Every finding on record at Legendary Health Care Center

Based on observation and interview, facility administration failed to implement an effective system for ordering sufficient supplies necessary to meet residents' needs. The facility census was 37.The facility did not have a policy regarding sufficient supplies. 1. Review of Resident #3's Care Plan, dated 6/23/25 and revised on 9/25/25, showed the following:-He/She was able to perform his/her activities of daily living (ADLs) with staff's assistance;-He/She had frequent urinary incontinence; -He/She waited too long to get to the bathroom and voided down his/her legs and on the floor;-He/She wore size five-X incontinence briefs. Observation on 1/6/26 at 12:19 P.M., showed the following: -There were no gloves in the resident's room;-One incontinence brief two sizes too small for the resident was by the resident's bed;-The resident wore pants but did not wear an incontinence brief. During an interview on 1/6/26 at 12:19 P.M., the resident said the following: -There were no gloves in his/her room;-The facility's incontinence supplies had been low for two months;-The facility was out of incontinence briefs in his/her size; -He/She went without wearing incontinence briefs when the facility was out of incontinence briefs;-Staff brought him/her an incontinence brief two sizes too small today; -He/She could not wear the incontinence brief because it was too small;-He/She had three incontinent episodes yesterday and four incontinent episodes today. He/She had to change his/her clothes after he/she was incontinent because he/she did not have incontinence briefs to wear;-He/She felt humiliated when he/she was incontinent when not wearing an incontinence brief. During an interview on 1/6/26 at 1:35 P.M., Certified Nurse Assistant (CNA) B said the following:-The facility often ran out of gloves, incontinence briefs, and wipes;-The facility ran out of the bigger sizes of incontinence briefs;-The facility tried to accommodate when they ran out of incontinence briefs by using smaller size incontinence briefs; -Resident #3 had to go without incontinence briefs;-Resident #3 complained to him/her about not having incontinence briefs; -He/She reported to the charge nurse more than once about Resident #3 not having incontinence briefs. During an interview on 1/6/26 at 2:08 P.M., CNA E said the following:-The facility's supply of gloves, incontinence briefs and wipe had been low since August; -Resident #3 went without incontinence briefs due to the facility not having any incontinence briefs in his/her size. During an interview on 1/6/26 at 2:46 P.M., the Director of Nursing (DON) said Resident #3 had not had incontinence briefs for four days. 2. Review of Resident #2's Care Plan, dated 7/7/25 and revised on 12/8/25, showed the following:-The resident had some incontinence; -He/She needed assistance with toileting hygiene;-Wash, rinse and dry perineum and change clothing after incontinence episodes;-Utilize incontinence briefs as needed and change when soiled. Observation on 1/6/26 at 4:55 P.M., showed there were no gloves or incontinence briefs in the resident's room. During an interview on 1/6/26 at 4:55 P.M., the resident said the following:-He/She wore an incontinence brief when the facility had them; -He/She went without incontinence briefs when the facility ran out;-Staff told him/her today they were out of large incontinence briefs; -He/She did not wear an incontinence brief today, because none were available; -He/She did not have any gloves in his/her room. 3. Review of Resident #4's care plan, dated 11/22/24 and revised on 11/26/24, showed the following:-He/She was frequently incontinent of bowel and bladder;-Provide peri-care with each incontinence brief change. Observation on 1/6/26 at 5:07 P.M., showed there were no gloves or incontinence briefs in the resident's room. During an interview on 1/6/26 at 5:07 P.M., the resident said the following:-The facility ran out of his/her size incontinence briefs two weeks ago; -Staff put an incontinence brief that was too small on him/her because the facility ran out of his/her size; -He/She had an incontinent episode yesterday and had to change his/her clothes because his/her incontinence brief was too small. During an interview on 1/6/26 at 5:10 P.M., Nurse Assistant (NA) G said the following:-The facility ran out of Resident #4's size of incontinence briefs two days ago;-Staff put a smaller brief on the resident when they were out of his/her size. During an interview on 1/6/26 at 1:50 P.M., Certified Medication Technician (CMT) C said yesterday, the resident had to wear an incontinence brief that was much too small because the facility was out of the resident's size. 4. Observation on 1/6/26 at 11:10 A.M of the storage rooms where the incontinence supplies were stored, showed the following:-Four packages of size small pull-on incontinence briefs;-Four packages of size medium pull-on incontinence briefs;-11 packages of size small incontinence briefs;-Five packages of size medium incontinence briefs.(The facility did not have a supply of incontinence briefs larger than size medium.) Observation on 1/6/26 at 11:12 A.M. of the resident list with type of incontinence briefs used and size posted in the incontinent supplies storage rooms showed the following:-No residents required size small;-Five residents required size medium;-Eight residents required size large;-Six residents required size extra-large;-One resident required size triple extra-large;-Two residents required quadruple/quintuple extra-large. 5. Observation on 1/6/26 at 11:00 A.M., showed there were no gloves in Resident #5's room. During an interview on 1/6/26 at 11:00 A.M., Resident #5 said the following:-There were no gloves in his/her room;-Staff had gloves in their pockets when they came in to provide his/her care. 6. Observation on 1/6/26 at 11:06 A.M., showed there were no gloves on the medication cart at the nurse's station. Observation on 1/6/26 at 3:30 P.M., showed there were no gloves in occupied resident rooms 1, 3, 11, 12, 15 19, 20 and 28. Observation on 1/6/26 at 3:30 P.M., showed boxes of gloves at the nurse's station. 7. During an interview on 1/6/26 at 11:06 A.M., Certified Medication Technician (CMT) A said the following:-The facility glove supply was low;-The gloves were kept at the nurse's station when the glove supply was low. During an interview on 1/6/26 at 1:50 P.M., CMT C said the following:-The facility had issues with not having enough supplies since August; -There should be gloves in each resident's room, however, the gloves were kept at the nurse's station when the supply was low. During an interview on 1/6/26 at 1:50 P.M., CNA D said the following:-The facility had issues with not having enough supplies since August; -The facility ran low on incontinence briefs, wipes and gloves;-Residents had to go without wearing incontinence briefs, because the facility did not have incontinence briefs available in the correct sizes. During an interview on 1/6/26 at 2:22 P.M., Registered Nurse (RN) F said the following:-The facility's supply of incontinence briefs, wipes and gloves had been an issue since August; -He/She voiced concern about the low supplies to administration, and administration said the supplies were on order;-There were no gloves in the residents' rooms when the glove supply was low;-The gloves were kept at the nurses station when the glove supply was low;-Staff kept gloves in their pockets when the glove supply was low;-The residents had to go without incontinence briefs or staff used smaller sizes of incontinence briefs on residents when the facility was out of the bigger sizes. During interviews on 1/6/26 at 2:46 P.M., 1/7/26 at 9:20 A.M. and 1/13/26 at 11:04 A.M., the Director of Nursing (DON) said the following:-She expected staff to report to her if a supply of incontinence briefs or gloves was low to prevent running out;-She was to complete an inventory of supplies daily; however, she completed an inventory of supplies every other day;-Staff discussed the supply of incontinence briefs and gloves every day in morning meeting;-She was not aware the facility was completely out of larger sizes of incontinence briefs until 1/6/26 when staff reported this to her; -Staff should have told her the incontinence brief and glove supply were low, so staff could purchase supplies locally and increase the number of these supplies on the next order;-The MDS Coordinator bought gloves and incontinence briefs on 1/6/26 due to running low or being out of these supplies;-She was responsible for ordering supplies and ordered supplies twice a month;-When she ordered supplies, the supply orders were delayed due to the approval process;-She expected gloves to be in every resident room and on every medication and treatment cart;-When the glove supply was low, gloves were kept at the nurse's station. She expected staff to take a handful of gloves with them and to put the gloves in their pockets or to put them on the medication and treatment carts even if this was an infection control issue. During interviews on 1/6/26 at 2:46 P.M., 1/7/26 at 9:20 A.M., and 1/13/26 at 9:34 A.M., the Administrator said the following:-The facility had an issue with running low or out of supplies; -The facility was low on supplies because the facility had not established a sufficient supply due to a higher usage of gloves and incontinence briefs than in the past;-He expected the DON to order more supplies on the next order if an item was low or the facility ran out of the item;-Staff were to notify him or the DON when supplies were low to ensure the facility did not run out of the supplies;-He monitored to ensure there were sufficient supplies by discussing with staff during the morning meeting.-He was aware most of the time when supplies were low; -He was aware gloves and incontinence briefs were low on 1/6/25 and approved for staff to purchase gloves and incontinence briefs. Complaint #2687268

Based on interview and record review, the facility failed to follow professional standards of care for one resident (Resident #2), in a review of six sampled residents, when staff failed to follow physician's orders related to administering Xarelto (blood thinner used to treat and prevent blood clots). The facility census was 37.Review of the undated and untitled facility policy for medication administration showed the following:-The facility shall ensure medications will be administered according to physician's orders;-The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: -Medication administered not in accordance with the prescriber's orders. Examples include, but not limited to: -Incorrect dose, route of administration, dosage form, time of administration; -Medication omission; -Incorrect medication;-If a medication error occurs, the nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible. Review of Resident #2's Face Sheet showed he/she had diagnoses of atrial fibrillation (an irregular and often very rapid heart rhythm) and atrial flutter (a type of heart rhythm disorder). Review of the resident's Physician Orders, dated December 2025, showed an order for Xarelto 15 milligrams (mg) one tablet in the evening (original order dated 6/27/25). Review of the resident's most recent Care Plan, dated 7/7/25, showed the following:-The resident was on anticoagulant therapy related to atrial fibrillation;-Administer anticoagulant medications as ordered. Review of the resident's Medication Administration Record (MAR), dated December 2025, showed staff did not administer Xarelto 15 mg on 12/11/25, 12/12/25, 12/13/25, 12/14/25, 12/15/25 and 12/16/25. Staff documented they were awaiting the medication on all six days. During an interview on 1/12/26 at 4:49 P.M., Licensed Practical Nurse (LPN) I said the following:-Xarelto was not available in the medication cart or in the emergency kit on 12/11/25 to administer to the resident;-He/She reported to the charge nurse, LPN H, that the medication was not available and was not administered to the resident;-He/She did not report to the pharmacy, physician, Director of Nursing (DON), or the administrator the medication was not available or administered to the resident; -He/She was not sure of the pharmacy process to follow when a medication was unavailable. During interviews on 1/6/26 at 5:18 P.M. and 1/12/26 at 4:26 P.M., LPN H said the following:-He/She was the charge nurse on 12/11/25 and usually did not pass medications;-He/She helped LPN I pass medications on the night shift of 12/11/25; -The resident's Xarelto was not available on 12/11/25; -Xarelto was not available in the medication cart or emergency kit for the resident on 12/11/25;-He/She did not usually contact the pharmacy when a medication was not available;-The Certified Medication Technicians (CMTs) were responsible to contact the pharmacy when a medication was not available;-He/She sent a request to the pharmacy to request the medication on 12/12/25;-He/She did not report to the physician or the on-call physician that the medication was not available and not administered to the resident;-He/She should have contacted the physician or physician on call;-The resident did not receive his/her Xarelto from 12/11/25 through 12/16/25. Review of the communication platform between the facility and the pharmacy, dated 12/12/15 at 2:45 P.M., showed the following:-LPN H requested a refill of the resident's Xarelto;-The pharmacy responded they needed the order for the medication to be updated since the resident's readmission on [DATE]. Review of the resident's progress notes showed no documentation the facility sent an updated order for the resident's medication to the pharmacy on 12/12/25 through 12/15/25. Review of the communication platform between the facility and the pharmacy, dated 12/15/25 at 9:22 A.M., showed the following:-The pharmacy received a refill request for the resident's Xarelto;-The pharmacy could not refill this medication due to the order being over a year old. Can we please have an updated order sent over to us? Review of the communication platform between the facility and the pharmacy, dated 12/16/25 at 9:46 P.M., showed Xarelto should be coming out on the pharmacy's evening delivery run. During an interview on 1/6/26 at 4:55 P.M., the resident said he/she went without his/her blood thinner for five to six days in December. During interviews on 1/6/26 at 5:35 P.M. and 5:47 P.M., 1/7/26 at 9:20 A.M. and 1/13/26 at 11:04 A.M., the DON said the following:-She was not sure why staff did not give the resident Xarelto on 12/11/25, 12/12/25, 12/13/25, 12/14/25, 12/15/25 and 12/16/25; -Staff did not inform her the resident did not receive the Xarelto on 12/11/25 through 12/16/25;-She expected staff to inform her when a medication was not administered to a resident;-Staff ordered the Xarelto from the pharmacy on 12/11/25 and did not receive the Xarelto from the pharmacy until 12/16/25;-The Xarelto was not available because the order needed to be reinstated, which means the facility staff had to delete the order out of the system and restart the order; -The physician did not need to sign for the order to be reinstated since the prescription was still good;-She was not aware of the process for reinstating an order for the pharmacy until this resident;-She expected staff to resubmit the order to the pharmacy if the medication was still not available on 12/12/25;-Staff did not follow up on the resident's medication request until 12/15/25 due to the weekend nurse not following up with the pharmacy or physician;-LPN H notified the physician's office on 12/16/25 to get the medication prescription renewed; -She expected staff to notify the physician or physician on call if a medication was not available or administered;-Staff did not notify the resident's physician or the on-call physician when the resident did not receive the Xarelto from 12/11/25 to 12/16/25. During an interview on 1/8/26 at 2:22 P.M., the resident's physician said the following:-The resident was to receive an anticoagulant daily for atrial flutter and to prevent stroke;-Staff did not notify him/her and he/she was unaware the resident went six days without his/her anticoagulant medication;-He expected staff to notify him when a resident's anticoagulant was not available and not administered, especially if it was for more than a couple of days. Complaint #2702244

Based on observation, interview, and record review, the facility failed to conduct a complete assessment to identify a history of trauma, the presence of symptoms related to the trauma, and triggers that may cause re-traumatization and to develop an individualized care plan with interventions to mitigate and eliminate these triggers for two residents (Residents #30 and #14), in a review of 14 sampled residents. Resident #30 had a diagnosis of post traumatic stress disorder (PTSD, a mental health condition triggered by a terrifying event, either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) related to sexual abuse as a child. The facility failed to identify the resident's triggers, which included feeling unsafe during mechanical lift transfers. The resident said the trauma he/she experienced as a child made him/her feel trapped and instilled fear in him/her and taught him/her to freeze during times of fear. Even though the transfers were different than his/her trauma, the transfers brought up similar feelings. During the mechanical lift transfer, he/she felt out of control, helpless, stuck, not able to get free, and trapped. The facility to develop interventions to address this trigger to prevent re-traumatization for the resident. Resident #14 had a history of trauma involving death of a family member in a fire. The facility failed to identify the triggers, which included sounding of the facility's fire alarm, which caused a negative response as a result of the resident's trauma, and failed to develop interventions to reduce/prevent re-traumatization. The facility census was 31. Review of the facility's policy, Trauma Informed Care and Culturally Competent Care, revised [DATE], showed the following: -Purpose: to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice and to address the needs of trauma survivors by minimizing triggers and/or re-traumatization; -Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being; -Trauma-informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization; -Trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening; -Nursing staff are trained on trauma screening and assessment tools; -For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization; -Triggers are highly individualized. Some common triggers may include: -Experiencing a lack of privacy or confinement in a crowded or small space; -Exposure to loud noises or bright/flashing lights; -Certain sights, such as objects; and/or -Sounds, smells, and physical touch; -Evaluate the need for trauma-informed practices as part of the facility assessment; -Include trauma-informed care as part of the QAPI process, so that needs and problem areas are identified and addressed; -Establish an environment of physical and emotional safety for residents and staff; -Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events; -Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant and sensitive; -Utilize initial screening to identify the need for further assessment and care; -Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers; -Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments; -Use assessment tools that are facility-approved and specific to the resident population; -Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate; -Identify and decrease exposure to triggers that may re-traumatize the resident; -Recognize the relationship between past trauma and current health concerns (e.g., substance abuse, eating disorders, anxiety and depression). 1. Review of Resident #30's Face Sheet showed the following: -He/She admitted on [DATE]; -He/She had diagnoses of PTSD, bipolar disease (a mental illness characterized by extreme mood swings, ranging from periods of elevated mood (mania) to periods of depressed mood), and depression. Review of the resident's Trauma Informed Care Assessment, completed on [DATE], showed the following: -Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, and/or having a loved one die through homicide or suicide; -Have you ever experienced this kind of event? Yes (if yes, please answer questions in the next section); -In the past month have you: -Had nightmares about the event(s) or through about the event(s) when you did not want to? No; -Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? No; -Been constantly on guard, watchful, or easily startled? No; -Felt numb or detached from people, activities, or your surroundings? No; -Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? Yes. (The assessment did not include any specifics to identify the resident's history of trauma and the triggers that may be stressors or may prompt recall of the traumatic events in order to provide person-centered care to meet the resident's psychological needs and to prevent retraumatization.) Review of the resident's Level II Preadmission Screening and Resident Review (PASRR), dated [DATE], showed the following: -The resident had a serious mental illness; -The following supports and services were to be provided by the nursing facility: -Behavioral Support Plan; -Structured Environment; -Crisis Intervention Services; -Medication Therapy; -Activities of Daily Living (ADL) Program; -Personal Support Network; -The resident's diagnoses included major depressive disorder, PTSD, and bipolar disorder; -The resident had a diagnosis of PTSD related to a history of sexual molestation and rape as a child by family from age three to 16; -The resident had current symptoms of being withdrawn and depressed; -The resident had numerous family stressors causing his/her severe anxiety. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Cognitively intact; -Diagnoses of PTSD and depression; -A completed level II preadmission screening and resident review (PASRR). Review of the resident's care plan, updated on [DATE], showed the following: -He/She had a history of PTSD and depression most of his/her life. He/She had some traumatic events happen to him/her in his/her younger years that he/she has trouble dealing with at times. When not on his/her appropriate medication, he/she displays behaviors; -Administer medications as ordered; -Behavioral health consults as needed; -At times, the resident needs time to talk; encourage him/her to express feelings; -Monitor/document/report any risk for intentionally trying to slide out of chair or refusing to eat or drink, refusing medication or sense of hopelessness or helplessness, impaired judgment or safety awareness; -Monitor for and report to physician mood patterns and signs and symptoms of depression, anxiety, and sad mood as per facility behavior monitoring protocols. (The resident's care plan did not include information about the resident's PTSD triggers or interventions related to those specific triggers to prevent the resident from experiencing further re-traumatization related to his/her diagnoses of PTSD.) During an interview on [DATE] at 10:24 A.M., the resident said the following: -He/She had issues with mechanical lift transfers since he/she was admitted ; -Sometimes, the transfer was rough because the wheels stuck and the staff had to use a lot of force to move it; -Sometimes, the battery died during the transfer and staff had to change it to finish the transfer; -He/She had anxiety about being transferred because he/she felt unsafe. Observations on [DATE] showed the resident remained in bed all day. During interviews on [DATE] at 7:08 A.M. and [DATE] at 11:41 A.M. and 2:46 P.M., the resident said the following: -On Monday ([DATE]), staff went to put him/her back into bed, and the mechanical lift got stuck at the top and would not lower with him/her in the lift. Staff had to use the emergency release button to lower him/her into the bed; -This was not the first time a situation like this had happened; -Since he/she had been at the facility (approximately seven months), he/she had issues with two different mechanical lifts. The lifts would quit working mid-lift and staff had to push/shove hard on the mechanical lift which made the transfers feel unsafe; -When he/she felt unsafe in the lift, it could cause an anxiety attack (an episode of heightened anxiety where you feel overwhelmed and experience physical and mental symptoms) or a panic attack (a sudden, intense episode of fear); -He/She had a history of PTSD related to childhood sexual trauma. The trauma he/she experienced made him/her feel trapped and intimidated, instilled fear in him/her and taught him/her to freeze during times of fear; -The mechanical lift transfer wasn't the same as the trauma he/she experienced, but it did bring up similar feelings; -The fear of getting hurt, along with the feeling of being unsafe, triggered his/her anxiety and panic attacks and increased the fear around transfers; -Being in the air during a mechanical lift transfers, made him/her feel out of control, helpless, stuck, not able to get free, trapped, and immobile; -During the transfer back to bed on Monday ([DATE]), the battery on the lift stopped working and staff had to change out three batteries, all of which did not work, which resulted in staff having to use the emergency button; -He/She did not get up for two days due to the fear of another transfer like Monday's; -During the transfer on Monday, he/she just sat frozen, afraid to move, and began shaking out of fear of getting hurt or hurting others. -Things that could help with the fears surrounding the transfers would be a consistently working lift, and communication or small talk with staff to help keep his/her mind off of the fear and silence; -He/She had never really voiced his/her fears and symptoms of that fear surrounding the hoyer lift transfers; he/she felt the staff would not listen to his/her concerns; -He/She did not remember any staff completing a Trauma Informed Care Assessment with him/her on admission, and did not remember anyone asking what his/her triggers were. During an interview on [DATE] at 4:12 P.M., Certified Nurse Assistant (CNA) H said he/she was not aware of any residents who had a diagnosis of PTSD or history of past trauma. During an interview on [DATE] at 4:33 P.M., CNA G said he/she was not aware of any current residents who had PTSD or past trauma. During an interview on [DATE] at 1:36 P.M., Nurses Aide (NA) J said the following: -The resident had voiced that he/she feared the mechanical lift might quit mid lift; the resident didn't say he/she had any PTSD or past trauma; -He/She had experienced transfers with the resident when the lift quit mid lift; -He/She was not aware of any residents who had PTSD or trauma with major triggers that staff would need to be aware of that could impact their regular day-to-day cares. During an interview on [DATE] at 10:01 A.M., the MDS/Care Plan Coordinator said the following: -The resident's care plan did not include triggers, coping skills, or additional services, so it could have been more comprehensive; -She did not feel it was her place to pry into the resident's past, so she allowed the residents to tell her what they wanted; -If the resident did not want to share any additional information she did not document it as a refusal or that the resident declined to answer; -She was not aware that she should be asking about symptoms, triggers, and treatments as part of her assessment to add to the care plan. 2. Review of Resident #14's face sheet showed the following: -admitted on [DATE]; -Diagnosis of depression. Review of the resident's Trauma Informed Care Assessment, completed on [DATE], showed the following: -Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, and/or having a loved one die through homicide or suicide; -Have you ever experienced this kind of event? Yes (if yes, please answer questions in the next section); -In the past month have you: -Had nightmares about the event(s) or through about the event(s) when you did not want to? Yes; -Tried hard not to think about eh event(s) or went out of your way to avoid situations that reminded you of the event(s)? No; -Been constantly on guard, watchful, or easily startled? No; -Felt numb or detached from people, activities, or your surroundings? No; -Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? No. (The assessment did not include any specifics to identify the resident's history of trauma and the triggers that may be stressors or may prompt recall of the traumatic events in order to provide person-centered care to meet the resident's psychological needs and to prevent retraumatization.) Review of the resident's trauma informed care assessment, completed on [DATE], showed the following: -Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, and/or having a loved one die through homicide or suicide; -Have you ever experienced this kind of event? Yes (if yes, please answer questions in the next section); -In the past month have you: -Had nightmares about the event(s) or through about the event(s) when you did not want to? Yes; -Tried hard not to think about eh event(s) or went out of your way to avoid situations that reminded you of the event(s)? No; -Been constantly on guard, watchful, or easily startled? No; -Felt numb or detached from people, activities, or your surroundings? No; -Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? No. (The assessment did not include any specifics to identify the resident's history of trauma and the triggers that may be stressors or may prompt recall of the traumatic events in order to provide person-centered care to meet the resident's psychological needs and to prevent retraumatization.) Review of the resident's trauma informed care assessment, completed on [DATE], showed the following: -Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, and/or having a loved one die through homicide or suicide; -Have you ever experienced this kind of event? Yes (if yes, please answer questions in the next section); -In the past month have you: -Had nightmares about the event(s) or through about the event(s) when you did not want to? No; -Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? Yes; -Been constantly on guard, watchful, or easily startled? No; -Felt numb or detached from people, activities, or your surroundings? No; -Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? No. (The assessment did not include any specifics to identify the resident's history of trauma and the triggers that may be stressors or may prompt recall of the traumatic events in order to provide person-centered care to meet the resident's psychological needs and to prevent retraumatization.) Review of the resident's care plan, dated [DATE], showed the following: -He/She was treated for depression; -His/Her mood needed to be monitored; -He/She had a traumatic experience in his/her lifetime, involving the death of his/her family member, and sometimes had dreams about it; -Administered antidepressant medications as ordered; -Offer one-on-one visits when he/she has these dreams and allow him/her to express his/her sadness; -Offer counseling as needed; -Report any changes in his/her mood or depression. Review of the resident's trauma informed care assessment, completed on [DATE], showed the following: -Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, and/or having a loved one die through homicide or suicide; -Have you ever experienced this kind of event? Yes (if yes, please answer questions in the next section); -In the past month have you: -Had nightmares about the event(s) or through about the event(s) when you did not want to? No; -Tried hard not to think about eh event(s) or went out of your way to avoid situations that reminded you of the event(s)? No; -Been constantly on guard, watchful, or easily startled? No; -Felt numb or detached from people, activities, or your surroundings? No; -Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? No. (The assessment did not include any specifics to identify the resident's history of trauma and the triggers that may be stressors or may prompt recall of the traumatic events in order to provide person-centered care to meet the resident's psychological needs and to prevent retraumatization.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Diagnosis of depression. Review of the resident's care plan, last reviewed/updated [DATE], did not include information about the resident's past trauma triggers or interventions to prevent the resident from experiencing further re-traumatization related to his/her diagnoses of PTSD. During an interview on [DATE] at 4:17 P.M., the resident said the following: -He/She did not have a diagnosis of PTSD, but had trauma related to his/her family member's death in a fire; -Occasionally, he/she had thoughts and dreams about it; -At times, the fire alarms brought up some feelings, and he/she found himself/herself joking with staff to push down the thoughts and memories; -He/She had not voiced this to any staff as he/she felt it was not his/her job to notify all the staff. He/She felt staff should have asked him/her; -He/She did not remember any staff interviewing him/her about the trauma, any symptoms he/she suffered, or any triggers; -He/She felt the facility could do a better job of communication and asking questions about his/her past trauma. He/She did not feel like it was his/her job to notify all the staff members because he/she did not want to talk about the trauma over and over again. 3. During interviews on [DATE] at 9:40 A.M. and [DATE] at 2:45 P.M., the DON said the following: -The MDS/Care Plan Coordinator was responsible for completing the Trauma Informed Care Assessment. The MDS/Care Plan Coordinator was the only one who completed the assessments to avoid re-traumatizing the residents by having multiple staff asking questions; -The Trauma Informed Care Assessment was the only assessment the facility completed related to trauma-informed care; -The care plans were based off of the Trauma Informed Care Assessment; -The care plan should include the diagnosis of PTSD or trauma, and include the resident's triggers, symptoms, coping mechanisms, and any other pertinent information. -She expected staff to adequately and completely assess residents with PTSD or a history of trauma; -She would expected staff to follow the facility's policy for trauma-informed care. During an interview on [DATE] at 10:01 A.M. the MDS/Care Plan Coordinator said the following: -She was responsible for completing the Trauma Informed Care Assessment; -If the resident answered yes (to the question related to history of trauma), the assessment prompts more questions to be answered; -She did not have any additional assessments she completed, other than the trauma informed care assessment; -She was unsure what she would include in the care plan, as it depended on what the resident was willing to share; -She did not feel it was her place to pry into the resident's past, so she allowed the residents to tell her what they wanted; -If the resident did not want to share any additional information, she did not document it as a refusal or that the resident declined to answer; -She was not aware that she should be asking about symptoms, triggers, and treatments as part of her assessment to add to the care plan; -She was not aware of any triggers for either resident (Resident #30 or #14). During an interview on [DATE] at 2:45 P.M., the Administrator said he expected a resident's PTSD or history of trauma to be adequately assessed and documented on the care plan.

Based on observation, interview, and record review, the facility failed to follow proper hand hygiene techniques when preparing and serving food to residents, and failed to ensure food items in the freezers were stored in good condition without freezer burn. The facility census was 31. 1. Review of the facility policy, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, last revised November 2022, showed the following: -Employees must wash their hands: Before coming in contact with any food surfaces, after handling soiled equipment or utensils, and after engaging in other activities that contaminate the hands.; -Gloves are considered single-use items and must be discarded after completing the task for which they are used; -The use of disposable gloves does not substitute for proper handwashing; -Food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. Observation on 5/13/25 at 11:45 A.M., in the kitchen, showed the following: -The Dietary Manager wore gloves as she served the lunch meal trays from the steam table; -Without changing gloves, she went to the preparation table across from the steam table and grabbed three dessert bowls by placing her gloved thumb into each bowl; -She placed sliced peaches into each of the three bowls and placed the bowls on residents' meal trays. -The Dietary Manager continued to serve the lunch meal trays from the steam table; -Without changing gloves, she went to the preparation table across from the steam table, grabbed slices of bread, sliced deli meat, and sliced cheese with her gloved hands, prepared a sandwich, and placed the sandwich on a resident's plate; -Without changing gloves, the Dietary Manager reached into a bag of cheese puffs, grabbed a hand full of cheese puffs with her gloved hand, and place them on the resident's plate. Observation on 5/13/25 at 11:55 A.M., in the kitchen showed the following: -The Dietary Manager wore gloves as she served the lunch meal trays from the steam table; -Without changing gloves, she went to the preparation table across from the steam table, grabbed slices of bread, sliced deli meat, and sliced cheese with her gloved hand, and prepared a sandwich; -She placed sandwich onto the resident's plate. Observation on 5/13/25 at 12:30 P.M., in the kitchen showed the following: -The Dietary Manager wore gloves as she served the lunch meal trays from the steam table; -Without changing gloves, she went to the preparation table across from the steam table, reached into the lettuce container with her gloved hands, and obtained a hand full of lettuce; -She placed the lettuce from her hand into a bowl and placed the bowl on a resident's meal tray; -Without changing gloves, she grabbed slices of bread, sliced deli meat, and sliced cheese with her gloved hand, prepared a sandwich, and placed the sandwich on a resident's plate. During an interview on 5/14/25 at 3:30 P.M., the Dietary Manager said the following: -She did not realize she used the same gloved hands without washing/re-gloving hands, during the lunch meal service; -She should not have reached into the dessert bowls, bread bag, cheese container, cheese puffs bag, or lettuce container with the same gloved hands she used to serve from the steam table; -She should have used serving tongs or washed her hands and put on new gloves instead of using the same gloved hands. 2. Observations on 5/13/24 between 9:00 A.M. and 10:10 A.M., during the dietary/kitchen department tour, showed the following: -In freezer #1, a bag of fish sticks, dated 3/21/24, had an accumulation of ice crystals and signs of freezer burn; -In freezer #2, a bag of chicken breasts, dated 1/23, had an accumulation of ice crystals and signs of freezer burn; -In freezer #4, four packages of sliced oven roasted turkey breast, dated 4/10, had signs of freezer burn; -In freezer #4, two packages of sliced smoked ham, dated 5/1, had signs of freezer burn; -In freezer #6, a bag of broccoli cuts, dated 10/10, had an accumulation of ice crystals and signs of freezer burn; -In freezer #6, a bag of crinkle cut sliced zucchini and squash had an accumulation of ice crystals and signs of freezer burn. During an interview on 5/14/25 at 3:30 P.M., the Dietary Manager said the following: -She was not aware of the identified items in the freezers; -An accumulation of ice crystals, product looking dried out or discolored were signs of freezer burn/product damage; -Staff should remove and discard damaged items.

Based on observation, interview and record review, the facility failed to follow current infection control standards for three residents (Residents #28, #20 and #19), in a review of 14 sampled residents, when staff failed to follow facility policy related to handwashing and glove usage when providing personal care to the residents. The facility failed to implement the facility policy to address Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) standards, and failed to complete a facility water assessment to identify potential sources of Legionella growth. The facility did not implement a water management team, a water flow map, parameters for findings related to water monitoring, and did not train staff or implement monitoring residents with pneumonia for possible Legionnaire's Disease as directed by the facility policy. The facility census was 31. Review of the facility policy, Hand washing/Hand Hygiene, revised August 2019, showed the following:- -This facility considers hand hygiene the primary means to prevent the spread of infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: -When hands are visibly soiled; -After contact with a resident with infectious diarrhea; -Use an alcohol-based hand rub containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after direct contact with residents; -Before performing any non-surgical invasive procedures; -Before and after handling an invasive device (e.g., urinary catheters, IV access sites); -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; -After contact with blood or bodily fluids; -After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; -After removing gloves; -Before and after entering isolation precaution settings; -Hand hygiene is the final step after removing and disposing of personal protective equipment; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections; -Single-use disposable gloves should be used: -Before aseptic procedures; -When anticipating contact with blood or body fluids; and -When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. 1. Review of Resident 28's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 02/01/25, showed the following: -Dependent on staff for toileting hygiene and personal hygiene; -Frequently incontinent of bowel and bladder. Observation on 05/14/25 at 6:35 A.M., showed the following: -Certified Nurse Assistant (CNA) C approached the resident's room, applied alcohol rub to his/her hands and put on gloves; -CNA C removed the resident's urine soiled incontinence brief and performed pericare for the resident; -CNA C did not remove his/her gloves. CNA C dressed the resident, touched the skin on the resident's legs, arms, and abdomen and the resident's clean brief and clean clothing. CNA C combed the resident's hair, opened drawers and a closet, touched the resident's wheelchair, and clean items (deodorant, sling, wheelchair and walker), on the resident's table, and transferred the resident to his/her wheelchair while wearing the same gloves he/she wore when providing incontinence care to the resident. During an interview on 05/14/25 at 6:50 P.M., CNA C said the following: -Staff were to change their gloves and clean their hands prior to providing care for residents and when they have completed providing care for a resident; -Staff were to remove gloves and clean hands when moving from contaminated or dirty areas before touching clean areas; -He/She should have removed his/her gloves after cleaning bodily fluids and before touching clean items. 2. Review of Resident #20's significant change MDS, dated [DATE], showed the following: -The resident had a urinary catheter; -Frequently incontinent of bowel. -Dependent on staff for toileting and personal hygiene; Review of the resident's care plan, dated 05/01/25, showed the following: -The resident was dependent with grooming and personal cares; -The resident used a bed pan but was often incontinent; -He/She was dependent with toileting hygiene and needed two staff to assist. Observation on 05/13/25 at 9:25 A.M., showed the following: -CNA Q and Nurse Assistant (NA) B brought the resident back from the shower in his/her wheelchair; -CNA Q and NA B applied gloves before entering the resident's room. Neither staff washed or sanitized their hands prior to putting on gloves; -CNA Q and NA B transferred the resident from the wheelchair to bed with the mechanical lift; -The resident had formed feces in the mechanical lift sling; -CNA Q used a gloved hand to remove the feces from the sling and disposed of the feces in the trash can; -CNA Q removed his/her gloves, did not wash his/her hands, put on new gloves and provided peri care to the resident's buttocks which were soiled with feces; -CNA Q did not remove his/her gloves; -CNA Q and NA B rolled the resident to his/her side and removed the soiled lift sling from under the resident; -CNA Q provided frontal peri care with the same gloved hands; -CNA Q removed his/her gloves, did not wash his/her hands, and put on new gloves; -CNA Q placed a clean incontinence brief, pants and shirt on the resident; -CNA Q moved the mechanical lift to the resident's bed to attach the lift sling and touched the lift controls as he/she and NA B transferred the resident to the wheelchair with the lift. 3. Review of Resident #19's annual MDS, dated [DATE], showed the following: -Dependent on staff for toileting and personal hygiene; -Always incontinent of bladder and frequently incontinent of bowel. Review of the resident's care plan, dated 03/28/25, showed the following: -Check and change soiled incontinence brief; -Provide peri-care when incontinent. Observation on 05/13/25 9:25 A.M., showed the following: -CNA C sanitized his/her hands, entered the resident's room, and put on gloves; -CNA C removed the urine-soiled incontinence brief from the resident and provided peri care to the resident's front peri area; -CNA C did not remove his/her gloves or wash his/her hands, and placed a new incontinence brief on the resident. Observation 05/14/25 1:15 P.M., showed the following: -Without sanitizing or washing his/her hands, NA J put on gloves and placed a gait belt on the resident; -NA J transferred the resident from the wheelchair to the bed; -NA J removed the resident's feces-soiled incontinence brief and provided peri care to the resident's buttocks. NA J did not provide peri care to the resident's front peri area; -Without changing his/her gloves, NA J placed a new incontinence brief on the resident. During an interview on 05/14/25 at 2:35 P.M., the Director of Nursing (DON) said she expected staff to wash hands and put on gloves prior to providing care to a resident if contact with body fluids or contaminated surfaces was anticipated. She expected staff to remove their gloves and wash their hands when care has been completed. She expected staff to remove their gloves and clean their hands when their hands were contaminated or worked in a dirty/contaminated area, prior to touching clean items or the resident's clean skin. During an interview on 05/20/25 at 2:45 P.M., the Administrator said he expected staff to change gloves and wash their hands in between every procedure and wash their hands after removing gloves. He expected staff to change gloves and wash their hands after providing perineal care and before touching clean items. 4. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following: -The bacterium Legionella can cause a serious type of pneumonia called LD (Legionnaire's disease) in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. Review of the facility policy, Legionella Surveillance and Detection, revised 2017, showed the following: -Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella; -Legionnaire's disease will be included as part of our infection surveillance activities; -As part of the infection prevention and control program, all cases of pneumonia that are diagnosed in residents greater than 48 hours after admission will be investigated for possible Legionnaire's disease; -Clinical staff will be trained on the following signs and symptoms associated with pneumonia and Legionnaire's: -Cough; -Shortness of breath; -Fever; -Muscle aches; -Headache; -Diarrhea, nausea and confusion associated with Legionnaire's disease; -If pneumonia or Legionnaire's disease are suspected, the nurse will notify the physician or practitioner immediately; -Residents who have signs and symptoms of pneumonia may be placed on transmission-based (droplet) precautions, although person-to-person transmission is rare; -Diagnosis of Legionnaire's disease is based on a culture of lower respiratory secretions and urinary antigen testing (concurrently); -Depending on the severity of illness, a hospital transfer may be initiated. -If Legionella is detected in one or more residents, the infection preventionist will: -Initiate active surveillance for Legionnaire's diseases; -Notify the local health department; and -Notify the administrator and the director of nursing services; -The infection preventionist will meet with the water management team to investigate the possible source of contamination; -Environmental Prevention: -Facility water temperatures will be checked monthly to ensure water temperatures are maintained at levels to prevent the growth of bacteria; -All faucet screens and shower heads will be cleaned quarterly with an ammonia and baking soda mixture to prevent the growth of bacteria and remove any buildup; -The facility will conduct in-house testing quarterly to ensure water is free from bacteria; -The facility Environmental supervisor will clean all air conditioning units and filters quarterly. Review of the facility policy, Legionella Water Management Program, revised 2017, showed the following: -Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella; -As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team; -The water management team will consist of at least the following personnel: -The infection preventionist; -The administrator; -The medical director (or designee); -The director of maintenance; -The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease; -The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing a Legionella water management program; -The water management program includes the following elements: -An interdisciplinary water management team; -A detailed description and diagram of the water system in the facility, including the following: -Receiving; -Cold water distribution; -Heating; -Hot water distribution; -Waste -The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following: -Storage tanks; -Water heaters; -Filters; -Aerators; -Showerheads and hoses; -Misters, atomizers, air washers and humidifiers; -Hot tubs; -Fountains; -Medical devices such as CPAP machines, hydrotherapy equipment, etc. -The identification of situations that can lead to Legionella growth, such as: -Construction; -Water main breaks; -Changes in municipal water quality; -The presence of biofilm, scale or sediment; -Water temperature fluctuations; -Water pressure changes; -Water stagnation; -Inadequate disinfection; -Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants); -The control limits or parameters that are acceptable and that are monitored; - A diagram of where control measures are applied; -A system to monitor control limits and the effectiveness of control measures; -A plan for when control limits are not met and/or control measures are not effective; and -The water management program will be reviewed at least once a year, or sooner if any of the following occur: -The control limits are consistently not met; -There is a major maintenance or water service change; -There are any disease cases associated with the water system; or -There are changes in laws, regulations, standards or guidelines. During an interview on 05/14/35 at 2:35 P.M. and 05/20/25 at 2:45 P.M., the DON said the following: -She was the Infection Preventionist (IP) for the facility; -She know of no water management team at the facility; -She did not know what ASHRAE was; -The facility did not screen residents with pneumonia for Legionella; -She does not know what symptoms the facility is supposed to monitor in residents to ensure they do not have possible exposure to Legionella; -The Maintenance Supervisor checked hot water temperatures. -She was not aware of either of the facility policies related to Legionella; -She had had no training on signs and symptoms associated with pneumonia and Legionnaire's (as the policy indicated). Review of the facility's undated Antibiotic Log showed the following: -Resident #1 was diagnosed and treated for pneumonia on 09/05/24; there was no documentation to show the resident was tested for legionella; -Resident #11 was diagnosed and treated for pneumonia on 03/17/24; there was no documentation to show the resident was tested for legionella. During an interview on 05/15/25 at 7:25 A.M., the Maintenance Supervisor said the following: -The facility did not have a water management team; -The facility did not have a water flow map; -He had a cleaning schedule to cleans faucets and shower heads quarterly for calcium build up with a baking soda and vinegar soak (not with an ammonia and baking soda mixture as the facility policy instructed); -In empty rooms, he flushes the toilets; -On 03/10/25, he cleaned all the faucets and flushed the toilets in the empty rooms; -He checked hot water temperatures daily; he will do three to five faucets and work his way around the building so all faucets' hot water was checked every month; -He does not check cold water temperatures; -The lowest hot water temperatures he measured were in the 80's (degrees Fahrenheit (F)) on the closed wing, and temperatures were not supposed to be over 120 degrees F; -He does not check chlorine or ph levels; -He was not aware of the CDC toolkit or ASHRAE guidelines; -There was no quarterly in-house testing completed as the policy directed; -He was not aware of their facility policies; -He had been employed with the facility for seven months; the water management program had not been reviewed since he was employed; -He was not cleaning all air conditioning units and filters quarterly (as the policy instructed). During an interview on 05/20/25, at 2:45 P.M., the Administrator said the facility was a low risk building so they did not have to do all the monitoring. The Maintenance Supervisor will check temperatures and flush toilets. He expected staff to follow the CDC guidelines and QSO memos. He was not aware of the ASHRAE guidelines. He was aware of their facility policies. He did not know when the water management program had last been reviewed. 50189 51988 -

Based on interview and record review, the facility failed to maintain a system to assure eight discharged residents' (Residents #103, #107, #105, #101, #108, #106, #102, and #104) personal funds were not maintained in the facility's operating account when the facility did not reimburse the residents and/or their responsible parties after the residents were discharged from the facility. The facility census was 31. Review of the facility policy, [NAME], revised March 2021, showed upon resident discharge from facility, any credit balance remaining will be issued within 30 days of discharge. Review of the facility Admission Agreement Exhibit B, Resident's Rights, revised 7/14/17, showed the following: -In general, the facility must deposit any residents' personal funds in excess of $100 in an interest bearing account that is separate from any of the facility's operating accounts; -For residents whose care was funded by Medicaid, the facility must deposit the resident's funds in excess of $50 in an interest bearing account that was separate from any of the facility's operating accounts; -The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf; -The system must preclude any commingling of resident funds with facility funds or with the funds of any persona other than the resident. 1. Review of Resident #103's face sheet showed he/she discharged on [DATE]. Review of the facility maintained A/R Aging Report, dated 5/19/25, showed the resident maintained a balance of $3,900.00 in the facility operating funds account. 2. Review of Resident #107's face sheet showed he/she discharged on [DATE]. Review of the facility maintained A/R Aging Report, dated 5/19/25, showed the resident maintained a balance of $3,630.00 in the facility operating funds account. 3. Review of Resident #105's face sheet showed he/she discharged on [DATE]. Review of the facility maintained A/R Aging Report, dated 5/19/25, showed the resident maintained a balance of $2,350.00 in the facility operating funds account. 4. Review of Resident #101's face sheet showed he/she discharged on [DATE]. Review of the facility maintained A/R Aging Report, dated 5/19/25, showed the resident maintained a balance of $2,310.00 in the facility operating funds account. 5. Review of Resident #108's face sheet showed he/she discharged on [DATE]. Review of the facility maintained A/R Aging Report, dated 5/19/25, showed the resident maintained a balance of $940.00 in the facility operating funds account. 6. Review of Resident #106's face sheet showed he/she discharged on [DATE]. Review of the facility maintained A/R Aging Report, dated 5/19/25, showed the resident maintained a balance of $900.00 in the facility operating funds account. 7. Review of Resident #102's face sheet showed he/she discharged on [DATE]. Review of the facility maintained A/R Aging Report, dated 5/19/25, showed the resident maintained a balance of $581.52 in the facility operating funds account. 8. Review of Resident #104's face sheet he/she discharged on [DATE]. Review of the facility maintained A/R Aging Report, dated 5/19/25, showed the resident maintained a balance of $360.00 in the facility operating funds account. 9. During interviews on 5/19/25 at 8:40 A.M. and 10:36 A.M., the Business Office Manager said the following: -The resident money listed in the A/R Aging Report was held in the facility's operating funds account; -The facility's billing company ran the A/R Aging Report and sends it to her; -She was responsible for reviewing the A/R Aging Report and determining if a resident was due a refund; -She didn't always take the time to review the A/R Aging Report; -She sends the A/R Aging Report to the corporate office to review as well. The corporate office will also notify her if a refund needed to be issued; -She was not sure why the residents' money had not been refunded following discharge. During an interview on 5/20/25 at 2:45 P.M., the Administrator said the following: -The Business Office Manager and the corporate office were responsible for reviewing the A/R Aging Report; -Resident refunds should be returned within 30 to 60 days, but typically within 30 days.

Based on observation and interview, the facility failed to ensure staff dated insulin (a medication used to treat diabetes) pens for three residents (Resident #15, #19 and #20) when opened to ensure the insulin was used within 28 days of opening. The facility census was 31. Review of the facility policy, Medication Labeling and Storage, revised February 2023, showed the following: -Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial; -Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date; - If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. Review of Drugs.com, on [DATE], showed the following: -Use Admelog, or insulin lispro, (a rapid acting injectable insulin used to treat diabetes) within 28 days of opening; -Use Novolog, or insulin lispro, (a rapid acting injectable insulin used to treat diabetes) within 28 days of opening; -Use Basaglar, or insulin glargine, (a long-acting injectable insulin used to treat diabetes) within 28 days of opening. -Use Lantus (a long-acting injectable insulin used to treat diabetes) within 28 days of opening. 1. Review of Resident #15's Physician Order Summary, dated [DATE], showed the following: -Diagnosis of type II diabetes mellitus without complications; -Humalog KwikPen (insulin lispro), inject 5 units subcutaneously one time a day related to diabetes mellitus. Observation on [DATE] at 7:24 A.M. showed Licensed Practical Nurse (LPN) A administered 5 units of Admelog (insulin lispro) to the resident. Review of the insulin pen showed it was labeled with the resident's name but was not labeled with a date to show when it was opened. During an interview on [DATE] at 7:50 A.M., LPN A said the following: -He/She did not notice the insulin pen was not dated prior to administering the insulin to the resident; -Had he/she noticed it was not dated prior to administering, he/she would not have administered the insulin; -He/She would have discarded the pen and obtained a new pen to open, date, and administer. 2. Observation of the nurse medication cart on [DATE] at 8:18 A.M. showed the following: -One Novolog FlexPen, in use, labeled for Resident #19, was not labeled with an open date; -One Basaglar KwikPen, in use, labeled for Resident #19, was not labeled with an open date; -One Lantus KwikPen, in use, labeled for Resident #20, was not labeled with an open date. 3. During an interview on [DATE] at 2:45 P.M. the Director of Nursing (DON) said the following: -Staff should label insulin pens with the resident's name and the date opened; -If an insulin pen is not dated, staff should discard it; -Staff should check the medication carts every Tuesday for expired or unlabeled medications. During an interview on [DATE] at 2:45 P.M. the Administrator said he would expect for insulin pens to be stored and labeled correctly.

Based on interview and record review, the facility failed to ensure information on how to file a grievance/complaint was available to the residents, failed to ensure timely and consistent follow up with resident groups who filed a grievance/complaint, and failed to ensure a system was in place to allow for residents or their families to make an anonymous grievance/complaint. The facility census was 31. Review of the facility policy, Filing Grievances/Complaints, revised April 2017, showed the following: -Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman); -The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/ or representative; -All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response; -Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedure is posted on the resident bulletin board; -Grievances and/or complaints may be submitted orally or in writing, and may be filed anonymously; -Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance and/or complaint; -The administrator will review the findings with grievance officer to determine what corrective actions, if any, need to be taken; -The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems: -The administrator, or his or her designee, will make such reports orally within working days of the filing of the grievance or complaint with the facility; -A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office; -The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. Review of the facility policy, Recording and Investigating Grievances/Complaints, revised April 2017, showed the following: -The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer; -Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations; -The grievance officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The following information will be recorded and maintained in the log: -The date the grievance/complaint was received; -The name and room number of the resident filing the grievance/complaint (if available); -The name and relationship of the person filing the grievance/complaint on behalf of the resident (if available); -The date the alleged incident took place; -The name of the person(s) investigating the incident; -The date the resident, or interested party, was informed of the findings; -The disposition of the grievance (i.e., resolved, dispute, etc.); -The Resident Grievance/Complaint Investigation Report Form will be filed with the administrator within five (5) working days of the incident; -A copy of the Resident Grievance/Complaint Investigation Report Form must be attached to the Resident Grievance/Complaint Form and filed in the business office; -Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. 1. Review of the last four months of resident council meeting notes, on 5/12/25, showed the following: -On the 1/23/25 meeting, residents voiced that call light response time was an ongoing issue; residents reported waiting up to 45 minutes. Sometimes the food was spicy or burnt; -On the 2/26/25 meeting, Council Action Forms for last months complaints were reviewed. Council Action Form, dated 2/26/25, to nursing from resident council, with concerns for call light response time and recommendation of needing more help. The Director of Nursing's (DON) response, dated 3/5/25, showed staff in-serviced on 3/5/25. Management will continue to check call light times. Council Action Form, dated 2/26/25, to the Dietary Manager from resident council, with concerns with hard sausage patties and toast and recommendation of having a meeting with the dietary staff to go over not overcooking food. Response from (left blank), dated 3/5/25, showed they will try harder. -On 3/19/25 meeting, residents voiced the call lights were a little better, but not much. Dietary not following meal cards, and the food is cold. Council Action Form, dated 3/19/25, to dietary from resident council, with concerns of dietary starting to ask what residents want, following diet cards, and food being cold. Response from (left blank), dated 3/30/25, to make sure steam table is turned on in time so food doesn't lose temperature, made a substitute list for staff to ask residents, have residents sign for substitutions, and advised staff to read diet cards; -On 4/15/25 meeting, reviewed that dietary is meeting with Administrator three times a week to discuss any kitchen issues. Residents voiced dietary was improving, but call lights were an ongoing issue. During the resident council meeting on 5/13/25 at 1:20 P.M., one of the 16 residents in attendance said there was a grievance form to complete and give to staff. Other residents said they told staff verbally and were not aware of a grievance form. The residents said they did not always get a response, and sometimes felt like staff didn't even listen or acknowledge their concerns. Observation on 5/14/25 at 5:50 A.M. showed no grievance/complaint procedure located on the resident bulletin board in the 300 hall next to the activity calendar or in any other location in the facility. During an interview on 5/14/25 at 6:31 A.M., Resident #14 said the following: -He/She was not aware of a formal grievance process; -If he/she had a concern he/she talked to the Social Services Director, however, the Social Services Director was not always available; -He/She did not know he/she could file a grievance anonymously or how to do that; -He/She was not aware of any grievance form to complete, which he/she felt contributed to the lack of follow through and response from staff; -He/She felt like the staff didn't listen or acknowledge the residents' concerns sometimes. During an interview on 5/14/25 at 7:08 A.M., Resident #30 said he/she did not know how to file a grievance and was not aware of any grievance forms. 2. During an interview on 5/19/25 at 9:40 A.M., the Director of Nursing (DON) said the following: -The Social Services Director was primarily responsible for grievances, but the Administrator assisted as well; -There were no grievance forms available for residents, family, or staff to obtain without asking for a copy; -If residents, family, or staff had a grievance, they told the Social Services Director and she completed the grievance form with them; -The department the grievance involved was notified and had five days to respond in writing with their response; -The response was given back to the Social Services Director who notified the person who filed the grievance and would then keep a copy for their records. During an interview on 5/19/25 at 11:06 A.M., the Social Services Director said the following: -She had only received two or three grievances since she started; -Residents came to her to fill out a grievance form. There were no grievance forms available for residents to obtain without asking; -After a grievance was filed, she gave the form to the DON and/or Administrator who followed up with the grievance and obtained a resolution/response; -Once a resolution/response was obtained, the DON or Administrator notified the resident who filed the grievance, then they returned the completed form to her to file; -Since the DON or Administrator follow up with the residents, she would sometimes check in with the resident a week or two later to ensure the resident felt things had improved and the resident had no further concerns; -Residents were made aware of the grievance process upon admission when she went over it with them; -The grievance process was not posted anywhere and it was not regularly reviewed with the residents. During an interview on 5/20/25 at 2:45 P.M., the Administrator said the following: -He expected residents to be able to file a grievance anonymously, without having to ask for a grievance form; -He expected a process to be in place for residents to file a grievance without having to go to a staff member; -He expected the grievance filing process to be reviewed in resident council.

Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for three residents (Resident #2, #14 and #30), in a review of 14 residents. The facility census was 31. Review of email correspondence on 05/29/25 at 9:19 A.M., the Director of Operations said they do not have a Care Plan policy, they follow the guidance in the Resident Assessment Instrument (RAI) Manual. Review of the RAI Manual, dated 10/01/24, showed the following: -As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool; -It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; -The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care; -The Level II Preadmission Screening and Resident Review (PASRR) determination and the evaluation report specify services to be provided by the nursing home and/or specialized services defined by the State; -The State is responsible for providing specialized services to individuals with mental illness (MI) or intellectual disabilities (ID)/developmental disabilities (DD); -In some States specialized services are provided to residents in Medicaid certified facilities (in other States specialized services are only provided in other facility types such as a psychiatric hospital); -The nursing home is required to provide all other care and services appropriate to the resident's condition; -The services to be provided by the nursing home and/or specialized services provided by the State that are specified in the Level II PASRR determination and the evaluation report should be addressed in the plan of care. Review of the facility's policy, Trauma Informed Care and Culturally Competent Care, revised August 2022, showed the following: -To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice; -To address the needs of trauma survivors by minimizing triggers and/or re-traumatization; -Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate; -Identify and decrease exposure to triggers that may re-traumatize the resident; -Recognize the relationship between past trauma and current health concerns (examples: substance abuse, eating disorders, anxiety and depression). 1. Review of Resident #2's Pre-Admission Screening/Resident Review (PASRR) Level II Evaluation, dated 02/21/23, showed the following: -Resident (in a previous facility) wheeled his/her chair into traffic and said he/she wanted to die; -Mental illness diagnosis included dysthymic disorder (a chronic form of depression characterized by a persistent low mood and other symptoms, which can last for at least two years), major depressive disorder, major neurocognitive disorder likely due to Alzheimer's disease, adjustment disorder with disturbance of emotions and conduct; -Resident repeatedly asks, why am l here, why did they dump me here?; -He/She was not able to do self-care at the time of admission, and is not able to now; -Resident isolates to room, resident feels down and has little energy, suspicious of staff at times, believes they are trying to keep him/her in a nursing home and he/she can go home and care for himself/herself. -Resident unable to process that he/she needs assistance and would not be able to care for self at home; -Resident becomes upset and verbally aggressive at times due to family placing him/her in a nursing home; -Resident said he/she wants to die; -Resident was confused at times and asks why he/she is in the nursing home and said his/her family placed him/her against his/her will; -Resident was recently hospitalized on [DATE] - 01/10/23 (diagnosis of senile dementia) due to leaving a facility and saying he/she wanted to die. Psychiatric consult when he/she wheeled himself/herself into traffic outside of the facility he/she resided in (a residential care facility) with the intention of being hit by a car. Resident allegedly brought back to the facility by people driving down the road; - Passive death wish, wheeled chair out in traffic, saying he/she wanted to die; - Wandered off from previous facility and requires skilled facility for safety; - Passive death wish, ongoing psychiatric follow up/treatment needed; - Required skilled care for activity of daily living (ADL) assist he/she wants to go home to his/her home; - Assess and plan for Crisis Intervention that provides emotional support, education, safety planning and case management to handle an immediate crisis. List need or behavior necessitating crisis intervention, include need for suicide, assault, and elopement precautions; -Safety plan to monitor for danger to self, leaving facility, etc. Plan should identify clear steps that will be taken to support individual during a crisis situation, specify who to contact for assistance, how staff should work together with individual during the crisis, as well as identify when the physician, emergency medical services and/or law enforcement should be contacted. Facility may also wish to utilize Department of Mental Health Behavioral Health Crisis hotline; -The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interactions, agitation, exacerbated signs and symptoms associated with the illness or withdrawal from situations, sell-injurious, self-mutilation, suicidal (ideation, gestures, threats, or attempts), physical violence or threats, appetite disturbance, delusions, hallucinations, serious loss of interest, tearfulness, irritability, or requires intervention by mental health or judicial system; -Resident suspicious of staff at times believes they are trying to keep him/her in a nursing home and he/she can go home and care for himself/herself. Resident isolates in room and has feelings of being down. Resident unable to process that he/she needs assistance and would be able to care for self at home. Resident becomes upset and verbally aggressive at times due to family placing him/her in a nursing home. Resident states that he/she wants to die. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 05/21/24, showed the following: -The resident has been evaluated by Level II Preadmission Screening and Resident Review (PASRR) and determined to have a serious mental illness and/or mental retardation or related condition; -Severe cognitive impairment; -Diagnosis include dementia, depression, restless with agitation, pain and vision disease; -Mild depression symptoms; -Physical and verbal behavioral symptoms directed towards others one to three days during the look back period; -Requires supervision/touching assistance from staff members to wheel 50 feet, and wheel 150 feet; -Receives antipsychotic, antidepressant, and opioid medications. Review of the resident's Nurses Note, dated 05/21/24 at 1:34 P.M., showed the resident told staff that he/she wanted to die. Review of the resident's Nurses Note, dated 05/21/25 at 9:18 P.M., showed the resident wanted to speak to a manager up front. When staff told the resident that they have left for the day, he/she proceeded to try to pull open every door in the back unit; when trying to re-direct, he/she became combative, hitting and trying to bite staff. Review of the resident's Care Plan, dated 05/23/24, showed the following: -Resident no longer ambulates but uses a wheelchair to get around on his/her own; -Supervise the resident's whereabouts; -History of agitation more so in the afternoons; -Expresses he/she is ready to die at times; -Resident does not understand why he/she is at the facility when he/she has a home to go to; -Resident generally acts out during the afternoon; -Monitor behaviors, document observed behavior and attempted interventions; -The resident triggers for verbal aggression related to why he/she is here and he/she feels her family dumped him/her here, do not bring up his/her family as it escalates his/her agitation; -Monitor/document/report any risk for harm to self: suicide plan, risky actions, intentionally harm or attempt to harm self, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness, and impaired judgment or safety awareness; -Monitor/document/report any symptoms of depression including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive or anxious or health-related complaints, tearfulness. The resident's care plan did not include information from the resident's PASRR including crisis intervention services. Assess and plan for crisis Intervention that provides emotional support, education, safety planning and case management to handle an immediate crisis. List need or behavior necessitating crisis intervention, include need for suicide, assault, and elopement precautions. Safety plan to monitor for danger to self, leaving facility, etc. Plan should identify clear steps that will be taken to support individual during a crisis situation, specify who to contact for assistance, how staff should work together with individual during the crisis, as well as identify when the physician, emergency medical services and/or law enforcement should be contacted. Facility may also wish to utilize Department of Mental Health Behavioral Health Crisis hotline. 2. Review of Resident #14's face sheet showed the following: -admitted on [DATE]; -Diagnosis of depression. Review of the resident's trauma informed care assessment, completed on 10/25/22, showed the following: -Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, and/or having a loved one die through homicide or suicide; -Have you ever experienced this kind of event? Yes (if yes, please answer questions in the next section); -In the past month have you: -Had nightmares about the event(s) or through about the event(s) when you did not want to? Yes; -Tried hard not to think about eh event(s) or went out of your way to avoid situations that reminded you of the event(s)? No; -Been constantly on guard, watchful, or easily startled? No; -Felt numb or detached from people, activities, or your surroundings? No; -Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? No. Review of the resident's trauma informed care assessment, completed on 5/8/23, showed the following: -Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, and/or having a loved one die through homicide or suicide; -Have you ever experienced this kind of event? Yes (if yes, please answer questions in the next section); -In the past month have you: -Had nightmares about the event(s) or through about the event(s) when you did not want to? Yes; -Tried hard not to think about eh event(s) or went out of your way to avoid situations that reminded you of the event(s)? No; -Been constantly on guard, watchful, or easily startled? No; -Felt numb or detached from people, activities, or your surroundings? No; -Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? No. Review of the resident's trauma informed care assessment, completed on 7/24/23, showed the following: -Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, and/or having a loved one die through homicide or suicide; -Have you ever experienced this kind of event? Yes (if yes, please answer questions in the next section); -In the past month have you: -Had nightmares about the event(s) or through about the event(s) when you did not want to? No; -Tried hard not to think about eh event(s) or went out of your way to avoid situations that reminded you of the event(s)? Yes; -Been constantly on guard, watchful, or easily startled? No; -Felt numb or detached from people, activities, or your surroundings? No; -Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? No. Review of the resident's care plan, dated 10/29/23, showed the following: -He/She is being treated for depression; -His/Her mood needs to be monitored; -He/She had a traumatic experience in their lifetime, involving the death of his/her sister, and sometimes has dreams about it; -Administered antidepressant medications as ordered; -Offer one-on-one visits when he/she has these dreams and allow him/her to express their sadness; -Offer counseling as needed; -Report any changes in his/her mood or depression. Review of the resident's trauma informed care assessment, completed on 10/21/24, showed the following: -Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, and/or having a loved one die through homicide or suicide; -Have you ever experienced this kind of event? Yes (if yes, please answer questions in the next section); -In the past month have you: -Had nightmares about the event(s) or through about the event(s) when you did not want to? No; -Tried hard not to think about eh event(s) or went out of your way to avoid situations that reminded you of the event(s)? No; -Been constantly on guard, watchful, or easily startled? No; -Felt numb or detached from people, activities, or your surroundings? No; -Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? No. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Diagnosis of depression. Review of the resident's care plan, last reviewed/updated 5/1/25, did not include information about the resident's past trauma triggers or interventions to prevent the resident from experiencing further re-traumatization related to his/her diagnoses of PTSD. 3. Review of Resident #30's face sheet showed the following: -He/She was admitted on [DATE]; -He/She had diagnoses of PTSD, bipolar disease, depression, and insomnia. Review of the resident's trauma informed care assessment, completed on 10/28/24, showed the following: -Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, and/or having a loved one die through homicide or suicide; -Have you ever experienced this kind of event? Yes (if yes, please answer questions in the next section); -In the past month have you: -Had nightmares about the event(s) or through about the event(s) when you did not want to? No; -Tried hard not to think about eh event(s) or went out of your way to avoid situations that reminded you of the event(s)? No; -Been constantly on guard, watchful, or easily startled? No; -Felt numb or detached from people, activities, or your surroundings? No; -Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? Yes. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/28/25, showed the following: -Cognitively intact; -Diagnoses of PTSD and depression; -A completed level II preadmission screening and resident review (PASRR). Review of the resident's care plan, updated on 2/4/25, showed the following: -He/She had a history of PTSD and depression most of his/her life; -The resident displays behaviors when not on appropriate medications; -Administer medications as ordered; -Behavioral health consuls as needed, previously seen at a behavioral health center; -At times the resident needs time to talk, encourage him/her to express feelings; -Monitor for sense of hopelessness or helplessness, impaired judgement or safety awareness; -Monitor for and report to physician mood patterns and signs and symptoms of depression, anxiety, and sad mood as per facility behavior monitoring protocols; -Put interventions in place to minimize risk for falls or injuries. Review of the resident's care plan, last reviewed/updated 2/4/25, did not include information about the resident's PTSD triggers or interventions to prevent the resident from experiencing further re-traumatization related to his/her diagnoses of PTSD. During an interview on 5/19/25 at 10:01 A.M. the MDS/Care Plan Coordinator said the resident's care plan did not include triggers, coping skills, or additional services, so it could have been more comprehensive. 4. During an interview on 5/19/25 at 9:40 A.M. the DON said the following: -PTSD and trauma informed care was screened for on admission, if someone has it, they complete a level II PASRR if necessary; -The MDS/Care Plan coordinator will complete the trauma informed care screening; -The care plans and needs are based off of that assessment; -There were no additional assessments that the facility completes, other than the trauma informed care assessment; -The care plan should include the diagnoses of PTSD or trauma, along with their triggers, coping mechanisms, and any other pertinent information. During an interview on 5/19/25 at 10:01 A.M. the MDS/Care Plan Coordinator said the following: -She was responsible for completing the trauma informed care assessment; -If the resident answered yes, it is a positive screening and it prompts more questions to be answered; -She did not have any additional assessments she completed, other than the trauma informed care assessment; -She was unsure what she would include in the care plan, as it depended on what the resident was willing to share. During an interview on 5/20/25 at 2:45 P.M., the DON said the following: -She would expect residents with PTSD or a history of trauma to be adequately and completely assessed by staff; -She would expect for triggers and symptoms to be listed on the care plan; -Information from PASRRs are expected to be included on the resident's Care Plan; she completes that area of the care plan now, but not sure who completed it prior to her employment with the facility (July 2024); -She would expect the facilities policy and the RAI manual to be followed. During an interview on 5/20/25 at 2:45 P.M., the Administrator said the following: -He would expect all care plans to be comprehensive; -He would expect a resident's PTSD or history of trauma to be adequately assessed and documented on the care plan. 50189

Based on interview and record review, the facility failed to ensure staff training needs as identified in the facility assessment and the annual in-servicing calendar were met, and 12 hours of training were completed per year to include dementia management and resident abuse prevention training per year for five certified nurse assistants (CNA)'s (CNA C, CNA R, CNA G, CNA Q and CNA H), in a sample of five CNA's who have been employed over a year. The facility census was 31. Review of the Facility Assessment, dated [DATE], showed the following -Staff competencies and annual training requirements per regulatory authority and/or facility policy included: -Abuse, neglect, exploitation and misappropriation; -Job responsibilities and lines of authority; -Advance directives; -Emergency preparedness; -Behavioral health facility policies and procedures; -Communication; -Change in condition; -Compliance and ethics; -Cardio pulmonary resuscitation (CPR); -Dementia care management; -Equipment and assistive device training; -Infection control; -Promoting resident's independence; -Quality assurance and performance improvement (QAPI); -Resident rights including confidentiality of resident information, right to dignity, privacy, and property; -Safety and emergency procedures, including the Heimlich maneuver; -Other areas identified as areas of weakness during annual performance review/competency evaluation; -Education identified related to resident population: -Catheter care; -lncontinence/toileting program; -End of life care; -Dementia care; -Ostomy care; -Restorative nursing, dressing,grooming, and bathing; -Pressure ulcer prevention and treatment; -Fall risk identification; -Intravenous therapy, IV nutrition, medication administration and/or blood transfusion; -Respiratory treatment; -Tracheostomy care; -Behavioral healthcare (including post traumatic stress disorder (PTSD) and trauma history); -Gastronomy tube care/use; -Pain management; -Infection control; -Communication and interpersonal needs; -Safety and emergency procedures; -Assessing nutritional needs; -Meeting the needs of individuals with mental illness/intellectual disability/developmental disability (Ml/ID/DD); -Change in condition; -Restorative nursing training shall be conducted by a registered nurse or qualified therapist. The training must include the following elements: -Turning and positioning for the bedridden residents; -Range of motion (ROM) exercises; -Ambulation assistance; -Transfer procedures; -Bowel and bladder retraining; -Activities of daily living. 1. Review of the undated facility's Annual In-servicing Calendar showed the following schedule of trainings included the following: -January: advanced directives, and abuse policy; -February: survey preparedness and nutrition and hydration; -March: Quality Assurance and Process Improvement (QAPI) and fire safety; -April: end of life care and infection prevention and control; -May: workplace emergencies and hazardous chemicals; -June: workplace violence and sexual harassment; -July: dementia care and team building; -August: back injury prevention and preventing slips, trips and falls; -September: restorative and ROM, customer service and effective communication; -October: HIPAA, resident rights and behavior management; -November: smoking policy and trauma informed care; -December: lock out/tag out; -Quarterly training: nurse skills checks, CNA skills checks, CPR policy and abuse policy. 2. Review of the facility's In-Service Record Book, dated [DATE] - [DATE], showed completed trainings included the following: -[DATE] meeting agendas included dementia training by outside source (QIPMO), basic grooming and clarifications of items for specific residents and miscellaneous announcements; it did not include end of life care or infection prevention and control; the meeting minutes did not include the length of time of the training or details on contents of training; -[DATE] meeting agendas included general information/reminders on call lights, respiratory equipment, snacks, ice, wheelchair safety and clarifications of items for specific residents and miscellaneous announcements; the agendas did not include workplace emergencies or hazardous chemicals; -[DATE] meeting agendas included infection control, glove reminders, resident council concerns, fire drill review and clarifications of items for specific residents and miscellaneous announcements; the agenda did not include workplace violence or sexual harassment; -[DATE] meeting agendas included infection control topics, enhanced barrier precautions (EBP), grooming, antibiotic stewardship topics and clarifications of items for specific residents and miscellaneous announcements; the agendas did not include dementia care or team building; -[DATE] meeting agendas included dietary policies, falls and clarifications of items for specific residents and miscellaneous announcements; the agendas did not include back injury prevention; -[DATE] meeting agendas included peri care, EBP, turn and reposition, restorative nursing and clarifications of items for specific residents and miscellaneous announcements; the agendas did not include customer service and effective communication; -[DATE] meeting agendas included HIPPA, resident rights, behavior management, code status and clarifications of items for specific residents and miscellaneous announcements; -[DATE] meeting agendas included smoking policy, hand washing, personal protective equipment, trauma informed care, CPAP and BIPAP, EBP, gait belts, privacy, cleaning equipment and clarifications of items for specific residents and miscellaneous announcements; -[DATE] meeting agendas included lock out tag out, clarifications of items for specific residents and miscellaneous announcements and reminders; -[DATE] meeting agendas included abuse and neglect, customer service, advance directives, fire drills, training program and clarifications of items for specific residents and miscellaneous announcements and reminders; -February 2025 meeting agendas included survey preparedness, nutrition and hydration and clarifications of items for specific residents and miscellaneous announcements and reminders; -[DATE] meeting agendas included QAPI, survey, tornado and fire drill, change in condition and clarifications of items for specific residents and miscellaneous announcements and reminders; -[DATE] meeting agendas included infection prevention and control, end of life care, tornado and fire education, change of condition and clarifications of items for specific residents and miscellaneous announcements and reminders; -[DATE] meeting agendas included work place emergencies, hazardous chemicals and clarifications of items for specific residents and miscellaneous announcements and reminders; -The facility did not include training on all topics required on the facility's annual in-service calendar; -The facility did not include training on the topics included in the facility assessment including job responsibilities and lines of authority, compliance and ethics, CPR, equipment and assistive device training, promoting resident's independence, Heimlich maneuver, other areas identified as areas of weakness during annual performance review/competency evaluation, catheter care, incontinence/toileting program, ostomy care, restorative nursing: dressing, grooming and bathing, pressure ulcer prevention and treatment, fall risk identification, respiratory treatment, pain management, meeting the needs of individuals with Ml/ID/DD, ambulation assistance, transfer procedures, bowel and bladder retraining and activities of daily living as directed in the facility assessment. 3. Review of the employee file for CNA C showed his/her hire date as [DATE]. Review of the facility in-service book, dated [DATE] - [DATE], showed the following: -CNA C attended the [DATE] staff meeting that included infection control; -CNA C attended the [DATE] staff meeting that included infection control; -CNA C attended the [DATE] staff meeting that included EBP training; -None of the staff meetings documented the hours of training for each meeting. Review of in-service book and the CNA C's employee file showed no documentation CNA C attended 12 hours of training or training on abuse, neglect, exploitation and misappropriation; job responsibilities and lines of authority; advance directives; emergency preparedness; behavioral health (including PTSD and trauma history and facility policies and procedures,); communication; change in condition; compliance and ethics; CPR; dementia care management; equipment and assistive device training; promoting resident's independence; QAPI; resident rights including confidentiality of resident information, right to dignity, privacy, and property; safety and emergency procedures, including the Heimlich maneuver; other areas identified as areas of weakness during annual performance review/competency evaluation; catheter care; incontinence/toileting program; end of life care; ostomy care; dressing, grooming and bathing; pressure ulcer prevention and treatment; fall risk identification; respiratory treatment; pain management; nutritional needs; meeting the needs of individuals with Ml/ID/DD; restorative nursing training must including turning and positioning for the bedridden residents; ROM exercises; ambulation assistance; transfer procedures; bowel and bladder retraining; activities of daily living as directed in the facility assessment. 4. Review of the employee file for CNA R, showed his/her hire date as [DATE]; Review of the facility in-service book, dated [DATE] - [DATE], showed the following: -CNA R attended the [DATE] staff meeting that included EBP training; -CNA R attended the [DATE] staff meeting that included EBP, peri care, nutrition, and restorative nursing; -CNA R attended the [DATE] staff meeting that included EBP, gait belts, peri care, gloves, privacy, and cleaning multi-use equipment; -CNA R attended the [DATE] staff meeting that included QAPI and IJ tag (safety and assessment), tornado/fire drill, and change in condition; -None of the staff meetings documented the hours of training for each meeting. Review of in-service book and the CNA C's employee file showed no documentation CNA R attended 12 hours of training and did not attend training for the following topics: abuse, neglect, exploitation and misappropriation; job responsibilities and lines of authority; advance directives; emergency preparedness; behavioral health (including PTSD and trauma history and facility policies and procedures,); communication; compliance and ethics; CPR; dementia care management; equipment and assistive device training; promoting resident's independence; resident rights including confidentiality of resident information, right to dignity, privacy, and property; safety and emergency procedures, including the Heimlich maneuver; other areas identified as areas of weakness during annual performance review/competency evaluation; catheter care; incontinence/toileting program; end of life care; ostomy care; dressing, grooming and bathing; pressure ulcer prevention and treatment; fall risk identification; respiratory treatment; pain management; meeting the needs of individuals with Ml/ID/DD; ambulation assistance; transfer procedures; bowel and bladder retraining; activities of daily living as directed in the facility assessment. 5. Review of the employee file for CNA G, showed his/her hire date as [DATE]. Review of the facility in-service book, dated [DATE]-[DATE], showed the following: -CNA G attended the [DATE] staff meeting that included infection control; -CNA G attended the [DATE] staff meeting that included EBP training; -CNA G attended the [DATE] staff meeting that included EBP, peri care, nutrition and restorative nursing; -CNA G attended the [DATE] staff meeting that included EBP, gait belts, peri care, gloves, privacy and cleaning multi-use equipment; -CNA G attended the [DATE] staff meeting that included abuse and neglect, advance directives and EBP; -CNA G attended the [DATE] staff meeting that included nutrition; -CNA G attended the [DATE] staff meeting that did not include an agenda; -CNA G attended the [DATE] staff meeting that included change of condition, care plans, gait belts and call lights; -None of the staff meetings documented the hours of training for each meeting. Review of in-service book and the CNA C's employee file showed no documentation CNA G attended 12 hours of training and did not attend training for the following topics: Job responsibilities and lines of authority; emergency preparedness; behavioral health (including PTSD and trauma history and facility policies and procedures); communication; compliance and ethics; CPR; dementia care management; equipment and assistive device training; promoting resident's independence; QAPI; resident rights including confidentiality of resident information, right to dignity, privacy, and property; safety and emergency procedures, including the Heimlich maneuver; other areas identified as areas of weakness during annual performance review/competency evaluation; catheter care; incontinence/toileting program; end of life care; ostomy care; dressing, grooming and bathing; pressure ulcer prevention and treatment; fall risk identification; respiratory treatment; pain management; meeting the needs of individuals with Ml/ID/DD; ambulation assistance; transfer procedures; bowel and bladder retraining; activities of daily living as directed in the facility assessment. 6. Review of the employee file for CNA Q, showed his/her hire date as [DATE]. Review of the facility in-service book, dated [DATE]-[DATE], showed the following: -CNA Q attended the [DATE] staff meeting that included dementia training by QIPMO; -CNA Q attended the [DATE] staff meeting that included call lights, wheelchair safety, respiratory equipment and snacks; -CNA Q attended the [DATE] staff meeting that included infection control; -CNA Q attended the [DATE] staff meeting that included EBP training; -CNA Q attended the [DATE] staff meeting that included EBP, peri care, nutrition, and restorative nursing; -CNA Q attended the [DATE] staff meeting that included EBP, gait belts, peri care, gloves, privacy and cleaning multi-use equipment; -CNA Q attended the [DATE] staff meeting that included EBP, gait belts, peri care, gloves, privacy and cleaning multi-use equipment; -CNA Q attended the [DATE] staff meeting that included abuse and neglect, advance directives and EBP; -CNA Q attended the [DATE] staff meeting that included QAPI and IJ tag (safety and assessment), tornado/fire drill, and change in condition; -None of the staff meetings documented the hours of training for each meeting. Review of in-service book and the CNA C's employee file showed no documentation. CNA Q attended 12 hours of training and did not attend training for the following topics: job responsibilities and lines of authority; emergency preparedness; behavioral health (including PTSD and trauma history and facility policies and procedures); communication; compliance and ethics; CPR; equipment and assistive device training; promoting resident's independence; QAPI; resident rights including confidentiality of resident information, right to dignity, privacy, and property; safety and emergency procedures, including the Heimlich maneuver; other areas identified as areas of weakness during annual performance review/competency evaluation; catheter care; incontinence/toileting program; end of life care; ostomy care; restorative nursing: dressing, grooming and bathing; pressure ulcer prevention and treatment; fall risk identification; respiratory treatment; pain management; meeting the needs of individuals with Ml/ID/DD; ambulation assistance; transfer procedures; bowel and bladder retraining; activities of daily living as directed in the facility assessment. 7. Review of the employee file for CNA H, showed his/her hire date as [DATE]. Review of the facility in-service book, dated [DATE]-[DATE], showed the following: -CNA H attended the [DATE] staff meeting that included dementia training by QIPMO; -CNA H attended the [DATE] staff meeting that included infection control; -CNA H attended the [DATE] staff meeting that included EBP training; -CNA H attended the [DATE] staff meeting that included falls training; -CNA H attended the [DATE] staff meeting that included food safety training; -CNA H attended the [DATE] staff meeting that included EBP, peri care, nutrition and restorative nursing; -CNA H attended the [DATE] staff meeting that included HIPAA, resident rights and behavior management; -CNA H attended the [DATE] staff meeting that included EBP, gait belts, peri care, gloves, privacy, and cleaning multi-use equipment; -CNA H attended the [DATE] staff meeting that included abuse and neglect and advance directives; -CNA H attended the [DATE] staff meeting that included nutrition; -CNA H attended the [DATE] staff meeting that included QAPI and IJ tag (safety and assessment), tornado/fire drill and change in condition; -CNA H attended the [DATE] staff meeting that did not include an agenda; -CNA H attended the [DATE] staff meeting that included end of life care, infection prevention and tornado/fire education; -CNA H attended the [DATE] staff meeting that included change of condition, gait belts, care plans and call lights; -CNA H attended the [DATE] staff meeting that included EBP, gait belts, peri care, gloves, privacy and cleaning multi-use equipment; -CNA H attended the [DATE] staff meeting that included workplace emergency, hazardous chemicals, cleaning equipment, hoyer lift transfers, call lights and care plans; -None of the staff meetings documented the hours of training for each meeting. Review of in-service book and the CNA C's employee file showed no documentation. CNA H attended 12 hours of training and did not attend training for the following topics: job responsibilities and lines of authority; emergency preparedness; communication; compliance and ethics; CPR; equipment and assistive device training; promoting resident's independence; Heimlich maneuver; other areas identified as areas of weakness during annual performance review/competency evaluation; catheter care; incontinence/toileting program; ostomy care; dressing, grooming and bathing; pressure ulcer prevention and treatment; respiratory treatment; pain management; meeting the needs of individuals with Ml/ID/DD; ambulation assistance; bowel and bladder retraining; activities of daily living as directed in the facility assessment. 8. During an interview on [DATE] at 03:57 P.M., the Business Office Manager/Human Resources staff said the following: -The facility had a form to track CNA training but no one was using it; -The facility staff did not communicate who was tracking the CNA training so there were no individual records to see if the CNA's met their 12 hours of training or the topics they were required to have; -The only documentation the facility had was what was in the in-service book. During an interview on [DATE] at 03:57 P.M., the Director of Nursing (DON) said the following: -She just discovered the facility does not have tracking of the CNA's training to ensure they have the 12 hours that are required or the required topics; -She thought human resources was tracking CNA training; -Right now, there was no way to tell if the CNA's attended 12 hours of training or if they met all the required topics.

Based on observation, interview, and record review, the facility failed to ensure equipment used to transfer residents and wheelchairs were maintained in good repair and in safe operating condition. The facility census was 31. Review of the facility policy, Safe Lifting and Moving of Residents, revised [DATE], showed the following: -Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote charges shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged; -Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order; -All equipment design and use will meet or exceed guidelines and regulations concerning resident safety. Review of the facility policy, Maintenance Services, revised [DATE], showed the following: -The maintenance department is responsible for maintain the buildings, grounds, and equipment in a safe and operable manner at all times; -The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner; -Maintenance personnel shall follow the manufacturer's recommended maintenance schedule. 1. During an interview on [DATE] at 10:24 A.M., Resident #30 said the following: -He/She had issues with mechanical lift transfers since he/she was admitted ; -Sometimes the transfer was rough because the wheels on the mechanical lift stuck, and the staff had to use a lot of force to move it; -Sometimes the battery died during the transfer, and staff had to change it out to finish the transfer. During an interview on [DATE] at 11:41 A.M. and 2:46 P.M., the resident said during his/her transfer back to bed on Monday ([DATE]), the battery on the mechanical lift stopped working, and staff had to change out three batteries, all of which did not work, which resulted in staff having to use the emergency button to lower him/her into bed. Observation on [DATE] at 12:50 P.M. showed the following: -Staff said the mechanical lift was not working correctly and made a noise; -Staff lifted the Maintenance Supervisor in the mechanical lift in the Director of Nursing (DON) office; -When the Maintenance Supervisor was completely raised in the mechanical lift, the lift stopped and would not go down. Staff had to pull down on the red emergency lever to get the lift to release and lower the Maintenance Supervisor. During an interview on [DATE] at 4:12 P.M., Certified Nurses Assistant (CNA) H said the following: -The mechanical lift had a lot of problems with the battery randomly dying; -There were times the battery would quit after a resident was lifted, then it wouldn't lower, and staff would have to change the battery. During an interview on [DATE] at 4:33 P.M., CNA G said the following: -He/She had issues recently with the mechanical lift; -The mechanical lift would work fine to start, then the battery would die mid lift. Typically, staff could change the battery and the mechanical lift would work again. During an interview on [DATE] at 1:36 P.M., Nurse Assistant (NA) J said the following: -The mechanical lift battery would quit working mid lift; -He/She had experienced transfers with a resident when the mechanical lift quit mid lift. During an interview on [DATE], at 3:05 P.M., the Maintenance Director said the following: -Staff had complained a few times over the last few months about the mechanical lift, and he worked on it and thought he had it fixed; -Staff told him on Tuesday [DATE] that the mechanical lift made an odd noise, so he had staff lift him in the mechanical lift; -The mechanical lift did not lower him until staff used the emergency switch; -The battery for the mechanical lift would not stay charged; -The staff also reported the mechanical lift was hard to push; -He worked on the mechanical lift before and it pushed with a little resistance, but staff told him it was harder to push when they had a resident in the lift; -Staff were to report malfunctioning equipment to him either verbally or through the maintenance request log. During an interview on [DATE], at 3:44 P.M. the Director of Nursing (DON) said the following: -She reported issues with the mechanical lift to the Maintenance Director on Monday ([DATE]); -Maintenance Director looked at it Monday ([DATE]) and thought he had it fixed; -Staff used the mechanical lift after the Maintenance Supervisor had worked on it, and it was not fixed; -The battery on the mechanical lift always had issues; -Staff had worked on the wheels on the mechanical lift several times and they were never perfect but were better at times. 2. Observation on [DATE] at 10:05 A.M. of Resident #9's wheelchair showed the following: -The wheelchair seat was cracked; -The right armrest latch button lock that locked the armrest into place was missing. During an interview on [DATE] at 10:05 A.M., the resident said the following: -He/She had been at the facility for two months and received the wheelchair on admission; -The cracked wheelchair seat hurt his/her legs, and the right armrest did not latch, was loose and moved freely. During an interview on [DATE] at 10:40 A.M., the Maintenance Supervisor said the following: -Nursing staff notify him if a wheelchair was broken; -He would wait until nursing staff replaced the broken wheelchair, then he would take the broken wheelchair for repairs. During an interview on [DATE] at 2:45 P.M., the Administrator said the following: -Staff were to notify administration when repairs were needed; the preferred way was through the maintenance log; -He expected repairs to be completed within a few days to a week; -He expected facility equipment to be in good working condition. 50189

Based on interview and record review, the facility failed to ensure gradual dose reductions (GDR's) were attempted, or document clinical contraindications for all psychotropic medications for one resident, (Resident #4 ), in a review of five residents sampled for unnecessary medications. The facility census was 31. Review of the facility policy, Tapering Medications and Gradual Drug Dose Reduction, revised June 2022, showed the following: -After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences; -All medications shall be considered for possible tapering. Tapering that is applicable to psychotropic medications are referred to as gradual dose reductions; -Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; -Periodically, the staff and practitioner will review the continued relevance of each resident's medications; -The attending physician and staff will identify target symptoms for which a resident is receiving various medications. The staff will monitor for improvement in those target symptoms, and provide the physician with that information; -The staff and practitioner will consider tapering of medications as one approach to finding an optimal dose or determining whether continued use of a medication is benefiting the resident; -The staff and practitioner will consider tapering under certain circumstances, including when: -The resident's clinical condition has improved or stabilized; -The underlying causes of the original target symptoms have resolved; -Non-pharmacological interventions, including behavioral interventions, have been effective in reducing symptoms; or -A resident's condition has not responded to treatment or has declined despite treatment; -The physician will review periodically whether current medications are still necessary in their current doses; for example, whether an individual's conditions or risk factors are sufficiently prominent or enduring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medications, or with a lower dose; -The physician will order appropriate tapering of medications, as indicated; -The time frames and duration of tapering attempts should be based on relevant factors including other medications that the resident is taking, underlying causes of symptoms, individual risk factors, and pharmacologic characteristics of the medications. Some medications (e.g., antidepressants, sedative/hypnotics, opioids) may need more gradual tapering in order to minimize withdrawal symptoms or other adverse consequences; -When a medication is tapered or stopped, the staff will closely monitor the resident and will inform the physician if there is a return or worsening of symptoms; -When a medication is tapered or stopped, the staff and practitioner shall document the rationale for any decisions to restart a medication or reverse a dose reduction; for example, because of a return of clinically significant symptoms; -Residents who use psychotropic medications shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. Pertinent behavioral interventions will also be attempted. (Behavioral interventions refer to non-pharmacological attempts to influence an individual's behavior, including environmental alterations and staff approaches to care.); -Within the first year after a resident is admitted on a psychotropic medication, or after the resident has been started on a psychotropic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated; -For any individual who is receiving a psychotropic medication to treat behavioral symptoms related to dementia, the GDR may be considered clinically contraindicated if: -The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility; and -The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior; -For any individual who is receiving a psychotropic medication to treat a psychiatric disorder other than behavioral symptoms related to dementia (for example, schizophrenia, bipolar mania, or depression with psychotic features), the GDR may be considered contraindicated, if: -The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; or -The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; -Attempted tapering of sedatives and hypnotics shall be considered as a way to demonstrate whether the resident is benefiting from a medication or might benefit from a lower or less frequent dose. Tapering shall be done consistent with the following: -For as long as a resident remains on a sedative/hypnotic that is used routinely and beyond the manufacturer's recommendations for duration of use, the physician shall attempt to taper the medication at least quarterly unless clinically contraindicated. Clinically contraindicated means: -(1) the continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; or -(2) the resident's target symptoms returned or worsened after the most recent attempt at tapering the dose within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; -Attempted tapering of psychotropic medications other than antipsychotics or sedatives and hypnotics shall be considered as a way to demonstrate whether the resident is benefiting from a medication or might benefit from a lower or less frequent dose. Tapering shall be done consistent with the following: -During the first year in which a resident is admitted on a psychotropic medication (other than an antipsychotic or a sedative/hypnotic), or after the facility has initiated such medication, the facility will attempt to taper the medication during at least two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, tapering will be attempted at least annually, unless clinically contraindicated. The tapering may be considered clinically contraindicated, if: -(1) the continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; or -(2) the resident's target symptoms returned or worsened after the most recent attempt at tapering the dose within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. 1. Review of Resident #4's face sheet showed diagnosis of major depressive disorder, anxiety disorder, and insomnia. Review of the resident's Physician's Orders, dated 06/21/22, showed venlafaxine (antidepressant medication) hcl extended release (ER) 300 milligrams (mg) daily for major depressive disorder. Review of the resident's Physician's Orders, dated 05/30/23, showed orders for the following: -Buspirone hcl (medication for anxiety, also known as Buspar) 15 mg in the morning and 10 mg in the evening for anxiety disorder; -Ambien (hypnotic medication) 5 mg daily; Review of the resident's Care Plan, dated 06/23/23, showed the following: -Resident has some anxiety issues when in groups of people, provide one on one room visits and reading materials he/she likes; -Resident frequently complains about not being able to sleep at night; -Resident has had depression and anxiety for many years; -Provide medications as ordered; -Monitor for side effects; -Pharmacy consult on attempting drug reductions. Review of the resident's Pharmacist Recommendations to the Physician, dated 04/04/24, showed the pharmacist recommended a gradual dose reduction for Ambien 5 mg daily to 2.5 mg daily if clinically appropriate. The physician responded and checked the an attempted GDR is likely to result in impairment of function of increased distressed behavior and the disagree boxes on 04/19/24. The physician did not indicate a specific written clinical reason the GDR could not be attempted. Review of the resident's Pharmacist Recommendations to the Physician, dated 05/06/24, showed the pharmacist recommended a gradual dose reduction for Buspar 15 mg in the morning and 10 mg in the evening to 10 mg two times daily if clinically appropriate. The physician responded and checked the an attempted GDR is likely to result in impairment of function of increased distressed behavior and the disagree boxes on 05/18/24. The physician did not indicate a specific written clinical reason the GDR could not be attempted. Review of the resident's Pharmacist Recommendations to the Physician, dated 06/03/24, showed the pharmacist recommended a gradual dose reduction for Ambien 5 mg daily to 2.5 mg daily if clinically appropriate. The physician responded and checked the an attempted GDR is likely to result in impairment of function of increased distressed behavior and the disagree boxes on 06/05/24. The physician did not indicate a specific written clinical reason the GDR could not be attempted. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 06/21/24, showed the following: -Cognitively intact; -Diagnosis include anxiety and depression; -Resident does not have serious mental illness or mental retardation; -No behaviors or rejection of care; -Symptoms of moderately severe depression; -Resident receives antianxiety, antidepressant and hypnotic medications. Review of the resident's Physician's Orders, dated 08/07/24, showed Xanax (antianxiety medication) 0.25 mg three times daily for anxiety disorder. Review of the resident's Pharmacist Recommendations to the Physician, dated 09/08/24, showed the pharmacist recommended a gradual dose reduction for Xanax 0.25 mg three times a day to 0.25 mg two times a day if clinically appropriate. The physician responded and checked the an attempted GDR is likely to result in impairment of function of increased distressed behavior and the disagree boxes on 09/12/24. The physician did not indicate a specific written clinical reason the GDR could not be attempted. Review of the resident's Physician's Orders, dated 09/10/24, showed Imipramine (antidepressant medication) 25 mg daily for major depressive disorder. Review of the resident's quarterly MDS, dated [DATE], showed no symptoms of depression. Review of the resident's Pharmacist Recommendations to the Physician, dated 10/06/24, showed the pharmacist recommended a gradual dose reduction for venlafaxine (antidepressant) extended release 300 mg daily to 225 mg daily if clinically appropriate. The physician responded and checked the disagree box on 12/5/24. The physician did not indicate a specific written clinical reason the GDR could not be attempted. Review of the resident's Nurses Notes did not show any documented behaviors, such as increased depression or insomnia from 01/01/25 to 05/20/25. During an interview on 05/20/25 at 01:22 P.M., the Director of Nursing (DON) said the following: -She tries to remind the physicians to document specific reasons they decline a GDR recommendation; she may miss some; -Physicians are expected to document specific clinical reasons if they decline a GDR recommendation.

Based on observation, interview, and record review, the facility failed to meet professional standards of quality for one resident (Resident #9), in a review of 14 sampled residents, when staff failed to follow physician's orders. The facility census was 31. 1. Review of Resident #9's undated Face Sheet showed the following: -The resident admitted to the facility on [DATE]; -The resident had private insurance and Medicaid was pending. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 04/17/25, showed the following: -Admission diagnosis of fracture and other multiple traumas; -Orthopedic surgery to repair fractures of the pelvis, hip, leg, knee or ankle; -Cognition was intact; -Independent with transfers; -Upper and lower extremity impairment on one side; -Independent with a wheelchair. Review of the resident's nursing progress notes, dated 4/22/25 at 8:11 P.M., showed the resident returned from an orthopedic appointment. The resident continues to be non-weight bearing of the right ankle. Review of the resident's Therapy Orders, dated 4/22/25, received from the resident's orthopedic physician, showed physical therapy to provide active and passive range of motion three to five times per week for six weeks. Review of the resident's physician orders, dated 4/23/25, showed the resident's primary care physician ordered a physical therapy evaluation. Review of the resident's nursing progress notes, dated 4/23/25 at 2:08 P.M., showed orthopedic physician's progress note forward to the resident's primary care physician. Waiting on insurance verification on therapy orders. Review of the resident's medical record showed no documentation physical therapy evaluated the resident as ordered on 4/23/25 and no documentation the facility staff notified the resident's physician when the order was not completed. Review of the resident's nursing progress notes, dated 5/7/25 at 11:26 A.M., showed orthopedic visit note received with recommendations for resident to be at 25% weight bearing to right ankle/foot for one week, 50% weight bearing to right ankle/foot for one week, then 75% weight bearing to right/ankle foot for one week. Primary care provider aware of the orders. Review of the resident's physician orders, dated 5/7/25, showed the following: -25% weight bearing to right ankle/foot for one week; -May use platform walker. Review of the resident's nursing progress notes, dated 5/7/25 at 1:14 P.M., showed the MDS Coordinator documented staff spoke with the resident and explained therapy would be in tomorrow. Will obtain a platform walker for the resident to use. During interviews on 05/12/25 at 10:05 A.M. and 05/14/25 at 12:51 P.M., the resident said the following: -He/She had a prescription for a platform walker; -He/She did not have a platform walker; -He/She wanted to use the platform walker since he/she was able to bear weight on his/her right leg; -He/She needed the platform walker due to right sided weakness from falling and history of spinal surgeries; -He/She wanted a platform walker to use in addition to the wheelchair; -He/She wanted to know why therapy had not seen him/her. Observation on 05/14/25 at 12:51 P.M., showed the following: -The resident sat in a wheelchair in his/her room; -The resident did not have a platform walker in his/her room. During interview on 05/15/25 at 12:06 P.M., Certified Nurse Assistant (CNA) I said he/she did not recall seeing a walker in the resident's room. During interview on 05/15/25 at 12:06 P.M., Nurse Assistant (NA) B said he/she did not recall seeing a walker in the resident's room. During interview on 05/14/25 at 2:12 P.M. and 2:56 P.M., the MDS Coordinator said the following: -He/She entered the order for the physical therapy evaluation and platform walker; -The physical therapy evaluation had not been done because the resident's insurance was out of network with the facility; -The Business Office Manager told the resident multiple times his/her insurance would not cover any additional therapy; -He/She did not know if the facility gave the resident a private pay option for the physical therapy evaluation; -Staff did not notify the resident's physician the physical therapy evaluation ordered on 04/23/25 was not completed due to insurance; -If therapy felt the resident was safe to use the platform walker, he/she would provide the resident with the platform walker. During interview on 05/14/25 at 2:56 P.M., the Business Office Manager said he/she was not aware of the order for the physical therapy evaluation and did not offer the resident private pay for the physical therapy evaluation. During interview on 05/15/25 at 2:13 P.M., Physical Therapist (PT) P said the following: -Therapy had not received an order for a physical therapy for the resident until 5/14/25 at 4:00 P.M. (The resident's physician ordered a physical therapy evaluation on 4/23/25); -The MDS Coordinator called and told PT P the resident needed a physical therapy screen due to the resident not having benefits for therapy; -He/She expected new physical therapy evaluations to be completed in 24 to 48 hours after the order was received. During interview on 05/15/25 at 3:27 P.M. and 05/20/25 at 2:45 P.M., the Director of Nurses said the following: -The physical therapy evaluation was not completed for the resident due to therapy not showing up; -She was aware of the delayed physical therapy evaluation; -She was aware the resident had not received the platform walker; -The platform walker ordered on 5/7/25 was not given to the resident due to non-weight bearing status; -Staff were to notify the physician if an order was delayed and were to document the notification in the resident's progress notes. -Staff did not notify the physician of the incomplete physical therapy evaluation and platform walker orders; -She expected staff to notify the physician when the platform walker was not given to the resident. During interviews on 05/15/25 at 10:59 A.M. and 05/20/25 at 2:45 P.M., the Administrator said the following: -He did not know about the resident's order for the physical therapy evaluation until a couple of days ago; -He was not aware the order was written on 04/23/25; -He would pay for the physical therapy evaluation if the resident was not able to. -He expected staff to contact their immediate supervisor, the Director of Nursing (DON) or Administrator if an order could not be carried through; -He expected staff to notify the physician when an order could not be carried through. During interview on 05/14/25 at 4:40 P.M., the Chief Operator of the facility said the following: -The physical therapy evaluation for the resident was not done; -Staff were to follow up on any physician's order in 24 hours; -The order for the physical therapy evaluation fell through the cracks. During interview on 05/19/25 at 10:25 A.M., the resident's primary care physician/Medical Director said the following: -She was aware of the resident's order for the physical therapy evaluation and expected new orders to be completed within a week; -She was not aware the physical therapy evaluation had not been completed; -She expected staff to communicate if an order was delayed or not completed; -He/She was not aware the resident did not receive the platform walker. 50189 51988

Based on interview and record review, the facility failed to ensure one nurse aide (NA B), completed a nurse aide training program within four months of employment with the facility. The facility census was 31. 1. During an interview on 05/13/25 at 4:34 P.M., the Director of Nursing (DON) said the facility did not have a policy on nurse aide training. She expected staff to follow regulatory guidance. 2. Review of the facility staff title listing, dated 05/12/25, showed the facility hired NA B on 09/20/24. 3. Review of NA B's employee file showed a hire date of 09/20/24 as a nurse aide. His/Her employee file did not include documentation he/she had completed his/her certification for a nurse assistant. 4. Review of NA B's nurse aide registry check showed no documentation to show NA B had a Certified Nurse Assistant (CNA) certification. Review of the facility May 2025 schedule, dated 05/12/25-05/20/25 (duration of survey), showed NA B scheduled to work as a nurse assistant on 05/12/25 day shift, 05/13/25 day shift, 05/15/25 day shift, 05/17/25 night shift, 05/18/25 night shift and 05/20/25 day shift. Observation on 05/13/25 9:25 AM, showed the following: -CNA Q and NA B brought a resident back from the shower in his/her wheelchair; -CNA Q and NA B donned gown and gloves before entering resident's room; -CNA Q and NA B transferred the resident from the wheelchair to his/her bed with a mechanical lift; -CNA Q and NA B provided perineal care to the resident; -CNA Q and NA B transferred the resident to his/her wheelchair by mechanical lift. During an interview on 05/13/25 at 09:25 A.M., NA B said the following: -He/She was hired in September 2024; -He/She failed the skills part of the CNA test; -He/She would retest again soon. During an interview on 05/13/25 at 4:34 P.M., the DON said nurse aides have to be certified within four months of hire. If they do not get their certification in that four months, they have to be terminated or transfer to another position. She did not realize NA B's hire date was 09/20/24 and he/she had not completed his/her certification within four months. She hired the NA's, the Business Office Manager does the new hire paperwork, the Minimum Data Set Coordinator (MDSC) does the skills checks, but no one monitored to ensure the NA's were certified within four months.

Based on interview and record review, the facility failed to ensure one staff, Nurse Assistant (NA) J, in a review of five NA employee files, had completed a new training and competency evaluation program or a new competency evaluation program on hire. NA J, a former Certified Nurse Assistant (CNA), who did not continue working as a CNA for 24 consecutive months, had let his/her CNA certification expire. NA J had not completed the required retraining and had not been accepted to challenge the CNA exam or have any other approval to work as a CNA. The facility census was 31. 1. During an interview on [DATE] at 4:34 P.M., the Director of Nursing (DON) said the facility did not have a policy on nurse aide training. She expected staff to follow regulatory guidance. 2. Review of NA J's nurse aide registry check showed his/her CNA certification expired [DATE]. 3. Review of NA J's employee file showed the following: -Date of hire [DATE]; -No documentation to show he/she was in a training and competency evaluation program approved by the state; -No documentation he/she had recently successfully completed a training and competency evaluation program or competency evaluation program approved by the State; -His/Her CNA/NA orientation checklist had half of the tasks initialed by an unidentified staff member (no name, and initials not a licensed nurse) and did not include the date and time training was completed or a signature of who completed the training; -No documentation to show NA J had completed the required retraining. During an interview on [DATE] at 1:36 P.M., NA J said the following: -He/She was hired at the end of March; -He/She was previously a Certified Nurse Aid (CNA) and Certified Medication Technician (CMT), but his/her certification lapsed; -He/She did not need any additional hands on training after hire, he/she just had to challenge the state to retest; -His/Her challenge was approved but he/she has yet to retest; -He/She had six months to complete; -He/She did not receive any form of NA training through the facility after being hired. -He/She worked as a NA. During an interview on [DATE] 4:34 P.M., and 5:00 P.M., the DON said the following: -Nurse aides do eight hours of videos and eight hours of job shadowing when they are hired; -The facility had not received the letter about no longer being approved to provide NA training until [DATE] (letter dated [DATE], received by mail [DATE]); -NA J was expected to complete 16 hours of instructional training prior to direct contact with a resident; -NA J's CNA certification was expired, so he/she should be trained like a NA until approval was received to challenge the CNA test.

Based on observation, interview, and record review, the facility failed to ensure staff provided one resident (Resident #9's), in a review of 14 sampled residents, with an appropriately sized wheelchair that did not impede his/her ability to self-propel in his/her wheelchair. The facility census was 31. Review of the facility's policy, Accommodation of Needs, dated March 2021, showed the following: -The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered; -Needs are evaluated upon admission and reviewed on an ongoing basis; -Provides a variety of types (for example, chairs with or without arms), sizes (height and depth), and firmness of furniture in rooms and common areas so that residents with varying degrees of strength and mobility can independently arise to a standing position. 1. Review of Resident #9's Care Plan, dated 04/16/25, showed the resident was independent in using a wheelchair. Review of resident's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 04/17/25, showed the following: -Cognition was intact; -Independent with transfers and mobility with a wheelchair. During interview on 05/13/25 at 10:13 A.M., the resident said a staff member got him/her a new wheelchair last night and the wheelchair sat a little low. During interview on 05/19/25 at 10:24 A.M., the resident said he/she told a nurse the next day (on 5/13/25) that the wheelchair was too small and his/her leg did not fit properly, but could not recall the nurse's name. Observation on 05/14/25 at 12:51 P.M., showed the following: -The resident sat in his/her wheelchair; -The wheelchair measured 16 inches from the ground to the wheelchair seat; -The resident's knees were higher than the seat when his/her feet were flat on the ground; -The resident's knees extended three to four inches from the edge of the wheelchair seat; -The wheelchair seat width was 16 inches; -There was approximately one finger width on each side of resident's legs in the wheelchair seat. During interview on 05/14/25 at 12:51 P.M., the resident said the following: -He/She felt the wheelchair was too small; -It was hard for him/her to self propel in the wheelchair. During interview on 05/19/25 at 11:27 A.M., Certified Nurse Assistant (CNA)/Certified Medication Technician (CMT) O said the following: -The resident said his/her wheelchair seat was torn and cutting his/her leg and wanted a new one; -He/She picked out a replacement wheelchair (on 5/12/25) from the storage room that was similar to the broken one and gave it to the resident. During interview on 05/19/25 at 1:53 P.M., Physical Therapist P said the following: -Therapy can complete different wheelchair assessments to determine the appropriate size of wheelchair for a resident; -Therapy staff measure hip width and make sure the resident's feet are able to touch the ground flat footed especially if the resident is able to self-propel; -The space on each side of the hips is to be one to two inches, and to measure from hip bone to the bend of the knee to determine depth of the wheelchair; -He/She did not complete the wheelchair measurements so he/she was not sure on the specifics, but one inch or two inches would be appropriate distance from the bend of the knee to the wheelchair seat. During interviews on 05/15/25 at 3:27 P.M. and 05/20/25 at 2:45 P.M., the Director of Nursing (DON) said the following: -Therapy collaborates with her and the MDS Coordinator on getting the accurate size of an assistive device for a resident; -If the resident did not have therapy, she, the MDS Coordinator, or Administrator decide on the accurate size of an assistive device for a resident; -She expected a nurse or CNA to replace the resident's wheelchair when resident requested a new one. -She was not aware of any issues with the resident's wheelchair.

Based on observation, interview, and record review, the facility failed to ensure residents were aware of posted resident rights, and failed to ensure resident rights were reviewed with residents during their stay. The facility census was 31. Review of the facility policy, Resident Rights, revised December 2016, showed the following: -Federal and state laws guarantee certain basic rights to all residents of this facility; -These rights include the residents right to: -Exercise his/her rights as a resident of the facility and as a resident or citizen of the United States; -Be supported by the facility in exercising his/her rights; -Exercise his/her rights without interference, coercion, discrimination or reprisal from the facility; -Be informed about his/her rights and responsibilities; -Communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter; -Copies of our resident rights are posted throughout the facility. Review of the facility policy, Acknowledgment of Resident Rights and Responsibilities, revised March 2017, showed the following: -Each resident (or resident representative) will be provided and must acknowledge receipt of a written copy of resident rights and all rules, regulations, and policies governing the resident's conduct and responsibilities during his/her stay in the facility; -Resident rights will be reviewed annually with resident and/or his/her representative during annual care plan meeting; -Resident rights will also be reviewed annually with residents during resident council meetings. 1. During the group interview on 5/13/25 at 1:20 P.M., 13 residents in attendance said the facility had not reviewed resident rights with them. The residents said they were not aware of where resident rights were posted in the facility. Observation on 5/14/25 at 5:50 A.M. and 5:58 A.M. showed resident rights were posted along the 300 hall wall, next to the activity calendar, by the nurses station. A small, approximately 5 inch by 9 inch, Know Your Rights plaque was located on a four foot tall counter, located by the entrance to the kitchen, in the dining room. During an interview on 5/14/25 at 6:31 A.M., Resident #14 said the facility staff did not discuss resident rights at council meetings. During an interview on 5/15/25 at 3:52 P.M., the Director of Nursing (DON) said the following: -She was not sure where resident rights were posted; -She expected the residents to know they had rights; -She expected the residents to be re-educated regularly, at least annually, maybe even at quarterly care plan meetings or resident council meetings. During an interview on 5/19/25 at 11:06 A.M., the Social Services Director said the following: -She reviewed resident rights with residents upon admission, but did not review them with the residents after that; -She did not review resident rights at resident council meetings, but would discuss them if the residents brought them up. During an interview on 5/20/25 at 2:45 P.M., the Administrator said the following: -He expected resident rights to be highlighted and discussed in resident council meetings; -He expected staff to review the resident rights with the residents at least every six months.

Based on observation, interview, and record review, the facility failed to ensure the contact information for the State Long-Term Care Ombudsman Program and the State Survey Agency were posted in a location that was accessible to all residents and could be read by residents in the facility without assistance. The facility census was 31. Review of the facility policy, Resident Rights, revised December 2016, showed the following: -Federal and state laws guarantee certain basic rights to all residents of this facility; -These rights include the resident's right to: -Communication with and access to people and services, both inside and outside the facility; -Communicate with outside agencies (local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter. 1. During group interview on 5/13/25 at 1:20 P.M., 11 residents in attendance said they knew who their ombudsman was, but did not know where the contact information was posted. The residents said they did not know how to contact the State Survey Agency if they had any concerns. Observation on 5/14/25 at 5:59 A.M. showed two 9 inch by 10 inch picture frames hung in the dining room, between the Business Office Manager's office and the Social Services Director's office, approximately five feet off the floor. One frame contained a printed paper with the Ombudsman contact information and the other was a printed flyer with the Elder/Disabled Hotline number. During an interview on 5/14/25 at 6:31 A.M., Resident #14 said the following: -He/She had not been educated on how to contact the Ombudsman or the State Survey Agency; -He/She was not aware if the Ombudsman or State Survey Agency numbers being posted anywhere in the facility. During an interview on 5/14/25 at 7:08 A.M., Resident #30 said he/she was not aware if the Ombudsman or State Survey Agency phone numbers being posted anywhere in the facility. Observation on 5/15/25 at 3:04 P.M. showed Resident #14 sat in a wheelchair in the dining room. During an interview on 5/15/25 at 3:04 P.M., Resident #14 (after being shown where the Ombudsman and State Survey Agency numbers were posted) said the following: -The Ombudsman information was too small for him/her to read; -He/She could barely read the State Survey Agency phone number; -The signs were up pretty high. It would help if they were bigger and lower to the ground. Observation on 5/15/25 at 3:10 P.M. showed Resident #11 sat in a motorized wheelchair and squinted at the Ombudsman and State Survey Agency postings. During an interview on 5/15/25 at 3:10 P.M., Resident #11 (after being shown where the Ombudsman and State Survey Agency numbers were posted) said the following: -He/She could not read the Ombudsman information; the print was too small; -He/She could see the State Survey Agency phone number, but could not read anything else on the paper to know that was what the number was for; -The signs were up high. It would be easier to read them if they were lower to the ground and bigger. During interviews on 5/15/25 at 3:52 P.M. and 5/19/25 at 9:40 A.M., the Director of Nursing (DON) said the following: -She expected the Ombudsman and State Survey Agency contact information to be posted at Americans with Disabilities Act (ADA) guidelines height and large enough residents could easily see and read; -The Social Services Director was responsible for ensuring residents were aware of the Ombudsman and State Survey Agency contact information. During an interview on 5/19/25 at 11:06 A.M., the Social Services Director said the following: -Residents were given the Ombudsman and State Survey Agency contact information on admission; -The Ombudsman and State Survey Agency contact information were also posted on the wall in the facility, but she was not sure where; -After being notified of the posted location of the Ombudsman and State Agency contact information, she said the contact information was posted very high on the wall. During an interview on 5/20/25 at 2:45 P.M., the Administrator said he expected the Ombudsman and State Survey Agency contact information to be posted at a height for all residents to see, ideally wheelchair height.

Based on observation, interview, and record review, the facility failed to post the results of the most recent survey and complaint investigations in a place readily accessible to all residents. The facility census was 31. Review of the undated facility policy, Resident Rights, showed the resident has the right to examine survey results. Review of the Examination of Survey Results, dated April 2007, showed the following: -A copy of the most recent standard survey, including any subsequent extended surveys, follow up revisits, reports, etc., along with state approved plans of correction of noted deficiencies, is maintained in a three-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room; -Copies of previous survey reports and state approved plans of correction are available upon request to the public, residents or their legal representatives, designated ombudsman representative and staff members. 1. During the resident council meeting on 05/13/25 at 1:20 P.M., three of the 16 residents in attendance said they were not aware they could see the results of the annual inspections/surveys or any complaint investigation. They did not know where the facility kept results of any survey. Observations on 05/14/25 at 5:51 A.M. and 5:30 P.M., showed a binder, which contained the 2019 survey results only, located on a table in the front vestibule of the facility. The vestibule was a secure area, located behind a locked door, which required a four-digit pin in order to enter and exit the area without sounding an alarm. The residents did not have access to the area where the survey binder was kept without staff assistance. During an interview on 05/15/25 at 7:20 A.M., the Director of Nursing (DON) said the survey results binder was located on the counter in the dining room. Observation on 05/15/25 at 7:25 A.M., showed the survey binder was located in a corner on top of a four foot tall counter, located by the entrance to the kitchen, in the dining room. A large nurse appreciation sign hung from the ceiling and covered the counter-top so the binder was not visible. The survey binder was located where wheelchair bound residents would not be able to see or reach the binder. Review of the survey binder, located on the counter in the dining room, on 05/15/25 at 7:25 P.M., showed the following: -The most recent survey results from 08/11/23 were in the front of the binder; -The binder did not include any statements of deficiencies issued or plans of correction developed after 8/11/23. During an interview on 05/20/25 at 2:45 P.M., the Administrator said the following: -He expected the binder in the dining room to include the most recent survey results; -He expected the surveys from the last three years and complaints to be in the binder; -He expected the binder to be accessible to residents.

Based on interview and record review, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) and a complete Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (CMS-10055) to two residents (Residents #13 and #20), in a review of three sampled residents, or the resident's representatives, when the facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. The facility census was 31. During an interview on 05/28/25 at 1:39 P.M., the Business Office Manager (BOM) said the facility did not have a policy for SNFABN CMS-10055 and the NOMNC CMS-10123 forms. Staff just followed the regulation. 1. Review of Resident #13's discharge Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 10/24/24, showed the resident discharged to the hospital on 10/24/24. Review of the resident's entry MDS, dated [DATE], showed the resident readmitted to the facility. Review of the undated SNF Beneficiary Protection Notification Review form, completed by the facility for Resident #13, showed the following: -Medicare part A Skilled Services started on 10/30/24; -Last covered day of Part A Service 11/26/24; -The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The resident remained in the facility. Review of the resident's SNFABN CMS-10055 form, dated 11/24/24, showed the following: -On 11/24/24, the facility staff notified the resident he/she would be discharged from Medicare part A services on 11/26/24. The resident may have to pay out of pocket for this care if he/she did not have other insurance that may cover these costs; -The resident was receiving daily skilled nursing care and this care will not longer be occurring daily because you have met your goals; (Staff did not include an estimated cost for the services if the resident chose to continue the skilled nursing care services.) Review of the resident's medical record showed no documentation staff provided the resident with a NOMNC (CMS 10123). 2. Review of Resident #20's discharge MDS, dated [DATE], showed the resident discharged to the hospital. Review of the resident's entry MDS, dated [DATE], showed the resident readmitted to the facility. Review of the undated SNF Beneficiary Protection Notification Review form, completed by the facility for Resident #20, showed the following: -Medicare Part A Skilled Services started on 10/12/24; -Last covered day of Part A Service was 10/20/24. -The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The resident remained in the facility. Review of the resident's SNFABN CMS-10055 form, dated 10/18/24, showed the following: -On 10/18/24, facility staff notified the resident he/she would be discharged from Medicare part A services on 10/18/24 and the resident may have to pay out of pocket for this care if they did not have other insurance that may cover these cost; -The resident was receiving physical therapy and daily skilled nursing care. These cares will not longer be occurring daily, for the following reasons (left blank); -Staff did not include the estimate that the services would cost if the resident chose to continue services. During an interview on 5/28/25 at 1:39 P.M. and 3:45 P.M., the Business Office Manager said the resident's last covered day was 10/20/24. She did not know why the notice said services ended on 10/18/24. Review of the resident's medical record showed no documentation staff provided the resident with a NOMNC (CMS 10123). 3. During an interview on 5/28/25 at 1:39 P.M. and 3:45 P.M., the Business Office Manager said the following: -The Social Service Designee (SSD) completed the SNFABN and NOMNC forms, and was responsible to inform the resident/resident representative when residents' Medicare Part A services were ending; -The SSD no longer worked for the facility, however, she trained the SSD on the ABN process and will be responsible to give the notices until a new SSD was trained; -She did not know a NOMNC was required for all residents to show discharge from Medicare part A when there were days remaining; she had never seen the NOMNC before; -The estimated cost of the discontinued services was required to be on the SNFABN form; -She did not know why the estimated costs were not on the SNFABNs. During an interview on 5/20/28 at 2:45 P.M., the Administrator said the resident or resident representative should receive the written copy of the SNFABN and NOMNC when the resident discharged from Medicare A services. He expected the dates on the forms to match the dates Medicare part A starts and stops, and all areas on the form were to be completed as the form directed including cost of services.

Based on interview and record review, the facility failed to thoroughly assess one resident (Resident #1) and notify the physician after the resident sustained an unwitnessed fall that resulted in increased pain, dizziness, vomiting, and a fractured hip, in a review of 10 sampled residents. After the fall, staff transferred the resident from the floor to the toilet, to a wheelchair, and then to his/her bed. During the transfer, staff said the resident yelled and screamed out in pain. The resident complained of his/her head hurting and feeling dizzy. Registered Nurse (RN) A and Licensed Practical Nurse (LPN) B did not perform neurological checks (assessing level of consciousness, visual fields, pupil constriction and dilation, upper and lower limb strength or limitation, speech and vital signs) with the resident after the unwitnessed fall. RN A and LPN B did not report the resident's pain or changes of condition to the physician and did not send the resident to the hospital. After the resident's fall, RN A ordered an x-ray of the resident's hip without a physician order. The resident began vomiting, lost consciousness, and died at the facility. The facility census was 32. The Administrator was notified on [DATE] at 4:00 P.M. of the Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's policy Falls - Clinical Protocol, dated [DATE], showed the following: -The nurse shall assess and document and report vital signs, injury, especially fracture or head injury, musculoskeletal function, observing for changes in normal range of motion, weight bearing, neurological status, and pain; -The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. Review of the facility's policy Assessing Falls and Their Causes, dated [DATE], showed the following: -The purpose of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall; -If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities; -Obtain and record vital signs as soon as it is safe to do so; -If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately; -Notify the resident's attending physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone. Review of the facility's policy Change in a Resident's Condition or Status, dated February 2021, showed the following: -The facility promptly notifies the resident, physician, and the resident's representative of changes in the resident's medical/mental condition and/or mental status; -The nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident, significant change in the resident's physical, emotional, or mental condition, and need to transfer the resident to a hospital or treatment center; -The nurse will record in the resident's medical record information relative to changes in the resident's medical or mental condition or status. Review of the facility's policy Pain - Clinical Protocol, dated [DATE], showed the following: -The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain; -The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity; -The nursing staff will identify any situation or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation, or repositioning; -The physician will perform or order appropriate tests as needed to help clarify sources of pain. For example, an x-ray may help to identify the cause of joint pain. 1. Review of Resident #1's undated Face Sheet showed the following: -The resident had diagnoses that included Alzheimer's disease (a progressive, neurodegenerative disorder that affects memory, thinking, and behavior), mild cognitive impairment, muscle wasting and atrophy (the loss of muscle mass and strength), muscle weakness, unsteadiness on feet, abnormal posture, need for assistance with personal care, history of falling, overactive bladder, osteoporosis (a condition that weakens bones, making them fragile and prone to fractures, often going unnoticed until a bone breaks, particularly in the hip, spine, or wrist), collapsed vertebra (causes a vertebral compression fracture that can be caused by trauma or osteoporosis), difficulty in walking, and cognitive communication deficit; -The resident had a code status of do not resuscitate. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated [DATE], showed the following: -The resident's cognition was severely impaired; -The resident had diagnoses that included Alzheimer's disease and osteoporosis; -The resident required substantial/maximum assistance from staff for lying to sitting and sitting to lying repositioning, and chair to bed transfers. Review of the resident's Care Plan, dated [DATE], showed the following: -The resident had chronic pain in his/her back from past falls and prior fractures of his/her spine; -The resident was able to voice discomfort; -The resident had a history of several falls as he/she takes self to the bathroom frequently. He/She has osteoporosis which put him/her at risk for further injuries; -The resident required assistance with part of his/her activities of daily living (ADLs). Review of the resident's nursing note, dated [DATE] at 3:50 P.M., entered by RN A showed the following: -The resident hollered for help; -Staff approached the bathroom and found the resident on the floor; -The resident had an unwitnessed fall trying to get himself/herself to the toilet; -Two staff members assisted the resident off the bathroom floor, then assisted with changing the resident's clothes; -Staff transferred the resident to his/her wheelchair, vital signs taken, the resident complained of right hip pain; -The physician, Director of Nursing (DON), and administrator notified; -A portable x-ray was ordered. Review of the resident's nursing note, dated [DATE] at 3:52 P.M., entered by RN A showed the following: -A fall occurred on [DATE] at 2:16 P.M. that was not witnessed; -The resident attempted to toilet himself/herself and the reason for the fall was not evident; -An injury did not occur as a result of the fall and the fall did not result in an emergency room visit; -The physician was notified on [DATE] (no time documented) of the resident's fall with new order received (see order sheet for new order); -The resident's blood pressure was ,d+[DATE] (reference range is ,d+[DATE] to ,d+[DATE]), pulse was 73 (reference range is 60 to 100 beats per minutes), respirations were 18 (reference range is 12 to 20 breaths per minute, (all within normal limits), oxygen level was 90% on room air (reference range is 92% to 100%), and temperature was 97.7 degrees Fahrenheit (reference range is 97.8 degrees Fahrenheit to 99.1 degrees Fahrenheit); -The resident voiced complaints of sharp pain in his/her right hip, rating it a 6 out of 10 on a scale of 1 to 10 with 10 being the worst pain; -The resident had a change in mobility status; -The resident had recent pain and blood pressure medication changes. Review of the resident's physician order sheet, dated [DATE], showed the following: -No evidence of a standing order for x-rays; -RN A entered an order at 4:03 P.M. for a two view portable x-ray of the resident's right hip for a fall, pain in hip, unable to bear weight, and non-ambulatory; -RN A entered the Medical Director as the ordering physician; -The communication method was marked as prescriber written. Review of the resident's nursing note, dated [DATE] at 7:00 P.M., entered by LPN B showed the following: -The resident's blood pressure was ,d+[DATE], pulse 74, respirations 18, oxygen level 90% on room air and temperature 97.7; -The resident said his/her hip was still hurting and would not let LPN B assess it; -The resident's hand grips were of equal strength; -The resident's pedal (foot) pulses were strong; -The resident refused his/her evening meal but did take a few sips of water and drank a cup of coffee. Review of the resident's nursing note, dated [DATE] at 9:26 P.M., entered by LPN B showed the following: -At approximately 8:00 P.M. staff notified LPN B the resident was unresponsive; -LPN B immediately called 911; -Upon entering the resident's room, the resident was noted to be gray in color with his/her head slumped on his/her chest; -Staff tried to rouse the resident but were unsuccessful and LPN B was unable to find a pulse or heartbeat. During interviews on [DATE] at 2:47 P.M. and [DATE] at 10:46 A.M., RN A said the following: -The resident fell about 3:15 P.M. The resident hollered for help and he/she went to the resident's room and found the resident sitting on the bathroom floor; -The resident's wheelchair was in the doorway and the footrests were down; -The resident said he/she did not hit his/her head. RN A felt the back of the resident's head and there were no cuts, bleeding, or bumps; -RN A assessed the resident by moving his/her leg up and down and the resident said no; -The resident complained his/her right hip hurt; -Two aides came in the bathroom and assisted the resident to the toilet, cleaned the resident up and changed his/her incontinent brief; -When the aides stood the resident, the resident did not have any shortening of either leg (this would be an indication of a hip fracture). The resident could only put weight on his/her right toes and put most of his/her weight on his/her left side. Staff transferred the resident to his/her wheelchair; -RN A took the resident's blood pressure, pulse, respirations, and temperature; -RN A said he/she talked to the physician. RN A then responded that he/she called the physician's office and no one answered and RN A said based on his/her best nursing judgement, he/she put in a standing order for an x-ray; -He/She called the mobile x-ray company and ordered a stat (immediate) x-ray of the resident's right hip; -He/She only did an initial assessment when finding the resident on the bathroom floor; -RN A did not complete neurological assessments (assessing level of consciousness, visual fields, pupil constriction and dilation, upper and lower limb strength or limitation, speech and vital signs) on the resident. RN A did not know what the protocol was for neurological assessments for an unwitnessed fall at the facility; -RN A checked on the resident two or three times after the fall and before the end of his/her shift, but did not complete neurological assessments; -RN A did not call the on-call physician and did not feel like the resident needed to go to the hospital; -RN A did not feel it was an emergent situation; -RN A did not think the resident had broken his/her hip; -Staff never told RN A the resident felt dizzy, had a headache, or wanted to go to the hospital after the fall. During an interview on [DATE] at 1:31 P.M., LPN B said the following: -He/She came on duty at 6:00 P.M. on [DATE]; -He/She got report from RN A and was told Resident #1 fell in the bathroom and had an x-ray of his/her right hip. The results had not come back yet and LPN B was to watch for them; -He/She saw the resident for the first time on his/her shift at 7:00 P.M., the resident said his/her right leg hurt; -He/She felt strong pulses in both feet. He/She did not do a push/pull leg strength assessment because the resident's right leg hurt; -The resident was not able to give a number on a scale of one to 10 (with 10 being the worst pain) to rate his/her pain; -LPN B did not notify the physician of the resident's pain. The resident had opioid pain medication scheduled at 8:00 A.M., 1:00 P.M., and 6:00 P.M. that Certified Medication Technician (CMT) E administered to the resident at 7:00 P.M. -The resident refused his/her evening meal but did take a few sips of water and then drank a cup of coffee; -About 8:00 P.M., Nursing Assistant (NA) C, NA D, and CMT E were all in the resident's room. One of them yelled out that the resident was vomiting and was unresponsive; -He/She called 911 at 8:00 P.M. During an interview on [DATE] at 3:37 P.M., NA C said the following: -He/She entered the resident's room after the fall occurred on [DATE] at approximately 2:20 P.M.; -He/She helped transfer the resident from the toilet to the wheelchair; -RN A took the resident's vital signs after the resident was in the wheelchair; -The resident stayed in his/her wheelchair until about 5:00 P.M. when the mobile x-ray company arrived; -NA C heard the resident screaming down the hallway and went to his/her room to see if the resident needed help, staff had just transferred the resident to his/her bed to get the x-ray; -NA C and Certified Nurse Aide (CNA) I helped the resident roll to his/her side for the x-ray technician could. When staff rolled the resident, he/she said, Stop, pain, it's hurting; -The resident continued to yell out in pain off and on after the x-ray was completed as NA C and other staff assisted other residents on the hall; -NA C went to the resident's room after the x-ray was completed and the resident wanted his/her family called but the facility did not have a number for the requested family member. The resident kept asking for that particular family member; -NA C and CNA I told RN A a little while after the x-ray was completed the resident asked to go to the hospital. RN A said there was nothing he/she could do until the x-ray results came back; -LPN B came on duty at 6:00 P.M., but did not go see the resident until about 7:00 P.M.; -NA C sat with the resident in between answering call lights and the resident would randomly scream out in pain. If NA C left to answer a call light the resident would yell out, Come back, help me!; -The resident told NA C he/she was waiting for the ambulance and NA C said the ambulance was not coming. The resident told NA C he/she wanted to go to the hospital; -The resident complained of his/her head hurting really bad and asked for pain medication; -NA C was not in the resident's room the first time the resident vomited, but about 7:45 P.M. the resident vomited again and it looked like coffee grounds. The head of the bed was at a 45 degree angle and staff raised it to a 90 degree angle; -The resident complained of being dizzy and said his/her head hurt; -CMT E checked the resident's oxygen level and it was 48%. They told LPN B and he/she said to get oxygen for the resident; -The resident vomited for the third time, mumbled incoherently and then became unresponsive; -Staff told LPN B and he/she called 911; -CMT E checked the resident's pulse and it was very faint. The pulse oximeter (device used to measure oxygen levels) would not read the resident's oxygen level; -Emergency Medical Services (EMS) arrived and took over. During an interview on [DATE] at 4:08 P.M., NA D said the following: -CNA I and NA D were in another resident's room when they heard Resident #1 screaming. The aides went to the resident's room. RN A was in the bathroom where the resident was on the floor yelling I think I broke my leg!; -RN A bent the resident's leg at his/her knee back and forth and the resident yelled Ouch, that hurt!; -The resident kept yelling out I think I broke my leg!; -RN A and the two aides assisted the resident from the floor to the toilet. When the resident stood up, he/she did not put any weight on his/her right leg; -RN A said he/she would call about an x-ray; -The resident wanted to go to the dining room, so NA D pushed the resident to the dining room; -The mobile x-ray company arrived and NA D pushed the resident to his/her room and then someone else assisted the resident to bed; -NA D helped roll the resident so the x-ray technician could take the x-ray. The resident cried ouch when staff rolled him/her; -The resident asked to go to the hospital and kept saying he/she was waiting for the ambulance; -NA D told RN A the resident wanted to go to the hospital and RN A said he/she couldn't do anything until the x-ray results were back; -The resident said he/she was extremely dizzy, his/her head hurt and his/her heart hurt; -NA D told this information to RN A, but he/she did not say anything; -The resident vomited the first time about 6:00 P.M. and then about 6:30 P.M. to 7:00 P.M., the resident vomited a second time. After vomiting the second time the resident became pale and was gurgling. NA D sat the head of the bed up more and told LPN B; -LPN B went to the resident's room, took his/her vital signs, gave the resident a few sips of water and a cup of coffee, which the resident drank; -A little bit later, the resident vomited for a third time, the vomit was brown, and afterwards the resident became unresponsive; -LPN B left the room and called 911; -EMS arrived and said the resident had a faint pulse. EMS placed the resident on their monitor and there was no pulse. During an interview on [DATE] at 10:17 A.M. CMT E said the following: -Around 3:00 P.M. on [DATE] RN A told him/her the resident had fallen; -RN A said the DON did not answer his/her call and he/she called the MDS Coordinator and discussed a plan for the resident; -The resident was in his/her room sitting in a wheelchair and said his/her leg hurt. A short time later, the resident went to the dining room and was alert, oriented, quiet and CMT E administered evening medications to the resident; -The mobile x-ray company arrived and CMT E and NA D took the resident to his/her room. CMT E and NA D transferred the resident to his/her bed with a gait belt. The resident did not bear weight on his/her right leg at all and cried out in pain during the transfer; -The resident usually transferred with one staff member's assistance from the chair to the bed; -CMT E and NA D had to roll the resident on his/her side so x-ray tech could get a board under the resident's hip for the x-ray. During the roll the resident screamed out in pain; -At about 7:00 P.M., CMT E walked past the resident's room and he/she yelled out he/she was in pain. CMT E administered the resident's scheduled opioid pain medication; -About 7:45 P.M., CNA I told LPN B the resident did not look good and should go to the emergency room . LPN B said he/she couldn't send the resident out, because there were no orders to send the resident to the hospital; -CMT E asked LPN B if the resident's vital signs had been taken recently. LPN B said he/she had not, so CMT E took the resident's blood pressure and it was ,d+[DATE] and the resident's oxygen level was 90%. LPN B said to put the resident on oxygen and he/she called 911; -Right after CMT E placed the oxygen on the resident, the resident vomited a brown mucous liquid from his/her mouth and nose. The resident then became unresponsive; -CMT E did a sternal rub on the resident's chest and did not get a response from the resident, could not get a pulse at the resident's wrist, and did not see the resident breathing; -EMS arrived and placed monitors on the resident and did not get a pulse. During an interview on [DATE] at 10:35 A.M., the MDS Coordinator said the following: -RN A called him/her after the resident fell and asked what he/she thought about sending the resident to the emergency room versus getting an x-ray; -He/She thought RN A was asking for an opinion to recommend to the physician; -Standing orders were for over the counter medications only, not for x-ray orders. During an interview on [DATE] at 1:56 P.M., Emergency Medical Services (EMS) Staff J said the following: -When he/she arrived in the resident's room the resident was ashen, unresponsive and if he/she was breathing it was minimal; -The resident was placed on the cardiac monitor and there was no pulse. During an interview on [DATE] at 1:10 P.M. and [DATE] at 11:16 A.M., the DON said the following: -She expected staff to follow the policy as written and complete neurological checks and reassess the resident as needed; -She expected the physician/on-call physician to be notified if a resident had a fall; -She would not expect a nurse to place an order for an x-ray without a physician's order; -The facility did not have standing orders for x-rays. During an interview on [DATE] at 11:16 A.M., the Administrator said the following: -RN A should have called the on-call physician; -He would have expected staff to complete neurological assessments on Resident #1 because it was an unwitnessed fall; -He would not expect a nurse to order an x-ray without a physician's order. During an interview on [DATE] at 4:37 P.M. the On-Call Physician said the following: -He/She had missed a call on [DATE] at 9:53 P.M. from the facility; -At 10:00 P.M. he/she got a call from LPN B and was told Resident #1 passed away and the body had been released; -He/She did not receive any calls prior to 9:53 P.M. on [DATE] from the facility. During an interview on [DATE] at 1:29 P.M. and [DATE] at 11:40 A.M., the Medical Director said the following: -She was not notified of Resident #1's fall on Sunday, [DATE]; -She did not order a mobile x-ray for the resident; -She would have expected the nurse to call the on-call physician on a Sunday; -She would expect neurological checks to have been completed every 15 minutes for at least the first hour and further assessments of the resident should have been completed after his/her fall; -The resident may have had a different outcome if staff had sent the resident to the hospital; -The nurse should have called the physician and gotten the resident sent to the hospital. MO250114 MO250199 NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on observation, interview, and record review, the facility failed to report one resident's (Resident #9's) significant weight loss to the physician, and failed to ensure the registered dietician assessed the resident and made recommendations regarding his/her weight loss. The facility also failed to consistently provide physician ordered interventions to prevent weight loss and failed to offer the resident his/her preferred food items. A sample of 20 residents was selected for review. The facility census was 33. Review of the facility's policy, Nutrition (Impaired)/Unplanned Weight Loss, revised September 2017, showed the following: -Nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time; -The staff and physician will define the individual's current nutritional status and identify individuals with weight loss or gain and significant risk for impaired nutrition; -The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss or impaired nutrition; -The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake; -The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes; -The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions. 1. Review of Resident #9's Nutrition Note from the registered dietician showed on 4/25/20, the resident was on a regular diet. Intake had been fair. The resident weighed 157 pounds. Staff should continue with the 2 cal (liquid dietary supplement) twice a day. No new recommendations were made. (Review of the resident's medical record showed no further notes from the registered dietician after this date.) Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 7/11/20, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognition was intact; -Weight 155 pounds; -Independent with eating; -No weight loss or gain. Review of the resident's documented weights showed the following: -On 8/26/20, the resident weighed 154 pounds; -On 9/2/20, the resident weighed 152 pounds; -On 10/5/20, the resident weighed 152 pounds; -On 11/2/20, the resident weighed 152 pounds; -On 12/4/20, the resident weighed 147 pounds; -On 1/12/21, the resident weighed 142 pounds; -On 2/23/21, the resident weighed 143 pounds; -On 3/2/21, the resident weighed 137 pounds (a 6 pound weight loss in seven days). Review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Regular diet; -2 Cal 60 milliliters (ml) twice a day; -Give ice cream with lunch and supper two times a day related to mild protein-calorie malnutrition. Further review of the resident's documented weights showed on 3/8/21, the resident weighed 136 pounds. Review of the resident's Interdisciplinary Team (IDT) note, dated 3/26/21, showed the resident worked with occupational therapy five times a week on strength and positioning. The resident was still losing weight. Will schedule Boost (dietary supplement). The resident refused to eat many meals. There was no documentation found in the resident's record to show that Boost was implemented as recommended on 3/26/21. Further review of the resident's documented weights showed on 4/6/21, the resident weighed 131 pounds. (An 11 pound weight loss (7.75 % weight loss) in three months and a 21 pounds (13.82%) weight loss in six months. Review of the resident's IDT note, dated 4/21/21, showed the facility would call the resident's family about a possible hospice referral for weight loss. Further review of the resident's documented weights showed on 5/3/21, the resident weighed 135 pounds. Review of the resident's POS for May 2021 showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (The IDT discussed implementing this as an intervention of 3/26). Review of the resident's Significant Change in Status MDS, dated [DATE], showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognition was mildly impaired; -Height 69 inches -Weight 69 pounds (error); -Weight loss of 5% or more in one month and 10% or more in six months that was not physician prescribed. Review of the resident's care plan, dated 5/13/21, showed the following: -The resident was a very picky eater and often did not eat well which had caused him/her to lose weight; -The resident was able to make food choices and feed himself/herself; -The resident needed optimal protein intake to prevent skin breakdown and to prevent weight loss; -The resident liked protein drinks and kept these in a refrigerator in the room; -The resident preferred to eat in bed in his/her room; -The resident did not like chicken or turkey, offer a substitute; -The resident liked crisp bacon and tomato juice for breakfast; -Offer Boost or Ensure when the resident did not eat; -Offer food choices the resident liked; -Provide and serve 90 ml of 2 Cal twice a day. The resident would also ask for Boost or Ensure out of his/her refrigerator; -Registered dietician to make diet change recommendations as needed; -The resident would eat a baked potato. The resident liked milk, ice cream, and boiled eggs, however, the resident would get tired of these things and change his/her preferences. Review of the resident's nurse's note, dated 5/14/21, showed a care plan meeting was held with the resident and his/her weight loss was discussed. The resident said he/she gained four pounds and felt he/she was not getting enough Ensure/Boost. The resident said he/she would like to have sauerkraut and tomato juice more often. The resident did not want hospice services. Further review of the resident's documented weights showed on 6/3/21, the resident weighed 131 pounds. Review of the resident's medical record showed no documentation facility staff notified the resident's physician of the resident's weight loss. Observation on 6/16/21 at 12:20 P.M. showed the following: -Staff served residents baked chicken breast, peas, carrots, garlic bread, and cake; -Certified Nurse Assistant (CNA A) delivered Resident #9 his/her meal tray to his her/room; -The resident's diet card showed the resident was on a regular diet, 60 ml of 2 Cal twice a day. The resident didn't like meat. He/She liked burnt bacon, tomato juice, crab meat and seafood; -Staff served the resident garlic bread, peas, carrots, one glass of milk, and cake. Staff did not serve the resident the 2 Cal supplement or ice cream with his/her meal tray. Staff did not serve the resident the chicken breast or a substitute for the chicken; -The resident drank all of the glass of milk in one drink; -The resident did not eat any of his/her meal; -Staff did not provide the resident with Boost or Ensure. During an interview on 6/16/21 at 12:22 P.M., the resident said he/she did not want the chicken breast and would not eat if it had been on his/her plate. The resident said he/she might eat the piece of cake and would drink another glass of milk and eat some ice cream if it were served. During an interview on 6/16/21 at 1:00 P.M., CNA A said he/she was not sure why staff did not serve the resident a piece of chicken. CNA A said he/she did not ask the resident if he/she would like anything else to eat. The resident had Boost shakes in the refrigerator in his/her room. Staff did not give these to the resident unless the resident asked for them. During an interview on 6/16/21 at 5:38 P.M., the Director of Nursing (DON) said there were no dietary notes from the dietician found for the resident after 4/25/20. The dietician was supposed to review all residents monthly but he/she had not made any recommendations for the resident. The facility provided the resident with the 2 Cal supplement. If the resident wanted Boost or Ensure, the resident or his/her family purchased these. The DON was aware Resident #9 had lost weight because he/she just wouldn't eat. The resident did not eat meat but he/she liked burnt bacon and shrimp. The resident also really liked sauerkraut. Staff should provide the resident with foods he/she preferred. Observation on 6/16/21 at 5:50 P.M. showed staff served the resident shepherd's pie (ground beef with mashed potatoes), salad, milk, tomato juice, and a cookie. Staff did not offer a substitute for the entrée that contained meat. Staff did not serve the resident ice cream or 2 Cal supplement with his/her supper meal. Staff did not provide the resident with Boost or Ensure. Observation on 6/17/21 at 8:05 A.M. showed staff served the resident very crispy bacon, tomato juice, 2 Cal, chocolate milk and cake. The resident drank all of the 2 Cal and the milk and ate all of the bacon. During an interview on 6/17/21 at 8:10 A.M., the resident said he/she liked bacon and ate it all. The resident said he/she did not get any ice cream with his/her supper the evening before (6/16/21), and he/she would have eaten it if staff would have served it to him/her. The resident said he/she liked eggs but did not get any with breakfast that morning. During an interview on 6/17/21 at 8:35 A.M., Licensed Practical Nurse (LPN) B said the resident's ice cream comes on his/her meal tray from the kitchen with lunch and supper. The 2 Cal also comes from the kitchen with the resident's breakfast and supper trays. During an interview on 6/17/21 at 9:08 A.M., the dietary manager said the resident's diet order was for no meat, and ice cream and 2 Cal supplement. The resident liked bacon well done, sauerkraut, tomato juice, grapes, and ice cream. The resident usually consumed the dietary supplement as well. Nursing staff were supposed to ask the resident if he/she wanted the ice cream, and they would come to the kitchen and ask for it if the resident requested it. The ice cream did not automatically come on the resident's meal tray. The 2 Cal supplement was served with the resident's meals. The dietary manager was aware the resident had lost weight. The resident did not like most meat, and if meat was served with a meal, staff should offer the resident a substitute of peanut butter sandwich, egg salad, or tomato soup. The dietary manager was not sure if the registered dietician had assessed the resident. The dietician had not made any recommendations to the dietary manager about the resident's weight loss or nutritional needs. The resident should have received an alternate at both lunch and supper the day before (6/16/21). During an interview on 6/17/21 at 10:A.M., Dietary Aide C said he/she worked at the facility for one year. The resident did not like to eat most meats and didn't like bread. The resident would eat burnt bacon, tuna, and sauerkraut. The resident received the 2 Cal supplement on his/her meal tray and had Boost in his/her room. Nursing staff would come to the kitchen and ask for ice cream if the resident requested it. Staff did not automatically serve the ice cream with the resident's tray. If a meal had meat, kitchen staff tried to give the resident tuna. It was kind of hard to figure out what to serve the resident and he/she was not really sure what to offer the resident as a substitute for meat. During an interview on 6/17/21 at 11:06 A.M., the resident's physician's nurse, LPN E, said the last time the physician saw the resident was in March. LPN E did not find any contact from the facility to the physician regarding the resident's weight loss. The physician would expect the facility staff to call and notify him/her if a resident had a significant weight loss. During an interview on 6/17/21 at 11:22 A.M., the DON said she expected staff to notify the physician if a resident had a significant weight loss. The IDT reviewed residents' weights weekly. The IDT had not discussed the resident's weight loss since April 2021 and no further recommendations had been made. Usually staff weighed residents with weight loss weekly, but this was not done for Resident #9 because he/she would not get out of bed to be weighed. Kitchen staff should give the resident ice cream with lunch and supper on his/her tray. The kitchen staff should also offer and provide a substitute any time meat was served the resident wouldn't eat. Complaint MO 6

Based on observation, interview, and record review, the facility failed to monitor the effectiveness of current fall interventions and modify the interventions as necessary to prevent further falls for one resident (Resident #32) in a review of thirteen sampled residents who fell five times from 10/24/17-11/2/17 and ultimately sustained a [MEDICAL CONDITION]. Facility staff also failed to remove medication from one resident's (Resident #32's) bedside after the medications were discontinued. The facility census was 32. 1. Review of the facility's undated Fall Protocol showed the following: All incidents including falls are reported using incident report forms. Incidents are reported to the Director of Nursing (DON), physician, and responsible party (if indicated). Incidents are discussed, and interventions are reviewed at stand-up morning meeting, weekly at interdisciplinary team (IDT) meeting, monthly at QAPI, and as needed; Interventions can include, but are not limited to: 1.Follow-up assessment and documentation for 72 hours; 2. Physical therapy (PT) and Occupational therapy (OT) are notified of all falls-they will screen when indicated; 3. Assessment for mental or physical status changes; 4. Follow-up review will be completed by nursing (QAPI/IDT meeting); 5. General preventative measures (monitoring of appropriate interventions); 6. Physician assessment or ER evaluation if indicated. 2. Review of the facility's Administering Medications policy revised December 2012 showed the following: Policy statement: Medication shall be administered in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. 3. Review of Resident #32's fall risk assessment dated [DATE] showed a score of 18 (total score of 10 or above represents HIGH RISK.) Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/9/17 showed the following: -Severely impaired cognition; -Independent with bed mobility and transfers; -Required supervision and set up help only to walk in room and corridor; -No impairment in functional limitation in range of motion; -Mobility device: walker; -Fall since admission or prior assessment; -One fall with injury (except major injury). Review of the resident's care plan dated 10/10/17 showed the following: -Resident doesn't always recall safety measures; -Needs reminding to use his/her walker and call light; -Allow him/her to make his/her decisions daily. Monitor for safety and those that are in my best interest; -If you see the resident without his/her walker remind him/her to use it; -Remind the resident if not feeling well or dizzy to call for help; -Educate him/her on getting up slowly and get his/her balance before he/she ambulates; -Maintain routines as much as possible; -Ongoing cueing on date and time; -Check and make sure he/she is wearing his/her non-skid socks at night; -Physical therapy to evaluate for safety measures; -Resident has very fragile bones and has history of frequent falls; -Doesn't always use his/her walker; -Has some unsteadiness and shuffles his/her feet; -Resident is to wear gripper socks; -Apply puffy paint to the bottom of socks and compression hose when needed. Review of the resident's fall risk assessment dated [DATE] showed a score of 16 (a total score of ten or above represents HIGH RISK.) Review of the resident's nurses' notes dated 10/24/17 at 9:22 P.M. showed the following: -Resident found by staff laying on the floor in room; -Resident was alert and denies hitting head; -Resident doesn't appear to have any injury at this time; -Resident said he/she was getting clothes out and lost balance; -Call light wasn't on and walker was across the room. Review of the resident's incident report dated 10/24/17 showed the following: Incident type: fall/no head injury; Type of injury: none apparent; Immediate actions taken: Resident assisted to bed; Additional follow-ups: 10/25/17 Resident educated on the use of walker to ambulate and utilize his/her call light if he/she requires. Review of the resident's care plan showed no documentation regarding the 10/24/17 fall. Review of the resident's nurses' notes dated 10/25/17 at 6:44 P.M. showed the following: -Resident was found by staff sitting on floor in front of the recliner in the room; -Resident said he/she slid out of the chair onto the floor; -Resident denies striking his/her head and denies any pain or discomfort at this time; -Resident has no apparent injury at this time; -Call light was in reach but was not used. Review of the resident's medical record showed no evidence an incident report was completed for the 10/25/17 fall. Review of the resident's care plan showed no documentation regarding the 10/25/17 fall. There was no documentation to support interventions to prevent falls were evaluated for effectiveness or new interventions put into place to address the resident's falls. Review of the resident's fall risk assessment dated [DATE] showed a score of 16 (a total score of ten or above represents HIGH RISK.) Review of the resident's nurses' notes dated 10/26/17 at 2:41 A.M. showed the following: -Heard resident hollering for help; -Found resident siting on the floor next to his/her bed; -No sign/symptoms of injuries; -Assisted off floor by two staff members using gait belt. -Resident said he/she was trying to make his/her bed and fell . Review of the resident's incident report dated 10/26/17 showed the following: Incident type: fall/no head injury; Type of injury: none apparent; Immediate actions taken: Resident assisted to his/her recliner; Additional follow-ups: Resident re-educated on utilizing his/her call light and his/her walker. Resident has been non-compliant in doing both. Review of the resident's care plan showed no documentation regarding the 10/26/17 fall. The resident's care plan showed no evidence staff evaluated current interventions or implemented new interventions to prevent further falls after the 10/26/17 fall. Review of the resident's nurses' notes dated 10/26/17 at 2:44 P.M. showed received order to obtain urinalysis (UA) from the physician's office. Review of the resident's nurses' notes dated 11/2/17 at 12:33 P.M. showed the following: -Resident remains on antibiotics for urinary tract infection; -Resident fell in room and was found sitting on the floor on his/her bottom in front of the sink; -Denies hitting his/her head; -No new injuries or bruising. Review of the resident's incident report dated 11/2/17 showed the following: Incident type: fall/no head injury; Type of injury: none apparent; Immediate actions taken: Assisted resident into chair and discussed the use of the call light with him/her for assistance; Additional follow-ups: Resident has confusion and forgets to utilize his/her call light due to his/her active UTI this is currently being treated with antibiotics. Resident re-educated on the importance of utilizing his/her call light to ask for assistance and that he/she needs to use his/her walker on transfers. Review of the resident's care plan showed no documentation regarding the 11/2/17 fall or any new interventions to address the resident's fall risk. Review of the resident's nurses' notes dated 11/2/17 at 7:03 P.M. showed the following: -Resident found by staff on floor on left side; -Resident complains of a great deal of left sided pain; -Resident is alert and responsive but not oriented; -Left on his/her side on floor until Emergency Medical Services (EMS) arrived; -Resident is not bleeding at this time; -Received physician order [REDACTED]. -Resident states he/she was ambulating without walker trying to hang up clothes; -Resident's call light was not on and resident requested no assist prior to fall. Review of the resident's nurses' notes dated 11/2/17 at 10:42 P.M. showed the resident was admitted to the hospital with [REDACTED]. During interview on 12/21/17 at 2:15 P.M. Registered Nurse (RN) A said the following: -The resident was a fall risk prior to his/her [MEDICAL CONDITION]; -Staff reminded the resident to use his/her call light, checked him/her often and made sure his/her walker was close by. During interview on 12/21/17 at 3:20 P.M. the MDS/ Care plan Coordinator said the following: Hiss/her job is to complete the MDS and care plans; -The Director of Nurses (DON) was responsible for re-evaluating current fall interventions and/or implementing new interventions after a resident falls; -The resident was a fall risk prior to his/her [MEDICAL CONDITION]; -The care plan should have been updated after each fall; -The CNAs are verbally told what to do to prevent falls; -The resident would not remember to call for help or use his/her walker; -He/She monitors to ensure staff are implementing care planned interventions by following behind them. During interview on 12/21/17 at 3:55 P.M. and 4:50 P.M. the DON said the following: -Staff discuss falls in weekly meetings; -Interventions are on the fall incident report or on the care plan; -No interventions were put into place to prevent further falls after the 10/25/17 fall because no incident report was given to him; -He would expect staff to complete a fall incident report after each fall; -He would expect fall interventions to be re-evaluated or new interventions to be implemented after each fall to prevent further falls; -He doesn't know why current fall interventions were not re-evaluated or new interventions were not implemented after the resident's falls on 10/24/17, 10/25/17 and 11/2/17; -He would expect the care plan to be updated after each fall. Observation on 12/18/17 at 10:35 A.M. in the resident's room showed the following: -The resident lay awake in bed; -Two bottles of Refresh [MEDICATION NAME] eye drops sat on the counter top by the sink; -A bottle of no-drip nasal spray sat on the resident's bedside table. Observation on 12/19/17 at 7:56 A.M. in the resident's room showed two bottles of Refresh [MEDICATION NAME] eye drops and one bottle of no-drip nasal spray on the resident's bedside table. Observation on 12/20/17 at 12:31 P.M. in the resident's room showed two bottles of Refresh [MEDICATION NAME] eye drops and one bottle of no-drip nasal spray on the resident's bedside table. Observation on 12/21/17 at 10:00 A.M. in the resident's room showed two bottles of Refresh [MEDICATION NAME] eye drops and one bottle of no-drip nasal spray on the resident's bedside table. Review of the resident's December 2017 physician's orders [REDACTED]. -No order for Refresh [MEDICATION NAME] eye drops; -No order for no-drip nasal spray; -No order to self-administer medications. During interview on 12/21/17 at 12:25 P.M. Licensed Practical Nurse (LPN) M said the following: -The resident does not have an order for [REDACTED].>-The resident is not able to self-administer medications; -It is not safe for medications to be at the resident's bedside because he/she is unable to administer them. During interview on 12/21/17 at 4:50 P.M. the DON said the following: -The resident is not capable of self-administering any medication; -He would not expect staff to leave eye drops or nasal spray at the resident's bedside.

Based on observation, interview, and record review, the facility failed to provide protective oversight and supervision to ensure one resident (Resident #1), with mental status changes did not leave the facility without staff knowledge, in a review of eight sampled residents. The facility failed to reassess the resident's risk for elopement and develop interventions after the resident left the faciity on [DATE]. The resident exited the facility again on 7/27/16 at approximately 9:00 P.M., without staff knowledge and was found by a community member two blocks from the facility with the wheel of his/her wheelchair caught on the curb. A community member notified the facility staff of the resident's whereabouts. In addition, the facility failed to follow the facility policy and residents' plan of care to ensure safe transfers for three residents (Residents #2, #11, and #12). Staff identified Resident #11 required assistance from two staff to transfer, however, only one staff transferred the resident without the use of a gait belt. The resident fell during the transfer and fractured his/her left toe, which resulted in amputation of the toe. The facility census was 44. 1. Review of the facility's policy on elopement, revised December 2007, showed the following: -Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or Director of Nursing (DON); -If an employee observes a resident leaving the premises, he/she should attempt to prevent the departure in a courteous manner, get help from other staff members if necessary, and notify the charge nurse or Director of Nursing that a resident has left the premises; -If an employee discovers a resident is missing from the facility unauthorized, he/she shall initiate a search of the building and premises. If the resident is not located, notify the Administrator, the DON, the resident's legal representative, attending physician, law enforcement, and volunteer agencies and initiate an extensive search of the surrounding area; -When the resident returns to the facility, the DON, or charge nurse shall examine the resident for injuries, contact the attending physician, complete and file an incident report, and document relevant findings in the resident's medical record. Review of the facility's policy titled Signing Resident's Out, revised August 2006, showed the following: -All resident's leaving the premises must be signed out; -A sign out register is located at each nurse's station. Registers must indicate the resident's expected time of return; -Staff observing a resident leaving the premises, and having doubts about the resident being signed out, should notify their supervisor at once; -Inquiries concerning the signing out of resident's should be referred to the DON or Administrator. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/23/16, showed the following: -[DIAGNOSES REDACTED]. -Cognition was intact; -Delirium was not present; -No acute mental status changes; -No psychosis, delusions, or hallucinations; -Required supervision and set up help only with activities of daily living; -Wandering did not occur; -Utilized a walker and a wheelchair for mobility; -Received oxygen therapy; -Received anti-anxiety and antidepressant medications daily; -No behaviors; -Balance was not steady but the resident could stabilize without human assistance. Review of the resident's care plan, reviewed on 6/24/16, showed the following: -Encourage the resident to use a reacher device, assist the resident to the bathroom, offer to walk with the resident using his/her walker daily, keep his/her room clutter free, and offer the resident assistance when he/she feels ill; -Administer oxygen therapy as ordered obtain and record oxygen saturation levels, assess respiratory status, encourage the resident to take breaks between activities, monitor for any mental status changes, educate the resident on the importance of wearing the oxygen; -Requires staff assistance with mobility; -Supervise all ambulation with a wheeled walker, use a wheelchair for long distance mobility, educate the resident on the importance of safety issues. Review of the resident's elopement risk assessment completed on 6/24/16, showed the resident was not identified as being at risk for elopement. Review of the resident's physician order [REDACTED]. Review of the resident's physician progress notes [REDACTED]. -Judgement and insight were appropriate; -Oriented to person, place, month, and year; -Short term recall was normal; -Increased anxiety and depression; -Cymbalta (medication used treat depression, anxiety, and help relieve nerve pain) 30 milligrams (mg) daily was added. Further review of the resident's nurses notes from 7/11/16 through 7/21/16 showed no documentation the resident was having increased confusion or hallucinations. Review of the resident's medical record showed the resident's oxygen saturation level dated July 2016, ranged from 91 percent to 98 percent with and without the use of oxygen. Review of the resident's nurse's note, dated 7/22/16 at 10:44 P.M., showed the resident displayed some confusion during the evening meal. Licensed Practical Nurse (LPN) L assessed the resident's oxygen saturation to be 93%. The resident would not leave his/her oxygen on and made attempts to walk unassisted. LPN L redirected the resident to his/her wheelchair and called the resident's family member who was out of town at the time. Staff assisted the resident to the phone to speak with the family member. The resident used cupped hands to put away an animal in a drawer to keep it safe before coming to the telephone. The door alarm sounded and a family member of another resident reported to LPN L a resident in a wheelchair had just exited through the door at the end of hall four. Staff located the resident on the sidewalk (outside the building), moving quickly, near the door located near the dining room. Staff returned the resident to the building. The resident's oxygen saturation was between 91% and 93%. The Director of Nursing (DON) was notified and requested the resident receive an anti-anxiety medication. Staff reported the resident had already received an anti-anxiety medication, so the DON requested LPN L contact the resident's physician. LPN L contacted the resident's physician and left a message about the incident. The resident continued to attempt to stand up without assistance and shouted at staff members. Record review of the resident's plan of care, dated 6/24/16, showed no new interventions were developed to address the resident's elopement risk after he/she left the faciity on [DATE]. During an interview on 7/29/16 at 4:22 P.M., LPN L said he/she was the charge nurse on the resident's unit on the evening of 7/22/16, when the resident left the building. LPN L said the resident had been very confused. The resident attempted several times to walk unassisted in the dining room during supper and would not leave his/her oxygen on. LPN L called the resident's family member, so the resident could speak with him/her on the phone at the nurse's station. The resident's family member was out of town and this agitated the resident, because the family member would not come to the facility to see him/her. The resident wheeled himself/herself down the hall to his/her room and back out into the hallway several times. LPN L heard the alarm sound and started to the front nurse's station to check the control panel to see which door had triggered the alarm. LPN L did not remember exactly what time this occurred, but thought it happened between 8:00 P.M. and 9:00 P.M. A family member of another resident stopped LPN L and told him/her they observed a resident in a wheelchair go out the exit door at the end of hall four. The resident had asked this family member if they thought the door would alarm if the he/she went through it. The family member said yes. The resident responded he/she didn't care and was going out the door anyway. Staff members found the resident outside by the dining room door in the back of the building in his/her wheelchair and brought the resident back inside. LPN L called the DON who instructed LPN L to give the resident an as needed medication for anxiety, but the resident had already received this medication prior to leaving the building. The DON instructed LPN L to keep a close eye on the resident. During an interview on 8/5/16 at 2:15 P.M., Certified Nurse Assistant (CNA) M said he/she worked the evening of 7/22/16 when the resident got out of the building. CNA M said this occurred between 8:00 P.M. and 8:30 P.M. CNA M heard the door alarm sound. Staff checked all the exit doors, found the resident by the dining room doors outside in the back of the building, and returned the resident back inside. Staff members were instructed to keep a close eye on the resident and to pay particular attention if they observed the resident out and about in the hallways. During an interview on 7/29/16 at 2:55 P.M., LPN O said he/she worked when the resident left the faciity on [DATE]. LPN O was not certain what time this occurred, but said it had started to get dark outside. LPN O was not working in the area of the facility where the resident lived, but did hear the door alarm sound. Staff located the resident outside by the back of the building on the sidewalk in his/her wheelchair. Staff members were instructed to monitor the resident more closely after this incident. The resident had been more confused recently. The resident had some recent medication changes. The resident's family member had also recently gone out of town and LPN O said some of the resident's behavior may be attention seeking. During a telephone interview on 8/8/16 at 3:00 P.M., CNA N said he/she worked the evening of 7/22/16, but did not remember the resident exiting the building on this date or hearing the door alarm sound. CNA N did not remember receiving any special instructions regarding monitoring of the resident on this date. Review of the resident's sign out sheet from the facility showed the resident had not signed out on 7/22/16. Review of the resident's nurses notes between 7/22/16 and 7/27/16 showed no documentation the resident was having increased confusion or hallucinations. Review of the resident's nurse's note, dated 7/27/16 at 11:09 P.M., showed the resident was upset about another resident being transported out of the facility by emergency medical services. At the 8:30 P.M. smoke break, the resident was upset about not getting two cigarettes. At approximately 9:00 P.M., LPN L observed the resident sitting by the counter in the dining room while LPN L entered another resident's room. When LPN L came back into the hall, he/she observed two staff members leaving the facility at a quick pace. LPN K had received a phone call from someone in the community that the resident was approximately three blocks from the facility and observed the resident in his/her wheelchair in the street. Staff members returned the resident to the facility. The resident appeared confused and thought someone had taken his/her pictures. Staff assisted the resident to his/her room. The resident's vital signs were within normal limits. The resident's oxygen saturation was 93%. The resident would not leave the oxygen on. Staff observed the resident walking in the hallway. The resident said he/she saw boys on the fence outside and could not get there quickly enough in his/her wheelchair. Staff assisted the resident back to his/her room. Staff notified the administrator of the event. During an interview on 8/5/16 at 11:22 A.M., a community member said he/she observed the resident in the road in a wheelchair on 7/27/16 at approximately 9:00 P.M. The community member passed by the same area again between approximately 9:15 P.M. and 9:20 P.M. and observed the resident in the same location. The resident's wheelchair wheel was caught on the curb. The community member stopped after observing the resident the second time and went to a neighbor's house and asked the neighbor to call the facility. The neighbor called the facility and reported the resident's location and provided the resident with a glass of water. The resident said he/she was headed for the police station and seemed confused. The community member was concerned for the resident, because it was hot outside and the resident seemed anxious about returning to the nursing home for fear he/she would be in trouble. The community members remained with the resident until staff arrived a few minutes later. The staff did not ask the community members or the resident any questions. The staff member told the resident to pick his/her feet up as he/she wheeled the resident back towards the facility. During an interview on 8/4/16 at 4:56 P.M., the community member who called the facility said on 7/27/16, three people came to his/her door and asked him/her to call the facility because a resident was in the road with his/her wheelchair stuck on the curb outside of the community member's home. The community member said he/she could not be positive of the time frame, but thought he/she called the facility between 9:20 P.M. and 9:30 P.M. The community member gave the resident a glass of water and the resident drank almost all of it. The resident seemed confused. Two facility staff members arrived a few minutes later. The staff members did not ask the resident or the community members any questions and returned the resident to the facility. During an interview on 7/29/16 at 4:55 P.M., LPN K said on 7/27/16 a little after 9:00 P.M., he/she received a phone call from a community member about a person in a wheelchair, observed in the middle of the street, who said he/she lived at the facility. LPN K immediately grabbed CNA M and they went to the location, which was about two blocks from the facility. The resident was pleasant when they arrived. The neighbor had gotten the resident over to the side of the road by the curb. The resident did not have oxygen on. CNA M wheeled the resident back to the facility. The resident was agitated once he/she was back in the building, but calmed down a little later. LPN K said staff members were to monitor the resident more closely after he/she eloped on 7/27/16. The resident was now on 30 minute checks. Review of LPN K's statement, obtained by the facility, showed on 7/27/16 at or around 9:00 P.M., showed LPN K received a phone call from a community member stating a resident from our facility was going down the middle of the street in front of his/her house. The caller had approached the resident and the resident said he/she was from the facility. The caller was able to keep the resident with him/her and called the facility. LPN K and a CNA went to the location and returned the resident to the facility. LPN K questioned the resident once back in the facility as to why he/she had left. The resident stated staff could not call him/her crazy. The resident was alert and oriented times two and appeared agitated. Staff redirected the resident back to his/her room, but the resident continued to roam the hallways in the facility. During an interview on 8/5/16 at 2:15 P.M., CNA M said he/she worked the evening of 7/27/16 when the resident eloped a second time. LPN K received a call around 9:15 P.M. from a neighbor stating the resident was found down the street. No staff members observed the resident leave the building and no door alarm sounded. CNA M and LPN K went to the location, about two blocks from the facility, and saw the resident in the street next to the curb on the corner. CNA M and LPN K returned the resident to the facility. CNA M asked the resident what he/she was doing but the resident didn't know and seemed confused. The resident was agitated, but was able to calm down after a short time. The resident was then placed on 30 minute checks. Staff members documented these checks on a sheet at the nurse's station. The documentation was everyone's responsibility to complete and was not assigned to any particular staff member. During an interview on 7/29/16 at 4:22 P.M., LPN L said he/she was the charge nurse on the resident's unit on the evening of 7/27/16, when the resident eloped a second time. The resident was upset over another resident being sent to the hospital earlier that day and about not getting two cigarettes at the 8:30 P.M. smoke break. LPN L said he/she knew the resident was upset. LPN L said he/she observed the resident by the counter in the dining room at approximately 9:05 P.M., as he/she was checking other residents' blood sugar levels. LPN L saw LPN K and CNA M leaving the building quickly. At approximately 9:15 P.M., LPN K received a phone call from a community member that they had observed a resident in a wheelchair in the middle of the road. LPN L said staff knew immediately it was Resident #1. The resident exited the building unobserved and no door alarm sounded and staff were unaware the resident had left the building prior to the phone call from the community member. LPN K and CNA M returned the resident to the facility. The resident was confused. LPN L contacted the Administrator who said to place the resident on 15 minute checks. LPN L said he/she felt the resident needed one-on-one supervision, but that was not feasible with the number of staff members available. LPN L said he/she felt the resident had observed staff for an opportunity to exit the facility unobserved. LPN L instructed staff remain in the dining room to watch the resident's hall to ensure the resident did not leave his/her room. The next day the resident was placed on 30 minute checks documented on a sheet at the nurse's station. During a telephone interview on 8/8/16 at 3:00 P.M., CNA N said he/she worked the evening of 7/27/16. CNA N provided care for another resident when CNA M told him/her a neighbor had found Resident #1 down the street. After staff members returned the resident to the facility, CNA N was instructed to document checking on the resident every 30 minutes. During an interview on 7/29/16 at 10:05 A.M., Resident #1 said a few nights before he/she had been cleaning his/her room and saw a man in his/her bed. A female staff member told the resident it was not his/her room and that the resident was confused. The resident said he/she kept trying to get into the room, but staff wouldn't let him/her. The resident said he/she became upset and thought I'll show you, I'm leaving. The resident said he/she went out the front door of the facility. The resident was trying to get to the police station. The resident said the next thing he/she remembered was two staff members came to pick him/her up and brought him/her back to the facility. The resident said staff told him/her this could not happen again. The resident didn't remember anything after that, but said he/she was able to get into his/her room and hadn't had any trouble since. During the interview, the resident asked the surveyor if it was raining inside his/her room, because the resident thought he/she could hear it raining. Review of the facility's Investigation Report, completed by the DON, dated 7/28/16, showed the following: -Location of the incident: Elopement from the facility, approximately two blocks away; -Cognitive status of the resident: On and off confusion, knows staff names; -Mobility status: Wheelchair; -Summarize cause: Appears the resident was confused and upset due to a fell ow resident being transferred out by emergency personnel. The resident was also upset because he/she wanted two cigarettes instead of one. Unaware of all contributing factors, reviewing medication regimen; -Was the cause preventable: Yes; -Action taken to prevent re-occurrence: The resident is currently on 30 minute checks. Reviewing medications. Spoke with the resident and family. Informed the resident, he/she could ask for nurse, the DON, or to call a family member when he/she was upset. Monitor confusion. Elopement assessment done and staff are aware to keep the resident on his/her unit as much as possible; -Was the action taken effective?: Yes; -Is further action necessary?: Yes. Continue 30 minute checks throughout the weekend and continue to monitor; -Reviewed and signed by the Administrator. Observation on 7/29/16 at 5:15 P.M., of the route from the facility driveway to the location where the resident was found showed the distance to be approximately two blocks from the facility in a residential neighborhood. There were no sidewalks. The road had a slight downward slope leading away from the facility to the location the resident was found. The route passed through a four way stop where two roads intersected. Review of the resident's sign out sheet from the facility showed the resident had not signed out on 7/22/16 or 7/27/16. Review of the facility's documentation on the 30 minute checks for the resident showed the documentation started on 7/28/16 at 6:30 A.M. Review of the resident's elopement risk assessment completed on 7/28/16, showed the following: -The resident was identified as being at risk for elopement; -The resident had impaired cognition and poor decision making skills; -The resident had a history of [REDACTED].>-The resident wandered to find a spouse or family member; -Summary: The resident had some recent medication changes. The resident had delusional thoughts and increased confusion. The physician was notified of the resident's mental status changes. Review of the resident's care plan, updated 7/28/16, showed the following: -The resident wandered especially at night. The resident had gone outdoors, unsupervised or alerting staff he/she was going outdoors. The resident had delusional thoughts and hallucinations; -Check exits and be sure door alarms are on; -Explain to the resident's family that the resident may not be able to remain in the facility if he/she continues to try to leave; -Keep the physician informed of the resident's mental status; -Obtain laboratory results from 7/25/16 and send to the neurologist; -Check with the physician about obtaining other labs; -Alert staff to the resident's wandering behavior; -Provide diversion activities when the resident is restless; -If the resident is wandering away from the unit, instruct staff to stay with the resident, converse and gently persuade the resident to go back to the unit with them; -Perform 30 minute checks: -Note which exits the resident favors for elopement from the facility and alert staff working near those areas; -If the resident elopes from the facility, implement the facility protocol for locating the resident; -Remind visitors of the need to inform staff if they are leaving the designated area with the resident; -Social Services to evaluate the resident; -Monitor and document the resident's behavior at least every shift and report negative findings to the physician; -Review resident's drug regimen. During an interview on 7/29/16 at 2:50 P.M., CNA J said he/she was aware the resident had gotten out of the facility twice. CNA J was not working during either of these times. CNA J said staff members were told to monitor the resident more frequently after the first elopement from the building. The resident had increased confusion and had delusions at times. The resident left the facility a second time on 7/27/16. Staff members now documented the 30 minute checks on a sheet kept at the nurse's station. CNA J made sure to know the resident's whereabouts in the facility at all times when he/she worked. During an interview on 7/29/16 at 3:05 P.M., the DON said the resident had been more confused over the past week. The DON said the resident's confusion could be caused from a combination of things. The resident often refused to wear oxygen, had some recent medication changes, and it could also be a behavioral issue. Staff monitored the resident's oxygen saturation which was consistently between 91% and 93%. The DON had spoken with the resident's family member who expressed the resident had hallucinations in the past prior to admission to the facility. The resident did not have a [DIAGNOSES REDACTED]. The DON said staff called him/her on 7/22/16, when the resident left the building the first time. The DON instructed staff members to keep a closer eye on the resident and to lay eyes on him/her every 30 minutes. The 30 minute checks were not documented and the resident's care plan was not updated after this incident. The resident eloped from the facility again on 7/27/16. The DON instructed staff to continue the 30 minute checks of the resident. The DON instructed staff to begin documentation of the 30 minute checks on 7/28/16 at 6:30 A.M. The resident's elopement risk assessment was updated as well as the resident's care plan after the incident on 7/27/16. The facility planned to install an alarm system on the front door as well as a wander guard system to alert staff if the resident came within a certain distance of the front door. The front door currently had no alarm in place. All other exit doors in the facility were alarmed. During an interview on 8/5/16 at 9:50 A.M., the Administrator said the facility did not have a date set for the installation of the alarm for the front door. The front door was the only exit door in the facility that wasn't alarmed. The facility determined the resident left through the front door on 7/27/16, because no alarm sounded. The Maintenance Supervisor checked the exit door alarms on a routine basis and the Administrator had not received any reports about issues with the alarms not functioning. LPN K and CNA G observed the resident go out the front door on 8/2/16 at 4:45 P.M The resident remained on the front porch of the facility. CNA G continued to observe the resident while LPN K informed the Administrator. The resident did not attempt to leave the front porch. LPN K and CNA G brought the resident back into the building without incident. The Administrator spoke with the resident and explained if the resident wanted to go outside staff had to go out with him/her. The Administrator would have expected to be informed about the resident leaving the facility on 7/22/16, but was not aware until after the resident eloped again on 7/27/16. The resident's elopement risk assessment and care plan should have been updated after the incident on 7/22/16. During an interview on 8/5/16 at 10:05 A.M., the care plan coordinator (CPC) said he/she was not made aware the resident had eloped on 7/22/16, until after the resident eloped again on 7/27/16. The CPC updated the resident's elopement risk assessment and care plan on 7/28/16. The CPC tried to review residents' nurse's notes once a week to identify concerns. The CPC did not anticipate any changes or issues occurring with the resident prior to 7/28/16. During an interview on 8/5/16 at 11:50 A.M., the resident's physician said the facility notified him/her about the resident's elopements on 7/22/16 and again on 7/27/16. The physician instructed staff to monitor the resident closely and report any changes to him/her after both incidents. The resident had experienced some confusion and hallucinations which staff had reported to him/her. The physician had consulted the resident's neurologist and discussed these issues as well as the resident's medications. 3. Review of the undated facility policy Transferring and Lifting, showed the following: -Any resident who was non-weight bearing, or who cannot support weight on one good leg, there would be two people doing the lift and transfer at all times; -No one was to attempt the transfer mentioned above with the aid of another nursing personnel. -Hoyer lifts were available for residents of large stature, but did not eliminate the need for a two person assist; -Gait belts were required to be used at all times when transferring and providing assistance with ambulation. 4. Review of the undated facility policy Safety Device, showed the following were the mandated safety devices for the facility: -Gait belts at all times; -Non-skid shoes at all times; -Hoyer lift when directed by physician or administration. 5. Review of Resident #11's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance of two staff for transfers, walk in room and corridor, and using the toilet; -History of falls in last month, last two to six months, and one fall since admission with no injury; -Height of 65 inches and 268 pounds; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 8/1/16, showed the following: -Required staff assistance for most activities of daily living (ADL)s; -History of multiple falls and was unable to transfer or ambulate without the assistance of two staff; -Knees give out without warning and at risk for injuries; -Two person assist with transfers and ambulation using the walker, and gait belt. Staff to keep the wheelchair close behind; -Assist with getting into and out of bed; -Assist with toileting as the resident requests with two staff; -Use the wheelchair to take to the bathroom at night; -Give verbal reminders not to ambulate or transfer without assistance; -Ensure that the resident has and wears properly-fitting non-skid socks for ambulation; -Be sure the resident has his/her walker, gait belt on and wheelchair close behind for all ambulation using two staff. Review of the resident's incident report, dated 8/3/16 at 11:45 P.M., showed the following: -Called to the resident's room; -The resident lay on the floor and stated his/her knees gave out while transferring; -Blood noted on the left foot and the skin was split open on the little toe and between it and the toe next to it; -Range of motion within normal limits and no other signs or symptoms of injuries; -LPN A cleaned the area and applied a bandage; -Staff transferred the resident using the hoyer (mechanical) lift into the wheelchair; -LPN A notified the physician and the family; -Sent the resident to the emergency room to evaluate for possible stitches; -The DON reviewed the report and comments were Resident admitted with fractured toe to the hospital. Review of the resident's Fall Investigation, dated 8/3/16 at 11:45 P.M., showed the following: -Transferred self with standby assist of staff; -Location of fall was in the resident's room; -Shoes or non-slip footwear was not on; -The resident was transferring so he/she could go to the bathroom; -LPN A documented this investigation report. Review of the departmental notes, dated 8/4/16, showed the following: -At 12:27 A.M., LPN A documented the nurse aide called him/her to the resident's room where the resident lay on the floor; -The resident said his/her knees gave out while transferring; -There was blood on the resident's left foot; -The skin was split under the left little toe and between the little toe and the toe next to it; -Staff transferred the resident off the floor by using the hoyer lift and into a wheelchair; -LPN A notified the physician to send to the emergency room for stitches; -LPN A notified the family. -At 2:32 A.M., the resident was admitted to the hospital with [REDACTED]. During interview on 8/11/16 at 4:00 P.M., the resident said the following: -It was at night (on 8/3/16) when one nurse aide came in to take him/her to the bathroom; -The nurse aide helped him/her stand up to his/her walker by the bed and then went to open the bathroom door; -The nurse aide assisted the