Every finding on record at Nazareth Living Center

Based on interview and record review, the facility failed to provide adequate assistance to prevent the risk of accidents by failing to ensure appropriate and safe transfer techniques were used in the care of one resident (Resident #1). The resident had a history of a knee replacement and had hardware surgically inserted into the lower end of the femur (upper bone of the leg). As early as 1/28/26, the resident reported pain to the right leg, and no documentation showed staff assessed the leg at this time. On 2/1/26, staff failed to use the foot pedals on the resident's wheelchair while propelling him/her to breakfast and lunch. This resulted in the resident's legs dragging and caused the resident more discomfort in the right leg. In addition, after the resident expressed more pain to the right leg, staff failed to transfer the resident with a mechanical lift per the facility's expectation. An x-ray completed at the facility found a right femur fracture, age-indeterminate (it could not be determined if the fracture was new or old). The physician could not confirm findings on the x-ray represented the initial fracture requiring hardware placement or a new acute fracture around the surgically placed hardware. The sample was 10. The census was 86.The Administrator was notified on 2/5/26 of the past non-compliance. The facility in-serviced nursing staff on using footrests while propelling in a wheelchair, moving residents with a suspected injury, and transferring residents using the proper transfer status. The deficiency was corrected on 2/3/26. Review of the facility's Safe Lifting and Movement of Residents Policy, effective 9/13/24, showed: -Policy: In order to protect the safety and well-being of associates and residents, and to promote quality care, all communities use appropriate techniques and devices to lift and move residents.-Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents;-Nursing associates, in conjunction with the rehabilitation associates, shall evaluate individual resident needs for transfer assistance on an ongoing basis. Associates will document resident transferring and lifting needs in the care plan. Evaluations shall include the following:--Resident's mobility (degree of dependency);--Resident's size--Weight-bearing ability;--Cognitive status;--Whether the resident is usually cooperative with staff; and-Associates responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices;-Mechanical lifting devices shall be used whenever possible, including lifting and moving residents when necessary. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/24/25, showed:-Severe cognitive impairment;-No upper or lower extremity impairment;-Resident needed substantial/maximal assistance with toileting, upper body dressing, personal hygiene; -Resident dependent with shower/bathe self, lower body dressing, and put on/take off footwear;-Resident uses wheelchair for mobility. For transfer, resident needed partial/moderate assistance with roll left and right and sit to lying;-Resident needed substantial/maximal assistance with lying to sitting on bed side, sit to stand, chair/bed to chair transfer, and toilet transfer;-Diagnoses include high blood pressure, depression, anxiety, and non-Alzheimer's Dementia. Review of the resident's care plan, revised on 12/23/25, showed:-Problem: Falls, Unsteady Gait does not ask for assistance;-Goal: No major injuries related to falls through next review;-Approach: Staff to offer assistance with toileting/activities daily living care during rounds and as needed, make sure my walker/wheelchair is beside me and the bathroom light is turned on, transfer with gait belt and assist of one staff. Review of the resident's electronic Physician Order Sheet (ePOS), showed:-An order dated 2/1/26, for x-ray to right lower extremity. Pain, decreased range of motion and swelling on knee area;-An order dated 2/2/26 and end date 2/2/26, x-ray to right lower extremity. Pain, decreased range of motion and swelling on knee area; Review of the resident's medical record showed a provider note, dated 2/2/26, which included:-Chief Complaints: Patient is being seen for knee pain;-Resident with a history as below seen today for acute visit. On 2/1 the on-call physician was notified of patient having pain to Right Lower Extremity (RLE) with swelling, decreased range of motion, and pain with movement. Orders were given for x-ray Reviewed nurses notes today, no documentation of falls noted in the last 1 month;-Around 1:00 P.M., nurse came to report results of x-rays. Right femur x-ray showed an age-indeterminate distal femur fracture. This may represent the initial fracture requiring hardware placement, may represent a new acute peri (area around) hardware fracture, indeterminate given the lack of prior studies. Patient now with severe pain, swelling, deformity noted to the right knee. Will send to emergency room for further evaluation/treatment. Review of the facility's investigation into the Certified Nursing Assistant (CNA), who propelled the resident in a wheelchair with no foot pedals, showed:-Description of What Was Observed: Staff member was transporting Resident #1 to breakfast. While being pushed down the hallway, the resident suddenly screamed. The Licensed Practical Nurse (LPN), who was a few feet away, heard the scream and immediately responded. Upon evaluating the resident, the LPN noted that the wheelchair did not have foot pedals attached. He/She instructed staff to place the foot pedals on the wheelchair and then assessed the resident for pain. After the resident's feet were placed on the pedals, the resident denied further pain. No injuries were observed upon inspection. The LPN notified the on-call physician of the potential injury, and an x-ray was ordered. The resident was then taken to breakfast, where he/she voiced no additional complaints of pain. The resident remained in his/her wheelchair until lunch at 12:00 P.M. Shortly after lunch, the resident's family member arrived for a visit and expressed concern about a possible injury. The family member took the resident to his/her room. During an interview, the family member stated that he/she typically transfers the resident independently using a gait belt, despite acknowledging that the resident requires a two-person Hoyer lift (full body mechanical lift) transfer. The family member reported that when he/she moved the resident's leg off the pedal, the resident screamed. The family member then activated the call light for nursing assistance. Two staff members assisted with transferring the resident from the wheelchair to the bed. One staff member stood the resident, turned, and pivoted him/her toward the bed while the second staff member moved the wheelchair out of the way. The family member then grabbed the resident's ankles and assisted in lifting his/her legs into the bed. The resident expressed discomfort during this process;-Injuries Observed at Time of Incident: No visible injuries noted, only verbal discomfort expressed during movement of lower extremity. Resident has had knee surgery. Which causes his/her knees to naturally appear malformed.-Determined Cause or Contributing Factors: Lack of foot pedals on wheelchair and improper transfer. Review of the resident's progress notes, showed:-On 2/1/26 at 2:47 P.M., resident is complaining of pain to right lower extremity, assessments done, and notes is as follows: swelling on right knee, decreased range of motion, pain upon movement, physician on call notified. New order given for an x-ray;-On 2/1/26 at 8:08 P.M., x-ray representative called facility and notified this writer that the x-ray will be rescheduled for tomorrow reason being they do not have a tech available for tonight;-On 2/2/26 at 10:40 A.M., resident Hoyer lift to bed with assistance of tech. Briefs changed. Complaints of pain when bilateral (both sides) lower extremity (BLE). X-ray done. Resident lying in bed resting;-On 2/2/26 at 12:50 P.M., x-ray results received. Age-indeterminate distal femur fracture. Report given to physician and Nurse Practitioner (NP). Orders to send to ER for assessment. During an interview on 2/4/26 at 9:10 A.M., the Director of Nursing (DON) said the resident was sent out on 2/2/26. He/She was found to have a right femur fracture. They do not think the fracture was caused by a transfer by the family. The resident did not have a fall. The CNA over the weekend was propelling the resident in his/her wheelchair. The resident's nurse heard the resident say ow. After the nurse attended to the resident, the physician was called and x-ray was ordered. The resident was sent out 2/2/26 after x-ray results came back. The resident is still in the hospital. He/She had history of osteoporosis (thinning of the bone) and knee replacement with hardware, so his/her knee/leg presented as looking off anyway. During an interview on 2/4/26 at 10:02 A.M., Licensed Practical Nurse (LPN) F said he/she sent the resident to the hospital on Monday, 2/2/26. The resident had been complaining of leg pain. He/She got in report that morning that the resident had fallen down a few days ago and the x-ray was ordered but not done. He/She believes that he/she was told the resident fell on Saturday but not sure. There were no notes in the medical record about the fall, only that the resident's leg hurt. During an interview on 2/4/26 at 10:30 A.M., the Administrator said when the facility first reported the incident with the resident. They were not sure what happened. They are still finishing their investigation. The resident has not had a fall documented since December. During an interview on 2/4/26 at 11:30 A.M., CNA C said he/she last worked with the resident on 2/2/26 when he/she provided feeding assistance to the resident. CNA C is not sure when the resident's leg injury happened. The resident said it was hurting last week. When he/she came in last Wednesday (1/28/26), the resident was complaining. He/She screamed and pointed/held the leg. The CNA saw it looked slanted so tried to find a Broda chair (medical reclining chair) because he/she figured it would be easier for the resident to sit in that. The CNA found a physical therapist to request the chair. The Physical Therapist (PT) went to assess and said the Broda chair was not appropriate but gave elevated foot pedals. CNA C said he/she reported the resident's symptoms to nurse on duty. The nurse told him/her the resident must have had a fall. CNAs do not know what nurses can see so assumed an x-ray was done at that time. CNA C worked with the resident the rest of the week and not much changed. The CNA returned on Monday and felt that something was wrong. When the CNA and another aide tried to get the resident up the resident was screaming louder. There was more swelling. If CNA C had known the leg was broken, he/she would not have gotten the resident up. Review of the resident's medical record, showed no documentation the resident was assessed for injury after reporting pain on 1/28/26. During an interview on 2/4/26 at 3:25 P.M., the Physical Therapist said he/she was the one who assessed the resident last week. The resident was not suitable for Broda chair but was for the elevated leg rest. The resident yelled out when the PT moved his/her leg. After the PT got the elevating leg rests, the resident did not yell at the PT the second time. The PT was not sure if the leg was swollen, the resident was wearing pants. The PT did let the nurse know. The resident is receiving occupational therapy for his/her wrist. He/She is not currently receiving physical therapy. The PT said it is not unusual for the resident to scream out. During an interview on 2/4/26 at 3:41 P.M., the resident's physician said on Sunday 2/1/26, the nurse notified the on-call physician about the resident. An x-ray and labs were ordered. The x-ray was ordered standard, not STAT so they would have 24 hours to complete the x-ray. During an interview on 2/5/26 at 9:42 A.M., CNA G said he/she worked evening shift three days last week. He/She did not recall the resident complain of pain and was not grabbing at his/her leg. The resident's leg did not appear swollen and he/she did not cry out more than normal when rolling or transferring with the Hoyer lift. The resident did tend to cry out and yell a lot and would get agitated very easily. CNA G did not work over the weekend. The last day worked was Friday 1/30/26. He/She does not remember any signs of anything out of the normal for pain or the resident being hurt. The resident is transferred by a Hoyer lift. During an interview on 2/5/26 at 1:35 P.M., LPN B said he/she worked both Saturday and Sunday. On Saturday, the resident was acting normal. On Sunday, the LPN reports he/she was doing tasks and saw the assigned CNA, CNA A, propelling the resident in the wheelchair and heard screaming. The aide was propelling the resident with no leg rests and the resident's right leg was observed to be dragging. The resident's right leg has always been weak. The nurse went to assess the resident. When LPN B touched the resident's right leg, the resident screamed. The nurse touched the leg a second time and the resident did not scream. The resident then laughed. The nurse assisted getting the residents foot pedals and the CNA took the resident to lunch. LPN B said he/she called the physician because the resident's leg was dragging and it was a little swollen. The resident seemed ok. After lunch, LPN B said he/she saw CNA A and Certified Medication Technician (CMT) D in the resident's room with the family member and no Hoyer lift. LPN B stopped to make sure everything was ok. The resident was already transferred into bed. LPN B said the family member assisted in putting the resident to bed too. They should have used a Hoyer lift. LPN B said the resident's leg was a little swollen but the resident was not screaming and was calm. During an interview on 2/5/26 at 1:50 P.M, CNA A said he/she arrived at the facility at 6:45 A.M. on 2/1/26. Ther resident was already up in a wheelchair. The resident is a Hoyer transfer but did not have Hoyer sling under him/her. CNA A said he/she got other residents up and then came back to take the resident to breakfast. As CNA A propelled the resident, the resident hollered. CNA A said the resident yells a lot, so he/she just thought it was the resident's behavior. CNA A instructed the resident to put his/her legs up and CNA A continued taking the resident to breakfast. When CNA A was propelling the resident to lunch, it happened again but a louder holler and thought the leg looked swollen so the CNA just got nurse. LPN B asked if the resident had any foot pedals and found them in the corner of the room. CNA A said they got the foot pedals but normally the resident does not need them. The resident did holler when staff lift his/her leg on the foot pedal then he/she was fine. Around 12:30 or 1:30 P.M., staff put the resident to bed. CNA A said he/she asked CMT D to assist. They just lifted him/her and had the resident stand/pivot and set him/her on edge of bed. CMT D laid the resident's head down and then the resident's family member moved his/her legs. CNA A believes the injury happened the morning before he/she got there with the overnight CNA. The resident was in a chair and not on a Hoyer pad so CNA A believes the resident was already hurt. CNA A did not see the resident's leg drag when he/she was propelling the resident in the wheelchair. During an interview on 2/5/26 at 1:52 P.M., CMT D confirmed he/she assisted CNA A with the transfer. The family member was there but did not say anything except talking about getting x-ray because the resident hurt his/her leg. Staff and family stood the resident up and stand pivoted the resident to the bed. The family member grabbed the resident's leg and the resident made a noise but that was the only time. CMT D did not see any swelling of the right leg. CMT D said he/she was not aware of the resident's transfer status and does not normally transfer the resident. During an interview on 2/5/26 at 2:45 P.M., the Administrator said CNA A should have used foot pedals with the wheelchair and the Hoyer lift should be used. They would have expected the staff to get the nurse to assess when the family was wanting to transfer the resident without a Hoyer. At 4:45 P.M., the Administrator said based on their investigation findings they think the resident's injury may have occurred when he/she was transported in his/her wheelchair by the CNA. During an interview on 2/6 at 8:45 A.M., the Physician said it would be appropriate to transfer without the foot pedals only if they could self-propel. During an interview on 2/6/26 at 8:55 A.M., CNA H confirmed he/she worked the weekend of 1/30/26 through 2/1/26, with the resident. On Friday 1/30/26, the resident was in a mood where he/she did not like to be moved or messed with much. On Saturday, 1/31, the resident said ow and did not like his/her leg moved. CNA H said he/she told the charge nurse who reported that he/she would check on the resident. On Sunday 2/1/26, the resident was worse. The resident was crying after he/she changed the resident. CNA H was not sure where the pain was coming from. The resident has been known to thrown herself on the floor so CNA H said he/she just puts pillows around the resident so he/she cannot do that. CNA H said sometimes he/she just picks the resident up and places him/her on the recliner to calm him/her down when he/she is restless in bed. The resident was just tense but still somewhat normal. The resident did not like to be moved back and forth. The resident is supposed to be Hoyer transfer but they switch the resident so much. CNA H said he/she just does what everyone else does as far as transfers. He/she thinks the resident can also be a 1-2 assist. After the shift on Sunday night, the resident did not want to get up that next morning so CNA H just let the resident be in bed. 2733825

Based on observation, interview and record review, the facility failed to ensure treatments and medications were administered as ordered for two of four sampled residents (Resident #4 and Resident #2). The census was 93.Review of the facility's policy on Physician Services, dated 2019, showed the following:-Policy: It is the policy of the facility to provide care and services related to Physician Services in accordance with State and Federal regulations;-Procedure: #8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift. Review of the facility's policy on Administering Medications, dated 2020, showed the following:-Purpose: To ensure safe administration of resident's medication as indicated and ordered by the provider;-Policy: To administer resident medications in a safe manner that will ensure the six rights of patient identification for administration;-Procedure: 1. Medications are to be administered by licensed nurses or as delegated, trained associates. 2. Medications are administered in the accordance with the orders;-Medication error is the preparation or administration of drugs or biologicals which is not in accordance with the attending providers orders, manufactures specifications or accepted standards and principles of the professional providing the services;-Examples of medication errors: Omissions. 1. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/9/25, showed the following:-Diagnoses of diabetes, high blood pressure, and peripheral vascular disease (poor circulation);-Required moderate assistance of staff for bathing and dressing; -Two arterial ulcers (ulcer caused by fluid build-up in the skin from poor arterial function)/venous ulcers (lower leg ulcer that develops when the leg veins fail to return blood back toward the heart normally). Review of the resident's care plan, dated 10/3/25, showed the following:-Problem: Chronic wounds to his/her gluteal (buttocks), left ischium (hip), left ankle and left heel;-Approaches included treatment orders per physician and weekly skin assessments. Review of the resident's physician order sheet (POS) and treatment administration record (TAR) for December 2025, showed:-A physician order, dated 12/4/25, to cleanse left heel with wound cleanser, apply Aquacel AG (an antimicrobial wound dressing used for infected or at-risk wounds) to wound bed and cover with foam dressing daily and as needed (PRN);-On 12/4/25, and 12/6/25 through 12/9/25, staff documented the treatment as completed;-On 12/5/25 and 12/10/25, staff documented the treatment not completed due to resident at dialysis;-No documentation that incomplete treatments were completed on a different shift. Review of the resident's progress notes, showed the following:-From 12/4/25 through 12/10/25, no documentation regarding the resident's wound treatment;-On 12/11/25 at 2:29 P.M., staff documented the resident seen by wound company. Dressing removed from left heel dated 12/8/25. No signs/symptoms of infection. Odor noted to old dressing. No change in treatment plan. Review of the wound care company note, dated 12/11/25, showed the following:-Chief complaint: Vascular wound (a persistent skin ulcer caused by poor blood circulation in the arteries or veins) to the left heel;-History of present illness: Vascular wound to the left heel. Resident states the wound has been present for several weeks. Resident has an MRI (a specialized imaging test) scheduled for mid-December;-Plan of care: Goal of treatment: Heal. Wound progress: Dressing in place dated 12/8/25, wound has 70% granulation (healing tissue) and 30% eschar (hard dead tissue) with a small amount of drainage. Further review of the resident's TAR and progress notes for December 2025, showed:-From 12/11/25 through 12/14/25, and 12/16/25, staff documented the resident's treatment completed;-On 12/15/25, staff documented the treatment not completed due to resident at dialysis;-No documentation that incomplete treatments were completed on a different shift. Observation on 12/16/25 at 9:10 A.M., showed the resident sat in his/her wheelchair. His/her left heel had a dressing dated 12/16/25. Licensed Practical Nurse (LPN) A removed the dressing from the resident's left heel. Observation showed a wound approximately 3.0 by 5.0 centimeters (cm) with a red and yellow wound base. LPN A cleaned the wound with normal saline, dried and applied Aquacel AG, large gauze pad and a gauze wrap. During an interview on 12/16/25 at 9:15 A.M., LPN A said he/she completed the resident's treatment earlier that morning. He/She has found the resident's dressing unchanged at times. Wound treatments are to be completed as ordered. Further review of the resident's TAR and progress notes for December 2025, showed:-On 12/17/25, staff documented the treatment not completed due to resident at dialysis;-No documentation that the incomplete treatment was completed on a different shift. Review of the resident's MRI results, completed 12/18/25, showed the following: -MRI of the left foot completed;-Findings: Osteomyelitis (bone infection) of the left heel. Review of the resident's progress note, dated 12/18/25 at 4:59 P.M., showed new order received to send to emergency room (ER) related to MRI results. During an interview on 1/5/26 at 3:02 P.M., the Director of Nurses (DON) said she expected the staff to complete the resident's dressing change when he/she returned from dialysis. The DON was unaware staff weren't completing treatments as ordered. During an interview on 1/5/26 at 3:25 P.M., the resident's physician and Medical Director said she expected the staff complete the dressing change to the resident's foot as soon as possible. During an interview on 1/8/26 at 10:00 A.M., the Administrator said he expected staff to complete orders as written by the physician. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following:-Diagnoses of high blood pressure, anxiety, and depression;-Required maximum assistance of staff for bathing and toileting;-Required moderate assistance of staff for personal hygiene, dressing and putting on shoes. Review of the resident's POS and medication administration record (MAR) for November 2025, showed:-A physician order, dated 3/31/25, for levothyroxine (a medication used to treat underactive thyroid) 175 micrograms (mcg), once a morning at 6:00 A.M.;-From 11/1/25 through 11/13/25, 11/16/25, 11/20/25, and 11/23/25, staff documented the medication not administered;-On 11/14/25,11/15/25, 11/17/25 through 11/19/25, 11/21/25, 11/22/25, and 11/24/25 through 11/30/25, staff documented the medication administered. Review of the resident's progress notes, showed the following:-On 11/10/25 at 10:48 A.M., staff documented levothyroxine 175 mcg not administered on 11/3/25. Physician and family aware;-On 11/11/25 at 1:24 P.M., staff documented levothyroxine 175 mcg not administered on 11/7/25. Physician and family aware;-No further documentation regarding missing levothyroxine. During an interview on 1/5/25 at 1:50 P.M., LPN B said he/she works the night shift. He/She was aware the resident's levothyroxine was not available. He/She was unable to say why the medication wasn't available. Medications are usually ordered by the Certified Medication Technician (CMT) on day shift. LPN B assumed the medication was on order. During an interview on 1/5/26 at 3:02 P.M., the DON said she expected the staff to notify her if they are unable to obtain a resident's medication or if it was unavailable. In addition, staff are to notify the family and the physician each time a medication was missed. During an interview on 1/5/26 at 3:25 P.M., the resident's physician and Medical Director said she expected the staff to notify her when a resident has not received an ordered medication. During an interview on 1/8/26 at 10:00 A.M., the Administrator said he expected staff to complete orders as written by the physician. 27089692697423

Based on observation, interview and record review, the facility failed to ensure residents are free from accidents when staff failed to properly secure straps in the facility's van during transportation to an appointment, resulting in one resident flipping backward in their wheelchair (Resident #1). The census 101.The Administrator was notified on 12/16/25 of the past non-compliance. The facility in-serviced staff responsible for providing transportation to residents on proper wheelchair positioning and the facility's policy of transporting one wheelchair-bound resident at time in the medical van. The deficiency was corrected on 12/8/25. Review of the facility's policy on Fleet Safety Program, dated 2021, showed the following:-Purpose: To promote safe operation of vehicles within the facility's community and to satisfy auto insurance underwriting requirements;-Policy: The facility established the Fleet Safety Program applicable to all associates and volunteers of the facility and community;-Driving Guidelines: Accident Protocol will be followed in the event of an accident while driving a facility vehicle or when driving a personal or rented vehicle for business purposes;-Accident Protocol: In the event of an accident involving a facility vehicle or a personal or rented vehicle being driven on company business: Contact the police and unless they instruct you to do otherwise, do not leave the scene until the police have arrived and collected necessary information. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/19/25, showed: -Diagnoses of spinal stenosis (a narrowing of spaces within your spine which puts pressure on the spinal cord often causing numbness and pain), anxiety, and depression;-Required total assistance of staff for transfers;-Falls: Yes. Review of the resident's care plan, updated 11/4/25, showed:-Problem: Resident is at risk for falling related to weakness and physical performance limitations affecting balance, gait, strength and muscle endurance;-Approach: Keep bed in lowest position with brakes locked. Remind the resident to use call light. Keep call light within reach at all times. Review of the resident's progress notes, dated 12/3/25, showed:-At 10:04 A.M., during transport to a doctor's appointment, transport reported the resident fell back in his/her wheelchair. No visual injuries. Complaints of pain in head and neck. Family was notified. Vital signs: blood pressure (BP) 153/85 (normal blood pressure 120/80), pulse (P) 72 (normal pulse 60 to 100);-At 10:14 A.M., resident transported to hospital via ambulance;-At 4:10 P.M., resident returned from the hospital accompanied by family. Paperwork received from family. Resident in main dining room for evening meal. Diagnosis of closed head injury. Vital signs: BP 131/65, pulse 78, oxygen saturation (O2 sat) 92% (normal O2 sat 95 to 100%). Neuro checks (neurological assessments) completed and within normal limits. Resident responds appropriately to verbal stimuli. Eating dinner without issue. During an interview on 12/16/25 at 11:26 A.M., Van Driver D said he/she works at the facility as a van driver and has driven residents in the medical van. The facility's policy is that only one wheelchair resident can be in the medical van at a time because the van only has six straps. He/She was recently in-serviced regarding this. During an interview on 12/16/25 at 12:56 P.M., Van Driver A said he/she worked at the facility as a van driver and he/she was the driver when the resident fell backward in his/her wheelchair. On 12/3/25, Resident #3 was being transported to an appointment in the facility's medical van along with another resident. Both residents' appointments were at the same place and around the same time. Van Driver A made the decision to take both residents at the same time to prevent them from being late. He/She placed the first resident in the van and strapped his/her wheelchair in place, then placed Resident #3 in the van and strapped his/her wheelchair in place. While driving, he/she made a turn and Resident #3's wheelchair flipped backward. He/She pulled the van over and checked to see if the resident was hurt. The resident said he/she wasn't hurt. Van Driver A sat the resident upright in his/her wheelchair, secured him/her in the van with the wheelchair straps, and returned the resident to the facility since they weren't that far. He/She has transported two residents in the medical van before without a problem. He/She has been in-serviced on the facility's policy of only transporting one wheelchair resident in the medical van due to the number of straps in the van. The medical van has six straps and in order to transfer two residents safely, it needs to have eight straps. During an interview on 12/15/25 at 8:30 A.M., the facility's Executive Director said she was unaware the facility's medical van didn't have eight straps until after the resident's fall. All van drivers have been in-serviced and completed a return demonstration on how to properly position a wheelchair resident on the medical van and facility's policy of transporting only one wheelchair-bound resident at a time in the medical van. In addition, van drivers have been in-serviced to call 911 whenever a resident has an incident or falls during transportation. 2683397

Based on interview and record review, the facility failed to ensure one resident (Resident #1) received care consistent with professional standards when staff failed to report a large bruise and abrasion to the resident's head immediately, delaying assessment, proper care and required notifications to family and physician. The sample size was three. The census was 88.Review of the facility's Change in Condition policy, dated 10/2/23, showed:-Purpose: To provide care and services based upon the current needs of the resident under the direction of the attending provider. To inform resident/resident representative and attending provider when a significant change in resident condition occurs;-Policy: When a significant change in the resident's physical, mental or psychosocial status is identified by the licensed nurse, or when there is a need to alter treatment significantly, the licensed nursing associate consults with the attending provider and notify the resident/resident representative;-Procedure: --Licensed nursing associate: --Assess significant change in the resident's condition noted through direct observation, interview or report for other staff; --Obtain a set of vital signs and repeat as needed or ordered; --Open matrix event and conduct a symptom review and assessment, as condition warrants; --Notify the attending provider of the change in condition and implement orders for treatment and appropriate monitoring as directed; --Notify the resident/resident representative; --Document symptom(s), assessment, observations, resident/resident representative and medical provider notification; --Monitor and provide treatment as ordered by the attending provider. Review of Resident #1's medical record, showed:-Diagnoses included Alzheimer's disease and age-related osteoporosis (weak/brittle bones). Review of the resident's progress notes, showed on 10/13/25 at 1:20 P.M., the resident's hospice worker reported a knot to the resident's head. Upon assessment, a large knot with bruising was noted to the left side of the forehead and a small cut to the center of the knot. The nurse practitioner (NP) and family were made aware. The resident had no pain or discomfort. After cleansing the area, a small scab fell off. There was no bleeding noted. At 8:44 P.M., the resident continued on observation related to a bump on his/her head. The resident did not display any signs of pain or discomfort during observation. He/She has a golf ball sized bump to the left side of the forehead with small abrasions at the center. Review of a typed statement dated 10/14/25, by Certified Nurse's Aide (CNA) A showed the employee was feeding the resident on 10/12/25 and he/she got hold of the tray before the CNA could get to it and turned it over on him/herself. The CNA got the resident another tray and cleaned him/her and the room up. The CNA did not report the incident because he/she did not think anything about it. Review of event information report, dated 10/13/25, showed:-Event category and description: Other events -Situation, Background, Assessment and Recommendation (SBAR)-Physician/NP/Physician Assistant (PA) communication Tool and progress note;-When occurred: 10/13/25, 10:56 A.M.-Description: Knot to forehead;-Vitals for this event: No vitals have been recorded for this event;-Orders for this event: Post-fall signs for fall with injury-complete and record full set of vitals;-Progress notes for this event: There are no associated progress notes. Review of a written statement by Certified Nurse's Aide A, dated 10/14/25, showed when the CNA went to check on the resident on 10/13/25, he/she had a big bruise on his/her forehead with a small amount of dried blood. During interviews on 10/22/25 at 12:00 P.M. and on 10/23/25 at 10:30 A.M., CNA A said he/she did not receive report on the morning of 10/13/25 when he/she started his/her shift and did not know the resident was injured. When he/she went to check on the resident around 9:00 A.M., to get the resident ready for breakfast, he/she noticed the large knot on the resident's head. He/She did not say anything because he/she thought someone would have already reported it since the knot did not look new and the blood was dried on the cut. During an interview on 10/23/25 at 2:00 P.M., the hospice social worker said he/she got to the facility around 10:00 A.M. on 10/13/25. The resident was sleeping so he/she sat by his/her bedside for a little while until he/she woke. He/She noticed a large spot of blood on the resident's pillow and dried blood on the bed rail. When the resident turned over, to his/her left side, the social worker noticed a golf sized knot on his/her head with dried blood on it. He/she immediately went to the nurse's station to report the injury to the nurse who had no idea what happened. The nurse checked the resident's medical record to see if there was any note about what happened and there was nothing documented. During an interview on 10/22/25 at 1:50 P.M., Licensed Practical Nurse (LPN) D said he/she was not working the resident's floor on 10/13/25, but he/she was standing at the nurse's station when the hospice staff came and reported the injury. He/She and the floor nurse went in and assessed the resident together. The resident had a large knot on his/her head. During an interview on 10/22/25 at 2:00 P.M., LPN D said on 10/13/25, the hospice social worked came to the desk and questioned him/her about the resident's injury. No one said anything to him/her in shift change about the resident being injured. When he/she went and assessed the resident, he/she had a significant knot on his/her head from the front to the back. Review of the resident's medical record, dated 10/23/25, showed:-On 10/9/25 at 2:44 P.M., vitals documented;-On 10/13/25 at 8:41 P.M., vitals documented;-No vitals documented between 10/9/25 at 2:44 P.M. and 10/13/25 at 8:41 P.M.;-No documented assessment or neurological checks on 10/13/25 from 9:00 A.M. to 11:30 A.M. During an interview on 10/22/25 at 2:45 P.M., the Director of Nursing said the staff should have reported the incident of the tray to the nurse if it hit the resident even if there were no immediate injuries. The staff should have also immediately reported the injury to the nurse as soon as it was noticed. Not reporting the incident and/or injury could delay assessment and care for the resident. All this information should have been documented. During an interview on 10/22/25 at 3:15 P.M., the Administrator said he expected staff to report all resident injuries immediately so care can be provided. This information should also be documented. 2646327

Based on interview and record review, the facility failed to ensure one resident (Resident #4) received treatment and care in accordance with acceptable standards of practice when the facility failed to follow physician orders for a Prevena (wound vac, negative pressure wound therapy (NPWT) system used to manage closed surgical incisions) and the resident's wound dehisced (separation of the edges of a surgical wound, either partially or completely, due to failure of proper wound healing). Additionally, the facility failed to administer physician ordered medications and failed to notify the physician and resident representative (RR) that the medications and treatments were not administered. The census was 84.Review of the facility's physician services policy, copyright 2022, showed:-Policy: It is the policy of the facility to provide care and services related to Physician Services in accordance with State and Federal regulation;-Procedure: 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded in the resident's medical record during that shift. Review of the prevention and treatment of skin breakdown policy, copyright 2018, showed: - Purpose: Maintaining intact skin is integral to resident health and wellness. Care and service are delivered to maintain skin integrity and promote skin healing if skin breakdown should occur;-Policy: Resident skin integrity is assessed upon admission and weekly thereafter. A skin risk assessment is completed upon admission and weekly for 4 weeks upon significant change, and quarterly thereafter. Those residents at an increased risk for impaired skin integrity are provided preventative measures to reduce the potential for skin breakdown. Those residents' who experience a break in skin integrity or wounds are provided care and service to heal the skin according to professional standards of care;-If a resident is admitted with impaired skin integrity or a new pressure injury (localized damage to the skin and underlying tissue, usually over a bony prominence, caused by prolonged pressure or pressure combined with shear) or lower extremity wound develops the licensed nurse implements the following items: -1. Documentation of the skin impairment is completed in the medical record. Staging of Pressure Injury is completed as necessary by trained licensed associates. Other lower extremity wounds with be described a partial thickness loss or full thickness loss; -2. Standing orders/protocol for skin wound are initiated; -3. Notify attending provider, resident and resident representative. Attending provider determines wound type and may provide additional orders; -4. Notify Supervisor/designee; -5. Evaluate current pressure reduction interventions and revise resident centered care plan; -6. Notify dietitian for nutritional interventions; -7. Notify therapy associates and other members of the care team as appropriate for possible additional treatment interventions; -8. Educate resident/resident representative on skin wound/pressure injury and care plan interventions; -10. Weekly the licensed nurse will stage, measure, and examine the wound bed and surrounding skin. If wound bed has deteriorated; notify provider;-12. Documentation reflects areas as addressed above. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Cognitively intact;-Rejection of care not exhibited;-Indwelling catheter; -Occasionally incontinent of bowel;-Antibiotic (ABT) not marked as taking or indication noted; -Surgical wounds;-Diagnoses included fracture of lower end of left femur (the thigh bone), weakness, dementia, type two diabetes, high blood pressure, congestive heart failure (CHF, heart doesn't pump blood efficiently, leading to fluid buildup in the body) and chronic respiratory failure. Review of the resident's care plan, during the survey, showed:-Problem: Resident is limited in ability to walk in room related to left femur fracture, created [DATE];-Goal: Resident will ambulate with walker 75 feet with supervision, created [DATE];-Approach: Monitor/record/report presence of pain/intolerance during ambulation (walking);-Problem: Potential for discomfort and side effects related to the use of ABT, created [DATE];-Goal: Resident will be free of any discomfort or adverse side effects, created [DATE];-Approach: -Administer medication as ordered, created [DATE]; -Monitor for adverse consequences, created [DATE]; -Observe for possible side effects, created [DATE]. Review of the resident's Medication Administration Record (MAR), Treatment Administration Record (TAR) and progress notes, dated [DATE] through [DATE], showed:-Amlodipine (treats high blood pressure) 25 mg at bedtime, start date [DATE], discontinue (DC) [DATE]; -[DATE], Not administered: Drug item unavailable;-Furosemide (Lasix, treats flid retention, swelling) 20 mg once daily, start date [DATE], DC [DATE]; -[DATE], Not administered: Drug item unavailable;-Levetiracetam (anticonvulsant, used primarily to treat and prevent seizures) 500 mg twice daily, start date [DATE], DC [DATE]; [DATE] A.M. medication pass, Not administered: Drug item unavailable;-Omeprazole (treats heartburn) 20 mg once daily, start date [DATE], DC [DATE]; - [DATE], Not administered: Other comment: New Admit;-Glimepiride (medication used to manage blood sugar (BS) levels in individuals with type two diabetes) 1 mg before meals, start date [DATE], DC [DATE]; -[DATE], 7:30 A.M., Not administered: Other comment: New Admit; -[DATE], 11:30 A.M., Not administered: Other comment: New Admit; -[DATE], 4:30 P.M., Not administered: Other comment: New Admit;-Amlodipine 25 mg at bedtime, start date [DATE], DC [DATE]; -[DATE], Not administered: Drug item unavailable. Review of the Orthopedic Trauma Service Postoperative Patient Visit, dated [DATE], showed: -Diagnosis: Left periprosthetic distal (away from center of the body) femur fracture (broken bone in the lower part of the thigh near a knee replacement, specifically on the left side);-History: The patient returns to clinic today for postoperative (following a surgical operation) visit. They are now approximately 3 weeks out from surgery. Patient is doing well. He/She does complain about some serous (clear liquid) drainage from his/her lateral (outer) mid-thigh wound. He/She denies any fever, chills, sweats, malaise (general feeling of discomfort, weakness, or illness) or other infectious symptoms. He/She says that the nursing facility is not doing a great job at changing his/her dressings or getting him/her up to walk;-Physical exam on left lower extremity (LLE): Focused orthopedic exam of the LLE shows no gross deformity or areas of edema (swelling). His/Her mid-thigh lateral incision is partially healed with very loose surrounding erythema (redness), no fluctuance (feeling obtained during palpation of a swelling or wound that contains fluid) but serosanguineous drainage (drainage containing both blood and clear serum). Other incisions have partial healing with minimal surrounding erythema and no drainage. No tenderness to palpation (touching or feeling the surface of the body during a physical exam) of the bony prominences of the knee, ankle, or foot. Full passive range of motion (PROM, movement of a joint where the person whose body is being moved doesn't use their own muscles to initiate or control the movement) of the hip, knee, and ankle. Patient is able to weakly flex hip, flex/extend the knee, dorsiflex (bending the foot upward)/plantar flex (pointing the toes downward) ankle, flex/extend the great toe. Intact sensation to light touch in the superficial peroneal (nerve that arises as a branch of the common peroneal nerve (a branch of the sciatic nerve (largest nerve in the human body, running from the lower back, down the buttock and thigh, and branching into the lower leg and foot) to the lower leg and foot)), deep peroneal (branch of the common peroneal nerve that plays a crucial role in controlling muscles in the lower leg and foot, particularly those responsible for dorsiflexion), tibial (larger of the two bones in the lower leg, commonly known as the shinbone), saphenous (sensory nerve in the leg), and sural nerve (sensory nerve located in the lower leg that provides sensation to the lateral side of the foot and ankle) distributions. Toes are warm and well perfused with capillary refill (used for assessing the blood flow through peripheral (away from the center) tissues by compressing the nail bed until it blanches (temporary whitening of the skin) and record the time taken for the color to return to the nail bed. Normal capillary refill is less than 3 seconds) less than two seconds. Two plus (+) (indicates a moderate, but diminished, pulse strength in both the dorsalis pedis (DP, blood vessel located on the top of the foot) and posterior tibial (PT artery in the lower leg, responsible for supplying blood to the back of the leg and sole of the foot) arteries palpable DP and PT pulses;-Assessment: sustained a left side periprosthetic distal femur fracture now three weeks status post open reduction and internal fixation (ORIF, surgical procedure used to treat severe bone fractures by realigning the broken bone fragments and stabilizing them with implants like screws, plates, or rods), retrograde intramedullary (IM) nail (surgical option for treating a distal femur fracture) periprosthetic distal femur fracture. He/She has some serosanguineous drainage from his/her mid-thigh lateral wound which appears to be associated with some delayed healing and resolving seroma (clear, yellowish fluid that accumulates under the skin, usually after surgery). We will place him/her on Keflex (cephalexin, ABT) for the next 2 weeks and place a one week Prevena which will be changed by his/her wound care nurse at the facility. We would like see him/her back in two weeks for repeat wound evaluation and x-rays of the left femur. The patient is in agreement with this treatment plan. Review of the resident's MAR, TAR and progress notes, dated [DATE] through [DATE], showed: -Glimepiride 1mg before meals, start date [DATE], DC [DATE]; -[DATE], 7:30 A.M., Not administered: Other comment: 11:30 A.M. med given too late; -Progress note dated [DATE] at 4:30 P.M., Resident returned from Orthopedics with a wound vac (negative pressure wound therapy, (NPWT) a medical device that uses negative pressure to help wounds heal) placed to his/her distal lateral left thigh. Wound vac is intact at this time, Spoke to orthopedics office at approximately 4:20 P.M. for clarification on the Keflex ABT medication order for 14 days. Physician order sheet does not state the frequency or strength of medication. Office stated that everyone has left the office for the day, and he/she will give the supervisor a call back tomorrow on [DATE] with the correct ABT order;-Wound vac to left distal thigh set to mode continuous with pressure setting of 125 millimeters of mercury (mmHg) one time, start [DATE], DC [DATE]; -[DATE], Not administered: Other comment: Wound nurse;-Progress note, dated [DATE] at 10:54 A.M., Spoke to orthopedics office to get clarity in regards to ABT medication. Order clarified for Keflex 500 mg twice daily for 14 days. Order faxed to pharmacy;-Progress note, dated [DATE] at 10:56 A.M., NO for Keflex 500 mg twice daily for 14 days for incision;-Left knee clean with normal saline (NS, a sterile solution of sodium chloride (salt) and water) and cover with border gauze once a day, start date [DATE] through [DATE]; -[DATE], Not administered: Other comment: Unable to complete;-Left upper and lower hip clean with NS and cover with island dressing (wound dressing that features a central absorbent pad with an adhesive border that surrounds it) once a day, start date [DATE], DC [DATE]; -[DATE], Not administered: Other comment: Unable to complete;-Left upper inner thigh clean with NS apply two by two xeroform and cover with border gauze once daily, start date [DATE], DC [DATE]; -[DATE], Not administered, Other comment: unable to complete;-Wound vac functioning check every shift, start date [DATE], DC [DATE]; -[DATE], 5:00 P.M., Not administered, Other comment: Unknown if working;-Keflex 500 mg twice daily for 14 days, start date [DATE] through [DATE]; -[DATE], 5:00 P.M., Not administered: Drug item unavailable; -[DATE], 9:00 P.M., Not administered: Drug item unavailable; -[DATE], 5:00 P.M., Not administered: Drug item unavailable; -[DATE], 9:00 P.M., Not administered: Drug item unavailable;-Progress note dated [DATE] at 3:02 A.M., Keflex order to arrive tonight due to billing;-Wound vac functioning check every shift, start date [DATE], DC [DATE]; -[DATE], 11:30 A.M., Not administered: Drug item unavailable;-Glimepiride 1mg before meals, start date [DATE], DC [DATE]; -[DATE], 11:30 A.M., Not administered: Drug item unavailable; -[DATE], 4:30 P.M., Not administered: Drug item unavailable;-Wound vac functioning check every shift, start date [DATE], DC [DATE]; -[DATE], 4:30 P.M., Not administered: Drug item unavailable;-Wound vac dressing change once a day on Wednesday, start [DATE], DC date [DATE]; -[DATE], Not administered: Other comment: Waiting on clarification orders;-Left upper inner thigh clean with NS apply two by two xeroform and cover with border gauze once daily, start date [DATE], DC [DATE]; -[DATE], Not administered: Drug item unavailable;-Levetiracetam 500 mg twice daily, start date [DATE], DC [DATE]; -[DATE] A.M. medication pass, Not administered: Drug item unavailable; -[DATE] P.M. medication pass, Not administered: Drug item unavailable;-Wound vac functioning check every shift, start date [DATE], DC [DATE]; -[DATE], 9:00 A.M., Not administered, Other comment: Prior shift. Review of the Orthopedic Trauma Service Postoperative Patient Visit, dated [DATE], showed:-History: The patient returns to clinic today for their postoperative visit. They are now approximately five weeks out from surgery. At his/her last clinic visit, he/she has some serous drainage from his/her lateral incision and a wound vac was placed in clinic with instructions for changes at the facility. The resident's daughter notes the wound vac was removed at the facility and not replaced. They are not pleased with the care received at the facility. Denies any fevers or chills at the facility. He/She thinks his/her wound is getting better;-Physical Exam to LLE: Focused orthopedic exam of the LLE shows lateral incision with superficial dehiscence (separation of the edges of a surgical wound, either partially or completely, due to failure of proper wound healing) with exudate (a fluid that has seeped out of a tissue) at the wound base. There is no surrounding erythema. No further serous drainage. Patient is able to weakly flex/extend the knee, dorsiflex/plantar flex ankle, flex/extend the great toe. Intact sensation to light touch in the superficial peroneal, deep peroneal, tibial, saphenous, and sural nerve distributions. Toes are warm and well perfused with capillary refill less than two seconds. Two + palpable DP and PT pulses;-Review of x-rays: I have ordered, interpreted and reviewed x-rays of the patient's left femur demonstrating: nail plate combination for a periprosthetic fracture. No evidence of hardware complication or failure. Alignment maintained compared to previous. Minimal to no callus (a thickened and hardened part of the skin or soft tissue) formation;-Assessment: Left side periprosthetic distal femur fracture now 5 weeks status post ORIF, retrograde IM nail periprosthetic distal femur fracture. We discussed his/her lateral based incision appears to be healing appropriately, though with some superficial wound dehiscence. We discussed that this appears without any signs of infection. We can continue to treat this conservatively. We discussed that regarding his/her shoulder, it would be unlikely for it to be dislocated without any injury but that we would obtain x-rays of the shoulder to confirm. We also discussed his/her shoulder did not appear to have concerns for dislocation on exam today. We will have him/her obtain these x-rays on the way out. We will plan to see the patient back in 4 weeks for repeat wound assessment with repeat x-rays. Review of the resident's MAR, TAR and progress notes, dated [DATE] through [DATE], showed: -Left upper inner thigh clean with NS apply two by two xeroform and cover with border gauze once daily, start date [DATE], DC [DATE]; -[DATE], Not administered, Other comment: unable to complete;-Wound vac dressing change once a day on Wednesday, start [DATE], DC date [DATE]; -[DATE], Not administered: Other comment: Unable to complete;-Wound vac functioning check every shift, start date [DATE], DC [DATE]; -[DATE], 9:00 A.M., Not administered, Other comment: Unable to complete; -[DATE], 9:00 A.M., Not administered: Discontinued; -[DATE], 5:00 P.M., Not Administered: Other comment: No wound vac; -[DATE], 12:00 A.M., Not administered: Drug item unavailable; -[DATE], 9:00 A.M., Not administered: Other comment: not applicable (N/A); -[DATE], 5:00 P.M., Not administered: Other comment: N/A; -[DATE], 9:00 A.M., Not administered: Other comment: N/A;-Glimepiride 1mg before meals, start date [DATE], DC [DATE]; -[DATE], 7:30 A.M., Not administered: Other comment: Too late noon dose given;-Wound vac functioning check every shift, start date [DATE], DC [DATE]; -[DATE], 12:00 A.M., Not administered: Drug item unavailable;-Wound vac functioning check every shift, start date [DATE], DC [DATE]; -[DATE], 9:00 P.M., Not administered: Drug item unavailable;-Cyclobenzaprine (muscle relaxant) 10 mg every eight hours, start date [DATE], DC [DATE]; -[DATE], 12:00 A.M., Not Administered: Drug item unavailable;-Progress note, dated [DATE] at 3:58 P.M., Spoke with previous wound care nurse who placed treatment orders in place regarding treatments discontinued. Treatments reactivated. Will notify physician;-Progress note dated [DATE] at 10:01 A.M., Wound vac removed. Site clean, dry and intact. No draining or odor noted;-Progress note dated [DATE] at 12:48 P.M., Resident was scheduled to discharge to another facility. Per physician, resident needs to be sent to emergency room (ER) to be treated for wound. RR spoke to Administrator who arranged for transportation to ER. Upon release from hospital resident will discharge to other facility. Facility transported resident to hospital. Resident was in stable condition when left the facility. Review of the resident's hospital records, showed: -[DATE], 5:48 P.M., lateral/distal wound dehiscence. Per family, patient was sent to facility post-operatively where he/she received little to no wound care or dressing changes. He/She was seen three weeks post operatively and found to have delayed healing of his/her incision which was treated with wound vac application. Family reports the facility removed the wound vac without replacing it; -Exam: Nontender to palpation over the lateral incision. Two-centimeter (cm) dehiscence present along proximal (situated closer to the center of the body or to the point of attachment or origin of a structure) aspect of lateral incision. Three cm dehiscence present along distal aspect of lateral incision. Fibrinous tissue (tissue characterized by the presence of fibrin (a protein involved in blood clotting) often found in areas of inflammation or injury) present at incision edges. Erythema surrounding dehiscence sites but doesn't extend more than 0.5 cm from wound edges; -[DATE], 5:58 A.M., Patient presents with wound dehiscence of the lateral and distal aspects of the incision site. The patient was discharged to a skilled nursing facility post-operatively. The family reports that the patient received minimal wound care and infrequent dressing changes during his/her stay at the facility. At his/her three-week post-operative follow-up, the patient exhibited delayed healing of his/her incision, and a wound vac was applied to aid in healing. Subsequently, the family reports the facility removed the wound vac without replacing it. Had a detailed discussion with the patient and his/her family regarding the current status of the wound dehiscence and non-operative and operative intervention. Given the status of his/her wound dehiscence, this wound will likely not heal without surgical intervention, The risks of no-operative management included: delayed wound healing, deep infection, systemic illness (affects the entire body, rather than just one specific area). Explained recommendation would be operative intervention in the form of an irrigation (washing out wound with a continuous flow of water or medication) and excisional debridement (surgical procedure involving the cutting away or removal of devitalized (dead or non-living tissue), necrotic (tissue has died due to lack of blood flow, infection, or severe injury), or slough tissue (layer of dead tissue, often yellow or white, that can be soft, stringy, or even thick and adherent to the wound bed) from a wound, burn, or infection). There is a need for surgical intervention to optimize healing and do not believe he/she will heal this wound without surgical intervention. Reviewed the operative plan, which includes debridement of the dehisced areas, thorough irrigating, obtaining cultures, and closure of the wound with appropriate techniques to promote healing and prevent recurrence, Emphasized the necessity of meticulous post-operative wound care, regular dressing changes. Reassured the patient and his/her family that the goal of the surgical intervention is to prevent infection, promote healing, and facilitate recovery, The patient and family expressed their understanding and through shared decision making consented to proceed with the operative intervention. The plan includes pre-operative preparation and consent, followed by surgical intervention involving debridement, irrigation, and closure technique, which will be determined intra-operatively (during a surgical procedure) based on wound assessment. Post-operatively, close monitoring of wound healing, adherence to a strict wound care protocol, and follow-up appointments with wound care specialists are crucial. The risks, benefits, alternatives and potential complications of surgical intervention were discussed in detail with the patient. The risks include, but are not limited to: bleeding, persistent infection, need for serial debridement's (repeated removal of dead tissue from a wound over a period of time), damage to surrounding structures including blood vessels and nerves, fracture nonunion (when a broken bone doesn't heal properly), fracture malunion ( broken bone heals in an abnormal or incorrect position), hardware complications, incomplete resolution of symptoms or recurrence, and possible re-operation or need for further surgery for these, or any other reasons. Anesthesia and surgical risks also discussed include possibility of heart attack, thromboembolic event (blood clot that breaks and travels through the bloodstream), stroke or death. The patient also demonstrates an understanding of the need for compliance with post-operative instructions and therapy protocol(s) to minimize complications and maximize benefits; During an interview on [DATE] at 12:16 P.M., Licensed Practical Nurse (LPN) B said on [DATE] he/she put a note in that the wound vac was removed because there was an order into monitor a wound vac. LPN B did not recall the resident having a wound vac and did not recall one being removed. LPN B did not want to discontinue the order because he/she did not get the orders to monitor the wound vac. During an interview on [DATE] at 12:44 P.M., Clinical Manager (CM) F said when the facility transitioned his/her role to clinical manager and that included wound care on [DATE], CM F looked at the resident and the resident did not have a wound vac on. CM F asked the previous wound nurse what the resident's treatment orders were and how his/her care needed to be managed going forward. CM F did not recall what the previous wound nurse said. The resident had an order for Keflex to start on [DATE] there is a progress note on [DATE] that the pharmacy was called, and the order was changed and started on [DATE] through [DATE]. CMTs can pull medication if it is not available. If the Certified Medication Technician CMT is an agency CMT, they would need to ask the nurse or clinical manager to pull the medication. If the medication is not available in the automated dispensing unit (ADU, computerized cabinets or machines that store and dispense medications within the facility), the CMT must report it to the nurse so the nurse can contact the pharmacy, physician and the RR. The notifications and steps that were taken are documented in the resident's progress notes. The concern with a resident not receiving ordered ABT timely is the infection would not resolve and could worsen. During an interview on [DATE] at 11:17 A.M., CM I said he/she was the wound nurse prior to [DATE], then the roles were changed and the CMs became responsible for any wounds on their units. The resident did not admit to the facility with a wound vac. The resident went to a doctor's appointment and came back with a wound vac. CM I did not recall what the orders were for the wound vac. CM I said an unknown nurse told him/her the resident came back with a wound vac and he/she believes that nurse put the orders in for the wound vac. CM I did not know when the wound vac was removed and who removed the wound vac. During an interview on [DATE] at 11:20 A.M., the Orthopedic Trauma Service Office said the resident was seen in the office following his/her surgery on [DATE]. The first appointment was on [DATE] and the physician put a Prevena wound vac on the left thigh to the distal lateral incisions with instructions for the wound vac to be replaced in one week on [DATE] and for the resident to start on Keflex x 14 days. The resident was scheduled for a second follow up appointment on [DATE]. During the appointment, the resident did not have a Prevena wound vac on as ordered at the previous appointment. The office was not made aware the resident did not start the Keflex on [DATE] and that it was not started until [DATE]. The office was also not made aware of the removal of the Prevena wound vac until the resident was seen at the office on [DATE]. During an interview on [DATE] at 1:41 P.M., the Executive Director (ED), Assistant Executive Director (AED), and the Interim Director of Nursing (IDON) said they expected staff to be knowledgeable of and follow the facility policies. They expected physician orders to be followed. If a resident missed a scheduled dose of medication, they expected the nurse to contact the physician and the RR and document the notifications in the resident's progress notes. They expected residents to receive medication like an ABT that was ordered at the time the medication was ordered. They expected the medication to be pulled from the ADU until it arrives from pharmacy. If the medication is not available in the ADU they expected the nurse to contact the pharmacy and the physician and put a progress note in the resident's chart with any new orders received. If a resident missed a scheduled treatment, they expected the nurse to contact the physician and the RR and document the notifications in the resident's progress notes. 2565253

Based on interview and record review, the facility failed to establish a system for records of disposition of all controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) in sufficient detail to enable an accurate reconciliation with the narcotic delivery reconciliation logs and shift to shift count sheets for four carts out of four carts that had controlled substances. This had the potential to affect all residents with controlled substance orders. The census was 84.Review of the facility's Controlled Substances Policy, copyright 2025, showed:-Purpose: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V (CII, medication with higher potential of dependency and abuse), Schedule three controlled medication (CIII, medication with low to moderate potential of dependency and abuse), Schedule four controlled substance (CIV, medication with low potential of dependency and abuse), Schedule five controlled substance (CV, lowest potential of dependency and abuse) of the Comprehensive Drug Abuse Prevention and Control Act of 1976);-Procedure: Handling Controlled Substances; -1. Only authorized licensed nursing and/or pharmacy personnel have access to Schedule II controlled substances maintained on premises; -2. The director of nursing (DON) services identifies staff members who are authorized to handle controlled substances; -3. Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication another associate must count the controlled substances together. Both individuals sign the designated controlled substance record. If the count is inconsistent with the prescription label, the licensed nurse will contact the pharmacy; -4. An individual resident-controlled substance record is made for each resident who will be receiving a controlled substance. The facility will maintain a bound book with a log of the receipt, release and destruction of any controlled substances. Do not enter more than one prescription per page. This record contains: resident and prescription specific information;-Storing Controlled Substances: -1. Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected; -2. The licensed nurse on duty maintains the keys to controlled substance containers;-Dispensing and Reconciling Controlled Substances: -1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up; -2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: -a. Records of personnel access and usage; -b. Medication administration records; -c. Declining inventory records; -d. Destruction, waste and return to pharmacy records; -3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count; -4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. The oncoming nurse reconciles the controlled substance while the off going nurse reads the log. Both nurses are responsible for verification of accuracy; -5. The director of nursing services documents irreconcilable discrepancies and notifies the Administrator: -a. If a major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, the director of nursing completes the Narcotic Discrepancy Report and notifies the Administrator and consultant pharmacist immediately; -b. The Administrator, consultant pharmacist, and/or director of nursing services determine whether other action(s) are needed, e.g., notification of police or other enforcement personnel and any state agency; -c. The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of therapy is met (example: a resident receiving a pain medication complains of unrelieved pain); -d. The director of nursing services consults with the provider pharmacy and the administrator to determine whether any further legal action is indicated; -6. Unless otherwise instructed by the director of nursing services, when a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given) the medication is destroyed, and may not be returned to the container; -7. Waste and/or disposal of controlled medication are done in the presence of the nurse and another licensed associate who also signs the disposition sheet; -8. Medications returned to the pharmacy are recorded and signed by the director of nursing services (or designee) and the receiving pharmacy; -9. Disposal methods are used to prevent diversion and/or accidental exposure to controlled or hazardous substances. Fentanyl patches are disposed of in one of the following ways: -a. Per state regulation, or; -b. Using approved drug disposal products specifically for fentanyl patches; -10. Controlled substances are not surrendered to anyone, including the resident's provider, except for the following: -a. For a resident on pass or therapeutic leave; as ordered by the attending physician; -b. To a resident or responsible party upon discharge from the facility, or; -c. To the DEA or other law enforcement officials functioning in a professional capacity in exchange for a receipt documenting the transaction; -11. In the event there is concern about controlled substances being discharged with the resident and/or resident's representative, the attending physician may choose not to discharge the resident with those medications; -12. Some controlled substances may be stored in the emergency medication supply. Reconciliation of controlled substances in the emergency supply is conducted at intervals established by the director of nursing services; -13. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed; -14. Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation; -15. The consultant pharmacist, Director of Nursing or designee routinely monitors controlled substance storage records; -16. The director of nursing services maintains and disseminates to appropriate individuals a list of staff who have access to medication storage areas and controlled substance containers; -17. For guidelines pertaining to disposing of controlled substances, see Discarding and Destroying Medications policy;-3. Controlled Substances Disposal: -a. Unused portions of a controlled substance may be given to a resident or resident's representative upon the resident's discharge or transfer to another setting if the following conditions are met: -i. The healthcare practitioner has provided an order authorizing the currently prescribed controlled substances to be released with discharge/transfer; -ii. If currently prescribed controlled substances are released to a responsible person, this person who, because of the resident's incapacity, makes decisions about the individual's care must be identified in the resident record; -iii. Associate documents the release of the controlled drug medication, listing the date, quantity, name, strength, and dosage form of the medication; prescription number, name, address and telephone number of dispensing pharmacy; name and signature of the person releasing the drug; and name and signature of the person receiving the controlled drug upon discharge; -b. When these four conditions are not met, unused portions of a controlled substance remaining must be disposed of with disposal documented in accordance with State and Local regulations; -c. Unused portions of a controlled substance remaining at the building following the resident's death may not be released to the responsible person but must be destroyed. Disposal must occur within a timely manner by a licensed nurse and witnessed by another licensed nurse or pharmacist. 1. Review of the [NAME] Hall, narcotic book count signatures, dated 6/21/25 through 7/17/25, showed:-Incoming nurse responsible for counting medications, outgoing nurse responsible for following index log and verifying count in narcotic book;-Signing indicates that controlled substances have been counted for this cart and are deemed correct;-Forty-two staff signatures missing out of 154 opportunities. Review of the [NAME] Hall, narcotic delivery reconciliation logs, dated 5/26/25 through 7/14/25, showed:-Reminder, each card of medication needs to be listed separately, even if they have the same prescription number;-When a medication is completed or destroyed, please locate the medication from the above list, have two nurses initial and highlight in yellow; -When a medication was completed or destroyed, it was not highlighted in yellow and did not always have two nurses' signatures/initials;-Twelve medications were completed/destroyed and had one nurse's initial:-Medication: Norco (Hydrocodone/Acetaminophen, medication containing hydrocodone and acetaminophen used to managing pain that is moderate to moderately severe);-Dosage: 7.5 milligram (mg) hydrocodone, 325 mg acetaminophen;-Date completed/destroyed: 5/26/25; -Medication: Lyrica (pregabalin, use to treat nerve pain); -Dosage: Not documented; -Date completed/destroyed: 5/30/25; -Medication: Norco; -Dosage: 7.5/325 mg; -Date completed/destroyed: 5/30/25; -Medication: Clonazepam (Klonopin, used to treat panic disorders, anxiety and seizures); -Dosage: 0.5 mg; -Date completed/destroyed: 5/31/25; -Medication: Norco; -Dosage: 7.5/325 mg; -Date completed/destroyed: 6/15/25; -Medication: Norco; -Dosage: 7.5/325 mg; -Date completed/destroyed: 6/22/25; -Medication: Percocet (Oxycodone/Acetaminophen, combination pain medication used to treat moderate to severe pain); -Dosage: 10/325 mg; -Date completed/destroyed:7/10/25; -Medication: Phenobarbital (used to treat anxiety and seizures); -Dosage: Not documented; -Date completed/destroyed: 7/10/25; -Medication: Tramadol (used to treat moderate to moderately severe pain); -Dosage: 50 mg; -Date completed/destroyed: 7/10/25; -Medication: Percocet; -Dosage: 5/325 mg; -Date completed/destroyed:7/10/25; -Medication: Vicodin (Hydrocodone/acetaminophen, combination pain medication used to treat moderate to severe pain); -Dosage: 5/325 mg; -Date completed/destroyed:7/11/25; -Medication: Morphine (used to treat moderate to severe pain); -Dosage: Not documented; -Date completed/destroyed: Not documented. 2. Review of the Fontbonne Hall, narcotic book count signatures, dated 6/27/25 through 7/17/25, showed:-Incoming nurse responsible for counting medications, outgoing nurse responsible for following index log and verifying count in narcotic book;-Signing indicates that controlled substances have been counted for this cart and are deemed correct;-Missing 12 staff signatures out of 124 opportunities. Review of the Fontbonne Hall, narcotic delivery reconciliation logs, dated 5/26/25 through 7/17/25, showed:-Reminder, each card of medication needs to be listed separately, even if they have the same prescription number;-When a medication is completed or destroyed, please locate the medication from the above list, have two nurses initial and highlight in yellow; -When a medication was completed or destroyed, it was not highlighted in yellow and did not always have two nurses' signatures/initials;-Seventeen medications were completed/destroyed and had one nurse's initial:-Medication: Lyrica; -Dosage: 150 mg; -Date completed/destroyed: 6/5/25;-Medication: Vicodin; -Dosage: 5/325 mg; -Date completed/destroyed: 6/5/25; -Medication: Lyrica; -Dosage: 75 mg; -Date completed/destroyed: 6/7/25;-Medication: Clonazepam; -Dosage: 0.5 mg; -Date completed/destroyed: 6/11/25; -Medication: Xanax (Alprazolam, used to treat anxiety); -Dosage: 0.25 mg; -Date completed/destroyed: 6/13/25; -Medication: Morphine; -Dosage: 100 mg per 5 milliliters (ml); -Date completed/destroyed: 6/13/25;-Medication: Lorazepam (Ativan, used to treat anxiety); -Dosage: 2 mg per ml; -Date completed/destroyed: 6/13/25;-Medication: Lyrica; -Dosage: 75 mg; -Date completed/destroyed: 6/22/25;-Medication: Lyrica; -Dosage: 75 mg; -Date completed/destroyed: 7/7/25;-Medication: Morphine; -Dosage: 100 mg per 5 milliliters (ml); -Date completed/destroyed: 7/8/25;-Medication: Lorazepam; -Dosage: 2 mg per ml; -Date completed/destroyed: 7/8/25;-Medication: Clonazepam; -Dosage: 0.5 mg; -Date completed/destroyed: 7/8/25;-Medication: Vicodin; -Dosage: 5/325 mg; -Date completed/destroyed:7/8/25; -Medication: Lyrica; -Dosage: Not documented; -Date completed/destroyed: 7/12/25;-Medication: Armodafinil (Stimulant, wakefulness-promoting medication which is used to treat excessive daytime sleepiness); -Dosage: 150 mg; -Date completed/destroyed: 7/15/25;-Medication: Clonazepam; -Dosage: 0.5 mg; -Date completed/destroyed: Not documented; -Medication: Lorazepam (Ativan, used to treat anxiety); -Dosage: Not documented; -Date completed/destroyed: Not documented. 3. Review of the [NAME] Hall, narcotic book count signatures, dated 6/25/25 through 7/17/25, showed:-Incoming nurse responsible for counting medications, outgoing nurse responsible for following index log and verifying count in narcotic book;-Signing indicates that controlled substances have been counted for this cart and are deemed correct;-Missing 38 staff signatures out of 112 opportunities. Review of the [NAME] Hall, narcotic delivery reconciliation logs, dated 5/30/25 through 7/16/25, showed:-Reminder, each card of medication needs to be listed separately, even if they have the same prescription number;-When a medication is completed or destroyed, please locate the medication from the above list, have two nurses initial and highlight in yellow; -When a medication was completed or destroyed, it was not highlighted in yellow and did not always have two nurses' signatures/initials;-Ten medications were completed/destroyed and had one nurse's initial:-Medication: Lorazepam; -Dosage: 0.5 mg per ml; -Date completed/destroyed: 6/30/25;-Medication: Tramadol; -Dosage: 50 mg; -Date completed/destroyed: 7/8/25; -Medication: Lorazepam; -Dosage: 0.5 mg per ml; -Date completed/destroyed: 7/8/25;-Medication: Hydromorphone (Dilaudid, used to treat moderate to severe pain); -Dosage: 1 mg per ml; -Date completed/destroyed: Not documented;-Medication: Clonazepam; -Dosage: 0.5 mg; -Date completed/destroyed: Not documented; -Medication: Percocet; -Dosage: 7.5/325 mg; -Date completed/destroyed: Not documented;-Medication: Hydromorphone (Dilaudid, used to treat moderate to severe pain); -Dosage: 1 mg per ml; -Date completed/destroyed: Not documented;-Medication: Morphine; -Dosage: 100 mg per 5 ml; -Date completed/destroyed: Not documented;-Medication: Lorazepam; -Dosage: 2 mg per ml; -Date completed/destroyed: Not documented;-Medication: Hydromorphone; -Dosage: Not documented; -Date completed/destroyed: Not documented. 4. Review of the [NAME] Hall, narcotic book count signatures, dated 6/20/25 through 7/17/25, showed:-Incoming nurse responsible for counting medications, outgoing nurse responsible for following index log and verifying count in narcotic book;-Signing indicates that controlled substances have been counted for this cart and are deemed correct;-Missing 25 staff signatures out of 148 opportunities. 5. Review of the Controlled Substance Emergency Drug Supply, shift change count record signatures, showed:-All discrepancies must be reported to the Missouri Bureau of Narcotics and Dangerous drugs;-Signing indicates package quantity matches package log and tablets remaining match medication administration count sheet;-Time: 7:00 A.M., 3:00 P.M., and 11:00 P.M.;-5/1/25 through 5/31/25: -One nurse initialed at 11:00 P.M., on 5/14/25 and on 5/22/45; -All other dates and times are blank with no documentation; -Missing 91 staff signatures/initials out of 93 opportunities.-June 2025: No documentation for June, 2025;-7/1/2025 through 7/17/25: -One nurse initialed at 7:00 A.M. on 7/3/25; -All other dates and times are blank with no documentation; -Missing 49 staff signatures/initials out of 50 opportunities. 6. During an interview on 7/17/25 at 10:16 A.M., Licensed Practical Nurse (LPN) A said the controlled medication count is completed at the beginning and end of each shift with the oncoming and off-going nurse. It takes two licensed nurses to count the controlled mediations, and they sign to verify the count is correct. If there is no signature, then it was not completed. Only licensed nurses have access to the controlled medications. The Certified Medication Technicians (CMT) do not pass controlled modifications at this facility. The controlled substance emergency drug supply is in the medication room in a cabinet on the wall. It should also be counted at the beginning and end of each shift. The nurse on the rehab floor has the key to the cabinet. If the Alixa (machine that dispenses medication) does not have the controlled medication, it can be pulled from the controlled substance emergency drug supply that is on the wall in the medication room. During an interview on 7/21/25 at 12:16 P.M., LPN B said the controlled medication count is completed at the beginning and end of each shift with the oncoming and off-going nurse. It is documented as completed by signing in the ongoing and off-going nurse spots. During an interview on 7/28/25 at 1:41 P.M., the Executive Director (ED), Assistant Executive Director (AED), and the Interim DON said they expected staff to be knowledgeable of and follow the facility policies. They expected when nurses are receiving controlled medication from the pharmacy to immediately validate the medication. Two nurses are to validate the medication with the manifest and log it appropriately on the narcotic delivery reconciliation log and on the controlled narcotic count book. They expected the nurses to count the controlled medications with the ongoing and off-going nurse and to document it was completed by signing their name. They expected the controlled substance emergency drug supply to be counted each shift by the ongoing and off-going nurses from the rehab hall. On 7/29/25 at 3:09 P.M., they said the reason it is important for staff to complete the controlled substance count at the beginning and end of each shift is to validate the medication is secure and the count is correct because it is the resident's property. 2562318

Based on interview and record review, the facility failed to ensure services provided met professional standards of practice when facility staff failed to administer physician ordered medications for three residents (Resident #1, Resident #2 and Resident #6) and failed to notify the physician and resident representative (RR) that the medications were not administered. The facility failed to follow parameters in the physician orders for one resident (Resident #5) and administered medications outside of the parameters and did not notify the physician or RR when medication was administered outside the set parameters. The census was 84.Review of the facility's physician services policy, copyright 2022, showed:-Policy: It is the policy of the facility to provide care and services related to Physician Services in accordance with State and Federal regulation;-Procedure: 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded in the resident's medical record during that shift. Review of the facility's physician services policy, copyright 2020, showed:-Policy: To administer resident medications in a safe and accurate manner that will ensure the 6 rights of patient identification for administration;-Purpose: To ensure safe administration of resident's medication as indicated and ordered by the provider;-Procedure:-1. Medications are administered by licensed nurses or as otherwise delegated, trained associates;-2. Medications are administered in accordance with the orders;-3. Medications are administered within their prescribed time;-4. The person preparing or administering the medication will contact the provider if there are questions or concerns regarding medication;-5. With any irregularities, appropriate notifications will be completed for clarification;-7. Obtain vitals as ordered with medication administration prior to administering the medications.-10. Administer medications following the 6 Rights of medication administration: -a. Right Resident; -b. Right Medication; -c. Right Dose; -d. Right Time; -e. Right Route; -f. Right Documentation;-11. Sign medication out in electronic record/Medication Administration Record (MAR) at time of medication administration. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/2/25, showed the following:-Cognitively intact;-Rejection of care not exhibited;-Upper and lower extremity impairment on both sides;-Intermittent catheterization (procedure where a flexible tube (catheter) is inserted into the bladder to drain urine); -Always incontinent of bowel and bladder;-Antibiotic (ABT) not marked as taking or indication noted;-Diagnoses included burns involving 50-59 percent (%) of body surface with 40-49% third degree burns (involves all of the layers of skin and sometimes the fat and muscle tissue under the skin), acquired absence of right leg above knee, acquired absence of left leg above knee, dependence on renal (kidney) dialysis (removes waste products and excess fluid from the blood when the kidneys can no longer perform this function adequately), osteomyelitis (a bone infection) of vertebra (individual bones of the spine), sacral (sacrum, the bony structure at the base of the spine) and the coccyx (known as the tailbone or the base of the spine) and sacrococcygeal region (the region of the body located between the sacrum, anuria (complete absence of urine production) and oliguria (decreased urine production) and weakness. Review of the resident's care plan, during the survey, showed:-Problem: Infection, created 6/16/25;-Goal: Resident will not develop newly acquired multidrug resistant organism (MDRO, infection that is resistant to many ABT), resident will not develop signs or symptoms of acute (condition that develops suddenly and lasts for a limited time that usually lasts less than six months) infection, created 6/16/25;-Approach: -Monitor for signs and symptoms of infection, created 6/16/25; -Notify physician or nurse practitioner (NP) as needed for signs and symptoms of active infection, created 6/16/25;-Problem: Indwelling catheter (a flexible tube inserted into the bladder to drain urine), resident requires bladder scans every six hours and required straight catheter if greater than 300 milliliters (mls) is detected, edited 6/9/25; -Goal: Resident will have a catheter care managed appropriately as evidenced by not exhibiting signs of infection or ureteral (the ureters, which are two narrow tubes that carry urine from the kidneys to the bladder) trauma, edited 6/9/25;-Approach: Bladder scans as ordered per physician every six hours, 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M., created 6/9/25;-Problem: Medication, resident has the potential for discomfort and side effects related to the use of ABT for the diagnosis of active wound infection, edited 6/9/25;-Goal: Resident will be free of any discomfort or adverse side effects, edited 6/9/25;-Approach: -Administer medications as ordered, created 5/29/25; -Monitor for adverse consequences, created 5/29/25; -Observe for possible side effects every shift, created 5/29/25. Review of the resident's MAR and progress notes, dated 5/27/25 through 6/23/25, showed: -Ondansetron (medication used to prevent nausea and vomiting) 4 mg disintegrating tablet (ok to use regular tablets) every 12 hours, start date 5/28/25, discontinue (DC) date 7/14/25; -5/29/25, Not administrated: Drug item unavailable;-Tamsulosin (Flomax, treats symptoms of benign prostatic hyperplasia (BPH), also known as an enlarged prostate) 0.4 mg capsule at bedtime, start date 5/28/25, DC date 5/31/25; -5/29/25, Not Administered: Drug item unavailable;-Renvela (sevelamer carbonate, medication used to control high blood phosphorus levels for individuals with chronic kidney disease (CKD) and are on dialysis) powder in packet; 0.8 gram (gm) three times a day, start date 5/28/25, discontinue date 7/14/25; -5/30/25 at 9:00 A.M., Not administered: Drug item unavailable, Comment: waiting on order;-Progress note dated 5/30/25 at 12:58 P.M., Dialysis center contacted and Renvela ordered. Awaiting approval per nurse;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -5/30/25, 1:00 P.M., Not administered: On hold, Comment: On order; -5/30/25, 5:00 P.M., Not administered: Drug item unavailable; -5/31/25, 9:00 A.M., Not administered: Drug item unavailable; -5/31/25, 1:00 P.M., Not administered: Drug item unavailable; -5/31/25, 5:00 P.M., Not administered: Drug item unavailable; -6/1/25, 9:00 A.M., Not administered: Drug item unavailable; -6/1/25, 1:00 P.M., Not administered: Drug item unavailable; -6/1/25, 5:00 P.M., Not administered: Drug item unavailable; -6/2/25, 9:00 A.M., Not administered: Drug item unavailable; -6/2/25, 1:00 P.M., Not administered: Drug item unavailable; -6/2/25, 5:00 P.M., Not administered: Drug item unavailable;-Progress note, dated 6/3/25 at 12:39 P.M., NP D notified in regards to missed medication administration. Follow up with dialysis regarding missing medication Renvela;-Progress note, dated 6/3/25 at 12:57 P.M., Spoke to nurse at dialysis center. Stated medication will be sent with resident upon arrival. Will place an order in the system for nursing to follow up with dialysis if no medications are received by Monday;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/3/25, 1:00 P.M., Not administered: Drug item unavailable; -6/3/25, 5:00 P.M., Not administered: Drug item unavailable; -6/4/25, 9:00 A.M., Not administered: Drug item unavailable, Comment: Waiting for delivery from dialysis; -6/4/25, 1:00 P.M., Not administered: Drug item unavailable, Comment: Waiting for delivery from dialysis; -6/4/25, 5:00 P.M., Not administered: Drug item unavailable, Comment: Waiting for delivery from dialysis; -6/5/25, 9:00 A.M., Not administered: Other, Comment: Waiting for new order (NO); -6/5/25, 1:00 P.M., Not administered: Other, Comment: New admit; -6/5/25, 5:00 P.M., Not administered: Other, Comment: New admit; -6/6/25, 9:00 A.M., Not administered: Other, Comment: Giving at dialysis; -6/6/25, 1:00 P.M., Not administered: Other, Comment: Giving at dialysis; -6/6/25, 5:00 P.M., Not administered: Other, Comment: Giving at dialysis; -6/9/25, 9:00 A.M., Not administered: Other, Comment: On order; -6/9/25, 1:00 A.M., Not administered: Resident unavailable; -6/11/25, 9:00 A.M., Not administered: Drug item unavailable; -6/11/25, 1:00 P.M., Not administered: Drug item unavailable; -6/11/25, 5:00 P.M., Not administered: Drug item unavailable; -6/12/25, 9:00 A.M., Not administered: Other, Comment: Not available in automated dispensing unit (ADU, computerized cabinets or machines that store and dispense medications within the facility), nurse made aware, and pharmacy; -6/12/25, 1:00 P.M., Not administered: Other, Comment: Pharmacy called to send out medication; -6/12/25, 5:00 P.M., Not administered: Other, Comment: Pharmacy called to send out medication;-Renal Vitamin (vitamin supplement formulated to address the unique nutritional needs of individuals with chronic kidney disease (CKD) especially those undergoing dialysis (treatment that helps people whose kidneys are failing to remove waste products and excess fluid from the blood)) 0.8 mg tablet once a day, start date 5/28/25, DC 7/14/25; -6/13/25, Not Administered: Drug item unavailable;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/13/25, 9:00 A.M., Not administered: Drug item unavailable; -6/13/25, 1:00 P.M., Not administered: Drug item unavailable;-Progress note, dated 6/13/25, 2:27 P.M., Resident visited by physician, NO for one time order for potassium chloride (used to prevent or treat low levels of potassium) 20 milliequivalent (mEq);-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/13/25, 5:00 P.M., Not administered: Drug item unavailable; -6/14/25, 9:00 A.M., Not administered: Drug item unavailable; -6/14/25, 1:00 P.M., Not administered: Drug item unavailable;-Potassium chloride 20 mEq tablet extended release (ER), start date 6/14/25, DC date 6/14/25; -6/14/25, Not administrated: Drug item unavailable;-6/14/25, 3:28 P.M., Resident complained of shortness of breath (SOB). Oxygen saturation (Sp02, measures amount of oxygen in the blood, normal SpO2 is between 90 and 100%) would drop to 89% then recover at 94% instantly. Resident placed on two liters (l) of oxygen which improved resident symptoms. Lung sounds clear. Physician NO for chest radiographs (x-ray);-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/15/25, 9:00 A.M., Not administered: Drug item unavailable; -6/15/25, 1:00 P.M., Not administered: Drug item unavailable;-Progress note, dated 6/15/25, 3:33 P.M., Resident had abnormal lab reported. NO for Levaquin 500 mg now. Levaquin 250 mg daily for six days, on coming nurse aware;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/15/25, 5:00 P.M., Not administered: Drug item unavailable; -6/16/25, 9:00 A.M., Not administered: Drug item unavailable; -6/16/25, 1:00 P.M., Not administered: Drug item unavailable; -6/16/25, 5:00 P.M., Not administered: Drug item unavailable; -6/17/25, 9:00 A.M., Not administered: Drug item unavailable, Comment: Waiting on pharmacy; -6/17/25, 1:00 P.M., Not administered: Drug item unavailable; -6/17/25, 5:00 P.M., Not administered: Drug item unavailable;-Progress note, dated 6/17/25, 6:11 P.M., Levaquin (Levofloxacin, broad-spectrum ABT) order updated to be administered in the evening due to resident having dialysis during the day;-Levaquin 250 mg daily for six days, start date 6/18/25, DC date 6/20/25; -6/18/25, Not administrated: Drug item unavailable, Comment: No more in emergency medication kit (e-kit, supply of medications maintained within the facility to address medical needs of residents when standard pharmacy services are not immediately accessible);-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/18/25, 9:00 A.M., Not administered: Drug item unavailable; -6/18/25, 1:00 P.M., Not administered: Resident unavailable, Comment: Dialysis;-Progress note, dated 6/18/25, 2:23 P.M., Called dialysis to check on status of Renvela medication. Spoke to nurse will call back to verify if order has been received by dialysis. Will implement a generic order to follow up within 48 hours for completion;-Progress note, dated 6/18/25, 4:25 P.M., Dialysis returned call back at 3:36 P.M., spoke to nurse, stated the medication Renvela is not covered by the dialysis center. Nurse stated that the pharmacy the resident uses at the facility will have to supply this medication. Order was faxed to the pharmacy at this time;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/18/25, 5:00 P.M., Not administered: Drug item unavailable, Comment: Call out to dialysis client; -6/19/25, 9:00 A.M., Not administered: Drug item unavailable, Comment: Dialysis will provide;-Progress note, dated 6/19/25, 10:31 A.M., Follow up Renvela to confirm if medication can be delivered. Pharmacy stated if dialysis doesn't deliver the medication the facility must cover the cost. Requesting pharmacy to send a copy of the documentation to get an approval;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/19/25, 1:00 P.M., Not administered: Drug item unavailable, Comment: Dialysis will provide; -6/19/25, 5:00 P.M., Not administered: Drug item unavailable;-Levaquin 250 mg daily for six days, start date 6/18/25, DC date 6/20/25; -6/19/25, Not administrated: Drug item unavailable;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/19/25, 1:00 P.M., Not administered: Drug item unavailable, Comment: Dialysis will provide; -6/19/25, 5:00 P.M., Not administered: Drug item unavailable; -6/20/25, 9:00 A.M., Not administered: Drug item unavailable, Comment: Giving at dialysis; -6/20/25, 1:00 P.M., Not administered: Resident unavailable;-Progress note, dated 6/20/25, 2:22 P.M., Physician present NO for two view chest x-ray in seven days to evaluate right lower lobe pneumonia;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/20/25, 5:00 P.M., Not administered: Drug item unavailable;-Levaquin 250 mg once an evening for six days, start date 6/20/25, DC date 6/22/25; -6/20/25, Not administered, Other: New order;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/21/25, 9:00 A.M., Not administered: Drug item unavailable; -6/21/25, 1:00 P.M., Not administered: Drug item unavailable; -6/21/25, 5:00 P.M., Not administered: Drug item unavailable;-Levaquin 250 mg once an evening for six days, start date 6/20/25, DC date 6/22/25; -6/21/25, Not administrated: Drug item unavailable;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/22/25, 9:00 A.M., Not administered: Drug item unavailable; -6/22/25, 1:00 P.M., Not administered: Drug item unavailable; -6/22/25, 5:00 P.M., Not administered: Drug item unavailable;-Levaquin 250 mg once an evening for six days, start date 6/20/25, DC date 6/22/25; -6/22/25, Not administrated: Drug item unavailable; -Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/23/25, 9:00 A.M., Not administered: Drug item unavailable;-Progress note, dated 6/23/25, 10:32 A.M., NP D called this A.M. and stated that resident will need to be sent out due to not receiving dose of ABT that was scheduled. RR notified that resident is being sent out. Emergency Medical Services (EMS) just arrived and resident is stable upon discharged . Review of the resident's Treatment Administration Record (TAR) and progress notes, showed: -Bladder scan and straight catheter if urine exceeds 300 cubic centimeter (cc) every 6 hours, start date 5/29/25, DC date 6/3/25; -5/29/25, 12:00 P.M., Not administered: Drug item unavailable; -5/29/25, 6:00 P.M., Not administered: Drug item unavailable; -5/30/25, 6:00 A.M., Not administered: Drug item unavailable; -5/30/25, 12:00 P.M., Not administered: Resident unavailable, Comment: Dialysis; -5/31/25, 12:00 A.M., Not administered: Other, Comment: Bladder scanner unavailable; -5/31/25, 6:00 A.M., Not administered: Other, Comment: Scan not unavailable; -5/31/25, 12:00 P.M., Not administered: Other, Comment: Bladder scanner unavailable; -5/31/25, 6:00 P.M., Not administered: Other, Comment: Resident urinating; -6/1/25, 12:00 A.M., Not administered: Other, Comment: Unable to complete; -6/1/25, 6:00 A.M., Not administered: Other, Comment: Unable to complete; -6/1/25, 12:00 P.M., Not administered: Drug item unavailable; -6/1/25, 6:00 P.M., Not administered: Drug item unavailable; -6/2/25, 12:00 A.M., Not administered: Drug item unavailable; -6/2/25, 12:00 P.M., Not administered: Resident unavailable; -6/2/25, 6:00 P.M., Urine: None; -6/3/25, 12:00 A.M., Not administered: Other, Comment: Night shift nurse unable to complete; -6/3/25, 6:00 A.M., Not administered: Other, Comment: Night shift nurse unable to complete; -6/3/25, 12:00 P.M., Not administered: Other, Comment: Bladder scanner unavailable.-Progress note dated -6/3/25, 12:39 P.M., NO for straight catheter every shift;-Progress note dated 6/3/25, 12:41 P.M., New order from NP D in place. Straight catheter every shift, discontinue (d/c) bladder scan. During an interview on 7/15/25 at 10:30 A.M., Certified Medication Technician (CMT) C said he/she remembered passing medication to the resident. CMT C said if any medication were not available on the medication cart, they would ask the nurse to pull the medication from the ADU. The nurse contacts the pharmacy if a medication is not available. During an interview on 7/15/25 at 11:48 A.M., NP D said the resident was started on Levaquin on 6/15/25 for pneumonia. NP D saw the resident on 6/17/25 and the resident was still on oxygen and had two doses of ABT at that point. NP D was not notified by the facility that the resident did not receive any more doses of the ABT after the first two initial doses. The RR called NP D and was upset because the resident had not received the ABT since 6/16/25. On 6/20/25, the resident still had not received the ABT that was ordered. If the facility would have notified NP D or the physician, they could have escalated the problem and brought it to management's attention. The physician was at the facility on 6/18/25 and nobody at the facility reported the resident not receiving the ABT to the physician. The physician could have changed the ABT on 6/18/25 if he/she would have been made aware of the facility not having the ABT. On 6/19/25 in late in the evening, they were notified by the RR that the resident still had not received the ABT. The physician looked at the resident on 6/20/25 and the resident looked clinically alright, and the physician reordered the ABT for 6 days and the nurse told the physician they would receive the ABT on 6/20/25. On 6/23/25, the RR called and reported the resident did not receive the ABT all weekend. NP D spoke to the physician, and they decided to have the resident sent out. They did not want to take the chance of the resident deteriorating. NP D did not know the facility didn't have the bladder scanner anymore. Apparently it went missing from the facility. The order was changed after she was notified the facility did not have the bladder scanner anymore. The order was updated to monitor output every eight hours and to straight catheter if there was no urine output. NP D was aware the resident missed a day or two of Renvela. She was not aware the facility never had the Renvela. NP D said Renvela is a phosphate binder and the resident's phosphate was alright when she reviewed his/her labs. NP D expected to be updated in real time when a medication was not available. During an interview on 7/21/25 at 12:44 P.M., Clinical Manager (CM) F said staff did not report the resident did not have his/her ABT as ordered. CM F was also not made aware of the resident not receiving the one-time order for potassium chloride. The potassium chloride would have been important because a one-time dose is usually due to labs being off. During an interview on 7/22/25 at 12:35 P.M., CMT E said he/she remembers the resident having an order for Levaquin. He/She said the RR asked him/her one evening about the ABT. CMT E looked in the cart and did not see it in the cart and told the RR it was not in the cart. The RR was upset and spoke to the nurse. CMT E said the nurse said the ABT was on the nurses' MAR and the nurse would move the ABT over to the CMT's MAR. CMT E checked the ADU for the ABT and the ADU did not have the ABT. CMT E said the ABT disappeared off his/her MAR again after that. CMT E said sometimes medications are placed onto the nurses' MAR if they have problems and want to make sure it is administered. 2. Review of Resident #2's medical record, showed: -admission: [DATE];-discharge: [DATE];-Severe cognitive impairment;-Diagnoses included Parkinsonism (collection of symptoms that resemble Parkinson's disease, including tremors, stiffness, and slow movement), muscle weakness, type two diabetes mellitus with diabetic chronic kidney disease and retention of urine. Review of the resident's MAR and progress notes, dated 7/5/25 through 7/7/25, showed: -Amlodipine (treats high blood pressure and chest pain) 5 mg once a day, start date 7/5/25, no end date; -7/6/25, Not administrated: Drug item unavailable;-Glimepiride (medication used to manage blood sugar (BS) levels in individuals with type two diabetes) 1 mg daily at breakfast, start date 7/5/25, no end date; -7/6/25, Not administrated: Drug item unavailable;-Meclizine (prevent and treat nausea, vomiting, and dizziness) 25 mg daily with breakfast, start date 7/5/25, no end date; -7/6/25, Not administrated: Drug item unavailable;-Pioglitazone (used to treat type two diabetes) 30 mg daily at breakfast, start date 7/5/25, no end date; -7/6/25, Not administrated: Drug item unavailable;-Quinapril (treats high blood pressure) 40 mg daily, start date 7/5/25, no end date; -7/6/25, Not administrated: Drug item unavailable;-Provigil (used to improve wakefulness) 200 mg once a day, start date 7/5/25, no end date; -7/6/25, Not administrated: Drug item unavailable;-Sodium bicarbonate (antacid) over the counter (OTC) 650 mg three times daily, start date 7/5/25, no end date; -7/6/25, 9:00 A.M., Not administrated: Drug item unavailable;-Rivastigmine tartrate (treats mild to moderate dementia) 4.5 mg mouth two times daily, start date 7/5/25, no end date; -7/6/25, A.M. medication pass (6:00 A.M. to 10:30 A.M.), Not administrated: Drug item unavailable;-BS check (80-130 mg per (/) deciliter (dl) before meals and less than 180 mg/dL two hours after meals) three times a day, start date 7/5/25, no end date; -7/6/25, 7:30 A.M., 119 mg/dl; -7/6/25, 11:30 A.M., 114 mg/dl; -7/6/25, 4:30 P.M., 152 mg/dl;-Rivastigmine tartrate 4.5 mg mouth two times daily, start date 7/5/25, no end date; -7/6/25, P.M. medication pass (3:00 P.M. to 7:30 P.M.), Not administrated: Drug item unavailable;-BS check three times a day, start date 7/5/25, no end date; -7/7/25, 7:30 A.M., 229 mg/dl; -7/7/25, 11:30 A.M., 439 mg/dl; -7/7/25, 4:30 P.M., 476 mg/dl;-Progress note 7/7/25 at 6:24 P.M., BS 475 mg/dl. Vital signs Blood pressure (BP, read in milliliters of mercury (mmHg) when referring to Systolic (SBP, top number, normal is below 140), diastolic (DBP, bottom number, normal is below 90) 88/54, respirations (R, breaths per minute, normal is 12 - 18) 18, Pulse rate (PR, heart beats per minute (BPM), normal range 60 - 100) 52, temperature, (T, normal 98.6 degrees Fahrenheit (F)) 97.0 F. Resident slow to response to question and having some tremor. Physician notified of change N.O. send to emergency department (ED) for evaluation and treatment. Family notified and requested local ambulance, explained the only way to get the local ambulance was to call 911. Family states they did not care and requested nurse to call 911. Local ambulance arrived at 6:15 P.M. and resident transferred to local hospital ED. Review of the EMS run sheet, dated 7/7/25, showed: -Primary impression: diabetic hyperglycemia (high BS);-6:20 P.M., BP 101/51, PR 66, R 14, Sp02 98% on room air;-6:21 P.M., BP 114/52, PR 61, R 16, Sp02 87%, BS 551;-6:25 P.M., BP 99/49, PR 64, R 14, Sp01 85%;-6:28 P.M., BP 118/63, PR 65, R 19, Sp02 94%;-6:33 P.M., BP 113/64, PR 63, R 21, Sp02 91%;-6:38 P.M., BP 128/53, PR 73, R 17, Sp02 94%;-6:43 P.M., BP 128/64, PR 78, R 15, Sp02 98%;-Dispatched for sick case: Upon arrival, resident sitting in in wheelchair, resident is alert to person and place which is baseline per RR. Licensed Practical Nurse (LPN) G reported he/she got multiple hypotensive (low BP) readings. Resident is also a diabetic and resident's BS readings are hyperglycemic. Resident's skin feels clammy. Resident denies chest pain, shortness of breath (SOB), abdominal pain, nausea or vomiting. Resident is a two person lift onto EMS stretcher. Resident's BP is no longer reading hypotension, but BS is still reading hyperglycemic (high blood sugar (BS)). Resident transferred to hospital ED. During an interview on 7/22/25 at 9:50 A.M., NP D said if a resident has an order to check BS readings three times a day, the nurses should report high BS readings above 350 mg/dl if on oral medication for diabetes and should report low BS readings below 70 mg/dl. NP D said it was not reported that the resident did not receive medication, including the oral diabetic medication, on 7/6/25. NP D said the BS readings from 7/7/25 at 7:30 A.M., 229 mg/dl and 11:30 A.M., 439 mg/dl were not reported to her or the on-call physician. NP D said the first call regarding the resident was when the nurse reported, BS 497, Sp02 85-88 on room air, BP 88/44, P 94, and the nurse said the resident was lethargic, his/her skin was cold and clammy, the resident was alert to self, and this was the baseline and the resident had a poor oral intake and output. The nurse was instructed to send the resident to the hospital. During an interview on 7/23/25 at 12:32 P.M., LPN H said nurses are responsible for taking residents' BS and administering insulin. LPN H said a high BS that he/she would contact the physician would be anything above 160 mg/dl and a low BS that he/she would contact the physician would be anything below 60 mg/dl. LPN H worked on 7/7/25 day shift (6:45 A.M. to 3:00 P.M.). LPN H said he/she did not remember the resident. LPN H said the BS reading of 229 mg/dl that was documented as obtained by LPN H at 8:33 A.M. and the BS reading of 439 mg/dl that was documented as obtained by LPN H at 12:16 P.M., LPN H said he/she would have called the doctor and requested an order for something to lower the resident's BS. LPN H said he/she would have entered a progress note and any orders the physician would have given. There were no orders entered on 7/7/25 by LPN H and no progress notes entered by LPN H on 7/7/25. LPN H said there would not have been documentation anywhere else other than the orders and progress notes. LPN H would not have let a resident have a BS reading in the 400s and not contact the physician. LPN H did not remember any residents having a high BS on 7/7/25. During an interview on 7/28/25 at 11:02 A.M., LPN G said nurses are responsible for taking residents' BS and administering insulin. LPN G said a high BS that he/she would contact the physician would be anything above 400 mg/dl and a low BS that he/she would contact the physician would be anything below 80 mg/dl. LPN G said he/she worked with the resident on 7/7/25 on the evening shift (2:45 P.M. through 11:00 P.M.). LPN G said he/she did not get anything in report from the day shift nurse regarding the resident's BS being elevated during the day. LPN G said he/she learned the resident had high BS readings during the day when he/she reviewed the resident's chart. LPN G went into check the resident's BS and it was 476 mg/dl. LPN G told the RR he/she was going to contact the physician regarding the high BS after he/she completed taking the other residents' BS. LPN G said when he/she was getting ready to call the physician, a Certified Nurse Aide (CNA) brought vitals that were out of range, including a low BP and low SpO2 reading. LPN G manually checked the resident's vitals. The resident's SpO2 was at 88%, so LPN G had the resident take a deep breath and cough and it came up to 92%. LPN G called the physician and received an order to send the resident to the ED. The RR requested the local ambulance and told the RR he/she would have to call 911. The RR said that is what he/she wanted and LPN G called 911. During an interview on 7/28/25 at 1:44 P.M., the Executive Director (ED), Assistant Executive Director (AED), and the Interim Director of Nursing (IDON) said they expected the resident's BS reading on 7/7/25 at 12:16 P.M. to be reported to the physician and for staff to document the notification in the resident's progress notes showing what orders the physician gave. 3. Review of Resident #6's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Rejection of care not exhibited;-Diagnoses included high blood pressure, hemiparesis (weakness on one side of the body) and hemiparesis (weakness on one side of the body ) following cerebral infarction (stroke) affecting left non-dominate side, expressive language disorder, and dystonia (involuntary muscle contractions that cause twisting and repetitive movements or abnormal postures). Review of the resident's care plan, during the survey, showed:-Problem: Resident has the potential for discomfort and side effects related to the use of antihypertensive mediation for the diagnosis of high blood pressure, created 6/11/25;-Goal: Resident will be free of any discomfort or adverse side effects, created 6/11/25;-Approach: Administer mediations as ordered, hold for SBP less than 100 or P less than 60, created 6/11/25. Review of the resident's MAR and progress notes, dated 7/28/25, showed: -Nifedipine (treats high blood pressure) 60 mg once daily, start date 2/29/24, no end date; -7/28/25, A.M. medication pass, Not administered: Other comment: On order nurse aware called pharmacy and medication will be here with tonight's medication;-No progress notes of notifications the medication was not administered as ordered to physician and RR. During an interview on 7/28/25 at 12:56 P.M., CMT J said he/she made the nurse aware the resident did not receive his/her dose of Nifedipine. CMT J said the pharmacy said the medication should be delivered this evening. 4. Review of Resident #5's admission MDS, dated [DATE], showed the following:-Severe cognitive impairment; -Rejection of care not exhibited;-Diagnoses included dementia, Parkinson's disease, high blood pressure, pneumonia and type two diabetes. Review of the resident's care plan, during the survey, showed:-Problem: Administer medication per physician orders, created 6/24/25;-Goal: Administer medication per physician orders while daughter is present, created 6/24/25;-Approac[TRUNCATED]

Based on interview and record review, the facility failed to ensure residents were free from misappropriation (unauthorized, improper, or unlawful use of funds or other property) when staff misappropriated $90.00 of the resident's money from his/her personal account and without the resident's consent (Resident #8). The census was 84.Review of the facility's Abuse Prevention Plan policy, copyright 2017, showed: -3. Training of Employees, Contract Staff, and Volunteers: Training will be provided to all new and existing employees, contract employees, and volunteers through orientation and annual training programs related to effective communication, dementia management and abuse prevention, freedom from abuse, neglect, and exploitation. This includes training and orientation to resident needs for agency staff. Nurse's aides are required to have 12 hours of training annually. These programs include topics required by 42 C.F.R. S 483.95, including, but not limited to, the following: -a. Definitions of abuse, neglect, and financial exploitation; -b. Providing protection for residents involved in incidents of abuse, neglect, misappropriation of resident property and/or financial exploitation; -e. Annual training on state and federal abuse prevention and reporting requirements, e.g., the Resident's [NAME] of Rights, Elder Justice Act, and state-specific laws;-4. Prevention of Abuse, Neglect, Misappropriation of Resident Property, and Financial Exploitation: In order to prevent abuse, neglect, misappropriation of resident property, and financial exploitation, the facility shall do the following: -a. Identify, correct, and intervene in situations where abuse, neglect, misappropriation of resident property, and/or financial exploitation occurs; -d. Encourage residents and families to report concerns, incidents, and grievances to appropriate staff. Residents and resident representative will be informed of reporting procedures through Resident Council, Family Council, and upon admission; -e. Require staff to report concerns, incidents, and grievances immediately to their supervisor. Ensure concerns, incidents, and grievances are promptly investigated and appropriate steps are taken to minimize the likelihood of re-occurrence;-5. Abuse Prevention Plans: -a. The facility will develop an individual abuse prevention plan for each vulnerable adult who receives services in the facility; -b. The plan shall contain an individual assessment of: -The resident's susceptibility to abuse, neglect, and financial exploitation by other individuals, including other vulnerable adults; -Specific measures to be taken to minimize the risk of abuse, neglect, and financial exploitation of residents and other vulnerable adults;-6. Identification of possible incidents which need investigation: -c. Any allegations involving abuse, neglect, misappropriation of resident property and/or financial exploitation will be investigated; -e. Events may include, but are not limited to, staff to resident physical abuse, staff to resident verbal abuse, resident to resident altercations (a resident to resident altercation is an incident involving a resident who willfully inflicts injury upon another resident. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm), misappropriation of a resident's funds, property or personal effects, etc. This list is not intended to be exhaustive and the facility will review any potential incident for conduct that meets the definitions of abuse, neglect, misappropriation of resident property, or financial exploitation; -f. Report within the timelines of the guidance: -Staff will notify the facility charge of building immediately of any reports of possible abuse, neglect, misappropriation of resident property, and/or financial exploitation. The charge of building will immediately notify the Administrator, Director of Nursing (DON), and Director of Social Services (DSS);-7. Investigation of Incidents and Allegations: -a. All accidents and incidents as well as allegations of abuse, neglect, misappropriation of resident property, and/or financial exploitation will be thoroughly investigated by DSS, DON, or their appropriate designees; -e. Identify and interview all who might have knowledge of the incident including the alleged victim, perpetrator, witnesses or others who may have had related contact with the alleged perpetrator, related to the incident in question; -f. The focus of the investigation is to determine the extent, cause and future prevention with thorough documentation of the investigative process completed;-9. Reporting of suspected resident abuse and/or neglect: -a. Staff will notify the facility charge of building immediately of any reports of possible abuse, neglect, misappropriation of resident property, and/or financial exploitation. The charge of building will immediately notify the Executive Director (ED) or designee in the ED's Absence; -b. The community is responsible for reporting suspected abuse, neglect, misappropriation of resident property, and/or financial exploitation in accordance with legal requirements. If the event that caused the suspicion involves abuse or results in serious bodily injury, the individual is required to report the suspicion immediately, but not later than two hours after forming the suspicion. If the event does not involve abuse and does not result in bodily injury, the individual is required to report no later than 24 hours after forming the suspicion; -h. The facility will not retaliate against an individual who notifies or reports a suspicion of abuse, neglect, misappropriation of resident property and/or financial exploitation in good faith. The facility must post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if they believe the facility has retaliated against an employee or individual who reported a suspected crime and how to file such a complaint;-Definitions: - Misappropriation of resident property: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent; - Vulnerable Adult: Any person [AGE] years of age or older who is a client, tenant, or resident of the facility or is otherwise receiving care from the facility (collectively resident);- Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of Resident #8's medical record, showed:-Cognitively intact;-Diagnoses included pneumonia, chronic obstructive pulmonary disease (COPD, lung conditions that cause breathing difficulties and airflow obstruction), shortness of breath (SOB), high blood pressure, and muscle weakness. Review of Certified Nurse Aide (CNA) K's Employee information sheet, showed: -Date of hire: 2/10/25;-Emergency contact(s) (EC): -Name: CNA K's EC; -Address: Same address listed as CNA K's address; -Relation: Son. Review of the resident's debit card transactions, dated 7/19/25 through 7/20/25, showed: -7/19/25, 7:14 P.M., Blitz - Win Cash New Approved [NAME] (mobile application that allows users to play skill-based games and potentially win cash prizes), $8.00, approved;-7/19/25, 11:11 P.M., Imo's [NAME] St. Louis 31, $55.55, approved;-7/20/25, 12:44 P.M., Cash App CNA K, $40.00, approved;-7/20/25, 1:18 P.M., Door dash NEWYORKGR 1, $12.22, approved;-7/20/25, 1:26 P.M., Cash App CNA K, $50.00, approved;-7/20/25, 1:32 P.M., Go Puff LIC (offers rapid delivery of everyday essentials, including groceries, home products, over-the-counter medications, and alcohol in St. Louis), $57.83, declined; -Charge attempted four times (at same time as listed above) all four times all were declined;-7/20/25, 1:33 P.M., Go Puff LIC, $43.43, declined; -Charge attempted four times (at same time as listed above) all four times all were declined;-7/20/25, 1:34 P.M., Go Puff LIC, $36.10, declined; -Charge attempted four times (at same time as listed above) all four times all were declined;-7/20/25, 1:51 P.M., Cash App CNA K's Emergency Contact (EC), $20.00, declined. Review of a text message from CNA K sent to the Assistant Executive Director (AED), dated 7/21/25 at 2:06 P.M., showed:-To whom it may concern: CNA K has been in this line of work since 2009. Never has CNA K took anything from a resident. CNA K never entered a residents room without the resident being there. CNA K takes pride in his/her work. (He/She) is upset at the fact that someone will tarnish (his/her) character in such a way. CNA K gives his/her all when caring for the resident's. This is his/her passion CNA K loves what he/she does. CNA K's name listed and his/her phone number. Review of facility's corrective action form, dated 7/21/25, showed:-Employee Name: CNA K;-Job title; CNA;-Summary of incident and/or behavior: CNA K has been suspended pending an investigation into allegations of stealing resident credit cards and financial information. He/She is accused of the following: -Stealing residents' financial information from their room; -Using that information to make unauthorized purchases; -Transferring funds to his/her personal CashApp account;CNA K's name was found on the resident's financial records, supporting the allegations. Additionally, local authorities have been contacted, and criminal charges have been filed;-Expectations and performance plan: -Any form of financial theft, or misuse of resident or funds is strictly prohibited and will result in immediate disciplinary action, up to and including termination and legal prosecution;-Action being taken: Suspension. Review of the facility's corrective action form, dated 7/21/25, showed:-Employee Name: CNA K;-Job title; CNA;-Summary of incident and/or behavior: Following a thorough investigation into allegations of financial abuse, we have determined that CNA K will be held responsible for multiple serious violations, including: -Accessing residents' financial information without authorization; -Making unauthorized purchases using resident credit cards; -Transferring money to her personal CashApp account; -Forging signatures on credit card transactions;-Due to the severity of these actions and the breach of trust involved, we are seeking immediate termination. Additionally, local authorities have been contacted, and criminal charges have been filed;-Action being taken: Termination. Review of a resident interview completed by the facility on 7/22/25, showed: -Resident said he/she did not witness anyone taking his/her debit card out. Resident said it was always kept in the drawer of the nightstand next to his/her bed. Review of the facility's investigation, dated 7/22/25, showed: -AED spoke with Police Officer (PO) L. PO L said he/she spoke with CNA K. PO L said he/she looked through CNA K's cell phone and could not find anything on it. PO L thinks CNA K might have gone in and cleared the items off of his/her phone since he/she was called and asked questions about the debit card by the facility. PO L is working on getting statements from the bank at this time. Review of the facility's investigation, dated 7/25/25, showed:-It was reported on 7/21/25 around 1:00 P.M. that resident's debit card was used to make purchases that he/she did not approve. The resident's spouse brought in the bank statements. After looking at the bank statements the AED noticed one of the facility's employee's names on it. The employee, CNA K works evenings as a CNA. CNA K has consistently had the assignment that the resident resides on. On the bank statement it shows that someone was trying to send CNA K $40.00 through cash app (mobile payment service that allows users to send, receive, and manage money digitally). CNA K was immediately suspended pending investigation, and the police were called to come take a police report. Two police officers came out and took report from the facility and spoke with the resident and his/her spouse obtaining their statements. CNA K's name, phone number, address and date of birth were provided to police. Police took a copy of the bank statement for their investigation and provided the report number. After the police left that same day, they called and left a voice mail that they will call back in 10 minutes since AED did not answer the phone. They did not call back. AED ended up calling them the next day. PO L informed AED that they went to CNA K's house and spoke with him/her. He/She showed them his/her phone and they did not see anything. PO L said he/she thinks CNA K might have cleared it since the facility called him/her to ask him/her about it and get his/her statement. The PO L said CNA K has not been arrested but they will get information from the bank. PO L said they will be in touch. I had social services go and talk with the resident to get his/her statement along with other residents to see if they noticed anything missing. All the other residents stated they were not missing anything. The resident said he/she kept his/her debit card in the top drawer. He/She never asked any of the staff to take it out for him/her. He/She thought her spouse was the only one that was aware of where it was located. Even though the police have not provided any further information, given the bank statement showing CNA K's name, we have requested approval for termination form the Human Resources (HR) department. During an interview on 7/29/25 at 1:18 P.M., CNA K said he/she has been a CNA since 2009. CNA K confirmed his/her home address and email address. He/She worked evening shifts for the facility from 3:00 P.M. until 11:00 P.M. CNA K denied having a door dash app, cash app, blitz app, and using the go puff app. CNA K said he/she does not use go puff, he/she only uses online shopping like Walmart, Macy's and target and he/she uses his/her own debit card. CNA K denied knowing the name that was listed first on his/her emergency contact list. CNA K said when the police officers came to his/her house, they looked through his/her phone and did not find anything on his/her phone related to the charges. During an interview on 8/8/25 at 12:00 P.M., PO M said he/she went to CNA K's house and interviewed him/her. CNA K admitted knowing CNA K'S EC who was listed on the bank statement for a $20.00 cash app charge that was declined. CNA K said someone was setting him/her up. CNA K allowed PO M to look through his/her phone on the cash app and nothing was there. PO M said CNA K had advanced noticed that PO M would be out to speak with him/her and he/she probably cleared it out of his/her phone before PO M arrived. PO M is in the process of getting more detailed information from the bank regarding the charges and will be issuing subpoenas for the other unauthorized charges that were made on the resident's debit card. During an interview on 7/28/25 at 1:41 P.M., the Executive Director (ED), AED, and the Interim Director of Nursing (IDON) said they expected staff to be knowledgeable of and follow the facility policies. They expected staff to never use any resident credit or debit card even if the resident where to ask. 2567421

Based on observation, interview and record review, the facility failed to have a system in place to ensure drugs and biologicals (medications that are grown from bacteria or viruses) stored in the medication room refrigerator were being stored at a proper temperature for 1 out of 1 medication rooms observed. The facility failed to have medication storage boxes filled with medication in a secure area. The census was 93. Review of facility's Medication Storage Policy, dated, March, 2017, showed: -Policy: Medication and biologicals are stored safely, securely and properly, following manufacturer's recommendation or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Procedure: The facility should maintain a temperature log in the storage area to record temperatures at least once a day. 1. Observation on 3/11/25 at 10:30 A.M., of the medication room on Fontbonne/[NAME] Hall, showed a black refrigerator with a lock. Inside the refrigerator was a thermometer, insulin pens, Aranesp injections (medication to increase red blood cells in the body), intravenous (IV) antibiotics and Tylenol suppositories. Review of the refrigerator log, dated February, 2025, showed the temperatures were not checked on: 2/1, 2/2, 2/5, 2/6, 2/11, 2/12, 2/13, 2/14, 2/15, 2/16, 2/17, 2/18, 2/19, 2/20, 2/21, 2/23, 2/24, 2/25, 2/26, 2/27, and 2/28/25. Review of the refrigerator log, dated March, 2025, showed the temperatures were not checked on: 3/1 though 3/11/25. During an interview on 3/11/25 at 10:30 A.M., Licensed Practical Nurse (LPN) I said he/she thought the temperatures were to be checked daily by the nurses but wasn't sure. 2. Observation on 3/12/25 at 7:45 A.M., and on 3/13/25 at 10:10 A.M. and 12:05 P.M., at the [NAME] nurses' station, showed two red medication storage containers and one black medication storage container, on the floor in nurses' station. Pill packages and IV antibiotics were overflowing from the boxes. The boxes did not have locks and the nurses' station did not have a door. Residents and visitors were walking past the [NAME] nurses' station while the unsecured boxes were positioned on the floor. During an interview on 3/13/25 at 12:50 P.M., LPN N said he/she saw the unsecured boxes at the [NAME] nurses' station and was going to work on getting them packed up and sent to the pharmacy for a credit. The boxes are to be secured with a special tape they use until the pharmacy can remove them. The pharmacy technician can only take two boxes at a time. The boxes should be in the locked med room until they are ready to be picked up. 3. During an interview on 3/11/25 at approximately 12:00 P.M. and on 3/14/25 at 11:13 A.M., the Director of Nursing (DON) said she expected the temperatures to be checked for the med room refrigerator once a day. It is expected for the night shift nurse to obtain the temperatures and write them on the temperature log. All medications should be secured with a lock. She expected staff to not leave the medications in a box, unsecured at the nurses' station. The unsecured medications could be taken by the residents or visitors.

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than 5%. Out of 31 opportunities observed, twelve errors occurred, resulting in a 38.71% error rate (Resident #83, Resident #196, Resident #79 and Resident #197). The census was 93. Review of the facility's Administrating Medications policy, revised 8/31/23, showed: -Purpose: To ensure safe administration of resident's medication as indicated and ordered by the provider; -Procedure: Medications are administered in accordance with the orders and within their prescribed times; The person preparing or administering the medication will contact the provider if there are questions or concerns regarding the medication; With any irregularities, appropriate notifications will be completed for clarification. -Administer medications following the six rights of medication administration; -Right resident; -Right medications; -Right dose; -Right time; -Right route; -Right documentation. Review of the facility's medication crushing guidelines, dated 12/17, showed: -Medications that should not be crushed or chewed: -Enteric Coated tablets are designed to pass through the stomach whole and then dissolve in the intestinal tract. Review of the manufacturer's instructions for fluticasone propion-salmeterol inhaler, showed the resident should rinse his/her mouth without swallowing to prevent oropharyngeal candidiasis (mouth and throat yeast infection). 1. Review of Resident #83's face sheet, undated, showed diagnoses that included fracture of the humerus (arm bone), infection of orthopedic devices, anxiety, high blood pressue, kidney failure and obesity. Review of the resident's Physician Order Sheet (POS), dated 3/25, showed; -An order, dated, 2/27/25, Astepro Allergy (medication to treat allergy symptoms) 205.5 micrograms (mcg), two sprays, each nostril, once daily; -An order, dated, 1/9/25, Cyclosporine (medication to treat dry eyes) dropperette, 0.05%, give one drop to both eyes, twice a day; -An order, dated, 1/9/25, daily multi-vitamin give one tablet, once daily; -An order, dated, 1/9/25, fluticasone furate-vilanterol (inhaler used to treat lung disease) 100-25 mcg one puff, once daily; -An order, dated, 1/9/25, fluticasone propion-salmeterol (inhaler used to treat lung disease) 100-50 mcg, one puff, twice daily; -An order, dated, 1/9/25, fluticasone propionate spray (medication to treat allergy symptoms), 50 mcg, two sprays, nasally, once daily; -An order, dated ,1/9/25, Metamucil powder (fiber supplement), 3.4 gram (gm)/ 5.4 gm, give orally, once daily; -An order dated, 1/9/25, polyethylene glycol powder (laxative)17 gm, give orally, once a day; -An order dated, 1/9/25, sennosides-docusate sodium (stool softener), 8.6-50 milligrams (mg), give one tablet, once daily. Observation on 3/11/25 at approximately 9:00 A.M., showed Certified Medication Technician (CMT) J prepared the resident's medication at the medication cart. CMT J entered the resident's room and gave the resident his/her oral medication. CMT J then positioned the fluticasone propion-salmeterol inhaler at the resident's mouth, had the resident inhale, and instructed the resident to hold his/her breath once the medication was inhaled. CMT J removed the fluticasone propion-salmeterol inhaler from the residents mouth. CMT did not instruct the resident to rinse his/her mouth afterwards. CMT opened the cyclosporine vial and administered 4-5 drops in the left eye and 4-5 drops in the right eye. The medication was dripping down the resident's cheeks and CMT J provided the resident with a tissue to wipe his/her face. CMT J did not administer a multi-vitamin, Astepro Allergy nasal spray, fluticasone furate-vilanterol inhaler, fluticasone propionate spray nasal spray, Metamucil powder, polyethylene glycol powder, and sennosides-docusate sodium. During an interview with the resident on 3/12/25 at 1:00 P.M. and on 3/14/25 at 7:55 A.M., the resident said there is always a mix up with his/her medications. His/Her medications are frequently late or not given. There is no consistency. 2. Review of Resident #196's face sheet, showed diagnoses included Alzheimer's disease, dementia, weakness, high blood pressure and chronic kidney disease. Review of the resident's POS, dated 3/25, showed: -An order, dated, 2/27/25, aspirin tablet 81 mg, delayed release, enteric coated (EC), give one tablet daily. During observation and interview on 3/11/25 at 8:40 A.M., CMT J said the resident had to have his/her medication crushed. CMT J prepared the resident's medication, including the aspirin 81 mg EC, placed them in a clear pouch and crushed them, using the pill crusher. The medication was mixed in yogurt. CMT J entered the resident's room and administered the medication to the resident by using a spoon and encouraging the resident to swallow the medication. 3. Review of Resident #79's face sheet, undated, showed diagnoses included kidney failure, high blood pressure, myocardial infarction (heart attack), cardiomyopathy (enlarged heart), malnutrition (poor nutrition) and brain cancer. Review of the resident's POS, dated 2/13/25 through 3/13/25, showed: -An order, dated 1/28/25, stop date, 2/24/25, Megace (medication used to stimulate appetite) 40 mg, give one tablet four times a day. Observation on 3/11/25 at 9:17 A.M., showed CMT J was preparing the resident's medications at the medication cart and entered the resident's room. CMT J administered the resident's medication. Megace 40 mg was administered to the resident. 4. Review of Resident #197's face sheet, undated, showed diagnoses included, femur (leg bone) fracture, muscle weakness and osteoarthritis (arthritis in the bone). Review of the resident's POS, dated 3/25, showed: -An order, dated, 3/1/25, cholecalciferol (vitamin D3) 50 mcg, give one capsule daily. Observation on 3/11/25 at 9:00 A.M., showed CMT J prepared the medications at the medication cart and entered the resident's room and administered the resident his/her medication. CMT J did not administer the resident's cholecalciferol 50 mcg capsule. 5. During an interview on 3/11/25 at 8:50 A.M., CMT J said pill packs are what the facilty uses, along with floor stock medcations that are in bottles located on the medication cart. The medication orders are compared against the pill packs prior to administering the medications. Discontinued medications have to be removed by staff out of the pill packs. 6. During an interview on 3/13/25 at 12:50 P.M., Licensed Practical Nurse (LPN) N said CMTs and nurses should follow the six rights of administration and follow the physician orders. The pill packs the resident's medication is dispensed from should be accurately checked against the resident's POS before giving medication. If the staff member is giving medication just off of memory or assuming the pill packs are correct and not comparing the medcation to the POS, medication errors will likely occur. Any discontinued medication should be removed from the pill packs. 7. During an interview on 3/14/25 at 11:13 A.M., the Director of Nurses (DON) said she expected staff administering the resident's medication, to give the medication accurately and with proper technique. When inhalers are administered to the residents, she expected staff to instruct the resident to rinse after use if the inhaler required them to do so. She expected staff to not crush EC medications.

Based on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for three out of four medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 93. Review of the facility's Controlled Substance Storage policy, revised, March, 2017, showed: -Policy: Medications included in the Drug Enforcement Administration (DEA) classifications as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations; -At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including, refrigerated items is conducted by two licensed nurses and is documented on the shift verification of controlled substance count. 1. Review of [NAME] Hall narcotic book count sheets, dated , 3/1 through 3/11/25, showed: -Eleven out of 30 shifts have no nurse signature on the shift change count; -Four out of 30 shifts only have one nurse signature on the shift change count; -No documentation that a shift change count was completed 3/8/25 through 3/11/25. 2. Review of the [NAME] narcotic book count sheets, dated, 3/1 through 3/11/25, showed: -Seven out of 30 shifts have no nurse signature on the shift change count; -Eleven out of 30 shifts only have one nurse signature on the shift change count; -No documentation that a shift change count was completed 3/10/25 through 3/11/25. 3. Review of [NAME] Hall narcotic book count sheets, dated 3/1 through 3/11/25, showed: -Eight out of 30 shifts have no nurse signature on the shift change count; -Thirteen out of 30 shifts only have one nurse signature on the shift change count. During an interview on 3/11/25 at 10:30 A.M., Licensed Practical Nurse (LPN) I said the nurses are the only staff that administer narcotics. The narcotic sheets are to be signed by one oncoming and one off going nurse every shift, every day. 4. During an interview on 3/14/25 at 11:13 A.M., the Director of Nursing (DON) said she would expect the nurses to count narcotics with one oncoming nurse and one off going nurse every shift, every day. Nurses are expected to sign the narcotic count sheet once the count is completed.

Based on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges, and failed to provide a written notice of transfer/discharge to one resident (Resident #90) and/or resident representative when the resident was transferred to the hospital. The sample was 21. The census was 93. Review of the facility's Discharge Planning policy, dated 11/28/17, showed: -Purpose: To prepare the resident for and ensure a safe discharge from the facility; -The policy did not provide guidance related to notification to the Ombudsman regarding resident transfer and discharges; -The policy did provide guidance related to ensuring residents and/or resident representatives are provided with written notification as soon as practicable following a resident's transfer to the hospital. 1. During an interview on 3/6/25 at 2:07 P.M., the Ombudsman said he/she has not received monthly notification of transfers and discharges from the facility on a consistent basis. He/She has gone months without receiving notice of transfer/discharge from the facility. During an interview on 3/11/25 at 11:30 A.M., the Assistant Executive Director was asked to provide documentation of the facility's notification of transfer/discharge to the Ombudsman's office for the last six months. During an interview on 3/13/25 at 10:34 A.M., the Social Services Director (SSD) said she has been in her current position with the facility for two years. Until this week, she was not aware she needed to notify the Ombudsman's office of resident transfers/discharges. During an interview on 3/12/25 at 7:12 A.M. with the Executive Director and Assistant Executive Director, they said the current SSD began working with the facility in April 2023. She was not aware she needs to provide the Ombudsman's office with notification of transfers/discharges. The expectation is for the facility to notify the Ombudsman of transfers/discharges on a monthly basis. 2. Review of Resident #90's medical record, showed: -admission date 12/11/24; -discharged [DATE]; -No documentation the resident and/or their representative provided with a written notice of transfer/discharge. Review of the facility's admission/discharge report, dated 12/14/24, showed the resident discharged /transferred to hospital for inpatient care. During an interview on 3/13/25 at 10:34 A.M., the SSD reviewed the resident's medical record and did could not locate a discharge summary or notice of discharge. She thought the resident was discharged to the hospital. During an interview on 3/13/25 at 12:14 P.M. with the Executive Director and Assistant Executive Director, they said the resident wanted to go out to the hospital, so his/her family picked him/her up and brought him/her to the hospital. The resident called the facility later and said he/she was not coming back. Facility staff should have sent a notice of transfer with the resident when he/she went out to the hospital.

Based on interview and record review, the facility failed to develop and implement baseline care plans within 48 hours of a resident's admission for three residents (Residents #90, #195 and #194). The census was 93. Review of the facility's Comprehensive Assessments and Care Planning policy, revised [DATE], showed: -Purpose: To provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs, using the Resident Assessment Instrument (RAI) specified by the State; -Policy: --The assessment process begins with the development of the baseline care plan within the first 48 hours of admission. The baseline care plan includes the minimum healthcare information necessary to care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury. Baseline care plans address, at a minimum, the following: -Initial goals based on admission orders; -Physician orders; -Dietary orders; -Therapy services; -Social services; -Preadmission Screening and Resident Review (PASARR) recommendation, if applicable; --The baseline care plan reflects the resident's stated goals and objectives, and includes interventions that address his or her current needs. If the resident experiences a significant change in condition prior to the implementation of the comprehensive care plan - changes will be made to the baseline care plan to reflect the new approaches. 1. Review of Resident #90's medical record, showed: -admitted [DATE]; -Diagnoses included Parkinson's disease (movement disorder), history of failing, hemiplegia (paralysis to one side of the body) or hemiparesis (weakness to one side of the body) following stroke, heart failure, other frontotemporal neurocognitive disorder, major depressive disorder, generalized anxiety disorder; -discharge date [DATE]; -No baseline care plan documented during the resident's stay at the facility from [DATE] to [DATE]. 2. Review of Resident #195's medical record, showed: -admitted [DATE]; -Diagnoses included right hip fracture, right joint replacement, emphysema (a lung disease), history of falling and high blood pressure; -No baseline care plan documented. Observation and interview on [DATE] at 6:10 P.M., howed the resident lay in bed. The resident said he/she fell while in the community and sustained a fractured right hip. The orthopedic surgeon said his/her hip was shattered and required a lot of fixing. The resident said he/she was having a lot of pain. He/She currently uses a wheelchair, and therapy is assisting him/her to walk. He/She requires assistance from staff to use the bathroom and today was the first shower he/she had received by the facility staff since he/she had been admitted to the facility. 3. Review of Resident #194's medical record, showed: -admitted [DATE]; -Diagnoses included clostridium difficile (C-diff, an infection in the intestine that causes diarrhea), bronchitis (inflammation of the lungs), repeated falls, COVID-19, influenza A (flu) with respiratory manifestations, orthostatic hypotension (low blood pressure that occurs when sitting or standing) and incontinence of feces; -No baseline care plan documented. Observation and interview on [DATE] at 1:45 P.M., showed the resident in bed and a wheeled walker was positioned next to the resident's bed. The resident said he/she was at home and fell , then went to the hospital. The resident said he/she arrived at the facility on [DATE] around 2:00 or 3:00 P.M. He/She has bruised ribs with pain on movement. He/She is incontinent of stool but had been changing him/herself and brought his/her own incontinent briefs. He/She was not told what type of infection he/she has, but noticed isolation gowns and masks were hanging on the outside of the door to be worn by staff. The resident did not receive any medications and felt as though he/she was just left alone in the room, like in a jail cell. The resident also said his/her family member died suddenly and was very sad. 4. During an interview on [DATE] at 9:14 A.M., Licensed Practical Nurse (LPN) A said nurses are responsible for completing baseline care plans within 48 hours of a resident's admission to the facility. Baseline care plans should include information related to the resident's mental status, activities of daily living (ADL) needs, diet, behaviors, and adaptive equipment. 5. During an interview on [DATE] at 11:13 A.M. the Director of Nurses (DON), Executive Director, and Assistant Executive Director said nurses are to complete baseline care plans within 48 hours of a resident's admission. The baseline care plan should be documented in the resident's electronic medical record (EMR). Baseline care plans should include information related to all of the resident's care needs. 42795

Based on observation, interview, and record review the facility failed to develop a plan of care specific to each resident's needs. Concerns were found in the care plans for three out of 21 sampled residents when the facilty failed to include the presence of side rails (Resident #52), presence of a urinary catheter (Resident #11), and presence of hospice services (Resident #20) in the resident care plans. The facility census was 93. Review of the facility's Comprehensive Assessments and Care Planning Policy, revised 9/27/23, showed: -Purpose: To provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental, and psychological functioning possible, a facility must make a comprehensive assessment of each resident's needs, using the Resident Assessment Instrument, (RAI, a federal assessment tool used to identify specific resident needs) specified by the State; -A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals, and sign and certify the assessment is completed; -The assessment must accurately reflect the resident's status, and each person who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment; -The resident's comprehensive assessment, completed within 14 calendar days after admission, must include at least the following: Demographic information, customary routine, cognitive patterns, communication, vision, mood and behavior problems, psychosocial wellbeing, Preadmission Screening and Resident Review (PASARR, a federal assessment tool used to ensure proper placement of individuals in facilities equipped to handle their care) recommendations as applicable, physical functioning and structural problems, continence, disease diagnosis and health conditions, dental and nutritional status, skin conditions, activity pursuit, medications, special treatments and procedures, discharge planning, documentation of summary information regarding additional assessment performed through the resident assessment protocols, documentation of participation in assessment, resident strengths, goals, life history, and preferences. 1. Review of Resident #52's medical record, showed: -Diagnoses included spinal stenosis (chronic pain and stiffening of the spinal column), history of falls, high blood pressure, and muscle spasms; -No active physician order for side rails; -A Restraints/Adaptive Equipment Consent recorded on 3/3/25 and left blank; -A Restraints/Adaptive Equipment Use Observation recorded on 3/3/25. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/28/25, showed: -Cognitively intact; -Impairment to both lower extremities with full strength of upper extremities; -Independent with mobility areas: Roll left and right, sit to lying, and lying to sitting on side of bed. -Use of siderails not checked. Review of the resident's care plan, in use at the time of survey, showed no mention of the resident's use of side rails while residing in the facility. Observation and interview on 3/10/2025 at 11:31 A.M., showed the resident resting in bed with circular positioning rails installed on both sides of the bed. The resident said he/she uses the side rails for bed mobility and has had them since admission to the facility. During an interview on 3/14/25 at 7:58 A.M., Certified Nursing Assistant (CNA) Q said side rails should be included on a resident's care plan to help facility CNAs provide adequate and personalized care to each resident. Resident #52 utilizes the facility's halo rails for bed mobility and positioning. During an interview on 3/14/25 at 7:48 A.M., CMT (Certified Medication Technician) K said the resident utilizes side rails for positioning and bed mobility, and he/she would expect side rails to be included on the resident's care plan. 2. Review of Resident #11's medical record, showed: -Diagnoses included: Diabetes, retention of urine (the inability to routinely void urine), presence of urogenital implants (medical devices inserted in the urinary tract to aid in voiding of urine), high blood pressure, and spinal stenosis -A physician order placed on 2/4/25 to change indwelling catheter and bag as needed (PRN) based on clinical indications; -No further orders for the resident's indwelling catheter. Review of the resident's admission MDS, dated [DATE], showed: -Cognitively intact; -Use of catheter not checked; -Care Area Assessment triggers for Urinary Incontinence for level of assistance needed with toileting needs and actual incontinent episodes. Review of the resident's care plan, in use at the time of survey, showed no mention of the resident's catheter status, size of the catheter, or care needs. Observation and interview on 3/10/25 at 10:57 A.M., showed the resident resting in bed with his/her catheter covered and hanging from the wheelchair. During an interview, the resident said he/she has had intermittent problems with receiving catheter care, including the draining of the catheter bag. The resident said he/she has urinated on the bedsheets while residing at the facility because staff would not drain the catheter bag. Observation and interview on 3/12/25 at 10:27 A.M., showed the resident resting in bed with his/her catheter covered and hanging from the bed frame. During an interview, the resident said an agency CNA worked the hall overnight, and the resident had to get on them to drain his/her catheter bag. The resident said the CNA seemed surprised and confused the resident had a catheter when entering the room to provide care. During an interview on 3/14/25 at 7:58 A.M. CNA Q said he/she knew the resident well and was aware the resident had an indwelling catheter that required staff care. Care plans at the facility are made with input from facility CNAs, and the presence of an indwelling catheter should be included on a resident's care plan if it is in use and/or requires care. Care plans are important so that each resident's specific care needs are communicated to staff. During an interview on 3/14/25 at 7:48 A.M., CMT K said he/she was unaware the resident had an indwelling catheter and thought the resident had it removed some time ago. CMT K would expect the resident's urination status to be included on the resident's care plan, and all care plans should be developed and tailored to each resident's specific care needs. 3. Review of Resident #20's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included Alzheimer's disease, diabetes, and congestive heart failure (CHF); -Resident is on hospice. Review of the resident's physician order sheet (POS), in use at the time of the survey, showed: -An order, dated 4/24/24, resident admitted to hospice with the diagnosis of acute congestive heart failure. Review of the resident's care plan, in use at the time of the survey, showed: -The care plan did not address the resident receiving hospice care. During an interview on 3/14/25 at 7:38 A.M., Licensed Practical Nurse (LPN) A said the care plan should include hospice care. This is important so staff are aware of the care the hospice company provides, and so care is cohesive. During an interview on 3/14/25 at 8:51 A.M., CNA D said the resident's care plan should indicate if the resident is on hospice. 4. During an interview on 3/14/25 at 11:21 A.M., the Administrator and Director of Nursing (DON) said they would expect hospice care, presence of an indwelling catheter, and utilization of side rails to be included on resident care plans. Care plans are developed by the Interdisciplinary Team made up of nursing staff, therapy staff, the MDS coordinator, and social services staff. It is important that all residents' care plans address their specific care needs in order to provide care tailored to each specific resident. 46888

Based on observation, interview and record review, the facility failed to provide services to meet professional standards of practice when staff held medications for two residents (Residents #79 and #83) with low blood pressure and failed to notify the nurse so the nurse could notify the physician to initiate parameters. Staff failed to ensure medication was available for administration and to administer available medications for one resident (Resident #15), and the facility failed to have a sufficient system in place to track pharmacy refill requests. The sample was 21. The census was 93. Review of the facility's Change in Condition policy, undated, showed; -Purpose: To provide care and services based upon the current needs of the resident under the direction of the attending provider; To inform the resident and/or resident's representative and attending provider with a significant change in a resident occurs; -Policy: When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is a need to alter treatment significantly, the licensed nursing associate consults with the attending provider and notify the resident or the resident's representative; -Procedure: Assess significant change in the resident's condition noted through direct observation, interview or report from other staff; Obtain a set of vital signs and repeat as needed or ordered; Notify the attending provider of the change in condition and implement orders for treatment and appropriate monitoring as directed; Monitor and provide treatment as ordered by the attending provider. Review of the facility's Ordering and Receiving Non-Controlled Medications from the Dispensing Pharmacy policy, dated December 2017, showed: -Policy: Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt; --Ordering Medications from the Dispensing Pharmacy: -Medication orders are written on a medication order form (i.e., telephone order sheet, reorder form, electronically, etc.) provided by the pharmacy, written in the chart by the physician, electronic order, or written on a transfer order form and transmitted to the pharmacy; -Reorder medication five days in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand. --Receiving Medications from the Pharmacy -A licensed nurse: -Receives medications delivered to the facility and documents that the delivery was received and was secure (on the medication delivery receipt, or other documentation system); -Verifies medications received and directions for use with the medication order form; -Immediately delivers the medications to the appropriate secure storage area (or a designee under the direct supervision of the licensed nurse); -Assures medications are incorporated into the resident's specific allocation prior to the next medication pass. 1. Review of Resident #79's face sheet, undated, showed diagnoses included kidney failure, high blood pressure, myocardial infarction (heart attack) and cardiomyopathy (enlarged heart). Review of the resident's Physician Order Sheet (POS), dated March 2025, showed; -An order, dated, 2/26/25, Aldactone (medication used to treat high blood pressure) 25 milligrams (mg), give one half a tablet, once a day at 6:00 A.M. through 10:30 A.M.; -No parameters to hold medication were included in the order; -An order, dated, 2/26/25, Entresto tablet (a medication used to treat heart failure) 24-26 mg, give twice a day at 6:00 A.M. through 10:30 A.M. and 6:30 P.M. through 7:30 P.M.; -No parameters to hold medication were included in the order; -An order, dated, 2/27/25, Toprol XL tablet extended release 24 hour, (a medication used to treat high blood pressure) 25 mg, give one tablet once a day at 6:00 A.M. through10:30 A.M.; -No parameters to hold medication were included in the order. Observation and interview on 3/11/25 at 9:17 A.M., showed Certified Medication Technician (CMT) J was preparing the resident's medications and entered the resident's room and obtained the resident's blood pressure with an automatic blood pressure machine. The reading on the machine was 93/56, (normal, 120/80). CMT J said the resident's blood pressure was too low and said he/she was going to hold the medication. CMT J exited the room and returned to the medication cart. CMT J removed the Aldactone, Entresto and Toprol XL tablets out of the medicine cup using a spoon. CMT J re-entered the resident's room and gave the resident the remaining medication. Review of the resident's Medication Administration Record (MAR), dated 3/1 through 3/12/25, showed; -On 3/11/25, at 9:20 A.M., Aldactone 25 mg, documented as held due to low blood pressure, 92/56; -On 3/11/25, at 6:00 A.M. through 10:30 A.M., Entresto 24-26 mg, documented as given; -On 3/11/25, at 9:20 A.M., Toprol XL 25mg, documented as held due to low blood pressure, 92/56. Review of the resident's progress notes, showed no documentation the physician was notified of the resident's low blood pressure. 2. Review of Resident #83's face sheet, undated, showed diagnoses included high blood pressure and kidney failure. Review of the resident's POS, dated March 2025, showed: -An order, dated, 1/9/25, amlodipine (medication used to treat high blood pressure) 5 mg, give one tablet one a day; -No parameters to hold medication were included in the order. Observation and interview on 3/11/25 at 9:11 A.M., showed CMT J had the resident's blood pressure written on a sheet of paper. CMT J said the resident's blood pressure was 119/63 and he/she was going to hold the medication because his/her blood pressure was too low. CMT J removed the amlodipine out of the resident's medication roll pack. Review of the resident's MAR, dated 3/1 through 3/12/25, showed: -On 3/11/25, at 9:13 A.M., amlodipine 5 mg, documented as held and the resident's blood pressure, 119/63. Review of the resident's progress notes, showed no documentation the physician was notified of the resident's low blood pressure. During an interview on 3/14/25 at 9:17 A.M., Licensed Practical Nurse (LPN) A said the CMT is expected to notify the nurse when medication is held, especially related to blood pressure medications. The physician should be notified if the resident's blood pressure is low, and blood pressure medications are being held. Parameters from the physician should be in place for the CMTs and nurses to hold medication. During an interview on 3/14/25 at 9:40 A.M., CMT J said the nurse is to be notified when any heart related medication is held for any reason. CMT J would go back and assess the resident's blood pressure in one to two hours after the last blood pressure was taken to see if the resident's blood pressure is better. Parameters for medications should be included in the orders to give the staff more guidance. During an interview on 3/14/25 at 11:13 A.M., the Director of Nursing (DON) said she expected the CMTs to inform the nurse if the resident's blood pressure is low and medication was held. The nurse is expected to notify the physician of the low blood pressure and determine if the physician wants to add parameters to the orders. This communication with the physician would be documented in the resident's progress notes. 3. During a group interview on 3/12/25 at 1:00 P.M., five out of five residents, whom the facility identified as alert and oriented, said there are ongoing issues with the facility running out of their medications or not administering medications as prescribed. 4. Review of Resident #15's medical record, showed diagnoses included cerebral palsy (movement disorder), major depressive disorder and anxiety disorder Review of the resident's POS and MAR for March 2025, showed: -An order, dated 5/22/18, for baclofen (muscle relaxer) 10 mg, one tab twice a day for cerebral palsy; -On 3/6/25 at 5:43 P.M., staff documented the medication not administered, drug/item unavailable; -On 3/7/25 at 8:53 A.M., staff documented the medication not administered, discontinued; -On 3/7/25 at 3:53 P.M., staff documented the medication not administered, drug/item unavailable; -An order, dated 10/6/20, for quetiapine (antipsychotic medication) 50 mg, one tablet once a morning for depression; -On 3/4/25 at 9:20 A.M., staff documented the medication not administered, drug/item unavailable; -On 3/5/25, 3/6/25, 3/7/25, and 3/8/25, staff documented the medication administered; -On 3/9/25 at 12:06 P.M., staff documented the medication not administered, drug/item unavailable; -On 3/10/25 at 8:05 A.M., staff documented the medication not administered, drug/item unavailable. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/6/25, showed he/she was cognitively intact. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident uses antipsychotic, antianxiety, hypnotic, and antidepressant medication for diagnoses of cerebral palsy, anxiety and depression; -Approaches included: Administer medication as ordered. During an interview on 3/10/25 at 12:31 P.M., the resident said he/she has been having issues with the facility running out of his/her medication. He/She takes medication for tremors and depression and has not received some of his/her medication in several days. Observation and interview on 3/12/25 at 9:48 A.M., showed CMT L removed all of the resident's medications from the medication cart. The resident did not have any quetiapine 50 mg on the medication cart. The blister pack of Baclofen 10 mg, showed the medication was filled by the pharmacy on 2/26/25 for a quantity of 60, with 48 tablets left on the card. CMT L said If administered twice daily per physician order, the card filled on 2/26/25 would have less than 48 tablets remaining. When a medication is not on the medication cart, staff should check the bottom drawer of the cart. If they cannot locate the medication, they should notify the nurse that the medication is not on hand. The nurse orders the medication from the pharmacy. Blister pack medications have a blue strip in the last row that prompt staff to reorder medication before the resident completely runs out. During an interview on 3/12/25 at 10:12 A.M., LPN I said the resident's pharmacy does not have an emergency kit in the facility. There is an emergency kit for residents who use a different pharmacy, but the resident's medications cannot be pulled from that kit since he/she goes through the other pharmacy. CMTs and nurses should order medications before a resident runs out of their medication. Refill requests are faxed to the pharmacy. There is no way for staff to track when refill requests are made. There is no system in place for who is responsible for following up on refill requests. When medications are received, they are put on the medication cart. During an interview on 3/13/25 at 11:53 A.M., Pharmacy Representative V said the resident's quetiapine 50 mg was filled 2/25/25 and there should be approximately two weeks' worth of medication left on the card. 5. During an interview on 3/13/25 at 1:01 P.M., CMT K said medications are reordered when the medications on the blister cards reach the last row. Staff should reorder medication before the cards are empty. Refill requests are faxed to the pharmacy. There is no way for staff to track if or when someone else ordered the medication. 6. During an interview on 3/14/25 at 8:52 A.M., CMT J said some staff don't remove medications from the blister cards in order, so they might not be able to clearly tell when a blister card is about to be out of medication. Seeing the medication left in the last row of the blister card is what prompts staff to reorder the medication. Reordering medications can get missed. There is no way to tell if an employee has already ordered a medication. If staff cannot find a resident's medication on the medication cart, they should check the bottom drawer of the medication cart, then notify the nurse. Facility staff can check the emergency kit. Agency staff do not have access to the emergency it. Agency staff might not know where they can find medications. CMT J has seen staff document on the MAR that medications are unavailable, but they are on the cart. When staff document in this way, there is no way to tell if a medication was actually administered. 7. During an interview on 3/14/25 at 10:57 A.M., the DON, Executive Director, and Assistant Executive Director said if staff cannot find a medication on the medication cart, they should check the emergency kit. If a medication is not in the emergency kit, staff should contact the pharmacy. Facility staff and supervisors have access to the emergency kit. Agency staff know what the facility's processes are from getting report from facility staff. Any attempts to reach the pharmacy for refills should be documented. If a medication cannot be administered because it is not on hand, the physician should be notified. The expectation is for staff to accurately document medication administration on the MAR. If a medication is available, staff should not document the medication was not available. When staff document a medication was unavailable when it is on hand at the facility, there is no way to tell if the medication was administered. 42795

46888 Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) care was provided for three of 21 sampled residents. The facility failed to ensure one resident had accurate skin assessments, trimmed nails and clean skin (Resident #82). The facility also failed to ensure two residents received facial hair grooming (Residents #65 and #20). The census was 93. Review of the facility's ADL policy, dated 2021, showed: -Policy: residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication and mobility; -Implementation: care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care, mobility (transfer and ambulation, including walking), elimination (toileting), dining (meals and snacks), and communication (speech, language, and any functional communication systems); -If residents with cognitive impairment or dementia exhibit behavioral expressions of resistance to care, associates will attempt to identify the underlying cause of the problem and not assume the resident is declining or refusing care. Approaching the resident in a different way, or at a different time, or having another associate speak with the resident may be appropriate. If a resident refuses care, associates will approach at a different time, or have another associate speak with the resident as needed. Interventions to improve and/or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 1. Review of Resident #82's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 2/17/25, showed: -Cognitively intact; -Dependent on staff for toilet and bathing hygiene; -Required maximum assistance removing socks and foot wear; -Required moderate assistance from staff for personal hygiene; -Dependent on staff to roll left and right. Review of the resident's care plan, in use at the time of survey, showed the care plan did not address the resident's ADL needs related to bathing and showering. Review of the resident's face sheet, undated, showed his/her diagnoses included lymphoma (a type of cancer that is in the lymph nodes), respiratory failure, viral infection, urinary retention, gastrostomy tube (a tube that is surgically inserted into the abdomen and is used for liquid nutrition and medications), chest pain and atrial fibrillation (a-fb, an irregular heart beat). Review of the resident's Skin Monitoring : Comprehensive Certified Nursing Assistant(CNA) Shower Review sheets, showed: -On 2/12/25, the resident received a bed bath; Does the resident need their toe nails cut?; Box checked: Yes; -On 2/15/25, the resident received a bed bath; -On 2/19/25, the resident received a bed bath; Does the resident need their toe nails cut?; Box checked: Yes; -On 2/26/25, the resident received a bed bath; -On 3/1/25, the resident received a bed bath; Does the resident need their toe nails cut?; Box checked: Yes; -On 3/8/25, the resident received a bed bath; -On 3/10/25, the resident received a bed bath; Does the resident need their toe nails cut?; Box checked: No; Observation and interview on 3/10/25 at 11:00 A.M., showed the resident lay in bed. His/Her face was unshaven, hair appeared disheveled, and both of his/her hands had one fourth of an inch of jagged nails. The resident said he/she only gets bed baths because he/she did not think he/she could stand in the shower. He/She was never offered by a staff member a shower with the use of a shower chair. The last bed bath he/she received was approximately two weeks ago. Observation and interview on 3/11/25 at 10:30 A.M., showed the resident lay in bed. His/Her face was unshaven, hair appeared disheveled, and both of his/her hands had on fourth of an inch of jagged nails. Certified Nurse Aide (CNA) F assisted the resident with providing perinium care (peri-care, cleansing of the genitals and rectal area). The resident's abdomen had dark, caked like, discolored, flaky skin on his/her right torso, wrapping around to his/her flank area. CNA F removed the resident's socks and both of the resident's feet had thick crusted flakes and cracks of dry skin. Large white flakes of dry skin were falling out of the resident's socks onto the resident's navy blue mattress. The resident's toenails were extremely thick, jagged and approximately one fourth of an inch long. The resident said no staff member had trimmed his/her toenails. CNA F said to the resident, your feet are really dry. During an interview of 3/13/25 at 12:10 P.M., CNA E said he/she will apply lotion to dry skin and feet. Fingernail care can be provided during the bathing process by CNAs. Usually toenails are trimmed by the nurse or doctor. 2. Review of Resident #65's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required moderate assistance for toilet and bathing hygiene. -Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side and chronic kidney disease (CKD). Review of the resident's care plan, in use at the time of the survey, showed: -Problem: resident requires total care for bathing, grooming, dressing, toileting, oral hygiene, shaving and set up assist for eating; -Goal: ADLs completed each day to resident comfort and satisfaction; -Approach: assist resident with (setup, supervision, hands-on), assist of (one or two) with bathing. Do not leave resident unattended in shower chair. Provide privacy by closing cubicle curtains when personal care is given. Assist as indicated with hygiene after using toilet. Respect resident's personal preferences related to ADLs including allowing resident to make choices regarding his/her care and participate as much as possible. Observation and interview on 3/10/25 at 12:12 P.M. showed the resident's beard was unkempt with food particles and white flakes. The resident said he/she would like his/her beard trimmed and groomed. He/She said most of the time he/she has to wait for his/her family to come to the facility and help him/her with his/her beard because nursing staff do not assist him/her. Observation on 3/11/25 at 10:30 A.M., showed the resident's beard was unkempt with food stuck in the hair. Observation on 3/12/25 at 9:30 A.M., showed the resident's beard was unkempt and had food particles and white flakes. 3. Review of Resident #20's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Dependent on staff for toilet and bathing hygiene; -Diagnoses included Alzheimer's disease, type 2 diabetes and congestive heart failure (CHF, a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply). Review of the resident's care plan, in use at the time of the survey, showed: -Problem: resident needs assistance with dressings, toileting, personal hygiene and bathing. Resident requires supervision on the unit to ensure safety; -Goal: resident will have all ADL care completed with usual standards daily; -Approach: allow resident time to participate in his/her care. Please provide assistance with transfer, dressings, toileting, personal hygiene and bathing, nail care twice weekly or as needed. Observation on 3/10/25 at 1:35 P.M., showed the resident had a patch of hair on his/her chin. Observation on 3/11/25 at 5:19 A.M., showed the resident had a patch of hair on his/her chin. Observation on 3/12/25 at 8:40 A.M., showed the resident had a patch of hair on his/her chin. During an interview on 3/13/25 at 8:43 A.M., the resident nodded and said yes when asked if he/she would like his/her chin hairs shaved. During an interview on 3/14/25 at 7:40 A.M., Licensed Practical Nurse (LPN) A said facial hair maintenance is done by CNAs before or after showers or as needed. He/She expected staff to ask residents if they would like their facial hair trimmed, shaved or groomed. During an interview on 3/14/25 at 8:52 A.M., CNA C said facial hair grooming is a part of ADL care and is normally completed after showers. Staff are expected to ask residents if they want their facial hair trimmed, shaved or groomed. During an interview on 3/14/25 at 11:02 A.M., the Director of Nurses (DON) and Administrator said they expected staff to address resident skin conditions completely and accurately. They said the shower assessments should include any nail or skin issues. The CNA has the shower sheet signed by the nurse to ensure the nurse is aware of any concerns. They expected staff to ensure residents' facial hair is trimmed, groomed or shaved according to resident preference during ADL care.

Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards. Staff failed to obtain treatment orders for one resident (Resident #195) who had a recent hip surgery. The sample size was 21. The census was 93. Review of the facility's Prevention and Treatment of Skin Breakdown policy, dated 9/1/18, showed: -Purpose: Maintaining intact skin is integral to the resident's health and wellness. Care and service are delivered to maintain skin integrity and promote skin healing if skin breakdown should occur; -Procedure: Skin is observed daily with care; Documentation of the skin impairment is completed in the medical record; Notify the attending provider and the attending provider may provide additional orders. Review of Resident #195's, face sheet, undated, showed: -An admitted [DATE]; -Diagnoses that included; right hip fracture, right joint replacement, emphysema (a lung disease), history of falling, and high blood pressure. Review of the resident's record showed: -No baseline care plan was available for review. Review of the resident's physician order sheets (POS), dated March, 2025, showed: -An order dated, 3/11/25, monitor surgical incision for signs and symptoms of infection, redness pain and exudate (pus), change dressing if saturated, daily and as needed. Review of the resident's progress notes dated, March, 2025, showed: -On 3/6/25 at 11:56 P.M., the resident arrived to the facility at 6:45 P.M., the resident is able to make needs known and is cognitively intact. The resident has 69 staples in place, with a dressing intact to his/her right hip from recent surgery. -On 3/13/25 at 11:40 A.M., resident seen for incisional skin check, some erythema (redness) noted at points along the staple line. -No further documentation related to the resident's incision was noted. Observation and interview on 3/10/25 at 6:10 P.M., showed the resident lay in bed. The resident said he/she fell while out in the community and sustained a fractured right hip. The resident said the orthopedic surgeon (a bone surgeon) said his/her hip was shattered and required a lot of fixing. The resident was having a lot of pain. The resident had a shower and his/ her dressing was saturated. The dressing to the resident's right hip was dated 3/8/25 and was saturated with a serous (yellow) fluid. The resident said he/she had asked a nurse to change it on 3/8/25 because the orthopedic surgeon said the resident needed to have a clean dressing applied to his/her incision line every day; that was the last time his/her hip dressing was changed. The resident worries about getting a hip infection. Observation and interview on 3/11/25 at approximately 8:30 A.M., showed the resident lay in bed and said that the same hip dressing was on his/her incision and no staff had changed it. The resident turned slightly to his/her left side and exposed his/her right hip dressing. The dressing was dated 3/8/25 and was saturated with serous drainage. Observation and interview on 3/12/25 at 7:21 A.M., showed the resident lay in bed. The resident said the Wound Nurse came in on 3/11/25 and changed his/her right hip dressing. The resident turned to his/her left side and had an undated, dry hip dressing present. During an interview on 3/13/25 at 12:50 P.M., Licensed Practical Nurse (LPN) N said on admission, the facility staff obtain orders for any type of skin condition. The Wound Nurse does the treatments during the week and the nursing staff complete the weekend treatments. The nurse can change a dressing anytime especially if it is soiled or wet. Nursing does not have to wait on the Wound Nurse to complete treatments. During an interview on 3/14/25 at 7:45 A.M., the Wound Nurse said he is to check every single wound, every single day, and complete the resident's treatment. When residents are new admissions he will generally scroll through the resident's electronic medical record (E-MAR) to see if the resident has any wounds. Sometimes the staff will just inform him verbally if the resident has a wound. He was not aware of the resident's right hip surgical incision and saw it for the first time on 3/11/25. The floor nurses are responsible to get admission orders for any type of skin condition. He is not sure what happened and why there were no treatment orders obtained for the resident. Nursing staff are responsible to change soiled or saturated dressings as needed. During an interview on 3/14/25 at 11:13 A.M., the Director of Nursing (DON) said she would expect staff to obtain orders related to the resident's skin condition on admission and change dressings if they are soiled or saturated. The Wound Nurse is responsible for wound checks and dressing changes.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #82) had urinary catheter (tube that drains the urine from the bladder) orders and failed to flush one resident's urinary catheter who had a history of hematuria (blood in the urine) (Resident #1). The sample was 21. The census was 93. Review of the facility's Prevention of Catheter-Associated Urinary Tract Infections policy, undated, showed when a resident is admitted to the facility with a catheter in place, a thorough physical assessment, as well as history review will be completed. 1. Review of Resident #82's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/17/25, showed: -Cognitively intact; -The resident has an indwelling urinary catheter; -Diagnosis included cancer, benign prostatic hypertrophy (BPH, an enlarged prostate gland) and renal failure, and obstructive uropathy (blockage that makes it difficult for urine to pass); Review of the resident's care plan, in use at the time of survey, showed; Problem: The resident has a indwelling urinary catheter related to obstructive uropathy; Approach: Change catheter per physician orders: Keep catheter in a closed system as much as possible; Position catheter below the bladder; Provide assistance with catheter care; Store urine collection bag in a dignity pouch. Review of the resident's Physician Order Sheet (POS), dated February, 2025, showed no orders related to the resident's urinary catheter. Review of the resident's Treatment Administration Record (TAR), dated 2/11 through 2/28/25, showed no orders related to the resident's urinary catheter. Review of the resident's POS dated March, 2025, showed no orders related to the resident's urinary catheter. Review of the resident's TAR, dated 3/1 through 3/11/25, showed no orders related to the resident's urinary catheter. Observation and interview on 3/10/25 at 11:00 A.M., showed the resident lay in bed. The resident had a urinary catheter hanging on the resident's bedframe in a privacy pouch. The resident's urine was yellow with some sediment in the urinary catheter tubing. The resident said he/she had problems urinating on his/her own and that is why he/she has a catheter. The resident also said he/she didn't think he/she could urinate laying down. Observation and interview on 3/11/25 at 10:30 A.M., showed the resident lay in bed. CNA F assisted the resident with providing perinium care (peri-care, cleansing of the genitals and rectal area). The resident had a urinary catheter in place. The urinary catheter bag was in a privacy pouch. The resident's urine was yellow with some sediment in the urinary catheter tubing. During an interview on 3/13/25 at 12:50 P.M., Licensed Practical Nurse (LPN) N said there is a set of orders the nurses can place in the physician orders that cover urinary catheter care. The orders for the resident should have been placed on admission. 2. Review of Resident #1's admission MDS, dated , 1/27/25, showed: -admitted [DATE]; -Cognitively intact; -Indwelling catheter present. Review of the resident's care plan, in use at the time of survey, showed; -Problem: The resident has an indwelling urinary catheter related to urogenic bladder; -Approach: Assess the drainage, record the amount, color type and odor. Change catheter per physician orders: Keep catheter in a closed system as much as possible; Position catheter below the bladder; Provide assistance with catheter care every shift and as needed; Store urine collection bag in a dignity pouch. Review of the resident's face sheet, undated, showed diagnoses included osteomyelitis (bone infection) to the sacrum (tailbone), Stage 4 pressure wound (a wound that has full thickness skin and tissue loss caused by extended pressure) to the sacrum, incomplete quadriplegia (paralysis of both arms and legs), chronic pain syndrome, and depressive disorder, hematuria (the presence of blood in the urine) and neurogenic bladder (an inability to urinate due to ta dysfunction of the nervous system). Review of the resident's POS, dated March, 2025, showed: -An order dated, 2/26/25, flush urinary catheter with 30 milliliters (ml) of sterile water, every shift. Review of the resident's TAR, dated 3/1 through 3/14/25, showed, -An order, dated 2/26/25, flush urinary catheter with 30 milliliters (ml) of sterile water, every shift, 7:00A.M. to 3:00 P.M., 3:00 P.M. to 11:00 P.M., and 11:00P.M. to 7:00 A.M. -On 3/11/25, the 7:00 to 3:00 P.M. shift, treatment was documented as completed. Review of the resident's progress notes, showed no documentation related to the resident's hematuria. Observation and interview on 3/11/25 at 7:07 A.M., showed the resident lay in bed with an indwelling catheter hanging on the resident's bedframe. There was a small amount of dark, maroon colored urine in the resident's urinary catheter bag, The resident said the night shift Certified Nursing Assistant (CNA) just emptied his/her catheter bag, The resident said he/she has a history of having hematuria because he/she is on a blood thinner. At 8:11 A.M., the resident's urinary catheter bag was filled with approximately 200 milliliters (ml) of dark maroon colored urine with stringy clots in the catheter tubing. At 12:15 P.M., the resident's urinary catheter bag was filled with approximately 300 mls of dark, maroon, colored urine and small clots in the catheter tubing. The resident said he/she is worried his/her catheter will become occluded because it has happened to him/her before and he/she had to have two giant bags of fluid connected to his/her catheter to irrigate his/her bladder while in the hospital. During an interview on 3/12/25 at 9:00 A.M., LPN W said he/she was assigned to the resident on 3/11/25 on the 7:00 to 3:00 P.M. shift. LPN W signed off on the urinary catheter flush treatment on the 7:00 A.M. to 3:00 P.M. shift. LPN W said he/she was not aware of the resident's hematuria on 3/11/25. LPN W remembered he/she did not complete the urinary catheter flush and should not have documented it was completed when it was not. LPN W just thought the evening shift could do it. 3. During an interview on 3/14/25 at 11:13 A.M., the Director of Nursing (DON) said she expected staff to obtain urinary catheter orders for residents who have catheters while they are a resident at the facility. It is unacceptable for staff document a treatment order completed when it is not. Once staff observe any type of dysfunction or change in the resident's urine, the physician should be notified.

46888 Based on observation, interview, and record review the facility failed to ensure one resident had all the required physician's orders and documentation of oxygen usage (Resident #16), and failed to ensure one resident's discontinued physician's orders related to oxygen usage were reinstated after a hospital stay (Resident #2). The sample was 21. The census was 93. Review of the facility's oxygen therapy policy, dated 2017, showed: -Policy: Residents are assessed to ensure their respiratory needs are being met. Residents identified in need of oxygen therapy have interventions/equipment implemented in accordance with the resident-centered care plan; -Procedure: Obtain physician orders for specifics regarding administration. Administration of the oxygen therapy is completed by nursing associates. Document assessment of resident oxygen status, tolerance, vital signs, and respiratory status in medical record as necessary. Follow manufacturer recommendations for safe handling, cleaning, humidification, storage, and dispensing, maintenance of equipment in accordance with the manufacturer specifications and consistent with federal, state, and local laws and regulations. 1. Review of Resident #16's medical record, showed: -Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease), and lobar pneumonia (type of pneumonia affecting one or more sections of the lungs). Review of the resident's electronic physician order sheet (POS) and administration record for March 2025, showed: -An order, dated 1/25/25, for oxygen 2 liters (L) as needed (PRN) for shortness of breath; -No orders for changing the resident's oxygen tubing or humidifier; -No documentation the resident's oxygen was administered in March 2025. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/1/25, showed: -Cognitively intact; -Oxygen not documented as received. Review of the resident's care plan, in use at the time of survey, showed: -No documentation related to the use of oxygen. Observation and interview on 3/11/25 at 8:14 A.M., showed an oxygen concentrator next to the foot of the resident's bed. A piece of tape on the oxygen tubing dated 1/19/25 and initialed, SN. The nasal cannula was uncovered and tucked underneath the handle of the oxygen concentrator. During an interview, the resident said he/she uses his/her oxygen every night because he/she cannot breathe. Observation and interview on 3/12/25 at 8:12 A.M., showed an oxygen concentrator next to the foot of the resident's bed. A piece of tape on the oxygen tubing dated 1/19/25 and initialed, SN. The nasal cannula was uncovered and tucked underneath the handle of the oxygen concentrator, in a different position than the day before. During an interview, the resident said he/she used his/her oxygen again last night, as always. The resident did not know what cleaning was done with the oxygen tubing. Observation on 3/13/25 at 6:29 A.M., showed the resident in bed with nasal cannula on and oxygen concentrator running at 3 L per minute. The tape on the oxygen tubing dated 1/19/25 and initialed, SN. During an interview on 3/13/25 at 9:19 A.M., Certified Nursing Assistant (CNA) H said the resident uses his/her oxygen every night. He/She sometimes uses his/her oxygen in the morning if he/she is having shortness of breath. During an interview on 3/14/25 at 8:52 A.M., Certified Medication Technician (CMT) J said the resident uses oxygen at night and as needed. During an interview on 3/13/25 at 12:52 P.M., Licensed Practical Nurse (LPN) I said the resident wears his/her oxygen on and off. During an interview on 3/13/25 at 12:52 P.M., LPN I said residents have physician orders specifying their oxygen use. Residents receiving continuous oxygen should have physician orders for cleaning the oxygen tubing and humidifier. Humidifiers and tubing should be cleaned weekly. When tubing or humidifiers are cleaned, they should be dated and initialed by the staff who completed the task. Residents who use oxygen on a PRN basis do not need to have orders to clean or change the tubing or humidifier because the nurse has to bring the oxygen concentrator into the resident's room for PRN use, and it does not remain in the room when the resident stops using it. When a nurse administers a resident's oxygen, they should mark it as administered on the administration record. 2. Review of Resident #28's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included COPD, acute respiratory failure, and diabetes. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: Resident has COPD and requires oxygen at 2 L via nasal canula (NC); -Goal: Resident will breathe easy without signs or symptoms of respiratory distress evidenced by oxygen saturations between 93-98%; -Approach: Monitor/Document respiratory status and oxygen saturations every shift and as needed. Monitor and report signs of respiratory distress. Review of the resident's progress notes, showed: -A progress note, dated 3/1/25 at 5:29 P.M., this writer has noted resident on floor and hospital ambulance service was immediately called. Resident had fallen out of bed and is alert. Resident has full cognition to relative baseline. Unable to retrieve vitals due to resident's positioning at this time. Emergency Medical Services (EMS) assisted with resident first aid. Resident has hematoma (collection of blood outside of the blood vessels) to left side of the head. Resident has no issues at this time. Family and attending physician notified; -A progress note, dated 3/3/25 at 9:40 P.M., resident returned to facility at 6:20 P.M. via EMS stretcher from the hospital. Review of the resident's POS, for March 2025, showed: -An order, discontinued on 3/1/25, oxygen at 4 liters/min per nasal cannula every shift; -An order, discontinued on 3/1/25, change oxygen tubing weekly. Once a day on Saturday; -An order, discontinued on 3/1/25, change humidifying jar weekly. Once a day on Saturday; -An order, discontinued on 3/1/25, please keep resident on oxygen at all times; -No active orders for oxygen. Observation on 3/10/25 at 5:07 P.M., showed the resident in his/her bed awake. The resident had a nasal canula in his/her nose which was connected to a concentrator. The concentrator had a humidifier bottle attached to it. The concentrator was set to 3. The nasal canula tubing was dated for 2/23/25. Observations on 3/11/25 at 6:05 A.M. and 10:32 A.M., showed the resident in his/her bed asleep. The resident had his/her nasal canula in his/her nose. The resident's concentrator was on and set to 3. The nasal canula tubing was dated 2/23/25. Observations on 3/12/25 at 7:05 A.M., 8:39 A.M., and 10:34 A.M., showed resident in his/her bed awake. The resident had a nasal canula in his/her nose which was connected to a concentrator. The concentrator had a humidifier bottle attached to it. The concentrator was set to 3. The nasal canula tubing was dated for 2/23/25. Observation on 3/13/25 at 8:47 A.M., showed the resident in his/her bed asleep. The nasal canula tubing had been changed and was dated for 3/13/25. The concentrator was on and set to 3. During an interview on 3/14/25 at 7:43 A.M., CNA D said residents' oxygen tubing and concentrator humidifier bottles should be changed according to the physician's orders and facility policy. If a resident's orders are discontinued when they go out to the hospital, he/she would expect the treatments to stop or for the nurse to obtain new orders. 3. During an interview on 3/14/25 at 9:14 A.M., LPN A said any resident who uses oxygen should have physician orders to change the oxygen tubing and humidifier, regardless of whether oxygen use is continuous or PRN. Oxygen tubing and humidifiers should be cleaned or changed by nurses weekly. If a resident goes out to the hospital, when they return, their physician orders should be reviewed. If a resident had orders for oxygen prior to going to the hospital the nurse who admits the resident back to the facility should ensure oxygen orders are re-obtained by the physician or that the orders should be stopped. The oxygen rate on the concentrator should match the physician's orders. The care plan should reflect the resident's current physician's orders. 4. During an interview on 3/14/25 at 11:21 A.M., the Administrator and Director of Nursing (DON) said they would expect residents' oxygen tubing and humidifier to be changed according to the facility's policy and physician's orders. Oxygen rates should be followed according to the physician's orders and be accurate on the resident's care plan. If a resident goes out to the hospital, their orders should be re-evaluated upon the resident's arrival back to the facility. If a resident's orders are discontinued, they would expect those treatments to be stopped or for the nurse to call the physician to obtain new orders.

46888 Based on observation, interview, and record review, the facility failed to ensure pain management for three of 21 sampled residents who experienced pain, consistent with professional standards of practice (Residents #195, #1, and #7). The census was 93. Review of the facility's Pain Management policy, dated 2022, showed: -Policy: Benedictine considers pain that impacts the function or quality of life of our residents a significant concern and evaluation will be ongoing. The Benedictine interdisciplinary team will strive to manage pain in residents experiencing mild to debilitating pain to the point where functionality and quality of life can be increased. Benedictine clinicians will be aware of the unique needs and circumstances of residents from different age groups, ethnic and cultural backgrounds. Current and historical medical diagnoses including substance use disorders and mental health diagnoses will be considered when implementing an effective pain management plan of care; -Procedure: Evaluate the resident for verbal and nonverbal signs and symptoms of pain. Encourage the resident to tell the care giver about the pain. Educate the resident on the importance of reporting pain and the negative effects of pain, including but not limited to: Physical pain, emotional pain, social pain, spiritual pain, and financial pain. Identify the exacerbating factors and the type(s) of pain if possible, acute and/or chronic. Include the resident and responsible party in the development of pain management interventions. Review with the inter disciplinary team to develop and implement individualized measures to promote comfort. Communicate interventions to staff and provide training as needed. Provide resident and responsible party education as needed. Reevaluate pain and document: at regular intervals according to the needs of the resident, with each new report of pain, at appropriate intervals after pharmacological or non- pharmacological interventions. Review and revise the plan of care as necessary. Review of the facility's administering medication policy, dated 2020, showed: -Policy: To administer resident medications in a safe and accurate manner that will ensure the six rights of patient identification for administration; right resident, right medication, right dose, right time, right route, and right documentation; -Procedure: Medications are administered within their prescribed time. Sign medication out in electronic record at time of medication administration. Review of the facility's call light policy, undated, showed: -Purpose: The purpose of this procedure is to ensue timely responses to resident needs and requests. Residents are provided with a means to call for staff assistance through a communication system that directly notifies a staff member or a centralized work station; -Procedure: Calls for assistance may be triaged and answered as soon as possible based on immediate needs. 1. Review of Resident #195's, face sheet, undated, showed: -An admitted [DATE]; -Diagnoses that included: Right hip fracture, right joint replacement, emphysema (a lung disease), history of falling, and high blood pressure. Review of the resident's record showed: -No baseline care plan available for review. Review of the resident's physician order sheets (POS), dated, March, 2025, showed: -An order, dated, 3/6/25, Oxycodone (pain medication) 5 milligrams (mg), one tablet, every four hours as needed. Observation on 3/10/25 at 1:28 P.M., showed the resident's call light was on, and the resident was heard from the hallway shouting, Ow! I am in so much pain. I need a pain pill. At 1:30 P.M., the call light board located on the [NAME] Hall showed the resident's call light was on for 27 minutes and three seconds. At 1:32 P.M., the resident's call light was off. At 1:35 P.M., the resident's family member came out of the resident's room and walked to the [NAME] nurses' station and asked for a pain pill for the resident and said the resident was in a lot of pain. Observation and interview on 3/10/25 at 1:40 P.M., showed the resident sat in his/ her wheelchair and said he/she was in excruciating pain. The resident was rubbing his/her right leg and grimacing. The resident said he/she recently had hip surgery on 3/3/25 and required pain medication every four hours. The resident said he/she has been waiting for someone to answer his/her call light for over 30 minutes and it seemed like he/she had been waiting forever. Licensed Practical Nurse (LPN) N entered the room with a medicine cup and placed the medicine cup with a pill in it on the bedside table that was positioned in front of the resident and said, Here is your pain pill. LPN N did not observe the resident take the medication before he/she left the room. Review of the resident's progress notes showed: -On 3/10/25 at 1:45 P.M., the resident's family member came to the nurses' station and said that the resident was experiencing pain. Pain was noted to be seven out ten and PRN (as needed) oxycodone was administered at approximately 1:40 P.M. During observation and interview on 3/10/25 at 6:10 P.M., the resident lay in bed. The resident said he/she fell while out in the community and sustained a fractured right hip. The resident said the orthopedic surgeon (a bone surgeon) said his/her hip was shattered and required a lot of fixing. The resident said he/she was having a lot of pain. The resident said he/she currently uses a wheelchair, and therapy is assisting him/her to walk. The resident requires assistance from staff to use the bathroom The resident said there frequently is a delay in getting pain medication from the nurses. During an interview on 3/11/25 at 10:30 A.M., Certified Nursing Assistant (CNA) F said call lights are to be answered within 15 minutes. During an interview on 3/14/25 at 9:15 A.M., LPN A said residents' call lights are to be answered within 15 minutes. Waiting 40 minutes for pain medication is unacceptable, and the resident must feel like it is an eternity waiting so long. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/27/25, showed: -admitted [DATE]; -Cognitively intact; -Receives scheduled and PRN pain medication; -Experiences pain frequently; -Pain occasionally interferes with his/her sleep; -Pain occasionally interferes with therapy activities; -Pain rarely interferes with day to day activities; -Pain verbal descriptor scale: Moderate. Review of the resident's care plan, in use at the time of survey, showed: -Problem: The resident experiences pain and discomfort related to chronic pain; The residents baseline pain is 4 out of 10; -Interventions: When the resident expresses pain, rest, repositioning, and medication administration are interventions used. Review of the resident's face sheet, undated, showed diagnoses that included: Osteomyelitis (bone infection) to the sacrum (tailbone), stage 4 pressure wound (a wound that has full thickness skin and tissue loss caused by extended pressure) to the sacrum, incomplete quadriplegia (paralysis of both arms and legs), chronic pain syndrome, and depressive disorder. Review of the resident's Medication Administration Record (MAR), dated 3/1 through 3/14/25, showed: -An order, dated, 2/10/25, hydrocodone-acetaminophen (narcotic pain medication) 5/325 mg administer one tablet every six hours, hold for sedation; -Scheduled times: 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. -On 3/3/25; Scheduled time: 12:00 A.M.; Charted: 3/3/25 at 1:34 A.M.; Reason: Administered late; -On 3/3/25: Scheduled time: 6:00 A.M.; Charted: 3/3/25 at 7:29 A.M.; Reason: Administered late; -On 3/9/25; Scheduled time: 12:00 P.M.; Charted: 3/9/25 at 11:36 A.M.; Reason: Not administered, the resident was sleeping; -On 3/9/25: Scheduled time: 6:00 P.M.; medication documented as given; -On 3/11/25; Scheduled time: 12:00 A.M.; Charted: 3/11/25 at 1:11 A.M.; Reason: Administered late; -On 3/11/25: Scheduled time: 6:00 A.M.; Charted: 3/11/25 at 8:16 A.M.; Reason: Administered late. -An order dated, 1/27/25, baclofen (muscle relaxer used to treat painful muscle spasms) 20 mg, give one tablet every eight hours; -On 3/1/25: Scheduled time: 8:00 A.M.; Charted date: 3/1/25 at 10:08 A.M.; Reason: Administered late; -On 3/2/25: Scheduled time: 8:00 A.M.; Charted date: 3/2/25 at 9:44 A.M.; Reason: Administered late; -On 3/4/25: Scheduled time: 8:00 A.M.; Charted date: 3/4/25 at 9:16 A.M.; Reason: Administered late; -On 3/5/25: Scheduled time: 4:00 P.M.; Charted date: 3/5/25 at 5:10 P.M.; Reason: Administered late; -On 3/8/25: Scheduled time: 8:00 A.M.; Charted date: 3/8/25 at 1:27 A.M.; Reason: Administered late; -On 3/9/25: Scheduled time: 8:00 A.M.; Charted date: 3/9/25 at 9:38 A.M.; Reason: Administered late; -On 3/10/25: Scheduled time: 8:00 A.M.; Charted date: 3/10/25 at 10:49 A.M.; Reason: Administered late; -On 3/11/25: Scheduled time: 4:00 P.M.; Charted date: 3/11/25 at 6:12 P.M.; Reason: Administered late; -On 3/12/25: Scheduled time: 8:00 A.M.; Charted date: 3/12/25 at 10:25 A.M.; Reason: Administered late; -On 3/14/25: Scheduled time: 12:00 A.M.; Charted date: 3/14/25 at 2:11 A.M.; Reason: Administered late. During an interview on 3/10/25 at 10:50 P.M., the resident said he/she has been paralyzed for at least [AGE] years. The resident said he/she was admitted to the facility because he/she had developed a pressure wound to his/her tailbone at home. The resident said he/she has been on pain medication which include hydrocodone with acetaminophen and baclofen for years. He/She has muscle spasms and pain in his/her back that he/she can feel. The resident said he/she is on routine pain medication and muscle relaxers currently at the facilty. The staff are frequently late with his/her muscle relaxer and narcotic pain medication. The resident said that on 3/9/25, the resident was not given his/her pain medication at noon because the staff said he/she was sleeping. When he/she asked the nurse about his/her pain medication, he/she was informed that he/she would have to wait until it was due again. He/She went without pain medication for 12 hours. The resident's pain level is a six out of ten when he/she has to wait for pain medication. During an interview on 3/14/25 at approximately 10:00 A.M., Certified Medication Technician (CMT) T said medications that have a specific time listed on the MAR should be administered one hour before or one hour after when the medicine is due. The nurses administer narcotic pain medications. During an interview on 3/14/25 at 10:32 A.M., LPN U said scheduled medications are to be given one hour before or one after the time it is due. If a resident was sleeping at the time a pain medication was due, LPN U said he/she would go back within an hour and see if the resident was awake and administer the medication at that time. Staff should not inform the resident that they will have to wait until the next dose is due because that is too long to wait. During an interview on 3/14/25 at 11:13 A.M., the Director of Nursing (DON) said depending on what was happening on the floor, staff are expected to answer call lights in a reasonable time frame. The resident should not wait 40 plus minutes for pain medication. The staff are expected to give scheduled medications one hour before or one hour after the medication is due. If the resident were sleeping at the time of the scheduled medication, she would expect staff to go in and reassess within an hour to determine if the resident still requires the pain medication. The resident should not wait until the next time the pain medication is due. 3. Review of Resident #7's admission MDS, dated [DATE], showed: -admitted [DATE]; -Cognitively intact; -Diagnoses included end stage renal disease, congestive heart failure (CHF), and displaced bimalleolar fracture (ankle injury that involves breaks in both the medial and lateral malleolus bones, located at the ends of the tibia and fibula) of right lower leg. Review of the resident's care plan, in use at the time of the survey, showed: -The care plan did not address the resident's pain management. Review of the resident's POS, in use at the time of the survey, showed: -An order dated 1/8/25, dialysis three times a week; -An order, dated 3/7/25, apply cavilon (barrier film) skin sealant to unburst blister daily; -An order, dated 3/7/25, right heal wound, clean with normal saline, calcium alginate (wound dressing) and ABD (gauze pad), wrap with kerlix (gauze roll), change daily, and as needed if soiled, saturated, or dislodged; --An order, dated 12/31/24, hydrocodone-acetaminophen, 5-325 mg, one to two tablets taken orally, every four hours as needed for pain. Review of the resident's MAR, dated 3/1/25 through 3/11/25, showed: -The resident did not receive his/her PRN pain medication at all in the month of March. Observation on 3/11/25 at 7:52 A.M., showed the resident seated in his/her wheelchair in his/her room. The resident's family member was standing beside him/her. The Wound Nurse was changing the dressing on the resident's right heel wound. As the Wound Nurse lifted the resident's right leg, the resident grimaced and said Ow that hurts. The Wound Nurse did not address the resident's pain and walked out of the resident's room after finishing the dressing change. During an interview on 3/11/25 at 8:04 A.M., the resident's family member said the resident had been complaining to staff of pain in his/her right foot and lower leg. The family member was not sure if the facility was addressing the resident's pain. The resident had not received any pain medication prior to the Wound Nurse completing wound care. During an interview on 3/12/25 at 1:17 P.M., the Wound Nurse said the resident has experienced pain in his/her feet and legs since he/she admitted to the facility. He/She heard the resident say Ow while he/she was performing the dressing change but said the resident's pain was not significant enough to alert the resident's nurse or to provide the resident with pain medication. He/She does have access to resident medications and is able to administer pain medication to the residents. The resident has an as needed pain medication that could be given. During an interview on 3/14/25 at 7:45 A.M., LPN A said if a resident is complaining of pain, nurses should assess the resident and implement interventions for the pain. If the resident is non-verbal, nursing staff should be assessing the resident's body language to determine if the resident is in pain. He/She would expect staff to inform the nurse anytime a resident reports pain. Any time a resident experiences pain, it should be documented in the medical records. He/She would expect residents who are in pain to receive pain medication if that is their intervention. Resident #7 shows signs of pain, especially after dialysis. The resident has scheduled and as needed pain medication. 4. During an interview on 3/14/25 at 9:06 A.M., CNA D said if a resident is complaining of pain or showing signs of being in pain, nurses are responsible for assessing the resident and providing an intervention. All staff are to report to the nurse any time a resident reports pain. He/She would expect residents to receive their pain medication if they are in pain. 5. During an interview on 3/14/25 at 11:06 A.M., the DON and Administrator said if a resident is complaining of pain or is showing signs of pain, nurses should assess the pain and take care of it. They would expect all staff to report to the charge nurse if a resident is reporting or showing signs of pain. They would expect any pain to be documented in the residents' medical records. They would expect Resident #7 to have received his PRN pain medication. They would have expected the Wound Nurse to inform the resident's charge nurse of his/her pain.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #96) received appropriate supervision for wandering. The resident was admitted to the facility from the hospital on 7/26/23. The resident's hospital records showed the resident was found on 7/19/23, by a bystander, confused and wandering around his/her apartment complex. The resident was unable to tell Emergency Medical Staff (EMS) where he/she lived. The resident's family informed hospital staff the resident had been having progressive, worsening mental functioning and forgetfulness. The facility failed to ensure admission staff thoroughly read the hospital records and put elopement/wandering interventions in place upon the resident's admission. On 8/4/23 around 11:40 A.M., the Health Information Director (HID) opened the door and allowed the resident to leave unsupervised. The HID assumed the resident resided in the Independent Living facility. The HID was not aware the resident resided in the skilled nursing facility because the resident had no wander alert alarm on and had not been added to the elopement/wandering book at the receptionist desk. At approximately 12:40 P.M., the facility was notified the resident had been found on the grounds approximately 325 feet away from the facility entrance. The resident was transported to the hospital and returned that same day with a laceration and sutures to the left eyebrow. A wander alert alarm was applied to the resident upon readmission on 8/4/23, and the resident was discharged to another facility on 8/5/23. At the time of the survey, the facility identified 10 current residents at risk to elope/wander and there were no problems identified. The census was 86. The Administrator was notified on 10/26/23, of the past non-compliance. The facility has changed their process on how they assess residents at risk for elopement as well as their process to prevent elopements for residents at risk. Staff were in-serviced on the new process. The deficiency was corrected on 8/29/23. Review of the facility's undated Elopement policy, showed: Purpose: -To provide a safe and least restrictive environment for the residents. To maintain the safety of residents who are at risk of wandering and/or active elopement; -Policy: Associates will engage in interventions to prevent wandering and active elopement; -Procedure: Assessment of Potential Risks and Resident Needs: -The nurse or social services will evaluate each resident's potential for wandering upon admission and as needed; -The nurse or social services identifies necessary interventions for each resident in their care plan, assessment, and/or abuse prevention plan; -The registered nurse will provide necessary training on interventions and techniques for each resident; -A current photograph of each resident at risk for inappropriate wandering and/or elopement and a description of any unique identifiers will be located in the EHR (electronic health record) and may be kept in another specified area in the community for identification purposes; -Nursing and social services partners with the resident's family and friends to support resident safety in regards to wandering and/or elopement, such as asking them to contact the community when they escort the resident on an outing; -Active Attempt/Elopement: -When a wandering or elopement attempt has been resolved, associate will inform the nurse of the situation; -The registered nurse or social services will re-assess the resident and determine if changes need to be made to the resident's care plan and/or new interventions added to the abuse prevention plan to prevent future elopement attempts; -Return to Facility: Upon return of the resident to the facility, the following steps will be followed: -All persons and organizations will be notified of the resident's return to the facility; -The resident will have a complete assessment done to determine if any injuries occurred; -The nurse responsible for the resident's care will document all pertinent details of the elopement into the resident's medical record, including: times, persons contacted, condition of resident upon returning to facility, physician notification, physician orders, treatment indicated, any other pertinent information; -The resident's care plan must be reviewed and revised to reflect the elopement and a prevention plan developed; -Post-Incident Investigation: -A complete and thorough investigation of the elopement will be done within 24 hours of the resident's return, to prevent another occurrence, as well as to protect other residents; -Questions to be asked include: Were there any deficient practices or system failures?; -Definitions: Resident elopement is defined as a dependent resident in a licensed facility who leaves without staff observation or knowledge of their departure. Review of Resident #96's pre-admission (to the facility) hospital records, showed: -admitted on [DATE] to the hospital; -History of Present Illness: -Resident unable to provide much history. He/She does not remember what happened to him/her; -Resident was found confused and wandering around his/her apartment complex, and unable to recall his/her apartment number. He/She was brought to the emergency room by EMS; -Further history from family showed the resident having progressive worsening of his/her mental function and becoming more forgetful with a history of dementia; -Resident oriented to self, location, and situation, however unable to recall month or year. Resident denies he/she is confused, and demonstrated irritation about being in the hospital. Screener completed and results indicate moderate-severe memory and problem solving deficits, poor thought organization and verbal reasoning; -Resident was diagnosed with dementia in the past; -Neurological Exam: -Significant word finding issues, uses vague language with conversation. Conversation does not make sense most of the time. Able to follow commands. Not able to recall his/her age, but able to recall his/her date of birth; -Impression/Plan: -Increased confusion. Suspect this is due to dementia on top of acute medical illness; -Psychiatrist saw resident and added Seroquel (an antipsychotic used to treat schizophrenia, depression etc.) and was discussed with family; -Discussed with family that if resident remains like he/she is now, the resident should not live alone, requiring assisted living at the least. During an interview on 10/26/23 at 11:33 A.M., the Case Management Director (Admission Coordinator) said she recalled receiving and reviewing the resident's hospital information prior to the resident's admission. The hospital Social Service Department said the resident had no exit seeking behaviors since admission to the hospital on 7/19/23. She did discuss the resident being found confused and wandering around his/her apartment complex with the former Administrator. He did not give a directive to place a wander alert alarm (a bracelet or anklet that locks an exit door and sounds an alarm when a resident wearing the bracelet/anklet gets too close to an exit door) on the resident or place the resident's information on the elopement risk lists at the nurse's stations or into the elopement book at the receptionist desk. He said the resident should be ok as long as his/her room was in the middle of the building. Review of the resident's facility admission face sheet, showed the resident was admitted on [DATE]. Review of the resident's progress note, dated 7/26/23 at 10:08 P.M., showed the resident arrived to facility at 3:00 P.M. with family. Resident is alert and oriented 2-3 (orientation is referred to one or all of the following: person, place, time/date and/or situation) with confusion and is being skilled for stroke. Noted healing bruise to right side of forehead, a large bruise on top of right hand and scattered bruising along arms and right upper thigh. Resident has a steady gait (walking) and took several steps in his/her room with supervision. Review of the resident's Elopement Risk Assessment, dated 7/26/23, showed: -Does the resident exhibit any of the following behaviors: Packing Belongings: Not indicated; -Has the resident exhibited or experienced any of the following?: -Changes in Medication: No indicated; -Wandering in Past 60 Days: Yes; Does the resident have any of the following conditions?: -Alzheimer's Disease: Yes; -Anxiety Disorder: Not indicated; -Dementia: Not indicated; -Based on assessment, does resident present an elopement risk?: Low risk indicated; -Indicate Preventative Action Taken: Choices included: Door alarm band, photograph posted, frequent room checks, personal alarms, social services. None of the preventative actions were checked. Review of the resident's progress notes, showed: -7/27/23 at 2:58 P.M., and documented by the Social Service Director: Resident scored a Brief Interview of Mental Status (BIMS) of 7/15 (severe impairment). Resident is able to express himself/herself with disorganized thinking and loses track of what is being said; -7/29/23 at 3:10 P.M.: Resident observed on the floor by the elevator. Resident does have a bump on the head. Resident was ambulating without shoes/socks. Helped resident to a wheelchair and moved to a more visible area by nursing station. All parties notified. Will continue to monitor. Review of the resident's BIMS, dated 7/31/23, showed a score of 8 (a score of 8-12, indicating moderately impaired cognition). Review of the resident's Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, 5-Day PPS assessment, dated 8/1/23, showed: -admitted (to facility) on 7/26/23; -Makes Self Understood: Usually understood - difficulty communicating some words or finishing thoughts, but able if prompted or given time; -Ability to Understand Others: Usually understands - misses some part/intent of message, but comprehends most conversation; -BIMS score of 7 (a score of 0-7, indicates severely impaired cognition); -Wandering - Presence and Frequency: Behavior not exhibited; -Indoor Mobility: Independent; -Functional Cognition: Needed some help; -Mobility Devices: [NAME] not indicated; -Walk 10 feet (ft): Supervision or touching assistance required; -Walk 50 ft with the ability to make two turns: Supervision or touching assistance. Helper provides verbal cues or touching/steadying assistance as resident completes activity; -Walk 150 ft in corridor or similar space: Supervision or touching assistance. Helper provides verbal cues or touching/steadying assistance as resident completes activity; -Diagnoses of dementia, anxiety and depression; -Fall History on Admission: -Did resident have a fall any time in the last month prior to admission?: Yes; -Did resident have a fall any time in the last 2 to 6 months prior to admission?: Yes; -Any fall since admission?: Yes, one fall without injury; -Current Skilled Therapies: Physical Therapy, Occupational Therapy, and Speech Therapy. Review of the resident's care plan, showed the following problems: -7/28/23: Spiritual; -7/31/23: Activities; -8/1/23: Nutritional Status; -No problems or interventions had been added to address the resident's dementia, that he/she had been found on 7/19/23, with increased confusion and wandering around his/her apartment complex and unable to say where he/she lived. Review of the resident's progress notes, showed: -8/1/23 at 1:40 P.M.: Short-term memory ok: Memory problem. Long-term memory ok: Memory problem. Memory/Recall Ability: Location of own room. Orientation: Alert, disoriented; -8/2/23 at 3:03 A.M.: Short-term memory ok: Memory problem. Long-term memory ok: Memory problem. Memory/Recall Ability: Location of own room. Orientation: Alert, disoriented; -8/2/23 at 11:43 A.M.: Short-term memory ok: Memory problem. Long-term memory ok: Memory problem. Memory/Recall Ability: Location of own room. Orientation: Alert, disoriented; 8/3/23 at 2:23 A.M.: Short-term memory ok: Memory problem. Long-term memory ok: Memory problem. Memory/Recall Ability: Location of own room. Orientation: Alert, disoriented; -8/3/23 at 9:28 A.M.: Short-term memory ok: Memory problem. Long-term memory ok: Memory problem. Memory/Recall Ability: None of the above were recalled. Orientation: Alert, Disoriented; -8/3/23 at 5:50 P.M.: Short-term memory ok: Memory problem. Long-term memory ok: Memory problem. Memory/Recall Ability: None of the above were recalled. Orientation: Alert, Disoriented; -8/4/23 at 1:04 P.M. and documented by Nurse K: Message left for physician regarding resident's fall and transfer to hospital; -8/4/23 at 6:13 P.M.: Resident returned to facility from hospital with diagnosis of closed head injury. Resident assessed. Resident has bruising to right inner forearm, sutures to left eyebrow. Wander device applied to right ankle. Review of the facility's investigation, received by the Department of Health and Senior Services (DHSS) on 8/9/23, regarding the resident being found unsupervised outside the facility on 8/4/23, showed: -Timeline of Events: -Resident seen getting water and walking outside to sit on front patio as many other residents walking through the door after Mass at 11:40 A.M.; -12:12 P.M., resident seen (after the fact) walking along the sidewalk, toward the front entrance of campus; -The fill-in (replaced the receptionist for his/her lunch period) came back to the front desk around 12:25 P.M. to inform the receptionist about the resident. The resident was not there (on the front patio); -Around 12:35 P.M., an independent living employee (Concierge) saw the resident sitting in the grass near the sidewalk, a few hundred feet from the front entrance of the campus. The employee noticed the resident bleeding. He/She got the resident's name, called 911, then went back to the independent living to gather supplies (to clean the resident up) and inquire if the he/she lived at the facility; -During that time a passerby stopped to sit with the resident and the ambulance showed up; -The independent living Concierge called to other receptionist on campus to find out the resident had a room in the skilled nursing facility. The assisted living receptionist contacted the Housing Director, who then contacted the skilled nursing facility administrator at 12:40 P.M.; -The skilled nursing facility Administrator and the Housing Director left the building to look for the resident at about 12:42 P.M. The ambulance was still on the side of the road around 12:45 P.M.; -The skilled nursing facility Administrator knocked on the ambulance door and was let in. When the resident was asked where he/she was walking to, he/she said I was walking home; -Around 12:49 P.M., EMS pulled ambulance into campus to gather pertinent paperwork; -12:50 P.M., resident taken to hospital for 2 centimeter laceration above the right eye, no stitches needed; -Resident returned to skilled nursing facility that evening and a wander device was immediately placed; Summary: -Facility reviewed all ambulatory short-stay residents; -The resident who eloped was noted to have had a wandering/elopement episode in the last 60 days; -Facility made initial report to DHSS on 8/4/23. During an interview on 10/24/23 at 11:09 A.M., the HID said on 8/4/23 around 11:45 A.M., she relieved the receptionist at the front desk so the receptionist could go on break. About that time, a group of about 5 residents from the independent living building came out of the chapel after mass and entered into the lobby area where she was sitting at the receptionist desk. Resident #96 was walking with them, so she thought Resident #96 was an independent living resident as well. They stopped for water and then she let them out, including Resident #96. Resident #96 was walking independently and did not have a wheeled walker. After exiting, Resident #96 sat down in a chair right outside the skilled nursing building while the other residents went on to the independent building. The receptionist came back from lunch and she left to collect some forms from around the skilled nursing facility. At some point she came back to speak to the receptionist about Resident #96. She wanted to make sure the resident was not still sitting outside as it was warm out, but not hot. The resident was no longer sitting outside and she gave the receptionist a description of the resident, but the receptionist did not know who he/she was. It was about that time someone came in from another building and said someone had fallen outside. The Concierge from the independent building called and spoke to the former Administrator and asked if a resident was missing. She and the former Administrator walked down to where the resident had fallen and she told him this is the resident that was sitting outside. The former Administrator identified the resident as Resident #96. During an interview on 10/24/23 at 8:47 A.M., Concierge L said he/she works in the independent living building. On 8/4/23, he/she had just gotten off work, and was on his/her way home when he/she noticed a person (Resident #96) off campus laying on the ground. He/She did not know the person was a resident at that time. A community bystander had already stopped to help the person and had called 911. The person was bleeding bad from a cut above the left eyebrow. He/She went back to the independent living building to get bandages for the person's laceration. He/She told the other Concierge about what had happened, but at that time he/she did not know the person's name or that he/she was a resident. After he/she went back with the bandages, the person told him/her, his/her name. Since the person did not reside in the independent living building he/she still did not realize he/she was a resident from the skilled nursing facility. He/She asked the person if he/she lived at the facility and the person said no, but he/she lived in the neighborhood. He/She called the other Concierge and told him/her the person's name. The other Concierge said the person's name was not listed in the elopement book. It was not until later he/she learned the person was a resident from the skilled nursing facility. Using a campus map, Concierge L identified the location where he/she found the resident. The location was off the facility campus property next to the road located directly in front of the campus. The surveyor walked the distance from the entrance of the skilled nursing facility to the place the Concierge identified which was 325 feet from the skilled nursing facility entrance door. During an interview on 10/25/23 at 10:23 A.M., the Rehabilitation Manager said the resident received speech therapy, occupational therapy, and physical therapy while residing at the facility. The last day he/she received physical therapy was 8/4/23. The resident walked 300 ft with a wheeled walker and supervision (supervision is within eyesight). The last day he/she received Speech Therapy was on 8/2/23. A SLUMS (St. Louis University Mental Status) examination was completed that day and the resident's score was a 20 out of 30, indicating the higher end of dementia. She would not recommend the resident to be walking without the wheeled walker or to be outside without supervision. He/She attended the facility in-service on elopement since this occurred. During an interview on 10/25/23 at 10:48 A.M., Nurse I said had he/she admitted the resident, he/she would have reviewed the hospital information and had he/she seen the resident had been found confused and wandering, he/she would have placed a wander alert alarm on the resident and added the resident to the list of residents at risk to elope/wander. He/She received elopement in-servicing since this occurred. During an interview on 10/25/23 at 2:51 P.M., Certified Nursing Assistant (CNA) M said he/she had taken care of the resident. On the evenings and nights, the resident mostly stayed in his/her room. The resident did not sleep in bed, he/she slept in his/her recliner. The resident would not use his/her walker. He/She would say he/she did not need it. Sometimes the resident would be confused about where he/she was and would start looking for his/her family. He/She never saw the resident trying to leave the facility. One time after his/her family visited, the resident was packing his/her belongings and said he/she was going home, but he/she did not attempt to leave. He/She did not tell the nurse about the resident packing his/her belongings, because he/she was easy to redirect. He/She attended the facility in-service on elopement since this occurred. During an interview on 10/25/23 at 5:03 P.M., the Medical Director said she expected some form of communication between the hospital and facility that would have identified the resident's history of increased confusion and wandering. She expected the facility to follow their protocol. If part of their protocol is to place a wander alert alarm on the resident, then that is what should have been done. She expected the facility to follow their policies. During an interview on 10/26/23 at 7:47 A.M., Nurse K said the resident walked around independently. He/She was very pleasant. He/She was not aware of the resident wandering prior to being admitted to the facility. He/She never saw the resident packing his/her belongings, making statements about leaving or attempting to leave. The resident would get confused and need help to find his/her room. The resident did not have his/her walker on 8/4/23, when he/she left the facility. Had he/she admitted the resident, he/she would have reviewed the hospital records and would have placed a wander alert alarm on the resident. He/She attended a facility elopement in-service since this happened. On 10/26/23 at 8:23 A.M., an interview was conducted with the Executive Director, Skilled Nursing Facility Administrator, and Director of Nursing (DON) in attendance. The DON said the admitting nurse on 7/26/23 told her he/she had reviewed the hospital record sent upon admission, but he/she did not pick up on the fact the resident was found confused and unable to say where he/she lived. Had the admitting nurse identified that information and notified her, she would have told the admitting nurse to place the resident's name on the elopement/wandering list, place his/her information in elopement book at the receptionist desk, and place a wander alert alarm on the resident. All of this would have been added to the resident's care plan. The Nurse Manager is responsible to check all admission paper work within 12 hours after the admission. She spoke to the Clinical Nurse Manager (CNM) who was responsible and that CNM said she did not feel it was necessary to review hospital records so he/she did not. All the nurses have been in-serviced to always review hospital records upon admission. All staff have been re-inserviced to the facility elopement policies and procedures as well. The Executive Director and Administrator agreed with the DON. During an interview on 10/26/23 at 9:32 A.M., Clinical Nurse Manager O said had she reviewed the resident's hospital records, she would have placed the resident on the elopement lists and given the resident a wander alert alarm. Review of the resident's progress note, dated 8/5/23 at 9:35 A.M., showed the resident was transferred to another facility. MO00222537

Based on observation, interview and record review, the facility failed to ensure that a resident who admitted to the facility with intact skin, received treatment and care in accordance with professional standards of practice, when staff failed to provide timely skin assessments and monitoring for one resident (Resident #1). The resident admitted to the facility with known lower leg circulation issues and intact skin on 4/12/23. The facility did a skin assessment on 4/17/23, with no skin issues. On 4/28/23, the resident arrived at a scheduled appointment and upon voicing foot pain, the clinic removed the resident's socks. They assessed the resident's right foot had and observed 3 necrotic (dead, black tissue) toes and a wound in between the toes. The resident was immediately admitted to the hospital for evaluation and treatment. The sample was two. The census was 88. Review of the facility's weekly skin assessment policy, revised 4/2023, showed: -Objective: to assure resident's skin conditions are identified, monitored and resolved properly; -Procedure: -Resident skin will be assessed each week by a certified nursing assistant (CNA) with bath/shower; -Each resident's weekly skin assessment will be assigned to one day if multiple baths/showers occur; -All skin abnormalities such as bruises, skin tears, redness, rashes, birthmarks, will be documented on the body sheet provided; -When scheduled assessments are complete the CNA will review with the charge nurse all complete skin assessments; -The charge nurse will complete any further assessments as needed; -The unit manager will review and monitor all skin assessments for proper documentation and appropriate treatment. Review of the facility's undated skin/wound documentation/treatment guidelines, showed: -A skin assessment with Braden scale (a scale which measures risk to develop skin impairment and sores) completed within 8 hours of admission and done weekly for 4 weeks after admission or re-admission, quarterly, annually or with a significant change; -Open any skin events noted upon admission and/or any time a skin event is warranted such as a bruise, burn, impaired skin integrity, pressure sore (injury to the skin and/or underlying tissue, as a result of pressure or friction)/or stasis ulcer (wound developed as a result of poor blood circulation), rashes and cuts; -Fill out the event noting a description of the skin related issue and completing the information within the event; -Implement standing orders or contact the physician for orders. We want to clean, protect and cover wounds; -Enter any new pressure related events into the system; -On all residents, skin is observed daily with care. If any skin concerns are noted, they are reported to the licensed nurse for follow up; -Weekly skin audits are performed by licensed nurse and documented: -Can be documented in progress notes; -For any new stasis ulcers when community or facility acquired; -Document all wounds weekly every 7 days with measurements, location, stage, wound base description, drainage, edges, odor, or pain; -If the facility does not have a wound nurse to track and monitor every 7 days, a treatment order may be entered to remind the nurse to complete the measurements; -Notify the physician if no improvement; -Provide summary progress notes wound condition with interventions, dressing, notification; -Update the care plan with treatment changes and re-evaluate as needed; -Update/consult with dietician, therapy or other members of the care team. Review of Resident #1's hospital discharge paperwork, dated 4/7/23 through 4/12/23, showed: -On 4/7/23 at 1:12 P.M., reason for visit: lower leg pain, swelling; -Assessment: alert and orientated x 4 (alert to person, place, time and situation); -Plan: -Leg cramping likely due to electrolyte imbalance resolved with fluids and peripheral vascular disease (PVD, poor circulation in the lower extremities) which should be monitored; -Liver cirrhosis end-stage, requiring frequent paracentesis (draining fluid from the abdomen); -Lung and kidney disease; -The discharge summary, dated 4/12/23, showed: -Discharge diagnoses: acute kidney injury, liver cirrhosis, leg pain and lower leg swelling; -No documented skin concerns; -Discharge to skilled nursing facility. Review of the facility's wound report, dated 4/1/23 through 4/30/23, showed the resident not listed on the report. Review of the resident's medical record, showed: -admitted to the facility on [DATE]; -Diagnoses included: liver cirrhosis, left leg pain, kidney disease and right iliac artery stenosis (narrowing of the major blood vessel that supplied blood flow to the right leg) and stent placement. Review of the admission physician order sheet, dated 4/12/23, showed: -Admit for daily skilled services; -Discharge potential: excellent; -Physical and occupational therapy; -Rehabilitation potential: good; -Weekly paracentesis. Review of the resident's baseline care plan, dated 4/12/23, showed: -Goals: discharge home with family; -Cognition: alert/cognitively intact; -Communication: verbal; -Vision: adequate; -Hearing: impaired, hard of hearing; -Regular diet; -Safety: fall risk; -Assist of one for transfers, dressing, walking, toileting, hygiene, mobility and used walker and wheelchair; -Skin: skin intact, turn and reposition and encourage resident to assist; -Discharge goal: home with family. Review of the facility progress notes, showed on 4/12/23 at 4:14 P.M., the resident admitted to the facility from the hospital. admitted for treatment for leg cramps and pain to the right flank. He/She needs one staff assist. Foot pulses are present, no open or soft areas to the heels. Review of the resident's physician history and physical, dated 4/12/23, showed: -History of present illness: resident has medical history significant for hypertension (high blood pressure), peripheral vascular disease with right lower extremity stenting (surgical procedure used to open lower leg veins to improve blood flow to lower legs and feet) and end stage liver cirrhosis with weekly paracentesis. Resident was admitted to the hospital from 4/7/23 to 4/12/23 with complaints of leg pain and cramps. While admitted he/she was treated for kidney injury, and urinary tract infection (UTI). He/She received a paracentesis and fluid was removed. He/She underwent a lower extremity arterial Doppler (ultrasound of the arteries) which revealed severe right iliac level stenosis. Resident's leg pain/cramping improved after hydration; -Initial visit: Resident seen for admission visit. He/She is awake and alert but appears alert to self and somewhat place; -Review of systems: Skin- no rash or lesion; -Physical exam: -Skin: skin clean, dry and intact. No rashes or lesions; -Imaging reviewed: ultrasound lower extremity: Impression- severe right iliac stenosis, no evidence of left lower extremity arterial stenosis; -Assessment and Plan: -Left leg cramping: resolved, suspect electrolyte imbalance and improved with hydration. Physical and occupational therapy consulted; -History of peripheral vascular disease: continue medications; -admitted to skilled nursing facility; -Continue with physical therapy (PT)/occupational therapy (OT) as guided by evaluations and recommendations. Review of the resident's progress notes, showed on 4/16/23 at 2:47 P.M., skilled note: generalized weakness, needs assistance of one and walker for ambulation and transfers. Review of the resident's physician progress note, dated 4/21/23, showed: -Follow up visit: Resident is alert and oriented to person and place (A&OX2). He/She denied pain. Discussed hospice care based on care meeting with family, he/she stated he/she wanted to discuss more with family; -Assessment: skin- clean, dry and intact. No rashes or lesions. Review of the resident's skin risk assessment with Braden Scale, dated 4/24/23 at 10:26 A.M., showed: -Does the resident have any of the following risk factors for developing pressure sores: acute condition; -Does the resident have one or more unhealed pressure ulcers/injury: no; -Bed mobility: limited assistance; -Mobility devices: wheelchair; -No current wounds or skin issues; -No venous or stasis ulcers (wounds as a result of poor blood flow to the lower legs/feet); -No swelling, pale skin, dehydration, or calf tenderness; -Sensory perception: slightly limited; -Activity: walks occasionally; -Mobility: slightly limited; -Nutrition: adequate; -Friction and shear: no apparent problem; -Score: 19- not at risk to develop pressure injury; -Skin risk summary note: the writer did the skin assessment due to the writing assessment completed on 4/17/23. Writer could not locate the proper computer documentation from one week ago. Review of the resident's progress notes, showed on 4/28/23 at 7:41 A.M., the resident left the facility to the hospital for a procedure. Review of a hospital endoscopy nurse progress note, dated 4/28/23 at 9:25 A.M., showed the patient complained of foot pain from socks being too tight. The socks were removed and found that the right foot had three toes that are black in color. The second and third toe are black with obvious skin breakdown between the toes and the fifth toe is discolored as well. Review of the hospital admission history and physical, dated 4/28/23 at 3:46 P.M., showed: -History of present illness: the patient presented to the hospital for outpatient procedure to reassess prior procedure. The patient presented to endoscopy from the skilled nursing facility and found to be hypotensive (low blood pressure). He/She was also found to have ischemia (inadequate blood supply to a part of the body)/necrotic area of the second through fourth toes on the right. The decision was made to cancel the planned endoscopy procedure and admit to the hospital for non-healing ischemic ulcer of the foot. The patient was started on intravenous (IV) Vancomycin (antibiotic) in case of secondary bacterial infection of the necrotic toes, however, patient and family decided to pursue comfort measures and hospice has been consulted. The patient was examined and endorsed being very tired and just wanting to not be here anymore and stated he/she is tired of living because this is not living. He/She also endorsed significant right foot pain; -Physical exam: -Cardiovascular: both feet pulses are not palpable (able to be felt); -Impression and plan: Diagnosis: non-healing foot ulcer, PVD, liver cirrhosis and acute hypotension; -Orders: Non-healing foot ulcer: PVD: Received vancomycin one time, however the toes do not appear to be acutely infected and will discontinue the antibiotic. The toes are not likely to be salvageable (saved). The patient is a very poor surgical candidate and would like to pursue hospice care. Care management will assist with hospice assessment and arrangement. Will provide local wound care and otherwise treat to maximize comfort. Review of the resident's hospital physician progress note, dated 4/29/23 at 5:03 P.M., showed: -Cardiovascular: pedal (foot) pulses are non-palpable; -Skin: right toes 2-5 are dusky (darker, bluish tint) and cold. Digit 2 has a large area of necrosis on the medial (middle) and plantar (bottom) surface. Exam consistent with dry gangrene (occurs when the blood supply to tissue is cut off. Tissue becomes dry, shrinks, and turns black. Normally occurring slowly), and unchanged from yesterday. Review of the resident's hospital discharge summary, dated 5/1/23 at 12:22 P.M., showed: -Reason for hospitalization : hypotension; -Hospital course/significant findings: the patient presented to the hospital on 4/28/23 for outpatient repeat endoscopy from his/her skilled nursing facility and found to be hypotensive. He/She was also found to have ischemic/necrosis of the second through fourth toes on the right. The patient and family elected comfort measures and received as needed Ativan (used to treat anxiety) and Morphine (narcotic pain medication); -Exam: -Cardiovascular: both foot pulses are non-palpable; -Skin: right toes 2-5 are dusky and cold. Digit 2 has a large area of necrosis on the medial and plantar surface. The exam is consistent with dry gangrene. Foot pulses cannot be palpated; -Discharge: home with hospice services. During an interview on 4/29/23 at 11:30 A.M., Hospital Registered Nurse (RN) A said the resident had liver disease and poor lower right leg circulation. He/She had a history of blockage of the iliac artery and stents placed previously for profusion. The resident was admitted to the hospital from endoscopy with low blood pressure and black, necrotic toes to the right foot the morning of 4/28/23. The right foot also had a large wound between the toes. The toes were not salvageable. The resident voiced severe pain to the right foot and he/she received routine pain medication. The family and resident were considering hospice services. RN A had not be able to assess the right foot, the foot was covered in a bandage. During an interview on 4/30/23 at 10:30 A.M., Hospital RN B said he/she was caring for the resident today. The resident and the family elected hospice services. The resident's right foot had very poor blood flow. Upon assessment, the right great (big) toe had dark discoloration and the top and bottom of the foot were beginning to darken. The second-fifth toes were black, and cold to touch. There was a wound between the second and third toe. The resident did not allow staff to change dressings without medication and the resident was receiving morphine for pain management. The facility staff should have noticed the circulation changed to the foot, the necrosis would have developed over time. During an interview on 5/1/23 at 10:17 A.M., Occupational Therapist D said the resident missed two sessions of therapy. One OT and one PT related to fatigue. The resident did not voice pain to his/her feet during therapy sessions. The resident ambulated with a walker 150 feet on 4/26/23. During an interview on 5/1/23 at 10:29 A.M., the facility's Wound Nurse said he assessed the resident's skin on 4/17/23. He did not have access to the wound/skin assessment in the computer system and he documented the 4/17/23 assessment from notes that were entered into the computer system. He did not assess the resident on 4/27/23. The resident had a history of iliac artery blockage, liver cirrhosis and had scheduled paracentesis. The resident needed one staff assist for dressing and hygiene. The CNAs are responsible to bathe or shower the resident one to two times a week per resident preference. The aides complete a paper shower/bath sheet on all residents. If changes in skin occur, the aide is to document and report the change to the nurse. The charge nurse should assess the wound, document and notify him. If the wound nurse is not present, the charge nurse should call the physician for orders. The resident's feet should have been observed daily by CNAs with dressing or bathing. During an interview on 5/1/23 at 2:04 P.M., the Administrator said he could not locate any shower or bath sheets for the resident from admission 4/12/23 to discharge on 4/28/23. He expected the CNAs to complete a shower/bath sheet on every resident. If a resident refused a bath/shower, that should be documented in the chart. The bath/shower is used to also look at the resident's skin. During an interview on 5/2/23 at 11:45 A.M., the Director of Nursing (DON) said the CNAs are responsible to complete a shower/bath sheet on all residents. Residents are bathed twice a week. Part of dressing a resident is removing socks and applying clean socks daily. If a change in skin is observed, the aide should document on the bath sheet and inform the nurse. The nurse is responsible to assess the skin, notify the wound nurse and if he is not available, then contact the physician. All residents receive a weekly skin assessment completed by the wound nurse. The skin documentation should match the day the assessment is completed. Residents with poor lower extremity blood flow should not miss skin assessments. The DON could not confirm if the resident had not been bathed since his/her admission but verified no shower/bath sheets could be located. During an interview on 5/2/23 at 1:00 P.M., the resident's family said the resident had passed away earlier in the morning. The resident was in severe pain in his/her right foot. The hospice provider gave the family morphine but that did not last long and the resident did not have a peaceful death. The toes were black and the wound between the toes looked deep. The family member was very tearful and upset on how the facility did not see the discoloration of the toes prior to 4/28/23. During an interview on 5/2/23 at 2:27 P.M., the endoscopy clinic RN C said the resident arrived at the clinic for a repeat endoscopy. The resident voiced pain in the right foot and requested the nurse to remove his/her sock, and the sock was tight. The nurse observed the right foot to have multiple toes that appeared black, necrotic and a wound in between the second and third toes. The physician added the toes appeared gangrene and ordered the resident to be admitted to the hospital emergently for assessment and treatment. The discoloration would have occurred over time. The resident had a history of poor circulation to the right leg. The resident would have been a poor surgical candidate. MO00217708 MO00215893

Based on interview and record review, the facility failed to ensure a resident was free from neglect by failing to ensure a staff member, contracted through an agency to provide goods and services to the residents, provided the services necessary to avoid physical harm. Certified Nursing Assistant (CNA) A failed to follow the resident's plan of care, the facility abuse and neglect policy and acceptable standards of practice for one resident (Resident #2) when he/she transferred the resident in a Hoyer lift (mechanical lift) without a second staff person to assist as required. The sample was 9. The census was 88. Review of the facility's undated Abuse Prevention Plan, showed: -Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility's Mechanical Full Body Lift transfer policy, revised 4/30/10, showed: -Objective: To transfer guests who are unable to bear weight to lower extremities in a safe manner; -Procedure: See operational manual for additional information; -Utilize the amount of trained care partners needed to ensure safe guest handling. Review of the EZ Way Smart Lift manual, showed it was designed to be operated by one person. However, with some patients, it is best to use two people. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/6/21, showed: -A Brief Interview of Mental Status (BIMS) score of 4 out of 15; -A BIMS score of 4, showed severe cognitive impairment; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Total dependence on staff for transfers with two or more person physical assist. Review of the resident's care plan, dated 6/26/19, and updated 4/27/21, showed: -Problem: Resident is limited in ability to transfer self: -Goal: Resident will transfer with a Hoyer lift; -Approach: Two medical staff employees when using a Hoyer at all times. Follow proper techniques for transfers. Keep resident arms inside, on lap at all times. Report any problems immediately to supervisor; -Problem: Resident is on hospice. He/she has diseases and health problems that cause pain: -Goal: To keep him/her as pain free or to a minimum as possible; -Approach: Evaluate pain every time staff come into the room. If resident is grimacing, moaning, or grasping, please tell the nurse, so his/her pain can be addressed; -Problem: Activities of Daily Living (ADLs) require extensive to total assist of one for bathing, grooming, AM/PM care, dressing, toileting, and oral hygiene. Transfer with Hoyer lift. Can feed self with set up and supervision: -Goal: ADLs completed each day to his/her comfort and satisfaction; -Approach: Hoyer lift assist of two for transfers; -Problem: He/she has a history of falling due to decreased advanced age and cognitive decline: -Goal: He/she will remain free from serious injury in the event of a fall; -Approach: Transfer him/her with Hoyer lift and assist of two staff. Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 4/29/19, for non-weight bearing to left extremity; -An order, dated 8/6/19, please move legs gently as they are very sensitive, per family request, every shift; -An order, dated 4/28/21, for [MEDICATION(S)] (narcotic pain medication), one milligram (mg) per milliliter (ml), every two hours as needed for pain; -An order, dated 4/28/21, for [MEDICATION(S)] 1 ml, every eight hours as needed for pain. Review of the resident's quarterly functional abilities assessment, dated 4/5/21, showed: -Sit to lying: dependent. Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity; -Lying to sitting on side of the bed: dependent. Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity; -Sit to stand: dependent. Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity; -Chair/bed to chair transfer: dependent; -Toilet transfer: dependent. Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity. Review of the resident's progress notes, showed: -On 4/25/21 at 1:48 P.M., resident told aide that his/her arms and legs was hurting during transfer into bed after lunch. Aide stated that he/she said his/her legs and arms were broke. This nurse went into room to assess resident and he/she was sound asleep. This nurse checked both legs and arms and did an assessment with touching, resident did not have any response to any touch or sensation; -On 4/26/21: -At 1:54 P.M., Hospice nurse and staff called this nurse to resident room to look at resident's left forearm. Upon arriving to resident's room, this nurse observed resident lying in bed holding left arm. Large purple bruised area, swelling, and slight deformity noted to left upper arm. Resident crying and stating my arm is broken. Upper arm area cool to touch. Call placed to physician. Orders received to obtain x-ray of left arm and to notify facility Director of Nursing (DON) for further investigation. Will contact DON and Assistant Director of Nursing (ADON) to notify of resident injury. Will place call to obtain x-ray at this time; -At 2:10 P.M., X-ray contacted. Representative states technician will be out this evening. Resident in bed with eyes closed and resting at this time. Continues to hold left arm. This nurse will continue to attempt to contact facility DON and ADON; -At 2:23 P.M., Resident given [MEDICATION(S)] (generic form of [MEDICATION(S)]) 1 ml for control of pain. Resident in bed resting at this time. Will continue to monitor this shift; -At 4:06 P.M., 3:00 P.M. to 11:00 P.M. shift nurse notified of resident injury and will contact resident family/power of attorney (POA). ADON and DON made aware of resident injury and condition; -At 4:15 P.M., Spoke to family and informed about the bruise on resident's arm. He/she would like to be called with the results of the x-ray when received; -At 4:45 P.M., X-ray tech arrived with machine to take an x-ray on this patient. Order reads left forearm. This nurse examined the patient's arm and noticed ecchymosis to the left anterior (front) bicep (upper arm muscle) area. Area was tender to the touch and movement. No discoloration or tenderness was present to the left forearm. So the x-ray order was changed to the left humerus (bone in the upper arm); -At 11:31 P.M., Staff notified of x-ray results. New order for sling. Attempted to reach family; -On 4/27/21 at 6:16 A.M., resident in bed with sling intact to left arm. Bruising noted to left upper extremity. Call light is within reach and bed is in low locked position. Will continue to monitor for the remainder of this shift; -At 9:57 A.M., this nurse spoke with power of attorney (POA) to report radiology findings. He/she was grateful for the call. Stated to keep resident comfortable; -At 10:26 A.M., Resident complaining of left arm pain when physically touched. Left inner upper extremity has purplish-blue bruising. Arm is currently immobilized by sling per physician orders. Resident given [MEDICATION(S)] for pain control; -At 2:27 P.M., Resident has new order for [MEDICATION(S)] 1 ml scheduled every eight hours and as needed (PRN) every two hours for pain; -At 4:57 P.M., Sling intact to left arm. Resident lying in bed without complaints of pain voiced. Will continue to monitor; -At 11:23 P.M., Resident wearing left arm sling. Neuro-circulation to left hand adequate. Fingernails blanch well. [MEDICATION(S)] 1 mg by mouth given at 6:00 P.M. as ordered for routine dose for comfort measures. Resident voices no complaints of pain or discomforts except with gentle movement for patient care and appears comfortable with shift with face relaxed. Will continue to monitor resident for comfort; -On 4/29/21 at 12:52 P.M., resident lying in bed with sling intact to left arm. Non weight bearing status maintained. No complaints of pain or discomfort. Review of the resident's x-ray result of the left humerus, dated 4/26/21, showed acute proximal (situated nearer to the center of the body or the point of attachment) humerus fracture with comminution (a break of the bone into more than two fragments) and mild displacement (bones no longer align) seen. No joint dislocation. The bones appear diffusely demineralized (a thinning and weakening of the bone). Soft tissue swelling noted. Review of CNA A's interview statement, dated 4/27/21, showed he/she worked on 4/25/21 from 7:00 A.M. to 3:00 P.M. When he/she arrived on the unit, all of the residents on his/her assignment were up and dressed. He/she took Resident #2 his/her breakfast tray around 8:00 A.M. CNA A assisted with feeding the resident. While feeding, he/she stated, I'm cold and everything hurts. He/she was not specific about what actually hurt. At about 1:00 P.M., after lunch, CNA A used the Hoyer lift to put him/her back to bed. While CNA A was transferring him/her with the Hoyer lift, the resident began saying ouch, ouch. Once he/she was in the bed, he/she stopped saying ouch. When CNA A repositioned him/her in the bed, the resident started saying ouch my legs, arms, and everything hurts. CNA A cleaned the resident up and reported his/her complaints to the nurse. The nurse went to the resident's room to assess her. During an interview on 5/3/21 at 12:46 P.M., CNA A said he/she worked at the facility on 4/25/21 from 7:00 A.M. to 3:00 P.M. He/she confirmed the statement received by the DON. When CNA A arrived, the resident was already dressed and in his/her wheelchair. He/she assisted the resident with breakfast. During breakfast, the resident said he/she was in pain. When asked what was hurting, the resident said everything. This was normal behavior for the resident. He/she always said everything hurt. CNA A said the resident always complained that everything hurts, so he/she was not paying attention because he/she always said it. The resident remained in the wheelchair and was not transported out of his/her room. CNA A returned to the resident's room to assist him/her with lunch. At approximately 1:00 P.M., CNA A used the Hoyer lift to transfer the resident from the wheelchair to the bed. CNA A confirmed that he/she operated the Hoyer lift alone. CNA A explained that there were only agency staff and the facility was short staffed. CNA A said, if everyone was assisting the residents, then there isn't anyone to help. He/she was aware the Hoyer lift should be operated by two people and had been educated in using the Hoyer lift. CNA A said during the lift, he/she controlled the lift, but the resident was not guided or spotted when the Hoyer lift was moved above the bed. During the lift, the resident continued to say ouch. When the resident was in bed, he/she said his/her legs, arms, and everything hurt. CNA A said the resident was specific that time, which the resident was not usually specific to what was hurting in the past, but CNA A believed it was because the resident did not want to be moved and flipped. After the resident was in bed, CNA A provided incontinence care. When he/she left the room, he/she reported to the nurse that the resident complained of pain. CNA A did not tell the nurse that he/she operated the lift alone because the nurse did not ask. The nurse did an assessment, but did not find anything at that time. CNA A did not have interaction with the resident after he/she transferred her to the bed. Review of Licensed Practical Nurse (LPN) B's interview statement, dated 4/27/21, showed LPN B worked on 4/25/21 at 7:00 A.M. to 3:00 P.M. He/she went into the resident's room to perform a treatment on the roommate. The resident was in his/her chair watching a movie. He/she did not complain of pain or discomfort. After lunch, the CNA stated, he/she was placing the resident in the bed and he/she started saying my legs and arms are broke. The CNA said he/she put the resident to bed using the Hoyer lift. LPN B accompanied the CNA into the room and assessed him/her. LPN B lift the cover up off his/her legs and felt his/her legs. The resident did not complain of pain. LPN B looked at the resident's arms and lift his/her arms and he/she did not grimace or complain of pain. LPN B documented the assessed. LPN B did not notice any bruising or swelling to the body. Before LPN B left the shift, he/she checked on the resident again. No complaints voiced. He/she reported the assessment to the oncoming nurse. During an interview on 4/30/21 at 1:18 P.M. and 5/10/21 at 11:32 A.M., the DON confirmed that CNA A operated the Hoyer lift alone. CNA A was aware that the Hoyer lift is operated by two people. CNA A told the DON that he/she looked down the hall and did not see anyone. During the investigation, staff confirmed that the resident did not have complaints of pain prior to 4/25/21. During the transfer, the resident did not fall or bump into anything. CNA A really wanted to get him/her into the bed, so he/she could provide care. The DON would expect staff to following the transfer policy. The DON understood not following the Hoyer lift transfer guidance, this was neglect. MO 575

Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible, when the facility failed to maintain safe water temperatures, between 105 degrees Fahrenheit (F) and 120 degrees F, for the residents at the facility, for three of four shower/spa rooms and three of four resident halls. The census was 106 with 48 residents in certified beds. Of the 48 residents, five residents were identified as physically able to gain access to the sink or shower and had cognitive impairment or physical conditions that decreased touch sensation. In addition, three residents voiced concerns with the hot water. (Residents #301, #302, #304, #305, #306, #8, #36 and #7). Water temperatures in the facility accessible to residents, registered up to 139.3 degrees F. Water temperatures in resident rooms at the sink measured up to 138 degrees F. The census was 106 with 48 residents in certified beds. 1. Review of Resident #301's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/5/18, showed: -Usually understood and usually understands; -Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 5 out of a possible score of 15. A BIMS score of 0-7, showed the resident had severe cognitive impairment; -Cognitive skills for daily decision making: (Blank); -Wandering: The behavior occurred one to three days; -Supervision required for locomotion on and off the unit; -Balance during transitions and walking: Not steady, but able to stabilize without staff assistance. Review of the resident's face sheet, showed [DIAGNOSES REDACTED]. Review of the resident's electronic care plan, dated 2/13/18 and in use at the time of the survey, showed: -Problem: Wandering. Goal: To remain within defined safe areas. Approach: If wandering, walk beside and attempt to direct back to safe areas; -Problem: Mobility, required training and skill practice in walking and upper extremity exercise. Goal: Walk in corridor and exercise 2-3 times a week as tolerated. Approach: Remind not to ambulate without assistance; -Problem: Activities of daily living (ADLs) requires supervision, set up, and limited assist of one for bathing, grooming, care, dressing, toileting. Pleasant but confused. Requires instructions/cuing, uses walker with assistance. Goal: ADLs will be completed each day. Approach: Assist with bathing; -Problem: [DIAGNOSES REDACTED]. Goal: Make decisions that are within ability. Interventions: Re-orient to person, place and time, speak in clear voice at eye-level in an unhurried manner. Re-phrase and repeat as needed. Review of the resident's nursing summary, dated 3/21/18, showed: -Usually understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Usually understands-misses some part/intent of message but comprehends most conversation; -Cognitive skills for daily decision making: Modified independence-some difficulty in new situations only. Review of a list of care needs and cognitive abilities for residents, provided by the facility on 3/27/18, showed confused, transferred with stand by assist, propelled self in the wheelchair and walked in the room. 2. Review of Resident #302's annual MDS, dated [DATE], showed: -BIMS score of 4 out of a possible score of 15. A BIMS score of 0-7, showed the resident had severe cognitive impairment; -Limited assistance required to walk in the room and locomotion on the unit; -Mobility devices used: Walker and wheelchair. Review of the resident's face sheet, showed [DIAGNOSES REDACTED]. Review of the resident's nursing summary, dated 3/4/18, showed: -Sometimes understood-ability is limited to making concrete requests; -Sometimes understands-responds adequately to simple, direct communication only; -Short and long term memory problem; -Moderately impaired-decision poor. Cues/supervision required. Review of the resident's progress notes, showed on 3/5/18 at 3:29 A.M., (MONTH) monthly summary-Resident is alert to self and is confused to his/her surroundings. Has moments of confusion at night and looking for his/her family. States, he/she is looking for his/her car. Resident was up in the wheelchair during the night. Review of the resident's care plan, dated 3/13/18 and in use at the time of the survey, showed: -Problem: Memory/recall problem related to [MEDICAL CONDITION]. Goal: Improve memory/recall ability as much as possible. Approach: Provide verbal and visual reminders; -Problem: Behavioral symptoms, wandering. Goal: Remain within defined safe area. Approach: High risk time for wandering/door seeking is during waking hours. Staff will redirect, use diversional activities during these hours; -Problem: Cognitive loss/dementia, at times may be confused and forgetful. Goal: Make decisions that are within ability. Approach: Re-phrase repeat as needed. -Problem: ADL function, ability to perform ADLs fluctuates, can be confused, uses wheelchair for mode of getting around. Goal: No further deterioration in performance of ADLs. Will not be adversely affected by choices. Approach: Do not rush. Allow extra time to complete ADLs. Review of a list of care needs and cognitive abilities for residents, provided by the facility on 3/27/18, showed alert and oriented times one (alert and oriented to (one) person, (two) person and place, (three) person, place and time, and (four) person, place, time and situation), confused, transferred times one assist standby and propelled self in the wheelchair. 3. Review of Resident #304's face sheet, showed [DIAGNOSES REDACTED]. Review of the resident's electronic care plan, in use at the time of the survey, showed problem start date 3/1/18, mobility: The resident required assistance of (blank) for transfers and toileting related weakness due to (blank) diagnosis. Goal: The resident will be (blank) for all transfers and toileting. Approach: Certified nursing assistant (CNA) to use a (blank) and assist for all transfers and toileting. Resident will make an individualized plan of care to enable independence with mobility. Review of a list of care needs and cognitive abilities for residents, provided by the facility on 3/27/18, showed alert and oriented times two, confusion, propelled self in the wheelchair. 4. Review of Resident #305's face sheet, showed [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS, dated [DATE], showed: -BIMS score of 15 out of a possible score of 15; -A BIMS score of 13-15, showed the resident cognitively intact; -Supervision required for walking in the room and in the corridor; -Supervision required for locomotion on and off the unit. Review of a list of care needs and cognitive abilities for residents, provided by the facility on 3/27/18, showed history of short term memory loss, [MEDICAL CONDITION] (TBI) and walked with walker. 5. Review of Resident #306's face sheet, showed [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS, dated [DATE], showed: -BIMS score of 0 out of a possible score of 15. A BIMS score of 0-7, showed the resident had severe cognitive impairment; -Short and long term memory problems; -Cognitive skills for daily decision making: Severely impaired; -Disorganized thinking: Behavior fluctuates; -Had delusions; -Wandering occurred daily; -Supervision required to walk in the room and corridor; -Supervision required for locomotion on the unit. Review of a list of care needs and cognitive abilities for residents, provided by the facility on 3/27/18, showed confused, ambulated but should have stand by assistance. 6. Observation of water temperatures, taken at the sink with calibrated thermometers, showed the following hot water temperatures measured after allowing the water to run a minimum of two minutes: -Shower room [ROOM NUMBER], door unlocked and accessible to residents: -On 3/27/18 at 10:52 A.M., hot water measured 137.8 degrees F with a digital thermometer and 138 degrees F with a dial thermometer. Steam visible and the water hot and burned to the touch; -On 3/27/18 at 12:20 P.M., hot water measured 138.4 degrees F with a digital thermometer and 138 degrees F with a dial thermometer. Steam visible; -On 3/27/18 at 2:59 P.M., hot water measured 125 degrees F with a dial thermometer; -Shower room [ROOM NUMBER], door opened, unlocked and accessible to residents: -On 3/27/18 at 11:04 A.M., hot water measured 137.3 degrees F with a digital thermometer and 138 degrees F with a dial thermometer. Steam visible; -On 3/27/18 at 12:23 P.M., hot water measured 139.3 degrees F with a digital thermometer and 139 degrees F with a dial thermometer. Steam visible; -On 3/27/18 at 2:56 P.M., hot water measured 125 degrees F with a dial thermometer; -On 3/27/18 at 5:32 P.M., hot water measured 123.4 degrees F with a digital thermometer; -Sitting/activity area across from room [ROOM NUMBER], accessible to residents: -On 3/27/18 at 11:39 A.M., hot water measured 135 degrees F with a dial thermometer; -On 3/27/18 at 12:46 P.M., hot water measured 132 degrees F with a dial thermometer and 133.7 degrees F with a digital thermometer; -Spa room [ROOM NUMBER], door unlocked and accessible to residents: -On 3/27/18 at 11:44 A.M., hot water measured 128 degrees F with a dial thermometer; -On 3/27/18 at 12:50 P.M., hot water measured 126 degrees F with a dial thermometer and 127.6 degrees F with a digital thermometer; -room [ROOM NUMBER]: -On 3/27/18 at 11:08 A.M., hot water measured 130 degrees F with a dial thermometer and 131.2 with a digital thermometer; -On 3/27/18 at 12:27 P.M., hot water measured 129 degrees F with a dial thermometer and 130.1 degrees F with a digital thermometer; -room [ROOM NUMBER]: -On 3/27/18 at 11:16 A.M., hot water measured 136.3 degrees F with a digital thermometer and 138 degrees F with a dial thermometer. Steam visible and the water hot and burned to the touch; -On 3/27/18 at 12:30 P.M., hot water measured 134 degrees F with a dial thermometer and 135.5 degrees F with a digital thermometer. Water splashed on the surveyor's finger from the sink as the temperature obtained with the dial thermometer, burned to the touch and left a red mark that lasted and stung for approximately one minute; -On 3/27/18 at 2:53 P.M., Resident #301 propelled him/herself out of the bathroom in his/her wheelchair and to his/her bed. No staff in the room; -room [ROOM NUMBER]: -On 3/27/18 at 11:12 A.M., hot water measured 136 degrees F with a dial thermometer and 133.4 degrees F with a digital thermometer; -On 3/27/18 at 12:33 P.M., hot water measured 130 degrees F with a dial thermometer and 131.5 degrees F with a digital thermometer; -room [ROOM NUMBER]: -On 3/27/18 at 11:21 A.M., hot water measured 130 degrees F with a dial thermometer and 129.6 degrees F with a digital thermometer; -On 3/27/18 at 12:37 P.M., hot water measured 131 degrees F with a dial thermometer and 132.8 degrees F with a digital thermometer. Steam visible; -room [ROOM NUMBER]: -On 3/27/18 at 11:24 A.M., hot water measured 127.6 degrees F with a digital thermometer and 128 degrees F with a dial thermometer; -On 3/27/18 at 12:42 P.M., hot water measured 128 degrees F with a dial thermometer and 129.6 degrees F with a digital thermometer; -room [ROOM NUMBER]: -On 3/27/18 at 11:32 A.M., hot water measured 126.9 degrees F with a digital thermometer. Steam visible; -On 3/27/18 at 1:00 P.M., hot water measured 122 degrees F with a dial thermometer; -room [ROOM NUMBER]: -On 3/27/18 at 11:37 A.M., hot water measured 131.1 degrees F with a digital thermometer and felt hot to the touch; -On 3/27/18 at 3:07 P.M., hot water measured 121.3 degrees F with a digital thermometer; -room [ROOM NUMBER]: -On 3/27/18 at 11:45 A.M., hot water measured 126 degrees F with a dial thermometer; -On 3/27/18 at 12:57 P.M., hot water measured 126 degrees F with a dial thermometer. Steam visible; -room [ROOM NUMBER]: -On 3/27/18 at 11:43 A.M., hot water measured 130 degrees F with a dial thermometer; -On 3/27/18 at 1:06 P.M., hot water measured 129 degrees F with a dial thermometer. 7. Observation on 3/27/18 at 1:03 P.M., of the water heater system, showed three large water tanks, each tank set on 150 degrees F. A pipe connected to the tanks and had a mixing valve, to control water temperatures and a water softener. There was no thermometer or gauge to test the water temperature after the mixing valve. During an interview on 3/27/18 at 11:50 A.M., the environmental director said the staff take temperatures every night, on the night shift and document the temperatures in a log book. They test every spa room, every night. The staff do calibrate their thermometers by taking the temperature down to zero, but did not know how to take the thermometer temperature down to zero. He/she had never trained the staff on how to calibrate a thermometer. She reviews the log books regularly and she noticed the high water temperatures but thought the employee taking the temperatures, was doing them wrong, so she told the night shift staff to not let that employee take temperatures any more. The director did not retest the water when it was noticed that hot water was documented. During an interview on 3/27/18 at 11:54 A.M., Maintenance Worker D said there are three new water heaters that were installed (MONTH) (YEAR). All three water heaters are set at 150 degrees F. The hot water travels from the tanks to the mixing valves. The hot water temperatures are taken nightly in the spa rooms at random times. It could be 2:00 A.M. or at midnight. They test the hot water after letting it run for five minutes first. The staff use a digital thermometer. The water tanks have been worked on a few times. The water softener was worked on, but the water temperature was not an issue in the past. The environmental services director was not aware that the hot water temperature was too high or hot and was never told by anyone in the facility. If notified, he/she would check to see if there was a problem. The facility lost hot water twice in (MONTH) (YEAR) and once in January. They put in a water softener, but the mixing valve had not been checked. There was an employee that took the hot water temperatures, but he/she may not have been doing it right. The night shift takes temperatures. There is maintenance staff here, on-site, 24 hours a day, seven days a week. One water heater fed the kitchen and laundry area and the other two fed water to resident use areas. The water heaters have been worked on several times. The last time was about two months ago because the water was too cold, due to hard water. A water softener had to be added. The area directly above the boiler room, was the short resident hall, closest to the boiler room. The water temperatures would be higher on that hallway versus the hallway furthest from the boiler room. The mixing valve does not have a read out on it. You cannot tell what the water temperature is for the water going out the pipe through the mixing valve, to the resident use areas. You can only turn the knob up or down to regulate the mixing valve. 8. Review of the facility's temperature log, showed: -Month of February, (YEAR): -No temperatures obtained in resident rooms; -Fahrenheit vs Celsius not specified; -No documentation if the temperatures were obtained at the sink or shower; -First hot water temperatures documented on 2/5/18; -Environmental Specialist E documented water temperatures on 2/1, 2/5, 2/6, 2/7, 2/8, 2/20, 2/21 and 2/22/18 only; -Environmental Specialist E documented the following water temperatures above 120 degrees F: -Fontbonne tub room (room [ROOM NUMBER]): On 2/5/18 - 130 degrees, on 2/6/18 - 128 degrees, on 2/7/18 - 122 degrees, on 2/8/18 - 120 degrees, on 2/20/18 - 122 degrees and on 2/21/18 - 128 degrees; -Carondelet tub room (room [ROOM NUMBER]): On 2/5/18 - 130 degrees, on 2/6/18 - 128 degrees, on 2/7/18 - 120 degrees, on 2/8/18 - 120 degrees, on 2/20/18 - 128 degrees and on 2/21/18 - 128 degrees; -All water temperatures obtained by all other environmental specialists, measured below 120 degrees F; -Month of March, (YEAR): -No temperatures obtained in resident rooms; -Fahrenheit vs Celsius not specified; -No documentation if the temperatures were obtained at the sink or shower; -Environmental Specialist E documented water temperatures on 3/1, 3/5, 3/20 and 3/21/18 only; -Environmental Specialist E documented the following water temperatures at or above 120 degrees F: -Rosati tub room (room [ROOM NUMBER]): On 3/1/18 - 120 degrees, on 3/5/18 - 120 degrees, on 3/20/18 - 128 degrees and on 3/21/18 - 122 degrees; -Fontbonne tub room (room [ROOM NUMBER]): On 3/1/18 - 128 degrees, on 3/5/18 - 132 degrees and on 3/20/18 - 132 degrees; -Carondelet tub room (room [ROOM NUMBER]): On 3/1/18 - 130 degrees, on 3/5/18 - 132 degrees and on 3/20/18 - 132 degrees; -All water temperatures obtained by all other environmental specialists, measured below 120 degrees F. During an interview on 3/27/18 at approximately 11:50 A.M., the environmental director said there was an issue with Environmental Specialist E taking water temperatures wrong, so he/she was told not to take water temperatures anymore. During an interview on 3/27/18 at 3:31 P.M., Environmental Specialist E said he/she works the night shift, takes water temperatures and documents them in the facility log book. Sometimes the hot water temperatures are too high and he/she reports those temperatures to Environmental Specialist F. He/she is not sure what the boss does after that. The Carondelet and Fontbonne halls are always the warmest. Sometimes, Environmental Specialist F does not want him/her to write the temperatures down when they are too high. When he/she takes water temperatures, he/she writes down the actual temperatures and they are always higher then what other staff document. He/she has never seen steam come from the water, but it is very hot. The last time he/she took temperatures, the temperatures were 128 degrees F or 130 degrees F and Environmental Specialist F told him/her that he/she would test the water him/herself. Environmental Specialist F told him/her to stop taking temperatures. During an interview on 3/27/18 at 3:39 P.M., Environmental Specialist F said he/she works the night shift and takes and logs water temperatures. The water temperatures are supposed to be between 108 degrees F and 110 degrees F, if the temperatures are higher than that, he/she reports it immediately to the environmental director. The environmental director tells him/her to keep an eye on the temperatures and the boilers. There was nothing he/she could do to the boilers. The director could call a company to go to the facility to look at the boilers. He/she has never told Environmental Specialist E to not take temperatures, but he/she thinks Environmental Specialist E takes too long to take temperatures and that causes his/her temperatures to be higher than everyone else's. Environmental Specialist F calibrates the thermometer before he/she takes water temperatures and said he/she was formally trained and had to sign that he/she had been trained on how to do this. Environmental Specialist F then said he/she did not actually know how to calibrate the thermometer, but thought he/she would take the temperature down to zero on the thermometer and that would calibrate it. 9. Review of Resident #8's quarterly MDS, dated [DATE], showed a BIMS score of 15 out of 15 and showed the resident cognitively intact. Review of Resident #36's quarterly MDS, dated [DATE], showed a BIMS of 12 out of 15 and showed the resident cognitively intact. During an interview on 3/27/18 at 11:12 A.M., Residents #8 and #36 said they both have burned their hands under the hot water, in the bathroom sink. They had to turn the cold water on, to cool the water. This happened about a month ago and they did not report it to staff. 10. During an interview on 3/27/18 at 1:02 P.M., Certified Nurse Assistant (CNA) B said when he/she turns on the water at the sink, it is hot, then cold and it jumps around. It will get real hot. 11. During an interview on 3/27/18 at 1:04 P.M., CNA C said the water in the shower rooms can get hot. Residents complain that it gets too hot. 12. During an interview on 3/27/18 at 3:30 P.M., CNA L said there was one resident that complained about the water being too hot. When he/she turned the handle to release the hot water, he/she has to really angle it so it can get warm otherwise it gets too hot. 13. During an interview on 3/27/18 at 3:40 P.M., Resident #7 said he/she does not require assistance from staff with turning on the water. He/she knows how to adjust the water his/herself. The water is hot and it could hurt if you are not careful or if a resident does not know what they are doing. The aides are very careful when they are turning on the water. 14. During an interview on 3/27/18 at 3:55 P.M., with the administrator and maintenance worker with the plumbing company contracted by the facility to work on the water heater, the maintenance worker said about four months ago the facility had three new boilers installed. Two service resident halls. In (MONTH) or (MONTH) there were malfunctions related to hard water. The hard water caused the temperatures in the water tank to be low. The water sensors were replaced three weeks ago. There have been no issues since. The temperatures at the boiler have been good. They are set at 150 degrees F. After leaving the boiler, the water goes through a mixing valve to mix cold water in with the hot. A water softener was added and three weeks ago the first full cycle of the softener had gone through. There is not a temperature gauge after the mixing valve to test the temperature of the water as it heads out to the floor. The administrator said the standard for water temperatures is for it to be between 110 degrees F and 115 degrees F. 15. During an interview on 3/27/18 at 5:25 P.M., the plumber with the company contracted to work on the water heater for the facility, said there is currently no way to know the water temperature after it passes the mixing valve. Water temperatures at 138 degrees F are way in the scalding category. There are no thermostats to regulate the temperature of the water at the sinks, only in the showers. 16. During an interview on 3/28/18 at 2:30 P.M., the Medical Director said if a resident has dementia, they are like babies and do not understand what is going on. They could easily burn themselves. Residents that have diabetes or [MEDICAL CONDITION] may not be able to feel the true sense of a hot water temperature. That could lead to burning. 17. During a group interview on 3/28/18 at 3:15 P.M., five out of five residents agreed that staff have a hard time adjusting the water. It is either too hot or too cold. 18. Review of the facility's undated hot water temperature policy, showed: -It is the policy of the environmental services department to take temperature checks of the hot water; -Procedure: -Pick up the clipboard and temperature probe report; -On the documentation sheet in the proper box, place the date and initials of the person obtaining the temperatures; -Water temperatures are to be taken in the bathing rooms on the night shift; -If the water temperatures are over 120 degrees or under 105 degrees, please document and notify the director or housekeeping supervisor; -The director or housekeeping supervisor will notify the building engineer to check this and get the problem corrected; -No direction for staff to calibrate their thermometer, how to calibrate the thermometer, or the proper technique on taking water temperatures. During an interview on 3/27/18 at 3:01 P.M., the environmental director said the policy talks about a building engineer, but this position no longer exists. The person left and the facility will not replace the position. The facility needed to update its policy. *The higher classification is merited due to the affect or potential effect on the residents. NOTE: At the time of the survey, the violation was determined to be at an immediate jeopardy J level. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility adjusted the mixing valves, monitored water temperatures, educated maintenance staff on proper method of calibrating the thermometer and taking water temperatures. All environmental staff were trained on this method prior to coming on duty. Temperatures that were taken were logged. The plumber was notified and came out to evaluate the further adjustment of the mixing valve to regulate temperatures. The bathing areas were closed for use during times when the water temperature was above 120 degrees Fahrenheit. Skin assessments were conducted on all residents to ensure no injuries had occurred. The facility still needed to determine how they will implement their plan of correction on a long-term basis and keep their systems in place. 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 theE 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).