Every finding on record at Monarch Springs Wellness & Rehabilitation

Based on observation, interview and record review, the facility failed to store and serve food in accordance with professional standards for food service safety. The facility failed to maintain kitchen equipment in a clean condition and failed to ensure that the floors were swept and mopped during three of four days of observation. The facility also failed to ensure that the wash and rinse cycles reached the required temperatures during the dishwashing process on the dishwasher. The census was 53.1. Observations of the kitchen on 5/4/26 at 6:53 A.M., 5/5/26 at 4:45 P.M, and 5/6/26 at 11:36 A.M., showed:-Stove: -Caked-on stains along the front and on the top of the stove; -Caked-on stains and spots on the burners on the stove; along the front;-Oven: -Right side: -Heavy caked-on stains along the front inside doors; -Heavy caked-on stains along the bottom, top, and sides of oven; -Left side: -Caked on matter along the front inside doors; -Caked on matter along the bottom, top, and sides of oven;-Deep fryer: -Dirty grease in the deep fryer; -Heavy caked-on stains along the inside of the fryer;-Floor was noticeably dirty with food crumbs, dirt, and debris. Review of the kitchen daily/after each use cleaning schedule forms showed:-Week of 3/29/26- 4/14/26: -Floor initialed off as been cleaned Monday through Friday; -Range/Grill initialed off as been cleaned Monday through Friday; -Oven (spills) initialed off as been cleaned Monday through Friday; -No responsible party listed for any of the days.-Week of: 4/12/26- 4/18/26: -Floor initialed off as been cleaned Monday through Friday; -Range/Grill initialed off as been cleaned Monday through Friday; -Oven (spills) initialed off as been cleaned Monday through Friday; -No responsible party listed for any of the days.-Week of: 4/19/26- 4/25/26: -Floor initialed off as been cleaned Monday through Friday; -Range/Grill initialed off as been cleaned Monday through Friday; -Oven (spills) initialed off as been cleaned Monday through Friday; -No responsible party listed for any of the days.-Week of: 4/26/26- 4/30/26: -Floor initialed off as been cleaned Monday through Friday; -Range/Grill initialed off as been cleaned Monday through Friday; -Oven (spills) initialed off as been cleaned Monday through Friday; -No responsible party listed for any of the days. 2. Observation of the dishwasher during the dishwashing process, showed the wash cycle to reach 88 degrees and the rinse cycle to reach 104 degrees. Review of the April 2026 dish machine log, showed:-Wash Cycle: The temperatures were logged and initialed at 120 degrees and/or above for 0 out of 90 opportunities;-Sanitizer: The temperatures were logged and initialed at 120 degrees and/or above for 22 out of 90 opportunities. Review of the May 2026 dish machine log, showed:-Wash Cycle: The temperatures were logged and initialed at 120 degrees and/or above for 0 out of 18 opportunities;-Sanitizer: The temperatures were logged and initialed at 120 degrees and/or above for six out of 18 opportunities. Review of the May 2026 dish machine log showed: -For low temperature dish machines: -The wash temperature: > (greater) than 120 degrees (or per manufacturer instruction); -The rinse temperature: > (greater) than 120 degrees (or per manufacturer instruction); -Sanitizer: 50 to 200 PPM (parts per million) (or per manufacturer instruction). 3. During an interview with the Dietary Manager (DM) and [NAME] J on 5/7/26 at 12:20 P.M., [NAME] J said they run the dishwasher a couple of times to get it up to the temperature of where it needs to be. The wash cycle should be at 120 degrees, and the rinse cycle should be at least 115 degrees or above. They had to do a large amount of work with the electrical system, so they are installing a booster to make the water temperatures hotter. The DM said it was his expectation that water temperatures should be reaching the required temperatures during the wash and rinse cycles. The grease in the deep fryer was normally changed depending on what they were frying. The grease is drained from the fryer and fryer is cleaned approximately every week and a half. The kitchen appliances and equipment should be clean and in proper working order, and the floor should be swept, cleaned, mopped, and free of debris. General cleaning is done daily to include sweeping and mopping, wiping equipment and appliances down, and cleaning the steam tables upstairs. Deep cleanings were done monthly.

Based on interview and record review, the facility failed to provide or offer vaccinations for influenza and/or pneumococcal disease for four of five residents sampled for immunization status. The sample was 16. The census was 58.Review of the facility's Pneumococcal Disease Prevention policy, revised 6/2020, showed:-Before offering pneumococcal vaccines, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization;-The resident or the residence legal representative has the opportunity to refuse immunization, with such refusal being noted in the residence medical record;-The resident's medical record includes documentation that indicates, at a minimum, the following: That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of the pneumococcal polysaccharide vaccine, the informed consent/refusal is to be placed in the resident's medical record, and the resident either received the pneumococcal vaccine or did not receive the vaccination due to medical contraindications or refusal. Review of the facility's Influenza Prevention and Control policy, revised 6/2020, showed:-Influenza season will be defined by the Center for Disease Control (CDC) guidelines;-Residents are offered an influenza immunization during flu use an annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;-The resident or the resident's legal representative has the opportunity to refuse immunization, with such refusal being noted in the residence medical record;-The resident's medical record includes documentation that indicates at a minimum the following: that the resident or legal representative was provided education regarding the benefits and potential side effects of influenza immunization, that the Influenza Vaccination-Informed Consent/Refusal will be placed in the resident's medical record, and that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. 1. Review of Resident #2's electronic medical record (EMR), showed:-admission date 9/15/25;-No documentation the resident received or was offered influenza or pneumococcal vaccines. 2. Review of Resident #9's EMR, showed:-admission date 9/22/25;-No documentation the resident received or was offered influenza or pneumococcal vaccines. 3. Review of Resident #40's EMR, showed:-admission date 1/19/26;-No documentation the resident received or was offered influenza or pneumococcal vaccines. 4. Review of Resident #33's EMR, showed:-admission date 12/24/25;-No documentation the resident received or was offered pneumococcal vaccine. 5. During an interview on 5/7/26 at 9:12 A.M., LPN (Licensed Practical Nurse) A said the admitting nurse was expected to check for a resident's immunization records upon the resident's admission. The admitting nurse should offer influenza and pneumococcal vaccines upon a resident's admission and when seasonally appropriate. Immunizations should be documented in the resident's EMR. 6. During interview on 5/7/26 at 1:37 P.M., the Director of Nurses (DON) and Administrator said they expected residents to be offered influenza and pneumococcal vaccinations upon admission, unless documentation of previous immunization is available. Immunizations should be documented in the EMR. Auditing of resident vaccination statuses is the responsibility of the Assistant Director of Nursing (ADON), who also serves as the facility Infection Preventionist (IP).

Based on observation, interview and record review, the facility failed to obtain and/or follow physician orders for three residents (Residents #37, #9, and #41). The facility failed to ensure blood pressure parameters were followed prior to medication administration (Resident #37). The facility failed to administer meal supplements (Resident #9) and failed to update dietary orders (Resident #41). The sample size was 16. The census was 53.Review of the facility's Physician Orders policy, revised June 2020, showed:-Policy: The medical records department will verify that physician orders are complete, accurate, and clarified as necessary;-Procedure: Telephone orders: A licensed nurse will transcribe telephone orders with date, time, and signature of the person receiving the order;-Orders will include a description complete enough to ensure clarity of the physician's plan of care;-Physician orders will only include abbreviations that have been approved by the facility;-Whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order;-Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care discipline will be transcribed onto the appropriate communication system for that discipline;-Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the Medication Administration Record (MAR)/Treatment Administration Record (TAR). 1. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 3/13/26, showed:-Severe cognitive impairment;-Diagnoses included amenia, heart failure, hypertension (high blood pressure), orthostatic hypotension (sudden drop in blood pressure), diabetes, bipolar disorder ( a mental health condition characterized by dramatic shifts in mood), asthma and respiratory failure. Review of the resident's care plan, in use during survey, showed:-Focus: Resident is a moderate risk for falls related to high risk medications, impulsivity, impaired mobility, severe cognitive impairment, and incontinence;-Focus: Resident has congestive heart failure with bilateral edema and uses daily diuretic and is at risk for fluid overload;-Focus: Resident has chronic pain related to polyosteoarthritis (degenerative joint disease), neuropathy (nerve damage) and pain in his/her left shoulder. He/She receives anticonvulsants (anti-seizure) for neuropathy daily;-Interventions: Administer Gabapentin (anticonvulsant) oral capsule 100 milligram (mg) as ordered. Review of the resident's Physician's Orders Sheet (POS), dated May 2026, showed:-An order, dated 4/5/26, Hydrochlorothiazide (diuretic) oral tablet 12.5 mg, give one tablet by mouth in the morning for bilateral edema related to heart failure. Hold if blood pressure is less than 100/60;-An order, dated 4/5/26, Gabapentin oral capsule 100 mg, give one capsule by mouth, two times a day related to type two diabetes. Hold if blood pressure is less than 100/60;-An order, dated 10/24/25, Midodrine (used to treat low blood pressure) hydrochloride (HCI) oral tablet 10 mg, give one tablet my mouth, three times a day related to orthostatic hypotension. Hold if systolic (top number in a blood pressure reading) is greater than or equal to 100 millimeters of mercury (mmHg) (normal is 120 mmHg or less) or diastolic (the bottom number in a blood pressure reading) is greater than or equal to 80 mmHg (normal 60-80 mmHg). Review of the resident's Medication Administration Record (MAR), dated May 2026, showed:-On 5/4/26, staff documented the administration of Hydrochlorothiazide12.5 mg. The resident's blood pressure was documented 89/54;-On 5/4/26 morning medication administration, staff documented the administration of Gabapentin 100 mg. The resident's blood pressure was documented 89/54;-On 5/3/26 morning medication administration, staff documented the administration of Midodrine oral tablet 10 mg. The resident's blood pressure was 130/75;--Afternoon medication administration, showed staff documented the administration of the Midodrine. The resident's blood pressure was 134/71;-On 5/5/26 bedtime medication administration, staff documented the administration of Midodrine. The resident's blood pressure was 125/70;-On 5/6/26 morning medication administration, staff documented the administration of Midodrine. The resident's blood pressure was 111/62;--Afternoon medication administration, staff documented the administration of Midodrine. The resident's blood pressure was 137/67;-On 5/7/26 morning medication administration, staff documented the administration of Midodrine. The resident's blood pressure was 131/83. During an interview on 5/7/26 at 11:12 A.M., Licensed Practical Nurse (LPN) A said the resident's order for Midodrine specified it was either diastolic or systolic number. If either number was greater than what the order specified, the medication should have been held. LPN A was asked if the Midodrine should have been administered on 5/7/26 when the blood pressure was 131/83. LPN A said the Midodrine should have been held. The Certified Medication Technician (CMT) administered the medication. During an interview on 5/7/26 at 1:30 P.M., the Director of Nursing (DON) said she would have expected staff to follow physician's orders. She would have expected the resident's blood pressure to be taken and documented prior to administration. She would have expected staff to follow the blood pressure parameters prior to administering the medications. The DON confirmed staff should have held the Midodrine that morning if the resident's blood pressure was 131/83 and notified the nurse. She would have expected staff to hold the resident's gabapentin and hydrochlorothiazide if the resident's blood pressure was not within parameters. It was important for staff to follow the blood pressure parameters, so the resident did not become hypotensive. 2. Review of Resident #9's progress notes showed a note from the Registered Dietician on 3/27/26 at 9:18 A.M., indicating the resident had stable weekly weights and the recommendation was made to continue the resident's order for 60mL MedPass (a meal supplement used to provide additional calories with meals to patients suffering from malnutrition) three times daily with meals unless weight loss was noted. Review of the resident's quarterly MDS, dated [DATE] showed:-The resident is not cognitively intact;-Medical Diagnoses including: End Stage Renal Disease (ESRD, a chronic condition that impairs the kidneys' ability to filter toxins from the blood), aphasia (a language disorder caused by damage to the brain that impairs the ability to speak, read and write), seizure disorder, and malnutrition (a chronic condition in which the body fails to absorb an adequate amount of nutrients from food products). Review of the resident's progress note, showed a note from the Registered Dietician on 4/30/26 at 1:26 P.M. indicating the resident was noted to have weight loss based on weekly weights and had begun to downtrend after the resident's weekly weights had been increasing. A recommendation was made to increase the resident's MedPass (a high-calorie high-protein nutritional shake) supplement from 60mL three times daily to 120mL three times daily. Review of the resident's physician orders, active through the survey, dated May 2026, showed:-An order for 60mL MedPass 2.0 three times daily with meals entered on 10/8/25 with an end date of 4/30/26;-An order for 120mL MedPass 2.0 three times daily with meals entered on 4/31/26 with a stop date of 5/1/26;-An active order for 120mL MedPass 2.0 three times daily with meals entered on 5/7/26 with no stop date. Observation on 5/4/26 at 7:53 A.M., showed the resident ate breakfast and was assisted by staff. No meal supplement shake was provided to the resident during the breakfast meal. At the conclusion of the meal the resident was wheeled back to his/her room in a Broda chair (a specialized, high-performance mobility device used to provide long-term comfort, pressure relief, and safe positioning for individuals with limited mobility) by staff. No meal supplement shake was provided to the resident after being transferred to his/her room. Observation on 5/5/26 at 12:51 P.M. showed the resident ate lunch and was assisted by staff . No meal supplement shake was provided to the resident during the lunch meal. At the conclusion of the meal the resident was wheeled back to his/her room in a Broda chair by staff. No meal supplement shake was provided to the resident after being transferred to his/her room at the end of the lunch meal. Observation on 5/6/26 at 1:12 P.M. showed the resident ate lunch and was assisted by staff. No meal supplement shake was provided to the resident during the lunch meal. At the conclusion of the meal the resident was wheeled back to his/her room in a Broda chair by staff. No meal supplement shake was provided to the resident after being transferred to his/her room at the end of the lunch meal. During interview on 5/8/26 at 9:06 A.M. CMT B (Certified Medication Technician) said he/she was unsure if the resident had experienced weight loss, but knew the resident was to receive meal supplements with all meals. Supplement shakes are provided by the facility CMTs and kept on the medication carts. The Registered Dietician made recommendations monthly, and the Director of Nursing (DON) was responsible for ensuring those orders were transcribed and followed up on. During interview on 5/8/26 at 9:09 A.M. LPN A (Licensed Practical Nurse) said the resident had experienced documented weight loss between 4/7/26 and 4/29/26 and had active orders for 120 mL MedPass 2.0 three times daily with meals. The facility contracted with a Registered Dietician who entered their own orders in and floor nurses were to confirm those orders were accurate and transcribed each month. During interview on 5/8/26 at 1:37 P.M. the facility Administrator and DON said the resident had fluctuating weight loss but were unsure of his/her exact orders for meal supplement shakes. Facility CMTs were responsible for providing meal supplement shakes as they were a physician's order and kept on the medication cart. The facility's Registered Dietician was able to input his/her own orders, and facility nursing staff were responsible for reviewing those orders. The orders were not entered correctly and the resident missed dosages of MedPass. The facility Administrator and DON would have expected orders for meal supplements to be provided as ordered or recommended monthly by the Registered Dietician and entered onto the physician's order correctly. The resident missed dosages of Medpass from 5/1 through 5/7 due to the orders not transcribed correctly. 3. Review of Resident #41's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Diagnoses included non-traumatic brain dysfunction, Alzheimer's disease, and malnutrition;-Supervision or touching assistance with eating;-No signs and symptoms of swallowing disorder. Review of the care plan, in use at the time of survey, showed:-Focus: Resident has nutritional problem related to unplanned weight loss related to severe cognitive impairment, terminal diagnosis, refusal to allow staff to assist with meals, low BMI (body mass index) and variable by mouth intake. Resident requires a mechanically altered diet. Weight loss is expected during end of life stage;-Interventions: Provide and serve diet as ordered. Regular diet, minced and moist texture, thin consistency. Review of the resident's POS, dated May 2026, showed an order, dated 12/30/25, regular diet, minced and moist texture, thin consistency. Observation on 5/5/26 and 5/6/26, showed:-On 5/5/26 at 12:44 P.M., the resident was served spaghetti, vegetables, and garlic bread that was in a pureed consistency;-On 5/6/26 at approximately 5:30 P.M., the resident was served beef tacos, Spanish rice, and refried beans that was in a pureed consistency. During an interview on 5/4/26 at 1:30 P.M., the Administrator said speech therapy assessed the resident and could change the order of their diet. They transcribed the orders. Speech therapy was responsible for changing a resident's diet order in the electronic medical record. He would have expected the diet orders to be accurate and for the care plan to also have reflected a pureed diet.

Based on interview and record review, the facility failed to ensure staff completed bed rail assessments and updated care plans, for two residents (Residents #43 and #33) whose beds were equipped with assist rails. The sample was 16. The census was 53. Review of the facility's bed rail policy reviewed June 2020, showed:-Purpose: -To determine the appropriateness of bed rail use for individual residents;-Policy: -Decisions to use or to discontinue the use of a bed rail will be made in the context of an individualized resident assessment using an Interdisciplinary Team (IDT) and will take into account the resident's medical needs, comfort, and freedom of movement.-Procedure: -The Assessment of whether to use bed rails should include an evaluation of the alternatives to the use of bed rail that were attempted and how these alternatives failed to meet the resident's assessed needs; -If bed rails are to be used, the assessment Bed Rail Utilization by a Licensed Nurse and/or the IDT; -The Licensed Nurse and/or the IDT-Restraint Reduction Committee may refer to the Bed Rail Decision Tree during the assessment. -Before installing a bed rail the Facility must: -Assess the resident for risk of entrapment from bed rails; -Ensure the bed's dimensions are appropriate for the resident's size and weight. The manufacturer's recommendations and specifications for installing and maintaining bed rails will be followed; -If a bed rail is used as an enabler, the resident/resident representative's informed consent will be obtained by a Licensed Nurse or the physician; -The resident's plan of care will be updated to reflect the use of bed rails. The plan of care should also include documentation of the type of specific direct monitoring and supervision provided during the use of the bed rails and the identification of how needs will be met during the use of bed rails (e.g., repositioning, hydration, etc.); -Ongoing Monitoring and Supervision: -After installation of bed rails, the IDT will document the review of the use of bed rails at a minimum of quarterly. Re-evaluations should include a discussion of any adverse effects of bed rails and attempts to eliminate the need for the bed rail if it is being used as a restraint; -Maintenance/Designee will assess the bed dimensions no less than quarterly by utilizing Maintenance Inspection Checklist - Resident Rooms. Maintenance will also check bed rails regularly to ensure they are still installed correctly, as rails may shift or loose over time. 1. Review of Resident #43's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/9/26, showed:-Intact cognition;-Diagnoses include depression, anxiety disorder, asthma, and malnutrition. Review of the resident's care plan, in use during survey, showed use for assist and/or enabler rail(s) not documented. Review of the resident's medical record, showed the following:-admission date of 1/29/26;-readmission date of 3/6/26;-Additional diagnoses of dystonia (a syndrome of abnormal muscle contraction that produces repetitive involuntary twisting movements and abnormal posturing of the neck, trunk, face, and extremities), hallucinations (are false or distorted sensory experiences that appear to be real perceptions, anemia, and rhabdomyolysis (an acute, fulminating, potentially fatal disease of skeletal muscle that entails destruction of muscle);-No physician order for assist rails for the resident;-No bed rail assessment. Observations of the resident and the resident's room showed:-On 5/4/26 at 9:20A.M., the resident lay in his/her bed awake. Both assist rails were up;-On 5/5/26 at 1:03 P.M., the resident in his/her bed awake, in his/her room, eating lunch. Both assist rails were up;-On 5/6/26 at 12:30 P.M., the resident lay in his/her bed awake. Both assist rails were up. 2. Review of Resident #33's quarterly MDS completed by facility staff, dated 4/13/26, showed:-Intact cognition;-Diagnoses included depression, anxiety disorder, asthma, other orthopedic conditions, and peripheral vascular disease (PVD, poor circulation). Review of the resident's care plan, in use during survey, showed use for assist and/or enabler rail(s) not documented. Review of the resident's medical record, showed the following:-admission date of 12/24/25;-readmission date of 1/23/26.-Additional diagnoses of major depressive disorder, hypothyroidism (the thyroid is not making enough thyroid hormone), and atrial fibrillation (A-Fib, irregular heart rhythm);-No physician order for assist rails for the resident;-No bed rail assessment. Observations of the resident and the resident's room showed:-On 5/4/26 at 8:56 A.M., the resident lay in his/her bed awake. out of the room. Both assist rails were up;-On 5/5/26 at 1:13 P.M., the resident in his/her bed awake, in his/her room, eating lunch. Both assist rails were up;-On 5/6/26 at 5:44P.M., the resident lay in his/her bed awake. Both assist rails were up. 3. During an interview on 5/7/26 at 11:40 A.M., the Director of Nursing (DON) said it was her expectation that bed rail assessments should have been done for any residents with assist rails or bed rails, and there should also be physician orders for the assist rails. They want the rails to be assistive and not restraints because they don't want the rails to restrict the residents' movements. She wasn't sure if the rails had come with the beds when the beds were ordered or if they were installed when the beds came.

Based on interview and record review, the facility failed to ensure that the physician provided responses to pharmacist recommendations for three sampled residents (Residents #43, #33, and #4). The sample was 16. The census was 53.Review of the facility's Medication Regimen Review policy, effective August 2020, showed:-Purpose: -The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. The MRR also involves a thorough review of the resident records and may include collaboration with other members of the interdisciplinary team, collaboration with the resident, family members, or other resident representatives. MRR also involves reporting of findings with recommendations for improvement. All findings and recommendations are reported to the Director of Nursing, the Attending Physician, the Medical Director, and the Administrator or in accordance with facility policy; -Policies and procedures developed by the contracted consultant pharmacist services and facility supersede procedures outlined in this policy;-Procedures: -The consultant pharmacist reviews the medication regimen of each resident at least monthly. A more frequent review may be deemed necessary if, for example, the medication regimen is thought to contribute to an acute change in status or adverse consequence or the resident is not expected to stay 30 days; -The findings are phoned, faxed, or e-mailed within 24 hours, or in accordance with facility policy, to the Director of Nursing or designee and are documented and stored with the other consultant pharmacist recommendations in the resident's active record; -The prescriber is notified if needed; -The consultant pharmacist identifies irregularities through a variety of sources including the resident's clinical record, pharmacy records, and other applicable documents. The facility shall make available to the consultant pharmacist all appropriate records. In addition to review pharmacy and clinical records (such as medication administration records (MARs), prescriber's orders, progress notes of prescribers. nurses, and or consultants, the Resident Assessment Instrument (RAI), laboratory and diagnostic test results, and behavior monitoring information), the consultant pharmacist may need to interview the facility staff, the attending physician, and the resident; -Resident-specific irregularities and/or clinically significant risks resulting from or associated with medication are documented in the resident's active record and reported to the Director of Nursing, Medical Director, and/or prescriber as appropriate. -Notification mode is dependent on severity of irregularity and is determined through consultation between consultant pharmacist and the Director of Nursing. -If no irregularities are found, the consultant pharmacist also documents this in the resident's active record and signs and dates such documentation; -If a continuing irregularity is deemed to be clinically insignificant or evidence of a valid clinical reason for rejecting the recommendation is provided, the consultant pharmacist will reconsider whether to report the irregularity again or make a new recommendation on an annual basis; -Recommendations are acted upon and documented by the facility staff and/or the prescriber; -The prescriber accepts and acts upon recommendation or rejects provides an explanation for disagreeing; -If there is a potential for serious harm and the attending physician or prescriber does not concur, or refuses to document an explanation for disagreeing, the Director of Nursing and the consultant pharmacist will contact the medical director. If the attending physician who disagrees is also the medical director, the consultant pharmacist and the Director of Nursing arrange a meeting with the medical director to discuss the issues. All parties must come to agreement or a formal complaint should be initiated according to facility policy. If there is potential for serious harm to the resident, this process must be completed in a manner to ensure no actual harm occurs; -At least monthly, the consultant pharmacist reports any irregularities to the attending physician, medical director, and director of nursing, at a minimum. 1. Review of Resident #43's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/9/26, showed:-Intact cognition;-Diagnoses include depression, anxiety disorder, asthma, and malnutrition. Review of the resident's care plan, in use during survey, showed-Focus: The resident requires antidepressant and hypnotic medication Fluoxetine HCl and Ramelteon for diagnoses of major depressive disorder and insomnia and for sleep;-Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date;-Interventions: Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Antidepressants side effects: Dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. Monitor/document/report to Physician as needed (PRN) ongoing signs and symptoms (s/sx) of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Psychiatric evaluation and treat.-The care plan did not address drug regimen review or monitoring of any medications. Review of the resident's medical record, showed the following:-admission date of 1/29/26;-readmission date of 3/6/26;-Additional diagnoses of dystonia (a syndrome of abnormal muscle contraction that produces repetitive involuntary twisting movements and abnormal posturing of the neck, trunk, face, and extremities), hallucinations (false or distorted sensory experiences that appear to be real perceptions), anemia, and rhabdomyolysis (an acute, fulminating, potentially fatal disease of skeletal muscle that entails destruction of muscle);-A monthly medication review (MMR), dated 3/29/26 showed the resident was taking Diazepam 5 milligrams (mg) (anti-anxiety) medication every eight hours on a PRN basis for anxiety; -Per regulatory guidelines, the duration of treatment with such medications on a PRN basis should be limited to 14 days, however, a new order may be written to extend the duration beyond 14 days if the prescriber believes it is appropriate;-The MMR dated 3/29/26 showed the Pharmacist recommendation to please evaluate the continued need for this medication. If it is to be extended, please document the rationale for the extended time period in the medical record and indicate a specific duration: -Discontinue Order; -Extend for _____ Days. Review of the resident's medical record showed:-No documentation of the physician's rationale for the extended time period for the medication;-No documentation of the physician's response to the MMR, dated 3/29/26. 2. Review of Resident #33's medical record, showed the following:-admission date of 12/24/25;-readmission date of 1/23/26.-Diagnoses included major depressive disorder, hypothyroidism (the thyroid is not making enough thyroid hormone), and atrial fibrillation (A-Fib, irregular heart rhythm). Review of Resident #33's quarterly MDS, dated [DATE], showed:-Intact cognition;-Diagnoses included depression, anxiety disorder, asthma, other orthopedic conditions, and peripheral vascular disease (PVD, poor circulation). Review of the resident's care plan, in use during survey, showed:-Focus: The resident is on anticoagulant therapy Enoxaparin related to unspecified atrial fibrillation;-Goal: The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date;-Interventions: Labs as ordered. Report abnormal lab results to the Physician. Monitor/document/report to Physician PRN s/sx of anticoagulant complications: blood tinged or frank blood (clearly visible) in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath (SOB), loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs (v/s). Review medication list for adverse interactions. Avoid use of aspirin or non-steroidal anti-inflammatory drugs (NSAIDS). -Focus: The resident requires anticonvulsants and opioids (a type of pain medication) for acute and chronic pain r/t neuropathy (nerve damage), left knee effusion (excess fluid) and rheumatoid arthritis (RA);-Goal: The resident will not have an interruption in normal activities due to pain through the review date;-Interventions: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain or discomfort. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion (ROM), withdrawal or resistance to care. The resident is able to call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increases or alleviates pain. -Focus: The resident requires antidepressant medication Lexapro 10 mg and Trazodone 50mg for diagnosis of depression;-Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date;-Interventions: Monitor/document/report to Physician PRN ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement , agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. -The care plan did not address drug regimen review or monitoring of any medications. Review of the resident's medical record showed:-A monthly MMR, dated 3/29/26, showed the Pharmacist recommendation to consider discontinuing the PRN orders for cyclobenzaprine (muscle relaxer, Flexeril) 10 mg every eight hours and tizanidine (short-acting muscle relaxer) 4 mg every six hours, as neither muscle relaxant has been utilized since his/her admission on [DATE]; this will reduce the risk of central nervous system (CNS) depression and potential polypharmacy. Review of the resident's medical record showed:-No documentation of the physician's response to the MMR, dated 3/29/26. 3. Review of Resident #4'significant change MDS, dated [DATE], showed:-Moderate impaired cognition;-Diagnoses included depression, dementia, stroke, psychotic disorder, anxiety disorder, coronary artery disease (CAD, narrowing or blockage of the arteries and vessels that provide oxygen and nutrients to the heart), Parkinson's disease (a disorder of the brain that leads to tremors, difficulty with walking, movement and coordination), and hyperlipidemia (high cholesterol). Review of the resident's care plan, in use during survey, showed:Focus: The resident requires Duloxetine HCl Oral Capsule Delayed Release Sprinkle 30 mg for diagnosis of major depressive disorder;-Goal: He/She will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date;-Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Discuss with Physician, family regarding ongoing need for use of medication. Educate the resident/family about risks, benefits and the side effects and/or toxic symptoms of psychoactive medication drugs being given. Monitor/record occurrence of target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. Monitor/record/report to Physician PRN side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia (abnormal movements due to anti-psychotic medications), EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person.-The resident's care plan did not address drug regimen review or monitoring of any medications. Review of the resident's medical record, showed the following:-admission date of 8/23/23;-readmission date of 1/31/26;-A monthly MMR, dated 1/29/26, showed to please note per Center for Medicare & Medicaid Services (CMS) requirements, the use of psychotropic medications are confined to limited duration of use without reassessment of a gradual dose reduction or discontinuation.-The resident has been receiving Duloxetine 30 mg two times a day since 5/2025. An evaluation for gradual dose reduction should be documented at this time. If gradual dose reduction is contraindicated, please review the following and check if appropriate: - _____ The resident's target symptoms returned or worsened after the most recent attempt at tapering dose; -_____ Past reduction attempts have resulted in problematic behavior and/or staff inability to provide care; -_____ Past reduction attempts have resulted in psychiatric instability by exacerbating an underlying medical or psychiatric disorder. -_____ Past reduction attempts have caused the resident to pose danger to self or others. Review of the resident's medical record showed:-Nothing marked on the MMR dated 1/29/26 to indicate if an evaluation for the gradual dose reduction and/or if a gradual dose reduction had been completed or not;-No documentation of the physician's response to the MMR, dated 1/29/26. 4. During an interview on 5/7/26 at 11:40 A.M., the Director of Nursing (DON) said she would expect for the Physician to document a response to the Pharmacist recommendation and/or to document a rationale if they decide not to follow the pharmacist's recommendation. She usually did audits to follow up to ensure Physician responses to the monthly medication recommendations were done. It was expected for gradual reductions to be made and/ or evaluated. Once indicated, it was her responsibility to ensure that the gradual dose reductions were evaluated and/or completed. It was also her responsibility to ensure that monthly medication reviews were acted upon.

Based on observation, interview, and record review, the facility failed to ensure residents received medications as ordered by the physician. Concerns were noted when one resident's (Resident #18) blood pressure was not taken prior to the administration of an anti-hypertensive (blood pressure) medication and when one resident's (Resident #10) medication was dropped on the floor and unable to be replaced from the medication cart. The medication error rate was 5.41%, with concerns noted with two of 37 observed medications administered. The sample size was 16. The census was 58.Review of the facility's Medication Administration policy, with no revision or implementation date listed, showed:-Medication will be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner, or as consistent with state law;-Tests and taking vital signs (measurements of a person's bodily function), upon which administration of medications or treatments are conditioned, may be performed as required by state law, and the results recorded;-When administration of the drug is dependent upon vital signs or testing, the vital signs or testing will be completed prior to administration of the medication and recorded in the medical record;-Medications will not be left at the bedside. 1. Review of resident #18's admission MDS (Minimum Data Set, a federally mandated assessment instrument completed by facility staff), dated 5/5/26 showed:-The resident is cognitively intact;-Medical diagnoses including congestive heart failure (a chronic condition in which the ventricles of the heart are unable to pump blood effectively to the body), hypertension (high blood pressure), Urinary Tract Infection (UTI, an infection in the urine causing damage to the kidneys and altered mental status), and Type I Diabetes. Review of the resident's physician orders, active through the survey, dated May 2026, showed an active order for Losartan Potassium Oral Tablet 25 milligrams (mg) (a prescription oral medication used primarily to treat high blood pressure, reduce stroke risk in patients with heart enlargement, and manage kidney disease in type 2 diabetics), with instructions to give one tablet by mouth one time a day related to hypertension. Observation on 5/5/26 at 8:35 A.M., during the morning medication pass, showed CMT (Certified Medication Technician) G entered the resident's room to provide morning medications, including losartan. The medication cup was handed to the resident, who took the medications with water and without issue. CMT G then applied an automatic blood pressure cuff to the resident's left arm to obtain the resident's blood pressure. 2. Review of resident #10's quarterly MDS, dated [DATE] showed:-The resident is cognitively intact;-Med Diagnoses including stroke, hypertension, hemiplegia (loss of motor function and feeling in half of the extremities), malnutrition (a chronic lack of nutritional intake leading to weight loss, weakness, and fatigue), and Chronic Obstructive Pulmonary Disease (COPD, a chronic narrowing of the airways leading to shortness of breath, fatigue, and low blood oxygen levels). Review of Resident #10's active physician orders, dated May 2026, showed an active order for gabapentin 100mg (a prescription medication used to control partial seizures in epilepsy, treat nerve pain, and manage restless legs syndrome) capsules with orders for one tablet to be given three times daily with meals. Observation on 5/5/26 at 8:41 A.M., during the morning med pass, showed CMT G entered the resident's room to provide morning medications, including gabapentin. While taking the administered oral medications the resident dropped the gabapentin capsule on the floor. CMT G retrieved the capsule from the floor and wasted the medication as it was no longer clean per infection control policy. After returning to the cart, CMT G said the medication was not available, as the capsule provided to the resident was the last capsule in the medication card. No additional medication card for gabapentin was found, and none had been indicated as reordered in the system. During the observation, CMT G said the facility CMTs were expected to order a refill of a resident's medication when three days were left on the medication card to avoid missed doses. 3. During an interview on 5/7/26 at 8:31 A.M. RN (Registered Nurse) D said vital signs should be taken prior to the administration of medications that would reduce blood pressure or alter insulin levels. Staff was expected to refill a medication three to four days prior to giving the last dose from a medication card to avoid missed doses due to accident. 4. During an interview on 5/7/26 at 1:37 P.M. the facility Administrator and Director of Nursing (DON) said CMTs were expected to refill a resident's medication three to four days prior to giving the last dose from a medication card to avoid residents missing a dose of a medication due to unforeseen circumstances like dropping a medication on the floor. When administering antihypertensive medications staff should have taken a resident's blood pressure prior to administering the medication to avoid unexpected hypotension.

Based on observation, interview, and record review, the facility failed to properly store medications and biologicals in facility medication rooms. Concerns were noted when 17 bags of intravenous antibiotics were noted in one of two facility medication rooms. The sample size was 16. The census was 53.Review of the facility's Storage of Medications policy, revised 9/2018, showed:-Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access;-Except for those requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated area;-Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. 1. Observation on 5/7/26 at 7:58 A.M. of the third-floor medication storage room, behind the nurse's station, showed:-Six bags of 100 milliliters (mL) normal saline solution for dilution of 2gm (grams) of intravenous cefepime (a broad-spectrum cephalosporin antibiotic used to treat moderate to severe bacterial infections) prescribed for a resident, expired as of 2/7/26;-Six bags of 100mL normal saline solution for dilution of 2gm of intravenous cefepime prescribed for a resident, expired as of 2/24/26;-Five bags of 200 mL normal saline solution for dilution of 100mg of intravenous vancomycin (powerful glycopeptide antibiotic used to treat severe, resistant gram-positive bacterial infections) prescribed for a resident, expired as of 3/1/26. 2. During an interview on 5/7/26 at 8:27 A.M., CMT (Certified Medication Technician) E said no facility staff member was primarily responsible for ensuring medications were removed or wasted when expired, but each CMT or nurse was expected to remove or waste medications if they were noted as expired. Facility staff was expected to remove or waste medications per policy, and the facility pharmacy partner came a couples times per week to remove or waste medications as necessary. During an interview on 5/7/26 at 8:31 A.M., RN (Registered Nurse) D said no member of the nursing staff routinely went through the third-floor medication room, and most of the facility's stock medications were kept in the second-floor central supply room. Facility administration would expect staff to remove or waste medications if noted during medication administration or seen while in a medication storage room. No one member of the nursing staff was responsible for ensuring medications were wasted per facility policy. The facility had a pharmacy partner that came on a weekly basis to remove and/or waste expired medications. 3. During an interview on 5/8/26 at 1:37 P.M., the facility Administrator and Director of Nursing (DON) said they would have expected staff to waste or remove expired medications. The resident with the expired medication had changes to his/her medication treatment for an infection, including the completion of rounds of antibiotic therapy. Staff was expected to remove or waste expired medications, and the facility pharmacy partner came twice daily to provide medication wasting and removal services.

Based on interview and record review, the facility failed to follow appropriate discharge procedures for one resident when staff failed to re-admit the resident after returning from the hospital following an immediate discharge (Resident #50). The sample size was 16. The census was 53.Review of the facility's transfer and discharge policy, revised June 2020, showed:-The Facility may transfer or discharge a resident for the following reasons:--The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;--The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;--The safety of individuals in the Facility is endangered by the resident's presence;--The health of individuals in the Facility would otherwise be endangered by the resident's presence;--The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomeseligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid;--The facility ceases to operate;-The facility may not transfer or discharge a resident while the appeal to the notice oftransfer/discharge is pending, unless it is documented that failure to transfer or discharge the resident would endanger the health or safety of the resident or other individuals;-Facility staff will provide the resident with reasonable advance notice of the transfer or discharge before it occurs. Unless exigent circumstances exist, the notice should be provided 30 days prior to the proposed date of transfer/discharge. Situations that may prevent 30 days' notice include:--The resident poses a threat to the health or safety of other individuals at the facility;--The resident's health improves sufficiently to allow for more immediate transfer/discharge;--The resident is experiencing urgent medical needs;--The resident has not resided in the Facility for 30 days;-Cases in which 30 days' notice is not possible, notice of transfer or discharge should be provided to the resident of his/her responsible party as soon as practicable;-Documentation of written or telephone acknowledgement of the resident's transfer by theresident's personal representative may occur after the transfer in an emergency situation;-Documentation relating to resident's transfer/discharge will be maintained in the resident's medical record;-The Facility may use Notice of Transfer/Discharge or another comparable form to provide the resident of his/her personal representative with advance notice of the transfer or discharge. The notice will include the following information: The reason the resident is being transferred/discharged ;-The effective date of the transfer/discharge;-The name, complete address and telephone number to which the resident is beingtransferred;-A statement that the resident has the right to appeal the action to the state, contactinformation for the state entity which receives appeal hearing requests, and information for how to request an appeal;-The name, address, and telephone number of the State Long Term Care Ombudsman;-For residents with intellectual or developmental disabilities, the mailing address andtelephone number of the agency responsible for the protection and advocacy ofdevelopmentally disabled individuals;-For residents with a mental disorder, the mailing address and telephone number of the agency responsible for the protection and advocacy for individuals with mental disorders. Review of the facility's Resident drug and alcohol abuse policy, revised August 2020, showed:-The Facility will admit a resident who has a history of drug and alcohol abuse as long as their primary diagnosis is suitable for skilled care at this Facility;-The Facility has a zero-tolerance policy for the use or possession of illegal drugs (includingmarijuana) or any type of drug apparatus in the Facility or on the grounds of the Facility. All illegal drugs and/or drug paraphernalia will be confiscated from the resident and /or their room;-For the purpose of this policy alcohol is not considered to be an illegal drug;-The only drugs permissible at the Facility and/or on Facility grounds are those for which there is an Attending Physician order. Any alcohol served on Facility grounds will only be provided with Administration's approval and in accordance with an approved activity plan with the resident;-The facility has zero-tolerance policy for abuse of alcohol in the facility or grounds of the facility;-Any resident found in violation of this policy will be discharged to a more appropriate setting for care;-Violations: Any drugs, drug paraphernalia, or alcohol will be destroyed or handed over to the authorities as required;-If a resident violates this policy, the resident will also be subject to drug screening to test for the presence of any illegal substances in their body;-If the drug screening is positive, the resident will be discharged according to Facility discharge procedures;-If the resident refuses the drug screening, they could be discharged according to the Facility discharge procedures. Review of Resident #50's quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), dated 2/21/26, showed:-Diagnoses included anemia, neurogenic bladder, wound infection, malnutrition and asthma;-Cognitively intact;-Uses wheelchair. Review of the resident's care plan, in use during survey, showed:-Focus: Resident has tested positive for illicit substances Phencyclidine (PCP or angel dust, hallucinogenic drug) while in the facility;-Interventions: Complete a room search for unauthorized or illicit items per facility policy and as indicated;-Encourage resident to participate in counseling or support groups related to substance use;-Resident and belongings will be searched upon returning from leave of absence (LOA) related to history of and current use of PCP use;-Monitor him/her for signs and symptoms of substance use or intoxication;-Perform random urine drug screen as ordered or per facility protocol;-Provide education to him/her regarding the health risks associated with illicit substance use and the potential for discharge if facility policies are not followed;-Focus: Resident has an extensive history of substance use leading to altered mental status, impaired judgement, and safety risks following LOA. Resident will refuse to be sent out to emergency room (ER) and have urine drug screen (UDS) done;-On 3/17/26, ER visit for altered mental status (AMS). UDS positive for PCP;-On 4/3/26, ER visit for AMS. Refused to have UDS done;-On 4/11/26, admitted for AMS. UDS positive for marijuana and PCP. Review of the resident's progress notes, showed:-On 4/14/26 at 1:59 P.M., Administrator, Director of Nursing (DON), and Social Services (SS) had a private discussion with this resident regarding his drug abuse problem. Resident stated he/she was sent out to the hospital most recently for being unresponsive because of the heat. Resident denies taking illicit drugs and stated that no one in the facility is supplying him with illicit drugs. Resident stated that the nurse from the hospital is lying and that he/she did not say that. Resident was informed about having an emergency discharge if he/she is to go out LOA again and return altered and/or suspected to be under the influence of illicit drugs. Resident eventually agreed that he/she has a drug problem and that he/she needs help. Resident is agreeable to receiving help from an alternative detox facility. When asked how PCP is getting in his/her system, resident states that he/she does not know how and suggested that maybe it is because of the cigarettes he/she smokes. Resident denies his/her sibling supplying him/her with PCP and denies mother supplying him/her with PCP. Resident was given opportunity to ask questions or voice concerns to us about his/her plan of care. Resident did not have any further questions and is agreeable to everything stated as far as care planning;-On 4/14/26 4:09 P.M., this resident returned from hospital by emergency medical service (EMS) transferred into bed by EMS staff. Resident able to make all needs known call placed to physician to make aware of resident's return, voicemail box is full at this time. Resident alert and oriented times three, call light in reach. No signs and symptoms of pain or discomfort. Orders being placed in electronic medical record by Assistant Director of Nursing (ADON);-On 4/15/26 at 3:51 P.M., the DON and I went into resident's room and re-educated him/her on the drug and alcohol policy here at the facility. In the acknowledgement form, it states that anymore drug use will result in an immediate discharge with no 30-day notice given. Resident agreed and DON signed the document for him/her. Review of the resident's drug and alcohol abuse policy acknowledgement form, dated 4/15/26, showed:-Statement of Acknowledgement: I acknowledge that I have received and understand the facility Drug and Alcohol Abuse policy, and I agree to abide by the terms of the policy throughout my stay at the facility. You are also agreeing to the understanding that anymore drug use will result in an immediate discharge from facility and you will be not be given a 30-day notice;-Resident's signature line was blank, but dated 4/15/26;-Handwritten note, resident is unable to sign, but agrees to acknowledgement form;-Signed by DON as witness. Review of the resident's care plan, showed:Focus:-On 4/17/26, behavior discussed with resident and Durable Power of Attorney (DPOA) that if resident leaves this facility and returns under the influence again, or if he/she somehow obtains drugs while in this facility, he/she will be sent out to the hospital with an emergency discharge and will not be able to return;-Interventions: On 4/22/25, may not go on LOA with meds without proper authorization from POA;-On 4/22/26, POA also does not want friend at facility around resident and wants to be notified;-Assess resident immediately upon return from LOA;-Fall precautions will be initiated if altered;-Resident and belongings will be searched for any substance that may have been brought into the facility;-Resident is to be send to the ER for any noted changes in consciousness after returning from LOA;-UDS test upon return back to the facility will be performed for every LOA. Review of the resident's notice of transfer or discharge notice, dated 4/22/26, showed:-You have the right to appeal this proposed transfer or discharge. If you believe you should not have to leave the facility, you may request a hearing with the Missouri Department of Health and Senior Services;-Deadline to appeal: You must submit your request within 30 days of receiving this notice;-If you submit a timely appeal, you will not be transferred or discharged until a hearing is held and a decision is made, unless an emergency transfer is authorized under applicable law;-Reason for transfer or discharge: On 1/15/26, resident read and agreed to the drug and alcohol policy. A staff member signed as witness for him/her;-Resident continues to leave the facility and go into the community;-Resident has returned from the community intoxicated and needs EMS called;-On 3/17/26, resident tested positive for PCP;-Resident received Narcan (lifesaving medication that reverses opioid overdoses) on 4/6/26 after returning to the facility from out in the community;-On 4/10/26, resident left to go to his/her mom's house. On 4/11/26, resident tested positive for PCP while at the hospital;-The resident is a danger to him/herself;-The resident presents a danger to others with drug use at the facility;-Resident's safety cannot be met when he/she leaves the facility and goes into the community;-Based on the details listed above, an immediate and emergent discharge is necessary. Review of the resident's progress notes, showed:-On 4/25/26 at 2:40 P.M., resident requesting to go out of the facility for a couple of hours to get some air. Resident's DPOA contacted. He/She spoke with resident and this nurse and gave permission for resident to leave the facility. DPOA requested facility contact him/her when resident returns;-On 4/25/26 at 7:30 P.M., resident has not returned back to facility. Called placed to DPOA to inform him/her. DPOA thanked this nurse for updating him/her and stated he/she is going to go out and look for the resident. Director of Nursing (DON) updated and informed this nurse if resident does not return to the facility or DPOA has not located him/her by 10:00 P.M., to contact 911. Night nurse here and updated on the above;-On 4/26/26 at 7:00 A.M., upon wound change of resident, resident eyes where noted to be dilated +6 (healthy adult pupils range from 4 to 8mm (millimeter), if pupils remain dilated 6mm+ in bright light or do not respond to light, it may indicate medication side effect, trauma, or neurological issues), resident was originally searched when coming back to the facility due to previous episodes of being positive for illegal substances. Resident belongings were once again searched due to change in condition where it was discovered that resident has in his/her bag in the bottom of the inner lining were four cigars dipped in a wet unknown substance (Fry or PCP, cigarette or cigar dipped in embalming fluid which contains formaldehyde, methanol, and ethanol) with a pungent smell. Vital signs were taken resident blood pressure: 113/66 (normal range 120/80), pulse 88 (normal range 60 to 100), oxygen 98% room air (normal 95 to 100%), temp 98.7 Fahrenheit (F) (97 degrees F to 99 degrees F), resident remained alert and oriented times four, wound change on resident was completed. Resident's Power of Attorney (POA) was contacted. OK to send him/her out for further evaluation. Resident's physician was made aware. Administrator was made aware. Emergency medical services (EMS) and police was contacted and resident was taken to hospital for further evaluation. Police report was given for the illegal substance with the police department. Given previous acts of using substance, immediate discharge paper work was given to resident;-On 4/26/26 at 10:27 A.M., the social worker from hospital reached out to inform me that this resident will be returning to the facility despite being issued immediate discharge that they never received. It was documented that this resident received immediate discharge paperwork upon departure. This social worker claims that resident has the right to appeal for a 30-day discharge appeal, however he/she was informed that this resident signed immediate discharge paperwork stating if this resident was to leave the facility and return with altered mental status (AMS), he/she will be served an immediate discharge effective immediately and cannot return to this facility. This writer is a witness to this consent issued by this resident as well as the administrator. Another copy of the immediate discharge paperwork has been faxed to the number the social worker has provided me. Social worker stated he/she is still going to try to appeal and send the resident back to the facility anyway, and that he/she doesn't know why the Ombudsman we consulted would tell us this was okay because what we are doing is illegal. Nurse on duty notified that this resident is not to be accepted back to the facility. Administrator notified;-On 4/26/26 at 2:48 P.M., Received update from social worker from hospital and confirmed that they have received the immediate discharge paperwork;-On 4/27/26 at 8:31 A.M., Social Services Designee (SSD) & the Administrator met with DPOA this morning regarding the incident that occurred over the weekend with this resident. Resident remains at hospital at this time. Resident was issued an Emergency Discharge related to violating the Behavioral Contract issued, waiving the right to appeal. (See Administrator's Progress Note of 4/15). The Administrator did advise DPOA that he/she is not willing to except resident back and that he/she has been working with Department of Health and Senior Services (DHSS) and the Ombudsman for guidance to manage this situation resident's behavior continued without regard. DPOA voiced an understanding of this entire situation, stating; I just want to choke him/her. This is the same stuff that caused him/her to be in this wheelchair. DPOA left with the understanding that facility not be accepting resident back and that the hospital social worker is responsible for finding an accepting facility. During an interview on 5/6/26 at 5:34 P.M., Certified Nurse Aide (CNA) C said he/she was familiar with the resident. He/She had a drug problem. He/She went outside the facility and would get high. He/She returned and would run into things with his/her wheelchair. He/She would ride the elevator, attempting to get off the elevator, but would just ride up and down. CNA knew the resident at a prior facility. The resident did the same thing and got kicked out. During an interview on 5/6/26 at 4:54 P.M., the Social Worker (SW) said the resident signed him/herself out and returned high. He/She was sent to the hospital and tested positive for PCP. It happened more than once. His/Her sibling became the resident's DPOA. The resident was not allowed to leave without the DPOA, and the resident's friend was not allowed in the facility because that friend got the resident high. When he/she returned with PCP in his/her system, he/she fell out of the chair, his/her eyes were wide opened, and he/she could not respond to anything. His/Her friend was the one that brought the resident back to the facility by using the resident's joystick on the wheelchair. There were room searches as well. They once found cigars dipped in a substance, which was PCP. The SW tried to find a rehab facility, but the resident required too much care. At one point the resident told the SW that he/she did not know how he/she tested positive for PCP. Toward the end, he/she owned up to drug use. During an interview on 5/7/26 at 8:17 A.M., the Administrator said back in January, the resident went to the hospital for altered mental status and a drug test showed he/she had PCP in his/her system. He/She signed him/herself out and came back under the influence. A week later, there was a facility wide search with police for drugs, and they also went around with a drug and alcohol acknowledgement that was signed by the resident. They sent a referral that month, but no facility would accept him/her. In March 2026, he/she had another AMS and PCP was in his/her system. Early April, it was the same situation. He/She had another AMS and returned to the facility. The Administrator contacted the Ombudsman and DHSS, and they believed there was enough to issue an emergency discharge. The Administrator did not issue the notice on that day, but he contacted the physician and discussed emergency discharge in the future. The resident came back around April 11th after being discharged from the hospital. The Administrator, DON, and SW, who was on the phone, spoke to the resident. The resident was informed if he/she went out again and came back under the influence, he/she would receive an emergency discharge. The Administrator re-educated him/her on the drug and alcohol policy. If he/she violated that, he would then forego the appeals process. That was just for this resident. They asked if he/she wanted help and he/she agreed to get help, but no one would accept him/her because of his/her condition. He/She required more care than what they would have provided. On April 25th or 26th, the resident wanted some fresh air, and his/her DPOA said it was okay. The next morning, he/she had AMS. He/She obtained three cigarettes that were dipped in a wet liquid. The police was notified. The resident admitted that he/she dipped it and smoked it. The Administrator said he was out of town on the last day the resident was at the facility, but he made sure the final education and discharge notice was given to the resident. He was also in contact with facility, hospital, and attorney. The Administrator said he stood firm that the resident was a danger to himself. The Administrator said he had not received information regarding the appeal and/or if the hospital filed an appeal. The hospital said they did not have paperwork, so the administrator provided the paperwork to the hospital. The hospital said they would appeal the discharge, and the attorney advised to accept the resident back if he/she returned. During an interview on 5/7/26 at 1:30 P.M., the DON said she spoke to the hospital social worker regarding the emergency discharge. The resident was given the immediate discharge but may not have had it in the hospital. The DON was not aware of the resident's right to return and appeal the discharge until the hospital told her. Intake: 2994401

Based on observation, interview, and record review, the facility failed to ensure staff provided one (Resident #51) of 16 sampled residents with the appropriate bed rails to assist with repositioning. The census was 53.Review of the facility's Bed Rails policy, revised June 2020, showed:-The assessment of whether to use bed rails should include an evaluation of the alternatives to the use of bed rail that were attempted and how these alternatives failed to meet the resident's needs;-If bed rails are to be used, the assessment Bed Rail Utilization by a licensed nurse and or the IDT (Interdisciplinary team);-The licensed nurse and/or the IDT-restraint reduction committee may refer to the bed rail decision tree during the assessment;-Before installing a bed rail, the facility must: Assess the resident for risk of entrapment from bed rails and;--Ensure the bed's dimensions are appropriate for the resident's size and weight. The manufacturer's recommendations and specifications for installing and maintaining bed rails will be followed;-If a bed rail is used as an enabler, the resident/resident's representative informed consent will be obtained by a licensed nurse or physician;-The resident's plan of care will be updated to reflect the use of bed rails. Review of Resident #51's admission Minimum Dats Set (MDS, a federally mandated assessment instrument completed by staff), dated 3/20/26, showed:-Diagnoses included deep venous thrombosis (blood clots), heart failure, arthritis, malnutrition;-Cognitively intact;-Uses wheelchair;-Impairment to both sides of the upper and lower extremities;-Substantial/maximal assistance required to roll left and right;-Dependent sitting to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer;-Bed rail not used. Review of the resident's care plan, in use during survey, showed:-Focus: Resident needs assistance with Activities of Daily Living (ADLs) related to chronic pain, right above the knee amputation, osteoarthritis, chronic pulmonary edema and congestive heart failure;-Interventions: Bed Mobility: the resident requires (X) staff participation to reposition and turn in bed;-Interventions did not include the number of staff participation to reposition and turn in bed. Review of the resident's Bed Rail Utilization Assessment, dated 4/20/26, showed:-Recommendations: Bed rails are indicated and served as an enabler to promote bed mobility and independence;-Bilateral 1/4 rails. Observation and interview on 5/4/26 at 9:36 A.M., showed the resident in bed. He/She had an above the knee amputation to the right leg. He/She did not have a side rail on the bed. The resident said he/she wanted a side rail to assist with repositioning. During an interview on 5/6/26 at 11:34 A.M., the resident said he/she was supposed to have bed rails. Therapy put in a request and ordered the rail, but he/she did not have bed rails on the bed. During an interview on 5/7/26 at 12:31 P.M., the Maintenance Director said he was told residents in the facility did not use side rails. He had worked for the facility for two years and had not installed a side rail. He was told it was dangerous, and they did not want residents to have the side rails on the bed. He was not aware of side rails installed on any resident beds. During an interview on 5/7/26 at 11:12 A.M., the Director of Rehab said he/she was aware of the resident's assessment, and he/she was able to receive side rails. The assessment was completed by therapy. After the assessment, the side rail was ordered. He/She clarified and said the part needed to be ordered. He/She would have expected the resident to have side rails if the assessment was completed on 4/20/26, but it depended on the type of rail and the type of bed the resident had. During an interview on 5/7/26 at 1:30 P.M., the Administrator said residents were able to have side rails. Once a resident was assessed, they got an order from the physician, had the resident sign the assessment form, and the side rails were installed after. There was no physician order for the resident to have the side rail. Staff had to notify the physician. The Administrator had not been able to put an order in. He was not aware the side rail was ready to be installed. Therapy would give the okay and maintenance would install the bed rail. He would have expected the resident to have the side rails on the bed if the assessment was completed on 4/20/26.

Based on observation, interview, and record review, the facility failed to follow acceptable standards of practice for infection control when staff failed to use Enhanced Barrier Precautions (EBP, precautions for use during high-contact resident care activities to reduce transmission of multidrug-resistant organisms (MDROs, microorganisms that are resistant to one or more classes of antimicrobial agents) as recommended by the Centers for Disease Control and Prevention (CDC) and as required by the Centers for Medicare and Medicaid Services (CMS) when staff failed to wear a gown and glove while providing direct care to one resident (Resident #9) and by failing to ensure appropriate personal protective equipment (PPE) was easily accessible by the room of one resident (Resident #33) with physician orders for EBP. The sample was 16. The census was 58. Review of the facility's Standard and Enhanced Precautions policy, revised 4/1/24, showed:-EBP should be used for any residents who meet the following criteria, wherever they reside in the facility. The facility has discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with a MDRO that is not currently targeted by CDC;-For residents whom EBP are indicated, EBP should be used when performing the following high contact resident care activities: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care;-EBP are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at high risk. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/13/26, showed:-Cognitively impaired;-Diagnoses included presence of a gastrostomy tube (g-tube, a surgical line inserted into the stomach to provide nutrition and medication). Review of the resident's care plan, in use at the time of survey, showed:-Focus: EBP;-Goal: Reduce transmission of pathogens;-Interventions included instructions for direct care staff to utilize gowns and gloves when providing any direct care and to educate the resident of responsible party on the requirements of EBP. Review of the resident's electronic physician order sheet (ePOS), showed no active order for EBP related to the resident's g-tube. Observation on 5/5/26 at 12:51 P.M., showed staff assisted the resident with eating lunch. At the conclusion of the meal, the resident was wheeled back to his/her room in a Broda chair (reclining chair) by CNAs Certified Nurse Aide (CNA) H and CNA I. CNA H and CNA I assisted the resident from the Broda chair into bed and covered him/her with the bed sheets. Neither CNA donned PPE prior to providing direct care to the resident. Observation on 5/6/26 at 8:23 A.M., showed CNA H and CNA I assisted the resident with transferring from the Broda chair to the bed after the breakfast meal. Neither CNA donned PPE prior to providing direct care to the resident. 2. Review of Resident #33's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included depression, anxiety disorder, asthma, other orthopedic conditions, and peripheral vascular disease (PVD, poor circulation). Review of the resident's care plan, in use during survey, showed:-Focus: EBP related to having open active wounds, infectious disease;-Goal: Reduce transmission of pathogens;-Interventions: Staff members will wear clean gowns and gloves while performing high contact resident care activities to include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical. Staff to follow standard precautions. Review of the resident's ePOS, dated 3/5/26, showed:-An order, dated 1/23/26, for contact isolation precautions due to vancomycin (an antibiotic)-resistant enterocci (VRE, a bacteria resistant to vancomycin). Resident resides in a single occupancy room with all meals, medications, activities, activities of daily living (ADLs) and therapy provided in room. Residents have active infection with highly transmissible/epidemiological significant pathogens acquired by physical contact/airborne/droplet transmission. The resident must remain in a private room for duration of isolation every shift;-An order, dated 3/17/26, for EBP related to wounds: Staff members will wear a clean gown and gloves while performing high contact resident care activities to include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices every shift; -An order, dated 2/5/26, for left lateral (to the side), posterior (to the back) calf venous insufficiency ulcer (ulcer that develops when the veins fail to return blood back toward the heart normally: Cleanse wound with normal saline (NS), pat dry. Apply calcium alginate with silver (provides a moist environment for wound healing), superabsorbent dressing, and wrap with kerlix (gauze bandage) as needed if soiled, dislodged, or saturated;-An order, dated 3/12/26, right anterior (to the front) groin surgical dehiscence (surgical incision opens after surgery) wound: Dressing daily every 24 hours as needed for wound care;-An order, dated 3/12/26, right anterior groin surgical dehiscence wound: Dressing daily every night shift every Tuesday, Thursday, and Saturday for wound care; -An order, dated 4/17/26, right anterior groin surgical dehiscence wound: Cleanse with NS, pat dry, apply calcium alginate and cover with superabsorbent dressing every night shift for wound treatment. Observations of the resident and the resident's room on 5/4/26 at 8:56 A.M., 5/5/26 at 1:13 P.M., and 5/6/26 at 1:01 P.M., showed the resident in his/her room. An EBP sign on the door to the resident's room. No PPE near the door to the resident's room; the resident lay in his/her bed. 3. During an interview on 5/8/26 at 8:12 A.M., CNA F said residents with g-tubes, wounds, colostomies, COVID, or residents who are coming from the hospital are put on EBP. Staff should wear PPE when providing care such as feeding, perineal care, or getting residents up out of bed. When transferring a resident, staff are expected to wear a gown and gloves for personal protection, if the resident is on EBP. 4. During an interview on 5/8/26 at 8:18 A.M., Licensed Practical Nurse (LPN) A said any resident with a g-tube, open wounds, catheters, or tracheostomy should have active EBP orders adhered to by staff. Any resident care involving direct contact by staff requires staff to don PPE, including gown and gloves. 5. During an interview on 5/8/26 at 1:37 P.M., the Director of Nursing (DON) and Administrator said they expected staff to adhere to facility policy and EBP guidelines by using PPE as appropriate for a resident's diagnosis when providing care that includes direct contact with the resident. Staff should wear the PPE provided in the halls when providing direct care. Any resident with EBP orders should have PPE materials at or near the door to the room for staff to access when providing care. The DON would not expect staff to utilize PPE when transferring a resident from the wheelchair to the bed.

Based on observation, interview and record review, 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 53.Observation on 5/4/26, 5/5/26, 5/6/26, and 5/7/26, showed no posted information for the State Long-Term Care Ombudsman program or the State Survey Agency hotline number in the facility entrances, dining room, and halls of each unit. During a group interview on 5/6/26 at 11:30 A.M., nine out of nine residents said they did not know where the information regarding the State Long-Term Care Ombudsman program and/or the State Survey Agency hotline number was located. During an interview on 5/7/26 at 1:30 P.M., the Administrator said the contact information for the Ombudsman and State Survey Agency information was posted on a sheet of paper across from the elevator. There was a white 8 x11 inch sheet of paper posted observed when exiting the elevator. Observation and interview on 5/7/26 at 2:02 P.M., showed a white sheet of paper across from the first-floor elevator. There were several contact numbers listed on the paper. The Administrator said the Resident's Rights could have been removed from the area, but it was in the admission packet. He would have expected the information to have been posted.

Based on observation, interview, and record review, the facility failed to ensure one resident with a history of elopement was provided with adequate supervision and staff oversight (Resident #2). On 3/10/26 at approximately 11:20 A.M., staff observed through the window that the resident was outside, across the street from the facility. The resident had a wanderguard (device that sets off an alarm when the person wearing it attempts to exit the facility) on his/her wheelchair and was able exit the building unnoticed through one of two exit doors on the second floor, which were alarmed but did not have a wanderguard sensor. The facility identified 10 residents who were at risk for elopement. The sample was 4. The census was 58. Review of the facility's Wandering and Elopement Policy, dated 08/2020, showed the following:-Purpose: To enhance the safety of residents of the facility;-Policy: The facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement;-Procedure: --The licensed nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition to determine their risk of wandering/elopement;--The resident's risk for elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition;--Response to Resident Elopement:---The licensed nurse most familiar with the incident will document in the resident's medical record how the elopement occurred. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/23/25, showed the following:-Moderate cognitive impairment;-No wandering behavior exhibited;-Mobility with a wheelchair;-Diagnoses included dementia, depression, Wernicke's encephalopathy (acute neurological disorder causing brain injury), heart failure, high blood pressure, and diabetes. Review of the resident's care plan, dated 10/14/25, showed the following:-Focus: The resident is at risk for elopement related to elopement evaluation risk score;-Interventions/tasks included elopement attempts from previous facility or hospital. Wanderguard, check for placement every shift. Supervise closely and make regular compliance rounds. Review of the resident's Elopement Risk Evaluation, dated 10/14/25, showed the following:-Imminent Risk;--Physical: Patient ambulates and propels self, and/or wanders. Patient has intentionally or unintentionally attempted to leave community: Yes;-Action: Implement elopement risk care plan. Interventions: Wanderguard and/or secure environment placement;-Comments: Resident elopement occurred, the resident returned to facility, staff on one to one (1:1) observation with the resident presently, wanderguard placed, notifications to the resident's responsible party and physician. Review of the resident's nurse's note, dated 3/10/26 at 5:04 P.M., showed staff documented the resident eloped outside of facility. The resident was escorted back into facility. A head to toe assessment was completed. The resident had zero bruising and no other changes noted. The resident's emergency contact and physician were made aware and the resident's vital signs were stable. The nurse's note did not specify how the resident eloped from the facility. Review of the second floor staffing sheets, dated 3/10/26, showed one nurse and one Certified Medication Technician (CMT) scheduled for day shift. No other staff scheduled for the second floor on day shift. Observation on 3/19/26 at 1:40 P.M., showed the resident seated in his/her wheelchair with a wanderguard device in the pocket of his/her wheelchair. During an interview, the residentsaid he/she did not remember getting out of the facility. He/She would like to go outside at times. During an interview on 3/20/26 at 10:29 A.M., CNA E said he/she was assigned to the resident on 3/10/26. The last he/she saw the resident was in his/her room at approximately 7:30 A.M. to 8:00 A.M. and he/she was asleep. CNA E thought the resident had eloped before but did not know the date. During an interview on 3/19/26 at 9:42 A.M., Licensed Practical Nurse (LPN) D said on 3/10/26, he/she was the nurse scheduled on the second floor. He/She received a text from the facility that the resident had gotten out. He/She saw the resident being escorted back inside the facility by staff. He/She never heard any alarm sound when the resident left the floor. During an interview on 3/19/26 at 12:35 P.M., the Director of Rehabilitation (DOR) said on 3/10/26, she was in the therapy room second floor working with a resident. She looked out the window and saw Resident #2 across the street, standing with his/her wheelchair. The DOR was the only one working in the therapy room on 3/10/26 and the door was closed and the music was loud. She did not hear any alarms sounding at the facility. If she or any of her staff would have heard any alarms, she would expect them to go and investigate. Observations of the second floor on 3/19/26, showed the following:-At 12:40 P.M., no staff visible on the second floor. During a test for staff responsiveness, conducted with the facility's Administrator, the exit door near room [ROOM NUMBER] was opened and an alarm sounded for approximately three seconds, then stopped, while the door remained open. No staff responded to the alarm. During an interview, the Administrator said from the exit door to where the resident was found outside, it appeared to be a distance of approximately 700 yards;-At 12:50 P.M., Housekeeper A was by the second floor dining room. During an interview, he/she said he/she had been on the second floor for about 10 minutes. He/She did not hear an alarm sound;-At 12:52 P.M., a test for staff responsiveness was conducted with the facility's Administrator at the exit door in the second floor dining room. The exit door was opened and an alarm sounded for approximately 30 seconds. No staff responded to the alarm;-At 12:55 P.M, Physical Therapist (PT) B and PT C were in the therapy room inside the second floor dining room. During an interview, PT B and PT C said they heard an alarm sound a couple minutes ago but they did not go and investigate the alarm. PT B said he/she did not know there was an exit door in the second floor dining room. PT B and PT C said they should have investigated the alarm. During an interview on 3/20/26 at 9:24 A.M, the Maintenance Director said the front door is the only door with a wanderguard sensor. All exit door alarms should sound for 20 to 30 seconds. He was not aware the exit door alarm near room [ROOM NUMBER] was not working properly by sounding for only a few seconds. During an interview on 3/20/26 at 1:02 P.M., the DON said the resident is an imminent risk for elopement, meaning he/she is at high-risk for elopement. The DON did not know how the resident got outside of the building. She expected the elopement policy to be followed as written. During an interview on 3/20/26 at 1:04 P.M., the Administrator there should be at least one staff member on the second floor at all times. The resident got out of the facility through one of the second floor exits. The Administrator did not know how long the second floor exit door near room [ROOM NUMBER] was malfunctioning. He expected staff to respond to any door alarms immediately and for staff to be on the floor as scheduled. He did not know why this did not happen on the day of the resident's elopement. 2801617

Based on interview and record review, the facility failed to notify one resident's legal guardian of a change of condition and transfer to a hospital (Resident #3). The sample size was 4. The census was 45.Review of the facility's Change of Condition Policy, dated 1/2025, showed the following:-Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner;-Policy:- Definition: An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death;-I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent an ACOC;-II. The facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to:--A. An injury/accident;--B. A significant change in the resident's physical, cognitive, behavioral or functional status;--C. A significant change in treatment; and/or a decision to transfer or discharge the resident from the facility;-Procedure:-Family Notification: The Licensed Nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes in the resident's condition as soon as possible. Review of Resident #3's medical record, showed diagnoses included schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) and major depression. Review of the resident's care plan, dated 11/2/25, showed the resident has a Public Administrator appointed as his/her legal guardian, who manages the resident's medical and financial needs. Review of the resident's medical record, showed documentation of the Public Administrator Guardianship, dated 8/20/25. Review of the resident's nurse's note, dated 12/24/25 at 6:34 A.M., showed the resident remains in the hospital. Review of the Complaint/Investigation Report, dated 12/26/25 showed, the reporter was contacted on 12/25/25 by the hospital psychiatrist asking mental health questions about the resident. The resident had been at the hospital since 12/23/25 and no one from the hospital or facility called to notify the resident's guardian that the resident had been sent out to the emergency room and admitted until two days later. Review of the resident's nurse's note, dated 12/27/25 at 6:16 P.M., showed the resident returned from hospital via ambulance. Further review of the resident's medical record, showed no documentation of the resident's change of condition or the resident's guardian being notified of the resident's change in condition. During an interview on 12/29/25 at 12:25 P.M. Licensed Practical Nurse (LPN) A said the Administrator, the Social Service Director and other management were present while the resident was having behaviors. LPN A was instructed to send the resident to the hospital. LPN A was working with an orientee at the time and assumed the orientee called the resident's physician and guardian and documented the incident. During an interview on 12/29/25 at 12:35 P.M., the resident said he/she went the hospital but was not sure when. He/She has a guardian but was not sure of his/her name. He/She did not know if the facility should contact his/her guardian regarding his/her care. During an interview on 12/30/25 at 9:50 A.M., LPN B said LPN A should have called the resident's physician and guardian about the resident going to the hospital. He/She was not sure if the guardian was notified. There was a lot going on at that time. On the day the resident went out to the hospital, LPN B was an orientee and it was his/her first day. Standard protocol for any facility is to call the resident's physician and get an order to send the resident to the hospital and to contact the guardian to make them aware. During an interview on 12/29/25 at 2:25 P.M. with the Director of Nursing (DON) and Administrator, the DON said LPN A should have called the resident's guardian and documented the call and the change of condition in the resident's medical record. LPN A did not do a proper follow-up. The DON did not know why this was not completed. The Administrator agreed with the DON. 2701154

Based on interview and record review, the facility failed to provide care and services to ensure one resident (Resident #1) was free from accident hazards when a Certified Nurse Aide (CNA) failed to secure the resident in bed before leaving to answer the call of another resident in a different room. The resident rolled of the bed and hit his/her head on the floor. The resident suffered two lacerations to the top of his/her head. The sample was four. The census was 44. The Administrator was notified on 1/31/25 at 2:53 P.M., of the past non-compliance, which occurred on 1/16/25. The facility provided training and in-servicing for all staff regarding the facility's resident safety policy. The facility also updated the resident's care plan to ensure the resident's bed is in the lowest position with a mat next to the resident's bed. The deficiency was corrected on 1/20/25. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/21/24, showed the following: -Severe cognitive impairment; -Dependent with activities of daily living; -Diagnoses of Alzheimer's Disease, depression and high blood pressure; -History of one fall without injury. Review of the resident's care plan, dated 1/20/24, showed the following: -Problem: The resident is at risk for injury regards to fall, unsteady gait/balance, wheelchair bound and poor safety awareness; -Intervention: Keep bed in lowest position with brakes locked. Review of the resident's nurse's note, dated 1/16/25 at 4:57 P.M., showed the nurse was at the desk when the CNA yelled out and said that the resident had fallen out of the bed. The CNA had heard another resident yelling and he/she went to see about this resident and when he/she came back, the resident had fallen. Pressure was applied to the wound and 911 was called. Review of the resident's hospital aftercare medical record, dated 1/16/25, showed the resident has a history of Alzheimer's disease, nonverbal at baseline, congestive heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should), high blood pressure and severe malnutrition, who is coming in from his/her nursing home for a fall out of bed. The resident is unable to participate in gathering history however information from Emergency Medical Services (EMS) said he/she was found out of bed at his/her nursing home with a laceration to his/her head. Observation on 1/27/25 at 10:07 A.M., showed the resident lay in a low bed with a mat on the floor. The resident had six sutures on the top of his/her head which measured approximately 4 centimeters (cm) by 3 cm. During an interview on 1/27/25 at 9:45 A.M., CNA A said he/she started his/her rounds. He/She went into the resident's room to give care. CNA A said just as he/she raised the resident's bed to give care, he/she heard another resident screaming out his/her name for help. CNA A went to check on the other resident because he/she did not know if something happened. CNA A found the other resident sitting on the side of his/her bed. CNA A told this other resident he/she would be right back. When CNA A got back to the resident, he/she was on the floor. CNA A said he/she immediately got the charge nurse. CNA A did not secure the resident before leaving and the resident rolled off the bed. CNA A said he/she should have secured the resident before leaving. CNA A said he/she was recently inserviced on the importance of securing a resident before leaving the resident. During an interview on 2/6/25 at 12:36 P.M., Licensed Practical Nurse (LPN) B said CNA A yelled for him/her to come to the resident's room. The resident had fallen out of bed. When LPN B got to the resident's room, the resident was on the floor bleeding from his/her head. LPN B used a towel stop the bleeding. After he/she got the bleeding under control and the DON arrived, he/she called 911. The resident should have been in a low bed with a mat to the floor. LPN B said when he/she entered the room, the bed was not in a low position and a mat was not on the floor. CNA A should have secured the resident before leaving the resident. During an interview on 1/27/25 at 10:25 A.M., the Director of Nurses and Administrator said CNA A should have secured the resident before leaving the resident. The Administrator said all staff have been inserviced and tested with return demonstration on the importance of securing a resident before leaving the resident. MO00248146 MO00248335

Based on interviews, and document review, the facility failed to ensure that a facility with more than 120 beds employed a full time qualified social worker which included a bachelor's degree in social work or a bachelor's degree in a human services field and one year of supervised social work experience. This failure has the potential to cause residents to not receive the necessary services to maintain as normal a possible lifestyle. Findings include: Review of the facility's undated job description titled, Social Worker Job Description, revealed The Social worker and/or social worker designee in a nursing home setting plays a crucial role in providing comprehensive social services to residents, their families, and caregivers. They assess residents' psychosocial needs, develop care plans, and coordinate services to enhance residents' quality of life and ensure their well-being. During an interview on 07/10/24 at 1:15 PM with the Administrator and Director of Nursing (DON), the Administrator revealed the facility was currently working with the local office to decrease the number of beds to 118 and they were currently licensed for 130 beds. The Administrator stated they currently did not have a full-time license social worker. She stated the current Social Service Director (SSD) had a certification as a social service designee in long-term care facilities. During an interview on 07/12/24 at 1:13 PM, the Social Service Director (SSD) revealed not being a licensed social worker but was functioning in the full-time position as the social worker. The SSD stated she had a certification for a social service designee in long-term care facilities. The SSD stated she did not have a degree. Review of the certification for Social Service Director (SSD), revealed a Certificate of Attendance, dated December 2017 for the satisfactory completion of the 36-hour basic online course for Social Service Designee in long-term care facilities. The program was recognized by the Missouri Department of Health and Senior Services.

Based on observations, interviews, document review, and facility policy review, the facility failed to ensure cleanliness and ensure food stored in one of one kitchen and in the unit nourishment room, was labeled, dated, and not expired. The failure had the potential to increase the prevalence and spread of foodborne illness and infection for 49 census residents. Findings include: Review of the facility's undated job description titled, Dietary Manager indicated it was the responsibility of DM to ensure compliance with regulatory standards during food preparation, storage, and service. Review of the facility's undated policy titled, Sanitation, indicated that the can opener should be cleaned after each use and unbolted from the table monthly to thoroughly clean the table where the base rests. Further review revealed that the ceilings need to be in good repair. 1. During an observation on [DATE] at 8:55 AM the following items were observed in dry storage and verified by [NAME] (C) 1 during the initial kitchen tour: -Eight re-packaged bags of cereal with no label or date. -Fourteen bowls of cereal with no label or date. -Fifteen loaves of bread with no date. -Eight packages of hamburger buns with no date. During an observation on [DATE] at 8:55 AM the following was observed in cold storage and verified by C1 during the initial kitchen tour: -An observation of the walk-in freezer's temperature log revealed missing temperatures from [DATE] to [DATE]. -There was water leaking from the walk-in refrigerator. Observation of the interior of the walk-in refrigerator revealed towels on the floor of the walk-in soaked in water. -Additional observations revealed bottled maraschino cherries with a date of ,d+[DATE] (no year documented), sweet relish with a date of ,d+[DATE] (no year documented) and 33 thawed Ready Shakes with manufacturers instructions to use within 14 days of thawing. There were no dates as to when the shakes expired. During an observation on [DATE] at 8:55 AM the following was observed in preparation areas and verified by C1 during the initial kitchen tour: -There was a one-gallon bottle of pan cleaner and a spray bottle of Spic and Span stored on the shelf with cooking utensils. -Cook1 tested the sanitizer bucket on the cook's table. The test strip indicated there was no sanitizer in the bucket. During an interview on [DATE] at 8:55 AM, C1 stated he used sanitizer from the pot sink in the bucket and did not know why it wasn't registering on the test strip. 2. During a second observation of the kitchen with the Dietary Manager (DM) present on [DATE] at 11:54 AM, there was water leaking from the walk-in refrigerator. Observation of the cook's preparation area revealed the tabletop can opener was dirty with black substance encrusted around the edge and base seams of the opener. Additionally, there were 12 water-stained ceiling tiles and three missing ceiling tiles above the preparation area exposing the pipes and venting. During an interview on [DATE] at 1:23 PM, the Administrator stated that a work order had been placed for the walk-in refrigerator in the kitchen and they did not know what was causing the leak. During an interview on [DATE] at 3:01 PM, the DM stated that items needed to be labeled and dated before placing them in storage and staff had been trained. During an observation on [DATE] at 12:48 PM, the third-floor nourishment refrigerator revealed no thermometer and no temperatures documented. There were three ham and cheese sandwiches stored on top of the refrigerator with no date and no cooling mechanism. An observation of the interior of the refrigerator revealed sticky shelves and melted popsicles stuck to the ice in the freezer box. During an interview on [DATE] at 12:38 PM, the Registered Dietitian (RD) stated that she was not aware there was not a thermometer in the nourishment refrigerator and agreed the temperature should have been monitored and the sandwiches refrigerated.

Based on interviews and facility policy review, the facility failed to ensure infection control measures were appropriately implemented and maintained for Legionellosis assessment and prevention in the facility. This failure has the potential to affect 49 of 49 census residents. Finding Include: Review of website for ASHRAE [he American Society of Heating, Refrigerating and Air-Conditioning Engineers] titled Risk Management for Legionellosis, dated 10/15, located https://www.ashrae.org/, indicated .The design engineer first needs to evaluate which requirements of the standard apply to their project. This evaluation determines if the project contains any of the following building risk factors .Health-care facility with patient stays over 24 hours .Facilities designated for housing occupants over age 65 .The risk of disease or illness from exposure to Legionella bacteria is not as simple as the bacteria being present in a water system. Other factors that contribute to the risk are environmental conditions that promote the growth and amplification of the bacteria in the system, a means of transmitting this bacteria (via water aerosols generated by the system), and the ultimate exposure of susceptible persons to the colonized water that is inhaled or aspirated by the host providing a pathway to the lungs. The bacteria are not transmitted person-to-person, or from normal ingestion of water. Susceptible persons at high risk for legionellosis include, among others, the elderly, dialysis patients, persons who smoke, and persons with medical conditions that weaken the immune system . Review of facility's undated policy titled, Nursing Home Legionella Water Policy, revealed the objective of the policy is to minimize the risk of Legionella contaminations in our water system and to protect the health of our residents, staff, and visitors. The policy statement includes, Conduct a comprehensive risk assessment of all water systems within the facility at least annually to identify potential sources of Legionella growth and spread. The assessment will be carried out by qualified personnel or a third-party expert. During an interview on 07/11/24 at 5:44 PM, the Administrator stated, The facility does not have a water legionella system, there was no diagram that provided information of the flow of the water, a comprehensive assessment had not been completed, nor has the water been tested . The administrator stated understanding the Water Legionella requirements for long term care, but the facility had not been following the requirements. During an interview on 07/12/24 at 3:41 PM the Maintenance Director (MD) revealed not being aware of the water legionella program and requirements. When asked about the comprehensive risk assessment of the water systems in the facility, the MD indicated that he did not know what that meant.

Based on observation, interview, record review, and facility policy review, the facility failed to promote a dignified dining experience by serving beverages in disposable cups, and food on disposable plates at meals for one Resident (R) 24 and one of two dining rooms of 23 sample residents. This failure had the potential to affect all residents who were served meals prepared in the facility's one of one kitchen. Findings include: Review of the facility's policy titled, Dinnerware and Dining Services, revised 01/24, indicated, To ensure residents receive meals served consistent with proper dining expectations, in a clean and attractive setting and with oversight to support feeding needs. To comply with federal and state regulations governing dining services. 1. Observation on 07/09/24 from 12:35 PM to 1:25 PM, revealed residents in the 300-hall dining room were being served and eating their lunch meals. Further observations of the 300-hall lunch meal service revealed 18 of 22 residents eating in this dining room were served frosted cake on a small disposable Styrofoam plate and 15 of 22 residents were served beverages in disposable Styrofoam cups. 2. Observation on 07/11/24 from 12:33 PM to 1:22 PM, revealed residents in the 300-hall dining room were being served and eating their lunch meals. Further observation of the 300-hall lunch meal service revealed 19 of 23 residents eating in this dining room were served a brownie for dessert on a small disposable Styrofoam plate and 15 of 23 residents were served beverages in disposable Styrofoam cups. 3. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/29/24, located in the resident's electronic medical record (EMR) under the RAI (Resident Assessment Instrument) tab revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated the resident was cognitively intact. Observation on 07/09/24 at 12:40 PM revealed R24 was in the facility's 300 hall dining room waiting to be served his lunch meal. Observation revealed staff served R24, two beverages in disposable Styrofoam cups and a piece of cake on a small disposable Styrofoam plate. During an interview on 07/09/24 at 3:51 PM, R24 stated at meals the facility served desserts on disposable Styrofoam plates and beverages in disposable Styrofoam cups. R24 stated he would prefer to receive his food on regular dishware and beverages in regular cups instead of Styrofoam. Observation on 07/10/24 at 12:50 PM revealed R24 was in the facility's 300 hall dining room eating his lunch meal. Observation revealed staff served R24 a beverage in disposable Styrofoam cup. Observation on 07/11/24 at 12:50 PM revealed R24 was in a facility's 300 hall dining room eating his lunch meal. Observation of the resident's meal revealed he was served cake on a disposable Styrofoam plate and two beverages in disposable Styrofoam cups. During an interview on 07/10/24 at 3:01 PM, the Dietary Manager (DM) stated the kitchen did not have enough regular plates and cups for the entire resident meal service, so at meals the dietary staff served resident food on disposable plates and beverages in disposable cups. During an interview on 07/12/24 at 12:38 PM, the facility's consultant Registered Dietitian (RD) stated residents should not be served food and beverages in disposable plates and cups at meals because it was a dignity issue. The RD stated more regular dining service dishware would be ordered, so residents would not be served food on disposable plates and beverages in disposable cups. 39411

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a clean and comfortable environment for two of the two dining rooms. This failure had the potential to affect all residents who ate meals in the facility's two dining rooms. Findings include: Review of the facility's undated policy titled, Housekeeping, indicated Cleaning Schedule and Protocols: Regular Cleaning: Specify the frequency and procedures for daily cleaning of resident rooms, common areas, bathrooms, and high-touch surfaces. Deep cleaning: Outline the procedures for periodic deep cleaning of carpets, upholstery, and other surfaces. 1. Observations of the facility's 300 hall dining room, during resident meal service, revealed the following concerns with the dining room's environment: a. Observation on 07/09/24 from 12:35 PM to 1:25 PM, revealed 22 residents were in the facility's 300 hall dining room being served and eating their lunch meals. Observations of the dining room's environment revealed chairs were stained and unclean with dried food spills, walls were unclean with what appeared to be dried food, and window curtains were unclean and stained. Observation on 07/09/24 from 1:10 PM to 1:25 PM, revealed Certified Nurse Assistant (CNA) 3 fed a randomly observed resident her lunch meal in the 300-hall dining room at a table which was very unbalanced. The table was observed to rock up and down as CNA3 fed the resident her lunch meal. b. Observation on 07/10/24 from 12:48 PM to 1:33 PM revealed residents were in the facility's 300 hall dining room being served and eating their lunch meals. Observations of the dining room's environment revealed chairs were stained and unclean with dried food spills, walls were unclean with what appeared to be dried food, and window curtains were unclean and stained. c. Observation on 07/11/24 from 12:33 PM to 1:02 PM, revealed 23 residents were in the facility's 300 hall dining room being served and eating their lunch meals. Observations of the dining room's environment revealed chairs were stained and unclean with dried food spills, walls were unclean with what appeared to be dried food, and window curtains were unclean and stained. 2. Further observations of the facility's two dining rooms on 07/12/24, prior to the resident lunch meal service, revealed the following: a. Observation of the facility's 300 hall dining room on 07/12/24 at 10:57 AM, with the Administrator present, revealed 10 of 20 dining room chairs were stained and had dried food spills present, fourteen of sixteen window curtains were stained and unclean, four of 20 dining room chairs were unbalanced, and three of 12 dining room tables were unbalanced. One of the unbalanced dining room tables had a very loose base which did not touch the floor. This dining room table was fully supported by two of its sides being placed directly on top of the two tables positioned next to it which elevated the table's base off the floor. During an interview on 07/12/24 at 10:57 AM, the Administrator confirmed the above observations of the environment of the 300-hallway dining room. The Administrator stated the housekeeping staff and dietary staff were responsible for cleaning the dining rooms and the maintenance staff were responsible for ensuring dining room tables and chairs were balanced and in good repair. Review of the facility's 300 hallway maintenance book revealed an uncompleted Maintenance Request, dated 03/10/24, regarding a dining room table being wobbly. During an interview on 07/12/24 at 11:20 AM, the Maintenance Director (MD) revealed he was not aware of the unbalanced tables and chairs that were currently in the 300-hallway's dining room. The MD also stated he was also not aware of the uncompleted Maintenance Request dated 03/10/24 that was in the 300 hallway's maintenance book regarding a dining room table being wobbly. b. Observation of the facility's 200 hall dining room on 07/12/24 at 11:15 AM, with the Administrator present, revealed 4 of 8 dining room chairs were stained and had dried food spills present. During an interview on 07/12/24 at 11:15 AM, the Administrator confirmed the four unclean and stained chairs that were in the facility's 200 hallway dining room and stated it was the housekeeping department's responsibility to clean the chairs in the facility's dining rooms. During an interview on 07/12/24 at 11:25 AM, the Housekeeping Supervisor (HKS) stated the cleaning of the chairs in the facility's dining rooms on the 200 and 300 hallways was not on the housekeeping's schedule for routine cleaning. The HKS also stated she did not know when the chairs and curtains were last cleaned in the facility's dining rooms.

Based on observations, interviews, and facility policy review, the facility failed to ensure expired medications and supplies were removed from one of one treatment carts, one of one medication rooms and failed to ensure one of one treatment cart and one of two nurse carts were locked. This had the potential to affect any resident who might be administered expired medications/use of expired supplies. The unlocked carts had the potential to be accessed by unauthorized residents, staff, and visitors. Findings include: Review of the facility's policy titled, Medication Labeling and Storage, dated 2001, indicated (2) The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and (3). If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. During an observation of the medication room for Hall 300 on 07/10/24 at 9:48 AM, alongside the Licensed Practical Nurse (LPN) 1, the following expired items were found: -One vial of ipratropium bromide albuterol sulfate (medication used for breathing treatments in a nebulizer) containing one vial, expired 02/23 -Five test tubes for viruses, mycoplasma, and chlamydia, expired on 04/12/21, the five swabs with the vials expired on 09/22. -Two test tubes for viruses expired on 01/08/19 and the swabs expired on 03/20. -Four [NAME] Brand test kits (used for testing for sexually transmitted diseases and to culture wounds) expired on 04/01/24. -Four sterile testing swabs expired on 08/11/23. -Two BD brand Eswab Collection and transport system for Aerobic, Anaerobic, and Fastidious bacteria expired on 05/31/23. -Four Eswab collection and preservation kits for aerobic, anaerobic, and fastidious bacteria expired on 08/31/23. -Five universal transport medium translucent with red cap tube format (utm-rt) 3ml test tubes w/o (without) beads transport and preservation medium for viral molecular diagnostic testing expired 01/31/24. -Twenty-four tubes utm-3ml test tubes w/o beads transport medium for viral molecular diagnostic testing expired on 05/31/24. -Thirty-nine-nine acetaminophen suppositories expired on 04/24. -Six prochlorperazine 25 mg expired on 04/24. During an interview on 07/10/24 at 9:48 PM, LPN1 verified the expiration dates and, that the testing supplies and expired medications were still available for resident use. LPN1 stated the night shift nurse should have checked the medication room. LPN1 did not know if the nurse was responsible for checking the medication expiration dates. During an interview on 07/10/24 at 2:00 PM, the Director of Nursing (DON) stated each shift should have checked the medication room for expired medications and supplies. The DON verified the supplies in the medication room were still available for resident use. During an observation on 07/10/24 at 3:42 PM, the treatment cart on Hall 200 was unlocked and parked in front of the elevator. The following expired items were located on the cart: -Nine xeroform petrolatum two by two dressings expired on 03/23/24. -One container of zinc oxide cream expired on 09/23. -Twelve boxes of covid-19 tests with two tests per box expired on 11/07/23. -One box of covid-19 tests with four tests inside it expired on 11/07/23. During an interview on 07/10/24 at 3:55 PM, LPN2 stated she knew her cart should have been locked. LPN2 stated she thought it was ok to leave it unlocked if she was sitting at the nurses' station and could see it. LPN2 verified the expired covid-19 test kits, petrolatum dressings, and zinc oxide were still available for resident use. She stated the CDC (Centers for Disease Control and Prevention) gave an extension for the self-administering covid-19 tests that extended the expiration by seven months. LPN2 stated the tests came from the CDC and that extension expired the end of June 2024. During an observation and interview on 07/11/24 at 8:57 AM, the nurse cart on Hall 300 was left unattended and unlocked. LPN3 was the charge nurse and stated she knew she should not leave the cart unlocked. During an interview on 07/11/24 at 1:51 PM, the DON stated she expected the staff to keep the treatment and medication carts locked when they are not using them. She stated staff should not keep the carts unlocked even while sitting at the nurses' station.

Based on observation, interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), would be provided if such care was needed per the resident's choice, and would only be provided to a resident subject to related physician orders and resident choice. The facility failed to have a system to ensure resident code statuses are obtained, ensure code status matched the resident's wishes, and ensure code statuses were accurately documented. The facility failed to obtain an ordered code status for 2 residents and failed to have congruently documented code status for 2 residents, out of 37 residents investigated for advanced directives. One resident had an order for full code, but a face sheet indicated do not resuscitate (DNR). The resident said he/she wanted to be a full code (Resident #4). One resident had an order for full code, but a face sheet that indicated DNR. The resident's representative said the resident was a DNR (Resident #3). One resident had a face sheet that showed DNR, a signed code status for DNR, but no ordered code status. The face sheet in the code status binder showed full code (Resident #5). One resident had no ordered code status, a signed code status sheet for DNR, and the face sheet showed DNR. The resident representative said the resident is a DNR (Resident #6). The census was 37. The administrator was notified on [DATE] at 10:30 A.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. 1. Review of the facility's Do Not Resuscitate Order policy, revised [DATE], showed: -Policy Statement: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect; -Policy Interpretation and Implementation: Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record; -A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record; -DNR orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order; -Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request; -Both witnesses must have heard the request and both individuals must document such information on the physician's order sheet; -The Attending Physician must be informed of the resident's request to cease the DNR order; -The Interdisciplinary Care Planning Team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives; -The resident's Attending Physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. 2. Review of the facility's Cardiopulmonary Resuscitation policy, revised February 2018, showed if the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or physician's order not to administer CPR. 3. Review of Resident #4's face sheet, showed: -admitted on [DATE]; -DNR code status. Review of the resident's code status sheet, dated [DATE], showed DNR checked and signed by the resident on [DATE]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included heart failure, high blood pressure, atrial fibrillation (irregular heart rate), diabetes and schizophrenia (disorder that affects the ability to think, feel, and behave clearly). Review of the resident's Physician's Orders Sheet (POS), dated [DATE], showed an order dated [DATE], for full code. Review of the facility's Emergency Evacuation binder, printed on [DATE], showed the resident's face sheet with a DNR code status. During an interview on [DATE] at 3:00 P.M., the resident said staff did not talk to him/her about the code status. He/she would prefer to be a full code. 4. Review of Resident #3's face sheet, showed: -admitted on [DATE]; -DNR code status. Review of the resident's Outside the Hospital Do-Not-Resuscitate (OH-DNR) order, dated [DATE], showed DNR checked and signed by the resident on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed: -Severely impaired cognition; -Diagnoses included high blood pressure, Alzheimer's disease and depression. Review of the resident's POS, dated [DATE], showed an order dated [DATE], for full code. Review of the resident's care plan, in use during the survey, showed: -Problem: Resident is a DNR effective [DATE] per patient and family wishes; -Goal: The facility will respect the resident's decision to be a DNR; -Approach: If there is an absence of vital signs, do not call 911 or initiate CPR. During an interview on [DATE] at 3:20 P.M., the resident's family member said the resident's code status is DNR. He/She spoke to staff last month just to clarify and they went over the code status with him/her. Review of the facility's Emergency Evacuation binder, printed on [DATE], showed the resident's face sheet with a DNR code status. 5. Review of Resident #5's face sheet, showed: -admitted on [DATE]; -DNR code status. Review of the resident's annual MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high blood pressure and anxiety. Review of the resident's undated code status sheet, showed DNR checked and signed by the resident. Review of the resident's POS, dated [DATE], showed no order for code status. Review of the facility's Emergency Evacuation binder, printed on [DATE], showed the resident's face sheet with a DNR code status. 6. Review of Resident #6's face sheet, showed: -admitted on [DATE]; -DNR code status. Review of the resident's OH-DNR order, dated [DATE], showed DNR checked and signed by the resident's Power of Attorney (POA) on [DATE]. Review the resident's quarterly MDS, dated [DATE], showed: -Severe cognitively impairment; -Diagnoses included high blood pressure, kidney failure, diabetes, Alzheimer's disease, dementia, depression and schizophrenia. Review of the resident's POS, dated [DATE], showed no order for code status. Review of the resident's care plan, in use during the survey, showed: -Problem: The resident is a DNR; -Goal: The facility will respect the resident's decision to be a DNR; -Approach: If the resident is found unresponsive and has no pulse and not breathing do not initiate CPR and do not call 911. Review of the facility's Emergency Evacuation binder, showed a POS, dated [DATE] through [DATE], with a full code status. No face sheet was found. During an interview on [DATE] at 4:30 P.M., the resident's POA said he/she was aware of the resident's DNR code status and the resident wanted to be a DNR. 7. During an interview on [DATE] at 1:50 P.M., Certified Nurse Aide (CNA) A said if he/she had to find the resident's code status quickly, it is found in the code status binder at the nurse's station. It was the only place he/she knew to look. During an interview on [DATE] at 1:52 P.M., Licensed Practical Nurse (LPN) B said he/she would find the resident's code status on the face sheet. If there is nothing there, he/she would initiate CPR. Observation and interview on [DATE] at 2:02 P.M., Restorative Aide (RA) C said every month he/she receives a print off of all the resident's codes status from their orders and that is where he/she would look for a code status. Every resident has a code status on his/her list. If the resident was a new admit or not on the list, there is a binder at the nurse's station. RA C looked through a binder and did not find any code status and said the binder was a cheat sheet for the nurses. Normally the code statuses would be in the binder. Review of RA C's print off list, showed: -No documentation of Residents #4 and #5 on the list; -Resident #6 showed a DNR code status; -Resident #3 showed a DNR code status. During an interview on [DATE] at 3:22 P.M., Certified Medication Aide (CMT) D said he/she would check the binder at the nurse's station for code statuses. He/she was pretty sure it is updated, but he/she was not responsible for updating it. He/she will also check the Medication Administration Record (MAR) in the medical record. If there was no code status, he/she would get the nurse. During an interview on [DATE] at 5:15 P.M., the Administrator in Training and Director of Nursing (DON) said when a resident is admitted to the facility, they are a full code unless they sign a DNR. It is a part of the admission packet. The code status is also on the POS. If there are changes in the resident's code status, the charge nurse is responsible for updating it in the medical record. If there is a care plan meeting, quarterly or significant change, the code status is reviewed with the resident. They review it and sign it. There is a red piece of paper in front to notify the DON that the code status was changed at the care plan meeting. The MDS coordinator changes the code status since they are present during the care plan meeting. If hospice speaks to the resident about their code status, they are to notify the DON. The charge nurse is expected to change it. They keep a copy of the code status sheet in hard files and it is uploaded to the electronic medical record. In order to find the resident's code status, they look in the electronic medical record, on the header where their picture is found. If the resident is a full code, it is green and DNR is in red. The binder with the code status is not at the nurse's station. The binder with the code statuses are in the facility's emergency evacuation binder. The resident's face sheets are in the binder with their code status at top of face sheet. It is updated quarterly and as needed if new admission or changes. The binder is located in the DON's office. The DON was unsure if staff were aware the binder was in the DON's office. The binder is updated by the DON. It was updated within the last 3 months. The Administrator in Training said she would expect resident's code status on the face sheet, POS and signed code status sheet to all match. They recently had an audit. All residents should have an order for DNR if they are a DNR, but for residents who are a full code, the administrator in training said she would need to follow up with DON. She did not believe they would need an order for full code. If staff were unable to find a resident's code status, they would treat them as full code. During an interview on [DATE] at 5:40 P.M., the Administrator confirmed that POS were not checked during the audit. She would expect staff to check the POS during their audits. It should be reflected on their care plans. All resident's code status are expected to match and have an order on the POS. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on interview and record review, the facility failed to ensure one resident was free from physical and verbal abuse and involuntary confinement (Resident #1). On 5/14/23 between 1:00 P.M. and 1:30 P.M., during lunch in the dining room, Certified Nursing Assistant (CNA) CNA A was observed by the Dietary Supervisor (DS), Dietary Aide (DA) B and Residents #3, #6, #2, #5 and #4 either hitting the resident in the head, raising his/her arms to the resident, yelling/cursing at the resident, and/or forcefully grabbing the resident's wheelchair to prevent the resident from exiting the dining room to go to his/her room and lay down. The DS and DA B failed to immediately intervene by separating the resident from the CNA and reporting what they witnessed to Nurse C. The CNA eventually took the resident out of the dining room to the nurse's station where the resident told Nurse C the CNA hit him/her in the head. Nurse C did not immediately separate the resident from the CNA, did not report what the resident said to the Director of Nurses (DON) and did not separate the CNA from residents, pending an investigation. The CNA finished his/her shift which was approximately five more hours. The CNA was assigned to provide care to 13 residents, including Resident #1. In addition, Nurse C called the Psychiatric Nurse Practitioner (NP) after the incident occurred, informing him the resident was aggressive, grabbed the CNA's arm and scratched the CNA, but did not inform him the resident said the CNA hit him/her in the head. The NP increased the resident's risperidone (an antipsychotic medication used to treat behavioral disorders). In addition, the facility policies did not show how the facility would protect the resident once an allegation of abuse was made. Six residents were sampled. The census was 38. The administrator was notified on 6/6/23 at 11:30 A.M. of an Immediate Jeopardy (IJ) which began on 5/14/23. The IJ was removed on 5/25/23, as confirmed by surveyor onsite verification. Review of the facility's Resident Abuse Policy and Procedures, revised on 8/31/18, showed: -Purpose: -This facility maintains a no tolerance policy on any form of abuse towards residents. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, visitors and friends, or other individuals; -Definitions: -Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or in their hearing distance, regardless of their age, ability to comprehend, or disability; -Physical abuse including hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment; -Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation; -Involuntary seclusion is defined as separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will, or the will of the resident's legal representative; -The facility prime directive towards resident abuse is to develop and operationalize policies and procedures for screening and training all staff, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, in an effort to prevent occurrences of resident abuse; -Training: All staff will be trained through orientation and quarterly in-services that focus on issues related to abuse prohibition practices which include but not limited to: -Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; -How staff should report their knowledge relating to allegations without fear of reprisal; -What constitutes abuse, neglect and misappropriation of resident property; -Prevention: -Residents, families, volunteers and staff are provided with the necessary information through the New Admission Handbook on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed. Individuals can make their concerns anonymously by filling out a grievance form and placing it under the Administrator's door and/or social worker's office door. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of the resident property is or likely to occur; -Identification and Investigation: -The direction of an abuse investigation will be determined following the identification of suspicion of alleged abuse including but not limited to suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; -1. Staff, residents, family members and visitors are to report any suspected abuse to any of the following persons: a) Administrator - Grievance Officer; b) Director of Nursing; c) Charge Nurse; d) Social Worker - Grievance Officer; e) Any Member of Management (Minimum Data Set (MDS) Coordinator, Dietary Manager, Human Resource Manager); -2. Investigation shall follow facility's Incident Reporting Policy: -The timeliness of the Investigation: -The facility must begin the investigation in order to collect accurate data related to the incident. Any delay in starting the investigation can cause valuable information to be either lost or altered; -Thoroughness of the Investigation: -Federal law requires the facility to do a thorough investigation of the incident. In order for the facility to provide evidence of the thoroughness of the investigation the information must be recorded. A thorough investigation may require (2) phases of the fact gathering: -Phase I: Must be completed and reported no later that 2 hours after an allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. If Phase I is not successful in determining a reasonable cause, an extended phase must follow; -Phase II: The investigation should end with the identification of who is involved in the incident, and what, when, where, why and how the incident happened, including probable or reasonable cause. It should also allow the facility to determine if the allegations were true or not; -Each phase of a thorough investigation includes: Data collection and data analysis. Review of the facility's undated policy, Incident Reporting Policy, showed: -All staff are required to understand what constitutes as abuse, neglect, mistreatment of residents, injury of an unknown origin and misappropriation of their property which are outlined in Resident Rights and Abuse & Neglect Policy which are accordance to Federal and State law; -Staff must protect residents from harm, immediately report incidents as required by federal and state law, and begin investigation as soon incident is made known. It is [NAME] Park's responsibility to immediately: -Protect resident(s) from reoccurrence; and -Take any action necessary to treat the ill effect(s) experienced by the resident(s) as a result of the alleged incident(s); -The policy does not show how the resident will be protected from any alleged perpetrator(s). Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/17/23, showed: -Adequate hearing and vision; -Speech Clarity: Unclear speech - slurred or mumbled words; -Makes Self Understood: Usually understands - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to Understand Others: Understood - clear comprehension; -Severely impaired cognition; -Physical behavioral symptoms directed toward others (e.g.; hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior of this type occurred 1 to 3 days (over the past 7 days); -Verbal behavioral symptoms directed toward others (e.g.; threatening others, screaming at others, cursing at others): Behavior of this type occurred 1 to 3 days; -Rejection of care: Behavior not exhibited; -One person physical assistance required for transfers, locomotion on the unit; -Mobility Devices: [NAME] and wheelchair; -Diagnoses of non-traumatic brain dysfunction (brain injury that is not caused by any external force, instead the cause is due to medical conditions and illnesses that disturb the normal functioning of the brain) and stroke. Review of the resident's care plan, undated, showed: -Problems: -Behavioral Symptoms: Resident noted to have physical and verbally aggressive behaviors; -Falls: Resident will attempt to transfer self from wheelchair to bed and bed to wheelchair; -Activities of Daily Living Functional Status: Resident requires assist of 1 with pivot transfer. He/She is nonambulatory and propels himself/herself independently in the wheelchair; -Mood State: Receives antidepressants and antipsychotics for mood disorder; -Approaches: -Monitor/supervise resident in more frequent intervals as needed; -Provide clear and concise boundaries; -Redirect as needed and remove from situations that are harmful to him/her or others; -Maintain a calm environment and approach to the resident; -Maintain a calm, slow, understandable approach with the resident; -Provide assistance with transferring. Encourage resident to ask for assistance; -Monitor behavior every shift; -The resident's care plan did not identify a problem/intervention with the resident frequently requesting/wanting to lay down after he/she finished eating. Review of the facility Administrator's initial report, on 5/15/23 at 12:11 P.M., showed the following: Summary of Alleged Incident: -On 5/14/23, it is alleged CNA A hit Resident #1 in the back of the head with his/her fists and roughly pulled the resident up to the dining room table. The incident was witnessed by the Dietary Supervisor who reported the incident; -Incident Information: -On 5/15/23 at approximately 11:00 A.M., the DON was reviewing another investigation when the DS approached the DON and handed her some paper saying You need to read this. The DON discovered the paper was a statement signed Anonymous and regarded an allegation that CNA A physically assaulted the resident in the dining room during lunch on 5/14/23 (The DS later acknowledged she was the author of the anonymous statement). She said during lunch on 5/14/23, she witnessed CNA A get frustrated with the resident and forcibly push his/her wheelchair into the table. The resident was trying to go to his/her room and the CNA stopped him/her and started wrestling with the resident. The resident put his/her hands up to block the CNA and the CNA started punching the resident in the back of the head. The CNA then grabbed the resident and started swinging the resident around and the resident was halfway out of his/her wheelchair; -At approximately 11:15 A.M. (5/15/23), the DON immediately notified the Administrator and Administrator in Training (AIT) regarding the DS's statement. An investigation was immediately started; -The DS was immediately interviewed over the phone by the Administrator (the Administrator was at home, the DS was at the facility) with the AIT and DON who were present at the facility with the DS. -DA B said he/she saw the resident scratching CNA A when he/she was trying to take the resident to his/her room. The CNA was trying to stop the resident from agitating the other residents while eating and the resident became upset. -CNA A was interviewed by phone. He/She said he/she tried to redirect the resident because the resident was bothering other residents while they were eating and the resident was going to the steam table (a heated table used to keep food hot). The resident was not able to be redirected and since he/she was done eating he/she tried to remove the resident from the dining room. The resident did not want to go and was upset because he/she would not allow him/her to bother the other residents. When he/she tried to remove the resident, the resident started scratching his/her arm and then tried to hit him/her. He/She tried to keep the resident's hands away from him/her so the resident would not injure him/her. He/She said he/she would never hit a resident and he/she was not angry with the resident. He/She said there were dietary staff and residents in the dining room at the time. Once he/she was able to get the resident out of the dining room, he/she took the resident to Nurse C who was behind the nurse's station; -The DON and AIT interviewed 12 residents, None of their statements were consistent with the DS's statement. One resident (Resident #3) said CNA A was grabbing the resident's arm to prevent the resident from hitting him/her. Resident #3 did express the CNA may have been a little too aggressive; -Conclusion: -Due to the inconsistencies of the statements, it could not be determined whether the allegation was founded. However, there was evidence CNA A did not handle the situation appropriately and as a result was terminated. All employees received an inservice about mandated reporting of abuse and anyone failing to report abuse of any kind will also be held accountable. Review of the facility completed investigation e-mailed to DHSS on 5/22/23, showed: -A written statement from the DON dated 5/15/23: When she reported to work on 5/15/23, at approximately 11:00 A.M., as she was exiting the elevator the DS handed her a statement signed anonymous. Upon discovering alleged abuse (regarding CNA A and Resident #1), she immediately notified the AIT, and they notified the Administrator. An investigation was launched; interviewing residents and staff; followed by in-depth inservicing of staff was started on 5/15/23 and is on-going;-The anonymous note was given to the DON by the DS on 5/15/23: On Sunday 5/14/23 at 12:50 P.M. some residents were done eating their food and started to move around the dining room. Resident #1 was trying to go to his/her room. CNA A was upset with the resident and he/she pushed the resident's wheelchair with so much force back to the table. Moments passed and the resident tried leaving out of the dining room again but this time the CNA was really upset and started to wrestle with the resident. The resident then put his/her hands up trying to block CNA A from hitting him/her in the head. The CNA's fists were balled up and he/she was hitting the resident in the head and face. The CNA then started to grab onto the resident's shirt with force slinging the resident around in the wheelchair, pushing on the resident, and handling the resident with the most disrespectful force until the resident was almost on the floor. The CNA then grabbed the resident by the front of his/her shirt and pushed threw the resident back into his/her wheelchair. Then the CNA started to swing the wheelchair forcefully against the door and wall and said to the resident don't play with me I'll lose this job from fucking you up. The resident got very upset and I was yelling at the CNA to leave the resident alone, then Resident #4 was yelling at the CNA to leave the resident alone. The other CNAs were not in the dining room when this happened. A few minutes later people said they wasn't going to report the incident/abuse because they are too short staffed. The CNA told Nurse C the resident was trying to scratch him/her so he/she wouldn't have any consequences following this. I wanted to call the police on the CNA but she figured you all should know first. She is reporting this now. It was very horrible what she witnessed. Signed: A very concerned witness - anonymous; -During the facility investigation the DS confirmed she had written the anonymous note; -The DS's written statement dated 5/15/23, completed after giving the DON the anonymous statement: As some residents were done eating their food and started to move around to leave out of the dining room, Resident #1 kept trying to go to his/her room. CNA A was getting upset with the resident and he/she pushed the resident's wheelchair with so much force against the table. The resident tried leaving again and this time the CNA was very upset and was trying to get the resident to stop but the resident tried to keep going and the CNA balled up his/her fist and hit the resident a few times. She asked the CNA to stop and he/she wasn't listening, then the resident was asking the CNA to stop as well. She then left to go back to the kitchen after being in shock after what she had witnessed. The very next day she reported it to the DON; -A typed statement from the Administrator dated 5/17/23: On 5/15/23 the Administrator (at home) interviewed the DS by phone (DS was at the facility). The following questions were asked during the interview: Question (Q): What staff were present? Answer (A): DA B, CNA A and the DS; Q: How did CNA A hit the resident, how many times, where? A: A few times, in the back of the head with his/her fists; -DA B's undated written statement (per interview with the Administrator, DA B's statement was written and given to Nurse C on 5/14/23): CNA A was taking Resident #1 out of the dining room. The resident started fighting the CNA. The CNA never put his/her hands on the resident. The resident started swinging on the CNA; -A written statement from Nurse C, dated 5/15/23: On 5/14/23, during lunch meal, Resident #1 was brought to the nurse's station by CNA A. This nurse asked the resident again what happened and the resident said the CNA hit him/her. When asked where the CNA hit him/her, he/she said in the head. When asked where in the head, he/she said he/she didn't know. This nurse assessed the resident's head, no redness, swelling, or open areas. This nurse asked the CNA if anyone else was in the dining room during the incident and he/she said DA B. DA B was asked to come to the nurse's station. This nurse asked him/her if he/she had seen the incident between the CNA and resident. He/She said he/she had. When the CNA tried to push the resident out of the dining room he/she started scratching the CNA; -A written statement from the Housekeeping Supervisor (HS) dated 5/17/23: She was at the front desk talking to Receptionist H on 5/15/23 around 7:30 A.M The DS came to the front desk and sat in a chair. The DS stated CNA A was pulling and hitting Resident #1. She asked the DS if she stopped the CNA from hitting the resident and he/she said no. She asked the DS if she called anyone and she said no because Nurse C was standing there. I asked the DS if she called the DON or Administrator and she said that is what she is waiting for them to come in so she can tell them. That was about 7:45 A.M. on 5/15/23; Resident statements, dated 5/15/23: -Resident #2: CNA A was pulling Resident #1's wheelchair and Resident #1 was resisting; -Resident #3: CNA A and Resident #1 were fighting. The CNA was grabbing the resident arms trying to stop the resident from hitting him/her. The CNA was pulling on the resident's wheelchair trying to get the resident out of the dining room. He/She (Resident #3) felt like the CNA was being a little too aggressive; -Resident #5: CNA A was trying to stop Resident #1 from messing with other people and the resident got upset. The resident was then trying to go to the steam table and the CNA tried to pull the resident's wheelchair away. The resident got aggressive and started swinging at the CNA. The CNA was just trying to get the resident out of the dining room. The resident was swinging at the CNA; -Resident #6: He/She saw CNA A pulling Resident #1's wheelchair. The CNA was pulling it kind of hard because the resident was pushing against the CNA. He/She did not see any hitting. Review of the resident's electronic medical record, showed an Events Detail form completed by Nurse C on 5/17/23 at 8:18 P.M., which included the following: -When Occurred: 5/14/23 1:30 P.M.; -Progress Note: At approximately 1:30 P.M. during lunch meal, the resident started propelling around the dining room touching other residents while they were eating. Third assignment CNA requested resident to stop touching others, however behavior continued. He/She attempted to escort the resident out of the dining room. The resident then grabbed his/her arm and started scratching him/her. The resident was brought to nurse's station for close supervision. When asked why he/she (resident) did the above, the resident said they lying on me. Psychiatric Nurse Practitioner (NP) informed of behavior. New order received for risperidone 0.5 milligrams (mg) every morning. Physician and DON informed of behavior and new psych recommendation. Review of the resident's Physician's Order Sheet, showed: -An order dated 2/3/23, for risperidone 1 milligram (mg) daily at hour of sleep (HS) med pass 7:00 P.M. - 11:00 P.M.; -An order dated 5/14/23 for risperidone 0.5 mg daily during the A.M. med pass (7:00 A.M. - 11:00 A.M.). Review of the resident's medication administration record (where nurses initial a medication has been administered per physician orders), for May 2023 and June 2023. showed: -An order for risperidone 0.5 mg at A.M. med pass and initialed as administered daily from 5/15/23 thru 5/31/23, and 6/1/23. During an interview on 5/25/23 at 8:40 A.M., the Administrator said the facility investigation sent to DHSS on 5/22/23 was complete and she had nothing more to add. CNA A is the shower aide but was working the floor as a CNA on 5/14/23. He/She was assigned a group of residents to care for that day, which included Resident #1. CNA A worked his/her 12 hour shift on 5/14/23, from 6:30 A.M. to 6:30 P.M. Review of CNA A's time sheet, dated 5/14/23, showed he/she clocked in at 6:50 A.M. and clocked out at 6:30 P.M. During an interview on 5/25/23 at 10:40 A.M., Resident #1 said staff treat him/her good and no one has been mean or abusive to him/her. He/She said he/she did remember CNA A would not let him/her leave the dining room one day, but could not recall what day that was. He/She wanted to lay down. The CNA grabbed his/her wheelchair and wouldn't allow him/her to leave. That made him/her mad. He/She thinks the CNA may have hit him/her in the front of his/her head, but he/she is not sure. The resident was not afraid of the CNA that day, he/she just wanted to lay down. He/She had not had any problems with the CNA prior to that day. During an interview on 5/26/23 at 9:15 A.M., the DS said on 5/14/23 during lunch, she, DA B and CNA A were in the dining room. Resident #1 was in his/her wheelchair and trying to go back to his/her room. The resident was trying to wheel himself/herself out of the dining room to the hall that leads to his/her room and the CNA was getting frustrated with the resident telling him/her that he/she couldn't leave the dining room. The CNA grabbed the resident's wheelchair hand bars and dragged the resident backwards back into the dining room multiple times. The DS heard a commotion and turned to see the CNA hit the resident. The CNA had his/her fists balled up and hit the resident in the back of the head more than one time. The resident had his/her hands up trying to block the CNA from hitting him/her. The CNA very loudly told the resident you don't know me, I'll lose my job and that he/she did not have time to keep bringing him/her back. The DS told the CNA that's enough, you need to stop it. The resident kept saying he/she wanted to go to his/her room. The resident had slipped down in his/her wheelchair and the CNA grabbed a hold of his/her shirt and pushed the resident back into the wheelchair seat. After that, the CNA took the resident to the nurse's station. The DS did not report what she saw because Nurse C was standing in the hall at his/her cart and she assumed the nurse saw what happened. She did not see the nurse intervene or say anything to the CNA. The DS did not speak to the nurse about what happened, she went downstairs. She is the one that wrote the anonymous letter and gave it to the DON. The DS wrote it anonymously because she wanted to avoid confrontation or retribution. During an interview on 5/25/23 at 9:15 A.M., DA B said on 5/14/23, it was CNA A, the DS, and DA B in the dining room during lunch. The resident had no behaviors while he/she was eating. After the resident finished eating, he/she saw the resident going and talking to other residents. The resident always does this. The resident did not appear to be bothering anyone and the other residents were not complaining. It was after this when the resident told the CNA he/she wanted to go to bed. The CNA told the resident he/she was not going to take him/her to bed. This is when the resident began to get upset. The resident was trying to wheel himself/herself out of the dining room. The resident got to the doorway and the CNA brought the resident back. The resident did not want to come back, saying he/she wanted to go to his/her room. The CNA grabbed the resident's wheelchair by the handles, preventing the resident from leaving. The resident was trying to go one way and the CNA was making him/her go another. That's when the resident began swinging at the CNA. He/She did not see the resident scratch the CNA, but the resident was swinging his/her arms at the CNA who was standing behind the resident's wheelchair. DA B saw the CNA put his/her arms up and the CNA was swinging his/her arms. He/She did not see the CNA hit the resident in the head, but it could have happened because the CNA had his/her arms up too. He/She heard the DS say if the resident wants to go to his/her room, let him/her go to his/her room. The entire incident lasted approximately 6 or 7 minutes. DA B did not say anything to anyone because he/she thought CNA A would tell Nurse C what happened. Review of Resident #6's annual MDS, dated [DATE], showed: -Adequate hearing; -Vision impaired - sees large print, but not regular print in newspapers/books; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Usually understands - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to Understand Others: Understands - clear comprehension; -Cognitively intact. During an interview on 5/26/23 at 12:38 P.M., Resident #6 said he/she was in the dining room at lunch on 5/14/23. CNA A got real loud with Resident #1 because the resident wanted to stay in the dining room, he/she did not want to leave the dining room. He/She saw the CNA swinging on the resident. The CNA hit the resident, but he/she did not see where he/she hit the resident. The resident was using his/her feet to stop the CNA from pushing his/her wheelchair. The CNA was very aggressive and jerking the resident's wheelchair around. The resident was yelling at the CNA to stop and the CNA was yelling at the resident. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands - clear comprehension; -Cognitively intact. During an interview on 5/25/23 at 11:03 A.M., Resident #2 said he/she was in the dining room on 5/14/23 during lunch. The CNA was trying to pull Resident #1's wheelchair and the resident did not want to be pulled. The resident was putting his/her feet down on the floor to stop the CNA from pulling him/her. Resident #2 thinks the resident was mad because he/she was kind of swinging at the CNA. The CNA did not swing at the resident that he/she saw. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands - clear comprehension; -Cognitively intact. During an interview on 5/26/23 at 12:30 P.M., Resident #5 said he/she was in the dining room on 5/14/23 during lunch. Resident #1 was trying to leave the dining room and CNA A kept pulling the resident back into the dining room. The resident seemed to be getting upset as he/she was swinging his/her arms. Review of Resident #4's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands - clear comprehension; -Cognitively intact. During an interview on 5/25/23 at 11:13 A.M., Resident #4 said he/she was in the dining room during lunch on 5/14/23. He/She did not see too much because his/her back was toward where the incident was taking place. He/She did turn around and saw CNA A pulling on Resident #1's wheelchair. The resident did not want to go with the CNA. The CNA was pulling the resident out of the dining room to the nurse's station. The CNA kept pulling the resident backwards, but the resident was resisting. During an interview on 5/25/23 at 8:06 A.M., Nurse C said he/she was the nurse on duty on 5/14/23. He/She was sitting at the nurse's station around 1:00 P.M. to 1:30 P.M. and he/she heard loud voices coming from the dining room area. Then CNA A brought Resident #1 to the nurse's station, saying the resident had grabbed his/her arm and scratched him/her. The CNA had some minor scratches on one of his/her arm. The resident denied scratching the CNA. The resident said the CNA hit him/her. At first, the resident did not know where the CNA had hit him/her, then eventually said in the head. The CNA was allowed to be there while questioning the resident. Nurse C assessed the resident's head and found no marks. The resident has a poor memory. The CNA said DA B was the only other staff present in the dining room. Nurse C talked to DA B, who said he/she did not see the CNA hit the resident. He/She did see the resident scratch the CNA's arm. DA B said the CNA was trying to get the resident out of other residents' personal space. The CNA asked the resident to stop, prior to grabbing the resident's wheelchair and trying to redirect the resident. That's when the resident grabbed the CNA's arm and scratched him/her. The DS never reported anything to him/her about what she had allegedly saw that day. Nurse C went to the kitchen after the incident, looking for DA B and the DS was in the kitchen and did not say anything to him/her. Nurse C did not interview any of the residents who were in the dining room when the incident occurred. During an interview on 5/26/23 at 7:23 A.M., Nurse C said on 5/14/23, he/she called the DON about DA B and told her the resident was agitated and scratched CNA A. He/She did not tell the DON the resident said the CNA hit him/her in the head because the resident has a history of making statements that are not true. On 5/15/23, he/she spoke to the DON and told her about the resident's statement. The DON told him/her to add that to his/her written statement. Nurse C should have told the DON on 5/14/23 the resident said the CNA hit him/her in the head. He/She should not have allowed the CNA to be present when he/she was questioning the resident. Nurse C could see how that could be intimidating to the resident. During an interview on 5/31/23 at 2:50 P.M., CNA A said the resident was assigned to him/her on 5/14/23 for the entire 12 hour shift. During lunch that day, he/she was the only nursing staff in the dining room. DA B was also in the dining room. He/She did not recall the DS being in the dining room. The resident had eaten and he/she always wants to lay down after he/she eats. The resident started to wheel himself/herself out of the dining room and into the hall where the elevators are. He/She got the resident and took him/her back to the table and locked his/her wheels. CNA A

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when the facility failed to assess wounds, document changes to the wound and/or notify the physician of the wound changes. This resulted in a delay in identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound was identified as moisture associated skin damage (MASD, a skin condition causing irritation and redness of the skin due to constant contact with a source of moisture) upon admission and was identified as a Stage IV pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough (moist, dead tissue) and/or eschar (dry, dead tissue) may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling (passageways between the skin surface, tunneling generally occurs in one direction, whereas undermining may occur in one or more directions) often occur) 11 days later. During the following 11 days of daily skin observations, staff did not document changes to the area in accordance with the facility's policy, and staff did not notify the physician of those changes. This affected one of 21 sampled residents. The census was 48. Review of the facility's Pressure Ulcer/Skin breakdown Clinical Protocol Policy, dated 2005, (revised October 2010), included: -Assessment and Recognition: -The nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores: For example, immobility, recent weight loss and history of pressure ulcer(s); -In addition, the nurse shall assess and document/report the following: -Full assessment of pressure sore, including location, state, length, width and depth, presence of exudates (fluid that leaks out of blood vessels into nearby tissues) or necrotic (dead) tissue; -The following information should be recorded in the resident's medical record: -Any change in the resident's condition; -All assessments (color, size, pain, drainage, etc.,) when inspecting the wound; -Skin and Wound Treatment, Pressure Ulcer Treatment: -The purpose of this procedure is to provide guidelines for the cure of existing pressure ulcers and the prevention of additional pressure ulcers; -Preparation: Review the resident's care plan to assess for any special needs of the resident; -General Guidelines: The pressure ulcer treatment program should focus on the following strategies; -Assessing the resident and the pressure ulcer(s); -Managing tissue loads; -Pressure ulcer care; -Managing bacterial colonization and infection; -Definitions and Descriptions; -Stage II (skin is broken, leaves an open wound ) Pressure Ulcer: -Partial thickness, loss of dermis (inner layer of the two main layers of the skin), presenting as a shallow open ulcer with a red pink wound bed, without slough (dead skin or tissue that has fallen off). May also present as an intact or open/ruptured serum (the fluid and solute component of blood which does not play a role in clotting) filled blister; -Stage III (extends into the tissue beneath the skin, forming a small crater) Pressure Ulcer: -Full thickness tissue loss. Subcutaneous (under the skin) fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling; -Stage IV (very deep, reaching into muscle and bone and causing extensive damage) Pressure Ulcer: -Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling; -Further description. Stage IV ulcers can extend into muscle and/or supporting structures, tendon or joint capsule, making [CONDITION(S)] (inflammation or swelling that occurs in the bone) possible. Exposed bone/tendon (muscle/bone connective tissue) is visible or directly palpable (can be touched); -Pressure Ulcer Interventions/Care Strategies; -Stage II; -Protect; -Manage drainage; -Promote moist wound healing; -Treatment: -Cleanse with normal saline (mixture of [MEDICATION(S)] (salt) and water, used to clean skin) or other skin cleanser in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Apply barrier cream, hydrogel (a gel which offers a non-greasy way to maintain a hydrated environment for proper wound healing) or hydrogel sheet (dressing which aides in the wound healing process); -Cover with non-adhesive light gauze or transparent dressing; -Alternate dressing, use of thin [MEDICATION(S)] (breathable, and adheres to the skin, so no separate taping is needed); -Change per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Manage pain; -Follow up: If wound does not improve in 2-3 weeks, notify physician. Consider a skin consult with a wound specialist; -Stage III; -Protect; -Fill dead space, including tunnels and undermining; -Manage drainage; -Promote moist wound healing; -Manage pain; -No drainage treatments; -Irrigate wound with normal saline or other designated wound cleanser, use syringe to apply 4-15 psi (psi, pounds per square inch, corresponds with syringe size); -Apply hydrogel to wound cavity; -Change per order and manufacturer's directions; -Medium to heavy drainage treatment; -Follow above procedure, consider substituting alginate (multi-purpose wound dressing) or foam; -Stage IV; -Protect; -Fill dead space, including tunnels and undermining; -Manage drainage; -Promote moist wound healing; -Debride slough/eschar: -Treatment: -Irrigate wound with normal saline or other designated wound cleanser. Use syringe to apply (4-15 psi); -Apply an alginate dressing, foam dressing or hydrogel to wound cavity; -Cover with dry sterile dressing, change daily; -Change per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Pain management. Review of Resident #12's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/27/21, showed: -admitted [DATE]; -Severe cognitive impairment; -Total dependence of at least two persons required for bed mobility, dressing, toilet use and transfers; -One staff person's assistance required for eating and personal hygiene; -No behaviors; -No upper/lower extremity impairment; -Mobility device: wheelchair/walker; -Incontinent of bowel and bladder; -Determination of pressure ulcer risk, formal assessment instrument/clinical assessment; -At risk for pressure ulcers, yes; -Unhealed pressure ulcer at Stage I or higher, yes; -Number of Stage II pressure ulcers, one; -Skin and pressure ulcer treatments, pressure ulcer care; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's initial care plan, dated 8/21/21, showed: -Four care areas addressed: Full code, high blood pressure, [CONDITION(S)], and at risk for contracting COVID-19; -Skin concerns/pressure ulcers not addressed on the care plan. During an interview on 10/12/21 at 1:05 P.M., the MDS nurse said she made an error and miscoded the pressure wound, it should have been a MASD. When she did the seven day look back, she thought the wound was a Stage II. She should have coded it as MASD, not a Stage II. She doesn't do the skin assessments unless she is the nurse on the floor. She looks at the skin assessments. The resident was Medicare A and required daily focused observations. The resident did not have a pressure wound when he/she arrived. It was an area which was moisture associated, really shiny, and not open. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 8/20/21, for house barrier cream (places a physical barrier between the skin and contaminants that may irritate the skin) to skin for irritation or incontinence, every shift/as needed (PRN); -An order, dated 8/31/21, for Dakin's solution (used to kill germs and prevent germ growth in wounds), administer 1 gauze wet to dry. Cleanse coccyx area with dermal wound cleanser (DWC) and use Dakin's solution, wet to dry, cover with abdominal pad (ABD, gauze pad for heavily draining wounds) and secure with tape. Diagnosis, pressure ulcer of sacral region, Stage IV. Review of the resident's treatment administration record (TAR), showed: -Order date, 8/20/21, House barrier cream to skin for irritation or incontinence, PRN. On 8/20/21 through 8/31/21, not documented as administered; -Order date, 8/31/21, Dakin's solution, administer one gauze wet to dry. Cleanse coccyx area with DWC and use Dakin's solution, wet to dry, cover with ABD pad and secure with tape. Review of the resident's Observation Detail List Report, showed: -On 8/20/21 at 2:55 P.M., Skin: warm, dry, normal color, normal turgor (elasticity) normal. MASD to left gluteal fold (area between buttock and thigh); -Braden Scale is an evidenced-based tool that predicts the risk for developing a hospital- or facility- acquired pressure ulcer or injury. The Braden Scale uses scores from less than or equal to 9 to as high as 23. The lower the number, the higher the risk is for developing an acquired ulcer or injury; -19-23 = no risk; -15-18 = mild risk; -13-14 = moderate risk; -less than 9 = severe risk; -Braden score 13, Level: Moderate Risk; -On 8/20/21 at 10:37 P.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; comments: MASD ulcer left gluteal fold; -On 8/21/21 at 1:06 A.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; comments: MASD lesion left thigh; -On 8/21/21 at 8:59 A.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; -On 8/21/21 at 9:57 P.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; comments: MASD to left upper gluteal area and upper hip area; -On 8/22/21 at 2:33 A.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; comments: MASD left upper gluteal/hip area; -On 8/22/21 at 7:30 P.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; -On 8/22/21 at 10:22 P.M., Skin: warm, dry, normal color, normal turgor, alterations in skin, no; Comments: MASD to left upper gluteal area and upper hip area; -On 8/23/21 at 1:16 A.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; MASD to left upper gluteal area and upper hip area; -On 8/23/21 at 12:22 P.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; -On 8/24/21 at 4:58 A.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, yes; comments: MASD left upper gluteal/hip area, area to coccyx with no drainage/odor; -On 8/25/21 at 1:25 P.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; comments: resident has areas to coccyx and buttocks, prior to admission, currently being treated by wound nurse; -On 8/25/21 at 7:59 P.M., Skin normal, intact, other (see TAR); -Review of the resident's TAR, showed on 8/25/21, no treatment documentation, other than the barrier cream order, and staff did not documented this as applied; -What type of impaired skin integrity does the resident present with? Pressure ulcer/injury checked; -Is this condition new or chronic? Blank; -No new skin issues; -On 8/26/21 at 4:14 A.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, comments: areas coccyx, with ongoing treatments; -On 8/26/21 at 11:45 A.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; comments: area to coccyx MASD; -On 8/27/21 at 3:13 A.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, yes, comments: MASD, left upper gluteal fold, coccyx; -On 8/27/21 at 8:43 P.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; -On 8/28/21 at 12:41 P.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; -On 8/29/21 at 5:55 A.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; -On 8/30/21 at 8:20 P.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; -On 8/31/21 at 8:50 P.M., Skin: warm, dry, normal color, normal turgor, alterations to skin, no; comments: Coccyx decubitus. Review of the resident's nurse's progress notes, showed: -On 8/20/21, at 2:00 P.M., arrived by emergency medical services on a stretcher from the hospital. admitted following a fall and has an L1 (first vertebrae of the lumbar (lower) part of the spine) fracture requiring resident to wear a [MEDICATION(S)] lumbar sacral orthosis (TLSO, a brace used to limit motion in the [MEDICATION(S)], lumbar and sacral regions of the spine) while out of bed. One area of MASD to his/her left gluteal fold, moisture barrier crème applied. Resident is incontinent of bowel and bladder; -On 8/27/21 at 10:02 A.M., dietary note, Registered Dietician (RD), resident with adequate oral intake as evidenced by weight gain. Consistency of diet order decreased by Speech Therapy due to swallowing difficulty. Continue regimen and monitor. Skin: No decubitus; -On 8/31/21 at 5:12 P.M., spoke with physician's office regarding treatment order for coccyx, which is measuring at 4.5 centimeter (cm) X 3.5 cm X 1.0 cm deep. Area to coccyx is open and edges are irregular and open, decubitus a Stage IV, with black areas around the edges and foul smelling drainage. Further review of the resident's medical record, showed no documentation regarding skin/wound measurements and/or physician notification in regard to a change to the resident's skin, other than MASD, prior to 8/31/21. During an interview on 10/12/21 at 2:25 P.M., the RD said when determining diets/changes, she referred to the resident's wound reports and assessments to check if residents have a decubitus ulcer. During an interview on 10/7/21 at 9:11 A.M., the wound nurse said a wound tracking report was not available because the facility does not keep a tracking report. Observations of wounds are kept in the resident's progress notes. She said she completes wound assessments on Thursdays. If she finds something wrong with the resident's skin, staff assess, measure and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If a change to the skin is observed, staff should notify the charge nurse and herself. Staff should call the family and physician and get an order as soon as possible. A resident considered at high risk for pressure ulcers would be someone who is diabetic, has [CONDITION(S)] (PVD, a slow and progressive circulation disorder) and blanchable areas. Another risk factor would be lack of mobility, and an air mattress would be a prevention measure, which would require a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents have a head to toe weekly skin assessment, and the person responsible to ensure assessments are completed is the Director of Nursing (DON). She said she would expect the wounds to be described and measured on the resident's skin observation note and a more detailed note be in the resident's progress notes. During an interview on 10/12/21 at 3:03 P.M., the DON said the resident's wound was discovered on 8/31/21 during a weekly wound assessment. The resident is Medicare A and is required to have daily assessments. The assessments are located in the focused observations. The focused observations do not require staff to identify the wound by size, color, or description, they are only required to document the location. She said she was not sure what the wound policy required as far as documentation. During an interview on 10/22/21 at 11:00 A.M., the physician's social worker/long term care navigator, said 11 days is a very short time to go from no pressure wound to a stage IV. The physician would have expected to have been notified regarding any changes to the resident's skin, and had he been notified, he would have written a treatment order. MO 437 MO 420 MO 047 MO 828

Based on observation, interview and record review, the facility failed to assess, monitor and treat a residents pain which resulted in a resident having unrelieved pain, failed to appropriately follow up after a critically high blood glucose reading, failed to follow physician orders [REDACTED].#4, #3 and #17). The census was 70. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/24/16, showed: -Able to make self understood; -Brief interview for mental status (BIMS) score of 12 out of a possible 15; -A score of 8 through 12, indicate moderate cognitive impairment; -Limited assistance of one person required for bed mobility; -Extensive assistance of one person required for transfer and dressing; -[DIAGNOSES REDACTED]. -No pain. Review of the resident's care plan, dated 9/11/15, showed the resident had a [MEDICAL CONDITION] related to a fall. Monitor/document/report to the physician as needed signs and symptoms of [MEDICAL CONDITION] complications: Pain, difficulty breathing, impaired mobility, unrelieved pain and poor air exchange. Review of the resident's physician order [REDACTED]. -An order dated 2/21/16, for [MEDICATION NAME] (narcotic pain medication used to treat break through pain) 5 milligram (mg) every four hours as needed for pain; -An order dated 10/11/16, for MS ER ([MEDICATION NAME] sulfate extended release, narcotic pain medication used to maintain tolerable pain levels for residents with chronic pain and commonly used in conjunction with a pain medication for breakthrough pain. Takes 30 minutes to an hour to take effect) 15 mg two times a day at 8:00 A.M. and 8:00 P.M.; -An order dated 11/8/16, for [MEDICATION NAME] (Tylenol) 500 mg every eight hours as needed for pain/fever; -an order for [REDACTED]. Observation on 12/13/16 at 6:35 A.M., showed the resident sat in a wheelchair in the second floor dining room. He/she said I need a pain pill. At 6:37 A.M., Registered Nurse (RN) B said he/she will get the resident medication for his/her pain. At 6:40 A.M., RN B entered the dining room and asked the resident what kind of pain he/she was having. The resident described chest pain from coughing rating 10 out of 10. RN B said he/she will get the resident something for pain as soon as he/she gets the keys to the medication cart from the night shift nurse. At 6:46 A.M., RN B told Certified Medication Technician (CMT) C that he/she could not get into his/her medication cart and asked if CMT C could get into his/hers. CMT C said he/she did not have the keys to get into the medication cart. At 6:53 P.M., RN B said he/she was going to pull the pain medication from stock. He/she got onto the elevator and went up to the third floor medication room. RN B searched through the stock medications and said that he/she was looking for [MEDICATION NAME] or [MEDICATION NAME] but he/she could not find any of these medications in stock. He/she does not know where the night nurse is to get the keys. He/she returned to the second floor. At 6:57 A.M., a staff person came up to the resident in the dining room and asked him/her if he/she was okay, the resident said that he/she was still in pain. At 7:08 A.M., RN B said he/she was going to find Tylenol 500 mg for the resident's pain. At 7:11 A.M., he/she brought the Tylenol 500 mg to the resident in the dining room. The resident reported his/her pain as 10 out of 10. He/she had a grimaced expression on his/her face and he/she slouched foreword in his/her chair towards the table. The resident said he/she did not think the Tylenol would work for his/her pain and RN B told the resident that he/she did not have the keys to access any stronger medication and he/she would return later to reassess the pain. At 7:15 A.M., the resident took the Tylenol. At 7:19 A.M., the resident requested staff take him/her to his/her room because of the pain. Review of the resident's medication administration record (MAR), dated 11/14/16 through 12/13/16 and reviewed on 12/13/16 at 7:16 A.M., showed [MEDICATION NAME] 500 mg given for pain rating of 10. The resident's [MEDICATION NAME] and [MEDICATION NAME] were both available to be administered, but had not been documented as given. Observation on 12/13/16 at 7:31 A.M., showed Licensed Practical Nurse (LPN) A came to the second floor with the keys to the medication cart. LPN A and RN B counted the narcotic medications on the medication cart. At 7:48 A.M., RN B was moved to the third floor and LPN D took over the assignment on the second floor. Observation on 12/13/16 at 8:18 A.M., showed the resident sat in his/her room in a wheelchair. He/she had a grimaced expression. The resident said I hurt so bad, the Tylenol did not help and he/she wanted to go to bed. At 8:19 A.M., Certified Nursing Assistant (CNA) E entered the resident's room. He/she assisted the resident into bed. The resident said he/she has had a rough day, and he/she has had a painful cough. It is a terrible, painful cough. CNA E told the resident he/she would tell the nurse about his/her pain. At 8:31 A.M., CNA E told LPN D the resident had pain. At 8:39 A.M., LPN D obtained the resident's scheduled MS ER 15 mg and gave it to the resident. The resident said I'm in terrible pain, I can hardly move. During an interview on 12/13/16 at 9:37 A.M., the resident said he/she was still in terrible pain. He/she rated the pain as 9. The resident put his/her call light on at this time to request additional pain medication. Observation on 12/13/16 at 9:40 A.M., showed two staff entered the resident's room. The resident informed the staff that he/she needed something for pain. The two staff turned off the call light and left the room. The two staff walked down the hall and into another resident's room. During an interview on 12/13/16 at 9:47 A.M., the resident said he/she told the staff that he/she was in pain, but he/she did not know what they were doing about it. The resident's respirations were deep and heavy, and he/she had facial grimacing. As of 10:27 A.M., no staff had returned to the resident's room. Further review of the resident's MAR, on 12/14/16, showed no [MEDICATION NAME] or additional Tylenol administered on 12/13/16. Review of the resident's nurse's notes, on 12/14/16, showed no documentation of the resident's pain on 12/13/16, an assessment of the resident's cough or follow-up of the residents pain levels. During an interview on 12/15/16 at 8:50 A.M., Director of Nursing (DON) T said if a resident had pain rating of 10 and had a choice of [MEDICATION NAME] or Tylenol, she would expect the [MEDICATION NAME] be given. The assessment of the resident's pain and follow-up after the medication was given should be documented on the back of the MAR. Staff should follow up on the effectiveness of pain medications 15 minutes after the administration. If the pain continued to be rated as 9, additional medication should be given. In this incident, the [MEDICATION NAME] should have been given first, but if the Tylenol did not work, the [MEDICATION NAME] should definitely be given after the second request. If a resident tells staff that he/she had pain, she would expect the staff to inform the nurse so the nurse could follow-up with the resident. Staff should have followed-up on the resident's complaint of a cough and the physician should have been notified if the resident was having so much pain from a cough. The resident usually does not have pain, so having a pain rating of 10 is unusual. During an interview on 12/15/16 at 1:15 P.M., Physician K said he/she was notified that the resident on the first and second floor could not receive their medications on 12/13/16. He/she would expect staff to give medications as ordered. 2. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Short and long term memory impairment; -Severe impairment with decision making; -Dependent on staff for activities of daily living (dressing, eating, etc.); -Impairment in both lower extremities (hip, knee, ankle, foot) that interfered with daily functions or placed resident at risk of injury. Review of the resident's medical record, showed: -A care plan, dated 11/9/15 and in use at the time of the survey, showed the following: -Problem: Takes a water pill daily due to high blood pressure and [MEDICAL CONDITION]; -Intervention: Elevate lower extremities as needed; -Problem: [MEDICAL CONDITION] (fluid retention) in lower extremities related to dementia and obesity; -Intervention: Check skin when giving care and notify charge nurse of any red/open areas. Monitor for any increased [MEDICAL CONDITION] and report to the physician and encourage resident to elevate lower extremities as needed; -A POS, dated 11/14/16 through 12/13/16, showed the following: -An order dated 7/30/16, for [MEDICATION NAME] (water pill, used in the treatment of [REDACTED]. -A standing order for [MEDICATION NAME] (elastic tubular support bandage) apply to both lower extremities in the morning and remove at night; -A MAR, dated 11/14/16 through 12/13/16, showed staff failed to document the administration of [MEDICATION NAME] on 12/13/16. Observation on 12/14/16 at 10:30 A.M., showed the resident sat in a wheelchair in the second floor TV area without his/her legs elevated. Staff had applied compression stockings to his/her legs. The top of each compression stocking was positioned above the calf and below the knee and made deep indentations into his/her [MEDICAL CONDITION] legs. Observation on 12/14/16 at 11:20 A.M., showed the resident remained in the wheelchair in the TV area of the second floor. He/she had [MEDICAL CONDITION] to his/her lower legs and the compression stockings left an indentation on each leg calf region. DON T performed an assessment of the resident's lower extremities and said, the legs are [MEDICAL CONDITION] and the stockings are too tight leaving indent markings in the skin, they need to be removed so he/she does not develop a blood clot. DON T further said she had spoken with the nursing staff this morning about the need to contact the resident's physician regarding the swelling in both legs and to order new compression stockings, elevate the resident's legs and discuss his/her medications. Further review of the resident's medical record, on 12/15/16 at 6:50 A.M., showed: -No nurse's notes showed staff contacted the resident's physician regarding the resident's [MEDICAL CONDITION] of the lower extremities and no new physician's orders [REDACTED]. -A MAR, dated 12/14/16 through 1/13/17, showed staff failed to document the administration of [MEDICATION NAME] on 12/14/16. Observation on 12/15/16 at 7:35 A.M., showed the resident sat in his/her room in a wheelchair. His/her legs hung down at an approximate 90 degree angle. The resident wore compression stockings, rolled and bunched below the knee. His/her bilateral legs were swollen. The right leg was significantly swollen with a deep indention below the knee where the stocking bunched up. Both legs contained swelling above and below the indention line. As the nurse pulled the stocking up above the resident's knee, the resident yelled, That hurts. During an interview on 12/15/16 at 9:00 A.M., DON T said if a medication is not documented on the MAR, it was not given. She would expect the staff assigned to the resident to notify the charge nurse of the resident's [MEDICAL CONDITION] to the lower extremities. The charge nurse then should contact the resident's physician for further instructions/orders. During an interview on 12/15/16 at 1:15 P.M., the resident's primary care physician, Physician K, said he/she did not recall if facility staff called him/her yesterday about the resident's [MEDICAL CONDITION]. 3. Review of Resident #17's POS, dated 11/14/16 through 12/13/16, showed: -[DIAGNOSES REDACTED].>-An order dated 10/12/16, for blood sugar checks four times a day with meals. Review of the resident's nurse's MAR, dated 11/14/16 through 12/13/16, showed on 12/10/16 at 12:00 P.M., the resident's blood sugar level results as HI. Review of the resident's nurse's notes, showed no documentation that staff rechecked the resident's blood sugar level after the HI reading, assessed or documented the resident's condition or physician notification on 12/10/16. Review of the facility's blood sugar machine user manual, showed: -Understanding a blood sugar test result: If the meter displays a result that is HI, contact the physician or healthcare provider; -Trouble shooting: HI = the blood sugar is higher than 600; -What should you do: Caution, if you see HI displayed the blood sugar level may be above 600. Repeat the test. If you receive the same results, contact the physician or healthcare provider. During an interview on 12/15/16 at 1:47 P.M., DON T said she is not sure what a HI reading on the blood sugar machine means, but if staff were to get this reading, she would expect staff to immediately recheck the resident's blood sugar. If the blood sugar continued to show HI, she would expect the staff to contact the physician, assess the resident and obtain orders to treat the high blood sugar levels. This should be documented in the nurse's notes.

Based on interview and record review the facility failed to provide prompt and adequate assessment, intervention, documentation and physician notification for two residents who suffered a change of condition and died . One resident's change in condition took place over the course of nine hours. The change was noted at the beginning of the night shift, but the resident did not go to the hospital until after the day shift began. The other resident's change in condition occurred suddenly after just returning from a hospital stay. (Residents #1 and #2) The census was 44. 1. Review of Resident #1's hospital discharge orders, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -[MEDICATION NAME] (long acting) insulin 13 units daily; -Decrease accuchecks (a finger stick method of testing blood sugar levels) from four times a day to two times a day; -[MEDICATION NAME] (an antibiotic used to treat bacterial infections of the urinary tract and pneumonia) 600 milligrams (mg) every twelve hours. Review of the resident's physician's orders [REDACTED]. -Readmission to the facility; -[DIAGNOSES REDACTED]. -[MEDICATION NAME] 13 units daily at 6:00 A.M.; -Accucheck twice a day with sliding scale regular insulin; -[MEDICATION NAME] 600 mg every twelve hours to treat the [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Short/Long term memory loss; -Cognitive impairment; -Totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing; -Held food in mouth/cheeks, residual food in mouth after meals; -Incontinent of bowel and bladder. Review of the resident's nurse's note, dated [DATE], showed the following: -No time documented, staff reported the resident was coughing during breakfast, call to the physician, order received for speech evaluation; -4:30 P.M., Resident up in gerichair, sweating, respirations labored. Vital signs (VS): blood pressure (B/P) ,[DATE] (normal ,[DATE]), pulse (P) 116 (normal range 60 - 80), respirations (R) 24 (normal 12 - 20), Temperature (T) 102 Fahrenheit (F) (normal 98.6), blood sugar (BS) 302 (normal range before a meal 70 - 100 and after a meal 135 - 140). Call to physician, order received to send to hospital, ambulance called; -5:30 P.M., Ambulance arrived. Review of the resident's hospital's transfer assessment, discharge summary, dated [DATE] showed the following: -Reason for transfer: stable; -Current [DIAGNOSES REDACTED]. -Full code; -Pupils equal and reactive to light (PERL); -Lungs: slightly coarse, oxygen saturation 97% to 100%; -BP ,[DATE], P 68, R 16 and T 98.2 F. Review of the resident's ambulance patient care report, dated [DATE], showed the following: -5:45 P.M., BP ,[DATE], P 78, R 18; -Patient on room air; -Airway, breathing and circulation intact; -Patient responded with yes/no answers; -Had a terrible cough. Review of the resident's hospital discharge orders, dated [DATE] showed the following: -[MEDICATION NAME] 13 units once daily; -Discontinue sliding scale insulin; -Accucheck once a day; -Bethaprim DS (antibiotic) twice a day for seven days. Review of the resident's POS, dated [DATE], showed the following: -Readmission to facility; -[DIAGNOSES REDACTED]. -Full code; -Accucheck once daily at 7:00 A.M.; -[MEDICATION NAME] 13 units once daily in the morning at 7:00 A.M.; -Bethaprim DS (antibiotic) twice a day for seven days to treat a UTI. Review of the resident's nurse's note, dated [DATE], showed the following: -At 6:30 P.M.; -readmitted to the facility from the hospital (no mention of current diagnosis/reason for hospitalization ); -Alert and oriented to name; -No vital signs documented; -Pupils equal and reactive to light; -Lung sounds clear; -Respirations even and unlabored; -No distress noted. -At 7:00 P.M.; -Doctor notified and orders verified. Review of the resident's skilled nursing flow sheet, dated [DATE], showed the following: -Night shift: 3:00 A.M., BP ,[DATE], P 100, R 20, T 98.7 F. Resident rested in bed, no signs or symptoms of discomfort or distress, diaphoretic (sweating); -Day shift: 2:00 P.M., BP ,[DATE], P 88, R 20, T 98.4 F. Up in dining room, consumed 100% of breakfast and lunch, speech therapy observed during the meals, no distress noted or voiced; -Evening shift: 10:00 P.M., BP ,[DATE], P 90, R 20, T 98.0 F. Resident in bed resting, continued to be diaphoretic, total dependence on staff for care, no signs or symptoms of distress. During an interview on [DATE], at 3:40 P.M. Certified Nurse Aide (CNA) A said he/she took care of the resident on the evening shift of [DATE]. He/She fed the resident 100% of his/her evening meal. While providing care he/she noticed the resident was sweating and told the nurse. The nurse said to monitor the resident and to wash him/her with cool towels. The CNA said the resident would follow his/her movements with his/her eyes and he/she did not notice any problems with the resident's breathing. During an interview on [DATE], at 12:55 P.M., Nurse B said he/she worked the evening shift of [DATE], and remembered telling staff to get the resident up for dinner. Staff fed the resident 100% of his/her meal. The resident's vital signs were stable and he/she did not notice any distress. Review of the resident's skilled nursing flow sheet, dated [DATE], showed the following: -Night shift: 3:00 A.M., BP ,[DATE], P 116, R 22, T 104.1 F. Head of bed up. Tylenol given, temperature up to 104.1 F. Blood sugar 404, [MEDICATION NAME] given (no dose documented). Diaphoretic, beads of sweat on the resident's forehead, will continue to monitor. No further documentation regarding the resident's condition; -Day shift: 8:50 A.M., No documentation of the resident's BP, P, R or T. Transported to hospital, resident unresponsive, breathing labored with periods of apnea (absence of breathing) for 30 seconds; -Front of flow sheet: Day shift: 8:50 A.M., PERL: (nothing marked), lung sounds irregular, with the word "gurgles" written in, skin cold, clammy and the word "mottled" (bluish, blotchy color, occurs when circulation in body has decreased) written in. During an interview on [DATE], at 2:10 P.M., CNA C said he/she took care of the resident on the night shift that started at 11:00 P.M. on [DATE] and went until 7:00 A.M. on [DATE]. He/She saw the resident at 11:15 P.M., while making rounds and noticed he/she wasn't himself/herself. The resident's respirations were heavy, but not to the point of being scary and he/she was covered in sweat. While making rounds at 1:00 A.M., the CNA noticed the resident didn't speak and he/she told the nurse the resident didn't look good. The resident was panting and he/she told the nurse again the resident didn't look too good. He/She thought the nurse gave the resident Tylenol but wasn't sure. During rounds at 3:00 A.M., the resident's respirations were rapid, he/she remained sweaty and hadn't been incontinent of bowel or bladder all night, which was unusual. The CNA last saw the resident between 6:30 A.M. and 6:45 A.M., and his/her respirations were rapid and hard and he/she was sweating profusely. He/She did not make rounds with the oncoming shift and left work at 7:00 A.M. During an interview on [DATE] at 12:22 P.M., Nurse D said his/her shift began at 11:00 P.M. on [DATE], and he/she learned in report the resident had returned from the hospital on the evening shift of [DATE]. During rounds at 11:30 P.M., he/she noticed beads of sweat on the resident's forehead but did not check his/her temperature or do an assessment. CNA C checked the resident's vital signs at 1:00 A.M., and reported a temperature of 104.1 F. The nurse administered Tylenol but failed to do an assessment. He/She saw the resident again at 5:00 A.M., rechecked the temperature which was around 102 F, but failed to document the results in the nursing notes. He/She checked the resident's blood sugar and obtained a reading of 404 and administered [MEDICATION NAME] and sliding scale insulin. He/She did not call the physician to notify him/her of the elevated blood sugar or the elevated temperature. The nurse would not give an explanation as to why he/she documented giving [MEDICATION NAME] at 3:00 A.M., why he/she did not monitor the resident's condition throughout the night and why he/she did not call the resident's physician about the resident's change in condition. The day shift nurse, Nurse E, arrived at 7:00 A.M. Nurse D placed a call to the physician after 7:00 A.M., and informed him/her of the resident's elevated blood sugar and temperature. The physician gave an order to send the resident to the hospital. He/She placed a call for a routine ambulance, not a 911 call. The resident's legs were turning blue but he/she did not start any oxygen. The nurse did not recall what the resident's respirations were and when asked about the pulse of 116, said he/she wasn't focused on the resident's high pulse. The resident had been to the hospital four times recently and each time he/she returned in worse condition. Nurse D said the resident was a Full Code and he/she should have done a better job of documenting the resident's condition. The nurse did not mention calling the Director of Nurses (DON) at the end of the shift. During an interview on [DATE] at 12:48 P.M., Nurse E said his/her shift started at 7:00 A.M. on [DATE]. In report Nurse D said the resident had a 104.1 F temperature, a blood sugar of 404 and Nurse E would probably have to send him/her out. During rounds Nurse E noted the resident was diaphoretic, respirations were labored, lung sounds were wet and his/her legs were mottled from the knees to the feet. He/She told Nurse D the resident's condition did not just occur, he/she needed to call the physician and get an order to send the resident to the hospital. Nurse E said he/she did not do an assessment, obtain vital signs or start any oxygen. The resident remained diaphoretic with wet lung sounds so loud the resident could be heard gurgling from out in the hall. Nurse E said the resident's eyes were open, but he/she was not alert and did not respond when the nurse did a sternum (bone in the center of the chest) rub (a painful procedure used to determine the alertness of a resident). The paramedics arrived between 8:30 A.M. and 8:45 A.M., and asked about the resident's baseline. He/She told them the resident was normally able to talk and respond. When they asked why the resident hadn't been sent out 911 earlier, he/she told them he/she didn't know. Nurse E said it was a nursing judgment call; if a resident had a high temperature or was unstable, the nurse should call the physician and send the resident out. Review of the resident's Emergency Medical Service (EMS) Patient Care Report, dated [DATE], showed the following: -Arrived on scene at 8:32 A.M.; -8:45 A.M.: Orientation - 0, BP ,[DATE], P 76 weak and thready, Breathing Rate and Effort: 6 (no scale given) with apnea, breath sounds: diminished and coarse, skin condition: pale, cool, clammy, oxygen saturation: 88% (normal range is greater than 90%); -[AGE] year old found in bed, pale cool, clammy, respirations: 6 to 7 times a minute with 10 to 15 seconds of apnea, mottled skin; -Moved to ambulance, placed on 15 liters per minute of oxygen; -Coded (heart stopped) while in route to hospital, CPR started. During an interview on [DATE] at 8:55 A.M., Emergency Medical Technician (EMT) F said he/she arrived on the scene and spoke with Nurse E, who reported the resident had recently been discharged from the hospital with a [DIAGNOSES REDACTED]. The resident's mouth was not just open but gaped open. He/She took the resident's blood pressure, which registered ,[DATE]. The EMT asked Nurse E how long the resident been breathing like that and he/she said since he/she arrived at 7:00 A.M., and that the night nurse had said throughout the night. EMT F asked why staff didn't send the resident out sooner and Nurse E said he/she didn't know why 911 wasn't called earlier. Review of the resident's hospital's Emergency Record, dated [DATE], showed the following: -Arrived at 9:24 A.M.; -[AGE] year old brought in by ambulance in full [MEDICAL CONDITION]; -Brought in undergoing CPR, lost pulses while en route to hospital; -CPR continued for 30 minutes; -Time of death 9:53 A.M. During an interview on [DATE] at 10:50 A.M., the resident's physician said facility staff should have called him/her about the resident's elevated blood sugar and temperature. Facility staff did not inform him/her of administering [MEDICATION NAME] or sliding scale insulin to the resident at 3:00 A.M. During an interview on [DATE] at 9:25 A.M., the DON said Nurse D no longer worked at the facility. On [DATE], she gave staff an in-service on emergency procedures. When she questioned Nurse D about the situation with the resident and his/her documentation of giving [MEDICATION NAME] at 3:00 A.M., Nurse D said he/she didn't know why he/she documented he/she gave the [MEDICATION NAME] at that time and didn't given any other explanation about the situation. Nurse D had called her at 7:00 A.M., at the end of his/her shift, and told her about the resident's condition. The DON said she told the nurse to send the resident to the hospital. The DON said the nurse should not have waited for the physician to call back, he/she should have sent the resident out 911. The DON said the nurse should have assessed and monitored the resident, obtained and documented the vital signs including oxygen saturations and called the physician with the change in condition. She said Nurse D had difficulty understanding the facility's emergency procedure. The facility didn't have a written policy on emergency procedures but he/she expected the nurses to use their judgment regarding whether they should call the physician and wait for his/her response or call 911. 2. Review of Resident #2's most recent MDS, dated [DATE], showed the following: -No short/long term memory loss; -No cognitive impairment; -Limited assistance of staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Continent of bowel and bladder. Review of the resident's readmission nursing assessment, dated [DATE], showed the following: -admitted at 2:30 P.M.; -Vital signs: BP ,[DATE], P 86, R 20, T 97.2 F; -No pain. Review of the resident's face sheet, dated [DATE], showed [DIAGNOSES REDACTED]. Review of the resident's nurse's note, dated [DATE], at 3:00 P.M., showed the following: -Returned to the facility with daughter; -No shortness of breath; -No complaints of pain; -Complained of being tired; -Lungs clear. Review of a nurse's note, dated [DATE], no time, showed the resident rested in bed, oxygen on at 2 liters/minute, no signs or symptoms of distress. Review of the resident's nurse's note, dated [DATE] at 3:25 P.M., showed the following: -Rested in bed quietly, asleep, no signs or symptom of distress; -No shortness of breath; -Respirations even and unlabored; -Skin warm and dry. Review of resident's the nurse's note, dated [DATE] at 4:00 P.M., showed the following: -Awake, complained of pain, no documentation of where the pain was located; -Anxious behavior; -Periods of rapid breathing; -Oxygen at 2 liters/minute; -Call placed to physician, awaiting return call; -Will continue to monitor; -No documentation of current vital signs or oxygen saturation levels. Review of a nurse's note, dated [DATE] at 4:15 P.M., showed a call was placed to the resident's family member. Review of the resident's nurse's note, dated [DATE] at 4:19 P.M. showed the following: -Called to the room per facility staff; -Unresponsive; -Oxygen on at 2 liters per minute; -Code blue called and cardiopulmonary resuscitation started; -911 called; -911 responded at 4:35 P.M., transported to the hospital. Review of the resident's 911 ambulance trip sheet, dated [DATE], showed the following: -Arrived at 4:28 P.M.; -[AGE] year old patient, with a history [MEDICAL CONDITION]; -Primary complaint of cardiac/respiratory arrest; -Unconscious, unresponsive; -CPR performed by staff; -Staff states the resident complained of difficulty breathing; -Staff left the room, when returned to check on the patient, he/she was pulseless; -Facility staff initiated CPR; -Placed on cardiac monitor, showed no heart rate; -Transferred to hospital, patient remained pulseless throughout the trip to the hospital; -Arrived at hospital at 4:53 P.M., and declared deceased . During an interview on [DATE] at 11:48 A.M., CNA G said his/her shift started at 3:00 P.M. on [DATE]. He/She learned in report the resident had returned from the hospital. While transferring the resident to the wheelchair, the resident began to complain of shortness of breath and sat back on the bed. The CNA told the resident he/she wanted to keep an eye on him/her while doing rounds and tried to transfer the resident to the wheelchair. The resident said, "No, I can't do it. Please call my daughter, tell her to come back to the nursing home because I don't feel well. I don't think I'm going to make it". CNA G called the daughter. The resident continued to complain of shortness of breath and CNA G yelled for the nurse. Nurse H entered the room, said he/she had to verify the resident's medications and left the room without assessing the resident or taking his/her vital signs. The CNA made no mention of getting or being asked to get the resident's vitals signs. The resident tried to sit on the side of the bed, said, "I can't make it" and slumped over. CNA G yelled for Certified Medication Technician (CMT) F and he/she helped put the resident back to bed. The CNA yelled for the nurse and started CPR. CNA G called 911 and code blue and the other nurses came to assist with the code. After a few minutes the paramedics came and he/she left the room. During an interview on [DATE] at 11:27 A.M., Resident #2's daughter said she and the resident returned from the hospital on [DATE] around 1:30 P.M., or 2:00 P.M.. The resident had been in the hospital with pneumonia. The resident got settled in his/her room and there were other visitors in the room as well. They were all talking and laughing with Resident #2. She left and later received a call from the facility. She could hear the resident in the background, gasping for breath and asking for help. The next call she received from the facility informed her of the hospital where Resident #2 was en route. During an interview on [DATE] at 3:35 P.M., Nurse H said his/her shift began at 3:00 P.M. on [DATE]. He/She received report from the day shift nurse and made rounds at about 3:15 P.M., when he/she first saw the resident. The nurse saw the resident again about 30 to 40 minutes later, when he/she complained of pain. Nurse H told the resident he/she would call the physician and left the room. He/She told staff to take the resident's vital signs, but failed to document them. Nurse H failed to do an assessment of the resident's pain or condition. After approximately 15 minutes staff called him/her back to the room. The resident was unresponsive, he/she initiated CPR and staff called 911 and a code blue at that time. During an interview on [DATE] at 2:15 P.M., the DON said the facility did not have a written policy regarding emergency situations. She expected staff to use their nursing judgement to determine whether to call the physician and wait for a return call or to send a resident out 911. The DON said the nurse should have assessed and monitored the resident, gotten and documented the vital signs including oxygen saturations. During an interview on [DATE] at 3:50 P.M., the administrator said they did not have a written policy regarding emergency procedures. He expected the nurses to follow their judgment in regards to whether to call and wait on the physician or to call 911. During an interview on [DATE] at 8:44 A.M., the resident's physician said he/she would expect the nurses to do what nurses are supposed to do. If a resident was short of breath, they should call the physician and send the resident out to the hospital. He/She said it might of made some difference in the outcome if staff had called the physician and sent the resident to the hospital right away. MO 276 MO 539 Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to lower the violation at the time. During the onsite visit, the facility implemented a plan of correction which included the following: All licensed nursing staff were instructed one on one, by the DON to immediately call 911 for change of condition. After calling 911, nursing staff have been instructed to immediately contact the DON. In-services have been conducted for all licensed nursing staff on the following procedures: Medication Procedures, Nursing assessment procedures including Code Blue procedures, assessment, documentation, physician notification and 911 procedures. All staff will be in-serviced once a month on emergency procedures. A nursing in-service will be held for all nursing staff on [DATE], covering the following topics: Emergency procedures, mock code, how to run a code, [DIAGNOSES REDACTED], [MEDICAL CONDITION], when to call 911, when to wait on the next available ambulance,[MEDICAL CONDITION] and ABC'S (airway, breathing circulation). A CPR in-service will be held on [DATE], by an ambulance company which will include a surprise mock code demonstration. In addition non licensed staff and other facility staff will receive CPR training on or before [DATE]. All charge nurses have been instructed to call the DON with a shift report at the end of their shift. The DON and Administrator will meet within the first hour and the last hour of each work day to discuss current situations. The facility has scheduled two clinical consultants from outside agencies to visit the facility weekly and monthly. They will visit during the week of [DATE], and be available for phone consultation at any time. Their visits will focus on the emergency procedures listed above and will include their ongoing assessment of the clinical staff, policies and procedures. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).