Every finding on record at Marymount Manor

Based on interview and record review, the facility failed to ensure residents with pressure ulcers (injuries to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) received assessment, care, and treatment in accordance with their policy for one resident (Resident #1) who developed a new pressure ulcer at the facility. On 04/05/26, staff identified an open area to the resident's gluteal fold. Staff failed to document physician orders for barrier cream on the resident's treatment administration record (TAR) and failed to administer the treatment. Staff failed to complete skin assessments on a weekly basis, as ordered by the physician. On 07/03/26, the resident was identified as having unstageable pressure ulcers (slough (dead tissue) present, the actual base and condition of the ulcer cannot be determined) to his/her buttocks. The resident's pressure ulcers worsened and on 07/14/26, he/she was unresponsive and sent to the hospital, where he/she was diagnosed with septic shock (severe blood infection associated with low blood pressure), vertebral osteomyelitis (bone infection), and an enterocutaneous fistula (abnormal tunnel connecting the gastrointestinal tract to the skin). The sample was 6. The census was 78. The Administrator was notified on 08/04/26 at 1:05 P.M. of an Immediate Jeopardy (IJ) which began on 07/01/26. The IJ was removed on 08/04/26, as confirmed by surveyor onsite verification. Review of the facility's Pressure Ulcer: Prevention and Findings Reporting policy, undated, showed the following:-Purpose: To prevent pressure ulcers by identifying residents at risk;-Policy and Procedure:--The Certified Nurse Aide (CNA) is to observe and report any areas of change in appearance on the skin during routine care and during the resident showers (the CNA must document on the shower sheet, sign and have the charge nurse and review). Report to charge nurse for further assessment and follow-up;--The charge nurse is to do a skin assessment at least weekly (during routine care and showers);--The charge nurse will complete an initial approximate measure and description of the wound in the nurse's notes;--If there is a need for treatment, the charge nurse and or the wound nurse will phone the physician and implement the order as described;--The treatment will be placed on the TAR (treatment administrator record) at the time the physician order is executed;--The wound nurse will assess the area of concern and will review the physician's order for any details that might need to be described further or the need to be followed by Wound Care Nurse Practitioner (NP);--The wound nurse will confirm and document wound care in a nurse's note. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/09/26, showed:-Diagnoses included high blood pressure, Alzheimer's disease, dementia, and Parkinson's disease (nervous system disorder affecting movement);-Dependent on staff assistance with toileting and showering/bathing;-At risk for developing pressure ulcers;-No pressure ulcers at the time of assessment. Review of the resident's nurse's notes, showed:-On 04/05/26, staff reported the resident had an open area to his/her gluteal fold. Measured approximately 1.75 centimeters (cm) by (x) 1.5 cm. Resident clean and dry. Placed on a disposable incontinent pad. Remains on an air mattress. Staff encouraged to turn and position every two hours. Resident encouraged to reposition self as needed. Will continue to monitor;-No documentation the physician was notified of the wound noted on 04/05/26 or that a treatment was obtained;-No further documentation in the nurse's notes regarding the resident's wound until 05/06/26. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 04/06/26, showed the following:-Front of diagram: Blank;-Rear of diagram: Circle drawn on right buttock;-Intervention: Blank. Review of the resident's physician order sheet (POS), dated April 2026, showed a physician order, dated 04/18/26 for Wound Consult to eval and treat as needed. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 04/20/26, showed the following:-Front of diagram: Blank;-Rear of diagram: Resolved, written on right buttock. Review of the resident's POS, dated April 2026, showed:-A physician order, dated 04/23/26, to complete head to toe skin assessment every Thursday on the skin data sheet;-No documentation for treatment to the resident's buttocks. Review of the resident's TAR, dated 04/01/26 through 04/30/26, showed the following:-A physician order, dated 04/23/26, to complete a head-to-toe assessment every Thursday on dayshift. Document on skin data sheet. Any new skin issues are to be measured and put into the nurses note with a detailed description. Do not stage wound. Notify administration on physician messaging system;--Staff documented assessment as complete on 04/23/26. Review of the resident's skin data sheet, dated 04/23/26, showed the following:-Skin: Skin color normal;-Rash/Redness: Yes;-Location of Rash/Redness: Buttocks;-Wound: Yes;-Location of wound: Buttocks. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 04/30/26, showed the following:-Front of diagram: Blank;-Rear of diagram: Blank. Review of the resident's medical record, showed no documentation of a Wound Care consult completed in April 2026 or May 2026. Review of the resident's skin data sheet, dated 05/01/26, showed the following:-Skin: Skin color normal;-Rash/Redness: No;-Wound: No. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 05/04/26, showed the following:-Front of diagram: Blank;-Rear of diagram: Blank. Review of the resident's nurse's notes, showed:-On 05/06/26 at 4:36 A.M., during rounds, noted two broken skin areas on the right buttock. No drainage or smell. Areas were red. Measured: 0.5 cm x 0.5 cm x 1.0 cm for both areas. Staging to be determined by Wound Care nurse. Remains on two hourly turning and pressure ulcer care;-No further documentation in the nurse's notes regarding the pressure ulcers until 07/03/26. Review of the facility's physician messaging system notes, dated 05/06/26, showed staff messaged the physician that during rounds, the resident was noted to have two broken skin areas on the right buttocks. Both areas measured 0.5 cm x 0.5 cm x 1.0 cm. Staging will be determined by the wound nurse. The physician asked if there was a lot of drainage. Staff responded there was no drainage. No documentation regarding a treatment order. Review of the resident's medical record, showed no skin data sheet completed as scheduled on 05/07/26. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 05/11/26, showed the following:-Front of diagram: Blank;-Rear of diagram: Circle on the right buttock with Two small spots, written on the diagram;-Intervention: Blank. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 05/14/26, showed the following:-Front of diagram: Blank;-Rear of diagram: Circle on the right buttock with One small spot, written on the diagram;-Intervention: Blank. Review of the resident's medical record, showed no skin data sheet completed as scheduled on 05/14/26. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 05/18/26, showed the following:-Front of diagram: Blank;-Rear of diagram: Circles on the left and right buttock with Small wound on bottom, written on the diagram;-Intervention: Blank. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 05/21/26, showed the following:-Front of diagram: Blank;-Rear of diagram: Resolved, written on the diagram;-Intervention: Blank. Review of the resident's skin data sheet, dated 05/21/26, showed the following:-Skin: Skin color normal;-Rash/Redness: No;-Wound: No. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 05/28/26, showed the following:-Front of diagram: Blank;-Rear of diagram: Blank;-Intervention: Blank. Review of the resident's skin data sheet, dated 05/28/26, showed the following:-Skin: Skin color normal;-Rash/Redness: No;-Wound: No. Review of the resident's TAR, dated 05/01/26 through 05/31/26, showed the following:-A physician order, dated 04/23/26, to complete a head-to-toe assessment every Thursday on dayshift. Document on skin data sheet. Any new skin issues are to be measured and put into the nurses note with a detailed description. Do not stage wound. Notify administration on physician messaging system;--Staff documented assessments as complete on 05/07/26, 05/14/26, 05/21/26, and 05/28/26. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Required total staff assistance for bathing and toileting;-Required moderate staff assistance for toileting, bathing, personal hygiene;-At risk of developing pressure ulcers;-No pressure ulcers present at the time of assessment. Review of the facility's Wound Report, dated 05/01/26 through 05/31/26, showed no documentation regarding a wound to the resident's buttocks. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 06/01/26, showed the following:-Bed bath written on sheet;-Front of diagram: Blank;-Rear of diagram: Blank;-Intervention: Blank. Review of the resident's skin data sheet, dated 06/04/26, showed the following:-Skin: Skin color normal;-Rash/Redness: No;-Wound: No. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 06/09/26, showed the following:-Bed bath written on sheet;-Front of diagram: Blank;-Rear of diagram: Blank;-Intervention: Blank. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 06/11/26, showed the following:- All good written on sheet;-Front of diagram: Blank;-Rear of diagram: Blank;-Intervention: Blank. Review of the resident's skin data sheet, dated 06/11/26, showed the following:-Skin: Skin color normal;-Rash/Redness: No;-Wound: No. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 06/18/26, showed the following:-Front of diagram: Blank;-Rear of diagram: Blank;-Intervention: Blank. Review of the resident's skin data sheet, dated 06/18/26, showed the following:-Skin: Skin color normal;-Rash/Redness: No;-Wound: No;-No further skin data sheets were completed for the resident. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 06/22/26, showed the following:-Bed bath, no new skin abnormalities;-Front of diagram: Blank;-Rear of diagram: Blank;-Intervention: Blank. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 06/25/26, showed the following:-Front of diagram: Blank;-Rear of diagram: Blank;-Intervention: Blank. Review of the resident's shower sheet, completed by the CNA and signed by the charge nurse, dated 06/29/26, showed the following:-Bed bath;-Front of diagram: Circle on neck with Slight redness, written on diagram;-Rear of diagram: Circle on center of both buttocks with Small scab, written on diagram;-Intervention: Blank. Review of the resident's TAR, dated 06/01/26 through 06/30/26, showed the following:-A physician order, dated 04/23/26, to complete a head-to-toe assessment every Thursday on dayshift. Document on skin data sheet. Any new skin issues are to be measured and put into the nurses note with a detailed description. Do not stage wound. Notify administration on physician messaging system;--Staff documented assessment as complete on 06/04/26, 06/11/26, 06/18/26, and 06/25/26;-No documentation regarding a treatment to the resident's buttocks. Review of the facility's Wound Report, dated 06/01/26 through 06/30/26, showed no documentation regarding a wound to the resident's buttocks. Review of the resident's medical record, showed no documentation of a Wound Care consult completed in June 2026. Review of the facility's physician messaging system note, dated 07/01/26 at 4:34 P.M., showed staff messaged the physician that the resident had scabbed area on his/her right gluteal fold, approximately 1.0 cm x 2.0 cm. Both gluteal folds were red. Applying barrier cream to the areas. The physician texted if staff thought Wound Care needed to see the resident, the physician was fine with that. Review of the resident's POS, dated July 2026, showed a physician order, dated 07/02/26 at 6:22 P.M., to cleanse wound to right buttock with wound cleaner, apply Santyl (a topical prescription ointment used to remove dead tissue) ointment nickel-thick to the wound, apply ABD (large cotton dressing) pad, and tape. Review of the resident's nurse's notes, showed:-On 07/03/26 at 3:15 P.M., resident has a wound to his/her sacral/gluteal fold. Measured 7.3 cm x 3.0 cm along the gluteal fold. Left buttock measured 5.0 cm x 2.0 cm. Both wounds were unstageable. Treatment orders for Santyl daily. Will refer to Wound Care. Air mattress with wedge in place. Reposition every two hours;-No documentation the family was notified of the resident's pressure ulcer. Review of the resident's POS, dated July 2026, showed a physician order, dated 07/03/26 at 10:19 A.M., to apply Santyl at bedtime, to sacral wounds 7.3 cm x 3.0 cm and to left buttock 5.0 cm x 2.0 cm. Review of the facility's physician messaging system notes, showed:-On 07/06/26 at 5:32 A.M., staff messaged the physician that the resident had pain due to pressure ulcer to buttocks. Resident had Tylenol for pain as needed. Asked physician if they could get something stronger while the wound was being treated. The physician asked how big the wound was. Staff responded 7.3 cm x 2.5 cm, he/she would see Wound Care today. The physician asked how deep the wound was, how long the resident had been complaining of pain, and if the pain had gotten worse recently. Staff responded the wound was not deep, just large in length, and the resident's complaint of pain has gotten worse since last night and Tylenol was not helping. The physician said to try ibuprofen every six hours as needed while getting wound care;-On 07/07/26 at 6:17 A.M., staff messaged wound treatment complete. There was hard black eschar (dead tissue) above gluteal fold with foul smell, small red patches on upper gluteal folds, he/she continued with pressure ulcer wound care. Physician responded Wound Care should be addressing this. Review of the resident's nurse's notes, dated 07/07/26, showed the following:-At 10:53 A.M., call placed to responsible party to discuss Wound Care, no answer, message left to return call;-At 11:44 A.M., call placed to the resident's power of attorney (POA) to discuss code status and confirmed consent for Wound Care consult. Wound Care consent faxed to wound company;-At 10:13 P.M., wound swabbed for culture and sensitivity (C&S, diagnostic laboratory test used to identify types of bacteria and to determine types of antibiotic that can be used to treat the bacteria). Review of the resident's wound culture report, dated 07/08/26, showed the resident's lab results showed multiple gram-negative rods (indicative of bacterial infection) and a moderate amount of white blood cells. Review of the resident's POS, dated July 2026, showed a physician order, dated 07/08/26, for doxycycline (a broad-spectrum antibiotic used to treat bacterial infections) 100 milligram (mg) one capsule every 12 hours for 10 days for left buttock wound. Review of the resident's nurse's notes, showed the following:-On 07/12/26 at 2:05 A.M., assessed coccyx/buttock wound. Wound bed: soft black necrotic tissue with active bleeding and foul odor. Wound measurements unable to be obtained due to the extent of necrotic tissue and bleeding. Wound cleansed per facility protocol, sterile dressing applied, and pressure relieving interventions. Remains on doxycycline for wound treatment. Wound consultation pending;-On 07/12/26 at 11:44A.M., out of bed for lunch. Appetite poor. New order labs: complete blood count (CBC, determines general health status and screens for and monitors for a variety of disorders, including anemia) and comprehensive metabolic panel (CMP, measurement of blood sugar, electrolytes, fluid balance, kidney and liver function);-On 07/13/26 at 1:49 P.M., cleaned in bed today, repositioned with edge from side to side. New dressings applied to open areas on sacrum and gluteal folds. Staff reports appetite poor today, drank fluids at breakfast. Refused lunch. Will try again at dinner;-No further documentation whether CBC and CMP lab test were obtained. Review of the resident's Wound Care company notes, dated 07/14/26 at 10:58 A.M., showed the following:-Resident presents today, 07/14/26, for evaluation and treatment of open wound/skin lesion;-Vitals: blood pressure 60/42 (normal blood pressure is 120/80), pulse 100 (normal pulse is 60 to 100), oxygen saturation (O2 Sats) 90%, temperature 98.1 degrees Fahrenheit (F) (normal temperature is 98.6 degrees F);-Focused wound exam #1:--Location: Sacral;--Primary etiology: Pressure;--Pressure ulcer stage: Unstageable;--Wound size: 19.5 cm x 11.5 cm x unable to determine (UTD) cm depth;--Exudate (drainage): Moderate;--Odor: Malodorous (bad, foul or offensive smell);--Wound Bed: 10% granulation tissue (healing tissue), 80% wet stable eschar, 10% slough;--Conclusion: Initial assessment. Order given to send to the emergency department (ER) for evaluation and treatment of irregular pulse rate, unresponsiveness, and deteriorating wound status. Review of the resident's nurse's notes dated 07/14/26, showed:-At 11:02 A.M., vital signs of temperature 98.1 degrees F, pulse 100, respiration 18 (normal is 12 to 20), blood pressure 62/40. Resident was not speaking or opening his/her eyes. Took morning medications, appetite poor, had difficulty swallowing. Order received to send to hospital per outside wound company nurse practitioner;-At 11:21 A.M., sent to hospital. Message left for POA;-At 4:00 P.M., resident seen by Wound Care company this morning. Pressure ulcer measured 19.5 cm x 11.5 cm x UTD. New treatment order to clean pressure ulcer with Dakin's Solution (antiseptic solution made from diluted bleach, baking soda and water), apply betadine (used to clean wounds) moistened gauze, cover with an ABD pad, and secure with tape and as needed. Order was given to send the resident to the hospital. The resident's physician and family were made aware. Review of the resident's hospital record, dated 07/14/26, showed the following:-admitted on [DATE];-Diagnoses of septic shock, acute hypoxemic respiratory failure (lungs are unable to transfer oxygen), enterocutaneous fistula, and vertebral osteomyelitis (serious life threating infection of the spine);-Computed tomography (CT scan, uses a computer that takes data from several X-ray images of structures inside a humans or animals body and converts them into pictures on a monitor) of the chest, abdomen, and pelvis showed osteomyelitis. Impression: Large sacral decubitus (pressure ulcer) with underlying emphysematous osteomyelitis (a very rare and severe bone infection) of the coccyx;-History and physical: Resident presents to the emergency room (ER) unresponsive, nursing home noted resident hadn't eaten in a week, sacral pressure ulcer. Review of the facility's Wound Report, dated 07/01/26 through 07/31/26, showed no documentation regarding a wound to the resident's buttocks. During an interview on 07/31/26 at 11:05 A.M., CNA B said he/she had taken care of the resident. Approximately two months ago, the resident began to decline. He/She was unable to walk, required a Hoyer lift (mechanical device used to transfer dependent resident from bed to wheelchair), and needed to be fed by staff. On 04/06/26, CNA B reported to the Assistant Director of Nurses (ADON) the resident had a small open area to his/her right buttock. The ADON applied barrier cream and said he/she was going to put it in the chart and notify the physician via the physician messaging system. The ADON told CNA B to lay the resident down after meals and to apply barrier cream after care. Each time CNA B took care of the resident, he/she saw the wound on the resident's buttocks. There was no dressing on the wound at first, and it began to get bigger and appear dark in color. CNA B reported it to the charge nurses and asked what was going to be done about the resident's wound. The nurses said they were waiting on consent from the family for a Wound Care consult. CNA B was concerned about the resident because the area wasn't getting any better. The resident complained of pain when gotten up in his/her wheelchair. After a while, the wound got so bad the nurses told the CNAs to leave the resident in bed. In late June 2026, the wound was on each side of the resident's buttocks, and it had turned black and had an odor. During an interview on 07/31/26 at 12:17 P.M., CNA C said he/she took care of the resident occasionally when the regular CNA was off. The resident had a wound on his/her buttock, and CNA C would apply barrier cream to the area. One day, he/she was assigned to take care of the resident because his/her regular aide was off. It had been awhile since he/she had seen the resident's buttocks. The wound had gotten much worse since the last time CNA C saw it. The wound was dark, deep, and had an odor. He/She reported it to Licensed Practical Nurse (LPN) K to make sure he/she was aware. LPN K measured it and made the ADON aware. When providing care, CNA C could tell the resident's buttocks hurt. During an interview on 07/31/26 at 12:59 P.M., the ADON said staff reported the pressure ulcer on the resident's buttocks. It was a small, open area with some redness. He instructed the staff to apply barrier cream, to keep the resident turned and positioned, and to lay the resident down after meals. The facility's policy is when a wound is found, the nurse is to measure the wound, and to notify the physician and family. The nurse would suggest a treatment to the physician, who would agree or change the treatment. The nurses wrote the treatment orders and documented them on the TAR and in the nurse's note. During an interview on 08/03/26 at 8:49 A.M., the Administrator said the DON was off work at the time of interview. The facility had four different DONs within the last year, which caused some inconsistencies in care. She expected the staff to report any changes in the residents' skin or their conditions to the charge nurse. The nurse should follow the facility's policy regarding wounds. If staff felt like problems weren't being addressed, they should report them to the DON, ADON, and Administrator. During a second interview on 08/03/26 at 10:11 A.M., CNA B said when he/she gave a shower, he/she signed the shower sheet, gave it to the charge nurse, and reported any problems with the resident's skin to the nurse. He/She didn't mark anything on the sheet him/herself. The nurses were to write any skin issues on the shower sheets. On 04/06/26, he/she reported to the nurse the resident had a wound on his/her bottom. He/She didn't write Resolved on the 05/06/26 shower sheet because the wound was present on the resident's buttocks at that time. He/She reported the resident's wound to the nurses each time he/she took care of the resident because the wound didn't seem to get better. During an interview on 08/03/26 at 10:57 A.M., CNA E said he/she had taken care of the resident. The first time he/she saw the wound on the resident's buttocks was in April 2026. It seemed to get better and then it got progressively worse. CNA E reported it to the nurses. In late June 2026, the wound had gotten worse and had an odor. The resident was in bed most of the time. He/She was very confused and hollered out for his/her significant family members. The nurses were aware of the resident's increased confusion. During an interview on 08/03/26 at 11:37 A.M., CNA G said he/she had assisted CNA B with the care of the resident on the dayshift. The first time he/she saw the wound on the resident's buttocks, it was small. The next time he/she saw the wound, it was much larger and had an odor. During an interview on 08/03/26 at 12:21 P.M., Nurse Aide (NA) F said he/she started working at the facility in early June 2026 and took care of the resident with another CNA. This was the first time he/she saw the resident's wound. It was black and was located near the center of his/her buttocks. They reported it to LPN K. Several days later, he/she took care of the resident and the wound had an odor and didn't seem to be getting better. While providing care, the resident hollered out in pain. During an interview on 08/03/26 at 1:28 P.M., LPN A said he/she has worked at the facility for 11 years and took care of the resident. The resident had some skin breakdown. Nurse A didn't remember what treatment he/she applied to the resident, but he/she was sure he/she put something on it, even though the treatment wasn't on the TAR. He/She didn't recall talking to the physician or family about the wound. He/She worked the dayshift on 06/29/26 and 07/01/26 and didn't remember if the wound had drainage or an odor. During a second interview on 08/03/26 at 2:30 P.M., the ADON said it was the change of shift on 04/06/26 when staff reported the open area on the resident's buttocks. He believed he passed the information to LPN A in report at shift change. ADON didn't notify the physician or document a treatment on the resident's TAR. The resident had a standing order for Calmoseptine (a moisture barrier and skin protectant cream used to heal minor skin irritations), but ADON was unable to find the order for Calmoseptine on the resident's TARs for April, May, and June 2026. Staff made him aware of the pressure ulcers on 05/05/26 and he notified the physician. The resident's pressure ulcers worsened and the physician was notified. The nurses did their own treatments. The facility had changed DONs at least four times in the last year. This is what caused the inconsistency in care. He expected staff to measure and assess pressure ulcers, and to notify the physician and family, and to document in the nurses note. He should have made sure the treatment was on the resident's TAR. During an interview on 08/04/26 at 9:56 A.M., the resident's physician/facility Medical Director said staff notified her on 04/06/26 of a small area to the resident's right buttock. Staff said they were applying barrier cream as a treatment. Staff notified her on 05/06/26 of the resident's skin breakdown and reported they were applying barrier cream. She believed the resident was being seen by Wound Care. She was not aware the resident was not being seen by Wound Care at that time. She was not aware staff failed to document they were applying the treatment to the resident's buttocks on the TAR. She expected staff to document the treatment on the TAR to ensure the treatment was being done. If a treatment was not documented, it was not done. The resident was sent to the hospital due to low vital signs and possible sepsis. During an interview on 08/04/26 at 11:19 A.M., the outside Wound Care company Nurse Practitioner (NP) said he/she saw the resident for the first time on 07/14/26. The resident was unresponsive. His/Her blood pressure was low and pulse was irregular. NP assessed the resident's wound, which measured 19.5 cm x 11.5 cm x UTD. The wound was unstageable and malodorous. NP gave orders to send the resident to the hospital for evaluation. 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. 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 violation(s). 3097769

Based on interview and record review, the facility failed to adequately assess resident falls by ensuring residents received treatment and care in accordance with acceptable standards of practice when staff failed to accurately complete neurological (neuro) evaluations (pulse (P), respiration (R), and blood pressure (BP) measurements; assessment of pupil size and reactivity; and equality of hand grip strength) if the fall was unwitnessed or if the resident had an incident in hitting their head, for three of three residents sampled. In addition, the facility failed to adequately assess resident falls by ensuring residents received treatment and care in accordance with acceptable standards of practice and the facility's policy when staff failed to complete incident follow up (IFU) documentation for 72 hours post fall in the progress notes each shift, for three of three residents sampled (Residents #1, #2 and #3). The census was 73.Review of the facility's Accident and Incident Report policy and procedure, revised 2/6/18, showed:-Procedure:-1. Resident: -a. The charge nurse will fill out the incident report, in detail, noting cause or probable cause of the incident; -b. Administer first aid as indicated; -c. Notify family/responsible party of incident; -d. Notify physician;-4. In All Cases: -a. Give exact description of the circumstances surrounding the accident; -b. Obtain statement from the resident, employee or visitor, if possible; -c. Chart the resident's incident in the nursing notes; -d. Submit the completed accident report to the nursing office. 1. Review of Resident #1's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/14/25, showed:-Severe cognitive impairment;-Always incontinent of bowel and bladder;-Falls since admission/entry or reentry or the prior assessment, Yes; -No injury, two or more; -Injury (except major), two or more;-Diagnoses included high blood pressure, Alzheimer's disease (progressive and irreversible brain disorder that causes memory loss, cognitive decline, and behavioral changes), Parkinson's disease (a progressive, chronic brain disorder that primarily affects movement), anxiety disorder, depression and lower back pain. Review of the resident's care plan, in use during the survey, showed:-Problem: Resident is at risk for falls;-Goal: Resident safety will be maintained through next review date;-Interventions: Neuro checks for 72 hours. Review of the resident's progress notes, showed:-On 7/27/25 at 7:49 A.M., Resident was found on the floor beside his/her bed after rolling out of bed. Resident has an 8-centimeter (cm) X 2 cm abrasion with swelling on his/her right cheek area. Nurse put a cold compress on the swelling. Notified physician and family member. Neuros started. Resident denied pain;-On 7/27/25 at 3:35 P.M., incident follow up (IFU) due to recent fall. No signs or symptoms of infection noted to abrasion to right cheek. Slight edema noted to right cheek, no bleeding or drainage noted. Resident denies pain or discomfort. No changes in level of care for resident;-On 7/27/25, Night shift (7:00 P.M. to 7:00 A.M.): No IFU documentation;-On 7/28/25 at 1:49 P.M., Resident remains on observation. No c/o pain or discomfort noted at this time. No distress noted at this time;-On 7/29/25 at 5:35 A.M., Remains on IFU. No signs or symptoms (s/s) of distress noted. Resting in bed with eyes closed at this time. Voices no complaints of pain or discomfort;-On 7/29/25, Day shift (7:00 A.M. to 7:00 P.M.): No IFU documentation;-On 7/29/25, Night shift: No IFU documentation. Review of the resident's Neurological Evaluation, dated 7/27/25, showed:-On 7/28/25, Day shift, not completed;-On 7/29/25, Night shift, not completed. Review of the resident's progress notes, showed:-8/11/25 at 5:50 P.M., Roommate notified nurse that the resident rolled out of bed. When entered room, observed resident lying face down on fall mat to the left of head of bed. Bed was in lowest position and fall mats on both sides of bed. Staffed assisted resident to bed. Resident has small cut on bridge of nose. Nose and cheek red. Provide first aid. Range of motion (ROM, extent of movement possible at a joint) within normal limits (WNL) for resident. Notified physician and family. Notified Hospice. Resident is up in geri chair (supportive recliner with wheels designed for individuals with limited mobility) for dinner. Will continue to monitor.-On 8/11/25, Night shift: No IFU documentation;-On 8/12/25, Day shift: No IFU documentation;-On 8/12/25, Night shift: No IFU documentation;-On 8/13/25, Day shift: No IFU documentation;-On 8/13/25 at 7:01 P.M., Resident continues on IFU charting. Resident with no new injury from previous fall. Denies pain or discomfort. Review of the resident's Neurological Evaluation, dated 8/11/25, showed:-8/13/25, Day shift, not completed;-8/13/25, Night shift, not completed;-8/14/25, Day shift, not completed. Review of the resident's progress notes, showed:-On 8/14/25 at 10:06 A.M., Resident rolled out of bed this morning. Bed was in lowest position and fall mats were in place. No signs of injury and no reports of pain. Vital signs stable. Hospice, physician and family have been notified. Bolsters have been added to the bed;-On 8/14/25, Night shift: No IFU documentation;-On 8/15/25, Day shift: No IFU documentation;-On 8/15/25, Night shift: No IFU documentation;-On 8/16/25, Day shift: No IFU documentation;-On 8/16/25, Night shift: No IFU documentation. Review of the resident's medical record, showed no Neurological Evaluation completed for the fall on 8/14/25. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Always incontinent of bowel and bladder;-Falls since admission/entry or reentry or the prior assessment, Yes; -Injury (except major), two or more;-Diagnoses included Alzheimer's disease, stroke and anxiety disorder. Review of the resident's progress notes, showed:-7/13/25 at 7:59 A.M., showed the resident slid out of geri chair at the nurses station. Incident was witnessed by two Certified Nurse Aides (CNAs). Lacerations at hairline. Raised bruise approximately 2 cm hairline and knuckles both hands are red;-On 7/13/25, Night shift: No IFU documentation;-On 7/14/25 at 4:41 P.M., Resident continues observation for fall. Resting in bed with call light in reach. Bed in lowest position, fall mat in place. Will continue to monitor;-On 7/14/25, Night shift: No IFU documentation. Review of the resident's Neurological Evaluation, dated 7/13/25, showed:-7/13/25, Night shift, not completed;-7/14/25, Night shift, not completed. Review of the resident's progress notes, showed:-On 7/15/25 at 3:38 P.M., Resident continues observation for fall. Resting in bed with call light in reach. Bed in lowest position, fall mat in place. Will continue to monitor;-On 7/16/25 at 6:48 A.M., Resident continues on observation post fall with injury. Continues to have steri strips (adhesive-backed paper tape used to close wounds together to aid in healing) across forehead with some noted discoloration. Neuro checks within normal limits. Resident unable to voice needs but shows no s/s of acute distress;-On 7/20/25 at 5:34 P.M., Resident rolled out of bed. Bed was in lowest position, fall mat in place. Physician and primary contact notified;-On 7/20/25, Night shift: No IFU documentation;-On 7/21/25, Day shift: No IFU documentation;-On 7/21/25, Night shift: No IFU documentation;-On 7/22/25, Day shift: No IFU documentation;-On 7/22/25, Night shift: No IFU documentation;-On 7/23/25 at 1:01 P.M., Resident rolled out of bed again. Bed was in the lowest position and floor mat was on the floor. No apparent injuries noted;-On 7/23/25, Night shift: No IFU documentation;-On 7/24/25, Day shift: No IFU documentation;-On 7/24/25, Night shift: No IFU documentation;-On 7/25/25, Day shift: No IFU documentation;-On 7/25/25, Night shift: No IFU documentation. Review of the resident's medical record, showed no Neurological Evaluation completed for the falls on 7/20/25 and 7/23/25. 3. Review of Resident #3's admission MDS, dated [DATE], showed:-Severe cognitive impairment;-Occasionally incontinent of bowel and bladder;-No falls anytime in the last month;-Diagnoses included high blood pressure, end stage renal (kidney) disease (ESRD), stroke, dementia and depression. Review of the resident's progress notes, dated 7/28/25 at 7:48 A.M., showed the resident was found on the floor next to his/her bed on his/her face as if he/she rolled out of bed. No apparent injury noted. Physician, supervisor and family notified, neuro checks started. Review of the resident's Neurological Evaluation, dated 7/28/25, showed:-7/28/25 at 7:03 A.M., not completed;-7/28/25 at 7:33 A.M., not completed;-7/28/25 at 8:03 A.M., not completed;-7/28/25 at 9:03 A.M., not completed;-7/28/25 at 10:03 A.M., not completed;-7/29/25, Day shift, not completed. Review of the resident's progress notes, dated 7/29/25, Day shift: No IFU documentation. Review of the resident's Neurological Evaluation, dated 7/28/25, showed:-7/30/25, Day shift, not completed;-7/30/25, Night shift, not completed. 4. During an interview on 9/8/25 at 12:43 P.M., Licensed Practical Nurse (LPN) A said when a resident has a fall, the nurse assesses the resident for any injuries and vital signs are completed. Neuro checks are also completed if the resident hit their head or if the fall was unwitnessed. The nurse then would contact the physician, resident's family, the nursing supervisor and hospice if the resident is on hospice. A nurse's note would be completed on how the resident fell, if there were any injuries and the notifications that were made. An incident report would be filled out regarding the fall. A nurse's note would be completed each shift for three days for the IFU that would include if there was any new bruising or complaints of pain and vital signs each shift. During an interview on 9/8/25 at 1:02 P.M., LPN B said when a resident has a fall, the nurse completes a full body assessment on the resident and vital signs. Neuros are completed if the fall was unwitnessed or if the resident hit their head. The nurse notifies the physician and the resident's family and documents the notifications and a description of the fall in a nurses note. An incident report is also completed on the fall. IFU documentation is completed for three days on each shift in the nurse's notes. The documentation includes vital signs, and the assessment of the resident for that shift. During an interview on 9/8/25 at 2:23 P.M., the Administrator and Director of Nursing (DON) said when a resident has a fall, they expected the nurse to assess the resident to check for any injuries. They expected the nurse to notify the physician, Administrator, DON and family and document the notifications in the nurses note and incident report. They expect the nurses note and incident report to include what contributed to the fall and if there were any injuries, what happened, where it happened, how it happened and who was notified. They expected the summary of the incident to show a picture of what happened. They expected neuro checks to be completed for any resident who hits their head or if the fall is unwitnessed. They expected IFU documentation to be completed for 72 hours and that documentation to include the full assessment of the resident and if there is any change of condition. If there is any change in condition, they expected the nurse to contact the physician, family, Administrator and DON. They expected the change of condition and notifications to be documented in a nurses note. They expected staff to be knowledgeable of and to follow the facility policies. 2572487

Based on observations, interview, and record review, facility staff failed to provide appropriate respiratory care and services, when staff failed to change oxygen tubing or properly clean and maintain oxygen concentrators for two (Resident #77, and #81) out of three sampled residents and failed to obtain an order and care plan oxygen use for one (Resident #17) of three sampled residents. The facility census was 79. 1. Review of the facility's Oxygen Therapy policy, dated 06/05/25, showed: -Label humidifier with date and nurse initials; -Place a storage bag on the side of the concentrator to store oxygen tubing between use and not in use; -Change clean storage bag weekly and as needed; -The policy did not contain direction or guidance how often to change the oxygen tubing. Review of the facility's Nebulizer Mask Policy, undated, showed: -After the resident is finished with the nebulizer medication the mask is placed back on the machine and covered with a plastic bag; -All nebulizer masks are to be changed weekly, and labeled with date and initials on mask. 2. Review of Resident #17's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/28/25, showed staff assessed the resident as: -Cognitively intact; -No oxygen. Review of the resident's Physician Order Sheet (POS), dated June 2025, showed the POS did not contain an order for oxygen use or care. Review of the resident's care plan, dated 06/10/25, showed the care plan did not contain direction or guidance for oxygen use. Observation on 06/10/25 at 10:36 A.M., showed the resident in bed with an oxygen cannula in reach at 2 liters (L). During an interview on 06/10/25 at 10:36 A.M., the resident said he/she wears oxygen when he/she lays on his/her side to help him/her breath better. 3. Review of Resident #77's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate Cognitive impairment; -Diagnosis of asthma, chronic obstructive pulmonary disease, or chronic lung disease. Review of the resident's POS, dated 05/31/25, showed an order for ipratropium 0.5 milligram (mg)-albuterol 3mg/3 milliliter (ml) (to treat asthma) nebulization solution, one solution for nebulization inhalation two times per day. Review of the resident's POS, dated 06/2025, showed the POS did not contain an order for changing or dating nebulizer tubing. Review of the resident's care plan, dated 06/2025, showed the care plan did not contain direction for staff in regards to nebulizer therapy. Observation on 06/10/25 at 2:15 P.M., showed the nebulizer machine mask and tube on the night stand, unlabeled and undated. Observation on 06/11/25 at 09:19 A.M., showed the nebulizer machine mask and tube on the night stand, unlabeled and undated. Observation on 06/12/25 at 10:19 A.M., showed the nebulizer machine mask and tube on the night stand, unlabeled and undated. 4. Review of Resident #81's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Received oxygen therapy; -Received hospice services; -Diagnosis of congestive heart failure. Review of the resident's POS, dated 06/2025, showed the POS did not contain an order for oxygen. Review of the residents care plan, dated 06/2025, showed the care plan did not contain direction for staff in regards to oxygen therapy. Observation on 06/10/25 at 2:15 P.M., showed the resident in bed with oxygen via nasal cannula. Observation showed the oxygen tube undated. Observation on 06/12/25 at 10:35 A.M., showed the resident in bed with oxygen via nasal cannula. Observation showed the oxygen tube undated. Observation on 06/13/25 at 1:45 P.M., showed the resident in bed with oxygen via nasal cannula. Observation showed the oxygen tube undated. 5. During an interview on 06/13/25 at 3:18 P.M., the Assistant Director of Nursing (ADON) said oxygen and nebulizer tubing is the responsibility of the nurses but is not sure when they get changed or what is put onto the tubing. He/She said there should be an order for oxygen since it is considered a medication. During an interview on 06/13/25 at 3:51 P.M., the Director of Nursing (DON) said oxygen should have an order for use and to change the tubing weekly. He/She said it is the responsibility of the restorative aide to change the oxygen tubing. The DON said nebulizer tubing and masks should be rinsed and put onto the nightstand since that is the only place to put them. All tubing should be put into a bag when not being used and supposed to have a label and date when changed. During an interview on 06/13/25 at 4:38 P.M., the restorative aide said he/she only monitors the oxygen room and orders oxygen supplies if needed. During an interview on 06/13/25 at 4:44 P.M., the administrator said oxygen requires an order but is not sure how often the tubing needs to be changed but should be dated and initialed when putting a new one out. He/She said he/she believes the nurses are the ones responsible to change the tubing and work with the oxygen.

Based on interview and record review, facility staff failed to accurately code five (Resident #13, #18, #28, #60 and #73) of five sampled residents who received an antiplatelet (used to prevent and treat cardiovascular diseases) on the Minimum Data Set (MDS), a federally mandated assessment tool. The facility census was 79. 1. Review of the facility's MDS policy, undated, showed the facility will complete MDS assessments in accordance with state guidelines. Review of the Resident Assessment Instrument (RAI) manual, used to facilitate accurate and effective resident assessment practices, version 1.19.1, dated October 2024, showed the manual instructed staff to not code antiplatelet medications such as clopidogrel (antiplatelet) as an anticoagulant. 2. Review of Resident #13's admission MDS, dated [DATE], showed staff assessed the resident received an anticoagulant and antiplatelet medication in the look-back period. Review of the Physician Order Sheet (POS), dated June 2025, a physician order for clopidogrel 75 milligrams (mg) daily. The POS did not contain an anticoagulant. 3. Review of Resident #18's admission MDS, dated [DATE], showed staff assessed the resident received an anticoagulant and antiplatelet medication in the look-back period. Review of the POS, dated June 2025, showed a physician order for clopidogrel 75 mg daily. The POS did not contain an anticoagulant. 4. Review of Resident #28's Quarterly MDS, dated [DATE], showed staff assessed the resident as received an anticoagulant and antiplatelet medication in the look-back period. Review of the POS, dated June 2025, showed a physician order for clopidogrel 75 mg daily. The POS did not contain an anticoagulant. 5. Review of Resident #60's Quarterly MDS, dated [DATE], showed staff assessed the resident as received an anticoagulant and antiplatelet medication in the look-back period. Review of the POS, dated June 2025, a physician order for clopidogrel 75 mg. The POS did not contain an anticoagulant. 6. Review of Resident #73's admission MDS, dated [DATE], showed staff assessed the resident as received an anticoagulant and antiplatelet medication in the look-back period. Review of the POS, dated June 2025, a physician order for clopidogrel 75 mg. The POS did not contain an anticoagulant. 7. During an interview on 06/13/25 at 3:01 P.M., the MDS Coordinator said he/she thought clopidogrel was an anticoagulant and coded it as such. He/She said the prior MDS nurse taught him/her the process. During an interview on 06/13/25 at 3:18 P.M., the Director of Nursing (DON) said he/she was unaware to code clopidogrel as an antiplatelet and not anticoagulant medication. He/She would expect the MDS nurse to follow the RAI manual for correct coding. During an interview on 06/13/25 at 03:51 P.M., the administrator said the MDS nurse is responsible for the MDS assessments and would expect them to use the RAI manual for correct coding. He/She was unaware clopidogrel is an antiplatelet medicaiton.

Based on interview and record review, facility staff failed to document the administration of the pneumococcal (lung inflammation caused by bacteria or viral infection) vaccine for four residents (Resident #16, #54, #70, and #71) out of 10 sampled residents and failed to document the administration of the influenza (contagious respiratory infection caused by a virus) vaccine for four residents (Resident #13, #16, #70 and #71) of ten sampled residents. The facility census was 79. 1. Review of the Facility's Pneumococcal Vaccination Policy and Procedure, dated 12/12/2023, showed the communities will offer pneumococcal vaccination on admission and annually. The resident may refuse to receive the vaccination. The Community will get consent form the resident or responsible party. If the resident agrees to the vaccination the community will provide the vaccination on admission and annually. Review of the Center for Disease Control (CDC) guidelines, dated 03/15/23, showed the following: -People age [AGE] or older who have no pneumococcal vaccines should receive 20 valent pneumococcal conjugate vaccine (PCV20) or 15 valent pneumococcal conjugate vaccine (PCV15), and then one year later pneumococcal polysaccharide vaccine (PPSV23); -People age [AGE] through 64 who have no pneumococcal vaccines should receive PCV20 or PCV1, and then one year later PPSV23. 2. Review of Resident #16's medical record showed: -The resident age [AGE]; -admitted to facility on 2/09/18; -The record did not contain documentation the resident received or refused the pneumococcal vaccine. 3. Review of Resident #54's medical record showed: -The resident age [AGE]; -admitted to facility on 3/24/25; -The record did not contain documentation the resident received or refused the pneumococcal vaccine. 4. Review of Resident #70's medical record showed: -The resident age [AGE]; -admitted to the facility on [DATE]; -The record did not contain documentation the resident received or refused the pneumococcal vaccine. 5. Review of Resident #71's medical record showed: -The resident age [AGE]; -admitted to the facility on [DATE]; -The record did not contain documentation the resident received or refused the pneumococcal vaccine. 6. Review of the Facility's Influenza Vaccination Policy and Procedure, dated 12/12/2023, showed the RSP communities will offer influenza vaccination annually to all residents. The resident(s) may refuse to recieve the vaccination. The community will get consent from the resident or responsibly party. If the resident agrees to the vaccination the community will provide the vaccination annually. Review of the CDC, Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities, reviewed 2/5/24, showed: -If possible, all residents should receive inactivated influenza vaccine (IIV) annually before influenza season; -In the majority of seasons, influenza vaccines will become available to long-term care facilities beginning in September, and influenza vaccination should be offered by the end of October; -Informed consent is required to implement a standing order for vaccination, but this does not necessarily mean a signed consent must be present; -Although vaccination by the end of October is recommended, influenza vaccine administered in December or later, even if influenza activity has already begun, is likely to be beneficial in the majority of influenza seasons because the duration of the season is variable, and influenza activity might not occur in certain communities until February or March. -In the event that a new patient or resident is admitted after the influenza vaccination program has concluded in the facility, the benefits of vaccination should be discussed, educational materials should be provided, and an opportunity for vaccination should be offered to the new resident as soon as possible after admission to the facility. -According to requirements, each resident is to be vaccinated unless contraindicated medically, the resident or legal representative refuses vaccination, or the vaccine is not available because of shortage. This information is to be reported as part of the Minimum Data Set (MDS), which tracks nursing home health parameters. 7. Review of Resident #13's medical record showed: -admitted to the facility on [DATE]; -The record did not contain documentation the resident received or refused the influenza vaccine. 8. Review of Resident #16's medical record showed: -admitted to the facility on [DATE]; -The record did not contain documentation the resident received or refused the 2024 influenza vaccine. 9. Review of Resident #70's medical record showed: -admitted to the facility on [DATE]; -The record did not contain documentation the resident received or refused the influenza vaccine. 10. Review of Resident #71's medical record showed: -admitted to the facility on [DATE]; -The record did not contain documentation the resident received or refused the influenza vaccine. 11. During an interview on 06/12/25 at 1:01 P.M., the Administrator said the Assistant Director of Nursing (ADON) is responsible for scheduling and implementing all resident immunizations. He/She said the Director of Nursing (DON) is responsible for ensuring immunizations are completed timely. He/She said he/she expects the immunizations, consents, education and refusals to be documents and/or scanned into the resident's medical record. He/She said the flu and pneumonia immunizations are offered upon admission and then during annual clinics after. He/She said he/she was not aware that residents medical records were missing documentation of flu and pneumonia immunization records, education, refusals, or consents. During an interview on 06/12/25 at 1:24 P.M., the ADON said he/she is new and just started. He/She said he/she is not currently responsible for resident immunizations and is not sure if he/she will be in the future. During an interview on 06/12/25 at 1:25 P.M., the DON said the previous ADON used to do the resident immunizations. He/She said the ADON left in the middle of February, and he/she has been responsible for maintaining and tracking immunizations since then. He/She said when the ADON left he/she was not able to meet with him/her to go over documentation and his/her process, so he/she has been struggling to find what he/she needs and to figure out where the previous ADON was in the process. He/She said the flu and pneumonia immunizations should be documented in the resident's chart under the immunization tab and/or be scanned into their record. He/She said consents or refusals should also be documented and/or scanned into the medical record. He/She said he/she has been trying to catch up and keep up with resident immunizations but has been struggling trying to do both ADON/DON duties alone.

Based on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate or alert staff of residents who required EBP, failed to place appropriate signage to alert staff of EBP needs, and failed to place appropriate personal protective equipment (PPE) in close proximity for four residents (Resident #4, #5, #32, and #54) of five sampled residents who had a wound and failed to ensure sanitary conditions for one (Resident #14) out of two residents with a catheter. The facility's census was 79. 1. Review of the facility's EBP policy, dated 04/2024, showed: -Whenever a resident has an infection regardless of their multidrug-resistant organism status, the facility will utilize EBP for any time that physical contact is needed in caring for the resident; -The EBP will be utilized by the staff for any resident with chronic wounds or indwelling medical devices during any high-contact with that resident; -The gowns and gloves will be outside the resident room for the staff to don (apply) before entering the room and two containers will be in the room, 1) for soiled linens or clothing and 2) for the soiled gloves and gowns to be disposed of after use by staff; -In-services for EBP for the staff will be conducted every six months. 2. Review of Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/17/25, showed staff assessed the resident as: -Moderate Cognitive impairment; -Stage one or greater unhealed pressure ulcers; -Two stage two pressure ulcers, three stage three pressure ulcers, one stage four pressure ulcer; -Diagnosis of heart failure. Observation on 06/11/25 at 02:17 P.M., showed the Assistant Director of Nursing (ADON) did not wear a gown while he/she performed wound care on the resident. Observation showed the PPE not in proximity of the resident's room or signage directing staff of EBP need. During an interview on 06/13/25 at 03:22 P.M., ADON said he/she did not know what EBP was until the other day. He/She said he/she should have worn a gown during wound care. He/She said the facility has not done any education or training on EBP that he/she is aware of. 3. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -No skin issues; -Diagnosis of anemia and heart disease. Observation on 06/12/25 at 11:18 A.M., showed Registered Nurse (RN) D provided wound care to the resident and did not wear a gown. Observation showed the PPE not in proximity of the resident's room or signage directing staff of EBP need. During an interview on 06/12/25 at 12:52 P.M., RN D said he/she did not know what EBP was and did not know to wear a gown or extra PPE. He/She said he/she does not remember an EBP training. 4. Review of Resident #32's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Indwelling catheter; -Diagnosis of urinary retention. Observation on 06/12/25 at 1:03 P.M., showed Certified Nurse Aide (CNA) F provided catheter care to the resident and did not wear a gown. Observation showed the PPE not in proximity of the resident's room or signage directing staff of EBP need. During an interview on 06/12/25 at 1:17 P.M., CNA F said EBP is when staff use gloves and bag up the linens and trash at the bedside and wash and sanitze the hands. He/She said gowns and other PPE are worn when a resident is on quarantien. He/She said he/she did not have training on EBP. 5. Review of Resident #54's Significant Change of Status Assessment (SCSA), dated 06/07/25, showed staff assessed the resident as: -Severely cognitively impaired; -Presence of one Stage IV pressure injury; -At risk for pressure injury; -Received pressure ulcer care; -Diagnosis of pressure ulcer to left buttock, Stage IV. Observation on 06/12/25 at 2:14 P.M., showed the PPE not in proximity of the resident's room or signage directing staff of EBP need. Observation showed Licensed Practical Nurse (LPN) I assisted with wound care and did not wear a gown. During an interview on 06/12/25 at 2:34 P.M., LPN I said gowns and extra PPE would be worn if a resident has Tuberculosis (TB) or COVID or other communicable disease or infection but not for wounds or catheters. He/She said he/she was not trained on EBP. 6. During an interview on 06/13/25 at 3:18 P.M., the Infection Preventionist said he/she just learned about EBP and still learning about it. He/She said he/she is confused about when it should be used. He/She said gowns and gloves should be used for all catheters and residents with a wound dressing, or anyone harboring an infection. There has not been any training at the facility and the facility is going to order PPE hangers for the doors to make the PPE more accessible for the staff but is not implemented yet. During an interview on 06/13/25 at 3:51 P.M., the Director of Nursing (DON) said he/she was not familiar with EBP until yesterday and would need to research it to learn more about it. He/She said the facility is not utilizing EBP. During an interview on 06/13/25 at 4:44 P.M., the administrator said he/she is not sure what EBP is and the facility is not using EBP. 7. Review of the facility's Protocol for Urinary Catheters, dated August 2024, showed the policy did not contain direction or guidance for catheter or catheter tubing placement. 8. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Indwelling catheter; -Diagnosis of stroke. Observation on 06/10/25 at 1:00 P.M., showed the resident in the dining room his/her wheelchair with the catheter bag and the tube on the floor underneath his/her wheelchair. Observation on 06/11/25 at 3:45 P.M., showed the resident in the hallway in his/her wheelchair with the catheter bag and the tube on the floor underneath. Observation on 06/12/25 at 12:55 P.M., showed the resident in the dining room his/her wheelchair with the catheter bag and tubing on the floor underneath his/her wheelchair. During an interview on 06/13/25 at 1:58 P.M., CNA F said catheters and catheter tubing should not be on the floor for infection prevention and should be covered for privacy at all times. During an interview on 06/13/25 at 3:18 P.M., the infection preventionist said catheters should be kept off the floor because there are germ and bacteria on the floor and could cause an infection. During an interview on 06/13/25 at 3:51 P.M., the DON said catheters kept off the floor due to bacteria being on the floor that could create an infection for the resident During an interview on 06/13/25 at 4:44 P.M., the Administrator said catheter tubing should be kept off the floor. If staff observe the tubing and/or catheter on the floor it is considered dirty or contaminated or could cause a risk of trauma to the resident if they fall over it.

Based on observation, interview and record review, facility staff failed to maintain professional standards of documentation when staff failed to complete weekly skin assessments for three (Resident #5, #17, and #54) of three residents. Staff failed to administer eye medication per policy for two (Resident #7 and #55) out of two sampled residents. The facility census was 79. 1. Review of the facility's Skin Assessment policy, dated July 2021, showed: -In order to prevent skin breakdown and promote health of our residents, it is the policy of the facility to perform skin assessments on a weekly basis by a Registered Nurse (RN) or Licensed practical nurse (LPN); -The LPN or RN are to visually inspect all areas of the body and note/document any abnormalities. If abnormalities are found, the LPN or RN performing the skin assessment is to notify the physician, resident and or resident representative and Director of Nursing (DON). Review of the Barrier Policy for Pressure Ulcer Prevention and Managing Skin Integrity policy, dated November 2017, showed skin assessments will be completed on a weekly basis by a nurse, unless otherwise specified by a physician. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/03/25, showed staff assessed the resident as: -Cognitively intact; -At risk for developing a pressure injury; -No skin breakdown; -Diagnosis of anemia (low blood iron), heart disease, and diabetes. Review of the resident's care plan, dated 6/11/25, directed the nurse to complete a weekly head to toe skin assessment and document the results. Review of the resident's medical record showed: -An undated physician note that showed: stage III pressure wound to mid back measured 1.2 centimeters (cm) by 3 cm by 0.2 cm; -A physician note dated 05/29/25, initial encounter, mid-thoracic back with a moisture associated skin damage secondary to pressure measured at 11.5 cm by 13.6 cm by 0.1 cm with a small amount of drainage; -The record did not contain documented weekly skin assessments. Observation on 06/12/25 at 11:18 A.M., showed the resident with a wound to his/her left knee and middle back. 3. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -At risk for developing a pressure injury; -No skin breakdown; -Diagnosis of malnutrition. Review of the resident's care plan, dated 6/10/25, directed the nurse to complete a weekly head to toe skin assessment and document the results. Review of the medical record showed the record did not contain documented weekly skin assessments. 4. Review of Resident #54's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Resident has a stage 1 or greater; -Resident at risk of pressure ulcers; -Receives Hospice care. Review of the resident's care plan, dated 6/11/25, showed skin breakdown: at risk for/actual breakdown present. The care plan directed staff to inspect skin complete body head to toe every week and document results. Review of the resident's medical record showed: -Physician order dated, 05/22/25 for x-ray to rule out osteomyelitis; -X-ray result dated, 05/27/25 showed no evidence of osteomyelitis; -Family Nurse Practitioner-Certified (FNP-C) wound note dated 05/29/25 with measurements of 2.8 x 4 by 9 x 0.3 cm; -A FNP-C wound note dated 06/05/25 with measurements of 4.6 x 3 by 7 x 0.8 cm. Review of the resident's medical record, showed the record did not contain documented weekly skin assessments Observation on 06/12/25 at 2:14 P.M., showed LPN I assisted with wound care. 5. During an interview on 06/12/25 at 3:39 P.M., the DON said skin assessments are done during showers by the aides and if they have a wound, the nurse. The aides complete shower sheets during showers but are not a part of the resident record. During an interview on 06/13/25 at 3:18 P.M. the Assistant DON (ADON) said skin assessments are completed by the aides during showers and tell the nurse if there are any skin issues. The nurse will make a note if there are issues. During an interview on 06/13/25 at 3:51 P.M., the DON said aides complete shower sheets and skin issues are documented on them. He/She said the aides turn in the shower sheets, the nurse signs off on them and the nurse turns them into him/her. He/She said he/she reviews the shower sheets as they are brought to him/her but would expect the nurse to document notification of the physician, wound measurements and appearance and notification of him/her of any wound. The DON said there has been a lot of new staff lately. During an interview on 06/13/25 at 4:38 P.M., the Administrator said there has been a struggle getting the documentation completed. The nurses are responsible to complete skin assessments weekly and document those in the resident record. 6. Review of the facility's Ophthalmic (eye) medication policy, dated May 2017 showed the policy directed staff: -To hold the lower eyelid away from the eye to form a pouch, instill the drops onto the pouch, with a finger hold pressure to the inside corner of the eye for about one minute, and instruct resident to keep eyes closed for a few minutes; -Wait five minutes between instilling another eye medication. 7. Review of Resident #7's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact with a diagnosis of glaucoma (disease that damages the nerve responsible for vision). Review of the resident's Physician Order Sheet (POS) dated June 2025 showed: -Muro 128, 5% eye drops (decreases swelling of the eye surface), one drop in each eye three times a day for glaucoma; -Refresh tears 0.5% eye drops (decreases irritation from dry eyes), one drop in each eye twice a day for glaucoma. Observation on 06/12/25 at 8:12 A.M., showed Certified Medication Technician (CMT) B administer one Muro eye drop into the left eye followed by the right eye. The resident held open his/her lower lid creating a pocket for the drops. The CMT instructed the resident to hold pressure on the inner eye but did not instruct resident to keep eye closed a few minutes. After changing gloves and waiting 2 minutes, the CMT instilled one drop Refresh tears into the left eye followed by one drop to the right eye. The resident held open his/her lower lid creating a pocket for the drops. The CMT instructed the resident to hold pressure on the inner eye but did not instruct resident to keep eye closed a few minutes or wait five minutes between eye drops. During an interview on 06/12/25 at 06/12/25 at 12:40 P.M., CMT B said he/she should wait three minutes between eye drops and does not feel like he/she waited the appropriate time. He/She said pressure should be held for 30 seconds after drop administration. He/She said he/she was nervous and has not had any specific eye drop administration training. 8. Review of Resident #55's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with a diagnosis of stroke. Review of the POS dated June 2025, showed: -Loteprednolol etabonate 0.5% eye drops (treats eye conditions that cause inflammation, redness and itching), one drop in each eye twice a day for dry eye syndrome; -Cyclosporine 0.05% eye drops (increases tear production), one drop in each eye twice a day for rheumatoid arthritis. Observation on 06/12/25 at 8:43 A.M., showed CMT L instill one drop Loteprodnolol into the right eye instructed the resident to close their eyes and then one drop into the left eye. The resident kept blinking. The CMT did not hold pressure to the inner aspect of the eye or instruct the resident to hold pressure. The CMT administered the Cyclosporine eye drops into the right eye followed by the left eye. The resident kept blinking. The CMT did not hold pressure to the inner aspect of the eye or instruct the resident to hold pressure and did not wait five minutes between drops. During an interview on 06/12/25 at 12:49 P.M., CMT L said he/she should wait five minutes between eye drops unless otherwise directed but was nervous being watched. He/She said drops are administered in the inner corner of the eye and is unsure if he/she is supposed to hold pressure unless directed to do so in the order. The CMT said he/she has not had any eye drop training at the facility. 9. During an interview on 06/13/25 at 3:15 P.M., the ADON said staff should have the resident tilt head back, hold the lower lid open and administer the drop and hold pressure for a little bit to keep the fluid in the eye. Staff should wait two to three minutes between eye drops. During an interview on 06/13/25 at 3:51 P.M., the DON said staff should pull the eyelids apart and instill the drop in the edge of the eye and wait, depending on the drop, at least two minutes before giving another drop. Staff should hold pressure for at least 10 seconds after giving. He/She said there has not been any education offered about eye drops at the facility.

Based on observation, interview and record review, the facility staff failed to ensure expired medications were destroyed or returned appropriately and ensure multi-dose medications were dated when opened in two of three medication storage carts and one of two medication storage rooms and failed to store one liquid medication labeled keep in refrigerator in the refrigerator. The facility census was 79 residents. 1. Review of the facility's Storage of Medication policy, dated 2022, showed staff are directed as follows: -The nursing staff shall be responsible for maintaining medication storage; -Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals; -Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location; -Medications must be stored separately from food and must be labeled accordingly. Review of the facility's Expired Medications policy, dated October 2015, showed the policy did not contain direction for when a medication is considered expired. Review of the facility's Medication Administration General Guidelines, dated May 2020, showed staff are directed to check expiration dates on the package or container. Many products have specific end-of-use dating defined by the manufacturer. The date opening should be noted on the container/vial of multi-use containers. Review of the facility's pharmacy Insulin storage guide, undated, showed once the Lantus, Humalog, Aspart, Tresiba and Basaglar insulin is opened, it must be used within 28 days. Review of the facility's pharmacy Beyond Use-by Date guide, undated showed Tubersol (Tuberculin Purified Protein Derivative (PPD), a medication used in a skin test to help detect infection with bacteria that causes Tuberculosis (a bacterial infection to the lungs), must be used within 30 days after opened. 2. Observation on 06/10/25 at 10:15 A.M., showed the 200 Hall Certified Medication (CMT) medication storage cart contained: -One open bottle of cyclosporine eye drops dated 04/28/25; -One open, undated bottle of Flucortisone nasal spray; -One open bottle of Latanoprost eye drops dated 04/22/25. Observation on 06/10/25 at 10:22 A.M., showed the 200 Hall medication storage room contained: -One open, undated bottle of PPD solution; -A package of five acetaminophen suppositories with an expiration date of 04/03/2025. Observation on 06/10/25 at 10:36 A.M., showed the 300 hall nurse medication storage cart contained: -Three Lantus insulin pens opened, undated; -Two Humalog insulin pens opened, undated; -One Aspart insulin pen opened, undated; -One Basaglar insulin pen opened, undated; -One Tribecca insulin pen opened, undated ; -One bottle of Lorazepam (an antianxiety medication) labeled keep in refrigerater. 3. During an interview on 06/10/25 at 10:15 A.M., Certified Medication Technican (CMT B) said eye drops and nasal sprays are good for 30 days once opened. He/She said if there is not a date on the bottles then staff do not know if the medication is good anymore and should not give it. CMT B said he/she did not know the medication was undated. The CMT's are responsible to check the CMT carts everyday. During an interview on 06/10/25 at 10:36 A.M., RN D said the nurses are responsible for the medication storage rooms and nurse medication storage carts to include checking for outdated/expired medication. He/She said the expiration dates on the insulin pens is what he/she used to determine when the insulin expired. He/She said he/she guessed it was good for 30 days after opening but was not for sure The RN said he/she did not know the Lorazepam needed to be refrigerated or how long PPD solution was good for once opened. During an interview on 06/13/25 at 3:51 P.M., the Director of Nursing (DON) said the CMT's are responsible to check their medication carts and the nurses are responsible to check their medication cart. The pharmacy will check all the carts and medication rooms monthly during their routine visits for expired medications. The DON said insulin, eye drops, nasal sprays and PPD solution are good for 30 days once opened. If there is no date, staff are expect to discard the medication. He/She said the person who opens the medication is responsible to date it. The DON was unaware there was undated and expired medication in the medication storage areas. During an interview on 06/13/25 at 4:44 P.M., the administrator said the nurses are responsible to ensure medication rooms and carts are checks for expired and undated medication at least weekly. He/She said they are unaware of how long things are good for but would expect staff to date items when opened and to discard if not dated.

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 79. 1. Review of the facility's policy titled, Resident Services dated 01/2024, showed the facility provides sufficient licensed nursing and ancillary services 24 hours a day, including a Registered Nurse for at least eight consecutive hours daily. 2. Review of the facility's RN staff schedule, dated March 2025, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates of: -Sunday, 03/02/2025; -Sunday, 03/16/2025; -Sunday, 03/30/2025. 3. Review of the facility's RN staff schedule, dated April 2025, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates of: -Sunday, 04/13/2025; -Sunday, 04/27/2025. 4. Review of the facility's RN staff schedule, dated May 2025, showed the facility did not have an RN, eight consecutive hours a day, in the building for 05/25/24. 5. Review of the facility's RN staff schedule, dated June 2025, showed the facility did not have an RN, eight consecutive hours a day, in the building for 06/08/2025. 6. During an interview on 06/13/25 at 3:18 P.M., the Staffing Coordinator said the facility needs a RN in facility eight consecutive hours daily. He/She said he/she believes they are meeting that requirement. He/She said he/she is unsure why there was not RN coverage on the days but thinks maybe they were down an RN at that time. During an interview on 06/13/25 at 4:04 P.M., the Director of Nursing (DON) said the facility should have an RN in building eight consecutive hours daily. He/She said he/she was not aware there was not an RN in the building on those days. During an interview on 06/13/25 at 4:44 P.M., the administrator said at minimum the facility needs an RN eight consecutive hours daily. He/She said he/she was not aware of any day they were short RN hours. He/She said the staffing coordinator creates the schedule and if he/she is missing anyone then he/she lets the DON or administrator know and they will ask people to work.

Based on observation, interview, and record review, facility staff failed to ensure the environment remained safe and free of accident hazards for eight residents (Residents #11, #17, #18, #19, #31, #40, #41 and #70) out of eight sampled residents who use side rails when staff did not obtain an order, signed consents for side rails, and failed to complete entrapment assessments. The facility census was 79. 1. Review of the facility's Bed Rails policy, dated 09/05/17, showed: -Assess the resident for risk of entrapment from bed rails prior to installation; -Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation; -Ensure bed dimensions are appropriate for resident's size and weight; -Regularly check for areas of possible entrapment; -Ensure there is no gap wide enough to entrap a resident's head or body; -Check beds regularly to make sure they are installed correctly as rails may shift or loosen over time; -Care plan interventions are implemented when side rails are utilized and reviewed at least quarterly. 2. Review of Resident #11's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -No restraints; -Required supervision to touch assistance from staff to roll left and right in bed and for all transfers. Review of the resident's care plan, dated 06/2025, showed the care plan did not contain direction or guidance for bed rail use. Review of the resident's POS, dated 06/2025, showed the POS did not contain an order for bed rails or grab bars. Review of the resident's medical record showed the record did not contain a signed bed rail/grab bar consent or entrapment assessment. Observation on 06/12/25 at 2:30 P.M., showed the resident in bed with grab bars up on both sides of the bed. 3. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -No restraints; -Required substantial to maximal assistance from staff to roll left and right in bed and dependent on transfers; -Limited range of motion in all extremities. Review of the resident's care plan, dated 06/10/25, showed the care plan did not contain direction or guidance for bed rail use. Review of the resident's POS, dated June 2025, showed the POS did not contain an order for bed rails or grab bars. Review of the Side Rail Evaluation, dated 05/29/25, showed a recommendation for quarter rails up on both sides of the bed. Review of the resident's medical record, showed the record did not contain a signed bed rail consent or bed entrapment assessment. Observation on 06/11/25 at 8:24 A.M., showed the resident in bed with bed rails up on both sides of the bed. During an interview on 06/11/25 at 8:24 A.M., the resident said the rails on the bed help him/her to move around in bed. During an interview on 06/13/25 at 1:58 P.M., Certified Nurse Assistant (CNA) F said the resident uses bed rails. 4. Review of Resident #18's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required substantial to maximal assistance from staff to sit to lie, lie to sit, and sit to stand; -Dependent for transfers from bed to chair to bed; -Limited range of motion in all extremities; -Diagnosis of heart disease. Review of the resident's care plan, dated 06/11/25, showed the care plan did not contain direction or guidance for bed rail use. Review of the resident's POS, dated June 2025, showed the POS did not contain an order for bed rails or grab bars. Review of the Side Rail Evaluation, dated 04/18/25, showed the evaluation did not contain recommendations. Review of the resident's medical record, showed the record did not contain a signed bed rail consent or bed entrapment assessment. Observation on 06/10/25 at 1:48 P.M., showed the resident in bed with bed rails up on both sides of the bed. Observation on 06/13/25 at 1:57 P.M., showed the resident in bed with bed rails up on both sides of the bed. During an interview on 06/13/25 at 1:58 P.M., CNA F said the resident uses bed rails. 5. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive impairment; -No restraints; -Required partial to moderate assistance from staff to roll left and right in bed and on transfers; -Limited range of motion impairment on one side of lower extremity. Review of the resident's care plan, dated 04/03/25, showed the care plan did not contain direction or guidance for bed rail use. Review of the resident's POS, dated June 2025, showed the POS did not contain an order for bed rails or grab bars. Review of the Side Rail Evaluation, dated 04/03/25, showed a recommendation for quarter rails up on both sides of the bed. Review of the resident's medical record, showed the record did not contain a signed bed rail consent or bed entrapment assessment. Observation on 06/13/25 at 01:43 P.M., showed the resident in bed with bilateral bed rails in the upright position. 6. Review of Resident #31's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate Cognitive Impairment; -No restraints; -Independent assist with rolling left and right in bed and transfers. Review of the resident's care plan, dated 05/09/25, showed the care plan did not contain direction or guidance for bed rail use. Review of the resident's POS, dated June 2025, showed the POS did not contain an order for bed rails or grab bars. Review of the Side Rail Evaluation, dated 05/09/25, showed a recommendation for half bed rails up on left side of the bed. Review of the resident's medical record, showed the record did not contain a signed bed rail consent or bed entrapment assessment. Observation on 06/10/25 at 11:57 A.M., showed the resident in bed with bilateral bed rails in upright position. Observation on 06/11/25 at 09:00 A.M., showed the resident in bed with bilateral bed rails in upright position. Observation on 06/12/25 at 10:17 A.M., showed the resident in bed with bilateral bed rails in upright position. Observation on 06/13/25 at 10:02 A.M., showed the resident in bed with bilateral bed rails in upright position. 7. Review of Resident #40's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required substantial to maximal assistance for bed mobility and transfers; -Limited range of motion to one side; -Diagnosis of stroke. Review of the resident's care plan, dated 06/09/25, showed the care plan did not contain direction or guidance for rail use. Review of the resident's POS, dated June 2025, showed the POS did not contain an order for bed rails or grab bars. Review of the Side Rail Evaluation, dated 05/29/25, showed a recommendation for quarter rails up on left side of the bed. Review of the resident's medical record, showed the record did not contain a signed bed rail consent or bed entrapment assessment. Observation on 6/10/25 at 1:48 P.M., showed the resident in bed with one side rail up on the left side of the bed. Observation on 06/11/25 at 8:48 A.M., showed the resident in bed with one side rail up on the left side of the bed. 8. Review of Resident #41's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively Intact; -No restraints; -Supervision or touching assist with rolling left and right in bed and transfers. Review of the resident's care plan, dated 04/23/25, showed the care plan did not contain direction or guidance for bed rail use. Review of the resident's POS, dated June 2025, showed the POS did not contain an order for bed rails or grab bars. Review of the Side Rail Evaluation, dated 04/13/25, showed no recommendation for bed rails. Review of the resident's medical record, showed the record did not contain a signed bed rail consent or bed entrapment assessment. Observation on 06/10/25 at 12:04 P.M., showed the resident in bed with left bed rail in the upright position. Observation on 06/11/25 at 09:14 A.M., showed the resident in bed with left bed rail in the upright position. 9. Review of Resident #70's Quarterly MDS, dated [DATE], showed staff assess the resident as: -Moderate Cognitive impairment; -No restraints; -Independent assist with rolling left and right in bed and supervision or touching assist from staff for transfers; -Limited range of motion impairment on one side of lower extremity. Review of the resident's care plan, dated 05/21/25, showed the care plan did not contain direction or guidance for bed rail use. Review of the resident's POS, dated June 2025, showed the POS did not contain an order for bed rails or grab bars. Review of the Side Rail Evaluation, dated 05/21/25, showed a recommendation for quarter bed rails up on both sides of the bed. Review of the resident's medical record, showed the record did not contain a signed bed rail consent or bed entrapment assessment. Observation on 06/12/25 at 02:09 P.M., showed the resident in bed with bilateral bed rails in the upright position. 10. During an interview on 06/13/25 at 2:42 P.M., the Maintenance Director said he/she has not done any entrapment assessments. He/She said he/she knows this was an issue last year, but he/she does not do any measurements. He/She said he/she is responsible for putting the assist bars on the bed, but that is it. He/She said he/she is unsure who is responsible for doing entrapment measurements. During an interview on 06/13/25 at 03:30 P.M., the Assistant Director of Nursing (ADON) said he/she is unsure who is responsible for side rail consents and entrapment assessments. He/She said if its done on admission then it would be the charge nurse on duty, but unsure of anyone specific makes sure it is being done. During an interview on 06/13/25 at 4:16 P.M., the Director of Nursing (DON) said he/she did not know that side rail consents needed to be done along with entrapment assessments and measurements. He/She said the admitting charge nurse is responsible to get side rail consent and put an order in. He/She said the Charge nurse will have to be the one to do the entrapment measurements upon admission. He/She said they should be completed quarterly. He/She said the resident should be in the bed when measurements are completed. He/She said the importance of entrapment measurements are to ensure the resident does not get harmed. During an interview on 06/13/25 at 04:54 P.M., the administrator said no consents or entrapments measurements were completed. He/She said charge nurses and the DON should ensure that consents are obtained, and an order is in the computer for side rails. He/She said entrapment assessments should be completed annually. He/She said the importance is to ensure the side rails are not restraining the resident and that they are for a benefit not a harm.

Based on observation, interview, and record review, facility staff failed to complete the required nurse staffing information to include the facility census. The facility census was 79. 1. Review of the facility's Daily Staff Postings policy, dated 10/27/2015, showed information to be posted on the form to include the total number and total hours of the Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nurses Aide's (CNA) staffed. The policy did not contain information to include the facility census. 2. Review of facility's daily staffing sheets, dated March 1-31, 2025, showed the sheets did not contain the facility census. Review of facility's daily staffing sheets, dated April 1-30, 2025, showed the sheets did not contain the facility census. Review of facility's daily staffing sheets, dated May 1-31, 2025, showed the sheets did not contain the facility census. During an interview on 06/18/25 at 08:05 P.M., the receptionist said he/she is responsible for filling out the daily staff sheet each morning and hanging it up. He/She said the sheet includes date, before noon and after noon hours of RN's, LPN's, and CNA's. He/She said he/she was not aware the facility census needed to be on the daily staffing sheet. During an interview on 06/13/25 at 04:05 P.M., the Director of Nursing (DON) said the front desk fills the daily staffing sheet out each morning. He/She said the sheets are given to him/her and he/she keeps them in a file. He/She said he/she was not aware that the census was not on the sheet. During an interview on 06/13/25 at 4:44 P.M., the administrator said the receptionist or business office does the daily staffing sheets. He/She said the daily staffing sheets are to include the facility census. He/She said he/she was not aware that the census was not on the daily sheet.

Based on interview and record review, facility staff filed to ensure the residents' medical records included documentation the resident or resident's representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine, and each dose of COVID-19 vaccine administered to the resident, if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal for five residents (Resident #12, #16, #70, #71, and #77) of nine sampled residents. The facility census was 79. 1. Review of the Facility's COVID-19 Vaccine Policy - Residents, date 4/21/2023, showed residents who reside in Marymount Manor will be offered upon admission and annually for their consent to be provided a COVID-19 vaccination. 2. Review of Resident #12's medical record showed: -admitted to the facility on [DATE]; -The record did not contain documentation the resident received education, refused, or offered the second dose or an updated booster of the COVID-19 vaccine. 3. Review of Resident #16's medical record showed: -admitted to the facility on [DATE]; -The record did not contain documentation the resident received education, refused, or offered the second dose or an updated booster of the COVID-19 vaccine. 4. Review of Resident #70's medical record showed: -admitted to the facility on [DATE]; -The record did not contain documentation the resident received education, refused, or offered the second dose or an updated booster of the COVID-19 vaccine. 5. Review of Resident #71's medical record showed: -admitted to the facility on [DATE]; -The record did not contain documentation the resident received education, refused, or offered the second dose or an updated booster of the COVID-19 vaccine. 6. Review of Resident #77's medical record showed: -admitted to the facility on [DATE]; -The record did not contain documentation the resident received education, refused, or offered the second dose or an updated booster of the COVID-19 vaccine. During an interview on 06/12/25 at 1:24 P.M., the ADON said he/she is new and just started. He/She said he/she is not currently responsible for resident immunizations and is not sure if he/she will be in the future. During an interview on 06/12/25 at 1:25 P.M., the DON said the previous ADON used to do the resident immunizations. The DON said he/she has been struggling to find what he/she needs and to figure out where the previous ADON was in the process. He/She said the covid immunizations should be documented in the resident's chart under the immunization tab and/or be scanned into their record. He/She said consents or refusals should also be documented and/or scanned into the medical record. He/She said he/she has been trying to catch up and keep up with resident immunizations but has been struggling trying to do both ADON/DON duties alone.

Based on observation, interview and record review, facility staff failed to provide a clean, comfortable and homelike when staff failed to maintain resident rooms in good repair. Facility census was 79. 1. Review of the facility's Homelike Environment policy, dated March 2017, showed the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting to include clean, sanitary and orderly. Review of the facility's policy titled Maintenance Service, dated December 2009, showed functions of maintenance personnel include, but are not limited to, maintaining the building in good repair, free from hazards and in compliance with current federal, state, and local laws, regulations, and guidelines and the maintenance director is responsible for developing and marinating a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. Observation on 06/10/25 at 11:50 A.M., showed resident room [ROOM NUMBER] walls with chipped paint and gouged. 3. Observation on 06/10/25 at 11:59 A.M., showed resident room [ROOM NUMBER] walls with chipped paint and gouged. 4. Observation on 06/10/25 at 12:04 P.M., showed resident room [ROOM NUMBER] walls with chipped paint and gouged. The closet door pushed inward and did not work. 5. Observation on 06/11/25 at 8:30 A.M., showed resident room [ROOM NUMBER] walls with chipped pain and gouged. 6. Observation on 06/11/25 at 10:15 A.M., showed resident room [ROOM NUMBER] wall by the sink with the baseboard detached. 7. Observation on 06/11/25 at 10:20 A.M. and 06/12/25 at 7:45 A.M., showed resident room [ROOM NUMBER] floor with multiple areas of a dried on white substance and a portion of the baseboard removed from the wall. 8. Observation on 06/11/25 at 10:23 A.M., showed resident room [ROOM NUMBER] bathroom door with two holes. 9. Observation on 06/11/25 at 10:30 A.M., showed resident room [ROOM NUMBER] window did not have a window screen and the door scraped the floor. 10. Observation on 06/11/25 at 1:45 P.M., showed resident room [ROOM NUMBER] walls with multiple areas gouged and areas of the trim around the base of the floor coming detached from the wall. Observation showed the closet doors did not completely push inward. 11. Observation on 06/12/25 at 11:37 A.M., showed resident room [ROOM NUMBER] closet door off the hinges and propped against the window and headboard off the bed with exposed screws. Observation showed the walls with chipped paint and gouged. 12. Observation on 06/12/25 at 11:05 A.M., showed resident room [ROOM NUMBER] bathroom wall with an approximate eight inch by eight inch square hole cut with exposed pipes. During an interview on 06/12/25 at 11:05 A.M., the maintenance director said they had to repair a water leak in the bathroom a couple of weeks ago. The maintenance director said after they fixed the leak, he/she left the hole open to the let the wall dry out so it would not mold and he/she just forgot to go back and patch the wall. 14. Observation on 06/12/25 at 11:25 A.M., showed resident room [ROOM NUMBER] walls and floor around the toilet with water damage. Observation showed a sign placed on the toilet Do not use-broken- maintenance is aware. During an interview on 06/12/25 at 11:25 A.M., the maintenance director said the bathroom sustained damage from a water leak that happened in room [ROOM NUMBER] about two months prior. The maintenance director said they planned to make repairs to the bathroom after they fixed the damage in room [ROOM NUMBER], but guessed they forgot to go back and fix it. 15. Observations on 06/12/25 from 1:55 P.M. to 2:30 P.M., showed resident rooms 106, 110 and 120 closet doors off track and resident rooms 111, 117, 124 and 125 did not have a toilet paper roll holder. 16. During an interview on 06/12/25 at 3:00 P.M., the maintenance director said if staff notice something in the facility needs fixed, they are directed to provide a work order to the maintenance department, he/she had not received any work orders about the areas found in disrepair and he/she did not know about the issues with the areas. During an interview on 06/13/25 at 1:58 P.M., Certified Nurse Aide (CNA) F said if he/she notices something that needs a repair, he/she will fill out a work order that are kept at the nurse station and place it into the maintenance department. During an interview on 06/13/25 at 2:42 P.M., the maintenance director said he/she does rounds of the facility, but it has been slacking a little bit on repairs because of other things that need done first. He/She said walls should have been fixed, but he/she has been busy with other things. During an interview on 06/13/25 at 3:54 P.M., the Director of Nursing (DON) said if staff see something that needs repairs they are to write a maintenance order and put it in the box at the front desk and maintenance will pick them up and repair what needs fixed. During an interview on 06/13/25 at 4:54 P.M., the administrator said if staff see something that need repaired, he/she expects them to alert maintenance or charge nurse to submit a work form. He/She said depending on the situation then it may need a direct call to maintenance director to fix as soon as possible.

Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three residents (Resident #11, #18, and #70) out of three residents sampled. The facility census was 79. 1. Review of Marymount Manor Senior Living Community Handbook, dated July 9, 2021, showed the Bed Hold Policy: -Before there is a transfer of a resident to a hospital or resident goes on a therapeutic leave, the resident and family or Durable Power of Attorney (DPOA) will be notified twice. First will be during the admission process by the reading of the Bed Hold Policy. Second notice will be provided to the resident and family or DPOA at the time of transfer to the hospital. A copy of this policy will be sent with other papers accompanying the resident to the hospital. Review of the facility's policies, showed staff did not provide a Bed Hold Policy. 2. Review of Resident #11's medical record showed the resident discharged from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold upon discharge with the resident or the resident's responsible party. 3. Review of Resident #18's medical record showed the resident discharged from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold upon discharge with the resident or the resident's responsible party. 4. Review of Resident #70's medical record showed the resident discharged from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold upon discharge with the resident or the resident's responsible party. During an interview on 06/13/25 at 3:40 P.M., the Director of Nursing (DON) said the facility does not send bed holds with the resident or their responsible party at time of transfer. The DON said there is a bed hold policy in the admission packet they sign at admission, but otherwise did not know this was to be done. During an interview on 06/13/25 at 4:40 P.M., the Administrator said she was aware bed hold being given upon transfer and discharge is in the facility policy and a regulation, however said she believes staff was just not aware they were supposed to be doing which is why it is not being done. The administrator said at this time no one is responsible for this process as it is not being done, but will be assigned to someone going forward.

Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs for eight residents (Resident #12, #17, #18, #19, #29, #31, #41, and #70) out of twelve sampled residents. The facility census was 79. 1. Review of the facility's Care Planning policy and procedure, dated January 2020, showed: -A care plan will be developed upon admission per Centers for Medicaid and Medicare Services (CMS) guidelines; -The care plan will be updated quarterly and annually per CMS guidelines to ensure that there is a continuity of care, and is in accordance with the individuals needs; -The care plan will be updated with a significant change of status condition; -The care plan must be based on the resident assessment, choices, and advanced directives, if any; -As the resident's status changes, the facility, attending physician and the residents representative, to the extent possible, must review and revise care plan goals and treatment choices. 2. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/04/25, showed staff assessed the resident as: -Cognitively impaired; -Independent to complete Activities of Daily Living (ADL); -Diagnosis of dementia. Review of the resident's care plan, dated 04/23/25, showed the care plan did not contain direction or preferences for facial hair or shaves. Observation on 06/10/25 at 11:04 A.M., showed the resident with long facial hair. Observation on 06/11/25 at 9:11 A.M., showed the resident with long facial hair. During an interview on 06/10/25 at 11:04 A.M., the resident said he/she can shave him/herself every couple days. During an interview on 06/13/25 at 1:58 P.M., Certified Nurse AIde (CNA) F said the resident does his/her own personal hygiene but is not sure what the care plan says. 3. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -No restraints; -Required substantial to maximal assistance from staff to roll left and right in bed and dependent on transfers; -Limited range of motion in all extremities; -No oxygen. Review of the resident's care plan, dated 06/10/25, showed the care plan did not contain direction or guidance for oxygen or bed rail use. Observation on 06/11/25 at 8:24 A.M., showed the resident in bed with grab bars up on both sides of the bed. The resident had an oxygen cannula in reach with the concentrator running at two liters (l). During an interview on 06/11/25 at 8:24 A.M., the resident said he/she uses the oxygen when he/she is on her side to help his/her breathing. He/She said the rails on the bed help him/her to move around in bed. During an interview on 06/13/25 at 1:58 P.M., Certified Nurse Assistant (CNA) F said the resident uses bed rails but was unaware of oxygen use. He/she said he/she would have to look at the care plan to know what it says. 4. Review of Resident #18's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required substantial to maximal assistance from staff to sit to lie, lie to sit, and sit to stand; -Dependent for transfers from bed to chair to bed; -Limited range of motion in all extremities; -Diagnosis of heart disease. Review of the resident's care plan, dated 06/11/25, showed the care plan did not contain direction or guidance for bed rail use. Observation on 06/10/25 at 1:48 P.M., showed the resident in bed with grab bars up on both sides of the bed. Observation on 06/13/25 at 1:57 P.M., showed the resident in bed with grab bars up on both sides of the bed. During an interview on 06/13/25 at 1:58 P.M., CNA F said the resident uses bed rails. He/she said he/she would have to look at the care plan to know what it says. 5. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive impairment; -No restraints; -Required partial to moderate assistance from staff to roll left and right in bed and on transfers; -Limited range of motion impairment on one side of lower extremity. Review of the resident's care plan, dated 04/03/25, showed the care plan did not contain direction or guidance for bed rail use. Observation on 06/13/25 at 01:43 P.M., showed the resident in bed with bilateral hand rails in upright position. 6. Review of Resident #29's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required set-up and clean up assistance from staff for personal hygiene; -Diagnosis of aphagia (language disorder effecting ability to communicate) and stroke. Review of the resident's care plan, dated 06/11/25, showed the care plan did not contain direction or preferences for facial hair or shaving. Observation on 06/10/25 at 10:58 A.M., showed the resident with long facial hair and long fingernails. Observation on 06/11/25 at 8:24 A.M., showed the resident with long facial hair and long fingernails. During an interview on 6/10/25 at 10:58 A.M., the resident was difficult to understand but when asked if he/she was able to perform own hygiene, he/she indicated a thumbs up. During an interview on 06/13/25 at 1:58 P.M., CNA F said the resident needs assistance with shaves and nail care but will normally tell the staff when ready. 7. Review of Resident #31's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate Cognitive Impairment; -No restraints; -Independent assist with rolling left and right in bed and transfers. Review of the resident's care plan, dated 05/09/25, showed the care plan did not contain direction or guidance for bed rail use. Observation on 06/10/25 at 11:57 A.M., showed the resident in bed with bilateral bed rails in upright position. Observation on 06/11/25 at 9:00 A.M., showed the resident in bed with bilateral bed rails in upright position. Observation on 06/12/25 at 10:17 A.M., showed the resident in bed with bilateral bed rails in upright position. Observation on 06/13/25 at 10:02 A.M., showed the resident in bed with bilateral bed rails in upright position. 8. Review of Resident #41's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively Intact; -No restraints; -Supervision or touching assist with rolling left and right in bed and transfers. Review of the resident's care plan, dated 04/23/25, showed the care plan did not contain direction or guidance for bed rail use. Observation on 06/10/25 at 12:04 P.M., showed the resident in bed with left hand rail in the upright position. Observation on 06/11/25 at 09:14 A.M., showed the resident in bed with left hand rail in the upright position. 9. Review of Resident #70's Quarterly MDS, dated [DATE], showed staff assess the resident as: -Moderate Cognitive impairment; -No restraints; -Independent assist with rolling left and right in bed and supervision or touching assist from staff for transfers; -Limited range of motion impairment on one side of lower extremity. Review of the resident's care plan, dated 05/21/25, showed the care plan did not contain direction or guidance for bed rail use. Observation on 06/12/25 at 02:09 P.M., showed the resident in bed with bilateral hand rails in the upright position. 10. During an interview on 06/13/25 at 1:58 P.M., CNA F said he/she has access to the care plans but just knows the resident's needs because he/she takes care of them everyday and does not always read the care plans. During an interview on 06/13/25 at 3:01 P.M., the MDS nurse said he/she is responsible for updating care plans. He/She said ADL preferences are not always included on the care plans. Side rails or bars are typically added to the quarterly side rail assessments and not the care plans. During an interview on 06/13/25 at 3:51 P.M., the Director of Nursing said care plans should include oxygen, bed rail use, activities, social service needs, and ADL preferences and needs. He/She said the MDS nurse is responsible to oversee that care plans are kept up to date and correct. During an interview on 06/13/25 at 3:55 P.M., the Administrator said care plans should reflect resident care needs and be kept up to date and accurate by the MDS nurse using the Resident Assessment Instrument (RAI) manual, a manual used to facilitate accurate and effective resident assessment practices.

Based on observation, interview and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interests for residents who reside on the memory care unit. The facility census was 79. 1. Review of the facility's policy titled, Memory Care Policy, undated, showed staff were directed to do the following: -Activities are done three times a day, seven days a week on memory care. -We include crafts, spiritual, emotional, cognitive, social, physical, creative, and independent activities; -We offer a one-to-one program to those who choose to not attend group activities or who cannot attend group activities. 2. Review of the Memory Care Unit Activity Calendar, dated June 2025, showed: -Tuesday, 06/10/25; 10:00 A.M. This day in History, 10:30 A.M. Seek and Find, 3:00 P.M., Iced Tea and Snack Social; -Wednesday, 06/11/25; 10:00 A.M. Manicures, 2:30 P.M. National German Chocolate Day; -Thursday, 06/12/25; 10:00 A.M. This day in History, 1:30 P.M. Curt [NAME] Music, 3:00 P.M. No bake cookie making; -Friday, 06/13/25; 10:00 A.M. This day in History, 1:30 P.M. Chair Dance Class, 3:30 P.M. Patio Social. 3. Observation on 06/10/25 at 11:31 A.M., showed the memory care unit did not have a current activity calendar posted in residents' rooms. Observation on 06/11/25 at 9:11 A.M., showed room [ROOM NUMBER] activity calendar dated November 2024. Observation on 06/11/25 at 9:17 A.M., showed room [ROOM NUMBER] activity calendar dated December 2024. Observation on 06/11/25 at 10:05 A.M., showed the memory care unit did not have a scheduled activity. Observation showed ten residents in the dining room without an activity. Observation on 06/11/25 at 3:00 P.M., showed the memory care unit did not have a scheduled activity. Observation showed 14 residents in the dining room without an activity. Observation on 06/12/25 at 10:10 A.M., showed ten residents in dinning room and five residents in the hallway without a staff lead activity. Observation on 06/12/25 at 1:38 P.M., showed one resident in dining room and six residents in the hallway without an activity. Observation on 06/12/25 at 3:21 P.M., showed eight residents in dining room and three residents in hallway without an activity. Observation on 06/13/25 at 10:10 A.M., showed six residents in dining room and five residents in hallway without an activity. Observation on 06/13/25 at 1:40 P.M., showed seven residents in dining room and four residents in hallway without an activity. 4. During an interview on 06/13/25 at 10:06 A.M., Nurse Aide (NA) A said on slow days they have a balloon and pool noodles they can toss around with the residents. He/She said they pass out water and lemonade and the residents can watch tv. He/She said if its nice outside they can take residents out back to the patio. He/She said sometimes they can do nails with the ladies. During an interview on 06/13/25 at 10:15 A.M., the Certified Medication Technician (CMT) B said if the aides have time they toss around balloons, paint fingernails, or take residents out on the back patio if its nice outside. He/She said he/she has not seen an activity calendar around on the memory care unit, but its usually behind the nurses station. During an interview on 06/13/25 at10:21 A.M., the Registered Nurse (RN) C said its usually the aides who do activities on the memory care unit if they have time. He/She says sometimes they have a music person go down on unit or if they have enough staff the resident can come out to the main dining room and listen to music. He/She said he/she does not remember seeing an activity calendar on the memory care unit. During an interview on 06/13/25 at 2:23 P.M., the activity assistant said he/she tries to go back on the memory care unit once a day to do an activity. He/She said if there is enough staff to come with residents, then the residents can out to main dinning room and listen to music. He/She said there is another activity assistant but he/she is out at the hospital. During an interview on 06/13/25 at 2: 36 P.M., the activity director said activities are done three times a day. He/She said he/she does the activities that are on the calendar provided and each activity is listed by where it is located. He/She said on memory care unit sometimes the residents don't want to do the listed activity and if that is the case they find a different activity that they want to do. He/She said there were no staff lead activities this week on memory care unit because their part time activity staff is in hospital. He/She the activity assistant goes around the beginning of each month and posts activity calendars in each resident's room and at the nurses station. He/She said the importance of activities on the memory care unit is the help with behaviors and to give them stimulation other than just sitting there. During an interview on 06/13/25 at 4:14 P.M., the Director of Nursing (DON) said activities on the memory care have been a problem and they haven't had a lot of activities. He/She said the memory care unit maybe only has one activity every once in a while. He/She said an activity calendar should be in each room, dinning room, and at nurses station. He/She said it is the activity director responsibility to ensure calendars are posted, but said he/she has not had time, due to working the floor. He/She said the importance of having activities on the memory care unit is it keeps the residents busy, helps with memory, and it's just good all the way around for them and keeps them from getting in trouble. During an interview on 06/13/25 at 4:44 P.M., the administrator said memory care should have activities three times a day, seven days a week. He/She said the activities should be something of purpose and not just sitting and watching tv or coloring, something stimulating for the residents. He/She activity calendars should be posted in resident rooms and out by the nurse's station. He/She said the importance of activities is to help lower behaviors and stimulation to help prevent wandering and prevent further confusion.

Based on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor antibiotic use. The facility census was 79. 1. Review of the facility's policy titled, Antibiotic Stewardship, dated 8/9/17, showed as a facility, Marymount will do the following to improve antibiotic use: -Commit resources for monitoring antibiotic use and providing feedback to staff; -Identify and empower the medical director and/or consultant pharmacist to assist in the leadership stewardship activities; -Have clear policies to improve prescribing practices for staff to ensure residents are not started on antibiotics unless needed; -Establish minimum criteria for prescribing, antibiotics (medical director) -Develop facility-specific standards for empiric antibiotic use, based on data from the facility -Review antibiotic appropriateness and resistance patterns on a regular basis. Review of the facility's antibiotic stewardship program, showed staff did not have a program in place to track and trend antibiotic usage. During an interview on 06/13/25 at 12:45 P.M., Assistant Director of Nursing (ADON) said he/she will be in charge of this task but has not started or been trained to do so yet. During an interview on 06/13/25 at 1:00 P.M., the Director of nursing (DON) said he/she has not been doing an antibiotic stewardship program, the previous ADON was responsible for it, and he/she walked out. The DON said he/she was not trained how to do this task so it is not done. The DON said the ADON will be responsible for this task eventually. During an interview on 06/13/25 at 1:45 P.M., the administrator said he/she was not aware of the program not being done until today. The previous ADON was the one responsible but is not longer here.

Based on interview and record review, the facility staff failed to follow their abuse and neglect policy by not reporting an allegation of sexual abuse within the required time frame. This affected one resident (Resident #2). The sample was 9. The census was 80. Review of the facility's Abuse Policy and Procedures/Investigation Protocols, dated 12/14/18, showed: -The facility is committed to protecting residents from mistreatment, neglect, abuse and misappropriation of resident property; -The following policy has been put in place to insure protection and prevention from such treatment: -1. All employees hired are subject to a criminal record check; -a. Results of criminal record check will be reviewed by the Administrator and appropriate department manager to determine employment eligibility; -b. Any criminal conviction that may be cause for concern will result in immediate dismissal (if conviction is after hire) or employment ineligibility; -2. The Department of Health and Senior Services is contacted on each new employee to verify that they are not listed on the EDL (employee disqualification list); -3. All new hires are subject to a 90-day probation period to insure stability for this type of employment; -4. All employees are required to attend an orientation which covers our policies/procedures; -Time Period for Reporting Possible Abuse/Neglect: The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey agency) in accordance with State law through established procedures; -If an incident occurs that warrants police intervention, the administrator and/or appropriate manager will notify the [NAME] Police Department at [PHONE NUMBER]; -Facility Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, abuse or misappropriation of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: -Conducting pre-employment screening of employees; -Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect, abuse and misappropriation; -Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; -Identify occurrences and patterns of potential mistreatment; -Immediately protecting residents involved in identified reports of possible abuse; -Implementing systems to investigate all reports and allegations of mistreatment promptly, aggressively and making the necessary changes to prevent future occurrences; -Filing accurate and timely investigative reports. -This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. This facility will not knowingly employ an individual who has been convicted of abusing, neglecting, or mistreating individuals; -Definitions: -Abuse: Abuse means any physical or mental injury, or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental and psychosocial well-being. This assumes that all instances of abuse of residents even those in a coma, cause physical harm or pain or mental anguish; -Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual Abuse is defined as non-consensual sexual contact of any type with a resident. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Orientation and Training of Employees: During orientation of new employees, the facility will cover the following topics: -Sensitivity to resident rights and resident needs; -Dementia Management - Person-Centered Care of Persons with Dementia and Prevention of Abuse; -Staff obligations to prevent and report abuse, neglect and misappropriation of resident property; and how to distinguish theft from lost items and willful abuse from insensitive staff actions that should be corrected through counseling and additional training/education; -How to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff; -How to recognize and deal with burnout, frustration and stress that may lead to inappropriate responses or abusive reactions to residents; -On an annual basis, staff will receive a review of the above topics; -Internal Reporting Requirements and Identification of Allegations: -Employees are required to report any occurrences of potential abuse, neglect, exploitation, and/or misappropriation of resident property they observe, hear about, or suspect to the Administrator or Director of Nursing (DON) via phone call immediately; -Internal Investigation of Allegations and Response: -1. Appointing an Investigator. Once the Administrator/DON determines that there is possible mistreatment, the Administrator or DON will appoint a person to take charge of the investigation. The person in charge of the investigation will obtain a copy of any documentation relative to the incident and the Resident Protection Investigation Procedures. -2. Following the Resident Protection Investigation Procedures. The appointed investigator will follow the Resident Protection Investigation Procedures. The procedures contain specific investigation paths depending on the nature of the allegation, and procedures for investigation, interview parameters and reporting requirements. -3. Confidentiality. The investigator shall do as much as possible to protect the identities of any employees and residents involved in the investigation, until the investigation is concluded. After a conclusion based on the facts of the investigation is determined, internal reports, interviews and witness statements shall be released only with the permission of the Administrator or the facility attorney. Even if the facility investigation is not complete, the Administrator will cooperate with any Department of Health and Senior Services investigation in the matter; -4. Updates to the Administrator. The person in charge of the investigation will update the Administrator or designee during the progress of the investigation. The Administrator or DON will keep the resident or resident's representative informed of the progress of the investigation; -5. Final Investigation Report. The person in charge of the investigation will report the conclusions of the investigation to the Administrator or designee within five working days of the reported incident. The final investigation report shall contain the following: -Name, age, diagnosis and mental status of the resident allegedly abused or neglected; -The original allegation (note day, time, location, the specific allegation, by whom, witness to the occurrence, circumstances surrounding the occurrence and any noted injuries.); -Facts determined during the process of the investigation, review of medical record and interview of witnesses: -Conclusion of the investigation based on known facts; -If there is a police report, attach the police report; -If the allegation is determined to be valid and perpetrator is an employee, include on a separate sheet the employee's name, address, phone number, title, date of hire, date of birth, social security number, copies of previous disciplinary actions and current status (still working, suspended or terminated); -Attach a summary of all interviews conducted, with the names, addresses, phone numbers and any other identifying information; -The Administrator will review the report. The Administrator/DON is responsible for informing the resident or their representative of the results of the investigation and any corrective action taken. The final written report will be sent to the Department of Health and Senior Services; -Protection of Residents: The facility will take steps to prevent mistreatment while the investigation is underway; -Residents who allegedly mistreated another resident will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his/her safety, as well as the safety of other residents; -Accused individuals not employed by the facility will be denied unsupervised access to the resident during the course of the investigation; -Employees of this facility who allegedly mistreated the resident(s) will be suspended or terminated immediately until the results of the investigation have been reviewed by the Administrator; -Investigation Procedures: Regardless of the specific nature of the allegation (physical, sexual, verbal/mental, misappropriation or neglect), the investigation shall consist of: -A review of the incident reports; -Completion of a written report on the status of the investigation; -An interview with the person(s) reporting the incident; if warranted after obtaining statement; -An interview with the resident; -Where appropriate, an interview with the resident's attending physician or psychiatrist; -A review of the medical records of any residents involved in the occurrence; -If the accused individual is an employee, review the personnel file to check for references, background check and documentation of orientation and training; -An interview with staff members having contact with the resident and accused individual during the period of the alleged incident; -Where appropriate, interviews with the resident's roommate, family members, visitors or others who were in the vicinity of the incident; -Interview other employees to determine if they have witnessed other incidents of mistreatment; -Obtain address, phone number and social security number of the accused individual; -An interview with the accused individual or individuals; -A review of all circumstances surrounding the incident; -The Interview Process: -The interviewer will be asking the person being interviewed to write the details of the incident in their own handwriting; -Witnesses must sign and date statements; -As much as possible, all interviews should be conducted with a witness to review; -Record the name, address, phone number, date of birth and social security number of each witness; -For the protection of both employees and residents involved in the investigation, these interviews should be kept confidential during the progress of the investigation and only released with the permission of the Administrator or facility attorney; -Final Investigation Report: -The summary, conclusions and results of the investigation will be recorded on a final written report and submitted to the Administrator within five days of the occurrence. The Administrator or DON may forward a copy to the facility attorney; -After a conclusion based on the investigation is determined, internal reports, interviews, witness statements and identities of individuals involved shall be released only with the permission of the Administrator or facility attorney. Even if the facility investigation is not complete, the Administrator will cooperate with the Department of Health and Senior Services investigation into the matter; -After reviewing the final report, the Administrator or DON will notify the resident's representative of the results of the investigation; -The Administrator or designee shall answer any questions regarding a particular incident; -A summary of incident investigations involving the resident harm and possible mistreatment of the resident will also be sent to the facility Quality Improvement Committee, with the identity of the individual involved kept confidential; -Resident Protection Investigation Paths: Possible Sexual Abuse; - Definition: Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes, but is not limited to: -Unwanted intimate touching of any kind especially of breasts or perineal area; -All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; -Forced observation of masturbation and/or pornography; -Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident; -Appears to want the contact to occur, but lacks the cognitive ability to consent; -Does not want the contact to occur; -Other examples of nonconsensual sexual contact may include, but are not limited to, situations where a resident is sedated, is temporarily unconscious, or is in a coma; -Determine if the allegation involves either physical sexual contact involving penetration, or verbal harassment or physical contact that did not involve penetration. Review of Resident #2's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 8/29/24, showed: -Moderate cognitive impairment; -Verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others): Behavior of this type occurred one to three days; -Rejection of care: Behavior not exhibited; -Upper and lower extremity impairment on one side; -Frequently incontinent of bladder; -Occasionally incontinent of bowel; -Diagnoses included traumatic brain injury (TBI), seizure disorder, hemiplegia (total or partial paralysis of one side of the body), anxiety disorder, depression, and schizophrenia (mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). Review of the resident's current care plan, showed no care plan or interventions related to behaviors regarding making allegations of inappropriate touching. Review of the facility's initial reporting form, dated 9/15/24, showed: -Allegation type: Sexual; - Licensed Practical Nurse (LPN) D, reported the incident on 9/15/24 at 4:30 P.M., Previous Administrator (PA) notified on 9/15/24 at 4:45 P.M.; -Alleged victim: Resident #1; -Alleged perpetrator: Nursing Assistant (NA) B; -Allegation details: It was reported that a staff member was changing the resident's diaper and started playing with the resident's genitals, the resident did not know the staff member's name; -No physical harm or pain. Resident was upset and crying saying it was not right, no change in condition from baseline; -NA B suspended pending investigation. DON spoke with the resident and the resident said it happened yesterday on 9/14/24 in the afternoon. When asked to describe the staff member the resident said it was Certified Nursing Assistant (CNA) C's sibling. The resident described the staff member as an African American. The resident stated NA B was changing his/her diaper and started playing with his/her genitals. Resident said he/she did not report it to anyone yesterday. DON informed staff when providing care for the resident there needs to be two staff members; -On 9/16/24 at 1:51 P.M., the DON reported the resident told LPN D on 9/15/24 about the allegation of a staff member playing with his/her genitals while changing the resident, resident told LPN D that he/she did not think it was right and did not appear distressed at the time. The resident has told four different stories including different dates and circumstances. Initially the resident reported an African American staff member came into his/her room on Saturday afternoon 9/14/24 to change him/her and while doing so was inappropriately touched. There were not staff members working at that time that matched the resident's description. The resident then reported it happened while he/she was being put to bed. In a statement NA B said after midnight on 9/14/24 the resident asked for help, the resident said his/her bed was wet and he/she needed changed. NA B changed the resident's bedding and the resident and put on a new brief. The resident requested water and NA B got the resident water. A few hours later, the resident said the brief was too small and he/she needed to be changed. NA B got a different brief and changed the resident and did not fasten the brief too tightly so it would not be uncomfortable. The resident then asked to sit up in bed and told NA B that a staff member that looked like him/her had touched him/her earlier in the night. NA B went and got his/her sibling CNA C, and the resident said it was not CNA C but the person looked like him/her. Neither NA B nor CNA C reported what the resident said. The resident told the PA the incident happened on Wednesday night and the staff member did it with a towel. The DON believes the resident mistook being cleaned as being touched inappropriately. Review of witness statement from NA B, undated, showed: -During my shift starting Saturday night 9/14/24 going into Sunday morning a hour or 2 after 12:00 A.M. I heard the resident asking for help from his/her room. When I went to check on him/her he/she told me that his/her bed was wet, so I asked him/her if he/she needed his/her brief changed and he/she said yes. I went to get towels, a brief and a bed pad and told him/her I was going to change him/her brief for him/her. I sprayed him/her with soap and wiped him/her with towels and replaced his/her brief and bed pad and he/she asked for a drink of water which I gave to him/her. Sometime later he/she turned on his/her call light and I went to check on him/her. He/She told me that his/her brief was too tight. I told him/her I will be going to get a new brief and that I would make sure I didn't make it too tight. I changed his/her brief again and he/she told me he/she wanted to sit up for a bit. I helped him/her sit up in the bed for a bit and when he/she told me he/she was ready to lay back down I helped him/her lay back down and asked him/her was the position of the bed comfortable for him/her and he/she said yes. He/She then told me that someone was in his/her room earlier playing with him/her. I asked him/her what did he/she mean and he/she said someone touched him/her. He/She then said that it looked like my sibling, but it wasn't my sibling. When he/she said that I assumed maybe he/she thought I was CNA C at the time given the circumstances as I was the only one who had been in there to change him/her but I did not touch him/her inappropriately and I felt maybe he/she had just woken up from his/her sleep and was a bit disoriented. It was close to time to start getting the residents up so as me and CNA C prepared, we started with the resident since he/she had already woken up. He/She asked me to get him/her a cup of water for another drink and then he/she asked if I could get him/her a peanut butter and jelly sandwich and I did then I asked him/her if he/she needed anything else he/she said no. I told CNA C about what he/she said and it was time to start getting the residents up and we did the resident first since he/she had recently woken up. When we went into his/her room he/she told CNA C the same thing he/she told me when I was in there to change his/her brief. He/She told CNA C that the staff member looks like CNA C's sibling, but it wasn't CNA's sibling. CNA C pointed at me and asked him/her was I the person he/she was talking about, and the resident looked at me and said no it wasn't me it was somebody else. We proceeded to get the rest of the residents up and that was the end of shift. Review of witness statement from CNA C, undated, showed: -At some point in the night NA B approached me and stated the resident had told him/her someone came into his/her room and was inappropriately touching him/her. The resident was asleep the first time we checked on him/her. So, when NA B checked on the resident, he/she had just woken up and after a long time of working with the resident I know that he/she can be disoriented when waking up or at random. So, when NA B told me that I brushed it off because there were times where the resident told me his/her sibling was just in his/her room or other people that were not around or haven't seen the resident that day. Later for get up we got the resident up first because he/she was yelling my name for help. The resident then told me the same thing that someone touched him/her and the resident said that person looked like my sibling bit it was not my sibling. I even pointed to my sibling and asked him/her if it was NA B and the resident said no it was not NA B but when the resident said no he/she was smirking like it was a joke as if there's no way it was NA B that did it. We got him/her changed and dressed and he/she never mentioned it again. I am not calling the resident a liar but he/she does have a brain injury which is why he/she says things that do not make sense. The resident is often confused and talks to people who are not there. Review of witness statement from LPN D, dated 9/15/24, showed: -I just finished helping the resident to stand up against the wall using the handrail. The resident said come here, I came closer and he/she said in a whisper that a staff member was rubbing his/her genital area and he/she did not know the staff member's name. Then he/she said I don't think its right. I comforted him/her and took him/her to the TV area and got him/her a drink. The resident is not upset or crying at this time. Review of witness statement from PA, dated 9/16/24, showed: -On 9/16/24 at approximately 10:00 A.M. I spoke with the resident regarding the incident he/she reported yesterday. The resident stated that an African American staff member wearing work clothes (yellow shirt with suspenders) about 5 foot 11 inches with short black hair was changing his/her diaper and was rubbing his/her genital area. I asked if the staff member was wearing gloves, and the resident stated the he/she did not know. I asked if the staff member had anything in his/her hand and the resident stated the staff member was using a towel. I asked what day this occurred, and the resident stated Wednesday, and it was before dark. I asked the resident what day today was and he/she said Tuesday (it is Monday). Review of the facility follow up investigation report, dated 9/16/24, showed: -DON obtained statements from staff and no other staff members saw or heard anything. The resident has changed his/her story a few times. Resident has a TBI and does get confused at times; -On 9/16/24 the DON spoke to the resident representative (RR) and the RR stated that the resident has made previous accusations before and the RR thinks that the facility should keep the staff member working at the facility and just move the staff member to a different hall; -DON interviewed the resident and all staff involved and that was at the facility at the time of the allegation; -DON does not have any reason to believe that NA B did anything to the resident; -No evidence of staff doing anything inappropriate; -Residents interviewed did not see anything going on between the resident and NA B; -LPN D was on the hall when the resident told what happened but it was the next day; -None of the staff saw anything happen; -There was no evidence of NA B doing anything to the resident. The residents statement has changed several times. The resident does have a history of TBI; -The DON does not feel that the staff member NA B did anything to the resident; -The resident will have two staff members at a time when care is provided. During an interview on 9/24/24 at 10:17 A.M., the DON said she did not believe what the resident said happened. The first time she interviewed the resident, he/she said he/she was touched inappropriately on his/her genital area. The resident stated he/she did not know who it was and said it happened around 3:30 P.M. to 4:00 P.M. in the afternoon. The resident said it was not NA B or CNA C. The PA interviewed the resident after the DON interviewed the resident the next day. The resident told LPN D on Sunday and LPN D reported it to the DON and the DON came into the building Sunday evening and interviewed the resident and NA B and the other staff. NA B said when he/she went in to clean up the resident Saturday 9/14/24 night into Sunday morning, the resident told NA B someone had touched him/her inappropriately. NA B and CNA C went into the resident's room together and the resident could not tell them anything else. NA B and CNA C did not report the allegation to anyone. The DON expected both NA B and CNA C to report the allegation immediately to the Charge Nurse and the DON. The DON said she educated NA B and told him/her if anyone makes an accusation, it needs to be reported immediately. The DON said NA B is new and the facility just hired him/her. NA B is not certified and is going through classes to obtain his/her certification. The DON said there have not been any complaints regarding NA B and the care provided. The resident has a history of making false allegations of people touching him/her. The DON said the RR said the resident has made allegations in the past and asked the facility not to terminate NA B regarding the allegation. CNA C did not say why he/she did not report the allegation to anyone. The DON did not reeducate CNA C. During an interview on 9/25/24 at 7:11 A.M., NA B said he/she went into the resident's room to check on him/her. The resident needed to be changed, and NA B sat him/her up on bed. The second time he/she went into change him/her is when the resident told NA B someone was playing with him/her. NA B asked the resident what he/she meant, and the resident said someone was touching him/her and it looked like your sibling, but it wasn't your sibling. NA B said that threw him/her off when he/she said that because NA B knew he/she was the only one in the room at that point. NA B thought maybe he/she was confused, and he/she was talking about NA B and not CNA C. NA B said he/she did not touch the resident inappropriately at all when providing peri care (washing the genitals and anal area). He/She provided the peri care as normal. NA B said he/she used a washcloth and soap spray when cleaning the resident. After that, NA B told his/her sibling what happened. CNA C went into the room with NA B and the resident said the same thing to CNA C. The resident said someone was playing with him/her and told CNA C it looked like his/her sibling NA B. CNA C pointed to NA B and asked if it was NA B and the resident said it was not NA B. NA B said he/she didn't tell anyone other than CNA C because he/she was thrown off and didn't know what to do. During an interview on 9/25/24 at 7:33 A.M., CNA C said NA B approached CNA C during the night shift on 9/14/24 and informed him/her what the resident said; that someone went into his/her room and was feeling on him/her inappropriately. CNA C went into the resident's room towards the end of the shift. The resident did not give too much detail and just said someone was feeling on him/her inappropriately. The resident said the staff member kind of looked like your sibling, but it was not your sibling, NA B and CNA C were both in the room at that time. CNA C made sure the resident knew who CNA C was and who he/she was talking to. CNA C asked the resident to look at him/her and asked the resident if it was NA B and had the resident look at NA B and asked the resident if it was NA B and he/she said, oh no it was not NA B. CNA C said sometimes when he/she went in to care for the resident, at like midnight, the resident might say something when he/she wakes up. The resident has said his/her sibling was just in his/her room yelling and woke him/her up. CNA C said he/she has not reported that type of situation to the nurse but with the accusation the resident made, he/she should have reported it to the nurse. CNA C said he/she did not report it because he/she has seen the resident have confusion before. CNA C would normally report it if the resident was in the right state of mind. CNA C now knows he/she should have reported it right away even if the resident is confused. During an interview on 9/25/24 at 7:49 A.M., Certified Medication Technician (CMT) E said he/she worked the night shift on 9/14/24 on the resident's hall. CMT E said there was nothing abnormal that night. CMT E said the resident yells out and is not very coherent. The resident will yell out different staff members names and family members names. CMT E administered Tylenol to the resident around 6:00 A.M. The resident did not mention anything to CMT E when he/she administered the medication. The resident never reported anything to him/her about being touched inappropriately. During an interview on 9/25/24 at 9:30 A.M., the resident said this staff member changed his/her diaper and he/she was lying in bed and the staff member had his/her hand in a towel and he/she was doing circles on his/her genital area. The resident said he/she felt like the staff member was doing more than just cleaning and it made him/her feel uncomfortable. The resident said it was disgusting and makes him/her feel sick. The resident said he/she is almost positive it was a staff member and he/she thinks the person had staff member clothes on. The resident could not describe what staff member clothes the person had on. The resident said he/she does not know who it was. The resident said the staff member came into his/her room that night and asked if he/she needed anything, and the resident said no he/she was fine, and the person left. The resident does not know if he/she has seen that person again after that night. The staff member was African American and had really short hair. The resident said he/she told the staff members so-called sibling about it but he/she doesn't know if it was the sibling or not. The resident reported the incident to LPN D a couple of hours after it happened. The resident said they were at a function where they were all having lunch together. The resident said he/she was not sure if he/she should tell LPN D or not and the resident waited a couple hours and then told LPN D. The resident said it happened in the late afternoon, he/she didn't remember what day it happened, but it was a weekday. The resident said he/she feels safe at the facility. During an interview on 9/25/24 at 10:06 A.M., the RR said he/she is aware of the accusation the resident made. The facility contacted him/her. The RR said the resident has a history of making accusations. He/She made them at his/her previous facility. The RR said he/she cannot rely on the resident's mental capacity and he/she doesn't know what to believe half the time. During an interview on 9/25/24 at 10:36 A.M., LPN D said during the afternoon/evening on 9/15/24, the resident called LPN D over to him/her. LPN D thought the resident was going to say he/she needed change

Based on interview and record review, the facility failed to follow their written policy permitting residents to return to the facility after they have been hospitalized , for one of 9 sampled residents (Resident #1). The census was 80. Review of the facility's Discharge Procedures policy, undated, showed: -Discharge Procedures - The facility shall permit each resident to remain in the facility unless: -The transfer or discharge is appropriate because the resident's welfare and the resident's needs cannot be met by the facility; -The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; -The safety of individuals in the facility is endangered; -The health of individuals in the facility would otherwise be endangered; -The resident has failed, after reasonable and appropriate notice, to pay for (or have paid under Medicare or Medicaid) a stay at the facility; -Definitions: -Transfer: Moving a resident from one institutional setting to another institutional setting for care; -Discharge: Releasing from a facility or refusing to readmit a resident from a community setting under circumstances where the resident has not consented or agreed with the move or decision to refuse readmittance. Refusal to readmit a former resident shall not constitute a discharge if the former resident has been absent from the facility for more than ninety days; -Consent to or agreement with transfer or discharge means one of the following: -1. The resident or a legally authorized representative has consented to, agreed with, or requested the discharge; -2. The resident's treating physician has ordered the transfer, and the releasing facility intends to readmit the resident (example: hospitalization ); -Consent of the resident: The resident, with sufficient mental capacity to fully understand the effects and consequences of the transfer or discharge, consents to or agrees with the transfer or discharge; -Legally authorized representative: A duly appointed guardian or an attorney-in fact who has current and valid power to make health care decisions for the resident; -Documentation: When transferring or discharging a resident, the resident's clinical record shall be documented. Record and document in detail in each affected resident's record the reason for the transfer or discharge. The recording of the reason for transfer or discharge shall be entered into the resident's record prior to the date the resident receives notification of transfer or discharge, or prior to the time when the transferring or discharging facility decides to transfer or discharge the resident. Documentation for the transfer or discharge is obtained from: -The resident's personal physician; -The facility administrator or Director of Nursing; -Before transfer or discharge, the facility shall: -1. Send written notification to the resident in a language and manner reasonably calculated to be understood by the resident. The notice must also be sent to any legally authorized representative of the resident and to at least one family member. A copy of the notice will be forwarded to the Department of Health and Senior Services regional office and the regional coordinator of the Missouri State Ombudsman's office; -2. Include the following information in the written notice: -The reason for the transfer or discharge. Include specific details regarding the reason and previous intervention attempts, if appropriate; -The effective date of transfer or discharge; -The resident's right to appeal the transfer or discharge to the director of the Department of Health and Senior Services hearing official within thirty days of the receipt of the notice; -The address to which the request for a hearing should be sent: Administrative Hearings Unit, Division of Legal Services, PO Box 570, [NAME] City MO 65102-1527; -That filing an appeal will allow a resident to remain in the facility until the hearing is held unless a hearing official finds otherwise; -The location to which the resident is being transferred or discharged ; -The name, address and telephone number of the designated regional long- term care ombudsman office; -Time Frames: The notice of transfer or discharge shall be made no less than 30 days before the resident is to be transferred or discharged . In the case of an emergency discharge, the notice shall be made as soon as practicable before the discharge when it specifically alleged in the notice: -The safety of individuals in the facility would be endangered. The notice must include specific facts upon which the facility has based its determination that the safety of said individuals would be so endangered; -The health of individuals in the facility would be endangered. The notice must include specific facts upon which the facility has based its determination that the health of said individuals would be so endangered; -The resident's health has improved sufficiently to allow a more immediate transfer or discharge. The notice must include specific facts upon which the facility has based its determination; -An immediate transfer or discharge is required by the resident's urgent medical needs. The notice must include specific facts upon which the facility has based its determination; -The resident has not resided in the facility for thirty days; -hospitalized Residents: If a hospitalized resident, and/or proxy, decides the resident will not return to the facility following hospitalization , facility will document conversation with family in the resident's medical record. When the resident, and/or proxy, comes to pick up the resident's belongings, the facility will have the resident, and/or proxy, sign the discharge form stating the resident will no longer return to the facility. The facility staff will inform the resident, and/or proxy, should they wish to return, the facility will follow new admission protocols by reviewing the resident's hospital records to determine admission. Review of the facility's Admissions Policy, dated 10/30/17, showed: -Purpose: The facility understands that the transition into a skilled nursing facility can be trying. The purpose of this policy and procedure is to facilitate a fluid transition of a resident into the skilled nursing facility; -5. Medical information will be requested to be reviewed by the interdisciplinary team to ensure the facility will be able to meet the needs of the potential resident. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/18/24, showed: -Admission: 7/11/24; -Moderate cognitive impairment; -Preadmission screening and resident review (PASRR): Has the resident been evaluated by level II PASRR and determined to have a serious mental illness and/or mental retardation or related condition: Yes; -Level II PASRR conditions: Serious mental illness and mental retardation; -Delirium: Is there evidence of an acute change in mental status from the resident's baseline: Behavior not present; -Inattention: Did the resident have difficulty focusing attention, for example being easily distractable, or having difficulty keeping track of what was being said: Behavior not present; -Disorganized thinking: Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject): Behavior not present; -Social isolation: Never; -Behavioral symptoms: -Physical behavioral symptoms directed toward others (hitting, pushing, scratching, grabbing, abusing others sexually): Behavior not exhibited; -Verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others): Behavior not exhibited; -Other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds): Behavior not exhibited; -Rejection of care: Behavior not exhibited; -Lower extremity (hip, knee, ankle, foot): Impairment on one side; -Dependent on staff for toileting, lower body dressing, put on/take off footwear, roll left to right, sit to lying and lying to sitting on the side of the bed; -Substantial/Maximal assistance (helper does more than half the effort) for upper body dressing and personal hygiene; -Always incontinent of bladder and bowel; -Discharge Plan: Is there an active discharge plan in place for the resident to return to the community: No; -Diagnoses included bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), diabetes, diabetic peripheral (away from the center) angiopathy (disease of the blood vessels) with gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), cutaneous (skin) abscess of left lower limb, chronic kidney disease (CKD, impaired kidney function), respiratory failure with hypoxia (low levels of oxygen in body that can causing difficulty breathing, confusion, restlessness, rapid heart rate, and bluish colored skin) and severe sepsis (Sepsis causes an inflammatory response in the body. Severe sepsis occurs when one or more of your body's organs are damaged from the inflammatory response) with septic shock (life-threatening condition that happens when blood pressure drops to a dangerously low level after an infection). Review of the resident's current care plan, showed no care plan interventions related to behaviors or interventions. Review of the resident's nurse's notes, dated 7/11/24 through 7/26/24, showed: -7/11/24 at 6:11 P.M., resident admitted to the facility; -7/11/24 at 6:17 P.M., resident alert and oriented (A&O) times (x) 2 (Level of awareness of (1) self, (2) place, (3) time, and (4) situation. The higher the number, the better oriented a person is considered. Healthcare providers score a person's orientation on a scale of 1 to 4.) with some mild retardation noted; -7/13/24 at 11:09 P.M., resident resistive to care at times. One on one resident becomes less anxious and makes needs known; -7/15/24 at 12:14 P.M., resident needs total care with transfers and activities of daily living (ADLs, activities related to personal care bathing, toileting, dressing, etc.) and meals. Resident assisted into wheelchair and resident yelled so much the resident was assisted back to bed; -7/16/24 at 1:05 P.M., resident at times can make sense when verbalizing his/her needs; -7/18/24 at 11:25 A.M., resident A&O x 1 (self). Resident hollers out inappropriately and difficult to redirect; -7/19/24 at 11:30 A.M., resident yells loudly at people in hallway walking past his/her door, resident yells for his/her mom; -7/20/24 at 6:26 P.M., resident slid out of wheelchair earlier today. Resident now yelling loudly that his/her shoulder hurts. Nurse did range of motion (ROM) with right shoulder after fall and resident had no complaints of pain at that time. Now resident yelling loudly to call the ambulance, primary care physician (PCP) and resident representative (RR) notified resident being sent to emergency room (ER) for evaluation and treatment for right shoulder pain; -7/20/24 at 7:12 A.M., resident returned to facility from hospital at 6:35 A.M. with nondisplaced fracture to right humerus (long bone that runs from the shoulder and scapula (shoulder blade) to the elbow). Resident noncompliant with right arm sling, removes arm from sling; -7/21/24 at 1:22 P.M., resident is screaming down the hall and stating he/she wants to go to the hospital. Spoke with RR and RR will be at the facility today with treats to talk to resident. Resident refusing to wear sling to right arm; -7/22/24 at 12:27 P.M., interdisciplinary team (IDT) review of ER visit and return to facility. Diagnosis closed fracture of proximal humerus with routine healing, unspecified fracture morphology (number of fragments and fracture lines). Resident returned to facility with new order to follow up with physician; -7/22/24 at 4:44 A.M., IDT clinical review 7/19/24 5:14 P.M., fall with injury. Resident became anxious while sitting up in wheelchair and slid into the floor. Assessed with complaints of pain to right shoulder. PCP and RR notified. Sent to ER for evaluation and treatment; -7/24/24 at 11:12 A.M., resident skilled for above knee amputation (AKA) and right humerus fracture. Resident in bed yelling that he/she drank to much whiskey last night (resident did not). Resident will not allow sling to be put on right arm; -7/25/24 at 1:46 P.M., resident skilled for AKA and right humerus fracture. Resident in bed resting at this time, quieter today; -7/26/24 at 9:21 P.M., resident noted to have increased discomfort, behavioral issues noted throughout the day, attempts to redirect using non-pharmacological methods. Used music, hydration, repositioning, and soda etc. continued to be ineffective, as needed (PRN) pain medication utilized with minimal relief. Resident at this time requested to be sent to ER. Administration notified per facility policy any resident or family member requesting to go to the hospital needs to be sent to the ER. Call out to PCP and RR related to resident's request. Call placed to 911, emergency medical technicians (EMT) arrived at 3:55 P.M. Resident transferred to stretcher and resident out of building at 4:05 P.M. Spoke with RR informed of resident's decision and was thanked by RR. Review of the resident's hospital notes, dated 7/26/24, showed: -7/26/24 at 4:28 P.M., Resident presents with chief complaint of pain in upper right arm; -7/26/24 at 7:13 P.M., Registered Nurse (RN) at hospital received a call from Licensed Practical Nurse (LPN) A charge nurse at the facility. LPN A said the facility is refusing to accept the resident back into their care because the resident is agitated, yells, and disturbs other residents. LPN A said the facility made this decision 15 minutes (min) ago and they have not tried any interventions to help the resident, have not tried to transfer the resident to a different facility, and that, the doctors are not willing to prescribe anything to chemically restrain the resident. LPN A said the decision was made by the Director of Nursing (DON) and Interim Administrator (IA); -7/26/24 at 7:19 P.M., RN at hospital received a call from the DON confirming the facility is not accepting the resident back into their care; -7/26/24, admitted Emergency Department (ED) observation at 9:58 P.M. During an interview on 9/24/24 at 10:17 A.M., the DON said the resident was sent to the hospital on 7/26/24 because of his/her disruptive behaviors. The DON said residents on the hall made comments threatening to harm the resident due to his/her disruptive behaviors of yelling out all the time. The DON said she was concerned for the resident's safety and refused to accept the resident back from the hospital. The DON said she spoke with the IA and the IA agreed on not accepting the resident back at the facility. The DON said an emergency discharge letter was not given to the resident at discharge and an emergency discharge was not given the next day. During an interview on 9/25/24 at 12:10 P.M., the IA and DON said they both expected staff to be knowledgeable of and follow the facility policies. They were concerned for the residents' safety and felt it was an unsafe situation for the resident and everyone else due to the resident's outbursts and behaviors. They expected if an emergency discharge notice needed to be given, the emergency discharge process would be followed. The emergency discharge notice was not given to the resident and the emergency discharge process was not followed for the resident. MO00239903

Based on observation, interview and record review, the facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. This failure has the potential to affect all residents. The facility census was 74. 1. Review of the facility's Warewashing and Storage policy dated January 2019, showed the policy directed staff to allow all washed and sanitized dinnerware, utensils, preparation and service supplies to air dry prior to storage. Observation on 03/27/24 at 9:18 A.M., showed Dietary Aide (DA) V pulled a rack of sanitized plastic cups from the mechanical dishwasher, stacked the cups together while wet and then placed the cups on a service tray on a utility cart. Observation on 03/27/24 from 9:23 A.M. to 9:32 A.M., showed DA W removed two racks of sanitized insulated plate covers from the mechanical dishwasher, stacked the covers together while wet and then placed the covers on the service. Observation showed the DA then removed a rack of sanitized glasses from the dishwasher, stacked the glasses together while wet and then placed the glasses on a tray on a utility cart. Observation showed the DA continued to remove sanitized dishes from the dishwasher, stack the dishes together while wet and then put the dishes away multiple times. During an interview on 03/27/24 at 9:32 A.M., DA V said the dishes stored on the utility cart are to be put away in the dining room service station for use at meals. The DA said dishes should be dry before they are put away and he/she just got in a hurry. During an interview on 03/27/24 at 9:34 A.M., DA W said dishes should be dry before they are put away, but he/she did not have enough room or time to let the dishes air dry before he/she put them away. During an interview on 03/27/24 at 10:05 A.M., the Dietary Manager (DM) said staff should allow sanitized dishes to air dry before they are stacked together and put away and staff are trained on this requirement. Observation on 03/27/24 at 10:40 A.M., showed eight metal food preparation and service pans stacked together wet under the counter in the cook's station. During an interview on 03/27/24 at 10:43 A.M., Cook X said the cooks are responsible to wash the pots and pans and they should be air dried before they are stacked and put away. The cook said he/she did not wash those pans that morning, but they should not be stacked together wet. Observation on 03/27/24 at 12:07 P.M., showed showed staff used wet stacked glasses and plate covers for service of food items during the lunch meal. During an interview on 03/27/24 at 1:25 P.M., the administrator said staff should allow all dishes to dry before they are put away, staff are trained on this requirement and he/she would expect the DM to monitor dish washing and storage daily when on duty as part of his/her management duties. The administrator said the DM is not expected to documented those inspections.

Based on interview and record review, the facility failed to ensure physician orders were followed when a resident (Resident #1) experienced a change in condition. Staff received orders for intravenous (IV) fluids on [DATE] due to abnormal blood chemistry. Staff did not administer the ordered IV fluids. The facility also did not administer an additional ordered fluid intake of 240 milliliters three times a shift (shifts were 12 hours) ordered to be administered for three days or obtain ordered vital signs every shift for three days. The staff did not notify the resident's physician or nurse management of the inability to administer the IV fluids. As a result, the resident continued to decline during the night. On [DATE] the day shift nurse observed the resident as extremely lethargic, unresponsive, and sent the resident to the hospital emergently. The resident was diagnosed with dehydration and acute kidney injury at the hospital and was administered IV fluid boluses (type of IV therapy administration). The resident expired at the hospital on [DATE] at 8:25 A.M., due to diagnoses of sepsis, cellulitis, and acute kidney injury. The census was 85. The administrator was notified on [DATE] at 1:45 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the undated Physician Order Policy, showed: -Policy: to transcribe and follow the physician orders accurately; -Procedure: there shall be a written order on a physician order sheet for all medications, treatments, and diets. -A Registered Nurse (RN) or Licensed Practical Nurse (LPN) within the scope of practice is under the supervision of the physician; -When making rounds with the physician, review orders before he/she leaves. Questions should be asked if unsure of the order; -Certified nurse aides (CNA) are informed of orders that effect their case. Changes are made to assignments as needed; -Orders received by physicians are to be followed as prescribed. Review of the Significant Change in Condition policy, dated [DATE], showed: -Significant change is a decline in a resident status that will not normally resolve itself without further intervention by staff or by implementing clinical interventions and impacts on more than one area of the resident's health status; -Examples of decline, include: decision making ability has changed, a presence of moods not previously reported by the resident or staff and/or an increase in the symptom frequency, changes in the severity of behavioral symptoms, any decline in an activity of daily living (ADL, self-care) where more assistance from staff is required, weight loss, skin condition changes, development of a disease/condition in which the resident is judges to be unstable. Review of the Peripheral Intravenous (IV) Access, Therapy and Maintenance policy, dated ,d+[DATE], showed IV therapy will be ordered by the physician. Parenteral fluids (the administration of solutions or suspensions of nutritional and essential substances through pathways other than the gastrointestinal) must be administered consistent with professional standards of practice and in accordance with physician's orders. Ongoing support and monitoring of the resident during and after IV therapy shall be completed by competent and qualified staff. If the resident chooses to have IV fluid infused that the facility does not allow, the facility must assist with the transfer to another facility or relocation to a setting of his/her choosing that provides the IV service. Review of the Resident #1's quarterly Minimum Data Set (MDS) a federally required assessment instrument, completed by facility staff, dated [DATE], showed: -admitted : [DATE]; -Cognitively intact; -Verbal and physical behaviors at times; -Does not reject care; -Used wheelchair for mobility; -Needs staff assistance with dressing, hygiene, toileting, upper and lower body dressing, putting on shoes and turning in bed; -Diagnoses included: diarrhea, heart failure, vascular disease, chronic kidney disease stage III (moderate). Review of the care plan, updated ,d+[DATE], showed: -Problem: Resident is at risk for skin breakdown and decreased mobility. He/She is independent with most care. (The care plan was not updated to reflect the more current MDS.) -Goal: the resident will maintain clean and intact skin, measures will be taken to prevent skin breakdown; -Interventions: dietician referral, inspect skin daily with care, bathing and report changes to the nurse, keep skin clean and dry, monitor nutritional intake; -Problem: cognitive deficit related to long term memory loss; -Goal: the resident will show no change or decline in cognitive status; -Interventions: monitor for changes in decline or change in cognitive status, staff assess contributing factors, onset, duration and medications. Review of the nursing progress notes, showed: -On [DATE] at 12:23 P.M., the resident reported to have a significant change of condition, the resident is showing decline and confusion. The resident was tested for Covid-19 with negative results. Oxygen saturation (PSO2, level of oxygen in the blood) at 92 percent (%). Blood pressure 118 (systolic)/69 (diastolic) (normal ,d+[DATE]), pulse 74 (normal ,d+[DATE]), respirations 16 (normal ,d+[DATE]), temperature 98.1 (normal 97XXX,d+[DATE].0). The resident states he/she does not feel well. Lung sounds diminished, upper chest congestion, and appears to have nasal congestion. Edema noted to both lower hands. A skin tear noted to the top of the left hand. The area was cleaned and new dry dressing applied. General appetite as fair, skin color is pallor (pale); -No documentation staff contacted the resident's physician or nurse practitioner (NP); -On [DATE] at 5:24 P.M., the Nurse Practitioner (NP) assessed the resident and new orders were given for immediate blood laboratory testing for complete metabolic panel (CMP, the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working), complete blood count (CBC, identifies and counts the 7 types of cells found in the blood), B12 (vitamin), folate (vitamin). Laboratory provider notified and will arrive to obtain sample this evening. Additional orders were Seroquel (antipsychotic used to treat behaviors) 12.5 milligram (mg) tablet every night, dietician evaluation, encourage oral fluids, house supplements twice a day and give fluids. The resident appeared dry and the NP ordered an IV of normal saline at 75 milliliters (ml) per hour for one liter. Review of the [DATE] physician order sheet (POS), showed: -An order, dated [DATE], for NS 1 liter IV one time, infuse at 75 ml/hr; -An order, dated [DATE] to obtain vital signs twice a day for three days once a shift, and document in the nurse notes; -An order, dated [DATE], drink 240 mls of fluid three times a shift (12 hours) for three days. Review of the [DATE] treatment administration record (TAR), showed: -An order, dated 11//,d+[DATE] for 1 liter of NS, infuse at 75ml/hr. Scheduled at 7:00 A.M. On [DATE], [DATE] and [DATE] documented as blank; -An order, dated [DATE]: Document vital signs twice a shift for three days and document in the nurse notes. Scheduled at 7:00 A.M., and 8:00 P.M. daily, showed: -On [DATE] documented as not active for scheduled times; -On [DATE] documented as not active at 7:00 A.M., and completed at 8:00 P.M.; -On [DATE] documented as completed at 7:00 A.M., and hospitalized at 8:00 P.M.; -An order, dated [DATE] to drink 240 ml of fluid three times a shift - the facility runs 12 hr shifts for three days. Scheduled daily at 7:00 A.M., 12:00 P.M., and 5:00 P.M. -On [DATE], all times documented as not active; -On [DATE], the 7:00 A.M., and 12:00 P.M., documented as not active. The 5:00 P.M., documented as medication administered; -On [DATE], the 7:00 A.M., time documented as medication administered. The 12:00 P.M., and 5:00 P.M., administrations were documented as resident hospitalized . Review of the nurse notes, showed: -On [DATE] (Saturday) at 3:44 P.M., the NP called with new orders to obtain a urinalysis and culture (test used to determine urinary infection), staff will obtain tomorrow for a Monday morning pick up. Vital signs every shift for three days. Start the IV which was ordered on [DATE] of 1L of NS at 75 mls/hr. Repeat the CBC and BMP on Monday, [DATE]. Push fluids- drink 240 mls three times a day for three days. The resident is in bed, vital signs temperature 97.4, pulse 68, respirations 20, blood pressure ,d+[DATE]. The lungs are clear; -On [DATE] at 11:35 P.M., the resident heard yelling 'help' from his/her room. When staff entered the room, the resident found lying on his/her back. The left hand noted to be bleeding. Hand was cleaned and a skin tear noted to the index finger and pinky finger tips. No other signs of bleeding noted. He/She denied pain and color is very pale. He/She is alert, but not making sense with speech. The resident was placed in a wheelchair and brought to the nurses' station for close observation. Neurological assessments initiated and within normal limits. Vital signs: blood pressure ,d+[DATE], pulse 119, respirations 16, temperature 95.0; -On [DATE] at 11:41 P.M., the resident observed at the nurse station in a wheelchair, and yelling out occasionally. He/She observed to reach out for things that are not there. Skin tears on fingers cleaned and bandaged, speech is non-sensical (garbled, or mumbled speech); -On [DATE] at 10:38 A.M., resident in bed. Mouth open and breathing, looks pale. Vital signs blood pressure ,d+[DATE], pulse 48, respirations 20, temperature 96.8. The pulse is weak and thready (the pulse is not felt easily and does not have a regular rhythm). Attempted to give fluids by mouth, he/she was unable to place lips around the straw. He/She appeared dry. CBC and CMP were obtained yesterday. BUN is high at 39, hemoglobin is 10.3. The on-call nurse practitioner contacted to update on current condition. New order given to send the resident to the hospital. Review of the hospital record, showed: -admitted on [DATE] at 10:33 A.M.; -Arrived by ambulance following abnormal laboratory results; -Chief complaint: the patient is a poor historian. The family is at the bedside and reports he/she had been receiving inadequate care and had not been eating much. Vital signs: blood pressure ,d+[DATE], pulse 73 and respiration 18; -Physical exam: -Vitals: hypotensive (low blood pressure); -Appearance: ill-appearing, cachectic (marked weight loss and muscle loss), alert and orientated; -Tests preformed: -Wound culture, results pending; -CT (computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) chest: large right pleural effusion (buildup of fluid between the tissues that line the lungs and the chest), right lung atelectasis (the collapse of a lung or part of a lung) and small left pleural effusion; -Clinical impression: acute kidney injury (AKI), failure to thrive and hypoalbuminemia (low albumin); -Medical decision note: admitted from nursing home for AKI and failure to thrive. Upon arrival, the patient was ill appearing but not in acute distress. He/She was hypotensive upon arrival with a blood pressure of ,d+[DATE]. Glucose (blood sugar) low at 62, which improved after dextrose (sugar). No evidence of systemic infection. He/She came in for abnormal labs with results showing AKI, likely from severe dehydration. He/She was given 2 L of IV fluids. Suspect skin and soft tissue infection (the hospital took a wound culture from the left lower leg), moderate purulent (discharging pus) cellulitis (a deep bacterial infection of the skin). Vancomycin ordered at 1,500 mg every 24 hours; -A hospitalist note, on [DATE] at 7:50 A.M.: the patient's family is at bedside and reported to provider that he/she requested the resident to be sent to the hospital on Wednesday [DATE] for altered mental status and the facility declined. The family visited again today, and the patient was in worse condition. The patient has wounds to the upper extremity and left lower extremity are new within the last ,d+[DATE] weeks. Hospital wound photographs, dated [DATE], showed the following wounds: -Left lower leg; -Top of the left hand; -Left elbow; -Left lower extremity; -Left upper extremity; -Right elbow; -Assessment and plan: -Comfort measures only; -Failure to thrive; -Metabolic encephalopathy (an underlying condition that affects your metabolism), secondary to hypotension, acute renal failure and sepsis (blood infection). Continue gentle IV fluids and antibiotic; -On [DATE] at 8:59 A.M., the patient expired at 8:25 A.M. During an interview on [DATE] at 1:15 P.M. Licensed Practical Nurse (LPN) A said he/she cared for the resident on the day shifts of [DATE], [DATE] and [DATE]. He/She worked from 7:00 A.M., to 7:00 P.M. The resident had experienced increased behaviors of yelling out and occasionally would refuse care. He/She did not eat much food. On [DATE] the NP came to the facility and assessed the resident. He/She ordered an IV of fluids to be started and blood testing. The orders were received near the end of LPN A's shift and he/she passed on the IV orders to the night shift nurse. On [DATE], LPN A reported to work in the morning around 6:50 A.M., he/she checked on the resident and offered some fluids, the resident refused the fluids. The IV had not been started from the day before. LPN A could not start the IV due to lack of supplies in the e-kit. The pharmacist said IV supplies were in the e-kit and it was kept stocked by the pharmacy staff. He/She did not notify the physician, NP or the facility nursing management. The resident looked pale and sick. He/She passed onto the night shift nurse the resident needed the IV administered on [DATE] and again on [DATE]. On [DATE] LPN A assessed the resident. The resident lie in bed and looked really bad, the resident was moaning and not speaking clearly. He/She appeared very lethargic. LPN A called the physician regarding the change of condition and new orders were given to send the resident to the hospital. During an interview on [DATE] at 3:30 P.M., LPN B said he/she worked the night shifts on [DATE] and [DATE] and assisted in the resident's care. He/She did not begin the resident's IV because he/she did not feel comfortable initiating the IV. He/She did not notify the resident's physician or nurse practitioner. He/She worked the scheduled shifts and got busy with other facility duties. He/She did not assess or check on the resident until he/she fell the evening of [DATE]. The resident did not drink or eat much fluids or food. The resident preferred to be left alone. During an interview on [DATE] at 2:01 P.M., Certified Nurse Aide (CNA) F and CNA G said on [DATE] the resident lie in bed, dressed in clothing, not responding much to verbal stimulation and moaning occasionally. CNA G got the day shift nurse and notified him/her of the resident's condition. The nurse entered the room, attempted to wake the resident and told the aides the resident was going to the hospital. CNA F and CNA G said the nurse called emergency services and the resident left in the ambulance. They were not told to offer the resident additional fluids the previous day. During an interview on [DATE] at 12:16 P.M., the hospital ER Physician Assistant said he was present and assisted in the care of the resident when he/she admitted to the hospital on [DATE]. The resident was very ill and appeared dehydrated. The resident had abnormal laboratory results. The hospital attempted to rehydrate the resident with IV fluids and provide other medications. The resident continued to decline and the RP/NOK elected comfort measures only. The resident expired at the hospital from acute kidney injury and the resident was severely dehydrated upon admission. The dehydration complicated the kidney injury. During an interview on [DATE] at 12:45 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said neither were notified of the physician orders to receive bolus IV fluids, additional oral fluids and vital sign monitoring. The facility maintains IV fluids in the emergency kit, kept in the medication room. If the nurse is unsure how to begin an IV, the nurse should call the DON or ADON. The nurse should follow physician orders. If orders can not be followed, the nurse should call the prescribing physician or NP and notify them the order can not be administered. Review of the facility Emergency Medication Kit Supply (STAT) list, dated [DATE], showed: -Miscellaneous medications: -IV 12 inch extension kit (extend tubes that are used to supplement an existing IV delivery system), 4 available; -IV catheter (allows for the administration of medications, fluids and/or blood products) 22 gauge, 4 available; -IV catheter 24 gauge, 4 available; -IV start kit, 3 available; -Sodium Chloride (NS, normal saline) 1000 milliliter bag, 3 available. During an observation on [DATE] at 11:45 A.M., the DON accessed the facility e-kit. Drawer 4 contained six 1 liter bags of NS, 8 bags of 50 ml NS and 8 IV start kits. The DON said the pharmacy is responsible to stock the e-kit with needed supplies. During an interview on [DATE] at 10:01 A.M., during an interview the facility pharmacy supplier said the pharmacy consultant visits the facility monthly. The consultant will also check and monitor the supplies in the facility e-kit. The facility IV supplies and IV fluids were placed into the e-kit in [DATE]. A total of five 1 liter normal saline bags were placed into the e-kit. In of [DATE] one liter bag was used which left 4 one liter normal saline bags. The current NS bags will not expire until ,d+[DATE]. During an interview on [DATE] at 1:28 P.M., the resident's physician said she was not notified the ordered IV had not be administered. The resident was seen by the NP and she ordered the fluids due to abnormal blood chemistry results. If the resident had received the ordered IV fluids and oral fluids it could have prevented the severe dehydration he/she admitted into the hospital with. The staff should have immediately notified the prescribing NP or the physician when the IV was not initiated. The physician would have sent the resident to the hospital for evaluation and treatment. During an interview on [DATE] at 6:49 P.M., the resident's responsible party and next of kin (RP/NOK) said on or about [DATE] he/she told the nurse the resident needed to go to the hospital due to his/her behavior. The resident normally was very clear spoken, able to make his/her needs and wants known. The resident spoke to the RP/NOK on the phone on [DATE] and did not make any sense and had forgotten who the RP/NOK was. The nurse told the RP/NOK the resident would not be sent to the hospital. On [DATE] the RP/NOK was contacted and told the resident was sent to the hospital due to a change in condition and he/she was very sick. At the hospital, the resident declined very quickly. The resident could not recover from the lack of fluids, wound infections and expired 24 hours after being admitted to the hospital. 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). MO00227921

Based on observation, interview and record review, the facility failed to ensure scheduled pain medication was available and/or administered as ordered for one of 7 sampled residents (Resident #4). The facility failed to assess and monitor the resident for pain, notify the resident's physician when the pain medication was not delivered, and to notify the physician of increased pain. This resulted in the resident, with a history of a compression fracture in a bone in the spinal column, to experience increased pain, causing the resident to cry, have difficulty sleeping, and limiting his/her desire to move. The census was 85. Review of the facility's undated physician order policy, showed: -Policy: to transcribe and follow physician orders accurately; -Procedure: -There shall be a written order for all medications, treatments and dated and signed by the physician and placed on the resident's chart. Orders received orally or by telephone shall be taken, signed and dated by the registered nurse (RN) and Licensed Practical Nurse (LPN) within the scope of practice; -When taking orders for medications, include the following information: name, dosage, frequency and special instruction; -When transcribing physician's orders: -Read carefully-check with another nurse if unsure. Check with the physician if there is any questions; -Medication orders: placed in the electronic health record; -Certified Nurse Aides (CNA) are informed of orders that affect their care. Changes are made to assignment as needed; -Orders received by physician are to be followed as prescribed. Review of the facility's pain management policy, dated 8/16/17, showed: -Purpose: provide guidelines for consistent assessment, management and documentation of pain in order to provide optimal comfort and enhanced quality of life; -Guidelines: -Ensuring involvement of resident in pain management; -Recognizing and recording pain as the 5th vital sign; -Assessing pain and evaluating response to pain management intervention using a pain management scale based on the resident self-report or objective assessment for the cognitively impaired; -Intervening to treat pain before the pain becomes to severe; -Using non-drug interventions to assist in pain management; -Using knowledge of dosages to maintain both resident safety and pain relief as routines and types of ordered drug change; -Documenting pain assessment, interventions, and evaluation activity in a clean and concise manner per plan of care; -Intervening to minimize side effects. Review of the facility's medication administration general guidelines, revised 5/2020, showed: -Policy: medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practice; -Administration: medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or medication order seems unrelated to the resident condition or diagnosis, the nurse calls the provider pharmacy for clarification. The interactions with the pharmacy are documented in the nursing notes. Review of Resident #4's hospital discharge paperwork, dated 12/12/23 at 5:49 P.M., showed: -Diagnoses: low back pain, compression fracture of the T12 (thoracic 12, mid back) vertebra (bone of the spinal column); -History of present illness: low back pain, sent from primary physician following an x-ray showing a L1 (lumbar 1, lower back) compression fracture. The patient fell sometime around Thanksgiving, the pain had increased; -Physical exam: -Musculoskeletal: no midline or lumbar tenderness. Reports pain is worse upon standing; -Computed tomography (CT, imaging test) of lumbar spine: acute appearing, moderate to high-grade compression fracture deformity of the T12 vertebral body; -Stable to discharge; -Begin taking: lidocaine (topical pain relief) 5% patch. Apply 1 patch to skin once daily. Apply patch to the most painful area and remove after 12 hours. May reapply a new patch 12 hours later. Review of the resident's medical record, showed: -admitted : 12/12/23; -Diagnoses included: wedge compression fracture of the second thoracic vertebra, high blood pressure, chronic kidney disease, stroke, and diabetes. Review of the resident's pain risk assessment, dated 12/13/23 at 5:54 A.M., showed: -Can the resident verbalize pain: yes; -Current pain intensity: 5; -Location of pain: upper back; -Description of pain: stabbing; -Breathing: normal; -Negative vocalization: none; -Body language: tense, distressed pacing, fidgeting; -Consolability: no need to console; -Diagnoses likely to cause pain: wedge compression fracture, low back pain; -Pain medication: Lidocaine 5% patch, one time a day, apply to mid to lower back, leave on 12 hours then off 12 hours and Tylenol 325 milligram (mg), take two tablets every six hours for pain; -Onset: within last 7 days; -Duration: daily; -Frequency: all the time; -Usually intensity of pain 0-10 (0 indicates no pain and 10 indicates the worse pain imaginable): 6; -Acceptable pain level: 4; -What improves the pain: activity and pain medication; -What makes the pain worse: activities and movement; -How does pain affect quality of life: activity of daily living (how one cares for oneself, independently) and ambulation. Review of the resident's nurse note, showed on 12/13/23: -At 6:15, the resident arrived with family on 12/12/23. Vital signs stable. She/He is admitted due to a wedge compression fracture, will be doing therapy. Medications verified with the physician; -At 9:56 A.M., Tylenol 325 mg two tablets administered. No documented pain assessment or pain scale. Review of the resident's physician order sheet, showed an order dated 12/12/23, for lidocaine 5% topical patch. Apply one patch one time per day on mid to upper back. Leave on for 12 hours. Review of the resident's medication administration record (MAR), dated 12/12/23 through 12/14/23, showed: -An order dated 12/12/23 for Lidocaine 5% topical patch. Apply one patch one time a day, apply to the mid to upper back. Leave on for 12 hours then remove for 12 hours. Scheduled daily at 7:00 A.M. Documented as not administered on 12/13/23 and 12/14/23; -An order dated 12/12/23, for Tylenol (for pain relief) 325 milligram (mg). Take two tablets every six hours as needed for pain or temperature for wedge compression fracture. No documented pain assessments or administration of the ordered Tylenol. During an interview on 12/13/23 at 12:40 P.M., the resident and the resident's responsible party (RP) said he/she admitted during the evening of 12/12/23, following a fall. At the hospital he/she was diagnosed with a lower spinal fracture. He/She is sensitive to medications and the hospital applied a lidocaine patch to his/her lower back and it helped with the pain. The hospital also ordered Tylenol for pain. At the time of the interview, the resident rated his/her pain at 2 out of 10 (2/10). He/She is planning to receive physical therapy and discharge out of the facility in a few weeks. During an interview on 12/13/23 at 2:33 P.M., the resident said his/her pain is increasing. The patch from the hospital remained on his/her lower back. The facility staff did not remove the patch at the ordered time following admission. He/She had not received a new patch or Tylenol. He/She told the aide he/she wanted a pain pill, but the medication had not been delivered yet. Review of the resident's nurse note, dated 12/13/23 at 9:14 P.M., showed the resident admitted to the facility the evening of 12/12/23. Noted compression fracture of the back. He/She reported no pain when laying in the bed without movement, with movement reports pain at a 10. Administered Tylenol for the pain. He/She is able to walk with stand by assist and a wheeled walker. He/She did not want to leave his/her room this morning. RP here earlier to visit. During an observation and interview on 12/14/23 at 8:15 A.M., the resident sat in the chair next to the bed. The resident appeared tearful and used a tissue to blot tears from his/her eyes. The resident said his/her pain was a 10/10. He/She did not sleep well last night. An aide assisted him/her to get up and to the bathroom, and the aide removed the patch, still on from the hospital, off his/her back. That patch was applied from the hospital before coming to the facility. The aide removed the patch and placed it in the bathroom trash can. He/She told the aide he/she was in pain and he/she had difficulty sleeping from the pain. He/She had been told by the medication aide, the Lidocaine patch had not arrived and the facility did not have it to apply to the lower back. During an interview on 12/14/23 at 8:55 A.M., Nurse Aide (NA) E said he/she assisted the resident to get up at approximately 7:45 A.M. The resident complained of pain moving in bed, dressing and walking to the bathroom. NA E said a patch was falling off the resident's lower back. NA E removed the patch and threw it in the resident's bathroom trash can. The resident needed assistance getting dressed and ambulated slowly with a walker to the chair next to the bed. NA E told LPN B the resident complained of pain. NA E had not been instructed on other pain relief options. During an interview on 12/14/23 at 8:20 A.M., Certified Medication Aide (CMT) C said the resident admitted to the facility the evening of 12/12/23. The ordered Lidocaine patches had not been delivered to the facility. The resident had one in place from the hospital when he/she admitted on [DATE]. The resident has not received a Lidocaine patch since admission. The resident had a lower spinal fracture. The CMTs apply the Lidocaine patches. He/She had not been notified if the resident was experiencing pain. CMT C said he/she had not administered the resident's morning medication and was behind on the morning medication pass. During an interview on 12/14/23 at 8:32 A.M., Licensed Practical Nurse (LPN) B said the resident admitted to the facility the evening on 12/12/23. He/She admitted with a Lidocaine patch in place to the lower back from the hospital. The ordered Lidocaine patches had not been delivered to the facility. The LPN did not follow up with the pharmacy. The nurse aide who assisted the resident up, told LPN B the resident was in pain. LPN B notified CMT C, the resident had an order for as needed Tylenol. LPN B was unsure if pain medication had been administered. The resident's Lidocaine patch was ordered to be applied on for 12 hours, off for 12 hours. During an observation and interview on 12/14/23 at 1:01 P.M., the resident sat in a chair next to the bed. The resident rated his/her pain at 9 out of 10 and said he/she was recently administered two Tylenol for pain. No Lidocaine patch had been applied. The resident lifted his/her shirt and exposed his/her lower back. No patch noted to the back. The resident added staff had not asked about his/her pain during the day. He/She had not been seen by physical therapy, but he/she had too much pain to attend. During an interview on 12/15/23 at 10:01 A.M., the pharmacy provider said the pharmacy received the Lidocaine patch order on the evening of 12/13/23. The Lidocaine 5% patches were delivered to the facility on [DATE] at 9:30 A.M., 30 patches were delivered. During an interview on 12/15/23 at 8:44 A.M., the resident said a Lidocaine patch was applied to his/her lower back late evening on 12/14/23. The Lidocaine patch was removed this morning by the CNA when he/she got up. His/Her pain was 10/10 most of the day and even with the patch applied last night, the Tylenol did not help much and he/she did not sleep well. During an interview on 12/15/23 at 11:45 A.M., the Director of Nursing (DON) said the resident admitted to the facility following a lower spinal fracture the evening of 12/12/23. The hospital ordered a Lidocaine 5% patch to be applied on the lower back 12 hours, then off 12 hours. The resident is sensitive to medication and was also ordered Tylenol. Review of the pharmacy delivery sheet, showed the patches were delivered to the facility on [DATE]. After review of the MAR, the DON said the MAR was documented as the patch applied on 12/13/23 and 12/14/23. The patches were not delivered until sometime on 12/14/23. The resident did not receive a Lidocaine patch on 12/13/23, had no documented Tylenol administration and no documented pain assessments. The DON said staff should have called the physician to get orders for increased pain. The DON said the resident did not receive patches on 12/13 or 12/14. The DON said the facility could not locate the patches even though they had been delivered on 12/14 per the pharmacy. During an interview on 12/14/23 at 1:28 P.M., the resident's physician said the resident admitted to the facility on [DATE] from the hospital with a T12 spinal fracture. He/She had not yet assessed the resident. The hospital ordered Lidocaine 5% patch to be applied to the lower back, on for 12 hours and off for 12 hours. The resident is noted to be sensitive to pain medication and also ordered Tylenol. The facility contacted him/her on 12/13/23 at 1:21 P.M., and requested the Tylenol be given routinely. The facility did not contact him/her again regarding pain or a notification that the patches had not been delivered. He/She expected staff to monitor residents for pain. A spinal fracture would be painful and the ordered patch should have been applied as ordered. He/She expected staff to contact him/her when pain medication is not administered or delivered to the facility. The physician would have discussed other options for pain management until the patch could have been applied. Review of the December MAR, on 12/18/23, showed the following: -An order for Lidocaine 5% patch to be administered to the mid lower back. Scheduled daily at 7:00 A.M.: -Documented as administered to the right abdomen on 12/17/23 at 7:00 A.M.; -Documented as administered to the right leg on 12/18/23 at 7:00 A.M.

Based on interview and record review, the facility failed to follow acceptable standards of nursing practice, when staff failed to assess Resident #1's skin and document or report changes in the resident's skin condition to the physician. The resident was at risk to develop skin impairment. The resident admitted to the hospital on [DATE] and was observed with an untreated wound to the sacrum (tailbone) and an additional area to the right buttock. The facility failed to have a system in place to ensure skin assessments were being performed by licensed nursing staff, to detect changes in residents' skin so prompt care and treatment could begin. The sample size was seven. The census was 85. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel 2014 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., wound improvement, wound deterioration, more or less exudate (drainage), signs of infection, or other complications); -Address the signs of deterioration immediately. Review of the Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dry and dark colored dead tissue) may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (opened area that extends under the wound edges) and tunneling (open area that extends under the wound edges and into the subcutaneous tissue) may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury; -Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough and/or eschar. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Review of the facility's skin event report policy, revised [DATE], showed: -Procedure: The charge nurse will fill out the skin event report in detail, noting cause or probable cause of the event; -Administer first aid as indicated; -Notify the physician; -Notify the family/responsible party of the resident; -Give exact description of the circumstances surrounding the event; -Obtain employee investigation statements from all staff involved; -Chart the resident's event in the nurse notes; -Submit the completed event report to the nursing office; -Complete documentation in the resident's chart for 24 hours if no injury occurred and 72 hours if injury has occurred. Review of the facility wound report, dated [DATE] through [DATE], showed Resident #1 not listed as having any wounds. Review of Resident #1's pressure ulcer risk assessment, dated [DATE], showed: -Factors that increase the risk of developing pressure ulcers: -Mobility problems: anything that affects your ability to move some or all of your body; -Poor nutrition: for your skin to remain healthy, it requires nutrients that can only be supplied by eating nutrition diet; -An underlying heart condition: that disrupts your blood supply or makes your skin more vulnerable to injury and damage; -Being over [AGE] years old; -Urinary incontinence and/or bowel incontinence; -Serious cognitive/mental health conditions; -Diagnoses that place the resident at higher risk for pressure ulcer: diabetes, peripheral arterial disease (poor circulation in the lower extremities), heart failure, pulmonary disease, kidney failure, poor appetite, arthritis, Alzheimer's disease and paralysis; -Total score: 20, mild risk. Review of the resident's quarterly Minimum Data Set (MDS) a federally required assessment instrument, completed by facility staff, dated [DATE], showed: -admitted : [DATE]; -Cognitively intact; -Verbal and physical behaviors at times; -Does not reject care; -Used wheelchair for mobility; -Required staff assistance with dressing, personal hygiene, toileting, upper and lower body dressing, putting on shoes and turning in bed; -Occasionally incontinent of bladder and bowel; -Diagnoses included: diarrhea, heart failure, vascular disease, and chronic kidney disease stage III (moderate); -At risk to develop skin impairment; -No current skin issues. Review of the resident's medical record, showed: -A nurse note on [DATE] at 10:38 A.M., resident in bed. Mouth open and breathing, looks pale. The pulse is weak and thready (the pulse is not felt easily and does not have a regular rhythm). Attempted to give fluids by mouth, he/she was unable to place lips around the straw. The on-call nurse practitioner contacted to update on current condition. New order given to send the resident to the hospital. -The medical record did not contain skin assessments, shower sheets (often used by bathing aides to document skin concerns identified during care) or any documented skin impairments. Review of the resident's hospital records, showed: -Date of service [DATE] at 10:34 A.M. The patient arrived by emergency medical services from nursing home for abnormal labs; -On [DATE] at 4:08 P.M., assessment and plan: Patient has suspected skin and soft tissue infection with moderate purulent (containing puss) cellulitis (skin infection); -A wound/skin note dated [DATE] at 5:17 P.M., showed pictures of wound to the tailbone and right buttocks area. During an interview on [DATE] at 11:33 A.M., the Hospital Wound Care Manager said the resident admitted to the hospital on [DATE] and was very ill. The resident admitted with multiple wounds. The manager reviewed the wound photographs and added the wound to the coccyx (tailbone area) appeared to be an unstageable wound, the skin around the unstageable area was opened and had areas of eschar. The coccyx wound likely developed over a week or more and would have been painful in development. In addition, the area to the right buttock was opened and appeared to be a stage II. The skin to the lower buttock appeared to also have moisture associated skin damage (MASD, inflammation or skin erosion caused by prolonged exposure to a source of moisture) During an interview on [DATE] at 1:55 P.M., the Hospital Wound Nurse consultant reviewed the resident's medical record and the hospital wound pictures and said the resident expired before the he/she could start wound care on the resident. The photos were taken by the resident's primary hospital care nurse. The wound to the sacrum appeared to be a stage III or more likely an unstageable pressure wound. The wound appeared to have edema (swelling) and moisture associated skin damage (MASD). The right buttock wound, is located on the area of the right ischium (bone of the pelvis that forms the lower and back part of the hip bone) and appeared to be a stage III wound. The wound appeared red, had edema around and appeared wet. Both wounds would have developed over a week or longer. During an interview on [DATE] at 1:15 P. M., Licensed Practical Nurse (LPN) A said he/she cared for the resident frequently and sent the resident to the hospital on [DATE]. He/She was not aware of any skin issues. The resident was incontinent of bowel and needed assistance to apply pants, socks and shoes. The aides provided bathing assistance. The Certified Nurse Aides (CNAs) should report skin changes to the charge nurse. The nurse would then assess the skin, contact the physician and document in the medical record. The nurses do not provide skin assessments on any routine schedule and rely on the aides to report skin changes. During an interview on [DATE] at 2:01 P.M., CNA F said he/she worked the day shift and assisted with the resident's care. The resident refused care at times. He/She needed staff assistance with lower body dressing. He/She was not aware of any skin issues the resident had. During an interview on [DATE] at 12:00 P.M., the Director of Nursing and Assistant Director of Nursing said the facility nurses do not conduct weekly skin assessments. The facility aides are expected to report skin changes to the charge nurse. The nurse should provide a skin assessment, document the changes and begin a skin event in the medical record. The resident did not have any reported skin conditions. The resident was incontinent of bowel. He/She needed assistance getting dressed with pants, socks, shoes and incontinence care. Each facility resident is given a head to toe assessment twice a month. During an interview on [DATE] at 1:28 P.M., the resident's Physician said she had not been contacted regarding any changes in the resident's skin. She expected staff to monitor the resident's skin and report any changes. The resident was admitted to the hospital on [DATE].

Based on observation, interview and record review, the facility failed to provide protective oversight for one resident (Resident #1) who eloped from the facility without staff knowledge on 1/17/22 at approximately 5:30 P.M. The facility failed to check all exit doors when the alarm to the door went off. The resident was found on the ground right outside the exit door by facility staff who had arrived to the facility. This failure resulted in the resident falling out his/her wheelchair and laying on the ground outside for approximately 15-20 minutes with skin scrapes on both shins and a red area the size of a quarter on his/her left knee. The sample was 4. The census was 67. The administrator was notified on 1/28/22 at 10:00 A.M., of the past non-compliance which occurred on 1/17/22. On 1/17/22, the administrator became aware of the violation. The facility in-serviced staff on the elopement policy and procedures. An investigation was completed. The staff member who did not properly respond to the door alarm was suspended and later terminated. The deficiency was corrected on 1/18/22. Review of the facility's Elopement Policy and Procedure Guide, dated 10/20/21, showed: -Responsibility: The following individuals may have responsibility for preventing resident elopement specific to state professional licensing requirements: -Administrator; -Registered Nurse (RN); -Licensed Practical Nurse (LPN); -Certified Nurse Aide (CNA); -Staff to include department managers; -Definition: Elopement, for purposes of this policy and procedure, is defined as that situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety needs and therefore at risk for injury outside the confines of the facility has left without knowledge of staff; -Purpose: The purpose of the elopement policy is to: -Identify residents at risk for elopement; -Minimize episodes of elopement; -Protect residents that are not capable of protecting themselves; -Provide the techniques and equipment to minimize safety risks; -Educate staff; -Door alarms and resident protection alarms: A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents; -Door alarms are tested daily. The results of the tests are then recorded on the designated log; -Only the administrator or designee may authorize disabling the alarm system and is responsible for the method of monitoring for resident's safety and resetting the alarm; -When door alarm batteries are required to be changed, the door alarm must be retested immediately after the change occurs and documented on the log; -Maintain roster of bracelet battery expiration dates and replace prior to expiration date; -The charge nurse or designee shall test resident personal alarms/devices according to manufacturer's recommendation; -In the event of a power loss or disaster, refer to guidelines on providing a safe environment during power loss; -Environmental guidelines: The facility will identify any external environment hazards as well as entrances, stairwells or exits that pose a foreseeable danger to residents who wander or have an exit seeking behavior; -The facility will implement interventions to minimize these risks and hazards as appropriate; -Missing resident events: The facility will implement the following plan for conducting internal and external searches to locate missing residents. The charge nurse is responsible for coordinating the search. If a resident is discovered missing or suspected of having eloped, the charge nurse takes the following steps: -Initiate a search of the resident's unit with all employees assigned to that unit; -If the resident is not located immediately, the charge nurse will page elopement code (code green) and state the name of the unit (example code green Terrace hall). The charge nurse must remain at the desk to answer calls from other units before leaving to assist in the search; -Charge nurses on other units will phone the code green unit for the name of the resident and check the Elopement Manual for an identifying photograph. If the resident is not in the Elopement Manual, a brief description will be provided. Charge nurses will conduct a search of their unit immediately and send the CNA whose name is first on the run sheet to assist in the external search; -Once the search of all areas has been conducted, all available employees will join in searching all areas of the facility and external premises; -If the resident cannot be located, the administrator, director of nursing, clinical manager (or change nurse if administrator is not available) shall: -Notify the resident's family or responsible party; -Notify the police; -Notify the physician; -Complete the missing resident profile and attach a current photograph of the resident; -Report to the Department of Health and Senior Services. Review of Resident #1's medical record, showed: -admitted on [DATE], Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/17/21, showed: -Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating severe cognitive impairment; -Diagnoses included hypertension ([CONDITION(S)], high blood pressure), urinary tract infection, arthritis, dementia, depression, malnutrition and respiratory failure; -Has the resident wandered: Behavior not exhibited; -Required extensive assistance with two or more person physical assist with transfers and toileting; -Required extensive assistance with one person physical assist with dressing and bed mobility; -No range of motion impairment; -Used a wheelchair and walker. Review of the resident's care plan, updated 1/6/22, showed: -Problem: Cognitive deficit: decision making; -Goal: -Resident safety will be maintained; -Resident will show no change or decline in cognitive status; -Interventions: - Monitor for any changes or decline in cognitive status; -Offer resident two simple choices to reduce the stress of decision making and increase resident's sense of autonomy; -Reassessment of [CONDITION(S)] with medication review, labs, assess for pain, constipation, and urinary tract infection; -Problem: Fall Risk: Resident required extensive assist of two with transfers and toileting. He/she is not able to ambulate at this time. Per resident's family, he/she had two falls within the past six months. Prior to admission, he/she was noted lying on the floor on 11/26/21. No noted injuries. He/she receives an antidepressant; -On 1/5/21, resident was found on the floor next to the bed. He/she stated he/she was going to the bathroom to help the man out of the bath; -Goal: -Resident will verbalize understanding of the need for assistance; -Resident at risk for falls. Resident safety will be maintained; -Resident will demonstrate ability to use assistive device safely and consistently over the next three days; -Utilize interventions to help limit increase risk for falls and/or injuries; -Interventions: -Anticipate resident needs check frequently; -Assess contributing factors related to fall history; -Assess medications for contributing factors; -Assist resident with activities of daily living (ADLs) as needed; -Assist resident with toileting as needed; -Bed wheels in locked position; -Due to dementia, resident does not always remember to call for assistance with transfers. Staff to check frequently for possible needs; -Give frequent reminders to ask for assistance with transfers and toileting; -Maintain record of falls and evaluate for patterns; -Maintain room and pathways free of clutter; -Provide 1:1 with resident as needed to help keep his/her mind occupied; -Problem: On 1/16/22 at 2:30 P.M., observed on floor next to bed. No injury. Resident states he/she was trying to leave the car lot because he/she did not want the car they were selling; -Interventions: -Resident is placed in wheelchair and put at nurse's station for closer observation; -Neuro checks initiated and will continue x 72 hours; -Continue to keep bed in low position with fall mat in place; -When silent alarm remote goes off, attempt to get to room immediately; -Fall anticipated due to poor safety awareness. He/she does not realize he/she cannot do what he/she wants to do. Review of the resident's Physician's Order Sheet (POS), dated 1/1/22, showed: -On 1/7/22, floor mats to sides of the bed when resident is in bed. Bed to be in low and locked position when resident is in bed every two shifts; -An order, dated 1/11/22, monitor and report behaviors when appropriate, document in nurses note. Physician/responsible party notification. Psych notification if applicable; -An order, dated 1/11/22, for oxygen at 2 liters via nasal cannula per minute every two shifts continuous; -An order, dated 1/13/22, patient to be assisted x 2 for safe transfers; -An order, dated 1/14/22, may trial a silent alarm on bed to prevent resident from getting up unassisted. Make sure family signs a consent. Review of the resident's progress notes, showed: -On 1/16/22 at 3:25 P.M., showed the resident observed on the floor at approximately 2:30 P.M., resident explained he/she was trying to leave the car lot because he/she did not want the car they were trying to sell. This nurse attempted to assess resident's vital signs, resident continued to take blood pressure cuff and oxygen saturation machine off. After attempting to get resident's vital signs three times, this nurse will attempt once more when resident is sleeping or is calmer. No complaints of pain at this time. Resident is placed in wheelchair at nurse's station at this time. Neurological checks put into place. Fall packet completed; -On 1/16/22 at 6:30 P.M., this nurse was notified that the resident was outside on the ground. Resident observed on the ground by this nurse, after getting resident back in chair and immediately back in the building. Resident stated, I wanted to go see about the bike outside. Skin tears to both shins noted, this nurse cleaned both shins and applied triple antibiotic ointment (TAO) to skin tears. Blood pressure 131/74 (normal 90/60 through 120/80). Pulse 68 (normal 60 through 100), respirations 24 (normal 12 through 22), temperature 96.4 (normal 97.8 through 99.1) at this time. Blankets placed on the resident and placed in front of heat unit at this time; -On 1/17/22 at 4:55 A.M., resident continues on incident follow up due to a new fall and exiting the building this evening. Vitals signs are as follows 153/82, 70, 18, 97.3, and 96% on 2 liters of oxygen. Eyes are within normal limits with ROM in legs being a little less due to weakness of resident. Abdominal sounds in all four quadrants, lungs are clear in all four quadrants. Resident is on [MEDICATION(S)] (antibiotic) due to urinary tract infection, resident is afebrile at 97.3 degrees. Resident has become increasingly forgetful and into other resident's room yesterday day shift. New order for Wanderguard (device used to alert staff if the resident gets too close to a wander guard protected exit), this nurse put it on his/her right wrist. Resident has slept all night this night and had been up for two nights straight. Review of the facility's investigation report, dated 1/16/22, showed at approximately 6:15 P.M., the administrator received a phone call from the Wing 2 charge nurse, Nurse A, that Resident #1 was found outside of the facility at the Wing 2 exit door, out of his/her wheelchair on the ground. The resident was brought back in, found to have skin scrapes on both shins and a red area the size of a quarter on his/her left knee. Resident was asked what was he/she doing. He/she was looking for a bike. Nurse stated the resident did not show any signs of hypothermia (low body temperature), but was wrapped in blankets while his/her vitals and assessment were completed. Nurse A stated he/she called the family, place a call to the physician's exchange, but did not have a call back yet. Review of CNA B and CNA C's interview statement, completed by the administrator, dated 1/16/22, showed CNA B and CNA C stated they were taking residents to the dining room for meals. The alarm went off, but they thought it was a different patient that set off the alarm. They did not exit the door to ensure or check to see if a resident had exited the door. The last time they saw the resident, it was approximately between 5:15 P.M. and 5:20 P.M. The patient was found at 5:30 P.M. Review of the facility's investigation report, dated 1/16/22, showed the administrator interviewed staff and they confirmed the alarm did go off, but the CNAs thought it was a different resident that set the alarm off. They did not exit the door and look outside. This was at approximately 5:15 P.M. to 5:20 P.M. They stated they knew that because they were taking residents to the dining room. Another employee (Maintenance D) come into work was outside and saw the resident. The resident was out of the chair and lying next to the chair. Maintenance D ran into the building and to get the nurse and aides. They went out and assessed the resident, brought him/her back in and wrapped him/her in blankets while getting vitals. This was at 5:30 P.M. and they were back in the building by 5:40 P.M. It is estimated that the resident was outside for approximately 15-20 minutes total. Review of Maintenance D's undated written statement, showed he/she arrived to the facility at approximately 5:30 P.M. to 5:45 P.M. He/she pulled up to the employee entrance in the back of the facility and saw a wheelchair sitting beside the pavement. When he/she opened the car door, he/she heard a voice hollering, help me. Maintenance D ran into the building to find a charge nurse and informed him/her there was a resident hollering outside of Wing 2. They ran down to the emergency exit door when the nurse pulled the Velcro stop sign and pushed open the door, setting off the alarm. When he/she got to the resident, he/she begged them to help him/her up. The charge nurse saw the other nurse bringing a resident to their room on the hall, so he/she got their attention to come help. When that nurse arrived, the charge nurse helped get the wheelchair behind the resident so Maintenance D and the other charge nurse could lift the resident up to sit him/her in the wheelchair. Staff wheeled the resident inside and Maintenance D left and went home. Review of Nurse A's interview statement, completed by the administrator, dated 1/16/22, showed Nurse A stated they were working on getting ready for super and an incoming employee came and said we need help, a resident is outside of Wing 2 exit door. Nurse A ran out and they assisted him/her, brought back in, blankets applied, and assessment started. Nurse A stated he/she called the physician exchange and family. Review of the administrator's written statement, showed she verified the events that were explained by Nurse A and aides who worked on Wing 2 during the event. All three employees gave a version that did not reflect the actual events. The administrator was physically in the building for three hours interviewing them, asking questions, and documenting the findings. The administrator went to Wing 2 hall and pointed at the exit door they believed the resident went out. All three stated, yes. After interviewing the employee who found the resident, Maintenance D said the resident was at Wing 2 end of hall exit door, on the side walk, and was next to his/her wheelchair. Maintenance D did not believe the resident went out that exit. The resident was brought back in by that door and to do so, they had to remove a Velcro stop sign, so that indicates he/she likely did not exit that door in a wheelchair. No one saw the resident exit any door, so it is not known what door he/she went out. The next reasonable option would be the laundry hallway exit door. The administrator researched and confirmed with the maintenance manager that the door is not alarmed or locked and only had a Wanderguard alarm on it. Presuming this door is the possible door he/she exited, measures had been put in place. During an interview on 1/20/22 at 1:47 P.M., CNA B confirmed he/she heard the alarm go off on Wing 2. He/she was transporting residents to the dining room. He/she believed it was the door alarm, not the Wanderguard alarm. He/she did not check the doors when the alarm went off. Everyone was doing something when the alarm went off. CNA B later said he/she was in the dining room feeding a resident, so he/she did not hear the alarm. CNA B did confirm again he/she heard an alarm and did not go to the doors or assess whether or not a resident eloped. During an interview on 1/20/22 at 11:36 A.M. and 2:00 P.M., the administrator said the three staff, Nurse A, CNA B and CNA C believed the door was triggered by another resident that was too close. They thought it was a Wanderguard, not breach of the door. They thought the alarm was off and they did not do anything. She spoke to Maintenance D and there was a Velcro stop sign intact when they brought the resident inside. The administrator was not able to follow up with CNA B and CNA C because they quit later that evening and Nurse A was asked to not return. The administrator confirmed they do not have any other proof that the resident could have eloped from the door near the laundry room other than the Velcro stop sign was intact on Wing 2 exit door. It was possible the resident could have eloped from the Wing 2 door and someone else could have placed the Velcro sign back afterwards. They installed an alarm on the exit door near the laundry and they received physician's orders for a Wanderguard for the resident. She would expect staff to check the doors when the alarm went off and complete a count. The administrator confirmed that there was a system failure once the alarm went off and staff did not check the doors or provide protective oversight for the resident. MO 067

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents by failing to identify risks and hazards, evaluating them and implementing interventions for one resident who fell from an elevated bed resulting in his/her death (Resident #1), monitoring two residents at risk for elopement and implementing interventions to address wandering (Residents #2 and #14). The sample size was 15. The census was 63. The Chief Financial Officer was notified on [DATE] at 5:00 P.M., of an immediate jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's fall policy, reviewed on [DATE], showed the following: -Purpose: To assess and evaluate resident falls and preventative measures to prevent further falls; -Fill out a fall event report for any falls sustained by a resident; -Review preventative measures to prevent future falls; -Notify physician and family; -Review with the physician the necessity of physical therapy (PT) and/or occupational therapy (OT) evaluation; -Complete documentation in the resident's chart; -Send the fall event to the nursing office; -Investigation: The employee statement must be submitted to the charge nurse/nurse manager or the supervisor prior to leaving work or clocking out; -The nursing office will follow up with the review and assessment. The Assistant Director of Nursing (ADON) will follow up with the interventions and place a star on name plate outside the resident's room after a fall occurs; -A licensed nurse will do a finger stick blood glucose level check (to assess the amount of sugar in the blood stream), a urine dip stick test (to check for abnormalities in the urine) and report to the physician; -The fall committee meeting will meet monthly to review falls. 1. Review of Resident #1's medical record, showed the following: -Fall risk assessment on [DATE], showing high fall risk; -A note on [DATE] at 6:48 A.M., showing on [DATE] at 7:55 P.M., the resident was found on the floor by nursing staff. The resident had three skin tears on his/her left forearms, one skin tear on the top of his/her right hand and a small bump was noted on the right side of his/her head. Neurological checks (neuro checks, assess an individual's neurological functions and level of consciousness to determine whether the individual is functioning properly and react appropriately to the tests) were within normal limits and throughout the night. The nurse notified the primary care physician (PCP) and family; -There were no details found in the medical records showing the fall was investigated; -On [DATE] at 11:09 A.M., the resident received an x-ray of his/her left ankle and left knee. The PCP saw the resident and gave orders to set up an appointment for the resident to see an orthopedist and to keep the resident non-weight bearing for now; -On [DATE] at 9:02 A.M., the resident refused to get out of bed and asked to be sent to the hospital. The nurse notified the PCP and family and the resident was sent out to the hospital; -On [DATE] at 6:27 P.M., the resident arrived back to the facility via ambulance and was assisted to bed by four people. The resident had a cast on his/her lower left leg related to a tibia/fibula (the two bones in the lower leg. The tibia carries the majority of the body's weight with the support of the fibula) fracture. Review of the resident's care plan, dated [DATE], showed the following: -Problem: Cognitive deficit in decision making; Goal: The resident's safety will be maintained; Interventions: Monitor for any changes or decline in cognitive status; -Problem: High fall risk evidenced by problem with balance, three or more general health conditions present, mildly/moderately impaired cognitive status, total dependence of transfer; Goal: The resident's safety will be maintained: Interventions: Assess contributing factors related to fall history, assist resident with activities of daily living as needed; -Problem: Neuromuscular Disease (disease affects the function of the muscles due to problems with the nerves and muscles, causes muscle weakness) as evidenced by decreased movement of right and left upper limbs, decreased movement of right and left lower limbs, right and left hand grip weak; Goal: Improve or maintain a maximal level of neuromuscular fitness; Intervention: therapy referral as needed. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated [DATE], showed the following: -admitted [DATE]; readmitted on [DATE]; -Cognitively intact; -Feeling tired or having little energy, frequency of ,d+[DATE] days; -No rejection of care; -Required extensive assistance of one person for bed mobility; -Total dependence of two or more persons for transfers; -Surface to surface transfer (transfer between bed and chair or wheelchair), not steady, only able to stabilize with human assistance; -Impairment on both sides of upper and lower body; -Diagnoses included diabetes mellitus, fracture, depression, [CONDITION(S)] (chronic [CONDITION(S)] disorder causing painful swelling of the joints) and morbid obesity; -Used wheelchair for mobility. During an interview on [DATE] at 12:13 P.M., certified nursing assistant (CNA) A said staff were expected to put fall mats down on the floor, keep the residents' beds at the lowest position, and transfer residents safely in order to prevent falls for residents who were a fall risk. During an interview on [DATE] at 1:18 P.M., Nurse B said the following: -Every time he/she saw the resident sitting on the edge of his/her bed, the bed was raised to his/her waist level; -All staff knew the resident kept his/her bed high in the air and that is why he/she never wrote a note in the resident's medical file describing the behavior. Observation on [DATE] at 1:18 P.M., showed Nurse B measured 41 inches at waist level from the ground. During an interview on [DATE] at 1:45 P.M., CNA A said the following: -The resident liked to sit on the edge of the bed when the bed was high off the floor; it was pretty much common knowledge; -The resident would lean to one side, and when tired, would lean forward. During an interview on [DATE] at 4:30 P.M., CNA E said it was common knowledge the resident kept his/her bed really high. During an interview on [DATE] at 2:06 P.M., the social worker said the resident was alert and oriented, but fluctuated. The social worker saw the resident slumped in the wheelchair when he/she was eating. The resident's diagnosis affected that. Staff had talked in the morning stand up meeting about a month ago, about the resident's refusal to lower the bed. The resident kept the bed remote handy. During an interview on [DATE] at 4:47 P.M., the Director of Nursing (DON) said the following: -The resident was a fall risk because he/she liked to sit on the edge of the bed and kept the bed in the highest position; -It was common knowledge among staff the resident preferred to sit on the edge of his/her bed raised high in the air. Further review of the resident's care plan, showed staff had not addressed the resident's preference for sitting on the edge of the bed with the bed in a high position, education provided to the resident, the resident's tendency to lean, and the risks and interventions. Further review of the resident's medical record, showed the following; -On [DATE] at 1:48 P.M., the resident told nursing staff he/he believed he/she was having a stroke, complained he/she could not concentrate, felt weak, could not perform tasks as usual, was dropping items, and felt like his/her body parts were disconnected. The nurse noted the resident was slurring his/her words and would stop mid-sentence and stare into space. The nurse notified the PCP and received orders for lab work and a urinary analysis (UA); -On [DATE] at 7:08 P.M., the resident's positive UA results were reported to the PCP who ordered antibiotics twice a day for five days; -On [DATE] at 11:01 P.M., the resident continued on antibiotic therapy for the UA, complained of trouble sleeping, restlessness and bad dreams. The resident also had a low grade fever; -On [DATE] at 10:58 P.M., the resident had a fall with injury. The nurse was called to the resident's room, found the resident on the floor lying down, with his/her face looking towards the right. Upon speaking to the resident, he/she turned his/her head forward and there was a large amount of blood noted on the floor in front of the dresser and underneath the head of the resident, and to the right side of his/her head. The nurse was unable to determine and pinpoint the exact area the blood was coming from other than the resident's scalp. Emergency medical services (EMS) was called and they arrived within minutes to the facility. EMS assessed the resident and noted a left arm fracture noticeable near the resident's left elbow. EMS applied a splint to the resident's left upper arm, applied a cervical collar around the resident's neck and secured him/her to a backboard before transferring the resident to the stretcher. The resident left the building to go to a local hospital. During an interview on [DATE] at 4:45 P.M., the resident's roommate said the following: -He/she heard a crash coming from the other side of the room, but could not see what happened because there was a curtain between his/her bed and the resident's bed; -He/she called out to the resident to see if the resident was ok, and he/she heard the resident faintly say help me; -The roommate pressed the call light, used the phone to call the facility's main number and began yelling for help; -Two CNAs entered the room about two minutes later and saw the resident on the floor than ran out to get the nurse, who also came to the room very quickly; -The resident always sat on the edge of his/her bed and raised the bed as high as possible. He/she liked to dangle his/her feet off the side of the bed; -The roommate showed the surveyor a picture of the resident's side of room the night of the incident. It showed the bed raised in a high position in relation to the roommate's bed and in relation to the dresser. During an interview on [DATE] at 4:30 P.M., CNA E said the following: -He/she worked with the resident almost every day; -He/she was in the resident's room an hour before the incident occurred on [DATE] and saw the resident was sitting on the side of the bed with the bed elevated off the floor, eating a candy bar and watching T.V.; -The resident's bed was higher when CNA E came into the room and found the resident had fallen off his/her bed; -The resident had a urinary tract infection ([CONDITION(S)]) and was weaker and more tired than usual that night before the incident; -The resident was seen slumped over his/her lap when in a seated position more often ever since he/she was diagnosed with the [CONDITION(S)]. During an interview on [DATE] at 2:25 P.M., Nurse B said the following: -He/she was the nurse on duty on [DATE] and was told by two CNAs the resident had fallen off his/her bed onto the floor; -The resident was able to make eye contact with the nurse; -It did not appear the resident hit his/her head on any furniture; -EMS was called and arrived very quickly; -EMS asked the resident questions and he/she said he/she was sitting on the edge of the bed when he/she leaned forward and fell off the bed, hitting his/her head on the floor; -The resident's bed was raised to the highest level and was about waist high to the nurse; -The resident was often observed sitting on the side of the bed, raised high in the air, so the resident could swing his/her legs back and forth without hitting the floor, watching T.V., slumped over his/her lap; -The two CNAs who were working with the resident that evening told Nurse B they had both seen the resident sitting on the side of the bed, bed raised high in the air, watching T.V., slumped over his/her lap, prior to the fall; -Nurse B asked the resident if he/she could move his/her limbs, and the resident refused. The resident did move his/her head to the side and complained his/head and left shoulder hurt; -EMS assessed the resident and transferred out to the building to the hospital; -Nurse B notified the PCP and the family of the incident; -Nurse B told the family member the resident had fallen out of a bed, when the bed was raised high in the air. The family member was confused and asked why and how the resident could move the bed up so high; -Nurse B said it was common knowledge in the facility amongst staff the resident preferred to have his/her bed raised to the highest level. Staff often educated the resident that it was not safe and should be lowered, but the resident did not listen to them -The resident was a known fall risk; -There were no fall mats next to the resident's bed because he/she had never fallen from the bed before; -He/she was not aware the facility had a fall prevention program which included stars on residents' doors; Review of the resident's hospital record, dated [DATE], showed the following: -admitted [DATE]; -Resident was admitted to hospital after a fall out of bed to floor which resulted in head lacerations (cuts), right subdural hematoma with midline shift (pool of blood between the brain and outermost covering resulting in pressure that causes the brain to shift to one side), atlanto-occipital dislocation (internal decapitation where there is a separation of the ligaments connecting of the spinal column from the skull base) and cervical spine spondylosis ([CONDITION(S)] arthritis of the spine). Shortly after arrival, the patient had [CONDITION(S)] like activity and apneic episodes (temporary cessation of breathing) necessitating intubation (placing tube in throat to open airway to provide oxygen mechanically to breathe). Resuscitative attempts were made; -A long conversation was held with family about the resident's prognosis and comfort measures only were decided; -On [DATE] at 1:23 P.M., the resident died . Observation on [DATE] at 11:13 A.M., showed no star on the resident's name plate outside of his/her bedroom door. Observation on [DATE] at 10:45 A.M., showed the resident's bed was measured 42 inches off the floor when raised to the highest position. During an interview on [DATE] at 4:01 P.M., MDS Coordinator D said the following: -He/she was responsible for updating care plans after falls; -He/she would discuss the details of falls with the nursing staff and therapy department to get input of why falls happened in order to write appropriate interventions; -He/she used the information found in the residents' medical records to write care plans; -Residents who kept their bed in the highest position was considered a risky behavior, increasing their risk for an accident; -He/she expected nursing staff to alert him/her to risks for accidents, so he/she could write the correct interventions in the care plan; -He/she was not told the resident kept his/her bed high off the ground while sitting on the side of the bed and it was not included in the resident's progress notes. During an interview on [DATE] at 4:47 P.M., the DON said the following: -She expected the care plan to include interventions to keep the resident safe from falling from his/her bed; -She expected fall mats in place in order to keep the resident safe from injury if he/she fell from his/her raised bed and was not sure why nursing staff did not put that in place; -She expected staff to tell charge nurses and nurse managers when a resident has risky behaviors which jeopardizes their safety, so they could put a plan in place to keep them safe; -She expected staff to write in the resident's medical record when they educated the resident on keeping his/her bed low for safety; -She expected staff to make frequent checks on the resident to make sure he/she kept the bed in a lowered position for safety; -She expected nurses to write a note in the residents' medical record following an incident or accident which detailed what happened, what they did, who they notified, note new orders, and how they followed up. She also expected nurses to initiate 72 hour neurological checks for unwitnessed falls and when a resident hits their head which are completed in the resident's electronic medical record; -The interdisciplinary team (IDT) meets to discuss the fall and then writes a note in the residents' medical record detailing what corrective action was taken. This usually occurs within 24 hours after the incident or fall. During an interview on [DATE] at 10:59 A.M., Administrator D said the following: -He expected staff to document when a resident exhibits behavior which could increase risk of falling or accidents so the facility could address the behavior in order to keep resident's safe; -The MDS Coordinator uses the notes in the medical records to drive care plans; -The facility was aware the resident liked to keep his/her bed raised high in the air; -He could not answer if the resident sitting on the edge of his/her bed while it was raised in the highest position was a dangerous behavior; -It was the resident's choice to keep his/her bed so high; -Fall prevention strategies included lowered bed, fall safety mats, mattresses with bolsters, and placing pool noodles around perimeter of bed; -He was not sure if fall mats would have been an appropriate safety measure for the resident; -He did not know what fall preventions were put in place for the resident; -The facility was responsible for keeping residents safe. During an interview on [DATE] at 10:38 A.M., the DON said the resident was not receiving therapy or restorative therapy since July, 2021. The resident was able to pull his/her legs up into bed by scooting and wiggling on his/her bottom. Then staff would come in and use a draw sheet to move the resident into the appropriate position on the bed for sleeping, bringing his/her head up the head of the bed and straightening his/her legs out. During an interview on [DATE] at 8:43 A.M., the resident's PCP said the following: -She was not aware the resident routinely raised his/her bed up in the highest position such that he/she could dangle his/her feet over the bed; -She expected staff to document risky behavior in the resident's medical record such that they could be addressed; -She expected residents who were at higher risk for falls to have interventions in place, such as a low bed and fall mats; -She expected nursing staff to document when they gave education to residents; -The resident was in imminent danger because the facility knew the resident routinely put his/her bed in the highest position and did not put any interventions in place to keep him/her safe. 2. Review of the facility's elopement policy/protocol, dated [DATE], showed the following: -Elopement of a resident is defined as leaving a facility by a resident who has impaired decision making ability, is oblivious to his/her own safety needs, and is at risk for injury outside the confines of the facility without knowledge of the staff; -Goal: The facility has the responsibility to maintain an environment which will keep the residents safe, protect them from harm, while allowing them as much freedom within the facility as possible; -Plan: If a door alarm sounds, staff members are to respond immediately and go outside the doors and check for any residents and call for assistance if necessary. The staff will also look internally for the potential elopement resident. If the resident is found, the staff will assist him/her back into the building and re-set the alarm. If the resident is still not found, the staff will notify the doctor and the family. The staff will document and refer information to the care plan coordinator for care planning. Review of Resident #2's elopement risk assessment, dated [DATE], showed the following: -Ambulates independently; -Highly confused or demented; -Exhibited angry aggressive behavior; -Moderate risk for elopement. Review of the resident's, annual MDS dated [DATE], showed the following: -Date of admission [DATE]; -Diagnoses included dementia, weakness, [CONDITION(S)] (CHF, a chronic condition in which the heart doesn't pump blood as well as it should) and disorientation; -Adequate vision and hearing; -Sometimes understands and rarely/never makes self understood; -Inattention, disorganized thinking; -No behavioral symptoms; -Does not reject care; -Wandering behavior not exhibited; -Independent with transfers and walking on unit; -Supervision required for locomotion off unit. Staff provides oversight and cueing; -Alarms - Wander-elopement alarm - used daily. Review of the resident's care plan, dated [DATE], showed the following: -Care area/problem: Cognitive deficit: Decision-making. Evidenced by disoriented to place and time, inattention, poor decision making, long-term memory problems, short term memory problems and needs help making decisions in a new situation; -Goal: Resident safety will be maintained; -Interventions: Offer resident two simple choices to reduce the stress of decision making and increase resident's sense of autonomy; -Care area/problem: Behavioral changes evidenced by behavioral aggression; -Goal: Resident will demonstrate improvements in behavior; -Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and assess external and internal contributors; -Care area/problem: Wandering/at risk for elopement as evidenced by exit seeking upon admission; -Goal: Utilize approaches to help limit risk of elopement; -Interventions: Bracelet for alarm doors. Check placement of Wanderguard (a monitoring device that activates an alarm) every shift. Check working condition of Wanderguard monthly. Redirect the resident, as needed, toward safer areas. Review of the resident's progress notes, showed the following: -On [DATE] at 9:00 P.M., the resident wanted to go home and did walk under the chain divider and up the ramp to the residential care facility double doors and was able to open the door that leads to outside right before the double doors. He/she was able to go outside and refused to come back inside the building. Multiple staff members attempted to convince him/her to come in and then were able to coax him/her with an ice cream sundae; -On [DATE] at 6:20 A.M., the resident once again was able to get outside the same door. He/she came back inside when asked. -On [DATE] at 8:00 P.M., another resident reported the resident was walking around outside by the wing 3 patio. Staff went outside to get the resident inside. The resident's Wanderguard was in place and the alarm was going off, but somehow the resident was still able to get out the door without a passcode; -On [DATE] at 5:54 A.M., dispatch reported to staff they were glad they received a call to transport another resident to the emergency room for evaluation, because this resident was walking in the middle of the road and they almost hit him/her. The dispatch person stated his/her partner was with another facility employee at the end of the road walking the resident back to the facility. The resident's Wanderguard was in place when walking back to the facility, and the alarm did go off when the resident walked through the door. The nurse and another staff member checked the front door the resident came through before putting the code in and deactivating the code to make sure the door did indeed lock. The door was locked while the alarm was going off. The staff were unsure how the resident was able to get out of the facility when all the doors were closed and the resident had a Wanderguard on. During an interview on [DATE] at 9:30 A.M., CNA F said he/she worked the 200 hall the night the resident got out ([DATE]). The resident was on the 300 hall and was known to wander. The nurse called 911 to send another resident to the hospital. When the EMS member arrived at the facility, he/she told CNA F they almost hit a person at the end of the driveway as they were turning in from the road. The EMS person had sent a co-worker back to the road to check on the individual and the CNA ran to the road to check on the person. He/she was shocked as he/she did not know there was anyone missing from the facility and did not remember any alarms going off. The resident was miffed about returning to the facility. He/she was confused and thought he/she was going to go see a friend. They put 15 minute checks in place after this incident. Before that they would close the doors leading from the 300 hall to the dining room area because the resident liked to go out the doors outside the 300 hall. The fifteen minute checks were effective if they were fully staffed, but sometimes they would only have two staff for over 40 residents. If they got busy with a resident or were in an area where they might not hear the alarm go off, he/she did not know if they could keep the resident safe. Further review of the resident's progress notes, showed: -On [DATE] at 11:29 A.M., the resident was placed on 15 minute checks to be initialed by staff of his/her whereabouts; -On [DATE] at 6:34 A.M., nursing staff found the resident walking outside on the wing 3 patio digging through an ashtray. The Wanderguard alarm was going off, but the resident was still somehow able to get out of the doors, located by the bistro next to wing 3. Nursing staff went outside and re-directed the resident back inside; -On [DATE] at 2:52 P.M., the resident continuously attempted to elope through the outside door behind the main office, next to the apartments. The activity assistant attempted to redirect the resident, but he/she refused to return. The nurse was able to redirect the resident. Observations on [DATE] and [DATE] between 6:30 A.M. and 3:00 P.M., showed the resident wore a Wanderguard on his/her right ankle. He/she would sit at a table approximately 50 feet from the 300 wing alarmed door. He/she would sporadically pace the area between the dining room and the 300 doorway, adjacent to the alarmed door. During interviews on [DATE] at 7:35 P.M. and at 8:10 P.M., Nurse G said the resident wanders in the hall all of the time. Staff try to keep the double doors to the 300 hall closed. They were propped open on [DATE], when the resident got out. He/she did not think the resident could have propped the doors open. He/she was taking care of a resident on the 200 wing. An aide told him/her the front door alarm was going off. He/she did not hear the alarm go off. He/she did not know who got out or if anyone got out. The nurse and the aide walked out the front door, to the front parking lot and around the building, but did not find anyone. They came back in the building and the nurse reset the code to the door. He/she told the aide to do a bed check to make sure no one was missing and then went back to the resident on the west wing. He/she was sending the resident out to the hospital. When EMS personnel arrived at the building, he/she met them at the front reception. The EMS person told the nurse his/her partner was at the end of the street by the white fence because they almost hit a resident. The EMS person and CNA F walked the resident back to the building. It was approximately 10 to 15 minutes between the door alarm and when the resident was found in the road. They did not know how he/she was getting out of the building at first, but figured out if he/she pushed the door long enough it would automatically open. They put 15 minute checks into place after this incident. Nurse G knew to watch him/her and the aides who usually work with him/her know to do this, but he/she did not know if agency staff were aware. He/she prays that everyone passes this information along. During an interview on [DATE], MDS Coordinator D said the resident was placed on 15 minute documented checks. The resident needed more observation in the evenings. He/she was concerned the resident would get out of the building and staff needed to watch him/her like [NAME]. He/she was responsible for updating the care plans and the fact the resident knew how to bypass the Wanderguard system and the need for 15 minute checks should have been added to the care plan. Due to staffing shortages, he/she had been pulled to work the floor for several months and had not been able to update the resident's care plan. Staff provided interventions based on the care plan. During an interview on [DATE] at 2:30 P.M., the DON said MDS Coordinator D was responsible for updating the resident's care plan and absolutely should have done so after his/her attempted elopements. This should have included the resident's ability to bypass the alarm system and the 15 minute checks put into place. She was not working at the facility when the resident got out of the building. 3. Review of Resident #14's care plan, dated [DATE], showed the following: -Problem: Cognitive deficit related to decision making; Goal: Resident safety will be maintained; Interventions included offer resident two simple choices to reduce stress of decision making; -Problem: Communication evidenced by unclear speech, makes sounds, gestures, signs; Goal: Resident will communicate needs without frustration; Interventions included anticipate needs. Review of the resident's 15 minute checks and Wanderguard placement sheets, showed the following: -On [DATE], there was no documentation found from 12:00 A.M. through 6:45 A.M. and from 2:00 P.M., through 2:45 P.M.; -On [DATE], there was no documentation found from 4:45 A.M. through 9:00 A.M.; -On [DATE], there was no documentation found from 12:00 A.M. through 3:45 P.M. and from 4:15 P.M. through 5:45 P.M. Review of the resident's medical record, showed the following: -Medical diagnoses included disseminated malignant neoplasm (cancer that is spread throughout the body) and disorientation; -On [DATE], at 8:05 P.M., the DON witnessed the resident trying to elope out of the back hall door. The door alarm was activated. The door alarm was reset and the resident was directed back to his/her room. Three minutes later, the resident attempted to elope again. The resident was given a snack in his/her room to distract him/her. All staff were notified that the resident is to remain on 15 minute checks for safety and elopement prevention. Further review of the resident's 15 minute checks and Wanderguard placement sheets, showed the following: -On [DATE], there was no documentation found from 12:00 A.M. through 6:45 A.M. and from 3:15 P.M. through 6:45 P.M.; -On [DATE], there was no documentation found from 1:45 P.M. through 6:30 P.M.; -On [DATE], there was no documentation found from 7:00 A.M. through 6:30 P.M. and from 9:00 P.M. through 10:00 P.M.; -On [DATE], there was no documentation found from 4:45 A.M. through 9:45 P.M.; -On [DATE], there was no documentation found from 2:15 P.M. through 9:00 P.M.; -On [DATE], there was no documentation found from 6:00 A.M. through 7:45 A.M., from 12:30 P.M. through 1:45 P.M. and from 4:00 P.M. through 10:45 P.M.; -On [DATE], from 8:00 A.M. through 2:45 P.M.; -On [DATE], from 4:30 A.M. through 7:45 A.M.; -On [DATE], from 6:30 A.M. through 6:30 P.M.; -No documentation found for [DATE] or [DATE]; During an interview on [DATE] at 10:38 A.M., the DON said the following: -She expected care plans to be updated when a resident continually gets out of the building; -MDS Coordinator D was responsible for updating care plans; -Residents who were identified as elopement risks were put on a 15 minute check and staff kept them close to the nurses station; -She expected staff to make sure door alarms are on, and staff to go to the door that is alarming to check if a resident eloped; -When a resident was on 15 minute checks, there was a paper check off to document that

Based on interview and record review, the facility failed to follow professional standards of practice when one resident had a change of condition after sustaining a fall and hitting his/her head. Staff did not notify the physician of the resident's blood pressure changes and complaints of pain (Resident #12) . The sample size was 23. The census was 63. Review of the facility's fall policy, dated 10/20/21, showed the following: -Following a resident's fall: -The licensed nurse assesses the resident for injuries (including neuro checks if indicated) and provides the necessary treatment; -The physician and the resident's representative are notified; -Appropriate interventions are implemented; -Update care plan; -Continue ongoing assessment and documentation by licensed nurses per practice; -The licensed nurse documents occurrence on the 24-hour Nursing Summary; -Ongoing assessment including neurological, pain and alert charter documentation shall occur per policy; -Falls with significant injury will be escalated per the Post Fall Assessment Process. Review of Resident #12's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/10/20, showed the following: -admitted [DATE]; -Severe cognitive impairment; -Inattention and disorganized thinking present; -Required extensive assistance of one person for bed mobility, transfers, dressing, toilet use and personal hygiene; -Impairment on both sides of lower body; -Used a wheelchair for locomotion; -Frequently incontinent of bladder, occasionally incontinent of bowel; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, undated, showed the following: -Problem: Anticoagulant (blood thinner) use; Goal: Utilize interventions to limit abnormal bleeding, bruising or injury; Interventions included: Handle the resident carefully when turning, positioning or transferring. Monitor for hematuria (bleeding) tarry colored stools, and bleeding after brushing teeth. Notify the nurse/doctor/family of unusual bleeding, bruising, pain, swelling, headache, dizziness or weakness; -Problem: Fall risk; Goal: The resident's safety will be maintained; Interventions included: Remind resident to ask for assistance with transfers and toileting. Notify doctor and family of any noted deterioration in status, keep call light and most frequently used personal items within reach. Review of the resident's medical record, showed the following: -On 9/19/21, a fall risk assessment with a score of 7 out of 18, showing high risk for falls; -An order dated 10/18/21, for [MEDICATION(S)] (blood thinner used to prevent and treat blood clots, may cause severe bleeding) 4 milligrams (mg), give one tablet at bedtime for 22 days. Give with [MEDICATION(S)] 5 mg to equal 9 mg; -An order dated 10/18/21, for [MEDICATION(S)] 5 mg, give one tablet at bedtime for 22 days. Give with [MEDICATION(S)] 4 mg to equal 9 mg; Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 4 mg was administered on 11/1, 11/2, 11/3, 11/4, 11/5, 11/6 and 11/7; -[MEDICATION(S)] 5 mg was administered on 11/1, 11/2, 11/3, 11/4, 11/5, 11/6 and 11/7. Further review of the resident's medical record, showed: -A progress note, dated 11/8/21 at 6:40 P.M., the resident's Prothrombin Time (PT, evaluates the ability of blood to clot properly/used to help diagnose bleeding; International Normalized Ratio (INR) used to monitor the effectiveness of blood thinning drugs. Normal PT range is between 11 and 13 seconds. Normal INR range is between 2.0 and 3.0; High PT/INR levels indicates it takes longer for the blood to clot) test resulted; PT was 39.4 and INR was 3.8. The PCP was notified and gave a new order to reduce [MEDICATION(S)] to 8 mg a day; -An order, dated 11/8/21 for [MEDICATION(S)] 8 milligrams (mg) once a day; -A progress note, dated 11/9/21 at 2:07 P.M., the resident was found on the floor of his/her spouse's room, lying in front of his/her wheelchair. The resident said he/she was helping his/her spouse, went to sit on his/her wheelchair, and missed the seat. The resident denied any injury, said he/she did hit the back of his/her head. There was no bruising or swelling noted, neurologic checks were within in normal limits. The resident was assisted up by two staff members without difficulty, encouraged the resident to call for assistance with the spouse's care. The resident's blood pressure was 126/65, pulse was 83 beats per minute (bpm) and respirations were 18 breaths a minute. A message was sent to the primary care physician (PCP); -A progress note, dated 11/10/21 at 1:33 A.M., the resident continued on incident follow up charting and observation for an unwitnessed fall. The resident complained of pain to the left side of his/her neck, stating the pain was related to the fall on 11/9/21. The PCP was notified with new orders to apply [MEDICATION(S)] 1 % (a topical gel used to treat pain) to the areas of pain as needed twice a day. The writer will contact the family representative in the morning. The resident's neurological checks were within normal range; -A progress note, dated 11/10/21 at 7:02 A.M., showed at 6:05 A.M., the resident's co-roommate walked out into the hall way and informed the nurse the resident was sitting on the floor and was covered in blood. The nurse found the resident sitting on the floor, in front of his/her bed and wheelchair, covered in blood and holding a bed pad (an absorbent cloth used for incontinence episodes) to the left side of his/her head. The resident could not remember how he/she ended up on the floor. The co-roommate said he/she thought the resident was sitting in his/her wheelchair before the resident was sitting on the floor. There was a medium sized laceration (cut) to the left side of the resident's head. The resident complained the left side of his/her head hurt and it was tender. The resident's laceration was cleaned and a clean linen was applied. The nurse called 911, report was given, and emergency services arrived to the facility 10 minutes later. The resident was sent out to the hospital emergency room at 6:30 A.M. The immediate family was notified. The nurse will inform the PCP of the recent incident. Review of the resident's hospital discharge papers, dated 11/10/21, showed the following: -The resident was seen in the emergency department for a fall from wheelchair; -A computed tomography (CT scan, combines a series of x-ray images taken from different angles around the body), dated 11/10/21 at 8:26 A.M., showed the resident did not have any injury to his/her brain; -Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of the resident's medical record, showed: -A progress note dated 11/10/21 at 2:33 P.M., the resident returned from the hospital via ambulance. The resident was alert and oriented to self, place and time. The resident said he/she fell out of his/her wheelchair when he/she was leaning over to look at something. There was an abrasion on the left side of the resident's head. Staff encouraged the resident to ask for assistance for safety. The PCP was made aware of the resident's return and new orders were given to treat the abrasion; -A progress note dated 11/10/21 at 3:09 P.M., the resident's blood pressure was 132/64, pulse was 81 beats per minute (BPM) and blood oxygen saturation (O2 sats, the amount of oxygen in the blood) was 96%; -A progress note dated 11/11/21 at 1:30 A.M., the resident was on a new incident follow up (IFU) charting and observation for an unwitnessed fall that occurred at 6:05 A.M. on 11/10/21. The resident complained of pain to his/her lower back (unrelated to the fall) and refused any medication. Neurological checks were within normal range. No other concerns or distress at this time; -A progress note dated 11/11/21 at 1:26 P.M., the resident continued on post fall vital signs and neurological checks for unwitnessed fall that occurred on 11/10/21. The resident was sleeping in his/her wheelchair during the day and he/she complained his/her head and leg hurt. The resident refused any medication for pain. The resident's blood pressure was 160/62, pulse was 84 bpm, and O2 sat of 96%. Neurological checks were normal. Will continue to monitor; -There was no documentation that staff notified the PCP of the increased vital signs and resident's complaint of pain to his/her head; -Review of the resident's MAR, dated November 2021, showed on 11/13/21, during day shift, the resident's blood pressure laying down was 155/56; -There was no documentation the facility notified the physician of the resident's increased blood pressure. Review of the resident's MAR, dated November 2021, showed the following: -[MEDICATION(S)] 8 mg was administered on 11/8, 11/9, 11/10, 11/11, 11/12, 11/13 and 11/14. Further review of the resident's medical record, showed the following: -A progress note, dated 11/15/21 at 1:28 A.M., the resident complained of pain to his/her whole back rated 9 out of 10 (on a pain scale of 1-10, 10 as the worst pain) and also complained of a headache. The resident refused to take any medication for the pain. Education was provided. The nurse will continue to monitor the resident throughout the shift; -There was no documentation detailing what type of education was provided to the resident. There was no documentation of the nurse notifying the PCP of the resident's complaint of a headache, pain of 9/10; -Review of the resident's MAR, dated November 2021, showed on 11/15/21 at 7:30 A.M., the resident's blood pressure was 170/91; -There was no documentation the facility contacted the PCP to report the resident's blood pressure at 170/91; -A progress note on 11/15/21 at 5:35 P.M., the resident's PT/INR test resulted at 53.4/5.1. The PCP was notified and new orders were received to hold [MEDICATION(S)] 8 mg for three days; -A progress note on 11/15/21 at 5:35 P.M., the resident was observed sitting on the floor next to his/her bed that morning. The resident said he/she slid out of his/her wheelchair after placing a pillow on the seat of the wheelchair. There were no injuries noted upon examination and the resident's vitals were stable. Neurological check was within normal limits. The PCP was notified via Mediprocity (a secure communication tool to send a message to healthcare providers via phone or desktop computer) and a message was left for the resident's family member; -A progress note dated 11/16/21 at 12:15 A.M., the resident continued on IFU and observation for an unwitnessed fall. The resident denied pain or discomfort at time of assessment. The resident said he/she felt weak and fatigued and told the nurse to leave him/her alone and to not touch him/her. Neurological check was within normal limits and vital signs were within normal limits; -A progress note dated 11/16/21 at 11:40 A.M., the resident was in bed resting with his/her eyes closed. The resident was easily awakened and oriented only to self. The resident answered questions with a one word answer and closed his/her eyes after each question. The resident's blood pressure was 158/62, pulse rate was 85 bpm, respirations were 18 breaths a minute and O2 sat was 94%. The PCP gave an order to send the resident to the hospital for evaluation due to change of condition. Emergency services was called and arrived to the facility to transport the resident to the hospital; -A progress note dated 11/16/21, at 2:07 P.M., showed the facility notified the PCP of resident having multiple falls (3) in the last week, poor appetite, and weakness. An order was received to send the resident out to the hospital for evaluation. The charge nurse was made aware. Facility will send the resident out the hospital. Review of the resident's hospital record, dated 11/16/21 through 11/18/21, showed the following: -The resident was admitted to the hospital on 11/16/21 at 12:07 P.M. due to multiple falls and complex medical history; -On 11/16/21, a CT scan of the resident's head showed a 7 millimeter (mm) thick subacute left cerebral convexity/tentorial (left side of the brain) subdural hematoma (a pool of blood between the brain and its outermost covering. Usually caused by a head injury strong enough to burst blood vessels. Blood thinning drugs increase risk) with a 4 millimeter (mm) midline shift (occurs when pressure exerted by the buildup of blood and swelling around the damaged brain tissue is powerful enough to push the entire brain off center) after fall from wheelchair; -On 11/17/21 at 2:25 A.M., the resident's PT/INR test resulted high at 37.4/3.8; -On 11/17/21, a CT scan of the resident's brain showed a slight increase in the size of the small left subacute subdural hematoma with about a 5 mm midline shift. Due to the coagulopathy (the bloods ability to clot), surgical intervention is contraindicated until INR is less than 1.4. During an interview on 11/23/21 at 10:07 A.M., Nurse I said the following: -He/she was on shift when the resident fell from his/her wheelchair on 11/9/21; -He/she completed neurological checks on the resident during his/her shift and reported the fall to the on-coming nurse; -The resident seemed normal after the fall; the resident said the only injury he/she had was his/her pride. During an interview on 11/23/21 at 12:16 P.M., Certified Nurse Assistant (CNA) M said the following: -He/she was working on 11/9/21 with Nurse I when they found the resident in his/her spouse's room, on the floor; -The resident said he/she was helping his/her spouse and missed the seat of the wheelchair when he/she went to sit back down; -The resident said he/she thought he/she had hit the back of his/her head but was not sure; -Nurse I assessed the resident and took his/her vital signs; -He/she worked until 3:00 P.M. that day but could not remember if the resident had any change in behavior after the fall. During an interview on 11/23/21 at 11:57 A.M., CNA J said the following: -He/she found the resident on the floor on 11/15/21 after breakfast; -The resident had not felt well and was eating in his/her room, which was very unusual as the resident usually ate with his/her spouse; -The resident said he/she hit his/her head and it hurt; -The resident was found next to his/her bed with his/her wheelchair nearby. The resident's wheelchair had a lot of stuff in the chair, like blankets and bags and it did not appear as if the resident was able to sit on it; -Nurse K assessed the resident and told CNA J and CNA L it was ok to transfer the resident back into his/her wheelchair; -The resident did not want to go to the dining room for lunch because his/her head was hurting. During an interview on 11/24/21 at 8:32 A.M., CNA N said the following: -The resident was pretty independent and could transfer him/herself; -The resident seemed very tired, could not keep his/her eyes open on 11/16/21 before he/she was sent to the hospital; -He/she did not know the resident had a fall on 11/15/21; -He/she did not remember telling the nurse the resident was not acting like his/her usual self. During an interview on 11/24/21 at 8:39 A.M., Nurse K said the following: -He/she was working on 11/15/21 when the resident had his/her fall; -The resident slid out of his/her wheelchair because he/she had put a pillow on the seat; -One of the CNAs found the resident and notified him/her; -He/she assessed the resident and found range of motion, neurological checks and vital signs were normal; -The resident had no complaints of pain; -The resident reported he/she was very tired that day but since the resident's neurological checks were within normal range, the nurse did not tell the PCP; -He/she knew the resident had fallen before and was a high fall risk so he/she made frequent checks on the resident; -He/she was not alerted to any new change of condition after the resident's prior two falls. During an interview on 11/24/21 at 8:56 A.M., MDS Coordinator D said the following: -She was working on 11/16/21 and knew something was not right with the resident after nurses reported he/she had increased confusion; -She tried to call the PCP on Mediprosity to get an order to either get labs on the resident or to send the resident out to the hospital. She was not able to get the PCP to respond timely so she asked the DON to contact the PCP; -The DON was able to contact the PCP and received orders to send the resident out to the hospital. The DON did not assess the resident; -Nurse G reported the resident was complaining of a headache during the night but refused to take any medication. During an interview on 11/24/21 at 9:30 A.M., Nurse O said the following: -He/she was working the morning of 11/16, training with Nurse P; -He/she was told the resident had fallen previously and was still on 72 hour neurological checks; -He/she got a message that the facility was sending the resident out to the hospital; -The CNAs did not tell him/her the resident was not acting like his/her usual self. During an interview on 11/24/21 at 11:55 A.M., Physician Q said the following: -He was in charge of the PCP's case load while she was on vacation and had access to all her notes and resident medical records; -There was no log or note in the resident's medical record that the facility contacted the PCP on 11/9; -There was a log entry and note in the resident's medical records of the facility notifying the PCP on 11/10 of the resident's fall and subsequent order to go out to the hospital for evaluation; -He expected the facility to notify the physician if the resident had an increased blood pressure and complained of a headache, especially if the resident was on [MEDICATION(S)] and had hit his/her head previously; -The plan of care would have changed if the physician was notified of the headaches and increased vital signs. He would have prescribed different medications, increased monitoring of the resident's neurological checks, and/or frequent follow up assessments and reports to make sure they did not miss anything that could be detrimental to the resident's health; -The resident may have been sent out the hospital sooner if the physician was notified of the change of condition. During an interview on 11/24/21, the administrator said the following: -She expected nurses to notify the PCP when the resident had increased blood pressure, complained of a headache after two falls, especially since the resident was on [MEDICATION(S)] and had a high PT/INR; -The resident was not him/herself after the falls on 11/9 and 11/10. The resident was not a typical [NAME] so it was very unusual that the resident fell twice; -The resident's second fall on 11/10 was a red flag that something was going on, and the facility sent the resident out for evaluation; -After the third fall on 11/15, it was discussed in morning meeting that something was going on with the resident as he/she had an ongoing decline. MO 599

Based on observation, interview and record review, facility staff failed to routinely provide ongoing assessment of pain management and failed to assess the effectiveness of the pain medication after administration for one resident (Resident #4) with signs and symptoms of pain. Additionally, the facility failed to administer PRN (as needed) pain medication for the resident, who exhibited signs and symptoms of pain during the treatment, before administering treatment for [REDACTED]. 1. Review of Resident #4's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/30/14 showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive staff assistance with bed mobility, transfers, toilet use and personal hygiene; -Always incontinent of urine; -Frequently incontinent of stool; -[DIAGNOSES REDACTED]. -No pain at present; -Has not received a PRN pain medication ; -Has not received non-medication interventions for pain; -Has not been on a scheduled pain medication regimen; -Resident does have a life expectancy of less that six months. Review of the resident's comprehensive care plan dated 2/4/14, direct staff on the following interventions for pain: -Assist with care as needed, allow the resident to assist if he/she wishes; -Give pain medication as ordered to help remain as comfortable as possible; -Lay down for naps per resident request and as needed to maintain comfort; -Monitor bowel sheets to make sure having regular bowel movements, give bowel care as needed; -Provide one-on-one to allow resident to express feelings; -Provide repositioning for comfort as needed. Further review of the comprehensive care plan showed staff did not include interventions to direct staff about how often to assess for signs and symptoms of pain or how to evaluate the effectiveness of the medication. Review of the resident's medical record showed the Nurse's Progress Notes did not include a section for staff to assess the resident's pain. At this time, LPN N said pain should be assessed quarterly in the Nurse's Progress Notes. Review of the Physicians Order Sheet (POS) dated March 2014, showed the physician ordered the [MEDICATION NAME] (pain medication) 5/325 mg(milligrams) be changed from PRN to scheduled to be given twice a day. Further Review of the POS [REDACTED]. Review of the resident's Wound Record showed staff documented the following: -4/3/14 showed staff documented a unstagleable left ishium (lower buttocks area) pressure ulcer that measured 3.3 cm (centimeters) x 5.1 cm x 2.1 depth. Further, staff documented 2.2 cm tunneling from 10 to 3 o'clock. - 4/10/14 showed staff documented a unstageable left ishium pressure ulcer that measured, 3.8 cm x 4.4 cm x 1.9 cm depth. Further, staff documented 3.2 cm of tunneling from 10 to 1 o'clock. Review of the nurse's notes dated 4/1/14, showed staff documented the wound doctor here and the staff administered resident [MEDICATION NAME] 5/325 mg routine dose as ordered prior to dressing change of wound and "helped". Staff documented no signs or symptoms of pain. Review of nurse's notes dated 4/14/14, showed staff documented they gave [MEDICATION NAME] 5/325 mg at 5:30 A.M. prior to dressing change to left buttock wound. Staff documented little pain or discomfort. Review of the Medication Administration Record [REDACTED]. Further documentation showed staff documented the medication as effective. Observation on 4/16/14 at 3:00 P.M., showed LPN G entered the room to perform a dressing change on the left ishium pressure ulcer. LPN G removed the old dressing and cleansed the wound. During this time, the resident hollered out, " Oh, oh, oh" while he/she attempted to guard the left ishium (lower buttocks area) area. LPN G then used a cotton applicator and placed a nickel-size amount of ointment inside the depth of the pressure ulcer. During this time, the resident again hollered out, "Oh, oh, oh." LPN G did not administer pain medications prior to the dressing change to the pressure ulcer. LPN G did not assess the resident before, during or after the dressing about pain or stop the dressing change to administer pain medications. Observation on 4/17/14 at 3:00 P.M., showed a Hospice aide transferred the resident into bed from the wheelchair. The resident hollered out, "oh, oh, oh," during the entire transfer. At this time, the Hospice aide said he/she could only do a partial bath due to the resident's signs and symptoms of pain. The Hospice aide said he/she informed an unknown CMT about the resident's pain and that the resident may need pain medication. (Review of the MAR indicated [REDACTED] During an interview on 4/18/14 at 11:15 A.M., LPN N said staff are expected to monitor for pain signs and symptoms at all times. LPN N said the resident has problems with pain and the physician recently increased the [MEDICATION NAME] 5/325 mg to twice a day instead of PRN. LPN N said staff are expected to assess for pain by monitoring body language and verbal outbursts, then encourage the resident to take something for pain if symptoms are present. During an interview on 4/18/14 at 12:00 P.M., the Director of Nursing (DON) said staff are expected to monitor the need to give pain medication before a dressing change. Further, the DON said pain assessments are expected to be done upon admission and quarterly but staff are to monitor for signs and symptoms of pain at all times.

Based on observation, interview, and record review, staff did not provide care to prevent accidents and possible injury for one resident (Resident #6) dependent on staff for safety during transfers. The facility census was 110. 1. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 02/23/12, showed staff assessed the resident as follows: - Independent with cognitive skills for daily decision making; - Required limited assistance from staff for bed mobility, transfer, dressing, toilet use, and hygiene. Review of the resident's most current Side Rail Assessment, dated 02/23/12 showed staff assessed side rails as an enabler to promote independence. The assessment at that time did not indicate a risk of safety. Further review showed staff did not reassess the resident side rail use after an injury involving side rail use on 04/27/12. Review of the resident's nurses note, dated 04/27/12 at 8:00 P.M. showed staff documented a Certified Nursing Assistant (CNA) transferred the resident from the wheelchair to the resident's bed. Review showed the resident's leg hit the side rail on the bed and received a deep and long laceration on the lateral aspect (outer portion) of the right lower leg. Further review showed the staff sent the resident to the local emergency room for treatment. Review of the facility incident and accident report dated 04/27/12, showed staff documented as follows: - Side rail involved; - Side rail in down position; - Deep laceration. Review of the resident's plan of care, dated 02/07/12, showed no new interventions added since the injury with transfer involving the side rail. Further review showed staff were directed to: - Assist resident out of bed several times daily; - Body and skin audit weekly; - Half side rails up when in bed to assist with bed mobility and safety; Additionally, staff documented the CNA transferred the resident to his/her bed causing the resident right leg to "rub" against the side rail causing a deep laceration on the right lower leg. Review of the resident's nurse's note, dated 04/28/12 at 3:03 P.M., showed resident returned from hospital. Review showed the staff documented the sutures intact to resident right leg, treatment to the laceration done and leg brace applied as ordered. Review of hospital records dated 04/28/12, showed the emergency room Physician instructed staff to follow up with the residents physician for removal of stitches. Review of the facility investigation dated 04/27/12, showed staff documented there is a knob on the bed which would coincide with the area on the resident's leg and the "C" shape injury. Further review showed nothing else found that could be noted to have caused the injury. Reviews of the resident's Physician order [REDACTED]. Review of the resident's nursing notes, dated 05/08/12 at 11:00 P.M., showed staff documented removing twenty- seven stitches and applying steri-strips (adhesive strips) to the resident's right lower leg. Review also showed staff documented the resident received antibiotics for leg infection. Observation on 5/23/12 at 9:50 A.M., showed the resident in bed following a shower with both legs elevated and side rails not in use. Observation showed the lower area of the right leg red, dry and swollen. Observation showed the surgical wound located on the outer portion of the right lower leg approximately 15.0 cm in length. Observation showed approximately 5.0 cm of the upper portion of the surgical wound open with a green slough center. Observation showed the edges of the surgical wound raised and red. Observation on 5/25/12 at 9:35 A.M., showed the wound care nurse entered the resident's room to provide wound care. Observation showed the resident had an opened surgical wound on his/her lower outer portion of the right leg that measured 5.1 cm by 1.8 cm and the wound bed had green slough with red surrounding edges. Further, observation showed four additional open wounds on the lower outer portion of the right leg measuring: - 1.0 cm in length by 1.0 in width and unable to determine depth; - 0.3 cm in length by 0.1 in width and unable to determine depth; - 0.4 cm in length by 0.2 in width and unable to determine depth. Additional observation on 05/25/12 at 9:35 A.M., showed several areas of dried blood present on the side rail. During an interview on 05/25/12 at 8:41 A.M., the DON said she implemented the protective sleeve use for the legs. The DON said the resident complained of wearing the sleeves on occasion and would not wear the sleeves. The DON said she would implement padding the side rails if the incident occurred again. The DON said she would expect staff to update the care plan with the resident's new interventions for side rail use and treatment for [REDACTED]. During an interview on 05/25/12 at 8:58 A.M., the MDS Coordinator said he/she would expect the licensed staff to update the care plan with intervention for the resident involving side rail use and physician ordered treatment interventions.

Based on observation, interview and record review the facility failed to provide appropriate care to prevent a facility acquired unstageable pressure ulcer and three facility acquired Stage II pressure ulcers (partial thickness skin loss) for one resident (Resident #3) of 22 sampled residents. The facility census was 110. 1. Review of Resident #3's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/12/12, showed staff assessed the resident as: - Severely impaired cognitive skills for daily decision making; - Extensive assistance for bed mobility, transfers, locomotion, dressing, eating, toileting, and personal hygiene; - Transported per wheelchair; - Frequently incontinent of urine and bowel; - [DIAGNOSES REDACTED]. - At risk for pressure ulcers; - No pressure ulcers present. Review of the resident's plan of care, dated 4/17/12, showed staff are directed to: - Examine skin during bathing for signs and symptoms of breakdown; - Apply heel protectors when in bed; - Body/skin audit at least weekly; - Keep skin clear and dry; - Apply moisture barrier cream after cleansing; - Treatments as ordered; - Wheelchair cushion. Further, review of the resident's plan of care showed staff updated the care plan with the following interventions; - On 4/24/12 - an unstageable pressure wound noted to left heel and wear heel protectors at all times; - On 5/11/12 - Suspected deep tissue injury noted to right upper buttocks and a stage II pressure ulcer noted to left buttocks. - On 5/22/12 - Turn side to side frequently each shift and Roho (pressure relieving) cushion. Review of the resident's Braden Scale (assessment tool used to predict resident's pressure ulcer risk), dated 2/23/12, showed staff assessed the resident at mild risk for pressure ulcers. Review of the resident's Admission Nursing Assessment, dated 4/3/12, showed staff did not document any skin breakdown on readmission to the facility. Review of the resident's Physician order [REDACTED]. - [DIAGNOSES REDACTED]. - Tilt back wheelchair; - Moisture barrier cream to buttocks twice daily; - May be transferred per Hoyer lift with abductor pillow in place; - Cleanse left heel with normal saline twice daily and apply skin prep (provides protective coating); - 4/24/12- Heel protectors to bilateral feet at all times; - 5/23/12 - Right upper buttocks- cleanse with normal saline, apply Santyl (removes damaged tissue) and dry dressing daily until healed; - 5/22/12 - admit to Hospice and provide low air loss mattress, Broda chair (repositioning chair) as tolerated and Star cushion (pressure relieving). - 5/23/12 - discontinue ted hose (compression stockings) treatment due to pressure areas to heels. Review of the resident's Treatment Administration Record (TAR), dated 5/1/12 to 5/31/12, showed staff are directed to: - Cleanse left heel with normal saline, apply skin prep and heel protectors at all times. Further, review of the resident's TAR, showed staff did not document the above treatment on the 7:00 A.M. to 7:00 P.M. shift on 5/11/12 and 5/17/12 and on the 7:00 P.M. to 7:00 A.M. shift on 5/14/12. Review of the facility's Wound Care Protocol, undated, showed staff are directed to: - Always notify physician of wounds and receive treatment orders; - Notify physician if wound is not making progress; - Notify family of wounds; - Notify wound nurse of wounds. Observation on 5/23/12 at 11:15 A.M., showed Certified Nurse Assistant (CNA) D and Licensed Practical Nurse (LPN) C provided incontinence care and wound care for the resident. Observation showed the resident in bed with heel protectors on and an abductor pillow between his/her legs. LPN C removed the dressing on the resident's left heel and the resident's heel had a 5.0 centimeter (cm) by 5.0 cm black area surrounded by a blister. During an interview at this time LPN C said the left heel black area was an unstageable pressure ulcer. LPN C cleansed the resident's left heel with normal saline, applied the skin prep and put the resident's heel protectors on. Observation on 5/23/12 at 12:30 P.M., showed LPN C entered the resident's room to provide wound care. Observation showed the resident had a Stage II pressure ulcer on his right outer buttocks that measured 2.5 cm by 1.5 cm and the wound bed was blood red. Further, observation showed a Stage II pressure ulcer on the resident's upper right buttocks that measured 0.8 cm by 1.0 cm and a Stage II pressure ulcer on the resident's coccyx that measured 1.0 cm in diameter. During an interview at this time LPN C said that weekly skin assessments are not done by licensed staff. LPN C said the CNA's observe the resident's skin during the resident's bath or shower. If the CNA observes any skin breakdown it is recorded on the shower sheet and given to the nursing office for review. Further, LPN C said the resident did not have heel protectors on until the left heel developed the unstageable pressure ulcer. Review of the resident's nurses notes, dated 4/22/12 at 11:40 P.M., showed staff documented resident's left heel had a dark spot with signs and symptoms of pressure wound. Will inform skin assessment nurse for measurements. Review of the resident's nurses notes, dated 4/23/12 at 11:00 (no A.M. or P.M. documented) showed staff documented left message for wound nurse, in bed elevate heels above bed and heel protectors applied bilaterally. Further, staff documented skin prep to left heel. Review of the resident's nurses notes, dated 5/3/12 at 3:30 (no A.M. or P.M. documented) showed staff documented resident has reddened area on upper portion of right buttock toward lower back. Further, review did not show staff documented the physician was notified. Review of the resident's Wound skin/healing records showed staff documented the following for the resident's left heel: - Date of onset: 4/22/12 and facility acquired; - On 4/26/12: Unstageable and 3.7 cm by 6.0 cm and unable to determine depth. Black/brown wound bed. Treatment: Cleanse with normal saline, skin prep and apply dressing. No documentation physician notified. - On 5/4/12: Unstageable and 6.0 cm by 6.5 cm and unable to determine depth. Black/brown wound bed. Response to treatment showed deteriorated. Continue treatment and use heel protectors. No documentation physician notified. - On 5/11/12: Unstageable and 3.2 cm by 4.7 cm and unable to determine depth. Black/brown wound bed. Continue treatment with skin prep and no documentation physician notified. - On 5/18/12: Unstageable and 3.0 cm by 5.0 cm and unable to determine depth. Black wound bed. No change in response to treatment and continue previous treatment. Review of the resident's Wound skin/healing records showed staff documented the following for the resident's left buttock: - Date of onset: 5/11/12 and new facility acquired pressure ulcer; - On 5/11/12: Stage II pressure ulcer that measured 1.7 cm by 1.0 cm and 0.1 cm in depth. No documentation physician notified and comments showed staff directed to apply moisture barrier cream and turn side to side. - On 5/18/12: Stage II pressure ulcer that measured 0.4 cm by 0.5 cm and 0.1 cm in depth. wound bed was red . Continue moisture barrier cream. Review of the resident's Wound skin/healing records showed staff documented the following for the resident's right outer buttocks: - Date of onset: 5/3/12 and facility acquired; - On 5/4/12: Suspected deep tissue injury that measured 4.0 cm by 8.0 cm. Wound bed red. No documentation physician notified and comments showed staff are directed to keep off area. Treat with moisture barrier cream. - On 5/11/12: Suspected deep tissue injury that measured 3.0 cm by 4.0 cm and wound bed red. Area remains hard and red, apply moisture barrier cream. Low air loss mattress to resident's bed. No documentation physician notified. - On 5/18/12: Suspected deep tissue injury that measured 4.5 cm by 6.0 cm and wound bed red. Area remains hard and red, apply moisture barrier cream. No documentation physician notified. During an interview on 5/24/12 at 8:00 A.M., the Director of Nursing (DON) said a weekly skin assessment is not done on each resident. The wound nurse provides wound treatment and assesses any wounds on Fridays and the charge nurse provides treatment the other days. The DON said the CNA's are expected to observe the resident's skin during showers and document any concerns on the shower sheet and give to the nursing office. The shower sheets are not kept as part of the resident's permanent medical chart. The DON said she did not have any shower sheets available for the resident. Further, the DON said that if a resident can move him/herself and needs turning and repositioning that heel protectors should be applied prior to skin breakdown developing. During an interview on 5/25/12 at 8:45 A.M., the DON said the resident's physician should be notified of any new skin breakdown and changes in the wound.