Every finding on record at Life Care Center of St Louis

Based on interview and record review, the facility failed to ensure residents were free from physical restraints when staff tied a towel around the face of one resident (Resident #3) during a shower. The sample was 3. The census was 92. The Administrator was notified on 08/14/26 at 10:59 A.M. of the past non-compliance, which occurred on 08/04/26. All staff have been in-serviced on the facility's policy regarding restraints and addressing behaviors. The deficiency was corrected on 08/05/26. Review of the facility's Restraint Re-Education document, dated 08/04/26, showed:The facility is a restraint-free facility. This means cannot restrain resident by chemical or physical means. Physical restraint can be holding residents down, preventing them from proceeding where they wish to go, threatening action if they go to a certain place, or physically tying their person. Tying items around a resident can lead to major injury up to and including death depending on what is used and the location it is used on. It is never ok to tie a resident down or tie anything to a resident. We care for residents who sometimes have behaviors. Behaviors do not negate the care we are required to provide, but steps should be taken to keep you both safe. If you should encounter a resident who spits and you must provide care, it is appropriate to have the resident don a surgical mask as personal protective equipment (PPE) if they are willing. Review of Resident #3's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/26/26, showed the following:-Severe cognitive impairment;-No moods or behaviors exhibited;-Partial to moderate assistance required for showers/bathing and personal hygiene;-Diagnoses include dementia, dementia, and aphasia (a brain disorder that affects how a person speaks, writes, reads, and understands language). Review of the resident's care plan, in use at the time of the survey, showed the following:-Focus: The resident has an activity of daily living (ADL) self-care performance deficit regarding confusion and impaired balance;-Intervention: Bathing and showering - the resident is able to bathe self after setting up and supervision;-Focus: Impaired cognitive ability/impaired thought processes. May become anxious without disturbance at times;-Focus: At risk for change in mood or behavior due to medical condition. May resist care, swat at staff, or make a spitting sound with his/her mouth;-Interventions included if resident is making a spitting sound/motion, please offer them a surgical mask if he/she will accept and don personal protective equipment (PPE) for yourself during care;-Focus: The resident has a behavior problem regarding spitting food particles. The resident was involved in an alleged incident with staff member;-Intervention: If reasonable, discuss the resident's behavior. Explain and reinforce why behavior is inappropriate and/or unacceptable to the resident and protect his/her rights. Observe for behavior episodes and attempt to determine underlying cause. Review of the facility's investigation, dated 08/04/26, showed the following:-On 08/04/26 at 7:46 P.M., the Director of Nursing (DON) was contacted by telephone by Licensed Practical Nurse (LPN B) to report the resident was receiving a shower by Certified Nurse Aide (CNA) A when staff heard CNA A call out for help with the resident. Upon entering the shower room, LPN B and Certified Medication Technician (CMT) C noted resident to be in the shower room in a shower chair by toilet. They noticed a bath towel covering the resident's face from just below the eyes down. The towel was also tied in a knot behind the resident. Resident was not observed to be in distress at the time. LPN B immediately removed the towel from the resident and assessed for injury. LPN B then called DON with CNA A. CNA A had no further contact with the resident or any other resident. CNA A was questioned and suspended pending investigation and escorted from facility. The resident was again assessed for injury and assisted to bed. The was no injury was found. The resident made no verbal statements or gave visible signs of discomfort or fear from staff;-Conclusion: While providing a shower to Resident #3, CNA A did use a towel to cover the resident's face in an effort to prevent his/her bodily fluids from coming in contact with his/her skin. While use of this method is not the standard of care or within facility policy, the CNA did not willfully intend harm to the resident, and the resident suffered no physical harm. CNA A was terminated from employment for failure to follow facility policy and poor customer service. During an interview on 08/13/26 at 10:16 A.M., LPN B said he/she was giving care to another resident when CNA A yelled out for assistance with the resident. LPN B and CMT C went through the door of the shower room and the resident had a towel around his/her face. LPN B asked CNA A why the resident had a towel around his/her face. CNA A said the resident was spitting and CNA A did not want the resident spit on him/her. LPN B took the towel from around the resident's face and assisted the resident to dry off. LPN B called the DON and was instructed to escort the employee out of the building. CNA A should have used personal protective equipment to prevent bodily from getting on him/her. During an interview with the Administrator and DON on 08/14/26 at 10:59 A.M., the DON said she expected the facility's policies to be followed as written and a towel should never be tied around a resident's face. The staff were re-educated on how to care for residents with behaviors by 08/05/26. The Administrator agreed with the DON's expectations. 3134906

Based on interview and record review the facility failed to ensure one resident (Resident #3), diagnosed as having dementia with behavioral disturbance and exhibiting symptoms/behaviors of allegedly spitting while receiving a shower, received the appropriate treatment and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being. The Certified Nurse Aide (CNA) place a towel around the resident's face to prevent bodily fluids from hitting his/her skin while giving a shower to the resident. The sample of was three. The census was 92. The Administrator was notified on 08/14/26 at 10:59 A.M. of the past non-compliance, which occurred on 08/04/26. All staff have been in-serviced on the facility's Care of Cognitively Impaired (Dementia Care) Policy and additional ways to give care with proper psychosocial well-being. The deficiency was corrected on 08/05/26. Review of the facility's Care of Cognitively Impaired (Dementia Care) Policy, dated 09/02/25, showed the following:-Policy: -The facility will provide dementia treatment and services which may include, but are not limited to the following:Ensuring adequate medical care, diagnosis, and supports based on diagnosis;Ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety;Utilizing individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being.-Definitions: Dementia - This is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptomology and rates of progression. -Procedure:Identify, address, and/or obtain necessary services for the dementia care needs of residents;Develop and implement person-centered care plans that include and support the dementia care needs, identified in the comprehensive assessment;Develop individualized interventions related to the resident's symptomology and rate of progression (e.g., providing verbal, behavioral, or environmental prompts to assist a resident with dementia in the completion of specific tasks);Review and revise care plans that have not been effective and/or when the resident has a change in condition;Modify the environment to accommodate resident care needs;Achieve expected improvements or maintain the expected stable rate of decline.Review of Resident #3's Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 5/26/26, showed the following:-Severe cognitive impairment;-No moods or behaviors;-Partial to Moderate assistance with activities of daily living (ADLs);-Diagnoses include high blood pressure, stroke, dementia and aphasia (a brain disorder that affects how you speak, write, read, and understand language). Review of the resident's care plan used during the time of the survey process, showed the following:-Focus: Th resident has an ADL self-care performance deficit regarding confusion and impaired balance. The resident has a behavior problem regarding spitting food particles. The resident was involved in an alleged incident with staff member;-Intervention: Bathing and showering, the resident is able to bath self after setting up and supervision. If reasonable, discuss the resident's behavior. Explain and reinforce why behavior is inappropriate and/or unacceptable to the resident and protect his/her rights. Review of the facility's investigation, dated 08/04/26, showed the following:-08/04/26 at 7:46 P.M., the Director of Nursing (DON) was contacted by telephone by Licensed Practical Nurse (LPN B) to report the resident was receiving a shower by Certified Nurse Aide (CNA) A when staff heard CNA A call out for help with the resident. Upon entering the shower room LPN B and Certified Medicine Technician (CMT) C noted resident to be in the shower room in a shower chair by toilet. They noticed a bath towel covering resident's face from just below the eyes down. The towel was also tied in a knot behind the resident. Resident was not observed to be in distress at the time. LPN B immediately removed the towel from the resident and assess for injury. LPN B then called DON with CNA A. CNA A had no further contact with the resident or any other resident. CNA A was questioned and suspended pending investigation and escorted from facility. The resident was again assessed for injury and assisted to bed. The was no injury was found. The resident made no verbal statements or gave visible signs of discomfort or fear from staff;-Conclusion: While providing a shower to Resident #3, CNA A did use a towel to cover the resdient's face in an effort to prevent his/her bodily fluids from coming in contact with his/her skin. While use of this method is not the standard of care or within facility policy, the CNA did not willfully intend harm to the resident, and the resident suffered no physical harm. CNA A was terminated from employment for failure to follow facility policy and poor customer service. During an interview on 08/13/26 at 10:16 A.M., LPN B said he/she was giving care to another resident when CNA A yelled out for assistance with the resident. He/She and CMT C went through the door, and the resident had a towel around his/her face. LPN B asked CNA A why the resident had a towel around his/her face? CNA A said the resident was spitting and he/she did not want to spit on him/herself. LPN B said he/she took the towel from around the resident's face and assisted the resident to dry off. LPN B called the DON and was instructed to escort the resident out of the building. LPN B said he/she was in-serviced on the facility's dementia policy. LPN B said the CNA should have used personal protective equipment to prevent bodily from getting on him/her. During an interview on 08/14/26 at 10:59 A.M., the DON said she would expect the facility's policy to be followed as written. The staff were educated on how to care for residents with dementia behavior. All staff were educated by 8/5/26. The administrator was present and agreed with the DON. 3134906

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program when staff failed to change gloves, wash or sanitize hands and wear gowns during care for residents on enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) for four residents (Residents #101, #81, #9 and #56). The staff failed to change gloves and wash hands during perineal care (cleaning the genital and anal areas) for one resident observed during care (Resident #63). In addition, laundry staff failed to separate dirty linens from clean and washed linens. The sample was 23. The census was 90.Review of the facility's Hand Hygiene Policy, dated 10/28/25, showed:-Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and waterin most clinical situations;-Associates perform hand hygiene (even if gloves are used) in the following situations, before performing a procedure such as an aseptic task (e.g. dressing care). Review of the facility's Droplet Precaution sign, undated showed:-Everyone must clean their hands, including before entering and leaving the room;-Make sure your eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. Review of the facility's Contact Precautions Policy, undated showed:-Everyone must clean their hands, including before entering and leaving the room;-Providers and staff must also put on gloves before room entry. Discard gloves before room exit;-Put on gown before room entry. Discard gown before room exit. Review of the facility's Activities of Daily Living (ADL) Policy, dated 9/4/25, showed after cleansing the perineum, perform hand hygiene, apply new gloves, apply a moisture-barrier skin protectant as needed to protect, and maintain intact skin or treat nonintact skin. Review of the facility's EBP sign, undated showed:-Everyone must cleanse their hands, including before entering and when leaving the room;-Providers and staff must also wear gloves and gowns for the following high contact resident care activities: dressing, transferring, providing hygiene, changing briefs or assisting with toileting;-Device care or use: wound care, any skin opening requiring a dressing. 1. Review of Resident #101's medical record, showed:-Alert and oriented times four (person, place, time, and situation);-admitted with right knee and sacral (the triangular region at the base of the spine) skin issues noted;-Diagnoses included sepsis (body's extreme reaction to infection) and high blood pressure. Review of the resident's physician order summary, dated 1/12/26, showed:-A physician order to cleanse the right knee with normal saline, apply xeroform (sterile, non-adherent wound dressing) and Allevyn (wound dressing) every day for treatment;-A physician order to cleanse sacral area, apply Duoderm (protective dressing) twice weekly on Wednesday and Saturday for treatment. Observation on 1/14/26 at 8:52 A.M., showed EBP signage on the resident's door, and the resident lay in bed. The Nurse Practitioner (NP) entered the room, performed hand hygiene and put gloves on. No gown was worn. The NP removed the dressing from the right knee, cleaned and measured the wound. Licensed Practical Nurse (LPN) F stood at the treatment cart. Once the NP instructed him/her on what was needed for the treatment, he/she entered the room, performed hand hygiene and put gloves on, no gown was worn. LPN F applied Triple Antibiotic Ointment (TAO) and a foam dressing. LPN removed his/her gloves and performed hand hygiene and went back to the cart. The resident was assisted to roll towards the door by the NP. The NP removed the sacral dressing, while wearing the same gloves used to remove the knee dressing, measured and cleaned the sacral area. LPN F entered the room, performed hand hygiene, put gloves on and applied a foam dressing, no gown was worn. The NP removed her gloves and performed hand hygiene. 2. Review of Resident # 81's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) dated 10/4/25, showed:-Cognitively intact;-Dependent on staff for toilet hygiene;-Partial/moderate assistance (helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) for rolling left to right;-Frequently incontinent of urine and occasionally incontinent of bowel;-Diagnoses included hemiplegia or hemiparesis (paralysis and/or weakness to one side of the body), and left and right above knee amputation. Review of the resident's care plan in use at the time of survey, showed:-Focus: Stage 2 pressure ulcer injury (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, may also present as an intact or open/ruptured blister) and right stump surgical wounds, start date was 7/6/25;-Interventions included: EBP. Review of the resident's physician order summary dated 1/13/26, showed a physician order to cleanse the sacral area with normal saline/wound cleanser, pat dry, and apply Duoderm for protection every Wednesday and Saturday. Observation on 1/12/26 at 11:30 A.M., showed EBP signage on the resident's door and there was no PPE outside the resident's room. The resident lay in bed. Certified Nurse Aide (CNA) G entered the room, performed hand hygiene and put gloves on. No gown was worn. He/She performed perineal care and assisted the resident to get dressed; a mechanical lift sling was placed under the resident. When the resident was rolled onto his/her side, a Duoderm dressing was visible on the resident's sacrum. Registered Nurse (RN) H came into the room, performed hand hygiene and put gloves on. No gown was worn. The nurse told the CNA that the resident needed a full body lift. The lift sling was removed from under the resident. The nurse removed his/her gloves and left the room to look for a lift sling. Neither staff wore a gown. Observation on 1/14/26 at 9:03 A.M., showed EBP signage on the resident's door. LPN F entered the resident's room, performed hand hygiene and put on gloves. No gown was worn. LPN F assisted the resident to roll towards the window and removed the Duoderm dressing from the resident's sacrum. He/she cleansed the sacral area with wound cleanser, changed his/her gloves and applied a Duoderm dressing. LPN F said the resident did not have a wound. The Duoderm was used for protection. 3. Review of Resident #9's medical record, showed:-admitted with left thoracotomy (open surgical incision through the chest wall), with daily treatment orders;-An order dated 12/17/25, to cleanse left upper lateral chest wound with normal saline or wound cleanser, pat dry, apply wet to dry dressing using saline soaked Kerlix (gauze bandage), then apply calcium alginate (antimicrobial wound dressing), cover with ABD (absorbent dressing) and secure with tape;-Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD, lung disease), cognitive communication deficit, and dysphagia (difficulty swallowing). Review of the resident's care plan in use at the time of survey, showed:-Focus: resident has a left rib wound;-Goal: minimize risk of symptoms of infection;-Interventions included: EBP, treatment as ordered, weekly skin checks. Observation on 1/14/26 at 9:19 A.M., showed EBP signage on the resident's door. The NP and LPN F entered the room with gloves on and no gowns on. LPN F placed a clean plastic trash bag on the overbed table and lay clean wound treatment supplies on top. The NP removed the old wound dressings and placed them inside the plastic bag with clean supplies still on top. The NP removed the resident's soiled dressing and removed the gloves, but no hand hygiene was completed prior to applying clean gloves. He/She measured and cleaned the wound, then applied treatment and new dressing. The NP did not change gloves and performed hand hygiene after cleansing the wound and before applying wound treatment and new dressing. 4. Review of Resident #56's medical record, showed:-admitted with wounds to the buttocks;-An order dated 12/31/25, to cleanse both buttocks with normal saline or wound cleanse, pat dry, apply Flagyl (antibiotic medication) powder to wound bed, then apply Fibracol (sterile collagen and calcium alginate wound dressing) to the middle and right wound bed, apply Xeroform (a sterile, fine-mesh gauze impregnated with petroleum) to left buttock, cover with ABD and secure with tape;-Diagnoses included cutaneous abscess of buttock, hidradenitis suppurativa (a chronic, painful skin condition causing recurring boil-like lumps, tunnels, and scarring), and squamous cell carcinoma (skin cancer). Review of the resident's care plan, in use at the time of survey, showed:-Focus: At risk for unavoidable pressure injury development or decline of skin integrity;-Goal: Maintain intact skin with no skin breaks;-Interventions included: treatment as ordered, weekly skin checks. Observation on 1/14/25 at 9:36 A.M., showed EBP signage on the resident's door. The NP and LPN F entered the room with no gowns on. LPN F placed a clean plastic trash bag on the overbed table and lay clean wound treatment supplies on top. The NP obtained several gloves from the PPE container hung by the door. He/She dropped a glove on the floor, picked it up and placed it with the other gloves and clean supplies on the overbed table. Both LPN F and the NP placed gloves on, removed the old wound dressing, then changed gloves with no hand hygiene prior to applying new gloves. The NP cleansed the wound area then applied the treatment without changing gloves prior to obtaining the treatments or medications. LPN F assisted the NP in applying Xeroform, dressing and tape. 5. Review of Resident #63's admission MDS, dated [DATE], showed:-Severe cognitive impairment;-Dependent on staff for toilet hygiene and rolling left to right;-Always incontinent of bowel and bladder;-Diagnoses included heart failure, high blood pressure, Alzheimer's disease, and hemiplegia or hemiparesis. Review of the resident's care plan in use at time of survey, showed:-Focus: resident had an ADL self-care performance deficit related to Alzheimer's, impaired balance, limited mobility, and trauma;-Interventions included: toilet use: dependent on staff for toileting needs. Observation on 1/14/26 at 9:30 A.M., showed the resident lay in bed. Certified Nurse Aide (CNA) I entered the residents room, performed hand hygiene and put gloves on. CNA I unfastened the resident's brief, provided perineal care, rolled the resident onto his/her side removed the brief and cleansed the resident's buttocks. He/She then tucked a new brief halfway under the resident and rolled the resident onto his/her back, pulled the brief up between the resident's legs and fastened the brief. CNA I did not change his/her gloves after touching soiled areas and before touching clean areas. 6. Review of the facility's Laundry Service Policy, dated 7/5/25, showed facility staff should handle all used laundry as potentially contaminated and use standard precautions with appropriate personal protective equipment. Observation on 1/14/26 at 7:10 A.M., showed Laundry Aide K removed the clean laundry from the washer and put it in a gray cart lined with linen. A sheet and pillowcase fell on the floor. The laundry aide picked up the pillowcase and threw it to the side and said he/she discards pillowcases with stains on them. He/She picked up the sheet and tossed it on top of the clean linens. Laundry Aide J pushed the grey cart to the dryer; there was a sheet dragging on the floor. All linens were tossed into the dryer. 7. During an interview on 1/15/26 at 2:51 P., the Infection Control Preventionist (ICP) said residents were placed in EBP rooms if they had gastrostomy tubes (device used to provide nutrition to people who cannot obtain nutrition by mouth), colostomies (opening in the abdomen to the large intestine), intravenous lines (IV), wounds, and urinary catheters. EBP signage was hung on the residents' doors. Staff should apply gowns and gloves when providing care. Eyewear can be worn as needed. When providing care involving high contact with residents, including personal care and wound care, personal protective equipment (PPE) should be worn. The ICP expected staff to change gloves from dirty to clean contact and perform hand hygiene in between glove changing. The ICP also expected to maintain infection control in the laundry area. Linen should not be dragged on the floor. If washed or clean linens were dragged and dropped on the floor, they were considered dirty and should be re-washed. 8. During an interview on 1/16/25 at 1:01 P.M., RN P said EBP rooms have signage on the door and instructions on what PPEs are to be used. Gowns and gloves should be worn when providing care to the residents on EBP. Hand hygiene should be performed before and after changing gloves. 9. During an interview on 1/16/26 at 1:36 P.M., the Regional Nurse Consultant (RNC) said staff were expected to follow the infection control policies.

Based on interview and record review, the facility failed to ensure five out of 10 randomly selected Certified Nurse Aide (CNA)/Certified Medication Technicians (CMT), employed by the facility for over 12 months received their annual 12 hours of in-service training. The census was 90.Review of the facility's CNA 12 Hours of Inservice Training policy, dated 12/17/25, showed the Staff Development Coordinator (SDC) will develop, implement, and maintain an effective in-service program for all nurse aides to ensure they have received the necessary in-services and education to meet the federal requirement. CNAs have a requirement of at least 12 hours of continuing competency every 12 months and must include dementia management training and resident abuse training. Review of the facility's Personal In-Service Records, dated in-service year 2025, and reviewed on 1/12/26, showed:-CMT R, date of hire 6/20/22, with 2.0 hours of in-service training;-CMT S, date of hire 10/30/18, with 3.25 hours of in-service training;-CNA T, date of hire 7/25/18, with 2.0 hours of in-service training;-CNA U, date of hire 7/7/98, with 2.0 hours of in-service training;-CNA V, date of hire 11/30/21, with 2.5 hours of in-service training. During an interview on 1/13/26 at 3:30 P.M., Registered Nurse N said the facility did not have any more in-service training hours. During an interview on 1/16/26 at 1:36 P.M., the Regional [NAME] President said she would expect for CNAs/CMTs to have 12 hours of education completed and documented annually.

Based on observation, interview and record review, the facility failed to create an environment that supported and respected the right of a resident to make choices about significant aspects of daily life. The failure affected one resident (Resident #66) who requested to get out of bed for meals. Resident #66 required extensive assistance with activities of daily living (ADLs) due to left-side paralysis and required staff assistance for transfers out of bed. The facility utilized a get-up list to determine which residents would be assisted out of bed in the morning. This process did not consider or honor the resident stated preference to be out of bed for all meals. The facility census was 90. Review of the facility's Policy for Resident Rights, dated 6/8/2020, showed:-The resident has the right to be informed of, and participate in, his or her treatment, including the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition; the right to participate in the development and implementation of his or her person centered plan of care; -The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/14/25, showed the following:-Diagnoses included hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side; dysphasia (disorder that affects the ability to speak) following cerebral infarction; and abnormal posture; -Moderately impaired cognition.Review of the resident's care plan, last reviewed/revised on 11/12/25, showed the following: -Focus: ADL self-care performance deficit related to hemiplegia, impaired balance, and stroke;-Goal: Maintain current level of function through the review date;-Interventions: Require moderate assist by one staff to turn and reposition in bed and as necessary, need assistance by one staff to dress. The resident required set up assistance with bed mobility and transfers;-The resident's care plan did not include his/her preference for wake-up time. Observation and Interview on 1/12/25, showed the following:-At 11:37 A.M., the resident lay in his/her bed at an angle with his/her dominant right-side against the right quarter bedrail and mattress, raised at a 90-degree angle. The resident's dominant right arm was tucked under resident's upper body and the call light was tied to the bottom of the right bottom quarter bedrail, inaccessible for the resident to reach. The resident had crumbs of eggs on his/her chest. The resident said he/she was unable to get to his/her call light with his/her left hand due to a stroke that affected the left side of his/her body. The resident said he/she did not like eating in his/her room but when he/she requests to get up, he/she is told to wait until after breakfast.-At 12:15 P.M., Certified Nurse Aide (CNA) I entered the room with another CNA and said we are going to get up for lunch. The resident told CNA I he/she should have already been up. -At 12:20 P.M., CNA I said he/she knows the resident does not like being in bed and tries to make sure the resident is up after breakfast. Normally the night shift gets the resident up for breakfast but sometimes they run short. Today he/she was just running behind. Observation and Interview on 1/13/25, showed the following:-At 10:24 A.M., the resident lay in bed and watched television. The resident said he/she requested assistance to get up for breakfast; however, the CNA did not return. The resident said he/she preferred to be out of bed for meals and that eating in bed was difficult due to his/her history of stroke. He/She slid down in bed or leaned to one side while eating. The bedside table contacted the quarter side rails, and his/her positioning makes digestion difficult.-At 10:40 A.M., the resident lay in bed and watched television.-At 11:50 A.M., two CNAs entered the resident's room, pushing a mechanical lift and told the resident they were there to get him/her up. Observation and Interview on 1/14/25, showed the following:-At 8:16 A.M., the resident ate breakfast in bed, with the bed positioned at a 45-degree angle with the resident's legs pointing to the bottom left side of the bed and right shoulder closer to the right side of the bed. The resident's upper body rested on the quarter side rail. The center section of the resident's chest rested in the crease of the mattress bend. The bedside table had several puddles of spilled coffee.-At 11:15 A.M., Occupational Therapist Registered (OTR) K said the resident has extensor tone pattern (muscles that straighten or stiffen the limb are dominating or difficult to relax) from his/her stroke which causes the resident to slide in bed. OTR K preferred to have all residents eating in the dining room for safety reasons, but residents have the right to decide to eat in their room or in the dining room and their choice should be honored. -At 1:40 P.M., CNA J said the resident does not like being in bed so if night shift was not able to get resident up before breakfast, he/she would make sure the resident got up after breakfast. -At 1:50 P.M., Registered Nurse (RN) H, said the resident always requested to get up because the resident does not like being in bed. RN H was not sure why the resident was not up for breakfast. The nurses generated a get-up list for nights and was not sure why the resident was not on the list. Observation and Interview on 1/15/25, showed the following:-At 8:10 A.M., the resident ate breakfast in bed, with the bed positioned at a 45-degree angle. The resident said he/she did not like eating in bed, and he/she ate better when out of bed. -At 9:38 A.M., CNA G said the facility has a get up list for nights to determine which residents are up before breakfast. The resident is not on the get up list, but nights sometimes will get the resident up. CNA G was unaware the resident did not like eating in bed but knew the resident did not like being in bed. -At 10:15 A.M., CNA G assisted the resident into the main dining room. During an interview on 1/16/26 at 2:30 P.M., the Operation Specialist said resident rights should be honored regarding when a resident gets up in the morning.

Based on observation, interview and record review, the facility failed to ensure residents or the resident's Durable Power of Attorney - Healthcare (DPOA-Healthcare) were invited to participate in all aspects of person-centered care planning for one resident (Resident #67) who was not notified in spending down the resident's resources on medical requirement in the amount of $2,725.80 and did not authorize the funds to be spent. The sample was 23. The census was 90.Review of the facility's Policy for Resident Rights, dated 6/8/20, showed:-The resident has the right to be informed of, and participate in, his or her treatment, including the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition; the right to participate in the development and implementation of his or her person centered plan of care;-The resident has the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care;-The resident has the right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care;-The resident has the right to be informed, in advance, of changes to the plan of care. Review of the facility's Policy for Resident Trust Fund, dated 5/6/25, showed:-For the purposes of these resident trust procedures, a representative may act on behalf of the resident only when a legal document is on file detailing the representative's power of attorney, guardianship, conservatorship, or other relationship granting the representative the authority to act on behalf of the resident;-The facility will provide written notification to the resident and/or authorized resident representative when the resident's trust account is within $200.00 of the resource limit for Medicaid eligibility for that state. In the same written notification, the resident will be advised that reaching the state's resource limit in the account could jeopardize the resident's Medicaid and/or Supplemental Security Income (SSI) eligibility;-Withdrawals from the Resident Trust - all withdrawals from a resident's trust account must meet two requirements to be paid: a) The withdrawal must be authorized by signature of the resident or of the resident's authorized representative. b) The withdrawal must be of benefit to the resident.-Documentation for both requirements shall be maintained in the resident's financial files. When a resident is unable to approve a purchase and an authorized representative is unavailable, the receipt may be signed by a facility representative. This signature shall be accompanied by witness signatures of not less than two (2) other facility associates from a nonbusiness office department.-A disbursement of cash to a resident should be documented with a signed receipt in triplicate. One copy of the signed receipt shall be provided to the resident. Review of Resident #57's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/10/25, showed: -Diagnoses included diabetic, stroke, difficulty with speech and swallowing; -Severe cognitive impairment;-No behaviors and/or depression. Review of the resident's care plan, in use during survey, showed: -Focus: Resident has impaired cognitive ability;--Goal: Resident will be able to communicate basic needs through the review date;--Intervention: Ask yes/no questions in order to determine his needs;-Focus: Resident has difficulty performing activities of daily living;--Goal: Maintain current level of function through the review date;--Intervention: requires substantial assist of one for wheelchair mobility. Review of the resident's quarterly resident fund statement, dated 10/1/25 through 12/31/25, showed the following:-On 10/1/25, beginning balance of $2,618.26;-On 10/7/25, a withdraw with a description Medical equipment in the amount of $2,725.80;-On 12/31/25, an ending balance of $101.60. Observation on 1/15/26 at 11:20 A.M., showed the Business Manager Assistant (MBA) and the Activity Director (AD) asked the resident to sign the top page of a packet that read Trust Fund Disbursement Authorization Form. The form was visibly incomplete with only the resident's name, amount ($2,725.80) and the payable to sections completed. The resident said he/she was having problems holding the pen to sign. Observation on 1/15/26 at 11:21 A.M., showed the packet presented to the resident contained the following documents:-Trust Fund Disbursement authorization form with the sections: Date, Resident/Authorized Signer, (2) Facility Witness were blank. Sections that were written in black ink reflected the resident's name, $2,725.80 and payable to a medical equipment company.-The medical equipment company invoice- dated 9/11/2025, included the resident's name at the top, itemization of wheelchair parts including amounts and invoice total of $2,725.80. -A copy of the facility's Petty Cash Account check #2050, dated 10/7/25 in the amount of $2,725.80. Wheelchair written at the bottom left side of check.-A withdrawal Record dated 10/6/25, showed created by Business Manager Assistant (BMA) with BMA authorized signature, reflecting the medical equipment withdraw from the resident's patient trust account.-A copy of the resident's quarterly resident fund statement, dated 10/1/25 through 12/31/25, with a written X at the top of the statement, no other signatures or markings. During an interview on 1/15/26 at 11:21 A.M., the BMA said the Business Manager (BM) gave direction to have the resident sign a new Trust Fund Disbursement Authorization Form because the original form that was completed back in October of 2025 was misplaced. During an interview on 1/15/26 at 11:24 A.M., the resident said he/she was not sure what he/she was asked to sign, if the wheelchair was new or if he/she had purchased the wheelchair. During an interview on 1/15/26 at 12:10 P.M., the Operations Specialist said she was the administrator at the time the resident's wheelchair was purchased and recalled talking to the family and said the facility did not communicate prior to the purchase, to discuss the needs of the resident. The Operations Specialist was not aware the resident was missing the Trust Fund Disbursement Authorization form. Having a resident sign for a back-dated purchase is not acceptable practice. During an interview on 1/15/26 at 4:20 P.M., the resident's Durable Power of Attorney (DPOA) said the facility made him/her aware of the purchase of the wheelchair, after the fact. He/she would have liked to have a discussion prior to the purchase, since the resident has no burial arrangements and still needs funds to purchase cremation. During an interview 1/16/26 at 2:30 P.M., the Operational Specialist said it is expected that staff follow the facility's patient trust policy and procedures.

Based on observation and interview, the facility failed to post in a place readily accessible to residents, family members and legal representatives of residents, the results of the most recent survey and complaint investigations of the facility in a location where they would not be required to ask staff for assistance. The census was 90.Observations on 1/12/26 through 1/15/26, showed no survey results maintained at the entrance of the building, in the lobby of the building or at the desk with the receptionist. No signs were posted for the location of the survey results and/or availability of the last survey or complaint investigations. During a group interview on 1/13/26 at 10:00 A.M., six residents, who the facility identified as alert and oriented, attended the group meeting. All six residents said they were unaware of where the state survey results were located. Observation on 1/15/26 at 11:48 A.M., showed a dresser diagonal from the receptionist's area, No signs or posting sat on top of the dresser, or anywhere in the area surrounding the dresser. Upon opening the dresser, the most recent survey and complaint investigations were in a binder, inside of the dresser. During an interview on 1/15/26 at 11:49 A.M., the Receptionist said the survey binder was in the dresser and was always kept there. There was no sign indicating the survey results were available. The binder was not accessible to residents, families or visitors. During an interview on 1/16/26 at 1:36 P.M., the Regional Nurse, Regional [NAME] President and Operations Specialist said the survey binder should have been available and accessible for residents, families and visitors. The binder was not accessible prior to 1/16/26.

Based on interview and record review, the facility failed to ensure services provided meet professional standards when one resident's physician order was not transcribed onto the physician order sheet timely (Resident #91). The sample was 23. The census was 90.Review of Resident #91's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/25, showed:-Moderately impaired cognition;-No rejection of care;-Resident had an indwelling catheter (a sterile tube inserted into the bladder to drain urine);-Diagnoses included renal (kidney) insufficiency, renal failure or end stage renal disease (ESRD, chronic irreversible kidney failure) and obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow). Review of the resident's care plan, in use at the time of survey, showed:-Focus: had a left nephrostomy (a flexible tube inserted through the back into the kidney to drain urine when the normal urinary tract is blocked) related to obstructive uropathy;-Goal: will have no complications related to nephrostomy use;-Interventions included catheter care every shift, check tubing for kinks each shift, educate resident and/or family regarding indwelling catheter and care, observe for and report to medical doctor for signs and symptoms urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of the resident's Transfer Orders for Receiving Facility, admission date 10/21/25 and expected discharge date [DATE], showed:-Your discharge diagnosis was kidney stone;-General instructions: left nephrostomy tube dressing to be changed every 1-2 days and when soiled. Keep nephrostomy tube clamped. Call if patient has increased flank/back pain with tube clamped;-After a Percutaneous Nephrolithotomy (PCNL, procedure to remove kidney stone), a left nephrostomy tube remained in place, please keep this tube clamped. Change dressing every 24-48 hours and when soiled. If pain worsens on the left back/flank, please contact Genitourinary (GU, medical term for urinary specialist) for further instructions. Review of the resident's physician order summary, in use at the time of survey, showed:-A physician order for nephrostomy tube output every shift, start date 10/23/25;-A physician order to keep nephrostomy tube clamped, per urology every shift, start date was 11/10/25;-There was no order for a dressing change and no order prior to 11/10/25 to clamp the nephrostomy tube. Review of the resident's progress notes dated 10/23/25 through 10/31/25, showed:-On 10/23/25 at 5:39 P.M., resident arrived from hospital. All orders verified with medical doctor;-On 10/24/25 at 1:40 P.M., physician note, left nephrostomy tube to remain in place at discharge. Keep Percutaneous Nephrostomy (PCN, a medical procedure used to drain urine directly from the kidney when the normal flow is blocked) clamped. Change dressing every 24-48 hours and when soiled;-On 10/27/25 at 12:56 P.M., physician note, seen today. Urinary catheter and nephrostomy tube in place. Assessment/plan: left nephrostomy to remain in place until follow up with urologist. Review of the residents Medication and Treatment Administration Records (MAR and TAR) dated 10/23/25 through 10/31/25, showed a physician order for nephrostomy tube output every shift. Documentation showed: On day shift: five out of eight opportunities an output was documented; on evening shift: six out of eight opportunities an output was documented; on night shift: five out of nine opportunities an output was documented. Review of the resident's progress notes dated 11/1/25 through 11/10/25, showed:-On 11/3/25 at 3:01 P.M., indwelling catheter and nephrostomy tube patent and intact, both draining via gravity;-On 11/5/25 at 11:45 A.M., resident returned from doctor's appointment, no new orders, no paperwork sent with resident;-On 11/5/25 at 10:40 P.M., resident had an indwelling catheter and a nephrostomy tube, both draining to gravity;-On 11/7/25 at 4:02 P.M., has an indwelling and nephrostomy tube, both draining to gravity;-On 11/8/25 at 2:48 P.M., has an indwelling and nephrostomy tube, both draining to gravity;-On 11/9/25 at 11:52 A.M., has indwelling and nephrostomy tube, both draining to gravity;-On 11/10/25 at 11:10 A.M., physician note, seen today, indwelling and nephrostomy tube in place. Followed up with urology on Wednesday-failed trail void. Per urologist plan clamp nephrostomy tube. Nurse given orders today, not sent with resident last week. Review of the resident's MAR dated 11/1/25 through 11/10/25, showed:-A physician order for nephrostomy output every shift. Documentation showed on day, evening and night shift, eight out of nine opportunities, output was documented;-A physician order to keep the nephrostomy tube clamped every shift. The start date 11/10/25. During an interview on 1/15/26 at 1:43 P.M. Licensed Practical Nurse (LPN) E said when a resident is admitted to the facility, the nurse on the floor was responsible for entering the orders into the computer and completing the assessments. The hospital discharge orders are verified with the doctor or the nurse practitioner (NP). If a change was made during the reconciliation process, he/she would note it on the hospital discharge paperwork. When the doctor or NP made rounds at the facility, they make a note in the computer. They also enter their own orders into the computer. The nurse had to confirm the order to activate it. LPN E did not review the doctors or NP notes unless they said something like there were new orders. If a resident went out for an appointment and came back with no paperwork, he/she would call the provider to obtain the records and document it. When the resident admitted to the facility, he/she had an indwelling catheter and a nephrostomy tube, the nurse could not remember if the nephrostomy tube was clamped or not. During an interview on 1/15/26 at 2:28 P.M., the Nurse Manager said the nurse on the floor was responsible for admitting the residents. The after-visit summary is what they used for orders. The orders are verified with the doctor. The next day, admissions are audited by nurse management. When a provider visits the facility, they make notes in the progress notes. The Nurse Managers reviews their progress notes. Providers enter their own orders into the computer and the nurse is responsible for confirming the orders. Any nurse can confirm an order. If a resident went out to see a provider and returned with no paperwork, the nurse would call the office and document it in the progress notes. During an interview on 1/15/26 at 3:49 P.M. Registered Nurse (RN) N said the facility used the after-visit summary for the discharge orders. The nurse should read the whole document for orders. RN N said the nephrostomy tube should have been clamped, and the dressing should be changed every 24-48 hours, unless the orders changed when they were verified. If the tube was clamped there would be no output from the tube. During an interview on 1/16/26 at 11:01 A.M., the NP said the general instructions and care of sites should be verified when the resident is admitted . The NP looked at the progress notes and said the doctor verified the orders with the nurse on 10/23/25 and she saw the resident on 10/24/25 and wrote a note. The order for the tube to be clamped and the dressing changed should have been placed. If the tube was clamped there would be no output from the tube. During an interview on 1/16/26 at 9:09 A.M., RN Q said the resident had a nephrostomy tube because he/she had an obstruction. The tube was clamped to see if the resident could void more on their own. If the tube was clamped there would be no output from the tube. Sometimes there may be a small amount of drainage from around the tube but that would not be measurable. The dressing around the tube was to help keep the area clean and dry. During an interview on 1/16/25 at 1:36 P.M., the Director of Nursing said the resident's orders were verified with the physician on admission. 2713882

Based on observation, interview and record review, the facility failed to ensure a resident who required assistance with activities of daily living (ADL) received showers and personal care in accordance with their personal needs, for one of 23 sampled residents (Resident #56). The census was 90. Review of the facility's Activities of Daily Living (ADLs) policy, reviewed 9/10/24, showed:-Policy: The resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse;-A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident #56's medical record, showed diagnoses included hidradenitis suppurative (HS, a chronic painful skin condition causing recurring boils, blackheads, and painful lumps that form deep in hair follicles, often in skin folds leading to pus drainage, tunnels and inflammation. Common areas affected are buttocks and around the anus), muscle weakness and cancer. Review of the resident's admission minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/24/25, showed:-Mild cognitive impairment;-No behaviors;-Required partial/moderate assistance with showering/bathing;-Required supervision or touching assistance with personal hygiene;-Diagnoses included cancer. Review of the resident's care plan, revised 12/29/25, and in use during the time of the investigation, showed:-Focus: The resident has an ADL self-care performance deficit related to impaired balance, limited mobility and pain;-Goal: The resident will improve current level of function through the review date;-Interventions: The resident requires moderate assistance for bathing at least twice a week and as necessary. The resident requires personal assistance for personal hygiene. Review of the resident's shower calendar, showed the resident was admitted [DATE]. Showers and/or bed baths were documented as provided on 12/25/25, 1/5/26, 1/8/26, 1/10/26 and 1/14/26. During observation and interview on 1/12/26 at approximately 11:30 A.M., the resident lay in bed on his/her stomach. The resident's hair was approximately eight inches long and appeared matted and unkempt. An odor of bowel movement was present throughout the resident's room. The resident said he/she was admitted to the facility about three weeks ago. He/she had pain due to boils on his/her buttocks. The boils leaked and caused an odor, pain and discomfort. He/she had not had a shower since being admitted to the facility. Observation on 1/12/26 at 5:43 P.M., showed the resident lay in bed on his/her stomach. An odor was present in the resident's room. He/She said he/she was not offered a shower or bed bath today. Observation on 1/13/26 at 2:33 P.M., showed the resident lay on his/her stomach in bed and said he/she just received the treatment to his/her wounds. The wound nurse cleansed the area surrounding the wound. The resident said he/she was not offered a bed bath or shower. Observation on 1/14/26 at 3:11 P.M., showed the resident lay in bed on his/her stomach asleep. The resident's hair appeared matted and unkempt. During an observation and interview on 1/15/26 at 10:39 A.M. and 3:51 P.M., the resident lay in bed on his/her stomach. The resident's hair was matted and unkempt. The resident said no staff had offered to wash his/her hair since he/she was admitted to the facility. He/She was able to walk to the bathroom and attempted to wash him/herself but could not reach behind him/herself to clean or could not wash his/her own hair. Staff had observed the resident at the sink washing him/herself, but no one had offered to assist. The resident wanted a shower or bed bath and wanted his/her hair washed. During an observation and interview on 1/16/26 at 9:46 A.M., the resident was observed in bed on his/her stomach. The smell of bowel movement was present in the resident's room. His/her hair appeared matted and unkempt. The resident said last night, he/she was offered a bed bath, but when they attempted to provide it, there were issues with the water temperature. He/she was moved to another room for the bed bath, but there was a mix up with another resident in the room. He/she asked to be moved back to his/her room and never received the bed bath. The resident said this upset him/her and he/she expected more but did not want to get anyone in trouble. During an interview on 1/16/26 at 9:43 A.M., Certified Nursing Assistant (CNA) O said he/she was familiar with the resident and he/she was able to stand on his/her own. The resident needed some assistance with showers or bed baths. The resident needed his/her hair washed and treated. Staff was expected to offer the resident two showers per week. The resident did not refuse care. During an interview on 1/16/26 at 9:59 A.M. and 12:36 P.M., CNA I said he/she was assigned to the resident and was familiar with the resident. The residents received two showers per week. CNA I checked the resident's shower schedule and said, the resident is not due for a shower today. The resident received showers on Mondays and Thursdays on evening shifts. When asked about the resident's hair, CNA I said he/she has an afro. What do you expect? If the resident wanted his/her hair washed, he/she would wash the resident's hair. During an interview on 1/16/26 at 10:13 A.M., Registered Nurse (RN) P said the resident needed assistance with showers and personal care. The resident was to receive at least two showers per week. Hair care was part of receiving a shower or bed bath. RN P was not sure what staff was doing about the resident's hair. During an interview on 1/16/26 at 1:36 P.M., the Regional Nurse, Regional [NAME] President and Operations Specialist said the resident should have received at least two showers per week, including washing the resident's hair, if he/she requested it. 2713882

Based on interview and record review, the facility failed to follow physician orders for x-rays for one of seven sampled residents (Resident #1) who had fallen from his/her bed on 9/6/24. The x-ray order was not completed for nine days, during which time the resident experienced pain and refused care, which he/she had not done prior. The resident was diagnosed with a fractured hip. The sample was 7. The census was 86. The Administrator was notified on 10/21/24 at 3:46 P.M., of the Immediate Jeopardy (IJ) past non-compliance, which occurred on 09/06/24. Facility staff were inserviced beginning on 9/13/24 and a system was implemented to monitor the completion of ordered x-rays. The IJ was corrected on 9/16/24. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/13/24, showed the following: -Diagnoses of diabetes, heart failure and peripheral vascular disease (PVD, a circulatory condition that occurs when blood vessels outside of the heart and brain narrow, spasm, or become blocked); -Short-term memory loss; -No behaviors; -Dependent on staff for toileting, bathing, and transfers. Review of the resident's progress notes, dated 9/6/24 at 3:34 P.M.: Late entry for 9/6/24 at 12:15 P.M., showed the following: Noise heard from room, resident yelled for help. Resident lay on the left side of the bed with his/her phone in his/her hand. Resident stated he/she was reaching for his/her phone. Range of motion (ROM) completed with complaints of pain. Assisted off the floor with Hoyer lift (mechanical device used to assist residents who are unable to stand and transfer) and three staff members. Spouse and physician notified. Orders received. Review of the resident's Physician Order Sheet (POS), dated 9/2024, showed the following: -Order dated 9/6/24, for a stat (urgent or rush) x-ray of the left shoulder, left arm, left hip two views, right hip two views and chest x-ray; -Tramadol (medication used to treat moderate to severe pain) 50 milligram (mg) every six hours as needed (PRN) for pain; -Tylenol extra strength 500 mg one tablet by mouth every six hours PRN for pain and elevated temperature. Review of the resident's progress notes, showed the following: -9/7/24 at 11:16 A.M., Resident screaming out in pain during care. Staff reported the resident requested pain medication. Tramadol 50 mg every six hours PRN for pain; -9/7/24 at 10:56 P.M., Tylenol extra strength given for complaint of pain; -9/8/24 at 2:31 P.M., Tramadol 50 mg given for complaint of pain; -9/8/24 at 5:34 P.M., Tramadol 50 mg given for complaint of pain; -9/9/24 at 12:20 P.M., Cleanse right medial (closer to the midline of the body) thigh with normal saline, cover with hydrocolloid dressing (forms a hydrated gel over the wound, creating a moist environment that promotes healing and protects new tissue) every Monday and Friday. Resident refused to allow nurse to touch his/her thigh; -9/9/24 at 2:06 P.M., Resident remains on incident follow up for unwitnessed fall. Resident had pain pill this shift. Refused treatment due to pain; -No documentation to show whether x-rays ordered for 9/6/24, were completed. Review of the resident's care plan, updated 9/9/24, showed the following: -Problem: At risk for falls/injury related to history of falls and bilateral amputee; -Intervention: Ensure frequently used items are within reach. Fall mats beside bed when in bed. Hoyer lift used for transfers, staff to ensure proper positioning while in bed Review of the resident's progress notes, showed the following: -9/10/24 at 06:47 A.M., Tramadol 50 mg given for complaint of leg pain; -No documentation to show whether x-rays ordered for 9/6/24, were completed. Review of the POS, dated 9/10/24 at 8:00 A.M., showed an order for a x-ray to bilateral hips. Review of the resident's progress notes, showed the following: -No documentation whether x-ray to bilateral hips was completed on 9/10/24; -9/12/24 at 12:24 A.M., Tramadol 50 mg as needed for pain; -9/12/24 at 12:24 A.M., Tylenol extra strength 500 mg given for pain; -9/13/24 at 6:28 A.M., Tramadol 50 mg given for pain; -9/13/24 at 6:37 A.M., Resident medicated with Tramadol 50 mg for complaints of pain when turned and repositioned during care. Review of the resident's progress note, dated 9/13/24 at 10:55 A.M., showed mobile x-ray in the facility to complete x-ray to right and left shoulder and right and left hip. Review of the resident's progress notes, showed the following: -9/13/24 at 10:30 P.M., Certified Nurse Aide (CNA) reported the resident being combative during night rounds times two; -9/14/24 at 5:32 A.M., Tramadol 50 mg effective for pain; -9/15/24 at 9:10 A.M., Tramadol 50 mg for complaint of pain all over body. 10 out of 10. Review of the resident's x-ray, completed on 9/13/24, showed the following: -Left hip and pelvis: No evidence of obvious fracture; -Right hip and pelvis: Possible fracture at the femoral (thigh) neck; -Handwritten by staff: Staff notified the resident's physician on 9/15/24 at 10:10 A.M. Order received to repeat stat x-ray of the right pelvis and hip. Review of the resident's progress notes, showed the following: -9/15/24 at 1:49 P.M., Tylenol extra strength 500 mg given for complaint of pain, 10 out of 10; -9/15/24 at 8:57 P.M., Result of x-ray showed possible fracture at the neck of the femur. Physician ordered a computed tomography (CT, imaging technique that uses x-rays to create detailed cross-sectional images of the body) scan of the right hip and pelvis to be scheduled on 9/16/24; 9/16/24 at 4:07 A.M., Staff attempted to provide peri care (cleansing of the hips, genitals and rectal area), resident allowed limited peri rectal hygiene. During an interview on 9/16/24 at 9:06 A.M., the Medical Director and resident's physician said she was sending the resident to the emergency room for continued complaints of pain. His/Her x-ray showed possible fracture of the right hip. Observation on 9/16/24 at 9:13 A.M., showed the resident lay in bed on his/her back. Fall mat noted to left side of the bed. Bruises noted to left inner arm. The resident had bilateral above the knee amputations. The resident was unable to say how he/she got the bruises to his/her arm. Review of the resident's progress notes, showed the following: -9/16/24 at 10:10 A.M., Tramadol 50 mg given for complaint of hip/pelvis, 10 out of 10; -9/16/24 at 12:50 P.M., New order received to send resident to the hospital for evaluation of pain to right hip and pelvis. Review of the resident's hospital admission records, showed he/she was admitted to hospital on 9/16/24 for repair of right hip fracture. During an interview on 10/8/24 at 1:43 P.M., CNA A said he/she worked on the day-shift and has taken care of the resident. On 9/6/24, the resident fell from his/her bed. When he/she and CNA B entered the room, the resident said he/she was reaching for his/her phone and fell out of the bed. The Assistant Director of Nurses (ADON) entered the room and assessed the resident. They used a Hoyer lift to assist the resident back to bed. The resident complained of pain in his/her back and said his/her legs hurt. The ADON said he/she was going to call the physician for an x-ray order. CNA A took care of the resident several days after his/her fall. The resident complained of severe pain each time he/she went in to change him/her. It was difficult to provide care. The resident required two staff to provide care because the resident would resist. At times, the nurse would come in to assist. This was not the resident's normal behavior. It usually took one staff member to provide care and the resident was able to turn to each side when asked. Now two staff had to roll him/her from side to side and the resident would yell out in pain. CNA A could tell the resident was in a lot of pain. They would report it to the nurse each time the resident complained. The nurse would give him/her pain medication. CNA A was concerned about the resident and thought the pain was caused by the fall. During an interview on 10/8/24 at 2:30 P.M., the ADON said she assessed the resident after his/her fall on 9/6/24. She called the physician and got orders for stat x-rays of his/her left shoulder, left arm, left hip two views, right hip two views and chest x-ray. The orders were sent to the x-ray company. She didn't realize the x-rays weren't completed until grand rounds with the Director of Nursing (DON) on 9/13/24. No one reported the resident's increase in pain. She was surprised the resident was taking the Tramadol because that was not something he/she usually did. She expected staff to inform her of the resident's complaints of pain. She should have followed up the next day to ensure the x-rays were completed. She doesn't know why she failed to do so. During an interview on 10/16/24 at 12:56 P.M., Licensed Practical Nurse (LPN) D said he/she worked for an agency. He/She worked on 9/13/24. In report, he/she was told the resident had an order for a hip x-ray to be completed on his/her shift. He/She didn't receive the results on his/her shifts. During an interview on 10/16/24 at 10:36 A.M., LPN E said he/she worked the night shift and had taken care of the resident. Prior to the fall, one staff member could provide care. After the fall, it took two people to turn and provide care. At times, LPN E had to go in and help the staff. The resident complained of pain while staff provided care. LPN E gave the resident pain medication a couple of times when he/she asked for it. He/she doesn't recall receiving any x-ray results on nights but if he/she had, they would come directly to the floor via the fax machine. If a result came in and it showed a fracture, LPN E would call the doctor to report it. He/She would also notify the DON and document it. During an interview on 10/15/24 at 2:25 P.M., LPN G said the ADON asked him/her to help get the resident off the floor on 9/6/24. When they entered the room, the resident sat on the left side of the bed, on the floor. After the ADON assessed the resident, several staff assisted the resident via the Hoyer lift to the bed. The ADON reported the fall to the doctor and got orders for x-rays. LPN G didn't follow up because he/she wasn't the resident's nurse. Several days later during morning rounds, the DON asked if the x-ray was completed. It was at that time staff realized the x-ray wasn't done. During an interview on 10/15/24 at 1:00 P.M., LPN F said he/she worked for the agency and recalled hearing in report about an x-ray from the ADON. LPN F wasn't the resident's nurse so he/she didn't follow up. Several days later, when he/she returned to work, the DON asked whether the x-ray had been completed during rounds. They talked about the x-ray not being completed. During an interview on 10/8/24 at 1:35 P.M., CNA B said he/she has taken care of the resident on day-shift. The resident required total care from the staff. After the fall, the resident would complain of pain in his/her back, legs and refused to get out of bed. CNA B would report to the nurse when the resident complained of pain. During an interview on 10/8/24 at 2:21 P.M., CNA C said he/she works on the day-shift and has taken care of the resident. Prior to the fall, the resident was able to turn easily by him/herself. During rounds, the resident would complain of pain in his/her back and hips. It was difficult to clean him/her because of the pain. It took two staff to get him/her cleaned up. The resident would say, I can't do it, it hurts when staff would try to clean him/her. CNA C reported the resident's complaints of pain to several nurses. The nurse would go in to check on him/her and give pain medication. During an interview on 10/9/24 at 1:37 P.M. a representative from the mobile x-ray company said on 9/6/24, they received an order for x-rays of the left shoulder and arm, left hip two views, right hip two views and chest x-ray. They tried to contact the facility to recommend the resident be sent to the hospital due to the high exposure to radiation. They placed several calls to the nursing station but no one answered the phone. During an interview on 10/21/24 at 11:20 A.M., the DON said she was unaware the x-rays ordered on 9/6/24 weren't completed until 9/13/24, during rounds. No one reported the resident's complaints of pain during care. She expected the ADON to follow up the next day regarding the x-rays. She was unaware a new order was received on 9/10/24. Staff failed to complete the x-ray until 9/13/24. She expected staff to complete orders as written. During an interview on 10/17/24 at 11:14 A.M., the resident's physician and Medical Director said she expected staff to complete the 9/6/24 x-rays as ordered. Staff notified her on 9/10/24 of the resident's complaints of pain. She ordered an x-ray of the right and left hip and pelvis. She was not aware the x-ray was not completed until 9/13/24. She expected the x-rays to be completed as ordered. She expected staff to notify her if mobile imaging is unable to complete the x-ray as ordered. MO00242412 MO00243201

Based on interview and record review, the facility failed to submit facility initiated transfers (such as an emergency transfer to the hospital with intent to take the resident back) to the Ombudsman on a monthly basis. The census was 92. During an interview on 4/16/24 at 11:07 A.M., Ombudsman F said the facility had not sent their monthly transfer notifications to the ombudsman office since November of 2022. Review of the email communication between the facility Social Service Director and the ombudsman office, dated 4/18/24 at 9:13 A.M., showed an admission/discharge log dated 4/1/24 through 4/18/24. During an interview 4/18/24 at 9:35 A.M., the Administrator said the social worker will be responsible to submit hospital transfer logs monthly to the Ombudsman. It has not been done since she started two weeks ago and that is about the same time the Social Service Director started. She is not sure when the last submission was completed. The Social Service Director just turned in a submission today for April 2024 and will be submitting them at the end of each month ongoing.

Based on interview and record review, the facility failed to encode and transmit resident assessment data within 7 days after a facility completes a resident's assessment for 12 of 19 residents investigated for MDS encoding and transmission, as indicated by the MDS showing in progress (Residents #22, #51, #54, #6, #53, #43, #2, #7, #29, #14, #30, and #23). The census was 92. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-Admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the Admission assessment, the MDS Completion Date must be no later than 13 days after the entry date; -Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). 1. Review of Resident #22's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 3/25/24 with ARD date 3/25/24, in progress. 2. Review of Resident #51's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 2/20/24 with ARD date 2/20/24, in progress. 3. Review of Resident #54's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 1/25/24 with ARD date 1/25/24, in progress. 4. Review of Resident #6's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 12/29/23 with ARD date 12/29/23, in progress. 5. Review of Resident #53's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 2/13/24 with ARD date 2/13/24, in progress. 6. Review of Resident #43's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 2/18/24 with ARD date 2/18/24, in progress. 7. Review of Resident #2's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 2/8/24 with ARD date 2/8/24, in progress. 8. Review of Resident #7's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 1/27/24 with ARD date 1/28/24, in progress. 9. Review of Resident #29's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 2/17/24 with ARD date 2/17/24, in progress. 10. Review of Resident #14's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 2/15/24 with ARD date 2/15/24, in progress. 11. Review of Resident #30's medical record, showed: -admitted [DATE]; -An annual MDS assessment, dated 4/1/24 with ARD date 2/24/24, in progress. 12. Review of Resident #23's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 2/4/24 with ARD date 2/4/24, in progress. 13. During an interview on 4/22/24 at 10:09 A.M., the MDS Coordinator said she has been the MDS Coordinator for 5 years. The facility just hired a new MDS staff who is in training. She has been the only MDS Coordinator since 2021. If an MDS shows in progress, this means it either still needs to be completed or needs to be signed off on. She would expect MDS assessments to be encoded and transmitted per the RAI manual. Comprehensive MDS assessments are completed on admission and at least annually. Quarterly assessments are completed quarterly, in between the comprehensive assessments. She is aware she is behind on MDS assessments. The facility has been without a social worker for about a year and a half, so the business office manager, director of rehab, and herself have been filling the role.

Based on interview and record review, the facility failed to complete quarterly resident assessments for nine of 19 residents investigated for quarterly assessment completion (Residents #54, #6, #53, #43, #2, #7, #29, #14 and #23). The census was 92. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-Admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the Admission assessment, the MDS Completion Date must be no later than 13 days after the entry date; -Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). 1. Review of Resident #54's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 1/25/24 with ARD date 1/25/24, in progress. 2. Review of Resident #6's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 12/29/23 with ARD date 12/29/23, in progress. 3. Review of Resident #53's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 2/13/24 with ARD date 2/13/24, in progress. 4. Review of Resident #43's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 2/18/24 with ARD date 2/18/24, in progress. 5. Review of Resident #2's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 2/8/24 with ARD date 2/8/24, in progress. 6. Review of Resident #7's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 1/27/24 with ARD date 1/28/24, in progress. 7. Review of Resident #29's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 2/17/24 with ARD date 2/17/24, in progress. 8. Review of Resident #14's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 2/15/24 with ARD date 2/15/24, in progress. 9. Review of Resident #23's medical record, showed: -admitted [DATE]; -A quarterly MDS assessment, dated 2/4/24 with ARD date 2/4/24, in progress. 10. During an interview on 4/22/24 at 10:09 A.M., the MDS Coordinator said she has been the MDS Coordinator for 5 years. The facility just hired a new MDS staff who is in training. She has been the only MDS Coordinator since 2021. If an MDS shows in progress, this means it either still needs to be completed or needs to be signed off on. Quarterly assessments are completed quarterly, in between the comprehensive assessments. She is aware she is behind on MDS assessments. The facility has been without a social worker for about a year and a half, so the business office manager, director of rehab, and herself have been filling the role.

Based on interview and record review, the facility failed to ensure eight of 10 randomly selected Certified Nurse Aides (CNAs) received the required annual 12 hour resident care training. The census was 92. Review of the facility assessment, showed: -Staff training/Education and Competencies: Facility provides staff training/education and competencies through a variety of methods such as new employee orientation, impromptu small group training during the regular course of business, scheduled in-house in-services, webinars, classes, seminars, memos, Healthcare Academy, etc. on subjects that are either required for continued certification or in areas determined to need education or re-education. The facility provides or arranges for personnel to receive outside education to meet staff certification and re-certification requirements as applicable. The facility provides or arranges for training in the following subject areas. This is not an inclusive list: -Communication; -Resident's right and facility responsibilities; -Abuse, neglect, and exploitation; -Infection control; -Medication administration; -Measurements; -Resident assessment and examinations; -Caring for persons with Alzheimer's disease or other dementia; -Specialized care; -Caring for residents with mental and psychosocial disorders. Review of the CNA individual in-service records, showed the following: -CNA L hired 7/7/98, showed no documentation of an in-service education tracking record; -CNA M hired 3/15/07, with 0 hours of in-service education; -CNA N hired 6/2/02, with 7.49 hours of in-service education; -CNA O hired 11/23/22, with 0 hours of in-service education; -CNA P hired 10/14/22, with 0 hours of in-service education; -CNA Q hired 2/3/23, with 0 hours of in-service education; -CNA R hired 8/24/23, with 0 hours of in-service education; -CNA S hired 5/11/22, with 0 hours of in-service education. During an interview on 4/22/24 at 1:05 P.M., the Administrator said CNA L was not logged into the system to take any trainings. During an interview on 4/23/24 at 9:50 P.M., the Administrator said the facility did not currently have a Staff Development Coordinator (SDC), who would be responsible for tracking the in-service training for CNAs. Healthcare academy would send the report and the SDC would pull the report to see what was due. Since there was no one in that position, that is why it is deficient.

Based on observation, interview and record review, the facility failed to post the required nurse staffing in a prominent place, readily accessible to residents and visitors on a daily basis. The census was 92. Review of the facility assessment, showed: -Scheduling plan: 8 + full-time per unit on 6:30 A.M. to 2:30 P.M. shift; -8 + full-time per unit on 2:30 P.M. to 10:30 P.M. shift; -6 + full-time per unit on 10:30 P.M. to 6:30 A.M. shift. Observations from 4/17/24 through 4/19/24 and 4/22/23 and 4/23/24, showed a board on the wall behind the front desk reception desk. The board contained categories for date, census, total number and actual hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nurse Aides (CNA) per shift; -On 4/17/24 at 10:10 A.M., 4/18/24 at 6:20 A.M., and 4/19/24 at 6:44 A.M., showed a date of 4/4/24 and census of 92. There was no documentation of the total number and actual hours worked by RNs, LPNs, and CNAs per shift; -On 4/22/24 at 12:35 P.M. and 4/23/24 at 8:59 A.M., showed a census of 92. The date showed only the month and year. There was no documentation of the total number and actual hours worked by RNs, LPNs, and CNAs per shift. During an interview on 4/23/24 at 9:50 A.M., the Administrator said the nursing staffing information is to be written on the board, but the Director of Nursing (DON) had put the information on a paper copy to be framed. The frame was kept on the reception desk. Since the DON was not there during the survey, no one completed it. The Administrator would expect the nurse staffing information to be completed daily.

Based on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection prevention and control when staff failed to change gloves while administering medication via an enteral nutrition device (feeding tube) and left suction equipment at the bedside uncovered for one resident (Resident #1), and not testing new hire employees for Tuberculosis (TB) per their policy for eight of eight employees sampled. The census was 92. 1. Review of the facility's Administration of Medications policy, dated 8/24/23, showed: -The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Review of the facility's Enteral Nutrition Therapy policy, dated 8/8/23, showed: -The facility will provide bolus enteral nutrition therapy in accordance with physician orders and professional standards of practice. This facility will utilize the Lippincott procedures, Enteral tube feeding, gastric; -Lippincott Nursing Procedures, Ninth Edition, 2023, page 295 Enteral tube feedings shows: Implementation: Perform hand hygiene. Review of the facility's Oral Suctioning policy, dated 8/22/23, showed: -The facility will provide oral suctioning in accordance with professional standards of practice and physicians order, to clear secretions from the mouth in the event a resident in unable to remove secretions or foreign matter by effective coughing; -General Considerations: Yankauer (brand of suction device) and tubing should be stored in a patient setup bag when not in use. Review of Resident #1's Medication Administration Record (MAR) for April 2024, showed: -An order dated 11/21/20, for Aspirin Tablet Chewable 81 milligram (mg). Give 81 mg via Gastronomy Tube (G-Tube, tube inserted into the stomach to provide fluid, medication, and nutrition) one time a day for heart health; -An order dated 3/3/22, for Famotidine (used to treat heart burn) tablet 20 mg, give 20 mg via G-Tube one time a day for acid reflux; -An order dated 10/25/22, for Atenolol (used to treat high blood pressure) tablet 100 mg, give one tablet via G-Tube one time a day for high blood pressure; -An order dated 1/31/24, for Amlodipine Besylate (used to treat high blood pressure) oral tablet 5 mg, give one tablet via G-Tube in the morning for high blood pressure; -An order dated 2/1/24, for Iron oral tablet, give 325 mg via G-Tube one time a day for low iron. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: The resident requires tube feeding related to trouble swallowing and his/her stomach has difficulty processing food dated 4/18/19; -Goal: The resident will remain free of the side effects or complications related to tube feeding dated 3/18/24. The resident will maintain adequate nutritional and hydration states as evidenced by having a stable weight, no signs or symptoms of malnutrition or dehydration dated 3/18/24. Observation on 4/18/24 at 8:20 A.M., showed Licensed Practical Nurse (LPN) T near the nurse's station, put on a pair of gloves, pushed the medication cart passed two residents rooms and stopped at the resident's room. LPN T prepped the medications in the doorway of the room, on the medication cart. LPN T did not remove gloves or wash his/her hands. He/she brought medications into the resident's room, administered medications via the G-tube, and returned to the medication cart. LPN T did not remove his/her gloves or wash his/her hands. LPN T proceeded to the next resident room. During an interview on 4/23/24 at 7:41 A.M., Registered Nurse (RN) J said that anytime a nurse puts on and takes off gloves they should wash their hands. Nurses should not put gloves on at the nurse's station and proceed to administer medications or treatments to residents. The importance of handwashing is to prevent the spread of infection. During an interview on 4/23/24 at 7:46 A.M., the Assistant Director of Nursing (ADON) said that the nurses should wash their hand or use alcohol gel every time the nurses take off their gloves. Nurse should not put gloves on the nurse's station and go to provide care to the residents. The G-Tube is an entry way for bacteria and that is why the nurses should wash their hands and wear gloves. Observation of care provided for the resident on 4/19/24 at 7:20 A.M., showed Certified Nursing Assistant (CNA) H assisted the resident to turn to his/her side to perform care. During care, the resident began drooling from the left side of his/her mouth. CNA H used the Yankauer connected to the suction machine and lay it directly, uncovered on the bedside table to remove the drool from the resident's mouth and then placed the Yankauer back on the top of the machine, uncovered. The Yankauer and tubing was left uncovered on 4/22/24 at 9:14 A.M. and 4/23/24 at 7:37 A.M. During an interview on 4/23/24 at 7:41 A.M., RN J said that the suction tubing and Yankauer should be covered when not in use to decrease the chance of introduction of bacteria. During an interview on 4/23/24 at 7:46 A.M., the ADON said that after each use of the suction equipment, it should be disposed of but she had to check the policy. 2. Review of the facility's Tuberculosis-Testing and Screening (Associates and Volunteers) policy, dated 6/6/23, showed: -The facility will evaluate each associate and volunteer for tuberculosis in accordance with current Centers for Disease Control and Prevention (CDC) guidelines, unless more stringent guidance is provided by local or state regulation; -New Associate or Volunteer Testing: (1) New associates or volunteers who have been made a conditional offer shall be screened for presence of infection through the following measures; (b) The facility should also perform skin test for M Tuberculosis using the Mantoux TST skin test. Skin testing will employ the two-step procedure. (If the reaction to the first is less than 10 millimeters (mm) induration (swelling and redness), a second test will be given 1-3 weeks later). A positive second test is indicative of boosted reaction and not a new infection. If the second test remains negative, the person is classified as uninfected. Review of the employee files, showed: -Employee AA date of hire 9/20/23. No documentation for TB testing; -Employee BB date of hire 8/23/23. No documentation for TB testing; -Employee CC date of hire 1/25/24. No documentation for TB testing; -Employee DD date of hire 3/27/24. First step TB test completed on 3/27/24 and read negative on 3/29/24. No documentation of a second step TB test; -Employee EE date of hire 1/24/24. No documentation for TB testing; -Employee FF date of hire 3/10/23. No documentation for TB testing; -Employee GG date of hire 3/20/24. First step TB test completed on 3/27/24 and read negative on 3/29/24. No documentation of a second step TB test; -Employee HH date of hire 2/24/23. No documentation for TB testing. During an interview on 4/23/24 at 7:48 A.M., the ADON said that she expects new hires to have the Tuberculosis Screening per policy. The process is done in 2 steps and there is one to three weeks between them. The Director of Nursing (DON), ADON, Unit Managers (UM), and the wound nurse could administer, assess, and document the results of the testing. The importance of the testing is to prevent the spread of the disease.

Based on interview and record review, the facility failed to complete a comprehensive resident assessment for one of 12 residents investigated for comprehensive assessment completion (Resident #30). The census was 92. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-Admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the Admission assessment, the MDS Completion Date must be no later than 13 days after the entry date; -Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). Review of Resident #30's medical record, showed: -admitted [DATE]; -An annual MDS assessment, dated 4/1/24 with ARD date 2/24/24, in progress. During an interview on 4/22/24 at 10:09 A.M., the MDS Coordinator said she has been the MDS Coordinator for 5 years. The facility just hired a new MDS staff who is in training. She has been the only MDS Coordinator since 2021. If an MDS shows in progress, this means it either still needs to be completed or needs to be signed off on. Comprehensive MDS assessments are completed on admission and at least annually. She is aware she is behind on MDS assessments. The facility has been without a social worker for about a year and a half, so the business office manager, director of rehab, and herself have been filling the role.

Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address specific needs of the residents for two of 19 sampled residents (Residents #175 and #59) and one of three sampled closed records (Resident #174). The census was 92. 1. Review of Resident #175's medical record showed: -admitted on [DATE]; -Diagnoses included encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (deepest layer of the skin), severe sepsis (complication of an infection) without septic shock (widespread infection causing organ failure and dangerously low blood pressure), iron deficiency anemia (low red blood cells) secondary to blood loss, unspecified open wound left leg, necrotizing fasciitis (serious bacterial infection that destroys tissue under the skin), muscle weakness, and difficulty walking. Review of the resident's electronic Physician's Orders Sheet (ePOS), dated April 2024, showed: -An order dated 2/28/24, for Roxicodone (opioid, treats severe pain) oral tablet 5 milligram (gm). Give two tablet by mouth every six hours as needed (PRN) for severe pain; -An order dated 3/29/24, to cover lower left extremity wound with normal saline (NS), apply xeroform gauze (fine mesh gauze used on low drainage wounds) and bacitracin (topical antibiotic ointment) to entire wound, cover with dry kerlix (dry sterile bandage roll) and secure with ace wrap (compression bandage designed to wrap snugly). Change daily and PRN, every day shift for necrotizing fasciitis. Review of the resident's progress notes, showed: -On 2/28/24 at 10:03 P.M., resident admitted to room via stretcher from the hospital. Resident alert and oriented x 3-4 (person, place, time, situation). Skin assessment done. Resident has wound to lower left leg with approximately 111 staples. Dressing done. All medications verified; -On 3/25/24 at 1:36 P.M., met with resident today related to requesting housing. At this time, resident does not have income. He/She was made aware that social services will assist and refer him/her to a program after income starts. Per resident statement, he/she had no stable prior living arrangements and previously worked at McDonalds. He/She plans to remain long term care (LTC) at this time. Will continue to follow up as needed; -On 4/17/24 at 1:36 P.M., office visit with resident today to check on well-being. Resident is pleasant but sad stating he/she would like to go home. At this time, resident does not have a home to go to. He/She is currently applying for Social Security disability benefits. Social services made him/her aware that assist will be offered to help him/her with housing once income is established. Resident states he/she has family support but sometimes gets upset with his/her sibling. He/She is unable to live with his/her family and wants his/her own place. Resident made aware this writer is here for room visits and to offer assistance. He/She also agreed to behavioral health services. Nurse Practitioner in office after visit and signed new patient referral and will write order. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Activities of Daily Living (ADL) assistance and therapy services needed to maintain or attain the highest level of function; -Goal: Resident wishes to attain prior level of function; -Interventions: Assist with mobility and ADLs as needed. Therapy services as ordered; -Focus: Resident express pain/discomfort related to (blank); -Goal: The resident will express pain relief; -Interventions: Evaluate the effectiveness of pain interventions. Pain medications as ordered; -The care plan did not show focus, goals, and interventions related to the resident's diagnosis of Necrotizing Fasciitis of the lower left extremity, discharge planning goals, and mental health concerns. Location of pain cause was not documented. Observation and interview on 4/17/24 at 11:47 A.M., showed the resident in his/her bed. He/She had a bandage wrapped around the left leg. The dressing was dated 4/16. Drainage visible on the bottom of the wrapped leg that leaked onto the resident's sheet. The resident said he/she had a skin graft (donor tissue surgically applied to an area of tissue loss). He/She receives pain medication. He/She was trying to figure out what is next after his/her treatment. He/She had no care plan meeting with staff. Observation and interview on 4/18/24 at 8:10 A.M., showed the resident in his/her bed. The left leg wrapped in ace wrap, no drainage noted. Resident said he/he was in pain and always had pain with his/her leg. 2. Review of Resident #59's medical record, showed: -admitted on [DATE]; -Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body) following unspecified cerebrovascular disease (disease of the vascular system in the brain) affecting left dominant side, dysphagia (difficulty swallowing) following other cerebrovascular disease, gastrostomy status (tube surgically inserted into the stomach for fluid, medications, and nutrition), other speech and language deficits following stroke, and need for assistance with personal care. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 2/21/24, showed: -Diagnoses included stroke, hemiplegia or hemiparesis, high blood pressure, and heart failure; -No swallowing disorders; -Nutritional approaches: Feeding tube; -Proportion of total calories the resident received through parenteral (administered or occurring elsewhere in the body than the mouth and alimentary canal) or tube feeding: 51% or more; -Average fluid intake per day by intravenous (IV) or tube feeding: 501 cubic centimeter (cc)/day or more. Review of the resident's ePOS, dated April 2024, showed: -An order dated 11/14/23, for enteral feed (tube feeding) order every four hours. Verify position of enteral access device by comparing the documented length or numerical marking at the exit site of the device to the previously documented length. If changes have occurred and concern for migration exist, contact provider; -An order dated 11/14/23, enteral feed order for every 8 hours as needed. Verify position of enteral access device prior to feeding/medication administration, compare documented length or numerical marking at the exit site to the previously documented length. If changes have occur/concern for migration, contact provider; -An order dated 11/14/23, for enteral feed order every day shift. Assess the tube exit site for new or increasing pain and signs of skin breakdown, redness, edema (swelling), leakage, induration (when soft tissue becomes thicker), bleeding, and wear and tear; -An order dated 11/14/23, for enteral feed order every shift. Administer at least 15 milliliter (ml) of purified water via enteral access device after administration of each medication; -An order dated 11/14/23, for enteral feed order every shift. At least 15 ml purified water flush before and after medication administration; -An order dated 11/14/23, for enteral feed order every shift. Check residual at beginning of shift and record amount. Flush tube with 30 ml of water following residual check. Notify physician if residual is greater than 60 ml or if resident has nausea, abdominal distension (bloating or swelling) or bleeding; -An order dated 11/14/23, for enteral feed order every shift. Head of bed elevated at least 30 degrees; -An order dated 11/14/23, for enteral feed order every shift. If percutaneous endoscopic gastrostomy (PEG, feeding tube through the skin and stomach wall) tube bumper not snugly against the skin, hold tube firmly with one hand and slide the bumper against the abdominal with the other. Do not place bumper too tightly against skin as it will result in skin breakdown; -An order dated 11/14/23, for enteral feed order every shift. Verify position of external bumper on PEG tube. Bumper to remain snugly flush against abdominal with dry slit gauze placed underneath; -An order dated 12/19/23, for regular diet, puree (smooth, crushed, or blended food) texture. Add ice cream to lunch and dinner tray for nutrition; -An order dated 4/6/24, for Jevity 1.5 calorie (therapeutic nutrition that provides complete, balanced nutrition for long or short term tube feeding)/fiber oral liquid, nutritional supplement. Give 237 ml by mouth after meals and at bedtime for one hour after meals. Review of the resident's progress notes, showed: -On 4/14/24 at 10:27 A.M., alert and oriented 1-2 to self. Able to make some needs known. Dysphagia present. Take medication by mouth. Gastric tube (G-tube, feeding tube) patent and intact flushes without difficulties. Jevity bolus (single, large dose of medicine) 237 ml given and tolerated well; -On 4/6/24 at 2:36 P.M., resident can take medicine by mouth per physician. New order Bolus feed x 4 at bedtime. Observation on 4/18/24 at 8:08 A.M., showed the resident lay in bed. He/She was served a puree meal. Observation on 4/17/24 at 1:10 P.M., showed the resident in his/her room and ate a meal. He/She was served a puree meal on a divided plate. Jevity 1.5 bottle sat on the bedside table next to the bed. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident is at risk for rehospitalization due to (blank); -Goal: Resident will not have an avoidable rehospitalization related to current medical diagnosis within the first 30 days; -Interventions: Interdisciplinary team to meet as needed to discuss resident's condition and interventions. Labs as ordered. Staff to provide timely communication to physician and nurse practitioner regarding any change in resident condition; -Focus: Resident is at risk for falls; -Goal: Blank; -Interventions: Blank; -Focus: Bowel incontinence; -Goal: Will have no skin breakdown related to bowel incontinence; -Interventions: Blank; -The care plan did not show focus, goals, and interventions related to the resident's dietary status, difficulty swallowing, and PEG tube. There was no documentation of the resident's rehospitalization , falls, and bowel incontinence focus, goals, and interventions. 3. Review of Resident #174's medical record, showed: -admitted on [DATE]; -Diagnoses included encounter for surgical aftercare following surgery on the respiratory system, malignant (cancer) neoplasm of pharynx (throat), tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) status, cognitive communication deficit; -discharged on [DATE]. Review of the resident's hospital record, dated 1/16/24, showed patient with pharyngeal (pharynx) mass, dysphagia, and weight loss who presented 1/16/24 for planned awake tracheotomy, direct laryngoscopy (procedure to examine the larynx (voice box), PEG and biopsy. Biopsy showed p16 (tumor suppressor protein) negative invasive keratinizing (cancer cells producing keratin) squamous cell carcinoma (SCC, skin cancer). Computed Tomography (CT, diagnostic imaging test) chest and neck performed showing large heterogeneously (different gene mutations (changes) cause the same disease or condition) enhancing mass extending from the right posterior oropharynx (middle part of the throat) inferiorly to involve the hypopharynx (bottom part of the pharynx) and supraglottic (upper part of the larynx) larynx. Patient now status post total laryngectomy with bilateral neck dissection, right pharyngectomy (surgery to remove all or part of pharynx) right thyroidectomy (surgical removal of all or part of the thyroid gland), right anterolateral (both anterior and lateral) thigh free flap and pharyngeal (group of muscles) repair on 1/29. Salivary bypass tube (directs the saliva into the distal esophagus and allows for spontaneous closure of the fistula) removed 2/9 and subsequent esophogram (x-ray of the esophagus) without leak. Review of the resident's progress notes, showed: -On 2/23/24 at 2:47 P.M., resident arrived via stretcher at 1:05 P.M. Resident alert and uses dry erase board for communication. Resident with [NAME] box (voice box), and g-tube. Physician here and reviewing discharge orders at this time. Received call from physician with reports of follow up radiation oncology appointment on 2/28/24 at 10:30 A.M.; -On 2/22/24 at 3:33 P.M., call to resident's adult child for care plan and pre discharge planning. Resident's children have moved into home and will be primary caretakers for him/her. Resident lives in a house with bedroom and bathroom on main level. There are 3 steps, walkway and 5 steps to enter house. Patient has no durable medical equipment (DME) at home. Adult Child stated patient has never had to use any DME prior to hospitalization . Patient uses store delivery for medications. Adult Child inquired about activating Medicaid for chore worker services when discharged home. Referred to Business Office Manager (BOM). Educated on education needed for [NAME] tube (flexible silicone tube designed to maintain the stoma right after the laryngectomy surgery) care and g-tube care. Adult Child requested patient to also learn how to administer tube feeding herself. Stated when visits the resident, will ask nurses to start [NAME] tube and g-tube training. Explained to adult child since resident receives an oral diet and tube feeding insurance will not pay for tube feeding at home and recommendations will be made at time of discharge. Home health for physical therapy (PT)/ occupational therapy (OT) and speech therapy (ST) referrals will be made and any equipment needed will be ordered closer to discharge date . Adult child had no further questions/concerns at this time; -On 2/24/24 at 3:43 P.M., resident remains on observation for new admit. Resident has [NAME] tube in place suctioned x 3. Disposable tube changed during this shift. Bed side commode placed in resident room. Resident assisted x 3 to commode during this shift. Resident is nonverbal, but able to write all needs down on paper; -On 3/12/24 at 2:48 P.M., home health referral sent to company and wheelchair request along with trach supplies sent to medical company for pending discharge home 3/15. Requested wheelchair be delivered to the facility; -On 3/13/24 at 10:53 A.M., met with patient and niece this morning with MDS and Director of Rehabilitation (DOR) to discuss discharge for 3/15. Patient's family is to speak with adult child to have him/her come tomorrow for training in [NAME] tube and g-tube and for training with therapy. Home health referrals sent to companies; -On 3/13/24 at 1:50 P.M., spoke with nurse practitioner regarding tube feeding orders for discharge. Received orders Ensure plus (nutritional health shake) 4 cans/day with calories goal of 1200-1500 calories per day; -On 3/21/24 at 5:11 P.M., instructed resident on how to remove and replace Heat Moisture Exchange (HME, provide humidification to adult tracheostomy patients) cap while [NAME] tube has been removed for cleaning, repeat demonstration given successfully; -On 3/22/24 at 11:49 A.M., resident left via stretcher at 11:20 A.M. for radiation. Ambulance to transport resident home after radiation treatment. Resident's family at his/her bedside and this nurse sent remaining medications and discharge instructions home after reviewing all with him/her. States nurse to meet family at home for continuing care. Resident provided [NAME] tube care this morning, suctioned per his/her request, had puree diet with good food and fluid intake. Resident also administered all peg-tube medications per order without difficulty. Resident alert and appeared stable upon leaving. Review of the resident's ePOS, dated April 2024, showed: -An order dated 2/23/24, for enteral feed order as needed. Enteral access site care; verify tube securement in place; -An order dated 2/23/24, for enteral feed order every six hours, 200 ml water/ hour via peg tube; -An order dated 2/23/24, for enteral feed order every day shift. Assess the tube exit site for new or increasing pain and signs of skin breakdown, redness, edema, leakage, induration, bleeding, and wear and tear; -An order dated 2/23/24, for enteral feed order every day shift. Enteral access site care. Verify tube securement is in place; -An order dated 2/23/24, for enteral feed order every shift. Administer at least 15 ml of purified water via enteral access device after administration of each medication; -An order dated 2/23/24, for enteral feed order every shift. At least 15 ml purified water flush before and after medication administration; -An order dated 2/23/24, for enteral feed order every shift. Check residual at beginning of shift and record amount. Flush tube with 30 ml of water following residual check. Notify physician if residual is greater than 60 ml or if resident has nausea, abdominal distension or bleeding; -An order dated 2/23/24, for enteral feed order every shift for nutrition nocturnal tube feeding. Jevity 1.5 start 8:00 P.M. to 6:00 A.M. at 40 cc. Increase as tolerated in 12-24 hours to 60 cc; -An order dated 2/23/24, for enteral feed order every shift. Head of bed elevated at least 30 degrees; -An order dated 2/23/24, for enteral feed order every shift. Verify position of external bumper on PEG tube. Bumper to remain snugly flush against abdominal with dry slit gauze placed underneath; -An order dated 2/23/24, for enteral feed order two times a day for feedings. Jevity 1.5 bolus 240 ml via gravity twice a day (BID); -An order dated 2/23/24, may suction [NAME] stoma as needed; -An order dated 3/12/24, for high humidity [NAME] (HHC) at 35%. Review of the resident's care plan and in use during the resident's stay, showed: -Focus: Resident is at risk for falls; -Goal: blank; -Interventions: Assist with ADLs as needed. Call light within reach. Complete fall risk assessment. Education provided to dietician on safe weighing of residents; -Focus: At risk for weight fluctuation related to current health status; -Goal: Resident wishes to maintain current weight; -Interventions: Diet order (blank). Enteral feeding as ordered; -Focus: At risk for respiratory illness related to recent hospitalization ; -Goal: blank; -Interventions: Monitor for change in condition and notify practitioner of findings; -The care plan did not show focus, goals, and interventions related to the resident's dietary status, [NAME] tube, current radiation treatments, and discharge planning. There was no documentation of the resident's rehospitalization and fall goals. 4. During an interview on 4/23/24 at 9:54 A.M., the Administrator said she would expect the dietary, [NAME] tube, g-tube, and discharging planning to be care planned. Each department is expected to go and address the needs of the resident. The MDS coordinator is responsible for going over the care plans. 5. During an interview on 4/23/24 at 10:47 A.M., MDS Coordinator said she updates the care plans annually and quarterly. She also works with nursing when updating the care plans. A resident's use of g-tube is care planned. Any dietary needs such as mechanical or renal (kidney) diets are expected to be care planned. After the admission MDS is completed, she will complete the care plan. Nursing is also able to enter information and possibly the Certified Nurse Aides (CNA), but they have access to Kardex (summary of patient information such as medications, clinical follow up, and daily care schedules). The information on the Kardex comes from the care plan. Discharge planning is expected to be on the care plan. The MDS Coordinator confirmed that Resident #174 had only a baseline care plan. She would expect the care plans to meet the resident's medical, nursing, and mental psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plans are expected to be completed timely.

Based on interview and record review, the facility failed ensure a safe resident discharge to the community by failing to ensure referrals to local contact agencies and orders for medical equipment were sent timely for one of two residents reviewed with an order to discharge home (Resident #174). The resident was discharged without home health set up or durable medical equipment after a change in the discharge date . This has the potential to affect all residents who discharge from the facility. The census was 92. Review of the facility's Discharge Plan policy, reviewed 8/9/23, showed: -Policy: The discharge planning process will address each resident's discharge goals and needs including caregiver support and referrals to local contact agencies, as appropriate, and involves the resident and if applicable, the resident representative and the interdisciplinary team in developing the discharge plan; -Procedure: Identify the patient's needs and goals regarding discharge upon or as soon as practicable after admission; -Social Services or Care Management associates will complete the initial discharge plan evaluation form within 48 hours of admission to collect data that will assist in development of the discharge plan; -The Discharge Plan is incorporated into the Interdisciplinary Care Plan. It originates on the baseline care plan and will be included on the patient's comprehensive care plan, once developed; -Involve the patient and patient representative. Consider the patient's support/care giver's availability, capacity, and capability to perform required care when identifying discharge needs. Document the patient/patient representative involvement in the discharge plan development; -Involve other interdisciplinary team (IDT) members in the identification of needs and development of the plan. The IDT should include but is not limited to: -The attending physician; -The registered nurse (RN) with responsibility for the patient; -The nurse aide with responsibility for the patient; -A member of food and nutrition services staff; -To the extent it is practicable the patient and their representative; if this is not practicable document why; -Other appropriate staff or professionals in disciplines as determined by the patient's needs or as requested by the patient; -After the needs and goals are identified, ensure this results in the development of a discharge plan for the patient; -Address the patient's goals and treatment preferences in the plan; -Inform the patient and patient's representative of the final plan; -Document that the patient has been asked about their interest in receiving information regarding returning to the community; -Document any referrals to local contact agencies or other appropriate entities made based on the patient's choices and interest returning to the community; -Document if the discharge to the community is not feasible, who made the determination, and why; -Involve the patient, patient's representative, and the IDT with any re-evaluation of the patient's needs or goals that require modification of the discharge plan and update the plan as needed; -Document the date and any updated information in the discharge plan; -Include if the discharge plan was updated based on information received from referrals to local contact agencies or other appropriate entities; -The discharge plan will identify the discharge destination, and ensure it meets the residents' health and safety needs as well as preferences. If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs or appears unsafe, the facility must: -Discuss with the resident, (and/or representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to get the information as to why the resident is selecting that location; -Document that other, more suitable options of locations that are equipped to meet the needs of the resident were presented and discussed; -Document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings; -Determine if a referral to Adult Protective Services or other state entity charge with investigating abuse and neglect is necessary. The referral will be made at the time of discharge, if appropriate. Review of Resident #174's medical record, showed: -admitted on [DATE]; -Diagnoses included encounter for surgical aftercare following surgery on the respiratory system, malignant (cancer) neoplasm of pharynx (throat), tracheotomy (procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) status, cognitive communication deficit; -discharged on [DATE]. Review of the resident's hospital record, dated 1/16/24, showed patient with pharyngeal (pharynx) mass, dysphagia (difficulty swallowing), and weight loss who presented 1/16/24 for planned awake tracheotomy, direct laryngoscopy (procedure to examine the larynx (voice box), Percutaneous Endoscopic Gastrostomy (PEG, feeding tube) and biopsy. Biopsy showed p16 (tumor suppressor protein) negative invasive keratinizing (cancer cells producing keratin) squamous cell carcinoma (SCC, skin cancer). Computed Tomography (CT, diagnostic imaging test) chest and neck performed showing large heterogeneously (different gene mutations (changes) cause the same disease or condition) enhancing mass extending from the right posterior oropharynx (middle part of the throat) inferiorly to involve the hypopharynx (bottom part of the pharynx) and supraglottic (upper part of the larynx) larynx. Patient now status post total laryngectomy with bilateral (both sides) neck dissection, right pharyngectomy (surgery to remove all or part of pharynx), right thyroidectomy (surgical removal of all or part of the thyroid gland), right anterolateral (both anterior and lateral, front and side) thigh free flap and pharyngeal (group of muscles) repair on 1/29. Salivary bypass tube (directs the saliva into the distal esophagus and allows for spontaneous closure of the fistula) removed 2/9 and subsequent esophogram (x-ray of the esophagus) without leak. Review of the resident's care plan and in use during the survey, showed the care plan did not show focus, goals, and interventions related to the resident's discharge planning. Review of the resident's progress notes, showed: -On 2/23/24 at 2:47 P.M., resident arrived via stretcher at 1:05 P.M. Resident alert and uses dry erase board for communication. Resident with [NAME] box (artificial voice box), and gastric tube (g-tube, feeding tube). Physician here and reviewing discharge orders at this time. Received call from physician with reports of follow up radiation oncology appointment on 2/28/24 at 10:30 A.M.; -On 2/22/24 at 3:33 P.M., call to resident's adult child for care plan and pre discharge planning. Resident's children have moved into home and will be primary caretakers for him/her. Resident lives in a house with bedroom and bathroom on main level. There are 3 steps, walkway and 5 steps to enter house. Patient has no durable medical equipment (DME) at home. Adult child stated patient has never had to use any DME prior to hospitalization . Patient uses store delivery for medications. Adult child inquired about activating Medicaid for chore worker services when discharged home. Referred to Business Office Manager (BOM). Educated adult child on education needed for [NAME] tube (flexible silicone tube designed to maintain the stoma right after the laryngectomy surgery) care and g-tube care. Adult child requested patient to also learn how to administer tube feeding him/herself. Adult child stated when visits the resident, will ask nurses to start [NAME] tube and g-tube training. Explained to adult child since resident receives an oral diet and tube feeding, insurance will not pay for tube feeding at home and recommendations will be made at time of discharge. Home health for physical therapy (PT)/ occupational therapy (OT), and speech therapy (ST) referrals will be made and any equipment needed will be ordered closer to discharge date . Adult child had no further questions/concerns at this time; -On 3/12/24 at 2:48 P.M., home health referral sent to company and wheelchair request along with trach supplies sent to medical company for pending discharge home 3/15. Requested wheelchair be delivered to the facility; -On 3/13/24 at 10:53 A.M., met with patient and family this morning with Minimum Data Set (MDS) and Director of Rehabilitation (DOR) to discuss discharge for 3/15. Patient's family is to speak with adult child to have him/her come tomorrow for training in [NAME] tube and g-tube and for training with therapy. Home health referrals sent to companies; -On 3/13/24 at 1:50 P.M., spoke with nurse practitioner regarding tube feeding orders for discharge. Received orders for Ensure plus (nutritional health shake) 4 cans/day with calories goal of 1200-1500 calories per day; -On 3/15/24, (no documentation the resident was discharged or why the discharge date changed. No documentation the home health or DME companies were notified of the new discharge date ); -On 3/21/24 at 5:11 P.M., instructed resident on how to remove and replace Heat Moisture Exchange (HME, provide humidification to adult tracheostomy patients) cap while [NAME] tube has been removed for cleaning, repeat demonstration given successfully; -On 3/22/24 at 11:49 A.M., resident left via stretcher at 11:20 A.M. for radiation. Ambulance to transport resident home after radiation treatment. Resident's niece at his/her bedside and this nurse sent remaining medications and discharge instructions home after reviewing all with him/her. States nurse to meet family at home for continuing care. Resident provided [NAME] tube care this morning, suctioned per his/her request, had puree diet with good food and fluid intake. Resident also administered all peg-tube medications per order without difficulty. Resident alert and appeared stable upon leaving; -No documentation of change to resident's discharge date or home health referrals sent for an anticipated discharge date of [DATE]. Review of the resident's discharge order, dated 3/11/24, showed: -Discharge home with family, with home health, status post laryngectomy and esophagectomy (removal of part or all esophagus); -Expected to discharge on 3/15/24; -The following services are medically necessary home health services: -Physical therapy evaluation and treat; -Occupational therapy evaluation and treat; -Speech therapy evaluation and treat; -Registered nurse; -Evaluate and treat on disease process management with a focus strength and balance as it applies to home safety and independence with activities of daily living (ADLs); -Evaluate and treat on disease state management regarding education and instruction on intravenous (IV), j-peg, g-tube, tracheostomy care, and ostomy care; -Patient will need the following medical equipment: -Wheeled walker; -Trach supplies for [NAME] tube; -Two referrals for home health were faxed on 3/11/24 with a documented discharge date of [DATE]. Review of the resident's discharge summary, dated 3/18/24, showed: -discharged to home; -Accompanied by family; -Reason for discharge: Patient's health improved sufficiently so patient no longer needs services provided by facility; -Special instructions: [NAME] tube, g-tube care and administration of medications and food; -Cognitive status: Resident understands and able to communicate his/her needs; -Nutritional status: Nocturnal PEG tube feeding and bolus during wake hours; -Patient needs, strength, goals, life history, and preferences: Resident progressed in skilled therapy; -Participants in patient's assessment: Resident included and educated; -Additional discharge planning information: Continue radiation per schedule. Resident to follow up with his/her primary doctor within 7-10 days of discharging home; -Does patient need outpatient rehab services after discharge: yes; -Follow-up physician care: Call physician to schedule an appointment; -Recapitulation of stay: blank; -Rehabilitation/therapy: blank; -Copy of instructions given to: blank; -Name of patient/patient representative giving consent: blank; -Received by and date: blank; -Nurse signature and date: blank. Review of the resident's medical record, showed no documentation of an updated home health referral with the resident's new discharge date . During an interview on 3/29/24 at 1:55 P.M., Hospital Representative V said the resident presented to the hospital after he/she was sent home from the facility without proper equipment. Emergency medical services dropped him/her off at home but did not leave him/her at home because he/she did not have the necessary equipment delivered to care for him/herself (oxygen, suction, etc.). During an interview on 4/23/24 at 9:22 A.M., the Social Services Director said she had been at the facility for only three weeks. There was no Social Service Director at the time when she arrived. It had been a long time since the facility had one. If a resident is ready to be discharged , there is a 72 hour care plan if a referral is needed, she will ask the resident their discharge plan and go over it in the 72 hour care plan meeting. They try to send out the referral right away. They home health agencies need a discharge date so it cannot be sent too early. She likes to do it after the 72 hour care plan. If there are already services in place, then she will notify home health agency and let them know they are going home. If the resident does not discharge on their anticipated date, she will either call or email the home health agency and document it in the record. If there is a delay in discharge, the home health agency would let her know if they have anything available or not. If not, she would notify the family and let them know they would have to use another agency. The DME takes a while, but she will put the orders in. She cannot promise it will be available, the facility tries to work something out with the family. During an interview on 4/23/24 at 10:40 A.M., the Administrator would expect the referrals to be resent if the discharge date was changed. MO00233936

Based on observation, interview and record review, the facility failed to provide care and services related to communication, by failing to provide speech assistive devices for one of one sampled resident (Residents #32) who is deaf. The facility also failed to ensure staff were knowledgeable on how to locate information regarding how the resident communicated with staff. The census was 92. Review of Resident #32's quarterly assessment Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/14/24, showed: -Hearing highly impaired- absence of useful hearing; -Diagnoses included stroke, high blood pressure, and seizures; -No hearing aid or other hearing appliances used. Review of the resident's care plan, dated 5/30/19, showed: -Focus: I have a hearing deficit/deaf and I have difficulty understanding. I prefer to have an American Sign Language (ASL) interpreter to assist me with understanding; -Goal: My needs will be anticipated and met by staff by next review date, and I will be able to communicate my needs through next review date; -Interventions: Anticipate and meet needs, be conscious of resident position when in groups, activities, dining room to promote proper communication with others, allow adequate time to respond, repeat as necessary, do not rush, requestion clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off TV/radio to reduce environmental noise, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. Review of the MDS Kardex Report (a report to direct care staff on how to care for residents), printed 4/22/24, showed: -Communication is highly impaired; -No directions/guidance on how to communicate with the resident. During an observation and interview with the resident on 4/17/24 at 11:20 A.M., it was noticed that the resident had difficulty hearing questions, would make grunt like noises, and point. The resident pointed to his/her ears and said deaf. He/She was able to convey that he/she could read lips but not very well. There was no communication device available to the resident during the interview. With written questions on paper, the resident was able to answer yes and no questions. The resident communicated that he/she liked living at the facility, had no complaints, and the staff treated him/her well. During an interview on 4/19/24 at 9:09 A.M., Certified Nursing Assistant (CNA) G said that he/she is aware that the resident is deaf. He/She gets information on how to care for the residents from the nurses during report. He/She is not aware of other resources available to get information regarding care for the residents. During an interview on 4/19/24 at 9:09 A.M., CNA H said he/she worked for a staffing agency and is aware that there is a resident who is deaf. He/She gets information on resident care while listening to report from the nurses and information from full-time staff. He/She works on different floors at the facility and is unaware of resources available regarding resident care. During an interview on 4/22/24 at 10:49 A.M., the Administrator provided a Kardex for the resident. She said that the interventions on the care plan have not been transferring over to the Kardex and this is something that she and the Director of Nursing (DON) would be addressing. She expects the staff to review to the Kardex, that is located in the computer, when performing resident care. During an interview on 4/23/24 at 7:31 A.M., CNA I said that he/she gets information from the nurse during report or reviews the report sheet. He/She does not have access to the computer and is unaware of other resources to get information on resident care. CNA I said being able to communicate allows the staff to know if the resident is hungry, needs to use the restroom, take a shower, or needs to be turned. During an interview on 4/23/24 at 7:41 A.M., Registered Nurse (RN) J said that he/she gets information about resident care during report. He/She has access to the Care Plan in the computer. During an interview on 4/23/24 at 7:46 A.M., the Assistant Director of Nursing (ADON) said that she expects the staff to access the computer and to review the Kardex to provide care to the residents. She is aware that there are CNAs who do not have access to the computer. The ADON said she expects the staff to report if they are unable to access the computer and it is her responsibility to create access for the CNAs.

Based on observation, interview, and record review, the facility failed to implement Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) recommended infection control practices in order to control and prevent the potential spread of COVID-19 amongst the facility residents and staff. The facility allowed staff to work and provide care to residents after reporting COVID-19 symptoms and/or fevers, failed to thoroughly screen staff for COVID-19 prior to caring for residents in the facility, and failed to ensure staff providing care to residents and working in resident areas wore appropriate PPE. A determination was made that the facility's noncompliance with one or more of the requirements of participation placed all residents in the facility in immediate jeopardy. On [DATE] at 2:30pm, the Administrator was informed of the immediate jeopardy at F880, Infection Prevention and Control. The IJ was found to have started on [DATE] with the failures to appropriately screen staff for signs and symptoms of COVID-19 and prevent staff who were ill and/or COVID-19 positive from caring for the residents. Findings include: On [DATE] at 10:27am, the Administrator and Director of Nursing (DON) indicated that the facility experienced an outbreak of COVID-19, beginning in late March. The facility experienced 41 positive cases, of which seven residents died . The Administrator and DON indicated that during the outbreak, any positive residents were quarantined on the 4th floor. The Administrator and the DON indicated that the facility did not have any active cases of COVID-19 at the time of survey, and transferred the residents after they were asymptomatic from the 4th floor to the 2nd or 3rd floors. Following the outbreak, the 2nd floor of the facility was the clean floor, and that the 3rd floor was the unknown, or under observation for COVID-19, floor. The Administrator and the DON indicated that on the 2nd floor, staff were expected to appropriately wear a facemask when providing care to residents. On the 3rd floor, staff were expected to wear full PPE, consisting of an N95 respirator mask, disposable shoe covers, a gown, hairnet, gloves, and eye protection when assisting residents. Staff may wear an appropriately applied disposable surgical mask when in common areas, not providing resident care. The Administrator and DON indicated that a Physical Therapy Assistant (PTA1) recently tested positive for COVID-19. On [DATE] at 8:40am, Licensed Practical Nurse (LPN1), who stood at the medication cart on the second floor, pulled her N95 respirator mask down, exposing her mouth and nose. LPN1 indicated that the facility had an outbreak of COVID-19 about one to two months ago. LPN1 indicated that maybe 20 residents contracted the disease, and that they were quarantined on the 4th floor of the facility for 14 days. LPN1 indicated that over the weekend, all of the residents on the 4th floor were moved back downstairs because the quarantine was over. LPN1 indicated that staff must wear full PPE when entering resident rooms. LPN1 indicated that she knew pulling her facemask down to expose her mouth and nose was not proper mask usage, and could expose herself and/or other residents to possible contagions. On [DATE] at 9:00am, Maintenance staff (M1) left resident room [ROOM NUMBER] after cleaning the room. M1 wore a disposable gown, gloves, and a disposable surgical mask. M1 failed to change her gloves and sanitize her hands after leaving the room. M1 then entered resident room [ROOM NUMBER] and began cleaning, continuing to wear the same gloves. M1 cleaned the bathroom of room [ROOM NUMBER]. M1 indicated that she failed to change her gloves and sanitize her hands after cleaning room [ROOM NUMBER], indicating that normally, she only would change her gloves. M1 also indicated that the facility provided her with an N95 respirator, but that she chose to wear disposable surgical masks, because the N95 was uncomfortable, and that she had hot flashes and couldn't wear them. On [DATE] at 9:05am, Occupational Therapy Assistant (OTA1) indicated that the facility had an outbreak of COVID-19 in March and April. All residents who were positive were moved to the 4th floor. OTA1 indicated that approximately 30 residents required quarantine because of COVID-19. OTA1 indicated that facility staff must wear PPE with all residents, due to the recent outbreak. OTA1 indicated that a Physical Therapy Assistant( PTA1) tested positive for COVID-19 last week, and had been working with residents prior to her test. On [DATE] at 9:10am, the Central Supply (CS) supervisor stepped out of the elevator onto the 2nd floor. The CS supervisor wore only a disposable surgical mask, and failed to wear any other PPE. The CS supervisor indicated that the expectation of facility staff was that all staff were to wear gowns and facemasks while on the 2nd and 3rd floors, because of the COVID-19 outbreak. On [DATE] at 9:15am, Nurse Aide (NA1) exited the elevator onto the 3rd floor. NA1 walked from the elevator, past the nursing station, and to an empty office area. NA1 wore a disposable surgical mask, but failed to wear any other PPE. At 9:20am, NA1 indicated that she escorted a resident downstairs to the transportation van, disposed of her other PPE, and had failed to don more before entering the 3rd floor. On [DATE] at 9:25am, the Administrator and the CS supervisor exited the elevator onto the 3rd floor. Both wore disposable surgical masks, and failed to wear any other PPE. On [DATE] at 9:27am, LPN2 wore a disposable surgical facemask. LPN2 indicated that the facility provided her with an N95 respirator, but chose not to wear it because it was uncomfortable. Two boxes of N95 respirators sat on the counter of the nursing station. On [DATE] at 9:35am, LPN2 stood at the medication cart and finished preparing medications for a resident. LPN2 then took the prepared medications and entered resident room [ROOM NUMBER], wearing eye protection, a gown, an N95 respirator, and disposable shoe covers. LPN2 failed to wear gloves while giving the resident their medications. On [DATE] at 9:40am, LPN1 sat at the computer at the nursing station. LPN1 wore a facemask, however, the mask was pulled beneath her chin, leaving her mouth and nose exposed. On [DATE] at 10:25am, the CS supervisor indicated that the facility had not experienced a shortage or low levels of PPE. The CS supervisor indicated that the facility had a sufficient supply of PPE and had five or six days of backup PPE. On [DATE] at 11:48am, the Administrator and DON indicated that the expectation of facility staff was to wear PPE appropriately and perform hand hygiene after leaving resident rooms. - Review of staff screening sheets documented that the facility permitted staff to work while feverish or reporting signs or symptoms of COVID-19: 1. On [DATE], the facility failed to thoroughly screen 17 staff, one of which reported body aches, two reported sore throats, and one reported shortness of breath. None of the 17 staff had documented temperatures. 2. On [DATE], the facility failed to thoroughly screen two staff, who had temperatures taken, but failed to answer any screening questions. 3. On [DATE], a staff person documented a temperature of 100.3F on the screening sheet. The staff person documented no other signs or symptoms of COVID-19. Review of the staff person's time clock records documented that they worked from 6:35am to 2:42pm that day. 4. On [DATE], the facility failed to thoroughly screen six staff reporting for work, when the staff failed to answer screening questions. Additionally, the DON reported a temperature of 100.3F, and failed to answer any screening questions. Time clock records documented that the DON worked her scheduled shift that day. 5. On [DATE], the facility failed to thoroughly screen five staff reporting for work, when the staff failed to answer screening questions. 6. On [DATE], the facility failed to thoroughly screen four staff reporting for work, when the staff failed to answer screening questions. 7. On [DATE], the facility failed to thoroughly screen three staff, when the staff failed to answer screening questions. 8. On [DATE], the facility failed to thoroughly screen four staff, when the facility failed to ensure that two staff had their temperature taken before working and all four failed to answer screening questions. 9. On [DATE], the facility failed to thoroughly screen all staff when a staff person had an elevated temperature of 99.4F, reported that they had signs and symptoms of COVID-19, and that they had close personal contact with a person with a confirmed case of COVID-19. Review of the staff person's time clock records for [DATE] revealed that the staff person worked from 6:28am to 3:02pm that day. On [DATE] at 10:27am, the Administrator and DON indicated that the expectation of staff would be that all facility staff would be thoroughly screened prior to beginning a shift. Staff with a fever or who answered affirmatively to screening questions would be sent home, or would be more thoroughly screened by administrative staff. The DON indicated that she was not aware of any current issues with the screening process.

Based on interview and record review, the facility failed to provide the necessary care and services for one of three sampled residents. The facility failed to recognize and assess risk factors of a stroke, and failed to monitor, evaluate a resident's response to interventions, and revise the interventions as appropriate, causing a delay in the resident's transfer to the hospital (Resident #[AGE]0). The census was [AGE]. 1. Review of Resident #[AGE]0's quarterly Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff, dated 09/23/19, showed: -Brief interview of mental status (BIMS, a brief screener of cognition) score of 15 out of a possible 15 (cognitively intact); -Adequate vision, sees fine detail, including regular print in newspapers/books; -Independent with eating; -[DIAGNOSES REDACTED]. Review of the facility's 24 hour report sheet, used to inform nursing staff of resident's conditions, and/or new orders, showed the following resident condition entries for the resident: -On 12/2/19, Day shift noted ok; Evening shift noted Urgent X-ray of kidneys, ureter, and bladder (STAT KUB, an x-ray used to assess the organs of the urinary and gastrointestinal systems used to diagnose causes of abdominal pain); Night shift noted ok. Review of the resident's progress notes, showed: -On 12/2/19 at 7:02 P.M., resident got a STAT KUB done this shift for abdominal pain, results called to the primary care physician (PCP), new order for [MEDICATION NAME] 30 milliliters (ml) (used to relieve occasional constipation and irregularity, generally causes a bowel movement in 15 minutes to one hour), one time only for constipation and [MEDICATION NAME] (a medication used for nausea), 4 mg (milligrams) for nausea, one time only; -On 12/3/19 at 12:20 P.M., Certified Medication Technician (CMT) informed this nurse that the resident was having trouble seeing and following cues. This nurse entered the room and assessed the resident. The resident's coordination was off, he/she was unable to identify the cup to drink with medications, his/her eyes were favoring his/her right side, also noted with elevated respirations and wheezing (a high-pitched [MEDICATION NAME] sound made while breathing) present. NP notified with new orders for [MEDICATION NAME] (diuretic) 40 milligrams (mg) by mouth, one time, Douneb treatment (inhaled medicine used to open airways) and 2 view chest x-ray; Further review of the facility's 24 hour report sheet, showed the following resident condition entries for the resident: -On 12/3/19, Day shift noted Confused, respirations (breaths) elevated, visual deficit, Nurse Practitioner (NP) notified, new order to give [MEDICATION NAME] and chest x-ray; Evening shift did not write a note; Night shift noted, Patient confused, visual deficit. During an interview on 1[DATE] at 11:45 A.M., Certified Nurse Assistant (CNA) D said: -On 12/3/19, the CNA cared for the resident in the morning and noticed the resident was looking up and to the right. It appeared he/she could not see anything, and the resident was knocking items to the floor. The CNA reported the symptoms to the nurse on duty. During an interview on 1[DATE] at 12:14 P.M., CMT B said: -The resident was feeling poorly on [DATE], and showed a decline on 12/2/19. The CMT told Nurse A, who notified the NP; -On 12/3/19, the CMT reported to the nurse on duty, Nurse C, that the resident was confused and not able to see correctly or swallow his/her medications. Nurse C told the CMT to crush the resident's medications. The CMT was not sure if Nurse C notified the NP. Further review of the resident's progress notes, showed: -On [DATE] at 10:48 A.M., at 10:45 A.M., NP here in facility to assess resident regarding recent change in condition. Call placed to family member with request to send the resident to the hospital for evaluation related to stroke, vision changes, and left sided weakness. Further review of the facility's 24 hour report sheet, showed the following resident condition entries for the resident: -On [DATE], Day shift noted, Confusion, needs assistance with taking medication, has not been eating; Evening shift noted, Sent to hospital, left at 12:10 P.M. During an interview on 1[DATE] at 12:14 P.M., CMT B said: -On [DATE], the CMT told Nurse C the resident was not eating, was confused, and had a visual deficit. When Nurse C did not notify the NP, the CMT went and told Nurse A to come and evaluate the resident. Nurse A assessed the resident with the facility's staff development coordinator and notified the NP. During interviews on 1[DATE] at 12:06 P.M. and 12:55 P.M., Nurse A said: -CMT B asked him/her to evaluate the resident. He/she evaluated the resident and contacted the NP. -A change of condition was when a resident was acting abnormally from their baseline; -He/she would assess the resident, get a set of vitals, check the resident's medical history and recent progress notes to see if there was anything new that would explain the change in condition, hypothesize the situation, notify the PCP and family, obtain new orders and follow them; -The change of condition would be documented in the resident's medical record under progress notes and in the 24 hour report. During an interview on [DATE] at 2:15 P.M., the Director of Nursing said: -Nurses are expected to notify the physician and family members when a resident has a change of condition; -Nurses are expected to document the change of condition, the resident's assessment, who they notified, and what new interventions and/or new orders received in the progress notes; -Nurses are expected to use the SBAR tool (Situation: Clearly describe the resident's condition right now, including vital signs and head to toe assessment; Background: What is the clinical background information that is pertinent to the situation; Assessment: Nurse's conclusion on what the problem might be; and Recommendation: What would the nurse recommend); -Nurses are expected to make a note if a resident declines; they are not expected to write a note following up on the effectiveness of the new order or intervention; -Nurses are expected to follow facility policies. During an interview on [DATE] at 3:13 P.M., the nurse practitioner (NP) said: -On 12/3/19, the nurse reported the resident had wheezing and shortness of breath. The NP ordered the [MEDICATION NAME] treatment and a chest x-ray as the resident has a history of [MEDICAL CONDITION]. The NP did not recall the nurse informing her the resident had a change in vision, was unable to identify a cup to drink with medication, nor that the resident's coordination was off. If she was given report of those symptoms, the NP would have called the family and discussed sending the resident to the hospital, as she did on [DATE]; -On [DATE], the NP saw the resident in person, noted the vision changes and given his/her history of [MEDICAL CONDITION], suspected the resident had a stroke. The NP called the resident's family and discussed sending the resident out for emergency care; -When a resident has a change of condition, the NP expects nursing staff to assess the resident and give full report to herself or the PCP. Nurses can either call or tell the medical team personally as they are often in the building; -The NP expects nurses to follow the new orders, and reassess the resident's condition for effectiveness at least once a shift, as it is part of nursing care. If the resident does not show improvement, the NP expects them to notify her, or the physician; -The NP expects nursing staff to report a change of condition such as a vision change, and/or loss of coordination. Review of the resident's discharge hospital record, dated [DATE], showed: -admitted : [DATE]; -Discharge Diagnosis: [REDACTED]. During an interview on [DATE] at 2:06 P.M., the Administrator said nurses are expected to follow policy and report all symptoms of a change of condition to the NP or PCP. Review of the facility's change in resident's condition or status policy, dated 11/26/18 and reviewed on 4/15/19, showed: -Purpose: To outline the actions required to address a change in resident's condition or status; -Procedure: This facility will utilize the Lippincott Procedure: Change in status, identifying and communicating, long term care; -Lippincott Procedure: -The facility will utilize SBAR tool when assessing a resident's change of condition; -Nurses can anticipate some acute changes in status by identifying such risk factors such as chronic diseases, previous hospitalization s, and conditions identified through the medical history; -Chronic diseases and conditions can lead to potentially life-threatening conditions. It is nurses' responsibility to be informed of the resident's status and to monitor for changes; -At a minimum, staff should assess the resident by: Reviewing the medical record; Asking how the resident feels and what symptoms are present; Obtain vital signs; Observe the resident's overall condition, including function and cognition; Exploring complaints; -Every health care team member is responsible for communicating a resident's change in status from their baseline (normal); -Nurses are responsible for communicating a resident's change in status, including assessment finding, to the PCP; -Essential elements of professional communication promote diagnosis, care planning, care implementation, and continuity of care, including: -Reviewing the resident's history, medications, laboratory test results, treatments, and other significant information; -Providing details of the resident's current status using objective findings; -Using correct terminology and details; -Allowing for two-way communication; -Clarifying and questioning orders or feedback that isn't understood or seems inaccurate; -Documenting communication; -Vague, subjective communication can lead to mis[DIAGNOSES REDACTED]. -Document the acute change in status, behavioral changes, vital signs, and other assessment findings in the appropriate areas in the medical record. Record nursing interventions and the resident's response. MO 874