Every finding on record at Manchester Rehab and Healthcare Center

Based on observation, interview and record review, the facility failed to ensure one resident received adequate supervision and interventions to ensure their safety. Resident #131 admitted on [DATE] from the hospital with altered mental status suspecting underlying dementia with psych issue, and in need of a secure unit. On 4/11/25, the resident left through an alarmed exit door on the secured memory care unit. The alarm sounded on the exit door, however, staff did not visually verify the location of residents on the unit. On 4/19/25, Resident #131 smashed a window with a toilet tank lid, cried and said he/she wanted to leave and threatened to jump out the window. He/She was hospitalized for two days and returned on 4/21/25 with a diagnosis of severe urinary tract infection (UTI). When the resident returned, he/she was suppose to be on enhanced visual monitoring or 1:1 monitoring, neither of which were communicated to staff, and staff did not provide increased supervision. On 4/24/25 at approximately 5:45 P.M., staff noticed the resident missing after he/she was last seen at 5:00 P.M. Staff found the resident broke the window in his/her room and left the building. The resident was found approximately 1.6 miles away from the facility, down a high-traffic main road. Police brought the resident back approximately two hours after staff determined the resident was missing. Staff who were present at the time of the incident were unaware of the resident's prior elopement attempts. Observations showed the door alarms on the secured memory care unit failed to properly display which exit door was opened during a test of the alarm system on 5/22/2025. In addition, facility staff failed to implement care-planned interventions for two residents identified as high fall risk (Residents #15 and #67) and failed to use a gait belt during an assisted transfer for one resident (Resident #76). The sample was 19. The census was 74. The Administrator was notified on 5/22/25 at 12:47 P.M., of an immediate jeopardy (IJ) which began on 4/21/25. The IJ was removed on 5/23/25, as confirmed by surveyor onsite verification. Review of the facility's Wandering & Elopement policy, revised 10/24/22, showed: -Purpose: To enhance the safety of residents of the facility; -Policy: The facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement; -Procedures included: -The resident's risk for elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated by the interdisciplinary team (IDT) upon admission, readmission, quarterly, and upon change in condition according to the Resident Assessment Instrument (RAI) guidelines; -IDT may consider interventions listed in the Elopement Risk Reduction Approaches form for residents identified to be at risk for elopement; -Response to Resident Elopement: --The Licensed Nurse most familiar with the incident will document in the resident's medical record how the elopement occurred; -Return of Resident: --The Licensed Nurse will initiate or update the resident's Care Plan and implement immediate intervention(s) to prevent further wandering/elopement by the resident; --The IDT, with input from the Licensed Nurse, will conduct a thorough review of the elopement, document its findings in the IDT notes, and update the Care Plan to prevent a recurrence. Review of the facility's Fall Management Program policy, revised, 10/24/22, showed: -Purpose: to prevent resident falls and minimize complications associated with fall through the development of a fall management program; -Policy: The facility will provide the highest quality in the safest environment for the residents residing in the facility; The facility has developed a fall management program that strives to prevent resident falls through meaningful assessments, interventions, education and reevaluation; -Procedure: -Assessment: -The Licensed Nurse will assess each resident for their risk of falling upon admission, quarterly and with a significant change in condition; -Based on the information gathered from the history of the assessment of the resident, the nursing staff and IDT, with input from the attending physician, will identify and implement interventions to reduce the risk of falls; -Care Planning: -The nursing staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls; -Universal fall prevention measures for all residents: -Orient the resident to their environment; -Position, call bell, urinal if applicable, and bedside stand within reach; -Keep walkways obstruction and spill free; -Place bed in lowest position with brakes locked; -Residents should wear non-skid footwear whenever out of bed; -Assist residents with toileting as appropriate; -Encourage use of assistive devices as appropriate. Review of the facility's Gait Belt policy, revised, 10/24/22, showed: -Purpose: To provide assistance to clinical staff when moving a resident from one place to another and to increase the safety of resident by allowing clinical staff members to grip it and keep the resident from falling; -Policy: A gait belt may be used for residents who are too weak to walk or stand alone, or requires assistance. Review of the facility's Communication-Call System policy, revised 10/24/22, showed: -Purpose: To provide a mechanism for residents to promptly communicate with nursing staff; -Policy: The facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities; -Procedure: Call cords will be placed within the resident's reach in the resident's room. 1. Review of Resident #131's pre-admission documentation, effective 4/9/25, showed: -Communication to post-acute referral provider from hospital: --Resident admitted to hospital on [DATE] with complaints of motor vehicle accident. Resident with history of dementia (a general term for memory loss and decline in other cognitive abilities, severe enough to interfere with daily life). Found by police walking up and down the road with his/her car in the ditch. Resident has unstable gait. He/She does not know where he/she is, the time/year/month. He/She does not know his/her medications. He/She cannot remember what happened; -Diagnoses included bipolar disorder (a mental health condition characterized by extreme mood swings, ranging from periods of intense highs (mania) to periods of deep lows (depression)) and depressive disorder (characterized by persistent low mood and a loss of interest in activities); -Assessment and plan, dated 4/9/25, showed altered mental status suspecting underlying dementia with psych issue; -Referral message from hospital to facility showed resident is in need of a secure unit; -Referral message from facility to hospital showed resident looks appropriate for secured unit. Review of the resident's medical record, showed: -admitted [DATE] to room on the 500 hall, the facility's secured memory care unit; -Diagnoses included unspecified dementia with agitation, bipolar disorder, depression, cognitive communication deficit, difficulty walking, and unsteadiness on feet; -admission assessment, dated 4/11/25 at 10:23 A.M., showed resident alert, oriented to person and place. Behaviors: wandering. Review of the resident's Wandering Risk Assessment, dated 4/11/25 at 10:33 A.M., showed: -Has history of wandering; -Medical diagnosis of dementia/cognitive impairment; diagnosis impacting gait/mobility or strength; -Has wandered within the home without leaving grounds; -Has wandered in the past month; -High risk to wander. Review of resident's nursing note, dated 4/11/25 at 2:50 P.M., flagged as late entry, showed: -The resident was brought through front door by laundry attendant. Police officers were present. Nurse and attendant did not know who the resident was and were taking precautions by calling 911. Resident opened the side door setting off alarm on 500 hall exit. Maybe 20 minutes before when I heard the alarm, I came and turned it off. I did a walk down the hall and didn't see anything out of the norm and continued with med pass. Maybe 15 minutes later is when they walked through the door. I confirmed with the officers and nurse that he/she was with us and returned him/her to the hall. Resident was in a good mood, just a bit confused; -No documentation the writer of the nursing note completed a head count upon hearing the door alarm on the 500 hall; -No documentation the physician or Nurse Practitioner (NP) were notified of the resident's elopement from the facility. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident is an elopement risk/wanderer; -Goal, initiated 4/11/25: Resident's safety will be maintained through the review date; -Interventions, initiated 4/11/25: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers (blank). Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. During an interview on 5/22/25 at 7:33 A.M., the Director of Nursing (DON) said when the door alarms sounded on the secure unit on 4/11/25, staff should have checked the door and then completed a head count. After the resident eloped from the secure unit on 4/11/25, he/she was placed on 15-minute checks for one day. Documentation of the 15-minute checks should be uploaded into the resident's medical record. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/16/25, showed: -Moderate hearing difficulty; -Short and long term memory problem; -Severe cognitive impairment; -Cognitive skills for daily decision making: Severely impaired. Review of the resident's NP note, dated 4/16/25, showed: -Resident pulled out his/her urinary catheter on 4/15/25, was sent to the hospital, and returned to the facility promptly with antibiotics prescribed for seven days; -Diagnoses included Alzheimer's disease (the most common cause of dementia, a progressive neurological disorder that leads to memory loss, thinking difficulties, and changes in behavior) with late onset; -No documentation related to the resident's elopement from the memory care unit on 4/11/25. Review of the resident's NP note, dated 4/18/25, showed resident seen for effectiveness of antibiotics. Currently on antibiotics for UTI. Resident pulled out catheter this morning. Plan is to continue antibiotics from 4/18/25 to 4/28/25. Review of the resident's Situation, Background, Assessment, Request (SBAR, communication tool) communication form and progress note, dated 4/19/25 at 7:20 P.M., documented by Licensed Practical Nurse (LPN) FF, showed: -Situation: Resident broke full window with toilet lid cover out of room on secure unit on 4/19/25. Since this started, it has become worse. Resident attempting jumps out broken window. Nothing could have been done to change resident due to high-risk, suicide. This condition, symptom, or sign has not occurred before. Resident was agitated, increased anxiety; -Background: Primary diagnosis of dementia. Mental status changes include increased confusion and delirium (a temporary state of altered consciousness characterized by confusion, disorientation, and difficulty concentrating); -Assessment: The resident appears anxious, agitated, confused, alert and oriented x 2-3; -Request: Resident observed standing at window with toilet top, window observed broke and screen broken. Resident stated, I am going to jump, two times. Nurse yelled for other nurse on duty to assist. Other resident was able to deescalate resident and resident brought to nurse station and 1:1 sitter until Emergency Medical Services (EMS) and police arrived. Resident sent to hospital for psychiatric evaluation and treatment. Review of the resident's transfer to hospital summary, dated 4/19/25 at 9:38 P.M., showed LPN FF documented hospital specialist called facility and LPN gave information regarding resident's stay and exit seeking behaviors, behaviors since resident admission. During an interview on 5/21/25 at 9:43 P.M., LPN FF said he/she worked 7:00 P.M. to 7:00 A.M. on 4/19/25. During his/her shift, he/she heard glass break in one of the rooms on the memory care unit. He/She found the resident standing in front of the window with a toilet tank lid in his/her hands and the window broken. The resident was crying and said he/she wanted to leave. The resident was sent out to the hospital for a psych eval and came back a couple days later with a diagnosis of severe UTI. The resident was not on any kind of plan for increased monitoring. LPN FF was not aware the resident got off the secured unit on 4/11/25. This information was not communicated to him/her and would have been helpful to know when monitoring the resident. Review of the resident's hospital Discharge summary, dated [DATE], showed: -History of present illness (HPI): A few days ago, patient apparently ripped out his/her Foley (urinary catheter). He/She went to the hospital for an evaluation and he/she was placed on antibiotics. Earlier today, he/she got very agitated again and was screaming at staff. Apparently he/she took a toilet seat and broke a window and tried to escape. He/She apparently yelled that he/she is sick of it here, it is full of old people; -Hospital course: --Acute metabolic encephalopathy (alteration of brain function) - resolved; ---On admit, patient was confused, agitated, and apparently broke a window. Much improved after starting antibiotics for urinary infection on admit. Patient also has a significant psychiatric history with bipolar and depression; --Complicated UTI; --Bipolar disorder. Review of the resident's medical record, showed: -Resident readmitted to facility's secure memory care unit on 4/21/25; -No documentation related to increased supervision or other interventions related to safety for the resident following attempted elopement on 4/19/25. During an interview on 5/22/25 at 7:33 A.M., the DON said after the resident attempted to elope on 4/19/25, the resident was sent to the hospital and returned two days later. He/She was on antibiotics for a UTI and was supposed to be referred to a psychiatrist, but she is not sure that had happened, yet. The DON suggested using rounding sheets for the resident, and the resident should have been checked on every 15-minutes for 48 hours following the resident's return to the facility on 4/21/25. This need was discussed in the daily stand-up meetings. The resident's care plan should have been updated by the nurse within 24 hours of the attempted elopement, and should have shown updated interventions for elopement incidents. Review of the resident's Wandering Risk Assessment, dated 4/22/25 at 1:29 P.M., showed: -Has wandered aimlessly within the home or off the grounds; -Has wandered in the past month; -High risk to wander. Review of the resident's NP note, dated 4/22/25, showed: -Resident is a readmit to the facility. Sent to emergency department (ED) for confusion and agitation. Was treated for UTI. Long-term and short-term memory deficit; -Plan related to confusion arousals: Maintain dementia unit, psychotropic medication, and psych eval. Review of the resident's care plan, in use at the time of survey, showed: -No documentation of resident's elopement from secure memory care unit via unit doors on 4/11/25; -No documentation of the resident breaking the window using a toilet tank lid and expressions of wanting to leave the secure memory care unit on 4/19/25, and no new interventions identified related to the resident's behavior and supervision needs or physical environment. Review of the resident's behavior note, dated 4/24/25 at 7:53 P.M., showed LPN HH documented patient had increased behaviors during this shift and patient managed to elope out of facility by breaking his/her bedroom window and going through the window. During an interview on 5/21/25 at 5:24 P.M., LPN HH said he/she came in for his/her shift on 4/24/25 just before 6:00 A.M. During report, the night nurse did not mention anything about the resident's prior elopement attempts or that the resident was supposed to be on 1:1 monitoring. At around 5:45 P.M., the Certified Nurse Aide (CNA) reported he/she could not find the resident. LPN HH saw the resident about an hour prior to that, at around 4:45 P.M. LPN HH went to the resident's room and found the window had been busted out and the busted window screen was inside the room. There was shaving cream all over the place and the resident was gone. Staff started looking for the resident and the police and DON were notified. About an hour or so later, police located the resident at a restaurant off the main road outside of the facility. The resident was brought back to the facility and placed on 1:1 monitoring with the DON. 1:1 monitoring means staff should check the resident every 15 minutes. The DON said the resident was supposed to be on 1:1 monitoring, 15-minute checks, during the shift before the resident eloped, however, this was never reported to LPN HH or the CNAs who worked with him/her that day. No one knew the resident was supposed to be on 1:1 monitoring on 4/24/25, before the resident eloped from the facility. On the secure unit, the usual protocol is for staff to check residents every hour. Review of the police department investigative report, printed 4/29/25, showed: -Date/time received: 4/24/25 at 6:10 P.M.; -Subject information: Missing person. Subject has dementia and is hearing impaired; -Narrative: Responded to facility in reference to missing person. Prior to arrival, communications advised subject had broken his/her window and left the facility. Worker stated resident was last seen walking westbound on main road. Upon arrival, spoke with LPN HH, who stated he/she had last seen resident at 5:00 P.M. LPN HH stated he/she went to check on resident around 5:45 P.M. and discovered he/she was missing and his/her window had been smashed out. Resident had a history of escaping/attempting to escape the facility. Review of the facility's investigation into the resident's elopement on 4/24/25, reviewed on 5/22/25, showed: -Timeline of events: --5:00 - 5:20 P.M.: Staff discovered resident's window broken, management notified; --7:09 P.M.: Resident found by police department and enroute to facility. Review of Google Maps, showed approximate walking distance of 1.6 miles from the facility to the restaurant off the main road outside of the facility, where police located the resident. During an interview on 5/21/25 at approximately 2:15 P.M., CNA A said at around dinnertime on 4/24/25, he/she did a count of residents and could not find the resident. He/She saw the resident 30 to 45 minutes prior to this. He/She checked the resident's room and found shaving cream all over the window, the window broken with glass all over the floor, and the screen outside of the window. He/She reported it to the nurse and everyone started searching for the resident. The resident was gone for at least 45 minutes after that. Police found the resident at a restaurant down the main road outside of the facility. The resident was not on 1:1 or increased monitoring prior to this day. During an interview on 5/21/25 at 7:10 P.M., CNA B said he/she worked on the secure unit on 4/24/25 from 7:00 A.M. to 7:00 P.M. The resident was not on 1:1 monitoring during the shift. Close to dinnertime on 4/24/25, the other CNA saw the resident was missing. The other CNA went to the resident's room and saw the resident's window was broken. Staff searched for the resident, but could not find him/her. The police brought the resident back to the facility a couple hours later, just before CNA B's shift ended at 7:00 P.M. The resident told staff he/she covered his/her window in shaving cream to muffle the sound of the glass breaking. CNA B was not aware the resident had two prior actual or attempted elopement attempts. This information would have been good for staff to know. CNA B was later told the resident should have been on 1:1 monitoring during the day shift on 4/24/25, but this was never communicated to CNA B. 1:1 monitoring means checking the resident every 15 minutes. There are no set guidelines for completion of routine rounds on the memory care unit. Following the incident on 4/24/25, CNA B was not in-serviced on 1:1 monitoring or elopement protocol. During an interview on 5/21/25 at 9:43 P.M., LPN FF said on 4/24/25, he/she came in for his/her shift at 5:50 P.M., and an elopement code had just been called for the resident. He/She looked for the resident in the nearby neighborhood at 6:00 P.M., and one of the neighbors said he/she saw someone matching the resident's description about 45 minutes prior to that. Police returned the resident to the facility at around 7:30 P.M., before 8:00 P.M. During an interview on 5/22/25 at 7:33 A.M., the DON said on 4/24/25, the resident was not seen by staff for 45 minutes, which is too long for him/her to go in between checks. Staff should complete rounds every two hours on the secure unit. If residents exhibit behaviors, they should be checked more frequently. The DON, Assistant Director of Nurses (ADON), Administrator, Social Services Director (SSD), and MDS Coordinator determine interventions. Interventions are communicated to staff during daily stand-up meetings. The resident should have been checked more frequently on 4/24/25. The Administrator investigated the resident's elopement incidents and the DON did not see the statements obtained during the investigation. During an interview on 5/22/25 at 8:21 A.M., the Administrator said when the door alarms sounded on the memory care unit on 4/11/25, staff should have checked the doors and immediately completed a head count to determine who was missing. Once a resident was identified as missing, staff would have called the code to alert everyone to search for the missing resident. The resident's physician and responsible party should have been notified. After the resident eloped on 4/11/25, the Administrator spoke with the resident's family member, who said the resident still had his/her right mind. The family member said it was helpful for staff to talk to the resident about what he/she liked to do and to give the resident something to do. The Administrator spoke with some staff about their interactions with the resident and keeping him/her occupied. On 4/19/25, the Administrator conducted an investigation into the resident's elopement. While in the hospital for this incident, it was found the resident had a UTI. Upon the resident's return to the facility, staff was instructed to keep the resident on enhanced visuals. There are no policies or specific expectations for rounding on residents on the memory care unit. Two hours is an acceptable timeframe to complete rounds on residents on the memory care unit. Staff typically round on the residents and constantly watch them. To place a resident on enhanced visuals means to watch them more frequently than two hours, but there is no specific definition or expectation for more frequently. Enhanced visuals are more frequent than rounding every two hours, but less often than placing a resident on 1:1 monitoring. Enhanced visuals are not documented. 1:1 monitoring means staff should have visual on the resident at all times and keep track of their monitoring on a written log. The Administrator is not sure how long the resident was on enhanced visuals following the incident on 4/19/25, but the information is documented in the investigation she completed. Interventions, such as enhanced visuals, are communicated to staff through in-servicing. Interventions should be documented on a resident's care plan. Documentation of the in-servicing should be documented in the investigation she completed. On 4/24/25, the resident eloped by breaking the window in his/her room. When he/she came back to the facility, he/she was able to say why he/she eloped and how he/she used shaving cream on the window to reduce the noise of the broken glass. The Administrator investigated the elopement and found one of the CNAs who worked on 4/24/25 reported the incident to his/her family first, rather than the DON or Administrator. The investigations into the resident's elopements on 4/11/25, 4/19/25, and 4/24/25, are all in the same investigation file. Review of the facility's investigation file regarding the resident's elopements, provided 5/22/25 at approximately 11:55 A.M., showed: -No documentation related to the elopement on 4/11/25, including employee statements, physician notification, and in-service training; -No documentation related to the attempted elopement on 4/19/25, including employee statements and in-service training; -23 staff completed a questionnaire on 4/28/25 and 4/29/25 with the following questions: -What is the code for a missing resident; -Who do you report a missing resident to: -How often do you complete rounding on your residents; -No documentation related to in-service training with staff related to verification of resident locations on the unit upon door alarms sounding on the memory care unit, specific instruction for enhanced visual or 1:1 monitoring, or utilization of care plans to identify specific interventions for residents identified as high risk for elopement. During an interview on 5/22/25 at 9:45 A.M., the Medical Director said all residents on the memory care unit have dementia. When an exit door on the memory care unit is opened, the alarms at the doors should sound. When staff hear the door alarms, they should immediately check the doors to determine where the alarms are coming from. When the door alarm sounded after the resident's elopement on 4/11/25, staff should have conducted an immediate head count. He cannot recall being notified of this incident. He was notified of the resident's attempted elopement on 4/19/25. It would be expected for the resident to have been on an increased watch following this incident. At minimum, staff should have discussed with their supervisors what next steps should be taken to address the incident. Hourly checks for residents on the memory care unit could be ok for most residents, and should be more frequent for other residents, depending on the general understanding of the residents on the memory care unit. During an interview on 5/22/25 at 12:09 P.M., the Medical Director said the resident was not safe to be on his/her own. Upon admission, something told the facility right off the bat that the resident required placement on a memory care unit. During an interview on 5/22/25 at 2:47 P.M., Regional Nurse II said the Elopement Risk Reduction Approaches form referenced in the Wandering & Elopement policy is the same thing as the Wandering Risk Assessment. Regional Nurse CC said the facility did not classify the resident's elopement attempt on 4/19/25 as an elopement event; they classified it as a suicidal behavior event. The resident was cleared by the hospital's psychiatrist and additional monitoring was not needed when the resident returned to the facility because he/she had been cleared. During an interview on 5/23/25 at 11:35 A.M., Regional Nurse CC said the DON in-serviced all staff following the resident's elopement on 4/24/25. In-servicing with staff was ongoing and the exact dates of in-services are unknown. Review of the facility's in-service training documentation, provided on 5/23/25, showed: -12 staff signed in-service sheet for enhanced monitoring/1:1 monitoring on 4/24/25; -11 staff signed in-service sheet for elopement policy on 4/24/25; -10 staff signed in-service sheet for reporting on 4/24/25; -11 staff signed in-service sheet for elopement drill/missing resident drills on 4/24/25; -7 staff signed in-service sheet for Resident #131's placement on 1:1 monitoring on 4/24/25; -An employee list, dated 4/24/25, in which verbal I.S, documented next to the names of staff, undated, and NS documented next to the names of other staff who were not employed on 4/24/25. During an interview on 5/23/25 at 12:01 P.M., the DON said she verbally in-serviced some of the staff following the resident's elopement on 4/24/25. She could not recall the exact dates of the in-service training. During the in-service, she discussed the facility's elopement procedures. During an interview on 5/21/25 at 1:26 P.M., Housekeeper L said he/she has been employed by the facility for a few weeks. He/She is not sure what the protocol is for a missing resident or door alarms sounding. He/She has not been in-serviced on these topics. During an interview on 5/22/25 at 6:43 A.M., Nurse Aide (NA) K said he/she has been employed by the facility for five weeks and he/she just got access to resident care plans this week. Care plans tell staff exactly what is going on with residents and he/she would like to have access to these so he/she could know about the residents he/she is supposed to monitor. All residents on the memory care unit should be seen by staff every 15 minutes because of their wandering. During an interview on 5/22/25 at 7:11 A.M., NA JJ said he/she has been employed by the facility for a few weeks. All residents on the memory care unit have elopement tendencies. Residents on the memory care unit should be checked every 15 to 30 minutes. Staff know which residents should be on 1:1 or increased monitoring by learning their behaviors. He/She does not know if care plans are used by the facility. 2. Observation on 5/22/25 at 9:09 A.M., showed the 400 and 500 halls located on the secure memory care unit, with exit doors located on both halls. Twelve residents were in the dining room. LPN F, CNA A, and CNA W, worked on the secure unit. During a test of the alarm, the exit door on the 400 hall opened at 9:09 A.M. The door opened without a 15-second delay. An alarm sounded at the panel at the nurse's station, but did not sound at the alarm box above the open door. Observation on 5/22/25 at 9:19 A.M., showed the alarm panel at the nurse's station showed 123. The Maintenance Director said the panel should indicate which door was opened, but currently, it was not showing the correct door. The Administrator said the exit doors on the 500 and 400 halls should be on 15-second delays and both doors should be alarmed. The Regional Maintenance Director said when either exit doors are opened on the 500 and 400 halls, [TRUNCATED]

Based on observation and interview, the facility failed to ensure food was served at a palatable, safe and appetizing temperature during tray service by failing to maintain the temperature of hot food at least at 120 degrees Fahrenheit (F). This affected five of 19 sampled residents (Residents #17, #36, #38, #50 and #55). The census was 74. Review of the facility's food temperature policy, dated 10/24/22, showed: -Policy: foods prepared and served in the facility will be served at proper temperatures to ensure food safety; -Procedure: if temperatures do not meet the required serving temperatures, reheat the product or chill the product to the proper temperature. -Acceptable food temperatures: meat should be greater than 135 degrees F, potatoes should be greater than 135 degrees F. 1. Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/23/25, showed: -Cognitively intact; -Diagnoses included acute respiratory failure, muscle weakness and depression. During an interview on 5/19/25 at 5:52 A.M., the resident said food is normally delivered cold. 2. Review of Resident #36's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included epilepsy (seizure disorder), muscle weakness and quadriplegia (paralysis of all four limbs). During an interview on 5/19/25 at 6:57 A.M., the resident said the food is cold most of the time. 3. Review of Resident #38's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart failure and anxiety. During an interview on 5/19/25 at 11:17 A.M., the resident said food is cold at all meals. 4. Review of Resident #50's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included muscle weakness and paraplegia (paralysis of lower portion of the body and of both legs). During an interview on 5/19/25 at 7:24 A.M., the resident said food is normally cold when delivered. 5. Review of Resident #55's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included chronic obstructive pulmonary disease (lung disease), muscle weakness and chronic respiratory failure. During an interview on 5/19/25 at 6:05 A.M., the resident said the food tastes okay, but can be cold. 6. Observation on 5/19/25 at 9:13 A.M., of breakfast on the 300 hallway, showed: -Scrambled eggs measured 99.2 degrees F; -Bacon measured 97.5 degrees F; -Toast was soggy. 7. Observation on 5/21/25 at 1:48 P.M., of lunch on the 800 hallway, showed: -Herbed baked chicken measured 109 degrees F; -Green beans measured 96 degrees F. 8. During an interview on 5/21/25 at 10:30 A.M., the corporate owners said they pulled staff and a Dietary Manager from another facility, due to the Dietary Manager walking out the week before. The facility cook had only been working for four days and had not been trained properly. During an interview on 5/22/25 at 8:19 A.M., Dietary Aide I said food should be delivered to residents at a safe and palatable temperature. During an interview on 5/22/25 at 8:24 A.M., Dietary Aide J said food should be delivered at a safe and palatable temperature. He/She said he/she wouldn't want his/her food to be cold. During an interview on 5/23/25 at 7:49 A.M., the Administrator said she expected staff to serve food to residents at a safe and palatable temperature. The cook is responsible to ensure food is at the appropriate temperature before leaving the kitchen but the current cook was not doing this. MO00244287

Based on observation, interview and record review, the facility failed to ensure medications and solutions kept in the facility's medication rooms and on medication carts were not expired. In addition, the facility failed to ensure temperature logs in the facility's medication rooms were completed. The sample was 19. The census was 74. Review of the facility's Storage of Medications policy, revised April 2007, showed: -Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers; -The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed; -Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents; -Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. 1. Observation on 5/20/25 at 12:18 P.M. of the 300 hall medication room, showed: -One bottle of GeriCare Oyster Shell Calcium (used to help aid in the absorption of calcium and improve bone health) 500 milligram (mg) tablets expired 10/24; -A physical temperature log for the medication room refrigerator being used to store resident-specific insulin. No temperature was recorded on the log on the night shifts for 4/23/25 through 4/26/25, and no temperature was recorded on the log for any shift from 4/27/25 through 4/31/25. 2. Observation on 5/20/25 at 12:35 P.M. of the 700/800 hall medication room, showed: -A physical temperature log for the medication room refrigerator. No temperature was recorded on the log for any date in 2025 prior to 4/28/25. No temperature was recorded on the night shift from 4/28/25 to 5/19/25. 3. Observation on 5/21/25 at 10:18 A.M. of a medication cart on the 500 hall, showed: -One bottle of GeriCare docusate sodium (a stool softener used to help reduce constipation) 100 mg tablets expired 5/25; -One box of EvenCare glucose control solution (solution used to calibrate glucometers to obtain accurate blood sugar readings) expired 8/18/24. 4. Observation on 5/21/25 at 10:26 A.M. of a medication cart on the 800 hall, showed: -One card of Methocarbamol (a muscle relaxant used to relieve spasms and pain) 500 mg tablets ordered for a resident who expired in 4/25 with 9 doses left on the card. -One bottle of GeriCare Vitamin E (a fat-soluble vitamin) 100 mg tablets expired 1/25. 5. Observation on 5/21/25 at 10:35 A.M. of a treatment cart on the 300 hall, showed one box of Assure Dose glucose control solution for glucometer expired 9/20/23. 6. During an interview on 5/23/25 at 9:34 A.M., Certified Medication Technician (CMT) O said he/she goes through the medication cart at the beginning of each shift and keeps a permanent marker on his/her person to mark bottles left undated when opened. Medications that are expired should be removed from the cart, and it is the nursing staff's collective responsibility to do this. Medication room refrigerators are the responsibility of the nursing department, but CMT O said the temperature logs should be filled out daily on each shift. During interview on 5/23/25 at 10:17 A.M. Licensed Practical Nurse (LPN) P said he/she did not know how often medication carts and treatment carts were audited, but believed it was the Director of Nursing's (DON) responsibility to complete the audits of hall carts. Medications found on carts that are expired should be removed. Refrigerator temperature logs are the responsibility of night shift nursing staff and should be completed daily. During an interview on 5/23/25 at 9:34 A.M., the DON said she completed weekly audits of medication rooms, medication carts, and treatment carts in the facility and expected any expired medications to be removed from these areas as soon as they are noted by staff. Night shift nursing staff should complete refrigerator temperature logs in the medication rooms once daily on each evening shift. During an interview on 5/23/25 at 11:28 A.M., the Administrator said she expected all medications kept on treatment carts and medication carts in the facility to be within expiration date and to be removed if past expiration. Medication room refrigerator logs should be completed by nursing staff nightly on each shift. The audits for both of these items are the collective nursing staff's responsibility.

Based on observation, interview and record review, the facility failed to ensure residents had a safe, homelike environment by failing to ensure residents and staff had access to clean towels for three sampled residents (Resident #34, #36 and #58). Staff also failed to ensure one resident's broken window was fixed (Resident #15), failed to ensure three resident's personal refrigerators had completed temperature logs (Resident #4, #8 and #23) and failed to maintain the hot water at the minimum required temperature of 105 degrees Fahrenheit (F) for three residents (Resident #36, #23 and #55). In addition, staff failed keep the hallway on the Memory Care Unit free from trash. The sample was 19. The census was 74. Review of the facility's housekeeping policy, dated 10/24/22, showed: -Purpose: To ensure the Facility is clean, sanitary, and in good repair at all times so as to promote the health and safety of residents, staff, and visitors; -Policy: All rooms of the facility are kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for our residents; -Procedure: The Housekeeping Department is responsible for completing the daily, weekly, and monthly cleaning procedures. The housekeeping staff's general duties are to: Maintain clean bed and bath linens that are in good condition for residents; sweep and mop, or vacuum, all floors; clean all surfaces in restrooms, showers, and utility rooms; damp-wipe all furniture (except cloth upholstered), counters, windowsills, ledges and doors, wheelchairs, equipment, telephones, lamp bases, light fixtures, and nurses' call lights; clean all mirrors; wash windows as necessary; empty and clean all waste containers. Review of the facility's housekeeping daily cleaning schedule, showed: -Floors: sweep and mop; -Furniture: bed, nightstand, chairs, trash cans; -Bathrooms: toilet, sink, mirror, shower unit, towel racks, and safety bars. 1. Review of Resident #34's medical record, showed diagnoses included heart failure (a reduction in the heart's ability to pump blood to the organs), Chronic Obstructive Pulmonary Disease (COPD, chronic inflammation of the airways in the lungs), Type II Diabetes, Cognitive Communication Deficit, and Presence of Gastrostomy (a surgical appliance inserted into the stomach used to administer medication or supplemental nutrition). During interview on 5/21/25 at 10:18 A.M. the resident said he/she received a shower from facility staff as requested, but the aide had to use a blanket to help dry the resident as there was only one clean towel on the hall. 2. Review of Resident #36's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by the facility staff, dated 4/11/25, showed: -Diagnoses included epilepsy (seizure disorder), muscle weakness, and quadriplegia (paralysis); -Cognitively intact. During an interview on 5/22/25 at 1:44 P.M., the resident said there was not enough linen in the building. 3. Review of Resident #58's medical record, showed: -Diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture) and muscle weakness; -Cognitively intact. Review of the resident's shower sheet dated 4/29/25, showed Licensed Practical Nurse (LPN) MM signed his/her name on the shower sheet and documented the shower was not completed due to no linen available. 4. Observation of the laundry room on 5/22/25 at 10:22 A.M., showed no clean or dirty towels. Observations of the 300 hallway linen closet and linen cart on 5/22/25, showed: -At 7:06 A.M., no towels or wash cloths. -At 10:15 A.M., two clean towels. No wash cloths; -At 3:10 P.M., two clean towels. No wash cloths. Observation of the 500 hallway linen cart on 5/22/25 at 3:12 P.M., showed no towels or wash cloths. Observations of the 700 hallway linen cart on 5/22/25, showed: -At 7:02 A.M., no clean towels or wash cloths; -At 10: 16 A.M., no clean towels or wash cloths; -At 3:06 P.M., no clean towels or wash cloths. Observation of the 700 hallway linen cart on 5/23/25 at 6:35 A.M., showed no clean towels. Observations of the 800 hallway linen cart on 5/22/25 at 6:58 A.M., 10:17 A.M., and 3:04 P.M., showed no towels or wash cloths. Observation of the 800 hallway linen cart on 5/23/25 at 6:36 A.M., showed no clean towels. Observations of the 900 hallway linen cart on 5/22/25, showed: -At 7:00 A.M., no clean towels or wash cloths; -At 10:18 A.M., five clean towels and two wash cloths; -At 3:05 P.M., two clean towels and no wash cloths. Observation of the 900 hallway linen cart on 5/23/25 at 6:37 A.M., showed no clean towels. During an interview on 5/22/25 at 6:55 A.M., Laundry Aide G said he/she was one of two employees in the laundry room. He/She said staff threw away towels a lot. He/She said the evening shift did not always show up, so towels were not cleaned. Laundry Aide G was not able to get to them because resident clothing was a priority. During an interview on 5/22/25 at 10:58 A.M., Nursing Assistant (NA) H said there was a problem with the lack of linen. He/She said on 5/21/25, he/she could not shower any residents until 5:00 P.M., due to the lack of linen in the building. During an interview on 5/22/25 at 11:01 A.M., Certified Nursing Assistant (CNA) E said recently there had been issues with linens not being cleaned on time. During an interview on 5/22/25 at 11:04 A.M., Hospice CNA NN said when he/she came to the building to work with clients, normally it was hard to find clean towels. He/She said sometimes blankets had to be used. During an interview on 5/23/25 at 7:51 A.M., the Administrator said there should be enough linen to ensure all residents received a shower. She said new linen had been ordered. She said the census of residents had gone up and laundry staff were unable to keep up with the demand. 5. Review of Resident #15's quarterly MDS, dated , 4/9/25, showed: -Severe cognitive impairment; -Diagnoses include: cancer, Alzheimer's disease, and depression. Observations of the resident's room on 5/19/25 at 6:19 A.M. and 7:00 A.M., and 5/20/25 at 11:01 A.M., showed a window. One side of the window was boarded with plywood and secured with multiple screws. During an interview on 5/19/25 at 7:00 A.M., the resident said he/she had noticed the window boarded up and thought it didn't look nice. The resident didn't like the way it looked. During an interview on 5/22/25 at approximately 9:00 A.M., Maintenance Assistant Z said the resident's window had been boarded up for about a month. The repair work had to be approved by the corporate office, which they were waiting on. The boarded window was not considered a home like environment. During an interview on 5/22/25 at 9:16 A.M., Housekeeper AA said the resident's window had been boarded up for about three weeks. The room had been occupied by residents since the window was broken. The boarded window was not considered a home like environment. During an interview on 5/22/25 at approximately 11:00 A.M., the Regional Maintenance Director said they were having a contractor come out that day. The glass wasn't the only repair the window needed. The structure of the actual window needed to be repaired. There should not have been residents occupying that room since the window was broken out in April, 2025. The boarded window was not homelike. During an interview on 5/23/25 at 2:06 P.M., the Administrator said the boarded window in the resident's room was not acceptable and was not homelike. She would have expected the residents to be moved out of the room until it was repaired. 6. Review of Resident #4's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Upper extremity impairment on both sides; -Dependent for transfers and walking; -Diagnoses included stroke. Observation on 5/19/25 at 9:13 A.M., showed a mini refrigerator against the wall in the resident's room. A temperature log on the side of the refrigerator, dated 2025, was blank with no dates filled out. Bologna, cheese slices, cupcakes, and various beverages were observed inside the refrigerator. During an interview, the resident said staff did not check the temperature of his/her refrigerator. Observations on 5/20/25 at 11:11 A.M. and 5/21/25 at 8:43 A.M., showed the refrigerator temperature log was blank. 7. Review of Resident #8's annual MDS, dated [DATE], showed: -Diagnoses included acute kidney failure, dementia, and type two diabetes mellitus; -Cognitively intact. Observation on 5/19/25 at 5:44 A.M., showed a mini fridge on the resident's night stand. The temperature log, dated 2025, was blank. A cup of pudding and a drink were in the refrigerator. Observation on 5/21/25 at 10:40 A.M., showed the refrigerator temperature log dated 2025 was blank. 8. Review of Resident #23's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Upper extremity impairment on both sides; -Lower extremity impairment on one side; -Dependent for transfers and walking; -Diagnoses included stroke. Observation on 5/19/25 at 8:49 A.M., showed a mini refrigerator against the wall in the resident's room. A temperature log on the front of the refrigerator, dated 2025, was blank. Cheese, cottage cheese, ranch dressing, fruit cups, and soda were inside the refrigerator. During an interview, the resident said he/she did not know if staff checked the refrigerator temperature. Observation on 5/20/25 at 7:52 A.M. and 5/21/25 at 8:38 A.M., showed the refrigerator temperature log was blank. During an interview on 5/22/25 at 12:48 P.M., Maintenance Assistant Z said the Housekeeping Supervisor was responsible for maintaining the temperature logs for residents' personal refrigerators. He said he was currently overseeing the Housekeeping Supervisor role and had not been taking the temperatures. During an interview on 5/23/25 at 7:51 A.M., the Administrator said the Housekeeping Supervisor was normally responsible to take the temperatures of the residents' personal refrigerators. She said currently Maintenance Assistance Z should be maintaining the temperature logs. She would expect the temperatures to be taken to ensure the residents' food did not spoil. 9. Review of Resident #36's quarterly MDS, dated [DATE], showed: -Diagnoses included epilepsy, muscle weakness, and quadriplegia; -Cognitively intact. Observation and interview on 5/22/25 at 1:44 P.M., showed the resident's bathroom sink water measured a temperature of 67 degrees F. The resident said the cold water was uncomfortable when staff used the water to bathe him/her During an interview on 5/22/25 at 1:45 P.M., Maintenance Assistant Z said the facility had known about the resident's water temperature being cold for a while. He said the facility was in the process of fixing it. Observation on 5/22/25 at 2:56 P.M., showed the bathroom sink water measured a temperature of 97.1 degrees F. Observation on 5/23/25 at 6:49 A.M., showed the bathroom sink water measured a temperature of 69 degrees F. 10. Review of Resident #17's quarterly MDS, dated [DATE], showed: -Diagnoses included acute respiratory failure, muscle weakness, and depression; -Cognitively intact. Observation and interview on 5/22/25 at 2:00 P.M., showed the water at resident's bathroom sink measured a temperature of 88 degrees F. The resident had no concerns about the water temperature. He/She did not use the sink. Observation on 5/22/25 at 2:59 P.M., showed the bathroom sink water measured a temperature of 102 degrees F. Observation on 5/23/25 at 6:43 A.M., showed the bathroom sink water measured a temperature of 67.1 degrees F. 11. Review of Resident #55's quarterly MDS, dated [DATE], showed: -Diagnoses included COPD, muscle weakness, and chronic respiratory failure; -Cognitively intact. Observation on 5/22/25 at 1:50 P.M., showed the water from the bathroom sink measured a temperature of 93.3 degrees F. Observation on 5/22/25 at 2:54 P.M., showed the water from the bathroom sink measured a temperature of 95 degrees F. During an interview on 5/23/25 at 6:39 A.M., the resident said the water in his/her bathroom was usually cold from the sink. Observation on 5/23/25 at 6:47 A.M., showed the water from the bathroom sink measured a temperature of 74 degrees F. During an interview on 5/23/25 at 7:35 A.M., Licensed Practical Nurse (LPN) X said if the water in a resident's room was too cold staff should tell maintenance. During an interview on 5/23/25 at 11:25 A.M., the Administrator said maintenance staff should be ensuring water temperatures in resident bathrooms are at the required temperature. She would expect nursing staff to inform maintenance if there is a water temperature issue. 12. Observations of the Memory Care Hall on 5/19/25 at 5:07 A.M., at 6:20 A.M. and 6:42 A.M., showed a crumbled pile of white wipe cloths with brown matter and a bag of trash between rooms [ROOM NUMBERS] near the exit door. Snack chip bags, candy wrappers, and clear drinking cups were located on the floor in front of the nurses' station. Multiple staff members walked past the trash and did not pick the trash up off the floor. During an interview on 5/22/25 at 9:16 A.M., Housekeeper AA said he/she saw the trash in the halls when he/she came in the morning of 5/19/25. Cleaning the halls and picking trash off the floor was everyone's job. Trash on the floor was not homelike and he/she would not like trash in his/her house. During an interview on 5/23/25 at 12:50 A.M., CNA W said all staff, including nursing staff, could pick up trash off the floor and help maintain a clean comfortable environment for the residents. During an interview on 5/23/25 at 2:06 P.M., the Administrator said she would expect all staff to pick up trash off the floor. Trash on the floor was not homelike. MO00244287 MO00245936 MO00245936 MO00253003

Based on interview and record review, the facility failed to complete criminal background checks in accordance with their policy on newly hired or transferred employees, prior to the employee's start date, and failed to ensure the employees were screened to rule out the presence of a Federal Indicator through the Nurse Aide (NA) Registry, for three of 10 employees hired since the last survey. In addition, the facility's policy for screening new hires failed to include completion of checking the NA Registry. The census was 74. Review of the facility's Abuse Prevention and Prohibition Program policy, revised 10/24/22, showed: -Purpose: To ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Procedure: --Screening: -The facility does not knowingly employ anyone who has had disciplinary action against his/her professional license or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment or misappropriation or has been convicted of abusing, neglecting, or mistreating other people. See policy Staff Screening. Review of the facility's Staff Screening policy, revised 10/24/22, showed: -Purpose: To ensure the highest quality of care through the utilization of qualified staff, consultants and volunteers. -Procedure: --Prior to employment or commencement of a contract, the facility will verify and document or obtain a copy, if applicable, of the following information that may include, but not limited to: -Criminal background checks; -State exclusion screening, if applicable; -The facility's policy did not include completion of checking the NA Registry. 1. Review of Housekeeper LL's personnel file, showed: -Hire date: 1/23/25; -Family Care Safety Registry (FCSR) check: 5/20/25; -NA Registry check: 5/20/25. 2. Review of the Activities Director's personnel file, showed: -Hire date: 12/3/24; -FCSR check: 3/25/25; -NA Registry check: 3/25/25. 3. Review of Certified Nurse Aide (CNA) E's personnel file, showed: -Hire date: 11/6/24; -FCSR check: 3/20/23; -NA Registry check: 3/20/23. 4. During an interview on 5/21/25 at 3:29 P.M., the Regional Human Resources (HR) said she has been working with the facility for one month as corporate support. A new HR employee has been hired, but has not begun working yet. When a new employee is hired by the facility, HR is responsible for running pre-employment background checks prior to the employee starting work, which include FCSR checks and NA registry checks. If an employee transfers from a sister facility, they must be treated as a new hire and all pre-employment background checks must be run on the employee before they start working in the building. Housekeeper LL began working with the facility in January 2025 and his/her pre-employment background checks had not been run. The employee was sent home yesterday, 5/20/25, until the appropriate checks could be run. CNA E transferred from another facility and should have had new background checks completed before he/she started work at this facility. Pre-employment background checks should be run on every single employee for the safety of residents as part of the facility's abuse prevention. During an interview on 5/21/25 at 3:56 P.M., the Administrator said she expects HR to run FCSR checks and NA Registry checks on all new hires, prior to the employee starting work in the facility. The same pre-employment checks should be run on new employees who transfer from sister facilities. Pre-employment background checks must be run prior to an employee starting work in the facility for abuse prevention.

Based on observation, interview and record review, the facility failed to ensure residents that required assistance with activities of daily living (ADLs- bathing, dressing and toileting) received necessary services to maintain adequate personal hygiene when staff left three residents soiled for an extended period (Resident's #67, #65 and #17). The facility staff did not provide showers to two residents (Resident #17 and Resident #29). The sample size was 19. The census was 74. Review of the facility's Care and Services policy, revised 10/22/24, showed: -Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of an environment that enhances quality of life in the scope of a long-term facility; -Care and Services are provided in a manner that consistently enhances self-esteem and worth. Review of the facility's Showering a Resident policy, revised 10/24/22, showed: -A shower or bath is given to the residents to provide cleanliness, comfort and to prevent body odors; -Residents are offered a shower at a minimum of once weekly and given per resident request. 1. Review of Resident #67's, quarterly Minimum Data Set, (MDS, a federally mandated assessment instrument completed by facility staff) dated, 2/18/25, showed: -Severe cognitive impairment; -Dependent on staff for toilet hygiene and toilet transfers; -Requires maximum assist from staff for personal hygiene; -Always incontinent of bowel and bladder; -Diagnoses included: Alzheimer's disease, aphasia (inability to speak), and stroke. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is incontinent of bowel and bladder; -Interventions included: Check the resident every two hours and assist with toileting as needed; Encourage the resident to evacuate his/her bowels if possible; Observe patterns of incontinence and initiate toileting schedule if indicated; Provide perineum care (cleansing of the anal area and genitals) after each incontinent episode. Observation of the resident's room on 5/19/25 at 5:07 A.M., showed the resident's door was open, and he/she lay in bed uncovered on his/ her left side. The resident was a wearing a shirt and a brief. The room had a strong odor of urine and stool. The resident was visibly soiled and saturated; with stool and urine coming out the sides of the brief. The white bed pad underneath the resident was saturated with yellow urine. The resident's call light was clasped to a cord on the wall behind the privacy curtain. The resident could not reach the call light. Observation and interview on 5/19/25 at 5:35 A.M., showed the resident stood in his/her room next to his/her bed. The resident's brief appeared heavy and soiled with stool and urine. The resident's call light was clasped to a cord on the wall behind the privacy curtain out of the resident's reach. Certified Nursing Assistant (CNA) U observed the resident out of bed from the hallway and instructed the resident to go back to bed. A white bed pad located on the resident's bed was saturated with yellow urine. The resident sat on the edge the bed and then laid down. Observation and interview on 5/19/25 at 5:50 A.M., showed the resident lay in bed. CNA U removed the resident's brief. The resident's brief was saturated with stool and urine. The white bed pad underneath the resident was saturated with yellow urine. CNA U provided perineum care to the resident and applied a clean brief. 2. Review of Resident #65's, quarterly MDS, dated [DATE], showed: -The resident is rarely understood; -No rejection of care; -Occasionally incontinent of urine and frequently incontinent of bowel; -Requires maximum assist from staff for toileting hygiene; -Diagnoses included Alzheimer's disease. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has ADL deficit; -Intervention: The resident requires one person assist with toilet hygiene; -Focus: The resident has occasional urine incontinence; -Intervention: Clean perineum area after each incontinent episode; Check the resident for urinary incontinence as needed and provide incontinent care. Observation on 5/19/25 at 5:06 A.M., showed the resident lay in bed with his/her eyes closed, covered with a sheet and blanket. The resident's room had a strong odor of stool and urine. Observation on 5/19/25 at 6:04 A.M., showed the resident's door to his/her room was open and the resident was getting out of bed. The resident walked to the doorway wearing a shirt and a soiled brief with loose stool oozing out of the sides onto the floor. The resident's brief appeared heavy and was falling down between the resident's legs. The resident's bed and bed pad were saturated with urine and diarrhea. Graduate Practical Nurse (GPN) DD assisted the resident to walk into the bathroom. CNA U entered the room and provided perineum care, applied a clean brief and clean clothing. During an interview on 5/19/25 at approximately 6:15 A.M., CNA U said the last time he/she checked the residents on the hall was several hours ago and changed the residents briefs at approximately 11:00 P.M. Residents should be checked every two and half hours for incontinence and anything else they needed. Observation and interview on 5/23/25 at 8:28 A.M., showed the resident lay in bed. A strong odor of urine and stool was present. Licensed Practical Nurse (LPN) P was changing the resident's lower leg dressing and the resident's lower portion of his/her legs was uncovered. A dark amber ring of urine was on the resident's white fitted sheet. LPN completed the treatment and covered the resident's legs with a blanket and said to the resident, I will get an aide to help you get cleaned up. LPN P left the resident's room. Observation on 5/23/25 at 8:47 A.M., showed the resident lay in bed with his/her eyes closed. A strong odor of urine and stool was preset. A dark amber ring of urine was on the resident's white fitted sheet. Observation and interview on 5/23/25 at 9:35 A.M., showed the resident stood at the side of his/her bed. Nurse Assistant (NA) BB assisted the resident with changing his/her brief. The resident's bed pad, fitted sheet, and brief were saturated with diarrhea and urine. NA BB said he/she checked in on the resident earlier in the morning, but did not physically go into the resident's room and did not pull the covers back to determine if the resident was soiled. NA BB was not aware the resident was so soiled or else he/she would have cleaned the resident earlier. 3. Review of Resident #17's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Frequently incontinent of bowel and bladder; -Dependent on staff for toilet and personal hygiene; -Requires maximum assistance for showering and bathing; -Diagnoses included acute respiratory failure, muscle weakness, and depression. Review of the resident's care plan, dated 4/14/25, showed: -Focus: resident has an ADL self-care performance deficit; -Goal: the resident will maintain current level of function through the review date; -Interventions: check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Provide sponge bath when a full bath or shower cannot be tolerated. Monitor, document, and report any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function; Focus: The resident has bowel and bladder incontinence; Interventions: Check as needed for incontinence and provide incontinent care after each episode. -The care plan did not include OTC dandruff shampoo and directions for frequency and use. Review on 5/22/25, of the resident's shower sheets, showed: -On 5/6/25, the resident received a shower; -On 5/9/25, the resident received a shower; -On 5/13/25, the resident received a bed bath. Observations on 5/19/25 at 5:39 A.M., and 5/20/25 at 10:57 A.M., showed the resident in bed and awake. A strong odor emitted from the resident. The resident's hair was oily. The resident's face and scalp had white skin flakes and was reddened. During an interview on 5/19/25 at 5:40 A.M., the resident said staff do not shower him/her at least twice a week. He/She said it had been a week since his/her last shower. During an interview on 5/20/25 at 1:20 P.M., the resident's family member said he/she has special Nizoral shampoo for dandruff and psoriasis (condition in which skin cells build up and form scales and itchy dry patches). He/She said the resident does not normally refuse care. During an interview on 5/21/25 at 6:05 P.M., the resident said he/she has special shampoo for his/her scalp, but staff do not shower him/her regularly so his/her head and scalp was itchy. Review of the resident's POS, dated May 2025, showed no order for Nizoral shampoo (used to treat and control flaking, scaling, and itching from dandruff). During an interview on 5/23/25 at 7:33 A.M., LPN X said residents should receive at least two showers or bed baths a week. He/She would expect any skin concerns to be documented on the CNA's shower skin assessments and the nurse's weekly skin assessment. He/She said if a resident had a special shampoo there should be an order, it should be care planned and the resident's hair should be washed regularly. He/She said there currently was no order in the resident's chart for psoriasis shampoo and that was probably why the resident's skin was acting up. Observation and interview on 5/20/25 at 12:48 P.M., showed the resident lay in bed. CNA B and LPN X entered the room and explained to the resident they had to check the resident's skin. CNA B lowered the front part of the resident's brief. The resident had a moderate amount of stool on his/her genital area and groin. CNA B and LPN X rolled the resident to his/her left side and the resident's brief was saturated with urine and soft stool. CNA B and LPN X provided perineum care and applied a clean brief. During an interview on 5/20/25 at 1:20 P.M., the resident said he/she always waited a long time to be cleaned after he/she was incontinent. During an interview on 5/20/25 at 1:25 P.M., CNA B said the last time he/she checked the resident for incontinence was at 9:00 A.M. Residents should be checked for incontinence every two hours and as needed. During an interview on 5/22/25 at 6:55 P.M., LPN T said residents should be checked or taken to the restroom every two hours or as needed. Any nursing staff member could assist with providing care to the residents. 4. During an interview on 5/23/25 at 1:00 P.M., the Director of Nursing (DON) said she would expect staff to check residents for incontinence or offer them to use the bathroom every two hours and as needed. Any nursing staff can change the resident. The residents are expected to be cleaned immediately if the staff member was aware that the resident was soiled. 5. Review of Resident #29's quarterly MDS, dated [DATE], showed: -Usually makes self understood; -Moderate cognitive impairment; -Rejection of care behavior not exhibited; -Upper extremity impairment on one side; -Lower extremity impairment on both sides; -Setup or cleanup assistance required for eating; -Dependent on assistance for showering/bathing self and personal hygiene. Review of the the resident's medical record, showed: -Diagnoses included traumatic brain injury, abnormalities of gait and mobility, unsteadiness on feet, generalized muscle weakness, anxiety disorder, depression, post-traumatic stress disorder (PTSD, mental health condition that can develop after a traumatic event), and schizoaffective disorder (mental health condition that includes features of a mood disorder and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves)); -No documentation of refusals for showering/bathing assistance, hand hygiene, or nail care in April or May 2025. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident prefers to eat with his/her hands and prefers to not have his/her food altered for his/her independence; -Interventions: Nursing will provide hand hygiene in between meals and as needed (PRN). Nursing will provide nail care trim/file routine and PRN; -Focus: Resident has an ADL self-care performance deficit. Shower days: Tuesday and Friday evenings; -Interventions included: Check nail length and trim and clean on bath day and PRN. Provide sponge bath when a full bath or shower cannot be tolerated. Total assist with bathing/showering; -Focus: Resident is resistive to care, taking showers related to confusion at times due to traumatic brain injury; -Interventions included: Allow resident to make decisions about treatment regime to provide sense of control. If possible, negotiate a time for ADLs to that the resident participates in the decision making process and return at the agreed upon time. Review of the facility's shower schedule, undated, showed the resident scheduled for showers on Tuesday and Friday night. Review of the resident's shower sheets for April and May 2025, reviewed on 5/22/25, showed: -An undated shower sheet. No documentation related to the resident's fingernails; -A shower sheet, dated 5/14/25. No documentation related to the resident's fingernails; -No shower sheets for 18 out of 20 opportunities. Observation on 5/19/25 at 9:51 A.M., showed the resident in bed. His/Her fingernails were long and jagged with dark matter underneath the fingernails. Observation on 5/20/25 at 8:00 A.M., showed the resident in bed. His/Her fingernails were long and jagged with dark matter underneath the fingernails. During an interview, the resident was unable to respond verbally and he/she nodded or shook his/her head and used the ok hand gesture to respond to questions. The resident indicated he/she cannot walk. Observations on 5/20/25 at 9:17 A.M., 12:17 P.M., and 1:20 P.M., showed the resident in bed. His/Her fingernails were long and jagged with dark matter underneath the fingernails. During an interview at 1:20 P.M., the resident said his/her hands were dirty and he/she needed assistance from staff to wash them. He/She could not recall the last time his/her hands were washed or when he/she had a shower. Observation on 5/21/25 at 9:18 A.M., showed the resident in bed eating mechanical-soft sausage and scrambled eggs with his/her hands. The resident's fingernails were long and jagged with dark matter underneath the fingernails. During an interview on 5/23/25 at 7:53 A.M., CNA KK said the resident could not walk. He/She ate with his/her hands. He/She needed total assistance from staff for his/her hygiene needs. CNAs should clean the resident's hands after he/she eats as part of routine daily care. CNAs should ensure the resident's fingernails were trimmed and clean. The resident was supposed to get showers and he/she did not have a history of refusing showers. When CNAs provided showers or bed baths, they should document them on shower sheets. If a resident refused a shower or bed bath, staff should offer again and if the resident continued to refuse, it should be reported to the nurse. Refusals should be documented on shower sheets and signed by the resident. Completed shower sheets went to the nurse. During an interview on 5/23/25 at 7:27 A.M., LPN X said residents' fingernails should be cleaned and trimmed. CNAs should trim fingernails and use a washcloth to clean a resident's hands after meals. Staff should follow the shower schedule posted at the nurse's station and document bed baths and showers on shower sheets. If a resident refused their bed bath or shower, staff should offer twice, then report it to the nurse. Resident refusals should be documented on shower sheets. Completed shower sheets were signed by the nurse, then given to the DON. During an interview on 5/23/25 at 8:10 A.M., the DON said the resident could not walk and ate with his/her hands. Staff should clean the resident's hands for him/her, and clean the dark matter out from underneath the resident's fingernails, as he/she cannot do this him/herself. CNAs should trim the resident's fingernails. 6. During an interview on 5/23/25 at 8:10 A.M., the DON said residents should be showered or bathed in accordance with their needs and preferences. Residents want to feel good about themselves and good hygiene helps with this. She expected staff to follow the shower schedule at the nurse's station. If staff could not complete a shower during their shift, it should be passed on to the next shift. Showers and bed baths should be documented on shower sheets. If a resident was out in the hospital during the scheduled shower day, it should be noted on a shower sheet. If a resident refused their shower, staff should come back later to offer again. If the resident continued to refuse, it should be documented on a shower sheet and reported to the nurse, who should chart a note on it. Completed shower sheets were supposed to be reviewed and signed by the nurse. Once signed by the nurse, the shower sheet was given to the DON for review. She had been working with staff ensuring residents received their showers. MO00254289 MO00245476

Based on interview and record review, the facility failed to ensure residents received an accurate assessment reflective of resident status at the time of assessment by coding side rails as restraints on the Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, for three residents who were determined to use side rails without restriction of freedom of movement (Residents #50, #23, and #20). The sample was 19. The census was 74. Review of the facility's Resident Assessment Instrument (RAI) Process policy, showed: Purpose: To ensure that the RAI is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified; -Policy: --The facility will utilize the RAI process as the basis for the accurate assessment for each resident's functional capacity and health status, as outlined in the Centers for Medicare and Medicaid Services (CMS) RAI MDS 3.0 Manual; --The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts; -Procedure included: --The facility uses the RAI MDS 3.0 Manual as a reference tool; --All information recorded within the MDS assessment must reflect the resident's status at the time of the Assessment Reference Date (ARD). Review of the CMS Long-Term Care (LTC) Facility RAI 3.0 User's Manual, revised October 2024, showed: -Section P: The intent of this section is to record the frequency that the resident was restrained by any of the listed devices, at any time during the day or night, during the 7-day lookback period. Assessors will evaluate whether or not a device meets the definition of a physical restraint and code only the devices that meet the definitions in the appropriate categories; -Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. 1. Review of Resident #50's medical record, showed diagnoses included spina bifida (condition affecting that spine), paraplegia (paralysis affecting the lower half of the body), muscle wasting and atrophy, and generalized muscle weakness. Review of the resident's side rail assessment, dated 3/25/25, showed: -Recommendation: The resident has expressed a desire to have bed rails raised while in bed; -If bed rails are indicated, please specify: Bilateral. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Physical restraints: Bed rails used daily. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident has an activities of daily living (ADL) selfcare performance deficit. Per request, u-rails to assist in bed mobility and positioning; -Interventions included half rails up per physician's order for safety during care provision, to assist with bed mobility. Observation on 5/21/25 at 9:15 A.M., showed the resident sat in bed with side rails raised bilaterally at the head of the bed. During an interview, the resident said he/she uses the side rails for bed mobility and they are not a restraint. 2. Review of Resident #23's medical record, showed diagnoses included generalized muscle weakness and muscle wasting and atrophy. Review of the resident's side rail assessment, dated 3/25/25, showed: -Recommendation: The resident has expressed a desire to have bed rails raised while in bed; -If bed rails are indicated, please specify: Bilateral. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Physical restraints: Bed rails used daily. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Per resident request, u-rails for mobility and positioning; -Interventions included discuss and record with the resident/family/caregivers, the risks and benefits of the u-rail, when the u-rail should/will be applied, and any concerns or issues regarding u-rails. Observation on 5/19/25 at 8:49 A.M., showed the resident sat in bed with side rails raised bilaterally at the head of the bed. During an interview, the resident said he/she used the side rails for repositioning and holding him/herself in position while receiving care. He/She had not tried moving the side rails and they did not restrict him/her. 3. Review of Resident #20's medical record, showed diagnoses included multiple sclerosis (MS, neurological disorder). Review of the resident's side rail assessment, dated 10/7/24, showed: -Recommendation: Bed rails are indicated and serve as an enabler to promote bed mobility and independence; -If bed rails are indicated, please specify: Bilateral. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Physical restraints: Bed rails used daily. Review of the resident's care plan, in use at the time of survey, showed the resident has limited physical mobility related to muscle weakness and unsteadiness on his/her feet. Per resident preference, u-rails for positioning. U-rails are placed in down position, patient able to complete mobility without rails; however, requested to keep on. Observation on 5/21/25 at 9:16 A.M., showed the resident sat in bed with the side rail lowered at the head of the bed on the left side. During an interview, the resident said he/she could move the side rails up and down if desired, but he/she did not use the side rails at all. 4. During an interview on 5/22/25 at 3:14 P.M., the MDS Nurse said all residents in the facility with side rails had been assessed to use them safely. No side rails were being used as a restraint. She thought all side rails must be coded as a restraint on the MDS, period, even if the side rails were not used as a restraint. During an interview on 5/23/25 at 8:32 A.M., the MDS Nurse said she spoke with her Regional MDS Coordinator and learned that side rails should not be coded as a restraint unless they were being used as a restraint. During an interview on 5/23/25 at 8:36 A.M., the Administrator said she expected the MDS Nurse to code items in accordance with the guidelines outlined in the RAI Manual. If side rails did not restrict freedom of movement, they were not considered a restraint and should not be coded as such on the MDS.

Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards. Staff failed to obtain treatment orders for a dressing to the resident's left leg, apply compression stockings to his/her legs, and complete an accurate assessment of the resident's edematous (swollen with excess fluid) legs (Resident # 27). In addition, the facility failed to perform a post-fall neurological assessment (an assessment that checks the resident's mental status, level of consciousness, pupil reaction, motor (movement) response to stimulation, and sensation) on two residents (Resident #27 and #15). The sample size was 19. The census was 74. Review of the facility's Care and Services policy, revised 10/22/24, showed: -Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of an environment that enhances quality of life in the scope of a long-term facility; Care and services are provided in a manner that consistently enhances self-esteem and worth. Review of the facility's Neurological Assessment policy, revised, 10/24/22, showed: -Purpose: To provide guidelines for the performance of a neurological assessment on residents; -Policy: -Nursing staff will perform a neurological assessment in the following circumstances: -Upon physician order; -Following an unwitnessed fall; -Following a fall or other accident or injury involving head trauma; -When indicated by the resident's condition; -Neurological checks will be performed as follows or other wise ordered by the physician: -Every 15 minutes for one hour, then; -Every 30 minutes for one hour, then; -Every hour for two hours, then; -Every four hours for a combined total of 72 hours; -Procedure: -Determine the resident's orientation to time, place and person; -Observe the resident's patterns of speech and speech clarity; -Take the resident's vital signs that include, temperature, pulse, respiratory rate, and blood pressure; -Check the pupillary (part of the eye that reacts to light) reaction; -Have the resident move all extremities; -Ask the resident to squeeze the nurse's fingers with their hand, note the strength bilaterally (both); -Have the resident plantar flexion (the foot moves down away from the leg) and dorsiflexion (the foot moves upward and towards the leg), note the strength bilaterally (both); -Documentation: -The following information will be documented in the resident's medical record: -The date and time the procedure was performed; -The name and title of the individual who performed the procedure; -All assessment data obtained during the procedure, including: -Eye opening; -Verbal response; -Motor response; -Pupillary response; -Limb response. -The signature and title of the person recording the data. 1. Review of Resident #27's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/8/25, showed: -Severe cognitive impairment; -No rejection of care; -Required maximum assistance from staff with lower body dressing and putting on and taking off footwear; -Impairment to both upper extremities; -Requires maximum assistance from staff from sitting to standing position, chair to bed transfers and toilet transfers; -Dependent on staff for walking 10 feet and picking up objects; -Uses a manual wheelchair; -Always incontinent of bowel and bladder; -Diagnoses included dementia. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is at risk for skin impairment; -Interventions: Follow facility protocol related to treatment of injury; Identify or document causative factors and eliminate and resolve when possible; Keep skin clean and dry; Monitor document location, size and treatment of skin injury; Weekly treatment documentation. -The care plan did not address the resident's leg edema; -Focus: The resident is at risk for falls related to dementia; -Interventions: The resident is to be at nurses station or high traffic areas: Anticipate the needs of the resident; Educate the resident, family and caregivers about safety reminders and what to do if a fall occurs; Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair; Red tape to the wheelchair brakes as a visual cue; Ensure the resident's call light is within reach. Review of the resident's medical record, showed diagnoses that included traumatic subdural hemorrhage (a collection of blood between the inner layer of the skull and the surface of the brain) without the loss of consciousness, difficulty walking, muscle weakness, abnormal posture, repeated falls, heart disease and aortic valve stenosis (a part of the heart that is narrow and causes the heart to not function properly). Review of the resident's nursing skilled notes. showed: -On 5/13/25, days, cardiovascular: mild edema present; -On 5/13/25, nights, cardiovascular: edema present: blank; -On 5/14/25, days, cardiovascular: edema: blank; -On 5/15/25, days, cardiovascular: pitting (an indentation in the skin can be seen when pressed) edema preset; -On 5/15/25, nights: cardiovascular: edema present: blank; -On 5/16/25, days: cardiovascular: edema present: blank; -On 5/17/25, days: cardiovascular: edema present: blank; -On 5/18/25, days: cardiovascular: edema present: blank; -On 5/19/25, days: cardiovascular: edema present: blank. Review of the resident's skin assessment, dated 5/13/25, showed it did not address the resident's edematous legs. Review of the physician orders, dated 5/19/25, showed: -An order, dated 4/8/24, compression stockings to bilateral (both) lower extremities. -No treatment orders to left leg. Review of the resident's Treatment Administration Record (TAR), dated 5/1 through 5/19/25, showed no order for compression stockings. Review of the resident's progress notes, dated 5/1 through 5/19/25, did not show communication with the physician related to the resident's left leg requiring a dressing or treatment. Observation and interview on 5/19/24 at 7:30 A.M., showed the resident sat in his/her wheelchair at the nurses' station on the Memory Care Hall. The resident's bilateral lower extremities were shiny and edematous The resident's left leg had a large undated dressing that was saturated with yellow drainage. The resident did not have compression stockings on. The resident bent over in his/her wheelchair and fell forward landing on his/her left side and striking his/her head. Regional Nurse R and Certified Nurse Aide (CNA) S applied the gait belt to the resident and assisted the resident from the floor to a standing position and into his/her wheelchair. At approximately 7:35 A.M., Emergency Medical Services (EMS) arrived and transferred the resident to the stretcher. Paramedic GG asked Regional Nurse R why a dressing was on the resident's left leg. Regional Nurse R said, I'm not sure. Regional Nurse R then asked the Assistant Director of Nursing (ADON) why the resident had a dressing on his/her left leg. The ADON said the resident always has edematous legs, the resident's legs weep and a staff must have put it on to address his/her weeping legs. Observation on 5/20/24 at 5:07 A.M., showed the resident sat in his/her wheelchair in his/her room. The resident wore a shirt and a brief. The resident's bilateral lower extremities were shiny and edematous. The resident's left leg had a large undated dressing that was saturated with yellow drainage. The resident did not have a compression stocking on. Observation on 5/20/25 at 8:51 A.M. and 11:01 A.M. on 5/21/25 at 4:12 P.M., showed the resident sat in his/her wheelchair on the Memory Care Hall near the nurses' station. The resident's bilateral lower extremities were shiny and edematous. The resident did not have compression stockings on. The resident did not have a dressing on his/her left leg. During an interview on 5/20/25 at 8:00 A.M., Nurse Assistant (NA) BB said the resident always has edema to his/her legs. NA BB said the resident used to have compression stockings to wear, but he/she has not been able to find them in several weeks. NA BB said the resident's legs looked so much better and had less swelling when the resident wore the compression stockings. The resident will usually have some type of drainage from his/her legs and occasionally will see a dressing on his/her legs. The resident's family member would usually bring the compression stockings in and that someone would need to call the family member to bring in more stockings. During on interview on 5/22/25 at 3:25 P.M., Licensed Practical Nurse (LPN) F said he/she was not aware of the order for compression stockings. The compression stocking would help with the integrity of the resident's skin. If the resident requires a treatment, the physician should be notified and documented in the progress notes. The resident always has edema, and it should be charted in his/her skilled nursing note, skin assessment or progress notes to determine the progress of the edema. During an interview on 5/23/25 at 9:30 A.M. Regional Nurse CC said the order was placed in the electronic medical record incorrectly and that is why the order did not show up on the TAR to complete. The Director of Nursing (DON) and the ADON are expected to check orders for accuracy. During an interview on 5/23/25 at 1:00 P.M., the DON said she expected the physician orders to be placed in the electronic medical record accurately. She expected staff to document daily and accurately on the resident's edema and what interventions were in place. She expected staff to obtain a treatment order from the physician and not just place a dressing over an area of the leg and no one knows why it is there. She expected documentation of the communication with the physician to be placed in progress notes. Review of the facility's incident and accidents, showed the resident had an unwitnessed fall on 4/19/25. No fall was listed for 5/3/25. Review of the resident's progress notes, showed: -On 4/19/25 at 6:34 P.M., the resident was found sitting on the floor near the nurse's station. The resident was attempting to get up out of the wheelchair and when he/she attempted to sit back down, the wheelchair went behind the resident. No apparent injury. Vital signs, pupillary reaction, range of motion (ROM) of extremities within normal limits. No complaints of pain or distress; -On 5/3/25 at 4:26 A.M., the resident was observed on the floor at the foot of bed nearest to the window laying on his/her side. There was bowel movement on the floor; The resident was cleaned and assessed for injuries. The resident has two skin tears to the right elbow. The area was cleaned and a dressing applied. No further injuries noted. Unwitnessed fall charting initiated. Review of the resident's neurological assessment forms, showed: -On 4/19/25, no neurological assessments were performed; -On 5/3/25 at 12:00 A.M., 12:15 A.M., 12:30 A.M., 12:45 A.M., 1:00 A.M., and 1:15 A.M., a neurological assessment was documented as completed; -No further neurological checks were documented as completed. 2. Review of Resident #15's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Requires moderate assistance from staff for toileting and personal hygiene; -Requires moderate assistance from staff to walk 10 feet; -Uses a manual wheelchair; -Frequently incontinent of bowel and bladder; -Diagnoses include cancer, Alzheimer's disease, and depression. Review of the resident's care plan, in use at the time of survey, showed: Focus: The resident is at risk for falls; Interventions: Post a sign in the resident's room to use the call light for assistance; Continue to educate resident on use of call light; Anticipate the resident's needs; Apply mattress with bolsters (a mattress with raised defined edges); Enhanced visuals as needed. Review of the facility's list of incidents, showed the resident had an unwitnessed fall on 4/19/25 and another 5/7/25. Review of the resident's fall risk assessment, dated 5/14/25, showed the resident assessed as a high fall risk. Review of the resident's progress notes, showed: -No documentation dated 4/19/25, related to the resident's unwitnessed fall; -On 4/20/25 at 3:58 P.M., received in report the resident was on a follow up for non-injury fall, 4/19/25. The resident has been sitting up in his/her wheelchair and denies any pain or discomfort. Vital signs obtained. No injuries observed; -On 5/7/25 at 2:56 A.M., the CNA alerted the nurse that he/she heard a loud noise. The resident was observed on the side of his/her bed. The resident said he/she hit his/her head on the dresser. A completed head to toe assessment was completed and no injuries were observed. The resident said he/she was trying to get out of bed and fell to the floor and hit his/her head. The resident does not know where he/she was going or what he/she was doing. Vital signs obtained. Neurological checks started. The ADON is in the building and is aware of the incident. Review of the resident's medical record, showed no documented neurological checks for the resident's unwitnessed falls on 4/19/25 and 5/7/25. 3. During an interview on 5/21/25 at 10:59 A.M., LPN V said neurological checks are to be implemented as per policy for witnessed falls that the resident struck their head, if the resident said they struck their head, and all unwitnessed falls if head involvement is unknown. During an interview on 5/23/25 at 1:00 P.M., the DON said she expected neurological checks to be completed timely and accurately per the facility policy. Neurological checks are to be completed for witnessed falls if the resident struck their head, if the resident said they struck their head, and all unwitnessed falls if head involvement is unknown.

Based on observation, interview and record review, the facility failed to ensure bipap (a form of non-invasive ventilation therapy) masks were properly stored for two residents (Residents #17 and #55) and failed to ensure the oxygen concentrator (medical device that separates nitrogen from the air) was set to the proper rate for one resident (Resident #55). The sample was 19. The census was 74. Review of the facility's oxygen administration policy, dated 10/24/22, showed: -Policy: a physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include: oxygen flow rate, method of administration (e.g. nasal cannula (NC)), usage of therapy (continuous or as needed (PRN)), titration instructions (if indicated), and indication for use. Oxygen saturations will be measured and documented at a minimum of daily for resident's receiving oxygen therapy. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. 1. Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/23/25, showed: -Diagnoses included acute respiratory failure, muscle weakness, and depression; -Cognitively intact. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: resident has a diagnosis of acute respiratory failure; -Goal: the resident will have improved lung expansion and mobilization of secretions (mucus or saliva). -Interventions: assess breath sounds pre/post and document. Assess for pain and treat if necessary. Notify providers with any concerns. Review of the resident's Physician's Order Summary (POS), dated 5/19/25, showed an order, dated 3/11/25, Ipratropium-Albuterol Solution (combination medication used to prevent wheezing, difficulty breathing, chest tightness, and coughing) 0.5-2.5 (3) milligram (mg)/3 milliliter (ml), inhale orally every 4 hours. Review of the resident's Medication Administration Record (MAR), dated May 2025, showed: -The resident received their ordered breathing treatment on 5/19/25 every four hours; -The resident received their ordered breathing treatment on 5/20/25 every four hours. Observation on 5/19/25 at 5:43 A.M., showed the resident's oxygen mask lying on the ground next to the resident's bed. The resident's bipap machine was on the resident's nightstand. Observation on 5/20/25 at 11:44 A.M., showed the resident's oxygen mask lying on the ground next to the resident's bed. The resident's bipap machine was on the resident's nightstand. 2. Review of Resident #55's quarterly MDS, dated [DATE], showed: -Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease), muscle weakness and chronic respiratory failure; -Cognitively intact. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: resident has COPD; -Goal: resident will have symptoms controlled through the review period; -Interventions: give medications, treatments, for COPD as ordered, monitor for effectiveness. Oxygen if ordered/indicated, oxygen saturations as ordered/indicated. Oxygen at 2 Liters/NC to keep saturations above 92%. Review of the resident's POS, dated 5/19/25, showed: -An order, dated 5/3/2025, Albuterol Sulfate Nebulization Solution (2.5 mg/3 ml) 0.083%, 1 application inhale orally via nebulizer every 4 hours as needed for shortness of breath (SOB); -An order, dated 2/13/2025, oxygen therapy: oxygen via NC at 2 liters to keep saturation above 92% as needed for SOB related to COPD. Observation on 5/19/25 at 6:06 A.M., showed the resident's oxygen mask lying on the ground next to the resident's bed. The resident's bipap machine was on the resident's nightstand. Observation on 5/20/25 at 7:52 A.M., showed the resident in his/her bed awake. The resident's NC was in his/her nose. The concentrator was on and set to 4 liters. Observation on 5/20/25 at 7:57 A.M., showed the resident's oxygen mask lying on the ground next to the resident's bed. The resident's bipap machine was on the resident's nightstand. Observation on 5/20/25 at 10:55 A.M., showed the resident in his/her bed awake. The resident's NC was in his/her nose. The concentrator was on and set to 4 liters. Observation on 5/23/25 at 8:49 A.M., showed the resident's oxygen mask lying on top of the resident's bipap machine, uncovered. 3. During an interview on 5/23/25 at 7:34 A.M., Licensed Practical Nurse (LPN) X said the concentrators should be set at the rate indicated by the physician. Staff should ensure the rate is correct. Oxygen masks should be stored when not in use, in a bag. During an interview on 5/23/25 at 9:15 A.M., the Director of Nursing said concentrators should be set at the rate indicated by the physician. Staff should ensure the rate is correct during their rounds. Oxygen masks should be stored when not in use in a bag. Oxygen masks should not touch the ground. During an interview on 5/23/35 at 11:25 A.M., the Administrator said she expected staff to follow the oxygen administration policy. Staff should ensure oxygen masks are stored properly and not on the ground. Staff should ensure oxygen concentrators are set to the proper rate.

Based on interview and record review, the facility failed to maintain ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one resident (Resident #63). The facility identified one resident receiving dialysis. The sample was 19. The census was 74. Review of the facility's Dialysis Care policy, revised 10/24/22, showed: -Purpose: To provide are for residents diagnosed with renal disease requiring ongoing dialysis treatments; -Policy: --The facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment, and providing for all nondialysis needs of the resident including during the time period when the resident is receiving dialysis; --The facility maintains a contract with a dialysis service provider which addresses communications between the facility and provider; -Procedure: --Communication and Collaboration: -The nursing staff, dialysis provider, and the attending physician will collaborate on a regular basis concerning the resident's care as follows: -Nursing staff will communicate pertinent information in writing to the dialysis staff which may include: -Any medication changes; -Any recent changes in condition; -The resident's tolerance of dialysis procedures; -The dialysis provider will communicate in writing to the facility: -The resident's current vital signs; -Pre and post dialysis weight; and -Any problems encountered while the resident was at the dialysis provider -Nursing staff may use a Nurses Dialysis Communication Record to convey information to the dialysis center; --Documentation: -All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record; -Documentation may include the Nurses Dialysis Communication Record, Dialysis Flow Sheet, or Dialysis Medical Intake Sheet. Review of the facility's Dialysis Communication Form, undated, showed: -Pre-dialysis information to be completed by facility staff included resident's name and physician, vital signs, medications administered prior to dialysis, meal/snack sent, shunt location/status, additional information (changes in condition, physician order changes, new labs since last visit), and nurse signature; -Dialysis center information to be completed by dialysis staff included vital signs, pre and post weight, dialysis start and end time, fluid removed, meal/snack intake, shunt location/status, additional information, new physician orders/recommendations, and nurse signature; -Post dialysis information to be completed by facility staff included vital signs, shunt location/status, bruit/thrill present, bleeding, general condition of resident, and nurse signature. Review of Resident #63's electronic medical record (EMR), showed: -Diagnoses included end state renal disease (ESRD, kidney failure), dependence of renal dialysis, diabetes, and heart failure; -An order, dated 4/7/25, for resident to receive dialysis on Monday, Wednesday, Friday at 10:30 A.M.; -No dialysis communication forms, nurse's notes, dialysis treatment reports, or other documentation related to communication between the facility and dialysis center in April and May 2025. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/8/25, showed: -Cognitively intact; -Rejection of care behavior not exhibited; -Dialysis received. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident has renal insufficiency related to ESRD; -Focus: Resident requires dialysis Monday, Wednesday, and Friday; -The care plan did not provide guidance on how facility staff should maintain communication with the dialysis center. During an interview on 5/19/25 at 10:11 A.M., the resident said he/she goes to dialysis every Monday, Wednesday, and Friday. The facility staff do not give him/her a communication form or any paperwork to bring to the dialysis center. The dialysis center does not give him/her a communication form or any paperwork to bring back to the facility. During an interview on 5/21/25 at 8:15 A.M., the resident said the facility nurse did not give him/her a communication form for him/her to bring to dialysis on 5/19/25, and he/she did not bring a communication form back from the dialysis center. During an interview on 5/23/25 at 7:27 A.M., Licensed Practical Nurse (LPN) X said he/she has worked for the facility for over five months. To his/her knowledge, there is no communication form used between the facility and dialysis center. If the dialysis center staff call the facility to say something went wrong, that is the only time the facility communicates with the dialysis center. Otherwise, facility nurses do not call the dialysis center unless they notice something out of the ordinary when the resident comes back from dialysis. During an interview on 5/23/25 at 7:56 A.M., LPN Q said he/she does not know if the facility uses communication forms for residents on dialysis. He/She does not know what the facility's method is for communicating with the dialysis center. During an interview on 5/23/25 at 8:10 A.M., the Director of Nurses said before a resident goes out to dialysis, the nurse should assess the resident and document their findings on a Dialysis Communication Form. Blank Dialysis Communication Forms are kept at the nurse's station. Once the form is completed by facility staff, it goes with the resident to the dialysis center. The dialysis center fills out their portion of the form and sends it back to the facility with the resident. Once the form is returned, it should be uploaded to the resident's EMR. If the form does not return to the facility from the dialysis center, the nurse should call the dialysis center to get report and document this communication as a note in the EMR. It is important for the facility to maintain ongoing communication with the dialysis center for continuity of care. During an interview on 5/23/25 at 8:36 A.M., the Administrator said before sending a resident out for dialysis, the nurse should assess the resident and fill out a Dialysis Communication Form, which should be at the nurse's station or in easily accessible areas. The form should go with the resident to the dialysis center. The form should come back to the facility with the resident after dialysis. If the form does not return to the facility, the nurse should call the dialysis center and get the form sent over or get report from the dialysis center and document it in the resident's EMR. Once the form returns to the facility, it should be scanned into the EMR. The facility should have ongoing communication with the dialysis center to ensure quality of care.

Based on observation, interview and record review, the facility failed to provide or obtain laboratory services as ordered by the physician for one resident (Resident #65). The sample was 19. The census was 74. Review of the facility's Laboratory, Diagnostic and Radiology Services policy, revised on 10/24/22, showed: -Purpose: To ensure that laboratory, diagnostic and radiology services are provided to meet resident needs; -Policy: Laboratory, Diagnostic and Radiology services will be coordinated pursuant to an order by physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with the scope of practice under state law; The facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic or radiology provider. Review of Resident #65's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/1/25, showed: -The resident is rarely understood; -No rejection of care; -Occasionally incontinent of urine and frequently incontinent of bowel; -Required maximum assist from staff for toileting hygiene; -Diagnosis included Alzheimer's disease. Review of the resident's Treatment Administration Record (TAR) dated 4/1/25 through 4/30/25, showed: -An order dated, 4/7/25, collect urine and label and put in lab fridge for Wednesday pickup, every shift, for two days; -An order dated, 4/9/25, collect urine and label and put in lab fridge for Friday pickup, every shift, discontinued date 4/17/25; -An order dated, 4/18/25, one time order for straight catheterization (a tube inserted into the bladder to drain urine) to obtain urine for a urinalysis (UA, a urine test to check for a infection) and culture (a test that determines the type of bacteria growth), one time, discontinue date, 4/19/25; -An order dated, 4/19/25, one time order for straight catheterization, to obtain a UA and culture, place in specimen fridge for Monday pickup, discontinue order once specimen is collected; -On 4/7/25, the urine collection documented: completed on day and night shifts; -On 4/8/25, the urine collection documented: see progress notes on day shift; completed on 4/8/25, night shift. -On 4/9/25, the urine collection documented: hold, see progress notes, on the day shift; completed on the night shift; -On 4/10/25, the urine collection documented: completed on day and night shifts; -On 4/11/25, the urine collection documented: see progress notes on day shift; completed for night shift; -On 4/12/25, the urine collection documented: completed on day and night shifts; -On 4/13/25, the urine collection documented: completed on day shift; hold, see progress notes for night shift; -On 4/14/24, the urine collection documented: drug refused on day shift; completed on the night shift; -On 4/15/25, the urine collection documented: drug refused on day shift; completed on the night shift; -On 4/16/25, the urine collection documented: see progress notes on day shift and night shifts; -On 4/17/25 ,the urine collection documented: a blank box on day shift and a X on night shift; -On 4/18/25, the urine collection documented: see progress notes; -On 4/19/25, the urine collection documented as completed. Review of the resident's progress notes, showed: -On 4/8/25 at 5:33 P.M., unable to obtain this shift, the resident would not sit long enough to void (urinate); -On 4/9/25 at 3:57 P.M., the resident would not let staff attempt to obtain sample; -On 4/11/25 at 2:48 P.M., lab to pick up in early AM; -On 4/13/25 at 10:33 P.M., it is Sunday and the sample will not be useful; -On 4/14/25 at 6:53 P.M., the resident refused to use the bathroom at this time to provide a sample, reported to the night shift to reattempt; -On 4/16/25 at 6:10 P.M., unable to have resident sit long enough for specimen; -On 4/17/25 at 5:26 A.M., unsuccessful at collecting urine specimen; -On 4/18/25 at 5:54 P.M. unable to obtain specimen. -No documentation staff notified the physician regarding the urine specimen not obtained from the resident. Review of the resident's lab results, showed no UA or culture results. During an interview on 5/23/25 at 8:55 A.M., Certified Nursing Assistant (CNA) W said the resident is able to sit on the toilet if you encourage him/her to do so. A specimen collection container is placed in the toilet to obtain the sample. If staff is unable to obtain the specimen, the nurse is notified and will need to get a straight catheterization order. The resident does not normally refuse care but requires cues and prompting for tasks. During an interview on 5/23/25 at 9:30 A.M., Regional Nurse CC said urine testing results were not found in the lab system for the resident. During an interview on 5/23/25 at 11:45 A.M., Licensed Practical Nurse (LPN) Q said urine specimens are obtained using the specimen collection container that fits in the toilet or a straight catheterization. The physician should always be notified when a lab specimen is not obtained, and it should be documented in the resident's progress notes. Lab work and specimens are picked up Monday through Friday in the early morning. STAT (to be completed immediately) labs are the only labs that are completed on the weekend. During an interview on 5/23/25 at 1:00 P.M., the Director of Nursing (DON) said the physician is expected be notified each time the resident refuses or the staff is having difficulty obtaining the sample. The physician may place the resident on antibiotics without urine test results if the specimen is impossible to obtain or the resident refuses. She expected clear and accurate documentation in the TAR and progress notes. The DON was not aware the resident's urine specimen was not obtained. She would have assisted with obtaining the specimen if she would have known. Multiple days of not being able to obtain a urine sample is unacceptable.

Based on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible by failing to properly secure the resident's wheelchair to all of the locking mechanisms used to hold the resident's wheelchair in place during transport to another facility (Resident #1). This failure resulted in the wheelchair to fall/flip over backwards during a turn with the resident still in his/her wheelchair. The resident sustained a small gash in the back of his/her head which required first aid to stop the bleeding. The census was 53. The Administrator was notified on [DATE], of the past non-compliance. On [DATE], the facility initiated an investigation, interviewed staff, completed an evaluation of the van with no concerns, and provided video education to the driver related to review of all straps and proper securement of residents for transportation. The deficiency was corrected on [DATE]. Review of the facility's Vehicle and Driver Safety Program, showed: -The purpose of this policy is to ensue the safety of those individuals who drive company vehicles, their passengers, and the public. Vehicle accidents are costly to our company, but more importantly, they may result in injury to you or others. It is the driver's responsibility to operate all vehicles in a safe manner and to drive defensively to prevent injuries and property damages; -Definitions: -Company Vehicle: Includes any car, van, SUV (Sport Utility Vehicle), truck, or other motorized transport owned by the company; -Driver: Shall include employees designated to perform duties that require operating a company vehicle; -Rules: -All drivers and passengers operating or riding in company vehicles must wear seat belts; -All drivers must ensure that a proper vehicle restraint system in used for all passengers in wheelchairs; -Report any mechanical difficulties or repair needs immediately to the Administrator; -Driving Safely -Starting: -Conduct pre-trip inspection; -Wear seatbelts at all times; -Authorized Employees: -Agree to abide by all Vehicle and Driver Safety Policies; -Conduct a pre-trip inspection before any first daily use; -Ensure all vehicle occupants wear seatbelts before moving the vehicle; -Ensure all wheelchairs are tied down securely and resident is secure in the chair before moving the vehicle; -Participate in driver training programs; -Training: All employees authorized to operate company-owned or leased vehicles will participate in initial and ongoing driver-safety training. Review of the facility's investigation, dated [DATE], showed: -On [DATE] at approximately 11:15 A.M. the Administrator was notified by the Activity Director of an incident involving a resident during transportation. Resident was fidgeting with the straps that secure the wheelchair and resident fell backward, hitting his/her head on the floor of the van. The driver immediately pulled into a parking lot, Activity Director completed first aid as resident sustained a small laceration to the back of his/her head. Driver (Maintenance Worker A) completed trip to receiving facility. Driver and Activity Director returned to the facility and evaluation of van was completed; -Initial interventions: -Staff interviews completed: -Activity Director's investigation statement, dated [DATE], showed: -Doing a ride along transport leaving the facility and taking a resident to another facility. While transporting, the resident fell backwards and hit his/his head on the van floor. We (Maintenance Worker A and Activity Director) pulled the van over in a safe place. Activity Director and Maintenance Worker A assessed the resident and upon assessment of the resident, he/she had a small gash on the back of his/her head. Activity Director looked over the resident's head. She assessed the resident, stopped the bleeding, and called the ambulance. They also called the resident's family. When the ambulance came to the scene, the bleeding was stopped. The ambulance only took the resident because he/she was on blood thinner (medications that prevent blood clots); -Maintenance Worker A's investigation statement, dated [DATE], showed: -Today left the facility to take a resident to another facility. Before leaving, we (Maintenance Worker A and Activity Director) used all straps on all four wheels along with seatbelt to strap the resident in. Maintenance Worker A and Activity Director secured the resident and proceeded to drive to the new facility. Five minutes away from our destination, the wheelchair flipped and the resident was in the back of the van, due to he/she had flipped out of the wheelchair. We immediately pulled over, got out of the van and helped the resident back into his/her chair. We noticed blood, so we pulled the chair in the up-right position, (the chair) still caught in the strap. Once he/she was back in (the chair), the ambulance was called. The Activity Director, who was with me administered care. The resident seemed to be fine. The paramedics did take the resident to the hospital. Family was called. Report was given to the other facility about what took place and returned to the facility; -Evaluation of van completed with no concerns; -Education with Driver (Maintenance Worker A); -Review of education document, dated [DATE], showed: -Video (FaceTime) education conducted with the Regional Director of Plant Operations with Maintenance Worker A on review of all straps and proper securement of residents for transportation; -No signature of Maintenance Worker A and/or Regional Director of Plant Operations on the training document; -No education/re-education of Activity Director noted; -Findings: There were not any malfunctioned items discovered during the evaluation of the van. All straps were functional; -Conclusion: On [DATE], resident was being transported to another facility. This individual sustained a fall in the van with a minor scrape to the head. Staff immediately pulled into a parking lot and provided first aid; all proper entities notified. The van was returned to the facility where an inspection was completed with no faulty equipment identified. At this time, we were unable to determine the cause of the fall. Review of Maintenance Worker A's Transportation Safety Competency, dated [DATE], showed: -Instructor/Trainer: Administrator; -Reason for Competency: Orientation; -Task: -Uses of seat belts at all times: Goal Met was checked; -Safely Securing a resident in van/bus: Goal Met was checked: -Ensure resident is seated properly in the wheelchair before loading in van/bus: Goal Met was not checked; -When securing resident/wheelchair, uses proper technique: Goal Met was not checked; -Floor straps secured properly: Goal Met was not checked; -Ensures wheelchair is secure, including wheelchair locks being engaged: Goal Met was not checked; -Seatbelt is safely secured: Goal Met was not checked. Review of Resident #1's medical record, showed: -admitted : [DATE]; -Diagnoses included nondisplaced simple supracondylar fracture (a break in the upper arm bone (humerus) just above the elbow where the bones are still aligned) without intercondylar fracture (a break in the condyles, which are the thickened areas at the ends of bones where they meet other bones) of right humerus, subsequent encounter for fracture with routine healing, muscle weakness, generalized. Review of the resident's Baseline Care Plan, dated [DATE], effective date [DATE], showed: Falls: -Problem(s): At risk for falling -Goals: Maintain safety from falls. Will not experience any injuries related to falling; -Interventions: Observe for unsafe actions and intervene. Review of the resident's progress notes, dated [DATE] at 10:44 A.M., showed: -Nursing note: Resident discharged to a different skilled facility and the current facility provided transportation; -No documentation related to the resident falling in the van. Review of the resident's emergency room discharge note, date [DATE] at 2:05 P.M., showed: -Clinical Impressions: -Fall from wheelchair, initial encounter; -Abrasion to scalp, initial encounter; -Anticoagulated (treated with anticoagulants, medications that prevent blood clot). During an interview on [DATE] at 1:14 P.M., Maintenance Worker A said he assisted with transportation sometimes. He couldn't say if the facility really had a transporter, but the Activity Director did most of the transporting. He said the Activity Director was CPR (Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating) certified, but he was not. Maintenance Worker A said the last time he transported a resident, there was an accident whereby the resident fell out of his/her wheelchair in the van. He and the Activity Director strapped the resident in the way he was shown. About five minutes away from the destination, the long seatbelt came undone or broke, he wasn't sure. The resident fell backwards in his/her wheelchair. They pulled the van over and stopped. There was blood on the resident's head. They tried to turn the wheelchair upright with the resident in it, but realized part of the chair was still strapped in. They pulled the resident out of the wheelchair and carried him/her out of the van by placing hands underneath the resident's arms and legs. Afterwards, they unstrapped the wheelchair, pulled it out of the van, and put the resident back in his/her wheelchair. There was a small gash in the back of the resident's head. The Activity Director gave the resident first aid to stop his/her head from bleeding. The ambulance and police were called. The ambulance took the resident to the hospital as a precaution because he/she was on blood thinners. Maintenance Worker A said it was really sad. He drove that day against his better judgement, and he strapped the resident in like they showed him. During an interview on [DATE] at 2:04 P.M., the Activity Director said she transported a resident to another facility, but couldn't remember his/her name. The date was [DATE]. She said that was the only resident transported that day. She was CPR certified but didn't have any in-service training on how to strap residents in wheelchairs in facility vehicles. The resident was strapped in the van prior to driving off from the facility. She said while they were driving, Maintenance Worker A moved from one lane to the next and when he did that, the resident went backwards in the wheelchair. After the resident fell backwards, she told Maintenance Worker A to go to a safe place, which was a parking lot, to pick the resident up. They pulled over, both unbuckled their seatbelts, exited the van, and preceded to enter the van through the double doors. The resident was still laying back in the wheelchair on the van floor. She said the resident wasn't secured anymore. The seatbelt came undone from the securing latch on the floor. She told Maintenance Worker A they would try to sit the resident upright in the wheelchair inside the van but that didn't work. They grabbed the resident's legs and upper part of his/her body and scooted him/her towards the door and then out of the van. Once they got out of the van, they saw the resident had hit the back of his/her head. There was a small gash. There was blood on the van ramp. The resident was talking and said he/she had fell . The Activity Director got the first aid kit. She called the Administrator and told her what happened. The ambulance, police, and the resident's family were called/notified. During an interview on [DATE] at 2:32 P.M., the Administrator said the Activity Director was there as a ride along for assistance and only Maintenance Worker A had transportation safety competence training. The resident was going to another facility. The Activity Director called the Administrator and said the resident had fallen backward in his/her wheelchair in the van and cut his/her head. The Administrator said the Activity Director didn't give her a reason for why the wheelchair fell back. The resident's seatbelt came undone, maybe the resident pushed the button. She didn't know because the van was new (2023). She expected the resident to be transported safely and be free from accidents. She said the Regional Maintenance Director checked the vehicle after the accident. Maintenance Worker A and Activity Director were not the regular transporters. The Activity Director did ride alongs once in a while. During an interview on [DATE] at 3:08 P.M., Maintenance Worker A said he locked the seatbelt across the resident's chest, locked the wheelchair, and attached the wheelchair to the hooks that come from the floor in the van for the front and back wheels of the resident's wheelchair. He said attaching it that way was supposed to keep the wheelchair from moving. He said his boss's boss, the Regional Director of Plant Operations, took him to the van to make sure it was right. He showed the Regional Director of Plant Operations where he had strapped the wheelchair and the Regional Director of Plant Operations said that was right. Maintenance Worker A said he didn't know what happened and that had never happened before. He wasn't sure if the resident hit the mechanism or not, but they had driven about 15 minutes before the wheelchair fell backwards. Maintenance Worker A said he had no formal training and said he watched and went by what the Activity Director did to strap the resident in on her side. Then that's what he did. He said the Activity Director was replacing the regular driver until he/she came back from leave. Maintenance Worker A said the video in-service education was on the proper way to secure straps to the wheelchair. It was a FaceTime Video call, and his boss's boss told him once the resident was strapped in to pull on the straps to make sure they were secure. Maintenance Worker A said the Regional Director of Plant Operations did not walk him out to the van or check his work for competency. The day the resident fell , he strapped his/her wheelchair in on one side and the Activity Director strapped the other side. Maintenance Worker A said he was just the driver. He said the straps, seatbelts, and ratchets were ok. The Administrator went out after the incident to see what they did to secure the wheelchair. He said the Administrator let him and the Activity Director secure her in a wheelchair inside the van. Maintenance Worker A said the Administrator said it seemed to be ok. During an interview on [DATE] at 3:49 P.M., the Maintenance Supervisor said the van received maintenance on [DATE]. He said there was nothing wrong with the seatbelts or the seatbelts' locking mechanisms and there was nothing wrong with the locking latches on the floor in the van. He didn't know of any training Maintenance Worker A had received. The Maintenance Supervisor said Maintenance Worker A was with the Activity Director when the incident happened. The vehicles received monthly maintenance and if there were any problems with the vehicles, staff would let him know. During an interview on [DATE] at 3:58 P.M., the Administrator said the original transporter was out on leave. The Administrator said she had the Regional Director of Plant Operations on FaceTime, and he walked Maintenance Worker A through securing the straps from the wheelchair to the van while transporting. Right now, the facility used a vendor for transportation. They were not using the facility vehicle for transportation until the regular driver returned back from leave. The Administrator said she couldn't determine a cause for the incident. She didn't expect what happened to the resident to be in his/her progress notes/medical records because he/she was discharged from the facility. She didn't re-educate the Activity Director because she was just a ride along. She expected all drivers, whether permanent or temporary assignment, to be competent and follow the facility's vehicle policy. She said competency was done during orientation and annually, as needed. She expected staff to follow the policy and inspect the vehicle daily prior to first use of the day. MO00244174

Based on interview and record review, the facility failed to ensure professional standards of practice were met, when the facility admitted a resident without physician's orders and failed to provide prescribed medications that evening. The resident was sent to a different hospital, 14 hours later, without physician's orders (Resident #1). The facility did not have a policy for obtaining physician orders at the time of admission. The sample was 3. The census was 49. Review of the resident's hospital discharge summary and discharge instructions, received via email from the facility Administrator on 9/18/24 at 5:11 P.M., with a printed time and date stamp of 8/21/24 at 2:03 P.M. central daylight time (CDT), showed: -Diagnoses of Alzheimer's dementia, high blood pressure, diabetes type 2, coronary artery disease (CAD) with left anterior descending (LAD) artery stent placement (treatment for a condition that occurs when there is a blockage in the LAD artery, which can lead to a heart attack), hypothyroidism (thyroid gland does not produce enough thyroid hormones), anxiety, depression, and seizure disorder (condition causing repeated seizures, which are abnormal electrical brain activity); -The resident had a seizure-like episode at home, on 8/12/24, with tongue biting, and was unresponsive upon arrival. The resident had another seizure in the emergency room , lasting two minutes, and characterized as a tonic-clonic (type of seizure that involves violent muscle contractions and loss of consciousness) episode with tongue biting. The resident was admitted for recurrent seizures, was stabilized eight days later and was ready for discharge but developed severe left knee pain from an acute flare of gout (a type of arthritis that causes joint pain and swelling due to a buildup of urate crystals in the joints). The resident was started on colchicine (medication used to prevent or treat gout attacks/flares) stat (immediately), followed by 0.6 mg to be continued twice daily for 5 days. -The resident's hospital discharge instructions showed the following orders: -Regular diet; -Vital signs every morning and evening; -Physical Therapy to evaluate and treat; -Occupational Therapy to evaluate and treat; -Blood sugars daily; -Weekly weights; -Colchicine 0.6 milligrams (mg) tablet, twice daily, for acute gout flare, for 4 days; -Lacosamide (anticonvulsant/seizure medication) 100 mg twice daily; -Lamotrigine (anticonvulsant/seizure medication) 25 mg once daily; -Metformin (treats type 2 diabetes) 500 mg twice daily; -Januvia (treats type 2 diabetes) 100 mg daily; -Levothyroxine (treats hypothyroidism) 75 micrograms (mcg) daily at bedtime; -Losartan (treats high blood pressure) 50 mg daily; -Atenolol (treats high blood pressure) 25 mg once daily; -Clopidogrel (prevents platelets from sticking together & forming dangerous blood clots) 75 mg daily; -Aspirin (used as blood thinner to prevent blood clots) 81 mg daily at bedtime; -Fluoxetine (antidepressant) 40 mg daily; -Omeprazole (treats gastroesophageal reflux disease) 40 mg daily before breakfast; -Timolol ophthalmic (for glaucoma) 0.5% solution, one drop into both eyes daily; -Sodium chloride hypertonic ophthalmic drops (for dry eyes), apply every evening; -Vitamin D3 (vitamin supplement) 1000 units twice daily; -Melatonin (sleep aide supplement) 10 mg daily at bedtime; -Cyanocobalamin (Vitamin B12) 500 mcg daily; -Folic acid (a B vitamin) 1 mg daily; -Glucosamine (supplement for joint health) 500 mg daily; -Omega-3 (polyunsaturated fatty acid supplement) 500 mg daily. During an interview on 9/17/24 at 11:45 A.M., the Administrator said they did not have an admissions policy which encompasses the step-by-step admission process/instructions. Review of the Resident #1's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/22/24, showed: -admitted [DATE]; -Moderate impairment of cognition; -Incontinent of bowel and bladder; -Functional abilities were blank/not completed. Review of the resident's medical record diagnoses, showed: -Encephalopathy (brain dysfunction with confusion, memory loss, personality changes, or coma-resulting from things such as over medicated, infection, toxins, etc.) -Conversion disorder with seizures (a mental health condition that can cause physical symptoms, including seizures, that are not caused by an underlying neurological pathology); -Type 2 diabetes; -High blood pressure; -Atherosclerotic heart disease (coronary/heart artery disease); -Open angle glaucoma (chronic eye disease of increased intraocular pressure, leading to optic nerve damage and vision loss if left untreated); -Dementia (progressive decline in cognitive abilities) with behavioral disturbances. -Alzheimer's disease (a type of dementia); -Hypothyroidism; -Major depressive disorder (persistently depressed mood, causing significant impairment in daily life); -Sleep apnea (sleep disorder-causing breathing to stop at times, during sleep); -Gastro-esophageal reflux disease (GERD-stomach contents leak into the esophagus); -Protein-calorie malnutrition (inadequate intake of protein, calories, and essential nutrients); -Unsteadiness on feet; -Vertigo (symptoms of spinning, swaying, or tilting). Review of the resident's Physician Order Sheet, dated 8/21/24, showed: -Do not resuscitate/no cardiopulmonary resuscitation. -No special care orders, diet orders, or medication orders were listed. Review of the resident's Medication Administration Record, dated August 2024, showed No order data found. Review of the resident's electronic admission assessments list, showed: -8/21/24, Weekly skin observation; -8/21/24, Nursing admission assessment; -8/22/24, Situation-Background-Assessment-Recommendation (SBAR, a form completed by nurses, regarding important resident information/condition, to facilitate and increase the probability of effective, accurate, communication between health care professionals) communication form. Review of the resident's licensed nurse admission assessment, authored by Registered Nurse (RN) A, dated 8/21/24 at 6:29 P.M., showed: -admitted [DATE] at 1:30 P.M.; -No history of falls; -Oriented to situation and place (orientation to person & orientation to time, boxes not checked off); -Anxious mood; -Exit seeking behaviors; -Verbal communication garbled; -Understands-verbal comprehension; -Sometimes understood; -Drug regimen review was blank/not filled out. Review of the resident's progress notes, dated 8-21-24, showed: -No notes by RN A, the resident's 12-hour day shift nurse (7:00 AM to 7:00 PM), documenting the resident's arrival, admission orders verified by the physician, or medication orders sent to the pharmacy; -4:15 P.M., RN C (facility wound nurse) documented the resident's skin assessment was completed, there were skin issues present, but no open wounds; -9:01 P.M., Licensed Practical Nurse (LPN) B documented the resident was on the floor, next to the bed, lying on his/her right side. An assessment was completed and there were no injuries, skin issues, or pain. The physician was notified via a message. The resident's spouse was not reachable via the phone number provided. Review of the resident's progress notes, dated 8-22-24, showed: -3:30 A.M., LPN B documented the staff responded to a noise from the resident's room and found him/her on the floor. An assessment was completed, and the resident complained of left hip pain but refused assessment of the left hip area. The spouse's phone number did not go through. Awaited return call from the physician, Director of Nursing (DON) was notified, and ambulance service was requested; -3:50 A.M., LPN B documented the ambulance arrived and the resident was transferred to the hospital; -6:01 A.M., LPN B documented the hospital called, reported there was no fracture, and the resident was returning to the facility; -7:00 A.M., LPN D documented the resident attempted to strangle Emergency Medical Services (EMS) personnel upon return to the facility. EMS personnel did not remove the resident from the stretcher, upon return to the facility, and 911 was called to return the resident to the hospital due to the resident's harmful behavior. Review of the resident's care plan, showed: -Fall on 8/21/24 with no injury; -Fall on 8/22/24, complained of hip pain; -Interventions-Resident sent to theER on [DATE], therapy to evaluate, staff will not leave resident up in chair in room unattended, and transfer from chair to low bed in the evening; -There were no other focus items in the care plan. During an interview on 9/17/24 at 2:15 P.M., the DON said the nurse called her about both falls. The resident was in the recliner when he/she fell the first time. She told the charge nurse to put the resident to bed and for staff not to leave the resident alone when up in the chair. She added the fall care plan into the resident's electronic record later that day, on 8/22/24, after the resident was sent back to the hospital early that morning. During an interview on 9/20/24 at 12:17 P.M., LPN B said he/she did not know the resident was a new admission and could not recall what exactly RN A said about the resident during their change of shift report. He/She was not aware the resident did not receive any medications that evening, as the Certified Medication Technician (CMT) did not report the absence of medications or orders for the resident. It was not until he/she was sending the resident to the hospital, around 3:00 A.M. on 8/22/24, that he/she became aware there were no orders for the resident. There was a manila envelope on the nursing desk, with the resident's name on it, but it was empty. There were no admission papers found at the nursing station or in the DON's mailbox. LPN B sent the resident to the hospital (not the same hospital discharged from) without physician's orders. The hospital called, requesting the resident's orders, and he/she told them there were no orders for the resident in his/her chart. During an interview on 9/20/24 at 1:55 P.M., CMT E said not every resident has medications in the evening. If a resident has medication(s) ordered to be given during his/her shift, from 6:00 P.M. to 6:00 A.M., their name will appear in the electronic record. He/She then clicks on the resident's name and the medications to give at that time, will appear. Therefore, if there are no medications ordered to be given, during that time of day, the resident's name will not appear. CMT E said he/she had no way of knowing the resident had no evening medications, because the resident's name never appeared. During an interview on 9/20/24 at 2:33 P.M., Certified Nurse Aide (CNA) F said she thought they brought the resident a dinner hall tray on 8/21/24. During an interview on 9/17/24 at 4:30 P.M., CNA G said they went to the kitchen, on 8/21/24, got the resident a dinner tray, and the tray was empty when they picked it up. During an interview on 9/13/24 at 12:15 P.M., the Administrator said the hospital, that discharged the resident to their facility, did not send any discharge papers or orders with the resident. They did not know what RN A did about it. The Administrator said it was the DON's responsibility to check all new admissions, the next day, to ensure the admission process was completed. During an interview on 9/17/24 at 12:40 P.M., the DON said she did not check the resident's chart, to ensure the admission process had been completed, because the resident discharged early that morning, on 9/22/24, before she arrived at work. The DON said she was not aware the resident was admitted without any orders, until questioned about it, by the surveyor, on 9/13/24. During an interview on 9/17/24 at 11:55 A.M., the Regional Corporate Nurse said the admission nurse's number one priority, for a new admission, is to obtain and quickly transcribe the physician's orders, so the medication orders can be sent to the outside pharmacy, and complete the whole-body skin assessment. All other assessments can be completed within the 24-hour period and the interim/initial care plan within 48 hours. The admitting nurse should have immediately called the hospital and had the resident's discharge orders faxed to the facility. MO00240959

Based on observation, interview and record review, the facility failed to ensure a resident's right to be safe during a transfer when a staff member transferred the resident without a using a Hoyer lift (a mechanical device to assist with transferring) and/or without additional staff assistance, and against the facility's policy, which resulted in the resident sustaining a fractured leg (Resident #20). The facility also failed to ensure all nursing staff had access to residents' electronic medical records through Point Click Care (PCC) prior to working with residents. This prevented staff from having access to care plans and/or Kardex (filing system used as a quick reference for staff) information. The facility failed to inservice staff and update care plans with the most current information regarding resident care needs. The facility also failed to prevent a cognitively impaired resident (Resident #19) from exiting through a secured door without staff knowledge and leaving the facility property. The resident walked 0.1 miles away from the facility towards a busy street. The facility failed to put additional interventions in place to ensure the resident's safety, and/or inservice all staff on the facility elopement policy so staff were able to identify residents at risk for elopement. The sample size was 14. The census was 52. Review of the facility's Total Mechanical Lift policy, revised: August 1, 2023, showed: Purpose: A mechanical lift is used appropriately to facilitate transfers of residents. Policy: I. Nursing Staff will be trained to use the mechanical lift; II. The resident will have a physician's order for the use of a mechanical lift; Ill. Resident will be transferred with a mechanical lift as per manufacturer's guidelines. IV. Nursing Staff will lock brakes according to the manufacturer's guidelines; -Procedure: I. Wash hands before and after each procedure; II. Explain procedure to resident and provide privacy; Ill. Place lift sling under resident; A. The resident should be in center or one side of their bed; B. Roll the resident on the side away from staff; C. Roll the client towards the staff; D. Fold the sling in half lengthwise and place it next to the resident. The bottom end should be just above the resident's knees and the top end should be just above the armpits; E. Roll the resident onto his/her back and to the other side; F. Pull the remaining half of the sling from under the resident to unfold it so that it lays flat on the bed; G. Roll the resident onto his/her back, over the sling. Arrange the resident's arms so they are straight and flat next to the body.; IV. Position the lift under the bed or around the resident's chair as applicable. V. Set base legs to the widest position under resident. VI. Lower the boom bar. Lower it enough that the sling loops will reach the sling hooks, but not so low that it touches the resident; VII. Hook the loops on the sides of the u-sling to sling bar. Attach each corner of the sling to the correct hook on the sling bar; For slings with leg loops, cross the leg loops under the resident's legs and bring the end of the straps through the legs. Make sure the left loop is reaching across to hook to the right hook, while the right loop is reaching across to hook to the left hook, and that the hooks are set away from the boom of the lift apparatus. This crisscross helps the resident's legs stay together and keeps the user from slipping out of the sling; VIII. Raise the boom bar on the lift; IX. Keep resident centered between legs of the base and facing toward the person who is operating the mechanical lift. X. Move resident to destination. XI. Lower resident and position comfortably. XII. Narrow the base's legs and return the lift to the storage area; -The facility policy did not address how many staff were to be present during a total lift transfer. Review of the facility's Wandering & Elopement policy, revised: October 24, 2022, showed: -Purpose: To enhance the safety of residents of the Facility. -Policy: The Facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement. -Procedure: I. The Licensed Nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition according to the RAI guidelines to determine their risk of wandering/elopement; II The resident's risk for elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition according to the RAI guidelines; Ill. IDT may consider interventions for residents identified to be at risk for elopement; IV. Residents with a history of wandering or who IDT have assessed to be at risk for wandering or elopement will have a photograph maintained in their medical record; V. Facility Staff will reinforce proper procedures for leaving the Facility for residents assessed to be at risk of elopement; VI. If Facility Staff observes a resident leaving the premises without having followed proper procedures, he/she may: A. Try to prevent the departure in a courteous manner; B. Get help from other Facility Staff in the immediate vicinity, if necessary; C. Direct another Facility Staff member to inform the Charge Nurse or Director of Nursing Services that a resident is trying to leave the premises; Response to Resident Elopement A. The facility Staff member who finds that a resident is missing will alert facility Staff; B. The Charge Nurse will call CODE. _____ and organize a search. facility Staff will search areas of the facility, including common areas, bathrooms, showers, outside areas, etc; C. If the resident cannot be located, the Charge Nurse will notify: i. Administrator/designee; ii. Director of Nursing Services/designee; iii. Attending Physician; iv. Responsible Party; D. The Administrator/designee will contact local law enforcement and provide them with the following information: i. The resident's name, description (hair and eye color, complexion, weight, height, clothing, distinguishing marks, etc.), addresses and telephone number of resident's previous residence and family members; ii. The resident's mental status and pertinent medical conditions; iii. How to return the resident to the facility; A. The Administrator/designee will continue to work with law enforcement and the responsible party until the resident is located; F. The Licensed Nurse most familiar with the incident will document in the resident's medical record how the elopement occurred; G. The Facility will make necessary reports to state agencies; -VIII. Return of a Resident: A. When an individual who departed without following proper procedures returns to the Facility, the Director of Nursing Services or licensed Nurse should: i. Examine the resident for any possible injuries; ii. Notify the Attending Physician; iii. Notify the resident's responsible party. B. The Licensed Nurse will initiate or update the resident's Care Plan and implement and immediate intervention(s) to prevent further wandering/elopement by the resident; C. The IDT, with input from the Licensed Nurse, will conduct a thorough review of the elopement, document its findings in the IDT notes, and update the Care Plan to prevent a recurrence. D. The Quality Assessment & Assurance Committee will review all instances of elopement. 1. Review of Resident #20's medical record, showed his/her diagnoses included muscle weakness, contracture of left hand (deformity and rigidity of joints), muscle wasting (loss of muscle mass and strength), need for assistance with personal care, contractures of the left and right upper arm and traumatic brain injury (TBI-brain dysfunction caused by an outside force to the head). Review of the resident's care plan, dated 9/11/23 and revised on 7/2/24 (two days after the resident was discharged from the facility), showed: -Focus: Resident has an Activities of Daily Living (ADL) self-care deficit related to TBI; Goal: Resident will maintain current level of function through the next review date; -Interventions: Resident is total assist with bed mobility, the Resident is a total assist for locomotion in manual wheelchair, bathing, bed mobility, dressing, personal hygiene, and toilet use. The resident requires a mechanical lift with (2) staff assistance. Review of the resident's care plan, dated 10/19/23, revised on 11/28/23, showed: -Focus: Resident is at risk for falls; -Goal: Resident will not sustain serious injury through the review date; -Interventions: -Anticipate and meet the resident's needs as needed; -Educate the resident and family/caregivers about safety reminders and what to do in case a fall happens; -Ensure the resident's call light is in reach and encourage resident to use it for assistance as needed; -Ensure the resident is wearing appropriate footwear when ambulating or mobilizing in a wheelchair, follow facility fall protocol. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/5/24, showed: -admitted to facility on 8/26/24; -Severely cognitively impaired; -No behaviors; -No refusal of care; -Impairment of upper and lower extremities; -Dependent for tub/shower transfer; -Dependent for chair/bed-to chair transfers; -Non-ambulatory; -No musculoskeletal diagnosis including osteoporosis (thinning of the bones). Review of the resident's Physician's Order Sheets (POS) for June 2024, showed no order for a mechanical lift or any information about the resident's transfer status. Review of the resident's progress notes, dated 6/29/24, showed: -10:37 A.M., (late entry), staff placed a call to physician, awaiting return call; -11:33 A.M., (late entry), Certified Nursing Assistant (CNA) came to this writer and stated the resident complained of pain in his/her right knee after returning to bed after a shower. Family member at bedside. The writer assessed the resident and noted redness or swelling on right thigh and shin without discoloration. The resident said he/she was in pain when being repositioned and requested as needed (PRN) medication. Staff administered medication; -11:48 A.M., (late entry) staff notified the Director of Nursing (DON) and Administrator of resident's pain after transfer and orders for X-rays; -12:15 P.M., (late entry) the physician returned call, ok for x-ray of right hip, tibia (large bone on inner side of lower leg), fibula (bone on the outer side of the lower leg), femur (large bone in upper leg), knee and ankle; -2:57 P.M., (late entry) the resident resting comfortably in bed in no obvious distress. No bruising noted to right lower extremity (leg). No questions or concerns at this time; -10:50 P.M., results of X-ray showed acute fracture involving proximal tibial metaphysis (knee area). Staff reported findings to resident's physician. New order to send the resident to the hospital for evaluation and treatment. Staff called the DON to inform her. Review of the resident's radiology results, dated 6/29/24, showed: -PROCEDURE: X-ray tibia and fibula; -Findings: -There is decreased bony ossification (old bone breaks down faster than new bone can grow) of the lower extremity; -Acute fracture involving the proximal tibial metaphysis; -The ankle and knee joint spaces are grossly intact; -No evidence of osteomyelitis (bone infection); -Impression: -Acute proximal tibial fracture, mild osteopenia (thinning of bones). Review of the facility's undated investigation provided to the surveyor on 7/3/24, showed: -Date of Incident: 6/29/2024; -Initial Investigation: -The resident resides at [NAME] Rehab and Healthcare; -He/She has the diagnoses of but not limited to traumatic subdural hemorrhage (brain bleeding), nontraumatic subdural hemorrhage (brain bleeding not caused by trauma), alcohol abuse, muscle wasting and atrophy, osteopenia, and contractures of upper extremities; -The resident was noted to have a right tibial fracture; -Initial Interventions: -Pain medication administered; -MD notified; -X-ray ordered; -Increased monitoring of the resident monitoring pain; -Staff interviews initiated; -Investigation: -The resident has been working with therapy since September 2023 with Physical Therapy (PT)/Occupational Therapy (OT) and in the last two months, he/she has progressed to standing, pivoting transfers, and using parallel bars with therapy staff; -Therapy has noted that family takes it upon themselves to stretch the resident and do range of motion with him/her; -They have also been noted to assist with transferring resident as well; -After his/her therapy sessions this past week (as of 6/24/24), the resident began to complain of knee fatigue and Bilateral Lower Extremities (BLE-lower legs) discomfort; -He/She has been bedbound for approximately a year and half to two years so some discomfort would be expected; -X-ray results showed the resident's right knee is showing arthritic changes of the knee with proximal tibial fracture; -Osteopenia also noted in the knee at this time; -Femur showed normal bony ossifications (soft tissue get hard); -Hip and knee joint spaces are grossly intact; -The right hip showed arthritic changes along with osteopenia. -The right ankle decreases in bony ossification, arthritic changes at the mortise (ankle) with spurring (bone spurs) at the medial (inner) and lateral (outside) malleolus (ankle); -The right tibia and fibula showed decreased bony ossification of the lower extremity; -Acute fracture involving the proximal tibial metaphysis (wide part of the bone); -Noted osteopenia; -Spoke with physician regarding the X-ray result; -Physician stated (no date, time or written evidence) since the resident has severe osteopenia, he felt this could have been a spontaneous fracture and even a slight trauma/bump could have caused a fracture; -On 6/29/24 (no time provided), resident had pain to the RLE after shower; -CNA/shower aide interviewed and stated that he/she transferred the resident from the shower chair to her bed using a gait belt (assistive safety device); -As the resident stood with assist, the resident stiffened his/her leg and locked his/her knees; -At that time no pain was stated from the resident; -Transfer was completed; -The resident was situated in bed, prior to CNA leaving; -The resident stated he/she was having knee pain; -The CNA reported the resident's complaint to the nurse; -The CNA told the nurse of the stiffening during the transfer but that the resident did not yell out or complain immediately of pain; -The nurse assessed the resident and provided him/her with pain medication; -The nurse observed and palpated the resident's leg, all color and size were normal; -When the nurse assessed the pain, the resident stated he/she was in pain, medication administered; -Call was placed to the MD to order x-ray as precaution; -Conclusion: We cannot conclude if the resident sustained the fracture during transfer with CNA or if it was a spontaneous fracture since he/she was recently noted to be working with therapy on stand/pivot transfers to include standing in the parallel bars; -The investigation did not include any additional witness statements from staff, other residents, any representative of skilled therapy services and/or any family members. Review of the resident's skilled PT notes dated 6/1/24 to 6/28/24, showed no documentation the PT therapist worked with the resident for stand and pivot transfers. During an interview on 7/8/21 at 10:28 A.M., PT S said: -The only time he/she did a stand to pivot transfer with the resident was months ago when the resident first started working with physical therapy; -The resident was unable to perform a stand to pivot transfer safely and the exercise was not attempted again; -No facility staff were present during the stand to pivot transfer; -The physical therapy department never told staff the resident was appropriate for a stand to pivot exercise and no staff were ever trained or educated on a stand to pivot transfer for the resident; -In his/her professional opinion, it would be very unsafe to transfer the resident using one person and a gait belt; -The resident was a mechanical lift; -Physical therapy had been working with the resident for upper body strengthening, sitting straight in his/her bed and/or wheelchair, passive low-load stretching to maximize range of motion (ROM); -The resident often complained of aches and pains; -During the last treatment session on 6/28/24, the resident did not vocalize complaints of pain in his/her right lower extremities; -Facility staff were never told the resident's transfer status was anything but a mechanical lift. During an interview on 7/8/24 at 10:19 A.M., OT T said: -OT had been working with the Resident for several months; -OT had been working with the resident for upper extremity strengthening; -OT did not determine how residents were transferred; -He/She never worked with the resident for a stand to pivot transfer; -He/she knew the resident was a mechanical lift. Review of the resident's skilled OT notes dated 6/1/24 to 6/28/24, showed no documentation the OT therapist worked with the resident for stand to pivot transfers. During a telephone interview on 7/9/24 at 10:15 A.M., the resident's family member said: -The resident has been at the facility since September of last year; -The resident is not able to stand and bear weight; -No facility staff notified the family member of the incident that occurred on 6/23/24; -The resident's roommate called and told him/her what was going on; -He/She called and asked staff to have the DON return her call; -He/She was never notified the resident was complaining of pain after an inappropriate transfer, he/she was not notified the facility was getting X-rays; -The resident was a Hoyer lift and had been a Hoyer lift since admission; -The resident's family was in close contact with the facility's therapy department; -The family worked with the resident with some things like holding a cup or fork, sitting up straight and would help with ROM and stretching exercises; -The resident's family would offer to help staff when they were providing care; -The resident's family had not ever attempted to transfer the resident without staff; -The resident's family, including the resident's parent, nor siblings, had ever been educated to not assist the resident. Review of the resident's shower sheet, showed it was dated 6/29/24 at 10:15 A.M., and signed by CNA F and Registered Nurse (RN) S. Review of a handwritten statement, dated and signed on 6/29/24, (no time noted) by CNA F, showed he/she transferred the resident twice using a gait belt. The resident complained of knee pain immediately after the second transfer. CNA F went and told the nurse on duty. Review of the resident's Kardex, dated 7/2/24, showed the resident was a 2-person, mechanical lift transfer; During a telephone interview on 7/2/24 at 1:20 P.M., CNA F said: -He/She worked at the facility on 6/29/24 during the 7:00 A.M. to 7:00 P.M. shift as the shower aide; -He/She was told by an unknown staff member the resident was a one person-gait belt transfer from the bed to the shower chair and vice versa; -Around 10:30 A.M., he/she transferred the resident using a gait belt into the shower chair; -The resident transferred without issue; -When he/she went to transfer the resident back into bed, the resident tensed up and his/her foot bent back and the resident said Oh my knee, my knee is broken; -CNA F went and got the nurse and the nurse came into the room and assessed the resident; -CNA F did not have access to the facility's electronic medical records system, Point Click Care (PCC), and had not received an access code to PCC until 6/30/24, after the transfer; -6/29/24 was the first time he/she had worked with the resident; -He/She just transferred the resident with the information he/she was provided; -When he/she was hired he/she was provided two days of training with a preceptor then was given his/her own assignment; -He/She had no access to the resident's Kardex and/or care plan and transferred the resident like she was told; -He/she has been suspended from the facility. Review of an email dated 7/1/24, at 11:20 A.M., from RN S to the Administrator, showed: Subject: Resident's statement: -CNA approached the nurse stating (no date or time provided): -CNA reported he/she transferred the resident to bed from the shower chair, the resident complained of pain in his/her right knee; -RN S went into the resident's room and the resident was resting in bed; -Upon assessment, there was no redness, swelling bruising or pain upon palpation of the right knee; -The resident was guarding right knee, in anticipation of pain when he/she was touched; -When asked if the resident was in pain, he/she said yes. When asked what the resident's pain level was on a scale of 1 to 10, the resident replied 10; -The resident's parent was at the bedside; -The resident's parent stated the resident needed pain medication to which the resident agreed; -Writer returned to bedside and administered the resident's pain medication; -Writer placed a call to MD, DON and Administrator to make aware of incident; -New orders received for X-ray of leg from physician; -The Administrator asked this writer to inform the DON; -The DON asked the writer to wait before creating an incident report; -Call placed to mobile X-ray company to request X-rays; -Informed resident and his/her parent of new orders; -Approximately one hour later, the resident was resting quietly. During an interview on 7/2/24 at 7:11 A.M. the DON and Administrator said: -Over the weekend the resident was being transferred from the shower chair to his/her bed and sustained a fracture; -The resident was usually a mechanical lift; -The CNA who did the transfer was suspended pending investigation; -The facility did not notify the Department of Health and Senior (DHSS) of the inappropriate transfer which resulted in a resident sustaining a fracture; -The facility did not consider the transfer inappropriate, and no neglect was suspected; -The resident had been working with therapy for the last month or so on sit to pivot transfers; -The resident was sent to the hospital and had not returned; -The DON came in over the weekend to start to in-servicing staff on where to locate a resident's transfer status and to make sure every nursing employee had access to PCC; -The DON was still in-servicing staff that morning when the surveyor came to the facility; -The investigation was ongoing. During an interview on 7/2/24 at 2:15 P.M., Certified Medication Technician (CMT) R said: -He/She is the facility's Human Resources (HR) person; -His/Her responsibility with new employees included obtaining required paperwork and background checks; -He/She went over the rules, time clock, dress code, schedules, and the handbook; -The handbook was online and new staff were expected to log in and read the handbook; -All new nursing employees then went to the DON and Assistant Director of Nursing (ADON) for additional training specific to the nursing department; -The DON was the one who gave new nursing employees access to PCC; -CNA F was not provided access to PCC until the 6/30/24. One day after the incident. Review of an active employee report as 6/30/24, showed: -Check marks by each employee's name with no explanation of what the check marks meant; -An un-dated list of employees with access to PCC. Review of an in-service sign-in sheet dated, 6/30/24 (no times or duration of presentation listed), showed: -In-service provided by the DON: Description of presentation: Resident information on proper transfer is on the resident's Kardex and on the care plan in PCC. *Do not transfer a resident without knowing how they transfer; -The in-service sign in sheet had 25 nursing staff signatures with two staff signing the in-service sheet twice. During an interview on 7/2/24 at 5:47 A.M., the DON said she was at the facility early to in service on transfers. She did not provide any additional information. During an interview on 7/2/24 at 2:32 P.M., the DON and Administrator said: -CNA F did not have a password to access PCC; -During the course of their investigation, it was noted some nursing staff did not have access to PCC; -On 6/30/24, the DON did an audit and made sure all nursing employees were provided access to PCC; -The DON did not in-service staff on the use of Hoyer lifts on 6/29, 6/30, 7/1 or 7/2/24. She in-serviced staff where to look in the resident's record to identify their transfer status; -Resident care plans should address the resident's transfer status. Review of the active nursing employee list, dated 6/20/24, showed 22 active employees had not been in-serviced on where to find residents' transfer status as of 7/8/24. During an interview on 7/2/24 at 5:30 A.M., CNA E said: -He/She had worked for the facility for 9-10 months; -He/She had not received any recent in-service training regarding how to determine a resident's transfer status; -He/She just has to ask a co-worker, the nurse or the resident. During an interview on 7/2/23 at 9:25 A.M., Licensed Practical Nurse (LPN) G said: -The resident had always been a mechanical transfer; -There should always be two staff present for a mechanical lift transfer; -He/She did not work the day of the incident; -He/She was not aware of what training was provided to new staff in regard to resident transfers; -He/She thought all residents had a Kardex; -CNAs always ask the nurse about a resident's transfer status. During an interview on 7/3/24 at 7:48 A.M., LPN I said: -He/She knew the resident was a mechanical lift at all times; -He/She didn't know what information was provided to new staff during training; -He/She had never received training about the mechanical lifts specific to this facility; -There was not classroom training; -The DON spoke to him/her and asked if he/she knew where to find residents' transfer status; -He/She signed the in-service sign in sheet. During an interview on 7/3/24 at 7:59 A.M., CNA J said: -He/She had worked for the facility for about two months; -He/She knew the resident was always a mechanical lift; -He/She never received training about the mechanical lifts specific to this facility. During an interview on 7/3/24 at 8:26 A.M., CMT K said: -He/She knew the resident needed to be transferred with a mechanical lift; -He/She did not receive any education from the DON about where to find transfer information on residents; -He/She didn't know which staff had access to PCC and who did not have access. During an interview on 7/3/24 at 8:34 A.M., CNA L said: -He/She knew the resident used a mechanical lift for transfers; -He/She knew mechanical lifts required two people to be in the room; -He/She never received training about the mechanical lifts specific to this facility; -He/She worked the day the resident's leg was broken; -CNA F transferred the resident using a gait belt; -CNA F never asked him/her what the resident's transfer status was; -CNA F had not worked since the day of the incident. During an interview on 7/3/24 at 8:18 A.M., CNA M said: -He/She knew the resident was supposed to be a Hoyer lift at all times; -He/She heard the resident was transferred with a gait belt and fractured his/her leg; -He/She knew a mechanical lift required two staff to be present at all times; -He/She had not been in-serviced about mechanical lifts and/or how to find a resident's transfer status since the incident occurred. During an interview on 7/3/24 at 8:38 A.M., CNA O said: -He/She knew the resident's leg was broken during a one-person transfer; -The resident has always been a mechanical lift since the day he/she was admitted ; -He/She did not remember any in-services on how to use the facility's mechanical lifts; -It is known two staff should be in the room during a Hoyer lift transfer. During an interview on 7/3/24 at 8:44 A.M., CNA P said: -He/She knew two people should be in a room during a mechanical lift transfer; -He/She knew that the resident was sent to the hospital because another staff member transferred the resident only using a gait belt; -He/She had not been in-serviced or trained on the facility's mechanical lifts. During an interview on 7/3/24 at 9:23 A.M., LPN Q said: -He/She heard the resident sustained a fractured leg due to an inappropriate transfer; -He/She did not know what training was provided to CNA's prior to them being put on the floor. During an interview on 7/3/24 at 7:52 A.M., the resident's roommate said: -His/Her roommate was in the hospital; -On 6/29/24, an unknown CNA transferred his/her roommate from a shower chair into bed which caused the roommate to break his/her leg; -Staff always used a Hoyer lift when transferring the resident, except when it was shower day; -Most staff did not use the lift when they put the resident in the shower chair because the lift pad would get wet; -He/She never saw the resident's family members attempt to transfer the resident without assistance. During an interview on 7/3/24 at 1:28 P.M., with the DON, Administrator and two corporate nurses; -The Administrator said the resident's roommate was alert and oriented to person, place, time and situation; -When told what the roommate said, the DON said the roommate had schizophrenia (mental illness that affects a person's ability to think, feel and behave clearly) and just liked to stir the pot; -His/Her statement was not to be trusted; -The DON called the resident's responsible party and notified him/her of the resident's X-ray results. During an interview of 7/8/24 at 11:49 A,M., the DON and Administrator said all inservicing had been completed regarding staff having PCC access and how to locate a resident's transfer information in PCC. During a telephone interview on 7/8/24 at 4:05 P.M., the resident's primary care physician said: -He was notified by staff the resident was complaining of right leg pain; -Staff did not provide any other details except to say the resident's leg was bumped; -He ordered X-rays of the resident's right leg including hip, pelvis, knee, and ankle; -He was not at the facility and did not assess the resident prior to ordering the X-rays; -He only knew what the staff reported to him; -He was not told the resident started complaining of pain after a transfer; -When the facility notified him the resident's X-rays were positive for a fracture, he had the facility transport the resident to the hospital for evaluation and treatment; -He said any person with severe osteopenia was at higher risk for fractures including spontaneous fractures. Some residents with severe osteopenia could sustain a fracture from an incident as small as bumping their leg or repositioning them. He was not specifically speaking about the resident; -If the facility's policy shows physician's orders are required for the use of Hoyer lifts, the facility should make sure the order was obtained from him or any other physician who had residents in that facility; -If a resident had an order for a mechanical lift, a mechanical lift should be used at all [NAME]

Based on observation, interview and record review, the facility failed to ensure five residents who required assistance with activities of daily living (ADLs, personal care) received showers in accordance with their needs and preferences (Residents #4, #5, #7, #11 and #2). The sample was 11. The census was 44. Review of the facility's Skin Monitoring: Comprehensive Shower Review Sheet, showed: -Perform a visual assessment of a resident's skin while giving them a shower; -Report any abnormal looking skin (as described below) to the charge nurse immediately; -Forward any problems to the Director of Nursing (DON) for review; -Use the form to show exact location and description of the abnormality, using the body chart: -Describe and graph all abnormalities by number; -A space designated for residents' name and date; -A numerical listing from 1 to 14 for examples of visual assessment; -Space designated for certified nurse aide (CNA) signature and date shower provided; -Space designated to show if resident needed toenails cut; -Space designated for charge nurse signature; -Space designated for charge nurse assessment; -Space designated for interventions; -Space designated to show if forwarded to DON and DON's signature with date. Review of the Resident Showers policy, dated 10/22/22, showed: -Purpose: A shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors; -Policy: Residents are offered a shower at a minimum of once weekly and given per resident request: Procedure: Assist the resident to the shower room and assist to bathe as needed; -Assist the resident with dressing as needed; -Dry and comb the resident's hair; -Report any broken skin, bruises, rashes, cut, skin discoloration or reddened areas to the Charge Nurse; -Update the resident's Care Plan as needed. Review of the shower schedule on 5/23/24, showed: -Showers/baths were assigned by room number and not resident preference; -A note at the bottom of the sheet read: do not alter or change without DON or Assistant Director of Nursing (ADON) approval; -The shower sheet did not direct staff to chart showers/baths had been given or where to put the completed shower sheets to show a shower/bath had been given. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/3/24, showed: -Cognitively impaired; -Substantial/Maximal assistance needed for toileting and showering with the helper doing more than half the effort; -Dependent assistance for transfers with helper doing all of the effort; -Uses a wheelchair. Review of the resident's undated care plan, in use during the survey, showed: -Focus: Resident has an ADL self-care performance deficit; -Goal: Resident will maintain current level of function in ADL's through the review date; -Interventions: Bathing/showers, total assistance, dressing, total assistance, oral care, resident has his/her own teeth, personal hygiene/oral care, total assist, transfer, resident requires mechanical lift with two staff assistance for transfers; -The care plan did not address the resident's preference for what time or days the resident should receive a shower. Review of the shower schedule, showed the resident's shower days were Wednesday and Saturday on the day shift. Review of the resident's shower sheets on 5/23/24, showed: -On 4/10/24, resident received a bed bath; -On 4/20/24, resident received a bed bath; -On 4/27/24, resident refused a bed bath; -On 5/8/24, resident received a bed bath; -On 5/15/24, resident refused a bed bath; -No other shower sheets were provided by the facility. Observations on 5/21/24 at 6:40 A.M., 9:08 A.M., and 12:32 P.M., on 5/22/24 at 6:23 A.M., 8:40 A.M., and 2:10 P.M., and on 5/23/24 at 7:10 A.M., showed the resident lay in bed with a Gastrostomy (g-tube, a tube surgically inserted through the abdomen into the stomach to provide hydration, nutrition and medications) infusing a nutritional supplement. His/Her hair was greasy with white flakes scattered throughout. His/Her mouth and teeth were coated with a thick white substance. His/Her fingernails were long and dirty. He/She had a distinct foul body odor. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -No rejection of care exhibited; -Functional abilities: Dependent on staff for: -Transfers; -Oral Hygiene; -Shower/bath; -Personal hygiene. Review of the resident's undated care plan, in use during the survey, showed: -Focus; Resident has an ADL self-care performance deficit; -Goal; Resident will maintain current level of function in ADL's through the review date; -Interventions; Bathing/showers, total assistance, dressing, total assistance, oral care, and personal hygiene/oral care; -The care plan did not address the resident's preference of what time or days the resident should receive a shower. Review of the shower schedule, showed the resident should have shower/bath on Tuesdays and Fridays on the night shift. Review of the resident's shower sheets on 5/23/24, showed: -On 4/2/24, resident received a shower; -On 4/16/24, resident received a shower; -On 4/30/24, resident received a shower; -On 5/10/24, resident received a shower; -No other shower sheets were provided. Observations on 5/21/24 at 7:38 A.M., 12:24 P.M. and 2:00 P.M. and on 5/22/24 at 7:00 A.M., 12:15 P.M., and 2:15 P.M., showed the resident lay in bed. His/Her hair was long and greasy. He/She had very long dirty facial hair with bits of dried food. His/Her fingernails were long and dirty. He/She smelled of body odor. During an interview on 5/21/24 at 9:30 A.M., the resident was able to answer yes or no questions. When asked if he/she had been provided a shower in the past week, the resident said no. When asked if he/she had received a shower/bath in the past two weeks, the resident said no. When asked if the resident preferred his/her hair long and wanted long facial hair the resident said no. When asked if staff brushed his/her teeth and/or trim his/her fingernails the resident said no. 3. Review of Resident #7's admission MDS, dated [DATE], showed: -No speech -Cognitively impaired; -Refusal of care 4-6 days but not daily; -Substantial/Maximal assistance needed for transfers, oral hygiene, personal hygiene, toileting and showering with the helper doing more than half the effort. Review of the resident's care plan, in use during the survey, showed: -Focus: Resident has ADL self-care performance deficit; -Goal: Resident will maintain current level of function through the next review date; -Interventions: Resident totally dependent on (X) staff for repositioning and turning in bed (Specify Frequency) and as necessary. The resident is totally dependent on (X) staff for transferring; -The care plan did not address any additional ADL needs including preferred days and times for bathing and personal hygiene. Review of the shower sheet schedule, showed the resident was scheduled to receive showers on Monday and Thursday on the day shift. Review of the resident's shower sheets on 5/23/24, showed: -On 4/8/24, resident received a bed bath. No nurse signed the shower sheet; -On 4/15/24, resident received a shower. No nurse signed the shower sheet; -On 4/18/24, resident received a bed bath; -On 4/24/24, resident received a shower; -On 5/2/24, resident received a bed bath. No nurse signed the shower sheet; -On 5/6/24, resident received a bed bath; -On 5/9/24, resident received a shower; -On 5/16/24, resident received a shower; -On 5/20/24, resident received a shower. Observations on 5/21/24 at 7:18 A.M., 11:28 A.M., and 2:10 P.M., and 5/22/24 at 6:20 A.M., 8:20 A.M., 9:49 A.M., and 12:10 P.M., and on 5/23/24 at 7:10 A.M., showed the resident lay in bed with tube feeing infusing. He/She was non-verbal and not interviewable. His/Her hair was greasy with white flakes scattered throughout. His/Her mouth and teeth were coated with a thick white substance. His/Her fingernails were long and dirty. He/She had a distinct foul body odor. 4. Review of Resident #11's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No rejection of care exhibited; -Required total assistance with transfers; -Required partial/moderate assistance for showers bathing and personal hygiene; -Required set up help with eating and oral hygiene. Review of the resident's undated care plan, in use during the survey, showed: -Focus; Resident has an ADL self-care performance deficit. -Goal: Resident will maintain current level of function in ADL's through the review date. -Interventions: Bathing/showers, total assistance, transfers, totally dependent on two staff using mechanical lift; -The care plan did not address what time or days the resident preferred to receive a shower. Review of the shower schedule, showed the resident should have a shower/bath on Tuesdays and Fridays on the night shift. Review of the resident's shower sheets on 5/23/24, showed: -On 4/8/24, resident received a bed bath. Shower sheet not signed by nurse; -On 4/18/24, resident received a shower; -On 5/9/24, resident received a shower; -On 5/16/24, resident received a bed bath; -On 5/20/24. Resident received a bed bath; -No other shower sheets were provided. Observations on 5/22/24 at 9:38 A.M. and on 5/23/24 at 7:00 A.M., 12:15 P.M., and 2:15 P.M., the resident lay in bed. His/Her hair was long and greasy. He/She had very long dirty facial hair with bits of dried food. His/Her fingernails were long and dirty. He/She smelled of body odor. During an interview on 5/21/24 at 9:30 A.M., the resident said he often refused to take a shower. He/She preferred bed baths. During bed baths staff did not offer to assist him/her with brushing his/her teeth, washing his/her hair, shaving or trimming his/her fingernails. 5. Review of Resident #2's quarterly MDS, dated [DATE], showed: -An original entry date of 2/7/24; -Cognitively impaired; -No refusal of care; -Substantial/maximum assist with eating, toileting, shower/baths, transfers and positioning in bed. Review of the resident's progress notes, dated 5/14/24, showed he/she was sent to the hospital. The facility was unable to provide any shower sheet for the resident. During an interview on 5/22/23 at 1:30 P.M., the DON said she was unable to produce any shower sheets for Resident #2. Shower sheets were the only documentation to show if staff provided a shower or bath. The shower sheets should be scanned into the resident's electronic medical record. Records were kept for [AGE] years. Showers were assigned by the resident's room number and not the resident's preferences. That was the system in place when she started working at the facility two months ago. Showers and baths should be based on the resident's preferences and not assigned just by their room numbers. The residents' care plans should identify what the residents' preferences were for bathing. The care plans should provide guidance to what is needed to be provided during a bath or shower. During an interview on 5/23/24 at 12:30 P.M., the Administrator said she expected for residents to receive showers per their scheduled day. Staff should shower the residents and document the showers on the shower sheets provided at the nurses station. The shower sheets should be scanned into the residents' electronic records. MO00235838 MO00235862 MO00236188

Based on observation, interview and record review, the facility failed to maintain complete and accurately documented clinical records regarding pressure ulcers (injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure or friction) for one of 11 sampled residents (Resident #2). The census was 44. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/8/24, showed the following: -admitted [DATE]; -Cognitively intact; -Able to make self-understood; -Rejection of care 1-3 days per week; -Dependent on staff for transfers, locomotion, personal hygiene and bathing; -admitted with one Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister on his/her coccyx (tailbone)); -admitted with one Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). Review of the resident's undated care plan, showed the following: -Focus: Resident has pressure ulcer to right buttock and coccyx (tailbone). Will refuse to turn and reposition. Refuses treatments and bathing; -Goals included resident will have no further skin breakdown; -Interventions included complete treatments as ordered by physician. To be followed by wound clinic. Review of the resident's treatment administration record (TAR), dated for February, March, April and May of 2024, showed staff documented they provided treatment to the coccyx/buttock area. Review of the facility's wound reports dated, 2/8/24, showed the resident listed on the wound report. The report included measurements, treatment orders and interventions. Review of the resident's progress notes dated 2/8/4, showed the resident had been seen by the wound physician. The physician's notes were not in the resident's medical record. Review of the facility's wound reports dated, 2/15/24, showed the resident listed on the wound report. The report included measurements, treatment orders and interventions. Review of the resident's progress notes dated 2/15/24, showed the resident was seen by the wound physician. The physician's notes were not in the resident's medical record. Review of the facility's wound reports dated, 2/20/24, showed the resident was hospitalized . Review of the facility's wound reports dated, 2/27/24, showed the resident listed on the wound report. The report included measurements, treatment orders and interventions. Review of the resident's progress notes dated 2/27/24, showed the resident had been seen by the wound physician. The physician's notes were not in the resident's medical record. Review of the facility's wound reports dated, 3/6/24, showed the resident listed on the wound report. The report included measurements, treatment orders and interventions. Review of the resident's progress notes dated 3/6/24, showed the resident had been seen by the wound physician. The physician's notes were not in the resident's medical record. Review of the facility's wound reports dated, 3/13/24, showed the resident listed on the wound report. The report included measurements, treatment orders and interventions. Review of the resident's progress notes dated 3/13/24, showed the resident had been seen by the wound physician. The physician's notes were not in the resident's medical record. Review of the facility's wound reports dated, 3/20/24, showed the resident listed on the wound report. The report included measurements, treatment orders and interventions. Review of the resident's progress notes dated 3/20/24, showed the resident had been seen by the wound physician. The physician's notes were not in the resident's medical record. Review of the facility's wound reports dated, 3/27/24, showed the resident listed on the wound report. The report included measurements, treatment orders and interventions. Review of the resident's progress notes dated 3/27/24, showed the resident had been seen by the wound physician. The physician's notes were not in the resident's medical record. Review of the facility's wound reports dated, 4/3/24, showed the resident listed on the wound report. The report included measurements, treatment orders and interventions. Review of the resident's progress notes dated 4/3/24, showed the resident had been seen by the wound physician. The physician's notes were not in the resident's medical record. Review of the facility's wound reports dated, 4/10/24, showed the resident listed on the wound report. The report included measurements, treatment orders and interventions. Review of the resident's progress notes dated 4/10/24, showed the resident had been seen by the wound physician. The physician's notes were not in the resident's medical record. Review of the facility's wound reports dated, 4/17/24, showed the resident listed on the wound report. The report included measurements, treatment orders and interventions. Review of the resident's progress notes dated 4/17/24, showed the resident had been seen by the wound physician. The physician's notes were not in the resident's medical record. Review of the facility's wound report dated, 4/24/24, showed the resident was in the hospital. Review of the facility's wound reports dated, 5/1//24, showed the resident listed on the wound report. The report included measurements, treatment orders and interventions. Review of the resident's progress notes dated 5/1/24, showed the resident had been seen by the wound physician. The physician's notes were not in the resident's medical record. Review of Review of the facility's wound reports dated, 5/8/24, showed the resident listed on the wound report. The report included measurements, treatment and interventions. Review of the resident's progress notes dated 5/8/24, showed the resident had been seen by the wound physician. The physician's notes were not in the resident's medical record. Review of the resident's progress notes showed he/she was sent to the hospital for evaluation and treatment. The resident was not going to return to the facility. During an interview on 5/23/24 at 12:30 P.M., the Director of Nursing (DON) said the wound nurse was responsible for measuring the wounds along with the wound physician. (Pressure and non-pressure) on a weekly basis. The measurements should be put on the wound report and then transcribed to the resident's weekly skin condition report in each resident's individual chart. The physician notes should be sent to the facility and scanned into each resident's permanent medical record. The facility did not have a current wound nurse, the Assistant Director of Nursing (ADON) had been filling in for the wound nurse. The facility wound reports were not part of the resident's medical records. The facility had been going through management changes. The wound nurse was terminated recently and had not been replaced yet. She could not explain why the wound reports were completed but the information was not put in the medical record. She said all of the residents' records from support services should be in the resident's medical record and available for review.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 42 opportunities, 4 errors occurred, resulting in an 9.52% error rate (Residents #4 and #5). The census was 44. Review of the facility's Medication policy dated 10/24/22, showed: Procedure: Nursing Staff will keep in mind the seven rights of medication when administering medication: -The right medication; -The right amount; -The right resident; -The right time; -The right route; -Right indication; -Right outcome; -Additional considerations include: The Rule of 3. The Licensed Nurse administering medications will perform three checks comparing the physician's order, pharmacy label, and Medication Administration Record (MAR): -Compare the Licensed Practitioner's prescription/order with the MAR (first check); -Compare the Licensed Practitioner's order with the pharmacy label on the medication package (second check); -Compare the pharmacy label and MAR (third check); Documentation: -The time and dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment; -Recording will include the date, the time and the dosage of the medication or type of the treatment. 1. Review of Resident #5's medical record, showed: -Diagnoses included post heart attack, high blood pressure, vitamin B12 deficiency, and major depression; -An order, dated 5/31/23, for chewable aspirin (blood thinner used to prevent blood clots) 81 milligrams (mg) once daily; -An order, dated 6/09/23, for multiple vitamin tablet (vitamin supplement) once daily. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/8/24, showed the resident: -Was cognitively impaired; -Dependent on staff for all Activities of Daily Living (ADL's, personal care). During a medication administration observation on 5/21/24 at 7:28 A.M., Certified Medication Technician (CMT) A: -Did not administer chewable aspirin 81 mg; -Did not administer a multivitamin. 2. Review of Resident #6's medical record, showed: -A quarterly MDS, dated [DATE], showed the resident was cognitively intact; -Diagnoses included high blood pressure and anxiety disorder; -An order, dated 2/6/24, for losartan potassium (treats high blood pressure) 50 mg one tablet once a day; -An order, dated 3/27/24, for metoprolol succinate extended release (treats high blood pressure) 50 mg 24-hour tablet once daily. During a medication administration observation on 5/21/24 at 7:30 A.M., CMT A: -Did not administer losartan potassium 50 mg; -Did not administer metoprolol succinate ER 50 mg. 3. During an interview on 5/22/24 at 9:30 A.M., the Director of Nursing (DON), said CMT A said she thought he/she had provided the medications. CMT A didn't realize he/she had overlooked the over the counter (OTC) medications. CMT A did not have an explanation why the other mediations were not provided. She expected medications to be given as ordered. MO00235838

Based on interview and record review, the facility failed to follow their abuse policy by not thoroughly investigating an allegation of a resident being hit in the head by a male nurse. The facility failed to interview the resident and the resident's sibling who reported the allegation to the facility's Marketing Director while he/she was visiting the resident in the hospital (Resident #1). The sample was three. The census was 45. Review of the facility's Abuse Prevention and Prohibition Program, revised 10/24/22, showed the following: -Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: -1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; -2. The Facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial well being; -3. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems; -Procedure: The Administrator may delegate coordination and Implementation of components of the abuse prevention program to other staff within the Facility. -Investigation: -A. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts. The Facility has protocols for investigations of theft/misappropriation of resident property abuse; -B. If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, injuries of an unknown source or crime, the Administrator or designee, may appoint a member of the Facility's management team (the Investigator) to investigate the alleged incident. If the investigation is delegated, the Administrator provides the Investigator with any supporting documents related to the alleged incident; -C. The Facility ensures protection of residents during abuse investigations; -D. The Investigator may take some or all of the following steps: -Reviews all relevant documentation; -Reviews the resident's medical record to determine events preceding the alleged incident; -Interviews the person(s) making the incident report; -Interviews any witnesses to the alleged incident; -Interviews the resident (as medically appropriate); --Interviews the resident's roommate, family members, and visitors. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed the following: -No cognitive impairment; -No moods or behaviors; -Dependent for activities of daily living; -Diagnoses included diabetes, osteoporosis and Down Syndrome (a genetic disorder which causes a distinct facial appearance, intellectual disability, developmental delays, and may be associated with thyroid or heart disease). Review of the facility's investigation, dated 1/5/24, showed the following: -On 1/4/24, the resident was discharged to hospital per his/her family's request due to swelling of the left hand. On 1/5/24, the Marketing Director went to visit the resident at the hospital. While the Marketing Director was in the room conversing with the resident and the family, the resident mentioned that he/she was hit in the head. The resident was only able to say a male but was not able to give any timeline on when it may have happened and did not say where it happened. The family was very pleasant and didn't give the Marketing Director any feeling that it happened in the facility. The resident had to use the restroom, so the Marketing Director was asked to leave the room while the nurses did care. The Marketing Director called the Administrator and the Director of Nursing (DON) and let them know what was said. The Marketing Director reported the resident did not have any marks or bruising on his/her head or face; -The facility has four male workers that could be considered. All four males were interviewed. The facility interviewed 10 residents and all 10 residents feel safe and have never seen any resident being hit by a staff member. The investigation does not show any signs that the resident was physically abused by any staff members at the facility; -Further review showed no documentation of an interview with the resident or the resident's family sibling. Review of the resident's medical record, showed no documentation regarding the allegation of abuse. During an interview on 1/10/24 at 1:35 P.M., the Marketing Director said he/she went to do a bed side visit on 1/5/24 at the hospital. The resident's family member came into the resident's room and the resident started to speak with the family member. The family member said the resident just told him/her, he/she was hit in the head. The Marketing Director was asked to leave the room because the resident had to use the bed side commode. A male nurse came in and he/she stepped out. The Marketing Director called the Administrator and DON. The DON and Administrator asked him/her to get more details. The resident's family member said he/she would get more details and call later. The Marketing Director said this was the end of his/her communication with the incident. He/She did not know if the DON or Administrator contacted the resident's family member for an interview. During an interview on 1/11/24 at 7:55 A.M., Family Member A said on 1/5/24, he/she was at the hospital visiting the resident. The Marketing Director came to visit the resident. The resident said he/she had to go to the bathroom and he/she had everyone step out. A male nurse came in to assist the resident and the resident got scared and starting said NO! NO! NO! so the male nurse left the room. Family Member A said the resident told him/her, he/she was hit in the head by a male nurse at the facility. Family Member A told the Marketing Director this allegation. Family Member A said neither the Administrator nor the DON called him/her or the resident for an interview. During an interview on 1/10/24 at 11:49 A.M., the DON said she received a for your information (FYI) from the Marketing Director saying some male nurse hit the resident. The DON said she and the Assistant Administrator immediately called all male nurses and suspended them pending an investigation and interviewed them. The DON said they interviewed 10 residents as well. The DON said she did not contact the resident or the resident's family member for an interview. During an interview on 1/10/24 at 12:12 P.M., the Administrator said he/she did not call the resident or the resident's family for an interview. The Administrator said he/she did not think of it and it should have been done to make the investigation complete. MO00230006

Based on observation, interview and record review, the facility failed to report an allegation of resident abuse to the Department of Health and Senior Services (DHSS) as required, within a two-hour time frame, for one of three sampled residents (Resident #1). The census was 45. Review of the facility's Abuse Prevention and Prohibition Program, revised 10/24/22, showed the following: -Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: -1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; -2. The Facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial well being; -3. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems; -Procedure: The Administrator may delegate coordination and Implementation of components of the abuse prevention program to other staff within the facility. -Reporting/Response; -A. Facility Staff are Mandatory Reporters; -All covered individuals will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be financial abuse, physical abuse, neglect, abandonment, isolation, abduction, or other treatment resulting in physical harm or pain or mental suffering, deprivation of goods or services that are necessary to avoid physical harm or mental suffering; -The Facility will not impede or inhibit a facility staff member's reporting duties, nor will facility staff be reprimanded or disciplined for reporting abuse; -The Facility has a strict non-retaliation policy for good faith reporting in compliance with the Elder Justice Act and any other state specific laws; -Failure to report suspected or known abuse may result in legal action against the individual(s) withholding such information; -B. Administrator, or his/her designee, as Abuse Coordinator; -In order to facilitate reporting, ensure confidentiality, and promote order at the Facility, the Administrator, or his/her designee, shall be the individual who reports known or suspected instances of abuse of residents at the Facility to the proper authorities; -Facility staff will report known or suspected instances of abuse to the Administrator, or his/her designee; -Facility staff members shall be notified that the Administrator, or his/her designee, has this responsibility, and that inquiries concerning resident abuse and reporting requirements should be referred to the Administrator, or his/her designee; -C. The Facility will report known or suspected instances of physical abuse, including sexual abuse, and criminal acts to the proper authorities by telephone or through a confidential Internet reporting tool as required by state and federal regulations; -Initial Report - Facility Reported Incidents; -Immediately, but no later than two hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement; -No later than 24 hours after forming the suspicion - if the alleged violation (e.g., misappropriation of property, neglect) does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed the following: -No cognitive impairment; -No moods or behaviors; -Dependent for activities of daily living; -Diagnoses included diabetes, osteoporosis and Down Syndrome (a genetic disorder which causes a distinct facial appearance, intellectual disability, developmental delays, and may be associated with thyroid or heart disease). Review of the facility's investigation, dated 1/5/24, showed the following: -On 1/4/24, the resident was discharged to hospital per his/her family's request due to swelling of the left hand. On 1/5/24, our Marketing Director went to visit the resident at the hospital. While the Marketing Director was in the room conversing with the resident and the family, the resident mentioned that he/she was hit in the head. The resident was only able to say a male but was not able to give any timeline on when it may have happened and did not say where it happened. The family was very pleasant and didn't give the Marketing Director any feeling that it happened in the facility. The resident had to use the restroom, so the Marketing Director was asked to leave the room while the nurses did care. The Marketing Director called the Administrator and the Director of Nursing (DON) and let them know what was said. The Marketing Director reported the resident did not have any marks or bruising on his/her head or face. Review of the resident's medical record, showed no documentation regarding the allegation of abuse or notifying the state agency. During an interview on 1/10/24 at 1:35 P.M., the Marketing Director said he/she went to do a bed side visit on 1/5/24 at the hospital. The resident's family member came into the resident's room and the resident started to speak with the family member. The family member said the resident just told him/her, he/she was hit in the head. The Marketing Director was asked to leave the room because the resident had to use the bed side commode. A male nurse came in and he/she stepped out. The Marketing Director called the Administrator and DON. The DON and Administrator asked him/her to get more details. The resident's family member said he/she would get more details and call later. The Marketing Director said this was the end of his/her communication with the incident. He/She did not know if the DON or Administrator contacted the resident's family member for an interview. He/She did not know if the DON or Administrator contacted the state agency. During an interview on 1/10/24 at 11:49 A. M., the DON said she received a for your information (FYI) from the Marketing Director saying some male nurse hit the resident. The DON said she and the Assistant Administrator immediately called all male nurses and suspended them pending an investigation. The DON said they interviewed 10 residents as well. The DON said since the allegation was abuse, the State Agency should have been notified within the required time frame. During an interview on 1/10/24 at 12:12 P.M., the Administrator said with allegation of abuse, a for your information (FYI) notification should have been called into the State Agency within the required time frame. MO00230006

Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed for the final accounting for residents who expired, within 30 days. This affected two residents who expired and had money in their accounts (Residents #301 and #302). The sample size was 15. The census was 43. Review of Resident #301's medical record, showed: -discharged on [DATE] and expired on [DATE]; -On [DATE], an ending balance of $4554.33; -No documentation of TPL completed. Review of Resident #302's medical record, showed: -discharged to the hospital on [DATE]; -On [DATE], an ending balance of $4194.75; -No documentation of TPL completed. During an interview on [DATE] at 11:59 A.M., the Business Office Manager (BOM) confirmed Resident #302 expired in September after he/she was sent to the hospital. The accounts for Resident #301 and #302 were locked so she could not access their money. TPL letters were not sent and should have been sent 30 days after the residents expired. 46888

Based on observation, interview and record review, the facility failed to administer care in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well- being of each resident. The facility initiated the transfer of residents to other facilities, particularly within their corporation, without appropriate notice, reason or discharge planning (Residents #6, #7, #8, #100, #101, #104). Residents who had been transferred did not have their personal belongings and/or medically necessary equipment (Residents #100, #104 and #101). According to staff, residents had been heavily recruited by the Administration of a sister-facility to move, and had not initiated a move on their own. According to staff, residents had been moved to a sister facility due to this facility closing. In addition, the residents were provided meals on Styrofoam because dietary staff said they have been instructed to pack up everything and send it to another facility. The census was 27. The Administrator was notified on 4/28/23 at 3:15 P.M. of an Immediate Jeopardy (IJ), which began on 4/24/23. The IJ was removed on 4/29/23 as confirmed by surveyor onsite verification. Review of the facility's Transfer and Discharge (Including AMA) Policy, revised 9/1/21, showed: -Resident initiated transfer defined as a situation in which the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility; -Facility initiated transfer defined as a situation in which transfer or discharge which the resident objects to, did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences; - The facility may initiate transfers or discharges in the following limited circumstances: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The resident's health has improved sufficiently so that the resident no longer needs the care and/or services of the facility; c. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident; d. The health of the individuals in the facility would otherwise be endangered; e. The resident has failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his or her stay at the facility; f. The facility ceases to operate; -For Anticipated Transfers or Discharges which the policy defines as initiated by the resident, the facility will ensure the following is documented: a. Obtain physicians' orders for transfer or discharge and instructions or precautions for ongoing care; b. A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results. ii. A final summary of the resident's status. iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). iv. A post discharge plan of care that is developed with the participation of the resident, and the resident's representative(s) which will assist the resident to adjust to his or her new living environment. Review of the facility's Admission/Discharge To/From Report, showed 12 resident discharges to Sister Facility A from 4/24/23 to 4/27/23. 1. Review of Resident #100's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/3/23, showed the following: -Cognitively intact; -Special treatments while resident: Oxygen therapy; -At risk for pressure ulcers (Injury to skin and underlying tissue resulting from prolonged pressure on the skin): Yes; -Pressuring reducing device used for bed: Yes; -Diagnoses included respiratory failure, anxiety and depression; -Regarding the question Do you want to talk about the possibility of leaving this facility and returning to live and receive services in the community: No. Review of the resident's care plan, last revised on 4/11/23 and in use during the survey, included: -Focus: Residents' Rights are guaranteed by the Federal 1987 Nursing Home Reform Law. The law requires Skilled Nursing Facilities to promote and protect the rights of each resident, placing emphasis on individual preferences, dignity, and self-determination; -Goal: Resident's autonomy and dignity will be honored in the personal choices that he/she makes; -Interventions: The resident has the right to Accept and/or Refuse any medication, treatment, recommendation, or services that are offered. The Resident has the right to make independent informed choices to include: Personal decisions. Request reasonable accommodation of needs and preferences. Participation in community activities. Management of own financial/personal affairs; -Focus: Resident wishes to stay here long-term; -Goal: Resident will continue to express satisfaction with living arrangements through the review period. -Interventions: Discuss with resident and/or family/guardian any concerns that the resident might have regarding current living arrangements. Discuss with resident and/or family/guardian any concerns that they might have regarding long-term placement. Evaluate discharge and long-term care goals quarterly and as needed. Provide community resources to resident and/or family/caregiver as needed/requested; -Focus: Resident has an activities of daily living (ADL) self-care performance deficit related to bilateral lower extremity amputee; -Intervention: Allow resident to participate in decision making in regards to meeting his/her personal care needs and ADL task; -Focus: Resident has the potential for pressure injury development related to immobility and history of pressure ulcers; -Goal: Resident will have intact skin, free of redness, blisters or discoloration; -Interventions: Educate the resident/family/caregivers as to causes of skin breakdown. Resident uses a low air loss mattress (LAL, a mattress designed to prevent and treat pressure wounds). LAL mattress in place with U rails (used for repositioning). Review of the resident's physician order sheet (POS), showed: -An order dated, 4/27/23, may transfer to sister facility with medication including narcotics; -No order for a LAL mattress; -No order for U rails. Review of the resident's progress notes, showed: -A Social Service note, dated 4/27/23 at 11:05 A.M., showed writer (Senior Clinical Liaison from the corporate office) spoke with resident/responsible party regarding choice of facility to transfer if he or she or family member chose to do so. Spoke with resident and verbalized understanding that he/she can freely stay at this facility or transfer to another facility of choice, other sister facilities. All assistance, including transfer of medications and personal belongings will be provided for a smooth transition. Resident verbalized understanding that he/she can reach out to the staff for questions or concerns that he/she may have after this meeting/conversation. Patient chose to move to Sister Facility A; -A note, dated 4/27/23 at 6:13 P.M., showed the resident was transferred to Sister Facility A by facility transportation. All of the resident's medications, medication list and face sheet went with the resident. The resident's belongings were sent as well. Report was given to accepting facility. Physician aware. Review of the resident's medical record, showed: -No documentation the resident initiated or requested to transfer or discharge to another facility; -No documentation the transfer or discharge was necessary for the resident's welfare the resident's needs could not be met in the facility, the resident's health had improved sufficiently so that the resident no longer needed the care and/or services of the facility, the safety of the individuals in the facility were endangered due to the clinical or behavioral status of the resident, the health of the individuals in the facility would otherwise be endangered, the resident had failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his/her stay at the facility or that the facility planned to cease operation; -No documentation of information about or referrals to other facilities provided to the resident; -No documentation of a post discharge plan of care that was developed with the participation of the resident, and the resident's representative(s) to assist the resident to adjust to his/her new living environment. During an interview on 4/28/23 at 6:33 A.M., Employee E said he/she witnessed Administrator H tell Resident #100 the facility was closing and the resident could move to Sister Facility A. The resident was concerned about therapy, and Administrator H said all the therapy staff would be moving to Sister Facility A. The resident said he/she needed a few days to think about it and talk to his/her family. Administrator H said the resident had a day to make the choice. There was going to be a barbeque and party at Sister Facility A on 4/28/23 and Administrator H didn't want the resident to miss it. The employee did not hear Administrator H give any other options. The employee did not hear the resident agree to move. The resident called his/her family member who left work to come to the facility to find out what was going on. During an interview with the resident and family member on 4/28/23 at 12:10 P.M., the family member said he/she had no clue how this all came to be. He/she called the facility on 4/27/23 and the person at the front desk said the resident was in therapy and then said the resident was moving to a different facility that day. The family member missed the last two hours of work because he/she had to go to the facility to figure out what was going on. When the family member arrived, there were boxes in the resident's room. At that point, no one had said where the resident was going. The resident moved that night to Sister Facility A. Upon arrival, the resident's room did not have an LAL mattress. The Senior Clinical Liaison said the LAL mattress would be delivered to Sister Facility A on 4/28/23, so the resident had to sleep on a regular mattress. The resident has had serious pressure ulcers in the past and the family member is very concerned about the resident's skin. The family member said the whole experience was shocking and very upsetting. The family member would've preferred the resident move somewhere closer to him/her. The family member had to take the day off work to help the resident adjust to the new facility. The resident started crying when asked if he/she wanted to move to Sister Facility A. The resident said he/she agreed to move because staff said they were all moving to Sister Facility A. This was not the resident's idea. Staff approached him/her about moving. During an interview on 5/1/23 at 11:47 A.M., the Director of Nursing (DON) said the resident never had an order for a LAL mattress. The family requested it, but there was never an order. The family was present when the resident's items were transported to Sister Facility A. During an interview on 4/28/23 at 2:38 P.M., Administrator H said Corporate Consultant C told her she needed to go to the facility because residents had questions about Sister Facility A. She did not know how the residents became curious about her facility. She was told to go and follow up with residents about questions. She talked to the resident who expressed interest in the sister facility. The resident said he/she wanted to move. Administrator H denied telling the resident he/she had to make a decision so they wouldn't miss the barbeque. Medical equipment should be in place when a resident moves in. Personal items should also accompany residents when they move in. Most of the residents who transferred to Sister Facility A got a bulk of their personal items the same day they moved in. She knew a LAL mattress was on order for the resident, but could not recall seeing one in the resident's room at Sister Facility A. 2. Review of Resident #104's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Moderate cognitive impairment; -No behaviors; -No wandering; -Diagnoses included: anxiety, depression, schizophrenia (a disorder that affects the way a person thinks, feels and behaves) and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after a terrifying event); -Regarding the question Do you want to talk about the possibility of leaving this facility and returning to live and receive services in the community: No. Review of the resident's care plan in the electronic medical record (EMR), showed: -Focus: Resident wishes to stay here long term, date initiated 5/22/22; -Interventions: Discuss with resident and/or family/guardian any concerns that the resident might have regarding current living arrangement; discuss with resident and/or family/guardian any concerns that they might have regarding long-term placement; encourage social interactions and participation in activities with others that have similar interests; -Focus: Residents' Rights are guaranteed by the Federal 1987 Nursing Home Reform Law. The law requires skilled nursing facilities to promote and protect the rights of each resident, placing emphasis on individual preferences, dignity, and self-determination, date initiated 5/22/22; -Goal: The resident's autonomy and dignity will be honored in the personal choices that they make; -Interventions: The resident has the right to accept and/or refuse any medication, treatment, recommendation, or services that are offered, the resident has the right to be fully informed of care and environment which included advance plans of a change in rooms/roommates; the resident has the right to be treated with consideration, respect, and dignity; -Focus: The resident has the potential to be physically aggressive related to anger, poor impulse control and striking out at another resident, date Initiated: 4/19/2023; -Interventions: Resident will be provided physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; give the resident as many choices as possible about care and activities; Resident was sent to the ER for a psych evaluation and returned with no new orders, on one-on-one supervision at this time, restarted on Depakote (seizure medication that can also treat certain psychiatric disorders); monitor/document/report as needed (PRN) any signs/symptoms of resident posing danger to self and others; psychiatric/psychogeriatric consult as indicated; when the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of the discharge progress note, dated 4/27/23 at 7:51 P.M., showed the resident was transferred to a sister facility by facility transportation. All of the resident's medications, medication list and face sheet went with the resident. The resident's belongings were sent as well. Report was given to accepting facility. Physician aware. Review of the social service note, dated 4/27/23, showed writer (Senior Clinical Liaison) spoke with resident/responsible party regarding choice of facility to transfer if he or she or family member chose to do so. Spoke with resident and verbalized understanding that he/she can freely stay at this facility or transfer to another facility of choice, other sister facilities. All assistance, including transfer of medications and personal belongings will be provided for a smooth transition. Resident verbalized understanding that he/she can reach out to the staff for questions or concerns that he/she may have after this meeting/conversation. Patient and power of attorney (POA) have chosen to go to a sister facility. Review of the resident's medical record, showed: -No documentation the resident initiated or requested to transfer or discharge to another facility; -No documentation of information about or referrals to other facilities provided to the resident; -No documentation of a post discharge plan of care that was developed with the participation of the resident, and the resident's representative(s) to assist the resident to adjust to his/her new living environment. During an interview on 4/28/23 at 12:15 P.M., the resident's POA said he/she has known the resident for [AGE] years and helps the resident with decisions. The facility contacts him/her when the resident has a change of condition. Someone from the facility called him/her on 4/27/23 and said they were moving the resident to another facility that day. The staff member said the resident needed more care and the facility did not have enough staff to care for the resident. The POA knew the resident had been involved in a recent altercation and wondered if it had something to do with that. The staff member did not give the POA an option of where to move the resident and just said that the resident would be moving to a sister facility. The staff member said they were packing up the resident's stuff and would transfer him/her on the bus. The resident is confused about the move and was in someone else's room this morning. They sent his/her TV but not the power cord, so the resident cannot watch TV. The POA thinks the resident would have preferred to stay at the original facility because he/she was comfortable there and knew where places like the dining room were located. During an interview on 4/28/23 at 2:30 P.M., Corporate Consultant C said she spoke with the resident's POA on 4/27/23. The resident needed more assistance and their sister facility has a memory care unit, so the resident could have more one-on-one care. She did not tell anyone, family/resident, they had to leave that day, but she did tell them they had transportation available that day. She told the POA there were other memory care units in the area, but did not provide anyone a list. 3. Review of Resident #101's quarterly MDS, dated [DATE], showed: -Cognitive skills for daily decision making: Independent, decisions consistent/reasonable; -Independent with most ADLs; -Diagnoses included heart failure, anxiety and depression. Review of the resident's care plan, last revised on 4/11/23, and in use during the survey, showed: -Focus: Residents' Rights are guaranteed by the Federal 1987 Nursing Home Reform Law. The law requires Skilled Nursing Facilities to promote and protect the rights of each resident, placing emphasis on individual preferences, dignity, and self-determination; -Goal: Resident's autonomy and dignity will be honored in the personal choices that he/she makes; -Interventions: The resident has the right to Accept and/or Refuse any medication, treatment, recommendation, or services that are offered. The Resident has the right to make independent informed choices to include: Personal decisions. Request reasonable accommodation of needs and preferences. Participation in community activities. Management of own financial/personal affairs. Review of the resident's medical record, showed: -A progress note, dated 4/14/23, showed the resident was sent to the hospital for evaluation and treatment. He/she was her own responsible party; -No documentation the resident initiated or requested to transfer or discharge to another facility; -No documentation the transfer or discharge was necessary for the resident's welfare the resident's needs could not be met in the facility, the resident's health had improved sufficiently so that the resident no longer needed the care and/or services of the facility, the safety of the individuals in the facility were endangered due to the clinical or behavioral status of the resident, the health of the individuals in the facility would otherwise be endangered, the resident had failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his/her stay at the facility or that the facility planned to cease operation; -No documentation of information about or referrals to other facilities provided to the resident; -No documentation of a post discharge plan of care that was developed with the participation of the resident, and the resident's representative(s) to assist the resident to adjust to his/her new living environment; -No documentation regarding the resident's belongings being transported to a new facility. During an interview on 4/28/23 at 10:07 A.M., the facility Social Services Director (SSD), said the resident went to the hospital and was now at Sister Facility A. She did not know how long the resident had been at the new facility because the resident transferred from the hospital. Observations of the resident's room on 4/28/23 at 9:23 A.M. and 5/1/23 at 9:33 A.M., showed the resident's closet contained clothing, a flat screen TV on his/her bedside table next to his/her bed and personal items on top of the night stand and personal items inside the drawers. Review of the resident's admission MDS, dated [DATE], showed an admitted [DATE] to Sister Facility A. During an interview on 5/1/23 at 11:47 A.M., the DON said the resident's items had been packed up and were in the front lobby waiting to be transported to Sister Facility A. She did not know when the resident was admitted to the new facility. 4. Review of Resident #6's medical record, showed: -The resident is his/her own representative; -Medical diagnoses included: Non-traumatic extradural hemorrhage (a collection of blood between the outer layer of the brain and inner skull), syncope (light headedness affecting consciousness) and collapse, and cognitive communication deficit; -A progress note on 4/24/23 at 1:26 P.M., from Social Services, stating the resident had been approached and given the choice to either stay at the facility or transfer to another facility of choice, including other sister facilities; -A progress note on 4/24/23 at 3:52 P.M., stating the resident had been transferred to Sister Facility A. Some of the resident's belongings were transferred at that time, with the rest of his/her belongings to be transferred over to the sister facility, over the course of the coming week; -No discharge notice found in the record; -No discharge summary found in the record. During an interview on 4/25/23 at 2:36 P.M., the resident said he/she was approached by a member of the corporate team on 4/24/23, asking him/her if he/she would like to transfer to another facility. At that time, the Administrator for Sister Facility A, Administrator H, was in the building and encouraged the resident to transfer to Sister Facility A, as they had a friendly relationship when Administrator H worked at the facility in the past. The resident said he/she decided to transfer to Sister Facility A, with his/her roommate for a change of scenery. The resident said he/she did not initiate the conversation regarding the transfer. 5. Review of Resident #8's medical record, showed: -The resident is his/her own responsible party; -Medical diagnoses included: Bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood), major depressive disorder, anxiety disorder, and unspecified hearing loss; -A progress note on 4/24/23 at 1:35 P.M., from Social Services, stating the resident had been approached and given the choice to either stay at the facility or transfer to another facility of choice, including other sister facilities; -A progress note from 4/24/23 at 3:49 P.M., stating the resident had been transferred to Sister Facility A with some of his/her belongings and all medications; -No discharge notice found in the record; -No discharge summary found in the record. During an interview on 4/25/23 at 2:36 P.M., the resident said he/she was approached by a member of the corporate team on 4/24/23, asking him/her if he/she would like to transfer to another facility. The resident decided to transfer to Sister Facility A because his/her roommate, Resident #6, was transferring there and the two had a great relationship while rooming together at the facility. 6. Review of Resident #7's medical record, showed: -The resident is not his/her own responsible party; -Medical diagnoses included: acute and chronic respiratory failure (failure of the lungs to properly oxygenate the organs), unspecified heart failure, congenital hydrocephalus (a neurological disorder caused by an abnormal buildup of cerebrospinal fluid in the cavities within the brain), and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). -A progress note on 4/24/23 at 1:27 P.M., from Social Services, stating the resident had been approached and given the choice to either stay at the facility or transfer to another facility of choice, including other sister facilities; -A progress note on 4/24/23 at 3:55 P.M., stating the resident had been transferred to Sister Facility A with all medications; -No discharge notice found in the record; -No discharge summary found in the record. During an interview on 4/25/23 at 2:34 P.M., the resident said he/she did not remember the origin of the conversation regarding his/her transfer, but decided to transfer to Sister Facility A for a change of scenery, and liked the outdoor space at the facility. The resident was unable to remember the name of the individual at the facility who offered him/her the choice to transfer to Sister Facility A. During an interview on 4/25/23 at 11:27 A.M., the individual designated in the medical record as the resident's responsible party said he/she had not been notified of the resident's transfer and was not consulted prior to the transfer occurring. He/She was not surprised, as communication from the facility regarding the resident is often sparse and infrequent. 7. Review of Resident #5's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Independent with all ADLs; -Diagnoses included high blood pressure, diabetes and depression. During an interview on 4/28/23 at 6:50 A.M., the resident said he/she and other residents feel hoodwinked. Administrator H had been coming to the facility to talk to residents about moving to her facility. The resident does not want to move. Corporate Consultant C told him/her last week he/she had the choice of moving to Sister Facility A or B. The resident had to decide in a week. Then Corporate Consultant C said the resident could stay as long as he/she wanted. Corporate Consultant C said the building will stay open, but moving residents will help fill beds for other sister facilities. This facility was under receivership and the corporation will no longer be able to operate the building. The resident thinks the corporation wants all the residents who complain to leave. The resident is very irritated with the corporation. It is very chaotic and everyone is upset. 8. During an interview on 4/28/23 at 6:27 A.M., Nurse H said he/she has heard the building was supposedly sold and then it wasn't. Staff were called last Thursday to choose a different location at sister facilities to work. He/she then came to work on 4/24/23 and residents were leaving. Residents have been given the choice of moving to a sister facility or they can stay. A timeframe for moving had not been given. During an interview on 4/28/23 at 6:33 A.M., Employee E said staff were told on 4/20/23 or 4/21/23 that staff were going to Sister Facility A and to carry on as is. The employees' payroll also switched to Sister Facility A with no explanation of what was really happening. He/she had heard the building was closing because of the budget, management and state. Administrator H from Sister Facility A started taking residents to her facility earlier in the week. Residents who could advocate for themselves could choose which sister facility they wanted to move to. Residents with dementia or who couldn't advocate for themselves went to Sister Facility A. It also seemed like insurance played a role. Residents who were on Medicare A or B went to Sister Facility A. Families and residents have asked the employees what was going on, but no one has any information to provide. During an interview on 4/28/23 at 7:25 A.M. Cook K said today was the last day for dietary staff. A new company was starting tomorrow, 4/29/23. Cook K and other dietary staff were going to Sister Facility A. During an interview on 4/28/23 at 8:45 A.M., Housekeeper I said he/she was told by the DON and Human Resources the building was being shut down on 4/28/23. Staff were given the option to stay or go to Sister Facility A. Residents were given the option to stay or go to a sister facility. He/she is going to start work at Sister Facility A on 5/1/23. During an interview on 4/28/23 at 9:32 A.M., the Director of Rehab (DOR) said she received a call last Thursday or Friday from the [NAME] President of Therapy. She was told staff were being redistributed and could move to Sister Facility A. An option to stay was not presented. She was then told on 4/27/23 the facility will continue to provide therapy as long as there were residents. There was confusion about what was happening with the building. Most residents who receive Medicare A have been moved to Sister Facility A. Residents have not requested to move because they wouldn't know to ask to move. It has been a very abrupt occurrence. Residents have not been given a choice. Administrator H has been at the facility and heavily recruiting residents to move to Sister Facility A. The DOR thought the building was closing, but as the week progressed, there had only been more confusion. During an interview on 4/28/23 at 10:07 A.M., the SSD said she had not been involved in any of the recent resident transfers to Sister Facility A. That was something the SSD would normally coordinate. Corporate staff were handling it and she had not been involved in any of those conversations. The option to transfer was presented by corporate staff. Residents and families seemed confused after being approached by corporate staff. She has seen the Senior Clinical Liaison's name, but doesn't know what she does within the company. She told anyone who had come to her with questions that they can stay there, move to a sister facility or to another facility. During an interview on 4/28/23 at 11:07 A.M., the Administrator said the building was leased and the company was trying to decide what to do with it. They would hopefully know today whether or not the company would keep the building. If the corporation kept the building, the plan was to get the census down to a size to allow construction to be done on halls not occupied by residents. Staff went around and informed residents and families that the options were to stay, transfer to a sister facility or to another facility. Staff were told they could stay or transfer. She had not been involved in telling residents what the options were. Corporate Consultant C and the Senior Clinical Liaison initiated these conversations with residents and families. The transfers that have occurred had not been initiated by residents; however, they signed a form stating they agreed to move. She was not aware Administrator H was coming in to speak to residents. That was not appropriate. It was also not appropriate for Administrator H to talk to residents about moving to her facility and giving a deadline to make a decision. The plan was to get the census down to prepare for further [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #2) was free from abuse when Certified Nurse Aide (CNA) E grabbed the resident's arm and threatened to break it which caused bruising to the resident's arm and caused him/her to be scared of the employee. The incident was witnessed by staff, who failed to report the abuse. CNA E finished working his/her shift and returned the next day, prior to the resident reporting the abuse and the facility beginning their investigation. The sample was five. The census was 41. The Administrator was notified on 4/5/23 at 1:22 P.M. of an Immediate Jeopardy (IJ) past-noncompliance which began on 1/25/23. The facility conducted an investigation and immediately in-serviced staff on 1/26/23 regarding abuse. The facility instituted corrective measures on 1/26/23 including termination of CNA E's employment with the facility. The IJ was corrected on 1/26/23. Review of the facility's Abuse, Neglect and Exploitation policy, revised 9/22/22, showed: -Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property; -Definitions: --Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology; --Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment; --Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation; -Policy Explanation and Compliance Guidelines: --The facility will develop and implement written policies and procedures that: --- Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; ---Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention; --The facility will provide ongoing oversight and supervision of staff to assure that its policies are implemented as written. Review of CNA E's time sheet, showed: -On 1/25/23, employee worked 9:45 A.M. to 6:42 P.M.; -On 1/26/23, employee worked 8:37 A.M. to 10:13 A.M. Review of Resident #2's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/13/22, showed: -Brief Interview for Mental Status (BIMS) score of nine out of a possible 15, showed the resident with moderate cognitive impairment; -Behavioral symptoms and rejection of care not exhibited; -Limited assistance of one person physical assist required for eating; -Upper extremity impairment on one side; -Diagnoses included stroke, hemiplegia (paralysis on one side of the body) or hemiparesis (weakness on one side of the body), generalized muscle weakness, need for assistance with personal care, altered mental status, and cognitive communication deficit. Review of the resident's BIMS evaluation, dated 1/26/23, showed a score of 15, which showed the resident cognitively intact. Review of the resident's care plan, in use at the time of survey showed: -Focus: Resident has an activities of daily living (ADL) self-care performance deficit with eating, toileting, transfers, bed mobility and dressing with one to two assist as needed; -No documentation indicating the resident exhibits behaviors or makes false accusations. Review of the facility's initial self-report, submitted to the Department of Health and Senior Services (DHSS) on 1/26/23, showed: -Reporting category: Abuse; -Date and time of alleged incident: 1/26/23 at 9:45 A.M; -Resident involved: Resident #2; -Staff involved: CNA E; -Summary: Certified Occupational Therapy Assistant (COTA) reported the following to the Administrator, DON, Assistant Director of Nurses (ADON), and Social Services Director (SSD). COTA was working with resident and remarked on a new bruise and scratch on the resident's upper right arm. When asked where it came from, the resident said in the dining hall, CNA E grabbed his/her arm and hit him/her in the forehead. Resident described the specific incident that occurred when CNA E grabbed his/her arm very tightly and twisted it while digging his/her nails in. Resident said he/she was fearful because CNA E told him/her, If you ever breathe a word to anyone, you're dead. The resident was afraid to report sooner because of the threat made by the employee. Review of COTA's statement, dated and submitted to DHSS on 1/26/23, showed on 1/26/23, the resident explained an incident occurred last night, 1/25/23, in the dining area at dinner. The resident states a person hit him/her on the forehead, grabbed his/her arm and twisted it, and dug his/her nails into the resident's arm. The person took the resident's food away and grabbed his/her stuffed animal dog and threatened to shred it. The bruise on the resident's right arm above the elbow is a darker red/purple color and there is a scratch. Review of the resident's progress notes showed: -Nurse's note, dated 1/26/23 at 10:24 A.M., in which Director of Nurses (DON) C documented physician notified of new bruises and skin tears. Wound nurse will conduct full body assessment; -Skin/wound note, dated 1/26/23 at 11:12 A.M., in which the Wound Care Nurse (WCN) documented a skin assessment was conducted. The resident had a new bruise to the inner portion of his/her right arm, 0.8 centimeters (cm) x 3.0 cm x 0 cm. The resident denied pain; -Nurse's note, dated 1/26/23 at 11:16 A.M., in which the WCN documented she spoke with the resident regarding the incident that occurred. The resident said he/she was fearful. The WCN assured the resident there was no need to feel fearful; that the person was no longer in the building. For comfort, the resident was given his/her stuffed dog. Observation on 4/5/23 at 9:45 A.M., showed the resident sat in a reclining chair with a stuffed toy dog underneath his/her left arm and shoulder. During an interview, the resident said a person was mean to him/her one time. The person threw his/her arms all around and threw his/her dog on the floor. The person grabbed his/her arm. The resident was unable to recall additional information specific to the incident. During an interview on 4/5/23 at 10:24 A.M., Housekeeper F said he/she was in the dining room during dinner when he/she saw CNA E sitting at a table with the resident. The resident said he/she wanted to eat and CNA E told the resident he/she had to wait. The resident asked for his/her juice and CNA E grabbed the resident's arm and said, If you reach for that juice again, I'm gonna break your arm. The resident tried to pull his/her arm back and looked at CNA E like he/she could not believe what just happened. The resident has some confusion, but he/she knows when something is wrong. Housekeeper F left the dining room, finished his/her work and left for the day. He/She did not report the incident to anyone, because he/she was stunned and shocked by what he/she saw. The next day, Administration asked about the incident and he/she provided a statement. If he/she could do the situation over again, he/she would have reported the incident to a supervisor when it happened. During an interview on 4/6/23 at 2:42 P.M., CNA G said a couple months ago, he/she observed an employee in the dining room, arguing with the resident. The resident was getting upset because he/she wanted his/her drink and the employee was holding it back. The resident does not eat much, but does like to drink. He/She has a stuffed toy dog and the employee kept taking it away from him/her. CNA G tried to tell the employee to stop. He/She did not report the incident that day. The ADON called CNA G about it the next day, and CNA G told the ADON what he/she saw. During an interview on 4/5/23 at 9:51 A.M., the COTA said while doing therapy with the resident in his/her room one morning, the COTA noticed a red bruise on the resident's upper right arm, approximately 2.0 inches (in) x 1.0 in, with a large red scratch within the bruise. The COTA asked the resident what happened, and he/she said in the dining room the night before, someone pushed his/her meal tray away and hit him/her in the forehead. The person twisted his/her arm and threatened to shred his/her toy dog. The person told the resident if he/she ever spoke of it, he/she would never see the light of day. The resident was very calm, but upset, when describing the incident. He/She described the incident in detail and was able to answer questions appropriately. Sometimes the resident has confusion, but overall, his/her memory was pretty good. The resident was able to remember things discussed in therapy weeks before. After the resident described the incident, the COTA reported it to the SSD and Administrator A (the previous Administrator of the facility). Administrator A, the COTA, the SSD, and the previous DON (DON C), met with the resident in the front office. The resident reported his/her account of what happened in the same exact way he/she did earlier. He/She was unable to recall the name of the person who twisted his/her arm, but provided a physical description that matched CNA E. During an interview on 4/5/23 at 10:37 A.M., the SSD said around 9:00 A.M. on 1/26/23, the COTA came to her office and reported the resident said someone grabbed his/her arm and hit him/her in the head. The person was mean to the resident's toy dog, took it away, and told the resident he/she could not have it back. The SSD observed a bruise and small cut on the resident's arm. The SSD reported the allegation to Administrator A. Administrator A, DON C, the ADON, the SSD, and the COTA interviewed the resident. The resident repeated the same exact story he/she gave to the COTA. The resident had some memory issues, but he/she repeated the same account of events, even when the same question was asked in a different way. The resident did not know the name of the person who grabbed him/her, but provided a physical description that matched CNA E. The resident was nervous about the employee finding out he/she told about what happened. The SSD interviewed other residents and Resident #5 said he/she witnessed the incident. Resident #5 was very cognitively intact. Review of Resident #5's quarterly MDS, dated [DATE], showed a BIMS score of 15, which showed the resident cognitively intact. During an interview on 4/5/23 at 10:54 A.M., Resident #5 said he/she could not recall the date or the name of the employee involved, but he/she saw an employee throw Resident #2's stuffed toy dog on the floor in the dining room. Resident #5 picked up the dog and handed it to Resident #2. The employee said no, Resident #2 could not have the dog, and put the dog back on the floor. What the employee did was cruel. During an interview on 4/5/23 at 11:13 A.M., the WCN said on 1/26/23, she was called to the SSD's office, where Administrative staff were sitting with Resident #2. The resident had already been interviewed and said someone hit him/her. The ADON asked the WCN to complete a skin assessment and they brought the resident to his/her room. During the skin assessment, the WCN observed about three bruises, approximately the size of dimes, on the inside of the resident's upper arm. The ADON asked the resident about what happened and the resident said someone hit him/her. He/She said something about his/her dog being dropped. The resident had a stuffed toy dog he/she uses as a pillow. The resident considers the dog as a friend. It would be antagonistic and abusive to threaten or take away the resident's dog. During the skin assessment, CNA E passed down the hall and stopped in the doorway to the resident's room. The resident said CNA E was the person who hit him/her. During an interview on 4/5/23 at 11:25 A.M., the ADON said she was present during Administration's interview with the resident on 1/26/23. The resident said at the table in the dining room, an employee bumped the resident in the head and scratched his/her arm. The employee took the resident's stuffed toy dog and threw it on the floor. The resident had a stuffed toy dog that the resident used as a pillow and considered as a friend. The resident had some confusion and his/her cognitive status fluctuated, but his/her story that day was consistent. The resident gave a physical description of the employee that matched CNA E. After the resident's interview, the ADON and the WCN took the resident to his/her room for a skin assessment. The ADON observed a scratch on the resident's upper arm. The resident had not had any recent falls. CNA E stopped at the resident's doorway and the ADON asked him/her if he/she had a snack for the resident. CNA E said no, he/she did not have anything for the resident because the resident hit him/her in the head. The resident said, No, you hit me and took my dog. The resident said CNA E was the person who hit him/her. The allegations made by the resident would be considered abuse. If staff witnessed a coworker being abusive, the ADON would have expected staff to immediately report the situation to the Administrator. An alleged perpetrator should be separated from the resident and suspended pending investigation in order to protect all residents from potential further abuse. During an interview on 4/6/23 at 8:21 A.M., CNA E said a couple months ago, he/she was feeding Resident #2 at dinner. The resident had use of one of his/her arms and not the other. The resident knocked CNA E's hand out of the way, causing CNA E to drop the spoon. The resident hit CNA E in the face, so CNA E grabbed the resident's arm and blocked it. CNA E denied withholding food from the resident, hitting the resident, threatening the resident, or taking the resident's stuffed toy dog. After dinner, CNA E continued working the rest of his/her shift and clocked out around 6:00 P.M. He/She worked for several hours the next morning before he/she was let go by the Administrator. During an interview on 4/6/23 at 12:02 P.M., DON C said on 1/26/23, the SSD made her and Administrator A aware of an allegation of abuse. They interviewed the resident, who said a person dug his/her nails into the resident's arm. DON C observed two small scratches on the resident's upper arm. During an interview on 4/6/23 at 1:25 P.M., Administrator A said she was the facility's Administrator at the time of the incident in January 2023. On the morning of 1/26/23, the COTA and the SSD notified her and DON C of an allegation of abuse. They interviewed the resident, who provided a vivid description of what occurred. The resident said an employee grabbed his/her arm and did something to his/her dog. He/She was fearful of the employee finding out he/she reported because the employee had threatened him/her. The resident's story was clear, consistent, and did not waiver. The resident can be confused at times and completely lucid at other times. The SSD completed a BIMS on the resident that day, which showed a score of 15. The resident had a scratch and bruise on his/her arm. He/She provided a detailed description of the employee, which matched the description of CNA E. While the ADON and the WCN completed a skin assessment on the resident, CNA E walked by the room and the resident pointed at him/her and said CNA E was the one who hit him/her. CNA E was suspended and provided a written statement about some form of incident with the resident. Based on the investigation, Administrator A substantiated the allegation of abuse. MO00213191

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) received care consistent with professional standards to prevent and treat pressure ulcers (a localized injury to skin and/or underlying tissue as a result of pressure or friction). This resulted in the resident's identified moisture associated skin damage (MASD, inflammation and erosion of the skin caused by prolonged exposure to moisture) skin to worsen and develop into an unstageable pressure ulcer (full-thickness pressure injuries in which the base covered by slough (yellow, stringy tissue) and/or eschar (black, dead tissue). The sample was four. The census was 50. Review of the facility's Pressure Injury Prevention and Management policy, dated 9/2021, showed: -Policy: The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries; -Explanation and compliance guidelines: -The facility will establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factor, monitoring the impact of the interventions and modifying the interventions as appropriate; -Assessment of pressure injury risk: -Licensed nurses will conduct a pressure injury risk assessment on all resident upon admission/readmission, weekly for four weeks, then monthly or whenever the resident's condition changes significantly; -Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly and after any newly identified pressure injury. Findings will be documented in the medical record; -Assessments of pressure injuries will be performed by a licensed nurse, and documented in the medical record. The staging of pressure injuries will be clearly identified to ensure correct coding; -Nursing assistants will inspect the skin during bathing and will report any concerns to the resident's nurse immediately after the task; -Interventions, prevention and to promote healing: -After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions; -Interventions will be based on specific factors identified in the risk assessment, skin assessment and any pressure injury assessment (moisture management, impaired mobility, nutritional deficit, staging and wound characteristics); -Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include: Redistribute pressure (such as repositioning, protecting and/or offloading heels). Minimize exposure to moisture and keep the skin clean, especially of fecal matter. Provide appropriate, pressure-redistributing support surfaces. Maintain or improve nutrition and hydration status, where feasible. Interventions will be documented in the care plan and communicated to the staff; -Monitoring: -The Registered Nurse (RN) unit manager, or designee will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing and compliance at least weekly and document a summary of findings in the medical record; -The physician will be notified of the presence of a new pressure injury upon identification, the progression towards healing/or lack of healing and any pressure injuries weekly and any complications as needed. Review of the facility's wound treatment policy, dated 9/1/21, showed: -Policy: to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with the current standards of practice and physician orders; -Explanation and compliance guidelines: -Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of the dressing change; -In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse; -Dressing changes may be provided outside the frequency parameters in certain situations such as feces seeped under the dressing, the dressing had dislodged and the dressing is soiled otherwise; -Dressings will be applied in accordance with manufacturer recommendations; -Treatments will be documented on the treatment administration record; -The effectiveness of treatments will be monitored through ongoing assessment of the wound. Review of Resident #1's hospital discharge summary, dated 1/27/22, showed: -Braden (a scale made up of six subscales, which measure elements of risk that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure) score on 1/18/23 of 6 (very high risk to develop pressure injury); -Braden score on 1/26/23 of 13 (high risk to develop pressure injury); -Inspect buttocks daily; -Skin: no obvious rashes. Review of the resident's re-admission Braden scale, dated 1/27/23, showed: -Sensory perception-ability to respond to meaningfully to pressure-related discomfort: blank; -Moisture-degree to which skin is exposed to moisture: blank; -Activity-degree of physical activity: blank; -Mobility-ability to change and control body position: blank; -Nutrition-usual food intake pattern: blank; -Friction and shear: blank; -Score: 30 (high risk). Review of the resident's medical record showed no admission skin assessment documented for the resident's January 27, 2023 admission. Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 2/2/23, showed: -readmitted [DATE]; -Severe cognitive impairment; -Total dependence for bed mobility, transfers, dressing, toilet use and personal hygiene; -Incontinent of bowel and bladder; -Diagnoses included: stroke, paralysis, seizures and traumatic brain injury; -At risk to develop pressure injury/ulcer; -No unhealed pressure injury/ulcer; -Had MASD; -Received pressure-reducing device for bed and chair; -Turning and repositioning program; -Nutritional/hydration interventions. Review of the resident's Braden scale, dated 1/30/23, showed: -Sensory perception-ability to respond to meaningfully to pressure-related discomfort: blank; -Moisture-degree to which skin is exposed to moisture: blank; -Activity-degree of physical activity: blank; -Mobility-ability to change and control body position: blank; -Nutrition-usual food intake pattern: blank; -Friction and shear: blank; -Score: 10- high risk. Review of the resident's January 2023 Treatment Administration Record (TAR) showed an order, dated 1/7/23, to apply barrier cream as needed to redness or excoriation, and/or after incontinent episodes. All days 1/27/23 through 1/31/23 left blank. Review of the resident's care plan, dated 2/2/23, showed: -Focus: The resident has a self-care performance deficit; -Goal: The resident will maintain the level of functioning; -Interventions included: Bed mobility- the resident is totally dependent on staff for turning and repositioning in bed. Skin inspection: the resident requires a skin inspection (frequency: blank). Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse; -Focus: The resident has a potential for skin impairment related to decreased mobility; -Goal: The resident will maintain clean and intact skin; -Interventions: Avoid scratching, encourage good nutrition and hydration, elevate heels, keep the skin clean and dry, monitor and report any signs of skin breakdown, provide pressure relieving devices, provide preventative skin care, and use caution during transfers and bed mobility. Review of the facility's wound report, dated 2/3/23, showed the resident not listed. Review of the resident's medical record showed no weekly skin assessment for the week of 1/30 - 2/3/2023. Review of the resident's progress notes, dated 2/6/23 at 12:52 P.M., showed the resident was noted to have a small 0.3 centimeter (cm) x 0.3 cm area to the right buttock. Staff had applied barrier ointment. The physician notified and a new order given for Solosite (used to create a moist environment for the treatment of minor conditions such as minor burns, superficial lacerations, cuts and abrasions and skin tears) paste to be applied. The area is MASD, with a red center and non-painful. A dressing applied. Family at bedside and aware. Review of the February TAR showed: -An order dated 2/6/23 for Solosite apply to the right buttock every day shift for wound care: -On 2/6/23 and 2/7/23: documented as incomplete; -On 2/11/23 and 2/12/23: documented as incomplete; -On 2/14/23: documented as incomplete Review of the resident's weekly skin check, dated 2/9/23, showed: -Site: right buttock; -Type: MASD and pressure; -Length: blank; -Width: blank; -Depth: blank; -Notes: Stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, may also present as an intact or open/ruptured blister). Review of the resident's February 2023 TAR, reviewed on 2/15/23, showed: -An order dated 1/7/23, to apply barrier cream as needed to redness or excoriation, and/or after incontinent episodes. All days 2/1/23 through 2/15/23 left blank; -A new order, dated 2/10/23, for Solosite wound gel. Apply to the right buttock topically every day shift. Cover wound with Allevyn (for drainage absorption and the management of partial to full-thickness wounds) foam dressing. Not documented as completed on 2/11/23, 2/12/23 and 2/14/23. During an interview on 2/15/23 at 7:50 A.M., the wound nurse said she had worked at the facility for five months. She was notified by the nurse or the aides of resident skin changes. If the wound was greater than a stage II, she would contact the family and obtain consent for the resident to be seen by the wound care physician. Each resident should have a weekly skin assessment, completed by the charge nurse. Incontinent and bed bound residents should be turned and repositioned frequently. During an interview on 2/15/23 at 8:30 A.M., the resident's family said the resident readmitted to the facility from the hospital. The staff provided total care for the resident. The family stayed with the resident daily for 10-12 hours during the day. The family had discovered the resident multiple times saturated with urine or feces in the morning. The family was considering being at the resident's bedside at times during the night to ensure changing and repositioning occurs. The resident had a small red area to the buttock with a small opening. No staff had asked for the resident to be seen by the wound physician. During an observation and interview on 2/15/23 at 12:26 P.M., Licensed Practical Nurse (LPN) H and Certified Medication Technician (CMT) I said the resident had an open wound to his/her tailbone area. The wound nurse had recently applied a dressing. The resident's family said he/she had not seen the wound and would like to look at the area. LPN H and CMT I assisted the resident onto his/her side and exposed the buttocks. The tailbone noted be covered with a white foam dressing. The dressing was undated and not initialed. A circular area of red and brown tinged drainage was visible on the outside dressing that had permeated through the dressing layers. LPN H removed the dressing and exposed the wound. CMT I said he/she did not know the wound looked that bad. The family member said the wound looked deep, red, and painful. He/she wanted to know why the wound had worsened from redness to a deeper wound. LPN H said the wound appeared to have approximately 25 % slough and a small area of necrotic tissue, and the wound was a stage III (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). CMT I said at approximately 6:45 A.M., he/she assisted staff to change the resident at the beginning of the shift, and the resident did not have a treatment in place at that time. The resident had been urine saturated. He/she had forgotten to notify the nurse the wound was uncovered. He/she assisted the wound nurse to cover the wound at approximately 12:20 P.M. Review of the resident's weekly skin check, dated 2/15/23 at 12:57 P.M., showed: -Site: Right buttock; -Type: Pressure; -Length: 2 cm -Width: 1 cm; -Depth: 0 cm; -Stage: unstageable; -Notes: yellow tissue and red peri-wound (wound edges). Wound changed since last assessment. Review of the resident's Braden scale, dated 2/15/23, showed: -Sensory perception: 4- no impairment, responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort; -Moisture: 3- occasionally moist, skin is occasionally moist, requiring an extra linen change approximately once a day; -Activity: 1-bedfast, confined to bed; -Mobility: 2- very limited, makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently; -Nutrition: 3- adequate, receives tube feeding; -Friction and shear: 1- problem, required moderate to maximum assistance with moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in the bed/chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction; -Score: 14-Moderate risk During an interview on 2/15/23 at 1:45 P.M., the wound nurse said the resident was noted to have MASD to the right buttock on 2/6/23. His/Her skin was not opened at that time and staff should have applied barrier cream. The resident was not added to the wound report for tracking at that time. She did not continue to assess the area after 2/6/23 and assumed the nurses and aide would notify her of changes. She was notified on 2/15/23 the wound appeared worse by an aide. She assessed the wound and applied a dry dressing and notified the physician for new orders. The wound was an unstageable pressure wound. She could not see the wound bed. The wound had worsened from 2/6/23. Blanks on the TAR would reflect a treatment was not completed. Incomplete treatments could worsen a wound. The resident should have been added to the wound report for tracking and assessments after 2/6/23. She often worked the floor, was unable to conduct weekly wound assessments and relied on the floor nurses to conduct those assessments. She would discuss with the family to add the resident to the wound physician weekly appointments. The wound nurse said the resident was not listed on the wound report. She was adding the resident due to the now unstageable pressure ulcer. During an interview on 2/15/23 at 2:01 P.M., Corporate Nurse B said the charge nurse was responsible to conduct weekly skin assessments. The assessment was documented in the medical record. Any changes in skin should be reported to the resident's physician, family and the facility wound nurse. A blank area on the TAR means the treatment was not completed. Incomplete treatments could result in worsening wounds. Wounds should reflect on the wound report. She had been unaware skin assessments were not being conducted as assumed the wound nurse or charge nurse had been completing them. MO00213917

Based on interview and record review, the facility failed to provide adequate supervision to prevent the elopement (leaving the premises or a safe area without authorization and/or any necessary supervision to do so) of three cognitively impaired residents (Resident #1, Resident #4 and Resident #7). Upon admission, Resident #1 was assessed as being at high risk for wandering and noted to have a history of wandering. While unsupervised, he/she eloped from the facility's secure unit, via an unlocked side door and patio gate, without staff knowledge, wandered away to a busy four lane intersection, and fell into a ditch incurring knee pain due to [MEDICATION(S)] trauma. The resident, who had Alzheimer's disease, was extremely confused and could not recall where he/she had come from or where he/she had attempted to go. Resident #4 was admitted with a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment, which showed he/she had a diagnosis of mental [CONDITION(S)] and required a sitter 24/7. He/She eloped from an otherwise unoccupied isolation hall via the fire exit door. Staff left him/her unsupervised a second time, failing to follow the administrator's instructions to place the resident on the facility's secure unit for the resident's safety, earlier in the evening after he/she opened the fire exit door and triggered the alarm. Resident #7 eloped after being left unsupervised on the facility's secure unit long enough to remove screws, which kept the window of another resident's room from opening higher than six inches. Police officers located the resident a day later, 24 miles away from the facility. After all three elopements, staff did not fully follow the facility's elopement policy. The census was 53. The administrator was notified on 04/16/21 at 1:15 P.M. and on 05/4/21 at 2:40 P.M. of an Immediate Jeopardy (IJ) which began on 4/13/21. The IJ was removed on 5/5/21, as confirmed by surveyor onsite verification. Review of the facility policy titled Elopements revised December 2007, showed direction for staff to investigate and report all cases of missing residents. Staff was to promptly report any resident who tried to leave the premises or was suspected of being missing to the charge nurse or Director of Nursing (DON). When a departing resident returned to the facility, the DON or charge nurse was to do the following: -Examine the resident for injuries; -Notify the attending physician; -Notify the resident's legal representative (sponsor) of the incident; -Complete and file a report of incident/accident; -Document the event in the resident's medical record. 1. Review of Resident #1's undated face sheet, showed the following: -admitted [DATE]; -Spouse listed as power of attorney; -Diagnoses including Alzheimer's disease with late onset, generalized anxiety disorder, ischemic [CONDITION(S)] (weakened heart muscles due to a heart attack/coronary heart disease), unspecified chronic obstructive pulmonary disease ([CONDITION(S)], group of progressive lung disorders characterized by increasing breathlessness) and unspecified chronic kidney disease. Review of the resident's admission assessment, dated 4/12/21, showed the following: -admitted from home; -Reason for admission, as per client or family/caregiver: family unable to cope with wandering behavior and activities of daily living (ADL) assistance any longer, spouse is elderly. Review of the resident's baseline care plan, dated 4/12/21, showed the following: -Cognitive impairment; -No mobility assistive devices; -Hospice/end of life care; -Shortness of breath/congestive heart failure/[CONDITION(S)]. Review of the resident's fall risk assessment, dated 4/12/21, showed a score of 14 (risk for falls). Review of the resident's wandering risk scale, dated 4/12/21, showed the following: -Score 14 (high risk to wander); -Can follow instructions; -Ambulatory; -History of wandering (past hospitalization or history from resident/family); -The resident wandered within the home. Review of the resident's brief interview for mental status (BIMS, brief screening tool of cognition), dated 4/13/21, showed a score of 7 out of a possible 15 (severe cognitive impairment). Review of the resident's wandering risk scale, dated 4/13/21, showed the following: -Score of 15 (high risk to wander); -Ambulatory; -Inability to follow instructions; -The resident has wandered aimlessly within the home or off the grounds. Review of the resident's progress notes, showed the following: -On 4/12/21 at 1:28 P.M., the resident came to the facility with his/her family present at 11:00 A.M. The resident was alert and oriented times two, could talk and answer questions appropriately at times. -On 4/12/21 at 2:19 P.M., staff documented the resident's family was preparing to leave, when he/she forced his/her way out of the (secure) hall and tried to follow his/her spouse. The resident did not want to let his/her spouse out of sight. Staff had to take the spouse down the hall a different way. The resident pushed the staff person down the hall, who attempted, unsuccessfully, to get the resident to listen and understand. The resident gave no indication of understanding. He/she attempted to follow his/her spouse out through the side door, which they held shut so that the resident could not push it. Staff directed the resident into the Alzheimer's hall. -On 4/13/21 at 3:57 P.M., staff documented the resident's spouse dropped off some belongings at the facility for the resident between 2:00 P.M. and 2:10 P.M. and left. Staff documented that at 2:20 P.M. a police officer saw the resident down the street sitting. After trying to get him/her to answer questions, he finally found out the resident's name. The officer called emergency medical services (EMS). The resident's spouse granted permission for him/her to return to the facility. A facility nurse performed a full assessment. Staff installed a new lock on the outer gate. At 4:26 P.M., staff documented the following vital signs: blood pressure 138/70 (normal range: 90/60 millimeters/Hg (millimeters of mercury), pulse 54 (normal range: 60-100 beats per minute), temperature 98.8 (normal range: 97.8-99.1 degrees Fahrenheit), respirations 18 (normal range: 12-18 breaths per minute), oxygen saturation 95% (normal range: 95%-100%) on room air. The resident's family and MD were informed. Review of the resident's police report, dated 4/13/21, showed the police department dispatch received a call for a welfare check on the street/highway/sidewalk/alley and dispatched an officer to the scene. While enroute, communications advised the officer of the resident's appearance, attire, that he/she was elderly and had fallen into the ditch alongside the road (which intersects with the facility's road). The officer arrived at a nearby intersection. Upon arrival, he observed the resident standing on the shoulder of the roadway. The officer made contact and attempted to ask his/her name. The resident continuously responded to the officer's questions by saying, no. The resident appeared to be extremely confused and did not comprehend the majority of the officer's questions. The resident also appeared to be struggling to balance while standing. After the officer asked several times, the resident said his/her name, but the officer could not get any further information and called for paramedics. When EMS arrived on the scene, the resident could not answer the paramedic's questions. The paramedic assisted the resident to climb into the ambulance and onto a stretcher. The resident recalled the street that he/she previously lived on and reported his/her birthdate (correct month and day, incorrect year). The officer asked dispatch to find Department of Revenue (DOR) information on the resident. Communications advised the officer of a home address at which an individual of the same name with a date of birth (with the same month and day, but [AGE] years older) resided. The officer looked up the information on the Regional Justice Information Service (REJIS) database and confirmed that the resident's DOR photo matched. While the officer was on the scene with paramedics, his sergeant responded to the nursing facility, to see if any residents had recently walked away from the facility. The administrator informed the sergeant that a resident was checked into the facility on the previous night by his/her spouse, who was his/her power of attorney (POA), for similar behavior. The administrator gave the sergeant the spouse's phone number and he called the spouse, who wanted the resident returned to the facility. The paramedics advised that the resident's vitals were fine, but recommended a psychiatric evaluation. The resident said no, to going to the hospital. The resident returned to the facility via ambulance. Review of the resident's EMS and fire protection ambulance run sheet, dated 4/13/21, showed dispatch was notified of a fall on the side of the road at 2:28 P.M. and paramedics arrived on the scene at 2:31 P.M. Their primary impression of the resident was that he/she had altered mental status. The resident was alert and oriented times one only to self. He/she could not tell the paramedics where he/she was headed or coming from. The resident could not tell them where he/she lived and had no forms of identification or a phone with him/her. They were informed that the resident was walking along the side of the road and fell into a ditch. He/she had a wet stain on the right knee of his/her pants. The resident reported that his/her right knee did hurt, but he/she was not able to describe the pain. The resident gave a possible address a few blocks away, but further investigation by the police officer determined that the resident did not live there. Due to [MEDICATION(S)] trauma to the right knee, he/she was experiencing knee pain. The resident's vital signs were as follows: blood pressure 153/75 (normal range: 90/60 mm/Hg (millimeters of mercury) to 120/80 mm/Hg), pulse 76 (normal range: 60-100 beats per minute), respiratory rate 16 (normal range: 12-18 breaths per minute), oxygen saturation 96% (normal range: 94%-99%), and temperature 98.2 degrees Fahrenheit (normal range: 97.8-99.1 degrees Fahrenheit). The resident was eventually able to provide enough information for the officer to ascertain that the resident was admitted to a facility on the previous day. The facility's administrator provided a phone number for the resident's POA, who was contacted and said the resident had Alzheimer's, was exhibiting normal behavior and that when the family dropped the resident off at the facility he/she became violent with the family and began to shove them, which the administrator said was abnormal behavior. The administrator and POA were both informed of the resident's behavior, pain in his/her leg and the paramedics' belief that the resident should be transported to the hospital. The POA requested the resident be returned to the facility and the administrator was all right with that decision. Review of the weather history for 4/13/21 at 1:51 P.M., showed the temperature was 61 degrees Fahrenheit. Review of MapQuest.com showed the police officer found the resident 0.4 miles from the facility. Observation on 4/20/21 at 11:55 A.M., showed the location in which the resident was found, was a busy, well-traveled four lane road, with a speed limit of 40 miles per hour. Review of the resident's progress notes on and after 4/13/21, showed no documentation of the resident's fall, knee pain, monitoring of the resident's injury or notification to the resident's physician of his/her knee pain. During an interview on 4/15/21 at 1:45 P.M., Certified Nurse Aide (CNA) B said during the day shift on 4/13/21, the only two staff assigned to the secured hall were CNA B and Nurse C. That day, the resident only took a few bites of breakfast and lunch. He/she did not talk but did not appear to be upset. The resident was wandering around the hall. Right after breakfast, he/she went to the keypad at the double doors leading to the rest of the facility and pushed some of the buttons. CNA B redirected the resident saying, don't do that. The resident shook his/her head. He/she did not appear to be trying to get out. CNA B had only been at the facility for two weeks, was newly placed on that hall and had not received any training or instructions on providing care to residents with Alzheimer's disease or dementia. CNA B was normally informed of any resident needs or issues during the change of shift report or by the charge nurse. CNA B did not work in the secured hall on the previous day. No one informed CNA B of the resident's attempt to force his/her way off of the hall. If CNA B had known that, then he/she would not have left the charge nurse alone on the hall. Sometime between 2:15 P.M. and 2:30 P.M., CNA B informed Nurse C that he/she was taking a break, went outside and sat in his/her car on the parking lot. He/she did not hear an alarm sound. At around 2:43 P.M., a police car pulled onto the parking lot. Ten minutes later, the Assistant Director of Nursing (ADON) came outside and said the resident had gotten out. CNA B did not see the resident leave the premises. CNA B returned to the hall and the maintenance director was working on the door. He said the alarm was functioning. When the resident returned to the facility, they placed him/her under 1:1 supervision. He/she kept going to the side exit door and other residents were following him/her. The resident eventually went through the door, picking up speed as he/she went out. He/she only had to push on the unlocked door. An alarm sounded, but no delayed egress mechanism was triggered. There needed to be two CNAs on the secured hall, if the resident was going to return. He/she ambulated very good. There were others on the hall who also walked well and would follow him/her. During an interview on 4/15/21 at 2:17 P.M. Nurse C said on 4/13/21, Nurse C and CNA B were the only two staff assigned to the secured hall during the day shift. No one had informed him/her of the resident's attempt to force his/her way off the hall during the previous evening. The night shift nurse reported the resident was a little aggressive and non-compliant during the night shift, but other than that had a good night. The resident was quietly sitting in the secured hall TV room, prior to the POA's visit. He/she was still quiet, after the POA left. At the time of the resident's elopement, CNA B was on a break. Nurse C last saw the resident before the POA departed from the facility. When the police came, the ADON approached Nurse C and asked if he/she knew the whereabouts of the resident. Nurse C said the resident was in the TV room and was informed the resident had eloped. No alarm sounded and there were no alarm lights flashing on the secured hall to alert Nurse C the resident had exited. When the resident returned and was placed under 1:1 supervision, whenever staff did not sit with the resident, he/she stood up, looking around and had to be redirected. Nurse C was attending to another resident, when Resident #1 went through the side exit a second time. Nurse C heard the alarm. CNA B was able to catch up to the resident and direct him/her back to the hall. There needed to be two CNAs on the memory care hall when Nurse C was busy, which happened a lot. During interviews on 4/14/21 at 11:10 A.M., 4/15/21 at 2:44 P.M., 4/16/21 at 11:25 A.M. and 3:15 P.M., the administrator said the resident eloped from the facility right after his/her spouse dropped off some of the resident's clothing and left. The resident was experiencing difficulty with transitioning from living at home. Elopement was part of his/her issue there as well. Although the resident was able to tell the police officer his/her first and last name, the resident thought it was 1976 and [NAME] was president. She was not informed of the resident's fall into a ditch or expressed knee pain. Upon his/her return to the facility, the resident was placed under 1:1 supervision for the first 24 hours and then on 15 minute checks. The resident received an order from Psychiatrist A to go to the hospital for a psychiatric evaluation, after the resident attempted to elope a second time. No one reported to her the resident got through the side door secure unit exit a second time. Nothing was documented in his/her medical record about that incident. The facility did not complete an investigation summary or obtain witness statements regarding the resident's elopement. Maintenance monitored the functionality of the door alarm on the secured hall side door twice a week. Normally, the door alarm was audible on the hall and a blue alarm light flashed outside of the hall. However, the alarm did not go off on 4/13/21, when the resident eloped. The alarm system malfunctioned. She did not see the blue light flashing, when the police arrived saying the resident was down the street and she went back to the secure unit. Residents could push the door open, because it never locked down. There was no 15 second delayed release. Due to residents on the hall who were high elopement risks, staff was initially instructed to check the door every 15 minutes and kept the door within their line-of-sight, until the facility began posting a staff person by the door. The patio gate only had a latching mechanism, so the facility placed a lock on it, after the resident eloped. The facility only had a day shift and a night shift. Staff used jot sheets to list resident behaviors. The facility did not have a policy specifying how often staff was expected to conduct rounds. The secure unit housed a total of 15 residents assessed as being elopement risks: five low risk, two at moderate risk, and eight who were at high risk for elopement. During an interview on 4/16/21 at 9:48 A.M., the resident's POA said the resident was not aggressive at home and did not engage in risky behaviors or wander off, but the POA had him/her admitted to the facility because he/she appeared to be sundowning (a state of confusion occurring in the late afternoon and spanning into the night. Sundowning can cause a variety of behaviors, such as confusion, anxiety, aggression or ignoring directions). During the day, there were no behavioral problems. At night, the resident tended to become watchful and increasingly anxious, wondering what was about to happen. His/her primary care physician was concerned for the POA's safety and felt the resident would be better taken care of via placement in a nursing facility. When the family took the resident to the facility, he/she wanted to leave with them. He/she was upset, because they had said, just stay a little while. The next day, the POA dropped some of the resident's things off at the facility. He/she stayed outside and handed them in to a staff person. The resident saw the POA's car and became agitated again. The resident was an engineer who was very high functioning. He/she followed the instructions on the sign (to hold the handle for 15 seconds) and walked out through an unlocked gate at the rear of the building. He/she almost escaped a second time. However, the facility did not call and inform the POA. The POA called and found out. During an interview on 4/16/21 at 10:35 A.M., Psychiatrist A said he/she met with the resident twice at the hospital. Psychiatrist A did not see him/her at the facility. The resident had severe dementia which was Alzheimer's. On a really good day, the resident might be alert and oriented times two (to person and place). Realistically, he/she was alert and oriented times one. The resident had nil and zero safety awareness. His/her aggressive behavior could pose a safety risk for other residents, that was why he/she was hospitalized . The resident was not aggressive in the hospital, just ungodly confused. It was appropriate for the facility to place the resident on the locked hall and monitor him/her. During an interview on 4/20/21 at 9:09 A.M., the ADON said the standard of care for resident supervision was every two hours. Staff kept residents who were on 1:1 supervision within line-of-sight and always within reach. Staff already knew the resident was exit seeking. Consequently, his/her care plan was not updated to reflect that behavior. After the resident's elopement, his/her care plan was revised to fit his/her needs at that date and time. 2. Review of Resident #4's PASRR assessment, dated 4/2/21, showed the following: -Diagnoses of anxiety, attention deficit, autistic disorder, depression, mental [CONDITION(S)], pneumonia, [CONDITION(S)] disorder and deficiency of malnutrition; -Behavioral information: minimum confusion, maximum supervision for safety, moderate behaviors controlled with medications; -Assessed needs: minimal mobility, physical assist times one, encouragement needed; maximum behavior/mental condition-sitter 24/7; uncooperative; has legal guardian; moderate assist with ADLs (bathing, grooming, bladder). -Potential problem areas: outburst; yelling; requires sitter 24/7. Review of the resident's undated face sheet, showed the following: -admitted [DATE]; -Parent as power of attorney; -Diagnoses including unspecified intellectual disabilities, autistic disorder, attention-deficit [CONDITION(S)] disorder predominantly inattentive type, anxiety disorder, major depressive disorder single episode. Review of the resident's baseline care plan, dated 4/14/21, showed the following: -Cognitive impairment; -Resident does not understand the staff; -Wheelchair mobility; -Required locomotion assistance. Review of the resident's progress note, dated 4/14/21 at 6:10 P.M., showed on 4/14/21 at or around 5:30 P.M., the resident arrived to the community via ambulance on a stretcher dressed in a hospital gown. Resident's parent met him/her at the community. Review of the resident's care plan, dated 4/15/21, showed the following: -Activities of daily living (ADL) self-care performance deficit related to fatigue; impaired balance; mental [CONDITION(S)] developmental disabilities (MRDD); and general weakness; -Resident is an elopement risk/wanderer related to disorientation to place, impaired safety awareness, new surroundings, and being MRDD; -Identify a pattern of wandering: is wandering purposeful, aimless or escapist? Intervene as appropriate. Review of the resident's wandering risk assessment, dated 4/15/21, showed a score of 11 (high risk to wander). Review of the resident's progress notes, showed the following: -4/15/21 at 1:12 P.M., the resident was alert and oriented times one to two and has clear, whiny speech. The resident does not form complete thoughts and sentences but does respond to simple questions. The resident does not follow commands. He/She must be watched 24/7, or else he/she will attempt to transfer into his/her wheelchair or bed. The resident's gait was unsteady and he/she was maximum assist of one for transfers. During an interview on 4/21/21 at 2:31 P.M., CNA E said on the night of 4/14/21, CNA E and Nurse F were getting report and putting eye on two aggressive residents on the secure unit who were not getting along with one another. A door alarm went off. CNA E did not know which door was alarming, because staff could not see the light over the south hall door from the end of the hall due to the fact that the door was set into the wall. Also, the light switched off when the door closed. So initially, staff did not know who they were looking for. CNA E was starting an outside perimeter search, when he/she encountered the west hall charge nurse, who said it was a false alarm because the charge nurse had set off the alarm while going out to put a padlock on the courtyard gate. CNA E went back inside and spoke with Charge Nurse F, who said CNA E was assigned to the resident. CNA E went down the hall and looked into the resident's room. It was empty. Staff were conducting a head count, when the resident's guardian knocked on the side entrance door sometime between between 8:15 P.M. and 8:30 P.M. saying the resident was outside. The resident was wearing a hospital gown and adult brief. Staff placed him/her on the locked hall. During an interview on 4/21/21 at 1:38 P.M., Nurse F said on 4/14/21, he/she arrived at the facility late. Shift change had occurred at 7:00 P.M. The day shift nurse was still there. At around 8:00 P.M., all of the night shift staff were at the nurse's station getting report, when a door alarm sounded. Everyone went running around the facility searching for an eloping resident. Within five minutes, they found the resident sitting outside in front of the facility. Staff had placed the resident on the isolation hall (which is on the south side of the building and not locked) earlier for a 14 day stay, because he/she was a new admission. The resident had just arrived one hour prior to the start of Nurse F's shift. No one informed him/her the resident was an elopement risk. Staff intended to send the resident to the hospital, but could not determine who his/her physician was, because the physician listed on the face sheet was no longer practicing medicine. Consequently, staff talked to Physician H about it and placed the resident on the secure unit instead. Nurse F did not document the incident, because he/she wound up working on the West hall that night. During an interview on 4/26/21 at 2:45 P.M., Nurse D said approximately 30 minutes prior to Resident #4's elopement at 8:27 P.M. on 4/14/21 Resident #7 banged on the secure unit doors from the inside. Nurse D stepped onto the secure hall, to see what the resident wanted. Resident #7 complained that another resident would not get out of his/her room. Nurse D got the resident to come out of Resident #7's room. As Nurse D was coming out of the secure unit, he/she saw Resident #4 standing at the entrance to the isolation hall and told Resident #4 to return to his/her room because you're on quarantine. Resident #4 said, no I wanna walk. Nurse D walked with the resident briefly and then escorted the resident back to his/her room. Nurse D returned to the nurse's station, started searching for a pen, got one from the nearby medication cart and returned to the nurse's station. As he/she sat back down, a door alarm sounded. Staff started searching the building. Nurse D walked down the isolation hall and while passing the fire exit door, he/she looked through the window in the door and saw the resident sit down on the grass and told the resident to come back inside. The resident refused saying, no I wanna feel the breeze. Nurse D did not push the resident. The resident's guardian pulled onto the parking lot, got out of the car carrying fast food for the resident and asked, what's going on? Nurse D informed him/her the resident would not get up. The guardian was holding a walking cane, with which the resident attempted pull him/herself up. Nurse D stopped the resident, saying that he/she would get a wheelchair and then discovered that the side door had locked behind them. Nurse D knocked on the door. When a staff person opened it, Nurse D propped the door open, retrieved a wheelchair and another staff person assisted Nurse D to transfer the resident into the wheelchair. Nurse D called the nurse manager, said the resident had eloped and they wanted to send the resident out. The nurse manager said to move the resident to the secure unit instead. When asked if he/she had assessed the resident, Nurse D said yes and that he/she did not recall the resident saying his/her ankle hurt or setting off the fire exit door alarm more than one time that night. Nurse F said he/she would document the incident and assessment. During an interview on 4/20/21 at 3:30 P.M., the resident said on the night he/she walked out of the facility alone, he/she just wanted to take a walk and get some fresh air. The resident twisted his/her ankle and fell , when a staff person pushed him/her from behind. He/she did not know the staff person's name and could not describe what the person looked like. The resident told staff his/her ankle hurt. During an interview on 4/20/21 at 9:35 A.M., the resident's guardian said at 8:00 P.M. on 4/14/21, he/she found the resident outside lying on the ground in the front yard of the facility with a staff person. It was cold outside and the resident was only wearing an adult brief and gown. The guardian was concerned, because although the resident was [AGE] years old, he/she was developmentally disabled with the mindset of a five or six year old and the door alarm was not working. Review of the resident's progress notes, showed no documentation of the resident's elopement, subsequent fall or any physical assessment conducted, no vital signs obtained by staff, and no notification provided to Physician H, nursing supervisory staff or the administrator. Review of the weather history for 4/14/21 at 7:51 P.M., showed the temperature was 56 degrees Fahrenheit. Review of the resident's progress notes, dated 5/2/21 at 11:26 A.M., showed a CNA found the resident's left foot was swollen and bruised. The nurse palpated the area and the resident said it hurt a bit. The resident also had an abrasion to the right lower extremity above the ankle. During interviews on 4/16/21 at 2:45 P.M. and 4/26/21 at 11:35 A.M., the administrator said she was present when the resident arrived at the facility on 4/14/21 and when staff reported that the resident opened the fire exit door on the isolation hall and set off the alarm. The resident was not placed on 1:1 supervision. The administrator was under the impression the resident did not ambulate. The administrator did instruct them to move the resident onto the locked hall for his/her safety, until he/she could be re-evaluated. That occurred before 5:00 P.M. Staff did not report to her the resident went outside unsupervised that night. They should have notified the resident's physician, her and the DON or on call person of the resident getting out of the building unsupervised later that night. She was unaware that occurred, until informed by the surveyor. Although staff was told, the door alarm was a false alarm they should have and did conduct a head count. Staff should have completed an incident report. Nurse D failed to complete an incident report. The nurse should have completed and documented a head-to-toe physical assessment of the resident, neurochecks and took his/her vital signs, after finding the resident outside on the ground. If it was not documented, then it did not occur. During an interview on 4/16/21 at 2:20 P.M., the DON said staff did not perform a wandering risk assessment on the resident on 4/14/21. She did one on 4/15/21 (the score was 11, indicating a high risk to wander). During an interview on 5/13/21 at 2:12 P.M., Physician H said the first mention of the resident falling and/or experiencing ankle pain was on 5/2/21. He/she ordered x-rays which showed the resident had a sprained ankle. Physician H expected to be notified of the resident's fall on 4/14/21. The nurse was supposed to document the incident, what time it occurred, the type of fall, physical assessment findings and the resident's vital signs. He/she only saw the resident twice. The resident was able to answer questions and appeared to be mentally stable. The resident had a mental age of a five or six year old and consequently required staff supervision of his/her daily activities. 3. Review of Resident #7's level one nursing facility PASRR assessment, dated 1/6/21, showed the following: -Legal guardian; -Resident was oriented to person and place, alert with a fair memory; -Diagnoses including [CONDITION(S)], [CONDITION(S)] (a serious mental illness that affects how a person thinks, feels and behaves), malnutrition and [MEDICATION(S)] dependence; -Behavioral information: moderate confusion and suspicion, maximum wandering, maximum supervision for safety, maximum control with medication; -Potential problem areas: resident

Based on interview and record review, the facility failed to maintain appropriate staffing levels, in order to provide adequate resident supervision and care. During the night shift of 4/28/21, the facility was staffed with two certified nurse aides (CNAs), one staffing agency nurse and one certified medication technician (CMT), to supervise and provide care to 53 residents. Resident #12 required 1:1 supervision for disruptive behaviors which included repeatedly entering other resident rooms, climbing into their beds and becoming combative with redirection. There were periods during which the secured unit (which housed residents with cognitive impairment and some with risk for elopement) was unsupervised. As a result, staff did not discover that one cognitively impaired resident (Resident #7) eloped, by removing screws from a window in another resident's room and leaving it open, until the next morning. In addition, two residents fell (Resident #8 and Resident #12). Staff failed to fully follow the facility's significant change policy and document assessments and vital signs as well as notification of the residents' families. The facility housed three residents who experienced changes in condition, in addition to four residents with continuous tube feedings, one of whom also had a [CONDITION(S)] (surgically created incision through the neck into the trachea (windpipe) made to allow direct access to the breathing tube) which required care. The census was 53. The administrator was notified on 5/4/21 at 2:40 P.M. of an Immediate Jeopardy (IJ) which began on 4/29/21. The IJ was removed on 5/5/21, as confirmed by surveyor onsite verification. Review of the undated policy, entitled Significant Change in Condition Policy and Procedure, showed a list of what indicated a change in condition which included changes in cognition, incidents involving the resident (i.e. falls, loss of consciousness, lowered to the floor, resident-to-resident altercations, etc.), alteration in gait/ambulation/transfers, changes in pain level, and changes in vital signs. Staff was to conduct a complete assessment, document vital signs as well as notification of physician, family and any other providers included in treating the condition being identified. According to the Administrator, the facility does not have a staffing policy. 1. Review of the facility's undated tube feeding list, showed four residents were receiving tube feedings and one of those residents had a [CONDITION(S)]. Review of the facility's undated mechanical transfer list, showed the following residents required two person Hoyer lift (mechanical) transfers: -300 Hall: three residents; -400 Hall: three residents; -700 Hall: five residents. Review of the facility's undated two person transfer assist list, showed one resident on the 300 Hall and one resident on the 700 Hall required two person transfer assistance. Review of the facility's undated one person transfer assist list showed the following: -300 Hall: six residents; -400 Hall: one resident; -500 Hall: one resident; -700 Hall: four residents (one of those residents required 1-2 person assistance); -800 Hall: one resident. Review of employee electronic timesheets, dated 4/28/21, showed the following: -CNA E worked from 3:17 P.M. to 8:55 A.M.; -CNA G worked from 3:24 P.M. to 8:38 A.M.; -CMT J worked from 6:36 P.M. to 8:16 A.M. Nurse I was employed by a temporary staffing agency and consequently had no facility timesheet. 2. Review of Resident #12's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/1/21, showed the following: -Short-term memory problems; -Signs and symptoms of delirium: fluctuating inattention and disorganized thinking; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required supervision of eating; -Required limited assistance with bathing, personal hygiene and toilet use; -No mobility device; -No falls since admission and prior assessment. Review of the resident's baseline care plan, dated 4/27/21, showed the following: -Cognitive impairment; -Independent ambulation; -No mobility assistive devices; -Up ad lib (as desired) with steady gait; -Medical treatment via anti-psychotics/psychotropics. Review of the resident's progress note, dated 4/29/21 at 4:30 A.M., showed the resident paced the floor all night, in and out of other resident rooms, gait unsteady, resident running up and down hallway, leaned forward and fell on to the floor. The fall was witnessed. The resident had no head injury or complaint of pain. The nurse did not note any skin alterations. The resident resumed pacing the floor. Nursing applied his/her tennis shoes. Further review of the resident's only progress note, showed no documentation of notification provided to the resident's physician or family. Vital signs were not documented. 3. Review of Resident #7's Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment, dated 1/6/21, showed the following: -Legal guardian; -Resident was oriented to person and place, alert with a fair memory; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Behavioral information: moderate confusion and suspicion, maximum wandering, maximum supervision for safety, maximum control with medication; -Potential problem areas: resident eloped twice from his/her group home and would benefit from placement in a locked skilled nursing facility for his/her own safety; -Assessed needs: independent mobility with supervision, elopement precautions needed due to two recent elopements, supervised activities of daily living (ADLs), [CONDITION(S)] controlled with medications and dependence on assistance with medications. Review of the resident's undated face sheet, showed an admitted [DATE]. Review of the resident's elopement assessment, dated 1/6/21, showed the resident was at risk for elopement. The preventative interventions put in place by staff were moving the resident to a secure unit and providing frequent visual monitoring. Review of the resident's progress note, dated 3/31/21 at 6:27 P.M., showed the resident was becoming agitated and exit-seeking. He/she was argumentative and aggressive with staff. Staff attempted redirection twice which was temporarily effective. The resident's agitation was increasing. Staff placed a call to Psychiatrist A, who ordered [MEDICATION(S)] (anti-anxiety medication) 0.5 milligram every six hours as needed for anxiety for 14 days. Review of the resident's wandering risk scale, dated 4/13/21, showed a score of 11 (high risk). Review of the resident's care plan, updated 4/14/21, showed the following: -Resident has a behavior problem; -Resident is an elopement risk/wanderer related to disorientation to place and impaired safety awareness; -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or book; -Identify pattern of wandering: Is wandering purposeful, aimless or escapist? Is resident looking for something? Does it indicate the need for more exercise: Intervene as appropriate. Review of the resident's police report, dated 4/29/21, showed staff reported discovery that the resident was missing from the secure unit at approximately 7:25 A.M. The window in his/her room was partially open and the screen was pushed out. Some of the resident's belongings were on the ground below the window. Staff also located a backpack containing more of the resident's belongings. There was an open window in the room across the hall from the resident's assigned room. The window was all of the way up and the screen was pushed out. Staff initiated a search, in an attempt to find the resident and concluded that the resident had left the faciity on foot. Review of the progress notes, showed no documentation of the resident's elopement on 4/29/21. 4. Review of Resident #8's care plan, updated 3/17/21, showed the resident had an ADL self-care deficit and required total assistance of two staff members using a mechanical lift for transfers. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Weight: 192 pounds, height 72 tall; -Long and short-term memory problems; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Total dependence on one staff member for locomotion, eating, personal hygiene and bathing; -Total dependence on two or more staff for bed mobility, transfers, dressing and toilet use; -Always incontinent of bowel and bladder; -[MEDICATION(S)]/intravenous feeding and feeding tube; -No fall since admission or prior assessment. Review of the resident's fall assessment, dated 4/29/21, showed the following: -A score of 22 (risk for falls); -Confined to chair; -During the last 90 days, the resident had three or more falls; -Moderately impaired vision: limited vision, but can identify objects. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -1/13/21, turn every two hours; -1/13/21, change [CONDITION(S)] collar sponge daily and as needed (PRN); -1/13/21, [MEDICATION(S)] 100 halls (U)/milliliters (ml) inject subcutaneously every 6 hours per sliding scale; -1/13/21, [MEDICATION(S)] injection (insulin) 100 ml, inject 20 halls Sub-Q twice daily for diabetes mellitus; -1/13/21, Glucose meter check and record every 6 hours; -1/13/21, Glucerna (tube feeding) 85 cubic centimeters (CC) per hour off at 12:00 A.M. on at 4:00 A.M.; -1/13/21, check residual each shift; -1/16/21, flush gastrostomy tube (g-tube, a feeding tube surgically inserted into the abdomen via small incision which delivers nutrition, hydration and medication administration directly to the stomach) with 200 ml of water every 4 hours; -1/13/21, change g-tube dressing daily and as needed (PRN); -1/31/21, pain assessment every shift. Review of the resident's progress notes, showed the following: -4/18/21 at 2:36 A.M., CNA found the resident on the floor at 1:45 A.M., lying sideways on his/her right side. Range of motion and neuro checks were within normal limits (WNL) to resident's baseline. No injuries found. Vital signs were WNL to the resident's baseline: blood pressure (BP) 129/82 (normal range: 90/60 mm/Hg (millimeters of mercury)/120/80 mm/Hg, temperature (T) 97.7 (normal range: 97.8-99.1 degrees Fahrenheit (F), pulse 91 (normal range: 60-100 beats per minute), respiration (R) 19 (normal range: 12-18 breaths per minute) even and unlabored; -4/27/21 11:04 A.M., a nurse was walking by the resident's room and saw him/her lying on his/her left side on the floor at 10:20 A.M. A skin assessment showed no bruising, redness, open area, swelling or signs or symptoms of limb shortening. When instructed to, the resident could lift his/her limbs. Vital signs: 98.5, 144/84, 96% (oxygen saturation normal range: 95%-100%) on room air; -4/29/21 at 6:00 A.M., staff observed the resident on the floor in a supine position (facing upwards), no skin alterations noted, neuro checks WNL. Staff notified the resident's physician of the incident and did not receive any new orders. Further review of the resident's progress notes, showed staff did not document vital signs or notification of the resident's family member after his/her fall on 4/29/21. 5. During an interview on 4/30/21 at 2:00 P.M., CNA G said he/she was on duty from 3:24 P.M. on 4/28/21 until 8:38 A.M. on 4/29/21. There was one other CNA, a charge nurse and a CMT providing care for the entire building during the night shift. CNA G arrived and started his/her shift between 3:00 P.M. and 3:30 P.M. He/she checked the West hall and noted several activated call lights. So, CNA G provided assistance to residents on that hall, before beginning rounds on the rest of the building. He/she finished conducting rounds on the West hall at 4:40 P.M., then started conducting rounds on the South hall with CNA E and finished at 5:40 P.M. and returned to the secure unit before 6:00 P.M. Resident #12 was housed on the secure unit and put a curve ball in everything. That resident was a menace. He/she repeatedly went into the rooms of residents of the opposite sex, climbed into their empty beds, would not listen to CNA G's attempts to redirect and became combative when separated from the other residents. CNA G spent all of his/her time on the secure unit keeping Resident #12 out of residents' rooms. Because of that wandering resident, CNA G had lost control of the secure unit. Approximately 17 hours into his/her shift, they discovered that Resident #7 was missing. CNA G was frustrated, because there was only so much he/she could do when there was only one other CNA helping him/her care for over 40 residents. During an interview on 5/3/21 at 1:46 P.M., CNA E said on the night of 4/28/21, the facility was severely understaffed. There were only two CNAs in the whole building. Normally, each CNA was assigned to around 10 to 12 residents. At the beginning of CNA E's shift, he/she got report and began checking on the residents, to make sure everyone was in bed and dry. CNA E conducted walking rounds every 30 to 45 minutes in different halls, spending 10-15 minutes in each room. More time was spent with residents requiring peri care and/or transfer assistance for toileting. Some residents were heavy wetters, which required them to be changed more frequently. He/she never stopped moving. The residents required general care, [CONDITION(S)] care and feeding tubes which had to be monitored. At one point, a resident on the South hall fell and both CNAs had to help Nurse I get that resident up off of the floor. There were a lot of issues on the locked hall. It was hectic trying to supervise all of the residents on the secure unit who were at risk for elopement. Resident #12 was agitated and paced for hours, going into the rooms of residents of the opposite sex, which agitated those residents. At one point, CNA E could see Resident #12 was so agitated that he/she was going to fall. CNA E had to leave the hall, in order to alert the charge nurse. On the way out, CNA E turned and saw the resident fall. After falling, Resident #12 continued trying to get up. Consequently, CNA E stayed in his/her room holding the resident, rubbing his/her back and rocking him/her to sleep. Resident #7 became very agitated and was so uncomfortable with the resident's behavior to the point that Resident #7 said, I'm not sleeping here. It was clear the resident had already planned to elope, but may not have known at what moment he/she would do it. The events of that night might have pushed Resident #7 over the limit. CNA E last saw the resident at 9:30 P.M. CNA E and CNA G were rotating through the hall. The next rotation onto that hall for CNA E was when it was time to get residents up the next morning. Between 6:00 A.M. and 6:23 A.M., CNA E entered the resident's room, to get his/her roommate up and noticed that Resident #7 was not in bed or in the bathroom. Normally, he/she slept until staff got him/her up. The resident was very street savvy and manipulative. When he/she had first arrived at the facility, he/she watched staff to see how they did things, asked for the address of the facility and what area it was in. During an interview on 4/30/21 at 2:30 P.M., Nurse I said during the night shift on 4/28/21, he/she was the only nurse on duty for the entire building. He/she had a charge CMT working one floor (West), but Nurse I still had to supervise the West hall, secure unit, rehab and long term care units. There was a lot going on throughout his/her shift and the Charge CMT was not qualified to assess residents. On the West hall, two residents in the same room began exhibiting altered mental status; increased confusion and difficulty speaking as well as disorientation. They were alert two days prior, so Nurse I put in orders for labs. On the same hall, at the other end, Nurse I assessed a resident who began complaining of abdominal pain. Nurse I also had to attend to two residents with feeding tubes, one of whom also had a [CONDITION(S)] which required care. On the secure unit, Resident #12 kept going in and out of other residents' rooms, so Nurse I had to go and supervise that resident so the only two CNAs providing care to all of the residents in the facility could conduct rounds. There needed to be staff specifically assigned to the secure unit, because two CNAs could not keep a close eye on those residents, when they were the only CNAs for the entire building and working multiple halls. Resident #12's gait became weak at 3:00 A.M. He/she fell and Nurse I assessed him/her. A resident on the South hall fell and it took both CNAs and Nurse I to get him/her up off of the floor. Nurse I had to assess that resident. Nurse I said, it was really chaotic that night. He/she expressed the belief that Resident #7 might have been able to observe that and took advantage of the situation to elope. That resident's elopement was an example of why there needed to be staff assigned to the secure unit. Staff never knew what could be happening on the side of the building opposite from the hall on which they were working. The day shift nurse arrived at 6:00 A.M. and started assisting the CNAs with rounds, because there were residents who had to leave by 7:00 A.M. for medical appointments. During an interview on 5/3/21 at 10:48 A.M., CMT J said during the night shift of 4/28/21, he/she was the Charge CMT for the West hall only, which consisted of passing medications, performing glucometer checks and meeting the residents' care needs. Nurse I passed medications to the rest of the residents. A lot was going on in the South hall. CMT J talked to CNA G about staying over there: one resident fell and both CNAs had to assist the nurse to get him/her off of the floor, one resident kept attempting to stand unassisted and another was always trying to climb out of bed. Both CNAs had to supervise residents on the secure unit. CNA G assisted CMT J with rounds on the West hall and then periodically checked on CMT J. CNA G provided assistance, when he/she noticed that CMT J had stepped away for a break or was in a resident's room providing care. From time to time, CNA E would come over to the West hall and ask if CMT J needed assistance. At around 7:00 A.M., CMT J heard that Resident #7 was missing. There was supposed to be at least three CNAs working the night shift. During interviews on 4/16/21 at 11:25 A.M., 4/26/21 at 3:01 P.M. and 5/6/21 at 10:16 A.M., the administrator said the secure unit housed a total of 15 resident assessed as being elopement risks: five low risk, two at moderate risk, and eight who were at high risk for elopement. Facility staffing levels were determined by fire code, level of care and number of residents in-house. The night shift was typically staffed by a nurse, charge CMT and two CNAs. The CMT assisted the nurse in the South hall. There was always at least four staff assigned to the night shift. Staff was expected to contact the staffing coordinator or on-call supervisory nurse and report any staffing issues. Resident nursing assessments should be documented. If it was not documented, then it did not occur. No incident reports were documented for the falls of Resident #8 or Resident #12, which occurred on 4/29/21. 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, it was determined the facility had implemented corrective action to address and lower the violation at that time. A revisit/final revisit will be conducted to determine if the facility is in substantial compliance with the 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 198.0261 RSMo) requiring that prompt remedial action be taken to address Class I violation(s). MO 683