Every finding on record at New Madrid Living Center

Based on interview and record review, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer, and of the bed hold policy, including the bed hold rate at the time of the transfer, for four residents (Residents #2, #6, #10, and #21) out of five sampled residents. The facility's census was 54. Review of the facility's policy titled, Discharge/Transfer of Resident, dated March 2015, showed: - Explain transfer and reason to the resident and/or representative and give copy of signed transfer or discharge notice to the resident and/or representative or person responsible for care. If emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible. - Explain and give a copy of the bed hold form to the resident and/or representative. Review of the facility's policy titled, Bed Hold Guidelines, not dated, showed: - This facility will notify all resident and/or their representative of the bed hold guidelines; - This notice shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave; - If the resident or resident representative want to hold the bed, a signed authorization must be obtained with each discharge; - Bed holds are strictly voluntary. 1. Review of Resident #2's medical record showed: - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident's representative was informed in writing of the transfer/discharge to the hospital at the time of the transfer on 03/13/25; - No documentation the bed hold rate was provided to the resident and the resident representative for the transfer on 03/13/25; - No documentation of the reason for the transfer was provided to the resident and the resident representative for the transfer on 03/13/25. 2. Review of Resident #6's medical record showed: - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident's representative was informed in writing of the transfer/discharge to the hospital at the time of the transfer on 04/10/25; - No documentation the bed hold rate was provided to the resident and the resident representative for the transfer on 04/10/25; - No documentation of the reason for the transfer was provided to the resident and the resident representative for the transfer on 04/10/25. 3. Review of Resident #10's medical record showed: - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident's representative was informed in writing of the transfer/discharge to the hospital at the time of the transfer on 01/24/25 and 07/24/25; - No documentation the bed hold rate was provided to the resident and the resident representative for the transfer on 01/24/25 and 07/24/25; - No documentation of the reason for the transfer was provided to the resident and the resident representative for the transfer on 01/24/25 and 07/24/25. 4. Review of Resident #21's medical record showed: - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident's representative was informed in writing of the transfer/discharge to the hospital at the time of the transfer on 06/08/25; - No documentation the bed hold rate was provided to the resident and the resident representative for the transfer on 06/08/25; - No documentation of the reason for the transfer was provided to the resident and the resident representative for the transfer on 06/08/25. During an interview on 09/17/25 at 2:25 P.M., Licensed Practical Nurse (LPN) A said he/she copied the transfer and bed hold forms from the resident's admission packet and gave to the resident before each transfer. He/She did not do the bed hold rate or send to the resident representative unless the resident's family asked for it. During an interview on 09/17/25 at 2:30 P.M., the Social Services Designee (SSD) said the bed hold rate was not filled out on the Bed Hold form given to the resident at the time of the transfer, but a notice was sent by mail if the bed hold rate changed. During an interview on 09/18/25 at 9:31 A.M., the Assistant Director of Nursing (ADON) said the nurses printed the Bed Hold policy and had the resident sign it. It was then given to the SSD to review the next day. During an interview on 09/18/25 at 11:55 A.M., the Administrator said he thinks the resident's responsible party was notified verbally of the reason for the resident's transfer to the hospital and he expected that to be documented in the chart. He would expect the resident and/or their responsible party to be notified in writing of the bed hold policy at the time of the transfer, but that they had never included the bed hold rate on the form.

Based on interview and record review, the facility failed to develop and implement a baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for one resident (Resident #44) out of three sampled residents. The facility census was 54.Review of facility's policy titled, Care Plan, Temporary, dated March 2015, showed:- A temporary care plan will be implemented for the resident within 24 hours of admission to assure that the resident's immediate care needs are met and maintained;- The interdisciplinary care plan team and/or admitting nurse will review the physician orders and implement a nursing care plan to meet the immediate care needs of the resident. Review of Resident #44's medical record showed:- An admission date of 06/11/25;- Diagnoses of dementia (a group of conditions that cause a decline in cognitive functions, such as memory, thinking, problem-solving, and language), presence of cardiac pacemaker (a small implantable device that helps regulate the heart's rhythm by sending electrical impulses), atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart beat irregularly and rapidly), hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), interstitial pulmonary disease (a group of disorders that cause progressive scarring of lung tissue), type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), major depressive disorder (a common and debilitating mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), congestive heart failure (CHF - a chronic condition where the heart cannot pump blood efficiently enough to meet the body's needs), and pain.- No baseline care plan with specific interventions. Review of resident's Physician's Order Report, dated 06/01/25 through 09/17/25, showed:- An order for physical therapy and occupational therapy to evaluate and treat, dated 06/11/25;- An order for oxygen two liters per minute continuous, dated 06/11/25;- An order for the head of the bed elevated while lying flat, dated 06/11/25;- An order for a regular diet, dated 06/11/25. During an interview on 09/18/25 at 11:16 A.M., Registered Nurse (RN) B said the admitting nurse was responsible for implementing a care plan within 48 hours of admission. During an interview on 09/18/25 at 11:55 A.M., the Administrator and the Director of Nursing (DON) said they would expect a resident's baseline care plan to be completed within 48 hours of admission.

Based on interview and record review, the facility failed to ensure a code status was accurately and consistently documented throughout the medical record for two residents (Residents #6 and #17) out of 14 sampled residents. The facility census was 54.Review of the facility policy titled, Advanced Directive, revised [DATE], showed: - Upon admission of a resident to the facility, the social services designee (SSD) will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advanced directive; - Upon admission of a resident, the SSD will inquire of the resident, and his/her family members, about the existence of any written advance directives; - Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advanced directive tab; - Do Not Resuscitate (DNR)- Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR – an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) or other life-saving methods are to be used. 1. Review of Resident #6's Physician Order Sheet (POS), dated [DATE], showed: - An admission date of [DATE]; - An order for a full code status, dated [DATE]. Review of the resident's Outside the Hospital Do Not Resuscitate (OHDNR) form, dated [DATE], showed: - DNR status; - Signed by the resident and the physician on [DATE]. Review of the resident's Care Plan, dated [DATE], showed: - DNR code status. During an interview with the resident on [DATE] at 1:45 P.M., he/she wanted to be a full code. 2. Review of Resident #17's POS, dated [DATE], showed: - admitted on [DATE]; - An order for a full code, dated [DATE]. Review of the resident's OHDNR form, dated [DATE], showed: - DNR status; - Signed by the resident on [DATE], and the physician on [DATE]. Review of the resident's DNR form, dated [DATE], showed: - DNR status; - Reviewed and verified by the SSD. Review of the resident's Care Plan, dated [DATE], showed: - DNR code status. During an interview on [DATE] at 9:30 A.M., Licensed Practical Nurse (LPN) A said he/she looked at the main screen in the resident's electronic medical record (EMR) on the top left where it showed the code status. The facility also had a paper folder file system where a green folder was for full code and a red folder was for DNR. He/She did not know how often the code status as addressed, but the full code status for Resident #17 was most likely the standard admission order since everyone was a full code until asked about the code status which should be done on admission. During an interview on [DATE] at 11:20 A.M., LPN C said he/she would look in the resident's chart/face sheet for the code status. The code status should also be checked on the physician's order sheet for verification. He/She would expect a resident's code status to be documented accurately and consistently throughout the resident's medical record. During an interview on [DATE] at 11:25 AM., LPN A said he/she would expect the code status to be documented accurately and consistently throughout the resident's medical record. During an interview on [DATE] at 11:30 A.M., Certified Nursing Assistant (CNA) D said he/she would look at the nurses' station for a resident's code status. During an interview on [DATE] at 10:50 A.M., the SSD said the resident's code status was reviewed at the first of each month and with quarterly assessments. Residents were asked which code status they wanted to be on admission. Resident #6 must have signed in the wrong spot when signing his/her code status form upon admission. During an interview on [DATE] at 11:40 A.M., Registered Nurse (RN) B said a resident's code status was reviewed quarterly with the care plan meetings and/or with any change in conditions of the resident. During an interview on [DATE] at 11:55 A.M., the Administrator and the Assistant Director of Nursing (ADON) said they would expect the code status to be documented consistently and accurately throughout the resident's medical record.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) for two residents (Residents #10 and #28) out of 15 sampled residents. The facility census was 59. The facility did not provide a policy. 1. Review of Resident #10's medical record showed: - An admitted [DATE]; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), traumatic subdural hemorrhage (brain bleed affecting the body and how it works), seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness), aphasia (loss of ability to understand or express speech caused by brain damage), gastroesophageal reflux disease (GERD - stomach acid being forced back into the throat region), anxiety (persistent worry and fear about everyday situations), major depressive disorder (MDD - long-term loss of pleasure or interest in life), and osteoporosis (a condition causing loss of bone mass, predisposing a person to fractures); - An order for famotidine (used to treat acid reflux) 40 milligrams (mg) twice a day by mouth for GERD, dated 09/23/24; - An order for raloxifene (used to treat osteoporosis) 60 mg once a day by mouth for osteoporosis, dated 09/23/24; - No order for hypoglycemic (medications used to lower blood sugar) and antipsychotic (psychiatric medication used to treat psychosis) medications. - A care plan, dated 10/02/24, addressed dementia; Review of the resident's admission MDS, dated [DATE], showed: - Diagnoses of GERD, osteoporosis, and dementia not documented; - Received hypoglycemic and antipsychotic medications on a routine basis. 2. Review of Resident #28's medical record showed: - An admitted [DATE]; - Diagnoses of dementia, bradycardia (slow heart rate), depression, hemiplegia (paralysis of one side of the body) and hemiparesis (lack of sensation of one side of body) following a stroke affecting the right side, anxiety, type 2 diabetes mellitus (abnormal blood sugar), MDD, and GERD; - An order for pantoprazole (used to treat acid reflux) 20 mg once a day for GERD, dated 01/21/22; - No order for an antipsychotic medication; - A care plan, dated 08/01/24, addressed dementia; Review of the resident's quarterly MDS, dated [DATE], showed: - Diagnoses of bradycardia, GERD, dementia, anxiety, and stroke not documented; - Received antipsychotic medication on a routine basis. During an interview on 10/10/24 at 9:25 A.M., the MDS Coordinator said he/she completed the MDS assessments. The residents' information was gathered from the charts, electronic records, and staff. During an interview on 10/10/24 at 10:21 A.M., the Director of Nursing (DON) said the MDS Coordinator used the Resident Assessment Instrument (RAI) manual to complete the MDS assessments. During an interview on 10/10/24 at 11:00 A.M., the DON and Administrator said they would expect the MDS to accurately reflect the resident's current condition.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices for two residents (Residents #10 and #30) out of two sampled residents. This deficient practice had the potential to affect all residents in the facility. The facility's census was 59. Review of facility policy titled, Enhanced Barrier Precautions (EBP) to Infection Control Guidance, dated March 2024, showed: - Use of gloves and gown are required when conducting high-contact care activities to residents with indwelling medical devices. Review of the facility's policy titled, SARS-CoV-2 (Covid-19) For Long Term Care Facilities, dated 05/15/23, showed: - The strategies the Centers for Disease Control (CDC) recommends to prevent the spread of SARS-CoV-2 in long term care communities are the same strategies used every day to detect and prevent the spread of other respiratory viruses; - Keep residents and employees informed by describing what actions the facility takes to protect them; - Ensure facility employees are educated, trained, and have practiced the appropriate use of personal protective equipment (PPE) prior to caring for a resident; - Post signage regarding donning (putting on) and doffing (taking off) of PPE; - Healthcare personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a N95 particulate respirator, gown, gloves, and eye protection; -While not recommended, residents who are on transmission based precautions (TBP) or quarantine can still receive visitors. In these cases, visits should occur in the resident's room and the resident should wear a well-fitting facemask (if tolerated). Before visiting residents, who are on TBP or quarantine, visitors should be made aware of the potential risk of visiting and precautions necessary in order to visit the resident. Visitors should adhere to the core principles of infection prevention and wear appropriate PPE. 1. Review of Resident #10's medical record showed: - admitted [DATE]; - Diagnoses of traumatic subdural hemorrhage (a type of bleeding near the brain that can happen after a head injury), dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), malnutrition (a lack of sufficient nutrients in the body), and dysphagia (difficulty swallowing foods or liquids); - Physician Order Sheet (POS), dated 09/10/24-10/10/24, showed an order for Jevity 1.5 Cal (a type of tube feeding formula) bolus feeding of 10 ounces every four hours, dated 10/02/24; - Care Plan, last revised 10/02/24, showed EBP for the resident related to a gastrostomy tube (a tube inserted through the abdomen that brings nutrition, medications, and fluid directly to the stomach). Observation on 10/09/24 at 11:35 A.M., showed Licensed Practical Nurse (LPN) C failed to put on a gown prior to entering Resident #10's room to administer medication and feeding through the resident's gastrostomy tube. During an interview on 10/09/24 at 1:32 P.M., LPN C said EPBs were required for residents with gastrostomy tubes. Gloves and gowns were to be worn. During an interview on 10/10/24 at 11:00 A.M., the Director of Nursing (DON) said she would expect staff to use EBP per CDC guidelines when performing care on residents with an indwelling device, wound, or a transmissible organism. 2. Review of Resident #30's medical record showed the resident tested positive for Covid-19 on 09/30/24, and placed on Covid-19 isolation precautions in a private room. Observations on 10/08/24 at 10:45 A.M., and 11:12 A.M., showed the resident's door was open and the resident sat unmasked in a wheelchair inside the room. Observations on 10/08/24 at 11:25 A.M., and 11:27 A.M., showed Certified Nurse Assistant (CNA) A wore a N95 mask, entered through the resident's opened door without putting on a gown or gloves, failed to close the door, and failed to change the N95 mask and to close the resident's door when he/she exited the room. Observation on 10/09/24 on 12:01 P.M., showed the resident's s room door was opened. The resident sat up in bed unmasked and eating. Observation on 10/09/24 at 12:11 P.M., showed CNA B entered the resident's room with an isolation gown and N95 mask on but failed to put on gloves. CNA B exited the resident's room with the meal tray and left the door open. CNA B failed to change N95 masks and to close the resident's door upon exiting the resident's room. Observation on 10/09/24 at 1:20 P.M., showed the resident's door was open with one staff in the room wearing appropriate PPE. The unmasked resident visited with two visitors with N95 masks on in the room but without gowns and gloves and the door open. During an interview on 10/08/24 at 1:40 P.M., CNA A said he/she did not know the resident was on Covid-19 precautions since the door was open. If the door was closed, then he/she would have looked at the door or the name tag beside the door to see if the resident was on precautions. During an interview on 10/10/24 at 11:00 A.M., the DON and Administrator said they expected staff to follow the CDC guidelines for isolation precautions. 49999

Based on observation, interview, and record review, the facility failed to ensure the safety of one resident (Resident #1) when staff failed to follow the care plan and use proper technique during a transfer resulting in the resident entangling his/her legs together and sustaining a fractured right tibia/fibula ((tib/fib) the long bones in the lower leg). The facility census was 59. The facility did not provide a policy regarding proper transfers. 1. Record review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 01/01/2024 showed: - Diagnoses of Alzheimer (a disease of the brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), seizure disorder; - Cognition impaired; - No behavioral symptoms; - Dependent on staff with transfers, bed mobility, dressing, toileting, and bathing; - Non ambulatory; - Incontinent of bowel and bladder; - No rejection of care. Review of Resident #1's Care Plan, dated 04/02/2024, showed: - Assistance needed for activities of daily living (ADL's) including bathing, toileting, bed mobility, transfers and meals; - Use of wheelchair for locomotion, unable to ambulate (walk), requires assist of a mechanical lift to transfer. Review of the Nursing Assistant Assignment sheets located at the nurses station showed: - Resident #1 uses a wheelchair for mobility, propelled by self; - Mechanical lift for all transfers. Review of Resident #1's Resident Progress Notes, showed: - On 04/02/2024 Licensed Practical Nurse (LPN) was called to resident's room due to resident complaints of pain to lower left extremity; - Noted large bruise and swelling to area of left lower extremity just below the knee/shin area; - Painful upon movement or touch; - Resident unaware of how or when injury occurred; - Ice pack applied to area, removed after 20 minutes then re-applied; - Primary care physician notified. Received new orders for X-ray due to swelling. - Responsible party notified. Received X-ray results with fracture if tib/fib. Orders to elevate and position for minimal movement until the resident sees the Orthopedic physician. - On 04/03/2024 family requested to have resident transferred to hospital; - On 04/04/2024 the resident admitted to the hospital for tachycardia (increased heart rate) due to administration of morphine (medication used for pain) while at the hospital. Record review of the X-ray report, dated 04/02/2024, showed an acute non-significant displaced (broken bone which are spread apart) proximal (end of bone closer to the trunk of the body) tibia and fibular fractures and diffuse soft tissue swelling (swelling around the fractured area). During an interview on 04/08/2024 at 9:00 A.M., the Administrator said she was aware of an incident involving a resident transfer that resulted in a fracture. She began an investigation immediately on 04/02/2024 after finding out about the injury. She started the investigation at the time of discovery, and went backwards interviewing staff who had worked with the resident until she got to Certified Nurse Aide (CNA) B. CNA B informed her that on the early morning hours of 04/02/2024, he/she transferred Resident #1 without the use of a mechanical lift. The resident and the employee's legs got tangled up during the transfer. CNA B reported the resident only said ouch but did not complain of pain. The CNA did not report the incident to anyone due to not suspecting any injury. The Administrator said the resident was unable to say what happened or when due to cognitive issues. The Administrator said she would expect staff to follow the resident plan of care. During an interview on 04/08/2024 at 9:45 A.M., CNA C said on 04/02/2024 he/she and CNA D went to get Resident #1 up for the lunch meal and noticed the resident's left leg and knee area was swollen, purple and red in color. CNA C said he/she immediately reported to the charge nurse for assessment. The resident can't get up or down by himself/herself, but is able to propel him/herself in the wheelchair using his/her arms only. Resident #1 frequently wonders the facility in his/her wheelchair daily. The resident is able propel self in the wheelchair using his/her arms only, he/she never uses lower extremities to move around. During an interview on 04/08/2024 at 9:50 A.M., CNA D stated the resident is mobile using his/her arms only in the wheelchair, frequently wonders around the facility. The resident is unable to answer questions appropriately. On the morning of 04/02/2024, the resident was up in the dinning room upon arrival to work. He/she only noticed the bruising and swelling after he/she and CNA C was getting the resident up for lunch. The resident did not act out like in pain. They immediately informed the charge nurse who came down and assessed the injury. During an interview on 04/08/2024 at 11:50 A.M., Licensed Practical Nurse (LPN) A said he/she was working as charge nurse on the day of 04/02/2024 when CNA's C and D reported bruising to Resident #1's left lower leg area. LPN A said the resident's leg was notably swollen near the knee area with blue color bruising. The resident complained of pain in the bruised area when moving or changing positions. LPN A notified the physician of the injury and followed physician orders as received. LPN A said CNA's are expected to look at the assignment sheets kept at the nurse's station for the level and type of assistance each resident has been assessed for. During an interview on 04/08/2024 at 2:50 P.M., CNA B said he/she transferred Resident #1 on the morning of 04/02/2024, with no assistance from other staff. He/She did not use a gait belt or mechanical lift. He/She said, during the transfer on 04/02/2024, his/her and the resident's legs got tangled when he/she moved the resident from the bed to the wheelchair. CNA B stated he/she was unable to describe how their legs got tangled. The resident said ouch but then did not complain of anything after that. CNA B denied the resident falling or having any other concerns. CNA B said he/she knew some staff used the mechanical lift and some did not, so he/she chose not to use the lift. CNA B said he/she can find the information for the level of assistance each resident needs at the nurse's station. CNA B did not remember what level of assistance Resident #1 required and would have to look before answering MO234196

Based on interview and record review, the facility failed to ensure staff provided the necessary care and services in accordance with professional standards of practice for one resident (Resident #1) out of three sampled residents. Staff failed to notify the physician of the resident's critical lab values in a timely manner which resulted in the resident being admitted to the hospital from 08/27/23 through 09/01/23. The facility census was 60. Review of the facility's policy titled, Lab Reporting Guidelines, dated March 2015, showed: - Once lab results are returned to the facility, the nurse will notify the physician via fax and follow-up call within 12 hours for routine labs or within one hour for stat labs; - The nurse will document on the lab report that the physician has been notified and to include how they are notified, when (time and date) and the nurse's signature. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated, 08/21/23, showed: - Admission to the facility on [DATE]; - Diagnoses of hypertension (high blood pressure) and malnutrition (lack of proper nutrition); - Cognition moderately impaired; - The resident with a legal guardian. Review of the resident's progress notes showed: - On 08/25/23 at 2:42 A.M., a chemistry panel (lab) obtained, which included the sodium lab; - On 08/25/23 at 11:12 P.M., (Friday night) the sodium critical lab value of 165 (normal lab sodium values 136-145) faxed to the physician's office; - On 08/27/23 at 12:47 P.M., the nurse notified the nurse practitioner notified by phone of the sodium critical lab value of 165 and received a new order to send the resident by ambulance to the emergency room for evaluation and treatment; - admitted to the hospital for hypernatremia (a high concentration of sodium in the blood); - The hospital re-checked the sodium lab and received a value of 166 on 08/27/23. The resident's hospital history and physical, dated 08/27/23, showed: - The resident admitted with severe hypernatremia; - admitted to the intensive care unit; - Required cardiac (heart) monitoring. During an interview on 09/05/23 at 9:50 A.M., Licensed Practical Nurse (LPN) A said labs were usually drawn early in the morning. He/she said lab reports were usually back the same day, unless it was a send out lab. The resident's lab was not a send out. When there was a critical lab value, the lab would call the facility and speak with a nurse. The nurse should then notify the physician on call and the responsible party as well. During an interview on 09/05/23 at 10:00 A.M., the Administrator said she knew the nurse practitioner was notified and the resident had been sent out on 08/27/23. There was a nurse on-call for the evening and night shift. The LPN could have reached out to the on-call nurse or called the Administrator. During an interview on 09/05/23 at 11:07 A.M., the Nurse Practitioner (NP) said if a facility faxed labs to his/her office during the hours of operation, the staff would call him/her with the lab values. However, after hours in this situation, the labs would not be reviewed until Monday morning on 08/28/23. When the lab calls the facilities with critical lab values, then the nurse should call the on-call physician. There was a 24 hour, seven day a week on-call service. He/She was actually on call that particular weekend and was not contacted by facility until 08/27/23, when the nurse notified him/her of the resident's critical lab value and the order was given to send the resident to the emergency room for evaluation and treatment. During a telephone interview on 09/05/23 at 11:12 A.M., LPN B said he/she was notified between 8:00 P.M. - 9:00 P.M., on 08/25/23 of the critical lab value. He/She notified the nurse practitioner's office by faxing the lab report. He/She did not know what to do in that situation. Complaint #MO223597

Based on interview and record review, the facility failed to notify a resident's guardian after a change in the resident's condition with a critical lab value for one Resident (Resident #1) of three sampled residents. The facility census was 60. Review of the facility's policy titled, Charting and Documentation, not dated, showed the purpose of these guidelines is to provide: a completed account of the resident's care, treatment, response to the care, signs, symptoms, as well as the resident's progress; guidance to the physician in prescribing appropriate medications and treatments; the elements of quality medial nursing care; and documentation should also include any time the physician or family is called about the resident as well as their response. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 08/21/23, showed: - Admission to the facility on [DATE]; - Diagnoses of hypertension (high blood pressure) and malnutrition (lack of proper nutrition); - Cognition moderately impaired; - The resident with a legal guardian. Review of the resident's progress notes showed: - On 08/25/23 at 2:42 A.M., a chemistry panel (lab) obtained; - On 08/25/23 at 11:12 P.M., the sodium critical lab value of 165 (normal lab sodium values 136-145) faxed to the physician's office; - On 08/27/23 at 12:47 P.M., the nurse notified the nurse practitioner by phone of the sodium critical lab value of 165 and received a new order to send the resident by ambulance to the emergency room for evaluation and treatment; - No documentation of the guardian notified of the change in condition. During an interview on 09/05/23 at 9:50 A.M., Licensed Practical Nurse (LPN) A said labs were usually drawn early in the morning. He/she said lab reports were usually back the same day, unless it was a send out lab. The resident's lab was not a send out. When there was a critical lab value, the lab would call the facility and speak with a nurse. The nurse should then notify the physician on call and the responsible party as well. During an interview on 09/05/23 at 10:00 A.M., the Administrator said she knew the nurse practitioner was notified and the resident had been sent out on 08/27/23. She said the resident's representative should have been notified. During a telephone interview on 09/05/23 at 11:12 A.M., LPN B said he/she was notified between 8:00 P.M. - 9:00 P.M., on 08/25/23 of the critical lab value. He/She notified the nurse practitioner's office by faxing the lab report. He/She did not know what to do in that situation. During a telephone interview on 09/05/23 at 2:55 P.M., the guardian said he/she was not notified by the facility of the resident's critical lab results. Complaint #MO223597

Based on observation, interview and record review, the facility failed to assess for the risk of entrapment and review the possible risks and benefits of the side rails prior to installation or use and the facility failed to obtain informed consent of the side rails prior to use for one resident (Resident #1) out of four sampled residents. The facility census was 60. Review of the facility's policy titled, Bed Rails, not dated, showed: - Once the Bed Rail Observation is completed, the facility will print the observation and review the associated risks and benefits with the resident and/or resident representative. After the review is complete, the resident and/or resident representative will sign the consent line and the nurse will sign as well; - Educate the resident/legal representative on the benefits and risks of bed rail use. 1. Review of Resident #1's medical record showed: - admitted to the facility on [DATE]; - Diagnoses of hypertension (high blood pressure) and malnutrition (lack of proper nutrition); - Cognition moderately impaired; - The resident with a legal guardian; - No documentation of a Side Rail Assessment or informed consent for the use of the two quarter rails dated prior to the initiation of the side rails on 08/11/23; - Progress note, dated 08/11/23, side rails to the resident's bed; Review of the resident's Bed Rail Assessment, dated 08/14/23, showed: - No documentation of risks and benefits discussed with the resident's guardian; - No documentation of the signature or date of the guardian; - No documentation of consent given by the guardian. Observations on 09/06/23 at 9:05 A.M., 10:10 A.M., and 11:55 A.M., showed Resident #1 lay in bed with quarter side rails up on both sides of the bed. During an interview on 09/06/23 at 10:45 A.M., Licensed Practical Nurse (LPN) A said the concave (a deluxe grade mattress that features concave sides, so the patient is encouraged to lie in the middle of the bed) mattress and side rails were added to the resident's bed on 08/11/23, after the resident had rolled out of the bed. During an interview on 09/06/23 at 10:50 A.M., Registered Nurse (RN) G said he/she had not discussed the risks and benefits with or obtained consent from the guardian. During an interview on 09/06/23 at 11:45 A.M., the Administrator said RN G would complete a new bed rail assessment and consent form today. The facility would monitor the the resident and the resident's bed rail use closely. Complaint #223597

Based on observation, interview, and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS, a federally mandated assessment to be completed by the facility) for one resident (Resident #53) out of 14 sampled residents. The facility's census was 55. The facility failed to provide a policy for MDS assessment. 1. Record review of Resident #53's medical record showed: - An admitted [DATE]; - Diagnoses of psychosis (mental disorder characterized by a disconnection from reality), gastroesophageal reflux disease (acid reflux), hyperlipidemia (high blood level of cholesterol), depression (persistent feeling of sadness and loss of interest), hypertension (HTN, high blood pressure), hallucinations (seeing, hearing, or smelling things that seem real but are not), difficulty in walking, type 2 diabetes mellitus (elevated blood sugar in the blood stream), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities); - An order for Furosemide (also known as Lasix, a diuretic medication) 20 milligram (mg) by mouth every other day, dated 12/17/22; - An order for Novolog Insulin (medication to regulate blood sugar) via insulin pump, three times a day, dated 4/10/23. Record review of the resident's quarterly MDS, dated [DATE], showed: - Diuretic use not marked on Section N; - Insulin use not marked on Section N; - Dementia diagnosis not marked on Section I. During an interview on 6/29/23 at 8:57 A.M., the Director of Nursing, the Administrator, and the MDS Coordinator said they would expect the MDS to accurately reflect the condition of the resident. They would also expect that residents who require a diuretic or insulin be reflected on the MDS. The Administrator said the Resident Assessment Instrument (RAI) manual should be followed in regards to MDS assessments. 47678

Based on observation, interview, and record review, the facility failed to ensure medications in the facility were not expired in one of three medication storage rooms and one of three medication carts reviewed. This deficient practice affected one resident (Resident #38) outside of the 14 sampled residents and had the potential to affect one resident (Resident #45) outside the sample. Failure to remove expired medications from circulation increased the likelihood of unintended use and side effects, which had the potential to affect all residents. The facility census was 55. Record review of professional reference from the United States Food and Drug Administration (FDA), Expiration Dates - Questions and Answers last updated 10/24/22, retrieved from https://www.fda.gov/drugs/pharmaceutical-quality-resources/expiration-dates-questions-and-answers, revealed in pertinent part: - 1. Why are expiration dates important for consumers to pay attention to? Drug expiration dates reflect the time period during which the product is known to remain stable, which means it retains its strength, quality, and purity when it is stored according to its labeled storage conditions.; - 4. What potential risks are associated with expired drug? It's important to be aware that there are several potential harms that may occur from taking an expired medicine or one that may have degraded because it was not stored according to the labeled conditions. If a drug has degraded, it might not provide the patient with the intended benefit because it has a lower strength than intended. In addition, when a drug degrades it may yield toxic compounds that could cause consumers to experience unintended side effects. Patients with serious and life-threatening diseases may be particularly vulnerable to potential risks from drugs that have not been stored properly. The facility failed to provide a policy regarding expired medications. Observation of the 400 hall storage room and medication cart on 06/27/23 at 09:50 A.M. showed: - Resident #38 had a card of ondansetron (medication for nausea and vomiting) 4 milligrams (mg) dispensed from the pharmacy on 9/20/21 and expired 9/18/22 with one tablet remaining in the card; - Resident #45 had a card of meclizine (medication for nausea, vomiting and dizziness) 25 mg dispensed from the pharmacy on 3/16/22 and expired 3/2023 with one tablet remaining in the card; - INZO miconazole (antifungal cream) one opened tube on the medication cart expired 12/2021; -Gerilanta (medication for upset stomach and heartburn) one unopened bottle in the med storage room and expired 4/2023. Record review of Resident #38's Medication Administration Record (MAR), dated 6/29/23, showed: - Ondansetron 4 mg one tablet given on 6/12/23; - Ondansetron 4 mg one tablet given on 6/24/23. During an interview on 6/29/23 at 8:57 A.M., the Administrator said the medication storage rooms and medication carts should be checked at a minimum of once a month and in accordance with the pharmacy for expired medications. The Administrator said he/she would not expect expired medications to be in the medication storage rooms or in the carts. During an interview on 6/29/23 at 9:00 A.M., the Director of Nursing and Assistant Director of Nursing said the medication storage rooms and medication carts should be free from expired medications to avoid the potential for administering them to a resident.

Based on observation and interview the facility failed to provide a safe, clean, and homelike environment. The facility census was 56. The facility did not provide a policy or procedure regarding environmental maintenance. 1. Observations on 6/11/21 at 9:00 A.M. showed: - Room 106 an area 10 inch (in.) by 2 foot (ft.) ceiling tile with a dark brown ring and metal casing with rust above the resident's door; - Room 109 seven linear areas of scrapings to the wall above bed one; - Room 109 an area 3 ft. by 2 ft. scrapings to the wall above bed two; - Room 109 an area 6 in. by 8 in. wall scraped between the sink and restroom near the floor; - Room 110 a 1 inch by 1 ft. scrapings to the wall above bed two; - Room 206 an area 4 in. of sink counter top broken off with sharp edges. During an interview on 6/11/21 at 10:25 A.M. the Administrator said there is a book at the nurses station and anyone can fill out a maintenance concern. The maintenance staff will check the book for concerns. The Administrator said the maintenance staff had been working on the walls, was going to prepare them and paint them all at one time.

Based on interview and record review, the facility failed to electronically transmit an admission Minimum Data Set (MDS; a federally mandated assessment instrument to be completed by facility staff) in a timely manner and in accordance to guidelines for one resident (Resident #107) out of 14 sampled residents. The facility's census was 56. 1. Review of Resident #107's medical record showed: - admitted on [DATE]; - No MDS admission assessment submitted. During an interview on 6/11/21 A.M., the MDS Coordinator said they are new to the position and was not sure what happened to the assessment. The MDS Coordinator said they would look into the submission of the assessment. During an interview on 6/11/21 A.M., the Administrator said they checked into the submission of the admission MDS for the resident, however the previous MDS coordinator did not think it needed to be submitted since it was managed care. The MDS coordinator will get it completed.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff for one resident (Resident #51) out of 14 sampled residents. The facility census was 56. 1. Record review of Resident #51's Quarterly MDS, dated [DATE], showed: - A diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - The N410-E area marked for an anticoagulant (blood thinner, medication that slows down the process of making clots). Record review of the resident's June 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - No order for an anticoagulant. During an interview on 6/10/21 at 2:00 p.m., the Director of Nursing said she thought that aspirin was considered an anticoagulant, but will review any residents taking that medication and correct it on the MDS coding.

Based on interview and record review, the facility failed to electronically transmit annual and quarterly Minimum Data Sets (MDS; a federally mandated assessment instrument to be completed by facility staff) in a timely manner and in accordance to guidelines for five residents (Resident #3, #6, #7, #8, and #9) out of 18 sampled residents. The facility's census was 80. 1. Record review of Resident #3's medical record showed: - An annual assessment reference date of 4/24/19; - Submitted on 6/14/19 (37 days late). 2. Record review of Resident #6's medical record showed: - An annual assessment reference date of 5/1/19; - Submitted on 6/14/19 (30 days late). 3. Record review of Resident #7's medical record showed: - A quarterly assessment reference date of 5/1/19; - Submitted on 6/14/19 (30 days late). 4. Record review of Resident #8's medical record showed: - A quarterly assessment reference date of 5/1/19; - Submitted on 6/14/19 (30 days late). 5. Record review of Resident #9's medical record showed: - A quarterly assessment reference date of 5/1/19; - Submitted on 6/14/19 (30 days late). 6. During an interview on 6/19/19 at 11:23 AM, the Administrator said they've had an issue with MDSs being transmitted timely. They are working on the problem and will get it resolved. 7. Record review of the facility's policy, titled Center for Medicare and Medicaid Services Resident Assessment Instrument Version 3.0 Manual Submission and Correction of the MDS Assessments, dated (MONTH) 2010, showed for all Federal/Omnibus Budget Reconciliation Act and annual assessment updates, the MDS completion date may be no later than 14 days from the Assessment Reference Date.

Based on interview and record review, the facility failed to document preparation and orientation for transfer to the hospital for two residents (Resident #45 and #47) out of 18 sampled residents. The facility's census was 80. 1. Record review of Resident #45's progress notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfer out of the facility. 2. Record review of Resident #47's progress notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfer out of the facility. 3. During an interview on 6/2019 at 11:35 A.M., the Director of Nursing (DON) said she would expect the resident to be oriented and prepared for transfer from the facility and expect it to be documented. The DON said we do it but we probably don't document that we do. Most of the residents are not able to understand but we tell them, we just don't document it very well. 4. The facility did not provide a policy for orientation prior to hospital transfer.

Based on interview and record review, the facility failed to complete a significant change assessment for two residents (Resident #19 and #57) out of 18 sampled residents. The facility's census was 80. 1. Record review of Resident #19's (MONTH) (YEAR) physician's orders [REDACTED]. Record review showed the resident's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 1/16/19, showed section J1400 (a prognosis that may result in a life expectancy of less than six months) marked yes and section O 0100 K (special treatments, procedures, and programs performed in the last 14 days) marked yes for hospice care. Record review of the resident's comprehensive care plan, dated 1/24/19, showed hospice care discontinued without a discontinued date. Record review of the resident's quarterly MDS, dated [DATE], showed J1400 marked yes and section O 0100 K marked yes. Record review of the resident's nurse progress note, dated 3/21/19, showed hospice care discontinued per family request. Record review of the resident's significant change MDS, dated [DATE], showed J1400 marked no and section O 0100 K marked no, seven days late. Record review of the resident's POS, dated 6/18/19, showed order history for hospice services to be discontinued on 3/21/19. The facility failed to complete a significant change MDS assessment within 14 days of the resident's discontinued hospice benefit on 3/21/19. 2. Record review of Resident #57's POS, dated 6/18/19, showed an order dated 9/14/18 to admit to hospice care for [DIAGNOSES REDACTED]. Record review of the resident's significant change MDS, dated [DATE], showed J1400 marked yes, section O 0100 K marked yes, 62 days late. Record review of the resident's comprehensive care plan with a start date of 8/30/18, last updated 5/16/19, showed the resident to have hospice care services. The facility failed to complete a significant change MDS assessment within 14 days of the resident's admission to hospice care services on 9/14/18. 3. During an interview on 6/20/19 at 11:35 A.M., the Administrator said she would expect a significant change MDS to be completed within two weeks of the significant change. 4. Record review of the facility's policy, titled Center for Medicare and Medicaid Services Resident Assessment Instrument Version 3.0 Manual Submission and Correction of the MDS Assessments, dated (MONTH) 2010, showed for all Federal/Omnibus Budget Reconciliation Act, Annual assessment updates, and Significant Change in Status assessments, the MDS completion date may be no later than 14 days from the Assessment Reference Date.

Based on interview and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS; a federally mandated assessment instrument to be completed by the facility) for one resident (Resident #55) out of 18 sampled residents. The facility's census was 80. Record review of Resident #55's medical record showed on 2/25/19 the resident was found in his/her room on the floor with a pillow under his/her head. A small skin tear to his/her left arm was noted and already scabbed over and no longer bleeding. Record review of the resident's quarterly MDS, dated [DATE], showed: - Section J1800 (falls since prior assessment) no falls since last review dated 2/6/19; - Section J1900 (number of falls) no injury with fall. During an interview on 6/20/19 at 11:35 A.M., the Director of Nursing (DON) said she would expect a fall on 2/25/19 to be reflected on the MDS completed in May. The facility did not provide a policy for accuracy of MDS.

Based on observation, interview, and record review, the facility failed to implement an individualized comprehensive care plan for one resident (Resident #17) out of 18 sampled residents. The facility's census was 80. Record review of Resident #17's physician's orders [REDACTED]. - [DIAGNOSES REDACTED]. - an order written [REDACTED]. Observation on 6/17/19 at 11:03 A.M., showed the resident lay in bed, without hearing aids and when spoken to, the resident unable to hear. Record review of the resident's nurse progress notes showed: - Admission progress note, dated 3/2/19, showed VERY HARD OF HEARING; - On 3/3/19 showed VERY HARD OF HEARING; - On 3/6/19 showed VERY HARD OF HEARING, family looking for hearing aids and will bring them in when they find them; - On 3/12/19 showed VERY HARD OF HEARING, no hearing aids. Record review of the resident's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 3/6/19, section B 0200 (ability to hear) showed moderate difficulty hearing. Record review of the resident's comprehensive care plan, dated 3/7/19 and updated 5/22/19, showed slightly hard of hearing. During an interview on 6/20/19 at 11:35 A.M., the Director of Nursing (DON) said she would expect the nurse progress notes, the MDS, and the comprehensive care plan to document the same assessment of the resident's hearing status. The facility did not provide a policy for care plans.

Based on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months and failed to provide in-service education based on the outcome of these reviews. The facility's census was 80. Record review of the facility's in-services and educational reviews showed the facility administrative staff did not complete performance reviews for the nurse aides. During an interview on 6/19/19 at 9:49 A.M., the Director of Nursing (DON) and the Administrator said the facility does not do routine performance appraisals. During an interview on 6/20/19 at 11:35 A.M., the DON and Administrator said the facility drives in-services on things identified by the Quality Improvement Committee, sometimes in-services are specific to one person, a complaint, or a concern from resident council. Record review of the facility-provided form showed: - Center for Medicare and Medicaid Services (CMS) (guidance to direct the facility for sufficient nurse staffing and training), dated 1/18, as the facility policy; - An area highlighted on the form by the facility as: Does the facility provide nurse aide in-services, at least 12 hours in a year, including dementia training, abuse prevention training, areas of weakness as determined in the nursing aides' performance reviews, facility assessment, special needs of residents determined by facility staff, and care of the cognitively impaired resident for those nursing aides providing care for individuals with cognitive impairments?