Every finding on record at Living Community of St Joseph

Based on observation and interview the facility failed to store food in accordance with professional standards for food service safety when the facility failed to ensure food items were dated with an open date or expiration date, and when the facility failed to dispose of food items that had been expired. This had to potential to affect all residents. The facility census was 87.Review of the facilities Food Storage- Perishable dated 2012, showed:-Sanitary procedures will be maintained in perishable food storage to keep foods safe, wholesome and appetizing, and to prevent contamination;-Refrigerated frozen products must be properly stored immediately upon delivery;-All prepared food stored in the refrigerator units should be in covered, seamless containers or otherwise suitably protected with used by date. Containers should be arranged so that free circulation of air was allowed at all times.-The policy did not address food labeling, dating of foods or expired foods. Observation of the walk in refrigerator on 04/06/2026 at 8:48 A.M. showed:-Open package of lettuce not sealed shut and did not have an open date on the package;-Two packages of spinach not sealed shut and did not have an open date on the packages;-Container of grapefruit with a manufactures use by date of 2/13/26 and a written open date of 2/10/26;-Open package of shredded carrots with a use by date of 3/16/26;-Whipped cream cheese labeled with an X 3/19; During an Interview on 04/06/2026 at 9:00 A.M. the Registered Dietician said a package of food that had an X next to the date written on the package meant that date was the day the food expired.Observation of the walk in refrigerator on 04/08/2026 at 10:35 A.M. showed:-Container of grapefruit with a manufactures use by date of 2/13/26 and a written open date of 2/10/26;-Bag of spinach that did not have an open date and was not sealed shut. During an Interview on 04/08/2026 at 10:40 A.M. [NAME] A said:-A package of food that had an X next to the date written on the package meant that date was the day the food expired;-A package of food that had only a date written on it meant that was the day the package was opened;-The items that did not have a date indicating when they were opened or the date the food expires staff must have just forgotten to date them;-Open packages of lettuce should have been sealed shut. During an Interview on 04/08/2026 at 11:05 A.M. the Culinary Director said:-Food packaging should have a date written on it indicating the day it was open or the date with an X by it indicating the day the food expires;-Expired food should have been thrown away. During an Interview on 04/09/2026 at 8:17 A.M. the Administrator said:-Food items should have a date on the package indicating the day the package was open or the day the food item would expire;-Food that was expired should have been thrown away;-Food items from February 2026 should not still be stored in the kitchen in April.

Based on observation, interview and record review, the facility failed to ensure that medications used in the facility were labeled in accordance with professional standards, including expiration dates for seven sampled residents (Residents #10, #41, #46, #50, #79, #97, #102); when the facility had an open expired insulin pen (Resident #10); when the facility had an opened multi-use medicated nasal spray and eye drops with no open dates (Resident #79 & Resident #97); when the facility had an uncapped, pre-primed insulin needle and pen with dried blood on it (Resident #41); also when the facility had an opened large, floor stock powdered fiber medication with no open date, as well as two expired floor stock oral medications (Aspirin and guaifenesin); when the facility had four vials of expired blood sugar testing solutions that expire 90 days after opening and additionally when the facility had a clear storage bag containing medications for three different residents (Residents #102, #46, & #50). This affected seven of the 18 sampled residents. The facility census was 87.Review of the facility's Storage of Medication Policy dated 03/2017, showed:-Orally administered medications are kept separate from externally used medications;-Certain medications such as multi-dose injectables, nasal sprays, ophthalmic (eye drops and gels), and blood sugar testing solutions require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency;-When the original manufacturer's seal is initially broken, staff are to write the date opened on medication container or vial;-The staff will check the expiration date of each medication before administering medication;-No expired medication will be administered to a resident;-All expired, outdated or contaminated medications will be removed from active supply and destroyed in the facility, regardless of remaining quantity. Observation on 04/08/26 at 10:00A.M., the medication cart on the first floor showed:-Resident #10's multi-dose insulin pen with an open date of 03/05/2026, multi-dose medications are good to use for 28 days after opening;-Resident #79's open multi-dose eye drops without an open date;-An open vial of high control solution used for calibration of glucometer (a device used to check blood sugar) with an open date 12/2025 and labeled expiration date of 03/2026;-An open vial of normal control solution for glucometer calibration with an open date 12/2025 and labeled expiration date of 03/2026;-Resident #41's long-acting insulin pen with needle attached, uncapped, primed at 22 units, with dried blood on the pen, placed inside top drawer with floor stock oral medications, not in a bag or individual container. Observation of the medication cart on the skilled unit on 04/09/2026, showed:-An opened bottle of floor stock guaifenesin (a decongestant) 400mg tablets with a manufacturer expiration date of 03/2026;-An opened bottle of floor stock Aspirin 325mg with a manufacturer expiration date of 12/2025;-Resident #97's opened Flonase (a multi dose nasal spray) without an open date;-An opened package of floor stock fiber powder without an open date;-An open vial of high control solution used for calibration of glucometer (a device used to check blood sugar without an open date;-An open vial of normal control solution for glucometer calibration without an open date;-A clear storage bag, containing medications for three different residents. Resident #50 that had a labeled due date of 04/07/2026 at 09:00P.M, a medication for Resident #46 that had a labeled due date of 04/08/2026 at 07:30A.M. and a medication for Resident #102 that had a labeled due date of 04/08/2026 at 09:00A.M. During an interview on 04/08/2026 at 10:00A.M., RN C said that multi dose and multi use floor stock medications are labeled by the staff that open them and are good to use for 30 days after opening. During an interview on 04/09/2026 at 09:30A.M., LPN A said expired medications should not be kept on the medication cart; there is a medication disposal container on each floor that all certified medicine technicians (CMT)s and nurses are able to use. During an interview on 04/09/2026 at 09:40A.M., the Infection Preventionist/Clinical Manager said:-When asked if staff should have disposed of medications that were expired, he/she said that the staff could have disposed properly of the medications during his/her shift, there was no explanation or reason that the staff did not dispose of medications;-The facility CMTs and nurses all have access to medication disposal containers on each floor;-There is validation or competency during staff orientation regarding medication administration and storage, but he/she is unsure as to exactly what it entails;-It is safe to keep medications for multiple residents together in a bag if the medications are to be destroyed;-All expired medications should be removed from the cart and destroyed as soon as possible;-He/She usually checks the medication carts on his/her morning rounds but had not had the opportunity to yet. On 04/09/2026 at 11:00A.M., the Director of Nursing (DON) said:-The mediations contained in the bag on the medication cart had been disposed of;-If the bag containing medications for multiple residents was for disposal, then it is reasonable that it should have been labeled for disposal or destruction;-Opened multi dose vials are good for use for 28 days;-Expired medications should be destroyed by staff when they discover that medications are expired;-He/She had assigned staff to thoroughly check all medication carts weekly;-The Clinical Managers check his/her assigned units carts several times weekly for expired or outdated medications.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when the facility staff did not utilize enhanced barrier precautions by wearing appropriate protective equipment when caring for residents with an indwelling device for three residents (Residents #10, #37 & #39) and additionally when the facility staff did not change gloves between dirty and clean tasks for one resident (Resident #39); this affected three of the 18 sampled residents. The facility census was 87.Review of the facility's undated Enhanced Barrier Precautions (EBP) Policy showed:-EBP expands the use of protective equipment and refers to the use of gowns and gloves during high-contact resident care activities;-EBP will be utilized for any resident that has an infection with a Multi-Drug Resistant Organism (MDRO) (an infection resistant to multiple medications), a resident with a chronic wound or residents that have an indwelling medical device such as urinary catheters (a tube placed in the bladder to drain urine), dialysis ports (a surgically created site or a temporary catheter used to remove and clean blood through a machine) or feeding tubes (a tube surgically inserted into resident's abdomen and stomach to supplement or replace oral nutrition);-EBP must be worn during high-contact activities such as dressing, bathing, providing hygiene, changing briefs, assisting with toileting, indwelling medical device care or use (administering medications or nutrition through feeding tube or cleaning of urinary catheter.) Review of the facility's Administering Medications Policy dated 2020, showed that the facility staff are to follow established infection control procedures for the administration of medications. Review of the facility's Hand Hygiene Policy date 09/2023, showed:-Hand hygiene can be either washing hands with soap and water or use of alcohol-based hand rub (ABHR);-Hand hygiene should be performed after contact with a resident's body fluids;-Hand hygiene to be performed after removing gloves. 1.Review of Resident #37's Quarterly Minimum Data Set (MDS), A federally mandated assessment completed by facility staff, dated 03/20/2026, showed:-Resident cognitively intact;-Resident is incontinent of bowel and bladder;-He/She is dependent on dialysis (a life-sustaining treatment for kidney failure that filters waste and excess fluids from the blood);-Diagnoses included: end stage kidney disease, diabetes and high blood pressure. Review of the resident's care plan dated 03/19/2026, showed:-He/She is dependent on staff for toileting hygiene;-Resident requires assistance of two staff members with full body mechanical lift for transfers;-He/She requires EBP related to the presence of indwelling dialysis port. Observations on 04/07/2026 showed:-At 12:35P.M. LPN B performed accucheck (testing method where blood sugar levels are measured instantly at the bedside), wearing only gloves;-At 1:20P.M., CNA B and LPN B transferred the resident using mechanical lift and neither staff member had applied a protective gown;-At 2:07P.M., CNA B performed incontinence cares of resident and did not have a gown on. During an interview on 04/07/2026 at 2:20P.M., CNA B said that EBP is used to protect residents at risk for infection and that he/she should wear a gown when transferring a dialysis resident and providing incontinent care. During an interview on 04/07/2026 at 12:40 P.M., LPN B said that he/she should have worn a gown to perform Accu-Chek on a dialysis patient and that EBP helps protect residents from infection. 2.Review of Resident #10's Quarterly MDS dated [DATE], showed:-Mild cognitive impairment;-Resident receives 50% of total calories via feeding tube (a tube inserted into the abdomen to deliver liquid nutrition);-Diagnoses included stroke, diabetes, high blood pressure and Non-Alzheimer's Dementia. Review of the resident's care plan dated 02/16/2026, showed:-Resident is at increased nutritional risk related to diagnosis of dysphagia (difficulty swallowing);-He/She is dependent on staff and mechanical lift for transfers;-He/She requires EBP related to presence of a feeding tube;-Staff are to apply a gown and gloves prior to high-contact activities. An Observation on 04/08/2026 at 10:05A.M., showed:-RN C entered room of the resident after using ABHR and applied gloves;-RN C attached feeding tube to surgically placed port on resident's abdomen;-RN C administered fluids and tube feeding to resident;-Resident reported pain and requested pain medication;-RN C removed gloves, left room without performing hand hygiene and prepared medication for administration;-RN C returned to resident's room, did not perform hand hygiene or apply gloves upon entering, administered oral medications to resident;-RN C applied pain patches to resident's right knee and lower back;-RN exited room without performing hand hygiene. During an interview on 04/08/2026 at 10:20A.M., RN C said:-No gown is required for oral medication administration;-He/she should have applied a gown prior to administering tube feeding to protect resident who has increased risk of infection;-He/She should have performed hand hygiene each time he/she entered and exited resident's room. 3. Review of Resident #39's Quarterly MDS dated [DATE], showed:-Resident had severe cognitive impairment;-Resident needed set-up or clean-up assistance from staff for toileting hygiene;-Resident frequently incontinent of bowel and has a urinary catheter;-Diagnoses included high blood pressure, cognitive dysfunction and neurogenic bladder (characterized by weak muscle tone, inability to empty, and incontinence). Review of the resident's care plan dated 02/02/2026, showed:-Increased potential for infection related to urinary catheter;-He/She required EBP related to indwelling urinary catheter;-Staff to wear gown and gloves prior to high-contact care activities;-Staff to provide catheter care each shift and as needed. An Observation on 04/09/2026 at 10:15A.M. showed:-CMT A entered resident's room to assist with catheter care and hygiene;-CMT A performed hand hygiene, applied gloves and did not apply a protective gown;-Resident was assisted with incontinence cares and catheter care was provided by CMT A;-CMT A removed soiled brief and clothing and applied clean brief and clothing without changing gloves between dirty and clean tasks;-Clinical Manager (CM) A entered room with additional supplies wearing a gown and gloves;-CMT A turned off active call light with soiled gloves;-CMT A continued providing cares to resident, removed gloves and washed hands when finished. During an interview on 04/09/2026 at 10:40A.M., CMT A said:-A gown is required for peri care or catheter care;-He/She forgot to put on gown prior to entering room;-EBP is used to protect residents from infection;-He/She should have changed gloves and performed hand hygiene before applying new brief or clean clothes to the resident. During an interview on 04/09/2026 at 10:45A.M., CMT A said:-EBP is required for residents at increased risk of infection, such as those with wounds or catheters;-Staff should change gloves and perform hand hygiene between dirty and clean tasks;-Hand hygiene should be performed by staff before and after entering residents' rooms;-A gown should be worn for tube feeding administration and incontinence cares. During an interview on 04/09/2026 at 11:00A.M., the Director of Nursing said that all staff are trained in the need and use of EBP and additionally, gowns are required for peri/incontinence cares, tube feeding administration and catheter cares.

Based on interview and record review, the facility failed ensure one of 6 sampled residents (Resident #1) received adequate assistance and supervision to prevent accidents when the facility staff transferred the resident to a standing position without a gait belt. The resident ambulated to the restroom, notified staff that he/she felt dizzy, the staff member left the resident alone to go obtain a gait belt and the reisdent fell. The resident fractured his/her left hip and required surgery. The facility census was 77. Review of the facility policy titled, Integrated Fall Management Policy, dated 8/24/17, showed: -Fall Risk assessments are to be completed quarterly and upon significant change of condition; -Identify other risk factors in the Minimum Data Set (MDS) to identify additional risk factors and interventions; -Residents at risk for falls have an individualized resident centered care plan developed based upon the fall risk assessment; -Include other professionals to assess or intervene regarding fall risk prevention; -Residents are provided education, regarding her/his fall risk and interventions to reduce falls based on the fall risk assessment; -Completed fall risk assessments are maintained in the resident's medical record. Review of the facility policy titled, Transfer Belt (Gait Belt) Placement Education Document, dated 2009, showed when transferring a resident, staff should always apply belt over clothing around waist with buckle in front. Review of CNA A's orientation training packet, showed CNA A was trained on 2/08/25 for safe transfers and gait belt use by the facility for competency and facility policy. 1. Review of Resident #1's Face Sheet, dated 3/31/25., showed: -New admission to the facility; -Diagnoses included: Right lung cancer, high blood pressure, and a post-surgical wound left groin for clot removal. Review of the Resident's baseline care plan, dated 3/31/25, showed: - Resident's goals was not to sustain a fall with an injury; -The care plan did not identify the resident's activity level. -He/She was at risk for falls due to atherosclerosis of extremities; -Educate resident on the prevention and reduction of fall precautions; -No transfer or ambulatory status was care planned; -He/She was to receive PT/OT services to maintain highest functional ability; - The care plan did not address use of a walker or a gait belt for resident's mobility. -The care plan did not address how much staff assistance the resident required for mobility needs. Review of the Fall Risk Assessment, dated 3/31/25., showed: -The resident uses a front wheeled walker; - The resident's pain and wounds required the need for staff to assist with transfers. - The resident needs one staff person for transfer assistance with a gait belt and a second person for hygiene, equipment and clothing management recommended; - The resident was assessed as not being at risk for falls. Review of the Resident's documented Activities of Daily Living (ADL) and transfers document dated 4/6/25 at 3:33 P.M., showed the Resident required extensive assistance with transfers by staff to assist with ADLs. Review of the Resident's nursing progress notes on 4/6/25 at 12:55 P.M., showed: -Nursing staff transferred Resident in the bathroom with a walker, resident fell in bathroom. Resident went to turn and reach for the grab bar, but turned wrong and fell. - Resident fell to the floor with feet out in front of him/her and resident hit head against the bathroom wall; -The resident denied pain to his/her head but stated left hip pain was at a level 5 out of 10 on the pain scale, with 10 being the worst pain. -Emergency Medical Services (EMS) arrived to transfer the resident to the emergency room (ER). Record Review of the facility's fall event report, dated 4/6/25 at 6:08 P.M., showed: - The report was completed by LPN A; - The fall was witnessed by CNA A; -The Resident was transferred without the use of a gait belt by CNA A; -CNA A left the resident's side to grab a gait belt, and the resident lost balance and fell; -The resident complained of a pain level 7 (out of 10) for head and hip pain; -The resident complained of dizziness, lightheadedness, headache, and nausea vomiting. -The resident was sent to the hospital for evaluation of injuries; -The hospital provided an updated to LPN A that the reisdent sustained a left hip fracture injury. Review of the Resident's hospital records dated 4/6/25, showed: -He/She fell when left unassisted, and had sustained an injury at the facility; -He/she had left hip pain; -X-ray dated 4/6/25 resulted in a fracture of left femur; -Surgical intervention was completed on 4/8/25 to repair the fracture. During a interview on 4/23/25 at 5:30 P.M., Certified Nurses Aide (CNA) A said: - He/she transferred the reisdent from the bed to the standing position without a gait belt; -After he/she assisted the resident up off the bed, the resident immediately began walking towards the restroom before he/she could put a gait belt on the resident; -The gait belt was next to the resident's bed. -He/She heard the resident say he/she was dizzy; -CNA A told the resident to hold onto the bar and not move; -He/She left the resident standing in the bathroom alone holding on to the pull bar while she retrieved the gait belt; -As soon as CNA A took three steps to reach gait belt, the resident fell trying to turn him/herself in order to sit on the toilet. -The resident landed with his/her head against the wall. -The resident said he/she was in pain. -He/She knew he/she was supposed to use a gait belt when transferring the resident but did not use it; -He/She had been trained on transfers and resident safety with transfers. During an interview on 4/23/25 at 11:59 A.M., Licensed Practical Nurse (LPN) A said: -He/she was asked to go to the resident's room and assess the reisdent after the fell; -He/she said the resident was not wearing a gait belt and was already sitting in a wheelchair; -He/she did not know who transferred the resident up off the floor into the wheelchair. -He/she observed the resident being transferred with a gait belt from the wheelchair to the bed by 2 nursing staff members; -He/she assessed the resident and the resident did not appear to be in pain, but did complain of dizziness; -He/she assessed the resident's legs and the resident reported pain at a level of 5. - The reisdent denied any head pain; -There was no visible defects observed in the resident's skin integrity, and no leg rotation or shortening of the leg was observed; -Vital signs were monitored by LPN B; -Neurological nursing assessments were completed by LPN B. During an interview on 4/23/25 at 12:10 P.M., Registered Nurse (RN) A said all staff are to use gait belts when assisting residents to ambulate. During an interview on 4/24/25 at 4:44 P.M., Family Member (FM) A said: -He/she was in the room and witnessed the aide leave the resident unattended and the then the resident fell; -The residents fall could have been prevented if the resident was not left standing alone; -The resident was in pain and needed to be seen in the ER; -The resident had surgery to repair his/her broken hip and required additional surgery on his/her hip due to complications. During an interview on 4/23/25 at 10:55 A.M., Physical Therapist (PT) A said: -It is facility policy for staff to use gait belts when transferring residents, for the resident's safety. -He/She would expect that staff use a gait belt on the resident for staff assisted transfers and ambulation. During an interview on 4/23/25 at 1:00 P.M., The Administrator said: -She expects Activities of Daily living to be documented on every resident's care plan; -All employees are educated on how to perform safe transfers and how to assist with ambulation; -Gait belt use is an expectation for all staff. During an interview on 4/23/25 at 1:45 P.M., The Director of Nursing (DON) said: -She expects Activities of Daily living to be on each resident's care plan; -All nursing staff are educated on how to assist residents on ambulation and transfers; -All nursing staff are expected to use gait belts for transfers and ambulation; -All nursing staff are expected to stay with residents if the reisdent needs assistance from staff; -CNA A did not follow the facility policy regarding when to use gait belts, which resulted in the resident's fall. MO252397

Based on observation, interview and record review the facility failed to ensure two of 25 sample residents (Resident (R) 54 and R23) reviewed for self-administration of medications were permitted to exercise their resident rights. Specifically, the facility failed to ensure medications were not left at the bedside of R54 who was not assessed to be able to self-administer medications safely; and the facility failed to ensure R23, who desired to self-administer medications and was assessed to be safe to do so was permitted to. The facility census was 80. Findings include: Review of the facility's Self-Administration of Medications policy, dated 08/31/23, revealed the purpose was, To enhance resident independence to self-administer medications. The policy indicated, . Residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe . The nursing associates will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident . 1. Review of R54's Face Sheet, located in the electronic medical record (EMR) under the Dashboard tab, revealed R54 was admitted on [DATE] with diagnoses that included unspecified dementia, unspecified severity, with mood disturbance. Review of R54's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 10/23/24 and located under the RAI (Resident Assessment Instrument) tab in the EMR, revealed R54 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated R54 was moderately cognitively impaired. During an interview on 01/02/25 at 11:19 AM, R54 was observed to have a medication cup on his overbed table. The medication cup contained three pills. R54 stated, Those were left about an hour ago. I don't know what they are. I just have to take them. The medications left at the bedside were confirmed by the MDS Coordinator (MDSC1) on 01/02/25 at 11:22 AM. At 11:24 AM, the Certified Medication Technician (CMT1) entered R54's room and stated, I never leave them. I don't know why I did. CMT1 revealed, as entered on the Medication Administration Record (MAR) dated 01/2025, that the medications were aspirin, Gemtesa, senna, and vitamin D3. CMT1 stated, The vitamin D3 was not in the cup. CMT1 did not look for the medication, ask R54 if he had taken the medication, or look to see if it was in the trash directly under the overbed table where the medications had been placed or dropped on the floor. Review of R54's MAR for 01/02/25 revealed the medications were signed as administered at 10:25 AM. Review of R54's EMR Assessments tab revealed no assessment to determine if R54 could self-administer medication. Review of R54's Orders tab of the EMR revealed no physician's order to self-administer medications. In an interview on 01/02/25 at 12:10 PM, the Director of Nursing (DON) and Clinical Manager (CM)1 confirmed they were aware of the medications left at the bedside of R54. The DON stated, That should not have happened. 15406 2. Review of R23's undated Face Sheet, located in the EMR under the Resident tab, revealed R23 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. Review of R23's annual MDS, with an ARD of 08/06/24 and located under the RAI tab of the EMR, revealed R23's cognition was intact with a BIMS score of 15 out of 15. Review of R23's Observation Detail List Report [Self Administration of Medication Assessment], dated 11/04/24 and located in the EMR under the Document tab, revealed that R23 wanted to self-administer some medications. The report read, List of medications resident would like to self-administer - Nebulizer treatments, Advair Diskus inhaler nasal spray, Icy Hot - resident keeps vials at bedside and has order to self-administer. The Observation Detail List Report indicated R23 was appropriate to self-administer medications, and she was able to name the dosage, frequency, and reason for each medication, tell the time and state when each medication was due, and could read the label and identify each medication. It was recorded R23 was able to pour pills out of the bottle and properly dispense inhalers and nebulizers. It was recorded the appropriate medications for the resident to self-administer were, Nebulizer treatments, nasal spray and icy hot. Review of R23's Care Plan, dated 11/10/24 and located in the EMR under the RAI tab, revealed a problem of, I may self-administer nebulizer treatments, medication will be kept in the med [medication] cart. The goal was, Resident will safely demonstrate to the staff that she can complete this task. The approach was Staff will educate resident on the use of this medication, and keep it safely locked in the medication cart. Review of R23's Care Plan, dated 11/10/24 and located in the EMR under the RAI tab, revealed a problem of, Self-administration, Resident has a physicians' order to keep the following medications at bedside and self-administer: Resident has been assessed by Interdisciplinary care plan team to be capable of self-administration. Resident demonstrates ability to: Follow simple directions. Remember directions consistently. Read prescription labels adequately. Identify medications by appearance. The goal was, Resident will take medications safely and as Prescribed. Resident will demonstrate ability to take medications at correct dose, route, and time. Resident will verbalize and demonstrate understanding of: What each medication is supposed to do. What foods, drinks and other medications should be avoided while taking each medication. What the possible side effects are, and what should be done if they occur. Approaches in pertinent part were, Assess residents' ability to self-administer Ipratropium Bromide [medication treating breathing problems] 0.5 mg and Albuterol Sulfate [bronchodilator relaxing muscles in the airways] 3 mg, Cool Therapy Roll on Pain reliever, and Zinc 50 mg, 1 cap PO [orally], every other day, Albuterol Inhaler with admission, quarterly, with each assessment, and as needed . Review of R23's Physician Order Report, dated 12/02/24 - 01/02/25 and located in the EMR under the Orders tab, revealed current Physician's Orders for self-administration of medications for R23 as follows: Resident is ok to self-administer medications and keep locked in bedside drawer/key when not in room, initiated on 11/10/23. Cough drops (kept at bedside whenever [family member] will bring) Special Instructions: as needed for cough/throat lozenges, initiated on 07/04/24. May self-administer nebulizer treatments, initiated on 10/03/24. Medicated body Powder (menthol) [OTC - over the counter] powder; 0.15%; amt [amount] small amount; topical, Special Instructions: Resident keeps at bedside in locked cabinet, may self-administer, initiated 12/30/24. Neosporin (neo-bac-polym) (neomycin-bacitracin-polymyxin) [OTC] ointment; 3.5 mg [milligrams] - 400 unit - 5,000 unit/gram; amt: small amount; topical, Special Instructions: Resident and family request to keep at bedside. Order to keep at bedside and may self-administer, initiated on 12/30/24. Voltaren Arthritis Pain (diclofenac sodium) [OTC] gel; 1/5; amt: 2 gms [grams]; topical, Special Instructions: apply to shoulder and neck pain: PRN [as needed] pain. May keep at bedside, in locked cabinet, initiated on 12/30/24. During an interview on 12/30/24 at 11:02 AM, R23 stated that on this morning, while she was out of her room, the staff had come into her room and removed Tums and other medications/lotions from a locked drawer in her bedside table. R23 stated she was upset about the medications being removed and not being informed. R23 stated she was going to ask the nurse about it. During an observation on 12/30/24 at 11:05 AM, CM1 spoke to R23 and told her she had removed R23's medications because R23 did not have orders for the medications. During an interview on 12/31/24 at 2:56 PM, CM1 stated she told Family Member (F)1 to stop bringing in medications for R23. CM1 stated she had removed an unlabeled bottle of Tums from R23's beside table on 12/30/24 when R23 was out of the room. CM1 stated R23 had physician's orders to self-administer medicated powder, an inhaler (there was no order for the inhaler), and her nebulizer. CM1 stated physician orders were required for R23 to be able to self-administer medications. CM1 verified the cough drops and throat spray had been removed and stated the nursing staff would have to get orders for self-administration (R23 had a current order for self-administration of the cough drops). During an interview on 01/01/25 at 8:36 AM, R23 stated the nursing staff had returned the medicated powder but not the Tums, throat/cough lozenges (she had an order to self-administer cough drops) and throat spray that were removed from the locked drawer in her bedside table. R23 stated she wanted these items returned to her. R23 stated she currently self-administered her nebulizer and inhaler by herself (there was no order for self-administration of the inhaler). R23 stated she knew when and how to take the medications that had been removed (Tums, cough drops, and throat spray). R23 stated the facility was holding the confiscated medications for F1 to come and pick up. During a Resident Council meeting on 01/01/25 at 2:00 PM, R23 stated, The unit manager [CM1] came in on Monday and took all the medications that I keep in my room on my table. I've had them for a long time. Why is it a problem now? R23 stated the medications were removed from her room without her knowledge and when she was not in her room. During an interview on 01/02/25 at 11:21 AM, F1 stated she brought the Tums to R23 because R23 had indigestion and Tums helped. F1 stated family had brought in throat spray and lozenges/cough drops which were also beneficial to R23. F1 stated the facility staff had not contacted her about the medications that had been confiscated on 12/30/24. During an interview on 01/02/25 at 11:36 AM, R23 identified the medications she kept at her bedside as, Tums, Coricidin 10 cream, body powder, cough drops, and throat spray. Only the body powder was returned to me. During an interview on 01/02/25 at 12:10 PM, CM1 stated, I only took a cup with what may have been Tums, but I can't assume they were Tums, they were not in the original bottle. I don't know where the other medications are. I'll have to call the [family member] to bring in more. CM1 was asked if she had entered R23's room without the resident present to remove the Tums. CM1 stated, Yes. During an interview on 01/02/25 at 1:38 PM, Licensed Practical Nurse (LPN) 4 stated R23 self-administered her nebulizer and she could have cough drops at bedside. LPN4 stated nursing staff administered the inhaler as needed. LPN4 stated R23 could not have medicated powders or creams at bedside (R23 had a current order for self-administration of Neosporin and medicated body powder). LPN4 stated nursing staff administered Voltaren Gel (R23 had a current order to self-administer the Voltaren Gel).

Based on interviews, record review, and facility policy review, the facility failed to conduct a thorough investigation of an allegation of verbal abuse by a staff member for two of two residents (Resident (R) 26 and R32) reviewed for abuse out of a total sample of 25. This failure created the potential for abuse of other residents. The facility census was 80. Findings include: Review of the facility's Abuse Prevention Plan, dated 07/21/22, revealed, Any person with the knowledge or suspicion of suspected abuse, neglect, misappropriation of resident property, and/or financial exploitation must report immediately, without fear of reprisal and/or retaliation . Any allegations involving abuse, neglect, misappropriation of resident property and/or financial exploitation will be investigated . Measures will be taken to identify the source of the alleged abuse and prevent future incidents. Investigative packets will be utilized to systematically direct the team through the investigative process. Any evidence gathered will be handled with caution to ensure no tampering, destruction or alteration occurs . Identify and interview all who might have knowledge of the incident including the alleged victim, perpetrator, witnesses, or others who may have had related contact with the alleged perpetrator, related to the incident in question. The focus of the investigation is to determine the extent, cause and future prevention with thorough documentation of the investigative process . Review of R26's Face Sheet, located under the Dashboard tab in the electronic medical record (EMR), revealed R26 was admitted to the facility on [DATE] and passed away on 12/29/24. R26 had diagnoses that included dementia. Review of R26's annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 11/24/24, revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated R26 was severely cognitively impaired. R26 was noted to require one to two staff members to assist with activities of daily living (ADL) needs. Review of R32's Face Sheet, located under the Dashboard tab in the EMR, revealed R32 was admitted on [DATE] with diagnoses that included congestive heart failure. Review of R32's annual MDS, with an ARD of 12/10/24, revealed a BIMS score of 13 out of 15, which indicated R32 was cognitively intact. Review of the monthly Resident Council Minutes, dated 02/23/24 at 11:00 AM and provided by the Wellness/Activity Director (AD), revealed, . [R32] stated that on the 19th the nurse aide was inside his room on his roommate's side and was yelling at him. [R32] stated that he asked her to talk to him when she was done and he then asked her why she was yelling at his roommate [R26] and the nurse responded back that his roommate was not listening to her. [R32] stated that he does not sleep well at night when this stuff is going on . Review of the facility's investigation of the allegation, provided by the Director of Nursing (DON), revealed Fefiuary [sic] 23,2024 AT approximately 2:45pm. [AD] came into writer's office to review council meeting nursing concerns. One of the concerns was Resident [32] stated an agency aide on Monday who worked was yelling at his roommate [R26] calling him 'dumbass' and other things [R32] stated he could not repeat. [R32] stated he went over to speak to the aide telling her she should not speak to [R26] that way and wanted his shower. [R32] stated he was told by the aide it was not his business and if he contlnued [sic] to complain the aide would wait to give him his shower until last. Resident [32] did not get a shower until the next day when [Certified Medication Technician (CMT)1] gave him a shower first th ing [sic] . The facility's summary of the investigation recorded to refer to [Former Social Service Coordinator] notes for R32's interview. The notes were not contained in the investigative documentation and were not located by the DON; therefore, they were not reviewed. R26 was identified as not interviewable. An interview with R32, contained within the summary, read, [R32] told her the aide who worked days on Monday had been yelling and speaking aggressively to [R26]. When she asked what he meant by that, [R32] further stated that he stopped the aide on the way out of the room and told her she had no business talking to [R26] that way as he isn't capable of defending himself. [R32] also stated that the aide told him to mind his own business and let her do her job. The aide began to yell at him and he told her to leave his room and not come back. There was no documented evidence contained in the investigative documentation that the allegation of verbal abuse was investigated. There was no documentation that R26 was assessed. There was no documentation that other residents were interviewed. There was no documentation that non-interviewable residents cared for by the Certified Nurse Aide (CNA) were assessed. There was no documented evidence that the CNA was interviewed. It was recorded that the facility notified the employment agency that the identified CNA was not allowed to return to work in the facility. During an interview on 01/02/25 at 8:30 AM, R32 stated that he remembered what he reported in February 2024. R32 stated, I don't remember her name. My issues with the CNA were not addressed, not about me. I told her don't you speak to him [R26] like that, get out of this room and don't you ever come back in this room again or I'll call the police. R32 stated he did not remember the CNA's name but did remember the CNA yelling at his roommate (R26). During an interview on 01/02/24 at 6:00 PM, the DON was asked why the allegation was not investigated. The DON did not say why the allegation involving R32 and R26 were not investigated. The DON stated, I'm still looking for more paperwork. No additional information was provided as of exit on 01/02/25 at 7:30 PM.

Based on observation, interview, record review and policy review, the facility failed to ensure two of 25 sampled residents (Residents (R)37 and R21) were provided with sufficient supervision and assistive devices to prevent accidents. R37 experienced a fall in which she fell forward out of the bed onto the floor on 09/20/24. There was a lack of interventions implemented in response to the fall and seven days later, R37 experienced another fall onto the floor. R37 sustained injuries including abrasions to her knees, a nosebleed, bleeding gums, bruise to her right cheek, and experienced hip and knee pain. R21 wandered through out the First-Floor [NAME] unit and into residents' rooms, including the rooms of R37 and R32, putting herself and other residents at risk of injuries. R21 wandered at night into residents' rooms when there was less staffing on the unit to supervise her and when she had the potential to startle residents who were sleeping. The facility census was 80. Findings include: Review of the facility's Integrated Fall Management policy, dated 09/2023, revealed the purpose of the policy was, Fall risk assessment, identification and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls . Residents at risk for falls have an individualized resident centered care plan developed. Care plan interventions are based on the finding of the fall risk assessment . 1. Review of R37's Face Sheet, located under the Resident tab of the electronic medical record (EMR) revealed R37 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, need for assistance with personal care, muscle wasting and atrophy, acute and chronic respiratory failure, sleep apnea, adjustment insomnia, and end stage renal disease with dependence on renal dialysis. Review of R37's Care Plan, dated 02/26/21 and located in the EMR under the RAI [Resident Assessment Instrument] tab, revealed a problem of Falls, I am at risk for falls due to decreased cognition, bipolar-psychotropic & antidepressants medication use, DM [diabetes mellitus], neuropathy. The goal was, I will be free of injuries due to falls in the next 90 days. The approaches in total were: Keep my frequency used personal items within reach, initiated on 06/12/21. Assessed for proper Hoyer sling size, which is large, and what is being used initiated on 06/04/21. Increased staff supervision with intensity based on my need initiated on 02/26/21. Comprehensive medication review by pharmacist assess for polypharmacy and medications that increase the fall risk as needed initiated on 02/26/21. Review of R37's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 09/07/24 and located in the electronic medical record (EMR) under the RAI [Resident Assessment Instrument] tab, revealed R37 was admitted to the facility on [DATE] and was unimpaired in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. It was recorded R37 required substantial/maximal assistance with toileting hygiene and lower body dressing, was independent for rolling left to right, going from sitting to lying, and lying to sitting on the side of the bed. It was recorded that R37 was dependent for chair to bed transfers, had not walked during the assessment period, and had not experienced any falls since the previous MDS assessment. Review of R37's Nurse's Note, dated 09/20/24 at 2:15 AM and located in the EMR under the Progress Notes tab, revealed, . CNA [Certified Nursing Assistant] heard resident table fall and resident crying, attended immediately and saw resident lying in [sic] the floor. This writer was notified by CNA and attended as well. Resident was seen on right side lying position, facing the nightstand, feet were almost under the bed. When asked what she was doing and how she fell , the resident said she was sitting on the edge of her bed as she used to and fell asleep. Table was pushed, as she drops to her knees and fell completely. Physical assessment done, noted with abrasion on both knees. Resident claims her hips hurt but does not think she had fracture, just sore as verbalized. Res [resident] denies hitting her head claiming her face is the one that hit the floor, no bruise noted on face. Notified resource and came assess with the writer. Resident was able to move her legs and hand grips were equal. Neuro assessment done and recorded. Vital signs WNL [within normal limits]. No bruise nor other discoloration noted on hip and back, no visible fracture. Resident was able to roll over by herself while placing the Hoyer pad underneath to lift her. Transferred her back to bed safely with Hoyer Lift. Advised to refrain from sitting on edge of bed specially when she is sleepy, resident acknowledged. Safety measures ensured, kept her things within reach and reminded to call for any assistance needed . Review of the Event Report (fall investigation), dated 09/20/24 and provided by the facility, revealed R37 was in bed prior to fall that occurred at 3:15 AM. R37 was documented as being alert and oriented, not being able to ambulate (walk), complaining of mild pain to her hips. R37's range of motion (ROM) was normal, she was alert and without any changes to her mental status. Under the section Interventions - Immediate measures taken, the assessment was blank. Under the section Possible Contributing Factors, the assessment was blank. R37's physician and family were notified on 09/20/24 at 8:07 AM. There was no documentation of what the resident was doing prior to the fall. Registered Nurse (RN)1 was the nurse on duty and completed the Event Report. Review of R37's Care Plan, located under the RAI tab of the EMR, revealed no documented evidence that any interventions were identified and implemented in relation to the fall on 09/20/24. Review of R37's Nurse's Note, dated 09/27/24 at 11:30 PM and located in the EMR under the Progress Notes tab, revealed, . Writer and CNA heard a noise coming from resident room followed by a cry for help. Went to resident room immediately and saw resident sitting on the floor, her head under her bedside table. When asked what happened, she said she is trying to lay down on the bed but instead of going backwards, she slipped and eventually fell forward. Resident noted with nosebleed and bleeding on her front gums as a result of hitting the table in front of her, she also claims her Rt [right] eye was hit, light bruise noted on Rt cheek, no redness nor bleeding noted on rt eye. Ice pack applied on nose and mouth and instructed to lean forward while applying ice pack. Instructed to gurgle as well to wash blood in the mouth. Bleeding stopped after around 5 minutes of ice application. She also c/o [complained of] pain on L [left] knee that was hurt during the fall. Able to move upper and lower extremities with good ROM. Neuro vitals signs checked. Transferred to bed safely with Hoyer lift. Advised to refrain dangling her legs and to keep her whole body in the bed when sleeping, resident agrees and shows understanding. Tried to reach her [family member] to update but to no avail, left VM [voice message] instead including call back number . Review of R37's Event Report, dated 09/27/24 and provided by the facility, revealed the fall occurred at 11:30 PM. The fall was unwitnessed. R37 fell forward out of the bed onto the floor. R37 was assessed, ROM completed, and neuro checks were initiated. The physician was notified on 09/28/24 at 1:53 AM and the family on 09/28/24 at 12:53 AM. There was no documentation of immediate measures being implemented, and the pattern of the resident falling forward out of the bed onto the floor was not identified. RN1 was the nurse on duty when the fall occurred and had filled out the Event Report. Review of R37's Care Plan, dated 10/02/24 and located in the EMR under the RAI tab, revealed a problem of, Resident is at risk for falls due to lack of safety awareness. The goal was, Resident will be free of falls. Interventions in total were: -Keep frequently used items within reach, initiated on 12/06/24. -Keep my call light within reach while I'm in my room, initiated on 12/06/24. -Increased staff supervision with intensity based on resident need, initiated on 10/02/24. -Resident had two falls due to falling asleep at side of bed. Staff will get recliner for resident's room for her to sit in and resident will be educated not to sit on edge of bed, dated 10/02/24. Review of R37's Interdisciplinary Note, dated 10/02/24 and located in the EMR under the Progress Notes tab, revealed, IDT [interdisciplinary team] met to discuss falls on 9/20/24 and 9/27/24. Staff to encourage [R37] to sit in a recliner and not on the side of her bed. Review of a Work Order, dated 11/13/24 and provided by the facility, revealed R37 needed the rocker chair in her room replaced with a regular recliner. The work order was documented as being completed on 11/18/24. Review of the annual Minimum Data Set (MDS) with an ARD of 12/04/24 in the EMR under the RAI tab revealed R37 continued to be unimpaired in cognition with a BIMS score of 15 out of 15. During an interview on 12/30/24 at 3:13 PM, R37 stated she had fallen a couple times a few months ago. R37 stated she fell asleep when she was sitting up on the edge of the bed, fell forward out of the bed, and landed on the floor when each of the falls occurred. R37 stated she hit her face and had a bloody nose. R37 stated she did not know what interventions were added by staff to prevent falls. R37 stated she tried to lay down when she was getting tired and falling asleep. R37 stated that recently she had fallen backward when she was sitting up in bed and had fallen asleep instead of falling forward. She stated when this occurred, she landed on the mattress and had not injured herself. R37 stated she was supposed to have a recliner chair in her room, but she had not been provided with one. R37 was observed to have an upright cushioned chair that did not recline. The chair had an ottoman that pulled out for propping her feet up. During an interview on 01/02/25 at 9:10 AM, RN1 stated she had been working the night shift and was R37's nurse when the falls occurred on 09/20/24 and on 09/27/24. RN1 stated for the first fall on 09/20/24, R37 fell while going to sleep. RN1 stated she was at the nursing station at the time of the fall, and both she and the CNA heard a noise so they went to the rooms on that side and found R37 on the floor. RN1 stated R37 had said she fell asleep and fell out of bed onto the floor but was okay. RN1 stated R37 tended to sleep on the edge of the bed, and R37 told her she was sitting up and fell asleep while she was sitting. RN1 stated R37's bedside table was there with everything in reach at the time of the fall. RN1 stated the resource nurse came and assisted with assessing the resident. RN1 stated the intervention she implemented was educating R37 to lay back whenever it was nighttime. RN1 stated the staff made rounds and kept things R37 might need near her. RN1 stated that the fall on 09/27/24 was the same story on how it happened, with R37 falling forward again out of bed. RN1 stated the intervention was to continue to do rounds. RN1 stated on the night shift, she had two halls (First Floor South and West) that she covered with one CNA on each hall. RN1 stated someone should be on the hall and checking residents every hour or so. RN1 stated she advised R37 to sit in a chair if she wanted to. RN1 stated R37 had a chair in her room but she preferred to sit on the bed. RN1 stated R37 was cooperative and she did not have any problems caring for her. During an interview on 01/02/25 at 9:49 AM, the Environmental Services Director stated R37 wanted a reclining lift chair, but nursing approval was needed for that. The Environmental Services Director stated he was not able to provide a chair that electronically lifted residents up. The Environmental Services Director stated the chair currently in R37's room was the one he had placed in there when completing the work order on 11/18/24. He showed the surveyor the chair which was an upright sitting chair with an ottoman that pulled out; the chair did not recline. The Environmental Services Director stated R37 previously had a rocking chair in her room that he had to remove due to the facility's policy that no rocking chairs were allowed for safety reasons. During an interview on 01/02/25 at 1:27 PM, CNA1 stated R37 required staff assistance with some ADLs, was dependent on staff for transfers, and was unable to stand or walk. CNA1 stated she was not aware of R37 being at risk for falls. CNA1 stated there was a CNA cheat sheet that was available that provided information such as fall risk and interventions needed. During an interview on 01/02/25 at 1:41 PM, Licensed Practical Nurse (LPN) 4 stated R37 tended to sit on the side of her bed which put her at risk of falling due to going to sleep while she was sitting up. LPN4 stated she was not aware of any interventions to address the fall risk from sitting on the edge of the bed and going to sleep. LPN4 stated she had been informed that R37 did not sleep much at night; however, she slept a lot during the day. During an interview on 01/02/25 at 5:14 PM, the Director of Nursing (DON) and Clinical Manager (CM) 1 were interviewed and stated an IDT meeting was held daily, and in the meeting, falls were reviewed. The DON stated the Pharmacist reviewed R37's medications on 10/15/24 (two weeks after the second fall occurred on 09/27/24). The DON stated R37 was encouraged to lay down when she was tired and had been sleeping more. The DON stated therapy staff reviewed R37 on 09/27/24; however, she was at her baseline and they did not initiate therapy. They stated R37 tended to sit on the edge of the bed with her legs dangling and they wanted R37 to elevate her legs, and the family did not have the funds to purchase a recliner. They stated R37 did not want to sit in the chair that was currently located in her room. 2. Review of R21's Face Sheet, found under the Profile Tab in the EMR, indicated an admitted [DATE] with diagnoses of dementia, anxiety disorder, major depressive disorder, and Alzheimer's disease. Review of R21's Elopement Risk assessment, dated 08/24/24 and located under the Assessments tab of the EMR, revealed that R21 wandered with no rational purpose and attempted to open doors and was a high elopement risk. Review of R21's quarterly MDS, with an ARD of 08/27/24, recorded R21 did not exhibit the behavior of wandering. Review of R21's Assessments, found under the Assessment tab of the EMR, indicated that a quarterly Elopement Risk assessment for November 2024 had not been completed. Review of R21's annual MDS, with an ARD of 11/27/24 and found under the Assessments tab in the EMR, indicated R21 had a BIMS score of four of 15, which indicated R21 was severely cognitively impaired. It was recorded that R21 did not exhibit wandering. Review of R21's Care Plan, with a revision date of 12/02/24 and found under the Care Plan tab of the EMR, indicated a plan for Behavioral Symptoms with a start date of 04/21/23. The plan indicated that R21 . exhibited wandering with no rational purpose, seemingly oblivious to needs or safety. Approaches indicated to, . check double doors if alarm goes off to make sure I do not get off unit, monitor every shift if 'Wander Guard' is in place, to place [R21] in a secure environment, and to provide comfort measure for basic needs (e.g. Pain, hunger, toileting, too hot/cold, etc.) . Review of R21's Care Plan, with a revision date of 12/02/24 and found under the Care Plan of tab of the EMR, indicated a plan for Cognitive Loss/Dementia with a start date of 06/05/24. The plan indicated that R21 wanders on the hall of floor, may call out and ask where she is, what she should be doing, or how she got here. Reorient resident to the best of ability. Approaches indicated to place a green sign outside R21's room to help identify her room, to check the Wander Guard functionally each week, change the battery annually, check every shift for proper placement, distract from wandering by offering pleasant diversions, structured activities, food, conversation, television or book and help finding her room. During an observation on 12/31/24 at 2:36 PM, R21 was observed wandering up and down the hall and come and ask LPN3 and the surveyor where she was supposed to go and what she should do. During an observation on 01/01/25 at 8:46 AM, R21 was wandering in the hall near her room and was redirected by staff to her room. During an observation on 01/01/25 at 2:53 PM, R21 ambulated in the hallway slowly using her walker and stopped to talk to a staff member. The staff member led R21 to her room. An observation on 01/01/25 at 3:06 PM revealed R21 ambulated out of her room using her walker into the hallway. A staff member met R21 and walked with her back to her room. An observation on 01/01/25 at 3:19 PM revealed R21 ambulated out of her room using her walker into the hallway, then walked up to staff member and spoke to the staff member. R21 then turned and went back to her room. An observation on 01/01/25 at 3:22 PM revealed R21 ambulated out of her room using her walker into the hallway, walked slowly and approached a staff member and began talking. R21 then walked using her walker and entered the dining area on her unit and seated herself at a table. a. Review of R32's undated Face Sheet, located in the EMR under the Resident tab, revealed R32 was admitted to the facility on [DATE]. Review of R32's quarterly MDS, with an ARD of 12/08/24 and located in the EMR under the RAI tab, revealed R32 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 12/30/24 at 2:31 PM, R32 stated R21 was lost, and she came in and used his bathroom quite a bit. R32 stated, One time she was sitting on my stool and I had to pee. R32 stated that between 2:00 - 3:00 AM, R21 was up and hunting for the bathroom and came into his room, which was right next to hers. R32 stated R21 had come into his room without clothing on. R32 stated he could usually get R21 to leave his room but he had used the call light before for staff to come and get her. R32 stated R21 came into his room several times per day. During a subsequent interview on 01/01/25 at 8:48 AM, R32 stated, Everyone knows she [R21] has been in my bathroom. R32 stated R21 was confused and was not aware of what she was doing and that she would not hurt anyone; however, R32 stated he felt uncomfortable and thought it was against the law for him to see R21 undressed. R32 stated he felt like he was in trouble when R21, who was not dressed, came into his room during the night. During an interview on 12/31/24 at 2:34 PM, LPN3 stated R21 wandered in the unit and had a Wanderguard (wrist or ankle band alert system to alarm and lock monitored doors for wander-prone residents) to prevent her from leaving. LPN3 stated R21 was very confused and the staff kept an eye on her, redirected her, and did room checks to keep track of her whereabouts. LPN3 stated she did not work nights and had not heard of R21 wandering into other residents' rooms. During an interview on 12/31/24 at 3:01 PM, CM1 stated she was not aware of R21 wandering into other residents' rooms. During an interview on 01/02/25 at 9:10 AM, RN1 stated she routinely worked night shift on the hall where R21, R32, and R37 resided. RN1 stated R21 wandered at night. RN1 stated R21 got up around midnight to go to the bathroom and came out to the nursing station and asked staff, Where am I? Where is my room? RN1 stated she and the CNAs oriented R21 and put her back to bed. RN1 stated R21 often tried to go into one of the rooms right next to hers during night shift, and they redirected her out of the room. During an interview on 01/02/25 at 1:27 PM, CNA1, who worked day shift, stated R21 wandered and this was not a new behavior. CNA1 stated R21 occasionally went into other residents' rooms. CNA1 stated yesterday she observed R21 wandering into a resident's room that was not her own or that of R32 or R37. CNA1 stated residents, mostly R32, let her know if R21 was wandering into their rooms. CNA1 stated she had notified the nurse on duty when residents told her R21 wandered into their rooms. CNA1 stated R32 had notified her twice of R21 coming into his room and she had passed the information to the nurse on duty. b. Review of R37's annual MDS, with an ARD of 12/04/24 and located in the EMR under the RAI tab, revealed R37 was admitted to the facility on [DATE] and had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 12/30/24 at 3:30 PM, R37 stated R21 had dementia, was confused, and frequently wandered into her room. R37 stated R21's room was right next door to hers, which was confirmed by observation. R37 stated R21 came into her room three to five times a day, did not know where she was, and stated she wanted to go home. R37 stated she asked R21 to leave which she generally did; however, if she did not leave, R37 stated she pushed the call light for staff to come and get her out. During an interview on 01/02/25 at 5:27 PM, CM1 and the Director of Nursing (DON) stated night shift staff consisted of one nurse and two CNAs to cover First Floor South and First Floor [NAME] halls, each hall with 16 residents, and the night shift nurse was responsible for the medication pass on both units which occurred until 10:00 PM - 11:00 PM. They verified there could be times when there were no staff on the hallway on either side of the First Floor if the nurse was on the other side and the CNA on the hall was in a room with a resident. Both stated R21 had dementia, and it was common for her to be up early in the morning around 4:30 AM. They stated the facility did not have a memory care unit and they could not meet the needs of residents with significant wandering and had discharged residents to memory units when necessary. The DON stated the staff and residents had not reported that R21 was wandering into residents' rooms.

Based on observation, interview, record review, facility policy review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of 25 sampled residents (Resident (R) 21) residents had an accurate Minimum Data Set (MDS) assessment. This had the potential to cause the resident to have unmet care needs. The facility census was 80. Findings include: Review of R21's Face Sheet, found under the Profile tab in the electronic medical record (EMR), indicated an admitted [DATE] with diagnoses of dementia, anxiety disorder, major depressive disorder, and Alzheimer's disease. Review of the RAI Manual, dated 10/01/19, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. Review of the facility's undated policy titled Comprehensive Assessments and Care Planning, provided by the facility, indicated, . provide a comprehensive person-centered interdisciplinary care assessment of the residents' condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs, using the RAI specific by the State . The assessment must accurately reflect the resident's status, and each person who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment . Review of R21's Elopement Risk assessment, dated 08/24/24 and located under the Assessments tab of the EMR, revealed that R21 wandered with no rational purpose and attempted to open doors and was a high elopement risk. Review of R21's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 08/27/24, recorded R21 did not exhibit the behavior of wandering. Review of R21's annual MDS, with an ARD of 11/27/24 and found under the Assessments tab in the EMR, indicated R21 had a BIMS score of four of 15, which indicated R21 was severely cognitively impaired. It was recorded that R21 did not exhibit wandering. Review of R21's Care Plan, with a revision date of 12/02/24 and found under the Care Plan tab of the EMR, indicated a plan for Behavioral Symptoms with a start date of 04/21/23. The plan indicated that R21 . exhibited wandering with no rational purpose, seemingly oblivious to needs or safety. Approaches indicated to, . check double doors if alarm goes off to make sure I do not get off unit, monitor every shift if 'Wander Guard' is in place, to place [R21] in a secure environment, and to provide comfort measure for basic needs (e.g. Pain, hunger, toileting, too hot/cold, etc.) . Review of R21's Care Plan, with a revision date of 12/02/24 and found under the Care Plan of tab of the EMR, indicated a plan for Cognitive Loss/Dementia with a start date of 06/05/24. The plan indicated that R21 wanders on the hall of floor, may call out and ask where she is, what she should be doing, or how she got here. Reorient resident to the best of ability. Approaches indicated to place a green sign outside R21's room to help identify her room, to check the Wander Guard functionally each week, change the battery annually, check every shift for proper placement, distract from wandering by offering pleasant diversions, structured activities, food, conversation, television or book and help finding her room. During an observation on 01/01/25 at 2:53 PM, R21 ambulated in the hallway slowly using her walker and stopped to talk to a staff member. The staff member led R21 to her room. An observation on 01/01/25 at 3:06 PM revealed R21 ambulated out of her room using her walker into the hallway. A staff member met R21 and walked with her back to her room. An observation on 01/01/25 at 3:19 PM revealed R21 ambulated out of her room using her walker into the hallway, then walked up to staff member and spoke to the staff member. R21 then turned and went back to her room. An observation on 01/01/25 at 3:22 PM revealed R21 ambulated out of her room using her walker into the hallway, walked slowly and approached a staff member and began talking. R21 then walked using her walker and entered the dining area on her unit and seated herself at a table. During an interview on 01/02/25 at 10:35 AM, MDS Coordinator (MDSC)2 stated that social services completed the behavioral and wandering section of the MDS. When asked who was responsible for signing off on the accuracy of the MDS, she stated that the MDS Coordinators were. During an interview on 01/02/25 at 10:45 AM, Social Services Director (SSD)1 stated that it was her responsibility to complete the behavioral and wandering section of the MDS. She stated that she accepted the responsibility that nothing was entered on this section for R21. SSD1 stated that she did not know the resident wandered and that she should have asked more questions at team meetings regarding the resident. The SSD stated that she should have dug into it more. In an interview on 01/02/25 at 5:57 PM, the Director of Nursing (DON) stated that the reason the MDS assessment did not indicate that R21 was wandering was because wandering did not trigger in the look back period. The DON stated that her expectation would be that the MDS Coordinators and other staff members responsible for completing portions of the assessments would review progress notes, elopement risks, and review care plans during the completion of the assessment.

Based on interview, record review, and policy review, the facility failed to have an end date for an as needed (PRN) psychotropic medication for two of six residents (Resident (R) 16 and R282) reviewed for unnecessary medications out of a total sample of 25. The failure had the potential for residents to receive psychotropic medications without ongoing assessment by a physician or practitioner for continued appropriateness. The facility census was 80. Findings include: Review of the facility's Psychotropic Medication Use policy, reviewed on 09/07/23, revealed, . Psychotropic drug is any drug that affects brain activities associated with mental processes and behavior . PRN orders for psychotropic drugs are limited to 14 days. If the medical provider believes that it is appropriate for the PRN order to be extended beyond 14 days, the medical provider should document their rationale in the resident's medical record and indicate the duration for the PRN order . 1. Review of R16's Resident Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R16 was admitted to the facility on [DATE] with diagnoses that included anxiety with depression. Review of R16's [Hospital] DC [Discharge] Summary, dated 12/02/24 and located in the Admission Documents portion of the Resident Documents tab of the EMR, revealed an order upon discharge from the hospital to continue alprazolam (an anti-anxiety medication) 0.5 milligrams (mg) in the morning, at noon, and at bedtime PRN for anxiety. Review of R16's Orders tab of the EMR revealed an order dated 12/02/24 for alprazolam 0.5mg every eight hours PRN for anxiety. There was no end date for the PRN anti-anxiety medication until it was added on 12/31/24. Review of the facility's December SNF [skilled nursing facility] Review, completed by the pharmacist, revealed R16's medications were reviewed on 12/03/24, without mention of the alprazolam. Review of R16's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/08/24 and located in the RAI tab of the EMR, revealed R16 scored 15 out of 15 on her Brief Interview for Mental Status (BIMS), which indicated she was cognitively intact. During an interview on 01/01/25 at 11:10 AM, R16 reported she took the PRN alprazolam frequently at night to help her settle for the night and into the next morning. 2. Review of R282's Resident Face Sheet, located in the Face Sheet tab of the EMR, revealed R282 was admitted to the facility on [DATE]with diagnoses that included pneumonia and chronic respiratory failure. Review of R282's [Hospital] DC Summary, dated 12/06/24 and located in the Admission Documents portion of the Resident Documents tab of the EMR, revealed an order upon discharge from the hospital to start taking hydroxyzine pamoate (an antihistamine medication which can be used to help control anxiety) 50mg every six hours if needed for anxiety for up to 10 days. Review of R282's Orders tab of the EMR revealed an order dated 12/06/24 for hydroxyzine pamoate 50mg every six hours PRN for anxiety. The order had no end date. Review of the facility's December SNF Review, completed by the pharmacist, revealed R282's medications were reviewed on 12/07/24, without mention of the hydroxyzine. Review of R282's admission MDS, with an ARD of 12/12/24 and located in the RAI tab of the EMR, revealed R282 scored 14 out of 15 on his BIMS, which indicated he was cognitively intact. During an interview on 12/31/24 at 8:30 AM, R282 reported he did not think he had used the PRN hydroxyzine. During an interview on 01/01/25 at 11:23 AM, Licensed Practical Nurse (LPN) 2 stated PRN psychotropic medications or medications used as an anti-anxiety medication needed an end date. LPN2 stated she thought the end date was 14 days from the start of the medication. During an interview on 01/01/25 at 2:35 PM, LPN1 stated she believed scheduled psychotropic medications had an end date but PRN psychotropic medications did not have end dates. During a concurrent interview on 01/01/25 at 3:19 PM, with LPN Infection Preventionist (IP) and Registered Nurse, Clinical Manager (CM) 2, the IP stated if a PRN psychotropic medication was not needed, the facility checked with the provider about discontinuing it. The IP stated the pharmacist reviewed medications and rounded with the nurse practitioner, seeing residents weekly. The IP was uncertain what the regulatory requirement was regarding end dates for PRN psychotropic medications. CM2 stated she reviewed medication orders for newly admitted residents as did the pharmacist. CM2 stated the nurse practitioner or doctor set the end dates for PRN psychotropic medications. CM2 was unsure what the regulatory requirement was regarding end dates for PRN psychotropic medications. During an interview on 01/01/25 at 3:35 PM, the Director of Nursing (DON) reported she expected nurses to enter an end date of 14 days for PRN psychotropic medication orders, and after 14 days, the doctor could renew the order or discontinue the medication if it was not used. The DON stated consequences of not having an end date included falls, oversedation, and polypharmacy. The DON stated that R282 had not used his PRN hydroxyzine, so the facility would check on discontinuing it. The DON stated that since R16 used her PRN alprazolam frequently, hers was renewed for 14 days.

Based on interview, record review, and policy review, the facility failed to ensure the medical record was accurate and complete for one out of 25 sampled residents (Resident (R) 37). R37's record did not include the updated Preadmission Screening and Resident Review (PASRR) Level 1 form, and R37 was documented with a serious mental illness diagnosis of bipolar disease that was not accurate. This created the potential for R37 to experience the stigma associated with mental illness and for staff and medical providers not to have full and accurate information about R37's mental health condition. The facility census was 80. Review of the facility's Admission Prescreening for Individuals with Mental Retardation or Mental Illness policy, dated 2021, revealed, Missouri law mandates preadmission screening for all individuals with mental illness (MI) or mental retardation (MR) who apply to long term care facility . The policy indicated if the resident had a serious mental illness diagnosis, a referral would be made to the designated state agency titled COMRU. COMRU would determine whether a PASRR Level 2 screening would be required, and this should be completed prior to the resident's admission to the facility. Review of the facility's Charting and Documentation in the Medical Record policy, dated 2023, revealed the purpose was, To ensure objective, accurate, timely and clinically complete information in the individual resident medical record . The medical record facilitates communication between the interdisciplinary team regarding the resident's condition and response to care . Review of R37's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/04/24 and located in the electronic medical record (EMR) under the RAI [Resident Assessment Instrument] tab, revealed R37 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. It was recorded that R37 did not have a serious mental illness. Review of R37's Physician Order Report, dated 02/22/21 - 03/22/21 and provided by the facility, revealed documentation that R37 had a diagnosis of bipolar disorder. Review of R37's EMR revealed it did not have the most current PASRR Level 1 located within the record. Review of R37's PASRR Level 1, dated 02/16/21 and provided by the facility, revealed documentation R37 did not have a serious mental illness. The diagnosis of bipolar disorder was not identified. The PASRR Level 2, therefore, did not trigger to be completed and was not completed or found in the medical record. Review of the undated CCD [Continuity of Care Document], located in the EMR under the Resident tab and reviewed on 12/31/24, revealed a diagnosis of bipolar disorder, current episode hypomanic, initiated on 07/31/23. Review of R37's Care Plan, dated 07/12/24 and located in the EMR under the RAI tab, revealed a problem of Behavioral Symptoms, I have serious mental illness bipolar disorder, current episode hypomanic . Review of all the Progress Notes, from 01/01/2023 - 12/31/24 and located in the EMR under the Resident tab, revealed only one entry with documentation of bipolar disorder. Review of R37's IDT [Interdisciplinary] Psych Medication Note, dated 02/22/24 and located in the EMR under the Progress Notes tab, revealed, . Resident remains on Trazodone 150 mg [milligrams] at HS [hour of sleep] depression . Olanzapine [antipsychotic medication] 2.5 mg at HS, 5 mg [milligrams] at noon, Bipolar . Review of R37's medical record revealed additional conflicting information regarding whether R37 had a diagnosis of bipolar disorder. The Physician Order Report, dated 02/22/21 - 03/22/21 and provided by the facility, revealed R37 had a diagnosis of bipolar disorder; however, the current Physician Order Report, dated 12/02/24 - 01/02/25 and located in the EMR under the Orders tab under the heading of Diagnoses, did not document bipolar disorder. Review of R37's comprehensive MDS assessments, provided by the facility and from admission through the survey (admission MDS with an ARD of 02/24/21, annual MDS with an ARD of 02/08/22, annual MDS with an ARD of 12/21/22, and annual MDS with an ARD of 12/04/23), reviewed no documentation that R37 had a serious mental illness. Review of the untitled Discontinued Diagnoses Report, from admission through 01/02/25 and provided by the facility, revealed the diagnosis of bipolar disorder was first added on 02/18/21 and was discontinued on 10/27/22. The diagnosis of bipolar disorder was added a second time on 07/31/23 and was discontinued during the survey on 01/01/25. During an interview on 12/31/24 at 3:55 PM, the Administrator stated the PASRR Level 1 completed on 02/16/21 did not document presence of a serious mental illness. The Administrator stated if serious mental illness and/or a psychiatric stay or other indicator had been documented on the PASRR Level 1 form, the form would have been sent to the state agency COMRU (Central Office Medical Review Unit) to make the decision whether a PASRR Level 2 was needed. During an interview on 01/01/25 at 3:44 PM, the Director of Nursing (DON) stated she was not sure how the diagnosis of bipolar disease got added to the CCD/Face Sheet document. The DON stated the resident's attending Physician did not document bipolar disorder in the Physician Notes and neither did the Psychiatrist. The DON stated after the issue was brought to her attention during survey, she called R37's psychiatry physician group, and they reviewed R37's information and instructed the DON to discontinue the bipolar diagnosis from R37's record, which had been done. Review of R37's Nurse's Note, dated 01/01/25 and located in the EMR under the Progress Notes tab, revealed, Writer spoke to [Psychiatrist's name] resident's psychiatrist regarding bipolar diagnosis not found on recent past psych visits. [Psychiatrist's name] stated dc [discontinue] bipolar disorder and use major depressive disorder diagnosis. Bipolar diagnosis dc'd [discontinued] per MD [Medical Doctor] order. Call out to [family Member] to let her know Bipolar diagnosis was removed and keep Major Depressive Disorder. [Family Member] stated, 'Good, I have been telling them for years she is not Bipolar . Review on 01/02/25 of the undated CCD in the EMR under the Resident tab showed the diagnosis of bipolar disorder had been deleted. During an interview on 01/02/25 at 2:35 PM, the Administrator stated the bipolar diagnosis was first noted on 03/11/21 by the Nurse Practitioner (NP). The Administrator verified inconsistent documentation in the record regarding the bipolar disorder diagnosis. The Administrator stated R37 had several admissions in and out of the hospital since she was originally admitted to the facility. The Administrator stated an additional PASRR Level 1 form was found that identified serious mental illness with the diagnosis of bipolar disorder. The Administrator stated this PASRR Level 1 had not been in R37's EMR. Review of R37's PASRR Level 1, dated 02/16/24 and provided by the Administrator on 01/02/25 at 2:35 PM, revealed R37 had received intensive psychiatric treatment for a diagnosis of bipolar. This PASRR Level 1 had been referred to COMRU to determine whether a PASRR Level 2 was needed. An attempt to interview R37 was made on 01/02/24 at 11:40 AM; however, the resident was sleeping and was not available for interview.

Based on observation, record review and interviews, the facility failed to assure staff used the residents' comprehensive assessments to develop and implement a comprehensive person-centered plan of care consistent with the resident rights that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for four of 19 sampled residents (Resident #55, #89, #120 and #382). The facility census was 95. Review of the facility provided Comprehensive Care Plan Workload document, dated 9/1/22, showed: - The Minimum Data Set (MDS: a mandated assessment tool completed by the facility) Coordinator will use the Baseline Care Plan to build a Comprehensive Care Plan. Review of the Comprehensive Assessments and Care Planning policy, dated 2017, showed: - Purpose: To provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physicial, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs. - A facility should use the results of the assessment to develop, review, and revise the resident's person-centered comprehensive plan of care. - All person-centered care plan interventions will be implemented by qualified personnel. Interventions may be communicated through the electronic health record, resident profile, assignment sheets, and/or verbal communication. 1. Review of Resident #55's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 11/3/22, showed: - Staff did not complete the Brief Interview of Mental Status (BIMS) or indicate if the resident had any long- or short-term memory issues; - Extensive assistance to total dependence on staff for Activities of Daily Living (ADLs: activities related to personal care that include: bathing/ showering, dressing, getting in/ out of bed or a chair, walking, using the toilet, and eating.) - Functional limitation in range of motion (ROM: the normal range of movement of a joint) of the upper extremity including shoulder, elbow, wrist or hand. - Diagnoses of Alzheimer's dementia (a progressive disease that destroys memory and other important mental functions.), adult failure to thrive (a syndrome of weight loss, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function), and transischemic attack (a temporary blockage of blood to the brain with symptoms like a stroke, that may have lasting effects of weakness, decreased mobility and cognitive issues). Review of the physician order sheet dated February 2022 showed an order dated 9/24/21, to place a rolled washcloth in the resident's left hand to help with contractures. Review of the resident's comprehensive care plan, dated 8/3/21, showed: - Alterations in self care: need for assistance with ADLs; - Hospice care. - Impaired visual function. - Nutritional risk. - Risk for falls. - Behavioral symptoms: refusal of care - Staff did not include any interventions for the resident's contractures and the need for him/her to have a rolled washcloth in his/her left hand. Observation during the annual survey showed: - 3/1/23 at 3:55 P.M the resident had no washcloth in his/her left hand; - 3/2/23 at 9:02 A.M. the resident had no washcloth in his/her left hand; - 3/2/23 at 11:31 A.M. the resident sat up at the nurses' station, with no washcloth in his/her left hand. The resident was able to open his/her first finger and thumb. He/she was unable to straighten fingers #3-5. The resident was asked to open hand, he/she shook his/her head no. The resident was then asked if his/her hand hurt and resident shook his/her head no. Then the resident was asked if it hurt to open his/her hand, and the resident nodded his/her head yes. During an interview on 3/2/23 at 11:17A.M., Certified Nurse Aide (CNA) A who also worked as the restorative nursing aide (RA), said: - The resident is not currently on his/her RA caseload. - He/she worked the floor sometimes and helped the resident eat, and move his/her arms. - He/she did not know about a hand roll for this resident. - He/she would use the care plan to know what care to provide each resident. During an interview on 3/2/23 at 11:37 A.M., Licensed Practical Nurse (LPN) D said - He/she believed hospice staff may apply the washcloth to the resident's hand two to three times per week. - He/she and staff did not apply the hand roll. - He/she did not know the resident had an order for staff to place a rolled washcloth to the reisdent's hand. During an interview on 3/2/23 at 3:39 P.M., CNA D said: - The care plan was how he/she knew what care to provide residents. During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said: - The resident should have a washcloth in his/her hand. - The resident removed the washcloth at times. - The MDS Coordinator completed the care plans. - Charge Nurses on the floor can add information to the care plan as needed. 44939 2. Review of Resident #89's significant change in condition MDS, dated [DATE], showed: - He/she understood others and made him/herself understood. - Score of 10 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates moderately impaired cognition. - He/she required extensive assistance from staff with ADLs, including dressing, bathing, and personal hygiene. - Two Stage 2 pressure ulcers (partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater). - Diagnoses included stroke (damage to the brain from interruption of its blood supply), pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), and Diabetes Mellitus Type 2 (a chronic condition that affects the way the body processes blood sugar). Review of the resident's progress notes showed: -12/27/22 admitted to hospital for shortness of air. diagnosed at hospital with pneumonia after chest xray done. -1/3/23 Returned to facility with orders for oxygen as needed and antibiotics. -1/26/23 Skin assessment completed. No issues noted. -2/28/23 at 4:05 P.M.: Rash noted to under the resident's left breast on 2/27/23. Review of the resident's comprehensive care plan, dated 1/23/23, showed: - No care plan interventions addressing skin break down or rash under breast. - No care plan interventions addressing respiratory needs, including oxygen as needed. 47141 3. Review of Resident #120's face sheet shows: - admitted to facility on 12/31/22; - Diagnoses include morbid (severe) obesity with alveolar hypoventilation (rare disorder in which a person does not take enough breaths per minute), septic pulmonary embolism (unusual condition characterized by the implantation of infected thrombi into the pulmonary vasculature from a variety of infectious sources, resulting in a parenchymal infection with high morbidity and death) with acute cor pulmonale (a condition that causes the right side of the heart to fail). Review of resident's admission MDS dated [DATE], showed: - BIMS score of 12. - Diagnoses include pneumonia, chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs); - Required extensive assistance with bed mobility, dressing, and personal hygiene; activity did not occur for walking in room/corridor, locomotion on/off unit, total dependence on staff for toilet use and bathing; - Required a wheelchair for assistance. - Received oxygen therapy. Review of resident's undated care plan showed staff did not include any interventions to address the use of oxygen. 4. Review of Resident #382's admission MDS, dated [DATE], showed: - admitted to facility 2/1/23; - Cognitively intact; - Diagnoses include septicemia (disease caused by the spread of bacteria and their toxins in the bloodstream), Diabetes Mellitus (disease in which the body does not control the amount of glucose in the blood and the kidneys make a large amount of urine), aphasia (disorder that affects how you communicate), stroke, hemiplegia (condition caused by a brain injury that results in a varying degree of weakness, stiffness and lack of control in one side of the body), traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), malnutrition, respiratory failure (a serious condition making it difficult to breathe on your own); - Total dependence upon staff for bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing; - Direct care staff did not believe he/she was capable of increased independence in some activities of daily living (ADL). - Nutrition received via feeding tube. Review of the resident's baseline care plan summary, dated 2/1/23, showed: - admitted for encephalopathy (a broad term for any brain disease that alters brain function or structure; causes include infection, tumor, and stroke); - Unable to speak; non-verbal; - Dependent on staff for all ADLs; used a peg tube for eating; - Nothing by mouth; Isosource at 60 ml/hour continuous; flush with 150 cc water every four hours; - Frequent oral care; suction machine at bedside. Review of resident's undated care plan showed it did not address his/her nutritional status, ADL function, falls, skin, pain, mood, cognitive loss, medications, therapy services, communication, dehydration or special treatments. 5. During an interview on 3/6/23 1:16 P.M., the Clinical Reimbursement Coordinator said: - He/she is responsible for developing and updating care plans. - Clinical managers are also responsible for updating care plans. - Baseline care plans should be in the chart within the first 48 hours. - Comprehensive care plans should be completed within 7 days after the MDS is completed. - Care plans should be updated quarterly, significant change, annually and as needed. - He/she is aware that there are care plans that are late and have not been updated. During an interview on 3/6/23 at 3:54 P.M., the Administrator said: - The MDS Coordinator and nursing floor staff are responsible for creating and updating comprehensive care plans. - Comprehensive care plans should be in place 21 days from admission. They should be updated quarterly, significant changes, annuals and as needed. - It is his/her expectation that comprehensive care plan are in place, updated and correct.

Based on record review and interview, the facility failed to hold residents' monies separate from facility money when they did not reimburse residents and/or their responsible parties after the residents were discharged , which affected six residents (Residents #994, #995, #996, #997, #998, and #999). The facility census was 95. Review of facility policy, Refunds - Credit Balances, dated [DATE], showed: -Purpose: To prevent fraud, waste, and abuse and manage reimbursement; -Policy: All credit balances will be reviewed within 30 days from being identified. Under the Patient Protection and Affordable Care Act, Title VI entitled Transparency and Program Integrity section 6402; overpayments from Federal payers must be refunded within 60 days after the date on which the overpayment was identified. Federal payers include Medicare A and B, Medicaid, Veterans Association, Medicare Advantage or any other payer under title XVIII and XIX; -Private Pay - For residents who have discharged and have a credit balance, complete the eSource Request for Refund if, all other payer balances is zero. If there is a balance under another payer, refund amounts up to the outstanding balance owed under the other payer are allowed; -Resident Liability- If the resident expired, contact the county regarding disbursement location. If the resident discharges, refund the resident. 1. Review of the facility's Payer Aging Report (A/R) Credit Balance Summary, dated [DATE], showed: -Resident #994, discharged on [DATE], had a negative balance of -7.77; -Resident #995, discharged on [DATE], had a negative balance of -14.20; -Resident #996, discharged on [DATE], had a negative balance of -1420.00; -Resident #997, discharged on [DATE], had a negative balance of -5,565.00; -Resident #998, discharged on [DATE], had a negative balance of -4,000.00; -Resident #999, discharged on [DATE], had a negative balance of -1,375.00. During an interview on [DATE] at 8:41 A.M., the Business Office Manager said: -He/she started four months ago; -He/she did not know how long the facility held funds; -Resident #994 discharged and had a new balance this month; -Resident #995's check was issued for the wrong amount; the correct amount was being processed; -He/she did not know why Resident #996's funds were not refunded; -Resident #997 passed away on [DATE]; he/she did not know why funds had not been processed; -Resident #998 expired on [DATE]. The refund request was submitted to corporate on [DATE]; -Resident #999 expired on [DATE]; he/she did not know if a refund request had been made; -Refund requests are initiated at the corporate office level; -The refund process was led by corporate office who reviewed account credits and started the refund process; During an interview on [DATE] at 10:57 A.M., the Director of Revenue Cycle Management said: -Resident #995 was due a $14.20 refund. Corporate needed to issue a credit back and the refund request had not been made by the Business Office Manager -Resident #996 had a credit of $1420.00; The refund was in the final approval process; -Resident #997 had a credit of $5,565; The refund needed approved by the Executive Director first; -Resident #998 had a $4,000 credit; the refund request was entered on [DATE] but had not been approved by the Executive Director yet; -The Executive Director did not sign off on any refunds during February; -Resident #999 had a $1375 credit; the refund request was made on [DATE] and was waiting for Executive Director approval; -Resident funds should be returned in thirty days. During an interview on [DATE] at 11:15 A.M., the Executive Director said: -Resident funds should be returned within thirty days; -He/she was not aware funds had not been processed within thirty days; -He/she received emails of resident reimbursements for approval; -He/she was not aware of any unapproved reimbursements; -He/she was not aware of any reimbursements that had not been approved. During an interview on [DATE] 02:25 P.M., the Administrator said: -Funds should be returned to a resident within 30 days of discharge or expiration from facility; -He/she was aware of accounts that are beyond thirty days.

Based on the record review and interview, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected four of ten sampled staff (Cook A, Housekeeper A, Physical Therapy Assistant, Culinary Services Aide F). The facility census was 95. Review of the facility policy, Abuse Prevention Plan, dated 7/21/22, showed: -All potential employees will be screened during the hiring and re-hiring process for a history of abuse, neglect, financial exploitation, misappropriation of resident property, or mistreatment of a vulnerable adult; -Inquiries will be made into the state licensing authorities or Nursing Assistant Registry; -The facility will prohibit employment of individuals with a disciplinary action in effect against their professional license by a state licensure body as a result of a guilty finding of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. 1. Review of Cook A's employee file showed: -Hired on 12/5/2022; -No CNA Registry check found. 2. Review of Housekeeper A's employee file showed: -Hired on 2/20/23; -No CNA Registry check found. 3. Review of Physical Therapy Assistant's employee file showed: -Hired on 3/21/14; -No CNA Registry check found. 4. Review of Culinary Services Aide F showed: -Hired on 4/3/22; -No CNA Registry check found. During an interview on 2/28/23 at 3:54 P.M., the Administrator said he/she did not know non-nursing staff had to be checked on the nurse aide registry. During an interview on 3/2/23 at 9:38 A.M., the Human Resources Manager said: -Nurse aide registry checks should be completed twice a year or quarterly. -He/she completed registry checks in January; -He/she was not aware that CNA registry checks should be completed on all employees upon hire.

Based on interview and record review, the facility failed to ensure they completed and submitted to Centers for Medicare and Medicaid (CMS) comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by staff) according to the required timeframes. This affected two of 19 sampled residents (Residents #28 and #84). The facility census was 95. Review of the facility's Comprehensive Assessments and Care Planning policy, dated 2017, showed: - A facility must conduct a comprehensive assessment of a resident as follows: a. Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. b. Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. - Within seven days after a facility completes a resident's assessment: a. A facility must enter the MDS information into a computer. b. A facility must be capable of transmitting to the State information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. - A facility must electronically transmit, at least monthly, encoded, accurate, complete MDS data to the State for all assessments conducted during the previous month, including the following: a. Admission assessment b. Annual Assessment c. Significant change in status assessment - MDS will be completed by each department by day seven after the Assessment Reference Date (ARD, the last day of the observation period the assessment covers). - Annual MDS process must be completed no later than 366 days from the full MDS and not more than 92 days from the third quarterly MDS. - Significant Change MDS process must be completed 14 days from the time a significant change is identified. 1. Review on 2/28/23 of Resident #84's facility MDS records showed the facility completed the following assessments: - Significant change in condition MDS assessment was dated 11/11/22. gave me. - Alert noting the MDS was still In Process. - Last completed and submitted comprehensive MDS was a Significant Change assessment dated [DATE]. Review on 2/28/23 of the resident's MDS record in the Centers for Medicare and Medicaid's reporting system (ASPEN) showed: - Significant change in condition MDS assessment was dated 11/11/22. - Last completed and submitted comprehensive MDS was a significant change in condition assessment dated [DATE]. 2. Review on 2/28/23 of Resident #28's MDS facility record showed: - Quarterly MDS assessment dated [DATE]. - Alert noting that the MDS was still In Process. - Last completed and submitted comprehensive MDS was a Significant Change assessment dated [DATE]. Review on 2/28/23 of Resident #28's MDS record in ASPEN showed: -Quarterly MDS assessment dated [DATE]. -Last completed and submitted comprehensive MDS was a significant change in condiction assessment dated [DATE]. 3. During an interview on 3/6/23 at 2:00 P.M., the MDS Coordinator said: - He/she has worked in the MDS Coordinator position since August 2022. - He/she was responsible for completing and submitting MDS assessments. - MDS assessments should be completed and submitted in a timely manner, according to the appropriate time line. - Admission MDS should be completed within 14 days of a resident's admission. On Annual and Significant Change in condition MDS assessments, staff have seven days to conduct the assessment then seven days to enter the information into the MDS, which she then submitted. - She knew some of the MDS assessments were late and have not been submitted. They were just late. During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said: - The MDS team was responsible for completing and submitting MDS assessments. - She knew they had late MDS assessments that had not been submitted. - Several of the MDS team members had been out with health issues. There was also confusion in regards to what the corporate office wanted in regards to who was responsible for completing and submitted MDS assessments. During an interview on 3/6/23 at 3:54 P.M., the Administrator said: - The Clinical Reimbursement Nurse was also the MDS Coordinator and was responsible for completing and submitting MDS assessments. - She expected staff to complete and submit MDS assessments on time. - She knew they had MDS assessments that were late and not submitted.

Based on interview and record review, the facility failed to ensure they completed, submitted to Centers for Medicare and Medicaid (CMS) and they accepted the Minimum Data Set (MDS, a federally mandated assessment completed by staff) on a quarterly basis. This affected six of 19 sampled residents (Residents #28, #68, #75 #84, #87, and #227). The facility census was 95. Review of the facility's Comprehensive Assessments and Care Planning policy, dated 2017, showed: - A facility must conduct a comprehensive assessment of a resident as follows: c. Using the quarterly review instrument specified by the State and approved by Center for Medicare and Medicaid (CMS) not less frequently than once every 3 months. - Within seven days after a faciltiy completes a resident's assessment: a. A facility must enter the MDS information into a computer. b. A facility must be capable of transmitting to the State information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. - A facility must electronically transmit, at least monthly, encoded, accurate, complete MDS data to the State for all assessments conducted during the previous month, including the following: f. Quarterly Review - MDS will be completed by each department by day seven after the Assessment Reference Date (ARD, the last day of the observation period the assessment covers). - Quarterly MDS is due within 92 days of the last Quarterly or Full MDS. 1. Review on 2/28/23 of Resident #84's facility MDS record showed: - Significant change in condition MDS assessment dated [DATE]. - Alert noting the MDS was In Process. - Last completed and submitted comprehensive MDS was a Significant Change assessment dated [DATE]. Review on 2/28/23 of the resident's MDS record in the Centers for Medicare and Medicaid's centralized reporting system (ASPEN) showed: -Significant change in condition MDS assessment was dated 11/11/22. -Last completed and submitted comprehensive MDS was a significant change in condition assessment dated [DATE]. -There is one missing Quarterly assessment. 2. Review on 2/28/23 of Resident #68's MDS record showed: -Quarterly MDS assessment dated [DATE]. -Alert noting that the MDS was In Process. -Last completed and submitted MDS was an Admission assessment dated [DATE]. Review on 2/28/23 of the resident's MDS record in ASPEN showed: -Quarterly MDS assessment dated [DATE]. -Last completed and submitted MDS was an Admission assessment dated [DATE]. -There is one missing Quarterly assessment. 3. Review on 2/28/23 of Resident #227's MDS record showed: -Quarterly MDS assessment dated [DATE]. -Alert noting that the MDS was In Process. -Last completed and submitted MDS was a Quarterly assessment dated [DATE]. Review on 2/28/23 of the resident's MDS record in ASPEN showed: -Quarterly MDS assessment dated [DATE]. -Last completed and submitted MDS was a Quarterly assessment dated [DATE]. -There is one missing Quarterly assessment. 4. Review on 2/28/23 of Resident #87's MDS record showed: -Quarterly MDS assessment dated [DATE]. -Alert noting that the MDS was In Process. -Last completed and submitted MDS was a Quarterly assessment dated [DATE]. Review on 2/28/23 of the resident's MDS record in ASPEN showed: -Quarterly MDS assessment dated [DATE]. -Last completed and submitted MDS was a Quarterly assessment dated [DATE]. -There is one missing Quarterly assessment. 5. Review on 2/28/23 of Resident #28's MDS record showed: -Quarterly MDS assessment dated [DATE]. -Alert noting that the MDS was In Process. Review on 2/28/23 of the resident's MDS record in ASPEN showed: -Quarterly MDS assessment dated [DATE]. -There is one missing Quarterly assessment. 6. Review on 2/28/23 of Resident #75's MDS record showed: -Quarterly MDS assessment dated [DATE]. -Alert noting that the MDS was In Process. -Last completed and submitted MDS was a Significant Change assessment dated [DATE]. Review on 2/28/23 of the resident's MDS record in ASPEN showed: -Quarterly MDS assessment dated [DATE]. -Last completed and submitted MDS was a Significant Change assessment dated [DATE]. -There are 2 missing Quarterly assessments. 7. During an interview on 3/6/23 at 2:00 P.M., the MDS Coordinator said: - She has worked in the MDS Coordinator position since August 2022. - She is responsible for completing and submitting MDS assessments. - MDS assessments should be completed and submitted in a timely manner, according to the appropriate time line. -Staff have seven days to conduct the quarterly assessments then seven days to enter the information into the MDS, which they then submit. - She knew they had late MDS assessments that had not been submitted. They were late. During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said: - The MDS team was responsible for completing and submitting MDS assessments. - She knew MDS assessments were late and had not been submitted. - Several of the MDS team members had been out with health issues. There was also confusion in regards to what the corporate office wanted in regards to who was responsible for completing and submitted MDS assessments. During an interview on 3/6/23 at 3:54 P.M., the Administrator said: - The Clinical Reimbursement Nurse was also the MDS Coordinator and was responsible for completing and submitting MDS assessments. - She expected staff to complete and submit MDS assessments on time. - She knew they had late MDS assessments that not been submitted.

Based on interview and record review, the facility failed to ensure they completed and transmitted to Centers for Medicare and Medicaid (CMS) and they accepted the Minimum Data Set (MDS, a federally mandated assessment completed by staff) according to the required timeframes. This affected six of 19 sampled residents (Residents #28, #68, #75, #84, #87, and #227). The facility census was 95. Review of the facility's Comprehensive Assessments and Care Planning policy, dated 2017, showed: - A facility must conduct a comprehensive assessment of a resident as follows: a. Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. b. Within 14 days after the facility determines, or should have determined, that there has been a significant change int he resident's physical or mental condition. c. Using the quarterly review instrument specified by the State and approved by Center for Medicare and Medicaid (CMS) not less frequently than once every three months. d. Not less than once every 12 months. - Within seven days after a faciltiy completes a resident's assessment: a. A facility must enter the MDS information into a computer. b. A facility must be capable of transmitting to the State information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. - A facility must electronically transmit, at least monthly, encoded, accurate, complete MDS data to the State for all assessments conducted during the previous month, including the following: a. Admission assessment b. Annual Assessment c. Significant change in status assessment f. Quarterly Review - MDS will be completed by each department by day seven after the Assessment Reference Date (ARD, the last day of the observation period the assessment covers). - Quarterly MDS is due within 92 days of the last Quarterly or Full MDS. - Annual MDS process must be completed no later than 366 days from the Full MDS and not more than 92 days from the third Quarterly MDS. - Significant Change MDS process must be completed 14 days from the time a significant change is identified. 1. Review on 2/28/23 of Resident #84's MDS record showed: -Significant Change MDS assessment was dated 11/11/22. -Alert noting that the MDS was In Process. -Last completed and submitted comprehensive MDS was a Significant Change assessment dated [DATE]. Review on 2/28/23 of the resident's MDS record in CMS' centralized reporting system (ASPEN) showed: -Significant Change MDS assessment was dated 11/11/22. -Last completed and submitted MDS was a Significant Change assessment dated [DATE]. -There is one missing Quarterly assessment. 2. Review on 2/28/23 of Resident #68's MDS record showed: -Quarterly MDS assessment dated [DATE]. -Alert noting that the MDS was In Process. -Last completed and submitted MDS was an Admission assessment dated [DATE]. Review on 2/28/23 of the resident's MDS record in ASPEN showed: -Quarterly MDS assessment dated [DATE]. -Last completed and submitted MDS was an Admission assessment dated [DATE]. -There is one missing Quarterly assessment. 3. Review on 2/28/23 of Resident #227's MDS record showed: -Quarterly MDS assessment dated [DATE]. -Alert noting that the MDS was In Process. -Last completed and submitted MDS was a Quarterly assessment dated [DATE]. Review on 2/28/23 of the resident's MDS record in ASPEN showed: -Quarterly MDS assessment dated [DATE]. -Last completed and submitted MDS was an Quarterly assessment dated [DATE]. -There is one missing Quarterly assessment. 4. Review on 2/28/23 of Resident #87's MDS record showed: -Quarterly MDS assessment dated [DATE]. -Alert noting that the MDS was In Process. -Last completed and submitted MDS was a Quarterly assessment dated [DATE]. Review on 2/28/23 of the resident's MDS record in ASPEN showed: -Quarterly MDS assessment dated [DATE]. -Last completed and submitted MDS was a Quarterly assessment dated [DATE]. -There is one missing Quarterly assessment. 5. Review on 2/28/23 of Resident #28's MDS record showed: -Quarterly MDS assessment dated [DATE]. -Alert noting that the MDS was In Process. -Last completed and submitted comprehensive MDS was a Significant Change assessment dated [DATE]. Review on 2/28/23 of the resident's MDS record in ASPEN showed: -Quarterly MDS assessment dated [DATE]. -Last completed and submitted MDS was a Significant Change assessment dated [DATE]. -There is one missing Quarterly assessment. 6. Review on 2/28/23 of Resident #75's MDS record showed: -Quarterly MDS assessment dated [DATE]. -Alert noting that the MDS was In Process. -Last completed and submitted MDS was a Significant Change assessment dated [DATE]. Review on 2/28/23 of the resident's MDS record in ASPEN showed: -Quarterly MDS assessment dated [DATE]. -Last completed and submitted MDS was a Significant Change assessment dated [DATE]. -There are two missing Quarterly assessments. 7. During an interview on 3/6/23 at 2:00 P.M., the MDS Coordinator said: -He/she has worked in the MDs Coordinator position since August 2022. -He/she is responsible for completing and submitting MDS assessments. -MDS assessments should be completed and submitted in a timely manner, according to the appropriate time line. -Admission MDS should be completed within 14 days of a resident's admission. On Quarterly, Annual and Significant Change MDS assessments, staff have 7 days to conduct the assessment and then 7 days to enter the information into the MDS, which is then submitted. -He/she is aware that there are MDS assessments that are late and have not been submitted. When asked why this was, he/she said it was becuase they were late. During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said: -The MDS team is responsible for completing and submitting MDS assessments. -He/she is aware that there are MDS assessments that are late and not been submitted. -Several of the MDS team members have been out with health issues. There was also confusion in regards to what the corporate office wanted in regards to who was responsible for completing and submitted MDS assessments. During an interview on 3/6/23 at 3:54 P.M., the Administrator said: -The Clinical Reimbursement Nurse is also the MDS Coordinator. He/she is responsible for completing and submitting MDS assessments. -It is his/her expectation that MDS assessments are completed and submitted on time. -He/she is aware there are MDS assessments that are late and not been submitted. There is an action plan in place with the corporate office and the corporate team is assisting in getting the MDS assessments up to date.

Based on observation, interview and record review, the facility failed to date and time enteral feeding bag (bags that are used with feeding pumps) to ensure residents receiving nutrition via feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) are not receiving spoiled formula, for one resident (Resident #382) out of nineteen sampled residents. The facility census was 95. Review of the undated facility policy for Monitoring Residents Receiving Enteral Feedings (a form of nutrition that is delivered into the digestive system as a liquid) showed: - The nutritional status of resident's who receive enteral nutrition/feedings will be evaluated and monitored on an ongoing basis by the Dietitian/designee to assure their nutritional needs are being met. - Procedure: A resident who obtains nutrition per an enteral feeding will receive appropriate treatment and services to prevent complications and to restore if possible, oral intake; the nursing department is responsible for the administration of enteral feedings and all feeding equipment. - The policy did not address dating/timing the feeding bag. 1. Review of Resident #382's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 2/4/23, showed: - admitted to facility 2/1/23; - Cognitively intact; - Diagnoses include septicemia (disease caused by the spread of bacteria and their toxins in the bloodstream), Diabetes Mellitus (disease in which the body does not control the amount of glucose in the blood and the kidneys make a large amount of urine), aphasia (disorder that affects how you communicate), stroke, hemiplegia (condition caused by a brain injury that results in a varying degree of weakness, stiffness and lack of control in one side of the body), traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), malnutrition, respiratory failure (a serious condition making it difficult to breathe on your own); - Total dependence upon staff for bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing; - Direct care staff did not believe he/she was capable of increased independence in some activities of daily living (ADL). - Nutrition received via feeding tube. Review of the resident's baseline care plan summary, dated 2/1/23, showed: - admitted for encephalopathy (a broad term for any brain disease that alters brain function or structure; causes include infection, tumor, and stroke); - Unable to speak; non-verbal; - Dependent on staff for all ADLs; used a peg tube for eating; - Nothing by mouth; Isosource at 60 ml/hour continuous; flush with 150 cc water every four hours; - Frequent oral care; suction machine at bedside. Review of resident's current physician orders sheet (POS) showed: - Order dated 2/23/23: Isosource (a formula intended for the dietary management of malnourished or at risk of malnutrition patients) 1.5, 60 milliliters (ml) per hour continuous via peg tube (a tube inserted through the wall of the abdomen directly into the stomach) every shift. - Order dated 2/27/23: 150 cubic centimeter (cc) water flushes to peg tube every four hours (12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M.) Review of residents nutrition assessment dated [DATE] showed: - admitted related to metabolic encephalopathy due to sepsis, UTI, respiratory failure with history of brain aneurysm, DM. - Diet nothing by mouth (NPO) with g-tube feeding - Isosource 1.5 at 60 mls continous ith 150 ml's water flush every 4 hours to provide: 2160kcals, 98 grams protein and 2000 ml's fluid to meet estimated needs.- Eating ability: total assistance. Review of resident's undated care plan showed staff did not address anything related to his/her nutrition or he/she receiving enteral feeding via feeding tube. Review of resident's progress notes showed: - 2/15/23 at 1:37 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube. - 2/14/23 at 6:28 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube. - 2/13/23 at 5:16 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube. - 2/13/23 at 12:34 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube. - 2/12/23 at 3:45 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube. - 2/11/23 at 10:31 A.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube. - 2/10/23 at 1:52 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube. - 2/9/23 at 7:39 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube. - 2/8/23 at 11:08 A.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube. - 2/7/23 at 8:58 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube. Observation during the survey showed: - On 2/28/23 at 2:14 P.M., the resident had a feeding tube. He/she receiving 60 milliliters per hour via enteral feeding. A bag of Isosource hung from the pump without any date or time to indicate when staff hung the bag. - On 3/1/23 at 3:25 P.M., a bag of Isosource hung from the pump without any date or time to indicate when staff hung the bag; the pump ran at 60 ml/hour and had 450 ml remaining; - On 3/2/23 at 12:14 P.M., a bag of Isosource hung from the pump without any date or time to indicate when staff hung the bag. Review of the Isosource manufactuerer's usage showed, once opened, consume within twenty-four hours. During an interview on 3/2/23 at 11:15 A.M., Licensed Practical Nurse (LPN) B said: - Nursing staff administered feedings for residents who had peg tubes. - Staff should add a date and time to feeding begs when they hang them on the pumps for residents who had peg tubes. - He/she did not know how long a bag of Isosource was good for. During an interview on 3/2/23 at 11:45 A.M., Licensed Practical Nurse (LPN) B said: - He/she got clarification and the Isosource bag is only good for twenty-four hours. During an interview on 3/2/23 at 12:17 P.M., LPN C said: - Nursing staff hang the enternal feedings. - Staff should add the date and time they hang the bags - He/she believed it is policy. During an interview on 3/2/23 at 1:15 P.M., Registered Nurse (RN) A said: - LPN/RN provided any needed care for residents with a peg tube; - He/she will verify physicians order and check when in the room that it is working properly. - Staff should add the date and time to the bags when they hang them as they are only good for 24 hours. During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said: - The charge nurse is responsible or evaluation, changings and monitoring residents who require tube feedings. - Staff should be dating and timing the enternal feeding bags. - Adverse effect could be the resident getting spoiled formula if it is not dated.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain good personal hygiene for two of 19 sampled residents (Resident #39 and #95) who required assistance to perform activities of daily living. The facility census was 95. Review of the undated facility policy for activities of daily living showed: - The purpose is to provide residents with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). - Residents unable to carry out ADLs independently will receive the services necessary to maintain grooming and personal hygiene. - Care and services will be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistant with hygiene (bathing and grooming). - If resident refuses care, associates will approach at a different time, or having another associate speak with the resident as needed. - The resident's response to interventions will be documented, monitored, evaluated and revised as appropriate. 1. Review of Resident #39's face sheet showed: - readmitted [DATE]. - Diagnoses include post traumatic seizures, need for assistance with personal care, other reduced mobility, epilepsy (brain disorder that causes reoccuring, unprovoked seizures), muscle wasting and atrophy (thinning or loss of muscle tissue), difficulty in walking and encephalopathy (damage or disease that affects the brain). Review of resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 2/10/23, showed: - Brief Interview of Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment; - No rejection of activities of daily living (ADL) care; - Limited assist for bed mobility, transfers, dressing, toilet use, and hygiene with one person physical limited assist and physical help in part of bathing activity. - Always incontinent for urinary output; - Diagnosis of osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue). Review of resident shower sheets showed: - 2/4/23: resident refused; - 2/8/23: shower given - no documentation as to whether resident shaved. Review of progress notes showed: - 2/11/23 Resident received shower today no new skin issues noted. Reivew of resident's shower sheets showed: - 2/11/23: shower given - no documentation as to whether resident shaved; - 2/15/23: shower given - no documentation as to whether resident shaved; - 2/25/23: shower given - no documentation as to whether resident shaved. Observation and interview on 2/27/23 at 3:38 P.M., showed and the resident said: - He/she was observed with quarter inch chin hairs. - He/she did not know he/she had them and would like them removed. Review of progress notes showed: - 3/1/23 Resident received shower today from floor CNA, no new skin issues noted. Observation on 3/1/23 at 3:20 P.M., showed the resident observed with chin hairs. Review of resident shower sheets showed: - 3/1/23: shower given - no documentation on shower sheet to show resident shaved 2. Review of Resident #95's significant change in condition MDS, dated [DATE], showed: - readmitted back to facility on 12/10/22; - Unable to complete cognitive assessment; staff did not indicate if the resident had short- or long-term memory loss; - Diagnoses included hypertension, septicemia (blood poisoning by bacteria), wound infection and respiratory failure. - Extensive assist with bed mobility, dressing, eating, personal hygiene; two plus person assist with transfers; activity did not occur for walking in room, corridor or on/off unit or toilet use; total dependence upon staff for bathing. - Wheelchair for assistance. - Received oxygen therapy and hospice care. Review of resident's care plan, last reviewed and revised on 1/24/23 showed, it was not updated to reflect the significant change in activities of daily living. Review of resident's shower sheets showed: - 2/6/23: bed bath given. staff did not document to indicate they shaved the resident; - 2/16/23: bed bath given, staff documented they clipped the resident's nails and washed his/her hair but did not document they saved him/her. - 2/23/23: Shower not given. staff noted the resident's daughter told them hospice would provide a shower on Friday; - 2/27/23: Bed bath, hair washed. Staff did not document they shaved the resident. Observation on 2/28/23 at 9:51 A.M., showed: - He/she laying in bed; the resident had hair on his/her chin long enough to be observed when standing about 3 feet away; - A sign hung above the resident's bed which directed staff to not dry shave the resident as he/she had sensitive skin; During an interview on 2/28/23 at 2:37 P.M., the resident's representative said: - Resident was able to walk and talk when he/she admitted to facility but developed a pressure ulcer on his/her foot. - The resident then developed a pressure ulcer on his/her bottom and has since had a decline in health and is now on hospice care. - He/she had to put up signs in the residents room to direct staff not to dry shave the resident due to his/her sensitive skin. . During an interview on 3/2/23 at 9:25 A.M., Certified Nursing Aide (CNA) D said: - The facility had one shower aide who covered both the first and second floor. - Staff are expected to provide reidents with two showers per week; if they are on hospice, they get up to four showers a week. - He/she does not always depend on shower aides to give baths as he/she cannot guarantee showers will get done. - He/she has not been told by a resident recently they did not get a bath. - They fill out shower sheets and can write on shower sheets if residents were shaved, etc., but then he/she will pass that information on to the nurse as CNAs are unable to chart in their electronic medical record (EMR). If nursing does not get time to chart it, there can be communication errors on what was done. - After the shower sheets are filled out, they sign and give them to the nurse for them to review and sign. They then go to the Director of Nursing (DON). - For females, it is a dignity thing. If he/she noticed chin hair on female residents, he/she will shave them. - He/she recently had to shave Resident #90 and Resident #95. During an interview on 3/2/23 at 11:15 A.M., Licensed Practical Nurse (LPN) B said: - Everyone is responsible for resident showers including CNAs, nurses and shower aides. - They only have one shower aid for the first and second floor. - If shower aides are unavailable, CNAs do them. - Staff fill out a shower sheets after every bath/shower. - Once completed, they give to the nurse, they sign it and make a note in progress notes and then put in folder for the Clinical Resource Manager and then the Director of Nursing will upload them into the resident's medical record. - They have a shower schedule and residents get showers two times a week. - If a resident is on hospice, they will get two additional showers a week. During an interview on 3/2/23 at 12:17 P.M., LPN C said: - CNAs give residents baths two times a week. - Staff fill out shower sheets and if female residents needed shaved, they will document it on shower sheets. - Female residents should be asked if they want shaved. - When shower sheets are done, CNAs will put them on the desk for them to be reviewed by nursing. Depending on how the day is going, he/she will document it in the resident's progress notes. - Shower sheets are then put in a folder for the resource manager after they are signed. - He/she would not know if a female resident had chin hairs unless they were able to see them. During an interview on 3/2/23 at 12:38 P.M., CNA E said: - Shower aides normally give showers but they do not have one on the lower level. - Any nurse or CNA can give a resident a shower. - Shower sheets are filled out and then those are given to the nurse to review and sign. They are then given to the resource nurse. - They document any redness, bruising, rashes, scratches, document grooming, nail care and document if females were shaved. - Residents receive showers twice a week. - Every now again will have a few female residents who refuse showers and they will document on the shower sheets they refused. - If residents get sponge bathes, he/she tries to shave the female residents if she can see chin hair. 44395

Based on observation, interview and record review, record review, the facility staff failed to ensure they provided care and treatment in accordance with professional standards of practice for two of 19 sampled residents (Resident #41 and #78) when staff failed to label and date a dermal patch for Resident #41 and failed to clarify a physician's order for scheduled nasal spray for Resident #78. The facility census was 95. Review of the facility's undated Physician Service Policy, showed: - All physician's orders will be followed as prescribed; - If physician's orders are not followed the reason shall be recorded in the resident's medical record. Review of the facility's Transdermal Drug Delivery System (patch) Policy, revised, August, 2014 showed: - Remove the old patch; - Label patch with date and nurses initials; - Apply new patch firmly to skin. 1. Review of Resident #41's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 10/14/22, showed: - Cognitively intact; - Assist of two staff members with bed mobility and transfers; - On pain control regiment; - Diagnoses included: anemia, arthritis, highblood pressure. Review of the resident's undated care plan showed the resident experienced pain. Review of the resident's Physician Order Sheet (POS), dated 2/2/23 through 3/2/23, showed: - Start date: 2/27/23 - Lidocaine (a patch applied to the skin used to treat pain) adhesive patch, medicated, 4%, apply one patch daily to mid back, put on in the A.M. for 12 hours, then remove at night. Review of the resident's Medication Administration Record (MAR) dated 2/2/23 through 3/2/23, showed: - Start date: 2/27/23 - Lidocaine (a patch applied to the skin used to treat pain) adhesive patch, medicated, 4%, apply one patch daily to mid back, put on in the A.M. for 12 hours, then remove at night. - Initials of the staff that applied the patch on 2/28/23, at 10:00 A.M.; - Initials of the staff that removed the patch on 2/28/23, at 10:00 P.M. Observation and interview on 2/28/23 at 10:38 A.M., showed and the resident said: - The resident had a patch on the middle of his/her back with no date or initials; - The resident said the nursing staff applies the patch in the morning for his/her back pain and the nursing staff are supposed to take the patch off 12 hours later before he/she goes to bed: - The resident said the patch was not taken off last night. Observation and interview on 3/1/23 at 9:18 A.M., showed and the resident said: - The resident in bed with a patch on his/her middle back; - The patch did not have a date or initials on it; - The resident said the staff did not take the patch off last night. Observation on 3/1/23 at 9:42 A.M., showed: - Registered Nurse (RN) B removed a lidocaine patch, 4%, out of the medication cart and cut the top off the package; - The nurse removed the old patch from the resident's back that had no date or initials on it; - The nurse applied a new patch to the resident's back; - The nurse did not write his/her initials, or the time on the new patch. During an interview on 3/2/23 at 03:22 P.M., RN B said: - Staff should apply the resident's patch in morning, take it off at night and should add the date, time and the initials of the staff who applied the patch; - He/she said she forgot to date, time and initial the resident's patch on 3/1/23. 3. Review of Resident #78's admission MDS dated [DATE] showed: - Moderate cognitive impairment; - Assist of one staff member for bed mobility; - Assist of two staff members with transfers; - Oxygen therapy; - Diagnoses included: respiratory failure, pneumonia, and hyperlipodemia (high cholesterol). Review of the undated resident's care plan showed staff did not address the resident's use of nasal spray, inhalers and oxygen. Review of Resident #78's POS, dated 2/2/23 through 3/2/23, showed: - Start date: 12/21/22 - saline nasal spray (used to treat dry nasal passages) 0.65%, use for dry nose due to oxygen use, give two sprays four times a day; - The order for the saline nasal spray did not specify how many sprays to each nostril. Observation on 3/1/23 at 10:33 A.M., showed: - RN B administered one spray of the saline nose spray in the resident's right nostril and did not hold the left nostril closed; - RN B attempted to administer a spray in the left nostril but the medication came out as two drops instead of a spray and ran down the resident's face; - No other attempt were made to administer the nose spray. During an interview on 3/2/23 at 03:22 P.M., RN B said: - The physician should have been notified when the order for the residents nasal spray did not specify how many sprays to given in each nostril. During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said: -When a dermal patch is applied it must be labeled with the date, time and the initials of the staff member who applied it; -The old patch should be removed by the nurse as ordered by the physician; -Nasal sprays should be given per the facility policy; -If a physician's order is vague the physician should be called to clarify the order. 47141

Based on observations, interviews and record reviews, the facility failed to review and revise the comprehensive care plan to address residents who have had a significant change in health care status and dependent upon staff to carry out their activities of daily living for one sampled resident (Resident #95) out of 19 sampled residents. The facility census was 95. Review of the facility's undated policy for care plans showed: - Its purpose is to provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent care that will attain or maintain the highest practicable physical, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs using the resident assessment instrument (a tool to help care providers develop individualized care plans based on assessments of residents' strengths, limitations, and preferences) (RAI) specified by the State. - The assessment must accurately reflect the resident's status. - A facility must conduct a comprehensive assessment of a resident within fourteen days after the facility determines, or should have determined, there has been a significant change in the resident's physical or mental condition. - A facility should use the results of the assessment to develop, review and revise the resident's person-centered comprehensive care plan. 1. Review of resident #95's Admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 7/6/22 showed: - admitted to facility on 6/29/22. - Brief Interview of Mental Status (an assessment used to measure cognitive impairment) BIMS of 7 - Set up help only with bathing; independent with walking; limited assistance with bed mobility; and supervision with transfers, dressing, toilet use and personal hygiene. - Diagnosis included hypertension and bipolar disorder (a mental health condition that causes extreme fluctuation in thinking, mood and behavior). Review of resident's significant change MDS, completed by staff, dated 12/16/22 showed: - He/she was readmitted back to facility on 12/10/22. - He/she was unable to complete cognitive assessment. - Diagnosis included hypertension, septicemia (blood poisoning by bacteria), wound infection and respiratory failure. - Extensive assist with bed mobility, dressing, eating, personal hygiene; two plus person assist with transfers; activity did not occur for walking in room, corridor or on/off unit or toilet use; total dependence upon staff for bathing. - Wheelchair for assistance. - Receiving oxygen therapy and hospice care. Review of resident's care plan, last reviewed and revised on 1/24/23, showed: - Problem Start Date: 7/13/22; - Category: Activities of Daily Living (ADL) Functional/Rehabilitation Potential - He/she has some self-care deficits with ADL (bathing, grooming, oral cares, ambulation, transferring, mobility, vision, bowel and bladder related to cognitive and health status). Edited 1/24/23 - Goals: - Long Term Goal Target Date 3/22/23: He/she will maintain his/her current abilities through review period - edited 12/22/22. Approach - Start Date 7/13/22: He/she requires staff oversight to ensure his/her needs are met. He/she can dress themselves, toilet themselves, feed themselves, provide personal hygiene, transfer and ambulate independently. He/she requires staff assist of 1 to assist with bathing - edited 8/23/22. - Start Date 7/13/22: Offer to assist him/her with cares as indicated to promote his/her safety and that his/her needs are met. Report to charge nurse and/or physician if changes noted in his/her usual behavior and self-care abilities - edited 8/23/22. - Start Date 7/13/22: He/she is usually continent and takes his/herself to the bathroom, but will not always remember to verbally ask for assistance if needed. Make checks on me throughout shift. He/she wears pull ups for protection. Review of resident's shower sheets showed: - 2/6/23: bed bath given. Nothing documented resident was shaved. - 2/16/23: bed bath given, nails clipped and hair washed. Nothing documented resident was shaved. - 2/23/23: Shower not given. Note documented resident's daughter said hospice would do Friday. - 2/27/23: Bed bath, hair washed. Nothing documented resident was shaved. - 3/2/23: Complete bed bath given, hair washed, face shaved. Review of resident's progress notes showed: - Documentation bed baths were given on 2/16/23 and 2/20/23. - No documentation on resident being shaved. During observation on 2/28/23 at 9:51 A.M., showed: - He/she laying in bed and observed with chin hairs. - Signage above bed states resident has sensitive skin and not to dry shave. During an interview on 2/28/23 at 2:37 P.M., the resident's representative said: - Resident was able to walk and talk when admitted to facility but developed sore on his/her foot. - Resident then developed pressure sore on his/her bottom and has since had a decline in health and is now on hospice care. During an interview on 3/6/23 at 1:16 P.M. RN Clinical Reimbursement Coordinator said: - She is responsible for developing and updating care plans. - Clinical managers are also responsible for updating care plans. - Comprehensive care plans should be completed within seven days after the MDS is completed. - Care plans should be updated quarterly, during significant changes, annually and as needed. - She is aware there are care plans that are late and have not been updated. During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said: - MDS team is responsible for care plans. - MDS/care plan staff are under the administrator. Several staff have been out with health issues and there was some confusion in regards to what the corporate office wanted. - MDS staff are responsible for comprehensive care plan. - Floor nurses are responsible to keep update/add to care plan. - Care plan should be updated after unusual event, change of crucial medication (diuretic), infection, etc., quarterly, significant changes, admittance and annually. - Printed care plan is in blue book that floor staff write updates in those, then MDS picks them up and updates in computer. During an interview on 3/6/23 at 3:54 P.M., the Administrator said: - The Clinical Research Nurse and nursing staff are responsible for creating an updating care plans. - Comprehensive care plans should be in place in twenty-one days from admission. They should be updated quarterly, during significant changes and as needed. - Expectations are for care plans to be in place and correct.

Based on interview and record review, the facility failed to ensure the residents environment remains as free of accident hazards as is possible when the facility failed to assess residents for the ability to safely use a mechanical lift chair (MLC, a recliner that has a mechanical lifting mechanism with the lift mechanism used to push the entire chair up from the base, and forward, so as to assist the person sitting on it into a standing position by the use of a controller). This affected one resident (Resident #1), who used the chair's remote control and set the chair to standing position and the resident could not stand and fell . The facility census was 73. The Administrator was notified on 05/19/2021 at 4:33 P.M. of an Immediate Jeopardy (IJ) which began on 4/29/2021. The IJ was removed on 5/20/21, as confirmed by surveyor onsite verification. Review of the facility restraint/adaptive equipment information dated April 2019, for MLC showed: - Recent Brief Interview for Mental Status (BIMS), a cognitive assessment with a score from 1-15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact); - Could the resident transfer independently; - Could the resident identify the MLC controller and explain use of the controller; - Could the resident identify the safe use of the MLC; - Did the resident understand the adverse affects of improper chair usage. 1. Review of Resident #1's significant change in condition Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/15/21, showed: - A BIMS score of 7 (indicating severe cognitive impairment); - Required extensive staff assistance for mobility, dressing, and toileting; - Required total staff assistance for transfers and hygiene; - The resident did not ambulate; - Used a wheelchair; - Always incontinent of bowel and bladder; - Diagnoses included dementia and depression; - Received hospice care. Review of the resident's care plan, dated 3/25/21 showed: - The resident had an alteration in self care due to dementia, advanced age, and decreased mobility with staff meeting the resident's self care needs. - The resident had impaired bed mobility and required staff assistance with turning, lifting legs into bed, and laying down in bed. - The resident was a fall risk due to dementia, advanced age, and decreased mobility. - Did not address the resident's use of a MLC. Review of the resident's event report completed by LPN D, dated 4/8/21 at 4:35 P.M. showed: - Prior to the fall the resident was sitting in the MLC. - The resident was found lying on his/her left side next to the MLC. - The resident experienced mild pain. - The resident had falls prior to this assessment. Review of the resident's nurses' notes dated 4/29/21 at 6:08 P.M., by Licensed Practical Nurse (LPN) A showed the resident raised his/her lift chair all the way up and slid out on the floor landing on his/her bottom. No apparent injuries. Review of the resident's event report completed 4/29/21 at 12:54 P.M., showed: - The location of the fall was the resident's room. - The resident was in the MLC. - There were no immediate measures taken. - The resident's last fall was on 4/8/21 (note: the facility had conflicting information of when the resident had his/her last fall). Review of the resident's nurses' notes dated 4/30/21 at 12:38 P.M., by LPN C showed: -Resident continued to complain of pain to right lower extremity. -Right lower extremity dark discoloration and slightly swollen. -Hospice nurse notified. Review of the resident's nurses notes dated 4/30/21 at 2:36 P.M., showed LPN C called for an immediate X-ray. Review of the resident's nurses' notes dated 4/30/21 at 2:48 P.M., showed the resident's physician canceled the order for a mobile X-ray and requested that the resident be sent to the Emergency Department (ED) for treatment. Review of the resident's nurses' notes dated 4/30/21 at 3:18 P.M., by Registered Nurse (RN) A showed the resident was transferred by ambulance to the local ED. Review of the resident's ED notes, dated 4/30/21 at 3:55 P.M. by the resident's ED physician showed: - Bilateral tibia (one of the lower leg bones) fractures; - Swollen joint; - admitted for pain control. Review of the resident's history and physical dated 5/1/21 at 5:07 A.M. by the resident's admitting physician, showed: - The resident slipped and fell out of a recliner on 4/29/21. - Diagnoses included bilateral tibia fractures and a fractured left hip. - admitted for pain control. During an interview on 5/18/21 at 7:55 A.M., LPN A said: - The resident fell out of the MLC. - Three-fourths of the resident's falls were due to the MLC. - He/She did not know if the resident operating the remote caused the previous falls. During an interview on 5/17/21 at 12:05 P.M., the Director of Nursing (DON) said: - The resident's family insisted the resident use the MLC. - He/She told the family the resident's chair was dangerous for the resident. - He/She did not have any way to assess the safety for resident use of MLC. During an interview on 5/18/21 at 9:30 A.M. the resident's hospice physician said: - He/She was told the resident slid out of the MLC. During an interview on 5/19/21 at 12:15 P.M. the DON said: - The resident was not safe to use a MLC. - The DON felt the resident could not safely operate the chair, but did not use any formal assessment tool. - Staff did not care plan any interventions to prevent falls using a MLC. - He/she wanted to respect the family's request for the resident to use the MLC even though the resident was not safe using the MLC. He/She said he/she told the family the chair was not safe, but felt it was a resident's rights issue. - He/She was not aware of a facility policy on the use of MLC. - Staff did not assess residents for their ability to safely use a MLC. During an interview on 5/19/21 at 4:00 P.M., the DON said: - Staff assessed all residents with MLCs. - Staff found six out of 15 residents were not safe with a MLC. - The staff immediately began assessing all residents with mechanical lift chairs for the resident's safety to operate them. The facility immediately removed the MLC from the resident rooms that were assessed as not safe. MO 4, MO 0, MO 3 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on interview and record review, the facility failed assess, treat, and reassess a resident (Resident #1) for complaints of pain after he/she fell from his/her mechanical lift chair on 4/29/21. The facility failed to seek treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 77. The Administrator was notified on 5/19/2021 at 4:33 P.M. of an Immediate Jeopardy (IJ) which began on 4/29/2021. The IJ was removed on 5/20/21, as confirmed by surveyor onsite verification. Review of facility policy: Integrated Fall Management, dated 8/24/2017 showed: -When a resident falls the licensed nurse is notified. The nurse completes assessment of the resident's condition, completion of vital signs and a body assessment. -The medical provider is notified of the fall and resident's condition. Review of the facility's fall event checklist, dated 10/2020 showed: -Immediately evaluate the resident for any injury/pain. Proceed with emergency interventions as indicated. If there is a suspected head injury or possible significant injury or fracture, do not move resident until EMS arrives. -Neurological checks initiated for all un-witnessed falls and/or falls in which resident hit their heads. The facility did not provide a policy on post fall monitoring. 1. Review of Resident #1's significant change in condition Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/15/21, showed: - A brief interview for mental status (BIMS) score of 7 (a score of 0-7 indicated severe cognitive impairment); - Required extensive staff assistance for mobility, dressing, and toileting; - Required total staff assistance for transfers and hygiene; - Used a wheelchair; - Always incontinent of bowel and bladder; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Received hospice care. Review of the resident's care plan, dated 3/25/21 showed: - The resident had an alteration in self-care due to dementia, advanced age, and decreased mobility with staff meeting the resident's self-care need. - The resident had impaired bed mobility and required staff assistance with turning, lifting legs into bed, and laying down in bed. - The resident had impaired hearing treated with hearing-aides. - The resident had visual issues which were treated with glasses. - The resident was a fall risk due to dementia, advanced age, and decreased mobility. - Did not address the resident's use of a mechanical lift chair (MLC, a recliner that included a mechanical lifting mechanism with the lift mechanism used to push the entire chair up from the base, and forward, so as to assist the person sitting on it, into a standing position by the use of a controller). Review of the resident's nurses' notes dated 4/29/21 at 6:08 P.M., by Licensed Practical Nurse (LPN) A showed the resident raised his/her left chair all the way up and slid out on the floor landing on his/her bottom. No apparent injuries. During an interview on 5/18/21 at 7:55 A.M., LPN A said: - The resident fell out of the MLC on 4/29/21. - Three fourths of the resident's falls were due to the MLC. - The resident did not have any pain after the fall. - He/she did an initial assessment and vital signs, but did not do further checks. During an interview on 5/18/21 at 2:05 P.M., Registered Nurse (RN) B said: - He/she was the resource nurse when the resident fell on [DATE]. - He/she filled out the post fall assessment form, but he/she did not complete a physical assessment of the resident. - Staff checked to see if a resident hit his/her head. - Staff would ask a resident if the resident hit their head. - If a resident hit their head, then staff would do hourly assessments for four hours. - There were no facility forms for post fall assessments. Review of the resident's event report, completed on 4/29/21 at 12:54 P.M., by LPN E showed: - The location of the fall was the resident's room. - The resident was in the MLC. - The resident was confused. - The resident was unable to ambulate. - The resident did not exhibit pain. - Neurologic check showed no issues. - The resident had no change in mental status. - There were no immediate measures taken. - The resident's last fall was on 4/8/21 and was from the resident's MLC. - Staff notified the resident's physician and family. During an interview on 5/18/21 at 1:59 P.M., Certified Nurse Assistant (CNA) A said: - He/she heard the resident crying in pain on 4/29/21 around 12:50 P.M. - When he/she entered the resident's room, he/she found the resident on the floor with the MLC straight up. - He/she called for help. - The resident cried frequently in pain until his/her shift ended at 6:00 P.M. This was not normal behavior for this resident. - He/she called the charge nurse who looked at the resident following the fall. - On the day the resident fell , the resident did not eat because the resident said he/she hurt too much to eat. The resident normally ate well. - The CNA reported to the charge nurse the resident was not eating because of pain. Review of the resident's nurses' notes dated 4/29/21 at 11:26 P.M., by LPN B showed: - The resident continued on fall follow-up following recent fall/slide out of MLC. - No new skin issues, redness, or bruising observed. - Staff monitoring. During an interview on 5/18/21 at 12:00 P.M., LPN B said he/she did not conduct an assessment because the facility did not have staff assess or do vitals unless the resident was on anticoagulants or hit their head when they fell . LPN B said that a CNA told him/her that the resident did not eat and was complaining of pain, but the resident was a frequent complainer and he/she did not assess the resident. During an interview on 5/18/21 at 10:15 A.M., an unidentified CNA said the charge nurse insisted she give the resident a shower the day after the fall (4/30/21). The CNA said the resident complained of a lot of pain. Review of the resident's nurses' notes dated 4/30/21 at 12:38 P.M., by LPN C showed: - Resident continued to complain of pain to right lower extremity. - Right lower extremity showed dark discoloration and was slightly swollen. - Hospice nurse notified. During an interview on 5/18/21 at 1:46 P.M., LPN C said: - He/she was the resident's charge nurse on 4/30/21. - The resident complained of pain that morning, but the resident complained a lot. - He/said that the resident was a chronic complainer and he/she did not assess because of prior history. - He/she was told in change of shift report the resident had fallen. - He/she said there were no pending assessments. - He/she went to assess the resident around 12:45 P.M. - He/she did not know when the prior charge nurse assessed the resident. - The resident's leg appeared red and swollen, so he/she called the resident's physician. During an interview on 5/19/21 at 10:15 A.M., LPN C said: - The facility did not have any kind of form requiring post fall assessments. - The night nurse said he/she needed to do a progress note post fall. - He/she went to assess the resident 13 hours after the last assessment. - He/she found the resident's lower legs swollen, with bruising, and painful to touch. During an interview on 5/18/21 at 5:42 P.M., CNA A said: - On 4/30/21, the resident's legs appeared contracted (shortening of muscles and tendons leading to deformity), which was not normal for the resident. - The resident fell the day before. - The resident's legs were always painful with movement. Review of the resident's nurses' notes dated 4/30/21 at 2:36 P.M., showed LPN C called for an immediate X-ray. Review of the resident's nurses' notes dated 4/30/21 at 2:48 P.M., showed the resident's physician canceled the order for a mobile X-ray and requested the resident be sent to the Emergency Department (ED) for treatment. Review of the resident's nurses' notes dated 4/30/21 at 3:18 P.M., by Registered Nurse (RN) A showed the resident was transferred by ambulance to the local ED. Review of the resident's ED notes dated 4/30/21 at 3:55 P.M., by the resident's ED physician showed: - Bilateral tibia (one of the lower leg bones) fractures; - Swollen joint; - admitted for pain control. Review of the resident's history and physical dated 5/1/21 at 5:07 A.M., by the resident's admitting physician, showed: - The resident slipped and fell out of a recliner on 4/29/21; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - admitted for pain control. During an interview on 5/17/21 at 12:05 P.M., the Director of Nursing (DON) said the facility did not have any forms for post fall monitoring. During an interview on 5/18/21 at 9:30 A.M., the resident's physician said: - He/she was told the resident slid out of the MLC. - He/she received a picture of the resident's wounds. - The resident's legs appeared deformed. - The resident's family requested hospice be revoked and the resident be transferred to the ED for treatment. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 4, MO 0, MO 3

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1) received treatment and care in accordance with professional standards of practice when the facility failed to recognize and treat constipation before a fecal impaction (a large, hard mass of stool that gets stuck in the colon or rectum that it cannot be pushed out) occurred, which resulted in the resident being admitted to the hospital. The facility census was 79. 1. Review of Resident #1's medical record showed he/she was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Minimum Data Set, a federally mandated assessment instrument, dated 4/16/21, showed staff assessed the resident as: -Cognitive status was not assessed; -Bowel and bladder section marked as always continent; -Memory marked as ok. Review of the resident's Admission Assessment, dated 4/16/21, showed Registered Nurse (RN) A documented: - Last bowel movement (BM) noted on 4/12/21; - Bowel pattern: constipation present marked yes. Review of the resident's Care Plan, dated 4/17/21, showed the resident uses narcotic pain medications and staff are to monitor for constipation. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (stool softener) 17 grams mixed with 8 ounces fluid once a day, ordered on 4/17/2021; - Senna with [MEDICATION(S)] sodium (stool softener with [MEDICATION(S)]) 8.6-50mg twice daily, ordered on 4/17/2021; - Dulcolax suppository ([MEDICATION(S)]) 10mg rectally, daily as needed for constipation, ordered 4/17/2021; - [MEDICATION(S)]- Acetaminophen 5mg/325mg 1 tablet every four hours as needed for pain of 1-5 on pain scale; - [MEDICATION(S)]- Acetaminophen 5mg/325mg 2 tablets every four hours as needed for pain of 6-10 on pain scale; - No order for Milk of Magnesia noted; - No order for enema. Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 17 grams administered daily on 4/18, 4/19 and 4/20/21; - Senna with [MEDICATION(S)] sodium 8.6-50 mg administered twice daily on 4/18 and 4/19 and once daily on 4/17 and 4/20; - Dulcolax suppository 10 mg was not documented administered; - [MEDICATION(S)]- Acetaminophen 5mg/325mg 1 tablet every four hours as needed for pain of 1-5 on pain scale administrered once on 4/16, three times on 4/17, twice on 4/18, twice on 4/19 and once on 4/20. The dose on 4/20 was administered for complaints of back pain due to constipation. Review of Nurse Aide charting showed staff did not document the resident had a bowel movement from 4/16/21-4/20/21. Review of the resident's nurse's notes showed: - No bowel movement documented from 4/16/21 to 4/20/21 (five days); - On 4/20/21 at 3:30 P.M., Licensed Practical Nurse (LPN) C said the resident had been given Milk of Magnesia, which the resident complained made the pain worse and he/she requested an enema. The nurse offered an enema and resident refused. The resident requested to go to the emergency room multiple times; -On 4/20/21 at 5:30 P.M., the resident was admitted to a local hospital with admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's hospital records showed: -ER Report dated 4/20/21 at 8:43 PM, showed complaints of lower abdomenal pain and no BM since last Monday. -X-rays of abdomen on 4/20/21 showed moderate to large amount of stool. Follow up with CT Scan; -CT scan, dated 4/20/21, showed evidence of fecal impaction with moderate stool. No bowel obstruction; -Physicans Progress Notes, dated 4/20/21, showed impression and plan of acute (short term) fecal impaction disimpacted (use of fingers to aid in the removal of stool from the rectum) by nursing this AM. During an interview on 4/28/21 at 4:00 P.M., the Director of Nursing said: -They do not have a policy or procedure in place for bowel movement or lack there of; -The expectation is for nursing staff to notify the doctor if no bowel sounds are heard during assessment or no bowel movement occurs after 3 days. MO 4

Based on observations, interviews, and record reviews, the facility failed to ensure one of three sampled residents (Resident #1) received treatment and care in accordance with professional standards of practice when the facility failed to follow their policy and inform the physician and family or legal representative when the resident had a change of condition and developed symptoms of COVID-19 (an infectious disease caused by severe acute respiratory syndrome coronavirus 2 ([DIAGNOSES REDACTED]-CoV-2). Common symptoms include fever, cough, fatigue, shortness of breath, and loss of smell and taste for one of 3 sampled residents. The facility census was 57. Review of the facility's undated policy titled Infection Identification showed: -Early identification of an infection allows the Infection Preventionist (IP) to look at the individual resident information in a larger context to identify and analyze how the individual's condition may affect the facility as a whole; -When a resident exhibits signs/symptoms of suspected infection, the nursing associate will follow routine procedure for notifying the primary physician and family and begin close monitoring of vital signs, and other pertinent assessments dependent on the site of suspected infection; -Residents who present with respiratory symptoms such as cough, fever, shortness of breath will be placed on droplet precautions (used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing); -The provider will be notified of symptoms for order of testing diagnostics; -Any time there is an unusual suspected infection, or if the resident's condition is considered critical, the IP will be notified immediately, as well as the Director of Nursing; -Document in the Progress notes every shift for the presence or absence of symptoms; -Continue this documentation until 48 hours after symptoms have subsided, or until 48 hours after the last dose of antibiotics; -The primary physician and family or legal representative will be notified immediately of changes in the resident's condition. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Extensive staff assistance of two staff for bed mobility, dressing, and transfers; -[DIAGNOSES REDACTED]. -Hospice care. Review of resident's tracking MDS, dated [DATE], showed: -Death in facility on [DATE]. Review of the resident's Treatment Administration Record (TAR), dated [DATE], showed: -Check temperature, blood pressure, pulse, and oxygen saturation report temperature over 100 degrees Fahrenheit (F) to registered nurse (RN) twice daily; -[DATE] through [DATE], showed no documentation of respiratory symptoms including cough and fever; -[DATE], temperature 100.9 F (normal body temperature can have a wide range, from 97 F to 99 F); -[DATE], cough. Review of the resident's nurses note, dated [DATE] and [DATE], showed: -[DATE], no entries or documentation every shift for the presence or absence of symptoms, no staff assessment of the resident condition, no notification to the resident's primary physician, family, and hospice staff of the resident's temperature of 100.9 F; -No documentation that showed the nursing staff placed the resident on contact (used for infections, diseases, or germs that are spread by touching the resident or items in the room) or droplet precautions; -[DATE], no entries or documentation every shift for the presence or absence of symptoms, no staff assessment of the resident condition, no notification to the resident's primary physician, family, and hospice staff of the resident's history of fever and new cough. Review of the resident's medical records showed the resident was included in the facility wide testing for COVID-19 on [DATE]. Review of the resident's TAR, dated [DATE], showed: -Check temperature, blood pressure, pulse, and oxygen saturation report temperature over 100 degrees F to RN twice daily; -[DATE], cough; -[DATE], cough; -[DATE], cough and temperature 100.4 F; -[DATE], cough, and temperature 100.5 F; - [DATE], cough, and loss of taste; -[DATE], cough, fever, muscle aches, chills, temperature 101.0 F. Review of the resident's nurses note, dated [DATE] at 11:50 A.M., showed: -Resident refusing to have his/her weight obtained stating that he/she does not feel well and does not want to be bothered; -No documentation of the resident being tested for COVID-19; -No documentation showing facility staff notified the resident's primary physician and hospice staff of the resident's cough, history of fever, and complaints of not feeling well. Review of the resident's nurses note, dated [DATE] at 11:39 A.M., showed: -Weight deferred per resource nurse; -No documentation showing facility staff notified the resident's primary physician and hospice staff of the resident's cough, history of fever, and complaints of not feeling well. Review of the resident's nurses note, dated [DATE] at 5:24 P.M., showed: -Resident warm to the touch temperature 101.5 F orally. Tylenol given hospice on call nurse notified. No documentation showing facility staff notified the resident's primary physician or legal representative. Review of the resident's nurses note, dated [DATE] at 5:31 P.M., showed: -Update provided to hospice nurse he/she requested the facility keep them informed. Review of the resident's nurses note, dated [DATE] at 6:39 P.M., showed: -Resident's temperature 101.4 F orally at this time. Lungs diminished oxygen saturation 93 percent (%) on room air mouth very dry due to mouth breathing, fluids offered often. Eyes sluggish but reactive swelling noted to lower extremities. No documentation showing facility staff notified the resident's primary physician or legal representative. Review of the resident's nurses notes, dated [DATE] and [DATE], showed: -[DATE], no entries or documentation every shift for the presence or absence of symptoms showing facility staff assessed the resident, notified the resident's primary physician, family, and hospice staff of the resident's temperature of 100.5 F; -[DATE], no entries or documentation every shift for the presence or absence of symptoms showing facility staff assessed the resident, notified the resident's primary physician, family, and hospice staff of the resident's new symptom of loss of taste. Review of the resident's nurses note, dated [DATE] at 10:40 A.M., showed: -Staff provided a bed bath, nail care, and changed his/her bedding. Review of the resident's nurses note, dated [DATE] at 4:38 P.M., showed: -COVID-19 test results obtained today from test performed on [DATE], resident is COVID-19 positive the resident is being moved to the COVID unit. Review of the resident's nurses note, dated [DATE] at 11:59 P.M., showed: -Presented with elevated temperature of 99.8 F Tylenol administered rechecked came down to 99.0 F will continue to monitor. No documentation showing facility staff notified the resident's primary physician or legal representative. Review of the resident's nurses note, dated [DATE] at 3:51 A.M., showed: -Slept in intervals tonight was restless at the beginning of the shift oxygen saturation 84% on room air applied oxygen at two liters (L) oxygen saturation increased to 93% spoke with hospice to obtain order for oxygen therapy order to titrate to maintain oxygen saturation at 90% or above. No documentation showing facility staff notified the resident's primary physician or legal representative. Review of the resident's nurses note, dated [DATE] at 5:29 P.M., showed: -Resident moaning out loud a lot this shift very anxious and restless no complaints of shortness of air, oxygen saturation low 90's slight moist cough non productive oxygen at three L (liters) per nasal cannula, [MEDICATION NAME] (narcotic pain medication) and lorazapam ( fast-acting medication and is most commonly used to treat acute anxiety, anxiety disorders, or anxiety associated with end-of-life care) when due. Lungs diminished will continue to keep comfortable hospice has been notified of condition and plans to come to do a visit on [DATE]. No documentation showing facility staff notified the resident's primary physician or legal representative. Review of the resident's nurses note, dated [DATE] at 5:31 P.M., showed: -Elevated temperature this shift Tylenol administered which was effective. No documentation showing facility staff notified the resident's primary physician or legal representative. Review of the resident's nurses note, dated [DATE] at 6:49 A.M., showed: -Currently on hospice slept long intervals last night tired and lethargic (sleepy or fatigued and sluggish) coughs occasionally oxygen remains to be within normal limits. Review of the resident's nurses note, dated [DATE] at 7:04 A.M., showed: -Temperature 97.6 F this morning. Review of the resident's nurses note, dated [DATE] at 10:59 A.M., showed: -Received complete bed bath and bed linen changed. Review of the resident's nurses note, dated [DATE] at 3:05 P.M., showed: -Very restless, coughing a lot, oxygen saturation going down, now on five-six L oxygen. Oxygen mask on the resident, as the resident is tolerating the mask better, very restless. Crackles (heard in a lung field that has fluid in the small airway) noted to lungs. Hospice and family notified. Review of the resident's nurses note, dated [DATE] at 6:07 P.M., showed: -Continues to decline. Dose of [MEDICATION NAME] and lorazapam changed. Continues to cough and not eating or drinking temperature 99.4 F hospice notified. No documentation showing facility staff notified the resident's primary physician or legal representative. Review of the resident's nurses note, dated [DATE] at 11:10 P.M., showed: -Technician called nurse to room stated the resident is not breathing no heartbeat noted. Review of the resident's nurses note, dated [DATE] at 11:15 P.M., showed: -Staff called family to inform them the resident had expired. During a interview on [DATE], at 11:00 A.M., Hospice Staff (HS) A said: -He/She is a RN and weekly facility nursing visits have changed due to COVID-19; -Facility staff should inform hospice staff when a resident has a change in condition; -An onsite hospice visit was done on [DATE]; -Review of the record showed facility staff did not notify them the resident had fever on [DATE], and a cough on [DATE]; -On [DATE], hospice staff did a telephone visit with staff and was informed the resident's cough had increased. The resident had vomited and staff thought this was possibly due to the increased cough; -On [DATE], the facility notified them the resident had a fever; -On [DATE] at 3:47 A.M., the facility staff called to obtain orders for oxygen therapy; -An onsite hospice visit was done on [DATE]. During a interview on [DATE], at 11:15 A.M., Licensed Practical Nurse (LPN) A said: -He/She works 12 hour shifts during the evening/night; -On [DATE], he/she provided care for Resident #1; -On [DATE], the resident developed a fever; -The facility's protocol is to implement droplet and contact precautions for resident's that exhibit signs and symptoms of COVID-19; -Symptoms of COVID-19 include fever, cough, shortness of breath, and loss of smell and taste; -He/She placed the resident on contact and droplet precautions on ,[DATE] due to the resident having a fever; -He/She thought he/she notified the resident's primary care physician who is Nurse Practitioner (NP) A and hospice staff; -He/She assessed the resident but failed to document the assessment, the notification of NP A, hospice, and the implementation of contact and droplet precautions; -He/She worked on [DATE], and provided care for the resident; -He/She did not notify NP A and hospice staff that the resident had a cough. During a interview on [DATE], at NP A said: -Facility staff should notify primary care providers when a resident has a change of condition; -The facility staff did not notify him/her on [DATE], that the resident had a temperature of 100.9 F or a cough on [DATE]; -Facility staff did not notify him/her that the resident had a change of condition; -He/She assessed the resident on [DATE], for a regulatory visit. During a interview on [DATE], at 12:10 P.M., LPN B said: -He/she works 12 hour shifts during the daytime; -On [DATE], he/she provided care for the resident during the day he/she documented the resident had a cough; -The resident was on contact and droplet precautions related to an elevated temperature; -Frequently the resident had a cough so he/she did not consider the cough to be a new symptom; -He/She did not notify NP A or hospice staff of the cough and did not document in the resident's nurses notes; -He/She provided care for the resident on [DATE], during the day he/she should have notified NP A and hospice staff that the resident exhibited a new symptom which included loss of taste; -He/She should have documented care provided for this resident on [DATE]. During a interview on [DATE], at 5:40 P.M., RN A said: -He/She works 12 hour shifts during the evening/nights; -Signs and symptoms of COVID-19 include a fever and cough; -On [DATE], the resident had a fever on the day shift and staff had notified hospice staff; -On [DATE], the resident told him/her that he/she talked with his/her mother and soon his/her pain would go away because he/she would be going to heaven; -On [DATE], staffing was challenging and he/she was acting as the resource nurse and the charge nurse; -The resident did have an elevated temperature on [DATE], and he/she thought the resident was in the dying process because of the conversation that had occurred on [DATE]; - On [DATE], he/she did not document an assessment and did not notify NP A and hospice staff. During an interview on [DATE], at 3:00 P.M., the Director of Nursing (DON) said: -Resident #1 was placed on contact and droplet precautions on [DATE], when he/she developed a fever; -He/She was moved to the COVID unit on [DATE], when we were informed he/she tested positive for COVID-19; -When a resident has a change of condition facility staff should notify the resident's primary physician, family, and hospice staff if the resident receives these services; -This notification should be documented in the resident's nurses notes; -The resident's does not have a nurses note on [DATE], [DATE], [DATE], and [DATE]; -Preferably this resident should have been documented on each shift and at a minimum of daily.

Based on observation, interviews and record reviews, the facility failed to assure staff provided the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one resident (Resident #31). Staff failed to notify the physician of the resident's change in mental and physical status in a timely manner. This failure resulted in a delay in medical treatment. The facility census was 90. Review of the undated facility policy for Change in Condition showed: -Purpose to provide care and services based upon the current needs of the resident under the direction of the attending provider. To inform the resident or resident representative and attending provider when a significant change in resident condition occurs; -When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is a need to alter treatment significantly, the licensed nursing associate consults with the attending provider and notify the resident or resident representative; -The Licensed nursing associate will assess significant change in the resident's condition noted through direct observation, interview or report from other staff; -Obtain a set of vital signs and repeat as needed or ordered; -Conduct a symptom review and assessment, as condition warrants; -Notify the attending provider of the change in condition and implement orders for treatment and appropriate monitor as directed. If unable to contact the physician, contact the Medical Director; -Notify the resident or the resident representative; -Document symptom(s), assessment, observations, resident or resident representative notification and the medical provider notification; -Monitor and provide treatment as ordered by the attending provider; -Update the care plan as appropriate. 1. Review of Resident 31's hospital history and physician dated 12/9/19 showed: -The resident has [DIAGNOSES REDACTED]. He/she has been up and about, exceptionally active and the main caregiver for the spouse at home. He/she was brought to the emergency room due to agitation and confusion and was found to have an acute cerebellar bleed (Cerebellar hemorrhage is a form of [MEDICAL CONDITION] and is most frequently seen in the setting of poorly controlled hypertension). The resident is alert and will follow all commands without difficulty. He/she complains of a headache and dizziness. Review of the baseline care plan dated [DATE] showed: -Goal to discharge to the community; -Alert and oriented; -Receives physical therapy and occupational therapy; -Safety - nothing marked for any history of falls or at risk for falls; -Assistance of one staff member for bed mobility, transfers, walking, toileting and bathing. Review of the fall risk assessment dated [DATE] showed the resident was at low risk for falls. Review of the care plan for return to community dated 12/24/19 showed: -Goal to return to home. Review of the admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 12/25/19 showed: -admitted to the facility on [DATE]; -Alert and oriented and able to answer questions appropriately; -Extensive assistance of one person for Activities of Daily Living (ADL's); -No pain; -History of falls; -[DIAGNOSES REDACTED].; -Discharge plan to return home. Review of the physician's progress notes dated 1/2/20 showed: -The resident continues with some headache issues, and nausea and dizziness, particularly with any type of standing. Review of the nurses notes dated 1/3/20 at 12:42 P.M. showed: -At 12:30 P.M. went into the residents room to give him/her medications, he/she was trying to talk, but was not making any sense. His/her words were jumbled and slow and slurred. A neurological assessment was completed and it was determined that the primary care physician should be called. His/her left arm was flaccid (a part of the body soft and hanging loosely or limply) and he/she could not squeeze the nurses hand. His/her responses to questions were extremely delayed. Orders were received to send the resident to the emergency room (ER) for evaluation. Review of the resident's ER medical records dated 1/3/20 showed: -The resident comes into the ER for a stroke alert. The facility states that the resident was having left sided drooping of the face and speech. The resident had a brain bleed on 12/9/19. The resident was recently discharged from the hospital for a stroke and had speech deficits since. yesterday then the resident's family spoke with the neurologist, everything was fine, but today the nursing home staff noticed left sided weakness and facial droop. The resident was admitted to the hospital about two to three weeks ago for [MEDICAL CONDITION]. The resident was transferred to the nursing home and evaluated as an outpatient with no significant deficits. The resident was evaluated by the nursing staff today at the facility and they were concerned about an acute stroke. On presentation, however, the family indicates the resident is completely at baseline mental status and the resident neurological exam has not changed. The resident was noted to have mild neglect on the left side, which the family indicates is unchanged from previous. The resident was discharged back to the nursing home with orders to return if worse. Review of the nurses notes dated 1/3/20 at 4:30 P.M. showed: -The resident returned from the ER, he/she is leaned over on his/her left side in the wheelchair, the left arm remains flaccid, speech is still scattered and delayed responses noted. He/she is extremely weak. Review of the care plan for ADL functional/Rehabilitation Potential dated 1/3/20 showed: -The resident is at risk for deterioration in ADLs; -Goal: The resident will not deteriorate in ADLs as evidenced by maintaining the ability to assist in his/her own care; -Approaches: Assess the resident for deterioration and eliminate the risk factors, if possible; document and report any deterioration in status to the physician. Review of the care plan for falls dated 1/3/20 showed: -The resident is at risk for falls; -Goal to remain free from injury; -Approaches: Encourage the resident to assume a standing position slowly; encourage the resident use environmental devices such as hand grips and hand rails; give reminders not to ambulate or transfer without assistance; keep the bed in the lowest positron with the brakes locked. Review of the care plan for [MEDICAL CONDITION] (relating to or denoting drugs that affect a person's mental state) drug use dated 1/3/20 showed: -The resident received antiquity medication related to anxiety; -Goal: The resident will not exhibit drowsiness/over-sedation, delayed reaction, impaired cognition/behavior, disturbed balance, gait or positioning ability, drug dependence, sleep disturbances, rash, blurred vision or [MEDICATION NAME] symptoms (Side effects of [MEDICATION NAME] medications include dry mouth and related dental problems, blurred vision, tendency toward overheating (hyperpyrexia), and in some cases, dementia-like symptoms.); -Approaches: monitor the resident's mood and response to medications. Review of the nurses notes dated 1/14/20 showed: -The resident out to see the physician to be evaluated due to decline in condition. The resident is alert to self only, transfers with assistance of two and a mechanical lift, is incontinent of bowel and bladder and needs assistance with eating. Review of the physician progress notes [REDACTED]. -Seen for follow up on issues of HTN, cerebellar bleed and [MEDICAL CONDITION]. He/she has had an extensive workup over the last week failing to reveal any other new issues. The size of the bleed and swelling in the brain are less. At the same time, he/she is not doing as well and the family is concerned. Speech maybe is worse, not getting up and is just not doing as well. No report of headaches and the nausea is resolved. Still has some dizziness and balance issues; -Impressions and plan: [MEDICAL CONDITION] and perhaps depression contributing to the issues. Give [MEDICATION NAME] (an antidepressant with a side effect of dizziness) and consult with psychiatrist. Review of the nurses notes dated 1/16/20 through 1/21/20 showed the resident to have increased anxiety, tearfulness and restlessness. Required assistance of two staff members and mechanical lift for transfers and was incontinent of bowel and bladder. Review of the nurses notes dated 1/21/20 showed: -No acute confusion or decline in cognition noted. Continues to have frequent episodes of increased anxiety. Review of the nurses notes dated 1/26/20 signed by Registered Nurse (RN) B showed: -Resident has improved from one week ago. Appetite increased, able to make his/her needs known. Able to feed him/herself. Review of the Medication Administration Record [REDACTED] -[MEDICATION NAME] (used to treat anxiety disorders) 0.5 milligrams (mgs) and one half tablet every 12 hours as needed (PRN). Documented as given one time a day from 2/1/20 through [DATE]. Discontinued on [DATE] -[MEDICATION NAME] 325 mg, give two tables every four hours. Documented as given at 6:00 A.M., 2:00 P.M. and 10:00 P.M. with a pain level of no pain to mild pain. -[MEDICATION NAME] 15 mg at bedtime. Review of the therapy notes dated 2/5/20 showed: -The resident is now using a walker for stand and pivot transfers to and from the toilet. Educated the nursing staff. Review of the nurses notes dated 2/6/20 showed: -The resident had extreme anxiety throughout this shift, the resident was found in the room crying out, yelling, throwing things, screaming and hyperventilating. Physician notified. Review of the nurses notes dated [DATE] showed: -Follow up to physician notification of resident behavior on 2/6/20 with orders to give [MEDICATION NAME] .05 mg one half tablet every 12 hours. Review of the MAR indicated [REDACTED] -[MEDICATION NAME] 0.5 mg, give one half tablet two times a day with a start date of 2/11/20. Review of the nurses notes dated 2/9/20 at 3:33 A.M. signed by Licensed Practical Nurse (LPN) G showed: -The resident slept at long intervals. As needed [MEDICATION NAME] and anti-anxiety medication given per the residents request. Uses call light when in need of assistance. Required assistance with transfer to and from the wheelchair. Review of the nurses notes dated 2/10/20 at 4:26 A.M. signed by LPN G showed: -The resident called for assistance approximately 10 minutes after lying in bed and wanted to get up. The resident stayed up for approximately 20 minutes then requested to go back to bed. The resident was tearful. Review of the nurses notes dated 2/12/20 at 5:44 P.M. signed by RN B showed: -The resident is agitated throughout the day calling out and crying for staff. The resident will press the call light but will cry out before staff is able to respond. After providing care, the resident cried for staff to come back numerous times and stated his/her head was hurting. Administered prn [MEDICATION NAME]. Review of the nurse notes dated [DATE] at 7:25 A.M. signed by LPN G showed: -The resident slept very little. The resident rested in bed approximately from 7:30 P.M. to 9:00 P.M. The resident then started to yell out and crying. This nurse sat with the resident for a while then the resident began to yell out and crying. This behavior continued throughout the night. The resident complained of a headache. Review of the speech therapy notes dated [DATE] at 1:24 P.M. showed: -The residents behavior appears to be attention seeking/control. The resident also not speaking in a normal tone but whiny and immature syntax and low volume. Review of the nurses notes dated [DATE] at 4:38 P.M. signed by RN B showed: -Spoke with nurse at the physician's office regarding the resident's behaviors. Orders were received from the on call physician to increase the [MEDICATION NAME] to 1 mg two times a day prn and 1 mg at bedtime for anxiety. Review of the nurses notes dated [DATE] at 7:40 P.M. signed by LPN G showed: -The Certified Nurse Aide (CNA) was assisting the resident to the toilet and the resident fell to the floor. The resident obtained a skin tear to the right shin. Responsible party notified of the fall and skin tear. Review of the nurses notes dated [DATE] at 10:00 P.M. signed by LPN G showed: -The resident had been yelling and crying out loud since this nurse came on duty. The CNA and the nurse had checked on the resident multiple times. The nurse found the resident attempting to throw his/her legs off the bed. The resident had been wet. The CNA attended to his/her needs. The CNA then found the resident on the floor with his/her head under the bed. There was massive amounts of blood on the resident, the floor and the wall. The bed was moved enough to get to the resident. The residents head was cleaned and the resident had a contusion to his/her left eye brow and possible on the left side of the hair line. The CNA called for additional staff for assistance. Another nurse contacted emergency services and the resident was transported to the hospital ER. Review of the nurses notes dated [DATE] at 10:00 P.M. signed by RN C showed: -Called to the residents room and noted the resident on the floor lying on his/her back with his/her head toward the foot of the bed. The resident was yelling out incoherently with massive amounts of blood noted from head onto the floor and nearby wall. Unable to visualize the head wound due to massive blood to area. Emergency services called. Review of the nurses notes dated [DATE] at 10:10 P.M. signed by RN C showed: -Emergency services at the facility and transported the hospital. Review of the Emergency Medical Services (E[CONDITION]) report dated [DATE] at 11:06 P.M. showed: -Dispatched to the facility. Upon arrival the resident was laying on the floor with the nursing home staff at the resident's side. The resident had injured his/her head and forearm. The staff does not know how the resident was injured, possibly from a fall from the bed. There is a large amount of blood on the floor. The resident was also incontinent of both urine and stool. The resident had a laceration on his/her head. Information was vague from the staff. The bleeding was nearly controlled at the time of arrival. The resident had bled an inordinate amount. The resident's mental state made evaluation difficult. Review of the nurses notes dated 2/14/20 at 2:40 A.M. signed by LPN G showed: -The resident was admitted to the hospital with [REDACTED]. Review of the hospital emergency room report dated [DATE] at 11:40 P.M. showed: -The resident presents in the emergency room after a fall. Staff found the resident on the floor and report they were unsure of how long he/she laid on the floor; -CT (A computerized tomography (CT) scan combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body. CT scan images provide more-detailed information than plain X-rays do.) showed scatted small subdural hematoma over the left frontal part of the brain. Contusion to the anterior left frontal lobe of the brain. New stroke noted in the right part of the brain with cerebral [MEDICAL CONDITION]. The resident was admitted to the hospital. During an interview on 2/26/20 at 8:30 A.M. LPN G said: -He/she had worked on 2/9/20 and the resident was restless, but able to have a conversation about his/her family and current events; -When he/she came back to work on 2/11/20 the resident was a different person, he/she was very restless, no longer able to carry on a conversation, was agitated and complained of a headache; -The primary care physician was not available, the on call physician had ordered [MEDICATION NAME] to be given at bedtime; -On [DATE] the resident had two falls. The first fall occurred around 7:30 P.M. when CNA J had tried to transfer the resident to the toilet and was lowered to the floor; -The resident could not bear weight; -The resident got a skin tear to the left lower leg; -CNA J put the resident to bed after the fall, the resident was very restless, throwing his/her leg over the side of the bed, screaming out. He/she tried to check on the resident as much as he/she could. CNA J was busy laying other resident down; -At around 9:30 P.M. or 9:45 P.M., CNA J yelled for him/her to come to the resident's room; -When he/she entered the resident's room, the resident was laying on his/her back on the floor with his/her head at the foot of the bed, partially under the bed; -There was a lot of blood on the floor and on the walls; -The resident's bed was about a foot off the floor and there were no fall mats beside the bed, the resident had half rails at the head of the bed; -He/she moved the bed away from the resident's head and had CNA J call for the other staff; -The resident was yelling out, but would respond to his/her name; -He/she is unsure of how long the resident was on the floor before CNA J found him/her; -Another nurse called for an ambulance and the resident was transferred to the hospital. During an interview on 2/26/20 at 9:30 A.M. RN B said: -He/she took care of the resident on 2/12/20 and [DATE]; -The resident had complained of increased nausea and a headache on 2/12/20; -He/she received an order from the neurologist for medication for the nausea and the resident's [MED] prn order was changed to be given scheduled; -He/she had noted a behavior change in the resident; -The resident was more agitated and confused, the resident would yell out and was very anxious and impulsive, he/she would try to get out of bed; -The resident complained of a headache and was given [MEDICATION NAME] as ordered; -He/she would put a cool compress to the resident's head for comfort; -He/she did not know what else to do; -He/she contacted the primary care physician regarding the change in the resident's mental status and received an order from the on call physician to give [MEDICATION NAME] 0.5 mg in the morning and 1 mg at bedtime; -The primary care physician was not available to give an update on the change in the resident's mental status; -He/she did not think to call the Medical Director when the primary care physician was not available. During an interview on 2/26/20 at 10:30 A.M. the Director of Therapy said: -The resident was receiving physical, occupational and speech therapy due to the brain bleed and stroke; -The resident was progressing physically in therapy and was able to be transferred by one staff member; -On [DATE] the nursing staff requested a speech evaluation due to an increase in -behaviors, would yell out and become very anxious; -The speech therapist recommended the nursing staff contact the primary care physician. During an interview on 2/26/20 at 11:30 A.M. the Director of Nursing said: -The resident was admitted to the facility in December of 2019 from a spontaneous brain bleed and stroke. The resident was improving physically and mentally and had a goal to return to home; -The first part of January 2020, the resident showed a physical decline and was seen by the primary care physician and at the hospital. The CT of the head showed that the brain bleed was dissipating but the swelling remained. The resident returned to the facility and began showing progress again in therapy; -A few days before [DATE], the resident had an increase in agitation, anxiety, very restless and a decline mentally;-The primary care physician was called regarding the change in condition, but did not return the facilities calls; -On [DATE] RN B contacted the physician on call and received an order to increase the [MEDICATION NAME]; -She was notified on [DATE] around 7:30 P.M. of the residents fall in the bathroom and again at 10:00 P.M. of the resident being found on the floor and sent to the hospital; -She did not notify the Medical Director of the resident's change in mental status when the primary care physician was not available; -She did not think to send to the resident to the emergency room for the change in mental status when the primary care physician was not available; -She should have contacted the Medical Director. During an interview on 2/27/20 at 9:10 A.M. CNA J said: -He/she took care of the resident on [DATE]; -The resident was having a lot of behaviors. He/she was very impulsive and would attempt to throw him/herself off the bed. He/she would try to stand up and fall back onto the bed; -He/she was transferring the resident from the wheelchair to the toilet around 7:30 P.M. with a gait belt, when the resident said that he/she could not stand and that he/she was going to fall. He/she lowered the resident to the floor and call for the nurse; -The resident was assisted by him/herself and another CNA back into the wheelchair and he/she laid the resident in the bed; -The bed was about a foot off the floor with no fall mats beside the bed, there were half rails at the top of the bed; -About an hour and half to two hours later, he/she went by the residents room and saw the resident on the floor; -The resident's head was at the foot of the bed; -There was a lot of blood around the resident's head; -He/she called for the nurse. During an interview on 2/27/20 at 9:30 A.M. Physician A said: -He/she expects the nursing staff to notify the primary care physician of any changes in the resident's mental and/or physical status; -When the primary care physician is not available, then the nursing staff should contact him/her; -He/she was contacted when the primary care physician was not available when the resident showed a change in status; -He/she would expect to send a resident to the hospital when there is a significant change in status; -He/she would have expected the nursing staff to have sent the resident to the hospital emergency room when they noted the significant change in status and the primary care physician was not available. MO 1 and MO 7

Based on interviews and record reviews, the facility failed to assure staff provided the necessary care and services for two sampled residents (Resident #1 and #2) to attain their highest practicable mental and physical well being. Staff failed to obtain Resident #1's urinalysis (UA, a test to identify an infection) when a family member voiced concerns about the resident's increasing confusion and a correlation of confusion with urinary tract infections [MEDICAL CONDITION]. The resident was hospitalized that evening with an acute UTI and acute [MEDICAL CONDITION] (an altered mental status with numerous causes including infections). Staff failed to contact Resident #2's physician when they did not receive a timely response to a problem referral, failed to obtain the ordered UA, in a timely manner, and failed to start the ordered antibiotic, to treat the UTI, for two days because the facility had a policy to not use medications from the emergency kit (E-Kit, an assortment of medications to administer to residents until the pharmacy filled the prescription) for the long term care residents. The facility census was 87. 1. During an interview on 8/4/16, at 2:50 P.M., the Director of Nursing (DON) said: - The facility had a contract with the local hospital to do the residents' laboratory tests. - Staff entered laboratory test orders into the computer. - Seven nights a week, the night shift nurses printed the list of the needed lab tests. - If the night shift nurse did not obtain the lab sample he/she told the day shift nurse and that nurse obtained the needed test sample. - Staff called the hospital's courier and the courier picked up the lab samples and transported them to the lab. - Staff called the courier to pick up all lab samples. - The laboratory staff completed the test and faxed the results to the facility computer system. - The facility assigned a resource nurse to each shift. That resource nurse entered the lab results into residents' electronic medical record (eMR). - The nurses' accessed the residents' eMRs from their nurses station. 2. Review of Resident #1's quarterly Minimum Data Sets (MDS), a federally mandated assessment completed by facility staff, dated 5/11/16, showed: - Staff entered a score of 15, out of a possible 15, to show no cognitive impairment; - Speech was clear, distinct, with intelligible words; - Clear comprehension; - No behaviors; - Required extensive assistance for toileting and personal hygiene; - Frequently incontinent of bowel. Review of the care plan, dated 6/22/16, showed: - Problem of bladder and bowel incontinence with a goal of adequate urine output and bowel elimination; - Approaches directed staff to provide meticulous hygiene, keep resident clean and dry, monitor for signs and symptoms of UTI, and report to the physician as needed. During a telephone interview on 8/5/16, at 4:50 P.M., Family Member (FM) A said he/she visited about 7:30 A.M., on 7/17/16, and the resident communicated clearly and ambulated. During a telephone interview on 8/5/16, at 12:28 P.M., Licensed Practical Nurse (LPN) C said: - He/she did not work on the resident's hall often, maybe two or three days a month. - On 7/17/16, he/she worked the day shift (7:00 A.M., to 7:00 P.M.) to orient a Graduate Practical Nurse (GPN) to the resident's hall. That day he/she tripped over the resident's wheelchair pedals but was not hurt. The resident kept asking if he/she was okay and he/she told the resident he/she was fine, so the resident did not seem confused. That evening the resident refused to take his/her [MEDICATION NAME] (blood thinner medication). He/she explained the importance of [MEDICATION NAME] but the resident continued to refuse it, and that was unusual for the resident. During a telephone interview on 8/5/16, at 4:50 P.M., FM A said: - When he/she returned about 9:00 P.M., on 7/17/16, the resident was confused and weak and he/she reported this to Certified Nurse Aide (CNA) B. CNA B told FM A that the day shift staff said the resident did not feel well and refused supper. CNA B said LPN D took the resident's vital signs and they were fine. He/she stayed until about 11:30 P.M., to talk with LPN D but did not see him/her. When he/she left, CNA B said LPN D was on the other hall. During an interview on 8/2/16, at 8:50 P.M., CNA B said he/she worked the night shift on 7/17/16. The resident was confused off and on, but felt that was normal for him/her. Review of the progress notes (the area in the eMR for staff documentation) showed no entries for 7/17/16. During a telephone interview on 8/5/16, at 4:50 P.M., FM A said: - He/she called the resident about 8:00 A.M., on 7/18/16, but the resident did not answer the phone. - When he/she arrived about 9:30 A.M., on 7/18/16, the resident sat in the recliner, was confused, and only answered, I don't know. FM A asked to talk with Unit Coordinator (UC) B; staff said he/she was in a class so the DON would talk with him/her. He/she told the DON the resident did not feel well yesterday, refused supper, was confused last night, and still confused. He/she told the DON that he/she wanted a UA done because when the resident was that confused it signaled a UTI. During an interview on 8/4/16 at 10:45 A.M., the DON said: - On 7/18/16, FM A asked to speak with UC B. She met with FM A, about 10:00 A.M., because UC B was busy with a class. FM A told her the resident did not eat last evening, 7/17/16, was more confused than last evening, and he/she was concerned the resident had a UTI. She assured FM A that she would have LPN B, the charge nurse, assess the resident and contact the physician. - She told LPN B to assess the resident and get a UA. LPN B did not need to contact the physician for a UA order, because that physician had a protocol for staff to obtain and send a UA as needed. - The DON said she did not see the resident that day. During a telephone interview on 8/5/16, at 4:50 P.M., FM A said: - A short time after he/she talked to the DON, LPN B approached him/her, with a sheet of paper, and asked if he/she wanted blood tests and a UA. - FM A told LPN B that he/she wanted a UA done because he/she felt the confusion was related to a UTI. - He/she knew all of the discussion took place before 10:45 A.M., because he/she had to leave for an appointment. During a telephone interview on 8/5/16, at 11:50 A.M., LPN B said: - He/she knew the resident but that was not his/her regular hall. - The resource nurses made the assignments and he/she worked where they assigned him/her. - Since staff worked 12 hours shifts he/she was off for three days and may not notice a change in a resident. The nurse that gave report may have only been on that hall for one day and may not notice a change in a resident. - At times, the resource nurse assigned him/her to two halls and a certified medication technician (CMT) to pass medications. - On 7/18/16, he/she thought they assigned him/her to both the west and south halls. - On 7/18/16, the DON told him/her to assess the resident and get a UA. He/she talked with FM A who said the resident had a poor appetite and was a little confused. He/she asked FM A if he/she wanted blood tests and a UA. FM A said he/she wanted the UA. He/she did not think the resident was more confused. - He/she was very busy with both halls and did not know if he/she did any other assessment or wrote a nurse's note. Review of the progress notes, dated 7/18/16, showed LPN B made his/her first entry at 7:00 P.M. During an interview on 8/4/16 at 10:45 A.M., the DON said LPN B assessed the resident, did not think he/she was more confused, but got the UA. During a telephone interview on 8/5/16, at 4:50 P.M., FM A said: - When he/she returned to the facility about 5:30 P.M., on 7/18/16, he/she found the resident in the recliner, slumped forward, rocking back and forth, with the meal tray in front of him/her. The resident was very confused and unable to communicate. - He/she told LPN B about the resident's condition and that he/she wanted the resident sent to the hospital. During a telephone interview on 8/5/16, at 11:50 A.M., LPN B said: - He/she did not get the UA because he/she was very busy. - That evening he/she called the physician and asked if he/she wanted a UA; the physician said to send the resident to the hospital. Review of a physician's orders [REDACTED].M., showed: - LPN B entered an order to send the resident to the emergency room (ER) for evaluation per FM request related to increased confusion and poor intake. During an interview on 8/4/16 at 10:45 A.M., the DON said: - She reviewed the eMR and LPN B must not have obtained the UA before sending the resident to the ER. - According to a late entry note, LPN B sent the resident to the ER at 7:00 P.M., on 7/18/16. Review of the progress notes, dated 7/18/16, showed three entries: - At 7:00 P.M., LPN B documented the ambulance staff transported the resident to the ER. - At 7:11 P.M. CNA E documented staff sent the resident to the ER. - At 9:49 P.M. Registered Nurse (RN) A documented that a FM said the resident was admitted to the hospital with [REDACTED]. Review of hospital ER records, dated 7/18/16, showed: - The resident arrived with an altered mental status that started yesterday. - Resident answered to his/her name but did not answer any other questions appropriately. - Family reports that the resident usually had these symptoms when he/she had a UTI. - The UA, obtained in the ER, showed the urine contained abnormal results of 3-5 red bloods cells (normal 0-2), 11-20 white blood cells (normal 0-5), and was positive for [MEDICATION NAME] and leukocyte esterase (normal was negative for both). - Physician's impressions included acute UTI and weakness. - admitted for observation to the telemetry unit. Review of the hospital's history and physical, dated 7/18/16, showed: - Blood cultures drawn and initial dose of intravenous (IV, given through sterile tubing into a vein) [MEDICATION NAME] (antibiotic) given in the ER; - Physician's impressions and plans included: 1. Acute UTI - initiate [MEDICATION NAME] and await urine culture; 2. Accelerated hypertension - re-initiate anti-hypertensive (medication to lower blood pressure) medications, monitor, and add [MEDICATION NAME] (to treat elevated blood pressure) IV as needed; 3. Acute [MEDICAL CONDITION] suspected as secondary to the above. Review of the urine culture and sensitivity (C&S, test to show the type and amount of bacteria and a list of medications effective in treating the infection), obtained on 7/18/16, showed the urine contained Escherichia coli and [MEDICATION NAME] faecalis (both bacteria are normally found in the bowels and can cause an UTI, if they entered the urinary tract). During an interview on 8/4/16, at 10:45 A.M., the DON said she did not know LPN B did not get the UA. She did not see any documentation to show staff attempted to get the UA. She expected staff to get the UA. 3. During an interview on 8/4/16, at 2:50 P.M., the DON said: - Resident #2's physician made rounds on Mondays, Wednesdays, and Fridays. - The physician also had nurse practitioners (NP), in his/her practice, and one of the NP came to the facility seven days a week. - When staff had a concern about a resident they should complete a problem referral to physician (PRP) form and put that form in that physician's book. The physician or NP reviewed and responded to the PRP forms that day or the next day, depending on when staff put them in the book. - The facility scheduled a resource nurse each shift and the resource nurse or admissions nurse returned the PRP forms to the correct wing. - The charge nurses entered any orders into the computer. Review of Resident #2's quarterly MDS, dated [DATE], showed: - Short and long-term memory problems; - Moderately impaired cognitive ability; - Indwelling urinary catheter; - Frequently incontinent of bowel. Review of the care plan, dated 6/24/16, showed: - Problem of indwelling catheter with a goal of managing catheter care appropriately as evidenced by no signs of infection. Approaches directed staff to report signs and symptoms of a UTI which included acute confusion, concentrated urine, foul odor, blood in urine, fever, chills, or nausea/vomiting. Review of LPN A's progress note, dated 7/1/16, at 6:50 P.M., showed: - The resident had amber colored urine which contained a lot of sediment. - He/she planned to report this to the oncoming staff and complete a PRP to inform the physician. May need to flush the catheter. During an interview on 8/4/16, at 4:25 P.M., LPN A said: - He/she wrote the PRP form on 7/1/16, because the resident had amber urine with a lot of sediment. Review of LPN A's PRP form, dated 7/1/16, showed: - Background: Staff changed the resident's catheter last night due to no urine output. - Assessment: Urine output today, but the urine was amber colored with a large amount of sediment. - Request: An order to flush catheter as needed. - A physician's orders [REDACTED]. - LPN E, initialed the PRP form to show he/she noted the order at 11:35 A.M., on 7/4/16. During an interview on 8/4/16 at 4:25 P.M., P.M., LPN A said he/she did not know the physician ordered a UA. Review of the urine output record, dated 7/4/16, showed staff recorded 1200 cubic centimeter (cc) of urine. Review of the eMR, showed staff entered the physician's UA ordered on [DATE], as ordered on [DATE]. During an interview on 8/4/16, at 2:50 P.M., the DON said: - LPN E, noted the UA order on 7/4/15 at 11:35 A.M. LPN E entered that order as 7/5/16, so staff would collect the UA on 7/5/16, and call the hospital courier to transport it. Review of the urine output record, dated 7/5/16, showed staff recorded 875 cc of urine. Review of LPN F's progress notes, dated 7/6/16, showed: - At 4:16 A.M., the resident had decreased urine output with a strong odor during the shift. LPN F advanced the catheter and noted some urine output. - At 5:20 A.M., LPN F irrigated the catheter with little or no return. He/she reported this to the resource nurse. - At 6:05 A.M., he/she removed the old catheter, inserted a new catheter, with immediate return of medium amber urine. Review of the urine output record, dated 7/6/16, showed staff recorded 1050 cc of urine. Review of the UA, dated 7/7/16, (three days after the physician ordered the UA) showed: - White blood cells 21-50 and the normal was 0-5; - Red blood cells 6-20 and the normal was 0-2; - Positive for [MEDICATION NAME] and leukocyte esterase and the normal was negative; - The physician wrote an order for [REDACTED]. Review of the C&S report, dated 7/9/16, showed: - The resident's urine contained Citrobacter koseri (bacteria normally found in the intestinal tract and can cause an infection if it entered the urinary tract). - The physician ordered [MEDICATION NAME] (antibiotic) 100 mg, twice a day, for seven days to treat the UTI. Review of CNA B's progress note, dated 7/10/16 at 8:45 P.M., showed: - Day shift CNA reported to him/her that the resident had little to no urine output and, at this time, the catheter bag was nearly empty. - Will continue to monitor for changes. During an interview on 8/4/16 at 4:25 P.M., P.M., LPN A said: - The resident's pharmacy delivered medications on Saturdays if staff - ordered the medications by noon, but did not deliver medications on Sunday or holidays. - He/she entered the [MEDICATION NAME] order on 7/11/16; that was the first day he/she knew about the order. - Sometimes the resource nurse or admissions nurse did not bring the labs or the PRP forms to the wing the day the physician wrote the orders. - He/she thought the E-Kit contained [MEDICATION NAME]. Review of the eMR, showed LPN A entered the physician's 7/9/16, order for [MEDICATION NAME], as ordered on [DATE]. Review of the electronic Medication Administration Record [REDACTED] - On 7/11/16, between 3:00 P.M., and 7:00 P.M., staff administered the first dose of [MEDICATION NAME] (two days after the physician ordered the antibiotic). During an interview on 8/4/16, at 2:50 P.M., the DON said: - She did not know why staff did not obtain the UA until 7/7/16. - She did not find any documentation where staff notified the physician that they did not obtain the UA until 7/7/16. - If night shift staff did not obtain the UA they should notify the day shift staff and they should get the UA. - Staff should contact the physician for orders and notify the pharmacy of the orders. - The resident's pharmacy did not deliver medications on weekends or holidays. During a telephone interview on 8/5/16 at 1:50 P.M., the Administrator and UC A said: - When staff had concerns about any resident they completed a PRP form. - UC A said the facility did not have any specific expectations for when staff should follow up with a physician. If the physician or NP did not respond and the problem continued the nurse should follow up with the physician. - UC A said she expected staff to send the resident's UA sooner because the resident had a catheter; so they should not have a problem obtaining the urine. - The facility contracted with a pharmacy to provide medications for residents admitted for skilled care under Medicare A or managed care. That pharmacy provided an emergency E-Kit that staff used for those skilled care residents. - It was not the facility's policy to use the E-Kit for long term care (LTC) residents because that created a problem in billing LTC residents for the medication. MO 7