Every finding on record at Life Care Center of Brookfield

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of three sampled residents, was free from significant medication error. Staff administered Resident #1 another resident's (Resident #3's) 8:00 A.M. scheduled medications\and then following the error, administered Resident #1's scheduled 8:00 A.M. medications. Resident #1 experienced low blood pressure, lethargy, increased weakness, and required intravenous (IV) fluids. The facility census was 78. Review of the facility policy Administration of Medications, dated 9/16/24, showed the following: -The facility would ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms; -Significant medication error meant one which caused the resident discomfort or jeopardized his/her health and safety. Significance may be subjective or relative depending on the individual situation and duration; -Medication administration was the responsibility of those individuals who through certification and licensure were authorized to administer mediations in a facility; -Staff who are responsible for medication administration will adhere to the 10 rights of medication administration; -Right drug. Every drug administered must have an order from the provider. Compare the order with medication administration record (MAR) for accuracy. Compare the label on the drug to the information on the MAR three times, before removing the container from the drawer, as the drug is removed from the container and at the bedside before administering it to the resident. Do not prepare unmarked drug containers or illegible containers; -Right resident. Use two identifiers; -Right dose. Check the MAR and the physician's order before medications are administered; -Right to refuse. Give the resident enough autonomy to refuse the medication after thoroughly explaining the effects. Medication refusals should be documented on the MAR with the reason for the refusal and follow up from the licensed professional; -All verbal orders and telephone orders must be read back and verified to ensure accuracy; -Any order that is incomplete, illegible or unclear, should be clarified; -Be aware of high-alert and hazardous medications. Review of the facility policy Resident Medication Rights, dated 6/1/24, showed the following: -Document when a resident refuses a medication or treatment; -Discuss the health and safety consequences of refused medications or treatments with the resident and/or representative as appropriate; -Notify the physician of a resident's refusal of treatment. Physician notification should include resident refusal of medications for periods greater than 24 hours. Facility should notify physician immediately if refused medication could affect the health or safety of the resident; -Wasted single doses of medication for disposal should be disposed of in a manner that limited access to them by unauthorized personnel or residents. 1. Review of Resident #1's Physician Order Sheet (POS), dated 2/3/25, showed the following: -Diagnoses of anxiety, depression, sleep apnea, chronic obstructive pulmonary disease (COPD, a group of lung diseases that cause airflow obstruction and breathing difficulties), lymphedema (swelling of the lymph tissue causing fluid filled tissue in the lower extremities), interstitial pulmonary disease (lung disease causing difficulty breathing), chronic respiratory failure with hypoxia (severe difficulty breathing with low oxygen levels), congestive heart failure (inability of the heart to pump blood effectively resulting in swelling of the tissues, shortness of breath, weakness, fatigue and chest pain), chronic kidney disease stage 2 (decline of the kidney function), atrial fibrillation (irregular heart rhythm) high blood pressure, pulmonary hypertension (a type of high blood pressure that affected the arteries in the heart and lungs), cardiomegaly (enlarged heart); -Lexapro (antidepressant medication) 20 milligrams (mg) daily; -Jardiance (medication used to treat heart failure and other diseases) 10 mg daily; -Cyanocobalamin (vitamin B-12 supplement) 2500 micrograms (mcg) daily; -Furosemide (medication used to treat fluid retention caused by congestive heart failure and other illnesses) 80 mg daily; -Gabapentin (medication used to treat nerve pain) 300 mg twice daily; -Isosorbide (medication used to treat chest pain in coronary heart disease) Extended Release (ER) 30 mg daily; -Macrobid (antibiotic medication) 100 mg daily; -Metoprolol (medication used to treat high blood pressure) ER 50 mg daily; -Namenda (mediation used to treat dementia) 10 mg daily; -Spironolactone (medication used to treat fluid retention and high blood pressure) 25 mg daily. Review of the resident's Care Plan dated 2/4/25 showed the following: -At risk for adverse effects from medications. The resident will have o serious or life-threatening complications related to the use of medications. Administer medications as ordered, monitor for serious or life-threatening complications such as respiratory distress, facial [NAME], chest pain and report to the physician; -The resident had congestive heart failure. The resident will have no complications related to CHF. Check breath sounds, observe for labored breathing, offer small frequent feedings, give cardiac medications as ordered, inform physician or any insomnia or anxiety, observe and report any signs or symptoms of CHF, swelling of the legs and feet, swelling about the eyes, shortness of breath upon exertion, cook skin, dry cough, weakness, weight gain unrelated to intake, crackles and wheezes of lung sounds, increased heart rate, lethargy, difficulty breathing when lying down flat; -The resident had hypertension. Goal ro remain free of complications related to hypertension. Administer medications as ordered, notify the physician of swelling, observe for abnormal urine output; -At risk for ineffective communication due to cognitive deficit and hearing deficit. Make basic needs known on a daily basis. Anticipate and meet need, allow time to respond, repeat as necessary, observe for physical/nonverbal indicators of discomfort or distress and follow-up as needed; -At risk for fluid volume deficit related to diuretic use. The resident will be free of symptoms of dehydration. Administer medications as ordered, vital signs as ordered per protocol and record. Notify physician or significant abnormalities; -The resident had COPD. Observe and report any signs or symptoms of respiratory infection, difficulty breathing, anxiety, confusion, restlessness, shortness of breath at rest; -Supplemental oxygen. Review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 2/6/25 showed the following: -Moderately impaired cognition; -Short of breath with exertion (such as walking, bathing, transferring) and at rest and when lying flat; -Received antipsychotic, antidepressant and diuretic medications. Review of the resident's nurses' notes showed staff documented the following the following: -On 2/10/25 at 9:00 A.M. blood pressure 172/83 (normal 120/80) and at 8:19 P.M. blood pressure 131/58; -On 2/11/25 at 10:06 A.M. blood pressure 110/60; -On 2/12/25 at 10:29 A.M. blood pressure 175/91; -On 2/13/25 at 9:31 A.M. blood pressure 162/86 and at 8:17 P.M. blood pressure 133/69; -On 2/14/25 at 8:25 A.M. blood pressure 148/73. Review of the resident's MAR dated 2/14/25 showed Certified Medication Technician (CMT) A documented he/she administered the following medications at 8:00 A.M.: -Lexapro 20 mg; -Jardiance 10 mg; -Cyanocobalamin 2500 mcg; -Furosemide 80 mg; -Gabapentin 300 mg; -Isosorbide ER 30 mg; -Macrobid 100 mg; -Metoprolol ER 50 mg; -Namenda 10 mg daily; -Spironolactone 25 mg. Review of the resident's nurses note, dated 2/14/25 showed at 9:42 A.M., Licensed Practical Nurse (LPN) B documented the CMT reported he/she gave the resident the wrong medications, and resident also received his/her scheduled medications. The resident was alert and oriented, denied feeling dizzy or lightheaded. Physician notified and instructed staff to monitor the resident's blood pressure. Review of the resident's MAR, dated 2/14/25 at 11:00 A.M., showed staff documented the resident's blood pressure was 117/65. Review of the resident's nurses note dated 2/14/25, showed at 11:51 A.M. LPN B documented the resident came out of the shower and said he/she did not feel well, complained of feeling dizzy. Blood pressure 72/44. Physician notified. New order received for intravenous (IV) fluids. IV (needle and catheter inserted into the vein to administer medications or fluids directly into the vein and circulatory system) started, 500 ml administered with blood pressure of 92/62. Physician notified of changes, orders received to continue IV fluids for one more bag, blood pressure now 120/64. Review of the resident's POS, dated 2/14/25, showed the following: -Monitor blood pressure and pulse every two hours for 24 hours; -Sodium chloride (normal saline fluid) 0.9 percent intravenous solution, 1000 ml intravenously over one hour for low blood pressure followed by 1000 ml intravenously at 150 ml per hour. Review of the resident's MAR dated 2/14/25 at 1:00 P.M., showed staff documented the resident's blood pressure was 110/58. Review of the resident's nurses note dated 2/14/25, showed at 12:58 P.M., the Director of Nursing (DON) documented she was notified by LPN B the physician wanted to start IV fluids due to low blood pressure. IV started, normal saline 0.9 percent ran in at 999 ml/hour 1000 ml bag. Physician notified 1000 ml bag was finished and blood pressure was 120/64. New order received to start IV fluids at 150 ml/hour, 1000 ml bag until finished. Resident sat up in bed, communicating. Review of the resident's MAR, dated 2/14/25, showed staff documented the following: -At 3:00 P.M. blood pressure was 82/48; -At 5:00 P.M. blood pressure was 98/58; -At 7:00 P.M. blood pressure was 90/50; -At 9:00 P.M. blood pressure was 95/56; -At 11:00 P.M. blood pressure was 90/60. Review of the resident's MAR, dated 2/15/25, showed staff documented the following: -At 1:00 A.M. blood pressure was 92/62; -At 3:00 A.M. blood pressure was 96/64; -At 5:00 A.M. blood pressure was 100/70; -At 7:00 A.M. blood pressure was 98/52; -At 9:00 A.M. blood pressure was 98/56. Review of the resident's nurses note, dated 2/15/25, showed Registered Nurse (RN) E documented the following: -At 1:34 P.M. blood pressure 98/58; -At 4:06 P.M. nurse called to resident's room by CNA, who said the resident felt dizzy and family member wanted the nurse. The resident sat in the wheelchair and complained of shakiness, awake and oriented. Blood pressure 96/56. Staff assisted the resident to bed, transferred without difficulty. Nurse Practitioner (NP) updated, the family questioned more IV fluid administration. NP declined IV fluids, did not want to overload the resident with his/her CHF diagnosis. Review of the resident's nurses notes showed staff documented the following: -On 2/15/25 at 9:27 P.M. blood pressure 137/53; -On 2/16/25 at 9:31 A.M. blood pressure 92/52; -On 2/16/25 at 10:32 P.M. blood pressure 138/83; -On 2/17/25 at 8:42 A.M., the resident had trouble breathing, physician notified and orders received for x-ray and laboratory tests; -On 2/17/25 at 9:24 A.M., blood pressure 115/70, lung sounds coarse respirations even and unlabored, occasional cough noted, complained of shortness of breath, weakness noted; -On 2/17/25 at 10:14 A.M., resident continued to complain of shortness of breath, increased weakness, NP aware and ordered chest x-ray and laboratory tests; -On 2/17/25 at 12:15 P.M., resident complained of increased shortness of breath while eating, oxygen saturation level 86 - 90 percent (normal greater than 92 percent), resident agreed to hospital transfer. Transported to local hospital by ambulance. Review of the resident's Emergency Department Physician's Note, dated 2/17/25, showed the following: -Complaints of shortness of breath, low blood pressures on Friday (2/14/25) with 1500 ml of IV fluid ordered; -Acute hypoxic respiratory failure; -Pneumonia (lung infection); -Acute on chronic renal failure (acute kidney failure with underlying chronic kidney failure). IV fluids given in emergency department; -Transfer to nephrology (kidney specialist) unit at a regional hospital. 2. Review of Resident #3's POS dated 3/25/24 showed the following: -Diagnoses of dementia and obstructive uropathy (swelling of the urinary system causing difficulty with urination and urine retention), hypertension (high blood pressure), retention of urine, and prostate cancer; -Prozac (antidepressant medication) 10 mg daily; -Seroquel (antipsychotic medication) 50 mg two times daily; -Amlodipine (antihypertensive medication given for high blood pressure and chest pain) 5 mg daily; -Bethanechol (medication used to treat urinary retention or trouble urinating) 10 mg three times daily; -Lisinopril (antihypertensive medication) 10 mg daily; -Propranolol (beta-blocker medication used to treat high blood pressure, heart rhythm disorders, chest pain and other heart or circulatory conditions) 20 mg three times daily; -Tamsulosin (medication used to treat enlarged prostate) 0.4 mg daily. Review of the resident's MAR dated 2/14/25 showed the following: -Prozac (antidepressant medication) 10 mg at 8:00 A.M. not administered, the resident refused; -Seroquel (antipsychotic medication) 50 mg at 8:00 A.M. not administered, the resident refused; -Amlodipine (antihypertensive medication given for high blood pressure and chest pain) 5 mg at 8:00 A.M. not administered, the resident refused; -Bethanechol (medication used to treat urinary retention or trouble urinating) 10 mg at 8:00 A.M. not administered, the resident refused; -Lisinopril (antihypertensive medication) 10 mg at 8:00 A.M. not administered, the resident refused; -Propranolol (beta-blocker medication used to treat high blood pressure, heart rhythm disorders, chest pain and other heart or circulatory conditions) 20 mg at 8:00 A.M. not administered, the resident refused; -Tamsulosin (medication used to treat enlarged prostate) 0.4 mg at 8:00 A.M. not administered, the resident refused. 4. During an interview on 2/19/25 at 11:50 A.M. CMT A said the following: -On 2/14/25 he/she was running behind passing morning medications. Resident #3 refused to take his/her 8:00 A.M. medications from CMT A. LPN B said he/she would try to give Resident #3 his/her cup of medications. While LPN B tried to administer Resident #3's 8:00 A.M. medications, CMT A prepared Resident #1's 8:00 A.M. medications and sat the cup of medications on the medication cart. Resident #3 refused to take the medications from LPN B. LPN B handed Resident #3's cup of 8:00 A.M. medications back to CMT A. CMT A sat Resident #3's cup full of medications on the med cart, picked up the wrong cup and administered Resident #3's 8:00 A.M. medications to Resident #1; -CMT A immediately told LPN B he/she had given Resident #1 the wrong medication. LPN B said to go ahead and give Resident #1 his/her 8:00 A.M. medications. CMT A administered Resident #1's 8:00 A.M. medications. The resident took all of his/her regularly scheduled 8:00 A.M. medications after taking the cup of Resident #3's 8:00 A.M. medications; -He/She needed to stay more focused while preparing and administering resident medications to prevent medication errors. He/She should not prepare more than one resident's medications at a time. During interview on 2/19/25 at 10:50 A.M. and 2:30 P.M., LPN B said the following: -On 2/14/25 at about 8:30 A.M., CMT A informed LPN B of a medication error. CMT A gave Resident #3's 8:00 A.M. medications to Resident #1. The medications included bethanechol chloride 10 mg, Seroquel 50 mg, Prozac 10 mg, propranolol 20 mg, amlodipine 50 mg, lisinopril 10 mg and Flomax 0.4 mg; -LPN B called the physician and explained the medication error and the medications administered. LPN B read the list of Resident #1's routine 8:00 A.M. medications as well as the list of medications given to Resident #1 in error. The physician said to give Resident #1 his/her 8:00 A.M. medications. LPN B hollered down the hall and told CMT A to go ahead and administer Resident #1's 8:00 A.M. medications; -LPN B did not question the physician regarding administration of Resident #1's 8:00 A.M. medications including additional blood pressure and cardiac medications after the resident received other medications in error; -LPN B then informed the Director of Nurses (DON) of the medication error; -LPN A attempted to administer Resident #3's 8:00 A.M. medications after the resident refused to take the medications from CMT A. When Resident #3 refused his/her morning medications, LPN B should have destroyed the medications and not given the full medication cup back to CMT A. During an interview on 2/20/25 at 8:40 A.M. RN E said he/she was aware a medication error occurred with Resident #1 on 2/14/25. Resident #1's routine morning medications included cardiac and blood pressure medications. The charge nurse and CMT involved should have consulted the DON, stopped and figured out the situation and clarified clearly with the physician before proceeding. The resident required IV fluids in response to the drop in blood pressure. The medication error should not have occurred. The staff member passing medications should not prepare more than one resident's medications at a time. During an interview on 2/19/25 at 3:00 P.M. RN/Staff Development Coordinator D said on 2/17/25 the DON asked her to provide nursing staff education on the seven rights of medication administration for all staff who administered resident medications. She had not provided CMT A any in-service education regarding medication administration since 2/14/25. The in-service education also included CMT staff should inform the charge nurse if a resident refused medication. The charge nurse should intervene, talk to the resident and notify the physician of refused medications. She did not educate staff on destroying medications if the medications were refused and did not educate staff to avoid preparing more than one resident's medications at a time. Errors occurred when staff was not focused on one resident's medications at a time. She did not know the circumstances of the 2/14/25 medication error and did not know what medications were given in error. The charge nurse should communicate effectively with the physician and review the situation again if any concerns occurred. Any concerns should be addressed with the physician and DON before administration of multiple medications following a known medication error. During an interview on 2/19/25 at 12:30 P.M., the DON said the medication error led to the resident's change in condition. The resident required IV fluids for treatment of low blood pressure. The physician and NP were notified multiple times of the resident's change in condition on 2/14/25, 2/15/25 and 2/16/25. Family was present and declined transfer to the hospital until 2/17/25 when the resident's condition worsened. During an interview on 2/19/25 at 3:45 P.M., the NP said the medication error should not have occurred. The error led to a change in condition and need for the resident to receive IV fluids due to a drop in blood pressure. Communication with the physician and NP was very important to ensure complete understanding of the situation. During an interview on 2/19/25 at 1:00 P.M. the resident's physician said he was aware of the medication error involving Resident #1 on 2/14/25. He understood the nurse who called him to say staff had administered Resident #1's morning routine medications prior to the medication error. The nurse gave him the list of medications the resident received. If he had understood staff had not administered Resident #1's 8:00 A.M. medications, he would have told staff to hold the medications and not administer Resident #1's 8:00 A.M. medications on top of the medications given in error. This was a major medication error and caused the resident's blood pressure to drop and the resident's decline in condition. The resident required IV fluids in response to the low blood pressure. If a resident refused their medications staff should destroy the medications immediately and avoid preparing multiple residents' medications at the same time. During an interview on 2/19/25 at 1:30 P.M. the administrator said CMT A made a significant medication error. The resident's blood pressure dropped and required IV fluids for treatment. He expected staff to communicate clearly with the physician when explaining a resident's condition. Staff should ensure the physician understood the situation clearly and correctly. Staff should follow the medication pass policy and if a resident refused medications, destroy the refused medications immediately. Staff preparing more than one resident's medications at a time increased the risk of errors. MO 249731 MO 249733

Based on observation, interview, and record review, the facility failed to ensure ice machines were free of a buildup of black debris, were equipped with an appropriate air gap and had clean water filters, failed to ensure food items were not stored directly on the floor, failed to ensure food items were closed or sealed properly after use, and failed to ensure a ceiling vent was free of a buildup of debris. The facility census was 89. 1. Review of the facility policy, Ice Machines, revised 6/12/23 showed ice machines should be maintained in a clean and sanitary state following infection prevention and control guidelines. Review of the facility policy, Preventative Maintenance-Ice Machines, revised 1/11/23 showed all ice machines in the facility will be inspected by the in-house maintenance department on a monthly basis and the coils will be cleaned every quarter. 1. Observation on 12/2/24 at 9:39 A.M. of the ice machine inside the kitchen showed a plastic PVC drainpipe sat directly on the floor and made direct contact with the floor drain grate. No air gap was visible. A buildup of black-colored debris was visible inside the machine over the accumulated ice below. Observation on 12/3/24 at 9:04 A.M. of the ice machine located in the dining room, showed the interior portion of the ice machine had a buildup of black debris on the side walls over the ice below and also had white crusty buildup inside the unit near the door hinges. [NAME] and red crusty debris was also visible on the exterior of the ice machine on the side of the unit closest to the wall. The ice machine water filter was labeled with a date of 8/16/23. The ice machine drain was equipped with an appropriate air gap. 2. Review of the facility policy, Food Safety, revised 4/26/23, showed the following: -Food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth; -Food is stored a minimum of six inches off the floor; -Pre-packaged food is placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). 'Use by Date' is noted on the label or product when applicable; -Cold Food Storage: Food in a walk-in cooler/freezer is stored six inches off the floor; -Dry Storage: Opened packages of food are resealed tightly to prevent contamination of the food item and 'use by date' will be used when applicable. Observation on 12/2/24 at 9:49 A.M. in the walk-in freezer showed a cardboard box of fresh cut vegetables sat directly on the floor of the freezer and was not stored up off the floor. Observation on 12/2/24 at 9:50 A.M. showed individual containers of spices sat on a rolling cart with open lids on the containers that were unsealed on 18-oz ground black pepper, 21-oz garlic powder and 18-oz ground cinnamon. 3. Review of the facility policy, Food Safety, revised 4/26/23, showed the following: Dry Storage: All food is stored six inches off the floor and 18 inches from the ceiling and is stored in a clean, dry area which is free of contaminates and away from sewer/waste disposal pipes and vents. Observation on 12/2/24 at 9:33 A.M. and on 12/3/24 at 9:13 A.M. showed a ceiling vent inside the dry storage room in the kitchen had a buildup of fuzzy debris on the vent cover that blew in the breeze. 4. During an interview on 12/3/24 at 9:21 A.M., the Dietary Manager said the following: -He had been the dietary manager for approximately six to seven months; -All food items/ingredients in containers should be closed or sealed. Spice lids should be closed when not in use; -No food should be stored on the floor and should be stored six inches up off the floor; -The facility received food shipments via truck on Mondays and Fridays-those days were hectic days trying to get food put away; -Maintenance cleaned the coils on the ice machine. Maintenance/Dietary worked together and coordinated a day to to clean the ice machines. During this process, staff empty the ice, sanitize the inside of the unit, make new ice (dump the first couple batches) and then leave new ice inside. This process was done quarterly and was last conducted possibly in September 2024; -An outside vendor changed the water filter on the ice machine either every six months or once a year, depending on the filter. The Dietary Manager checked the interior of ice machines weekly and wiped them down when needed; -He was unaware that an air gap was required with an ice machine; -Maintenance was responsible for cleaning ceiling vents/fans monthly. During an interview on 12/3/24 at 9:58 A.M., the Maintenance Director said the following: -The ice machine was emptied and cleaned quarterly and he worked with dietary staff in completing this process. He also cleaned the ice machine coils and performed a weekly visual check to ensure the ice machines were running well and nothing out of the ordinary was going on; -The ice machine filter was changed by an outside vendor either yearly or every 6 months. The facility owned the ice machines; -He checked/cleaned ceiling vents monthly.

Based on observation, interview, and record review, the facility failed to provide care in a manner to prevent the development and transmission of diseases and infections for four residents (Residents #41, #55, #293, and #22), in a review of 20 sampled residents, and three additional residents (Resident #30, #80 and #294). Staff failed to utilize Enhanced Barrier Precautions (an infection control intervention that utilizes personal protective equipment to reduce the spread of multi drug-resistant organisms) during personal care for one resident (Resident #55), who had a tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) tube and a feeding tube (tube inserted into the stomach for nutrition); failed to utilize proper handwashing and gloving when providing incontinence care to one resident (Resident #22); failed to effectively clean a multi-use glucometer (used to check blood sugar levels) according to manufacturer's instructions between each resident for three residents (Resident #30, #41 and #80) during a medication pass; and failed to properly clean equipment used for dressing changes for two residents (Residents #294 and #293). The facility census was 89. Review of the facility's policy, Cleaning and Disinfection of the Glucometer, last reviewed 9/23/24, showed to prevent the spread of infection, specifically blood borne pathogens through the use of the point of care blood glucose monitoring, clean and disinfect glucometers after each resident use. Review of the manufacturer's instructions for the glucometer (used for Residents #41, #80, and #30), undated, showed the following: -The meter should be cleaned and disinfected after use on each patient; -The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure; -The disinfecting procedure is needed to prevent the transmission of blood borne pathogens; -Only wipes with EPA registration numbers listed below have been validated for use in cleaning and disinfecting the meter: Clorox Healthcare Bleach Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Super Sani-Cloth Germicidal Disposable Wipe and CaviWipes1; -Cleaning: wear appropriate protective gear such as disposable gloves, open the cap of the disinfectant container and pull out one towelette and close the cap, wipe the entire surface of the meter three times horizontally and three times vertically using one towelette to clean blood and other body fluids, carefully wipe around the test strip port by inverting the meter so that the test strip port is facing down. This prevents disinfectant liquid from entering the meter, NOTE: no actual drying of the meter is necessary before the disinfecting procedure. -Disinfecting: open the towelette container and pull out one towelette and close the lid, wipe the entire surface of the meter three times horizontally and three times vertically to remove blood-borne pathogens, carefully wipe around the test strip port by inverting the meter so that the test strip port is facing down. This prevents disinfectant liquid from entering the meter, properly dispose of the used towelette, treated surface must remain wet for recommended contact time, for all other contact times, refer to wipe manufacturer's instructions. DO NOT WRAP THE METER IN A WIPE, once contact time is complete, wipe meter dry. 1. Observation on 12/3/24 at 8:04 A.M. showed the following: -Licensed Practical Nurse (LPN) A obtained a glucometer from the medication cart and placed the glucometer on a tissue in Resident #41's room; -LPN A cleaned the resident's finger with alcohol, obtained a blood sample and checked the resident's blood sugar with the glucometer; -LPN A placed the glucometer on the medication cart, picked up an alcohol pad and cleaned the glucometer; -LPN A did not sanitize the glucometer with an approved disinfectant wipe. Observation on 12/4/24 at 6:43 A.M., showed the following: -LPN A obtained a glucometer from the medication cart and placed the glucometer on a tissue in Resident #80's room; -LPN A cleaned Resident #80's finger with alcohol, obtained a blood sample and checked the resident's blood sugar with the glucometer; -LPN A returned to the medication cart, cleaned the glucometer with an alcohol pad and placed the glucometer back into the medication cart drawer; -LPN A obtained the same glucometer from the medication cart and placed the glucometer on a tissue in Resident #30's room; -LPN A did not sanitize the glucometer prior to checking Resident #30's blood sugar; -LPN A cleaned Resident #30's finger with an alcohol pad, obtained a blood sample and checked the resident's blood sugar with the same glucometer; -LPN A returned to the medication cart, cleaned the glucometer with an alcohol pad, and placed the glucometer back into the medication cart drawer. During interview on 12/5/24 at 10:00 A.M., LPN A said he/she cleans the glucometer with alcohol wipes or the purple top germicidal wipes (Sani-Cloth wipes) after each use. He/She used the alcohol pads because there were on the medication cart at the time. During interview on 12/5/24 at 2:17 P.M., the Director of Nursing (DON) said the following: -Staff should clean the glucometer with Sani-Cloth wipes after each resident use; -Staff should follow facility policy and Sani-Cloth wipes, not alcohol pads to clean the glucometer. Review of the facility's policy, Enhanced Barrier Precautions, last reviewed 6/3/24, showed the following: -The facility should use EBP as an additional MDRO mitigation strategy for residents who meet the following criteria, during high-contact resident care activities; -EBP are indicated for residents with any of the following: -1. Infection or colonization with a Centers for Disease Control and Prevention (CDC) targeted MDRO when Contact Precautions do not otherwise apply; or -2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; -Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid(R)) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers; -Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP; -EBP refer to an infection control intervention designed to reduce transmission of multi drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities; -High contact care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, medical device care or use, and wound care; -Examples of high-contact resident activities requiring gown and glove use include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care (any skin opening requiring a dressing). 2. Review of Resident #55's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/1/24, showed the following -Dependent on staff for all activities of daily living (ADLs); -Received tracheostomy care; -The resident had a feeding tube for nutrition; -Stage II pressure ulcer (partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer) present on admission. Review of the resident's care plan, last revised 11/8/24, showed the following: -The resident received all his/her nutritional intake via feeding tube due to his/her traumatic brain injury (TBI); -He/She had a Stage II pressure injury to his/her right outer foot; -Provide feeding tube site care and monitor for irritation as ordered; -The resident has a tracheostomy and is at risk for respiratory distress and aspiration; -Enhanced Barrier Precautions (EBP) per protocol every shift for tracheostomy; -Provide tracheostomy care and suction tracheostomy tube as ordered. Review of the resident's Physician Order Sheet (POS), dated December 2024, showed the following: -Assess the tube exit site for new or increasing pain and signs of skin breakdown, redness, edema, leakage, induration, bleeding, and wear and tear every day shift; -Change drainage sponge every day shift; -Enhanced Barrier Precautions (EBP) per protocol every shift for tracheostomy and feeding tube site; -Diagnoses included diffuse traumatic brain injury, functional quadriplegia, Stage II pressure ulcer, tracheostomy, and gastrostomy (an opening into the stomach from the abdominal wall). Observation on 12/4/24 at 5:40 A.M., showed the following: -EBP hung on the outside of the resident's room door; -LPN B entered the resident's room, did not put on a gown or wash his/her hands, and put on gloves; -LPN B removed a wipe from a package of disposable wipes and cleaned around the resident's tracheostomy tube; -LPN B removed his/her gloves, did not perform hand hygiene, put on new gloves, picked up a split sponge dressing package, opened the dressing package and placed the split sponge around the tracheostomy site; -LPN B removed the soiled split sponge dressing from around the feeding tube; -Without changing gloves, LPN B picked up a new split sponge and placed it around the feeding tube site; -LPN B did not clean around the feeding tube site prior to putting on the new split sponge; -LPN B removed his/her gloves, did not perform hand hygiene, and left the room. During interview on 12/4/24 at 5:38 A.M. and 6:15 A.M., LPN B said the following: -He/She did not know what EBP was and thought the door was an easier place to keep the gloves since there was more respiratory infections and C-diff (a bacterium that can cause diarrhea, colitis and other intestinal conditions) going around the facility; -He/She only wore gloves when taking care of the resident; -Staff should sanitize or wash their hands before entering the resident's room, between providing tracheostomy care and feeding tube care, between glove changes and before leaving the room; -Day shift normally cleaned around the resident's feeding tube site but he/she just changed the dressing because it was soiled. During interviews on 12/3/24 at 12:05 P.M. and 12/4/24 at 9:35 A.M., the Infection Preventionist said the following: -All full time, part time and as needed (PRN) staff have been inserviced on EBP; -There was EBP signage on the doors and additional PPE on the outside of the door; -The signage on the door tells staff what PPE to wear. She would expect staff to wear PPE as required. During interview on 12/5/24 at 2:17 P.M., the Director of Nurses (DON) said the following: -Staff should wear a gown and gloves when EBP was in place; -All staff have been educated on EBP; -Staff should wear PPE (personal protective equipment) when taking care of Resident #55. During interview 12/5/24 at 2:32 P.M., the Administrator said the following: -Staff should wear PPE for EBP when going into a room where there would be close contact with the resident; -Staff should wear PPE for EBP when caring for Resident #55. Review of the facility's undated policy, Wound Care, showed the following: -Wound cleaning: Wound care supplies, sterile normal saline solution or commercially prepared wound cleaner. Maintain solution as clean; -Routine dressing change: Wound care supplies. Maintain supplies as clean. 3. Review of Resident #294's face sheet showed a diagnosis of fracture of left lower end of left tibia, open fracture (a fractures of a bone in the lower leg), with routine healing that occurred on 11/25/24. Review of the resident's Care Plan, revised 11/27/24, showed the resident had a surgical incision to his/her left ankle. Review of the resident's December 2024 POS showed an order to change dressing to left lower extremity every 72 hours, cleanse areas with wound cleanser and apply foam (non-adherent) dressing, wrap with kerlix (a wrap designed to cover a dressing to hold it in place), then ace wrap and as needed for soiling of dressing on day shift every three days. Observation on 12/03/24, at 11:16 A.M., showed the following: -Infection Preventionist (IP)/Wound Care Nurse positioned a bedside table from the hallway into the resident's room; -IP/Wound Care Nurse did not clean/sanitize the top of the bedside table or place a barrier on the table; -IP/Wound Care Nurse placed a bottle of wound cleanser, a stack of 4x4 gauze, a package containing a foam dressing, a package containing kerlix wrap, and tape directly on the bedside table; -IP/Wound Care Nurse removed the dressing from the resident's wound and used all of the 4x4 gauze from the table to clean the wound; -After IP/Wound Care Nurse completed the dressing change, she took the bedside table out of the resident's room and into Resident #293's room. 4. Review of Resident #293's face sheet showed a diagnosis of orthopedic aftercare following surgical amputation. Review of the resident's December 2024 POS showed an order to cleanse left below the knee amputation stump incision with wound cleanser, apply folded gauze along incision line, cover with a clear dressing, change daily on day shift. Observation on 12/03/24, at 11:35 A.M., showed the following: -IP/Wound Care Nurse positioned a bedside table from Resident #294's room and entered this resident's room; -IP/Wound Care Nurse did not clean/sanitize the top of the bedside table or place a barrier on the table; -IP/Wound Care Nurse placed a stack of 4x4 gauze and tape directly on the bedside table; -IP/Wound Care Nurse removed the old dressing, cleansed the surgical site with wound cleanser and 4x4 gauze from the bedside table, folded two 4x4 gauze and applied them directly to the surgical site; -Once the dressing was completed, IP/Wound Care Nurse took the table from the room. During an interview on 12/05/24, at 1:03 P.M., the IP/Wound Care Nurse said the following: -She should clean the wound care cart/bedside table before it was used and should place a clean barrier on the cart before it was used for wound care supplies; -If she took the bedside table into a resident's room, she should clean and disinfect the table between each resident; -Unpackaged wound care supplies should not directly touch a surface that is not clean, such as the bedside table, and should be placed on a barrier; -She should not have placed the wound care supplies for Resident #294 directly on the bedside table; -She should have cleaned the bedside table before entering Resident #293's room, since it came directly from Resident #294's room. She should have placed the dressing supplies on a barrier. During interview on 12/5/24 at 2:17 P.M., the DON said staff should use a barrier for wound care supplies and should not place the wound care supplies directly on an unclean table top. During interview 12/5/24 at 2:32 P.M., the Administrator said if staff take a treatment cart into a resident's room, they should clean the cart and place the dressing supplies on a barrier. Review of the facility's policy, Hand Hygiene, last reviewed 6/3/24, showed the following: -Associates perform hand hygiene (even if gloves are used) in the following situations: -Before and after contact with the resident; -After contact with blood, body fluids, or visibly contaminated surfaces; -After contact with objects and surfaces in the resident's environment; -After removing personal protective equipment (e.g., gloves, gown, eye protection, facemask); -Before performing a procedure such as an aseptic task (e.g., insertion of an invasive device such as a urinary catheter, manipulation of a central venous catheter and/or dressing care); 5. Review of Resident #22's quarterly MDS, dated [DATE], showed the following: -Required substantial/maximum staff assistance for personal hygiene; -Frequently incontinent of bladder. Review of the resident's care plan, revised on 09/20/24, showed the following: -Check the resident routinely and assist with toileting as needed; -Peri-care as needed. Observation on 12/04/24, at 5:10 A.M., showed the following: -Certified Nursing Assistant (CNA) C and CNA D entered the resident's room and put on gloves without performing hand hygiene; -CNA C unfastened the resident's urine soiled incontinence brief and performed peri-care to the resident's front peri area; -CNA C removed his/her gloves, did not perform hand hygiene, put on a new pair of gloves and put a new incontinence brief under the resident; -CNA D put skin protectant on the resident's buttocks, bilateral groin and along the resident's perineal area; -CNA D completed incontinence care, did not remove his/her gloves, and applied the new incontinence brief on the resident. During an interview on 12/04/24, at 5:56 A.M., CNA C said the following: -He/She should change his/her gloves after providing peri-care and when they get dirty in any way; -He/She should wash his/her hands after he/she performed peri-care, when he/she removed his/her gloves; -He/She did not wash his/her hands or perform hand hygiene prior to putting on gloves and between gloves changes when providing care for the resident and should have. During an interview on 12/04/24, at 6:05 A.M., CNA D said the following: -He/She should change his/her gloves anytime they were dirty and when going from a clean process to a dirty process; -He/She should wash his/her hands anytime they were dirty and between glove changes; -He/She did not perform hand hygiene or wash his/her hands prior to putting on gloves and between glove changes when he/she provided care for the resident and should have; -He/She should have changed gloves after he/she applied skin protectant to the resident's bottom and prior to applying the skin protectant to the resident's groin and frontal perineal area to avoid cross-contamination that could cause issues like an infection. During interview on 12/5/24 at 2:17 P.M., the DON said staff should wash their hands before providing care, when their gloves are dirty and before leaving a room. During interview 12/5/24 at 2:32 P.M., the Administrator said he expected staff to wash their hands before and after providing care and anytime staff went from a dirty to clean task during care. 36219 42592

Based on interview and record review of a sample of seven residents, the facility failed to ensure one resident (Resident #6 ), received care according to professional standards when staff failed to obtain and administer medications per physician's orders upon admission for Resident #6, with a tracheostomy (surgical opening into the trachea or windpipe from outside the neck which allows breathing through a tube inserted into the opening), including breathing treatments, injectable medication to prevent blood clots, and medications to stimulate the resident to stay awake. The facility also failed to ensure the resident received the prescribed dosage of heart failure medication and cholesterol medication. The resident developed severe respiratory issues and required emergent treatment in the hospital. Staff also failed to adequately assess one resident (Resident #4's) skin condition following a fractured humerus (upper arm bone), and application of a partial cast when the resident developed an open, draining wound in the axilla (armpit). The facility census was 90. Review of the facility policy Physician Orders, dated 3/10/23, showed the following: -A physician must provide orders for the resident's immediate care and ongoing care of the resident. The facility was obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines; -The receiving nurse immediately entered telephone or verbal orders into the clinical software; -Physician orders included medications and treatments, and special medical procedures required for the safety and well-being of the resident. Review of the facility Admission Policy, dated 8/9/23, showed the following: -The facility must establish and implement an admissions policy; -The health referral form submitted by the attending physician would contain medical findings, diagnoses, treatment to follow, prescribed diet, medication and treatment orders, functional state, and signed orders for immediate care. These should be available at the time of admission. Review of the facility policy titled Skin Integrity and Pressure Ulcer/Injury Prevention and Management, revised 8/25/21, showed the following: -The policy provides licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards; -A comprehensive skin assessment on admission and readmission may identify pre-existing signs of possible tissue damage already present; -Skin observations also occur throughout the point of care provided by staff during bathing, dressing, incontinent care, etc. Any changes are reported to the nurse; -A skin assessment should be preformed weekly by a licensed nurse; -A resident's risk may increase due to an acute illness or condition change and may require additional evaluation. 1. Review of Resident #6's care plan, dated 11/24/23, showed the following: -admitted [DATE]; -Diagnoses of chronic obstructive pulmonary disease (COPD, a lung disease that blocks airflow and caused breathing difficult), tracheostomy, gastrostomy (surgical opening into the stomach which allowed feeding and medication administration through a tube inserted through the opening into the stomach), pneumonia (infection of the lung), encephalopathy (declining ability to reason and concentrate, causes may include infection or stroke), dysphagia (difficulty swallowing), cognitive communication deficit, hemiplegia (paralysis of one side of the body usually caused by a stroke), stroke, aphasia (loss of ability to understand or express speech, caused by brain damage), and muscle weakness; -The resident required staff assistance to maintain or attain his/her highest level of function. He/She had impaired cognitive ability and impaired thought processes. Staff should assist with Activities of Daily Living (ADLs). Review of the resident's hospital discharge orders, dated and signed by the physician on 11/24/23, showed the following: -Caffeine (medication used as an alertness aid to keep awake) 200 mg (milligram) daily; -Doxazosin (medication used to treat urinary problems caused by an enlarged prostate) 4 mg daily; -Coreg (medication used to treat heart failure and high blood pressure) 12.5 mg, administer 6.25 mg (half tablet) twice daily; -Hydrochlorothiazide (medication used to treat fluid retention and high blood pressure) 25 mg daily; -Modafinil (stimulant medication used to treat excessive sleepiness) 200 mg daily; -Baclofen (medication used to treat pain and muscle spasms) 10 mg three times daily; -Lovenox (injectable medication used to prevent blood clots) 40 mg/0.4 milliliters (ml) injection subcutaneous (SQ, administered just beneath the skin) daily at bedtime; -Brovana (medication inhaled used to relax muscles to the airways and improve breathing) inhalation 15 micrograms (mcg) 2 ml twice daily; -Albuterol (medication inhaled to relax muscles in the airways and increase air flow to the lungs) 2.5 mg/3 ml every 1 hour as needed (PRN); -Albuterol 2.5 mg/3 ml four times daily; -Albuterol-ipratropium (medication inhaled to prevent bronchospasm and improve breathing) 2.5 mg-0.5 mg/3 ml inhalation every 2 hours PRN; -Pulmicort (medication inhaled to reduce swelling and inflammation in the lungs and improve breathing) 0.5 mg/2 ml inhalation twice daily; -Rosuvastatin (medication used to lower cholesterol) administer 20 mg daily at bedtime. Review of the resident's nurses' notes, dated 11/24/23 at 3:59 P.M., showed staff documented the resident was admitted to the facility via ambulance with diagnoses of COPD and stroke, non-verbal, unable to make wants and needs known, total assist of two staff members with ADLs. Review of the resident's Physician Order Sheet (POS), dated 11/24/23, showed the following: -Nothing by mouth due to external feed (feeding by gastrostomy tube) and tracheostomy; -Oxygen at 10 liters continuously per tracheostomy mask (breathing mask fitted over the tracheostomy tube); -Keep oxygen saturation rates (level of oxygenation in the blood) above 92 percent (normal reading is above 92 percent); -Suction resident every two hours and as needed; -Caffeine 200 mg daily through gastrostomy tube for encephalopathy; -Doxazosin 4 mg daily through gastrostomy tube for enlarged prostate; -Coreg 12.5 mg give 1 tablet two times daily (hospital discharge order was 6.25 mg twice daily) through gastrostomy tube for hypertension; -Hydrochlorothiazide 25 mg daily through gastrostomy tube for hypertension; -Modafinil 200 mg daily through gastrostomy tube for encephalopathy; -Baclofen 10 mg three times daily through gastrostomy tube for pain; -Lovenox 40 mg/0.4 ml injection subcutaneous daily at bedtime to prevent blood clots; -Brovana inhalation 15 mcg/2 ml twice daily breathing treatment through tracheostomy for COPD; -Albuterol 2.5 mg/3 ml every 1 hour through tracheostomy as needed for shortness of breath; -Albuterol 2.5 mg/ 3 ml four times daily through tracheostomy for COPD; -Albuterol-ipratropium 2.5 mg-0.5 mg/3 ml inhalation through tracheostomy every 2 hours as needed for COPD; -Pulmicort 0.5 mg/2 ml inhalation through tracheostomy every 12 hours for COPD; -Rosuvastatin 10 mg daily through gastrostomy tube (hospital discharge order was 20 mg daily at bedtime) at bedtime. Review of the resident's admission collection tool, dated 11/24/23, showed staff documented the following: -Impaired cognitive, speech, sensation and range of motion status; -Alert, unable to make self-understood, understood others; -Swelling of the right leg and left arm; -Irregular respiratory rate, short of breath, labored, noisy breathing and had shortness of breath or trouble breathing when sitting at rest and when lying flat; -Coarse breath sounds throughout lung fields; -Tracheostomy present; -Required total staff assistance with all ADLs; -Nebulizer (breathing treatments) therapy, supplemental oxygen at 10 liters/minute by mask and tracheostomy care required. Review of the resident's Medication Administration Record (MAR), dated 11/24/23 at 8:00 P.M.,. showed staff documented the following: -Lovenox 40 mg/0.4 ml not administered, medication not available from pharmacy; -Brovana 15 mcg/2 ml not administered, not available from pharmacy; -Coreg 12.5 mg administered (hospital discharge order was 6.25 mg); -Rosuvastatin 10 mg daily at bedtime administered (hospital discharge order was 20 mg daily at bedtime). Review of the resident's MAR, dated 11/25/23 at 8:00 A.M., showed staff documented the following: -Modafinil 200 mg not administered, medication not available from pharmacy; -Albuterol inhalation 2.5 mg/3 ml not administered, medication not available from pharmacy; -Baclofen 10 mg not administered, medication not available from pharmacy; -Caffeine 200 mg not administered, medication not available from pharmacy; -Coreg 12.5 mg administered (hospital discharge order was 6.25 mg); -Doxazosin 4 mg not administered, medication not available from pharmacy; -Hydrochlorothiazide 25 mg not administered, medication not available from pharmacy; -Brovana 15 mcg/2 ml not administered, medication not available from pharmacy, physician aware (no additional documentation regarding physician instructions); -Pulmicort 0.5 mg/2 ml not administered, medication not available from pharmacy. Review of the resident's MAR, dated 11/25/23 at 12:00 P.M., showed staff documented Albuterol inhalation 2.5 mg/3 ml not administered, medication not available from pharmacy. Review of the resident's nurses notes, dated 11/25/23 at 12:40 P.M., showed staff documented the resident was alert, non-verbal, responded to stimuli, unable to make wants and needs known. Medications given via gastrostomy tube. Tracheostomy in place, suctioned every two hours with thick mucus noted, breathing treatment had not arrived from pharmacy at this time. Resident able to cough mucus up. Required total care by staff. There was no documentation found in the resident's record staff notified the physician about the resident's medications not being administered as ordered. Review of the resident's MAR, dated 11/25/23 at 2:00 P.M., showed staff documented Baclofen 10 mg not administered, medication not available from pharmacy. Review of the resident's MAR, dated 11/25/23 at 4:00 P.M., showed staff documented Albuterol inhalation 2.5 mg/3 ml not administered, medication not available from pharmacy. Review of the resident's MAR, dated 11/25/23 at 8:00 P.M., showed staff documented the following: -Lovenox 40 mg/0.4 ml not administered, medication not available from pharmacy; -Coreg 12.5 mg administered (hospital discharge order was 6.25 mg); -Brovana 15 mcg/2 ml not administered, medication not available from pharmacy; Review of the resident's nurses' notes, dated 11/26/23 at 4:30 A.M., showed staff documented humidified oxygen attached to tracheostomy, suctioned every two hours for thick and copious (abundant in supply or quantity) secretions. Received breathing treatment per tracheostomy. Gastrostomy tube used for feeding and medications, flushed easily. There was no documentation found in the resident's record staff notified the physician about the resident's medications not being administered as ordered. Review of the resident's MAR, dated 11/26/23 at 8:00 A.M.,. showed staff documented the following: -Modafinil 200 mg one time daily not administered, medication not available from pharmacy; -Caffeine 200 mg not administered, medication not available from pharmacy; -Coreg 12.5 mg administered (hospital discharge order was 6.25 mg); Review of the resident's nurses' notes, dated 11/26/23 at 10:20 A.M., showed staff documented resident alert, non-verbal, responds to stimuli, continues with medications as ordered via gastrostomy tube. Tracheostomy in place, suctioned every two hours with thick mucus noted, breathing treatment administered. Review of the resident's MAR, dated 11/26/23 at 8:00 P.M., showed staff documented Coreg 12.5 mg administered (hospital discharge order was 6.25 mg). Review of the resident's care plan, updated 11/27/23, showed the resident had potential for dehydration and fluid deficit, required tube feeding due to swallowing problem, received sedatives and pain medication and had a tracheostomy due to history of respiratory failure. Staff should administer medications as ordered, assess and report any change in hydration status, provide tube feedings as ordered, observe for adverse reactions to pain medication and report to physician, observe for changes in level of consciousness, mental status and lethargy, suction as necessary and observe respiratory rate, depth and quality. Review of the resident's MAR, dated 11/27/23 at 8:00 A.M., showed staff documented the following: -Modafinil 200 mg one time daily not administered, medication not available from pharmacy; -Caffeine 200 mg not administered, medication not available from pharmacy; -Coreg 12.5 mg administered (hospital discharge order was 6.25 mg). Review of the resident's nurses notes, dated 11/27/23 at 5:44 P.M., showed staff documented the resident responded at times by nodding his/her head. Tracheostomy suctioned with minimal amounts of mucus coughed or suctioned. Review of the resident's MAR, dated 11/27/23 at 8:00 P.M., showed staff documented Coreg 12.5 mg administered (hospital discharge order was 6.25 mg). Review of the resident's MAR, dated 11/28/23 at 2:56 A.M., showed staff documented Albuterol 2.5 mg/3 ml breathing treatment administered for shortness of breath. Unknown if the treatment was effective. Review of the resident's nurses notes, dated 11/28/23, showed staff documented the following: -At 3:56 A.M. temperature 99.8 degrees (normal is 98.6 degrees) with no fever earlier in the shift. Respirations increased to 30 breaths per minute (normal 10 to 16 per minute) and oxygen saturation levels between 86 percent and 90 percent (normal above 92 percent). Lung sounds coarse (congested). Resident pointed to his/her head when staff assessed the resident. Tylenol (medication used for pain and fever reducing) and a breathing treatment given. Notified the on-call physician. Orders received to send resident to the emergency room by ambulance; -At 6:40 A.M. staff added the resident was suctioned every two hours with a tint of green sputum noted, lung sounds coarse before and after breathing treatment. Review of the emergency room records dated 11/28/23 showed the resident's admitting diagnoses were pneumonia and respiratory failure. During an interview on 11/30/23 at 2:20 P.M. LPN D said the following: -Resident #6's medication orders were faxed to the pharmacy on 11/24/23. Staff should call the on call pharmacist if orders were faxed later in the day to ensure the orders were received and filled the same day. Staff should ensure residents received medications as ordered and did not miss medications due to pharmacy delay. A local pharmacy was also available for delivery of medications if needed. Lovenox 40 mg was available in the emergency kit. The emergency kit did not contain the resident's breathing treatment medications; During interview on 11/30/23 at 12:05 P.M. Licensed Practical Nurse (LPN) A said he/she was the resident's charge nurse on 11/25/23. The resident was lethargic that morning with thick mucus. LPN A suctioned the resident frequently. The resident's medications had not arrived from the pharmacy and there were no breathing treatments for administration. The pharmacy delivered the resident's medications that afternoon. After starting the breathing treatments the resident's secretions thinned and the resident improved in the afternoon. He/She notified the physician that the resident's medications had not arrived from the pharmacy and reported the resident's condition. The on-call physician said to call back if the resident's condition changed. During interview on 11/30/23 at 3:45 P.M. LPN E said on 11/24/23, the day of Resident #6's admission, he/she was the charge nurse. The resident had arrived prior to 5:30 P.M. when LPN E arrived to work. The resident was coherent, non-verbal with a functioning tracheostomy. He/She suctioned the resident every two hours or more often. The resident was on humidified supplemental oxygen and was congested with a lot of sputum, light green/yellow in color. The resident's oxygen saturation rates were 97 percent on 8 to 10 liters of oxygen. The physician discharge orders were put into the electronic system and he/she pulled medications and gave whatever he/she could find in the emergency kit. LPN E did not fax the resident's medication orders to the pharmacy. He/She borrowed an Albuterol from another resident and administered it to Resident #6. The resident was very congested. He/She did not give Brovana breathing treatment or the Lovenox injection, as those medications were not in the emergency kit and pharmacy did not deliver the resident's medications that night. LPN E was not aware how to obtain stat (at once or right away) medications. During an interview on 11/30/23 at 2:35 P.M. the Nurse Practitioner said she followed Resident #6's care and was not aware the resident had not received all of his/her medications, including breathing treatments and Lovenox injections as ordered. She expected staff to obtain and administer resident's medications as ordered starting the day of admission. Missed breathing treatments and medications could have negatively affected the resident's respiratory status. The resident's history was significant and included respiratory failure. The facility should have a system to obtain medications without delay. Delaying medication administration for 24 hours or longer could have a negative impact on a resident's condition. Staff should notify the physician or nurse practitioner if medications were not administered and obtain further instructions for care. During an interview on 11/30/23 at 2:00 P.M. and 12/4/23 at 4:00 P.M. the Administrator said the following: -He/She was not aware staff had not administered Resident #6's medications and had not received all the resident's medications from the pharmacy the day of admission. On admission, staff should fax the medication orders to the contract pharmacy and call the on call pharmacist if after hours to ensure the medications were filled and delivered the day of admission. Staff should pull medications from the emergency kit if available. The breathing treatment would have improved the resident's respiratory status. 2. Review of the resident's annual Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff ), dated 7/17/23 showed the following: -Moderately impaired cognition; -Required substantial staff assistance with mobility (staff provided more than half the effort); -Required substantial staff assistance with dressing upper and lower body. Review of Resident #4's care plan, updated 6/19/23, showed the following: -Diagnoses of stroke with hemiplegia (paralysis of one side of the body) of the right side, unsteadiness on feet, contracture (limited mobility of the joints) of the right shoulder, elbow and hand; -The resident was at risk for skin breakdown due to limited mobility. Staff should monitor skin and report any abnormal findings and perform weekly skin assessments. Review of the resident's skin assessment, dated 10/16/23, showed staff documented the resident's skin was intact. Review of the resident's nurses' notes showed staff documented the following: -On 10/17/23 at 11:24 P.M. the resident fell to the ground and staff heard the resident's right arm snap. The right arm appeared broken, was cold with no radial (wrist) pulse. Emergency services called and the resident was transported to the hospital; -On 10/18/23 at 8:22 A.M. the resident returned to the facility from the hospital following a fall with right humerus fracture (broken right upper arm bone). The resident's right arm was in a cast, wrapped with ace wrap and a sling was in place. Review of the resident's physician order sheet (POS), dated 10/18/23, showed keep the splint/cast to the resident's right arm dry and right arm in a sling related to right humerus fracture. Review of the resident's Braden score (assessment for predicting pressure sore risk), dated 10/18/23, showed staff documented the following: -Skin occasionally moist; -Chairfast; -Very limited mobility; -Score of 17, indicating mild risk for pressure ulcer development. Review of the resident's care plan, updated 10/18/23, showed the resident had a fractured right arm. Staff should keep the cast clean and dry and ensure resident wore the right arm sling as ordered. There were no instructions for staff regarding assessing the resident's skin with a cast. Review of the resident's POS, dated 10/27/23, showed an order to not remove the right humerus brace. Check for skin integrity at right shoulder and right elbow every shift. Review of the resident's Treatment Administration Record (TAR) from 10/27/23 through 10/31/23 showed staff documented the right humerus brace was not removed, and the right shoulder and right elbow were checked for skin integrity every shift. Review of the resident's nurses' note, dated 11/6/23 at 10:36 A.M., showed staff documented they called the physician regarding the resident's complaint of pain in the right arm. Tramadol (pain medication) continued and the resident continued to wear the splint to the right arm. Review of the resident's TAR from 11/1/23 through 11/10/23 showed staff documented the right humerus brace was not removed, and the right shoulder and right elbow were checked for skin integrity every shift. Review of the resident's skin assessment, dated 11/8/23, showed staff documented the resident's skin was intact. There was no documentation regarding the condition of the resident's skin on his/her right arm. Review of the resident's record showed no documentation staff completed a weekly skin assessment between 10/16/23 and 11/8/23. Review of the resident's nurses' note, dated 11/10/23 at 8:19 P.M., showed staff documented the resident was noted with drainage on shirt when staff assisted with clothing change. The drainage was light yellow with odor noted to armpit area, slough (dead cells accumulated in the wound bed with drainage) noted to wound in armpit around the top of the splint. Open area 5 centimeters (cm) in length and 0.25 cm deep. The area was hard to measure due to fracture and resident unable to fully extend his/her arm. Staff removed the splint to assess the area. The physician was notified and orders received to send the resident to the emergency room for evaluation and treatment. Review of the resident's hospital emergency room medical records dated 11/10/23 showed the following: -Stage 2 (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured blister) pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) of the right axilla; -Measured 5 centimeters (cm) long by 3 cm wide and 1 cm deep. Review of the resident's POS showed the following new orders from the physician: -On 11/10/23, cleanse right axilla with wound cleanser, apply xeroform (wound treatment dressing to promote healing), cover with absorbent dressing and wrap, monitor area for change every shift. Do not put brace on due to open area, only wear sling, monitor right arm for skin integrity change. Monitor blister to back of right arm every shift; -On 11/11/23, wound check once daily, irrigate (the process of flushing a wound with a gentle stream of a specific liquid to remove dead tissues) right axilla wound with saline (cleansing solution) and cover with xeroform, apply absorbent dressing and wrap. Bactrim (antibiotic medication) 800-160 mg twice daily for right axilla wound for 7 days. During an interview on 11/30/23 at 1:05 P.M. Certified Nurse Aide (CNA) B said the resident had a cast on his/her right arm. The cast was solid to the back of the arm from the resident's wrist and into the armpit and was wrapped in place with an ace wrap. During an interview on 11/30/23 at 1:15 P.M. and 12/4/23 at 11:30 A.M. LPN C said the following: -The resident had a fractured right arm and was in a partial cast wrapped with an ace wrap. The hard cast extended under the arm tight into the axilla and rubbed the resident's arm causing an open area about two to three inches in length. Staff sent the resident to the emergency room after the wound was discovered. This wound occurred from the cast rubbing on the skin; -Staff should complete weekly skin assessments. There were no weekly skin assessments documented for the resident from 10/16/23 until 11/8/23. During an interview on 11/30/23 at 2:45 P.M. the Director of Nursing said the following: -Resident #4's cast was in the armpit. Staff said they assessed the resident's arm and skin condition. The wound, when found, was 5 cm in length and caused by the cast rubbing in the armpit. Staff should conduct thorough assessments and ensure the resident's skin was intact around the cast; During an interview on 11/30/23 at 2:00 P.M. and 12/4/23 at 4:00 P.M. the Administrator said the following: -Resident #4 fell and fractured the right humerus. Staff sent the resident to the hospital and he/she returned with a partial cast secured with an ace wrap from the wrist to the axilla. The cast went up to the resident's arm pit. Staff documented assessment of the resident's skin and axilla area every shift. Staff were unaware the resident had a wound until drainage was noted 11/10/23. The wound was caused by the cast rubbing. He expected staff to complete thorough assessments. #MO00228015 #MO00227243

Based on interview and record review, the facility failed to report an allegation of verbal abuse for one resident (Resident #32), in a sample of five residents. The allegation was made on 5/9/23. The facility did not report the allegation to the state survey agency. The facility census was 94. Review of the facility policy, Abuse - Reporting and Response - Suspicion of a Crime, dated 10/4/22, showed the following: -The facility will ensure reporting reasonable suspicion of crimes against a resident or individual receiving care from the facility within prescribed time frames to the appropriate entities; -Identifying which cases of abuse, neglect, and exploitation may rise to the level of a reasonable suspicion of crime and recognizing the physical and psychosocial indicators of abuse, neglect and exploitation; -As part of the reporting process, law enforcement should inform the facility if an event reported does not rise to the level of a suspected or actual crime; -If there is a reasonable suspicion that a crime has occurred at the facility that involves any resident or other individual receiving care from the facility, it must be reported to local Law Enforcement and State Survey Agency as follows: 1. Serious Bodily Harm - Immediately but not later than two hours. If a resident or person receiving care at the facility suffers serious bodily injury resulting from the suspected crime, the suspicion shall be reported immediately, but not later than two hours after forming the suspicion; 2. No Serious Bodily Injury - As soon as practical, but not later than 24 hours. If the resident or person receiving care at the facility does not incur a serious bodily injury resulting from the suspected crime, the suspicion shall be reported not later than 24 hours after forming the suspicion; -Note: These reporting requirements are in addition to and do not change any existing reporting requirements under state law and local law enforcement agencies, as well as those required for Medicare and Medicaid certification; -Once an associate or other covered individual at the facility forms a reasonable suspicion that a crime has been committed against a resident or other individual receiving services at the facility, he or she must immediately notify the Executive Director of their suspicion; -The Executive Director must then notify Law Enforcement and the applicable State Survey Agency of the suspected crime within the time period as indicated above. 1. Review of Resident #32's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/11/23, showed the following: -Moderately impaired cognition; -Adequate hearing; -Clear speech; -Makes self understood and has clear comprehension. During interview on 5/10/23 at 6:20 P.M. and 7:02 P.M., the resident said LPN PP had gotten after him/her because he/she thought the resident was taking suckers from another resident's room and told him/her that he/she could not be in the room. During interview on 5/10/23 at 6:47 P.M., Certified Nurse Assistant (CNA) H said he/she was helping the resident on the evening of 5/9/23 and the resident told him/her, I'm so tired of being yelled and screamed at. The resident said Licensed Practical Nurse (LPN) PP had yelled at him/her to go to his/her room. He/She called the administrator at 7:22 P.M. and reported what the resident said. Review of the resident's nurses notes showed no evidence the resident reported to staff his/her concerns of LPN PP yelling at him/her. During interview on 5/10/23 at 4:58 P.M., the Director of Nurses (DON) said she was not aware of any staff yelling at residents. She said she talks to the resident every day and the resident had not reported any staff yelling at him/her. During interview on 5/10/23 at 4:58 P.M., the Director of Nurses (DON) said she was not aware of any staff yelling at residents. She said she talks to the resident every day and the resident had not reported any staff yelling at him/her. During an interview on 5/10/23 at 4:05 P.M., the Administrator said he had not had any reports of staff yelling at residents. During an interview on 5/10/23 at 7:26 P.M., the Administrator said he received a call from CNA H about 7:22 P.M. on 5/9/23 that LPN PP had yelled at Resident #32 and the resident was scared. He said he called the DON and she said she had spoken with the resident earlier in the day and the resident had no concerns. He said he remembered the phone call with CNA H after the surveyor had left the room earlier. He said he would consider yelling at a resident to be abuse. The allegation should have been reported to the state agency. MO218251

Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from a significant medication error, when staff failed to transcribe and administer levothyroxine (thyroid medication) to the correct resident. The facility administered 125 micrograms (mcg) to Resident #1 for at least 50 days when the resident did not have a diagnosis of a thyroid disorder. Because of the significant medication error, it put the resident at risk for likelihood of complications and side effects that could be caused by taking the medication. The facility census was 96. The administrator was notified of the Immediate Jeopardy (IJ) on 4/26/23 which began on 2/11/23. The IJ was removed on 4/27/23 as confirmed by surveyor onsite verification. Review of the facility policy General Dose Preparation and Medication Administration, dated January 2022, showed the following: -This policy sets forth the procedures relating to general dose preparation and medication administration; -Prior to administration of medication facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time for the correct resident, as set forth in the facility's medication administration schedule. Review of the facility policy Administration of Medications, dated 2/13/23, showed the following: -The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms; -The facility must ensure that residents are free of any significant medication errors; -Staff who are responsible for medication administration will adhere to the 10 rights of medication administration; right drug, right resident, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation/response and right education and information; -A significant medication error is one which causes the resident discomfort or jeopardizes his or her health and safety. Review of the facility policy Physician Orders, dated 3/10/23, showed the following: -All physician/practitioner orders, including verbal/telephone orders, are recorded on the Physician's Order Form for each resident and must be signed and dated within 14 days by the ordering physician, physician assistant or nurse practitioner unless state regulations mandate sooner; -It may be necessary to mail or take orders to a physician's office to obtain timely signatures. A log or a copy of all orders is kept for all orders that are sent out to be signed; -As a means of validation, any orders taken verbally or by telephone must be read back in their entirety to the person giving the orders; -The receiving nurse or therapist immediately enters telephone or verbal orders into the clinical software; -A monthly order summary is signed at least every 30 days by the physician. The summary may be printed and signed with a wet signature or may be signed electronically; -Orders must be authenticated, signed and dated, by the provider who gave the order. Signatures may be manual or electronic and may be accepted by fax. Review of levothyroxine (thyroid medication) on Providers Digital Reference.net showed: -Oral dosage for geriatric patients should be initiated with 12.5 to 25 mcg once daily with gradual increments at six to eight week intervals as needed; -Levothyroxine has a narrow therapeutic index. Over treatment or under treatment with the medication may have negative effects on cardiovascular function, bone metabolism, cognitive function and gastrointestinal function; -The signs and symptoms of over dosage are those of hyperthyroidism and Adverse Reactions. In addition, confusion and disorientation may occur. Cerebral embolism, shock, coma, and death have been reported. Symptoms may not necessarily be evident or may not appear until several days after ingestion of levothyroxine sodium; -Adverse reactions associated with levothyroxine therapy are primarily those of hyperthyroidism due to therapeutic over dosage. They include the following: fatigue, increased appetite, weight loss, heat intolerance, fever, excessive sweating, headache, hyperactivity, nervousness, anxiety, irritability, emotional lability, insomnia and hair loss. Seizures have been reported rarely with the institution of levothyroxine therapy. 1. Review of the Resident #1's undated face sheet showed the following: -The resident was admitted to the facility on [DATE]; -The resident had diagnoses that included hemiplegia/hemiparesis following non-traumatic intracerebral hemorrhage (bleeding into the brain tissue and the second most common cause of stroke) affecting the left non-dominant side, dysphagia (difficulty swallowing), muscle weakness, need for assistance with personal care, lack of coordination, speech and language deficits following non-traumatic intracerebral hemorrhage, gastro-esophageal reflux disease (when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) status, depression, seizures, aphasia (difficulty speaking) following non-traumatic intracerebral hemorrhage, colostomy (surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall). -The resident did not have a diagnosis of a thyroid disorder. Review of the resident's physician orders showed an order entered on 2/11/23 for levothyroxine 125 micrograms (mcg) once a day at 6:00 A.M. Review of the resident's electronic medication administration records, dated February 11-28, 2023, showed the resident received levothyroxine 125 mcg daily at 6:00 A.M. During an interview on 5/1/23 at 2:23 P.M., Licensed Practical Nurse (LPN) B said the following: -If a resident had a new medication added to the medication administration record in the electronic health records system, the system does not alert the nurse that it is a new medication or to verify the medication in any way; -He/She did not remember that he/she was the first nurse to administer levothyroxine to Resident #1; -He/She did not verify the medication to the order or with a physician; -He/She trusted that the other nurses put in the orders correctly and would have verified them prior to entering them in the electronic health record system. Review of the resident's electronic medication administration records, dated March 1 - 31, 2023, showed the resident received levothyroxine 125 mcg daily at 6:00 A.M. Review of the resident's electronic medication administration records, dated April 1 - 6, 2023, showed the resident received levothyroxine 125 mcg daily at 6:00 A.M. Review of the resident's progress notes, dated 4/5/23, showed the resident did not act himself/herself. The resident was anxious, pulling at his/her hair and spitting water at family. The family requested a urinalysis (UA, urinalysis involves checking the appearance, concentration and content of urine.). The physician was notified and new order for a UA was obtained. During an interview on 4/26/23 at 12:52 P.M., Resident #1 said the following: -He/She had hair loss while taking levothyroxine; -His/her hair loss had stopped since he/she was taken off the levothyroxine; -He/She had leg cramps while taking levothyroxine. During an interview on 4/26/23 at 12:57 P.M., Resident #1's personal nurse (not a facility staff member) said the following: -Resident #1 became more fidgety and agitated when he/she took the levothyroxine; -Resident #1 did not sleep well when he/she took the levothyroxine; -Resident #1 had increased confusion and periods of excessive sweating when he/she took the levothyroxine; -Resident #1 had hair loss (so much that it was on his/her pillow) when he/she took the levothyroxine; -The personal nurse was concerned about the symptoms the resident had and reported them to the nurse practitioner; -The nurse practitioner was at first concerned the resident may have had a urinary infection, but the resident's urinary lab results were normal; -The resident's personal nurse and the nurse practitioner reviewed the resident's medication list and that is when they found the resident was taking levothyroxine and should not have been taking the medication because he/she did not have a thyroid disorder. Review of the resident's progress notes, dated 4/6/23, showed the nurse practitioner saw the resident during rounds and gave an order to discontinue levothyroxine and obtain labs to monitor the resident's thyroid and seizure medication. During an interview on 4/26/23 at 12:12 P.M., the Director of Nursing said the following: -Once an order is received it is entered into the electronic health record system by a nurse; -Each nurse is assigned to a hall and reviewed their own orders; -The order was verified by the first nurse or certified med tech (CMT) that administered the new medication. During an interview on 4/27/23 at 4:20 P.M., the Medical Director and resident's physician said the following: -The resident did not have hyperthyroidism and therefore could not have side effects/adverse reactions from the thyroid medication even though he/she did not have a thyroid disorder; -The resident's body counteracted the medication and shut down his/her thyroid and kept his/her thyroid levels in the normal range; -The physician said the effects were not caused by the medication, but by the resident's recent COVID infection and did not support the error had any ill effect on this resident. During an interview on 5/15/23 at 8:59 A.M. the Nurse Practitioner said the following: -It was possible for the resident to have side effects (agitation, confusion, sweating, hair loss) from the levothyroxine; -Ideally a person should be tapered off levothyroxine, but the family wanted the resident off the medication so she stopped it immediately; -She had reviewed the resident's medication list since the levothyroxine was placed on the resident's medication administration record and didn't think anything about it, a lot of people are on levothyroxine. She did not look at the resident's medications in depth until the family brought the resident's behaviors to her attention. 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). MO217514

Based on observation, interview, record review, the facility failed to ensure one resident (Resident #18), a resident with diagnosis of muscular dystrophy, was free from misappropriation of medication when 46 of his/her oxycodone tablets (narcotic pain medication), were exchanged for 46 loratadine (allergy medication) tablets. The resident did not receive his/her ordered pain medication as a result for an undetermined amount of time from 4/11/23 (admittance to the facility) until 4/25/23. The resident reported he/she was not getting pain relief and his/her pain was not under control with the current dose of oxycodone. The facility census was 96. Review of the facility policy Abuse-Protection of Residents, Misappropriation of Property and Exploitation, dated 10/4/22 showed: -Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent; -Examples of resident property include money, theft of resident's personal belongings and missing prescription medications or diversion of a resident's medications, including but not limited to controlled substances for staff use or personal gain. Review of the facility policy Resident Rights, last reviewed 10/6/22, showed the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. 1. Review of Resident #18's face sheet showed the following: -The resident admitted to the facility on [DATE]; -The resident had diagnoses that included muscular dystrophy (a group of diseases that cause progressive weakness and loss of muscle mass), unsteadiness on feet, periodic limb movement disorder, repeated falls, lack of coordination and abnormal posture. Review of the resident's physician order sheet (POS) showed an order dated 4/11/23 for oxycodone 5 milligrams (mg) by mouth every six hours as needed for pain related to muscular dystrophy. Review of the resident's progress notes and comments, dated 4/11/23, Pharmacist H wrote the following: -The resident's medications were verified; -All appear to be as labeled; -Lisinopril (blood pressure medication) 20 milligram bottle; two different shapes/colors were in the bottle - both are lisinopril; -As needed pain reliever; two different shapes/colors were in the bottle - both are as labeled; -The note was signed by Pharmacist H. Review of the resident's care plan, dated 4/12/23, showed the following: -The resident expressed frequent pain due to his/her diagnosis of muscular dystrophy; -Administer pain medications as ordered; -Report any uncontrolled pain to the physician; -Perform pain assessments as per facility protocol. Review of the resident's pain assessment, dated 4/16/23, showed: -The resident said lying in the same position for long periods of time caused pain; -Repositioning and oxycodone as needed made the pain better. Review of the resident's pain assessment, dated 4/18/23, showed: -The resident said everything, especially movement made the pain worse; -Medication made the pain better; -The resident said the pain was constant. Review of the resident's progress notes, dated 4/18/23 at 11:18 A.M., showed the resident had pain all over. Review of the resident's progress notes, dated 4/18/23 at 1:50 A.M., showed the following: -The resident voiced his/her pain was not under control with the current dose of oxycodone; -The resident asked the nurse practitioner for an increase in his/her oxycodone. Review of the resident's progress notes, dated 4/18/23 at 4: 41 P.M., showed the resident's physician increased his/her oxycodone order to one or two tablets every six hours as needed. Review of the resident's POS showed an order dated 4/18/23 for oxycodone 5 mg by mouth, may have one or two tablets by mouth every six hours as needed for pain. Review of the facility Time Line of Events for Resident #18, dated 4/25/23, showed the following: -At 6:46 P.M. during change of shift narcotic reconciliation, medication didn't appear uniform to Licensed Practical Nurse (LPN) A and LPN E. Notification to the Director of Nursing (DON) and the administrator; -At 7:00 P.M., regional and divisional staff were notified, local police notified, statements from staff obtained; -Resident #18's oxycodone was removed from commission and medication used from the emergency box until verification and proper packaging secured; -On 4/26/23 Pharmacist I conducted a facility audit on medication carts. No gaps in process found. Review of a note signed by Pharmacist I on the local pharmacy letterhead, dated 4/26/23, showed all narcotics, controlled and liquid medications were verified at the facility on 4/26/23 During an interview on 4/26/23 at 9:47 A.M., LPN D said the following: -He/She and LPN E were counting the resident's oxycodone on 4/25/23 at evening shift change; -LPN E noticed a difference in some of the pills while they were counting; -The two nurses compared the pills and found there were different markings on some of the pills; -The nurses looked online to find out what the pills were. Forty-six of the pills were loratadine and 35 of the pills were oxycodone; -After finding the discrepancy in the pills they called the administrator and the DON. The DON told them to separate the pills and to lock them up. The resident was to begin receiving oxycodone from the emergency kit. -He/She did not take the pills and did not know who switched them; -He/She had not noticed a difference in any of the resident's medications before this day. During an interview on 4/26/23 at 12:39 P.M., LPN E said the following: -He/She counted the resident's oxycodone with LPN D; -He/She noticed the pills looked a little bit different and began looking at them closer; -After looking more closely at the pills he/she observed they had different markings on them; -The two nurses looked up the markings and found that 35 pills were oxycodone and 46 pills were loratadine; -After finding the discrepancy, the nurses called the administrator and the DON. -He/She did not switch the pills and did not know who switched them; -He/She had not noticed a difference in any of the resident's medications before this day. Observation on 4/26/23 at 9:47 A.M., of the resident's medication showed: -The oxycodone pill bottle contained 35 oxycodone 5 milligram pills that had the numbers 03 52 marked on one side of each pill and a M inside a square marked on the other side of each pill; -46 loratadine pills sealed in a plastic bag that had the numbers 439 marked on each pill. During an interview on 4/26/23 at 6:45 P.M., the resident said the following: -He/She was not getting pain relief with the oxycodone 5 mg; -Sometimes the resident would wake up with the shakes and that is when he/she knew it was time for more medication. During an interview on 4/26/23 at 9:03 A.M. and 5/18/23, the DON said the following: -The resident's oxycodone was filled at the local pharmacy and it was brought to the facility in a prescription bottle; -When the resident was admitted to the facility the local pharmacist came to the facility, took the resident's medications to the pharmacy, verified the medications and returned them to the facility before the resident received oxycodone at the facility; -The pharmacy did not bubble pack the resident's oxycodone and she was not sure why; -LPN D and LPN E found a discrepancy in the resident's oxycodone last night at shift change during the narcotic counts; -The nurses called her and the physician and police were notified; -She did not know who switched the pills out. During an interview on 5/15/23 at 3:34 P.M., the administrator said the following: -He expected 100% honesty from his staff; -He expected staff to count narcotics at each shift change and when administering the medications; -The pharmacist verified the oxycodone when the resident was admitted to the facility; -He does not know how the oxycodone pills got switched with the other pills. During an interview on 5/18/23 at 9:08 A.M., Pharmacist I said the following: -If a nursing home resident had a home medication that was filled at the pharmacy they would bubble pack it and send it back to the pharmacy for it to be administered to the resident instead of from a pill bottle; -He/She was at the facility on 4/26/23 and verified there were oxycodone in the resident's medication bottle; -The facility staff had already taken the other pills out of the oxycodone bottle and placed them in a plastic bag separate from the oxycodone. During an interview on 5/18/23 at 3:42 P.M., Pharmacist H said the following: -The facility brought the resident's medications to the pharmacy (4/11/23) for review about five minutes before closing time and the facility driver returned them to the facility after he/she reviewed them; -He/She can't 100% say if the oxycodone was reviewed. If he/she reviewed the oxycodone and there was a discrepancy in the pills he/she should have noted it in the progress note; -The pharmacist remembered he/she reviewed lisinopril, an over the counter generic Tylenol PM, multiple vials of testosterone and many blood thinners; -At the time the resident's medications were reviewed the pharmacy did not have a policy to bubble pack controlled substances for the nursing home; -When he/she verified the resident's medications on 4/11/23 and made note of one medication having two different pills it was probably because the resident had two different refills by different manufacturers mixed together. MO217558

Based on observation, interview, and record review, the facility failed to thoroughly assess one bed-bound bariatric resident (Resident #38), in a review of 20 sampled residents, to ensure the facility maintained the proper equipment to safely transfer the resident from his/her bed, and failed to ensure their policy and the resident's plan of care related to emergency evacuation procedures for a bariatric resident would be successful as they had not identified the number of staff required or the equipment necessary to safely evacuate the resident from the facility. The facility did not know the resident's current weight and could not determine if the transfer equipment available could meet the resident's weight requirement in order to safely transfer the resident without injury. The facility failed to implement interventions to ensure two sampled residents (Residents #28 and #64) who smoked were safe when smoking. The facility staff also failed to safely transport one sampled resident (Resident #14) and nine additional residents (Residents #19, #20, #22, #57, #147, #197, #401, #402 and #403) in wheelchairs with foot rests. The facility census was 92. The administrator was notified of the Immediate Jeopardy (IJ) on 4/12/23 at 7:30 P.M. which began on 4/10/23. The IJ was removed on 4/19/23 as confirmed by surveyor onsite verification. Review of the facility's policy Emergency Procedures for Specific Events, Severe Weather, last revised 4/13/21, showed the following: -Identify safe areas (inside hallways or windowless rooms) within the building; -Move all residents into hallways or rooms without windows; -If moving all residents is not practical, cover them with blankets, pillows, etc. -Close all cubicle curtains, windows, window curtains and blinds to provide a barrier between windows and the residents, and remove items from window ledges and pictures from walls. Review of the facility policy Facility Fire, last revised 4/26/21, showed the following: -There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. -Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff; -Evacuation of Smoke Compartment 1. Residents from fire compartment to be moved to adjacent side of fire smoke doors. 2. Begin with evacuation of the triangle of rooms surrounding the room of origin - the rooms on either side and directly across the hall 3. Systematically remove the remaining occupants within the smoke compartment (fire doors to fire doors or fire doors to exit) 4. Moving away from the proximity to the fire (not by ambulation status) 5. Do not to cross the line of fire with the residents 6. Adjacent smoke compartments should be ready to accept patients from the fire's point of origin. Review of the facility policy Evacuation/Relocation Plan, revised 2/24/23, showed the following: -It is the policy of the facility to ensure the safety and well-being of all residents, associates and visitors in this facility at all times; -Should there be an event or situation which renders the nursing home unsafe for occupancy or prevents the delivery of necessary resident care; evacuation (partial or complete) of residents will be performed in an effective, organized and safe manner that is conducive to ensuring continuity of resident care and safety; -There is a written plan for the protection of all patients and for their evacuation in the event of an emergency; -Pre-event resident evacuation considerations include: 1. Mobility status of residents (ambulatory, wheelchair bound, bed bound) a. If bed bound, determine if able to exit the room using the bed. Some patients may require another way of egress, secondary to equipment sizing. (e.g., bariatric patients may require being removed from room by sheet pull or stretcher if available) 2. Acuity status of residents (e.g., oxygen therapy, IV therapy, enteral nutrition, dialysis, hospice) 1. Review of Resident #38's face sheet showed the resident's diagnoses included depression, lymphedema (swelling in an arm or leg caused by a lymphatic system blockage), and morbid obesity. Review of the resident's Care Plan, revised 1/28/20, directed staff to obtain weight when requested by the resident. Nurse practitioner aware that being weighed in the Hoyer (mechanical lift) caused pain and discomfort for the resident. Review of the resident's Care Plan, last reviewed 6/24/21, showed the following: -Ensure this resident's safety at all times; -Requires Hoyer lift for transfers, but has been unable to transfer due to complaints of pain when getting out of bed; -Non-compliant with ambulating at times and stays in bed; -Chooses to stay in bed at all times; -He/She cannot exit his/her bed without total assist of staff and is refusing to get out of bed; -In the event of an emergency and needing to get the resident out of the building, use the sheet transfer technique to safely remove him/her from the building. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 2/16/23, showed the following: -Cognitively intact; -Requires extensive assistance of two or more staff for bed mobility; -Transfers and locomotion did not occur; -Functional limitation in range of motion to both lower extremities; -No mobility devices; -He/She weighed 412 pounds (lbs). Observation on 4/12/23 at 9:30 A.M., showed the following: -The resident lay in his/her bariatric bed; -The resident's bed was visibly wider than the doorframe to the resident's room; -The resident's weight was primarily in his/her lower body related to lymphedema; -His/Her legs went from one side of the bed to the other side of the bed, with very little room left at the edge of the bed; -The resident's legs were swollen and weeping (fluids leaking from the skin); -The resident did not have a sling for a mechanical lift or a full size sheet in his/her room. During an interview on 4/12/23 at 11:28 A.M., Licensed Practical Nurse (LPN) Q said the following: -He/She did not know if the facility had a Hoyer lift and sling that would accommodate the resident's weight; -The resident had not been weighed in quite a while because he/she refused as the sling hurt him/her; -In a fire staff would have to lower the resident to the ground and drag the resident out on a sheet; -He/She was not sure how many staff it would take to get the resident from bed or pull the resident to safety on a sheet. During an interview on 4/12/23 at 11:38 A.M., the resident said the following: -He/She has been in his/her room in his/her bed for three years, except for a hospitalization , and once to get his/her hair colored; -He/She was to be weighed daily, but staff had not weighed him/her in about a year because the sling hurt his/her legs too much to be lifted with the lift; -The staff say he/she refuses to get up, but the sling the facility has cuts into his/her legs; -The Hoyer lift hurts so bad he/she does not want to get up in the lift; -There is no way to get him/her out of bed in a safe way; -He/She can't get out of bed or leave his/her room and he/she did not feel safe if there is a fire or tornado; -There was a tornado warning recently and he/she heard the sirens. He/She was so scared. The other residents were in the hall, and he/she wanted to be in the hall too; -The staff moved out his/her roommate's bed, and moved his/her bed to the inside of the room, pulled the curtains and gave him/her a blanket to put over his/her head. Observation on 4/12/23 at 1:15 P.M., showed the facility's bariatric Hoyer lift had a label that showed a maximum weight of 660 lbs. The facility lift sling was rated for 550 lbs. The lift sling was made to go around the legs of the resident when lifted in the sling. During interviews on 4/12/23 at 1:30 P.M. and 2:15 P.M., LPN/Infection Preventionist (IP) QQ said the following: -The resident's bed broke a while back and it took six staff to move the resident to the new bed; -The bariatric beds do not fit through the doors of the resident's rooms unless the mattress is removed and the bed extensions on the sides are pushed in for transport; -For emergencies, staff are instructed to pull the resident to safety on a full size sheet; -He/She had been told two staff could pull any resident on a sheet. With this resident, he/she would think it would take at least four staff; -It may take more than four staff to lower the resident to the floor; -Staff would have to use the Hoyer lift to lower the resident to the ground and then pull him/her on a sheet; -The bariatric Hoyer lift in the building will go to 660 lbs; -He/She did not know what the resident weighed; the resident had not been weighed for a long time; -He/She did not know if the resident weighed less than 660 lbs. During an interview on 4/12/23 at 2:37 P.M., Physical Therapy Assistant (PTA) RR said the following: -Therapy has tried to get the resident out of bed with the Hoyer lift, but the facility does not have a sling that will fit around the resident's legs; -Therapy tried the facility's slings three to four times, and the last time the resident had cuts into his/her leg. During an interview on 4/12/23 at 2:51 P.M., the Director of Nursing (DON) said the following: -The facility had a fire consultant come to the facility on e or two months ago. The fire consultant said they could get any resident out of bed with two staff by letting their feet down first and then lowering them to the ground; -The fire consultant did not specifically evaluate the resident during the visit. The fire consultant said any resident could be removed from a bed with two staff; -Facility staff would have to use at least six employees to get the resident to the floor on a slide sheet; -He/She did not know if six employees was enough, as they had not attempted the transfer; -Ideally the fireman would be able to assist; -The DON did not know what the resident weighed at this time. The resident's legs were bigger than they were six months ago; -He/She did not know if the resident was over the weight limit of the Hoyer lift. During an interview on 4/12/23 at 5:25 P.M., the administrator said the following: -In an emergency, he would expect one staff member could get the resident out of bed safely to the ground, and two staff members to pull the resident to safety; -He did not know what the resident weighed or if there was a lift or sling that fit the resident. 2. Review of the facility policy, Smoking Facility, revised 08/10/22, showed the following: -The facility will provide a safe environment for residents who smoke tobacco products and to protect non-smoking residents from second-hand smoke. The facility will provide supervision to all residents who smoke tobacco products, as determined by their smoking assessment and identified in their care plan interventions; -Resident Smoking Determination; -Residents who currently smoke will have a smoking assessment completed upon admission, readmission, with significant change, and quarterly by a licensed nurse; -Once a smoking assessment is completed, the Interdisciplinary Team (IDT) will review the resident smoking assessments and develop an individualized smoking care plan that includes but is not limited to smoking safety/assistance and education of smoking policy and level of understanding; -The Director of Nursing (DON) or designee will review resident smoking assessments and care plans for accuracy and appropriateness; -Smoking Supervision & Monitoring; -Residents will be provided smoking supervision through direct (physically present) monitoring when smoking; -Smoking monitors should perform the following: -Check to ensure fire blanket, fire extinguisher, and other smoking safety equipment is available; -Assist with or place smoking aprons on identified residents; -Assist residents with lighting of cigarettes, use of ashtrays, extinguishing of cigarettes, etc; -Conduct walking rounds throughout the duration of the smoking time; -Check residents prior to their return indoors, that the residents do not have cigarettes, lighter/matches, etc. on their person. Remove all smoking aprons from residents; -Clean resident smoking aprons with disinfectant wipes and return to designated location. 3. Review of Resident #64's significant change MDS, dated [DATE], showed the following: -Diagnosis include chronic respiratory failure with hypoxia (lack of oxygen), dementia and essential tremor (neurological condition, that causes involuntary and rhythmic shaking); -Vision impaired; -Moderately impaired cognition; -Requires supervision and one staff member physical assist for eating. Review of the resident's Care Plan, last revised 2/3/23, showed the following: -The resident has chosen to smoke while a resident; -The resident will remain safe while smoking and staff will monitor for any changes in smoking ability and report to the charge nurse as needed; -The resident will wear a smoking apron per protocol. Review of the resident's smoking safety evaluation, dated 3/24/23, showed the following: - Resident drops ashes on himself/herself; -If resident had any unsafe activities such as dropping ashes, then the resident exhibits poor safety awareness when smoking and interventions must be put in place to promote safe smoking. Observation on 4/12/23 at 1:44 P.M. showed the following: -The resident was in the outside courtyard smoking with other residents; -The resident sat in a wheelchair and was hunched over; -He/She held a lit cigarette approximately three inches above his/her legs with his/her right hand which was shaking; -The resident was not wearing a smoking apron as directed in his/her care plan. 4. Review of Resident #28's face sheet, dated 3/30/23, showed the resident had a diagnosis of nicotine dependence to cigarettes. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was severely cognitively impaired; -His/Her diagnoses included Alzheimer's disease and dementia. Review of the resident's care plan, dated 4/04/23, showed no documentation the resident smoked and would be participating in smoking activity. Review of the resident's smoking safety evaluation, dated on 4/10/23, showed the following: -The resident did not drop ashes on himself/herself; -The resident demonstrated the ability to safely smoke with supervision; -The resident did not exhibit poor safety awareness when smoking; -The resident did not require smoking interventions to be put into place. Observation on 4/12/23 at 9:30 A.M., showed the resident was in smoking area. The resident's right hand was shaking while he/she was smoking a cigarette. Observation on 4/13/23 at 2:45 P.M., showed the resident sat in his/her wheelchair at the nurses station. Cigarette ashes were visible on his/her shirt and pants. During an interview on 4/18/23 at 1:34 P.M., Certified Nurse Aide (CNA) Z said a resident would need a smoking apron if he/she was shaky and if the resident had ashes on his/her clothes. He/She did not know if Resident #28 needed a smoking apron because he/she did not take the resident to smoke all the time. There was no list of residents in the smoking box (large plastic tackle box that contains smoking residents' cigarettes and lighters) which identified which residents needed a smoking apron. The nurses would report to the smoking staff which resident needed a smoking apron. During an interview on 4/18/23 at 2:20 P.M., Licensed Practical Nurse (LPN) D said nursing staff would complete a smoking evaluation on admission for a resident who smokes. The smoking evaluation is done by watching a resident smoke. If a resident is dropping ashes on themselves, is not able to see or is dropping a cigarette, that resident would need a smoking apron. If changes are observed, another smoking evaluation should be completed. The charge nurse communicates who needs to have a smoking apron. He/She did not know if Resident #28 was supposed to have a smoking apron. 5. Review of the facility's policy, Activities of Daily Living (ADLs), reviewed 8/22/22, showed the following: -Policy: The resident will receive assistance as needed to complete ADLs; -Procedure: For bed/wheelchair mobility, the following procedures will be followed: -Utilize appropriate safety measures and any necessary equipment to maintain resident safety. 6. Review of Resident #20's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Required extensive physical assistance from one staff for locomotion on and off the unit, -Required extensive physical assistance from two or more staff for bed mobility, transfers, and toilet use; -Used a walker and wheelchair for mobility. Observation on 4/10/23, at 12:58 P.M., showed LPN R propelled the resident in his/her wheelchair from the dining room to his/her room. There were no foot rests on the resident's wheelchair. The resident held his/her feet in the air. The resident dropped his/her feet causing the wheelchair to abruptly stop. LPN R told the resident, come on walk your feet with the chair or lift them up. The resident continued to stop the wheelchair as it propelled down the hall and he/she could not keep his/her feet in the air. During an interview on 4/10/23, at 3:23 P.M., LPN R said the following: -The resident cannot have foot rests on his/her wheelchair because he/she will try to get up and trip over the foot rest; -The resident cannot hold up his/her feet when going to the dining room in his/her wheelchair, and he/she cannot propel the wheelchair all the way down the hall. 7. Review of Resident #197's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive physical assistance from one staff for locomotion on and off the unit, -Required extensive physical assistance from two or more staff for transfers; -Limitation in range of motion in one lower extremity; -Wheelchair for mobility. Observation on 4/11/23, at 10:09 A.M. showed CNA MM propelled the resident in a wheelchair from the dining room towards his/her room. The wheelchair did not have foot rest. The resident attempted to hold up his/her left foot with his/her right foot (right foot rested on the resident's left foot crossing at his/her ankles). The resident's feet slid on the floor halfway down the hallway when his/her left foot fell off his/her right foot During an interview on 4/11/23 at 10:14 A.M., CNA MM said he/she had to propel the resident because the resident cannot propel himself/herself. The resident does not have foot rest for his/her wheelchair. A lot of the residents' wheelchairs do not have foot rests. 8. Review of Resident #19's quarterly MDS, dated [DATE], showed the following: -His/Her diagnoses included dementia, cerebrovascular accident (CVA; stroke), and transient ischemic attack (TIA; mini stroke); -He/She had severe cognitive impairment; -He/She used a wheelchair and required limited assistance with locomotion. Observation on 4/12/23 at 6:42 P.M. showed the following: -Registered Nurse (RN) GG pushed the resident in his/her wheelchair from the Special Care Unit dining room down the hallway. RN GG told the resident to pick up his/her feet; -The resident's wheelchair did not have foot rests; -The resident wore shoes and a blanket covered his/her lap; -The wheelchair became caught up with the blanket. RN GG stopped and adjusted the blanket, and continued to push the resident in the wheelchair to his/her room as the resident held his/her feet approximately three inches from the surface of the floor. 9. Review of Resident #403's significant change MDS, dated [DATE], showed the following: -His/Her diagnoses included arthritis, Alzheimer's disease, dementia, CVA, TIA or stroke; -He/She had severe cognitive impairment; -He/She used a wheelchair and required extensive assistance with locomotion. Observation on 4/13/23 at 4:31 P.M. showed the following: -CNA N pushed the resident in his/her wheelchair from the hallway to the main dining room; -The resident's wheelchair did not have foot rests; -The resident wore socks and his/her socked feet skimmed the surface of the floor as CNA N pushed the resident in the wheelchair. 10. Review of Resident #57's annual MDS, dated [DATE], showed the following: -His/Her diagnoses included osteoporosis, Alzheimer's disease, CVA, TIA or stroke, dementia, and traumatic brain injury; -He/She had severe cognitive impairment; -He/She used a wheelchair and required limited assistance with locomotion. Observation on 4/13/23 at 5:17 P.M. showed the following: -CNA X pushed the resident in his/her wheelchair from the hallway to the large Special Care Unit dining area; -The resident's wheelchair did not have foot rests; -The resident wore shoes and one foot pointed upward and the other pointed downward with the heel of one foot approximately 1/2 inch from the floor. Observation on 4/13/23 at 6:26 P.M. showed CNA X pushed the resident in his/her wheelchair from his/her room down the Special Care Unit hallway. The resident wore shoes and his/her right foot skimmed the surface of the floor. The resident's wheelchair did not have foot rests. 11. Review of resident #147's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Required extensive assistance from one staff for transfers and locomotion; -Used a wheelchair. Review of the resident's care plan, last revised 3/6/23, showed the following: -Diagnoses of dementia; -Monitor positioning of arms and legs when the resident is in wheelchair to monitor for safety when propelling in wheelchair; -Staff to monitor location of lower extremities when propelling in wheelchair. Observation on 4/12/23 at 5:44 A.M. showed CNA F pushed the resident in his/her wheelchair from the resident's rooms to the dining room. The resident's wheelchair did not have foot rests and the resident did not wear shoes (only socks). The resident held his/her feet in the air, but barely above the floor surface. During interview on 5/5/23 at 2:10 P.M., CNA F said foot rests should be used when pushing a resident in a wheelchair for support of their feet and so that their feet do not get caught or drag on the floor. 12. Review of Resident #14's significant change MDS, dated [DATE], showed the following: -His/Her diagnoses included stroke and dementia; -He/She had moderate cognitive impairment; -He/She used a wheelchair and required extensive assistance with locomotion. Observation on 4/11/23 at 11:32 A.M. showed the following: -RN GG pushed the resident down the Special Care Unit (SCU) hallway from the SCU dining room in his/her wheelchair. RN GG told the resident to pick up his/her feet; -The resident's wheelchair did not have foot rests; -The resident brought his/her feet beneath himself/herself and pointed his/her toes slightly downward with his/her toes approximately one inch from the floor as RN GG pushed the resident in the wheelchair. Observation on 4/12/23 at 6:08 A.M. showed the following: -The resident's wheelchair did not have foot rests; -As Nurse Assistant (NA) LL pushed the resident in the wheelchair. The resident held his/her feet up underneath the wheelchair with his/her toes pointing downward toward the floor. The toes of the resident's shoes were approximately two inches from the floor. 13. Review of Resident #401's quarterly MDS, dated [DATE], showed the following: -His/Her diagnoses included arthritis and Alzheimer's disease; -He/She had severe cognitive impairment; -He/She used a wheelchair and required limited assistance with locomotion. Observation on 4/12/23 at 6:05 A.M. showed CNA E pushed the resident from his/her room to the dining room in a wheelchair. The resident's wheelchair did not have foot rests. The resident held his/her feet in the air just above the floor surface. Observation on 4/13/23 at 4:27 P.M. showed the following: -Receptionist HH pushed the resident in his/her wheelchair from the nurses' station to the main dining room; -The resident's wheelchair did not have foot rests; -The resident wore socks and his/her toes were pointed downward toward the floor approximately 1/2 inch from the floor as Receptionist HH pushed the resident in the wheelchair. 14. Review of Resident #402's annual MDS, dated [DATE], showed the following: -His/Her diagnoses included dementia; -He/She had moderate cognitive impairment; -He/She used a wheelchair and required extensive assistance with locomotion. Observation on 4/13/23 at 4:30 P.M. showed the following: -Receptionist HH pushed the resident in his/her wheelchair from the hallway to the main dining room; -The resident's wheelchair did not have foot rests; -The resident wore shoes which were approximately 1/2 inch above the surface of the floor as Receptionist HH pushed the resident in the wheelchair. 15. Review of Resident #30's significant change MDS, dated [DATE], showed the following: -His/Her cognition was severely impaired; -His/Her diagnoses included senile degeneration of the brain; -He/She displayed fluctuating inattention and disorganized thinking; -He/She used a walker and a cane/crutch. Review of the resident's progress notes on 10/18/22 at 2:37 P.M. showed the resident ambulated with his/her walker but used his/her wheelchair for distance. Observation on 4/11/23 at 11:45 A.M. showed the following: -RN GG pushed the resident in his/her wheelchair from the hallway to the SCU dining room; -The resident's wheelchair did not have foot rests; -The resident wore shoes and his/her feet skimmed the surface of the floor less than 1/4 inch above the floor as RN GG pushed him/her in the wheelchair. 16. Review of Resident #22's quarterly MDS, dated [DATE], showed the following: -His/Her cognition was severely impaired; -His/Her diagnoses included dementia; -He/She used a wheelchair and required extensive assistance with locomotion. Observation on 4/10/23 at 9:47 A.M., showed CNA Z pushed the resident down the hallway in his/her wheelchair. The resident wore shoes. His/Her feet slid just above the surface of the floor. The resident's wheelchair did not have foot rests. During an interview on 4/13/23 at 6:02 P.M., the resident's representative said when staff pushed the resident in his/her wheelchair, a lot of times there were no foot rests on the resident's wheelchair. 17. During an interview on 4/20/23 at 4:38 P.M., the Administrator said the following: -He expected staff to propel residents in wheelchairs with foot rests. Staff should obtain foot rests for a resident's wheelchair prior to propelling a resident; -He would not expect staff to allow residents' feet to hover above or slide on the floor as staff propelled the residents in wheelchairs. During an interview on 4/20/23 at 4:38 P.M., the Director of Nursing said the following: -She expected staff to place foot rests on a resident's wheelchair prior to propelling the resident; -Staff should not propel a resident in a wheelchair without foot rests on their wheelchair; -If there was a resident propelled in a wheelchair without foot rests, a lot of consideration would be used to make that decision including assessment to see if the resident could hold their own feet up, as well as resident and staff had education; -If a resident did not prefer the use of foot rests on a wheelchair, then staff should ensure the resident was alert/oriented and able to lift their feet. Staff should communicate with the resident's family as necessary and place applicable information in the resident's care plan. 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). MO#193280 38016 44665 47008

Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet residents' needs in the event of an emergency when the facility was unsure how many staff it would require to safely evacuate one morbidly obese resident (Resident #38) of 60 sampled residents. The facility identified 23 residents that required mechanical lift transfers, 15 that required the assist of two staff and 22 that required staff stand-by assist to evacuate. Facility staff failed to ensure their policy for getting bariatric residents to safety in the event of an emergency would be successful as they had not practiced the plan. Some staff identified six staff would be enough to get Resident #1 to safety. Review of the staffing for 11:00 P.M. to 4:30 A.M. showed only six staff available, leaving no staff to ensure the safety of the other residents. The facility census was 92. The administrator was notified of the Immediate Jeopardy (IJ) on 4/12/23 at 7:30 P.M. which began on 4/10/23. The IJ was removed on 4/19/23 as confirmed by surveyor onsite verification. Review of the facility assessment, dated January 2023, showed the following: -The facility's overall acuity is moderate to high as the type of resident admitted to the facility has shifted to those with more diverse and complex medical conditions as described above; -Upon admission, residents require more assistance with activities of daily living, pain management, diabetes and other chronic disease management, including complex wound management; -Facility staff members are assigned to each of the seven departments in numbers that are determined by the scope of each department to perform designated tasks that ensure residents are cared for and needs are met; The facility assessment did not identify the number of staff needed for residents care and safety each day or shift. Review of the facility Fire Policy, dated February 2016, showed it is the nursing director/supervisor's responsibility to ensure adequate staffing of other areas of the building, especially the area to which the residents are being evacuated. Review of the facility policy Evacuation/Relocation Plan, revised 2/24/23, showed the following: -It is the policy of the facility to ensure the safety and well-being of all residents, associates and visitors in this facility at all times; -Should there be an event or situation which renders the nursing home unsafe for occupancy or prevents the delivery of necessary resident care, evacuation (partial or complete) of residents will be performed in an effective, organized and safe manner that is conducive to ensuring continuity of resident care and safety. -The policy did not identify the number of staff needed for evacuation. Review of the facility policy Facility Fire, revised: 9/9/2022, showed the following: -There is a written plan for the protection of all residents and for their evacuation in the event of an emergency; -Evacuation of Smoke Compartment should be moved to adjacent side of fire smoke doors; -Begin with evacuation of the triangle of rooms surrounding the room of origin -the rooms on either side and directly across the hall; -Systematically remove the remaining occupants within the smoke compartment (fire doors to fire doors or fire doors to exit); - If evacuation of floor or building is necessary, this shall take place from non-fire side of building, using exit farthest from fire. Building evacuation will be a Fire Department/ Administrative decision; -The policy did not identify the number of staff needed for evacuation. 1. Review of the resident list completed by staff, dated 4/12/23, showed the facility identified one resident that would require six or more staff members to transfer for evacuation, 23 residents that required mechanical lift transfers which involves two staff for safety, 15 residents that required the assist of two staff to transfer, and 22 residents that required staff stand-by assist to evacuate. 2. Review of the facility's Nursing Schedule, dated 4/10/23-4/13/23, showed the facility had six staff working from 11:00 P.M.-4:30 A.M. (night shift). 3. Review of Resident #38's face sheet showed the resident's diagnosis include bipolar disorder (drastic mood swings from depressed to elated), anxiety, depression, cellulitis (infection of the tissue) both lower extremities, arthritis, chronic pulmonary disease, lymphedema (swelling in an arm or leg caused by a lymphatic system blockage), and morbid obesity. Review of the resident's Care Plan, last reviewed 6/24/21, showed the following: -Ensure this resident's safety at all times; -Requires Hoyer lift (mechanical lift) for transfers, but has been unable to transfer due to complaints of pain when getting out of bed; -The resident cannot exit his/her bed without total assist of staff and is refusing to get out of bed; -In the event of an emergency and needing to get the resident out of the building, use the sheet transfer technique to safely remove him/her from the building. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment, dated 2/16/23, showed the following: -Cognitively intact; -Required extensive assistance of two or more staff for bed mobility; -Transfers and locomotion did not occur; -Functional limitation in range of motion to both lower extremities; -No mobility devices; -412 pounds (lbs). Observation on 4/12/23, at 9:30 A.M., showed the following: -The resident lay in his/her bariatric bed; -The resident's bed was visibly wider than the door to the resident's room; -The resident's weight was primarily in his/her lower body related to lymphedema; -His/Her legs went from one side of the other side of the bed, with very little room left at the edge of the bed; -The resident's legs were swollen and weeping (fluids leaking from the skin); -The resident did not have a sling for a mechanical lift or a full size sheet in his/her room. During an interview on 4/12/23, at 11:38 A.M., the resident said the following: -He/She has been in his/her room in his/her bed for three years, except for a hospitalization , and once to get his/her hair dyed which the resident said, was not worth it; -He/She said there is not a way to get him/her out of bed in a safe way and there is not a chair for him/her that is safe; -He/She can't get out of bed or leave his/her room, so he/she does not feel safe if there is a fire or tornado; -There was a tornado warning and he/she heard the sirens. He/She was so scared. The other residents were in the hall, and he/she wanted to be in the hall too; -The staff moved out his/her roommate's bed, and moved his/her bed to the inside of the room, pulled the curtains and gave him/her a blanket to put over his/her head. During an interview on 4/12/23, at 11:28 A.M., Licensed Practical Nurse (LPN) Q said the following: -He/She did not know if the facility had a Hoyer lift and sling that would accommodate the resident's weight; -In a fire, staff would have to lower the resident to the ground and drag the resident on a sheet; -He/She was not sure how many staff it would take to get the resident onto the floor. During an interview on 4/12/23, at 1:30 P.M. and 2:15 P.M., LPN/Infection Preventionist (IP) QQ said the following: -The resident's bed broke a while back and it took six staff to move the resident to the new bed; -For emergencies, staff are instructed to pull the resident to safety on a full size sheet; -He/She had been told two staff members could pull any resident on a sheet, however, he/she would think it would take at least four staff for this resident; -It may take more than four staff to lower the resident to the floor; -Staff would have to use the lift to lower the resident to the ground and then pull him/her on a sheet. During an interview on 4/12/23, at 2:51 P.M., the Director of Nursing said the following: -The facility had a fire consultant come to the facility. The fire consultant said you could get any resident out of bed with two staff by letting their feet down first and lowering them to the ground; -He/she did not specifically evaluate the resident for safe evacuation, he/she did not know how many staff it would take to do a complete evacuation; -The facility has not attempted to evacuate the resident in a drill; -Facility staff would have to use at least six employees to get the resident to the floor on a slide sheet; -He/She did not know if six employees was enough, they have not attempted the transfer; -Ideally the fireman would be able to assist; -There are six employees in the building from 11:00 P.M. to 4:30 A.M.; -He/She did not know if there would be enough staff from 11:00 P.M. to 4:30 A.M. to evacuate the residents During an interview on 4/12/23, at 5:25 P.M., the Administrator said he/she expected the facility to have enough staff to meet all the residents needs. NOTE: At the time of the abbreviated 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 ensure one resident (Resident #38) in a sample of 20 residents, who presented with diagnoses of bipolar and depression and who has a history of past traumatic events, including abuse and suicide attempts, received the necessary behavioral health care services to maintain the highest practicable physical, mental and psychosocial well-being. The facility failed to obtain the resident's level II screening completed in 2016. The facility also failed to obtain a level II screening when the resident had a change in behavior and status. Staff have not been educated regarding behaviors or mental illness and did not identify behavioral triggers or past traumatic experiences that affected the resident. The facility failed to identify the resident's worsening depression and to investigate the root cause of the resident's behaviors, including possible suicidal thoughts and to address appropriately. Instead, staff reinforced the resident's negative behaviors through their interactions with the resident. There was no care plan to direct staff in appropriate interaction and care of this resident with behavioral health care needs. The facility census was 92. The administrator was notified of the Immediate Jeopardy (IJ) on 4/13/23 at 5:15 P.M. which began on 4/10/23. The IJ was removed on 4/19/23 as confirmed by surveyor onsite verification. Review of the facility's policy Behavioral Health Services, dated 8/29/22, showed the following: -The facility will provide behavioral health care and services that create an environment that promotes emotional and psychosocial well-being, meets each resident's needs, and includes individualized approaches to care. -Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. -A resident whose assessment did not reveal or who does not have a diagnosis of a mental or psychosocial adjustment difficulty or a documented history of trauma and/or post-traumatic stress disorder does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident's clinical condition demonstrates that development of such a pattern was unavoidable; -Highest practicable physical, mental, and psychosocial well-being - is defined as the highest possible level of functioning and well-being, limited by the individual's recognized pathology and normal aging process. Highest practicable is determined through the comprehensive resident assessment and by recognizing and competently and thoroughly addressing the physical, mental or psychosocial needs of the individual. -Mental disorder - is a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. 1. Complete the nursing assessment and Social Services assessment upon admission/readmission, quarterly, and as needed with change in condition. Through this assessment the facility should identify residents who; a. Develop decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, and may have made verbalizations indicating these. b. Evaluate whether the resident's distress was attributable to their clinical condition and demonstrate that the change in behavior was unavoidable. c. Ensure an accurate diagnosis of a mental disorder or psychosocial adjustment difficulty, or PTSD (The condition may last months or years, with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions) was made by a qualified professional. 2. Identify if resident would benefit based on above assessment in conjunction with; mental health history, and current medication regimen additional mental health consultation (psychiatry, psychology, clinical social work). If a determined need is present, the facility should consult with attending physician to make referral to mental health professional for assessment and potential for ongoing follow-up. 3. Initiate Behavior Monitoring, Behavior Management Care Plan as indicated by assessment findings, use of psychoactive medications, resident/responsible party conversations, and observations. The Social Worker is primarily responsible for initiation of the Behavior Management Care Plan. 4. The facility must provide necessary behavioral health care and services which include: a. Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. b. Ensuring direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being. c. Providing an environment and atmosphere that is conducive to mental and psychosocial well-being. d. Providing meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community. Meaningful activities are those that address the resident's customary routines, interests, preferences, etc. and enhance the resident's well- being. e. Ensuring that pharmacological interventions are only used when nonpharmacological interventions are ineffective or when clinically indicated. 5. Communicate the Behavior Management Care Plan to the resident and/or responsible party and to relevant members of the interdisciplinary team. 6. Provide resident/responsible party and staff education as needed. 7. Review and revise the Behavior Management Care Plan as indicated. 1. Review of Resident #38's Preadmission Screening and Resident Review (PASRR), dated 11/17/16, showed the following: -Psychiatric diagnosis: bipolar disorder (mental condition marked by alternating periods of elation and depression), anxiety, adjustment disorder (a group of symptoms, such as stress, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event, reaction to the event are stronger than expected for the type of event that occurred), depressive disorder, post traumatic stress disorder (PTSD) (a mental health condition that's triggered by a terrifying event. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), borderline intellectual functioning, borderline personality disorder (a mental illness that severely impacts a person's ability to regulate their emotions. This loss of emotional control can increase impulsivity, affect how a person feels about themselves, and negatively impact their relationships with others), dependent personality disorder (a mental disorder that cause one to often feel helpless, submissive or incapable of taking care of themselves), blindness at birth (corrected with glasses); -Symptoms to support diagnosis: anxiety, depression, poor judgment, poor impulse control and history of suicidal ideation, inpatient stay July 2016; -Physical abuse by step parent; -Hospital stay July 2016 due to suicidal ideation after his/her children were removed from his/her care, (this is second hospitalization this year); -Records note history of labile mood, nightmares, and flashbacks related to past abuse; -Depressed over this hospitalization because he/she has not had thoughts of hurting himself/herself this admission; -Current symptoms include: anxiety, depression and poor impulse control; -Current psychiatric support/services: medication therapy administration and monitoring, psychiatric service provider, and safety precautions; -Medical diagnosis include: lymphedema, and chronic obstructive pulmonary disease; -Recommend ongoing psychiatric care and treatment, implementation of systematic plans to change inappropriate behavior, medication therapy and monitoring, structured environment, Activity of Daily Living (ADL) programs to increase independence and self-determination, development of personal support networks; -Would benefit from guardianship, family support/education, nutritional evaluation, art/music therapy, pet therapy, recreational therapy, grief/loss/adjustment counseling/emotional support, medication education/counseling, financial assistance/eligibility evaluation, medical follow up ongoing, and medication review ongoing; -Department of Mental Health records indicate resident received mental health services dating back to August 2008. The facility did not obtain this report on admission. The report was obtained through Central Office Medical Review Unit (COMRU) at the Department of Health and Senior Services (DHSS) by the surveyor. The facility did not have a copy of the residents PASRR. Review of the resident's Trauma Informed Care Assessment, dated 11/19/19, showed staff were not aware of any past traumatic events for the resident. Review of the resident's Trauma Informed Care Assessment, dated 2/16/21, showed staff were not aware of any past traumatic events for the resident. Staff did not identify the traumatic events listed in the resident's PASRR. Review of the resident's Telehealth (health provider visit via computer not in person) Psychiatric Note, dated 12/14/22, showed the following: -Resident seen via telehealth in his/her room; -Stable and at baseline, no behaviors reported, No suicidal or homicidal ideations; -Due to the nature of mental illness, he/she is unable to definitively state whether this resident is likely to attempt suicide or become physically aggressive; -Complexity of the resident's mental condition is severe; -Current medications are helping: -Current suicide risk at this time is low; -Follow up with primary care physician as needed; -Ensure adequate safety, nutrition and hydration; -Staff to continue to monitor and report for worsening of depression, anxiety, changes in condition, mental status changes or behavioral disturbances. Review of the residents record of One to One Activities, dated January 2023, showed the following: -1/6/23 nails, 10 minutes; -1/12/23 brought the resident busy bags pages to keep him/her busy, 5 minutes; -1/24/23 played a game farkle +25 minutes. Review of the resident's Care Plan, last reviewed 2/1/23, showed the following: -Resident has a diagnosis of depression and antidepressant medication, mood and cognition fluctuate due to his/her bipolar disorder, and at risk for change in mood and behavior related to medical condition; -Resident has anxious/tearful and attention seeking behaviors at times that are not always easily redirected and makes untruthful statements to gain attention. Resident has a history of manipulative behaviors and is at risk for being manipulated by others due to cognitive level/functioning; -Goal: resident will remain free of signs and symptoms of depression, anxiety or sad mood, and the resident will not harm self or others through next review; -Always treat any resident with dignity and respect; -Consult with resident on preferences regarding customary routine; -Psychiatric consult as indicated; -Encourage resident to express feelings; -Offer one on one conversations, visiting with other residents, visits from facility pets, likes to color in adult color books, phone calls with family and friends; -Offer activities that are brief and can be done in the resident's room; -Observe for and report any signs and symptoms of depression including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health related complaints, tearfulness, mood changes, making untruthful statements, and attention seeking behaviors; -When this resident makes untruthful statements, let the resident know that this behavior is not appropriate; -Allow resident to vent/share in a nonjudgmental way; -Assist/encourage/support the resident to set realistic goals; -Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears; -Consult with pastoral care, social services, and psychiatric services if requested; -Encourage participation from resident who relies on other to make decisions, to participate in facility life of choice; -Increase communication between resident/family/caregivers about care and living environment; -Observe for resident's usual response to problems; -Resident has a court appointed public administrator (PA), keep PA updated of resident behaviors and follow guidelines, boundaries, and instructions set by public administrator that are in the best interest of the resident. The facility did not obtain the resident's PASRR and did not include the recommendations from the PASRR, including the resident's history of post traumatic stress disorder, abuse, or other mental diagnosis. The care plan also did not contain the recommendations for art/music therapy, pet therapy, recreational therapy, grief/loss/adjustment counseling/emotional support, and medication education/counseling. The care plan did not show evidence of updates when the resident made allegations of staff treatment of the resident or resident being tearful and saying he/she wanted to go to heaven. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment, dated 2/16/23, showed the following: -Diagnosis included bipolar, anxiety, depression, cellulitis (infection of tissue) both lower extremities, lymphedema (swelling in an arm or leg caused by a lymphatic system blockage), morbid obesity, secondary hyperaldosteronism (high aldosterone levels can cause high blood pressure and low potassium levels. Low potassium levels may cause weakness, tingling, muscle spasms, and periods of temporary paralysis), hypokalemia (low potassium levels), history of blood clots; -The resident has not been evaluated by Level II PASRR; -No significant mental illness or conditions related to mental retardation or developmental delays marked as present; -Vision impaired sees large print but not regular print with corrective lenses; -Cognitively intact; -Moderately severe depression signs and symptoms; -Nearly everyday the resident has: little interest or pleasure in doing things; feeling down, depressed, or hopeless; feeling tired or having little energy; poor appetite or overeating; -Several days: feels bad about yourself, or that you are a failure or have let yourself or your family down; -No behaviors or rejection of care; -Resident preferences showed it is somewhat important to have snacks between meals; -Activities that are very important to the resident included music he/she likes, pets, keeping up with the news, doing favorite activities, going outside is important -but can't, or no choice, religious activities, and it is somewhat important to do things with groups of people; -Requires limited assistance of two or more staff for dressing and hygiene; -Requires extensive assistance of two or more staff for bed mobility, toilet use, and bathing; -Transfers and locomotion did not occur; -Functional limitation in range of motion to both lower extremities; -No mobility devices; -Scheduled and PRN (as needed) pain medications; -Pain frequently, makes it hard to sleep at night, limits day to day activities and rates pain a 10 on a scale of 0-10; -Short of breath with exertion and while lying flat; -Weight 412 pounds (lbs); -Antianxiety, antidepressants, and diuretics daily. During an interview on 4/10/23, at 12:27 P.M., the resident said the following: -The nurses aides aren't nice to him/her; -He/She pushed his/her call light, Certified Nurse Assistant (CNA) O came in and he/she asked for a soda; -CNA O said he/she had to ask the nurse first, CNA O said it angrily; -A while had past and he/she didn't know if CNA O was coming back and he/she turned his/her light back on because the window was open and he/she was getting cold; -CNA O returned and said, You knew I was coming right back, I hope you don't ask for anything else through the night; -CNA H on nights was snappy and rude with the resident and doesn't wake the resident up to change him/her; -CNA P works nights and is rude, snooty, mean, hateful, and snobby; -The resident said he/she asked to be moved off the hall; -Registered Nurse (RN) BB and Licensed Practical Nurse (LPN) R are rude and snappy; -LPN R is supposed to put the resident on the list to see his/her physician tomorrow, he/she wont, he/she never does; -LPN R did not come back and look at the resident's leg after CNA Z and CNA EE reported that it was still bleeding. LPN R won't, he/she never comes in when staff report things; -The resident said he/she felt ignored, like he/she isn't good enough to exist, and some staff make him/her feel like an inconvenience. He/She cannot get out of bed or go get anything for himself/herself; -He/She has told the Administrator (ADM) all of this before, he says he will check into it and never tells the resident anything afterwards. During an interview on 4/11/23 at 10:16 A.M., the resident said the following: -The nurse last night, LPN FF, told him/her that he/she cries wolf and makes allegations that aren't true and then the nurse took forever to bring a pain pill; - He/She is not sure how long the light bulb is burnt out over his/her bed; -Last night CNA CC said, Go to sleep because he/she was tired of coming in my room. Observation on 4/11/23, at 10:23 A.M., showed the Social Service Director (SSD) came into the resident's room. The resident began to cry, and said, I'm so glad your here, I need a friend, I just want to go home to heaven, I will be so much happier there, no one will pick on me there. Review of the resident's medical record showed no evidence the resident's statement regarding the resident wanted to go to heaven where staff would not pick on her to the SSD was addressed. There were no nurses notes or notifications to the physician documented. During an interview on 4/12/23, at 5:35 A.M., Registered Nurse (RN) DD said the following: -Some nights the resident may request 12 snacks and fluids all night even though the resident knows it is bad for him/her; -Some staff feel the need to educate the resident on what he/she eats and drinks related to his/her condition every time he/she requests it, which can come off as lecturing or berating; -He/She has instructed the staff to not comment on what the resident wants, the resident is aware of his/her condition; -Administrative staff are aware of his/her concerns. During an interview on 4/12/23, at 11:38 A.M., the resident said the following: -The ADM came and interviewed him/her on 4/11/23 and he/she told the ADM all of his/her staff concerns; -The staff say he/she refuses to get up out of bed, but the sling the facility has cuts into his/her legs, staff wouldn't get up if they would get cuts; -He/She would like to go outside with his/her depression or have a service dog, because he/she has severe bipolar disorder; -It was hard to stay happy; -CNA CC usually says What do you want? in a hateful way when he/she uses the call light and ask for ice or water; -Last time he/she asked CNA CC for ice and water around 10:00 P.M. the CNA said, You will have to wait until I pass ice at 11:30 P.M. which he/she thinks was a long time to be thirsty; -He/She has been physically or emotionally abused his/her whole life; -RN BB once made him/her wait three hours for a pain pill. RN BB always has an attitude; -He/She reported to CNA O one time that he/she was in pain, the CNA told him/her, Suck it up buttercup, you asked for this; -CNA H is another staff member who is not good to him/her, he/she was moved to another hall, but he/she would tell the nurses the resident refused to get changed when the CNA just wouldn't wake the resident up. If CNA H was mad at the resident he/she would report to the nurse that the resident refused to be changed; -The physician did not come see him/her, he/she doesn't think the nurse even put him/her on the list; -The Director of Nursing (DON) said they interviewed LPN FF and the reason he/she said the resident cried wolf is because the resident had asked for pain medication but when he/she came in the room she said the resident was on the phone laughing; -The resident said he/she may have not been in extreme pain when lying flat, but it was almost time for the staff to change him/her and that causes extreme pain; -It really hurts his/her feelings when they are so mean and rude to him/her; -He/She has asked the staff What did I ever do to you?; -CNA CC will say things like, if you want to waste your body away that's on you; -The resident said, The way they treat me makes me depressed; -He/She sees the psychiatric nurse practitioner with telehealth once a month, but he/she doesn't talk to him/her much, just reviews his/her medications and asks some questions. This was not like counseling; -The resident said, I want to go home to heaven, in heaven no one would pick on him/her; -The resident said it would be nice to have counseling or someone to talk to about things; -The resident said he/she was raped by his/her spouse, and was physically abused by him/her; -He/She had an inpatient stay in a psychiatric hospital in 2016 when he/she was suicidal and quit taking his/her bipolar medications; -That was when he/she lost his/her three children; -He/She had a boyfriend/girlfriend and was emotionally and physically abused; -He/She loves music, reading his/her Bible and his/her friends at the facility; -The activity director has been busy but he/she used to come play a game with the resident and his/her roommate once a week, now it's about once every month or two because he/she has personal stuff and has to leave by 3:00 P.M.; -He/She would like to play cards or games everyday, he/she really enjoyed games; -He/She would love to paint ,but the facility doesn't allow the residents to have paint in their rooms now; -He/She can't leave his/her room so he/she does not feel safe if there is a fire or tornado, he/she does not feel emotionally safe at the facility. During an interview on 4/12/23, at 2:51 P.M. and 4/20/23, at 4:00 P.M., the Director of Nursing (DON) said the following: -The resident is bipolar; -The resident has not received any professional counseling. The resident does see a psychiatric nurse practitioner for medication management via telehealth; -The resident was young and bored; -The resident has behaviors and needs tender loving care; -The resident calls the Social Services Director (SSD) when he/she is upset; -A PASRR is done on admission and with changes. The MDS Coordinator is in charge of that process; -The resident does not have a wheelchair that fits him/her; -She does not know if the resident is over the weight limit of the hoyer lift; -The DON relayed that besides the resident's weight and debility, the resident also has panic attacks when staff have attempted to get him/her up out of bed. The resident was scared and fearful; -The facility has a computer based education program that reviewed behavioral health care needs, he/she is not sure of the content or how often it is required, or if it is mandatory; -The facility has limited resources for mental health services; -She did not know if the facility could/would pay for mental health services. During an interview on 4/20/23, at 4:00 P.M., the Administrator said the following: -Traumatic events are expected to be captured on the trauma assessment, those events should be evaluated and interventions should be on the care plan; -Counseling should be provided for those residents with PTSD. NOTE: At the time of the recertification 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 G 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). 38016

Based on observation, interview, and record review, the facility failed to failed to provide a wheelchair and a lift sling to accommodate one resident (Resident #38) and failed to ensure call lights were in reach for three residents (Resident #28, #63, and #147), in a review of 20 sampled residents. Resident #38 was unable to transfer from his/her bed as the sling used with the facility's mechanical lift caused severe pain, cutting into his/her legs. Additionally, the facility did not have a wheelchair that fit the resident's physical needs. As a result, the resident's movements were restricted to his/her room for over two years, contributing to the resident feeling depressed and unsafe. The facility census was 92. Review of the facility policy Resident Rights last reviewed 10/6/22 showed a facility must care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The resident has the right to receive the services and/or items included in the plan of care. Review of the facility policy Resident Call System last revised 1/4/23 showed the following: -The facility must be adequately equipped to allow residents to call for assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities; -The call light should be positioned within reach of the resident; -The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room; -The call system must be accessible to the resident at each toilet and bath or shower facility 1. Review of Resident #38's face sheet showed the resident's diagnosis include bipolar disorder (drastic mood swings from depressed to elated), anxiety, depression, cellulitis both lower extremities, deep vein thrombosis (blood clots), arthritis, lymphedema (swelling in an arm or leg caused by a lymphatic system blockage), and morbid obesity. Review of the resident's Care Plan, last reviewed 6/24/21, showed the following: -Requires hoyer lift (mechanical lift) for transfers, but has been unable to transfer due to complaints of pain when getting out of bed; -The resident chooses to stay in bed at all times; -He/She cannot exit his/her bed without total assist of staff and is refusing to get out of bed. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 2/16/23, showed the following: -Cognitively intact; -Required extensive assistance from two or more staff for bed mobility, -Transfers and locomotion did not occur; -Functional limitation in range of motion to both lower extremities; -No mobility devices; -He/She weighed 412 pounds (lbs). Observation on 4/12/23 at 9:30 A.M., showed the following: -The resident lay in a bariatric bed; -The resident's bed was visibly wider than the doorframe to the resident's room; -The resident's weight was primarily in his/her lower body related to lymphedema; -His/Her legs went from one side of the bed to the other side of the bed, with very little room left at the edge of the bed; -The resident's legs were swollen and weeping (fluids leaking from the skin); -The resident did not have a sling for a mechanical lift or a full size sheet in his/her room. During an interview on 4/12/23, at 11:28 A.M., Licensed Practical Nurse (LPN) Q said the following: -The resident had not been weighed in quite a while; -He/she refuses because the hoyer lift sling hurts him/her; -He/She thought occupational therapy was working to get a wheelchair for the resident but hadn't heard anything about it in a while. During an interview on 4/12/23, at 11:38 A.M., the resident said the following: -He/She had been in his/her room in his/her bed for three years, except for a hospitalization , and once to get his/her hair dyed; -He/She was to be weighed daily, but staff had not weighed him/her in about a year because the sling hurt his/her legs too much to be lifted with the mechanical lift; -The staff say he/she refuses to get up, but the sling the facility has cuts into his/her legs; -The hoyer lift hurts so bad he/she does not want to get up in the hoyer lift; -His/Her lymphedema got worse and his/her legs got bigger. The wheelchair he/she had was not safe, it would tip forward; -The occupational therapist had him/her measured for a custom wheelchair, but the company went out of business and he/she has not heard anything else; -He/She would like to play cards or games everyday, he/she really enjoys games; -He/She would love to paint, but the facility doesn't allow the residents to have paint in their rooms now; -He/She can't leave his/her room so he/she does not feel safe if there is a fire or tornado, he/she does not feel emotionally safe at the facility. During an interview on 4/12/23, at 1:25 P.M., Certified Nurse Assistant (CNA) MM said the following: -The facility had slings for the hoyer lift that were rated for 440 lbs; -All the lift slings go around the resident's legs; -The facility does not have slings that are solid under the resident's whole body. During interviews on 4/12/23, at 1:30 P.M. and 2:15 P.M., LPN/Infection Preventionist (IP) QQ said the corporate approved brand of hoyer lifts does not make a full body solid sling, so the resident would have to use the sling that goes between his/her legs with the lift. During an interview on 4/12/23, at 2:37 P.M., Physical Therapy Assistant (PTA) RR said the following: -Occupation therapy was working with a company to get a custom wheelchair for the resident; -About four months ago, the company went out of business; -They have not been able to find another company to make the resident a custom wheelchair; -A regular bariatric chair would be so uncomfortable; -Therapy has tried to get the resident out of bed with the hoyer lift, but the facility does not have a sling that will fit around the resident's legs; -Therapy tried the facility's slings three to four times, and the last time the resident had cuts into his/her legs; -The hoyer lift sling hurts the resident. During an interview on 4/12/23, at 2:51 P.M., the Director of Nursing said the following: -The resident does not have a wheelchair that fits him/her; -His/Her legs got too big for his/her wheelchair, and the facility had not been able to get him/her a custom chair, therapy was working on it and the company went out of business; -He/She did not know if the resident was over the weight limit of the hoyer lift because they have not been able to weigh the resident. During an interview on 4/12/23 at 5:25 P.M., the Administrator said the following: -He did not know if the facility had a lift or sling that fit the resident; -The therapy staff tried to get a custom chair for the resident but there was a problem with the company. 2. Review of Resident #63's care plan, last revised 2/15/23, showed the following: -The resident was at risk for seizures; -The resident will occasionally press his/her call light when he/she believes he/she is having a seizure or is about to have a seizure; -Keep the call light within reach and encourage the resident to ask for assistance as needed. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 4/5/23, showed the following: -Severely impaired cognition; -Required extensive assistance from two staff for bed mobility and transfers; -Required extensive assistance from one staff for locomotion on and off unit; -Used a wheelchair. Observation on 4/10/23 at 9:27 A.M. showed the following: -The resident lay in his/her bed; -His/Her soft touch call light lay on the floor on the right side of the bed, out of the resident's reach. Observation on 4/11/23 at 4:50 P.M. showed the following: -The resident sat in his/her wheelchair to the left side of his/her bed; -The resident said he/she was cold; -The resident's call light lay on the floor on the right side of the bed; -The resident's roommate put on his/her call light for the resident, and said he/she saw the resident's call light on the floor a lot. Observations on 4/18/23 showed the following: -At 11:25 A.M., the resident sat in his/her wheelchair to the left side of the bed. The resident's soft touch call light lay on the floor to the right side of the bed. -At 6:10 P.M., the resident lay in bed with the head elevated. The call light was attached to siderail (which was lowered) and rested on the floor (on the right side of the bed), out of the resident's reach. 3. Review of resident #147's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Always incontinent of bowel and bladder; -Required extensive assistance from two staff for bed mobility, dressing and personal hygiene. Review of the resident's care plan, last revised 3/6/23, showed the following: -Diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning); -Assist with bed mobility, dressing and personal hygiene; -Ensure the resident's safety at all times; -Keep call light in reach. During interview on 4/11/23 at 3:00 P.M., the resident's family member said a few days ago the resident phoned to say he/she could not reach/find the call light. The family member called the facility at 9:00 A.M., spoke with an unknown staff and informed them that the resident could not reach the call light and needed attention. At 10:30 A.M., he/she spoke with the resident and no one had responded, so he/she called the facility again and this time he/she spoke with LPN D who responded right away. 4. Review of Resident #28's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included Alzheimer's disease and dementia; -Required extensive assistance from two staff for bed mobility, transfers, and toileting; -Used a wheelchair. Review of the resident's care plan, dated 4/4/23, showed the following: -The resident had limited mobility and activity of daily living (ADL) function due to Alzheimer's dementia, congestive heart failure and adult failure to thrive; -He/She was at risk for falls due to his/her limited mobility, unsteadiness, muscle weakness and history of falling with poor safety awareness; -The resident required extensive assistance from two staff for dressing, personal hygiene, toileting and transferring; -The resident was unable to ambulate at this time due to unsteadiness and weakness; -He/She used a wheelchair for his/her primary mode of locomotion and was dependent on staff to propel his/her wheelchair; -Keep call light within reach and encourage the resident to ask for assistance as needed. Observation on 4/10/23 at 9:40 A.M., showed the resident lay in bed on his/her back. The call light hung on the wall and was not in the resident's reach. Observation on 4/12/23 at 8:35 A.M., showed the resident sat on the side of his/her bed. The resident's call light hung on the wall and was not in the resident's reach. 5. During interview on 4/20/23 at 4:00 P.M. the Director of Nursing (DON) and the regional vice president said they expected call lights to be within the resident's reach at all times whether they were in the bed or up in a chair. During interview on 4/20/23 at 4:00 P.M., the administrator said call lights should be in the resident's reach at all times when they are in their rooms. MO216336

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #38), a resident with a past history of abuse and diagnoses including post traumatic stress disorder and depression, in a review of twenty sampled residents, was free from mental and emotional abuse. The resident was totally dependent on staff and was bed bound as a result of facility failure to ensure he/she had appropriate transfer equipment. The resident had not been able to leave his/her room in at least two years and participate in any activity outside of his/her room. The resident was alert and oriented. The resident reported staff were mean and hateful in their interactions with him/her, he/she felt ignored and an inconvenience for staff. Staff accused him/her of crying wolf and wasting his/her body. The resident relayed this made him/her feel humiliated and treated in a way that made him/her feel like staff did not like him/her. As a result of staff treatment, relative to her diagnoses and past experiences, the resident verbalized wanting to go home to heaven because no one would pick on him/her there. The facility census was 92. Review of the facility's policy Abuse Identification, dated 10/4/22, showed the following: -It is the policy of this facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to identifying and understanding the different types of abuse and possible indicators. -The facility will apply the following definitions to identify abuse, neglect, and exploitation. -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are residents from abuse. necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Involuntary seclusion is defined as separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the resident representative; -Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. -Willful is defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation; -Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse include, but are not limited to: o Harassing a resident; o Mocking, insulting, ridiculing; o Yelling or hovering over a resident, with the intent to intimidate; o Threatening residents, including but limited to, depriving a resident of care or withholding a resident from contact with family and friends; and o Isolating a resident from social interaction or activities. -Literature indicates that the most prevalent psychosocial outcomes of abuse are depression, anxiety, and posttraumatic disorder; -Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. o Neglect of goods or services may occur when staff are aware, or should be aware, of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as lack of training to perform an intervention (e.g., suctioning, transfers, use of equipment), lack of sufficient staffing to be able to provide the services, lack of supplies, or staff lack of knowledge of the needs of the resident. -Involuntary seclusion occurs when separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the resident representative o Involuntary seclusion may take many forms, including but not limited to the confinement, restriction or isolation of a resident. o Involuntary seclusion may be a result of staff convenience, a display of power from the caregiver over the resident or may be used to discipline a resident for wandering, yelling, repeatedly requesting care or services, using the call light, disrupting a program or activity, or refusing to allow care or services such as showering or bathing to occur. 1. Review of Resident #38's Preadmission Screening and Resident Review (PASRR) (a federally mandated screening process), dated 11/17/16, obtained by the state agency showed the following: -Psychiatric diagnosis: bipolar disorder (mental condition marked by alternating periods of elation and depression), anxiety, adjustment disorder (a group of symptoms, such as stress, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event, reaction to the event are stronger than expected for the type of event that occurred), depressive disorder post traumatic stress disorder (PTSD) (a mental health condition that's triggered by a terrifying event. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), borderline intellectual functioning, borderline personality disorder (a mental illness that severely impacts a person's ability to regulate their emotions. This loss of emotional control can increase impulsivity, affect how a person feels about themselves, and negatively impact their relationships with others), dependent personality disorder (a mental disorder that cause one to often feel helpless, submissive or incapable of taking care of themselves), blindness at birth (corrected with glasses); -Symptoms to support diagnosis: anxiety, depression, poor judgment, poor impulse control and history of suicidal ideation, inpatient stay July 2016; -Physical abuse by step parent; -Hospital stay July 2016 due to suicidal ideation after his/her children were removed from his/her care, (this is second hospitalization this year); -Records note history of labile mood, nightmares, and flashbacks related to past abuse; -Depressed over this hospitalization because he/she has not had thoughts of hurting himself/herself this admission; -Current symptoms include: anxiety, depression and poor impulse control; -Current psychiatric support/services: medication therapy administration and monitoring, psychiatric service provider, and safety precautions; -Recommend ongoing psychiatric care and treatment, implementation of systematic plans to change inappropriate behavior, medication therapy and monitoring, structured environment, ADL programs to increase independence and self-determination, development of personal support networks; -Would benefit from guardianship, family support/education, nutritional evaluation, art/music therapy, pet therapy, recreational therapy, grief/loss/adjustment counseling/emotional support, medication education/counseling, financial assistance/eligibility evaluation, medical follow up ongoing, and medication review ongoing. Review of the resident's Care Plan, last reviewed 2/1/23, showed the following: -Resident has a diagnosis of depression and is prescribed antidepressant medication; mood and cognition fluctuate due to his/her bipolar disorder, and is at risk for change in mood and behavior related to medical condition; -Resident has anxious/tearful and attention seeking behaviors at times that are not always easily redirected and makes untruthful statements to gain attention, resident has a history of manipulative behaviors and is at risk for being manipulated by others due to cognitive level/functioning; -Goal: resident will remain free of signs and symptoms of depression, anxiety or sad mood, and the resident will not harm self or others through next review; -Always treat any resident with dignity and respect; -Consult with the resident on preferences regarding customary routine; -Encourage resident to express feelings; -Offer one on one conversations, visiting with other residents, visits from facility pets, likes to color in adult color books, phone calls with family and friends; -Observe for and report any signs and symptoms of depression including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health related complaints, tearfulness, mood changes, making untruthful statements, and attention seeking behaviors; -When this resident makes untruthful statements, let the resident know that this behavior is not appropriate; -Allow resident to vent/share in a nonjudgmental way; -Assist/encourage/support the resident to set realistic goals; -Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears; -Encourage participation from the resident who relies on others to make decisions and to participate in facility life of choice; -Increase communication between resident/family/caregivers about care and living environment; -Observe for resident's usual response to problems. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff), dated 2/16/23, showed the following: -Diagnosis included bipolar, anxiety, and depression, -The resident has not been evaluated by Level II PASRR (an assessment completed on those residents identified during the Level I screening who are known or suspected to have a serious mental illness (such as schizophrenia, dementia, major depression, etc., mental retardation (MR) or related MR conditions to determine the need for specialized service); -Cognitively intact; -Moderately severe depression signs and symptoms; -Nearly everyday the resident has little interest or pleasure in doing things, feels down, depressed, or hopeless; feels tired or having little energy; poor appetite or overeating; -Several days: feels bad about self or that he/she has let self or your family down; -No behaviors or rejection of care; -Preferences: It is somewhat important to have snacks between meals; -Activities that are very important to the resident included: music; he/she likes pets, keeping up with the news, doing favorite activities, going outside is important -but can't, or no choice, religious activities and it is somewhat important to do things with groups of people; -Requires extensive assistance of two or more staff for bed mobility, toilet use, and bathing; -Transfers and locomotion did not occur; -Functional limitation in range of motion to both lower extremities; -No mobility devices; -Scheduled and PRN (as needed) pain medications; -Pain frequently, makes it hard to sleep at night, limits day to day activities and rates pain a 10 on a scale of 0-10; -Incontinent of bowel and bladder. During an interview on 4/10/23, at 12:27 P.M., the resident said the following: -The nurse aides aren't nice to him/her; -He/She pushed his/her call light and Certified Nurse Assistant (CNA) O came in; -CNA O's reply to his/her request was anger and that the he/she would need to ask the nurse first; -A while had passed and he/she didn't know if CNA O was coming back, so he/she turned his/her light back on because the window was open and he/she was getting cold; -CNA O came back and said, You knew I was coming right back, I hope you don't ask for anything else through the night; -CNA H works nights and is snappy and rude; CNA H does not wake the resident up to change him/her; -CNA P works nights and is also rude, snooty, mean, hateful, and snobby; -The resident said he/she asked to be moved off the hall because of the way staff treat him/her; -Registered Nurse (RN) BB and Licensed Practical Nurse (LPN) R are rude and snappy; -LPN R was supposed to put the resident on the list to see his/her physician tomorrow. LPN R won't do this, he/she never does; -LPN R did not come back and look at his/her leg after CNA Z and CNA EE reported that it was still bleeding; he/she won't, he/she never comes in when staff report things; -The resident said he/she feels ignored, like he/she isn't good enough to exist, and some staff make him/her feel like an inconvenience, but he/she cannot get out of bed or go get anything himself/herself; -Resident said he/she has told the administrator all of this before; he says he will check into it and never tells the resident anything afterwards. During an interview on 4/11/23 at 10:16 A.M., the resident said the following: -The nurse last night, LPN FF, told him/her he/she cries wolf and makes allegations that aren't true. LPN FF took forever to bring him/her a pain pill; -Last night, CNA CC said, Go to sleep, he/she was tired of coming in my room. Observation on 4/11/23, at 10:23 A.M., showed the Social Service Director (SSD) came into the resident's room. The resident began to cry, and said, I'm so glad you're here. I need a friend. I just want to go home to heaven. I will be so much happier there. No one will pick on me there. The SSD comforted the resident while in the room, but did not document or report to nursing the resident's concerns. During an interview on 4/12/23, at 11:38 A.M., the resident said the following: -The administrator came and interviewed him/her on 4/11/23 and he/she told the administrator all of his/her concerns about how staff are treating him/her; -The staff say he/she refuses to get up, but the sling the facility uses for the mechanical lift cuts into his/her legs, and that is why he/she doesn't want to get up. He/She does want to get out of bed and out of his/her room; -CNA CC usually responds to him/her by saying, What do you want, in a hateful way when he/she uses the call light and asks for ice or water; -Last time he/she asked CNA CC for ice and water around 10:00 P.M., the CNA said, You will have to wait until I pass ice at 11:30 P.M., which he/she thinks is a long time to be thirsty; -He/She has been physically or emotionally abused his/her whole life; -Registered Nurse (RN) BB once made him/her wait three hours for a pain pill; RN BB always has an attitude; -He/She reported to CNA O one time that he/she was in pain and CNA O told him/her to, Suck it up buttercup, you asked for this; -CNA H would tell the nurses he/she (the resident) refused to get changed, but he/she (CNA H) just wouldn't wake him/her up. If CNA H was mad at him/her, he/she (CNA H) would say he/she would report to the nurse that he/she (the resident) refused to be changed; -The Director of Nurses (DON) said they interviewed LPN FF and the reason he/she said the resident cried wolf is because the resident had asked for pain medication but when he/she came in the room he/she said the resident was on the phone laughing; -The resident said he/she may have not been in extreme pain when lying flat, but it was almost time for the staff to change him/her and that causes extreme pain; -It really hurts his/her feelings when staff are so mean and rude to him/her; -He/She has asked the staff What did I ever do to you; -CNA CC will say things like, If you want to waste your body away, that's on you; -The resident said, The way they treat me makes me depressed; -The resident said, I want to go home to heaven; in heaven no one would pick on me. During an interview on 4/27/23, at 2:02 P.M., CNA O said the following: -One nurse, LPN PP, was snappy with residents all the time -Staff have reported to the Director of Nurses (DON), the DON said he/she would take care of it, but there have been no changes; -He/She has witnessed Licensed Practical Nurse (LPN) PP be rude and mean to residents including Resident #38; -Before Resident #38's fluid restriction was discontinued, LPN PP would be snappy about the fluid restriction or what Resident #38 was eating; -LPN PP brags about being hateful; -Resident #38 gets his/her feelings hurt often, sometimes as a result of staff's tone of voice; -LPN PP has lectured Resident #38 multiple times about food and drink; -He/She reported it to the charge nurse on 200/400 halls but nothing was done. During an interview on 4/27/23, at 3:15 P.M. LPN FF said the following: -He/She has had staff be rude and snappy with Resident #38. The resident will make up things at times; -The resident asks why does everybody hate her? LPN FF has told the resident that some staff are concerned or scared to take care of him/her. The resident will tell people little lies. The resident once called him/her a liar. He/She has not called the resident a liar; -Resident #38 asked him/her why staff do not like him/her, and he/she explained to the resident the staff feel like he/she will make up stories or turn things around on staff, and it makes staff leery to go into his/her room; -CNA CC would not always wake Resident #38 up to change him/her and say he/she did; CNA CC is no longer able to go in Resident #38's room; -CNA CC and Resident #38 have a clash of personalities, it's possible CNA CC was rude to Resident #38, or for him/her and the resident to go back and forth with each other. During an interview on 4/27/23, at 5:09 P.M., CNA H said the following: -LPN PP, has gotten snarky with residents; -LPN PP is rude and will argue with residents, this is a common occurrence; -He/She has witnessed LPN PP be rude and almost yelling at Resident #38; -He/She has reported to the administrator and he has not done anything about the report. He will say the nurse is short tempered or didn't do or say it out of malice and try to justify the actions. During an interview on 4/12/23, at 2:51 P.M., the DON said the following: -She did not feel Resident #38 was abused; -The resident was sensitive to what staff say to him/her; -The resident has behaviors. During an interview on 4/11/23, at 5:37 P.M., and 4/20/23, at 4:00 P.M. the administrator said the following: -Staff are expected to speak to residents with dignity and respect, and should not use a loud tone or be short with a resident; -Staff should not be rude to residents; -Staff are expected to report any concerns reported by a resident; -To decide if a report was abuse or a dignity issue, he would consider if the resident was alert and oriented, and how the resident received it; -Should consider how actions made the resident feel; -He did not believe the allegations made by Resident #38 were true.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #28), of 20 sampled residents, had a nutritional assessment completed on admission, received weights per facility protocol, and failed to ensure his/her feeding tube was connected as ordered for continuous feeding to ensure he/she received adequate nutrition. The resident had a 9.5 pound (-7.68%) weight loss in ten days. The facility also failed to re-evaluate interventions to prevent weight loss for effectiveness, carry through recommendations from the Registered Dietitian, notify physician and dietitian with further weight loss, failed to update the resident's care plan timely when new weight loss was identified and take action to prevent further weight loss, or identify possible need for adaptive equipment for one sampled resident (Resident #64), which resulted in a 31.6% significant weight loss and severe protein-calorie malnutrition. The facility census was 92. Review of facility policy, Weight Monitoring, Long-Term Care, revised: August 19, 2022, showed the following: -Introduction: -Following a routine weighing schedule helps detect weight changes; -Unless otherwise specified, a resident's weight should be recorded at the time of admission, weekly for 4 weeks, and then monthly; -Unplanned weight loss in residents is associated with increased mortality; a decrease in weight of 5% or more in a month or of more than 10% in 6 months should be reported to the practitioner for further evaluation; -Compare the resident's current weight with previous measurements to assess for trends in weight gain or loss; -If you note a weight change, assess the resident to help determine a possible cause of the weight change; -Notify the practitioner if weight changes are beyond the expected range; -Documentation associated with weight monitoring includes: a. Resident's weight, according to your facility's documentation format; b. Assessment findings; c. Date and time that you notified the practitioner of significant weight changes; d. Prescribed interventions; -The facility has approved the following information as an addendum to the Lippincott procedure: a. Follow facility protocol to determine who is assigned to obtain residents' weights and heights; b. Maintain consistency when obtaining repeated weights (i.e., weigh at the same time of day, with the same equipment, with the resident wearing similar clothing); c. Notify the nurse if the weight obtained is significantly different from the prior weight (2.3 lbs. for a weekly weight; 2.5 lbs. for a monthly weight); d. Re-weigh as needed; e. The unit manager/designee should review and verify the weights on the day they are obtained to ensure there is no unexplained significant variance from the prior weight by utilizing the weight reports in Point Click Care (PCC) (residents' electronic record). Review of facility policy, Nutrition Assessment, revised 12/16/21 and reviewed: 04/27/22, showed the following: -Policy: -A representative from the Food and Nutrition Services department visits all residents upon admission and routinely thereafter. Food preferences, nutritional history and a visual assessment are documented; - Each resident receives a comprehensive nutrition assessment to determine nutritional needs on admission, annually and when the resident becomes at risk for compromised nutritional status; -The Director of Food and Nutrition Services/ RD or designee completes the Nutrition Data Collection section and food and beverage preference list; -The Registered Dietitian reviews the information and completes the RD portion of the nutrition assessment on the next visit or per state regulation; -The Director of Food and Nutrition Services/ designee reviews the medical record and notes the relevant physician's orders and history/transfer information; -The nutrition data collection includes at least feeding, chewing and swallowing ability - from visual observation; -The Nutrition Data Collection/Assessment is completed on admission, annually and whenever the Comprehensive Minimum Data Set (MDS) is completed; -The Director of Food and Nutrition Services or designed visits each resident within 72 hours of admission; -The resident's nutritional status is updated as it changes, but no less than quarterly; -The Registered Dietitian assesses the resident to determine nutritional needs by reviewing the information and completing the RD portion of the nutrition assessment. If there is a contract RD, it will be completed on the next visit or per state regulation; -Nutrition assessment includes an estimate of calorie, nutrient and fluid needs. Approximate needs are compared with approximate intake to determine if present intake is adequate to meet those needs; -A systematic approach will be used to optimize a resident's nutritional status. The process includes identifying and assessing each resident's nutritional status and risk factors, evaluating/analyzing the assessment information, developing and consistent implementing pertinent approaches and monitoring the effectiveness of interventions and revising them as necessary. 1. Review of Resident #28's face sheet showed the resident was NPO (nothing by mouth) and received continuous tube feedings of Jevity 1.5 (nutritional formula). Review of the resident's physician order summary, dated 3/01/23 - 4/30/23, showed the following: -Diagnoses of Alzheimer's disease, adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition) and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function); -Enteral (nutrition received through an opening in the stomach through a tube), feed order every shift Jevity 1.5 Cal at 60 ml/hour (milliliters per hour) continuous feeding via pump. Flush with 100 ml water every 2 hours; -Verify percutaneous endoscopic gastronomy (PEG) (a tube through the skin and the stomach wall) tube placement by checking gastric residual volume (GRV) and observing changes in external length of tubing; -No order documented for obtaining the resident's weight. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff,dated 4/3/23, showed the following: -Date of admission: 3/30/23; -The resident has severe cognitive impairment; -His/Her diagnoses include Alzheimer's disease, dementia, malnutrition, and depression; -The resident had coughing or choking during meals or when swallowing medications; -The resident had complaints of difficulty or pain with swallowing; -The resident's admission weight was 134 pounds on 3/30/23; -He/She has a feeding tube; -The resident receives 51% or more total calories through feeding tube; -The resident receives an average of 501 cubic centimeter (cc) ( fluid volume measurement) /day or more fluid by feeding tube. Review of the resident's care plan dated 4/4/23, showed the following: -The resident has impaired cognitive ability and impaired thought processes related to Alzheimer's dementia; -The resident receives all fluids and nutrients via tube and he/she is at risk for weight fluctuations due to a history of congestive heart failure; -Administer the tube feedings and flushes as ordered; -Follow the NPO diet as ordered; -Obtain his/her weight per protocol; -Refer to the dietician as needed; -The resident is at risk for aspiration due to dysphagia; -Monitor the resident for any signs or symptoms of aspiration pneumonia after any episodes of coughing or choking while eating or drinking (fever, cough, wet breath sounds, lethargy, etc) and report to the primary care physician; -He/She asks for drinks frequently and does not follow his/her NPO status; -Provide oral care as needed and remind him/her or his/her NPO status. Review of the resident's medical record showed no weight documented for the week of 4/2/23 through 4/8/23. Review of the resident's medical record showed the resident weighed 135.4 pounds on 4/9/23. Observation of the resident on 4/10/23 at 9:40 A.M., showed the resident's tube feeding pump was turned off and the resident was not connected to the feeding pump to receive his/her ordered Jevity. Observation of the resident on 4/12/23 at 8:35 A.M., showed the following: -The resident sat on the side of the bed; -The resident was hooked up to tube feeding; -The tube feeding formula bag was empty, pump read error, and air was in the line approximately 14 inches leading from the pump; -The resident's pants looked to be several sizes too big. Observation of the resident on 4/12/23 at 9:30 A.M., showed the resident was outside smoking and was not connected to the tube feeding pump. Review of the nursing progress note, dated 4/12/23 at 2:47 P.M., showed the following: -Whenever staff is in the room the resident will ask for a drink and says he/she is thirsty; -At times when this nurse is in the room giving medications via PEG tube, the resident will lean down to attempt to drink from the syringe the medications are in; -When the resident reports he/she is thirsty, this nurse will give him/her swabs to wet his/her mouth and that typically satisfies the resident for a short period. Observation of the resident on 4/13/23 showed the following: -At 12:50 P.M., the resident in his/her bed and not connected to the tube feeding pump; -1:35 P.M., the resident sat at the nurses' station and not connected to the tube feeding pump; -2:00 P.M., the resident outside smoking and not connected to the tube feeding pump; -2:20 P.M., the resident sat at the nurses' station and not connected to the tube feeding pump; -2:45 P.M. the resident sat at the nurses' station and not connected to the tube feeding pump; -3:15 P.M., the resident outside smoking and not connected to the tube feeding pump; -3:30 P.M., the resident lay in his/her bed and not connected to the tube feeding pump; -3:35 P.M., Licensed Practical Nurse (LPN) A reconnected the resident to the feeding pump; -The resident had been off of his/her feeding pump two hours and forty five minutes, (the resident was to receive his/her tube feeding continuously per pump). During an interview on 4/13/23 at 3:35 P.M., LPN A said the resident asked to be unhooked from his/her tube feeding to go outside and smoke. When the Certified Nurse Assistants (CNA)s bring the resident back from smoking they let him/her know the resident is ready to be connected to his/her tube feeding. The CNA told him/her the resident was back in his/her room after being outside for smoke break. Review of the resident's nursing progress note, dated 4/16/23 at 3:22 A.M., showed staff documented the resident was found by this nurse up at the sink with the water running and water on the floor and his/her shirt. The resident had his/her feeding tube stretched to its capacity from the pole. The resident was educated on the importance of not drinking due to being NPO at this time and it was not safe. Review of the resident's nursing progress note, dated 4/17/23 at 1:18 P.M., showed staff documented the resident is saying frequently he/she is thirsty. Review of speech therapy treatment encounter note dated 4/17/23, showed the following: - NPO; -Resident educated about the severe risk of aspiration with thin liquids. Patient let speech therapist know that he/she realizes he/she should not have thin water, but was so thirsty. Observation of the resident on 4/18/23 showed the following: -At 1:20 P.M., the resident sat at the nurses' station and not connected to the tube feeding pump; -1:34 P.M., the resident outside smoking and not connected to the tube feeding pump; -2:00 P.M., the resident sat at the nurses' station and not connected to the tube feeding pump; -3:06 P.M., the resident sat at the door that leads outside to the smoking area and was not connected to the tube feeding pump; -5:11 P.M., the resident lay in bed and was not connected to the tube feeding pump; -5:43 P.M., the resident lay in bed and was not connected to the tube feeding pump; -5:55 P.M., the resident hooked up to his/her tube feeding pump; -The resident was off of his/her feeding pump four hours and thirty five minutes. Review of the resident's nursing progress note, dated 4/19/23 at 12:56 A.M., showed staff documented the resident requested water frequently. Review of nutrition assessment, dated 4/19/23, showed the following: -NPO; -Total amount of water received from enteral feeding and water flushes 2294 ml; -What percent of the estimated fluid need does the enteral feeding and water flushes provide?100%; -Admit assessment body weight 135 with body mass index (BMI) (a measure of body fat based on height and weight) 18.4 (underweight) and diagnosis of protein-calorie malnutrition. Nutrition needs based on weight gain/muscle maintenance. Goal is weight maintenance and tube feeding tolerance; -The nutrition assessment was completed 20 days after the resident's admission and after the surveyor interview inquiring about the assessment. Observation of the resident on 4/19/23 showed the following: -At 10:40 A.M., the resident sat in his/her room and not connected to the feeding pump; -12:10 P.M., Licensed Practical Nurse (LPN) A reconnected the feeding pump for the resident; -The resident had been off of his/her feeding pump one hour and thirty minutes. Observation on 4/19/23 at 1:32 P.M., showed the following: -Certified Nurse Aide (CNA) NN weighed the resident while the resident sat in his/her wheelchair. The weight obtained was 168.6 pounds; -CNA NN weight the resident's wheelchair and obtained a weight of 43.6 pounds; -The resident weighed 125.0 pounds; -The resident had lost 9.5 pounds (-7.68%) in ten days. Observation on 4/19/23 at 1:30 P.M., showed LPN A unhooked the resident from tube feeding pump so he/she could go outside to smoke. During an interview on 4/19/23 at 1:25 P.M., CNA NN said he/she brings resident in from smoking and puts him/her in his/her room and then notifies the nurse so he/she can reconnect feeding tube. During an interview on 4/19/23 at 12:10 P.M., LPN A said CNA staff obtain a resident's weight on admission and reweigh the resident every day for three days, then weigh resident once weekly for four weeks and then weight the resident once monthly. During an interview on 4/19/23 at 1:52 P.M., LPN A said he/she had cleared the pump settings and does not chart the resident's input from the feeding pump. During an interview on 4/19/23 at 12:45 P.M., the Infection Preventionist said that staff obtain a resident's weight on admission and reweigh the resident every day for three days, then weigh once weekly for four weeks and then weight the resident once monthly. The dietician will complete a nutrition assessment on all new admissions within one week. There was currently no system in place for monitoring if the dietician had seen a new admission. During an interview on 4/20/23 at 4:00 P.M., the Director of Nursing (DON) said new admission weights should be obtained so a baseline weight is obtained, then weigh the resident every day for three days, then weigh the resident once weekly for four weeks until stable. The registered dietician assessments are done on admission, then quarterly and with changes. The dietician works remotely. The nutrition assessment usually starts within 24 hours after admission and is completed within seven days. The registered dietician should calculate the caloric need and rates for a new admission in the first week. Staff should follow physician orders for continuous tube feeding. If the resident is taken off the pump, he/she should not be off for extended periods of time. The physician should be notified if a resident is taken off a feeding pump for an extended period of time. If the resident is off of feeding pump for an extended period of time it could contribute to weight loss. If the resident did have weight loss, the staff would need to let the physician and dietician know so the feedings could be recalculated. During a phone interview on 5/2/23 at 2:10 P.M., the Regional Dietician said the following: -Nutritional assessments are performed through chart review and not in person; -Ideally a new admission nutrition assessment should be completed within 14 day; -A new admission who is on a feeding tube should have a nutrition assessment completed sooner than 14 days; -The consultant dietician runs reports to see if there are new admissions once weekly; -There is no system currently in place to monitor nutrition assessments for new admissions; -The facility should contact the dietetic service to advise them if there is a missed assessment for a new admission; -According to best practice, a new admission should be weighed once a week for the first four weeks; -If a resident is disconnected from a feeding pump it would decrease his/her caloric intake; -She was not aware the resident was being disconnected from his/her feeding; -The resident's charts are reviewed once monthly to see if there is any significant weight loss. 2. Review of Resident #64's care plan, updated 5/18/22, showed the following: -Resident has a history of weight loss and low body max index (BMI) related to chronic obstructive pulmonary disease (COPD) with air hunger, adult failure to thrive and a diagnosis of severe protein calorie malnutrition, dementia, and dysphagia (difficulty swallowing); -Goal, resident will increase his/her weight to an normal BMI of 25 to 28 over the next 90 days; -Document meal percentages per protocol and report any poor appetite to the charge nurse; -Ensure oxygen is in place to prevent dyspnea (shortness of breath) with eating; -Allow for frequent breaks during eating; -Follow residents food like and dislike listing; -Obtain weight per protocol; -Offer snacks in between meals as needed; -Prefers to eat meals in room; -Provide diet as ordered; -Provide food substitutes and always available menu items as needed; -Provide resident meal assist with meal set up and cueing as needed; -Provide supplements as ordered; -Refer to dietitian as needed; -Refer to speech therapy as needed. Review of the resident's physician's orders, dated August of 2022, showed the following: -Regular diet; -Med Pass (concentrated nutritional supplement, may use 2 Cal if Med Pass not available) 60 milliliters (ml) two times daily. Review of the resident's registered dietitian note, dated 8/19/22, showed the following: -Resident is at 113.6 lbs. with weight gain noted, change desirable; -Recommended weight range 117-143 lbs.; -Diagnosis of COPD, chronic respiratory failure, severe protein calorie malnutrition, and adult failure to thrive; -Estimated needs determined and met; -Continued gain is desirable; -Diet order remains appropriate; -Receives Regular Diet with 60 ml Med Pass two times daily. Review of the resident's weight record showed the following: -On 11/3/22, the resident weighed 117.8 pounds (lbs.); -On 12/4/22, the resident weighed 115.4 lbs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Admission to facility 3/16/21; -Diagnosis include chronic respiratory failure with hypoxia (lack of oxygen), dementia, malnutrition, dysphagia, essential tremor, chronic pain, and failure to thrive, -Vision impaired can see large print; -Cognitively intact; -Requires set up and supervision for eating; -115 lbs. (pounds), on a physician prescribed weight gain program; -Does not have a condition or disease that may result in life expectancy of less than six months. Review of the resident's weight record, dated 1/1/23-1/23/23, showed the following: -1/3/23 88.4 lbs; -1/5/23 86.4 lbs; -1/8/23 87.2 lbs; -1/22/23 88.6 lbs. Review of the resident's medical record showed no notifications to the dietitian or physician with the resident's weight loss from 1/3/23-1/23/23. Further review showed no new interventions, or orders in the resident's medical record during this time to prevent further weight loss. Review of the resident's registered dietitian note, dated 1/24/23, showed the following: -Weight Loss Note: Current body weight is 87 lbs., reweights obtained; -Weight is down from 115 lbs. in one month which is a 24% weight loss; -Weight is down from 117 lbs. in three months, which is a 26% weight loss; -Weight is down from 106 lbs. in six months which is 18% weight loss; -Tolerating regular textures; -2 Cal or Med Pass 60 ml two times daily; -Recommend: House shake two times daily to provide: 400 kilocalories, 12 grams of protein to promote weight gain; -Registered dietitian to follow up as needed. Review of the resident's physician's orders did not show a new order for house shakes two times daily. Review of the resident's weight record, dated 1/29/23, showed the resident weighted 86.2 lbs. The facility did not document notification to the dietitian or physician with further weight loss. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Requires supervision and one staff member physical assist for eating; -86 lbs, significant weight loss not on a physician prescribed weight loss plan. Review of the resident's weight record, dated 2/8/23, showed the resident weighs 81.4 lbs. Review of the resident's nurses notes, dated 2/10/23, showed the following: -Weight on 1/29/23 86.2 and weight 2/5/23 81.4, weight loss of 4.8 lbs.; -Continues regular diet with 2 cal med pass 60 ml two times daily; -Requires staff assist with meal set up, cueing, and encouragement to increase intake; -Staff continues to offer food substitutes, always available menu items, and snacks in between meals as needed; -Have discussed weight loss and refusal to eat or drink supplements at times with resident; -Will need to have meeting with family in regards to continued weight loss; -No new labs to review or interventions to be added at this time. Review of the resident's weight record showed the following: -2/12/23, the resident weighs 82.4 lbs; -2/16/23, showed the resident weighs 84.8 lbs. Review of the resident's medical record showed no notifications to the dietitian or physician with significant weight changes from 1/29/23-2/26/23. Further review showed no new interventions, or orders in the resident's medical record during this time to prevent further weight loss. The house shakes recommended by the registered dietitian on 1/24/23 were not ordered or documented as administered. The staff did not recommend trying any other supplements, therapy evaluations for feeding/swallowing/oxygen conservation techniques, textures to make chewing take less effort, possible adaptive equipment, or smaller meals at a higher frequency. Review of the resident's care plan, updated 2/28/23, showed the following: -2/1/23 actual weight loss; -Resident likes Fig Newtons. The recommended house shakes were not added to the resident's care plan. The registered dietitian did not document a review of the resident's weight loss in February. Review of the resident's weight record, dated 3/1/23-3/7/23, showed the following: -3/3/23 83.6 lbs.; -3/5/23 85.7 lbs. Review of the resident's registered dietitian note, dated 3/8/23, showed the following: -Monthly Weight Note: current weight 84 lbs.; -Weight is up from 81 lbs in the last month, 3.7% gain; -Weight is down from 112 lbs. in six months, 25% weight loss; -Receiving Med Pass 60 ml two times daily (240 kcals, 10 g protein); -Meeting estimated nutrition needs with meals, snacks, and supplements, goal is weight gain; -Registered Dietitian to follow up as needed. The note did not include the previous recommendation for house shakes, or that the recommendation was not followed, and did not recommend any further interventions. Review of the resident's weight record, dated 3/12/23, showed the resident weighed 80.0 lbs., 37 lbs. weight loss from 117 lbs 11/3/22, 31.6% weight loss in four months. The facility did not document dietitian or physician notification with further weight loss. Review of the resident's weight record, dated 3/9/23-4/10/23, showed the following: -3/19/23 81.6 lbs.; -3/26/23 82.2 lbs.; -4/1/23 83.6 lbs. Review of the resident's medical record showed no notifications to the physician with significant weight changes from 1/3/23-4/10/23. Further review showed no new interventions, or orders in the resident's medical record during this time to prevent further weight loss. The house shakes recommended by the registered dietitian on 1/24/23 were not ordered or documented as administered. The staff did not recommend trying any other supplements, therapy evaluations for feeding/swallowing/oxygen conservation techniques, textures to make chewing take less effort, possible adaptive equipment, or smaller meals at a higher frequency. Review of the resident's registered dietitian note, dated 4/11/23, showed the following: -Monthly Wound/Weight note: Current weight is 83.4 lbs; -Weight stable for one month with fluctuations noted; -Weight down from 87 lbs in three months 4.6 % weight loss; -Weight is down from 117 lbs. in six months for 29% weight loss, the resident is under ideal body weight; -Skin: Abrasion to left outer ankle; -Receiving Med Pass 60 ml two times daily; -Meeting nutrition needs with meals, supplements, snacks at this time; -Goal is weight maintenance; -Registered Dietitian to follow up as needed. Observation on 4/18/23, at 12:14 P.M.-12:45 P.M., showed the following: -The resident in his/her wheelchair in the dining room with his/her oxygen on via nasal cannula (tube to deliver oxygen through the nose); -Staff served the resident chicken, squash, baked beans, cornbread, cake with whipped cream, red drink, yellow drink, and coffee/tea; -Resident fed himself/herself; -The resident's hands had tremors when loading his/her utensils making food fall off of his/her fork and/or spoon, and food fell of the side of his/her plate when he/she attempted to scoop his/her food onto his/her fork. The resident did not have adaptive equipment (plate guard, weighted silverware); -The resident consumed a few bites of chicken; -At 12:20 P.M. the resident was short of breath and moved his/her plate to the side and stopped eating; -At 12:29 P.M., CNA U placed a clothing protector on the resident, did not cue or assist the resident to eat, and walked away; -At 12:45 P.M., CNA Z sat down to assist the resident (31 minutes after the resident was served); -CNA Z fed the resident a few bites of chicken and beans, the resident visibly short of breath, and said it doesn't taste good, cold; -The CNA did not offer to heat up the resident's meal; -The resident consumed less than 25% of his/her meal. During an interview on 4/18/23, at 1:45 P.M., CNA Z said the following: -The resident has never consumed large amounts at meals; -The resident used to be able to feed himself/herself but now has more trouble with tremors, and he/she gets winded while eating; -The resident had lost weight; -Most days he/she eats in his/her room and staff assist him/her; -He/She gets tired when eating and does not eat very much; -Staff are expected to offer to heat up a resident's meal if they request it; -The resident might do well with several small meals, he/she cannot tolerate eating for a long period of time. During an interview on 4/19/23, at 9:30 A.M., LPN QQ said the following: -The registered dietitian monitors weight loss through the electronic health record; he/she (the RD) is in a different state; -He/She was not sure why Resident #64's health shakes were not added; -Resident #64 has not had therapy evaluations for tremors or oxygen conservation that he/she knew of; -If there is weight loss the facility weighs the resident weekly and reviews the weights weekly; -The physician and dietitian can review weights in the electronic medical record; -When new interventions are added they would be added to the resident's care plan. During an interview on 4/18/23, at 3:20 P.M., the Director of Nursing said the following: -When a resident triggers for weight loss his/her weight is monitored weekly; -The facility tries to have weekly meetings to review weight loss, but this doesn't always happen; -If a resident has continued weight loss would attempt new interventions; -New interventions would be added to the care plan; -Staff are expected to notify the physician and dietitian of new or worsening weight loss; -She did not know Resident #64 has worsening tremors and shortness of breath while eating; -LPN QQ is expected to carry through dietitian recommendations timely and document if there is a reason they are not carried through; -CNA's are expected to assist residents timely and offer to heat food if it gets cold; -Therapy can be consulted to work on adaptive equipment, oxygen conservation techniques and swallowing issues. She did not know if Resident #64 has had therapy for those issues; -The facility does not have consumption logs for Resident #64. During an interview on 5/23/23, at 9:50 A.M., the Registered Dietitian (RD) said the following: -She was located in another state and would review residents remotely; -The facility did not include her in meetings about weight loss; -The facility did not notify her of weight loss, she would have to find it on review of the medical records; -She expected the facility to carry through recommendations; -She feels like the facility needed a dietitian that could be in the facility to assist with recommendations; -For weight loss there are many things you can try if you can see if a resident is struggling in one area; -She was unable to make meaningful recommendations because of the lack of communication with the facility. During an interview on 4/19/23, at 9:30 A.M., LPN QQ said the following: -The registered dietitian monitors weight loss through the electronic health record; he/she (the RD) is in a different state; -Not sure why Resident #64's health shakes were not added; -Resident #64 has not had therapy evaluations for tremors or oxygen conservation that he/she knows of; -If there is weight loss the facility weighs the resident weekly and reviews the weights weekly; -Physician and dietitian can review weights in the electronic medical record; -When new interventions are added they would be added to the resident's care plan. 47008

Based on observation, interview, and record review, the facility failed to ensure residents on a physician-ordered pureed diet received the appropriate portion size of food items and failed to ensure spreadsheet menus were utilized for all diets to ensure appropriate items and portion sizes were prepared and served. The facility census was 92. Review of the undated facility policy, Tools for Food Preparation, showed the following: -The menu is the primary tool used in food preparation; -It specifies the foods that are to be served on both the regular and therapeutic diets; -It specifies the portion sizes to be served. Review of the undated facility policy, Portioning and Measuring Utensils, showed all items must be measured during preparation and during serving according to recipes and the menu. Review of the undated facility policy, Portion Control, showed in portion control, the correct serving sizes of food items are determined and served, ensuring that the residents receive the recommended daily allowance of the foods specified on the menu. It is very important to provide the amount of food residents need to remain healthy. 1. Review on 4/10/23 of the resident tray tickets showed the lunch meal for 4/10/23 was spaghetti with meat sauce, Italian vegetables, bread stick and strawberry poke cake. (The facility did not have a diet spreadsheet available for staff to reference while preparing or serving the meal.) During an interview on 4/10/23 at 10:10 A.M., Dietary Cook K said he/she was unsure where the spreadsheets menus were, and he/she did not use anything to help him/her prepare the meal. The secretaries in the front office printed the menus that the resident used to select the food items they would like to eat. Observation on 4/10/23 at 11:55 A.M. showed a dry erase board mounted to a kitchen door showed there were three residents on a pureed diet and two residents were to receive pureed meat. Observation on 4/10/23 between 11:36 A.M. and 12:26 P.M., during the lunch meal service, showed staff served five residents a #12 (1/3 cup) serving of mashed potatoes with pureed spaghetti sauce on top of the potatoes. During an interview on 4/10/23 at 1:33 P.M., Dietary Cook M said dietary staff was supposed to have menus in the kitchen to refer to when preparing the meal. He/She had been asking for menus since he/she started working at the facility last summer, but they have never gotten any menus. He/She would use a spreadsheet to select the appropriate serving utensil, but the facility did not have current spreadsheet menus. He/She just knew what utensil to use because he/she had worked in dietary a long time. During an interview on 4/11/23 at 10:40 A.M., Dietary Cook K said he/she always used green-handled utensils for vegetables and blue-handled for meat. He/She didn't have anything to refer to when selecting a utensil. During an interview on 4/11/23 at 2:15 P.M., the administrator said staff should have menus to use to know what items to prepare for a meal. He would expect food be served at the appropriate portion sizes. The facility currently does not have a dietary manager. During an interview on 4/11/23 at 5:45 P.M., the consultant dietitian said staff should use a spreadsheet menu to know what items to prepare for a meal and what utensils to use when serving food to ensure appropriate portion sizes. Staff should have used a #8 (1/2 cup) serving utensil with mashed potatoes. A #12 (1/3 cup) serving utensil would have been too small for mashed potatoes. Staff should not have served spaghetti sauce on top of mashed potatoes. The two items should have been served separately. She was unaware the facility was not using spreadsheet menus and the facility had spreadsheet menus available to use, but they would need to print them off the computer. MO195530 MO195531 38016 47008

Based on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen. The census was 92. Review of the undated facility policy, Prevention of Foodborne Illness, showed the following: -To ensure that we prepare and serve safe food to our residents, we must consistently practice habits that help prevent foodborne illnesses. These practices must become a way of life in our department; -Avoid scratching, picking or rubbing your head, nose, face, or body surface. If you do so, wash your hands afterward; -Wash your hands after handling soiled dishes or utensils and before handling unwrapped flatware or clean equipment and utensils; -Wash raw vegetables thoroughly, and then wash your hands after washing the vegetables; -Store food in enclosed containers; -Label and date all food appropriately; -Keep equipment clean and in good repair; -Wash and rinse dishes and utensils thoroughly according to the manufacturer's instructions. Record temperatures and ppms (parts per millions) according to facility guidelines. Report any issues with temperatures and/or ppms to director of food and nutrition services; -Ensure that all dish machine chemicals are dispensing properly; -Handle food as little as possible; -Use glove or utensils when handling ready-to-eat food. Be sure to wash your hands before putting on gloves to work with food. 1. Record review of the facility's Dining Services and Sanitation Report, dated [DATE] and conducted by a consultant dietitian, showed the following: -Contents are correctly labeled (food item, prepared on date, use by date) and items are rotated first in first out: No, missing labels, some expired and not dated correctly; -There is no outdated food past the Use By Date or manufacturer's guidelines: No, Food in cooler out of date and missing labels; -Walk-in refrigerator is organized and clean inside and out (shelves, floors, walls, ceiling): No, needs cleaned and shelf liners on bottom shelves; -Open food items in preparation area are sealed, dated and labeled properly (cream of wheat, dry cereal, noodles, rice, etc.): No, not labeled and dated; -Food preparation sink is available and used properly: Need antimicrobial fruit and vegetable treatment for washing produce; -Staff are using proper hair restraints, covering all exposed hair (bangs and beards included): Recommend purchasing beard restraints to have on hand; -All food is stored 6 inches off of the floor and 18 inches from the ceiling and sprinkler: No, need shelf liners for all bottom shelves that are not solid. Some items were not 6 inches off floor; -Can opener is clean with no build-up around blade or base: No; -Microwave clean inside and out: No; -Dish machine temperatures and PPM (parts per million) are recorded at each meal and are within normal ranges per manufacturers guidelines: No; -Dishes, pots and pans are air-dried and stored inverted without signs of wet nesting; No. 2. Observations on [DATE] at 9:25 A.M. and on [DATE] at 10:25 A.M., showed a small saucepan sat on the stovetop burner (turned off) and contained melted and congealed butter with a basting brush inside. The pan was room temperature to touch and was uncovered. Observation on [DATE] at 1:52 P.M. showed Dietary Cook M used the basting brush in the sauce pan of butter that had been re-warmed on the cooktop. He/She basted the tops of whole raw potatoes. The saucepan had sat out uncovered all day on the stovetop. Observation on [DATE] at 9:26 A.M. in the dry storage room, showed two plastic bread sacks sat on the upright metal bread rack. One plastic sack contained three slices of bread open to air, and contained a second plastic sack that contained four hamburger buns open to air. The sacks were not closed or tied shut. Observation on [DATE] at 10:25 A.M. showed the sack of sliced bread was open to air and contained three slices of bread. The sack of hamburger buns was open to air and only contained three buns instead of four. An additional sack of buns was open to air and contained two hamburger buns. Observation on [DATE] at 9:28 A.M. of the walk-in cooler showed the following: -A large zipper bag of lettuce mix was not sealed and open to air; -A large zipper bag of shredded cheese and was ,d+[DATE] full, and was not dated; -A black plastic bowl contained a reddish colored liquid (what appeared to be tomato soup). The bowl was not labeled with the contents or dated; -A clear container was labeled Oreo Pudding and was dated ,d+[DATE]; -A clear container was labeled Taco Meat and was dated ,d+[DATE]; -Several pasteurized eggs (stamped with a P) sat in open egg crate on top of a box labeled Eggs. Several eggs were broken and had raw egg pooled in the cardboard egg crate and on the sides of the crate. Observation on [DATE] at 9:50 A.M. showed three stacked trays of individually plated desserts (cake and fruit crisp) were located inside the reach-in refrigerator located near the steam table. The desserts were not dated. Observation on [DATE] at 10:55 A.M. showed a 28-ounce opened box of cream of rice sat underneath the metal preparation counter. The box was not closed and was open to air. Observation on [DATE] at 11:50 A.M. showed a small chest freezer held a 1.5 quart container of strawberry ice cream. The lid to the container was completely removed and the lid stood upright inside the mostly empty container of ice cream. Observation on [DATE] at 12:12 P.M. showed Dietary Aide J placed the undated/unlabeled bowl containing what appeared to be tomato soup from the cooler into the microwave to re-heat and then plated the soup on a tray for a resident. Observation and interview on [DATE] at 1:24 P.M. showed a second small chest freezer had a plastic sleeve of veggie burgers that was open to air and not sealed. In addition, a large container of vanilla ice cream had a lid, but the lid was not secure on the container and was open to air. Dietary Cook M said these items belonged to a resident on a vegetarian diet. Observations on [DATE] at 1:18 P.M. and [DATE] at 10:25 A.M. showed the counter-mounted can opener had a buildup of red/brown crusty debris on the blade. Observations on [DATE] at 9:27 A.M. and on [DATE] at 10:25 A.M. in the dry storage room, showed one unopened 12 pound, 1 ounce cardboard box of peanut butter wafer snacks sat directly on the floor in the room. A second 13.68 pound unopened cardboard box of hot chocolate sat directly on the floor just outside of the dry storage room. Both boxes were stored on the floor. Observation on [DATE] at 1:19 P.M. showed a 6.60 pound box of saltine crackers sat directly on the floor in the dry storage room. 3. Observation on [DATE] at 9:30 A.M. showed the floor of the walk-in refrigerator was metal and had large areas of rust and reddish/brown debris on the floor. Liquid was visible on the floor on the left side toward the back of the unit. Large pieces of lettuce and pieces of tin foil lay on the floor in the refrigerator. Observation on [DATE] at 4:15 P.M. and on [DATE] at 10:25 A.M. showed the floor of the walk-in refrigerator was rusted and reddish/brown in color. The floor was not smooth and was not level and had raised areas in the flooring. Clear liquid with reddish/brown debris was visible and covered approximately ,d+[DATE] of the cooler floor. The floor was not easily cleanable. The metal shelving units inside the cooler had missing paint and were not easily cleanable. Observation on [DATE] at 9:45 A.M. showed the kitchen floor throughout the entire kitchen had a heavy buildup of crumbs, dried spills (predominantly brown and red), multi-colored dried stains, food debris (tator tots, onion skins and a small piece of sliced cheese), and a paper trash. Brown and red dried liquid spills were visible near the staff exit from the kitchen and ran in long lines out the exit door. Large brown coffee stains were visible on the floor in front of the coffee station on the floor tiles. Mustard packets, plastic wrap and paper trash was visible near the steam table. Observation on [DATE] at 9:48 A.M. and on [DATE] at 10:25 A.M. in the dish machine area of the kitchen, showed several areas of blue spills, drips and pooled areas on the floor near the three-compartment sink. (Buckets of blue product were either rinse additive or detergent stored in this area). Observation on [DATE] at 10:02 A.M. showed Dietary Cook K dropped the food processor bowl that contained pureed vegetables onto the floor. Numerous splatters of yellow-orange puree landed on the floor near the preparation counter. Dietary Cook K did not attempt to clean up the spill during or after the meal preparation. Observation on [DATE] at 10:30 A.M. showed the floor tiles in the dishroom had a heavy buildup of food debris, water and paper trash such as plastic straws, straw wrappers, and sugar packets all over the floor. 4. Observation on [DATE] at 9:42 A.M. and on [DATE] at 10:25 A.M. showed the inside of the microwave had red, yellow, orange and brown food debris on the glass plate. The exterior door had red debris on the timer knob and white debris on the corner of the unit. Observation on [DATE] at 9:44 A.M. and on [DATE] at 10:25 A.M. of the stove/cooktop showed the metal backsplash behind the six-burner stove had a heavy accumulation of black, brown and yellow debris. Observation on [DATE] at 9:48 A.M. and on [DATE] at 10:25 A.M. in the kitchen showed a heavy buildup of dark brown, greasy fuzzy debris on two white metal HVAC vents near the floor. A third HVAC vent closer to the ceiling had a mild buildup of fuzzy debris. Observation on [DATE] at 9:56 A.M. and on [DATE] at 10:25 A.M. showed the stand-up mixer had a buildup of a white powdery substance on the base above the mixing bowl. Observation on [DATE] at 10:04 A.M. showed the griddle surface on the cooktop had a heavy buildup of black debris on the left side. The right side had smaller areas of black debris and a buildup of orange and brown chunky debris and shiny debris. A round stockpot sat in the middle of the griddle and had tea bags steeping inside the liquid. Observation on [DATE] at 1:37 P.M. showed a stack of four large steam table pans and a stack of three medium steam table pans had droplets of water in between the pans when the pans were separated. 5. Observation on [DATE] at 10:01 A.M. showed Dietary Aide L wore a hairnet on his/her head and a surgical mask on his/her face. He/She had a beard, sideburns and a moustache and did not wear a beard restraint. The surgical mask covered his/her moustache and partially covered the beard and sideburns. Observation on [DATE] at 10:36 A.M. showed Dietary Aide J had a hair restraint on over his/her hair bun only. The remaining portion of his/her head was not covered with a hair restraint. Observation on [DATE] at 11:25 A.M. showed Dietary Aide L wrapped clean flatware inside napkins. His/Her surgical mask was below his/her chin. He/She had a beard, sideburns and a moustache and did not wear a beard restraint. The surgical mask partially covered his/her beard. 6. Observation on [DATE] at 10:36 A.M. showed Dietary Aide J did not wash his/her hands, donned (put on) gloves, and began scooping up cake with a green handled scoop. He/She plated the entire sheet pan of cake into small tulip bowls. He/She removed his/her gloves, scratched his/her nose with a bare hand, put on new gloves (did not wash his/her hands) and began dipping up butterscotch pudding into small tulip bowls. He/She removed his/her gloves and placed plastic lids on all of the bowls. He/She did not wash his/her hands and brought a stack of blue cloth napkins to the preparation table. He/She then left the kitchen. He/She re-entered the kitchen, did not wash his/her hands and did not put on gloves. He/She went to the dish room and began sorting clean silverware into separate containers and touched the eating surfaces of the flatware with his/her bare hands. Observation on [DATE] at 10:39 A.M. showed Dietary Cook K wore gloves and used a spray cleaner bottle and a yellow rag to wipe down a black rolling cart. He/She removed his/her gloves, did not wash his/her hands, and donned new gloves. He/She rolled the cart to the walk-in cooler, opened the door and removed zippered bags of lettuce, shredded cheese, sliced cheese, turkey and a bowl of tomato soup, and placed the items on the cart. He/She then went to the dry storage room and placed a loaf of bread on the cart. He/She rolled the cart to the preparation counter. He/She used the same gloves, grabbed handfuls of lettuce mix and placed the lettuce in bowls. He/She used the same gloves to reach inside the bag of shredded cheese and grab handfuls of cheese to put on top of lettuce in the bowls. He/She closed the zippered bags and placed the remaining head of lettuce into a zippered bag, then removed a large piece of turkey and placed it on a cutting board. He/She pulled back the wrapper on the turkey and sliced off several pieces. He/She placed the turkey back inside the bag. Using the same gloves, he/she reached inside the potato chip bag and grabbed a handful of chips and placed them in a baggie. He/She picked up the turkey slices and placed them on slices of bread to make sandwiches and placed them in baggies. He/She used the same gloves, opened a large package of sliced cheese and removed several cheese slices. He/She placed the cheese slices on the bread to make sandwiches and placed the sandwiches in baggies. Observation on [DATE] at 1:45 P.M. showed the handwashing sink near the walk-in cooler/freezer and the staff hallway entrance to the kitchen was not equipped with a soap dispenser for handwashing. Observation on [DATE] at 1:47 P.M. showed the handwashing sink in the dish room was blocked by carts and racks of clean dishes that were stored approximately one foot away from the sink. No trash can was located in the dish room next to the handwashing sink. During an interview on [DATE] at 10:40 A.M., Dietary Cook K said he/she should wash his/her hands in between clean and dirty tasks. He/She didn't wash his/her hands as much as he/she should because there was no soap dispenser at the handwashing sink near the staff hallway entrance to the kitchen. Observation on [DATE] at 10:58 A.M. showed no staff working in the dish room. The trash can in the dish room was uncovered and was half full of garbage, food debris and paper trash. Observation on [DATE] at 11:16 A.M. showed Dietary Cook K wore gloves and opened the walk-in cooler door with his/her gloved hand and obtained a head of lettuce. He/She placed the lettuce on a cutting board and removed the core. He/She did not wash the lettuce and pulled some lettuce leaves off the head. He/She then reached into a bag of sliced cheese with the same gloved hands and removed some cheese slices. He/She placed the lettuce and cheese slices into separate pans. Observation on [DATE] at 3:14 P.M. showed the handwashing sink located in the kitchen near the service hall contained no soap or paper towels. 7. Review of the High Temperature Dish Machine log sheet for January and February 2023, showed the following: -Instructions at the top of the sheet showed staff should check and record temperatures results before washing dishes. Wash needs to be a minimum of 150 degrees F or per manufacturer's specification and a rinse at 180 degrees F. The internal temperature test should be completed and logged at least one time per day using an internal thermometer (record temp). Notify your director with any issues; -January log sheet showed temperatures were recorded for 20 out of 31 days of the month. Documented wash temperatures ranged from ,d+[DATE] degrees F. The temperature was less than 150 degrees during the wash cycle on 16 days. The documented rinse temperatures ranged from ,d+[DATE] degrees F. The temperature was less than 180 degrees on 16 days; -February log sheet showed temperatures were recorded for five out of 28 days of the month. Documented wash temperatures ranged from ,d+[DATE] degrees F and documented rinse temperatures ranged from ,d+[DATE] degrees F (all documented temperatures were less than the required minimum temperatures for wash and rinse cycles); -No temperatures were documented for March or [DATE]. Observation and interview on [DATE] at 2:02 P.M. of the high temperature dish machine analog gauge showed the temperature of the wash cycle was 118 degrees Fahrenheit (F) and rinse cycle was 116 degrees F. The next subsequent cycle temperatures measured showed the wash cycle was 115 degrees F and the rinse cycle was 115 degrees F. A third subsequent cycle showed the wash cycle measured 117 degrees F and the rinse cycle was 116 degrees F. Dietary Aide L said they ran out of the red bucket product that hooked up to the dish machine. He/She did not know what product was in the red bucket, but knew it was needed for the wash cycle. He/She said the temperatures on the dish machine varied depending on when the laundry staff did laundry. When laundry was being washed, the water temperature on the dish machine was lower in the kitchen, but it never went below 110 degrees F on the dish machine. He/She said they used to document temperatures on the dish machine, but they ran out of log sheets, so they stopped tracking the temperatures. If something was wrong with the dish machine or he/she had concerns with it, he/she would contact the dietary manager and maintenance staff. No issues had been reported regarding the dish machine. Observation on [DATE] at 3:52 P.M. showed two buckets of product were connected to the dish machine. One bucket was labeled Ultra San and the other bucket was labeled Ecotemp Ultra Dry. A third length of red tubing was not connected up to any dish machine buckets. 8. Review of the Food and Drug Administration Food Code, dated 2013, showed an air gap between the water supply inlet and the flood level rim of the plumbing fixture or equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. Review of the ice machine manufacturer's guidance showed the following: -Ice storage bin - cleaning and sanitation: -Weekly: clean and sanitize the door liner, door gasket, and door frame; -Monthly: clean the exterior; -Semi-annually: clean and sanitize the entire interior of the bin; -Frequency of cleaning may need to be adjusted to local conditions, more frequent cleaning may be needed in certain environments; -Cleaning directions: soil and scale may be removed from the bin interior, exterior door and door frame with a mild soap or detergent solution. After cleaning, the bin interior must be thoroughly rinsed with clean potable water to remove all cleaner residue; -Remove any scale prior to sanitizing; -Sanitize the interior by thoroughly washing the interior of the ice storage bin with a locally approved sanitizer solution; -Ice machines require periodic maintenance in three areas: the ice machine's water system, storage bin, air filter or condenser; -Maintenance includes scale removal, sanitization, filter cleaning or change; -At some sites, the water supply to the ice machine will contain significant quantities of minerals that will result in a water system becoming coated with these minerals, requiring more frequent maintenance than twice per year; -Ice machine water system including water filters: remove scale from water system and change filters a minimum of every six months, sanitize the water system whenever scale has been removed; -Bin liner cleaning and sanitizing: at the same time of scale removal and ice machine sanitization; -Air filter cleaning: every six months with the ice machine scale removal or more frequently as needed; -Condenser coil cleaning: every six months with the ice machine scale removal or more frequently as needed. Review of the facility's work history report for ice machines showed the following: -[DATE] and [DATE], Maintenance Supervisor conducted visual check on ice machine, checked filter, cleaned coils, sanitized interior, and delimed as necessary; -[DATE] and [DATE], Maintenance Supervisor conducted a visual check on ice machine; -[DATE], Maintenance Supervisor conducted visual check on ice machine, checked filter, cleaned coils, sanitized interior, and delimed as necessary; -[DATE], Maintenance Supervisor conducted a visual check on ice machine; Observation on [DATE] at 3:16 P.M. showed the following: -One ice machine, located in the kitchen, showed four dried drips of a white substance approximately 0.25 inch by 2 inches on the inside of the ice machine door. At the back of the ice machine, there was an in-line water filter on the water supply line to the unit. The label on the water filter was faded and was illegible. No installation or replacement date was indicated on the label. The 1 inch PVC drain pipe from the ice machine to the floor drain had an approximate 0.25 inch gap between the drain pipe and the floor drain. A disposable glove was caught under the drain pipe. There was a moist black residue at the end of the drain pipe that extended up the pipe approximately 0.5 inch; -A second ice machine, located outside of the kitchen in a service hall, showed an area of brown and white dried residue approximately 0.5 inch by 12 inches and several 0.25 inch by 12 inch drips of a dried white substance on the outside of the ice machine. Duct tape was adhered to the hinges of the door on the interior of the machine. An area approximately 3 inches by 6 inches of moist black residue was located on the inside of the machine. At the back of the ice machine showed a plastic flexible drain hose approximately 1 inch in diameter that was inserted into an approximate 2 inch PVC pipe that was connected directly to the PVC piping to the drain of the handwashing sink. There was no air gap present. During an interview on [DATE], at 1:57 P.M., the Maintenance Supervisor said the following: -He cleaned the ice machine when TELS (maintenance tracking computer program) said it was due; -To clean the machine, he ran sanitizer in the machine for 20 or 30 minutes and wiped down the outside of the machine with sanitizer. That is all he did to clean the machine; -He didn't know if the ice machines had a filter or who changed them, possibly the company who did the repairs. During an interview on [DATE], at 2:05 P.M., the Central Supply Supervisor said the following: -Review of the maintenance invoices of the ice machine repairs did not include any type of cleaning or changing the filters; -There is no record in the facility system of ever purchasing any filters for the ice machines. During interview on [DATE] at 4:38 P.M., the Administrator said he expected there to be a sufficient air gap at the drains of the ice machines to prevent backflow of liquid into the ice machines. He expected the ice machines to be cleaned and maintained regularly per the manufacturer's guidelines. There was to be no visible slime or debris, and the filters should be changed routinely. He said the maintenance director was responsible for cleaning and changing of filters on the ice machines. 9. During an interview on [DATE] at 3:00 P.M., the Maintenance Supervisor said the following: -Maintenance staff cleaned the HVAC vents monthly; -The dish machine was a high temperature machine. He was unaware the dish machine temperatures were low and that the machine was out of cleaning product; -The water inside the walk-in cooler was leaking from the coil. The coil had been replaced before but kept going bad. Water collected on the floor and had rusted the floor. The entire walk-in cooler probably needed to be replaced, but that was pretty expensive. During an interview on [DATE] at 5:24 P.M., the Consultant Dietitian said the following: -She expected food items to be labeled, dated and stored properly; -All hair should be in a hair restraint; -Kitchen cooking equipment should be clean and in good repair. During an interview on [DATE] at 2:15 P.M., the administrator said the following: -Food items should be dated when opened and discarded by the best by date. Food items should be stored properly and not on the floor; -Broken eggs should be discarded; -The flooring in the walk-in cooler was rusty and wet. The cooling compartment was leaking. It had been repaired several times and it had apparently broken again. The facility was trying to figure out how to re-route the water; -Staff should clean the microwave every shift to remove food residue and at least clean it daily; -Staff should clean the metal backsplash regularly. Staff have had trouble getting it cleaned properly; -Staff should clean the griddle regularly; -Staff should sweep and mop the floors after each shift; -Maintenance staff cleaned the HVAC vents monthly; -Staff should clean the mixer after each use; -Staff should wear hair nets when preparing food and while in the kitchen. All hair should be inside a hair net. Staff with facial hair should wear beard restraints. They have had trouble finding a larger hair net for people with a lot of hair; -Staff should wash their hands after touching raw meat, after using the restroom, after touching their face or hair, and in between clean and dirty tasks; -If gloves were soiled, then staff should change their gloves. Staff should wash hands in between clean and dirty gloves; -The facility needed to install a soap dispenser in the kitchen at the staff handwashing sink; -Staff should clean the can opener daily; -Dishware should be air dried and stacked/stored dry. The kitchen did not have enough room to air dry everything that had to be washed; -He thought the dish machine was a low temperature machine but he was unsure. The wash and rinse temperatures should be 165 degrees F. He thought the machine used sanitizer solution; -Staff should wash fresh produce prior to use.

Based on observation, interview, and record review, the facility failed to develop specific control parameters based on Center for Disease Control (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards and failed to complete a facility assessment. The facility did not have a water management team, detailed water flow map, and did not implement the facility's Legionnaire Disease (severe pneumonia like infection caused by contaminated water) policy that instructed staff how to monitor residents for Legionnaire's disease. The facility also failed to ensure staff performed proper hand hygiene when caring for residents when staff failed to wash hands and change gloves during a blood sugar check and food preparation for one resident (Resident #50). The facility failed to ensure one residents' (Resident #66) catheter tubing and catheter bag were free from dragging on the floor when the resident sat in a wheelchair. The facility failed to ensure staff performed proper handwashing and glove changes with perineal and wound care for two residents (#38, and #198), and failed to ensure respiratory equipment was covered in order to remain free of contaminants for one resident (Resident #198) The facility census was 92. 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 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's policy Legionnaires' Disease, revised 6/7/22, showed the following: -The facility will identify cases of Legionnaires' disease promptly to determine if the case may be associated with the facility and will report Legionnaires' disease cases to local public health authorities quickly to investigate and prevent additional infections. 1. Communicate assessment findings to the resident's medical provider. a. Patients who have failed outpatient antibiotic therapy for community acquired pneumonia; b. Patients with severe pneumonia, in particular those requiring intensive care; c. Immunocompromised patients with pneumonia; d. All patients with pneumonia in the setting of a Legionnaires' disease outbreak; 2. Testing for Legionella species is recommended for residents with community-acquired pneumonia severe enough to be admitted to the ICU. Legionella diagnostic work-up should also be considered for healthcare-associated pneumonia, especially for groups at increased risk. a. The most commonly used laboratory test for diagnosis of Legionnaires' disease is the urinary antigen test (UA 1), which detects a molecule of the Legionella bacterium in urine. 3. Obtain an order for the preferred diagnostic tests for Legionnaires' disease; 4. Follow lab procedure for diagnostic testing. 5. Communicate and document findings to medical provider and patient/responsible party. 6. Report in accordance with the Reportable Disease Policy to the appropriate public health authorities. 7. The facility should refer to the Water Management Plan for additional guidance. The facility did not have documentation Legionnaires Disease screening or monitoring had occurred. Review of the facility's Water Management Program, dated 4/3/23, showed the following: -Water management team consist of Administrator (ADM), Medical Director, Director of Nursing (DON), Maintenance Supervisor (MS), Infection Preventionist (IP), and Environmental Services Director (ESD); -Facility uses aerosol generating devices such as medication nebulizers, CPAP, and BiPAP; -Facility has 6 water heaters, maximum temperature is 150 degrees F, usually at 110-115 degrees F, age of units [AGE] years old; -Thermostatic mixing valves are 24 inches from outlets; -Copper pipes, [AGE] years old; -Emergency water systems include fire sprinklers, and eye wash station; -Incoming water is city water and chlorine is method of disinfection; -Two ice machines and two water coolers; -Emergency water systems include fire sprinklers and eye wash station; -Facility has 68 rooms, 68 sinks (did not include kitchen), four showers, two jetted bathtubs, one standard bathtub, and two ice machines; -Hot water storage events that could occur are heater failure, build-up of sludge in tank, storage temperature too low (below 140 degrees F; -Operational Monitoring: Hot water - risk if water is too cold or too hot, water should be between 105 and 115 degrees F, will monitor one faucet at each grouping of hot water heaters, critical limit is 120 degrees F, will inspect hot water heaters, check function of TMV, check what the hot water temperatures are set to; -Unoccupied rooms allowed to be vacant without action for seven days, then will run hot and cold water for two minutes and flush toilets several times; -Nebulizers are to be cleaned after each use and stored in a bag; -CPAP and BiPAP to be cleaned with soapy water and hung to dry and reassembled weekly by central supply staff; -Drain shower heads after each use. The hot water heater temperature on the facility assessment did not meet the CDC recommendations of 150 degrees despite having mixing valves. The facility planned monitoring did not include monitoring for scaling, biofilm and sediment. The facility did not have a plan to monitor cold water temperatures. Review of the facility's water flow map, undated, showed the maintenance staff marked the water heaters and shut off valves on a facility floor plan map. During an interview on 4/18/23, at 1:40 P.M., the Administrator (ADM) said the facility has a water management plan. The water management team consist of himself (the Administrator), the Maintenance Supervisor (MS), and the Director of Nursing (DON). During an interview on 4/18/23, at 1:57 P.M., the MS said the following: -The facility does not have a water management team that he knew of; -He does not know what ASHRAE is or what their standards are; -TELS (a computer system that tracks maintenance items) generates a list of items to check and he checks the water temperatures when the system cues him to check them; -He checks the water temperatures at the beginning and end of each hall to make sure hot water temperatures are between 105 degrees Fahrenheit (F) and 120 degrees F when the TELs system cues him to check them weekly. During an interview on 4/19/23, at 8:23 A.M. the Infection Preventionist (IP) said the following: -The facility does not have a water management team that she knew of; -She does not monitor any residents for Legionella, she didn't know she was supposed to or how to monitor for Legionnaire's disease; -She was not sure what was supposed to be monitored; -She does not know what the water management team would do. During an interview on 4/20/23, at 4:00 P.M., the ADM said the following: -The facility needs to develop a detailed water flow map, and identify what ranges/parameters were acceptable for temperature or any other measured data; -The facility has not activated the water management team, was recently working on the facility assessment and had not implemented all of it at this time. 2. Review of Resident #198's admission Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 4/5/23, showed the following: -Resident admitted to the facility on [DATE]; -Diagnosis included respiratory failure with hypoxia (period without proper oxygenation), heart disease, heart failure, chronic obstructive pulmonary disease, and tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing); -Moderately impaired cognition; -Two venous and arterial ulcers; -Applications of nonsurgical dressings other than to feet; -Ointments and medications other than to feet; -Shortness of breath with exertion, when at rest, and when lying flat; -Oxygen therapy, suctioning, and tracheostomy care while a resident. Review of the resident's Care Plan, dated 4/5/23, showed the resident was at risk for skin breakdown due to limited mobility, being admitted with venous stasis ulcers to his/her lower extremities and incontinence.; -Resident has a tracheostomy that is capped and is at risk for respiratory distress due to his/her history of COPD, chronic respiratory failure, and obstructive sleep apnea. -Administer hand held nebulizer (devise that turns liquid medication to mist for inhalation) (HHN)'s or inhalers as ordered; -Apply oxygen as ordered. Review of the resident's physician orders, dated April 2023, showed the following: -Right lower and left lower limbs (legs) cellulitis (infection of the tissue): Wash open areas with wound cleanser, apply xeroform (an antimicrobial dressing) and wrap with kerlix (rolled gauze) every shift. -Albuterol sulfate (medication to improve breathing) Nebulization Solution 2.5 (milligram (mg)/3 millimeter (ml) 0.083% three ml inhale orally via nebulizer every hour as needed for shortness of breath; -Albuterol sulfate nebulization solution (2.5 mg/3 ml) 0.083% 3 milliliter inhale orally via nebulizer two times a day use with Mucomyst (a medication to dissolve mucous) ; -Arformoterol tartrate (medication for broncospasms) nebulization solution 15 microgram (mg)/2 ml, two ml inhale orally via nebulizer two times a day ; -Budesonide suspension (medication to decrease swelling and irritation in airways) 0.5 mg/ml, two ml inhale orally every 12 hours -Ipratropium-Albuterol solution (medication to improve breathing 0.5-2.5 (3) mg/ml three ml inhale orally via nebulizer every 12 hours as needed. Observation on 4/10/23, at 10:41 A.M., showed the following: -Resident sat in his/her room in his/her wheelchair; -Resident has a tracheostomy, oxygen at three liters per nasal cannula; -The resident's hand held nebulizer mask sat on the beside dresser uncovered. Observation on 4/10/23, at 3:50 P.M., showed the following: -The resident in bed; -Licensed Practical Nurse (LPN) R removed a soiled dressing from the resident's left lower leg, removed his/her gloves and did not wash or disinfect hands before donning (putting on) new gloves; -LPN R cleaned the open area on the resident's left lower legs, applied a new dressing, then removed his/her gloves and did not wash his/her hands; -LPN R donned new gloves, removed the dressing from the resident's right lower leg, removed his/her gloves and did not wash or sanitize his/her hands prior to applying new gloves; -LPN R cleaned the wounds on the resident's right leg, applied a dressing, then removed his/her right glove; -LPN R picked up the soiled dressings with his/her gloved left hand; -With his/her soiled right hand, LPN R touched cleans supplies, the call light cancel button, the resident's remote, the table, and the dresser; -LPN R disposed of the soiled dressings in a plastic bag, removed his/her remaining glove and left the resident's room without washing his/her hands. Observation on 4/11/23, at 9:58 A.M., showed the following: -The resident sat in his/her room in a wheelchair; -The resident's hand held nebulizer mask sat on the beside dresser uncovered. During an interview on 4/19/23, at 3:40 P.M. LPN R said the following: -All oxygen tubing and masks for nebulizers are expected to be stored in a clean bag when not in use; -Staff are expected to wash or sanitize their hands before and after care of each resident, between dirty and clean tasks, and with glove changes; -He/She did not wash or sanitize his/her hands because he/she forgot. 3. Review of Resident #38's annual MDS, dated [DATE], showed the following: -Diagnosis include cellulitis both lower extremities, lymphedema, and morbid obesity; -Cognitively intact; -Transfers did not occur (bed bound); -Functional limitation in range of motion to both lower extremities; -Always incontinent; -No open wounds or pressure ulcers. Review of the resident's care plan, revised 2/17/23, showed the following: -At risk for alteration in skin integrity related to incontinence, obesity and severe lymphedema. -Resident's venous ulcers will heal over the next 90 days; -Refer to wound nurse as needed; -Administer treatments per physician's order. Observation on 4/10/23, at 11:09 A.M., showed the following: -The resident in bed; -CNA Z and CNA EE entered the room and did not wash or sanitize their hands, then donned gloves; -CNA EE washed the resident's front legs and front perineal area; -CNA EE then applied a cream on the resident's front perineal area; -CNA EE removed his/her gloves and did not wash or sanitize his/her hands. CNA EE touched clean incontinence pads for the bed, the resident's blanket, then donned new gloves; -CNA EE and CNA Z assisted the resident to turn to his/her left side. There was a large open bleeding wound without a dressing or anything covering the wound on the resident's left lower posterior leg; -CNA Z washed the resident's back buttock region and washed the back of the resident's legs that were weeping from lymphedema (swelling that causes fluid to come out of the skin); -Blood ran down the resident's leg and onto the incontinence pads on the bed; -CNA Z used an incontinence wipe and wiped the blood off the resident's leg, and with the same wipe wiped the open wound, and used the wipe to apply pressure to the open wound; -CNA Z with the same soiled gloves, went to the resident's supplies and obtained wound cleanser and a hand towel. CNA Z sprayed the wound with wound cleanser, then wiped the blood running down the resident's leg and then the resident's open wound with the towel; -CNA Z removed his/her gloves, did not wash/sanitize his/her hands and donned new gloves; -The resident's leg continued to bleed and run down the resident's leg and onto the clean incontinence pad; -CNA Z placed soiled linen in a bag on the resident's floor, then using another hand towel, wiped the blood from the resident's leg about 12 inches out from the wound and wiped toward the resident's open wound, then wiped the resident's open wound; -CNA Z went to the resident's supplies and opened an absorbent pad with soiled gloves, placed it over the resident's wound, and assisted CNA EE to turn the resident to his/her back; -CNA Z and CNA EE with soiled gloves, covered the resident with blankets, and picked up soiled linens and clean supplies; -Both CNA's removed their gloves and left the room without washing their hands. During an interview on 4/10/23, at 1:25 P.M., CNA EE said the following: -Staff are expected to wash/sanitize their hands before and after care of each resident, with glove changes, and when going from dirty to clean tasks; -He/She did not wash/sanitize his/her hands with glove changes because he/she was trying to hurry because the resident was uncomfortable. During an interview on 4/12/23, at 2:40 P.M., CNA Z said the following: -Staff are expected to change their gloves and wash/sanitize their hands anytime their gloves are soiled before moving to the next task, when enter and leave the room, when going from a dirty to clean task; -He/She forgot to wash/sanitize his/her hands when he/she changed his/her gloves. 4. Observation of room [ROOM NUMBER]-2 on 4/10/23 at 9:15 A.M. showed a nebulizer system (including the mouth piece), was uncovered and sat in the wheelchair nearby. Observation of room [ROOM NUMBER] on 4/10/23 at 9:52 A.M. showed oxygen tubing/cannula lay across a urine soiled bed and an uncovered nebulizer system on the bedside table. 5. Review of Resident #50's quarterly MDS dated [DATE] showed the following: -He/She had diagnosis of diabetes; -He/She had orders for and received insulin on seven of previous seven days of the review period. Observation on 4/12/23 at 6:24 A.M. showed the following: -Registered Nurse (RN) GG dropped a clean, one-time use lancet (a finger-stick blood sampling device consisting of a holder and sharp point or needle within the holder used to obtain blood for testing blood sugar levels) on the floor by the medication cart; -He/She picked up the lancet with his/her ungloved hands and placed it on the medication cart, he/she did not wash or sanitize his/her hands nor did he/she obtain a new pen with lancet; -He/She placed two tissues on the medication cart and placed the lancet pen (that had been dropped on the floor), glucometer, test strip, and alcohol pads on the tissues; -He/She carried the tissues containing the lancet pen, glucometer, test strip, and alcohol pads to the resident's room and set the tissues holding the items on the resident's bedside table; -He/She washed his/her hands and donned gloves in the resident's room, used an alcohol pad to wipe the resident's finger and then used one of the tissues to dry the resident's finger prior to using the (previously dropped) lancet pen to obtain a blood droplet to apply on the test strip inserted into the glucometer; -While wearing the same gloves (and without changing gloves or washing his/her hands), he/she walked the resident out of the resident's room, assisted the resident by steadying the resident's arm with his/her contaminated, gloved hand; -RN GG used his/her contaminated gloved hand to pull a chair out from the table for the resident to sit in in the dining room; -RN GG walked to the kitchenette, located by the dining room, where he/she used his/her contaminated gloved hand's fingers to press the keys on the keypad of the kitchenette door to obtain entry to the kitchenette; -With the same contaminated gloved hands, he/she obtained paper towels from the dispenser in the kitchenette and placed them on the counter and placed the tissue containing the lancet pen, glucometer, and test strip on the paper towels; -He/She removed his/her contaminated gloves and threw them in a bucket, labeled 100 Linen, then grabbed the contaminated gloves out of the linen bucket with his/her bare hands and placed the gloves in the trash; -Without washing his/her hands, he/she used his/her bare hands to open and close the refrigerator door in the kitchenette twice, then opened the microwave door in the kitchenette; -He/She then carried the paper towel containing the tissue, glucometer, lancet pen, and test strip from the kitchenette counter to the medication cart, disposed of the used lancet and blood filled test strip in the receptacles on the medication cart, and quickly wiped the glucometer with a Sani-cloth wipe and immediately placed it into the upper drawer of the medication cart; -He/She then washed his/her hands in the resident's room. Observation on 4/12/23 at 6:38 A.M. showed the following: -RN GG used his/her bare hands to pick up trash off of the floor by the medication cart and put the trash in the trash container located on the medication cart; -Without washing or sanitizing his/her hands, he/she pushed the medication cart down the hall by the dining room and entered the nearby kitchenette; -In the kitchenette, he/she used his/her soiled hands to open the microwave, remove a cup from the microwave, tear open and pour the contents of a dry drink mix into the cup; -He/She then used his/her soiled hands to open a drawer below the counter, obtain two packages of saltine crackers, remove the crackers from the packages, place the crackers on a paper towel on the counter, obtain a knife from the drawer, obtain a container of peanut butter from the cabinet, and spread peanut butter on the crackers; -He/She then threw the paper towel containing the crackers and peanut butter in the trash along with the jar of peanut butter and said he/she didn't want to over-do it by giving the resident too much since the cart of meal trays was coming down the hall. 6. Review of Resident #66's significant change MDS, dated [DATE], showed the following: -The resident has a diagnosis of dementia; -He/She has an indwelling urinary catheter; -He/She uses a wheelchair for mobility. Observation on 4/10/23 at 11:50 A.M., showed the resident sat in his/her wheelchair in his/her room. The resident's catheter bag was in a privacy bag and the tubing was hanging out of the privacy bag and touching the floor. Observation on 4/12/23 at 8:05 A.M., showed the resident's catheter bag was in a privacy bag and the tubing was hanging out of the privacy bag and dragging the floor as the resident self-propelled his/her wheelchair down the hall. During interview on 4/18/23 at 5:07 A.M., CNA X said staff should wash their hands or use hand sanitizer before going into resident rooms, before and after providing care to residents, before giving residents their medication, after handling trash, and before serving food to residents. During interview on 4/20/23 at 4:00 P.M., 4:20 P.M. and 4:38 P.M., the Director of Nurses (DON) said the following: -She expected staff to wash their hands every time they came into contact with body fluids, before, during, and after providing resident care, before moving to a new area, such as dirty to clean, and after touching trash; -Urinary catheter tubing and catheter bags should be secured so they do not drag the floor. During interview on 4/20/23 at 4:38 P.M., the Administrator said he expected staff to wash their hands prior to handling/preparing residents' food and beverages, to wear gloves, and not touch a resident's food items with their bare hands. 44665 47008

Based on observation, interview and record review, the facility failed to treat six residents with dignity (Resident #44, #62, #147, #90, #35 and #83), in a review of 26 sampled residents. The facility census was 92. Review of the facility policy, Dignity, reviewed 9/30/22, showed each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input. Review of the facility policy Resident Rights last reviewed 10/6/22 showed a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. 1. Review of Resident #44's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/10/23, showed the following: -Cognitively intact; -No delirium; -Extensive assist of one staff for bed mobility; -Extensive assist of two staff for dressing, toilet use and personal hygiene; -Total dependence of two staff for transfers; -Frequently incontinent of bladder; -Always incontinent of bowel. Review of the resident's care plan last revised 3/20/23 showed the following: -Diagnoses included post-polio syndrome (gradual muscle weakness and muscle atrophy (loss of muscle) in people who have had polio; -Make atmosphere as homelike as possible; -Respect the resident's rights; -Approach in a positive manner; -Occasionally incontinent and required monitoring and assist with peri care; -Required assist with positioning in bed and electric wheelchair. Interview with the resident showed the following: -On 4/11/23 at 10:25 A.M. the resident said about a week ago a nurse came in and scolded him/her for turning his/her call light on when a Certified Nurse Assistant (CNA) had just left the room. He/She said if you complain, they (staff) will make you wait by not answering your light for three or four hours, especially from 6:00-9:00 P.M.; -On 4/18/23 at 12:20 P.M., the resident said the staff member who scolded him/her was Certified Nurse Aide (CNA) N. He/She said the nurse was aggressive when he/she yelled, You have your call light on again after someone was just in your room. You keep your light on all the time. This made the resident feel irritated and it was unfair, as a person cannot know all their needs in one moment. He/She felt that when staff refused to answer the call light for long periods of time, it was a form of retribution. 2. Review of resident #62's quarterly MDS, dated [DATE] showed the following: -Moderately impaired cognition; -Hearing adequate, no aid used. During interview on 4/12/23 at 5:10 A.M., Resident #62 said the following: -Staff used foul language at night; -Staff talk about what is going on with other residents and what a pain that resident was to them. 3. Review of Resident #147's quarterly MDS dated [DATE], showed: -Cognitively intact; -Always incontinent of bowel and bladder; -Extensive assist of two for bed mobility, dressing and personal hygiene. Review of the resident's care plan, last revised 3/6/23 showed: -Diagnosis of dementia; -Assist with bed mobility, dressing and personal hygiene. Observations on 4/10/23 showed the following: -At 10:14 A.M. the resident lay in his/her bed and wore only a shirt and incontinence brief. The door to the room was open and no privacy curtain was drawn. The resident was visible from the hall as visitors, residents and staff passed by the room; -At 2:44 P.M., the resident lay in the bed and wore only a shirt and an incontinence brief. The resident was visible from the hallway as visitors, residents and staff passed by the room. 4. Review of Resident #90's admission MDS, dated [DATE], showed the following: -His/Her hearing was adequate and he/she had clear speech; -He/She could make himself/herself understood and sometimes understood others; -He/She did not exhibit hallucinations, delusions, or behaviors; -It was very important to him/her to have his/her family or close friend involved in care discussions and very important to use the phone in private. Review of the resident's care plan, revised 1/31/23, showed the following: -Staff were to anticipate his/her needs as much as possible and monitor for nonverbal cues; -Staff were to allow extra time for him/her to respond to questions and instructions; -He/She had some limited mobility and activities of daily living (ADL's), staff were to encourage him/her to ask for assistance with ADL's and mobility as needed; -He/She needed supervision with set-up assistance for eating. During an interview on 4/12/23 at 7:47 A.M., the resident said he/she tried asking staff to help him/her call his/her family on the phone but staff didn't respond to his/her request and just fluffed him/her off. He/She didn't like how staff didn't listen to him/her. During an interview on 4/13/23 at 5:33 P.M., the resident said he/she asked for butter for his/her bread at dinner but staff didn't answer him/her. He/She would eat the bread if he/she had some butter for it. 5. Review of Resident #35's annual MDS dated [DATE] showed the following: -His/Her cognition was intact; -He/She could understand others and was able to make himself/herself understood. -His/Her vision was severely impaired; -He/She used a wheelchair; -He/She required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene. Review of the resident's care plan, revised 4/6/23, showed the following: -He/She had limited mobility and staff were to assist him/her to the toilet routinely and reposition him/her while in bed and in wheelchair routinely; -Staff were to keep his/her call light within reach and encourage him/her to ask for assistance as needed; -He/She needed staff assist for most of his/her activities of daily living and mobility; -He/She used a wheelchair for his/her primary mode of locomotion, he/she needed staff assistance due to being legally blind; -He/She was legally blind and could only see objects and shadows; -Staff were to approach him/her in a warm calm manner; -Staff were to allow him/her and his/her family to voice any concerns he/she had and listen in a nonjudgmental manner. During an interview on 4/12/23 at 5:43 A.M., the resident said the following: -He/She felt like he/she was always the last resident staff got to and staff told him/her 'there are other residents who need help too;' -It made him/her feel like staff didn't care about him/her. During an interview on 4/13/23 at 8:01 A.M. CNA JJ said he/she had heard staff yell at the resident when he/she had his/her call light on and say 'What do you want?' in a loud tone. 6. Review of the Resident #83's face sheet showed the resident was admitted on [DATE] due to an infection following a surgical procedure. Review of the Resident's significant change MDS dated [DATE], showed the following: -The resident was cognitively intact; -His/Her hearing was adequate; -He/She resident did not use hearing aids. During an interview on 4/10/23 at 1:45 P.M., the resident said there was a staff member that was being rude to him/her, but he/she did not feel comfortable giving a name and did not want to discuss in detail. During an interview on 4/13/23 at 4:00 P.M., the resident said there was a female staff member, who worked day shift that was rude to him/her, but he/she did not feel comfortable identifying them. During interview on 4/13/213 at 6:05 P.M. Certified Medication Technician (CMT) KK said the following: -He/She had known of two staff members,CNA F and CNA LL, who had horrible attitudes and were loud and rude with residents; -He/She had actually observed both of them on many occasions and their loud, rude attitude was the same all day, everyday. During interview on 4/20/23 at 4:00 P.M. the administrator said the following: -He would expect staff to speak to residents with dignity and respect; -Staff should not use a loud tone or be short with a resident; -Staff should no be rude to residents; -It would be considered a dignity issue if a resident who lay in bed wearing an incontinent brief (uncovered/undressed) could be seen from the hallway. Privacy should be provided. 38016 47008

Based on observation, interview, and record review, the facility failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for two residents (Residents #8 and #9) in a review of 14 sampled residents and six additional residents (Residents #21, #18, #16, #19, #17 and #20), who all had diagnosis of dementia, were cognitively impaired, and dependent on staff for assistance with activities of daily living. Staff woke and dressed the residents early in the morning without consideration of the resident's preferences for waking and for staff convenience. The facility census was 81. Review of the facility policy Dignity, revised 9/30/22, showed the following: -Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input; -Considering the resident's lifestyle and personal choices identified through their assessment processes torespect anddaccommodatee his or her individual needs and preferences. 1. Review of Resident #21's undated face sheet showed the following: -The resident admitted to the facility on [DATE]; -The resident had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems) with agitation Review of resident's care plan, reviewed 5/18/23, showed the following: -The resident had limited mobility and activities of daily living (ADL) function due to this/her Alzheimer's dementia; -Follow resident preferences for awakening and going to bed as requested and as applicable; -The resident required extensive to total assistance for most of his/her ADLs and mobility; -The resident required staff assistance to eat; -Respect the resident's rights. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/18/23, showed the following: -The resident's cognition was severely impaired; -The resident required extensive assistance of one staff for eating; -The resident required total assistance of two staff for transfers. During an interview on 7/13/23 at 5:40 A.M. and 6:15 A.M., Certified Nurse Aide (CNA) E said the following: -Staff know who to get up each morning; -During a staff in-service meeting, staff were told that all of the residents that required assistance with eating had to be gotten up early and taken to the dining room, even if the resident was still sleeping; - Resident #21 is one of the residents staff get up early because the resident required a Hoyer lift (a machine used to transfer residents who cannot provide assistance from one surface to another) to get out of bed and also required assistance to eat. Observation on 7/13/23 at 5:45 A.M. showed the following: -CNA E and Licensed Practical Nurse (LPN) B entered Resident #21's room and told the resident they were going to get him/her dressed; -The resident moaned and mumbled while staff dressed him/her; -After staff dressed the resident, they transferred the resident to his/her wheelchair with the Hoyerr lift; -Staff took the resident to the dining room and left the resident at a table. During an interview on 7/13/23 at 5:50 A.M., LPN D said the following: -There was a staff meeting where night shift staff were told to get the residents that required assistance to eat breakfast up before day shift came in; -Staff was to get the residents up even if they were asleep; -The residents on the locked unit were to be up as well, staff get some of the residents up at 4:30 A.M.; -Staff serve breakfast in the dining room anytime from 6:45 A.M. to 7:30 A.M. Observation on 7/13/23 at 5:55 A.M. showed the resident sat in his/her wheelchair in the dining room with his/her chin down to his/her chest asleep. Staff talked to the resident and asked the resident to wake up and asked the resident why he/she was so sleepy. During an interview on 7/13/23 at 1:50 P.M. the resident's responsible party said the following: -He/She was not sure why the facility would get the resident up so far in advance of breakfast; -He/She felt the resident should not be up until about 30 minutes before breakfast. During an interview on 7/13//23 at 2:08 P.M. LPN A said the following: -5:45 A.M. was not a reasonable time to wake the resident for breakfast; -The resident cannot make his/her wishes known; -The resident had to be assisted to eat meals and that was why staff got him/her up and to the dining room early. 2. Review of Resident #9's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assist of one for transfers; -Required limited assist of one for eating; -Diagnosis of dementia. Review of the resident's care plan revised 6/13/23 showed the following: -Allow this resident to make choices regarding his/her own schedule; -Respect this resident's rights; -Resident requires limited to extensive assist to complete ADLs at times related to dementia; -Follow resident preferences for waking, bathing, bedtime and where to eat as requested and applicable; -The resident is able to feed him/herself with set-up assist at times, but usually needs limited assist to eat. Review of the resident's electronic health record (EHR) showed special instructions for the resident to be up in the morning between 8:00 A.M. and 8:30 A.M. for breakfast. Observation of the resident on 7/13/23 from 5:35 A.M. until 7:23 A.M. showed the following: -At 5:35 A.M. the resident sat in his/her wheelchair at the table in the dining room and yelled out Help me!, let's go!; -At 5:51 A.M., 6:31 A.M., and 6:52 A.M. the resident remained in his/her wheelchair at the dining room table yelling out intermittently; -At 6:52 A.M. CNA N sat the resident's breakfast plate in front of him/her, the resident pushed his/her plate away and yelled nonsensically; -At 7:00 A.M. the resident rolled back and forth in his/her wheelchair. CNA R sat down beside the resident and attempted to feed the resident, the resident refused to eat; -At 7:23 A.M. the resident's eyes were closed and his/her breakfast was untouched. During interview on 7/13/23 at 9:20 A.M. the resident said the following: -He/She doesn't like to get up early; -He/She only likes to get up early if he/she is going to work and he/she doesn't have to work anymore. During interview on 7/13/23 at 2:05 P.M. the resident's responsible party said the following: -He/She did not want staff to wake the resident up between 3:30A.M and 4:30 A.M. in the morning; -When the resident was at home, he/she would normally sleep in later; -It would be okay for staff to wake the resident for breakfast around 7:00 A.M. 3. Review of Resident #19's admission MDS dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assist of one for transfers; -Required set up help for eating; -Diagnosis of dementia. Review of the resident's care plan dated 6/6/23 showed the following: -Allow the resident to make choices about his/her own schedule; -Respect the resident's rights; -The resident has limited mobility and ADL function due to his/her dementia; -Follow resident preferences for waking, bathing, bedtime and where to eat as requested and as applicable; -The resident requires set up assist for eating. Observation of the resident on 7/13/23 between 5:35 A.M. and 7:37 A.M., showed the following: -At 5:35 A.M. the resident sat in his/her wheelchair at the dining room table; -At 6:14 A.M. the resident remained at the table with his/her eyes closed; -At 6:28 A.M. the resident remained at the table with his/her eyes closed, the resident said he/she was sleepy; -At 6:39A.M. the resident remained at the table with his/her eyes closed; -At 656 A.M. CNA R sat a breakfast plate in front of the resident; -At 7:24 A.M. the resident sat at the table with his/her eyes closed and his/her breakfast tray was untouched; -At 7:37 A.M. CNA N sat down and by the resident and assisted the resident with his/her breakfast. 4. Review of Resident #17's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Totally dependent on two or more staff for transfers; -Required extensive assist of one for eating; -Diagnoses of dementia. Review of the resident's care plan revised 6/14/23, showed the following: -Provide resident assist with meal set up, cueing, and feeding as needed; -The resident requires assistance to complete his/her ADLs, due to his/her dementia and history of stroke; -Follow resident preference for waking, bathing, bedtime and where to eat as requested and as applicable; -The resident used a mechanical lift and assist of two for all transfers; -Allow the resident to make choices regarding his/her own schedule; -Respect the resident's rights. Observation on 7/13/23 at 5:43 A.M. in the resident's room showed the following: -The light was on above the resident's bed; -The resident lay in bed with his/her eyes closed; -The resident was fully dressed. Observation on 7/13/23 at 6:14 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair; -His/her eyes were closed. Observation on 7/13/23 at 6:51 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair; -His/her head eyes were closed, his/her mouth was open and head tilted back. Observation on 7/13/23 at 6:55 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair; -CNA R placed the resident's breakfast in from of him/her; -CNA R remarked, You aren't very wide awake are you? Observation on 7/13/23 at 7:23 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair; -His/Her eyes were closed, his/her mouth open and head tilted back; -CNA N walked up to the resident and said Hello, the resident flinched and opened his/her eyes. Observation on 7/13/23 at 7:33 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair; -His/her eyes were closed. Observation on 7/13/23 at 7:40 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair; -His/her eyes were closed, his/her head was tilted down with his/her chin on his/her chest; -The resident's hand lay in his/her plate. 5. Review of Resident #20's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assist of two or more staff for transfers; -Requires set up help for eating; -Diagnosis of dementia. Review of the resident's care plan revised 6/12/23, showed the following: -Provide resident assist with meal set up, cueing, and feeding as needed; -The resident requires assistance with his/her ADLs and mobility due to dementia; -Follow resident preferences for waking, bathing, bedtime and where to eat as requested and as applicable; -The resident is extensive assist of two for transfers; -The resident needs cueing and prompting to eat; -The resident would like to be up by 8:00 A.M. so he/she may have a hot breakfast; -Allow the resident to make choices regarding his/her own schedule. Observation on 7/13/23 at 5:35 A.M. in the resident's room showed the following: -The resident lay in bed with his/her eyes closed; -The resident was fully dressed. Observation on 7/13/23 at 5:48 A.M. in the resident's room showed the following: -The resident sat in his/her wheelchair at a table; -The resident's eyes were partially closed. Observation on 7/13/23 at 6:37 A.M. in the resident's room showed the following: -The resident sat in his/her wheelchair at a table; -The resident's eyes were partially closed. During interview on 7/13/23 at 6:37 A.M. the resident said she did not like to get up early and would like to sleep more. Observation on 7/13/23 at 6:58 A.M. in the resident's room showed the following: -The resident sat in his/her wheelchair at a table; -Staff sat the resident's breakfast in front of him/her. 6. Review of Resident #16's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Totally dependent on two or more staff for transfers; -Required extensive assist of one for eating; -Diagnosis of dementia. Review of the resident's care plan revised 2/21/23 showed the following: -The resident has limited mobility and ADL function due to his/her dementia and cognitive deficits; -The resident needs extensive assist of staff for most of his/her ADLs and mobility; -The resident needs staff assist to eat; -The resident uses a mechanical list and assist of two for all transfers; -Allow the resident to make choices regarding his/her own schedule; -Respect the resident's rights. Observation on 7/13/23 at 5:44 A.M. in the resident's room showed the resident lay in bed with his/her eyes closed. Observation on 7/13/23 at 6:05 A.M. in the resident's room showed the following: -The resident lay awake in bed fully dressed; -CNA N and CNA R entered the resident's room; -CNA N and CNA R transferred the resident's from his/her bed to a reclining wheelchair. Observation on 7/13/23 at 6:30 A.M. in the dining room showed the following: -The resident sat in his/her reclining wheelchair at a table; -The resident had facial grimacing and intermittently yelled out, Dear Lord! Observation on 7/13/23 at 6:43 A.M. in the dining room showed the following: -The resident sat in his/her reclining wheelchair at the table; -His/her eyes were closed. Observation on 7/13/23 at 7:02 A.M. in the dining room showed the following: -The resident sat in his/her reclining wheelchair at a table; -His/her eyes were closed; -CNA N sat the resident's breakfast down on the table; -CNA N began feeding the resident. 7. Review of Resident #18's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Requires extensive assist of one for transfers; -Requires limited assist of one for eating; -Diagnoses of Alzheimer's disease. Review of the resident's care plan revised 6/5/23 showed the following: -The resident has limited mobility and ADL function due to his/her cognitive deficits related to Alzheimer's disease; -Follow resident preferences for waking, bathing, bedtime and where to eat as requested and as applicable; -The resident needs extensive assist for transfers at times; -Allow the resident to make choices regarding his/her own schedule; -Respect the resident's rights. Observation on 7/13/23 of the resident in the dining room showed the following: -At 5:35 A.M. the resident sat in his/her wheelchair at the table; -The resident was awake and rolled back and forth in his/her wheelchair. Observation in the secured unit on 7/13/23 at 6:17 A.M., 6:28 A.M., 6:48 A.M., and 7:41 A.M., showed the resident propelled him/herself back and forth down the hallway in his/her wheelchair. 8. Review of Resident #8's care plan revised 6/1/23 showed the following: -Provide the resident assist with meal set up and cueing as needed; -The resident has limited ADL function and mobility due to his/her dementia; -The resident is extensive assist of two for transfers; -The resident needs extensive assist for eating. -Allow the resident to make choices regarding his/her own schedule; -Respect the resident's rights. Review of the resident's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assist of two or more staff for transfers; -Required set up help for eating; -Diagnosis of Alzheimer's disease. Observation on 7/13/23 at 5:35 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair at the table; -An empty coffee cup sat on the table in front of the resident. Observation on 7/13/23 at 6:15 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair at the table; -The resident faced the wall and yawned. Observation in the secured unit on 7/13/23 at 6:28 A.M. and 6:48 A.M. showed the resident propelled him/herself back and forth down the hallway in his/her wheelchair. Observation in the dining room on 7/13/23 at 6:58 A.M. showed the following: -The resident sat in his/her wheelchair at a table; -CNA N sat the resident's breakfast plate in front of the resident. During an interview on 7/13/23 at 1:52 P.M. the resident's responsible party said the resident should not be up two hours before he/she eats. During interview on 7/13/23 at 5:50 A.M. CNA O said the following: -He/She worked night shift on the secured unit; -He/She was unsure of residents' preferred wake up times; -He/She gets most of the residents up around 5:00 A.M.; -The residents that are able to toilet are toileted around 4:00 A.M. and dressed for the day at that time; -He/She dressed residents that required use of the mechanical lift for transfers at 5:00 A.M. During an interview on 7/13/23 at 6:05 A.M. CNA N and CNA R said the following: -Staff always get the residents who require the mechanical lift for transfers and the residents who required assistance to eat up for breakfast no matter whether they are awake or not; -They have to feed the residents, toilet and/or change them and have the residents ready for activities. During an interview on 7/13/23 at 10:05 A.M. Nurse Aide (NA) P said the following: -CNA O started waking residents up at 3:30 A.M.; -CNA O said he/she does that to help day shift; -CNA O told him/her that night shift gets all the residents on the unit up at 3:30 A.M.; -One resident was very verbal and told CNA O no when CNA O tried to get him/her up and CNA O told the resident no and got the resident up anyway; -One resident does not want to get up until 8:00 A.M., but CNA O got him/her up anyway; -This upset NA P; -He/She reported the early wake up to the charge nurse (unknown name) and the charge nurse told him/her to just follow CNA O's lead. During an interview on 7/13/23 at 8:58 A.M. CNA Q said the following: -The day shift aides get to the unit at 5:30 A.M.; -The day shift aides complained because they would get to work and no residents were up for breakfast; -CNA O has all the residents up for the day by 5:30 A.M.; -CNA O started at 3:30 A.M. getting residents up for the day and most were up by 4:30 A.M.; -Resident #9 was forced to get up, NA P was assisting CNA O on the hall this morning and NA P was in tears; -Resident #9 was not wanting to get up and CNA O got him/her up anyway; -He/She complained to the Director of Nurses (DON) about waking the residents on the unit early; -He/She refused to do the early morning get up on the unit so he/she was moved off the unit. During an interview on 7/13/23 at 2:57 P.M. Licensed Practical Nurse (LPN) B and staff educator said the following: -If residents are awake and act like they are ready to get up then staff can get them up; -Staff can wake the residents 30 minutes before breakfast; -Resident and/or family preferences for wake up time should be on the care plan; -Staff should not get a resident up to toilet at 4:00 A.M., fully dress the resident and put the resident back to bed; -If a resident seems sleepy staff should let them rest. During an interview on 7/13/23 at 2:07 P.M., the Social Service Designee said the following: -When a resident is first admitted the nurse gets the resident/family preferences at that time; -These preferences are reviewed at care plan meetings with the resident and/or family. During an interview on 7/13/23 at 7:34 A.M. Registered Nurse (RN) S, the unit charge nurse, said the following: -He/She was the day shift charge nurse; -If a resident wants to sleep staff should let them sleep; During an interview on 7/13/23 at 3:26 P.M. the Interim DON said the following: -The facility does not have a get up list; -Staff usually start at one end of the hall and work their way down the hall when getting residents up; -Staff can wake residents per their preference; -There are early risers in the unit and the unit residents are the first to be served breakfast; -Staff should not be waking the residents up; -Staff should not wake and dress residents at 4:00 A.M.; -If the resident is unable to say a preferred wake up time, staff should ask the family. During an interview on 7/13/23 at 4:15 P.M. the administrator said the following: -Staff should not wake residents early if the residents are not awake; -Staff should follow resident and/or family preferences regarding wake up times. MO 220767

Based on observation, interview, and record review, the facility failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for two residents (Residents #8 and #9) in a review of 14 sampled residents and six additional residents (Residents #21, #18, #16, #19, #17 and #20), who all had diagnosis of dementia, were cognitively impaired, and dependent on staff for assistance with activities of daily living. Staff woke and dressed the residents early in the morning without consideration of the resident's preferences for waking and for staff convenience. The facility census was 81. Review of the facility policy Dignity, revised 9/30/22, showed the following: -Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input; -Considering the resident's lifestyle and personal choices identified through their assessment processes torespect anddaccommodatee his or her individual needs and preferences. 1. Review of Resident #21's undated face sheet showed the following: -The resident admitted to the facility on [DATE]; -The resident had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems) with agitation Review of resident's care plan, reviewed 5/18/23, showed the following: -The resident had limited mobility and activities of daily living (ADL) function due to this/her Alzheimer's dementia; -Follow resident preferences for awakening and going to bed as requested and as applicable; -The resident required extensive to total assistance for most of his/her ADLs and mobility; -The resident required staff assistance to eat; -Respect the resident's rights. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/18/23, showed the following: -The resident's cognition was severely impaired; -The resident required extensive assistance of one staff for eating; -The resident required total assistance of two staff for transfers. During an interview on 7/13/23 at 5:40 A.M. and 6:15 A.M., Certified Nurse Aide (CNA) E said the following: -Staff know who to get up each morning; -During a staff in-service meeting, staff were told that all of the residents that required assistance with eating had to be gotten up early and taken to the dining room, even if the resident was still sleeping; - Resident #21 is one of the residents staff get up early because the resident required a Hoyer lift (a machine used to transfer residents who cannot provide assistance from one surface to another) to get out of bed and also required assistance to eat. Observation on 7/13/23 at 5:45 A.M. showed the following: -CNA E and Licensed Practical Nurse (LPN) B entered Resident #21's room and told the resident they were going to get him/her dressed; -The resident moaned and mumbled while staff dressed him/her; -After staff dressed the resident, they transferred the resident to his/her wheelchair with the Hoyerr lift; -Staff took the resident to the dining room and left the resident at a table. During an interview on 7/13/23 at 5:50 A.M., LPN D said the following: -There was a staff meeting where night shift staff were told to get the residents that required assistance to eat breakfast up before day shift came in; -Staff was to get the residents up even if they were asleep; -The residents on the locked unit were to be up as well, staff get some of the residents up at 4:30 A.M.; -Staff serve breakfast in the dining room anytime from 6:45 A.M. to 7:30 A.M. Observation on 7/13/23 at 5:55 A.M. showed the resident sat in his/her wheelchair in the dining room with his/her chin down to his/her chest asleep. Staff talked to the resident and asked the resident to wake up and asked the resident why he/she was so sleepy. During an interview on 7/13/23 at 1:50 P.M. the resident's responsible party said the following: -He/She was not sure why the facility would get the resident up so far in advance of breakfast; -He/She felt the resident should not be up until about 30 minutes before breakfast. During an interview on 7/13//23 at 2:08 P.M. LPN A said the following: -5:45 A.M. was not a reasonable time to wake the resident for breakfast; -The resident cannot make his/her wishes known; -The resident had to be assisted to eat meals and that was why staff got him/her up and to the dining room early. 2. Review of Resident #9's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assist of one for transfers; -Required limited assist of one for eating; -Diagnosis of dementia. Review of the resident's care plan revised 6/13/23 showed the following: -Allow this resident to make choices regarding his/her own schedule; -Respect this resident's rights; -Resident requires limited to extensive assist to complete ADLs at times related to dementia; -Follow resident preferences for waking, bathing, bedtime and where to eat as requested and applicable; -The resident is able to feed him/herself with set-up assist at times, but usually needs limited assist to eat. Review of the resident's electronic health record (EHR) showed special instructions for the resident to be up in the morning between 8:00 A.M. and 8:30 A.M. for breakfast. Observation of the resident on 7/13/23 from 5:35 A.M. until 7:23 A.M. showed the following: -At 5:35 A.M. the resident sat in his/her wheelchair at the table in the dining room and yelled out Help me!, let's go!; -At 5:51 A.M., 6:31 A.M., and 6:52 A.M. the resident remained in his/her wheelchair at the dining room table yelling out intermittently; -At 6:52 A.M. CNA N sat the resident's breakfast plate in front of him/her, the resident pushed his/her plate away and yelled nonsensically; -At 7:00 A.M. the resident rolled back and forth in his/her wheelchair. CNA R sat down beside the resident and attempted to feed the resident, the resident refused to eat; -At 7:23 A.M. the resident's eyes were closed and his/her breakfast was untouched. During interview on 7/13/23 at 9:20 A.M. the resident said the following: -He/She doesn't like to get up early; -He/She only likes to get up early if he/she is going to work and he/she doesn't have to work anymore. During interview on 7/13/23 at 2:05 P.M. the resident's responsible party said the following: -He/She did not want staff to wake the resident up between 3:30A.M and 4:30 A.M. in the morning; -When the resident was at home, he/she would normally sleep in later; -It would be okay for staff to wake the resident for breakfast around 7:00 A.M. 3. Review of Resident #19's admission MDS dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assist of one for transfers; -Required set up help for eating; -Diagnosis of dementia. Review of the resident's care plan dated 6/6/23 showed the following: -Allow the resident to make choices about his/her own schedule; -Respect the resident's rights; -The resident has limited mobility and ADL function due to his/her dementia; -Follow resident preferences for waking, bathing, bedtime and where to eat as requested and as applicable; -The resident requires set up assist for eating. Observation of the resident on 7/13/23 between 5:35 A.M. and 7:37 A.M., showed the following: -At 5:35 A.M. the resident sat in his/her wheelchair at the dining room table; -At 6:14 A.M. the resident remained at the table with his/her eyes closed; -At 6:28 A.M. the resident remained at the table with his/her eyes closed, the resident said he/she was sleepy; -At 6:39A.M. the resident remained at the table with his/her eyes closed; -At 656 A.M. CNA R sat a breakfast plate in front of the resident; -At 7:24 A.M. the resident sat at the table with his/her eyes closed and his/her breakfast tray was untouched; -At 7:37 A.M. CNA N sat down and by the resident and assisted the resident with his/her breakfast. 4. Review of Resident #17's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Totally dependent on two or more staff for transfers; -Required extensive assist of one for eating; -Diagnoses of dementia. Review of the resident's care plan revised 6/14/23, showed the following: -Provide resident assist with meal set up, cueing, and feeding as needed; -The resident requires assistance to complete his/her ADLs, due to his/her dementia and history of stroke; -Follow resident preference for waking, bathing, bedtime and where to eat as requested and as applicable; -The resident used a mechanical lift and assist of two for all transfers; -Allow the resident to make choices regarding his/her own schedule; -Respect the resident's rights. Observation on 7/13/23 at 5:43 A.M. in the resident's room showed the following: -The light was on above the resident's bed; -The resident lay in bed with his/her eyes closed; -The resident was fully dressed. Observation on 7/13/23 at 6:14 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair; -His/her eyes were closed. Observation on 7/13/23 at 6:51 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair; -His/her head eyes were closed, his/her mouth was open and head tilted back. Observation on 7/13/23 at 6:55 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair; -CNA R placed the resident's breakfast in from of him/her; -CNA R remarked, You aren't very wide awake are you? Observation on 7/13/23 at 7:23 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair; -His/Her eyes were closed, his/her mouth open and head tilted back; -CNA N walked up to the resident and said Hello, the resident flinched and opened his/her eyes. Observation on 7/13/23 at 7:33 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair; -His/her eyes were closed. Observation on 7/13/23 at 7:40 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair; -His/her eyes were closed, his/her head was tilted down with his/her chin on his/her chest; -The resident's hand lay in his/her plate. 5. Review of Resident #20's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assist of two or more staff for transfers; -Requires set up help for eating; -Diagnosis of dementia. Review of the resident's care plan revised 6/12/23, showed the following: -Provide resident assist with meal set up, cueing, and feeding as needed; -The resident requires assistance with his/her ADLs and mobility due to dementia; -Follow resident preferences for waking, bathing, bedtime and where to eat as requested and as applicable; -The resident is extensive assist of two for transfers; -The resident needs cueing and prompting to eat; -The resident would like to be up by 8:00 A.M. so he/she may have a hot breakfast; -Allow the resident to make choices regarding his/her own schedule. Observation on 7/13/23 at 5:35 A.M. in the resident's room showed the following: -The resident lay in bed with his/her eyes closed; -The resident was fully dressed. Observation on 7/13/23 at 5:48 A.M. in the resident's room showed the following: -The resident sat in his/her wheelchair at a table; -The resident's eyes were partially closed. Observation on 7/13/23 at 6:37 A.M. in the resident's room showed the following: -The resident sat in his/her wheelchair at a table; -The resident's eyes were partially closed. During interview on 7/13/23 at 6:37 A.M. the resident said she did not like to get up early and would like to sleep more. Observation on 7/13/23 at 6:58 A.M. in the resident's room showed the following: -The resident sat in his/her wheelchair at a table; -Staff sat the resident's breakfast in front of him/her. 6. Review of Resident #16's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Totally dependent on two or more staff for transfers; -Required extensive assist of one for eating; -Diagnosis of dementia. Review of the resident's care plan revised 2/21/23 showed the following: -The resident has limited mobility and ADL function due to his/her dementia and cognitive deficits; -The resident needs extensive assist of staff for most of his/her ADLs and mobility; -The resident needs staff assist to eat; -The resident uses a mechanical list and assist of two for all transfers; -Allow the resident to make choices regarding his/her own schedule; -Respect the resident's rights. Observation on 7/13/23 at 5:44 A.M. in the resident's room showed the resident lay in bed with his/her eyes closed. Observation on 7/13/23 at 6:05 A.M. in the resident's room showed the following: -The resident lay awake in bed fully dressed; -CNA N and CNA R entered the resident's room; -CNA N and CNA R transferred the resident's from his/her bed to a reclining wheelchair. Observation on 7/13/23 at 6:30 A.M. in the dining room showed the following: -The resident sat in his/her reclining wheelchair at a table; -The resident had facial grimacing and intermittently yelled out, Dear Lord! Observation on 7/13/23 at 6:43 A.M. in the dining room showed the following: -The resident sat in his/her reclining wheelchair at the table; -His/her eyes were closed. Observation on 7/13/23 at 7:02 A.M. in the dining room showed the following: -The resident sat in his/her reclining wheelchair at a table; -His/her eyes were closed; -CNA N sat the resident's breakfast down on the table; -CNA N began feeding the resident. 7. Review of Resident #18's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Requires extensive assist of one for transfers; -Requires limited assist of one for eating; -Diagnoses of Alzheimer's disease. Review of the resident's care plan revised 6/5/23 showed the following: -The resident has limited mobility and ADL function due to his/her cognitive deficits related to Alzheimer's disease; -Follow resident preferences for waking, bathing, bedtime and where to eat as requested and as applicable; -The resident needs extensive assist for transfers at times; -Allow the resident to make choices regarding his/her own schedule; -Respect the resident's rights. Observation on 7/13/23 of the resident in the dining room showed the following: -At 5:35 A.M. the resident sat in his/her wheelchair at the table; -The resident was awake and rolled back and forth in his/her wheelchair. Observation in the secured unit on 7/13/23 at 6:17 A.M., 6:28 A.M., 6:48 A.M., and 7:41 A.M., showed the resident propelled him/herself back and forth down the hallway in his/her wheelchair. 8. Review of Resident #8's care plan revised 6/1/23 showed the following: -Provide the resident assist with meal set up and cueing as needed; -The resident has limited ADL function and mobility due to his/her dementia; -The resident is extensive assist of two for transfers; -The resident needs extensive assist for eating. -Allow the resident to make choices regarding his/her own schedule; -Respect the resident's rights. Review of the resident's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assist of two or more staff for transfers; -Required set up help for eating; -Diagnosis of Alzheimer's disease. Observation on 7/13/23 at 5:35 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair at the table; -An empty coffee cup sat on the table in front of the resident. Observation on 7/13/23 at 6:15 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair at the table; -The resident faced the wall and yawned. Observation in the secured unit on 7/13/23 at 6:28 A.M. and 6:48 A.M. showed the resident propelled him/herself back and forth down the hallway in his/her wheelchair. Observation in the dining room on 7/13/23 at 6:58 A.M. showed the following: -The resident sat in his/her wheelchair at a table; -CNA N sat the resident's breakfast plate in front of the resident. During an interview on 7/13/23 at 1:52 P.M. the resident's responsible party said the resident should not be up two hours before he/she eats. During interview on 7/13/23 at 5:50 A.M. CNA O said the following: -He/She worked night shift on the secured unit; -He/She was unsure of residents' preferred wake up times; -He/She gets most of the residents up around 5:00 A.M.; -The residents that are able to toilet are toileted around 4:00 A.M. and dressed for the day at that time; -He/She dressed residents that required use of the mechanical lift for transfers at 5:00 A.M. During an interview on 7/13/23 at 6:05 A.M. CNA N and CNA R said the following: -Staff always get the residents who require the mechanical lift for transfers and the residents who required assistance to eat up for breakfast no matter whether they are awake or not; -They have to feed the residents, toilet and/or change them and have the residents ready for activities. During an interview on 7/13/23 at 10:05 A.M. Nurse Aide (NA) P said the following: -CNA O started waking residents up at 3:30 A.M.; -CNA O said he/she does that to help day shift; -CNA O told him/her that night shift gets all the residents on the unit up at 3:30 A.M.; -One resident was very verbal and told CNA O no when CNA O tried to get him/her up and CNA O told the resident no and got the resident up anyway; -One resident does not want to get up until 8:00 A.M., but CNA O got him/her up anyway; -This upset NA P; -He/She reported the early wake up to the charge nurse (unknown name) and the charge nurse told him/her to just follow CNA O's lead. During an interview on 7/13/23 at 8:58 A.M. CNA Q said the following: -The day shift aides get to the unit at 5:30 A.M.; -The day shift aides complained because they would get to work and no residents were up for breakfast; -CNA O has all the residents up for the day by 5:30 A.M.; -CNA O started at 3:30 A.M. getting residents up for the day and most were up by 4:30 A.M.; -Resident #9 was forced to get up, NA P was assisting CNA O on the hall this morning and NA P was in tears; -Resident #9 was not wanting to get up and CNA O got him/her up anyway; -He/She complained to the Director of Nurses (DON) about waking the residents on the unit early; -He/She refused to do the early morning get up on the unit so he/she was moved off the unit. During an interview on 7/13/23 at 2:57 P.M. Licensed Practical Nurse (LPN) B and staff educator said the following: -If residents are awake and act like they are ready to get up then staff can get them up; -Staff can wake the residents 30 minutes before breakfast; -Resident and/or family preferences for wake up time should be on the care plan; -Staff should not get a resident up to toilet at 4:00 A.M., fully dress the resident and put the resident back to bed; -If a resident seems sleepy staff should let them rest. During an interview on 7/13/23 at 2:07 P.M., the Social Service Designee said the following: -When a resident is first admitted the nurse gets the resident/family preferences at that time; -These preferences are reviewed at care plan meetings with the resident and/or family. During an interview on 7/13/23 at 7:34 A.M. Registered Nurse (RN) S, the unit charge nurse, said the following: -He/She was the day shift charge nurse; -If a resident wants to sleep staff should let them sleep; During an interview on 7/13/23 at 3:26 P.M. the Interim DON said the following: -The facility does not have a get up list; -Staff usually start at one end of the hall and work their way down the hall when getting residents up; -Staff can wake residents per their preference; -There are early risers in the unit and the unit residents are the first to be served breakfast; -Staff should not be waking the residents up; -Staff should not wake and dress residents at 4:00 A.M.; -If the resident is unable to say a preferred wake up time, staff should ask the family. During an interview on 7/13/23 at 4:15 P.M. the administrator said the following: -Staff should not wake residents early if the residents are not awake; -Staff should follow resident and/or family preferences regarding wake up times. MO 220767

Based on observation, interview, and record review the facility failed to provide a safe and homelike environment when it failed to maintain resident rooms and other areas within the facility in good working order. This deficient practice had the potential to affect residents, staff, and visitors of the facility. The census was 92. 1. Observations on 4/10/23 showed the following: -At 10:55 A.M. in occupied room [ROOM NUMBER]-2 gouges to the drywall at the head of the resident's bed. -At 3:30 P.M. in room [ROOM NUMBER]-1 the closet door was held in place in the track with one set of rollers on one side of the door, the other rollers were off the track and the door hung half off the track. Resident #54 resided in the room and said he/she did not know how long it had been off track; -At 11:27 A.M. in room [ROOM NUMBER] an un-made bed with a large urine soiled area covering a large portion of the fitted sheet, a plastic cup and lid on the floor near the bedside table, and clothing piled on the floor in the bathroom; -At 11:50 A.M. in Resident 366's room two wooden closet doors were not on the door track, but were propped up in a corner of the resident's room. Observation on 4/11/23 at 11:00 A.M. showed the doors on the closet in occupied resident room [ROOM NUMBER] had been removed. There were no doors or curtains to cover the closet. During an interview on 4/11/23, at 11:03 A.M., Resident #23 said the following: -He/She resided in room [ROOM NUMBER]; -It would be nice to have something to cover his/her clothes instead of looking like he/she was having a garage sale; -There used to be closet doors on the closet but the doors fell off; -When the doors fell off, they about hit his/her previous roommate; -All the rooms have problems with the closet doors; they fall off all the time 2. Observations on 4/12/23 at 8:00 A.M., in the Special Care Unit small dining room, showed the following: -The drywall was missing and the metal corner was exposed in an approximate 2 inch by 6 inch section at the corner of the wall near the entrance of the room (facing into the room); -The ceiling light fixture had an approximate 12 inch crack in the light cover and one of the four bulbs was not working; -The HVAC unit was missing fins from the front cover; -There were scuffs on the left side wall in a 0.5 inch by 2 foot section, scuffs on the outer wall in a 0.5 inch by 3 foot section, and several scuffs on the right side wall in 0.5 inch by 2 foot sections; -The television face plate was cracked and was no longer covered the opening, leaving a 0.5 inch exposed area into the wall; -There were multiple unpainted areas that were previously patched with drywall compound: a 2 inch by 2 inch areas on the left wall, a 2 inch by 2 inch area on the outer wall, two 3 inch by 3 inch areas on the right wall, and a 6 inch by 8 inch area on the right wall; -The ceiling contained two 4 inch by 6 inch discolored areas, five 1 inch by 1 inch areas of flaking paint, and a 1 inch by 2 inch area around one of two sprinkler head escutcheon plates with missing paint; -The cove base on the right wall of the room was pulled away from the wall approximately 2 inches for a length of approximately 12 inches. A 3 foot section of the cove base was bubbled in appearance and not smoothly attached to the wall. 3. Observations on 4/13/23 at 4:47 P.M. and 5:51 P.M., showed the following: -In the Special Care Unit shower room, the plastic faucet knob for the shower was broken with half of the plastic knob missing; -In occupied resident room [ROOM NUMBER], two approximately 1 inch by 3 inch sections of the ceiling had flaking paint. One section was located on the right side of the room above the bed and the other section was located above the bed located by the room door. There was a 3 inch by 12 inch scuffed area located on the wall by the window. 4. Observations on 4/18/23 between 12:12 P.M. and 5:37 P.M., showed the following: -In occupied resident room [ROOM NUMBER], the closet door was off the door track and was leaning inward against the other closet door; -In occupied resident room [ROOM NUMBER], the towel bar was missing from the sink counter and the brackets that once held the bar remained attached to the counter, the closet door was off the door track; -In occupied resident room [ROOM NUMBER], the left side of the window blind was broken with missing slats in an approximate 3 inch by 6 inch section. The towel bar was missing from the sink counter and the brackets that once held the bar remained attached to the sink counter; -In occupied resident room [ROOM NUMBER], the circular cover plate for the door handle to the room was not attached to the door and was hanging loosely on the door handle. -At 11:33 A.M. in room [ROOM NUMBER]'s bathroom showed a toilet lift seat (which sat over the toilet) caked with a build up of urine and feces (on the entire surface), of the underneath side; -At 2:45 P.M. resident room [ROOM NUMBER] strip covering wall at floor join removed from room with no paint or repair; -Resident room [ROOM NUMBER] with a long area against back wall that was scraped and missing paint; -In resident room [ROOM NUMBER] with a large circular area down to dry wall missing paint; -Resident room [ROOM NUMBER] with closet doors propped up in room, bare metal on outside corner of closet with no drywall or pain to cover and can see light coming above air conditioner/heating unit missing missing drywall or plaster. 5. Observation on 4//19/23 at 12:00 P.M. showed resident room [ROOM NUMBER] with two wooden closet doors propped up in a corner of the resident's room. During interview on 4/18/23 at 4:52 P.M., Certified Nurse Aide II said the following: -There were many items that needed repair and there was a maintenance log at each nurses' station where staff could report issues, however things didn't always get repaired; -There were several towel bars missing from resident rooms and the pieces left that once held the towel bars were sharp and he/she worried someone could get hurt on them. During an interview on 4/18/22, at 2:10 P.M., the Maintenance Supervisor said staff write down repairs that are needed in the resident rooms on the maintenance log. He fixes the items listed when he can. He has not had time to complete all the repairs. During an interview on 4/20/23 at 4:38 P.M., the Administrator said the following: -He expected resident care equipment, rooms, and common areas to be maintained appropriately and in safe working order; -There was a sheet at each nurses' station staff could note needed maintenance issues. The maintenance director reviewed the sheet daily, then the issues were prioritized and fixed; -Staff also reported issues during daily rounds in every room as part of the facility's guardian angel program, and housekeeping staff reported any issues during resident discharges; -He expected issues at the facility to be fixed although there were some things still on the list to be repaired; -He expected closet doors that were loose or off the track to be taken out of the resident rooms until repaired. Maintenance staff should take off the closet doors if there was a problem. 44665

Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from verbal and physical abuse from Certified Nurse Aide (CNA) A. Nurse Aide (NA) B and CNA C heard CNA A yell at the resident and say he/she wasn't going to [OBSCENITY] ing hit him/her and observed CNA A hold the resident's arms across his/her chest and roll him/her in the bed aggressively. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . A sample of five residents was selected for review. The facility census was 86. The administrator was notified on 6/6/22 of the Past Non-Compliance which occurred on 5/20/22. On 5/20/22 the facility became aware of the noncompliance when the issue was reported to the administrator and the Director of Nurses (DON). Facility staff immediately started an investigation, completed disciplinary action, and began in-servicing all staff. Facility staff also notified Department of Health and Senior Services (DHSS) and local law enforcement. The noncompliance was corrected on 5/20/22. Review of the facility's policy, Protection of Residents: Reducing the Threat of Abuse and Neglect, revised 8/10/21, showed the following: -The resident has the right to be free from abuse and neglect; -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; -Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability; -Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Residents must not be subjected to abuse by anyone. This includes but is not limited to staff; -Examples of injuries that could indicate abuse include but are not limited to injuries that are non-accidental or unexplained, skin tears and lacerations, bruises, including those found in lateral locations on the arms, increased agitation around a certain staff. 1. Review of Resident #1's face sheet showed the following: -Original admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, initiated 5/28/19, and updated on 2/15/22 showed the following: -The resident's cognitive impairment puts him/her at risk for ineffective communications and his/her ability to communicate and cognition fluctuates; -Allow the resident time to express himself/herself; -Anticipate the resident's needs as much as possible and monitor for nonverbal cues; -If the resident becomes agitated come back at a later time; -Nursing staff to allow the resident time to calm down if he/she is aggressive during cares; -The resident lives on the special care unit due to his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Approach in a calm positive demeanor; -If the resident's behaviors are disruptive and are not easily redirected, ensure his/her safety and come back at a later time; -If the resident's behaviors are disruptive try diversional activities such as toileting, food, music, quieter environment; -Allow the resident to make choices regarding his/her own schedule; -Respect the resident's rights and wishes; -Use the resident's preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions, turn off the television, radio, close the door, etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues. Stop and return of agitated. Review of the resident's Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 5/18/22, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive assistance of two or more staff for bed mobility, transfers, toilet, use, and hygiene; -Verbal behaviors directed towards others were present one to three days out of seven; -Rejection of care did not occur; -Always incontinent of bowel and bladder. Review of the resident's nurse's note, dated 5/20/22 at 2:35 A.M. showed the following: -Skin tear noted to the left arm in a Y shape with bruising noted around the skin tear; -Steri-strips applied and the physician faxed. Review of the facility's investigation, undated, showed the following: -The resident lived on the special care unit and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident was combative with care often and was sometimes difficult to redirect; -The resident required staff assistance with activities of daily living and care; -On 5/20/22 at 6:55 A.M. NA B notified the DON and Executive Director (ED) of an abuse allegation involving Resident #1 and CNA A; -On 5/20/22 at 7:00 A.M. the DON spoke with Registered Nurse (RN) D, who was the charge nurse on the Alzheimer's unit at the time of the alleged event. The DON also spoke with CNA C who was working at the time of the event; -On 5/20/22 at 7:15 A.M. the DON placed a call to CNA A with no answer. CNA A returned the DON's call at 10:30 A.M. and was asked to come to the facility and speak with the DON and ED regarding the allegation. CNA A stated he/she could not find a ride. The ED advised CNA A to inform the DON/ED when a ride could be obtained and educated on the importance of in person conversation regarding the allegation and investigation. CNA A had not returned any further calls or made any further attempts to communicate with the DON or ED; -NA B said he/she was called to the Alzheimer's unit around 2:30 A.M. by CNA C to assist with resident care due to having a good rapport with a resident who was exhibiting behaviors; -While in the television room with a resident, NA B heard CNA A yelling at another resident; -Upon investigation, NA B said he/she witnessed CNA A in Resident #1's room holding the resident's arms to his/her chest, forcefully rolling the resident (from side to side while in bed), yelling and cursing at the resident; -NA B said he/she asked CNA A to leave the resident's room at that time and let the resident calm down. CNA A refused to leave the resident's room; -NA B went up the hall to find someone to assist. NA B asked CNA C to come and assist; -CNA C said he/she was called to the Alzheimer's unit by NA B to assist with Resident #1's care; -CNA C said when he/she arrived to the unit, he/she took over Resident #1's care and asked CNA A to leave the room to allow the resident to calm down. CNA A was reluctant to leave the room but did end up doing so when CNA C demanded CNA A leave; -CNA C finished providing care for Resident #1 and noted a skin tear to Resident #1's left arm; -CNA C reported the skin tear and the above events to charge nurse RN D; -RN D said it was brought to his/her attention by CNA C that CNA A was witnessed by NA B holding Resident #1's arms to his/her chest while providing care due to the resident being combative and upon assessment a new skin tear and scattered bruising was noted to the resident's right and left forearm; -CNA A failed to come to the facility to meet with the ED/DON and was removed from the schedule and was self-terminated due to failure to follow the facility's investigation policy; -The facility investigation found the abuse allegation was substantiated. As a result, CNA A, RN D, and RN E were terminated from employment. Review of the statement (transcribed by facility staff) by NA B, undated, showed the following: -He/She was scheduled on 5/19/22 from 10:00 P.M. until 6:30 A.M.; -NA B was with Resident #5 in the television room; -A couple of minutes later NA B heard yelling, so he/she poked his/her head out the door to see what was going on; -NA B couldn't see anything, but he/she heard continued yelling; -NA B walked down the hallway with Resident #5 as he/she looked in and out of rooms; -When NA B arrived at Resident #1's room he/she saw both the room door and curtain were open; -NA B observed CNA A holding Resident #1's crossed arms against his/her chest; -NA B held Resident #1's arms to his/her chest while forcefully attempting to provide care and rolling the resident side to side in bed; -NA B heard CNA A yell at Resident #1, You're not going to hit, quit [OBSCENITY] ing hitting me; -NA B told CNA A he/she needed to leave Resident #1's room now and told CNA A the resident was safe, lower the bed to the floor, walk away and allow the resident time to calm down; -CNA A said, I have to get this [OBSCENITY] ing brief under him/her. Go get the [OBSCENITY] ing nurse; -At that point NA B still had Resident #5 standing in the hallway so NA B walked Resident #5 a little further down the hallway and went up the hall to ask CNA C if RN D was around; -CNA C said RN D was on break so NA B asked CNA C to come with him/her and briefly explained what had happened; -NA B and CNA C got to Resident #1's room and CNA C told CNA A to get out of the room and he/she would finish Resident #1's care; -CNA A continued to remain in the room and CNA C said, I told you to get out, just go and I will finish in here; -CNA A left the room and CNA C finished Resident #1's care; -When CNA C finished with Resident #1's care, he/she told NA B that he/she noticed a skin tear to Resident #1's left arm; -NA B and CNA C decided CNA A would no longer care for Resident #1 and NA B and CNA C would provide his/her care the rest of the night; -NA B was on the unit from around 2:30 A.M. until 4:30 A.M. when he/she left to go back to his/her assigned unit. NA B advised CNA C to check on the unit frequently and CNA C agreed that was a good idea; -CNA C spoke with RN D about the event; -NA B informed RN E about what had happened; -RN E later spoke to RN D about the events. During a telephone interview on 6/6/22 at 2:05 P.M. NA B said the following: -On 5/20/22, in the early morning hours, CNA C came to ask NA B to go help out on the special care unit with Resident #5 who was being combative; -NA B went to the unit and Resident #5 was near the door; -CNA A kept walking by and Resident #5 said there he/she is, the mean one; -Resident #5 was getting upset so NA B asked CNA A to stop walking by and NA B took Resident #5 into the television room; -NA B then heard screaming coming from a room and walked down the hall to figure out what was going on; -NA B got to Resident #1's room and saw CNA A had Resident #1's arms crossed across his/her chest and was pinning his/her arms to his/her chest; -CNA C told Resident #1, You're not going to [OBSCENITY] ing hit me. I'm [OBSCENITY] ing done with you; -CNA A looked at NA B and said, Will you go get the [OBSCENITY] ing nurse; -NA B asked CNA A to leave the room and he/she refused; -NA B went to the desk and told CNA C he/she needed him/her now; -CNA C came to Resident #1's room and told CNA A to get out of the room; -CNA A continued to stay in the room and CNA C forcefully told him/her you need to leave now. CNA A did finally leave the room; -CNA C allowed Resident #1 some time to calm down and then was able to get him/her changed; -NA B went back to his/her unit and told RN E about the incident; -CNA C reported what happened to RN D; -Resident #1 did have a skin tear to one arm and bruising to both arms; -NA B considered the event to be very traumatic and considered CNA A's actions to be both verbally and physically abusive. Review of the phone conversation between CNA C and the DON, transcribed by the DON and dated 5/20/22 (untimed), showed the following: -During 2:00 A.M. rounds NA B asked him/her to come to the unit and help the aide working back there (CNA A) with Resident #1 as he/she heard the resident screaming and carrying on; -When CNA C walked into Resident #1's room he/she witnessed CNA A holding Resident #1's hands against the resident's body, telling him/her to stop; -CNA C took over care of the resident and saw the resident had a large skin tear on his/her arm; -CNA A told CNA C that Resident #1 had ripped his/her sweatshirt; -CNA C asked CNA A to leave the room because his/her presence was upsetting the resident; -CNA C finished the resident's care and went and got the nurse to come and see the skin tear; -CNA C assisted the nurse to take care of the resident's wound; -CNA C told CNA A he/she would take care of Resident #1 for the remainder of the shift. During a telephone interview on 6/6/22 at 12:12 P.M. CNA C said the following: -On 5/20/22 at around 2:00 A.M. NA B was on the special care unit with Resident #5 because NA B deals well with him/her; -NA B heard Resident #1 screaming and yelling and NA B called for CNA C to come and help; -CNA C responded and entered Resident #1's room; -CNA C heard CNA A telling Resident #1, no, we're not going to be doing this. CNA A spoke very forcefully and was within 12 inches of the resident's face; -Resident #1 was screaming at CNA A to get out of his/her room; -CNA C observed CNA A with Resident #1's arms crossed and pressed into his/her chest, yelling at the resident; -CNA C could see blood on Resident #1's arm; -CNA C told CNA A to leave the room but CNA A just stepped back from the bed with his/her hands on his/her hips; -Resident #1 was really worked up and CNA C again forcefully told CNA A to get out of the room. CNA A did leave the room at that time; -CNA C reported what happened to both RN D and RN E; -CNA C told CNA A not to go back into Resident #1's room the rest of the night; -RN D assessed Resident #1's skin tear, applied steri-strips, and dressed the wound. During a telephone interview on 6/6/22 at 12:25 P.M. RN D said the following: -CNA C reported Resident #1 had a skin tear to his/her arm and CNA C heard CNA A tell the resident, You're not going to [OBSCENITY] ing touch me like that; -CNA C also said CNA A had Resident #1's arms crossed across his/her chest and held the resident's arms down against him/her; -RN D assessed the resident who had a Y shaped skin tear to his/her left arm. There was also some bruising present around the skin tear; -Resident #1 was very upset and worked up; -RN D and CNA C completed the rest of Resident #1's bed checks that morning; -RN D said he/she thought what was reported to him/her would be considered abuse, both verbal and physical abuse. During a telephone interview on 6/6/22 at 12:33 P.M. RN E said the following: -He/She was not the charge nurse for the special care unit on 5/20/22, but one of his/her aides, NA B, was asked to go to the unit to help calm a resident down; -NA B returned about 4:00 A.M. and said he/she heard hollering and saw CNA A has his/her hands on Resident #1; -NA B told CNA A to step away from the resident; -RN D told RN E Resident #1 sustained a skin tear. During an interview on 6/7/22 at 9:55 A.M. the administrator said the facility substantiated the allegation and the actions of CNA A to Resident #1 were determined to be abusive. CNA A was terminated because of this incident. MO 7

Based on interview and record review, the facility failed to monitor one resident (Resident #1) per facility policy, while the resident was outside for an extended period of time during high temperatures and a high heat index. Staff were not aware what length of time the resident was outside in the heat. The resident was found in the parking lot, with his/her shoe off near the edge of the road adjacent to the facility parking lot and with his/her wheelchair over a curb and unable to move, after the facility received a call from a community member alerting them a resident needed assistance. The resident was overheated with a body temperature of 100.4 degrees Fahrenheit and confused. The resident sustained a first degree burn to the bottom of his/her foot and a third degree burn to his/her great toe. The facility census was 88. Review of the facility policy, Inclement Weather Restrictions, dated as reviewed 5/18/20 showed the following: -Most facilities have courtyards, porches, or secured patios that are available for resident use and for outdoor facility activities and events. These are subject to inclement weather restrictions; -Courtyards, secured patios, and porches are available for resident use except during inclement weather conditions; -Guidelines to consider: Temperature <32 degrees or >90 degrees, heat index of greater than or equal to 100 degrees; -Each facility should provide for periodic monitoring of residents in courtyards, secured patios, or porches to provide hydration in warmer weather. Review of weather data for the facility location dated 8/9/21 for the Agricultural Science MO USA Weather Station showed the following: -Maximum temperature of 91.9 Fahrenheit and a mean dew point of 75.1 Fahrenheit; -Heat index calculated as 103 Fahrenheit (National Weather Service Heat Index Calculator based on temperature and dew point). Review of information from www.weather.gov showed any dew point above 70 Fahrenheit is oppressive and even dangerous. The higher the dew point, the muggier it feels. Review of Resident #1's Admission Record showed the following: -Initial admission of 7/7/15 and most recent admission 6/18/21; -The resident was his/her own responsible party. Review of the resident's Significant Change Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff, dated 6/1/21, showed the following: -Was cognitively intact; -It was very important for him/her to go outside for fresh air when the weather was good; -Required limited assistance of one staff for transfers, was unable to walk and used a wheelchair for locomotion; -Required supervision and oversight of one person to physically assist with locomotion off the unit; -Had impaired range of motion to his/her lower extremity on one side. Review of the resident's care plan last revised 8/12/21, showed the following: -The resident has limited mobility due to a history of right below the knee amputation and chronic pain. His/Her activities of daily living fluctuated depending on his/her mood, behaviors and motivation. He/She was at risk for falls due to his/her limited mobility, poor balance, poor safety awareness and weakness; -The plan directed staff to ensure the resident wore nonskid footwear, he/she may require limited assistance at times for mobility and activities of daily living; -The resident was at risk for skin breakdown due to limited mobility. -The plan identified the resident as a smoker and that the resident was aware of the risks of going out to smoke alone without staff present; -The care plan did not address any incident of the resident outside in extreme heat or staff monitoring of the resident to determine his/her location and ability to intervene on his/her behalf while outside in temperature extremes. Review of the resident's Medication Administration Record for August 2021 showed the following: -Metformin HCl 1000 milligrams (mg) by mouth two times daily scheduled for 0730 (7:30 A.M.) and 1630 (4:30 P.M.); -On 8/9/21 Metformin scheduled for 4:30 P.M. noted as given by Registered Nurse (RN) A. Review of the resident's Progress Notes dated 8/9/21 showed the following; -At 1815 (6:15 P.M.), a nurse brought the resident from outside of the building to the south side hall. It is unknown how long the resident had been outside. The temperature outside was in the upper 90's with a heat index over 100 and high humidity. Resident's body temperature 100.4 (no site noted - normal body temperature 98.6 degrees Fahrenheit-oral route). The resident was warm to touch and complained of headache. Staff administered oral fluids, resident changed/placed in bed with minimal clothing, Air conditioner turned down and fan turned to resident. Temperature gradually decreased and resident became more alert without headache. Physician and Director of Nurses (DON) notified. Review of the resident's Progress Notes dated 8/10/21 at 7:57 A.M. showed at 7:05 A.M. the resident was in bed and difficult to arouse. The resident complained of being tired. Resident assessed by the Family Nurse Practitioner (FNP) at 12:00 P.M. Educated to increase water and fluid intake today. Resident requested medication/vitamin/supplement to help improve brain functioning, complaints of not clear. Resident denied any recall of yesterday evening, resident said he/she went outside to look for the smokers. During morning care staff reported an open wound, wound plantar (sole of the foot), surface of the left foot 6 x 7 centimeters (cm.) superficial, open, moist area with peeling, thin tissue edges surrounding. A closed, flat blister mid plantar surface of the foot, 2 x 1.5 cm. Night nurse reports the resident did not have his/her shoe on the foot when he/she was brought back into the building last evening at the time he/she was found outside with decreased level of consciousness. Resident's left great toe inflamed, swollen, and red with chronic dry/soft brown callus tip of great toe. Resident reports diminished sensation to his/her left foot due to diabetic neuropathy. The FNP saw the resident and ordered Keflex 500 mg (antibiotic) three times daily for seven days. Resident said he/she had consumed multiple pitchers of water today. Review of the resident's Skin Integrity Data Collection dated 8/10/21 showed the following: -The resident had blisters and an open area/wound; -Site description included the left great toe noted as red, swollen and inflamed; -Plantar surface of left foot 6 x 7 cm. open, moist red tissue, thin peeling skin surrounds. Intact flat blister mid plantar surface 2 x 1.5 cm; -Areas were acquired and the facility specified them as thermal burn from hot pavement. Review of the resident's Progress Notes dated 8/10/21 completed by the resident's FNP showed the following: -History of Present Illness: Resident was outside yesterday in the heat and fell asleep and was found to have a temperature of 100.4. His/Her shoe was off and apparently burned the bottom of his/her left foot on the asphalt. His/Her left great toenail is fungal and has been red around it, but staff report much more red and warm and feel he/she needs an antibiotic; -Physical Exam: Left forefoot with large area of what appears to be a first degree burn. Left great toe with redness and warmth. Review of the resident's Wound Observation Tool dated 8/17/21 showed the following: -The resident had an acquired thermal burn from hot pavement left great toe, slough present and serosanquineous (yellow drainage with some blood), drainage measuring 2 x 2 cm; -Top tissue has sloughed off with tan slough to center of toe tip and white macerated edges (has been in contact with moisture), no odor, no drainage. Observation on 8/20/21 at 3:00 P.M. of the resident showed the following: -Entire plantar surface of the resident's left foot with slough (dead tissue), and slight yellow drainage. Xeroform (type of wound dressing), covered the tip of the great toe with a black area visible. During interview on 8/15/21 at 10:42 A.M., Licensed Practical Nurse (LPN) B said he/she received a telephone call from a community member during his/her shift that a resident was outside and needed to be checked. He/She went outside the front door to look and found Resident #1 in his/her wheelchair near the edge of the road (road runs in front of the facility and parking lot). They found the resident's shoe in the middle of the parking lot. This occurred about 6:30 P.M. (8/9/21). The resident's two front wheels were stuck. LPN B said he/she was not aware the resident had been outside. The resident is normally alert and oriented, but was confused when LPN B approached him/her. The resident was sweaty and red faced. He/She took the resident inside. The resident had been incontinent which was not normal for him/her. They put the resident to bed, removed his/her clothes and provided cool cloths and a fan. The resident was out of it and not making sense while talking. He/She did not see any injuries, but was later told there was an issue with the resident's left great toe. He/She reported to LPN C about the incident and returned to his/her assigned hall. He/She did not document in the record. He/She came to work at 6:00 P.M. and did not recall seeing the resident at that time, but did not enter the building at the front door. During an interview on 8/15/21 at 10:55 A.M., Certified Nurse Aide (CNA) said he/she worked the evening when the resident was found outside. LPN B asked him/her to help assist getting the resident to bed (after staff brought the resident back into the building). Normally the resident would not need help. LPN B was pushing the resident back to his/her room from outside. The resident was in his/her wheelchair, his/her head was down and he/she was not talking. The resident was sweaty and warm to touch. The resident had a fever and they put cool cloths to him/her after removing his/her clothing. The resident seemed confused, he/she was not sure how to drink from the cup at first. During interview on 8/20/21 at 10:0 A.M. and 8/25/21 at 8:35 A.M., showed Registered Nurse (RN) A said he/she worked 8/9/21 at the facility. He/She typically does not bother the resident. The resident is his/her own person. He/She was not aware the resident was outside. He/She worked until 6:30 P.M. that day (8/9/21). A resident should tell staff if they are going outside. The resident did not tell him/her, he/she was going outside. He/She went to the resident's room at 4:00 P.M. to give ordered Metformin. He/She did not see the resident in his/her room and held the medication for the next nurse to give. He/She did not look for the resident to give the resident his/her scheduled medication. He/She said the resident did not end up getting this medication, because it was too late by the time the next nurse came on duty. During interview on 8/25/21 at 8:15 A.M., Certified Medication Technician (CMT) A said he/she came in to work at 6:05 P.M. and saw the resident in his/her wheelchair in the north parking lot near the drive and at the end of a curb in the sun. She did not notice if the resident had a shoe on, or if he/she had any fluids with him/her. He/She asked the resident if she was okay and the resident said okay. He/She did not offer fluids. He/She left the resident and went on in the building to work. He/She did not report the resident being in the parking lot to anyone. The resident goes outside and might stay for a while. The resident will sit in the sun at times. During interview on 8/15/21 at 10:15 A.M., the interim Director of Nurses (DON) said she was made aware the resident was found outside by the cars in the facility parking lot near the edge of the road in his/her wheelchair. The resident frequently goes outside, the facility doors are coded and she was not sure how the resident got outside. Smokers are supervised and staff stay with them when smoking. Residents can remain outside, but have to ring the doorbell to get back in the building. When found, the resident's shoe was off and found in the parking lot behind him/her. This happened 8/9/21. During interview on 8/25/21 at 9:45 A.M. and 4:25 P.M., the interim DON said the following: -The resident normally ate in his/her room and hall trays go out at 5:00 P.M., the resident's hall would be the first to have trays passed; -She did not know if anyone saw the resident at dinner, she would check; -Documentation showed the resident received his/her tray at 5:00 P.M. with 0-25% consumption noted, this was charted at 9:00 P.M.; -She talked to the aide that passed the resident's meal tray on 8/9/21 and the aide said when he/she delivered the resident's tray, the resident was not in the room. The night before, the resident was in another resident's room, so he/she assumed the resident was there. He/She did not look for the resident to tell him/her the meal tray was delivered; -If the resident is not in his/her room, staff will let him/her know the tray is in his/her room when they see him/her out and about in the facility; -The resident's day revolved around smoke breaks. Normally the resident goes to the facility's interior courtyard when he/she goes outside, rather than in front of the facility. During interview on 8/15/21 at 10:31 A.M. LPN/ Wound Nurse A said the following: -She was told about the resident being outside on 8/10/21; -The resident frequently goes outside; -The doors are coded, he/she was not sure how the resident got outside; -Residents have to ring a doorbell to get back inside; -The resident's shoe was off and found in the parking lot behind him/her. The resident has a thermal burn on his/her only foot from the foot being on the pavement. During interview on 8/15/21 at 1:00 P.M., the resident said the following: -Someone from the trailer court called the facility to tell them he/she was outside on 8/9/21; -He/She did not recall what time he/she went outside, but was pretty sure it might have been at 3:00 P.M., smoke time; -He/She told someone (staff) he/she was going out, but could not remember who; -He/She did not know how long he/she was outside before being found; -He/She must have blacked out from the sun, he/she did not remember anything about being brought back in etc.; -He/She was out of it the next day and stayed in bed, just did not feel good; -He/She hurt his/her foot while outside, he/she normally does not have feeling in his/her foot. During interview on 8/15/21 1:35 P.M. and 8/24/21 at 2:50 P.M., the FNP said the following: -The resident's burn could have happened quickly, the pavement was hot; -She saw the resident's foot on 8/10/21 and considered the burn on the pad of the resident's foot to be a first degree burn and the burn on the toe to be a third degree burn; -She believes the resident experienced heat exhaustion when he/she was found outside; -She wanted to send the resident to the ER today, but the resident did not want to go. During interview on 8/15/21 at 11:08 A.M. and 1:30 P.M., the administrator said the following: -The resident was his/her own person and goes outside all of the time; -The resident should alert staff when he/she is going outside; -The resident would have had to request assistance because the key code was too tall for him/her to reach while sitting in his/her wheelchair to open the door to go outside; -Some residents know the door code; -She left work 8/9/21 at about 6:00 P.M. and the resident sat outside under the front awning in front of the facility; -She asked the resident what he/she was doing as conversation and the resident said we are waiting to smoke. The administrator asked who the we was the resident referred to as there was no one else with the resident; -She was not aware the resident was later found stuck or unable to move; -She was aware the nurse practitioner saw the resident and there was a treatment order; -She would expect staff to check on the resident every 15 minutes in extreme temperatures if they were outside; -Staff would need to know the resident was outside though (in order to monitor.) Some residents come and go and are their own person. MO189510

Based on interview and record review, the facility failed to protect two residents (Resident #10 and #9), of 18 sampled residents from verbal abuse when staff cursed at the residents. The facility census was 97. Record review of the facility policy, Protection of Residents: Reducing the Threat of Abuse and Neglect, last reviewed on 4/15/19 showed the following: -Introduction: To minimize the threat of abuse and /or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hard line, zero-tolerance approach to resident abuse; -Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. This includes but is not limited to corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms; -Residents must not be subjected to abuse by anyone: This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals; -The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; -Verbal abuse the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident's or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. 1. Record review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/29/21, showed the following: -Severe cognitive impairment; -Frequently incontinent of bowel and bladder; -Extensive assistance of one staff member with transfers, dressing, toilet use, locomotion on and off the unit and personal hygiene; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan last revised on 3/3/21 showed the following: -The resident required staff assist to complete his/her activities of daily living (ADL) due to mobility and failure to thrive; -Encourage to ask for assistance for ADLs and mobility as needed; -The resident has a mood problem related to his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident needs encouragement/assistance support to maintain as much independence and control as possible. Record review of the facility's investigation dated 4/1/21 at 3:20 P.M. showed the following: -Resident involved: Resident #10; -Staff involved: certified Nurse assistant (CNA) F; -Summary of alleged incident: the resident was alert and oriented to self and situation with periods of confusion per his/her normal, the resident depended on staff for assist for ADLs and cares; -On 4/1/21 at approximately 3:20 P.M., human information manager (HIM) reported to the MDS coordinator/Registered Nurse (RN) H that as he/she was walking down the hall and overheard CNA F reprimanding the resident for being incontinent of bowel, stating Why did you[OBSCENITY]yourself; -On 4/1/21 at 3:30 P.M. the MDS coordinator/RN H went to the resident's room immediately to assess the situation, upon arrival to the resident's room, MDS coordinator/RN H noted the resident in his/her bathroom, incontinence care was being provided by CNA F at the time; -While standing outside the door MDS Coordinator/RN H reported CNA F said to the resident You got [OBSCENITY] ing[OBSCENITY]everywhere; -CNA F was suspended pending investigation; -Following the facility investigation, it was substantiated that the associate did use inappropriate language around a resident. During an interview on 4/22/21 at 1:00 P.M. the resident said the nursing staff got aggravated and sometimtes yelled at him/her. During interview on 4/23/21 at 9:25 A.M., CNA F said the following: -On 4/1/21, sometime after 2:30 P.M., he/she was assisting Resident #10 with cares in his/her room; -The resident was covered in stool; it was everywhere, even up under the resident's shirt; -He/She hollered out I need help, and instructed the resident to stand up and transfer to the toilet; -He/She made a comment that there was[OBSCENITY]everywhere, to another coworker that was outside the door; -He/She did not feel it was appropriate to cuss around the resident, but it was not uncommon for other facility staff to cuss in front of the residents when caring for them; -He/She might have raised his/her voice while in the resident's room, he/she was flustered as he/she was not assigned Resident #10's hall that shift. During an interview on 4/21/21 at 2:15 P.M., the HIM said the following: -He/She was walking in the hall close to Resident #10's room, and overheard CNA F yell I can't believe you[OBSCENITY]yourself!; -The MDS Coordinator/ RN H was not too far away and was aware of situation; -CNA F was removed from the resident's room. During an interview on 4/21/21 at 2:30 P.M., MDS coordinator/RN H said the following: -The HIM came to him/her and said that CNA F was being inappropriate with Resident #10 over being incontinent; -RN H went to the resident's room and stood a few feet from the door and listened; -CNA F was overheard saying to Resident #10, You [OBSCENITY] ing[OBSCENITY]everywhere, why did you do this in a stern voice that could be heard from the hall; -He/She asked CNA F to step out of the resident's room and CNA F was somewhat confrontational; -He/She reported it to administration. 2. Record review of the Resident #9's care plan dated 3/18/19 showed the following: -The resident has a history of depression and anxiety, discuss with the resident /family/caregivers any concerns, fears issues regarding health or other subjects; -The resident has a psychosocial well being problem related to anxiety allow the resident time to answer questions and to verbalize feelings perceptions and fears. Record review of the resident's quarterly MDS dated [DATE] showed the following: -Cognition intact; -Feeling bad about yourself or that you are a failure or have let yourself or family down occurred 7-11 days more than half; -The resident required supervision of one staff member with transfers, to walk in room and in corridor, dressing and toilet use; -The resident required supervision and assistance of one staff member with personal hygiene; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the facility investigation dated 3/30/21 at 2:00 P.M. showed the following: -Resident involved: Resident #9; -Staff involved: CNA I; -The resident was alert and oriented and able to make wants and needs known; -The resident was independent with most of his/her ADLS and will ask for assistance when needed; -Approximately at 1:45 P.M., the resident reported concerns to the social service director, regarding CNA I; -Social service director reported to the DON at 2:00 P.M. that resident said CNA I called him/her a [OBSCENITY] ing [OBSCENITY] ; -On 3/30/21 approximately 2:10 P.M. upon follow-up interview with the resident by the DON, the resident said he/she thought it was last night or evening, or the evening before; -CNA I had come into his/her room, he/she didn't remember exactly what for, but probably to answer his/her call light; -After CNA I walked away from his/her bed, he/she walked around the room towards his/her sink, the curtain was closed and CNA I said you [OBSCENITY] ing [OBSCENITY] ; -He/She couldn't see CNA I but he/she heard him/her; -He/She thought CNA I was talking about him/her when the statement was made and thought CNA I was upset that he/she needed something. During an interview on 4/21/21 at 12:45 P.M. the resident said the following: -Approximately a month ago, (end of March 2021), CNA I was in his/her room caring for him/her on night shift; -CNA I was close to the door of his/her room, CNA I looked at the resident and said You are a [OBSCENITY] ing [OBSCENITY] ; -CNA I had also called him/her a [OBSCENITY] in the past; -When CNA I called him/her a [OBSCENITY] , it made the resident feel like CNA I hated him/her, and did not want him/her at the facility. During an interview on 4/21/21 at 1:00 P.M. Resident #18 (Resident #9's roommate) said the following: -He/She overheard CNA I call his/her roommate a [OBSCENITY] ing [OBSCENITY] ; -This happened about a month ago on night shift; -CNA I was at the end of his/her bed (which was located by the door); -CNA I looked directly at Resident #9 when he/she said it; -He/She felt degraded to hear CNA I talk like that towards a resident. During an interview on 5/4/21 at 9:45 A.M., the social service director said the following: -He/She was completing random interviews with residents in the facility regarding abuse; -He/She asked Resident #9 if he/she felt safe in the facility; -Resident #9 said no, when he/she questioned the resident why he/she did not feel safe, the resident responded because of CNA I; -When he/she asked the resident to be more specific he/she said that CNA I had called him/her a [OBSCENITY] ing [OBSCENITY] . During an interview on 4/22/21 at 3:20 P.M., CNA J said the following: -He/She worked with both CNA F and CNA I; -Both staff used foul language up and down the halls in the facility and around residents. During an interview on 5/4/21 at 3:35 P.M., the director of nurses (DON) said the following: -CNA F's behavior in Resident #10's room was hard to determine if it was verbal abuse, or just inappropriate behavior, vulgar language; -It would be considered verbal abuse for staff to speak like that and reprimand or scold the resident; -After the investigation was completed the facility felt CNA F should be terminated for his/her actions; -Resident #9 reported to social services that CNA I Called him/her a [OBSCENITY] ing [OBSCENITY] , the social service director reported the allegation to the DON and the resident was interviewed again; -Within a few minutes of reporting the allegation to social services the resident changed his/her story and said , CNA I may have said it under his/her breath, he/she wasn't sure if he/she was specifically speaking to Resident #9 or someone else in the hallway; -If CNA I said it either under his/her breathe, or directed towards the resident it would not be appropriate; -The facility educated CNA I on resident rights and using vulgar language in the resident's home. During an interview on 5/4/21 at 9:15 A.M., the administrator said the following: -CNA F's behaviors, scolding and speaking like he/she did to Resident #10 for being incontinent, would be considered verbal abuse; -Social services was interviewing residents about abuse and asked Resident #9 if he/she had ever been abused by staff, Resident #9 told social services that he/she heard CNA I say, [OBSCENITY] ing [OBSCENITY] ; - Resident #9 mentioned it was said behind the curtain but he/she felt like it was directed at him/her; -If it was said by CNA I, it would considered abuse; -She would expect staff to not verbally abuse a resident. MO 4, MO 9

Based on interview and record review, the facility failed to ensure one resident (Resident #5) of 18 sampled residents received the necessary care and services in accordance with professional standards of practice when the facility failed to report Resident #5's fever, abnormal lung sounds, overall decline, not eating, and withheld medication without a physician order. The facility census was 97. Record review of the facility's reviewed Changes in Resident's Condition or Status Policy dated 5/5/20 showed the facility will notify the resident, his/her primary care provider, and the resident/resident representative of changes in the resident's condition or status. 1. Record review of Resident #5's care plan dated 10/14/19 showed staff was directed to report any changes in the resident's activities of daily living to the physician. Record review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (insulin) (diabetes) 100 units/milliliter (ml) inject 5 units subcutaneously (SQ) three times a day with meals; -[MEDICATION(S)] (insulin) (diabetes) 100 units/ml inject 30 units at bedtime; -Acetaminophen (a pain and/or fever reducer) 500 milligrams (mg); two tablets by mouth every six hours as needed for pain. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/4/20, showed the following: -The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident required extensive assistance of one staff member to toilet, and dress; -He/She required limited assistance of one staff member to transfer, ambulate, bathe and move in bed. Record review of the resident's nurse's notes dated 9/20/20 at 1:54 P.M. showed the following: -The resident's temperature this A.M. 101.6 (normal 97.0 degrees to 99.0 degrees, anything more than 100.4 often means the fever caused by an infection); -His/Her face was flushed; -Acetaminophen administered, clothing changed and room temperature decreased; -At 9:30 A.M. the resident's temperature was 99.8; -His/Her lungs were diminished in bases (lower part of the lungs). Record review of the resident's administration note dated 9/20/20 at 8:32 P.M. showed the resident received acetaminophen for elevated temperature (temperature not recorded). Record review showed no documentation staff notified the resident's physician of the resident's increased elevated temperature or diminished lung sounds. Record review of the resident's nurse's note dated 9/23/20 at 3:22 P.M. showed the following: -The resident was weaker today; -He/She required a sit to stand mechanical lift for transfers; -His/Her temperature this morning was 100.6, then went down to 98.4; -His/Her lungs diminished at bases; -He/She continued to have 4+ [CONDITION(S)] (eight millimeter depression/indentation left after pushing on skin, normal - no [CONDITION(S)]) in his/her bilateral (both) lower extremities (legs). Record review showed no documentation staff notified the resident's physician of the increased weakness, need for a mechanical lift to transfer, elevated temperature, 4+[CONDITION(S)] or lungs diminished at bases. Record review of the resident's administration notes dated 9/29/20 at 8:06 A.M. showed the resident received acetaminophen 500 mg due to fever of 101.1. Record review showed no documentation staff notified the resident's physician of the resident's fever of 101.1. Record review of the resident's nurse's notes dated 9/29/20 at 10:45 A.M. showed the following: -The resident spiked (temperature elevated) a fever this A.M. of 101.1 and then 101.8; -He/She also had a new onset of a non-productive cough; -Lung sounds with crackles throughout (lungs); -Staff notified the resident's physician and received orders for a chest x-ray and as needed oxygen and Robitussin (cough syrup); -Staff to monitor the resident for temperature and oxygen saturation. Record review of the resident's nurse's note dated 10/1/20 at 10:05 A.M. showed staff held the resident's [MEDICATION(S)] due to the resident did not eat. Record review showed no documentation staff notified the resident's physician the [MEDICATION(S)] was held or the resident did not eat. Record review of the resident's nurse's note dated 10/1/20 at 5:48 P.M. showed staff held the [MEDICATION(S)] held due to the resident did not eat. Record review showed no documentation staff notified the resident's physician the [MEDICATION(S)] was held or the resident did not eat. Record review of the resident's nurse's note dated 10/1/20 at 8:06 P.M. showed staff held the resident's [MEDICATION(S)] due to the resident did not eat all day. Record review showed no documentation staff notified the resident's physician that [MEDICATION(S)] or [MEDICATION(S)] were held on 10/1/20. Record review of the resident's nurse's note dated 10/2/20 at 2:01 A.M. showed the following: -The resident's face was flushed; -Resident with a fever of 102.2; -The resident said his/her body aches; -He/She had no cough; -Overall, the resident had declined over the past five days; -Five days ago the resident conversed with others, fed him/herself, and participated in activities of daily living; -The resident with increase of assist requirements and decline in abilities. Record review of the resident's nurse's note dated 10/2/20 at 11:59 A.M. showed the resident's physician ordered to have the resident sent to the local ER. (The physician had contacted the facility to check on the resident, the facility had not contacted him/her about the resident's condition change identified at 2:01 A.M.). Record review of the resident's nurse's note dated 10/2/20 at 11:59 A.M. showed the resident's physician ordered to have the resident sent to the local ER. Record review of the resident's history and physical from an area hospital dated 10/2/20 showed: -The resident presented to the emergency room with a high fever ranging from 101-104; -The resident had become more lethargic; -Resident has history of [CONDITION(S)] (irregular heart rate); -Due to the rapid fatigue, he/she was brought in for evaluation to understand possible high fever such as [CONDITION(S)]; -The resident was admitted to the hospital on 10/20/20; -Resident's heart rate was very rapid, running from 140-150 (normal rate for age 60-100) [CONDITION(S)]. Record review of the resident's discharge summary from an area hospital dated 10/7/20 showed the following: -Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident was acutely bedfast; -The resident was placed in acute care for oxygen support; -He/She had very minimal neurological responses, which was not normal for the resident; -The resident's neurological function throughout remained bedfast and poor; -Communication was minimal; -Fever still persists; -Lung fields showing bilateral rales (rattling sound); -The resident was quite guarded (outcome of illness in doubt) and his/her fever significant. During an interview on 5/4/21 at 1:18 P.M., Licensed Practical Nurse (LPN) A said the following: -Staff are to notify the resident's physician with any change in a resident's condition including falls; -He/She did not know if staff notified Resident #5's physician. During an interview on 5/4/21 at 3:00 P.M., LPN B said the following: -Resident #5 did not get out of bed for a week or two; -On the day the resident transferred to the hospital, the resident was incoherent, unable to answer basic questions; -He/She did not report the resident's current condition to the resident's physician; -If a resident had a change in condition, the nurse who finds is to notify the resident's physician. During an interview on 5/4/21 at 3:34 P.M., the Director of Nursing said the following: -Any change in condition should be reported to the resident's physician including fever, decline in strength, ability to do usual activities of daily living, not eating and falls; -He/She expected any contact with physicians to be documented. During an interview on 5/5/21 at 9:48 A.M., the administrator said she expected staff to report recurring temperatures, abnormal lung sounds, not eating, decline in ADLs to the residents' physician. During an interview on 5/5/21 at 4:16 P.M., the resident's physician said he expected staff to notify him of a decline in resident's condition, fevers, abnormal lung sounds, not eating and holding insulin. MO# 3

Based on observation, interview, and record review, the facility failed to provide adequate supervision to one resident (Resident #4) of four sampled residents. Resident #4 had [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. On 04/01/14, the resident wandered into another resident's room and ingested an unknown amount of colostomy deodorizer. Staff observed the resident with the lid to an eight ounce bottle of colostomy deodorizer, but did not report it at that time. Later in the shift, the resident began vomiting a blue colored liquid (same color as the deodorizer). Facility staff contacted the resident's physician and obtained an order to have him/her sent to the local hospital for evaluation and treatment. The local hospital sent the resident to a tertiary care center for the specialized care of a gastroenterologist with the [DIAGNOSES REDACTED]. The census was 83. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 2/26/14 showed the resident: -Had short-term and long-term memory problems; -Sometimes understood others; -Was sometimes understood by others; -Had impaired vision; -Had severely impaired cognitive skills for daily decision making; -Exhibited inattention and disorganized thinking which did not fluctuate; -Exhibited verbal behaviors on four to six days of the review period, but less than daily; -Exhibited other behavioral symptoms on one to three days of the review period; -Rejected care on one to three days; -Wandered daily; -Took medications on seven of the seven review days which were classified as antipsychotic, antianxiety and antidepressant; -Required set up help only and supervision (oversight, encouragement or cueing) for ambulation in his/her room and in the corridor; -Required limited assistance of one person for eating; -Had no limitations in the movement of his/her upper or lower extremities. Review of the resident's care plan, dated 2/10/14 showed the following: -He/she had a history of [REDACTED]. The care plan directed staff to ensure the resident's safety at all times; -He/she was at risk for elopement related to vascular dementia and wandering behaviors. The care plan directed staff to allow the resident to safely wander in his/her environment, monitor wandering behaviors and report any negative findings to the primary care physician and staff were to redirect him/her during episodes of wandering; and -He/she had a history of [REDACTED]. The care plan directed staff to approach the resident in a warm, positive manner, monitor behaviors and cognitive changes and report any negative findings to the primary care physician and an update, dated 4/1/14 showed staff would monitor the resident's whereabouts due to poor decision making skills. Review of the facility's investigation regarding, dated 4/1/14 showed the following: -At 3:30 P.M., Certified Nurse Aide (CNA) C observed the resident standing in another resident's room with a lid to a bottle of Hollister M9 Drop Deodorizer in his/her hand and open bottle (less than half full) on the bedside table. CNA C removed the bottle from the residents' access; -At 5:00 P.M., the resident ate 100% of the evening meal in the dining room; -6:40 P.M., the resident sat across from the nurses' station on the dementia-specific unit and vomited twice. The emesis had a blue color to it; -At 7:00 P.M., Licensed Practical Nurse (LPN) B returned from supper. CNA C reported finding the resident in another resident's room at 3:30 P.M. with the lid to the M9 Drop Deodorizer in his/her hand; -At 7:16 P.M., LPN B assessed the resident and obtained a set of vital signs. The resident vomited twice during the assessment; -At 7:23 P.M., LPN B notified the resident's physician of the possible ingestion of M9 Drop Deodorizer and received orders to make the resident "Nothing by Mouth," (NPO), vital signs every 30 minutes for four sets, then hourly until morning and contact Poison Control; - At 7:28 P.M., LPN B placed a call to Poison Control and received instructions to give the resident water or milk and Poison Control would call back in 45 minutes with further instructions; -At 8:12 P.M., LPN B placed a call to the resident's family member notifying him/her of the possible ingestion; -At 8:27 P.M., Poison Control called back with the recommendation to have the resident evaluated by a physician at the local emergency department (ED); -At 8:40 P.M., LPN B called the resident's physician with the recommendation and received an order to transfer the resident to the local ED; -At 9:00 P.M., the resident left the facility with Emergency Medical Services (EMS) for transport to the local ED; -At 10:20 P.M., facility staff received notification from the local ED regarding the resident's transport to a tertiary care hospital; -On 4/2/14, the Director of Nursing (DON) began staff education on storage and handling of chemicals and toxins; -On 4/3/14, staff education continued regarding storage and handling of chemicals and toxins; -On 4/3/14 at 3:45 P.M., the resident returned from hospital at prior functioning level of care; -On 4/4/14, staff education continued regarding storage and handling of chemicals and toxins. Review of the resident's hospital records, dated 4/1/14 showed he/she: -Arrived to the hospital at 9:20 P.M. via facility transport; -Was believed to have ingested colostomy bag deodorizer and presented with greenish-blue vomit on his/her shirt and pants; -Was unable to provide any history due to his/her demented cognitive status; -Was transferred to a tertiary care center for the services of a gastroenterologist and hospitalist with [DIAGNOSES REDACTED]. Review of the resident's tertiary care hospital admission note, dated 4/2/14 at 2:34 A.M. showed the resident's chief complaint was a toxic ingestion. He/she presented after ingestion of Hollister ostomy odor eliminator. It was reported the resident may have ingested up to 120 ml of this product. The ingestion took place at approximately 6:00 P.M. on 4/1/14. The resident had resultant nausea, vomiting and abdominal discomfort. Poison Control had concerns with possible copper toxicity and potential need for evaluation with esophogastroduodenoscopy (EGD), a test to examine the lining of the esophagus (the tube that connects your throat to your stomach), stomach, and first part of the small intestine. It is done with a small camera (flexible endoscope) that is inserted down the throat for gastritis (inflammation of the stomach lining) and erosive effects of copper. The hospital admitted the resident with a problem list which included ingestion of toxic substance. The admission plan showed orders for Zofran (an antiemetic) as needed for nausea and vomiting, normal saline (an intravenous (IV) fluid), Protonix (a proton pump inhibitor (PPI) which block the production of acid by the stomach) 40 mg once a day via IV, monitor renal (kidney) function, serum copper level and provide a sitter at the bedside. During an interview on 4/3/14 at 3:30 P.M., CNA C said he/she did not normally work on the special care unit, but knew the resident wandered and could be agitated at times. He/she never used the odor eliminator drops for the resident with the colostomy. As he/she was getting residents up for supper, he/she found the resident on another resident's bed. He/she went in and tried to get him/her to come in for supper. The resident had a lid in his/her hand and CNA C asked the resident for it and got it from him/her. Initially, CNA C did not know where the lid belonged, but he/she looked around in the other resident's belongings and discovered the deodorizer drops without a lid. There was a little deodorizer remaining in the bottle. He/she assisted the resident to the dining room and he/she was fine. The resident spoke to him/her and he/she did not see any blue discoloration the resident's mouth. After supper, staff started helping residents to bed. At this time CNA C told another CNA about finding the resident with the lid to the deodorizer drops and the other CNA instructed him/her to put the bottle in the other resident's drawer. The resident said he/she did not feel well and started vomiting. The emesis was blue and CNA C said he/she knew the resident drank the deodorizer drops because they were also blue. When LPN B returned from supper, CNA C reported the resident's vomiting and the earlier discovery of him/her in another resident's room with the lid to the deodorizer drops in his/her hand. LPN B, the charge nurse for the special care unit, returned from supper break around 7:00 P.M. CNA C reported the earlier observation of the resident in Resident #2's room with the lid to the odor eliminator. LPN B asked CNA C to bring the odor eliminator to him/her. The resident only vomited blue liquid. CNA C said none of the food or beverages served during the supper meal were blue; supper on 4/1/14 was chicken parmesan, potato casserole, broccoli and apple slices. The resident had chocolate milk and cranberry juice to drink. The last emesis had some food particles in it. Staff gave the resident milk after he/she started vomiting, but he/she also vomited the milk. During an interview on 4/3/14 at 4:02 P.M., LPN B said he/she was the charge nurse the evening the resident ingested the Hollister M9 Drop Deodorizer. He/she returned from supper that night at 7:00 P.M. or 7:05 P.M. CNA C said the resident vomited at 6:40 P.M. CNA C informed him/her of seeing the resident at 3:30 P.M. that day with the lid and bottle of M9 Hollister M9 Drop Deodorizer in his/her hands, but he/she did not think to say anything until the resident vomited and both times the emesis was blue in color (the color of the drops). LPN B contacted the Director of Nurses (DON) who instructed him/her to contact the resident's physician. LPN B then called the Poison Control Center to seek advice. Poison Control suggested milk or water to coat the resident's stomach. The resident drank 120 milliliters (ml) of milk, but he vomited shortly after drinking the milk. The resident's physician ordered Phenergan (an antiemetic) 25 milligrams (mg) intramuscularly (IM) for one dose and to monitor vital signs every 30 minutes. Poison Control said they would call back after they were able to check a little more into the copper content of the Hollister M9 Drop Deodorizer. When the Poison Control representative returned the call, the representative said he/she had a high reading on copper and a low reading on copper for the drops, but could not identify which the resident ingested, so Poison Control recommended the resident be sent to the hospital for monitoring. LPN B had never seen the Hollister M9 Drop Deodorizer before this incident. Since the incident, staff were instructed to keep the Hollister M9 Drop Deodorizer locked in the shower room. He/she did not recall any food or beverage served during the supper meal which could have discolored the resident's emesis blue. Observation on 4/3/14 showed the following: -At 3:52 P.M., the resident in bed with a family member present; -At 4:14 P.M., the resident rested in bed and made non-sensical conversation. A clear plastic zip-top bag rested on his/her nightstand beside him/her. The clear zip-top bag included an eight ounce bottle of Hollister M9 Drop Deodorizer with Resident #2's name written on it, two tubes of calmoseptine (a topical skin protectant) and a bottle of lotion; -At 4:40 P.M., the resident remained in bed. The clear zip-top bag remained on the nightstand with the Hollister M9 Drop Deodorizer; -At 5:17 P.M., the resident removed his/her gown and wadded it up on top of him/her. The Hollister M9 Drop Deodorizer remained in the clear plastic zip-top bag on the nightstand; -At 5:20 P.M., the resident remained in bed. The Hollister M9 Drop Deodorizer remained in the clear plastic zip-top bag on the nightstand; -At 5:37 P.M., the surveyor requested LPN A remove the bottle from the clear zip-top bag. LPN A estimated approximately 15 ml of the blue liquid remained in the bottle. He/she summoned LPN B for the keys to the shower room on the dementia-specific unit and locked the Hollister M9 Drop Deodorizer in the shower room. During an interview at 5:40 P.M., LPN B said the resident returned to the facility via ambulance at "four-something" and he/she completed the admission assessment on the resident at that time. He/she would have normally checked the belongings in with the admission assessment, but "didn't because it's been so busy." Review of the Material Safety Data Sheet (MSDS), revised 6/29/12 showed Hollister M9 Drop Deodorizer was composed of ingredients which included water, phenoxyethanol, methylparaben, ethylparaben, copper sodium salt, butylparaben, propylparaben and isobutylparaben. First aid measures for ingestion showed instructions to give two glasses of water and induce vomiting. The appearance was a blue, odorless liquid. Review of the undated policy provided by the facility, titled "Poison," showed poison comes in many forms and types and a thorough discussion of all types would be impractical for this manual. In the event of a poisoning the nurse should: -Ascertain the exact product that caused the poisoning; -Notify the physician immediately; -Contact the nearest local Poison Control Center; notify them of the exact product and all contents, if possible; -Contact paramedics for immediate transfer to an acute care hospital. During an interview on 4/9/14 at 1:15 P.M., the DON said her expectation regarding toxics would be for staff to read labels, maintain Safety Data Sheets (SDS) on any toxics in the facility so they have that resource and if in doubt, ask and go up the chain until it is resolved. Regarding the security of toxics, she said the expectation would be that no toxics were accessible by residents. The facility investigation was unable to determine when the Hollister M9 Drop Deodorizer was last used. Complaint # MO