Every finding on record at Mcknight Place Extended Care

Based on interview and record review, the facility failed to establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation, for two out of two medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 58. Review of the facility's Counting Narcotics policy, updated 8/5/11, showed: -At the change of shift, an off-going nurse or Certified Medication Technician (CMT) and an oncoming Nurse or CMT must count all narcotics, routine and as needed (PRN); -The Nurses or CMTs counting must also verify that the count is correct and that the number of items (cards and bottles) is correct, on both green sheet and the count sheet; -Any Nurse or CMT who had access to the medication cart being counted must also stay until the count is completed. 1. Review of Fountain View Terrace Hall one narcotic book count sheets, dated 3/1 through 3/31/25, showed: -Twenty out of 93 shifts had no nurse or CMT signature on the shift change count; -Thirty four out of 93 shifts only had one nurse or CMT signature on the shift change count. 2. Review of Fountain View Terrace Hall one narcotic book count sheets, dated 4/1 through 4/7/25, showed: -Two out of 21 shifts had no nurse or CMT signature on the shift change count; -Nine out of 21 shifts only had one nurse or CMT signature on the shift change count. 3. Review of Fountain View Terrace Hall two narcotic book count sheets, dated 3/1 through 3/31/25, showed: -Twenty out of 93 shifts had no nurse or CMT signature on the shift change count; -Forty out of 93 shifts only had one nurse or CMT signature on the shift change count. 4. Review of Fountain View Terrace Hall two narcotic book count sheets, dated 4/1 through 4/7/25, showed: -Seven out of 21 shifts had no nurse or CMT signature on the shift change count; -Seven out of 21 shifts only had one nurse or CMT signature on the shift change count. 5. During an interview on 4/8/25 at 8:25 A.M., CMT A said the narcotic shift count is to be completed with one oncoming staff member and one off going staff member, every shift every day. 6. During an interview on 4/9/25 at 8:50 A.M., Licensed Practical Nurse (LPN) B said the narcotic shift count is to be completed with one oncoming staff member and one off going staff member, every shift, every day. 7. During an interview on 4/9/25 at 10:44 A.M., the Director of Nursing (DON) said she expected staff to complete the narcotic shift count completely and accurately with one oncoming staff member and one off going staff member, every shift every day.

Based on observation, interview and record review, the facility failed to have a system in place to ensure drugs and biologicals in the medication room refrigerator were stored at a proper temperature for one of one medication room observed. The census was 58. Review of the facility's Storage of Medications, revised April, 2007, showed: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The nursing staff shall be responsible for maintain medication storage and preparation areas in a clean, safe and sanitary manner; -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. Observation and interview on 4/8/25 at 7:54 A.M., showed the Fountain View Hall medication room refrigerator contained insulin pens, insulin vials, eye drops, protein shakes, an open carton of cranberry juice, and small containers of applesauce. The refrigerator temperature log was located on a clipboard above the refrigerator and the monthly refrigerator temperature log was dated November, 2024. There was no refrigerator temperature logs for December, 2024, January, February, March, or April, 2025. Certified Medication Technician A said the daily temperature log was to be completed by the night nurse. There should not be food stored in the refrigerator that contained residents' medications. During an interview on 4/9/25 at 8:50 A.M., Licensed Practical Nurse B said the daily refrigerator temperatures were to be completed by the night nurse. Food items should not be stored with the residents' medications. Temperature logs should be completed to ensure the efficacy of the medications. During an interview on 4/9/25 at 10:44 A.M., the Director of Nursing said the daily temperature logs for the medication refrigerators were the responsibility of the night nurse to complete. She would expect the temperatures to be checked and documented on the temperature log daily. Food should not to be stored with the residents' medications.

Based on observation, interview and record review, the facility failed to ensure floors and the ice cream freezer in the kitchen were clean. In addition, the facility failed to ensure proper hair restraints were worn. The census was 58. Review of the facility's food service hygiene policy, dated 4/2024, showed: -Policy: employees must meet acceptable standards of personal hygiene and appearance. -Facial hair, including overgrown sideburns, mustaches and beards is to be clean and required to be completely covered wearing protective cover gear. 1. Observation on 4/7/25, of the kitchen, showed: -At 9:17 A.M., the dry storage room had trash and food debris on the ground in various areas and a white powder spill on the floor in front of the bulk bin rack; -At 9:19 A.M., the ice cream storage cooler had ice cream smears and build up on the doors and sides; -At 9:21 A.M., the walk in refrigerator had food and trash debris on the floor in various areas and under the storage racks; -At 9:23 A.M., the walk in freezer had food and trash debris on the floor in various areas and under the storage racks; -At 9:24 A.M., the floor under the dish washing sink had grime build up and trash debris. 2. Observation on 4/8/25, of the kitchen, showed: -At 6:19 A.M., the dry storage room had trash and food debris on the ground in various areas and a white powder spill on the floor in front of the bulk bin rack, -On 6:21 A.M., the ice cream storage cooler had ice cream smears and build up on the doors and sides; -At 6:22 A.M., the walk in refrigerator had food and trash debris on the floor in various areas and under the storage racks; -At 6:23 A.M., the walk in freezer refrigerator had food and trash debris on the floor in various areas and under the storage racks; -At 9:08 A.M., the floor under the dish washing sink had grime build up and trash debris. 3. Observation on 4/8/25, of lunch preparations, showed: -At 10:08 A.M., Dietary Aide K stood over the prep station where uncovered breakfast food was located. His/Her beard was approximately 1/2 inch long. He/She was not wearing a beard net; -At 10:08 A.M., [NAME] J was cutting up meat. His/Her beard was approximately 1.5 inches long, and he/she did not have on a beard net; -At 10:11 A.M., [NAME] J put burger meat on the skillet, without a beard net; -At 10:13 A.M., [NAME] J put hot dogs on the skillet top, without a beard net; -At 10:18 AM Dietary Aide L was cleaning dishes and putting them away. His/Her beard was approximately 1 inch long. He/She did not wear a beard net. During an interview on 4/9/25 at 7:17 A.M., [NAME] I said he/she expected the floors to be clean and free from trash and debris. He/She expected the appliances to be clean. He/She expected staff to wear beard nets to avoid contaminating the food. During an interview on 4/9/25 at 9:17 A.M., the Dietary Supervisor said she expected the floors to be clean and free from trash and debris. He/She would expect the appliances to be clean. She expected staff to wear beard nets while in the kitchen. During an interview on 4/9/25 at 9:47 A.M., the Administrator said she expected the floors in the kitchen and walk ins to be clean and free from trash and debris. She expected kitchen appliances to be clean. She expected staff to wear beard nets while in the kitchen.

46888 Based on observation, interview and record review, the facility failed to ensure one resident had physician's orders for a wound dressing (Resident #42) and failed to ensure skin assessments detailed all skin concerns (Residents #42 and #15). The sample was 15. The census was 58. Review of the facility's skin assessment protocol, dated 12/3/20, showed: -A skin assessment is to be completed weekly on all residents by the charge nurse. If a new pressure ulcer develops, the initial wound assessment must be done by the charge nurse. Prior to any other assessments, consultations or obtaining orders from the physician or nurse practitioner wound consultant, the charge nurse must document the following in the resident's electronic medical record (EMR): location of pressure ulcer, stage, length, width and depth, pain, and mobility status; -The physician must then be notified and a treatment order obtained and/or an order for the resident to be seen and treated by the wound nurse practitioner consultant. 1. Review of Resident #42's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/18/25, showed: -Cognitively intact; -Requires maximum assist from staff for toilet hygiene, bathing hygiene, and putting on and taking off foot wear; -Diagnoses included type two diabetes, morbid obesity, end state renal disease (kidney failure), and muscle weakness. Review of the resident's care plan, dated 9/13/24, showed: -Problem: the resident has diabetes; -Goal: resident will have no complications from diabetes through the review date; -Intervention: weekly skin assessments with special attention to feet. Review of the resident's physician's orders, dated April 2025, showed no active orders for wound treatments for the resident's right lower leg. Review of the resident's most recent skin assessment, dated 3/7/25, showed scattered scabbed areas all over the body from scratching. During observation and interview on 4/8/25 at 11:25 A.M., the resident's left and right feet were scaly and had flakes of dry skin. Both of the resident's lower legs had deep crevices of dry skin and appeared leather-like. The resident's skin on both of his/her lower legs was discolored and had a purple hue. The resident's right lower leg had an undated white, border gauze (a specialized dressing). The dressing had a large shadow of dark maroon fluid. Licensed Practical Nurse (LPN) B removed the dressing slowly with wound cleaner. The dressing had adhered to the wound. When the dressing was removed, it showed maroon and yellow fluid on it. The dressing and wound had an odor. The wound appeared approximately quarter size and the wound bed was beefy red and moist. The resident said he/she had a history of vascular ulcers (open skin sores caused by poor blood flow) and said it had been months since the dressing was put on his/her leg. LPN B said there was no order for the treatment to the resident's right lower leg. 2. Review of Resident #15's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Requires maximum assistance from staff for toilet hygiene, bathing hygiene, and putting on and taking off foot wear; -Diagnoses included heart failure, heart disease, diabetes and respiratory failure. Review of the resident's care plan, in use at the time of survey, showed: -Problem: the resident has diabetes; -Intervention: weekly skin assessments with special attention to feet. Review of the resident's skin assessments, showed: -No skin assessments dated 2/1 through 2/28/25 were completed; -A skin assessment, dated 3/6/25: Observation: Groin, slightly red; Both arms and legs have scratches and scabs; -A skin assessment, dated 3/27/25: Skin intact: Yes; Areas of concern: No; -The resident's skin assessments, dated 3/6/25 and 3/27/25, did not address the resident's feet; -No further skin assessments, dated March, 2025, were completed. -No skin assessments for April, 2025, were completed. Observation and interview on 4/7/25 at 11:10 A.M., 4/8/25 at 7:45 A.M., and 4/9/25 at 7:47 A.M., showed the resident lay in bed with his/her feet exposed. The resident had a slight amount of swelling to his/her feet. Both feet were very red with some dryness. The resident said he/she had a groin rash that staff had been putting on some type of powder. The resident lifted his/her abdomen and exposed his/her groin. A slight red rash to the resident's bilateral (both) groin areas were present. During an interview on 4/9/25 at 8:50 A.M., LPN B said the resident has a private caregiver who completes the resident's bathing. LPN B said the skin assessments for the residents are weekly and it includes a head-to-toe assessment. Any skin condition should be on the skin assessment. During an interview on 4/9/25 at 10:44 A.M., the Director of Nursing (DON) said the nurses are expected to complete weekly skin assessments. Any skin condition is expected to be added to the resident's skin assessment. The previous skin assessment should be reviewed prior to completing the skin assessment to determine if the skin condition is improving or deteriorating. If the current treatments orders are not working, she expected staff to reach out to the Wound Nurse and the physician. The DON expected dry skin to be documented on the skin assessment. She expected physician's orders to be in place for all skin treatments. She expected wounds to be treated per physician's orders. The DON expected wound treatments to be dated. During an interview on 4/9/25 at 11:15 A.M., the Administrator said she expected staff to follow the skin assessment policy. She expected physician's orders to be in place for all wounds. She expected staff to ensure residents' skin conditions are documented on the skin assessment.

Based on observation, interview and record review, the facility failed to ensure one resident with a pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) had necessary treatments and services to promote healing (Resident #10). The sample size was 15. The census was 58. Review of the facility's Pressure Ulcer and Skin Breakdown policy, revised 3/26/14, showed: -The nursing staff and or Wound Nurse Practitioner will assess and document an individual's significant risk factor for developing pressure sores; -The wound nurse shall describe and document and report the following: -Full assessment of pressure sore including, location, stage, length, width, depth and presence of drainage or necrotic (dead) tissue; -Pain assessment; -The resident's mobility status; -Current treatments, including support surfaces; -All active diagnosis; -The nursing staff will examine the skin of a new admission for ulcerations or alterations of the skin; -The Wound Nurse Practitioner will assist the staff to determine the etiology (cause) and characteristics of the skin alteration. Review of Resident #10's admission Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated, 2/21/25, showed: -Cognitively intact; -Dependent on staff for toileting hygiene; -Requires maximum assist bed to chair transfers and rolling left to right; -Diagnosis included hip fracture, renal disease and depression. Review of the resident's medical record, showed: -admitted : 2/14/25; -discharge date : 3/31/25; -Re-admitted : 4/4/25. Review of the resident's baseline care plan, dated 4/4/25, showed it did not address the resident's skin condition. Review of the resident's comprehensive care plan, in use at the time of survey, showed: -Focus: The resident has potential impairment to skin integrity due to fractured left hip and decreased mobility; -Interventions: Follow facility protocols for treatment or injury. Avoid scratching and keep hands and body parts form excessive moisture. Keep the skin clean and dry. Encourage good nutrition and hydration. Monitor and document location, size, and treatment of skin injury. Report abnormalities, failure to heal or signs of infection to physician. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth type of tissue and exudate (pus)and any other notable changes or observations. Review of the resident's Braden Scale (a tool used to assess a resident's risk of developing a pressure wound), dated 4/4/25, showed the resident scored 15, indicating at risk. Review of the resident's admission nursing assessment, dated 4/4/25 at 4:30 P.M., showed: -Skin assessment: -Integrity: Intact and bruising; Site: Sacrum (tailbone); -No further description of the skin condition was addressed. Review of the resident's physician order sheet (POS), showed: -An order, dated 4/7/25, apply barrier cream to bottom for redness after each incontinent episode; -An order dated 4/7/25, refer to outside wound company for wound care; -An order, dated 4/8/25, cleanse area to bottom and apply Allevyn (a specialized wound dressing) or border gauze (a specialized wound dressing) as needed for shearing (friction on the skin that causes superficial skin removal); -An order, dated 4/9/25, cleanse area to bottom and apply mupirocin (antibiotic ointment) cover with Allevyn dressing or border gauze, every Tuesday, Thursday, and Saturday for wound care; -An order, dated 4/9/25, cleanse area to bottom and apply mupirocin, cover with Allevyn dressing or border gauze as need for shearing; -No order for Skin Prep (a type of liquid that is used to prepare skin before applying an adhesive by forming a protective barrier) to be applied to the wound was noted. During observation and interview on 4/7/25 at 10:01 A.M., the Resident Care Supervisor and Certified Nursing Assistant (CNA) D transferred the resident to his/her bed using the Hoyer lift (mechanical lift). The resident's brief was removed by CNA D and the resident was incontinent of a large amount of brown soft stool. On the resident's upper right buttock was a dark maroon colored, non-blanchable (returns to normal color after pressure released), moist, open wound. The wound was approximately the size of a quarter. The Resident Care Supervisor verified there was no dressing on the resident's buttock or that the dressing fell off in the resident's brief. The Resident Care Supervisor said she was going to inform the nurse about the wound on the resident and left the room. The Resident Care Supervisor returned to the room and continued with the resident's perineum care (peri-care, cleansing of the rectum and genitals) with CNA D. At 10:25 A.M., Licensed Practical Nurse (LPN) H entered the room. The resident was turned to his/her left side by the Resident Care Supervisor. LPN H sprayed the resident's wound with Skin Prep and dabbed the area of the wound with a gauze. LPN H then applied a border gauze and did not date the dressing. Review of the facility's Wound Nurse progress notes, dated 4/8/25, showed the resident has a right buttock Stage Two (a partial thickness skin loss presenting as a shallow ulcer and a red or pink wound bed). Wound bed: pink and moist; Measurements: 1.5 centimeters (cm) length, 2.5 cm wide, and 0.5 cm depth. During an interview on 4/9/25 at 8:50 A.M., LPN B said on admission the description of the wound should be added to assessment. If there was any type of wound, nursing staff usually would use the facility phone and take a picture of it and send it to the Wound Nurse. The Wound Nurse would give further orders and recommendations. When the admission orders were being verified the nurse could describe the wound to the best of his/her ability to obtain orders. When any type of skin condition was found, orders should be obtained as soon as possible. All treatments that require a dressing should have a date on it when it was completed. During an interview on 4/8/25 at 8:54 A.M., the Wound Nurse said today was the first time she saw the resident. The Wound Nurse said the resident had one right medial (towards the middle of the body) buttock Stage Two pressure injury wound. When she examined the resident there was no dressing on the resident's buttock pressure wound, only barrier cream. During an interview on 4/9/25 at 10:44 A.M., the Director of Nursing said the nurses did not stage a wound when first identified. That was the responsibility of the Wound Nurse. The nurses were expected to describe the wound and obtain measurements when the wound was newly identified in the resident's medical record. The nurse should have obtained orders for the wound when he/she was verifying admission orders with the physician. Interventions were expected to be in place such as frequent turning and any off loading devices. She would expect the skin assessment to be completed accurately and to include if any changes occurred with the wound. Skin assessment were done weekly and as needed. She would expect all treatments to be dated. The nurses could also send a picture to the Wound Nurse using the facility phone and obtain orders and recommendations. MO00252290

46888 Based on observation, interview and record review, the facility failed to ensure activities of daily living (ADL) were provided to three of 15 sampled residents. The facility failed to ensure one resident was toileted in a timely manner (Resident #10), failed to ensure two residents received nail care (Resident #15 and Resident #42), and failed to ensure one resident received routine showers (Resident #42). The census was 58. Review of the facility's ADL policy, dated 3/2018, showed: -Policy statement: residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Policy implementation: residents will be provided with care, treatment and services to ensure that ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene, mobility, toileting, dining, and communication. 1. Review of Resident #10's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/21/25, showed: -Cognitively intact; -Dependent on staff for toileting hygiene; -Required maximum assist for toilet transfers; -Diagnoses included hip fracture, renal disease and depression. Review of resident's care plan, in use at the time of survey, showed: -Focus: The resident has bowel incontinence related to decreased mobility and muscle weakness; -Interventions: Check the resident every two hours and assist with toileting as needed; -Provide a bedpan or a bedside commode. Take the resident to the toilet the same time everyday the resident has a bowel movement. Observation and interview on 4/7/25 at 9:07 A.M., showed the door to the resident's room was open and he/she could be heard yelling loudly, Please! Someone help me! I need to go to the bathroom! Hello! The resident sat in his/her wheelchair in his/ her room with a Hoyer (a specialized machine to used to transfer residents) pad underneath. The resident said staff got him/her up in the wheelchair about a half hour ago and said they would be right back because the resident needed to use the bathroom. The resident said he/she could not get to the bathroom by himself/herself. The resident said he/she would turn his/her call light on and call the front desk. When that didn't work and staff didn't come in, he/she would yell loudly. The resident said staff would frequently turn his/her light off without addressing his/her needs. The resident had an odor of bowel movement. The resident said he/she rarely got to use the toilet due to staff taking too long. The resident said he/she would just end up messing himself/herself and sitting in his/her own bowel movement. At 9:15 A.M., the resident's door was open and he/she could be heard from the hall yelling, Please help! I need to go to the bathroom! Certified Nursing Assistant (CNA) C entered the resident's room and asked the resident, What is wrong? The resident informed CNA C that he/she had to have a bowel movement and may have already been incontinent. CNA C left the resident's room and said he/she had to get more help. At 9:35 A.M., the resident was heard cursing and yelling, Help! from the hallway. The Resident Care Supervisor entered the resident's room and asked the resident, Why are you yelling? The resident said to the Resident Care Supervisor that he/she had to go to the bathroom. The Resident Care Supervisor left the room. At 9:45 A.M., CNA C, CNA D and the Resident Care Supervisor entered the resident's room. CNA D said to the resident, I think you have already had a bowel movement and we will have to get you in bed to clean you up. At 10:01 A.M., the Resident Care Supervisor and CNA D transferred the resident to his/her bed using the Hoyer lift. The resident's brief was removed by CNA D and the resident was incontinent of a large amount of brown soft stool. CNA D and the Resident Care Supervisor provided perineum care (cleansing of the rectum and genitals, peri-care) and reapplied a clean brief to the resident. The resident said he/she was exhausted. During an interview on 4/9/25 at 8:50 A.M., Licensed Practical Nurse (LPN) B said staff should explain to the resident why it may take longer than expected to provide care to the resident. The staff should not tell the resident they will be right back and not return in a timely manner. The resident should only have to wait ten to fifteen minutes to use the restroom. It shouldn't take a lot of time to get another staff member to assist with a Hoyer transfer. Leaving the resident in a soiled brief for more than ten to fifteen minutes was unacceptable. During an interview on 4/9/25 at approximately 10:00 A.M., CNA E said a resident should not have to wait more than ten minutes to use the restroom or get cleaned up. Staff should be making rounds on residents frequently to anticipate the residents' needs. Staff should not tell a resident they will be right back and not return in a timely manner. During an interview on 4/9/25 at 10:44 A.M., the Director of Nursing (DON) said the resident should not have to wait more than five minutes to use the restroom. It should only take a few extra minutes to have another staff member assist with a Hoyer lift transfer. The resident sitting in the wheelchair with a soiled brief for an extended amount of time was unacceptable. She would expect staff to clean incontinent residents in a timely manner. Staff should leave the resident's call light on until the resident's needs are met. 2. Review of the Resident #15's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required maximum assist from staff for toilet hygiene, bathing hygiene, and putting on and taking off foot wear; -Diagnoses included heart failure, heart disease, diabetes and respiratory failure. Review of the resident's care plan, in use at the time of survey, showed: -Focus: the resident has diabetes; -Intervention: weekly skin assessments with special attention to feet. Review of the resident's medical record, showed: -No skin assessments for February 2025 were completed; -The resident's skin assessments, dated, 3/6/25 and 3/27/25, did not address the resident's feet or toenails; -No further skin assessments, for March, 2025, were completed. Observation and interview on 4/8/25 at 7:45 A.M. and 4/9/25 at 7:47 A.M., showed the resident lay in bed and his/her feet were exposed. The resident had a slight amount of swelling to his/her feet. Both feet were very red with some dryness. The resident's left foot toenails were approximately one half of an inch long, thick and jagged. The resident's large toenail on his/her left foot was approximately one inch long and pointed. The resident's right foot toenails were thick, jagged and short in length. The resident said he/she had a lot of right heel pain. The resident had never seen a podiatrist (foot doctor) and said staff seemed to avoid his/her feet. He/She had asked staff a couple of times to be placed on the podiatrist list over the last several months. The resident said his/her toenails had not been trimmed by staff and just broke off when they got long. During an interview on 4/9/25 at 8:50 A.M., LPN B said the resident had a private caregiver who completed the resident's bathing. LPN B said the skin assessments for the residents were weekly and it included a head-to-toe assessment. LPN B did not normally add any assessment about the resident's toenails on the skin assessment. The podiatrist could only trim diabetic residents' nails. The nurses should let the Social Service Director (SSD) know when a resident needed to be seen by a podiatrist. During an interview on 4/8/25 at 9:30 A.M., the SSD said the resident lived at the facility for years and had just signed a podiatry consent for treatment on 4/7/25. The resident had been added to the podiatry list for April, 2025. The nurses were expected to complete an assessment of the residents' feet and then let her know if a resident needed to be seen by the podiatrist. 3. Review of the Resident #42's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required maximum assist from staff for toilet hygiene, bathing hygiene, and putting on and taking off foot wear; -Diagnoses included type two diabetes, morbid obesity, end state renal disease (kidney failure) and muscle weakness. Review of the resident's care plan, dated 9/13/24, showed: -Focus: resident has an ADL self-care performance deficit; -Goal: resident will improve current level of function in ADLs through the review date; -Interventions: check nail length and clean on bath day and as necessary. Report any changes to the nurse. The resident requires assistance by one staff with bathing/showering. Encourage the resident to use call light for assistance. Observation on 4/07/25 at 11:06 A.M., showed the resident in his/her room. The resident's hair was disheveled and appeared oily. Observation on 4/08/25 at 11:27 A.M., showed the was resident in bed and his/her feet were exposed. The resident's toenails were thick, yellow in color, and various lengths. The resident's hair was disheveled and appeared oily. During an interview on 4/8/25 at 11:46 A.M., the resident said it had been at least four months since his/her last shower. He/She said he/she does not sweat a lot so it did not bother him/her as much as if he/she sweated more. But, he/she did feel gross. The resident said he/she would like to receive at least two showers a week. He/She had not seen a podiatrist since he/she arrived to the facility. During an interview on 4/9/25 at 8:58 A.M., LPN B said he/she would expect the resident to be on the podiatrist list for his/her nail care due to being diabetic. He/She would expect the resident to receive at least two showers or bed baths a week. It was not acceptable for a resident to go four months without a shower. He/She said the resident received his/her showers on the evening shift. During an interview on 4/9/25 at 10:44 A.M., the DON said a toenail assessment should be included in the weekly skin assessment. She would expect the nursing staff to inform the SSD that a resident needed to be seen by a podiatrist. Nurses could trim diabetic residents' toenails. She would expect residents to receive at least two to three showers a week. She would expect staff to document if a resident refused a bath/or shower. During an interview on 4/9/25 at 11:43 A.M., the Administrator said she expected ADL care to be provided timely and per the scheduled times. She expected residents to receive at least two showers or bed baths a week. She expected staff to provide nail care or refer the resident to a podiatrist if needed. MO00252290

Based on observation, interview and record review, the facility failed to follow acceptable nursing practice when staff left medication in one resident's room who did not have a physician order for self-administration or for medications to be left at the bedside (Resident #15). The sample was 15. The census was 58. Review of the facility's Self-Administration of Medications policy, revised, December, 2016, showed: -The residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so; -As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident; -In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including the resident's: -Ability to read and understand medication label; -Comprehension of the purpose and proper dosage and administration time for his or her medications; -Ability to remove medications form a container and to ingest and swallow the medication; -Ability to recognize risks and major adverse consequences of his or her medications; -If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications; -The staff and practitioner will ask residents who are identified as being able to self-administer medications whether they wish to do so; -The staff and practitioner will document their findings and the choices of resident's who are able to self-administer medications; -The self-administering resident and the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medications were taken; -If the resident is able and willing to take responsibility for documenting their self-administration of medications, the resident will be instructed on how to complete a record indicating the administration of the medication; -Self-administration medications must be stored in a safe and secure place and is not accessible to other residents; -Staff shall identify and give the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party; -Nursing staff will review the self-administration medication record (MAR) on each nursing shift, and they will transfer pertinent information to the MAR kept at the nurse's station, appropriately noting that the doses were self-administered; -The staff and practitioner will periodically re-evaluate a resident's ability to continue to self-administer medications. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/9/24, showed: -Cognitively intact; -Diagnoses included heart failure, heart disease, diabetes, and respiratory failure; Review of the resident's care plan did not address if the resident was identified as being able to self-administer medications or medications could be left at the resident's bedside. Review of the resident's medical record showed, no self-administration of medication assessment completed. Review of the resident's physician order sheets (POS), dated 4/9/25, showed; -No order the resident could self-administer medications; -No order for any medication to be left at the bedside; -No order for Afrin (nasal decongestant) nasal spray; -No order for Voltaren ointment (ointment for pain relief); -No order for Thera-Worx muscle pain relief; -An order dated, 3/14/25, for saline (salt water)nasal solution, use one a day as needed for nasal congestion; -An order dated, 3/14/25, for Flonase nasal allergy spray, 50 micrograms (mcg), one spray each nostril, daily. Observation and interview on 4/7/25 at approximately 10:30 A.M. and on 4/8/25 at 12:45 P.M., in the resident's room, showed on the bedside table next to the resident's bed, were three bottles of Afrin nasal spray, one half tube of Voltaren ointment, three large bottles of Thera-Worx muscle pain relief, one bottle of saline nasal spray, and one bottle of Flonase nasal spray. The resident said he/she watched TV and saw the commercial for the pain relief medication. He/She would then call his/her physician about the medication and express his/her desire to use the medication. The resident would instruct his/her private caregiver to purchase the medications. The resident was pretty sure his/her physician had no idea what medications the resident had at the bedside. The resident said he/she used the Afrin nose spray at least once a day to help with his/her anxiety. The resident was aware that was not what Afrin was used for. He/She thought the medication was okay to leave at the bedside because it could be purchased at a store without a physician order. During an interview on 4/9/25 at 8:50 A.M., Licensed Practical Nurse B said she was not aware of any type of resident self-administering assessment. If resident medications were at the bedside, there should be a physician order stating the resident could have medications left at bedside. If there was no physician order for the medication that was at the bedside, it should be removed from the resident's room. During an interview on 4/9/25 at 10:44 A.M., the Director of Nursing said there were no residents in the building who could self-medicate. It was expected for staff to remove the medication from the room if there was not a physician order for the medication or for medications to be left at the bedside. She expected staff to complete the self-administration assessment if the resident requested to self-administer medications. The medication would have to be in a secure box so other residents didn't come into the room and remove it. They had instructed the resident in the past that he/she could not have medications at the bedside without approval of the physician.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents when staff transferred one resident improperly (Resident #10). The sample size was 15. The census was 58. Review of the facility's Safe Lifting and Movement of Residents policy, revised July 2017, showed: -In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriated techniques and devices to lift and move residents; -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of the residents; -Manual lifting of residents shall be eliminated when feasible; -Nursing staff, in conjunction with the rehabilitation staff shall assess individual residents' needs for transfer assistance on an ongoing basis; -Staff will document resident transferring and lifting needs in the care plan; -Such assessment shall include: -Resident preferences for assistance; -Resident's mobility (degree of dependency); -Resident's size; -Weight-bearing ability; -Cognitive status; -Whether the resident is usually cooperative with staff; -The resident's goal for rehabilitation, including restoring or maintaining functional abilities; -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, slider board) and mechanical lifting devices; -Mechanical lifting devices shall be used for heavy lifting including lifting and moving residents when necessary. Review of the facility's Gait Belt policy, dated 6/1/01, showed: -Gait belts are used to promote safety in transfer, ambulation, and balance activities; -Gait belts must be used at all times when performing balance activities and while transferring or ambulating patients as a part of the patient's plan of care or when safety dictates. Review of Resident #10's, admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/21/25, showed: -Cognitively intact; -Dependent on staff for toileting hygiene; -Required maximum assist for toilet transfers; -Diagnosis included hip fracture, renal disease, and depression. Review of the resident's care plan, in use at the time of survey, showed: -Problem: The resident has bowel incontinence related to decreased mobility and muscle weakness; -Interventions: Check the resident every two hours and assist with toileting as needed. Provide a bedpan or a bedside commode. Take the resident to the toilet the same time everyday the resident has a bowel movement; -The resident's care plan did not address the residents' transfer status. Review of the resident's physician order sheets (POS), dated, 4/9/25, showed: -An order dated 4/4/25, Hoyer lift (a specialized mechanical lift) for all transfers: -An order, dated 4/4/25, Toe touch weight bearing to left leg. Observation on 4/7/25 at 5:00 P.M., showed the resident in the bathroom holding onto the grab bars and he/she held up his/her left leg. The resident's gait was unsteady, and the resident was struggling to hold onto the grab bars. While the resident was holding onto the grab bars, Certified Nursing Assistant (CNA) F held onto the resident under his/her left arm and pulled the resident's shorts up. After CNA F pulled the resident's shorts up, CNA F held the resident under his/her left arm, and by using the back of the resident's shorts, quickly pivoted the resident into a wheelchair which had a Hoyer pad located in the seat. The resident continued to hold his/her left left leg up during the pivot transfer. CNA F wore a gait belt and did not utilize it during the resident's transfer. CNA F told the resident you have 'poop' on your shoe and I will clean it off. CNA F cleaned the resident's shoe and propelled the resident out of the bathroom and into his/her room. The resident said he/she was tired and denied any pain. During an interview on 4/7/25 at 5:20 P.M., CNA F said he/she was in a hurry to get the resident on the commode because the resident said he/she had to urgently use the bathroom. He/She was not aware of the resident's transfer status or weight bearing status. CNA F was not told in report that the resident required a Hoyer lift. At a minimum CNA F said he/she should have used the gait belt that he/she was wearing while transferring the resident or wait and get another person to help. CNA F said he/she forgot to do that because of the resident's urgent need to use the bathroom. During an interview on 4/7/25 at 5:30 P.M., Licensed Practical Nurse (LPN) G said CNAs should ask the nurse if they are unsure of the resident's weight bearing status or transfer status. The aides are supposed to carry a resident profile sheet in their pocket that focused on the resident's activities of daily living needs. The resident care sheet was updated daily by the Resident Care Supervisor. During an interview on 4/9/25 at 10:44 A.M., the Director of Nurses said she would expect staff to know what the resident's transfer status was prior to providing care. She would expect the staff to follow the physician orders and therapy recommendation for weight bearing status and transfer status.

46888 Based on observation, interview and record review, the facility failed to ensure one resident had physician's orders for dialysis (a procedure that cleanses the blood of its impurities) care and dialysis communication logs (Resident #10) and failed to ensure one resident had dialysis communication logs completed for all appointments (Resident #45). The sample was 15. The census was 58. Review of the facility's dialysis procedure, undated, showed: -The following must be done for residents each day they do out for dialysis: fill out page one of the communication form. Send page one and two of the communication form with the resident for the dialysis unit to complete and return with the resident; -If we do not receive page two of the form back when the resident returns, contact the dialysis unit and have them fax it to us. 1. Review of Resident # 10's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 2/21/25, showed: -Cognitively intact; -Diagnoses included hip fracture, renal disease, and depression; -Received dialysis. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has end stage kidney disease and is dependent on dialysis; -Interventions: Check and change dressing to dialysis site three times a week at access site. Do not draw blood or take blood pressure with the resident's left arm. Encourage resident to go for the scheduled dialysis appointments. Monitor intake and output; Monitor labs, and report to the doctor as needed. Monitor vital signs. Review of the resident's medical record, showed: -admitted : 2/14/25; -discharge date : 3/31/25; -Re-admitted : 4/4/25; -No dialysis communication forms completed for February, March, and April, 2025. Review of the resident's physician order sheets (POS), dated 4/4/25 through 4/9/25, showed no orders related to dialysis. During observation and interview on 4/7/25 at 5:10 P.M., the resident said he/she has an arterial venous (AV, a surgically created access port where the resident received dialysis) graft to his/her left arm for dialysis. The resident lifted his/her sleeve and showed the AV graft site on his/her left upper arm. The AV graft site was covered with an undated dressing. The resident said he/she went to dialysis three days a week at 10:30 A.M. During an interview on 4/9/25 at 8:50 A.M., Licensed Practical Nurse (LPN) B said she wasn't sure if there should be dialysis orders in the physician orders. During an interview on 4/9/25 at 10:44 A.M., the Director of Nursing (DON) said there should be orders related to the resident's dialysis that include, where the resident goes to dialysis, time of dialysis and the site where the resident is receiving dialysis to ensure no blood pressures or blood work is not obtained using the arm with an AV graft. 2. Review of the Resident #42's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included type two diabetes, morbid obesity, end stage renal disease (kidney failure), and muscle weakness; -Received dialysis. Review of the resident's care plan, dated 9/13/24, showed: -Focus: Resident has end stage renal disease and dependence on renal dialysis; -Goal: Resident will have no complications related to fluid overload through the review date; -Interventions: Daily weight, give medications as ordered by physician, monitor vital signs, observe dialysis shunt daily. Review of the resident's medical record, showed: -Two dialysis communication logs for February 2025; -One dialysis communication log for March 2025; -Three dialysis communication logs for April 2025. During an interview on 4/9/25 at 8:49 A.M., LPN B said dialysis communication logs should be filled out by the nurse and then sent with the resident when they went to dialysis. The log should then be filled out at dialysis and sent back with the resident. He/She would expect dialysis logs to be completed for every dialysis appointment and then scanned into the resident's electronic medical record. 3. During an interview on 4/9/25 at 10:00 A.M., the Administrator said she would expect dialysis communication logs to be completed every time a resident went to a dialysis appointment to ensure the resident's weight and vitals were being monitored. She would expect for residents to have physician's orders for dialysis care.

Based on observation, interview and record review, the facility failed to ensure respiratory services provided were consistent with professional standards of practice for one resident (Resident #15). The sample size was 15. The census was 58. Review of the facility's Oxygen Administration policy, revised October, 2010, showed: -The purpose of this procedure is to provide guidelines for safe oxygen administration; -Verify that there is a physician's order for this procedure; -Review the resident's care plan to assess for any special needs of the resident; -Assemble the equipment and supplies as needed. Review of the facility's Continuous Positive Airway Pressure Support (CPAP, a machine that assists with breathing when breathing slows down or stops during sleep) policy, dated March, 2015, showed: -Purpose: -To provide the spontaneously breathing resident with CPAP with or without supplemental oxygen; -To improve oxygenation in residents with respiratory insufficiency, obstructive sleep apnea (breathing slows down or stops during sleep) or restrictive lung disease; -To promote resident comfort and safety; -Preparation: -Only a qualified properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask; -Review the resident's medical record to determine his/her baseline oxygen saturation; -Review the physician's order to determine the oxygen concentration and flow, and the pressure for the machine; -General guidelines for cleaning: -There are general guidelines for cleaning; -Specific cleaning instructions are obtained from the manufacturer or supplier of the device; -Documentation: -A general assessment (including vital signs, oxygen saturation, respiratory, circulatory (blood perfusion around the body) and gastrointestinal (stomach and intestine) status prior to procedure; -The time the CPAP was started and duration of therapy; -Mode and settings; -Oxygen saturation and flow; -How the resident tolerated the procedure; -Oxygen saturation during therapy. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/9/24, showed: -Cognitively intact; -Required maximum assistance from staff for upper and lower body dressing; -Required a non-invasive mechanical ventilator (a device that assists with breathing); -Diagnoses included heart failure, heart disease, respiratory failure, depression and anxiety. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has shortness of breath related to respiratory failure; The resident wears a CPAP at night. -Interventions: Monitor breathing patterns; Monitor and document breathing abnormalities; -Focus: The resident is on a hypnotic therapy related to insomnia (inability to sleep) and sleep apnea; -Interventions: CPAP on at night and off in morning; -Focus: The resident has activities of daily living (ADL) deficit related to fatigue, impaired balance, and pain; -Interventions: The resident may have oxygen 2-5 liters (L); CPAP on a night and off in morning. Review of the resident's Physician Order Sheets (POS), dated 4/9/25, showed: -An order dated 3/14/25, oxygen 3L continuously at all times; -An order dated 3/14/25, Ipratropium-Albuterol inhalation solution 3 milligrams (mgs), 3 milliliter (mls), give every two hours as needed for shortness of breath; -No order for the resident's CPAP machine. Review of the resident's Treatment Administration Record (TAR), dated 4/1 through 4/7/25, showed: -An order, undated, oxygen 3L continuously at all times, every shift for oxygenation; -On 4/1, 4/2, 4/3, 4/4, 4/5, 4/6 and 4/7/25, on day, evening and night shifts, oxygen 3L continuously was documented as completed. Review of the resident's oxygen saturation levels, showed: -On 4/3/25, oxygen saturation 96% (normal values, 90-100%) on oxygen via nasal cannula; -No further oxygen levels documented dated, April 2025. Observation and interview on 4/7/25 at approximately 10:30 A.M. and at 11:10 A.M., showed the resident lay in bed with an oxygen nasal cannula (tubing that delivers oxygen to the resident in his/her nose), dated 3/30/25, in his/her nose. The oxygen tubing was dated 3/30/25, connected to a concentrator (a machine that delivers the oxygen) next to the resident's bed, and the oxygen concentrator was on and set on 2L. The resident's respiratory equalizer (a mask that delivers breathing medication) face mask with tubing was draped over a lamp attached to the wall. In the resident's bed, the extension oxygen tubing was coiled and positioned next to the resident. The extension tubing was not connected to the resident and was dated 11/13/24. The resident said staff use the extension tubing in case he/she needs extra tubing for further distances. The resident had a CPAP machine on his/her nightstand. Observation and interview on 4/8/25 at 7:45 A.M., showed the resident lay in bed with an oxygen cannula, dated 3/30/25, in his/her nose connected to the oxygen concentrator which was on and set on 2L. The resident's nebulizer face mask with tubing was draped over the lamp attached to the wall. The resident had a CPAP located on his/her nightstand. The resident's CPAP face mask lay on the floor next to the resident's bed. The resident said he/she just removed the mask, and the mask must have fallen on the floor. Observation and interview on 4/8/25 at 1:45 P.M., showed the resident seated in the dining room in his/her wheelchair. The resident did not have oxygen on. The resident said he/she did not need oxygen and he/she uses it on an average of one hour a day. The resident said staff help him/her at night to place his/her C-PAP machine on his/her face and staff turn the machine on. Private Caregiver J said he/she only fills the water chamber before he/she leaves for the day and he/she does not clean it. The resident said he/she receives nebulizer treatments up to three times a day for shortness of breath. During an interview on 4/9/25 at 8:50 A.M., Licensed Practical Nurse B said the resident's nebulizer mask should be stored on top of the nebulizer machine and he/she wasn't sure about how to clean the nebulizer mask. The resident's oxygen orders should read as needed and not continuously because the resident was not using oxygen very much. The oxygen saturation levels should be checked at least daily while the resident is weaned off the oxygen. All oxygen tubing and the nebulizer masks should be changed weekly by the night shift. The resident uses a CPAP machine at night but wasn't sure if the CPAP machine required any type of physician orders. During an interview on 4/9/25 at 10:44 A.M., the Director of Nurses (DON) said the night shift is responsible for changing the oxygen tubing and nebulizer mask weekly. The nebulizer mask should be rinsed with water after use, air dried on a paper towel and stored in a plastic bag next to the nebulizer machine. The oxygen the resident requires is expected to match the physician orders. The resident's oxygen levels should be checked at least daily, to make sure the resident can tolerate having the oxygen off. If the resident doesn't require oxygen continuously, then the oxygen orders are expected to be changed to reflect the resident's oxygen requirements. The DON expected physician orders related to the resident's CPAP machine.

Based on observation and interview, the facility failed to provide accessible information on the location of the State Long-Term Care Ombudsman program or the State Survey Agency hotline number that was readily available to residents in the facility without assistance. The census was 58. Observation throughout the survey on 4/7/25 through 4/9/25, showed the information regarding the State Agency hotline number and Ombudsman program was not visible throughout the facility. During a group interview on 4/8/25 at 11:00 A.M., five residents, who the facility identified as alert and oriented, attended the group meeting. All residents said they did not know where the State Agency hotline number or the Ombudsman information was posted. During an interview on 4/9/25 at 8:18 A.M., the Director of Nursing (DON) said she was not sure where the information was posted, but it should be accessible to residents and families. They were likely posted in the break room or social worker's office. At 8:25 A.M., the DON pointed out the sign where the Ombudsman's information was posted. The sign was in the lobby to the left of the front entrance, behind a wall. The DON said the information was not accessible to residents and families. During an interview on 4/9/25 at 8:45 A.M., the Activity Director brought a poster board with the activity schedule. At the bottom of the board was the State Agency Hotline number and Ombudsman's information. She said the number on the board for the hotline was the wrong number, and she corrected it today. The boards were placed outside of each activity room daily. Residents who attended activities in the activity room had access to the information. During an interview on 4/9/25 at 11:40 A.M., the Administrator and DON said the State Agency Hotline number and Ombudsman's information was not accessible to all residents and families. The Administrator would expect the information to be accessible.

Based on observation, interview and record review, the facility failed to ensure staff provided care to one resident, (Resident #1) in a manner which maintained his/her dignity when Licensed Practical Nurse (LPN) A berated the resident for pressing his/her call light several times, removing his/her brief, and asking for a soda. Additionally, LPN A, Certified Nurse Assistant (CNA) B and CNA C, yelled at the resident after he/she had an unwitnessed fall. The census was 54. Review of the facility policy titled, Quality of Life Dignity Policy, revised August 2009, showed: -Each resident shall be cared for in a manner which promotes and enhances quality of life, dignity, respect, and individuality; -Residents shall be treated with dignity and respect at all times; -Treated with dignity means the resident will be assisted in maintaining and enhancing his/her self-esteem and self-worth; -Staff shall speak respectfully to residents at all times; -Staff shall keep the resident informed and oriented to their environment; -Procedures shall be explained before they are performed; -Demeaning practices and standards of care that compromise dignity are prohibited; -Staff shall promote dignity and assist residents as needed by: -Promptly responding to the resident's request for toileting assistance; -Allowing residents unrestricted access to common areas; -Staff shall treat cognitively impaired residents with dignity and sensitivity by: -Addressing the underlying motives or root causes for behavior; -Not challenging or contradicting the resident's beliefs or statements. Review of the facility's Answering the Call Light Policy, revised October 2010, showed: -Turn off the signal light; -Identify yourself and call the resident by his/her name; -Listen to the resident's request; -Do what the resident asks of you, if permitted. If you are uncertain as to whether a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/7/23, showed the following: -The resident had clear speech, was always understood by others and always understood others; -Moderate cognitive impairment; -It was very important for the resident to have snacks in between meals and choose his/her bedtime; -The resident required substantial to maximum assistance with activities of daily living (ADLs), ambulating, transfers, and mobility; -The resident was dependent on staff for toileting and was always incontinent of bowel and bladder; -Diagnoses included stroke, muscle weakness (generalized), unsteadiness on feet, cognitive communication deficit, dysphagia and pain in hip. Review of the resident's care plan, dated 7/7/23, showed: -Focus: The resident had a monitoring device in his/her room; -Goal: The resident's rights and dignity would be always preserved; -Focus: The resident had an ADL performance deficit; -Intervention: Staff assisted resident to turn and reposition in bed, monitored bumpers on bed, lowered bed to floor with mats on floor and placed call light in reach. Resident on low concentrated sweets diet with mildly, thick consistency; -Focus: The resident had acute pain in lower back and hip; -Intervention: Administer pain reliever per orders. Anticipate the resident's need for pain relief and respond immediately to any pain complaint. Review of the resident's progress notes, dated 7/24/23 at 4:01 A.M., showed LPN A documented the resident was awake most of the night with his/her call light on. When staff entered his/her room, he/she only wanted to talk. LPN A told the resident staff could not sit and talk to him/her. They had to help other residents. The resident said he/she understood, then pressed the call light again. Staff answered his/her call light and he/she just wanted to talk or not speak at all. Staff checked on the resident several times during the night. He/She had not slept since 2:00 A.M. LPN A spoke to the resident at 3:45 A.M. and told him/her to go to sleep because it was 4:00 in the morning. The resident responded, Oh, I didn't know it was that time of the morning. Observation of video camera footage of the resident's room on 7/24/23 (time unknown), showed a housekeeper entered the resident's room, and the resident told him/her, he/she needed his/her left leg massaged. The housekeeper told the resident he/she would tell the nurse. LPN A entered the resident's room and said, Honey you need to quit calling your family members to shut off the light. The resident said Wait, let me explain. LPN A said No, I'm not waiting. LPN A turned off the resident's light and exited his/her room. Review of the resident's progress notes on 7/31/23 at 2:00 A.M., showed LPN A documented the resident was awake and in bed. He/She pressed the call light several times for small things. He/She asked staff to pull his/her sleeve up and down and fix his/her covers and call light. LPN A documented Most of these things (he/she) could have done for (him/herself), (he/she) just wanted someone to be in the room with (him/her) giving (him/her) their undivided attention. LPN A told the resident there were other residents in need of care. Staff did not have time to sit in with him/her to just talk and do the little things he/she could do for him/herself. The resident said he/she understood, then pressed his/her call light again. He/She was incontinent of bowel and bladder, ripped off his/her brief and liners, and threw them onto the floor in little pieces. The resident did not understand what happened. Review of video camera footage of the resident's room on 7/31/23 (time unknown), showed LPN A entered the resident's room and said, What do you need. The resident tried to respond, and LPN A cut him/her off. LPN A asked the resident what was on his/her floor. LPN A picked up a brief off the floor, next to the resident's bed, then dropped it back on the floor. The resident said the brief came off and LPN A said it does not just come off, you have to pull it off. LPN A asked the resident why he/she pressed the call light. The resident asked LPN A why he/she was challenging him/her. LPN A said, Don't tell me I am challenging you. I asked you a direct question. The resident said he/she wanted a 7 Up (soda). LPN A said they did not have any 7 Up. The resident asked what kind of soda was available and LPN A said we do not have any soda. The resident asked LPN A to look in his/her refrigerator and get a 7 Up. LPN A said Look (sir/madam), it is 3:00 in the morning we are not doing 7 Up. I am not playing these games. It is 3:00 in the morning and you are playing games. This is ridiculous. LPN A opened the refrigerator, removed a soda, slammed the refrigerator door, and slammed the soda on the resident's bedside table. LPN A told the resident he/she could not have a straw. The resident asked for a cup. LPN A said use the cup on your table. The resident said the cup was full of water. LPN A said, Well I do not know what to say (sir/madam). I am tired of this. LPN A grabbed the cup, went in the resident's bathroom, came out and sat the cup on the bedside table. LPN A asked the resident if he/she had to have thickeners in his/her liquids. The resident said, No. Why are you so mad. LPN A walked around to the left side of the resident's bed and said Because it is 3:00 in the morning and we are playing around. You have been awake all night with your call light. Pull my sleeve down, do this, do that. The resident said he/she was sorry. LPN A said, I would like to know why. You should not call us in here for things you can do yourself. If you pulled your sleeve up, you can pull it down. The resident said he/she was sorry for bothering LPN A. LPN A said, Well you did and now I have to have someone come in and change you, because you pulled your liner out. LPN A exited the resident's room. The resident attempted to open the soda. LPN A returned to the resident's room and snatched the soda out of his/her hand. LPN A said Oh no (sir/madam), do not drink that. You lied to me. You are supposed to have thickened liquids. The resident said he/she did not like thickened liquids. LPN A told the resident he/she had to have them, or he/she would choke. LPN A sat the soda on the dresser, answered his/her phone and walked out of the resident's room. Review of the resident's progress notes, dated 10/3/23 at 6:00 A.M., showed LPN A documented the resident was found on floor next to his/her bed with buttocks on floor, feet on foot of bed. Top of body on floor as well. Resident unable to say how this happened. Review of video footage of the resident's room on 10/3/23 (time unknown), showed: -Staff transferred the resident from the floor to his/her bed. The resident asked CNA B to remove his/her wet shirt. CNA B said Look, let us focus on getting you up (sir/madam). CNA B snatched the liner and sheet from under the resident. The resident said Oh. CNA B said This (man/woman) here. LPN A said (he/she) fell the other day. The resident continued to say his/her shirt was wet. CNA C pointed at the resident and said, We heard you. The resident asked CNA B if he/she would take his/her shirt off. CNA C leaned towards the resident's face and yelled, Can you give her a chance. Give her a chance. The resident said give me a dry shirt with long sleeves. CNA C said No. The resident said a dry shirt was all he/she asked for. CNA C got in the resident's face and yelled Stay in the bed is all we ask. CNA C started removing the resident's shirt and he/she said Good. CNA C yelled Thank you. You do not say good, you say thank you. The resident said, I thank you in my heart. CNA C said, No thank you, I want to hear it. The resident said you are not wrong. LPN A entered the resident's room and said, Are you kidding me? LPN A walked over to the resident's bedside and yelled, What is wrong with you, why can't you just stay in the bed? The resident said, you want me to stay in the bed. LPN A yelled Yes, stay in the bed. The resident said, I am in the bed. LPN A said, What is wrong with you. When you are in the bed you are supposed to stay in the bed and not get out by yourself. The resident asked LPN A to pull his/her shirt down. CNA C yelled (He/She) is not done yet. (He/She) will pull your shirt down when (he/she) puts your underwear on. You be worried about the wrong stuff. The resident said okay. CNA C told CNA B the resident wanted his/her shirt pulled down, but that was not important. LPN A said please do not get out of bed again. The resident told LPN A he/she thinks he/she met him/her before. LPN A said, Yeah you met me before when you were worried about a juice bottle on the floor instead of going to sleep. The staff laughed and exited the resident's room. During an interview on 5/31/24 at 11:58 A.M., LPN A said he/she could not recall a video monitoring device in the resident's room. He/She did not remember telling the resident to stop calling his/her family to ask staff to turn off his/her light. He/She was shown the video of the 7 Up incident. He/She said he/she should have known the resident was on thickened liquids and should not have given him/her the soda before checking. He/She thought it was appropriate to tell the resident to stop pressing the call light for things he/she could do for him/herself. His/Her behavior was unacceptable. He/She did not remember the conversation after the resident's fall. During an interview on 5/29/24 at 3:17 P.M., the Director of Nursing (DON) said the resident's family member sent two videos to his/her cell phone. She watched them with the Administrator then deleted them. LPN A spoke in a loud tone, but it was not demeaning. She talked to LPN A about the videos. LPN A was upset he/she was accused of treating the resident with a lack of dignity and respect. LPN A and the CNAs were allowed to continue providing care to the resident. During an interview on 5/31/24 at 9:45 A.M., the Administrator and DON reviewed the videos with the Department of Health and Senior Services, Senior Regulatory Auditor. They identified LPN A as the nurse in the videos. They could not identify the CNAs. The Administrator said they did not receive the videos. When told there was documentation the DON received the videos, the DON said she could not get the videos to play. LPN A should have known the resident was on thickened liquids. This behavior is not tolerated by staff.

Based on observation, interview and record review, the facility failed to assess a resident, (Resident #1) and properly transfer the resident from the floor to the bed, after an unwitnessed fall. The census was 54. Review of the facility's Answering the Call Light Policy, revised October 2010, showed: -Turn off the signal light; -Identify yourself and call the resident by his/her name; -Listen to the resident's request; -Do what the resident asks of you, if permitted. If you are uncertain as to whether a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance; -If assistance is needed when you enter the room, summon help by using the call signal. Review of the facility's Fall Protocol Policy, revised September 2012, showed: -The nurse shall assess and document/report the following: -Vital signs; -Recent injury, especially fracture or head injury; -Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; -Change in cognition or level of consciousness; -Neurological status; -Pain; -Frequency and number of falls since last physician visit; -Precipitating factors, details on how fall occurred. Review of the facility's Low Lifting Policy dated 2/18/97 and revised 5/1/24, showed: -To comply with the Occupational Safety and Health Administration (OSHA) regulations, the facility purchased a quantity of resident transfer devices to reduce the physical lifting of residents; -The equipment was designed to help make the transfers easier to perform and safer for both the staff and the residents; -The nurse with the assistance of therapy if needed, will evaluate the residents transfer technique on admission and as needed. This will be documented on the aide assignment sheet; -From this point forward, any employee found to be manually lifting any resident, except with the permission of their supervisor, failure to comply will result in violation of policy; - Any employee in violation of this policy will be subject to disciplinary action, which could conclude to immediate termination. Review of the Resident #1's care plan, dated 7/7/23, showed: -Focus: The resident had an activities of daily living (ADL) performance deficit; -Intervention: Staff assisted resident to turn and reposition in bed, monitored bumpers on bed, lowered bed to floor with mats on floor and placed call light in reach; -Focus: The resident had acute pain in lower back and hip; -Intervention: Administer pain reliever per orders. Anticipate the resident's need for pain relief and respond immediately to any pain complaint; -Focus: The resident was high risk for falls; -Intervention: Anticipate and meet the resident's needs. The resident needed prompt response to call for assistance. Follow facility fall protocol; -Focus: The resident was incontinent of bowel and bladder; -Intervention: Check resident every two hours and assist with toileting as needed. Provide bedpan/bedside commode transfer with two assist and Hoyer lift. Provide loose fitting, easy to remove clothing. Provide peri care after each incontinent episode. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/1/23, showed the following: -The resident had clear speech, was always understood by others, and always understood others; -Moderate cognitive impairment; -The resident did not have any behaviors; -The resident did not reject care; -It was very important for the resident to choose his/her bedtime; -The resident required substantial to maximum assistance with ADLs, ambulating, transfers, and mobility; -The resident was dependent on staff for toileting and was always incontinent of bowel and bladder; -Diagnoses included stroke, muscle weakness (generalized), unsteadiness on feet, cognitive communication deficit, dysphagia, and pain in hip. Review of the resident's progress notes, dated 10/3/23 at 6:00 A.M., showed Licensed Practical Nurse (LPN) A documented the resident was found on floor next to his/her bed with buttocks on floor, feet on foot of bed. Top of body on floor as well. Resident unable to say how this happened. He/She was assessed for injuries, none noted. Neuro checks initiated. Vitals taken, with in limits. He/She was assisted into bed with assist of two staff members and gait belt. Review of video footage of the resident's room, dated 10/3/23 (time unknown), showed: -The resident on the floor. His/Her back was on the floor and his/her legs and feet were on the bed. The resident's sheets were wrapped around his/her body and the bedside table metal bar was across his/her neck (not touching). The resident could not move. The resident was wearing a t-shirt, no brief, and socks. Certified Nurse Aide (CNA) B entered the resident's room. The resident said help. CNA B looked at the resident on the floor, sighed and said, Oh God, then exited the resident's room. The resident continued to yell help, please help. CNA B returned to the resident's room and said, wait a minute. He/She picked the bedside table up. He/She said, Something told me you were going to fall when you kept leaning over to the side. The resident said he/she could not get up. CNA B said, I know you can't. CNA B put the resident's pillows on his/her bed and picked up a sheet. CNA B said he/she had to go get help, stepped over the resident, and left the room. CNA B returned a few seconds later with CNA C. CNA B put his/her hands under the resident's neck. CNA C stood on the resident's bed and grabbed his/her legs. CNA B said 1, 2, 3 and lifted the resident off the floor by his/her neck, while CNA C lifted his/her legs. The resident's buttocks were on the bed and his/her legs were hanging off the left side of the bed. CNA B turned the resident's torso and CNA C forcefully swung the resident's legs onto the bed. The resident said, Oh shit. CNA C said That is how we feel. That is how we feel. Ouch. LPN A entered the room and asked the resident what he/she was trying to do when he/she got out of bed. The resident said he/she was trying to get up. LPN A said, So you were trying to get out of bed to get back in the bed. CNA B and CNA C laughed. The resident said he/she did not realize he/she was out of the bed. He/She knew he/she needed help. CNA B put a sheet on top of a liner and rolled them together. CNA pulled the resident by his/her right shoulder and LPN A grabbed the resident's legs. The resident said, wait. LPN A said, No we are not waiting. We have been waiting. The resident's legs were hanging off the left side of the bed. The resident yelled My legs, my legs. CNA C said You did that. Stop, I got you. Don't worry about your legs. The resident asked CNA C to pick up his/her legs. CNA C yelled, In a minute! You worried about falling, you should have thought about that a couple of minutes ago. CNA B pushed the liner and sheet under the resident's buttocks. LPN A grabbed the resident's legs and put them on the bed. CNA C and LPN A aggressively pushed the resident on his/her right side. The resident said Ouch, that hurts. That hurt my hip. LPN A said, You should have thought about that before you climbed out of bed in the first place. CNA B and CNA C put a brief on the resident without performing peri care. CNA B and CNA C turned the resident on his/her right side and placed a pillow under his/her back. The resident said, not so rough. LPN A said, When you do not help, they say you are rough. The resident said, you are being too rough. CNA C got in the resident's face and yelled If you would stay in bed, you would not have to worry about this. So let this be a lesson learned for the hundredth time. The resident said okay. During an interview on 5/31/24 at 11:51 A.M., CNA B said he/she entered the resident's room, saw the resident on the floor, left the room and called LPN A for assistance. LPN A was assisting another resident. CNA C helped him/her get the resident off the floor. CNA B could not remember what position the bedside table was in. CNA B said they got the resident up the best way they could. He/She denied lifting the resident off the floor by his/her neck. CNA B started yelling during the interview and terminated the call. During an interview on 5/31/24 at 11:58 A.M., LPN A said CNA B and CNA C should not have moved the resident. They should have removed the table from over the resident's neck, then waited for him/her to assess the resident. CNA B and CNA C should have used a Hoyer lift to transfer the resident. LPN A said he/she should have assessed the resident for injuries, took his/her vitals and started neuro checks. The DON and Administrator did not show him/her the video. He/She received a written warning for unprofessional behavior on 10/5/23. Review of LPN A, CNA B and CNA C employee files, showed: -LPN A received a counseling notice for unprofessional behavior on 10/5/23. The notice was signed by the Administrator and DON; -CNA B received a counseling notice for unprofessional behavior on 10/5/23. The notice was signed by the Administrator and DON; -CNA C received a counseling notice for unprofessional behavior on 10/5/23. The notice was signed by the Administrator and DON; During interviews on 5/29/24 at 3:17 P.M. and 5/31/24 at 9:45 A.M., the DON said the CNA walked into the room and saw the resident on the floor mat. The over the bed table was on the resident, but not on his/her neck. She could not identify the CNAs. The two CNAs lifted the resident on to the bed. The bed was low, and the CNA did stand on it. One had the upper body and the other had the lower body. They did not drag the resident. When the video was reviewed with the DON on 5/31/24, she said she did not see all the video previously. When informed there was documentation she received all the videos, she said they could not get the videos to play. When a resident has an unwitnessed fall, staff should complete an incident report and start neuro checks. The nurse is supposed to assess the resident. The CNAs should not have moved the resident until the nurse assessed him/her. The transfer was improper. The resident required a Hoyer lift for transfers, and they should have used one. During interviews on 5/30/24 at 8:54 A.M. and 5/31/24 at 9:45 A.M., the Administrator said they received the video of the resident's fall. She could not remember the date. There was no sound on the video. The table was over the resident, but it was not touching him/her. The CNA went to the door and called for help. Another staff member came in to assist the CNA. The resident's positioning was weird. One of the CNAs stood on the bed so he/she could get the resident's shoulders. The other CNA moved the resident's feet onto the bed. The CNAs did not drag the resident. She did not see anything in the video which would warrant an investigation. During review of the video on 5/31/24, the Administrator said they did not get the entire video. LPN A's, CNA B's and CNA C's behavior was unacceptable. If they would have seen the entire video, they would have terminated all of them. MO00236005

Based on record review, interviews, and facility policy review, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed at least every three months for 3 of 3 residents (Residents #27, #46, and #58) reviewed for timely completion of MDS assessments. Findings included: Review of a facility policy titled, Resident Assessment Instrument, revised September 2010, revealed, 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conducts timely resident assessments and reviews according to the following schedule: c. At least quarterly. Review of the Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, Version 1.18.11, dated October 2023, revealed, The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD [Assessment Reference Date - Item A2300] must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. 1. Review of Resident #27's Admission Record revealed the facility originally admitted the resident on 11/26/2018 and readmitted the resident on 01/23/2019. Review of Resident #27's medical record revealed an annual MDS with an Assessment Reference Date (ARD) of 11/18/2022. The most recent MDS available for review in the resident's record was a quarterly assessment with an ARD of 05/20/2023, which indicated the next quarterly assessment was due by 08/20/2023. During an interview on 10/10/2023 at 4:04 PM, the MDS Coordinator said she was responsible for ensuring the MDS assessments were completed, then the Director of Nursing (DON) signed and submitted them. The MDS Coordinator stated she had not been able to complete a quarterly MDS assessment for Resident #27 because she had gotten behind on completing the assessments. During an interview with the DON on 10/11/2023 at 3:26 PM, she stated the MDS assessments should be completed within 90 days of each other. The DON said she was not aware of the extent of the MDS Coordinator being behind on completing the MDS assessments. During an interview on 10/11/2023 at 4:12 PM, the Administrator said the MDS assessments should be completed within the timeframe the facility was given. The Administrator stated the MDS Coordinator was responsible for ensuring the MDS assessments were completed. 2. Review of Resident #46's Admission Record revealed the facility originally admitted the resident on 06/06/2022 and readmitted the resident on 12/07/2022. Review of Resident #46's medical record revealed an admission MDS with an Assessment Reference Date (ARD) of 11/01/2022. The most recent MDS available for review in the resident's medical record was a quarterly MDS with an ARD of 06/01/2023, which indicated the next quarterly assessment was due by 09/02/2023. During an interview on 10/10/2023 at 4:04 PM, the MDS Coordinator stated she was responsible for ensuring the MDS assessments were completed, then the Director of Nursing (DON) signed and submitted them. The MDS Coordinator indicated she had gotten behind on completing the quarterly MDS assessments. During an interview with the DON on 10/11/2023 at 3:26 PM, she said the MDS assessments should be completed within 90 days of each other. The DON said she was not aware of the extent of the MDS Coordinator being behind on completing the MDS assessments. During an interview with on 10/11/2023 at 4:12 PM the Administrator said the MDS assessments should be completed within the timeframe the facility was given. The Administrator stated the MDS Coordinator was responsible for ensuring the MDS assessments were completed. 3. Review of Resident #58's Admission Record revealed the facility originally admitted the resident on 06/04/2019 and readmitted the resident on 05/04/2022. Review of Resident #58's medical record revealed the most recent MDS assessment available for review was an annual assessment with an Assessment Reference Date (ARD) of 05/12/2023, which indicated the next quarterly assessment was due by 08/12/2023. During an interview on 10/10/2023 at 4:04 PM, the MDS Coordinator said she was responsible for ensuring the MDS assessments were completed, then the Director of Nursing (DON) signed and submitted them. The MDS Coordinator stated she was not able to complete the quarterly MDS assessment for Resident #58 because she had gotten behind. During an interview with the DON on 10/11/2023 at 3:26 PM, she stated the MDS assessments should be completed within 90 days of each other. The DON said she was not aware of the extent of the MDS Coordinator being behind on completing the MDS assessments. During an interview with on 10/11/2023 at 4:12 PM the Administrator said the MDS assessments should be completed within the timeframe the facility was given. The Administrator stated the MDS Coordinator was responsible for ensuring the MDS assessments were completed.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff followed infection control standards for hand hygiene for during catheter care to prevent potential infection for 1 (Resident #46) of 1 resident reviewed for catheter care. Findings included : Review of an undated facility policy titled, Catheter Care, Urinary, revised September 2014, indicated, Infection Control 1. Use standard precautions when handling or manipulating the drainage system. 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. The policy indicated the following Steps in the Procedure: - l. Place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached. 2.Wash and dry your hands thoroughly. - 5. Put on gloves. - 7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. - 10. Put on clean gloves. 11. Remove gloves and discard into the designated container. Wash and dry your hands thoroughly. - 20. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 21. Reposition the bed covers. Make the resident comfortable. 22.Place the call light within easy reach of the resident. 23.Clean wash basin and return to designated storage area. 24.Clean the bedside stand and/or overbed table. Return the overbed table to its proper position. 25.Wash and dry your hands thoroughly. Review of a facility policy titled, Hand Washing/Hand Hygiene, revised August 2015, indicated, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: The situations included the following: e. Before and after handling an invasive device (e.g. [for example], urinary catheters, IV [intravenous] access sites; - m. After removing gloves. The policy also indicated, Applying and Removing Gloves l. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. Review of Resident #46's Admission Record revealed the facility originally admitted the resident on 06/06/2022 and most recently admitted the resident on 12/07/2022. Review of Resident #46's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had an indwelling catheter. Review of a care plan focus statement, revised 06/12/2023, revealed Resident #46 had an indwelling catheter related to bladder neck obstruction (blockage of the narrow opening of the bladder). Interventions directed staff to change the resident's catheter every month on the 25th and monitor/record/report to the physician any signs/symptoms of urinary tract infection (UTI). During an observation of catheter care for Resident #46 on 10/11/2023 at 8:46 AM, Licensed Practical Nurse (LPN) #3 washed her hands in the bathroom and put on a pair of gloves. LPN #3 cleansed around the catheter insertion site then cleaned the catheter from the insertion site outward several inches. At 8:47 AM, LPN #3 removed her gloves, threw them in the trash, and put on another pair of gloves without performing hand hygiene. LPN #3 attached leg straps to the catheter tubing with gloved hands, then at 8:49 AM, LPN #3 took off her gloves and threw them in the trash. Without performing hand hygiene, LPN #3 rearranged Resident #46's bed covers and picked up the resident's bed controller and used it to lower Resident #46's bed. LPN #3 then went to the bathroom to wash her hands. During an interview on 10/11/2023 at 8:51 AM, LPN #3 admitted she did not perform hand hygiene between glove changes. LPN #3 stated she was still working on the resident at the same site. She stated while she did need to change gloves, she did not need to wash her hands between removing the soiled gloves and donning clean ones. She stated the need for hand hygiene depended on the situation. During an interview with the MDS Coordinator/Infection Preventionist (IP) on 10/11/2023 at 1:17 PM, she stated it was her expectation that staff perform hand hygiene in between glove changes, regardless of what task was being completed. During an interview with the Director of Nursing (DON) on 10/11/2023 at 2:42 PM, she stated it was her expectation that staff perform hand hygiene before and after using gloves and said that staff should follow the facility's policy. During an interview on 10/11/2023 at 2:49 PM with the Administrator, she stated it was her expectation that nurses should follow the infection control standards and facility policy.

Based on record review, interviews, and facility policy review, the facility failed to ensure antipsychotic medication prescribed on an as-needed (PRN) basis was limited to a 14-day duration in the absence of a physician's documented evaluation to support the continued use of the medication for 1 (Resident #44) of 5 residents reviewed for unnecessary medication. Findings included: Review of an undated facility policy titled, Antipsychotic Medication Use revealed, 12. The need to continue PRN orders for psychotropic medication beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 13. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. Review of Resident #44's Admission Record showed the facility admitted the resident on 06/08/2023. Review of Resident #44's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/15/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS indicated the resident had not had any behavioral symptoms during the assessment period, to include psychosis, physical behavioral symptoms directed toward others, or verbal behavioral symptoms directed toward others. The MDS indicated the resident received antipsychotic medication on seven days during the seven-day assessment period. Review of a care plan focus statement, dated as initiated 06/16/2023, revealed Resident #44 used psychotropic medications related to schizophrenia disorder. Interventions directed staff to consult with the pharmacy and Medical Director to consider a dosage reduction when clinically appropriate, at least quarterly. Review of the Resident #44's Order Summary Report, dated 10/10/2023, revealed an order for olanzapine (antipsychotic), 5 milligrams (mg) every eight hours as needed for agitation or nausea. The order indicated a start date of 06/08/2023 but did not indicate an end date. Review of a Medication Record Review (MRR) dated 06/21/2023 and signed by a physician on 07/28/2023 revealed the Pharmacist recommended the order for olanzapine 5mg PRN every eight hours be discontinued or, if the medication was still medically necessary, for the physician to evaluate the resident in person and document in the resident's medical record why the PRN medication was necessary. The MMR indicated the regulatory requirement was that all PRN antipsychotic drug orders have a maximum duration of 14 days and then be discontinued. The document indicated if the medication was to be continued long-term, then the steps to continue the medication were required for each renewal. The physician's handwritten response at the bottom of the form was that the resident was stable. The physician's response did not indicate the physician evaluated the resident in person and documented the reason the medication remained necessary. Review of Resident #44's Progress Notes, dated 07/28/2023, revealed the Medical Director reviewed the pharmacy consultation report and no new orders were given. The note indicated the resident was stable on olanzapine 5mg every eight hours as needed for agitation and nausea. The note was electronically signed by Licensed Practical Nurse (LPN) #11. During an interview on 10/11/2023 at 10:24 AM, the Pharmacist said he made a recommendation in June and July 2023 to discontinue the olanzapine for Resident #44. The Pharmacist stated PRN antipsychotic medication orders should only be written for 14 days. The Pharmacist said after the 14-day period, the resident must be seen by the physician for continued use of the medication. During an interview on 10/11/2023 at 3:26 PM, the Director of Nursing (DON) said the Pharmacist completed a monthly review of medications. She stated the review was submitted to three different people at the facility, including herself and LPN #11. She indicated LPN #11 was the designated person responsible for the reports. She stated the recommendations were put in the physician's folder to be looked at when the physician came to the facility. The DON said the physician came to the facility twice a week, and the Nurse Practitioner came once a week. The DON indicated Resident #44 was not seen by the physician every 14 days but was every 30 days. During an interview on 10/11/2023 at 4:12 PM, the Administrator stated that once the pharmacy reviews were received, the facility nurse would inform the physician, then the physician would either agree or decline the recommendations. The Administrator stated PRN psychotropic medications should only be used for 14 days.

Based on record review, interviews, and facility document and policy review, the facility failed to ensure 1 (Resident #46) of 5 sampled residents reviewed for immunizations was offered a pneumococcal vaccination. Findings included: A review of the facility's policy titled, Pneumococcal Vaccine, revised December 2012, revealed, Policy Interpretation and Implementation 1. Prior to or upon admission, residents will be assessed for eligibility to receive the Pneumovax (pneumococcal vaccine), and when indicated, will be offered the vaccine within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. A review of an Admission Record revealed the facility most recently admitted Resident #46 on 12/07/2022. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/2023, revealed Resident #46's pneumococcal vaccine was not up to date because the vaccine had not been offered. A review of the facility's Immunization Report that reflected the vaccination status of residents for the timeframe from October 2005 to October 2023 revealed no documentation that Resident #46 had received or been offered a pneumococcal vaccine. During an interview on 10/10/2023 at 11:04 AM, the facility's MDS Coordinator/Infection Preventionist (IP) acknowledged that Resident #46 was not up to date with their pneumococcal vaccine. During an interview on 10/11/2023 at 2:49 PM, the Administrator stated it was her expectation that the facility should offer all residents vaccinations according to the latest standards.

Based on record review, interviews, and facility policy review, the facility failed to ensure the comprehensive care plan addressed the care and monitoring required related to the use of Ativan (an antianxiety medication) and apixaban (a blood thinner) for 1 (Resident #43) of 5 residents sampled for medication review. Findings included: A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy specified, 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment and 8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems. A review of an Admission Record revealed the facility most recently admitted Resident #43 on 10/17/2022. A review of a Diagnosis Report, printed 10/10/2023, revealed Resident #43 had a medical history that included diagnoses of generalized anxiety disorder, gastrointestinal hemorrhage, hemorrhage of anus and rectum, and long term (current) use of anticoagulants (blood thinners). A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/17/2023, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 6, indicating the resident had severe cognitive impairment. According to the MDS, Resident #43 received an anticoagulant seven out of seven days of the assessment look-back period. A review of Resident #43's Order Summary Report, which listed active orders as of 10/10/2023, revealed the following: - An order dated 07/29/2023 for apixaban 5 milligram (mg) tablet, give 5 mg via gastrostomy tube every 12 hours for anticoagulant; and - An order dated 08/09/2023 for Ativan 0.5 mg tablet, give 0.25 mg (half tablet) via gastrostomy tube two times a day for anxiety. A review of Resident #43's comprehensive care plan for the resident's admission on 10/17/2022 revealed no Focus areas or interventions related to the resident's use of Ativan or apixaban. During an interview on 10/11/2023 at 2:04 PM, the Minimum Data Set (MDS) Coordinator / Infection Preventionist (IP) stated she was responsible for care plans. She explained some care plan areas were triggered by the MDS itself, and other times, care plan areas were triggered by residents' orders or preferences. The MDS Coordinator/IP stated no one went behind her to verify residents' care plans were correct. She stated that certain classes of medications should be addressed in the care plans. She confirmed Resident #43 was prescribed Ativan and apixaban and that the resident's comprehensive care plan did not address the use of either of the medications. The MDS Coordinator/IP confirmed Resident #43 should have been care planned for both medications, and she could not explain why Resident #43's care plan did not address the Ativan and apixaban. During an interview on 10/11/2023 at 2:19 PM, the Administrator stated she expected care plans to be completed timely and thoroughly. During an interview on 10/11/2023 at 2:28 PM, the Director of Nursing (DON) stated she expected care plans to be completed thoroughly and timely.

Based on interview and record review, the facility failed to ensure residents were free from misappropriation (unauthorized, improper, or unlawful use of funds or other property) when staff misappropriated from one of three sampled residents (Resident #1). The census was 57. Review of the facility policy entitled Abuse, reviewed June 2022, showed the facility affirmed the right of residents to be free from abuse, neglect and misappropriation of resident property, corporal punishment and involuntary seclusion. Misappropriation of resident property was defined as the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. During orientation of new employees, the facility was to cover staff obligations to prevent and report abuse, neglect and theft, how to report theft of lost items and willful abuse from insensitive staff actions, which should be corrected through counseling and additional training. Any allegations made involving misappropriation of resident property are to be reported immediately to the Director of Nursing (DON) and/or Administrator. The facility shall report allegations to the Department of Health and Senior Services not later than 24 hours, if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Once an allegation is reported involving misappropriation of resident property, an investigation was to be initiated. Review of Resident #1's undated face sheet, showed an admitted [DATE]. The resident's adult child was financial and care power of attorney (POA). A financial services company was listed as financial responsible party. Review of the facility responsibility for valuables/liability policy, signed by the resident on 9/20/17, showed the facility asked new families moving in not to bring jewelry or other valuable possessions, because it was impossible for the facility to ensure the safety of those possessions, due to the type of residents for which the facility provided care and the variety of people who came into the building. For residents who chose to bring valuables, the facility recommended that those residents purchased renter's insurance with the insurance company of their choice. That should include jewelry, dentures, hearing aids, eyeglasses and any other item of value. The facility did not pay for replacement of any lost or stolen items, unless caused by the facility's negligence. The facility may hold in safe-keeping cash amounts up to $100.00 per resident, not to exceed this amount at any time. The resident signed the policy, acknowledging he/she had been informed of the facility recommendation to not bring valuables to the facility and he/she would not be providing renter's insurance for his/her valuables. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/10/21, showed the following: -Cognitively intact; -Diagnoses including heart failure, orthostatic hypotension (sudden drop in blood pressure upon moving from a laying to sitting/standing position resulting in fainting), pneumonia, stroke, chronic lung disease, respiratory failure, paroxysmal atrial fibrillation (a rapid, erratic heart rate which begins suddenly and then stops on its own within seven days), retinal disorder, bronchiectas with (acute) exacerbation (an increase in daily respiratory symptoms such as cough, sputum production, malaise, fatigue and breathlessness), cough and muscle weakness. Review of the facility's investigation summary, dated 6/11/21, showed the resident was alert and oriented to date, time, place, situation and made his/her own decisions of daily living. On 6/7/21, the resident reported to the DON that the resident had reviewed his/her bank statement and noticed that there was a copy of a check and that check number was out of sequence. Upon further examination, he/she noticed that it was his/her name on the signature line of the check, but it was not his/her signature. It was not the way he/she signed his/her checks. The resident said he/she included his/her middle initial, when signing his/her name. The resident did not recognize the name (Certified Nurse Aide (CNA) E), to whom the check was made out. The resident knew he/she had not written the check (check#1095) and realized someone must have taken the check. When the resident showed it to staff, they recognized the name as a CNA who had worked at the facility in the past, but was no longer an employee. Staff notified the Administrator of the unauthorized check use and assisted the resident with filing a police report. The resident was keeping his/her checks in his/her room and refused to keep them in a locked drawer or box as was suggested by the facility. The resident said he/she wanted to keep them in a convenient location and liked to pay his/her own bills. The resident had a book of checks which completed the sequence to check #1095, but did not have any other checks, so it was assumed that a book of checks had been stolen instead of a single check. After the incident, the resident gave his/her checks to a family member for safe keeping. No other residents on the same hall reported any money or missing items, during the time that CNA E was employed at the facility 7/14/20 through 2/24/21. The facility concluded that it was an isolated incident and since CNA E was no longer employed at the facility, no other residents were at increased risk for theft or misappropriation of property. Review of the Administrator's undated written statement, showed on 6/7/21, the Administrator assisted the resident with contacting the police department, in order to report the unauthorized check on the resident's bank statement, dated 5/7/21 and payable to CNA E in the amount of $600. A police officer arrived at around 10:50 A.M. He met with the resident, Administrator and DON. The resident showed the officer the unauthorized check and explained that he/she did not give any checks to anyone to be cashed. The resident also had his/her bank statement which showed that the check was not in numerical sequence, as the other three checks that he/she had written during the previous month. The Administrator gave the officer pedigree (identification and contact) information on CNA E and explained that the last day CNA E had worked at the facility was on 2/24/21. The resident called and found out what needed to be done to close the bank account and open a new one. The next day, the resident's family member arrived to assist the resident with making the necessary phone calls. Review of the resident's police report, signed 7/9/21, showed on 6/7/21, the police officer responded to the facility for a larceny (theft of personal property) report. The resident reported noticing a suspicious transaction on their bank statement dated 5/11/21, for $600 made out to CNA E which the resident had not signed. The Administrator believed CNA E stole the resident's check. The resident kept his/her checkbook on top of his/her dresser and did not know if CNA E had stolen an entire check book or just one check sheet. The bank statement showed only one stolen check. It was unknown where CNA E used the check, because the bank statement did not include a name or location. The Administrator did not have problems with CNA E, during his/her employment at the facility. The officer contacted CNA E, who said he/she knew what the officer wanted to discuss with him her and that he/she was wrong for doing what he/she had done. CNA E agreed to come to the police statement for an interview, but failed to show up on the scheduled date and time. He/She did not answer the officer's phone calls. Review of the police supplemental narrative, dated 7/12/21, showed CNA E turned him/herself in to police custody at around 10:00 hours. The officer met with CNA E in the holding cell, escorted him/her to an interview room and advised him/her of his/her constitutional rights. CNA E said he/she was working for the resident at the facility in February. While at a facility bingo activity, the resident handed CNA E a blank check and asked CNA E to take it to the resident's room. CNA E put the check into his/her pocket. On the way to the resident's room, he/she was asked to assist other employees with a resident who had fallen down and needed assistance. After helping them, CNA E forgot the blank check and went on about his/her shift. When CNA E got home, he/she put the blank check, along with some other documents into a drawer and forgot about it. Approximately one month later, while doing some spring cleaning, CNA E found the check. At that time, he/she was in a financially difficult situation and needed money. CNA E made the check out to him/herself, signed the check, went to an automated teller machine (ATM) and used the money to pay his/her bills because he/she did not have enough money coming in. Due to Covid, CNA E's hours of work were cut and he/she was not scheduled for enough hours to financially support him/herself. CNA E said he/she felt very bad about taking the money from the resident, because the resident was always very nice to CNA E. However, CNA E felt as though he/she did not have a choice. While he/she did not want to write out a letter or voluntary statement, he/she was willing to make restitution to the resident. CNA E said he/she did not have any other checks from the resident. The officer escorted him/her to the booking room and finished the booking process. CNA E provided fingerprints, the officer added a charge of forgery to his/her booking sheet, gave him/her a new court date and released CNA E from police custody pending application of warrants. During an interview on 2/21/23 at 4:58 P.M., CNA E said on the day in question (date unknown), the resident was sitting at a table in the dining room playing bingo. He/She asked CNA E to take a blank check back to his/her room. Another resident fell . CNA E stuck the check in a pocket along with other pieces of paper and went to help other staff get the other resident up. CNA E forgot the check was in his/her pocket. When CNA E returned home, he/she put everything from his/her pockets into a drawer. Two months later, CNA E was cleaning out the drawer and came across the blank check. He/She was not working at that time, due to the pandemic. So, he/she made the check out to him/herself and used the money to pay bills. CNA E knew that it was a stupid thing to do. However, he/she was in a jam. Now, he/she is on probation for a year and has a misdemeanor on his/her record, which has kept him/her from getting jobs which he/she wanted. CNA E was honest about what he/she had done, because he/she knew what he/she had done was wrong. During an interview on 3/2/23 at 8:13 A.M., the resident said he/she never handed CNA E one of his/her checks for any reason and never asked CNA E to take one back to his/her room. The resident kept his/her checkbook in an unlocked drawer. He/She did not have a locked drawer or lockbox and the facility did not provide one. Employees at the facility who stole, did it while residents were at the bingo games because they knew residents would be away from their rooms for at least an hour. The resident was refunded the $600 CNA E stole by the bank, due to their error in cashing a check with a signature which did not even resemble the resident's signature. During his/her stay at the facility, the resident had quite a few things stolen. He/She reported to staff the other thefts which were not investigated and no refund or replacement of items was offered by the facility. When the resident was moving into the facility, staff put a chest full of his/her DVD collection into the hallway and someone took the entire chest. He/She never got any of it back. The resident kept $40 under the cushion of his/her armchair and that was stolen. Someone also stole the $50 as well as his/her spouse's war metals from his/her desk. When the resident reported those thefts, staff came in, searched for the items in his/her room and that was the end of it. Review of the inventory sheet from the resident's admission, included several movies on cassettes and DVD, [NAME] nacks and 6 silver like coasters. Review of the social service notes, showed no documentation the Social Services Director (SSD) employed at the time of the thefts investigated them. During an interview on 3/2/23 at 8:38 A.M., the DON said when residents checked in, they received a copy of the admissions policy which included their options for securing valuables and money at the facility. The resident's financial POA was not informed of the resident's decision not to heed the facility's recommendation, not bring valuables to the facility, allow social services to secure them or provide renter's insurance for valuables, because the financial POA only kicks in if the resident was incompetent. During an interview on 3/6/23 at 8:55 A.M., the Administrator said the theft of the resident's belongings and $90 were not investigated, because it was not reported to management. Direct care staff were trained during orientation and annual training on the procedure to report all allegations of misappropriation of money and/or property to the SSD, DON or Administrator. The theft allegations should have been reported to them. MO00186351

Based on interview and record review, the facility failed to ensure staff transferred residents in a safe manner, by including complete Hoyer lift (assistive hydraulic mechanical device which utilizes slings and pads to safely lift and transfer residents with reduced mobility) manufacturer instructions in the facility's policy and training in order to prevent injury or the possibility of injury. Staff failed to use the appropriate amount of staff assistance, when one certified nurse aide (CNA) attempted to perform a Hoyer lift transfer of a resident without assistance from a second staff person, for one of four sampled residents. The Hoyer lift fell forward and struck the resident in the face and on the top of his/her head, causing lacerations to both areas which had to be closed with sutures (Resident #2). The census was 57. 1. Review of the facility's policy titled Lifting Machine, Using a Mechanical, dated 2001, showed the procedure was to establish general principles of safe lifting using a mechanical lifting device. It was not a substitute for manufacturer's training or instructions. At least two nursing assistants were needed to safely move a resident with a mechanical lift. Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized by the facility. Staff were to make sure the lift was stable and locked. Review of the facility's summarized Hoyer lift manufacturer's instructions attached to the Lifting Machine, Using a mechanical policy, updated 4/2020, showed when using the adjustable base lift, the legs must be in the open/locked position, before lifting the resident. Review of an email from the Director of Nursing (DON) dated 3/2/23, showed Invacare was the manufacturer of the facility's lifts. Review of the Invacare manual/electric portable patient lift and slings owner's installation and operating instructions, showed Invacare did not recommend locking of the rear casters (small wheels attached to the base of a larger object to facilitate rolling) and of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. Invacare recommended the rear casters be left unlocked during lifting procedures, to allow the patient lift to stabilize itself when the patient was initially lifted from a chair, bed or any stationary object. Casters and axle bolts required inspection every six months to check for tightness and wear. 2. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument instrument completed by facility staff, dated 11/8/22, showed the following: -Hospice care; -Severe cognitive impairment; -Signs and symptoms of delirium, fluctuating inattention and disorganized thinking; -Wheelchair mobility; -Required extensive assistance of two+ staff with transfers and toilet use; -Diagnoses included history of other diseases of the musculoskeletal system (muscles, bones, tendons, ligaments, joints, and cartilage) and connective tissue, cerebrovascular accident (the rapid loss of brain function due to disturbance in blood supply to the brain), dementia without behavioral disturbance, psychotic disturbances (loss of contact with reality), mood disturbance and anxiety. Review of the resident's undated physician's orders, showed an order dated 11/8/21, for Hoyer transfer with two person assist for transfers every shift. Review of the resident's care plan, revised 11/8/22, showed the following: -The resident has impaired cognitive functioning related to a diagnosis of dementia; -He/She has a terminal progress related to Alzheimer's disease; -He/She is at high risk for falls related to confusion; -The resident has an activities of daily living (ADL) self-care performance deficit related to dementia; -The resident requires mechanical lift transfers by two staff members. Review of the resident's progress note, dated 12/19/22 at 8:19 A.M., showed CNA A called Nurse B to the resident's room at 5:20 A.M. Nurse B observed the resident sitting in his/her wheelchair with lacerations to the top of his/her forehead and to the inner bridge of his/her nose. Nurse B cleaned the area and applied steri-strips (thin adhesive bands placed across a wound to help hold the skin edges together), but they were not sticking. Nurse B alerted the resident's hospice to a concern regarding the resident needing sutures, notified the Director of Nurses (DON) at 6:38 A.M. and notified the resident's family at 6:40 A.M. The family wanted the resident's hospice nurse to evaluate the resident, to determine if the resident should be sent out for sutures. The hospice nurse was in the building, assessed the resident, decided to send the resident out and called for an ambulance. Emergency medical services arrived at 7:20 A.M. and left the facility with the resident at 7:30 A.M. The nurse notified the resident's physician via fax. Review of the undated written statement of CNA A, showed on 12/19/22, he/she was using the mechanical lift without assistance, when the mechanical lift fell over on both the resident and CNA A. Review of the written statement of Nurse B, dated 12/19/22, showed at 5:20 A.M., CNA A called for Nurse B to come to the resident's room. Nurse B observed the resident sitting in his/her wheelchair. CNA A was holding a towel over the resident's head and nose. Nurse B removed the towel and observed two large lacerations, one on the top of the resident's head and the other on the inner bridge of his/her nose. Both were bleeding. Nurse B cleaned the lacerations with normal saline and unsuccessfully attempted to apply steri-strips. Nurse B notified the resident's hospice company and family member. The family wanted the hospice nurse to see and evaluate the resident, before sending him/her out to get sutures. The hospice nurse agreed the resident needed to be sent out for sutures and the family was made aware. The hospice nurse called for an ambulance and gave report to the hospital emergency room . Paramedics entered the building at 7:20 A.M. and left with the resident. During an interview on 2/17/23 at 4:33 P.M., CNA A said on 12/19/22, when it was time to get the resident up, CNA A could not find anybody to assist him/her with the Hoyer lift transfer due to low staffing levels. CNA A would normally wait for assistance, but his/her supervisor still expected him/her to get all assigned residents up by a certain time, otherwise the supervisor has a fit. A single CNA using the Hoyer lift without assistance from a second staff person was a widespread practice at the facility. The other CNAs were busy and did not want to help with transfers. So, CNA A decided to transfer the resident without assistance. He/She was in the process of turning the lift, when it tipped forward and hit the resident in the nose. CNA A ran and got the Charge Nurse. During an interview on 2/17/23 at 5:27 P.M., Nurse B said he/she was up at the nurse's station charting, when CNA A hollered. Someone else came and got Nurse B, who went in and observed the resident already up in a wheelchair with gashes to the forehead and bridge of his/her nose. CNA A was very upset and did not explain how the resident was injured, beyond admitting to having attempted to transfer the resident using the Hoyer lift without assistance from a second staff person. CNA A was crying hysterically, saying that he/she would be fired. There was a total of three CNAs on duty. During an interview on 1/31/23 at 10:32 A.M., CNA C said CNA D had been transferring residents via Hoyer lift without assistance from a second staff person. It was common practice for some CNAs to transfer residents alone, without assistance from a second staff person. During an interview on 2/21/23 at 4:10 P.M., CNA D said he/she never transferred a resident via Hoyer lift without assistance from a co-worker. However, everybody used the Hoyer lift without assistance from a second staff person when they were in a hurry. The nursing supervisor rushed people to get a certain number of residents up by a certain time and sometimes the CNAs could not find anyone to help with a Hoyer transfer due to short staffing. Some staff members were afraid to ask for help, even when there were four CNAs on duty. During interviews on 2/27/23 at 11:41 A.M. and 3/2/23 at 8:38 A.M., the DON said the mechanical lift competency assessment was not filled out on each staff person who underwent training on facility mechanical lifts. During training, transfer abilities were not assessed individually. There was no documentation regarding CNA A's level of competency with mechanical lift transfers. The trainer used the competency assessment as a guideline for training and went over the Lifting Machine, Using a Mechanical policy with the trainees. Maintenance only checked the mechanical lifts if staff reported an issue with its functioning. After CNA A injured the resident due to operating the mechanical lift without assistance, his/her employment was terminated. There had been no prior concerns expressed regarding the functioning of the lift, so Maintenance was not asked to inspect the lift used by CNA A and he/she was not questioned about the manner in which he/she had operated the lift. It was not true that CNAs were expected to get residents up by a certain time. Each day, the facility served breakfast for a long time. There was not set time limit for getting residents up. The CNAs did not always get along, so they did not always have their buddy to help with transfers during the day shift. Each CNA was assigned eight to nine residents. If a CNA needed assistance with a mechanical lift transfer and none of the other CNAs were available or were refusing to provide assistance, then the CNA should notify a Charge Nurse or the Resident Care Supervisor. It was never acceptable for a CNA to perform a mechanical lift transfer without assistance from another staff person. During an interview on 3/6/23 at 8:55 A.M., the Administrator said the DON performed the facility mechanical lift training. The competency assessment should be filled out on each staff person who underwent training on operating a facility mechanical lift. CNA A reported he/she operated the mechanical lift without the assistance of a second staff person and no other issues were reported with the lift. Maintenance did not inspect the lift after it tipped over onto CNA A and the resident. A second staff person would have been able to stop the lift from tipping over. The facility had the mechanical lifts for approximately two to three years. Moving forward, the facility would have Maintenance perform routine checks of the facility mechanical lifts as well as inspections of lifts involved in incidents which could have been caused by a malfunction. MO00212438

Based on observation, interview and record review, the facility failed to ensure the resident received care in a safe environment when Certified Nursing Assistant (CNA) D, by him/herself, inappropriately transferred a resident (Resident #1) who required two person assistance. This resulted in the resident sustaining a fractured leg and large skin tears. The sample size was three. The census was 44. The administrator was notified on 2/4/21 at 9:45 A.M., of the past non-compliance which occurred on 4/23/20. On 4/23/20, the former assistant Director of Nursing (ADON) became aware of the violation of the resident's safe environment. The staff member was suspended and later terminated. The facility in-serviced the staff on ambulation, gait belts and transfers. The investigation was completed. Staff who were interviewed were familiar with the transfer policy. Residents who were interviewed had no concerns regarding transfers. The deficiency was corrected on 4/25/20. Review of Resident #1's face sheet, showed the following: -admitted [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/9/20, showed the following: -Severely impaired cognitive status; -Rarely makes self understood; -Sometimes understands others; -Extensive assistance of two persons required for transfers and toilet use; -Balance during transitions and walking - Not steady, only able to stabilize with human assistance; -Surface to surface transfers (transferring between bed and chair or wheelchair) - Not steady, only able to stability with human assistance. Review of the resident's care plan, dated 4/16/20, showed the following: -Focus: The resident had an activities of daily living (ADL) self-performance deficit related to aggressive behavior, Alzheimer's, confusion, dementia and impaired balance; -Goal: The resident will maintain current level of function in all ADLs through the next review date; -Interventions: Two person transfer with gait belt and walker. Please see resident care sheet for needs with ADL assistance and intermittent changes. Review of the resident care list, dated 4/25/20 put in effect on 4/23/20, showed the resident was alert with periods of confusion and forgetfulness. Agitated at times with care. Let him/her know what you are doing before you touch him/her. Transfers with the assist of two and gait belt with walker. Can stand and pivot with assist. Take your time with transfers. Gait unsteady. Fall precautions. Do not rush with care. Goes to bed between 8:00 P.M. and 9:00 P.M. Review of the resident's progress notes, showed a late entry on 4/23/20 at 8:28 P.M., staff called the nurse to the resident's room regarding two skin tears. The first skin tear was to the left forearm (FA) and measured 8 inches (in.) long. The second skin tear was to the left lower extremity and measured 7.5 in. The nurse cleansed the resident's skin, fully approximated both skin tears, applied steri-strips (used for wound closure), ABD (used for large wounds) pads and wrapped the wounds with kling (stretch performing gauze). Staff notified the wound nurse; -On 4/24/20 at 4:17 A.M., the nurse removed the kling wrap and ABD pads from the resident's lower left leg to assess the skin tear. The leg appeared to be broken based on the abnormal movement during treatment and the pain noted when touched. At 6:19 A.M., the x-ray technician came in to do an x-ray of the lower left leg and femur (thigh bone). At 10:44 AM., staff notified the family of the x-ray results and the physician's orders [REDACTED]. The family decided not to send the resident to the hospital. At 11:57 A.M., the resident's x-ray report showed an acute complex fracture (break in bone that occurs quickly) of proximal left fibula (calf bone) and mid-left tibia (large bone located in front of the leg). The nurse reported the injuries occurred during a transfer the prior evening. The resident also obtained two large skin tears to his/her lower left extremity (leg) and left upper extremity (arm). Review of the facility's typed incident review, dated 4/24/20, showed the resident was [AGE] years old with dementia and [MEDICAL CONDITION]. He/she required total care. Due to his/her dementia, he/she could be resistant to care at times. Due to the resident's advanced [MEDICAL CONDITION], he/she could not inform staff of what occurred. On 4/23/20 at approximately 6:35 P.M., the assistant director of nursing (ADON) went to speak with the nurse providing wound care to the resident. The resident had a skin tear on his/her left ankle and licensed practical nurse (LPN) E was treating the wound while CNA D stood by. The CNA simply stated he/she did not know what happened or what the resident's foot got caught on, but noted the resident to be bleeding when he/she placed him/her on the bed. At approximately 7:15 P.M., LPN E stated the resident also had a skin tear on his/her left arm that LPN F was treating. The resident appeared to be comfortable after treatments were completed. Staff notified the resident's family and physician. On 4/24/20 at approximately 4:17 A.M., the night nurse re-dressed the wound on the left ankle and noted some instability of the lower leg. He/she received an order for [REDACTED].M. At 7:55 A.M., staff received the x-ray report. Staff notified the physician who ordered [MEDICATION NAME] (used to treat pain) 50 milligrams, twice daily as needed for pain management. Review of the resident's x-ray dated 4/24/20, showed there was an acute complex [MEDICAL CONDITION] left fibula and mid left tibia. Review of the resident's wound reports, showed the following: -On 4/24/20 traumatic wound to the left forearm and left lower extremity; -The wound to the left forearm measured 15 centimeters (cm) in length, 7.0 cm in width and 0.20 cm in depth. The lower left extremity measured 7.5 cm in length, 2.2 cm in width and 0.20 cm in depth; -On 4/28/20, the left forearm wound measured 14.8 cm in length, 1.4 cm in width and 0.20 cm in depth. The left leg wound measured 8.0 cm in length, 5.0 cm in width and 0.20 cm in depth. Review of a typed interview conducted on 4/24/20 by the former Director of Nursing (DON), showed CNA D was hired by the facility and began orientation on 4/7/20. The CNA provided a written witness statement. The resident care coordinator (RCC) and administrator were also present during the interview. The CNA reported being a CNA for six years. The RCC asked him/her about orientation and what was covered. During orientation they covered the following: *All CNAs were told if they did not own a gait belt, one would be provided by the facility. The CNA's responsibility was to ask for the gait belt. CNA D acknowledged hearing this and was given a gait belt to use on the first day on the job. CNA D informed the RCC that he/she had his/her own gait belt and did not need it, but did not bring it to work on 4/23/20 or ask for a gait belt; *All CNAs are to ask for assistance rather than attempt a one person transfer. CNA D acknowledged hearing this information, but stated he/she did not see anyone at the nurse's station, so he/she did not ask for assistance; *All CNAs are informed they need to remove leg rests prior to transfer. CNA D reported he/she did this, and he/she knew it was important; *Resident care list containing pertinent information for each resident is located at each nursing station for the CNAs to review daily prior to caring for a resident. CNA D stated he/she knew about the resident care list, but did not review it on 4/23/20, prior to caring for the resident. CNA D was asked how many residents he/she used to care for in the past and he/she stated 12 or more. He/she was then asked how many residents he/she cared for on 4/23/20, and he/she stated five. He/she was asked if he/she felt rushed that evening, and CNA D said he/she did not feel rushed to put residents to bed. The resident was small (about 97 pounds) and CNA D was tall. He/she thought he/she could just transfer the resident alone because of his/her size. CNA D was asked to demonstrate how he/she transferred the resident, and he/she stated he/she placed the resident in his/her wheelchair, next to the resident's bed. He/she removed the leg rests from the wheelchair, placed the resident's arms over the CNA's shoulders and put his/her arms beneath the resident's arms. When asked if this was how he/she was trained to transfer, the CNA said it was not part of his/her training. He/she was trained to use a gait belt. CNA D then lifted the resident and attempted to pivot him/her towards the bed. He/she believed the resident's left leg was caught between the metal bottom frame of the bed and the wheelchair. The CNA was not sure what happened. He/she completed the transfer and pulled the resident's legs up onto the bed. The resident did not scream or yell out during the transfer, just hummed like usual. The resident did not indicate pain during the transfer. After CNA D got the resident's legs onto the bed, he/she saw the resident's leg was bleeding. At that time, he/she went to get the charge nurse to inform him/her of the skin tear and to evaluate the resident's wound. He/she did not know the resident had a skin tear on his/her arm at that time. The nurse noticed the skin tear on the resident's left arm after he/she completed care of the left leg. The resident did not fall to the floor during the transfer, and CNA D had no idea how the resident sustained [REDACTED]. In conclusion, the incident occurred because the CNA caring for the resident on 4/23/20 did not follow facility practice of reviewing the resident care list prior to caring for the resident and did not use proper transferring techniques, which provides safety for the resident and staff. Review of a written statement dated 4/23/20 by CNA D, showed on 4/23/20, as he/she transferred the resident from his/her wheelchair to his/her bed, the resident bumped against his/her wheelchair causing a skin tear on his/her lower leg and arm. During an interview on 2/3/21 at 10:35 A.M., CNA D said he/she had just started working at the facility. He/she had not been trained well on transfers. He/she did not pick up a resident care list that day so did not know the resident was a two person transfer. He/she did not usually work the resident's hall so he/she got information from another staff member who usually worked the hall. The other staff member told him/her the resident was a one person transfer. He/she could not remember the other staff member's name. On the evening of 4/23/20, after dinner, he/she went to put the resident in his/her bed. He/she wheeled the resident's wheelchair to the bed, put on the brakes and raised the leg rests. The CNA put a gait belt around the resident and lifted him/her from the wheelchair and pivoted him/her to the bed. He/she believes the resident got his/her pants caught on the wheelchair. When he/she got the resident onto the bed, he/she noticed blood on his/her leg. The resident had not cried out in pain or indicated he/she was hurt in any way. The CNA immediately went out and got a nurse to come assess the resident's injuries. When asked why he/she gave a different statement during his/her interview with administration, he/she said he/she did not remember saying those things. He/she did not bring a gait belt to work, but there was one in the resident's room. If he/she knew the resident was a two person assist, he/she would have requested help. During an interview on 2/3/21 at 11:00 A.M., LPN E said on 4/23/20, CNA D came and got him/her because the resident had some skin tears that were bleeding. When he/she entered the room the resident was on the bed bleeding from his/her leg. The wounds on the resident's leg were very bad; they were so deep. The LPN asked the CNA what happened, but he/she did not really explain it. The LPN reminded the CNA the resident was a two person assist and asked why he/she had not requested assistance. The CNA said he/she could not find anyone to help. The resident kept yelling out in pain each time they moved his/her leg as they tried to bandage it. The other nurse arrived shortly after to assist. LPN E did not remember seeing a gait belt in the room. During an interview on 2/2/21 at 12:35 P.M., LPN F said staff called him/her to the resident's room regarding skin tears. The leg was badly bleeding and the skin was torn badly. He/she and LPN E cleansed the wound, used cotton swabs to pull the skin back together and applied steri-strips to close the wound. While they were working on the leg, they noticed another large wound on the resident's left arm. It was obvious what happened. He/she asked CNA if he/she transferred the resident by him/herself, and he/she replied he/she had done the transfer alone. LPN F would have expected the CNA to ask for help with the transfer. He/she could have asked anyone, even the nurses would have helped him/her if asked. LPN F reminded the CNA the resident was a two person transfer, and the CNA said he/she thought he/she could transfer the resident by him/herself. LPN F asked if he/she used a gait belt because he/she did not see one, and the CNA replied he/she had not used one. LPN F believed the resident's feet got caught in the foot pedals. The resident's leg did not look swollen and the resident was not complaining of pain after the bandaging. Later that night, staff checked on him/her to change his/her bandaging and noticed the leg looked more swollen and ordered an x-ray. During an interview on 2/2/21 at 9:35 A.M., the RCC said he/she provided orientation to CNA D and told him/her about two person transfers and the resident care list. They keep the resident care list in the activity rooms and all staff have access to them. Staff should get the list and review it before they start their shift to find out what care each resident needs, including the number of people needed for transfers. On 4/23/20, CNA D got the resident up by him/herself. He/she had been trained to use a gait belt and to ask for help, but decided to do it on his/her own since the resident was so small. The resident had problems with pivoting and needed extra assistance to turn him/her slowly. The CNA admitted transferring the resident on his/her own without a gait belt, although he/she knew the resident was a two person assist. He/she told the RCC that he/she could not find any staff to help him/her, so he/she did it on his/her own. Observation on 2/2/21 at 12:15 P.M., of the activity room, showed several resident care lists on the table in the room. Review of the facility's Safe Lifting and Movement of Residents Policy, dated 10/2009, showed the following: -In order to protect the safety and well-being of staff and residents and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents. -Policy interpretation and implementation: 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; 2. Manual lifting of residents shall be eliminated when feasible; 3. Nursing staff in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident transferring needs and lifting needs in the care plan. Such assessment shall include: *Resident's preferences for assistance; *Resident's mobility (degree of dependence); *Resident's size; *Weight bearing ability; *Cognitive status; *Whether the resident is usually cooperative with staff and; *The resident's goals for rehabilitation, including restoring or maintaining functional abilities; 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices; 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary; 6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies regarding use of equipment and safe lifting techniques. During an interview on 2/2/21 at 1:00 P.M., the DON said the CNA was oriented to look at the resident care list. He/she should have done that before before starting his/her shift. He/she should have waited until assistance was available if he/she needed it. He/she should have made sure the leg rests were out of the way. During an interview on 2/4/21 at 9:45 A.M., the administrator said the CNA was very forthright and apologetic when he/she was interviewed about the incident. He/she admitted transferring the resident by him/herself even though he/she knew the resident was a two person assist. All staff are trained on how to transfer and how to obtain the resident care list. They are supposed to get a copy of the resident care list and take it with them so they can review it if there are any questions. All staff are issued a gait belt or they can supply their own. If they forget the gait belt, there are others at the facility for their use. The CNA never should have transferred the resident by him/herself if the resident was a two person transfer. MO 428

Based on interview and record review, the facility failed to follow one sampled resident's wishes and physician's order for Cardiopulmonary Resuscitation (CPR) when staff discovered the resident without signs of life. The nurse found the resident pulseless and not breathing, did not provide CPR and did not notify the other nurse on duty, but told the certified nurses aides to clean the resident up. This deficient practice also had the potential to affect the other 17 residents the facility identified as having a full code status. (Resident #1) The census was 56. Review of Resident #1's physician's orders, dated [DATE], showed the following: -admitted [DATE]; -[DIAGNOSES REDACTED]. -Oxygen at 2 liters per nasal cannula, PRN (as needed) to keep oxygen saturation (measures oxygen level in blood) above 92% (normal 100%); -Oxygen saturation every shift and as needed for shortness of breath; -CPR. Review of the resident's Code Status Form, dated [DATE], and signed by the resident showed the following: -RESUSCITATE -All measures of resuscitation will be taken including: -CPR; -Calling 911 immediately; -Emergency IVs (intravenous) and medication; -Transportation to closest hospital. Review of the resident's admission agreement packet, dated [DATE], showed no information to let the resident and family know of the facility's policy that CPR would not be done for full code residents if the nurse felt there were obvious signs of irreversible death. During an interview on [DATE] at 11:30 A.M., the administrator said the facility admission packet did not include information, explaining the facility policy, that CPR would not be done on full code residents if the nurse felt the situation was irreversible. During an interview on [DATE] at 1:40 P.M., the social worker said when he/she does an admission, the residents are told if they are a full code, CPR will be done. The facility admission packet did not include any information that CPR would not be done on full code residents if the nurse felt the situation was irreversible. The social worker did not inform residents or families of anything about CPR other than what was in the packet. Review of the resident's nurse's assessment, dated [DATE], showed the following: -Oriented to person, place and time; -Unsteady gait requiring supervision; -No changes in mood and behavior; -Uses commode; -Respiratory (breathing) status within normal limits. Review of the resident's progress note, dated [DATE] at 1:07 P.M., showed the resident was transferred to the hospital due to a critical lab result, BUN (blood urea nitrogen, a test to determine kidney function) 88 (normal 9 - 23). Review of the resident's hospital record, dated [DATE], showed admitting [DIAGNOSES REDACTED]. Review of the resident's hospital discharge instructions, dated [DATE], showed the following: -discharged to facility on [DATE]; -Take medications as prescribed by physician; -Call physician if feels worse, has problems breathing, has more swelling or becomes very tired. Review of the resident's progress notes, dated [DATE], (not received until [DATE]), showed the following: -Arrived at 7:30 P.M., by ambulance from the hospital. Alert, oriented and vital signs stable, temperature 97.3 Fahrenheit (F) (normal 97.6 to 99.6 degrees F), pulse 91 (regular) (normal 60 - 100), respirations 22 (normal 16 - 20), blood pressure ,[DATE] (normal ,[DATE]). Oxygen saturation 90% (on room air) (normal 100%). PRN oxygen given at 2 liters/minute; -No shortness of breath or cough; -Complains of nausea and loose stools (BM). No emesis, but had a loose stool. White soda provided. Stated felt better and wanted to rest; -Resident stated, I will be refusing my medications tonight and tomorrow morning. -Medications had not changed from last admission. Physician made aware of medications and resident complaints; -New orders received for [MEDICATION NAME] (for nausea) 10 milligrams, by mouth, every six hours as needed; -Resident denies any pain or discomfort at this time. Call light placed within reach. Review of the resident's progress notes, dated [DATE] at 11:45 P.M. (not received until [DATE]), showed the following: -Nurse B spoke with resident, who denies pain; -Head of bed elevated 90 degrees, oxygen at 2 liters per nasal cannula on resident. Oxygen saturation 92%; -Exertional shortness of breath, skin color/ashen; -Drank 60 cc of clear soda, begging for fluids, call light within reach. Review of the resident's vital sign summary sheet, dated [DATE] (not received until [DATE]), showed the following: -At 12:30 A.M., oxygen saturation 93%, via nasal cannula; -At 1:00 A.M., temperature 98.4 F, pulse 88, irregular-unable to determine onset, respirations 24 and blood pressure ,[DATE]. Review of the resident's progress notes, dated [DATE] (this was the only note provided during the onsite on [DATE], for the night shift of [DATE] into [DATE]), showed the following: -At 3:45 A.M., certified nurse aide (CNA) found resident sitting on floor at bedside, with back leaning against bed and legs stretched out in front of body. Oxygen off, denies pain, no noted wounds or deformities. Range of motion to all extremities within normal limits. Oxygen re-applied at 2 liters per minute. No evidence of head trauma. Assisted up with gait belt by three staff members. Ambulated to bed with staff assist. Head of bed at 90 degrees. Pupils equal and reactive to light. Hand grips equal bilaterally. Temperature 99.1 F, pulse 88, respirations 28 and blood pressure ,[DATE]. Brief wet with urine. Resident cleaned/dried. Resident unable to explain why he/she was getting up out of bed and begging for clear soda. -At 5:45 A.M., upon entrance to resident's room to administer morning medication, the resident was found unresponsive, had no pulse or respirations and his/her pupils were fixed/dilated. 911 called and Nurse B entered the resident's room to assist in performing CPR. CNA went to the front door to let emergency medical services (EMS) in at 5:50 A.M. Call placed to resident's emergency contact and voicemail left. Review of the resident's progress notes, dated [DATE] (not received until [DATE]), showed the following: Late Entry [DATE] at 5:20 P.M. -At 5:20 A.M., Nurse B to resident's room to give morning medications. Found resident unresponsive to voice or touch, no pulse or respirations. Head of bed elevated 90 degrees, oxygen in place per nasal cannula. Resident's head down, color ashen, pupils fixed/dilated, skin mottling to bilateral legs, from feet to top of thighs, upper shoulders and back of arms. Based on nursing assessment, CPR was not started; -Second nurse to room suggested CPR be started and to call 911. Chest compression and rescue breathing started per ambu bag; -Staff to front door to await arrival of EMS; -At 5:50 A.M., EMS here and applied monitor; -At 6:00 A.M., EMS stated to stop CPR because resident expired; -Police here and medical examiner notified. Coroner said to release body to medical examiner; -Resident's body cleaned and prepared for release; -Attempted to notify resident's sister, voice mail left on cell phone; -Physician's exchange notified of death. During an interview on [DATE] at 11:46 A.M., evening shift Nurse A said the following: -Nurse A sent the resident to the hospital on [DATE], due to a critical lab; -Nurse A received a call from the hospital nurse on [DATE], that resident was being sent back from the hospital that evening due to being non-compliant with care; -Nurse A was concerned about the resident's full code status because the resident refused medications and treatment; -Nurse A tried to speak to the resident about his/her code status, but he/she did not want to talk about it; -The resident did not have ashen (pale, gray color of ash) color or shortness of breath, but wanted the oxygen on; -The resident had nausea and loose stool (bowel movement); -Nurse A called the physician to get an order for [REDACTED]. During an interview on [DATE] at 3:10 P.M., the Director of Nurses (DON) said the following: -On [DATE], Nurse A called the DON to report the resident just returned from the hospital, was in poor health and refusing medication; -Nurse A said the resident's full code status needed to be addressed, but the resident did not want to talk about it. During an interview on [DATE] at 2:20 P.M., night shift Nurse B said the following: -On [DATE] at 11:30 P.M., Nurse B was surprised the resident was sent back from the hospital, because he/she was so sick. Nurse B talked to the resident, who looked terrible and had extreme shortness of breath. The resident had oxygen on and wanted fluid, so the nurse gave him/her 60 cubic centimeters (cc) of clear soda. Nurse A told Nurse B the resident was sick, had been sent to the hospital and came back that way; -On [DATE] at 2:45 A.M., the resident was in the same condition. The resident never said he/she had shortness of breath or pain. But from the looks of him/her, that's what he/she was used to; -Nurse B did not think the resident was going to die, even though the resident was not well; -Nurse B saw the resident three times and talked with him/her, but did not check the resident's vital signs. Nurse B said he/she checked the resident's pulse and respirations by looking at him/her the first two times; -CNA C checked the resident's vital signs and did not report any problems; -Nurse B knew Nurse E arrived to the facility at 4:00 A.M. Before that time, Nurse B was the only nurse at the facility with 60 residents: -At 5:45 A.M., Nurse B went to give the resident some medication and found him/her dead. The resident was in bed with the head of bed elevated at 90 degrees. His/Her head was flopped over, with the oxygen nasal cannula in place, and he/she had no breathing or pulse; -Nurse B put the head of the resident's bed down and removed his/her gown. The resident's pupils were fixed and dilated (wider or larger). The resident's face was ashen and his/her thighs, legs, feet, back and shoulders were a mottled (discoloration in irregular areas) purple color. The resident had no rigor mortis (stiffness of death). The resident was dead a while and the situation was irreversible; -The resident was a full code, but CPR would not have helped; -About 20 to 30 minutes after Nurse B found the resident dead, he/she told Nurse E, who just happened to call from the other nursing division, regarding something totally unrelated; -Nurse E thought they should call 911 and do CPR for the resident. Nurse E came and started chest compressions on the resident. Nurse B got the crash cart and ambu bag (manual resuscitator, used to force air into the lungs). When the emergency medical technicians got there, they said to stop CPR and pronounced the resident dead; -The facility policy is to do CPR, unless the nurse feels the situation is irreversible; -Nurse B heard the Assistant Director of Nurses (ADON) changed Nurse B's nurse's note for 5:45 A.M., but he/she did not know in what way. Nurse B then wrote a late entry note at 5:20 P.M.; -Nurse B continued to work all week on the night shift; -The administrator and DON talked with Nurse B, today [DATE], for the first time about what happened with the resident on Monday, [DATE]. During an interview on [DATE] at 8:19 A.M., CNA C said the following: -On [DATE] at 12:00 A.M. and 2:00 A.M., the resident was doing fine and had no shortness of breath or pain; -At 3:45 A.M., the resident was on the floor by the side of the bed. The resident's vital signs were stable and he/she had no injury; -At 4:00 A.M. and 4:10 A.M., the resident was asleep in bed; -At 5:00 A.M., CNA C and Nurse B went into the room and the resident was dead. Nurse B checked the resident's pulse and said the resident was gone. CNA C touched the resident's forehead, which felt slightly cold. The resident was not stiff. Nurse B said to get CNA D and clean the resident. CNA D had just been in the resident's room and could not believe the resident was gone, because he/she had just asked for water. CNA C and CNA D cleaned the resident. Nurse E came in the room and said they had to do CPR on the resident. Nurse B and Nurse E did CPR. Nurse B told CNA C to open the front door for the paramedics. Then the police and paramedics came to the resident's room. During an interview on [DATE] at 1:15 P.M., CNA D said the following: -On [DATE] at 3:45 A.M., CNA D helped CNA C and Nurse B get the resident back in bed after he/she fell ; -At 4:30 A.M., CNA D answered the resident's call light and he/she was sitting up in bed. The resident asked for soda and ice, but Nurse B said the resident could not have it because he/she was on fluid restriction; -At 5:20 A.M., CNA C asked CNA D for help to clean the resident, who died . CNA D helped clean the resident for 10 minutes and left the room; -CNA D was not in the room when the nurses did CPR for the resident. During an interview on [DATE] at 1:50 P.M., Nurse E said the following: -On [DATE] at 4:00 A.M., Nurse E arrived at the facility and saw the resident sitting on the bed, talking to CNA C. The resident was short of breath and wearing an oxygen cannula. He/She found out that the resident had a fall. He/She had been sitting on the side of the bed and slid to the floor at 3:45 A.M., but had no injury. The resident had [MEDICAL CONDITION], was alert, oriented, on fluid restrictions, and would let staff do some things for him/her; -At 5:42 A.M., Nurse E called the nursing station on the other division to ask Nurse B to sign a report. Nurse B was aware Nurse E was in the facility prior to that time. Nurse B told him/her the resident had been dead since 5:00 A.M., and did not feel it was an emergency. Nurse E told Nurse B the resident was a full code and they needed to do CPR. Nurse E called 911 and went to do CPR on the resident. The resident was cyanotic (bluish discoloration of skin due to not enough oxygen in the blood) in the face, with no respirations or pulse. Rigor mortis had not set in. A police officer arrived first and took over CPR. When the paramedics arrived, they put a defibrillator (delivers dose of electrical energy to heart) on the resident and did an EKG (electrocardiogram, checks for electrical activity of heart). They determined the resident was dead. Nurse E notified the physician; -Nurse E knew right away the resident was a full code. Nurse B should have notified Nurse E, called 911, and done CPR for the resident. Review of the fire department trip sheet, dated [DATE], showed the following: -Received 911 call from facility at 5:50 A.M.; -Arrived to facility at 5:54 A.M.; -Responded to facility for [MEDICAL CONDITION]; -No carotid pulse or breathing; -EKG monitor shows asystole (no electrical activity in heart). During an interview on [DATE] at 2:10 P.M., the administrator said the following: -Nurse B followed the facility policy and used professional discretion with the resident. Nurse B has excellent nursing skills and a [AGE] year career in nursing; -Nurse B found the resident with no signs of life and obvious signs of irreversible death. The resident was sitting up at a 90 degree angle in bed, with his/her head slumped, with an ashen, mottled, dead color on his/her back and legs, with pupils fixed and dilated; -Nurse E came to the facility at 4:00 A.M.; -At 5:30 A.M., Nurse B told Nurse E the resident passed away; -Nurse E did CPR on the resident. -The administrator and DON spoke with the facility medical director on [DATE], and Nurse B today ([DATE]), who wrote a statement. During an interview on [DATE] at 3:10 P.M., the DON said the following: -On [DATE], the DON received a telephone call early in the morning from Nurse E, who said the resident died . Nurse E said since the resident was a full code, staff should have done CPR; -The facility policy shows to do CPR on a resident who is a full code, unless there are signs of irreversible death; -Nurse B had experience to make the determination the resident was dead and CPR would not have done any good; -Staff should have monitored the resident more often, every hour, since he/she came back from the hospital not doing well; -Staff should have checked the resident's oxygen saturation, since he/she had shortness of breath; -The facility is thinking about changing the policy and doing CPR on all residents that have a full code status. Review of the facility's CPR policy and procedure, dated [DATE], showed the following: -The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support. -If an individual (resident, visitor or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless: -It is known that a Do Not Resuscitate order that specifically prohibits CPR/BLS and/or external defibrillation exists for that individual; -There are obvious signs of irreversible death (e.g., rigor mortis). Review of the Centers for Medicare & Medicaid Services (CMS) memorandum regarding initiation of CPR, dated [DATE], showed the following: -Initiation of CPR - Prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. CPR-certified staff must be available at all times. -Facility CPR Policy - Some nursing homes have implemented facility wide no CPR policies. Facilities must not establish and implement facility wide no CPR policies. -Surveyor Implications - Surveyors should ascertain that facility policies related to emergency response require staff to initiate CPR as appropriate and that records do not reflect instances where CPR was not initiated by staff even though the resident requested CPR or had not formulated advance directives. Review of the facility's investigation for [DATE], received in the mail on [DATE], showed the following: -Resident's diagnoses, interviews with staff and the conclusion the facility's CPR policy and procedure was followed; -Based on the investigation, the facility concluded no abuse or neglect had taken place; -Three nurses did not have current CPR certification. During an interview on [DATE] at 1:50 P.M., the resident's physician said the following: -The resident had heart and kidney failure and refused treatment at the hospital. That is why he/she came back to the facility on [DATE]; -If staff were concerned with the resident's condition, they could have called the physician and sent the resident back to the hospital; -It would not have made a difference with the outcome of the resident if staff had done CPR right away; -The facility policy should be changed. Review of information provided by the facility on [DATE], showed they currently had 17 residents with a full code status residing in the facility. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility developed a plan of correction which included changing their policy and inservicing staff regarding cardiopulmonary resuscitation (CPR) on residents who have a full code status. The code status is visible at all times while logged into each resident's electronic medical record, inside of the hard chart, in a folder in each resident's room, on the resident list provided to nursing staff and on the nursing report sheet available to each licensed staff member. The facility still needs to monitor their revised policy regarding the actual procedure for CPR. The facility will monitor residents and staff to assure appropriate measures are taken for residents with a full code status. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violation. MO 484