the facility's van resulting in a fracture of the resident's leg. The facility census was 54. Review showed the facility did not provide a policy and procedure, or a job description, specific to transporting residents in the facility van. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following information: -admitted [DATE]; -Diagnoses included hypertension (high blood pressure), congestive heart failure (CHF - chronic condition in which the heart doesn't pump blood as well as it should), and left leg amputation at the hip. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/06/24, showed the following information: -Cognitively intact; -Left leg amputation; -Dependent on staff for transfers from bed to wheelchair. Review of the resident's care plan, revised 07/23/24, showed the following information: -Resident at risk for falls due to weakness, decreased functional ability, chronic pain, and left leg amputation; -Extensive assistance needed for dressing, bathing, and toilet hygiene; -Total assistance needed for transfers and mobility. Review of the facility's Transport Incident Report, dated 07/17/24, showed the following: -On 07/09/24, staff were transporting resident back to the facility; -Transportation Staff A and Transportation Staff B loaded the resident into the back of the van in his/her electric wheelchair; -Transportation Staff A strapped down all four wheels on the resident's wheelchair. Transportation Staff A did not strap the resident's shoulder/lap seat belt in place; -Transportation Staff A reported three other residents were loaded in the front of the van and three wheelchairs were placed in the back of the van, in front of the resident's wheelchair; -Transportation Staff A was not able to strap the resident's shoulder/lap belt due to the three wheelchair's being stacked over the seatbelt strap that was located on the floor of the van; -During transport, the resident slid out of his/her wheelchair when the van stopped at a stop sign, hitting his/her knee on his/her leg rest of the wheelchair; -Transportation Staff A stopped the van and Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair; -Transportation Staff A remained next to the resident during the remainder of the transport. Review of the facility's signed statement by Transportation Staff A, dated 07/16/24, showed the following: -On 07/09/24, Transportation Staff B loaded the resident into the back of the van. Transportation Staff A strapped down all four wheels, but did not strap the shoulder/lap belt on the resident; -Transportation Staff A proceeded to assist in loading three other residents into the front bench seat of the van. Transportation Staff A placed all three wheelchairs in the back of the van next to the resident; -Transportation Staff A began driving the van back to the facility. When he/she stopped at a stop sign, he/she heard the resident yelling. Transportation Staff A stopped the van and went to the back of the van and saw the resident had slid out of his/her wheelchair seat, leaning forward, with his/her knee up against the leg rest of his/her wheelchair; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair and did not not secure the resident's shoulder/lap belt. -Transportation Staff A remained in the back of the van, next to the resident during the remainder of the trip. During an interview on 07/19/24, at 1:00 P.M., Transportation Staff A said the following: -On 07/09/24, he/she was transporting residents back and forth to the fairgrounds; -Transportation Staff B loaded the resident in the back of the van. Transportation Staff A strapped down all four wheels. Transportation Staff A then assisted Transportation Staff B in loading three additional residents in the front bench seat and then placing three wheelchairs in the back of the van next to the resident; -After placing the additional wheelchairs in the van, Transportation Staff A was not able to secure the shoulder/lap belt on the resident due to the wheelchairs being in the way of the belt; -They were driving back to the facility, stopped at a stop sign, and then heard the resident; -He/she stopped the van and went to the back of the van and saw the resident had slid out of his/her chair, leaning forward, up against the other wheelchairs with his/her knee resting on the leg rest of his/her wheelchair; -Transportation Staff A and Transportation Staff B pulled the resident back into his/her wheelchair and Transportation Staff A remained next to the resident the remainder of the trip allowing Transportation Staff B to drive back to the facility; -He/she received van transportation training on hire a few months ago by another transportation driver which included locking the wheels on the wheelchair, anchoring the wheelchair with four corner straps, and securing the resident with the shoulder/lap safety belt. Review of the facility's a signed statement by Transportation Staff B, dated 07/16/24, that showed the following: -On 07/09/24, Transportation Staff B loaded the resident into the van and Transportation A strapped down the resident's wheelchair, but did not buckle the shoulder/lap safety belt; -While Transportation Staff A was driving, the resident slid down off his/her wheelchair onto his/her footrest; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair and Transportation Staff A stayed in the back of the van with the resident; -Transportation Staff B drove back to the facility. During an interview on 07/19/24, at 1:22 P.M., Transportation Staff B said the following: -He/she loaded the resident into the back of the van and Transportation Staff A strapped down the wheelchair, but did not buckle the lap/shoulder safety belt. Transportation Staff B and Transportation Staff A then loaded three other residents into the front bench seat of the van placing three wheelchairs in the back of the van next to the resident; -Transportation Staff A was driving when they heard the resident yell. Transportation Staff A stopped the van, got out, and checked on the resident. Transportation Staff B then got out and saw the resident had slid out of his/her seat onto his/her footrest; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair. Transportation Staff A stayed in the back of the van and Transportation Staff B drove back to the facility; -Transportation B was hired to be a transportation driver. He/she received van transportation training a few years ago by another transportation driver which included locking the wheels on the wheelchair, anchoring the wheelchair with four corner straps, and securing the resident with the shoulder/lap safety belt. Observations on 07/19/24, at 2:10 P.M., of the facility van showed the van would accommodate one wheelchair. There were four-point straps and shoulder/lap belt on the floor in the back of the van. During an interview on 07/19/24, at 11:40 A.M., the resident said on 07/09/24, him/her and some of the other residents got to attend Senior Days at the fair. He/she remembered being loaded in the back of the van and remembered Transportation Staff A put both straps across his/her waist, but does not remember if both straps were placed coming back. Transportation Staff A drove over two large potholes in the road and it bounced him/her out of his/her seat in the wheelchair. He/she hit his/her right knee on the folded wheelchairs that were piled up in front of him/her. Transportation Staff A stopped the van and immediately came to the back of the van to check on him/her. Transportation Staff B then came to the back, and they were both able to lift the resident back up into his/her wheelchair seat. Transportation Staff A rode in the back of the van the rest of the way to the facility to make sure the resident did not fall again. Hitting his/her knee was painful. The nurse gave him/her pain medication and it helped, but as time went on the swelling and bruising started and the pain became worse. Review of the resident's nurses' notes, dated 07/09/24, showed Licensed Practical Nurse (LPN) C notified the physician of the incident and received orders for a portable x-ray of the right leg and left hand. Review of the resident's July 2024 Physician Order Sheet (POS) showed an order, dated 07/09/24, to obtain a portable x-ray of right leg and left hand. Review of resident's portable x-ray report, dated 07/10/24, showed a report of no acute findings. Review of the resident's nurses' notes, dated 07/15/24, showed LPN A notified the physician of bruising, swelling, and pain to resident's right leg and left hand. Review of the resident's nurses' notes, dated 07/16/24, showed the physician spoke with the Director of Nursing (DON) and requested an update on the bruising, swelling, and pain level of the resident. Review of the resident's July 2024 POS showed an order, dated 07/16/24, to send resident to the hospital for repeat x-ray of right leg and left hand. Review of the hospital Emergency Department Report, dated 07/16/24, showed a diagnosis of closed fracture of proximal end of right tibia (broken lower leg). Review of the resident's July 2024 POS showed the following: -An order, dated 07/17/24, to schedule MRI for right leg and left hand; -An order, dated 07/17/24, to schedule orthopedic appointment. During an interview on 07/19/24, at 12:40 P.M., the resident's physician said on 07/09/24, facility staff transported the resident to and from the fair for Senior Days. When returning to the facility, the resident fell out of his/her wheelchair while in the transportation van, hitting his/her right knee on the folded wheelchair in front of his/her. The physician did not know if the resident was properly secured during transportation. He/she ordered a portable x-ray the same day which did not show a fracture. He/she repeated the x-ray five days later, which then showed a fracture to the resident's leg. During an interview on 07/19/24, at 1:25 P.M., the Social Services Assistant (SSA) said that he/she is the supervisor for Transportation Staff A and Transportation Staff B. Both received training prior to SSA taking over the supervisor position. The driver should secure all wheelchairs with the four straps provided in the van and they should put the shoulder/lap safety belt on the resident. Everyone in the van should wear a seatbelt. During an interview on 07/25/24, at 10:10 A.M LPN A said the transportation staff should buckle up residents when transported in the facility van. During an interview on 07/25/24, at 1:40 P.M., the MDS Coordinator said the following: -The transportation staff are both certified nurse aides; -The transportation staff should ensure the front and back wheels on a resident's wheelchair are strapped correctly; -Staff should place the seat belt across a resident's wheelchair and buckle it; -It is not safe if staff did not buckle the seat belt. During an interview on 07/25/24, at 2:55 P.M., the DON said the following: -Staff load up a resident in the facility van and secure them; -Staff use the facility van's seat belts and floor straps to secure a resident in the van. During an interview on 07/17/24, at 1:40 P.M., with the former Administrator and the DON, the former Administrator said that he/she was notified of the incident the following day (07/10/24). The former Administrator said he/she was told that the resident had been strapped in except the top buckle had not been placed. A portable x-ray was obtained that reported no fracture initially. A repeat x-ray that was obtained 07/16/24 and showed a fracture to the resident's leg. The Administrator said the facility did not have a specific policy regarding van transportation. During an interview on 07/25/24, at 2:55 P.M., the current Administrator said she expected the staff to place the seat belt on residents for safety when transported in the van. MO00239377 34871

Based on observation, interview, and record review, the facility failed to ensure all residents were kept as free from possible accident hazards as possible when the facility staff failed to fully secure one resident (Resident #1) in a wheelchair during transport in the facility's van resulting in a fracture of the resident's leg. The facility census was 54. Review showed the facility did not provide a policy and procedure, or a job description, specific to transporting residents in the facility van. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following information: -admission date of 12/18/19; -Diagnoses included hypertension (high blood pressure), congestive heart failure (CHF - chronic condition in which the heart doesn't pump blood as well as it should), and left leg amputation at the hip. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/06/24, showed the following information: -Cognitively intact; -Left leg amputation; -Dependent on staff for transfers from bed to wheelchair. Review of the resident's care plan, revised 07/23/24, showed the following information: -Resident at risk for falls due to weakness, decreased functional ability, chronic pain, and left leg amputation; -Extensive assistance needed for dressing, bathing, and toilet hygiene; -Total assistance needed for transfers and mobility. Review of the facility's Transport Incident Report, dated 07/17/24, showed the following: -On 07/09/24, staff were transporting resident back to the facility; -Transportation Staff A and Transportation Staff B loaded the resident into the back of the van in his/her electric wheelchair; -Transportation Staff A strapped down all four wheels on the resident's wheelchair. Transportation Staff A did not strap the resident's shoulder/lap seat belt in place; -Transportation Staff A reported three other residents were loaded in the front of the van and three wheelchairs were placed in the back of the van, in front of the resident's wheelchair; -Transportation Staff A was not able to strap the resident's shoulder/lap belt due to the three wheelchair's being stacked over the seatbelt strap that was located on the floor of the van; -During transport, the resident slid out of his/her wheelchair when the van stopped at a stop sign, hitting his/her knee on his/her leg rest of the wheelchair; -Transportation Staff A stopped the van and Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair; -Transportation Staff A remained next to the resident during the remainder of the transport. Review of the facility's signed statement by Transportation Staff A, dated 07/16/24, showed the following: -On 07/09/24, Transportation Staff B loaded the resident into the back of the van. Transportation Staff A strapped down all four wheels, but did not strap the shoulder/lap belt on the resident; -Transportation Staff A proceeded to assist in loading three other residents into the front bench seat of the van. Transportation Staff A placed all three wheelchairs in the back of the van next to the resident; -Transportation Staff A began driving the van back to the facility. When he/she stopped at a stop sign, he/she heard the resident yelling. Transportation Staff A stopped the van and went to the back of the van and saw the resident had slid out of his/her wheelchair seat, leaning forward, with his/her knee up against the leg rest of his/her wheelchair; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair and did not not secure the resident's shoulder/lap belt. -Transportation Staff A remained in the back of the van, next to the resident during the remainder of the trip. During an interview on 07/19/24, at 1:00 P.M., Transportation Staff A said the following: -On 07/09/24, he/she was transporting residents back and forth to the fairgrounds; -Transportation Staff B loaded the resident in the back of the van. Transportation Staff A strapped down all four wheels. Transportation Staff A then assisted Transportation Staff B in loading three additional residents in the front bench seat and then placing three wheelchairs in the back of the van next to the resident; -After placing the additional wheelchairs in the van, Transportation Staff A was not able to secure the shoulder/lap belt on the resident due to the wheelchairs being in the way of the belt; -They were driving back to the facility, stopped at a stop sign, and then heard the resident; -He/she stopped the van and went to the back of the van and saw the resident had slid out of his/her chair, leaning forward, up against the other wheelchairs with his/her knee resting on the leg rest of his/her wheelchair; -Transportation Staff A and Transportation Staff B pulled the resident back into his/her wheelchair and Transportation Staff A remained next to the resident the remainder of the trip allowing Transportation Staff B to drive back to the facility; -He/she received van transportation training on hire a few months ago by another transportation driver which included locking the wheels on the wheelchair, anchoring the wheelchair with four corner straps, and securing the resident with the shoulder/lap safety belt. Review of the facility's a signed statement by Transportation Staff B, dated 07/16/24, that showed the following: -On 07/09/24, Transportation Staff B loaded the resident into the van and Transportation A strapped down the resident's wheelchair, but did not buckle the shoulder/lap safety belt; -While Transportation Staff A was driving, the resident slid down off his/her wheelchair onto his/her footrest; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair and Transportation Staff A stayed in the back of the van with the resident; -Transportation Staff B drove back to the facility. During an interview on 07/19/24, at 1:22 P.M., Transportation Staff B said the following: -He/she loaded the resident into the back of the van and Transportation Staff A strapped down the wheelchair, but did not buckle the lap/shoulder safety belt. Transportation Staff B and Transportation Staff A then loaded three other residents into the front bench seat of the van placing three wheelchairs in the back of the van next to the resident; -Transportation Staff A was driving when they heard the resident yell. Transportation Staff A stopped the van, got out, and checked on the resident. Transportation Staff B then got out and saw the resident had slid out of his/her seat onto his/her footrest; -Transportation Staff A and Transportation Staff B lifted the resident back into his/her wheelchair. Transportation Staff A stayed in the back of the van and Transportation Staff B drove back to the facility; -Transportation B was hired to be a transportation driver. He/she received van transportation training a few years ago by another transportation driver which included locking the wheels on the wheelchair, anchoring the wheelchair with four corner straps, and securing the resident with the shoulder/lap safety belt. Observations on 07/19/24, at 2:10 P.M., of the facility van showed the van would accommodate one wheelchair. There were four-point straps and shoulder/lap belt on the floor in the back of the van. During an interview on 07/19/24, at 11:40 A.M., the resident said on 07/09/24, him/her and some of the other residents got to attend Senior Days at the fair. He/she remembered being loaded in the back of the van and remembered Transportation Staff A put both straps across his/her waist, but does not remember if both straps were placed coming back. Transportation Staff A drove over two large potholes in the road and it bounced him/her out of his/her seat in the wheelchair. He/she hit his/her right knee on the folded wheelchairs that were piled up in front of him/her. Transportation Staff A stopped the van and immediately came to the back of the van to check on him/her. Transportation Staff B then came to the back, and they were both able to lift the resident back up into his/her wheelchair seat. Transportation Staff A rode in the back of the van the rest of the way to the facility to make sure the resident did not fall again. Hitting his/her knee was painful. The nurse gave him/her pain medication and it helped, but as time went on the swelling and bruising started and the pain became worse. Review of the resident's nurses' notes, dated 07/09/24, showed Licensed Practical Nurse (LPN) C notified the physician of the incident and received orders for a portable x-ray of the right leg and left hand. Review of the resident's July 2024 Physician Order Sheet (POS) showed an order, dated 07/09/24, to obtain a portable x-ray of right leg and left hand. Review of resident's portable x-ray report, dated 07/10/24, showed a report of no acute findings. Review of the resident's nurses' notes, dated 07/15/24, showed LPN A notified the physician of bruising, swelling, and pain to resident's right leg and left hand. Review of the resident's nurses' notes, dated 07/16/24, showed the physician spoke with the Director of Nursing (DON) and requested an update on the bruising, swelling, and pain level of the resident. Review of the resident's July 2024 POS showed an order, dated 07/16/24, to send resident to the hospital for repeat x-ray of right leg and left hand. Review of the hospital Emergency Department Report, dated 07/16/24, showed a diagnosis of closed fracture of proximal end of right tibia (broken lower leg). Review of the resident's July 2024 POS showed the following: -An order, dated 07/17/24, to schedule MRI for right leg and left hand; -An order, dated 07/17/24, to schedule orthopedic appointment. During an interview on 07/19/24, at 12:40 P.M., the resident's physician said on 07/09/24, facility staff transported the resident to and from the fair for Senior Days. When returning to the facility, the resident fell out of his/her wheelchair while in the transportation van, hitting his/her right knee on the folded wheelchair in front of his/her. The physician did not know if the resident was properly secured during transportation. He/she ordered a portable x-ray the same day which did not show a fracture. He/she repeated the x-ray five days later, which then showed a fracture to the resident's leg. During an interview on 07/19/24, at 1:25 P.M., the Social Services Assistant (SSA) said that he/she is the supervisor for Transportation Staff A and Transportation Staff B. Both received training prior to SSA taking over the supervisor position. The driver should secure all wheelchairs with the four straps provided in the van and they should put the shoulder/lap safety belt on the resident. Everyone in the van should wear a seatbelt. During an interview on 07/25/24, at 10:10 A.M LPN A said the transportation staff should buckle up residents when transported in the facility van. During an interview on 07/25/24, at 1:40 P.M., the MDS Coordinator said the following: -The transportation staff are both certified nurse aides; -The transportation staff should ensure the front and back wheels on a resident's wheelchair are strapped correctly; -Staff should place the seat belt across a resident's wheelchair and buckle it; -It is not safe if staff did not buckle the seat belt. During an interview on 07/25/24, at 2:55 P.M., the DON said the following: -Staff load up a resident in the facility van and secure them; -Staff use the facility van's seat belts and floor straps to secure a resident in the van. During an interview on 07/17/24, at 1:40 P.M., with the former Administrator and the DON, the former Administrator said that he/she was notified of the incident the following day (07/10/24). The former Administrator said he/she was told that the resident had been strapped in except the top buckle had not been placed. A portable x-ray was obtained that reported no fracture initially. A repeat x-ray that was obtained 07/16/24 and showed a fracture to the resident's leg. The Administrator said the facility did not have a specific policy regarding van transportation. During an interview on 07/25/24, at 2:55 P.M., the current Administrator said she expected the staff to place the seat belt on residents for safety when transported in the van. MO00239377

Based on interview, record review, and observation, the facility failed to have a system in place to ensure physician ordered appointments, labs, and procedures were scheduled timely resulting in an ordered mammogram and MRI for one resident (Resident #1) not to be completed for a possible breast cancer diagnosis which delayed treatment options. The facility census was 69. The Administrator and Director of Nursing (DON), were notified on 08/08/23, of the Past Non-Compliance Immediate Jeopardy which began on 03/01/23. On 08/01/23, the DON reviewed the resident's chart and began an investigation, educated the employees involved, in-serviced all facility staff, and is monitoring charts daily to ensure ordered appointments are being completed timely. The noncompliance was corrected on 08/04/23. Review showed the facility did not provide a policy related to scheduling appointments or medical testing. Review of the facility's policy titled, Resident Transportation Agreements, undated, showed the following information: -The Social Service Department will arrange transportation for appointments as directed by the physician, charge nurse, family or resident. The facility provides a passenger van for use by the facility personnel for travel on facility-related business or activities, or other uses deemed necessary by the Administrator; -Discuss resident trips with the charge nurse to make sure resident is able to make trip and determine if additional attendant is needed; -Each resident is to be signed out with the charge nurse before leaving the facility; -The designated driver will ensure the safety and placement of all residents preparing for travel by physically overseeing the preparation for travel; -Upon return, each resident will be signed back into the facility by notifying the charge nurse. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included malignant neoplasm (cancer) of left ovary (female reproductive organ in which eggs are produce), malignant neoplasm of overlapping site of colon (longest part of the large intestine), type 2 diabetes mellitus (problem in the way the body regulates and uses sugar as a fuel) without complications, dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), chronic obstructive pulmonary disease (COPD - condition involving constriction of the airways and difficulty or discomfort in breathing), and chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia (low blood oxygen in the tissues). Review of the resident's significant change of condition Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 04/18/23, showed the following: -Severe cognitive impairment; -Required extensive assistance of two staff for bed mobility, transfers, and dressing; -Required extensive assistance of one staff for locomotion and personal hygiene. Review of the resident's care plan, last reviewed 06/13/23, showed the following: -Resident was not able to understand everything being said due to impaired cognitive functioning; -Staff should speak in clear, simple sentences when addressing the resident; -Staff should identify self by name and address the resident by name; -Resident has generalized pain; -Staff should administer pain medications as ordered; -Staff should notify the charge nurse of signs and symptoms of pain, both verbal and non-verbal. Review of the resident's progress notes showed the following: -On 03/01/23, at 6:19 P.M., the resident was seen in-house by the physician. Physician ordered a referral for bilateral diagnostic mammogram to rule out cancer due to a mass noted to the right breast; -From 03/02/23 to 03/28/23, staff did not document follow-up regarding the order for a mammogram; -On 03/29/23, at 12:53 P.M., the resident was seen in-house by the physician. Resident's right breast is red and warm to the touch, orange peel-like appearance, with multiple small lumps, and history of cancer. Physician ordered referral for right breast biopsy, fine needle aspiration. Staff notified appropriate parties, including resident's guardian; -On 03/29/23, at 6:3 P.M., the resident had a mammogram appointment scheduled for 04/04/23 at 1:00 P.M.; -On 04/04/23, at 4:02 P.M., the resident returned from an appointment, he/she had a needle aspiration biopsy done. No new orders upon return. Staff ordered to leave the dressing in place until tomorrow and remove it. They will fax results when they are complete. -Staff did not document regarding mammogram not completed or reason why; -On 04/05/23, at 10:34 A.M., resident was seen in house by the physician. The physician issued no new orders at this time; -On 04/05/23, at 1:45 P.M., the physician documented the pathology report (medical report that describes the characteristics of a tissue specimen that is taken from a patient) revealed right breast edema (swelling or inflammation) punch biopsy fragments of benign (non-cancer) skin with mild perivascular (occurring around a blood vessel) chronic inflammation (slow, long-term inflammation lasting for prolonged periods of several months to years) of papillary (superficial layer) and deep dermis (deeper and thicker layer of the dermis (the middle layer of skin in the body), which lies above the subcutaneous layer of the skin), no atypia (abnormal cells), no malignancy (cancer) seen on the original and multiple step to step sections. Review of the resident's progress notes showed the following: -On 05/03/23, at 9:38 A.M., the resident was seen by the physician today with no new orders at this time; -On 05/04/23, at 9:52 A.M., received an order from the physician for clindamycin (antibiotic) 300 milligrams (mg) three times daily for ten days, for unspecified lump in breast. Staff notified the guardian. Review of the resident's Physician Order Sheet (POS), up to date as of 08/05/23, showed an order, dated 05/04/23, for clindamycin 300 mg, three times daily for ten days, for unspecified breast lump. Review of the resident's progress notes showed the following: -On 05/05/23, at 5:55 P.M., the resident is on an antibiotic due to a cyst in the left breast. The resident denies pain except on palpation (method of feeling with the fingers or hands during a physical examination). The area is red and hot at times, but afebrile (no fever). No adverse effect. The resident does not want to wear a bra at this time for support. Will continue current plan of care; -On 05/06/23, at 1:03 P.M., the resident continues on clindamycin until 05/13/23 for right breast infection. Right breast slightly red at this time. No open areas noted. Breast is tender to touch. Extremely hard area under nipple at this time that takes up most of lower breast. No signs or symptoms of any adverse reaction to antibiotic notes. Will continue to monitor; -On 05/07/23, at 3:13 P.M., the resident continued on clindamycin until 05/13/23 for right breast infection. Right breast slightly red at this time. No open areas noted. Breast is tender to touch. Extremely hard area under nipple at this time and takes up most of lower breast. No signs or symptoms of any adverse reaction to antibiotic noted. Will continue to monitor; Review of the resident's May 2023 Medication Administration Record (MAR) showed the resident received clindamycin 300 mg daily from 05/05/23 through 05/15/23. Review of the resident's progress notes showed the following: -On 05/16/23, at 2:18 P.M., the resident completed his/her antibiotic course on 05/13/23. The right breast remains swollen and hard, it has also spread to under his/her arm pit and side area. Physician notified and will see the resident in-house tomorrow; -On 05/17/23, at 9:59 A.M., the resident was seen in-house by the physician. Physician ordered an MRI (magnetic resonance imaging - noninvasive medical imaging test that produces detailed images of almost every internal structure in the human body) without contrast of right breast due to lump spreading. Review of the resident's POS, up to date as of 08/05/23, showed an order, dated 05/18/23, for an MRI for lump on right breast. Review of the resident's progress notes showed staff documented the following: -On 06/07/23, at 1:48 P.M., the resident was seen by the physician by telehealth visit with no new orders; -On 07/12/23, at 11:04 A.M., the resident was seen in house by the physician with no new orders; -From 05/18/23 to 07/25/23, staff did not document regarding the ordered MRI. Review of the resident's POS, up to date as of 08/05/23, showed the order, dated 05/18/23, for an MRI for lump on right breast was discontinued (fell off orders) on 07/26/23. Review of the resident's progress notes showed staff documented the following: -On 08/01/23, at 3:04 P.M., the resident had an MRI appointment on 09/05/23; -On 08/04/23, at 9:06 A.M., resident had a noted decline. He/she has not been wanting to eat or drink well. Voices very little, but appears to be in pain with Tylenol (brand name for acetaminophen - used to reduce mild to moderate pain and reduce fever) given as ordered and does not seem to help. Now he/she is having skin breakdown, the right breast continues to remain hard and tender to touch and had gotten larger since last assessment. Resident is having a hard time holding his/her head up and no trunk support. Maximum assist of two person needed. Requested management order broda chair (wheelchair that tilts and reclines to provide postural support and help the person to remain upright, even after extended periods of sitting) for more safe stability while up. Also have social services contact guardian and speak about hospice. Physician was sent the request for hospice consult; -On 08/04/23, at 10:31 A.M., MRI right breast scheduled for 08/17/23 at 10:00 A.M. During an observation and interview on 08/05/23, at 10:10 A.M., Licensed Practical Nurse (LPN) A said the resident's right breast was warm to touch. The area was red, with significant dimpling, and orange-peel appearance. There was an area with an approximate 2 by 3 inch dressing, with date 08/03/23, on the outer side of the breast. Review of the resident's progress notes showed staff documented the following: -On 08/08/23, at 10:45 A.M., MRI of the right breast was ordered on 05/17/23. The order was faxed on 05/22/23. Scheduling from the MRI facility called the nursing facility and when there was no answer the order was dropped. Continues to have some redness and swelling of the right breast despite pathology negative and treated for cellulitis; -On 08/09/23, at 5:22 P.M., the physician documented extremely suspicious of breast cancer inflammatory disease back in May. However to proceed with the diagnosis, he/she felt it was necessary to get an objective finding, such as a biopsy. The biopsy was negative. Having the diagnosis of inflammatory breast cancer in May would not have changed the treatment other than palliative treatment would have been instituted earlier. Making the definite diagnosis today will expedite comfort care treatment. Clinically this is inflammatory breast cancer with very poor prognosis. Keeping the public administrator involved and informed of any change is vital in the resident's care. During an interview on 08/08/23, at 11:50 A.M., Transportation E said he/she thought it was social services responsibility to make appointments. He/she said the order for the resident's MRI was faxed to the MRI facility. He/she was told they called, but were put on hold and hung up. He/she said LPN K will give the referral for appointments, then Transportation E faxed the orders as needed. He/she keeps a stack of all faxed referral orders. As the appointments are scheduled he/she took the order out of the faxed file and put it in an appointment stack. He/she did not follow up on the faxed pile, he/she just waited until someone called back or asked about it. During an interview on 08/08/23, at 11:33 A.M., Assistant Social Services Director (SSD), said he/she took over scheduling appointments at the end of May 2023. He/she and Transportation E sat down and discussed the scheduling process. Sometime during the end of June and beginning of July was the first time that he/she heard about the resident having a referral since 05/17/23 for an MRI, Transportation E did not say anything. Assistant SSD printed the order and taped it into his/her scheduling notebook. The first of July the MRI facility called and said the appointment required a prior authorization. He/she then notified LPN K about the required authorization needed, and put the order on his/her own desk. The referral sat for one week on his/her desk and when no one got back to Assistant SSD, he/she threw away the referral. Transportation E now completes the appointments. During an interview on 08/08/23, at 12:55 P.M., LPN K said he/she does rounds with the physician each week. He/she used to enter the orders, notify the charge nurse, and notify transportation, which was Assistant SSD and then Transportation E, and was then done with the referral with no further follow-up. During an interview on 08/05/23, at 10:18 A.M., the Social Services Director (SSD) said staff should notify LPN K when they receive an order for any type of appointment. LPN K helps set up the appointment and lets Transportation E know the appointment is scheduled. The resident has a type of managed care insurance and requires approval first for different types of appointments. Assistant SSD sends in the request for verification and once the approval is received, he/she should let Transportation E know so the appointment can be scheduled. The staff should let the nurse, transportation, and social services know if an appointment is rescheduled. On 07/28/23, SSD received an email from the insurance provider questioning the status of the resident's MRI. Staff then starting looking into why the resident had not had an MRI appointment. During an interview on 08/05/23, at 9:46 A.M., LPN A said after an order is received to schedule an appointment or testing, the nurse should let the social service department and DON know and put the order in the staff report book. The guardian should be notified. Transportation should be notified. The transportation staff provided the weekly appointment schedule to the nurse station and it should be followed through on the nursing report book. Social services schedules the resident appointments. During an interview on 08/05/23, at 9:55 A.M., Certified Nurse Aide (CNA) C said every morning in report rounds staff are made aware of all appointments for the day. Transportation E brings a weekly schedule for appointments that is posted at the nursing desk. CNA C did not know who actually scheduled resident appointments. During an interview on 08/08/23, at 12:45 P.M., LPN I said when the nurses receive an order for an appointment to be scheduled, they are to enter the order in the computer and print off the order and give one copy to transportation. LPN I does not personally follow up that the order gets completed. He/she said the department heads know and follow up. The transportation staff make resident appointments and would expect the staff to notify nursing if the appointment was delayed or re-scheduled. During an interview on 08/08/23, at 12:50 P.M., LPN J said when he/she enters an order for an appointment to be scheduled, he/she prints the order and gives a copy to transportation and to social services. LPN J said he/she would usually try to follow up personally a few days later. During an interview on 08/08/23, at 1:08 P.M., Registered Nurse (RN) G said when a doctor gives an order, he/she checks the system and if it was for a referral the nurse should give a copy of the order to Assistant SSD and Transportation E to schedule the appointment. Normally Transportation E sets up the appointment and notifies staff if there was a rescheduled appointment. During an interview on 08/08/23, at 12:00 P.M., the Physician said he/she really thought the resident had cancer from the beginning and was trying to save some time to get the diagnosis and wanted to start with an MRI instead of a mammogram. The surgeon that completed the biopsy also felt the resident had breast cancer. The physician said the ball got dropped when he/she did a telehealth visit in June and was not reminded of the referral for MRI. He/she said that everybody was involved in this appointment being missed, not just one person. He/she said that scheduling did not follow through, the surgeon did not follow through, and the physician him/her-self did not follow through. During interviews on 08/05/23, at 8:50 A.M., and on 08/08/23, at 2:00 P.M., the DON said the following: -Transportation E was in charge of transportation services, then the responsibility was changed to the Assistant SSD. The responsibility was then changed back to the transportation aide. During that time there was a failure to communicate. An appointment was scheduled for an MRI and was missed when it fell through the cracks. Nurses should communicate appointments with social services and the DON. Staff should document follow-up on appointment scheduling or re-scheduling. -The process before the current change was that staff would notify transportation of an appointment referral, then it changed to social services for a couple of months, and returned to transportation; -The DON expects the staff to follow up on appointments and notify nursing if there is a delay or rescheduled appointment. During interviews on 08/05/23, at 10:45 A.M., and 08/08/23, at 8:45 A.M., the Administrator said the following: -Staff should notify Assistant SSD and Transportation E when an appointment needs scheduled; -Staff should always notify the guardian or resident responsible party of health changes, appointments schedule or rescheduled or missed appointments; -She was not fully aware why this was overlooked; -She had called the MRI facility on the morning of 08/07/23 and they told her that once they had received the insurance approval to schedule the MRI, they called the facility and were put on hold. After waiting and not receiving an answer the MRI facility ended the call and did not call back; -The Administrator spoke with the insurance company to look into the authorization for the testing. The insurance company said they called one time and did not get to speak with anyone to notify of the authorization approval. The insurance company said it was their policy to only call one time. During an interview on 08/08/23, at 2:45 P.M., the Administrator and DON said staff should always follow through with physician orders, including referral orders for appointments, and that staff should notify the resident and responsible party of changes to the appointments. MO00222513

Based on observation, interview, and record review, the facility failed to provide protective oversight to all residents when staff failed to consistently implement elopement interventions, failed to care plan elopement interventions, failed to identify and care plan events that trigger exit seeking behaviors, and failed to monitor window stop devices, for one resident (Resident #1), with a history of exit seeking, who left the facility through a window and was later struck by a train and died . The facility census was 83. The administrator was notified on [DATE], at 5:25 P.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Record review of the facility's undated policy titled, Elopement-Missing Resident, showed the following guidelines: -Determine when the resident was last seen and by whom; -Description of the clothing; -Where the resident was last seen; -Notify all departments and begin search of the facility and grounds, including bathrooms, closets storage areas and crawl spaces; -Search streets and neighborhood adjacent to facility; -Notify Director of Nursing (DON) and Administrator; -Notify attending physician and responsible party; -If absence exceeds 30 minutes, notify law enforcement agency; -When located, be certain to notify all appropriate people/agencies and assess for injuries. Record review showed staff did not provide a policy regarding elopement prevention or interventions related to elopement or exit seeking behaviors. 1. Record review of Resident #1's face sheet (a brief resident summary) showed the following: -admitted [DATE]; -Diagnoses included traumatic brain injury with loss of consciousness, conversion disorder (medical condition in which the brain and body's nerves are unable to send and receive signals properly) with seizures, and major depressive disorder. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated [DATE], showed the following: -No behaviors; -Difficulty in decision-making skills; -Did not exhibit wandering during the evaluation period; -Able to ambulate without assistance. Record review of the resident's Progress Notes showed the following: -On [DATE], at 3:30 A.M., facility staff documented at approximately 12:30 A.M., staff performed a normal routine check on the resident and discovered the resident was not in his/her bed. Staff looked for the resident and notified the DON the resident was missing. The DON reported the missing person to the local law enforcement and notified the Next of Kin (NOK). The NOK asked the staff if the window screen was in place. Staff went to the resident's window and discovered the window screen was not in place and was in the resident's closet; -On [DATE], at 7:49 A.M., facility staff documented at 7:44 A.M., staff was outside and noticed the resident walking across the parking lot. Staff brought the resident into the building. The resident was cold and wearing a blue jean jacket. Staff notified the local law enforcement, NOK, and the DON. The resident complained of pain in left hip leg area and said the ground caused the pain. Staff documented the resident was placed on 30 minute checks. Record review of the facility's Elopement/Wandering Assessment Form, completed on [DATE], showed the following: -History of wandering; -Resident paces; -Takes medication that suppress the thought process ,narcotics, sedatives, anti-seizure, psychotics, hypnotics, tranquillizers, and anti-depressants; -Staff assessed the resident as an elopement risk. Record review of the resident's care plan, last revised on [DATE] ,showed the following: -On [DATE], staff documented the resident recently eloped and had potential to try to elope again; -Complete quarterly elopement assessments; -Monitor the resident frequently; -Monitor the resident for signs that may trigger the resident to be upset and elope. (Staff did not care plan the 30 minute checks from the progress note as documented in the progress notes on [DATE].) Record review of the resident's Progress Notes showed the following: -On [DATE], at 9:42 A.M., the facility physician wrote there is a concern the resident may want to try to find his/her family in St. Louis area where he/she intended to go when he/she eloped; -On [DATE], at 6:34 A.M., facility staff documented the resident was observed walking around the hallway and looking out the facility doors. Resident was placed on 30 minutes checks. (Staff noted progress note on [DATE], the resident was placed on 30 minute checks. Staff did not document ending these checks.) Record review of the resident's Progress Notes showed the following: -On [DATE], at 12:34 P.M., the facility physician wrote the resident had been relatively stable after he/she left the facility for about 24 hours. No one knows where he/she went. The resident returned to the facility on his/her own. Record review of the resident's care plan, last revised on [DATE], showed staff did not care plan the intervention of 30 minute checks noted in the progress notes dated [DATE]. During interviews on [DATE], at 9:20 A.M., and on [DATE], at 10:16 A.M., Licensed Practical Nurse (LPN) C said the resident was on A-wing when he/she initially eloped. During an interview on [DATE], at 9:30 A.M., Certified Nurse Aide (CNA) D said the following: -The resident got out of the building once. He/she heard about it, a long time ago, months ago. The resident lived on A wing. He/She thought the resident went out the back door or window. During an interview on [DATE], at 9:30 A.M., CNA E said the following: -He/she was not here the first time when the resident went out the window in a room. The resident came back to the front door, wanting coffee. He/she did not know how long the resident was gone, but it was more than overnight. During interviews on [DATE], at 11:41 A.M. and 3:00 P.M., Registered Nurse (RN) F said the following: -He/she she started as care plan coordinator about 2 ,d+[DATE] weeks in this role; -The RN did not know about the elopement attempt in [DATE]. During an interview on [DATE], at 7:28 P.M., CNA G said the following: -The first time the resident eloped was during daylight savings time, fall back. The resident jumped out the window and eloped. Staff found him/her three days later. Staff shortened the window opening, they put screws in the window where it would only open two to three inches. During an interview on [DATE], at 7:50 P.M., LPN A said the following: -The first time the resident eloped, he/she removed the window screen and hid it in the closet. When staff notified the resident's NOK, he/she asked if the window screen was intact; -After the resident eloped for the first time out a window, the resident told his/her NOK he/she would leave again if he/she wanted to; -After the first elopement attempt, the Maintenance Director (MD) placed an alarm on the resident's window. -Staff tried to keep his/her door open, but the resident would close the door because he/she wanted privacy; -If the NOK doesn't come every two to three days, that's when the resident tries to elope. During an interview on [DATE], at 12:16 P.M., the MD said he installed an alarm when the resident was in the A-wing. During interviews on [DATE], at 12:17 P.M. and 2:16 P.M., the Assistant Director of Nursing (ADON) said the following: -When the NOK tells the resident he/she is going out of town, the resident gets antsy; -He/she thought the NOK leaving is a trigger for the resident to attempt elopement; -When the resident eloped on [DATE], the Director of Nursing (DON) and Administrator instructed staff to check on the resident on an hourly basis and instructed staff keep the resident's door open at all times; -The maintenance director installed the window alarm after [DATE]. During an interview on [DATE], at 10:40 A.M. and 3:32 P.M., the DON said the following: -On [DATE], the resident lived on A wing and eloped out the window. After that, staff talked to the NOK and an alarm was put on the window (on A wing). This was a temporary measure until the room became available that opened to the courtyard from the window (on B wing); -On [DATE], the facility purchased an alarm and the MD fitted the alarm on the resident's window; -Staff were not monitoring the alarm. She would have expected staff and the MD to be monitoring the alarm on a regular basis as part of the overall care of the resident. There is no documentation regarding alarm checks; -The resident was high functioning. The only concerns was the resident had a speech impediment; -The resident walked laps around the facility; -Whenever the resident's NOK made plans to go out of town, the resident got agitated and tried to leave the facility. The resident always asked his/her NOK to visit family whenever the NOK does. The response from the NOK has not been favorable to the resident; -The resident's care plan should have reflected the MD installed the alarm; -She believes whenever the resident's NOK leaves town, the resident gets agitated. The resident wanted to visit family out of state where the NOK went. During an interviews on [DATE], at 4:00 P.M., and on [DATE], at 5:30 P.M., with the Administrator said the following: -About three months ago, (prior to the [DATE] elopement), the resident indicated he/she wanted to go home with his/her NOK; -After the first elopement attempt, the facility put alarms on the window in the resident's room as a temporary measure on [DATE]. They did this until the resident was less agitated. They did not take the alarm off, once set, left them on indefinitely. She did not think it was added to the resident's care plan; -The resident's NOK was the trigger that made the resident at risk to elope. Record review of the resident's care plan, last revised on [DATE], showed staff did not update the care plan regarding the resident's agitation and exit seeking when the NOK is out of town or use of a window alarm. Record review of the resident's Progress Notes showed the following: -On [DATE], at 10:20 A.M., facility staff reported the resident was observed leaving the facility building and grounds. Staff stayed with the resident and attempted to redirect to facility. Staff notified the DON, physician, and NOK. Staff returned with the resident into the building at 10:30 A.M. Staff and NOK agreed to move the resident to the facility's memory care unit (locked unit). Record review of the resident's Elopement/Wandering Assessment Form, completed on [DATE], showed the following: -Cognitively impaired, including diagnosis of Alzheimer's or dementia (a disorder of the central nervous system that affects memory, thinking and behavior); -Resident paces; -Takes medication that suppress the thought process, narcotics, sedatives, anti-seizure, psychotics, hypnotics, tranquillizers, and anti-depressants; -Staff assessed the resident as a risk for elopement. Record review of the resident's current care plan, last revised on [DATE], showed staff did not update the care plan with the [DATE] elopement or any new interventions regarding the elopement or exit seeking behaviors. Record review of the resident's Progress Notes showed the following: -On [DATE], at 4:07 P.M., the facility physician wrote the resident is a flight risk and does not give any kind of forewarning. Resident is currently in the memory care unit to help prevent risk for elopement. During interviews on [DATE], at 9:20 A.M., and on [DATE], at 10:16 A.M., LPN C said the following: -Staff moved the resident to the memory care unit; -The maintenance manager placed an alarm on the resident's window in the memory care unit. During an interview on [DATE], at 9:30 A.M., CNA D said the following: -Staff moved the resident to the memory care unit; -The resident did not attempt to leave the facility while he/she was in the memory care unit. The windows in the memory care unit open upwards only a few inches; -The CNA did not know of any other precautions in the unit; -The CNA was not aware of an alarm. During interviews on [DATE], at 11:41 A.M. and 3:00 P.M., RN F said the following: -February 2022 the resident tried to elope. The resident followed someone out the front door. It takes a moment for the door to lock after someone goes out. Staff stayed with him/her, followed him/her, and convinced him/her to come back in. The resident did not seem agitated that day; -After the [DATE] elopement, the resident was placed in the unit right after that, thought it was that exact day; -Staff completed 15-minute checks and observation on the resident after the attempt. They try to do the least restricted environment; -The window alarm should be on the care plan and added by the care plan coordinator. He/She did not know when the window alarm was placed for sure, but it was brought up in a meeting they were doing the window alarm; -He/she did not know if moving to the unit would be something added to the care plan or not. During interview son [DATE], at 10:30 A.M., and on [DATE], at 12:16 P.M., the MD said the following: -The windows in the unit, only open two to three inches, unless a button is pushed, then the window opens all the way on the unit; -When the resident moved to the memory care unit, he/she moved the alarm to the memory care unit. The resident was in the memory care unit for approximately three weeks. -The alarm on the window in the unit would set off an alarm at the desk. During interviews on [DATE], at 12:17 P.M. and 2:16 P.M., the ADON said the following: -Staff moved the resident to the memory care unit because of the resident's previous elopement attempts; -When the resident was moved to the memory care unit an alarm was placed on the window and no other interventions were put in place;. -Management thought the memory care unit was secure. The windows in the memory care unit lead to the fenced courtyard; -The window alarm should have been addressed in the resident's care plan. During interviews on [DATE], at 10:40 A.M. and 3:32 P.M., the DON said the following: -On [DATE], there was another elopement. The resident opened up the 15 second alarmed door. Staff never lost sight of him/her. The resident was walking laps and pushed the front door open. The resident set off the alarm, then went out. Staff never lost sight of the resident and brought him/her back in. This occurred during the day and the facility was concerned if the resident tried to do that at evening/night that were would be less staff around to catch him/her; -Staff moved the resident to the unit as a temporary measure because the room (on B hall) they wanted was still not available; -The resident was the only resident with the window alarm. Staff had a meeting and discussed it; -The resident would check the alarm and window periodically and set it off. Then, staff would have to come and close the window, and turn off the alarm; -Maintenance and staff rounds should check the window alarm as part of overall care. There is no documentation regarding checking for alarm function; -They didn't monitor the alarm on the unit because they didn't need it as an intervention. There was more individual monitoring and locked doors. During an interviews on [DATE], at 4:00 P.M., and on [DATE], at 5:30 P.M., with the Administrator said the following: -The resident's second elopement occurred [DATE]. Staff had eyes on him/her, he/she set off alarms on the door. Short term, they moved him/her to the unit until his/her agitation decreased with the understanding of the DPOA and to keep eyes on him/her more. They felt the window alarm was needed for temporary measure, second set of eyes. Record review of the resident's care plan, last revised on [DATE], showed staff did not update the care plan with an intervention of the window alarm. Record review of the resident's Progress Notes showed the following: -On [DATE], at 9:30 P.M., LPN A documented he/she went into the resident's room on B wing and observed the resident was not in the room. The window screen was in the resident's bathroom. The LPN instructed additional staff to look for the resident. The resident's window faces a fenced courtyard. Staff documented, the courtyard gates were locked. A chair was up next to the courtyard fence. He/she notified the DON , Administrator, local law enforcement, and NOK; -On [DATE], at 10:04 P.M., staff notified the facility physician the resident eloped via the window and utilized the courtyard chair to scale the fence and left the facility grounds. During an interview on [DATE], at 2:45 P.M., CNA B said on [DATE], at approximately 6:37 P.M., he/she saw the resident in his/her room. The resident was walking back and forth. Record review of the police report showed the following: -On [DATE], staff stated the resident had eloped from his/her room and was last seen at approximately 7:30 P.M., during a medication pass. Staff observed the window screen to to the resident room was removed and placed in the bathroom. Staff had canvassed the area looking for the resident and could not locate the resident. LPN A said the resident had eloped from the facility before and was located at the park. The officer canvassed the area and was unable locate the resident. During an interview on [DATE], at 11:30 A.M., the Administrator said the resident popped out the window screen, placed the window screen in the bathroom, and went through the window to the fenced courtyard. The resident used a garden chair and jumped over the fence. The resident has not been located since [DATE] at approximately 9:00 P.M. Observations on [DATE], at 12:17 P.M., of the resident's old vacant room in the memory care unit showed the following: -The room was empty and there was no alarm on the window; -The window opened all the way up; -The window faced the courtyard outside the memory care unit; -There was no safety/stopping device installed on the window; -Several Rooms in the memory care unit, including rooms B113, B115,B118, B120 and B121, were missing the stop devices and windows opened all the way without resistance. During interviews on [DATE], at 9:20 A.M., and on [DATE], at 10:16 A.M., LPN C said the following: -On [DATE], staff moved the resident from the memory care unit to the B wing; -Maintenance did not reinstall the alarm to the B wing; -The LPN had assumed the alarm moved with the resident. Observation on [DATE], at 9:30 A.M., showed the resident's current room on B-wing had the screen back in the window and the window opened normally (fully without restriction) with no alarm sounding. The window opened to the grassy area about 30 feet to the concrete patio, surrounded by a fence. During an interview on [DATE], at 9:30 A.M., CNA D said the following: -He/she checks on residents every two hours; -When a resident is missing, he/she notifies the charge nurse immediately; -CNA D had not received any training on elopement since he/she had been at the facility. During an interview on [DATE], at 9:30 A.M., CNA E said the following: -The just moved the resident to B wing, he/she thought on [DATE], temporarily. He/She thought it was permanent, but found out yesterday, it was temporary for a couple days while they worked on floors; -On [DATE] he/she worked from 7:30 A.M. to 7:30 P.M.; -He/she last saw the resident straightening up his/her room on [DATE]. The resident is mostly calm. He/she has trouble communicating. The resident uses simple short answers when communicating; -Staff do two hour checks on everyone. They check to see if the resident is there, dry, if they need anything. It takes a little over two hours to do rounds. Staff go room to room and start back over when they finish. During interviews on [DATE], at 11:41 A.M. and 3:00 P.M., RN F said the following: --Staff moved the resident from the memory care unit to the B wing. The B wing was the least restrictive environment as the resident was not a good fit for the memory care unit; -On [DATE], at approximately 9:00 P.M., he/she was outside taking a short break. CNA B approached him/her and said staff have not been able to locate the resident. The RN participated in the search and continued searching the surroundings. At approximately 9:30 P.M., the local law enforcement arrived at the facility. Staff are required to search the entire facility and surroundings when a resident is unaccounted for and notify the DON, Administrator, Law Enforcement, and NOK; -The resident has limited verbal skills and is reclusive. He/she likes quiet areas and has tried to elope before; -If a resident elopes, the interventions staff added would depend on the nature of the elopement; -Interventions should be added to the care plan as soon as identified; -They have an IDT (interdisciplinary team) team that discuss, including nursing, social services, anyone that could have input. It might be a morning meeting, but meet to determine interventions; -Elopement assessments are completed quarterly, unless something comes up, elopement attempt or something. They are completed on admission, quarterly, and annually; -He/she would have assumed the alarm would have moved with the resident from the unit to B wing; -He/she did not know anything about the window stop devices (prevent windows from fully opening) on the windows. He/she would guess maintenance would monitor the function; -To know if new interventions were put in place, staff should check the care plans. He/she did not know if the facility had policies on how to disseminate the information though. During an interview on [DATE], at 7:28 P.M., CNA G said the following: -Staff moved the resident from the unit to B wing. He/She did not know why they moved him/her to the last room; -When the resident was moved to the B wing, there was no special accommodations or interventions made to the resident's room; -On [DATE], he/she was working the evening shift on the B wing. LPN A instructed him/her to go look for the resident outside the facility at approximately 6:00 P.M. He/she entered the courtyard, noticed the garden chair was up against the wall. The pad locks in the courtyard had locks intact. He/she reported his/her observations to LPN A. The last time he/she saw the resident, he/she was walking back and forth in his/her room; -He/she always looks inside resident rooms when doing rounds in resident halls. Checks on residents are completed every two hours; -He/she does not know how to access a resident's care plan; -He/she receives new interventions by word of mouth. -When there is change in plan of care, they tell the aides during rounds, or by the nurse. Learning about new interventions is by word of mouth; -The care plan is on the computer and he/she thought the aides have access to it. During an interview on [DATE], at 2:25 P.M., the CNA D said there is a communication barrier when it comes to care plans. CNAs are not able to access residents care plans. When changes to care plans occur, it is difficult to access new interventions. During an interview on [DATE], at 7:50 P.M., LPN A said the following: -The resident's current room was the first door straight across from the nurses' station. The room was safer within direct sight from the nurses' station; -He/she was the charge nurse on the B wing on [DATE]. He/she started the shift at 6:00 P.M. and ended at 6:00 A.M.; -He/she discovered the resident was missing when he/she was doing med pass and temperature checks at approximately 8:50 P.M. He/she had a pain pill for the resident. The resident takes the pill at 9:00 P.M. daily; -He/she sent CNA B and RN F to look for the resident immediately. One of the CNAs located the window screen in the the resident's bathroom and proceeded to the courtyard and saw the chair, which was against the fence; -He/she called the Administrator, DON, ADON, and the local law enforcement department at approximately 9:15 P.M.; -Certified Medical Technician (CMT) I said he/she last saw the resident at approximately 7:30 P.M. during a medication pass; -He/she tries to complete rounds in resident halls every two hours. That night of [DATE], he/she had five halls to supervise. The resident was not showing any signs of agitation; -He/she would have expected the MD to move the alarm to the B hall room, the current room. He/she was not sure why staff moved the resident from the memory care unit; -Facility CNA's are not required to do two-hour checks, they walk around passing ice and water and answering call lights; -He/she believes the resident had planned to elope. The resident communicated to the NOK, he/she will try to elope again. The NOK reported the resident's intentions to the facility. During interviews on [DATE], at 10:30 A.M., and on [DATE], at 12:16 P.M., the MD said the following: -Staff moved the resident from the memory care unit to the B wing. Staff did not inform him about the move. He thought the move was temporary. If staff had communicated with him, he would have fitted the alarm on the resident's window in the B wing; -Facility windows should open up about three inches. During interviews on [DATE], at 12:17 P.M. and 2:16 P.M., the ADON said the following: -Staff moved the resident from the memory care unit and placed the resident in the B wing. The resident's current room is close to the nurses' station; -She assumed the MD re-installed the window alarm, when the resident moved to the B-wing from the memory care unit; -Staff were not monitoring the window alarm; -The ADON told the NOK to not to tell the resident he/she was going on a three week trip. If the NOK told the resident, the resident would try to leave. The resident shouldn't have known the NOK was leaving this time. -All the windows in the facility should have a functioning stop-device; -All rooms in the facility should have window stops to allow the window to only open two to three inches; -In the resident's room on B wing, the window stops are pushed in to allow the window to open all the way. Staff just realized the window stops had been removed; -Staff have not been monitoring the window stop device on all the windows in the facility for the last three to four years; -When a resident elopes, new interventions are put in place and the resident care plan is updated and old interventions are removed. Interventions include several changes based on a team approach, which includes the Administrator, Social Service Director (SSD), DON, ADON and can bring in therapy or maintenance in; -The physician and the NOK are notified, and their views and suggestions are included in the resident care plan. The care plan coordinator documents the new interventions into the resident care plan. Staff should document all changes in the care plan. Conversations with the physician and the NOK, are never documented; -It is the responsibility of the care plan coordinator to educate staff regarding new interventions; -The care plan review/revision should occur immediately after the elopement; -The window stop would not be care planned because all the windows in the facility should have those. Observation of rooms and window stop devices outside the memory care unit on [DATE], at 1:23 P.M. showed the following: -room [ROOM NUMBER] both windows opened all the way, one had the stop device, but was missing a part; -room [ROOM NUMBER] both windows had the stop, but the part was pushed in. The windows opened all the way; -room [ROOM NUMBER] one window (left), had the part, but missing the part that sticks out. The right window had the whole part, but the part was stuck in, both windows opened all the way; -room [ROOM NUMBER], left-side of window, had the stop, but it was pushed in, right window, had the stop, but missing the part that sticks out, window opens all the way; -room [ROOM NUMBER], both windows have the stop device, but pushed in. Windows opened all the way. During interviews on [DATE], at 10:40 A.M. and 3:31 P.M. the DON said the following: -She did not think the memory care unit was the appropriate setting for the resident; -On [DATE], staff moved the resident to B wing; -The MD did not move the alarm to the B wing; -The window stop-device should have prevented the resident from opening the window all the way. Had the window stop device been in place, the resident would not have eloped; -To keep the resident from going through the window, staff were depending on the window stops being in place and functioning; -All the windows in the facility are supposed to have a stop device. The MD should check the windows on a regular basis and should keep a log. The MD is supposed to keep track on all windows, which require repairs; -There is no documentation of monitoring of the window stop regarding it being functional and intact. Most of the staff do not know how to open the window all the way; -This last time, staff asked the NOK not to tell the resident when he/she is leaving. However, the NOK shopped for the resident before the NOK left. The NOK left the week before; -She conducts an in-service after a resident elopes. The in-service is never documented and it is done at shift change usually at the nurses station during shift change. -Standard of policy requires staff to perform 30-minute checks on high-risk residents. Staff are required to document 30-minute checks on a check sheet at the nurse's desk. When a resident goes missing after 30 minutes, staff begin to conduct exterior searches outside the facility. -The DON has not provided elopement training. They have had mini-huddles after the resident's elopements; -If a resident is high risk, they are put on 30-minute checks; -If a resident is missing, the aide should tell the charge nurse immediately. The aide starts a room to room search. All staff join in the search, then they start looking outside and search the grounds and then call the DON. If it has been more than 30 minutes, they call 911. The police and fill out a form for the police. They look at cameras to see where the resident was last seen. They do not have cameras in the courtyard area. -They completed in-services at the desk with staff about changes in interventions at shift change so they could catch everyone. In order to catch everyone, staff receive in-service training at shift change regarding any changes in interventions for the residents. These in-services are not documented anywhere. Some changes in interventions should be in progress notes. During interviews on [DATE], at 4:00 P.M., and on [DATE], at 5:30 P.M., the Administrator said the following: -She did not instruct staff to move the window alarm to room on B wing when the resident was moved from the memory care unit, because the resident was no longer exit seeking; -She noticed the resident was increasingly agitated when the NOK denied the resident's request to go out of state with him/her; -There was nothing done medically to alleviate the resident's agitation; -All windows in the facility should have a stop device. -Interventions should be documented in the nurses notes and progress notes; -This time, staff did not let the resident know and asked the NOK not to tell the resident he/she was leaving for trip. The facility did not think they needed to do anything extra because the resident didn't know the NOK was leaving; -They realized this morning the window stops were missing or not all parts there. They had to be removed; -Regarding the window stop, would not expect them to be disengaged. It would require someone to remove them, would not just fallen off. No one was monitoring them or docume

Based on interview and record review, the facility failed to consistently assess and implement interventions to promote optimal food intake for one resident (Resident #1). The facility failed to perform a speech therapy screen as recommended by the registered dietitian, failed to schedule a specialist consultation appointment in a timely manner, failed to ensure a speech evaluation was completed as recommended, and failed to update resident's care plan with interventions that addressed a plan for safe weight loss with proper nutrition maintained for the resident. The resident experienced significant weight and was admitted the hospital with acute [MEDICAL CONDITION], dehydration and difficulty swallowing. The facility's census was 103. Federal Guidelines define suggested parameters for evaluating significance of unplanned and undesired weight loss as: -A loss of 5% in one month indicates significant weight loss and greater than 5% indicates severe loss; -A loss of 7.5% in three months indicates significant weight loss and greater than 7.5% indicates severe loss; -A loss of 10% in six months indicates significant weight loss and greater than 10% indicates severe loss. Record review of the facility's policy, dated [DATE], titled Nutritional Risk Interventions, showed the following information: -The individual condition of each resident at nutritional risk must be considered when instituting nutritional intervention; -Liberalized diet order: A restrictive diet is rarely indicated for residents at nutritional risk. The resident's medical condition must be taken into consideration when requesting a liberalized diet from the physician. Calorie levels may be liberalized to No concentrated sweets and sodium restricted levels to No added salt. These change the nutritional available and palatability, thereby increasing intake; -Unacceptable parameters of nourishment include weight loss, clinical signs and symptoms of malnutrition, and abnormal lab results; -Clinical conditions-refusal to eat and/or refusal of other methods of nourishment. 1. Record review of Resident #1's care plan, for problem date [DATE], showed the following information: -Problem--Required a therapeutic diet related to weight and [DIAGNOSES REDACTED]. -Approach in a non-judgmental manner; -Praise for good dietary compliance; -Provide the resident with as much control as possible in routines, food preferences, etc. -Resident goal with target date of [DATE] is to attempt to lose weight, current goal weight per resident is to reach a weight of 200 pounds or below, but resident is happy with gradual loss. (The care plan did not address interventions to ensure weight loss was gradual and to ensure the resident's nutritional needs were met while loosing weight.) Record review of the resident's weight records showed the following information: -The resident weighed 212 pounds on [DATE]; -The resident weighted 207 pounds on [DATE]; -The resident weighed 208 pounds on [DATE]. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated [DATE], showed the following information: -Cognitively intact; -Independent with ambulation; -No complaints of difficulty or pain with swallowing; -Weight at 208 pounds; -Weight loss marked yes, not on physician-prescribed weight-loss regimen. Record review of the resident's nurses' notes showed the following information: -On [DATE] at 11:05 P.M., staff documented the resident refused care and dinner, no fever noted during the shift and staff will continue to monitor; -On [DATE] at 4:49 P.M., staff documented the resident reported not feeling well during the shift. Resident did not eat very well that day. Staff will continue to monitor; -On [DATE], at 11:56 A.M., staff documented the resident stated he/she was very tired and had been for a couple of days. The resident complained of pain, at times, in right side of abdomen. Staff documented no tenderness or rebound pain noted in this area. The resident had a poor appetite. Staff will continue to monitor. Record review of the resident's meal intake report, dated [DATE], showed the resident consumed less than 25% of the lunch and dinner meal. Record review of the resident's weight records showed a weight of 204 pounds on [DATE] (an eight pound loss (3.77%) since [DATE]). (Staff did not update the physician with the weight loss and did not update the care plan with weight loss.) Record review of the meal intake report showed the following information: -On [DATE], the resident consumed less than 25% of dinner. -On [DATE], the resident consumed less than 25% of dinner. -On [DATE], staff documented the resident did not eat any lunch. -On [DATE], the resident consumed less than 25% of dinner. -On [DATE], staff documented the resident did not eat any dinner. -On [DATE], the resident consumed less than 25% of breakfast and lunch, and did not eat any dinner. -On [DATE], the resident consumed less than 25% of breakfast. -On [DATE], the resident consumed less than 25% of breakfast. At 1:41 P.M., staff documented the resident had nothing by mouth (NPO) and refused lunch. Record review of the resident's nurses' notes showed the following information: -On [DATE] at 6:36 P.M., staff documented the resident complained of nausea and vomiting with consumption of meals. Staff notified the resident's physician's office of concerns and received new order for [MEDICATION NAME] (medication used to treat nausea and vomiting), 10 milligrams (mg), one tablet by mouth (PO) every six hours as needed; -On [DATE] at 6:58 P.M., staff documented the resident had complaints of nausea and vomiting with meals, poor appetite, and not feeling good. Staff will monitor. (Staff did not update the resident's care plan interventions to address the resident's poor meal intake, the recent episodes of nausea and emesis or the physician's orders [REDACTED]. Record review of the resident's meal intake report showed the following information: -On [DATE], staff documented the resident refused dinner; -On [DATE], the resident consumed less than 25% of breakfast. Record review of the physician's telephone order, dated [DATE], showed the physician ordered a gastrointestinal (GI) consult related to the resident's history of [MEDICAL CONDITION] stricture (narrowing of the esophagus, the passageway from the throat to the stomach). (Staff did not update the resident's care plan interventions to address the resident's poor meal intake, the recent episodes of nausea and emesis, and the GI consult.) Record review of the resident's meal intake report, dated [DATE], showed the following information: -The resident consumed less than 25% of lunch; -Staff documented the resident did not eat any dinner. Record review of the resident's meal intake report, dated [DATE], showed the following information: -Staff documented the resident refused breakfast; -Staff documented the resident refused dinner. Record review of the resident's meal intake report, dated [DATE], showed staff documented the resident refused lunch. Record review of the resident's meal intake report, dated [DATE], showed the following information: -On [DATE], staff documented the resident refused lunch; -On [DATE], the resident consumed less than 25% of lunch; -On [DATE], the resident consumed less than 25% of breakfast. Record review of the facility physician's progress note, dated [DATE], showed the physician saw the resident for nausea, emesis (vomiting), and depressed mood. The resident had symptoms including not eating and some recent nausea and emesis. Nursing reported his/her relative died in September. Resident states he/she is concerned about his/her [MEDICAL CONDITION]. (Staff did not update the resident's care plan interventions to address the resident not eating and the recent episodes of nausea and emesis.) Record review of the facility's fax cover sheet, dated [DATE], showed the facility faxed the physician's orders [REDACTED]. (six days after the physician wrote the order) Record review of the resident's meal intake report, dated [DATE], showed the following information: -On [DATE], staff documented the resident refused dinner. -On [DATE], the resident consumed less than 25% of lunch; -On [DATE], staff documented the resident refused dinner; -On [DATE], staff documented the resident refused breakfast. Record review of the resident's nurse's notes on [DATE], at 12:05 P.M., showed staff documented to discontinue the [MEDICATION NAME] and to start [MEDICATION NAME] (used to treat certain condition of the stomach and intestine), 10 mg three times per day 30 minutes before meals. (Staff did not update the resident's care plan interventions to address the resident's poor intake, the recent episodes of nausea and emesis and medication change.) Record review of the resident's meal intake report showed the following information: -On [DATE], staff documented the resident refused dinner; -On [DATE], staff documented the resident did not eat any dinner and had nothing by mouth; -On [DATE], the resident consumed less than 25% of lunch; -On [DATE], the resident consumed less than 25% of dinner; -On [DATE], the resident consumed less than 25% of breakfast; -On [DATE], staff documented the resident refused lunch; -On [DATE], staff documented the resident refused dinner. Record review of the facility physician's progress note, dated [DATE], showed the physician saw the resident for medical review and evaluation of chronic medical conditions and medication reconciliation. The resident had been having complaints of nausea. Staff note the resident currently has some vomiting. The resident has an upcoming GI appointment. The resident denies any chest pain or shortness of breath. The resident states he/she just does not feel well. Per resident and/or staff, the resident's appetite is fair and he/she does snack in his/her room. Record review showed as of [DATE] the staff did not document making the GI consult appointment or the reason for any delay in the making the appointment. (Staff did not update the resident's care plan with interventions regarding the resident's appetite and overall medical condition of the resident not feeling well.) Record review of the resident's meal intake report, dated [DATE], showed the following information: -The resident consumed less than 25% of breakfast; -The resident consumed less than 25% of lunch. Record review of the resident's nurse's notes showed the following information: -On [DATE], at 5:06 P.M., staff documented the resident's appetite as fair; -On [DATE], at 9:26 P.M., staff documented that the resident had been out with family for several hours this evening and family reported the resident was confused at times during their visit. The family requested someone call the physician in the morning to check if the antibiotic may be causing confusion. The family stated they were very concerned that the resident had a decline in health. Staff notified the physician, administrator, and nursing supervisor. Record review of the resident's meal intake report showed the following information: -On [DATE], the resident consumed less than 25% of dinner; -On [DATE], the resident consumed less than 25% of breakfast. Record review of the resident's nurse's note dated [DATE], at 12:56 A.M., showed the staff documented the resident came to the nurse at 8:00 A.M. stating he/she had no appetite and was dizzy and unsteady. The resident needed stand by assistance to walk. The resident consumed less that 25 % of breakfast. The nausea and loss of appetite had been occurring for at least the past month. The resident has a history of [MEDICAL CONDITION] stricture and states he/she used to have his/her esophagus stretched. Staff obtained an order from the physician for a GI consult over two weeks ago, but an appointment has not yet been made. Staff weighed the resident and the resident showed a weight loss of 16 pounds since [DATE]. The physician's office called and stated if staff sent the resident to the hospital emergency room and admitted the resident to the hospital, they could do the procedure if need be. (Staff did document why the appointment had not been made.) Record review of the weight records showed the resident weighed 188 pounds on [DATE] (a loss of 16 pounds since [DATE]). Record review of the facility's meal intake report, dated [DATE] through [DATE], showed the following information: -Staff documented none or refused for meal intake a total of 16 times; -Staff documented the resident consumed less than 25% of meal intake a total of 16 times; -Forty-two total meals offered to the resident from [DATE] through [DATE]. (The resident refused or consumed less than 25% of over half of the meals for the time period listed, Staff weighed the resident on [DATE] and the resident had a weight loss of 16 lbs since [DATE].) Record review of the hospital history and physical, dated [DATE], showed the resident's family member brought the resident in as he/she was not eating and drinking well and was having difficulty in the nursing home. The patient was mentally challenged, lives in a nursing home and has lost about 16 pounds in the last couple of weeks. The resident has only been drinking some liquids and some soft food. The resident says food gets stuck in his/her throat, and he/she has to throw it back out. The resident was evaluated in the emergency room . The [MEDICATION NAME], was consulted and will be evaluating the patient in the morning for [MEDICAL CONDITION] dilatation. Record review of the hospital physician progress notes [REDACTED]. The resident tolerated the procedure well. The assessment and plan showed the resident had the procedure and dysphagia (difficulty in swallowing) has improved. The resident had a [DIAGNOSES REDACTED]. Record review of the hospital's discharge instructions, dated [DATE], showed the resident had swallowing difficulty. The goal was to decrease the resident's difficulty with swallowing. Record review of the hospital's discharge summary data, dated [DATE], showed the resident had cognitive impairment and admitted to the hospital from a local nursing home for evaluation of dysphagia, reflux, and anorexia. [MEDICATION NAME] was consulted and performed an EGD. The EGD revealed an [MEDICAL CONDITION] stricture that was dilated and grade ,[DATE] esophagitis. Because of his/her dysphagia, he/she was quite dehydrated with evidence of acute [MEDICAL CONDITION]. This improved with intravenous therapy (infusion of liquid substances directly into a vein) (IV) fluids; however, creatinine (excreted by the kidneys and used to [DIAGNOSES REDACTED]. Record review of the resident's face sheet (admission data) showed the facility readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident's care plan, for problem start date of [DATE], showed the following information: -Problem: The resident had a potential for dehydration due to abnormal labs and [MEDICAL CONDITION] stricture and skin breakdown related to incontinence and diabetes; -Obtain labs per physician order [REDACTED]. -Record frequency, consistency, and amount of emesis; -Assist as needed with oral intake; -Needs assist with ambulation. Monitor for unsteady gait and assist as needed. - Record review of the resident's weight records showed a weight of 193 lbs on [DATE] (a five pound gain after the hospital stay and EGD). Record review of the meal intake report, dated [DATE], showed the resident consumed less than 25% of breakfast. Record review of the dietary manager's nutrition readmission review, dated [DATE], showed the resident's current weight at 193 lbs. The facility readmitted the resident to the facility on [DATE]. The resident will continue to receive the same diet at this time and eats most meals in his/her room. Staff will weigh the resident weekly for four weeks and monthly thereafter for monitoring. Dietary manager and staff will continue to assist as needed and monitor for changes and concerns. (Staff did not update the resident's care plan to reflect the history of weight loss before being sent to the hospital.) Record review of the meal intake report, dated [DATE], showed the following information: -The resident consumed less than 25% of breakfast; -Staff documented the resident refused lunch. Record review of the registered dietitian's (RD) progress note, dated [DATE], showed the following information: -Resident is a recent readmission; -Resident's weight is 193 lbs; -Resident feeds self with poor intake recently, 0%-25%; -Resident requested softer foods and reports that he/she is beginning to eat a little better now; -ERCP (endoscopic retrograde cholangiopancreatography - procedure to look at the bile ducts) done with dilation per resident discharge instructions; -Resident refuses offer for ground meat; -Resident does have a wound that is being treated; -Plan is to provide softer foods per resident request. In view of the resident's poor intake and wound, the RD recommended liberalizing the resident's diet to regular and offering house shake three times a day with meals. The RD recommended a speech therapy screen due to the resident's problem of difficulty swallowing noted on resident discharge instructions. Goal for skin healing and good oral intake. Dietary to remain available for assistance. (Staff did not update the resident's care plan with recommend speech therapy screen.) Record review of the meal intake report showed the following information: -On [DATE], staff documented the resident refused dinner; -On [DATE], the resident consumed less than 25% of breakfast. Record review of the laboratory results, dated [DATE], showed the [MEDICATION NAME] serum (protein in human blood plasma) was 3.0 which indicated lower levels than normal (low levels can be seen in inflammation, shock, and malnutrition). Record review of the resident's significant change MDS, dated [DATE], showed the following information: -Cognitively intact; -Required limited assistance with bed mobility, transfer, and dressing; -Required extensive assistance with ambulation in the resident room; -Supervision with eating; -Staff documented the resident did not have any complaints of difficulty or pain with swallowing; -[DIAGNOSES REDACTED]. The backwash (reflux) irritates the lining of your esophagus and causes GERD); and [MEDICAL CONDITION] obstruction; -Weight at 193; -Weight loss marked as yes, not on physician-prescribed weight-loss regimen. Record review of the resident's weight records showed a weight of 185 lbs on [DATE] (an additional 8 pound (4.15%) weight loss from [DATE]). Record review of the RD's progress note, dated [DATE], showed the following: -The resident's weight at 185 lbs (eight pound weight loss in seven days); -Note order to encourage oral fluids 2.5 to 3 liters per day of water; -Diet is regular RCS (reduced concentrated sweet diet); -Recommend sugar free shake three times a day between meals due to variable oral intake. Record review of the nurses' notes, dated [DATE], showed staff documented a weight meeting held with the DON and dietary manager. The staff reviewed the RD recommendations of liberalizing the resident's diet and adding a house supplement three times a day. Staff did not document any discussion regarding the recommended speech therapy screen. Record review of the resident's weight records showed the resident weighed 188 pounds on [DATE]. This indicated a severe weight loss of 7.8% of his/her body weight in a one month period (September through October). This indicated a severe weight loss of 9.17% of his/her body weight in a three month period (August through October). (Staff did not update the resident's care plan for interventions regarding the severe weight loss). Record review of the resident's care plan, updated on [DATE], showed the following changes: -Regular diet; -Obtain weight; - Inform family and physician of significant weight loss; -Record intake of all meals. (Staff did not update the care plan with interventions to address the resident's poor intake of meals and actual severe weight loss.) Record review of statement, dated [DATE], by physical therapy assistant showed the following information: -The assistant recalled a staff member asking about the resident having trouble feeding self and asked if therapy was working with the resident; -Therapy assured the staff that occupational therapy was working with the resident and would have them address the shaking with feeding (this was after his/her care plan earlier this month); -The DON asked therapy, just before the resident was sent to the emergency roiagnom on [DATE], about feeding and therapy did not have a chance to screen him/her. The RD recommended the speech therapy screen on [DATE] (15 days earlier). During an interview on [DATE], at 2:10 P.M., Certified Nursing Assistant (CNA) A said around summertime, the resident would not eat lunch and said his/her stomach did not feel good. The aide told the resident he/she would notify the nurse. During an interview on [DATE], at 2:26 P.M., Licensed Practical Nurse (LPN) B said the resident had poor appetite around the end of August/September. The resident said he/she did not feel like eating or have an appetite. Staff offered the resident snacks. The resident would say, I can't eat and would always eat at the nurses' desk. The resident would get mad and frustrated with the staff when encouraged to eat more. He/she said the resident improved with eating when he/she returned from the hospital. During an interview on [DATE], at 2:55 P.M., the dietary manager said if a resident has a significant weight loss, 5% in 30 days, 10% in 180 days or losing weight fast, depending on the diet, staff will sometimes add shakes at meals, offer fortified pudding or yogurts. She said the resident wanted to lose weight and always asked for soup a lot. She said the resident never complained of anything and liked to ask for the alternate meal if he/she did not like the scheduled meal. She said the resident ate fairly well and did not know about any choking or swallowing issues. Staff did not discuss care plan interventions because the resident desired to lose weight. During an interview on [DATE], at 3:45 P.M., the housekeeping supervisor said the following information: -The staff gave the physician order [REDACTED].>-The transportation department received the order for the consult on [DATE] and this was faxed to the specialist on [DATE]. During an interview on [DATE], at 4:15 P.M., the Director of Nursing (DON) said the resident at no time asked for a softer diet or said he/she had a history of [REDACTED]. She did not know the resident had swallowing problems. The resident wanted to be 200 lbs or under and was working toward not drinking dairy products due to it upset his/her stomach. She said the resident never mentioned loss of appetite. The resident said he/she was eating all he/she could be eating. The DON said the registered dietitian made the recommendation for the speech therapy screen on [DATE]. She said staff do not write orders for screens, this is done verbal. She spoke to the therapist regarding the speech therapy screen. She said, at no time, did the resident ask for a softer diet and never said he/she had a history of [REDACTED]. She said staff give the transportation department the physician order [REDACTED]. The process to schedule an appointment is for staff to obtain the physician order, make a copy of the order, and give it to the transport department. Medical records also receive the telephone order and will follow up with transportation to see if they received a copy of the order. She did not follow up with the appointment due to she was gone on vacation. During an interview on [DATE], at 5:26 P.M., and [DATE], at 11:56 A.M., the administrator said the resident had a gradual weight loss, but this was desired. He said this was not abnormal behavior for the resident to refuse meals. During a phone interview on [DATE], at 11:00 A.M., the MDS/care plan coordinator said dietary and the DON review meal intakes at the weekly weight meetings. She said staff adjust the plan of care as needed when a resident has several times of ,[DATE]% meal intake. Record review of the transportation staff statement, dated [DATE], showed the following information: -The resident's family member contacted him/her on [DATE] to confirm the date and time of the resident's GI appointment; -Staff told the family member that he/she did not know about the appointment, but would call and schedule an appointment once staff obtained the physician order. (This was three days after the physician order [REDACTED].) During a phone interview on [DATE], at 11:33 A.M., the registered dietitian said if a resident wants to lose weight, she would talk to the resident and determine if this was a serious goal and if it is determined a serious goal, to plan for one 1 pound per month. She said the individualized plan would include the goal, how realistic the diet is and physical state of the resident and if the resident wants to do this on his/her own. Complaint # MO 338

Based on record review, observation and interview the facility failed to document indications for use and failed to adequately monitor the response to [MEDICAL CONDITION] medications (a medication that directly and chemically affects a person's mental state), including antipsychotic medication and antianxiety medication, for one resident (Resident #9) who had a decline in his/her functional ability, and failed to document ongoing assessment/monitoring of potential side effects stemming from the continued use of [MEDICAL CONDITION] medications and an anti-convulsant medication (a medication used to prevent [MEDICAL CONDITION] activity in the brain) for one resident (Resident #3) in a selected sample of 13 residents. The lack of assessment and/or monitoring of potential side effects for Resident #3 resulted in an increase in hand tremors (shaking, jerking) and a decrease in the resident's ability to function independently in some areas of daily needs. The facility's census was 75. Review of the Medline Plus website, a service of the National Library of Medicine and National Institute of Health, showed the following information: -[MEDICATION NAME]: A medication used to treat [MEDICAL CONDITION]. The Food and Drug Administration (FDA) does not approve the use of [MEDICATION NAME] to treat behavior problems in older adults with dementia. Side effects may include drowsiness, dry mouth, loss of appetite, constipation, difficulty falling asleep or staying asleep, unusual, slowed, or uncontrollable movements of any part of the body, restlessness, agitation, nervousness, mood changes; -[MEDICATION NAME]: A medication used to treat [MEDICAL CONDITION] (sleeplessness). Side effects may include drowsiness and a hangover effect (feeling groggy the day after you take [MEDICATION NAME]); -[MEDICATION NAME]: A medication used to treat anxiety. Side effects may include drowsiness, tiredness, weakness, restlessness or excitement, shuffling walk and inability to sit still; -[MEDICATION NAME]: A medication used to treat anxiety. Side effects may include drowsiness, excitement, fatigue, nervousness, difficulty sleeping and weakness. 1. Record review of Resident #9's July physician's orders [REDACTED]. -Staff admitted the resident to the facility on [DATE]; -[DIAGNOSES REDACTED]. -On 07/01/12, an order for [REDACTED]. -On 07/01/12, an order for [REDACTED]. -On 07/01/12, an order for [REDACTED]. -On 07/01/12, an order for [REDACTED]. Record review of the nursing admission and assessment, dated 07/01/12, showed the following information: -Transferred, walked and ate independently; -Continent of bowel; -Occasionally incontinent of urine; -Required one person assistance for dressing, personal hygiene, bathing and toileting. Record review of the temporary problem list (those with anticipated duration of 14 days or less), undated, showed staff did not include interventions for staff to follow related to antipsychotic medications. Record review of the departmental notes showed the following: -On 07/01/12, at 11:18 P.M., a nurse documented the resident was on observation related to a fall which occurred during the shift. The resident missed the chair he/she was going to sit in, leaned against the wall and slid to the floor. The nurse assessed the resident and found no injuries; -On 07/02/12, at 4:36 A.M., a nurse documented the resident was awake all night. Staff administered a sleeping medication which had no affect on the resident. The resident sat in a chair at the nurses' station and made several attempts to get up by himself/herself. He/she required constant supervision due to his/her unsteady gait (how a person walks); -On 07/02/12, at 3:31 P.M., a nurse documented staff assisted the resident to bed between meals because the resident was very drowsy. He/she was unsteady and required assistance from two staff members to transfer; -On 07/02/12, at 11:59 P.M., a nurse documented the resident attempted to stand, without assistance, the entire shift. At 8:00 P.M. staff administered the as needed sleep medication to the resident. The resident was still awake at the end of the shift (10:00 P.M.); -On 07/03/12, at 4:30 A.M., a nurse documented the resident was awake until 3:00 A.M. At 1:00 A.M. staff administered a second dose of the sleep medication. The resident attempted to remove his/her lap buddy (a thick cushion which fits inside the arms of a wheelchair that can prevent a resident from rising) and was able to do so, at times; -On 07/03/12, at 3:26 P.M., a nurse documented the resident required a lot of one-on-one supervision due to constantly attempting to get up and walk unassisted; -On 07/03/12, at 5:19 P.M., a physical therapy aide (PTA) documented she would try to encourage the staff to walk with the resident when he/she attempted to stand. The resident required the assistance of one staff member for walking; -On 07/04/12, at 4:28 A.M., a nurse documented the resident slept about three hours then attempted to get out of bed. The resident ate a snack then fell asleep in his/her wheelchair. Staff assisted the resident to bed and within 20 minutes the resident was attempting to get out of bed. Staff transferred the resident to his/her wheelchair where he/she remained awake; -On 07/04/12, at 4:28 A.M., a nurse documented the resident had not exhibited any behaviors and his/her gait was extremely weak and unsteady; -On 07/04/12, at 3:33 P.M., a nurse documented the resident slept most of the shift; -On 07/05/12, at 3:51 A.M., a nurse documented the resident slept very little but was pleasant and cooperative; -On 07/06/12, at 3:20 P.M., a physical therapy aide documented the resident had a fall on 07/05/12. Staff requested a Physical Therapy evaluation to see if a merry walker (an enclosed framed wheeled walker) would be appropriate; -On 07/06/12, at 4:53 P.M., a nurse documented since shift change (2:00 P.M.) the resident had been a little drowsy; -On 07/07/12, 2:35 P.M., a nurse documented during the 6:00 A.M.-2:00 P.M. shift, the resident attempted to stand, stumbled against the piano and sat on the floor. The nurse assessed the resident and found no injuries; -On 07/08/12, at 1:15 P.M., a nurse documented the resident required one-on-one supervision most of the shift. Staff administered [MEDICATION NAME], 1 mg, at 12:00 P.M. with some relief; -On 07/09/12, at 1:53 A.M., a nurse documented staff administered sleep and pain medication to the resident. At approximately 12:00 A.M., staff took the resident to his/her room and transferred him/her to bed. The resident was restless causing the bed alarm to sound frequently. Staff heard the alarm and found the resident sitting on the side of his/he bed. Staff assisted the resident to the bathroom then sat him/her in his/her recliner. The resident fell asleep shortly after staff assisted him/her into the recliner; -On 07/09/12, at 3:07 P.M., a nurse documented the resident slept most of the shift. The resident did not exhibit increased agitation or restless. Record review of a physician's orders [REDACTED]. Record review of the physical therapy initial evaluation, dated 07/10/12, showed the following information: -The treatment [DIAGNOSES REDACTED]. -Prior level of function: Walked 150 feet with a front wheeled walker, required stand by assist (close enough to reach resident if assist is needed) for transfers and to stand, maintained sitting balance against minimal resistance and maintained standing balance with handhold support and occasional minimal assist; -Current level of function: Walked five feet with a front wheeled walker, required maximum assistance (76%-99% assist) with transfers, required moderate assistance to stand, maintained sitting balance with upper extremity support and required hand hold support and moderate assistance to maintain standing balance; -The resident demonstrated difficulty with the use of the merry walker. The resident stood 10 times with minimum to moderate assistance and walked a total of 22 feet with minimum to moderate assistance for advancement of the merry walker and verbal cues for proper placement; -Long term goal: The resident will improve gait ability with the merry walker to modified independence (assistive device or extra time needed; -Rehabilitation potential: Fair due to stable medical condition. Record review of the behavior documentation-psychopharmacological drug use, dated 07/01/12-07/10/12, showed the following information: -Specific targeted behaviors: Cussing, name calling, hitting and [MEDICAL CONDITION]; -On 07/01/12 (day shift) staff documented the resident hit a staff member two times in his/her stomach (review of nurses' notes and a behavior assessment showed this behavior occurred 07/10/12); -From 07/01/12 (evening shift) to 07/10/12 (evening shift) staff did not document monitoring the resident's behaviors. Record review of the resident behavior symptom reporting sheet, dated 07/10/12, showed at 10:00 A.M., when staff showered the resident he/she punched one of the aides twice, in his/her abdominal area. Record review of a nurses' note, dated 07/10/12, at 2:46 P.M., showed while staff and the resident was in the shower room, the resident punched one of the aides, two times, in his/her stomach. The nurse contacted the physician and hospice nurse who said they would follow up on the resident's medications. Record review of a physician's orders [REDACTED]. Record review of the behavior documentation-psychopharmacological drug use, dated 07/10/12-07/22/12, showed the following information: -From 07/10/12 (night shift) to 07/17/12 (evening shift) the resident exhibited behaviors (cursing, name calling and/or [MEDICAL CONDITION]) six out of 21 opportunities; -On 07/17/12 staff added "loud, agitated" to the targeted behaviors list; -From 07/17/12 (night shift) to 07/22/12 (night shift) the resident exhibited behaviors ([MEDICAL CONDITION] and loud, agitated) three out of 16 opportunities. Record review of the admission minimum data set (MDS), a federally mandated comprehensive assessment tool, completed by facility staff, dated 07/12/12, showed the following information: -Short and long term memory problems; -Required maximum assistance for daily decision making; -Inattention and disorganized thinking fluctuated (came and went, changed in severity); -Rejected care; -Wandered; -Required limited assistance with bed mobility and eating; -Required maximum assistance for transfers, walking, dressing, personal hygiene and bathing; -Occasionally incontinent of bowel; -Frequently incontinent of bladder; -No falls; -Received antipsychotic and antianxiety medications five out of the last seven days; -Received hypnotic medications three out of the last seven days. Record review of the departmental notes, showed the following: -On 07/12/12, at 12:00 A.M. the PTA documented he/she rescheduled therapy because the resident was not very alert and slept a lot; -On 07/12/12, at 2:40 P.M., a nurse documented the resident continued to be anxious and had periods of napping, approximately 45 minutes at a time. Staff to walk the resident to and from all meals. Staff assists the resident with all cares including feeding him/her part of his/her meals; -On 07/13/12, at 12:00 A.M., the PTA documented she tried to work with the resident all week but he/she had not been able to catch the resident alert. The PTA stood up the resident but he/she still had no real response to commands so he/she transferred the resident to bed with moderate assistance of two staff members. About an hour later the PTA transferred the resident into the merry walker with moderate assistance of two staff members. The resident walked, with small shuffled steps, 25 feet with verbal and tactile cues. He/she required moderate assist to stand. The PTA did not recommend the resident to use the merry walker unassisted; -On 07/13/12, at 10:20 A.M. a nurse documented the resident had been sleepy and was dependent on staff for all cares. Record review of the resident's current medical record showed no indication staff walked with the resident. Record review of the departmental notes, showed the following: -On 07/14/12, at 3:12 A.M., showed a nurse documented the resident had no behaviors; -On 07/15/102, at 1:20 P.M., a nurse documented the resident removed his/her seat belt, stood up and fell . The nurse assessed the resident and found no injuries. Record review of the physical therapy daily treatment note, dated 07/16/12, showed the resident required moderate to maximum assistance to stand. The resident placed his/her hands on the walker but did not take any steps and sat back down in the wheelchair. The PT attempted to walk with the resident later that afternoon but the resident continued to demonstrate difficulty using a walker and was unable to walk. Record review of the care plan, dated 07/16/12 and 07/18/12, showed staff did not address the resident taking antipsychotic, antianxiety or hypnotic medications and did not include interventions to assess or treat for decline in function related to psychoactive medications. Record review of the departmental notes showed the following: -On 07/16/12, at 4:26 A.M., a nurse documented at 11:00 P.M. staff administered [MEDICATION NAME] and [MEDICATION NAME] to the resident and within 45 minutes the resident was asleep. Approximately two hours later, the resident was wide awake. Staff transferred the resident into his/her wheelchair because he/she would not remain in the recliner; -On 07/17/12, at 3:28 P.M., the resident slept at the beginning of the shift and slept in the recliner a couple of hours; -On 07/18/12, at 6:28 A.M., the PTA documented she told staff when the resident was agitated or wanted to get up, they could walk with the resident with two staff assist; -On 07/18/12, 3:47 P.M., a nurse wrote a clarification order instructing staff to apply the quick release Velcro seat belt to the resident while in the wheelchair. Record review of the MAR, dated 07/01/12-07/22/12, showed the following information: -Staff administered [MEDICATION NAME] 5 mg every day (22 times); -Staff administered [MEDICATION NAME] 10 mg three times a day (64 times); -Staff administered [MEDICATION NAME] 1 mg every eight hours as needed 24 times; -Staff administered [MEDICATION NAME] 15 mg at bedtime, as needed 18 times. Record review of the resident's current medical record showed no indication staff contacted the physician or held the resident's medication due to drowsiness. An observation on 07/17/12, at 2:20 P.M., showed the resident sat in his/her wheelchair near the nurses' station. The resident had a Velcro seat belt fastened across his/her lap and appeared restless by attempting to stand several times. An observation and interview on 07/17/12, at 3:10 P.M., showed CNA K and CNA J in the resident's room, changing his/her clothes. The CNAs assisted the resident into a standing position, pulled up his/her pants and sat him/her into the wheelchair. CNA K said sometimes the resident stands "good" and sometimes he/she does not. It depends on how tired the resident is. Observations on 07/18/12 showed the following: -At 10:40 A.M., the resident, with his/her eyes closed, sat in a recliner near the nurses' station; -At 10:47 A.M. the resident opened his/her eyes, looked around and leaned forward as if he/she was going to get up from the recliner, but instead of attempting to stand he/she leaned back and closed his/her eyes; -At 10:50 A.M. the resident opened his/her eyes, looked around and scooted himself/herself forward in the chair until his/her feet touched the ground. LPN B observed resident and instructed him/her to lean back in the recliner. The resident laid his/her head on the pillow and closed his/her eyes; -At 2:30 P.M. the resident sat in his/her wheelchair, at the nurses' station, drinking from a cup. The resident had a Velcro seat belt fastened across his/her lap and a Tabs monitor string attached to the back of his/her shirt; Observations on 07/19/12 showed the following -At 12:18 P.M. staff wheeled the resident into the dining room and placed him/her at a dining room table. The resident sat, in the wheelchair, with his/her eyes closed and leaning to the left; -At 12:22 P.M. staff served the resident lunch and promptly began to feed him/her. The resident did not open his/her eyes or attempt to feed himself/herself. During an interview conducted on 07/20/12, at 10:12 A.M., the administrator and the director of nursing (DON) said when the resident attempts to stand, staff assists him/her to walk around the facility. The Administrator said he has walked with the resident, several times, but did not document it; walking decreased his/her restlessness. The DON said if the resident is strong enough, staff walks with him/her. Staff does not document walking with the resident but probably should. During an interview conducted on 07/20/12, at 12:15 P.M., the PTA said the resident is on hospice and we have to have a good reason in order to receive approval from them to treat the resident. Therapy evaluated the resident and received orders for three therapy sessions to see if he/she was appropriate to use a merry walker. The PTA did not think the resident could follow commands and he/she was not appropriate for the merry walker. The resident was often sleepy during treatment. She attempted to catch the resident awake several times. The resident would be awake and by the time the PTA came back with the walker the resident would be asleep. If she thought the resident had rehabilitation potential she would have asked hospice if they could treat the resident. The PTA did not think exercises would progress the resident because of his/her disease process. The only thing she could think of was for staff to walk with the resident. She did not suggest restorative therapy because the resident is often sleepy and anyone can walk with him/her not just the restorative aide. The PTA said when anyone sees the resident awake they walk him/her. During an interview conducted on 07/20/12, at 1:45 P.M., LPN Q said a restraint is the last resort. We try many things before applying a restraint such as talking to the DON, walking with the resident and administering medications. The resident often cat naps during the day but we (second shift) cannot keep up with him/her. The resident has an unsteady gait and does not understand the dangers of falling. Staff tries to walk with the resident to and from meals and should document walking with him/her on the ADL sheets. The resident has had some decline; he/she is weaker and is now dependent upon staff to feed him/her. The LPN thought the resident's disease process and medications has caused the decline in his/her functional abilities. During an interview conducted on 07/20/12, at 2:05 P.M., CNA R said he/she had not been back to work very long but since he/she had been back, he/she had not walked with the resident and the resident has been napping off and on more. During an interview conducted on 07/23/12, at 10:30 A.M., the activity director said since this admission (07/01/12), we have not walked the resident; he/she is weaker and sleeps more than he/she used to. He/she sleeps right after breakfast and is more awake in the afternoon. During an interview conducted on 07/23/12, at 12:25 P.M., the DON said staff admitted the resident to the facility from home. The resident takes [MEDICATION NAME] for [MEDICAL CONDITION]. At home he/she would not sleep for days or would sleep during the day and be up at night. The resident did not consistently take his/her medications and once we get his/her medications regulated we could probably back off them. The resident has not been in the facility for long so the pharmacist has not yet reviewed the resident's medications. The DON said the resident had been sleeping more but we do not know what medications he/she needs and not needs. Staff has reported this to the physician but he did not know the resident. We told him we would talk to the hospice nurse about the resident's medications. The DON talked to the physician last week but did not document the discussion. The DON did not know if the resident had actually declined or if his/her "medications have kicked in." During an interview conducted on 07/23/12, at 3:30 P.M., CNA J said he/she thought the resident had a decline. When the resident was admitted he/she only needed a little assist to walk to the bathroom and now it takes two people. During an interview conducted on 07/23/12, at 3:35 P.M., CNA S said the resident is more groggy and not as alert as he/she used to be. But if the resident is not groggy then he/she is trying to get out of the wheelchair and basically requires one-on-one supervision. When the resident was admitted he/she needed one person assist and now requires two. During an interview conducted on 08/02/12, at 9:45 A.M., the physician said the resident was on hospice and was already on [MEDICATION NAME] before staff admitted him/her to the facility therefore someone else had already authorized the resident's use of the medication. The physician expected the resident to have a decline because he/she was on hospice. Recently we either decreased or stopped the [MEDICATION NAME] because the resident was sleepy. 2. According to the website, Rx List (Internet Drug Index), the drug [MEDICATION NAME] ER (extended release anti-convulsant) may have the side effect of tremor (shaking.) The drug [MEDICATION NAME] (antipsychotic) can cause side effects that may impair thinking or reaction, and may cause the serious side effect of uncontrollable jerky muscle movements. A precaution is listed that there may be an interaction between the two drugs, [MEDICATION NAME] and [MEDICATION NAME]. Observations on 7/18/12 at 9:25 A.M. and 2:35 P.M. in the residents' room showed Resident #3 experienced severe hand tremors, worsening when he/she picked something up. He/she utilized a lidded drinking cup with a straw inserted in the top (for easier intake of beverage and to help prevent spills). He/she held the cup with both hands, but because of the hand tremors had difficulty keeping the cup in place to sip the liquid through a straw. Observation on 7/19/12 at 12:45 P.M. showed the resident sat at a dining table with three other residents. The resident's hands were very shaky and jerking as he/she picked up a lidded drinking cup to sip through a straw. Several times the tremor motion caused the cup and straw to be moved out of position for drinking. The resident's food was served on a scoop plate (adapted for easier use of spoon/fork). His/her attempts to eat was slow and difficult because of the continuous sporadic movement of the eating utensils caused by the tremors. A CNA assisted each of the four residents at the table by giving them bites of food and/or fluids to drink. Observation on 7/20/12 at 7:55 A.M. showed the resident in a wheelchair, brushing his/her hair. The activity was hindered by the presence of the resident's hand tremors. Observation on 7/20/12 at 12:05 P.M. showed the resident sat at a dining table with three other residents. The resident's hands were very shaky and jerking as he/she picked up a lidded cup to take a drink using a straw; he/she was only able to consume a small sip at a time due to the difficulty in keeping the cup/straw in position. Record review of the annual MDS, dated [DATE], showed the following information: -admitted [DATE]; -The resident scored 15 points out of a possible 15 (a score of 15 showed the highest cognitive ability) on a resident interview to determine cognitive ability; -Setup assistance and supervision for eating; -Extensive assistance required for transfers and bathing; -Total dependence on staff for dressing, and toileting; -Current regimen for administration of an antipsychotic medication; -[DIAGNOSES REDACTED]. Record review of the annual MDS, dated [DATE], showed the following information: -admitted [DATE]; -The resident scored four (4) points out of a possible 15 (a score of 15 showed the highest cognitive ability) on a resident interview to determine cognitive ability; -Evidence of acute change in mental status; -Extensive assistance required for eating; -Total dependence on staff for, transfers, dressing, toileting, and personal hygiene; -Current regimen for administration of an antipsychotic medication; -[DIAGNOSES REDACTED]. pain, and [MEDICAL CONDITION] disorder. Record review of AIMS (Abnormal Involuntary Movement Scale, used to assess a resident's abnormal muscle, facial, and body movements) reports, dated 12/23/11, 3/20/12, and 6/19/12, showed that staff did not document information noting resident's tremors. Record review of the Care Plan showed the following: Problem Onset: 6/16/11 Potential for adverse reactions/injury due to use of [MEDICAL CONDITION] medications and [MEDICATION NAME]. Goal & Target Date: Resident will experience minimal to no adverse reactions/side effects from [MEDICAL CONDITION] medication(s) thru next review. Approaches: Observe/document/report any noted side effects/adverse reactions to physician. Record Review of the POS [REDACTED] -On 7/02/10 an order for [REDACTED].; -On 7/02/10 [MEDICATION NAME] ER 500 mg, one tablet by mouth at 2:00 P.M. and at 11:00 P.M.; -On 3/18/12 an order to reduce [MEDICATION NAME] (an antispychotic medication) to 325 mg (from 350 mg); give by mouth at bedtime. Record review of Departmental Notes, an electronic record where nurses and responsible staff members within other resident care departments can document findings, ranging in date from 4/13/12 to 7/18/12, showed the following: -Nursing staff did not document any information regarding the resident's tremors; -Dietary staff documented that because of observed tremors and resulting difficulties with eating and drinking independently, the resident now sits at a dining table where a CNA is available to assist him/her with eating and drinking, and the resident uses a scoop plate and lidded cups with straws. Record review of physician notes in the resident's medical chart showed the physician did not document any information noting the resident's tremors. During an interview on 7/23/12 at 1:45 P.M., the DON said if a resident has a significant change in condition, the charge nurse should report that change to the physician and document that notification along with physician comments or new orders. DON said that upon record review he/she did not locate any physician notes regarding the resident's tremors, but was sure the physician was aware of the worsening tremors. There is no documented [DIAGNOSES REDACTED]. The AIMS assessment is completed upon admission of a resident, every quarter, and with a significant change or decline in a resident's condition. During an interview on 7/23/12 at 3:35 P.M., the MDS Coordinator stated that when a resident assessment is done for the MDS, he/she looks at all activities of daily living (ADLs), continence, and overall amount of care needed. A decline in more than one area would trigger the need for a Significant Change MDS. He/she stated that AIMS assessments are completed by the nurse upon a resident's admission to the facility in order to establish a baseline, again quarterly, and if a new [MEDICAL CONDITION] medication is ordered. The MDS Coordinator completes the quarterly, and as needed assessments, coordinating the timing with the required MDS assessment reports. MDS Coordinator E stated he/she would note the resident's tremors on the AIMS, but does not document them on the Care Plan. Record review of Physician's Progress Notes showed the following: 7/24/12 - Tremors most likely due to [MEDICATION NAME] and/or [MEDICATION NAME] which he/she needs to continue. Record Review of the POS [REDACTED] 7/25/12 - 1) Decrease [MEDICATION NAME] to 200 mg at bedtime; 2) [MEDICATION NAME] (used to treat tremors caused by [MEDICAL CONDITION] or by other medications) 2 mg three times per day, diagnosis - tremors.