Every finding on record at Maple Lawn Nursing Home

Based on observation, interview and record review, the facility failed to ensure staff provided adequate nutrition, monitored consumption, monitored or identify weight loss, completed assessments or notified the resident's provider or dietitian of weight loss, and did not evaluate the resident's care plan or initiate interventions to prevent further weight loss for one resident (Resident #14) in a sample of 17 residents. Review of the resident's weight records showed the resident lost 21.8 lbs. since 06/04/25, which was an 11.86 percent (%) weight loss in six months. The resident lost 15.2 lbs. since 10/01/25 (no weight for November documented) which was an 8.5% weight loss in two months. The resident experience significant weight loss with no staff identification, evaluation, notification, or intervention. The facility census was 59. Review of the facility's policy Documentation for weights, undated, showed:-Upon admission all residents will have their weight obtained and recorded in their medical record for four weeks if not otherwise ordered;-If not ordered per physician differently the resident will have their weight obtained and documented prior to the 7th of each month;-Some residents may have daily or weekly weights ordered per physician or due to weight loss;-These weights should be obtained prior to breakfast using the same scale each time;-The charge nurse will be responsible to make sure the weight is done;-Document in progress notes any weight changes, notification of Dr, any new orders received and notification of family;-The information will be faxed to the attending physician on a monthly basis after the weight committee has met and given any recommendations for change in plan of care. Review of the undated facility policy, Nutrition and Hydration, showed the following:-The facility will ensure that all residents receive adequate nutrition and hydration to maintain the highest practicable physical, mental, and psychosocial well-being;The facility will provide a nutritionally adequate diet, appropriate hydration, and necessary assistance based on each resident's assessed needs, preferences, cultural considerations, and clinical condition;-Nutrition and hydration services are resident centered, interdisciplinary and continuously evaluated;-Definition of adequate nutrition: Intake sufficient to meet assessed caloric, protein, vitamin and mineral needs;-Definition of clinically significant weight loss: Unplanned weight loss per facility parameters and clinical judgment;-Definition of therapeutic diet: Diet ordered by a practitioner to treat or manage a medical condition;1. Assessment-Nutrition and hydration status is assessed: a. On admission; b. With each comprehensive assessment; c. With any significant change in condition;d. Upon noted weight change, poor intake, or dehydration risk;-Assessments include: a. Height, weight, body mass index (BMI) b. Diet order and food preferences; c. Swallowing status; d. Hydration risk factors; e. Ability to eat/drink independently;2. Care Planning:-A person centered care plan is developed and updated by the interdisciplinary team (IDT);-Care plans address:a. Diet type and texture; b. Fluid goals; c. Adaptive equipment or feeding assistance; d. Meal location and timing preferences; e. Cultural and religious considerations;3. Diets and Meals:-Menus meet current Dietary Reference Intakes (DRIs) and are approved by a qualified dietitian;-Residents are offered: a. Regular and therapeutic diets as ordered; b. Texture modified diets when clinically indicated; c. Substitutions and alternatives when meals are refused;-Residents may refuse a therapeutic diet after informed consent; refusals are documented and care planned;5. Feeding Assistance: Residents who require assistance will receive timely and adequate help during meals;6. Monitoring and Documentation:-Intake is monitored based on resident risk level;-Weights are obtained per facility protocol or physician order;-The IDT reviews: a. Weight trends; b. Intake patterns; c. Lab values when indicated;-Significant findings are communicated to the practitioner and documented;7. Weight Loss and Nutritional Risk:-Unplanned weight loss triggers: a. IDT review; b. Root cause analysis; c. Care plan revision;-Interventions may include: a. Diet changes; b. Supplements; c. Enhanced feeding assistance; d. Medical evaluation;8. Refusals and Preferences:-Resident preferences are honored whenever possible;-Persistent refusals are: Investigated, documented and care planned;-Residents are not force fed or coerced;9. Advance Directives and End of Life Care:-Nutrition and hydration decisions respect advance directives, physician orders, and resident or legal representative choices;-Comfort focused approaches are used when appropriate.Staff Responsibilities:1. Nursing:-Monitor intake, hydration, and weight;-Implement care plan interventions;-Notify the provider and IDT of concerns;2. Dietary Services:-Plan and prepare nutritionally adequate meals;-Honor resident preferences;-Participate in IDT reviews;3. Medical Provider:-Order diets, supplements, and evaluations;-Review significant changes;4. Administration:-Ensure staff training and compliance;-Conduct audits and quality improvement activities. Review of the undated facility policy, Weight Loss / Poor Intake Trigger Flowchart, showed the following:-To provide a clear, survey-ready decision pathway for identifying, assessing, and responding to unplanned weight loss or poor oral intake in nursing home residents, consistent with federal requirements and interdisciplinary best practice.-STEP 1: Trigger Identification:Initiate the flowchart when ANY of the following occur:-Greater than or equal to ( ) 5 percent (%) weight loss in 30 days;- 7.5% weight loss in 90 days;- 10% weight loss in 180 days;-Poor intake (<75% of meals for 3 consecutive days);-Refusal of meals or fluids;-Signs of dehydration;-Change in condition affecting intake (illness, cognition, swallowing, mood);-STEP 2: Immediate Nursing Actions (Within 24 hours):-Verify weight accuracy (same scale, time, clothing);-Initiate or increase meal and fluid intake monitoring;-Assess for:Pain;Nausea/vomiting;Constipation;Dental/oral issues;Swallowing difficulty;Depression or behavioral changes;-Notify charge nurse/supervisor;-STEP 3: Physician/Practitioner notification:Notify provider if:-Weight loss meets trigger thresholds;-Poor intake persists > 3 days;-Dehydration suspected;Provider may order:-Diet change or texture modification;-Supplements;-Labs or diagnostic testing;-Medication review/changes;-STEP 4: Interdisciplinary Team (IDT) Review:IDT Members: Nursing, Dietary, Provider, Therapy, Social Services (as indicated)IDT evaluates:-Root cause(s) of weight loss/poor intake;-Food preferences and meal satisfaction;-Assistance needs and meal environment;-Cultural, psychosocial, and end-of-life considerations;-STEP 5: Interventions:Implement and document individualized interventions, such as:-Diet liberalization or resident-preferred foods;-Oral nutritional supplements;-Enhanced feeding assistance or cueing;-STEP 6: Care Plan update:-Update care plan with identified problems, goals, and interventions;-Include resident/representative preferences and consent;-Document education and discussion;-STEP 7: Monitoring and Re-evaluation:-Monitor intake daily (or per risk level);-Reweigh per protocol or provider order;-Evaluate effectiveness of interventions;If improvement noted: Continue interventions and routine monitoringIf NO improvement or continued decline: Reassess root cause Re-notify provider Revise interventions. 1. Review of Resident #14's face sheet showed the following:-Diagnoses included Alzheimer's disease, dementia, anxiety, and high blood pressure;-The resident had a healthcare proxy who was his/her emergency contact. Review of the resident's Care Plan, dated 10/25/23, showed the following:-Nutritional Status: Resident is on a consistent carbohydrate diet with thin liquids;-Goals: Resident will maintain optimal nutrition as evidenced by absence of significant weight loss through the next review;-Resident has a diagnosis of diabetes (inability to regulate blood sugar) and currently takes oral medications to control blood sugar;-Resident consistently asks for between meal snacks numerous times even right after eating a meal; -Resident was currently above ideal body weight;-Resident goes to the dining room for most meals. Review of the resident's December 2025 Physician Orders, showed the following:-Monitor weight monthly;-Regular, consistent carbohydrate diet (initiated 12/11/23). Review of the resident's annual Nutritional Assessment, dated 05/12/25, showed the Registered Dietitian documented the following:-Resident weighs 186 pounds (lbs.), usual body weight is 185 lbs.;-The resident's estimated nutritional needs are 1664 calories, 67 grams of protein and 2536 milliliters of fluid;-Resident has a wound;-Weight stable;-Overweight;-Goal to maintain weight or gradual weight loss. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 05/22/25, showed the following:-Moderate cognitive impairment;-No behaviors, hallucinations, delusions, or rejection of care;-It was very important to the resident to have snacks between meals; -Set up or clean up assistance from staff for eating; -Weighs 186 lbs., therapeutic diet;-The resident's MDS triggered an alert that the resident was at risk for alterations in nutrition and the facility indicated a care plan would be initiated for nutrition. Review of the resident's Physician Orders, dated May 2025, showed the resident continued monitoring of monthly weights and a regular, consistent carbohydrate diet. Review of the resident's weight record, showed facility staff obtained and documented the resident's weight as follows:-On 06/04/25, 183.8 lbs.;-On 07/02/25, 183.6 lbs.;-On 08/07/25, 184.4 lbs. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Alzheimer's and Dementia diagnosis;-184 lbs.;-New antipsychotic medication. Review of the resident's Progress Notes, dated 8/25/25 at 2:40 P.M., showed the following: -Quarterly nutrition review;-Consistent carbohydrate, regular diet; -Meal intake varied, does like snacks; -2500 ml fluid restriction; -Labs: 08/06/25: basic metabolic panel (BMP - a common blood test that checks your body's chemical balance, metabolism, and kidney function) all within normal limits, except glucose (blood sugar) 176 (history of diabetes) (normal glucose range on a BMP is 70 - 100); -Skin: No pressure injuries; -Height: 64 inches, weight 184.4 pounds;-Weight stable/no significant changes in the past quarter;-Diet order remains appropriate and adequate to meet needs;-No changes advised continue plan of care. Review of the resident's Nurses Notes, dated 09/09/25, at 1:33 A.M., showed the resident's appetite varied from 25% to 100%. The resident fed self and liked snacks. Review of the resident's weight record, showed facility staff obtained and documented the resident's weight as follows:-On 09/10/25, 180.8 lbs.;-On 10/01/25, 177.2 lbs.;-On 10/02/25, 177.6 lbs. a 2% weight loss in one month, 4.5% weight loss in six months. Review of the resident's Nurses Notes showed staff documented the following:-10/07/25 at 2:00 P.M., the resident has refused both meals again this shift. He/She sleeps most of the shift and is not asking for snacks;-10/07/25 at 6:25 P.M., the resident has refused supper again this shift. Education given to resident;-10/08/25 at 2:35 P.M., staff instructed to give the resident snacks when he/she asked even if he/she doesn't eat meals;-10/08/25 at 9:52 P.M., the resident asked for ice cream and water numerous times and was redirected. The resident refused all three meals today;-10/12/25 at 9:56 P.M., (3:00 P.M. to 11:00 P.M. shift) the resident was very demanding and verbal this shift, constantly asking for snacks and drinks;-10/13/25 at 10:20 P.M., the resident refused to eat his/her supper, then after the trays were removed, resident started asking for snacks. The resident asked for ice cream, but this nurse offered him/her a sandwich instead. Resident said he/she did not want a sandwich and that he/she already ate supper. Resident reminded he/she didn't eat supper and asked if he/she would eat a sandwich before ice cream. Resident agreed and ate the sandwich. Resident given ice cream. Resident came back to this nurse immediately after eating ice cream and asked for more. Resident informed they were currently out of ice cream and the snack drawer was also empty. The resident was angry and walked back to his/her recliner;-10/17/25 at 8:19 P.M., the resident approached the nurses station asking for another snack. Reminded he/she just received a snack. Resident picked up a fly swatter, swung it at nurse and said, I'll smack you. Resident approached the nurses station about every ten minutes asking for snacks and drinks repeatedly. Snacks and drinks provided, but resident continued to request more, even after just receiving a snack and drink;-10/25/25 at 9:00 P.M., the resident approached this nurse asking for another snack. Snack just provided a few minutes prior. When the resident was reminded he/she just had a snack, the resident smacked this nurse in the back;-11/01/25 at 11:35 A.M., the resident was encouraged to come to the dining room for meals. Appetite remains poor to fair. Continues to request a snack as soon as he/she gets up from the table;-11/10/25 at 9:22 P.M., the resident has been asking all staff for water refills and snacks all shift. Resident would argue if he/she was told no. Resident asked for a snack every 30 minutes and argued when informed he/she just had one. Review of the resident's Registered Dietician's Progress Notes, dated 11/13/25 at 3:13 P.M., showed the following: -Quarterly nutrition review;-Consistent calorie, regular diet;-Meal intake varies, likes snacks;-2500 ml fluid restriction;-Labs: 11/12/25: Hemoglobin A1C (a blood test measuring your average blood sugar (glucose) over the past 2-3 months) 7.7% (indicates a blood sugar average of 169 to 183;-Skin: No pressure injuries;-Height: 64 inches, weight 177.6 pounds;-No significant weight changes in the past quarter, weight is trending down, but not of concern at this time, will continue to monitor;-Diet order remains appropriate and adequate to meet needs;-No changes advised, continue plan of care. Review of the resident's weight record showed no evidence of staff obtaining the resident's weight for November 2025. Review of the resident's Nurses Notes showed staff documented the following:-11/16/25 at 10:06 P.M., the resident was speaking in a very hateful manner to staff, demanding drinks and snacks;-11/19/25 at 8:01 P.M., the resident refused to get up from recliner for supper. Resident refused to go to the dining table, yelled at nurse and rammed nurse with her walker when attempting to talk to resident about eating. Day shift reports resident has refused all meals today. Snack provided with bedtime medications;-11/25/25 at 9:40 P.M., the resident refused supper tonight and has not asked for snacks;-11/28/25 at 9:30 P.M., the resident refused supper then requested several snacks;-11/30/25 at 9:05 P.M., the resident refused supper then continued to ask for snacks. Review of the resident's weight record, showed staff obtained and documented the resident's weight on 12/01/25 as 162 lbs. Review of the resident's weight records showed resident lost 21.8 lbs. since 06/04/25, which was an 11.86 % weight loss in six months and had lost 15.2 lbs. since 10/01/25 (no weight for November documented) which was an 8.5% weight loss in two months. Review of the resident's Physician Orders, dated December 2025, showed the resident continued monthly weight monitoring, and regular, consistent carbohydrate diet. Review of the resident's Care Plan showed no evidence new interventions or evaluation of the resident's nutrition goals after his/her weight loss in December. The last update to the care plan was 11/13/25 for psych med side effect monitoring, 12/5/25 for wound care related to two new pressure ulcers, and 12/8 honeycomb cushion pressure reduction for chair Review of the resident's medical record showed no documentation the resident's physician, dietician, IDT or resident's representative were notified of the resident's weight loss (per facility policy). Further review showed no assessment was completed upon the noted weight change. There was no documentation of an IDT review, root cause analysis or care plan revision being completed per facility policy. Review of the resident's Nurses Notes, dated 12/04/25 at 1:33 P.M., showed the resident had two new wounds to the coccyx (bony part of lower back/buttocks) area measuring 1.5 centimeters (cm) x 1 cm and 1cm x 1cm. Observation on 12/08/25 from 12:00 P.M. to 1:10 P.M. (continuous observation from the time the meal tray cart was opened until most residents left the dining area), showed the resident in a recliner with his/her legs elevated in the resident's television viewing area (common area with 18 recliners) The resident's eyes were closed during all observations. Staff served meal trays and offered assistance to other residents. No staff attempted to wake the resident or offer the resident a meal tray. The resident's mouth and lips were dry, flaky and cracked. Observation on 12/10/25 at 8:43 A.M., showed the resident in a recliner in the television viewing area with his/her legs elevated. Staff served meal trays and offered feeding assistance to other residents. Staff asked the resident if he/she wanted to eat breakfast, and the resident said no. Staff did not bring a tray to the resident or snack foods and only made a verbal offer. Staff did not serve any food to the resident. The resident had a pitcher of water beside him/her, but no staff offered the resident fluids, and the resident did not attempt to reach them him/herself. Review of the resident's medical record showed no documentation of the resident'spersistent refusal of meals was investigated or care planned per facility policy. Observation on 12/10/25 at 11:50 A.M. to 12:20 P.M., showed the resident in a recliner in the television viewing area with his/her legs elevated and his/her eyes closed. Staff served meal trays and offered feeding assistance to other residents. No staff attempted to wake the resident or offer the resident a tray. During the survey process from 12/08/25 through 12/11/25 and 12/15/25, when the state agency (SA) was on the locked dementia unit where the resident resided, the resident had a drink beside him/her but never attempted to get the drink and provide him/herself with fluids and never had food offered or in front of him/her during the time the SA staff did observations. All other residents had multiple meals during those times. During a telephone interview on 12/18/25 at 12:40 P.M., the resident's family representative said the following: -He/She was the resident's emergency contact and made decisions for the resident;-The facility did not notify him/her of the resident's weight loss;-He/She expected staff to try to get the resident to eat, and if he/she did not, staff should give the resident snacks, a shake, or something;-The facility had not notified him/her the resident was refusing meals or had varying intakes;-He/She felt like the facility was giving the resident too much medication and all the resident did was sleep; -He/She would prefer the resident not be so drugged up all the time, and maybe then the resident could eat. During an interview on 12/15/25 at 3:15 P.M., Licensed Practical Nurse (LPN) A said the following: -She usually worked on the Special Care Unit (dementia unit);-Weights for residents were reviewed by the charge nurse the first week of the month;-He/She did not work the first week of December and he/she was not sure who would have worked;-He/She did not know the resident had a significant weight loss, but the resident had not been eating well; -The resident will eat oatmeal cream pies;-The resident has not been on any supplements, and had no orders for extra snacks or anything that he/she knew of;-He/She was not sure why the resident did not have a weight in November;-If a resident had weight loss, the charge nurse was responsible to contact the physician;-The charge nurse was responsible to alert nursing administration when a weight loss was found. During an interview on 12/23/25, at 3:54 P.M., the Care Plan Coordinator said the following:-If a resident has a weight loss or gain the first thing staff are expected to do is reweigh the resident to ensure accuracy;-The charge nurse should have reported the resident's weight on 12/01/25, after they got a reweigh;-When there is a weight loss the charge nurse was expected to notify the physician, dietitian and get orders for supplements or an intervention;-The resident's fluid restriction was ordered when the resident had a low sodium last summer;-She was on a 2000cc fluid restriction for the low sodium level, then in June her physician increased her fluid allowance to 2500ml, which wasn't much of a restriction; the resident doesn't come close to drinking that much. During an interview on 12/15/25, at 4:43 P.M. the Director of Nursing (DON) said the following:-Staff are expected to weigh residents monthly;-When she started, staff said there had been a weight loss committee, but the meetings stopped;-There was no current IDT weight loss committee;-The charge nurses are expected to notify the physician and dietitian of any weight loss; -If weight loss was identified, staff would be expected to monitor the resident more closely by initiating weekly weights, monitoring intake, re-evaluate the care plan to find the root cause of the weight loss, and implement interventions to help the resident's weight to stabilize;-Staff are expected to physically bring food to every resident;-A resident with dementia may eat if food was placed within reach;-Staff did not make her aware of the resident's weight loss. She did not think anyone was monitoring weights like they needed to be monitored. During an interview on 12/18/25 at 9:10 A.M., the Registered Dietitian said the following:-The facility had not contacted her about weight loss for the resident;-There had been many changes to the administration at the facility and she had only been going to the facility for a few months. The facility did not seem to have someone in charge of evaluating the weights and communicating issues to her;-She comes to the facility once a month, so she expects the staff to notify her of a significant weight loss in between visits so a resident does not continue to lose weight;-She expected staff to start nutritional supplements, assist residents with eating or call her to discuss options until her next visit;-She documented on the last visit the resident had some gradual weight loss and to monitor, but they did not notify her that the resident had a significant weight loss on 12/01/25;-Weight loss can cause many health issues including skin breakdown, weakness, falls, and low blood sugars;-This resident had wounds that had just healed. She was also not notified the resident's wounds had reopened;-Communication and early interventions can improve outcomes with weight loss;-If staff had contacted her, she would have talked to the staff and made a recommendation for a supplement or something to start (based off their answers) until she could do a formal assessment. During an interview on 12/19/25, at 8:50 A.M., the resident's physician (Physician R) said the following:-She was not made aware of the resident's weight loss until she visited the facility on 12/18/25;-If a resident experienced significant weight loss, she expected staff to notify her and the dietitian as soon as weight loss was identified so interventions could be attempted;-She would expect communication for a weight loss with the family to see if they wanted aggressive or conservative interventions to be made;-She expects the facility to attempt to find the root cause of the weight loss, such as needed assistance, a dental issue, or some other issue contributing to the weight loss;-If staff had reported to her, she would try to find out what the family's goals were to determine if they wanted conservative or aggressive measures;-With conservative measures, they can attempt snacks, supplements like nutrition shakes, attempts to cue and assist a resident to eat;-If a family wanted more aggressive measure, they could look at appetite stimulants and more aggressive interventions;-Significant weight loss can lead to other health concerns so efforts should be made to slow weight loss down and stabilize a resident's weight if possible;-The resident was not on diuretics, he/she had issues with a low sodium in the past;-2500 ml wasn't much of a fluid restriction, just to make sure if his/her psychiatric medications cause him/her to be thirsty he/she isn't excessively drinking.

Based on observation, interview and record review the facility staff failed to ensure a resident with dementia (Resident #14), in a review of 17 sampled residents received high-quality, compassionate, and individualized care that supports his/her dignity, well-being, and independence, while addressing the unique challenges posed by dementia. The facility failed to find the root cause and triggers for a resident's behavior and initiate non-pharmacological Interventions, use effective communication strategies, and provide appropriate guidance to staff for managing behavioral symptoms. The resident experienced lethargy, weight loss, physical altercations, agitation, and new skin breakdown. The facility census was 59. Review of the facility's policy, Dementia Care for Long-Term Care Facility, undated, showed the following:-The purpose of this policy is to ensure that all residents with dementia in this long-term care facility receive high-quality, compassionate, and individualized care that supports their dignity, well-being, and independence, while addressing the unique challenges posed by dementia;-This policy applies to all residents diagnosed with dementia or related conditions such as Alzheimer's disease, vascular dementia, and other neurodegenerative diseases in this facility. It is intended for use by all staff members, including nursing, medical, therapy, dietary, and activity staff, to guide the provision of care for residents with dementia.-Person-Centered Care Approach:The facility is committed to providing person-centered care for all residents, with special emphasis on those with dementia. This approach recognizes and respects the individuality of each resident and seeks to maintain their dignity, autonomy, and quality of life. Care plans will be developed in partnership with the resident, their family members, and/or legal representatives.-Key Components of Person-Centered Care:Individualized Care Plans: Each resident will have a personalized care plan that addresses their specific needs, preferences, and abilities. This plan will be updated regularly to reflect changes in the resident's condition and abilities.Resident Preferences: Care plans will incorporate the resident's history, preferences, likes, and dislikes, including their previous lifestyle, routines, and cultural practices.Involvement of Family and Caregivers: Family members and caregivers will be encouraged to participate in the care planning process and ongoing decision-making. They will also be provided with educational resources and support regarding dementia care.-Staff Training and Education:Staff members involved in the care of residents with dementia will receive ongoing training on best practices for dementia care. The training will cover, but not be limited to, the following:Understanding Dementia: Types, stages, symptoms, and progression of dementia.Non-Pharmacological Interventions: Techniques for managing behavior without the use of medications, including redirection, environmental modifications, and structured activities.Communication Strategies: Methods to improve communication with residents who have cognitive impairments, including using simple language, non-verbal communication, and patience.Managing Behavioral Symptoms: How to address common dementia-related behaviors, such as wandering, aggression, agitation, and sundowning, in a safe and respectful manner.Person-Centered Care Practices: Ensuring that care is individualized, consistent, and compassionate;-Staff will undergo this training upon hire and at regular intervals, and training will be updated as new best practices or evidence-based approaches emerge.-Behavioral and Pharmacological Interventions:The facility will focus on non-pharmacological interventions to manage dementia-related behaviors, in line with CMS guidelines. When behavioral interventions are insufficient, medications may be considered, but only as a last resort and in accordance with the following:Behavioral Interventions First: Staff will prioritize non-medication approaches, such as redirection, individualized activity programs, and modifications to the environment, to address behaviors like agitation or aggression.Minimizing Medication Use: Antipsychotic medications and other sedatives will not be used as a primary method of managing dementia symptoms unless absolutely necessary. When medication is prescribed, it will be closely monitored for effectiveness and side effects, and dosage will be minimized.Regular Review: The use of medications, particularly antipsychotics, will be regularly reviewed by a physician and a multidisciplinary team to ensure they are still necessary and that non-pharmacological interventions are being utilized.-Resident and Family Rights:Residents with dementia have the same rights as other residents, including:Right to Autonomy: To the extent possible, residents will be allowed to make choices about their care and daily activities. Staff will encourage participation in decision-making, even if the resident cannot fully express themselves.Right to Privacy and Dignity: Residents will be treated with dignity and respect at all times. This includes respecting their personal space and ensuring confidentiality regarding their medical and personal information.Right to Participate in Care Planning: Family members and legal representatives will have the opportunity to participate in care planning and review. Any changes to care plans will be communicated to families regularly.Right to a Safe Environment: The facility will provide a safe and supportive environment that is free from abuse, neglect, and mistreatment. All allegations of mistreatment will be promptly investigated.-Evaluation and Continuous Improvement:The facility will continuously assess the effectiveness of its dementia care practices. This will include:Regular Care Plan Reviews: Care plans for residents with dementia will be reviewed and updated at least quarterly, or more frequently if needed.Resident and Family Feedback: The facility will actively solicit feedback from residents and their families about their satisfaction with the care provided. This input will be used to refine care practices and ensure that the facility is meeting residents' needs.Quality Assurance and Audits: The facility will conduct regular audits of care practices, safety procedures, and resident outcomes to ensure compliance with this policy and best practices in dementia care. Review of the facility's policy, Dementia Behavioral Symptom Flowchart, undated, showed the following:Step 1: Identify Behavior:Examples: Agitation, aggression, wandering, shouting, refusal of care, repetitive actions, sleep disturbances.Document behavior: type, frequency, severity, triggers.Step 2: Ensure Safety:Immediate risk to resident or others?Yes: Intervene to prevent harm, remove hazards, call for assistance.No: Proceed to Step 3.Step 3: Assess for Causes / Triggers (ABC Approach)A - Antecedent: What happened before the behavior? (environment, interaction, unmet needs);B - Behavior: Describe the behavior objectively;C - Consequence: How did staff or others respond?Common Triggers to Evaluate:Pain, hunger, thirst, fatigue;Infection, constipation, urinary retention;Environmental overstimulation or under stimulation;Change in routine or caregivers;Emotional needs (loneliness, anxiety).Step 4: Implement Non-Pharmacological Interventions First:Redirection, reassurance, and calm communication;Structured activities, music, or reminiscence therapy;Adjust environment (lighting, noise, seating, personal items);Offer comfort measures (hydration, snack, toileting, repositioning).Step 5: Evaluate Effectiveness:Behavior improved?Yes: Document interventions and continue monitoring;No: Proceed to Step 6.Step 6: Consider Medical / Pharmacologic Evaluation:Consult nurse or physician for potential medical causes (infection, pain, medication side effects);Medications for behavior only if non-pharmacologic interventions fail, with:Physician order;Monitoring plan;Documentation of rationale.Step 7: Update Care Plan:Record behavior, interventions, triggers, and outcomes in the resident's care plan;Share updates with interdisciplinary team and family;Revise strategies as needed.Key Notes:Always prioritize safety and dignity.Use consistent documentation for regulatory compliance.Involve family in care planning whenever possible. Review of drugs.com shows the following:-Risperidone, an antipsychotic medication, is used to treat schizophrenia (chronic brain disorder that disrupts how a person thinks, feels, and behaves, causing them to lose touch with reality (psychosis) through symptoms like hallucinations (hearing voices/seeing things), delusions (false beliefs), disorganized speech, and unusual motor behavior), bipolar (a mental health condition causing extreme mood swings between emotional highs (mania/hypomania) and lows), and agitation related to autism (neurodevelopmental disorder effecting social interaction and communication). Risperidone carries a warning for increased risk of death in elderly patients with dementia-related psychosis. Risperidone is not approved for use in older adults with dementia-related psychosis.-Seroquel, and atypical antipsychotic medication, is used to treat schizophrenia, mania or manic disorders, depression with bipolar disorder. Seroquel warnings include Increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel is not approved for the treatment of patients with dementia-related psychosis.-Haloperidol, and atypical antipsychotic medication, is used for schizophrenia, to treat motor control and speech ticks for Tourette's Syndrome (neurologic disease that presents with multiple tics). Warnings include Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Haloperidol injection is not approved for the treatment of patients with dementia-related psychosis. 1. Review of Resident #14's face sheet shows the resident had diagnoses of Alzheimer's, dementia, and anxiety. Review of the resident's Physician's Orders, dated 09/16/24, showed an order for Lexapro (an antidepressant medication) 10 mg daily for anxiety disorder. Review of the resident's Care Plan, last updated 11/13/24, showed the following:-The resident has cognitive deficits related to diagnosis of dementia;-Goal: maintain cognitive levels for Activities of Daily Living (ADLs), safety and quality of life through next review;-Encourage resident to attend activities so he/she can socialize with other residents;-Ask one question at a time and give him/her time to respond before asking another question;-Encourage him/her to come to the dining room for meals;-Psychotropic drug use: Potential for Adverse Drug Reactions:-Resident is on medication for anxiety;-Goals: Resident will not experience adverse reaction to medication thru next review.-Interventions:-Encourage verbalization of feelings;-Monitor for changes in behavior and mood (e.g., lethargy, change in gait or balance problem);-Observe for any signs of decline in functional or cognitive status, notify nurse of any findings;-Significant side effects of psychotropic drug therapy may include any of the following: low blood pressure, uncontrolled mouth movements, continual body movements, cognitive and behavioral changes. Report to nurse any declines with activities of daily living (ADLs) or mental status;-Report increased sleeping or restlessness;-Monitor for side effects of psychotropic medication to include any of the following: Drowsiness, dizziness, dry mouth, blurred vision, tiredness, nausea, constipation, weight gain, trouble sleeping or muscle or nervous system problems (anxiety, agitation, jitteriness, drooling, trouble swallowing, restlessness, shaking or stiffness). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 05/22/25, showed the following:-Moderate cognitive impairment;-No behaviors, hallucinations, delusions, or rejection of care;-Snacks between meals was very important to the resident;-Walker use;-Weighs 186 pounds (lbs.), therapeutic diet;-Independent with transfers, and ambulation 150 feet;-Set up or clean up assistance from staff for eating; -Antidepressant medication daily. Review of the resident's Physician's Orders, dated 07/17/25, showed an order for Seroquel (an antipsychotic medication for hallucinations and delusions) 25 milligrams (mg) daily for anxiety disorder. (Anxiety is not an approved use for Seroquel and is not approved for elderly residents with dementia. Review of the resident's Care Plan, updated 08/11/25, showed the following:-Behavior Management program:-Resident requires ongoing redirection, monitoring and structured activities to alter behavior problems;-Smacks staff and peers on buttocks, hits staff on arms, and goes into linen room for washcloths numerous times;-Refuses to go to meals at times and then wants snacks and fluids;-Refuses incontinent care at times;-Resident takes handfuls of napkins out of holders and puts them in his/her pants;-Resident will respond to redirection from staff when behavior occurs thru next review;-Resident will engage in on and off unit programs to maintain current sensory awareness thru next review;-Encourage family involvement in care and visits;-Provide structured programs appropriate for the resident's cognitive status;-Social Service intervention and evaluation as needed;-Prompt resident to not smack or hit staff;-Re-approach with refusal of incontinent care and meals by different staff members;-Medication changes;-Gentle approaching and re-direction;-Staff will monitor the resident closely when around peers;-Moved into a room by himself/herself due to resident-on-resident altercations. The care plan did not include staff evaluated the root cause of the resident's behaviors and interventions were planned as a result of this evaluation. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Physical behavioral symptoms directed towards others one to three days;-Diagnosis of Alzheimer's/dementia;-New Antipsychotic medication daily;-Antidepressant medication daily;-Weighs 184 lbs.;-No pressure ulcers. Review of the resident's Progress Notes, dated 8/25/2025 at 2:40 P.M., showed the following: -Quarterly Registered Dietitian nutrition review;-Consistent carbohydrate, regular diet; -Meal intake varies, does like snacks; -2500 ml fluid restriction; -Labs: 08/06/25: basic metabolic panel (BMP - a common blood test that checks your body's chemical balance, metabolism, and kidney function) all within normal limits, except glucose (blood sugar) 176 (history of diabetes) (normal glucose range on a BMP is 70 - 100); -Skin: No pressure injuries; -Height: 64 inches, weight 184.4 pounds;-Weight stable/no significant changes in the past quarter;-Diet order remains appropriate and adequate to meet needs;-No changed advised continue plan of care. Review of the resident's Nurses Note, dated 09/03/25, at 8:29 A.M., showed staff received a fax back from the physician about increased behaviors and the physician increased Seroquel to 25 mg twice daily. Review of the resident's medical record, including nurses' notes and resident documents, did not identify what behaviors were reported or what interventions had been attempted and failed related to the resident's behaviors. Review of the resident's Physician's Orders, dated 09/03/25, showed an order to increase Seroquel) 25 mg daily to two times per day, diagnosis of dementia. (dementia is not an approved use for Seroquel). Review of the resident's Nurses Note, dated 09/04/25, at 10:03 P.M., showed the resident continues obsession with hoarding of napkins and washcloths. Becomes aggressive with staff intervention. Resident smacked a staff member on his/her bottom. When resident told to keep his/her hands to himself/herself, he/she laughed. Review of the resident's medical record showed no documentation staff attempted to find the root cause of the resident hoarding napkins and washcloths, or provide accommodations to the resident to address the behavior (providing own supply of napkins etc. Review of the resident's Nurses Note, dated 09/07/25, at 10:15 A.M., showed the resident continues with behaviors such as yelling and hitting staff while attempting to get him/her up to use the restroom. After numerous attempts made to get him/her to use restroom finally used restroom but refused his/her breakfast. Review of the resident's medical record showed no documentation staff attempted to determine the root cause of the resident not wanting to use the bathroom, but showed staff repeatedly attempted to get the resident to use the bathroom which triggered physical and verbal behaviors. when the resident refused breakfast; the record showed no attempts by staff to offer alternatives like snacks to ensure the resident received nutrition. Review of the resident's Nurses Note, dated 09/08/25, at 9:00 P.M., showed the resident continues obsession with hoarding of napkins and washcloths. Has smacked and shoved staff three times so far this shift. Currently has multiple napkins and washcloths shoved in the side of his/her recliner and in the cup holder next to recliner. Review of the resident's weight record, dated 09/10/25, showed the resident weighed 180.8 lbs. Review of the resident's Nurses Note, dated 09/13/25, at 8:45 P.M., showed at supper the resident walked by a peer and pulled his/her hair unprovoked. Immediate staff intervention and separation of residents. Resident then re-approached the peer's table and was bothering them while they were trying to eat, again requiring staff intervention. At this time the resident swung at a nurse, attempting to hit her. Resident was very difficult to redirect and has been aggressive each time with staff intervention. Review of the resident's medical record showed staff no documentation staff attempted to identify what triggered the resident's physical behaviors, or what interventions were attempted besides redirection when redirection was not successful (i.e. pain, thirst, hunger, boredom). Review of the resident's Nurses Note, dated 09/17/25, at 8:06 P.M., showed the resident smacked the nurse when the nurse took his/her cup from his/her walker. The nurse had just provided 1/2 cup of ice water five minutes prior, and the resident took cup to the bathroom and filled it with water. Explained to the resident that he/she was on a fluid restriction and staff had to keep track of his/her intake. Review of the resident's medical record showed no evidence the resident was consuming a fluid amount contrary to his/her restriction. Staff documented this triggered the resident's behavior. Staff confronted the resident than adding the amount to the resident's intake and adjusting later if needed. Review of the resident's Nurses Note, dated 09/18/25, at 10:23 P.M., showed the resident was not cooperative with staff during this shift. He/She made repeated efforts to take napkins out of the holders and hide them. He/She continued to try to put the shades down, although the other residents asked him/her not to do so. He/She yelled at another resident (about taking the napkins when the other resident tried to stop him/her). He/She made repeated attempts to obtain beverages and would not take redirection (including trying to pour water from the pitcher on the med cart). At approximately 10:00 P.M., he/she sat in a recliner near the television and appeared to calm down. Review of the resident's medical record showed no evidence staff attempted to identify what triggered the resident's hoarding of napkin, or why the resident was closing the shades. When the resident was taking fluids from other resident's and the medication cart, staff did not document what interventions were attempted to alleviate the resident's thirst. Review of the resident's Nurses Note, dated 09/24/25, at 4:07 P.M., showed the resident refused breakfast or to get up to the bathroom. At lunchtime he/she screamed at staff numerous times. Once he/she was up he/she was obsessed with getting wash cloths and napkins which he/she put inside his/her incontinence brief, so he/she did not have to get up to go to the bathroom. The resident gets angry at staff when he/she was redirected and will hit staff. Updated physician on the resident's behaviors. Review of the resident's Nurses Note, dated 09/26/25, at 6:02 P.M., showed the physician's response to the fax about behaviors was I just increased Seroquel last week, gently redirect for now. Review of the resident's Nurses Note, dated 09/28/25, at 10:35 A.M., showed notified by staff this resident was becoming physically aggressive toward other residents. This resident was noted to bend another resident's left index finger back after the resident placed his/her hand over the napkin dispenser on his/her table to prevent this resident from taking it. This resident smacked another resident in the face on the left side. Resident hits staff unprovoked when he/she passes by them. Resident was unable to be redirected. Call placed to on call nurse practitioner to update on behavior. Requested order to possibly send to emergency room for evaluation. Order received for Haldol (antipsychotic medication) 5mg IM one time if resident continues to be physically aggressive toward other residents. Review of the resident's Physician's Orders, dated 09/28/25, showed an order for haloperidol lactate (an antipsychotic medication for hallucinations and delusions) 5 mg/milliliter (ml), inject intramuscularly (IM) for one dose for dementia. (dementia is not an approved use for haloperidol). Review of the resident's Nurses Note, dated 09/28/25, at 1:20 P.M., showed the resident continued to be physically aggressive toward staff and raised a hand to slap another resident again when the resident stopped this resident from removing napkins from his/her tray. Staff intervened and no contact made between residents. Haloperidol 5 mg given IM in right gluteal (muscle in the buttocks). Review of the resident's Nurses Notes, dated 09/28/25, at 4:55 P.M., showed staff updated the resident representative about the resident's behaviors and administration of Haldol today. Resident's representative states what am I supposed to do about it? Informed him/her we will be talking to the resident's primary care physician about resident behaviors and other possible interventions and will keep him/her updated. Review of the resident's Nurses Note, dated 09/28/25, at 7:06 P.M., showed at 5:30 P.M. the resident was walking back from the bathroom and approached a staff member. Resident shoved his/her walker into the back of staff very hard. Resident said he/she will do what he/she wants. Review of the resident's Nurses Note, dated 09/28/25, at 7:07 P.M., showed the resident again rammed his/her walker into a staff member. Review of the resident's medical record showed staff did not identify what possibly triggered the resident or the root cause of the behavior. The staff also did not document attempted interventions to alleviate the resident's triggers. Review of the resident's Nurses Note, dated 09/28/25, at 7:17 P.M., showed resident walked by a peer and smacked him/her on the bottom. Immediate staff intervention and separation of residents. Resident instructed to keep his/her hands to himself/herself. The resident laughed and walked away. Review of the resident's Nurses Note, dated 09/28/25, at 8:25 P.M., showed the resident approached this nurse asking for a drink and another snack, chocolate milk provided to the resident. The resident asked for another cookie. The resident has had three cookies and a snack in the last two hours, when another snack was not provided, the resident smacked this nurse. Instructed to keep his/her hands to himself/herself. Review of the resident's medical record showed staff did not show any dietary restrictions or the resident had a limit on snacks. Review of the resident's Nurses Note, dated 09/29/25, at 3:41 P.M., showed a representative for the resident visited and was updated on resident's behaviors, i.e. taking wash cloths and napkins and putting in his/her pants and hitting staff. Resident moved to a different room to prevent resident to resident issues. Resident representative requested to test for urinary tract infection, fax sent to the primary physician. Review of the resident's Nurses Note, dated 10/01/25, showed the physician responded with an order for a urinalysis with a culture and sensitivity. Review of the resident's Nurses Note, dated 10/01/25, at 5:52 A.M., showed urine sample obtained. Review of the resident's Nurses Note, dated 10/01/25, at 2:39 P.M. showed the physician ordered Rocephin (antibiotic) 1 gram IM one time and Cefdinir (antibiotic) 300 mg, by mouth twice a day for 7 days for a urinary tract infection. Review of the resident's urinalysis dated 10/01/25, showed the resident was positive for nitrates and bacteria, which indicated a urinary tract infection. Review of the resident's weight record, dated 10/02/25, showed the resident weighed 177.6 lbs. (2% weight loss in one month, 4.5% weight loss in six months). Review of the resident's Nurses Note, dated 10/10/25, at 9:36 P.M., showed the resident taking napkins from the dining room and stuffing them down his/her pants. Review of the resident's care plan showed no evidence of review or added interventions to address the resident's dementia or behaviors. Review of the resident's Nurses Note, dated 10/12/25, at 9:56 P.M., showed the resident was very demanding and verbal this shift, constantly asking for snacks and drinks. He/She was not taking redirection well. He/She made numerous attempts to obtain wash cloths and napkins and became loud and belligerent when staff attempted to take them from him/her. Review of the resident's medical record showed staff did not identify any food restrictions, or that the resident drank over his/her fluid restriction. The resident expressed being hungry and thirsty and wanted washrags and napkins and had behaviors when the staff did not meet his/her needs. Review of the resident's Nurses Note, dated 10/17/25, at 8:19 P.M., showed the resident continued with fixation with collecting napkins and washcloths. Has been extremely aggressive with staff intervention. Resident smacked this nurse when caught in linen closet shoving five washcloths down his/her pants. Resident later walked by nurse and hit him/her on his/her bottom unprovoked. Resident picked up fly swatter, swung it at nurse and said, I'll smack you. Fly swatter taken from resident and resident retreated to his/her recliner in the common area. Review of the resident's Nurses Notes, dated 10/31/25, at 7:23 P.M., showed the resident swung at another resident but did not make contact. Review of the resident's weight record, dated November 2025, showed no weight was documented for the resident. Review of the resident's Nurses Note, dated 11/01/25, at 3:47 A.M., showed the following:-Resident request snacks and water when awake constantly;-Hides wash cloth and napkins in his/her recliner;-Hoarding wash cloths and napkins. Review of the resident's Nurses Note, dated 11/01/25, at 11:23 A.M., showed the following:-Resident cursing or verbally aggressive;-Scratching or hitting others;-Screaming. Review of the resident's medical record showed staff did not identify what possibly triggered the resident or the root cause of his/her verbal or physical behaviors There were no documented interventions to alleviate the resident's triggers and prevent physical harm to other residents. Review of the resident's Nurses Note, dated 11/02/25, at 3:46 A.M., showed the following:-Resident yells when awakened to go use the bathroom;-Hoarding napkins and washcloths. Review of the resident's Nurses Note, dated 11/03/25, at 3:29 A.M., showed the following:-Resident yells when awakened to go use the bathroom, yells I don't gotta go and is usually already incontinent;-Hoarding napkins and washcloths. Review of the resident's Nurses Note, dated 11/03/25, at 2:22 P.M., showed the resident makes constant request for attention or help. Review of the resident's medical record showed staff did not identify what possibly triggered the resident or the root cause of why the resident was trying to get attention (bored, lonely, etc.). The staff also did not document attempted interventions to alleviate the resident's triggers. Review of the resident's Nurses Note, dated 11/04/25, at 3:50 A.M., showed the following:-Resident yells when encouraged to use the bathroom;-Hoarding napkins and washcloths. Review of the resident's Nurses Note, dated 11/07/25, at 6:17 A.M., showed the resident rammed his/her walker into a peers chair. Resident asked to walk away and hit nurse in the stomach, educated resident. Review of the resident's Nurses Note, dated 11/08/25, at 8:10 P.M., showed the resident observed in linen closet shoving washcloths down his/her pants. The resident also had about 10-15 washcloths in basket of his/her walker. The resident became aggressive with staff intervention and hit a staff member in the stomach when staff asked the resident to exit the linen room. Review of the resident's medical record showed staff did not identify what possibly triggered the resident or the root cause why the resident did not want to go to the bathroom (pain, physical limitation, environment like cold bathroom etc.), or why the resident hoarded napkins or washcloths (or provide the number of napkins/washcloths the resident wanted to discourage him/her taking other residents'). The staff also did not document attempted interventions to alleviate the resident's triggers. Review of the resident's Nurses Note, dated 11/15/25, at 3:50 A.M., showed the following:-Resident had aggression;-Scratching or hitting others. Review of the resident's Nurses Note, dated 11/16/25, at 6:15 A.M., showed the resident complained of chest pain. Vital signs showed temperature 99.0 degrees Fahrenheit, pulse 75 and regular, respirations 21, and blood pressure was 126/63, oxygen saturation 126/63 (all within normal limits). When resident complained of his/her chest pain he/she pointed to his/her mid sternal/epigastric region and stated, I feel like I am going to throw up. The resident described the discomfort as aching. The resident did not want to go to the hospital at this time, Tylenol (medication for pain/fever) 325 mg 2 tabs administered, and Zofran (medication for nausea) 4 mg administered. Resident later said his/her epigastric discomfort/chest pain was no better. Again, asked her if he/she wanted to go to the hospital and he/she replied, I think I better. Notified resident's representative of resident's complaints of chest pain and he/she was OK with sending him/her to the hospital. On call for physician notified. (Resident returned with medication to decrease acid production). Review of the resident's Nurses Note, dated 11/16/25, at 3:03 P.M., showed the following:-Resident was complaining;-Constant request for attention/help;-Cursing/verbal aggression;-Grabbing on to people. Review of the resident's medical record showed the resident did not feel well in the morning and went to the hospital. Staff document the resident was complaining and requesting attention/help, then had increased behaviors including cursing/verbal aggression and grabbing people. There was no evidence staff attempted to identify the root cause for the resident's continuing request for help or respond with interventions to assist the resident to prevent further behaviors. Review of the resident's Nurses Note, dated 11/25/25, at 2:58 P.M., showed the resident has redness in his/her abdominal folds. Left side measured 15 centimeters (cm) in length x 4 cm in width and right side measures 10 cm in length x 4.5 cm in width. The resident also has an excoriated area to the right buttock measuring 4.5 cm in length x 2.5 cm in width. Review of the resident's Nurses Note, dated 11/26/25, at 1:11 P.M., showed the resident has refused both meals this shift. He/She also refused to get up from the recliner and go to the bathroom. Received return fax from Physician R with order to discontinue Seroquel and switch to risperidone 0.5 mg two times daily. Review of the resident's medical record show[TRUNCATED]

Based on observation, interview, and record review, the facility failed to develop complete policies and procedures to monitor the facility's water system and implement the facility policy to monitor for Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)) standards. The facility failed to ensure staff performed proper infection control practices when providing care to one resident (Resident #32), in a review of 17 sampled residents sampled, and for one additional resident (Resident #56). The facility failed to handle linens in a way to prevent contamination. The facility census was 59. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following:-Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water;-CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical and epidemiological considerations for healthcare facilities are described in this toolkit;-Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system;-Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;-Specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's policy Legionella and Water Management Policy, dated 11/01/19 and reviewed 10/31/24, showed the following:-As part of the infection prevention and control program, our facility has a water management program, which is overseen by the maintenance department and the water management team;-The water management team includes the administrator, maintenance, director of nursing and the medical director;-The team is to identify areas in the water system where Legionella can grow and spread to reduce the risk of Legionnaire's disease;-The CDC water prevention toolkit and ASHRAE recommendations have been used in developing a water management program;-A detailed description and diagram of the water system in the facility will include: a. Water intake - comes from the city; b. Cold water delivery; c. Hot water delivery - Hot water heaters; d. Waste - out to sewer-Identification of areas in the water system that could encourage the growth and spread of Legionella include water heaters, filters, showerheads, hoses, personal humidifiers, medical machines such as a Continuous Positive Airway Pressure (CPAP) devices;-Measures used to control the spread of legionella: a. Diagram of where control measures are applied; b. Monitor control limits; c. Documentation of the program. Review of the facility's undated policy, Legionella Surveillance and Detection, showed the following:-Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella;-Legionnaire's disease will be included as part of our infection control program;-Clinical staff will be trained on signs and symptoms affiliated with pneumonia and Legionnaire's and when to notify physician in regard to testing: Cough, shortness of breath, fever, muscle aches, headache, and diarrhea, nausea and confusion associated with Legionnaires disease;-If pneumonia or Legionnaire's disease are suspected, the nurse will notify the physician immediately with an assessment of the resident's condition;-Physician will decide based on assessment if there is a need to test for Legionnaire's disease;-Depending on the severity of illness, a hospital transfer may be initiated;-If Legionella is detected in one or more residents: a. Initiate active surveillance for Legionnaires disease; b. Notify the local health department; and c. Notify the Administrator and Director of Nursing will contact the Department of Health and Senior Services;-The Water Management Team will investigate to possibly locate the source of contamination. Review of the facility policies did not include control limits, specific information for monitoring water temperatures, dead legs, flushing unused areas, monitoring for scaling, sediment, or biofilm within the water system or guidance on what to monitor and what actions to take if any findings were outside facility established parameters. The policies did not include what testing would be done if legionella was suspected. The facility did not implement a water management team or set parameters for the team to monitor. During an interview on 12/11/25, at 9:10 A.M., the Maintenance Director said the following:-He did not know much about Legionella;-He did not know what ASHRAE was or what it stood for;-The facility did not have a water management team or meetings to discuss Legionella;-He had never seen a water flow map in the facility, so he did not think the facility had one;-The facility did not have meetings to discuss anything related to water management. During an interview on 12/15/25, at 3:10 P.M., the Assistant Director of Nursing said she will be the primary Infection Preventionist. She did not know much about Legionella and had not heard about a water management team. During an interview on 12/15/25, at 4:43 P.M., the Director of Nursing said the following:-To her knowledge, the facility did not have a water management team;-To her knowledge, the facility did not screen residents with new cases of pneumonia for Legionella. -The facility did not currently monitor any residents for Legionella. During an interview on 12/15/25, at 4:30 P.M., the Administrator said he started in October 2025 and had not been able to fully evaluate the facility's water management program, however, he knew it was not being done properly. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grew well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Review of the facility's water temperature log, dated 04/01/25, showed the following hot water temperatures: -Dogwood Wing Central Bath 107.4 degrees F;-Dogwood Wing Clean Utility 89.7 degrees F;-Front Men's Bath 103.9 degrees F;-Front Women's Bath 96.4 degrees F. Review of the facility's water temperature log, dated 05/01/25, showed the following hot water temperatures:-Dogwood Wing Central Bath 107.6 degrees F;-Dogwood Wing Clean Utility 90.2 degrees F;-Therapy Bathroom [ROOM NUMBER] degrees F;-Front Men's Bath 86.5 degrees F;-Front Women's Bath 91.9 degrees F. Review of the facility's water temperature log, dated 06/15/25, showed the following hot water temperatures:-Ash Wing Clean Utility 81 degrees F;-Dogwood Wing Central Bath 106 degrees F;-Dogwood Wing Clean Utility 90 degrees F;-Therapy Bathroom [ROOM NUMBER].5 degrees F;-Front Men's Bath 88 degrees F;-Front Women's Bath 90 degrees F. Review of the facility's water temperature log, dated 07/18/25, showed the following hot water temperatures:-Ash Wing Clean Utility 80.5 degrees F;-Dogwood Wing Clean Utility 88 degrees F;-Therapy Bathroom [ROOM NUMBER].5 degrees F;-Front Men's Bath 79 degrees F;-Front Women's Bath 94 degrees F. Review of the facility's water temperature log, dated 08/27/25, showed the following hot water temperatures:-Ash Wing Clean Utility 82 degrees F;-Dogwood Wing Clean Utility 92 degrees F;-Therapy Bathroom [ROOM NUMBER] degrees F;-Front Men's Bath 82.5 degrees F;-Front Women's Bath 91 degrees F. Review of the facility's water temperature log, dated 09/17/25, showed the following hot water temperatures:-Ash Wing Clean Utility 79 degrees F;-Dogwood Wing Clean Utility 87.5 degrees F-Therapy Bathroom [ROOM NUMBER] degrees F;-Front Men's Bath 80 degrees F;-Front Women's Bath 95.5 degrees F; Review of the facility's water temperature log, dated 10/23/25, showed the following hot water temperatures:-Ash Wing Clean Utility 78.5 degrees F;-Dogwood Wing Clean Utility 90 degrees F;-Therapy Bathroom [ROOM NUMBER] degrees F;-Front Men's Bath 82.5 degrees F;-Front Women's Bath 96 degrees F. Review of the facility's water temperature log, dated 11/25/25, showed the following hot water temperatures below 108 degrees F.:-Ash Wing Clean Utility 83 degrees F;-Dogwood Wing Clean Utility 91.5 degrees F;-Front Men's Bath 78 degrees F. The facility provided no documentation showing monitoring of cold-water temperatures. Observation on 12/11/25, at 12:12 P.M. in the A hall Shower/Central bath showed the hot water temperature in the shower was 107.2 degrees F. Observation on 12/11/25, at 12:17 P.M. in the utility room, located around the corner from Dogwood Nurses Station, showed the water temperature was 91.5 degrees F when measured with a digital thermometer. Observation on 12/11/25, at 12:24 P.M. showed room the D hall shower faucet (round works hot and cold) turned to hot read 103.9 degrees F with a digital thermometer, and the faucet turned to the cold side read 80 degrees F with a digital thermometer. The sink in the D hall shower room faucet marked hot read 103 degrees F. Observation on 12/11/25, at 12:30 P.M. showed the C hall shower room sink faucet marked hot read 106.2 degrees F with a digital thermometer. The shower in C hall shower room with a round faucet turn same knob for cold and hot water, showed 101 degrees F for the hot side and 80 degrees F for the cold side. Observation on 12/11/25, at 12:40 P.M. showed room C-42 (occupied resident room) faucet marked hot read 104.7 degrees F with a digital thermometer, and faucet marked cold did not work, when the knob was turned no water came out. Observation on 12/11/25, at 12:44 P.M., in the C hall shower room showed the hot water temperature was 105 degrees F and the cold water temperature was 82 degrees F. During an interview on 12/11/25, at 9:10 A.M., the Maintenance Director said the following:-He did a chlorine test every month on the facility's hot water lines;-The water temperatures that he monitored were on the Water Temperature Log;-The maintenance department made sure the hot water was between 105 and 120 in resident rooms;-If the water temperatures were too low, they rechecked to make sure they were in range, but they did not document it anywhere;-The facility did not monitor any cold water temperatures. 2. Review of Resident #57's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/05/25, showed the following:-Required partial/moderate assistance for chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer;-Required substantial/maximal assistance for shower/bathe, upper body dressing, and lower body dressing;-Dependent on staff for toileting hygiene, put on/take off footwear, and personal hygiene;-Frequently incontinent of bowel and bladder. Observation on 12/10/25, at 6:36 A.M., showed the following:-Certified Nurse Assistant (CNA) DD propelled the resident in his/her wheelchair into the shower room; -CNA DD and CNA E put on gloves without washing their hands; -CNA DD and CNA E transferred the resident from his/her wheelchair to the shower chair;-CNA DD finished undressing the resident;-CNA E picked up trash and soiled linen left from previous residents in the shower room, did not change his/her gloves, and picked up clean items and put them in the cabinet; -CNA E removed his/her gloves, rinsed his/her hands in the sink (less than five seconds), did not use soap, turned the water off touching the knobs, dried his/her hands with paper towels, and left the shower room;-CNA DD proceeded to shower the resident;-CNA E returned to the shower room with clean towels, did not wash hands, and put on gloves;-The resident had a bowel movement during the shower and there was feces on the floor;-CNA DD wiped up the feces on the floor with a washcloth he/she used on the resident. Staff did not disinfect the floor;-CNA DD did not change his/her gloves after cleaning up feces off the floor and washed the resident's perineal area with wash cloths. Feces were observed on the washcloths;-CNA DD rinsed his/her gloves with the shower nozzle and washed the resident's hair while wearing the same soiled gloves;-CNA E bagged the dirty linens and trash from the resident's shower, wiped up water that was going across the floor from the shower, then removed his/her gloves, and without washing hands left the room;-CNA DD dried the resident, dressed the resident, and combed his/her hair with the same gloves he/she used to give the resident a shower and clean feces off the floor and from the resident;-CNA E returned to the shower room, without washing hands, he/she donned gloves;-CNA DD and CNA E placed a gait belt around the resident, assisted the resident to stand, and transferred the resident to his/her wheelchair;-CNA DD and CNA E removed their gloves. CNA DD washed his/her hands and propelled the resident to the common area. CNA E did not wash his/her hands after removing his/her gloves and left the shower room. During an interview on 12/10/25, at 7:10 A.M., CNA E said staff should change their gloves when contaminated. Staff should wash their hands before and after providing care to a resident. Staff should change gloves if they were contaminated and wash their hands if dirty. During an interview on 12/10/25, at 7:12 A.M., CNA DD said staff should wash their hands before and after caring for a resident. Staff should wear gloves if there was any chance of contact with body fluids. Staff should change gloves and wash hands if they were contaminated. Staff should wash their hands when they remove their gloves if they were contaminated. 4. Review of Resident #32's quarterly MDS, dated [DATE], showed the following:-He/She required substantial/maximum assistance with toileting and personal hygiene;-He/She was always incontinent of bowel and bladder. Review of the resident's care plan, last revised on 11/24/25, showed the following:-He/She was incontinent of bowel and bladder;-He/She was at high risk for urinary tract infections (UTIs);-Staff instructed to maintain infection control practices through proper handwashing. Observation on 12/11/25 at 11:40 A.M. showed the following:-The resident sat in his/her recliner and was incontinent of bowel and bladder;-CNA S wore gloves and removed the resident's feces-soiled pants and threw them directly onto the floor. He/She removed his/her gloves, did not wash his/her hands, opened the door to the room, and exited the room;-Feces was smeared on the resident's back, trunk, legs, and was under the resident's fingernails;-CNA S returned to the room, and without washing or sanitizing hands, put on new gloves and cleaned feces from the resident's perineal area and legs with multiple passes with a soapy washcloth. CNA S did not change the surface of the feces soiled cloth with each wipe; -CNA S threw feces soiled linens in a bag on the floor;-While wearing the same soiled gloves he/she wore to provide incontinence care, CNA S dressed the resident, assisted the resident to stand by holding onto the gait belt, removed feces from the resident's back and buttocks with multiple passes with the same surface of a soapy washcloth, and threw feces soiled wash cloths onto the floor;-CNA S did not sanitize the floor after throwing soiled linens on the floor. -Staff cleaned the resident's hands with a disposable wipe, but did not clean under the resident's fingernails. During an interview on 12/11/25 at 12:00 P.M., CNA S said the following:-The bathroom was occupied, so he/she provided the resident's incontinence care in the recliner; -He/She did the best he/she could to clean the resident; -It was almost time for lunch, and he/she didn't have time to take the resident to the shower to properly clean him/her; -He/She tried to get the resident cleaned quickly; -He/She should not have touched clean items with contaminated gloves and should have removed his/her soiled gloves and washed his/her hands. During an interview on 12/15/25, at 4:43 P.M., the Director of Nursing (DON) said the following:-Staff should not perform perineal care while the resident sat in a recliner;-If the resident had extensive soiling, staff should take the resident to the shower to properly clean the resident;-She expected staff to wash the resident's hands if he/she had feces under his/her fingernails;-Soiled linens should never be on the floor;-She expected staff to wash their hands and change their gloves when they were contaminated with body fluids before they touched any other item or area;-She expected staff to wash their hands with every glove change;-Staff were to remove their gloves and wash their hands before leaving a room. 5. Review of the facility's undated policy, Handling Soiled Linen, showed the following:-Soiled Linen: Any linen contaminated with blood, body fluids, secretions, excretions, or visibly dirty materials;-All soiled linen is treated as potentially infectious;-Hands must be washed or sanitized immediately after glove removal;-Place linen directly into designated leak-resistant laundry bags;-Soiled linen must be stored in designated, secure areas separate from clean linen;-Clean linen must never be stored in areas where soiled linen is handled. 6. Observation on 12/08/25, at 12:55 P.M., showed the following:-Housekeeper FF rolled a dirty linen cart next to the dining room in the kitchenette area, the housekeeper had gloves on;-Housekeeper FF went to the cabinet drawer with clean clothing protectors (cloth bibs) and rearranged the drawer;-Housekeeper FF removed unused clothing protectors from the tables and put them back in the drawer;-He/She then picked up soiled clothing protectors from the tables and placed them in the dirty linen barrel;-He/She did not remove his/her gloves or wash his/her hands and picked up unused clothing protectors that were on occupied tables but were still folded and put them in the drawer with other clean clothing protectors with the same soiled gloves; -The housekeeper picked up additional soiled clothing protectors and placed them in the dirty linen barrel;-He/She picked up more unused clothing protectors from other tables and placed them in the cabinet with clean clothing protectors with the same gloves. During an interview on 12/11/25, at 2:32 P.M., Housekeeper FF said clean linen had to be kept separate from dirty linen. Staff were to wear gloves when handling soiled linen. After he/she placed soiled linen in the dirty linen bin, he/she was supposed to remove his/her gloves and wash his/her hands. He/She should not put the unused clothing protectors from the tables in with clean linen. During an interview on 12/15/25, at 4:43 P.M., the Director of Nursing (DON) said the following:-Staff should remove their gloves and wash their hands after touching soiled linens and prior to touching clean linens;-Staff should re-launder unused clothing protectors left on the tables. Staff should not put the clothing protectors back into the drawer with the clean linens.

Based on observation, interview, and record review, the facility failed to ensure food service equipment/surfaces were appropriately cleaned under sanitary conditions in accordance with professional standards for food service safety. The facility census was 59.Record review of the facility's Guideline & Procedure Manual, 2011 Edition, showed the following:-Clean Equipment - All equipment used in food preparation is clean and sanitary. Equipment is washed, rinsed and sanitized after each use. Food contact surfaces are sanitized before they are used with a cleaning cloth that is stored in a sanitizer solution between uses;-Cleaning Rotation - Items cleaned daily (stove top), items cleaned weekly (hood/filters, shelves, ovens), Items cleaned monthly (walls);-Sanitation of Dining and Food Service Areas - The dining services manager will record the necessary cleaning and sanitation tasks for the department, all staff will be trained on the frequency of cleaning, a cleaning schedule will be posted for all cleaning tasks;-Cleaning Instructions (range) - Wipe the outside surface and burner knobs with a cloth soaked in hot, soapy water, scrub drip trays and the front, sides, and back of range with hot water and detergent, or degreaser, wipe the outside surface with a sanitizing solution and allow to air dry;-Cleaning Instructions (oven) - Wash outside of door, door handles and frame with hot, soapy water. 1. Observations in the kitchen on 12/8/25 between 10:05 A.M. and 1:40 P.M., and on 12/9/25 between 6:30 A.M. and 11:50 A.M., showed the following:-The top surface of the steamer oven, located next to the ice machine, had a moderate buildup of dust, debris, and oil;-The top surface of the upright four-door oven, located next to the four-burner stove top, had a moderate to heavy buildup of dust, debris and oil/grease coating;-The stainless-steel shelf above the four-burner stove top/griddle had a moderate buildup of dust, debris and oil;-Six range hood fire suppression nozzle cables, located above the four-door oven, four-burner stove top/griddle and deep fryer, had a moderate to heavy buildup of dust, debris and oil/grease coating;-A wall-mounted, metal electrical receptacle box and wire channel, located along and above a stainless-steel preparation table and behind a toaster and microwave oven, had a heavy buildup of dust, debris and oil/grease coating. During an interview on 12/8/25 at 1:15 P.M., [NAME] O said he/she had not noticed the identified areas with dust, debris, and oil/grease buildup. There was no set cleaning schedule for the identified areas. During an interview on 12/9/25 at 9:55 A.M., the Assistant Dietary Manager said the following:-She was not aware of the identified areas with a buildup dust, debris, oil, and grease. Some of the areas were on top of equipment and were more difficult to observe without a ladder;-The Dietary Manager and Assistant Dietary Manager monitored the kitchen daily. No logs are maintained for the identified areas;-She preferred the identified areas be kept clean. Staff working in those areas should clean the area after each meal. During an interview on 12/9/25 at 10:25 A.M., the Dietary Manager said the following:-The cooks and the Assistant Dietary Supervisor should monitor the identified areas weekly; -He was not aware of the identified areas having a dust, debris, and oil or grease;-He wanted the kitchen and identified areas to be clean and monitored.

Based on interview and record review, the facility failed to ensure staff training needs, as identified in the facility assessment, were met for four certified nurse assistants (CNA)s, in a review of five CNAs who were employed by the facility for over one year. Review showed the staff failed to complete the required 12 hours of training per year as required to maintain their certification, including dementia management and resident abuse prevention training. The facility census was 59. Review of the facility Assessment, dated 11/20/25, showed the following education requirements:-Resident Rights on hire, annually and as needed;-Abuse, neglect, and exploitation on hire, annually and as needed;-Infection Control on hire, annually and as needed;-Changes in Condition as needed.-Staff shall complete education to maintain their certifications/licenses. 1. Review of CNA HH's employee file showed his/her hire date as 11/13/17. Review of CNA HH's training record dated 12/01/24-12/15/25, showed he/she did not complete any training during that period. The facility did not have any other training record documented for the employee. 2. Review of CNA II's employee file showed his/her hire date as 10/16/23. Review of CNA II's training record, dated 12/01/24-12/15/25, showed the following: -Abuse, Neglect and Exploitation 0.75 hours completed on 03/06/25;-Dementia Care 0.5 hours completed on 04/04/25;-Transmission Based Precautions 0.5 hours completed on 07/01/25;-Workplace emergencies and Natural Disasters -0.5 hours completed on 07/01/25;-Patient Information Privacy and security 0.15 hours completed on 07/15/25;-Resident Rights 1 hour of training completed on 08/27/25;-Dementia care 0.5 hours of training completed on 09/05/25.(The employee's training record showed four hours of education completed in the last year. The facility did not have any other training record documented for the employee.) 3. Review of CNA JJ's employee file showed his/her hire date as11/19/22. Review of CNA JJ's training record dated 12/01/24-12/15/25, showed he/she did not complete any training during that period. The facility did not have any other training record documented for the employee. 4. Review of CNA F's employee file showed his/her hire date as 08/14/23. Review of CNA F's training record dated 12/01/24-12/15/25, showed the following: -Dementia Care 0.5 hours completed on 12/27/24;-Resident Rights 1 hour of training completed on 12/27/24;-Transmission Based Precautions 0.5 hours completed on 12/27/24;-Patient Information Privacy and security 0.15 hours completed on 12/27/24;-Employee Wellness, Managing Stress 0.25 hours completed on12/22/24.(The employee's training record showed two hours and 45 minutes of education completed in the last year. The facility did not have any other training record documented for the employee.) 5. During an interview on 12/10/25, at 2:59 P.M., the Director of Nursing said the following:-The facility had a web-based training that recorded the employees' training;-She found when reviewing the records that most staff had not completed the required trainings; -She had not had the opportunity to evaluate each employees' training records;-The facility was in the process of deciding how to ensure education was completed, along with competencies and evaluations, but it was not complete at this time. During an interview on 12/09/25, at 11:00 A.M., the Administrator said the facility did not keep good education records. They were using a web-based education system, but from what he could tell, they did not ensure the employees completed required training.

Based on observation, interview, and record review, the facility failed to complete a comprehensive assessment, including a review of the clinical rationale and approved indication for use of psychotropic medications, for three residents (Residents #14, #69, and #41) with a diagnosis of dementia, in a review of five residents selected for review of unnecessary medications, prior to utilizing anti-psychotic medications to treat the residents' behaviors. The facility failed to consistently identify and implement non-pharmacological interventions to address the residents' behaviors. The facility failed to conduct a gradual dose reduction (GDR) or provide documentation a GDR was clinically contraindicated for one resident's (Resident #14) antidepressant medication. The facility census was 59.Review of the facility's policy Psychotropic Medication, dated 10/16/24, showed the following:-Our facility will make every effort to comply with state and federal regulations related to the monitoring and use of psychopharmacological medications, this will include regular review for the continued need, appropriate dosage, side effects, risks and/or benefits;-Psychotropic medications: antipsychotics, antidepressants, antianxiety medications, hypnotics, mood stabilizers, anticonvulsants, muscle relaxants, anticholinergic medications, and antihistamines;-A nurse prior to requesting the need for this medication will do the following: a. Try to determine the underlying cause of the behavioral symptoms and take action to correct it; b. Document all interventions attempted prior to use or request of psychoactive medication. This includes but not limited to environmental changes, medical interventions such as pain medication and/ or evaluation for a change in condition. c. Evaluate/monitor the effects of the medications on the resident's behavior and keep physicians informed.-Nursing staff will develop a behavioral care plan and document behaviors:-Consulting pharmacist/physician: -Monitors psychotropic drug use in the facility to ensure that medications are not used in excessive doses or for excessive duration; -Participates in the interdisciplinary quarterly review of residents on psychoactive medications; -Notifies the physician and the Director of Nursing (DON) if whenever a psychotropic medication is past due for review. -Attempt a gradual dose reduction (GDR) decrease or discontinuation of psychotropic medications after no more than three months unless clinically contraindicated. Gradual dose reduction must be attempted for two separate quarters (at less one month between attempts). -Gradual dose reduction must be attempted annually thereafter or as a resident's clinical condition warrants, unless the physician has documented at least annually that this would not be indicated or in the resident's best interest.-After a medication is ordered each psychotropic medication must have a corresponding behavior appropriate for that classification the medication is ordered for;-These behaviors will be monitored and documented on the behavioral flow sheet every shift.-Types of medication and monitoring: -Antipsychotic medications common side effects include involuntary movements, including muscle spasms, tremors; stroke; dizziness; constipation; dry mouth; blurred vision, weight gain; sleepiness; -Antidepressants medications common side effects include dry mouth, nausea, vomiting, diarrhea, poor sleep, headache, dizziness, agitation, sleep problems, appetite issues, weight gain; -Sedatives common side effects include drowsiness, dizziness, poor concentration, confusion, impaired judgment, slowed breathing, blurred vision, impaired depth perception, slowed reaction times and reflexes. Review of the facility's undated policy, Antipsychotic Medication and Gradual Dose Reduction (GDR), showed the following:-To ensure that residents in this skilled nursing facility receive antipsychotic medications only when clinically appropriate, that gradual dose reductions are attempted when possible, and that all medication use is based on the resident's individual needs and regulatory guidance.-Antipsychotic medications shall only be used when: a. The resident has a documented diagnosis that justifies use (e.g., schizophrenia, bipolar disorder, Tourette's disorder), and b. non-pharmacological interventions have been attempted and documented;-Before Prescribing -Conduct a comprehensive assessment to identify the cause of behavioral symptoms; -Implement and document non-pharmacological interventions (e.g., environmental changes, structured activities, behavioral therapy);-Initiation of Antipsychotic: -Document specific diagnosis and clinical indications; -Set clear target behaviors/symptoms and measurable outcomes; -Review medication in the interdisciplinary team meeting and care plan. 1. Review of Resident #14's face sheet showed the resident had a diagnosis of Alzheimer's disease, dementia, and anxiety. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 05/22/25, showed the following:-Moderate cognitive impairment;-No behaviors, hallucinations, delusions, or rejection of care;-Independent with transfers and ambulation 150 feet;-Used a walker;-Antidepressant medication used daily. Review of the resident's Physician's Orders, dated 07/17/25, showed an order for Seroquel (an antipsychotic medication) 25 mg daily for anxiety disorder. Review of drugs.com for Seroquel showed the following:-Seroquel is an atypical antipsychotic medication used to treat schizophrenia, mania or manic disorders, and depression with bipolar disorder;-Seroquel warnings included: Increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death;-Seroquel is not approved for the treatment of patients with dementia-related psychosis. Review of the resident's medical record showed no documentation to show the rationale for the new order for Seroquel, ordered July 2025. Review showed no evidence the resident had a diagnosis of schizophrenia, manic disorders or bipolar disorder. Review of the resident's Care Plan, updated 08/11/25, showed the following:-Behavior management program:-The resident requires ongoing redirection, monitoring and structured activities to alter behavior problems;-Smacks staff and peers on buttocks, hits staff on arms, and goes into linen room for washcloths numerous times;-Refuses to go to meals at times and then wants snacks and fluids;-Refuses incontinence care at times;-The resident takes handfuls of napkins out of holders and puts them in his/her pants;-The resident will respond to redirection from staff when behavior occurs thru next review;-The resident will engage in on and off unit programs to maintain current sensory awareness thru next review;-Encourage family involvement in care and visits;-Provide structured programs appropriate for the resident's cognitive status;-Social service intervention and evaluation as needed; -Prompt resident to not smack or hit staff;-Different staff to re-approach the resident when he/she refused incontinence care and meals;-Medication changes;-Gentle approaching and re-direction;-Staff will monitor him/her closely when around peers;-The resident was moved into a room by himself/herself due to resident-on-resident altercations. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Physical behavioral symptoms directed towards others one to three days in the seven-day look back period;-Diagnosis of Alzheimer's/dementia;-New antipsychotic medication daily;-Antidepressant medication daily. Review of the resident's Physician's Orders, dated September 2025, showed the following:-An order for Lexapro (an antidepressant medication) 10 milligrams (mg) daily for anxiety disorder (original order dated 09/16/24);-An order, dated 09/03/25, to increase Seroquel 25 mg daily to two times per day for a diagnosis of dementia. Review of the resident's medical record showed no documentation a gradual dose reduction (GDR) was recommended for the resident's Lexapro (originally ordered on 9/16/24) and no documentation a GDR was contraindicated. Review of the resident's Nurses Notes, dated 09/13/25, at 8:45 P.M., showed at supper the resident walked by a peer and pulled his/her hair unprovoked. Immediate staff intervention and separation of residents. The resident then re-approached peers' table and was bothering them while they were trying to eat, again requiring staff intervention. At this time, the resident swung at the nurse, attempting to hit him/her. The resident was very difficult to redirect and has been aggressive each time with staff intervention. Review of the resident's Nurses Notes, dated 09/18/25, at 10:23 P.M., showed the resident was not cooperative with staff during this shift. He/She made repeated efforts to take napkins out of the holders and hide them. He/She continued to try to put the shades down, although the other residents asked him/her not to do so. He/She yelled at another resident about taking the napkins when the other resident tried to stop him/her. He/She made repeated attempts to obtain beverages and would not take redirection (including trying to pour water from the pitcher on the medication cart). Review of the resident's Nurses Notes, dated 09/24/25, at 4:07 P.M., showed the resident refused breakfast or to get up to the bathroom. At lunchtime, he/she screamed at staff numerous times. Once he/she was up, he/she was obsessed with getting wash cloths and napkins which he/she put inside his/her pull up, so he/she didn't have to get up to go to the bathroom. The resident got angry at staff when he/she was redirected and hit staff. Updated physician on the resident's behaviors. Review of the resident's Nurses Notes, dated 09/26/25, at 6:02 P.M., showed the physician's response to the fax about behaviors was, I just increased Seroquel last week, gently redirect for now. Review of the resident's Nurses Notes, dated 09/28/25, at 10:35 A.M., showed the resident was becoming physically aggressive toward other residents. This resident was noted to bend another resident's left index finger back after the resident placed his/her hand over the napkin dispenser on his/her table to prevent this resident from taking it. This resident smacked another resident in the face on the left side. The resident hits staff unprovoked when he/she passes by them. The resident was unable to be redirected. Call placed to the on-call nurse practitioner to update on behavior. Requested order to possibly send to emergency room for evaluation. Order received for Haldol (haloperidol, antipsychotic medication) 5 mg intramuscular (IM; injection into the muscle) one time if resident continues to be physically aggressive toward other residents. Review of the resident's Physician's Orders, dated 09/28/25, showed an order for haloperidol lactate 5 mg/milliliter (ml), inject intramuscularly for one dose for dementia. Review of drugs.com for haloperidol showed the following:-Haloperidol is a typical antipsychotic medication used for schizophrenia, to treat motor control and speech ticks for Tourette's Syndrome (neurologic disease that presents with multiple tics);-Warnings: Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo;-Haloperidol injection is not approved for the treatment of patients with dementia-related psychosis. Review of the resident's Nurses Notes, dated 09/28/25, at 1:20 P.M., showed the resident continued to be physically aggressive toward staff and raised his/her hand to slap another resident again when the resident stopped this resident from removing napkins from his/her tray. Staff intervened and no contact made between residents. Haloperidol 5 mg given IM in right gluteal (muscle in the buttocks). Review of the resident's Nurses Notes, dated 09/28/25, at 7:17 P.M., showed the resident walked by a peer and smacked him/her on the bottom. Immediate staff intervention and separation of residents. Staff instructed the resident to keep his/her hands to himself/herself. The resident laughed and walked away. Review of the resident's Nurses Notes, dated 10/12/25, at 9:56 P.M., showed the resident was very demanding and verbal this shift, constantly asking for snacks and drinks. He/She was not taking redirection well. He/She made numerous attempts to obtain washcloths and napkins and became loud and belligerent when staff attempted to take them from him/her. Review of the resident's Nurses Notes, dated 10/17/25, at 8:19 P.M., showed the resident continued with fixation of collecting napkins and washcloths. The resident has been extremely aggressive with staff intervention. The resident smacked this nurse when caught in linen closet shoving five washcloths down his/her pants. The resident later walked by the nurse and hit him/her on his/her bottom, unprovoked. The resident picked up a fly swatter, swung it at the nurse and said, I'll smack you. Staff took the fly swatter away from the resident, and the resident retreated to his/her recliner in the common area. Review of the resident's Nurses Notes, dated 10/31/25, at 7:23 P.M., showed the resident swung at another resident, but did not make contact. Review of the resident's Nurses Notes, dated 11/01/25, at 11:23 A.M., showed the following:-The resident cursed or was verbally aggressive;-The resident scratched or hit others and was screaming. Review of the resident's Nurses Notes, dated 11/07/25, at 6:17 A.M., showed the resident rammed his/her walker into a peer's chair. Staff asked the resident to walk away, and he/she hit the nurse in the stomach. Staff educated the resident. Review of the resident's Nurses Notes, dated 11/08/25, at 8:10 P.M., showed the resident was observed in the linen closet shoving washcloths down his/her pants. The resident also had about 10-15 washcloths in the basket of his/her walker. The resident became aggressive with staff intervention and hit a staff member in the stomach when staff asked the resident to exit the linen room. Review of the resident's Nurses Notes, dated 11/15/25, at 3:50 A.M., showed the following:-The resident had aggression;-The resident scratched or hit others. Review of the resident's Nurses Notes, dated 11/16/25, at 3:03 P.M., showed the following:-The resident was complaining;-The resident made constant request for attention/help;-The resident cursed and had verbal aggression; -The resident grabbed onto people. Review of the resident's Nurses Notes, dated 11/26/25, at 1:11 P.M., showed the resident refused both meals this shift. He/She also refused to get up from the recliner and go to the bathroom. Received return fax from Physician R with order to discontinue Seroquel and switch to risperidone (an antipsychotic medication for hallucinations and delusions) 0.5 mg two times daily. Review of the resident's Physician's Orders, dated 11/26/25, showed the following:-An order to discontinue Seroquel;-An order for risperidone 0.5 mg two times daily for dementia. Review of drugs.com for Risperidone showed the following:-Risperidone is an antipsychotic medication used to treat schizophrenia (chronic brain disorder that disrupts how a person thinks, feels, and behaves, causing them to lose touch with reality (psychosis) through symptoms like hallucinations (hearing voices/seeing things), delusions (false beliefs), disorganized speech, and unusual motor behavior), bipolar disorder (a mental health condition causing extreme mood swings between emotional highs (mania/hypomania) and lows), and agitation related to autism (neurodevelopmental disorder effecting social interaction and communication);-Risperidone carries a warning for increased risk of death in elderly patients with dementia-related psychosis;-Risperidone is not approved for use in older adults with dementia-related psychosis. Review of the resident's documents, dated 12/02/25, showed a fax to the resident's physician and the physician response. On 12/02/24, at 5:45 A.M., the nurse sent: The resident has been very sleepy this past week, lethargic on night shift. The resident had to use a wheelchair to transport to and from the bathroom. The resident started risperidone 0.5 two times daily on 11/27/25. The physician responded on 12/02/25 (no time listed) to decrease the risperidone to 0.5 mg at bedtime. Review of the resident's Physician's Orders, dated 12/03/25, showed an order for risperidone (an antipsychotic medication for hallucinations and delusions) 0.5 mg daily at bedtime for Alzheimer's. Review of the resident's Nurses notes, dated 12/07/25, at 3:49 A.M., showed the resident required the use of a wheelchair and two staff to transfer him/her. He/She will not stand. Observation on 12/08/25 at 12:00 P.M. to 1:10 P.M. (continuous observation from when the meal tray cart was opened until most residents left the dining area), showed the resident sat in a recliner with his/her legs elevated in the common area. The resident's eyes remained closed during all observations. Observation on 12/10/25, at 6:15 A.M. and 6:45 A.M., showed the resident sat in a recliner in the common area with his/her eyes closed. Observation on 12/10/25 at 11:50 A.M. to 12:20 P.M., showed the resident sat in a recliner in the common area with his/her legs elevated and his/her eyes closed. During an interview on 12/19/25, at 8:50 A.M., the resident's physician, Physician R, said the following:-He/She did not use Haldol to treat his/her elderly residents. He/She did not prescribe Haldol for Resident #14. An on-call physician must have prescribed the medication; -He/She changed the resident's Seroquel to risperidone (on 11/26/25) because the nursing staff reported repeatedly the resident had an increase in behaviors;-She felt like the residents could benefit from staff having more training on non-pharmacological interventions. Conservative interventions were the best way to manage dementia behaviors. 2. Review of Resident #69's face sheet showed he/she was admitted [DATE]. Review of the resident's Physician's Orders Sheet, dated 12/01/25, showed the following:-Trazodone (an antidepressant medication also used to treat anxiety and insomnia) 50 mg daily at bedtime for dementia;-Olanzapine (an antipsychotic medication) 2.5 mg daily for dementia. Review of drugs.com showed the following:-Olanzapine is an atypical antipsychotic that may be used to treat schizophrenia or bipolar disorder;-Olanzapine carries a Boxed warning for an increased risk of death in elderly patients with dementia-related psychosis. An increased risk of death, strokes, or mini-strokes called transient ischemic attacks (TIAs) have been reported in elderly people taking olanzapine who are confused, have memory loss, or have lost touch with reality (dementia-related psychosis). These people should not be given olanzapine;-Olanzapine is not approved for the treatment of patients with dementia-related psychosis. Review of the resident's Care Plan, dated 12/02/25, showed the following:-Psychotropic drug use with the potential for Adverse Drug Reaction (ADR);-The resident is on medication for dementia and to assist him/her to sleep at night;-Monitor for behaviors and side effects of medication including but not limited to tongue protrusion, grimacing, rapid eye blinking, lip smacking, pursing, or puckering, rapid movement of the arms or legs, or other involuntary movements of the head, face, neck and tongue muscles. Report findings to nurse;-Monitor for behaviors and side effects of psychotropic medication to include any of the following: Drowsiness, dizziness, dry mouth, blurred vision, tiredness, nausea, constipation, weight gain, trouble sleeping or muscle or nervous system problems (anxiety, agitation, jitteriness, drooling, trouble swallowing, restlessness, shaking or stiffness);-Report any behavior changes to the charge nurse: increased sleeping or restlessness.-The resident has cognitive deficits related to dementia and metabolic encephalopathy. Review of the resident's Nurses Notes, dated 12/03/25, at 9:18 P.M., showed the resident was constantly wandering around the unit, into other residents' rooms trying to eat other residents' snacks in their room, and constantly needing redirections. The resident was exit seeking, tried to find his/her car, and tried to go home. The resident was easily redirected, then forgets and continues the same behavior. The resident ended up near the back door trying to leave. Review of the resident's Nurses Notes, dated 12/04/25, at 6:48 A.M., showed the resident was confused and not orientated to place. The resident kept making different claims he/she has a ride to catch, look at the animals outside, and more. Staff found the resident on B hall, at the back entrance of the facility, and was at the entrance of other resident rooms. The resident has been redirected multiple times. The resident was unaware of his/her location, and the resident was restless. Both Certified Nurse Assistants (CNAs) have reported the resident has attempted to walk out the fire exit on A hall. The other CNA on staff said the resident was staring at the CNA and grabbed hold of his/her privates. The resident was redirected back to his/her bedroom. Review of the resident's Care Plan, updated 12/04/25, showed the following:-Behavior symptoms of wandering/risk of elopement;-The resident exhibits wandering behavior as evidenced by talking about going home frequently and is very confused (dementia) and has notable short-term memory loss;-Administer medications as ordered by the physician;-Document in the progress notes intensity, duration or frequency of behavior;-Redirect negative behaviors;-Regularly assess and evaluate risks for elopement;-Social service evaluation and follow-up. Review of the resident's Nurses Notes, dated 12/04/25, at 9:45 P.M., showed new orders received this evening for Seroquel 25 mg two times daily at 8:00 A.M. and 8:00 P.M. and Ambien (zolpidem - hypnotic medication) at bedtime. The resident has been exit seeking constantly, going into other residents' rooms, getting into other residents' and staff belongings. The resident was caught attempting to get into the medication cart, attempting to open closed doors, and arguing when staff attempt to redirect. The resident told a CNA that if he/she didn't let him/her out of here, he/she would bring hell down on everyone here. A staff member had to always be at the nurses station to keep an eye on the resident. Will administer new medications when they arrive and continue to monitor. Review of the resident's Physician's Orders, dated 12/04/25, showed the following:-Ambien 2.5 mg at bedtime;-Seroquel 25 mg twice daily. Review of the resident's Nurses Notes, dated 12/05/25, at 6:29 A.M. and 6:41 A.M., showed the resident was wandering into other resident's rooms and exit seeking from 11:46-1:20 A.M. The resident was looking for his/her spouse, and kitty. The resident was cooperative with redirection. Review of the resident's Nurses Notes, dated 12/07/25, at 9:57 P.M., showed the resident was talking to staff and messing with things on the counter. The resident was listening in on a conversation a couple CNAs were having, and the resident made the comment, All you need is one of these to take care of it while motioning using a shotgun. The resident was informed that his/her comment was inappropriate, and staff asked him/her not to say things like that again. Later in the evening after supper, the resident saw a CNA walking another resident into the sitting area, and the resident said to the CNA, Oh, are you training a new hooker? Staff informed the resident that what he/she said was mean and disrespectful, and the resident started laughing. The resident asked another CNA if they had a spare knife. The CNA asked what he/she wanted a knife for, and the resident made stabbing and cutting motions in his/her hand and laughed. A few moments later, the resident said, America will be nuked soon, you'll see. The resident made comments to the CNAs asking them to help him/her in the bathroom, help him/her get into bed, if they would join him/her in bed. This nurse called the physician and informed him/her of what was going on and he/she ordered to have the resident's Seroquel changed from 25 mg to 50 mg twice a day. A urinalysis was ordered for suspected urinary tract infection and a one-time order for Haldol 5 mg/ml injection, give 1 ml. The physician would like for the resident to have an appointment with geriatric psychiatrist soon for evaluation. This nurse contacted the resident's power of attorney (POA) and notified them of the changes in behavior and changes in medication. The resident's POA said the last time the resident took Seroquel; the medication did not work well with him/her and that it made his/her behaviors worse. Will make the physician aware of this to see if he/she would like resident to continue to take it. Will continue to monitor. Review of the resident's Physician's Orders dated 12/07/25, showed the following new orders: -Seroquel 25 mg two times daily for dementia was discontinued;-New order for Seroquel 50 mg two times daily; -Haloperidol lactate 5 mg/ml injection, administer now, for dementia. Review of the resident's Medication Administration Record, dated 12/07/25, showed staff administered haloperidol lactate 5 mg/ml, 1 ml (5 mg) by injection, intramuscularly. Review of the resident's Nurses Notes, dated 12/08/25, at 6:41 A.M., showed the resident awoke at 1:00 A.M. The resident was up walking in the hallway with an unsteady gate. The resident was groggy and disoriented and had an episode of bowel incontinence. The resident was not easily redirected to his/her room and was not allowing staff to clean him/her up. The resident was assisted back to bed and went to sleep. The resident was found wandering in the hallway with no pants or underwear at 4:00 A.M. The resident thought he/she was in his/her house. Redirected back to his/her room and helped back to bed. Review of the resident's Nurses Notes, dated 12/08/25, at 1:16 P.M., showed the nurse faxed the physician regarding the recent episodes with the resident. The physician said it was not the medications, it was the disease progression, dementia with agitation. The physician said he/she was called last night for orders. Ordered to do a urinalysis, discontinue Seroquel and change to risperidone 1 mg twice daily. Obtain geriatric psychology consult. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 12/08/25, showed the following:-admitted [DATE];-Severe cognitive impairment;-Mild depression symptoms;-The resident had delusions (misconceptions or beliefs that are firmly held contrary to reality);-No behaviors or rejection of care;-The resident was physically independent with ADLs but required one staff member to set up or cue resident;-Diagnosis include a urinary tract infection, dementia, chronic obstructive pulmonary disease, metabolic encephalopathy (a broad term for brain dysfunction (confusion, coma, personality changes) caused by an underlying chemical imbalance or illness affecting the body's metabolism), accidental opium poisoning;-No psychoactive medications or injections checked;-Antipsychotics were received on a routine basis only. Review of the resident's Physician's Orders, dated 12/09/25, showed a new order for risperidone 1 mg twice daily for dementia with other behavioral disturbances. Review of drugs.com for risperidone showed the following:-Risperidone is an antipsychotic medication used to treat schizophrenia, bipolar disorder, and agitation related to autism;-Risperidone carries a warning for increased risk of death in elderly patients with dementia-related psychosis;-Risperidone is not approved for use in older adults with dementia-related psychosis. Review of the resident's Nurses Notes, dated 12/10/25, at 2:47 P.M., showed the resident remains restless and irritable. The resident goes into other residents' rooms, follows staff into other residents' rooms and attempts to open exit doors. Review of the resident's Nurses Notes, dated 12/10/25, at 3:39 P.M., showed from 3:00 P.M. to 3:30 P.M., the resident has been under the dining room table. He/She put the chairs on top of the table and turned the table over. 3. Review of the Resident #41's admission MDS, dated [DATE], showed the following:-He/She admitted on [DATE];-His/Her cognition was severely impaired;-Diagnoses included non-Alzheimer's dementia, anxiety, and depression;-He/She had verbal and physical behaviors toward others;-He/She used psychotropic medication. Review the resident's Nursing Progress Note, dated 10/01/25 at 1:52 P.M., showed the resident was combative this morning. He/She did not want to be up but wanted to sleep. Review of the resident's Nursing Progress Note, dated 10/04/25 at 1:29 P.M., showed the resident's mood was very snappy, and he/she was short with the nurse. Review of the resident's Nursing Progress Notes showed no documented behaviors on 10/05/25 or 10/06/25. Review of the resident's Nursing Progress Note, dated 10/07/25 at 10:38 A.M., showed a new order was received to increase Seroquel to 100 mg at bedtime (HS). (Review showed no documented behaviors.) Review of the resident's Nursing Progress Notes, dated 10/07/25 through 10/10/25, showed no documented behaviors or agitation. Review of the resident's Physician Progress Note, dated 10/10/25, showed the following:-Nursing staff reported resident was having some issues with agitation, so Seroquel was increased to 100 mg;-The resident has been falling asleep a lot;-Diagnoses included vascular dementia with agitation;-Plan included to increase Seroquel. Review of the resident's Care Plan, last reviewed 10/10/25, showed the following:-He/She was on medication for generalized anxiety disorder;-He/She was combative with care at times and refusing medications at times;-He/She would show a decrease in episodes of physical aggression towards staff during careand will take his/her medications as ordered by next review;-Administer medications as ordered by physician;-Allow time to de-escalate and reapproach if agitated. Review of the resident's Physician's Orders, dated December 2025, showed the following:-Quetiapine (Seroquel) 100 mg tablet once daily at bedtime for diagnosis vascular dementia with agitation (original order dated 10/13/25); -Behavior charting every shift. Review of the resident's Progress Notes, dated 10/10/25 through 11/01/25, showed no documentation of any behaviors including verbal/physical aggression towards others or increased agitation. Review of the resident's Behavioral Charting, dated 11/6/25 at 6:33 P.M., showed the resident constantly requested attention or help. Review of the resident's Behavioral Charting, dated 11/14/25 at 9:27 P.M., showed the resident became agitated because no one came to his/her aid. He/She was in his/her room in bed with his/her call light on his/her chest, but he/she did not press the button. He/She yelled from his/her room. The nurse heard him/her and responded immediately. The resident said he/she was yelling for a while and was educated about using the call light rather than yelling for help. He/She said he/she needed to go to the bathroom. The nurse assisted the resident to the bathroom. Review of the resident's Behavioral Charting, dated 11/20/25 at 8:19 P.M., showed the resident constantly requested attention or help. Review of the resident's Behavioral Charting, dated 12/7/25, showed the resident was awake frequently throughout the night and kept trying to get out of bed and required redirection. Observation on 12/08/25 at 12:30 P.M. showed the resident calmly ate lunch in the dining room without any behaviors or agitation. Observation on 12/10/25 at 7:00 A.M. showed the resident lay in his/her bed with his/her eyes closed. Observation on 12/09/25 at 9:45 A.M., showed the resident slept in the recliner located in his/her room. Observation on 12/15/25 at 2:05 P.M. showed the resident calmy sat in a recliner watching television and eating a snack in sitting area in front of nurse's station. During an interview on 12/15/25 at 12:40 P.M., CNA N said the following:-The resident did not become agitated when he/she cared for him/her;-Before the resident came to t[TRUNCATED]

Based on observation and interview, the facility failed to ensure independently motorized exhaust ventilation units were free from a buildup of dust/debris. The census was 59. 1. Observations on 12/10/25 from 6:30 A.M. to 2:41 P.M., during the life safety code tour of the facility, showed the following:-In the men and women bathrooms at the main entrance, the vent covers on the independently motorized ventilation units were covered with a moderate to heavy buildup of dust/debris;-In the A-Hall shower room, the vent cover on the independently motorized ventilation unit was covered with a moderate to heavy buildup of dust/debris;-In room A-02 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris;-In room A-03 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris;-In room A-04 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris;-In the C-Hall central bath, the vent cover on the independently motorized ventilation unit was covered with a moderate to heavy buildup of dust/debris;-In room C-43 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris;-In room C-44 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris;-In room C-48 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris;-In room C-50 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate to heavy buildup of dust/debris;-In room C-53 bathroom, the vent cover on the independently motorized ventilation unit was covered with a light to moderate buildup of dust/debris;-In room D-64 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris;-In room D-65 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris;-In SCU-101bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris;-In SCU-103 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris;-In SCU-107 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate to heavy buildup of dust/debris;-In SCU-109 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris;-In SCU-111 bathroom, the vent cover on the independently motorized ventilation unit was covered with a light to moderate buildup of dust/debris;-In SCU-113 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris;-In SCU-114 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris;-In SCU-115 bathroom, the vent cover on the independently motorized ventilation unit was covered with a moderate buildup of dust/debris. During an interview on 12/11/25 at 4:00 P.M., the Maintenance Director said he was not aware of the dust and debris covering the vent covers to the independently motorized ventilation units. It was the maintenance departments responsibility to monitor the units at least monthly. He was not sure when each ventilations units were last inspected and cleaned.

Based on observation, interview and record review, the facility failed to ensure residents were awakened according to their preferences or according to how they were feeling that morning for one resident (Resident #57), in a review of 17 sampled residents, and three additional residents (Resident #14, #9 and #29). Per staff interview, for facility convenience, the facility had developed a get up list and early morning shower list for specific residents. This schedule was not consistent with the residents' plan of care. The facility census was 59. Review of the facility policy, Your Rights and Protections as a Nursing Home Resident, undated, showed the following:-As a nursing home resident, you have certain rights and protections under Federal and state law that help ensure you get the care and services you need; -You have the right to make your own decisions;-At a minimum, Federal law specifies that nursing homes must protect and promote the following rights of each resident;-Be Treated with Respect: You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose; -You have the right to decide when you go to bed, rise in the morning, and eat your meals. Review of the facility's Willow/Walnut (Special Care Unit (SCU) halls) 11:00 P.M. to 7:00 A.M. Natural Awakening List, updated 12/10/25, showed the following:-Night shift staff are responsible to get up a specific list of residents, including Residents #29, #14, #57 and #9 (six other residents were listed);-Night shift shower schedule (early morning showers-before 7:00 A.M.) included a list of specific residents for specific days, including Resident #57 (four other residents were listed). 1. Review of Resident #57's Care Plan, last updated 06/23/25, showed the following:-Resident's Activities of Daily Living (ADLs): dependent on staff for showers, locomotion, toileting and eating; -Substantial/maximum assist from staff for dressing, oral/personal hygiene; -Partial/moderate assist for transfers, ambulation; supervision/touching assist for bed mobility;-Incontinent of bowel and bladder, and wears pull ups;-The resident prefers to awaken around 7:00 A.M. and go to bed around 10:00 P.M.;-The resident prefers his/her showers during the day;-When he/she is restless at bedtime, he/she is brought to the common area to a recliner, he/she then will fall asleep;-He/She can make position changes on his/her own. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/05/25, showed the following:-Severe cognitive impairment;-Resident was not able to complete the interview for daily preferences;-Walker and wheelchair use;-Requires supervision/touching assistance from staff members for roll right and left, sit to lying, lying to sitting on bed side, and sit to stand;-Requires partial/moderate assistance from staff for eating, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer;-Requires substantial/maximal assistance from staff for shower/bathe, upper body dressing, and lower body dressing.-Dependent on staff for oral hygiene, toileting hygiene, put on/take off footwear, personal hygiene, wheeling wheelchair (50 and 150 feet);-Frequently incontinent of bowel and bladder. Observation on 12/10/25 at 6:30 A.M., showed the following:-Certified Nurse Assistant (CNA) E and CNA DD went into the resident's room;-The resident was in bed with his/her eyes closed;-CNA DD left the resident's room and said he/she would return;-CNA E attempted to wake the resident;-CNA E said the resident's name several times, rubbed the resident's arm, slightly shook the resident's hand, said the resident's name repeatedly and the resident did not respond in any way;-CNA DD returned to the resident's room and CNA E told CNA DD, I could not wake him/her (the resident) up, and when he/she made rounds at 3:00 A.M. the resident sat straight up, so he/she worried the resident may not be ready to get up this morning;-CNA DD said, let's sit the resident up and see if he/she wakes up;-CNA DD took the resident's upper body, shoulders and torso, and CNA E the resident's lower body, hips and legs, and sat the resident to the side of the bed;-The resident did not open his/her eyes;-CNA DD came over to the right side of the resident's bed and the CNA's put a gait belt on the resident, the resident's eyes remained closed;-CNA DD said, he/she is responding a little bit, let's go ahead and get him/her up;-CNA E and CNA DD grabbed the resident's gait belt and lifted the resident to a standing position;-The resident's feet shuffled without purpose while the CNA's guided the resident to his/her wheelchair and then the CNA's lowered the resident to his/her wheelchair;-CNA DD propelled the resident down the hall in his/her wheelchair, the resident's eyes remained closed. Observation on 12/10/25 at 6:36 A.M., showed the following:-CNA DD entered the shower room propelling the resident in his/her wheelchair, the resident's eyes remained closed;-CNA DD and CNA E transferred the resident from his/her wheelchair to the shower chair, the resident's eyes remained closed;-When the staff stood the resident up, the resident said, oh, no;-CNA DD finished undressing the resident;-CNA E left the shower room;-CNA DD proceeded to shower the resident;-CNA E came back into the shower room with clean towels;-CNA DD then rinsed his/her gloves with the shower nozzle and washed the resident's hair;-During the entire shower the resident's eyes remained closed;-CNA E left the room;-CNA DD dried and dressed the resident and combed his/her hair;-CNA E returned to the shower room;-CNA DD and CNA E placed a gait belt around the resident, stood the resident up, pulled his/her pants up, and pivot transferred the resident to his/her wheelchair;-CNA DD propelled the resident out to the common area, the resident still had his/her eyes closed. Observation on 12/10/25 at 6:45 A.M. showed staff transferred the resident to a recliner in the common area. The resident's eyes remained closed during the transfer and when he/she was placed in a recliner. During an interview on 12/10/25 at 6:35 and 6:45 A.M., CNA E said they had ten residents to get up on night shift and it was not optional because it was their assignment, per the list. Resident #57 was on the get up list and today they had to give him/her a shower, so he/she had to get up. Night shift usually had one to two showers to give for the morning. Sometimes the residents do not want to get up and they really fight staff. If the residents are awake, or awaken easily, all is good, but many times they must get residents up that do not want to get up, and that makes him/her uncomfortable. The charge nurse was During an interview on 12/10/25 at 6:45 A.M., CNA DD said there was a get up list and staff must start at 5:30 A.M. to get everyone up on time. 2. Review of Resident #29's Care Plan, dated 04/18/24, showed resident preferred to get up in the morning after 7:00 A.M. Review of the resident's annual MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Uses a walker and wheelchair;-The resident requires set up and cueing for ADLs. Observation on 12/10/25 at 6:15 A.M., showed the resident up in a recliner in the common area, dressed and with his/her eyes closed. Observation on 12/10/25 at 6:45 A.M. showed the resident up in the common area in a recliner with his/her eyes closed. During an interview on 12/10/25 at 6:35 and 6:45 A.M., CNA E said they had ten residents to get up on night shift and it was not optional. Resident #29 was on the night shift get up list. 3. Review of Resident #14's Care Plan, dated 06/05/23, showed the resident usually awakened around 7:00 A.M. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate Cognitive Impairment;-Walker use;-Independent with roll left and right, sit to lying, sit to stand, transfers, and ambulation 150 feet. -Set up assistance from staff for dressing upper and lower and footwear. Observation on 12/10/25 at 6:15 A.M., showed the resident up in a recliner in the common area, dressed and with his/her eyes closed. Observation on 12/10/25 at 6:45 A.M. showed the resident up in the common area in a recliner with his/her eyes closed. During an interview on 12/10/25 at 6:35 and 6:45 A.M., CNA E said they had ten residents to get up on night shift and it was not optional. Resident #14 was on the get up list. 4. Review of Resident #9's Care Plan, dated 09/25/23, showed the resident preferred to awaken after 7:00 A.M. He/She goes to bed after supper between 7:00 P.M. and 9:00 P.M. but often gets up in the night to see what was going on. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe Cognitive Impairment;-Requires supervision/touching assistance from staff members for roll left and right, lying to sitting on side of bed, walk 50 feet with 2 turns, walk 150 feet; -Requires partial/moderate assistance from staff for sit to stand, chair/bed-to-chair transfer, -Requires substantial/maximal assistance from staff for upper body dressing, lower body dressing, footwear. Observation on 12/10/25 at 6:15 A.M., showed the resident up in a recliner in the common area, dressed and with his/her eyes closed. Observation on 12/10/25 at 6:45 A.M. showed the resident up in the common area in a recliner with his/her eyes closed. The resident was making snoring sounds. During an interview on 12/10/25 at 6:35 and 6:45 A.M., CNA E said they had ten residents to get up on night shift and it was not optional. The resident was on the get up list. 5. During an interview on 12/10/25, at 6:46 A.M., Licensed Practical Nurse (LPN) EE said the night shift had a get up list for ten residents. They must get them up by the time day shift starts, or day shift will not have time to get everyone up for breakfast. During an interview on 12/15/25, at 4:43 P.M. the Director of Nursing said the following:-She had not had time to evaluate the schedule for getting residents up in the morning;-Staff should not wake a resident for their convenience, if there weas a list of early risers that would be acceptable if the residents wanted to get up early, however the resident would be able to change their mind anytime;-If a resident had a bad night and did not want to wake up or was hard to awaken, staff were expected to leave them in bed until they were ready to get up;-Staff are expected to treat residents like it was there home; if they want to sleep late, they are allowed and if a resident has a bad night leave them in bed.

Based on interview and record review, the facility failed to conduct and document a thorough nursing assessment of one resident (Resident #41), in a review of 17 sampled residents, when staff found the resident with a change in condition and was unresponsive. Staff failed to follow facility policy to immediately contact 911 when the resident had an emergent situation and was found unresponsive. The facility census was 59.Review of the facility's policy for contacting the physician, dated [DATE], showed the following:-The purpose of this policy is to give guidelines to nursing staff on contacting resident physicians or the on-call physician:-Notification of Physician in emergent/life threatening situations; -If a resident is having an acute change in condition, you must call the office and not fax. -Residents that are full code and have an emergent situation, the staff will call 911 and then notify the appropriate physician on duty, the family and the registered nurse (RN) on duty. -If a resident is a do not resuscitate (DNR), no hospitalization, or receiving palliative care, you will need to notify the resident's power of attorney (POA) to be sure their wishes are followed. If they wish for the resident to go to the hospital, then call 911, the physician on call, and the RN on duty. Some examples of emergent situations include a decline in the resident's normal consciousness;-Do not use fax to communicate with physicians when the situation is emergent. Call and speak with the physician. Do you delay resident transport; -Remember when in doubt, call the physician or Registered Nurse (RN) on duty for guidance. 1. Review of Resident #10's healthcare directive, dated [DATE], showed the following:-He/She did not want lifesaving code (cardiopulmonary resuscitation (CPR), an emergency lifesaving procedure performed when the heart stops beating); -He/She wanted to go to the hospital. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by facility staff, dated [DATE], showed his/her cognition was moderately impaired. During an interview on [DATE] at 1:23 P.M., Registered Nurse (RN) M said on [DATE], the certified nurse aides (CNA) reported the resident complained of a headache and had some emesis. He/She administered Tylenol and assisted the resident to the bathroom at approximately 5:30 A.M. At 6:40 A.M., the resident said he/she still had a headache. The resident's blood pressure was a little high. He/She reported the resident's complaint of headache, emesis, and the administration of Tylenol to Licensed Practical Nurse (LPN) K at approximately 7:00 -7:15 A.M. Review of resident's blood pressure record, dated [DATE] at 6:47 A.M., showed the resident's blood pressure was 183/95 (normal blood pressure is 120/80). Review of the resident's nursing progress notes, dated [DATE], showed no documentation of an assessment or the resident's condition, including the resident's headache and emesis and administration of Tylenol. Review of resident's Medication Administration Record (MAR), dated [DATE], showed Licensed Practical Nurse (LPN) K documented medications were not administered on [DATE] during the 7:00 A.M. to 11:00 A.M. medication pass due to condition. Review of the resident's progress notes, dated [DATE], showed no documentation related to the resident's condition that prevented staff from administering the resident's medications during the 7:00 A.M. to 11:00 A.M. medication pass. During an interview on [DATE] at 7:45 A.M., LPN K said the following:-On [DATE], he/she received report from RN M, the resident had emesis, stabbing headache, some confusion, and received Tylenol; -He/She went to the resident's room to assess the resident at 7:40 A.M. and found the resident in bed. The resident did not respond when spoken to and/or with touch stimuli but twitched his/her foot with sternal rub; -He/She ran out into the hall and asked the MDS Coordinator to check on the resident because he/she didn't think the resident was acting right as the resident would not wake up and/or respond to stimuli; -At 8:00 A.M., the MDS Coordinator said the resident was snoring and assumed the resident was sleeping; -At 9:00 A.M., he/she told the Assistant Director of Nursing (ADON) he/she did not think the resident was acting right and thought the resident needed to go to the hospital. The ADON did not help him/her and walked away; -He/She recently attended an in-service at the facility and was told residents could not be sent to the hospital without a physician's order; -He/She was not familiar with the facility's physicians and where to call. It was easier for him/her to fax the physicians, but the fax machine was not working correctly on [DATE]; -Between 9:00 A.M. and 10:00 A.M., he/she asked for RN L to assess the resident because something was not right with the resident; -RN L and RN M entered the resident's room to assess the resident. RN M came to the desk and said to send the resident to the hospital; -He/She contacted emergency medical services, and the resident was transported to the hospital; -He/She knew the resident needed to be sent to the hospital. If he/she had been at any other facility, he/she would have sent the resident and then notified the physician, but that was not what he/she was instructed to do; -He/She still did not have clarification for when to send a resident to the hospital. He/she did not document in the resident's progress notes because he/she did not have time. He/she should have documented the resident's status and events that occurred. Review of the resident's vital signs record, dated [DATE] at 10:32 A.M., showed the resident's blood pressure was 185/92. Review of the resident's nursing progress notes, dated [DATE], showed the following:-At 12:45 P.M., the Director of Nursing (DON) documented she was called to the resident's room for the resident not responding to verbal stimuli. Upon entering the resident's room, she found the resident in bed unresponsive to verbal and touch stimuli, pupils were fixed and dilated, face was flushed, and resident was incontinent of urine. The resident's blood pressure was 200/84 and his/her pulse was 106 (normal pulse is 60-100). Staff called EMS. EMS arrived and resident transferred to the hospital. Review of the resident's nursing progress notes, dated [DATE], showed staff documented the resident was sent to the hospital at 11:23 A.M. (Reviewed showed no documentation staff notified the resident's physician of the resident's change in condition when staff was unable to arouse the resident with physical intervention at 7:40 A.M. or upon additional assessments prior to 11:23 P.M. when the resident was sent to the hospital for evaluation. Review showed no documentation of the resident's condition between [DATE] at 3:11 P.M. and [DATE] at 11:23 A.M.) During an interview on [DATE] at 11:30 A.M., the MDS Coordinator said on [DATE] at approximately 8:00 A.M., LPN K gestured for her to step into the resident's room, because LPN K could not get the resident awake. The resident lay in bed fully clothed and was snoring. There was nothing that appeared altered about the resident. The resident just appeared as he/she was sleeping well. She did not sense any urgency from the staff or the resident at that time. She touched the resident's arm which altered the resident's snoring with movement. During an interview on [DATE] at 11:35 A.M., the ADON said the following:-On [DATE], RN M reported that the resident had complained of a headache, diarrhea, and received Tylenol at 5:30 A.M. She did not recall going over to the resident's hall and LPN K asking for her to assess the resident; -There had been a recent meeting the facility's medical director who said staff needed to call him and/or the resident's physician before sending a resident to the hospital. She was not sure if that meant staff were to call the physician prior to sending the resident to the hospital when it was an emergent situation. She felt staff should send residents out in an emergent situation, including when a resident was unresponsive. During an interview on [DATE] at 1:23 P.M., RN M said on [DATE] between 10:30 A.M. and 11:00 A.M., LPN K said the resident would not wake up. Upon assessment, the resident was unresponsive to sternal rub and was snoring. He/She instructed LPN K to call EMS. LPN K said he/she needed a physician's order. He/She instructed LPN K that this situation was emergent, and he/she needed to call EMS. He/She thought this was due to a misinterpretation of the medical director wanting staff to notify the physicians before sending residents to the hospital, but residents in an emergent situation needed to be sent and this needed better clarification. During an interview on [DATE] at 12:05 P.M., RN L said he/she was on the resident's unit the morning of [DATE] awaiting to speak to the ADON when LPN K came to him/her and asked him/her to evaluate the resident. The resident was unresponsive to verbal and touch stimuli including sternal rub, pupils were fixed and non-reactive, and the resident was incontinent. Report received was that the resident had a headache and was throwing up earlier that morning. Staff administered Tylenol, assisted the resident to the restroom, and was last noted well at 6:30 A.M. He/She instructed staff to contact EMS. The facility's Medical Director wanted physician's orders to send all residents to the hospital. Staff should have brought in a supervisor to assess the resident and send out to the hospital if the resident was unresponsive. During an interview on [DATE] at 10:00 A.M., the DON said the following: -She expected staff to call a resident's physician immediately with any emergent situations, including finding a resident unresponsive;-Prior to survey, staff were in-serviced during an all staff meeting regarding when to contact and send a resident to the hospital; -With emergent situations (such as unresponsiveness), staff were to contact 911, then the resident's physician, family, etc. In urgent situations (different from emergency situations), staff were to contact the physician for orders first;-Each emergent situation was different related to transfers to hospital with DNR residents. For example, if resident was on comfort measures and/or palliative care, staff would contact the physician and/or family prior to sending to the hospital; -Staff should have contacted 911 for emergent care for Resident #10, when he/she was found unresponsive at 7:40 A.M.;-She expected the MDS Coordinator to have completed an assessment, including obtaining vital signs if he/she was asked to look over the resident when staff reported the resident had changes in his/her status. During an interview on [DATE] at 10:00 A.M., the Administrator said the following: -He expected staff to send a resident to the hospital and not delay treatment in an emergent situation, including finding a resident unresponsive;-He was unaware of the situation with Resident #10 and the delay in resident's transfer was unacceptable;-He expected staff to contact 911 with residents who experienced an emergent event;-Resident #10 was not on palliative and/or comfort care, but still had DNR status;-Staff should have called 911 when they found Resident #10 unresponsive. During an interview on [DATE] at 12:45 P.M., the facility's Medical Director said he expected staff to send a resident to the hospital in an emergent situation based on the resident's wishes in their medical directive. If a resident was a do not resuscitate (DNR), do not intubate, and do not send to the hospital, staff should contact the physician first before sending the resident to the hospital. If the resident wanted to be sent to the hospital and the situation was emergent, staff should send the resident to the hospital and then contact the physician.

Based on interview and record review, the facility failed to ensure one nurse aide (NA) completed a state-approved training program within four months of hire. The facility census was 59. 1. Review of NA D's employee file showed a hire date of 02/18/25. Review of NA D's payroll showed the employee worked 205 hours as a NA from 11/12/25 to 12/15/25. Review of the facility's schedule for 12/11/25, showed NA D was scheduled for 11:00 P.M.-7:30 A.M. as a NA. During an interview on 12/16/25, at 4:00 P.M., NA D said he/she worked at the facility as an NA for since February 2025. He/She completed a training program but had not passed his/her test. During an interview on 12/09/25, at 11:30 A.M., the Administrator said NA D took the training course but failed the test twice. NA D was scheduled to test again. During an interview on 12/10/25 at 2:59 P.M., the Director of Nursing (DON) said NA D was not certified. NA D has worked as an NA since February 2025. NA D passed his/her class but failed the test. She did not know NA D could not work past four months if he/she was not certified.

Based on interview and record review, the facility failed to report injuries of unknown origin for one resident (Resident #7), who was found to have bruising and blood on his/her body, in a review of 17 sampled residents, and failed to report bruises of unknown origin for one additional resident (Resident #57). The facility census was 59. Review of the facility's policy, Abuse and Neglect, dated 2025, showed the following: -Injuries of Unknown Origin: Defined as an injury that was not observed and/or the injury could not be explained. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in areas that are not normally vulnerable to trauma), or the number of injuries observed on a resident at one time, or the reoccurrence of injuries over time (pattern identified); -All facility staff are required to immediately report suspicion/allegations of any type of abuse directly to the Administrator or designee. The Administrator will then report suspicion/allegations of abuse to the Missouri Department of Health and Senior Services immediately but no longer than two hours after the allegation was received. 1. Review of Resident #7's care plan, dated 02/08/24, showed the following: -Anticoagulant therapy/potential for bleeding. The resident was at risk for signs and symptoms of bleeding due to use of anticoagulant, warfarin; -Avoid bumping and handle gently when providing hands-on care Review of the resident's physician order sheet (POS) for September 2025 showed an order for warfarin (a blood thinner) 2.5 milligram (mg) tablet, give 1 tablet (2.5 mg) four times per week, schedule every week on Monday, Wednesday, Thursday, Friday at 07:00 P.M. to 11:00 P.M. Review of the resident's nursing progress notes, dated 09/04/25 at 1:48 A.M., showed Licensed Practical Nurse (LPN) I documented that a certified nurse assistant (CNA) notified him/her regarding a skin assessment on the resident. The resident was found to have bruises on his/her right wrist, right bottom, and bruise under right armpit. The charge nurse assessed the resident. Dried blood was found on the corner of the resident's mouth and in little specs all over his/her bed. The resident had little scratches that were bleeding on the sheets. Skin assessment was completed. Review of the resident's medical record showed no evidence the facility staff reported the bruising and bleeding as an injury of unknown origin, when it was discovered on 09/04/25 at 04:07 A.M. Review of the resident's annual Minimum Data Set (MDS), completed by facility staff, dated 11/25/25, showed the following: -Severe cognitive impairment; -Dependent for toileting and personal hygiene. During an interview on 12/29/25 at 9:10 P.M., LPN I said the following: -He/She was made aware of bruising and bleeding on the resident on 09/04/25 at 1:48 A.M. by a CNA but could not recall much about this event now; -He/She conducted a skin assessment on the resident. -He/She did not report the bruises or bleeding to administration because he/she did not think the bruises and/or bleeding were caused by abuse; -He/She could not remember if he/she had asked the CNA what happened; -He/She was not sure what had caused the bruising or bleeding, but the resident was on a blood thinner, so this might have contributed to it; -The resident was would not be able to say if he/she were abused. During an interview on 12/15/25 at 1:50 P.M., the Director of Nursing (DON) said the following: -She was not aware of the injuries of unknown origin (bruises and bleeding) found on the resident; -She would expect all staff to report any bruises or unexplained bleeding immediately to administration so an investigation could be started; -Bruising and bleeding of unknown origin could be a sign of resident abuse and should be fully investigated and reported to the state agency (SA) within two hours. During an interview on 12/15/25 at 4:00 P.M., the Administrator said the following: -Staff should assess bruising and bleeding of unknown origin on a resident right away to determine a cause, if able; -Administrative staff must be made aware of any bleeding so that an assessment and investigation could be started and a report made to the state agency (SA) within two hours. 2. Review of Resident #57's Care Plan, last updated 06/23/25, showed the following:-The resident was dependent on staff for showers, locomotion and toileting; required substantial/maximum assist from staff for dressing and personal hygiene; required partial/moderate assist for transfer and ambulation; required supervision/touching assist for bed mobility;-He/She was able to make position changes on his/her own. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 11/05/25, showed the following:-Severe cognitive impairment;-Required supervision/touching assistance from staff members for roll right and left, sit to lying, lying to sitting on bed side, and sit to stand;-Required partial/moderate assistance from staff for chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer;-Required substantial/maximal assistance from staff for shower/bathe, upper body dressing, and lower body dressing.-Dependent on staff for toileting hygiene and personal hygiene. Review of the resident's Physician Orders, dated December 2025, showed the resident was on Plavix (a medication that prevents blood clots by preventing the platelets from sticking together (blood will not clot as quickly). Observation on 12/10/25 at 6:36 A.M., showed the following:-Certified Nurse Assistant (CNA) DD and CNA E transferred the resident from his/her wheelchair to the shower chair;-CNA DD undressed the resident;-The resident had a large, purple bruise on the back of his/her left upper arm;-CNA DD said, I have not seen that bruise on the resident before. The resident also has a large bruise behind his/her right leg with a knot in the center. The resident has not fallen that he/she knew of. Review of the resident's Nurses Notes, dated 12/11/25 at 6:50 A.M., (one day after the bruising was identified in the shower room) showed the CNAs reported the resident has a bruise to his/her right calve and left upper arm. Examined the resident and noted a 5 centimeter (cm) in length by 4 cm in width area of bruising to his/her right posterior lower leg/calve that was light purple in color, and a 4.5 cm in length by 5 cm in width area of bruising to posterior left upper arm that was light purple in color. Etiology of bruising unknown, both bruises are non-tender. Fax sent to the resident's physician regarding bruises. During an interview on 12/23/25 at 7:15 A.M., LPN EE said the following:-Staff reported the resident's bruises to him/her on 12/11/25; -He/She assessed the bruises and reported to the day shift staff; -He/She didn't call the DON or Administrator because he/she did not think the bruises were caused by abuse; -He/She was not sure how the resident got the bruises. During an interview on 12/15/25 at 3:15 P.M., LPN A said the following: -The CNAs reported the resident's bruising on 12/11/25 during the night shift;-He/She obtained this information through report, so he/she didn't notify the DON or the Administrator because it didn't happen on his/her shift;-He/She did not know if the bruise was investigated to rule out abuse. During an interview on 12/15/25 at 1:50 P.M. and 4:43 P.M., the DON said no one told her about the bruising found on the resident.

Based on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for two residents ( Residents #14 and #9), in a review of 17 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the residents' health status and required interdisciplinary review and/or revision of the care plan. The facility census was 59.Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that:-Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and is not self-limiting;-Impacts more than one area of the resident's health status;-Requires interdisciplinary review and/or revision to the care plan.-The manual also showed a SCSA was appropriate if there was a consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of activities of daily living (ADL) decline or improvement);-Decline in two or more of the following: -Resident's decision-making ability has changed; -Presence of a resident mood item not previously reported by the resident or staff and/or an increase in the symptom frequency (PHQ-2 to 9(C)), e.g., increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for items in Section E (Behavior); -Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment; -Any decline in an ADL physical functioning area (e.g., self-care or mobility) (at least 1) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning; -Resident's incontinence pattern changes or there was placement of an indwelling catheter; -Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days); -Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status; -Resident begins to use a restraint of any type when it was not used before; and/or -Emergence of a condition/disease in which a resident is judged to be unstable.- Improvement in two or more of the following: -Any improvement in an ADL physical functioning area (at least 1) where a resident is newly coded as Independent, setup or clean-up assistance, or supervision or touching assistance since last assessment and does not reflect normal fluctuations in that individual's functioning; -Decrease in the number of areas where Behavioral symptoms are coded as being present and/or the frequency of a symptom decreases; -Resident's decision making improves; -Resident's incontinence pattern improves. 1. Review of Resident #14's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 05/22/25, showed the following:-Diagnosis: Anemia, coronary artery disease, diabetes mellitus (inability to regulate blood sugar), anxiety, and malignant neoplasm of breast;-No behaviors, hallucinations, delusions, or rejection of care;-Always incontinent of bowel and bladder;-One Stage 2 pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister), not present on admission. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Physical behavioral symptoms directed towards others one to three days (worsened);-Frequently incontinent of bowel and bladder (improvement);-Diagnoses of Alzheimer's and dementia checked (new);-New antipsychotic (medication for hallucinations or delusions) medication;-Pressure ulcer healed (improvement); The facility did not complete a SCSA when the resident had new diagnosis added for Alzheimer's/dementia, new antipsychotic medication; improved incontinence, healed pressure ulcers and worsening physical behaviors. Review of the resident's weight record, showed facility staff obtained and documented the resident's weight as follows:-On 09/10/25, 180.8 lbs.;-On 10/01/25, 177.2 lbs.;-On 10/02/25, 177.6 lbs. (2% weight loss in one month, 4.5% weight loss in six months). Review of the resident's weight record showed no evidence staff weighed the resident for November 2025. Review of the resident's weight record, showed facility staff obtained and documented the resident's weight on 12/01/25 as 162 lbs. The resident had had a 15.6 lbs. since the last obtained weight on 10/2/25. Review of the resident's weight records showed the resident lost 21.8 lbs. since 06/04/25, which was an 11.86 % weight loss in six months and had lost 15.2 lbs. since 10/01/25 (no weight for November documented) which was an 8.5% weight loss in two months. Review of the resident's Nurses Notes, dated 12/04/25 at 1:33 P.M., showed the resident had two new wounds to the coccyx (bony part of lower back/buttocks) area measuring 1.5 centimeters (cm) x 1 cm and the other as 1cm x 1cm. Barrier cream applied to both wounds and buttocks. Primary physician was faxed this information, waiting for new orders at this time. The facility did not complete a SCSA when the resident had new weight loss, new pressure ulcers, and the changes from the 08/22/25 MDS assessment. 2. Review of Resident #9's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 01/07/25, showed the following:-Severe cognitive impairment;-Diagnosis: Alzheimer's;-No behaviors or rejection of care;-Walker;-Set up or clean up assistance from staff for eating, and walking;-Requires supervision/touching assistance from staff members for roll left and right, sitting to lying, lying to sitting on side of bed, sit to stand, char/bed-to-chair transfer, toilet transfer, and tub/shower transfer, -Requires partial/moderate assistance from staff for upper and lower body dressing, -Dependent on staff for oral hygiene, toileting hygiene, shower/bathe, and putting on/taking off footwear;-One no injury fall, and one fall with injury;-Antianxiety medication. Review of the resident's quarterly MDS, dated [DATE], showed there were no significant changes. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Independent with walking up to 150 feet (improvement);-Set up or clean up assistance from staff for chair/bed-to-[NAME] (improvement), toilet transfer (improvement);-Requires partial/moderate assistance from staff for shower/bathe (improvement), tub/shower transfer (worsening), -No antianxiety medication (improvement). The facility did not complete a SCSA when the resident had improvements in the areas of walking and anxiety and worsening of assistance needed from staff for showering/bathing. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Requires supervision/touching assistance from staff members for walking 50 feet with two turns (worsening), and walking 150 feet (worsening); -Requires partial/moderate assistance from staff for shower/bathe (improvement), sit to stand (worsening), chair/bed-to-chair (worsening), and toilet transfer (worsening); -Dependent on staff for eating (worsening); -Scheduled pain medications (new); -New mechanically altered diet. The facility did not complete a SCSA when the resident had several declines in ADLs and one improvement, newly scheduled pain medications and a new mechanically altered diet. 3. During an interview on 12/23/25, at 3:00 P.M. the MDS coordinator said the following:-The facility had a clinical meeting daily to discuss declines in ADLs. If the change goes and comes back and doesn't return to baseline then staff know a significant change should be completed;-When doing resident's quarterly assessments, she compared the information to the last quarterly assessment;-If there was a gradual change within the year, it may not be as significant, usually within the quarter;-She was required to follow the RAI manual;-She had never heard of comparing the resident to the last comprehensive assessment.-She had not completed any official training, just what she had been able to find for guidance. During an interview on 12/15/25 at 2:30 P.M. the Director of Nursing said she did not know much about the MDS process but would expect staff to follow the RAI manual for completion of the MDS and Care plans.

Based on interview and record review, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program that monitored antibiotic use for two residents (Resident #2 and #32), in a review of 17 sampled residents. The facility had not had a designated Infection Preventionist or an active antibiotic stewardship program with tracking of infections or antibiotic use since November 2025. The facility census was 59. Review of the facility's policy, Antibiotic Stewardship, dated 10/15/24, showed the following: -Purpose: To ensure proper use of antimicrobials including appropriate treatment, duration of treatment and indication as well as ensuring that antibiotics are not used when contraindicated;-Policy: Nursing staff will not request antibiotics from attending physicians; -Culture shall be obtained when possible prior to antibiotics on all residents. Nursing will request cultures (for example, for urine or sputum) if a physician orders antibiotics without them; -When culture reports return to the facility, nursing will assess the results to assure that the antibiotic currently being used is sensitive and if resistant then request from the attending physician that the antibiotic be discontinued and /or changed; -A list of residents with infections and antibiotic use will be sent to the medical director on a monthly basis. This will include resident name, date, type of infection diagnosed, diagnostic testing, attending physician, medication dose and duration, whether the medication was discontinued if culture was negative and whether it was sensitive to the medication used; -The medical director will talk to and/or write letters to the attending physician if antibiotics are used inappropriately, including lack of diagnostic testing, wrong diagnosis, wrong antibiotic, wrong dose, or wrong duration. He/She will be in charge of educating the physicians and will also inform nursing administration when improvements could have been made in staff carrying out this policy. 1. Review of Resident #2's undated physician order sheet (POS), showed the following: -Macrobid (an antibiotic) 100 milligrams (mg) by oral route three times per week for chronic urinary tract infection (UTI), every week on Monday, Wednesday, Friday at 07:00 P.M. to 11:00 P.M.; -Original order date: 09/24/24; -Renewed on 11/20/25; -Open ended (no stop date). Review of the resident's Medication Administration Record (MAR), dated 09/01/25 through 09/30/25, showed the resident received Macrobid 100 mg by mouth daily on Monday, Wednesday, and Friday. Review of the resident's MAR, dated 10/01/25 through 10/31/25, showed the resident received Macrobid 100 mg by mouth daily on Monday, Wednesday, and Friday. Review of the resident's MAR, dated 12/01/25 through 12/15/25, showed the resident received Macrobid 100 mg by mouth daily on Monday, Wednesday, and Friday. During an interview on 12/11/25 at 10:15 A.M., Licensed Practical Nurse (LPN) CC said the following: -The facility did not have an infection preventionist (IP) or antibiotic stewardship program at this time; -Resident #2 was on an antibiotic, Macrobid 100mg three times a week for the prevention of a urinary tract infection; -The resident did not have any current signs or symptoms of a urinary tract infection, such as urgency, discomfort, or pain; -The resident had not had any recent urinary tract infections that he/she was aware of. 2. Review of Resident #32's urine culture and sensitivity (a test that identifies the bacteria or fungi in a urine sample causing the UTI and determines how to treat the infection), dated 11/21/25, showed the following:-Presence of Escherichia Coli (E. coli, bacteria that can be caused by not wiping properly after going to the bathroom which can cause E. coli from feces to get into the urinary tract, causing a UTI);-The resident was started on Macrobid (antibiotic) 600 milligrams (mg) twice daily;-Physician ordered Rocephin (antibiotic) 1 gram to be administered intramuscularly (IM) for three days. 3. During an interview on 12/15/25, at 3:10 P.M., the Assistant Director of Nursing said she will be the primary Infection Preventionist, but the Director of Nursing (DON) was also going to do the training and maybe another back up person. During an interview on 12/15/25 at 03:15 P.M., the DON said the following: -The facility previously had an IP who tracked antibiotic usage, but he/she left abruptly in November 2025, and the DON could not find the previous documentation or antibiotic tracking records; -The facility currently did not have a designated IP; -The facility was not tracking antibiotic usage of residents at this time. During an interview on 12/09/25, at 10:00 A.M., the Administrator said the following: -The Infection Preventionist (IP) quit two weeks ago and did not leave a lot of the paperwork and files that he/she was responsible for;-He did not know what documentation the facility had for antibiotic stewardship;-The Assistant Director of Nursing (ADON) was now the IP, and the Director of Nursing (DON) and another backup staff person would be trained so there were people who could fill in as needed; -The infection control monitoring was not up to date.

Based on interview and record review, the facility failed follow facility's policy/procedure to notify the physician for one resident (Resident #10), in a review of 17 sampled residents, after the resident fell on the weekend and hit his/her head. The facility also failed to timely notify Resident #10's physician after the resident presented with a change in condition. The facility census was 59.Review of the facility's policy for contacting the physician, dated 10/16/24, showed the following:-The purpose of this policy is to give guidelines to nursing staff on contacting resident physicians or the on-call physician:-Notification of physicians in non-emergent situations: -Nursing staff will fax the physician to relay reports or status change information regarding the resident. Staff will send faxes to the physician's office and ensure to include all pertinent information for the physician to be able to respond; -If no return call or fax is received from the physician's office by 4:00 P.M., the nursing staff will phone the physician's office. If he/she has left the office and a response is needed to provide care, the nurse will page the appropriate physician; -To notify the physician, call the hospital or physician answering service to have the physician paged. If no response after 30 minutes, place a second call to notify them the physician has not called back; -Never fax after hours and on weekends if a response is needed. When after hours, weekends and/or holidays, the charge nurse is to call the appropriate physician for all resident changes for orders. This includes wounds that need immediate treatment, falls with injury or change in medical condition;-Notification of Physician in emergent/life threatening situations; -If a resident is having an acute change in condition, you must call the office and not fax; -Do not use fax to communicate with physicians when the situation is emergent. Call and speak with the physician. -Remember when in doubt, call the physician or registered nurse (RN) on duty for guidance. 1. Review of Resident #10's undated face sheet showed the following:-He/She admitted to the facility on [DATE];-He/She was his/her own responsible party;-His/Her diagnoses included subarachnoid hemorrhage (bleeding in the area between your brain and the thin tissues that cover and protect it) and repeated falls. Review of the resident's progress notes, dated 11/22/25 (a Saturday) at 7:36 P.M., showed the following:-Staff documented the resident was found on the floor by the chair in his/her room;-Assessment revealed a small laceration to the resident's right front scalp;-Staff cleaned the area and applied pressure; and the bleeding stopped;-Staff sent a fax to the resident's physician. Review of the fax staff sent to the resident's physician, dated 11/22/25, showed the following:-Registered Nurse (RN) L wrote that the resident was found in front of the chair on the floor. See attached. (Review showed no attachments were sent with the fax); -RN L did not notify the resident's physician of the laceration to the right front scalp;-The physician responded on 11/28/25 (six days later) by writing noted monitor. Review of the resident's progress notes dated 11/22/25 to 11/28/25 showed no documentation staff followed up with the resident's physician with a phone call over the weekend when they did not receive a response to the fax as directed in the policy. During an interview on 12/10/25 at 12:05 P.M., RN L said he/she was present when the resident fell on [DATE]. The resident's vital signs were normal, the resident was alert and oriented, and his/her neurological assessments were within normal limits. The resident had a small abrasion to the right backside of the head with bleeding that stopped after application of pressure within five minutes. A fax was sent to the physician because neuro assessments were fine and there were no significant injuries noted. During an interview on 12/10/25 at 11:35 A.M., the Assistant Director of Nursing (ADON) said if a resident fell on a weekend and there was any injury, staff should notify the on-call physician by phone, not by fax. Staff should have called the resident's physician after the resident fell on [DATE] and had a laceration to his/her scalp. During an interview on 12/10/25 at 7:45 A.M., LPN K said the following:-On 12/01/25, he/she received report from RN M, who reported the resident had emesis, stabbing headache, some confusion, and received Tylenol; -He/She went to the resident's room to assess the resident at 7:40 A.M. and found the resident in bed. The resident did not respond when spoken to and/or with touch stimuli but twitched his/her foot with sternal rub. -He/She asked the Minimum Data Set (MDS) Coordinator to check on the resident as he/she (LPN K) didn't think the resident was acting right as the resident was unresponsive;-At 8:00 A.M., the MDS Coordinator said the resident was snoring and assumed the resident was sleeping;-At 9:00 A.M., he/she told the ADON he/she did not think the resident was acting right, and thought the resident needed to go to the hospital; -He/She was not familiar with the facility's physicians or where to call, so it was easier for him/her to fax the physicians; the fax machine was not working correctly on this day; -Between 9:00 A.M. and 10:00 A.M., he/she asked for RN L to assess the resident because something was not right with the resident; -RN L and RN M entered the resident's room to assess the resident. RN M came to the desk and said to send the resident to the hospital; -He/She contacted emergency medical services, and the resident was sent to the hospital. Review of the resident's nursing progress notes, dated 12/02/25, showed staff documented the resident was sent to the hospital at 11:23 A.M. Reviewed showed no documentation staff notified the resident's physician of the resident's change in condition when staff was unable to arouse the resident with physical intervention at 7:40 A.M. or upon additional assessments prior to 11:23 P.M. when the resident was sent to the hospital for evaluation. During an interview on 12/10/25 at 12:30 P.M., the Director of Nursing (DON) said the following -She expected staff to call a resident's physician when a resident fell on a weekend or after hours. A fax to the physician's office may not be seen until the next day and/or after the weekend when the physician returned to his/her office;-On 11/22/25 (Saturday), the resident fell and suffered a superficial laceration that did not require sutures;-Staff should call the physicians if there was any head injury or any bleeding noted from the head;-She expected staff to call a resident's physician immediately with any emergent situations, including finding a resident unresponsive. During an interview on 12/11/25 at 5:30 P.M., the Administrator said he expected staff to contact a resident's physician by phone if a resident fell and had any type of injuries. The facility had an on-call schedule for staff to reference to for which physician to contact after hours and/or weekends.

Based on observation, interview and record review, the facility failed to ensure inventories of schedule II narcotic controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence) and schedule IV and V narcotic controlled substance medications, were reconciled by at least two qualified staff to ensure accountability for ten residents (Resident #4, 9, 5, 7, 8, 10, 6, 11, 12 and 13) that had narcotics held in the A-hall medication cart each shift per policy. The facility census was 61. Review of the facility policy, Accountability of Controlled Substances, revised 11/27/24, showed the following: -The controlled substance count is completed at the start of each shift; the charge nurse is responsible for counting all controlled substances and for signing the narcotic sheet;-Two nurse signatures (two Licensed Practical Nurses (LPN), two Registered Nurses (RN), or one LPN and one RN, or one nurse (LPN/RN and one Certified Medication Technician (CMT) must sign off on each narcotic count sheet;-By signing these sheets, the charge nurses agree that the current narcotic count is correct not only at the beginning of the shift but also at the end of the shift. 1. Review of the facility Controlled Substance Drug Supply Shift Change Record, dated August 2025, for the A unit medication cart (which housed the narcotic box for the A hall residents) on 09/03/25 at 12:35 P.M. showed the following: -On 08/04/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) shift counts; there was no documentation of a total card count;-On 08/12/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) shift counts; there was no documentation of a total card count;-On 08/17/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) shift counts; there was no documentation of a total card count;-On 08/20/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) shift counts; there was no documentation of a total card count;-On 08/21/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) shift counts; there was no documentation of a total card count;-On 08/22/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) shift counts; there was no documentation of a total card count. 2. Review of the A hall narcotic card/bottle count (which listed the date, shift, beginning count, added, removed, names of cards added or removed, along with the signatures of oncoming and outgoing staff showing the items had been counted) on 09/03/25 at 12:40 P.M. showed the following:-On 8/4/25 at 7:00 A.M., 3:00 P.M. and 11:00 P.M. there were no nurse signatures documented in the boxes for oncoming and outgoing staff to show the count was completed;-On 8/12/25 at 7:00 A.M., 3:00 P.M. and 11:00 P.M. there were no nurse signatures documented in the designated boxes for oncoming and outgoing staff to show the count was completed;-On 8/17/25 at 7:00 A.M., 3:00 P.M. and 11:00 P.M. there were no nurse signatures documented in the designated boxes for oncoming and outgoing staff to show the count was completed;-On 8/20/25 at 7:00 A.M., 3:00 P.M. and 11:00 P.M. there were no nurse signatures documented in the designated boxes for oncoming and outgoing staff to show the count was completed;-On 8/21/25 at 7:00 A.M., 3:00 P.M. and 11:00 P.M. there were no nurse signatures documented in the designated boxes for oncoming and outgoing staff to show the count was completed;-On 8/22/25 at 7:00 A.M., 3:00 P.M. and 11:00 P.M. there were no nurse signatures documented in the designated boxes for oncoming and outgoing staff to show the count was completed. 3. Review of the individual resident's narcotic count sheets showed the following narcotic medications were stored in the narcotic lock box for the following residents:-Resident #4, Ativan (schedule IV narcotic controlled substance for anxiety) and morphine sulfate solution (schedule II narcotic controlled substance for pain);-Resident #9, hydrocodone (schedule II narcotic controlled substance for pain)/acetaminophen (apap);-Resident #5, Ativan, Roxanol (schedule II narcotic controlled substance for pain), hydrocodone/apap and Lyrica (schedule V narcotic controlled substance for pain); -Resident #7, Roxanol (schedule II narcotic controlled substance for pain) and Ativan;-Resident #8, Roxanol, Ativan and hydrocodone/apap;-Resident #10, tramadol (schedule IV narcotic controlled substance for pain), tramadol hydrochloride (HCL) (schedule IV narcotic controlled substance for pain) and hydrocodone/apap;-Resident #6, Ativan;-Resident #11, oxycodone instant release (IR) (schedule II narcotic controlled substance for pain) and oxycodone (schedule II narcotic controlled substance for pain);-Resident #12, tramadol hcl, Ativan and hydrocodone/apap;-Resident #13, tramadol hcl. 4. Review of the facility Controlled Substance Drug Supply Shift Change Record, dated September 2025, for the A unit medication cart on 09/03/25 at 12:35 P.M. showed on 09/02/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 3:00 P.M. or 11:00 P.M. shift counts; there was no documentation of a total card count. 5. Observation of the A hall narcotic card/bottle count binder showed there was no log sheet for September 2025, and no documentation of a count of cards/bottles by any staff for each beginning or ending shift, 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) for 09/01/25 and 09/02/25 and no documentation of a count of cards/bottles by any staff for the beginning of the shift at 7:00 A.M. on 09/03/25. 6. During an interview on 09/03/25 at 12:12 P.M., LPN B said the following:-Two staff (nursing) are to count the narcotics together at the beginning and end of each shift;-Both staff are to sign two documents (initial one to show the count was completed each shift change) and sign their signature to the other to show the number of cards/bottles were counted, added or removed. During an interview on 09/03/25 at 12:35 P.M., LPN A said the following:-Two staff were to count the narcotics at the beginning and end of each shift. They should initial the count was completed and accurate each time;-He/She was unsure what the other document (narcotic card/bottle count) was. During an interview on 09/03/25 at 3:25 P.M., the Director of Nursing said the following:-The charge nurses were responsible for completing the narcotic counts;-She would expect nursing to complete the narcotic counts at the beginning and end of each shift, initialing each time the count was completed; -They should also document the total number of containers/cards and each of them sign the sheet;-She expected nursing to initial and sign both documents any time they are taking over the medications and turning the keys over;-The initials and signatures are verifying that they have counted the narcotics and the number of containers and that they match;-It would be easier to identify when/if a medication count was off/or a medication disappeared if the counts were completed and signed as completed as protocol;-The RN supervisor was to do a narcotic audit once weekly;-She was unaware there was no September narcotic card/bottle count sheet for the A hall until the surveyor asked to review the count sheet. During an interview on 09/03/25 at 3:40 P.M., the Administrator said she expected staff to complete the narcotic counts at every shift change. Staff should initial and sign both sheets each time where necessary. MO#2592572

Based on interview and record review, the facility failed to follow their policy on reporting allegations of abuse to the state agency immediately, but no later than two hours after the allegation was made for one resident (Resident #1), in a review of eight sampled residents. Resident #1 reported an allegation of abuse to Certified Nurse Aide (CAN) A on 06/15/25. CNA A reported the allegation to his/her charge nurse, Licensed Practical Nurse (LPN) D, who also reported the allegation to Registered Nurse (RN) B. No staff reported the allegation to the Director of Nursing (DON) or the Administrator until four days later. Additionally, when the administrator became aware of the allegation on 06/19/25 at 10:45 A.M., she did not notify the state agency of the allegation until 1:12 P.M. (greater than two hours). The facility census was 65. Review of the facility policy for Abuse, Neglect and Reporting Reasonable Suspicion of a Crime, with a revision date of 02/13/25, showed the following: -It is the policy of this facility to protect the rights of all residents to be free from mistreatment, abuse, neglect, injuries of unknown sources and misappropriation or stealing of resident property or money; -Sexual Abuse is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault; -Reporting Abuse/Neglect: c. Reporting to Department of Health and Senior Services (DHSS) following the Guidelines for Facility Self-Reporting for Certified Facilities, the Administrator, Director of Nursing (DON) or Human Resources (HR) Director will call the Department of Health and Senior Services (DHSS) and make the necessary self-report immediately, but not later than two (2) hours after the allegation is made; d. If the report is made after office hours or on a weekend to a Unit Supervisor or Charge Nurse, they must contact the Administrator, DON or HR Director at their emergency number (numbers are listed on the Emergency Telephone Numbers list located at each Nurses Desk) to immediately report the abuse; Review of the resident's rights employee orientation, dated 2025, showed residents have the right to be free from verbal, sexual, physical, financial, mental abuse, and involuntary seclusion by anyone. This includes, but isn't limited to nursing home staff, other residents, consultants, volunteers, staff from other agencies, family members or legal guardians, friends, or other individuals. If you witness or suspect abuse or neglect is happening to anyone in the facility, please contact the Human Resources Director or Director of Nursing or Administrator immediately. 1. Review of Resident #1's face sheet showed his/her diagnoses included paraplegia (a condition characterized by paralysis of the lower half of the body, typically including the legs and sometimes the torso). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 05/20/25 showed the following: -The resident had the ability to make self-understood and able to understand others; -Brief Interview for Mental Status (BIMS-a brief, standardized assessment used to quickly screen for cognitive impairment, focusing on orientation, short-term memory, and attention, often used in long-term care facilities) with a score of 9 (moderate cognitive impairment); -No hallucinations or delusions; -No behaviors; -He/She was dependent on staff for toileting hygiene, showering, upper and lower body dressing, putting on/taking off footwear, rolling left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed to chair transfer, and tub/shower transfer. During an interview on 06/25/25 at 12:53 P.M., the resident said the following: -He/She had not been comfortable with CNA G; -Certified Nurse Aide (CNA) G stroked his/her hair and said he/she liked his/her hair; -He/She saw CNA G holding women's underwear and he/she had been stroking the underwear between his/her fingers. 2. Review of a facility abuse investigation, dated 06/25/25, showed the following: -On Thursday, June 19, 2025, CNA A reported to the administrator when he/she worked on June 15, 2025, Resident #1 confided in him/her that CNA G had done something sexually abusive to him/her but he/she wouldn't go into detail; -CNA A said he/she reported the allegation to Registered Nurse (RN) B, Licensed Practical Nurse (LPN) C, LPN D, LPN E and RN F. 3. During an interview on 06/25/25 at 12:25 P.M., CNA A said the following: -In May the resident told him/her he/she did not want CNA G in his/her room and would not tell him/her the reason; -The resident said he/she saw CNA G rubbing women's silk underwear between his/her fingers in the hallway outside of his/her room; -The resident said this was not the reason he/she did not want CNA G in his/her room, but that CNA G sexually assaulted him/her; -The resident would not tell him/her anymore and did not want him/her to report the sexual abuse allegation; -He/She told the resident he/she had to report the sexual abuse allegation; -He/She reported the sexual abuse allegation to his/her supervisor, LPN D on June 15, 2025. During an interview on 06/25/25 at 2:13 P.M., LPN D said the following: -About one to two weeks ago, CNA A reported the resident said CNA G did something sexual to him/her; -He/She immediately reported the allegation to RN B; -Two days later (on June 17th), he/she followed up with the DON and she had not received an abuse allegation report from RN B. During an interview on 06/25/25 at 3:34 P.M., LPN E said the following: -He/She and LPN D had been on orientation and working together on June 15, 2025; -LPN D had come to the nurses' station and told RN B he/she needed to have a private conversation with him/her about something disturbing that the resident had reported to CNA A; -LPN D said the resident reported CNA G had made inappropriate moves on him/her and pulled out a pair of women's silk panties from his/her pocket rubbed them. This was something that needed to be reported to the staff supervisor. The chain of command was the CNA would report to the LPN and the LPN would report to the charge nurse; -LPN D reported what CNA A reported to him/her to RN B; -LPN D said he/she would follow up and make sure the allegations had been reported to the DON. During an interview on 06/25/25 at 2:22 P.M. and 4:47 P.M., RN B said the following: -He/She was the nursing supervisor on June 15th; -LPN D told him/her the resident was supposedly sexually assaulted; -He/She tried to talk with the resident, but he/she would not talk with him/her. -He/She did not believe the resident had been sexually abused; he/she thought it was just CNA gossip and if he/she had been, there was a phone number on the door he/she was supposed to call; -Staff are supposed to call the abuse hotline if abuse allegations are reported; he/she did not call the abuse hotline; -He/She did not report the resident's allegation of abuse to the administrator. During an interview on 06/25/25 at 3:20 P.M., the Assistant Director of Nursing (ADON) said the following: -About four to five weeks ago a CNA came to her and said the resident was having problems with CNA G being in his/her room; -She interviewed the resident and asked if there was anything that needed to be addressed and the resident said, no, he/she just had not liked how CNA G took care of him/her; -She did not know the resident had reported he/she had been sexually abused; -No report of sexual abuse had been reported to her; -The staff member who received the report of abuse did not follow through with reporting the abuse allegation to the administrator. During an interview on 06/25/25 at 11:38 A.M., 2:40 P.M., 4:06 P.M. and 5:23 P.M., the DON said the following: -About five weeks ago, a CNA (did not remember who) reported to her the resident did not want CNA G in his/her room; the resident would not give a reason why he/she did not want CNA G in his/her room; -On June 17th, LPN D might have said something about the resident alleging abuse against CNA G, but she had not remembered asking him/her if RN B had informed her CNA A had reported the resident alleging sexual abuse. LPN D might have said something, but she had a lot of things going on and does not remember the conversation; -RN B had not reported an allegation of sexual abuse involving the resident to her; -She would have been responsible for telling the administrator about the reported allegation if she was made aware of it on 06/17/25; -She had not reported the resident's abuse allegations to the administrator or to the Department of Health and Senior Services on 06/17/25; -The first time she could remember being made aware of the resident's sexual abuse allegation was on June 19, 2025, when the administrator informed her about the resident's abuse allegations; -Abuse allegations should be reported to the state agency within two hours; -When abuse allegations are made, the facility is to report it to the state agency and start an investigation immediately; -The allegations of abuse should have been reported to the State immediately. During an interview on 06/25/25 at 11:00 A.M., 4:38 P.M. and 5:05 P.M., the Administrator said the following: -On 06/19/25 at 10:45 A.M., CNA A reported to her he/she had reported the sexual abuse allegation to his/her supervisor, LPN D, on June 15th; -On June 19th, she asked the DON if the allegation had been reported to her and the DON said no sexual abuse allegation had been reported to her; -She thought the DON had already completed a prior investigation regarding the resident and CNA G which had been unfounded; the prior allegation was not related to a sexual abuse; -She did not recognize this as an additional concern being reported; -She would expect her staff to contact her and report any abuse allegations immediately; -The resident's abuse allegation should have been reported to the state agency within two hours of getting the report from CNA A on June 15th. MO256136

Based on interview and record review, the facility failed to provide evidence that allegations of abuse were thoroughly investigated, per facility policy, for one resident (Resident #1), in a review of eight sampled residents. The facility census was 65. Review of the facility policy for Abuse, Neglect and Reporting Reasonable Suspicion of a Crime, with a revision date of 02/13/25, showed the following: -It is the policy of this facility to protect the rights of all residents to be free from mistreatment, abuse, neglect, injuries of unknown sources and misappropriation or stealing of resident property or money; -Sexual Abuse is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault; -Investigations of Abuse/Neglect: a. The facility will ensure that all alleged reports of mistreatment, neglect or abuse, injuries of unknown source and misappropriation of resident property are investigated; b. The Human Resources Director is responsible for investigations of alleged abuse by an employee or staff member; h. The documented contents of the investigation will include: a. specific description of the incident, people involved, date, time and location of the incident; b. relevant information from the resident's medical record; d. personal information for all staff involved in the incident; e. written, signed statements by all people involved in incident; f. documentation of interviews conducted by facility staff; h. a summary of the investigation including corrective action taken; i. any other relevant information to the incident. 1. Review of Resident #1's face sheet showed his/her diagnoses included paraplegia (a condition characterized by paralysis of the lower half of the body, typically including the legs and sometimes the torso). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 05/20/25, showed the following: -The resident had the ability to make self-understood and able to understand others; -Brief Interview for Mental Status (BIMS-a brief, standardized assessment used to quickly screen for cognitive impairment, focusing on orientation, short-term memory, and attention, often used in long-term care facilities) with a score of 9 (moderate cognitive impairment); -No hallucinations or delusions; -No behaviors. During an interview on 06/25/25 at 12:53 P.M., the resident said the following: -He/She had not been comfortable with Certified Nurse Aide (CNA) G; -CNA G had stroked his/her hair and said he/she liked his/her hair; -He/She had seen CNA G holding women's underwear and he/she had been stroking the underwear between his/her fingers. 2. Review of the facility's abuse investigation, dated 06/25/25 and signed as completed by the administrator, showed the following: -On Thursday, June 19, 2025, CNA A reported to the administrator when he/she worked on June 15, 2025, the resident confided in him/her CNA G had done something sexually to him/her but he/she wouldn't go into detail; -CNA A said he/she reported the allegation to Registered Nurse (RN) B, Licensed Practical Nurse (LPN) C, LPN D, LPN E and RN F; -The administrator went to the resident's room and asked the resident about the incident with CNA G; -The resident refused to talk with the administrator about the incident; -The administrator called the staff members who had been reported as aware of the situation and requested statements be sent to her; -Seven statements were included in the investigation, including statements provided from Registered Nurse (RN) B, Licensed Practical Nurse (LPN) C, LPN D, LPN E, RN F and the DON; -The administrator contacted the local police department; -The administrator contacted the next of kin. 3. During an interview on 06/25/25 at 4:09 P.M., CNA G said he/she had not been contacted by the facility in reference to an abuse allegation. During an interview on 06/25/25 at 2:13 P.M., LPN D said the following: -About one to two weeks ago, CNA A reported the resident said CNA G did something sexual to him/her; -He/She immediately reported the allegation to his/her charge nurse, RN B; -He/She did not talk with the resident about the allegation, he/she thought the Director of Nursing (DON) should have spoken with the resident; -He/She had not begun a facility investigation into this allegation. During an interview on 06/25/25 at 2:22 P.M., and 4:47 P.M., RN B said the following: -On June 15th, LPN D told him/her that the resident was sexually assaulted; -He/She was the nursing supervisor during that time; -He/She had not begun a facility investigation into this allegation; -He/She tried to talk with the resident, but he/she would not talk with him/her. During an interview on 06/25/25 at 3:20 P.M., the Assistant Director of Nursing (ADON) said the following: -About four to five weeks ago, a CNA came to her and said the resident was having problems with CNA G being in his/her room. She interviewed the resident and asked if there was anything that needed looked into or anything that needed to be addressed and the resident said, no, he/she just had not liked how CNA G took care of him/her; -She did not know the resident reported an additional concern that he/she had been sexually abused; -No report of sexual abuse had been reported her. During an interview on 06/25/25 at 11:38 A.M., the DON said the following: -About five weeks ago a CNA (did not remember who) reported to her, Resident #1 did not want CNA G in his/her room; -During the previous investigation she did not talk with staff about Resident #1 not wanting CNA G in his/her room; -She did not know how the present administrator would like abuse investigations to be conducted; -The old administrator would have the Social Service director (SSD) conduct resident interviews; -She had not conducted resident interviews regarding Resident #1's abuse allegation of 06/19/25. During an interview on 06/25/25 at 4:06 P.M., the DON said the following: -She was responsible for the duties of Human Resources and had been for the past four months; -She did not remember LPN D asking her or telling her about CNA A reporting the resident's sexual abuse allegations; -She would have been responsible for telling the administrator and she did not tell the administrator about CNA A reporting Resident #1's sexual abuse allegations; -When abuse allegations are made, the facility should start an investigation immediately; -When the investigation is finished, the facility faxes it to the state agency; -During an abuse investigation, the facility should talk with the resident first and statements are gathered from anyone involved; -On Monday June 19, 2025, the administrator informed her about the resident's abuse allegations; -She had not begun a facility investigation into this allegation; -She had not interviewed any other resident's during the facility investigation of this allegation. During an interview on 06/25/25 at 11:00 A.M., 4:38 P.M., 5:05 P.M. and 07/10/25 at 8:23 A.M., the Administrator said the following: -On 06/19/25 at 10:45 A.M., CNA A reported to her the resident said he/she had been sexually assaulted by CNA G; -She thought the DON had already completed a prior investigation regarding the resident and CNA G which had been unfounded; -She did not speak with CNA G, regarding the new allegation as he/she no longer worked at the facility; -She would not have expected LPN D or RN B to have spoken to the resident because it had been an ongoing issue the DON had already investigated; -There are cameras in the hallways; -She had not viewed the camera footage for any observation of CNA G standing outside the resident room rubbing silk underwear between his/her fingers; -The resident's abuse allegation investigation, dated 06/25/25, consisted of staff statements, calling the police, talking with the resident and the next of kin; -The abuse investigation had not included any other resident interviews; -All the supervisors would be involved during an abuse investigation; -She would expect the DON to conduct resident interviews to ensure other residents were okay; -There was no resident interviews conducted during the investigation. Review of the facility investigation showed it did not contain the following documentation as directed by the facility policy: -No written, signed statement by all people involved in the incident, including the resident and CNA G; -No documentation of the resident's refusal to provide a written statement; -No documentation of interviews conducted or attempted by facility staff; -No documentation of a summary of the investigation, including corrective action taken. MO256136

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of nine sampled residents, was free from verbal abuse. The resident reported staff (Licensed Practical Nurse (LPN) D) raised his/her voice and told the resident to come on, come on while the resident tried to wheel himself/herself to the bathroom in a wheelchair. Resident #1, who had a diagnosis of aphasia (language disorder that affects a person's ability to communicate effectively), tried to communicate specific needs to LPN D, and when LPN D was not understanding what the resident was trying to say, the resident reached out to touch LPN D's hand so he/she would listen to the resident. LPN D continued to yell at the resident and threaten to call the police. The resident said the verbal abuse made him/her upset and scared of LPN D. The facility census was 63. Review of the facility policy for Abuse, Neglect and Reporting Reasonable Suspicion of a Crime, with a revision date of 02/03/22, showed the following: -It is the policy of this facility to protect the rights of all residents to be free from mistreatment, abuse, neglect, injuries of unknown sources and misappropriation or stealing of resident property or money; -Verbal Abuse is defined as any use of oral, written or gestured language that includes belittling and derogatory remarks of resident or families, or within the hearing distance of residents, regardless of their age, ability to comprehend, or disability; -All employees will be trained in this Abuse/Neglect policy and in the Reporting Reasonable Suspicion of a Crime in a Long-Term Care Facility policy at New Hire Orientation and an annual review will be done at the mandatory in-service training. 1. Review of Resident #1's face sheet showed diagnoses included cerebral infarction due to embolism of left middle cerebral artery ( a stroke where a blood clot in the brain blocks blood flow and causes the brain tissue to die off due to lack of oxygen resulting in a brain infarction (tissue damage) in the affected area), aphasia from cerebra vascular accident, and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 12/03/24, showed the following: -Intact cognition; -Usually understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Understands others-clear comprehension; -Partial/moderate assistance with toilet transfer and toileting hygiene; -Independent with wheelchair mobility, able to wheel 50 feet with two turns; -No rejection of cares; -No behaviors. Review of the resident's care plan, last updated 01/30/25, showed the following: -Altered ability to make self-understood secondary to aphasia from cerebral vascular accident (CVA - stroke); -Allow increased time for the resident to respond; -Encourage the resident to speak slowly and clearly; -Speak slowly and clearly while facing the resident in a well lit area. During an interview on 03/04/25 at 10:43 A.M. and 2:30 P.M., the resident said the following; -The incident happened on Saturday morning, 03/01/25; -LPN D was trying to tell the resident how to wheel into the bathroom; he/she tried to tell LPN D that was not how he/she did it and LPN D became agitated; -LPN D said several times come on; he/she (the resident) tried to tell LPN D to wait a minute; -He/She (the resident) tried to touch LPN D's hand to get LPN D to listen to him/her; -LPN D jerked his/her hand away and said he/she was going to call the cops; -Another resident down the hall heard the incident; -He/She felt upset and scared of LPN D; -He/She was tearful during the interview and said, I don't know what I did wrong; -He/She said he/she did not grab LPN D's shirt. During an interview on 03/04/25 at 10:55 A.M., the resident's family member said the resident called him/her on Saturday morning (03/01/25) upset and crying about a nurse yelling at him/her. He/She has requested LPN D not work with the resident anymore due to the resident being upset and scared of the nurse. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -Intact cognition; -Understands others-clear comprehension. During an interview on 03/04/25 at 10:57 A.M., the resident said the following: -He/She heard yelling from his/her room, two doors down from Resident #1's room on Saturday morning (03/01/24) and came out into the hallway; -LPN D was screaming at the top of his/her lungs, saying he/she was going to have Resident #1 arrested; -Someone at the nurses station asked LPN D why, and he/she said because he/she (referring to Resident #1) grabbed me; -Resident #1 was one of the nicest people in the facility and was depressed the rest of the day as a result of the interaction. During an interview on 03/04/25 at 11:05 A.M., Certified Medication Technician (CMT) C said the following: -The resident's family member called his/her personal phone on 03/01/25 at 9:52 A.M. and asked him/her to have the resident call the family member; -He/She was not working, so he/she called the facility and asked LPN D to have the resident call his/her family member; -LPN D was agitated and said, I'm not doing this, I don't need you to tell me how to do my job. I've been doing this for [AGE] years; -He/She told LPN D he/she was not telling him/her what to do, but that he/she just need him/her to give a message to the resident; -He/She then asked LPN D to just have a Certified Nurse Assistant (CNA) help the resident to call his/her family member. During an interview on 03/04/25 at 10:20 A.M., LPN B said the following: -On Saturday March 1st, LPN D came to C and D hall stating Resident #1 was being rude and grabbed his/her shirt and Resident #1 needed to keep his/her hands to him/herself or he/she would call the cops; -Resident #1 has aphasia due to a stroke but is alert and oriented and knows what is going on; -He/She has never had any problems with Resident #1 when he/she has worked with the resident; -Resident #1 has always been pleasant and cooperative. During an interview on 03/04/25 at 10:05 A.M., RN Supervisor A said the following: -He/She was the supervisor on call and was working in the facility on Saturday March 1st; -He/She made his/her rounds to the other halls to see how things were going when LPN D said Resident #1 gave him/her attitude a few days prior and then later told him/her that he/she (LPN D) could not do it any more and that he/she would not take care of the resident due to the resident's behaviors; LPN D said the resident grabbed his/her shirt, and if the resident came at him/her again, he/she would call the cops; -He/She went to Resident #1's room to see what happened and the resident would not tell him/her what happened. During an interview on 03/04/25 at 2:15 P.M., the ADON said the following: -Resident #1's family member came to her office this morning to discuss the incident that happened over the weekend; -The family member said the resident called and was upset on 03/01/25, so he/she came to the facility today to check on the resident and found out the resident was upset with nursing staff that yelled at him/her on 03/01/25; -The family member requested LPN D not work with Resident #1. During an interview on 03/04/25 at 1:10 P.M. and 2:55 P.M., the DON said the following: -She would have considered it abuse and/or a dignity and respect issue; -She would expect staff to treat residents with dignity and respect; -She would not expect staff to raise their voice or yell at a resident no matter what; -She would not expect staff to threaten to call the cops on a resident. During an interview on 03/04/25 at 1:55 P.M. and 3:25 P.M., the administrator said the following: -She was unaware of the allegation until the state surveyor arrived today; -She started her investigation, and with the information she received from staff, the resident and the state surveyor, she would consider the incident abuse; -All staff are trained on resident rights, dignity, respect and abuse upon hire and annually; -She would not expect staff to raise their voice or yell at a resident no matter what; -She would not expect staff to threaten to call the cops on a resident; MO250423

Based on interview and record review, the facility failed to ensure a licensed nursing home administrator was employed by the facility. The facility census was 62. Review of the most current Facility Assessment, dated [DATE], showed the following: -Licensed beds: 109; -Average daily censes: 53; -23 residents required extensive assistance of two or more staff for activities of daily living (ADLs); -Services required: assistance with ADLs, transfers, ambulation, restorative nursing, bowel and bladder training programs, incontinence prevention and care, catheter and colostomy care, pressure injury prevention and care, managing medical conditions and medication related issues, medication administration, pain assessment and management, physical, occupational, speech and respiratory therapy, management of braces and splints, nutrition, specialized diets, intravenous nutrition, tune feeding, person centered, directed care, psychosocial and spiritual support and dementia specialized care; -Administrative staff personnel required: administrator, human resource director, social services director, accounting director, clerical and medical records. Review of the facility's Administrator Job Description policy, dated [DATE], showed the following: -Must possess a current Health Facility Administrator's license from the State of Missouri; -Knowledge of long-term care management, policies, budgeting, personnel management, and census development is required. During an interview on [DATE] at 2:30 P.M., the Director of Accounting said the facility did not currently have a licensed administrator. During an interview on [DATE] at 3:35 P.M., the Board of Director's [NAME] President said the following: -The Human Resources Director took care of the day to day activities at the facility; -The Board of Directors took care of writing checks to pay bills; -She went to the facility to be involved with the issues in the facility and help as needed. During an interview on [DATE] at 9:55 A.M., the Human Resources Director said the following: -The facility did not currently have a licensed administrator; -The previous administrator resigned [DATE]; -The Human Resources Director had a temporary emergency license that expired on [DATE]; -He was taking care of the daily needs of the facility and addressed issues when brought to him. MO246378

Refer to event id 84PV12 Based on observation, interview and record review, the facility failed to ensure two residents (Resident #1 and #3), received medications as ordered by the physician upon admission to the facility. Resident #1 did not receive medications due to some medications not being available from the pharmacy and because staff failed to accurately transcribe some medications from the resident's hospital discharge orders to the resident's medication administration record (MAR). Apixaban (blood thinner) was omitted from the MAR for 1/31/24 and 2/1/24 through 2/5/24 (10 missed doses). The resident subsequently had a decline which sent him/her to the hospital where he/she was diagnosed with a stroke. Staff omitted cefuroxime (antibiotic used to treat pneumonia) and amiodarone (treats irregular heartbeat) from the resident's MAR on 1/31/24 and entered on the MAR on 2/1/24 through 2/5/24 to be administered once a day instead of the ordered dose of twice a day (five doses of each medication were missed). Insulin glargine-yfgn (long-acting insulin) was listed on the MAR on 1/31/24 and 2/1/24 through 2/5/24 to administer 50 units instead of the ordered dose of 80 units. Resident #3 only received one half of the ordered dosage of levetiracetam (antiseizure medication) and double the amount of ferrous sulfate (treats or prevents low levels of iron in the blood) as ordered. The facility census was 51. Review of the facility policy, Administration of Medication, dated 11/19/2019, showed the following: -The policy is a guideline for staff to administer routine medications in a safe fashion to residents; -Check all physician orders for accuracy and do not administer medications without an order; -Read the electronic medication record to be sure you are giving the correct medication, correct dose, correct route, the correct time and to the correct resident; -If medications are not available then order and document medication unavailable. The charge nurse is to investigate why medication is not available and contact the pharmacy to send. Notify the oncoming shift to be alert for resident's medications. Review of the facility policy, Following Physician's Orders, dated 9/2022, showed the following: -Faxed orders are transcribed by the nurse and transcribed under the electronic health record's orders tab and resident's progress notes; -Make sure that all orders are transcribed in the appropriate places such as the medication administration record (MAR). 1. Review of Resident #1's hospital discharge orders, dated 1/31/24, showed the following: -Medications to be continued after discharge included carvedilol (treats high blood pressure and heart failure) 12.5 milligrams (mg) tablet, give 0.5 (half) tablet two times a day and insulin glargine-yfgn (used to treat diabetes, long-acting insulin) 80 units once a day at bedtime; -New medications to be taken after discharge included apixaban 2.5 mg one tablet two times a day, amiodarone (prevents and treats a fast or irregular heartbeat) 200 mg one tablet two times a day,cefuroxime (antibiotic used to treat pneumonia) 500 mg one tablet every 12 hours, and insulin Lispro (fast acting insulin) four times a day (before meals and at bedtime). Zero units if blood sugar 70-139, two units if blood sugar 140-175 units, three units if blood sugar 176-200, four units if blood sugar 201-250, six units if blood sugar 251-300, eight units if blood sugar 301-350, nine units if blood sugar 351-400 and 12 units if blood sugar is greater than 400. Review of the resident's medication administration record (MAR), dated 1/31/24, showed the following: -Apixaban 2.5 milligrams (mg) was not listed on the MAR to be administered to the resident; -Cefuroxime 500 milligrams (mg) was not listed on the MAR to be administered to the resident; -Amiodarone 200 mg was not listed on the MAR to be administered to the resident; -Insulin glargine-yfgn 80 units, staff documented administration of 50 units instead of the 80 units as ordered on hospital discharge orders; -Mexiletine (treats irregular heartbeats) 150 mg, staff documented this was not administered to the resident at 10:00 P.M. because it had not been delivered from the pharmacy; -Doxycycline hyclate (antibiotic used to treat pneumonia) staff documented this was not administered to the resident for his/her evening dose because it had not been delivered from the pharmacy. Review of the resident's progress note, dated 1/31/24 at 4:21 P.M., showed the following: -The resident admitted to the facility; -The resident was alert and oriented to person and place. He/She was confused and forgetful; -The resident transferred with assist of two staff members with a gait belt and a walker; -No evidence of documentation that showed the physician was notified of medications either not available or not administered as ordered. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 2/4/24, showed the following: -The resident admitted to the facility on [DATE]; -The resident was able to make himself/herself understood and understood others; -The resident had no impairments of upper or lower extremities; -The resident was independent with indoor mobility; -The resident had an active discharge plan to return to the community; -The resident did not have a condition or chronic disease that would be the result in a life expectancy of six months or less; -The resident had diagnoses that included cardiorespiratory condition, atrial fibrillation (A-Fib, an irregular and often very rapid heart rhythm that can lead to blood clots and increases the risk of stroke, heart failure and other heart-related complications); heart failure and hypertension (high blood pressure). Review of the resident's MAR, for 2/1/24 through 2/5/24, showed the following: -On 2/1/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/1/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/1/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/1/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/2/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/2/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/2/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/2/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/3/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/3/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/3/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/3/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/4/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/4/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/4/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/4/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/5/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/5/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/5/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/5/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily. Review of the resident's progress notes dated 2/1/24 through 2/5/24, showed there was no evidence of documentation that showed the physician was notified of the medications either not available or not administered as ordered. Review of the resident's progress note, dated 2/5/24, showed the following: -It was reported to the Director of Nursing (DON) at 1:15 P.M. by the therapy department that they attempted to stand Resident #1 at the parallel bars and he/she did not use his/her left hand or arm nor could he/she pay attention and acted like he/she had left sided deficit (weakness); -Upon assessment of the resident by the DON, the resident's hands were slightly chilly and she could only get an 80% reading of his/her oxygen level (92% - 100% is normal); -The resident could easily raise his/her right arm but had to use the right arm to raise the left arm (this was unusual for the resident); -The resident was able to easily move his/her right leg but had difficulty raising the left leg and foot; -The DON placed two fingers in front of the resident and asked how many fingers there were and the resident said five; -The DON was unsure if this could be from a possible cardiovascular accident (CVA-stroke) or cognitive issues; -The resident currently used a mechanical lift for all transfers due to poor standing balance and required total assistance for all activities of daily living (ADLs) except for eating; -The resident's appetite was poor at breakfast and lunch this day; -The physician was notified with orders to send the resident to the hospital for evaluation; -The resident was transferred by ambulance to the hospital at 1:30 P.M. During an interview on 2/20/24 at 2:16 P.M. and 2/21/24 at 1:28 P.M., Licensed Practical Nurse (LPN) A said the following: -The day the resident admitted to the facility the resident was able to transfer from the wheelchair to the recliner with staff assistance; -He/She transcribed the resident's admission orders from the hospital onto the facility MAR; -It was an oversight that he/she missed the apixaban on the hospital discharge orders and he/she did not get it entered on the resident's medication administration record; -When asked if he/she was aware of other medication order errors (missed doses and doses that should have been given twice a day) he/she said I probably just screwed that up too. He/She was not aware there were other medication errors on the resident's MAR; -If a residents' orders were entered onto the MAR and electronically sent to the pharmacy they would usually be delivered to the facility at the 3:00 A.M. delivery time the following morning. During an interview on 2/20/24 at 4:10 P.M., LPN E said the following: -On 2/5/24, after breakfast the resident went to physical therapy; -The physical therapy assistant (PTA) told LPN E the resident was not responding well, the resident was not talking or opening his/her eyes and they noticed left sided weakness when the PTA tried to get the resident to participate in therapy; -The PTA brought the resident to the nurses's station; -The Director of Nurses (DON) assessed the resident at the nurses station; -It was determined that the resident needed to go to the hospital. The physician and an ambulance were called and the resident was transferred to the hospital; -The hospital called and asked LPN E when the resident last took his/her apixaban. LPN E could not find the order and asked another staff member about it. They could not find the order on the resident's MAR. During an interview on 2/21/24 at 9:04 A.M., the resident's family member said the following: -The resident had a history of stroke and A-fib, and he/she had had a heart valve replacement; -Prior to the resident becoming ill he/she could walk in the house with a walker on his/her own; -The resident was in the hospital from 1/21/24 through 1/31/24 for COVID and pneumonia; -When the resident was in the hospital, he/she was walking with a walker around his/her bed and was using a bedside commode with assistance of two staff; -The family was told the resident would probably make a full recovery, but he/she would need some physical therapy rehabilitation; -The resident was admitted to the facility on [DATE]. The physical therapist was in to see the resident and stood the resident up to assess him/her for potential rehabilitation; -The resident's computerized tomography scan (CT scan, combines a series of x-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body), performed during his/her hospital stay, showed that the resident had an extensive stroke that covered three lobes of the brain with a brain bleed. During an interview on 2/20/24 at 12:59 P.M., the resident's physician said the following: -Missed doses of apixaban may have contributed to the resident's stroke, but he/she could not say for sure; -He/She would expect the facility staff to transcribe orders and administer medications as written by the physician. During an interview on 2/22/24 at 4:07 P.M., the resident's hospital physician said the following: -The resident's apixaban definitely should have been administered as ordered; -Not getting his/her medications as ordered could have played a roll in his/her stroke; -The hospital physician would expect the facility staff to transcribe orders correctly and administer medications as ordered. 2. Review of Resident #3's hospital discharge orders, dated 1/23/24, showed the following: -Medications to be continued after discharge included hydralazine (treats high blood pressure) 10 mg three times a day, and levetiracetam (antiseizure medication) 750 mg two tablets (1500 mg) two times a day; -New medications to be taken after discharge included ferrous sulfate 325 mg every other day. Review of the resident's medication administration record (MAR), dated January 2024, showed the following: -Staff documented the hydralazine was not administered to the resident for 10 doses (the evening dose on 1/23/24 and all three doses on 1/24/24 through 1/26/24) because it had not been delivered from the pharmacy; -Staff documented levetiracetam 750 mg one tablet two times a day was administered twice a day instead of the ordered dose of 750 mg, two tablets (1500 mg) twice a day from 1/1/24 through 1/31/24; -Staff documented ferrous sulfate 325 mg was administered daily from 1/1/24 through 1/31/24, instead of the ordered dose of 325 mg every other day; Review of the resident's progress notes dated 1/23/24 to 1/31/24, showed there was no documentation that showed the physician was notified of the medications either not available or not administered as ordered. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was admitted to the facility on [DATE]; -The resident had diagnoses that included A-fib, hypertension (high blood pressure), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and seizure disorder. Review of the resident's MAR, for 2/1/24 through 2/20/24, showed the following: -Staff documented levetiracetam 750 mg one tablet two times a day was administered instead of the ordered dose of 750 mg, two tablets (1500 mg) twice a day; -Staff documented ferrous sulfate 325 mg was administered every day instead of the ordered dose of 325 mg every other day. Review of the resident's progress notes dated 2/1/24 to 2/20/24, showed there was no evidence of documentation that showed the physician was notified of the medication either not available or not administered as ordered. Observation on 2/20/24 at 4:05 P.M. of a medication cart that contained Resident #3's medications showed the following; -A medication card for levetiracetam 750 mg twice a day; -The resident's ferrous sulfate 325 mg was administered from the facility stock bottle. During an interview on 2/20/24 at 4:05 P.M., LPN D said the following: -The levetiracetam 750 mg, one tablet, twice a day order for Resident #3 began on 1/23/24 and had not changed since the resident's admission; -The ferrous sulfate 325 mg order was for once a day and had been given once a day since the resident's admission. During an interview on 2/21/24 at 2:10 P.M. Registered Nurse (RN) F said the following: -The facility tried to have RNs double check orders but that got put off with the changing/training of new supervisors; -He/She did not review the orders transcribed by LPN A to check to make sure all the orders were correct for Resident #1; -He/She did not transcribe Resident #3's orders. He/She checked reviewed in the electronic medication administration record so the medications would be sent from the pharmacy. That was how the medications got ordered for the residents; -He/She did not review the medication orders or check to be sure they were entered correctly for Resident #3; -He/She did not know there was an error with the ferrous sulfate and levetiracetam for Resident #3. During an interview on 1/20/24 at 10:03 A.M. and 4:30 P.M., the DON said the following: -Prior to finding out about Resident #1's medication error, there was no double checking or review of orders put in by the admitting nurse. She had suggested it to the RN supervisors, but they were not doing it consistently; -She did not know that Resident #1 did not receive his/her apixaban until the hospital called and asked about it; -She was not aware of Resident #1's other medication errors (insulin, amiodarone and cefuroxime) until the facility did a review of the resident's chart after the resident was admitted to the hospital; -She did not know Resident #3 had incorrect orders placed in his/her MAR for levetiracetam and ferrous sulfate or that he/she did not receive hydralazine for 10 doses; -She would expect nurses to double check their orders when putting them in the resident's electronic health records. MO231557 MO231733

Based on observation, interview and record review, the facility failed to ensure two residents (Resident #1 and #3), received medications as ordered by the physician upon admission to the facility. Resident #1 did not receive medications due to some medications not being available from the pharmacy and because staff failed to accurately transcribe some medications from the resident's hospital discharge orders to the resident's medication administration record (MAR). Apixaban (blood thinner) was omitted from the MAR for 1/31/24 and 2/1/24 through 2/5/24 (10 missed doses). The resident subsequently had a decline which sent him/her to the hospital where he/she was diagnosed with a stroke. Staff omitted cefuroxime (antibiotic used to treat pneumonia) and amiodarone (treats irregular heartbeat) from the resident's MAR on 1/31/24 and entered on the MAR on 2/1/24 through 2/5/24 to be administered once a day instead of the ordered dose of twice a day (five doses of each medication were missed). Insulin glargine-yfgn (long-acting insulin) was listed on the MAR on 1/31/24 and 2/1/24 through 2/5/24 to administer 50 units instead of the ordered dose of 80 units. Resident #3 only received one half of the ordered dosage of levetiracetam (antiseizure medication) and double the amount of ferrous sulfate (treats or prevents low levels of iron in the blood) as ordered. The facility census was 51. Review of the facility policy, Administration of Medication, dated 11/19/2019, showed the following: -The policy is a guideline for staff to administer routine medications in a safe fashion to residents; -Check all physician orders for accuracy and do not administer medications without an order; -Read the electronic medication record to be sure you are giving the correct medication, correct dose, correct route, the correct time and to the correct resident; -If medications are not available then order and document medication unavailable. The charge nurse is to investigate why medication is not available and contact the pharmacy to send. Notify the oncoming shift to be alert for resident's medications. Review of the facility policy, Following Physician's Orders, dated 9/2022, showed the following: -Faxed orders are transcribed by the nurse and transcribed under the electronic health record's orders tab and resident's progress notes; -Make sure that all orders are transcribed in the appropriate places such as the medication administration record (MAR). 1. Review of Resident #1's hospital discharge orders, dated 1/31/24, showed the following: -Medications to be continued after discharge included carvedilol (treats high blood pressure and heart failure) 12.5 milligrams (mg) tablet, give 0.5 (half) tablet two times a day and insulin glargine-yfgn (used to treat diabetes, long-acting insulin) 80 units once a day at bedtime; -New medications to be taken after discharge included apixaban 2.5 mg one tablet two times a day, amiodarone (prevents and treats a fast or irregular heartbeat) 200 mg one tablet two times a day,cefuroxime (antibiotic used to treat pneumonia) 500 mg one tablet every 12 hours, and insulin Lispro (fast acting insulin) four times a day (before meals and at bedtime). Zero units if blood sugar 70-139, two units if blood sugar 140-175 units, three units if blood sugar 176-200, four units if blood sugar 201-250, six units if blood sugar 251-300, eight units if blood sugar 301-350, nine units if blood sugar 351-400 and 12 units if blood sugar is greater than 400. Review of the resident's medication administration record (MAR), dated 1/31/24, showed the following: -Apixaban 2.5 milligrams (mg) was not listed on the MAR to be administered to the resident; -Cefuroxime 500 milligrams (mg) was not listed on the MAR to be administered to the resident; -Amiodarone 200 mg was not listed on the MAR to be administered to the resident; -Insulin glargine-yfgn 80 units, staff documented administration of 50 units instead of the 80 units as ordered on hospital discharge orders; -Mexiletine (treats irregular heartbeats) 150 mg, staff documented this was not administered to the resident at 10:00 P.M. because it had not been delivered from the pharmacy; -Doxycycline hyclate (antibiotic used to treat pneumonia) staff documented this was not administered to the resident for his/her evening dose because it had not been delivered from the pharmacy. Review of the resident's progress note, dated 1/31/24 at 4:21 P.M., showed the following: -The resident admitted to the facility; -The resident was alert and oriented to person and place. He/She was confused and forgetful; -The resident transferred with assist of two staff members with a gait belt and a walker; -No evidence of documentation that showed the physician was notified of medications either not available or not administered as ordered. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 2/4/24, showed the following: -The resident admitted to the facility on [DATE]; -The resident was able to make himself/herself understood and understood others; -The resident had no impairments of upper or lower extremities; -The resident was independent with indoor mobility; -The resident had an active discharge plan to return to the community; -The resident did not have a condition or chronic disease that would be the result in a life expectancy of six months or less; -The resident had diagnoses that included cardiorespiratory condition, atrial fibrillation (A-Fib, an irregular and often very rapid heart rhythm that can lead to blood clots and increases the risk of stroke, heart failure and other heart-related complications); heart failure and hypertension (high blood pressure). Review of the resident's MAR, for 2/1/24 through 2/5/24, showed the following: -On 2/1/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/1/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/1/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/1/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/2/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/2/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/2/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/2/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/3/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/3/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/3/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/3/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/4/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/4/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/4/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/4/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/5/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/5/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/5/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/5/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily. Review of the resident's progress notes dated 2/1/24 through 2/5/24, showed there was no evidence of documentation that showed the physician was notified of the medications either not available or not administered as ordered. Review of the resident's progress note, dated 2/5/24, showed the following: -It was reported to the Director of Nursing (DON) at 1:15 P.M. by the therapy department that they attempted to stand Resident #1 at the parallel bars and he/she did not use his/her left hand or arm nor could he/she pay attention and acted like he/she had left sided deficit (weakness); -Upon assessment of the resident by the DON, the resident's hands were slightly chilly and she could only get an 80% reading of his/her oxygen level (92% - 100% is normal); -The resident could easily raise his/her right arm but had to use the right arm to raise the left arm (this was unusual for the resident); -The resident was able to easily move his/her right leg but had difficulty raising the left leg and foot; -The DON placed two fingers in front of the resident and asked how many fingers there were and the resident said five; -The DON was unsure if this could be from a possible cardiovascular accident (CVA-stroke) or cognitive issues; -The resident currently used a mechanical lift for all transfers due to poor standing balance and required total assistance for all activities of daily living (ADLs) except for eating; -The resident's appetite was poor at breakfast and lunch this day; -The physician was notified with orders to send the resident to the hospital for evaluation; -The resident was transferred by ambulance to the hospital at 1:30 P.M. During an interview on 2/20/24 at 2:16 P.M. and 2/21/24 at 1:28 P.M., Licensed Practical Nurse (LPN) A said the following: -The day the resident admitted to the facility the resident was able to transfer from the wheelchair to the recliner with staff assistance; -He/She transcribed the resident's admission orders from the hospital onto the facility MAR; -It was an oversight that he/she missed the apixaban on the hospital discharge orders and he/she did not get it entered on the resident's medication administration record; -When asked if he/she was aware of other medication order errors (missed doses and doses that should have been given twice a day) he/she said I probably just screwed that up too. He/She was not aware there were other medication errors on the resident's MAR; -If a residents' orders were entered onto the MAR and electronically sent to the pharmacy they would usually be delivered to the facility at the 3:00 A.M. delivery time the following morning. During an interview on 2/20/24 at 4:10 P.M., LPN E said the following: -On 2/5/24, after breakfast the resident went to physical therapy; -The physical therapy assistant (PTA) told LPN E the resident was not responding well, the resident was not talking or opening his/her eyes and they noticed left sided weakness when the PTA tried to get the resident to participate in therapy; -The PTA brought the resident to the nurses's station;-The Director of Nurses (DON) assessed the resident at the nurses station; -It was determined that the resident needed to go to the hospital. The physician and an ambulance were called and the resident was transferred to the hospital; -The hospital called and asked LPN E when the resident last took his/her apixaban. LPN E could not find the order and asked another staff member about it. They could not find the order on the resident's MAR. During an interview on 2/21/24 at 9:04 A.M., the resident's family member said the following: -The resident had a history of stroke and A-fib, and he/she had had a heart valve replacement; -Prior to the resident becoming ill he/she could walk in the house with a walker on his/her own; -The resident was in the hospital from 1/21/24 through 1/31/24 for COVID and pneumonia; -When the resident was in the hospital, he/she was walking with a walker around his/her bed and was using a bedside commode with assistance of two staff; -The family was told the resident would probably make a full recovery, but he/she would need some physical therapy rehabilitation; -The resident was admitted to the facility on [DATE]. The physical therapist was in to see the resident and stood the resident up to assess him/her for potential rehabilitation; -The resident's computerized tomography scan (CT scan, combines a series of x-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body), performed during his/her hospital stay, showed that the resident had an extensive stroke that covered three lobes of the brain with a brain bleed. During an interview on 2/20/24 at 12:59 P.M., the resident's physician said the following: -Missed doses of apixaban may have contributed to the resident's stroke, but he/she could not say for sure; -He/She would expect the facility staff to transcribe orders and administer medications as written by the physician. During an interview on 2/22/24 at 4:07 P.M., the resident's hospital physician said the following: -The resident's apixaban definitely should have been administered as ordered; -Not getting his/her medications as ordered could have played a roll in his/her stroke; -The hospital physician would expect the facility staff to transcribe orders correctly and administer medications as ordered. 2. Review of Resident #3's hospital discharge orders, dated 1/23/24, showed the following: -Medications to be continued after discharge included hydralazine (treats high blood pressure) 10 mg three times a day, and levetiracetam (antiseizure medication) 750 mg two tablets (1500 mg) two times a day; -New medications to be taken after discharge included ferrous sulfate 325 mg every other day. Review of the resident's medication administration record (MAR), dated January 2024, showed the following: -Staff documented the hydralazine was not administered to the resident for 10 doses (the evening dose on 1/23/24 and all three doses on 1/24/24 through 1/26/24) because it had not been delivered from the pharmacy; -Staff documented levetiracetam 750 mg one tablet two times a day was administered twice a day instead of the ordered dose of 750 mg, two tablets (1500 mg) twice a day from 1/1/24 through 1/31/24; -Staff documented ferrous sulfate 325 mg was administered daily from 1/1/24 through 1/31/24, instead of the ordered dose of 325 mg every other day; Review of the resident's progress notes dated 1/23/24 to 1/31/24, showed there was no documentation that showed the physician was notified of the medications either not available or not administered as ordered. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was admitted to the facility on [DATE]; -The resident had diagnoses that included A-fib, hypertension (high blood pressure), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and seizure disorder. Review of the resident's MAR, for 2/1/24 through 2/20/24, showed the following: -Staff documented levetiracetam 750 mg one tablet two times a day was administered instead of the ordered dose of 750 mg, two tablets (1500 mg) twice a day; -Staff documented ferrous sulfate 325 mg was administered every day instead of the ordered dose of 325 mg every other day. Review of the resident's progress notes dated 2/1/24 to 2/20/24, showed there was no evidence of documentation that showed the physician was notified of the medication either not available or not administered as ordered. Observation on 2/20/24 at 4:05 P.M. of a medication cart that contained Resident #3's medications showed the following; -A medication card for levetiracetam 750 mg twice a day; -The resident's ferrous sulfate 325 mg was administered from the facility stock bottle. During an interview on 2/20/24 at 4:05 P.M., LPN D said the following: -The levetiracetam 750 mg, one tablet, twice a day order for Resident #3 began on 1/23/24 and had not changed since the resident's admission; -The ferrous sulfate 325 mg order was for once a day and had been given once a day since the resident's admission. During an interview on 2/21/24 at 2:10 P.M. Registered Nurse (RN) F said the following: -The facility tried to have RNs double check orders but that got put off with the changing/training of new supervisors; -He/She did not review the orders transcribed by LPN A to check to make sure all the orders were correct for Resident #1; -He/She did not transcribe Resident #3's orders. He/She checked reviewed in the electronic medication administration record so the medications would be sent from the pharmacy. That was how the medications got ordered for the residents; -He/She did not review the medication orders or check to be sure they were entered correctly for Resident #3; -He/She did not know there was an error with the ferrous sulfate and levetiracetam for Resident #3. During an interview on 1/20/24 at 10:03 A.M. and 4:30 P.M., the DON said the following: -Prior to finding out about Resident #1's medication error, there was no double checking or review of orders put in by the admitting nurse. She had suggested it to the RN supervisors, but they were not doing it consistently; -She did not know that Resident #1 did not receive his/her apixaban until the hospital called and asked about it; -She was not aware of Resident #1's other medication errors (insulin, amiodarone and cefuroxime) until the facility did a review of the resident's chart after the resident was admitted to the hospital; -She did not know Resident #3 had incorrect orders placed in his/her MAR for levetiracetam and ferrous sulfate or that he/she did not receive hydralazine for 10 doses; -She would expect nurses to double check their orders when putting them in the resident's electronic health records. MO231557 MO231733

Based on observation, interview and record review, the facility failed to ensure two residents (Resident #1 and #3), received medications as ordered by the physician upon admission to the facility. Resident #1 did not receive medications due to some medications not being available from the pharmacy and because staff failed to accurately transcribe some medications from the resident's hospital discharge orders to the resident's medication administration record (MAR). Apixaban (blood thinner) was omitted from the MAR for 1/31/24 and 2/1/24 through 2/5/24 (10 missed doses). The resident subsequently had a decline which sent him/her to the hospital where he/she was diagnosed with a stroke. Staff omitted cefuroxime (antibiotic used to treat pneumonia) and amiodarone (treats irregular heartbeat) from the resident's MAR on 1/31/24 and entered on the MAR on 2/1/24 through 2/5/24 to be administered once a day instead of the ordered dose of twice a day (five doses of each medication were missed). Insulin glargine-yfgn (long-acting insulin) was listed on the MAR on 1/31/24 and 2/1/24 through 2/5/24 to administer 50 units instead of the ordered dose of 80 units. Resident #3 only received one half of the ordered dosage of levetiracetam (antiseizure medication) and double the amount of ferrous sulfate (treats or prevents low levels of iron in the blood) as ordered. The facility census was 51. Review of the facility policy, Administration of Medication, dated 11/19/2019, showed the following: -The policy is a guideline for staff to administer routine medications in a safe fashion to residents; -Check all physician orders for accuracy and do not administer medications without an order; -Read the electronic medication record to be sure you are giving the correct medication, correct dose, correct route, the correct time and to the correct resident; -If medications are not available then order and document medication unavailable. The charge nurse is to investigate why medication is not available and contact the pharmacy to send. Notify the oncoming shift to be alert for resident's medications. Review of the facility policy, Following Physician's Orders, dated 9/2022, showed the following: -Faxed orders are transcribed by the nurse and transcribed under the electronic health record's orders tab and resident's progress notes; -Make sure that all orders are transcribed in the appropriate places such as the medication administration record (MAR). 1. Review of Resident #1's hospital discharge orders, dated 1/31/24, showed the following: -Medications to be continued after discharge included carvedilol (treats high blood pressure and heart failure) 12.5 milligrams (mg) tablet, give 0.5 (half) tablet two times a day and insulin glargine-yfgn (used to treat diabetes, long-acting insulin) 80 units once a day at bedtime; -New medications to be taken after discharge included apixaban 2.5 mg one tablet two times a day, amiodarone (prevents and treats a fast or irregular heartbeat) 200 mg one tablet two times a day,cefuroxime (antibiotic used to treat pneumonia) 500 mg one tablet every 12 hours, and insulin Lispro (fast acting insulin) four times a day (before meals and at bedtime). Zero units if blood sugar 70-139, two units if blood sugar 140-175 units, three units if blood sugar 176-200, four units if blood sugar 201-250, six units if blood sugar 251-300, eight units if blood sugar 301-350, nine units if blood sugar 351-400 and 12 units if blood sugar is greater than 400. Review of the resident's medication administration record (MAR), dated 1/31/24, showed the following: -Apixaban 2.5 milligrams (mg) was not listed on the MAR to be administered to the resident; -Cefuroxime 500 milligrams (mg) was not listed on the MAR to be administered to the resident; -Amiodarone 200 mg was not listed on the MAR to be administered to the resident; -Insulin glargine-yfgn 80 units, staff documented administration of 50 units instead of the 80 units as ordered on hospital discharge orders; -Mexiletine (treats irregular heartbeats) 150 mg, staff documented this was not administered to the resident at 10:00 P.M. because it had not been delivered from the pharmacy; -Doxycycline hyclate (antibiotic used to treat pneumonia) staff documented this was not administered to the resident for his/her evening dose because it had not been delivered from the pharmacy. Review of the resident's progress note, dated 1/31/24 at 4:21 P.M., showed the following: -The resident admitted to the facility; -The resident was alert and oriented to person and place. He/She was confused and forgetful; -The resident transferred with assist of two staff members with a gait belt and a walker; -No evidence of documentation that showed the physician was notified of medications either not available or not administered as ordered. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 2/4/24, showed the following: -The resident admitted to the facility on [DATE]; -The resident was able to make himself/herself understood and understood others; -The resident had no impairments of upper or lower extremities; -The resident was independent with indoor mobility; -The resident had an active discharge plan to return to the community; -The resident did not have a condition or chronic disease that would be the result in a life expectancy of six months or less; -The resident had diagnoses that included cardiorespiratory condition, atrial fibrillation (A-Fib, an irregular and often very rapid heart rhythm that can lead to blood clots and increases the risk of stroke, heart failure and other heart-related complications); heart failure and hypertension (high blood pressure). Review of the resident's MAR, for 2/1/24 through 2/5/24, showed the following: -On 2/1/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/1/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/1/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/1/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/2/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/2/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/2/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/2/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/3/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/3/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/3/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/3/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/4/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/4/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/4/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/4/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/5/24 apixaban 2.5 mg was not listed on the MAR as a medication to be administered to the resident; -On 2/5/24 staff administered insulin glargine-yfgn 50 units (listed on the MAR to be administered at 50 units) instead of the ordered 80 units; -On 2/5/24 staff administered cefuroxime axetil 500 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily; -On 2/5/24 staff administered amiodarone 200 mg (listed on the MAR to be given once a day) instead of the ordered frequency of twice daily. Review of the resident's progress notes dated 2/1/24 through 2/5/24, showed there was no evidence of documentation that showed the physician was notified of the medications either not available or not administered as ordered. Review of the resident's progress note, dated 2/5/24, showed the following: -It was reported to the Director of Nursing (DON) at 1:15 P.M. by the therapy department that they attempted to stand Resident #1 at the parallel bars and he/she did not use his/her left hand or arm nor could he/she pay attention and acted like he/she had left sided deficit (weakness); -Upon assessment of the resident by the DON, the resident's hands were slightly chilly and she could only get an 80% reading of his/her oxygen level (92% - 100% is normal); -The resident could easily raise his/her right arm but had to use the right arm to raise the left arm (this was unusual for the resident); -The resident was able to easily move his/her right leg but had difficulty raising the left leg and foot; -The DON placed two fingers in front of the resident and asked how many fingers there were and the resident said five; -The DON was unsure if this could be from a possible cardiovascular accident (CVA-stroke) or cognitive issues; -The resident currently used a mechanical lift for all transfers due to poor standing balance and required total assistance for all activities of daily living (ADLs) except for eating; -The resident's appetite was poor at breakfast and lunch this day; -The physician was notified with orders to send the resident to the hospital for evaluation; -The resident was transferred by ambulance to the hospital at 1:30 P.M. During an interview on 2/20/24 at 2:16 P.M. and 2/21/24 at 1:28 P.M., Licensed Practical Nurse (LPN) A said the following: -The day the resident admitted to the facility the resident was able to transfer from the wheelchair to the recliner with staff assistance; -He/She transcribed the resident's admission orders from the hospital onto the facility MAR; -It was an oversight that he/she missed the apixaban on the hospital discharge orders and he/she did not get it entered on the resident's medication administration record; -When asked if he/she was aware of other medication order errors (missed doses and doses that should have been given twice a day) he/she said I probably just screwed that up too. He/She was not aware there were other medication errors on the resident's MAR; -If a residents' orders were entered onto the MAR and electronically sent to the pharmacy they would usually be delivered to the facility at the 3:00 A.M. delivery time the following morning. During an interview on 2/20/24 at 4:10 P.M., LPN E said the following: -On 2/5/24, after breakfast the resident went to physical therapy; -The physical therapy assistant (PTA) told LPN E the resident was not responding well, the resident was not talking or opening his/her eyes and they noticed left sided weakness when the PTA tried to get the resident to participate in therapy; -The PTA brought the resident to the nurses's station; -The Director of Nurses (DON) assessed the resident at the nurses station; -It was determined that the resident needed to go to the hospital. The physician and an ambulance were called and the resident was transferred to the hospital; -The hospital called and asked LPN E when the resident last took his/her apixaban. LPN E could not find the order and asked another staff member about it. They could not find the order on the resident's MAR. During an interview on 2/21/24 at 9:04 A.M., the resident's family member said the following: -The resident had a history of stroke and A-fib, and he/she had had a heart valve replacement; -Prior to the resident becoming ill he/she could walk in the house with a walker on his/her own; -The resident was in the hospital from [DATE] through 1/31/24 for COVID and pneumonia; -When the resident was in the hospital, he/she was walking with a walker around his/her bed and was using a bedside commode with assistance of two staff; -The family was told the resident would probably make a full recovery, but he/she would need some physical therapy rehabilitation; -The resident was admitted to the facility on [DATE]. The physical therapist was in to see the resident and stood the resident up to assess him/her for potential rehabilitation; -The resident's computerized tomography scan (CT scan, combines a series of x-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body), performed during his/her hospital stay, showed that the resident had an extensive stroke that covered three lobes of the brain with a brain bleed. During an interview on 2/20/24 at 12:59 P.M., the resident's physician said the following: -Missed doses of apixaban may have contributed to the resident's stroke, but he/she could not say for sure; -He/She would expect the facility staff to transcribe orders and administer medications as written by the physician. During an interview on 2/22/24 at 4:07 P.M., the resident's hospital physician said the following: -The resident's apixaban definitely should have been administered as ordered; -Not getting his/her medications as ordered could have played a roll in his/her stroke; -The hospital physician would expect the facility staff to transcribe orders correctly and administer medications as ordered. 2. Review of Resident #3's hospital discharge orders, dated 1/23/24, showed the following: -Medications to be continued after discharge included hydralazine (treats high blood pressure) 10 mg three times a day, and levetiracetam (antiseizure medication) 750 mg two tablets (1500 mg) two times a day; -New medications to be taken after discharge included ferrous sulfate 325 mg every other day. Review of the resident's medication administration record (MAR), dated January 2024, showed the following: -Staff documented the hydralazine was not administered to the resident for 10 doses (the evening dose on 1/23/24 and all three doses on 1/24/24 through 1/26/24) because it had not been delivered from the pharmacy; -Staff documented levetiracetam 750 mg one tablet two times a day was administered twice a day instead of the ordered dose of 750 mg, two tablets (1500 mg) twice a day from 1/1/24 through 1/31/24; -Staff documented ferrous sulfate 325 mg was administered daily from 1/1/24 through 1/31/24, instead of the ordered dose of 325 mg every other day; Review of the resident's progress notes dated 1/23/24 to 1/31/24, showed there was no documentation that showed the physician was notified of the medications either not available or not administered as ordered. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was admitted to the facility on [DATE]; -The resident had diagnoses that included A-fib, hypertension (high blood pressure), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and seizure disorder. Review of the resident's MAR, for 2/1/24 through 2/20/24, showed the following: -Staff documented levetiracetam 750 mg one tablet two times a day was administered instead of the ordered dose of 750 mg, two tablets (1500 mg) twice a day; -Staff documented ferrous sulfate 325 mg was administered every day instead of the ordered dose of 325 mg every other day. Review of the resident's progress notes dated 2/1/24 to 2/20/24, showed there was no evidence of documentation that showed the physician was notified of the medication either not available or not administered as ordered. Observation on 2/20/24 at 4:05 P.M. of a medication cart that contained Resident #3's medications showed the following; -A medication card for levetiracetam 750 mg twice a day; -The resident's ferrous sulfate 325 mg was administered from the facility stock bottle. During an interview on 2/20/24 at 4:05 P.M., LPN D said the following: -The levetiracetam 750 mg, one tablet, twice a day order for Resident #3 began on 1/23/24 and had not changed since the resident's admission; -The ferrous sulfate 325 mg order was for once a day and had been given once a day since the resident's admission. During an interview on 2/21/24 at 2:10 P.M. Registered Nurse (RN) F said the following: -The facility tried to have RNs double check orders but that got put off with the changing/training of new supervisors; -He/She did not review the orders transcribed by LPN A to check to make sure all the orders were correct for Resident #1; -He/She did not transcribe Resident #3's orders. He/She checked reviewed in the electronic medication administration record so the medications would be sent from the pharmacy. That was how the medications got ordered for the residents; -He/She did not review the medication orders or check to be sure they were entered correctly for Resident #3; -He/She did not know there was an error with the ferrous sulfate and levetiracetam for Resident #3. During an interview on 1/20/24 at 10:03 A.M. and 4:30 P.M., the DON said the following: -Prior to finding out about Resident #1's medication error, there was no double checking or review of orders put in by the admitting nurse. She had suggested it to the RN supervisors, but they were not doing it consistently; -She did not know that Resident #1 did not receive his/her apixaban until the hospital called and asked about it; -She was not aware of Resident #1's other medication errors (insulin, amiodarone and cefuroxime) until the facility did a review of the resident's chart after the resident was admitted to the hospital; -She did not know Resident #3 had incorrect orders placed in his/her MAR for levetiracetam and ferrous sulfate or that he/she did not receive hydralazine for 10 doses; -She would expect nurses to double check their orders when putting them in the resident's electronic health records. MO231557 MO231733

Based on interview and record review, the facility failed to ensure staff provided care according to acceptable standards of practice for one resident (Resident #9), in a review of five sampled residents and four closed records. The resident developed nausea, vomiting and diarrhea, a change in vital signs, required supplemental oxygen and became unresponsive over the course of 16 hours. Staff failed to notify the resident's physician and failed to seek treatment for the resident's change in condition until the following morning. On [DATE], day shift staff contacted the resident's family regarding the resident's condition. At that time the resident's family requested the resident be sent to the hospital. The facility census was 55. Record review of the facility policy, Contacting Physicians, dated [DATE], showed the following: -The purpose of the policy was to give guidelines to nursing staff on contacting resident physicians; -Notification of physicians in non-emergent situation: Nursing staff should fax physicians to relay reports or status change information regarding resident. Staff should send faxed to the physician's office and include all pertinent information. If no return call or fax was received from the physician office by 4:00 P.M. the nursing staff should call the physician's office or page the appropriate physician if a response was needed to provide care; -After hours, weekends and/or holidays, the charge nurse was to call the appropriate physician for any and all resident changes for orders; -Notification of physician in emergent/life threatening situation: Residents that were a full code and had an emergency situation the staff would call 911 and then notify the appropriate physician on duty, the family and the Registered Nurse (RN) on duty; -If a resident was a Do Not Resuscitate (DNR), no hospitalization , staff would need to notify the resident's family or responsible party to be sure their wishes were followed. If the wish was for the resident to go to the hospital, then call 911, the physician on call and the RN on duty; -If a resident had one or more of the following: airway obstruction or breathing problems new to the resident, circulation issues, rapid pulse or slow pulse or no pulse, a decline in the normal consciousness, excessive bleeding, chest pain and/or shortness of breath; do not fax to communicate with physician when the situation was emergent. Call and speak with the physician. 1. Record review of Resident #9's Healthcare Directive, dated [DATE] and signed by the resident, two witnesses, the Medical Director, administrator and Director of Nursing (DON) showed the following: -The document would be based upon instructions voiced or written on behalf of the resident or appropriate person who knew the resident or knew the resident's wishes regarding healthcare directives; -Do provide intravenous fluids (fluids administered through a vein) and oxygen; -Do not provide hospitalization , tube feedings, lifesaving code (CPR) (Cardiopulmonary Resuscitation, the act of providing lifesaving measures) or blood transfusions. Record review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance of two staff members with bed mobility, transfers, dressing, toileting and personal hygiene; -Required extensive assistance of one staff member with eating; -Occasionally incontinent of bladder and frequently incontinent of bowel; -Short of breath with exertion, at rest and lying flat. Did not require supplemental oxygen. Record review of the resident's Physician Order Sheet, dated [DATE], showed the following: -Date of admission [DATE]; -Diagnosis of osteoarthritis, atrial fibrillation (irregular heart rate), dizziness, chronic pain, anxiety, muscle wasting and atrophy, lack of coordination, chronic obstructive pulmonary disease (COPD, an illness of irreversible damage to the lungs causing blocked airflow and difficulty breathing), heart failure; -Do Not Resuscitate; -Meclizine (medication used for dizziness) 25 milligrams (mg) every six hours as needed for dizziness. Record review of the resident's care plan dated [DATE], showed the following: -Required total staff assistance with Activities of Daily Living (ADLs) with a goal the resident would be safe and free from accident and injury, adequately nourished and hydrated daily and not develop new skin breakdown. Staff should anticipate the resident's needs and provide morning and evening cares, feed the resident all meals, provide two to three staff member assistance with transfers with a mechanical lift for safety. Reposition in bed with total staff assistance every two to four hours; -The resident received anti-anxiety medication as needed for anxiety. Staff should administer the medication as ordered and assess the effectiveness of the medication; -Potential for gastrointestinal (GI) discomfort. Staff should monitor for GI upset such as nausea, vomiting, diarrhea, epigastric discomfort and indigestion. Notify the physician of increased complaint of GI upset. Record review of the resident's nurses' note, dated [DATE] at 2:23 P.M., showed Licensed Practical Nurse (LPN) I documented the resident had vomited twice during the shift and had a large loose stool three times that day. Staff administered meclizine. Clear fluids were encouraged, ice chips and white soda provided. The resident was afebrile (without fever) and vital signs were within normal limits. Record review showed no documentation on [DATE] that the resident's physician was notified of the resident vomiting, loose stools, or administration of meclizine. Record review of the nurses' note, dated [DATE] at 9:59 P.M., showed LPN E documented the resident had been up in a chair for supper, was ill all day with emesis (vomiting) and diarrhea. The resident was dependent on staff for all activities of daily living, required a mechanical lift for transfers, had pain in his/her legs and took scheduled narcotics. The resident did not require supplemental oxygen. During an interview on [DATE] at 4:45 P.M. LPN E said he/she worked on [DATE] from 3:00 P.M. to 11:30 P.M. The resident required a lot of care and was sick that day ([DATE]) with nausea, vomiting and diarrhea. The resident got a sick tray of Jello and white soda for supper and slept a lot. The resident was responsive during the shift but was not his/her normal self as he/she had not felt good all day. LPN E was still at the facility at 12:00 A.M. and the resident was responsive at that time. Staff should notify a resident's physician and family of any change in condition and obtain treatment. LPN E did not notify the resident's physician of the resident's change in condition. Record review showed no documentation on [DATE] that the resident's physician was notified of the resident vomiting, diarrhea, and feeling ill all day. Record review of the nurses' note dated [DATE] at 3:54 A.M. showed LPN A documented the resident was unresponsive (no response to verbal or tactile stimuli, unable to wake). Temperature 98 degrees (normal 98.6 degrees), pulse 118 (normal ,d+[DATE] beats per minute), blood pressure ,d+[DATE] (normal ,d+[DATE], a diastolic number, the bottom number, of 0 indicated severe alteration in the blood pressure), oxygen saturation 82 percent (a measure of the oxygen level circulating to the tissues, normal level greater than 92 percent). Staff applied supplemental oxygen (O2) and oxygen saturation increased to 90 percent on 3 liters of oxygen (delivered through a tube into the nose from either an oxygen tank or oxygen concentrator). Staff rechecked and the resident's oxygen saturation was 94 percent, pulse was 30 (severely slow heart rate and indicated poor circulation) and the resident opened his/her eyes to vocal stimuli. During an interview on [DATE] at 11:25 A.M. LPN A said the resident was unresponsive during the night. LPN A did not recall if the family or physician were notified. He/She tried to get the resident to respond to painful stimuli (inflicting pain by a deep sternal or chest rub with the knuckles). Usually if a resident was unresponsive, LPN A sent the resident out by ambulance to the emergency room for treatment. He/She did not notify the physician that the resident was unresponsive. LPN A was not sure why he/she did not notify the resident's physician and obtain treatment. Record review showed no documentation on [DATE] the resident's physician was notified the resident was unresponsive, the change in the resident's vital signs and oxygen saturation levels, the addition of supplemental oxygen or the resident's pulse of 30. Record review of the nurses' note dated [DATE] at 1:57 P.M. showed LPN B documented at 7:30 A.M. the night nurse reported to LPN B and the night CNA staff reported to the day shift CNA staff the resident was sick yesterday ([DATE]) with vomiting and diarrhea. Night shift staff checked on the resident at 2:00 A.M. and the resident was unresponsive. Oxygen was applied at 2 liters. LPN B assessed the resident, O2 was in place, the resident was unresponsive to verbal and physical stimuli, and breathing was labored with pupils fixed (no response of the pupils to light indicating a change in consciousness). Temperature 98.2, pulse 108, respirations 14, unable to obtain manual blood pressure, wrist monitor registered blood pressure of ,d+[DATE]. Staff notified the resident's family member and explained to the family member the resident's Advanced Directive included the resident did not want to go to the hospital and the resident was Do Not Resuscitate (DNR). The family member said he/she wanted the resident to be a DNR, but the resident had changed his/her mind after initially signing paperwork and the resident did want to go to the hospital for treatment. LPN B told the family member the physician would be called for further direction. The physician was notified. Family members arrived and said they wanted the resident transferred to the hospital, but his/her code status remained DNR. They again said they had discussed this as a family recently and the resident told them he/she did want to go to the hospital but remained a DNR. The physician ordered the resident sent to the hospital as the family wished since the resident was unresponsive and unable to communicate with the staff. At 8:00 A.M. the paperwork was competed for transfer, ambulance notified and resident sent to the local hospital. During an interview on [DATE] at 6:52 P.M. LPN B said he/she was the charge nurse on [DATE] and came to work at 7:00 A.M. He/She obtained report from the night shift and was told the resident was unresponsive at 2:00 A.M. LPN B asked LPN A if the resident's physician or family was notified and LPN A said no. LPN B assessed the resident and found the resident flat in bed with head of bed flat, mucous was coming out the resident's mouth. The resident's family member asked why no one called him/her. LPN B called the resident's physician and transferred the resident to the hospital. At the time of admission to the facility the resident was a DNR and had signed the paperwork requesting no return to the hospital. The resident's family requested the resident be sent to the hospital for treatment. During an interview on [DATE] at 4:00 P.M. the DON said the resident was admitted with poor mobility. The resident became unresponsive on [DATE]. There was no staff documentation that anything was done or the physician was notified for treatment. On [DATE] staff documented the resident was ill and no treatment was provided, the physician was not notified. The DON expected staff to notify the resident's physician of any change in condition. Staff should have documented the change in the resident's condition on the nurse's 24 hour report (a written report communication shared with each shift) with continual follow-up by staff and staff should have obtained treatment for the resident. During an interview on [DATE] at 12:50 P.M. the physician's nurse said the resident's physician documented on [DATE] at 7:50 A.M. he received a telephone call from the facility and was notified the resident had nausea and vomiting the day before ([DATE]) and was unresponsive in the night. The resident was a DNR. Vital signs were pulse 108, respirations 24, blood pressure 120 systolic (the top number of the blood pressure reading) and oxygen saturation of 82 percent on supplemental oxygen. The family requested the resident be sent to the emergency room for treatment. The physician gave orders for the resident's transfer to the emergency room . The physician was not notified of the resident's change in condition on [DATE] or prior to [DATE] at 7:50 A.M. The physician expected facility staff to notify him of any change in a resident's condition. The physician said it was unknown if earlier treatment would have made any difference in the resident's outcome. MO #186091

Based on interview and record review, the facility failed to provide adequate supervision and oversight to prevent falls for one resident (Resident #8) who staff identified as a high fall risk, in a review of five sampled residents and four closed records. The resident had a history of falls from bed and staff failed to implement care plan interventions in place to address that risk. The resident fell out of bed a subsequent time and sustained a hip fracture. The facility census was 55. Record review of the facility's Fall Prevention Program policy dated 7/13/12 showed the following in part: -All new admissions were assessed for fall risks, care plans were reviewed for completion; -The falls were reviewed weekly at the Quality Assurance meeting to ensure the accident and incident reports were completed, evaluate any interventions in place and additional interventions to prevent any further incidents; -The care plan was reviewed and updated with any new interventions if needed; -The hot list was updated with new interventions (list of residents with current change in care that required an assessment); -A leaf/star was placed above the bed of a resident on the program with quarterly review for continuation; -Therapy consults to discuss interventions/recommendations at the Quality Assurance meeting. 1. Record review of Resident #8's undated face sheet and diagnosis list showed the following: -admitted [DATE]; -Diagnosis of peripheral vascular disease (circulatory condition in the lower legs caused by narrowing blood vessels and reduced blood flow to the limbs), diabetes, chronic pain, difficulty walking, unsteadiness on feet, need for assistance with personal care, osteoporosis and on 2/1/21 below the knee amputation. Record review of the resident's Fall Risk assessment dated [DATE] showed the following: -Staff scored the resident in eight categories to determine the resident's fall risk; -Staff documented the resident had intermittent confusion, had one to two falls in the past three months, toileted with assistance, had adequate vision, not able to ambulate, took one to two medications that might contribute to falls and had one to two predisposing diseases that might contribute to falls; -Staff scored the resident's fall risk at 14, indicating the resident was at high risk for falls. Record review of the resident's side rail/mobility bar consent form dated 2/2/21 showed the resident signed and gave consent for the use of bed mobility bars for positioning and transfer assistance. Record review of the resident's significant change Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 2/4/21 showed the following: -Cognitively intact; -Required extensive assistance of two staff members with bed mobility, transfers, dressing, and toileting; -Required extensive assistance of one staff member with locomotion on and off the unit and with personal hygiene; -Walking in room did not occur; -Moving from seated to standing position and walking did not occur; -Not steady, only able to stabilize with staff assistance while moving on and off the toilet and during surface-to-surface transfers (between bed and chair or wheelchair); -Functional limitation in range of motion to one leg; -Required a wheelchair for mobility; -Occasionally incontinent of bladder and bowel; -No falls since admission; -The resident had a major surgical procedure during the prior inpatient hospital stay that required active care during the facility stay. Record review of the resident's Care Plan updated 2/18/21 showed the following: -The resident had a high risk for falls related to incidence of a fall in the past thirty days. Goals included the resident would be free of falls and free of injuries related to falls. Staff should anticipate the resident's needs with regard to Activities of Daily Living (ADLs), ensure the call light was within reach at all times, ensure use of proper footwear, evaluate patterns of falls if fell more than once, investigate cause of fall immediately, maintain safe environment by ensuring the floor was free from clutter, provide education on safety techniques and use assistive device and level of assistance as recommended; -The resident was on the Falling Star Program. Goals were to limit and prevent falls and injuries related to falls within the parameters that could be controlled through a structured program. Staff should answer the resident's call light promptly, non-skid socks or rubber soled shoes at all times when ambulating, provide supervision to walk with a walker or wheelchair; -The resident required assistance with transfers and could transfer with a slide board to and from the wheelchair with two staff members' assistance. Goal was improved level of participation in ADL as evidence by increased initiative with dressing, bathing and transfers. Staff should assist with transfers from bed, chair and toilet, encourage participation in transfers and ADL care, praise and provide positive reinforcement for completed tasks. Assist with safe transfers and utilize a mechanical lift as appropriate. Mobility bars were placed on the bed for repositioning and transfer assistance. Record review of the physician's order dated 4/2/21 showed bilateral (both sides) mobility bars for positioning and bed mobility, and slide board for all transfers. Record review of the resident's care plan updated 4/5/21 showed the following: -The resident rolled out of bed as staff was walking past. The resident yelled for help but staff were not able to get to the resident in time. Staff should prompt the resident to use the bilateral mobility bars to scoot over further in the bed so he/she would not roll out of the bed. Staff would have the resident demonstrate back to them that he/she could to scoot successfully; -Staff should provide environmental checks to maintain the floor free of clutter and dry and clean up spills immediately. Bed in lowest position for height. Check assistive devices daily for damage, check and ensure all locks were working on the bed wheels, commodes, wheelchairs and walker. Provide adequate lighting and keep water, food and personal items within reach. Keep the resident's bed in the lowest position and prompt the resident to be in the center of the bed for safety. Record review of the resident's Care Plan meeting notes dated 4/14/21 showed the following: -The resident and a family member were present at the care plan meeting; -The resident had one fall where he/she rolled out of the bed. Mobility bars and a fall mat were now in place. Record review of the resident's progress notes showed the following: -On 6/8/21 at 2:33 P.M. staff documented the resident was non-ambulatory but could pivot and transfer with assistance of one staff member and was able to roll from side to side in bed with no assistance; -On 6/22/21 at 12:09 P.M. staff documented the resident required one or two staff member assistance with transfers and used a slide board; -On 6/23/21 at 1:17 P.M. staff documented the resident tried to take him/herself to the bathroom and slipped and sat on the floor. Record review of the resident's quarterly MDS dated [DATE] showed the following: -Required limited assistance of two staff members with bed mobility and personal hygiene; -Required limited assistance of one staff member with transfers; -Required extensive assistance of two staff members with toileting; -Required supervision of one staff member with locomotion on and off the unit; -Walking in room did not occur; -Moving from seated to standing position and walking did not occur; -Not steady, only able to stabilize with staff assistance while moving on and off the toilet and during surface-to-surface transfers (between bed and chair or wheelchair); -Functional limitation in range of motion to one leg; -Required a wheelchair for mobility; -Continent of bladder and bowel; -One fall since the prior assessment with no injury. Record review of the resident's Care Plan meeting notes dated 7/16/21 showed the resident had two falls in the past 90 days with no injuries. He/She used the slide board for transfers with staff assistance and wheeled about the facility as desired. He/She required extensive assistance from staff with dressing and limited assistance with toileting and hygiene. Review of the resident's progress notes dated 7/27/21 at 10:05 A.M. showed Licensed Practical Nurse (LPN) I documented the following: -At 10:05 A.M. the resident was found on the floor at 10:00 A.M. on his/her right side near the bed from an apparent fall. The resident said he/she rolled out of bed. A small amount of bleeding was noted from the resident's left ear and right elbow. The resident complained of severe pain to the right hip and an abnormal looking bulge was noted at the right hip area. The resident's physician and family were notified; -At 10:55 A.M. the resident was sent to the emergency room for evaluation and treatment; -At 12:55 P.M. the hospital emergency room staff said the resident had a fractured right hip. Record review of the resident's progress note dated 7/30/21 at 6:55 P.M. showed staff documented the resident returned to the facility in a wheelchair and required a mechanical lift transfer. During an interview on 1/18/22 at 2:30 P.M., LPN I said the following: -He/She was the charge nurse the day Resident #8 fell out of bed and fractured his/her hip; -No staff were in the room at the time of the resident's fall; -The resident slept on the right side of the bed, usually on the edge and placed his/her right leg stump (below knee amputation to the right leg) over the left leg. Staff told the resident several times to move to the middle of the bed. The resident could roll side to side and had mobility bars on both sides of the bed. The mobility bars were in place at the time of the fall; -LPN I entered the room and the resident lay directly on the floor and had rolled out of the bed. The resident's injury seemed immediate and the resident was in a lot of pain. There was bleeding from the resident's ear and elbow. The right hip was obviously dislocated and bulging; -LPN I assessed the resident, called for assistance and called the ambulance. The resident remained in the floor until the ambulance arrived; -The resident's bed was in the normal position height, not lowered to the floor and there was no fall mat on the floor. Staff should have placed the bed in the lowest position with fall mats on the floor when not attending to the resident. LPN I did not know why staff did not place the bed in the lowest position and place the fall mats on the floor. During an interview on 1/19/22 at 8:16 P.M., the Care Plan Coordinator said the following: -The resident had an electric bed and staff could lower the bed down close to the floor. Staff should lower the resident's bed as close to the floor as possible when not providing care or supervising the resident; -Staff added fall mats to the resident's interventions on 4/14/21 following the first time the resident rolled out of bed (4/5/21). The fall mats were the length of the bed and a mat was placed on each side of the resident's bed; -Staff should ensure the resident's fall mats were in place and the resident's bed was in the lowest position at all times when staff were not attending to the resident to prevent falls. The resident had a history of rolling out of the bed. During an interview on 1/19/22 at 10:01 A.M., the previous Director of Nursing said the following: -He/She saw the resident on the floor with the right hip malformed. The resident rolled out of the bed; -Staff usually did not leave the mats on the floor during the day time when staff were working with the resident all day; -Staff should place fall mats on the floor next to the resident's bed and lower the resident's bed to the lowest position near the floor every time the resident was left unattended by staff. All resident beds in the facility could be lowered near the floor. During interview on 1/25/22 at 11:55 A.M. the current Director of Nursing said if a resident's care plan included a low bed and fall mats, staff should implement those interventions at all times when they leave a resident unattended. Staff should ensure the resident's bed was in the lowest position to decrease the resident's risk of falls. MO00188708 MO00188362

Based on interview and record review, the facility failed to ensure one resident (Resident #1), remained free from sexual abuse from another resident (Resident #3), of ten sampled residents. Resident #1 had impaired cognition and had a Durable Power of Attorney that was in effect due to his/her cognition. He/She was not able to consent to sexual interactions. Staff witnessed sexual interactions between Resident #1 and Resident #3 and provided the residents' privacy during these encounters prior to determining Resident #1 could not consent to the sexual interactions. Prior to the facility moving Resident #1 into the same room with Resident #3, another resident (Resident #2) made allegations of sexual abuse involving Resident #3. The facility census was 66. The administrator was notified on 9/24/20 at 8:54 P.M. of an Immediate Jeopardy (IJ) which began on 9/18/20. The IJ was removed on 9/25/20 as confirmed by surveyor onsite verification. Record review of the facility's policy, Abuse/Neglect and Reporting Reasonable Suspicion of a Crime Policy and Procedure, revised 1/5/17 showed the following: -The facility will not permit residents to be subjected to abuse or neglect by anyone, including staff members, other residents, consultants, volunteers, vendor, or staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals; -Sexual abuse is defined as, but not limited to, sexual harassment, sexual coercion and/or sexual assault. 1. Record review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 8/20/20, showed the following: -The resident's [DIAGNOSES REDACTED]. -The resident had moderate cognitive impairment; -He/She required limited assistance of one staff member to transfer, toilet, dress and ambulate. Record review of the resident's nurse's notes dated 8/25/20 at 6:11 P.M. showed the following: -At 12:35 P.M. staff reported the resident said his/her roommate (Resident #3) harassed him/her and tried to touch his/her genitals; -The resident told Registered Nurse (RN) A that Resident #3 had harassed him/her all day and tried to reach over and touch his/her genitals; -Resident #3 moved the room divider that separated the resident's recliners; -The resident said it had happened several times; -Staff moved Resident #2 to the common area under constant supervision; -RN A notified the Director of Nursing (DON), the Social Service Director (SSD) and the resident's physician. Record review of the resident's care plan dated 8/25/20 showed the resident made a complaint to staff and staff made a room change for the resident due to the complaint (the care plan showed no documentation regarding the nature of the resident's complaint). Review of the resident's census history showed on 8/25/20, Resident #2 was transferred to another room. 2. Record review of Resident #3's face sheet dated 10/22/19 showed his/her [DIAGNOSES REDACTED]. Record review of the resident's quarterly MDS dated [DATE] showed the following: -The resident was cognitively intact; -The resident was independent with walking and transfers; -He/She used a walker to ambulate. Record review of the resident's nurse's notes dated 8/25/20 at 5:59 P.M. showed the following: -RN A spoke with Resident #3 about what Resident #2 said happened; -Resident #3 said he/she did not touch Resident #2 in any way that would be deemed inappropriate and he/she did not even touch him/her (Resident #2); -Staff separated the residents after the initial incident was reported and the residents have not had contact with each other since. Record review of a typed statement dated 8/25/20 showed the SSD and RN A wrote the following: -At approximately 1:15 P.M., RN A/Supervisor of the Special Care Unit (SCU) reported to the SSD that Resident #2 told Certified Nurse Assistants (CNAs) that his/her roommate, Resident #3, had touched and played with his/her genitals; -SSD and RN A spoke with Resident #2; -He/She (Resident #2) said Resident #3 touched him/her anytime he/she was in the room by himself/herself; -Resident #2 said if staff was present (in the room), Resident #3 did not touch him/her; -Resident #2 said Resident #3 had touched and played with Resident #2's genitals since Resident #2 was admitted to the facility on [DATE]; -RN A asked Resident #2 what made today different; why he/she wanted to tell someone (now); -The resident said staff had not been in the room much that day and he/she had finally had enough; -The resident said he/she reached for the call button and Resident #3 held his/her hand down so he/she could not use it; -Staff moved Resident #2 from his/her room on the SCU to a room on the C/D wing. 3. Record review of Resident #1's Durable Power of Attorney (DPOA) (a written authorization to represent or act on another's behalf in private affairs, business, or other legal matter), provided by the facility, showed: -The resident's primary physician electronically signed the form on 4/17/14 and a neurologist electronically signed the form on 6/2/14 making the resident's next of kin an active DPOA; -The neurologist wrote the resident had significant difficulties in his/her cognitive functioning secondary to his/her dementia. It was difficult for him/her to fully understand and appreciate information that was provided to him/her and subsequently make appropriate decisions regarding his/her health, safety, medical care and financial decisions. Record review of resident's admission MDS dated [DATE] showed the following: -The resident's [DIAGNOSES REDACTED]. -The resident had moderate cognitive impairment; -The resident required limited assistance of one staff member to transfer, toilet and dress; -The resident made himself/herself understood; -The resident understood others. Record review of the resident's care plan dated 8/24/20 showed the following: -Dementia with short-term memory loss; -Mood state: depression; -Encourage decision-making, and verbalization of feelings; -He/She required limited assistance of one staff member to transfer and ambulate; -He/She used a walker to ambulate. Review of the resident's physician progress notes [REDACTED]. Record review of the resident's census history dated 9/17/20 showed the resident transferred into the same room as Resident #3 on 9/17/20 at 3:25 P.M. Record review of RN A's typed and signed statement dated 9/18/20 showed: -On 9/18/20 at approximately 8:20 A.M. he/she walked down the hallway and looked into Resident #1 and Resident #3's room and noticed Resident #3 and Resident #1 seated in their recliners (located side by side); -While outside the room, he/she noticed Resident #3 had his/her arm over on Resident #1's recliner and their hands intertwined; -When RN A entered the room and approached Resident #1's recliner, he/she saw Resident #1 had his/her genitalia exposed and Resident #3 had his/her hand on Resident #1's genitalia; -He/She told Resident #1 to cover his/her genitals and they needed to stop doing what they were doing; -Resident #1 covered his/her genitals and Resident #3 removed his/her arm and hand from Resident #1's recliner and leaned back to his/her recliner; -RN A told the charge nurse what he/she had just witnessed and let him/her know that he/she was going to find the DON; -RN A notified the DON of what had just occurred and RN A and the DON agreed to bring Resident #1 out of the room until they had time to investigate what was the best option; -He/She then went back to room the residents' room and upon entering the room again, found the two residents engaged in rubbing their (each others') genitals; -Resident #1 had his/her genitalia exposed and Resident #3 had his/her hand on Resident #1's genitals; -Resident #3 had his/her jumpsuit unzipped and his/her genitalia exposed; -Resident #1 touched Resident #3's genitalia; -RN A told Resident #1 he/she needed to come to the dining room for breakfast; -The residents covered their genitalia and Resident #1 got up to leave with RN A; -RN A took Resident #1 to his/her office to ask him/her about the incident; -He/She asked Resident #1 what he/she and Resident #3 were doing and Resident #1 said they were exercising; -He/She asked Resident #1 who initiated this and he/she said they both did; -He/She took Resident #1 to the dining room to eat breakfast; -He/She spoke with the SSD and the administrator about the next steps to take; -He/She and the SSD interviewed Resident #1; -The resident said they were exercising and Resident #1 demonstrated by rubbing his/her genitals; -When asked, the resident said they had both agreed to do it; -The SSD asked how many times this happened, the resident said it has happened a few times, then said it happened two times last night and once this morning; -When they asked if he/she was okay with it continuing, he/she said yes; -They asked if it was something he/she wanted to keep happening and he/she said that he/she was okay with it; -RN A and the SSD then went to interview Resident #3; -The SSD asked Resident #3 to tell him/her what happened this morning and he/she said nothing; -Resident #3 said that it was something that they had talked about before ever doing it; -Resident #3 said that it happened two times last night (9/17/20) and once this morning; -Resident #3 said that he/she let Resident #1 touch his/her genitals; -Resident #3 also said he/she was okay with it to continue; -RN A and SSD explained to both residents if it was consensual and something they wanted to continue, they needed to find a way that was more private for them, so it did not offend anyone that may walk by the room and see them; -The SSD and RN A offered suggestions for a blanket or use the call light to ask staff to close the door for some privacy. Record review of the SSD's typed and signed statement dated 9/18/20 showed: -The SSD and RN A sat down with Resident #1 this morning after RN A contacted him/her; -RN A reported to the DON that he/she caught Resident #1 and Resident #3 acting inappropriately; -Resident #1's statement included he/she and Resident #3 exercised together, but on further explanation, Resident #1 demonstrated they had rubbed each others' genitals; -Resident #1 said he/she and Resident #3 did it twice last night and once today; -Resident #1 said he/she would like a blanket when they do it for privacy and to keep warm; -He/She and RN A spoke with Resident #3; -Resident #3 said they (Resident #1 and Resident #3) agreed on it; -They (the SSD and RN A) asked what they agreed to and Resident #3 said playing with it; -SSD asked what they were playing with, and Resident #3 showed his/her genitalia area; -Resident #3 said it was not the first time they (Resident #1 and #3) did this; -They did it a couple of times last night and today; -Resident #3 said if Resident #1 was okay with it, he/she wanted to keep doing it because they like to do it to each other; -He/She and RN A informed both residents if this is something they wished to continue, the SSD and RN A could arrange to provide privacy. Record review of Resident #1's nurse's notes showed on 9/18/20 at 3:31 P.M., the resident expressed a physical relationship with his/her roommate (Resident #3), interest was consensual and privacy provided. Record review of Resident #3's nurse's notes showed on 9/18/20 at 3:30 P.M., the resident expressed a physical relationship with his/her roommate. Interest was consensual and privacy provided. Review of Resident #1's undated and unsigned Mini Mental State Exam showed a score of 16 of 30 points (a score of 13 to 20 suggested moderate dementia). During a telephone interview on 9/24/20 at 4:15 P.M. and 10/7/20 at 1:39 P.M., RN A said a mini mental exam was completed on Resident #1 on 9/18/20 per the DON's instruction to ensure Resident #1 had the mental capacity to consent to sexual relations. Record review of Resident #1's nurse's notes showed the following: -On 9/20/20 at 4:06 P.M., staff witnessed the resident standing next to his/her roommate (Resident #3) with his/her genitalia in the roommate's (Resident #3's), mouth; -Staff shut the door to offer privacy; -Roommate (Resident #3) turned on the call light; -Staff found Resident #1 on the floor on his/her buttocks between the recliners; -The resident said he/she fell off the bed; -On 9/21/20 at 1:06 P.M., staff observed the resident rubbing his/her roommate's genitals; -Both residents sat in recliners next to each other; -Privacy provided. Review of Resident #3's nurse's notes showed on 9/21/20 at 1:55 P.M., staff observed the resident seated in his/her recliner at 10:00 A.M., and his/her roommate (Resident #1), rubbed the resident's genitalia. Privacy provided. Record review of RN A's typed and signed statement dated 9/21/20 showed: -The hospice nurse came to RN A and told him/her Resident #1 was not comfortable in the room with Resident #3; -The hospice nurse had spoken to Resident #1 about an incident that occurred on Saturday; -The hospice nurse said Resident #1 was not in his/her right mind and he/she had a Durable Power of Attorney; -He/She and the hospice nurse brought the resident to his/her office; -An interview was conducted with the resident with the following staff present RN A, SSD, DON and the hospice nurse; -Staff reported, charted, and witnessed Resident #3 performed oral sex on Resident #1; -This morning, CNA B witnessed the two residents expose themselves as he/she walked down the hall; -Staff asked Resident #1 if this was something he/she wanted to happen (sexual interactions with Resident #3), and he/she said no; -Resident #1 did not want his/her roommate to touch him/her; -Staff contacted the resident's DPOA about the incident and he/she knew of and approved the room change; -They will move Resident #1 to a different room. Record review of the SSD's typed and signed statement dated 9/21/20 showed: -It was reported to him/her by the hospice nurse that Resident #1 was uncomfortable in his room with Resident #3; -RN A reported, charted and witnessed Resident #1 having oral sex performed on him/her by Resident #3; -LPN (Licensed Practical Nurse) B also witnessed the residents expose themselves as he/she walked down the hall; -Staff asked Resident #1 if this was something he/she wanted to happen and he/she said no and Resident #3 was too forward with him/her this morning; -Resident #1 said he/she did not want his/her roommate to touch him/her; -Staff contacted Resident #1's DPOA about the incident; -Resident #1 moved from his/her room to a different room. During an interview on 9/24/20 3:17 P.M., Resident #1 said the following: -Something was wrong with Resident #3 because he/she liked to mess around with the same sex (individual of the same sex); -Resident #3 asked Resident #1 if he/she would sleep with him/her and Resident #1 said no; -Resident #3 touched Resident #1's genitalia one or two days ago; -He/She was not okay with it; -Resident #3 kept it up too much; -Resident #1 believed staff saw them touching each other, but they (staff) did not do anything about it; -He/She felt uneasy about it and did not like it and did not want it (to happen). During an interview on 9/24/20 at 1:47 P.M., and 10/20/20 at 11:49 A.M., the hospice nurse said the following: -Staff brought to his/her attention Resident #1 had fallen and asked him/her to read the resident's nurse's notes; -He/She saw in the resident's 9/21/20 nurse's notes where Resident #3 had his/her mouth on Resident #1's genitals; -He/She asked Resident #1 about his/her roommate (Resident #3), and the resident said his/her roommate was odd; -He/She asked the resident what happened with specific questions, the resident said the roommate wanted him/her to do things, but he/she did not want to do those things; -Resident #1 said he/she did not want Resident #3 touching him/her; -He/She brought this information to the DON and asked the DON if Resident #1's DPOA was notified. The DON said the resident's DPOA was not active; -He/She called the resident's physician to check if his/her DPOA status was active; -The physician said absolutely and the only decision Resident #1 could make was what he/she would have for lunch. During an interview on 10/20/20 at 3:45 P.M. Resident #1's physician said the resident was not capable of making his/her own decisions regarding his care and medical choices weeks prior to his/her admission to the dementia unit at the facility. During an interview on 9/24/20 at 4:01 P.M., CNA E said the following: -He/She was unsure of the date, but during rounds he/she witnessed Resident #1 and Resident #3 reaching over each other's chairs and touching each others' genitals; -He/She asked if they were okay with this and Resident #3 said yes, and Resident #1 agreed; -He/She told RN A, who told him/her staff saw this previously, and the residents consented; -RN A told him/her to give the residents' privacy; -He/She reminded the residents to use the call light if needed and then provided the residents' privacy; -Resident #3 had the mental capacity to give consent; -Resident #1's mental cognition varied. During a telephone interview on 9/24/20 at 4:15 P.M. and 10/7/20 at 1:39 P.M., RN A said the following: -On 9/18/20 as he/she walked towards the nurse's station, he/she witnessed the Resident's hand in the chair and his/her other arm over Resident #1's lap; -He/She walked into the room, Resident #1 had his/her genitalia exposed and Resident #3 touched Resident #1's genitalia; -Resident #1 appeared to enjoy it and did not push Resident #3 away; -He/She told them to stop and cover their genitals; -He/She immediately went to the DON, but he/she was busy; -He/She went back to the room and both residents had their genitals out, and were rubbing each other's genitals; -He/She took Resident #1 out of the room; -Resident #1 said they were exercising, but found the resident meant they were rubbing each other's genitals; -Resident #1 said he/she was okay with it; -He/She felt Resident #1 had the mental capacity to make that decision; -Resident #3 was reluctant to talk about it, but motioned with his/her hand over his/her genitalia (demonstrating rubbing each other's genitalia); -Resident #3 said he/she was okay with it and it could continue; -Over the weekend, staff witnessed Resident #1 and #3 engaging in oral sex; -Resident #1 was transferred to a different room on 9/21/20; -The administrator, SSD, DON and RN A met and decided it was not in Resident #1's best interest to leave him/her in the room with Resident #3; -Resident #1 told the hospice nurse he/she did not want Resident #3 touching him/her sexually anymore; -Resident #2 made the same allegation, but Resident #3 denied the allegations; -He/She and the SSD decided to transfer Resident #1 into the same room with Resident #3 because there was no other room to put him/her in, it was either with Resident #2, who made allegations about Resident #3 or with Resident #3; -He/She thought Resident #1 would reject advances by Resident #3; -He/She did not feel this was sexual abuse because both residents consented; -Resident #1 told him/her, the SSD and the Hospice nurse, he/she did not want Resident #3 to touch him/her sexually. During an interview on 9/24/2020 at 4:57 P.M., the DON said the following: -The allegation from Resident #2 was investigated and the police were involved; -Resident #2 said it happened, but Resident #3 denied the allegation; -It was difficult to determine if anything happened; -Resident #1 was moved to Resident #3's room on 9/17/20; -On 9/18/2020 at approximately 9:00 A.M. RN A said he/she saw Resident #1 and Resident #3 with their hands on each others' genitalia; -She told RN A to separate the residents and have Resident #1 go to the common area because Resident #3 did not often leave his/her room except to shower or have window visits with family; -The administrator and the SSD were to start an investigation; -The investigation concluded that both residents were interested, liked it; and both consented; -She instructed the SSD to complete a mini mental exam on 9/18/20 on Resident #1, but he/she did not hear anything about the results until 9/21/20; -On 9/18/20 she told staff to provide privacy for the residents; -On 9/21/20 she was informed by the SSD the mini mental exam completed on 9/18/20 showed Resident #1 had impaired cognitive abilities; -She was not aware until 9/21/20 (when the hospice nurse brought it to her attention), that Resident #1's DPOA was active and had the SSD notify him/her; -She did not know why staff did not check both resident's BIMS on 9/18/20; -She was busy with other responsibilities on 9/18/20 and did not ensure the mini mental exam was completed and to check if Resident #1's DPOA was active and notified; -Someone should have notified her of the results of the mini mental exam on 9/18/20. During an interview on 9/24/20 at 5:30 P.M., the administrator said the following: -Resident #1 transferred into Resident #3's room last week; -He felt the residents would be all right with each other because they knew each other when they were out in the community (even though there had been past accusation by Resident #2 regarding Resident #3); -On 9/18/20, he thought both residents consented to a sexual relationship; -He thought Resident #1's DPOA was already involved; -The mini mental exam showed Resident #1 did not have the cognitive ability to consent to a sexual relationship; -Staff did not separate the residents until 9/21/20 after several staff witnessed sexual relations and closed the door for privacy; -He expected staff to have checked the BIMS of both residents on the MDS on 9/18/20; -Staff should have separated the residents sooner, prior to the oral sex and further sexual interaction between them. During an interview on 9/24/2020 at 2:37 P.M., Resident #1's family member/DPOA said the following: -The resident had poor cognition; -The resident would have been mortified had he/she thought this would ever happen to him/her; -He/She would have expected to be notified as soon as possible the first day staff were aware of the interactions between the two residents; -He/She would not have agreed for Resident #1 to have sexual relations with Resident #3; -The occurrence of the sexual interactions was not acceptable; -The DPOA status was active. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO# 7 and MO 7

Based on observation, interview, and record review, the facility failed to provide adequate assessment and supervision for three residents who smoked (Residents #5, #10, and #51). Two residents (Residents #10 and #51) had orders for continuous oxygen therapy and were observed with oxygen tanks on their wheelchairs while they smoked. The facility failed to develop a policy regarding residents smoking and failed to update smoking assessments. Facility staff failed to consistently implement and modify interventions as necessary, in accordance with current standards of practice to reduce the risk of falls for one resident (Resident #50), who had a history of [REDACTED].#57), in a review of 17 sampled residents. The facility census was 67. 1. During an interview on 11/27/18 at 9:55 A.M., the Administrator said the facility did not have a written policy regarding residents' smoking. 2. Review of Resident #51's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's Smoking Evaluation, dated 10/13/17, showed the following: -The resident smokes; -The resident uses oxygen; -The resident has severe respiratory disease; -The resident has no history of non-compliance with smoking policies; -The resident exhibits smoking activity done in safe manner. Review of the resident's medical record showed no evidence staff completed a smoking evaluation after 10/13/17. Review of the resident's care plan, dated 10/13/18, showed the following: -The resident's psychosocial history shows he/she is a known smoker; -The resident will smoke safely within the designated smoking area; -The resident will understand the dangers of smoking; -The resident may have cigarettes and lighter with him/her, as he/she is cognitively able to understand the smoking policy of the facility and supervision is not required at this time; -The resident requires use of oxygen due to episodes of shortness of breath; -The resident is aware of dangers of smoking and oxygen. The physician told him/her also about the dangers of smoking and now the resident is taking his/her oxygen tubing and draping it over his/her walker before smoking (added to care plan on 1/26/18). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/26/18, showed the following: -Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact; -Shows no rejection of care; -Oxygen therapy used; -Independent with transfers and locomotion on and off unit. Review of the resident's physician order [REDACTED]. Review of the resident's physician progress notes [REDACTED]. -The resident was out front of the facility smoking with his/her oxygen on a wheelchair behind him/her; -The physician warned the resident about this and told him/her not to blow himself/herself up. Observation on 11/27/18 at 10:54 A.M., showed the following: -The resident sat in his/her wheelchair in his/her room; -A plastic cup attached to the armrest of his/her wheelchair contained a pack of cigarettes and a lighter. Observation of the employee smoking area on 11/29/18 at 10:50 A.M., showed the resident sat in his/her wheelchair smoking a cigarette. No staff were present in the smoking area. The resident's oxygen tank was attached to the back of his/her wheelchair and was turned on and running at 2 liters per minute. The resident had removed the oxygen tubing from his/her nose and draped it over the right armrest of his/her wheelchair. The resident rested his/her right arm on the right armrest of his/her wheelchair with a lit cigarette in his/her right hand within approximately five inches of the oxygen tubing with oxygen running through the tubing. The resident had cigarette ashes on his/her jeans and on the the seat cushion of his/her wheelchair. At 10:57 A.M., four staff came out to smoke and stood approximately 20 feet away from the resident. No staff addressed the resident smoking with his/her oxygen turned on. Observation on 11/29/18 at 2:20 P.M., showed the resident outside smoking a cigarette. His/her oxygen tank was turned on and running at two liters per minute. The resident had removed his/her oxygen tubing from his/her nose and laid it across the right armrest of his/her wheelchair. He/she held a lit cigarette in his/her right hand, approximately six inches from the oxygen tubing connected to the open tank of oxygen. Another resident, Resident #10, sat in his/her wheelchair next to Resident #51 and lit a cigarette. During interview on 11/29/18 at 12:01 P.M., Licensed Practical Nurse (LPN) D said the following: -The resident was alert and oriented to person, place and time; -The resident was independent with care; -The resident was supposed to wear oxygen at all times; -The resident usually smokes at the front entrance; -The resident takes the oxygen with him/her when he/she goes to smoke, staff do not go with the resident or turn off his/her oxygen when he/she goes out to smoke, he/she was independent; -He/she thinks the resident takes off the oxygen when the resident smokes, but staff is not present when the resident is smoking, so he/she does not know for sure. During an interview on 11/29/18 at 1:09 P.M., the resident said the following: -He/she takes oxygen with him/her to smoke; -He/she never turns the oxygen off before going outside to smoke or when he/she was smoking; -The running oxygen tubing hangs on the arm of his/her wheelchair; -There was nothing dangerous about air and smoking; -Everybody in the medical profession has told him/her smoking with his/her oxygen on is dangerous, but it was not. During an interview on 12/3/18 at 4:00 P.M., the resident's physician said the following: -He/she warned the resident and staff repeatedly of the dangers of smoking and oxygen; -Residents would frequently be outside smoking with oxygen tanks on the wheelchairs when he/she was at the facility conducting rounds; -The resident did not have an order in place to take the oxygen tank off the wheelchair or to turn if off before smoking. During an interview on 11/29/18 at 1:00 P.M. the Director of Nursing (DON) said she assumed the Social Service Director (SSD) was completing the smoking evaluations for the residents who smoked. The DON thought the SSD updated the smoking evaluations annually. The DON found out if a resident smoked by either direct observation or the certified nurse aides (CNAs) would let her know. The smoking evaluations should be updated annually and with any significant change in the resident's condition. The DON was aware Resident #51 smoked while his/her oxygen was running. Staff and the resident's physician had told the resident to turn off the oxygen tank when he/she was smoking, because smoking while oxygen was running was dangerous. The DON would prefer residents leave their oxygen in the facility when they go outside to smoke. During an interview on 11/29/18 at 3:00 P.M., the Social Service Director said he/she was not aware he/she was to be completing or updating the smoking evaluations for residents and had not been doing so. During an interview on 11/29/18 at 2:10 P.M., the Administrator said he was aware Resident #51 was going out to smoke with the oxygen tank on his/her wheelchair, but he thought the resident was turning the oxygen tank off before smoking. 3. Review of Resident #10's face sheet showed the following: -An admission date of [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's care plan, effective 10/13/17, showed the following: -The resident was a known smoker; -The resident would understand and accept the facility policy on smoking; -Staff would review the smoking policy with resident and family on admission, readmission, and as needed; -Staff would check clothing regularly for signs of unsafe smoking; -Staff would provide the resident with a smoking apron as needed; -Staff would allow the resident to smoke in designated smoking area with supervision as needed. Review of the resident's smoking evaluation, dated 10/13/18, showed the following: -The resident used oxygen; -The resident was safe to smoke on his/her own; -The resident demonstrated and understood the smoking policy and guidelines. Review of the resident's physician order [REDACTED]. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognition was moderately impaired; -Required limited assistance of one staff for dressing, bed mobility, and transfers; -Impaired range of motion to the upper and lower extremity on one side; -Used a wheelchair; -Oxygen therapy. Observation on 11/29/18 at 9:43 A.M. showed the resident sat in a wheelchair in a common area inside the facility with a portable oxygen tank on the back of the chair. The resident had a pack of cigarettes and a lighter in the cup holder on the wheelchair. During an interview on 11/29/18 at 9:43 A.M., the resident said he/she smoked. He/she went outside the front of the facility to smoke and staff did not accompany him/her. The resident kept his/her own smoking materials. The resident said he/she was not sure why there was an oxygen tank on the wheelchair as he/she did not use it, but thought staff kept it there in case he/she ever needed oxygen. The resident said there were a few other residents in the facility who smoked. The resident said he/she generally went outside with other residents to smoke, but would sometimes go out by himself/herself. The resident said no one had ever spoken to him/her about smoking with the oxygen tank on his/her wheelchair. During an interview on 11/29/18 at 12:00 P.M., CNA C said the resident smoked. Staff kept a portable oxygen tank on the resident's wheelchair just in case he/she needed it, but the resident did not usually wear the oxygen. The resident kept his/her own cigarettes and lighter and went outside to the front of the building to smoke whenever he/she wanted. The resident's oxygen tank was not removed from the wheelchair when he/she went outside to smoke. During an interview on 11/29/18 at 12:06 P.M., CNA A said there were four residents in the facility who smoked, including Resident #10. CNA A had observed all four residents outside together smoking several times. Resident #10 had an oxygen tank on the back of his/her wheelchair, which remained on the wheelchair when he/she went outside to smoke. CNA A did not think the oxygen tank was running when Resident #10 went out to smoke, but was not certain. CNA A said all residents in the facility who smoke could take themselves outside to smoke whenever they wanted to. Residents were allowed to keep their cigarettes and lighters with them and did not need any help from staff to smoke. Observation on 11/29/18 at 2:20 P.M., showed Resident #10 propelled his/her wheelchair out the front entrance of the building. There was a portable oxygen tank on the back of his/her chair that was not turned on. Resident #51 was already outside smoking a cigarette. Resident #51's oxygen tank was on and running at two liters per minute. Resident #51 had removed his/her oxygen tubing and laid it across the right armrest of his/her chair. Resident #51 held a lit cigarette in his/her right hand, approximately six inches from the oxygen tubing that was connected to the running tank of oxygen. Resident #10 sat in his/her wheelchair next to Resident #51 and lit a cigarette. During an interview on 11/29/18 at 1:00 P.M., the DON said Resident #10 had orders to wear oxygen continuously, but refused to do. Resident #10 had a portable oxygen tank on his/her wheelchair, but the DON did not think the oxygen tank was turned on. The DON would prefer residents would leave their oxygen in the facility when they went outside to smoke. 4. Review of Resident #5's face sheet showed the resident was admitted on [DATE]. Review of the resident's smoking evaluation, dated 10/13/17, showed the resident demonstrated and understood the smoking policy and guidelines. The evaluation showed the resident was safe to smoke on his/her own. Review of the resident's care plan, effective 11/30/17, showed the following: -The resident was a known smoker; -The resident would understand and accept the facility policy on smoking; -Staff would review the smoking policy with the resident and family on admission, readmission, and as needed; -Staff would check clothing regularly for signs of unsafe smoking; -Staff would provide the resident with a smoking apron as needed; -Staff would allow the resident to smoke in designated smoking area with supervision as needed. Review of the resident's medical record showed no evidence staff completed a smoking evaluation after 10/13/17. Review of the resident's annual MDS, dated [DATE], showed the resident had moderate cognitive impairment. During an interview on 11/29/18 at 9:45 A.M., the resident said he/she smoked. The resident kept his/her cigarettes and lighter in his/her room. The resident said he/she smoked outside the front entrance of the facility. There were three other residents who smoked. He/she usually went outside to smoke with Resident #10, but occasionally all four residents who smoked (Residents #5, #10, #51 and #56) were outside smoking at the same time. 5. Review of the facility's policy, dated 7/13/12, showed the following: -All new admissions are assessed for fall risks, care plans are reviewed for completion; -The falls are reviewed weekly at the combined resident committee meeting, to review the reports, to evaluate any interventions that were in place and what interventions may be needed to be put in place to prevent any further incidents; -All reported falls are logged into the computer; -The care plan is reviewed; the care plan is updated in the computer with any new interventions if needed; -The unit supervisor will be sure the information is reviewed by staff members to ensure the interventions recommended by the committee are followed; -Each month the DON will provide pharmacy consultant a list of the previous month's falls. If a fall is emergent, caused injury or we feel is directly related to medication, we will fax immediately to pharmacy consultant for recommendations. -A leaf will be placed above the bed of resident on the program, this will be reviewed quarterly for continuation or discontinued. Review of Resident #50's care plan, dated 10/2/18, showed the following: -The resident was incontinent of urine. -Encourage frequent voiding every one to two hours; -The resident was at high risk for falls related to a history of falls in the last 30 days; -Anticipate the resident's needs regarding activities of daily living; -Provide reality orientation; -Ensure the use of proper footwear; -Maintain a safe environment by ensuring the floor is free from clutter; -Ensure the call bell is within easy reach at all times. Review of the resident's admission MDS, dated [DATE], showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Cognition was severely impaired; -Required limited assistance of one staff for transfers, walking, dressing, and toilet use; -Balance was not steady, but was able to stabilize without human assistance; -Frequently incontinent of bowel and bladder; -fell in the last month prior to admission; -fell in the last two to six months prior to admission; -Sustained a fracture related to a fall in the last six months prior to admission. Review of the resident's nurse's notes showed on 10/15/18 at 12:18 P.M., staff obtained post fall vital signs. The neurological assessment was normal. The resident denied pain or discomfort. Further review of the resident's care plan showed an update on 10/17/18 that the resident fell in his/her room while walking to the bathroom on 10/13/18. No injuries were noted. There were no additional interventions added to the care plan following this fall. Review of the resident's medical record showed no further documentation related to this fall, no evidence staff evaluated the cause for the fall, and no evidence staff modified or implemented interventions to prevent falls. Review of the resident's nurse's notes showed on 11/5/18 at 1:30 P.M., the resident sat on the floor in front of his/her recliner with his/her shoes off. The resident said he/she had attempted to walk to the bathroom and slipped and fell . The resident denied pain. Skin assessment revealed two abrasions to the left buttocks. Review of the resident's medical record showed no evidence staff modified or implemented interventions at the time of the fall to prevent future falls. Review of the resident's nurses notes showed the following: -On 11/5/18 at 6:00 P.M., staff observed the resident on the bathroom floor, lying on his/her right side. Staff noted bleeding from a laceration above the resident's left eye. The resident complained of left shoulder and upper arm pain. Staff cleansed a 3 centimeter laceration above the resident's right eye. There was swelling noted to the resident's left shoulder and the resident complained of pain when he/she tried to move his/her shoulder. Staff remained with the resident while emergency services were contacted and the resident was transported to the emergency room per ambulance via stretcher; -On 11/5/18 at 8:38 P.M., emergency room staff contacted the facility to relate the resident was returning. The resident had sustained a left shoulder fracture and had a sling in place. The laceration above the resident's left eye was glued. Review of the resident's care plan showed the following: -An update on 11/6/18 showing the resident fell twice on 11/5/18, one fall resulting in injury; -An update on 11/8/18 with interventions listed to remind the resident to use the call light and await assistance before getting up and to ensure proper footwear was on before walking. Staff placed a silent alarm on the resident's bed. Observation on 11/28/18 showed the following: -At 10:55 A.M., the resident sat in a wheelchair in the therapy room. The resident's left arm was in a sling; -At 11:25 A.M., staff pushed the resident in his/her wheelchair from the therapy room to the activity room. Staff did not offer or ask the resident about needing to use the bathroom. -At 12:00 P.M., staff wheeled the resident from the activity room to the dining room for lunch. Staff did not offer or ask the resident about needing to use the bathroom; -From 12:00 P.M. until 1:49 P.M., the resident sat in a wheelchair in the dining room; -At 1:49 P.M., CNA F and CNA G transferred the resident from the wheelchair to a recliner chair in the common area with a gait belt. Staff did not offer or ask the resident if he/she needed to use the bathroom. During an interview on 11/28/18 at 11:31 A.M., the resident said he/she thought he/she had fallen several times in the facility, but was not sure of when or why the falls happened. The resident said he/she was not supposed to get up by himself/herself, but sometimes he/she disobeyed. The resident said he/she tried not to be a bother or cause any trouble. During an interview on 11/29/18 at 2:15 P.M., CNA C said the resident would tell staff when he/she needed to use the bathroom and was not on a routine toileting schedule. The resident had fallen in the facility. CNA F tried to keep the resident in common areas when he/she was not in bed, so the resident could be observed more closely. During an interview on 12/4/18 at 1:07 P.M., the DON said the resident had fallen in the facility, the last fall resulted in a fracture. The DON could not find any documentation in the resident's record regarding the fall on 10/13/18. The DON said there were no further interventions added to the care plan after the fall on 10/13/18. Both of the resident's falls on 11/5/18 resulted from the resident attempting to get to the bathroom. The DON expected staff to offer the resident the bathroom routinely and not wait for him/her to ask to use the bathroom. During an interview on 12/4/18 at 2:30 P.M., the DON said the charge nurse on duty at the time a fall occurs should document the facts regarding the fall in a progress note. Staff should put an intervention in place at the time of the fall to attempt to prevent further falls. Interventions put in place to prevent falls should be added to the care plan. Any licensed staff could update a resident's care plan, but it was ultimately the Care Plan Coordinator who was responsible to ensure interventions to prevent falls were added to the care plan. Resident falls were discussed in a weekly meeting. Falls and care plans were reviewed during that time. 6. Review of the facility's Using Gait Belts on Residents policy, last revised 12/29/16, showed the following: -All employees during orientation are shown how to use gait belt properly on residents; -Residents should be able to bear weight on at least one lower extremity to do a stand pivot transfer. Review of the Nurse Assistant in Long Term Care Facility, Student Manual Revised Edition 2001, showed the following: -The nurse assistant should never transfer or ambulate residents by grasping their upper arms or under their arms; -Such a transfer could result in skin tears, damage to nerves and arteries, and possible dislocation of the shoulder; -If a resident is non-weight bearing the CNA should transfer him/her using a mechanical lift; -Safety Measures for a resident that is weak, you must have control of the shoulders and hips during the transfer, do not attempt to transfer a resident who cannot bear any of his/her weight by yourself. Review of Resident #57's care plan, dated 9/19/18, showed the following: -Resident requires assistance with activities of daily living; -Resident needs two staff assist with transfers. -The care plan did not address using a mechanical lift to transfer the resident. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Long and short-term memory problems; -Daily decision making was severely impaired; -Required extensive assistance of two staff for bed mobility and transfers; -Surface-to-surface transfer (transfer between bed to chair or wheelchair) not steady, only able to stabilize with human assistance. Review of the resident's physician order [REDACTED]. Observation on 11/27/18 at 4:08 P.M., showed the following: -The resident sat in a recliner by the nurse's station; -CNA H placed a gait belt on the resident, stood on the resident's left side, and grasped the gait belt at the resident's waist; -CNA G stood on the resident's right side and grasped the gait belt; -The CNAs lifted the resident from the recliner. The resident's feet were crossed and drug on the floor as the CNAs moved the resident to his/her wheelchair. The resident did not assist in lifting his/her feet or pivoting during the transfer. Observation on 11/28/18 at 1:45 P.M., showed the following: -The resident sat in a wheelchair by the nurse's station; -CNA F placed a gait belt on the resident, stood on the resident's left side, and grasped the gait belt at the resident's waist; -CNA I stood on the resident's right side and grasped the gait belt; -The CNAs lifted the resident from the wheelchair. The resident's heels drug on the floor as the CNAs moved the resident to a recliner. The resident did not assist in lifting his/her feet or pivoting during the transfer. Observation on 12/4/18 at 9:45 A.M., showed the following: -The resident sat in a wheelchair by the nurse's station; -CNA G placed a gait belt on the resident, stood on the resident's left side, and grasped the gait belt at the resident's waist; -CNA B stood on the resident's right side and grasped the gait belt; -The CNAs lifted the resident from the wheelchair. The resident's knees were bent at a 90 degree angle as the CNAs moved the resident to a recliner. The resident's feet did not touch the floor. During interview on 11/29/18 at 12:26 P.M., CNA G said the following: -The resident doesn't always bear weight with transfers; -It is care planned to use a sit-to-stand to transfer the resident. During interview on 12/4/18 at 1:10 P.M., CNA B said the following: -The resident doesn't always stand during transfers; -Staff sometimes use a sit-to-stand lift to transfer the resident; -It is safer to use a sit-to-stand lift to transfer the resident; -He/she doesn't know why the staff doesn't use the sit-to-stand lift all the time. During interview on 12/4/18 at 2:29 P.M., the DON said the following: -If a resident does not bear weight, he/she should not be transferred using a gait belt; -If the resident has an order for [REDACTED]. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility assessed all residents who smoked, including Resident #51, and educated these residents on safety measures when smoking. The facility developed and implemented a policy and procedure to ensure nursing staff removed oxygen tanks from residents' wheelchairs prior to the residents smoking. The oxygen tanks must be removed prior to the nursing staff providing the resident with a lighter to smoke. The facility's smoking policy also included nursing staff to complete assessments of residents who smoke on admission, with any change of condition, and at least annually. The facility immediately inserviced nursing staff on the facility's smoking policy. The inservices will continue until all nursing staff has been inserviced on the facility's smoking policy and procedures. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the G level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on interview and record review, the facility failed to consult with the physician and report a change in one resident's medical condition (Resident #2) in a review of 13 sampled residents. Facility staff failed to notify Resident #2's physician of an elevated temperature and bleeding from the oral cavity when the resident was on a blood thinning medication. The resident was hospitalized and required treatment to reverse hemorrhage. The facility census was 71. 1. Review of the facility's policy, Contacting Physicians, dated 3/19/11, showed the following: Policy: The purpose of this policy is to give guidelines to nursing staff on contacting the resident physician or the on call physician; General Statement: -Notification of Physicians in Non-Emergent situations: A.The nursing staff will fax physician to relay reports or status change information, (obtained from nurse, chart, and or resident). He/she will send faxed to the physician's office. Please be sure to include all pertinent information for the physician to be able to respond. Be sure to include physician's orders [REDACTED].>B.If no return call or fax received from the office by 4:00 P.M. the nursing staff will phone the physician's office. If he/she has left the office and a response is needed to provide care the nurse will page the appropriate physician. To notify the physician you can call them at home, call the hospital to have the physician paged and if unable to reach notify the Registered Nurse (RN) on call; C.When faxes are for information only then the staff does not need to call. Be sure to mark this on the fax face sheet. You may fax FYI communication after office hours and over the weekends. Never fax after hours and on weekends if a response is needed; D.After hours, weekends and/or holidays the charge nurse is to call the appropriate physician for any and all resident changes for orders. This includes wounds, falls with or without injury or change in medical condition. 2. Review of www.drugs.com <http://www.drugs.com> showed the following: Major Side Effects of [MEDICATION NAME] use: If any of the following side effects occur while taking [MEDICATION NAME], check with your physician immediately: -Abdominal or stomach pain with cramping; -Bleeding gums; -Confusion; -Coughing up blood. -Adjust [MEDICATION NAME] dose according to results of the International Ratio (INR) or [MEDICATION NAME] time (PT). Review of the Nursing 2015 Drug Handbook showed the following information regarding [MEDICATION NAME]: -PT and INR determinations are essential for proper control; -Adverse reactions include hemorrhage; -Interactions: [MEDICATION NAME] (antibiotic), [MEDICATION NAME] (antibiotic) and anabolic steroids may increase anticoagulant effect; -Monitor patient carefully for bleeding; -Regularly inspect patient for bleeding gums; -Elderly patients are especially sensitive to the drug's effect. Review of the Nursing 2015 Drug Handbook showed the following information regarding [MEDICATION NAME]: -Drug interactions: May alter dosage requirements of oral anticoagulants; -Monitor PT and INT closely. 3. Review of Resident #2's care plan dated 10/20/14 showed the following: -Problem: Diabetes; -Monitor weight monthly report any change of 5% to physician; -Problem: Hypertension; -Monitor vital signs and blood pressure as ordered by the physician; -Problem:[MEDICAL CONDITION] Drug Use: Anxiety state; -Monitor for side effects of medication such as confusion, urinary frequency/retention, weight loss/gain, etc.; -There was no recent update to the care plan, the care plan did not address the resident was on [MEDICATION NAME] (an anticoagulant), side effects of the use of [MEDICATION NAME] or monitoring of the resident while on [MEDICATION NAME]. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/4/16 showed the following: -Makes self understood; -Understands others; -Severely impaired cognition; -No indicators of [MEDICAL CONDITION]; -Independent for bed mobility, transfers, walk in room,walk in corridor, locomotion on and off unit and eating; -Required supervision from one staff member for dressing and toilet use; -Required limited assist of one staff member for personal hygiene. Review of the resident's physician's orders [REDACTED]. -[MEDICATION NAME] 7.5mg by mouth for one dose; -[MEDICATION NAME] 5mg by mouth one daily; -Recheck PT/INR (lab test used to monitor the effectiveness of the anticoagulant [MEDICATION NAME]. This drug helps inhibit the formation of blood clots) in one week. Review of the resident's nurses' notes dated 10/9/16 at 7:37 A.M. showed the following: -Temperature 101.5 (normal 98.6 degrees Fahrenheit); -Lung sounds reveal bilateral wheezes; -Noted occasional harsh non-productive cough; -Complained of headache. Tylenol (pain-reliever/fever reducing medication) provided. Review of the resident's medical record showed no evidence staff informed the physician of the resident's change in condition. Review of the resident's nurses' notes dated 10/10/16 at 3:31 A.M. showed the following: -Temperature 100.4; -Lung sounds reveal bilateral wheezes; -Noted occasional harsh productive cough with tan colored sputum; -Tylenol provided; -Rechecked temperature 99.3. Review of the resident's nurses' notes dated 10/11/16 at 3:12 A.M. showed the following: -At approximately 2:00 A.M. the resident had blood in his/her mouth; -Was actively spitting out blood tinged saliva and had congealed blood in his mouth; -Cleaned away the blood in his/her mouth looking for source; -Unable to identify the source; -Had blood on the gums and on the tongue when wiped off; -No injury noted; -Unable to determine if resident had removed a tooth; -No broken teeth or hole in the gum noted; -No obvious damage to the lips; -Resident has been pulling on bottom lip; -Was able to remove some of the blood along gum line behind lower lip; -Blood appears to be coming from this area. Review of the resident's nurses' notes dated 10/11/16 at 3:29 A.M. showed at 3:30 A.M. resident has loose tooth bottom left side then when he/she moves it active bleeding is noted. Review of the resident's care plan showed no direction for staff to monitor the resident for signs of active bleeding due to [MEDICATION NAME] use. Review of the resident's nurses' notes dated 10/11/16 at 10:41 A.M. showed the following: -Resident returned from physician's (psychiatrist) office appointment with complaints of dizziness, in noticeable distress; -Coughing, congested; -Physician (psychiatrist) recommended that primary care provider (PCP) be contacted ASAP (as soon as possible) for evaluation; -PCP office contacted with message left. Review of the resident's nurses' notes dated 10/11/16 at 12:10 P.M. showed the following: -PCP's nurse called back; -Informed her of the physician's orders [REDACTED]. -Registered Nurse (RN) Supervisor completed assessment; -Resident afebrile; -Resident does have an occasional nonproductive cough; -New orders received to monitor. Review of the resident's medical record showed no evidence facility staff informed the physician of the bleeding noted in the resident's mouth noted on 10/11/16. Review of the resident's laboratory report dated 10/11/16 showed the following: -PT 33.5 High (H): Normal range 11.5-14.8 seconds; -INR 3.38: Normal range 2.0-3.0. Review of the resident's nurses' notes dated 10/12/16 at 3:13 P.M. showed the following: -Resident continues with cold signs/symptoms; -Temperature 99.0; -Lung sounds reveal wheezes that clear with cough; -Cough is noted to be non-productive; -Noted left eye to be red and draining; -Resident denies pain but noted to be sleeping most of day. Review of the resident's nurses' notes dated 10/12/16 at 8:00 P.M. showed the following: -Temperature 98.6; -Resident continues to have nasal congestion; -Has wheezes in the upper lobes that clear with cough; -Resident has dried blood on his/her lips and shirt from a bad tooth he/she keeps manipulating; -Social Services is making an appointment with the resident's dentist; -Resident staying in room all evening. Review of the resident's medical record showed no evidence staff informed the physician of the dried blood on the resident's lips and shirt noted on 10/12/16. Review of the resident's nurses' notes dated 10/13/16 at 9:31 A.M. showed the following: -Eyes have green crusty matter, left eye bloodshot; -Lungs with wheezes throughout all lung fields; -Has nasal congestion and a non-productive wet sounding cough; -Clinical Supervisor notified of assessment and is calling PCP's office to get an appointment. Review of the resident's nurses' notes dated 10/14/16 at 4:06 A.M. showed the following: -Temperature 99.4; -Lung sounds reveal bilateral wheezes/rubs; -Continues with loose productive cough with greenish sputum. Review of the resident's nurses' notes dated 10/14/16 at 6:58 A.M. showed the following: -Noted right eye red, weeping; -Noted increased congestion with audible wheeze and harsh productive cough; -Noted to be short of breath with exertion; -Will report and monitor. Review of the resident's physician's orders [REDACTED]. -[MEDICATION NAME] (antibiotic) 250mg give two tablets by mouth once daily for one day; -[MEDICATION NAME] 250mg give one tablet by mouth once daily for four days; -[MEDICATION NAME] (steroid) 20mg give two tablets by mouth daily; -[MEDICATION NAME] (antibiotic) 5mg/gram (0.5%) eye ointment apply 1 centimeter (cm) ribbon into the lower conjunctival sac (eyelid) in both eyes two times daily for seven days. Review of the resident's nurses' notes dated 10/14/16 at 2:45 P.M. showed facility staff called the resident's family member and updated him/her on resident's new orders for antibiotic and nebulizer treatments for upper respiratory infection (URI) also dental appointment on 10/18/16. Review of the resident's nurses' notes dated 10/14/16 at 2:51 P.M. showed the following: -Resident with rhonchi (coarse rattling respiratory sounds, usually caused by secretions in [MEDICATION NAME] airways) throughout all lung fields; -Has a harsh wet cough along with nasal congestion; -Has dried blood on his/her lips and in his/her mouth from his/her tooth. Review of the resident's nurses' notes dated 10/14/16 at 4:15 P.M. showed new orders received this morning for Z-pack (antibiotic) as directed, [MEDICATION NAME] four times a day, [MEDICATION NAME] 40mg times five days and [MEDICATION NAME] (antibiotic) ointment to both eyes times seven days. Review of the resident's October 2016 Medication Administration Record [REDACTED]. Review of the resident's medical record showed no evidence staffinformedd the physician of the dried blood noted on the resident's lips and in his/her mouth on 10/14/16. Review of the resident's nurses' notes dated 10/15/16 at 8:04 P.M. showed the following: -At 9:45 A.M. resident continues on antibiotic therapy for upper respiratory infection; -Noted wheezes; -Continue with nebulizer treatments; -Resident continues to have blood in mouth and around lips; -Staff reports resident has broken tooth; -This nurse looked in resident's mouth and noted a broken tooth to top right back tooth; -No blood coming from tooth was noted at this time; -Resident refusing to eat breakfast or lunch, states stomach hurts; -Unit Supervisor/RN (Registered Nurse) G in facility at this time and also noted broken tooth. Review of the resident's nurses' notes dated 10/15/16 at 8:19 P.M. showed the following: -At 6:00 P.M. this nurse went to resident's room to assess resident; -When entered resident room noted resident to be pale in color; -Blood in mouth and on lips; -Resident holding abdomen and moaning his/her belly hurt; -Lung sounds have rubs and crackles bilaterally; -Attempted to sit resident up at this time and resident stated belly hurt too bad to sit up; -This nurse had resident cough and instructed resident to spit out what he/she could at this time; -At this time resident coughed up a large dark purple thick clot of blood and stated he/she has been spiting these out; -At this time resident's spouse wanting family member updated; -This nurse updated family member of how resident feeling and spouse wanting resident to be sent to ER for evaluation; -This nurse spoke to on call physician who gave orders to send to ER for evaluation; -911, transported at 6:45 P.M. Review of the resident's hospital History and Physical dated 10/16/16 showed the following: -Chief complaint: Oral hemorrhage with coughing up dark blood and clots; -History of present illness: I received a call from nursing staff late last evening stating that the resident was having difficulty with what they perceived was a broken tooth and had bright red blood in his/her mouth. He/she was however also coughing up dark blood and clots. The nursing staff that I talked to felt as though that was coming up with emesis but report was given to the emergency room (ER) physician that this sounded more [MEDICAL CONDITION] in nature. The resident's medical decision maker wanted him/her transferred to the ER for an evaluation. The resident presented to the ER last evening at approximately 7:30 P.M. The resident had an ER evaluation that revealed a severely prolonged PT/INR. The resident is on long-term [MEDICATION NAME] treatment and apparently had an INR just barely above 3 earlier in the week for which he/she had a change in his/her [MEDICATION NAME] dosing. It was however later noted on review of the resident's nursing home records that on 10/14/16 the resident was placed on [MEDICATION NAME] (oral steroid) 40 milligrams (mg) by mouth for five days, [MEDICATION NAME] (oral antibiotic) for five days and [MEDICATION NAME] treatments for what must have been some sort of acute [MEDICAL CONDITION] type presentation with the resident's primary care physician that day; -The resident did receive two units of fresh frozen plasma (FFP) overnight and the third unit was ordered before this morning's laboratory results came back. -The resident is unable to provide any meaningful information. He/she was unaware of where he/she was this morning or what the date was. He/she just kept saying that something needs to be done regarding his/her perceived shortness of breath and abdominal discomfort; Laboratories: Lab results obtained upon presentation to the ER last evening include a Complete Blood Count (CBC) demonstrating white blood cell count (WBC) of 11.2 (normal range 4.5-10). His/her BNP level (lab test to detect heart failure) was 809 (a BNP value of less than 100 pg/mL essentially rules out heart failure, whereas values greater than 400 pg/mL indicate a 95% likelihood of heart failure.) His/her initial INR was greater than 15 which was up from a value obtained on 10/11/16 of 3.38; Impression and Plan: 1.Supratherapeutic INR with hemorrhage. The resident's [MEDICATION NAME] anticoagulation has been reversed with the use of two units of FFP. He/she received some Vitamin K (medication used to treat and prevent low levels of clotting factors that increase the risk for unusual bleeding) through the ER as well. The supratherapeutic INR was likely the result of underlying [MEDICATION NAME] anticoagulation with antibiotic and systemic corticosteroid therapy for an apparent acute [MEDICAL CONDITION] episode as well as acute hemorrhage. ER physician last evening felt as though [MEDICAL CONDITION] hemorrhage could have been a possibility. Review of the resident's hospital discharge summary dated 10/24/16 showed the following: Discharge Diagnoses: [REDACTED].Bilateral pneumonia; 2.Chronic obstructive [MEDICAL CONDITION] exacerbation; 3.Supratherapeutic INR; 4.Hemoptysis; define 5.Acute on [MEDICAL CONDITION]; 6. History of [MEDICAL CONDITION]. Hospital Course: The resident was admitted , bleeding rapidly resolved with treatment of [REDACTED]. He/she did have urine retention, necessitating a urinary catheter placement. He/she is able to be weaned off of that and had post-residual of less than 50 milliliters (ml) on day of discharge. During interview on 12/7/16 at 11:15 A.M. the DON said she would expect staff to follow the Interact Tool for Physician Notification kept at each nurses' station. Record review of the Interact Tool Version 3.0 dated 2011 hanging at each nurses' station directed facility staff to report the following: -Vital Signs: -Temperature: Oral greater than 100.5; -Report immediately. During interview on 12/7/16 at 1:11 P.M. the Clinical Supervisor/LPN H said the following: -She is the go between the resident and the physician; -She would expect the charge nurse to notify her with any elevated temperature; -On 10/9/16 the resident started getting sick; -Staff should have called the physician with a temperature of 101.5; -She was not aware of the blood in the resident's mouth prior to the resident being hosptalized on [DATE]; -She did not notify the physician about blood in the resident's mouth; -Staff should have called the physician with bleeding from the mouth; -She was notified about the resident's condition change on 10/13/16; -The Unit Supervisor/RN G contacted the physician on 10/14/16 and obtained new orders. During interview on 12/7/16 at 3:00 P.M. the Unit Supervisor/RN G said the following: -She notifies the physician of change of condition or notifies the Clinical Supervisor; -She made the physician aware of the resident's [MEDICATION NAME] use when she contacted him/her on 10/14/16. During interview on 12/7/16 at 4:15 P.M. and 12/21/16 at 3:28 P.M. the DON said the following: -She would expect staff to administer Tylenol for a temperature greater than 100; -The Medical Director wants to be notified for temperature greater than 101.5 if no decrease in temperature in two hours after Tylenol administered; -She would expect staff to notify the physician if a resident receiving [MEDICATION NAME] is having bleeding from the mouth and repeat the PT/INR; -The resident saw the psychiatrist on 10/11/16; -The resident was seen by the psychiatrist for psychiatric issues; -[MEDICATION NAME] use and the associated risks of bleeding should have been on the resident's care plan. During interview on 12/19/16 at 3:49 P.M. the resident's physician said the following: -He would expect staff to notify him for temperature of 100.5; -He would expect staff to notify him if a resident receiving [MEDICATION NAME] was bleeding from the mouth and staff was unable to stop the bleeding.

Based on observation, interview, and record review, the facility failed to initiate cardiopulmonary resuscitation (CPR), a combination of rescue breathing and chest compressions delivered to victims thought to be in [MEDICAL CONDITION], for one resident (Resident #12) of 15 sampled residents identified as having a full code status (all possible measures are to be taken to revive a person and sustain life. CPR would be started). Staff found the resident unresponsive and without a pulse or respirations on [DATE] and failed to initiate CPR and call 911. The resident expired at the facility. The facility also failed to implement their policy and procedure and assure all staff were educated on the process to identify a resident's code status. The facility maintained a blue dot system to identify full code status but failed to assure all blue dots were posted as appropriate on the door of residents who were full code. The facility failed to ensure staff were trained, certified, and available to provide CPR for all shifts and when transporting residents in the facility van who requested to be full code. One resident (Resident #12) of the 15 sampled residents, who was a full code, was transported by the facility transporter who was not certified to perform CPR. The facility census was 90. 1. Review of the facility's policy Contacting Physicians dated [DATE], showed the following: -Residents that are a full code and have emergent situation the staff will call 911, then notify the appropriate physician on duty, the family and the Registered Nurse (RN) on duty; -Examples of an emergency situation include circulation issues rapid pulse or slow pulse or no pulse; -A decline in the resident's normal consciousness; -Airway obstruction or breathing problems new to the resident; -Call and talk with the physician do not delay the resident's transport. 2. Review of the facility's policy Admission of Resident to Facility dated [DATE], showed the following: -The admitting nurse along with a second nurse will discuss with the resident health care directive instructions and have the resident, or Power of Attorney sign; -The copy is placed in the DNR (Do Not Resuscitate) book and original to be sent to the front office for physician signatures; -Once signatures are obtained from physician, the report will be scanned into the resident record and original placed in the book at the nursing station; -The alerts needed will be placed in the computer by the nursing staff such as full code, fall etc. 3. Review of the resident's Physician order [REDACTED]. -On [DATE], an order for [REDACTED].>-The physician renewed the resident's full CPR status on [DATE]; -[DIAGNOSES REDACTED]. -Oxygen at three liter per nasal cannula to maintain oxygen level of 92%; -Rehab potential poor; -admitted [DATE]. Review of the resident's nurse's notes dated [DATE] at 6:07 P.M., showed the resident's family member at bedside, reviewed advanced directives, resident to be full code, paper work filled out. Review of Resident #12's initial care plan dated [DATE] showed the following: -Required limited assistance of two staff for bed mobility and toilet use; -Required extensive assistance of two staff for transfers and personal hygiene; -Required assistance of one to two staff for turning and repositioning as scheduled; -Discharge planning to home/community after completion of skilled treatment; -Code status not addressed. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff dated [DATE], showed the following: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Cognition moderately impaired; -Required limited assistance of one staff for bed mobility; -Required extensive physical assistance of two staff for transfers, dressing, toilet use and personal hygiene; -Required supplemental oxygen use. During the initial tour of the facility on [DATE] at 10:45 A.M., LPN BB said: -The resident had a [DEVICE] (wound vac) on the resident's left lower leg; -The wound vac was not doing well; -The resident had pain and was on pain medication; -The resident was not interviewable; -The resident's child came to visit the resident frequently; -The resident was dependent on staff for all ADLs; -Required oxygen continuously; -Right below the knee [MEDICAL CONDITION]; -The resident's left lower leg was red, warm to touch, and [MEDICAL CONDITION]. Observation during the initial tour on [DATE] at 10:50 A.M. showed: -The resident's name plate outside the resident's door did not have a blue dot indicating full code; -The resident lay on his/her back in bed with head of bed at a 90 degree angle. Review of the resident's nurse's notes dated [DATE] at 11:08 P.M., showed the following: -Resident noted to have lethargy (lack of energy, drowsiness) this shift; -Resident said, I'm just exhausted, I have had a busy day. Review of the resident's nurse's notes dated [DATE] showed: -At 5:09 A.M., staff entered the resident's room to give AM (morning) medications, no response noted, vital signs not present; -At 5:10 A.M., special care unit Licensed Practical Nurse (LPN) verified death; -At 5:15 A.M., notified family member of resident passing, answered questions, requested funeral home; -At 5:18 A.M., the resident's physician paged; -At 5:45 A.M., staff received phone call from resident's physician and an order received to release the body; -At 5:48 A.M., staff notified funeral home and coroner; -At 6:32 A.M., funeral home picked up the resident's body with glasses; -At 7:17 A.M., Addition added, upon entering the room to give 5:00 A.M. medications the resident was not responsive, cold to touch, stiff and pale, pupils not reactive, no heart beat felt or heard, no respirations heard or seen. Interview on [DATE] at 5:20 A.M., showed LPN B said: -The resident had just passed away unexpectedly; -The family was notified. Observation on [DATE] at 5:32 A.M., showed the resident's name located on the outside of the room door, no blue dot to indicate full code status by the resident's name. During interview on [DATE] at 5:35 A.M., LPN A said; -The resident passed away, he/she had verified death with LPN B; -He/she didn't know if the resident was a full code or DNR. Record review on [DATE] at 5:45 A.M., showed no paperwork indicating the resident's code status in the code status book at the B wing nurse's station where the resident resided. (The resident had previously resided on C wing) Record review of the resident's physician orders [REDACTED].M., showed the resident was a full code. During interview on [DATE] at 6:38 A.M., LPN B said: -He/she worked at the facility for the past two years; -He/she started his/her shift at 11:00 P.M., and made resident rounds; -He/she was in the Resident #12's room at 2:00 A.M., to do vital signs; -Vital signs were within normal limits (blood pressure ,[DATE], pulse 82, respirations 20, temp 96.8, and oxygen saturation 97% with oxygen per nasal cannula at three liters continuously); -At 4:00 A.M., he/she walked by the resident's room and the resident appeared to be sleeping; -At 5:07 A.M., he/she entered the resident's room to give medications, the resident lay in bed with eyes and mouth closed, arm cold to touch, the resident did not respond to touch. He/she looked and listened for respirations, and felt for carotid pulse, he/she saw and felt no respirations, and felt no heart rate, he/she opened the resident's eyelid and pupil non reactive; -At 5:12 A.M., he/she called LPN A to the B wing to verify death and notified the resident's family member of death; -At 5:17 A.M., he/she paged the resident's physician; -At 5:45 A.M., he/she spoke with the resident's physician and received an order to release the body; -LPN B said the resident was a full code, he/she had checked the computer at 5:07 A.M. to determine the resident was a full code; -He/she was not sure if there was a blue dot on door to indicate the resident was a full code; -He/she checks the computer to determine code status, there was also a book that showed the resident's code status, but he/she did not check the book; -He/she did not perform CPR because the resident had been dead for awhile, very cold, stiff, pale, no respirations, no heart rate and pupils non reactive; -If residents who are full codes have no heart beat or respirations, he/she should call 911, start CPR and notify the physician. During interview on [DATE] at 7:10 A.M., LPN A said: -He/she has worked at the facility for [AGE] years; -Around 5:10 A.M., the Certified Nursing Assistant (CNA) from B wing called and asked him/her to come and verify a death with the B wing LPN; -When he/she entered the resident's room, the resident lay on his/her back in bed, arms at side, pale in color, torso cool to touch but not as cold as extremities; -No mottling (blood vessels changes in the skin causing a patchy appearance) was seen; -He/she checked for heart beat and respirations by feeling and listening; -He/she verified death; -He/she did not check the resident's code status, he/she would expect the charge nurse caring for the resident to have already checked code status. During interview on [DATE] at 7:40 A.M., CNA C said: -He/she worked at the facility on 11:00 P.M. to 7:00 A.M.; -The resident required staff assistance with toileting and turning; -The resident would turn on the call light to use the bedpan at night when he/she needed to use the bathroom; -He/she started work at 11:00 P.M. and had not provided any care for the resident on [DATE]; -He/she went into the resident's room a little after 2:00 A.M., and the resident had his/her eyes closed, lay on his/her back with left arm down to side and right arm slightly bent over his/her torso; - This was the last time CNA C saw the resident; -The resident was breathing and looked pale as per the resident's normal appearance; -LPN B notified him/her that the resident had passed away and needed post mortem care around 5:10 A.M. to 5:15 A.M.; -He/she provided post mortem care (included bathing the resident, changing bedding, and changing the resident's hospital gown) around 5:15 A.M. to 5:20 A.M.; -He/she did not know the code status of the residents; -He/she was not CPR certified; -He/she had been CPR certified in high school but was not comfortable any longer providing CPR; -He/she would rely on the charge nurse to let him/her know what to do if a person was a full code. Record review on [DATE] at 7:46 A.M., at the C hall nurse's station showed Resident #12's health care directive was present in a binder, labeled C/D wing DNR Records and Resident Sign in/out book. (the resident previously resided on C/D wing before moving to B wing). During interview on [DATE] at 7:50 A.M., LPN B said: -He/she did the resident's vital around 2:00 A.M. in the morning; -The resident woke up during the vitals and asked what the time was. The resident had no concerns and the vitals were within normal limits; -He/she walked by the resident's room at 4:00 A.M., the resident appeared to be resting quietly; -He/she did not look close enough to see if the resident was breathing or not at 4:00 A.M.; -He/she entered the resident's room to give the resident medication around 5:00 A.M., the resident was unresponsive; -He/she used a stethoscope to check pulse and looked for breathing. The resident did not have a heart beat and was not breathing; -He/she lifted the resident's eye lids and the resident's pupils were fixed; -The resident's arm was cold to touch and stiff when he/she lifted it up; -He/she did not see any mottling; -He/she did not call 911; -He/she did not see a blue dot on the door; -He/she came up to the nurses stations, looked at the computer and the resident was a full code; -He/she called the physician but was unable to talk with him, he/she paged the physician; -He/she had one CNA on the floor working B hall; -He/she instructed CNA C to call LPN A and ask LPN A to come over to verify death around 5:10 A.M.; -The resident's physician called back around 5:45 A.M. and he/she notified the physician of the resident's death; -He/she did not notify the physician of the resident's code status; -He/she told the physician the resident's death was unexpected and gave the physician the resident's lab values and that the resident was scheduled for a heart catheterized on Friday; -He/she was current with his/her CPR certification. During interview on [DATE] at 8:05 A.M., CNA C said: -Around 5: 10 A.M., LPN B notified him/her the resident had passed away, instructed him/her to call LPN A in the (special care unit) SCU and ask him/her to perform post mortem care; -He/she called LPN A and asked her to come over and verify death for the resident; -He/she did not know if the resident was a full code or DNR; -He/she provided post mortem care around 5:15 A.M., the resident lay on his/her back, eyes closed, mouth closed, skin was pale but the resident's skin was normally pale, the resident's lips were flesh to pink colored, the resident had no purple tinge or mottling noted, the resident's leg, thighs, and torso were warm from being covered. He/she turned the resident with ease and the resident's back was pretty warm due to laying on it. The resident's arms and leg bent easily, no popping, cracking or sounds when he/she bent them during care. The resident's limbs were not stiff, the elbow and knee's straightened and bent with ease. During interview on [DATE] at 9:58 A.M., the resident's physician said: -The resident was a full code; -He/she received a phone call from the staff at the facility around 5:00 A.M.; -He/she was told by facility staff, the resident did not have a pulse, was rigid and cold, and had not been checked on since 2:00 A.M.; -He/she would not expect CPR to be performed after a three hour period; -He/she would expect staff to perform CPR if the resident was a full code and did not have a pulse and respirations and a lot of time had not passed. During interview on [DATE] at 8:10 A.M., the Director of Nurses (DON) said: -Resident #12's code status was in the computer; -Resident #12 was a full code. During interview on [DATE] at 4:00 P.M., the DON said: -He/she would expect staff to check on residents at least every two hours; -He/she would expect staff to make sure the resident was breathing when checking on them. During interview on [DATE] at 2:00 P.M., the administrator said: -He/she would expect staff to check on residents at least every two hours or more often; -He/she would expect staff to go into the resident's room to see if they were breathing; - If a resident was found without a pulse and/or no respirations, he/she would expect staff to call 911 and start CPR if the resident was a full code. Moved from below 4. Record review on [DATE] at 7:51 A.M., on the D hall showed Resident #38's name was on the list at the nurses' station as being a full code; Record review on [DATE] at 7:52 A.M., on the C hall showed Resident #36 was not on the list at nurses' station as being a full code; Observation on [DATE] at 7:53 A.M., showed Resident #38 did not have a blue dot by his/her name on his/her door. Observation on [DATE] at 7:54 A.M., showed Resident #36 did have a blue dot by his/her name on his/her door. During interview on [DATE] at 7:43 A.M., CNA F said there was a list of full code residents behind the nurse's station and some full code residents had a dot on their headboard. During interview on [DATE] at 8:05 A.M., CNA W said he/she had worked at the facility for [AGE] years. He/she said residents who were full code status were noted on a paper posted at the nurse's station with their name. He/she said other than the paper posted with residents' names at the nurse's station there was no other quick way to know a resident's code status. During interview on [DATE] at 8:45 A.M., CNA V, who was working in the special care unit and said he/she had worked at the facility for four years. He/she said residents with full code status have a blue dot posted on their door. He/she said there was no other way to know a resident's code status. CNA V said if a resident was somewhere in the facility other than their room and became unresponsive, he/she would not know that resident's code status. During interview on [DATE] at 3:20 P.M., social services staff Y said: -He/she worked in social services and helped transport residents to physician appointments, hospital, shopping and wherever the residents need to go; -He/she transported the residents by him/herself most of the time; -The nurses were responsible for getting all the resident's paper work together for the transport; -He/she knew there was an emergency box on the van that included Band-Aids and usually oxygen; -The face sheet had the resident's code status on it; -He/she would pull over and call 911 and wait for help if an incident occurred; -He/she was not currently CPR certified; -He/she was CPR certified many years ago and would be comfortable performing CPR; -He/she did not know current practice guidelines for performing CPR; -He/she transported Resident #12 to an appointment on [DATE]. During interview on [DATE] at 1:15 P.M., the Social Service Director (SSD) said: -He/she was in charge of transportation; - The facility did not have a transportation policy; -The facility had a handicapped van to transport residents to appointments and hospital. During interview on [DATE] at 8:10 A.M., the DON said: -All LPN's are CPR certified, except the new ones; -A resident's code status was on the Medication Administration Record [REDACTED] -If a resident was a full code staff should always call 911 and start CPR. During interview on [DATE] at 9:08 A.M., the DON said: -The facility did not have a policy on CPR or a process in place to identify residents who were full codes; -All residents' code status can be found on the computer, MAR, Treatment Administration Record (TAR), ancillary log, CPR book at each nurses' station and a typed list at each nurses' station of full codes; -Full code residents were identified with a blue heart in the computer and staff places a blue dot on the resident's nametag on his/her door; -Two LPNs can verify death on no code residents; -A physician has to identify death on a full code resident; -He/she would expect staff to start CPR, call 911 then notify physician and family if a full code resident if found without a pulse and/or respirations; -The facility used to put a blue dot on the resident's headboard but when residents left the facility then no one removed the sticker; -Facility staff received training on the blue dot system during orientation and annually; -He/she was responsible for placing the blue dot; -He/she would expect a blue dot to be on the nametag of each full code resident's door; -He/she does not know why there was no blue dot on Resident #12's door; -The resident moved from C hall to B hall on [DATE] because he/she wanted a private room; -He/she would have expected the resident's health care directive to be moved from C hall to B hall when the resident moved halls; -On [DATE] 11:00 P.M. to 7:00 A.M., there were two CPR certified staff working LPN B was certified and LPN D was certified she was working C/D wing that night -The facility has several current staff that needed CPR certification updated; -The facility had a total six staff with current CPR certification, with one of the six staff being the maintenance supervisor. During interview on [DATE] at 4:00 P.M., the DON said: -The resident's code status was on the paperwork given to the transporters; -If a resident was found without a pulse and/or respirations he/she would expect the transporter to pull the van over and call 911 and wait for help to arrive. During interview on [DATE] at 2:00 P.M., the administrator said: -He/she said one of the transporters was CPR certified; (transporter AA is CPR certified, however he/she did not transport the resident on [DATE]) - He/she does not know if the transporter would be comfortable performing CPR if an incident occurred; -He/she would expect the transporter to call 911 and head to the hospital if a resident was without a pulse and/or respirations. During interview on [DATE] at 3:25 P.M., the facility Medical Director said: -CPR should be provided for all full code residents; -He/she would expect staff to start CPR, call for help, call 911, and continue to perform CPR on a resident that was unresponsive without a pulse and/or breathing until the ambulance arrived. NOTE: At the time of the annual survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the survey, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the survey, the facility began inservicing nursing staff immediately regarding procedures to follow if a resident was found without respirations, including initiating CPR to a resident in accordance with his/her's advanced directive. The remainder of nursing staff were to be inserviced prior to contact with residents until all nursing staff had received this inservice. The facility will inservice any newly hired employees and all staff annually on the facility's CPR policy. The facility immediately reviewed current residents' medical records for code status. The DON will place a blue dot on the name plate on the residents' doors and the medical record staff will check to ensure that the blue dot is present and the list at the nurses's station is updated and current. Facility will have a CPR instructor on-site [DATE] and [DATE] to retrain all licensed staff. All new employees will be asked for proof of current certification, if none, arrangements will be made to send to next available class and nursing scheduler will ensure that a least one person is certified in the facility each shift. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address class I violations.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to address one resident's (Resident #1) pain of four sampled residents. The resident was complaining of pain and wanted to go to the hospital. Staff administered an [MEDICATION NAME] and a muscle relaxer that was not effective and the resident continued to complain of pain. The resident left the facility without staff knowledge and was found sitting outside the facility at 3:00 A.M. The resident continued to complain of pain, saying he/she wanted to go to the hospital. The resident left the facility again that night without staff knowledge. Staff located the resident approximately four-tenths of a mile from the facility on a main street/business highway at approximately 5:30 A.M. The resident told staff he/she was walking to the hospital. The facility census was 89. 1. Review of the facility's policy for administration and documentation of pain medication revised on 4/21/14 showed: -Policy: Resident experiencing an alteration in comfort, whether acute or chronic, will be monitored and maintained by optimal medication selection, specific administration regimens and effectiveness evaluation; -The pain management on the MAR (medication administration record), utilizes a 1-10 pain intensity scale, will be initiated and completed on all residents for whom more than one pain relief medication or alternative dosages are prescribed; -Will use the Abbey Pain Scale and Pain-Aide for cognitively impaired; -When use of a pain scale indicates medication is not effective, remember to notify the physician to request possible change of medications; -Document all findings from assessment in the nursing notes; -When a physician orders [REDACTED]. -The 1-10 scale will be used as follows; -1-3-mild (pain); -4-6 moderate (pain); -6-10-severe pain; -Document the medication on the MAR; -Document the site of pain in the designated area, the type of pain (progress note), the intensity level (1-10); aggravating factors (progress note) and any non-medication intervention (progress notes); -Check on the resident to see if effective in 60 minutes; -Let the charge nurse know if the resident complains the medication is not effective so the physician can be notified for a possible change. 2. Review of Resident #1's care plan updated on 4/2/15 showed no problems, goals or interventions related to pain. Review of the resident's significant change minimum data set (MDS), a federally mandated assessment instrument required to be completed by staff dated 7/18/15 showed the resident had impaired vision and severely impaired cognition with one-sided impairment of his/her upper extremities. He/she had no pain. The resident was able to make him/herself understood and he/she understood others. He/she did not wander and had no behaviors. Review of the resident's current physician's orders [REDACTED]. -The resident had [DIAGNOSES REDACTED]. -an order for [REDACTED].>-Monitor pain, follow up in 60 minutes; -an order for [REDACTED].>-Monitor for effectiveness/follow up in 60 minutes. Review of the resident's nurse's notes dated 8/10/15 at 3:22 P.M. showed the resident lay in bed, complaining his/her back was sore. Staff administered Tylenol ([MEDICATION NAME]) and [MEDICATION NAME]. Review of the resident's nurse's notes dated 8/12/15 showed: -At 1:59 A.M., Licensed Practical Nurse LPN) A documented the resident complained of severe flank (side/back) pain. Staff gave the resident Tylenol and [MEDICATION NAME]. The resident sat in a recliner at the time and was unable to sleep. LPN A documented staff would continue to monitor the resident; -At 4:01 A.M., LPN A documented when he/she went to follow up on the resident's pain, the resident was not in his/her room; -Staff found the resident sitting outside the special care unit (outside the facility); -The resident continued to complain of right sided back pain; -The resident and staff walked back to the resident's room; -The resident was currently seated in his/her recliner. -At 7:28 A.M., the ADON (assistant director of nursing) documented at 6:00 A.M., when the ADON entered the facility, the resident sat near the nurse's station with a CNA (certified nurse aide). The resident had his/her head in his/her hands and was tearful, saying his/her side hurt. When asked where, the resident started rubbing his/her right flank; -When asked to rate his/her pain, the resident said, It's awful, it doesn't matter how I sit or move, it hurts really bad. The resident described the pain as, it comes and goes, and said It feels like I am being stabbed. Orders received from the physician to send the resident to the emergency room . Review of the facility's investigation dated 8/12/15 showed: -LPN said on 8/12/15 at approximately 2:00 A.M., the resident complained of right flank pain. The resident rated his/her pain an eight (1-10 scale with 10 being the most severe pain); -LPN A gave the resident two Tylenol 325 mg and [MEDICATION NAME]. The resident sat at the nurse's station in a recliner and was unable to sleep. LPN A said he/she wanted to see if the medication helped with the pain; -At 3:00 A.M., LPN A went into the resident's room to check on the resident; -The resident was not there; -Staff checked all areas on the wing and notified other units to check their areas; -Meanwhile, Certified Nurse Aide (CNA) B went out the front door and could see the resident sitting on a bench outside the special care unit; -CNA B walked the resident back inside the building; -The resident said he/she was hurting and wanted to go to the hospital; -LPN A said the resident did not appear to be in as much pain so LPN A had the resident sit at the nurse's station in a recliner for a while; -LPN A was not sure of the time the resident went to his/her room; -At 3:30 A.M., LPN A notified the assistant director of nursing (ADON) who instructed LPN A to keep a close eye on the resident; -At 5:00 A.M., LPN A went to the resident's room and the resident was not in bed; -Staff searched the inside and outside of the building and could not locate the resident; -CNA B got in his/her vehicle and searched for the resident; -CNA B found the resident (at approximately 5:30 A.M.), on the main street walking toward the hospital; -The DON and ADON arrived at 5:55 A.M.; -The resident said he/she still had pain; -Staff notified the physician who directed staff to send the resident to the hospital if he/she wanted to go. Interview on 8/19/15 at 11:08 A.M. showed the resident said his/her pain (pointed to his/her right flank/side) just came upon him/her and it was terrible. Interview on 8/24/15 at 7:19 A.M. showed CNA B said: -On 8/12/15, the resident came to the nurse's desk between 2:00 A.M. and 2:30 A.M.; -The resident complained of pain and told the nurse he/she was in pain; -The nurse gave the resident a heat pad; -The resident came back five minutes later and said the heat pad was not helping; -The nurse gave the resident Tylenol; -At 2:45 A.M., the resident was upset and wanting to go to the hospital; -During bed checks, staff noticed the resident was gone; -CNA B found the resident sitting outside the special care unit; -The resident was upset and in pain; -CNA B and the nurse from the special care unit walked the resident back to the D hall; -Between 3:00 A.M. and 3:45 A.M., the resident was back up at the nurse's desk, complaining of pain; -The resident was mad and wanted the nurse to call the physician; -The resident was upset because the nurse would not call the physician; -At 4:30 A.M., the resident was gone again; -CNA B looked all over; -CNA C found the resident. Review of a written statement dated 8/24/15 showed CNA B said: -About 2:15 A.M. or 2:30 A.M. (the morning of the incident), the resident came up to the nurse's desk complaining of pain in his/her abdomen; -The nurse gave the resident a heating pad; -Fifteen minutes later, the resident received Tylenol; -A little bit later (about 2:45 A.M.), the resident was upset and wanted go to the physician; -The nurse told the resident to lay down and let the medication kick in; -CNA B went to make rounds and noticed at 3:15 A.M., the resident was gone; -Staff looked for the resident; -CNA B found the resident outside (in front) the special care unit, sitting on a bench; -CNA B and the nurse from the special care unit walked the resident back to the C/D wing of the building; -The resident still complained of pain and wanting to go to the physician; -The resident was very upset; -The resident went back to his/her room; -At 4:15 A.M., staff started bed checks; -At 4:30 A.M., CNA B got to D hall (for bed checks), and the resident was gone again; -CNA B went looking for the resident all over and outside; -CNA C found the resident by a local grocery and brought the resident back to the facility. Interview on 8/24/15 at 7:10 A.M. showed CNA C said: -On the night of the incident, he/she worked the A/B hall; -At just after 5:00 A.M., he/she had gone outside to get something from his/her vehicle; -He/she saw two CNA's from the C/D hall outside with flash lights; -CNA C asked them if the resident had gotten out again and they said yes; -The aides said the resident wanted to go to the hospital; -The resident did not usually complain of pain, kept to him/herself and took care of him/herself; -He/she got in his/her vehicle and went to look for the resident; -He/she found the resident about five blocks away from the facility on the main street of town; -The resident said he/she was headed to the hospital. Review of a written statement dated 8/24/15 showed CNA C said: -Just after 5:00 A.M. (on the morning of the incident), he/she went outside to the front parking lot; -The two aides from the C/D hall told him/her the resident got out again; -He/she asked the two aides what was wrong with the resident and they said the resident wanted to go to the hospital; -CNA C got in his/her vehicle and told one of the other aides to get in their vehicle and look in the opposite direction of CNA C; -CNA A found the resident on the main street of town; -He/she brought the resident back. Interview on 8/24/15 at 7:30 A.M. showed LPN A said: -The resident complained of right back/flank pain; -He/she gave the resident some Tylenol; -Fifteen minutes later, the resident said the Tylenol was not working; -LPN A gave the resident a muscle relaxer; -LPN A did not give the resident a heating pad; -The resident wanted to go to the hospital; -The resident had been by the nurse's station sitting after LPN A gave the resident the muscle relaxer; -LPN A noticed the resident was not there anymore; -Staff found the resident out by the special care unit; -Staff brought the resident back in; -The resident said the medication was not working and not effective, but LPN A thought the resident was better; -The resident still wanted to go to the hospital; -LPN A contacted the ADON who instructed LPN A to document (the incident), and they would deal with it in the morning; -The ADON said to keep an eye on the resident so staff had the resident sit by the nurse's station; -At 4:00 A.M., LPN A observed the resident sitting in his/her recliner in his/her room; -At 5:00 A.M., LPN A went in to give the resident his/her morning medications, and the resident was gone; -CNA C got in his/her vehicle to look for the resident; -By the time LPN A called 911, CNA C had already found the resident. -LPN A did not contact the resident's physician because he/she wanted to see if the medication he/she had given the resident would work; -The resident sat at the nurse's station for the longest time; -The resident was usually happy at 5:00 A.M. when LPN A would give the resident his/her medications; -The resident had slept all night the night before; -LPN A was told the resident was a chronic complainer but the resident had never been that way with him/her before. Review of a written statement dated 8/24/15 showed LPN A said: -The resident complained of right flank pain; -He/she gave the resident Tylenol; -He/she was called to another resident's room and when he/she came back and was documenting on the resident's Tylenol, the resident still complained of pain; -LPN A noticed the order for a PRN (as needed), muscle relaxer so he/she gave the resident the muscle relaxer at that time; -The resident sat in a recliner at the nurse's station; -The CNA told LPN A the resident was missing; -They did a room check and looked outside; -Staff found the resident sitting on a bench on the property; -The resident complained of wanting to go to the hospital; -LPN A called the ADON; -LPN A talked to the resident about giving the pain medication and muscle relaxer a chance to work; -The resident sat at the nurse's station until 4:00 A.M., then went to sit in his/her own room; -LPN A observed the resident sitting in his/her room at 4:00 A.M. when LPN A went to assist another resident; -At 5:00 A.M., LPN A went to give the resident his/her morning medications and the resident was not in his/her room; -Staff completed a room to room search and property search; -The ADON was called and directed staff to contact 911 if the resident was not on the property; -While on the phone with 911, staff found the resident. Review of the resident's emergency room transfer sheet dated 8/12/15 showed: -The resident was given [MEDICATION NAME] (narcotic pain medication) 25 mgs, Zofer (nausea/vomiting) 4 mgs and [MEDICATION NAME] (anxiety) 2 mgs while in the emergency room ; -Discharge [DIAGNOSES REDACTED]. -Orders for [MEDICATION NAME] 5/325 mgs every four to six hours as needed for pain. Interview on 8/24/15 at 7:58 A.M. showed the DON said she would have expected staff to notify the physician and send the resident to the hospital for complaints of pain and wanting to go to the hospital. Interview on 8/24/15 at 2:55 P.M. showed the resident's physician said the facility did contact him/her at 6:00 A.M., but they should have contacted him/her sooner regarding the resident's pain and the resident wanting to go to the hospital. MO# 0

Based on observation, interview, and record review, the facility failed to consistently implement and modify interventions as necessary, in accordance with current standards, to reduce the risk of falls for one resident (Resident #17) with history of falls. The resident sustained [REDACTED]. The facility failed to consistently implement and communicate to staff the interventions to prevent falls listed in the care plan, failed to include all interventions to prevent falls in the care plan, and failed to use appropriate transfer technique with a gait belt during transfers for one resident (Resident #4). The facility failed to implement effective and meaningful interventions following falls for one resident (Resident #12) with a history of falls, in a review of 18 sampled residents. The facility census was 90. 1. Review of the facility's Fall Prevention Program Policy, dated 7/13/12, showed the following: -All new admissions are assessed for fall risk, care plans are reviewed for completion; -Falls are reviewed weekly at the combined resident committee meeting, to review the reports, to evaluate any interventions that were in place and what interventions need to be added to prevent further incidents; -All reported falls are logged into the falls analysis log book by the therapy department; -The care plan is reviewed and updated with any new interventions as needed; -Minutes are recorded and each Unit Supervisor will receive a copy of the minutes; -The unit supervisor will be sure the information is reviewed by staff members to ensure the interventions are followed; -The Director of Nursing (DON) will assist the committee chairman in locating and follow up of incidents; -Each month the chairman of the falls committee will provide pharmacy consultant a list of the previous month's falls. If a fall is emergent, caused injury, or is felt to be directly related to a medication, we will fax immediately to the pharmacy consultant for recommendations. 2. Review of the facility's policy on reporting incidents and accidents involving residents, revised 9/30/14, showed the following: -After a fall, a licensed personnel shall assess and document the resident's condition in the progress notes on each shift following the occurrence for a minimum of 72 hours; -Licensed personnel responsible for the resident at the the time of discovery/report of the occurrence are required to initiate the incident/accident report. If the cause is unknown then the licensed personnel will begin the investigation by checking the area or environment for structural causes. Each staff member will make a statement that is documented. They will investigate and document the circumstances surrounding the occurrence and document any interventions completed at that time; -After the above report is complete a message will be sent via computer to the clinical supervisor so he/she will follow up with physician recommendations; -The unit supervisor will monitor for notifications of incidents and accidents for their unit. They will investigate and review in the weekly care plan meetings. The committee will provide the needed interventions and the care plan will be updated; -Accident/incident statistics will be reviewed at the facility's Quality Assurance Committee meetings for identification of patterns or trends. The care plan committee will discuss any interventions that may be needed to correct the situation. The care plan will be updated, if needed, at the care plan meeting. 3. Review of the facility's Gait Belt Policy, written 2/12/09, showed the following: -Appropriate Donning of a Gait Belt: For most patients it is appropriate to place the gait belt around waist just above the hips and snug enough you can get two hands under the gait belt; -Appropriate Lifting of Patients Using a Gait Belt: Patients should be able to bear weight in at least one lower extremity to do a stand and pivot transfer. If unable, should be referred to restorative therapy to change transfer status; -Two Person Transfer: Each person should be facing the patient on each side of the patient. Using inner arm, whoever is performing the transfer should put hand in the gait belt. Instruct the patient to push from the arms of the chair or grab the arms of each person performing the transfer below the elbow. Lifting in this manner will allow the persons transferring to have more control with their outside hand to help with hygiene, clothing management, or to help move the wheelchair or chair closer if needed. Persons performing transfer should use good body mechanics, bending at the knees and giving the patient time to transfer. Never lift under the shoulders for any reason; -Procedure: Explain the procedure to the resident. Apply the gait belt around the resident's waist. Ensure the belt is snug but allow enough room for your hand to comfortably grasp it. Assist the resident to a standing position by grasping the belt from underneath. Pivot the resident into chair or bed. 4. Review of Resident #17's annual MDS, dated [DATE], showed the following: -Severely cognitively impaired; -Active [DIAGNOSES REDACTED]. -The resident was dependent on two or more staff for bed mobility, transfer, toilet use, walk in room and corridor, and locomotion on and off the unit; -The resident was not steady with moving from seated to standing position, walking, turning around, moving on and off the toilet, or surface-to-surface, he/she was only able to stabilize with staff assistance; -Had impairment on both upper and lower extremities; -Frequently incontinent of bladder; -Always incontinent of bowel; -Had two or more non-injury falls since last MDS (2/21/14); -The resident received an antipsychotic, antianxiety, and antidepressant during the look back period; -The resident received no occupational or physical therapy; -The resident received five days of passive range of motion. Review of the resident's care plan, dated 5/24/14, showed the following: -Problem: History of falls, fall risk, falls in past 30 and 31 to 180 days, unsteady gait, and wandering; -Goal: The resident will not have a fall with serious injury. He/she will wait for assist before getting up; -Approaches: The resident has a tabs monitor and a bed alarm for when in bed. Make sure they are in good working order. If fall occurs, follow fall protocol. Assess past falls. Keep bed at lowest level at night, and when taking a nap. Two person assist when transferring and ambulating. Monitor him/her when in wheelchair, he/she has a habit of sliding out of chair to the floor. Continue with giving him/her lollipops, music, and a volunteer to sit with him/her when restless. Record review of the resident's nurse's notes, dated 6/1/14 at 11:15 A.M., showed the resident stood up and fell back hitting his/her head on the table and sat on the floor. Noted 3 centimeter (cm) by 0.8 cm red area to back of his/her head. Denied pain/discomfort. Review of the resident's care plan showed on 6/1/14, the following was added: -fell after getting up from wheelchair, hit head on table and sat on the floor, no serious injury; -New approach added: Antiroll back device for wheelchair ordered. Review of the resident's nurse's notes, dated 6/6/14 at 3:30 P.M., showed the resident got up from his/her wheelchair and sat on the floor. He/she did not hit his/her head. Staff witnessed the fall. The resident denied pain/discomfort. Review of the resident's care plan showed on 6/6/14, the following was added: -Got up from wheelchair and sat on the floor, no serious injury; -There was no documentation staff evaluated the current interventions or modified/added new approaches to prevent future falls. Review of the resident's nurse's notes, dated 7/14/14 at 5:50 P.M., showed the resident was very agitated during supper. He/She pushed himself/herself away from the table. He/She was rolling back and forth in the wheelchair when he/she leaned and rolled off the front of the wheelchair landing on the floor and on his/her right side. The resident did not hit his/her head. Full range of motion for this resident exhibited as resident was resistant to staff assisting him/her off of the floor. Review of the resident's care plan showed on 7/14/14, the following was added: -Rolling in wheelchair, rolled to the right and slid off front of wheelchair, didn't hit his/her head; -Goal: No falls with injuries for three months; -Approaches: Will see psychiatrist. Tabs are to be in place (already an approach). Review of the resident's fall assessment, dated 7/14/14, showed the following: -There was previous history of falls; -This fall followed a similar pattern to resident's previous fall; -Provide some suggestions on how we can prevent further falls was left blank. Review of the resident's nurse's notes, dated 8/3/14, showed the following: -At 3:30 P.M., the resident stood up from chair and fell landing on buttocks. The resident complained of left knee pain, has full range of motion of joint with no deformities noted; -At 6:45 P.M., noted bruise developing outer aspect of left knee; -At 9:00 P.M., the resident was in the common area and wanted to go to the bathroom so staff took him/her to the bathroom. In the middle of the transfer, the resident went limp, staff were able to get the resident onto the toilet, where he/she came to. Review of the resident's nurse's notes, dated 8/4/14, showed the following: -At 12:00 A.M., heard the resident talking in his/her room, checked on the resident. The resident was on the side of the bed. Two staff assisted the resident to the bathroom, noticed purple-reddish bruise to left knee, noticed the resident was non-weight bearing to left leg. Gave the resident two Tylenol and applied lidoderm to left knee for complaints of left knee pain; -At 3:00 A.M., gave Ativan (antianxiety) for increased anxiety; -At 4:00 A.M., staff took the resident to the bathroom and put him/her to bed without difficulty; -At 6:00 A.M., staff alerted the nurse to the resident's room. The resident was bleeding from his/her left knee, also noted white matter coming from the area that had split open. Physician notified and okayed transfer to hospital; -At 7:45 A.M., hospital called facility with report the resident [DIAGNOSES REDACTED]. During an interview on 12/18/14 at 1:40 P.M., the Director of Nursing (DON) said the following: -If new approaches were not added to the care plan, then the staff did not feel the approaches needed to be modified or added; -When the resident fell on [DATE], he/she did not have the tab alarm on as the care plan directed. 5. Review of Resident #4's fall risk assessment, dated 9/6/14, showed a score of 19, indicating high risk for falls. Review of the resident's care plan, effective 9/23/14, showed the following: -Problem: Activities of Daily Living, total assistance; -Goal: Resident will be free from accident/injury daily; Resident will tolerate personal cares without behaviors; Staff will meet all of the resident's needs; -Interventions: Anticipate the resident's needs, provide AM and PM care and provide privacy. Assist of two persons for transfers, feed the resident all meals, provide oral care every shift and as needed, restorative program to ambulate the resident long distances and exercise program with stretching of lower extremities five times a week; -Falls were not included on the resident's care plan, dated 9/23/14, after staff assessed the resident at high risk for falls on the fall risk assessment, dated 9/6/14. Review of the resident's fall risk score on 11/2/14 showed a score of 12, indicating high risk for falls. Review of the resident's quarterly MDS dated [DATE], showed the following: -The resident could sometimes make self understood and usually understood others; -Required extensive assistance of two or more staff for bed mobility, transfers, ambulation, dressing, eating, toilet use, and hygiene; -Balance was not steady and the resident required human assistance to stabilize. Review of the resident's nurse's notes showed the following: -On 11/30/14 at approximately 1:50 A.M., a staff member observed the resident walk out of his/her room into the hallway, walked across the hallway, slipped and fell , and landed on his/her left side. The resident received a laceration above the left eye. Staff applied pressure to the laceration and called the physician. The resident was not moved. Orders were received to transfer the resident to the emergency department by ambulance; -On 11/30/14 at 10:00 P.M., the resident was back in the facility. Staff returned the resident to bed and a tab alarm was placed on the resident for safety; -On 12/1/14 at 10:50 A.M., staff contacted the resident's physician and reported the resident screamed with any movement. Bruising and swelling were noted to the resident's left hip area. The physician gave an order for [REDACTED]. -On 12/1/14 at 11:25 A.M., the ambulance arrived and transported the resident back to the emergency room ; -On 12/1/14 at 1:30 P.M., the emergency room informed the facility the resident was being admitted to the hospital for a left hip fracture; -On 12/4/14 at 2:30 P.M., the resident arrived back at the facility by ambulance. The resident had sutures to the laceration above the left eye. The resident was placed in a low bed with a fall mat next to the bed. Review of the resident's care plan, effective 12/4/14, showed the following: -Problem: Fracture of the neck of the left femur; -Goal: The resident's pain will be managed at a tolerable level; -Intervention: Orthopedic consults as needed, X-rays as ordered, assess pain and medicate as needed, OT to evaluate for wheelchair management and positioning, neuromuscular re-education, and therapeutic procedure, ensure the call light is in reach at all times, bed alarm on when in bed. (The care plan was not updated to include the low bed or the fall mat next to the bed which was implemented on 12/4/14); -Problem: Falls; -Goal: Resident will be free from serious injury related to falls; -Interventions: Investigate the cause of falls immediately, evaluate patterns of falls, anticipate the resident's needs, provide reality orientation, use appropriate assistive devices and the level of assistance recommended, ensure use of proper footwear, provide education on safety techniques, maintain a safe environment by ensuring the floor is free of clutter, perform medication reviews related to recurrent falls. Review of the resident's fall risk assessment, dated 12/5/14, showed a score of 12, indicating high risk for falls. Observation on 12/16/14 at 7:50 A.M. showed the resident in a low bed with a fall mat on the left side of the bed. A grab bar was raised on the right side of the bed. Observation on 12/16/14 at 9:30 A.M. showed Certified Nurse Assistant (CNA) M and CNA K stood on each side of the resident and transferred him/her with a gait belt from the wheelchair to a recliner in front of the nurse's station. CNA M and CNA K each placed one arm under each of the resident's underarms, grabbed the gait belt around the resident's waist and lifted the resident up under both arms out of the wheelchair. The gait belt slid up around the resident's chest. CNA M and CNA K pivoted the resident and sat him/her in the recliner. Observation on 12/16/14 at 11:50 A.M. showed CNA M and CNA K stood on each side of the resident and transferred him/her with a gait belt from the recliner to the wheelchair. CNA M and CNA K each placed one arm under each of the resident's underams, grabbed the gait belt around the resident's waist and lifted the resident under both arms out of the recliner. CNA M and CNA K pivoted the resident and sat him/her in the wheelchair. Observation on 12/17/14 at 6:00 A.M. showed the resident on the floor on his/her left side of the bed in his/her room. The fall mat was positioned on the right side of the bed. There were no staff in the resident's room. Once aware of the fall, CNA I retrieved Licensed Practical Nurse (LPN) H. Staff assessed the resident and no injury was found. The Director of Nursing (DON) and CNA J entered the room. CNA I and LPN H placed a sheet under the resident. All four staff members transferred the resident back into bed using the sheet to lift the resident off the floor. No alarm was observed or heard at the time of the fall. During an interview on 12/17/14 at 6:20 A.M., CNA I said the last time he/she checked on the resident was around 4:00 A.M. when he/she turned the resident to the left side and placed a pillow behind him/her. CNA I said the resident did not have an alarm in place at the time of the fall. Observation on 12/17/14 showed the following: -At 6:22 A.M., the resident lay in a low bed on his/her right side. The grab rail was raised on the right side of the bed and a fall mat was on the floor on the left side of the bed. No alarm was observed. The call light was on the floor by the head of the resident's bed out of the resident's reach; -At 6:30 A.M., the resident lay on his/her back. No alarm was observed on the resident's bed and the call light remained on the floor out of the resident's reach. During an interview on 12/17/14 at 6:33 A.M., LPN H said the resident did not have an alarm on his/her bed. The resident had a low bed and a fall mat. The fall mat should be placed on the opposite side of the grab rail. Observation on 12/17/14 at 6:40 A.M. showed the resident's bed alarm was on the floor and not turned on. CNA I attached the alarm to the resident's bed and turned it on. CNA I demonstrated that when the alarm was on, a green light came on on the top of the alarm. During an interview on 12/17/14 at 6:40 A.M., CNA I said the alarm must have fallen off the resident's bed and turned off at some point and the alarm did not sound when the resident rolled out of bed. CNA I said the fall mat should have been on the side of the bed that didn't have the grab rail but he/she had not moved it. CNA I said the resident also rolled out of bed sometime last week. Observation and interview on 12/17/14 at 8:05 A.M. showed CNA K fed the resident breakfast in his/her room. CNA K said he/she was not aware the resident had fallen since his/her return from the hospital on [DATE]. Observation on 12/17/14 at 8:10 A.M. showed the resident had finished eating and remained in bed. The bed was in the lowest position. The fall mat lay at the foot of the bed, not beside the bed. Observation on 12/17/14 at 8:27 A.M. showed the resident remained in bed. The bed was in the lowest position and the bed alarm was attached to the foot of the resident's bed, however, the green light was not on, indicating the alarm was not on. Observation on 12/17/14 at 1:33 P.M. showed the resident sat in the wheelchair at the nurse's station. CNA M and CNA N stood on each side of the resident and transferred him/her with a gait belt from the wheelchair to a recliner in front of the nurse's station. CNA M and CNA K each placed one arm under each of the resident's underarms, grabbed the gait belt around the resident's waist and lifted the resident up under both arms out of the wheelchair. CNA M and CNA K pivoted the resident and sat him/her in the recliner. During an interview on 12/17/14 at 1:35 P.M., CNA M said he/she was taught to place one arm under each of the resident's underarms during a gait belt transfer for support and this was how he/she always performed gait belt transfers. Observation and interview on 12/18/14 at 7:42 A.M., showed the resident was in bed. An alarm was attached to the foot of the resident's bed. The green light on top of the alarm was not on. CMT L verified this meant the alarm was not on. CMT L turned the alarm on and left the room. Observation on 12/18/14 from 8:55 A.M. until 10:30 A.M. showed the resident lay in bed. The bed alarm was on the floor and the alarm was not on. During an interview on 12/18/14 at 10:10 A.M., the DON said Resident #4 had not rolled out of bed prior to the incident on 12/17/14. The resident had been caught by staff on the edge of the bed before he/she rolled out of the bed prior to the fall on 12/17/14. The resident had a bed sensor alarm that he/she was to wear while in bed so staff would be alerted if the resident rolled out of bed. The DON said it was not appropriate or correct procedure for a staff member to place their arms under the resident's underarms during a gait belt transfer. 6. Review of Resident #12's quarterly MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Independent with walking, transfers, and bed mobility; -Required limited assistance of one staff for toilet use, dressing, hygiene, and bathing; -Balance was steady; -Cognition was moderately impaired; -One fall without injury since the last assessment on 6/6/14. Review of the resident's care plan, effective 9/29/14, showed the following: -Problem: Falls; -Goal: Resident will be free from serious injury related to falls; -Interventions: Use appropriate assistive devices. Investigate the cause of the fall immediately. Evaluate patterns of falls. Anticipate the needs of the resident. Provide reality orientation. Use appropriate assistive devices. Ensure proper footwear. Maintain a safe environment free of clutter. Remind him/her to use the walker and assist as needed. Fall score was nine. Review the of resident's nurse's note, dated 10/10/14 at 4:45 A.M., showed the resident was found on the floor in the bathroom. The resident had a raised area on the back of his/her head the size of a ping pong ball. An ice pack was placed on the resident's head and the resident received pain medication and an anti-anxiety medication following the fall. Review of the resident's nurse's note, dated 10/11/14 at 1:56 P.M., showed the resident fell after lunch. The resident was evaluated in the emergency room for a computerized tomography (CT, an X-ray procedure that uses a computer to create three-dimensional images of the internal organs and structure of the body) scan of the head. Review of the resident's nurse's note, dated 11/30/14 at 5:45 A.M., showed the resident was found on his/her stomach on the floor between the bed and the bathroom. The resident said he/she hit his/her head. Bruising was noted on the right frontal region of the resident's face. Review of the resident's medical record showed no evidence staff evaluated the resident's falls on 10/10/14, 10/11/14, and 11/30/14 to determine the cause of the falls or evaluated the effectiveness and modified current interventions to prevent future falls. Review of the resident's fall risk assessment, dated 12/2/14, showed a score of 21, indicating a high risk for falls. Review of the resident's care plan, effective 12/5/14, showed the following: -Problem: Falls; -Goal: Resident will be free from serious injury related to falls; -Interventions: Use appropriate assistive devices. Investigate the cause of the fall immediately. Evaluate patterns of falls. Anticipate the needs of the resident. Provide reality orientation. Use appropriate assistive devices. Ensure proper footwear. Maintain a safe environment free of clutter. Remind him/her to ask for help when getting up at night. Ensure the call bell is in reach at all times. Provide education on safety techniques. (Staff implemented new interventions to remind the resident to ask for help, to ensure the call light was within reach and provided education to the resident related to safety techniques, however, staff evaluated the resident as having moderate cognitive impairment on the 9/6/14 MDS and the resident had a [DIAGNOSES REDACTED].) During an interview on 12/17/14 at 1:30 P.M., CNA Q said the last time the resident fell was a couple of months ago when he/she lost balance and fell while trying to get out of bed. Interventions to prevent falls for residents were passed on in change of shift report. Interventions used to be listed on the resident's care plan before the facility went to computerized charting. CNA Q was not aware of any interventions to prevent falls for the resident. During an interview on 12/18/14 at 9:45 A.M., RN D said Resident #12 was independent with transfers, walking, and dressing. RN D said the resident was confused and had fallen in the past. RN D would have to refer to the resident's care plan to know what interventions were in place to prevent falls for him/her. 7. During an interview on 12/18/14 at 10:10 A.M., the DON said she was not sure what was done for Resident #12 regarding the falls on 10/10/14, 10/11/14 and 11/30/14 and would have to refer to the resident's care plan. When a resident fell , the nurse evaluates the resident at the bedside. If the fall is unwitnessed, staff completed neurological checks and documented this in the nurse's notes. The DON, floor staff, and care plan coordinator discussed falls and interventions that could be put into place at a weekly meeting. The care plan coordinator added falls to the care plan and any new interventions. When a change was put into the care plan, it linked with the CNAs' instructions, and informed them of any changes made. The facility also utilized the consultant pharmacists to see if he/she had any recommendations.

Based on interview and record review, the facility failed to ensure adequate supervision and assistive devices to prevent accidents for one of three sampled residents (Resident #3). The facility census was 95. 1. Record review of Resident #3's Admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/19/12, showed the following: -Moderate cognitive impairment; -Required total assistance for transfers; -Required total assistance in wheelchair; -Required extensive assistance for toilet use; -Had limitation that interfered with daily functions or placed resident at risk of injury on one side of the lower extremities; -Balance was not steady, but able to stabilize without human assistance while moving from a seated to a standing position, walking, turning around and facing the opposite direction while walking, moving on and off toilet, and a surface to surface transfer (transfer between bed and chair or wheelchair); -Had a fall within in the last month prior to admission; -Had a fall within the last 2-6 months prior to admission; -Had a fracture related to a fall within the last 6 months prior to admission. Record review of Resident #3's physician's orders [REDACTED]. -Dementia; -Urinary tract infection; -History of Left knee surgery. Record review of Resident #3's Admission Evaluation and Interim Care Plan, dated 4/12/12, showed the following: -Nursing Admission History section: Resident stated reason for admission: for my hip to heal; -Resident Status section: Neurological: Left broken hip. Record review of Resident #3's Admission Evaluation and Interim Care Plan, Section C, Screen for Fall Risk dated 4/12/12 showed the following: -During the last 90 days the resident had 1-2 falls; -Resident had cognitive status changes in the last 90 days; -Resident displayed any of the following behaviors: easily distracted, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental function varies over the course of the day, wanders, abusive and resists care; -Resident needed elimination with assistance; -Resident ambulated with problems and with devices (gait was unsteady, slow, lurching); -Resident's balance while standing, sitting and during transitions was not steady, could only stabilize with physical assistance; -Resident had Less than 20 millimeters of mercury (mmHg) drop in blood pressure while lying, sitting and 1-3 minutes after standing; -Resident was [AGE] years or older, a "95" is indicated; -Resident had neuromuscular function and orthopedic health conditions; -Resident took 1-2 of the medications indicated to put at risk for falls currently or within the last 7 days; -Total score 22; -A resident who scores a 10 or higher is at risk for falls. Consider ENVIRONMENTAL RISK factors in resident's interventions. Record review of Resident #3's Care Plan, dated 4/12/12, showed the following: -PROBLEM: Is at risk for falls related to: fell in past 30 days, use of antipsychotic drug, and gait disturbance; -GOAL & TARGET DATE: "blank space" will be free from serious injury related to fall through "blank space," no target date specified; -6/13/12-Resident #3 tipped over recliner leaning forward-needs to be monitored close if feet are elevated in recliner. Keep tabs on; -Ensure balance in wheelchair, as needed; -Assist in transfers "blank" (no indication of how much assistance is needed); -Appropriate call light available; -Assist with mobility "blank" (no indication of how much assistance is needed); -Encourage rest periods to avoid overtiring; -Gather and document information if resident does fall per protocol (if hit head follow protocol); -Gait belt per protocol; -Wheelchair (transport, dining room, "blank space" ); -Institute fall prevention program; -Evaluate need for bed alarm "blank,"chair alarm "blank," tab alarm "blank " (no indication of what alarm, if any, was used); -Notify rehab for possible assessment; -Pharmacy consult to be notified if 3 or more falls in one month by LPN or RN Supervisor. Fall Committee to be notified each time a fall by ADON/DON, then Fall Committee to notify therapist for screening; -Given medications as ordered; -Monitor for signs and symptoms of side effects or adverse reactions; -Obtain labs as ordered; -Monitor blood pressure weekly & as needed; -Monitor for decline in cognitive status; -AIM every six months for antipsychotics; -Fall assessment every three months and as needed; -Pharmacist to review medications monthly; -Notify MD if problem arises. Record review of facility's "Incidents Without Details and Interventions by Date," dated 7/9/12, showed the following for Resident #3: -5/9/12, 8:10 P.M.,. fell in resident room while ambulating, no injury; -5/22/12, 9:10 P.M., fell in commons area, sitting in wheelchair, with injury; -5/29/12, 8:20 P.M., fell in commons area, "other" (for activity at the time), with injury; -6/13/12, 7:35 P.M., fell in commons area, reaching, no injury. Record review of the facility's Nursing Service Policy for reporting accidents/incidents involving residents dated 2/10/11, showed the following: -8. After a fall, the licensed personnel shall assess and document resident(s) condition in the medical record on each shift following the occurrence for a minimum of 72 hours. Complete the fall assessment sheet in the medical record. Policy #2-6.4; -9. Licensed personnel responsible for the resident(s) at the time of discovery/report of occurrences are required to initiate the incident/accident report. If the cause is unknown then the licensed personnel will begin the investigation by completing the accident/injury report along with the unknown cause form policy #2-6.3. They will investigate and document the circumstances surrounding the occurrence. Document any interventions completed at that time. Use both forms if unknown. (Review of Policy #2-6.3 and #2-6.4 showed the same document).; -10. After the above report is complete it will be turned into your unit supervisor; -11. The unit supervisor will complete her investigation and forward to the Director of Nursing. The nursing office will provide the needed departments with the information to assist with correction of issue. Such as Rehab and Care Plans for input; -Falls: Follow up to be done on all falls, send to the Attending Physician's office (this will be done by the clinical supervisors during business hours.) Copy of the incident report or cover page that explains the events that occurred with the fall a. Fall assessment sheet, b. POS and a copy of the Post fall Physician order [REDACTED]. Record review of Resident #3's Nurse's Notes, dated 5/9/12 at 8:10 P.M., showed the following: -Resident found in room sitting on floor at foot of bed. States he/she was going to clean out his/her drawers. Resident removed tab alarm (Fall/Restraint Committee's Falls: Analysis Log indicated alarm was intervention for fall on 5/22/12). Record review of Resident #3's Fall Assessment (done with each fall and reviewed by the Fall Committee) dated 5/9/12, showed this fall followed a similar pattern to resident's previous fall and no suggestions made to prevent further falls. Record review of Resident #3's post fall Physician order [REDACTED]. -No new medication adjustments indicated; -Nursing to assess/modify the room environment and make recommendations to physician if necessary; -Provide education/information to family and or staff involved to prevent a repeat occurrence where possible. Record review of Resident #3's Nurses Notes, dated 5/22/12 at 9:10 P.M., showed the following: -Resident attempted to stand from wheelchair in TV area by nurse's station, lost balance, fell to floor on right side. Resident assessed, assisted by this nurse and two staff to wheelchair. Noted 0.5 cm laceration to right eyebrow area. No edema, no drainage noted. Triple antibiotic ointment/band applied, ice pack. Record review of Resident #3's Nurses Notes dated 5/29/12 at 8:20 P.M., showed ran to nurses station due to screaming. Noted witnessing resident scream for help. Noted resident laid flat on back on floor, small amount of blood behind back on head. Resident complained of back and rib pain. C-spine held, sent aide for med nurse. Towel slid under head, two towels rolled up beside head held neck in place. Resident was able to move arms and legs as normal. Record review of Resident #3's Accident and Incident Report for fall on 5/29/12 (dated 5/30/12), showed that resident was sitting in recliner at nurse's station with tab alarm on. Resident removed tab, got up with feet of recliner still up. fell flat onto back. Record review of Resident #3's Nurses Notes, dated 5/29/12 at 8:27 P.M., showed 911 called. Notified of injuries. Record review of Resident #3's Nurses Notes, dated 5/29/12 at 8:30 P.M., showed paged physician. Record review of Resident #3's Nurses Notes, dated 5/29/12 at 8:40 P.M., showed physician ordered send to ER for evaluation and treatment. EMS arrived, assessed spine then back of head. Resident placed on back board. Record review of Resident #3's Fall Assessment (done with each fall and reviewed by the Fall Committee), dated 5/29/12, showed this fall followed a similar pattern to resident's previous fall and no suggestions made to prevent further falls. Record review of Resident #3's Emergency Physician Record, dated 5/29/12, showed the following: -Physical exam: abrasion, soft tissue swelling. (A diagram of the back of the head was shown with three horizontal lines drawn to indicate location); -Procedures: 2 cm, linear wound to the scalp repaired with three staples. Record review of Resident #3's Nurses Notes, dated 6/13/12 at 7:35 P.M., showed the resident in recliner at nursing lobby area. Resident leaned forward, tipped recliner over with foot rest out. Resident provided one on one until tired out. During an interview on 7/9/12 at 11:40 A.M., Licensed Practical Nurse (LPN) B said that when a resident falls the following should be done: -Assess the situation: what happened, any witnesses, how was he/she laying; -A full nursing assessment, vital signs, range of motion of extremities, ask the resident what happened; -Incident report; -Fall assessment; -Fax notification to the physician; -Neurological checks if he/she hit his/her head. During an interview on 7/9/12 at 11:40 A.M., LPN B said the following: -The fall assessment helped identify possible triggers, such as medications, which may have contributed to the fall and to identify patterns for possible change of care; -LPN C, the clinical supervisor (on the Fall/Restraint Committee), reviewed the fall assessments to try to revise care plan. During an interview on 7/9/12 at 12:00 P.M., the MDS Coordinator said he/she updates the care plan: -If there is a change in condition; -Each time a resident falls; -"We" have to update each time a resident falls; -He/she was just now working on January ' s assessments. During an interview on 7/9/12 at 1:00 P.M., the Director of Nursing (DON) said the system for falls was as follows: -The nurse filled out the incident report and gave to the unit supervisor and the unit supervisor investigated; -DON received a copy; -Clinical supervisor notified the physician the next morning, received new orders, if any, and then gave to staff; -Incident report also went to care plans and to rehab; -Rehab Director and Fall/Restraint Committee reviewed all falls once a week; -Rehab Director made recommendations; -Fall assessments completed with each fall and re-assessed three days after the fall and kept in the nurses notes; -Each incident should be noted on the care plan with a new intervention. Record review of Resident #3's medical chart showed the following: -No fall assessment or re-assessment three days after fall completed for falls on 5/22/12 and 6/13/12; -No re-assessment three days after fall completed on fall assessment dated [DATE]. Record review of Resident #3's Care Plan, dated 4/12/12, showed no entry nor new interventions for the falls dated 5/9/12, 5/22/12, and 5/29/12. During an interview on 7/9/12 at 1:50 P.M., Certified Nursing Assistant (CNA) D said the following: -He/she knew how to take care of Resident #3 from getting report and looking at the care plan; -CNAs didn't have time to read the care plans. During an interview on 7/9/12 at 1:50 P.M., CNA E said the following: -When a resident fell , he/she was told that a resident fell and how the resident fell ; -Instructed to take another person to give cares for resident and to be careful; -No one mentioned new interventions for each fall; -A lot of falls occurred on 3-11 shifts. Record review of facility's Falls/Restraint Committee Meeting minutes, dated 5/31/12, showed the following: -On 5/29/12, no report given Resident #3 fell ; -Falls: Analysis Log with entry of Resident #3, 5/22/12 at 9:10 P.M., laceration right eyebrow area, attempted to get up from wheelchair, lost balance-fell . Intervention-applied chair alarm.; -Entry of Resident #3, 6/13/12 at 7:35 P.M., no injury, sat in recliner-leaned forward, tipped over on right side. Intervention-monitor close when legs are elevated in recliner. Keep tabs on. Items close by her.; -No entry or intervention noted on log for fall on 5/9/12; -No entry or intervention noted on log for fall on 5/29/12. During an interview on 7/9/12 at 2:00 P.M., the Rehab Director said the following: -Analysis Log has resident's name, noted date and time of fall, possible causes of fall, and an intervention; -Interventions entered on care plan the same day committee met and discussed; -Resident #3 had been discussed at weekly committee meetings; -Did not receive an incident report for 5/9/12 or 5/29/12 for Resident #3; -Entry for 5/22/12 was not on care plan because he/she must ' ve missed it; -Heard "through the grapevine" that Resident #3 fell on [DATE]; -He/she should've followed up when he/she did not receive the report for the falls on 5/9/12 and 5/29/12; -As long as new interventions were in the care plan, the CNAs were supposed to look at it. During an interview on 7/9/12 at 2:20 P.M., Registered Nurse (RN) A said the following: -The Fall/Restraint committee meeting was every Thursday at 2:00 P.M.; -Interdisciplinary team discussed as a group to identify problems with interventions and figured out new interventions; -DON gave incident reports to LPN C for notifying the physician; -Then LPN C gave it back to DON to give to Rehab Director for Fall/Restraint Committee meeting. During an interview on 7/11/12 at 10:30 A.M., the DON said the following: -He/she was not on the Fall/Restraint Committee, so he/she didn't know what the objective of the committee and meetings; -To the best of his/her knowledge, the unit supervisors were part of the meeting and communicated new interventions to direct care staff. During an interview on 7/11/12 at 10:30 A.M., RN A said the following: -Objective of Fall/Restraint Committee meetings was to see what we can do to prevent falls and if committee couldn't prevent the falls, then to prevent injury; -At the meeting, information written in care plans; -Someone from each department came to the meeting and then went back and relayed information to the respective department; -There was a DON Report at nurses station where meeting information was put in and passed to each shift. During an interview on 7/11/12 at 2:35 P.M., the Rehab Director said the objective of Fall/Restraint Committee was to prevent residents from falling and getting hurt and to come up with interventions. Record review of Fall/Restraint Committee dated 5/31/12, showed the following: -Falls reported this week (followed by a list of residents who fell with notation of "no incident report submitted"); -Written below the end of the list: "Requested from DON." During an interview on 7/11/12 at 2:35 P.M., the Rehab Director said the following: -He/she requested the incident report for the 5/29/12 fall; -He/she requested the report after that meeting on 5/31/12; -Committee looked at times and residents to determine if falls are at certain times and things like that; -Committee monitored effectiveness of intervention by watching resident and discussed at the next week's meeting and if the nurse or nurses aides notified committee; -Ineffective interventions were modified at that next week's meeting. During an interview on 7/12/12 at 3:30 P.M., the DON said the following: -He/she didn't know what the "fall prevention program" was (as indicated as an intervention on Resident #3's care plan); -He/she didn't know if there was a written program known as the fall prevention program other than the fall risk assessment; -If a resident falls then he/she would be evaluated for special devices (for example, cushions for chairs for positioning if resident slipped and fell out of wheelchair) and his/her living area for possible modifications; -A pharmacy consult was a form that is faxed to the pharmacist for possible medication adjustments if a resident had three or more falls in one month (as indicated as an intervention on Resident #3's care plan); -A post fall physician's orders [REDACTED]. Record review of Resident #3's medical record showed no Post fall Physician order [REDACTED]. Record review of Resident #3's medical chart showed no pharmacy consultation for the fall on 5/29/12, which was his/her third fall in one month. During an interview on 7/13/12 at 1:00 P.M., the Rehab Director said the following: -On 5/31/12, he/she requested the incident reports for the reported falls with no report (as indicated on the Fall/Restraint Committee meeting notes dated 5/31/12) from the DON; -The DON said he/she would get them to the Rehab Director; -He/she never received the incident reports from the DON; -He/she didn't remind the DON regarding needing those reports. During an interview on 7/13/12 at 1:40 P.M., the DON said that he/she didn't remember the Rehab Director asking for the incident reports not received for the Fall/Restraint Committee meeting on 5/31/12. During an interview on 7/13/12 at 2:15 P.M., the DON said he/she signed the incident reports, made copies to give to clinical supervisor, Rehab Director and MDS Coordinator. He/she is not sure what happened in regards to Rehab Director not receiving a copy of the needed incident reports.

Based on observation, interview, and record review, the facility failed to have a system in place to monitor bed alarm functioning for 38 of 38 bed alarms in use for residents with a history of falls resulting in one resident (Resident #1), of three residents sampled, falling to the floor from the bed without the bed alarm sounding until approximately 5-10 minutes after staff found the resident on the floor. When staff found the resident he/she presented with a laceration to the head, in an unresponsive state, and choking on vomit/blood. Another resident (Resident #2), with a history of falls was observed in bed with a non-functioning bed alarm. The facility census was 99. 1. Review of Resident #1's 09/01/10 through 09/30/10 physician's orders [REDACTED]. Review of the resident's nurse's notes dated 06/12/10 at 8:00 P.M. showed the following: -The resident was yelling and said he/she fell on the floor and bumped his/her head while trying to go to the bathroom. Review of the resident's fall assessment dated [DATE] showed the resident had a history of [REDACTED]. Review of the resident's fall risk assessment dated [DATE] showed the resident scored 17 (10 or greater equals a high risk). Review of the resident's nurse's notes dated 07/31/10 at 4:00 A.M. showed the following: -The resident had been awake all night, attempting to get out of bed to go to the bathroom; -Staff assisted the resident out of bed several times. Review of the resident's annual minimum data set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated 08/07/10 showed the resident presented with the following: -Memory problems; -Moderately impaired cognition; -Periods of restlessness; -Wandering; -Resisted care; -Unsteady gait; -Required extensive assistance of two persons for transfers, walking, and toilet use; -Unable to attempt balance while standing without physical help. Review of the resident's RAP's (resident assessment protocol) for falls dated 08/09/10 showed the following: -The resident had fallen in the past 31-180 days; -The resident had a [DIAGNOSES REDACTED]. -The resident made poor choices and forgot he/she could not walk without assistance; -The resident needed cueing and reminding. Review of the resident's care plan on 06/18/10 and 08/10 (no year documented) showed the following approaches: -The resident fell on [DATE] at 11:15 P.M. crawling out of bed; -Offer to toilet, drink, reposition; - Offer back rub; -The resident forgets he/she can't walk; -When in recliner, keep in staff sight; -Transfer and walk with assistance of two and a gait belt; -Keep bed at lowest level at night and during naps/resting time to maintain safety; -Tabs monitor at all times; -Bed alarms as needed to maintain safety. Review of the resident's nurse's notes dated 09/11/10 showed the following: -At 9:15 P.M., staff found the resident on the floor at the foot of the bed; -The resident had a head wound on the right side of the head with a copious (large) amount of blood; -The resident was laying on his/her stomach, and was non-responsive with a moderate amount of vomiting; -At 9:20 P.M., Licensed Practical Nurse (LPN) C called the Registered Nurse (RN) (registered nurse) on call; -LPN C then called the physician on call with orders to send the resident to the emergency room ; -At 9:25 P.M., the resident remained non-responsive; -LPN C called the 911 operator; -At 9:30 P.M., the ambulance arrived; -At 9:45 P.M., the first responders were called; -The resident remained non-responsive with vomiting; -At 10:30 P.M., the ambulance left facility with the resident. During interview on 09/13/10 at 10:15 A.M. and 10:20 A.M., the Director of Nursing (DON) said the following: -The resident had fallen over the weekend; -Staff found the resident laying in the floor; -The resident was unresponsive and had lacerations on both sides of his/her head; -Staff found the resident's tabs monitor in the middle of the bed (where the resident had removed); -The resident's bed alarm (sentry) did not sound. During interview on 09/13/10 at 3:10 P.M., Certified Nurse Aide (CNA) A said the following: -On 09/11/10, CNA A got the resident ready for bed; -CNA A turned the resident's bed alarm on and placed a tab alarm on the resident; -15 minutes later, the resident's alarm went off; -CNA A went into the resident's room, and found the resident sitting on the edge of the bed; -The resident said he/she needed to go to the bathroom; -CNA A took the resident to the bathroom, then assisted him/her back into bed; -Between 9:10 and 9:15 P.M., CNA A came around the corner and saw CNA B down by the resident's room; -CNA B said the resident was on the floor; -CNA B was yelling for the nurse (LPN C); -CNA A entered the room and saw the resident laying on the floor on his/her stomach at the foot of the bed; -The resident was laying with the left side of his/her face on the floor; -There was a lot of blood on the floor; -The resident was not saying anything; -The nurse ran to call the physician; -CNA A and CNA B put towels on the floor; -The resident vomited a pretty good amount; -The resident's face was in the vomit; -CNA A wiped the vomit away from the resident; -CNA A did not move the resident; -The nurse told staff not to move the resident; -CNA A did not hear the resident's alarm sound before finding the resident in the floor; -The resident had removed his/her tab alarm (found laying in the bed); -The bed alarm sounded after the resident was found in the floor; -CNA A had been taught how to inflate the air mattress on the bed alarm (sentry), -CNA A did not check the dial of the bed alarm for seconds setting (time), after placing the resident in bed. Review of a written statement by CNA A dated 09/13/10 showed the following: -On 09/11/10 at 8:30 P.M., CNA A put the resident to bed; -CNA A turned the resident's bed alarm on and attached a tab alarm to the resident shirt; -Later, CNA A came around the corner (in the hall) and the resident's call light was on; -CNA B told CNA A that the resident was on the floor; -CNA A yelled for the nurse; -CNA A and CNA B were both in the resident's room when the resident's bed alarm (sentry) went off. During interview on 09/13/10 at 3:15 P.M., CNA B said the following: -On 09/11/10 between 9:00 P.M. to 9:05 P.M., CNA B went to put a resident to bed down the hall from Resident #1; -Between 9:15 P.M. to 9:20 P.M., CNA B was walking back up the hall and heard a slight moaning/gurgling sound; -CNA B looked in Resident #1's room and all he/she saw was the resident's feet; -CNA B turned the light on in the resident's room and saw the resident laying on the floor; -CNA B turned on the resident's call light; -The resident's bed alarm (sentry) was not sounding; -CNA B waited for one to two minutes, then began hollering for help; -CNA A came down and yelled up the hall to another CNA to get the nurse and come to the resident's room quick; -The other CNA came down to the room with towels; -The resident was choking on his/her own blood; -Staff tried to get some of the blood away from the resident's mouth to stop the resident from choking; -Staff applied cold wash clothes to the resident head wound to stop the bleeding; -After CNA B had been in the resident's room for 5-10 minutes, the bed alarm began sounding; -CNA A got up to turn off the alarm; -The nurse came down and checked the resident's vital signs; -The nurse had a hard time getting the vital signs (hard to hear); -The nurse left and went back up front to call the physician; -The resident started vomiting; -The resident was laying on his/her stomach with the left side of his/her face on the floor; -CNA B kept trying to wipe the vomit with towels; -The resident kept choking on the vomit; -Staff did not move the resident at all; -The resident kept gurgling/moaning; -CNA B kept calling the resident by name, but the resident did not answer; -A lot of the alarms malfunction, so staff put a tab alarm on the residents. Review of a written statement by CNA B dated 09/13/10 showed the following: -CNA B had put another resident to bed, and was walking back up the hall when he/she heard a moaning/gurgling sound; -CNA B started checking resident rooms; -When CNA B got to the resident's room, CNA B saw the resident's feet; -CNA B turned on the light; -No alarms were sounding; -The resident was laying on the floor on his/her stomach with his/her face toward the window; -CNA B ran over and pushed the call light; -CNA B waited a minute or two, then yelled for help; -CNA A was the first to come; -CNA A yelled back up the hall to another CNA (CNA E) to get the nurse and tell the nurse to come quick; -CNA E brought towels down and CNA A and CNA B started placing the towels by the resident's mouth; -CNA B went to the sink to get cold towels to clot the blood, and the bed alarm went off; -CNA A got up and turned the bed alarm off; -The nurse came down and staff began taking the resident's vital signs; -The nurse went back up the hall to call the RN and physician. During interview on 09/14/10 at 2:00 P.M., LPN C said the following: -On 09/11/10 about 9:00 P.M., LPN C was in the medication room finishing up the night time medication pass; -LPN C heard someone yelling, and stepped out to see what was going on; -Staff yelled for LPN C to come to the resident's room; -LPN C went to the resident's room, and saw the resident laying on the floor in a pool of blood; -The resident was laying on his/her stomach with his/her head to the left side; -LPN C could see the resident had a head injury on the right side of the head, but he/she did not move the resident to assess the injury; -LPN C knew it was a bad head injury as the resident was unresponsive; -LPN C checked the resident's vital signs, then went to the nurse's station to call the nurse on-call to get permission to contact the physician. Review of a written statement by LPN C dated 09/23/10 showed the following: -On 09/11/10 at approximately 9:10 P.M., LPN C was in the medication room; -LPN C heard staff yell for help, and saw CNA B standing in the resident's doorway; -LPN C went to the resident's room, and saw the resident laying on his/her stomach on the floor at the foot of the bed; -The resident's head was turned to the left side; -LPN C observed the resident had a gash on the right side of his/her head with a large amount of blood; -The resident was non-responsive; -LPN C checked the resident's vital signs and told the CNA to put a cool compress on the resident's head to stop the bleeding; -At 9:15 P.M., LPN C called the RN on-call, then contacted the local hospital to speak with the on-call physician. Review of the resident's Missouri Ambulance Reporting Form dated 09/11/10 showed the following: -Upon arrival, the ambulance staff found the resident laying face down with a large amount of vomit next to and under the resident; -The resident had lacerations on both temples; -The resident was sucking vomit into his/her airway with inhalation; -The resident had a moderate amount of blood that appeared somewhat dry and matted into his/her hair and the floor; -The resident was having some difficulty holding his/her own airway due to all the vomit in the airway; -The resident required upper airway suctioning, ventilation assistance, and endotracheal intubation. Review of the resident's regional hospital emergency department assessment dated [DATE] showed the following: -Resident assessed with [REDACTED]. The wound was closed with seven staples. During interview on 9/14/10 at 3:30 P.M. the resident's attending physician said the resident had a massive bleed from chronic diagnoses. The bleed was not the type of bleed associated with a fall, (the resident did have a laceration on the head from the fall). 2. Review of Resident #2's 09/01/10 through 09/30/10 physician's orders [REDACTED]. -The resident had [DIAGNOSES REDACTED]. Review of the resident's fall risk assessment dated [DATE] showed the resident scored 12 (10 or greater equals high risk). Review of the resident's annual minimum data set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated 06/21/10 showed the facility assessed the resident with the following: -Memory problems; -Moderately impaired cognition; -Wandering; -Repetitive physical movements; -Syncope (fainting); -Total dependance of two persons for transfers; -Total dependance of one person for toileting; -Unable to attempt balance while standing without physical help. Review of the resident's nurse's notes dated 07/24/10 through 08/26/10 showed the following: -On 07/24/10 at 4:10 A.M., staff found the resident laying face down on a mat (on the floor beside the bed); -Resident appeared to have rolled out of bed; -The resident's face was on the floor; -The resident complained of a small amount of pain in the right shoulder; -The resident had a broken nail on the right middle finger and a small amount of blood on the right first finger; -On 08/26/10 at 8:40 P.M., staff found the resident laying on his/her stomach on the floor; -Staff observed a moderate amount of blood coming from the resident's nose; -The resident complained of nose pain; -Staff observed a 1 1/2 centimeter cut on the bridge of the resident's nose with swelling. Review of the resident's fall assessment dated [DATE] showed the resident had a history of [REDACTED]. Review of the resident's care plan dated 06/23/10 showed the following approaches: -Keep bed at lowest level at night and during naps/resting time to maintain safety; -When up in a chair, keep within sight for supervision; -Use of tabs monitors and bed alarms for safety at all times. Observation of the resident on 09/13/10 at 2:30 P.M. showed the following: -Resident laying in bed; -Bed alarm (sentry) attached to the head of the bed; -The alarm was not on; -CNA D came in the room and checked the resident's alarm. During interview on 09/13/10 at 2:30 P.M., CNA D said the following: -The resident's bed alarm was not working; -He/She would have to notify maintenance to check the alarm; -The facility had problems with the bed alarms not functioning at times. During interview on 09/13/10 at 2:45 P.M., the DON said the following: -The facility sometimes had problems with the bed alarms; -Staff would report the problems and maintenance would check it out. During interview on 9/13/10 at 3:35 P.M. the DON said three of the bed (sentry) alarms, including Resident #2's, had been identified as not functioning (on 9/13/10), and had been repaired on 9/13/10. During interview on 09/14/10 at 11:20 A.M., the maintenance supervisor said the following: -The sentry alarms (bed alarms) work off an air-mattress; -There have been a lot of problems with the sentry alarms; -Some staff turn in a work order when an alarm is not working; -When maintenance checks the alarms usually the alarms are not working because the alarms are not plugged in; -Maintenance staff had not been doing a routine check on the alarms; -Maintenance staff only checked the alarms that were reported not working; -The dial (sensitivity adjustment) at the top of the alarm can be set from 1-6 seconds; -The maintenance supervisor would prefer staff set the dial at 0-1 seconds because six seconds is a long time; -An individual could be all the way off the bed before the alarm sounded; -The alarm will not sound until the individual is off the air mattress portion of the mattress. Review of the instructions for the use of the sentry bed alarm/Universal Medical Products, Inc (not dated) showed the following: -The time delay before the alarm sounds can be changed by resetting the sensitivity adjustment; -The delay can range from 0-6 seconds; -The usual setting is 2-3 seconds; -For maximum sensitivity (no delay in sounding the alarm), set the dial at 0 seconds. Complaint #MO and